COGNITIVE IMPAIRMENTCOGNITIVE IMPAIRMENT

IMPLICATIONS FOR SUBSTANCE IMPLICATIONS FOR SUBSTANCE ABUSE TREATMENT PROVIDERSABUSE TREATMENT PROVIDERS

April 23April 23rdrd and 24 and 24thth, 2009, 2009

GOALSGOALS

To increase understanding of the structures, To increase understanding of the structures, functions, and circuitry of the brain,functions, and circuitry of the brain,

To raise awareness of how drugs of abuse To raise awareness of how drugs of abuse impact cognitive systems, impact cognitive systems,

To increase understanding of the types of To increase understanding of the types of impairments that occur and the implications for impairments that occur and the implications for treatment, and treatment, and

To increase understanding of the types of To increase understanding of the types of modifications which need to be made to modifications which need to be made to treatment protocols to increase client retention treatment protocols to increase client retention and successand success

BRAIN OVERVIEWBRAIN OVERVIEW

BRAIN FACTSBRAIN FACTS

Brain weighs Brain weighs approximately approximately 33 pounds pounds

Brain has approximately Brain has approximately 100 billion neurons and 1 100 billion neurons and 1 trillion supporting cellstrillion supporting cells

Neurons grow and Neurons grow and organize themselves into organize themselves into efficient systems that efficient systems that operate a lifetimeoperate a lifetime

Brain controls Brain controls ALLALL activitiesactivities

Emotion and cognition are Emotion and cognition are intertwinedintertwined

Neurons can re-route Neurons can re-route circuitscircuits

Brain and environment Brain and environment involved in delicate duetinvolved in delicate duet

BrainBrain never stops adapting never stops adapting and changingand changing

BRAIN STRUCTURES AND BRAIN STRUCTURES AND FUNCTIONSFUNCTIONS

BRAIN STRUCTURESBRAIN STRUCTURES

Frontal LobeFrontal Lobe Parietal LobeParietal Lobe Temporal LobeTemporal Lobe Occipital LobeOccipital Lobe

CerebellumCerebellum Corpus CallosumCorpus Callosum Brain StemBrain Stem

Frontal Lobe: problem solving, concentration, self monitoring, mental flexibility, judgment, planning, understand consequences

Brain Stem: breathing, heart rate, sleep/wake functions, arousal, consciousness,

Parietal Lobe:

spatial/visual perception, sense of touch, differentiation of size, shape, color

Cerebellum: balance, coordination, skilled motor activity

Temporal Lobe: memory, hearing, organization, sequencing

Occipital Lobe: vision

FUNCTIONAL AREAS OF THE FUNCTIONAL AREAS OF THE BRAINBRAIN

http://universe-review

Central Nervous SystemCentral Nervous System Reticular activating systemReticular activating system

– Receives input from all the sensory systems Receives input from all the sensory systems and cerebral cortexand cerebral cortex

– Controls the brain’s state of arousal (sleep vs. Controls the brain’s state of arousal (sleep vs. awake)awake)

Basal gangliaBasal ganglia– Controls motor activityControls motor activity

Limbic systemLimbic system– Regulates emotional activities, memory, and Regulates emotional activities, memory, and

endocrine activityendocrine activity– DopamineDopamine

Central Nervous System Central Nervous System (continued)(continued)

The The cerebral cortexcerebral cortex– Helps interpret, process, and respond to Helps interpret, process, and respond to

informationinformation

The The hypothalamushypothalamus– Controls endocrine and basic body functionsControls endocrine and basic body functions

Central Nervous System Central Nervous System StructureStructure

INTEGRATION OF THE LOBESINTEGRATION OF THE LOBES

The different lobes of the brain The different lobes of the brain work work togethertogether– like – like instrumentsinstruments in an orchestra in an orchestra to play music or to play music or lettersletters in the alphabet to in the alphabet to form wordsform words

Each area makes specialized contributions Each area makes specialized contributions to certain functions, but many brain regions to certain functions, but many brain regions participate in forming human thoughts and participate in forming human thoughts and behaviorsbehaviors

