April 28

ASAM Launches Corporate Roundtable

The ASAM Corporate Roundtable (CRT) was created this year to allow leaders in the addiction community to support key ASAM initiatives. Support for the CRT is growing, and the first program to benefit is the Patient Advocacy Task Force.

The Corporate Roundtable is a membership entity with different giving levels and annual membership, said Penny Mills, MBA, ASAM Executive Vice President and CEO. The ASAM Board of Directors decides each year how to use the funds raised through the CRT.

The following companies have joined the CRT so far and their levels of support are: Visionary Level, Reckitt Benckiser; Leader Level, Millennium Laboratories; Advocate Level, Alkermes; Friend Level, BHG, Cigna, Orexo and Pfizer.

Corporate Roundtable membership provides an opportunity to share vision, intellect, and financial resources with the addiction medicine community. Its resources will be used to support Board-designated initiatives that will help improve the quality, access, and delivery of addiction care, and the training and resources for addiction medicine specialists.

To learn more about the CRT, go to the “Get Involved” tab on the ASAM website.

The Patient Advocacy Task Force was developed to gather data and educate policy makers about the importance of effective patient access to medications for treatment of opioid addiction. A Stakeholder Summit is scheduled for June 20 in Washington, D.C., to release the results of the Task Force research and its analysis results, and to solicit feedback from stakeholders.

“The Corporate Roundtable is an opportunity to partner with leading corporate supporters in the field and identify mutual areas of interest in which we cooperate,” said ASAM President Stuart Gitlow, MD, MPH, MBA, FAPA. “We look forward to the continued growth of the Roundtable membership in the future to benefit the addiction community.”

State of the Art Course to Address Latest Advances in Addiction Medicine

Mark your calendar now to attend one of the top education events for the specialty, the State of the Art Course in Addiction Medicine, Oct. 24-26 in Crystal City, Va. Presented every two years, it provides an advanced level of knowledge about the latest developments in addiction medicine.

“It is one of the nation’s premier courses on the science of addiction, presented by the nation’s leading addiction clinicians and researchers,” said Raye Z. Litten, PhD, one of the course’s two co-chairs. To register, go to the Education tab on the ASAM website.

The course is presented by ASAM along with several key federal agencies involved in addiction policy, research and treatment. The theme of this year’s course is “Emerging Problems and Advances in Addiction Treatment.” The target audience is addiction physicians, pain specialists, family physicians, nurses, and physician assistants.

“As important as it is for education, it also is an opportunity to have some bonding among addiction specialists,” said Dr. Litten, Associate Director, Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism. “People attend to learn the latest findings. It is for everyone at all levels.”

Sessions in the course are

  • Emerging Drugs of Abuse: Bath Salts and Synthetic Canabinoids
  • Alcohol Pharmacotherapy: Translation and Barriers to Use
  • Opioids: Can’t Live Without Them, Learning to Live Safely With Them
  • Screening and Drug Testing
  • Changing Marijuana Laws: Where Do We Go From Here?
  • Behavioral Intervention in Addiction Treatment

The Opening General Session of the course will review the ASAM clinical guidelines and standards, updated ASAM criteria, and updated standards for addiction physicians being developed by the ASAM Practice Improvement and Performance Measurement Action Group.

A highlight of every State of the Art Course is special addresses by directors of federal agencies that help ASAM organize the course—the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and the Substance Abuse and Mental Health Services Administration. The addresses will be followed by question-and-answer sessions with the directors, Dr. Litten said.

“People attend this course because they are interested in knowing what’s coming down the road,” he said. “Treating addiction is complex; one treatment does not work for everybody. Clinicians are looking for tools to help them treat these patients. Clinicians want to do a better job, and coming to a course like this helps them learn the latest. It also gives them hope that they may have better treatments five or 10 years down the road.”

Ruth Fox Scholarship Recipients to Be Recognized

The six recipients of Ruth Fox scholarships and donors to the Ruth Fox Memorial Endowment Fund were recognized at an invitation-only reception Friday night.

The Ruth Fox Memorial Endowment fund was established in 1990 to raise $10 million to support the society in times of need or for special projects, said Andrea Barthwell, MD, FASAM, Incoming Chair of the committee that oversees the fund. The fund is kept separate from ASAM’s operating fund and it has reached about half of its fundraising goal.

“The endowment fund helps ensure the survival and vitality of the society,” Dr. Barthwell said. “It has loaned ASAM funds through the ups and downs of the recent economy so the society can meet its goals of improving physician education, advocacy, and practice support for addiction medicine.”

