A Neurobiological Look at the Bio-Psycho-Social-Spiritual Disease: Defining Addiction

Michael M. Miller, MD, FASAM, FAPAmmiller@rogershospital.orgMedical Director, Herrington Recovery Center (HRC)Rogers Memorial HospitalOconomowoc, WisconsinAssociate Clinical ProfessorUniversity of Wisconsin School of Medicine and Public HealthAssociate Clinical ProfessorMedical College of Wisconsin, Dept of Psychiatry & Behavioral HealthPast President and Board ChairWisconsin and American Societies of Addiction MedicineDirectorAmerican Board of Addiction Medicine

DescriptionThrough an exploration of the 2011 Definition of Addiction of the AmericanSociety of Addiction Medicine as well as its historical roots, attendees willbecome equipped to teach patients and families about how addictionis not about alcohol or other drugs, but it‟s about brains; and how it‘snot just about mesolimbic reward circuitry, but is about the role of otherbrain regions in the relationship that persons with addiction developwith sources of reward and relief.The presentation will help attendees discriminate between descriptionsand definitions that focus on substances and behaviors that providereward or relief, versus the underlying biology which leads to alteredthe thoughts, emotions, and behaviors seen in persons with addiction.

ASAM‟s MissionThe American Society of Addiction Medicine’s mission is to:• Increase access to and improve the quality of addiction treatment;• Educate physicians (including medical and osteopathic students), other health care providers and the public;• Support research and prevention;• Promote the appropriate role of the physician in the care of patients with addiction;• Establish addiction medicine as a specialty recognized by professional organizations, governments, physicians, purchasers and consumers of health care services, and the general public.Approved by ASAM Board, 7-2006;http://198.65.155.172/CMS/images/PDF/General/Strategic%20Plan.pdf

Addiction Medicine:The specialty of medicine devoted todiagnosis, treatment, prevention, education, epidemiology, research, and public policy advocacy regarding addiction andother substance-related health conditions

How to Identify a Physician Recognized forExpertise in the Diagnosis and Treatment ofAddiction and Substance-related HealthConditions (ASAM Public Policy Statement)www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html

www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html• Completion of a residency/fellowship in Addiction Medicine or Addiction Psychiatry• Certification in Addiction Medicine by the American Society of Addiction Medicine (ASAM)• Subspecialty certification in Addiction Psychiatry by the American Board of Psychiatry and Neurology (ABPN)• A Certificate of Added Qualification in Addiction Medicine conferred by the American Osteopathic Association (AOA)• Board Certification in Addiction Medicine by the American Board of Addiction Medicine (ABAM)

Scope of Practice for Addiction MedicinePhysicians (ABAM)The addiction medicine physician provides medical care withinthe bio-psycho-social framework for persons withaddiction, for the individual with substance-related healthconditions, for persons who manifest unhealthy substanceuse, and for family members whose health and functioningare affected by someone‘s substance use or addiction.

American Board of Addiction MedicineMission StatementABAM’s mission is to contribute to the improvement of carefor patients suffering from addiction to alcohol, nicotine andother addicting drugs (including some prescription drugs), andto establish and maintain standards and procedures forcertification, recertification and maintenance of certification ofphysicians who specialize in Addiction Medicine.

How is it that DRUGS aredifferent from BROCCOLI?• It‘s because of what ‗drugs‘ do to the BRAIN• Drugs enter the body via various routes – Oral, Intravenous, Intramuscular, Intranasal, transdermal, transbuccal, or transalveolar• Drugs that affect mood/thought/behavior cross the ‗blood brain barrier‘• Drugs act on nerve cells by binding to specialized portions of the outer membrane of nerve cells

The Irony...• Addiction is not about DRUGS !• Addiction is about BRAINS!• It‘s not about the quantify/frequency of use• It‘s about the – Quality of use – Pattern of use – Relationship the person has to ‗their drug‘• It‘s about how the person with addiction is changed when using

New Understandings about Addiction• Addiction is a disease of the brain• Dopamine in the VTA and the Nucleus Accumbens is important in Drug Reward (the ‗Reward Pathway‘ of the MFB etc.)• BUT we now understand that the Nuc Acc is where REWARD HAPPENS, whereas ADDICTION resides in the OFC and in connections among the Nuc Acc, the OFC, the hippocampus and the amygdala

Addiction „Resides‟ in the Orbitofrontal Cortex (OFC)and in connections between OFC et al.• Addiction is use despite adverse consequences, returning to use after periods of abstinence even with previous life catastrophes, inability to control use, cognitive preoccupation, conscious and unconscious craving• It involves memory, judgment, ‗executive functions‘ of planning and deciding to defer gratification• All these are Frontal Lobe functions

Addiction „Resides‟ in the Orbitofrontal Cortex (OFC)and in connections between OFC et al.

