Postcards from the Id

Book Quote - Considerations For The Treatment Of Methamphetamine Addiction

"The motivations and consequences of methamphetamine use examined in previous chapters clearly suggest that treatment models should be holistic in their approach and imbue a biopsychosocial paradigm that considers mind-body connections.  Biopsychosocial methodologies consider the interplay between the intrapsychic and biological processes of persons, their behaviors, the physical and mental health consequences of these behaviors, and individual influences.  Such treatment approaches support the view of addiction as a chronic brain disease (Leshner, 1997).  Specifically, imaging research has concluded that the methamphetamine-addicted brain has depleted dopamine function, reduced cellular activity in the frontal cortex, which affects decision making, and that reduced dopamine receptor levels may create a higher level of vulnerability to methamphetamine abuse and addiction (Fowler, Volkow, Kassed, & Chang, 2007).  Taken together, these elements indicate treatment modalities that underscore the biological elements of addiction, in addition to intrapsychic, behavioral, and environmental processes."

- From Methamphetamine Addiction, by Perry N. Halkitis (pg. 108) 

Quote - The Biopsychosocial Effects of Methamphetamine Use

"The effects of chronic methamphetamine use are numerous and often pronounced.  Brecht, O'Brien, von Mayrhauser, and Anglin (2004) found that in a sample of 350 individuals recruited from a publicly funded treatment site, 84% reported weight loss because of their methamphetamine use.  Other problems included sleeplessness (78%), financial problems (73%), paranoia (67%), legal problems (63%), hallucinations (61%), work problems (60%), violent behavior (57%), dental problems (55%), and skin problems (36%).  Such consequences of continued use of the drug result from the stress the drug places on the physical being of the individual.  Also, behavioral outcomes associated with methamphetamine use in terms of impaired cognitions and emotions place additional stress on the homeostasis and well-being of the human organism.  In one extreme case, a 44-year old White man bisected his penis in a methamphetamine-induced psychosis (Isreal and Lee, 2002)."

- From pages 50-51 of Methamphetamine Addiction, by Perry N. Halkitis

One last Friday post snuck in!  I chose this topic mainly because we are seeing just a ton of guys for evaluations who's past functioning has been chronically impaired by methamphetamine use, so we're really having to study up of the various symptoms associated with methamphetamine use, withdrawal, etc.  The other reason is because I am preparing to launch a Breaking Bad marathon within the next couple of weeks, courtesy of receiving Seasons 1 and 2 as a birthday present.  Nothing like some light, fluffy entertainment... 

Profile Of Alcoholics Anonymous

Here is a link to Wired Magazine's article about Alcoholics Anonymous.  I found the article both interesting and assessible, though I wonder what AA particpants think of it.  Even within the field of psychology, there is an air of mysteriousness to AA, for reasons outlined in the article - a primary reason being the ananymousness of the program (and lack of research as a result).  It certainly works for some people, however, and is a valuable resource, especially in this day and age when treatment for everything is increasingly expensive.  Attending a dual diagnosis conference a few years ago, the presenter noted research indicating the most important aspect of treatment for those in recovery is that they are actively participating in recovery, rather than what modality they are in.  If some individuals find active participation is easier in AA, then a clinician should facilitate such participation as much as possible.

Outside of the treatment efficacy issues, the article is still a very interesting read.  It reviews the origins of the organization, statistics regarding participation, effectiveness, etc., and also provides a basic (but up-to-date) review of research on the issues associated with alcoholism.  Defenitely worth a read. 

Interesting Article on Information and Choices

This article at Science Daily reviews research into how people make decisions, even fully informed decisions, based on short-term or long-term gain.  Seems that, even when fully informed about how the long-term decision pays off way more (in the long-term), people will more often choose the route with the short-term pay-off.  From the article:

As part of the study, 78 subjects were repeatedly given two options through a computer program that allowed them to accumulate points. For each choice, one option offered the subject more points. But choosing the other option could lead to more points further along in the experiment.

A small cash bonus was tied to the subjects' performance, providing an incentive to rack up more points during the 250 trial questions.

However, subjects who were given full and accurate information about what they would have to give up in the short term to rack up points in the long term, chose the quick payoff more than twice as often as those who were given false information or no information about the rewards they would be giving up.

