THE SCIENCE OF
RECOVERY: AN ADVANCED
SEMINAR
CARDWELL C. NUCKOLS, PhD
cnuckols@elitecorp1.com
WWW.CNUCKOLS.COM
THE SCIENCE OF RECOVERY
“…this business of resentment is
infinitely grave. We found that it is
fatal. For when harboring such
feeling we shut ourselves off from
the sunlight of the Spirit. The
insanity of alcohol returns and we
drink again. And with us, to drink is
to die.” Big Book page 66
THE SCIENCE OF RECOVERY
GRATITUDE (LOVE)
A CHANGE IN WORLDVIEW
GRANDIOSITY(CHARACTER
DEFECTS)
GRATITUDE
UNCONDITIONAL LOVE
HUMILITY
ACCEPTANCE
FORGIVENESS
SURRENDER
COURAGE AND HONESTY
GRANDIOSITY AND HUMAN SUFFERING
WHAT DO YOU SEE?
NUCLEUS BASALIS
THE SCIENCE OF RECOVERY:
NEUROPLASTICITY
THE NUCLEUS BASALIS IS…
THE MODULATORY CONTROL
CENTER FOR PLASTICITY
THE SCIENCE OF RECOVERY:
NEUROPLASTICITY
YOU ARE NEUROPLASTICIANS!
WHAT ENHANCES PLASTICITY?
• NOVELTY
• THERAPEUTIC RELATIONSHIPS
• PHYSICAL EXERCISE
• MINDFULNESS
NEUROPLASTICITY
• BRAIN AT ALL AGES IS RESPONSIVE
TO ENVIRONMENTAL STIMULI
• SYNAPSES CAN CHANGE IN MINUTES
WHEN STIMULATED
• NEUROPLASTICITY IS MODULATED
BY
– GENETIC FORCES
– EPIGENETIC FORCES
ADDICTION AND RECOVERY
RECOVERY
• PREFRONTAL
CORTEX
ADDICTION
• MIDBRAIN
• LIMBIC
• BRAIN STEM
ACUTE
• LOCUS
ABSTINENCE COERULEUS
THE SCIENCE OF
RECOVERY:GENETICS
• GENETICS
–A1 ALLELE OF THE DOPAMINE
D2 RECEPTOR GENE
–FOUND IN ONE-THIRD OF
POPULATION
–LOW DOPAMINE TONE
THE SCIENCE OF
RECOVERY:GENETICS
• TWIN STUDIES SUGGEST GENES AND
ENVIRONMENTAL FACTORS EACH
INFLUENCE THE VULNERABILITY TO
DEVELOPING ADDICTION
• STRESS IS ONE, IF NOT THE PRINCIPLE,
ENVIRONMENTAL FACTOR THAT INCREASES
ADDICTION POTENTIAL
• IN BOYS WITH THE A1 ALLELE STRESS WAS
SIGNIFICANTLY CORRELATED WITH
COGNITIVE FUNCTIONAL PROBLEMS
NOBLE AND BENTON. THE D2 DOPAMINE RECEPTOR GENE AND FAMILY
STRESS. INTERACTIVE EFFECTS ON COGNITIVE FUNCTIONING IN
CHILDREN. BEHAV GENET, 1997; 27:33-43.
THE SCIENCE OF
RECOVERY:GENETICS
• GENETIC VULNERABILITY
– SONS OF ALCOHOLICS HAVE
DECREASED SENSITIVITY TO ALCOHOL
• ENORMOUS AMOUNT OF
DEVELOPMENTAL STRESS
• EITHER CAN CAUSE IRREGULARITIES
IN BRAIN CHEMISTRY SUCH AS
DOPAMINE BLUNTING
THE SCIENCE OF
RECOVERY:GENETICS
• Treatment dropout linked to elevated
stress response (Drug and Alcohol Depd.
