Addiction and the Neuroscience of the Brain, Part 2

JOE LUNIEVICZ: Welcome, everybody Good afternoon

Welcome to the Neuroscience of Addiction, Part 2, the second of a three-part series running each Thursday through next week in September, September 27 Next week is the last of the pieces that we've got And my name is Joe Lunievicz I'm the director of the Training institute at NDRI, and I'll be your presenter today So I want a special– to put out a special note of appreciation to Clyde Frederick, our webinar organizer and administrative technologist who is keeping the webinar running smoothly from a technological perspective

So today, I'll be talking to you about how the disease of drug addiction plays out throughout the different stages of recovery, focusing on specifically the early stages of recovery when you'll be working mostly with our drug court participants Just a reminder– this webinar is brought to you by the Bureau of Justice Administration, BJA, Drug Courts Technical Assistance Project at American University over in Washington, DC, in collaboration with us here at NDRI, or the National Development Research Institutes So let's take a look at some webinar logistics For those who have never been on a webinar before For those of you who have seen this before, just hang in there, and we'll get through them relatively quickly

What we've got– hold on one second There we go There we go Here's our webinar logistics So four tools– three tools that we have in one help spot for technical difficulties

The first thing you need to know is on the right hand corner is your control panel, and you can see that right here And you can access the control panel by using that orange arrow right there Click it once, and it'll disappear Click it again It'll open up for you

When I ask you questions, or I say, please text in an answer, this is what you'll go to If I ask you to raise your electronic hand, this is where you'll go to also You've also got the ability to ask questions and/or to answer questions that I have for you So you can see right here, at the question box, you'll simply type in your response or your question, and then click right here on the Send button It'll come right into me, and they'll get lined up in a queue

And I'll take them as soon as I can And I'll let you know when I'm answering or when I'm giving your responses So that's questions There's also the ability to raise your electronic hand I just love that term

There's something about it which– just I don't know– electronic hand-raising So you can see where it is Do me a favor right now, and everybody find that electronic hand, and click it just so I know that you're here, that you've heard this, since I have no physical audience onsite I do have an electronic one I see hands going up across the board

Everybody's able to find it Some of you are not raising your hands Just go on over there, and raise your hands Excellent Looks like I got most everybody

It even gives me a percentage of hand raises That's really cool too I've got lots of numbers in front of me on my screen All right So let's take the hands all down

Terrific Thank you So that's hand-raising, raising your electronic hand In case I ask that, that's how you do that And then last but not least, if there are technical difficulties of some sort, you can call 800-263-6317

That gets you in touch with the Citrix folks who do the software, GoToWebinar So they'll help you if there's audio problems or some screen problems, and they'll help you figure it out right away, so you can get back online with me All right So with that then, let's go to a little bit of information about me I'm the the director of the Training Institute at National Development Research Institutes

I've got over 20 years experience in drug treatment work, not only as a provider, but also, of course, as a trainer of providers, and most specifically, in the last decade or so a drug court staff developer and in areas of drug treatment and in the disease model So let's take a look, then, at what we're going to cover today What we'll cover in part two is we're going to really take a look at disease model within kind of the larger context of what is called the bio-psycho-social, and then we add in these days a spiritual model We're going to take what we learned about neuroscience and the damage that's been done to the brain through the process of drug addiction and see how it will present itself throughout the different stages of recovery And we'll talk about what's called the developmental model of recovery as a way to see these stages of recovery, just as we kind of talked about stages of illness in Part 1

And of course, how this impacts on drug court and your work with drug court participants and how you can then take this information and apply it directly– we'll see if we can do all that in our hour together So also, before I forget, at the end of the webinar, there will be an opportunity to fill out an evaluation Please make sure when the webinar voice says the webinar is over, it will pop up on your screen Please take a few moments Fill it out

It will take you only a couple of minutes, and then send it back into us, so we can collect evaluation information about your experience with this webinar also So a review from last time– neuroscience supports that addiction is a brain disease We're not going to rehash that information too much, but I do want us just to keep this in mind And it's so important I think we should all actually say it together

Let's all say this together Addiction is a brain disease All right, one more time, together Addiction is a brain disease Now one time on your own

Pretend I can hear you If you're not laughing or chuckling, I'm not sure what else I can do All right So keep that in mind Addiction, brain disease– but it has or that needs to be seen in biological, sociological, psychological components

So all throughout today, we're going to try to see how biologically, psychosocially, and spiritually, how the disease then can be treated from different perspectives So let's just remind ourselves, then, of these key elements, that there is the pathway of understanding addictive effects on drugs in the brain and behavior It all takes place for most of the drugs that our folks use right here in what's called the reward pathway– reward pathway– where the neurotransmitter dopamine, in particular, is synthesized, sent on its pathway to the prefrontal cortex, where pleasure and other kinds of feelings, but especially the feeling of pleasure, occurs Now, the neurotransmitted dopamine also modulates the functioning of this area, the prefrontal cortex And again, as a reminder, what's so important about the prefrontal cortex is that it's sometimes called the executive suite of our brain in that it helps us to make decisions, helps us with concentration, focus

