In the beginning, you take methamphetamine, you activate this reward pathway. You keep taking the methamphetamine because you still wanna get that reward, but what you find is that in time you get less and less reward, but you want that reward so you're craving increases. And craving can have specific triggers, can have specific cues, specific things that can make it escalate. So, for example, if someone who used methamphetamine for 10 years, then stopped for a couple of years and then is exposed to a small amount or uses a small amount of methamphetamine, they'll tell you, they don't know how they can't give you a good play by play, but they went from that one brief relapse or that one brief use event to full-fledged daily use pretty quickly because the craving is primed by having that small dose, right? So they were abstinent from methamphetamine for several years, they get a small dose of methamphetamine, all of a sudden the craving becomes woo through the roof and they start using consistently again. That's kinda how they go from a lapse to a relapse. There's cue induced triggers. So you're an alcoholic or you have an alcohol use disorder and you find yourself walking past the bar that you used to drink out with your friends 10 years ago. And all of a sudden you find yourself in the bar, sitting at the bar. Next thing you know, you've got a drink in front of you. This is the sort of what a lot of people with substance use disorders will describe as sort of like they go into autopilot. And Alcoholics Anonymous, a 12-step program has known this for a long time. And they refer to this as people, places, things. That if you find yourself in an environment or around people that you used to use with, or that was associated with your old use, it actually primes you to use again. And then stress, both positive and negative stresses can cause craving to increase significantly. Okay, so I wanna pivot now to the last of my three parameters here, which is that addiction is or substance use disorder is a behavioral disorder. This is a very text heavy slide. And I wanna highlight here that according to our diagnostic manual, the DSM 5, we have 11 different criteria that we use to describe addiction or substance use disorder. So eight of these are behavioral in nature. And I'm highlighting this not because I want people to necessarily remember this, but I wanna kinda highlight the idea that our understanding of addiction over the last 30, 40 years has moved largely away from the idea that the severity of the illness is dictated by how bad your withdrawal is or how much your tolerance has escalated. So in our newer evolving conception of addiction, what we see is that the things that really are important in addiction, not the tolerance and withdrawal, are not important parts of addiction to certain substances, but what we tend to see is that the thing that really drives and the thing that really is causing the problems for most people are behavioral. That they lost control over the use of their substance. Their craving is one that sort of, I have there as sort of behavioral because craving often leads to loss of control. So technically, I don't have that kind of qualified as one of the eight of 11, so to speak here, but maybe we could say eight or nine of the 11 diagnostic criteria are behavioral in nature. So social impairment, failure to fulfill role obligations continued use despite these problems. Giving up on activities that they once enjoyed or found rewarding, they give up on all these things. This is a reflection in many respects of the behavioral component to addiction. So in many respects, we kind of recognize that we missed the boat around addiction if we're just focused on tolerance and withdrawal, because there's many people who do not experience significant tolerance or withdrawal from the substance that they're using, but have significant impacts on their life in terms of failure to fulfill a role obligations, et cetera. So another way of conceptualizing this, that role supervisor of mine, Jodi Suzuki, liked to kind of describe was as a behavioral disorder, we think of addiction and substance use disorder as the four C's, a loss of control, an increase in cravings, an increase in the compulsive use of the substance, and the escalation in negative consequences as a result of using the substance. So again, if you can't remember sort of like all of this sort of very techie language around sort of the behavioral disorder of addiction, think of the four C's. But again, kind of emphasizing the idea that these are the real things that we focus on in addiction treatment. And we also know that dopamine alone doesn't count for everything. So there is hope. And I'm gonna pivot a little bit here to talk about this. I love this cartoon because it highlights the idea that like the light goes on, I pull the lever, the food comes, it's a full life. Because that in real life, we found that the idea that if everything was just driven by dopamine, there are some things that tell us, or we have experience with that indicate that that's not entirely the case. So the two that I'm gonna discuss here briefly, and I'm just gonna go through these briefly are the rat park experiments and the Vietnam War study. So I'll start with the rat park experiments. So in the rat park experiments, what some research, and this is very controversial, you can read about it in New York Times, Washington, something or other it has been written about in a lot of different places. And it's been somewhat controversial. But it highlights something that I think is important to recognize even though there is some question about the sort of the veracity of the scientific method that was employed here. But the idea being that Olds and Milner, they put these rats in cages and gave them two options. They said, you can either hit this button and you get food, you hit this button and you get shocked in this part of your brain, right? Well, other researchers came along and said, well, that's great, but the problem is that rats don't live in cages, rats live in a highly complex social miliue. So how about we do the same experiment more or less, but we do it with rats in a more natural environment. And let's see what the impacts are. So what these individuals did is they took two groups of rats. They put one group of rats in cages with the option of two different waters to drink. One water had morphine in it, one water didn't. And they monitored those rats. And they said, how much of the morphine water did they drink relative to the normal water? And then they did it. The second group of rats were put in what they called a rat park. So, again, whatever rats like, I guess garbage cans and whatnot. But most importantly they were around other rats. They had distractions, they had other things to play with, I guess, if rats play, but they were in an environment that more closely mimicked what the natural environment might look like for a rat. And they looked at them and they offered them both, sort of morphine water versus regular water. What they found when all was said and done was that the rats that were in the park opted to drink the morphine water 19 times less than the caged rats did. And the thing I wanna highlight here is that the emphasis here on the fact that, wait a minute, maybe context matters. Maybe it's not just all about the dopamine release, but dopamine release is an important factor, but maybe it's just one of many other factors which might be contextual. So let's move away from rats and talk about people. So Vietnam War study. So many people may remember that in the Vietnam War, a lot of military personnel that were stationed in Southeast Asia had ready access to heroin. And a lot of military personnel got used to