105 (3):202-208, 2009)
– Salivary cortisol can predict how long a drug
user will remain in treatment
– Cortisol measured at base for both men and
women in a residential treatment center
before giving them stressful tasks
– Prior to the stressors cortisol levels were
similar for the 21 participants who dropped
out as compared to the 81 who completed
treatment
THE SCIENCE OF
RECOVERY:GENETICS
• Treatment dropout linked to elevated
stress response (Drug and Alcohol
Depd. 105 (3):202-208, 2009)
(continued)
– The patients who dropped out had cortisol
levels 3-5 times higher than those patients
who remained in treatment
– For each unit of increase in cortisol after
the stressful tasks, there was a four-fold
increase in risk of dropping out
THE SCIENCE OF
RECOVERY:GENETICS
• WHEN YOU DISCONTINUE TO DRINK
CIRCUITS ARE STILL PRESENT
– CORTICOTROPIN RELEASING FACTOR
(CRF) SYSTEM PRODUCES A CHRONIC
STRESS RESPONSE THAT IS A SET-UP
FOR RELAPSE
– 60-70% OF RELAPSE OCCUR UNDER
CONDITIONS OF NEGATIVE EMOTIONAL
STATE
THE SCIENCE OF
RECOVERY:GENETICS
• A shortage of D2 receptors, some
researchers surmise, could predispose a
person to addiction.
• Nora Volkow, NIDA Director, led two
studies that involved artificially increasing
the number of D2 receptors in rats by
administering adenoviral vectors directly
into their brains. Viral vectors transmit
their genetic material and makeup into
foreign cells, in this case increasing the
number of D2 receptors in the new cells to
match their own.
THE SCIENCE OF
RECOVERY:GENETICS
• In one study involving rats and alcohol,
the increased number of D2 receptors
led the rodents to consume less
alcohol, compared with their baseline
intake.
• In the other study, the D2-receptor
increase caused rats to significantly
reduce their intake of cocaine.
THE SCIENCE OF
RECOVERY:GENETICS
• Association between DA D2 receptor
numbers and drug self-administration
(PET)
– Increased D2 receptors reduced alcohol
consumption
– Decreased D2 receptors higher risk
• DA D2 receptor levels influenced by
stress and social hierarchy
THE SCIENCE OF
RECOVERY:GENETICS
• Michael Nader, a researcher at Wake Forest
School of Medicine, is investigating ways to
raise D2-receptor levels naturally.
• One experiment he helped conduct focused on
five separate groups of four monkeys. Each
had been self-administering cocaine to the
point of habit and were then deprived of the
drug for an eight-month period. To create a
picture of D2-receptor availability, the
monkeys were given a radioactive tracer that
competes with dopamine for receptors.
THE SCIENCE OF
RECOVERY:GENETICS
• The monkeys were then randomly put in social
groups of four and given the opportunity to
self-administer the drug again.
• Positron emission tomography (PET) imaging
of the monkeys over time showed fluctuations
in dopamine levels, which allowed the
researchers to estimate the changing numbers
of available D2 receptors.
• After only three months, the socially dominant
monkeys in each group had naturally
increased their numbers of D2 receptors.
THE SCIENCE OF
RECOVERY:GENETICS
• There was no increase in the subordinate
monkeys.
Further,
the
subordinate
monkeys reverted to using cocaine at
much higher levels than the dominant
monkeys.
• "There is an interesting relationship
between
D2-receptor
numbers
and
vulnerability to drug addiction," Nader
said. "It appears that individuals with low
D2 measures are more vulnerable
compared to individuals with high D2receptor numbers."
THE SCIENCE OF
RECOVERY:GENETICS
• Why did the socially dominant monkeys
show D2-receptor increases?
• One
hypothesis
is
environmental
enrichment. For the monkeys, it seems,
being dominant was the enriching trigger.
• One
physiological
consequence
of
involvement
in
12-step
meetings,
therefore, could be an increase in the
natural production of D2 receptors.
