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1
 Substance Use Disorder

Frates B, Bonnet JP, Joseph R, Peterson JA. Substance Abuse. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy Learning;
2021:397-430.
Disclaimer
•ACLM abides by strict professional and clinical standards with
published evidence-based positions and guidelines on the therapeutic
approaches that make up Lifestyle Medicine. These standards are
posted for public review at
www.lifestylemedicine.org/aclm-standards.
•Members and certified professionals are authorized to use ACLM
branding, presentations and approved messaging for the
enhancement of our stated mission and vision. ACLM is not
responsible nor accountable for individual deviations,
misrepresentations and misinterpretations.
•Faculty members utilizing this slide deck must acknowledge any slides
or content that have been added as it may represent the viewpoint of
the presenter and not the viewpoint of ACLM.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 3

 Acknowledgements
Editors: Kaitlyn Pauly MS, RDN; Shannon Worthman; Monami Brierley

Reviewers: Brenda Rea MD, DrPH, PT, RD; Wayne Dysinger MD, MPH, FACLM; Amanda
McKinney MD; Susan Benigas, MS

This PowerPoint was created under the umbrella of the

Lifestyle Medicine Pre-Professional Member Interest Group

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 4

Learning Objectives
By the end of this module, participants will be able to:
• Define and categorize substance use disorders
•Identify the importance of substance use disorders
•Recognize the impact of substance use disorders on health
•Explain treatment options for various forms of substance
use disorders
•Formulate possible lifestyle interventions for substance use
disorders

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 5

 Guiding Questions
•What is substance use disorder?
•What are the signs and symptoms of substance use?
•What is the impact of substance use on society?
•What is the impact of substance use on health?
•What are common ways of treating substance use?
•What are barriers to treating substance use?
•What techniques can lifestyle medicine practitioners
use when dealing with patients who use substances?
Frates B, Bonnet JP, Joseph R, Peterson JA. Substance Abuse. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy
Learning; 2021:397.

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 Important Terms
•Drug addiction
•Drug dependence
•Drug overdose
•Drug tolerance
•Substance abuse
•Withdrawl

Frates B, Bonnet JP, Joseph R, Peterson JA. Substance Abuse. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy
Learning; 2021:398.

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 Addiction
•Gray areas
•Definitions vary
•Disagreement
•Confusion
•Controversy
•Inconsistency
•Frustration
•Passion
•Not a nice neat box

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Addictions
•Different Types
•Focus on smoking and alcohol
•Opioid (heroin, morphine, oxycodone, hydrocodone, pain
med prescriptions)
•Amphetamines (methylphenidate, cocaine, crack)
•Benzodiazepine (diazepam, alprazolam, lorazepam)
•How assessing addiction and substance use fits into
lifestyle medicine

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 9

Addiction
Addiction - compulsive need for and use of a habit-forming
substance (as heroin, nicotine, or alcohol) characterized by
tolerance and by well-defined physiological symptoms upon
withdrawal
-Merriam-Webster Dictionary

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 10

Tolerance
•The capacity of the body to endure or become less
responsive to a substance (such as a drug) or a physiological
insult especially with repeated use or exposure developed
a tolerance to painkillers
Merriam-Webster Dictionary

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Withdrawal
•The characteristic withdrawal syndrome for the given
substance
OR
•The given substance (or one in the same family) is taken to
relieve or avoid withdrawal symptoms.
•Specific signs and symptoms occurring after discontinuing
the given substance.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 12

 Dependence
•Physiological dependence if the person shows withdrawal
or tolerance
•This term is not used in the DSM V
•Substance Use Disorders

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Dependence
•1964- WHO introduced the term dependence to replace
“addiction” and “habituation.”
•Effort to reduce stigmatization of those suffering from this
disease.
•Terminology changed to Substance Use Disorder DSM V
•Dependence usually refers to physiological dependence if
the person shows withdrawal or tolerance

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 14

SUBSTANCE USE DISORDER

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Spectrum of Substance Use
Disorders
•Mild: 2-3 symptoms
•Moderate: 4-5 symptoms
•Severe: 6 or more symptoms

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The American Society of
Addiction Medicine — Disease
Model
•Addiction definition
•Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry.
•Dysfunction in these circuits leads to characteristic
biological, psychological, and social manifestations.
•This is reflected in an individual pathologically pursuing
reward and/or relief by substance use and other behaviors.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 17

The American Society of
Addiction Medicine — Disease
Model
•Like other chronic diseases, addiction often involves cycles
of relapse and remission.
•Without treatment or engagement in recovery activities,
addiction is progressive and can result in disability or
premature death

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 18

Is it chronic? always progressive?
•Not always
•Maturing out --- 15%
•Atypical use vs progressive use
•Gray areas, not black and white
•Not one size fits all
•You must get to know your client/patient

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 19

 ABCDE of Addictions
A - Inability to consistently Abstain
B - Impairment in Behavioral control
C - Craving; or increased “hunger” for drugs or rewarding
experiences
D - Diminished recognition of significant problems with
one’s behaviors and interpersonal relationships; and
E - A dysfunctional Emotional response

Definition of Addiction. In: American Society of Addiction Medicine; 2019.

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Three Cs
•Cravings - strong
•Consequences-serious
•Control - lost

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 Continuum of Addiction

Addiction. Wellesley Academics. http://academics.wellesley.edu/Chemistry/Chem102/addiction/addiction.html. Accessed July 20, 2020.

