Download The Science of Recovery - AAP

Cardwell C. Nuckols MA, PhD
[email protected]
(407) 758-1536
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Facilitated by:
 NOVELTY
 ENVIRONMENTAL
ENRICHMENT
 PHYSICAL EXERCISE
 NUTRITION
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Group Therapy
Individual Counseling
Sober Living
Higher Power
Assessment
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Alcohol/Drug
Psyhosocial
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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
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Stimulates production of brain-derived
neurotrophic factor (BDNF)
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Neurotrophin that governs maturation and
development of neural systems
Enhances executive functioning
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Obey social rules
Adapt to changing & unpredictable
environment
Short term working memory
Multi-tasking
Self-directedness
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Self-directedness
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Responsible
Purposeful
Resourceful
Increases neurotransmitters
 Monoamines
 Serotonin
 Dopamine
 Norepinephrine
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Association between DA D2 receptor
numbers and drug self-administration
Increased D2 receptors reduced alcohol
consumption
 Decreased D2 receptors higher risk
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DA D2 receptor levels influenced by
stress and social hierarchy
Helps explain influence of environment
and genes
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Subordinate animals more likely to selfadminister cocaine
Dominant animals no more likely to selfadminister cocaine than placebo
Social interventions can change
neurobiology
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Increased DA D2 receptors
Reduced self-administration
Behavioral interventions could counteract
the aversive effects of drug abuse and
reinforce the power of group approaches
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Group Therapy
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Milieu
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Active participation
Successful completion of assignments
Leadership
Modeling
Self help
Coffee and chairs
 “Telling story”
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Acute intoxication results in activation
and deactivation of regions connected to
the DA system
These regions are involved in
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REWARD
MEMORY
MOTIVATION/DRIVE
CONTROL
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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
Volkow, N. D. et al. J. Clin. Invest. 2003;111:1444-1451
Copyright ©2003 American Society for Clinical Investigation
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Location
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Nucleus Accumbens (NAc)
Ventral Tegmental Area (VTA)
Impact of drugs of abuse
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Increased extracellular levels of DA in
striatum (NAc)
Reinforcing effects related to:
 Magnitude of DA increase
 Abruptness of DA increase
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Reduced sensitivity to natural reinforcers
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Goals:
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Management of craving
Reduce reward value of drugs
Reduce pleasure (create unpleasantness)
from drug experience
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Situational triggers
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Emotional triggers
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Environment (People, Places And Things)
Internal (Hungry, Angry, Lonely, Tired,
Reward and Bored)
Acute Abstinence Syndrome
Stress
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In presence of:
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Alcohol and drugs
Alcohol and drug
users
Places where used
to use or purchase
Negative feeling
states particularly
anger but also:
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Boredom
Loneliness
Fear
Anxiety
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Positive feeling states
Physical pain
Use of mood-altering prescription drugs
Suddenly having a lot of cash
Complacency
Insomnia
Sexual functioning
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Psychotherapy
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Behavior Therapy
 Structure
 Recovery Foundation Program
 Changing patterns
 Safety Plan
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Pharmacological
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Acute
Maintenance
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.”
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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
TASK
SH
TX
FUN
NUT
PEX
MON TU
WED THU FRI
SAT SUN
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Carter is 24 yo and just getting out of
treatment for alcohol and drug addiction
His early A/D history included….
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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
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
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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’.”
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Opioid Maintenance Medications
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Methadone
LAAM
Buprenorphine
Naltrexone
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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
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Subutex-Buprenorphine. sublingual (SL)
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2mg and 8mg tablets
Suboxone-Buprenorphine/Naloxone SL
tablets
Buprenorphine 25-50 x’s more potent
than morphine
Partial agonist
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Increasing dose does not increase effect like a
full agonist
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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
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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
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If taken under
the tongue you
get predominant
buprenorphine
effect
If dissolved and
injected get
predominant
naloxone effect
(precipitates
withdrawal)
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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
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Instruct client to abstain for 12-24 hours
Need to be in mild withdrawal before first
dose
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Disulfiram, 1951
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Acamprosate, 2004
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Oral naltrexone, 1994
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Injectable extended-release
naltrexone, 2006
NONE OF THESE ARE ADDICTIVE
Dopamine
Increased Release
GABA
Glutamate
Opioid Peptides
Increased
Sensitivity to
GABA
Decreased
Activity
Increased Endogenous
Opioid 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.