FRONTAL LOBEFRONTAL LOBE Seat of Seat of personality, judgment, reasoning, personality, judgment, reasoning,

problem solving, and rational decision makingproblem solving, and rational decision making Provides for Provides for logic and understanding oflogic and understanding of

consequencesconsequences Governs Governs impulsivity, aggression, ability to impulsivity, aggression, ability to

organize thoughts, and plan for the futureorganize thoughts, and plan for the future Controls capacity for Controls capacity for abstraction, attention, abstraction, attention,

cognitivecognitive flexibility, and goal persistenceflexibility, and goal persistence Undergoes significant changes during Undergoes significant changes during

adolescence — adolescence — not fully developed until mid not fully developed until mid 20’s20’s

FRONTAL LOBEFRONTAL LOBE As the “prefrontal cortex” area of the frontal lobe As the “prefrontal cortex” area of the frontal lobe

matures and heals, matures and heals, through treatment, through treatment, experience and practice, experience and practice, clients can reason clients can reason better,better, develop more impulse control, and make develop more impulse control, and make better judgmentsbetter judgments

Prefrontal cortex is Prefrontal cortex is one of the last areas of the one of the last areas of the brain to fully developbrain to fully develop

Adolescents have an Adolescents have an increasedincreased need for struc- need for struc-

ture, mentoring, guidanceture, mentoring, guidance

TEMPORAL LOBESTEMPORAL LOBES

Responsible for hearing, understanding speech, Responsible for hearing, understanding speech, and forming an integrated sense of selfand forming an integrated sense of self

Responsible for sorting new information and for Responsible for sorting new information and for short term memoryshort term memory

Contains the limbic-reward system Contains the limbic-reward system (amygdala, (amygdala, hippocampus, nucleus acumbens, and ventral hippocampus, nucleus acumbens, and ventral tegmental area (vta)tegmental area (vta)

Matures around ages 18-19Matures around ages 18-19

TEMPORAL LOBE/LIMBIC SYSTEMTEMPORAL LOBE/LIMBIC SYSTEM

Limbic system regulates emotions and Limbic system regulates emotions and motivations— motivations— particularly those related to particularly those related to survival—such as fear, anger, and pleasure survival—such as fear, anger, and pleasure (sex and eating)(sex and eating)

Feelings of pleasure/reward are very Feelings of pleasure/reward are very powerful and self-sustaining. powerful and self-sustaining. Pleasurable Pleasurable behaviors activate a circuit of specialized behaviors activate a circuit of specialized nerve cellsnerve cells in the limbic area that is devoted in the limbic area that is devoted to producing and regulating pleasure called to producing and regulating pleasure called the reward systemthe reward system

REWARD SYSTEMREWARD SYSTEM

Drugs of abuse Drugs of abuse activate the reward system activate the reward system in the limbic area of the brainin the limbic area of the brain —producing —producing powerful feelings of pleasurepowerful feelings of pleasure

Desire to repeat drug using behavior is Desire to repeat drug using behavior is strongstrong

Drugs of abuse can/do exert powerful control Drugs of abuse can/do exert powerful control over behavior because they act directly on the over behavior because they act directly on the more primitive, survival limbic structures— more primitive, survival limbic structures— over-ride the frontal cortex in controlling over-ride the frontal cortex in controlling ourour behaviorbehavior

BRAIN CIRCUITRYBRAIN CIRCUITRY

Brain CircuitryBrain Circuitry NEURON NEURON —specialized cell designed to —specialized cell designed to

transmit information to other nerve cells and transmit information to other nerve cells and musclesmuscles

Each neuron consists of a cell body, axon, Each neuron consists of a cell body, axon, and dendriteand dendrite

AxonAxon– an – an electricityelectricity conducting fiber that conducting fiber that carries information away from the cell bodycarries information away from the cell body

DendriteDendrite– receives messages from other – receives messages from other neuronsneurons

SynapseSynapse– contact point where one neuron – contact point where one neuron chemicallychemically “communicates” with another “communicates” with another neuronneuron

NeuronsNeurons

Neurons can send discrete Neurons can send discrete excitatoryexcitatory or or inhibitoryinhibitory messages to their target messages to their target cells.cells.

Neurons are distinguished by the type Neurons are distinguished by the type of neurotransmitter they release.of neurotransmitter they release.

Neurotransmitters represent a wide Neurotransmitters represent a wide variety of chemical substances and variety of chemical substances and functions.functions.– Example: Example: Dopamine activates the Dopamine activates the

pleasure center.pleasure center.

