Presentation on theme: "THE SCIENCE OF RECOVERY: AN ADVANCED SEMINAR"— Presentation transcript:
1 THE SCIENCE OF RECOVERY: AN ADVANCED SEMINAR CARDWELL C. NUCKOLS, PhD
2 THE SCIENCE OF RECOVERY “…this business of resentment is infinitely grave. We found that it is fatal. For when harboring such feeling we shut ourselves off from the sunlight of the Spirit. The insanity of alcohol returns and we drink again. And with us, to drink is to die.” Big Book page 66
3 THE SCIENCE OF RECOVERY GRATITUDE (LOVE)A CHANGE IN WORLDVIEWGRANDIOSITY(CHARACTER DEFECTS)
4 GRANDIOSITY AND HUMAN SUFFERING GRATITUDEUNCONDITIONAL LOVEHUMILITYACCEPTANCEFORGIVENESSSURRENDERCOURAGE AND HONESTYGRANDIOSITY AND HUMAN SUFFERING
8 THE SCIENCE OF RECOVERY: NEUROPLASTICITY THE NUCLEUS BASALIS IS… THE MODULATORY CONTROL CENTER FOR PLASTICITYNOVELTY
9 THE SCIENCE OF RECOVERY: NEUROPLASTICITY YOU ARE NEUROPLASTICIANS!WHAT ENHANCES PLASTICITY?NOVELTYTHERAPEUTIC RELATIONSHIPSPHYSICAL EXERCISEMINDFULNESS
10 NEUROPLASTICITYBRAIN AT ALL AGES IS RESPONSIVE TO ENVIRONMENTAL STIMULISYNAPSES CAN CHANGE IN MINUTES WHEN STIMULATEDNEUROPLASTICITY IS MODULATED BYGENETIC FORCESEPIGENETIC FORCES
11 ADDICTION AND RECOVERY ACUTE ABSTINENCEPREFRONTAL CORTEXMIDBRAINLIMBICBRAIN STEMLOCUS COERULEUS
12 THE SCIENCE OF RECOVERY:GENETICS A1 ALLELE OF THE DOPAMINE D2 RECEPTOR GENEFOUND IN ONE-THIRD OF POPULATIONLOW DOPAMINE TONE
13 THE SCIENCE OF RECOVERY:GENETICS TWIN STUDIES SUGGEST GENES AND ENVIRONMENTAL FACTORS EACH INFLUENCE THE VULNERABILITY TO DEVELOPING ADDICTIONSTRESS IS ONE, IF NOT THE PRINCIPLE, ENVIRONMENTAL FACTOR THAT INCREASES ADDICTION POTENTIALIN BOYS WITH THE A1 ALLELE STRESS WAS SIGNIFICANTLY CORRELATED WITH COGNITIVE FUNCTIONAL PROBLEMSNOBLE AND BENTON. THE D2 DOPAMINE RECEPTOR GENE AND FAMILY STRESS. INTERACTIVE EFFECTS ON COGNITIVE FUNCTIONING IN CHILDREN. BEHAV GENET, 1997; 27:33-43.
