The Brain and Recovery: An Update on the Neuroscience of Addiction

the last 20 years have produced an explosion of understanding about addiction and how our brains make pleasure based decisions dr. Kevin McCauley explains how the brain constructs pleasurable experiences what happens when this process goes wrong and why this can have a dramatic impact on our ability to make proper choices well good evening thank you very much for coming it's wonderful to be back in Juneau I really enjoyed my trip six seven years ago the weather was fantastic then and it's fantastic today so thank you the minute I made a second DVD a second film about addiction one of the first copies went to NC a DD in Juneau because I was kind of hoping that they would bring me back so they did so it's a real pleasure you know June has always been very special to me you know I go around the country I talk a lot about addiction it's my favorite topic I hope I can impart some of that enthusiasm to you I find it one of the most fascinating puzzles in clinical medicine and in just in society in general we find ourselves in the in the in the moment of this terrible epidemic of opioid overdose and so everywhere I go every community has a different thing to teach me about about what how they're handling this and so what I would want to do if I came to a new community is is give just a brief overview of addiction try to bring you right to the edge of what it is that we know in medicine about this particular topic and the hope is that people with addiction or needing recovery or in recovery will feel a little better understood and people who are trying to support those folks their families will feel like there's a lot more hope because most people who stick with this recovery thing they do eventually get it and I think a lot of what goes a long way is really understanding exactly what's happening in the brain and when a person becomes addicted to drugs or alcohol so difficulty with addiction is that I'm not sure I could have done a better job if I was trying to design a disease that was as maximally confusing as maximally unpleasant as maximally difficult to figure out as addiction is so if I was not a good doctor if I was a evil doctor let's say like this guy all right and and I went to an evil medical school maybe there would be an evil class project where I would have to kind of come up with the most evil disease that I could think of and what I mean by evil is not that the patient is evil see that's that's part of the evilness is that we would think that the patient was evil when in fact they had a disease and this disease wouldn't just harm the individual but it would harm the people around them and their society as a whole and it would be very very very confusing for for people to figure out hey this is a public health issue right well if I would do that if I were sit down with a piece of paper from scratch what would that disease look like well the first thing I would do is I would make its status as a disease already a contested question so before we even got out the starting gates if I said addictions the disease people would roll their eyes and fold their arms and leave my lecture and so it would be you know already an argument if I tried to use that term and that is in fact what's going on with addiction right I would make it run in families but without any particular pattern to it okay it would hit one sibling but not another that way could do as much damage as possible to that family okay I would create a disease that had symptoms that were so repulsive that they did not look like symptoms that they were more easily confused with just wilful bad behavior okay I would create a disease that as it progressed the patient would lose insight into how sick they were right that would be part of the pathophysiology everyone around them could see it but they'd say they would say oh come on you're overreacting I'm just fine that would be part of the disease right I would create a disease that in most folks who get it they would over time mature out right they would kind of get better on their own without treatment but there would be a group of pee with this disease who would not get better and they would eventually and many of them would eventually succumb to it right I would make a disease not that could be treated with a single hospitalization or with a single course of antibiotics or other medication this would be a chronic disease the patient would can't carry the diagnosis in one form or another for the rest of their life the disease might go into remission it might go into long-term remission but the person would have to do certain things maybe even every day to keep that disease in check and it would have a relapsing pattern in some patients and in some patients it would have a quickly relapsing pattern right this terrible evil disease that I'm trying to think up would be as culturally and politically divisive as possible imagine a disease if you can of Liberty a disease of freedom we are Americans we print these words on our money these are holy values to us can you imagine what would happen if a group if a nation so conceived and those values had a group of its citizens who had a disease in those very values and lastly I would create a disease this evil disease that would only finally give way to weird solutions solutions that traditional medicine didn't recognize the patient's themselves would have to get together and help each other they'd be healthy people would really have to look at themselves and examine their values as part of that healing process and perhaps as part of that healing process they would have a deep personal transformative experience a spiritual change if you will so you see addiction is almost the perfect storm all right if I was trying to be a jerk I'm not sure I could have come up with a better disease that would be as confusing and is difficult to figure out and take as long to finally untangle but fortunately now we can fortunately we're starting to get a bead on this and we realize that there really are brain changes behind these very confusing behaviors but it goes beyond just the individual there are decisions that we as a society as a nation as a state make that can make the disease worse beyond just what the individual chooses and so here we are in this moment of time at one of the worst epidemics in American public health history where we have the very healthiest demographic in our in our country young people succumbing not to motor vehicle accidents which is owned really throughout history as long as we've been collecting these numbers the only thing that could really affect the mortality of young people but that has now been surpassed by prescription drug overdoses quickly migrating into heroin overdoses and the numbers came out two months ago from the CDC for 2015 and so all of those curves are going up and they're going up faster the problem is getting worse and it's getting worse even more quickly and this is a scary thing because it doesn't show any signs of stopping not even of slowing down now if we look at the areas of the country that started to see the problem first or see the problem intense as intentionally will find that it tends to cluster in certain geographic areas right and almost each of these communities has a unique feature cultural feature geographic feature that gives it a special vulnerability to this problem all right so we can go to those communities and I used to live in the state of Utah Utah was seeing this problem ten years before the rest of the country right so there are some very very interesting cultural reasons for why Utah has the lowest in the nation rate of youth drinking youth smoking youth cannabis use but for many years that had the highest rate of youth hair youth heroin use because there was great cultural vulnera silient against these other drugs but not against prescription drugs right but the state of Health Department in Utah managed to get some very very good epidemiologic data together to figure out exactly who was succumbing how they could strategize to stop this and and the state of Utah was the first state they're trying to reverse the trend right so there's this is this is a difficult time this is this is quite scary but we are seeing some bright spots there are some glimmers of hope and one of those is the recovery movement itself people who are in recovery who are getting together becoming active going to college running for office and and making that statement hey you know it's not that everybody just dies people get sober all the time and they go on to live great lives and do great things I think that is a very very valuable community in our nation a very very strong case a group of people with strong resilience against that this problem right one of the areas of this that I think is particularly moving is the collegiate recovery movement right different schools different colleges that have organizations of recovering students who go to class together go to go to meal recovery meetings together keep each other healthy and and are really you know working towards their future and those folks have very very high recovery rates some of the highest in the nation well over 90 percent and so I think these groups of recovering people can teach us something meleave it's they're the ones who will Shepherd us out of this problem that our entire nation faces where I first became interested and even aware of this idea that people get better was when I was a flight surgeon in the Navy that's me on the on the right there and thinner day is I can't wear that flight suit anymore but I learned in medical school that you really can't help addicts it's very sad tune him up get him out of the hospital when I got to the Navy the Navy