a neurobiological look at the bio-psycho-social-spiritual disease: defining addiction

Michael M. Miller, MD, FASAM, [email protected]

Medical Director, Herrington Recovery Center (HRC) Rogers Memorial Hospital Oconomowoc, Wisconsin

Associate Clinical ProfessorUniversity of Wisconsin School of Medicine and Public Health

Associate Clinical ProfessorMedical College of Wisconsin, Dept of Psychiatry & Behavioral Health

Past President and Board ChairWisconsin and American Societies of Addiction Medicine

DirectorAmerican Board of Addiction Medicine

Description

Through an exploration of the 2011 Definition of Addiction of the American Society of Addiction Medicine as well as its historical roots, attendees will become equipped to teach patients and families about how addiction is not about alcohol or other drugs, but it’s about brains; and how it’s not just about mesolimbic reward circuitry, but is about the role of other brain regions in the relationship that persons with addiction develop with sources of reward and relief.

The presentation will help attendees discriminate between descriptions and definitions that focus on substances and behaviors that provide reward or relief, versus the underlying biology which leads to altered the thoughts, emotions, and behaviors seen in persons with addiction.

ASAM’s Mission

The American Society of Addiction Medicine’s mission is to:• Increase access to and improve the quality of addiction treatment;

• Educate physicians (including medical and osteopathic students), other health care providers and the public;

• Support research and prevention;

• Promote the appropriate role of the physician in the care of patients with addiction;

• Establish addiction medicine as a specialty recognized by professional organizations, governments, physicians, purchasers and consumers of health care services, and the general public.

Approved by ASAM Board, 7-2006; http://198.65.155.172/CMS/images/PDF/General/Strategic%20Plan.pdf

Addiction Medicine:

The specialty of medicine devoted to diagnosis, treatment, prevention, education, epidemiology, research, and public policy advocacy regarding addiction and other substance-related health conditions

How to Identify a Physician Recognized for Expertise in the Diagnosis and Treatment of Addiction and Substance-related Health Conditions (ASAM Public Policy Statement)

www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html

www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html

• Completion of a residency/fellowship in Addiction Medicine or Addiction Psychiatry

• Certification in Addiction Medicine by the American Society of Addiction Medicine (ASAM)

• Subspecialty certification in Addiction Psychiatry by the American Board of Psychiatry and Neurology (ABPN)

• A Certificate of Added Qualification in Addiction Medicine conferred by the American Osteopathic Association (AOA)

• Board Certification in Addiction Medicine by the American Board of Addiction Medicine (ABAM)

Scope of Practice for Addiction Medicine Physicians (ABAM)

The addiction medicine physician provides medical care within the bio-psycho-social framework for persons with addiction, for the individual with substance-related health conditions, for persons who manifest unhealthy substance use, and for family members whose health and functioning are affected by someone’s substance use or addiction.

American Board of Addiction MedicineMission Statement

ABAM’s mission is to contribute to the improvement of care for patients suffering from addiction to alcohol, nicotine and other addicting drugs (including some prescription drugs), and to establish and maintain standards and procedures for certification, recertification and maintenance of certification of physicians who specialize in Addiction Medicine.

How is it that DRUGS are different from BROCCOLI?

• It’s because of what ‘drugs’ do to the BRAIN• Drugs enter the body via various routes– Oral, Intravenous, Intramuscular, Intranasal, transdermal,

transbuccal, or transalveolar

• Drugs that affect mood/thought/behavior cross the ‘blood brain barrier’

• Drugs act on nerve cells by binding to specialized portions of the outer membrane of nerve cells

The Irony...

• Addiction is not about DRUGS !

• Addiction is about BRAINS!

• It’s not about the quantify/frequency of use

• It’s about the

– Quality of use

– Pattern of use

– Relationship the person has to ‘their drug’

• It’s about how the person with addiction is changed when using

New Understandings about Addiction

• Addiction is a disease of the brain

• Dopamine in the VTA and the Nucleus Accumbens is important in Drug Reward (the ‘Reward Pathway’ of the MFB etc.)