In a real-life scenario, a student who stayed home to study and then learned he had missed a fun party would be less likely to study next time in a similar situation -- even if that option provides more long-term benefits.

I think this gets to the essence of many issues involved in the process of therapy, at least from my perspective.  I've never been the biggest fan of "insight" as a catalyst for change.  The idea that someone gains new information, or is able to see something from a new pespective, can have value.  However, I haven't seen much evidence that such insight leads to a permanent shift towards healthier behavior.  I mean, really, who requires "insight" to learn that that Big Mac you want to eat may be quick, cheap, and easy (and satisfies a craving), but isn't as good for your long-term health compared to that salad you could make.  Everyone knows this; often, people even understand their own eating issues.  But that doesn't stop millions of people from ordering Big macs on a regular basis.  This point is touched on in the article:

"You'd think that with more information about your options, a person would make a better decision. Our study suggests the opposite," says Associate Professor Bradley Love, who conducted the research with graduate student Ross Otto. "To fully appreciate a long-term option, you have to choose it repeatedly and begin to feel the benefits."

What I point out to people who are attempting to change behavior is that information is necessary, but not suffiecient, for behavior change.  Yes, you need to know what the better alternatives are.  But how to make those alternative behaviors your new habits requires far more than simply a cognitive understanding of them.

This certainly applies in the case of addictive behavior.  On a certain intellectual level, most people with, say, an alcohol problem will have at least moments of clarity, where they gain insight into the impact their drinking is having on them.  However, this alone is rarely enough to reduce alcohol consumption.  Why?  In part (as related to the findings of the article), sobriety really sucks - from the perspective of the alcoholic.

Let me elaborate.  I think oftentimes people with good intentions will attempt to motivate a loved one or friend to address their alcohol problem with promises of what sobriety will do for them.  This, however, is not a great way to proceed.  Simply put, sobriety does nothing for alcoholic - short-term.  In fact, it tends to suck way more than alcoholism.  If it were so great, no one would need treatment.  The problem is that sobriety is a much better long-term life decision, but in the short-term, it is very uncomfortable.  This is one of the reasons AA and others will state that most people need to hit rock bottom before they get serious about recovery - becasue that's the only vantage point from which the sober lifestyle looks appealing.

I've warned clients who are attempting to quit alcohol and drug use - the next month is going to really, really suck.  You'll feel miserable, irritable, short-fused, poor sleep, etc.  However, if you can get through that month, you will then start to also experience some of the benefits of this alternative lifestyle.  Soberiety may never be easy, but it will get easier, as the advantages catch up, and then pass, the diaadvantages.  But short-term, forget it.

Another little tidbit that's important:

"Basically, people have to stay away from thinking about the short-term pains and gains or they are sunk and, objectively, will end up worse off," says Love.

This is extremely important in facilitating behavior change - filling in the empty spaces.  If you are helping someone try to quit using alcohol, to stay with the example, you can't simply focus on the "don'ts," as in: "Don't do this, don't do that, don't go here," etc.   This is a person who has spent a lot of their day thinking about drinking, thinking about where to get their drinks, actually drinking, recovering from drinking, etc.  There will be a lot of spaces in the day, both mentally and behaviorally.  What should fill in those gaps?:  Something...and that is a post for another time.  But in general, you need "Do's" too - like 90 meetings in 90 days - something to distract from the short-term pain, and to help fill in those gaps.  Otherwise, the old habits will come back, further reinforcing the undesired behavior. 

 

 

Low Response To Alcohol Increases Risk Of Alcoholism

I attended a conference several years ago on conceptualization and treatment of dual diagnoses: individuals with a mental health issue as well as a substance abuse problem.  The conference was top notch, presenting a wide range of information on the subject of excessive drug and alcohol use.  One part of the presentation that caught my eye was the information discussed in this article, which discusses how individuals who have a low physiologic response to alcohol tend to have more significant problems with alcohol.