said yeah we know that we've had a problem with alcoholism in our aviators we've known this for a long time we also know that if we take a zero-tolerance attitude and just kick them out the problem gets worse because they don't come forward they're kind of trying to fix it themselves they go underground and you don't find out about it until there's a fatal mishap right but the Navy and I find this very interesting decided to see this not as a moral issue but as a safety issue and the astute zero tolerance for risk management right if you have zero tolerance for risk in aviation you don't fly so in aviation we learn to manage those risks and the Navy created a program and they tell their student pilots this listen we know this is an issue we don't like it we're gonna do everything we can to prevent it but if you think you have a problem with alcohol if you think you have a squadron mate who has a problem please come to your flight surgeon we'll get you the best treatment money can buy and then once you're safe we'll return you to the cockpit we will keep you in the role that gives your life meaning we care about you guys we we want you to do well you got to get sober we do have this program you don't have to lose your life or your career just because you developed this problem there is something that is very powerful about getting sober in the context of the peers who understand you that that ready room camaraderie alright and when I ran my sober living house in Utah I was trying to the best I could kind of recreate some of that camaraderie where everyone knows each other and takes care of each other so these programs have been around not for five years or 10 years we've been doing this for four decades and not just in the military but also in commercial aviation right this is the program for the Air Line Pilots Association so that includes American Airlines they call their program the human intervention motivation study it has that terrible name because if you called it the American Airlines alcoholic pilot program it would get a little unwanted attention right so these programs have been around for a long time and they're the reason why we have not had a commercial aviation mishap due to drugs or alcohol in the last forty years and that begs the question why can't we give this to everybody if it's good enough for the person flying the plane why isn't it good enough for the person turning wrenches on the plane and so this this is a whole area called recovery management which we've had success in for a very long time in certain groups of recovering professionals and now the task before us is how do we give that that resilience how do we give that opportunity to as many Americans as we can and so I was very moved by this I was very moved by this dedication to a culture of safety that even if it sounds crazy like putting an alcoholic back in the cockpit let's see if it works better and in aviation it did and that's why we do it and that's why we can do what I think is the most amazing thing that human beings do and that is every day on the planet Earth we fly tens of thousands of people all around the planet without a single mishap that is the equivalent of doing the Apollo moon shot every single day why can we do that how is it that we are able to do that because we look at this as a problem of safety not as a problem of moral delinquency right and so there's quite a bit I think we can still learn from all of these groups to help us in this time so I love this job I wanted to do it for the rest of my life I loved flying and then something happened as always does in these cases I had to have a surgery to stay physically fit to fly and I couldn't take a medication so I had to have the surgery and at the end of that surgery they gave me a big fat bottle of this stuff now today we know why this is we know why some people respond differently to opioids all right some people you give them hope you ides and they get me forea and it's a big experience and they quickly put it in context they say wow that was great and they move on with their lives some patients don't get you for it they get dis for it they climb out of their skin these are the patients who tell you don't ever give me that drug again doc I'll just suffer with my tooth pain I can't see how anyone would ever be a heroin addict but there is a group of patients who should you give them an opioid even and the legitimate treatment of their pain they will have a very powerful hyper euphoric experience literally they will say wow where has this been I'm going to do this until the day I die it turned out I was one of those people and I make it into the nitty-gritty but within about six months I had a pretty severe intravenous Demerol problem and I tried to quit I knew that this is not something that a flight surgeon to be doing I tripped up my triplicates I called the California Medical Board no one really knew what to do with me because I was in the military so I tried to you know stay sober I went to meetings I I would make it for a little while and then I have a relapse and I get back on the horse and eventually the Navy caught me and they were they were kind of pissed as you can imagine and and they sent me to their long-term treatment facility for drug addicts they have their own little Betty Ford Center it's called Leavenworth right and so I found myself sitting in the basement of our nation's maximum-security prison for for for a nation's military right and I mean you find yourself in this situation and it kind of makes you think a little bit and I was thinking gee how did this happen how why would I throw away such a great career for a momentary you know bit of euphoria and as I thought about this more and more when I found out I've discovered that it was really an interesting intellectual problem you know everyone was telling me that addiction was a disease I really didn't believe that because I thought that diseases were something else and patients didn't really cause them but addicts do and and I thought well let me try to untangle those and so this was the year 1997 and the task that I set out for myself was to learn everything that there was to know about addiction 1997 it was still possible in one human lifetime to learn everything that we knew all the medicine all the science all the history all the law all of it today in the year 2017 it is not possible to learn all that we now know that has been the nature of the explosion of understanding that we have witnessed just in our lifetime very few times in the history of Medicine have we learned so much about a single topic so quickly and as these journal articles and books started to come in and the stuff stacked up in the corners of my cell I read and I read and I read and I realized wow this is big this stuff is amazing there really are brain chemistry reasons for the things that I'm going through for the things that I did that absolves none of the culpability that that is it doesn't take away any responsibility for managing it but just knowing that there was a reason was very very helpful to me in my sobriety and that's why I think that learning the neuroscience of addiction can make the difference for many many people and the lecture that we're doing now is essentially the evolution of that work that I did when I was in Leavenworth when the Navy gave him me on a nice little time off of work in a nice quiet place to study so I have always been fascinated with this puzzle is addiction a choice is it a disease I will say this I don't have I'm not an evangelist necessarily for the disease model all right I believe that it is a disease I think the evidence is there but I meet lots of people who do not believe that addiction is a disease so it's certainly not a condition for one sobriety I mean lots of people with great sobriety you just don't think that addiction is a disease so if you leave here saying okay well that was great but I just don't think addiction is a disease I'm cool with that but it's so fascinating and I think it's therapeutic to kind of go through why one feels this way or feels that way right and this is basically what has occupied me for the last 15 16 17 years what I what I believe is that most of the arguments against calling addiction of disease have at their core a refusal to believe that the capacity for choice which is realized in the brain can be part of a disease process addiction is a disorder or if you like a disease of volition this is a capacity that we take for granted and we don't think is is mutable by disease processes but it is and so that's what I want to know rather than just saying well it's it's it's it's not a disease it's a choice I want to know how does choice work how does the brain do that and can that process break and if it can break can it be fixed what are the things that I need to put into my life that can support the rehabilitation basically of my ability to make decisions like I don't want to get you know high today so if I could just take all of this neuroscience and summarize it in three simple sentences those sentences would be these one at its heart addiction is a disorder in the brain's ability to properly perceive pleasure addiction is a hedonic dysfunction it's a broken pleasure sense and so in the same way that a blind person can't receive light or a deaf person can't perceive sound addicts cannot perceive pleasure correctly and that undermines their ability to make choices our capacity for free will volition agency would ever want to call it upon proper processing deeper in the brain and so if pleasure or more specifically reward breaks what goes next is decision-making you have to have a perfectly functioning reward system that has to be firing on all 12 cylinders if we're going to make decisions that