Getting Help: Drug Addiction Series Part I

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Getting Help: Drug Addiction Series Part I

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What do you do when you find out your child is a drug addict? First in a series of expert interviews.
by Kim Duffy

duffeydrugaddictIt's been called the second worst thing that can happen to your child, because it veers so acutely toward the first. It's a chronic, life-long affliction – scientists call it a disease – and it's best treated with the gravity of a life-threatening illness.

So what do you do when you find out your child is a drug addict? Do you call your therapist, if you are lucky enough to have one? Or do you phone the pediatrician, your insurance company, your clergy, or the police? You may do all of these eventually, but in a moment of crisis, when their peculiar behavior finally has a name, it would help to know where to get assistance. This is too complex to grapple with alone.

Over the next few months, this column will interview addiction specialists in an attempt to explain the problem and outline the variety of solutions offered in the Salt Lake valley. This first installment addresses the science of the addicted brain.

{quotes align=right}Don't let yourself think substance abuse is essentially youthful indifference or maliciousness, which can be nagged or shamed away. Drugs actually change the brain's structure.{/quotes} In the ensuing months, we will hear from people who evaluate addicts and recommend treatment, people who detox addicts and try to convince them to begin recovery work, people who send addicts to jail and those who keep them out, people who deliver bad news, people who welcome the addict back repeatedly as they attempt to reconfigure their thinking, and people who have lost children to drugs and have turned to helping newly dazed parents find their way.

Glen Hanson, DDS, PhD, was acting director of the National Institute of Drug Abuse (NIDA), a component of the National Institutes of Health (NIH) from 2001-2003. At the University of Utah, he continues his decades of research on the effects of stimulants on brain systems, and frequently travels to NIDA in Maryland to serve as a senior advisor. The following is an interview with Dr. Hanson regarding the addicted brain.

How do you define addiction?

It's an uncontrolled, repetitive, compulsive behavior that occurs despite very negative consequences. In the addict's brain, very compelling and dominant pathways have been created associated with using that drug. These neurobiological changes now drive this person's behavior, their life. It becomes their number one behavior, which takes precedence over all others.

There are two main components to an addiction. One is the obvious behavior: Seek the drug, get the drug, take the drug. The second is the competing behavior: Take care of my family, go to work, do good things in the community, engage in healthy behavior. The second comes from the prefrontal cortex, which establishes priorities, suppresses some behaviors, and activates others.

And the first behavior comes from the lizard brain?

Yes, well I haven't called it a lizard brain – it's the amygdala, or the limbic system. This is the part of the brain that kicks in when you're in a crisis. Someone is coming at you with a weapon, and you've got to make a fast decision. It's a disadvantage to process this through your prefrontal cortex, because that part of your brain is thoughtful: It pulls in moods, memories, evaluation, what you sense, and what this is going to mean to you in an hour, a day, a week. Well, you don't have time to do that in a crisis; you've got to duck, run, scream, protect yourself.

So in this kind of situation, which is major stress, your brain says, 'Let's get rid of this high-processing function, the prefrontal cortex, which isn't doing any good right now.' So you turn that system off and rely upon the amygdala, which is reactive and will get you out of immediate trouble. Then the stress goes away, the prefrontal cortex comes back online, and you're back processing like you're supposed to do.

Bit if you're an addict, constantly fighting these compulsive behaviors that drive you to use drugs, you're also in a very stressful environment. You want to control all this compulsive behavior, but you're so stressed that it's turned off your prefrontal cortex that would otherwise keep you under control. When it goes off, it means that your behavior is really being driven by the amygdala, and you're even more vulnerable to using these drugs than before.

I can tell you that I'm going to throw you in jail, take away everything that's important to you, take your kids away, and you'll never see them again.   {quotes}I can try to motivate you, but if your prefrontal cortex isn't capable of suppressing this addictive behavior, it doesn't matter what I do, you're going to go back and get some drugs.{/quotes}

Does the maturity of the brain have anything to do with this vulnerability?

From puberty up through the mid-20s (and it varies from person to person), humans go through a period when the prefrontal cortex gets toned down. This happens in all mammalian species; we think this happens because it helps encourage the individual to leave their genetic home and interact with a new genetic pool. That brings diversity and strength to the species. And they want to leave their home! If the prefrontal cortex were functioning at its mature level in an 18-year-old, it would say, 'Boy, it's really nice here at home. All my meals are provided, I get a car, I get a bedroom, and they pay for school. Why should I leave?'

But if you turn the prefrontal cortex down a few notches, then it's the limbic part of the brain that's making the decisions. Those decisions are based not on logic but on impulse, risk-taking and novelty-seeking. It wants something exciting, high-risk and thrilling – like climbing up the side of a mountain or trying drugs.

