S. Alex Stalcup, M.D. New Leaf Treatment Center 251 Lafayette Circle, Suite 150 Lafayette, CA Tel: Fax:

Functions of the Reward/Pleasure System of the Brain Rewards pursuit of instinctive drives (food, sex, nurture) Attention Enjoyment Rewards social contact Give pleasure to sensations, emotions, thoughts (rewarding) Assigns value (interest) to sensations, emotions, thoughts

What is a Drug? A drug is a pleasure producing chemical. Drugs activate or imitate chemical pathways in the brain associated with feelings of well-being, pleasure and euphoria.

Neuroadaptation, Tolerance, and Withdrawal Neuroadaptation: The brain’s response to over stimulation from drugs. In direct response to overstimulation, the brain regions decrease in sensitivity and become unresponsive (deaf) to normal levels of stimulation. Tolerance: The process by which the reward and pleasure centers of the brain adapt to high concentrations of pleasure neurotransmitters. Withdrawal Symptoms: The mirror image of the drug effects will always appear when a tolerant user tries to stop use. Cessation of drug use leads to ‘inversion of the high’. Under unstimulated conditions (without drugs) there is profound interference with the ability to experience normal pleasure. When sober, the user feels anhedonia, anxiety, anger, frustration and craving. The pleasure system remains impaired for months to years, interfering with sobriety, learning, and impulse inhibition. In addition to pleasure circuits each drug type affects other neurotransmitter circuits. These brain pathways overstimulated by drugs also neuroadapt and become under active, leading to anxiety, depression, and loss of energy.

Compulsion: loss of control The user can’t not do it s/he is compelled to use. Compulsion is not rational and is not planned. Continued use despite adverse consequences An addict is a person who uses even though s/he knows it is causing problems. Addiction is staged based on adverse consequences. Craving: daily symptom of the disease The user experiences intense psychological preoccupation with getting and using the drug. Craving is dysphoric, agitating and it feels very bad. Denial/hypofrontality: distortion of cognition caused by craving Under the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using. Definition of Addiction

Model for nicotine addiction cycle during daily cigarette smoking

C I M Model Treatment Causes of Craving EWMS Environmental cues (Triggers ) immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiences Drug Withdrawal inadequately treated or untreated Mental illness symptoms inadequately treated or untreated Stress equals craving

Environmental Cueing = Conditioned Craving Drug pleasure becomes associated with specific people, places, and things; to encounter any of those things in the environment is to trigger craving for the drug. Such triggers persist for decades after use.

Abuse versus Addiction Substance Abuse is distinguished from Addiction by the appearance of tolerance and withdrawal, leading to loss of control over use. Substance Abusers require motivation to stop. Addicts require treatment to stop.

END SEGMENT ONE

Nicotine Addiction 75.5% ever try nicotine 49.5% become daily smokers 24.1% develop nicotine dependence 50% of lifetime (daily + dependent) smokers die prematurely from nicotine-related diseases Male smokers lose 13.2 years of life Female smokers lose 14.5 years of life

Are you at Risk? BPSM The Bio-Psycho-Social Model EWMS Environment Withdrawal Mental Health Stress

Bio-Psycho-Social Model Predisposition Genetics Childhood Sexual Abuse Mental Illness Acquired Hypofrontality in utero alcohol/drug exposurelow birth weight perinatal asphyxiahead injury The Drug / Circumstances of First Use Enabling System

Drugs+Drink+Smoke Drink+Smoke Smoke Darrell’s Family

Percentage of U.S. Adults Aged 18 and Older Dependent on Alcohol, by Age of Drinking Onset

Addiction: Risk & Resilience Inherited predisposition (genetics) Childhood trauma or abuse Unwanted sexual involvement before age 13 Mental Illness: depression, anxiety, personality disorder Attention Deficit Disorder (ADD) Learning disabilities/school failure Subjected to teasing, bullying Acne and/or obesity Other than heterosexual orientation Social rejection Early sexual involvement Onset of drug use before age 16 Enabling environment Ignorance No family history of addiction Good mental health Academic competence Positive relationship with an adult Family eats dinner together 5 days/wk Peer group participation (clubs) Participation in sports Participation in music, drama or dance Involvement in faith-based activities Taking care of pets Volunteer activities Social acceptance Environment disapproves of drug use Immediate, appropriate scaled consequences for alcohol/drug use. Early intervention for alcohol/drug use

Nicotine Effects Receptor Activation Increase arousal Heighten attention Influence stages of sleep Produce states of pleasure Decrease fatigue Decrease anxiety Reduce pain Lessen depression Improve cognitive function

Nicotine Withdrawal Anger Anxiety Difficulty with Concentration Sadness Hungry Difficulty with Sleep Craving

NICOTINE WITHDRAWAL ASSESSMENT KEY

Bio-Psycho-Social Model Are you at Risk? Apply B P S M (bio-psycho-social model) to yourself: Family history of addiction? Do you have a tendency to boredom or ADHD? Are you anxious or depressed? Have you suffered sexual trauma? Do you use substances to reduce stress? Did drug and alcohol use enter your life at a difficult time? Are you surrounded by drug and alcohol users?