Addiction „Resides‟ in the Orbitofrontal Cortex (OFC)and in connections between OFC et al.• The site of action for reward/drug-induced euphoria is the nucleus accumbens (an oversimplification)• The site of action for addiction is interplay between the frontal lobes and the Nuc Acc, and among the Nuc Acc, the hippocampus (memory), and the amygdala (motivation) – Judgment / Evaluation – Planning – Drive (drug hunger/craving; drug seeking/use) – Recalling past experiences

Circuits Involved in Drug Abuse and Addiction PFCCONTROL ACG MEMORY/INHIBITORY OFC Hipp LEARNING SCC CONTROL NAc c VP Amy g REWARDMOTIVATION/ DRIVE

Addiction „resides‟ somewhat in the Orbitofrontal Cortex(OFC) and in other areas with connections to Reward Circuitry• The site of acute action for euphoriants is the nucleus accumbens (an oversimplification)• The site of action for the chronic, recurrent, relapsing exposure to euphoriants--as is see in addiction—is the interplay among the Nuc Acc, the hippocampus (memory; recalling past experiences), the amygdala (motivation, drive, drug hunger/craving; drug seeking/use), and the frontal lobes (judgment/evaluation, planning, delay of gratification, inhibition of urges/impulses)

Construction AnatomyBrain Development:Proliferation and pruning occursfrom back to frontBack:Region that mediates direct contactwith environmentNext:Regions that coordinate thosefunctionsLast:Prefrontal Cortex

Right Lateral and Top Views of the Dynamic Sequence ofGM Maturation Over the Cortical Surface Source: Gogtay, Nitin et al (2004) Proc. Natl. Acad. Sci. USA 101; 8174-8179 Copyright 2004 by the National Academy of Sciences

Exposure to drugs of abuse during adolescence could haveprofound effects on Brain Development and Brain PlasticityUnderstanding drug abuse and addiction from a developmental perspectivehas important implications for their prevention and treatment

Cartoon Break

Non Addicted Brain Addicted Brain Control STOP ControlSaliency Drive Saliency Drive GO Memory Memory

The Physiology of AddictionCertain substances have the ability to interact with thebrain‘s Reward Circuitry and are thus euphoriants; they arereinforcing, and, in lab animals, self-reinforcing. They act firstby being external ligands for neuro-transmitter receptors, orby causing release of (or otherwise altering levels of) neuro-transmitters.They hijack the reward system, and the individualcompulsively pursues these rewards instead of naturalrewards.

The Physiology of AddictionOnce the Reward Circuitry is turned on, there are changes inrelated brain areas or neuronal circuits, and these result in thecharacteristic manifestations of addiction [altered memory ofpast intoxication experiences, altered cue response, changesin motivation so that ‗the drug‘ (which can be a substance, ora pathologically rewarding activity) becomes ‗the salientreinforcer,‘ replacing other healthy rewards]. All thiscontributes to preoccupation and loss of control. The mostcontemporary term for all this circuitry is the brain‘s ―incentivesalience circuitry.‖

The Physiology of Addiction• Changes in frontal lobe function (executive functioning; the inhibition of impulses to use) are key: the brain fails in efforts to inhibit the drive to obtain/use the drug to create ‗the high‘.• Impairment in control and preoccupation are the key behavioral/cognitive characteristics of addiction, and have an anatomical/physiological substrate in the brain.• Relapse is intrinsic to virtually all chronic diseases; the animal model of relapse is ―reinstatement‖ of drug use or drug preference.

Addiction is…• A BRAIN DISEASE• A primary, relapsing and remitting CHRONIC DISEASE….• A PEDIATRIC DISEASE….

Addiction is a Developmental Disease 1.8 TOBACCO 1.6 THC ALCOHOL 1.4% in each age to develop first-time dependence 1.2 1.0 0.8 0.6 0.4 0.2 0.0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 Age Age at tobacco, at alcohol and at cannabis dependence, as per DSM IV National Epidemiologic Survey on Alcohol and Related Conditions, 2003

Griffith Edwards (1976)Edwards (Griffith), Gross (Milton)―Alcohol dependence: provisional description ofa clinical syndrome‖British Medical Journal, 1:1058-1061 (1976)

Griffith Edwards (1976)Essential elements of the syndrome:• subjective awareness of a compulsion to drink• reinstatement of the syndrome after abstinenceAll these elements exist in degree, thus givingthe syndrome a range of severity.