Since its inception, 98 percent of the endowment fund’s principal has come from ASAM members to achieve those goals.

“We wanted to offer education for non-addiction physicians,” Dr. Barthwell said of what has been accomplished through the Ruth Fox Memorial Endowment Fund. “We wanted to develop residency and fellowship programs in this area. We also wanted to provide practice support to other practice arenas where people were dealing with alcoholism and other addictions. Lately, we wanted to deal with method of payment so we would have adequate insurance reimbursement for the services we provide.”

The fund also has been used to encourage fellows and residents to attend the Med-Sci Conference by not charging those young professionals ASAM dues or registration fees for the conference. Eventually, the Ruth Fox Scholarship Committee was established to fund scholarships using a percentage of the interest earned on the endowment fund’s principal. Since 2002, 65 scholarships have been funded, and six scholarships have been awarded this year.

“We have a process where people apply and are reviewed by a committee,” Dr. Barthwell said of the scholarship applications. “During this reception, the scholars get to meet the most supportive and senior members of ASAM.”

“This is a way for us to see what our contributions have done to support new people in the field and to acknowledge people who are continuing to join our numbers and support this fund.”

This year’s Ruth Fox Scholars 

R. Joel Bush, MD, Addiction Medicine Fellow at the University of Maryland, Baltimore, is a primary care physician who is in U.S. Army. “I will be able to use the learning at the ASAM conference to solidify my understanding of addictive disorders and propagate that knowledge to my colleagues within the military, helping to spread addiction medicine.”

Elizabeth Bulat, MD, Livonia, Mich., is a senior internal medicine resident who will start an addiction medicine fellowship July 1. “During my internal medicine residency, while setting up an addiction medicine elective at my program, I researched different learning opportunities for residents to learn about the diagnosis and treatment of alcoholism and other drug dependencies.”

Clifford Cabansag, MD, is an addiction fellow at the Cincinnati Veteran’s Administration Medical Center and the University of Cincinnati Department of Psychiatry. “As part of an addiction medicine rotation during my intern year, we visited the local methadone clinic. As soon as I stepped on to the grounds, I felt the sensation that this was almost sacred ground. This was the physical space where people were literally fighting for their lives. This epiphany culminated in my acceptance into an ABAM-accredited fellowship. By attending this conference, I hope to learn as much as  I can so as to be able to provide better care for our patients and assist others in doing the same.”

Elina Chernyak, DO, University Heights, Ohio, is a primary care physician. “Through the course of my work, I’ve discovered an inseparable correlation between family practice and treating addiction. It’s a symbiotic relationship that works through both clinical and practical means that can yield significant benefits for the patient.”

Yelena Chorny, MD, MSc, is an addiction medicine fellow at the Center for Addiction and Mental Health, University of Toronto, who trained in family medicine and plans to combine her work in both fields. “I would like to help increase training so family physicians have more of a screening and identification role and have a backup with someone who has more training in addiction. That is lacking.”

Michael Dekker, DO, is a psychiatric resident who will soon start a fellowship at Boston University in addiction psychiatry. “I think that the Ruth Fox Scholarship will be extremely helpful at this early point in my career because it will provide the opportunity to start to develop relationships with experts in the field.

Case-based Session to Feature Addiction Care Pearls for Primary Care

A patient complains of difficulty with concentration. Is the culprit attention deficit hyperactivity disorder or substance abuse? Another patient has hypertension and obesity, and consumes quite a bit of alcohol. Might the alcohol be triggering the hypertension and obesity? Those are examples of cases two primary care addiction specialists will present during Workshop 11 “Improving Addiction Care in Primary Care” from 10:15 a.m. to 12:15 p.m. today in Continental B, lobby level of the Hilton Chicago.

“We will address issues that primary care doctors deal with in their patents involving potential substance abuse,” said speaker Norman Wetterau, MD, FASAM, Addiction Medicine Specialist and Family Physician, Tri-County Family Medicine, Dansville, N.Y. “We will ask the audience how they would approach the cases and come up with the treatment approach, though we will offer insights and recommendations.”

Bruce Maslack, MD, Medical Director, St. Mary’s Health Care Addiction Services, Amsterdam, N.Y., also a speaker, said, “We believe a case-based approach will make this information memorable and applicable to practice.”

The key to resolving a patient’s medical problem may be to address that individual’s alcohol use, Dr. Wetterau said.

