Mindfulness, Meditation, and Drug and Alcohol Use THOMAS LYONS, PH.D. LOYOLA NEUROSCIENCE SEMINAR MARCH 18, 2014 Mindfulness, Meditation and Drug and Alcohol Use What is mindfulness? Enhancement of mindfulness through meditation training Neurobiology of meditation and drug addiction Mindfulness Based Relapse Prevention Addiction and the criminal justice system: mindfulness programs in jails and prisons Research program at Chicago State University Summary and conclusions “Life is available only in the present moment.” ― Thích Nhất Hạnh What is mindfulness? “Paying attention in a particular way; on purpose, in the present moment, and non-judgmentally.” (Kabat-Zinn) Attention to thoughts, emotions and feelings in the present moment Attitude of acceptance/non-reactivity and non-judgement A very old concept Sati in Sanskrit means “awareness”, also remembrance, an important concept in Buddhism Came into Western languages in the 1970s through work of Vietnamese monk Thich Nhat Hanh and others What is mindfulness? Can be conceptualized as A mental state that varies from moment to moment in an individual A personality trait or disposition perduring over time that can be measuring with personality inventories The goal of mindfulness practice Five Facets Mindfulness Questionnaire (Baer et al 2006) Dispositional Mindfulness Dispositional mindfulness is associated with adaptive functioning (Baer et al 2006). Anxiety levels and history of depression (Grossman et al 2004) less severe gambling outcomes (Lakey et al 2007). diabetes self-management (Gregg et al 2007). Many other cross-sectional studies Difficulties with the construct of mindfulness as a trait (Grossman 2011) Self reports may not be accurate Experienced meditators may be more aware of their own limitations and rate themselves as less mindful Dispositional Mindfulness and Drug/Alcohol Use Among college age drinkers, relationship to alcohol use is “paradoxical” (Eisenlohr-Moul et al 2012) Higher levels of awareness Lower levels of non-reactivity Lower levels acting with awareness Sample in drug treatment (Bowen and Enkema, 2014) Mindfulness inversely related to severity of dependence Cultivating Mindfulness Meditation Types of meditation Concentration or focused meditation, including TM Insight or mindfulness meditation Certain types of Hatha Yoga Insight Meditation Various eastern traditions including Zen, Vipassana and Tibetan traditions can be grouped under mindfulness meditation Often builds from awareness of the breath to awareness of the whole field of phenomena at the present moment Can include sitting, walking meditation Short demonstration: Mindfulness Based Cognitive Therapy (0:39:00) Several short term or medium term interventions but for many, a lifetime practice http://www.youtube.com/watch?v=6-91LUJZoHo Neurobiology of meditation Types of studies: Measurement of brain state changes during meditation vs. rest or other activities Cross sectional comparison between long term meditators, short term participants in interventions, and/or nonmeditation control groups Neural correlates of meditation/mindful states in these groups Or response to a stimulus such as pain stimulus, emotional triggers Longitudinal studies before and after meditation training Comparisons to control group Neurobiology of meditation Structural vs. functional studies Healthy samples vs. clinical samples (with symptoms of depression, addiction etc) Evidence from EEG, PET, fMRI, and SPECT Multiple brain structures affected Prefrontal cortex Somatosensory regions Dorsolateral PFC Hippocampus Insulae Amygdala Functional networks Eg insula plus somatosensory regions Cortex plus limbic system Neurobiology of meditation Cross sectional comparison of long term meditator vs non meditators show enhanced activity in the PFC, right anterior insula and right hippocampus (Chiesa & Seretti, 2010) Eight week meditation training increases grey matter density in hippocampus, cerebellum compared to controls (Hölzel et al 2010) Specific or non-specific effect? Mindfulness Meditation as a Behavioral Therapy “Third wave” of therapeutic interventions based on acceptance of negative thoughts and emotions rather than attempts to manage or control them. Mindfulness-based Stress Reduction for chronic pain (KabatZinn 1980) Acceptance and Commitment Therapy for depression and anxiety (Hays et al 2006) Mindfulness-based Cognitive Therapy for depression (Segal et al 2002) Dialectical Behavior Therapy for borderline personality disorder (Hays et al 2004) Possible mechanisms of clinical benefit Strengthening connectivity between the cortex and limbic system (Chiesa, 2013) Dampen automatic amygdala activation stress response, anxiety and other emotional states pain perception May be interpreted as an increased conscious control Increasing grey matter density in specific regions (Hö lzel et al 2010) Before meditation, high emotional reactivity is observed. The amygdala easily activates in response to negative stimuli and the PFC is not able to inhibit the amygdala. (Chiesa et al. 2010) After meditation training, amygdala activity is usually reduced. If amygdala activates in response to negative stimuli, PFC is engaged in order to dampen automatic amygdala responses. (Chiesa et al 2010) Neurobiology of addiction Effect of drugs of abuse is related to the mesolimbic reward system: ventral tegmental area, ventral striatum, amygdala and medial PFC – the “reward circuit”. Compulsive use also involves the dorsal striatum – “habit circuit” Addiction also involves dysfunction in the cortex, including dlPFC and activation of subgenual ACC Effect of mindfulness meditation training Mindfulness training primarily targets the cortex; at least initially, a “top down” process of improving control over functioning Self referential thinking and rumination activate midline PFC areas in both depression and addiction (Brewer et al. 2009) Mindfulness practice may shift activation from midline PCC to dlPCC – more objective awareness Lateralization of brain activation Effect of a brief mindfulness meditation training 47 treatment-seeking