Science of Addiction & Recovery Julie Cole, LMSW, CACII, NCACI Project Coordinator SC Department of Alcohol & Other Drug Abuse Services
Why am I doing this?
Learning Objectives
• Increase understanding of the neurobiology of substance use disorders, addiction and recovery
• Increase understanding of criteria by which addiction is defined as a chronic disorder
Why talk about neuroscience?
• Understand addiction
• Understand recovery
How the brain behaves in health and disease may well be the most important question in our lifetime. Richard D. Broadwell, 1995
Attitudes about addiction • Disease?
• Behavioral Problem?
• Self-Inflicted Vice?
• Moral/emotional weakness?
Is addiction a disease… or a behavior? • Prior to brain science, addiction was treated as a
behavior. Some of the behaviors that were “treated” were:
• Lying -Being irresponsible
• Cheating -Denial
• Stealing -Selfishness
• Manipulating -Lack of Caring
Perceived causes of these behaviors • Sociopathy
• Criminality
• Self-Centered
• Character Defects
• Gang Culture
• Bad Parenting
• Demonic Possession
What can neuroscience teach us about addiction and recovery? • Abuse of alcohol and other drugs are preventable
behaviors
• Many people choose to abuse alcohol & other drugs
• Changing language through the years has contributed to this confusion
• Alcoholic/Addict >>> Chemically Dependent >>> Substance Abusing
• To that end, the current focus on distinction and languaging is intended to address this issue
What can neuroscience teach us about addiction and recovery? • Alcohol and drug addiction is a disorder that
people can recover from
• Recovery from addiction is a reality and happens every day
Why the science of addiction and recovery is important • For the individuals, family and for professionals:
• Helps explain the unexplainable
• Reduces stigma, blame, and anger
• What other diseases have seen a reduction in stigma and blame due to science?
Why the science of addiction and recovery is important • For the person in recovery:
• Helps people in recovery understand their cravings
• Helps people on their recovery journey
• Facilitates the recovery process for the person and family members
Why do people use alcohol and other drugs?
• To have feelings
• To have sensations
• To have experiences
To feel good (to create)
• To lessen anxiety, stress, fear, depressions, hopelessness
To feel better (to remove)
Why do people use alcohol and drugs? A major reason is that they like what it does to their brain!
Which leads to one of the most popular questions:
Why do some people become addicted while others do not?
Vulnerability
Previous theories about addiction:
• Environment – people who were exposed to addiction become addicted
• Psychological – people had underlying psychological issues that needed resolution
• Genetic – it is in the genes and there is nothing a person can do.
Vulnerability
Neurobiology
Environmental
Psychological
Genetics
There is one place that all of these factors converge – one organ that is responsible for processing it all. Addiction, as a disease, irrefutably
starts in once place: the brain.
Vulnerability We know there is a genetic contribution. In fact, we know this
contribution is big.
unpleasant response
pleasant response
Dopamine Receptor Levels & Response to Methylphenidate
Subjects with low receptor levels found MP pleasant while those with high levels found it unpleasant.
Source: Adapted from Volkow et al, American Journal of Psychiatry 156:9; 1999
Additional Vulnerability Factors
• History of trauma
• Chronic stress
• Drug used
• Route of Administration
• Dose
• Frequency Used
• Length of Use
• Availability
• Acceptability
• Settings
• Presence of conditioned cues
• Available alternatives
Back to the brain… and it’s role in the development of addiction
• The brain is very complex – and as such, the reasons people may – or may not – become addicted are as complex.
• The brain is responsible for everything that is the human experience:
• Every movement
• Every thought
• Every sensation
• Every emotion
The brain’s complexity
• Approximately 4-6 pounds
• Several thousand miles of interconnected nerve cells (100+ billion)
• 10,000 varieties of neurons
• Trillions of supportive cells
• Trillions more synaptic connections
• Miles of blood vessels
Source: National Institute on Drug Abuse Teaching Packet
The reward, memory and pain units of the brain make up the primitive part of the brain. It is the first part of the brain to mature and is responsible for survival, among
other things.
Communication of the brain
• Neuron = nerve cell
• Nerve cells have many different shapes, depending on the specialization
• Communication between neurons start out as an electrical signal but then changes to a chemical signal
• There are hundreds of billions of neurons in the CNS. None of them actually touch. They communicate through neurochemicals.
Source: National Institute on Drug Abuse Teaching Packet
34
Other behaviors that Affect Dopamine • Food
• Sex
• Relationships
• Gambling
• Performance (“workaholics”)
• Accumulation (“shopaholics”)
• Media/Entertainment
• Rage/Violence
Circuits involved in addiction
Back to why people use alcohol and other drugs… • Initially, a person uses a substance hoping to
change their mood, perception, emotional state…
• …which means that they are hoping to change their brain.
And what happens with addiction • The issue is that the brain is a complex system
that sets behavioral priorities and this system becomes captured by the addicting drug.
