neurobiology of substance dependence
TRANSCRIPT
Neurobiology of Substance Dependence
By-
Dr.Sunil SutharUnder Guidance of-
Dr.Suresh Gupta
CLINICAL FEATURES OF SUBSTANCE DEPENDENCE
Core criteria
Tolerance
Withdrawal
Craving
Impaired control/Compulsive use/Relapse
Socio-occupational dysfunction
Persistent use despite psycho/physical harm
ADDICTION DEFINED NEUROBIOLOGICALLY
Maladaptive alterations
in
spontaneous behavior
&
the behavioral response to re-administration of the drug
due to
drug-induced changes in the CNS (transmitters, receptors, circuits, volume)
Risk factor for substance abuse/dependence
Environmental• Availability of drugs• Poverty• Social change• Peer culture• Occupation• Cultural norms, attitudes• Policies on drugs:
tobacco and alcohol
Individual• Genetic disposition• Victim of child abuse• Personality disorders• Family disruption and
dependence problems• Poor performance at
school• Social deprivation• Depression and suicide
World Health Organization2004
Protective factor for substance abuse/dependence
Environmental• Economic situation• Situational control• Social support• Social integration• Positive life events
Individual• Good coping skills• Self-efficacy• Risk perception• Optimism• Health-related behaviour• Ability to resist social
pressure• General health behaviour
World Health Organization 2004
To understand neurobiology……..
• Neuroanatomy of reward system
• Evidence from animal studies
• Drugs of abuse: action & withdrawal
• Genetic predisposition
Natural rewards• Food, water, sex, &
nurturing are natural rewards.
• They allow organism to feel pleasure when eating, drinking, sex & being nurtured.
• They reinforce the behavior for repetition.
• These are required for survival.
• Brain has pathway responsible for reward.
The reward pathway Ventral Tegmental Area(VTA), Nucleus accumbens (NA) & Prefrontal cortex (PFC). VTA is connected to both NA &
PFC via this pathway sending information via its dopaminergic neurons,
Dopamine released in NA & PFC
• 3 brain areas mediate adaptive behaviour
Nucleus accumbens mediates reward related activities (positive valence);
Amygdala involved in fear motivated behaviour (negative valence)
Prefrontal cortex involved in decision making & predicting rewarding behaviour by:
- salience attribuition of environmental stimuli & - directing intensity of behavioural response.
• A balanced combination of motivational & affective states with external stimuli predicts reward, & determines overall output of a given behavioural response in acquiring natural reward
Dopamine•Receptors: D1, D2•Function: pleasure, euphoria, mood, motor function
Serotonin•Receptors: 5HT3•Function: mood, impulsivity, anxiety, sleep, cognition
Cannabinoids•Receptors: CB1•Function: Pain, appetite, memory
Opioid peptides (Endorphins, Enkephalins)
•Receptors: Kappa, Mu, Delta•Function: pain
The following neurotransmitters act on the reward pathway:
In all rewards, dopamine is the final activation chemical.
Dopamine Pathways: Reward, Pleasure, Euphoria, Motor Function, Decision making
Serotonin Pathways: Mood, Memory, Sleep, Cognition
Raphe
Prefrontal cortex
Nucleusaccumbens
Ventraltegmentalarea
Dopamine
Ventral tegmental area, nucleus accumbens
Opioid Peptides
Nucleus accumbens, amygdala, ventral tegmental area
GABA
Amygdala, bed nucleusof stria terminalis
Glutamate
Nucleus accumbens
Neurotransmitters and anatomical sites involved in the acute reinforcing effects of drugs of abuse
Activation of reward pathway by an electrical stimulus: animal model
• Rats trained to press lever for electrical jolt to certain part of brain, ie NA
• Rats keep pressing lever to receive electric stimulus because it is pleasurable.
• Reward feeling is positive reinforcement, which occurs due to increased dopamine release.
• If dopamine release is prevented rat won't press for electrical jolt.
`Rewarding input to the
nucleus accumbens is due to bursts of dopamine release and thus phasic dopamine firing with "fun" and potentiation of conditioned reward as the result.
Connections of the amygdala with the nucleus accumbens communicate that emotions have been triggered by internal or external cues and signal an impulsive, almost reflexive response to be taken.
Substance abuse can arise from impairment of top-down inhibitory
control (impairement of prefrontal cortex)
behaviors implementation
The amygdala can not only learn that a drug causes pleasure but can also associate cues for that drug with pleasure. Thus, when cues are encountered, the amygdala signals dopamine neurons in the ventral tegmental area (VTA) that something good is coming; it may even signal the relief from drug craving (1 and 2). This leads to dopamine release in the nucleus accumbens (3), which triggers GABA-ergic neuron .