are really know considerate of past consequences and future consequences and and in line with our values right so now we and the third sentence that I would say about addiction and this is not one that's you know often accepted very readily but I'm going to make it just the same addictions caused by stress what's at the core and we'll talk more about this of the reward system is the chemical dopamine it's not the only chemical but it's the core chemical right and it turns out that that defect in the dopamine system can be caused by all different kinds of stress especially early stress early continuous poorly managed even inherited stress can affect the functioning of the dopamine system and let me just introduce you to an idea which I think is helpful in understanding that third sentence one of the stressors that we face one of the things that's out there in the environment usually that we come across in opportune times like for instance when we're young is the stress of intoxication itself and so if intoxication comes intensely enough and frequently enough that can be enough to mobilize the changes in the stress system that break the dopamine system so when people say hey you know I I definitely think that I'm an alcoholic but I grew up in a wonderful family no one ever harmed me I wasn't exposed to any early childhood adversity well it turns out the patterns of intoxication can often be enough to cause these changes in the brain so now today we have a very good working model in medicine of what's going on in the brains of people with addiction or the term of art today is substance use disorder I'm going to use those terms interchangeably right this is the American Society of addiction medicine z' definition of addiction it came out in 2011 but it's holding up very well quite frankly even as more information comes in it's an eight page document this is just my one parent a summation of that eight-page document don't bother reading it it's got a whole bunch of different words we're going to talk about these what I want you to take away from this now is that we have more than one thing going wrong in the brain there are at least five different systems involved five different things that break simultaneously and they all influence each other and the task before us is if we want to understand what we're going through if we're a person needing sobriety or in recovery if we want to understand that person that we care about it helps to understand each of these five systems how they work how they break and how that explains the symptoms that are confusing very frustrating symptoms sometimes illegal symptoms that we see behind addictive behavior I would love to send this this definition to you you can go on the American Society of addiction medicine website and find it yourself it is a beautiful document it summarizes very well the neuroscience as we know it and I think it speaks very eloquently to the things that addicts go through and overcome but if we want to understand addiction we have to understand what goes on with the level of genetics we have to understand what goes on very very deep in the brain in the dopamine system the level that processes a reward this isn't pleasure yet this is still a very unconscious concept of it right we have to understand what goes on in the memory and learning areas of the brain there are two very fine books out right now one of the authors was interviewed on NPR and they're making the argument that addiction is not a disease it's more of a learning disorder right and the very system that got you into addiction the learning system can get you out of it you can learn better things that aren't associated with drugs I like that last part if addiction only involved that third one I think that statement would be true that addiction is a learning disorder and it's really just a phase that people pass through and calling a person in recovery is not really accurate because they're just moving through a difficult time in their life all right if it only was about memory that would be true but it's more complex than that I would get some arguments about this but I think 98 to 99 percent of the time you're on a very firm ground if you think of the cause of addiction as stress in all the myriad forms that it comes all right and you see what we're doing we're just climbing levels of brain processing one after the other until we find ourselves in the frontal cortex in the area of the brain where we process higher emotions where we make choices where we have some insight into our own social behavior and where we construct things like personality and so they're like dominoes the minute there's a problem in one they just go one after the other and by the time we're up in the cortex well that's what results in the behavior that could land a person in a court-martial if you're not careful oh by the way I went on the website of Leavenworth not too long ago and I found out that they actually tore it down they took a wrecking ball to it and now it no longer exists it's um it's a it's a very emotional thing when they tear down your prison I don't know if any of you know that's just me huh all right well let's keep it down so you know what I'd love to do is I just love to stay out of the frontal cortex I'm still plagued by that thing that I learned in medical school which is wrong that what's at the heart of that addiction is an addict personality that addicts are liars cheats and thieves that they're you know incapable of empathy that they don't have a conscience like you and I do and that's what allows them to use drugs in that fashion this is a holdover from psychoanalysis and it is wrong right so I would love to just stay in the deeper areas of brain talk about dopamine all day long but I have to be true to the science there do seem to be things about the frontal cortex I don't think that they rise to the level of personality which may be different I'm open to the idea of neuro diversity maybe their pathology things like ADHD which are differences in the brain which can increase a person's vulnerability to addiction later in life you've probably heard of the famous Walter Mitchell Stanford marshmallow experiment right this is an experiment did you do on four-year-olds you ask their parents to bring them in don't feed him breakfast bring him in hungry and you sit the kid down and you give him a marshmallow or her and you say would you like a second one and of course the kid wants the second marshmallow I want a second marshmallow right and you say wait a minute don't eat that marshmallow just yet I'm gonna go down the hall okay and when I get back I will you that second marshmallow and here's the thing some kids can do it in some kids camp 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 essentially expose themselves to marshmallow cues they they touch the marshmallow they sniff the marshmallow they taste the marshmallow that's a bad idea well it turns out this simple test of delayed gratification Mitchell found that that it can predict things like your SAT scores your level of educational attainment sadly for me even your BMI so is this pathology is a diversity I don't know but there are differences and that means that this person's ability to make choices of the kind that we would care about is just a little degraded all right having ADHD is a risk factor for adult addiction if it's not changed how it should be treated that's a big discussion don't necessarily want to get into that but there are these differences and we believe they also involve the dopamine system right so the areas of the brain that we know are important and addiction there's a number of them and that number is growing but the ones that are that have very solid science behind them are the orbital frontal cortex this is the part of the brain that's right above my eyeballs on both sides this part of the brain essentially helps me give things value okay if an object or an idea or a person comes into my world and I give that object ID or a person value I'm using my orbital frontal cortex okay patients who have strokes in the orbital frontal cortex they look normal but they have some important deficits things they can't do one of the things they can't do is guess the price of consumer objects correctly right they're terrible on the game show The Price is Right and that might seem like a very small thing but it turns out that their entire emotional functioning collapses they lose their their jobs they have no friends they get divorced and so our ability to correctly value valuation is a very important sub component of volition choice and if you break that you've essentially lost the steering mechanism for choice and what's is one of the things that goes wrong in the brain why do addicts can in you to use drugs despite the fact that they might lose their health or their lives or their family or their jobs because something has gone wrong in the valuation system in the brain the drug has an artificially high value that really doesn't affect what the person truly cares about right so that's one area here's another area the anterior cingulate cortex it does a whole bunch of things but one of the things that it does is it picks up on errors in the environment and helps me correct my behavior this is the part of the brain that if I do something it says to me you did that wrong try again so one of the things the anterior cingulate cortex does is it picks up on social cues and helps me guide my behavior this is the part of my brain where I observe myself through your eyes right so I'm standing up here and I'm giving this lecture got a relatively good idea of how I'm doing losing a couple people sorry got some friends thank you I appreciate that I can do that I can self monitor in a social context