smokers (12-h abstinent from smoking) viewed images while undergoing fMRI (Westbrook et al 2011). Passively vs. trained to engage in mindful attention Mindful attention reduced neural activity in subgenual anterior cingulate cortex (sgACC) Reduced connectivity with other craving related regions including insula and ventral striatum Also reduced self-reported craving (Westbrook et al. 2011) Effect of a brief mindfulness meditation training 47 treatment-seeking smokers (12-h abstinent from smoking) viewed images while undergoing fMRI (Westbrook et al 2011). Passively vs. trained to engage in mindful attention Mindful attention reduced neural activity in subgenual anterior cingulate cortex (sgACC) Reduced connectivity with other craving related regions including insula and ventral striatum Also reduced self-reported craving (Westbrook et al. 2011) Top-down or bottom-up process? Experienced meditators exhibit changes in limbic system functioning during meditation that are independent of cortical control.(Chiesa et al 2013) May depend on length of involvement in meditation May depend on type of sample: healthy vs. clinical samples (eg smokers trying to quit) Mindfulness Based Relapse Prevention (Chawla et al 2011) Based on Mindfulness Based Stress Reduction An eight week course including meditation, yoga, and discussion of relapse, triggers, and relapse prevention Designed for individuals coming out of drug treatment Mindfulness Based Relapse Prevention In a randomized controlled trial (RCT), significant reductions in substance use and craving were observed in the MBRP group compared to treatment as usual (Bowen et al, 2009b) A second RCT compared mindfulness meditation to cognitive behavioral therapy for substance use and found reduced craving and physiological stress indices in the treatment group (Zgierska et al 2010) Mindfulness Based Relapse Prevention Might have particularly long-lasting effects on reducing drug use (Zgierska et al 2009). However, strong evidence for effectiveness of mindfulness-based treatment for substance use disorders is still lacking. (Zgierska et al 2009) Difficulties with MM in drug treatment Anxiety in early withdrawal (Vallejo et al 2009) Restlessness/agitation History of trauma An adjunct, not a substitute for drug treatment May require a period of abstinence from substances Research at Chicago State University Urban Mindfulness and Addictions Research MBRP in jail drug treatment Mindfulness with case managers: enhancing the working alliance and therapeutic outcomes Mindfulness, substance abuse, and medication adherence Drug discovery program as adjunct to mindfulness therapy Addiction and the Criminal Justice System More than 60% of prisoners are estimated to have a substance use disorder(National Center on Addiction and Substance Abuse 2010) In Cook County the majority of detainees are charged with low level drug offenses(Lyons et al 2013) Addiction and the Criminal Justice System Five fold growth in incarceration rates among people of color since 1980 has largely been a result of drug related arrests and convictions(Alexander 2010). African Americans are 54% of those incarcerated for drug offenses and are 10 times more likely than whites to be sentenced to prison for a drug law violation(Human Rights Watch 2000). Cycles of repeated arrest and imprisonment for drug related crimes often reflect untreated addiction(Langan and Levin 2002). Addiction and the Criminal Justice System Much mindfulness meditation research has been with white, middle class patients. No studies of mindfulness meditation that focus on cultural adaptations for African American men. Meditation training in a jail context Limited in duration Linked to post-release services Participants should be over the acute withdrawal stage Why meditation programs in jail? 7x as many individuals released annually from jails as from prisons Many jails have existing drug treatment programs Enforced abstinence may promote benefit of mindfulness training Mindfulness training may promote engagement in aftercare Goals of the study Culturally tailor the MBRP intervention for an urban, primarily African American population of inmates Test efficacy via a quasi-experimental clinical trial within a men’s drug treatment program at the Cook County Jail. Goals of the study At 5-month intervals over the course of 36 months, successive cohorts will be given either mindfulness training or an attention control communication skills intervention. Pre- and post-test assessments, at an equivalent interval, of mindfulness, psychological symptoms, and PTSD symptoms. Participants in the experimental condition will be referred to post-release meditation groups Goals of the study To assess the efficacy of the intervention, rearrest and reincarceration data will be compared for the treatment and control groups at a minimum of 12 months post release. Contact participants by telephone 3 months post release and obtain self reported substance use data qualitative interviews with a subset of participants in the experimental group one month post-release will explore whether and how they implemented mindfulness Formative research to adapt intervention Focus group Working with African American, culturally competent trainers Adapting and simplifying manual Mindfulness Based Relapse Prevention: A Clinician’s Guide (Chawla et al. 2011) Some conclusions Mindfulness as an attentional state, personality trait, and goal of meditation practice As a trait, mindfulness is probably important for understanding addiction, but research is just beginning Related to deficits in executive functioning, impulsiveness, and sensation seeking Some conclusions Meditation practice changes brain structure and functional circuits Most studies cross sectional and involve small samples Prospective studies with appropriate control groups needed Meditation training may be a potent tool in drug addiction treatment May have long lasting effects Stage and context of recovery important Linking behavioral and pharmacological treatment Thank you! 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