It allows us the ability to say things in our minds at least On second thought, maybe I ought not to do that So this "on second thought" thinking process, the ability to stop ourselves from maybe even impulsive behavior is what a fully matured and functioning prefrontal cortex can do for us The problem, of course, that occurs in addiction and chemical dependency is that this reward pathway gets damaged So it impairs the capability of individuals over time to feel, to have feelings, especially reward feelings

It impairs decision-making, concentration, focus, and the ability to stop impulsive behavior [INAUDIBLE] so this is what we call mitigating circumstances in our drug court participants So this is what we're talking about again is addiction Remember, there is use, abuse, addiction There's this whole spectrum of illness, and addiction, chemical dependency, when someone is chemically dependent, that's when this process is at its harshest and when we really have to think in terms of how we're going to deal with the brain disease

So to the right here, these PET scans, so it's just to get a sense of what it looks like again On the right side here is damage to the prefrontal cortex Your drug users have far less dopamine activity, which is what we're talking about right here So it's a nice visual to see what we mean PET scans, again, our Positron Emission Tomography, kind of like MRIs in the sense that they give us scans of what's going on in the brain from a neurotransmitter perspective

So the question for us, then, is and how we're going to have to deal with treatment is we need to know, is this damage permanent? Can treatment do something about the damage that occurs during dependency when this has occurred? And so of course, the answer is simple and not simple The answer is no and yes No, yes, yes, no– kind of both Is the damage permanent? Sometimes it is But even when damage is permanent, when the ability to synthesize more dopamine or the ability to have receptors that are fully functioning or to have enough of them, other pathways in the brain can compensate for damaged pathways that can't be repaired

The problem is, of course, it may not be as good It may not help you to function as quickly or in quite the same way So this is all part of this process of, what do we mean by treatment? So there is increasing evidence of brain recovery Yes, and you can see that with some scans in the next slide But remember, some drugs like, for example, long-term heavy alcohol use– for that matter, long-term methamphetamine use does result in some permanent damage to the central nervous system of the brain to this reward pathway in particular

Time frames for recovering areas that have been damaged can be sometimes six months to several years Depending upon, of course, the drug itself, the type of damage it does, the amount of usage, any genetic vulnerability in an individual who already has to substance dependency, and, of course, the environment that they're in, because all kinds of external stimuli also influence behavior and the ability for folks to take actions So much can be restored You can also find new pathways The problem may be that they may not be as effective as the original pathways

And this can be done This treatment can be done biologically, psychologically, socially, and/or spiritually So just remember, when we say, not just biologically, but psychologically, socially, the majority of treatments that are out there that are evidence-based practices, for example, through NIDA, are psychosocial treatments That influence, of course, are brought to us through what we see, hear, say, do, even experience So you remember things like trauma of violence, abuse, love, friendship, hanging out with people, hanging out in a bar– all these experiences are going to impact on a person's ability to recover, to recover damage to these pathways in the brain and, more specifically, to their reward pathway

But we can recircuit them We can find new pathways, even if they are damaged So what this looks like– oh, before I forget this last point, fundamental neurochemical imbalances that were there before the addiction may still need attention So what does that mean? Just a kind of reminder that if someone has a genetic vulnerability that is severe to substance use, and they have difficulty processing or creating or working with or modulating through the use of specific neurotransmitters, that they are deficient in serotonin or dopamine or something like that or have too much of it, this may still need to be addressed in some way, shape, or form and maybe even biologically with treatment for the rest of somebody's life it really depends on all of these bio-psycho-social factors But keep that in mind

Some imbalances may not be able to be completely re or balanced out without outside intervention So why is continued or long-term treatment critical? So remember, to the left here, you've got a normal brain, and the red is the most number of dopamine transporters Then it's yellow, and then green And that's the normal functioning brain And then you see a meth user, for example, one month abstinent

You can see how it's significantly reduced This is reduced ability to feel, reduced ability to be able to focus, concentrate, be able to modulate and utilize those prefrontal cortex functions And then you can see even 36 months later, so 36 months later, you've got– a lot of it's repaired, but notice how it looks different Somebody said, sometimes you can't have the actual pathway repaired, and you need different pathways to compensate for them You can see how that, in a very visual way, occurs right here at 36 months

So even at 36 months, some things are different They may not be exactly the same So just think about how that's going to be for a drug court participant in trying to figure out what this means for them, how this is different It doesn't feel the same way How am I going to cope or deal with that? So this all points, then, to this idea of a disease model of chemical dependency

Remember, it's a disease of the brain It's a chronic condition that requires lifelong management You may compare it to illnesses like type 2 diabetes, chronic hypertensive disease, asthma, or obesity, all of the above of which have a complex of physiological and behavioral health components, all of which also have no one treatment episode that will completely resolve illness so that a course of dependency is usually multiple episodes of treatment, various recovery activities, relapse periods– small, short, long– and then back to recovery activities So we're looking for periods of stabilization over time So if we look at this, then, and start breaking it down into the bio-psycho-social-spiritual model, last time, we talked about some of the reasons for starting drug use

