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Cardwell C. Nuckols MA, [email protected]
(407) 758-1536
Facilitated by:
NOVELTYENVIRONMENTAL ENRICHMENT
PHYSICAL EXERCISENUTRITION
Group Therapy Individual Counseling Sober Living Higher Power Assessment
Alcohol/Drug Psyhosocial
Recovery housing Healthy milieu Self help meetings Church From isolation to living “one day at a
time” in the presence of others striving for a more fulfilling life
Stimulates production of brain-derived neurotrophic factor (BDNF) Neurotrophin that governs maturation and
development of neural systems Enhances executive functioning
Obey social rules Adapt to changing & unpredictable
environment Short term working memory Multi-tasking Self-directedness
Self-directedness Responsible Purposeful Resourceful
Increases neurotransmitters Monoamines
Serotonin Dopamine Norepinephrine
Association between DA D2 receptor numbers and drug self-administration Increased D2 receptors reduced alcohol
consumption Decreased D2 receptors higher risk
DA D2 receptor levels influenced by stress and social hierarchy
Helps explain influence of environment and genes
Subordinate animals more likely to self-administer cocaine
Dominant animals no more likely to self-administer cocaine than placebo
Social interventions can change neurobiology Increased DA D2 receptors Reduced self-administration
Behavioral interventions could counteract the aversive effects of drug abuse and reinforce the power of group approaches
Group Therapy Active participation Successful completion of assignments
Milieu Leadership Modeling
Self help Coffee and chairs “Telling story”
Acute intoxication results in activation and deactivation of regions connected to the DA system
These regions are involved in REWARD MEMORY MOTIVATION/DRIVE CONTROL
Reward Circuit-Nucleus Accumbens and Ventral Pallidum
Motivation/Drive Circuit-Orbitofrontal Cortex
Memory & Learning Circuit-Amygdala and Hippocampus
Control Circuit-Prefrontal Cortex & Anterior Cingulate Gyrus
Copyright ©2003 American Society for Clinical Investigation
Volkow, N. D. et al. J. Clin. Invest. 2003;111:1444-1451
Location Nucleus Accumbens (NAc) Ventral Tegmental Area (VTA)
Impact of drugs of abuse Increased extracellular levels of DA in striatum
(NAc) Reinforcing effects related to:
Magnitude of DA increase Abruptness of DA increase
Reduced sensitivity to natural reinforcers
Goals: Management of craving Reduce reward value of drugs Reduce pleasure (create unpleasantness)
from drug experience
Situational triggers Environment (People, Places And Things)
Emotional triggers Internal (Hungry, Angry, Lonely, Tired, Reward
and Bored) Acute Abstinence Syndrome Stress
In presence of:› Alcohol and drugs› Alcohol and drug
users› Places where used
to use or purchase Negative feeling
states particularly anger but also:› Boredom› Loneliness› Fear› Anxiety
Positive feeling states Physical pain Use of mood-altering prescription drugs Suddenly having a lot of cash Complacency Insomnia Sexual functioning
Psychotherapy Behavior Therapy
Structure Recovery Foundation Program
Changing patterns Safety Plan
Pharmacological Acute Maintenance
31 yo Nicki-a recovering methamphetamine addict- just got her first paycheck. She cashed her check and cruised thru the neighborhood where she used to score dope. Rock music blared from her speakers. Soon she was thinking, "I worked hard all week. I deserve a little fun.”
In an inpatient setting the patient schedule serves this purpose
On an outpatient basis or upon discharge from inpatient a recovery plan or contract is appropriate
Remember that most addicts have little or no recent experience living a drug free lifestyle
TASK MON TU WED THU FRI SAT SUN
SH
TX
FUN
NUT
PEX
Carter is 24 yo and just getting out of treatment for alcohol and drug addiction
His early A/D history included…. Started drinking on Friday nights with friends
in high school Turned-on to cocaine and marijuana by friends
on weekends Started to buy drugs to sell from a distributor
on Wed nights
MY PERSONAL SAFETY PLAN
• Remember that craving go away• I can write in my journal• I can call my sponsor (299-289-5555)• I can call my lover (299-426-1776)• I can read from my favorite recovery book• I can read affirmations
TH: “On the back of the index card, come up with a saying or a prayer that gives you strength.”
CT: “ I have always liked ‘Lord help me to be the best possible person I can be today’.”
