The Importance of The Importance of Knowing Addiction as a Knowing Addiction as a

Brain DiseaseBrain DiseaseCarlton Erickson, Ph.D.Carlton Erickson, Ph.D.

Director, Addiction Science Research and Director, Addiction Science Research and Education CenterEducation Center

University of Texas at Austin, USAUniversity of Texas at Austin, USA

APIA-Singapore, 2004APIA-Singapore, 2004

What IS addiction?What IS addiction?• • heroin addictionheroin addiction• • cocaine addictioncocaine addiction• • alcohol addiction (“alcoholism”)alcohol addiction (“alcoholism”)• • marijuana addictionmarijuana addiction• • amphetamine addictionamphetamine addiction• • nicotine addictionnicotine addiction

What IS addiction?What IS addiction?• • sex addiction??sex addiction??• • gambling addiction??gambling addiction??• • food addiction??food addiction??• • shopping addiction????shopping addiction????• • internet addiction????internet addiction????• • cell phone addiction????cell phone addiction????

A World ProblemA World Problem• • The ability to solve a world The ability to solve a world

problem is directly proportional problem is directly proportional to to our ability to define itour ability to define it..

• • Are we dealing with a Are we dealing with a problemproblem or or a a diseasedisease??

A World ProblemA World Problem• • The ability to solve a world The ability to solve a world

problem is directly proportional to problem is directly proportional to our ability to define itour ability to define it..

• • Are we dealing with a Are we dealing with a problemproblem or a or a diseasedisease??

• • (Guess what? It doesn’t have to (Guess what? It doesn’t have to be be one or the otherone or the other. It could be . It could be BOTH!)BOTH!)

How do we define How do we define addiction?addiction?

• • some people think it’s based some people think it’s based upon upon problemsproblems people have people have when they are addictedwhen they are addicted

- I have - I have problemsproblems with my with my mother-in-law. Am I mother-in-law. Am I addicted addicted to my mother-in-law?to my mother-in-law?

How do we define How do we define addiction?addiction?

• • some people think it’s based some people think it’s based upon upon how much and how oftenhow much and how often the drug (activity) is carried outthe drug (activity) is carried out- university students drink - university students drink a a great amount of alcohol, great amount of alcohol, usually many days a weekusually many days a week. Are . Are they all they all addictedaddicted to alcohol? to alcohol?

How do we define How do we define addiction?addiction?

• • some people think it’s based some people think it’s based upon a person’s upon a person’s personalitypersonality or or lack of will powerlack of will power

- many addicts are - many addicts are highhigh functioningfunctioning, intelligent people , intelligent people with with no other psychopathologyno other psychopathology

- does this make sense?- does this make sense?

How do we define How do we define addiction?addiction?

• • I contend that “addiction” is I contend that “addiction” is not a useful not a useful scientific termscientific term- chocolate addiction, exercise- chocolate addiction, exercise

addiction, television addictionaddiction, television addiction• • Is heroin addiction Is heroin addiction similar tosimilar to exercise exercise

addiction? (Probably not..)addiction? (Probably not..)• • Has this dichotomy Has this dichotomy caused a problemcaused a problem in in

getting support for getting support for treatment, research, treatment, research, & education& education??

In Fact, It’s Even Worse!In Fact, It’s Even Worse!• • SStigmatigma (against the disease) (against the disease)• • PPrejudicerejudice (against the addict) (against the addict)• • AAngernger (toward the addict) (toward the addict)• • MMisunderstandingisunderstanding (about what to do) (about what to do)

SPAM leads to SPAM leads to mythsmyths: widely-held : widely-held inaccurate beliefs, as compared to inaccurate beliefs, as compared to research-generatedresearch-generated factsfacts))

Too Many Myths!Too Many Myths!• “• “treatment treatment doesn’t workdoesn’t work””• “• “addicts are addicts are bad, crazy, stupidbad, crazy, stupid””• “• “crack is crack is worseworse than cocaine” than cocaine”• “• “marijuana marijuana rots your brainrots your brain””• “• “there is an there is an addictive personalityaddictive personality””• “• “sugarsugar is addicting” is addicting”

The Facts……The Facts……• • DSM and ICD: DSM and ICD: twotwo drug problems drug problems• • abuseabuse: caused by rebellion, money, : caused by rebellion, money,

boredom, experimentation, thrill-boredom, experimentation, thrill-seeking, desperation, self-medicationseeking, desperation, self-medication

• • dependencedependence: caused by genetics, : caused by genetics, brain chemistry sensitivity, with input brain chemistry sensitivity, with input from the environmentfrom the environment

• • we have medical and social we have medical and social criteriacriteria….….

How to reduce these…How to reduce these…• • abuseabuse - education, coercion, - education, coercion,

punishment, environmental punishment, environmental change, maturation, pressure to change, maturation, pressure to stop, life eventsstop, life events

• • dependencedependence - “treatment” to - “treatment” to positively affect abnormal brain positively affect abnormal brain function to function to reduce needreduce need for drug for drug

Where Drugs WorkWhere Drugs Work

Medial Forebrain BundleMedial Forebrain Bundle

• • ventral tegmental area (VTA)ventral tegmental area (VTA)• • (lateral) hypothalamus (LH)(lateral) hypothalamus (LH)• • nucleus accumbens (NAc)nucleus accumbens (NAc)• • frontal cortex (FC) - key portionsfrontal cortex (FC) - key portions - - prefrontal prefrontal cortex (pfc)cortex (pfc) - - orbitofrontalorbitofrontal cortex (ofc) cortex (ofc)

Drugs Associated wth Drugs Associated wth Neurotransmitters Neurotransmitters

Why do people have “drugs of choice”?Why do people have “drugs of choice”?

