Objectives. Fundamental Framework for Today

Transcription

1 The Brain, Behavior & Addiction: Increasing Outcomes for Long Term Recovery Flo Hilliard Division of Continuing Studies University of Wisconsin-Madison Objectives 1. The brain as the affected organ. 2. How addiction affects behavior (brain science perspective) 3. Implementation into treatment and relapse prevention. 4. Long term recovery management planning. Fundamental Framework for Today Your Client Comes With Set of Beliefs: Historical Cultural Individual Impaired Brain 1

2 Fundamental Framework Continuous use causes changes in brain: (harder to learn new cues for non drug using pathways) J Neurosci Oct 13; 30(41): Fundamental Framework Where neurons fire together they wire together! Like any skill: brain becomes more efficient the more you practice (repeat) positively or negatively Takes time and practice to change the brain s efficiency of strongly wired connections 2

3 % in each age group who develop first-time dependence Addiction Is A Developmental Disease that starts in adolescence and childhood 1.8% 1.6% 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% TOBACCO CANNABIS ALCOHOL Age Age at tobacco, alcohol, and cannabis dependence per DSM IV National Epidemiologic Survey on Alcohol and Related Conditions, Advances in Science Have Revolutionized Our Fundamental Views of Drug Abuse and Addiction 3

4 When We Had No Science Drug kit on sale at Macys (circa 1908) with vials of cocaine and heroin. Sears Roebuck also sold a drug kit. Courtesy of Fritz Hugh Ludlow Memorial Library. When We Had Some Science 4

5 Your Brain on Drugs in the 1980 s Bringing the Full Power of Science to Bear on Drug Abuse & Addiction Your Brain on Drugs Today YELLOW shows places in brain where cocaine binds (e.g., striatum) Fowler et al., Synapse,

6 What Does Science Tell Us About Addiction? Addiction is A Brain Disease Vulnerability Why do some people become addicted to drugs while others do not? 6

7 Addiction Like Other Diseases Is preventable Is treatable Changes biology If untreated, can last a lifetime Decreased Brain Metabolism in Drug Abuser High Decreased Heart Metabolism in Heart Disease Patient Healthy Brain Diseased Brain/ Cocaine Abuser Low Healthy Heart Diseased Heart Research supported by NIDA addresses all of these components of addiction. Science Changes the Dialogue: Substance Use Disorders: Abuse of alcohol and other drugs are preventable behaviors Alcohol and drug addiction is a chronic but treatable disease Recovery from addiction is a reality 7

8 Source: National Institute on Drug Abuse Teaching Packet The Neuron: How the Brain s Messaging System Works Dendrites Cell body (the cell s life support center) Neuronal Impulse Axon Terminal branches of axon Myelin sheath Donald Bliss, MAPB, Medical Illustration Source: National Institute on Drug Abuse Teaching Packet 8

9 Brain Reward Pathway (Circuit) How do alcohol and other drugs work in the brain? Despite many differences, virtually all substances with the potential for addiction affect dopamine levels in the pleasure/reward pathway of the brain. 9

10 Why Do People Take Drugs in The First Place? To Feel Good To have novel: feelings sensations experiences AND to share them To Feel Better To lessen: anxiety worries fears depression hopelessness A major reason people take a drug is they like what it does to their brains. Opiates & Opioids Opiates: strict definition Alkaloids extracted from poppy pods and their semi-synthetic counterparts which bind to opioid receptors. Morphine, Codeine pure alkaloids (opiate) Heroin, semi-synthetic opiate/opioid 10

11 Opioids How do they work in the brain? Very effective for pain reduction Converts to morphine Changes Neurochemical Structures Creates tolerance, physical dependence, and toxicity (respiratory centers in the brain) Opioids Opium (opiate) Morphine (opiate) Codeine (opiate) Heroin Vicodin Dilaudid Percocet Darvon Demerol Fentanyl Talwin OxyCodone OxyCotin Methadone (opioid) Buprenorphine Subutex, Suboxone (naloxone added) Vulnerability Why do some people become addicted to drugs while others do not? 11

12 Individual Differences in Response to Drugs: DA Receptors influence drug liking High DA receptor high Low DA receptor low As a group, subjects with low receptor levels found MP pleasant while those with high levels found MP unpleasant Adapted from Volkow et al., Am. J. Psychiatry, Science of Addiction ENVIRONMENTAL PSYCHOLOGICAL GENETIC NEUROBIOLOGY ADDICTION Addiction is A brain disorder which manifests as: compulsive non-medical use of a substance loss of control over its use continued use despite negative consequences 12

13 Circuits Involved in Drug Abuse and Addiction Initially, a person takes a drug hoping to change their mood, perception, or emotional state TRANSLATION... Hoping to change their brain. The vulnerable system becomes captured by the addicting drug restructuring the complex system that sets behavioral priorities. 13

14 % of Basal Release % of Basal Release % of Basal Release % of Basal Release % of Basal DA Output DA Concentration (% Baseline) Natural Rewards Elevate Dopamine Levels 200 Food NAc shell 200 Sex Empty 50 Box Feeding Time (min) Female Present Sample Number Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, Effects of Drugs on Dopamine Release Amphetamine Accumbens DA DOPAC HVA hr Nicotine Accumbens Caudate Accumbens Cocaine DA DOPAC HVA hr Accumbens Morphine Dose 0.5 mg/kg 1.0 mg/kg 2.5 mg/kg 10 mg/kg hr Time After Drug Di Chiara and Imperato, PNAS, hr Time After Drug Why Can t Addicts Just Quit? Non-Addicted Brain Addicted Brain Control Control Saliency Drive NO GO Saliency Drive GO Memory Memory Because Addiction Changes Brain Circuits Adapted from Volkow et al., Neuropharmacology,

