The Brain Disease

Model of Addiction

Ruth A. Potee, MD, DASAM

Family Physician & Addictionologist
Medical Director, Franklin County House of Corrections
Director of Substance Use Disorders, Behavioral Health Network
Medical Director, Pioneer Valley Regional School District
Medical Director, Opioid Taskforce Franklin County and North Quabbin

1
 EAT, DRINK, HAVE SEX
(AND USE DRUGS)

Set respectful
Have
boundaries
patience.
Listen Innovate!
deeply
Create

Run!
Fight!
Get Laid! Take the
long view.
Lizard brain advice Cortex advice

4
DOPAMINE & SEROTONIN
Location and Function

5
8
How Cocaine Works
How Heroin Works
 Volkow ND et al. N Engl J Med 2016;374:363-371

Neurobiologic Advances from the Brain Disease Model of Addiction

Nora D. Volkow, M.D., George F. Koob, Ph.D., and A. Thomas McLellan, Ph.D.
N Engl J Med 2016; 374:363-371January 28, 2016
 American Society of Addiction Medicine (ASAM)
Addiction Definition, April 2011
Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry
• Affects neurotransmission such that addictive behaviors replace healthy
self-care related behaviors
• Genetics account for 50% of addiction development
• Significant self-deception
• Disruption of healthy supports and problems in interpersonal relationships
• History of trauma or stressors that overwhelm an individual’s coping
abilities
• The presence of co-occurring psychiatric illness
• Distortion in meaning, purpose and values that guide attitudes, thinking
and behavior
• The effects to the brain allow external cues to trigger craving and drug use
• Persistent risk of and/or recurrence of relapse
• Impaired executive function so that perception, learning, impulse control.,
compulsivity and judgment are impaired.
Addiction is a treatable, chronic medical disease involving
complex interactions among brain circuits, genetics, the
environment, and an individual’s life experiences. People
with addiction use substances or engage in behaviors that
become compulsive and often continue despite harmful
consequences. Prevention efforts and treatment
approaches for addiction are generally as successful as
those for other chronic diseases.

Adopted by the ASAM Board of Directors September 15, 2019

 4 C’s of Addiction

Compulsive Use
Loss of Control
Continued Use Despite Harm
Cravings
Genetics Early Use Trauma

Poor Mental Health

 Addiction is a Developmental Pediatric Disease

35%
Percentage in each age group who

Age of First Alcohol Use

30% Age at first Nicotine Use
Age of First Cannabis Use
begin using alcohol

25%

20%

15%

10%

5%

0%
5 10 15 20 25 30 35 40 45 50
Age
Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
Prevalence of Lifetime Alcohol Dependence by Age of First
Alcohol Use and Family History of Alcoholism

60 2001-2002

50

40
% Prevalence
30

20

10

0
<=13 14 15 16 17 18 19 20 >=21
Age at First Use of Alcohol

Source: 2001-2002 National Epidemiologic Survey on Alcohol nad Related

Conditions; Laboratory of Epidemiology and Biometry; DICBR, NIAAA,
Bethesda, MD.

Parental History Positive

Total
Parental History Negative
Adverse Childhood Experiences – ACEs

Emotional Neglect
Abuse
Household Dysfunction
 Length of Treatment
Research is unequivocal: good outcomes depend on
adequate treatment length
McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness:
implications for treatment, insurance, and outcomes evaluation. JAMA. 2000 Oct 4;284(13):1689-95.
doi: 10.1001/jama.284.13.1689. PMID: 11015800.
 What It Takes To Get Better

Having a Sense of Purpose Stable & Sober Housing

Physical Movement

Methadone
Medicine Buprenorphine
Positive Relationships
Naltrexone

Mental Health Treatment

Stable & Sober Housing Medicine Mental Health Treatment

Positive Relationships Physical Movement Having a Sense of Purpose
 What It Takes To Get Better

Stable & Sober Housing Having a Sense of Purpose Medicine

Mental Health Treatment Positive Relationships Physical Movement
Working Parenting Going to 12 Step Recovery
Growing into an Adult Brain Getting Treatment for Trauma
Hope Self Love Feeling Acountable
 ruthpotee.com
potee.connect@gmail.com
#ASAM2020
Gerstein, D.R., Harwood, H.J. (Eds.), Treating Drug Problems, vol. 1. Institute of Medicine. National Academy Press, Washington, DC 1990.
Glasscote, R., Sussex, J.N., Jaffe, J.H., Ball, J., Brill, L. 1972. The treatment of drug abuse-programs, problems, prospects. Joint Information Service.
American Psychiatric Association, Washington, DC

#ASAM2020
 Methadone
1967-1970 - Investigational New Drug

FDA doubted efficacy Clinics Profiteering – No Standards

Harry Anslinger Influence – Get Rid of
the “Addict”
Push back from communities of color
that this was Government mind-control
“Drug Free” treatment preference
Treatment of people with unclear OUD
Reports of unlimited quantities of
methadone
Reports of children overdosing on
methadone

Reports of diverted methadone

#ASAM2020
J.H. Jaffe, C. O’Keeffe / Drug and Alcohol Dependence 70 (2003) S3/S11
 March 1973 Regulations
Unprecedented Departure from Allowing Licensed Physicians to Use Judgement

• Age (18)
• Length of Use (at least one year)
• Maximum initial doses (30 mg)
• Minimum amount of counselling
• Specifics limitations on take home doses
• Closed system: approved clinics and hospital pharmacies

Jaffe, Jerome H., and Charles O'Keeffe. "From morphine clinics to buprenorphine:
regulating opioid agonist treatment of addiction in the United States." Drug and
alcohol dependence 70.2 (2003): S3-S11

#ASAM2020
#ASAM2020
 Narcotic Addict Treatment Act of 1974
DEA Jurisdiction Over Methadone
• Specific licenses for clinics and providers
• Restrictive storage rules
• Specific safes size, weight, alarming to police stations or 24 hour security
system alarming to central authority.
• Specifics of who can distribute methadone and all of their personal data
(social security numbers, home addresses, etc)
• Clearly delineated “reverse distribution”
• Strong preference for using computerized dispensing through expensive
software programs

J.H. Jaffe, C. O’Keeffe / Drug and Alcohol Dependence 70 (2003) S3/S11 #ASAM2020
#ASAM2020
#ASAM2020
#ASAM2020
Substance Abuse and Mental Health Services Administration: Use of Medication-Assisted Treatment in the Criminal Justice Settings.
HHS Publication No. PEP19-MATUSECJS Rockville, MD: National Mental Health and Substance Use Policy Laboratory.
Substance Abuse and Mental Health Services Administration,
2019.

#ASAM2020
Keen, Jenny, et al. "Does methadone maintenance treatment based on the new national guidelines work in a
primary care setting?." Br J Gen Pract 53.491 (2003): 461-467.

Calcaterra, S. L., et al. "Methadone matters: what the United States can learn from the global effort to treat opioid
addiction." Journal of general internal medicine 34.6 (2019): 1039-1042.

#ASAM2020
• Safe wired to police stattion
• Vibrating safe with train tracks
• Software for liquid methadone – very strong preference.
• Signing intot he Exception site to register every person who gets
arrested more than twice a year

#ASAM2020
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