Bio-Psycho-Social Model Are you in trouble? How can you tell if you are getting into trouble? Are you using more frequently and using greater amounts? Have you developed tolerance? Is your use causing adverse consequences: grades, friends, money, health, unwanted sexual behavior? Do you crave the drug under addiction conditions: Environment, Withdrawal, Mental Health, Stress (EWMS) If so, when you crave the drug, can you talk yourself into using it, even when you have resolved to not use? When you have resolved not to use, under known craving conditions, do you find yourself using: environmental cues, anxiety or blue, withdrawal (bored, irritable, sleep), or when you are stressed?

Bio-Psycho-Social Model Are You an Addict? TRY THE “EXPERIMENT” Resolve not to use. Go about your usual daily activities. Put yourself around the drug and people using it. Each day, score how high or low your craving to use has been for that day.

C I M Model Treatment Questions about Craving 1.What is your craving score? 2.Why is your craving score high? or low? 3.How are you going to manage the craving? 4.How are you going to manage the craving for the rest of the day?

Bio-Psycho-Social Model Are You an Addict? Were you able to not use? Did you find your mind talking you into using? Did you struggle not to use? Were you able to have pleasure without using? Did you have problems with boredom, depression or anxiety?

Bio-Psycho-Social Model What to do Get out of the using environment. Find alternative sources of pleasure. Work on balancing stress. Seek help for mental health issues and other personal stresses.

Addiction: Risk & Resilience Inherited predisposition (genetics) Childhood trauma or abuse Unwanted sexual involvement before age 13 Mental Illness: depression, anxiety, personality disorder Attention Deficit Disorder (ADD) Learning disabilities/school failure Subjected to teasing, bullying Acne and/or obesity Other than heterosexual orientation Social rejection Early sexual involvement Onset of drug use before age 16 Enabling environment Ignorance No family history of addiction Good mental health Academic competence Positive relationship with an adult Family eats dinner together 5 days/wk Peer group participation (clubs) Participation in sports Participation in music, drama or dance Involvement in faith-based activities Taking care of pets Volunteer activities Social acceptance Environment disapproves of drug use Immediate, appropriate scaled consequences for alcohol/drug use. Early intervention for alcohol/drug use

END SEGMENT TWO

Overview Bio-Psycho-Social factors Genetics: Does alcoholism or drug addiction run in your family? Were you truly bored in school? Were you hyperactive? Can you hold your liquor better than others? Childhood Abuse: Did you suffer trauma (physical or sexual abuse) during your childhood? Did you experience any other life-changing difficulties? Mental Illness: Do you have a parent or grandparent who is has a mental illness: depression, anxiety, bipolar disorder or schizophrenia? Have you been diagnosed with a mental health problem? Do you become really anxious, depressed, or unable to sleep when you stop using alcohol or drugs? The Drug: How old were you when you first started using alcohol or drugs? How long did it take before you used regularly? Circumstances of First Use: What was going on in your life when you first began using? Was it a good time or a bad time? What benefits did using give you? Enabling System: How easy was it for you to get alcohol/drugs? Did your parents and peers approve or disapprove of your use?

Bio-Psycho-Social Model Assessment Goal: Develop an assessment of risk for becoming addicted 1.Develop a family tree, noting all inherited diseases, school failure, mental illnesses, and protective factors 2.Are symptoms of the addiction present in family or individual? 3.If you are concerned, screen Mental Health using Beck Depression Inventory and Beck Anxiety Inventory 4.Assess circumstances of first use

Drugs+Drink+Smoke Drink+Smoke Smoke Darrell’s Family

Bio-Psycho-Social Model Analysis of Early Drug Use Analysis: 1. Age of onset, time to regular use, use patterns, dosage form (eat, snort, smoke, inject) presence or absence of intoxication resistance. 2.Circumstances of early use: difficult or positive time in life, awareness of drug effect beyond getting high 3.What else did the drug do for you beside make you high, e.g., promote sleep, relieve depression or anxiety or boredom, help fit in, lose weight, make stronger?

