no financial ties to any drug company not a consultant, speaker, etc. no individual stocks in drug...

AA and the Brain Disease Model of Addiction

Luis A. Giuffra, MD, PhDProfessor of Clinical Psychiatry

Washington University in St. LouisMedical Director, Clayton Behavioral

•No financial ties to any drug company

•Not a consultant, speaker, etc.

•No individual stocks in drug companies

Disclosures

1. Evidence that AA works2. A theory of why AA works3. A brief comment on the debate about

AA and MAT4. A few slides on the future of drug

treatment

This talk will include:

Part 1 :Does AA Work?

A Cochrane review of studies on alcohol treatment conducted between 1966 and 2005 found:

No experimental studies unequivocally demonstrated the effectiveness of AA for reducing alcohol dependence or

problems.

The AA controversy

Journalism in the Public Interest

“Twelve Steps to Danger: How Alcoholics Anonymous Can Be a Playground for Violence-Prone Members”

ProPublica

Those who attend AA are a biased sample of motivated people who would do well anyway, with or without AA.

Scientific American

“The Irrationality of AA”

How can we tell if a treatment works?

Causation or correlation?

1. Magnitude of the effect: There are more smokers among patients with carcinoma of the lung

2. Dose Effect: The more you smoke, the higher the risk3. Consistency: same findings in different studies and in different

countries4. Temporality: Smoking precedes lung cancer5. Plausibility: Carcinogens in tobacco smoke6. Specificity: Removal of all confounding factors that could explain

the finding by correlation and not causation.

Sir Austin Bradford Hill: Smoking and Carcinoma of the Lung (1950)

Note:No human experiments done

“If we had any thought or knowledge that in any way we were selling a product harmful to consumers, we would

stop business tomorrow”George Weissman, VP, 1954

Cochrane Review,2011: Intercessory Prayer

“Overall, there was no significant difference in recovery from illness or death between those prayed for and those not prayed for”Bradford Hill criteria:1. Magnitude of the effect - None2. Dose response effect - None3. Consistency - None4. Temporality - None5. Plausibility - None6. Specificity - None

What to do?

1. Magnitude of the effect:Abstinence is 2x higher among AA members2. Dose response effect:Frequency of attendance correlates with abstinence3. Consistency:Same results in different samples around the world4. Temporality:Prior attendance predicts future abstinence5. Plausibility: This talk will address plausibility6. Specificity:A problem! May never be fully addressed

AA: Bradford Hill criteria(Dr. Lee Ann Kaskutas)

There must be coherence with existing knowledge. “AA works because….”

Plausibility

Part 2:How does it work?

Why would it work?

The Brain Disease Model of Addiction

Addiction causes Hypofrontality

1-6 weeks since last use

Helpful traits

• Poor insight• Manipulative• Selfish• Dishonest• Inconsiderate• Entitled

Unhelpful traits

• Good insight• Generous• Honest• Considerate• Non-demanding

What behaviors help the RS achieve its goal?

Non-addict (FL)

• Observes data, then draws a conclusion

• “Drugs cause problems. I should stop drugs and avoid the problems”

• Uses logic to draw a conclusion

Addict (RS)

• Starts with a conclusion (“drugs are not a problem”), then manipulates data

• “How can I use and avoid the problems?”

• Uses Rationalization to justify initial assumption and makes it look like a logical conclusion

The Precontemplative Stage:A different use of logic and reason

FL to FL

Talking to a precontemplative brain

RS to FL

• For the reward system: ABSTINENCE. We know of no other reliable way to reset the pleasure threshold.

• For the frontal lobes: stop practicing behaviors that fuel addiction. Practice behaviors that promote abstinence.

Treatment

1. The disease presents with impaired insight. The addict’s frontal lobes cannot fix themselves. The addict needs a trusted SURROGATE DECISION-MAKER. Internal motivators are almost never enough.

2. The disease presents with undesirable behaviors. The addict should diligently practice the opposite ones: BEHAVIORAL COMPENSATION.