What is meant by low physiologic response is that, for most people, they will start to experience the effects of alcohol consumption after 1-2 drinks; from there on, they will continue to experience an increase in these effects (on speech, relaxation, etc.) with additional drinks.  Low responders, on the other hand, experience only minimal "pre-intoxication" effects - they will look almost the same at six beers as they did after one beer.  The problem is that after the seventh beer, both types of individuals look the same - the low responder simply makes up all of that physiologic ground with one more drink, catching up in a hurry.  From the article:

"If a person needs more alcohol to get a certain effect, that person tends to drink more each time they imbibe," explained Marc A. Schuckit, director of the Alcohol Research Center, Veterans Affairs San Diego Healthcare System, professor of psychiatry at the University of California, San Diego, and corresponding author for the study.

"Other studies we have published have shown that these individuals also choose heavy drinking peers, which helps them believe that what they drink and what they expect to happen in a drinking evening are 'normal,'" he said. "This low LR, which is perhaps a low sensitivity to alcohol, is genetically influenced."

So why is this a problem?  Well, in addition to the information above, it is important to note that experiencing some effect of alcohol use, without becoming intoxicated, serves as a warning for people that "they've had enough."  The effect after two or three drinks, whether initially desired or not, is enough.  Individuals with low response to alcohol, however, do not benefit from such warnings - they are able to drink and drink, right up to the point where they experience the effects rapidly, and have now consumed too much.  Their body doesn't give them a "head's up" like most folks.  This contrast is very easy to demonstrate on a graph, a bit harder to describe in words, but hopefully you get the gist.  Also from the article:

"Because alcoholism is genetically influenced, and because a low LR is one of the factors that adds to the risk of developing alcoholism," said Schuckit, "if you're an alcoholic, you need to tell your kids they are at a four-fold increased risk for alcoholism. If your kid does drink, find out if they can 'drink others under the table,' and warn them that that is a major indication they have the risk themselves. Keep in mind, however, that the absence of a low LR doesn't guarantee they won't develop alcoholism, as there are other risk factors as well."

The flip side to this, of course, is that even if both parents of an individual are alcoholics, it isn't "written in stone" that the person themself will be.  If I recall correctly, and individual with niether parent as an alcoholic has a 12% chance (roughly) of developing alcoholism; one parent=25% chance, and two parents roughly a 46% chance.  These statistics can be helpful in overcoming doom-n-gloom in a person's consideration of their future regarding alcohol, that they aren't automatically destined for severe alcohol problems, especially if they are willing to put in the effort necessary to address areas of concern.

  

Binge Drinking among College Students Related to College Environment

Here is an article reviewing new research into binge drinking on college campuses. The research suggests binge drinking is significantly related to the type of environment and found on the college campus. Among the factors most significantly associated with a high level of binge drinking were a strong drinking culture, relatively few alcohol control policies, weak enforcement of those policies, and easily assessable alcohol. The article goes on to discuss other factors and issues as well.

A major issue I found when I was an undergraduate student (about a thousand years ago) was a lack of alternatives to the party scene on Friday and Saturday nights. I always found it interesting the university administration consistently reached low tolerance for alcohol abuse (I attended a Jesuit university), yet never seemed concerned enough to actually offer any other activities over the weekend. The library closed at 5 p.m. on Friday and Saturday evening, and while there were occasional performance art-related activities offered here and there, the schedule was inconsistent at best, and there were very few seats in any event. The school’s sporting events were generally over by 9 p.m. What did the administration think the students were going to do? By the time I was a senior, the university had taken some small steps to remedy this, including an occasional “all niter” at the recreation center (which normally closed by 9 p.m.), as well as an increase in performances by the various performing arts groups. By the time I graduated, however, there was still very little to do most weekend evenings, outside of going to a party. I certainly hope that the situation has changed, as I agree with the assertion by the researchers that if real alternatives were offered, students will take advantage of them. I can only speak for myself and my friends at the time, but if they have left the recreation center open until midnight on the weekends, we would have been in there every Friday and Saturday night playing pickup basketball, or some other sport. We likely would have even been in there working out in the event the courts were too crowded - I know this because there were several times I found myself jogging around the track late at night on the weekend after getting off of work. It was too late to find anywhere to go, I wanted to get it some exercise, and the university saw fit to restrict available options to me jogging around a track that wasn’t even lit. Yet, they were very concerned about alcohol use (sarcasm off).

