neurobiology of substance use disorder · • practices acceptance, compassion and cooperation •...

Neurobiology of Substance Use Disorder

INTEGRATED ADDICTION TREATMENT ADDRESSING THE COGNITIVE, SOMATIC, BEHAVIORAL, NEUROBIOLOGICAL AND SOCIOECONOMIC ROOT CAUSES OF ADDICTION

© The Haven Model, 2018

How Addiction Develops:

Trauma

Less than adequate nurturing in-uteroLess than adequate attachment 1st yearOn-going chronic trauma through out childhoodAcute traumatic experiencesEnvironment modifies geneticsDrugs change neuro-pathways

Neural Pathways Re-routed

Orbito-frontal Loop Disconnect

Deep Right Limbic System by-passedAmygdala over-sensitizedHippocampus compromisedImplicit trauma memories created vs explicit memories

Neurotransmitter Imbalance

Lower Serotonin Levels

Lower Dopamine LevelsToo little or too much NorepinephrineHigh Cortisol LevelsHigh Adrenaline LevelsLow GABA Levels

Unrelenting Pain

Neurotransmitter imbalance can result in debilitating pain:PhysicalPsychologicalEmotionalSelf-medicating and chemical coping begin

Dopamine-driven Behaviors

Need of system to create homeostasis and balance creates dopamine seeking behaviors.Under stress, these behaviors become obsessions and compulsionsADDICTION BEGINS


Early Childhood Trauma/SUD Progression

In-Utero:• Som atosensory D istress• Neura l path d isconnect

0-12 mos:• “Sense of Se lf” can’t deve lop• Traum a/Stress m em ories can’t re lease

• F ight/F light/Freeze experience is the norm

1-3 yrs:• Attachm ent patterns established:

• Dom inance, Dependence, D isordered• “Not Be longing” established• Superiority/Inferiority established

• No authentic sense of se lf

• Hard to m ake sense of experiences = traum a• Non-verba l: Language learning and understanding

Early Childhood:• Verba l: language integrated into thought process• No authentic sense of se lf• M ask/Persona created

• Core be lie fs, behaviors & em otions created by externa l experiences

• “Traum a Cluster” begins to deve lop:• Depression• Anxie ty• OCD

• PTSD• Suicida lity

Adolescence:• Black & white th inking established

• Perfectionism• Unrea listica lly h igh expectations

• Fee lings of sham e, guilt, hum ilia tion and re jection• Se lf-hatred, Se lf-loathing• Sense of not be longing re inforced

• Traum a C luster issues increase in intensity• Beginning of chem ica l coping/se lf m edicating

• Occasiona l re lie f drinking/using

• Increase in To lerance• Increasing dependence• Guilt

• Unable to d iscuss problem s• Persistent rem orse

• Loss of other interests

Young Adult:• No “Sense of Se lf”

• No re lease of traum a m em ories• Se lf-hatred, se lf- loathing

• Fee lings of sham e, guilt, hum ilia tion and re jection• Chronic stress/fight, flight, freeze• Hope lessness

• Escape from unceasing, pa infu l se lf-awareness becom es com pelling:

• Sleep

• Cutting/se lf m utila tion• Alcohol• Drugs

• Eating d isorder• Death

• Fam ily and friends avoided• Unreasonable resentm ents• Drinking/using w ith chronic users• Im pa ired th inking

Adult:• Obsessive drinking/using continues in vicious

cycles

• Unable to in itia te action• Fam ily, re la tionship, m oney and em ploym ent

troubles

• Unbearable em otiona l, physica l, psychologica l pa in


Early Childhood Trauma/SUD RecoveryBeginning of Chemical Coping/Self Medicating:

• Occasiona l re lie f drinking/using

• Increase in To lerance• Increasing dependence• Guilt• Unable to d iscuss problem s

• Persistent rem orse• Loss of other interests

• Escape from unceasing, pa infu l se lf-awareness

becom es com pelling:

• Sleep• Cutting/se lf m utila tion

• Alcohol• Drugs

• Eating d isorder• Death

• Fam ily and friends avoided• Unreasonable resentm ents

• Drinking/using w ith chronic users• Im pa ired th inking

• Obsessive drinking/using continues in vicious cycles

• Unable to in itia te action• Fam ily, re la tionship, m oney and em ploym ent

troubles• Unbearable em otiona l, physica l, psychologica l pa in

Process of Recovery:M onth 1

• Detox/M AT• Assess co-occurring m enta l illness

• Assess m edica l issues• Assess chronic stress

M onths 1 - 3

• Relaxed M uscle Body

• Create sa fe , com passionate re la tionships: increase sense of be longing

• Increase body awareness• Activa te right bra in

• “Sense of Se lf” Deve lopm ent• Create Hope

M onths 3 - 12

• Attachm ent Patterns• Core Be lie fs

• Spiritua l Se lf/M indfulness/Detachm ent• Em otions: M om ent of Choice

• Build ing a Tribe (re la tionships)

