New Tools and Troubles in Addiction Treatment

1
New Tools and Troubles in Addiction
Treatment

• Paul H. Earley, M.D., FASAM
• Medical Director
• Talbott Recovery Campus
• Atlanta, Georgia
• USA

2
Outline of this Talk

• Trouble Public Opinion
• Tool Clarifying Addiction Craving
• Trouble Addiction Memory
• Tool EMDR and Meditation
• Tool Buprenorphine
• Trouble Buprenorphine

3
TroublePublic Opinion
4
Has Public Perception Improved?Brian West and
the California Physician Diversion Program
5
ToolClarify Addiction Craving
6
Craving Classification

• Cue-based craving
• Craving is a response to environmental cue
• Cue creates internal state which is recognized as
  craving
• Most notable in cocaine, methamphetamine and
  nicotine
• State or stress-based craving
• Emotional tone and the level of perceived stress
  set a specific state
• Craving appears to emerge out of the more
  difficult of these states
• Most notable in alcohol, opioids, and sedatives
• Addiction Memory cravings
• Replay of using-related material
• Related to Euphoric recall

7
Cue-based craving
8
Craving Workbook

• Cue-based craving
• Break down major cues into
• A - Always avoid
• B - Avoid now
• C - Desensitize
• Develop avoidance plans for A
• Decide when to expose and a response plan for B
• Begin cue exposure and desensitization for C

9
TroubleAddiction Memory
10
Learning about Addiction Memory

• Neural circuitry of relapse
• Fear
• PTSD Physiology
• Addiction Memory

11
Craving is an Internal Battle

• Once the hypothalamus is entrained to seek reward
  through addiction
• A constant battle emerges between the more
  primitive parts of the brain and the
  contemplative frontal cortex
• The primitive parts of the brain recruit
  behaviors and thoughts to hijack recovery

12
Conflicts in Control Lead to Relapse
I shouldnt, look what it will do. I promised,
etc.
I want to. I long for it.
13
The Amygdala
from Sundsten, University of Washington Digital
Anatomist Project
14
The two pathways of fear
LeDoux as described by The Brain from Top to
Bottom, McGill University
15
Acute Fear Normal Processing

• A traumatic event occurs
• The amygdala sounds an alarm through the short
  loop. More malleable and slower responses to the
  event occur through the thalamocortical (long)
  loop.
• The pituitary gland secretes Corticotropin-releasi
  ng Factor (CRF)
• The cerebellum is mobilized for movement
• The medulla oblongata activates the
  cardiovascular system and shuts down digestion.
  The pons increases respiration.

16
Acute Fear Normal Processing

1. The locus coeruleus secretes norepinephrine and
   the nucleus accumbens and surrounding structures
   secrete dopamine to rivet attention.
2. The visual cortex, in concert with the
   hippocampus, creates a visual recording of the
   event.
3. When the acute situation subsides, the cortex
   revisits the images, reprocessing the event into
   semantic and episodic memory. This deactivates
   the amygdala-driven memory circuits.
4. Dreams further process the meaning of the
   fear-event, providing behavioral alternatives to
   avoid or deflect the trauma and improve
   survivability. Dreaming encodes complex
   behavioral responses (procedural memory) and
   draws associations between the current fear event
   and past fear memories.

17
Post-traumatic Stress Disorder

• Singular or recurrent trauma
• Produces persistent, frightening thoughts and
  memories or flashbacks of the ordeal
• Persons with PTSD often feel chronically
  emotionally numb
• Flashbacks are often similar to a movie clip
• PTSD victims have an exaggerated startle response
• Once PTSD circuits are engaged, other strong
  memories are encoded in PTSD memory circuits
  instead of being processed into episodic memory

18
What happens with PTSD?

• The acute trauma is either too overwhelming or is
  repeated, preventing the individual from
  reprocessing the trauma
• The trauma tape becomes stuck in visual memory
• The victim numbs to avoid emotionally
  experiencing the trauma
• Dreams and further meaning-extraction does not
  occur, rending the organism susceptible to
  recurrence
• The victim may engage in trauma re-enactment to
  reactivate the release of endorphins and dopamine

