Know the Disease of Addiction Know the Treatment of Addiction Burns M. Brady, MD, FASAM.
Is Addiction Really a “Disease?” - National Council on ... handouts to the DVD Adapted from the...
Transcript of Is Addiction Really a “Disease?” - National Council on ... handouts to the DVD Adapted from the...
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Pleasure Unwoven: A Personal Journey about Addiction
companion handouts to the DVD
Adapted from the lecture “Is Addiction Really a Disease?” by Kevin
McCauley
and produced by the Institute for Addiction Study, Salt Lake City, UT
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Any good theory of addiction has to
explain …
• Genetic vulnerability
• Why some and not others?
• Loss of Control
• Persistent Use Despite Negative Consequences
• Drug of Choice
• Relapse
• Cross-Addictions
• Special utility of social/spiritual solutions
• Unpredictability of rewards/punishments in stopping addiction
• Why some are “instantly addicted”
• Why some drink/use socially for long periods & only later develop problems
• Sudden “cures”
• Self “cures”
• Personality changes
• Problematic history of pharmacological treatments
• Psychiatric co-morbidity
• Emotional “longing” component of craving
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“Choice” vs.
“Disease” • Free Will exists
• Responsibility
• Can stop
• Punishment and
Coercion DO
work
• BEHAVIORS
• No Free Will
• No Responsibility
• Can’t stop
• Punishment and
Coercion DON’T
work
• SYMPTOMS
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The
Disease
Model
(a CAUSAL model)
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If ever we could fit addiction into this
model, then it would win admission
into ”The Disease Club”. . .
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Addiction is a BRAIN disease
• The brain’s a HARD organ - very complex and difficult to study
• There are no good tests for brain diseases (yet)
• So people with brain diseases start out at a disadvantage
• The symptoms of brain diseases are more likely to be labeled as “badness”
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The Limbic (Emotional) Brain
CORTICAL
(Conscious)
• Prefrontal Cortex (PFC)
• Orbitofrontal Cortex
(OCC)
• Anterior Cingulate
Cortex (ACC)
SUBCORTICAL
(Unconscious)
• Midbrain
• Ventral Tegmental Area
(VTA)
• Nucleus Accumbens (NA)
• Hippocampus
• Amygdala
• Hypothalamus
(note: I use the term “midbrain” in
the DVD to denote all the
subcortical structures of the
limbic brain)
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The Key Parts of the Limbic
Brain
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The Frontal Cortex
•The “Human” Brain
•Processes judgment,
executive decision making,
•Conscious emotions
•Confers emotional
meaning onto objects in
the world
•Seat of the Self and
Personality
•“Love, Morality, Decency,
Responsibility, Spirituality”
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Orbitofrontal Cortex (OFC)
• Decision-making guided
by rewards
• Integrates sensory and
emotional information
from lower limbic
structures
• Flexible assignment of
value to environmental
stimuli to motivate or
inhibit choices & actions
• Self-monitoring and
social responding
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damage to Orbitofrontal Cortex
(OFC) • Causes a loss of a crucial
behavioral guidance
system
• Responses are impulsive
and inappropriate
• Deficits of self-regulation
• Inability to properly
assign value to rewards
(such as money vs.