THE SCIENCE OF
RECOVERY:GENETICS
• Social interventions can change
neurobiology
– Increased DA D2 receptors
– Reduced self-administration
• Behavioral interventions could
counteract the aversive effects of
drug abuse and reinforce the
power of group approaches
THE STRIATUM
• The basal ganglia are nestled inside
cortex, surrounding the thalamus (see
image above). The striatum (part of the
basal ganglia circuitry) is composed of
the putamen, caudate, and nucleus
accumbens. Other important parts of the
basal ganglia are the globus pallidus
(which has an internal and an external
segment, GPi and GPe respectively) and
the subthalamic nucleus (STN).
NEURAL PATHWAYS
CORTICOSTRIATAL
CIRCUITRY
• This impairment could arise from two general
pathologies in corticostriatal circuitry: addicts
could have pathologically strengthened drugseeking
behaviors,
or
they
could
have
pathological impairments in the capacity to control
drug-seeking behaviors. These two possibilities
are not mutually exclusive.
• Corticostriatal circuitry has two subcircuits: the
limbic subcircuit, which comprises brain regions
such as the prefrontal cortex, the amygdala, the
nucleus accumbens (NAc) and the ventral
tegmental area (VTA); and the motor subcircuit,
which contains the motor cortex, the dorsal
striatum and the substantia nigra.
CORTICOSTRIATAL
CIRCUITRY
CORTICOSTRIATAL
CIRCUITRY
• Corticostriatal
projections
are
responsible not only for generating
learnt, well-established behaviors such
as in drug taking, but also for changing
behaviors in response to a variable
environment, and thereby generating
new adaptive behaviors
• Addicts have difficulty modulating
drug-seeking
behaviors
with
information that should suppress the
behavior
CORTICOSTRIATAL
CIRCUITRY
• The NAc serves as a gateway through
which information
that has been
processed in the limbic subcircuit gains
access to the motor subcircuit.
• Relapse to compulsive drug seeking
arises from an impaired ability of the
limbic subcircuit to effectively process
and/or use the negative environmental
contingencies associated with relapse.
The result is that behavior is dominated
by the previously learnt, well-established
drug-seeking strategies.
THE SCIENCE OF RECOVERY:
DOPAMINE (DA) TONE
Ventral
Tegmental
Area
Nucleus
Accumbens
Dopamine
Arcuate
Nucleus
Opioid Peptides
Naltrexone
THE SCIENCE OF RECOVERY:
DOPAMINE (DA) TONE
• TWO TYPES OF LOW DA TONE (CONTINUED)
• SYMPTOMS WILL BE THOSE OF REDUCED DA
TONE AT NAc REGARDLESS OF THE
LOCATION OF FEEDBACK PROBLEM
• FROM TREATMENT PERSPECTIVE WHAT
DIFFERENTIATES WHETHER DA OR OPIOID
CAUSATION OF LOW DA TONE IS….
– HISTORY OF DRUG USAGE AND EFFECTS THAT
USER EXPERIENCES
THE SCIENCE OF RECOVERY:
DOPAMINE (DA) TONE
• SUFFICIENT
– DA TONE IN REWARD CIRCUITRY YIELDS
ADEQUATE
•
•
•
•
ATTENTION
MOTIVATION
ATTACHMENT
HEDONIC TONE
THE SCIENCE OF RECOVERY:
DOPAMINE (DA) TONE
• REDUCED OR LOW DA TONE
– ANHEDONIC RELATIVE TO THOSE
AROUND THE INDIVIDUAL
– SENSE OF NOT FITTING IN
– POOR ATTENTION
– POOR LEVEL OF MOTIVATION
– RESTLESS
– IRRITABLE
– DISCONTENTED
PREFRONTAL CORTICAL
DOPAMINE
• Optimal levels of prefrontal cortical
dopamine are critical to various executive
functions such as working memory,
attention,
inhibitory
control,
and
risk/reward decisions, all of which are
impaired in addictive disorders such as
alcoholism.