Opioid Maintenance Medications Methadone LAAM Buprenorphine Naltrexone
Naltrexone (Revia, Vivitrol) Pure antagonist Poor compliance
Less than 10% for street addicts Better compliance
Healthcare professionals Parole/Probation
New suspension with q30d administration should dramatically increase compliance and reliability of drug
Subutex-Buprenorphine. sublingual (SL) 2mg and 8mg tablets
Suboxone-Buprenorphine/Naloxone SL tablets
Buprenorphine 25-50 x’s more potent than morphine
Partial agonist Increasing dose does not increase effect like a
full agonist
Very high affinity for mu opioid receptor Mu receptor will choose buprenorphine
over other opioids Buprenorphine will displace other opioids Slow dissolution from mu receptor
Half-life on receptor is 34-36 hrs Heroin on and off receptor in millisecond At Buprenorphine dose of 16mg almost no
binding to other opioids
If taken under the tongue you get predominant buprenorphine effect
If dissolved and injected get predominant naloxone effect (precipitates withdrawal)
Buprenorphine equally effective as 60 mg of Methadone per day
If patient needs 80-100 or more mgs of Methadone to be comfortable, Buprenorphine probably will not work
With client dependent on short-acting opioids Instruct client to abstain for 12-24 hours Need to be in mild withdrawal before first
dose
Disulfiram, 1951
Acamprosate, 2004
Oral naltrexone, 1994
Injectable extended-release naltrexone, 2006
NONE OF THESE ARE ADDICTIVE
DopamineIncreased ReleaseDopamineIncreased Release
GABAIncreased Sensitivity to GABA
GABAIncreased Sensitivity to GABA
Opioid PeptidesIncreased Endogenous Opioid Activity
Opioid PeptidesIncreased Endogenous Opioid Activity
GlutamateDecreasedActivity
GlutamateDecreasedActivity
De Witte P. Addict Behav 2004;29:1325; Gianoulakis C. Curr Top Med Chem 2004;4:39-50; Nestler EJ. Nat Neurosci 2005;8:1445-1449; Tupala E, Tiihonen J. Prog Neuropsychopharmacol Biol Psychiatry 2004;28:1221-1247.
De Witte P. Addict Behav 2004;29:1325; Gianoulakis C. Curr Top Med Chem 2004;4:39-50; Nestler EJ. Nat Neurosci 2005;8:1445-1449; Tupala E, Tiihonen J. Prog Neuropsychopharmacol Biol Psychiatry 2004;28:1221-1247.
Glutamate SystemGlutamate System
Adaptation # and/or function of NMDAreceptors on neurons
Balances acute alcohol effect
Effect: tolerance, dependence
Adaptation # and/or function of NMDAreceptors on neurons
Balances acute alcohol effect
Effect: tolerance, dependence
Chronic Alcohol UseChronic Alcohol Use
WithdrawalIncreased glutamatergic activity
Effect: - Acute: dysphoria, hallucinations- Post-acute: sleep/mood disturbances
WithdrawalIncreased glutamatergic activity
Effect: - Acute: dysphoria, hallucinations- Post-acute: sleep/mood disturbances
Removal of AlcoholRemoval of Alcohol
Alcohol-Free CNS Equilibrium
Alcohol-Free CNS Equilibrium
Acute Alcohol EffectInhibits NMDA receptors
Effect: anxiety, sedation
Acute Alcohol EffectInhibits NMDA receptors
Effect: anxiety, sedation
Administrationof AlcoholAdministrationof Alcohol
Littleton. Alcohol Health Res World 1998;22:13.Littleton. Alcohol Health Res World 1998;22:13.
N = 605
Fuller RK, et al. JAMA 1986;256:1449-1455.
N = 605
Fuller RK, et al. JAMA 1986;256:1449-1455.
0
10
20
30
40
50
Noncompliant (80%) Compliant (20%)
% R
em
ain
ing
Ab
stin
en
t
Disulfiram 250 mg
Disulfiram 1 mg
Counseling
0%
5%
10%
15%
20%
25%
30%
Counseling Disulfiram 1 mg Disulfiram 250 mg
% D
ays
Dri
nkin
g
*
N = 605
* p < .05
Fuller RK, et al. JAMA 1986;256:1449-1455.
N = 605
* p < .05
Fuller RK, et al. JAMA 1986;256:1449-1455.
GlutamateGlutamate
aa AcamprosateAcamprosate
NMDA ReceptorNMDA Receptor
Reduction in glutamate release
Reduction in glutamate release
Reduction in postsynaptic effects
Reduction in postsynaptic effects
mGluR5 receptormGluR5 receptor
aa
aa
aa
aa
aa
NMDA = N-methyl-D-aspartatemGluR5 = metabotropic glutamate subtype 5 receptor NMDA = N-methyl-D-aspartatemGluR5 = metabotropic glutamate subtype 5 receptor
N = 272
Sass H, et al. Arch Gen Psychiatry 1996;53:673-680.
N = 272
Sass H, et al. Arch Gen Psychiatry 1996;53:673-680.
