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

jcole@daodas.sc.gov

803-896-2837