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Petros Levounis, MD, MA Chair
Department of Psychiatry Rutgers – New Jersey Medical School
Rutgers – New Jersey Medical School Fundamentals of Addiction Medicine Summer Series
Newark, NJ – July 3, 2013
NEUROBIOLOGY OF ADDICTION
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1. Neurobiology of Addiction 2. Psychotherapy of Addiction 3. Principles of MI 4. Practice of MI 5. Addiction Pharmacotherapy 6. Conclusions
Outline
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1 Neurobiology of Addiction
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~ 2000
The Fundamental Model
Biological
Psychological
Social
Use Brain Switch
1. Stress 2. Triggers (Cues) 3. Exposure (Primers)
Relapse
Addiction
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0
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0 60 120 180
Time (min)
% o
f Bas
al D
A O
utpu
t
Empty
Food Sex
Box Feeding
100
150
200
DA
Con
cent
ratio
n (%
Bas
elin
e)
Sample Number
1 2 3 4 5 6 7 8
Female Present
Natural Rewards and Dopamine Levels
Adapted from: Di Chiara et al, Neuroscience, 1999 Adapted from: Fiorino and Phillips, J Neuroscience, 1997
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0 1 2 3 4 5 hr
% o
f Bas
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elea
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COCAINE
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250
0 1 2 3 hr
% o
f Bas
al R
elea
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NICOTINE
Adapted from: Di Chiara and Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of Nora D Volkow, MD
Effects of Drugs on Dopamine Levels
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0 1 2 3 4hr
% o
f Bas
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elea
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0.25 0.5 1 2.5
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Dose (g/kg ip)
ETHANOL
MORPHINE %
of B
asal
Rel
ease
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100
150
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250
0 1 2 3 4 5 hr
0.5 1.0 2.5 10
Dose mg/kg
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0 1 2 3 4 5 hr
% o
f Bas
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elea
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DA
Effects of Drugs on Dopamine Levels
AMPHETAMINE
Adapted from: Di Chiara and Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of Nora D Volkow, MD
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Pleasure-Reward Pathways
Nucleus Accumbens
Hippocampus
Striatum Frontal Cortex
Ventral Tegmental
Area
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Adapted from: National Institute on Drug Abuse, www.nida.nih.gov, 2000
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2013
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Neural Circuitry of Addiction
Hippocampus
Striatum Frontal Cortex
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Koob, Pharmacopsychiatry, 2009
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1. Dopamine 2. Glutamate 3. γ-Aminobutyric Acid (GABA) 4. Serotonin 5. Norepinephrine 6. Corticotropin-Releasing Factor (CRF) 7. Opioids 8. Cannabinoids
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1. Addiction Neurotransmitters
Koob, J Drug Issues, 2009
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2. Motivation: More than an Amoeba
Adapted from: Flaherty, Coaching: Evoking Excellence in Others, 2005; graphic by Lukas Hassel.
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3. The Anti-Reward Pathways
Volkow ND and Baler RD, Neuropharmacology, 2013.
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Gardner, Chronic Pain and Addiction, 2011
Reward and Antireward Systems
GAME 1 A. A sure gain of $250.
B. 25% chance to gain $1,000,
75% chance to gain nothing.
Adapted from: Tversky and Kahneman, Science, 1981
Reward Systems
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84%
16%
GAME 2 A. A sure loss of $750.
B. 25% chance to lose nothing,
75% chance to lose $1,000.
Antireward Systems
Adapted from: Tversky and Kahneman, Science, 1981
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13%
87%
GAME 1
25% + 750 25% - 250 25% - 250 25% - 250
GAME 2
25% + 750 25% - 250 25% - 250 25% - 250
MATHEMATICS
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People avoid risks to ensure gains (even small gains).
People take risks (even big risks) to avoid definite losses.
Psychology trumps probability.
HUMAN NATURE
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2 A Brief History of the
Psychotherapy of Addiction
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1. Psychoanalysis works for all treatable mental illness.
