Its a Brain Disease: Beyond a Reasonable Doubt

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Understanding the Science of Addiction
Mark Stanford, Ph.D. Santa Clara County Dept of A
lcohol Drug Services Addiction Medicine Divisio
n Association for Medical Education Research
In Substance Abuse (AMERSA) Associate Professor
Psychopharmacology - Dept. of Biological
Sciences and Mathematics, UC Berkeley Extension
and Cal State Hayward
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• Presentation Objectives
• Examine contribution of nature vs. nurture
• Explain why some drugs have abuse potential
• Understand how prolonged drug use changes brain
  circuitry
  
• Understand addiction as a chronic condition
  requiring chronic care

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How we used to perceive and treat mental illness
Some treatments were designed to induce fear.
Spinning the patient until loss of consciousness
occurred was thought to help rearrange the
contents of the brain. Other techniques include
d insulin shock and frontal lobotomies.
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Weve changed how we perceive and treat mental
illness (thank God!)
During the Middle Ages and Renaissance Period,
witchcraft and demonic possession were considered
to be the root of psychosis and schizophrenia.
Physical interventions included trepanation - the
boring of holes in the skull to release the evil
spirits.
Was this an evidence-based practice during that
time?
This illustration shows a colonial surgeon
attempting a trepanation procedure, which
required up to 60 minutes of constant drilling.
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The evidence is that schizophrenia is a
biologically-based disease of the brain.
This evidence is supported by brain imaging
showing precisely the wave of tissue destruction
that takes place in the brain that is suffering
from schizophrenia.
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How we used to perceive and treat drug and
alcohol addiction
In the past, society viewed drug addiction as a
moral flaw. Popular "treatments" involved
imprisonment, sentencing to asylums, and
church-guided prayer.
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The evidence is that drug addiction is a
biologically-based chronic disease expressed as
compulsive drug seeking and using behavior and
characterized by fundamental and long-lasting
changes in the brain.
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• Addiction is a Chronic Illness Because
• It has both a genetic and environmental basis
  influencing its development and manifestation
  
• Recovery from it is often a long-term process
  requiring repeated treatments
  
• Relapses can occur during or after successful
  treatment episodes
  
• Participation in self-help support programs
  during and following treatment can be helpful in
  sustaining long-term recovery

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And yet, despite the large body of science,
several myths about addiction still persist,
including

• Addiction is a moral weakness
• You have to hit rock bottom to recover
• You have to want treatment for it to be
  successful
  
• Drug abuse is more common among minorities
• Alcohol is not really a drug

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used to be
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A Paradigm Shift in Addiction Treatment
Traditional Psychosocial
Neuro-biological Physiological
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Your Brain on Drugs Today
YELLOW shows places in brain where cocaine goes
(striatum)
Front of Brain
Back of Brain
Fowler et al., Synapse, 1989.
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Advances in science have revolutionized our
fundamental views of drug abuse and addiction,
showing us that
? abuse is a preventable behavior
? addiction is a treatable disease
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Why do some drugs have abuse potential?
There are about 15,000,000 substances in the wor
ld. However, of these only about 55,000 are a
vailable for human consumption.
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Interestingly, of these 55,000 substances . .
. .
only about 25 have abuse potential !!
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Drugs With Abuse Potential

• Uppers CNS Stimulants. Amphetamine,
  methamphetamine, cocaine

• Downers CNS Depressants. Alcohol,
  benzodiazepines (like valium, etc), barbiturates
  (like seconal, etc.), Inhalants, etc.

• All-arounders Hallucinogens. LSD, mescaline,
  MDMA (XTC), psilocybin (magic mushrooms), PCP,
  etc.

• Pain Killers Opioids. Heroin, codeine,
  morphine, vicodin, fentanyl, Oxycontin, etc.

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Why do some drugs have abuse potential and others
do not?
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Prior to the 1950s, not much was known about the
brain/behavior link, let alone the addictive
nature of drugs.
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Research in the 1970s began to investigate the
nature of addiction. From the 1990s, dramati
c advances were made about the biobehavioral
basis of addictions and improved treatment
methods based on scientific research.
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Behaviors that result in the experience of
release from a biological tension (i.e. eating)
make us feel good.
This feel good response is registered in a
certain part of the brain and with a brain
chemical called dopamine.
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Behaviors experienced as pleasurable are
processed in an area known as the
Mesocorticolimbic Pathway (MCLP)
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Natural Rewards
The MCLP is necessary for survival since it
motivates important activities such as food
seeking and eating, mating, and parenting.

