Biological Foundation for Addiction
Richard A. Rawson, Ph.D, Professor
Integrated Substance Abuse Programs
David Geffen School of Medicine
University of California at Los Angeles
www.uclaisap.org
rrawson@mednet.ucla.edu
Supported by:
National Institute on Drug Abuse (NIDA)
Pacific Southwest Technology Transfer Center (SAMHSA)
International Network of Treatment and Rehabilitation Resource Centres (UNODC)
A KEY PRINCIPLE IN
ADDICTION
Drug use is a voluntary,
preventable behaviour
Why do people initiate drug use?
Key Motivators



Fun (pleasure)
Forget (pain amelioration)
Functional (purposeful)
(NCETA, 2004)
Also initiation starts through:
 Experimental use
 Peer pressure
but...
Drug addiction is not just
“a lot of drug use”.
Drug Addiction is..
Compulsive drug seeking
and use, even knowing the
negative health and social
consequences
Why Do People Try Drugs?
•Curiosity
•Availability
Peer Pressure
•To have fun
•Gain Energy
•Lose Weight
•Reduce Pain
Why Do People Like Drugs?
To feel good
To have novel:
Feelings
Sensations
Experiences
AND
To share them
To feel
better
To lessen:
Anxiety
Worries
Fears
Depression
Hopelessness
Withdrawal
In other words:
A Major Reason People
Take a Drug is they Like
What It Does to Their Brains
Addiction and the Reward Pathway
The brain’s reward pathway is critical
to the development of addiction
Addiction and the Reward pathway
The over-stimulation of this pathway,
which rewards our life essential
behaviours (eating, drinking, sexual
behaviour), produces the euphoric effects
sought by people who abuse drugs and
teaches them to repeat the behavior
The addicted brain is fooled into believing
drugs are essential for life
Drugs and Dopamine

Psychostimulants, (cocaine and amphetamines)
directly increase available dopamine for postsynaptic signalling



Alcohol, opioids, cannabis and nicotine increase
dopamine activity indirectly


increase release or
reduce reuptake (block dopamine agonist transporter)
stimulating neurons that influence dopamine neurons
Nicotine is atypical addictive drug

does not increase dopamine as much as
psychostimulants and opiates
How the brain response to drugs
 The
brain adjusts to the overwhelming surges
in dopamine (and other neurotransmitters) by
producing less dopamine or by reducing the
number of receptors
Dopamine D2 Receptors are Lower in Addiction
DA
DA
DA
DA DA DA
DA
DA
DA DA
DADA
Ice & Cocaine
Reward Circuits
Non-Drug Abuser
Alcohol
DA
DA
DA
DA
DA
DA
Heroin
control
addicted
Reward Circuits
Drug Abuser
Their Brains
have been
Re-Wired
by Drug Use
Drug addiction is a
chronic brain disorder
The brain shows distinct changes
after drug use that can persist
long after the drug use has
stopped
Decreased dopamine transporter
binding in METH users resembles that
in Parkinson’s Disease
Control
Meth
PD
Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp. 8417-8422, October 15, 1998.
Prolonged Drug Use Changes
The Brain In Fundamental and
Long-Lasting Ways
Gray Matter Deficits in Cortex
PM Thompson et al., J. Neurosci., 2004
How much
does the brain heal?
Partial Recovery of Brain Dopamine
Transporters in Methamphetamine (METH)
Abuser After Protracted Abstinence
3
0
ml/gm
Normal Control
METH Abuser
(1 month detox)
METH Abuser
(24 months detox)
Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.
Why can’t people just stop drug
use?
Prolonged drug use changes
the brain in fundamental and
long-lasting ways!
Voluntary
Drug Use
Compulsive
Drug Use
(Addiction)
Drug addiction is a chronic
relapsing disorder similar to
other chronic diseases such
as diabetes, asthma, arthritis
and cardiovascular disease.
RELAPSE RATES ARE SIMILAR FOR DRUG ADDICTION &
ALL THESE OTHER CHRONIC ILLNESSES.
Environmental factors

A range of environmental factors impact on drug use,
including price and availability of both licit and illicit
drugs

Other environmental factors include prenatal
problems, early childhood experiences, family
relationship and bonding, and early educational
opportunities.

