Treatment?

Drug companies say that a pill is the cure, but pills don’t teach skills and may make

addicts ill!

Why not use stimulants?

Description

• Amphetamine is a stimulant that is primarily used to treat narcolepsy and attention-deficit hyperactivity disorder. It is also used recreationally as a club drug and as a performance enhancer.

• Prescription amphetamines are subject to diversion and are one of the most frequently- abused drugs in high schools and colleges.

• A Schedule II drug is classified as one that has a high potential for abuse, has a currently-accepted medical use under severe restrictions, and has a high possibility of severe psychological and physiological dependence.

HO

HO

NH2

OH

Norepinephrine(Noradrenaline)

NH2

Amphetamine

CH3

NHCH3

Methamphetamine

CH3

Methylphenidate(RitalinTM)

HN

O O

Me

0100200300400500600700800900

10001100

0 1 2 3 4 5 hr

Time After Amphetamine

% o

f B

as

al

Re

lea

se

DADOPACHVA

Accumbens AMPHETAMINE

0

100

200

300

400

0 1 2 3 4 5 hrTime After Cocaine

% o

f B

as

al

Re

lea

se

DADOPACHVA

AccumbensCOCAINE

0

100

150

200

250

0 1 2 3 4 5hrTime After Morphine

% o

f B

as

al

Re

lea

se

Accumbens

0.51.02.510

Dose (mg/kg)

MORPHINE

0

100

150

200

250

0 1 2 3 hrTime After Nicotine

% o

f B

as

al

Re

lea

se

AccumbensCaudate

NICOTINE

Di Chiara and Imperato, PNAS, 1988

Effects of Drugs on Dopamine Release

Would these responses

differ between controls

and addicted subjects?

Would these responses

differ between controls

and addicted subjects?

CA

PUTStriatumStriatum

VTA/SN

CGCG

PreFPreF

OFCOFCnucleusaccumbens

Would increasingDA enhance activity in the OFC?

Would increasingDA enhance activity in the OFC?

Compared the response to IV MP (methylphenidate given in 2 sequential doses of 0.5 and 0.25 mg/kg) in 15 controls and 21 cocaine abusers using FDG and PET to measure regional brain glucose metabolism

Compared the response to IV MP (methylphenidate given in 2 sequential doses of 0.5 and 0.25 mg/kg) in 15 controls and 21 cocaine abusers using FDG and PET to measure regional brain glucose metabolism

00

22

44

66

88

1010

ControlsControls AbusersAbusers

baselinebaselineFirst MPFirst MPSecond MPSecond MP

Sel

f R

epor

t C

ravi

ng

Sel

f R

epor

t C

ravi

ng

(0-1

0)(0

-10)

00

22

44

66

88

1010

ControlsControls AbusersAbusers

Sel

f R

epor

t H

igh

Sel

f R

epor

t H

igh

(0-1

0)(0

-10)

Self Reports of Drug Effects After MP in Controls and in Cocaine Abusers

Self Reports of Drug Effects After MP in Controls and in Cocaine Abusers

P < 0.001P < 0.001 P<0.001P<0.001

MP-induced Increases in Metabolism

OFC

1.001.00

1.051.05

1.101.10

1.151.15

1.201.20

1.251.25

1.301.30

ControlsControls AbusersAbusers

BaselineMP

Rec

tal G

yrus

/Bra

inR

ecta

l Gyr

us/B

rain

-4.0-4.0 -2.0-2.0 0.00.0 2.02.0 4.04.0 6.06.0 8.08.0 10.010.0-0.2-0.2

-0.1-0.1

0.00.0

0.10.1

0.20.2

0.30.3

CravingCraving

Rec

tal

Gyr

usR

ecta

l G

yrus

(MP

- P

lace

bo)

(MP

- P

lace

bo)

p < 0.005p < 0.005

Abusers > Controls p = 0.001

p < 0.01p < 0.01

How Much of the Differences BetweenControls and Cocaine Abusers Reflect

their Past Experience with Drugs?