The Definition of Alcoholism(NCADD / ASAM – 1990, JAMA 1994: Morse et al.)Alcoholism is a primary, chronic disease withgenetic, psychosocial, and environmental factors influencingits development and manifestations. The disease is oftenprogressive and fatal. It is characterized by continuous orperiodic: impaired control over drinking, preoccupation withthe drug alcohol, use of alcohol despite adverseconsequences, and distortions in thinking, most notablydenial.

What is Addiction?American Society of Addiction Medicine • April 2011Definition of Addiction: ―Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.‖

Definition of AddictionAmerican Society of Addiction Medicine • April 2011―Addiction is characterized by inability to consistentlyabstain, impairment in behavioralcontrol, craving, diminished recognition of significantproblems with one’s behaviors and interpersonalrelationships, and a dysfunctional emotionalresponse. Like other chronic diseases, addiction ofteninvolves cycles of relapse and remission. Withouttreatment or engagement in recoveryactivities, addiction is progressive and can result indisability or premature death.‖

ASAM‟s New Definition of Addictionhttp://www.asam.org/for-the-public/definition-of-addiction

Downward Spiral / ProgressionAddiction(constriction –ofaffects, behaviors,social network)

Atrophy• Of social network – People…• Of activities / interests – Places, Things• Of emotions – Flatness, less expressive, dysthymic / alexithymic• Of rewards – Salience

Downward Spiral of Addiction andUpward Spiral of RecoveryAddiction Recovery(constriction –of (expansion—affects, behaviors, of feelings, rewards,social network) activities, social connections)Copyright (c)2011, Covington, Griffin, & Dauer

How to come out of the depths?How to RECOVER?• “Re-people-ization” – AA – Sponsor – Church – Social clubs – Activities with others – Family• Professional Treatment (group therapy, meet others)• Re-Connectedness

ASAM Public Policy Statement:Definition of Addiction (Long Version)Addiction is a primary, chronic disease of brainreward, motivation, memory and related circuitry. Addictionaffects neurotransmission and interactions within rewardstructures of the brain, including the nucleusaccumbens, anterior cingulate cortex, basal forebrain andamygdala, such that motivational hierarchies are altered andaddictive behaviors, which may or may not include alcohol andother drug use, supplant healthy, self-care related behaviors.

ASAM Public Policy Statement:Definition of Addiction (Long Version)Addiction also affects neurotransmission and interactionsbetween cortical and hippocampal circuits and brain rewardstructures, such that the memory of previous exposures torewards (such as food, sex, alcohol and other drugs) leads to abiological and behavioral response to external cues, in turntriggering craving and/or engagement in addictive behaviors.

The neurobiology of addiction encompassesmore than the neurochemistry of reward.1The frontal cortex of the brain and underlying white matterconnections between the frontal cortex and circuits ofreward, motivation and memory are fundamental in themanifestations of altered impulse control, [and] alteredjudgment….

…and the dysfunctional pursuit of rewards (which is oftenexperienced by the affected person as a desire to ―be normal‖)seen in addiction--despite cumulative adverse consequencesexperienced from engagement in substance use and otheraddictive behaviors.

The frontal lobes are important in inhibiting impulsivity and inassisting individuals to appropriately delay gratification. Whenpersons with addiction manifest problems in deferringgratification, there is a neurological locus of these problems inthe frontal cortex.

Frontal lobe morphology, connectivity and functioning are stillin the process of maturation during adolescence and youngadulthood, and early exposure to substance use is anothersignificant factor in the development of addiction. Manyneuroscientists believe that developmental morphology is thebasis that makes early-life exposure to substances such animportant factor.

Footnote 1: The neurobiology of reward has been well understoodfor decades, whereas the neurobiology of addiction is still beingexplored. Most clinicians have learned of reward pathwaysincluding projections from the ventral tegmental area (VTA) of thebrain, through the median forebrain bundle (MFB), and terminatingin the nucleus accumbens (Nuc Acc), in which dopamine neuronsare prominent. Current neuroscience recognizes that theneurocircuitry of reward also involves a rich bi-directional circuitryconnecting the nucleus accumbens and the basal forebrain.

Footnote 1 (continued): It is the reward circuitry where reward isregistered, and where the most fundamental rewards such asfood, hydration, sex, and nurturing exert a strong and life-sustaining influence. Alcohol, nicotine, other drugs andpathological gambling behaviors exert their initial effects byacting on the same reward circuitry that appears in the brain tomake food and sex, for example, profoundly reinforcing. Othereffects, such as intoxication and emotional euphoria fromrewards, derive from activation of the reward circuitry.

