Dr. Kevin McCauley -- "The Neuroscience of Addiction"

here he's been a colleague of mine for going on 20 years now and my right he has taught me so much and he is one of the pioneers in this neuroimaging he's got a harrowing story of his own so I give you dr. Kevin McCall thank you Bill very much thank you so I understand I'm amplified as long as I stay at this table here so I'll try very hard to constrain myself you know I I go a lot of places around the country I see how different communities are facing this unprecedented challenge of addiction especially in young people I'm moved by the way each community kind of brings part of their own culture to bear on the problem Richmond has always been one of my favorite places to come and so it's wonderful to be back in your beautiful city especially at the on the threshold of spring it's always nice to see old friends I want to thank bill I want to thank the Virginia Commonwealth University collegiate recovery program I want to thank Karen and Cirque for bringing me out and for supporting my own work thank you for bringing me here and allowing me to talk about what is the love of my life and that is this extremely interesting complex tragic but yet hopeful problem of addiction and also the promise of recovery I have to say Tom your opening was probably one of the most moving things I've ever heard in terms of summarizing where we are in society right now I'm so glad that you see it as clearly as you do and that makes me very happy that that young people really do see this problem for what it is it is an issue of social justice it is a moment in history that we find ourselves thrust into we do have a duty to make the benefits of recovery accessible to everyone I talk a lot about pilots I talk a lot about healthcare professionals I talk a lot about people who can afford the kind of high quality recovery management that folks like Bill provide but I believe that those things access to treatment access to a safe sober housing access to employment reintegration into society these are not just good public health policies they're their human rights and and even though addiction is very much an an equal opportunity disease the opportunity for recovery is not equal it is very unequal ly distributed and I think that that's the past that lies before us you know those of us who got sober have an obligation to make sure that the things that we got and maybe even some of the things that we didn't get that other people have access to those things so that they can find their own path not my path not your path but their own path into recovery and that's what I think makes this a very exciting time and really in many ways the eyes of the world are on the collegiate recovery communities because as bad as this problem is and I mean we again we find ourselves in a moment in history that we have never been in before you know if you look as I have if you take a cold dispassionate analytical somewhat you know callous I add death tables in the United States of what actually kills people and when they die what you'll find is that old people tend to die it's very tragic you know I don't mean to be you know callous here but but that's what 70 and 80 year olds kind of do all right even the 50 year old like me if I drop over dead at the end of this lecture yeah that's within the realm of possibility when you look at a 22 year old though the the mortality rates dropped so precipitously it is really quite impressive that young people don't die they're amazingly resilient and for a long time the only thing that killed them were motor vehicle accidents in a sense some of the things that go along with youth for the first time in the history of these numbers ever being recorded the leading cause of death is now not motor vehicle accidents it is opioid and other prescription drug poisonings that's the term of art poisonings because that's what it is and the fact that there is an iatrogenic component in other words a physician caused component to this is what leaves us breathless in this moment where parents you can almost hear the the the peal of tears and crying of parents throughout this country as they bury the flower of our of our youth and with all of that and and and very few people will really see it the way as clearly as you do Tom and see that that there are things that we should be doing but the one thing that you can do and all in the moment of in this dark dark moment is you can point to the collegiate recovery programs at least you can say but look at that you know this this is terrible and awful and and and we've got to do something but look at the collegiate recovery programs because we see in them and the people you know and the students and the people who run it what could be if people had the right kind of support and so when I sit down with a family and they're that that that parent those parents are worried am I gonna have to bury my child that is really what is going through the mind of that parent in that moment and I can sit down with them and not talk to them about you know which I definitely will talk to them about you know gnarrk having a emergency narcan in your household and and and and maybe you know we've got to come take this path or that path and it's gonna be very very difficult but when I can point to the collegiate recovery programs and I'm talking about college you should see what happens in the eyes of that family it is an immensely powerful tool to be able to to bring them into that idea that maybe there is a way out of this and so to the collegiate recovery communities of the country and certainly to the one at VCU thank you that gives me an immensely powerful tool to be able to help parents at a very very very dark time and and their loved ones as well you know I got an inkling of this at a very very early stage of my development as a physician the idea that wait a minute maybe addicts don't just die all the time maybe there is a way that people can get sober because I never learned that in medical school what I learned in medical school was hey you know these are this is not our responsibility all right I mean alcoholics okay tune him up get him out of a hospital we got real patients to see and if you find you got a drug addict on your hands don't even let him in the front door throw them in the street all right it's actually better for them because you know to show them kindness is not good for addicts and you know that all kind of you know the garbage that that really runs through all of prejudice and then I joined the Navy and I became a flight surgeon this is me on the end there and thinner days this is an extremely this was a wonderful job I love this job taking care of this extremely charismatic group of patients in many ways pilots are heroes in our society we love them we want them to do well we've given them the best of everything they do not ordinarily like doctors by the way there's an old saying you know don't go to the flight surgeon don't slicers you can never help you all right I don't don't don't don't go there if you want to be a good flight surgeon you kind of have to learn to deal with that you kind of have to learn to gain their trust I used to tell my pilots you know the only reason I have gold wings on my chest is to protect the gold wings on your chest and if something happens I will do everything in my power to make sure that you can continue to do the thing that you know gives your life meaning to retain you in that role right and of course at first they were like yeah okay great doc you know we'll see but over time I was able to gain their trust and they would come to me and when the door was closed right as many clinicians discover this magic when it's just you and the patient the client right that magic occurs where they will reveal things to you potentially career-ending problems because you have created that atmosphere of trust you've created that safe place why would they do that because in aviation medicine we have an overwhelming value that that rules everything and that is a dedication to a culture of safety to a culture of safety even it rises above any one person's needs right we do the thing that is safest all right that is that is the the god thing i do we pray to alright and so when I learned that the Navy knew that it had a problem with alcoholism and it's aviators that they've had that for they've known that for a long time and that they took not a zero