And I'm just going to take what you guys had written or sent in last week, and break them down into and bio, psycho, and social, and spiritual areas So for example, reasons for starting drug use– biologically increased energy, staying awake, weight loss, to relax, to sleep Psychologically, we've got to feel better, to medicate feelings, to escape from bad feelings, to escape from trauma that's occurred, increased self-confidence even, to medicate for mental illness that may have occurred, social reasons We had talked about having fun, peer pressure Family– that's using a culture that uses in order to lessen inhibitions– for example, even to meet somebody

And then spiritually, we've got to feel more connected to a higher power, if that's part of where someone is at or were to have what we call a spiritual sense of self So those are reasons for starting drug use Reasons for continued drug use over time– of course, you talked about from the perspective of dependency, including the drug itself and genetics, which would all fall probably within the biological circle So different drugs have different chances or risks of dependency over time, some more than others So for example, nicotine, heroin, crack cocaine, and alcohol are like the big four or five that have the highest risk with no other factors considered

Then there's the idea of genetic vulnerability, the idea that you have a family history so that genes may be abnormal There may be problems with neurotransmitter modulation or synthesizing so that you're more vulnerable, if you use substances over time And then, of course, the environment, which takes care of our psychosocial and spiritual areas like the community, peers, family, school, work So let's take a look, then, at one last area I'm going to get you guys involved– around treatment approaches, when looked at from a bio-psycho-social-spiritual perspective

So you tell me, what are examples? So go to your text box Open it up– your question box And let's text in What are some examples of biological treatments? How would you consider– what would you consider to be biological treatments? Think in terms of things that are physiological in their effect or biological in their effect, from what you know Send them in

And I'll wait for them over here, and as they come up, I'll let folks know So someone wrote in naltrexone Medically, assisted treatment, MAT sometimes abbreviated as Any kind of medications– sure Those would be biologically based, examples of treatments that would be biological

Terrific Let's move on to our next one What about psychological or social treatments? So let's use, actually– let's group them both together Psychosocial treatments– so this is where the most [INAUDIBLE] evidence, evidence-based practices are listed So what are the ones that you've been working with, just so I have a sense, but also, tell me which ones you think are psychosocially based? Someone wrote, relaxation techniques, recovery support group interactions, therapy, mentoring

Any other ones that you guys are using? 12-step programs, like AA, for example Sure There is a certain evidence base for them also CBT, cognitive behavioral therapy, referral to therapists Excellent

So let's do one more then And this sometimes can be challenging These days, this fourth circle, the spiritual component– for those for whom this can be important, because remember, behavior, thoughts, anything that comes in from the outside as an external stimuli is going to have a chance to help direct pathways within the brain So a spiritual component can be very powerful What would be a treatment that might be spiritually-based, if you can imagine one? What do you think? Text in your responses

So take a moment to think about that There we go Meditation therapy, someone wrote, religious organizations Someone wrote, prayer To celebrate recovery– sure

Some folks would consider, for example, yoga, which is developing slowly but surely an evidence base to be considered a spiritual practice Excellent So these are examples of biological, psychological, social, spiritual treatments And each of them is going to address in that sense the reward pathway and to rework the pathways to help those dopamine receptors to be more fully functioning so that the prefrontal cortex can modulate itself better So then what's the definition– given this, then, what is our definition of recovery? And how is that going to help us to see the stages of recovery? So we've got an ongoing process of improving one's level of functioning and, of course, the theme we've got today, from a biological, a psychological, a social, and a spiritual context

All of the treatments that you just saw, the idea of the treatments, that we just talked about and that we'll go further into as we got through this afternoon, are going to repair the reward pathway or make new adaptations to the pathways so that functioning can occur at a higher level Keep those images from the PET scan, and then from other MRI scans in mind, that we want to try to repair that pathway or make adaptations or compensations so that we can still get to that front part of the brain and help it to function in a more effective way Before I forget, someone else wrote in, native rituals and/or ceremonies for spiritual, so thank you for that So of course, all these things in functioning that are biologically, psychologically, socially, spiritually, while maintaining abstinence I just want to add in one other aspect of a definition

The Betty Ford Institute came out with a definition, where they included citizenship, which I thought was interesting, and the concept of voluntarily maintained lifestyle And citizenship they defined as improved quality of social function, as defined and measured by or scored on the social function environment and independent living domains from the World Health Organization's quality of life or quality of living scale So that's interesting to me that we have a citizenship quality or ability to be able to measure that too, especially because of the work that we do, where we're trying to think of community safety specifically So recovery– ongoing process Ongoing doesn't just– one treatment episode doesn't occur, and all of a sudden, everything's better

