1.Carl Christensen, MD PhD, FASAMAssociate Professor, Depts OB Gyn &PyschiatryDawn Farm Spera Center Pain Recovery Solutions, A2cchriste@med.wayne.edu

2. Physiology of Addiction 3 3. Physiologic Dependence? Lack of willpower? An amoral condition? A brain disease? Physiology of Addiction 5 4. Tolerance: requiring increasing amounts ofdrug to get the same effect Withdrawal: the opposite effect of the drugwhen it is removed NEITHER of these imply chemicaldependency (addiction)Physiology of Addiction 6 5. 100 people are treated with morphine for twoweeks after an accident. Their insurance runs out, the morphine issuddenly stopped. 95 of them will have the flu (physicalwithdrawal) and will go on with their lives. 5 of them will start robbing party stores toget more morphine!!!! = ADDICTIONPhysiology of Addiction7 6. Physiology of Addiction 8 7. Physiology of Addiction 9 8. Physiology of Addiction 10 9. Physiology of Addiction 11 10. Physiology of Addiction 13 11. Responds to dopamine (DA) Part of the LIZARD BRAIN Responds to drugs Responds to food Responds to sex Sends signals to your frontalcortex THE PLEASURE CENTER ISABNORMAL (DAMAGED) INADDICTIONPhysiology of Addiction 14 12. Physiology of Addiction 16 13. Physiology of Addiction 17 14. Physiology of Addiction 18 15. Physiology of Addiction 19 16. Physiology of Addiction 20 17. Physiology of Addiction 21 18. Physiology of Addiction 22 19. Physiology of Addiction 23 20. Physiology of Addiction 24 21. Do some people develop addiction becausethey have reward deficiency syndrome(decreased dopamine) OR: Do people with addiction have low dopaminebecause they have burned out theirpleasure centers? Physiology of Addiction 25 22. Physiology of Addiction 26 23. Physiology of Addiction 27 24. Physiology of Addiction 28 25. Physiology of Addiction 29 26. Physiology of Addiction 30 27. Those who enjoyed methylphenidate(amphetamine) had LOWER levels ofdopamine. Those who found it unpleasant hadNORMAL levels of dopamine Conclusion? -addiction is an abnormal response to rewardPhysiology of Addiction 31 28. Women who have an abnormal receptor(brain protein) for dopamine had brain scans Those who had the abnormal receptorenjoyed a milkshake LESS Were more likely to gain weight! Conclusion? -addiction is an DECREASED response toNORMAL reward If you dont like something as much, you need tocompensate! Physiology of Addiction 32 29. Decreased Dopamine receptors=decreased Dopamine = Decreased HedonicTone Salsitz 2006Grand Rounds Hutzel 4 17 07 33 Physiology of Addiction 33 30. Physiology of Addiction 34 31. Physiology of Addiction 35 32. Alcoholics/addicts who finish treatment willoften relapse when they re-enter society. They will almost ALWAYS relapse if theyundergo quick detox and re-enter society. But: their withdrawal is gone. SO: why do they relapse?????Physiology of Addiction36 33. HighflowHealthy Control Cocaine-dependent LowflowGottschalk, 2001, Am J PsychiatryPhysiology of Addiction37 34. Highblood flowNon usersCocaine users, 10 days sober LowbloodCocaine Users, 100 days soberflow Physiology of Addiction38 35. Highblood flowNon usersCocaine users, 10 days sober LowbloodCocaine Users, 100 days soberflow Physiology of Addiction39 36. Highblood flowNon usersCocaine users, 10 days sober LowbloodCocaine Users, 100 days soberflow Physiology of Addiction40 37. Highblood flowNon usersCocaine users, 10 days sober LowbloodCocaine Users, 100 days soberflow Physiology of Addiction41 38. Physiology of Addiction 43 39. Tolerance Great deal of time Withdrawal spent in Take more/take obtaining/usinglonger than intended /recovering Important activities Cant cut down or given up 2 to usecontrol use Use despite physical/psych problem Physiology of Addiction44 40. A chronic progressive disease characterized by the followingphysical and psychological symptoms (the four (five) Cs): Craving Compulsion Loss of Control Continued use despite consequences, and Chronic use Physiology of Addiction 45 41. Physiology of Addiction 46 42. Physiology of Addiction 47 43. Physiology of Addiction 48 44. Physiology of Addiction 50 45. Physiology of Addiction 51 46. Physiology of Addiction 52 47. People who recover from alcoholism may: Gain weight Increase their smoking Start gambling Become involved in sexual addiction, internet addiction Physiology of Addiction53 48. People who undergo gastric bypass surgerymay: Become alcoholics Develop chronic pain-opiate dependence Gain weight! Physiology