drugs)
• Tendency to choose
small & immediate
rewards over larger but
delayed rewards
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Anterior Cingulate Cortex (ACC)
• Works with OFC:
decision-making
based on reward
values
• But also generates
new actions based on
past
rewards/punishments
• Appreciation and
valuation of social
cues
• MRI: active in tasks
requiring empathy
and trust
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damage to Anterior Cingulate Cortex
(ACC)
• Just as with OFC
damage: causes a loss
of a crucial behavioral
guidance system
• Inflexibility/Inability to
respond to errors in the
past with regard to
rewards/punishments
• Deficits in social
responding due to
decreased awareness
of social cues
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Prefrontal Cortex (PFC)
• Behavioral
regulation
• Reflective decision-
making
• Inhibition of socially
inappropriate
actions
• Emotional and
sensory integration
• Planning complex
behaviors
• Personality
expression
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damage to Prefrontal Cortex
(PFC)
• Failure of
executive function
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Failure of Executive
Functioning • Premature, unduly risky, poorly conceived
actions
• Urgency
• Sensation seeking
• Expressed emotions inappropriate to the
situation
• Deficits in attention, lack of perseverance
• Rapid responses without reflection or
premeditation
• Insensitivity to consequences
• Impulsive choice (increased delay
discounting)
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Conditions associated with
deficits in impulsive control
• Adolescence
• Alcohol use disorders
• Substance abuse
• ADHD
• Anti-social personality disorder
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But addiction does not begin
in the Frontal Cortex …
… addiction begins at a deeper
(and older) part of the brain: the
“Midbrain”
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The Midbrain is the SURVIVAL brain
• Not conscious
• Acts immediately, no future planning or assessment of long-term consequences
• A life-or-death processing station
for arriving sensory information
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The Midbrain (aka Limbic Brain)
is your SURVIVAL brain. It handles:
• EAT!
• KILL!
• SEX !
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Drugs work in the Midbrain
• NOT in the Cortex
(and how do we know
this? …)
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James Olds, PhD (1922 -
1976) • Discovery of the
reward system in the midbrain
• Mice will self-administer electric currents to the Ventral Tegmental Area of the midbrain
• They prefer the electrical stimulation over other survival rewards such as food
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Olds experiments:
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Mice preferentially self-administer
drugs of abuse like cocaine ONLY
to the Reward Centers of the
Midbrain
• To the exclusion of
all other survival
behaviors
• To the point of
death
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Mice get addicted to drugs, but …
• Mice don’t weigh moral consequences
• Mice don’t consult
their “Mouse God”
• Mice aren’t sociopaths
• Mice don’t have
bad parents
• There are no
“Mouse Gangs”
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In addiction, the drug hijacks the survival
hierarchy and is so close to actual survival
that it is indistinguishable from actual
survival
New #1:
DRUG!
2. EAT!
3. KILL!
4. SEX !
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In addiction, the drug is equated
with survival at the level of the
unconscious (i.e. the drug IS
survival)
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In addiction: a line is crossed
------------|------------>
NON-ADDICT (never used drugs)
(experimented in past)
(uses drugs)
(abuses drugs)
DRUG = DRUG
ADDICT
DRUG =
SURVIVAL
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Addiction is a disorder in the
brain’s Reward (Hedonic) System
It is a broken “pleasure sense” in the
brain
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Brain Perceptual Systems (all of them):
1. Vision
2. Hearing
3. Touch
4. Smell
5. Taste
6. Linear Acceleration
7. Angular Acceleration
8. Gravity (Proprioception) perceptual construct
9. Blood pO2 and pCO2
10. Pleasure perceptual construct
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Addiction is a disorder of …
5. … CHOICE (motivation)
4. … STRESS (anti-reward system)
3. … MEMORY (learning)
2. … PLEASURE (hedonic
system)
1. … GENES (vulnerability)
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Five Theories of Addiction
1. Genetic Vulnerability (Schuckit et al)
2. Incentive-sensitization of Reward (Robinson & Berridge)
3. Pathology of Learning & Memory (Hyman, Everitt & Robbins)
4. Stress and Allostasis (Koob & LeMoal)
5. Pathology of Motivation and Choice (Kalivas & Volkow)
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Addiction is a disorder of …
5.
4.
3.
2.
