the neurobiology of street drugs and addiction joe …...the neurobiology of street drugs and...
TRANSCRIPT
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The Neurobiology of Street Drugs and Addiction
Joe Gilboy PA-C
Hoag Hospital Emergency Department
Irvine and Newport Beach, CA
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Your brain is a complex neural network
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“What fires together wires together”
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Neuroplasticity
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I want you to leave with more questions and less answers
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Let's go back to school and learn some neurobiology
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Presynaptic Cell
Postsynaptic Cell
Synaptic area
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Uptake pumps
Dopamine
Dopamine receptor sites
Normal day
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Ventral tegmental area
Reward System
Limbic SystemDopamine (Reward Chemical)
Remember this area is your hard drive level
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Caudate Nucleus
Regulation of movement
Remember these drugs are working at a prehistoric wiring level
Respiratory center
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0100200300400500600700800900
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Time After Drug
Morphine
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Nicotine
Effects of Drugs on Dopamine Release
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Accumbens
0.51.02.510
Dose mg/kgmg/kg
mg/kgmg/kg
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Methamphetamines
Stimulation of dopamine in the limbic systemCan be snorted, smoked, or injected
Highly addictive and tissue tolerancestrong cravings
“Tweakers” are highly agitated and paranoid
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Amphetamine
Methamphetamine
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What’s the difference??Generation Adderall A version of this article appears in print on Oct. 15, 2016,
New York Times Sunday Magazine
Psychosis with Methylphenidate or Amphetamine in Patients with ADHDMarch 21, 2019
N Engl J Med 2019; 380:1128-1138DOI: 10.1056/NEJMoa1813751
https://www.dea.gov/press-releases/2019/02/14/whitinsville-woman-faces-20-years-prison-adderall-distribution
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cAMP
Meth
S
Dopamine receptor site breaks down after chronic use
Mitochondrial breakdown because of glutamateAnn N Y Acad Sci. 2008 Oct;1139:232-41. doi: 10.1196/annals.1432.028.
Methamphetamine changes NMDA and AMPA glutamate receptor subunit levels in the rat striatum and frontal cortex.
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Memory
Emotions
Thought
MRI of a Methamphetamine Addict
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Opiate receptor sitesMethamphetamines stimulates dopamine receptor sites in the Nucleus accumbens
Nucleus accumbens
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End result stimulation of the reward system
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Narcotics/OpiatesHeroin,oxycodone, Vicodin
It was brought to China by Arab traders in the eighth century
The British, East India Company became a chief supplier and promoter of opium for the Chinese
market
In England heroin is mixed with alcoholcocktail to terminally ill cancer patients
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No competition more stimulation of dopamine receptor sites (Mu can grow when stimulated)
Heroin/opiate
Mu receptors
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Opiate Binding Sites
Nucleus Accumbens
Memory
Movement
Respiration
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End result stimulation of the reward system
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Treatment for Heroin Patients
1st Line Subutex (buprenorphine)
2nd Line Suboxone (buprenorphine+ naloxone)
Can use methadone prefer to give at methadone clinics where it is dispensed as a liquid to prevent abuse
Chasing Heroin PBS Frontline Special
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The worst drug crisis in American history
• Death rates now rival those of AIDS during the 1990s
• Overdoses from heroin and other opioids now kill more than 27,000/year
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What started the fire • Pain 5th vital sign
• Originated in the VA hospital system late 1990s and became a Joint Commission standard in 2001.
• Purdue Pharmaceutical
• OxyContin, introduced in 1995, was Purdue Pharma’s breakthrough palliative for chronic pain
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How bad is the opiate problem??
• In 1999, there were more than twice as many motor vehicle deaths as fatal drug overdoses. By 2014, those numbers had flipped
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Chasing Heroin PBS Frontline Special
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Kim Jadda’s vaccine works a bit like a sponge it sucks up the heroin and prevents it from reaching the brain
the vaccine prevents the drug from reaching the brain at all. Narcan in a vaccine
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One way to look at it is that addiction is the compulsive repetition of getting “a reward” despite life damaging
consequences
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Do they work?
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What is the standard rehab success rate?
There is no standard definition of rehabMany base their success rates on unreliable metrics:
• Completion of the program• Sobriety rates immediately after treatment• Client interviews• Internal studies
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• Dr. Lance Dodes spent more than 20 years studying and treating addiction. His latest book:
• The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry.
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AA Success Rate 5-10%
• And to its credit• AA describes itself as a
“brotherhood rather than a treatment”
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Drug & Alcohol Rehabilitation Clinics industry trends (2014-2019)Average industry growth 2014–2019: 4.6%
700 Billion: Nation annually in costs related to crime, lost work productivity and health care
3x: The amount the business of recover increased in the last 25 years
14,000: The amount of addiction treatment facilities
$35 billion: annual revenue generated by the addiction treatment industry
Lyft -- $15.1 billion
Source: Substance Abuse and Mental Health Services Administration
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Sober living home average about $1,500-2,500 per month. Missing a payment can result in expulsion from the home.
Source: Substance Abuse and Mental Health Agency (SAMHSA)
In the end rehab facilities don’t work $$expensive$$
www.thebusinessofrecovery.com
Generally, the price tag for rehab is:
•Outpatient: $3,000 – $10,000 for 90 days
•Inpatient: $5,000 – $20,000 for 30 days
•Luxury: $30,000 – $100,000 for 30 days
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Here’s a bright idea!!
