Showing papers on "Addiction medicine published in 2016"

Neurobiologic Advances from the Brain Disease Model of Addiction

Abstract: This article reviews scientific advances in the prevention and treatment of substance-use disorder and related developments in public policy. In the past two decades, research has increasingly supported the view that addiction is a disease of the brain. Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned, perhaps because the aberrant, impulsive, and compulsive behaviors that are characteristic of addiction have not been clearly tied to neurobiology. Here we review recent advances in the neurobiology of addiction to clarify the link between addiction and brain function and to broaden the understanding of addiction as a brain disease. We review findings on the desensitization of reward circuits, which dampens the ability to feel pleasure and the motivation to pursue everyday activities; the increasing strength of conditioned responses and stress reactivity, which results in increased cravings for alcohol and other drugs and negative emotions when these cravings are not sated; and the weakening of the brain regions involved in executive functions such as decision making, inhibitory control, and self-regulation that leads to repeated relapse. We also review the ways in which social environments, developmental stages, and genetics are intimately linked to and influence vulnerability and recovery. We conclude that neuroscience continues to support the brain disease model of addiction. Neuroscience research in this area not only offers new opportunities for the prevention and treatment of substance addictions and related behavioral addictions (e.g., to food, sex, and gambling) but may also improve our understanding of the fundamental biologic processes involved in voluntary behavioral control. In the United States, 8 to 10% of people 12 years of age or older, or 20 to 22 million people, are addicted to alcohol or other drugs. 1 The abuse of tobacco, alcohol, and illicit drugs in the United States exacts more than $700 billion annually in costs related to crime, lost work productivity, and health care. 2-4 After centuries of efforts to reduce addiction and its related costs by punishing addictive behaviors failed to produce adequate results, recent basic and clinical research has provided clear evidence that addiction might be better considered and treated as an acquired disease of the brain (see Box 1 for definitions of substance-use disorder and addiction). Research guided by the brain disease model of addiction has led to the development of more effective methods of prevention and treatment and to more informed public health policies. Notable examples include the Mental Health Parity and Addiction Equity Act of 2008, which requires medical insurance plans to provide the same coverage for substance-use disorders and other mental illnesses that is provided for other illnesses, 5 and the proposed bipartisan Senate legislation that From the National Institute on Drug Abuse (N.D.V.) and the National Institute of Alcohol Abuse and Alcoholism (G.F.K.) — both in Bethesda, MD; and the Treatment Research Institute, Philadelphia (A.T.M.). Address reprint requests to Dr. Volkow at the National Institute on Drug Abuse, 6001 Executive Bld., Rm. 5274, Bethesda, MD 20892, or at nvolkow@ nida . nih . gov.

Survey Highlights Differences In Medicaid Coverage For Substance Use Treatment And Opioid Use Disorder Medications

Abstract: The Affordable Care Act requires state Medicaid programs to cover substance use disorder treatment for their Medicaid expansion population but allows states to decide which individual services are reimbursable. To examine how states have defined substance use disorder benefit packages, we used data from 2013–14 that we collected as part of an ongoing nationwide survey of state Medicaid programs. Our findings highlight important state-level differences in coverage for substance use disorder treatment and opioid use disorder medications across the United States. Many states did not cover all levels of care required for effective substance use disorder treatment or medications required for effective opioid use disorder treatment as defined by American Society of Addiction Medicine criteria, which could result in lack of access to needed services for low-income populations.

Pharmacotherapy for Alcohol Dependence: The 2015 Recommendations of the French Alcohol Society, Issued in Partnership with the European Federation of Addiction Societies