Glutamate System
Acute Alcohol Effect
Administration
of Alcohol
Chronic
Alcohol Use
Inhibits NMDA receptors
Effect:  anxiety,  sedation
Alcohol-Free
Adaptation
# and/or function of NMDA
receptors on neurons
CNS Equilibrium
Withdrawal
Increased glutamatergic activity
Effect:
- Acute: dysphoria,
hallucinations
- Post-acute: sleep/mood
disturbances
Littleton. Alcohol Health Res World 1998;22:13.
Balances acute alcohol effect
Effect: tolerance, dependence
Removal of
Alcohol
N = 605
Fuller RK, et al. JAMA 1986;256:1449-1455.
*
N = 605
* p < .05
Fuller RK, et al. JAMA 1986;256:1449-1455.
a
Reduction in
postsynaptic effects
a
Reduction in glutamate
release
a
a
Glutamate
NMDA
Receptor
a Acamprosate
NMDA = N-methyl-D-aspartate
mGluR5 = metabotropic glutamate subtype 5 receptor
a
mGluR5 receptor
N = 272
Sass H, et al. Arch Gen Psychiatry 1996;53:673-680.
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Location
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Orbitofrontal Cortex (OFC)
Impact of Drugs of Abuse
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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
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Hypothalamus
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Amygdala
Reticular formation
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Head ganglion of ANS & locus of drive
Brainstem regulation of arousal
Frontal cortex
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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
AUTONOMIC NERVOUS SYSTEM
PARASYMPATHETIC
DISSOCIATION
(FREEZE)
SYMPATHETIC
HYPERAROUSAL
(FIGHT/FIGHT)
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Increase value of non-drug
reinforcers
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Positive Connection to Others
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Therapeutic Relationship
How we communicate
“Mirror” neurons
Family and couples therapy
12 step meetings
Connection to Higher Power of Your Choice
 Mindfulness Meditation
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Location
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Amygdala
Hippocampus
Impact of Drugs of Abuse
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People, Places and Things (“cues” or
“triggers”) create an intense desire to use
(“craving”)
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Impact of Drugs of Abuse (cont.)
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These cues automatically trigger habit
learning
 Release of DA
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Declarative learning links emotional states to
use (“Hungry, Angry, Lonely and Tired”)
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Behavioral
 Extinguish learned
positive
association with
drug or drug
“cues”
 Promote
reinforcement of
positive behaviors
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Recovery in
neuropsychological
functioning
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Most of treatment is
during time of
greatest dysfunction
Recovery is;
 Time-dependent
 Due to sustained
abstinence
 Experiencedependent
 Active rehabilitation
or repetitive
behavior
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Repetitive
recovery-oriented
behaviors
Repetitive
recovery-oriented
thoughts
Neurons that “fire
together, wire
together”
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Location
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Prefrontal Cortex
Anterior Cingulate Gyrus
Impact of Drugs of Abuse
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Disruption of prefrontal cortical functions
removes self-directed behavior in favor of
sensory-driven behavior
Lack of vertical integration
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Control
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Strengthen Prefrontal Cortical Control
 Cognitive Therapy
 Education
 Exercises
 Puzzles
 Computer Games
 Crossword Puzzles
 Vertical Integration
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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
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Positive role models (Sponsor)
Surrogate family (Home Group)
“Growing Up In AA”
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Coordinate the many brain activities
needed to utilize:
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Executive Functions
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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
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Why give an alcoholic or addict a 60
minute didactic or video?
A new format
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15-20 minute simple didactic
 How to participate in treatment
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10 minute questionnaire
30 minute discussion group
I THINK………..
I FEEL…………..
I LEARNED……
MY FUTURE BEHAVIOR WILL CHANGE…
BE KIND, CONSIDERATE, FORGIVING
AND COMPASSIONATE AT ALL
TIMES, PLACES AND UNDER ALL
CONDITIONS WITH EVERYONE, AS
WELL AS, YOURSELF
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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
Cloninger, Robert. Feeling Good: The
Science of Well-Being. Oxford University
Press, New York, 2004.
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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.
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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.
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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.
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http://draonline.org - Dual Recovery
Anonymous
Http://www.alcoholics-anonymous.org –
Alcoholics Anonymous
http://www.wsoinc.com – Narcotics
Anonymous
http://www.ca.org – Cocaine Anonymous


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http://www.whitebison.org – Wellbriety
http://www.nami.org – National Alliance
for the Mentally Ill
www.facesandvoicesofrecovery.org –
Faces and Voices of Recovery (FAVOR)
www.gwcinc.com/drnuck
ols.htm
 www.hcionline.com/cnuckols
 http://www.hazelden.org
/OA_HTML/hazCSrdSrchR
esults.jsp?event=&cg=200&kw=NUCKOLS
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