• Food

• Water

• Sex

• Nurturing

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Natural Rewards Elevate Dopamine Levels
SEX
FOOD
200
200
NAc shell
150
150
DA Concentration ( Baseline)
100
100
of Basal DA Output
Empty
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Box
Feeding
0
0
60
120
180
Female Present
Time (min)
Sample Number
Di Chiara et al., Neuroscience, 1999.
Fiorino and Phillips, J. Neuroscience, 1997.
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Drugs and alcohol effect the same areas in the
brains reward pathway . . .
. . . But in a way that is dangerous and
potentially fatal!
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Effects of Drugs on Dopamine Release
Di Chiara and Imperato, PNAS, 1988
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If taking drugs makes people feel good or better,
whats the problem?
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Repeated use of drugs and alcohol saturate the
brains reward pathway to the point that

• the person becomes conditioned to the intense
  level of drug-induced pleasure,

• the normal level of natural rewards are no
  longer experienced as very pleasurable, and

• after chronic use, the brains reward pathway
  becomes drained so that nothing is pleasurable
  not even the drugs!

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Neuroscience Research and Brain Imaging Technolo
gy
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Science has generated much evidence showing that

prolonged drug use changes the brain in fundament
al
and long-lasting ways
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Even 80 days after detox, a methamphetamine
users dopamine transporter system (right) hasnt
recovered to normal levels (left)
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DA Receptors and the Response to
Methylphenidate (MP)
High DA receptor
high
Dopamine receptor level
low
Low DA receptor
As a group, subjects with low receptor levels
found MP pleasant while those with high levels
found MP unpleasant
Adapted from Volkow et al., Am. J. Psychiatry,
1999.
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A critical part of addictions treatment is the
prevention of relapse behaviors.
Drug craving behaviors are triggered by a
conditioned response of the nervous system when
re-exposed to an environmental cue it has
associated with drug use.
And . . . this conditioned response can last a
lifetime.
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Vulnerability
Why do some people become addicted while others
do not?
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We Know Theres a Big Genetic Contribution to D
rug Abuse and Addiction .Overlapping with Env
ironmental Influences that Help Make Addiction a
Complex Disease.
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Biology/genes
Biology/ Environment Interactions
Environment
IFH high tolerance 60 IFH low tolerance
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Marc Schuckit. 2002.
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Whats Being Done About All of This?
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From the research over the last 8 - 10 years, we
have learned that . . .
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Facts of Addiction Treatment

• Addiction is a brain disease
• A chronic disorder requiring multiple strategies
  and multiple episodes of intervention
  
• Treatment works in the long run
• Treatment is cost-effective

NIDA. 2007.
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What does the Science say about
the best ways to TREAT drug addiction?
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Evidence-Based Practices (EBP)
Interventions that show consistent scientific
evidence of being related to preferred client
outcomes.
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Why Evidence-Based Practice?

• Why is this different than what we are already
• doing?
• Consumers communities deserve best possible
  services.
  
• Quality is associated with rigorous research.
• To get there from here requires an evolving
  system.
  
• Science and practice must inform each other.

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How Does EBP Relate to Recovery and Resiliency?

• In order to avoid cookie-cutter care, EBP
  requires clinicians to listen and respond to
  consumers concerns
  
• Evidence-based thinking enables clinicians to
  adapt EBPs to conditions and population groups
  for which EBPs have not been established.

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Scientifically-Based Approaches to Addiction
Treatment

• Cognitivebehavioral interventions
• Community reinforcement
• Motivational enhancement therapy
• 12-step facilitation
• Contingency management
• Pharmacological therapies
• Systems treatment
• L. Onken (2002). Personal Communication.
  National Institute on Drug Abuse.
  
• Principles of Drug Addiction Treatment A
  research-based guide (1999). National Institute
  on Drug Abuse
  

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Treatment and the Chronic Nature of Addiction
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Based on the science, how is addiction currently
defined?

• A brain disease expressed as a compulsive
  behavior
  
• The continued abuse of drugs despite negative
  consequences
  
• A chronic, potentially relapsing disorder

NIDA. 2004
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We know from decades of long term studies that
substance abuse treatment is effective.
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SO
Why Does Treatment Seem So Ineffective?
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How Do We Deliver Treatment ?
What is the model ?
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In a nice simple acute care world
Problem
Treatment
Problem solved life goes on as usual
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Example Treatment for an acute health problem
Bronchitis
Treatment (penicillin)
Problem solved and chart closed
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Actually, all treatment methods, regardless of an
acute or chronic condition, do not have a one
size fits all approach
Even though antibiotics are a standard treatment
choice . . .
ASSESSMENT is critical
Bronchitis
Treatment (penicillin)
Choice of antibiotics? What dose and for how
long? Patients statistics? Medical history?
Previous treatments? Other health concerns? etc.
Problem solved
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How would treatment for hypertension be using an
acute care model? How about the treatment outco
mes?
Question
Hypertension

• After the diagnosis, the patient is given one
  prescription with no-refills, a certificate of
  treatment completion, and the chart is closed.
  
• What happens? Is the problem really solved?
• Does the patient stay symptoms free?
• Does life go on as usual?