Common NeurotransmittersCommon NeurotransmittersNeurotransmitter type of effect CNS changes drugs of abuseDopamine

GABA

Serotonin

Acetylcholine

Endorphins

inhibitory-excitatory

inhibitory

inhibitory

excitatory-inhibitory

inhibitory

euphoria agitation paranoiasedation relaxation drowsiness depressionsleep relaxation sedationmild euphoria excitation insomniamild euphoria block pain slow respiration

amphetamines, cocaine

alcohol, Valium-type barbiturates

LSD

tobacco, nicotine

narcotics

LEARNING IS A PROCESS OF LEARNING IS A PROCESS OF CREATINGCREATING AND AND

STRENGTHENINGSTRENGTHENING NEURAL NEURAL SYNAPSES AND CORTICAL SYNAPSES AND CORTICAL

INTEGRATIONINTEGRATION

ADDICTION PROCESS ADDICTION PROCESS WITHIN BRAIN CIRCUITSWITHIN BRAIN CIRCUITS

Copyright ©2003 American Society for Clinical Investigation

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

OFCOFCSCC

NAcc

NAcc VPVP

REWARDREWARD

PFCPFC

ACGACG

INHIBITORY INHIBITORY CONTROLCONTROL

INHIBITORY INHIBITORY CONTROLCONTROL

MOTIVATION/MOTIVATION/DRIVE DRIVE

(saliency)(saliency)

MOTIVATION/MOTIVATION/DRIVE DRIVE

(saliency)(saliency)

Brain Circuits Involved in Brain Circuits Involved in Drug AddictionDrug Addiction

Brain Circuits Involved in Brain Circuits Involved in Drug AddictionDrug Addiction

HippHipp

AmygAmygMEMORY/LEARNING MEMORY/

LEARNING

ADDICTION PROCESSADDICTION PROCESS

During addiction, the During addiction, the enhanced valueenhanced value of of the drug in the reward, motivation, and the drug in the reward, motivation, and memory circuits memory circuits overcomes the overcomes the inhibitory control exerted by the inhibitory control exerted by the prefrontal cortexprefrontal cortex,, thereby favoring a thereby favoring a positive feedback loop initiated by the positive feedback loop initiated by the consumption of the drug and perpetuated consumption of the drug and perpetuated by the enhanced activation of the by the enhanced activation of the motivation/drive and memory circuits motivation/drive and memory circuits (Volkow, (Volkow, Fowler, and Wang, 2003)Fowler, and Wang, 2003)

00100100200200300300400400500500600600700700800800900900

1000100011001100

00 11 22 33 44 5 hr5 hr

Time After AmphetamineTime After Amphetamine

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DADADOPACDOPACHVAHVA

AccumbensAccumbens AMPHETAMINEAMPHETAMINE

00

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200200

300300

400400

00 11 22 33 44 5 hr5 hrTime After CocaineTime After Cocaine

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DADADOPACDOPACHVAHVA

AccumbensAccumbensCOCAINECOCAINE

00

100100

150150

200200

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00 11 22 3 hr3 hr

Time After NicotineTime After Nicotine

% o

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AccumbensAccumbensCaudateCaudate

NICOTINENICOTINE

Source: Di Chiara and ImperatoSource: Di Chiara and Imperato

Effects of Drugs on Dopamine ReleaseEffects of Drugs on Dopamine ReleaseEffects of Drugs on Dopamine ReleaseEffects of Drugs on Dopamine Release

Much greaterActivity than anyOther drug of abuse -causes neurotoxicity

100100

150150

200200

250250

00 11 22 33 4hr4hrTime After EthanolTime After Ethanol

% o

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ase

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AccumbensAccumbens

00

Dose (g/kg ip)Dose (g/kg ip)

ETHANOLETHANOLETHANOL

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AccumbensAccumbens

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Dose (g/kg ip)Dose (g/kg ip)

ETHANOLETHANOLETHANOL

ADDICTION PROCESSADDICTION PROCESS

The reward value of the drug The reward value of the drug is much greater than is much greater than any natural reinforcerany natural reinforcer – these can no longer – these can no longer compete as viable alternative choices compete as viable alternative choices (priority/saliency has become fixed in the (priority/saliency has become fixed in the orbitofrontal cortex (OFC which is part of the orbitofrontal cortex (OFC which is part of the prefrontal cortex and located above your temples)prefrontal cortex and located above your temples)

Withdrawal state Withdrawal state reactivates the OFCreactivates the OFC and results and results in compulsive drug takingin compulsive drug taking