14 THE SCIENCE OF RECOVERY:GENETICS GENETIC VULNERABILITYSONS OF ALCOHOLICS HAVE DECREASED SENSITIVITY TO ALCOHOLENORMOUS AMOUNT OF DEVELOPMENTAL STRESSEITHER CAN CAUSE IRREGULARITIES IN BRAIN CHEMISTRY SUCH AS DOPAMINE BLUNTING
15 THE SCIENCE OF RECOVERY:GENETICS Treatment dropout linked to elevated stress response (Drug and Alcohol Depd. 105 (3): , 2009)Salivary cortisol can predict how long a drug user will remain in treatmentCortisol measured at base for both men and women in a residential treatment center before giving them stressful tasksPrior to the stressors cortisol levels were similar for the 21 participants who dropped out as compared to the 81 who completed treatment
16 THE SCIENCE OF RECOVERY:GENETICS Treatment dropout linked to elevated stress response (Drug and Alcohol Depd. 105 (3): , 2009) (continued)The patients who dropped out had cortisol levels 3-5 times higher than those patients who remained in treatmentFor each unit of increase in cortisol after the stressful tasks, there was a four-fold increase in risk of dropping out
17 THE SCIENCE OF RECOVERY:GENETICS WHEN YOU DISCONTINUE TO DRINK CIRCUITS ARE STILL PRESENTCORTICOTROPIN RELEASING FACTOR (CRF) SYSTEM PRODUCES A CHRONIC STRESS RESPONSE THAT IS A SET-UP FOR RELAPSE60-70% OF RELAPSE OCCUR UNDER CONDITIONS OF NEGATIVE EMOTIONAL STATE
18 THE SCIENCE OF RECOVERY:GENETICS A shortage of D2 receptors, some researchers surmise, could predispose a person to addiction.Nora Volkow, NIDA Director, led two studies that involved artificially increasing the number of D2 receptors in rats by administering adenoviral vectors directly into their brains. Viral vectors transmit their genetic material and makeup into foreign cells, in this case increasing the number of D2 receptors in the new cells to match their own.
19 THE SCIENCE OF RECOVERY:GENETICS In one study involving rats and alcohol, the increased number of D2 receptors led the rodents to consume less alcohol, compared with their baseline intake.In the other study, the D2-receptor increase caused rats to significantly reduce their intake of cocaine.
21 THE SCIENCE OF RECOVERY:GENETICS Association between DA D2 receptor numbers and drug self-administration (PET)Increased D2 receptors reduced alcohol consumptionDecreased D2 receptors higher riskDA D2 receptor levels influenced by stress and social hierarchy
22 THE SCIENCE OF RECOVERY:GENETICS Michael Nader, a researcher at Wake Forest School of Medicine, is investigating ways to raise D2-receptor levels naturally.One experiment he helped conduct focused on five separate groups of four monkeys. Each had been self-administering cocaine to the point of habit and were then deprived of the drug for an eight-month period. To create a picture of D2-receptor availability, the monkeys were given a radioactive tracer that competes with dopamine for receptors.
23 THE SCIENCE OF RECOVERY:GENETICS The monkeys were then randomly put in social groups of four and given the opportunity to self-administer the drug again.Positron emission tomography (PET) imaging of the monkeys over time showed fluctuations in dopamine levels, which allowed the researchers to estimate the changing numbers of available D2 receptors.After only three months, the socially dominant monkeys in each group had naturally increased their numbers of D2 receptors.
24 THE SCIENCE OF RECOVERY:GENETICS There was no increase in the subordinate monkeys. Further, the subordinate monkeys reverted to using cocaine at much higher levels than the dominant monkeys."There is an interesting relationship between D2-receptor numbers and vulnerability to drug addiction," Nader said. "It appears that individuals with low D2 measures are more vulnerable compared to individuals with high D2-receptor numbers."
25 THE SCIENCE OF RECOVERY:GENETICS Why did the socially dominant monkeys show D2-receptor increases?One hypothesis is environmental enrichment. For the monkeys, it seems, being dominant was the enriching trigger.One physiological consequence of involvement in 12-step meetings, therefore, could be an increase in the natural production of D2 receptors.
27 THE SCIENCE OF RECOVERY:GENETICS Social interventions can change neurobiologyIncreased DA D2 receptorsReduced self-administrationBehavioral interventions could counteract the aversive effects of drug abuse and reinforce the power of group approaches
28 THE STRIATUMThe basal ganglia are nestled inside cortex, surrounding the thalamus (see image above). The striatum (part of the basal ganglia circuitry) is composed of the putamen, caudate, and nucleus accumbens. Other important parts of the basal ganglia are the globus pallidus (which has an internal and an external segment, GPi and GPe respectively) and the subthalamic nucleus (STN).
