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Pathological Drug Dependence and Its Treatment. Carlton Erickson, Ph.D. Director, Addiction Science Research and Education Center University of Texas at Austin, USA APIA-Singapore, 2004. RESEARCH VALIDITY ESTIMATE (RVE). (A Thoughtful Appraisal of High-Quality Scientific Research).

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pathological drug dependence and its treatment

Pathological Drug Dependence and Its Treatment

Carlton Erickson, Ph.D.

Director, Addiction Science Research and Education Center

University of Texas at Austin, USA

APIA-Singapore, 2004

research validity estimate rve

RESEARCH VALIDITY ESTIMATE (RVE)

(A Thoughtful Appraisal of

High-Quality Scientific Research)

High RVE

• many large, well-controlled studies

• replicable results

• much peer-reviewed, published literature

Low RVE

• few replicable studies

• highly speculative results

• little peer-reviewed, published literature

100

- 0

the essential feature of dependence is impaired control
The essential feature of dependence is impaired control
  • Two components (Ch. 2, Big Book)
  • 1. loss of control (within an episode)
  • 2. inability to abstain (between episodes)

60

model of impaired control
Model of Impaired Control
  • • Circuit #1: LIKE (pleasure) circuit.
  • • Circuit #2: WANT (desire, urge) circuit.
  • Robinson and Berridge, 1993

MFB Circuits

model of impaired control1
Model of Impaired Control
  • • Circuit #1: LIKE (pleasure) circuit.
  • • Circuit #2: WANT (desire, urge) circuit.
  • • Circuit #3: NEED (pathological desire, demand) circuit. This is associated with sensitization (severe dependence).

MFB Circuits

70

features of the need circuit
Features of the “Need Circuit”
  • • We know where it is (MFB)
  • • How does it become sensitized?
  • • Some people talk about an “addictive switch” - is this it?
  • • Let’s look at the neurochemistry
the mesolimbic dopamine system model of impaired control a k a medial forebrain bundle mfb
The Mesolimbic Dopamine System*Model of Impaired Control___________________* a.k.a. Medial Forebrain Bundle (MFB)
dependence brain areas
“Dependence” Brain Areas
  • • mesolimbic dopamine system
  • • “key elements of a basal forebrain macrostructure”
  • extended amygdala (Koob)
  • - central nucleus of amygdala
  • - bed nucleus of the stria terminalis
  • - transition zone, medial (shell) of NAc

60

medial forebrain bundle
Medial Forebrain Bundle
  • • ventral tegmental area (VTA)
  • • (lateral) hypothalamus (LH)
  • • nucleus accumbens (NAcc)
  • • frontal cortex (FC) - key portions
  • - prefrontal cortex (PFC)
  • - orbitofrontal cortex (OFC)

95

drugs associated wth neurotransmitters
Drugs Associated wth Neurotransmitters
  • Why do people have “drugs of choice”?
  • • Dopamine - amphets, cocaine, ETOH
  • • Serotonin - LSD, ETOH
  • • Endorphins - opioids, ETOH
  • • Gamma-aminobutyric acid - benzos, ETOH
  • • Glutamate -ETOH
  • • Acetylcholine - nicotine, ETOH
  • (Marijuana?)

70

what goes wrong with the neurotransmitter system s

What Goes Wrong With The Neurotransmitter System(s)?

• genetic “malfunctions”?

• drug-induced changes?

• other aspects of the

environment, besides drugs?

60

genetics of alcohol dependence
Genetics of Alcohol Dependence
  • • family, twin, & adoption studies
  • • “the tendency to become alcohol dependent is inherited”
  • • major question: what is passed from parent to child?
  • • alcohol dependence (perhaps other dependencies?) is polygenetic!

80

rationale based on genetics

Rationale Based on Genetics

abnormal genes abnormal proteins

abnormal transmitter synthesizing enzymes

abnormal transmitter breakdown enzymes

abnormal receptors

neurotransmitter dysfunction in the pleasure pathway

impaired control

90

a brain chemistry disease
A Brain Chemistry Disease!
  • • addicting drugs seem to “match” the transmitter system that is not normal
  • • cases range from mild to severe
  • • detox is the first step, followed by accessing the “wreckage of the past”
  • • methadone and nicotine maintenance is evidence that some people require a chemical to overcome the non-normal transmitter system

80

today s options it s all about options
Today’s Options (It’s all about options….)
  • • traditional: 12 step programs (abstinence)
  • • talk: inpatient/outpatient/aftercare
  • • misunderstood: harm reduction, MM
  • • new: brief motivational counseling, CBT, MET, SO-involved therapy, vouchers
  • • medical tx: new medications to enhance abstinence - anticraving meds, methadone, buprenorphine, vaccines
  • (MM= Moderation Management, CBT= cognitive behavioral therapy,
  • MET= motivational enhancement therapy, SO = significant other)
newer medications
Newer Medications
  • • naltrexone (ReVia) - alcohol
  • • ondansetron (Zofran)* - alcohol
  • • acamprosate (Campral)* - alcohol
  • • topiramate (Topamax)* - alcohol
  • • buprenorphine (Subutex) - heroin
  • • bupropion (Zyban) - nicotine
  • *Not yet approved for dependence treatment
question
Question:
  • What is the similarity between behavioral (talk) therapies and pharmacotherapies in the waythey work?
  • • grief • anger • learning
  • • talking to others in an
  • emotional group setting?
new brain scan research
New Brain Scan Research…
  • • Psychotherapy and meds work on the basal ganglia in treatment of depression (Martin et al., 2001)
  • • CBT and meds work on the same brain areas in treating social anxiety (Furmark et al., 2002)
  • • CBT appears to modify “bad circuits” associated with anxiety disorders (Paquette et al., 2003)

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