the role of mft in addiction and chronic draft 2

The Role of MFT in Addiction and Chronic Pain

P. Joseph Frawley,M.D.

Principles of Addiction Medicine

• 1. Addiction is a disease of the Survival Brain• 2. It is a chronic illness• 3. It is fatal if left untreated• 4. Treat it as a chronic

illness.• 5. People can and do

recover

Ventral Tegmentum to Nucleus Accumbens

Disease of AddictionSurvival Brain

Brain Reward Circuits

Natural History

•Addiction has a Natural History

Natural History of Alcoholism8 years in Clinic Sample Vaillant,1995

• 100 patients• Ave age 45• Prior Jail 71%• Alone or street 50% • Live with spouse 35%• Reg Employment 27%• Attended College 19%• Stable Psyc/Soc 17%

Natural History of AlcoholismCore City Sample Vaillant,1995

• Control Group for Juvenile delinquent Study.

• 456 Men follow up• 150 had DSMIII alcohol

abuse at some point.• 116 with alcohol abuse

followed through study

Natural History of AlcoholismCollege Sample Vailant,1995

• Population of College Graduates

• 268 Men Had Follow Up• 46 Men had DSM III

Alcohol Abuse at some point

What is the Natural Historyof Opioid Dependence?

• 581 male addicts admitted to California• Civil Addict Program in 1962-1964• 33 year follow-up 48.9% dead• Of the 242 interviewed• 55.8% urine neg for opiates• 14% incarcerated

33 Year F/U Narcotic AddictsArch Gen Psych 58, May 2001 p. 503 (Hser et al)

• Compulsory Treatment Program for Narcotic Dependent Criminal Offenders.

• Yr N Mean Age• 1962 581 25.4 • 1974 439 36.8 • 1985 354 47.6• 1996 242 57.4

Age of Drug Use Patterns

The Nature of Addiction

• 1. The Reward System• 2. The Memory of Reward• 3. The Triggers for Addiction• 4. Tolerance and Withdrawal• 5. Shame of loss of Control• 6. Emotional Damage• 7. Denial• 8. Enabling

Animals will self stimulate the Reward Center and forget other rewards

How The Survival Brain Works

Reward Center Need O2 Monitor Reward Safety Water Food Respect Companionship

Brain Reward Center

1. Cells that monitor thestatus of needs normally stimulate these centers

2. Meeting the needs will stimulate reward

3. Anticipation of reward will highly stimulate these centers

Reward Center Need O2 Monitor Reward

Safety Water Food Respect

Companionship

Memory Stores the Results of Actionand Strengthens Connections

Memory Action Need

O2 Monitor Reward Safety Water Food Respect

Companionship

PlleasureReliefNeed is met

Brain Reward Center

When needs are not met we experience alarm:Irritability

Tension

Anxiety

Anger

Pain

Panic

Reward Center Need O2 Monitor Reward

Safety Water Food Respect

Companionship

Stages of Alarm to Threat• Irritability• Tension• Anxiety• Anger• Pain

Panic

The Survival Brain motivates us to change and stores the results

Reward Center Need O2 Monitor Reward

Safety Water Food Respect

CompanionshipPain PanicAnxiety AngerIrritability Tension

Emotional Memory is layeredand is our emotional filter and reactor

• 0-5 5-10 10-15 15-20Mixed FeelingsNo confidenceLots of confidence

• Tape Recorder that plays back the past to motivate and guide you in the present-

• positively or negatively.

Emotional Brain is quicker and faster than the Slower Creative Intellect

However, as humans we come to conclusions about our experience so we can plan

• These can be called cognitions, beliefs, viewpoints, etc.

• During development, parental guidance is essential in healthy development in this area.