30 CORTICOSTRIATAL CIRCUITRY This impairment could arise from two general pathologies in corticostriatal circuitry: addicts could have pathologically strengthened drug-seeking behaviors, or they could have pathological impairments in the capacity to control drug-seeking behaviors. These two possibilities are not mutually exclusive.Corticostriatal circuitry has two subcircuits: the limbic subcircuit, which comprises brain regions such as the prefrontal cortex, the amygdala, the nucleus accumbens (NAc) and the ventral tegmental area (VTA); and the motor subcircuit, which contains the motor cortex, the dorsal striatum and the substantia nigra.
32 CORTICOSTRIATAL CIRCUITRY Corticostriatal projections are responsible not only for generating learnt, well-established behaviors such as in drug taking, but also for changing behaviors in response to a variable environment, and thereby generating new adaptive behaviorsAddicts have difficulty modulating drug-seeking behaviors with information that should suppress the behavior
33 CORTICOSTRIATAL CIRCUITRY The NAc serves as a gateway through which information that has been processed in the limbic subcircuit gains access to the motor subcircuit.Relapse to compulsive drug seeking arises from an impaired ability of the limbic subcircuit to effectively process and/or use the negative environmental contingencies associated with relapse. The result is that behavior is dominated by the previously learnt, well-established drug-seeking strategies.
34 THE SCIENCE OF RECOVERY: DOPAMINE (DA) TONE VentralTegmentalAreaNucleus AccumbensBrain areas involved in the brain reward pathway include:Nucleus accumbens (NA), activated by alcoholVentral tegmental area (VTA), directly targeted by drugs of abuseArcuate nucleus (AN), which contains neurons that produce β-endorphins, one of the three types of endogenous opioid peptidesThe effects of alcohol in this pathway are believed to be: [Gianoulakis 1998,208,Figure 4] [Boehm,121; 125,6]Stimulation of β-endorphin release from the ANβ-endorphin binding to the opioid receptors from the VTA, resulting inInhibition of GABA production, which allows more dopamine productionDopamine release in the NA, andHeightened feelings of pleasure and reinforcementThe neurobiological mechanisms responsible for the reduction in alcohol consumption observed in alcohol-dependent patients treated with naltrexone are not entirely understood. However, involvement of the β-endorphins in the endogenous opioid peptide system is suggested by preclinical data. Naltrexone, a potent opioid antagonist, is thought to interfere with this β-endorphin /dopamine reward system by blocking opioid receptors that normally receive β-endorphin. This leads to a reduction in alcohol consumption.DopamineArcuate NucleusOpioid PeptidesNaltrexone
35 THE SCIENCE OF RECOVERY: DOPAMINE (DA) TONE TWO TYPES OF LOW DA TONE (CONTINUED)SYMPTOMS WILL BE THOSE OF REDUCED DA TONE AT NAc REGARDLESS OF THE LOCATION OF FEEDBACK PROBLEMFROM TREATMENT PERSPECTIVE WHAT DIFFERENTIATES WHETHER DA OR OPIOID CAUSATION OF LOW DA TONE IS….HISTORY OF DRUG USAGE AND EFFECTS THAT USER EXPERIENCES
36 THE SCIENCE OF RECOVERY: DOPAMINE (DA) TONE SUFFICIENTDA TONE IN REWARD CIRCUITRY YIELDS ADEQUATEATTENTIONMOTIVATIONATTACHMENTHEDONIC TONE
37 THE SCIENCE OF RECOVERY: DOPAMINE (DA) TONE REDUCED OR LOW DA TONEANHEDONIC RELATIVE TO THOSE AROUND THE INDIVIDUALSENSE OF NOT FITTING INPOOR ATTENTIONPOOR LEVEL OF MOTIVATIONRESTLESSIRRITABLEDISCONTENTED
38 PREFRONTAL CORTICAL DOPAMINE Optimal levels of prefrontal cortical dopamine are critical to various executive functions such as working memory, attention, inhibitory control, and risk/reward decisions, all of which are impaired in addictive disorders such as alcoholism.Imaging studies of alcoholics have demonstrated less dopamine in the striatumVolkow ND; Wang GJ; Telang F; Fowler JS; Logan J; Jayne M; Ma Y; Pradhan K; Wong C: Profound decreases in dopamine release in striatum in detoxified alcoholics: possible orbitofrontal involvement. J Neurosci 2007; 27:12700–12706