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 Risk Factors for Addiction
• Genetic
• 50% genetic
• Level of dopamine receptors
• Age, gender, ethnicity, co-morbid mental illness
• Environmental
• Drug availability
• Peer pressure, physical abuse, sexual abuse, witnessing violence
• Development
• The earlier a person begins using drugs, the more likely addiction will
develop
• Adolescent brains are still developing, especially frontal lobe, executive
function like decision making and judgment
NIDA. Drugs, Brains, and Behavior The Science of Addiction. National Institute on Drug Abuse website.
https://www.drugabuse.gov/sites/default/files/soa_2014.pdf. Accessed July 20, 2020.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 23

 Perspectives on Addiction from a
Former Lifestyle Medicine
Student
•Choice
•Lack of connection
•Michael Dwyer-Clonts, author and 1st Lifestyle Medicine
Class Student at Harvard
•Frenzied Mind
•“A complex and multidimensional brain disorder with
varying degrees of severity in which biological,
physiological, environmental, and psychological factors
interact with one another to enhance personal
susceptibility.”
Dwyer-Clonts M. A frenzied mind: clarifying the science behind addictive disorders. CreateSpace Publishing; 2015.

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Addiction and the Brain
•Reward
• Nucleus accumbens
• Dopamine
•Motivation
• Orbitofrontal cortex
•Memory
• Hippocampus, amygdala
•Cognitive control
• Prefrontal cortex, cingulate gyrus

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 DSM V
•“All drugs that are taken in excess have In common direct
activation of the brain reward system, which is involved in
the reinforcement of behaviors and the production of
memories.”

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 26

Reward Pathway

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 27

 Dopamine

NIDA. Drugs and the Brain. National Institute on Drug Abuse website.
https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain. July 10, 2020 Accessed July 14, 2020.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 28

 It is not only drugs that have
effects on the reward system

Volkow ND, Wang G-J, Tomasi D, Baler RD. The addictive dimensionality of obesity. Biological psychiatry. 2013;73(9):811-818.

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Addiction and the Brain
•Reward
• Nucleus accumbens
• Dopamine
•Motivation
• Orbitofrontal cortex
•Memory
• Hippocampus, amygdala
•Cognitive control
• Prefrontal cortex, cingulate gyrus

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 30

 Orbitofrontal---Motivation
Prefrontal---Control

The Neuroscience of Being ‘Us’; the cortex and emotion. Alchemy Therapies.
http://www.alchemytherapies.co.uk/2016/03/18/the-neuroscience-of-being-us-the-cortex-and-emotion/. Published 2016. Accessed July 17, 2020.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 31

 Hippocampus---Memory

Villalba C. Overcoming addiction: Paths toward recovery. Harvard Health Publications; 2008.
AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 32
 Schematic

Nucleus Prefrontal cortex

Accumbens

Orbitofrontal cortex

Hippocampus
Volkow ND, Wang G-J, Fowler JS. The addicted human brain: insights from imaging studies. J Clin Invest.
2003;11(10):1444-1451.
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 Neurotransmitters:
involved in substance use
•Stimulants - activate Dopaminergic (DA) pathway to most
extreme degree.
•Ethanol, opioids, and nicotine have effects through
activation of opioid receptors.
•Other neurotransmitters associated with the pleasure and
addiction include GABA and serotonin.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 34

LIVE AND LEARN

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 35

Words of Wisdom – Empathy
“No one cares how much you know,
until they know how much you care.”
- Teddy Roosevelt

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THE SUBSTANCES OF SUBSTANCE USE DISORDER

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 Addictions and DSM V
Substance Related and Addictive Disorders
•Tobacco-Tobacco Use Disorder
•Alcohol-Alcohol Use Disorder
•Opiates-Opioid Use Disorder
•Caffeine-Caffeine-Related Disorder
Non substances Related Disorders
•Gambling
Conditions for Further Study
•Internet Gaming Disorder
Binge Eating Disorder (New to DSM V)
Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Non-Substance Addictive
Behaviors
• DSM V = Gambling Disorder
• Other conditions included in DSM V =
• Internet gaming disorder (a condition requiring further study)
• Chinese Government has labeled it an addiction. Treatment in place.
• Other conditions considered =
• Hypersexual Disorder (HD)
• Sexual Addiction and Compulsivity. 2013;20:27-47
• Exercise
• Int. J. Environ. Res. Public Health. 2011;8:4069-4081
• Shopping
• Food or Eating
• “At this time there is insufficient peer-reviewed evidence to establish the diagnostic
criteria and course descriptions needed to identify these behaviors as mental health
disorders.”

Potenza MN. Non-substance addictive behaviors in the context of DSM-5. Addictive behaviors. 2014;39(1).

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 39

 ALCOHOL

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 40

Alcohol
•Good and bad
•A matter of quantity
•National Institute on Alcohol Abuse and Alcoholism (NIAAA)

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 41

American Heart Association and
Alcohol
•1 drink for woman
•2 drinks for man
•Women have less alcohol dehydrogenase (ADH) in their
stomach linings and thus metabolize only a small amount of
alcohol in their stomachs. The rest goes into the blood
stream. Thus, ETOH in women has about twice the effect as
that in men.
Recommendations:
•If you don’t drink, don’t start.
•If you drink, limit yourself to 1 for women and 2 for men.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 42

Alcohol Metabolism
Alcohol Aldehyde
Dehydrogenase Dehydrogenase

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 43

Alcohol Serving Sizes
•12 ounces of regular
beer, which is usually
about 5% alcohol
•5 ounces of wine, which
is typically about 12%
alcohol
•1.5 ounces of distilled
spirits, which is about
40% alcohol

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 44

Binge Drinking
•Binge drinking, for a typical adult, is defined as:
• Consuming five or more drinks in about 2 hours for men,
or four or more drinks for women.

