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Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

Based on the Substance Abuse and

Mental Health Services Administration’s

Technical Assistance Publication #21:

“Addiction Counseling Competencies”

The Science of Addiction: The Brain on AdolescenceKen Winters, PhD

Essential Substance Abuse Skills Webinar Series: A Guide for Professionals

This webinar is provided by the National American Indian & Alaska Native ATTC, a program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT).

For more information on the ATTC Network, visit: attcnetwork.orgTo find your regional center, visit: attcnetwork.org/findregcenter.asp

For more information on the National American Indian & Alaska Native ATTC, visit: attcnetwork.org/americanindian, or call 319-335-5564

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This series is designed to: Assist in preparing participants for written alcohol and drug certification examinations Enhance knowledge for existing behavioral health professionals Improve overall competence and treatment outcomes Introduce Technical Assistance Publication (TAP) #21

Limitations: This training series is designed as a broad overview Previous education or training is necessary in order to pass alcohol and drug

certification exams Each module covers a wide range of concerns and issues Some topics are addressed only briefly Participants are recommended to seek additional preparatory help

Referral, Service Coordination, and Documentation presented by: Dee Le Beau-Hein, MS, Cheyenne River Sioux Tribe

Treatment Knowledgepresented by: Bob Rohret, MPH, IADC

Upcoming webinars from the National American Indian & Alaska Native ATTC

Bridging the Gaps in Culture and Geography: Telehealth with American Indian Communitiespresented by: Spero Manson, PhD, Pembina Chippewa

Disrespecting Our Elders: Elder Abuse Indicators and Screening in Indian Countrypresented by: Jacque Gray, PhD, Choctaw & Cherokee Nation

For more information about our webinar series, contact Kate Thrams at kate-thrams@uiowa.edu or 319-335-5362

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Webinar Follow-Up

CEHs are available upon request for $10 per session. • This session has been approved for 1.5 CEH’s by:

• NAADAC: The National American Indian & Alaska Native ATTC is a NAADAC (The Association for Addiction Professionals) certified educational provider, and this webinar has been pre-approved for 1.5 CEH.

• To obtain CEHs for this session, submit a CEH Request Form and payment to the National AI & AN ATTC. A request form is available for download in the “Files” pod in the webinar screen. If you choose to download a file, a new tab will be opened in your browser, and you will have to click on the webinar window to return to view the webinar.

• Participants are responsible for submitting state specific requests under the guidelines of their individual state.

Presentation handouts:• A handout of this slideshow presentation is also available by download.

If you are unable to download the documents from the webinar, please contact Kate Thrams at kate-thrams@uiowa.edu or 319-335-5362

Continuing Education Hours (CEH)

Webinar Follow-Up

This webinar is provided by the National American Indian & Alaska Native ATTC, a program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT).

Participation in our evaluation lets SAMHSA know:

• How many people attended our webinar

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We appreciate your response and look forward to hearing from you.

Evaluation: SAMHSA’s GPRA

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Today’s Speaker

Ken Winters, PhD, is the Director of the Center for Adolescent Substance Abuse Research, a Professor in the Department of Psychiatry at the University of Minnesota Medical School, and a Senior Scientist at the Treatment Research Institute. He received his BA from the University of Minnesota and a PhD in Psychology (Clinical) from the State University of New York at Stony Brook.

His primary research interest is the prevention and treatment of adolescent drug abuse. Dr. Winters has published numerous research articles in this area, and has received several research grants from the National Institute of Health and various foundations. He is on the Editorial Boards for the Psychology of Addictive Behaviors, Journal of Child and Adolescent Substance Abuse, Journal of Gambling Studies, and the Journal of Substance Abuse Treatment.

He was also the Lead Editor for two Treatment Improvement Protocol Series (#31 and #32) published by the Center for Substance Abuse Treatment (SAMHSA) that focused on adolescent drug abuse assessment and treatment. He is a consultant to many organizations, including the Hazelden Foundation, National Institute on Drug Abuse, World Health Organization, and the Mentor Foundation (an international drug abuse prevention organization).

This is Your Brain on Adolescence

Ken Winters, Ph.D.Department of PsychiatryUniversity of Minnesotawinte001@umn.edu

January 22, 2014

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1. Addiction as braindisease

2. Brain development

3. Developing brain & alcohol risk

4. Summary

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1. Addiction as braindisease

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DopamineNeurotransmission

VTA/SNVTA/SNnucleus accumbensnucleus accumbens

frontalcortexfrontalcortex 00

100100200200300300400400500500600600700700800800900900

1000100011001100

00 11 22 33 44 5 hr5 hr

Time After AmphetamineTime After Amphetamine

% o

f B

as

al R

ele

as

e%

of

Ba

sa

l Re

lea

se

AMPHETAMINEAMPHETAMINE

00

5050

100100

150150

200200

00 6060 120120 180180Time (min)Time (min)

% o

f B

asal

Rel

ease

% o

f B

asal

Rel

ease

EmptyEmptyBoxBox FeedingFeeding

Di Chiara et al.Di Chiara et al.