Damage to the OFC results in Damage to the OFC results in behavioral behavioral compulsioncompulsion to take the drug even when it is no to take the drug even when it is no longer reinforcing/pleasurable longer reinforcing/pleasurable (Volkow et al., 2003)(Volkow et al., 2003)

CONTROL CIRCUITSCONTROL CIRCUITS

fMRI studies demonstrate fMRI studies demonstrate abnormalities in the abnormalities in the Prefrontal Cortex (PFC)–Prefrontal Cortex (PFC)– area for decision making area for decision making and inhibitory controland inhibitory control

These abnormalities could be involved in the These abnormalities could be involved in the changes in decision making, judgment, and changes in decision making, judgment, and cognitive controlcognitive control that occur in addiction that occur in addiction

Changes in the PFC could lead to the Changes in the PFC could lead to the loss of self-loss of self-directed/willed behaviordirected/willed behavior in favor of automatic in favor of automatic sensory driven behavior (sensory driven behavior (Goldstein & Volkow, 2002)Goldstein & Volkow, 2002)

COGNITIVE IMPAIRMENTCOGNITIVE IMPAIRMENT

COGNITIVE IMPAIRMENTCOGNITIVE IMPAIRMENT

Cognitive impairment may be an important Cognitive impairment may be an important factor in explaining/predicting treatment factor in explaining/predicting treatment failurefailure

Research indicates that Research indicates that 30-80%30-80% of clients of clients entering substance abuse treatment entering substance abuse treatment programs may have measurable cognitive programs may have measurable cognitive impairment (Aharonovich, E., et al., 2003; impairment (Aharonovich, E., et al., 2003; Fals-Stewart, 1996; Grohman, 2003))Fals-Stewart, 1996; Grohman, 2003))

COGNITIVE IMPAIRMENTCOGNITIVE IMPAIRMENT Research suggests that chronic use of Research suggests that chronic use of

psychoactive substances is associated psychoactive substances is associated with cognitive deficits, with cognitive deficits, especially in especially in executive functioning and memoryexecutive functioning and memory (Ersche, K.D., et al, 2006)(Ersche, K.D., et al, 2006)

Cognitive functions including: Cognitive functions including: decision decision making, attention, working memory, making, attention, working memory, inhibitory control, planning, fluency, inhibitory control, planning, fluency, reasoning, and processing speedreasoning, and processing speed are all are all negatively impacted with drug use negatively impacted with drug use (Verdejo-(Verdejo-Garcia, A. & Perez-Garcia, M., 2007; Lundqvist, T., Garcia, A. & Perez-Garcia, M., 2007; Lundqvist, T., 2005; Quednow, B. et al., 2006; Lamers, C. et al., 2006; 2005; Quednow, B. et al., 2006; Lamers, C. et al., 2006; & Vik P. et al., 2004)& Vik P. et al., 2004)

COGNITIONCOGNITIONCognition is Cognition is basicbasic to the acquisition of knowledge to the acquisition of knowledge

and includes:and includes:learning, reasoning, problem solving, perception, learning, reasoning, problem solving, perception, judgment, concentration, ability to analyze, judgment, concentration, ability to analyze, discriminate, organize, categorize, memorize discriminate, organize, categorize, memorize and perform functions influenced by emotions and perform functions influenced by emotions and social feelingsand social feelings

When operating, When operating, cognitioncognition allows an individual to allows an individual to process information and to appropriately interact process information and to appropriately interact with the worldwith the world

Cognitive skills are the Cognitive skills are the scaffoldingscaffolding upon which one builds knowledge, success, and understanding (Medalia & Revheim, 2003)

IMPORTANT ASPECTS OF IMPORTANT ASPECTS OF COGNITIONCOGNITION

COGNITIONCOGNITION includes: includes:

ability to pay attentionability to pay attentionability to remember and recall ability to remember and recall informationinformationability to process information quickly ability to process information quickly ability to initiate speechability to initiate speechability to think criticallyability to think criticallyability to plan, organize, and problem ability to plan, organize, and problem solvesolve

IMPACT ON TREATMENTIMPACT ON TREATMENT

Impaired memory, attention, learning, reaction Impaired memory, attention, learning, reaction time, and cognitive flexibility are documented time, and cognitive flexibility are documented consequences of chronic cocaine use consequences of chronic cocaine use (Mann, (Mann, 2005)2005)

Treatment drop out rates have been Treatment drop out rates have been correlated correlated with degree of cognitive impairment with degree of cognitive impairment (Aharonovich, (Aharonovich, E., et al., 2003)E., et al., 2003)