15 Understanding the Science of Addiction and Recovery is Important for Your Client: Understand biological factors Plan for Recovery Management Understand and Manage Cravings What about relapse? Why Can t They Just Quit? Form of Classical Conditioning Sets off physiological chain reaction in the body coming from the brain. Relapse Involves Cues that Trigger Cravings Examples of external triggers: cash Fridays using buddies 15

16 What About Relapse? Examples of internal triggers: loneliness celebration emotional pain anger boredom So Addiction: Fires and strongly wires efficient pathways in the brain That reacts to it s environment (Internal and External). To create powerful emotional memories (cue/triggers) at a biochemical level in the part of the brain that drives behaviors in all of us for survival. Markers that addiction is a disease: Can be reliably produced and easily recognized in animals. Patterns of intake resemble humans - drug for drug. For Humans: Follows behavioral symptoms of other chronic diseases resistance, denial, anger, relapse, etc. 16

17 Recovery From Active Addiction Science has shown that: Brain has remarkable ability to adapt, heal and change. Key is length of time and experiences after drug leaves system. Sources: Volkow, et al., Synapse, 11: , 1992 & Volkow, et al., Synapse, 14: , 1993 Sources: Volkow, et al., Synapse, 11: , 1992 & Volkow, et al., Synapse, 14: ,

18 Partial Recovery of Brain Dopamine Transporters in Methamphetamine (METH) Abuser After Protracted Abstinence 3 0 Normal Control METH Abuser (1 month detox) METH Abuser (14 months detox) ml/gm Source: Volkow, ND et al., Journal of Neuroscience 21, , Treatment & Early Recovery Medical Management 1. Subutex (Buprenorphine) 2. Suboxone (Buprenorphine & Naloxone) 3. Vivitrol (Naltrexone) 3 Important skills for long term recovery 1.Know relapse triggers and manage them 2.Change destructive thinking/feeling patterns 3.Identify stress triggers and manage them All related to changing brain wiring 18

19 University of Wisconsin-Madison Dr. Richard Davidson, MD The Emotional Life of Your Brain Hudson St. Press, 2012 Transform Your Mind, Change Your Brain YouTube Dr. Davidson s Work Affective Neuroscience Brain Plasticity ability to change structure and function throughout life Experiences - external Thoughts - internal Dr. Davidson s Work Affective Neuroscience Brain Plasticity ability to change structure and function throughout life Experiences - external Thoughts - internal 19

20 His research shows that: Behavioral interventions are actually Biological In fact: Behavioral interventions can change the brain in more targeted and specific ways than pharmaceuticals without all the side effects Example: Davidson s work: Compassion training down regulates amygdala Dr. Davidson s Research Mental training (meditators) can strengthen brain activity for: Empathy Compassion Optimism Sense of Well-Being 20

21 Other Research on Mindfullness Benefits from smaller doses Thirty minutes five/six days/wk for 2 months 4 min x 4 times. Two weeks Training over the internet Other Research on Mindfulness Generalized Anxiety Disorder Roemer, Orsillo Clinical Psychology Science and Practice, 2001 Substance Use Disorders and Anxiety and Mood Disorders with drugs and alcohol NIH News 2004 In Mindfulness we can work with old, strongly held connections Practice becoming aware when they happen Stepping back from (loosening ourselves): the auto pilot thought, feeling, reaction by nonjudgmental awareness Deciding if the thought, feeling, reaction is helpful to us 21

22 This practice changes neurochemistry to more positive functioning Cognitive Behavioral Therapy Emphasize role of thinking in: How we feel What we do CBT Based on an educational model Oppositional to talk therapy Unlearning old patterns Learning/practicing new patterns Inquiry and debate using opposing viewpoints Relying on asking and answering questions to stimulate critical thinking 22

23 Automatic Thoughts Mental reactions to a situation - Real, Imaginary, Anticipated Short spontaneous thought Internal monologue Mental Image Cognitive Behavioral Therapy Levels of Cognitions: 1. Automatic Thoughts 2. Conditional (Intermediate) Beliefs 3. Core Beliefs (Schemas) Interactive Sequence CORE BELIEFS Conditional Beliefs Situations Automatic Thoughts Feelings Results Behaviors 23

24 Cognitive Distortions 1. All or Nothing Thinking 2. Over-generalization 3. Mental Filter 4. Disqualifying the Positive 5. Jumping to Conclusions (mind reading, and fortune teller error) 6. Magnification (Catastrophizing) or Minimization 7. Emotional Reasoning 8. Should Statements 9. Labeling 10. Personalization and blame CBT Time limited Agreed upon at first session Therapist/Client relationship not the focus Learning skill most important 24

25 CBT Collaborative effort of therapist & client Client s goals Structured and directive Not with the what but the how Where attention goes, neurons fire. And where neurons fire, they can re-wire. Daniel Siegel, The Mindful Brain: Reflection And Attunement in the Cultivation of Well- Being (2007), p. 291 Conclusion Like other chronic diseases. Changes the brain structurally and functionally. Bio-psychosocial elements must be considered. If relapse occurs, like other chronic conditions, the recovery journey can continue. Recovery can be from many pathways. 25

26 There are millions of Americans in long-term recovery. Faces & Voices of Recovery Summit