The Role of MFT in Addiction and          Chronic Pain        P. Joseph Frawley,M.D.
Principles of Addiction Medicine• 1. Addiction is a disease of the Survival Brain• 2. It is a chronic illness• 3. It is fa...
Ventral Tegmentum to Nucleus          Accumbens
Disease of Addiction   Survival Brain
Brain Reward Circuits
Natural History•Addiction has a Natural History
Natural History of Alcoholism8 years in Clinic Sample    Vaillant,1995               •   100 patients               •   Av...
Natural History of Alcoholism   Core City Sample   Vaillant,1995               • Control Group for                 Juvenil...
Natural History of Alcoholism    College Sample   Vailant,1995               • Population of College                 Gradu...
What is the Natural History          of Opioid Dependence?•   581 male addicts admitted to California•   Civil Addict Prog...
33 Year F/U Narcotic Addicts     Arch Gen Psych 58, May 2001 p. 503 (Hser et al)                              • Compulsory...
Age of Drug Use Patterns
The Nature of Addiction•   1. The Reward System•   2. The Memory of Reward•   3. The Triggers for Addiction•   4. Toleranc...
Animals will self stimulate the Reward  Center and forget other rewards
How The Survival Brain Works              Reward Center           Need           O2      Monitor Reward           Safety  ...
Brain Reward Center1. Cells that monitor the       Reward Center   status of needs          Need   normally stimulate     ...
Memory Stores the Results of Action  and Strengthens Connections        Need is metMemory Action         Need             ...
Brain Reward CenterWhen needs are not met         Reward Center  we experience alarm:     Need   Irritability            O...
Stages of Alarm to Threat•   Irritability•   Tension•   Anxiety•   Anger•   Pain    Panic
The Survival Brain motivates us to  change and stores the results                                         Reward Center   ...
Emotional Memory is layeredand is our emotional filter and reactor• 0-5 5-10 10-15 15-20                           Mixed F...
Emotional Brain is quicker and faster than the Slower Creative Intellect
However, as humans we come toconclusions about our experience so            we can plan                  • These can be ca...
As we learn, we form cognitions about     what we need to do to surviveCognition Memory Action                            ...
Addictive Drugs are Mimics of our own  Reward Chemistry: They Lie to Us                   Opiates     Endorphin           ...
How Addictive Drugs Addict the           Person- The Good1. The drug stimulates the          Reward Center   reward center...
Dopamine and Reward
How Addictive Drugs Addict the                 Person-The Bad1.    The drug suppresses the normal monitor             Rewa...
How Addictive Drugs Addict the            Person-The Ugly1. When the drug is gone,           Reward Center   the normal sy...
Drug Works-I Don’t WorkIn withdrawal we                    Reward Center    experience alarm and       Need    Monitor Rew...
Brain Imaging shows suppression• After use of cocaine  there is suppression of  dopamine receptors
Positive Emotional Drug Memory can  also stimulate the reward center             =CRAVING                   Drug Memory   ...
Anxiety and Mood Disorders oftenbegin in Teens and Young Adult hood
In Dual Diagnosis There are several       mechanisms for anxiety and               depressionCognition Memory Skills   Nee...
In Dual Diagnosis the drugs carry a bigger impact and development stopsCognition Memory Skills   Needs Biochemical        ...
The Disease Progresses           • Tolerance, Physical             Dependence           • 5-7 years of struggle for       ...
The Family Disease Progresses
Denial and Enabling          I can’t conceive living            without it          It is what I need          It is my nu...
Recovery Needs and Problem Drinking            ScoresVaillant,1995
Shame of Loss of Control of Illness                  • Alcoholics spend 5-7                    years struggling for       ...
Getting to Treatment          • It is hard and scary            to change          • If the addict takes a            firs...
We can Help the Process Along• Each stage has appropriate interventions
The Team Approach
DetoxificationWe taper medications over        Reward Center   time to allow the        Need    Monitor Reward   nervous s...
Opiate StabilizationSome people stay too              Reward Center   agitated when coming      Need     Monitor Reward   ...