because I have this part of my brain when I use drugs I lose that and my behavior becomes socially atrocious now many of you are family members you know what this looks like you don't need any reminding but if you ever want to point this out to somebody tell them to turn on that television show intervention and when you see that behavior when you see that otherwise loving young man use the f-word with his 85 year old grandmother be aware of what you're watching you're watching a person have a stroke or at least a really really bad TIAA but they're not losing their ability to speak or move they're losing social cognition they're losing a part of them that makes them them and this is a very ugly and very scary symptom I do not particularly like this show I think you are filming a person at what must surely be the worst moments of their life when they can consent them nothing I'm alone having the worst moments of their life filmed for a national television audience right but the fact is addicts make good television it's absolutely shocking to see them you know in their worst moments when their brain shuts down what is never indicated is that this can be fixed there are things that I can do to recalibrate my social cognition now there are lots of ways to do it but one of the ways is to go to these mutual support groups these meetings these endless and interminable meetings that just go on and on and on and on and over the months and years I come to know a group of other sober men and they serve as sort of surrogate anterior singular cortices in my life and I essentially am engaged in this very intense sometimes painful social interaction and they can bounce my behavior back to me they can pull me aside and say hey maybe you're not seeing this correctly maybe you might want to change and I can hear it from them in a way I might not be able to say for Mom or the Medical Board right and so there are many ways to do this it's not just 12-step groups and things like that there's also all kinds of other mutual support groups that are cropping up but it's very very hard if not impossible to get sober in isolation if you want these areas of brain to get fixed it takes that social interaction and that's not my tendency my tendency is to is to move quite frankly when I was in jail I had a lot of fantasies about moving to Alaska and just kind of being away from everybody so I haven't had to do that yet here's an interesting part of the brain that's involved so these this was discovered by this guy neck v who was studying people who had strokes in this interesting part of the brain called the insular cortex all right now these patients that he was studying were very severe smokers and they had this stroke and they just kind of forgot that they were smokers two and three pack a day smoker they didn't even go through nicotine secession and so this got a lot of attention it still is the insert cortex appears to be the part of our brain that attaches our consciousness to our body all the signals that were not conscious of that come from our gut in our diaphragm and our heart all of this come into the brain and they go here and they if they're aberrant can affect things like craving they can affect things like a person's ability to not relapse right and so these areas were learning about them we're figuring out what they do each one of them handles a different chunk or component of decision-making right and also self-awareness right so when this one goes and when this one goes what you have is very very poor decision-making right that's my deficit I have an impairment in my ability to make choices and and this is the scary part I can't see it there's loss of insight involved when these areas of the brain fail and that is I think very scary indeed and these are patients who are not pleasant looking they can often be criminal but they're also extremely vulnerable and easily exploited cults prey on addicts I grew up in San Francisco I barely remember the Jonestown disaster MIT massacre but most people don't remember about the people in Jonestown was that they were San Francisco's attics they were taken in so there is I think an addiction medicine a sense of Defense of these patients who are not at their best we we essentially try to to protect them and preserve their dignity until the time that they can get the tools to get better right so we talked about what goes on in the cortex let me come all the way back down and talk about what goes on at the level of genetics genes are very important in addiction they are not the cause of addiction okay but we know that there are certain genes that can determine differences in how drugs feel from person to person all right so doctor chuckit has found a genetic vulnerability in sons of alcoholics and that is being a low responder to alcohol these people it takes more beer to get them drunk right they are more likely to go on to become alcoholics as they progress into adulthood so it's almost exact opposite of what you often see with opioids on the nickel hyper euphoric response on exposure to opioids even if given the legitimate treatment of pain can predict opioid use disorder right so it's important to kind of understand we're all thrown into the world with this combination of these genetic vulnerabilities and resilience ease right where things get interesting is when you look not at genetics but at epigenetics right this is a very new field I'll confess to I understand it imperfectly but the way it's been explained to me is that epigenetics is a way of taking information in the present and sending it into the future right so the most famous epigenetic study that was ever done the one that really started it all it's called the överkalix study överkalix is this tiny little town in the very northern part of Sweden way up by the Arctic Circle cut off from the rest of Sweden genetically isolated but a town that has exquisite records going back several hundred years and when these investigators epidemiologists looked at them they discovered something very interesting if a young boy at a specific window of development seven to 14 years of age was exposed and this is usually because the whole town was exposed to food scarcity right maybe the crops almost failed and they didn't quite have enough food to get through the winter right they nearly starved that exposure to food scarcity increased the diet the rate of Exuma decreased the right of diabetes not in him not in his son but in his grandson if a young woman in that same window of development 7 to 14 years of age was exposed to food scarcity the rate of diabetes went up not in her not in her daughter but in her grand daughter and so this was a very very powerful idea the idea that stressors in one generation can have transgenerational effects on disease expression right and so this is kind of scary right I mean maybe that's it maybe there's nothing I can do well the thing about epigenetics is that it's reversible the changes can occur in the bad direction but there are things that people can do to push it back into a good direction and one of those is getting into recovery right so if I have the genes for alcoholism and I become an alcoholic and I die that is not so good but if I have the genes for alcoholism and I become an alcoholic and I recover that is very very good because that's an adaptation nature loves adaptations and so I tried to impress this on the patients in our treatment center is that they're often you know coming to us at bad moments in their life they feel terrible they feel physically terrible and they also feel very ashamed and there very worried that they've passed on their addiction to their children right and I've seen a lot of parents and tears you know is there nothing I can do is my son going to become an alcoholic just like me and I tell them listen there's nothing I can do about your genetics there's nothing I can do about the fact that your child saw you drunk but here's something else your child will see your child will see you get sober and everything that you do every tool that you learned every day of sobriety that you put on top of the next that benefit goes to your child - and when they go out into the world they don't just go with those terrible awful alcoholic genes they also go with your recovery and that provides some protection right if I had a magic wand and I could give one family one thing to protect them in this time of you know this opioid overdose epidemic it would be a family member in recovery I just came back from Australia New Zealand a few months ago and I was doing a lecture for Air New Zealand and Qantas airlines and they're trying to you know boost up their own hems program which is very good and they were saying it was quite moving to watch the pilots say this we know that we have pilots and recovery in our company if we only knew who they were because they would be such an asset to us we could have you know one of our pilots who was struggling call that person right so I never want to close the door on the idea that even though we were thrown into the world with these terrible genetics we can adapt to them we can we can acquire resilience ease that make up for any genetic vulnerabilities that we may have had every recovering person in every community is a resilience factor for that community okay so we've talked about what goes on at the level of genetics now we'll go up to my favorite area which is the level of reward whenever I have a pleasurable experience let's say the young of grandmas amazing chocolate cake all right the very first thing that happens in my brain at the core of that pleasurable experience is the release along this pathway of nerves right here it goes from the VTA the ventral tegmental area deep in the midbrain the cell bodies there