Abstract: BACKGROUND: The latest French good practice recommendations (GPRs) for the screening, prevention, and treatment of alcohol misuse were recently published in partnership with the European Federation of Addiction Societies (EUFAS). This article aims to synthesize the GPRs focused on the pharmacotherapy of alcohol dependence.METHODS: A four-member European steering committee defined the questions that were addressed to an 18-member multi-professional working group (WG). The WG developed the GPRs based on a systematic, hierarchical and structured literature search and submitted the document to two review processes involving 37 French members from multiple disciplines and 5 non-French EUFAS members. The final GPRs were graded A, B, or C, or expert consensus (EC) using a reference recommendation grading system. RESULTS: - The treatment of alcohol dependence consists of either 1) alcohol detoxification / abstinence maintenance programs or 2) drinking reduction programs. - The therapeutic objective is the result of a decision made jointly by the physician and the patient.- Benzodiazepines (BZDs) are the first-line medication for detoxification (GRADE A). - BZD dosing should be guided by regular clinical monitoring (GRADE B). - Residential detoxification is more appropriate for patients with a history of seizures, delirium tremens, unstable psychiatric comorbidity, or another associated substance use disorder (GRADE B). - BZDs are only justified beyond a one-week period in the case of persistent withdrawal symptoms, withdrawal events or associated BZD dependence (GRADE B). - BZDs should not be continued for more than four weeks (GRADE C). - The dosing and duration of thiamine (vitamin B1) during detoxification should be adapted to nutritional status (EC). - Medications for relapse prevention should be automatically associated with adapted psychosocial support (GRADE A). - Acamprosate and naltrexone are the first-line options for relapse prevention (GRADE A). - Disulfiram can be proposed as second-line treatment in patients who are correctly informed and adequately supervised (EC).- Medications for reducing alcohol consumption are only indicated in dependent individuals (EC). - Nalmefene is indicated as a first-line treatment for reducing alcohol consumption (GRADE A). - The second-line prescription of baclofen, up to 300 mg/d, to prevent relapse or reduce drinking should be carried out according to the “temporary recommendation for use” (TRU) issued by the French Health Agency (EC).- Abstinence is recommended throughout pregnancy (EC).- If medically‐assisted withdrawal is necessary during pregnancy, BZD use is recommended (GRADE B).- No medication other than those for alcohol withdrawal should be initiated in pregnant or breastfeeding women (EC).- In a stabilized pregnant patient taking medication to support abstinence, the continuation of the drug should be considered on a case‐by‐case basis, weighing the benefit/risk ratio. Only disulfiram should be always stopped, given the unknown risks of the antabuse effect on the fetus (EC).- First‐line treatments to help maintain abstinence or reduce drinking are off-label for people under 18 years of age and should thus be considered on a case-by-case basis after the repeated failure of psychosocial measures alone (EC).- Short-half-life BZDs should be preferred for the detoxification of elderly patients (GRADE B).- The initial doses of BZDs should be reduced by 30 to 50% in elderly patients (EC).- In patients with chronic alcohol-related physical disorders, the goal of abstinence is recommended (EC)- Any antidepressant or anxiolytic medication should be introduced after a psychiatric reassessment after 2-4 weeks of alcohol abstinence or low-risk use (GRADE B).- A smoking cessation program should be offered to any smokers involved in an alcohol treatment program (GRADE B).

Meditation Awareness Training for the Treatment of Sex Addiction: A Case Study.

Abstract: Background Sex addiction is a disorder that can have serious adverse functional consequences. Treatment effectiveness research for sex addiction is currently underdeveloped, and interventions are generally based on the guidelines for treating other behavioral (as well as chemical) addictions. Consequently, there is a need to clinically evaluate tailored treatments that target the specific symptoms of sex addiction. It has been proposed that second-generation mindfulness-based interventions (SG-MBIs) may be an appropriate treatment for sex addiction because in addition to helping individuals increase perceptual distance from craving for desired objects and experiences, some SG-MBIs specifically contain meditations intended to undermine attachment to sex and/or the human body. The current study conducts the first clinical investigation into the utility of mindfulness for treating sex addiction. Case presentation An in-depth clinical case study was conducted involving an adult male suffering from sex addiction that underwent treatment utilizing an SG-MBI known as Meditation Awareness Training (MAT). Following completion of MAT, the participant demonstrated clinically significant improvements in addictive sexual behavior, as well as reductions in depression and psychological distress. The MAT intervention also led to improvements in sleep quality, job satisfaction, and non-attachment to self and experiences. Salutary outcomes were maintained at 6-month follow-up. Discussion and conclusion The current study extends the literature exploring the applications of mindfulness for treating behavioral addiction, and findings indicate that further clinical investigation into the role of mindfulness for treating sex addiction is warranted.

Neuroscience of drug craving for addiction medicine: From circuits to therapies.