using heroin. This was so much so that this became a problem. And when we were trying to bring people back from Vietnam, the concern was, wait a minute, we've got a whole bunch of military personnel that are now consistently using heroin. We don't wanna bring them back to the US, back to the mainland, just to have them continue to use heroin back in the US. So they initiated a, this wasn't the official term, but I think in 1971 it become known as operation golden flow, which represent or is reflective of the fact that what the leadership did is they said, well listen, if you wanna come back to the US, if you're done with your tour and you wanna come back to the US, you just have to provide urine, that's negative for heroin. Now, again, hence the golden flow part of this. So now, if it was just about dopamine, what you would have expected would have been that people would be highly incentivized to produce a negative urine, just to get out of Vietnam and come back to the US. And that once they get back into the US, we would expect that many, or at least a vast majority of those people, if again, it was all dictated by dopamine, that many of those individuals would pick up their opioid use when they come back to the US. What they found is though that we studied this, we looked at them and we followed people. And what we found was that of the people that were active heroin substance use disorder people in Vietnam, when they came back to the US, only 5% of them used heroin within the first year back. So only 5% of the people that really had an opioid addiction in Southeast Asia, when you brought them back to the US, only 5% of them went back to using opioids. Again, if it was all about dopamine, that wouldn't make sense. So this is also highlighting the idea that if you disrupt the environment, if you change the environment and take someone literally out of war and put them in an environment where they're surrounded by things that they enjoy, people that they love, things that are familiar to them, that the urge to use, or that the triggers to use, or that the need to use can be mitigated. So again, a lot of what we do in addiction treatment focuses on how do we get people to get out of war and reorient their lives towards things where it's more conducive to not using. So how do we disrupt the environment of the individual who's using substances? So I'm gonna pivot just for a second, kind of out of this frame of mind into giving a nod here to the idea that one of the things that we also struggle with is looking at in terms of context, that a lot of individuals who have a co-occurring mental health issue, schizophrenia, bipolar, depression, anxiety, a lot of those individuals also meet criteria for substance use disorder. This particular slide, this is how SAMHSA displayed this data for many years now. The numbers change from year to year, but they always use these sort of two circles with the ven overlap. I don't know if it accurately represents, I feel like what most of us in clinical practice would describe, which is that almost everybody that has substance use disorder has some other co-occurring mental illness, whether it's full blown schizophrenia, or whether it's more of a general anxiety or worry that the overlap in these circles at least clinically seems to be much higher than this data would suggest. But even so, the overlap is significant. In particular, trauma and trauma related psychiatric illnesses tend to have such a profound effect on people in relation to the development, and then the sustaining part in relation to a substance use disorder. So again, we're just, I think now as a field overall, starting to really dive into and understand the far reaching consequences of trauma and trauma related disorders, and the impacts that they can have on behavior, thinking, and functioning, but suffice it to say, and it probably comes as no surprise to any of you listening to this, that people who have experienced trauma are at higher likelihood of also experiencing other mental health issues and other mental health symptoms, as well as substance use disorder symptoms and vice versa. People that have substance use disorders or people that have other mental health disorders are also at a higher likelihood of experiencing or witnessing traumas as well. So it's sort of a two way street in many ways. But I wanted to kinda highlight that relationship and the importance of trauma and the importance of being attuned to trauma as part of the context that can really matter when thinking about addiction. So what are some of the take home points from my ramblings of today? So some of the take home points are that people have a lot of preconceived notions about addiction, and it's good to acknowledge that, it's good to validate the fact that there's a very diverse set of ideas of what people have about addiction and substance use disorder. Addiction and substance use disorder is not a moral failing, it isn't glamorous, and it isn't just as simple as someone using a substance. Educating people about what we know about addiction can be a powerful means of countering stigma. Education. When looking at the literature around how do you counter stigma, how do you counter bias, most of the literature comes back and says, well, education and direct contact. So combination of sort of being taught about what you're seeing and then continuing to see it and engage is how you change your mind about stigma and biases. So get the terms correct. I know I've kind of used it interchangeably here that addiction and substance use disorder as opposed to substance abuse or saying addict or user, get the terms correct, substance use disorder really is the preferred term. If you're gonna use addiction, just be careful that you don't shorten that to addict. But generally speaking, if we have this talk in 10 years, my hope is that we're really just talking about substance use disorders at that point. Remember, addiction is a chronic relapsing medical illness, that is in part a manifestation of disordered brain reward circuitry, and it manifests itself symptomatically as a behavioral disorder. So addiction is the end product of a complex interplay between genetic, physiologic, environmental and social factors. And it is experienced by both those that suffer from it and all those around them. That's one of the features I think that's really unique. If you have a urinary tract infection, pretty much the only person that's bothered by the urinary tract infection is the person with the urinary tract infection. Addiction is unique in the sense that not only is the person who is suffering from the substance use disorder, suffering symptomatically, but it's experienced socially, it's experienced by everyone around them in addition to that. And finally, addiction is treatable and people do get better. So part of the goal of teaching is in the back of one's mind to be remembering and thinking about, well, if I'm gonna be trying to educate people about addiction, what would I consider to be a successful intervention? And I think that a successful intervention would be defined as somebody walks away from your talk with a sense of like, wow, I didn't know that about addiction. And what I didn't know about addiction leads me to feel like maybe there is more hope around treating addiction. If you plant that seed of hope, then people are more likely to wanna get more education and engage more around individuals with addiction and substance use disorders. For that, or on that note let's say, I am gonna draw to a close here, and I appreciate everybody's attention. For free localized education and training designed to meet your needs, contact the Opioid Response Network.

addiction

substance use disorder

reward pathway

craving

relapse