send their axons up to a part of the dorsal striatum called the nucleus accumbens now when you hear those terms if you're ever reading a New York Times article on you'll know what they are that pathway is the first pathway that's active and those neurons release the first chemical of a pleasurable experience and that is dopamine right dopamine is not the only chemical that we're gonna talk about but it's the first it's what begins what we now call the hedonic cascade all the different chemicals that the brain uses to create that yum of grandma's amazing chocolate cake at the core of it is dopamine what does dopamine do is it the love chemicals that the player chemical no that's that's very inaccurate what dopamine does is it tells me when I have come across something that is salient noticeable important for survival it gets my attention it's zeroes me and it tells me this is important to pay attention to it alright the other thing that dopamine does is it tells me if I ever come across something that is better than I had expected it would be okay so this is I think a very fascinating concept my choice making depends upon my brain's ability to accurately predict the future and so if I think something's going to be pretty good right so let's say I'm standing at a vending machine and I want to buy a let's say I'm a pot addict I want to buy a bag of Funyuns right no one can figure out the connection between Funyuns and pot it's just one of the things we'll just have to accept all right and so I put in $1.00 right Funyuns cost $1 and due to a freak of vending machine physics I get two bags of Funyuns this is when the brain releases dopamine all right it's a reward but it's better than expected in the brain says hey look at this we were expecting one we got to we got to now pay attention to this this might be really important for survival put this a little higher on the survival priority list that's what dopamine does it allows us to recognize things that are good for survival learn them and then predict them and the deficit and dopamine creates a problem in my brain where I over value future drug related rewards and overestimate the probability that they work out as intended and undervalue any consequences that will result and under estimate the probability of those consequences coming true that's how human choice fails in many diseases but in addiction right so think about that person who's in treatment suffering with craving and they want to leave they know they shouldn't they know they're in big trouble if they do but can you see what's actually happening in their brain they're not seeing what you and I are the areas of the brain that essentially say this is going to be great and it's completely going to work out they are winning over the areas of the brain that say hey no no remember what happened last time we don't want to do this it's not going to work out right okay what all drugs of abuse do is they affect the dopamine system negatively all right in high doses and in fast-acting doses so what all drugs do is they create surges of dopamine in this area of the brain along that pathway and what intoxicants specifically do is they cause spikes of dopamine right so again let me restate that the what normal pleasures do going for a walk on the beach having dessert at your favorite restaurant on your birthday is create normal releases of dopamine what drugs do is they cause these spikes and so every time a person smokes crystal meth or binge drinks or injects heroin they're getting that surge of dopamine and they're essentially getting a signal that says hold the phone man this is way better than expected even though the drug is not better than expected this is really good for survival even though the drug is actually quite harmful right this is better than other things for survival right and what all drugs of abuse do is this this is sort of the central concept of addiction neuroscience that all intoxicants released open the uppers down or strong weak doesn't seem to matter okay and so this is I think the one merciful thing that nature gave us was this rather elegant hypothesis experience to be true that if I am addicted to one I have a risk of becoming addicted to any or all the others right so if I'm a cocaine or methamphetamine addict right and I wanted to get sober by switching over to a marijuana maintenance program that might work for a little while but because the same thing is happening in my brain it's very very likely that after a while I will relapse back to my drug of choice I don't know how many you know people come to me and they want to switch from alcohol to pot you can see that the the the issue there okay if I continue I if I'm in treatment for one of the others and I continue to drink I've still got the same problem what I think is powerful about this theory is that it doesn't just explain what we're seeing it doesn't just predict what we will see it can expose errors that were making today in addiction treatment and I believe those errors surround center around the issue of nicotine right I was told in treatment not to make any big changes for the first year I think that's why is it an advice but that advice is sort of morphed into don't try to quit smoking in the first year of treatment it's too hard you're gonna crave more right you're gonna relapse and when all the research shows us is that that is not true is that people who continue to smoke after treatment report worse cravings they are more likely to relapse people who quit smoking in their first year after treatment are more likely to be sober from their primary drug nine years later so this is something that's causing a bit of a crisis of conscience in the addiction treatment industry what is our duty to patients who come to us with a serious methamphetamin alcohol or heroin problem not a smoker and leave us with that methamphetamine heroin or heroin alcohol program problem in hand but have initiated smoking on our premises you can make the argument that we might have made things worse because I can tell you right now the drug that is most likely to kill any patient in any treatment center in the United States today is not heroin its nicotine it's down the road yes but it's an important I think ethical question to ask ourselves and this is what the dopamine hypothesis gives us they all do the same thing and it's not just chemicals that do this behaviors can too and so what the dopamine hypothesis allowed us to do is to take five steps back and look at the entirety of the problem right they all essentially do the same thing and this is why you can have cross diction this is why you can have people moving from one to the other right so they all make an impact on that pathway from the VTA to the NA they increase dopamine and where we see the problem is not really in the dopamine itself it's in the receptors for dopamine once the spikes have dopamine occur the brain takes away those receptors okay specifically it takes away a population called the dopamine d2 receptor right and it's the number of dopamine d2 receptors that I have that can predict how well my frontal cortex is functioning all right so this is nora volkoff's work at the National Institute of drug abuse she was able to find that there was a paucity of dopamine d2 receptors in people who were using or newly sober from drugs relative to normal people now when people get sober did they go back to normal I think many do but it's possible that it doesn't quite come all the way back right and this is what I see when I go to an AAA meeting I see people who are long sober they're doing well but they know that at least socially something's not quite right and they're using the power of the group and shared values to cope to adapt to that right because it's the number of dopamine receptors that really can affect how well my frontal cortex is working I was trying to find a way to make this part electrical a little faster you know talk about cross addiction and one day I was looking at that thing remember that thing from high school chemistry the periodic table of the elements I came up with a periodic table of the intoxicants right so there they all are these are all the intoxicants that you're likely to see in the United States arranged according to class they all do the same thing they all release dopamine the bottom there you would see what we call the process addictions now for a long time there wasn't really good evidence that the behavioral addictions release dopamine the same way the chemicals do but now we have evidence that in the case of pathological gambling right exactly the same thing is going on in the brain when a person uses alcohol or cocaine in fact some of the medications that work on alcoholism also work on pathological gambling right the the green ones there are the opiates and opioids those are the classic narcotic pain relievers and as you go from left to right they get you know either stronger or more likely to be abused the prototypical opioid is the M morphine that's the one we measure all the others by all right there are drugs that are super opiates drugs like fentanyl fentanyl is 100 times the potency of morphine it's the FE there at the end on the right side of that green stripe I never ever ever thought that I would apply this information to human beings but the drug on the end there is called car fentanyl it's not used in human medicine it's used as a essentially a large animal tranquilizer think elephant right it is ten thousand times the potency of morphine and the DEA has reported seizures that contain of opioids that contained car fentanyl and they're making the case in their bulletins to law enforcement to really to the whole world that merely to be in this stuff's presence is dangerous right so the sudden