Year 2

• Superiority/inferiority• M ask/Persona or Authenticity

• Blk & Wht Thinking or Ra inbow Thinking• Se lf Acceptance

• Sham e

Consequences of Early Childhood Trauma:

• Co-occurring M enta l Illness

• Traum a m em ories not re leased• Chronic stress/fight, flight, freeze• Black & white th inking• Perfectionism

• Unrea listica lly h igh expectations• Fee lings of sham e, guilt, hum ilia tion and re jection

• Sense of not be longing re inforced• Superiority/Inferiority established

• Dim inished “Sense of Se lf” (don’t know who they

rea lly are)• Se lf-hatred, Se lf-loathing

• Attachm ent patterns established: Dom inance, Dependence, D isordered

• “Traum a Cluster issues m anefest

• M ask/Persona created

• Core be lie fs, behaviors & em otions created by externa l experiences, not interna lized

learning/deve lopm ent• Hope lessness

• “Traum a C luster issues increase in intensity


Create a Safe Relationship

Calm the Body

Activate the Right Brain

Integrate the Whole Brain and

Whole Body

Reframe & Release, Validate &

Support

Steps to Prepare Clients Neurobiologically


Create a Safe Relationship

Calm the Body

Activate the Right Brain

Integrate the Whole Brain and

Whole Body

Reframe & Release, Validate &

Support

Techniques to Prepare Clients NeurobiologicallyLimbic Resonance

Guided RelaxationMovement/Stretching

BreathworkTappingAcudetox

Rhythmic StimulationStorytelling

WritingRole-playing

Experiential Exercises

Continuous Check-in with Somatosensory

Experience

ChildWild WomanWise Woman


The Effects of Neurotransmitter Imbalance are Chronic and Cumulative:

Trauma Genetics & Environment

Opioid Use

In-utero

0-12 mos

12-36 mos

3-10 yrs

10-19 yrs

Adult

F/F/F constant state:Depression, anxiety, OCD, PTSD - severe

Low concentration ability, low attention span

Sense of Self under-developed

Low trauma release: low resiliency

Low confidence/self esteem

F/F/F sensitivity:Depression, anxiety, OCD, PTSD - probable

Ability to concentrate and focus

Sense of Self somewhat developed

Some trauma release: some resiliency

Low confidence/self esteem

F/F/F reaction to danger

Neurotransmitter balance

High ability to concentrate and focus

Healthy Sense of Self

Healthy trauma release:

High resiliency

Healthy confidence/self esteem

Not all addiction is the same; treatment needs are based on amount & length of trauma-based neurotransmitter imbalance.


Current Substance Use Disorder/Addiction Treatment

Reduce Stigma

Detox

MAT Post Acute Withdrawal

Current Treatment

Addiction is a Disease

• Not a choice• Punishment• Brain Pathways

Disconnected• Neurotransmitter

Dysfunction• Integrated Behavioral

Health Approach Required

Remove the Coping Chemicals

• Medical Detox Protocol

• Inpatient• Outpatient• Focus on Acute

Withdrawal Symptoms and Behaviors

• Integrated Behavioral Health Approach Required

Withdrawal Syndrome

• Relieve PAW Symptoms with Medication

• Vivitrol• Suboxone• Campral• Anabuse• Methadone• Naloxone• Reduces Relapse• Allows for

Treatment to be More Effective

• Go back to Work

Residential, PHP,Intensive Outpatient

• CBT• DBT• REBT• Trauma-informed

therapies• EMDR• Psycho-ed• Healthy activites:

hiking, exercise, swimming, yoga

• Art therapy• Music therapy• Psychodrama


Reduce Stigma

Detox

MAT

Post Acute Withdrawal

Current

Treatment

Medical Model for Substance Use Disorder/Addiction Treatment

Addiction is a Disease

• Not a choice• Brain Pathways

Disconnected• Neurotransmitter

Dysfunction• Integrated Behavioral

Health Approach Required

Remove the Coping Chemicals

• Medical Detox Protocol

• Inpatient• Outpatient• Focus on Acute

Withdrawal Symptoms and Behaviors

• Integrated Behavioral Health Approach Required

Withdrawal Syndrome

• Relieve PAW Symptoms with Medication

• Vivitrol• Suboxone• Campral• Anabuse• Methadone• Naloxone• Reduces

Relapse• Allows for

Treatment to be More Effective

• Go back to Work

MAT Post Acute Withdrawal

Current Treatment

Chronic Disease

Management

Residential, PHP,Intensive Outpatient

• CBT• DBT• REBT• Trauma-informed

therapies• EMDR• Psycho-ed• Healthy activites:

