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David Gastfriend, M.D. at the NH Addiction Forum

David Gastfriend, M.D. at the NH Addiction Forum


[Music] – Longer than we, and we
develop compulsive urges until the drug dominates our
behavior on a regular basis. And that’s regardless of our good sense, and it’s to the detriment of our health, function,
and relationships. It’s a chemical process. It’s happening deep below the
thinking regions of the brain, and below our conscious capacity, to inhibit the continued
taking of these drugs. So, Jacqueline’s addiction,
as we go to the next slide, was a brain disease that
disrupted two key systems that regulate all behavior. The reward center and
the inhibition center. The reward center has a
disruption of healthy motivation, the “go” signal. In the inhibition center,
drugs disrupt the ability to control behavioral
impulses, the “no go” signal. It’s this balance between the “go” system and the “no go” system that helps us be
functioning, healthy people, seeking the benefits in our environment, and protecting us from the risks. If we want to treat addiction, we have to treat both disruptions. We need a scientifically
balanced approach. Next slide. So, what does this tell us
for the science of prevention? Well, it gives us three steps that we can institute right away. Number one, let’s teach
our doctors this story. If all health professionals
can be taught to prescribe only enough painkillers to reduce pain to the point of allowing healing function, but not eliminating pain, we can prevent the environment in that health epidemic triangle that I talked to you about. We can prevent the environment from becoming a rich, dangerous,
high-risk environment. Another measure for prevention. Let’s monitor prescriptions. Not on a voluntary basis. Only the good doctors
want their medications to be monitored on a voluntary basis. Not every human being who’s a physician is careful, or good, or right. If all pharmacy services and
insurance medication billings are routinely monitored, we could automatically
notify every prescriber. When patients are on too much medication, or on too many medications, or when more than one pharmacy is filling their medications. Or more than one state is
filling their medications. These programs shouldn’t be state-by-state “one-off”s, as they are today. New Hampshire has finally instituted its prescription monitoring program, but we need a mandated, a nationwide, get the NHR in agreement, prescription monitoring system. Third, we can cut overdose deaths in half, by broadly prescribing
and marketing naloxone. This should be over the counter. It should be covered by
Medicaid and all insurances. Not just the first responders, but to the families, to the friends, to the loved ones. It should be a requirement in counseling that the patient who starts a treatment for opioid disorder, who starts in detox, should have their
significant other come in for a lesson in Narcan. We can cut these deaths in half. We don’t withhold Epi-pens from people with life-threatening allergies, because they’ll just be
reckless around peanuts, do we? (audience laughs) I mean, I’m from Massachusetts, so I say that New Hampshire
word, like… (indistinct) (audience laughs) The data proves that it saves lives, and it does not encourage morph addiction. (applause) But once a patient has an addiction, it’s too late for prevention. And it’s insufficient,
because then we scare doctors into cutting off the opioid medications. All that does is drive the
patient to street heroin. They have no choice. It is not a conscious decision. At that point, it is a
chemically-driven decision. Epidemiologists are telling us that this is exactly what’s happening. So, we need to make treatment accessible, effective, and accountable. Because bad treatment only
stimulates more stigma. We’ve got to fix that. So, what is addiction treatment? And what is scientific that
accountable addiction treatment? Show me the next slide, please. Brain science has really deepened our understanding of treatment. And the reward system is a
very strong, effective system. It evolved hundreds of billions
of years ago, actually, to kinds of dinosaurs. And it hasn’t changed much, since. Now, I’m not talking
about the outer thinking region of the brain, I’m talking about the “drive” system. It’s extraordinarily efficient. So, evolution preserves
this drive system structure. In this brain structure,
normal reinforcers like water when we’re thirsty,
food when we’re hungry, or mating, when we’ve
matured to the point of being able for reproducing. These all release a
natural brain chemical, a neurotransmitter called dopamine. Dopamine signals our brain
to persist in behaviors that promote survival of the species. And drugs of abuse cause
the release of dopamine, but more release than
normal, healthy behaviors, and faster release than
normal, healthy behaviors. So, drugs cause us to meritilize these drug-seeking behaviors, at the expense of healthy behaviors. The brain science also teaches us that both the positive
reinforcement of excessive reward, and the negative reinforcement
of withdrawal pain, are chemical structures,
chemical processes that target the deep brain