tolerance policy where they said you know hey if we ever find out you're an alcoholic you'll never fly again but in fact they said listen we know this is a problem and if you think you have an issue please come to your flight surgeon we'll get you the best treatment money can buy and then when you're safe we'll put you back in the cockpit and as long as you stay sober and you've got to do certain things you can do the thing that gives your life meaning and it was when I saw that I had two alcoholic pilots I never saw it coming they came to me and when I saw that I knew that wow maybe some of the prejudice that I've been talked about drug addicts you know an alcoholics is wrong I mean maybe there is a different way and so I really enjoyed this job now I see today the things that we do for pilots things that we do for healthcare professionals can also be given to collegiate recovery programs I don't know how many times I would give this lecture and I'd talk about pilots and I talked about you know crack smoking neurosurgeons who were in recovery and there would always be a family member in the back of the room with their arms crossed that's probably there's six family program and they say yeah well you know what my kidding a pilot all right my kid ain't a doctor he doesn't have a job that he really really likes pot you got a job that involves pot he'll do that and so for a long time it was like well the reason that they're getting better is that they're better people they they have more right they're accomplished and then came the collegiate recovery communities where we could see that if people were simply you know given that identity and embraced in that social support and had that validation and had that future they did as well if not better than the pilots and the doctors and the lawyers and the dentists and the nurses and all those other people and that's why I think in many ways the collegiate recovery communities are the the brightest star in the sky we can always draw power from what they have discovered and what they accomplished and it can serve as a model that we could conceivably yes give to everybody and I think that that is that is the task is to make sure that it's not just you know high-end white males getting all this really really good recovery management support but that it goes to everybody right and so this was really the the pivot of my entire professional career that that that this pragmatic safety based view of this problem could work right and I love this job and I wanted to do it for the rest of my life and then something happened I mean I'm not I come from a family of alcoholism but I was never really a big drug user in high school I didn't use drugs and I drank a lot in medical school but but you know I wouldn't say that I cross the line into addiction but then I had to have a surgery to stay physically fit to fly and the end of that surgery they gave me a big big fat bottle of this stuff and and now we know that there is a differential risk when you prescribe opioids I would say if you take 10 people off the street and you give them all an 80 milligram oxycontin right the first three to four people don't like it they crawl it of their skin they don't get you for they get dysphoria and these are the patients who tell you hey Doc don't ever give him you that opioid again that was a terrible experience I'll just suffer with my tooth pain I can't see how anyone would be a heroin addict right that kind of thing the next four to five patients that you give that opioid to they do like it but they go wow that's great and that's the end of it they wake up the next day they don't lose their house they don't lose their family they it was a powerful experience but they quickly put it into context and behind it right they have what I would call little eu4 but about 1/2 of that 10 15 maybe 20 percent you give them that opioid and it is a life-changing experience and they say where is this been I'm gonna do this until the day I die they have biggie euphoria and that is purely genetic we come into the world with that vulnerability or that resilience and of course I was in the hyper euphoric camp and I won't get into the details but within about six months I had a pretty severe intravenous Demerol problem and I tried everything to quit I mean I knew I couldn't do this I called the California Medical Board I reached out as best as I could to to other people but no one knew what to do with me I mean the Medical Board had a diversion program but they're like well you gotta go to the Betty Ford Center I'm like I keep any Ford's I can't say hey I need you know 30 days to go deal with my you know intravenous opioid problem the military is not going to really respond well to that and so no one really knew what to do with me and for a while I was able to stay sober but then I would relapse and then I'd stay sober again I went to meetings I tried my best I just didn't have you know enough monitoring I didn't have enough of what you know folks like Bill do right and eventually the Navy caught me they knew exactly what to do with me they stuck me in their treatment center for drug addicts called Leavenworth and so I very quickly found myself in the basement of this maximum-security prison this is actually a picture of Alcatraz but it looked almost exactly like that and I was sitting in my underwear in this cell in the warden of the prison the chief of staff the prison came up and and I saw the Eagles on his collar and I snapped to attention as best as you can and your underwear and and he said you know I Lieutenant Macaulay I read your file you seem like a pretty good guy who got himself into a real Jam you know I mean use their time here try to figure out what got you here and and do your time and go home and get on with your life and I thought that that was a pretty fair offer and so I wanted to know you know how did I get here you know is this really a disease this became kind of the central question of my life then and it's been you know my my delight ever since to try to figure this out I have to tell you I'm in the disease camp but I don't believe it everybody you know in fact it doesn't matter what I believe there are lots of people with really good sobriety that don't believe in addictions and disease I'm perfectly cool with that but the exegesis that trying to figure it out that the this is an amazingly fascinating deep puzzle to try to pick apart and so I started to read I I ordered every book I ordered every journal article I could find the stuff poured into the prison mail room it stacked up in the corners of my cell and I read and I read and I read and what I read blew me away the things that we are learning about the human brain and what happens when a person becomes addicted to drugs they're not just fascinating from a neuroscientific viewpoint right they're not just interesting from a clinical viewpoint we learn about how normal brains work by studying people with damaged brains and addicts they give us something very precious I know addicts aren't supposed to be you know valuable to society they are they teach us how Jois works how the brain actually does something like free will because that is what addiction is if if such a thing could occurr and I mean even the mere idea is huge the idea that there could be a disease of volition a disease of choice you know that's what addicts teach us how do we as human beings make choices it's by studying them that we learn those secrets those precious secrets that they purchase for us with their suffering and their years spent in prison and their lives now we find ourselves in the middle of this public health crisis but also in a time of unbelievable promise where we now have the tools and thank you very much bill but I don't do any research in neuroimaging I read a lot of it I'm kind of a parasite on other people's research but I mean when you read this stuff it is you really realize wow this is big and this will change the way we view ourselves as cogent beings with free will that's how powerful this this science is and so if I had to summarize all of it in three simple sentences they would be these first addiction it turns out is a disorder in the way the brain perceives pleasure so addiction is essentially a broken pleasure sense it's a it's a hedonic dysfunction in the same way that a blind person can't perceive sound correctly addicts cannot perceive pleasure correctly and that has