• This creates a complex behavioral neurobiological disorder which in turn creates powerful emotional memories (both fear and pleasure) – like those that drive survival behavior in all of us.
And what happens with addiction
• These emotional memories become kin to survival in the addicted brain
• For many people, drug = drug
• For some who misuse substances, drug = vital
• For someone with addiction, drug = survival
• Thus behavior that “flies” in the face of logic now makes sense
Brain Mechanisms
-Previous history -Expectation -Learning
-Trauma -Social Interactions -Stress -Conditioned Stimuli
-Genetics -Disease States -Gender -Circadian Rhythms
Historical
Environmental
Physiological
Drugs
Behavior
Environment
Addiction is not
• Addiction is not just tolerance
• Reduced drug effect with repeated administration of the same dose of the drug, or a need for an increased dose to maintain the same level of effect
• Not just physical dependence
• When drug cessation produces pathologic symptoms and signs
Addiction is • Compulsive non-medical use of a substance
• Loss of control over use despite negative consequences
• Can include physical dependence (but not necessarily)
More About Addiction as a Disorder
An Acute Condition has:
• Rapid onset
• Short course
• May be severe
• Potential cure
A Chronic Condition has:
• Gradual onset
• Lifetime course
• May have “acute” episodes
• No cure
Addiction is… Addiction is a primary chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction
in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is
reflected in an individual pathologically pursuing reward and/or relief by substance use and other
behavior. Addiction is characterized by inability to consistently abstain, impairment in behavior control,
craving, diminished recognition of significant problems with one’s behavior and interpersonal relationships and a dysfunctional emotional response. Like other chronic diseases, addiction often involves a cycle of relapse and
remission. Without treatment or engagement in recovery activities, addiction is progressive and can
result in disability or premature death. American Society of Addiction Medicine, 2011
DSM-5 Criteria for Substance Use Disorder Two or more of the following occurring at any time during the same 12 month period:
1. Substance taken in larger amounts or over a longer period than was intended.
2. Persistent desire or unsuccessful efforts to cut down or control use.
3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
4. Craving, or a strong desire or urge to use substances. 5. Recurrent use resulting in a failure to fulfill major role obligations
at work, school, or home. 6. Continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the effects of the substance.
7. Important social, occupational, or recreational activities are given up or reduced because of substance use.
DSM-5 Criteria for Substance Use Disorder 8. Recurrent substance use in situations in which it is physically
hazardous.
9. Substance 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 the substance.
10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for substance b. Substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.
DSM-5 Criteria for Substance Use Disorder (con’t) Mild – presence of 2-3 symptoms
Moderate – Presence of 4-5 symptoms
Severe – Presence of 6 or more
DSM-5 Criteria for Substance Use Disorder (con’t) • Criteria 1-4 related to use
• Criteria 5-8 related to social/behavioral issues associated with use
• Criteria 9-11 related to physical/emotional issues
DSM-5 Criteria Differentials
All criteria are not equal in implications
Some criteria are found predominately among those with the severe alcohol or other substance use disorder diagnoses
Other criteria are more common among the mild to moderate alcohol use disorder group
Tolerance and dangerous use are actually common among those with no diagnosis
SUD Criteria primarily in severe designation
The “Big Five”
Criteria 2:Wanting to cut down/setting rules
Criteria 4: Craving and/or compulsion to use
Criteria 5: Failure at role fulfillment due to use
Criteria 7: Sacrifice activities to use
Criteria 11: Withdrawal symptoms
Sample of Alcohol Diagnostic Documentation
Alcohol Diagnosis Diagnostic Criteria
1 2 3 4 5 6 7 8 9 10
11
Case 1 X X X X X X X X
Case 2 X X X
Case 3 X X X X X
Case 4 X X X X X
Severe
Mild
Moderate
Moderate
Cases 3 & 4 with the same diagnosis may have different prognoses if the Big Five are related to outcomes
CASE 3: Positive DSM-5 Criteria 3. Great deal of time using
10. Tolerance
1. Unplanned use: more or longer use
8. Use in hazardous situation (impaired driving)
6. Recurrent interpersonal conflicts
Conclusions • No loss of control indicated • Misuse and possible irresponsible behavior • Moderation may be a reasonable initial goal
CASE 4: Positive DSM-5 Criteria 1. Unplanned use: more or longer use
2. Desire/efforts to cut down
4. Craving/compulsion to use
5. Role obligation failures
7. Sacrificing activities to use
Conclusions • Loss of control clearly indicated • Positive on 4 of the “Big Five” • Abstinence indicated goal for recovery
What about reoccurrence? • Complex triggers can set off physiological chain reactions
in the body that come from the brain
• Examples of external cues:
• Cash
• Friday
• Using “buddies”
• Examples of internal cues:
• Loneliness
• Celebration
• Emotional pain / Trauma / Grief
Reoccurrence Rates
Reoccurrence rates are similar to other diseases:
• Hypertension & Asthma – 50-70%
• Substance Use Disorders – 40-60%
• Type I Diabetes – 30-50%
There is hope…
• Science is also revealing much about recovery, what works in treatment and other pathways to recovery
• Research shows that the brain has a remarkable ability to adapt, heal and change.