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 CAGE Questionnaire
•Have you ever felt you should Cut down on your drinking?
•Have people Annoyed you by criticizing your drinking?
•Have you ever felt bad or Guilty about your drinking?
•Have you ever had a drink first thing in the morning to steady
your nerves or to get rid of a hangover (Eye opener)?
•Scoring:
•Item responses on the CAGE are scored 0 or 1, with a higher
score an indication of alcohol problems. A total score of 2 or
greater is considered clinically significant.
Ewing JA. Detecting alcoholism: the CAGE questionnaire. Jama. 1984;252(14):1905-1907.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 46

 Alcohol Facts
•In 2018, how many adults 18 years old or older reported that
they drank alcohol at some point in their lives.
86.e%
•What percent drank alcohol in the past year?
70%
•What percent drank alcohol in the past month?
55.3%

National Institutes of Health. (2017). Alcohol facts and statistics.

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 Drinking Levels—low risk drinking
•A major nationwide survey of
43,000 U.S. adults by the
National Institutes of Health
shows that only about 2 in 100
people who drink within both
the single-day and weekly
limits below have alcoholism or
alcohol abuse

What are the different drinking levels? National Institute on Alchol Abuse and Alcholism
http://rethinkingdrinking.niaaa.nih.gov/isyourdrinkingpatternrisky/whatslowriskdrinking.asp. Accessed July 15, 2020.

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 At risk drinking
•Men: More than 4 drinks on • The more drinks on any day and the
more heavy drinking days over time, the
any day or more than 14 per greater the risk—not only for alcoholism
week and alcohol abuse, but also for other
health and personal problems.
• 1 heavy drinking day a month
•Women: More than 3 drinks
• 1 in 5 has alcohol abuse
on any day or more than 7
per week • 1 heavy drinking day a week.
• 1 in 3 has alcohol abuse
• 2 or more heavy drinking days a week.
What are the different drinking levels? National Institute on Alchol Abuse and Alcholism • 1 in 2 has alcohol abuse
http://rethinkingdrinking.niaaa.nih.gov/isyourdrinkingpatternrisky/whatslowriskdrinking.asp. Accessed July 15, 2020.

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 Alcohol Use Disorder (AUD) by
DSM V
A problematic pattern of alcohol use leading to clinically
significant impairment or distress, as manifested by at
least two of the following, occurring within a 12-month
period.
1) Alcohol is often taken in larger amounts or over a longer
period than was intended.
2) There is a persistent desire or unsuccessful efforts to cut
down or control alcohol use.

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Alcohol Use Disorder Continued
3) A great deal of time is spent in activities necessary to
obtain alcohol, use alcohol, or recover from its effects.
4) Craving, or a strong desire or urge for alcohol
5) Recurrent alcohol use resulting in a failure to fulfill major
role obligations at work, school, or home.
6) Continued alcohol use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of alcohol.

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Alcohol Use Disorder Continued
7) Important social, occupational, or recreational activities
are given up or reduced because of alcohol use.
8) Recurrent alcohol use in situations in which it is physically
hazardous.
9) Alcohol use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem
that is likely to have been caused or exacerbated by alcohol.

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Alcohol Tolerance
10) A need for markedly increased amounts of alcohol to
achieve intoxication or desired effect
Or
A markedly diminished effect with continued use of the same
amount of alcohol

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Alcohol Withdrawal
11) The characteristic withdrawal syndrome for alcohol
Or
Alcohol (or a closely related substance, such as a
benzodiazepine) is taken to relieve or avoid withdrawal
symptoms.

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Criteria for Alcohol Withdrawal
A) Cessation of alcohol use that has been heavy and prolonged.
B) Two or more of the following, developing within several hours to a
few days after cessation of (or reduction in) alcohol use
• Autonomic hyperactivity (sweating, HR 100)
• Increased hand tremor
• Insomnia
• Nausea or vomiting
• Transient visual, tactile, or auditory hallucinations or illusions.
• Psychomotor agitation
• Anxiety
• Generalized tonic-clonic seizures
Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Alcohol Intoxication
A. Recent ingestion of alcohol
B. Clinically significant problematic behavioral or
psychological changes (e.g. inappropriate sexual or
aggressive behavior, mood lability, impaired judgment) that
developed during or shortly after, alcohol ingestion.

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Alcohol Intoxication
C. One (or more) of the following signs or symptoms developing during,
or shortly after, alcohol use:
• 1. slurred speech
• 2. incoordination
• 3. unsteady gait
• 4. nystagmus (side to side movements of the eyes)
• 5. impairment in attention or memory
• 6. stupor or coma
D. The signs or symptoms are not attributable to another medical
condition and are not better explained by another medical disorder,
including intoxication with another substance.
Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Treatment Options
•Alcoholics Anonymous (AA)
•Secular Organizations for Sobriety (SOS)
•SMART Recovery
•Women for Sobriety
•Working with a therapist
•Inpatient Rehabilitation programs

Shaffer H. Overcoming Addiction: Finding an effective path toward recovery. 2017.

