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S. Alex Stalcup, M.D.
New Leaf Treatment Center
251 Lafayette Circle, Suite 150
Lafayette, CA 94549
Tel: 925-284-5200
Fax: 925-284-5204
[email protected]
www.nltc.com
Functions of the
Reward/Pleasure System of
the Brain
• Rewards pursuit of instinctive drives
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(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
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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.
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Tolerance: The process by which the reward and pleasure centers of the brain
adapt to high concentrations of pleasure neurotransmitters.
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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’.
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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.
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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.
Definition of Addiction
• 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.
Model for nicotine addiction cycle
during daily cigarette smoking
C I M Model Treatment
Causes of Craving
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Environmental cues (Triggers)
immediate, catastrophic, overwhelming craving stimulated by
people, places, things associated with prior drug-use experiences
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Drug Withdrawal
inadequately treated or untreated
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Mental illness symptoms
inadequately treated or untreated
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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 exposure
perinatal asphyxia
low birth weight
head injury
• The Drug / Circumstances of First Use
• Enabling System
Darrell’s Family
Drink+Smoke
Drugs+Drink+Smoke
Smoke
Percentage of U.S. Adults Aged 18 and Older Dependent on Alcohol, by Age of
Drinking Onset
Addiction: Risk & Resilience
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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
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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
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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
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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:
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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?
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Is your use causing adverse consequences: grades, friends, money, health,
unwanted sexual behavior?
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Do you crave the drug under addiction conditions: Environment,
Withdrawal, Mental Health, Stress (EWMS)
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If so, when you crave the drug, can you talk yourself into using it, even
when you have resolved to not use?
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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
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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
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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
Darrell’s Family
Drink+Smoke
Drugs+Drink+Smoke
Smoke
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
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W
M
S
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Environmental cues (Triggers)
immediate, catastrophic, overwhelming craving stimulated by
people, places, things associated with prior drug-use experiences
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Drug Withdrawal
inadequately treated or untreated
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Mental illness symptoms
inadequately treated or untreated
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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
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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.
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Monitor sleep, boredom, depression, anxiety, irritability
Use test instruments to formally assess symptoms
Develop access to medical assessment and treatment
Monitor impact of treatment on symptoms and abstinence
C I M Model Treatment
Assessment for Stressors
STRESS EQUALS CRAVING
Personal stressors
Relationship conflict
Financial problems
Work school issues
Parenting conflicts
Legal issues
Lifestyle stressors
Hunger
Anger
Loneliness
Tired
Stress Management
Goal: to develop alternatives to drug use that are pleasureable and reduce
boredom and stress
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Practice effect of exercise, music, sports, social contact, fun
activities on craving scores
Experiment with scheduling day as stress response technique
Practice fun alternative to use
Promoting Resilience
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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):707-13
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(2002).
Bechara A. Decision making, impulse control and loss of willpower to resit
drugs: a neurocognitive perspective. Nature Neuroscience. 8:1458-63 (2005)
Dackis C, O’Brien C. Neurobiology of addiction: treatment and public
policy ramifications. Nature Neuroscience. 8(11):1431-6 (2005).
Nestler EJ, Malenka RC. The addicted brain. Scientific American.com
February 9, 2004.
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(10:1444-51
(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
Forebrain
Midbrain
Alcohol Poisoning
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Binge drinking
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Five or more drinks in two hours (male)
Four or more drinks in two hours (female)
Signs of severe alcohol toxicity - Call 911
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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
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Careful monitoring - Do not leave the patient alone.
Airway protection to prevent breathing or choking problems.
Medications
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Administration of fluids through a vein (intravenously) to prevent dehydration
Oxygen therapy