Footnote 1 (continued): While intoxication and withdrawal arewell understood through the study of reward circuitry,understanding of addiction requires understanding of a broadernetwork of neural connections involving forebrain as well asmidbrain structures. Selection of certain rewards, preoccupationwith certain rewards, response to triggers to pursue certainrewards, and motivational drives to use alcohol and other drugsand/or pathologically seek other rewards, involve multiple brainregions outside of reward neurocircuitry itself.

Naqvi NH, Bechara ATrends in Neurosciences, 32:56-67, 2008―Although the dopamine system clearly has an important rolein addiction to drugs of abuse, drug use does more for theaddicted individual than merely providing a means ofreleasing dopamine in the brain. Drug use involves a complexset of rituals imbued with emotional meaning (both positiveand negative) for the addicted individual.‖

Genetic factors account for about half of thelikelihood that an individual will develop addiction.Environmental factors interact with the person‘s biology andaffect the extent to which genetic factors exert theirinfluence. Resiliencies the individual acquires (throughparenting or later life experiences) can affect the extent towhich genetic predispositions lead to the behavioral and othermanifestations of addiction. Culture also plays a role in howaddiction becomes actualized in persons with biologicalvulnerabilities to the development of addiction.

Environmental / Cultural Factors• Availability • ―Peer Pressure‖• Social Norms for/against • Siblings – Indoor smoking bans • Parents – MADD – Their Use – ―Those Who Host Lose the – Their Attitudes (perceived Most‖ harm)• Perceived Harm – Their Rules/Consequences• Consequences (legal (parents are ‗the antidrug‘) status; drug-free schools)

Other factors that can contribute to the appearance ofaddiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include:• The presence of an underlying biological deficit in the function of reward circuits, such that drugs and behaviors which enhance reward function are preferred and sought as reinforcers;• The repeated engagement in drug use or other addictive behaviors, causing neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors;• Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception;

“…neuroadaptation in motivational circuitry leading toimpaired control over further drug use or engagement inaddictive behaviors….”[O‘Brien: ―addiction = neuroplasticity‖] changes in motivation/control changes in cue responsiveness[See also: Koob GF, Volkow ND. ―Neurocircuitry of addiction.‖ Neuropsychopharmacology. 2010 Jan;35(1):217-38.]

Other factors that can contribute to the appearance ofaddiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include:• Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies;• Exposure to trauma or stressors that overwhelm an individual‘s coping abilities;• Distortion in meaning, purpose and values that guide attitudes, thinking and behavior;• Distortions in a person‘s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others); and• The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviors.

Addiction is characterized by2:• Inability to consistently Abstain;• Impairment in Behavioral control;• Craving; or increased ―hunger‖ for drugs or rewarding experiences;• Diminished recognition of significant problems with one‘s behaviors and interpersonal relationships; and• A dysfunctional Emotional response.

Footnote 2: These five features are not intended to be used as―diagnostic criteria‖ for determining if addiction is present ornot. Although these characteristic features are widely presentin most cases of addiction, regardless of the pharmacology ofthe substance use seen in addiction or the reward that ispathologically pursued, each feature may not be equallyprominent in every case. The diagnosis of addiction requiresa comprehensive biological, psychological, social and spiritualassessment.

Naqvi NH, Bechara ATrends in Neurosciences, 32:56-67, 2008―…Studies using animal models [which] have emphasized therole of subcortical systems such as the amygdala, nucleusaccumbens and the mesolimbic dopamine system…havetended to focused on externally observable aspects ofaddiction (emphasis added)‖

The power of external cues to trigger cravingand drug use, …as well as to increase the frequency of engagement inother potentially addictive behaviors, is also a characteristic ofaddiction, with the hippocampus being important in memory ofprevious euphoric or dysphoric experiences, and with theamygdala being important in having motivation concentrate onselecting behaviors associated with these past experiences.

Although some believe that the difference between those whohave addiction, and those who do not, is the quantity orfrequency of alcohol/drug use, engagement in addictivebehaviors (such as gambling or spending) 3, or exposure toother external rewards (such as food or sex)…,

…a characteristic aspect of addiction is the qualitative way inwhich the individual responds to such exposures, stressors andenvironmental cues. A particularly pathological aspect of theway that persons with addiction pursue substance use orexternal rewards is that preoccupation with, obsession withand/or pursuit of rewards (e.g., alcohol, nicotine and other druguse) persist despite the accumulation of adverse consequences.These manifestations can occur compulsively or impulsively, asa reflection of impaired control.