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Neuroplasticity
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Neuroplasticity
the potential that the brain has to reorganize by creating new neural pathways to adapt, as it
needs
Changes being made in the brain as the brain's way of tuning itself to meet your needs
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Formerly held belief that the adult brain was pretty much a physiologically static organ
hard-wired after critical developmental periods in childhood
your brain is much more plastic during the early years and capacity declines with age
WRONG: plasticity happens all throughout your life
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Neuroplasticity• Ability of the brain to change structure and
function based on input from repeated behaviors, emotions, and thoughts
“What fires together wires together”
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Shackleton-Jones, Nick (2019-05-03). How people learn : designing effective training to improve employee performance. London, United Kingdom. ISBN 9780749484712. OCLC 1098213554
O'Brien CP. Neuroplasticity in addictive disorders. Dialogues Clin Neurosci. 2009;11(3):350–353.
Shaffer J. Neuroplasticity and Clinical Practice: Building Brain Power for Health. Front Psychol. 2016;7:1118. Published 2016 Jul 26. doi:10.3389/fpsyg.2016.01118
In Donald Hebb's (1940s) memorable words:
What fires together wires together — neurons that activate each other become more strongly connected —
through adjustments (increased efficiency) in their synapses. Neuroplasticity is the brain's natural starting point for all learning processes — processes that might
include not only addiction but also recovery
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Brain plasticity is a two-way street; it is just as easy to generate negative changes as it is positive ones
What fires together wires together
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Why do people become addicts??
Epigenetics
Mu receptorsAddiction vs dependenceEnvironment
Neuroplasticity
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• Recent studies provides strong evidence that stimulant addiction may result in large part from underlying, inherited genetic abnormalities in brain structure that encourage impulsive behavior and impaired control.
• Ersche KD et al. Abnormal brain structure implicated in stimulant drug addiction. Science2012 Feb 3; 335:601.
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Complexity to a level nobody understandsLets all agree what we have been doing
doesn’t work
time to look for a new way
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Neuroplasticity
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• Ketamine improves mood disorders within hours not weeks
• Repairing damage connections • SSRIs may be wrong
Depression may be the result os stress-induced damage to brain cells that control mood
The use may lead to newer drugs
• National Institute of Mental Health (NIMH)
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Neurons with budding after Ketamine
About 99 percent of genes in humans have counterparts in the mouse 80%have identical, one-to-one counterparts
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What fires together wires together
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LSD and Anxiety in Cancer patients
• Long-term follow-up of psilocybin-assisted psychotherapy for psychiatric and existential distress in patients with life-threatening cancer
• J Psychopharmacol. 2020 Feb;34(2):155-166. doi: 10.1177/0269881119897615. Epub 2020 Jan 9
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LSD and nicotine addiction• Johnson, M.W., Griffiths, R.R. Potential
Therapeutic Effects of Psilocybin Neurotherapeutics 14, 734–740 (2017)
• South America• Ibogaine is converted into a noribogaine• targets the areas of the brain affected by drug-seeking and
addictive behaviors• Noribogaine “rewires” these areas, allowing the brain to
restructure itself to a state similar to before addiction was triggered.
• Belgers, M., Leenaars, M., Homberg, J. et al. Ibogaine and addiction in the animal model, a systematic review and meta-analysis. Transl Psychiatry 6, e826 (2016).
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• Rat Park (environment)
• was a study into drug addiction conducted in the late 1970s (published in 1980) by Canadian psychologist Bruce K. Alexander and his colleagues at Simon Fraser University in British Columbia, Canada
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• The researchers built a rat colony
• (Rat Park) which was 200 times the size of a normal laboratory cage
• Housed between 16 – 20 rats of both sexes.
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His neural connections are healthy, and his wiring is working well
What fires together wires together
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So the opposite of addiction is not sobriety
It is human connection
Neuroscientist Marc Lewis argues that addiction – or dependence, is the result of "deep learning", probably
triggered by stress or alienation.
It can duly be unlearned by forging stronger synaptic pathways via better habits.
What fires together wires together
The Biology of Desire: Why Addiction Is Not a Disease by Professor Marc Lewis
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Nearly fifteen years ago, Portugal had one of the worst drug problems in Europe
1 percent of the population addicted to heroin
They had tried a drug war, and the problem just kept getting worse
So they decided to do something radically different. They resolved to decriminalize all drugs
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They transferred all the money they use to spend on arresting and jailing drug addicts and spend it
instead on reconnecting them to their feelings, and to the wider society
The most crucial step they secure housing, and subsidized jobs so they have a purpose in life, and
something to get out of bed forBottom line it works
The 15th anniversary of the Portuguese drug policy: Its history, its success and its future
Tiago S Cabral First Published January 1, 2017 Research Article
Want to Win the War on Drugs? Portugal Might Have the AnswerBy Naina Bajekal | Photographs by Gonçalo Fonseca
August 1, 2018
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Neuroplasticity
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Maybe your genetics affects your body’s response to drugs, foods, medicine and maybe addiction
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“Dare to Think” Maybe it’s the cage the patient is in along with genetics and
the cure is neuroplasticityWhat fires together wires together