Addiction Neuroscience 101

why is addiction a disease that we have to understand the main reason for this is 21 million people in the United States have the disease of addiction 15 million of those suffer from an alcohol use disorder and 3 million of those suffer from an opioid use disorder an opioid use disorder is an addiction to things like painkillers and heroin it's the number one cause of injury-related death in our country the number one cause more than car accidents and gun violence in 2015 we had over 50,000 people died of overdose 50,000 people of a preventable disease the CDC even called this an epidemic and so now what we have are people who have a disease that we can identify that we can treat but we're not so how are we going to stem the tide of this problem well let's go back and start about thinking in a way that we can understand addiction from a human standpoint so we need 3 things to survive you need food you need water need dopamine now some of the people who get a little antsy say we also need oxygen yes well we also need skin but I'm not gonna really talk about that today we're gonna talk about the three things we absolutely need to survive as a human in today's world and that is food water and dopamine we need dopamine because it's the chemical responsible for motivation it's this thing that's responsible for us going and making a friend having a mother have a bond with a baby it's the thing that motivates us when we do good to do better when somebody Pat's you on the back and says good job and you go to do something more significant that's because your dopamine has gotten pinged and it's just something pushing you this invisible chemical that's pushing you along the path on a normal day we even know how much dopamine we're supposed to have so on Monday morning when I wake up and I have to get up and I go to work I live in the range of about 50 nanograms per deciliter of dopamine that sits in the central part of my brain and that's required for me to get out of bed and go get that first cup of coffee now what about the worst day the really bad day the day you you know you called your office and you fake vomit on the phone and you decide not to go in you're like I just can't make it that's about 40 nanograms per deciliter so not much lower but low enough to where you just want to sit around and your pajamas all day and do nothing what about the best day ever you know the day we're all at once you win the lottery you have 2% body fat and you're living on the beach all of those things happen at the exact same time we even know that one that's a hundred nanograms per deciliter our brain is meant to go all the way to there it's not really meant to go above and we can look at things like your favorite food which is like 94 nanograms per deciliter and Sachs 92 nanograms per deciliter bummer right couldn't have predicted that maybe they need to redo that research but at the same time we know that we're supposed to live within this relative normal state between 40 on a horrible day and a hundred on our best day so what happens when we add a chemical into the brain like methamphetamine this chemical is really important because it pushes us way past that hundred nanograms per deciliter in fact it actually pushes up to 1,100 nanograms per deciliter more than ten times the amount of dopamine that our brain should be making and then if we look at things like marijuana or alcohol or heroin these are things that push it up into the high hundreds this is not what we're supposed to be doing as we look at this we have the normal that we're supposed to be we have this large jump for something like methamphetamine and then we have these other drugs that drive that dopamine up and when that happens it starts to take over that part of the brain and no longer does going to your child's birthday make you happy it's not happening the things that normally make us feel happy start to pale in comparison this is because the brain is built to survive in fact we know that this is a survival issue for the brain mainly because dopamine is what drives us to procreate to get food to get water like we talked about and we know so much about addiction and all of these things that are going on in that part of the brain that we actually know the parts of the brain responsible for this motivation in this dopamine release it's places like the anterior cingulate gyrus the lateral bed nuclei of the amygdala the the nucleus accumbens the ventral tegmental area the periaqueductal gray we know this and by the end of all of these videos on this side you're gonna know exactly what each of those parts do but for now you should understand that this area of the brain called the limbic system which includes but it's not limited to the ventral tegmental area in the nucleus accumbens are responsible for reward and the fact that we can look on an MRI and see these parts of the brain working and we can see them working in a patient who is not on any drugs and those that have been on illicit substances for a long time and see major differences in how these structures work is really important because it allows us to start to understand things like behavior we can see that all of the focus is on the dopamine part of the brain remember that nucleus accumbens and ventral tegmental area that we talked about in that part of the brain when you've been taking things like methamphetamine for a long time every time that you take the methamphetamine it goes from a thousand one hundred then the next time maybe it's 900 then six hundred and five hundred and two hundred and 100 then you're required to take that drug even to get you up to that normal level of 50 nanograms per deciliter let's say we found this person we get them into treatment and we remove that drug now we have people whose dopamine goes all the way