• • DopamineDopamine - amphets, cocaine, ETOH - amphets, cocaine, ETOH • • SerotoninSerotonin - LSD, ETOH - LSD, ETOH • • EndorphinsEndorphins - opioids, ETOH - opioids, ETOH • • GABAGABA - benzos, ETOH - benzos, ETOH • • GlutamateGlutamate -ETOH -ETOH • • AcetylcholineAcetylcholine - nicotine, ETOH - nicotine, ETOH

(Marijuana?) (Marijuana?)

A Brain Chemistry Disease!A Brain Chemistry Disease!• • addicting drugs seem to addicting drugs seem to “match”“match” the the

transmitter transmitter systemsystem that is that is not normalnot normal• • a a chronicchronic, , relapsing, medicalrelapsing, medical disease disease• • there are there are mild, moderatemild, moderate, and , and severesevere forms forms• • detox detox is traditionally the first step in the total is traditionally the first step in the total

treatment processtreatment process• • methadone and nicotine maintenancemethadone and nicotine maintenance is is

evidence that some people require a evidence that some people require a chemical to overcome the non-normal chemical to overcome the non-normal transmitter system transmitter system

Important Point!Important Point! Dependence is Dependence is not a loss ofnot a loss of “will “will

power”power”, for two reasons:, for two reasons: • • The main problem with dependenceThe main problem with dependence lies in the lies in the subconscioussubconscious MFBMFB. . • • Problems with the Problems with the frontal cortexfrontal cortex produce a produce a pathological impairment of pathological impairment of decision-makingdecision-making.. Thus, Thus, dependence is dependence is notnot primarily primarily

under under conscious controlconscious control!!

What Shall We Do?What Shall We Do?• • remember that “addiction” is an remember that “addiction” is an

imprecise termimprecise term; use “dependence” to ; use “dependence” to indicate indicate diseasedisease

• • use “abuse” or “misuse” for use “abuse” or “misuse” for overuseoveruse• • remember that most people remember that most people

misunderstandmisunderstand “alcoholism” “alcoholism”• • try to use try to use proper terminologyproper terminology in all in all

technical and clinical situationstechnical and clinical situations

Precedents for ChangePrecedents for Change• • Hansen’s Disease - Hansen’s Disease - leprosyleprosy• • blood sugar disease - blood sugar disease - diabetesdiabetes• • Grave’s Disease - Grave’s Disease - hyperthyroidismhyperthyroidism• • common cold - common cold - influenzainfluenza• • Lou Gehrig’s Disease - Lou Gehrig’s Disease - ALSALS• • Goldflam Disease - Goldflam Disease - myasthenia myasthenia

gravisgravis

Today’s Options Today’s Options (It’s all about options….)(It’s all about options….)

• • traditionaltraditional: 12 step programs (abstinence): 12 step programs (abstinence)• • talktalk: inpatient/outpatient/aftercare : inpatient/outpatient/aftercare • • misunderstoodmisunderstood: harm reduction, MM: harm reduction, MM• • newnew: brief motivational counseling, CBT, MET, : brief motivational counseling, CBT, MET,

SO-involved therapy, vouchersSO-involved therapy, vouchers• • medical txmedical tx: new medications to enhance : new medications to enhance

abstinence - anticraving meds, methadone, abstinence - anticraving meds, methadone, vaccines, drugs to alleviate withdrawalvaccines, drugs to alleviate withdrawal

(MM= Moderation Management, CBT= cognitive behavioral therapy,(MM= Moderation Management, CBT= cognitive behavioral therapy, MET= motivational enhancement therapy, SO = significant other)MET= motivational enhancement therapy, SO = significant other)

How does “talk therapy” How does “talk therapy” work to help people stop work to help people stop

using drugs?using drugs?

Logic Says:Logic Says: Behavioral Therapies Behavioral Therapies

Probably Change Brain Probably Change Brain Chemistry!Chemistry!

We need more research!We need more research!• • There is lots of There is lots of disagreementdisagreement and and

misinformationmisinformation in this field. in this field.• • This is a result of This is a result of not havingnot having all of all of

the the factsfacts..•• Facts come from Facts come from good scientific good scientific

researchresearch..• • Facts Facts reduce reduce myths and stigma.myths and stigma.

RESEARCH VALIDITY RESEARCH VALIDITY ESTIMATE (RVE)ESTIMATE (RVE)

High RVEHigh RVE• • many large, well-controlled studiesmany large, well-controlled studies• • replicable resultsreplicable results• • much peer-reviewed, published literaturemuch peer-reviewed, published literatureLow RVELow RVE• • few replicable studiesfew replicable studies• • highly speculative resultshighly speculative results• • little peer-reviewed, published literaturelittle peer-reviewed, published literature

(A Thoughtful Appraisal ofHigh-Quality Scientific Research)

100 - 0

Things to RememberThings to Remember• • New researchNew research is changing our is changing our

understanding of dependence understanding of dependence (“addiction”).(“addiction”).

• • Learning this new information Learning this new information requires a requires a willingness to give up willingness to give up old ideas and learn new onesold ideas and learn new ones..100