1. Cardwell C. Nuckols MA, PhD cnuckols@elitecorp.org (407) 758-1536

2.  Facilitated by:  NOVELTY  ENVIRONMENTAL ENRICHMENT  PHYSICAL EXERCISE  NUTRITION

3.  Group Therapy  Individual Counseling  Sober Living  Higher Power  Assessment  Alcohol/Drug  Psyhosocial

4.  Recovery housing  Healthy milieu  Self help meetings  Church  From isolation to living “one day at a time” in the presence of others striving for a more fulfilling life

5.  Stimulates production of brain-derived neurotrophic factor (BDNF)  Neurotrophin that governs maturation and development of neural systems  Enhances executive functioning  Obey social rules  Adapt to changing & unpredictable environment  Short term working memory  Multi-tasking  Self-directedness

6.  Self-directedness  Responsible  Purposeful  Resourceful  Increases neurotransmitters  Monoamines  Serotonin  Dopamine  Norepinephrine

8.  Association between DA D2 receptor numbers and drug self-administration  Increased D2 receptors reduced alcohol consumption  Decreased D2 receptors higher risk  DA D2 receptor levels influenced by stress and social hierarchy  Helps explain influence of environment and genes

10.  Subordinate animals more likely to self- administer cocaine  Dominant animals no more likely to self- administer cocaine than placebo  Social interventions can change neurobiology  Increased DA D2 receptors  Reduced self-administration  Behavioral interventions could counteract the aversive effects of drug abuse and reinforce the power of group approaches

11.  Group Therapy  Active participation  Successful completion of assignments  Milieu  Leadership  Modeling  Self help  Coffee and chairs  “Telling story”

12.  Acute intoxication results in activation and deactivation of regions connected to the DA system  These regions are involved in  REWARD  MEMORY  MOTIVATION/DRIVE  CONTROL

13.  Reward Circuit-Nucleus Accumbens and Ventral Pallidum  Motivation/Drive Circuit-Orbitofrontal Cortex  Memory & Learning Circuit-Amygdala and Hippocampus  Control Circuit-Prefrontal Cortex & Anterior Cingulate Gyrus

14. Copyright ©2003 American Society for Clinical Investigation Volkow, N. D. et al. J. Clin. Invest. 2003;111:1444-1451

15.  Location  Nucleus Accumbens (NAc)  Ventral Tegmental Area (VTA)  Impact of drugs of abuse  Increased extracellular levels of DA in striatum (NAc)  Reinforcing effects related to:  Magnitude of DA increase  Abruptness of DA increase  Reduced sensitivity to natural reinforcers

17.  Goals:  Management of craving  Reduce reward value of drugs  Reduce pleasure (create unpleasantness) from drug experience

18.  Situational triggers  Environment (People, Places And Things)  Emotional triggers  Internal (Hungry, Angry, Lonely, Tired, Reward and Bored)  Acute Abstinence Syndrome  Stress

19.  In presence of: › Alcohol and drugs › Alcohol and drug users › Places where used to use or purchase  Negative feeling states particularly anger but also: › Boredom › Loneliness › Fear › Anxiety

20.  Positive feeling states  Physical pain  Use of mood-altering prescription drugs  Suddenly having a lot of cash  Complacency  Insomnia  Sexual functioning

21.  Psychotherapy  Behavior Therapy  Structure  Recovery Foundation Program  Changing patterns  Safety Plan  Pharmacological  Acute  Maintenance

22. 31 yo Nicki-a recovering methamphetamine addict- just got her first paycheck. She cashed her check and cruised thru the neighborhood where she used to score dope. Rock music blared from her speakers. Soon she was thinking, "I worked hard all week. I deserve a little fun.”

23.  In an inpatient setting the patient schedule serves this purpose  On an outpatient basis or upon discharge from inpatient a recovery plan or contract is appropriate  Remember that most addicts have little or no recent experience living a drug free lifestyle

24. TASKMONTUWEDTHUFRISATSUN SH TX FUN NUT PEX

25.  Carter is 24 yo and just getting out of treatment for alcohol and drug addiction  His early A/D history included….  Started drinking on Friday nights with friends in high school  Turned-on to cocaine and marijuana by friends on weekends  Started to buy drugs to sell from a distributor on Wed nights

26. MY PERSONAL SAFETY PLAN Remember that craving go away I can write in my journal I can call my sponsor (299-289-5555) I can call my lover (299-426-1776) I can read from my favorite recovery book I can read affirmations

27.  TH: “On the back of the index card, come up with a saying or a prayer that gives you strength.”  CT: “ I have always liked ‘Lord help me to be the best possible person I can be today’.”

