October 21, 2010 Medical Director Panel Al J. Mooney MD Medical Director, The Healing Place of Wake County Chairm

1. Addiction Medicine: Orientation to the Science of Addiction orAn experienced addictionist reflects on applying science to service in a peer driven homeless shelter environment October 21, 2010 Medical Director Panel Al J. Mooney MD Medical Director, The Healing Place of Wake County Chairman, Willingway Foundation Associate Clinical Professor of Family Medicine, UNC Chapel Hill

2. Discussion point #1 • Solving America’s #1health problem • Alcoholism and drug dependency conditions are major contributors to morbidity and mortality in mental health and physical health environments

3. Discussion point #2 • “If a tree falls in the woods and nobody is there, does it make a noise?” • Knowledge of recent addiction science and neuroscience strengthens our understanding of addictive illness and recovery

4. Discussion point #3 • “Walk a mile in my shoes” • Peer and mutual support (AA, NA, 12 step work, and mutual support) are promising to be effective bridges to life-long addiction recovery

5. Discussion point #4 • “S*** happens” • Understanding that life-long recovery exists in three phases (or zones) assists an individual establish healthy sobriety and negotiate good and bad times throughout their recovering life

6. Putting it all together There is a problem We can identify the problem There is a free solution We can connect the free solution with the problem

7. Where science meets the sickness What evidence is there that the alcohol and drug problem is the number one health problem in America?

8. Disease facts – The problem • Fatal illness • 100,000 deaths annually • YPLL = Cancer + Heart Disease • >80% unanticipated deaths in community mental health • Number 1 Health problem • $466 billion annual cost of NOT treating • No claims data to use for policy formulation • 7% U.S. population afflicted • ¼of hospital admissions • Family morbidity 43% (76,000,000) • 100% increase in healthcare costs • Primary cause of preventable birth defects • Treatment yield of $7 for $1 expense • $39 Yield for each $1 spent in medical settings • Prevention reduces risk by 75%

9. How to be “blinded by the evidence” • Scientific methods are being used in ways that corrupt measurement of meaningful outcomes • Adjust length of study to misrepresent outcome • Measure effects that justify use of medication • Avoid measurement of side effects • Emphasize statistical endpoints not relevant to clinical efficacy • Pay researchers to publish positive outcomes • Don’t report negative results • Publish research ghostwritten by marketing staff under physician bylines • Avoid comparison with alternatives known to be effective

11. Suicide (1950-2005) Sources: Centers for Disease Control and Prevention, National Center for Health Statistics. From Health, United States, 2005

12. Suicide by age (1990-2005)

15. Infection Death Rates

17. Settlements for illegal or unethical drug marketing practices • Astra Zeneca $520,000,000 • http://www.astrazeneca-us.com/about-astrazeneca-us/newsroom/8936389?itemId=8936389 • Pfizer $2,300,000,000 • http://www.ama-assn.org/amednews/2009/09/14/prl20914.htm • Purdue Pharma $634,500,000 • http://www.nytimes.com/2007/05/11/business/11drug.html?_r=1&scp=1&sq=Purdue%20Pharma%E2%80%99s%20May%2011%20plea%20agreement%20&st=cse • Lilly $1.400,000,000 • http://www.bmj.com/content/338/7688/News.full.pdf http://www.taf.org/top20.htm

18. Drinking behavior in America • ⅓ nondrinkers • ⅓ occasional drinkers • ⅓ regular drinkers (high alcoholism risk) • >50% consumption by 6% adults

19. Disease facts – The problem • Fatal illness • 100,000 deaths annually • YPLL = Cancer + Heart Disease • >80% unanticipated deaths in community mental health • Number 1 Health problem • $466 billion annual cost of NOT treating • No claims data to use for policy formulation • 7% U.S. population afflicted • ¼of hospital admissions • Family morbidity 43% (76,000,000) • 100% increase in healthcare costs • Primary cause of preventable birth defects • Treatment yield of $7 for $1 expense • $39 Yield for each $1 spent in medical settings • Prevention reduces risk by 75%

