Mark Lim M.D FASAM Medical Director NorthLakes Community Clinic Recovery Program Board Certified in Family Medicine Board Certified in Addiction Medicine mlim@northlakesclinic.org 7156852200
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 Pain The 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 Ambivalence For 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)
Natural Rewards and Dopamine Levels % of Basal DA Output 200 150 100 50 0 Food Empty 0 60 120 180 Time (min) DA Concentration (% Baseline) 200 150 100 Sample Number Sex Female Present 1 2 3 4 5 6 7 8 Adapted from: Di Chiara, Neuroscience, 1999; Fiorino & Phillips, J Neuroscience, 1997; courtesy of Nora D. Volkow, MD.
% of Basal Release % of Basal Release 250 200 150 100 0 250 200 150 100 Effects of Drugs on Dopamine Levels 1 MORPHINE Dose mg/kg 0.5 1.0 2.5 10 0 1 2 3 4 5 hr NICOTINE % of Basal Release % of Basal Release 400 300 200 100 0 250 200 150 100 COCAINE 0 1 2 3 4 5 hr ETHANOL Dose (g/kg ip) 0.25 0.5 1 2.5 0 0 0 1 2 3 4hr 0 1 2 3 hr 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 2 1100 % of Basal Release 1000 900 800 700 600 500 400 300 200 100 AMPHETAMINE DA 0 0 1 2 3 4 5 hr Adapted from: Di Chiara & Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of Nora D. Volkow, MD. 28
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
sense of connection to something bigger than ourselves, and it typically involves a search for meaning in life. Spirituality
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 y rəˈkəv(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/Symptoms Addiction 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 Rewired brain and altered neural humoral Change in gene expression Addiction interactive disorder Emotional damage, shame, guilt Unmanageability of life Damaged families & other relationship Characterologic/personality X X X X X X X 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 Intervention Formats: 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, positive messages 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.