Abstract: Drug craving is a dynamic neurocognitive emotional-motivational response to a wide range of cues, from internal to external environments and from drug-related to stressful or affective events. The subjective feeling of craving, as an appetitive or compulsive state, could be considered a part of this multidimensional process, with modules in different levels of consciousness and embodiment. The neural correspondence of this dynamic and complex phenomenon may be productively investigated in relation to regional, small-scale networks, large-scale networks, and brain states. Within cognitive neuroscience, this approach has provided a long list of neural and cognitive targets for craving modulations with different cognitive, electrical, or pharmacological interventions. There are new opportunities to integrate different approaches for carving management from environmental, behavioral, psychosocial, cognitive, and neural perspectives. By using cognitive neuroscience models that treat drug craving as a dynamic and multidimensional process, these approaches may yield more effective interventions for addiction medicine.

Substance Use and Misuse: Emerging Epidemiological Trends, New Definitions, and Innovative Treatment Targets.

Abstract: Millions of people worldwide suffer from addiction and related comorbidities.1,2 Given its association with high rates of mental and physical problems as well as premature mortality,3-6 substance misuse remains a significant global public health problem and a heavy burden for abusers and their families alike. In addition, methods of administration, including injection and some smoking practices, lead to greater risk of users contracting blood-borne diseases such as HIV, viral hepatitis, and subacute bacterial endocarditis.7 Clearly, addiction is a multifaceted, frequently comorbid problem that cannot be reduced to compulsive substance use. In response to this challenge and to take into account such complexity, addiction research has evolved tremendously over the past few years. Many changes are currently taking place in the field of addiction from both an epidemiologic and clinical research perspective. This In Review represents a timely opportunity to provide psychiatrists and other clinicians with a glance at these new trends and research agenda. We also hope that it will contribute to bolstering a growing interest for substance use disorders within the mental health field.The addiction research community has historically relied on American and European epidemiologic studies to identify and understand trends in substance use and misuse. Largescale Canadian samples have recently generated critical national data and informed more refined and detailed descriptions of these trends in specific populations. Roy, Arruda, and collaborators present a review of Canadian epidemiologic data on substance misuse with a specific focus on newly identified phenomena. They highlight a number of results obtained over the past decade from longitudinal cohorts of street-based drug users, and they discuss the emergence of a prescription opioid use epidemic and its comorbid correlates. This article also looks into the highly prevalent but poorly investigated phenomenon of binge drug use. The authors pinpoint what could be a significant vector of risky behaviours and comorbidities and provide the basis for a complete research agenda that could significantly help to identify a new treatment target. Finally, Roy et al. establish critical emerging trends of mental health comorbidity among highly vulnerable populations of drug users in Canada. This endeavour reminds the field of psychiatry that addiction and ''classic'' mental health problems cannot be dissociated and that the accuracy of our understanding of psychiatric diagnoses, the impact of their symptoms, and their etiology may have to be reassessed in substance users.Blaine and collaborators provide another fascinating example of the widened conception of addiction, which goes beyond substance use per se. Stress vulnerability and craving have been acknowledged as prominent features of addiction, and the latter has even been included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for substance use disorder. They are now known to be associated with a wealth of adverse outcomes such as higher rates of relapse even after prolonged periods of abstinence. A significant number of biological, neuroanatomic, psychologic, and environmental correlates of craving have been identified and are now better understood. Craving and stress have thus become key targets of addiction treatments, including pharmacotherapy and relapse prevention therapy. In this very thorough yet accessible article, Blaine and collaborators review the main findings pertaining to craving and stress vulnerability as critical features of alcohol dependence, and they underline their potential as innovative treatment targets to reduce the burden related to addictive disorders.While these developments have made significant contributions to our understanding of addiction and its comorbidities, we are left with many challenges. An overhaul of current practices is undoubtedly required to have a concrete positive impact on the lives of substance abusers and their families. …

Response inhibition and addiction medicine: from use to abstinence.

Abstract: Historically, neuroscientific research into addiction has emphasized affective and reinforcement mechanisms as the essential elements underlying the pursuit of drugs, their abuse, and difficulties associated with abstinence. However, research over the last decade or so has shown that cognitive control systems, associated largely but not exclusively with the frontal lobes, are also important contributors to drug use behaviors. Here, we focus on inhibitory control and its contribution to both current use and abstinence. A body of evidence points to impaired inhibitory abilities across a range of drugs of abuse. Typically, studies suggest that substance-abusing individuals are characterized by relative hypoactivity in brain systems underlying inhibitory control. In contrast, abstinent users tend to show either normal or supernormal levels of activity in the same systems attesting to the importance of inhibitory control in suppressing the drug use urges that plague attempts at abstinence. In this chapter, the brain and behavioral basis of response inhibition will be reviewed, with a focus on neuroimaging studies of response inhibition in current and abstinent drug abusers.

