Hope for Addiction: A Brain Not on Drugs
 

Course Number	LWD401
Objectives	At the end of this course, you will  1) the meaning of addiction, 2) how addiction affects the brain, 3) treatments for addiction, and 4) prevention of addiction.
Credit Hours and Fee	3.0 CE Credit Hours with a fee of $24.00
Instructor	Rudolf Klimes, PhD (Indiana University), MPH (Johns Hopkins University), Adjunct Professor at Folsom Lake College, Folsom, CA.

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“To understand adolescent substance abuse we need to understand first of all the cultural context in which it occurs.  This, in a sense, is the first risk factor, and applies to most youth, for America has become a drug oriented society: in other words, our ethics with respect to the use of mood-altering chemicals are basically permissive and sympathetic.” (Joseph Nowinski)

“On the Eve of the Millenium, I ventured out with many of my friends to party the new year in. We had already passed the countdown and it was getting late, about 1 or 2 am. My friends Joe, Mike and Nester all showed up at the party I was at and asked if I wanted to go with them to rave. I agreed because I am a big lover of the rave scene. So we all piled into Mike's car and went to his house. Joe said he got Mike 4 hits of x and we were all going to share. We all took a hit. I remember Joe came up to me, put the pill in my hand and handed me the Gatorade. I drank it down and he said ' Don't think about it, and it will hit you quicker' So we proceeded to Mike's bedroom and we all sat around talking. Mike put on some Bjork, and we all just enjoyed the music.

   Soon enough I felt a tingling all over my body. I noticed my skin felt like a different surface, like rubber. I put my head in my hands and felt the strands of hair flow between my fingers. I went to lie down on the bed and put my jacket over my face. The lining was so soft and seemed to flow like water over my face. They asked me 'Are you okay?' I answered back, 'Mmmhmm.' They asked me to go sit by them on the floor. As I sat down, I felt the white carpet rub against my hands. I had never felt such softness in a carpet. I noticed this and yearned to feel the carpet on my arms and body. So I lay down on the floor and proceeded to roll around like a cat… rubbing my body all over the carpet. Nester got me up and put my hands on his head. It was incredible. He had a shaved head and the peach fuzz was so incredibly soft, I never felt anything like it.” Source 

 1. The meaning of addiction

1.1 What is addiction?

1.2  What is a craving?

The essence of addiction is uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences. This is the crux of how many professional organizations all define addiction, and how we all should use the term. It is really only this expression of addiction - uncontrollable, compulsive craving, seeking and use of drugs - that matters to the addict and to his or her family, and that should matter to society as a whole. These are the elements responsible for the massive health and social problems caused by drug addiction.

Drug craving and the other compulsive behaviors are the essence of addiction. They are extremely difficult to control, much more difficult than any physical dependence. They are the principal target symptoms for most drug treatment programs. For an addict, there is no motivation more powerful than drug craving. As the movie "Trainspotting" showed us so well, the addicts entire life becomes centered on getting and using the drug. Virtually nothing seems to outweigh drug craving as a motivator. People have committed all kinds of crimes and even abandoned their children just to get drugs. Source NIDA

Regardless of professional identity or discipline, each treatment provider must have a basic understanding of addiction that includes knowledge of current models and theories, appreciation of the multiple contexts within which substance use occurs, and awareness of the effects of psychoactive drug use. Each professional must be knowledgeable about the continuum of care and the social contexts affecting the treatment and recovery process. Each addictions specialist must be able to identify a variety of helping strategies that can be tailored to meet the needs of the individual client. Each professional must be prepared to adapt to an ever-changing set of challenges and constraints.

Although specific skills and applications vary across disciplines, the attitudinal components tend to remain constant. The development of effective practice in addictions depends on the presence of attitudes reflecting openness to alternative approaches, appreciation of diversity, and willingness to change. Source

 2. How addiction affects the brain

2.1  In what way is addiction a brain disease?

2.2  How does the effect on the brain differ when it comes to different drugs?

2.3  What is the place of dopamine and other neurotransmitter in addiction?

Drug abuse is a brain disease that changes the brain physically and chemically. Addiction alters the way the brain's pleasure circuit (also called the reward circuit or  hedonic circuit) works. Food, sex, gambling, personal power and novelty also increase the brain's dopamine (a brain neurotransmitter) level, create pleasure and may be addictive. But drugs change the brain over time, flood it with dopamine and eventually reduce the pleasure effect. Thus the addict takes more and more drugs just to feel less miserable. The pleasure is gone. 

