The Science Behind Powerlessness

George Kolodner, MD

Chief Clinical Officer

Kolmac Outpatient Recovery Centers

Clinical Professor of Psychiatry

Georgetown University and University of Maryland Schools of Medicine

Introduction

• Changing opinions about alcoholism as a

disease

• New research

– Adoption and twin studies

– New technology: Imaging studies (MRI, PET)

• Who becomes alcoholic?

– High tolerance

– *Decreased internal control

Step One

We admitted we were powerless over alcohol and drugs – and that our lives had become unmanageable.

Loss of Control

“We alcoholics are men and women who have lost the ability to control our drinking. We know that no real alcoholic ever recovers control. All of us felt at times that we were regaining control, but such intervals – usually brief – were inevitably followed by still less control, which led in time to pitiful and incomprehensible demoralization.”

Some Pieces of the Puzzle of Powerlessness

1. Drivers of Drinking

2. The Power of Triggers

3. An Overview of the Addicted Brain

1. DRIVERS OF DRINKING

Progression of Drivers

• Liking– Response to drinking

• Wanting, craving– Before or after starting to drink

• Needing– Physical withdrawal symptoms if not drinking

Liking

“Men and women drink essentially because they like the effect produced by alcohol. The sensation is so elusive that, while they admit it is injurious, they cannot after a time, differentiate the truth from the false.”

Alcohol and Beta Endorphin

• Alcohol stimulates release of beta endorphin, which sets of a release of dopamine

• Genetic difference in some alcoholics (strong positive family history and onset before 25)

– Low baseline beta endorphin levels

– Increased sensitivity of mu receptor• A118G allele codes for mu receptor sensitivity

– Result: more intense pleasure response

• Medication: naltrexone– Reduces rewarding response to alcohol by blocking mu

opioid receptor

– Reduces craving by unknown mechanism

The “Blahs” After the Pink Cloud

• Disruption of the brain reward system

– Increased sensitivity to substance

– Decreased sensitivity to natural rewards

• Normal response returns over time

– “Keep coming back.”

Wanting

“... [alcoholics/addicts] have one symptom in common: they cannot start drinking without developing the phenomenon of craving.”

2. THE POWER OF TRIGGERS

Relapse Triggers

1. Exposure to the substance

2. Drug associated cues (“People, places, and things”)

3. Stress (“HALT”)

Triggers and Dopamine Release

• Trigger for dopamine release: “I didn’t expect that.”– Released by surprise, both positive and

negative

• In the addicted brain, dopamine release is greater in response to the trigger than to the substance

• Examples

Seals

Needing

• Homeostasis: The tendency of the body to seek and maintain a condition of balance or equilibrium within its internal environment, even when faced with external changes

– Example: body temperature maintained at 98.6 despite temperature of the environment

• Allostasis: a form of homeostasis occurring in response to chronic stress which masks a shift from normal equilibrium

Glutamate: Excitatory Neurotransmitter

• Suppressed by chronic heavy alcohol use

• Up-regulation is hidden during active use

• Cessation of alcohol use unmasks the existence of the increased glutamate level

• Experienced as anxiety and seizures

• Medication: acamprosate (Campral)

– Modified amino acid (taurine)

– Expedites brain renormalization

– Experienced as calming

4. OVERVIEW OF THE ADDICTED BRAIN

Impact of Chronic Heavy Drinking

• Enhances sub-cortical limbic centers which deal with reward, emotion, and stress

• Suppresses cortical areas which deal with reason, good judgment, and inhibitory control of behavior

Result: “Stinking Thinking”

• Thought processes and decision making characterized by faulty reasoning and poor judgment

• Behavior dominated by impulsiveness, short sightedness– Game example

• A shift of what part of the brain is in charge– Bottom up versus top down decision making

– Horse and rider analogy

Recovery, Not Cure

“Most of us have believed that if we remained sober for a long stretch, we could thereafter drink normally. But here is a man who at fifty-five years found he was just where he left off at thirty.”

Thank youGeorge Kolodner, M.D.

gkolodner@kolmac.com