28.  Opioid Maintenance Medications  Methadone  LAAM  Buprenorphine  Naltrexone

29.  Naltrexone (Revia, Vivitrol)  Pure antagonist  Poor compliance  Less than 10% for street addicts  Better compliance  Healthcare professionals  Parole/Probation  New suspension with q30d administration should dramatically increase compliance and reliability of drug

30.  Subutex-Buprenorphine. sublingual (SL)  2mg and 8mg tablets  Suboxone-Buprenorphine/Naloxone SL tablets  Buprenorphine 25-50 x’s more potent than morphine  Partial agonist  Increasing dose does not increase effect like a full agonist

31.  Very high affinity for mu opioid receptor  Mu receptor will choose buprenorphine over other opioids  Buprenorphine will displace other opioids  Slow dissolution from mu receptor  Half-life on receptor is 34-36 hrs  Heroin on and off receptor in millisecond  At Buprenorphine dose of 16mg almost no binding to other opioids

32.  If taken under the tongue you get predominant buprenorphine effect  If dissolved and injected get predominant naloxone effect (precipitates withdrawal)

33.  Buprenorphine equally effective as 60 mg of Methadone per day  If patient needs 80-100 or more mgs of Methadone to be comfortable, Buprenorphine probably will not work  With client dependent on short-acting opioids  Instruct client to abstain for 12-24 hours  Need to be in mild withdrawal before first dose

34.  Disulfiram, 1951  Acamprosate, 2004  Oral naltrexone, 1994  Injectable extended-release naltrexone, 2006 NONE OF THESE ARE ADDICTIVE

35. Dopamine Increased Release Dopamine Increased Release GABA Increased Sensitivity to GABA GABA Increased Sensitivity to GABA Opioid Peptides Increased Endogenous Opioid Activity Opioid Peptides Increased Endogenous Opioid Activity Glutamate Decreased Activity Glutamate Decreased Activity De Witte P. Addict Behav 2004;29:1325; Gianoulakis C. Curr Top Med Chem 2004;4:39-50; Nestler EJ. Nat Neurosci 2005;8:1445-1449; Tupala E, Tiihonen J. Prog Neuropsychopharmacol Biol Psychiatry 2004;28:1221-1247.

36. Glutamate System Adaptation  # and/or function of NMDA receptors on neurons Balances acute alcohol effect Effect: tolerance, dependence Adaptation  # and/or function of NMDA receptors on neurons Balances acute alcohol effect Effect: tolerance, dependence Chronic Alcohol Use Chronic Alcohol Use Withdrawal Increased glutamatergic activity Effect:- Acute: dysphoria, hallucinations - Post-acute: sleep/mood disturbances Withdrawal Increased glutamatergic activity Effect:- Acute: dysphoria, hallucinations - Post-acute: sleep/mood disturbances Removal of Alcohol Removal of Alcohol Alcohol-Free CNS Equilibrium Alcohol-Free CNS Equilibrium Acute Alcohol Effect Inhibits NMDA receptors Effect:  anxiety,  sedation Acute Alcohol Effect Inhibits NMDA receptors Effect:  anxiety,  sedation Administration of Alcohol Administration of Alcohol Littleton. Alcohol Health Res World 1998;22:13.

37. N = 605 Fuller RK, et al. JAMA 1986;256:1449-1455. N = 605 Fuller RK, et al. JAMA 1986;256:1449-1455.

38. * N = 605 * p <.05 Fuller RK, et al. JAMA 1986;256:1449-1455. N = 605 * p <.05 Fuller RK, et al. JAMA 1986;256:1449-1455.

39. Glutamate a a Acamprosate NMDA Receptor NMDA Receptor Reduction in glutamate release Reduction in postsynaptic effects mGluR5 receptor a a a a a a a a a a NMDA = N-methyl-D-aspartate mGluR5 = metabotropic glutamate subtype 5 receptor NMDA = N-methyl-D-aspartate mGluR5 = metabotropic glutamate subtype 5 receptor

40. N = 272 Sass H, et al. Arch Gen Psychiatry 1996;53:673-680. N = 272 Sass H, et al. Arch Gen Psychiatry 1996;53:673-680.

41.  Location  Orbitofrontal Cortex (OFC)  Impact of Drugs of Abuse  Drug as reinforcer far exceeds that of natural reinforcers  OFC hypoactive during AAS  Exposure to drug or other “cues” during withdrawal precipitates craving and compulsive drug use

43.  Hypothalamus  Head ganglion of ANS & locus of drive  Amygdala  Reticular formation  Brainstem regulation of arousal  Frontal cortex

44.  Modulates instinctive behavior and internal drives  Processes face and voice information for appraisal of external environment  Therefore, integrates external and internal environment  Early developmental trauma has negative impact on OFC

45. AUTONOMIC NERVOUS SYSTEM PARASYMPATHETIC SYMPATHETIC DISSOCIATION HYPERAROUSAL (FREEZE) (FIGHT/FIGHT)

46.  Increase value of non-drug reinforcers  Positive Connection to Others  Therapeutic Relationship  How we communicate  “Mirror” neurons  Family and couples therapy  12 step meetings  Connection to Higher Power of Your Choice  Mindfulness Meditation

47.  Location  Amygdala  Hippocampus  Impact of Drugs of Abuse  People, Places and Things (“cues” or “triggers”) create an intense desire to use (“craving”)