Cultural norms around drug use also act as powerful
determinants of the use of both licit and illicit
substances
Important terminology
1.
Harmful use
2.
Physical dependence vs. addiction
3.
Psychological craving
4.
Tolerance
5.
Withdrawal symptoms
6.
Neurotransmitters and receptors
What is harmful use? (ICD-10)
A pattern of psychoactive substance use
that is damaging to physical and / or
mental health.
What is drug addiction?
Drug addiction is a complex illness characterised
by compulsive, and at times, uncontrollable drug
craving, seeking, and use that persist even in the
face of extremely negative consequences.
(NIDA, 1999)
Characteristics of addiction

Compulsive behaviour
 Behaviour is reinforcing (rewarding or
pleasurable)
 Loss of control in limiting intake
(NIDA; www.projectcork.org)
Psychological craving
Psychological craving is a strong desire or
urge to use drugs. Cravings are most
apparent during drug withdrawal.
Tolerance
A state in which a person no longer
responds to a drug as they did before, and
a higher dose is required to achieve the
same effect.
Withdrawal (1)
A period during which somebody addicted to
a drug or other addictive substance reduces
their use or stops taking it, causing the
person to experience painful or uncomfortable
symptoms
OR
A person takes a similar substance in order to
avoid experiencing the effects described
above.
Withdrawal (2)
When a drug is removed, physical and / or mental
disturbances may occur, including:
Physical symptoms
Emotional problems
Cognitive and attention deficits
Aggressive behavior
Hallucinations
Convulsions
Death
Why Should We Treat Addiction As A
Chronic Illness?
Addiction: A Chronic Condition
Drug addiction is a chronic
relapsing disorder similar to
other chronic diseases such
as diabetes, asthma, arthritis
and cardiovascular disease.
A Comparison with Three Chronic
Medical Illnesses
 Hypertension
 Diabetes
 Asthma
Why These?
• No Doubt They Are Illnesses
•
All Chronic Conditions
•
Influenced by Genetic, Metabolic and
Behavioral Factors
•
No Cures - But Effective Treatments Are
Available
Adherence
Hypertension:
< 60%
Diabetes
< 50%
Asthma
< 30%
Addiction
30 - 50%
Treatment Research Institute
Other Long-term Outcome
Studies

Alcohol: Vaillant: multiple studies reporting a majority
of alcoholics who enter treatment experience multiple
relapses and retreatments with about 30-50%
achieving stable abstinence.

Cocaine; Hser: Ten year follow-up of cocaine
dependent patients in treatment indicates that fewer
than 50% achieve extended periods of abstinence.
Most reenter treatment multiple times.

Methamphetamine: Marinelli-Casey 3 year follow up
indicates of a cohort of 600 MA dependent individuals
about 50% continue to use MA at a moderate or
severe level during the 3 year post treatment 36
month period.
Re-Addiction Following Prison
• Vaillant
• 447 opiate addicts
• Maddux & Desmond
• 594 opiate addicts
• Nurco & Hanlon
• 355 opiate addicts
• Hanlon & Nurco
• 237 mixed addicts
91%
98%
88%
70%
Many Other Studies Including:
(Simpson, Wexler, Inciardi, Hubbard, Anglin)
Treatment Research Institute
Public Expectations of Substance
Abuse Interventions
 Safe,
complete medical withdrawal
 Reduced use of medical services
 Eliminate crime
 Return to employment/self support
 Eliminate family disruption
 No return to drug use
How Do We Think About Treatment?
 “The
28 day cure”
 Put them in a box, something happens
and they come out fixed.
 The washing machine model: Put a “dirty
addict” in, run the washer, and take out a
“clean citizen”.
Traditionally, Substance Use
Disorder Treatment has been an
Acute Response
Admission
Treatment …
Discharge
A Nice Simple Treatment Model
Substance Abusing Patient
Treatment
Non- Substance Abusing Patient
Addiction: A Chronic Health Problem
1. Similar Genetic Heritability
2. Shared Influence:
Individual &
Environmental
Factors
3. Both Chronic:
Relapsing and
Remitting
- McLellan et al., 2000
Treatment Services for
Substance Use Disorders
(SUDs)
Treatment and Support Services
Inpatient Withdrawal
and Stabilization
Residential
Rehabilitation
Treatment
Intensive
Outpatient/Psychosocial
Behavioral Treatment
Outpatient Withdrawal
And Stabilization
Sober Living Residence
Medication Assisted
Treatment
Continuing Care/Aftercare Services
Medical Withdrawal and Stabilization
Services
Inpatient Withdrawal
and Stabilization
Outpatient Withdrawal
And Stabilization

