Hi, my name is Tina Nadeau, and I'm the Chief Justice at the New Hampshire Superior Court. I was fortunate enough to be in Reno with some specialists on addiction psychiatry and other judges and we had a chance to get together and talk about the nature of addiction and how we need to be understanding it and addressing it in our courtrooms. In this presentation, you're gonna hear from Dr. DeVido, who will talk to you about the brain science behind substance use disorder. Many of you may know how the brain operates when it's been damaged by the use of substances, but all of us don't appreciate that. And what we need to understand as judges is using drugs or not using drugs is not a matter of willpower. But it's actually a matter of how the brain has been damaged by years and years and years of drug use. And what we can recognize as judges as significant substance use disorder. So gone are the days when we can order somebody to stop using drugs because we tell them to. We need to understand that in order for them to stop using, they have to get their brains and behavior actually treated. And that's what Dr. DeVido will talk to you about here today. So I wanna welcome everyone to this session. And this is as you can see, by the title, "The Science of Addiction: Teaching the Science of Addiction to Non-Clinical Professionals." This was a presentation that I had made a couple months back in Reno Nevada. And I was fortunate because I was the sort of the first talk in a number of series. So kind of nice to set the stage here with some background, or at least you'll get my sense of sort of how I think about the science of addiction. So a little bit more about me. So I'm a psychiatrist by training, and I have board certifications in adult Psychiatry, as well as Addiction Psychiatry and Addiction Medicine. I'm currently the Chief of Addiction Services in Marin County, California at the Department of Health and Human Services there. And I'm also the Behavioral Health Clinical Director with Partnership HealthPlan of California, which is a large, 14 County managed Medicaid program here in California. Also, as you can see here, an avid fly fisherman, father of three and shirker of yard work duties, although I must say that recently I did do some yard work. So that was a reportable event. No relevant financial disclosures to this talk. I do want to add that the viewpoints expressed in this talk are of mine alone and don't represent any institutional viewpoints of either of my employers. So first and foremost here, addiction is not glamorous. And for folks that might remember this is a sort of a movie promotional photo in relation to a movie that "Trainspotting" that came out several years ago. And "Trainspotting" was interesting, because for folks that haven't seen this movie, it really kind of portrayed heroin use in Scotland in particular, as something that was really gritty, it was not a very sort of fancy glamorous movie. But it had sort of this opposite effect, where, almost around this movie developed this culture of sort of what we call the heroin chic, the sort of emaciated, sort of it almost became glamorized, which I don't think was the intent of the movie necessarily. But nonetheless, a lot of people walked away and sort of there's a whole cultural social movement that reflected in fashion, and sort of demeanor known as heroin chic. And, again, even though there were some pretty gritty, pretty raw portrayals of addiction in this movie, I think it's worth highlighting that addiction is not glamorous, there's nothing glamorous about heroin injection. There's nothing glamorous about having an out of control, alcohol use disorder, but sometimes in the media and sometimes in popular culture, it can take on a sort of glamorous feel. So what is addiction? Or what is not addiction? This is a quote here from Michael Botticelli, which, I think highlights one of the ideas that I was mentioning before around a sense of stigmatized view of addiction as being something that's a moral failing to spiritual illness. And Michael Botticelli here is talking about the reality that as we learn more about addiction, and we're gonna talk more about sort of the biology of addiction. "Addiction is a brain disease. This is not a moral failing. This is not about bad people who are choosing to continue to use drugs because they lack willpower." Some other things that addiction is not. Addiction is not as simple as just being physically dependent on a substance. The example that I give here is the individual who has chronic cancer pain. They've got, let's say, bone metastases from a nasty cancer. And they're in a tremendous amount of pain. And they're put on opioids in order to treat that pain, which is understandable. They've got metastases in their bones, incredibly painful. That individual is taking opioids on a daily basis to treat the pain, they will become physically dependent on the opioids. And by physically dependent I mean that they will require increasing doses of the opioid in order to achieve the pain relief that they need. And if you were to stop it, cold turkey, they would get sick, they would go into withdrawal. Now, that's physical dependence that's different than addiction. And we'll tease this out a little bit more as we go along. But the idea here being that