• Imaging studies of alcoholics have
demonstrated less dopamine in the
striatum
Volkow ND; Wang GJ; Telang F; Fowler JS; Logan J; Jayne M; Ma
Y; Pradhan K; Wong C: Profound decreases in dopamine release in
striatum in detoxified alcoholics: possible orbitofrontal involvement. J
Neurosci
2007;
27:12700–12706
PREFRONTAL CORTICAL
DOPAMINE
• Less dopamine in the prefrontal cortex, which
governs executive functions, is important
because it could impair the addicted person’s
ability
to
learn
and
utilize
informational/behavioral strategies critical to
relapse prevention. This is supported by literature
that links prefrontal cortical dopamine with
executive functions, such as attention, working
memory, behavioral flexibility, and risk/reward
decision making, all of which are impaired in
addictive disorders such as alcoholism.
Floresco SB; Magyar O: Mesocortical dopamine modulation of executive functions:
beyond working memory. Psychopharmacology (Berl) 2006; 188:567–585
PREFRONTAL CORTICAL
DOPAMINE
• It is tempting to speculate that the failure to
incorporate past negative consequences in a
decision to drink alcohol during abstinence
is related to decreased prefrontal cortical
dopamine in alcoholism.
• Unclear
whether decreased dopamine
transmission in alcoholism represents a
premorbid trait or alcohol-induced state
Narendran, et al. Decreased Prefrontal Cortical Dopamine Transmission in
Alcoholism. Am J Pscyhiatry. 2014;171:881-888.
doi:10.1176/appi.ajp.2014.13121581
THE SCIENCE OF RECOVERY:
DOPAMINE (DA) TONE
• INCREASING DA TONE AT NAc
– THREE POSSIBLE APPROACHES
• INCREASE AMOUNT OF DA RELEASEDCURRENTLY HAVE MEDS LIKE SUBOXONE
THAT WILL DO THIS
• INCREASE NUMBER OF RECEPTORS-MEDS
NOT AVAILABLE FOR THIS
• REDUCING REUPTAKE OF DA-HAVE MEDS
THAT WILL DO THIS (PROVIGIL)
THE SCIENCE OF RECOVERY:
THE OPIATE EXPERIENCE
HIGH
ABNORMALLY NORMAL
SUBJECTIVE W/DRAWAL
ACUTE ABSTINENCE SYN.
THE SCIENCE OF RECOVERY:
DOPAMINE (DA) TONE
• SUBUTEX-Buprenorphine. sublingual
(SL)
– 2mg and 8mg tablets
• SUBOXONE-Buprenorphine/Naloxone
SL tablets AND FILM
• Zubsolv SL
• PARTIAL AGONIST
– Increasing dose does not increase effect
like a full agonist
THE SCIENCE OF RECOVERY:
DOPAMINE (DA) TONE
• BUPRENORPHINE-Very high affinity for
mu opioid receptor
• Mu receptor will choose buprenorphine
over other opioids
• Buprenorphine will displace other opioids
• Slow dissolution from mu receptor
– Half-life on receptor is 34-36 hrs
– Heroin on and off receptor in millisecond
– At Buprenorphine dose of 16mg almost no
binding to other opioids
PHARMACOLOGICAL
• NALTREXONE (Revia, Vivitrol)
• Pure antagonist
• Poor compliance
– Less than 10% for street addicts
• Better compliance
– Healthcare professionals
– Parole/Probation
• New suspension with q30d administration
should dramatically increase compliance and
reliability of drug
VIVITROL Carton Components
47
VIVITROL
VIVITROL
VIVITROL
VIVITROL
VIVITROL
Important Safety Information
53
•
VIVITROL is contraindicated in patients receiving opioid analgesics or
with current physiologic opioid dependence,patients in acute opiate
withdrawal, any individual who has failed the naloxone challenge test or
has a positive urine screen for opioids, or in patients who have previously
exhibited hypersensitivity to naltrexone, PLG, carboxymethylcellulose or
any other components of the diluent.
•
VIVITROL patients must be opioid free for a minimum of 7-10 days before
treatment.
•
Attempts to overcome opioid blockade due to VIVITROL may result in a
fatal overdose.