major consequences for the brain's ability to assess future value and future risk and that it turns out that that what they what is called fictive imagining what what is likely and what is good that I might choose in the future that ability is at the core of our ability to make choices right so that broken pleasure sense right addiction is a broken pleasure sense has major consequences for the brain's ability to make choices okay decision making only works if the pleasure system is working perfectly so when I have a pleasurable experience right let's say the yum of grandma's amazing chocolate cake I don't know what she puts in it but it's no one makes cake like grandma we love grandma we love her cake I'm sure you got the same grandma and she makes the same cake right when I put her cake into my mouth and I say YUM and then I make a decision to have a second piece of chocolate cake even though I'm trying to stick to my diet and I probably shouldn't be eating cake at all right that's a process going on in my brain it's not just one place it's a whole bunch of different areas of the brain working together and what addiction is is that process unraveling right and the third sentence and this ghosts I think very eloquently to what what Tom said what Tom said very eloquently is that the cause of this appears to be stress especially chronic severe repetitive early in life stress breaks the dopamine system which is only one system involved in addiction but it seems to be the most central system in addiction so this was a study done by the department of health of the state of minnesota looking at the prevalence the the occurrence of adverse childhood experiences in the general population and when you're talking about the more mild ones they're quite prevalent about you know quarter to a third of all people have been exposed to at least one of the more mild ones as you start to get into the more severe ones the prevalence goes down but their effect is about as common as substance use disorder in the general population and it's a an extremely powerful connection in fact it's almost a dose-response to relationship the number of adverse childhood experiences you've been exposed to can predict your lifetime risk of developing at least alcohol use disorder in this thing right and here's the thing it's not just addiction it's not just mental illness it's also the likelihood of developing cancer diabetes and heart disease and so it appears that early adversity is a nexus through which many chronic diseases are operating right and so if you want to do one thing if you've got some time to volunteer you want to you know donate your time and you want to do one thing that is maximally efficient work on domestic violence or the more appropriate term intimate partner fun you do for intimate partner violence you're doing for addiction too you're working to put me out of business which I hope you will do and so the connection between things like housing policy and equal opportunity at an education and the ability of a state to meet the need of battered women which my former home the state of Utah is exactly dead last in the country at doing right and trying to explain that to the legislature of Utah try to explain that the law that they passed in Utah requiring sober living houses to be licensed and that license costs over a thousand dollars which is effectively eliminated high-quality low-cost sober housing for poor people to try to explain that that would decrease the entire state's resilience to the problem of youth opioid addiction is not an easy task but the science is there and we can stand on firm ground when we say those things right those policies matter there is a mechanism by which they change you know the way the brain works and so today unlike when you know William circle silkworth wrote the doctor's opinion way back in the 30s unlike the time when I was in prison now today we have a very good working model of what's going on in the brains of people with addiction this is the American Society of addictions definition of addiction it's it's a few years old but it's holding up quite well it's actually an 11 page document I would love to send you this document it is a beautiful summation of the neuroscience as we understand it and I think it speaks very eloquently to the things that addicts go through and and overcome this is just my one paragraph summation it's a busy slide we're gonna talk about all these things but what I'd like you to take away from it right now is that we have more than one thing failing at once in addiction it's not just one thing it's not just two things it's at least five different things that are going wrong at the same time in addiction so if we want to understand addiction if we want to understand what comes out of the mouth of a person who's in active addiction or in early recovery if we want to understand what we're going through when we have a terrible awful craving and we want to use drugs even though we know it'll send us back to prison or something like that we have to understand all of those systems how they work and how they break we have to understand what goes on at the level of genetics we have to understand what goes on in the very early reward structures of the brain this is where dopamine plays its role but we also have to understand what goes on not just in reward but in reward learning how does the brain learn things as the memory system figure in here a lot of the quite eloquent arguments against the idea of addiction being a disease that have been raised in the last year and a half have focused on addiction not being a disease but a disorder of learning a learning disorder right something like autism something like ADHD that's that's their argument and if all you do is look at this part of addiction that's true it's a bit look like looking at a Christmas tree through a toilet paper to write a Christmas tree is lights it's an ornament it's the train underneath it's the star but actually addiction is much much bigger than that and I think these arguments are a little sophomoric and the fact that they're not looking at the breadth of the research ok but they are making a very important argument right most people with drug and alcohol problems mature out of them they get over them usually young people who even have a severe heroin problem they kind of mature out by the time they're in their mid-30s right and this is research that has essentially come out of the nice arc study the National epidemiologic survey on alcoholism and related conditions which is a powerful study over 40,000 people asked questions at three different points in time over a period of 20 years and what it seems to find is that people with severe addictions kind of stopped doing them as the normal stresses of and responsibilities of adult life kick in right I think it's it's important data it's a good study these kinds of community studies are important to listen to because they can tell us a lot lots of studies do this and they and they're valuable but how did you think that they assessed whether or not people were using drugs from point to point they asked the individual right which has value but I got to be honest with you I don't know all the ways that my addiction is still playing itself out even though it's been a long time since I've actively used drugs so these are important studies but I would I would question I I kind of agree with Bill I mean recovery to me is proven recovery it's it's it's a family that can tell me that things have changed it's a it's a it's an employer who can say yeah you know he's he or she is doing great it's it's negative drug tests on a lab sheet okay it's it's a it's a much more global measure than just hair you still using heroin right because most people that you ask hey are you still using heroin usually they're not okay how many times have given this lecture and and at the end of it there has been someone who has come up to me and buttonholed me and said you know what I got to tell you your lecture fine but I was a heroin addict and one day I just was holding that needle in my hand and I looked at it and I looked at my arm and I said no way and I put it down I walked away that was the end of it so how do you explain that if addiction is a disease and I'm like wow you know what I I can't that first of all congratulations that is amazing story I'm very proud of you you should be proud of yourself I'm sure you