Medical withdrawal and stabilization (W and S) is a
treatment service used to systematically withdraw
individuals from a substance in an inpatient or outpatient
setting.

Treatment is provided under the care of a medical doctor.

W and S is a short treatment and does not address the
psychosocial and behavioral issues linked to addiction.

W and S is most valuable when it encompasses formal
processes of assessment and results with a referral to
successive substance abuse treatment.
Inpatient Residential Treatment

Residential Treatment is
provided within the context of
a cooperative living
arrangement.

Residential Treatment should
use evidence-based
medication and
behavioral/psychological
therapies including the 12-step
approach.

Sober Living Residence is a
living environment that has
supervision and a recovery
environment. It should be
used in conjunction with
Residential
Rehabilitation
Treatment
Sober Living Residence
Medication Assisted Treatment
Medication Assisted
Treatment



Medication (e.g. Methadone, Buprenorphine,
Naltrexone) provided in phases by a certified, licensed
Opioid Treatment Program (OTP) or a through a trained
medical doctor.
Medication Assisted treatment provides maintenance
pharmacotherapy using an opioid agonist, a partial
agonist, or an antagonist medication.
The medication may be combined with other treatment
services, including medical and psychosocial services.
Intensive Outpatient Treatment
Intensive
Outpatient/Psychosocial
Behavioral Treatment

Outpatient Treatment varies in length of stay,
but typically lasts at least 90 days and is
followed by outpatient continuing care.
 Patients generally receive 6 to 30 contact
hours per week.

Core services include: group, individual and family
counseling, psychoeducation, CBT and
motivational interviewing , positive reinforcement
techniques; family involvement; urine and breath
alcohol testing; 12 Step (or alternative)
participation; case management; medication,
vocational and educational services.
Outpatient Treatment for
Substance Use Disorders: A Definition
A collection of evidence-based services and
activities designed to teach and support
abstinence from alcohol and drug use while
individuals live in the community. In addition,
skills are taught to prevent relapse and
improve other areas of functioning. Services
are delivered by addiction professionals and
may include medications.
Continuing Care/Aftercare Services

Continuing Care Activities include a range of
ongoing support activities. These include:

12 Step Program participation
Other peer support groups
Continuing care group and individual sessions
Recovery “Check-ups”
Telephone call recovery support
Internet recovery support
m-Health recovery support






The Continuum of Care for
SUD Care
What Exactly is Continuity of Care
for SUDs?
Withdrawal and
Stabilization
Residential
Treatment
Arrow =
Referral/
Transfer
“Stepping down” from
higher-intensity to lowerintensity services, or
stepping up, if necessary
Outpatient/Psychosocial
Behavioral Treatment
Sober Living
Residence
Continuing Care/Recovery Support Services
Residential
Prevention
The
Outpatient
SUD
Treatment
Healthcare
System
System
Medically
Assisted
Treatment
Sober
Living
Mental
Health
Recovery
Support
EVIDENCE-BASED PRACTICES
Definition of EBP

Institute of Medicine (2001):
Evidence-based behavioral practice (EBBP) “making
decisions about how to promote health or provide care
by integrating the best available evidence with
practitioner expertise and other resources, and with
the characteristics, state, needs, values and
preferences of those who will be affected.
Evidence is comprised of research findings derived
from the systematic collection of data through
observation and experiment and the formulation of
questions and testing of hypotheses" (www.ebbp.org).
Which Evidence-Based Practices
can be implemented into
community SUD treatment
settings?
What are the most important
EBPs?

