Petros Levounis, MD, MA Chair

Department of Psychiatry Rutgers – New Jersey Medical School

Rutgers – New Jersey Medical School Fundamentals of Addiction Medicine Summer Series

Newark, NJ – July 3, 2013

NEUROBIOLOGY OF ADDICTION

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1. Neurobiology of Addiction 2. Psychotherapy of Addiction 3. Principles of MI 4. Practice of MI 5. Addiction Pharmacotherapy 6. Conclusions

Outline

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1 Neurobiology of Addiction

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~ 2000

The Fundamental Model

Biological

Psychological

Social

Use Brain Switch

1. Stress 2. Triggers (Cues) 3. Exposure (Primers)

Relapse

Addiction

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Food Sex

Box Feeding

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Female Present

Natural Rewards and Dopamine Levels

Adapted from: Di Chiara et al, Neuroscience, 1999 Adapted from: Fiorino and Phillips, J Neuroscience, 1997

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NICOTINE

Adapted from: Di Chiara and Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of Nora D Volkow, MD

Effects of Drugs on Dopamine Levels

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Effects of Drugs on Dopamine Levels

AMPHETAMINE

Adapted from: Di Chiara and Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of Nora D Volkow, MD

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Pleasure-Reward Pathways

Nucleus Accumbens

Hippocampus

Striatum Frontal Cortex

Ventral Tegmental

Area

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Adapted from: National Institute on Drug Abuse, www.nida.nih.gov, 2000

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2013

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Neural Circuitry of Addiction

Hippocampus

Striatum Frontal Cortex

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Koob, Pharmacopsychiatry, 2009

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1. Dopamine 2. Glutamate 3. γ-Aminobutyric Acid (GABA) 4. Serotonin 5. Norepinephrine 6. Corticotropin-Releasing Factor (CRF) 7. Opioids 8. Cannabinoids

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1. Addiction Neurotransmitters

Koob, J Drug Issues, 2009

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2. Motivation: More than an Amoeba

Adapted from: Flaherty, Coaching: Evoking Excellence in Others, 2005; graphic by Lukas Hassel.

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3. The Anti-Reward Pathways

Volkow ND and Baler RD, Neuropharmacology, 2013.

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Gardner, Chronic Pain and Addiction, 2011

Reward and Antireward Systems

GAME 1 A. A sure gain of $250.

B. 25% chance to gain $1,000,

75% chance to gain nothing.

Adapted from: Tversky and Kahneman, Science, 1981

Reward Systems

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84%

16%

GAME 2 A. A sure loss of $750.

B. 25% chance to lose nothing,

75% chance to lose $1,000.

Antireward Systems

Adapted from: Tversky and Kahneman, Science, 1981

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13%

87%

GAME 1

25% + 750 25% - 250 25% - 250 25% - 250

GAME 2

25% + 750 25% - 250 25% - 250 25% - 250

MATHEMATICS

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People avoid risks to ensure gains (even small gains).

People take risks (even big risks) to avoid definite losses.

Psychology trumps probability.

HUMAN NATURE

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2 A Brief History of the

Psychotherapy of Addiction

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1. Psychoanalysis works for all treatable mental illness.

2. Psychoanalysis does not work for addiction.

3. Therefore, addiction cannot be treated.

1st Wave: Psychoanalysis

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The prototype, Synanon, was founded in California in 1958 to address heroin addiction.

The goal was to: break down defenses, bust through denial, and reshape the addict’s personality.

2nd Wave: Boot Camps

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1. Shaving heads

2. Hanging humiliating signs around residents’ necks

3. Subjecting patients to “encounter groups” involving loud, free flowing attacks from staff and fellow residents

2nd: Therapeutic Communities

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During the 1970s and 1980s, most Therapeutic Communities evolved beyond the Synanon model.

People started recognizing the limits and dangers of confrontive techniques.

3rd Wave: Modified TCs

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1. Based on Operant Conditioning

2. Functional Analysis

3. Skills Training to: identify, avoid, and cope with thoughts & cravings

3rd: Cognitive-Behavior Therapy

Kadden, Cognitive-Behavioral Coping Skills Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and Dependence, 1992 25

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The Frying Pan Revisited

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Volkow et al, J Neuroscience, 2001

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1. 12-step Facilitation

2. Relapse Prevention

3. Family Therapy

4. Primary Care

5. Mental Health Services

6. Aftercare

4th: The Kitchen Sink Approach

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Nunes, Selzer, Levounis, Davies, Substance Dependence and Co-Occurring Psychiatric Disorders, 2010.

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12-Step Facilitation

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1. Spiritual Health

2. Professional and Vocational Health

3. Interpersonal and Family Health

4. Mental Health

5. Physical Health

6. Life

The AA Elevator Slogan

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Medical Student Attitudes

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PATIENTS 1. Inner peace 2. God 3. Medical Svcs 4. AA 5. Housing 6. Spirituality 7. Outpatient Svcs 8. Community 9. Gov’t Svcs 10. Trusting People 11. Job

PERCEPTION 1. Housing 2. Outpatient Svcs 3. Medical Svcs 4. Job 5. Trusting People 6. AA 7. Inner Peace 8. Community 9. Gov’t Svcs 10. Spirituality 11. God

STUDENTS 1. Housing 2. Gov’t Svcs 3. Medical Svcs 4. Outpatient Svcs 5. Job 6. Community 7. Trusting People 8. Inner peace 9. God 10. Spirituality 11. AA

Goldfarb, Am J Drug Alcohol Abuse, 1996.

