Mark Lim M.D FASAMMedical Director NorthLakes Community Clinic Recovery ProgramBoard Certified in Family MedicineBoard Certified in Addiction Medicinemlim@northlakesclinic.org7156852200

“Listen & Hear”https://www.youtube.com/watch?v=5EZMWAkg

4Lo

“Thoughts”, sounds familiar?...

• “once a junkie, always a junkie”• Moral failing• “dirty” urine• “They could quit when they want to”• “weak” for relapsing• “I’m a failure, I disappointed you”

(family,provider, love ones)

• “Is it in my head?” or “its just in your head”• Late policy: 10-15mins, appointment canceled• Missed appointment: 1-3x your out• Mental Health Provider: “you need to be clean”,

“its just the drug talking” – unavailable for the work of psychotherapy.

• Medical Provider: “just go to meetings”• “I can’t be an alcoholic or an addict, because I

can’t be anything that horrible”

• Crack babies, meth heads/freaks, junkies• War on drugs• “waiting list” for treatment• Insurance policy covers only detoxification or

short term treatment services• “Prioritized” populations for treatment• Kicked out of treatment for unable to achieve

abstinence.

Effect of thoughts

Isolation Shame Denial

Effect of thoughts

Isolation

Isolation

• create distance• Propelled by myths, stereotypes, disapproval

& discrimination• Faced with disapproval & discrimination,

many seek out the company of the only people who seems to understand them- other who share their addiction.

Effects of thoughts

Shame

Shame

• Natural consequences of isolation• A force that propels people deeper and

deeper into isolation

Shame

-isn’t strong enough to defeat that urge, but it is strong enough to destroy people:• Sense of hope in their ability to recovery• Knowledge of their own value as human being• Belief in their own dignity

Effect of thoughts

Denial

Denial

Effect of stereotype and myths creates:

Addicts are bad people I’m no a bad person I must not be an addict If I’m not an addict, I don’t need help

or

Denial

I’m an addict, and addicts are bad people I must be a bad person If I’m a bad person, I don’t deserve any help

Experiences of active Addiction

-it cause Pain, Ambivalence and Fear to individual, family, providers and community

Experiences of Active Addiction

PainThe words and actions of people in active addiction sometimes bring pain to themselves and people around them:

• Fail to fulfill important responsibilities• Take money or valued possession from people they love.• Overreact to minor mistakes with extreme anger &

coldness• Withhold signs or expression of love or respect• Neglect or abuse people who are important to them,

including their children

Healing the Stigma of Addiction 2005. Pamella Woll MA CADP

Experiences of Active Addiction

AmbivalenceFor concerned friends, colleagues, and love ones, the behavior of people in active addiction often doesn’t make sense. It produce conflicting emotions.• Concerned• Sympathetic• Fearful for the person w/addiction, ourselves or love ones• Helpless • Angry at the person w/ addiction• Angry w/ ourselves of being angry• Angry with ourselves putting up with the effect of the

addiction

Healing the Stigma of Addiction 2005. Pamella Woll MA CADP

Experiences of Active Addiction

Fear

The fear of Pain and Ambivalence, which creates distances and defenses to protect us from the experience, and also could cause discomfort.

Healing the Stigma of Addiction 2005. Pamella Woll MA CADP

Definition of Addiction

is a primary, chronic disease of brain reward, motivation, memory &

related circuitry

Addiction

• Dysfunctional in these circuits leads to characteristic manifestation: biological, psychological, social and spiritual. This is reflected in an individual pathologically pursuing rewards and/or relief by substance use and other behavior

Circuitry

Brain’s PLEASURE circuitry?

Brain’s MOTIVATION circuitry?

Brain’s MEMORY circuitry?

Brains EXECUTIVE circuitry?

Circuitry

The Pleasure/Reward Circuitry of the Brain

The crucial reward neurotransmitter is

Dopamine (DA)

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Adapted from: Di Chiara, Neuroscience, 1999; Fiorino & Phillips, J Neuroscience, 1997; courtesy of Nora D. Volkow, MD.

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Adapted from: Di Chiara & Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of Nora D. Volkow, MD.

Effects of Drugs on Dopamine Levels 1

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Adapted from: Di Chiara & Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of Nora D. Volkow, MD.

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Contributions to the disease of Addiction

• 50% Genetic• 50% Environmental

• NOT biology vs. environment• The act together to produce the addiction

behavior phenotype• Substantial evidence that environmental & social

factors influence neurobiological (brain) substrates of addiction

Biological

Psychological

• One of the psychological effects of addiction involved in craving is the belief the addict cannot function or handle life without use of the drug.

Psychological

Spiritual

“spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred”

Spirituality

sense of connection to something bigger than ourselves, and it typically involves a search for meaning in life.

Now we Know….

Addiction is a primary, chronic disease of brain circuitry:• Reward• Motivation• Memory• Executive functions

Now we know…

Dysfunctional circuits leads to dysfunction• Biological• Psychological• Social• Spiritual

This is reflected in an individual pathologically pursuing rewards and/or relief by substance use and other behaviors.

What is Recovery?

re·cov·er·yrəˈkəv(ə)rē/noun

1. a return to a normal state of health, mind, or strength.2. the action or process of regaining possession or control of something stolen or lost.

RECOVERY = WELLNESS

Process of change through which the individual improves his health and wellness, live a self directed life and strive to reach their full potential.• Health• Home• Purpose• Community• “Spiritual growth”

RECOVERY = WELLNESS

RECOVERY = WELLNESS

Abstinence from all drugs and behaviors that pathologically stimulates the reward pathways is to be considered an optimal component of wellness (recovery)

Treatment

MAT = Medication Assisted Treatment ?

Treatment

MAR = Medication Assisted Recovery

Pathology/SymptomsAddiction Consequences Medication Psychosocial

/ Spirituality

Acute withdrawal symptoms X X

Post acute withdrawal symptoms X X

Craving X X

Psychiatric Problems X X

Response to environmental cues X

Rewired brain and altered neural humoral X

Change in gene expression X

Addiction interactive disorder X

Emotional damage, shame, guilt X

Unmanageability of life X

Damaged families & other relationship X

Characterologic/personality X

Psychosocial Intervention

Goal is to help patient control urges to use drugs and remain abstinent, while serving to patients in coping with emotional strife that accompanies addiction.

Psychosocial InterventionFormats:• Social skills training• Individual therapy• Group therapy• Couple counseling• Cognitive-behavioral therapy (CBT)• Contingency management (CM)• 12 Step Facilitation therapy• Motivational Interviewing• Family Therapy

Structure is important!!

Structure…structure…structure!

• Aims to put a person on path back to healthier habits, in turn promoting healthier thoughts & actions.

• Structure in addiction recovery treats addiction behavior.

Structure…structure…structure!

• Structured program can remove some pressure from outside world & allow the person in treatment to feel sufficiently at ease to start the serious work of self reflection

• Promotes long term sobriety

Healing process

Its not enough just to hear from you, or to read in a couple books, that those beliefs (negative)/myths aren’t rooted in reality, the person needs to hear the new, positivemessages over & over again, from many different people, before the new information can even begin to “tape over” the old messages.

Healing process

The person needs not just to hear about hope, but to see hope, in face after face and life after

life.