Cognitive interventions for addiction medicine: Understanding the underlying neurobiological mechanisms.

Abstract: Neuroimaging provides a tool for investigating the neurobiological mechanisms of cognitive interventions in addiction. The aim of this review was to describe the brain circuits that are recruited during cognitive interventions, examining differences between various treatment modalities while highlighting core mechanisms, in drug addicted individuals. Based on a systematic Medline search we reviewed neuroimaging studies on cognitive behavioral therapy, cognitive inhibition of craving, motivational interventions, emotion regulation, mindfulness, and neurofeedback training in addiction. Across intervention modalities, common results included the normalization of aberrant activity in the brain's reward circuitry, and the recruitment and strengthening of the brain's inhibitory control network. Results suggest that different cognitive interventions act, at least partly, through recruitment of a common inhibitory control network as a core mechanism. This implies potential transfer effects between training modalities. Overall, results confirm that chronically hypoactive prefrontal regions implicated in cognitive control in addiction can be normalized through cognitive means.

Developing Core Competencies for the Prevention and Management of Prescription Drug Misuse: A Medical Education Collaboration in Massachusetts.

Abstract: Drug overdose has become the leading cause of injury death in the United States. More than half of those deaths involve prescription drugs, specifically opioids. A key component of addressing this national epidemic is improving prescriber practices.A review of the curricula at the four medical schools in Massachusetts revealed that, although they taught components of addiction medicine, no uniform standard existed to ensure that all students were taught prevention and management strategies for prescription drug misuse. To fill this gap, the governor and the secretary of health and human services invited the deans of the state's four medical schools to convene to develop a common educational strategy for teaching safe and effective opioid-prescribing practices. With leadership from the Department of Public Health and Massachusetts Medical Society, the deans formed the Medical Education Working Group in 2015. This group reviewed the relevant literature and current standards for treating substance use disorders and defined 10 core competencies for the prevention and management of prescription drug misuse.The medical schools have incorporated these competencies into their curricula and have committed to assessing students' competence in these areas. The members of the Medical Education Working Group have agreed to continue to work together on key next steps, including connecting these competencies to those for residents, equipping interprofessional teams to address prescription drug misuse, and developing materials in pain management and opioid misuse for practicing physicians. This first-in-the-nation partnership has yielded cross-institutional competencies that aim to address a public health emergency in real time.

Neuroscience of inhibition for addiction medicine: from prediction of initiation to prediction of relapse

Abstract: A core deficit in drug addiction is the inability to inhibit maladaptive drug-seeking behavior. Consistent with this deficit, drug-addicted individuals show reliable cross-sectional differences from healthy nonaddicted controls during tasks of response inhibition accompanied by brain activation abnormalities as revealed by functional neuroimaging. However, it is less clear whether inhibition-related deficits predate the transition to problematic use, and, in turn, whether these deficits predict the transition out of problematic substance use. Here, we review longitudinal studies of response inhibition in children/adolescents with little substance experience and longitudinal studies of already addicted individuals attempting to sustain abstinence. Results show that response inhibition and its underlying neural correlates predict both substance use outcomes (onset and abstinence). Neurally, key roles were observed for multiple regions of the frontal cortex (e.g., inferior frontal gyrus, dorsal anterior cingulate cortex, and dorsolateral prefrontal cortex). In general, less activation of these regions during response inhibition predicted not only the onset of substance use, but interestingly also better abstinence-related outcomes among individuals already addicted. The role of subcortical areas, although potentially important, is less clear because of inconsistent results and because these regions are less classically reported in studies of healthy response inhibition. Overall, this review indicates that response inhibition is not simply a manifestation of current drug addiction, but rather a core neurocognitive dimension that predicts key substance use outcomes. Early intervention in inhibitory deficits could have high clinical and public health relevance.