Swedish Randomized Trial     The Lancet 361,Feb 22,2003 (Kakko et al)                          • Heroin Dependence by     ...
The Work of RecoveryCognition Memory Skills   Needs Biochemical                          O2                          Safet...
Safe Environment• The patient needs to be    • This will help determine  in a safe environment to     the level of care th...
The Biochemical• 1. Detoxification/taper/   • Close communication     maintenance               between the team is• 2. St...
Medications• Antabuse-                • Reduces impulsive use• Campral                  • Reduce Craving (mild            ...
The Needs• Safety                   • 1. The most essential• Respect                    aspect of a program is• Companions...
The Skills• 1. Managing Craving         • Recovery is like learning a                                sport or to dance• 2....
The Emotional Memory• Time has no meaning         • 1. In addition to the life  to the emotional              memories tha...
Cognitions•   Denial                  • Cognitive Skills and•   Shame                     Creativity•   Core Beliefs•   Co...
Chronic PainLow Back Pain                  Migraine                Fibromyalgia   Headache
Prior Trauma and PTSD and Chronic Pain• 1. Common Histories       a. Adultified Child       b. Abused Child   2. High Anxi...
Trauma and Vulnerability to Pain• N=520 Traumatized subjects: assessed for-•  PTSD,dissociation,somatization, affect• No P...
Chronic Pain Predisposition                                       Reward Center                             Need          ...
Limbically Augmented Pain             Syndrome• Patients w/ depression, behavioral  dysfunction, heightened sensitivity to...
Wind-Up in Fibromyalgia Staud,R. Arthritis Research & Therapy 2006,8:208Windup pain ratings ofnormal control (NC) andfibro...
After Central Sensitization• after central sensitization has been established  only minimal nociceptive  input is required...
The Work of Recovery from Chronic Pain• 1. Acknowledgement of the injury and its effect upon the person at  all levels.• 2...
Pain Recovery Skills• 1. Pacing                 • 1. Respecting who you                              are, not who you were...
Moving from Rejection to Respect                • The drugs reject                  reality.                • Recovery is ...
The Twelve Steps-• STEP 1                    • How do respect your                              self with this?• Powerless...
The Twelve Steps• Step 2                   • How do we respect• Came to believe that a     ourselves when we  Power greate...
The Twelve Steps• Step 3                    • What does God look                              like?• Made a decision to tu...
Alcoholics Anonymous And Spirituality• The emergence of AA as a potent vehicle for  personal transformation has been influ...
Practical Spirituality• Learning how to respect oneself as a limited  person who has limited control and is not  perfect• ...
The Balance of Spirituality and           Psychology • INVESTMENT->      •   No Time CARING              •   No Money     ...
The Balance of Spirituality and          Psychology                    •   No Time• CARING                    •   No Money...
The Balance of Spirituality and   Psychology(the Serenity Prayer)     CARING                  Accept what can’t be        ...
Thank You-Team!
Treatment of Addiction•   1. 12 step programs•   2. Counseling programs•   3. Medication•   4. Residential Treatment
How Addictive Drugs Addict the         Person- Dual Diagnosis1. The drug stimulates the          Reward Center   reward ce...
How Addictive Drugs Addict the         Person- Dual Diagnosis1. The drug stimulates the          Reward Center   reward ce...
Stages of Alarm and Defense       involve both feeling and action•   Irritability   Annoyance more than fear•   Tension   ...
The Survival Brain is a teachingmachine that stores its results                                        Reward Center      ...
The role of mft in addiction and chronic draft 2
The role of mft in addiction and chronic draft 2
The role of mft in addiction and chronic draft 2
The role of mft in addiction and chronic draft 2
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The role of mft in addiction and chronic draft 2

  1. 1. The Role of MFT in Addiction and Chronic Pain P. Joseph Frawley,M.D.