of Addiction54 49. You are worried about your best friend. She has a 20 year history of heavy drinkingand has just been diagnosed withhypertension and hyperlipidemia (highcholesterol). You advise her to quit.Physiology of Addiction 55 50. You went to the Dawn Farm lecture onaddiction and you know it is a disease. To your surprise, she does so, without anytreatment. You vow never to waste your time going toany more Dawn Farm lectures. How did she do it?????Physiology of Addiction56 51. Failure to fulfill work/school/social obligations Continued use is risky situations (ie, drunkdriving) Recurrent legal problems (DUI)* Continued use despite social or interpersonalproblems (MOR) Never fit the criteria for dependence Physiology of Addiction57 52. The majority of patients you see withdrug/alcohol problems do NOT haveaddiction Most people with drug/alcohol problems willbe able to stop on their own. (William White) The 4Cs helps you to determine which oneshave addiction!Physiology of Addiction 58 53. Most people who havea problem with alcoholor drugs will stop ontheir own The majority of peoplewho stop do sowithout treatment. Even many heroinaddicts will quit andresume normal lives.Physiology of Addiction 59 54. A 45 YEAR OLD WITH ANA 45 YEAR OLD WITH ANOVARIAN TUMOR. OVARIAN TUMOR. Physiology of Addiction 60 55. FAMILY HISTORY OF BREASTNO FAMILY HISTORY CANCER Physiology of Addiction61 56. HAS THE BREASTNO GENETICCA/OVARIAN CA GENEPREDISPOSITIONBRCAPhysiology of Addiction62 57. Abuse is a BEHAVIOR. Addiction is a DISEASE!! Mark Minestrina, MD Brighton HospitalPhysiology of Addiction63 58. anyone can quit drinking Just walk up and hit a cop! Herb Malinoff, MDPhysiology of Addiction 64 59. Drug triggered: I thought I could(eat/smoke/drink) just one. Stress triggered: Im going through toomuch right now. Gimme that! Cue triggered: Wet faces and wet places Physiology of Addiction65 60. Physiology of Addiction 66 61. Physiology of Addiction 67 62. Physiology of Addiction 68 63. Physiology of Addiction 69 64. Physiology of Addiction 70 65. Physiology of Addiction 71 66. Physiology of Addiction 72 67. Physiology of Addiction 73 68. Physiology of Addiction 74 69. Physiology of Addiction 75 70. Physiology of Addiction 76 71. Physiology of Addiction 77 72. Physiology of Addiction 78 73. Hypertension: the most common cause ofessential (unexplained) hypertension isalcohol. Diabetes: damage to the pancreas(temporary or permanent) Cholesterol: LDL (bad cholesterol) goesup, triglycerides (fat) goes up.Physiology of Addiction 79 74. Fatty liver: from drinking; body uses alcoholrather than fat. Fat accumulates. Alcoholic Hepatitis: inflammation of theliver; fever, jaundice, pain, nausea andvomiting. Viral Hepatitis: usually hepatitis C, fromsharing needles, straws (cocaine), sex. Cirrhosis: scarring of the liverPhysiology of Addiction 80 75. Your friend is an alcoholic. His family left him. When you see him today, he denies that he hasa problem, but says that he needs to "take abreak". His wife left him, he says, because ofhis mother in law. As you discuss his situation, you are amazedby his ability to: Minimalize -Rationalize Deny -Deflect Physiology of Addiction81 76. Recovering addicts make bad decisions Ex: 3 weeks into recovery, a man decides tomake a trip to Amsterdam? Q: what does an alcoholic bring on a 2nddate? A: a U haul.Physiology of Addiction 82 77. Physiology of Addiction 83 78. Physiology of Addiction 84 79. You are asked to see him in the hospital severalyears later. He says he knows you, but cannot rememberyour name. You become alarmed. You ask him who the president is, he repliesWho cares? Theyre all crooks. He walks with a shuffling broad-based gait andhas to hold his hand on the wall to keep hisbalance.Physiology of Addiction85 80. Immediately after stopping drinking:Wernikes encephalopathy (brain disease) Caused by thiamine (B1) deficiency Eye muscles are paralyzed Ataxia (cant walk straight) Encephalopathy: confusion, agitation, restlessnessPhysiology of Addiction86 81. Confabulation: make things up Retrograde amnesia: cant remember whathappened in the past Antegrade amnesia: cant remember infoyou are given (remember these 3 objects) Polyneuropathy: periperhal nerve damage Physiology of Addiction87 82. You see him one more time, several years later. Hehas been readmitted for vomiting blood, jaundice, andencephalopathy. He is given multiple transfusions. He hasesophageal varices from