no one would say or no one should say that the person with bone metastases, terminal cancer, who requires high doses of opioids in order to treat their pain is an addict per se, or an addict is a somewhat pejorative term. But we wouldn't say that they have addiction, per se, they have physical dependence. Occasional use of a substance is not in and of itself, addiction. Addiction is more than just taking the substance. Addiction is the whole constellation of behavioral factors that we'll talk about. And I put this in quotes here. Addiction is not substance abuse. So we really as a field trying to move away from the term abuse when talking about substance related illnesses. And we'll talk about sort of more of the specific terminology that we like to use now. But I want people to kind of start to get in the habit of thinking about substance abuse as sort of an old term, that's now becoming outdated. And in part because the idea of abuse is pejorative. And it's not helpful and kind of characterizing what we now know, as sort of a complex illness that involves neurobiological factors in addition to behavioral factor and manifests as behavioral factors in many respects. So finally, what is addiction not? It's not hopeless, this goes back to the comment I was making before, which is that it's easy to think, if all you ever see are people who are sort of the sickest of the sick with addiction. It's easy to think that this is a hopeless disease. Similarly, if all you saw were people with end stage lung cancer, you would think that lung cancer is a hopeless disease. If you weren't in a place where you could see people improving or getting better, then you would think that these are hopeless illnesses. I can tell you as an addiction treatment provider, and many of my other colleagues who will be presenting to you through these lecture series will tell you the same thing that in our experience, what keeps us going is the fact that we work with individuals who get better. And we get to see that glorious other side of the picture, which is that people get better. And as a result, addiction is not hopeless. And part of our role then is to convey to the person who is struggling at the sickest point of their illness, that there is hope, we've seen other people get better. So terminology. This is somewhat a gray area in some respects. But I wanna highlight the idea that back to this notion of substance abuse, which I mentioned before, that we're trying to no longer use that term. The terms that we like to use now are addiction and substance use disorder. So these are used in some circles fairly interchangeably. The technical way of looking at this is that substance use disorder encompasses the whole panoply of disorders that are related to the use of a substance. And addiction, really technically refers to sort of the severe variant of that. So the sort of severe end of substance use disorder. I tend to advise people to consider changing their lexicon as best as possible to be using the term substance use disorder, as opposed to addiction. And the reason is not because I don't like the term addiction, and you'll hear me using these terms somewhat interchangeably. But the primary reason that I think using substance use disorder is helpful in kind of changing our mindset is because when we use the word addiction, we can be inclined to shorten that word when we talk about individuals and refer to them as addicts. And the term addict, even though it's just the shortened version of addiction. The term addict tends to be perceived pejoratively, tends to be perceived as having negative connotation, tends to be associated with sort of these old abuse willpower deficit models of addiction. So we tend to try to encourage people to use substance use disorder, but you will still hear people kind of use these interchangeably. And I wanted to kind of introduce the idea that we will be striving as a field to be more consistently using the term substance use disorder. And this was actually something that was highlighted in the Surgeon General's Report on addiction in America several years ago, which I thought, by the way, was a fantastic summary and synopsis of sort of the state of addiction and addiction research. So another thing that I like to highlight for folks is that addiction and substance/substance use disorder is potentially terminal, lots of people die. And again, you'd have to be living under a rock in the last several years to not know that a lot of people have been dying in a shocking sort of volume, as a result of their addictive illnesses, in particular around opioid use disorder, which you're gonna hear more about in other talks. But I do think that it is worthwhile kind of highlighting. This is a slide I like to put up in a lot of my talks is sort of the read my mind slide, like what are these numbers represent? So I'm not gonna do that I'm actually gonna tell you what these are. And this is 2018 data that we get from SAMHSA. And this is survey related data that SAMHSA, which is the Federal Substance Abuse, Mental Health Services Administration in DC, that collects this information on a yearly basis. But the 2018 data, the 10.3 million represents the people aged 12 years or older who misused opioids in the past year. The 20.3 million represents the people aged 