The science and spirituality of addiction
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The Science and Spirituality of Addiction . Assoc Professor Alan Gijsbers Addiction Medicine RMH President ISCAST Australia. Drug Dependence Comparing ICD-10 and DSM-IV Criteria. In common Withdrawal, tolerance and salience ICD-10

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The science and spirituality of addiction

The Science and Spirituality of Addiction

Assoc Professor Alan Gijsbers

Addiction Medicine RMH

President ISCAST Australia


Drug dependence comparing icd 10 and dsm iv criteria

Drug Dependence Comparing ICD-10 and DSM-IV Criteria

  • In common

    • Withdrawal, tolerance and salience

  • ICD-10

    • Rx withdrawal, compulsion, narrowing of repertoire, early relapse

  • DSM-IV

    • Lack of control 3 (greater use than intended, unsuccessful reductions, time on activity), use despite damage due to use


Science is more than phenomenology

Science is More Than Phenomenology

  • Accurate observation leads to hypothesis testing especially asking the question,

  • Why is it so?

  • This leads to some theories about mechanisms, which if tested and found to be robust, become the established explanation.


Mind altering drugs

Mind-altering Drugs

  • Pleasure Effect

    • Drugs of addiction enhance the limbic system (pleasure centre) of the brain.

    • “Artificial instant chemical pleasure”

  • Anaesthetic Effect

    • “...The need for chemical vacations from intolerable self-hood and repulsive environments will undoubtedly remain...”

      (A Huxley, 1953)


Neurobiological circuits in addiction

Neurobiological Circuits in Addiction

“Circuits that serve to color an experience with emotion and direct the individual’s response to rewarding stimuli, including food, sex and social interaction.”

Nestler EJ, Malenka RC. The addicted brain.

Scientific American. March 2004;290:78-85


Reward pathways

Reward Pathways

Glutamate

Excitatory Input

Enkephalin or

Dynorphin

Inhibitory Neuron

k Opioid

Receptors

Dopamine Receptors

Enkephalin

Inhibitory

Neuron

Dopamine Neuron

GABA

Neuron

REWARD

m Opioid

Receptors

GABA-A Receptors

GABA Inhibitory Feedback

Presynaptic

Opioid

Receptors

(m, d?)

GABA

Inhibitory

Neuron

Ventral Tegmental Area

(VTA)

Nucleus Accumbens

(NAc)


Addiction more than just reward

Addiction – More Than Just Reward?

  • Not just the pursuit of pleasure

  • But a drive to use – cravings and compulsions

  • Add drive, control and memory to the basic reward mechanisms


The science and spirituality of addiction

Localization of Addiction PathwaysVolkow ND. Fowler JS. Wang GJ. The addicted human brain: insights from imaging studies. [Review] Journal of Clinical Investigation. 2003;111:1444-51,

  • Control – prefrontal cortex and the anterior cingulate gyrus

  • Drive - Orbito-frontal cortex

  • Reward – Nucleus accumbens and the ventral pallidum

  • Memory – Amygdala and hippocampus


Integration of pleasure pathways

Integration of Pleasure Pathways


Not all brains are the same

Not All Brains Are the Same

  • Varying responses to post-anaesthetic analgesia

  • Even those pain-killers that give pleasure do not necessarily lead to addiction

  • Not many patients in palliative care develop tolerance

  • Not all chronic pain patients develop tolerance


Different responses to acute cocaine in non addicted subjects

Different Responses to Acute Cocaine in Non-addicted Subjects


The full range of issues

The Full Range of Issues?

  • Emotional circuits

  • Evolved to enhance relationships and social survival

  • Emotional dysregulation and interpersonal ineffectiveness seem to be dominant issues in patients with addictions

  • Emotions may even be more important than cravings


I don t drink because i have cravings

I don’t drink because I have cravings...

“...I drink because I am angry, or I am pissed off...”

“...I drink because the pressure of work is too much....”

“...I drink because I want to get up my partner’s nose...”

“...I drink to drown the memory of my abuse...”

“...I drink to shut up the committee in my head...”

“....I drink to relax...”

“...I dunno, I just do.....”


Vaillant s positive emotions

Vaillant’s Positive Emotions

Faith, love, hope, joy, forgiveness, compassion, awe and mystical illumination are important limbic system drivers of human flourishing

Vaillant GE. Spiritual Evolution: how we are wired for faith, hope and love. Broadway books, New York. 2008.