  2. 2. Principles of Addiction Medicine• 1. Addiction is a disease of the Survival Brain• 2. It is a chronic illness• 3. It is fatal if left untreated• 4. Treat it as a chronic illness.• 5. People can and do recover
  3. 3. Ventral Tegmentum to Nucleus Accumbens
  4. 4. Disease of Addiction Survival Brain
  5. 5. Brain Reward Circuits
  6. 6. Natural History•Addiction has a Natural History
  7. 7. Natural History of Alcoholism8 years in Clinic Sample Vaillant,1995 • 100 patients • Ave age 45 • Prior Jail 71% • Alone or street 50% • Live with spouse 35% • Reg Employment 27% • Attended College 19% • Stable Psyc/Soc 17%
  8. 8. Natural History of Alcoholism Core City Sample Vaillant,1995 • Control Group for Juvenile delinquent Study. • 456 Men follow up • 150 had DSMIII alcohol abuse at some point. • 116 with alcohol abuse followed through study
  9. 9. Natural History of Alcoholism College Sample Vailant,1995 • Population of College Graduates • 268 Men Had Follow Up • 46 Men had DSM III Alcohol Abuse at some point
  10. 10. What is the Natural History of Opioid Dependence?• 581 male addicts admitted to California• Civil Addict Program in 1962-1964• 33 year follow-up 48.9% dead• Of the 242 interviewed• 55.8% urine neg for opiates• 14% incarcerated
  11. 11. 33 Year F/U Narcotic Addicts Arch Gen Psych 58, May 2001 p. 503 (Hser et al) • Compulsory Treatment Program for Narcotic Dependent Criminal Offenders. • Yr N Mean Age • 1962 581 25.4 • 1974 439 36.8 • 1985 354 47.6 • 1996 242 57.4
  12. 12. Age of Drug Use Patterns
  13. 13. The Nature of Addiction• 1. The Reward System• 2. The Memory of Reward• 3. The Triggers for Addiction• 4. Tolerance and Withdrawal• 5. Shame of loss of Control• 6. Emotional Damage• 7. Denial• 8. Enabling
  14. 14. Animals will self stimulate the Reward Center and forget other rewards
  15. 15. How The Survival Brain Works Reward Center Need O2 Monitor Reward Safety Water Food Respect Companionship
  16. 16. Brain Reward Center1. Cells that monitor the Reward Center status of needs Need normally stimulate O2 Monitor Reward these centers Safety2. Meeting the needs will Water stimulate reward Food3. Anticipation of reward Respect will highly stimulate these centers Companionship
  17. 17. Memory Stores the Results of Action and Strengthens Connections Need is metMemory Action Need O2 Monitor Reward Safety Water Food Respect Companionship
  18. 18. Brain Reward CenterWhen needs are not met Reward Center we experience alarm: Need Irritability O2 Monitor Reward Tension Safety Anxiety Water Anger Food Pain Respect Companionship Panic
  19. 19. Stages of Alarm to Threat• Irritability• Tension• Anxiety• Anger• Pain Panic
  20. 20. The Survival Brain motivates us to change and stores the results Reward Center Need O2 Monitor Reward Safety Water Food Respect Companionship Irritability Tension Anxiety Anger Pain Panic
  21. 21. Emotional Memory is layeredand is our emotional filter and reactor• 0-5 5-10 10-15 15-20 Mixed Feelings No confidence Lots of confidence • Tape Recorder that plays back the past to motivate and guide you in the present- • positively or negatively.
