Opioid Addiction Biology 101 Dopamine Dr Brian Spitsbergen

Opioid Addiction Biology 101 - Dopamine Dr. Brian Spitsbergen Ph. D, LPC, CAADC Michigan Recreation & Park Association Presentation 1/29/20

Nature of Addiction

How Drugs & Alcohol Get the Job Done • They interact with nerve circuits, centers, and chemical messengers • Results I Feel Good – Euphoria & Reward I Feel “Better” – Reduce negative feelings This Feels “Normal” I’m craving it, tolerating its effects, withdraw/feel sick

Three “C’s” of Addiction Control – Early social & recreational use Eventual loss of emotional & behavioral control – Cognitive distortions (denial & minimization) – Tolerance & Withdrawal Compulsion – Drug-seeking activities & Craving Addiction – Continued use despite adverse consequences Chronicity – Natural history of multiple relapses preceding stable recovery – Possible relapse after years of sobriety

PROGRESSION OF USE in Change tate S n i a r B Addiction Harmful Involvement Early Experimentation Time Middle Late

Addiction • Addiction is a "baffling, cunning and powerful disease, " so the Big Book says. • In a sense, it is pretty simple -- "People use substances to feel good. " • This "good feeling" comes when people self-medicate

Addiction • But how does it begin? • • • Early deprivation Abuse Trauma dysfunctional attachment Genetics • All cause imbalances in brain state which can be a set up for addiction • Imbalances in brain can lead to the feeling that something is missing…. . And the substance seems to fit perfectly.

Control • The Addicteds motivation is control, not abstinence If I can have just one, then I will be normal, just like my friends

Where it Starts…… • Often, the disease of addiction starts between the ages of 12 and 15 • A number of people will have had their first drink, their first joint or their first cigarette between these ages • Use of opioids is not far behind • For many this will merely be a passing curiosity, but for those with a genetic predisposition for addiction this can become a haunting lifelong torment

When the Brain is Out of Balance

Overview of Opioid Use • From the Institute of Addiction Medicine: – Americans, represent less than 5% of the world's population, use 80% of the world's supply of opioids – 99% of hydrocodone is used in the U. S. – 31% opioid users first started with the nonmedical use of prescription drugs.

Symptoms of Imbalance Anxiousness Appetite control Attention issues Developmental delays • Behavioral problems • • • Low mood Fatigue Low libido Headaches Mood disorders Sleep disorders

When we are missing something……

Pleasure/Satisfaction

Brain – 3 Operating Units • Reptile (Primitive) Brain 1. Sensation 2. Connected with Survival (Hunger, Thirst, Procreation) 3. Flight or Fight Mammalian Brain Emotion and Feelings • Frontal Lobe Logic and Reason (Amygdala)

The Brain’s Vulnerability to Opioids • Researchers suggest the path to addiction requires two things: 1. genetic vulnerability-variables may include the quantity of dopamine receptors in the brain 2. Too few receptors - taking the drug is not particularly memorable 3. Repeated assaults to the spectrum of circuits regulated by dopamine, involving motivation, expectation, memory and learning, among many others, appear to fundamentally alter the brain’s workings.

What Matters - Recovery Retention from pre to post-care Progress toward self-regulation Successful days of engagement in recovery Frequency of Re-engagement in Primary Care/Public Safety • Positive movement toward dealing with difficult/negative emotions • Development of successful self-care skills • Development of healthy relationships • •

Initially… using Opioids • USE PRODUCES EUPHORIA • MODIFIES THE PLEASURE CIRCUITS • MASSIVE RELEASE OF DOPAMINE Survival Becomes Equated with Pleasure • Euphoria Becomes a Survival Response, • Like Satiation after Eating • Explosive Biochemical Linkage is Made between Feeling Good and Survival • Survival Connects to the Primitive Brain, Where Sensation Controls and Dictates Action

Then the Brain……. . • ATTEMPTS TO READJUST • FROM THE REDUCTION IN NEUROTRANSMITTERS & RECEPTOR SITES • TRYING TO RETURN TO “NORMAL” • • Deep emotional connection Leads to urges and cravings Opioids can permanently alter brain state Addiction results in long lasting effects on thinking, emotions, perception, memory and recall

When the Brain is Imbalanced Due to Opioid Addiction…………. It Will Seek Relief/Resolution!!!!!!

The Role of Dopamine in Our Brain • • • Primitive Brain Recognizes Dopamine Reward/Survival Dopamine Creates the Reward Reinforces Learning Sets Us Up to Learn, Act, Respond Links Primitive Brain, Emotional Memory and Frontal Lobe (Rational Thought)

Dopamine When we have lots of dopamine we have: • Feelings of pleasure • Feelings of attachment/love • Sense of altruism (unselfish concern for the welfare of others) • Integration of thoughts and feelings

Dopamine And when we have Dopamine Deficiencies: • Anhedonia (lack of pleasure) • Lack of ability to feel love, sense attachment to another • Lack of remorse about actions • Distractibility

Dopamine and Mood Disorders • Disruptions in dopamine production can result in severe disorders including psychosis and schizophrenia • There is a strong genetic component to mood disorders