down to as low as 10 nanograms per deciliter and on their best day ever it's only 20 nanograms per deciliter these are numbers that matter and we're gonna keep hammering on these because when you have 10 nanograms per deciliter you can't get out of bed you can't get up to put your clothes on and go to a job interview or to even take care of yourself or your family when we lack dopamine the body craves it and when you crave dopamine you get into survival mode and that leads to primal action and that primal action is a lot of times the behavior that we see how can they take grandma's jewelry how can they steal credit-card how can they pawn something that they owned their brain is telling them that they are not going to survive if they don't get dopamine and the thing that gives them the dopamine that they need as far as they know is that drug of choice behavior is so much about how we define addiction that we even use it as the diagnosis the dsm-5 the diagnostic and statistic manual version 5 which is what all psychiatrists use to help define mental health disorders defines addiction not based on some lab tests not based on a urine drug screen but very much basis it on the behaviors of a person and we break it into really four major areas four pillars and there are eleven criterion in those four pillars and when we look at it you look at impaired control of use of the drug meaning you can't really say no to the next one or even the first one we look at other things like social impairment how much does it really mess up the people around you and the interactions that you have with your parents or your friends or your spouse or people that work and then we have risky use risky use means do I know injecting this is gonna cause me to get an infection in my heart or could give me HIV or hepatitis C but I'm still going to use it and then we have the pharmacological properties which are really two out of the eleven so nine of these eleven have nothing to do with chemistry or labs or EKGs it's purely based on the behavior of the person it is unacceptable that we are removing patients out of primary care offices in any other place in the in the healthcare system like a hospital or an emergency department when their behavior is bad because of addiction because that's how we define it that is the diagnosis so we should assume that behavior is a symptom and not a frustration when we look at craving which again is what drives a lot of this behavior we actually have good data around craving and how that looks so when we look at functional MRIs of the brain is a picture of the brain and we can see areas light up in these areas light up you know consistent with what part of the brain is working and how hard it's working we had patients who were dehydrated we're in starvation mode and had not received their drug of choice for a period of time we had patients who hadn't had anything to drink for three days that's a long time and these are patients who are starting to get to the point of dehydration where it's gonna be survival need for water and not just I'm a little bit thirsty so for these patients we looked at a functional MRI we put them in in the tube in the MRI and we would ask them questions like tell me about a waterfall we would play you know sounds of waterfalls in the background and we would sprinkle water on their feet and take pictures of the brain and we can look at these areas of the brain that are responsible for craving like the anterior cingulate gyrus that one we talked about earlier and it would light up to about the relative size of a baseball we did this for food so we had patients who didn't get any physical food and no / oral meaning they didn't eat any food for five days they would get some IV fluids and some vitamins because we don't want to kill people that we're trying to test but at the same time five days without food and then we put them into the functional MRI we then talk to them about their favorite food we then brought their favorite food into the MRI suite and we kind of washed it it into the MRI tube so they could smell it and then we have them talk about how it would taste and then we had them taste it and spit it out and through all of these we looked at the brain through this functional MRI and in those same areas instead of a baseball for dehydration we had the size of about a basketball for starvation so we know what people will do when they're dying of thirst or they're dying of starvation I mean they will rob they will steal I mean imagine if you walk through the desert and in three days time you walk through the desert and you get to the end and all of a sudden there's this pedestal with a beautiful glass of water with condensation coming down the side if it was me and I walked up to that and then somebody stepped in front of that glass of water and said no no this is this is my water I'd be like okay stab and I would move them out of the way and then I would take this water and I would drink that water immediately because that is survival and people get into getting in the way of survival they really put themselves at risk and we know that and actually will kind of accept that when people are looting stores when there's a famine or when people are doing what they can to survive for their children or to not die we accept those things what about in addiction we took patients who hadn't had their drug of choice and in these cases for these studies it was alcohol and opioids and so when we took those patients and we put them in a functional MRI and we asked him a couple of basic questions tell me about the first time that you used your drug and the last time that you used your drug that's all we really asked that craving of just thinking about the drug lit that brain up and it lit it up no matter if you were 30 days 60 days 90 days or one year it