  22. 22. Emotional Brain is quicker and faster than the Slower Creative Intellect
  23. 23. However, as humans we come toconclusions about our experience so we can plan • These can be called cognitions, beliefs, viewpoints, etc. • During development, parental guidance is essential in healthy development in this area. • These are our cognitive filters
  24. 24. As we learn, we form cognitions about what we need to do to surviveCognition Memory Action Reward Center Need O2 Monitor Reward Safety Water Food Respect Companionship
  25. 25. Addictive Drugs are Mimics of our own Reward Chemistry: They Lie to Us Opiates Endorphin Speed Dopamine/ Adrenaline Valium GABA THC Anandamide Alcohol Several systems Genetics influences how well they work and how we adapt to them
  26. 26. How Addictive Drugs Addict the Person- The Good1. The drug stimulates the Reward Center reward center according Need Monitor Reward to its chemical action, O2 state of the system and genetics. Safety DRUG2. The message is Drug Water Works! Food3. The meaning can be: The Respect drug is a new/better way Companionship to feel good
  27. 27. Dopamine and Reward
  28. 28. How Addictive Drugs Addict the Person-The Bad1. The drug suppresses the normal monitor Reward Center and reward systems according to its chemical action ,state of the system and genetics. Monitor Reward2. The brain adapts: tolerance People physical dependence Places DRUG Activities3. There is a shift in people, places and Need activities towards getting the drug. O2 Safety Water4. The meaning can be:Apparent balance is progression of disease FoodCoping Skills lag in developmentEmotional memory is lied to RespectCognitions are distorted Companionship
  29. 29. How Addictive Drugs Addict the Person-The Ugly1. When the drug is gone, Reward Center the normal system does Need Monitor Reward not work depending on O2 drugs chemical action ,state of the system and Safety DRUG genetics. Water2. The brain adapts: Food withdrawal Respect Companionship3. The meaning is:The drug is needed to Survive
  30. 30. Drug Works-I Don’t WorkIn withdrawal we Reward Center experience alarm and Need Monitor Reward we learn our own system doesn’t work:Memory Action O2 Drug Craving Irritability Safety Tension Water Anxiety Food Anger Respect Companionship Pain Panic
  31. 31. Brain Imaging shows suppression• After use of cocaine there is suppression of dopamine receptors
  32. 32. Positive Emotional Drug Memory can also stimulate the reward center =CRAVING Drug Memory People Places
  33. 33. Anxiety and Mood Disorders oftenbegin in Teens and Young Adult hood
  34. 34. In Dual Diagnosis There are several mechanisms for anxiety and depressionCognition Memory Skills Needs Biochemical O2 Safety Food H2O Respect Companionship
  35. 35. In Dual Diagnosis the drugs carry a bigger impact and development stopsCognition Memory Skills Needs Biochemical O2 Safety Drug Food H2O Respect Companionship
  36. 36. The Disease Progresses • Tolerance, Physical Dependence • 5-7 years of struggle for control • Craving for the drug during attempts to quit • Denial because I need the drug so much • Shame at not being able to be in control
  37. 37. The Family Disease Progresses
  38. 38. Denial and Enabling I can’t conceive living without it It is what I need It is my number one priority I didn’t drink or use that much It doesn’t bother them
  39. 39. Recovery Needs and Problem Drinking ScoresVaillant,1995
  40. 40. Shame of Loss of Control of Illness • Alcoholics spend 5-7 years struggling for control • They don’t know how to respect themselves with being out of control • They have an illness
  41. 41. Getting to Treatment • It is hard and scary to change • If the addict takes a first step then we need to meet him/her there and facilitate their progress. • The addict may need intervention
  42. 42. We can Help the Process Along• Each stage has appropriate interventions
  43. 43. The Team Approach
  44. 44. DetoxificationWe taper medications over Reward Center time to allow the Need Monitor Reward nervous system to stabilizeMemory Action O2 Drug tapering Safety Water Food Respect Companionship
  45. 45. Opiate StabilizationSome people stay too Reward Center agitated when coming Need Monitor Reward off opiates and need to be stabilized on themMemory Action O2 Drug Stabilization Safety Water Food Respect Companionship
  46. 46. Swedish Randomized Trial The Lancet 361,Feb 22,2003 (Kakko et al) • Heroin Dependence by DSM IV • Placebo Bupr • ASI 1.84 2.11 • Yrs Heroin 4.8 5.8 • Hep B 35% 35% • Hep C 80% 60% • HIV 0 1
  47. 47. The Work of RecoveryCognition Memory Skills Needs Biochemical O2 Safety Drug Food H2O Respect Companionship
  48. 48. Safe Environment• The patient needs to be • This will help determine in a safe environment to the level of care that feel calm enough to they need. begin to learn new • 1. Hospital skills, ways of thinking • 2. Sober Living and to experience feeling better. • 3. Intensive Outpatient• The addiction is still • 4. Outpatient very reactive. • 5. 12 Steps
  49. 49. The Biochemical• 1. Detoxification/taper/ • Close communication maintenance between the team is• 2. Stabilize Mood important.• 3. Stabilize Anxiety • 1. Symptoms vs Disease states• 4. Reduce Craving • 2. Reactive vs biochemical imbalance • 3. Pain vs function
  50. 50. Medications• Antabuse- • Reduces impulsive use• Campral • Reduce Craving (mild effect)• Naltrexone • Block reward of drinking or using opiates• Provigil/Nuvigil • Help with stimulant withdrawal/ADD
  51. 51. The Needs• Safety • 1. The most essential• Respect aspect of a program is• Companionship safety. • 2. Respect needs to be modeled and starts with• These have often been acknowledgement. severely damaged. Part of treatment is to • 3. Sober friends and provide a systematic family and meetings structure to help form the initial restore them. community of recovery.