are that is a great great recovery story and I I have no explanation for that and I pick up my my computer and I go off to my car and and I meet his wife and hitch and I say wow isn't that great that he just put the heroine down and walked away and just got better like that she goes yeah he didn't tell you that he smokes pot every day right and that he hasn't had a job in six months and they were getting a divorce because he's an all right oh gosh no I didn't I didn't hear that part so the the argument that is being made these days is true the the drugs themselves are just kind of one part of it but there are brain states that persist long after the drug is gone and when I go to an a a meeting that's what I look at yeah well that's what I see I see people who have been long sober but they know something's not quite right and they're using the power of the group and shared values to cope with that deficit and I think that's a very beautiful and humane process a human process but some of these arguments I think are only looking at the problem through a toilet paper roll right and if all you do is look at the memory part of addiction yes it looks much more like a learning disorder that people will eventually just mature out it right if you want to pick one cause for addiction and be on very very firm ground pick that one the science is extremely strong but but you see what we're doing we're just kind of climbing levels of brain processing until finally we find ourselves up in the areas of the brain where we really do the things that we measure ourselves as humans for right where we you know have more you make choices where we where we have a capacity for emotional functioning and and formation of relationships where we have social connectedness which is so important in recovery right where we where we do the things that you know the frontal cortex was meant to do and what addiction is is it's just like dominoes one goes the next goes the next goes the next goes and by the time we're up in the frontal cortex things have gone very wrong indeed right now you know I'll tell you these studies which are quite fascinating just slide over here but they matter and I don't mean to dismiss them probably the the study that started not just nice arc but but one of the studies that was done by dr. Sir at UCLA looked at heroin addicts over time and found that not all heroin addicts fit the same trajectory of their addiction that there seemed to be people who who stayed bad but there were also a lot of people who kind of got bad over time and this is that why the doctor sir uses this sort of life course analysis that there are many different populations of people in there and if all we do is say well you know most people you know die then we're not really looking at the the full breadth of all the other trajectories of recovery that we see right and this is a again more of dr. sirs research that there's this basic pattern that you see and the numbers actually hold quite well from drug to drug you see the same basic pattern with heroin with marijuana with methamphetamine you've got some people who start out really bad and stay bad some people who start out bad and get better over time some people who start out and pretty bad but quickly remit some people kind of stay at that low level and some people who start out low and get worse and these percentages are a pretty a breakdown you can kind of kind of look at over time and this is what dr. Haman pointed out in his I think very the best worked out argument against the idea that addiction is a disease how can this be a chronic disease if the majority of people with it are spontaneously remitted right if most people are getting better well I just think that that shows a lack of imagination of disease right I mean the people who really understand disease are pathologists and if you sit down with a pathologist and it's a five-year residency after medical school right that's a long time because there's so much disease out there and they will tell you the expression of disease is huge there are all kinds of diseases that do all kinds of things and yes many things are diseases and they get better on their own the flu most people who get the flu do not need to be admitted they may not be needed to be put on antivirals or intubated right they they summon their sort of internal resources and they get better right but that doesn't mean that the flu isn't the ninth leading cause of death in the United States so people who are especially vulnerable right are going to do worse when in fact most people might do better that doesn't mean that something isn't a disease right so I I don't a lot of the people who are making this argument their arguments are good and I love reading their arguments but they don't treat a lot of patients and they see a lot of disease and through the eyes of a physician I can tell you the arguments really just don't hold water right but we do have to be kind of you know true to this fact that that you will see remission over time and I don't mean to to dismiss that but this is sort of the the current argument that's out there this is a title that is designed to sell books let me tell you narang and dr. lewis the canadian neuroscientist is making I think a really good point just because Nora volkoff's these changes on MRI scans all right which are very very impressive is that disease does that make it pathologic because the brain does everything everything we do shows a brain change right so maybe we're actually looking at something physiologic and when a person gets into a heroin problem for instance a heroin addiction maybe that's just not that's not a disease but it's just a really really bad habit that has gotten out of control is now self-destructive maybe it's a very deep form of learning but it's not pathology it's not disease because the person can use the very same learning system to get out of it and I kind of like that you know that you're using the same system to get that got you into the problem to get out of it I think that's absolutely true I think you can say that addiction is a learned behavior but that doesn't mean that it's it's not a disease right so so I think you know what I find so fascinating about this debate as it goes back and forth and there was just a another publication this week by another filmmaker who said well you know it doesn't matter that at whether addiction is a disease or not actually I think it does because that's sort of what helps us form policy so I'm gonna make a you know I'm gonna make that chat out but I guess yeah and if a person sits in front of me and says you know what I had a really bad problem and I you know I did some I made some changes in my life and I don't do that anymore and I just don't think I had a disease I'm cool with that III think if that's the way that person wants to frame their experience great I'm certainly not gonna argue with it right the people that I see saying this I noticed that they've got some things in common they're white most of them are male they from privilege they had the opportunity to get treatment right and so yeah for them I think you know you could say that but but at the treatment center that I work in Utah we've got some severely and persistently mentally ill people with I've daily IV heroin use and just say that well you've just got a learning disorder it's just a little callus in their case because those people are not necessary we're gonna just you know snap out of it when they're 30 and their parents certainly don't want to hear that so when we asked this question about addiction we're asking some big questions and the question that I'm asking is not really a question about what it will do see that's a lot of the arguments about whether addictions of disease or not are based on what it will do there Taliah logic questions right if we call addiction then more people come to treatment then stigma goes down which is actually not true as we have learned more and more about addiction and as if the pot as the population has learned more and more about the brain nature of addiction stigma has actually gone up not down very very interesting study done by Pesce Delino I can send it to you right so there is always a possibility that we might be making things worse as we teach the general public that were you know talking about a brain disease here so it's not a foregone conclusion but these questions are a very Tahlia