Treatment (antihypertensives)
Problem solved
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Efficacy outcomes research on chronic conditions
doesnt look at outcomes post-treatment, but at
the effect of ongoing interventions like
medications and continuing care such as lifestyle
changes and self management. Doctors treating o
ther chronic medical conditions take a
disease-management approach to treatment which is
the basis upon success is measured.
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In the treatment of chronic illness, effects are
significant but not long lasting after discharge
unless some level of continuous care is provided.
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Improving Chronic Illness Care
Hypertension
Continuing Care
Treatment (antihypertensives)

• Lifestyle changes
• Dietary changes
• Exercise regime
• Self management support
• Home blood pressure measures
• Regular follow ups with physician
• Education support groups

Blood pressure improved
Lower blood pressure maintained
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How Is Addiction Treatment Compared With
Treatments for Other Chronic Illnesses?
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Drug addiction is a chronic illness with relapse
rates similar to those of hypertension, diabetes,
and asthma
McLellan et al., JAMA, 2000
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If addiction is a chronic condition, why do we
provide treatment using an acute care model??
Acute Care Treatment
Chronic condition
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Its Confusing to our System of Care

• Because of the invariably conflicting outcomes,
  the effectiveness of treatment can be
  
• controversial which can then lead to
• uncertainty about the most appropriate care
• not implementing scientific findings about the
  best care (evidence-based methods)
  
• conflicting information about treatment
  standards

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In addictions treatment, as with other chronic
conditions effects are significant but not l
ong lasting after discharge unless come level of
continuous care is provided.
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Efficacy in the Treatment of Drug Addiction
Conclusion (Incorrect) Treatment not effective
because sustained change does not occur after a
treatment episode.
Treatment Research Institute
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Many systems of care still treat addiction as an
acute care problem
Substance Abuser
Entry into the system with problems and a
treatment plan developed
Treatment
Exit from the system with problems resolved
(hopefully) and case is closed
Non- Substance Abuser
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Traditional Continuum of Care Model

Completion of care, discharge, referral to
self-help meetings and case closed

Detox Residential Outpatient
Transitional
housing

The continuum of care system stops short of
providing continuing care services an essential
element in treating the chronic condition of
addiction.
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Reconceptualizing The System of Care
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• Multiple Acute Care Episodes IS NOT a Continuing
  Care Strategy
  
• Expensive and Wasteful
• Patient Education Is Necessary
• Align Patient and Provider Incentives to
  Promote Adherence/Compliance
  

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• Patient Retention is Critical
• Make Treatment Attractive
• Offer Options/Alternatives
• Increase Monitoring/Management

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• Evaluations of Continuing Care Should Occur
  DURING Treatment
  
• Need for interim performance markers (retention,
  linkage, urines, pro-social behaviors, etc.)

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• Patients who are not in some
• form of treatment or monitoring
• are at elevated risk for relapse

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• Monitoring is Part of Health Care
• Telephone and Internet Useful
• Saves Provider Time, Reduces Number and Severity
  of Relapses
  
• Not Currently Reimbursed

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What Does All This Mean?

• We have an opportunity to improve treatment
  systems of care and the services they contain and
  how services are implemented.
  
• There are effective and cost-efficient treatments
  and continuing care approaches for alcohol and
  drug dependence that embrace more of the chronic
  care disease management principles.
• Institute of Medicine, 1998. Bridging the Gap
  Between Practice and Research. Washington, DC
  National Academy Press

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Toward an Improved Approach
1 retain patients at an appropriate level of
care and 2 prepare patients to do well in the
next level of care and with skills to
self-manage their condition 3 offer continuou
s recovery monitoring after the primary treatment
episode
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What If . . .
The current health care delivery moved from being
reactive to being pro-active regarding
treatment and recovery? In addition to the nece
ssary acute interventions, what if extra time,
effort resources were placed on promoting
wellness (prevention) and stabilization (disease
management)? What if the system of care shifted
from its traditionally paternalistic approach
towards a more bilateral partnership, where
patient takes responsibility for his/her recovery
process and there are continuing care services?
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A New Continuum of Care
As personal responsibility increases, treatment
intensity decreases

Treatment Intensity
Treatment intensity
Personal responsibility
Continuous Recovery Monitoring (CRM)
Detox Residential Outpatient
Transitional Post- treatment
housing check-ups. Commun
ity support

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Frequent contact from program staff would be
essential from both an outcomes and a cost
perspective, as experience in the care of other
chronic illnesses demonstrates.
They care about you, but thats not why theyre
calling. They are managing you because they want
to keep you at the low end of the continuum care,
not where its expensive. Thomas McLellan, PhD.
Treatment Research Institute. 2003.
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A Conceptual Model Continuous Recovery Monitoring
Determinants of Progress in Treatment
Patient motivation, responsibility, choice
Predisposing factors Enabling factors/bar
riers Illness/Need factors System of Ca
re characteristics
Prepare client for Continuous Recovery Monitoring
Detox Residential Outpatient
Transitional Post-Treatment
housing check-ups.
Identify within-session patient-therapist
behaviors that predict subsequent dropout or
relapse and titrate the counseling dose
accordingly.

• Patients are taught to be proactive, not
  reactive, to their disease.
  
• Continuous monitoring
• Healthy lifestyle
• Self management support
• Patient family education
• Regular follow ups with provider
• Support groups

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Thank You!