19
What happens with Addiction?

• Use is repeated over time, preventing the
  individual from reprocessing the experience.
• Some of the intense using experiences produce a
  tape which becomes stuck in visual memory.
• The addict numbs to avoid emotionally
  experiencing the consequences of their illness.
• Dreaming is suppressed and further
  meaning-extraction does not occur, rending the
  organism susceptible to continued use and
  relapse.
• To stimulate the release of endorphins and
  dopamine, the addict re-enacts addiction
  behaviors (even before drugs enter the system).

20
Is Addiction Recovery like PTSD?
Addiction

• Makes many alcoholics and addicts feel
  simultaneously in love and abused
• Hijacks the self-preservation circuits of the
  brain
• Overwhelms memory circuits
• Stimulates dopamine in the nucleus accumbens
• Produces memory tapes which over-ride normal life
  experiences making them seem pale in comparison
  to their alcohol or drug use

like PTSD
21
ToolEMDR
22
EMDR

• Stands for Eye Movement Desensitization and
  Reprocessing
• Patient identifies past visual imagery related to
  the traumatic memory, a negative belief about
  self, and related body sensations.
• While focusing on the above, the patient follows
  the therapists finger moving their eyes across
  their field of vision for 20-30 seconds or more.
  Other lateralizing stimuli (tones or tapping) are
  also used.
• Distress from the memories, beliefs and
  sensations is managed so the patient can return
  to the procedure.
• Once started, EMDR does follow where the
  patients thoughts lead.
• The outcome, over time, is a belief in positive
  characteristics of self and decreased distress
  over trauma experiences.

23
Theories on how EMDR works

• Eye movement invokes the same brain circuitry as
  REM sleep allowing memories to move from
  unprocessed amygdala-evoked memories to semantic
  memory.
• The alternating lateralizing stimuli (eye
  movement, tapping) forces the movement of
  memories into both cortical hemispheres, away
  from the lateralized (right amygdala dominance)
  of PTSD circuits.

24
Research on EMDR

• EMDR decreases left and right occipital lobe
  activity and left parietal lobe.
• EMDR increases activity in the anterior cingulate
  gyrus and the left frontal lobe.
• These brain correlates confirm that the
  successful treatment of PTSD does not reduce
  arousal at the limbic level, but instead,
  enhances the ability to differentiate real from
  imagined threat.

Levin P, Lazrove S, van der Kolk, B. J. Anxiety
Disorders Jan-Apr13(1-2)159-72 (1999).
25
EMDR and Recovery

• EMDR helps patients reframe their attachment to
  drug use and drug lifestyle into addiction
  trauma.
• EMDR decreases traumatic memories that
  destabilize the path to recovery.
• EMDR provides hope of trauma resolution for
  patients who have suffered past physical, sexual
  and emotional trauma in addition to addiction
  trauma.
• EMDR may decrease euphoric recall.
• EMDR may reprogram the procedural learning
  produced by past use behaviors, and thus,
  decrease relapse.

26
ToolMeditation
27
Meditation

• Practiced in many forms, both as part of Eastern
  religions and in non-sectarian situations
• Often one sits in a predefined position and
  minimizes or eliminates body movement
• Eyes are open or closed
• The primary goal is to let go of or eliminate
  thought, to reach a place where you are in the
  presence of mind without the brain chatter
• Christian meditation may achieve the same state
  (listening to God)

28
What does meditation do?

• Even simplified low dose meditation produces
  reduced heart rate, slowed breathing, and
  decreased blood pressure
• Meditation practitioners develop an increase in
  synchronous gamma-frequency oscillations on EEG.
  In addition their EEGs show phase-synchrony
  during meditation. Both of these phenomenon are
  predominantly over the frontal lobes. (Davidson,
  2004)