logic you know insurance covers it more or we can get better things I'm not asking a teleological ester I'm asking an ontological could a disease of volition even exists is that something that is possible in the natural world and I don't see any scientific reason why not choice is something the brain does why would why would volition suddenly be immune to the same laws that that that other areas of the brain are held to I can think of religious reasons why volition Campion's I can think of political reasons why volition can't be diseased but I can't come up with a scientific reason and so I think you know this is a an argument that will go continue to go back and forth but I have to say if it were to turn on a dime as many of these authors are suggesting because that's really their you know everything is being rethought you know we're totally moving in a different direction I gotta tell you that's not true all right that's just wrong that's just factually wrong if we were to turn on a dime and say oh it's not disease let's go in the other direction we've got better evidence that would be the first time in the history of science that's something like that had ever happened right so you know like you said Bill it's it's it's not even debated anymore that it's a brain disease well it is in the mind of the public it may not be in scientific communities but it is in the mind of the public and now we have to confront some of this better epidemiology that we have that says yes most people spontaneously remit how do we fit that in to our concept of addiction being a disease so I'll move on this is just kind of my little thing I've thought about it's kept me sober I think for about 15 years but it goes back and forth and this is kind of you know what I spend my time doing so you know what I'd like to do is I'd love to just stay down here and talk about dopamine all day and stay out of the frontal cortex and there's a reason for that I am still haunted by what I was taught in medical school that addiction is a variant of antisocial personality disorder this Bugaboo of an addict personality right it still bothers me right that really at the bottom of all of this I'm just a jerk I'm just a liar cheat and a thief okay I have this attic personality right this is the first thing I did when I was in prison and I wanted to try to figure out do I even have a functioning brain here I tried to give myself a little course in medical ethics in my prison cell and just see if everything was working correctly and for the most part it was I wanted to know you know am i a sociopath it's a very interesting epistemic question because you know how do you know if you're not a sociopath maybe that's the first per thing a sociopath tells himself don't worry you're not a sociopath don't even think about okay so I mean I'm still plagued by this I remember when I when I was I was at the I was kept in solitary confinement for the first 90 days of my sentence at the Camp Pendleton brig and one day they sort of opened my door and every time my cell door open there was usually someone on the other side of it who wanted to yell at me so I actually be kind of came you know happy when the door didn't open up you know so I mean solitary confinement I don't mean to be melodramatic here but it me up a little bit I'm sorry I don't mean I don't use language like that I'm from Utah shouldn't be doing that but I can tell you right now solitary confinement is very definitely neurotoxic and it is a cruel thing that history will not remember us well for but one of the days they opened up the cell door and they shackled me up and they took me this little room with a chair and a table and a phone and they said pick up the phone picked up the phone the handcuffs on like this and it was an administrative law hearing to have my license taken away forever and the guy on the other side of the Attorney General a Deputy Attorney General and the administrative law judge were talking and the Deputy Attorney General said you know dr. McCauley is a drug addict he's been convicted he's in prison he does not admit powerlessness he does not think he has a problem I want his license and I want it you know gone forever and I want a layer of cement put over his career and the administrative law judge said well dr. McCauley what do you have to say for yourself and I say well there's not really much that I can say everything factually that that the Deputy Attorney General said is true and I'm very very sorry for this but I will tell you I do admit powerlessness I mean it's all around me I do have a problem and I would ask sir that you if not you know take away my license maybe put it on the shelf and allow me to get through this and get treatment and then you know we appear before you maybe I can get my license back and he said yeah I think that that's exactly what I'm going to do and I think mr. Layton dorothea Deputy Attorney General is a little moved by my plea and when the Attorney General or when they had administrative law judge got off the phone we talked and and he you know was a lot warmer now that he kind of put a you know voice at least to this terrible stuff on paper about me which still exists and he said you know I'll tell you I hope it will get a chance to meet again when you get out of there but you know I've dealt with this problem a lot I've seen a lot of addiction you know over the course of my professional career and what I can tell you is you know addiction is really about maturity and most people when they kind of grow up they stop using drugs and I think that that's the case in you I mean I think you know once you kind of grow up a little bit the problem will go away and you'll be fine and what I wanted to say was well how about that all right you just got it all figured out so all those people doing research you know at NIDA they can just stop you know all those you know journal articles and the dusty shelves of medical libraries you just throw all that away because really all we needed to do was come to you right because you've got it all figured out and I fortunately I did have enough bring healing to be circumspect and I kept my mouth shut but I gotta be honest with you and I was 15 some years ago more than that I've never been able to shake what he said and so yeah I do think that there are things that are not quite right in the frontal cortex I've got to be true to that science do they rise to the level of personality I don't believe so but there are things about the frontal cortex that can actually be seen at it at a very early age you've probably heard of the famous Stanford marshmallow experiment where you you ask the kid you ask the parent to bring the kid in now come on this hasn't been going recently okay I'm gonna you got to see this it's very funny it's worth it you ask the parent to bring the kid in and you say hey don't don't feed and Breakfast bring him in hungry and you sit the kid down and you say hey would you like a marshmallow and of course the kid once a marshmallow who doesn't want a marshmallow right and you say wait a minute don't eat the marshmallow just yet I'm gonna go down the hall for a few minutes and when I get back if the marshmallow is still there I'll give you a second marshmallow right and here's the thing some kids can do it and some kids can't now it appears that the kids who are successful they don't think about the marshmallow they distract themselves from the marshmallow the kids who are not successful exposed themselves to marshmallow cues they they touch the marshmallow they they sniff the marshmallow this bad strategy don't do that if you want to win this oh this I love this kid she figures if there is some marshmallow remaining when the adult gets back that that should count as a marshmallow and she should get her second marshal alright this is me the kid with ADHD doesn't not even wait for the instructions whatever shut up meet Lamarr and so here here's the thing this this simple test of delayed gratification or the ability to delay one's gratification can predict things down the road like your SAT scores your educational attainment sadly for me your BMI right so I have to be true to the data it was actually Jorge coupe who pointed this out to me did some of the research we'll talk about that there is something that might be different is it pathologic is it a matter of near diversity I'm certainly you know open to that but things like ADHD for instance