Understanding Drug Abuse and Addiction Steve Hanson Director, John L. Norris ATC NYSOASAS Lecturer, SUNY Brockport stevehanson@oasas.state.ny.us Psychopharmacology is the study of the effects of drugs on behavior. There are two points I hope will be repeated through out this presentation and I would like you to keep them in mind during the course of the presentation.

Why can’t/won’t some people stop? Basic Q uestions Why do people do drugs? Why can’t/won’t some people stop? Here I make a reference to those people who seem to be in the news all the time about being in an out of rehab – Robert Downey Jr., Darryl Strawberry for example. We hope to be able to explain why some people have a very hard time stopping.

We all like things faster and easier Realities People like Drugs We all like things faster and easier People like drugs – aspirin, medications, a cocktail at a party etc. For faster and easier I make a comment about having a microwave oven to popcorn in versus the old fashioned jiffy pop method. Drug users use drugs to get them to feeling states faster and easier.

Use Addiction Although persons may choose whether or not to initiate the use of psychoactive substances and / or alcohol, drug dependence is an involuntary result. Nobody chooses/plans to be an alcoholic, junkie, crackhead, etc. something happens.

Addiction is a Brain Disease Prolonged Use Changes the brain in Fundamental and Long Lasting Ways

Simple Brain Structure Frontal Lobe ( Cortex ) Judgement and reason Mid brain ( Limbic ) Emotions and reward sites Hind brain ( Stem ) Bodily functions Basic description of the major areas of the brain. Example of alcohol impairing judgment in the cortex, changing emotions in the limbic system, and in an overdose respiratory and cardiac arrest.

Neurotransmitter Action Reuptake Release of NT Receptor Neurotransmitters are how messages are sent from one cell to another. The first neuron releases a Neurotransmitter (NT) into the synapse. The NT crosses the synapse and fits into the receptor site on the second neuron and activates it. Once that happens, the receptor releases the NT and it is recycled by the first neuron by reuptake. Drugs change this process. Prozac and Zoloft block the reuptake of Serotonin. All of the serotonin then keeps returning to the receptor sites and keeps reactivating the 2nd neuron. Cocaine works the same way, only it stops the reuptake of dopamine and norepinephrine. Methamphetamine greatly increases the amount of NT released by the first neuron (turns your kitchen faucet into a fire hose) Heroin resembles a NT (endorphin) and can activate the receptor site itself.

Neurotransmitters Acetylcholine – Memory Dopamine – Reward/Euphoria Norepinephrine – Metabolic Rate Serotonin – Mood, Sleep Regulation Acetylcholine - memory – Alzheimers disease not enough Acetylcholine – marijuana lowers Acetycholine results in poor memory when high Dopamine – key to addiction – the high Norepinephrine – this is the chemical that controls heart rate, respiration, blood pressure and the fight/flight response. Serotonin – mood, sleep regulation, rage control

Rebound Death Alert & Cheerful Seizure Alert Asleep Coma Rebound – Describe the continuum of alertness on the left side- demonstrate how we go through different levels at different times of the day (wake up tired, had an interesting morning so we were alert, got tired in the afternoon, went home and got all excited because American Idol was on). We can use drugs to change where we are. For example coffee can be used to help wake us up. The caffeine makes us feel alert and cheerful. Imagine that your body’s alertness level is a pendulum. Taking a stimulant like caffeine pulls it to one side, when the caffeine wears off, it swings back to the other side creating the opposite feelings of what the drug produces – in caffeine’s case alert and cheerful become tired and grumpy. This is just a one dose version of withdrawal. It is the law of the nervous system – what goes up (or down) must come down (or up). Some people redose to get the positive feelings back again. If they didn’t the pendulum would return to normal. In time frames – you drink the caffeine at 8:15 – feel the alert and cheerful around 9:00 and bottom out at 10:00am – coffee break time. If you don’t have any more coffee you will return to normal about noon. Now consider how many people never let their pendulum find where it should be – they are always pulling in to one side or the other with caffeine, nicotine, alcohol, cocaine, etc,. Their body after a while gets so used to being pulled around, that they cannot remember what “Normal” feels like and finds it very uncomfortable. Coma Tired & Grumpy Death

Awake, Powerful, Euphoric, Sexy Crash Here’s a rebound chart for cocaine. You feel awake, confident, sexy etc. People like that. They don’t like the depressed and powerlessness. So they keep taking the drug to keep from having the rebound. But eventually they run out of $, the drug, etc. and experience the crash. Depressed, Powerless

The Reward Pathway and Addiction

Natural Rewards Food Water Sex Nurturing These things are naturally rewarding – they feel good. Imagine what would happen if they were painful – we’d stop eating, drinking, having sex, and taking care of our kids. Our species would become extinct.