Perspectives on neurocognitive rehabilitation as an adjunct treatment for addictive disorders: From cognitive improvement to relapse prevention

Abstract: Addiction, as a brain disorder, can be defined with two distinct but interacting components: drug dependency and neurocognitive deficits. Most of the therapeutic interventions in addiction medicine, including pharmacological or psychosocial therapies, that are in clinical use have been mainly focused on directly addressing addictive behaviors, especially drug use and urges to use drugs. In the field of addiction treatment, it is often presumed that drug users' neurocognitive deficits will reverse following abstinence. However, in many cases, neurocognitive deficits are not fully ameliorated following sustained abstinence, and neurocognitive function may further deteriorate in early abstinence. It can be argued that many cognitive functions, such as sustained attention and executive control, are essential for full recovery and long-term abstinence from addiction. Recent advances in cognitive neuroscience have provided scientific foundations for neurocognitive rehabilitation as a means of facilitating recovery from drug addiction. Neurocognitive rehabilitation for drug addicted individuals could be implemented as part of addiction treatment, with highly flexible delivery methods including traditional "paper and pencil" testing, or computer-based technology via laptops, web-based, or smartphones in inpatient and outpatient settings. Despite this promise, there has been limited research into the potential efficacy of neurocognitive rehabilitation as a treatment for drug addiction. Further, many questions including the optimum treatment length, session duration, and necessary treatment adherence for treatment efficacy remain to be addressed. In this chapter, we first introduce cognitive rehabilitation as one of the potential areas to bridge the gap between cognitive neuroscience and addiction medicine, followed by an overview of current challenges and future directions.

Resting state functional connectivity analysis for addiction medicine: From individual loci to complex networks.

Abstract: Resting state functional connectivity (rsFC) has provided a new and valuable tool for investigating network-level dysfunction in addiction. Following the recent development of a framework of large scale network disruptions, we have been able to arrive at unique insights into craving-related aspects of addiction using rsFC. However, such network-level advancement has thus far eluded our understanding of mesocorticolimbic involvement in addiction. Given the importance of this system in vulnerability and resilience to addiction, understanding mesocorticolimbic dynamics to the same extent could provide critical insights into the disease. To this end, we review here recent studies on addiction that employ rsfC and suggest a new approach, one that combines a novel model for addiction with new experimental techniques as well as participant groups, to accelerate progress in this arena.

A review of a national training initiative to increase provider use of MAT to address the opioid epidemic

Abstract: Background and Objectives The Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT) initiative focuses on training and mentoring health professionals in the treatment of opioid use disorders (OUD) using pharmacological strategies. Led by the American Academy of Addiction Psychiatry (AAAP), PCSS-MAT is a consortium representing four of the five national professional organizations authorized by DATA 2,000—AAAP, American Osteopathic Academy of Addiction Medicine, American Psychiatric Association, and American Society of Addiction Medicine. DATA organizations are authorized to train physicians to prescribe buprenorphine for OUD treatment. The primary aim of PCSS-MAT is to substantially increase evidence-based practices with medications for OUD. Methods This review describes the development of PCSS-MAT, an ongoing national initiative funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), to address the training needs posed by this critical public health problem. Core initiatives include: (1) Training and mentoring activities for primary care physicians; (2) Outreach to multidisciplinary professional organizations, (3) Creating a resource portal for families, patients, and communities for OUD treatment. Results Educational outreach to providers addresses the needs of patients with OUD and common co-occurring psychiatric and medical disorders. Discussion and Conclusions The overall scope of PCSS-MAT is to increase access to evidence-based treatment of substance use disorders as a public health priority. Recently enacted legislation requires office-based opioid treatment programs to offer all Food and Drug Administration-approved (FDA) forms of MAT. Scientific Significance Working with health care providers to effectively deliver MAT is key to integrating behavioral and physical medicine. (Am J Addict 2016;25:603–609)

Some Additional Considerations Regarding the American Society of Addiction Medicine National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use.

Abstract: A recent summary guideline in the Journal of Addiction Medicine summarized the newly released ‘‘American Society of Addiction Medicine National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use’’ (Kampman and Jarvis, 2015). In the midst of a vast epidemic of opioid use, for which medication treatment (commonly known as medication-assisted treatment or MAT) stands as the best antidote, the guideline serves an important purpose by bringing together in 1 document both scientific knowledge and expert wisdom concerning the use of the 3 medications currently approved to treat opioid use disorder. It logically organizes the relevant topics and highlights key concepts of using these medications. Creating a treatment guideline presents challenges. It often comes as a surprise how little rigorous and replicated evidence exists to inform the clinical interventions necessary to treat a complex disease like opioid use disorder. Guideline developers then face the choice of recommending only the interventions supported by very high levels of evidence or of melding high levels of scientific evidence with expert opinion to craft recommendations. The former approach can leave the guideline user uncertain how to proceed in managing various

Neuroscience of learning and memory for addiction medicine: from habit formation to memory reconsolidation.