•
In prior opioid users, use of opioids after discontinuing VIVITROL may
result in a fatal overdose because patients may be more sensitive to
lower doses of opioids.
VIVITROL[full prescribing information]. Cambridge, MA: Alkermes, Inc; May 2009.
THE SCIENCE OF
RECOVERY:GLUTAMATE
• NOTION THAT ADDICTION EQUALS TOO
MUCH DOPAMINE IS A GROSS
OVERSIMPLIFICATION
• IN ANIMAL STUDIES
– EVEN WHEN DA RECEPTORS ARE BLOCKED
SOME DRUG-SEEKING BEHAVIOR PERSISTS
• EXTERNAL CUE DRIVEN
– DRUGS AFFECTING DA DIRECTLY HAVE BEEN
INEFFECTIVE
– INDIRECT APPROACHS SUCH AS INCREASING
GABA EFFECT AND REDUCING GLUTAMATE
EFFECT SEEM MORE PROMISING (EXAMPLETOPIRIMATE)
BRAIN WORKS. VOL 18, NO 5, SEPT/OCT 2008, PGS 1 AND 2.
THE SCIENCE OF
RECOVERY: GLUTAMATE
• TWO STAGE MODEL OF ADDICTION
– STAGE 1-OCCASIONAL DRUG USE BECOMES
INCREASINGLY CHRONIC AND UNCONTROLLED.
THE NEUROBIOLOGICAL SOURCE OF THESE
SYMPTOMS IS DRUG-INDUCED DEREGULATION
OF THE BRAIN’S REWARD CENTER
• DOPAMINE
– STAGE2-ADDITIONAL FEATURES INCLUDE
WITHDRAWAL SYMPTOMS, PERSISTENT
VULNERABILITY TO RELAPSE WITH
ALTERATIONS IN DECISION MAKING AND
OTHER COGNITIVE PROCESSES
• DRUG-INDUCED SIGNALS BY NEUROTRANSMITTER
GLUTAMATE FROM BRAIN AREAS PRIMARILY
ASSOCIATED WITH JUDGMENT
THE SCIENCE OF
RECOVERY: GLUTAMATE
• CHANGES IN BRAIN GLUTAMATE SIGNALING
INDUCED BY CHRONIC DRUG EXPOSURE
HAS A WIDE VARIETY OF NEUROBIOLOGICAL
EFFECTS INSTRUMENTAL IN THE
TRANSITION FROM DRUG ABUSE TO
ADDICTION (KAVALIS,2009)
• THESE NEURAL ALTERATIONS LIMIT THE
ABILITY TO ADAPT TO NEW INFORMATION
(TO STOP TAKING DRUGS IN SPITE OF
ADVERSE CONSEQUENCES)AND
STRENGHTEN THE POWER OF DRUG
LEARNED ASSOCIATIONS
THE SCIENCE OF RECOVERY:
GLUTAMATE
• Addiction as impairment in reversal
learning
IN ADDICTION…
“WHEN I USE DRUGS I FEEL GOOD”
CHANGES TO
“WHEN I USE DRUGS BAD THINGS
HAPPEN”
NEW RULE BUT CANNOT ADAPT
THE SCIENCE OF RECOVERY:
GLUTAMATE
• ADDICTS CAN LEARN A NEW RULE BUT RUN
INTO PROBLEMS WHEN THE RULES CHANGE
– COCAINE AND ALCOHOL ABUSERS WERE
ASKED TO PRESS KEY EACH TIME THEY SAW A
GREEN RECTANGLE ON THE SCREEN
– AFTER 500 REPETITIONS TOLD NOT TO PRESS
KEY WHEN SAW GREEN RECTANGLE
– CONTROLS EASILY ADAPTED WHILE ADDICTS
KEPT PUSHING THE KEY EVEN AFTER GIVEN
FEEDBACK
• IMPAIRED REVERSAL LEARNING DUE TO DRUG USE
AND NOT GENETICS
THE SCIENCE OF RECOVERY:
COGNITIVE FUNCTION
• Addiction is a disorder of altered
cognition
• Addiction impacts…
–
–
–
–
–
LEARNING
MEMORY
ATTENTION
REASON
IMPULSE CONTROL
• Effects are particularly disruptive when
exposed during brain development and in
the co-occurring population
THE SCIENCE OF RECOVERY:
COGNITIVE FUNCTION
• Cognitive deficits in chronic drug abuse
– Withdrawal produces cognitive symptoms
• Cocaine-deficits in cognitive flexibility
• Amphetamine-deficits in attention and impulse
control
• Opioids-deficits in cognitive flexibility
• Ethanol-deficits in working memory and attention
• Cannabis-deficits in cognitive flexibility and
attention
• Nicotine-deficits in working memory and
declarative learning
THE SCIENCE OF RECOVERY:
COGNITIVE FUNCTION
• Why give an alcoholic or addict a 60
minute didactic or video?
