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 fatal if left untreated• 4. Treat it as a chronic illness.• 5. People can and do recover
Natural History•Addiction has a Natural History
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%
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
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
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
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
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
Animals will self stimulate the Reward Center and forget other rewards
How The Survival Brain Works Reward Center Need O2 Monitor Reward Safety Water Food Respect Companionship
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
Memory Stores the Results of Action and Strengthens Connections Need is metMemory Action Need O2 Monitor Reward Safety Water Food Respect Companionship
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
Stages of Alarm to Threat• Irritability• Tension• Anxiety• Anger• Pain Panic
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
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.
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 called cognitions, beliefs, viewpoints, etc. • During development, parental guidance is essential in healthy development in this area. • These are our cognitive filters
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
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
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
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
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
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
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 People Places
Anxiety and Mood Disorders oftenbegin in Teens and Young Adult hood
In Dual Diagnosis There are several mechanisms for anxiety and depressionCognition Memory Skills Needs Biochemical O2 Safety Food H2O Respect Companionship
In Dual Diagnosis the drugs carry a bigger impact and development stopsCognition Memory Skills Needs Biochemical O2 Safety Drug Food H2O Respect Companionship
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
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
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
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
The Work of RecoveryCognition Memory Skills Needs Biochemical O2 Safety Drug Food H2O Respect Companionship
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
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
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
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.
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.
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
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 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
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)
Chronic Pain Predisposition Reward Center Need O2 Monitor Reward Safety Water Food Respect Companionship Irritability Tension Anxiety Anger Pain Panic
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.
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)
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.
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
Moving from Rejection to Respect • The drugs reject reality. • Recovery is a return to respect for reality and oneself and ones relationships with others
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
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
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.
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.
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
The Balance of Spirituality and Psychology • INVESTMENT-> • No Time CARING • No Money • No Understanding • No Knowledge • Etc.• When caring is blocked. = Stress
The Balance of Spirituality and Psychology • No Time• CARING • No Money • No Understanding • No Knowledge • EtcDrugs take thecaring away =No Stress
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
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
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
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
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