Cocaine stops the molecules that usually mop up excess dopamine. Amphetamines push the dopamine out of the sacs where it is stored. Heroin makes the dopamine-containing neurons fire more. Alcohol helps release more dopamine. Thus with an excess of dopamine, the addict feels high.

Drugs affect memory and even the recall of drug-situations can cause relapses. Starting is easy, stopping is not. Relapses are very common. 

Researchers in NIDA's Division of Intramural Research (DIR) have recently published brain imaging findings that show that cue-induced drug craving is linked to distinct brain systems that are involved in memory. (For more on using imaging to study craving, see NIDA-Supported Researchers Use Brain Imaging to Deepen Understanding of Addiction)

"Drug craving is a central aspect of addiction and poses an obstacle to treatment success for many individuals," says NIDA Director Dr. Alan I. Leshner. "Twenty years of neuroscience research have brought us to where we can actually see increases in specific brain activity that are linked to the experience of craving. If we can understand the mechanisms that cause craving in people addicted to cocaine or other drugs, more effective treatment strategies can be developed that counteract craving." NIDA

Some researchers ( Michael Bordo, Mary Jeanne Kreek) suggest that the dopamine system that is activated by drugs may also be turned on by novelty-seeking behavior. People who always look for the next new thing may be driven by the same pleasure system as drug abusers.

Dopaminergic genes are likely candidates for heritable influences on cigarette smoking. Lerman reports associations between allele 9 of a dopamine transporter gene polymorphism (SLC6A3-9) and lack of smoking, late initiation of smoking, and length of quitting attempts. The present investigation extended their study by examining both smoking behavior and personality traits in a diverse population of nonsmokers, current smokers, and former smokers ( N = 1,107). A significant association between SLC6A3-9 and smoking status was confirmed and was due to an effect on cessation rather than initiation. The SLC6A3-9 polymorphism was also associated with low scores for novelty seeking, which was the most significant personality correlate of smoking cessation. It is hypothesized that individuals carrying the SLC6A3-9 polymorphism have altered dopamine transmission, which reduces their need for novelty and reward by external stimuli, including cigarettes. Lerman et al

The Please Chemical: Dopamine

Attributed to Hippocrates (470-377 B.C.), this riveting quotation is a haunting description of drug abuse and addiction:

"Men ought to know that from the brain, and from the brain only, arise our pleasures, joys, laughter and jests, as well as our pains, sorrows, griefs and fears. It is the same thing that makes us mad or delirious, inspires us with dread and fear, whether by night brings sleeplessness, inopportune mistakes, aimless anxieties, absentmindedness and acts that are contrary to habit. These things that we are suffer come from the brain when it was not healthy."

Hippocrates surmised, rightfully, that the brain was the source of pleasure and pain. What he could not envision 2,500 years ago was that, at the end of the 20th century, advanced technologies would produce drugs that mimic all the sensations that the brain produces endogenously.

The progression of drug abuse to addiction and recovery can be described in phases: the acute drug phase that produces pleasure, the addiction phase, withdrawal, and abstinence. The first part of Hippocrates' quotation refers to the initial state of drug use, when sensations are positive and incentive builds to use again. The second part of the quote corresponds to the second, third, and final stages of drug use-addiction, withdrawal, and craving. This presentation focuses on the initial phase and the initial targets of cocaine in the brain.