HYPOTHESIS
Dopamine is the basis of the ‘rewarding’ drug experience
Enhanced dopamine release in the meso-cortico-limbic circuit results in maladaptive drug-related behaviors
LACUNAE
Several drugs of abuse do not have prominent dopaminergic actions.
Role of NTs like GABA, glutamate and limbic and cortical brain areas unexplained.
Non-dopamine substrates can elicit addiction behaviors (Giro et al, 1996; Rocha et al, 1998).
Development of addiction may consist in part of a transition from dopamine-dependent behaviors to glutamate-dependent behaviors (as is true for natural rewards).
Cortical and allocortical areas prominent in ‘learning’ addiction behaviors.
Drug action in brain Acute drug administration modifies brain function,
Repeated exposure causes pervasive changes in brain function & persist long after individual stops taking drug.
Effects of chronic drug administration have been identified at cellular, molecular, structural & functional level.
An addicted brain is different from a non-addicted brain.
There are changes in brain metabolic activity, receptor availability, gene expression & responsiveness to environmental cues.
Name NT Circuit/Area
Mechanism
Amphetamine DA VTA and NA; brain stem
Displaces DA, NE from storage sites
Alcohol GABA, glutamate, DA, 5-HT, endorphins
Dose dependent:VTA;Cortical, limbic, basal ganglia, brain stem
Enhances GABAergic, inhibits glutamatergic actions
Cocaine DA, 5-HT, NE, glutamate
VTA; cortex, limbic area
Re-uptake inhibitor
Name NT Area/ circuit Mechanism
Nicotine DA, glutamate, GABA
VTA Direct receptor action
Cannabis Ach, DA, GABA, histamine, serotonin, NE, endorphins, PGs
Basal ganglia, cerebellum, hippocampus, dentate gyrus, cortex, brain stem
Enhance formation of DA, NE, 5-HT, GABA
Name NT Area/ Circuit
Mechanism
Phencyclidine Glutamate Hippocampus,anterior forebrain
NMDA receptor antagonist
Opioids Opioid receptors
Widespread: CNS, ANS
G-protein mechanisms: cAMP dependent kinases
Molecular Biology of Addiction: Addiction is a form of drug-induced neural plasticity
Upregulation of cAMP pathway• Occurs in response to chronic administration of drugs• Resulting activation of transcription factor
CREB(cAMP response element-binding)• Both mediate aspects of tolerance and dependency
Induction of another transcription factor, d FosB -• May contribute to sensitized responses to drug
exposure
Ref: Nestler, Eric - Molecular Biology of Addiction. Am J of Addictions 10:201-217, 2001
Basis for Plasticity: Summary
Drugs enter the brain and bind to an initial protein target
Binding perturbs synaptic transmission which in turn cause the acute behavioral effects of the drug
Acute effects of the drug do not explain addiction by themselves
Ref: Nestler, Eric - Molecular Biology of Addiction. Am J of Addictions 10:201-217, 2001
Addiction produces a change in brain structure and function (adaptation to the drug)
molecular and cellular changes in particular neurons alter functional neural circuits
This leads to changes in behavior consistent with addicted states
Addiction is therefore a form of drug induced neural plasticityRef: Nestler, Eric - Molecular Biology of Addiction. Am J of Addictions 10:201-217, 2001
Addiction process behaviour
Two factors modulate behaviour in addiction
(1) Reinforcement: stimulus increases the probability of response. positive reinforcement for pleasure from drug. negative reinforcement to relieve withdrawal symptoms – self-medication.
(2) Neuro-adaptation: Initial drug responses are attenuated or enhanced by repeated drug exposure
Withdrawal
Result of an abrupt cessation of the drug.
This syndrome involves:• disturbance of the autonomic nervous system• activation of the thalamus• release of corticotrophin releasing factor (CRF)• activation of the locus coeruleus (LC)
Withdrawal: Corticotrophin Releasing Factor (CRF) Involvement
The CRF system mediates the affective and somatic symptoms of drug withdrawal
Heart rateBlood pressureBlood glucose
Koob, 2008, PNAS 105(26), 8809-10, Copyright 2008, National Academy of Sciences, U.S.A. Response to stressors
Withdrawal: Neurotransmitter Involvement
Withdrawal Dopamine: dysphoria Dynorphin: dysphoria
Serotonin: dysphoria CRF: stress
Opioid Peptides: increased pain
GABA: anxiety, panic attacks NE: stress
Glutamate: hyperexcitability
Patient feels dysphoric, irritable, depressed and angry
“Drug craving” behavior: Type one
Cue triggered: animal develops conditioned self-stimulation in association with sensory stimuli or preferred place
If removed from environment for extended time And reintroduced to sensory stimuli or preferred place,
quickly reinstates behavior despite lack of reward Originates in hippocampus & amygdala; “emotional
memories” Neurotransmitter: glutamate
“Drug craving” behavior: Type two
Stress triggered: animal develops conditioned self-stimulatory behavior
Reward stopped & behavior extinguishes Relatively minor stress reinstates behavior & place
preference even in absence of further reward Mediated by corticotropin releasing factor in amygdala, &
NE from brainstem
Relapse studies
Stress induced relapse
‘Non-specific’
Pathways
• Mesolimbic dopamine system
• Corticotropin releasing factor (CRF): activates HPA axis – peripheral glucocorticoid release increased – facilitates excitatory input to VTA DA neurons
DRUG USE(Self-Medication)DRUG USE
(Self-Medication)
STRESSSTRESS
CRFCRF
AnxietyAnxiety
CRFCRF
AnxietyAnxiety
What Role Does Stress Play In Initiating Drug Use?