“Whether it’s sleep problems, depression, stomach pain, or hypertension, the doctor needs to connect the alcohol to the specific problem,” he said. “The patient does want to know what is causing the problem. In cases where alcohol is involved, the brief intervention is effective, and it doesn’t take that much time.”

Dr. Wetterau also will describe how to make a “no” answer into a “yes” answer. Instead of telling a patient, “No, I will not prescribe an opioid for pain,” a more effective approach is to say, “We have something I believe will work better for you.” That turns a negative into a positive and guides the patient toward addressing the pain’s source via physical therapy, physical activity, or an antidepressant.

An area ripe for redirection involves neurostimulants. Dr. Maslack will present the latest data from the University of Maryland on their use for attention deficit hyperactivity disorder. Other patients seek these neurostimulants for neurological enhancement as a means to improve themselves.

“We have an epidemic of prescribing these medications for patients who are having concentration or behavioral problems,” he said. “We are not really assessing that and screening for the patient who might have an alcohol or drug problem masking as a behavioral problem. I would like primary care physicians to look at this carefully in their practices.”

When substance use issues surface with patients, Dr. Maslack encourages primary care physicians not to abandon patients by referring them out of their practices entirely, essentially firing the patient.

“We are trying to help primary care physicians see a different

approach to patients with addiction,” he said. “Often, patients with substance use issues are not the ones we see in addiction treatment programs. They have problematic use of these substances that we may be able to do something about through a brief intervention and advice.”

Dr. Wetterau will advise primary care physicians how to get paid appropriately for these services by applying the correct evaluation and management (E/M) codes. He will teach how to upcode when the patient presents at least three problems or when a problem is unstable. For example, if a patient on buprenorphine also complains of anxiety and uses tobacco, those are three problems the physician will address, document, and subsequently upcode. As for unstable conditions, substance-positive urine tests, reports of substance-use slips, or development of constipation are indicative of instability in treating the ongoing substance use. Therefore, the primary care physician may upcode because of the additional time it will take to resolve.

“With the Affordable Care Act, we are implementing new codes and ways to bill for services in primary care settings for patients with addiction,” Dr. Maslack said. “For that reason, we need to know how to handle coding for these situations.”

Addiction Medicine Facing Increased Interaction With Primary Care

Collaboration among health care specialties for better efficiency is a cornerstone of health system reform, so a symposium today will look at ways addiction physicians can play a more prominent role in working with primary care physicians to coordinate and improve care.

Symposium 10, “The Addiction Medicine/Primary Care Interface: Models of Integrated Care,” sponsored by the National Institute on Drug Abuse, will feature presentations examining standards of care for treating chronic pain, integrating HIV care with alcohol and drug treatment, and the role of addiction treatment centers in the patient-centered medical home. The session will be presented from 8 to 10 am today in Continental A on the lobby level of the Hilton Chicago.

“We will review the research that has been done about the benefits of integrated care for patients in addiction and primary care,” said Judith Martin, MD, who helped organize the session and is a presenter. “We will focus on one major area of integration, which is chronic pain treatment with opiates. We also will talk about the patient-centered medical home and health home concepts, and whether addiction treatment sites can be patient-centered medical homes and/or health homes for patients with complex conditions who have addictions.”

Alexander Walley, MD, MSc, will discuss health and addiction-related outcomes of providing substance abuse treatment in conjunction with medical care, HIV prevention, and risk reduction counseling in an innovative primary care setting in Boston. He is Medical Director of the Massachusetts Department of Public Health’s Opioid Overdose Prevention Pilot Program.

“He is a pioneer on HIV prevention, testing, and treatment, and addressing overdoses in the community,” Dr. Martin said of Dr. Walley. “He is going to talk about integrating HIV care with alcohol and drug treatment, and review the research base behind integrated care. A number of research papers show that integrated care is better in various ways.”

Daniel Alford, MD, MPH, FASAM, FACP, will address how to safely prescribe opioids for chronic pain treatment in primary care. He is Associate Professor of Medicine at Boston University School of Medicine and Medical Director of Office-based Opioid Treatment at Boston Medical Center.

“Dan does a lot of physician education on this topic,” Dr. Martin said, “including having a patient-provider agreement, monitoring progress in treatment, and early detection of patients who are not thriving with opiate treatment in order to offer alternative care, in particular monitoring behaviors that are concerning and might indicate loss of control and addiction to opiates.”