• A new format
– 15-20 minute simple didactic
• How to participate in treatment
– 10 minute questionnaire
– 30 minute discussion group
THE SCIENCE OF RECOVERY:
COGNITIVE FUNCTION
I THINK………..
I FEEL…………..
I LEARNED……
MY FUTURE BEHAVIOR WILL CHANGE…
THE SCIENCE OF RECOVERY
• RELAPSE FALLS ALONG A
SPECTRUM
• COMPULSIVE RELAPSE
• PREFRONTAL CORTEX OFF-LINE
• REGULATED RELAPSE
• SOME PREFRONTAL AVAILABILITY
• LITTLE OR NO RELAPSE
• PREFRONTAL CORTEX AVAILABLE
THE SCIENCE OF RECOVERY
CRAVING MANAGEMENT
• Though some relapse triggers can be
consciously avoided, such as people,
places and things related to drug use, other
subconscious triggers related to the brain's
reward system may be impossible to avoid - they can gain entry to the unconscious
brain, setting the stage for relapse.
• Baclofen, commonly used to prevent
spasms in patients with spinal cord injuries
and neurological disorders, can help block
the impact of the brain's response to
"unconscious" drug triggers well before
conscious craving occurs.
THE SCIENCE OF RECOVERY
CRAVING MANAGEMENT
• Subliminal drug "reminder cues" (the sights,
sounds, smells, and memories of the drug)
could activate the brain's reward circuit.
• 23 cocaine-dependent men, ages 18 to 55.
Each reported using cocaine on at least eight
of 30 days before screening. Inclusion in the
study required that they stay for up to 10 days
in a supervised inpatient drug treatment
facility, be drug-free for the duration, not be on
any medication affecting dopamine or
neurotransmitter response, and have no
history of psychosis, seizures, or brain
syndromes unrelated to cocaine use.
THE SCIENCE OF RECOVERY
CRAVING
MANAGEMENT
• Upon admission, patients were randomized to receive
baclofen or placebo. Over the first six days, patients in
the baclofen group received the medication in
increasing dosage to 60 mg. While on the full 60 mg
dose of baclofen, patients were placed in an fMRI and
shown a series of images, to measure their neural
responses to "ultra-brief" pictures of cocaine or other
comparison pictures. Each of the ultra-brief 33 msec
"target" pictures was immediately followed by longer
picture of non-drug objects or scenes. Under these
conditions, the participants are aware of the longer
pictures, but the ultra-brief target pictures remain
completely outside conscious awareness -- they are
"backward-masked."
THE SCIENCE OF RECOVERY
CRAVING MANAGEMENTNT
• What the team found was that the patients
who were treated with baclofen showed a
significantly lower response in the reward
and motivational circuits to subliminal
cocaine cues versus neutral cues, as
compared to the placebo-treated control
group.