• BUT we now understand that the Nuc Acc is where REWARD HAPPENS, whereas ADDICTION resides in the OFC and in connections among the Nuc Acc, the OFC, the hippocampus and the amygdala

Addiction ‘Resides’ in the Orbitofrontal Cortex (OFC) and in connections between OFC et al.

• Addiction is use despite adverse consequences, returning to use after periods of abstinence even with previous life catastrophes, inability to control use, cognitive preoccupation, conscious and unconscious craving

• It involves memory, judgment, ‘executive functions’ of planning and deciding to defer gratification

• All these are Frontal Lobe functions


• The site of action for reward/drug-induced euphoria is the nucleus accumbens (an oversimplification)

• The site of action for addiction is interplay between the frontal lobes and the Nuc Acc, and among the Nuc Acc, the hippocampus (memory), and the amygdala (motivation)– Judgment / Evaluation

– Planning

– Drive (drug hunger/craving; drug seeking/use)

– Recalling past experiences

PFCPFC

ACGACG

OFCOFCSCCSCC

HippHipp

NAccNAcc

VPVP

Amyg

Amyg

REWARDREWARD

CONTROL INHIBITORY

CONTROL

CONTROL INHIBITORY

CONTROL

MOTIVATION/DRIVE

MOTIVATION/DRIVE

MEMORY/LEARNING MEMORY/

LEARNING

Circuits Involved in Drug Abuse and Addiction

Addiction ‘resides’ somewhat in the Orbitofrontal Cortex (OFC) and in other areas with connections to Reward Circuitry

• The site of acute action for euphoriants is the nucleus accumbens (an oversimplification)

• The site of action for the chronic, recurrent, relapsing exposure to euphoriants--as is see in addiction—is the interplay among the Nuc Acc, the hippocampus (memory; recalling past experiences), the amygdala (motivation, drive, drug hunger/craving; drug seeking/use), and the frontal lobes (judgment/evaluation, planning, delay of gratification, inhibition of urges/impulses)

Construction Anatomy

Brain Development:Proliferation and pruning occurs from back to frontBack:Region that mediates direct contact with environmentNext:Regions that coordinate those functions Last:Prefrontal Cortex

Source: Gogtay, Nitin et al (2004) Proc. Natl. Acad. Sci. USA 101; 8174-8179Copyright 2004 by the National Academy of Sciences

Right Lateral and Top Views of the Dynamic Sequence of GM Maturation Over the Cortical Surface

Understanding drug abuse and addiction from a developmental perspective has important implications for their prevention and treatment

Exposure to drugs of abuse during adolescence could have profound effects on Brain Development and Brain Plasticity

Cartoon Break

Control

DriveSaliency

Memory

Non Addicted BrainNon Addicted Brain Addicted BrainAddicted Brain

Control

Saliency

Memory

Drive

STOPSTOP

GOGO

The Physiology of Addiction

Certain substances have the ability to interact with the brain’s Reward Circuitry and are thus euphoriants; they are reinforcing, and, in lab animals, self-reinforcing. They act first by being external ligands for neuro-transmitter receptors, or by causing release of (or otherwise altering levels of) neuro-transmitters.

They hijack the reward system, and the individual compulsively pursues these rewards instead of natural rewards.


Once the Reward Circuitry is turned on, there are changes in related brain areas or neuronal circuits, and these result in the characteristic manifestations of addiction [altered memory of past intoxication experiences, altered cue response, changes in motivation so that ‘the drug’ (which can be a substance, or a pathologically rewarding activity) becomes ‘the salient reinforcer,’ replacing other healthy rewards]. All this contributes to preoccupation and loss of control. The most contemporary term for all this circuitry is the brain’s “incentive salience circuitry.”


• Changes in frontal lobe function (executive functioning; the inhibition of impulses to use) are key: the brain fails in efforts to inhibit the drive to obtain/use the drug to create ‘the high’.