Treatment completers tend to score higher in all Treatment completers tend to score higher in all cognitive domainscognitive domains vs. treatment drop outs vs. treatment drop outs (attention, abstract reasoning, memory, spatial (attention, abstract reasoning, memory, spatial processing, and reaction time) processing, and reaction time) [Aharonovich, E., et [Aharonovich, E., et al., 2003]al., 2003]

IMPACT ON TREATMENTIMPACT ON TREATMENT

Therapy Therapy (especially CBT & MET) focuses (especially CBT & MET) focuses on teaching the connections between on teaching the connections between thought, feelings, and actionsthought, feelings, and actions

TherapyTherapy involves thinking, planning, involves thinking, planning, analyzing situations, controlling impulses, analyzing situations, controlling impulses, and changing habitsand changing habits

TherapyTherapy involves many cognitive functions involves many cognitive functions—if these are impaired, clients are more —if these are impaired, clients are more likely to drop out of treatment likely to drop out of treatment (Aharonovich, E., (Aharonovich, E., et al., 2003)et al., 2003)

IMPACT ON TREATMENTIMPACT ON TREATMENT

If clients are If clients are unable to understand, process, and unable to understand, process, and relate to what is being saidrelate to what is being said in a therapy group, the in a therapy group, the group is not meaningful, increases client frustration, group is not meaningful, increases client frustration, and may lead to dropping out of treatmentand may lead to dropping out of treatment

Treatment protocols need to be modified Treatment protocols need to be modified Client resistance, lack of motivation, bad attitude, Client resistance, lack of motivation, bad attitude,

anger need to be re-examined in the context of anger need to be re-examined in the context of cognitive impairment cognitive impairment (Grohman, K. & Fals-Stewart, W., (Grohman, K. & Fals-Stewart, W., 2003)2003)

Clinicians and other systems Clinicians and other systems assumeassume that clients that clients have all of the cognitive skills needed to benefit have all of the cognitive skills needed to benefit from treatment from treatment

HOW COGNITIVE IMPAIRMENTS HOW COGNITIVE IMPAIRMENTS IMPACT TREATMENTIMPACT TREATMENT

ATTENTION–ATTENTION– Some clients have difficulty paying Some clients have difficulty paying attention, difficulty concentrating, unable to follow attention, difficulty concentrating, unable to follow what they are reading/hearing, lose track of what they are reading/hearing, lose track of important points, difficulty concentrating when important points, difficulty concentrating when there are distractions, fail to understand the big there are distractions, fail to understand the big picture, unable to multi-taskpicture, unable to multi-task

MEMORY–MEMORY– Directions may be forgotten, clients Directions may be forgotten, clients may be unable to recall information, may be able may be unable to recall information, may be able to remember old routines, but are unable to to remember old routines, but are unable to learn/remember new routineslearn/remember new routines

HOW COGNITIVE IMPAIRMENTS HOW COGNITIVE IMPAIRMENTS IMPACT TREATMENTIMPACT TREATMENT

INFORMATION PROCESSING–INFORMATION PROCESSING– Client’s Client’s ability to process information is slower, ability to process information is slower, response times are slower, takes longer response times are slower, takes longer for information to register, speech may for information to register, speech may seem slower, or difficulty forming answers seem slower, or difficulty forming answers (Medalia, A. & Revheim, N., 2003)(Medalia, A. & Revheim, N., 2003)

Attention, memory, and information Attention, memory, and information processing are critical to a client’s ability to processing are critical to a client’s ability to handle the cognitive aspects of substance handle the cognitive aspects of substance abuse treatment abuse treatment (Fein, G., et al., 1990).(Fein, G., et al., 1990).