Effects of Expectation on the Brain Metabolic Responses

To iv MP in Cocaine Abusers

How Much of the Differences BetweenControls and Cocaine Abusers Reflect

their Past Experience with Drugs?

Effects of Expectation on the Brain Metabolic Responses

To iv MP in Cocaine Abusers

Source: Volkow, ND et al., Journal of Neuroscience, 23, pp. 11461-11468, December

2003.

Effects of Expectation on the Response to MP on Brain Glucose Metabolism and Behavior

Increases in Metabolism Were About 50% Larger When MP Was

Expected Than Unexpected

Increases in Metabolism Were About 50% Larger When MP Was

Expected Than Unexpected

“High” Was About 50% Greater When MP Was

Expected Than Unexpected

“High” Was About 50% Greater When MP Was

Expected Than Unexpected

0

2

4

6

8

10

Pl/

PL

PL

/MP

MP

/MP

MP

/PL

Feel

Dru

g

0

2

4

6

8

10

Pl/

PL

PL

/MP

MP

/MP

MP

/PL

Hig

h

0

2

4

6

8

10

Pl/

PL

PL

/MP

MP

/MP

MP

/PL

Like

Dru

g

0

2

4

6

8

10

Pl/

PL

PL

/MP

MP

/MP

MP

/PL

Rest

less

ness

00

551010

1515

2020

2525

3030

% C

han

ge%

Ch

ange

Une

xpec

ted

MP

Une

xpec

ted

MP

Expe

cted

MP

Expe

cted

MP

Expe

cted

MP

Got

Pla

cebo

Expe

cted

MP

Got

Pla

cebo

Source: Volkow, ND et al., Journal of Neuroscience, 23, pp. 11461-11468, December 2003.Source: Volkow, ND et al., Journal of Neuroscience, 23, pp. 11461-11468, December 2003.

Where the Rubber Meets the RoadData from Dr. Lloyd Gordon from the treatment of patients at COPAC

Information obtained from CAPTASA 2012 website

• Two interviewers had to agree with diagnosis (MD, PhD, PNP)

• Hx of stimulant abuse not exclusionary unless DOC

• Initial poor outcomes on Adderall led to switch to “safer” drugs (e.g. Concerta, Vyvanse)

• One psychiatrist did all med. adjustments

• Inclusion– No discussion on unit– 1 year enrollment in treatment– Leaving treatment meant no follow-up

from providers– 1+ prior CD treatments

• All had CBT manually/workbook driven and special groups with psychiatrist and psychiatric NP

• Behavioral problems resulted in one verbal warning, then behavioral contract, then discharge

• N=43

• Ages 18-55

AGE DISTRIBUTION CONTROL VS STIMULANT

18-25 26-35 36-45 46-550

5

10

15

20

25

19

10 82

22

127

2

CONTROL STIMULANT

RELAPSE AND LOST TO FOLLOW UP FOR STIMULANT TREATMENT OF ADHDBY QUARTER100%(43/43)

2

13

8

13

10

5

10

2

4

6

8

10

12

14

0-3 4-6 7-9 10-12

RELAPSE LOST TO FOLLOW UP

Results and Conclusions of COPAC Study

• 100% (43/43) participants were relapsed and/or lost to follow-up.

• 31% of controls (12/39) relapsed and/or were lost to follow-up

• Only 25% of the stimulant group had abused stimulants in the past

• There were many more behavioral discharges in the stimulant vs. control groups though the disease severity was equal. (Some of the control group participants were given Welbutrin or Clonidine. Strattera was not available at the time of the study.)

• Stimulants do not work in the 1st year of treatment.

The Benefits of Recovery

• Living in the solution

– One day at a time, easy does it, first things first, keep it simple

– Acceptance– Utilize tools such as smart phones– Delegate– View the energy and creativity as wonderful gifts– Consider safe medications, but don’t expect to be

“normal” (False expectation of stimulants as cure.)