Reward Pathways The parts of the brain that are involved in feeling good are called reward pathways. The main reward pathway involves three areas – the nucleus accumbens, the Ventral Tegmental Area, and connects to the prefrontal cortex.

Behavior Pathways Rewarding behaviors can become routine “Subconscious” control of the behavior Difficult to extinguish behaviors because people are not always aware when they are initiated. Resistant to change People start doing the things “automatically” – have two cigarettes lit, drive home and can’t remember if you stopped for that stop sign. Ask the participants to quickly cross their arms – then have them cross them the “other way” – it feels weird and you have to think about it. Drug use can become an automatic behavior – so can overeating.

Chemical Dependency Chronic Disease Prone to Relapse Requires significant behavior changes Similar to Heart Disease, Diabetes, Asthma, Gingivitis,etc. Similar treatment “success” Compliance rates are similar for these diseases. Ask if anyone knows a diabetic who doesn’t comply with what their doctor says, or heart disease patients who don’t change their diet. How many of the participants are 100% compliant with what their dentist tells them. Now drug courts increase success because of the monitoring. Do you think you’d be more compliant if your dentist gave you a urine test every week that would tell if there were any times that you skipped flossing?

Relapse Happens Poor Craving Management The Relapse Process – Gorski Get the train back on the tracks

Cocaine Natural Stimulant - South America Crack is a purer form that is smoked

Cocaine Effects - Euphoria Blocks Reuptake of DA and NE – increases activity Central Nervous System - Euphoria Peripheral NS - ­ NE Fight/Flight ­ HR, BP, Temp, bronchodilation, dilates pupils

Alert, Awake, Powerful, Confident Drowsy, Powerless, Low Self esteem, Depression

Smoked - onset 5-12 seconds 30-40 mins Snorted - onset 2 mins. Using a pen, mimic taking a hit off a crack pipe. Count 5 seconds – this is the time it takes for Dopamine to start flooding the reward system and the limbic system. It is “instant on” for the drug user. With crack there is a higher,quicker high and a lower faster low. 15 mins 1 hour

Dose Response As dose increases the effects change. At initial dose level, the person feels energized and euphoric – sort of like you do when you’ve gotten the best news you can imagine – won the lottery. Increase the does and it turns into restless and aggressive – some people like this because it helps them at their job – traders on a stock exchange floor for example Increase some more and repetitive behavior – banging on something for a long period of time – as well as a sense of paranoia. At the highest level people have delusions including formication (coke bugs) – they look psychotic. Metabolic crisis – heart rate 150+. BP 240/95, temp 103+ - dangerous leads to stroke, heart attack, seizure.

3rd study – essentially unlimited cocaine – all dead in five days – seizure, heart attack, stroke Cocaine only drug that monkeys will self administer til death.

Stopping Cocaine Use Anhedonia - Dopamine depletion Craving - intense craving for drug

The Memory of Drugs Nature Video Cocaine Video Front of Brain Back of Brain Amygdala not lit up Amygdala activated Slide 10: The memory of drugs. This slide demonstrates something really amazing—how just the mention of items associated with drug use may cause an addict to “crave” or desire drugs. This PET scan is part of a scientific study that compared recovering addicts, who had stopped using cocaine, with people who had no history of cocaine use. The study hoped to determine what parts of the brain are activated when drugs are craved.   For this study, brain scans were performed while subjects watched two videos. The first video, a nondrug presentation, showed nature images—mountains, rivers, animals, flowers, trees. The second video showed cocaine and drug paraphernalia, such as pipes, needles, matches, and other items familiar to addicts. This is how the memory of drugs works: The yellow area on the upper part of the second image is the amygdala (a-mig-duh-luh), a part of the brain’s limbic system, which is critical for memory and responsible for evoking emotions. For an addict, when a drug craving occurs, the amygdala becomes active and a craving for cocaine is triggered. So if it’s the middle of the night, raining, snowing, it doesn’t matter. This craving demands the drug immediately. Rational thoughts are dismissed by the uncontrollable desire for drugs. At this point, a basic change has occurred in the brain. The person is no longer in control. This changed brain makes it almost impossible for drug addicts to stay drug-free without professional help. Because addiction is a brain disease. Photo courtesy of Anna Rose Childress, Ph.D.