yes they do predict problems down the road and it seems that there are a number of areas a number of traits I don't think these rise to the level of personality but they do seem to predict earlier age of first use which is highly predictive of lifetime risk of addiction right and there are areas of the frontal cortex that do seem to suffer like for instance the orbital frontal cortex which essentially helps us confer value on to things right and so people who have strokes here they they look normal but they can't do some significant things like one of the things that they can't do is they can't guess the price of consumer objects correctly right so they're terrible in the game show The Price is Right I mean they just can't do it right and that might seem like a very small thing you can't guess the price of something but it turns out their entire emotional functioning falls apart they get divorced they lose their jobs they have no and so our ability to value valuation is a very important sub component of volition and if you break that you've essentially lost the steering mechanism for choice okay this is one of the areas of the brain that's suffers in addiction okay another area the anterior cingulate cortex this is very important in social cognition it helps me pick up on social cues and guide my behavior accordingly so another way of thinking about this part of the brain is that this is where I observe myself through your eyes right and so as as I stand up here and I give this lecture I've got a relatively good idea of how I'm doing I'm losing a couple people sorry got some friends thank you I appreciate that I can do that I can self monitor because I have this area of my brain and when I use drugs I lose that and my behavior becomes socially atrocious okay and this is what Bill was talking about this is what you look what you're looking at when you turn on that television show intervention and you see that otherwise the loving young man use the f-word with his grandmother you're watching a person have a stroke or at least the really really bad PIAA right but they're not losing their ability to speak or move they're losing social cognition right and so these areas of the brain are starting to stack up we're starting to learn more about areas like the insular cortex which is very important in entero ception right there's this weird series of cases of people who are severe smokers who have strokes in the insular cortex and they just kind of forget that they were smokers they don't go through nicotine withdrawal or anything they just wake up and their loved ones say oh wow you're back great we were worried would you like a cigarette and they're like why would I want a cigarette because you're a three pack a day smoker I am oh how about that all right so I mean this is these are all these little things that we're learning about the quartet frontal cortex there that are very very important and they give us this capacity that we take for granted until we don't have it and this I think is the the the really the chief symptom of addiction that is most definition that persists even if the person becomes abstinent right their decision-making is poor and they lose insight into just how impaired it is right I'll give you an example of what this looks like so I went to treatment back in 1998 in East San Diego County and like most treatment centers there's a family program and my mother came to my family program at my treatment center and you know you do the two three day thing and if you do it they give you a pass and so my mother and I got a pass we went to lunch it was a beautiful sunny day on Coronado Island and we sat by the water and when I felt the time was right I reached out my hand and I put it on hers and I said mom I just want you to know I love you very much and I'm very grateful to you for sticking by me through all this I want you to know I love recovery I see a real future in sobriety and and mom I'm at the greatest girl here in treatment oh we are so in love I just know you're gonna love her too she gets out of detox next Tuesday maybe we can all go to lunch right there it is that that piss-poor decision-making plus my own loss of insight into just how impaired it is you know there there are a lot of diagnostic signs in medicine signs are things that you see in the patient and you know you're dealing with a specific disease there there's Levine sign in cardiology if a patient does this that's about 90 percent sensitive for active heart attack you know in process heart attack there's Babinski sign in Neurology I think it's high time in addiction medicine that we should have a sign and since I'm not grandiose at all I'm gonna call it McCauley sign Hey so so what is McCauley sign well it's not something that you actually see in the patient you see it in the people around the patient and it is that that little wrinkle that furrow that appears right here between the eyes it's not so much pity it's not anger it's more like are you completely out of your mind and I saw McCauley sign a lot back in those days I saw it in my mother all of my sponsors quite a few attorneys and judges right and it is that little you know that inability to see just how poor my decision-making is and that is a very very vulnerable state for a patient to be in and it's really where we do a lot of our damage but it's also where people can prey on addicts a lot of people have kind of learned how to use addicts in that brain state and this is kind of you know what we suffer with right the all of these areas of the brain work together and they each handle a part of choice but when the diction comes along they fail and that capacity that we have taken for granted unravels okay so now that we've talked about this let's come back down to this part of the brain and we'll talk a little bit about the genetics all right there are genes that can determine differences in how drugs feel from person to person so mark Succot at UC san diego has found one of them he's found a genetic difference okay and it is essentially ones response to alcohol he's been studying sons of alcoholics for a long time and he's found that those sons of alcoholics who are low responders to alcohol in other words it takes more beer to get them drunk they have a higher likelihood of becoming alcoholics as they progress into adulthood right so here is a genetic vulnerability we came into the world with it other people who are high responders one beer drunk right they actually have a resilience to becoming an alcoholic and this is what was all quite in place before we were you know even born so at least 50% of the vulnerability to substitutes disorder is genetic right and of course the opposite is true for opioids if you have an initial hyper euphoric response even on a you know clinically appropriate exposure to opioids these people genetically are more likely to progress into opioid addiction right so this kind of teaches us wow we really have to know what's going on with our patient we we have to kind of maybe get a sense of their pharmacogenomic you know expression right or the different you know polymorphisms that they might have if we want to prescribe safely to these patients and so this is something that we do at our treatment center in Utah is the psychiatrist won't even start pharmacotherapy without giving getting this this this pharmacogenomic testing because this medication may not work in them and so this is a way of sort of individualizing patient care and understanding that what is safe in one patient can be very very toxic in another where things get really interesting is where when you look at the epigenetics of things like addiction now I got to be honest with you I understand this imperfectly but the way epigenetics has been explained to me is that it's essentially a way of taking information about the present and sending it into the future okay so the most famous epigenetic study ever done is called the överkalix study överkalix is a tiny little town way in the northern part of Sweden right at the Arctic Circle okay so these people who've lived in this town have always lived on the edge of existence sometimes there was enough food sometimes the town nearly starved but what överkalix is special for is that it has exquisite records going back several hundred years and what the epidemiologists discovered is they looked at these records okay is that at a certain period of development a window