We've got multiple episodes of treatment changing over time, depending upon the stage of recovery and depending upon what damage has been repaired, what still needs to be repaired, and then how that translates into our drug court participant's behavior, what we see and hear them do So let's take a look at, then, this developmental model of recovery It comes from Terrence Gorski It's been around for a while I like this model, because it's used by SAMHSA and NIDA as an example in their treatment– their tips to improving protocols and TAPs, Technical Assistance Publications

It's a good model It's a flexible model The danger in using it is to become very rigid with it in either time frames or in step-by-step process, thinking everything has to move from one place to the next There is overlap in the stages, and the time frames are simply reference points to give you an idea of where someone might be Some people, again, depending on the drug itself, how long they've been using, how much they've used, their genetic vulnerability, and the environment that they're in will impact on the length of time that they'll go through each of these stages and how they will progress– slowly or quickly through each event

So you guys tell me, first off, given these six stages, we've got something called transition, which I'll go over each of these in a moment We've got stabilization, and they kind of mean what they sound like, which occurs in the first zero to six months once you enter treatment Early recovery is six months to two years Middle of recovery– another two to three years worth of middle recovery– and then late recovery in three to five more years, and then maintenance, which occurs afterwards You tell me– text in your answer– where are we working with our drug court participants? Which areas? What do you think? Where are we working in with them? Which stage or stages? I see one person says, transistence stabilization

Excellent Early recovery There's a whole bunch of them coming in one after another Excellent Yep

Stabilization and early recovery, mostly In a sense, because this is drug court, we are forcing the transition in many ways Even though it's not mandatory treatment, it is voluntary that people can choose to be in drug court or to do jail And the concept of being placed in treatment as opposed to with no outside interference, going through that on your own– it plays with the concept of transition, which we'll talk about it in a moment So yeah, mostly, we're dealing with stabilization early recovery

Middle recovery, late recovery all happens afterwards That's what we maybe hear about later on But the idea of not forgetting middle, late, and maintenance, those are other aspects that people continue with And the importance of, when looking at this from the disease model, of chronic illness, that people need to be connected in some way, shape, or form to recovery activities throughout their lives, that that'll be very useful for them– some more, some less, depending upon the factors that we've gone over already We need to always keep that in mind as far as the way aftercare works

So remember, different drugs have different repair times Just as we have a spectrum of illness for a disease, we also have this spectrum of recovery Remember, it's a flexible, not a static model And what we try to do is, given this sense of time frame of things that someone will go through, we then want to choose the correct treatment modality that will help someone move through these in the most effective way So the first choice for treatment is treatment modality

In its most basic sense, you can think of in-patient and patient-intensive, outpatient, outpatient-intensive, longer periods, shorter periods But those decisions, first, are going to tell us, are we going to based on the intensity level of treatment that someone may need to help them move through these appropriately and effectively? And then it's what's on the treatment menu at that place, and those we want to try to titrate or match to what's going on in the brain and how it can most effectively repair the damage to the brain at those time periods So let's look at transition first, then So transition begins the first time a person experiences a drug or alcohol-related problem With us in the court, with the law, maybe it can be from a hangover, or some kind of social difficulty occurs

They show up late They lose their job They get into a fight, because they're inebriated This is when it begins Whether or not it's recognized as a problem is another issue

So one of the things that we look for is the development of what we call motivating problems It ends with identification of drug use in some way as problematic, even if it is, that's why I'm in jail, as opposed to, I have an addiction And so many of our folks may not even have an addiction They may have diagnosis of abuse They may be using and selling

So there's different ways to help motivate someone forward, but they don't have to say that they are an addict to be able to move forward into the next stages of recovery Can it be useful? Yes Do they have to? No, they can still move forward We know that mandated treatment works just as well as non-mandated treatment So there may be attempts at normal problem-solving

There may be attempts at controlled use There may be acceptance to the need for abstinence, and there may be acceptance to the need for help There may be I did a whole bunch of focus groups here in New York with courts that will go unnamed, and about 80 or 90 young adults in treatment, mostly male, some females, and we asked them in these focus groups, those who've been in about one to three months, do you think you have a problem with your drug when you first were brought into the drug court? And those who've been in the program about one to three months said, basically, I don't have a problem My problem is I got caught

We asked the same group, and we've got different folks who now have been there in the program for about six months And when they say, you think you had a problem when you first got into drug court, they'll go, well, that's still not a problem It wasn't really a problem, but I did get caught, and that's really the main issue that I've got here And the next time when I get out of here, I'm going to use my consequential thinking and not use when I'm selling, because that's how I got caught the first time Now you've got to give them credit for thinking up that, and you also got to give the treatment program credit for getting consequential thinking in the front part of their brain

And they are using that problem solving– maybe not for the best purpose, but still, that's the good thing So you've got to look for the benefits when they come about But it's really an interesting example of how the problem-solving process can be aided and what can occur at one month, two months, or three months, starts to occur in some way, shape, or form at six months And of course, the folks in the group who've been there 12 months and who did have an addiction problem or an abuse issue were saying things like, I can't believe how messed up I was when I first got here and how much help I've had since I've been here So just keep that in mind