• These are our cognitive filters

As we learn, we form cognitions about what we need to do to survive

Cognition Memory Action Reward Center Need O2 Monitor Reward

Safety Water Food Respect

Companionship

Addictive Drugs are Mimics of our own Reward Chemistry: They Lie to Us

Opiates EndorphinSpeed Dopamine/ AdrenalineValium GABATHC AnandamideAlcohol Several

systems

Genetics influences how well they work and how we adapt to them

How Addictive Drugs Addict the Person- The Good

1. The drug stimulates the reward center according to its chemical action, state of the system and genetics.

2. The message is Drug Works!

3. The meaning can be: The drug is a new/better way to feel good

Reward Center Need Monitor Reward O2

Safety DRUG Water Food Respect

Companionship

Dopamine and Reward

How Addictive Drugs Addict the Person-The Bad

1. The drug suppresses the normal monitor and reward systems according to its chemical action ,state of the system and genetics.

2. The brain adapts:tolerancephysical dependence

3. There is a shift in people, places and

activities towards getting the drug.

4. The meaning can be:Apparent balance is progression of diseaseCoping Skills lag in developmentEmotional memory is lied toCognitions are distorted

Reward Center

Monitor Reward People

Places DRUG Activities Need O2 Safety Water Food Respect Companionship

How Addictive Drugs Addict the Person-The Ugly

1. When the drug is gone, the normal system does not work depending on drugs chemical action ,state of the system and genetics.

2. The brain adapts:withdrawal

3. The meaning is:The drug is needed to Survive

Reward Center Need Monitor Reward O2

Safety DRUG Water Food Respect

Companionship

Drug Works-I Don’t Work

In withdrawal we experience alarm and we learn our own system doesn’t work:

Memory Action Irritability

Tension

Anxiety

Anger

Pain

Panic

Reward Center Need Monitor Reward

O2 Drug Craving

Safety Water Food Respect

Companionship

Brain Imaging shows suppression

• After use of cocaine there is suppression of dopamine receptors

Positive Emotional Drug Memory can also stimulate the reward center

=CRAVING

Drug MemoryPeoplePlaces

Anxiety and Mood Disorders often begin in Teens and Young Adult hood

In Dual Diagnosis There are several mechanisms for anxiety and depression

Cognition Memory Skills Needs BiochemicalO2SafetyFoodH2ORespectCompanionship

In Dual Diagnosis the drugs carry a bigger impact and development stops

Cognition Memory Skills Needs BiochemicalO2Safety DrugFoodH2ORespectCompanionship

The Disease Progresses

• Tolerance, Physical Dependence

• 5-7 years of struggle for control

• Craving for the drug during attempts to quit

• Denial because I need the drug so much

• Shame at not being able to be in control

The Family Disease Progresses

Denial and Enabling

I can’t conceive living without it

It is what I need It is my number one

priority I didn’t drink or use

that much It doesn’t bother them

Recovery Needs and Problem Drinking Scores Vaillant,1995

Shame of Loss of Control of Illness

• Alcoholics spend 5-7 years struggling for control

• They don’t know how to respect themselves with being out of control

• They have an illness

Getting to Treatment• It is hard and scary to

change• If the addict takes a

first step then we need to meet him/her there and facilitate their progress.

• The addict may need intervention

We can Help the Process Along

• Each stage has appropriate interventions

The Team Approach

Detoxification

We taper medications over time to allow the nervous system to stabilize

Memory Action

Reward Center Need Monitor Reward

O2 Drug tapering

Safety Water Food Respect

Companionship

Opiate Stabilization

Some people stay too agitated when coming off opiates and need to be stabilized on them

Memory Action

Reward Center Need Monitor Reward

O2 Drug Stabilization

Safety Water Food Respect

Companionship

Swedish Randomized TrialThe Lancet 361,Feb 22,2003 (Kakko et al)

• Heroin Dependence by DSM IV

• Placebo Bupr• ASI 1.84 2.11• Yrs Heroin 4.8 5.8• Hep B 35% 35%• Hep C 80% 60%• HIV 0 1

The Work of Recovery

Cognition Memory Skills Needs BiochemicalO2Safety DrugFoodH2ORespectCompanionship

Safe Environment

• The patient needs to be in a safe environment to feel calm enough to begin to learn new skills, ways of thinking and to experience feeling better.