K. A. Young, T. R. Franklin, D. C. S. Roberts, K. Jagannathan, J. J. Suh, R.
R. Wetherill, Z. Wang, K. M. Kampman, C. P. O'Brien, A. R.
Childress. Nipping Cue Reactivity in the Bud: Baclofen Prevents
Limbic Activation Elicited by Subliminal Drug Cues. Journal of
Neuroscience, 2014; 34 (14)
ROBIN WILLIAMS
“I realized... you keep going with
this, you’ll wake-up in a field with
a
small
animal,”
laughed
Williams. “If you’re violating your
standards faster than you can
lower them, time to go away.”
THE SCIENCE OF
RECOVERY: HABIT
YOU CANNOT
EXTINGUISH A BAD
HABIT; YOU CAN ONLY
CHANGE IT
THE SCIENCE OF
RECOVERY: HABIT
THE CUE TRIGGERS
THE ROUTINE AND
ALSO TRIGGERS THE
CRAVING FOR THE
REWARD TO COME
THE SCIENCE OF
RECOVERY: HABIT
• When a habit begins the whole brain is
activated as it actively processes all of the
stimuli
• After this phase the higher brain begins to
reduce level of activation
• Then even the memory centers reduce
activity
• BASAL GANGLIA has now taken control
of recalling the patterns and acting on
them
BASAL GANGLIA
THE SCIENCE OF
RECOVERY: HABIT LOOP
CUE
REWARD
ROUTINE
THE SCIENCE OF
RECOVERY: HABIT
• CUE AND REWARD BECOME
INTERTWINED CREATING A CRAVING
(CONDITIONING)
• In a habit the brain reduces emphasis
on decision making
• Pattern unfolds automatically unless
you find a new routine
• After craving develops, cannot
extinguish a bad habit, you can only
change it
THE SCIENCE OF
RECOVERY: HABIT LOOP
SAME
CUE(S)
SAME
REWARD
DIFFERENT
ROUTINE
THE SCIENCE OF
RECOVERY: HABIT
• ALMOST ANY HABIT CAN CHANGE IF
YOU KEEP THE SAME CUE(S) AND
SAME REWARD
• ALCOHOLICS ANONYMOUS changes
the habit loop
• ALCOHOLICS ANONYMOUS succeeds
because it helps use the same cues
and get the same rewards but shifts the
routine
THE SCIENCE OF
RECOVERY: HABIT
• To change a habit must address the same
cues and rewards as before and feed the
craving by inserting a new routine
• WHAT DO ALCOHOLICS AND ADDICTS
CRAVE?
– It isn’t a craving to be drunk
– Physical effects of alcohol are the least
rewarding (the same can be said for cocaine,
methamphetamine, etc.)
– Is it connection, reduce anxiety, forget
worries?
– Meetings and companionship-another bar to
escape to, catharsis, distraction
THE SCIENCE OF
RECOVERY: HABIT
• What is the pleasure we seek in the first
place?
– Is it…
•
•
•
•
•
•
•
COMPLETION
RELAXATION
TO FORGET
TO CONNECT
TO REWARD MYSELF
TO GIVE ME COURAGE
TO FEEL LIKE YOU BELONG AS ONE OF THE
GROUP
THE SCIENCE OF
RECOVERY: HABIT
• ALMOST ANY HABIT CAN CHANGE IF
YOU KEEP THE SAME CUE(S) AND
SAME REWARD
• ALCOHOLICS ANONYMOUS changes
the habit loop
– AA offers…
•
•
•
•
Escape
Catharsis
Distraction
Relief via talking
THE SCIENCE OF
RECOVERY: HABIT
• ALCOHOLICS ANONYMOUS succeeds
because it helps use the same cues and get
the same rewards but shifts the routine
• AA forces new routines for what to do each
night as opposed to drinking
• To change a habit must address the same cues
and rewards as before and feed the craving by
inserting a new routine
• WHAT DO WE CRAVE?
– Is it connection, reduce anxiety, forget worries?
– Meetings and companionship-another bar to
escape to, catharsis, distraction
THE SCIENCE OF
RECOVERY: HABIT
• What is the thirst behind the thirst?
– “I was thirsty because I was feeling
incomplete and alcohol helped me feel
more connected, more alive.”