Positive emotions

Positive Emotions

  • Are parasympathetic and soothing as opposed to the negative emotions which are sympathetic and arousing

  • Are long-term and reach out

  • Negative emotions are immediate and protective

  • Positive emotions create relational bonds which build community rather than the negative emotions which protect the immediate individual


Emotions

Emotions

Humans thus seen are members of community rather than individuals and the emotions (especially the positive emotions) are designed to build community and the individual in that community


The science and spirituality of addiction

Thus

Emotions are not just to be avoided but essential to being human

Emotions predate verbal reasoning

Vaillant then makes much of the spirituality of the positive emotions in contrast to the barren rationalism of fundamentalism

Limbic is lyrical: Lexical is lame


Kandell s model

Kandell’s Model -

  • Neurology is a function of gene expression, but gene expression changes according to mental (learning) input.


The science and spirituality of addiction

WHO MODEL OF DRUG USE

SOCIAL AND INDIVIDUAL CONSEQUENCES

SOCIAL AND INDIVIDUAL ANTECEDENTS

Aversive Consequences

e.g. toxic effects reduced drug effect

organic damage psycho-social dysfunction

Distal Antecedents

e.g. peer groupsfamily interactionsparental drug use

Immediate Antecedents

e.g. licensing lawssocial pressuresavailabilitydemographic variables

AvoidanceLearning

SOCIAL

Tolerance

Dispositionto usedrug

Drug Use

Neuro Adaptive State

Distal Antecedents

e.g. early learningdrug experiencegenetic endowmentdevelopmental events

Immediate Antecedents

e.g. mood stateswithdrawal statesexpectations

Withdrawal Symptoms

INDIVIDUAL

ApproachLearning

Reinforcing Consequences

e.g. mood enhancement psycho spcial facilitation avoidance of relief of withdrawl symptoms


Summary of the science

Summary of the Science

  • Addictive behaviours

  • Mind-altering drugs affecting the reward mechanism

  • Drive, reward, memory and control

  • Heterogeneity of the brain

  • Complexity of neuroscience

  • Emotions and relationships

  • Regarded by some as spirituality....


Spirituality

Spirituality

  • Left brain definition of right brain activity [limbic activity]?

  • Describe the indescribable?

  • Raises questions of the scientific evaluation of what’s going on!


The science and spirituality of addiction

Spirituality Publications 1975–2001


The science and spirituality of addiction

Addiction and Spirituality Publications 1981–2001


Spirituality1

Spirituality

“Spirituality simply means the direct experience of something special in life and living.”- S.Biddolph


Domains of spirituality cch cook addictions 2004 99 539 551

Relatedness

Transcendence

Humanity

Core/force/soul

Meaning/Purpose

Authenticity/Truth

Values

Non-materiality

(Non)-religiousness

Wholeness

Self-knowledge

Creativity

Consciousness

Domains of SpiritualityCCH Cook. Addictions. 2004;99:539-551


Spirituality as drive life

Spirituality as Drive/Life

  • Spirit = Breath = Life = Liveliness= Enthusiasm

  • Spirited person, spirited defence, spirited horse

  • Inspired

  • Expired

  • Dispirited


Eudaemonia

Eudaemonia

  • Eu = balance

  • Daemon = One's genius; a tutelary spirit or internal voice; as, the demon of Socrates. [Often written d[ae]mon.]drive

  • Eudaemonia = Balance of the drives = Aristotle’s ideals for which one strived

  • Addiction could then be described as dysdaemonia (!)


Spirituality2

Spirituality

  • Meaning

  • Purpose

  • Relationships


Relationships

Relationships

  • To self

    • Insight

    • Acceptance

  • To the environment

    • Which feeds and breathes us

    • Which touches us aesthetically

  • To other humans

    • Partner

    • Family

    • Friends

    • Community

    • Society

    • Enemy

  • To the Higher power

    • Imago dei

    • Strength [spirit] to live


Spirituality3

Spirituality

  • Meaning Faith

  • Purpose Hope

  • Relationships Love


Faith

Faith

  • Asking what are the core understandings that shape a person’s attitudes to life.

  • Spiritual attitudes are sometimes shaped by a person’s faith in God, but there are other ways of expressing a person’s core beliefs and attitudes

  • Modern secular society however discourages the exploration of these dimensions (Taylor C, Ethics of Authenticity).