Abstract: Identifying effective pharmacological treatments for addictive disorders has remained an elusive goal. Many different classes of drugs have shown some efficacy in preclinical models, but the number of effective clinical therapeutics has remained stubbornly low. The persistence of drug use and the high frequency of relapse is at least partly attributable to the enduring ability of environmental stimuli associated with drug use to maintain behavioral patterns of drug use and induce craving during abstinence. We propose that stimuli associated with drug use exert such powerful control over behavior through the development of abnormally strong memories, and their ability to initiate subconscious sequences of motor actions (habits) that promote uncontrolled drug use. In this chapter, we will review the evidence suggesting that drugs of abuse strengthen associations with cues in the environment and facilitate habit formation. We will also discuss potential mechanisms for disrupting memories associated with drug use to help improve treatments for addiction.

Drug-induced neurotoxicity in addiction medicine: From prevention to harm reduction.

Abstract: Neurotoxicity is considered as a major cause of neurodegenerative disorders. Most drugs of abuse have nonnegligible neurotoxic effects many of which are primarily mediated by several dopaminergic and glutamatergic neurotransmitter systems. Although many researchers have investigated the medical and cognitive consequences of drug abuse, the neurotoxicity induced by these drugs still requires comprehensive attention. The science of neurotoxicity promises to improve preventive and therapeutic strategies for brain disorders such as Alzheimer disease and Parkinson's disease. However, its clinical applications for addiction medicine remain to be defined adequately. This chapter reviews the most commonly discussed mechanisms underlying neurotoxicity induced by common drugs of abuse including amphetamines, cocaine, opiates, and alcohol. In addition, the known factors that trigger and/or predispose to drug-induced neurotoxicity are discussed. These factors include drug-related, individual-related, and environmental insults. Moreover, we introduce some of the potential pharmacological antineurotoxic interventions deduced from experimental animal studies. These interventions involve various targets such as dopaminergic system, mitochondria, cell death signaling, and NMDA receptors, among others. We conclude the chapter with a discussion of addicted patients who might benefit from such interventions.

Barriers to female sex addiction treatment in the UK

Abstract: BackgroundOver the last 20 years, behavioral addictions (e.g., addictions to gambling, playing video games, work, etc.) have become more accepted among both public and scientific communities. Addiction to sex is arguably a more controversial issue, but this does not take away from the fact that some individuals seek professional help for problematic excessive sex, irrespective of how the behavior is conceptualized. Empirical evidence suggests that among treatment seekers, men are more likely than women to seek help for sex addiction (SA).MethodsUsing the behavioral addiction literature and the authors’ own expertise in researching female SA, this paper examines potential barriers to the treatment for female sex addicts.ResultsFour main types of barriers for female sex addicts not seeking treatment were identified. These comprised (a) individual barriers, (b) social barriers, (c) research barriers, and (d) treatment barriers.ConclusionsFurther research is needed to either confirm or disconfirm the identifi...

Neuroscience of resilience and vulnerability for addiction medicine: From genes to behavior.

Abstract: Addiction is a complex behavioral disorder arising from roughly equal contributions of genetic and environmental factors. Behavioral traits such as novelty-seeking, impulsivity, and cue-reactivity have been associated with vulnerability to addiction. These traits, at least in part, arise from individual variation in functional neural systems, such as increased striatal dopaminergic activity and decreased prefrontal cortical control over subcortical emotional and motivational responses. With a few exceptions, genetic studies have largely failed to consistently identify specific alleles that affect addiction liability. This may be due to the multifactorial nature of addiction, with different genes becoming more significant in certain environments or in certain subsets of the population. Epigenetic mechanisms may also be an important source of risk. Adolescence is a particularly critical time period in the development of addiction, and environmental factors at this stage of life can have a large influence on whether inherited risk factors are actually translated into addictive behaviors. Knowledge of how individual differences affect addiction liability at the level of genes, neural systems, behavioral traits, and sociodevelopmental trajectories can help to inform and improve clinical practice.

Specifying and Pilot Testing Quality Measures for the American Society of Addiction Medicine's Standards of Care.