– Bill Wilson, “Before A.A. we were trying to
drink God out of a bottle.”
– Gerald May- a deep yearning for fulfillment
or completion; a longing to love and be
loved and a desire for the source of this
love-God
THE SCIENCE OF
RECOVERY: HABIT
• What is the thirst behind the thirst?
– The great analyst Carl J. Jung put it thus, “His
craving for alcohol was the equivalent, on a
low level, of the spiritual thirst of our being for
wholeness, expressed in medieval language:
the union with God.”
– An intense, urgent, or abnormal desire or
longing. At the time it seems more painful
than any other longing. It subsumes us and
we are a slave to it…and it seems it will never
end. Although not understood in that moment,
it is really a powerful thirst to go “home.”
THE SCIENCE OF
RECOVERY: HABIT
• REPLACEMENT ROUTINES ONLY
BECOME DURABLE NEW BEHAVIORS
WHEN SPIRITUALITY IS ADDED (this is
what gets you through the major crises
in your life)
• PATTERN:
– Could only stay sober by habit
replacement until a major crisis hit
– Add spiritual element and now can get
through these tough times
DOPAMINE (DA) TONE-GENDER
DIFFERENCES
• WOMEN ESCALATE FASTER TO
HEAVY USE
• WOMEN MORE READILY SUCCUMB TO
SOCIAL AND PHYSICAL DAMAGE
• REPRODUCTIVE HORMONES MAY
UNDERLIE THIS SUSCEPTIBILITY
– REMOVE OVARIES OF FEMALE RAT (NO
LONGER PRODUCE ESTROGEN) AND
REDUCE DRUG SEEKING BEHAVIOR FOR
COCAINE AND AMPHETAMINE
DOPAMINE (DA) TONE-GENDER
DIFFERENCES
• ESTROGEN MAY SPUR ADDICTION BY
STIMULATING BRAINS REWARD
PATHWAYS ENHANCING “HIGH” BY
INCREASING DA
(ANTHES, EMILY. “SHE’S HOOKED”. SCIENTIFIC AMERICAN MIND.
MAY/JUNE 2010, PGS.14-15.)
• PROGESTERONE APPEARS TO OPPOSE
ESTROGEN’S ABILITY TO PROMOTE
ADDICTION
• GIVE BOTH ESTROGEN AND
PROGESTERONE TO RATS WITHOUT
OVARIES AND NO ACCELERATION OF
ADDICTION
DOPAMINE (DA) TONE-GENDER
DIFFERENCES
• FEMALE RESPONSE VARIES ACROSS
MENSTRUAL CYCLE AS LEVELS OF
ESTROGEN AND PROGESTERONE WAX
AND WANE (2007, SUZETTE EVANS, COLUMBIA UNIVERSITY)
– STIMULANTS MORE PLEASURABLE TO WOMEN
DURING ESTROGEN-DOMINATED FOLLICULAR
PHASE WHICH OCCUPIES APPROXIMATELY 2
WEEKS FROM ONSET OF PERIOD UNTIL
OVULATION THAN DURING THE LUTEAL PHASE
AFTER OVULATION WHEN BOTH ESTROGEN
AND PROGESTERONE ARE HIGH
DOPAMINE (DA) TONE-GENDER
DIFFERENCES
• ASKED ONE-HALF OF 202 FEMALE
CIGARETTE SMOKERS TO TRY TO ABSTAIN
DURING LUTEAL PHASE AND THE OTHER
HALF TO TRY TO ABSTAIN DURING THE
ESTROGEN RICH FOLLICULAR PHASE
– THIRTY-FOUR (34) PERCENT OF WOMAN IN
FIRST GROUP HAD NOT SMOKED AT 30 DAYS
– FOURTEEN (14) PERCENT OF WOMEN IN THE
SECOND GROUP HAD NOT SMOKED AT 30 DAYS
(2008, SHARON ALLEN, UNIVERSITY OF MINNESOTA MED SCHOOL)