  52. 52. The Skills• 1. Managing Craving • Recovery is like learning a sport or to dance• 2. External Triggers • Patients will make mistakes and lose• 3. Internal Triggers confidence • They may relapse• 4. Communication Skills • They may get frustrated• 5. Setting Boundaries It is not what they know but how they• 6. Dealing with the past react.
  53. 53. The Emotional Memory• Time has no meaning • 1. In addition to the life to the emotional memories that are memory stored there (good and• It records and it replays bad) it has been lied to• It is primitive but by the addictive drug. powerful • 2. It has to go through• It is influenced by retraining. current status of needs • 3.We have to have and cognitive filters compassion for it, for it is sick
  54. 54. Cognitions• Denial • Cognitive Skills and• Shame Creativity• Core Beliefs• Cognitive Distortions 1. Mood Logs 2. Untwisting one’s thinking 3. New Perspectives and Options
  55. 55. Chronic PainLow Back Pain Migraine Fibromyalgia Headache
  56. 56. Prior Trauma and PTSD and Chronic Pain• 1. Common Histories a. Adultified Child b. Abused Child 2. High Anxiety a. If I set boundaries I will be rejected b. I can’t say no. c. I must succeed d. Past intrudes into the present3. Persona vs Person a. What I do defines/hides me
  57. 57. Trauma and Vulnerability to Pain• N=520 Traumatized subjects: assessed for-• PTSD,dissociation,somatization, affect• No PTSD<lifetime PTSD<Current PTSD• disaster victims<adult interpersonal trauma<childhood trauma• Conclusions: PTSD,dissociation, somatization,affect dysregulation co-occur• (Covington,2004)
  58. 58. Chronic Pain Predisposition Reward Center Need O2 Monitor Reward Safety Water Food Respect Companionship Irritability Tension Anxiety Anger Pain Panic
  59. 59. Limbically Augmented Pain Syndrome• Patients w/ depression, behavioral dysfunction, heightened sensitivity to internal and external stimuli• Pain: chronic,often atypical, resistant to analgesics• Assoc w/ disturbed mood, sleep, energy, libido, memory/concentration/behavior• Amplification,spontaneity,anatomic spreading,cross sensitization.(Covington,2004)
  60. 60. Wind-Up in Fibromyalgia Staud,R. Arthritis Research & Therapy 2006,8:208Windup pain ratings ofnormal control (NC) andfibromyalgia syndrome (FM)patients. All subjects received15 mechanical stimuli (taps(T)) to the adductor pollicismuscles of the hands atinterstimulatory intervals of 3s and 5 s. FM patients showedmechanical hyperalgesiaduring the first tap andgreater temporal summationthan NCs at bothinterstimulatory intervals. Anumerical pain scale was used(0 to 100). The shaded arearepresents pain threshold.