The strategy is similar to Risk Evaluation and Mitigation Strategy (REMS) education, focused on primary care physician education, she said.

In her presentation, Dr. Martin, Medical Director of Substance Abuse Services, Department of Public Health, City and County of San Francisco, will discuss the patient-centered medical home (PCMH) and the health home for Medicaid, and what it takes for addiction treatment centers to become the PCMH for addiction medicine patients.

“The patient-centered medical home is typically a primary care site where the primary care team is led by a physician, and then a lot of coordination or integration of psychosocial and other services also happens on site,” she said. “The way a methadone clinic could do that, which our clinic, the Turk Street Clinic, did, is to have a community clinic license and have both types of clinics under the same roof with the same staff.”

Dr. Martin will describe an effort to improve retention and reduce hospital days for older patients on methadone maintenance using a team care approach where drug counselors became health coaches for medically vulnerable patients.

“We hope those who attend our symposium will share their own experiences in managing care transitions and access to primary care for their addicted patients.”

Session to Examine International Addiction Treatment Trends

The latest trends in addiction treatment outside the United States will be examined in presentations today during Symposium 11, “International Perspectives on Addiction Medicine.”

The session, presented from 10:15 a.m. to 12:15 p.m. in Continental A on the Lobby Level of the Chicago Hilton, is sponsored by the International Society of Addiction Medicine (ISAM). It will feature presentations from two addiction specialists from Iceland, as well as reports on work in the United Kingdom and Russia.

“In addition to providing a perspective on new research that emerged internationally, the session also will give attendees an idea of what practice is like overseas, and that puts a lot of what we do into perspective,” said presenter Marc Galanter, MD, FASAM, Professor of Psychiatry and Director of the Division of Alcoholism and Drug Abuse, New York University Medical Center.

ISAM was developed to help establish projects to integrate the most recent research findings for presentations to clinicians worldwide and to promote further research. Iceland is of particular interest because it is an island of about 325,000 people that is relatively homogenous, said Jag Khalsa, PhD, MS, Chief of the Medical Consequences Branch, National Institute on Drug Abuse.

Thor Tyrfingsson, MD, Medical Director of Treatment at SAA, the National Center of Addiction Medicine, Iceland, and Ingunn Hansdottir, PhD, Assistant Professor at the University of Iceland, will discuss the importance of international connections on the island in a unique situation.

“We had a collapse of the financial system in Iceland in 2008. That has had a huge impact on our living and social conditions,” Dr. Tyrfingsson said. “There has been tremendous change in our society. I will talk about how that has affected stimulant abuse in Iceland.”

In the weak economy, the use of the three leading illegal drugs—amphetamines, cocaine, and ecstasy—declined, probably because people had less money to buy drugs, he said

“What we found was that people started to use methylphenidate instead of illegal drugs,” Dr. Tyrfingsson said. “What happened was that methylphenidate was used more often per day. This drug that we used to think was harmless [to treat ADHD] can be used compulsively and dangerously, as it has been used in Iceland.”

Iceland has a health care system where the government pays for most of the costs of medications, so citizens began taking advantage of the increase in ADHD diagnoses.

“They emphasize diagnosing ADHD better for children, adolescents, and grown-ups, and try to monitor the prescriptions,” Dr. Tyrfingsson said. “A lot of money has gone out to the community. They spend more on that drug in Iceland than for detoxification for all alcohol and drug addiction.”

Using a grant from the U.S. National Institute of Drug Abuse, Iceland has increased its data collection to share internationally.

“If you follow the news, you know about the financial crisis in Europe,” Dr. Tyrfingsson said. “The question is what happens in that social situation. Iceland is a small laboratory to research what happens to drug addicts in a country that goes into a financial crisis.”

Another speaker in the session will be George Woody, MD, Professor, Department of Psychiatry, University of Pennsylvania, who is involved in collaborative research worldwide. He will discuss addiction treatment in Russia.

Brian Hurley, MD, a resident in the adult psychiatry residency training program at Massachusetts General Hospital and McLean Hospital, will discuss the treatment of opioid addiction in the United Kingdom.

New Website Developed to Teach Trainees About Addiction Medicine Specialty

A new website aimed at trainees has been developed to increase awareness of the addiction medicine specialty and explain how to become an addiction medicine physician.

The site, which can be accessed from the ASAM website under the Resident and Student Center link, was launched at the start of the Medical-Scientific Conference by the ASAM Physicians in Training Committee.

