New Tools and Troubles New Tools and Troubles in Addiction Treatmentin Addiction Treatment

Paul H. Earley, M.D., FASAMPaul H. Earley, M.D., FASAMMedical DirectorMedical Director

Talbott Recovery CampusTalbott Recovery CampusAtlanta, GeorgiaAtlanta, Georgia

USAUSA

Outline of this TalkOutline of this Talk

• Trouble: Public OpinionTrouble: Public Opinion

• Tool: Clarifying Addiction CravingTool: Clarifying Addiction Craving

• Trouble: Addiction MemoryTrouble: Addiction Memory

• Tool: EMDR and MeditationTool: EMDR and Meditation

• Tool: BuprenorphineTool: Buprenorphine

• Trouble: BuprenorphineTrouble: Buprenorphine

Trouble:Trouble:Public OpinionPublic Opinion

Has Public Perception Improved?Has Public Perception Improved?Brian West and the California Physician Diversion Brian West and the California Physician Diversion ProgramProgram

Tool:Tool:Clarify Addiction CravingClarify Addiction Craving

Craving ClassificationCraving Classification

• Cue-based cravingCue-based craving– Craving is a response to environmental cueCraving is a response to environmental cue– Cue creates internal state which is recognized as cravingCue creates internal state which is recognized as craving– Most notable in cocaine, methamphetamine and nicotineMost notable in cocaine, methamphetamine and nicotine

• State or stress-based cravingState or stress-based craving– Emotional tone and the level of perceived stress set a Emotional tone and the level of perceived stress set a

specific statespecific state– Craving appears to emerge out of the more difficult of Craving appears to emerge out of the more difficult of

these statesthese states– Most notable in alcohol, opioids, and sedativesMost notable in alcohol, opioids, and sedatives

• Addiction Memory cravingsAddiction Memory cravings– Replay of using-related materialReplay of using-related material– Related to Euphoric recallRelated to Euphoric recall

Cue-based cravingCue-based craving

Craving WorkbookCraving Workbook

• Cue-based cravingCue-based craving– Break down major cues into:Break down major cues into:

•AA - Always avoid - Always avoid•BB - Avoid now - Avoid now •CC - Desensitize - Desensitize

– Develop avoidance plans for Develop avoidance plans for AA– Decide when to expose and a response Decide when to expose and a response

plan for plan for BB– Begin cue exposure and desensitization Begin cue exposure and desensitization

for for CC

Trouble:Trouble:Addiction MemoryAddiction Memory

Learning about Addiction Learning about Addiction MemoryMemory

• Neural circuitry of relapseNeural circuitry of relapse

• FearFear

• PTSD PhysiologyPTSD Physiology

• Addiction MemoryAddiction Memory

Craving is an Internal BattleCraving is an Internal Battle

• Once the hypothalamus is entrained Once the hypothalamus is entrained to seek reward through addiction:to seek reward through addiction:– A constant battle emerges between the A constant battle emerges between the

more primitive parts of the brain and the more primitive parts of the brain and the contemplative frontal cortexcontemplative frontal cortex

– The primitive parts of the brain recruit The primitive parts of the brain recruit behaviors and thoughts to hijack behaviors and thoughts to hijack recoveryrecovery

Conflicts in Control Lead to Conflicts in Control Lead to RelapseRelapse

I shouldn’t, look what it will do. I promised, etc.

I want to.I long for it.

The AmygdalaThe Amygdala

from Sundsten, University of Washington Digital Anatomist Project

The two pathways of fearThe two pathways of fear

LeDoux as described by “The Brain from Top to Bottom”, McGill University

Acute Fear – Normal Acute Fear – Normal ProcessingProcessing1.1. A traumatic event occursA traumatic event occurs

2.2. The amygdala sounds an alarm through the The amygdala sounds an alarm through the “short loop.” More malleable and slower “short loop.” More malleable and slower responses to the event occur through the responses to the event occur through the thalamocortical (long) loop.thalamocortical (long) loop.

3.3. The pituitary gland secretes Corticotropin-The pituitary gland secretes Corticotropin-releasing Factor (CRF)releasing Factor (CRF)

4.4. The cerebellum is mobilized for movementThe cerebellum is mobilized for movement

5.5. The medulla oblongata activates the The medulla oblongata activates the cardiovascular system and shuts down cardiovascular system and shuts down digestion. The pons increases respiration.digestion. The pons increases respiration.