appearance of fentanyl and car fentanyl manufactured in clandestine labs either in the United States or abroad is a particularly chilling twist to this opioid epidemic and hopefully we won't you know we'll get some handle on that so in the first film I really wanted to make the case that we need to pay it we all need to pay attention to that surge of dopamine right I need to pay attention to that surge of dopamine because as much as I have in toxic winces in my life even if they're not you know chemicals right like the old ones I've still got a problem and it's very easy for me to stand up here and be high-handed about cigarettes because I don't smoke but I have a lot of sympathy for my brothers and sisters in recovery who do smoke because I have a problem that is just as bad and just as dangerous with this and I'm telling you the problem is bad I miss driving up and down you have no 7-elevens here there's no way you can get a Slurpee in this town this is terrible I needed to know that before I went to bed right hey man I have struggled with this my entire life I have periods of success I relapse but I know that using sugar the way I do is not good for me it puts my sobriety at risk and I know that if I don't get a handle on it I will eventually die from my addiction I'll die from the of my overuse of sugar this is what life is like with too few dopamine receptors we struggle with these things sometimes for the rest of our lives okay so strategies to deal with this part of addiction we'd become cognizant of that try to take out the spikes and I think this is important put normal pleasures back into the picture okay so we've talked about dopamine okay we know that one of the causes of relapse is being exposed to drugs again right and that's mediated by dopamine but also being exposed to anything that causes dopamine spikes the other thing that causes relapse is being exposed to things that went along with drugs at the time of use people places times of day even now we're in the memory and learning part of the brain that explains addiction all right now we're in areas of the brain that are just kind of up a little bit and over and we're talking about the chemical glutamate which comes right behind dopamine and what glutamate does is it helps us to remember whatever released the dopamine so if I'm having a normal pleasure I release dopamine then I have a normal release of glutamate and glutamate just puts that into memory this is the way the reward learning system works in the brain but unfortunately with drugs the release of dopamine is so great that it creates an equally great response from the glutamate system and that response doesn't just create a drug memory it burns the drug into memory it creates a drug hyper memory and everything that went along with the drug at the time of use the people I was with the sights and smells at the moment the time of day they become part of that memory and they can now serve as drug cues and so even maybe many months through or even years after I've stopped using drugs if I should be exposed to that person or that place at that time of day in such a way these can cause triggers to relapse right so a lot of this work was done by Peter clevis at the Medical University of South Carolina one of the authors of the books that says that addiction is a learning disorder says that until people can point out the difference between learning like you learn the alphabet and learning like you learn you know drugs then it's impossible to say that addictions of disease well dr. Cole Edith did that a long time ago I think that that was a foolish statement to make and where we see we can actually see these these hyper memories being formed and essentially what's left over is all the sort of products of making these these these neural connections too strongly one of them is this transcription factor Delta phos B so there's plenty of evidence here that there's an over learning of drugs going on here and that's a pathology of learning it's not normal learning so we really have two systems we have the normal dopamine system going up which tells us to do things but in addiction its weight working way too hard these are very very strong impulses to use normally the glutamate system would come back down and it would have veto power over the dopamine system when it's working well it actually wins the day so if the dopamine says system says hey let's do this the glutamate system can come back down and saying no I don't think I want to do that we don't we don't want to do that what happens in addiction is that go is way too strong and the counterbalancing signal from glutamate is not strong enough there's too much go and not enough not go and so we have this weird this combination this fatal combination of behavioral impulsivity whatever thought comes into my head caused me to do something and a failure of behavioral inhibition parts of my brain that's saying no don't do that think about it they fail and this is why you can have these very powerful very reflexive and not entirely conscious relapses to drug use this is also why it's very very difficult for people who have completed treatment or are trying to stay sober to go back to the same environment in which they used to use drugs these cues are just too powerful that it's just too risky this is why I've always believed that the availability of sober housing is extremely important for people in recovery if I again had a magic wand and I could give one thing to every community that would increase that community's resilience to this terrible opioid epidemic it would be the easy availability of safe sober housing that's where you want to put your money okay because there's a lot of benefits that can come from that all right so strategies to use for the glutamate component of this it's tough because we're not always conscious of those triggers but there are things that can work I think this is where cognitive behavioral therapy works there are medications that are increasingly available that can help with these memories they just take the edge off of them a little bit and if everything else fails you can actually block at least in the case of opioids you can block that person from using with an opioid blocker okay the third thing that is known to cause relapse is exposure to stress it was noticed that in stressed laboratory animals if they were reexpose to cocaine after a period of absence they relapsed much faster okay the more they started to study the nature of stress induced relapse the more it became clear that this is really the cause of the whole thing so now we're in the stress system the normal stress system and in a stress response one area the brain releases this hormone CRH that signals another area of the brain to signal the adrenal glands to release a whole bunch of chemicals that go out over the body and rev it up to get ready to deal with stress right and then when the stress is dealt with the system feeds back on itself the whole thing shuts down that's the way it's supposed to work but sadly there are some environments where people cannot get away from the stress they're in situations of intimate partner violence they're in situations of danger and those folks their stress system never really gets a chance to go back in the box or people who are chronically intoxicated they're intoxicated all the time the system is constantly over driven the stress system is and so you just have this continuous spitting out of CRF and CRH they're really the terms can be used interchangeably and what happens is that chronic severe stress and those high levels of CRF or CRH caused a down regulation and dopamine d2 receptor so we're right back in the same situation that we were when we were having active drug use or making it even worse and what the patient feels is those receptors go away is an inability to feel normal pleasure from normally pleasurable things they become a little pleasure death right so if they can't hear normal pleasures like you know going for a walk on the beach or having dessert with your friends on your birthday what can they hear anything that shouts Bree notices that it says wow that's it that worked that pushed back against the stress system and increasingly the drug becomes the main way that the person copes with all stress big stress little stress doesn't matter so stress strategies to deal with this part of addiction can be as basic as the provision of safe housing right becoming a better stress manager and this is what I think a lot of people in 12-step meetings do they put these little silly rituals that bring the stress system down right and the peers that you're around can be a big part of how a person becomes more and more resilient to stress it's not about avoiding stress it's about getting better at handling it right so we're coming to the end here now the brain knows what it needs to secure survival it's got to find a way to motivate the individual to get that and it has a very cruel tool at its disposal and that tool is called craving craving is extremely difficult to explain to people who've never experienced it if you don't know what I'm talking about good I wouldn't wish this on my worst enemy lots of people have tried to capture craving in words they've tried they failed it's very hard very important to understand that craving is not the experience that most people use when they say they crave chocolate what most people mean is gee I really like chocolate and I I wish I had some chocolate when an addict uses the word craving they are up in the middle of the night they can't sleep their pulses at 120 they're staring at the ceiling thinking over and over and over again just one more time just one more time I want to feel the burn of that alcohol as it goes down my throat just one