Know perspective based on how much time someone has had to repair damage can really be a useful thing for us as workers So transition– that's, I think, for me, was a really powerful way to see how a transition occurs over time And of course, when we get folks, they are, in a sense, transitioning, because what's happened is they've been arrested, and they've decided to go to– because they're eligible, they've decided to go for treatment as opposed to jail So what we do then is we would use some kind of evidence-based tool to help assess and figure out, what's the best way to help them through the stages of recovery? What's the best way to help the participant through the stages of recovery so that they can repair any damage that's occurred to their brain and be able to function more fully over time? And one I like to talk about is the ASAM criteria, and you can really use any of them But I'll just use the American Society of Addiction Medicine's six dimensions as just a sample of how you can address, again from a bio-psycho-social perspective, things like acute intoxication or withdrawal potential

So this is like the basic question of, does someone need medical detox, or can they do a detox on their own? Do we need to have medical attention if they're, for example, addicted to alcohol, in which case, you're concerned about seizures? Or can they detox on their own, because it was marijuana, and they could? Biomedical conditions– for example, what are the physical problems they have? Do they have diabetes, high blood pressure, family history of addiction? So you'll notice the higher the severity of any of these, the more likely that a more intensive the treatment program would need And intensivity goes from outpatient to inpatient in its most basic way So we're talking about treatment modalities Emotional/behavioral conditions– is there history of mental illness like anxiety or depression? Was there suicidal ideation? Is there aggressivity? So these are the things that we would factor in Treatment acceptance– how motivated, what stage of readiness for treatment is someone in? Have they completed, for example, the transition phase of recovery, and say, I know that I have an addiction? What's their knowledge base around that, and how is it influencing their motivation? What's their relapse potential? Have they made attempts to quit before? Have they quit any other drugs like smoking, so they have a success to build from? Is there a family history? And then, of course, last is recovery or living environment

What's the family environment like? What's the home community like? What's work, schools? If they're in school, what are their peers and friends like? Prosocial, antisocial, pro-drug use, anti-drug use? So these are the assessment tools that will help us choose the appropriate level of intensivity– outpatient, inpatient, intensive, and non-intensive– amount of time that might be needed All these things are going to factor into the treatment modality, and then from the treatment modality to the correct program, that would have the specific interventions, such as cognitive behavioral therapy or motivational engineering that would meet the needs of the brain disease that the individual has So stabilization, then– zero to six months So stabilization is where we spend a lot of our time, and considering most relapse occurs within the first six months, there's a definite significant drop-off after six months A lot of work gets done in the first six months

So notice the difference between, for example, acute and post-acute withdrawal We'll talk about that a little more in a moment But the acute withdrawal is the physical withdrawal from a substance, and post-acute withdrawal is more psychological and social withdrawal It's more psychological Acute can begin anywhere from six to eight hours after the last usage, and just to give you an idea of acute withdrawal and what that can mean, so for heroin, for example, you can usually withdraw from acute– acute withdrawal can last three to four days

Usually, you get seven days in detox or longer, if there's a longer term problem or there are other extenuating circumstances And some of the, of course, physical symptoms we're talking about for heroin, for example– hypersensitivity to pain, sweating, vomiting, depression, muscle cramps, stomach cramps, chills Marijuana, by the way– I'm just going to use these two as an example, and I think marijuana, because a lot of people think that there are no withdrawal, there's no acute withdrawal from marijuana Marijuana takes seven to 14 days to get out of the system, but it can go up to 45 days, depending upon all of these factors we've talked about– usage, length of time, genetic factors, environment Marijuana– physical symptoms, irritability, restlessness, anger outbursts, depression, mood swings, craving, headaches

So then we talk about post-acute withdrawal This is after acute withdrawal Physical symptoms go away We've still got other symptoms that are going to occur, and these are the challenges of working with a brain that's been damaged through addiction So you may have things like mood swings, irritability, tiredness, variable energy, low enthusiasm, variable ability to concentrate, disturbed sleep, so many of these, of course, have to do with damage to the ability of the prefrontal cortex to be able to modulate itself and its functions

Then you've got interrupting addictive preoccupation I'll talk a little bit more about this in another slide, but remember, the majority of the reward pathway is taken over by the need for, the use of, the craving for of the drug that's caused the damage So that means that you're thinking a lot about how to get it, where to get it, what it's going to feel like to use, and how much you need it Part of the job of stabilization is to help individuals create new ways to deal with this, to create a new thought process, and to interrupt this addictive preoccupation So short-term social stabilization, learning non-chemical stress management, or coping skills, and it can take about six months to master new skills

It's about six weeks to six months, so at the minimum, six weeks to six months to learn new skills Depending upon the bio-psycho-social psychosocial factors that someone has impacting on their illness, this may take longer or less the amount of time Developing hope, of course, and then motivation is as the last piece of this, so this is stabilization, where we spend a lot of our time with our drug court participants Post-acute withdrawal, specifically for the criminal justice population– this is from SAMHSA's TAP 19 So this is interesting for our population specifically