Assessment Questions Have you ever used alcohol or other drugs ? Have you ever felt guilty about your use of substances? Have ever been criticized by other for your use of substances? Have you ever had legal difficulties related to substance use, such as a DUI or wet and reckless? Do you have history of addiction to alcohol/other substances? If so, when did the addiction start and what has happened since then? Have you ever received formal treatment for addiction or attended peer support, such as 12-step meetings?

C I M Model Treatment Causes of Craving EWMS Environmental cues (Triggers ) immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiences Drug Withdrawal inadequately treated or untreated Mental illness symptoms inadequately treated or untreated Stress equals craving

C I M Model Treatment Environmental Assessment Environmental Cueing immediate, high intensity craving caused by exposure to people, places, things, and events the user associates with getting and using alcohol or other drugs. People:Can you stay away from people you drank or used with? Places:Can you stay away from places where you drank or used? Things:Is your home a safe place? No alcohol? No drugs? No drug paraphernalia? Events: Do you have any upcoming events where people will be drinking or using?

C I M Model Treatment Cessation: Environmental Control Goal: to prepare home, school, and social environment to protect from exposure to environmental cues Cleaning out environments of ashtrays, paraphernalia, the drug, smell Rehearsing asking friends and family to discontinue use around client.

C I M Model Treatment Detoxification Use of medications to treat withdrawal symptoms.

Nicotine Withdrawal Mentally sluggish Inattentive Insomnia Boredom and dysphoria Fatigue Anxiety Increased pain sensitivity Depression Diminished cognitive function

C I M Model Treatment Mental Health Assessment Goal: to monitor whether mental health symptoms are exacerbated by abstinence. 1.Monitor sleep, boredom, depression, anxiety, irritability 2.Use test instruments to formally assess symptoms 3.Develop access to medical assessment and treatment 4.Monitor impact of treatment on symptoms and abstinence

C I M Model Treatment Assessment for Stressors Personal stressors Relationship conflict Financial problems Work school issues Parenting conflicts Legal issues Lifestyle stressors Hunger Anger Loneliness Tired STRESS EQUALS CRAVING

Stress Management Goal: to develop alternatives to drug use that are pleasureable and reduce boredom and stress 1.Practice effect of exercise, music, sports, social contact, fun activities on craving scores 2.Experiment with scheduling day as stress response technique 3.Practice fun alternative to use

Promoting Resilience  Positive relationship with an adult or supportive friend/family  Positive peer group activities  Involvement in faith-based activities  Participation in Drama or Music or Dance  Taking care of pets  Volunteer activities  Keep goal of one pleasureable activity per day  Strict adherence to a carefully balanced lifestyle

END SEGMENT THREE

REFERENCES --- Responsibility and choice in addiction. Psychiatric Services. 53(6): (2002). Bechara A. Decision making, impulse control and loss of willpower to resit drugs: a neurocognitive perspective. Nature Neuroscience. 8: (2005) Dackis C, O’Brien C. Neurobiology of addiction: treatment and public policy ramifications. Nature Neuroscience. 8(11): (2005). Nestler EJ, Malenka RC. The addicted brain. Scientific American.com February 9, Stalcup SA, Christian D, Stalcup JA, Brown M Galloway GP. A treatment model for craving identification and management. Journal of Psychoactive Drugs. 38:235-44, 2006 Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. The Journal of Clinical Investigation. 111(10: (2003). Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in progress. National Campaign to Prevent Teen Pregnancy. June 2005.

Craving Monster

C I M Model Treatment Enabling Environments Enabling: Protecting the user from the consequences of his or her use of alcohol and other drugs. Goal: Change school and home policies enabling use Identify local stores that sell cigarettes to youth Assess difficulty in accessing drugs Identify areas around school where tobacco/drugs are used Assess attitudes and use at home, among friends, and in places to hang out.

Behavior Control: The Balance Concept Greed Lust Fear Rage Jealousy Hunger Midbrain Forebrain Decision Making Logic Judgment Ethics Salience (weighing value) Drug Craving Weighing consequences Cueing

Alcohol Poisoning Binge drinking Five or more drinks in two hours (male) Four or more drinks in two hours (female) Signs of severe alcohol toxicity - Call 911 Mental confusion, stupor, coma, or person cannot be roused. Vomiting. Seizures. Slow breathing (fewer than eight breaths per minute). Irregular breathing (10 seconds or more between breaths). Hypothermia (low body temperature), bluish skin color, paleness. Observation Careful monitoring - Do not leave the patient alone. Airway protection to prevent breathing or choking problems. Medications Administration of fluids through a vein (intravenously) to prevent dehydration Oxygen therapy