Cardwell C. Nuckols MA, PhDcnuckols@elitecorp.org

(407) 758-1536

Facilitated by:

NOVELTYENVIRONMENTAL ENRICHMENT

PHYSICAL EXERCISENUTRITION

Group Therapy Individual Counseling Sober Living Higher Power Assessment

Alcohol/Drug Psyhosocial

Recovery housing Healthy milieu Self help meetings Church From isolation to living “one day at a

time” in the presence of others striving for a more fulfilling life

Stimulates production of brain-derived neurotrophic factor (BDNF) Neurotrophin that governs maturation and

development of neural systems Enhances executive functioning

Obey social rules Adapt to changing & unpredictable

environment Short term working memory Multi-tasking Self-directedness

Self-directedness Responsible Purposeful Resourceful

Increases neurotransmitters Monoamines

Serotonin Dopamine Norepinephrine

Association between DA D2 receptor numbers and drug self-administration Increased D2 receptors reduced alcohol

consumption Decreased D2 receptors higher risk

DA D2 receptor levels influenced by stress and social hierarchy

Helps explain influence of environment and genes

Subordinate animals more likely to self-administer cocaine

Dominant animals no more likely to self-administer cocaine than placebo

Social interventions can change neurobiology Increased DA D2 receptors Reduced self-administration

Behavioral interventions could counteract the aversive effects of drug abuse and reinforce the power of group approaches

Group Therapy Active participation Successful completion of assignments

Milieu Leadership Modeling

Self help Coffee and chairs “Telling story”

Acute intoxication results in activation and deactivation of regions connected to the DA system

These regions are involved in REWARD MEMORY MOTIVATION/DRIVE CONTROL

Reward Circuit-Nucleus Accumbens and Ventral Pallidum

Motivation/Drive Circuit-Orbitofrontal Cortex

Memory & Learning Circuit-Amygdala and Hippocampus

Control Circuit-Prefrontal Cortex & Anterior Cingulate Gyrus

Copyright ©2003 American Society for Clinical Investigation

Volkow, N. D. et al. J. Clin. Invest. 2003;111:1444-1451

Location Nucleus Accumbens (NAc) Ventral Tegmental Area (VTA)

Impact of drugs of abuse Increased extracellular levels of DA in striatum

(NAc) Reinforcing effects related to:

Magnitude of DA increase Abruptness of DA increase

Reduced sensitivity to natural reinforcers

Goals: Management of craving Reduce reward value of drugs Reduce pleasure (create unpleasantness)

from drug experience

Situational triggers Environment (People, Places And Things)

Emotional triggers Internal (Hungry, Angry, Lonely, Tired, Reward

and Bored) Acute Abstinence Syndrome Stress

In presence of:› Alcohol and drugs› Alcohol and drug

users› Places where used

to use or purchase Negative feeling

states particularly anger but also:› Boredom› Loneliness› Fear› Anxiety

Positive feeling states Physical pain Use of mood-altering prescription drugs Suddenly having a lot of cash Complacency Insomnia Sexual functioning

Psychotherapy Behavior Therapy

Structure Recovery Foundation Program

Changing patterns Safety Plan

Pharmacological Acute Maintenance

31 yo Nicki-a recovering methamphetamine addict- just got her first paycheck. She cashed her check and cruised thru the neighborhood where she used to score dope. Rock music blared from her speakers. Soon she was thinking, "I worked hard all week. I deserve a little fun.”

In an inpatient setting the patient schedule serves this purpose

On an outpatient basis or upon discharge from inpatient a recovery plan or contract is appropriate

Remember that most addicts have little or no recent experience living a drug free lifestyle

TASK MON TU WED THU FRI SAT SUN

SH

TX

FUN

NUT

PEX

Carter is 24 yo and just getting out of treatment for alcohol and drug addiction

His early A/D history included…. Started drinking on Friday nights with friends

in high school Turned-on to cocaine and marijuana by friends

on weekends Started to buy drugs to sell from a distributor

on Wed nights

MY PERSONAL SAFETY PLAN

• Remember that craving go away• I can write in my journal• I can call my sponsor (299-289-5555)• I can call my lover (299-426-1776)• I can read from my favorite recovery book• I can read affirmations

TH: “On the back of the index card, come up with a saying or a prayer that gives you strength.”

CT: “ I have always liked ‘Lord help me to be the best possible person I can be today’.”