39 PREFRONTAL CORTICAL DOPAMINE Less dopamine in the prefrontal cortex, which governs executive functions, is important because it could impair the addicted person’s ability to learn and utilize informational/behavioral strategies critical to relapse prevention. This is supported by literature that links prefrontal cortical dopamine with executive functions, such as attention, working memory, behavioral flexibility, and risk/reward decision making, all of which are impaired in addictive disorders such as alcoholism.Floresco SB; Magyar O: Mesocortical dopamine modulation of executive functions: beyond working memory. Psychopharmacology (Berl) 2006; 188:567–585
40 PREFRONTAL CORTICAL DOPAMINE It is tempting to speculate that the failure to incorporate past negative consequences in a decision to drink alcohol during abstinence is related to decreased prefrontal cortical dopamine in alcoholism.Unclear whether decreased dopamine transmission in alcoholism represents a premorbid trait or alcohol-induced stateNarendran, et al. Decreased Prefrontal Cortical Dopamine Transmission in Alcoholism. Am J Pscyhiatry. 2014;171: doi: /appi.ajp
41 THE SCIENCE OF RECOVERY: DOPAMINE (DA) TONE INCREASING DA TONE AT NAcTHREE POSSIBLE APPROACHESINCREASE AMOUNT OF DA RELEASED-CURRENTLY HAVE MEDS LIKE SUBOXONE THAT WILL DO THISINCREASE NUMBER OF RECEPTORS-MEDS NOT AVAILABLE FOR THISREDUCING REUPTAKE OF DA-HAVE MEDS THAT WILL DO THIS (PROVIGIL)
42 THE SCIENCE OF RECOVERY: THE OPIATE EXPERIENCE HIGHABNORMALLY NORMALSUBJECTIVE W/DRAWALACUTE ABSTINENCE SYN.
43 THE SCIENCE OF RECOVERY: DOPAMINE (DA) TONE SUBUTEX-Buprenorphine. sublingual (SL)2mg and 8mg tabletsSUBOXONE-Buprenorphine/Naloxone SL tablets AND FILMZubsolv SLPARTIAL AGONISTIncreasing dose does not increase effect like a full agonist
45 THE SCIENCE OF RECOVERY: DOPAMINE (DA) TONE BUPRENORPHINE-Very high affinity for mu opioid receptorMu receptor will choose buprenorphine over other opioidsBuprenorphine will displace other opioidsSlow dissolution from mu receptorHalf-life on receptor is hrsHeroin on and off receptor in millisecondAt Buprenorphine dose of 16mg almost no binding to other opioids
46 PHARMACOLOGICAL NALTREXONE (Revia, Vivitrol) Pure antagonist Poor complianceLess than 10% for street addictsBetter complianceHealthcare professionalsParole/ProbationNew suspension with q30d administration should dramatically increase compliance and reliability of drug
47 VIVITROL Carton Components Each VIVITROL carton includes the following components:Two 1½ inch 20 gauge administration needlesOne vial containing VIVITROL microsphere powderOne vial containing diluentOne single-use 5 mL syringeOne ½ inch 20 gauge preparation needleDo not substitute carton components.The entire carton should be stored in the refrigerator (2 – 8ºC, 36 – 46ºF).VIVITROL can be stored at temperatures not exceeding 25ºC (77ºF) for no more than 7 days prior to administration. Do not expose unrefrigerated product to temperatures above 25ºC (77ºF).47
53 Important Safety Information VIVITROL is contraindicated in patients receiving opioid analgesics or with current physiologic opioid dependence,patients in acute opiate withdrawal, any individual who has failed the naloxone challenge test or has a positive urine screen for opioids, or in patients who have previously exhibited hypersensitivity to naltrexone, PLG, carboxymethylcellulose or any other components of the diluent.VIVITROL patients must be opioid free for a minimum of 7-10 days before treatment.Attempts to overcome opioid blockade due to VIVITROL may result in a fatal overdose.In prior opioid users, use of opioids after discontinuing VIVITROL may result in a fatal overdose because patients may be more sensitive to lower doses of opioids.Speaker should review all points on the slideVIVITROL[full prescribing information]. Cambridge, MA: Alkermes, Inc; May 2009.