48.  Impact of Drugs of Abuse (cont.)  These cues automatically trigger habit learning  Release of DA  Declarative learning links emotional states to use (“Hungry, Angry, Lonely and Tired”)

50.  Behavioral  Extinguish learned positive association with drug or drug “cues”  Promote reinforcement of positive behaviors

51.  Recovery in neuropsychological functioning › Most of treatment is during time of greatest dysfunction › Recovery is;  Time-dependent  Due to sustained abstinence  Experience- dependent  Active rehabilitation or repetitive behavior

52.  Repetitive recovery-oriented behaviors  Repetitive recovery-oriented thoughts  Neurons that “fire together, wire together”

53.  Location  Prefrontal Cortex  Anterior Cingulate Gyrus  Impact of Drugs of Abuse  Disruption of prefrontal cortical functions removes self-directed behavior in favor of sensory-driven behavior  Lack of vertical integration

55.  Control  Strengthen Prefrontal Cortical Control  Cognitive Therapy  Education  Exercises  Puzzles  Computer Games  Crossword Puzzles  Vertical Integration

56.  PFC plastic especially between 0-5 and 10-20 years of age  Developmental delays occur secondary to early life trauma and early onset alcohol/drug abuse.  Treatment  Positive role models (Sponsor)  Surrogate family (Home Group)  “Growing Up In AA”

57.  Coordinate the many brain activities needed to utilize:  Executive Functions  Set goals  Make plans to attain those goals  Organize steps to carry out the plans  Ensure that desired outcomes are achieved  Conscience  Pursue Reward Within the Law

58.  Why give an alcoholic or addict a 60 minute didactic or video?  A new format  15-20 minute simple didactic  How to participate in treatment  10 minute questionnaire  30 minute discussion group

59. I THINK……….. I FEEL………….. I LEARNED…… MY FUTURE BEHAVIOR WILL CHANGE…

60. BE KIND, CONSIDERATE, FORGIVING AND COMPASSIONATE AT ALL TIMES, PLACES AND UNDER ALL CONDITIONS WITH EVERYONE, AS WELL AS, YOURSELF

61.  http://www.jci.org/cgi/content/full/111/1 0/1444 http://www.jci.org/cgi/content/full/111/1 0/1444  Nestler, Eric. “The Neurobiology of Cocaine Addiction”. Science & Practice Perspectives. December 2005, pgs 4-12.  http://www.medscape.com/viewprogram /3023_pnt http://www.medscape.com/viewprogram /3023_pnt  Cloninger, Robert. Feeling Good: The Science of Well-Being. Oxford University Press, New York, 2004.

62.  Panksepp, Jaak. Affective Neuroscience. Oxford University Press, New York,1998, pg 255.  Schore, Allan. Affect Regulation & the Repair of the Self. WW Norton, New York, 2003, pg 29-31.  Scaer, Robert. The Trauma Spectrum. WW Norton, New York, 2005, pgs 62-64.

63.  http://www.msu.edu/~brains/humanatla s/search.html http://www.msu.edu/~brains/humanatla s/search.html  Nuckols, Cardwell C. THE SCIENCE OF RECOVERY: “Connecting to Others and a Higher Power of Your Choice”. Counselor Magazine. Vol. 7, No. 1, Feb., 2006.  Nuckols, Cardwell C. THE SCIENCE OF RECOVERY: "Incorporating Neuroscience into Your Practice”. Counselor Magazine. December 2005, Vol. 6, no.,6, pgs 24-31.

64.  Gazzaniga, Michael (Editor). The Cognitive Neurosciences III. The MIT Press, London2004.  Rossi, Ernest. The Psychobiology of Gene Expression. WW Norton, New York,2002.  Blumenfeld, Hal. Neuroanatomy Through Clinical Cases. Sinauer Associates, Sunderland, MA., 2002.  McGlynn EA, et al. “The Quality of Healthcare Delivered to Adults in America”. New England Journal of Medicine. 2003;348:2635-2645.

65.  http://draonline.org - Dual Recovery Anonymous http://draonline.org  Http://www.alcoholics-anonymous.org – Alcoholics Anonymous Http://www.alcoholics-anonymous.org  http://www.wsoinc.com – Narcotics Anonymous http://www.wsoinc.com  http://www.ca.org – Cocaine Anonymous http://www.ca.org

66.  http://www.whitebison.org – Wellbriety http://www.whitebison.org  http://www.nami.org – National Alliance for the Mentally Ill http://www.nami.org  www.facesandvoicesofrecovery.org – Faces and Voices of Recovery (FAVOR) www.facesandvoicesofrecovery.org

67.  www.gwcinc.com/drnuck ols.htm www.gwcinc.com/drnuck ols.htm  www.hci- online.com/cnuckols www.hci- online.com/cnuckols  http://www.hazelden.org /OA_HTML/hazCSrdSrchR esults.jsp?event=&cg=- 200&kw=NUCKOLS http://www.hazelden.org /OA_HTML/hazCSrdSrchR esults.jsp?event=&cg=- 200&kw=NUCKOLS