hiking, exercise, swimming, yoga

• Art therapy• Music therapy• Psychodrama

Treating the NeurotransmitterDysregulation

• Identify the Root Cause of Self Medicating Behaviors

• Calm Central Nervous System

• Activate Trauma Release

• Deactivate Mesolimbic Dopamine System

• Balance Neurotransmitters

• Socio-economic Factors

• Genetics• Environment


Implementation of a Neurobiologically-based Program

INTEGRATED ADDICTION TREATMENT ADDRESSING THE COGNITIVE, SOMATIC, BEHAVIORAL, AND NEUROBIOLOGICAL ROOT CAUSES OF ADDICTION


Recovery With Respect

• Addiction is a Treatable Disease Requiring Medical Science and Psychological Science Integrated and Applied

• Our Neurobiological Treatment Approach Addresses the Root Causes of Addiction

• Respect and Compassion


Recovery Treatment Neuroscience Primary Focus:

Week 1

• Detox/M AT• Assess co-occurring m enta l illness

• Traum a assessm ent

• Assess m edica l issues• Assess chronic stress

Months 1 - 3• Create sa fe , com passionate re la tionships:

increase sense of be longing (lim bic resonance)

• Relaxed M uscle Body• Increase body awareness

• Activa te right bra in• “Sense of Se lf” Deve lopm ent

• Create Hope

Months 3 - 24

• Attachm ent Patterns• Core Be lie fs• Spiritua l Se lf/M indfulness/Detachm ent

• Em otions: M om ent of Choice• Build ing a Tribe (re la tionships)

• Superiority/inferiority• M ask/Persona or Authenticity• Blk & Wht Thinking or Ra inbow Thinking• Se lf Acceptance

• Sham e

Current Process of Recovery Treatment:

Months 1 - 3• Transform ing event, lega l consequences, fam ily/friend,

u ltim atum , intervention, m edica l cris is, DCS invo lvem ent,

em ployer intervention• Reach out for he lp (only 13% reach out)

• Detox• M AT• Psychia tric assessm ent

• PHP assessm ent• Treatm ent; residentia l, PHP , IOP , OP (50% graduate)

On-going

• 12 Step, Ce lebrate Recovery, White B ison, SM ART• Aftercare P rogram

Jellinek Cur ve Progression of Recovery:

• Honest desire for he lp

• Told addiction can be arrested• Learns a lcoholism is a d isease• Stops taking a lcohol

• M eets form er addicts norm al and happy• Assisted in m aking persona l stocktaking

• R ight th inking begins

• Physica l overhaul by doctor• Spiritua l needs exam ined• Onset of new hope

• Start o f group therapy• Apprecia tion of possib ilities of new way of life

• Dim inishing fears of the unknown future• Regular nourishm ent taken• Return of se lf-esteem• Rea listic th inking

• Desire to escape goes• Natura l rest and sleep

• Adjustm ent to fam ily needs• Fam ily and friends apprecia te e fforts• New interests deve lop

• New circle of stab le friends• Rebirth of idea ls

• Facts faced w ith courage• Applica tion of rea l va lues

• Increase of em otiona l contro l• F irst steps toward econom ic stab ility

• Confidence of em ployers• Care of persona l appearance

• Contentm ent in sobrie ty• Rationa liza tions recognized

• Increasing to lerance• Group therapy and m utua l he lp continue

• Enlightened and interesting way of life opens up w ith road ahead to higher leve ls than ever be fore