12 and older who had a substance use disorder related to their use of alcohol or illicit drugs in the past year. So of that 20.3 million, 14.8 million people had an alcohol use disorder, 8.1 million people had an illicit drug use disorder. The most common of the illicit drug use disorders was marijuana use disorder. Not surprisingly, it's one of the more available illicit substances. Well, it's still illicit on a federal level. I wanna kind of step back and kind of explain why this is significant. So the first number 10.3 million is representing the number of people who misused opioids in the past year. Again, this is not necessarily... This is encompassing those individuals that have gotten a valid prescription for an opioid to treat their cancer pain. This is based on survey, people that are endorsing at some point in the past year they misused an opioid whether that was heroin or prescription pain reliever. 20.3 million represents the number of people that based on the survey, met criteria for substance use disorder, which we talked about the terminology to drive at home. 20.3 million people aged 12 and older, met criteria or would have met criteria for having an addiction to alcohol or illicit drug in the past year. That's a big number when you think about that as a percentage of the population. So the number that people like to always talk about here and the one that I think is the most significant is this 11.1%. What does this 11.1% represent? This represents the percentage of people who, aged 12 or older who would... Of that 20.3 million people that met criteria for addiction or substance use disorder in the past year. 11.1% represents the percentage of those people who received specialty treatment or receive treatment at a specialty facility in the past year. So let me rephrase that. 90% of that 20.3 million did not receive treatment at a specialty facility in the past year. Now, that's not to say that all of those 90% that did not receive treatment at a specialty facility wanted or pursued getting treatment. But a significant proportion of individuals based on the survey data, at least, were trying to receive specialty or receive treatment in a specialty facility, but were unable to do so. So kind of, bringing this down, what does this mean to me? Well, this means that addiction and substance use disorders are very common, and they are very undertreated. So now, we're stepping into how I think about the illness of addiction or substance use disorder. And the model that I've used to convey as an addiction specialist to non-addiction specialist people. How do you teach about addiction or substance use disorder is this three part model. This is the three part way in which I see and talk about addiction and substance use disorder with individuals who are not addiction specialists. So the first one I'm gonna focus on down here is in the bottom right corner is that addiction is a chronic relapsing illness. So what do I mean by this? So very interesting story, this is back in 2000. On the next slide, I'm gonna fast forward here that you can see there's a reference here for the paper that I'm gonna be discussing. But there's a JAMA, this is the Journal of the American Medical Association. So no fly by night, throwaway journal, in 2000. And Tom McLellan and Herb Kleber, and others, did a very interesting thing. They went and they looked at what do we know about many of the other chronic medical illnesses or illnesses for which the idea that there are chronic medical relapsing illness is undisputed. So asthma, hypertension, diabetes. No one argues that asthma, hypertension, and diabetes are not chronic medical illnesses that require a certain amount of chronic and ongoing attention. So these are sort of well established chronic medical illnesses, asthma, hypertension, and diabetes. And what McLellan and colleagues did is they looked at what we know about addiction, and they compared it to what we know about these other well established chronic medical illnesses. And what they found was that on many levels, what we know about addiction is indistinguishable from what we know about these other chronic medical illnesses. They have a similar genetic profile. In other words, that they run in families, that there is a genetic contribution to asthma, that's as significant as the genetic contribution to addiction. We also know that in terms of when we get people into treatment, when we put people into treatment, when we recommend it, and they engage in treatment, we know that the generally speaking people comply with treatment at about the same rate, whether it's asthma, hypertension, or diabetes. And when I'm talking to medical providers who maybe are not as familiar with this, this is sort of my... Here's my reality dose for you today, which is that many of the individuals that are telling you that they're taking their medications every day for asthma, hypertension, and diabetes, are not. The estimates are about 30 to 50% compliance with the treatment that's recommended. So similarly, we make recommendations to an individual with addiction, we see about a 30 to 50% compliance rate. A lot of people look at people with addiction, and they say, well, nobody gets better, nobody engages in treatment. Well, actually, the data would say that they do and they