Slide 1 Neurobiology of Addiction - SaidDent.org ; SAIDsaiddent.org/admin/images/Handout...

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Slide 1 Neurobiology of Addiction Joyce D Leonetti, DO, MTS, MPH SAID Meeting October 2019 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 2 Disclosures I have no competing interests in this presentation. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Transcript of Slide 1 Neurobiology of Addiction - SaidDent.org ; SAIDsaiddent.org/admin/images/Handout...

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

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TheBasicModelofAddiction

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Slide 6

~ 1980How does addiction occur?

What’s involved?What are the mechanisms?

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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 18 2

Neurobiology

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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 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 32 AComplexIllness

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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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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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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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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 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 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 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 61 ThankYou

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