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Chemical Dependency Relapse Pathways

“Understanding the how, why, where and when.” Acknowledgements

„ La Hacienda Treatment Center

„ American Society of

„ National Institute on Abuse Definition of Dependency

„ A primary, progressive biochemical, ppysychosocial, ,g genetically transmitted chronic of relapse who’s hallmarks are denial, loss of control and unmanageability.

Natural Rewards Elevate Dopamine Levels FOOD SEX 200 200 ne)ne) NAc shell iiii

150 150 utpututput n (% (% (% n n BaselBasel OOOO ooo o Copulation 100 100 15

Empty 10 oncentrationcentrati F f Basal DA f Basal DA f Basal DA C CCC 50 requency ooo o Box Feeding

% % 5 DA DA DA

0 0 006060 120 180 ScrScrScrScr Scr Scr BasFemale 1 Present Female 2 Present Time (min) Sample 1122334455667788 991010 11 12 13 14 15 16 17 Number Mounts Intromissions Ejaculations

Source: Di Chiara et al. Source: Fiorino and Phillips Effects of on Dopamine Levels

Accumbens 1100 Accumbens 1000 400 900 800 DA DA 300 eleaseelease Release Release DOPAC llll 700 DOPAC RRRR HVA 600 HVA 500 200 400

% of Basa of Basa % % 300 200 of Basal of Basal % % 100 100 0 001122334455 hr 0 001122334455 hr Time After Amphetamine Time After Cocaine

250 NICOTINE 250 Accumbens MORPHINE Dose (mg/kg) 200 Accumbens 200 0.5 Caudate 1.0 l Releasel Release ReleaseRelease

aaaa 150 252.5 150 10 100 100 % of% of Bas Bas % of Basal of Basal % %

0 00112233 hr 0 00112233445hr5hr Time After Nicotine Time After Morphine

Source: Di Chiara and Imperato Dopamine Transporters in Abusers

2.4

2.2 rs ee 2.0

1.8 /Kd) ansport rr Normal Control xx 161.6

1.4 (Bma

amine T 1.2 pp

Do 1.0 Normal Meth Controls Abusers Methamphetamine Abuser p < 0.0002

Methamphetamine abusers have significant reductions in dopamine

transporters. BNL --UCLAUCLA -SUNY NIDA - ONDCP - DOE Dopamine Transporters in Methamphetamine Abusers

Motor Task 2.0 1.8 Loss of dopamine transporters 1.6 in the meth abusers may result 1.4 in slowing of motor reactions.

sporter 1.2 nn 1.07 8 9 10 11 12 13 Time Gait (seconds) mine Tra Bmax/Kd aa 2.0 Dop Memory Task 1.8 1.6 Loss of dopamine transporters 1.4 ithin the meth thb abusers may resu lt 1.2 in memory impairment. 1.0 16 14 12 10 8 6 4 Delayed Recall (words remembered) BNL/UCLA/SUNY NIDA, ONDCP, DOE Dopamine D2 Receptors in Addiction

Control Experimental groups groups Cocaine

Meth

Alcoh o l

Food

Addictions

„ Hypothalamic Dysregulation

„ Impacts other areas of the including the Prefrontal Cortex , Cingulate and Pre- cingulate Gyrus, the Hippocampus, and the Amygdala .

Cha llenge: Normal Drug Use Addiction Treatment Three Major Relapse Pathways

I. Cross Addicting Drugs II. People/Place/Things III. BHALTB.H.A.L.T. Cross Addicting D rugs

a. Chemical of choice b. Related drugs c. TbTobacco d. Life long relapse pathway Effects of Drugs on Dopamine Levels

Accumbens COCAINE 1100 AMPHETAMINE Accumbens 1000 400 900 800 DA DA 300 eleaseelease Release Release DOPAC llll 700 DOPAC RRRR HVA 600 HVA 500 200 400

% of Basa of Basa % % 300 200 of Basal of Basal % % 100 100 0 001122334455 hr 0 001122334455 hr Time After Amphetamine Time After Cocaine

250 NICOTINE 250 Accumbens MORPHINE Dose (mg/kg) 200 Accumbens 200 0.5 Caudate 1.0 l Releasel Release ReleaseRelease

aaaa 150 252.5 150 10 100 100 % of% of Bas Bas % of Basal of Basal % %

0 00112233 hr 0 00112233445hr5hr Time After Nicotine Time After Morphine

Source: Di Chiara and Imperato Cross Addicting D rugs

a. Chemical of choice b. Related drugs c. TbTobacco d. Life long relapse pathway Chemicals of Choice

„ Cannot be a social or recreational user

„ Cannot use in a different form or method

„ Cannot use “just on special occasions”

„ CCtPERIODannot use PERIOD CossCross-Addicting Chemicals

„ Impact on the hypothalamus as the drug of choice

„ Usually leads back to the drug of original dependency

„ Life long relapse pathway Pain Cont rol in Addiction

„ Opiates are high risk in

„ Non Steroidal Anti-inflammatories are safe

„ Some skeletal muscle relaxers are safe

„ Phys ical th erapy, st ret c hing, exerci se and massages are helpful

„ Having a target for pain control or reduction Anxiet y in Addictions

„ Benzodiazepines are rarely safe to use

„ SSRI’s can be used for Disorders

„ Other AntiAnti--DepressantDepressant Classes can also be helpful in Anxiety Disorders

„ Meditation and Relaxation Techniques

„ EXERCISE Sleep in Addictions

„ Do not recommend hypnotic agents

„ Go to bed at the same time every night

„ No caffeine within 6 hours of bedtime

„ Nlithi3hfbdtiNo meals within 3 hours of bedtime

„ No exercise within 3 hours of bedtime

„ Use the bed only for sleep. Tobacco

„ 23% of Americans are addicted to tobacco

„ >90% of the addicted population use tobacco

„ Tobacco Cessation MUST be encouraged

„ Relapse rates vary from 2 times to 5 times greater in a ddic ts w ho con tinue t o use tobacco People/Place/Things

a. Hist ory of discovery b. Three month limit for relapse

BHALTB.H.A.L.T.

„ All appear to be stress mediated

„ Relation to the Amygdala , the H -P-AAxisA Axis, and the release of CRF

„ Reduces with time as well

BHALTB.H.A.L.T.

a. Boredom b. Hunger c. / d. Loneliness e. Tiredness Relapse P re v ention Medications

I. Antabuse II. Campral III. RViReVia IV. Vivitrol V. Off label Antabuse

a. Mechanism of action b. Dosing c. Side Effects d. Efficacy Campral

a. Mechanism of action b. Dosing c. Side Effects d. Efficacy ReVia

a. Mechanism of action b. Dosing c. Side Eff ec ts d. Efficacy Vivit rol

a. Mechanism of action b. Dosing c. Side Effects d. Efficacy Off label Du al Diagnosis

1. Prevalence 2. Testing 3. Treatment Spiritual Component of Recovery Dr. Daniel Boone La Hacienda Treatment Center 800800--749749--61606160 dboone@l ah aci end a.com