do actually to the same extent as people with asthma, hypertension, and diabetes. And by that I mean when they've gotten into treatment and in a treatment plan and a protocol has been put forward. So again, indistinguishable between addiction and asthma, hypertension and diabetes. We also see that the treatment response rates are similar. If you are in treatment, and you engage in treatment for asthma, hypertension or diabetes, the one year outcomes are similar in terms of symptom management being around 40 to 60%, as it would be if we use as an endpoint abstinence for people with addiction. So, some other similarities, we also see that as with asthma, diabetes and hypertension, we see that there's no permanent cures, per se for diabetes. We don't say, well take this insulin for a week, and you should be better. And that the management strategy for addiction is similar to the management strategy for these long-term chronic relapsing medical illnesses, which is a combination of providing pharmacologic or medication interventions, advising and facilitating behavioral changes, exercise diet, going to meetings, whatever it might be. And long-term follow up is necessary. In other words, we don't talk about, again, kind of a quick cure, and then you're better and you move on your way, we require longer term follow up. So again, this was kind of a paper that really kind of set the field on its head, from the standpoint that it really drove home this idea that addiction, when you look at it is not all that dissimilar from these other chronic medical illnesses that we never question. When I presented this in person, I also included a quote here that I think drives home some of the discrepancy between how we view things like asthma, diabetes and hypertension and addiction. So let me just read to you a quote here. So, "In this regard, it is interesting that relapse among patients with diabetes, hypertension, and asthma following cessation of treatment has been considered evidence of the effectiveness of those treatments, and the need to retain patients in medical monitoring. So in contrast, relapse to drug or alcohol use following discharge from addiction treatment has been considered evidence of treatment failure. Imagine the same strategy applied to the treatment of hypertension. Hypertensive patients would be admitted to a 20 day hypertension rehabilitation program, where they would receive group and individual counseling regarding behavioral control of diet, exercise and lifestyle. Very few would be prescribed medications as the prevailing insurance restrictions would discourage maintenance medications. Patients completing the program would be discharged to community resources, typically, without continued medical monitoring, and evaluation of these patients, six to 12 months following discharge would count as successes, only those who had remained continuously normotensive for the entire post discharge period." Again, there was a lot of words there and a lot of description. But basically, the idea that's being driven home here is that we fundamentally see things like diabetes. If you're in treatment for diabetes, and you stop and your symptoms come back, we say, we need to get you back on that treatment, because it worked. When we have someone with alcohol addiction, or alcohol use disorder, and we put them in treatment, and they do well, then they leave treatment, and they do poorly or they relapse, we say the treatment didn't work. So we're holding these two illnesses, which on many respects are very similar. We're holding them to different standards. Okay, next up, disordered brain reward circuitry. Okay, so this is where I'm gonna get as science geeky as I can here. But I think it's important because it's our expanding understanding of the disordered brain reward circuitry around addiction, which has really changed the view of addiction in favor of viewing addiction as a disorder that's not just a spiritual or moral disorder, but one that actually has real biological underpinnings. So whenever I've given this talk, or whenever I've talked with people about this, I've had many people who have always said, their favorite slide is the rat slide. Okay, so here's the rat slide. Here's a picture of... I presume this is a rat, I don't know. But it's an old picture I presume this rat is not around anymore. But this is a picture from a study, or representative of a study that team of researchers did, Olds and Milner were their names, and they did a series of... It wasn't just one study, but they did a series of different studies back in the 50s. And what they were trying to do was at that time in the 50s, we still really didn't know a lot about the brain and how it worked and where different things happen in the brain. But we had glimpses, we had a sense that there were different parts of the brain that control different things. And what Olds and Milner were really interested in figuring out was, well, what about reward? The experience of reward is something that is universal among all creatures. And, it seems to be something so fundamental that they really wanted to understand like, is there a part of the brain that controls reward? Well, so what they did was, the now famous experiments where they cut open the rats heads, and they put electrodes in