Abstract: Author(s): Harris, Alex HS; Weisner, Constance M; Chalk, Mady; Capoccia, Victor; Chen, Cheng; Thomas, Cindy Parks | Abstract: ObjectivesIn 2013, the American Society of Addiction Medicine (ASAM) approved its Standards of Care for the Addiction Specialist Physician. Subsequently, an ASAM Performance Measures Panel identified and prioritized the standards to be operationalized into performance measures. The goal of this study is to describe the process of operationalizing 3 of these standards into quality measures, and to present the initial measure specifications and results of pilot testing these measures in a large health care system. By presenting the process rather than just the end results, we hope to shed light on the measure development process to educate, and also to stimulate debate about the decisions that were made.MethodsEach measure was decomposed into major concepts. Then each concept was operationalized using commonly available administrative data sources. Alternative specifications examined and sensitivity analyses were conducted to inform decisions that balanced accuracy, clinical nuance, and simplicity. Using data from the US Veterans Health Administration (VHA), overall performance and variation in performance across 119 VHA facilities were calculated.ResultsThree measures were operationalized and pilot tested: pharmacotherapy for alcohol use disorder, pharmacotherapy for opioid use disorder, and timely follow-up after medically managed withdrawal (aka detoxification). Each measure was calculable with available data, and showed ample room for improvement (no ceiling effects) and wide facility-level variability.ConclusionsNext steps include conducting feasibility and pilot testing in other health care systems and other contexts such as standalone addiction treatment programs, and also to study the specification and predictive validity of these measures.

Behavioral addictions in addiction medicine: from mechanisms to practical considerations.

Abstract: Recent progress has been made in our understanding of nonsubstance or “behavioral” addictions, although these conditions and their most appropriate classification remain debated and the knowledge basis for understanding the pathophysiology of and treatments for these conditions includes important gaps. Recent developments include the classification of gambling disorder as a “Substance-Related and Addictive Disorder” in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and proposed diagnostic criteria for Internet Gaming Disorder in Section 3 of DSM-5. This chapter reviews current neuroscientific understandings of behavioral addictions and the potential of neurobiological data to assist in the development of improved policy, prevention, and treatment efforts.

Federal Parity In The Evolving Mental Health And Addiction Care Landscape

Abstract: The intent of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 is to eliminate differences between health insurance coverage of mental health and substance use disorder benefits and coverage of medical or surgical benefits. The Affordable Care Act significantly extended the reach of the Wellstone-Domenici law by applying it to new insurance markets. We summarize the evolution of legislative and regulatory actions to bring about federal insurance parity. We also summarize available evidence on how the Wellstone-Domenici law has contributed to addressing insurance discrimination; rectifying market inefficiencies due to adverse selection; and altering utilization, spending, and health outcomes for people with mental health and substance use disorders. In addition, we highlight important gaps in knowledge about how parity has been implemented, describe the groups still lacking parity-level coverage, and make recommendations on steps to improve the likelihood that the Wellstone-Domenici law will fulfill the aims of its architects.

PET imaging for addiction medicine: From neural mechanisms to clinical considerations.

Abstract: Positron emission tomography (PET) has been shown to be an effective imaging technique to study neurometabolic and neurochemical processes involved in addiction. That is, PET has been used to research neurobiological differences in substance abusers versus healthy controls and the pharmacokinetics and pharmacodynamics of abused drugs. Over the past years, the research scope has shifted to investigating neurobiological effects of abstinence and treatment, and their predictive power for relapse and other clinical outcomes. This chapter provides an overview of PET methodology, recent human PET studies on drug addiction and their implications for clinical treatment.

Neural systems implicated in obesity as an addictive disorder: from biological to behavioral mechanisms.

Abstract: Contributing factors to obesity have been identified, yet prevention and treatment efforts have had limited long-term success. It has recently been suggested that some individuals may experience an addictive-like response to certain foods, such as losing control over consumption and continued consumption despite negative consequences. In support, shared biological and behavioral features seem to exist between "food addiction" and traditional substance-use disorders. "Food addiction" may be another important contributor to obesity. The current chapter reviews existing literature regarding neural systems implicated similarly in obesity and addiction, discusses unique considerations for addictive-like eating, and proposes directions for future research regarding "food addiction" as an emerging construct for addiction medicine.

Neuroscience of opiates for addiction medicine: From stress-responsive systems to behavior.