The science and spirituality of addiction

Hope

  • Frankl’s work, relationships and suffering.

  • Aristotle’s pursuit of the goods – eudaemonia Taylor’s Hypergoods – the core commitments which shape other commitments.

  • Without meaning and purpose life if hopeless, lacks momentum, and lacks drive.

  • Addiction is about the pursuit of immediate pleasure irrespective of the long-term consequences.


The science and spirituality of addiction

Love

  • Self

  • Others

  • Natural environment

  • A higher power

  • Supernatural forces

  • One of the dimensions of addiction is alienation and recovery focuses on reconnection


What about

What About?

  • Truth...(embodied and personified)?

  • Justice and righteousness?

  • Failure and forgiveness?


Spirituality4

Spirituality

  • Drive to life and liveliness

  • Meaning purpose and relationships

  • Truth, justice and mercy


Spirituality and religion wr miller

Aspect of the Individual

Difficult to delimit – transcendent

Can be stifled by religious rituals and practices

Socially organised structure

By definition boundaried - beliefs, practices, governance and rituals

Spirituality and Religion (WR Miller)


Contrast religion and spirituality

Contrast Religion and Spirituality


Spiritus contra spiritum

Spiritus Contra Spiritum

  • “You see, "alcohol" in Latin is "spiritus" and you use the same word for the highest religious experience as well as for the most depraving poison. The helpful formula therefore is: spiritus contra spiritum.”

    CG Jung Letter to Bill W http://www.sober.org/CarlJung.html


Flesh vs spirit

Flesh vs Spirit

  • Dominant ethic in Pauline writings (Rom 6-8, Gal 5:1-23).

  • Spirit – human spirit or Divine spirit indwelling humans?

  • Divine power to put to death the deeds of the flesh and to live a new life of freedom and love.

  • Fruits of the spirit contrasted with the deeds of the flesh.


Aa spirituality

AA Spirituality

  • Based on the Buchman’s Oxford Group Movement (Moral Rearmament) of the 1930’s

  • Buchman came into deeper experience of God at a Keswick Convention in about 1909

  • No doubt initially Christian based

  • Current tension between a generic spirituality on the one hand and the Christian Right on the other


Aa spirituality 12 steps

Powerless

Power available

Surrender to that Power

Moral inventory

Admit wrongs

Ready to remove defects

Ask Him to remove shortcomings

List persons harmed

Make amends

Continue inventory

Prayer to improve conscious contact

Spread message of spiritual awakening

AA Spirituality – 12 Steps


Spirituality and our patients

Spirituality and Our Patients

  • The spirituality gap

  • Respect for the patient’s integrity

  • Aware of need and hence the ability to meet it

  • Start them on a journey looking at meaning, purpose, power, relationships

  • Compassionate care expresses our spirituality


D a spiritual change

D&A Spiritual Change

  • From salience to perspective

  • Bondage to freedom

  • Powerlessness to power

  • Indiscipline to discipline

  • Self-centredness to other-centredness


D a spiritual change1

D&A Spiritual Change

  • Fear to trust

  • Sinfulness to goodness

  • Disorder to order

  • Despair to hope

  • Grace: an unconditional acceptance yet a maintenance of standards


From my practice

From My Practice

“You know after your session [on spirituality] I realised I was totally dispirited...I have no spirit...can you help?”


That afternoon

That Afternoon

  • Found a book in a secular bookshop Secrets of a Bullet Proof Spirit.


Conclusion

Conclusion

  • Science and spirituality interact in the field of addiction and a comprehensive program of recovery calls for a radical re-ordering according to a patient’s core values and hyper-goods. It also calls for relational repair. Spiritual input is thus crucial as people work through their pain and reach out for radical healing.


Harm minimization vs abstinence

Harm Minimization vs Abstinence

  • Abstinence from mind-altering drugs is the bottom line in addiction therapy

  • Harm minimization recognises the reality of ongoing drug use and seeks to reduce the degree of harm causes by use eg

    • Substitution pharmacotherapy

    • Needle and syringe exchange programs

    • Injecting rooms

    • Supply of clean opioids in a supervised situation

  • Abstinence is the best form of harm minimisation but carries greater risk of significant harm


Dole nyswander s original trial

DOLE & NYSWANDER’S ORIGINAL TRIAL

NEJM 1969;280:1372-1375


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