These are additional biological and psychosocial reasons for prolonged post-acute withdrawal– increases in the length of severity and in the length of the post-acute withdrawal period until that last image of the meth addict's brain where the passive pathways are more or less back in place, where the number of receptors is similar to the way they were before addiction had occurred So for our folks who are talking about from the biological perspective, if someone's a poly-drug user, risk factors are higher And most of our folks are poly-drug users They're using cocaine and alcohol, heroin and cocaine, so different combinations of substances Regular drug use before the age of 15, which, of course, impacts on the ability of the brain to mature

Even though a child's brain is more or less full-sized by about the age of 12, it then takes the next 14 years to fully mature And regular drug use before the age of 15 is going to impact the ability of the different parts of the brain, but especially prefrontal cortex to fully mature We've got abusive use for a period of 15 or more years, so length of substance use, 15 years or more, is another risk factor That's going to increase the severity and length of the post-acute withdrawal and the healing of the brain A history of head trauma– traumatic brain injury, working with the veterans who are returning from the war with different drug dependencies, and they may also have co-occurring head trauma from combat

And also, let's face it A lot of our participants have it from living on the street from the neighborhoods they live in, from violence they experience, family violence, neighborhood violence, history of trauma through fighting, through use of weapons or being near them Parental use of drugs during pregnancy We've got personal family history of diabetes, hypoglycemia, addiction, the individual being malnourished These are all going to be further risk factors

Physical illness or other chronic pain– you can see how these tie into the choice from the ASAM criteria also It's interesting how they all kind of connect Then if you look at the psychological and social, the psychosocial risk factors, you've got childhood or adult history of psychological trauma, sexual and/or physical abuse So tell me this then I'm going to just take a moment

Think about what the numbers are for– there's been a lot of research on, for example, sexual abuse of women in drug treatment What do you think the number is of women who are in drug treatment who have been sexually abused as children? Just take a moment Get a number in your head And if you said below 50%, you're way off If you said above– someone just wrote in 75%

Yeah, the numbers of the studies that I've seen, there's been a lot of them Someone just wrote in 80% Excellent They're actually between 70% and 95%, depending upon the program that was looked at This is tremendous numbers

Now here's a question for you How about for men, sexual abuse of men when they were children? What are the numbers for them? Type them in I see someone wrote 75 A little high It's got to be below– it's going to be below 50, but it's not going to be below 10%

Numbers are around– someone just wrote in 30 30, 35, 40 Those are numbers that I've seen i a lot of the studies, and I think that that's a lot higher than the folks that were– that we would assume or think has happened And of course, a lot of that kind of information comes out to us very late in treatment or after folks have left treatment completely Mental illness or severe personality disorders is going to, again, be another risk factor

High stress lifestyle or personality, high stress social environment– not that any of our drug court participants have stress or stressful social environment at all That was a joke So let's look at this concept of addictive preoccupation These are all the things that are being dealt with, especially in the stabilization period We've got obsessive thought patterns, and we're going to talk much more about this in Part 3 when we go over relapse, how neuroscience and relapse kind of work hand-in-hand

Compulsive behaviors– behaviors that are automatic, that are not being influenced by the "on second thought" decision-making capability, because there is limited or impaired capability to do that Physical cravings– these things are all these obsessive thoughts, compulsive behavior, physical cravings They're activated by what we call high risk situations and stress, including the famous people, places, and things And so these are the external stimuli that when come into our brain, we see them And because of the addictive patterns that are established, they act in compulsive ways and not necessarily helpful or healthy ones

So early recovery, then, is our six to 24 months It can last anywhere from one to two years long, and this is usually where we see the last of our folks, right? So what do they need? They need some understanding of addiction and what's going on in their bodies and in their brains They need to be able to recognize what addiction is Overall, you could say the mark of early recovery is the need to establish a chemical-free lifestyle, so you stabilize by giving new coping skills and stabilization But in early recovery, you really want to establish a chemical-free lifestyle that's, in a sense, in the laboratory of treatment, reinforced so that new pathways are firmly established in the brain, that that damage has been repaired to a good extent

Identifying and interrupting addictive thoughts, feelings, and actions, learning non-chemical coping skills, ways to use the body's natural opiates, like epinephrine and norepinephrine, developing the sobriety– actually, going back to that last one, a very simple way– this is just kind of a nice aside, but it's an interesting one A simple way to induce the body's natural opiates is simply to smile You don't even have to really want to smile If you smile, you automatically secrete some and start that process in the reward pathway It's really an interesting process

Also, as human beings, we have a mirror reflex If you smile at someone, they will automatically smile back at you They cannot help it As a student of body language, I think that's a wonderful thing Also, if you've got an enemy that you really don't like, and you smile at them, and they smile back at you, it'll make your day

Trust me on this So let's work with that So developing a sobriety-centered value system– back on track So these are early recovery, six to 24 months And then we've got middle recovery

And what's the task of middle recovery? Well, it kind of begins with coming to terms with the amount of work that there still is to be done Sometimes called demoralization crisis, demoralization crisis– I've gone this far It's been a couple of years I've been in treatment I went through drug court I'm back out