Acute Fear – Normal Acute Fear – Normal ProcessingProcessing6.6. The locus coeruleus secretes norepinephrine and the The locus coeruleus secretes norepinephrine and the

nucleus accumbens and surrounding structures secrete nucleus accumbens and surrounding structures secrete dopamine to rivet attention.dopamine to rivet attention.

7.7. The visual cortex, in concert with the hippocampus, The visual cortex, in concert with the hippocampus, creates a visual recording of the event.creates a visual recording of the event.

8.8. When the acute situation subsides, the cortex revisits When the acute situation subsides, the cortex revisits the images, reprocessing the event into semantic and the images, reprocessing the event into semantic and episodic memory. This deactivates the amygdala-driven episodic memory. This deactivates the amygdala-driven memory circuits.memory circuits.

9.9. Dreams further process the meaning of the fear-event, Dreams further process the meaning of the fear-event, providing behavioral alternatives to avoid or deflect the providing behavioral alternatives to avoid or deflect the trauma and improve survivability. Dreaming encodes trauma and improve survivability. Dreaming encodes complex behavioral responses (procedural memory) and complex behavioral responses (procedural memory) and draws associations between the current fear event and draws associations between the current fear event and past fear memories.past fear memories.

Post-traumatic Stress Post-traumatic Stress DisorderDisorder• Singular or recurrent traumaSingular or recurrent trauma

• Produces persistent, frightening thoughts and Produces persistent, frightening thoughts and memories or flashbacks of the ordealmemories or flashbacks of the ordeal

• Persons with PTSD often feel chronically Persons with PTSD often feel chronically emotionally numbemotionally numb

• Flashbacks are often similar to a movie clipFlashbacks are often similar to a movie clip

• PTSD victims have an exaggerated startle PTSD victims have an exaggerated startle responseresponse

• Once PTSD circuits are engaged, other strong Once PTSD circuits are engaged, other strong memories are encoded in PTSD memory circuits memories are encoded in PTSD memory circuits instead of being processed into episodic memoryinstead of being processed into episodic memory

What happens with PTSD?What happens with PTSD?

• The acute trauma is either too overwhelming or The acute trauma is either too overwhelming or is repeated, preventing the individual from is repeated, preventing the individual from reprocessing the traumareprocessing the trauma

• The trauma “tape” becomes stuck in visual The trauma “tape” becomes stuck in visual memorymemory

• The victim numbs to avoid emotionally The victim numbs to avoid emotionally experiencing the traumaexperiencing the trauma

• Dreams and further meaning-extraction does Dreams and further meaning-extraction does not occur, rending the organism susceptible to not occur, rending the organism susceptible to recurrencerecurrence

• The victim may engage in “trauma re-The victim may engage in “trauma re-enactment” to reactivate the release of enactment” to reactivate the release of endorphins and dopamineendorphins and dopamine

What happens with What happens with Addiction?Addiction?• Use is repeated over time, preventing the Use is repeated over time, preventing the

individual from reprocessing the experience.individual from reprocessing the experience.• Some of the intense using experiences produce a Some of the intense using experiences produce a

“tape” which becomes stuck in visual memory.“tape” which becomes stuck in visual memory.• The addict numbs to avoid emotionally The addict numbs to avoid emotionally

experiencing the consequences of their illness.experiencing the consequences of their illness.• Dreaming is suppressed and further meaning-Dreaming is suppressed and further meaning-

extraction does not occur, rending the organism extraction does not occur, rending the organism susceptible to continued use and relapse.susceptible to continued use and relapse.

• To stimulate the release of endorphins and To stimulate the release of endorphins and dopamine, the addict re-enacts addiction dopamine, the addict re-enacts addiction behaviors (even before drugs enter the system).behaviors (even before drugs enter the system).

Is Addiction Recovery like Is Addiction Recovery like PTSD?PTSD?

