2018 Statewide Tribal Opioid Summit Brain Health and Opioid Abuse Healing From Opiate Addiction Requires Comprehensive Approaches Psychological, Socio-Cultural, and Biological Donald R. Vereen, Jr., M.D., M.P.H. Director, Community Academic Engagement, Prevention Research Center (PRC-MI) Director, University of Michigan Substance Abuse Research Center (UMSARC) Former Special Assistant to the Director of National Institute on Drug Abuse (NIDA) Former Deputy Director, White House Office of National Drug Control Policy (ONDCP)
NEUROTOXICITY OBESITY AIDS CANCER MENTAL ILLNESS HEALTH CARE COSTS PRODUCTIVITY LOSS ACCIDENTS HOMELESSNESS CRIME VIOLENCE
Drug Abuse is a Preventable Behavior
Drug Addiction is a Treatable Brain Disease
Drug Overdose is a Another Way to Die
Increase in Opiate Prescriptions, 1991-2013 Volkow, N.D., NIDA, 2014
ENVIRONMENT BIO/PSYCHO/SOCIO/CULT INDIVIDUAL ASPECTS GROUP ASPECTS COMMUNITY ASPECTS CULTURAL SPIRITUAL NATIONAL BIOLOGICAL COMMUNITY PEOPLE FAMILIAL PSYCHOLOGICAL
DRUG ABUSE AND ADDICTION INVOLVE MULTIPLE AND INTERACTIVEFACTORS Biology/Genes Environment DRUG Brain Mechanisms Addiction
Drug/Alcohol Related Traffic Accidents Health Problems: Overdose Deaths Infections incl HIV CardioVascular Suicidal Behavior Drug Abuse Community Peer Cluster Family Individual Delinquency Academic Failure and Dropping Out of School Juvenile Depression Unwanted Pregnancies Running Away From Home
Examples of Risk and Protective Factors Risk Factors Domain Protective Factors Sensation-seeker Individual Successful student Child of drug user Bonds with family No supervision Family Consistent discipline Parent/sibling drug use Family/ Cultural values Pro-drug use norm School Anti-drug use norms Availability of drugs High academics Crime/poverty Community Consistent anti-drug messages No afterschool programs Community Collective Efficacy, Antidrug laws, Community Based Prevention Source: David Hawkins, Seattle Social Development Project
Beyond Individual Risk Factors: The Risk MACRO LEVEL Environment The Risk Environment Laws/regulations Political transitions Trafficking routes MESO LEVEL Enforcement Social norms Health services MICRO LEVEL Risk behaviors Health seeking Criminal behaviors Health outcomes Geospatial factors Adapted from Burris 2004, Galea 2003, and Rhodes 2003.
PRINCIPLES OF PREVENTION
Your Brain on Drugs Front of brain Back of brain 1-2 Min 3-4 5-6 YELLOW shows places in brain where cocaine goes (Striatum) 6-7 7-8 8-9 9-10 10-20 20-30
Effects of Drugs on Dopamine Levels Dopamine Pathways Principal Pleasure System of the Brain frontal cortex striatum hippocampus % of Basal Release 1100 1000 900 800 700 600 500 400 300 200 100 0 Accumbens AMPHETAMINE DA % of Basal Release 400 300 200 100 Accumbens COCAINE 0 1 2 3 4 5 hr 0 0 1 2 3 4 5 hr Time After Amphetamine Time After Cocaine Source: Di Chiara and Imperato DA nucleus accumbens substantia nigra/vta Natural Rewards Elevate Dopamine Levels % of Basal DA Output 200 150 100 50 0 FOOD Empty Box Feeding NAc shell 0 60 120 180 Time (min) Di Chiara et al. DA Concentration (% Baseline) 200 150 100 SEX 15 10 ScrScr Scr Scr BasFemale 1 Present Female 2 Present 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Sample Mounts Number Intromissions Ejaculations 5 0 Fiorino and Phillips Copulation Frequency
movement MOVEMENT motivation Dopamine addiction Reward & well-being
A New Way of Thinking About the Brain Research-based understanding of the brain integrates: nature and nurture mind and brain genes and the environment
The Brain is Dynamic We now understand that our genes specify a general plan with many options. Our brain changes its physical structure and function through behavior and interactions with the environment
Dopamine D2 Receptors are Lower in Addiction Cocaine DA DA DA DA DA DA DA DA DA DA DA DA Meth Reward Circuits Non-Drug Abuser Alcohol DA DA DA DA DA DA Heroin control addicted Reward Circuits Drug Abuser
x Volkow, N., Morales, M. cell.2015.07.046
Different Brain Circuitry Involved in Drug Reward and Drug Persistance Behavior dopamine vpfc dpfc Blockade in these regions blocks relapse or reinstatement glutamate NA shell NA core VTA dvp mvp SN Reward Limbic Subcircuit Drug Seeking Behavior Motor Subcircuit Source: Adapted from McFarland, K. and Kalivas, P.W. Journal of Neuroscience, 21(21), pp. 8655-8663, November 1, 2001.