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 FDA Approved Medications
Disulfiram
•Causes unpleasant effects (nausea, vomiting, flushing, and
others) from drinking alcohol
•Blocking acetaldedyde dehydrogenase so acetaldehyde builds
up.
Naltrexone (oral-short acting and injection-long acting)
•Reduces pleasurable effects of alcohol; reduces cravings
•Antagonist effect on opioid receptors
Acamprosate
•Reduces unpleasant effects of abstaining from alcohol
•Agonist effect on GABA
Shaffer H. Overcoming Addiction: Finding an effective path toward recovery. 2017.

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The Importance of the Social
History
•Social History
•Cigarettes
•Alcohol
•Sex

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 60

THE IMPACT OF ALCOHOL ON HEALTH

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 61

 Alcohol and its Effects on the
Brain
•Alcohol can produce detectable impairments in memory
after only a few drinks and, as the amount of alcohol
increases, so does the degree of impairment.
• Large quantities of alcohol, especially when consumed
quickly and on an empty stomach, can produce a blackout,
or an interval of time for which the intoxicated person
cannot recall key details of events, or even entire events.

Alcohol Alert. U.S. Department of Health & Human Services. https://pubs.niaaa.nih.gov/publications/aa63/aa63.pdf. Published 2004. Accessed June 22, 2020.

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 Alcohol and its Effects on the
Brain
•Alcohol can produce detectable impairments in memory
after only a few drinks and, as the amount of alcohol
increases, so does the degree of impairment.
• Large quantities of alcohol, especially when consumed
quickly and on an empty stomach, can produce a blackout,
or an interval of time for which the intoxicated person
cannot recall key details of events, or even entire events.

Alcohol Alert. U.S. Department of Health & Human Services. https://pubs.niaaa.nih.gov/publications/aa63/aa63.pdf. Published 2004. Accessed June 22, 2020.

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 Brain Damage with
Chronic Alcohol Use Disorder
•The symptoms of Wernicke’s encephalopathy include mental
confusion, paralysis of the nerves that move the eyes (i.e., oculomotor
disturbances), and difficulty with muscle coordination.
•Thiamine deficiency (B1)
• meat and poultry; whole grain cereals; nuts; and dried beans, peas,
and soybeans.
•Korsakoff’s psychosis-a chronic and debilitating syndrome
characterized by persistent learning and memory problems (can’t
remember past events or create new memories)

Alcohol Alert. U.S. Department of Health & Human Services. https://pubs.niaaa.nih.gov/publications/aa63/aa63.pdf. Published 2004. Accessed June 22, 2020.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 64

 Schematic Drawing of the Human
Brain:
regions vulnerable to alcoholism-related abnormalities

Alcohol Alert. U.S. Department of Health & Human Services. https://pubs.niaaa.nih.gov/publications/aa63/aa63.pdf. Published 2004. Accessed June 22, 2020.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 65

 Damage
Drinking a lot over a long time or too much on a single
occasion can damage the body, causing problems including
HEART LIVER
•Cardiomyopathy – Stretching and •Steatosis, or fatty liver
drooping of heart muscle
•Alcoholic hepatitis
•Arrhythmias – Irregular heart beat
•Fibrosis
•Stroke
•Cirrhosis
•High blood pressure

Alcohol Alert. U.S. Department of Health & Human Services. https://pubs.niaaa.nih.gov/publications/aa63/aa63.pdf. Published 2004. Accessed June 22, 2020.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 66

 Damage
Drinking a lot over a long time or too much on a single
occasion can damage the body, causing problems including
PANCREAS IMMUNE SYSTEM
•Pancreatitis = a dangerous •Weaken your immune system, making
your body a much easier target for
inflammation and swelling disease.
of the blood vessels in the •Chronic drinkers are at risk for pneumonia
pancreas that prevents and tuberculosis than non drinkers.
proper digestion. • Drinking a lot on a single occasion slows
your body’s ability to ward off infections –
even up to 24 hours after getting drunk.
Alcohol Alert. U.S. Department of Health & Human Services. https://pubs.niaaa.nih.gov/publications/aa63/aa63.pdf. Published 2004. Accessed June 22, 2020.

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 Increase Risk of Developing Certain
Cancers
•Mouth
•Esophagus
•Throat
•Liver
•Breast

Alcohol Alert. U.S. Department of Health & Human Services. https://pubs.niaaa.nih.gov/publications/aa63/aa63.pdf. Published 2004. Accessed June 22, 2020.

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 CANNABIS

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 Cannabis Use
•Most commonly used illicit drug in the US
•Subjective “high”
•Carcinogens present in all smokes
•Medical marijuana approved to treat nausea and vomiting
associated with chemotherapy

Frates B, Bonnet JP, Joseph R, Peterson JA. Substance Abuse. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy
Learning; 2021:407.

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THE IMPACT OF CANNABIS USE ON HEALTH

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 Cannabis And Physical Health
•Increased risk of heart attack
•Expand blood vessels in eyes
•Increased blood pressure and heart rate
•Breathing problems
•Problems with child development
•Relax and enlarge breathing passages
•Short and long term effects on the brain
•Impaired body movements
Frates B, Bonnet JP, Joseph R, Peterson JA. Substance Abuse. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy
Learning; 2021:408.