1. … GENES (vulnerability)
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Genetic Vulnerability
• Genetic difference determine “low responders” vs. “high responders” to the effects of alcohol (low responders more likely to become alcoholics)
• There are genetic differences in how people respond to methylphenidate (Ritalin) injections (some like it, some don’t care) implying different vulnerabilities
• For addicts, drugs really do “feel” different than they do to non-addicts
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COMT gene & Impulsiveness
• COMT (catechol-O-methytransferase ) is an enzyme
that breaks down mono-amine neurotransmitters
(Dopamine, Norepinephrine and Serotonin)
• Polymorphism at VAL-158-MET gene for COMT
influences impulsive decision-making style
• Individuals homozygous for more active 158-VAL
allele have an increased tendency to choose
immediate over delayed rewards
• This is an example of genetic variation that
contributes to impulsivity and may increase risk of
addiction
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Addiction is a disorder of …
5.
4.
3.
2. … PLEASURE (hedonic
system)
1. … GENES (vulnerability)
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Addiction Neurochemical #1:
Dopamine
• All drugs of abuse and potential compulsive behaviors release Dopamine
• Dopamine is first chemical of a pleasurable experience - at the heart of all reinforcing experiences
• DA is the neurochemical of salience (it signals survival importance)
• DA signals reward prediction error
• Tells the brain this is “better than expected”
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Drugs cause Dopamine Surges
in the midbrain reward system
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The Full Spectrum of Addiction
• Alcohol & Sedative/Hypnotics
• Opiates/Opioids
• Cocaine
• Amphetamines
• Entactogens (MDMA)
• Entheogens/Hallucinogens
• Dissociants (PCP, Ketamine)
• Cannabinoids
• Inhalants
• Nicotine
• Caffeine
• Anabolic-Androgenic Steroids
• Food (Bulimia & Binge Eating)
• Sex
• Relationships
• Other People
(“Codependency,” Control)
• Gambling
• Cults
• Performance
(“Work-aholism”)
• Collection/Accumulation (“Shop-aholism”)
• Rage/Violence
• Media/Entertainment
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Addiction is a disorder of …
5.
4.
3. … MEMORY (learning)
2. … PLEASURE (hedonic
system)
1. … GENES (vulnerability)
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Addiction Neurochemical #2:
Glutamate
• The most abundant neurochemical in the brain
• Critical in memory formation & consolidation
• All drugs of abuse and many addicting behaviors effect Glutamate which preserves drug memories and creates drug cues
• And … glutamate is the neurochemical of “motivation” (it initiates drug seeking)
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DOPAMINE (DA) GLUTAMATE
(Glu)
•All drugs of abuse and potential compulsive behaviors INCREASE DA
•Reward salience
•Reward Prediction Error
•“this is important!”
•“I really want this!”
•Rostral (up toward the nose) projections:
PFC < NA < VTA
•All drugs of abuse and potential compulsive behaviors EFFECT Glu
•Drug memories
•Drug seeking
•“OK, I’ll remember”
•“Fine, go and get it”
•Caudal (down toward the tail) projections:
PFC > NA
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Relapse
• Three things that are known to evoke relapse
in humans:
1. Brief exposure to drug itself (DA
release)
2. Exposure to drug cues (GLU release)
3. Stress (CRF release)
(example of a dangerous relapse-triggering behavior:
talking about drugs (cues) with other newly-sober
addicts in treatment (stressed) while smoking (DA
surge)
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Addiction is a disorder of …
5.
4. … STRESS (anti-reward system)
3. … MEMORY (learning)
2. … PLEASURE (hedonic
system)
1. … GENES (vulnerability)
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STRESS : a major player in addiction &
relapse
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We all face stress, yes . ..
But we don’t all:
• Face the same severity of stress
• Face the same pattern of stress
• Have the functioning coping mechanisms
• Come to the table with the same brain
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CHRONIC, SEVERE STRESS = CRF
and CRF = DAD2 receptors
and DAD2 receptors = Anhedonia
Anhedonia: Pleasure “deafness” (the patient is no longer able to derive
normal
pleasure from those things that have been
pleasurable in the past)
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Stress change the brain’s ability
to process Dopamine (pleasure)
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The Brain has a Hedonic “Set Point”
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Another “set point” in the brain . . .