• Makes many alcoholics and addicts feel Makes many alcoholics and addicts feel simultaneously in love and abusedsimultaneously in love and abused

• Hijacks the self-preservation circuits of the brainHijacks the self-preservation circuits of the brain

• Overwhelms memory circuitsOverwhelms memory circuits

• Stimulates dopamine in the nucleus accumbensStimulates dopamine in the nucleus accumbens

• Produces memory tapes which over-ride normal Produces memory tapes which over-ride normal life experiences making them seem pale in life experiences making them seem pale in comparison to their alcohol or drug usecomparison to their alcohol or drug use

Addiction:Addiction:

……like like PTSDPTSD

Tool:Tool:EMDREMDR

EMDREMDR

• Stands for: Eye Movement Desensitization and ReprocessingStands for: Eye Movement Desensitization and Reprocessing• Patient identifies past visual imagery related to the traumatic Patient identifies past visual imagery related to the traumatic

memory, a negative belief about self, and related body memory, a negative belief about self, and related body sensations.sensations.

• While focusing on the above, the patient follows the therapists While focusing on the above, the patient follows the therapists finger moving their eyes across their field of vision for 20-30 finger moving their eyes across their field of vision for 20-30 seconds or more. Other lateralizing stimuli (tones or tapping) seconds or more. Other lateralizing stimuli (tones or tapping) are also used.are also used.

• Distress from the memories, beliefs and sensations is Distress from the memories, beliefs and sensations is managed so the patient can return to the procedure.managed so the patient can return to the procedure.

• Once started, EMDR does follow where the patient’s thoughts Once started, EMDR does follow where the patient’s thoughts lead.lead.

• The outcome, over time, is a belief in positive characteristics The outcome, over time, is a belief in positive characteristics of self and decreased distress over trauma experiences.of self and decreased distress over trauma experiences.

Theories on how EMDR Theories on how EMDR worksworks• Eye movement invokes the same brain Eye movement invokes the same brain

circuitry as REM sleep allowing memories to circuitry as REM sleep allowing memories to move from unprocessed amygdala-evoked move from unprocessed amygdala-evoked memories to semantic memory.memories to semantic memory.

• The alternating lateralizing stimuli (eye The alternating lateralizing stimuli (eye movement, tapping) forces the movement movement, tapping) forces the movement of memories into both cortical hemispheres, of memories into both cortical hemispheres, away from the lateralized (right amygdala away from the lateralized (right amygdala dominance) of PTSD circuits.dominance) of PTSD circuits.

Research on EMDRResearch on EMDR

• EMDR decreases left and right occipital EMDR decreases left and right occipital lobe activity and left parietal lobe.lobe activity and left parietal lobe.

• EMDR increases activity in the anterior EMDR increases activity in the anterior cingulate gyrus and the left frontal lobe.cingulate gyrus and the left frontal lobe.

• These brain correlates confirm that the These brain correlates confirm that the successful treatment of PTSD does not successful treatment of PTSD does not reduce arousal at the limbic level, but reduce arousal at the limbic level, but instead, enhances the ability to instead, enhances the ability to differentiate real from imagined threat.differentiate real from imagined threat.

Levin P, Lazrove S, van der Kolk, B. J. Anxiety Disorders Jan-Apr;13(1-2):159-72 (1999).

EMDR and RecoveryEMDR and Recovery

• EMDR helps patients reframe their attachment to EMDR helps patients reframe their attachment to drug use and drug lifestyle into “addiction trauma.”drug use and drug lifestyle into “addiction trauma.”

• EMDR decreases traumatic memories that EMDR decreases traumatic memories that destabilize the path to recovery.destabilize the path to recovery.

• EMDR provides hope of trauma resolution for EMDR provides hope of trauma resolution for patients who have suffered past physical, sexual patients who have suffered past physical, sexual and emotional trauma in addition to addiction and emotional trauma in addition to addiction trauma.trauma.

• EMDR may decrease euphoric recall.EMDR may decrease euphoric recall.

• EMDR may reprogram the procedural learning EMDR may reprogram the procedural learning produced by past use behaviors, and thus, decrease produced by past use behaviors, and thus, decrease relapse.relapse.