Circuits Involved In Drug Abuse and Addiction CONTROL INHIBITORY CONTROL OFC MOTIVATION/ DRIVE PFC SCC ACG NAcc Amyg All of These Must Be Considered In Developing Strategies to Most Effectively Treat Addiction Hipp VP REWARD MEMORY/ LEARNING
Neurobiologic Advances from the Brain Disease Model of Addiction Nora D. Volkow, M.D., George F. Koob, Ph.D., A. Thomas McLellan, Ph.D. January 28, 2016 N Engl J Med 2016; 374:363-371
ADDICTION IS A DISEASE OF THE BRAIN like other diseases, it affects tissue function Decreased Brain Metabolism in Drug Abuse Patient High Control Cocaine Abuser Decreased Heart Metabolism in Heart Disease Patient Low Healthy Heart Diseased Heart Sources: From the laboratories of Drs. N. Volkow and H. Schelbert
ADDICTION IS A DEVELOPMENTAL DISEASE starts in adolescence and childhood % in each age group who develop firsttime cannabis use disorder 1.6% 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% Brain areas where volumes are smaller in adolescents than young adults. Sowell, E.R. et al., Nature Neuroscience, 2: 859-861, 1999 5 10 15 18 25 30 35 40 45 50 55 60 65 70 Age Age at cannabis use disorder as per DSM IV NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
Non-Addicted Brain Addicted Brain Control CG STOP Control Saliency NAc Drive OFC Saliency Drive GO Memory Amygdala Memory Adapted from: Volkow et al.,
Medications for Relapse Prevention Non-Addicted Brain Control Strengthen reinforcing effects of non-drug reinforcers Strengthen inhibitory control Saliency Drive Drive Memory STOP GO Strengthen prefrontalstriatal communication Interfere with conditioned memories (craving) Counteract stress responses that lead to relapse Adapted from: Volkow et al., J Clin Invest 111(10):1444-1451, 2003.
National Comorbidity Survey (NCS) Nearly half of individuals with a past year substance use disorder also had a mental disorder Mental disorders found to be most prevalent included affective disorders, anxiety disorders, personality disorders, and psychotic disorders
Need for and Receipt of Drug Treatment at a Specialty Facility Among U.S. Persons Aged 12 and older: 2014 Did Not Feel They Needed Treatment (5,879,000) 75% 20% 3% 2% Felt They Needed Treatment and Did Not Make an Effort (254,000) Felt They Needed Treatment and Did Make an Effort (145,000) Received Specialty Treatment (1,604,000) 7,881,000 Needing Drug Treatment at a Specialty Facility Source: SAMHSA, 2014 National Survey on Drug Use and Health (September 2015).
DRUG ABUSE AND ADDICTION INVOLVE MULTIPLE AND INTERACTIVEFACTORS Biology/Genes Environment DRUG Brain Mechanisms Addiction
drugabuse.gov