structure in our skull called the limbic system. Now, what is this limbic system? Haven’t heard about that much. Well, this is a system that’s deeper. It’s the pink area on the spine. It’s below the outer thinking cortex, where we learn, where we think, where we’re constantly making choices. The limbic system evolved in organisms as primitive as a lizard, and our human version isn’t
actually much different in size or structure. It’s responsible for primordial drives. A mother’s breast feeding response to an infant’s cry for milk. Although human beings have an enormously sophisticated outer cortex, the function of the thinking
brain, the outer cortex, is to serve the limbic system. It’s the limbic system’s chemical drives that recruit all the thinking
neurons of the cortex to do its bidding. We get very good at that. But, it doesn’t matter that
we have much more cortex. That doesn’t help us think our way out of a chemical addiction. So, what does that tell us
about addiction treatment? Well, there are hundreds of
studies, I mean hundreds, as many as in many areas
of general medicine, that tell us that we can
treat addiction effectively with evidence-based treatments. Medical detox is the first stage. It’s expert at overcoming
the negative reinforcement of opioid withdrawal, but only if it’s provided long enough, and with adequate medication. But there’s a risk if
we mismatch withdrawal. Too-brief or too-little a dose, and the withdrawal and the
craving not only recur, but studies show, it
recurs with a vengeance worse than before the
patient entered detox. So, short detox phases actually
make our problem worse, and detox itself is no
longer considered treatment. It is medical stabilization, but it is not part of
the recovery process. So, following detox, what the brain needs is to stabilize in a
post-withdrawal craving process. Now, this post-withdrawal
craving can go on for months. I participated in a study
that we published in Lancid, that found that opioid
craving, after detox, persisted for six months at least, on average, even during counseling. So, that’s a chemical process activity. That trips patients up with relapse. Counseling is happening
once or twice a week. They’re craving minutes, hours, days, weekends, holidays, nights. That’s not when the
sessions are happening. So we need medical
stabilization of that craving. And we know that this medication can counteract the cravings. It can block the rewards for opioids, so that if there’s a relapse,
it doesn’t do that much. We know that it can block
innumerable daily signals that trigger cravings, or
cues, in the environment. Even if somebody’s motivation is strong, those cues trigger the craving. So, anti-craving medications,
such as Methadone, Buprenorphine, or Suboxone. They provide effective
chemical stabilization of heroin recovery. And again, only if the dose is sufficient, and the treatment is long enough. Now, that’s chemical stabilization. But that’s not the solution either. In fact, that’s going to
exacerbate the problem, too. What’s next? Well, after stabilizing
withdrawal and craving, this is when the hard work really begins. This is what we mean by recovery. And we haven’t started recovery until now. The chemically-stable brain is a brain that is capable of learning. It is a brain that is
capable of growing again. So, chemical stabilization is a necessary, but insufficient,
prelimination for recovery. It’s the foundation. And now, we’ve got to do the frame, and the siding, and the roofing. Otherwise, this structure isn’t safe for the stormy winter of relapse. That construction project is the work of professional counseling, and it’s the work of
the recovery movement. (applause) We now know this, not
just from experience, but from science as well. People who are emerging from addiction need to accept their disease, need to know their vulnerabilities. They need to anticipate
their risk factors. They need to master new coping behaviors. They have to construct
healthy relationships, find purpose in life. Whether you call it
spirituality or something else, it’s beyond the individual, and they have to find those things. And, most important of all, they have to learn how
to insulate themselves from exposure to the drugs
that trigger relapse, even in times of stress. This is the work of recovery. And research has generated
formal treatment manuals to guide counselors to deliver
these treatments effectively. And those manuals need to be used. Now, it always raises the question, and the next slide brings this up, “is medication better,
or is counseling better?” and the answer is, “yes.” (audience chuckles) Both are essential. They must be provided
hand in hand, integrated. They’re usually, unfortunately, provided in segregated fashion. We keep trying to fight this disease with one hand tied behind our back, and blaming the patient for failing. The payers, especially government, have the power to fix this. A scientifically-grounded
policy should require programs to provide access to all
FDA-approved medication and the full range of
evidence-based counseling and other types of social monitors. (applause) Next slide, please. What about newer medications, like extended-release antagonists? Well, conventional approaches
have some limitations. All those studies consistently prove that Methadone and