different parts of the rat's brain. And the rat had the option of hitting a button that would provide an electrical impulse to the part of the brain where the electrode had been placed, or hit another button and get food. And they put this in different parts of the brain. And through that, what they were able to find out where that there were certain parts of the brain that when the rat learn pretty quickly, if you hit that button, that it feels really bad, and never do that again. And just hit the other one, once they learn that the other one provides food, that's all they did all day long, is just hit the one for the food. Well, they also stumbled on a deep old, calling it old, they didn't know it was old at that time. But evolutionarily, it's an old deep part of the brain, they got the electrode in there. And at that point, what they recognized was that the rats, when given the option of stimulating that part of the brain through that electrode, would choose to do that over and over and over again, 1000s of times a day, even at the expense of eating, drinking, and eventually dying. So they have stumbled on the idea that whoa, this is the reward center of the brain. So I wanna take a look at that. And kind of figure out subsequent to these studies, we've got a much better idea of what's actually going on in that part of the brain. So here's a very complicated diagram that I was very proud that I spent, I don't know how many hours trying to figure out how to make this work. But the idea here is that for those of you that are not familiar, this is sort of a cartoon depiction of two neurons. You can imagine that, in your brain, there are billions of neurons that make trillions of connections between these neurons. This is just a representation of two neurons, and their orientation to one another. And what I'm trying to highlight here is on one hand, blowing up this area between the neurons. The neurons don't actually touch one another, there's a space between them. A carefully monitored, a carefully oriented space between the two. And when a signal comes down one neuron, the neuron on the left, well, electrical signal propagates down the neuron, it gets to the end of that neuron, adjacent to that empty space. And if it wants to communicate to the next neuron over, what it does is it releases chemicals, little spurts of chemicals into this space, which is called the synaptic cleft. And those chemicals traverse or they move across that space to receptors on the other neuron, where when that neuron recognizes that, whop, something just tickled my receptors here, it then propagates a signal further down the line. And that's going on all the time. While you're asleep, or you're awake, these communications are happening between neurons. Maybe not so much happening right now, as you're starting to fade off, listening to my talk here. But the idea being that this is happening all the time. Now, there's lots of different kinds of chemicals. The neurons use a lot of different kinds of chemicals to communicate with one another. You've probably heard of these, and I'm not gonna go through great detail here. But some of these might sound familiar, and that's why I'm mentioning them, things like serotonin, norepinephrine, glutamate, GABA, endorphins, endocannabinoids. And then, the one that is of most interest here is one that is called dopamine. Dopamine is the chemical that we now know is largely responsible for communication between those neurons in that deep old reward part of the brain. So there's a deep old part of that brain where the neurons are responding and communicating with one another using dopamine. So, not surprisingly, if you do things that cause a release of dopamine in that part of the brain, it leads to the experience of reward. And how fundamental is this? Well, it's so fundamental that my colleague, Cory Waller, he describes this in much more engaging way than I ever could. So I encourage you to take a look at he's got a number of YouTube videos. With his permission, I've included kind of one of the general points that he makes here, which is that, what do we need for survival? Fundamentally, we need food, water, and we need dopamine. We need to be able to have a mechanism for recognizing that there's something good that we just did or experienced. And doing it again. Think about it this way. So I'm really hungry, and I eat a bowl of spaghetti. I happen to really like spaghetti. So to me, this is really rewarding, for other people, maybe it's not. But nonetheless, you're hungry, eat a bowl of spaghetti. You need to know, you need to catalog where was I when I got the spaghetti? Who was I around? How did I get there? You need to remember, hey, spaghetti was good. When I feel hungry, if I eat spaghetti, I will feel better. I need to remember to do that again. So in other words, when I'm hungry, and I eat some spaghetti, there's a little release of natural dopamine and that reward part of the brain that says, okay, pay attention, figure out how to get back here. And when you get there, get ready to eat. That's the whole sort of Pavlov, when you get there, you start to salivate, you start to prepare to get ready for eating. So again, if you didn't have a mechanism to kind of alert the body, to alert the brain that this is a good thing, and you