• Impairment in control and preoccupation are the key behavioral/cognitive characteristics of addiction, and have an anatomical/physiological substrate in the brain.

• Relapse is intrinsic to virtually all chronic diseases; the animal model of relapse is “reinstatement” of drug use or drug preference.

Addiction is…

• A BRAIN DISEASE

• A primary, relapsing and remitting CHRONIC DISEASE….

• A PEDIATRIC DISEASE….

Age at tobacco, at alcohol and at cannabis dependence, as per DSM IV

0.00.0

0.20.2

0.40.4

0.60.6

0.80.8

1.01.0

1.21.2

1.41.4

1.61.6

1.81.8

55 1010 1515 2020 2525 3030 3535 4040 4545 5050 5555 6060 6565

THCTHCALCOHOLALCOHOL

TOBACCOTOBACCO

7070 7575

National Epidemiologic Survey on Alcohol and Related Conditions, 2003

% in

eac

h ag

e to

dev

elop

fir

st-ti

me

depe

nden

ce

Age

Addiction is a Developmental Disease

http://www.mclean.harvard.edu/images/patient_care/guyoncouch.jpg

Griffith Edwards (1976)

Edwards (Griffith), Gross (Milton)

“Alcohol dependence: provisional description of a clinical syndrome”British Medical Journal, 1:1058-1061 (1976)


Essential elements of the syndrome:• subjective awareness of a compulsion to drink

• reinstatement of the syndrome after abstinence

All these elements exist in degree, thus giving the syndrome a range of severity.

The Definition of Alcoholism (NCADD / ASAM – 1990, JAMA 1994: Morse et al.)

Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic: impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.

What is Addiction? American Society of Addiction Medicine • April 2011

Definition of Addiction:“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

Definition of AddictionAmerican Society of Addiction Medicine • April 2011

“Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

ASAM’s New Definition of Addiction

http://www.asam.org/for-the-public/definition-of-addiction

Downward Spiral / Progression

Addiction(constriction –of affects, behaviors, social network)

Atrophy

• Of social network– People…

• Of activities / interests – Places, Things

• Of emotions– Flatness, less expressive, dysthymic / alexithymic

• Of rewards– Salience

Copyright (c)2011, Covington, Griffin, & Dauer

Downward Spiral of Addiction andUpward Spiral of Recovery

Addiction(constriction –of affects, behaviors, social network)

Recovery(expansion—of feelings, rewards,activities, social connections)

How to come out of the depths?How to RECOVER?

• “Re-people-ization”

– AA

– Sponsor

– Church

– Social clubs

– Activities with others

– Family

• Professional Treatment (group therapy, meet others)

• Re-Connectedness

ASAM Public Policy Statement: Definition of Addiction (Long Version)

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors.

ASAM Public Policy Statement: Definition of Addiction (Long Version)

Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.

The neurobiology of addiction encompasses more than the neurochemistry of reward.1

The frontal cortex of the brain and underlying white matter connections between the frontal cortex and circuits of reward, motivation and memory are fundamental in the manifestations of altered impulse control, [and] altered judgment….

…and the dysfunctional pursuit of rewards (which is often experienced by the affected person as a desire to “be normal”) seen in addiction--despite cumulative adverse consequences experienced from engagement in substance use and other addictive behaviors.

The frontal lobes are important in inhibiting impulsivity and in assisting individuals to appropriately delay gratification. When persons with addiction manifest problems in deferring gratification, there is a neurological locus of these problems in the frontal cortex.

Frontal lobe morphology, connectivity and functioning are still in the process of maturation during adolescence and young adulthood, and early exposure to substance use is another significant factor in the development of addiction. Many neuroscientists believe that developmental morphology is the basis that makes early-life exposure to substances such an important factor.