his cirrhosis. He is jaundiced. He says that he is asking his sisterto pay for a liver transplant. She died 5 years ago. When he are speaking to him, his hands willoccasionally flap. Physiology of Addiction88 83. Hardening of the liver (scar tissue) Causes blood to back up in the veins feedingthe liver: Esophageal varices: vomit blood Hemorrhoids: rectal bleeding Cant metabolize toxins: encephalopathy Cant make proteins: bleeding (coagulopathy) Cant hold fluids: ascitesPhysiology of Addiction89 84. Physiology of Addiction 90 85. Physiology of Addiction 91 86. Physiology of Addiction 92 87. Physiology of Addiction 93 88. He dies several weeks later of liver failure. Jails, institutions, and death Narcotics Anonymous Physiology of Addiction94 89. Physiology of Addiction 95 90. Physiology of Addiction 98 91. Physiology of Addiction 99 92. Physiology of Addiction 100 93. Physiology of Addiction 101 94. We have driven miles in the dead of night tosatisfy a craving for food. We have eatenfood that was frozen, burnt, stale, or evendangerously spoiled. We have eaten food offof other peoples plates, off the floor, off theground. We have dug food out of thegarbage and eaten it. Physiology of Addiction 102 95. THE SOLUTION? 96. Medical Behavioral Spiritual Surgical Physiology of Addiction 112 97. Agonists: similar to the drug Suboxone for opiate dependence Methadone for opiate dependence Nictotine patches for tobacco dependence THC for marijuana dependence Dilaudid for heroin dependence! (Canada) Physiology of Addiction 113 98. Antagonists: opposite effect of the drug Naltrexone for opiate dependence Oral: Rivea Injectable: Vivitrol Naltrexone for alcohol dependence: Vivitrol Disulfiram (Antabuse) for alcohol dependence Rimonabant for obesity Physiology of Addiction 114 99. Physiology of Addiction 115 100. Behavior (drinking) is due to false beliefs (Icant stop) Change the false beliefs, change thebehavior. Apologies to therapists everywhere Physiology of Addiction 116 101. CBT Iceberg ModelBehaviorwaterlineMoodThoughtsBeliefsPhysiology of Addiction117 102. DRINKING.Behavior Mood Thoughts Beliefs Physiology of Addiction118 103. DRINKING. BehaviorPITIFUL, INCORMPREHENSIBLEMoodDEMORALIZATIONThoughtsBeliefsPhysiology of Addiction119 104. DRINKING! BehaviorPITIFUL, INCORMPREHENSIBLE MoodDEMORALIZATION IM JUST GOING TO USE ThoughtsFlawed Beliefs/ ThinkingTHERES NO WAY THATBeliefsI CAN STOP USING.Physiology of Addiction 120 105. Alcoholics Anonymous:734 482 5700www.aa-semi.orgPhysiology of Addiction 121 106. Physiology of Addiction 122 107. ?Physiology of Addiction 123 108. Physiology of Addiction 125 109. Physiology of Addiction 126 110. Gastric Bypass for eating disorders Liver transplant for cirrhosis ETOH and Hepatitis C: most common indication Brain surgery for addiction? Destroy the nucleus accumbens (China, Russia) Accidental injury to the insula: quit smoking!Physiology of Addiction127 111. 129 112. 130 113. Only about 40% of patients will be abstinent at oneyear after treatment. Failure rates may be due to lack of aftercare, oftendue to insurance difficulties Low economic status, psych comorbidity and lackof family/social supports also predict relapse. Relapse is often viewed as inevitable and drugdependence as hopeless* 131 114. ONLY 60% OF TYPE I DIABETICS ADHERE TOMEDICATION SCHEDULE LESS THAN 40% OF ASTHMATICS ADHERE TOTREATMENT REGIMEN LESS THAN 40% OF HYPERTENSIVES ADHERE TOTHEIR TREATMENT REGIMEN DRUG DEPENDENCE =40 TO 60% ADHERENCE 132 115. If you were to stop taking your insulin, and youwound up in a coma in the ICU, your doctor wouldsay: you need to go back on insulin! You could havedied! If you were to stop your Suboxone/methadone/12step treatment, and wind up in the ICU, your doctorwould say: Youre an addict. Youre hopeless!!!!!133 116. Decreased HIV infection rates Decreased incarceration Decreased drug use Decreased mortality McLellan, 2000 134 117. There is little evidence of effectiveness fromdetoxification or short-term stabilizationalone without maintenance or monitoringsuch as in (opioid) maintenance or AA.135 118. 136 Suboxone lecture 2 5 07 119. Obesity Hypertension Diabetes Asthma Addiction Physiology of Addiction 137 120. Physiology of Addiction 143 121. Physiology of Addiction 144 122. Physiology of Addiction 145 123. ccmdphd@mac.com http://public.me.com/ccmdphd Voice mail: 734 448 0226 Fax: 313 447 2244 Pain Recovery Solutions (A2): 734 434 6600 Physiology of Addiction 146