I've got to now take the skills I learned and apply them to real life situations full time, and you realize, I messed up a lot when I was high I messed up a lot when I was using There's damage that's been done to my family, to my friends, to my children maybe, to my parents, maybe to my partner or spouse And now I have to work on that, sometimes called the demoralization crisis It can be hard to think, I still have more work to do, because we know that treatment is hard, that treatment is not easy to do, which is why sometimes people say, treatment is so hard I'd rather go to jail, because we've never heard that before

Repairing addiction-caused social damage, so what we've been talking about, and this idea of not only building but then practicing a balanced lifestyle So this usually happens after our folks leave It's part of aftercare or what the needs are around aftercare Then we've got late recovery, which occurs, again, even past here Really, the whole thing about late recovery is to deal with unfinished business from childhood

This gets very psychoanalytical, I know, but work with me on this This is when folks deal with, for example, childhood violence, sexual abuse, these kinds of things Now what happens is this may come up in early recovery or during stabilization You just may not want to go full force into dealing with someone's issues like that that early in recovery, because it can be a real trigger for relapse It doesn't mean you may not address these things earlier in recovery

You just won't address them in the same detail or to the same intensity, because you're trying to build a firm base to stabilize, practice, and then integrate into life Recognition that childhood issues are affecting the quality of recovery Learn about family of origin issues and how these may need to play themselves out Conscious examination of childhood, identification of self-defeating patterns or maladaptive patterns that may have been helpful in survival as a child, but not so helpful later on as an adult, and then, of course, figure out, how does this apply to adult living? That's late recovery Maintenance, then– so maintenance, maintenance

Lifelong process– this is what happens after It really has to do with coping with life, life occurrences and transitions that are going to occur and that will be challenges to someone's recovery process And that can include maintaining a recovery program, effective day-to-day coping, continued growth and development in the face of things like, birth, death, divorce, marriage, getting older, not necessarily getting younger, illnesses, all the things that occur and help transition life from one stage to next outside of the world of recovery, so continued growth and how we can grow and develop from them So coping with life transitions and complicating factors, so that's maintenance So now let's take this in our last 12 minutes or so and see how that's going to apply

I'll give you some examples I'm going to use the work of Richard Rawson over in California on stimulants, because number one, I think it's really good, and I think it shows us how we can apply specifically to the ways to repair damage from brain disease with very specific examples Stimulants in general, methamphetamine in particular I'll use with these examples But remember, as I go through, I'll try to give other examples, just so you have a sense of it I don't have time to go through five or six different drugs

We'll use one as an example for all So if you look at this, Rawson's work, here's stages of recovery for stimulants, just an overview And withdrawal stage– so he has a zero to 15 days This is acute withdrawal from physical symptoms, which means some of the problems or challenges that'll occur in the first 15 days may be the medical problems that have been masked by the use of the drug or that have been caused by the use of the drug There maybe alcohol withdrawal, because it may be a poly drug that's being used

It may be depression, difficulty concentrating, severe craving There may still be contact with stimuli people, places, and things Someone may sleep a tremendous amount So that's withdrawal stage The honeymoon stage is what happens from 15 days to 45

This is post-acute withdrawal begins, and that they may not actually feel very much of that at first What happens in the honeymoon stages, you feel so good, because you made it through detox and the acute withdrawal, and you're like, hey, that was easy It's done It's only a couple weeks, and I feel better So what are the problems? Well, you may get over-involved with work

The participant may be overconfident in their ability to remain abstinent, or they may think, well, I can use a little bit It's not going to be that big a deal There may be an inability to initiate further change, to move any further Ah, this is enough I can't go any further

There may be challenges in prioritizing Notice that that impacts prefrontal cortex Maybe alcohol use comes back into the picture Again, episodic cravings Someone may leave treatment

And then there's this thing called the wall stage, so when the symptoms come back, and it feels significantly worse in many ways than the withdrawal did all by itself And it lasts a long time– 45 to 120 days Maybe get [INAUDIBLE] boredom, depression, return to cocaine use, or being around stimulus, because you figure you could take it during the honeymoon stage Now all of a sudden, you can't So there may be justification in an individual's mind to relapse

There may be a treatment termination There may be alcohol use and, of course, relapse Two things– these are quotes from clients who are in the wall phase, and this is what they said "Lack of energy was almost constant, even if I slept for hours Lack of memory and ability to concentrate, and a gray film over my vision clouded my world

My sleep came mixed up I would be dead tired during the day and experience insomnia at night" Someone else said, "Throughout the wall, I didn't care about anything or anybody, including myself Nothing seemed important Nothing felt good

Boredom, hopelessness, my constant companions– I felt the whole thing would never end" So I think from the perspective of what goes on with our participants, those are two interesting quotes to help inform us So I'm not going any further than that on this chart But let's take a look at when we say what's going on with the brain, this is an interesting chart from Rawson's work on not just the frequency of impairment, but a percentage of impairment that occurs And you'll see for fluency of the executive systems functioning, for example, and learning and memory you've got for methamphetamine and stimulant users as high as 35% to 55% impairment