Treatment

Steps 1-3: A Surrogate Decision-Maker

God as we understood him:A Group of Drunks

Steps 1-3

• Realize that the rational mind has been hijacked by the reward system of the brain to advocate on behalf of alcohol and drugs. Can’t solve the problem alone: alcoholics are making decisions with the affected organ.

• Steps 1-3 encourage the use of a surrogate decision-maker, since the addict’s own one (the frontal cortex) is affected by the disease.

How about God, a Higher Power and Steps 1-3?

Behavioral Compensation: Steps 4-12

Behavioral Compensation

Being insightful, selfless, honest, considerate, altruistic and forgiving.

Steps 4 to 12

What traits help the frontal lobe regain control over the RS?

• Steps 4-12 offer an honest, selfless, altruistic, humble and considerate way of living

• Addiction is fueled by dishonesty, selfishness, egoism, arrogance and inconsiderate behaviors….all driven by the reward system in its evolutionary quest to “repeat what feels good”.

Working the steps

How about Step 11?It’s also a frontal lobe exercise

-Addiction hijacks the reward system

-Addiction affects the frontal lobes

-The 12 steps encourages a Surrogate Decision-Making (Steps 1-3) and Behavioral Compensation (Steps 4-12)

Is AA Plausible?

1. Magnitude of the effectAbstinence is 2x higher among AA members2. Dose response effectFrequency of attendance correlates with abstinence3. ConsistencySame results in different samples around the world4. TemporalityPrior attendance predicts future abstinence5. PlausibilitySurrogate Decision-Making, Behavioral Compensation and Behavioral models of change (acceptance, role models, empathy)6. SpecificityA problem! Causation or correlation?

AA and Specificity

•Requires experimental manipulation: randomization, blindness, control groups•No realistic opportunity to do this type of research in AA:–Requires a sincere desire to change–AA attracts, does not recruit, its members–Great variability among groups and sponsors–Self-report is unreliable–AA has no opinion on outside matters. AA has done well without the endorsement of academicians or clinicians. AA has no financial interest in its acceptance and success. Due to anonimity, AA does not track its members or conduct research. AA shall remain for ever nonprofessional.•AA’s major weakness. It may never be solved. However, AA is widely endorsed: NIH/NIDA, UK NHS, WHO, etc.•Yes, it lacks specificity, but AA is free and widely available.

6. Specificity

Part 3: A brief comment on AA

and MAT

• A controversial topic in the recovery community

• AA is not against MAT• How might the controversy be resolved in the

future?• The case of Raphael Osheroff

AA and Medication-Assisted Treatment

“Because of the difficulties that many alcoholics have with drugs, some members have taken the position that no one in AA should take medication. While this position has undoubtedly prevented relapse for some, it has meant disaster for others. It becomes clear that just as it is wrong to enable or support any alcoholic to become re-addicted to any drug, it’s equally wrong to deprive any alcoholic of medication that can alleviate or control other disabling physical and/or emotional problems.”

AA and Psychiatric MedicationsSeptember 7, 2010

• 1970s: Psychiatry was divided on using medications to treat mental illness

• Dr Osheroff spent 7 months at Chestnut Lodge, where team felt medications will interfere with recovery

• Lost his practice, his medical license and custody of his 2 sons

Raphael Osheroff, MD

• His parents took him to another hospital. Lithium helped within 3 days, discharged in 3 weeks

• Osheroff v. Chestnut Lodge: a battle of the experts• Arbitration sided for Osheroff: $250,000. He later settled

out of court• Chestnut Lodge went broke and closed in 2001. Osheroff

died in 2012• It’s not opinions, but what the data shows, that

constitutes the standard of care

Raphael Osheroff, MD

Part 4:A few slides on the future

of drug treatment

Optogenetics: the 2010 “Method of the Year”

Using light to turn on/off specific cells in a live animal

On-demand optogenetic control of spontaneous seizures in temporal lobe epilepsy (Nature, 2013)

Reversing cocaine-induced prefrontal cortex hypoactivity prevents compulsive cocaine seeking

(Nature 2013)(Optogenetic manipulation of the frontal lobe)

Alcohol-addicted rats treated with optogenetics stop drinking (2014)

(Optogenetic manipulation of the reward system)