2. Psychoanalysis does not work for addiction.
3. Therefore, addiction cannot be treated.
1st Wave: Psychoanalysis
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The prototype, Synanon, was founded in California in 1958 to address heroin addiction.
The goal was to: break down defenses, bust through denial, and reshape the addict’s personality.
2nd Wave: Boot Camps
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1. Shaving heads
2. Hanging humiliating signs around residents’ necks
3. Subjecting patients to “encounter groups” involving loud, free flowing attacks from staff and fellow residents
2nd: Therapeutic Communities
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During the 1970s and 1980s, most Therapeutic Communities evolved beyond the Synanon model.
People started recognizing the limits and dangers of confrontive techniques.
3rd Wave: Modified TCs
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1. Based on Operant Conditioning
2. Functional Analysis
3. Skills Training to: identify, avoid, and cope with thoughts & cravings
3rd: Cognitive-Behavior Therapy
Kadden, Cognitive-Behavioral Coping Skills Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and Dependence, 1992 25
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The Frying Pan Revisited
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Volkow et al, J Neuroscience, 2001
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1. 12-step Facilitation
2. Relapse Prevention
3. Family Therapy
4. Primary Care
5. Mental Health Services
6. Aftercare
4th: The Kitchen Sink Approach
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Nunes, Selzer, Levounis, Davies, Substance Dependence and Co-Occurring Psychiatric Disorders, 2010.
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12-Step Facilitation
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1. Spiritual Health
2. Professional and Vocational Health
3. Interpersonal and Family Health
4. Mental Health
5. Physical Health
6. Life
The AA Elevator Slogan
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Medical Student Attitudes
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PATIENTS 1. Inner peace 2. God 3. Medical Svcs 4. AA 5. Housing 6. Spirituality 7. Outpatient Svcs 8. Community 9. Gov’t Svcs 10. Trusting People 11. Job
PERCEPTION 1. Housing 2. Outpatient Svcs 3. Medical Svcs 4. Job 5. Trusting People 6. AA 7. Inner Peace 8. Community 9. Gov’t Svcs 10. Spirituality 11. God
STUDENTS 1. Housing 2. Gov’t Svcs 3. Medical Svcs 4. Outpatient Svcs 5. Job 6. Community 7. Trusting People 8. Inner peace 9. God 10. Spirituality 11. AA
Goldfarb, Am J Drug Alcohol Abuse, 1996.
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Psychiatric Co-Morbidities
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1. A third to two thirds of addicted people also suffer from another mental illness—not 10%, not 90%.
2. Treat both the addiction and the co-occurring psychiatric disorder(s).
3. Avoid benzodiazepines and use antidepressants as first line treatments for anxiety disorders.
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The Four-Quadrant Model
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3 Principles of
Motivational Interviewing 33
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1. “People are unmotivated” vs.
“People are always motivated for something.”
2. “Why isn’t the person motivated?” vs. “For what is the person motivated?”
Motivation
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Miller and Rollnick, Motivational Interviewing: Helping People Change, 3rd Edition, 2012.
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1. Ambivalence is normal; needs to
be explored, not confronted.
2. Ambivalence is a reasonable place to visit, but you wouldn’t want to live there.
Ambivalence
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Miller and Rollnick, Motivational Interviewing: Helping People Change, 3rd Edition, 2012.
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Principles
REDS 1. Roll with Resistance
2. Express Empathy
3. Develop Discrepancy
4. Support Self-Efficacy
Miller and Rollnick, Motivational Interviewing: Preparing People for Change, 2nd Edition, 2002.
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MI Today
Beyond REDS Engaging
Focusing
Evoking
Planning
Miller and Rollnick, Motivational Interviewing: Helping People Change, 3rd Edition, 2012.
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4 Practice of
Motivational Interviewing 38
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PHASE 1: Building Motivation for Change PHASE 2: Strengthening Commitment to Change
and Developing a Plan.