Inhibition– 20%, 25% Attention to psychomotor speed– 20% to 25% These are percentage impairments So this translates then into deficits on prefrontal cortex executive tasks associated with poor judgment, lack of insight into behavior, the inability to say, on second thought, I ought not to do that, poor strategy formation, impulsivity, reduced capacity to determine consequences of actions Then what do we do to treat this? How does it translate, for example, into treatment? So treatment for methamphetamine may include these areas from a biological, psychosocial perspective

First, from a biological perspective, bupropion is used in a number of places It's an anti-depressant Research has shown some help with reducing the high and decreasing craving for methamphetamine addicts Psychosocial interventions– cognitive behavioral therapy and CBT– by the way, also used for evidence base for alcohol, marijuana, cocaine, nicotine Motivational interviewing, which I know we hear a lot of– that's a good evidence base also for alcohol and marijuana

Contingency management, which is giving rewards, so really think about this I just love the concept of contingency management, giving rewards immediately when someone does something that you want them to do Rewards immediately, not waiting a day, two days, a week later, but immediate rewards And think about how that impacts on the reward pathway, creating new ones for positive behaviors 12-step facilitation therapy, also used for stimulants, opiates, alcohol, and of course, the matrix model of outpatient treatment is used specifically for opiates and has a nice evidence base to it also

These are treatment interventions Let's look even more specifically, even on a more micro level as to how you can address specific elements of brain disease Educate clients at the reality of, for example, methamphetamine addiction Employ varied adult learning formats to increase comprehension and retention of knowledge in view of cognitive deficiencies, especially verbal memory problems So if you know that people have trouble taking verbal instructions, then you're going to need to do things like provide workbooks, learning aids on relapse prevention for clients to take with them into continuing care

So they're going to need to have them with them as reminders If the verbal information is having difficulty, your impairment of being received and understood because of the cognitive problems of long-term addiction, then these are ways to help someone compensate, to have compensations that specifically address brain disease Other ones– strategies to reduce anhedonia, which is the inability to feel pleasure, specifically related to problems with the reward pathway And negative mood states– episodic paranoia, sleep problems, so how do you deal with that? Here's four tools, which have different types of evidence base– aerobic exercise to promote the natural neurotransmitters, which will lift mood Yoga, for example, has some evidence base to this- tai chi, meditation

So you can see how these are being specifically tailored to these symptoms Anger management strategies to cope with possible serotonergic dysregulation, induced irritability, and groups to address extensive maladapted sexual behaviors and expectations, so groups that will talk specifically about the issues to help people address behaviors and find new pathways in their brains to be able to deal with them, to help exercise and focus, refocus them so that compensations and adaptations can be made on the brain pathways And with that, that's kind of a way to close out This is from Rawson's work again Some of the outcomes with methamphetamine users, just this call of alarm to keep in mind of after our drug court participants leave, what are some things that we can do to help them, or how can we set them up to succeed outside of drug court? And he says the single most important factor for positive treatment outcomes will be the degree to which clients are retained in post-residential treatment

Use community care organizations with continuing care that can decrease and increase intensity of care when clinically indicated, so the idea to be flexible, depending upon how treatment of the brain is going Create treatment plans that maximize compliance by addressing clients where they're at through full assessments, which tell us how, what their risk factors are, and what the appropriate modality and interventions will be for them Employ positive reinforcement Remember, positive reinforcement promotes pathways in the brain significantly, more effectively than negative reinforcement You know positive reinforcement works better, but we're very– we're stingy with it

So remember that It's the basis of contingency management as an evidence-based practice Coordinate parole monitoring and treatment participation in community care Make mental health care available And last but not least, involve family and community care services

And you can see how these can be utilized for other substances just as well With our last couple of minutes, then, let me throw it open for questions We've got a couple minutes, two or three to be exact So let's see if we've got some questions as we move into our closing So if you've got a question, open your question box

Text me it in, and let's see what we've got While I'm waiting for question– or questions to come in, let me remind you all that next week will be the third and final piece on addiction in neuroscience of the brain, where we'll talk about relapse specifically, looking at cravings, acute preoccupation, et cetera And in the meantime, still waiting for another question Let's see if we have one OK, so if there are no questions, let's move on to our last piece, which is to remind everyone when we sign off in about 30 seconds, to please fill out the survey for today's workshop, your evaluation survey

And then send that right back in So someone did finally get in a question Will you cover anything related in incentives and sanctions connected to the presentation? Yes Next week, when we talk about relapse and how that's going to play itself out, we'll talk about sanctions and incentives as we look at how brain disease influences relapse and how we as drug court practitioners need to be able to deal with it from an appropriate perspective So yes, so thank you for that question also

Again, thank you for participation Fill out the survey when we sign off Thank you, Clyde Frederick, our administrate technologist for keeping everything running smoothly from a technological perspective And I hope to see you all next week

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