20. Attributable morbidity • 38% automobile fatalities • 5X risk of vehicle fatality • 20% suicides • 65% drownings • 70% crises in MH setting requiring institutionalization • 16X risk of fall mortality • 10X risk of fire/burn victim • 31% boating fatalities • 40% industrial fatalities

21. History of alcoholism • Ancient alcohol problems (Bible, Aristotle) • Alcoholic individual (Seneca) • Economics of alcohol and drugs • Native American fellowship circles • Progression of alcoholism (Benjamin Rush) • Washingtonian movement • Temperance movement

23. Benjamin Rush (1746-1813) • An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind, with an Account of the Means of Preventing and of the Remedies for Curing Them, New York, 1811

25. Medically-trained Harvard psychologist and philosopher William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"

26. Abraham Flexner (1866 - 1959) • "It seemed to me the time was ripe for the creation in America of an institute in the field of general scholarship and science...where everyone -- faculty and members -- took for granted what was known and published, and in their individual ways endeavored to advance the frontiers of knowledge.“                                               

27. Carl Jung • Carl Jung (1875-1961) was a Swiss psychiatrist, an influential thinker and is renowned as the founder of analytical psychology.  • “Every form of addiction is bad, no matter whether the narcotic be alcohol, morphine or idealism.”

28. Doctor Bob and Bill W.

30. Jellinek symptoms of alcoholism Social Drinking Relief Drinking Seek Drinking events Tolerance Psychological escape Prodrome Heavy Drinking Blackouts Gulping/sneaking drinks Chronic hangovers Crucial phase Loss of control Excuses Eye-openers Changing patterns of drinking Antisocial behavior Loss of friends, family, job Medical and mental problems Chronic phase Benders Tremors Protecting supply Resentments Nameless fears and anxieties Collapse of alibi system Surrender

33. Drug types Alter our perception of reality Alter a disease

34. Example: Benadryl Help allergy symptoms

35. Example: Benadryl Sedation or antianxiety = relapse risk Help allergy symptoms

36. Example: Morphine Euphoria or high = relapse risk Assist heart pumping

37. Drugs of abuse Stimulants Narcotics Other Sedatives

38. Drugs of abuse Ice Ritalin Crack Adderal Crystal Meth Ultram Methadone Special K Benadryl Buprenorphine Marijuana Glue Heroin LSD Prozac Codiene Peyote Paxil Morphine PCP Zoloft Dextromethoraphan “T” Alcohol Xanax Butalbital Ativan Restoril Chloral Hydrate Valium Methaqualone Klonopin Soma Ambien

39. Alcohol effect on brain < 0.05% Prefrontal Cortex disinhibition > 0.05% Amgdyla emotional >0.10% Cerebellum – ataxia >0.20% RAS hypnosis >0.30% Medulla - Respiratory depression and death

40. “The doctor’s theory that we have an allergy to alcohol interests us.”Alcoholics Anonymous p. XXIV • The alcoholic’s brain responds to chemicals and life differently than the brain of a normal individual. Multiple factors contribute to the development of addictions, but the total cause is still unknown to science.

41. Tolerance and dependence CNS Activity Time

42. Tolerance and dependence CNS Activity Time

43. Tolerance and dependence CNS Activity Time

44. CNS Activity Time Tolerance and dependence vs. addiction

45. Addictive cycle 1. Physical Allergy 2. Mental Obsession

46. Identification of alcoholism • Drinking in spite of adverse consequences

47. Recognition – old timer’s question • “Can you always predict how much or how long you will drink and/or use before you start?”

48. Natural rewards survival urges (nutrients) • Air • Food • Water • Sex • Intimacy (connectedness)

49. Brain regions

50. Brain Regions – Cognitive Areas