WHO Expert Committee on Mental Health, AlcoholismSubcommittee (2nd Report, 1952)―The subcommittee has distinguished twocategories of alcoholics, ―alcohol addicts‖ and―habitual symptomatic excessive drinkers. Forbrevity‘s sake the latter will be referred to asnon-addictive alcoholics. In both groups, theexcessive drinking is symptomatic ofunderlying psychological or social pathology….‖WHO Technical Report Series No. 48, August 1952, pp. 26-27

WHO Expert Committee on Mental Health, AlcoholismSubcommittee (2nd Report, 1952)―…but in one group after several years ofexcessive drinking “loss of control” over thealcohol intake occurs, while in the other groupthis phenomenon never develops. The groupwith “loss of control” is designated as“alcohol addicts.”WHO Technical Report Series No. 48, August 1952, pp 26-27

WHO Expert Committee on Mental Health, AlcoholismSubcommittee (2nd Report, 1952)―The disease conception of alcohol addictiondoes not apply to the excessive drinking, butsolely to the ‗loss of control‘ which occurs in onlyone group of alcoholics and then only aftermany years of excessive drinking.‖WHO Technical Report Series No. 48, August 1952, pg 27

WHO Expert Committee on Mental Health, AlcoholismSubcommittee (2nd Report, 1952)―The ‗loss of control‘ is a disease condition per se whichresults from a process that superimposes itself upon thoseabnormal psychological conditions of which excessivedrinking is a symptom. The fact that many excessive drinkersdrink as much as or more than the addict for 30 or 40 yearswithout developing loss of control indicates that in the group of‗alcohol addicts‘ a superimposed process must occur.‖WHO Technical Report Series No. 48, August 1952, pg 27

Griffith Edwards (1976)―Perhaps the key experience can bestbe described as a compulsion todrink….―The desire for a further drink is seenas irrational, the desire is resisted, butthe further drink is taken.‖

Griffith Edwards (1976)―…Awareness of ‗loss of control‘ is saidto be crucial to understandingabnormal drinking….―Control is probably best seen asvariably and intermittently impairedrather than ‗lost‘.‖

Although some believe that the difference between those whohave addiction, and those who do not, is the quantity orfrequency of alcohol/drug use, engagement in addictivebehaviors (such as gambling or spending) 3, or exposure toother external rewards (such as food or sex)…,

Footnote 3: In this document, the term "addictive behaviors"refers to behaviors that are commonly rewarding and are afeature in many cases of addiction. Exposure to thesebehaviors, just as occurs with exposure to rewarding drugs, isfacilitative of the addiction process rather than causative ofaddiction. The state of brain anatomy and physiology is theunderlying variable that is more directly causative of addiction.

Footnote 3: Thus, in this document, the term ―addictivebehaviors‖ does not refer to dysfunctional or sociallydisapproved behaviors, which can appear in many cases ofaddiction. Behaviors, such as dishonesty, violation of one‘svalues or the values of others, criminal acts etc., can be acomponent of addiction; these are best viewed as complicationsthat result from rather than contribute to addiction.

Persistent risk and/or recurrence of relapse, after periodsof abstinence, is another fundamental feature ofaddiction. This can be triggered by exposure to rewardingsubstances and behaviors, by exposure to environmentalcues to use, and by exposure to emotional stressors thattrigger heightened activity in brain stress circuits.4

Footnote 4: The anatomy (the brain circuitry involved) and thephysiology (the neuro-transmitters involved) in these threemodes of relapse (drug- or reward-triggered relapse vs. cue-triggered relapse vs. stress-triggered relapse) have beendelineated through neuroscience research.

Relapse triggered by exposure to addictive/ rewardingdrugs, including alcohol, involves the nucleus accumbensand the VTA-MFB-Nuc Acc neural axis (the brains mesolimbicdopaminergic "incentive salience circuitry"--see Footnote 2above). Reward-triggered relapse also is mediated byglutamatergic circuits projecting to the nucleus accumbensfrom the frontal cortex.

Relapse triggered by exposure to conditioned cuesfrom the environment involves glutamate circuitsoriginating in frontal cortex, insula, hippocampus andamygdala projecting to mesolimbic incentive saliencecircuitry.