of development if a person was exposed to food scarcity something very special happened not to them right so if the young boy was exposed to food scarcity between the ages of seven and fourteen years of age the rate of diabetes went down not in him not in his son but in his grandson okay if a young woman was exposed to food scarcity again and that latent phase seven to fourteen years of age the rate of diabetes went up not in her not in her granddaughter not in her daughter but in her granddaughter and what it went up that's right so the women got the short end of the stick yet again in public health right so so what this meant was is that the environmental stressors exposed that one generation was exposed to could have transgenerational effects and that that moment was where a large part of the puzzle about addiction was suddenly filled in right so this idea that trauma is her Edible that it can actually be passed on that's very scary right but it's not passed on genetically it's not actually changes that occur in the DNA these are epigenetic changes so they're things sort of attached to the DNA like methyl groups and so certain environmental stresses can change methylation of DNA and a number of others like a set elation and stuff like that and that can change how that can affect how tightly the DNA is wrapped and that can affect whether that gene which is there is actually turned into a protein or not okay if it's wrapped very tightly maybe not if it's wrapped loosely it's the gene is very available and it's readily turned into a protein right now this is kind of scary and when I talk to patients about this I'm very very careful there is good news here and that is that these epigenetic changes can work in both directions they can go in the bad direction but they can also go in the good direction and so I don't know about you if you if you work with patients a lot of our patients who are parents they feel very very guilty about their genetics and that they might have passed their own alcoholism on to their children and how many parents have come up to me with tears in their eyes saying you know is there nothing I can do my father was an alcoholic my mother used pills my son's father was a heroin addict I drank throughout my pregnancy you know my child has seen me drunk is there anything is my child going to become an alcoholic just like me and you know you kind of have to be careful how you answer this question because if you start sticking Gina grams up there and percentages the patient doesn't really hear that they just get more depressed but I think there is a way of reframing this genetic information or at least the epigenetic information which goes like this you know there's nothing I can do about the fact that you drank while you were pregnant or that child has seen you drunk but your child will also see you get sober and everything that you learn here in treatment every sober day that you put on top of the next that benefit goes to your child too right and so I think you know the ability to adapt to these resilience ease if I have the genes for alcoholism and I become an alcoholic and I die that's not so good but if I have the genes for alcoholism and I become an alcoholic and I recover that's very very very good because that's an adaptation and biology loves adaptations when we for our second film interviewed Katie Harris who runs the collegiate recovery program at Texas Tech her interviews was so good I had a terrible time editing it so what I did is I took the good parts and I put that in the film and then the rest of the clips we're gonna put on the film's website so they'll be available to everybody but probably the most moving thing that she said was you know collegiate recovery programs and the things that we learn about recovery management they're not just going to affect you know the people who get them they're going to affect future generations I have people in my program who were terrible terrible addicts and alcoholics and I see them on Facebook and they're getting married and they're raising children and those children will have never seen them in that state all they will ever know is a parent in recovery and that is a powerful resilience factor and so the genetics can be very depressing unless you frame it in such a way that actually it's it's quite hopeful right but if that problem is there it's still going to be there once we have a brain and we actually have a reward system right so when I have that pleasurable experience the UM of grandmas chocolate cake the if you go to the core of that pleasurable experience the very first thing my brain does is in this pathway of neurons right here going from the midbrain specifically an area of the brain called the ventral tegmental area the cell bodies there send their little tails their axons up to the striatum and a specific area called the nucleus accumbens and those cells release the chemical that we've all heard of which is dopamine now dopamine isn't the only chemical that's involved here it's merely the first it's the first chemical in what we call the hedonic cascade the series of chemicals that the brain is going to use to create that big conscious pleasurable experience but dopamine doesn't handle pleasure per se it handles just one central core component of pleasure namely salience it gets our attention it's zeroes us in it says hey this is important for survival pay attention to it it also handles if we come across a reward that is better than we had expected it would be and this is why I find addiction so fascinating it is very much a disease that requires time to exist so in the minute in the present and the locked-in immediacy of something like craving where a person cannot conceive of negative consequences even ten minutes down the road right that requires the present but to have that you have to have past drug-using sessions to create the changes in the brain to create that but where addiction really seems to be a problem is in our relationship with the future and again that capacity of fictive imagining so some of the people who are doing the most exciting research in addiction neuroscience are computational neuroscientists they've they've essentially their computer whizzes who have learned a computer model how choice actually works right and what they found is that when all humans stand on the threshold of a choice all of us what the brain does quite unconsciously very quickly is it projects itself into the future for each option and very quickly it assesses the value of each option and the likelihood of each option and as the information comes in it's a bit like a horse race right and each option is kind of racing against the other and once one of them reaches a certain threshold we default to that choice and it's very hard for us to back out of it what addicts have a tendency to do is dramatically over value future drug related rewards and overestimate the probability that they will in fact work out as intended right an undervalue the consequences that might result and underestimate the probability that those consequences will in fact come true so it's our relationship with risk that is broken in a sense and so when we talk about dopamine we really have to understand that this is a disease that's about the future it allows us to essentially assess if we come across something that is better than we had expected that it would be yes right now I'm looking at the clock so so let's talk about a bet on the future how about a vending machine right every vending machine is a bet on the future you hope that when you put your quarter in there you're gonna get your local candy and the little thing doesn't go around it's gonna be a real disaster right but let's say I walk up to this vending machine right and I want to buy a bag of Funyuns all right very popular among the cannabinoid users that our treatment center maybe you do right and so Funyuns at this vending machine cost a dollar and so I put in my dollar and due to a freak of vending machine physics I get two bags of Funyuns this is when the brain releases dopamine all right so it's a reward but it's better than expected in the brain says hey look at this we're expecting one we got to we got to now now pay attention to this it might be really good for survival it might be better than the other things in the past for survival why don't you put this a little higher on the survival priority list that's what dopamine