FOODFOOD

Your Brain on CocainePET scan

1-2 Min 3-4 5-6

6-7 7-8 8-9

9-10 10-20 20-30

Yellow = cocaine is binding or attaching itself to areas of the brain

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CocaineCocaine

AlcoholAlcohol

DA

DA

DA

DA DADA

DA

Reward Circuits

DADA DADA

DA

Reward Circuits

DA

DA

DA

DA DA

DA

Drug AbuserDrug Abuser

Non-Drug AbuserNon-Drug Abuser

HeroinHeroin

MethMeth

Dopamine D2 Receptors are Lower in Addiction

controlcontrol addictedaddicted

What about recovery?

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Your Brain After Cocaine

Normal

Cocaine Addict - 10 days

Cocaine Addict - 100 days

Yellow = normal brain functioning

1. Brain imaging: addiction as brain

disease

2. Brain development

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Cautions

• Brain imaging studies are based on small samples• gender, ethnic and cultural

differences may be significant.

Adolescence is a period of profound brain maturation.

We thought brain development was complete by adolescence

We now know… maturation is not complete until about

age 25.

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Important ages of majority and privileges

16 - emancipation- driving

18 - gambling (usually age 21 when alcohol served)- smoking (some at age 19- military

21 -drinking

Allstate ad, NY Times,May, 2007

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An Immature Brain = Less Brakes on the “Go” System

Brain Development

1 2 7 16 30

Prenatal Post-birth Age

RA

TE

OF

CH

AN

GE

Myelination

Synaptic Refinement

Volume

Metabolism

Blood Flow

Receptors

Tapert & Schweinsburg (2005)

Adolescence

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Maturation Occurs from Back to Front of the BrainImages of Brain Development in Healthy Youth

(Ages 5 – 20)

Source: PHAS USA 2004 May 25; 101(21): 8174-8179. Epub 2004 May 17.

Blue represents maturing of brain areas

Earlier:Motor CoordinationEmotionMotivation

Later:Judgment

• Preference for…

1. physical activity

2. high excitement and rewarding activities

3. activities with peers that trigger high intensity/arousal

4. novelty

• Less than optimal…

5. control of emotional arousal

6. consideration of negative consequences

• Greater tendency to…

7. be attentive to social information

8. take risks and show impulsiveness

Seven Implications of Brain Development for Adolescent Behavior

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• Preference for…

1. physical activity

2. high excitement and rewarding activities

3. activities with peers that trigger high intensity/arousal

4. novelty

• Less than optimal…

5. control of emotional arousal

6. consideration of negative consequences

• Greater tendency to…

7. be attentive to social information

8. take risks and show impulsiveness

Seven Implications of Brain Development for Adolescent Behavior

Risk-Taking• Based on science of brain development, a

modern view of risk taking in adolescence is…• normative; important to development

• evolutionarily adaptive

• due primarily to emotional and contextual, not cognitive, factors

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Impact of Peer Presence onRisky Driving in Simulated Context

Chein et al., in press

peer effect

An Immature Brain = Low Brain Power

Source: US News & World Report, 2005

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An Immature Brain = Absence of Judgment

Source: US News & World Report, 2005

1. Brain imaging: addiction as brain

disease

3. Developing brain & alcohol risk

2. Brain imaging: brain development

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Are adolescents more susceptible than adults to alcohol?

4 lines of evidence(acknowledgement to Linda Spear, Ph.D.)

Implications of Brain Development for Drug Abuse Vulnerability

Unethical to give human adolescents alcohol in the laboratory;much of the best evidence comes from adolescent rat studies.

Cautions

• Supporting evidence on alcohol sensitivity from animal models needs to be interpreted with prudence. • assumptions of commonality across species may not hold

pertaining to the aute effects of intoxication • lab rats are administered ethanol via injection or directly into the

stomach• stress of injection impacts absorption and behavioral effects

• Other developmental factors, such as hormonal changes, are also biomedical contributors to alcohol sensitivity.

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1. Evidence from epidemiological studies

Drug use starts early and peaks in the teen years

Prevalence of Past-Year DSM-IV Alcohol Dependence: United States, 2001-2002(Grant, B.F., et al., Drug and Alcohol Dependence, 74, 223-234, 2004)

12.211

5.8

4.1 3.9 3.8 3.7

1.9

0.3 0.20

2

4

6

8

10

12

14

15-20 21-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+

%

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Percentages of Past Year Alcohol Use Disorder (Abuse or Dependence) Among Adults Aged 21 or Older, by Age of First Use (SAMHSA, 2005)

1615

9

4.22.6

0

5

10

15

20

<12 yrs 12-14 yrs 15-17 yrs 18-20 yrs 21+ yrs

Age Started Drinking

%

Fewer Problems in ThoseWho Start Later

Are adolescents more susceptible to alcohol than adults?