Footnote 1: The neurobiology of reward has been well understood for decades, whereas the neurobiology of addiction is still being explored. Most clinicians have learned of reward pathways including projections from the ventral tegmental area (VTA) of the brain, through the median forebrain bundle (MFB), and terminating in the nucleus accumbens (Nuc Acc), in which dopamine neurons are prominent. Current neuroscience recognizes that the neurocircuitry of reward also involves a rich bi-directional circuitry connecting the nucleus accumbens and the basal forebrain.

Footnote 1 (continued): It is the reward circuitry where reward is registered, and where the most fundamental rewards such as food, hydration, sex, and nurturing exert a strong and life-sustaining influence. Alcohol, nicotine, other drugs and pathological gambling behaviors exert their initial effects by acting on the same reward circuitry that appears in the brain to make food and sex, for example, profoundly reinforcing. Other effects, such as intoxication and emotional euphoria from rewards, derive from activation of the reward circuitry.

Footnote 1 (continued): While intoxication and withdrawal are well understood through the study of reward circuitry, understanding of addiction requires understanding of a broader network of neural connections involving forebrain as well as midbrain structures. Selection of certain rewards, preoccupation with certain rewards, response to triggers to pursue certain rewards, and motivational drives to use alcohol and other drugs and/or pathologically seek other rewards, involve multiple brain regions outside of reward neurocircuitry itself.

Naqvi NH, Bechara ATrends in Neurosciences, 32:56-67, 2008

“Although the dopamine system clearly has an important role in addiction to drugs of abuse, drug use does more for the addicted individual than merely providing a means of releasing dopamine in the brain. Drug use involves a complex set of rituals imbued with emotional meaning (both positive and negative) for the addicted individual.”

Genetic factors account for about half of the likelihood that an individual will develop addiction.

Environmental factors interact with the person’s biology and affect the extent to which genetic factors exert their influence. Resiliencies the individual acquires (through parenting or later life experiences) can affect the extent to which genetic predispositions lead to the behavioral and other manifestations of addiction. Culture also plays a role in how addiction becomes actualized in persons with biological vulnerabilities to the development of addiction.

• Availability• Social Norms for/against – Indoor smoking bans– MADD– “Those Who Host Lose the

Most”• Perceived Harm• Consequences (legal

status; drug-free schools)

• “Peer Pressure”• Siblings• Parents– Their Use– Their Attitudes (perceived

harm)– Their Rules/Consequences

(parents are ‘the antidrug’)

Environmental / Cultural Factors

Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include:

• The presence of an underlying biological deficit in the function of reward circuits, such that drugs and behaviors which enhance reward function are preferred and sought as reinforcers;

• The repeated engagement in drug use or other addictive behaviors, causing neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors;

• Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception;

“…neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors….”

[O’Brien: “addiction = neuroplasticity”]

changes in motivation/control

changes in cue responsiveness

[See also: Koob GF, Volkow ND. “Neurocircuitry of addiction.” Neuropsychopharmacology. 2010 Jan;35(1):217-38.]

Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include:

• Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies;

• Exposure to trauma or stressors that overwhelm an individual’s coping abilities;

• Distortion in meaning, purpose and values that guide attitudes, thinking and behavior;

• Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others); and

• The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviors.

Addiction is characterized by2:

• Inability to consistently Abstain;

• Impairment in Behavioral control;

• Craving; or increased “hunger” for drugs or rewarding experiences;

• Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and

• A dysfunctional Emotional response.

Footnote 2: These five features are not intended to be used as “diagnostic criteria” for determining if addiction is present or not. Although these characteristic features are widely present in most cases of addiction, regardless of the pharmacology of the substance use seen in addiction or the reward that is pathologically pursued, each feature may not be equally prominent in every case. The diagnosis of addiction requires a comprehensive biological, psychological, social and spiritual assessment.


“…Studies using animal models [which] have emphasized the role of subcortical systems such as the amygdala, nucleus accumbens and the mesolimbic dopamine system…have tended to focused on externally observable aspects of addiction (emphasis added)”

The power of external cues to trigger craving and drug use,

…as well as to increase the frequency of engagement in other potentially addictive behaviors, is also a characteristic of addiction, with the hippocampus being important in memory of previous euphoric or dysphoric experiences, and with the amygdala being important in having motivation concentrate on selecting behaviors associated with these past experiences.