Accumulating evidence indicates that dopamine-containing neurons are principal targets of cocaine in the brain. Dopamine is found in neurons unevenly distributed in the brain. At least four major clusters of cells produce dopamine. Of these, the mesolimbic dopamine neurons are often implicated as the mediators of reward or reinforcement. They originate in the ventral tegmental area and project to various forebrain structures, including the nucleus accumbens and cortical regions. When dopamine is released from these projection neurons, it activates at least five subtypes of presynaptic and postsynaptic dopamine receptors. Receptor activation by dopamine is rapidly terminated by a number of processes, of which transport into the presynaptic neuron by the dopamine transporter (DAT) is one of the most significant. B. Madras, NIDA

Early studies showed that cocaine blocks the transporters for three different neurotransmitters: dopamine, serotonin, and norepinephrine. Later, one vein of research suggested that cocaine's blockade of the dopamine transporter was most important for producing the drug's euphoric effects. By blocking the dopamine transporter, some scientists theorized, cocaine might raise the level of extracellular dopamine in brain regions involved in the feeling of pleasure. This excess dopamine could continue to affect neurons in these regions, giving rise to euphoria.

All drugs of abuse disrupt the normal flow of the neurotransmitter dopa-mine, stimulating its release and increasing its brain levels. This action is believed to be significantly involved in producing drug-induced feelings of pleasure and reward and, over time, addiction and vulnerability to withdrawal symptoms. Drugs of abuse begin this action by chemically binding to specific molecular sites called receptors, some of which are found on dopamine nerve cells.

Recent findings from several NIDA-funded researchers confirm not only that nicotine is highly addictive but that it affects the same brain mechanism as other drugs of abuse and increases brain levels of dopamine. The findings also suggest how nicotine abstinence and withdrawal activate the body's stress systems. Two research teams have spotlighted how nicotine, just like heroin or cocaine, activates dopamine-containing nerve cells in the brain's mesolimbic system, which is involved in emotion and behavior. Another group has shown that some brain changes during withdrawal from chronic nicotine use are similar to those that occur during withdrawal from other drugs of abuse. Source NIDA

3. Treatments for addiction

3.1   How is addiction treated?

3.2  What is the disease model as it relates to addiction?

3.3  How is the spiritual component of addiction deal with?  

Treatment for addiction may be outpatient or inpatient, for about a month or a year.  The longer the treatment, the better the results. Phoenix House, with 5000 residences, is the nations largest network of centers.

Addiction is a major problem: 11 million Americans use marijuana; 430,000 are killed by tobacco, 100,000 die yearly of alcohol-related causes. Alcohol costs the nation $185 billion a year, more than all illegal drugs combined.  

Most drug abuse is treated with a combination of counseling, education, medications, and social/family support. The medications for alcohol are aften Antabuse, acamprosate and naltrexone; for herion, Methadone and buprenorphine. 

According to the philosophy underlying the IDC approach, addiction is a complex disease that damages the addict physically, mentally, and spiritually. Because of the holistic nature of the illness, the optimal treatment addresses the needs of the addict in many areas. Physical, emotional, spiritual, and interpersonal needs must all be addressed to support recovery.

The philosophy of this approach incorporates two important elements: endorsement of the disease model and the spiritual dimension of recovery. These elements differentiate the approach from some other forms of treatment currently in use and reflect the influence of the 12-step philosophy.

The disease model essentially states that addiction is more closely akin to an illness over which one has little, if any, control, compared to a behavior that one chooses to enact. Recent biologically oriented research suggests a genetic component to alcohol and other addictions and points to physiological changes in the brain that result from drug use. These findings are very consistent with the disease model (Bloom 1992; Heinz et al. 1998).

The element of spirituality is very general and not specific to any religion. Three of the main spiritual principles, as taken from Narcotics Anonymous (NA) philosophy, are honesty, openmindedness, and willingness. This spiritual component implies that there is a healing of one's life that needs to take place, and abstinence from the drug is merely the first step rather than the terminal goal. A holistic perspective on the individual is encouraged, which suggests that recovery involves a return to self-respect through honesty with oneself and others. Spirituality also involves a belief in or sense of connection to something greater than oneself, which is quite consistent with some of the newer models of psychotherapy. However, within addiction counseling, the role of spirituality in healing tends to be more focused and overtly stated than in most other therapeutic orientations. Source NIDA

 4. Prevention of addiction

4.1  How can addiction be prevented?

4.2  Why is it so difficult to prevent addiction?  

In a very simplistic way, the best preventative for addiction is total abstinence. People who do not experiment with drugs or who do not use drugs do not become addicts. Drug addiction is a consequence of drug use. It is similar to the fact that girls who do not have sex do not become pregnant. Pregnancies are consequences of sexual activities.