Relapse triggered by exposure to stressful experiencesinvolves brain stress circuits beyond the hypothalamic-pituitary-adrenal axis that is well known as the core of the endocrine stresssystem. There are two of these relapse-triggering brain stresscircuits – one originates in noradrenergic nucleus A2 in the lateraltegmental area of the brain stem and projects to thehypothalamus, nucleus accumbens, frontal cortex, and bednucleus of the stria terminalis, and uses norepinephrine as itsneurotransmitter; the other originates in the central nucleus of theamygdala, projects to the bed nucleus of the stria terminalis anduses corticotrophin-releasing factor (CRF) as its neurotransmitter.

“Relapse” or “Reinstatement”Griffith Edwards (1976)―Relapse into the previous stage of thedependence syndrome…follows anextremely variable time course.Typically, the patient who had only amoderate degree of dependence willtake weeks or months to reinstate it….‖

“Relapse” or “Reinstatement”Griffith Edwards (1976)―A severely dependent patient typicallyreports that he is again ‗hooked‘ within afew days of starting to drink, eventhough there are exceptions: on thefirst day he may become abnormallydrunk and be surprised to have lost histolerance.‖

“Relapse” or “Reinstatement”Griffith Edwards (1976)―A syndrome which had taken manyyears to develop can be fully reinstatedwithin perhaps 72 hours, and this is oneof the most puzzling features of thecondition.‖[kindling]

In addiction there is a significant impairment in executivefunctioning, which manifests in problems withperception, learning, impulse control, compulsivity, andjudgment. People with addiction often manifest a lowerreadiness to change their dysfunctional behaviors despitemounting concerns expressed by significant others in theirlives; and display an apparent lack of appreciation of themagnitude of cumulative problems and complications.

The still developing frontal lobes of adolescents may bothcompound these deficits in executive functioning andpredispose youngsters to engage in ―high risk‖behaviors, including engaging in alcohol, nicotine or otherdrug use. The profound drive or craving to use substances orengage in apparently rewarding behaviors, which is seen inmany patients with addiction, underscores the compulsive oravolitional aspect of this disease. This is the correlation with―powerlessness‖ over addiction and ―unmanageability‖ oflife, as is described in Step 1 of Twelve Step programs.

Addiction is more than abehavioral disorder.Features of addiction include aspects of a person‘s behaviors,cognitions, emotions, and interactions with others, including aperson‘s ability to relate to members of their family, tomembers of their community, to their own psychological state,and to things that transcend their daily experience.

Behavioral manifestations and complications ofaddiction, primarily due to impaired control, can include:• Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control;• Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the neglect of responsibilities at home, school or work);

Behavioral manifestations and complications ofaddiction, primarily due to impaired control, can include:• Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems which may have been caused or exacerbated by substance use and/or related addictive behaviors;• A narrowing of the behavioral repertoire focusing on rewards that are part of addiction; and• An apparent lack of ability and/or readiness to take consistent, ameliorative action despite recognition of problems.

Griffith Edwards (1976) ―…as dependence advances…theindividual gives priority to maintaininghis alcohol intake; indeed the failure ofunpleasant consequences to deter maybe a clinical indicator of the degree ofdependence.‖

Cognitive changes in addictioncan include:• Preoccupation with substance use;• Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviors; and• The inaccurate belief that problems experienced in one‘s life are attributable to other causes rather than being a predictable consequence of addiction.

Emotional changes in addictioncan include:• Increased anxiety, dysphoria and emotional pain;• Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that ―things seem more stressful‖ as a result; and• Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).

Memory and Learning(not in the Definition)Memory and learning in addiction involves more than recall ofprevious positive experiences with alcohol, tobacco or otherdrug use or other exposures to rewards, and more thanrepression or distortion of memories of the negativeexperiences associated with pursing or exposing oneself torewards. It also involves more than the cognitive andemotional aspects of conscious and unconscious craving andthe conditioning, through recollection of previous experienceswith learned triggers, to re-engage with the pathologicalpursuit of rewards.

Memory and Learning(not in the Definition)Memory in addiction also has a behavioral and motorcomponent, which seems to be mediated by the rostral(anterior) portion of the ventral tegmental area: certain motorbehaviors associated with pursing rewards, e.g., going outand finding supplies of drugs, or food, or gamblingmaterials, may be recalled or ingrained in circuitry of therostral VTA, such that those motor behaviors have been“learned” and reappear in the behavioral repertoire of theperson with addiction without there being a consciouscomponent to the behavior’s reoccurrence.

Memory and Learning(not in the Definition)Complex motor behaviors such as reaching for both cigarettesand ignition materials and “lighting up”—or even getting intoan automobile and driving to a liquor store—may occur basedon unconscious patterns of learned motor or kinestheticbehavior in addition to the emotional or physiological drive toexperience a drug effect or another reward. --Michael M. Miller, M.D.