So adolescents are very vulnerable, and on top of that you put the stress of teenage life, with all the natural development, which itself can be very stressful. The prefrontal cortex gets turned down even more, and it's less able to protect the individual from abusing drugs. We find that if they start using drugs in adolescence and continue into adulthood, it alters the way the brain develops.

Permanently?

Longitudinal studies haven't been well done at this point. But if we expose an animal to methamphetamine through adolescence, and then look at their adult brain, in some ways it works like it did when they were an adolescent. It doesn't grow up. In human beings, when you interact with people who were chronic users and now they're 30-35, you think you're talking to a 13-year-old.

But can't the brain compensate for some kinds of damages?

Yes. We like to parcel the brain out into regions according to function, but in reality, while there are certainly some areas of high-intensity function, there are very few places in the brain where a function only occurs in a small discrete region. It is usually dispersed to a lot of neighboring regions, and they sort of pitch in and integrate to achieve a function or behavior.

Is that understood very well?

"We understand that some of it happens through a process called synaptogenesis, the formation of contacts between brain cells. The brain is not a stagnant thing. One brain cell talks to thousands of other brain cells; as it talks, each of them make new connections. Depending upon what's going on, some of these connections may disappear and others may appear. If I were to stimulate a brain cell over and over again, I'd see that it tends to make more and more connections, sort of like a muscle. Exercise a muscle and it gets bigger and has greater influence. Exercise a brain cell and it gets more connections and becomes more influential.

Does dopamine have something to do with that?

Dopamine is a chemical that defines a brain cell. If I stimulate a dopamine neuron over and over again, it establishes additional contacts and will make additional connections with brain cells in the region. So one neuron, instead of having an influence on 500 brain cells, has an influence on 10,000 brain cells. Consequently, I've augmented its influence. One reason addiction occurs is likely through this process of synaptogenesis in response to repeated drug use. It causes more connections and strengthens a behavior pattern so it becomes more dominant.

Can this be reversed, and is it reversed behaviorally?

Behavior is neurobiology. {quotes align=right}What is behavior? It's an expression of brain cells talking to one another with a particular pattern of activity.{/quotes} You can't have behavior if you don't have brain cells releasing neurotransmitters and chemicals in the brain. But the individual can engage in competitive behaviors that become more dominant than the addictive behaviors, and that's one of the treatment strategies. We have to substitute this damaging behavior with other behaviors that are positive and stronger. Maybe your prefrontal cortex isn't powerful enough to suppress the bad behavior. If I can make this healthy behavior stronger, the prefrontal cortex doesn't have to work so hard to suppress the addiction. It's a combination of what the prefrontal cortex says and how dominant the competing behaviors are. The natural competition will suppress it and the healthy behavior will show up.

But what can compete, when the brain has been rewired by drugs?

If you use leverage against the addiction, and ratchet up the cost of their behavior, as they move into 25- 26-27 years old, the prefrontal cortex – while it's been altered because of drug use – is still moving in the mature direction. And at some point it may become strong enough to suppress the drug behavior and put the appropriate list of priorities back into place – and healthy behaviors will dominate over drug-using behaviors.

So finally development has caught up and they may be able to put things back in order, especially if treatment is ongoing, and they are getting good support. It will be very individualized, but many people are able to turn it around by their 30s.

If they're not dead.

If they're not dead.

When you were Acting Director of NIDA you probably ran across these statistics – do most addicts get better?

What we hear is if you get good treatment, and stay in treatment, the likelihood that you will get off drugs is about 60-70%. A lot of people won't go into treatment; a lot of alcoholics go into treatment and don't stay. A lot of addicts detox multiple times, and payment systems often confuse detox with treatment. All detox does is take you through withdrawal; you haven't even started treatment. Then the money runs out and many of these people don't have money to do treatment, so they go into the public system where the waiting list may be four to five months. Some resign themselves that the drug abuse will kill them and they have nothing to live for, so they're in total despair and give up trying to obtain help.

Do we have good public treatment in the Salt Lake valley?

Yes, I think we do. But they're overwhelmed.

Which treatment model works best?

That's very individualized, which is part of the problem. Certain groups have selected a treatment model and assume that it works on everybody.

Like the twelve steps?

And motivational enhancement or cognitive behavioral therapy. Everybody is different, and unfortunately the science hasn't developed the sophistication for good diagnostics. So, on the one hand we say it's a disease, but it's a disease that has many different expressions. And we're trying to cram in all expressions and fit them into the same treatment mode. Would you treat every cancer the same? Or would you treat all depression the same?