Although some believe that the difference between those who have addiction, and those who do not, is the quantity or frequency of alcohol/drug use, engagement in addictive behaviors (such as gambling or spending) 3, or exposure to other external rewards (such as food or sex)…,

…a characteristic aspect of addiction is the qualitative way in which the individual responds to such exposures, stressors and environmental cues. A particularly pathological aspect of the way

that persons with addiction pursue substance use or external rewards is that preoccupation with, obsession with and/or pursuit of rewards (e.g., alcohol, nicotine and other drug use) persist despite the accumulation of adverse consequences. These manifestations can occur compulsively or impulsively, as a reflection of impaired control.

WHO Expert Committee on Mental Health, Alcoholism Subcommittee (2nd Report, 1952)

“The subcommittee has distinguished two categories of alcoholics, “alcohol addicts” and “habitual symptomatic excessive drinkers. For brevity’s sake the latter will be referred to as non-addictive alcoholics. In both groups, the excessive drinking is symptomatic of underlying psychological or social pathology….”

WHO Technical Report Series No. 48, August 1952, pp. 26-27


“…but in one group after several years of excessive drinking “loss of control” over the alcohol intake occurs, while in the other group this phenomenon never develops. The group with “loss of control” is designated as “alcohol addicts.”

WHO Technical Report Series No. 48, August 1952, pp 26-27


“The disease conception of alcohol addiction does not apply to the excessive drinking, but solely to the ‘loss of control’ which occurs in only one group of alcoholics and then only after many years of excessive drinking.”

WHO Technical Report Series No. 48, August 1952, pg 27


“The ‘loss of control’ is a disease condition per se which results from a process that superimposes itself upon those abnormal psychological conditions of which excessive drinking is a symptom. The fact that many excessive drinkers drink as much as or more than the addict for 30 or 40 years without developing loss of control indicates that in the group of ‘alcohol addicts’ a superimposed process must occur.”

WHO Technical Report Series No. 48, August 1952, pg 27


“Perhaps the key experience can best be described as a compulsion to drink….“The desire for a further drink is seen as irrational, the desire is resisted, but the further drink is taken.”


“…Awareness of ‘loss of control’ is said to be crucial to understanding abnormal drinking….“Control is probably best seen as variably and intermittently impaired rather than ‘lost’.”

Although some believe that the difference between those who have addiction, and those who do not, is the quantity or frequency of alcohol/drug use, engagement in addictive behaviors (such as gambling or spending) 3, or exposure to other external rewards (such as food or sex)…,

Footnote 3: In this document, the term "addictive behaviors" refers to behaviors that are commonly rewarding and are a feature in many cases of addiction. Exposure to these behaviors, just as occurs with exposure to rewarding drugs, is facilitative of the addiction process rather than causative of addiction. The state of brain anatomy and physiology is the underlying variable that is more directly causative of addiction.

Footnote 3: Thus, in this document, the term “addictive behaviors” does not refer to dysfunctional or socially disapproved behaviors, which can appear in many cases of addiction. Behaviors, such as dishonesty, violation of one’s values or the values of others, criminal acts etc., can be a component of addiction; these are best viewed as complications that result from rather than contribute to addiction.

Persistent risk and/or recurrence of relapse, after periods of abstinence, is another fundamental feature of addiction. This can be triggered by exposure to rewarding substances and behaviors, by exposure to environmental cues to use, and by exposure to emotional stressors that trigger heightened activity in brain stress circuits.4

Footnote 4: The anatomy (the brain circuitry involved) and the physiology (the neuro-transmitters involved) in these three modes of relapse (drug- or reward-triggered relapse vs. cue-triggered relapse vs. stress-triggered relapse) have been delineated through neuroscience research.