Buprenorphine, Suboxone, can achieve harm reduction, and can dramatically stabilize patients. Because they are slow-acting,
they’re long-onset. They don’t produce euphoria. They don’t give a high. They allow the patient,
especially a patient with a chaotic lifestyle,
who can’t get back to any semblance of normal routine, to get back to a life. Study after study after study shows this. But the data also shows that many people don’t accept these medications. They don’t stick to them. Or, they relapse despite the medication. There is a diversion problem. A newer, injected medication
is a “blocker,” or antagonist, at the brain’s opioid receptors. Even if the patient uses, it literally blocks the
effects of the opioid, and it does it for 30
days, only one injection. This treatment, extended-release
naltrexone, or Vivitrol, is a non-narcotic approach. And, it’s the only agent approved to be effective for relapse prevention. So, there’s no single medicine
that’s right for everybody. What is right is that
the treatment program should provide access to all
the FDA-approved options, and they need providers
who have experience with all these options. Otherwise, the patient has to hunt down what they think they need. That’s not a person who is in a condition to be making those decisions. That care system has to make that decision and make the offerings available, free. Next slide, please. Now, there’s research on counseling models that are alternatives to the old ways. But I want to talk about
contingency management. This newer counseling approach helps the brain reward center come back to chemically-full function after months or years
of being desensitized by the overwhelming excessive
reward of opiate drugs. It’s called contingency management. It’s, by far, the most effective
counseling model, bar none. And, it’s as potent as any medication. It’s a counseling model. But, the way it works is, it
actually pays the patient cash, or other incentives,
and provides sanctions in small but
progressively-growing amounts, and this precisely cues the
chemical brain to begin feeling that normal, healthy
dopamine chemical reward, but now, for healthy brain behaviors, like turning in negative
urines on drug screens, or showing up on time for
counseling appointments. Virtually every single study done finds this to be effective, and yet, contingency management
is almost never used. Our state substance abuse
agencies must fix that. Now, is treatment enough? No. There’s another feature that we need to introduce widespread, and that’s recovery support services. This comes– (applause) The patient with addiction
finds every excuse to not make it to treatment,
and not stay in recovery. Now, Vermont has instituted an innovative “Hub and Spoke” delivery model, and that’s a very good system for introducing recovery support services. We should be doing this everywhere. It uses peer counselors. They may not have a degree. They may not be professionally
trained counselors, but they’re in recovery themselves. They know how to get
patients to treatment. They know how to check in at odd hours. – [Crowd member] Woo hoo! Yeah we do! (applause) – They know how to get the
patient into an A.A. meeting, whether it means driving them, holding their hand,
taking them on the bus. They know how to stand right beside a newly-recovering patient
at a job interview, or to apply for their benefits
for vital motion support. Our state substance abuse
agencies and Medicaid need to pay for and integrate
recovery support services into the overall system of care now. – [Crowd member] Oh, yeah! (audience applauds and cheers) – I want to talk about the
justice system for a moment. America’s “addiction warehouse”
is the justice system. And poll data tells us that
Americans are politically ready to trade incarceration for
treatment, if it’s effective. But, it’s not effective to
just do a wholesale discharge of people from prison into the streets without a place for them to get care. We will pay the price for that. It’s bad for public health, and it’s bad for public safety. We need to ramp up access to care for the hundreds of thousands of patients coming out of jails and prisons at the same time that we
have an opioid epidemic. I mean, talk about a perfect storm. So, let’s fix this man power
and service delivery shortage, or else we’ll pay the price. Now, people leaving prison, after an opioid-related
offense got them in, have 100 times the death rate
of the general population. And it’s due to craving,
and relapse, then overdose. That’s astounding, and it’s deadly. But many jurisdictions around the country have already initiated the solution. A pre-release injection of
extended-release naltrexone, with insurance coverage
immediately upon release, and with engagement directly
into counseling treatment under parole monitoring. It’s working in Governor
Kasich’s Ohio, actually. It’s working in Governor Bush’s Florida. It’s working in Massachusetts, next door. And Rikers Island, New York City, and many other places. Let’s do it nationally. (crowd murmurs agreement) Is addiction treatment only about getting medication and care
and nurturance and support? Well, that notion actually
riles some people. It does. And, actually, brain science teaches us that support, and providing