HOW COGNITIVE IMPAIRMENTSHOW COGNITIVE IMPAIRMENTS IMPACT TREATMENTIMPACT TREATMENT

Cognitive impairments impact client’s Cognitive impairments impact client’s ability toability to function at work, home, function at work, home, school, community, and in school, community, and in relationshipsrelationships

Research demonstrates that all drugs of Research demonstrates that all drugs of abuse create abuse create disruptionsdisruptions in the brain’s in the brain’s neural networks neural networks (Lunqvist, 2005)(Lunqvist, 2005)

ALCOHOLALCOHOL

First reports of cognitive impairment from alcohol First reports of cognitive impairment from alcohol were published as early as 1880 by Wernicke and were published as early as 1880 by Wernicke and KorsakoffKorsakoff

Research has consistently demonstrated that most Research has consistently demonstrated that most alcoholics alcoholics exhibit mild to moderate deficiencies exhibit mild to moderate deficiencies in intellectual functioningin intellectual functioning along with diminished along with diminished brain size and regional changes in brain cell brain size and regional changes in brain cell activity activity (Parsons, 1998)(Parsons, 1998)

Even mild to moderate drinking can adversely Even mild to moderate drinking can adversely affect memory activities such as acquiring, storing, affect memory activities such as acquiring, storing, and retrieving newly learned informationand retrieving newly learned information

ALCOHOLALCOHOL

Fein, et.al., describes three distinct patterns of Fein, et.al., describes three distinct patterns of cognitive deficits that relate to cognitive deficits that relate to length of length of abstinenceabstinence::

Acute detoxAcute detox – – first two weeks of abstinencefirst two weeks of abstinence Intermediate abstinence Intermediate abstinence – – begins afterbegins after

detoxification and extends through first two detoxification and extends through first two months of abstinencemonths of abstinence

Long term abstinence Long term abstinence – – extends from two extends from two months to five years of abstinencemonths to five years of abstinence

The following table from Fein et. al. outlines the cognitive deficits that a client may The following table from Fein et. al. outlines the cognitive deficits that a client may experience as a function of the length of abstinence:experience as a function of the length of abstinence:

TABLE 1. Cognitive Deficits as a Function of Duration of Abstinence(Fein et al.)

Cognitive Deficit Acute Detox Period

Intermediate Abstinence Period

Long Term Abstinence

Distractibility Yes ----- -----

Mild Confusion Yes ---- -----

Irritability Yes ---- ----

Attention & Concentration Yes Yes ----

Reaction Time Yes Yes ----

Verbal Learning Ability Yes Yes ----

Verbal Abstract Reasoning Yes Yes ----

Verbal Short Term Memory Yes Yes ----

Nonverbal Abstract Reasoning Yes Yes Yes

Visuospatial Abilities Yes Yes Yes

Mental Flexibility Yes Yes Yes

Nonverbal Short Term Memory Yes Yes Yes

ALCOHOLALCOHOL

Cognitive recovery appears to be Cognitive recovery appears to be influenced by:influenced by:

Age of initial use:Age of initial use: younger = more younger = more negative impactnegative impact

Educational level:Educational level: lower lower educational levels may be associated with educational levels may be associated with less bufferless buffer

Medical conditions:Medical conditions: pre-existing pre-existing conditionsconditions

Dual diagnosis:Dual diagnosis: exacerbate exacerbate cognitive impairmentscognitive impairments

HEROINHEROIN Executive functioning organized into four Executive functioning organized into four

separate components:separate components:UPDATING:UPDATING: taking in and taking in and

processing new informationprocessing new informationINHIBITION:INHIBITION: ability to control ability to control

impulsesimpulsesSHIFTING:SHIFTING: ability to flexibly change ability to flexibly change

forward or backward in relation to different forward or backward in relation to different tasks, mental operations, or schemastasks, mental operations, or schemas

DECISION MAKING:DECISION MAKING: ability to use ability to use all information to make appropriate, goal all information to make appropriate, goal directed decisionsdirected decisions

Verdejo-Garcia, Perez-Garcia, Fisk, Sharp, & Miyake, 2000

HEROINHEROIN

The The anterior cingulate cortexanterior cingulate cortex (of the limbic (of the limbic area) and the area) and the prefrontal cortexprefrontal cortex are are affected by the use/abuse of heroinaffected by the use/abuse of heroin

Memory and inhibition impairments may Memory and inhibition impairments may persist even after many years of persist even after many years of abstinenceabstinence

Heroin may cause structural changes in Heroin may cause structural changes in these two brain regions these two brain regions (Ersche, 2006)(Ersche, 2006)

Structural changes Structural changes may increasemay increase vulnerability to drug seeking behavior and vulnerability to drug seeking behavior and relapserelapse

STIMULANTSSTIMULANTS

Research on stimulants has documented Research on stimulants has documented deficitsdeficits in verbal learning, in verbal learning, delayeddelayed recall, recall, information information processingprocessing speed, speed, impairedimpaired/distracted attention, and /distracted attention, and reduced reduced cognitive flexibility cognitive flexibility (Lundqvist, 2004)(Lundqvist, 2004)