• The addiction is still very reactive.

• This will help determine the level of care that they need.

• 1. Hospital• 2. Sober Living• 3. Intensive Outpatient• 4. Outpatient• 5. 12 Steps

The Biochemical

• 1. Detoxification/taper/ maintenance

• 2. Stabilize Mood• 3. Stabilize Anxiety• 4. Reduce Craving

• Close communication between the team is important.

• 1. Symptoms vs Disease states

• 2. Reactive vs biochemical imbalance

• 3. Pain vs function

Medications

• Antabuse-

• Campral

• Naltrexone

• Provigil/Nuvigil

• Reduces impulsive use

• Reduce Craving (mild effect)

• Block reward of drinking or using opiates

• Help with stimulant withdrawal/ADD

The Needs

• Safety• Respect• Companionship

• These have often been severely damaged. Part of treatment is to provide a systematic structure to help restore them.

• 1. The most essential aspect of a program is safety.

• 2. Respect needs to be modeled and starts with acknowledgement.

• 3. Sober friends and family and meetings form the initial community of recovery.

The Skills

• 1. Managing Craving

• 2. External Triggers

• 3. Internal Triggers

• 4. Communication Skills

• 5. Setting Boundaries

• 6. Dealing with the past

• Recovery is like learning a sport or to dance

• Patients will make mistakes and lose confidence

• They may relapse• They may get frustrated

It is not what they know but how they react.

The Emotional Memory

• 1. In addition to the life memories that are stored there (good and bad) it has been lied to by the addictive drug.

• 2. It has to go through retraining.

• 3.We have to have compassion for it, for it is sick

• Time has no meaning to the emotional memory

• It records and it replays• It is primitive but

powerful• It is influenced by

current status of needs and cognitive filters

Cognitions

• Denial• Shame• Core Beliefs• Cognitive Distortions

• Cognitive Skills and Creativity

1. Mood Logs2. Untwisting one’s

thinking3. New Perspectives and

Options

Chronic Pain

Low Back PainFibromyalgia

Migraine Headache

Prior Trauma and PTSD and Chronic Pain

• 1. Common Historiesa. Adultified Childb. Abused Child

2. High Anxietya. If I set boundaries I will be rejectedb. I can’t say no.c. I must succeedd. Past intrudes into the present

3. Persona vs Person a. What I do defines/hides me

Trauma and Vulnerability to Pain

• N=520 Traumatized subjects: assessed for-• PTSD,dissociation,somatization, affect• No PTSD<lifetime PTSD<Current PTSD• disaster victims<adult interpersonal

trauma<childhood trauma• Conclusions: PTSD,dissociation,

somatization,affect dysregulation co-occur• (Covington,2004)

Chronic Pain Predisposition

Reward Center Need O2 Monitor Reward

Safety Water Food Respect

CompanionshipPain PanicAnxiety AngerIrritability Tension

Limbically Augmented Pain Syndrome

• Patients w/ depression, behavioral dysfunction, heightened sensitivity to internal and external stimuli

• Pain: chronic,often atypical, resistant to analgesics

• Assoc w/ disturbed mood, sleep, energy, libido, memory/concentration/behavior

• Amplification,spontaneity,anatomic spreading,cross sensitization.(Covington,2004)

Wind-Up in Fibromyalgia Staud,R. Arthritis Research & Therapy 2006,8:208

Windup pain ratings of normal control (NC) and fibromyalgia syndrome (FM) patients. All subjects received 15 mechanical stimuli (taps (T)) to the adductor pollicis muscles of the hands at interstimulatory intervals of 3 s and 5 s. FM patients showed mechanical hyperalgesia during the first tap and greater temporal summation than NCs at both interstimulatory intervals. A numerical pain scale was used (0 to 100). The shaded area represents pain threshold.

After Central Sensitization

• after central sensitization has been established only minimal nociceptiveinput is required for the maintenance of the chronic pain state.