healthier rewards, is only part of the answer. It’s not the whole answer. I told you the two brain systems, the “go” and the “no go” systems, are damaged by addiction. So, we need at least two
approaches to treatment. Certainly, the reward system responds to medication stabilization, and to counseling and support. But, the impaired
inhibitory control system also needs help. A heightened level of warnings, cautions, sanctions, monitors, and punishments to perceive the risks
of continued drug use and to marshal the brain’s efforts to protect against relapse. Studies have conclusively shown most people seek treatment
for this problem. Not because it’s a good
New Year’s resolution, it’s because of coercion. It’s some dramatic threat of a divorce, of bankruptcy, or of an arrest. Studies also show that coercion
is an asset to recovery. Probation, parole, job, custody sanctions are actually helpful, but
only if they’re done right. And we aren’t doing them right. We should’ve learned this from Pavlov. It’s counter-productive
to use massive punishments like “three strikes and you’re out.” It’s worthless to have
ridiculously-delayed court proceedings that resolve
eons after the offense. The brain doesn’t learn from that. Instead, researchers have proven the best outcomes occur
with continuous monitoring of urine outcomes,
attendance, rapid response of graduated punishments that are tailored to fit the violation. Programs such as Hawaii’s “Hope” or South Dakota’s “24/7 Sobriety” program. They reduce relapse. They reduce safety risks. They reduce domestic violence. I mean, it goes beyond drug use. They reduce cost, improve public
safety, and public health. Let’s do it nationwide. And finally, the best outcomes in society aren’t from the easiest patients. You don’t have to have
just good, easy patients to show good results. Some of the toughest patients in the world are doctors who were addicted. Why? Well, they’re very tough because they have lots of access to drugs. And they’re smart, so their limbic system can recruit a big cortex to figure out how to hide, deny, and be
surreptitious and covert. But addicted doctors have the
best recovery rates of anyone. 75 to 90 percent are abstinent and stable in recovery five years later. That beats a lot of bad cancers. So, why is it so good? Well, it’s because society uses a balanced approach with doctors. We have the supports, the medication. We have the monitoring and the sanctions. You balance these things carefully, according to science, you’re
going to get good results. Let’s do it for everybody. Now, instead of the crisis we have, we can have long-term effective, societally-congruent
prevention and treatment, but we’ve got to de-frag
the system, folks. This is a hard drive leak. It’s not just slowed down,
it’s ready for replacement. We need to integrate all of the services, the pain resources, the policies, so that the patient, who will fall through any
gap we allow in the system, is pulled across, channeled
through, into recovery, so that the brain’s natural
resilience can return. That resilience was on stage here. Governor Kasich showed
what resilience is like. Resilience takes somebody from a car, and living in the
streets, to Princeton, OK? We have that ability. The brain hasn’t lost that, no
matter how bad the addiction. So, we can’t pay into a bottomless hole a fee for service, because each relapse allows for more service and more fee. That’s not a way to do it! So let’s fix that, and let’s
hold programs accountable. Let’s have them measure. The American Society of
Addiction Medicine, ASAM, has criteria for who
should get what treatment. Let’s use those criteria uniformly. My institute, the Treatment
and Research Institute, has developed a consumer guide. It looks just like Consumer Reports. You can see what program has what quality for what kind of problems
that your loved one, or the patient you may
want to refer, might need. Let’s use the consumer
guide across states. And the three acts of
Congress that make this work are the ACA that has
brought millions of people who need this treatment into insurance. Number two, the High Tech Act, which makes electronic
monitoring really feasible, but it’s not available for addiction. Let’s fix that! And the Parity Law was passed in 2008. Come on, folks, let’s
make it work already! (applause) We have more deaths from opiates than from car accidents. But when we had a peak of car
accidents in this country, our leadership politically called for airbags in every car. Now, that’s about $1,000 per car. There are eight miliion
cars made in America and sold each year. That’s eight billion
dollars a year for air bags. We have people crashing from opiates. Can we put some money there, please? (applause and cheers from crowd) These are the Jacquelines,
they’re my family members, they’re my friends’
children who have died, our neighbors, they are us. We’ve done the science. We have the technology to
soften the addiction crash, too. We have the air bags for addiction. Science has done its
job; we know what to do. It’s time to make America’s crisis worth a capital and political investment. Thank you. (cheers and applause)

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