• The recovery process takes time:
• For the brain to heal
• To reduce the effects of relapse cues
• To learn new ways of reacting to the environment
Partial Recovery of Brain Dopamine Transporters in a Person with Methamphetamine (METH)
Use Disorder After Protracted Abstinence
Normal Control METH UD (1 month detox)
METH UD (14 months detox)
“Recovery is a process of change whereby individuals improve their health and wellness, to live a self-directed life, and strive to reach
their full potential.”
SAMHSA/CSAT 2011
Thinking about recovery
Neurobiology
Environmental
Psychological
Genetic
RECOVERY DIMENSIONS
51
Individuals and Families
HOME ↑ Permanent
Housing
COMMUNITY ↑ Peer/Family/
Recovery Network Supports
PURPOSE ↑ Employment/
Education
HEALTH ↑ Recovery
51
SAMHSA/Hyde, P. 2011
Guiding Principles of Recovery • Recovery emerges from hope
• Recovery is person-driven
• Recovery occurs via many pathways
• Recovery is holistic
• Recovery is supported by peers and allies
• Recovery is supported through relationship and social networks
• Recovery is culturally-based and influenced
• Recovery is supported by addressing trauma
• Recovery involves individual, family, and community strengths and responsibility
• Recovery is based on respect
Recovery-Oriented Approach A recovery-oriented systems approach supports
person-centered and self-directed approaches to
care that build on the strengths and resilience of
individuals, families, and communities to take
responsibility for their sustained health, wellness,
and recovery from alcohol and drug problems.
(SAMHSA, 2010)
Increased awareness of the
problem(s) Overcoming
reluctance and committing to
change
Sense of hope
Personal empowerment and self-respect
Improved wellness and
physical health
Reduction of illegal & risky
behaviors
Increased self-efficacy
Meaningful connection to
others
Meaningful work and safe
housing
Abstinence
Recovery: A Dynamic
Process
Race
Ethnicity
Family History
Sexual Orientation
Life-cycle stage
Environ-ment
Perspective
Unique Experiences
Strengths
Values
Needs & Desires
Each person is unique
And has many possible recovery outcomes
intensifying pre-treatment recovery support services
strengthening in-treatment recovery support services
shifting the focus of treatment from acute stabilization to support for long-term recovery maintenance.
The Shift to Recovery Management
Recovery Capital • Recovery Capital (RC)
is the breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery.
• There are three types of Recovery Capital that can be influenced by addictions professionals.
White and Cloud, 2008
Recovery Capital
Personal
Family/ Social
Community
Personal Recovery Capital Physical recovery capital includes: • physical health • financial assets • health insurance • safe and recovery-conducive shelter • clothing, food, and • access to transportation.
White and Cloud, 2008
Personal Recovery Capital
Human recovery capital includes: • values • knowledge • educational/vocation
al skills and credentials
• problem solving capacities
• self-awareness, self-esteem, self-efficacy
• hopefulness/optimism
• perception of one’s past/present/future
• sense of meaning and purpose in life, and
• interpersonal skills
White and Cloud, 2008
Family/Social Recovery Capital
• Encompasses intimate relationships, family and kinship relationships, and social relationships that are supportive of recovery efforts
• Is indicated by: • the willingness of intimate partners and family
members to participate in treatment
• the presence of others in recovery within the family and social network
• access to sober outlets for sobriety-based fellowship/leisure,
• relational connections to conventional institutions
Community Recovery Capital
Community recovery capital includes:
• active efforts to reduce addiction/recovery-related stigma
• visible and diverse local recovery role models
• a full continuum of addiction treatment resources
• recovery mutual aid resources that are accessible and diverse
• local recovery community support institutions
• cultural capital 60
White and Cloud, 2008
• Abstinence
• Education
• Employment
• Reduced criminal justice involvement
• Stability in housing
• Improved health
• Social connectedness
• Quality of life
Increased Access &
Capacity
Perception of Care
Recovery as a Reality
• There are currently 23 million people in recovery in the United States
• There are currently 300,000 people in recovery in the State of South Carolina
Additional Resources • Substance Abuse and Mental Health Services Administration
(SAMHSA) www.samhsa.gov
• National Institute on Drug Abuse (NIDA) www.nida.nih.gov
• SC Department of Alcohol and Other Drug Abuse Services (DAODAS) www.daodas.state.sc.us
• Faces and Voices of Recovery South Carolina www.favorsc.org
• Faces and Voices of Recovery www.facesandvoicesofrecovery.org
• William White Papers www.williamwhitepapers.com
Questions??
Thank you for your time!
Julie Cole
803-896-2837