• Additional, factors, including pain related negative affect and poor sleep have been shown to significantly contribute to clinical FM pain

• Arthritis research & therapy.; 2006 1 1;8(3)

The Work of Recovery from Chronic Pain

• 1. Acknowledgement of the injury and its effect upon the person at all levels.

• 2. Acknowledgement of the emotional state of the person’s reaction to the injury, the level of pain experienced by the person and their perceptions of their options.

• 3. Management of the pain at all three levels of pain.• a. Injury Site• b. Nervous System augmentation• c. Limbic System

• 4. Management of grief and co-occurring mental health disorders and /or chemical dependency if present.

Pain Recovery Skills

• 1. Pacing

• 2. Setting Boundaries

• 3. Learning how to manage anger

• 4. Learning how to manage anxiety

• 5. Connecting to people in a new way

• 1. Respecting who you are, not who you were

• 2. Respecting one’s limits

• 3. Communication Skills and options

• 4. Learning how to feel safe

• 5. Persona vs Self

Moving from Rejection to Respect

• The drugs reject reality.

• Recovery is a return to respect for reality and oneself and ones relationships with others

The Twelve Steps-

• How do respect your self with this?

• Answer:• You share it and receive

respect from others• You come to learn you

have an illness

• STEP 1

• Powerless over alc/drug• Life has become

Unmanageable

The Twelve Steps

• Step 2• Came to believe that a

Power greater than ourselves that could restore us to sanity

• How do we respect ourselves when we don’t have the answer?

• Answer:• Humility is the

beginning of Wisdom

The Twelve Steps

• Step 3

• Made a decision to turn our will and our lives over to God as we understand him

• What does God look like?

• Answer:• He/She cannot be a

human being.

Alcoholics Anonymous And Spirituality

• The emergence of AA as a potent vehicle for personal transformation has been influential, as it has brought the term spirituality to the attention of both the general public as well as the mental health and addiction treatment providers.

Practical Spirituality

• Learning how to respect oneself as a limited person who has limited control and is not perfect

• Drugs can disconnect the person from feeling one’s limits. Drugs are able to say “shut up” to parts of self the person doesn’t know how to deal with.

• In recovery the person goes from rejection to respect for these parts of self

The Balance of Spirituality and Psychology

• INVESTMENT->CARING

• No Time• No Money• No Understanding• No Knowledge• Etc.

• When caring is blocked. = Stress

The Balance of Spirituality and Psychology

• CARING • No Time• No Money• No Understanding• No Knowledge• Etc

Drugs take the caring away =No Stress

The Balance of Spirituality and Psychology(the Serenity Prayer)

CARING Accept what can’t be changed

Courage to change the things can be

Wisdom to know the differenceTime Out, Sharing, Asking for help = Managed Stress

Thank You-Team!

Treatment of Addiction

• 1. 12 step programs• 2. Counseling programs• 3. Medication• 4. Residential Treatment

How Addictive Drugs Addict the Person- Dual Diagnosis

1. The drug stimulates the reward center according to its chemical action ,state of the system and genetics.

2. The message is Drug Works!

3. The meaning can be:The drug is a better way to

Feel Good

Reward Center Need Monitor Reward O2

Safety DRUG Water Food Respect

Companionship

How Addictive Drugs Addict the Person- Dual Diagnosis

1. The drug stimulates the reward center according to its chemical action ,state of the system and genetics.

2. The message is Drug Works!

3. The meaning can be:The drug is a new/better

way to Feel Good

Reward Center Need Monitor Reward O2

Safety DRUG Water (_) Food Respect

Companionship

Stages of Alarm and Defenseinvolve both feeling and action

• Irritability Annoyance more than fear • Tension Alert to question of danger• Anxiety A feeling of needing to

escape• Anger A need to stay and defend• Pain The boundary has been crossed• Panic There is no escape

The Survival Brain is a teaching machine that stores its results

Reward Center Need O2 Monitor Reward

Safety Water Food Respect

CompanionshipPain PanicAnxiety AngerIrritability Tension