Understanding how drugs work on the human mind and body is a critical component to the resolution of questions and issues regarding drug use and abuse. This page approaches addiction to psychoactive substance by examining substances through the perspectives/theories of the following models: 1) Health-Disease Model, 2) Bio-Psycho-Social Model, and 3) Public Health Model. The emphases of these models are the maladaptive behavior changes (as identified by the presence of a persistent recurrent social, occupational, psychological, or physical problem(s)) exacerbated by the use of the substances.

The study of addiction deals with psychopharmacology, genetics, counseling theory, law, medicine, sociology and other disciplines as they are applied to provide a basic understanding of the practical issues surrounding the prevention and treatment of substance abuse and dependence.

 

Prevention programs should be designed to enhance "protective factors" and move toward reversing or reducing known "risk factors." Prevention programs should target all forms of drug abuse, including the use of tobacco, alcohol, marijuana, and inhalants. Prevention programs should include skills to resist drugs when offered, strengthen personal commitments against drug use, and increase social competency (e.g., in communications, peer relationships, self-efficacy, and assertiveness), in conjunction with reinforcement of attitudes against drug use. Prevention programs should include a parents' or caregivers' component that reinforces what the children are learning-such as facts about drugs and their harmful effects-and that opens opportunities for family discussions about use of legal andillegal substances and family policies about their use. Prevention programs should be long-term, over the school career with repeat interventions to reinforce the original prevention goals. For example, school-based efforts directed at elementary and middle school students should include booster sessions to help with critical transitions from middle to high school. Prevention programming should be adapted to address the specific nature of the drug abuse problem in the local community. The higher the level of risk of the target population, the more intensive the prevention effort must be and the earlier it must begin. Prevention programs should be age-specific, developmentally appropriate, and culturally sensitive. Effective prevention programs are cost-effective. For every dollar spent on drug use prevention, communities can save 4 to 5 dollars in costs for drug abuse treatment and counseling. www.nida.nih.gov

To help practitioners better match appropriate interventions to target populations, prevention experts redefined prevention approaches based on the groups for which they were designed (IOM, 1994). They concluded that there are three distinct types of prevention approaches:

1. Universal prevention strategies designed to prevent precursors of drug use or initiation of use in general populations, such as all students in a school

2. Selective prevention strategies designed to target groups or subsets of the general population, such as children of drug users or poor school achievers

3. Indicated prevention strategies created for participants who are already manifesting drug use initiation or precursors of drug abuse, such as conduct disorders, thrill seeking, aggression, and delinquency. Source: NIDA www.nida.nih.gov 

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Addiction Resources

Academy for Eating Disorders (AED)  

American Academy of Addiction Psychiatry (AAAP):

American Academy of Health Care Providers in the Addictive Disorders:

The American Anorexia Bulimia Association, Inc. (AABA):

American Society of Addiction Medicine (ASAM):

Employee Assistance Professionals Association, Inc. (EAPA):

National Association of Addiction Treatment Providers (NAATP):

National Association of Alcoholism and Drug Abuse Counselors (NAADAC):

National Association of State Alcohol and Drug Abuse Directors (NASADAD):

The National Council on Sexual Addiction and Compulsivity:

Addiction Research Foundation:

Addiction Technology Transfer Center Program:

Addiction Treatment Forum:

Canadian Centre on Substance Abuse (CCSA-CCLAT):

Center for Addiction Studies (CAS) at University of Minnesota, Duluth:

Center on Alcoholism, Substance Abuse, and Addictions (CASAA) at University of New Mexico:

National Center on Addiction and Substance Abuse at Columbia University (CASA):

National Institute on Alcohol Abuse and Alcoholism (NIAAA):

National Institute on Drug Abuse (NIDA)

Office of National Drug Control Policy (ONDCP)

 

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