more time I want to feel the heat of that glass pipe against my lips just one more time I want to see the swirl of blood in that syringe what William Burroughs called the beautiful rose just before I push down the plunger and every cell in my body says thank you that's great and make no mistake that is genuine suffering if I go into a detox and I do that stupid little soliloquy the needle addicts will fall out of their chairs and if you don't know what I'm talking about good good because it is a form of suffering that I think is is very very difficult to capture right and I believe that it's the presence of craving that ultimately defeats most choice arguments what I call the argument against the idea that addictions of disease the adherence of the choice argument make a very good point addicts are not powerless they can quit anytime they want right they can get sober for a court appearance if you put a bottle of alcohol in front of an alcoholic and a gun to their head they can choose not to drink yes that's true if you want to do that if you can do that you want to put that consequence to that immediate and the drug in front of them yes they can say okay I'm not gonna use drugs right but they can't choose not to crave see the choice argument believes that the narrative going through my head is oh I don't want to get shot in the head or go back to jail or whatever so I won't use drugs no that is not the narrative in my head I assure you what's going through my head sounds more like this I wonder if he'll really shoot me I don't even think he's got bullets in that gun his finger might slip off the trigger the bullet co make PO past my head I wonder if I can get this dragon for my brain before the bullet comes crashing through my skull that's not normal that's pathology that's suffering that's disease so once the drug has been tagged with survival you don't actually have to have drug use anymore you don't have to have the behavior for the person to be suffering with craving and we can actually see this happening now we're in the frontal cortex now we're in the choice system we can scan people what do we see we've shown pictures of people using drugs and then we scan them when they say that they're craving the orbital frontal cortex is one of the areas of the brain that changes that part of the brain that's so important in value it fails and all of a sudden value is completely upended in the service of the drug even the things that the person cares about they cannot in this moment hold a candle to what the drug can do right the anterior cingulate cortex the part of the brain that's so important in helping me gauge my social behavior and act appropriately socially care about the people that I that are around them that I do care about right show them that it fails and I enter a brain state where my thinking is extremely rigid very inflexible I cannot take the opinions of other people into account it's got to be my way that's it this is what we sometimes called the acquired narcissism of a craving state it's sort of a tongue-in-cheek State acquired narcissism narcissistic personality disorder is not acquired its genetic so when we say that we're sort of saying well here's narcissism but it's sort of temporary right version comes into it but they can also come out of it this is another area of confusion is that a person can lose this capacity for choice and self insight but it's variable sometimes it's on sometimes it's off and when it's off it's not good right the areas of the brain that help us decide what is the right thing to do what happened last time what's likely to happen they fail and addicts enter this brain state where they're making quick very risky poorly thought-out decisions everything is a crisis they're essentially going from fun thing to fun thing because they say they're bored I don't believe it's boredom we're using that word I think there's a much stronger dysphoria component to that boredom right they their feelings are way out of proportion to the insult that they might be facing in fact they might not even be able to name the feeling that they're facing they might have what we call alexithymia am i sad am i hungry I can't tell right they're very good at getting jobs they're terrible at keeping jobs right and this is what we deal with in the field of addiction medicine and this is the patient that most people run to the hills' when they see we can stay with these patients we can talk to them we know how we can preserve their dignity until the time that they can get the tools of recovery and this goes away and I think that that's what makes a diction treatment those who work in it and I invite you to consider a career in this field I think it's what makes this a very noble profession in a very dark time in our history strategies to turn the frontal cortex back on they are essentially the features of recovery management housing the opportunity to go back to school drug testing going to mutual support groups having health care having a doctor or nurse practitioner or a physician's assistant who understands the needs of patients in recovery having also a recovery coach or a recovery advocate these are all very very important things when people get them and we know this from the pilots and the doctors and the nurses and all those other folks and the college students they do great so we found ourselves back now at the ACM definition right the way we explain the symptoms of addiction is either with the ACM definition or with the dsm-5 which is the standard diagnostic Bible in psychiatry and we used to believe that there was something called a halt abuse or drug abuse and alcohol dependence or drug dependence we've gotten away from that either or to more of a spectrum diagnosis right and people can vary in their severity okay but when they're over on the severe side this is you know what we call true addiction the more severe version of substance use disorder and the symptoms that you can expect to see are symptoms when the brains valuation process goes awry they cannot fulfill their obligations they use larger amounts of drug over longer periods of time than intended anyone who tells me that they can save cocaine is ruling out all right oh yeah I had an 8-ball and I used a little and I put it aside yet no sorry that's not what I'm talking about here right this person has physical psychological problems but that doesn't change their use because the drug has so much value and the things that they used to love they give up because the drug those things compete with their use of the drug the problems the brain of learning in the brain people cannot reliably cut down or curtail their use more and more of their days taking up getting using and then recovering from the drug and then the symptoms of the frontal cortex failure in cognition emotional processing and decision making and the one that I think is is particularly devastating and the suffering is craving alright so that's essentially why we can consider addiction a disease a disease is a defect in a certain area of the brain that we can lead then we can associate with symptoms we now have the ability to do that to finish up I'd like to suggest that we might be missing another area of the brain that's active here when a person gets into recovery and that is the brain makes meaning the brain finds purpose and if we put that in there and we're starting to learn more about how the brain does this and how these things apply to recovery then I think that we can take into account why spiritual things have purchased against addiction in the way that medications alone may never and so if you think about the things that people really find meaningful in their recovery not all of them are entirely rational but they're very deeply held does anyone have any questions at this point I invite you to go to the to the microphone well I tell you what you can always contact me if you would like any of journal articles that I use to write this this lecture if you would like the slides I'd be more than happy to send those to you as well I can't really see does someone have it Chris okay I saw I thought I saw a couple hands go up yes sir thank you fantastic uh-huh couple questions yes sir that just kind of hit me as two went through one was if all drugs release dopamine why is it that I why is it that addicts have a drug of choice for instance right you know someone might be a cocaine addict yeah yeah they can't drink well some people have bad taste what can I say no I don't I don't mean to be flippant good yeah the the theory is and this is this is a theory that actually came from a particular gentleman a genius of psychoanalysis at Harbor by the name of Edward cancion and this is a self-medication hypothesis that the reason that people gravitate towards alcohol is that they're trying to self-medicate some anxiety disorder or some terrible traumatic memory that they're trying to get away from right the people that move to opioids very often they have this unique and very painful sensitivity to emotional pain in others or or things like that have happened to them people who move to cocaine or methamphetamine they often have problems with anger and trying to live from from abuse the problem with the self medication hypothesis even though it makes a lot of sense it's very intuitively appealing is that it doesn't really bear itself out it's when people who have bipolar disorder are not in mania that they tend to use drugs you know so when people are not necessarily expressing their symptoms that's when they can you know relapse so the self medication hypotheses I think carries a lot of weight makes a lot of sense but it's not a perfect explanation it could be that that's the drug that was available at that time in that person's world and