1. Agenda
I. Introduction & Overview
II. The Disease of Addiction
III. Population and Risk Factors
IV. Treatment
V. Center for Addiction Medicine Initiatives
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2. Substance Misuse: The Nation‟s
Number One Public Health Problem
 There are more deaths, illnesses, and disabilities from substance
use than from any other preventable health condition
 Of the more than 2 million deaths each year in the US, 1 in 4 is
attributable to alcohol, tobacco, and illicit drug use
 Alcohol alone causes about 20–30% of esophageal cancer, liver
cancer, cirrhosis of the liver, homicide, epileptic seizures, and motor
vehicle accidents worldwide (WHO, 2002).
 Over 22.6 million Americans have problem with alcohol or other
drugs
 More than half of all families in the US has or has had a family member
suffering from alcohol dependence (NIAAA, 2005)
 Alcohol use is involved in 25-50% of suicides
 37% of those with alcohol dependence and 53% of those with
dependence on an illicit drug have another psychiatric illness
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3. Economic Burden
 The economic burden associated with alcohol misuse
alone is approaching $200 billion annually, far exceeding
the cost associated with other medical conditions such
as cancer ($107 billion) and heart disease ($96 billion).
 When combined with other drugs the economic burden
is close to $400 billion annually.
Gruel and Rehm. 2003
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4. MGH Facts/Figures
 At MGH Outpatient Addiction Services, approximately 2
out of 3 patients have co-occurring mental health and
substance use disorder diagnoses
 Inpatients with an SUD primary or secondary diagnoses
had a LOS of 2.5 days longer than those without
 Patients with alcohol use issues comprise 5% of all ED
visits, but 7.2% of ED bed hours, or 3 beds in any 24
hour period
 32% admitted, compared to 26% of other patients
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5. Starkly Reduced
Dopamine
Receptor
Expression
Observed in Brain
Reward Centers in
the Striatum
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6. Reduced D2 Receptor Expression Experimentally
Induced by Social Stress and Correlation with
Cocaine Self Administration
Morgan, et al., 2002, Nat Neurosci 6

7. 7

8. 3-D Iso-surface Representation of Amygdala
in Cocaine Addiction Showing 23% Volume
Reduction
Superior
Right Amygdala
Right Lateral Ventricle = red Posterio Anterior
Left Lateral Ventricle = green r Patients
Normal Controls
Makris et al., 2004 Neuron
Common 8

9. Model of addiction
Addictive agent
Euphoria/
Positive Reinforcement
activated reward pathways
Drug Administration/ Neuroadaptations
Drug-Seeking Behavior Withdrawal and Tolerance
Failed impulse suppression Protracted hedonic dysregulation
Drug Craving/
Negative Reinforcement
Dysregulated reward pathways
Drug-related cues
Limbic activation
Stress
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10. Addiction
Addiction is a disorder of brain reward centers that normally
insure the survival of organisms and the species
Drugs activate and dysregulate endogenous reward systems such
that attention, motivation, behavior are directed away from
survival goals and toward drug-related cues
Dackis and O‟Brien, 2001
Defined by loss of control over intense urges to take the drug
despite adverse consequences
Volkow and Fowler, Cereb Cortex 2000
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11. Onset
 Substance use disorders typically have onset during
adolescence and young adulthood and tend to have a chronic
course without intervention - 90% of all adults with
alcohol/drug dependence started using under the age of
18, half under the age of 15 (NSDUH, 2006)
 75% of High School students have tried alcohol
 Nearly 50% of seniors drink at least once a week
 1 out of 4 seniors uses illicit drugs
 1 out of 3 teens, age 14-17, have used an illegal drug more than once
 Brain development continues well into mid-20‟s
 Sustained binge drinking may affect this process, may result in damage
to frontal-cortical regions
 Early intervention and recovery management offers hope for shortening
the intensity and course of the illness
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12. Age at Onset of DSM-IV Drug
Abuse and Dependence
Compton et al. Arch Gen Psychiatry/ Vol 64, May 2007; 45(11): 1294 - 1303 12

13. Who is Vulnerable?
 Adolescents
 40-60% of vulnerability for addiction genetically influenced
 Addiction is more prevalent in people who have the following
childhood psychiatric disorders:
 Depression and Bipolar Disorder*
 Anxiety
 Schizophrenia
 Post-Traumatic Stress Disorder
 Attention Deficit Hyperactivity Disorder
 Conduct Disorder*
* Denotes largest risk factor: Over half develop substance abuse
N. Volkow, 2007, Director National Institutes on Drug Abuse
Goldman, et al; ‘05 Nature Rev. Gen.; Hiroi, et al; ‘05 Mol Psychiatry
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14. Substances of Abuse are Deleterious
in Adolescent Brain Development
Negative CNS
effects of chronic
Prefrontal structures alcohol use in
teens:
- Learning
- Information
recall, memory
(verbal, nonverbal)
- Vocabulary
- Sleep (mood,
attention)
Striatum & Hippocampus
Medial Wall 14

15. Relationship between Mental Health
and Substance Use Disorders
 Complex, multifaceted
 Genetics/ neurobiological
 Affected by multiple systems of adolescent/young adult life
 Family, Community/ School, Peers, Media
 Life stresses, academic and social issues
 Dynamics-self medication
 Changes with maturation, normal development
 Substance use can worsen the severity of pre-existing mental
health conditions; untreated mental health issues exacerbate
substance use
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16. Clinical Imperative
 Substance Use Disorders are Highly Prevalent,
Under-recognized and Under-treated
 Screening is fast and effective
 Even brief intervention can effect salutary change
 Early Intervention is optimal
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17. What Can Be Done?
 Treatment works; extensive models are best suited
to the nature of addiction
 Effective treatments exist:
 Pharmacotherapy
Rarely Prescribed
 Cognitive-behavioral therapy
 Motivational Interventions
 Community Reinforcement Model
 12-step facilitation
 Family therapy
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18. Innovative Models of Care
 Extensive models are best suited to the nature of
addiction
 “Aftercare” – Continuing Care – Treatment
 Case monitoring
 Recovery management
Assertive Continuing Care
Mutual Help Groups/Peer Support
 Program Evaluation
 Science-based practice
 Practice-based science
 Intermediate Outcomes/Theory
 Provides for systematic evaluation; identification of patient
subgroups/non-responders
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19. Treatment Challenges - Stigma
 Conceptualized as a disorder of „Free Will‟
 “substance abuser”
 Perhaps even more than other mental illness, patients with
substance use disorders feel strong sense of
shame/embarrassment, and self-loathing
 Shame associated with substance use creates a barrier to
accessing treatment and disclosure/open communication
 Substance use disorder is a chronic health condition similar to
hypertension, diabetes and yet is not treated as such
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20. Is Substance-Related
Treatment Worth Its Cost?
 Addiction treatment is highly cost-effective
 Every $1 invested in addiction treatment programs yields a
$4-7 saving in reduced drug-related crime, criminal justice
costs, and theft alone.
 When health care savings are included, total exceeds costs by
ratio of 12 to 1
 Major savings to the individual and society also come from
significant drops in interpersonal conflicts, improvements in
workplace productivity, and reductions in drug-related
accidents.
Measuring and Improving Cost, Cost-Effectiveness, and Cost-Benefit for Substance Abuse Treatment Programs, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES, NIH, NIDA 1999.
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