1. Epidemiological data

Comparing adolescent and adult rats, bothhaving no prior exposure to alcohol and matched on temperament….

2. Adolescent rats are less sensitive to the sedative and motor impairment effects of intoxication.

• more drinking before “signals to stop”

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The Water Maze Test

Hidden

Slide courtesySion Kim Harris, Ph.D.

• Saline vs alcohol • Measures

-Swimming speed-Time to find platform

2. Survey Data Suggest that Adolescents Are Less Sensitive to Alcohol’s Effects

148

26 2430 32

0

20

40

60

80

100

8th Graders 10th Graders 12th Graders

5+ drinks in row, past 2 weeks

Been drunk past month

Monitoring the Future, 2001

Less sensitive

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Are adolescents more susceptible to alcohol than adults?

1. Epidemiological data2. Adolescent rats are less sensitive to the sedative and

motor impairment effects of intoxication.

3. Adolescent rats are more sensitive to the social disinhibition effects of alcohol.

• greater social comfort from intoxication

Wanna lookfor some cheese

with me?Sure!

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Are adolescents more susceptible to alcohol than adults?

1. Epidemiological data

2. Adolescent rats are less sensitive to the sedative and motor impairment effects of intoxication.

3. Adolescent rats are more sensitive to the social disinhibition effects of alcohol.

#2 and #3 : May contribute to binge drinking and increased risk to alcohol dependence.

Are adolescents more susceptible to alcohol than adults?

1. Epidemiological evidence2. Adolescent rats are less sensitive to the sedative and

motor impairment effects of intoxication.

3. Adolescent rats are more sensitive to the social disinhibition effects of alcohol.

4. Alcohol may produce greater cognitive disruptions in adolescents.

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Human Data: Alcohol’s Effectson Memory

4. Adolescent rats more sensitive to..

• disruption in memory

• impairment of neurotransmission in hippocampus and cortex

Where ismy cheese?

Source: Spear, 2002

Human Data: Alcohol’s Effectson the Hippocampus

4. Adolescents with a history of alcohol use disorder….

Hippocampus volume (10%)

Source: Tapert & Schweinsburg, 2005

Where is myiPod?

Hippocampus converts information to memory

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Human Data: Alcohol’s Effects

8687

9796

70

75

80

85

90

95

100

Alc Dep

Non-AlcDep

Verbalinformation

Nonverbalinformation

Ret

enti

on R

ate

%

Source: Brown et al., 2000

hippocampus

MRI: Hippocampal Size

Nagel, Schweinsburg, Pham, & Tapert, 2005

•Hippocampus– Encodes new info

– Left smaller in AUD teens (p<.01)

– But no relationship with cognitive functioning (due to less severe alcohol group than Brown et al. sample?)

•Hippocampus– Encodes new info

– Left smaller in AUD teens (p<.01)

– But no relationship with cognitive functioning (due to less severe alcohol group than Brown et al. sample?)

10% smaller volume

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Teen Drinking & Brain Activation

Non-Drinkers Heavy Drinkers

Act

ivat

ion

De-

activ

atio

n

Age 16

Age 20

Tapert et al., 2001, 2004Slide courtesy of Susan Tapert, PhD.

2 yrs

drinking

5 yrs

drinking

Meier et al., 2012; PNAS

Sidebar: IQ Changes and Cannabis

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1. Brain imaging: addiction as brain

disease

2. Brain imaging: brain development

3. Developing brain & alcohol risk

4. Summary

Summary • Adolescence is an extended period of

transition from reliance on adults to independence

• Normal adolescence is characterized by….• increase in conflicts with family

members• desire to be with one’s friends• resistance to messages from

authority• irritability• risk taking• proclamations of sheer boredom

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Summary • The brain undergoes a

considerable amount of development during the teen years.

• The last area to develop is the prefrontal cortex, which is involved in planning, decision making and impulse control.

Summary

• Several lines of evidence suggesting that adolescents are more vulnerable to the effects of drugs – particularly alcohol – than adults.

WHY ?

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• Preference for ….1. physical activity2. high excitement and low effort activities3. activities with peers that trigger high

intensity/arousal4. novelty

• Less than optimal..5. balance of emotion and logic when making

decisions6. consideration of negative conseq.