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The Dopamine System changes in
conditions of severe, chronic stress
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High stress hormone levels reset
the brain’s pleasure “set point”
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Change in Hedonic Set Point:
Old pleasures don’t show up
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Anhedonia: Pleasure “deafness”
• The patient is no longer able to derive
normal pleasure from those things that
have been pleasurable in the past
• Addiction is a stress-induced “hedonic
dysregulation”
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Drugs cause Dopamine
Surges in the midbrain
reward system
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In addiction, the drug hijacks the survival
hierarchy and is so close to actual survival
that it is indistinguishable from actual
survival
New #1:
DRUG!
2. EAT!
3. KILL!
4. SEX !
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Addiction is a disorder of …
5. … CHOICE (motivation)
4. … STRESS (anti-reward system)
3. … MEMORY (learning)
2. … PLEASURE (hedonic
system)
1. … GENES (vulnerability)
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The hypofrontal/craving brain state
represents and imbalance between 2
brain drives
Cortico-Striatal Circuit
• “STOP!”
• Organized, Attentive
• Sensitive to
consequences
• Well-planned
• Socially appropriate
THERE’S TOO LITTLE OF
THIS
Amygdalar-Cortical Circuit
• “GO!”
• Impulsive
• Non-reflective
• Poorly conceived
• Socially inappropriate
THERE’S TOO MUCH OF
THIS
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HYPOFRONTALITY: during craving states the cortex actually
shuts off
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The ventro-medial Prefrontal Cortex
(vmPFC)
• Bechara: research on patients with vmPFC lesions
• “Myopia for the future,” cognitive impulsiveness
- prefer immediate but disadvantagous rewards over delayed rewards advantageous in the long run
- guided primarily by immediate prospects and insensitive to pos or neg future consequences
- deny or are unaware of the problem
- preferred low immediate punishment over higher immediate punishment with greater advantage over time
• vmPFC pts similar to Substance Abusing patients on MRI
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Craving / Drug Seeking
• Not quite as conscious as deliberative acts
• More automatic - like driving a car home from
work without really thinking about it
• “I was vaguely aware that what I was doing
was not too smart”
• “There I was again with a drink in my hand
thinking that this time things would be
different”
• A “ruminative,” emotional and involuntary
process that many would describe as a form
of suffering
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Why the “Choice Argument” fails
…
• It fails to take into account CRAVING
• The “Choice Argument” measures
addiction only by the addict’s external
behavior
• It ignores the inner suffering of the patient
• You don’t actually have to have drug use
for the defective physiology of addiction to
be active
• The addict cannot choose to not crave
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How do we restore
the Frontal Cortex?
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Addiction Part One:
• Misperception of
the hedonic aspects
of the drug
And
• Attribution of
survival salience to
the drug on the level
of the unconscious
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Addiction Part Two:
• The drug takes on
personal meaning
• The addict
develops an
emotional
relationship with
the drug
• The addict derives
their sense of self
and exerts agency
through the drug
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The Two Tasks of Addiction Treatment:
1. To give the addict
workable,
credible tools to
proactively
manage stress
and decrease
craving
2. For each individual
addict, find the
thing which is
more emotionally
meaningful than
the drug - and
displace the drug
with it
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Then . . .
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Definition of Addiction:
Addiction is a dysregulation of the midbrain dopamine (pleasure) system due to unmanaged stress resulting in symptoms of decreased functioning, specifically:
1. Loss of control
2. Craving
3. Persistent drug use despite negative consequences
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Addiction
fits the
“Disease
Model!”
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Questions?
References available on request
Please contact:
Kevin McCauley
The Institute for Addiction Study
(435) 659-6293
Please also see: www.addictiondoctor.com
(©2010, Kevin T McCauley, not for resale, all rights reserved)