need to do it again. If you didn't have that mechanism, every time you were hungry, you'd have to figure out what do I do about this? And every time you'd have to say, oh, well, I'll sample this dirt. Okay, no, that didn't help. I'll sample this cardboard. No, that didn't help. Oh, spaghetti, that works. So in other words, it's fundamental just like water, if you don't have water, if you don't have air, if you don't have food, you can't survive. Similarly, if you don't have a mechanism for recognizing something that you should be doing again, and reward from that, then you wouldn't be able to survive. So, why am I spending all this time on this? Because I wanna highlight again, what we know is that there's this reward part of the brain, this sort of centrally located deep old evolutionary part of the brain that, if it gets stimulated, it will cause a release of dopamine in that part of the brain, which will cause the organism to experience reward. So that's fine and dandy, if you're eating a bowl of spaghetti. Problem is that in nature, there are other things that can, if ingested, if taken into the body, can also cause or command, that part of the brain to release dopamine. So all drugs of abuse, whether it's nicotine, whether it's marijuana, whether it's alcohol, whether it's methamphetamine, all of these either directly or indirectly, cause the release of dopamine in this reward part of the brain. And typically, they cause a release of dopamine far in excess of what you could possibly hope to achieve by something natural, like having a bowl of spaghetti. When dopamine is released, as I mentioned before it primes the brain. It says, woof, pay attention to everything you're doing. Where are you? What are you doing? You need to get back here and do this again. The more rewarding the experience is, the more your brain wants to pay attention to how you got there, remembering where you were, so that you can do it again. So not surprisingly, and I love to put this up on my slides. You have to kind of highlight this. And again, this is also reflected in some of the talks of Corey Waller, Dr. Waller to put it in perspective. On a normal day you're walking around, you have three meals, whatever it might be, you're always gonna be releasing dopamine at different times during the day. And on a normal day, you might be releasing about 50, let's say. I'm gonna leave the units out of this, but you're gonna be releasing about 50 of dopamine. A really great day like you won the lottery, maybe release 100. So think about that, like you win a lottery, you think that's a very rewarding thing to have happen. Maybe your top end of that is about 100. When you have sex, it's a little bit less than a lottery apparently. Again, they did these studies on rats, I don't know how they determine sort of necessarily, how to distinguish between the lottery and sex necessarily, but nonetheless, sex very rewarding. Maybe about 90 of dopamine gets released in that reward part of the brain. So let's put this in context. If I was teaching this live, I would be asking people for some suggestions around how much dopamine do you think gets released when someone smokes some ice? Well, about 1100. Okay, so put that in perspective. Sex is about 90, winning the lottery about 100, methamphetamine, about 1100. Okay, so and back to what I said before, in recognizing that the magnitude of dopamine release, also will determine and will dictate sort of how good it feels on one hand, and then also rewiring the brain to pay attention to that, to get back, they're really kind of hyper focusing, well, that was rewarding, do that again. So it kind of for me, it puts in perspective, kind of the power of what's going on when somebody uses methamphetamine. And why it becomes so much of a habit so quickly is because that reward is so astronomical in relation to what happens with individuals who are getting natural releases of dopamine for various daily activities. So that being said, I wanna pivot from this and talk about well what happens in time? So you continue to use methamphetamine, you continue to drink alcohol, what happens? So in the beginning, your continued use is driven by the fact that you like it. The reward of drinking in the beginning is great, you like it, you feel better. Over time, though, what ends up happening is that your body adjusts to the alcohol, your body adjusts to the methamphetamine and you never get back to that original high, that original sort of euphoria that original reward that you experienced. So on one hand at a certain point, over time, you start to move the liking it curve, so to speak, starts to drop off and you start to get less reward because your body is adjusting, your body doesn't wanna have that much dopamine released. But insidiously, what's happening at the same time, though, is that your body is saying but I really want that reward. So that's where craving comes in. And you can see sort of in this very complicated graphic on one hand liking it, the reward aspect of most drugs starts to taper off to different extents, while at the same time the craving or wanting more of the substance escalates. For free, localized education and training designed to meet your needs, contact the Opioid Response Network.

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