Tool:Tool:MeditationMeditation

MeditationMeditation

• Practiced in many forms, both as part of Practiced in many forms, both as part of Eastern religions and in non-sectarian Eastern religions and in non-sectarian situationssituations

• Often one sits in a predefined position and Often one sits in a predefined position and minimizes or eliminates body movementminimizes or eliminates body movement

• Eyes are open or closedEyes are open or closed• The primary goal is to let go of or eliminate The primary goal is to let go of or eliminate

thought, to reach a place where you are in the thought, to reach a place where you are in the presence of mind without the brain chatterpresence of mind without the brain chatter

• Christian meditation may achieve the same Christian meditation may achieve the same state (listening to God)state (listening to God)

What does meditation do?What does meditation do?

• Even simplified low dose Even simplified low dose meditation produces reduced meditation produces reduced heart rate, slowed breathing, heart rate, slowed breathing, and decreased blood pressureand decreased blood pressure

• Meditation practitioners Meditation practitioners develop an increase in develop an increase in synchronous gamma-frequency synchronous gamma-frequency oscillations on EEG. In addition oscillations on EEG. In addition their EEGs show phase-their EEGs show phase-synchrony during meditation. synchrony during meditation. Both of these phenomenon are Both of these phenomenon are predominantly over the frontal predominantly over the frontal lobes. (Davidson, 2004)lobes. (Davidson, 2004)

What does meditation do?What does meditation do?

• fMRI studies show increased blood flow in fMRI studies show increased blood flow in the dorsolateral prefrontal and parietal the dorsolateral prefrontal and parietal cortices, hippocampus / parahippocampus, cortices, hippocampus / parahippocampus, temporal lobe, anterior cingulate cortex, temporal lobe, anterior cingulate cortex, striatum, and pre- and post-central gyri striatum, and pre- and post-central gyri during meditation (Lazarus and Benson, during meditation (Lazarus and Benson, 2000)2000)

• Meditation increases cortical thickness in Meditation increases cortical thickness in several critical areas of the brain (Lazar, several critical areas of the brain (Lazar, 2005)2005)

Meditation and the EEGMeditation and the EEG

Davidson, 2004

Meditation and Cortical Meditation and Cortical ThicknessThickness

p<10-3 p<10-4

Cortical thickness is correlated with increased neuronal connections, glial volume or increased cerebral vasculature

Davidson, 2005

Meditation and RecoveryMeditation and Recovery

• Meditation increases synchrony between the Meditation increases synchrony between the right and left brain, and more importantly right and left brain, and more importantly between cortical and lower neuronal centers between cortical and lower neuronal centers of the brain.of the brain.

• Meditation increases anterior cingulate Meditation increases anterior cingulate function, important for salience testing and function, important for salience testing and attentionattention

• Meditation purports to inhibit amygdaloid Meditation purports to inhibit amygdaloid over-control by increasing frontal lobe over-control by increasing frontal lobe activity.activity.

Meditation and RecoveryMeditation and Recovery

• Meditation has been shown to decrease Meditation has been shown to decrease impulsivity and increase tolerance for impulsivity and increase tolerance for the “negative” emotions, especially in the “negative” emotions, especially in borderline PD patients (research from borderline PD patients (research from dialectical behavioral therapy)dialectical behavioral therapy)

• Meditation increases the quality of Meditation increases the quality of living-in-the-moment.living-in-the-moment.

• Meditation increases the sensation of Meditation increases the sensation of general well-being.general well-being.

Tool:Tool:BuprenorphineBuprenorphine

Buprenorphine - ToolBuprenorphine - Tool

• Mixed agonist/antagonist: Mixed agonist/antagonist: – At lower dose, it has primarily agonist At lower dose, it has primarily agonist

propertiesproperties– As the dose increases, increasing As the dose increases, increasing

antagonist action occursantagonist action occurs• Much simpler regulation of its prescription, Much simpler regulation of its prescription,

when compared to methadonewhen compared to methadone• Unlike methadone, no recorded cardiac-Unlike methadone, no recorded cardiac-

related deathsrelated deaths

Buprenorphine - ToolBuprenorphine - Tool

• Excellent detoxification medicineExcellent detoxification medicine– Has changed the detoxification environment Has changed the detoxification environment

and increased detoxification success ratesand increased detoxification success rates– Produces only mild euphoriaProduces only mild euphoria