I would say that the reason that we're seeing so many opioid addicts is not necessarily because everybody discovered opioids it's that the entire population of the United States was suddenly exposed to much much more potent opioids than even existed when I was in medical school does that help yes and one last thing I was really impressed and happy that you put number six on there meaning and purpose oh yes right very end Victor Frankel's man's search for meaning that I've read dozens of dozens of self-help books yeah that particular book transformed my life I think you know logo therapy would be my example I had a picture of Franco up there but I didn't have the rights to it so I took it down by couldn't agree with you more it's the ability to find meaning and purpose and then use the experience that we've gone through to help others to make them feel less ashamed that I think really solidifies that recovery and we have to look at that you're absolutely right thank you very much very much for coming yeah yes ma'am I have a question about what insight what advice you can give to us about having empathy for the drug addict because those of us who have dealt with drug addicts when people are drug addicts they are very unpleasant people and so how do we take that and try to deal people in active addiction who are in our lives how can respond in an empathetic manner a manner when at the same time we really really don't like those people right if we have very good reasons not to like them you absolutely do and this is a question that I think deserves a lot more consideration especially when it comes to treatment the families simply are not taken care of enough the the PTSD that families fall into when they're trying to live trying to help a person with addiction is as bad as any combat PTSD and that has to be addressed our behavior is not good it might not be that our nature our character but we still cause harm to those that we love and I think the the best existing to do would be to try to find either a parents group or a support group for people who are dealing with this there's there's always Alan on right I think there's a lot of you know at least feeling that I'm not in this alone in those groups and also saying hey I don't have to be drawn into the chaos of my loved ones drug use this is perfectly healthy to set boundaries and to be able to say you know what I love you I support your recovery but you can't live here and no I'm not going to give you any more money that's very hard to do very hard for any parent to do right but this is essentially one of the things that can get people sober at our treatment center in Utah we had a lot of AMAs against medical advice discharges people leading treatment right and I was hired to kind of analyze this and figure out okay why are all these people leaving and I found out that people were leaving in that instance really for three reasons one is they were suffering they were craving terribly and they wanted to leave but they had the means to leave they had a car they had a credit card or something like that the second one was they conspired with one of the other patients right and it was usually a local male saying to a you know out-of-state female hey I can get you heroin today and don't they were gone right the third one was they called their parents and said come get me and they did all right so so parental assisted I am a discharge was a large part of our problem I think about that parent I think about what my mother went through what I put my mother through and I really have a lot of empathy for for what she I can see it now you know I couldn't then right we tend to torture our parents especially male addicts we torture our mothers I'm sorry for that you're probably not going to get an apology from your son so let me apologize for him all right this is one of the things that we do and I think of that parent who facilitated the discharge and I realize how much they must be suffering how terrorized they are by the insistence of their loved one and those folks will need a lot of help they're gonna need a lot of support in fact I was just talking to someone who called me friend of my mother's this is one of the ways that I pay my mother back is that the other die mother's a physician and the other doctors that she works with I you know they are welcome to call me at any time if they ever god forbid should have this problem and the the husband was saying what should we do we don't know what has a family to do for my wife you know their mother and I said the first thing you need to do is you need to take care of yourself you need to get someone on your side you need to get a support group or a therapist or someone like that because this is going to be very very difficult and you have the right not to be terrorized by this disease and and then hopefully in the future that person will get sober and then they can come back and say you know what I am really sorry I didn't realize those are doing that and let me make amends and that's a large part I think of what really gets people into yes sir I was wondering about genes and vulnerability to you is it fact or a theory the reason why I'm asking is because to me it's more of a theory rather than a fact Donald Laura forty-eight there was a state that had a high degree of Indians had were in the program well they took up my majority of the program so after they were tested it was discovered that they had diabetes rather than alcoholism really and there was a book written about it it's called wrong diagnosis and wrong treatment so that's why I was wondering I I have another question but I sure wanted to know what you think about that yeah it's a you know just today there was a story on NPR about the fact that the typical tests that we give to measure how well a diabetic is managing their glich blood sugar I what's called an hemoglobin a1c is it has has essentially been standardized to white people and it hasn't been standardized to people of color and so the test is not valid in a lot of those patients it can't pick up people on there and I think that this is one of the things that gives should give us great humility is that most of all the research that we've done for medications for for things that might be good for addiction even the way the brain responds to drugs itself has been done on white males and we may have a very very different pattern of symptoms a different presentation maybe even a different disease depending on different things that people are born in to face culturally and I think we have to be much much more sensitive to that but yeah it may take a lot a little while for medicine to pick up on that it's not being done at the level of research I would like to read that book that's very interesting yeah my second question is almost like the first I was wondering what your opinion is on the theory of allergy right that alcoholism is an allergy yeah rather than a disease I mean it leans more towards the characteristics of allergy rather than anything else sure sure well I understand the the culture of recovery that's defined by 12 steps in perfectly but the way it's been explained to me is that when William circle Werth wrote the doctors opinion which is the front piece the the the cornerstone of a a is a statement by Bill Wilson's doctor that this may be were not sure but we kind of think it's a disease and he said it resembles an allergy right when he made when he made that statement the the pride the predominant theory about alcoholism at the time was that it was caused by an alcoholic personality that was due to certain personality characteristics and what was important about his statement as he said no it might be much more of a physical not necessarily characterological problem and so I think his metaphor is very good now an allergy we know today is an inappropriate reaction of the body's immune system to a foreign entity that's not quite what was going on in and and it's not quite what's going on in addiction but the metaphor is so apt I respond differently to these medications that's one of the reasons why I wanted to put this you know periodic table have a glad to send one of these too if you if you just email me I wanted people to really realize we seem to react differently if you want to call them analogy I think that that's a very good working definition it's not technically correct but who cares right I respond differently and so I'm gonna need to know that if as I get into my later years I should get cancer I'm going to need a doctor who understands how to manage pain in a recovering person safely without triggering relapse and that's again to your other question we don't really have that the way we should in that's why it would be good for every person in recovery to eventually be able to see a primary care physician who is also trained in the special needs of recovering people because they're not going to do something dumb like give me a prescription for ambien if I'm if I'm having a problem with insomnia let's say they'll walk me the long way around I hope that answer your question thank you yes thank you listen again thank you very much for having me to your community and I wish you all the best take care dr. Kevin McCauley spoke about the brain and recovery an update on the neuroscience of addiction this program was produced by 360 North with support from n Kat Juneau the Juneau Community Foundation the Alaska Department of Behavioral Health and the Juneau re-entry coalition it was recorded February 7th 2017 at 360 in Juneau

Channel: KTOO 360TV

Views: 106,236

Rating: 4.8272982 out of 5

Keywords: NCADD00H, Dr Kevin McCauley, recovery, addiction, opiods, alcohol, aa, al-anon

Id: zYphZvRHm6Y

Length: 79min 12sec (4752 seconds)

Published: Fri May 04 2018