Relapse triggered by exposure to addictive/ rewarding drugs, including alcohol, involves the nucleus accumbens and the VTA-MFB-Nuc Acc neural axis (the brain's mesolimbic dopaminergic "incentive salience circuitry"--see Footnote 2 above). Reward-triggered relapse also is mediated by glutamatergic circuits projecting to the nucleus accumbens from the frontal cortex.

Relapse triggered by exposure to conditioned cues from the environment involves glutamate circuits originating in frontal cortex, insula, hippocampus and amygdala projecting to mesolimbic incentive salience circuitry.

Relapse triggered by exposure to stressful experiences involves brain stress circuits beyond the hypothalamic-pituitary-adrenal axis that is well known as the core of the endocrine stress system. There are two of these relapse-triggering brain stress circuits – one originates in noradrenergic nucleus A2 in the lateral tegmental area of the brain stem and projects to the hypothalamus, nucleus accumbens, frontal cortex, and bed nucleus of the stria terminalis, and uses norepinephrine as its neurotransmitter; the other originates in the central nucleus of the amygdala, projects to the bed nucleus of the stria terminalis and uses corticotrophin-releasing factor (CRF) as its neurotransmitter.

“Relapse” or “Reinstatement”Griffith Edwards (1976)

“Relapse into the previous stage of the dependence syndrome…follows an extremely variable time course.Typically, the patient who had only a moderate degree of dependence will take weeks or months to reinstate it….”


“A severely dependent patient typically reports that he is again ‘hooked’ within a few days of starting to drink, even though there are exceptions: on the first day he may become abnormally drunk and be surprised to have lost his tolerance.”


“A syndrome which had taken many years to develop can be fully reinstated within perhaps 72 hours, and this is one of the most puzzling features of the condition.”[kindling]

In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications.

The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol, nicotine or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the correlation with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of Twelve Step programs.

Addiction is more than a behavioral disorder.

Features of addiction include aspects of a person’s behaviors, cognitions, emotions, and interactions with others, including a person’s ability to relate to members of their family, to members of their community, to their own psychological state, and to things that transcend their daily experience.

Behavioral manifestations and complications of addiction, primarily due to impaired control, can include:

• Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control;

• Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the neglect of responsibilities at home, school or work);

Behavioral manifestations and complications of addiction, primarily due to impaired control, can include:

• Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems which may have been caused or exacerbated by substance use and/or related addictive behaviors;

• A narrowing of the behavioral repertoire focusing on rewards that are part of addiction; and

• An apparent lack of ability and/or readiness to take consistent, ameliorative action despite recognition of problems.


“…as dependence advances…the individual gives priority to maintaining his alcohol intake; indeed the failure of unpleasant consequences to deter may be a clinical indicator of the degree of dependence.”

Cognitive changes in addiction can include:• Preoccupation with substance use;

• Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviors; and

• The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction.

Emotional changes in addiction can include:• Increased anxiety, dysphoria and emotional pain;

• Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and

• Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).

Memory and Learning (not in the Definition)

Memory and learning in addiction involves more than recall of previous positive experiences with alcohol, tobacco or other drug use or other exposures to rewards, and more than repression or distortion of memories of the negative experiences associated with pursing or exposing oneself to rewards. It also involves more than the cognitive and emotional aspects of conscious and unconscious craving and the conditioning, through recollection of previous experiences with learned triggers, to re-engage with the pathological pursuit of rewards.


Memory in addiction also has a behavioral and motor component, which seems to be mediated by the rostral (anterior) portion of the ventral tegmental area: certain motor behaviors associated with pursing rewards, e.g., going out and finding supplies of drugs, or food, or gambling materials, may be recalled or ingrained in circuitry of the rostral VTA, such that those motor behaviors have been “learned” and reappear in the behavioral repertoire of the person with addiction without there being a conscious component to the behavior’s reoccurrence.


Complex motor behaviors such as reaching for both cigarettes and ignition materials and “lighting up”—or even getting into an automobile and driving to a liquor store—may occur based on unconscious patterns of learned motor or kinesthetic behavior in addition to the emotional or physiological drive to experience a drug effect or another reward.