54 THE SCIENCE OF RECOVERY:GLUTAMATE NOTION THAT ADDICTION EQUALS TOO MUCH DOPAMINE IS A GROSS OVERSIMPLIFICATIONIN ANIMAL STUDIESEVEN WHEN DA RECEPTORS ARE BLOCKED SOME DRUG-SEEKING BEHAVIOR PERSISTSEXTERNAL CUE DRIVENDRUGS AFFECTING DA DIRECTLY HAVE BEEN INEFFECTIVEINDIRECT APPROACHS SUCH AS INCREASING GABA EFFECT AND REDUCING GLUTAMATE EFFECT SEEM MORE PROMISING (EXAMPLE-TOPIRIMATE)BRAIN WORKS. VOL 18, NO 5, SEPT/OCT 2008, PGS 1 AND 2.
55 THE SCIENCE OF RECOVERY: GLUTAMATE TWO STAGE MODEL OF ADDICTIONSTAGE 1-OCCASIONAL DRUG USE BECOMES INCREASINGLY CHRONIC AND UNCONTROLLED. THE NEUROBIOLOGICAL SOURCE OF THESE SYMPTOMS IS DRUG-INDUCED DEREGULATION OF THE BRAIN’S REWARD CENTERDOPAMINESTAGE2-ADDITIONAL FEATURES INCLUDE WITHDRAWAL SYMPTOMS, PERSISTENT VULNERABILITY TO RELAPSE WITH ALTERATIONS IN DECISION MAKING AND OTHER COGNITIVE PROCESSESDRUG-INDUCED SIGNALS BY NEUROTRANSMITTER GLUTAMATE FROM BRAIN AREAS PRIMARILY ASSOCIATED WITH JUDGMENT
56 THE SCIENCE OF RECOVERY: GLUTAMATE CHANGES IN BRAIN GLUTAMATE SIGNALING INDUCED BY CHRONIC DRUG EXPOSURE HAS A WIDE VARIETY OF NEUROBIOLOGICAL EFFECTS INSTRUMENTAL IN THE TRANSITION FROM DRUG ABUSE TO ADDICTION (KAVALIS,2009)THESE NEURAL ALTERATIONS LIMIT THE ABILITY TO ADAPT TO NEW INFORMATION (TO STOP TAKING DRUGS IN SPITE OF ADVERSE CONSEQUENCES)AND STRENGHTEN THE POWER OF DRUG LEARNED ASSOCIATIONS
58 THE SCIENCE OF RECOVERY: GLUTAMATE Addiction as impairment in reversal learningIN ADDICTION…“WHEN I USE DRUGS I FEEL GOOD”CHANGES TO“WHEN I USE DRUGS BAD THINGS HAPPEN”NEW RULE BUT CANNOT ADAPT
59 THE SCIENCE OF RECOVERY: GLUTAMATE ADDICTS CAN LEARN A NEW RULE BUT RUN INTO PROBLEMS WHEN THE RULES CHANGECOCAINE AND ALCOHOL ABUSERS WERE ASKED TO PRESS KEY EACH TIME THEY SAW A GREEN RECTANGLE ON THE SCREENAFTER 500 REPETITIONS TOLD NOT TO PRESS KEY WHEN SAW GREEN RECTANGLECONTROLS EASILY ADAPTED WHILE ADDICTS KEPT PUSHING THE KEY EVEN AFTER GIVEN FEEDBACKIMPAIRED REVERSAL LEARNING DUE TO DRUG USE AND NOT GENETICS
60 THE SCIENCE OF RECOVERY: COGNITIVE FUNCTION Addiction is a disorder of altered cognitionAddiction impacts…LEARNINGMEMORYATTENTIONREASONIMPULSE CONTROLEffects are particularly disruptive when exposed during brain development and in the co-occurring population
61 THE SCIENCE OF RECOVERY: COGNITIVE FUNCTION Cognitive deficits in chronic drug abuseWithdrawal produces cognitive symptomsCocaine-deficits in cognitive flexibilityAmphetamine-deficits in attention and impulse controlOpioids-deficits in cognitive flexibilityEthanol-deficits in working memory and attentionCannabis-deficits in cognitive flexibility and attentionNicotine-deficits in working memory and declarative learning