does right if I put in another dollar right and I only get one bag of Funyuns no excess dopamine is released it's not that the Funyuns aren't pleasurable they are I mean they got fun right in the title okay that's because other chemicals are going to take over and round out that pleasurable experience but the the pleasure is not better than expected there's no there's no reward prediction error if I put in another dollar and I get no Funyuns I release less dopamine okay because this reward was worse than expected of course if you don't get your Funyuns that's going to cause its own set of problems because so so we really have to be very careful about what we say dopamine does what dopamine allows us to do is is recognize things that are good for survival learn them and then predict them and it's that relationship with the future that really matters now let's talk and what all drugs of abuse do what they all have in common is they create these very large very fast surges of dopamine that's not what the system was meant to do was meant to handle normal pleasures normal releases of dopamine but every time a person smoked crack cocaine for instance and they get that surge of dopamine their brain gets a message that's kind of like you know hold the phone this is way better than expected even though it's not this is this is better than anything in the past even though it's not and it should be put higher on the value system even though the drug shouldn't have that value so sinisterly drugs actually create an illusion of their own importance even though it's not true now let me change my metaphor just a little bit and talk a little bit about David radishes work because this is his study all right let's say that I don't want to buy Funyuns let's say I want to buy a gumball specifically a yellow gumball alright and I walk up to this vending machine this gumball machine let's pretend it's real just looking at this gumball machine what do you think my chances are of getting a yellow gumball with any one quarter I've counted it up and it's about ten percent all right so fix that probability in your mind because that's reality it's not going to change the problem is for the patient who wants to leave treatment and almost every treatment center has this poor suffering individual who knows they should stay but they and if they leave they're gonna be in big trouble with the family or the job or the probation officer but they are suffering they are craving something is very powerfully pulling them out of treatment what's going on in their brain well they don't actually see this like you and I do all right because for a long time they've been putting a quarter in and getting two gumballs right and getting that surge of dopamine along that pathway of neurons one of which goes right into the orbital frontal cortex which assesses value under shifting conditions of red and so what you and I see is this the person who is craving who is who is it was in that decisional balance of whether or not to leave treatment they don't see this 10% they see this 20% they see this 33% they see this 100% and so this is the way human volition collapses we lose the ability to assess what is likely and valuable in the future our relationship with risk is destroyed and that's what that surge of dopamine does it just overwhelms that decision-making capacity and what all drugs do is release dopamine in this fashion right they all create these big surges of dopamine and so this is the dopamine hypothesis and there are some important implications if I've got a problem with one I have a potential to have a problem in any or all of the others and not only that it allows us to realize that it's not just chemicals that can do this behaviors can do and so the power of the dopamine hypothesis is that it allowed us to take five steps back and look at the entirety of the picture so I'm keeping my eye on the clock here I'm going to stop in the next couple minutes but in the spirit of your opening Tom what's that yeah I know it's I'm eight minutes over I'm making that's over I've got a clock right here yeah the clock is very wrong I just want to leave you you know with this what is our obligation to the patients who come to our treatment center who continue to smoke because this is the power of the of the dopamine hypothesis is that it not just explains things that we see now it not just predicts things that we might see in the patient but it exposes the errors in our thinking today and so when we allow continued smoking in our treatment center are we in fact continuing the problem because that insult even though it's a lot smaller than say crack smoking is still there and so here's the problem the drug that is most likely to kill the patients in the treatment center that I work at is not heroin it's not alcohol its nicotine right and so the old you know the old saw right don't quit it all at once you're gonna crave more you're more likely to relapse that is dead wrong people who continue to smoke report worst cravings they're more likely to relapse people who quit in the first year after treatment are more likely to be sober from their primary drug nine years later right so this is I think the power of this science is that it can expose things that that we've you know that we've haven't quite seen yet right they all essentially do the same thing and where we see the problem is in these dopamine receptors all right this is the primary pathologic defect the thing that makes the addict different from everybody else we have too few dopamine receptors specifically this population of d2 receptors right and that's essentially even though the drug is long gone that's what we have to cope with and I can say that I can say paucity of dopamine d2 receptors or I can say restlessness irritability and discontent because that's what that's the ism of alcoholism that remains even though the alcohol is gone and it is that population of receptors that really drives the functioning of the frontal cortex okay and so I was trying to find a way to make this part of the lecture go a little faster and one day I was looking at this this thing remember this thing from high school chemistry the fear I made up a periodic table of the intoxicants and so these are all the intoxicants that you're likely to see in the United States but they're arranged according to their class right but they all basically do the same thing whether they're cocaine or alcohol or heroin or steroids or codependence well actually I should be careful there's not a lot of good evidence that shows that codependency does the same thing that things like cocaine does but there is for gambling alright and so I'm gonna keep it up there I think it's just harder to get my mother and I into a functional MRI machine when we're in the middle of a fight so it looks a lot like addiction but it's harder to measure but this is I think the the one thing that nature gave us that was that was a benefit is that they're all kind of bound together by this this this commonality and that allows us I think to understand a lot more and to treat a lot more so I'll finish with this I'll skip that you really have to pay attention to this to this spike here and it's easy for me to be high-handed about cigarettes because I don't smoke but I got a problem that is just as bad with sugar and I guarantee you the drug that is most likely to kill this recovering addict in the long run is my relationship with sugar this is what life is like with too few dopamine receptors we we struggle with this in one form or another maybe for the rest of our lives and so a large part of recovery is trying to take this spike out and putting normal rewards normal pleasures back in in other words you know and that's my thing right there there's a difference between fruit okay and fruit loops all right fruit is fruit fruit is good for you have all the fruit you want all right that's safe that's a normal release of dopamine this is something very very different and it's it's all that sweet and all that flavor and all that color and smell extracted and packaged in a form that can be ingested within minutes and that's the real risk and so what this science tells us is that you know we got to stop that but do a lot more of that [Music]

Channel: VCU Rams in Recovery

Views: 56,278

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Id: MrN58NbI_8o

Length: 69min 50sec (4190 seconds)

Published: Fri May 27 2016