The emotional aspects of addiction are quitecomplex.• Some persons use alcohol or other drugs or pathologically pursue other rewards because they are seeking ―positive reinforcement‖ or the creation of a positive emotional state (―euphoria‖).• Others pursue substance use or other rewards because they have experienced relief from negative emotional states (―dysphoria‖), which constitutes ―negative reinforcement.―• Beyond the initial experiences of reward and relief, there is a dysfunctional emotional state present in most cases of addiction that is associated with the persistence of engagement with addictive behaviors.

The state of addiction is not the same as thestate of intoxication.When anyone experiences mild intoxication through the use ofalcohol or other drugs, or when one engages non-pathologically inpotentially addictive behaviors such as gambling or eating, onemay experience a ―high‖, felt as a ―positive‖ emotional stateassociated with increased dopamine and opioid peptide activity inreward circuits. After such an experience, there is a neurochemicalrebound, in which the reward function does not simply revert tobaseline, but often drops below the original levels. This is usuallynot consciously perceptible by the individual and is not necessarilyassociated with functional impairments.

Over time, repeated experiences with substance use oraddictive behaviors are not associated with ever increasingreward circuit activity and are not as subjectively rewarding.Once a person experiences withdrawal from drug use orcomparable behaviors, there is ananxious, agitated, dysphoric and labile emotionalexperience, related to suboptimal reward and the recruitmentof brain and hormonal stress systems, which is associatedwith withdrawal from virtually all pharmacological classes ofaddictive drugs.

While tolerance develops to the ―high,‖ tolerance does notdevelop to the emotional ―low‖ associated with the cycle ofintoxication and withdrawal. Thus, in addiction, personsrepeatedly attempt to create a ―high‖--but what they mostlyexperience is a deeper and deeper ―low.‖ While anyone may―want‖ to get ―high‖, those with addiction feel a ―need‖ to usethe addictive substance or engage in the addictive behavior inorder to try to resolve their dysphoric emotional state or theirphysiological symptoms of withdrawal.

Persons with addiction compulsively use even though it maynot make them feel good, in some cases long after the pursuitof ―rewards‖ is not actually pleasurable.5 Although people fromany culture may choose to ―get high‖ from one or anotheractivity, it is important to appreciate that addiction is not solely afunction of choice. Simply put, addiction is not a desiredcondition.

Edgar DegasL Absinthe(The Absinthe Drinker)1875-76Musée dOrsayParis, France

Griffith Edwards (1976)―Without withdrawing sympathy from thenon-dependent drinker who is experiencingharm, society should be asked to realizethat the person who has becomedependent on alcohol is certainly ill; andthe possibility of contracting this illnessawaits anyone who drinks very heavily.‖

Footnote 5: Pathologically pursuing reward (mentioned inthe Short Version of this definition) thus has multiplecomponents. It is not necessarily the amount of exposure tothe reward (e.g., the dosage of a drug) or the frequency orduration of the exposure that is pathological.

Footnote 5 (continued): In addiction, pursuit of rewardspersists, despite life problems that accumulate due to addictivebehaviors, even when engagement in the behaviors ceases to bepleasurable. Similarly, in earlier stages of addiction, or even beforethe outward manifestations of addiction have becomeapparent, substance use or engagement in addictive behaviorscan be an attempt to pursue relief from dysphoria; while in laterstages of the disease, engagement in addictive behaviors canpersist even though the behavior no longer provides relief.

Naqvi NH, Bechara ATrends in Neurosciences, 32:56-67, 2008―It is clear that both incentives and internal states (e.g.withdrawal) jointly determine the motivation to seek drugs.‖

As addiction is a chronic disease, periods ofrelapse, which may interrupt spans of remission, are acommon feature of addiction. It is also important torecognize that return to drug use or pathological pursuitof rewards is not inevitable.

Clinical interventions can be quite effective in altering the course ofaddiction. Close monitoring of the behaviors of the individual andcontingency management, sometimes including behavioralconsequences for relapse behaviors, can contribute to positiveclinical outcomes. Engagement in health promotion activities whichpromote personal responsibility and accountability, connection withothers, and personal growth also contribute to recovery. It isimportant to recognize that addiction can cause disability orpremature death, especially when left untreated or treatedinadequately.

The qualitative ways in which the brain and behavior respondto drug exposure and engagement in addictive behaviors aredifferent at later stages of addiction than in earlierstages, indicating progression, which may not be overtlyapparent.