was almost exactly the same that craving signal in the brain did not decrease until two years and what we found was the relative size of that craving was not a baseball or a basketball it was a baseball field so the craving for dopamine and that drug of choice so far out stretches the desire to not die from dehydration and starvation that it starts to make me understand why these behaviors happen so consistently among patients who have had the disease of addiction so if dopamine is lacking in the nucleus accumbens and this is the basis for driving this behavior then augmentation of dopamine might make sense right if we raise dopamine back up to normal levels then they won't feel craving and they won't be starving for the drug that can it allow us to have an appropriate conversation with a patient allow them to be engaged in treatment so when we look at how we do that we found that the two medications at least for opioid use disorder that do this are buprenorphine and methadone by giving those medications we actually can raise the dopamine back up to normal levels so that this person doesn't have to think about I need my drug I need my drug because what they're really thinking is I need dopamine I need dopamine I need dopamine and that starts in the morning from the second they wake up and it is there all day without this we're not able to get patients stable enough to have therapy do anything for them because without dopamine in the brain what you're not getting is even onboarding of emotional memory because it's required for that and so when they go into therapy without having their dopamine in the right place what they're hearing is right right right Ram they're not getting anything from that we have three major medications for opioids and one of those is now trekked zone and now trucks on actually blocks opioids so it doesn't necessarily increase dopamine but for some people with a less severe substance use disorder or motivation again there's that term motivation when we talk about motivation I always want you to think dopamine if you hear dopamine I want you to think motivation motivation equals dopamine dopamine equals motivation so when we talk about I really want a motivated patient or client to go get their therapy we're talking about someone who has enough dopamine to have that motivation without it they're not motivated we talked about this in a number of different ways we talk about it in stages of change are they pre contemplative you know are they in the action phase do they want to come and do something positive for themselves we use these really pejorative terms in addiction medicine like well they need to hit rock bottom first I don't think that's an option anymore given that we had 50,000 people died last year of overdose because that's rock-bottom for an opioid use disorder but for those patients who have a lesser version of opioid use disorder maybe something like an out wreck zone which is a chemical two blocks SOP or it can be really helpful for them because they already have that intrinsic motivation they're already ready to move forward because they have this dopamine we also have other parts of the brain like where alcohol works it works on another part of the brain other than the opioid receptors it works in the gamma-aminobutyric acid receptors right these really specific receptors that they're the ones that make you feel super happy after one or two drinks and then not so super half day after four or five drinks it's also the same part of the brain that drugs like Vin's adays apenas which are like ativan and valium or diazepam you know these are things that change that part of the brain what about parts of the brain that are affected by marijuana so marijuana releases dopamine from the nucleus accumbens and we found that we have a drug that actually blocks that extra release of dopamine so for people with a marijuana use disorder we even have medication that can change the way that that dopamine is released so for certain drugs it's all about dopamine and for other drugs it's indirectly about dopamine but the final common pathway is dopamine and whether you have the motivation to onboard therapy and the ability to stay retained in treatment one of the other things to think about is the whole point of decreasing craving is what think about it to keep the patient from relapsing that's the whole point because if you have craving you're more likely to go out and actually get a drug or take a drug or steal something to go get a drug so how would we decrease that relapse so there's some interesting research that's out there right now that talks about the more decisions we make in a day the less likely we are to make a good decision later this research that was originally done by parole board so they looked at the decision whether or not someone would be able to be let go from jail out on parole and they took the parole board and they looked at the decisions they made in the morning when they were fresh when they first started making decisions versus those decisions they made generally later in the day and what they found that if your case was heard early in the morning you were three times more likely to be let go as compared to being heard in the afternoon everything else was the same the severity of crimes the color of your skin male or female it didn't matter what it came down to was there's a point at which your brain is done taking risk or doing something different and for people who know that they can stabilize their dopamine who know that they can feel normal risk is saying no to that the Regular Decision the easiest decision is to say yes to that so think about if you wake up in the morning and the first thing you think of is please don't let me use today and the second immediate thing you think of is how can I get my drug of choice and