--Michael M. Miller, M.D.

The emotional aspects of addiction are quite complex.

• Some persons use alcohol or other drugs or pathologically pursue other rewards because they are seeking “positive reinforcement” or the creation of a positive emotional state (“euphoria”).

• Others pursue substance use or other rewards because they have experienced relief from negative emotional states (“dysphoria”), which constitutes “negative reinforcement.“

• Beyond the initial experiences of reward and relief, there is a dysfunctional emotional state present in most cases of addiction that is associated with the persistence of engagement with addictive behaviors.

The state of addiction is not the same as the state of intoxication.

When anyone experiences mild intoxication through the use of alcohol or other drugs, or when one engages non-pathologically in potentially addictive behaviors such as gambling or eating, one may experience a “high”, felt as a “positive” emotional state associated with increased dopamine and opioid peptide activity in reward circuits. After such an experience, there is a neurochemical rebound, in which the reward function does not simply revert to baseline, but often drops below the original levels. This is usually not consciously perceptible by the individual and is not necessarily associated with functional impairments.

Over time, repeated experiences with substance use or addictive behaviors are not associated with ever increasing reward circuit activity and are not as subjectively rewarding. Once a person experiences withdrawal from drug use or comparable behaviors, there is an anxious, agitated, dysphoric and labile emotional experience, related to suboptimal reward and the recruitment of brain and hormonal stress systems, which is associated with withdrawal from virtually all pharmacological classes of addictive drugs.

While tolerance develops to the “high,” tolerance does not develop to the emotional “low” associated with the cycle of intoxication and withdrawal. Thus, in addiction, persons repeatedly attempt to create a “high”--but what they mostly experience is a deeper and deeper “low.” While anyone may “want” to get “high”, those with addiction feel a “need” to use the addictive substance or engage in the addictive behavior in order to try to resolve their dysphoric emotional state or their physiological symptoms of withdrawal.

Persons with addiction compulsively use even though it may not make them feel good, in some cases long after the pursuit of “rewards” is not actually pleasurable.5 Although people from any culture may choose to “get high” from one or another activity, it is important to appreciate that addiction is not solely a function of choice. Simply put, addiction is not a desired condition.

Edgar Degas

L 'Absinthe (The Absinthe Drinker)1875-76

Musée d'OrsayParis, France


“Without withdrawing sympathy from the non-dependent drinker who is experiencing harm, society should be asked to realize that the person who has become dependent on alcohol is certainly ill; and the possibility of contracting this illness awaits anyone who drinks very heavily.”

Footnote 5: Pathologically pursuing reward (mentioned in the Short Version of this definition) thus has multiple components. It is not necessarily the amount of exposure to the reward (e.g., the dosage of a drug) or the frequency or duration of the exposure that is pathological.

Footnote 5 (continued): In addiction, pursuit of rewards persists, despite life problems that accumulate due to addictive behaviors, even when engagement in the behaviors ceases to be pleasurable. Similarly, in earlier stages of addiction, or even before the outward manifestations of addiction have become apparent, substance use or engagement in addictive behaviors can be an attempt to pursue relief from dysphoria; while in later stages of the disease, engagement in addictive behaviors can persist even though the behavior no longer provides relief.


“It is clear that both incentives and internal states (e.g. withdrawal) jointly determine the motivation to seek drugs.”

As addiction is a chronic disease, periods of relapse, which may interrupt spans of remission, are a common feature of addiction. It is also important to recognize that return to drug use or pathological pursuit of rewards is not inevitable.

Clinical interventions can be quite effective in altering the course of addiction. Close monitoring of the behaviors of the individual and contingency management, sometimes including behavioral consequences for relapse behaviors, can contribute to positive clinical outcomes. Engagement in health promotion activities which promote personal responsibility and accountability, connection with others, and personal growth also contribute to recovery. It is important to recognize that addiction can cause disability or

premature death, especially when left untreated or treated

inadequately.