Behavioral Approaches
•
•
•
•
•

Motivational Interviewing/Brief Intervention
Contingency Management
Cognitive-Behavioral Coping Skills Training
Couples and Family Counseling
12 Step Facilitation and 12 Step Program Participation
Medications
•
•
•
•
•
•
Methadone
Buprenorphine
Naltrexone (oral and extended release)
Naloxone (for overdose prevention)
Acamprosate
Antabuse
Motivational Interviewing: Definition
Motivational interviewing is a client-centered
style of interaction aimed at helping people
explore their ambivalence about their
substance use and begin to make positive
behavioral and psychological changes.
Summary of Motivational
Interviewing

Goal is to enhance motivation to change
behavior and elicit self-motivational
statements using a supportive, nonconfrontational style.
 The 5 principles of M.I. are:
1.Express empathy
2.Develop discrepancy
3.Avoid argument
4.Roll with resistance
5.Support self-efficacy
Contingency Management

Basic Assumptions
 Drug and alcohol use behavior can be
controlled using operant reinforcement
procedures
 Incentives can be used for money or goods
 Incentives should be redeemed for items
incompatible with drug use
 CM can be extremely useful in promoting
treatment retention and promoting medication
adherence
 CM for drug free urine tests can be useful in
decreasing drug use.
Contingency Management

Key concepts





Behavior to be modified must be objectively
measured
Behavior to be modified (e.g., urine test results) must
be monitored frequently
Reinforcement must be immediate
Penalties for unsuccessful behavior (e.g., positive
urine test) can reduce voucher amount
Incentives may be applied to a wide range of
prosocial alternative behaviors
Principles of Cognitive Behavioral
Therapy (CBT)

CBT is used to teach, encourage, and support
individuals about how to reduce / stop their
harmful drug use.

CBT provides skills that are valuable in assisting
people to achieve initial abstinence from drugs
(or to reduce their drug use).

CBT also provides skills to help people sustain
abstinence (relapse prevention).
Behavioral CBT Concepts
In the early stages of CBT treatment,
strategies emphasize behavior change,
and include:
 Setting
a schedule to promote
engagement in behaviors that are
inconsistent with substance use
 Recognizing
and avoiding “high risk”
situations
 Facilitating
positive coping skills
Cognitive CBT Concepts
As CBT treatment continues into later
phases of recovery, more emphasis is
given to the “cognitive” part of CBT. This
includes:




Psychoeducation regarding addiction
Teaching clients about triggers and cravings
Teaching clients cognitive skills (e.g., “thought
stopping” and “urge surfing”)
Identifying “red flag thoughts”
Family and couples counseling

There are a number of evidence-based family
and couples treatment interventions for SUD.
 Although the intensity and specific techniques
for working with couples and families, there is
one overarching finding: Treatment programs
that engage the significant others/families into
the SUD treatment process result in better
retention and outcomes for the individual in SUD
treatment.
12 Step Facilitation Therapy
 Project
Match and a number of other
studies have demonstrated that 12 Step
facilitation therapy (an approach that
educates patients about the 12 Step
program and promotes 12 step program
involvement) can increase involvement in
12 Step program participation.
12 Step Participation

There is an expanding body of research
literature that documents the benefits of 12 Step
program participation. Researchers at Stanford
University (Moos, Finney, Humphreys and
others) have amassed a substantial body of
evidence that individuals who engage in the 12
Step program have better SUD outcomes and
more improvement in the quality of life
measures, than individuals who do not
participate.
Medication Assisted Treatment
 Medications with evidence of efficacy.
• Methadone
• Buprenorphine
• Naltrexone (oral and extended release)
• Naloxone (for overdose prevention)
• Acamprosate
• Antabuse
Thank you
Richard Rawson, Ph.D.
rrawson@mednet.ucla.edu