  61. 61. After Central Sensitization• after central sensitization has been established only minimal nociceptive input is required for the maintenance of the chronic pain state.• Additional, factors, including pain related negative affect and poor sleep have been shown to significantly contribute to clinical FM pain• Arthritis research & therapy.; 2006 1 1;8(3)
  62. 62. The Work of Recovery from Chronic Pain• 1. Acknowledgement of the injury and its effect upon the person at all levels.• 2. Acknowledgement of the emotional state of the person’s reaction to the injury, the level of pain experienced by the person and their perceptions of their options.• 3. Management of the pain at all three levels of pain.• a. Injury Site• b. Nervous System augmentation• c. Limbic System• 4. Management of grief and co-occurring mental health disorders and /or chemical dependency if present.
  63. 63. Pain Recovery Skills• 1. Pacing • 1. Respecting who you are, not who you were• 2. Setting Boundaries • 2. Respecting one’s limits• 3. Learning how to • 3. Communication Skills manage anger and options• 4. Learning how to • 4. Learning how to feel manage anxiety safe• 5. Connecting to people • 5. Persona vs Self in a new way
  64. 64. Moving from Rejection to Respect • The drugs reject reality. • Recovery is a return to respect for reality and oneself and ones relationships with others
  65. 65. The Twelve Steps-• STEP 1 • How do respect your self with this?• Powerless over alc/drug• Life has become • Answer: Unmanageable • You share it and receive respect from others • You come to learn you have an illness
  66. 66. The Twelve Steps• Step 2 • How do we respect• Came to believe that a ourselves when we Power greater than don’t have the answer? ourselves that could restore us to sanity • Answer: • Humility is the beginning of Wisdom
  67. 67. The Twelve Steps• Step 3 • What does God look like?• Made a decision to turn our will and our lives • Answer: over to God as we • He/She cannot be a understand him human being.
  68. 68. Alcoholics Anonymous And Spirituality• The emergence of AA as a potent vehicle for personal transformation has been influential, as it has brought the term spirituality to the attention of both the general public as well as the mental health and addiction treatment providers.
  69. 69. Practical Spirituality• Learning how to respect oneself as a limited person who has limited control and is not perfect• Drugs can disconnect the person from feeling one’s limits. Drugs are able to say “shut up” to parts of self the person doesn’t know how to deal with.• In recovery the person goes from rejection to respect for these parts of self
  70. 70. The Balance of Spirituality and Psychology • INVESTMENT-> • No Time CARING • No Money • No Understanding • No Knowledge • Etc.• When caring is blocked. = Stress
  71. 71. The Balance of Spirituality and Psychology • No Time• CARING • No Money • No Understanding • No Knowledge • EtcDrugs take thecaring away =No Stress
  72. 72. The Balance of Spirituality and Psychology(the Serenity Prayer) CARING Accept what can’t be changed Courage to change the things can beWisdom to know the differenceTime Out, Sharing, Asking for help = Managed Stress
  73. 73. Thank You-Team!
  74. 74. Treatment of Addiction• 1. 12 step programs• 2. Counseling programs• 3. Medication• 4. Residential Treatment
  75. 75. How Addictive Drugs Addict the Person- Dual Diagnosis1. The drug stimulates the Reward Center reward center according Need Monitor Reward to its chemical action O2 ,state of the system and genetics. Safety DRUG2. The message is Drug Water Works! Food3. The meaning can be: RespectThe drug is a better way to Companionship Feel Good
  76. 76. How Addictive Drugs Addict the Person- Dual Diagnosis1. The drug stimulates the Reward Center reward center according Need Monitor Reward to its chemical action O2 ,state of the system and genetics. Safety DRUG2. The message is Drug Water (_) Works! Food3. The meaning can be: RespectThe drug is a new/better Companionship way to Feel Good
  77. 77. Stages of Alarm and Defense involve both feeling and action• Irritability Annoyance more than fear• Tension Alert to question of danger• Anxiety A feeling of needing to escape• Anger A need to stay and defend• Pain The boundary has been crossed• Panic There is no escape
  78. 78. The Survival Brain is a teachingmachine that stores its results Reward Center Need O2 Monitor Reward Safety Water Food Respect Companionship Irritability Tension Anxiety Anger Pain Panic

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