then you have to say no to that and then about every five seconds after that over and over and over again you're having to say no to that thought and then if you're walking down the street and somebody comes up to you you have to say no to that and you have to be in the right frame of mind by the end of the day if we haven't controlled craving in any other way we're gonna have someone who has run out of the capability to make the decision that they want to make and their brain will chemically not be able to make the right decision it is not like somebody draws a pros and cons sheet on the refrigerator and starts talking about the pros and cons of whether they're gonna go buy drugs today this is not how it works decisions fatigue is a huge player in what happens in the afternoon or evenings for these patients because by the end of that day they have said no 10,000 times and that 10,000 and first-time may be the time that they relapse and so using medications and other therapies to significantly decrease craving is really important we have treatments for opioid use disorder that are 75% effective we have treatments for alcohol use disorder that are 65 to 70% effective these are numbers that are better than any other disease I mean we have 75% rates for like strep throat with an antibiotic there's still 25% that don't actually get better but when you start looking at things like diabetes and hypertension these are people who getting better looks in about 45 to 50 percent we have this thing called the a Sam criteria and this criteria has been validated and is used in almost every state in the country behavioral health interventions also have a long history of being really helpful for these populations anywhere from one-on-one therapy to group therapy to self-help therapy these are all things that when applied to the right patient at the right time absolutely can increase this medication assisted treatment for all addictions that have medications should be thought of right out of the gates to help stabilize that craving so that the rest of these things can be helpful so when we look at opioid use disorder and we have methadone which is 75% effective buprenorphine that's about 65% effective now track zone which is anywhere from 25 to 60 percent effective and yet less than 10% of people even have access to these meds that's amazing to me well what about alcohol use disorder remember we talked about 15 million people have an alcohol use disorder and we have medications that have for a long time shown really effective treatment and those are now trucks owned again which for both of these it can't per se gabapentin disulfiram and even baclofen these meds that we use all the time and feel very comfortable with can be used to help decrease that craving so that we can increase the likelihood the behavioral therapies will work and then when we look at medication assisted treatment for marijuana we actually have a medication for that in acetylcysteine this is a med that's benign in all other capacities but can help to really get a patient successful without making it so tough for every single person that comes through what about society like is there an approach that we should be taking from a societal effort yeah I think one we have to start really taking a hard look at stigma and in fact I would reframe stigma and turn it into discrimination because we're at a point where if you come into the emergency department or after an overdose in your released 30 minutes after you arrived as compared to someone who's had chest pain and gets admitted and gets all of these testing that's discrimination that's not stigma and so we have to start understanding that we are not doing ethical things to these patients when they show up science is the basis for the approach that we need to take not a belief you can use your belief system and how you apply the evidence-based science in fact I think for patients that's probably a better way to do it but you can't use a belief system as the science this is doing a great disservice to patients and we have to start pulling those together in the way that it should be in criminal justice world we have to stop criminalizing these patients for having a disease that we have a treatment for we know that that behavior can be defined based on craving we know that craving can be seen on a functional MRI we know that it's greater than starvation and dehydration and most importantly we know we have treatments for this so to take someone who has very obvious behaviors of addiction and put them in jail no treatment doesn't make any sense and when we start to look at how we prevent this disease it has to be giving accurate appropriate knowledge to the kids not telling them to just say no not frying an egg in a pan and telling them that's what their brain looks like knowledge and education in the same sense that we would give anyone else the thing that I need you to walk away with after this video is that addiction is a predictable chronic brain disease not a moral failing it has treatments that are 60 to 75 percent effective it has behavioral therapies that are well identified and we can apply on a regular basis and that the fundamental funnel for all addictions is in this dopamine and reward axis that part of the brain is responsible for motivation and ultimately survival and if we can use the science to affect survival in these patients then we will absolutely come out ahead

Channel: HMA Institute on Addiction

Views: 212,667

Rating: 4.9119287 out of 5

Keywords: addiction, dopamine, waller, neuroscience, opioid addiction, addict, addicted, addicted brain, substance use disorder, SUD, R. Corey Waller, Corey Waller

Id: bwZcPwlRRcc

Length: 23min 29sec (1409 seconds)

Published: Wed Apr 04 2018

Reddit Comments

[u/jews_stevens]

But thats not at all how it works Lmao