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Psychiatric Co-Morbidities

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1. A third to two thirds of addicted people also suffer from another mental illness—not 10%, not 90%.

2. Treat both the addiction and the co-occurring psychiatric disorder(s).

3. Avoid benzodiazepines and use antidepressants as first line treatments for anxiety disorders.

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The Four-Quadrant Model

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3 Principles of

Motivational Interviewing 33

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1. “People are unmotivated” vs.

“People are always motivated for something.”

2. “Why isn’t the person motivated?” vs. “For what is the person motivated?”

Motivation

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Miller and Rollnick, Motivational Interviewing: Helping People Change, 3rd Edition, 2012.

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1. Ambivalence is normal; needs to

be explored, not confronted.

2. Ambivalence is a reasonable place to visit, but you wouldn’t want to live there.

Ambivalence

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Miller and Rollnick, Motivational Interviewing: Helping People Change, 3rd Edition, 2012.

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Principles

REDS 1. Roll with Resistance

2. Express Empathy

3. Develop Discrepancy

4. Support Self-Efficacy

Miller and Rollnick, Motivational Interviewing: Preparing People for Change, 2nd Edition, 2002.

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MI Today

Beyond REDS Engaging

Focusing

Evoking

Planning

Miller and Rollnick, Motivational Interviewing: Helping People Change, 3rd Edition, 2012.

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4 Practice of

Motivational Interviewing 38

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PHASE 1: Building Motivation for Change PHASE 2: Strengthening Commitment to Change

and Developing a Plan.

Phases

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1. Precontemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

6. Relapse

The Stages of Change

Prochaska and DiClemente, The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy, 1984.

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The Stages of Change Cycle

Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010. 41

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1. Identify the Stage of Change.

2. Help the person move a little bit

forward.

3. Don’t rush her or him.

Working the Stages

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Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010.

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1. Plant the seed of ambivalence.

2. Techniques: Ask for a description of a typical day. Hunt for the smallest discrepancy

between where people are and where they would like to be.

Precontemplation

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The Readiness Ruler

Adapted from: Miller and Rollnick, Motivational Interviewing: Preparing People for Change, 2nd Edition, 2002, Graphic by Dr. Chris Welsh. 44

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1. Open up to explosive decision analysis.

2. Techniques: Brainstorm widely. Explore both positive and negative

prospects of life with and without the proposed changes.

Contemplation

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The Decisional Balance

Levounis and Arnaout, Motivational Interviewing: Preparing People for Change, 2nd Edition, 2002, Graphic by Dr. Chris Welsh.

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1. Develop a realistic action plan.

2. Techniques: Anticipate problems and identify

solutions. Unforeseen complications and

frustrating obstacles may require revisiting “contemplation stage” techniques.

Preparation

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1. Based on principles of learning, replace maladaptive patterns of behaving and thinking.

2. Techniques: Essentially use a CBT model. Provide ample positive feedback,

encouragement, and support.

Action

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1. Back to the “kitchen sink” approach.

2. Techniques: Recruit motivational, cognitive-

behavioral, regulatory, disciplinary, and social approaches to sustain the desired change.

Explore disappointments, temptations, and doubts.

Maintenance

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1. Remember Confucius: “Our greatest glory is not in never falling but in rising every time we fall.”

2. Techniques: Accept relapse as an opportunity to

reengage, rethink, and reemerge stronger than before.

Reengage quickly, even if it is to the expense of deeper rethinking.

Relapse

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Make a guess as to what the patient means. Skillful listetning moves past what the person exacly said, without jumping too far.

Like interpretations in dynamic therapy, if the patient becomes defensive, you know that you jumped too far, too fast.

Technique: Reflective Listening

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Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010.

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As a person argues on behalf of one position, she or he becomes more committed to it; we literally talk ourselves into (or out of) things.

This may explain why the more “resistance” is evoked during a counseling session, the more likely it is that a person will continue to use.

Technique: Elicit Change Talk

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Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010.

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1. Listen > Ask > Give advice 2. Talk less than the patient. 3. Do not ask more than 3 consecutive

questions. 4. Avoid wordiness. 5. Avoid interrupting. 6. Cooperate, do not force knowledge. 7. Relax.

Practical Suggestions

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Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010.

5 An Even Briefer History of

Addiction Pharmacotherapy

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1. Agonists Nicotine Replacement Therapies Methadone for Opioids

2. Antagonists Naltrexone for Opioids

Two Main Strategies

Renner and Levounis, Office-Based Buprenorphine Treatment of Opioid Dependence, 2011

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Partial Agonists

Varenicline for Nicotine Buprenorphine for Opioids

The New Strategy

Renner and Levounis, Office-Based Buprenorphine Treatment of Opioid Dependence, 2011

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-10 -9 -8 -7 -6 -5 -4 0

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% Efficacy

Log Dose of Opioid

Full Agonist (Methadone)

Partial Agonist (Buprenorphine)

Antagonist (Naloxone)

The Ceiling Effect

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6 Conclusions

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1. Addiction hijacks both the pleasure/reward and anti-reward pathways of the brain.

2. Antireward pathways are likely responsible for the sustaining addiction.

3. Motivation has replaced confrontation as the primary focus of addiction treatment.

4. Motivational Interviewing is based on exploring and resolving ambivalence.

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Thank you

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