Neurobiology of Addiction and 12-step Recovery

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1 Neurobiology of Addiction and 12-step Recovery Luis Giuffra, MD, PhD Professor of Clinical Psychiatry Washington University in St. Louis

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3 William Silkworth,MD Alcoholism is: An allergic reaction of the body An obsession of the mind

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5 June 10 th, 1935

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7 Evidence-Based Treatment of Alcoholism Psychotherapies (CBT, MET) including web-based approaches Pharmacotherapies: Naltrexone, Acamprosate, Disulfiram Gabapentin, Topiramate, Baclofen Limitations: -Short-term studies -Outcomes rarely focus on full abstinence. They focus on days without drinking, number of drinks per week, time to first drink, etc.

8 Extended Abstinence is Predictive of Sustained Recovery After 5 years if you are sober, you probably will stay that way. It takes a year of abstinence before less than half relapse Dennis et al, Eval Rev, 2007

9 The AA controversy A Cochrane review of studies on alcohol treatment conducted between 1966 and 2005 found: "No experimental studies unequivocally demonstrated the effectiveness of AA for reducing alcohol dependence or problems."

10 ProPublica Journalism in the Public Interest. Twelve Steps to Danger: How Alcoholics Anonymous Can Be a Playground for Violence-Prone Members

11 Scientific American Most studies evaluating the efficacy of AA are not definitive; for the most part, they associate the duration of participation with success in quitting drinking but do not show that the program caused that outcome.

12 How can we tell if a treatment works? Causation vs Correlation: McDonald s and people with red hair

13 Sir Austin Bradford Hill: Smoking and Carcinoma of the Lung (1950) 1. Magnitude of the effect: There are more smokers among patients with carcinoma of the lung 2. Dose Effect: The more you smoke, the higher the risk 3. Consistency: same findings in different studies and in different countries 4. Temporality: Smoking precedes lung cancer 5. Plausibility: Carcinogens in tobacco smoke 6. Specificity: Removal of all confounding factors that could explain the finding by correlation and not causation. Note: No human experiments done.

14 If we had any thought or knowledge that in any way we were selling a product harmful to consumers, we would stop business tomorrow George Weissman, VP, 1954

15 Cochrane Review, 2011: Intercessory Prayer Overall, there was no significant difference in recovery from illness or death between those prayed for and those not prayed for Bradford Hill criteria: 1. Magnitude of the effect 2. Dose response effect 3. Consistency 4. Temporality 5. Plausibility 6. Specificity

16 AA: Bradford Hill criteria (Dr. Lee Ann Kaskutas) 1. Magnitude of the effect Abstinence is 2x higher among AA members 2. Dose response effect Frequency of attendance correlates with abstinence 3. Consistency Same results in different samples around the world 4. Temporality Prior attendance predicts future abstinence 5. Plausibility Behavioral and neurobiological explanations are now available 6. Specificity A problem! Causation or correlation?

17 5. Plausibility There must be coherence with existing knowledge. AA works because. Behavioral models: AA is consistent with established theories of behavioral change. Neurobiological models: Twelve Steps promote frontal cortex activities that override the evolutionary drive of the brain s reward centers.

18 What happens in the addict s brain? Two main brain changes:

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24 Decreased Frontal Brain Activity (1 6 weeks since last use)

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26 William Silkworth,MD The Doctor s Opinion Alcoholism is: An allergic reaction of the body (the hijacked reward system) An obsession of the mind (the hypoactive frontal lobes)

27 What behaviors help the RS achieve its goal? Helpful Traits Unhelpful Traits Insightles Selfish Dishonest Inconsiderate Egotistical Entitled Argumentative Insightful Selfless Honest Considerate Altruistic Non-demanding Open minded

28 What traits help the frontal lobe regain control over the RS? Being insightful, selfless, honest, considerate, altruistic and forgiving. Steps 4,5,6,7,8,9,10 and 12

29 Working the steps Steps 4-12 offer an honest, selfless, altruistic, humble and considerate way of living Addiction is fueled by dishonesty, selfishness, egoism, arrogance and inconsiderate behaviors.all driven by the reward system in its evolutionary quest to repeat what feels good.

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32 AA: Bradford Hill criteria 1. Magnitude of the effect Abstinence is 2x higher among AA members 2. Dose response effect Frequency of attendance correlates with abstinence 3. Consistency Same results in different samples around the world 4. Temporality Prior attendance predicts future abstinence 5. Plausibility Behavioral and neurobiological explanations are now available 6. Specificity A problem! Causation or correlation?

33 6. Specificity Requires experimental manipulation: randomization, blindness, control groups No realistic opportunity to do this type of research in AA: Requires a sincere desire to change AA attracts, does not recruit, its members Great variability among groups and sponsors Self-report is unreliable AA has no opinion on outside matters. AA has done well without the endorsement of academicians or clinicians. AA has no financial interest in its acceptance and success. Due to anonimity, AA does not track its members or conduct research. AA shall remain for ever nonprofessional. AA s major weakness.it may never be solved

34 Why AA helps: Coherence with existing knowledge The fellowship of AA may help by: -Mirroring one s own character flaws in others (modeling) -Accepting environment -Accountability to the group and sponsor -A sense of relating and belonging (reinforcement) -Awareness of what happens to active drinkers

35 Why AA helps: Coherence with existing knowledge The twelve steps may help by: -Addiction activates the reward system -Addiction inhibits the frontal cortex. -The 12 steps may offer ways to exercise the frontal cortex.

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37 How about God, a Higher Power and Steps 1-3? God as we understood him: A Group of Drunks Steps 1-3 Realize that the rational mind has been hijacked by the reward system of the brain to advocate on behalf of alcohol and drugs. Can t solve the problem alone: alcoholics are making decisions with the affected organ. Steps 1-3 encourage the use of a surrogate decision-maker, since the addict s own one (the frontal cortex) is affected by the disease.

38 Steps 1-3 for non-believers Powerless: Addicts cannot solve their addiction problem using the affected organs (the frontal lobes). A power greater than ourselves: A higher power can act as a surrogate decision-maker (surrogate frontal lobes). Turn over our will: The AA group can act as a surrogate decision-maker when the addict s frontal lobes show signs of the affliction ( stinking thinking ).

39 How about Step 11??

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