Opioid Maintenance Medications Methadone LAAM Buprenorphine Naltrexone

Naltrexone (Revia, Vivitrol) Pure antagonist Poor compliance

Less than 10% for street addicts Better compliance

Healthcare professionals Parole/Probation

New suspension with q30d administration should dramatically increase compliance and reliability of drug

Subutex-Buprenorphine. sublingual (SL) 2mg and 8mg tablets

Suboxone-Buprenorphine/Naloxone SL tablets

Buprenorphine 25-50 x’s more potent than morphine

Partial agonist Increasing dose does not increase effect like a

full agonist

Very high affinity for mu opioid receptor Mu receptor will choose buprenorphine

over other opioids Buprenorphine will displace other opioids Slow dissolution from mu receptor

Half-life on receptor is 34-36 hrs Heroin on and off receptor in millisecond At Buprenorphine dose of 16mg almost no

binding to other opioids

If taken under the tongue you get predominant buprenorphine effect

If dissolved and injected get predominant naloxone effect (precipitates withdrawal)

Buprenorphine equally effective as 60 mg of Methadone per day

If patient needs 80-100 or more mgs of Methadone to be comfortable, Buprenorphine probably will not work

With client dependent on short-acting opioids Instruct client to abstain for 12-24 hours Need to be in mild withdrawal before first

dose

Disulfiram, 1951

Acamprosate, 2004

Oral naltrexone, 1994

Injectable extended-release naltrexone, 2006

NONE OF THESE ARE ADDICTIVE

DopamineIncreased ReleaseDopamineIncreased Release

GABAIncreased Sensitivity to GABA

GABAIncreased Sensitivity to GABA

Opioid PeptidesIncreased Endogenous Opioid Activity

Opioid PeptidesIncreased Endogenous Opioid Activity

GlutamateDecreasedActivity

GlutamateDecreasedActivity

De Witte P. Addict Behav 2004;29:1325; Gianoulakis C. Curr Top Med Chem 2004;4:39-50; Nestler EJ. Nat Neurosci 2005;8:1445-1449; Tupala E, Tiihonen J. Prog Neuropsychopharmacol Biol Psychiatry 2004;28:1221-1247.

De Witte P. Addict Behav 2004;29:1325; Gianoulakis C. Curr Top Med Chem 2004;4:39-50; Nestler EJ. Nat Neurosci 2005;8:1445-1449; Tupala E, Tiihonen J. Prog Neuropsychopharmacol Biol Psychiatry 2004;28:1221-1247.

Glutamate SystemGlutamate System

Adaptation # and/or function of NMDAreceptors on neurons

Balances acute alcohol effect

Effect: tolerance, dependence

Adaptation # and/or function of NMDAreceptors on neurons

Balances acute alcohol effect

Effect: tolerance, dependence

Chronic Alcohol UseChronic Alcohol Use

WithdrawalIncreased glutamatergic activity

Effect: - Acute: dysphoria, hallucinations- Post-acute: sleep/mood disturbances

WithdrawalIncreased glutamatergic activity

Effect: - Acute: dysphoria, hallucinations- Post-acute: sleep/mood disturbances

Removal of AlcoholRemoval of Alcohol

Alcohol-Free CNS Equilibrium

Alcohol-Free CNS Equilibrium

Acute Alcohol EffectInhibits NMDA receptors

Effect: anxiety, sedation

Acute Alcohol EffectInhibits NMDA receptors

Effect: anxiety, sedation

Administrationof AlcoholAdministrationof Alcohol

Littleton. Alcohol Health Res World 1998;22:13.Littleton. Alcohol Health Res World 1998;22:13.

N = 605

Fuller RK, et al. JAMA 1986;256:1449-1455.

N = 605

Fuller RK, et al. JAMA 1986;256:1449-1455.

0

10

20

30

40

50

Noncompliant (80%) Compliant (20%)

% R

em

ain

ing

Ab

stin

en

t

Disulfiram 250 mg

Disulfiram 1 mg

Counseling

0%

5%

10%

15%

20%

25%

30%

Counseling Disulfiram 1 mg Disulfiram 250 mg

% D

ays

Dri

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g

*

N = 605

* p < .05

Fuller RK, et al. JAMA 1986;256:1449-1455.

N = 605

* p < .05

Fuller RK, et al. JAMA 1986;256:1449-1455.

GlutamateGlutamate

aa AcamprosateAcamprosate

NMDA ReceptorNMDA Receptor

Reduction in glutamate release

Reduction in glutamate release

Reduction in postsynaptic effects

Reduction in postsynaptic effects

mGluR5 receptormGluR5 receptor

aa

aa

aa

aa

aa

NMDA = N-methyl-D-aspartatemGluR5 = metabotropic glutamate subtype 5 receptor NMDA = N-methyl-D-aspartatemGluR5 = metabotropic glutamate subtype 5 receptor

N = 272

Sass H, et al. Arch Gen Psychiatry 1996;53:673-680.

N = 272

Sass H, et al. Arch Gen Psychiatry 1996;53:673-680.

