This document provides an introduction to addiction as a brain disease. It begins by defining substance use disorders and reviewing DSM-IV criteria for substance abuse and dependence. Epidemiological data on the prevalence of alcohol and drug use in the United States is presented. The neurobiology of addiction and how chronic drug use affects the brain is explained using imaging studies. The document concludes by discussing how physicians can intervene to treat addiction using screening, brief intervention, and referral to treatment methods.

1. Introduction to Addiction
Human Behavior
Lisa J. Merlo, Ph.D.
McKnight Brain Institute
Department of Psychiatry
Division of Addiction Medicine

2. Objectives
• Describe DSM-IV criteria for Substance
Use Disorders (SUDs)
• Review epidemiology of SUDs
• Explain neurobiology of addiction and
“disease model”
• Introduce Screening, Brief Intervention, &
Referral to Treatment (SBIRT) for
addiction

3. What is Addiction?
“Addiction” is a non-specific term that is
frequently used to refer to a variety of
substance-related disorders

4. Addiction is a brain disease

5. Addiction
• Addiction = “Substance Dependence”
• 3 Cs:
• Compulsive use
• Inability to Control use
• Continued use despite Consequences
• Addiction is not just physiological
dependence

6. Substance-Related Disorders
(DSM-IV, 2000)
• Substance Abuse
• Substance Dependence
• Substance Intoxication
• Substance Withdrawal
• Substance-Induced Mental Disorders
• Delirium, Persisting Dementia, Persisting Amnestic
Disorder, Psychotic Disorder, Mood Disorder, Sexual
Dysfunction, Sleep Disorder, Hallucinogen Persisting
Perception Disorder
• Substance Use Disorder, Not Otherwise
Specified

7. Substance Abuse
Maladaptive pattern of substance use, characterized
by 1 (or more) of following symptoms in a 12-month
period:
1. Recurrent substance use resulting in failure to fulfill
major role obligations
2. Recurrent substance use in situations in which it is
physically hazardous
3. Recurrent substance-related legal problems
4. Continued substance use despite having persistent
or recurrent social or interpersonal problems caused
or exacerbated by the effects of the substance
** The symptoms have never met the criteria for Substance
Dependence for this class of substance

8. Substance Dependence
Maladaptive pattern of substance use, characterized
by 3 (or more) of following symptoms in a 12-month
period:
1. Tolerance (need for more or diminished effect)
2. Withdrawal (characteristic syndrome or avoidance of symptoms)
3. Substance taken in larger amounts or over a longer period than
intended
4. Persistent desire or unsuccessful efforts to cut down or control
substance use
5. Great deal of time spent obtaining, using, or recovering from
effects of the substance
6. Important social, occupational, or recreational activities are given
up or reduced because of substance use
7. Substance use continued despite knowledge of having a
persistent or recurrent physical or psychological problem that
was likely caused or exacerbated by the substance

9. Substances of Abuse
• Alcohol (beer, wine, hard liquor)
• Amphetamine (methamphetamine, Adderall, diet pills)
• Caffeine (coffee, soda, tea, energy drinks)
• Cannabis (marijuana, pot, hashish)
• Cocaine (crack, coke, freebase)
• Hallucinogens (LSD, MDMA/Ecstasy, mescaline)
• Inhalants (gasoline, paint thinner, glue)
• Nicotine (tobacco)
• Opioids (heroin, methadone, Vicodin, Oxycontin, Percoset)
• Phencyclidine (PCP, ketamine)
• Sedative/Hypnotic/Anxiolytic (Valium, Xanax, sleeping pills)
• Other/Unknown (e.g., nitrous oxide)
• “Polysubstance”

10. Test Your Knowledge 1:
• How many chemicals are found in
marijuana?
a. 2
b. 8
c. 60
d. 175
e. 400

11. Test Your Knowledge 2:
• How long does the high from a hit of
crack cocaine typically last?
a. 1 minute
b. 5 minutes
c. 20 minutes
d. 45 minutes
e. 90 minutes

12. Test Your Knowledge 3:
• Which of the following poses the highest
immediate risk?
a. Inhalants
b. Marijuana
c. Tobacco
d. LSD
e. Crack

13. Epidemiology of Substance Abuse

14. ALL physicians need to know
about addiction because:
• 1 out of 7 individuals will have a serious
substance use problem (13.5% lifetime
prevalence)
• 1 out of 3 Americans are directly affected by
addiction
• Up to 50% of admissions to the ER are
substance-related
• Addiction is a common problem among
physicians and other health care providers

15. Alcohol Guidelines
• Moderate drinking =
• No more than 1 drink per day for women
• No more than 2 drinks per day for men
• Binge drinking =
• > 4 drinks for women
• > 5 drinks for men

16. Prevalence of Alcohol Use/Abuse

17. Prevalence of Drug Use

18. Perceived Risk vs. Actual Use
• Decades of research
have demonstrated
that drug use is
inversely related to
perceived risk of
taking the drug
• As population-wide
perceptions of the risk
of drugs decrease,
use of those drugs
increases

19. Drug Trends: 2007
• Declining
• Marijuana
• Amphetamines
• Overall use of any illicit drugs
• Holding Steady
• Cocaine, LSD, Heroin
• Increasing
• Ecstasy
• Prescription Drugs (decade trend)

20. Public Health Response

21. “Legal” Drug Abuse
0% 5% 10% 15% 20% 25% 30% 35%
Marijuana
Inhalants
Prescription Drugs
OTC Cough Medicine
Crack/Cocaine
Ecstasy
LSD
Meth
Ketamine
Heroin
GHB
33%
19%
19%
10%
9%
8%
7%
6%
5%
5%
4%
Percentage of U.S. Teens (Grades 7 to 12) Reporting Ever Trying Drugs, 2008
(N=6,518)

22. Trends in Florida
0
1
2
3
4
2001 2002 2003 2004 2005
Number of Drug-Caused Deaths
Per 100,000 Residents in Florida
Heroin-Caused Deaths
Methadone-Caused
Deaths
Merlo LJ, Goldberger BA, Gold MS. Patterns of heroin- and methadone-related deaths in
the state of Florida. Society for Neuroscience Annual Conference, 2007. San Diego, CA.