62 THE SCIENCE OF RECOVERY: COGNITIVE FUNCTION Why give an alcoholic or addict a 60 minute didactic or video?A new format15-20 minute simple didacticHow to participate in treatment10 minute questionnaire30 minute discussion group
63 THE SCIENCE OF RECOVERY: COGNITIVE FUNCTION I THINK………..I FEEL…………..I LEARNED……MY FUTURE BEHAVIOR WILL CHANGE…
64 THE SCIENCE OF RECOVERY RELAPSE FALLS ALONG A SPECTRUMCOMPULSIVE RELAPSEPREFRONTAL CORTEX OFF-LINEREGULATED RELAPSESOME PREFRONTAL AVAILABILITYLITTLE OR NO RELAPSEPREFRONTAL CORTEX AVAILABLE
65 THE SCIENCE OF RECOVERY CRAVING MANAGEMENT Though some relapse triggers can be consciously avoided, such as people, places and things related to drug use, other subconscious triggers related to the brain's reward system may be impossible to avoid -- they can gain entry to the unconscious brain, setting the stage for relapse.Baclofen, commonly used to prevent spasms in patients with spinal cord injuries and neurological disorders, can help block the impact of the brain's response to "unconscious" drug triggers well before conscious craving occurs.
66 THE SCIENCE OF RECOVERY CRAVING MANAGEMENT Subliminal drug "reminder cues" (the sights, sounds, smells, and memories of the drug) could activate the brain's reward circuit.23 cocaine-dependent men, ages 18 to 55. Each reported using cocaine on at least eight of 30 days before screening. Inclusion in the study required that they stay for up to 10 days in a supervised inpatient drug treatment facility, be drug-free for the duration, not be on any medication affecting dopamine or neurotransmitter response, and have no history of psychosis, seizures, or brain syndromes unrelated to cocaine use.
67 THE SCIENCE OF RECOVERY CRAVING MANAGEMENT Upon admission, patients were randomized to receive baclofen or placebo. Over the first six days, patients in the baclofen group received the medication in increasing dosage to 60 mg. While on the full 60 mg dose of baclofen, patients were placed in an fMRI and shown a series of images, to measure their neural responses to "ultra-brief" pictures of cocaine or other comparison pictures. Each of the ultra-brief 33 msec "target" pictures was immediately followed by longer picture of non-drug objects or scenes. Under these conditions, the participants are aware of the longer pictures, but the ultra-brief target pictures remain completely outside conscious awareness -- they are "backward-masked."