Research has also documented specific Research has also documented specific structural damagestructural damage such as gray matter such as gray matter atrophy, neurodegeneration of dopamine atrophy, neurodegeneration of dopamine axons, smaller hippocampal volumes axons, smaller hippocampal volumes (Thompson, 2003; McCann, 1998; Volkow, 2001b; and (Thompson, 2003; McCann, 1998; Volkow, 2001b; and Thompson, 2004)Thompson, 2004)

STIMULANTSSTIMULANTS

Research has also demonstrated that Research has also demonstrated that stimulants can impact the stimulants can impact the updating, updating, inhibition, shifting, and decision inhibition, shifting, and decision makingmaking components of executive components of executive functioning functioning (Verdejo-Garcia & Perez-Garcia, 2000)(Verdejo-Garcia & Perez-Garcia, 2000)

Impairments result in difficulty with self Impairments result in difficulty with self monitoring, impulsivity, lack of focus, and monitoring, impulsivity, lack of focus, and an inability to change inappropriate an inability to change inappropriate behaviorsbehaviors

UnclearUnclear to what extent these cognitive to what extent these cognitive deficits are reversible deficits are reversible (Thompson, 2004)(Thompson, 2004)

MARIJUANAMARIJUANA

Research has consistently demonstrated Research has consistently demonstrated that memory, learning, attention, that memory, learning, attention, psychomotor and motivation related psychomotor and motivation related activities are negatively impacted by activities are negatively impacted by cannabis use cannabis use (Karila, et.al., 2005)(Karila, et.al., 2005)

Research beginning to reflect changes to Research beginning to reflect changes to the underlying cortical, subcortical, and the underlying cortical, subcortical, and neuro-modulatory mechanisms that neuro-modulatory mechanisms that underpin cognitionunderpin cognition

Generally effects are divided into acute and Generally effects are divided into acute and residual categoriesresidual categories

MARIJUANAMARIJUANA AcuteAcute effects include mood changes, perceptual effects include mood changes, perceptual

changes, and impairment in memory, attention, changes, and impairment in memory, attention, motor skills, and reaction timemotor skills, and reaction time

ResidualResidual effects include “drug residue” effects effects include “drug residue” effects from cannabis accumulating in the bodyfrom cannabis accumulating in the body

Other residual effects include impairments in Other residual effects include impairments in memory, memory retrieval, and attention. These memory, memory retrieval, and attention. These effects may worsen with increasing years of effects may worsen with increasing years of regular cannabis use. regular cannabis use.

At present, it is At present, it is unclearunclear if effects resolve with long if effects resolve with long term abstinenceterm abstinence

Research suggests that cognitive impairments Research suggests that cognitive impairments from cannabis use are greater among substance from cannabis use are greater among substance abusers with co-occurring disorders abusers with co-occurring disorders (Lundqvist, (Lundqvist, 2005)2005)

HOW TO TREAT CLIENTS WITH HOW TO TREAT CLIENTS WITH COGNITIVE IMPAIRMENTSCOGNITIVE IMPAIRMENTS

Conduct Conduct initialinitial cognitive status exam– there is no one cognitive status exam– there is no one “best” test. Instead determine what you want to know, “best” test. Instead determine what you want to know, i.e., attention/concentration, verbal/non-verbal i.e., attention/concentration, verbal/non-verbal memory, conceptualization skills, planning skills, memory, conceptualization skills, planning skills, motor dexterity, cognitive flexibility skills, etc.motor dexterity, cognitive flexibility skills, etc.

Conduct Conduct periodicperiodic cognitive status exams to determine cognitive status exams to determine increases/decreases increases/decreases

Modify treatment protocolsModify treatment protocols Train staff to recognize and assess cognitive Train staff to recognize and assess cognitive

impairmentsimpairments Incorporate Incorporate cognitive remediation, compensatory cognitive remediation, compensatory

strategies, and adaptive approachesstrategies, and adaptive approaches

MODIFY TREATMENT MODIFY TREATMENT PROTOCOLSPROTOCOLS

DecreaseDecrease length of sessions (attention, length of sessions (attention, memory)memory)

IncreaseIncrease session frequency (practice) session frequency (practice) RepeatRepeat presentations of therapeutic information presentations of therapeutic information