0%
5%10%15%
20%25%30%35%
40%45%50%
Acamprosate Placebo
% o
f Pa
tien
ts W
ith
ou
t R
ela
pse
Location Orbitofrontal Cortex (OFC)
Impact of Drugs of Abuse Drug as reinforcer far exceeds that of
natural reinforcers OFC hypoactive during AAS Exposure to drug or other “cues” during
withdrawal precipitates craving and compulsive drug use
Hypothalamus Head ganglion of ANS & locus of drive
Amygdala Reticular formation
Brainstem regulation of arousal Frontal cortex
Modulates instinctive behavior and internal drives
Processes face and voice information for appraisal of external environment
Therefore, integrates external and internal environment
Early developmental trauma has negative impact on OFC
AUTONOMIC NERVOUS SYSTEM
PARASYMPATHETIC SYMPATHETIC
DISSOCIATION HYPERAROUSAL (FREEZE) (FIGHT/FIGHT)
Increase value of non-drug reinforcers Positive Connection to Others
Therapeutic Relationship How we communicate “Mirror” neurons Family and couples therapy 12 step meetings
Connection to Higher Power of Your Choice Mindfulness Meditation
Location Amygdala Hippocampus
Impact of Drugs of Abuse People, Places and Things (“cues” or
“triggers”) create an intense desire to use (“craving”)
Impact of Drugs of Abuse (cont.) These cues automatically trigger habit
learning Release of DA
Declarative learning links emotional states to use (“Hungry, Angry, Lonely and Tired”)
Behavioral Extinguish learned
positive association with drug or drug “cues”
Promote reinforcement of positive behaviors
Recovery in neuropsychological functioning› Most of treatment is
during time of greatest dysfunction
› Recovery is; Time-dependent
Due to sustained abstinence
Experience-dependent Active rehabilitation
or repetitive behavior
Repetitive recovery-oriented behaviors
Repetitive recovery-oriented thoughts
Neurons that “fire together, wire together”
Location Prefrontal Cortex Anterior Cingulate Gyrus
Impact of Drugs of Abuse Disruption of prefrontal cortical functions
removes self-directed behavior in favor of sensory-driven behavior
Lack of vertical integration
Control Strengthen Prefrontal Cortical Control
Cognitive Therapy Education Exercises
Puzzles Computer Games Crossword Puzzles
Vertical Integration
PFC plastic especially between 0-5 and 10-20 years of age
Developmental delays occur secondary to early life trauma and early onset alcohol/drug abuse.
Treatment Positive role models (Sponsor) Surrogate family (Home Group) “Growing Up In AA”
Coordinate the many brain activities needed to utilize: Executive Functions
Set goals Make plans to attain those goals Organize steps to carry out the plans Ensure that desired outcomes are achieved
Conscience Pursue Reward Within the Law
Why give an alcoholic or addict a 60 minute didactic or video?
A new format 15-20 minute simple didactic
How to participate in treatment 10 minute questionnaire 30 minute discussion group
I THINK………..I THINK………..
I FEEL…………..I FEEL…………..
I LEARNED……I LEARNED……
MY FUTURE BEHAVIOR WILL CHANGE…MY FUTURE BEHAVIOR WILL CHANGE…
BE KIND, CONSIDERATE, FORGIVING AND COMPASSIONATE AT ALL TIMES, PLACES AND UNDER ALL CONDITIONS WITH EVERYONE, AS WELL AS, YOURSELF
http://www.jci.org/cgi/content/full/111/10/1444
Nestler, Eric. “The Neurobiology of Cocaine Addiction”. Science & Practice Perspectives. December 2005, pgs 4-12.
http://www.medscape.com/viewprogram/3023_pnt
Cloninger, Robert. Feeling Good: The Science of Well-Being. Oxford University Press, New York, 2004.
Panksepp, Jaak. Affective Neuroscience. Oxford University Press, New York,1998, pg 255.
Schore, Allan. Affect Regulation & the Repair of the Self. WW Norton, New York, 2003, pg 29-31.
Scaer, Robert. The Trauma Spectrum. WW Norton, New York, 2005, pgs 62-64.
http://www.msu.edu/~brains/humanatlas/search.html
Nuckols, Cardwell C. THE SCIENCE OF RECOVERY: “Connecting to Others and a Higher Power of Your Choice”. Counselor Magazine. Vol. 7, No. 1, Feb., 2006.
Nuckols, Cardwell C. THE SCIENCE OF RECOVERY: "Incorporating Neuroscience into Your Practice”. Counselor Magazine. December 2005, Vol. 6, no.,6, pgs 24-31.
Gazzaniga, Michael (Editor). The Cognitive Neurosciences III. The MIT Press, London2004.
Rossi, Ernest. The Psychobiology of Gene Expression. WW Norton, New York,2002.
Blumenfeld, Hal. Neuroanatomy Through Clinical Cases. Sinauer Associates, Sunderland, MA., 2002.
McGlynn EA, et al. “The Quality of Healthcare Delivered to Adults in America”. New England Journal of Medicine. 2003;348:2635-2645.
http://draonline.org - Dual Recovery Anonymous
Http://www.alcoholics-anonymous.org – Alcoholics Anonymous
http://www.wsoinc.com – Narcotics Anonymous
http://www.ca.org – Cocaine Anonymous
http://www.whitebison.org – Wellbriety http://www.nami.org – National Alliance
for the Mentally Ill www.facesandvoicesofrecovery.org –
Faces and Voices of Recovery (FAVOR)
www.gwcinc.com/drnuckols.htm
www.hci-online.com/cnuckols
http://www.hazelden.org/OA_HTML/hazCSrdSrchResults.jsp?event=&cg=-200&kw=NUCKOLS