29
What does meditation do?

• fMRI studies show increased blood flow in the
  dorsolateral prefrontal and parietal cortices,
  hippocampus / parahippocampus, temporal lobe,
  anterior cingulate cortex, striatum, and pre- and
  post-central gyri during meditation (Lazarus and
  Benson, 2000)
• Meditation increases cortical thickness in
  several critical areas of the brain (Lazar, 2005)

30
Meditation and the EEG
Davidson, 2004
31
Meditation and Cortical Thickness
plt10-3 plt10-4
Cortical thickness is correlated with increased
neuronal connections, glial volume or increased
cerebral vasculature
Davidson, 2005
32
Meditation and Recovery

• Meditation increases synchrony between the right
  and left brain, and more importantly between
  cortical and lower neuronal centers of the brain.
• Meditation increases anterior cingulate function,
  important for salience testing and attention
• Meditation purports to inhibit amygdaloid
  over-control by increasing frontal lobe activity.

33
Meditation and Recovery

• Meditation has been shown to decrease impulsivity
  and increase tolerance for the negative
  emotions, especially in borderline PD patients
  (research from dialectical behavioral therapy)
• Meditation increases the quality of
  living-in-the-moment.
• Meditation increases the sensation of general
  well-being.

34
ToolBuprenorphine
35
Buprenorphine - Tool

• Mixed agonist/antagonist
• At lower dose, it has primarily agonist
  properties
• As the dose increases, increasing antagonist
  action occurs
• Much simpler regulation of its prescription, when
  compared to methadone
• Unlike methadone, no recorded cardiac-related
  deaths

36
Buprenorphine - Tool

• Excellent detoxification medicine
• Has changed the detoxification environment and
  increased detoxification success rates
• Produces only mild euphoria
• Good maintenance medication
• Less sedation than methadone
• Less stigmatizing, obtained through prescription
  rather that a drug clinic
• Very difficult to overdose with buprenorphine

37
TroubleBuprenorphine
38
Buprenorphine Trouble

• Physicians Issues
• Physicians who would never open up a methadone
  clinic need only obtain 8 hours or less of
  training to begin prescribing buprenorphine
• Physicians trained in abstinence-based beliefs,
  who previously looked down upon methadone, are
  amazed by the benefits of opioid-agonist therapy
• Buprenorphine has opened up a whole area of
  practice for the solo addiction medicine
  specialist
• Once on maintenance medication, patients will
  show up for return appointments

39
Buprenorphine Trouble

• Some buprenorphine proponents compare the use of
  buprenorphine to the introduction of SSRIs and
  non-addicting sleep aides into treatment centers
• But a fundamental difference exists
• Buprenorphine, as a µ agonist, blocks
  painincluding emotional painand thwarts
  psychotherapeutic and spiritual growth

40
Buprenorphine Trouble

• Abstinence-based Treatment Center Issues
• Once on buprenorphine, it is difficult is some
  patients to move from 2 mg / day to zero (the
  empty receptor syndrome)
• Because patients feel normal on buprenorphine,
  everyone is lulled into avoiding deeper
  examination of any incorrect treatment metaphors
• Some treatment centers mix buprenorphine-maintaine
  d patients with fully abstinent and proclaim
  there is no difference.
• But have we really examined what are we saying?

41
Buprenorphine Trouble

• We need to draw upon all of the sophistication we
  have available to us.
• We need not discard buprenorphine maintenance
  it is a valuable short term (3 to 9 month) and
  long term tool (1 year to lifetime).
• But we should not decide the type of treatment
  the patient receives based upon the training or
  bias of the caregiver.
• This means clear and methodology neutral
  treatment protocols

42
Buprenorphine Maintenance

• We suggest a finer granularity in our
  nomenclature
• For those on patients on sustained dosing of
  buprenorphine, a moniker is suggested
  Maintenance-assisted recovery
• This complements one other path
  abstinence-based recovery
• Patients may need to move from these two
  treatment types and we need to be able to clearly
  delineate treatment protocols
• Buprenorphine maintenance should always be
  buttressed by random urine drug screening

43
Education and Consultation

• Contact
• By phone [phone]
• By E-mail paul.earley_at_uhsinc.com