• Good maintenance medicationGood maintenance medication– Less sedation than methadoneLess sedation than methadone– Less stigmatizing, obtained through Less stigmatizing, obtained through

prescription rather that a “drug clinic”prescription rather that a “drug clinic”– Very difficult to overdose with Very difficult to overdose with

buprenorphinebuprenorphine

Trouble:Trouble:BuprenorphineBuprenorphine

Buprenorphine – TroubleBuprenorphine – Trouble

• Physicians IssuesPhysicians Issues– Physicians who would never open up a methadone Physicians who would never open up a methadone

clinic need only obtain 8 hours or less of training to clinic need only obtain 8 hours or less of training to begin prescribing buprenorphinebegin prescribing buprenorphine

– Physicians trained in abstinence-based beliefs, Physicians trained in abstinence-based beliefs, who previously looked down upon methadone, are who previously looked down upon methadone, are amazed by the benefits of opioid-agonist therapyamazed by the benefits of opioid-agonist therapy

– Buprenorphine has opened up a whole area of Buprenorphine has opened up a whole area of practice for the solo addiction medicine specialistpractice for the solo addiction medicine specialist

– Once on maintenance medication, patients Once on maintenance medication, patients willwill show up for return appointmentsshow up for return appointments

Buprenorphine – TroubleBuprenorphine – Trouble

• Some buprenorphine proponents Some buprenorphine proponents compare the use of buprenorphine to compare the use of buprenorphine to the introduction of SSRIs and non-the introduction of SSRIs and non-addicting sleep aides into treatment addicting sleep aides into treatment centerscenters

• But a fundamental difference exists:But a fundamental difference exists:– Buprenorphine, as a μ agonist, blocks pain–Buprenorphine, as a μ agonist, blocks pain–

including emotional pain–and thwarts including emotional pain–and thwarts psychotherapeutic and spiritual growthpsychotherapeutic and spiritual growth

Buprenorphine – TroubleBuprenorphine – Trouble

• Abstinence-based Treatment Center IssuesAbstinence-based Treatment Center Issues– Once on buprenorphine, it is difficult is some Once on buprenorphine, it is difficult is some

patients to move from 2 mg / day to zero (the empty patients to move from 2 mg / day to zero (the empty receptor syndrome)receptor syndrome)

– Because patients feel “normal” on buprenorphine, Because patients feel “normal” on buprenorphine, everyone is lulled into avoiding deeper examination everyone is lulled into avoiding deeper examination of any incorrect treatment metaphorsof any incorrect treatment metaphors

– Some treatment centers mix buprenorphine-Some treatment centers mix buprenorphine-maintained patients with fully abstinent and maintained patients with fully abstinent and proclaim there is no difference.proclaim there is no difference.

• But have we really examined what are we But have we really examined what are we saying?saying?

Buprenorphine – TroubleBuprenorphine – Trouble

• We need to draw upon all of the We need to draw upon all of the sophistication we have available to us. sophistication we have available to us.

• We need not discard buprenorphine We need not discard buprenorphine maintenance – it is a valuable short term (3 maintenance – it is a valuable short term (3 to 9 month) and long term tool (1 year to to 9 month) and long term tool (1 year to lifetime).lifetime).– But we should But we should notnot decide the type of treatment decide the type of treatment

the patient receives based upon the training or the patient receives based upon the training or bias of the caregiver.bias of the caregiver.

– This means clear and methodology neutral This means clear and methodology neutral treatment protocolstreatment protocols

Buprenorphine MaintenanceBuprenorphine Maintenance

• We suggest a finer granularity in our We suggest a finer granularity in our nomenclaturenomenclature– For those on patients on sustained dosing of For those on patients on sustained dosing of

buprenorphine, a moniker is suggested: buprenorphine, a moniker is suggested: “Maintenance-assisted recovery”“Maintenance-assisted recovery”

– This complements one other path: “abstinence-This complements one other path: “abstinence-based recovery”based recovery”

– Patients may need to move from these two Patients may need to move from these two treatment types and we need to be able to treatment types and we need to be able to clearly delineate treatment protocolsclearly delineate treatment protocols

• Buprenorphine maintenance should always Buprenorphine maintenance should always be buttressed by random urine drug be buttressed by random urine drug screeningscreening

Education and ConsultationEducation and Consultation

• Contact: Contact: – By phone: 678 251 3188By phone: 678 251 3188

– By E-mail: By E-mail: paul.earley@uhsinc.compaul.earley@uhsinc.com