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 Cannabis And Mental Health
•Altered senses and sense of time
•Anxiety
•Mood changes
•Depression
•Difficulty with thinking and problem solving
•Impaired memory
•Suicidal thoughts
•Reduced life satisfaction
Frates B, Bonnet JP, Joseph R, Peterson JA. Substance Abuse. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy
Learning; 2021:409.

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 TOBACCO

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Substances
•Nicotine

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 DSM V Tobacco Use Disorders
A problematic pattern of tobacco use leading to clinically
significant impairment or distress, as manifested by at least
two of the following, occurring within a 12-month period.
1) Tobacco is often taken in larger amounts or over a longer
period than was intended.
2) There is a persistent desire or unsuccessful efforts to cut
down or control tobacco use.

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Tobacco Use Disorders
3) A great deal of time is spent in activities necessary to
obtain tobacco, use tobacco, or recover from its effects.
4) Craving, or a strong desire or urge to use tobacco
5) Recurrent tobacco use resulting in a failure to fulfill major
role obligations at work, school, or home (e.g. interference
with work).
6) Continued tobacco use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of tobacco (e.g. arguments with
others
Association AP. Diagnostic about
and statistical tobacco
manual of mental use).
disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Tobacco Use Disorder
7) Important social, occupational, or recreational activities
are given up or reduced because of tobacco use.
8) Recurrent tobacco use in situations in which it is physically
hazardous (e.g. smoking in bed).
9) Tobacco use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem
that is likely to have been caused or exacerbated by tobacco.

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Tolerance with Tobacco Use
10) A need for markedly increased amounts of tobacco to
achieve the desired effect
Or
•A markedly diminished effect with continued use of the
same amount of tobacco

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Withdrawal from Tobacco
11) The characteristic withdrawal syndrome for tobacco
Or
•Tobacco (or a closely related substance, such as a nicotine)
is taken to relieve or avoid withdrawal symptoms.

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

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 Tobacco Withdrawal
A. Daily use of tobacco for at least several weeks.
B. Abrupt cessation of tobacco use, or reduction in the amount of
tobacco used, followed within 24 hours by four or more of the following
signs or symptoms.
• 1) Irritability
• 2) Anxiety
• 3) Difficulty concentrating
• 4) Increased appetite
• 5) Restlessness
• 6) Depressed mood
• 7) Insomnia
Staff M-W. Merriam-Webster's collegiate dictionary. Merriam-Webster; 2004.

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 Tobacco Withdrawal
C. The signs and symptoms in Criterion B cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning.
D. The signs or symptoms are not attributed to another
medial condition and are not better explained by another
mental disorder, including intoxication or withdrawal from
another substance.

Staff M-W. Merriam-Webster's collegiate dictionary. Merriam-Webster; 2004.

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 Effects of Smoking on the Body

Health Effects of Cigarette Smoking. Centers for Disease Control and Prevention.
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm#children. Published 2020. Accessed July 15, 2020.

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 Risks Associated with Smoking
Increased risk for coronary artery disease
•2-4 times
Increased risk for stroke
•2-4 times
Increased risk for lung cancer
•25 times

Health Effects of Cigarette Smoking. Centers for Disease Control and Prevention.
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm#children. Published 2020. Accessed July 15, 2020.

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 Smoking and Cardiovascular
Disease
•Even smoking 5 cigarettes a day puts you at increased risk
for signs of early cardiovascular disease.
•Smoking damages blood vessels.

Health Effects of Cigarette Smoking. Centers for Disease Control and Prevention.
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm#children. Published 2020. Accessed July 15, 2020.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 85

 Inflammation & Atherosclerosis

Atherosclerosis. National Heart, Lung, and Blood Institute. http://www.nhlbi.nih.gov/health/health-topics/topics/atherosclerosis/. Accessed July 15, 2020.

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 Chapter 8- Heart and Blood
Vessel Conditions and Stroke
•Layers of the artery
•First- in contact with the blood =
intima
•E cells= endothelial cells
•Second- middle- media
•SM cells= smooth muscle cells which
contract or relax
•Third- outermost= adventitia-
provides structural support, made of
Stein J, Silver JK, Frates EP. Life after stroke: the guide to recovering your health and preventing another stroke. Johns Hopkins University Press Baltimore, MD; 2006
connective tissue AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 87
 Effect of Cigarette Smoke on the
Arteries

Csordas A, Bernhard D. The biology behind the atherothrombotic effects of cigarette smoke. Nature Reviews Cardiology. 2013;10(4):219.

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 • E cells = bouncers, protection, gate keepers
• Oxidized LDL = food (salted potato chips)
• White blood cells (leukocytes, monocytes, macrophages) =
partiers
• Chemokines (cytokines, signaling proteins) = invitations to
smooth muscle cells to join party
• Atheroma or plaque = mess at the end of the party
Csordas A, Bernhard D. The biology behind the atherothrombotic effects of cigarette smoke. Nature Reviews Cardiology. 2013;10(4):219.

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 Smoking, hyperglycemia,
infection, oxidized LDL, and
hypertension

Elkind MS, Brown D, Worrall BB. Genetic and Inflammatory Mechanisms in Stroke. Neurology. 2006.

