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Slide 1
NeurobiologyofAddictionJoyce D Leonetti, DO, MTS, MPH
SAID Meeting October 2019
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Slide 2
DisclosuresI have no competing interests in this presentation.
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Slide 3 Learning Objectives
• 1. Identify the origins and current state of the opioid crisis in America.
• 2. Describe the basic elements of drive and cognition in the neurobiology of addiction.
• 3. Understand the structure and pathways associated with changes in the brain
• 4. Discuss the clinical use of psychotherapy and psychosocial interventions in the treatment of substance abuse disorders.
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Slide 4 Outline
• 1. The Basic Model
• 2. Neurobiology
• 3. New Neurobiological Concepts• 4. Treatments
• 5. New Directions
• 6. Conclusions
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Slide 5
1
TheBasicModelofAddiction
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Slide 6
~ 1980How does addiction occur?
What’s involved?What are the mechanisms?
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Slide 7
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Slide 8
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Slide 9
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Slide 10 TheRootCauseoftheProblem
Porter & Jick,NEJM,January 10, 1980
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Slide 11 TheMoneyInfluence
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Slide 12 TheFalsePromise
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Slide 13 1999-2009
Primarynon-heroinopioidadmissionrates(per100,000)
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Slide 14 FromPillstoHeroin
Compton, New England Journal of Medicine, 2016
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Slide 15 FromHerointoFentanyl
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Slide 16
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Slide 17
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Slide 18 2
Neurobiology
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Slide 19
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Slide 20
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Slide 21 EffectsofDrugsonDopamineLevels
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Slide 22 AddictionChangesintheBrain
•Over Time Addiction causes changes in the brain.•Brain Structure •Prefrontal Cortex, limbic system
•Brain Pathways (neural connections)•Dopamine pathway, serotonin pathway
•Brain Chemicals•Dopamine, serotonin, endorphin, glutamate
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Slide 23 AddictionChangesintheBrain
•Brain Structures(prefrontal and limbic systems)
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Slide 24 BrainRegions
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Slide 25 BrainRegionsandtheirFunctions
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Slide 26 Pleasure– RewardsPathways
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Slide 27 AddictionChangesintheBrain
•BrainPathways(neuralconnections)•Dopaminepathway,serotonin
pathway
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Slide 28
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Slide 29 AddictionChangesintheBrain
•BrainChemicals•Dopamine,serotonin,endorphin,glutamate,andGaBA
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Slide 30 Brain Chemicals
• Dopamine – a feel good chemical.• Serotonin – the happy, anti-
worry, flexibility chemical. • GaBA – an inhibitory
neurotransmitter that helps calm or relax the brain• Endorphins – the brains own
natural pleasure and pain killing chemical
• Glutamate – locks the pleasurable experience into memory
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Slide 31
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Slide 32 AComplexIllness
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Slide 33
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Slide 34 TheAddictionCycle&the4C’s• Loss of Control (damage to the prefrontal cortex; right & wrong)• Continued Use Despite Consequences - further damage to prefrontal
cortex (interferes with judgment).• Compulsion (low serotonin levels) • Craving (dopamine; brain is hard wired to crave rewards)
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Slide 35 Commonmedicationsusedtotreatdrugaddictionandwithdrawal•Opioid
• Methadone • Buprenorphine • Extended-release naltrexone • Lofexidine
•Nicotine• Nicotine replacement therapies (available as a patch, inhaler, or gum) • Bupropion • Varenicline
•Alcohol• Naltrexone • Disulfiram • Acamprosate
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Slide 36 3
•New Neurobiological Concepts
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Slide 37 ThreeNovelAreas
üMotivational Circuitry
üAnti reward Pathways
üInteroception
Levounis, JournalofMedicalToxicology,2016
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Slide 38 Motivation:TheStinking– ThinkingPart
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Slide 39 HowtheBrainDecides
AAAAAAHHH!!!!
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Slide 40 Motivation:TheStinking– ThinkingPart
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Slide 41
Anti-RewardPathways
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Slide 42 Rewards
“…or $12 a month
from now:”
“$10 now….?”
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Slide 43 HumanNature
People avoid risks to ensure gains (even small gains)
People take risks (even big risks) to avoid definite losses
Psychology trumps probability
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Slide 44 RewardandAnti-RewardSystems
Gardner, ChronicPainandAddiction, 2011
Pro Reward
Anti Reward
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Slide 45
Insula is in the anterior cingulate cortex (ACC)
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Slide 46 TheStop-GoModel
Volkow ND and Baler RD, Neuropharmacology, 2013
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Slide 47
4Treatments
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Slide 48 FirstWave:Psychoanalysis
Levounis, JournalofMedicalToxicology, 2016.
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Slide 49 2ndWave:BootCamps
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Slide 50 3rd Wave:TheCurrentApproach
üMedications
üCounseling and Psychotherapy
üMutual Help
Nunes, Selzer, Levounis, Davies, Substance Dependence and Co-Occurring Psychiatric Disorders, 2010.Levounis, Arnaout, and Marienfeld, Motivational Interviewing for Clinical Practice, 2017.Renner, Levounis, and LaRose, Office-Based Buprenorphine Treatment of Opioid Use Disorder, 2nd Ed., 2018.
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Slide 51
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Slide 52 CounselingandPsychotherapy
1.Cognitive- Behavior Therapy• Functional analysis
• Skills Training to identify, avoid & cope with thoughts & cravings
2. The Kitchen Sink approach• Family Therapy
• Relapse Prevention• 12 Step Faciliation (AA)
• Primary Care• Mental Health Services
• Aftercare
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Slide 53 MutualHelp
MotivationalInterviewing
MI is about arranging conversations so people talk themselves into change, based on their values and their interests.
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Slide 54
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Slide 55 Alcoholics/NarcoticsAnonymous
• AlcoholicsAnonymous (AA) is an international mutual aid fellowship with the stated purpose of enabling its members to "stay sober and help other alcoholics achieve sobriety.”
• AA is nonprofessional, self-supporting, and apolitical. Its only membership requirement is a desire to stop drinking.
• The AA program of recovery is set forth in the Twelve Steps.
• Narcotics Anonymous uses the same principles.
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Slide 56
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Slide 57 4th WaveMindfulness
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Slide 58 Psychodynamics
Atherapythathelpspeoplegaininsighttotheirlivesandproblemsby:
• Recognizing recurring patterns to avoid distress & develop coping mechanisms in an effort to produce change in these patterns or habits.
• Evaluating life factors of thoughts, emotions, early life experiences and beliefs.
• Developed as a simpler, goal oriented, less lengthy alternative to psychoanalysis.
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Slide 59
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Slide 60
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