(detox, 2 weeks, 4 weeks, 1 month, 3 months, (detox, 2 weeks, 4 weeks, 1 month, 3 months, etc)etc)

Multi-modal presentationsMulti-modal presentations — audio, visual, — audio, visual, experiential, verbal, hot/cold situations, etc experiential, verbal, hot/cold situations, etc (Grohman, K. & Fals-Stewart, W., 2003; Medalia, A. & Revheim, (Grohman, K. & Fals-Stewart, W., 2003; Medalia, A. & Revheim, N., 2003; & Arahonovich, E., et al., 2003)N., 2003; & Arahonovich, E., et al., 2003)

MODIFY TREATMENT MODIFY TREATMENT PROTOCOLSPROTOCOLS

Use Use memory aids—memory aids— calendars, planners, calendars, planners, appointment books, diagramsappointment books, diagrams

Teach Teach stress managementstress management skills skills ProvideProvide immediate feedback immediate feedback and and

corrective experiencescorrective experiences Repeat instructions, Repeat instructions, put things in writingput things in writing, ,

provide short/direct instructions, be aware provide short/direct instructions, be aware of distractions, be aware of need for restof distractions, be aware of need for rest

REMEDIATIONREMEDIATION

Includes Includes specific drillsspecific drills using computerized using computerized software, paper/pencil tasks, group software, paper/pencil tasks, group exercises to improve memory and attentionexercises to improve memory and attention

Treatment interventions include social, Treatment interventions include social, emotional, and functional componentsemotional, and functional components

NET, CRT, CET NET, CRT, CET combinedcombined with Work with Work TherapyTherapy

COMPENSATORY STRATEGIESCOMPENSATORY STRATEGIES

Rely on trade offsRely on trade offs Develop alternative methods for completing Develop alternative methods for completing

taskstasks Develop memory categories, memory aidsDevelop memory categories, memory aids

planners, pictures, etcplanners, pictures, etc ** Develop guiding questions, acronyms for ** Develop guiding questions, acronyms for

problem solving steps problem solving steps

ADAPTIVE APPROACHESADAPTIVE APPROACHES

Change the environment instead of the Change the environment instead of the personperson

Memory tools such as cassette recorders, Memory tools such as cassette recorders, Ipods, etcIpods, etc

Enlist family/environmental supportEnlist family/environmental support Try to enhance functioning through stable, Try to enhance functioning through stable,

predictable structurepredictable structure

COGNITIVE ENHANCEMENTCOGNITIVE ENHANCEMENT

GamesGames—scrabble, uno, chess, set—scrabble, uno, chess, set Computerized gamesComputerized games Interdisciplinary team approachInterdisciplinary team approach, ,

coordination with community resources, coordination with community resources, emphasis on self awareness of strengths emphasis on self awareness of strengths and weaknesses, supported risk taking and and weaknesses, supported risk taking and feedback, peer group therapy, and feedback, peer group therapy, and opportunities to practice social and opportunities to practice social and emotional coping skillemotional coping skill

CORTICAL INTEGRATIONCORTICAL INTEGRATION

StrengthenStrengthen the frontal cortex—judgment, the frontal cortex—judgment, reasoning, rational decision making, reasoning, rational decision making, problem solving, etcproblem solving, etc

Increase the ability of the cortexIncrease the ability of the cortex to process, to process, inhibit, and organize reflexes, impulses, inhibit, and organize reflexes, impulses, information, and emotionsinformation, and emotions

Increase abilityIncrease ability to engage thought with to engage thought with affect, words with emotion, and reasonaffect, words with emotion, and reason with with unconscious behavior unconscious behavior (Seigal,1999)(Seigal,1999)

MODIFY TREATMENT MODIFY TREATMENT PROTOCOLSPROTOCOLS

Train staff to: Train staff to: use an interdisciplinary team use an interdisciplinary team approach, coordinate with community approach, coordinate with community resources, put emphasis on self resources, put emphasis on self awareness of strengths and weaknesses, awareness of strengths and weaknesses, support client risk taking and feedback, support client risk taking and feedback, use peer group therapy, and provide use peer group therapy, and provide opportunities to practice social and opportunities to practice social and emotional coping skillemotional coping skill

BARBARA.SULLIVAN@HSC.UTAH.EDUBARBARA.SULLIVAN@HSC.UTAH.EDU

UTAH ADDICTION CENTERUTAH ADDICTION CENTERUNIVERSITY OF UTAHUNIVERSITY OF UTAH