Abstract: Opiate addiction, similarly to addiction to other psychoactive drugs, is chronic relapsing brain disease caused by drug-induced short-term and long-term neuroadaptations at the molecular, cellular, and behavioral levels. Preclinical research in laboratory animals has found important interactions between opiate exposure and stress-responsive systems. In this review, we will discuss the dysregulation of several stress-responsive systems in opiate addiction: vasopressin and its receptor system, endogenous opioid systems (including proopiomelanocortin/mu opioid receptor and dynorphin/kappa opioid receptor), orexin and its receptor system, and the hypothalamic-pituitary-adrenal axis. A more complete understanding of how opiates alter these stress systems, through further laboratory-based studies, is required to identify novel and effective pharmacological targets for the long-term treatment of heroin addiction.

Stress psychobiology in the context of addiction medicine: from drugs of abuse to behavioral addictions.

Abstract: In this chapter, we briefly review the basic biology of psychological stress and the stress response. We propose that psychological stress and the neurobiology of the stress response play in substance use initiation, maintenance, and relapse. The proposed mechanisms for this include, on the one hand, the complex interactions between biological mediators of the stress response and the dopaminergic reward system and, on the other hand, mediators of the stress response and other systems crucial in moderating key addiction-related behaviors such as endogenous opioids, the sympathetic-adrenal-medullary system, and endocannabinoids. Exciting new avenues of study including genomics, sex as a moderator of the stress response, and behavioral addictions (gambling, hypersexuality, dysfunctional internet use, and food as an addictive substance) are also briefly presented within the context of stress as a moderator of the addictive process.

Noninvasive brain stimulation for addiction medicine: From monitoring to modulation.

Abstract: Addiction is a chronic relapsing brain disease with significant economical and medical burden on the societies but with limited effectiveness in the available treatment options. Better understanding of the chemical, neuronal, regional, and network alterations of the brain due to drug abuse can ultimately lead to tailoring individualized and more effective interventions. To this end, employing new assessment and intervention procedures seems crucial. Noninvasive brain stimulation (NIBS) techniques including transcranial electrical and magnetic stimulations (tES and TMS) have provided promising opportunities for the addiction medicine in two main domains: (1) providing new insights into neurochemical and neural circuit changes in the human brain cortex and (2) understanding the role of different brain regions by using NIBS and modulating cognitive functions, such as drug craving, risky decision making, inhibitory control and executive functions to obtain specific treatment outcomes. In spite of preliminary positive results, there are several open questions, which need to be addressed before routine clinical utilization of NIBS techniques in addiction to medicine, such as how to account for interindividual differences, define optimal cognitive and neural targets, optimize stimulation protocols, and integrate NIBS with other therapeutic methods. Therefore, in this chapter we revise the available literature on the use of NIBS (TMS and tES) in the diagnostic, prognostic, and therapeutic aspects of the addiction medicine.

The benefits of customized dna directed nutrition to balance the brain reward circuitry and reduce addictive behaviors.

Abstract: DNA Customization of nutraceutical products is here. In the truest sense, "Gene Guided Precision Nutrition™" and KB220 variants (a complex mixture of amino-acids, trace metals, and herbals) are the pioneers and standard-bearers for a state of the art DNA customization. Findings by both, Kenneth Blum, Ph.D. and Ernest Noble, Ph.D. concerning the role of genes in shaping cravings and pleasure- seeking, opened the doors to comprehension of how genetics control our actions and effect our mental and physical health. Moreover, technology that is related to KB220 variants in order to reduce or eradicate excessive cravings by influencing gene expression is a cornerstone in the pioneering of the practical applications of nutrigenomics. Continuing discoveries have been an important catalyst for the evolution, expansion, and scientific recognition of the significance of nutrigenomics and its remarkable contributions to human health. Neuro-Nutrigenomics is now a very important field of scientific investigation that offers great promise to improving the human condition. In the forefront is the development of the Genetic Addiction Risk Score (GARS™), which unlike 23andMe, has predictive value for the severity of drug and alcohol abuse as well as other non-substance related addictive behaviors. While customization of neuronutrients has not yet been commercialized, there is emerging evidence that in the future, the concept will be developed and could have a significant impact in addiction medicine.

Animal models for addiction medicine: From vulnerable phenotypes to addicted individuals.

Abstract: This chapter highlights the use of several animal models of abuse liability. The overall goal is to describe the most frequently used methods, unconditioned behaviors and conditioned behaviors, and how investigators can use these techniques to compare drugs and to understand the mechanisms of action mediating abuse liability. Thus, for each type of animal model described, research will be highlighted on three general features related to the use of the model: (1) determine abuse potential, (2) treatment efficacy, and (3) brain-related changes associated with drug administration.