What Role Does Stress Play In Initiating Drug Use?
ProlongedDRUGUSE
ProlongedDRUGUSE
AbstinenceAbstinence
RELAPSERELAPSE
CRFCRF
AnxietyAnxiety
What Happens When A Person Stops Taking A Drug?
What Happens When A Person Stops Taking A Drug?
Cue-induced relapseEnvironmental stimuli – Pavlovian conditioning
Pathways
• Mesolimbic dopamine system: activation
• Amygdala
conditioning processes for stimuli
Cue-evoked recall
Activates VTA DA neurons (glutamatergic pathway) – increased DA in NAc
• Hippocampus, anterior cingulate cortex
The Development of Addiction: Genetics
Inheritability has been found to range from 40-60%Some variability between: gender and substances
Specifically:
4-fold increased risk in 1st degree relatives
4-fold increased risk also in adopted away children
• Variants of genes associated with drug abuse:
– FAAH missense mutation is associated with drug dependence.
– Polymorphism in promoter region of prodynorphin gene may beassociated with protection against cocaine dependence .
– Gene variants in nicotinic alpha 7 promoter associated with decreased expression of nicotinic alpha 7 subunit message in different regions of schizophrenic brains and with sensory gating defects in schizophrenics.
– 5HT1B receptor variant is associated with conduct disorder and Alcoholism.
Genes Implicated in Addiction
Genes Affecting Drug metabolism
• Ethanol - Acetaldehyde - Acetate-Individuals with defects in this metabolism pathway have a 5-10-fold reduction in risk for alcoholism
• Nicotine - Cotinine- Individuals with defects in this metabolism pathway appear to smoke fewer cigarettes
ADH2ADH3
ALDH2ALDH3
CYP2A6
Comorbidity of substance dependence and mental illness
Several hypotheses as to why mental illness and
substance dependence may co-occur:
1. There may be a similar neurobiological basis to both;
2. Substance use may help to alleviate some of the symptoms of the mental illness or the side effects of medication;
3. Substance use may precipitate mental illnesses or lead to biological changes that have common elements with mental illnesses.
Relationship of Addiction Behaviour and Treatment
Addictive component
Behavioural construct
Treatment focus
Pleasure Positive reinforcement
Motivational
Self-medication Negative reinforcement
AA and Motivational
Habit Conditioned positive reinforcement
Cognitive/behavioural
Habit Conditioned negative reinforcement
Cognitive/behavioural
(koob and nestler,1997)
TO SUMMARISE
Neuroplastic changes produced in various nuclei by repeated drug action integrated with environmental stimuli form behaviors characteristic of addiction
Corticofugal glutamate projection is necessary for the initiation of drug seeking
Different modes of stimuli inducing drug seeking involve distinct components of the circuit
All modalities of drug-seeking stimuli require dopamine transmission
Pharmacology Learning
Neuroplasticity
DRUG ENVIRONMENT
Motive circuit
Cortical and allocortical circuit
Molecular binding and cell signaling
SALIENCE AND SPECIFIC BEHAVIORAL RESPONSE
Neurobiological stages of addiction
Stage 1: Acute drug effects
Based on supraphysiological release of DA in the circuit
Induction of immediate early genes like c-fos (Graybiel et al, 1990)
Short-lived changes: hours to days
Stage 2: Transition to addictionAs a result of repeated drug use
Mediated by ΔFosB (Nye et al, 1995)
Reversible: diminish over days to weeks of
discontinuation
Stage 3: End-stage addictionLong-standing drug use
Enduring protein and cellular changes
Irreversible
Ref. books…..
• Stahls essential psychopharmacology 3rd edetion.• Kaplan and Sadocks comprehensive text book 9th edition. • Neuroscience of psychoactive substance use and
dependence.WHO,2004.