0%

5%10%15%

20%25%30%35%

40%45%50%

Acamprosate Placebo

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Location Orbitofrontal Cortex (OFC)

Impact of Drugs of Abuse Drug as reinforcer far exceeds that of

natural reinforcers OFC hypoactive during AAS Exposure to drug or other “cues” during

withdrawal precipitates craving and compulsive drug use

Hypothalamus Head ganglion of ANS & locus of drive

Amygdala Reticular formation

Brainstem regulation of arousal Frontal cortex

Modulates instinctive behavior and internal drives

Processes face and voice information for appraisal of external environment

Therefore, integrates external and internal environment

Early developmental trauma has negative impact on OFC

AUTONOMIC NERVOUS SYSTEM

PARASYMPATHETIC SYMPATHETIC

DISSOCIATION HYPERAROUSAL (FREEZE) (FIGHT/FIGHT)

Increase value of non-drug reinforcers Positive Connection to Others

Therapeutic Relationship How we communicate “Mirror” neurons Family and couples therapy 12 step meetings

Connection to Higher Power of Your Choice Mindfulness Meditation

Location Amygdala Hippocampus

Impact of Drugs of Abuse People, Places and Things (“cues” or

“triggers”) create an intense desire to use (“craving”)

Impact of Drugs of Abuse (cont.) These cues automatically trigger habit

learning Release of DA

Declarative learning links emotional states to use (“Hungry, Angry, Lonely and Tired”)

Behavioral Extinguish learned

positive association with drug or drug “cues”

Promote reinforcement of positive behaviors

Recovery in neuropsychological functioning› Most of treatment is

during time of greatest dysfunction

› Recovery is; Time-dependent

Due to sustained abstinence

Experience-dependent Active rehabilitation

or repetitive behavior

Repetitive recovery-oriented behaviors

Repetitive recovery-oriented thoughts

Neurons that “fire together, wire together”

Location Prefrontal Cortex Anterior Cingulate Gyrus

Impact of Drugs of Abuse Disruption of prefrontal cortical functions

removes self-directed behavior in favor of sensory-driven behavior

Lack of vertical integration

Control Strengthen Prefrontal Cortical Control

Cognitive Therapy Education Exercises

Puzzles Computer Games Crossword Puzzles

Vertical Integration

PFC plastic especially between 0-5 and 10-20 years of age

Developmental delays occur secondary to early life trauma and early onset alcohol/drug abuse.

Treatment Positive role models (Sponsor) Surrogate family (Home Group) “Growing Up In AA”

Coordinate the many brain activities needed to utilize: Executive Functions

Set goals Make plans to attain those goals Organize steps to carry out the plans Ensure that desired outcomes are achieved

Conscience Pursue Reward Within the Law

Why give an alcoholic or addict a 60 minute didactic or video?

A new format 15-20 minute simple didactic

How to participate in treatment 10 minute questionnaire 30 minute discussion group

I THINK………..I THINK………..

I FEEL…………..I FEEL…………..

I LEARNED……I LEARNED……

MY FUTURE BEHAVIOR WILL CHANGE…MY FUTURE BEHAVIOR WILL CHANGE…

BE KIND, CONSIDERATE, FORGIVING AND COMPASSIONATE AT ALL TIMES, PLACES AND UNDER ALL CONDITIONS WITH EVERYONE, AS WELL AS, YOURSELF

http://www.jci.org/cgi/content/full/111/10/1444

Nestler, Eric. “The Neurobiology of Cocaine Addiction”. Science & Practice Perspectives. December 2005, pgs 4-12.

http://www.medscape.com/viewprogram/3023_pnt

Cloninger, Robert. Feeling Good: The Science of Well-Being. Oxford University Press, New York, 2004.

Panksepp, Jaak. Affective Neuroscience. Oxford University Press, New York,1998, pg 255.

Schore, Allan. Affect Regulation & the Repair of the Self. WW Norton, New York, 2003, pg 29-31.

Scaer, Robert. The Trauma Spectrum. WW Norton, New York, 2005, pgs 62-64.

http://www.msu.edu/~brains/humanatlas/search.html

Nuckols, Cardwell C. THE SCIENCE OF RECOVERY: “Connecting to Others and a Higher Power of Your Choice”. Counselor Magazine. Vol. 7, No. 1, Feb., 2006.

Nuckols, Cardwell C. THE SCIENCE OF RECOVERY: "Incorporating Neuroscience into Your Practice”. Counselor Magazine. December 2005, Vol. 6, no.,6, pgs 24-31.

Gazzaniga, Michael (Editor). The Cognitive Neurosciences III. The MIT Press, London2004.

Rossi, Ernest. The Psychobiology of Gene Expression. WW Norton, New York,2002.

Blumenfeld, Hal. Neuroanatomy Through Clinical Cases. Sinauer Associates, Sunderland, MA., 2002.

McGlynn EA, et al. “The Quality of Healthcare Delivered to Adults in America”. New England Journal of Medicine. 2003;348:2635-2645.

http://draonline.org - Dual Recovery Anonymous

Http://www.alcoholics-anonymous.org – Alcoholics Anonymous

http://www.wsoinc.com – Narcotics Anonymous

http://www.ca.org – Cocaine Anonymous

http://www.whitebison.org – Wellbriety http://www.nami.org – National Alliance

for the Mentally Ill www.facesandvoicesofrecovery.org –

Faces and Voices of Recovery (FAVOR)

www.gwcinc.com/drnuckols.htm

www.hci-online.com/cnuckols

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