• Greater tendency to…7. take risks and show impulsiveness

Seven Implications of Brain Development for Adolescent Behavior

• The developing brain has a robust dopamine system

• Drugs may be more reinforcing to the developing brain and thus, more subjected to the hijacking process.

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CocaineCocaine

AlcoholAlcohol

DA

DA

DA

DA DADA

DA

Reward Circuits

DADA DADA

DA

Reward Circuits

DA

DA

DA

DA DA

DA

Drug AbuserDrug Abuser

Non-Drug AbuserNon-Drug Abuser

HeroinHeroin

MethMeth

Dopamine D2 Receptors are Lower in Addiction

controlcontrol addictedaddicted

“Priming the Pump” Theory

• Does early exposure to drugs alter the brain in ways that contribute to the addiction in an adolescent?

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Average Number of Self-Administered Doses of NicotineWhen Rats Were Adults (Levin et al., 2003)

10

4.5

0

2

4

6

8

10

12

Adolescent Adult

Average # self-admin.

Age of Rates When First Exposed to Nicotine. All DataCollected When Rats were Adults.

Brain Development: Reinforcing Need for Prevention and Treatment

• Youth is a particularly vulnerable period for developing a substance use disorder.

• Prevention and treatment programs are vital.

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Brain Development: Opportunities for Prevention and Treatment

• Discuss with teenagers the science of the neurobiology of addiction

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Brain Development: Opportunities for Prevention and Treatment

• Discuss the implications of using substances when the brain is still developing.

Human Data: Alcohol’s Effectson Memory

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Brain Development: Implications for Prevention and Treatment

• Teach important skills not optimal for the teen brain

• impulse control

• “second” thought processes

• social decision making

• dealing with risk situations

• taking healthy risks

• There are now some age-appropriate resources to educate youth about their developing brain.

• Resource from BSCS Drug Abuse, Addiction and the Adolescent Brain(www.BSCS.org)

• Hazelden has published an 8-lesson multi media resource: Drugs and the Developing Brain(www.hazelden.org)

Classroom Resources

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Parent Resources

Prevention Smart Parents

www. prevention-smart.org

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www.drugfree.org/Parent/

Working with Parents

P = Promote activities that capitalize on the strengths of the developing brain.

A = Assist children with challenges that require planning.

R = Reinforce their seeking advice from adults; teach decision making.

E = Encourage lifestyle that promotes good brain development.

N = Never underestimate the effects of drugs on the developing brain;

emphasize the importance of drug-free lifestyle.

T = Tolerate the “oops” behaviors due to an immature brain.

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Suggested Readings

Dahl, R.E. & Spear, L.P. (Eds.) (2004). Adolescent brain development: vulnerabilities and opportunities. NY, NY: Annals of the New York Academy of Sciences, Volume 1021.

Dubuc, B. (n.d.). The brain from top to bottom. Retrieved September 1, 2004, from McGill University Web site: http://www.thebrain.mcgill.ca/flash/index_d.html#

Nestler, E. J., & Malenka, R. C. (2004, March). The addicted brain. Scientific American, 290 (3), 78-85.

Wallis, C. (2004, May 10). What makes teens tick? Time, 163, 57-65.

U.S. News & World Report. (Special Issue, 2005). Mysteries of the teen years. Author.

Questions and Discussion

Evaluation :  SAMHSA’s GPRA

For additional information and follow-up questions contact:

THANK YOUKen Winters, PhDUniversity of Minnesotawinte001@umn.edu

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Questions and Discussion

Please type your questions or comments for the

presenter in the Q&A pod at this time…

Email Follow-up

Within the next 24 hours, you will receive an email from the National AI & AN ATTC which will include:

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We appreciate your participation in our survey, it should take you no more than 10 minutes to complete, and lets SAMHSA know:

• How many people attended our webinar

• How satisfied you are with our webinar

• How useful our webinars are to you

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Referral, Service Coordination, and Documentation presented by: Dee Le Beau-Hein, MS, Cheyenne River Sioux Tribe

Treatment Knowledgepresented by: Bob Rohret, MPH, IADC

Upcoming webinars from the National American Indian & Alaska Native ATTC

Bridging the Gaps in Culture and Geography: Telehealth with American Indian Communitiespresented by: Spero Manson, PhD, Pembina Chippewa

Disrespecting Our Elders: Elder Abuse Indicators and Screening in Indian Countrypresented by: Jacque Gray, PhD, Choctaw & Cherokee Nation

For more information about our webinar series, contact Kate Thrams at kate-thrams@uiowa.edu or 319-335-5362

Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

Based on the Substance Abuse and

Mental Health Services Administration’s

Technical Assistance Publication #21:

“Addiction Counseling Competencies”

Thank youfor taking time out of your very important

work to ensure quality service through education in collaboration with the persons

you serve