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 Metaflammation coined by Dr.
Gurkhan Hotamisligil
•1993 described this type of chronic
inflammation associated with obesity.
•Slightly increased pro-inflammatory markers
•Effects in lining of blood vessels throughout
body systematically and in internal organs.
•Perpetuate rather than resolve a disease by
disturbing the normal metabolic functioning and
causing dysmetabolism.
•Smoldering ashes as opposed to the raging fire
of acute
Ertunc ME, Hotamisligil GS. Lipid signaling and lipotoxicityinflammation.
in metaflammation: indications for metabolic disease pathogenesis and treatment. Journal of lipid research. 2016;57(12):2099-2114.

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Smoking and Lung Disease
•Smoking damages the air ways
and the alveoli in the lungs.
•It can cause: COPD
• Emphysema and Chronic
Bronchitis
•It can trigger asthma attacks
and make asthma worse.

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Smoking and Cancer
•Bladder •Oropharynx (includes parts of
the throat, tongue, soft palate,
•Blood (acute myeloid
and the tonsils)
leukemia)
•Pancreas
•Cervix
•Stomach
•Colon and rectum (colorectal)
•Trachea
•Esophagus
• Bronchus
•Kidney and ureter
• Lung
•Larynx
•Liver
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 How does smoking cause cancer?
•How many compounds are in •Nicotine
cigarettes? • addictive
•Over 4,000 •Carbon Monoxide
•Damage our cells • Poisonous gas

•Cause cancer •Tar

• Consists of several cancer-causing
•69 chemicals chemicals
• Handkerchief test

Smith A. The reasons why smoking is bad for you. Medical News Today. http://www.medicalnewstoday.com/articles/10566.php. Published 2020. Accessed July 15, 2020.

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 Examples of Ingredients
• Acetone – found in nail polish remover
• Acetic Acid – an ingredient in hair dye
• Ammonia – a common household cleaner
• Arsenic – used in rat poison
• Benzene – found in rubber cement
• Butane – used in lighter fluid
• Cadmium – active component in battery acid
• Carbon Monoxide – released in car exhaust
fumes
• Formaldehyde – embalming fluid
• Hexamine – found in barbecue lighter fluid
• Lead – used in batteries
• Naphthalene – an ingredient in moth balls
• Methanol – a main component in rocket fuel
• Nicotine – used as insecticide
• Tar – material for paving roads
Toluene
What's in a cigarette?•American - used to
Lung Association. manufacture paint
https://www.lung.org/quit-smoking/smoking-facts/whats-in-a-cigarette. Accessed July 17, 2020.

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 Quitting Smoking Helps
"Your risk for a heart attack drops sharply just 1 year after
you quit smoking.
After 2 to 5 years, your chance for stroke could fall to about
the same as a nonsmoker’s.
Within 5 years of quitting, your chance of cancer of
the mouth, throat, esophagus, and bladder is cut in half.
Risks for other conditions—including ulcer, peripheral
artery disease, and cancers of the larynx, lung,
and cervix—are reduced after quitting."
Benefits of Quitting. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/quit_smoking/how_to_quit/benefits/index.htm. Published 2020. Accessed
July 15, 2020.

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 Nicotine Replacement
Side-Effects
•Skin irritation (redness and
itching)
•Dizziness
•Racing heartbeat
•Sleep problems or unusual
dreams
•Headache
•Nausea
•Muscle aches and stiffness
Nicotine Replacement Therapy for Quitting Tobacco. American Cancer Society.
https://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-smoking/nicotine-replacement-therapy.html. Published 2017. Accessed July 15, 2020.

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 Symptoms of Nicotine Overdose
•Headache •Tremors (shaking)
•Nausea and vomiting •Confusion
•Belly pain •Disturbed vision and hearing
•Diarrhea •Weakness
•Agitation, restlessness •High blood pressure, which then drops
•Fast or irregular heartbeat •Dizziness or faintness due to low blood
pressure
•Cold sweat
•Seizures
•Pale skin and mouth
•Fast breathing in early poisoning,
•Weakness breathing may stop later
Nicotine Replacement Therapy for Quitting Tobacco. American Cancer Society.
https://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-smoking/nicotine-replacement-therapy.html. Published 2017. Accessed July 15, 2020.

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 FDA approved
medications for quitting smoking
•Chantix •Zyban
• Varenicline is an oral drug • Bupropion
• It competes with nicotine • Used in anti-depressant
from cigarettes for binding to • Wellbutrin
nicotine receptors in the
• Bupropion is a pill you take to
brain.
reduce your craving for tobacco.
• It blocks the stronger
• The exact mechanism is not
stimulation by nicotine.
entirely understood.
• Smokers do not experience
• It does not contain nicotine.
the full effect of smoking
while taking varenicline. • It decreases cravings and
withdrawal symptoms.
• FDA approved in 2006.
What Are the Medicines for Nicotine Withdrawal? http://www.webmd.com/smoking-cessation/bupropion-hydrochloride-zyban-for-quitting-smoking. Accessed July 15, 2020.

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 Who starts smoking and why?
•Teens •Anyone can become
•90% of smokers start addicted to nicotine.
smoking before 18. •The younger someone is
•People with parents or when they start smoking
friends who smoke the more likely they are to
become addicted.
•They just “wanted to try it.”
•They thought it was “cool”
to smoke.
Nicotine Replacement Therapy for Quitting Tobacco. American Cancer Society.
https://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-smoking/nicotine-replacement-therapy.html. Published 2017. Accessed July 15, 2020.

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 Secondhand Smoke
•More than 7,000 chemicals,
including hundreds that are
toxic and about 70 that can
cause cancer
•Since 1964, 2.5 million
nonsmokers have died from
exposure to secondhand
smoke.