“It is like ‘Addiction Medicine 101,’” said Robbie Bahl, MD, chair of the committee. “This is a reference site and an introduction for people who are unfamiliar with the specialty.

“We developed a flow chart that is currently on the website. It takes you through the steps of the training process, with links to official board certification sites and other pertinent references. The goal of the committee and the website is to get more trainees involved, join ASAM, have them come to the ASAM conferences, and to learn more about the specialty.”

The website is aimed at medical students, residents, and fellows, but also has information that is relevant to attending physicians interested in the specialty, he said.

“The site discusses how you can pursue the specialty from the standpoint of a medical student, a resident, or an attending physician,” Dr Bahl said. “It is a reference for anyone wanting to know more about the new and upcoming specialty and how to get board certified. It is for all physicians, but we are trying to focus on younger trainees.”

The website has several important links, including to the American Board of Addiction Medicine and the main ASAM website. Information and resources regarding the basics of the specialty are easy to find, said Dr. Bahl, an Addiction Medicine Fellow at The Addiction Institute of New York.

See Every Med-Sci Course at the e-Live Learning Center

e-LiveWith many overlapping sessions at the Med-Sci Conference, it is impossible to attend every education course you want, but the ASAM e-Live Learning Center allows you to see those courses 24 hours a day, seven days a week electronically after the conference.

The e-Live Learning Center also allows attendees to track and claim continuing medical education (CME) credits and see many other ASAM live courses presented throughout the year. Courses from this year’s conference will be posted to the site about 30 days after the end of Med-Sci.

To access the e-Live Learning Center, go to the ASAM website’s Education tab. It also is now available on iPads and other mobile devices, and uses a newly integrated media player to improve the learning experience.

Courses from this year’s conference are available for free to all Med-Sci Conference full registrants. The e-Live Learning Center contains more than 200 hours of audio-synchronized PowerPoint presentations and materials from 2011 and 2012 ASAM live courses. Courses that are free to view are designated with an icon on the site.

ASAM members and Med-Sci attendees do not even have to register to use the site. Their logon for the site is simply an email address and last name, and users can create their own passwords after logging in.

For more information about the e-Live Learning Center, go the Education Help Desk in the Registration area, where a member of the Education team can demonstrate the center or help you claim continuing medical education credits. The desk is open during regular Med-Sci Conference registration hours.

After the conference, customer service can be reached at (289) 695-5400 or multimediasupport@multiview.com.

Data Grow to Guide Treatment of PTSD, Substance Abuse

Forty years after the end of the Vietnam War and more than a decade after the start of U.S. fighting in Iraq and Afghanistan, the health care system has collected more data than ever about post-traumatic stress disorder (PTSD) and substance use disorder related to PTSD. This data and how it affects treatment will be discussed in a workshop today.

Workshop 10, “Substance Abuse and PSTD: Chicken First or an Egg?” will be presented from 8 to 10 a.m. in the Waldorf Room on the third floor of the Hilton Chicago by Charles Marmar, MD, Chair of the Department of Psychiatry, New York University Langone Medical Center.

Among the points Dr. Marmar will discuss are how the rate of co-occurrence is high, how the two disorders are connected, how gender differences have been minimized in recent years, and how patients with the disorders should be treated.

“Each disorder increases the risk for the other,” Dr. Marmar said. “If you have PTSD from war or other life events, you are more likely to use alcohol and drugs, in part as way to cope with the pain of your traumatic stress. The commonest form of self-medication is self-initiating drug and alcohol use. Alcohol use is particularly problematic. It often takes the form of binge drinking or drinking excessively to fall asleep at night. There may be other forms abuse, such as sedatives or prescribed drugs.”

If a patient has both disorders, it is best to treat both disorders at the same time, he said.

“The data available say that by treating the PTSD you will reduce drinking days or risk of alcohol and drug use generally,” Dr. Marmar said. “But if somebody has both PTSD and alcohol or drug use, and you treat the alcohol and drug use alone and don’t treat the PTSD, it generally does not reduce the level of PTSD until you provide the effective treatment of PTSD.”

Much of the information on treating PTSD and substance abuse comes from the National Vietnam Veterans Readjustment Study conducted in 1985-86. A 25-year follow-up, the National Vietnam Veterans Longitudinal Study, was just completed, and researchers will be modeling the risk of early death in the cohort.