The qualitative ways in which the brain and behavior respond to drug exposure and engagement in addictive behaviors are different at later stages of addiction than in earlier stages, indicating progression, which may not be overtly apparent.

Griffith Edwards (1976) on progression

“The model need not, of course, propose a rigidly stereotyped progression.

“…Milder degrees can indeed regress and the patient can return to normal drinking.”

[Vaillant 1980, The Natural History of Alcoholism: 11% of alcoholics return to controlled drinking]

Griffith Edwards (1976) on progression

“A patient with an intermediate degree of dependence is, if he continues to drink, much more likely to progress to severe dependence than to move backwards down the curve.

“Very severe dependence is usually irreversible, and if the patient will not accept abstinence he will repeatedly reinstate the syndrome.”

As is the case with other chronic diseases, the condition must be monitored and managed over time to: • Decrease the frequency and intensity of relapses;

• Sustain periods of remission; and

• Optimize the person’s level of functioning during periods of remission.

• In some cases of addiction, medication management can improve treatment outcomes.

• In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results.

• Chronic disease management is important for minimization of episodes of relapse and their impact.

• Treatment of addiction saves lives †

BEHAVIORAL CHANGES

• Eliminate alcohol and other drug use behaviors• Eliminate other problematic

behaviors• Expand repertoire of healthy

behaviors• Develop alternative behaviors

BIOLOGICAL CHANGES

• Resolve acute alcohol and other drug withdrawal symptoms• Physically stabilize the organism• Develop sense of personal

responsibility for wellness• Initiate health promotion

activities (e.g., diet, exercise, safe sex, sober sex)

Targeted Therapeutic Changes in Addiction Treatment

COGNITIVE CHANGES

• Increase awareness of illness• Increase awareness of negative

consequences of use• Increase awareness of addictive

disease in self• Decrease denial

AFFECTIVE CHANGES

• Increase emotional awareness of negative consequences of use• Increase ability to tolerate

feelings without defenses• Manage anxiety and depression• Manage shame and guilt


SOCIAL CHANGES

• Increase personal responsibility in all areas of life• Increase reliability and

trustworthiness• Become resocialized:

reestablished sober social network• Increase social coping skills:

with spouse/partner, with colleagues, with neighbors, with strangers

SPIRITUAL CHANGES

• Increase self-love/esteem; decrease self-loathing• Reestablish personal values• Enhance connectedness• Increase appreciation of

transcendence


Miller, Michael M. Principles of Addiction Medicine, 1994; published by American Society of Addiction Medicine, Chevy Chase, MD

• Question: Why is ASAM, as a medical organization, talking about “spirituality”?

• Answer: Because the members of the DDTAG, and of the BOD, recognize the multidimensional aspect of both the disease and of recovery

• Values matter• Violating your own values,

then re-establishing your values, matters.• Connectedness matters.• Meaning in life matters.• Recovery is many things,

including a search for meaning.

Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.

Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction.

As in other health conditions, self-management, with mutual support, is very important in recovery from addiction.

Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery. ‡

Recovery from addiction is best achieved through a combination of self-management, mutual support, and professional care provided by trained and certified professionals.

NIDA Principles of Drug Addiction Treatment (1999, rev 2009)

1. Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased.

2. No single treatment is appropriate for everyone.

NIH Publication No. 09–4180

www.drugabuse.gov


“Doctors should be aware that not every patient who drinks too much (for whatever reason) is necessarily dependent on alcohol, and different patients need different help and treatment.”

Herrington Recovery Center

Thank you!

Herrington Recovery Centerat Rogers Memorial Hospital

For more information, call 800-767-4411

or visitrogershospital.org

Michael M. Miller, MD, FASAM, [email protected]

800-767-4411rogershospital.org

Rogers treats children, adolescents and adults with:• Anxiety disorders• Mood disorders• Eating disorders• Substance-use disorders

a neurobiological look at the bio-psycho-social-spiritual disease: defining addiction

Health & Medicine