Secondhand Smoke. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/basic_information/secondhand_smoke/index.htm. Accessed July 15, 2020.

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 The Effects of Secondhand
Smoke
•Nonsmokers who are exposed to secondhand smoke
increase their heart disease risk by
•25–30%.
•It is estimated that secondhand smoke exposure caused
nearly 34,000 heart disease deaths annually (during
2005–2009) among adult nonsmokers in the United States.
•Stroke is caused by exposure to secondhand smoke.

Secondhand Smoke. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/basic_information/secondhand_smoke/index.htm. Accessed July 15, 2020.

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 Treatment Options
•The spectrum
•Simple advice
•Intensive behavioral support and pharmacological
treatment.
•Medications currently approved by the US Food and Drug
Administration for smoking cessation include nicotine
replacement therapy (patch, gum, lozenge, inhaler, and nasal
spray), bupropion, and varenicline.

Crain D, Bhat A. Current treatment options in smoking cessation. Hospital Practice. 2010;38(1):53-61.

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Smokefree.gov
•SmokefreeTXT is a mobile text messaging service designed
for adults and young adults across the United States who
are trying to quit smoking.

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Real Stories
•Role Models
•Videos available online from ex smokers
•http://www.cdc.gov/tobacco/campaign/tips/

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Online Programs
•American Lung Association
•Free From Smoking Programs
•http://www.ffsonline.org
•American Cancer Society
•http://www.cancer.org/treatment/index
•Become An Ex on the Ex program
•https://www.becomeanex.org/decide-to-quit/

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 STIMULANTS

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 Stimulants
Increase alertness, attention and energy
Elevate blood pressure, heart rate & respiration
Examples
•Amphetamines
•Methamphetamines
•Cocaine
•Caffeine (most common stimulant used daily)

Frates B, Bonnet JP, Joseph R, Peterson JA. Substance Abuse. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA:
Healthy Learning; 2021:417.

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 OPIOIDS

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 Opioids
•116 deaths daily from overdoses
•Drowsiness, confusion, euphoria, nausea, reduced pain
•Examples
•Morphine
•Heroin
•Fentanyl
•Codeine
•Oxycodone
Frates B, Bonnet JP, Joseph R, Peterson JA. Substance Abuse. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA:
Healthy Learning; 2021:419.

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OTHER ADDICTIONS

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 Comparison of Relapse Rates Between
Drug Addiction and Other Chronic
Illnesses

NIDA. The Science of Drug Use and Addiction: The Basics. National Institute on Drug Abuse website.
https://www.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basics. June 25, 2020 Accessed July 15, 2020.

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COUNSELING PATIENTS WITH ADDICTION

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Counseling for People Suffering
with Addictions
•The evolution
•The practice
•The opportunity

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 5As-Agree is Key
•Ask •Assess
•Assess •Advise
•Advise •Agree
•Assist •Assist
•Arrange •Arrange

Harris RP, Helfand M, Woolf SH, et al. Current methods of the US Preventive Services Task Force: a review of the process. American journal of preventive medicine.
2001;20(3):21-35.

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Transtheoretical Model of Change
• Stages
– Pre-contemplation
– Contemplation
– Preparation
– Action
– Maintenance
– Termination

James Prochaska,
PhD--University of
Stuttaford et al. 1994
R.I.
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 Spiral Model of TTM

Frates B, Bonnet JP, Joseph R, Peterson JA. Empowering people to change. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits.
Monterey, CA: Healthy Learning; 2021:80.

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 A tool to help practitioners
meet the needs of patients/clients

Frates B, Bonnet JP, Joseph R, Peterson JA. Empowering people to

change. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to
the Power of Healthy Habits. Monterey, CA: Healthy Learning; 2021:75.

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Core Motivational Interviewing
Skills
OARS
•Open ended questions
•Affirming
•Reflective listening
•Summarizing

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 Collaborating with Patients
Be Empathetic

Set Align
Accountability Motivation

Set SMART Build

Goals Confidence

Frates EP, Moore MA, Lopez CN, McMahon GT. Coaching for behavior change in physiatry. American Journal of Physical Medicine & Rehabilitation. 2011;90(12):1074-1082.

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To Wrestle or Dance

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 Beyond Addiction-Evidence Based
methods for families to motivate and
reinforce change
•Behavior Analysis of Substance
Use with a Chart
•Behavior, Triggers (External and
Internal), Consequences (Short
term positive, Long term
negative)

Foote J, Wilkens C, Kosanke N, Higgs S. Beyond addiction: How science and kindness help people change. Simon and Schuster; 2014.

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 How to work with motivation in
addiction
POSITIVELY IMPACT MOTIVATION CRUSH MOTIVATION
•Feeling acknowledged, •Feeling misunderstood and
understood, and accepted as you judged.
are
•Other people pushing you to do
•Getting information without
pressure it.
•Having options •Having only one option.
•Having reasons that make sense •Not having reasons for change
for a particular choice that make sense to you.
•Having a sense of competence •Not believing you can do it.
about how to change/steps to
take •Getting yelled at.
Foote J, Wilkens C, Kosanke N, Higgs S. Beyond addiction: How science and kindness help people change. Simon and Schuster; 2014.