“We are now asking questions like ‘Does PTSD alone or alcohol or drug use alone increase the risk of premature death in the Vietnam generation?’ ‘Does the combination of PTSD and alcohol or drug use lead to an early death?’ We should have the ability from that study to compare veterans with and without alcohol or drug use in their health, and mortality and morbidity,” Dr. Marmar said. “We have a well-designed study with the ability to allow us to answer the questions about the long-term health risks of PTSD and alcohol or drug use when it’s a war.”

That data is being supplemented by data of veterans of the Afghanistan and Iraq fighting treated in the Veteran’s Administration system and more data from the general public. That data show fewer differences that used to be seen between men and women.

“Rates of binge drinking between males and females are similar, whereas in the general population, men historically have been larger binge drinkers than women,” Dr. Marmar said. “That is changing in culture if you look at college students; binge drinking may be equally high among female students, which is a generational change in culture.”

For treatment, the use of cognitive behavior therapy will be addressed, as well as using drugs such as sertraline and disulfiram, and newer drugs, including topiramate and naltrexone.

“We will talk about the overall general principles of treatment,” Dr. Marmar said. “You want to avoid drug dependence, and it is important to normalize sleep.”

NIDA Director: Research Shows Substance Disorder a Chronic Disease

Nora Volkow, MD, receives the John P. McGovern, MD, Award from Louis E. Baxter, Sr., MD, FASAM, ASAM Acting Immediate Past President.

Nora Volkow, MD, receives the John P. McGovern, MD, Award from Louis E. Baxter, Sr., MD, FASAM, ASAM Acting Immediate Past President.

Nora Volkow, MD, has had a respected career as a leading researcher in how addiction affects the brain, and as Director of the National Institute on Drug Abuse she has focused her efforts on how some brains react to drugs of abuse. Saturday, she shared some of her scientific findings when she delivered the John P. McGovern, MD, Award and Lecture on Addiction and Society.

“My main mission is to change the culture and the view of substance use disorder so it is accepted as a medical disease,” Dr. Volkow said when she delivered her address during the ASAM Annual Awards Luncheon. Public perception that addiction is a social, moral, or criminal problem is shifting largely thanks to Dr. Volkow’s landmark work in defining addiction as a disease of the brain. She said she has used her studies to “come to understand the abnormalities of the brain” of people when they use drugs of abuse.

Drugs of abuse increase DA (dopamine) in the nucleus accumbens, which is believed to trigger the neuroadaptions that result in addiction, reported Dr. Volkow, who has used brain imaging to investigate the effects of drugs of abuse. Her studies have documented changes in dopamine production that affect functions in the frontal brain regions associated with motivation, drive and pleasure in addiction.

“How are different brain circuits regulated by DA involved in addiction?” she asked.

She answered that question by showing that cocaine abusers had lower dopamine increases and reduced reinforcing responses to methylphenidate. Brain scans of alcoholics also showed a decreased dopamine release and decreased reinforcing responses to methylphenidate.

Memory/conditioning studies in rats have shown that when they received a neutral stimuli with a drug, it elicited dopamine increases and reinstated drug self-administration. This demonstrates the relationship between increased dopamine production and drug craving when there is an underlying addiction.

In human subjects, cocaine abusers who were shown a video of cocaine scenes had decreased binding of [11C]raclopride, presumably a result of dopamine increases. This showed that cue-induced increases in dopamine are associated with craving.

This is “fundamental” in the understanding of how addiction affects the brain , Dr. Volkow said.

“This means a person addicted to a drug will have an automatic release of dopamine in response to environmental cues or what we understand as craving,” she said, and this craving “activates the urge to get a drug.”

In a study of addiction and the motivation and executive control circuits of the brain, changes in dopamine function were linked with disruption of frontal lobe activity. This was assessed by multiple tracer studies that evaluated the dopamine D2 receptors and brain glucose metabolism in subjects with addiction. Researchers found that the overexpression of dopamine D2 receptors reduces alcohol-self-administration.

“This makes us realize that these are not diseases where you have abnormality in one brain region,” Dr. Volkow said. “Addiction is a disease that disrupts multiple functional networks that are crucial … in making a decision.”

With this knowledge, researchers now can look for ways to counter what is happening to the brains of individuals with addictions, she said.

“It identifies the need for multiple approaches that will enable us to strengthen those circuits that are weakened by addiction,” Dr. Volkow said. “We may ultimately be able to use more medications to strengthen them.

“Substance disorder is a chronic disease. And it needs to be treated that way.”