Griffith Edwards (1976) on progression―The model need not, of course, propose a rigidlystereotyped progression.―…Milder degrees can indeed regress and thepatient can return to normal drinking.‖[Vaillant 1980, The Natural History of Alcoholism:11% of alcoholics return to controlled drinking]

Griffith Edwards (1976) on progression―A patient with an intermediate degree ofdependence is, if he continues to drink, muchmore likely to progress to severe dependencethan to move backwards down the curve.―Very severe dependence is usuallyirreversible, and if the patient will not acceptabstinence he will repeatedly reinstate thesyndrome.‖

As is the case with other chronic diseases, the conditionmust be monitored and managed over time to:• Decrease the frequency and intensity of relapses;• Sustain periods of remission; and• Optimize the person‘s level of functioning during periods of remission.

• In some cases of addiction, medication management can improve treatment outcomes.• In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results.• Chronic disease management is important for minimization of episodes of relapse and their impact.• Treatment of addiction saves lives †

Targeted Therapeutic Changes inAddiction TreatmentBEHAVIORAL CHANGES BIOLOGICAL CHANGES• Eliminate alcohol and other drug • Resolve acute alcohol and other use behaviors drug withdrawal symptoms• Eliminate other problematic • Physically stabilize the organism behaviors • Develop sense of personal• Expand repertoire of healthy responsibility for wellness behaviors • Initiate health promotion• Develop alternative behaviors activities (e.g., diet, exercise, safe sex, sober sex)

Targeted Therapeutic Changes inAddiction TreatmentCOGNITIVE CHANGES AFFECTIVE CHANGES• Increase awareness of illness • Increase emotional awareness• Increase awareness of negative of negative consequences of consequences of use use• Increase awareness of addictive • Increase ability to tolerate disease in self feelings without defenses• Decrease denial • Manage anxiety and depression • Manage shame and guilt

Targeted Therapeutic Changes inAddiction TreatmentSOCIAL CHANGES SPIRITUAL CHANGES• Increase personal responsibility • Increase self-love/esteem; in all areas of life decrease self-loathing• Increase reliability and • Reestablish personal values trustworthiness • Enhance connectedness• Become resocialized: • Increase appreciation of reestablished sober social transcendence network• Increase social coping skills: with spouse/partner, with colleagues, with neighbors, with strangers Miller, Michael M. Principles of Addiction Medicine, 1994; published by American Society of Addiction Medicine, Chevy Chase, MD

Dysfunction in these circuits leads to characteristicbiological, psychological, social and spiritual manifestations.• Question: Why is ASAM, • Values matter as a medical organization, • Violating your own talking about ―spirituality‖? values, then re-establishing your values, matters.• Answer: Because the members of the DDTAG, • Connectedness matters. and of the BOD, recognize • Meaning in life matters. the multidimensional aspect • Recovery is many of both the disease and of things, including a search recovery for meaning.

Addiction professionals and persons in recovery know thehope that is found in recovery. Recovery is available even topersons who may not at first be able to perceive this hope,especially when the focus is on linking the healthconsequences to the disease of addiction.

As in other health conditions, self-management, withmutual support, is very important in recovery fromaddiction.Peer support such as that found in various ―self-help‖ activitiesis beneficial in optimizing health status and functionaloutcomes in recovery. ‡

Recovery from addiction is best achievedthrough a combination of self-management, mutual support, andprofessional care provided by trained andcertified professionals.

NIDA Principles of Drug Addiction Treatment(1999, rev 2009)1. Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain‘s structure and function, resulting in changes that persist long after drug use has ceased.2. No single treatment is appropriate for everyone.NIH Publication No. 09–4180

www.drugabuse.gov

Griffith Edwards (1976)―Doctors should be aware that not everypatient who drinks too much (for whateverreason) is necessarily dependent onalcohol, and different patients needdifferent help and treatment.‖

Herrington Recovery Center

Thank you! Michael M. Miller, MD, FASAM, FAPA mmiller@rogershospital.org Herrington Recovery Center at Rogers Memorial Hospital For more information, call 800-767-4411 or visit rogershospital.org

Rogers treats children, adolescentsand adults with:• Anxiety disorders• Mood disorders• Eating disorders• Substance-use disorders 800-767-4411 rogershospital.org

A Neurobiological Look at the Bio-Psycho-Social-Spiritual Disease: Defining Addiction

by Rogers Memorial Hospital

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A Neurobiological Look at the Bio-Psycho-Social-Spiritual Disease: Defining Addiction Presentation Transcript