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 5 Reasons for Positive
Communication
•1. “A communication system •3. “The other person will
or style that frequently listen better, understand
breaks down into negativity more, and be able to respond
and attack or silence only less defensively and from a
deepens wounds and rifts.” more thoughtful, more
collaborative position…”
•2. Positive communication is
contagious. •4. It helps your loved one by
reinforcing positive change.
•5. It can be used everywhere.
•(work, home, doctor’s office)
Foote J, Wilkens C, Kosanke N, Higgs S. Beyond addiction: How science and kindness help people change. Simon and Schuster; 2014.

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 7 Elements of Positive
Communication
•1. Be Positive with word choice, •5. Offer an understanding
tone, and framing. “Here’s how statement
it looks to me…” instead of
“Yeah, I see how you
“That’s total b….s…”
would…”
•2. Be brief-Less gets more.
•6. Accept partial
•3. Be specific responsibility
“I loved it when you ….” “I know sometimes I
•4. Label your feelings over-react”

“I am so thankful when you help •7. Offer to help

with…” “How can I help?”
Foote J, Wilkens C, Kosanke N, Higgs S. Beyond addiction: How science and kindness help people change. Simon and Schuster; 2014.

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 Dr. Lance Dodes
•The Heart of •Assistant Clinical
Addiction: A 7 Step Professor of
Handbook for Psychiatry at HMS and
Ending any Former Director of
Addiction Substance Abuse
Treatment Unit at
McLean Hospital.

Dodes LM. The heart of addiction. HarperCollins Publishers; 2002.

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 7 Step Model for the Person with
Addiction
1) How to know if you have an addiction
2) How to think about yourself if you have an addiction
3) Recognizing the key moment in addiction
4) How you keep yourself from seeing the addiction ahead of
you
5) Understanding what is happening at the key moment in
addiction
6) Short term strategies for dealing with addiction
7) How to deal with addiction in the long term
Dodes LM. The heart of addiction. HarperCollins Publishers; 2002.

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 The Key Moment
•“The key moment in addiction is when the thought of it first
comes to mind. This may be hours or days before the
addictive act occurs.”
•It is about finding the root cause.
•Listen to the signs ‘inside’ you.
•The ways you deal with stress.
•“The feeling at the key moment along the path to addictive
behavior is helplessness or powerlessness. It feels like you
are in a trap that you can do nothing about.”
Dodes LM. The heart of addiction. HarperCollins Publishers; 2002.

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 Physicians’ Empathy Influences Clinical
Outcomes
•891 Diabetic patients
•29 Family physicians
•Hgb-A1c, LDL-C
•Jefferson Scale of Empathy
•High empathy scores for MD
correlated with good control of
Hgb A1c and LDL-C in patients

Hojat M, Spandorfer J, Louis DZ, Gonnella JS. Empathic and sympathetic orientations toward patient care: conceptualization, measurement, and psychometrics. Academic Medicine.
2011;86(8):989-995.
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 DSM Provides Guidelines for
Diagnosis
We need more---
•Beyond the Label: An Educational Kit to Promote
Awareness and Understanding of the Impact of Stigma on
People Living with Concurrent Mental Health and
Substance Use Problems.
•Lambert, M.J., Implications of outcome research for
psychotherapy integration. In Norcross, J.C. & Goldstein,
M.R., Handbook of Psychotherapy Integration (pp. 94–129).
New York: Basic Books. Cited in Centre for Addiction and
Mental Health. (2005).

Norcross JC, Goldfried MR. Handbook of psychotherapy integration. Oxford University Press; 2005.

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 Factors Influencing Ability to
Change

Tomas ML. The Contributing Factors of Change in a Therapeutic Process. Contemp Fam Ther. 2006;28:201–210.

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 Is Low Therapist Empathy Toxic?
Outcomes for
Clients of
Counselors with
Low, Medium, and
High Levels of
Rogerian
Interpersonal
Functioning
(from Valle, 1981)

Moyers TB, Miller WR. Is low therapist empathy toxic? Psychology of Addictive Behaviors. 2013;27(3):878.

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Carl Ransom Rogers and the
Person-Centered Approach
•Rogers’s main concepts
•Non-directive approach,
•Active person-centered
listening,
•Transparency,
•Congruency,
•Unconditional positive regard,
•Empathy
•Suspension of judgment.
AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 133
 LIVE AND LEARN
LIVE AND LEARN

Empathy and
Compassion:
“May I Say
Something?”

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New Coaching Framework
1) Ask don’t tell--
2) Olympian level listening– (2 ears + 1 mouth)
3) Follow their energy— (TTM)
4) Remember they are resourceful- (expert)
5) You can lead differently
6) Know what hat you are wearing

• SMART goals---action can be thinking/considering/researching/watching or

if patient is in pre-contemplation then there may be no specific goals
because they are not ready and willing.

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 Sir John Whitmore's GROW Model
G—What are your goals/dreams?
R—In reality, how close are you? Where are you now?
O– What options (pathways) do you have going forward?
W---What way forward will you take? What are next steps?

Sir John Whitmore, 1937-2017. Institute of Coaching. https://instituteofcoaching.org/sir-john-whitmore-1937-2017. Accessed July 15, 2020.

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Coach Approach is the KEY to
UNLOCK Substance Use Issues
•Why would someone admit that they
use?
•With whom will they discuss their
substance use?
•What is the root cause of the substance
use?
•Relief?
•Reward?
•What is going on?
•Get deep
AMERICAN COLLEGE OF LIFESTYLE MEDICINE 2020. ALL RIGHTS RESERVED. 137
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