Methamphetamine Popular in 1960’s - Hell’s Angels Crystal / Crank - snortable - 1980’s Ice - smokeable form -1990’s Started in Hawaii - California - Midwest Hells angels manufactured and sold it.

Meth - Signs of Abuse mean temperment compulsive excited talk rapid weight loss nervous energy no “need” for sleep aggressive mean temperment compulsive excited talk “Meth mouth”

Meth - Signs of Withdrawal long crash apathy depression fatigue anxiety suicidal ideation cravings

Methamphetamine Cocaine Synthetic Smoking High 8-24 hours No Medical Use Neurotoxic “Natural” Smoking High 10 - 30 minutes Local anesthetic Non-neurotoxic

Alcohol Most popular drug of abuse Probably the most physically toxic of drugs Damages almost every organ in the body Easy access, adults use, advertising, relatively inexpensive. THE DRUG for Youth

Action Dopamine – excitement & reward Serotonin – feel – “normal” GABA – lowers anxiety Endorphins – pain relief, reward, craving This slide shows the action of alcohol on various neurotransmitter systems.

Endorphins Drink Craving Endorphins Endorphins Reward Stop Drinking Description of the Endorphin theory of alcoholism. The theory states that some people are born with both a low level of normal endorphin activity as well as an increase in endorphin activity when alcohol is consumed. They drink – experience the reward of increased endorphins and drink more – when they stop drinking the decrease endorphins and begin craving. When they are given naltrexone (ReVia) and then drink they do not experience the endorphin reaction. They think we’ve ruined drinking for them. Stop Drinking Block Endorphins with Naltrexone – Break Reward Cycle

Opiates Dates to 4,000 BC Mimics endorphin activity Natural - Opium, morphine, codeine Semi-synthetic- Heroin, Dilaudid, Oxycontin Synthetics - Darvon, Demerol, Fentanyl,

Opiates Heroin more potent -60-80% - <10% in ‘70’s Younger age group - High School Users start with snorting - IV within 12 months Withdrawal painful - not deadly Lots of Relapse

Prescription Opiates OxyContin-an oral, controlled release form of the drug- Much abuse – crush the tablet – heroin-like high Darvon Vicodin Dilaudid

Ecstasy – “E” Club drugs – produce feelings of belongingness, warmth and affection Intense euphoric high Provide energy for dancing – raves Less hallucinogenic Dangers – teeth grinding (pacifiers) Hyperthermia/dehydration

Marijuana Used since 2,700 BC More potent today (5-10X) than ‘70’s Kids starting younger Eliminates boredom, focus concentration, lowered anxiety, euphoric, increased appetite.

Main Effects Decreased Anxiety - Euphoria Increase focus of concentration – eliminates boredom. Impaired Short Term Memory Perceptual changes – time Analgesia Increased Appetite

LSD Extremely powerful drug Doses in micrograms – 1/1000mg Dose is 30-50mg –Effects last 10-12 hours Illusions – pseudohallucinations Increase in sensory signal strength – intense emotional experiences

Club Drugs Phencyclidine – PCP – Angel Dust Ketamine – “K”, Special K, Super K Dextromethorphan – DXM, Robitussin, Coricidin GHB – Gamma Hydroxy-butyrate – “liquid X” – Also GBL – Blue Nitrol

Early Recovery Issues Loss of lifestyle Loss of Coping Strategy Withdrawal Cognitive deficits related to early abstinence

Cognitive Deficits Memory problems- short term loss Difficulty with abstractions Difficulty with impulse control Similar performance to those with brain damage - improves.

Addiction is like… A dog with a bone The dog does not want to let go of the bone (addiction/ denial). It gets excited when it thinks its going to get its bone (craving) It always wants more bones (loss of control) Sometimes the dog takes you for a walk.

Treatment is like… Obedience School for the Dog You teach the dog’s owner to control the dog. You develop a variety of tools (relapse prevention) to help the dog be obedient. Some dogs are harder to train.

PET Scan Images http://www.nida.nih.gov/pubs/Teaching/