Phases
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1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
6. Relapse
The Stages of Change
Prochaska and DiClemente, The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy, 1984.
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The Stages of Change Cycle
Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010. 41
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1. Identify the Stage of Change.
2. Help the person move a little bit
forward.
3. Don’t rush her or him.
Working the Stages
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Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010.
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1. Plant the seed of ambivalence.
2. Techniques: Ask for a description of a typical day. Hunt for the smallest discrepancy
between where people are and where they would like to be.
Precontemplation
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The Readiness Ruler
Adapted from: Miller and Rollnick, Motivational Interviewing: Preparing People for Change, 2nd Edition, 2002, Graphic by Dr. Chris Welsh. 44
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1. Open up to explosive decision analysis.
2. Techniques: Brainstorm widely. Explore both positive and negative
prospects of life with and without the proposed changes.
Contemplation
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The Decisional Balance
Levounis and Arnaout, Motivational Interviewing: Preparing People for Change, 2nd Edition, 2002, Graphic by Dr. Chris Welsh.
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1. Develop a realistic action plan.
2. Techniques: Anticipate problems and identify
solutions. Unforeseen complications and
frustrating obstacles may require revisiting “contemplation stage” techniques.
Preparation
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1. Based on principles of learning, replace maladaptive patterns of behaving and thinking.
2. Techniques: Essentially use a CBT model. Provide ample positive feedback,
encouragement, and support.
Action
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1. Back to the “kitchen sink” approach.
2. Techniques: Recruit motivational, cognitive-
behavioral, regulatory, disciplinary, and social approaches to sustain the desired change.
Explore disappointments, temptations, and doubts.
Maintenance
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1. Remember Confucius: “Our greatest glory is not in never falling but in rising every time we fall.”
2. Techniques: Accept relapse as an opportunity to
reengage, rethink, and reemerge stronger than before.
Reengage quickly, even if it is to the expense of deeper rethinking.
Relapse
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Make a guess as to what the patient means. Skillful listetning moves past what the person exacly said, without jumping too far.
Like interpretations in dynamic therapy, if the patient becomes defensive, you know that you jumped too far, too fast.
Technique: Reflective Listening
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Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010.
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As a person argues on behalf of one position, she or he becomes more committed to it; we literally talk ourselves into (or out of) things.
This may explain why the more “resistance” is evoked during a counseling session, the more likely it is that a person will continue to use.
Technique: Elicit Change Talk
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Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010.
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1. Listen > Ask > Give advice 2. Talk less than the patient. 3. Do not ask more than 3 consecutive
questions. 4. Avoid wordiness. 5. Avoid interrupting. 6. Cooperate, do not force knowledge. 7. Relax.
Practical Suggestions
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Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010.
5 An Even Briefer History of
Addiction Pharmacotherapy
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1. Agonists Nicotine Replacement Therapies Methadone for Opioids
2. Antagonists Naltrexone for Opioids
Two Main Strategies
Renner and Levounis, Office-Based Buprenorphine Treatment of Opioid Dependence, 2011
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Partial Agonists
Varenicline for Nicotine Buprenorphine for Opioids
The New Strategy
Renner and Levounis, Office-Based Buprenorphine Treatment of Opioid Dependence, 2011
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-10 -9 -8 -7 -6 -5 -4 0
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30
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50
60
70
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% Efficacy
Log Dose of Opioid
Full Agonist (Methadone)
Partial Agonist (Buprenorphine)
Antagonist (Naloxone)
The Ceiling Effect
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6 Conclusions
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1. Addiction hijacks both the pleasure/reward and anti-reward pathways of the brain.
2. Antireward pathways are likely responsible for the sustaining addiction.
3. Motivation has replaced confrontation as the primary focus of addiction treatment.
4. Motivational Interviewing is based on exploring and resolving ambivalence.
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Thank you
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