Dopamine and Mood Disorders • The cause of mood disorders appears to lie in an imbalance of brain chemicals that affect mood. • Noradrenaline, dopamine and serotonin irregularities are linked to depression and bipolar issues

Depression & Chronic pain • Depression, chronic pain & Dopamine share same neurotransmitters • Those who have damaged dopamine receptors with chronic pain report: 1. More intense pain 2. Less control of their lives 3. More unhealthy coping strategies

Low Dopamine Hopeless/Low Motivation • Tired • Problems feeling pleasure • Insomnia • Hard time getting up in the morning • Mood swings • Forgetting things • Problems with concentration and focus • Loss of memory • Low sex drive • Problems connecting to others • Craving caffeine • Craving carbs and sugar • Problems with weight loss • Problems dealing with stress

Dopamine Based Depression • Most depression is treated - low serotonin • Low dopamine = depressive symptoms – but they are different • Depressive symptoms due to low dopamine: • • low energy Can’t get out of bed complete lack of motivation Take medication and it doesn’t work

Current Epidemic • This problem didn’t occur overnight – Mid 1990’s – pain mgmt. • Acceptance - here to stay for at least a generation • We will have to devote more time and resources • Epidemic still being addressed reactively • Addiction has always been a part of society fabric • It affects everything • Impacts health care, public safety and individuals and families • We need solutions

What they told me……. • “I feared dope sickness more than I feared death” • I needed to experience a “moment of clarity” • “When I experienced “moments of clarity” - the support wasn’t there • “Moments of clarity” didn’t last long • The anxiety came back, sometimes very quickly – and the ability to make rational decisions was gone

Moment of Clarity “Pivotal moment” Person cannot stand using Person cannot imagine sobriety It is short in duration Anxiety/depression soon takes over If Moment not captured - return to use imminent • We NEED to “capture” this moment • Odds of long-term recovery could go up exponentially • • •

Current Systemic Problems • Inadequate - confused allocation of resources • Inappropriate - treatment admissions – results in poor outcomes • Reactivity (communities in crisis) • Financial/human resource strain on local communities • Significant numbers of preventable deaths • Unacceptable amount of Emergency Room “repeaters” • Stigma - addiction is a moral problem -“why don’t they just stop!”

What Happens Now……… Person goes to hospital Detoxed & medically cleared Released ASAP if no medical issues If no need for medical assistance A call is placed for detoxification Pihp responds – conducts assessment Person in crisis might have to wait up to 24 hours to secure bed • Beds are based on availability! • In either case, not being treated at the “moment of clarity” • •

Successful Detox Strategies • Yoga Movement/breathing • Nutritional intervention/management • Life-style counseling/Strategic Support Sessions • Emotional Regulation • Individual Trauma Therapy - mostly nontalk trauma therapy • Play Therapy • Medically Assisted treatment(s)

Anxiety Reduction anxiety associated with overdose/chronic use Trauma PTSD TBI Person cannot choose when disrupted Feelings/emotions are instead primary decision maker • Goal is to re-engage Frontal lobe if possible • Its not functioning properly • • •

Priority at Detoxification Anxiety reduction/emotional regulation Brain/body stabilization Consistent engagement with Peer Coaches First 48 -72 hours (most critical to retention) • Consider MAT (where applicable) • Extend detox stay (7 + days) when considering innovative MATs – vivitrol • •

Active Therapies Affective work Scaling worksheet - feelings Structured mindfulness Breathing exercises Before and after affective work and scaling • Nondirective play therapy • • •

Emotional Regulation • Emotional regulation - emotional adjustment & growth • Regulation includes - positive mood, negative mood, and anxiety • Identify and label emotions • Identify obstacles to changing emotions • Reduce vulnerability to emotion • Increase positive emotional events • Increase awareness to current emotional state

Nutrition • Receive the nutrients and tools needed to reset • Engage in quicker recovery and retention • Increase balance between oxidation and antioxidation • Counteract increases in low dopamine levels • Some amino acids and nutrients can improve the production of dopamine • Assess and replenish body where possible

Replenish Dopamine • Dopaminergic foods: • bananas, almonds, beets, apples, coffee, chocolate, lima beans, leafy greens, oatmeal, watermelon, sea vegetables, animal products, and watermelon • • exercise regularly Listen to music Meditate hobbies that are very creative: • house repair, photography, drawing, sewing and knitting.

Medically Assisted Treatments (MAT) • • Stabilization Confidence Anxiety reduction Time limited

Result – Brain Wellness • The body's natural move toward balance or homeostasis • Recovery process – clean time + clean activity = balance • Body, mind and spirit come into balance • Creates sustained recovery • Leading to a healthier balanced lifestyle

Low Serotonin – Loss of Pleasure • significant sensitivity to pain • angry all the time • constipation • carb cravings /binge eating • low mood from a lack of sunlight • problems with digestion • overwhelmed • dependency on other people • insomnia • lack of joy • migraines • lower self-esteem • ringing of the ears • poor cognition

Low Serotonin – What to Do • • • Exercise several days per week Exposure to sunlight Relaxing as much as you can Managing stress levels Adequate sleep Making changes to your diet: salmon, chicken, avocados, walnuts, baked potatoes, chickpeas, pumpkin seeds, sunflower seeds, and lentils. • Eat these foods several times daily.