68 THE SCIENCE OF RECOVERY CRAVING MANAGEMENTNT What the team found was that the patients who were treated with baclofen showed a significantly lower response in the reward and motivational circuits to subliminal cocaine cues versus neutral cues, as compared to the placebo-treated control group. K. A. Young, T. R. Franklin, D. C. S. Roberts, K. Jagannathan, J. J. Suh, R. R. Wetherill, Z. Wang, K. M. Kampman, C. P. O'Brien, A. R. Childress. Nipping Cue Reactivity in the Bud: Baclofen Prevents Limbic Activation Elicited by Subliminal Drug Cues. Journal of Neuroscience, 2014; 34 (14)
69 ROBIN WILLIAMS“I realized... you keep going with this, you’ll wake-up in a field with a small animal,” laughed Williams. “If you’re violating your standards faster than you can lower them, time to go away.”
70 THE SCIENCE OF RECOVERY: HABIT YOU CANNOT EXTINGUISH A BAD HABIT; YOU CAN ONLY CHANGE IT
71 THE SCIENCE OF RECOVERY: HABIT THE CUE TRIGGERS THE ROUTINE AND ALSO TRIGGERS THE CRAVING FOR THE REWARD TO COME
72 THE SCIENCE OF RECOVERY: HABIT When a habit begins the whole brain is activated as it actively processes all of the stimuliAfter this phase the higher brain begins to reduce level of activationThen even the memory centers reduce activityBASAL GANGLIA has now taken control of recalling the patterns and acting on them
74 THE SCIENCE OF RECOVERY: HABIT LOOP CUEROUTINEREWARD
75 THE SCIENCE OF RECOVERY: HABIT CUE AND REWARD BECOME INTERTWINED CREATING A CRAVING (CONDITIONING)In a habit the brain reduces emphasis on decision makingPattern unfolds automatically unless you find a new routineAfter craving develops, cannot extinguish a bad habit, you can only change it
76 THE SCIENCE OF RECOVERY: HABIT LOOP SAME CUE(S)DIFFERENT ROUTINESAME REWARD
77 THE SCIENCE OF RECOVERY: HABIT ALMOST ANY HABIT CAN CHANGE IF YOU KEEP THE SAME CUE(S) AND SAME REWARDALCOHOLICS ANONYMOUS changes the habit loopALCOHOLICS ANONYMOUS succeeds because it helps use the same cues and get the same rewards but shifts the routine
78 THE SCIENCE OF RECOVERY: HABIT To change a habit must address the same cues and rewards as before and feed the craving by inserting a new routineWHAT DO ALCOHOLICS AND ADDICTS CRAVE?It isn’t a craving to be drunkPhysical effects of alcohol are the least rewarding (the same can be said for cocaine, methamphetamine, etc.)Is it connection, reduce anxiety, forget worries?Meetings and companionship-another bar to escape to, catharsis, distraction
79 THE SCIENCE OF RECOVERY: HABIT What is the pleasure we seek in the first place?Is it…COMPLETIONRELAXATIONTO FORGETTO CONNECTTO REWARD MYSELFTO GIVE ME COURAGETO FEEL LIKE YOU BELONG AS ONE OF THE GROUP
80 THE SCIENCE OF RECOVERY: HABIT ALMOST ANY HABIT CAN CHANGE IF YOU KEEP THE SAME CUE(S) AND SAME REWARDALCOHOLICS ANONYMOUS changes the habit loopAA offers…EscapeCatharsisDistractionRelief via talking
81 THE SCIENCE OF RECOVERY: HABIT ALCOHOLICS ANONYMOUS succeeds because it helps use the same cues and get the same rewards but shifts the routineAA forces new routines for what to do each night as opposed to drinkingTo change a habit must address the same cues and rewards as before and feed the craving by inserting a new routineWHAT DO WE CRAVE?Is it connection, reduce anxiety, forget worries?Meetings and companionship-another bar to escape to, catharsis, distraction
82 THE SCIENCE OF RECOVERY: HABIT What is the thirst behind the thirst?“I was thirsty because I was feeling incomplete and alcohol helped me feel more connected, more alive.”Bill Wilson, “Before A.A. we were trying to drink God out of a bottle.”Gerald May- a deep yearning for fulfillment or completion; a longing to love and be loved and a desire for the source of this love-God
83 THE SCIENCE OF RECOVERY: HABIT What is the thirst behind the thirst?The great analyst Carl J. Jung put it thus, “His craving for alcohol was the equivalent, on a low level, of the spiritual thirst of our being for wholeness, expressed in medieval language: the union with God.”An intense, urgent, or abnormal desire or longing. At the time it seems more painful than any other longing. It subsumes us and we are a slave to it…and it seems it will never end. Although not understood in that moment, it is really a powerful thirst to go “home.”