You have to look at the client's vulnerability. The addict's genetics make them vulnerable. There are at least 50 different genes that increase vulnerability for addiction – probably more. What does their environment look like? Abusive? Confining? Controlling? High expectations? Are there underlying mental illnesses present that are being self-medicated with drugs of abuse? When these things interact there will be many different expressions of addiction.

Is cognitive behavior therapy successful? Isn't AA a kind of democratic version of that?

You may be affecting some aspect of cognition, but in that case what they're trying to do is strengthen and alter the relationship between addiction behavior vs. positive behavior. They're trying to build up the prefrontal cortex's ability to suppress the drug-seeking behavior. If I had a functional MRI (a brain imaging technique that measures regional brain activity in response to a task), this is what I would see as they go through the thought process. I would be able to see different parts of the brain lighting up and you'd see what regions are working. In the presence of AA techniques, does the prefrontal cortex get stronger? Possibly. In that regard, it's kind of cognitive therapy, but not in the sense that you're really developing the foundational aspect of how cognition is being accomplished in the brain.

This reminds me of the tests they've been running to see how meditation affects the brains of Buddhist monks.

And what does meditation do? It strengthens the prefrontal cortex. You've interfered with the system that typically shuts it down. Brain imaging helps us to study these mechanisms. It helps us to determine if there is a problem and whether treatment is working. Some people like the thought that there's some mystical element here, and when you show them that this really has to do with their brain circuitry, and can be demonstrated through the study of brain functions, it makes them uncomfortable. But for the scientist, they see that there's something naturally happening and if you can control nature in a positive way, that's not bad. You'd much rather do it naturally because you'll have fewer side effects, and it's a very targeted reconstruction of brain function. And it may be permanent, if done properly.

What medications are being used for addiction, and are there new medications being looked at?

We have medications for opiod addiction, like Methadone and Suboxone; there aren't any quick ways to get off heroin. Naltrexone is an opioid antagonist used for alcoholism. We have medications for nicotine dependence and are developing more. We don't have any good medications for cocaine or methamphetamine. There are clinical trials going on now for methamphetamine using bupropion (Wellbutrin, also called Zyban for cigarette smoking). There's a group in a Scandinavia who has found some positive effects using methylphenidate (Ritalin) for heavy-duty meth users. We are also looking at anti-seizure drugs….

Neurontin and Depakote?

Yes. In low doses. And we think the reason they might work is that they can enhance cognitive functions. So that's what we're looking at.

Do you think the stigma around addiction is decreasing in the same way it has for depression in the last couple of decades, as scientists can better explain the chemistry?

I think so. It's slow because this is harder for people to understand and identify with. Even for physicians. They understand the medical part intellectually, but in their hearts it's hard to buy into the disease model for drug addiction. Addiction is different from something organic that we can measure like Parkinson's disease, because it displays a behavior that makes the addict appear abnormal and frightening.

Addiction can't be measured, but can't it be seen on brain scans?

You can do a cognitive assessment on addicts and see the various pieces of the disease. Just like with congestive heart failure, there are a lot of values and symptoms you look at to make the diagnosis. In addiction, if you look in the brain you often see the underfunctioning prefrontal cortex that results in their inability to suppress the damaging behavior.

There is so much new information about the neurophysiology of addiction.

I think that's the secret – on the prevention side. {quotes}I wholly believe that that in the future we will be able to evaluate kids for vulnerabilities to addiction. {/quotes}Part of the evaluation may be genetic (when we determine what genes are involved), but part of it may be doing cognitive assessments to see how the brain is functioning. We could identify the children who are at highest risk for drug abuse, and then work with them to correct the vulnerabilities. Stimulate their cognitive systems and get them strong so that they're able to resist when the opportunity comes along to use drugs.

Or identify their anxiety or depression before they become vulnerable to drugs? There are a lot of high-functioning kids getting addicted to drugs.

IQ is not cognition. IQ is a very different animal. These adolescents are under stress, and their prefrontal cortex is turning off. Their IQ is fine, their memory is fine, but when they're in a crowd and there is a lot of peer pressure – that's another thing that turns the prefrontal cortex off. The stress and anger turns it temporarily off. It comes back online fairly quickly for most of us. Even mature folks can feel these surges of anger, and it serves as a reminder of how powerful these circuits are and how quickly our cognition can be compromised. We can be very vulnerable during these episodes of switching on and off, and if you add drugs into the mix you can have a disaster."

For additional information:

Science and the Origins of Addiction, NPR, Science Friday 6/16/2006 
www.npr.org/templates/story/story.php?storyId=5490892

"The Disease Model of Addiction," Kevin T. McCauley, M.D.

AddictionDoctor.com

Kim Hancey Duffy is a freelance writer living in Salt Lake City.

 
 
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