23. Past Month Non-Medical Use of
Prescription Drugs among Persons 12+
Percent Using in Past Month
+ Difference between this estimate and the 2006 estimate is statistically significant at the .05 level.
0.5
0.2
0.8
0.5
0.1
0.8
0.5
0.1
0.7
0.4
0.1
0.7
2.1
0.5
0.2
0.7
1.9+
2.0
1.8+
1.9
0
1
1
2
2
3
Pain Relievers Stimulants Sedatives Tranquilizers
2002 2003 2004
2005 2006

24. Neurobiology of Addiction

25. Addiction is a Brain Disease
• Not lack of will power or poor judgment
• Impaired control is caused by brain
chemistry malfunction
• Drug use produces brain damage!

26. Why Does Addiction Occur?
•Some drugs of abuse can release 2 to 10 times the amount of dopamine as natural rewards
•In some cases, this occurs almost immediately (as when drugs are smoked or injected), and
the effects can last much longer than those produced by natural rewards
•This creates a much stronger effect on the brain's pleasure circuit than those produced
naturally (e.g., food, sex)
•The effect of such a powerful reward strongly motivates people to take drugs again and again
From:
www.nida.nih.gov

27. Imaging Studies
Patients who abuse substances show:
• Structural abnormalities (MRI/MRS):
• frontal cortex, prefrontal cortex, basal ganglia, and amygdala
• Functional abnormalities (fMRI, PET, SPECT):
• caudate nucleus, cingulate, and prefrontal cortex become
activated during a drug “rush”
• nucleus accumbens becomes activated during periods of craving
• striatal dopamine spike associated with the pleasurable drug-
related “high”

28. Effects of Chronic Drug Use
• With repeated use, drugs
cause profound changes in
neurons and brain circuitry
• These changes are associated
with “tolerance”
• Decreased dopamine
transporters result in
depression-like symptoms
• Drugs are needed to “return
to baseline”

29. The SPECT images (top-down surface view)
depicting a normal brain vs. a brain affected by
chronic marijuana use
Defects of this type have been associated with
attention problems, disorganization,
procrastination and lack of motivation.

30. Developmental
Neurobiology
Early brain exposure to drugs of abuse:
• in utero
• through secondhand exposure
• and/or through early experimentation
sensitizes the brain, making abuse and dependence
more likely
• In an animal model, rats who were exposed to
THC during adolescence show higher levels of
opioid self-administration during adulthood than
rats who were not exposed

31. Addiction: Age of Onset
• Some experimentation during adolescence is
developmentally “normative” behavior
• However, addiction is now being referred to as a
“disease of pediatric origin”

32. Genetics
• Twins
• Identical 55%; Fraternal 28%
• Adoption studies
• genetics > environment
• Tendency to become alcoholic is inherited
• Alcoholic parent - 3 to 4 times higher
• Adult children of alcoholics have abnormal
brain cortisol reactions to stress
• Drugs induce changes in genes

33. Clinical Application:
Intervening With Patients

34. SBIRT
• Screening
• Brief Intervention
• Referral to
Treatment

35. SCREENING
1. ASK your patients about their
substance use:
• How many alcoholic drinks do you have in a
week? (not: “Do you drink alcohol?”)
• What sorts of drugs do you use?
• Tell me about your tobacco use and/or
secondhand exposure.

36. SCREENING
2. FOLLOW-UP on any positive responses:
• CAGE questionnaire, Alcohol Use Disorders
Identification Test (AUDIT), or Michigan Alcohol
Screening Test (MAST) for alcohol
• Drug Abuse Screening Test (DAST) or more
intense interviewing for drugs
• Fagerstrom Nicotine Dependence Test for
tobacco

37. SCREENING
3. Consider utilizing point-of-care testing:
• Breath-alyzer, saliva, or urine testing for alcohol
• Urine (or hair) testing for drugs
• Urine, saliva, or breath testing for tobacco
(nicotine)

38. BRIEF INTERVENTION
• FRAMES Method:
• offer Feedback
• emphasize personal Responsibility
• give Advice
• provide a Menu of options
• use Empathy
• support Self-efficacy

39. REFERRAL TO TREATMENT
1. Provide information on AA/NA Meetings
2. Offer referral to outpatient addiction
treatment clinic
3. Suggest inpatient detoxification and/or
long-term residential treatment

40. Florida Recovery Center
• http://shands.org/hospitals/vista/professionals/default.asp
For Healthcare Professionals
Shands.org seeks to provide tools and information to healthcare professionals to make it
easy to refer and transfer patients, answer medication questions, and provide tips for
running a better business.
Referrals
For Professionals Homepage - Shands system-wide information
Information
To learn more about Shands Vista, please call 352.265.5497.

41. Remember:
• Addiction is a TREATABLE brain disease
• Physicians must intervene to treat the
addiction, not just the physiological
symptoms that may result from chronic
substance use

42. Thank You.
Any questions?
lmerlo@ufl.edu