Recovery Treatment Models


10 Truths of Having a Strong Sense of Self

v You know how to self-soothe yourself

v You keep promises to yourself

v You make your own decisions and hold your own counsel

v You have your own hobbies and interests that you pursue outside of your friends/relationship

v You can set boundaries on other people’s demands on your time, energy and resources

v You can make your own life-choices without the need for constant reassurance and approval

v You act authentically, not how you “think” you should act

v You remain a leader of yourself no matter where your followers go

v You take full responsibility for your life

v You know yourself enough to be able to decide how true an insult is


Unhealthy Sense of Self Healthy Sense of Self

• feels not good enough• uses anger to control other people• uses substances to comfort, avoid, numb, escape or distract from

uncomfortable feelings• is reactive, dramatic, defensive or easily triggered• repeats problematic behaviors that cause suffering• fights reality or wishes it away• refuses to face fear and challenges• believes that happiness only occurs when there’s no emotional pain or

fear• often feels overwhelmed by emotions• expects perfection• personalizes what others say and do• uses blame, avoidance, criticism or denial to deal with difficult situations• feels a sense of entitlement or grandiosity• requires a lot of emotional validation and feels angry, anxious or

depressed if it’s not available• is unable to demonstrate compassion or understanding towards people

who hold different opinions or beliefs• feels a sense of competition with others• feels jealous or judgmental of other people’s success• avoids making apologies and taking responsibility• needs to be right and feel superior• is chameleon-like; changing to fit in or fulfill a role

• reflective, responsive, and resourceful• thinks in terms of possibilities• turns to healthy coping mechanisms during times of stress• optimistic and grateful• can understand, appreciate, and validate perspectives that are different• strong sense of capability and security• constantly growing in strength, confidence, and ability to handle

triggering situations• can tolerate discomfort and regulate emotions• curious• does not personalize what others say or do; maintains a healthy

perspective• embraces the imperfections of self, others and life• takes ownership of problems; let’s other people be responsible for

themselves• understands the difference between wants and needs• practices acceptance, compassion and cooperation• acts with integrity and authenticity• can discern between what can be changed and what can’t be• has a strong sense of personal power• is adaptive and flexible• feels worthy and deserving of good things• can give and receive love and appreciation• is aware of interests, desires, and talents

Sense of Self


What is Compassion?

Recovery with Respect


What is Compassion?


Wounded Healer

“Only wounded healers can heal, and only they can heal to the extent that they have healed themselves.”

Carl Jung


Trauma InformedTrauma changes the brain. These changes can make everyday life unbearable. The pain of merely existing affects people:• Physically• Emotionally• Psychologically• Spiritually

Over time, the person can’t even tell where the pain is coming from, it’s all one exhausting experience every day and night.


Recent Brain Science Enhances Psychotherapy

Old Paradigm1. An exper t authority2. Clients are patients with

psychological disorders3. A component approach4. Focus on symptom

reduction5. Remove negativity6. Medical way to treat mental

health

New Paradigm1. A wounded healer2. Clients are wor thy human

beings3. A holistic approach4. Focuses on both healing &

flourishing5. Embraces negativity6. Nature’s way to mental

health


This suffering is unrelenting, never lets up, it accumulates and gets worse over time.

Neurotransmitter Imbalance Can Cause Unbearable Physical, Psychological and Emotional Pain.


Neurotransmitter Imbalance Results in Psychological & Physical Pain:

LOW SEROTONIN

Fight/Flight/Freeze as natural stateAnxiety/OCD/PTSD/DepressionLowered ability to concentrate/focus, Poorly organizedUnable to release traumaDifficulty managing emotionsSense of not belonging anywhereNo sense of Self: Lower self-esteem, Lower self confidence

LOW DOPAMINE

Low pain threshold/chronic painDepressionLow ability to concentrate/focusLow energy/fatigueLow enjoyment/low interest levelsSocial withdrawalEmotional sadnessNo purpose or meaning in life


The person suffering is not enjoying themselves, they are self-medicating their pain.

They are not “chasing a high” they are trying to feel normal

The cycle of pain/suffering/relief begins and continues despite negative consequences.

The person who is self-medicating does not “choose” to continue, they themselves cannot explain their own behavior.

Substance Use Disorder is NOT About“Chasing the High”


The Most Common Reasons Given for RelapsingPHYSICAL PAIN/SUFFERING

“I’m in pain all the time, my whole body hur ts, its taken over my life, nothing helps”

“I can’t leave my house without something to control the panic”

“I am exhausted every day, I need to sleep, I lay awake all night worrying”

“I feel so agitated and angry, I am going to lose my job if I can’t control this”

“I have a headache constantly, nothing can relieve the pain except the drugs”

When I stop using, I get so sick I can’t function and I just want to die”

TRAIT/STATE HOPELESSNESS

“I hate myself”

“No one wants me around anymore”

“I can’t do anything right”

“I don’t remember what I did yesterday, or the day before, my mind is gone”

“I don’t care anymore, it’s not wor th it”

“F#*% it”

“I will never be good enough”

“There’s no hope for me, everyone is better off if I’m dead”


neurobiology of substance use disorder · • practices acceptance, compassion and cooperation •...

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