84 THE SCIENCE OF RECOVERY: HABIT REPLACEMENT ROUTINES ONLY BECOME DURABLE NEW BEHAVIORS WHEN SPIRITUALITY IS ADDED (this is what gets you through the major crises in your life)PATTERN:Could only stay sober by habit replacement until a major crisis hitAdd spiritual element and now can get through these tough times
85 DOPAMINE (DA) TONE-GENDER DIFFERENCES WOMEN ESCALATE FASTER TO HEAVY USEWOMEN MORE READILY SUCCUMB TO SOCIAL AND PHYSICAL DAMAGEREPRODUCTIVE HORMONES MAY UNDERLIE THIS SUSCEPTIBILITYREMOVE OVARIES OF FEMALE RAT (NO LONGER PRODUCE ESTROGEN) AND REDUCE DRUG SEEKING BEHAVIOR FOR COCAINE AND AMPHETAMINE
86 DOPAMINE (DA) TONE-GENDER DIFFERENCES ESTROGEN MAY SPUR ADDICTION BY STIMULATING BRAINS REWARD PATHWAYS ENHANCING “HIGH” BY INCREASING DA(ANTHES, EMILY. “SHE’S HOOKED”. SCIENTIFIC AMERICAN MIND. MAY/JUNE 2010, PGS )PROGESTERONE APPEARS TO OPPOSE ESTROGEN’S ABILITY TO PROMOTE ADDICTIONGIVE BOTH ESTROGEN AND PROGESTERONE TO RATS WITHOUT OVARIES AND NO ACCELERATION OF ADDICTION
87 DOPAMINE (DA) TONE-GENDER DIFFERENCES FEMALE RESPONSE VARIES ACROSS MENSTRUAL CYCLE AS LEVELS OF ESTROGEN AND PROGESTERONE WAX AND WANE (2007, SUZETTE EVANS, COLUMBIA UNIVERSITY)STIMULANTS MORE PLEASURABLE TO WOMEN DURING ESTROGEN-DOMINATED FOLLICULAR PHASE WHICH OCCUPIES APPROXIMATELY 2 WEEKS FROM ONSET OF PERIOD UNTIL OVULATION THAN DURING THE LUTEAL PHASE AFTER OVULATION WHEN BOTH ESTROGEN AND PROGESTERONE ARE HIGH
89 DOPAMINE (DA) TONE-GENDER DIFFERENCES ASKED ONE-HALF OF 202 FEMALE CIGARETTE SMOKERS TO TRY TO ABSTAIN DURING LUTEAL PHASE AND THE OTHER HALF TO TRY TO ABSTAIN DURING THE ESTROGEN RICH FOLLICULAR PHASETHIRTY-FOUR (34) PERCENT OF WOMAN IN FIRST GROUP HAD NOT SMOKED AT 30 DAYSFOURTEEN (14) PERCENT OF WOMEN IN THE SECOND GROUP HAD NOT SMOKED AT 30 DAYS(2008, SHARON ALLEN, UNIVERSITY OF MINNESOTA MED SCHOOL)