Discontinuing Even Moderate Drinking May Be Connected to Depression

New research conducted on mice indicates that the cessation of even moderate drinking may lead to the experience of depression in the days and weeks ahead. According to this article, mice were provided with a moderate amount of alcohol on a daily basis for 28 days. Researchers then discontinued providing the mice with alcohol. Fourteen days after the discontinuation, the mice were displaying behaviors that correlate with depressed mood in humans. From the article:

"Our research in an animal model establishes a causal link between abstinence from alcohol drinking and depression," said study senior author Clyde W. Hodge, Ph.D., professor of psychiatry and pharmacology in the UNC School of Medicine. "In mice that voluntarily drank alcohol for 28 days, depression-like behavior was evident 14 days after termination of alcohol drinking. This suggests that people who stop drinking may experience negative mood states days or weeks after the alcohol has cleared their systems,"

The article also indicates that researchers determined in association between the period of time when the depression was present, and the discontinuation of the formation of neurons in an area the brain known as the hippocampus. This discontinuation of neural formation has also been associated with mood difficulties in people. Interestingly, the researchers found that administering antidepressant medication insulated the brain from this discontinuation, and also prevented the onset of the depressive symptoms.

What I find interesting about this particular bit of research is that moderate drinking has been associated with a number of different functional benefits. It appears that the discontinuation of moderate drinking may be experienced negatively. I wonder if this is a physiological response designed to encourage people to re-engage in moderate drinking? Certainly, an experience of depressed mood following a discontinuation of any behavior, including moderate drinking, would be experienced as a punishment, behaviorally speaking. What would be interesting to know is how soon after an individual starts to drink again do they experience an improvement in mood.

From a clinical perspective, it is always extremely important when working with an individual who was attempting to reduce and/or stop their alcohol consumption as part of her treatment to prepare that individual for the increase in negative mood and negative physical response. Individuals who are either alcoholic or engage in problem drinking often assume, erroneously, that upon discontinuing their alcohol use they will immediately experience an improvement in how they think and feel. This is generally not the case. People who discontinue alcohol use (or other drug use) will often feel worse before they feel better. They often do not expect the increase in difficulties they experience, and this will often lead to relapse. Explaining this to an individual beforehand, and helping them work through it, provides a much greater chance for treatment to be effective. I suppose the findings of the research cited above is consistent with the experiences of individuals attempting to discontinue alcohol abuse. This makes it even more important to accurately assess a client’s alcohol use, in order to determine whether an intervention regarding his/her alcohol use is warranted. This would appear to be especially true if the other issue requiring treatment his depression. If so, the clinician needs to be aware that there may be an increase in depressive symptomatology that is related to the decrease in alcohol consumption, and not necessarily confuse this increase with any other issues, including a failure of the treatment intervention.

Mental Strategies Can Curb Arousal Based on Expected Reward

According to this study, the use of mental strategies, such as relaxation techniques, can decrease the level of physiological arousal associated with an expected reward. That is, our bodies often experience an increase in arousal when we expect some sort of positive outcome or reward. This is not in and of itself a bad thing. However, when the arousal is associated with a “reward” that is actually unhealthy, such as a high from drug use, a reduction in that physical tension would be beneficial. From the article:

Skin conductance responses (SCRs) of the participants were taken at the beginning of each conditioned stimulus. These served as a behavioral measure of physiological reaction potentially related to reward anticipation.

The results showed that the participants' emotion regulation strategies could influence physiological and neural responses relevant to the expectation of reward. Specifically, results from the SCRs revealed that the subjects' emotion regulation strategies decreased arousal that was linked to the anticipation of a potential reward.

"Our findings demonstrated that emotion regulation strategies can successfully curb physiological and neural responses associated with the expectation of reward," said Delgado. "This is a first step to understanding how our thoughts may effectively control positive emotions and eventual urges that may arise, such as drug cravings."

One of the things I’ve often educated substance abuse client about (as well as other clients who have difficulty managing either emotions or other cravings) is that the longer they go without indulging their cravings, the more effective they will be in discontinuing future maladaptive behavior. Unfortunately, as an individual attempts to resist the urge to engage in the behavior, they will often become uncomfortable, if not downright ill (in the case of substance withdrawal). While “doing nothing” is certainly a substitute for engaging in the maladaptive behavior, in reality clients often desire something else to do. Exercise is one behavior people will often switch to when they are giving up an unhealthy behavior (and note, exercise is a very effective stress management technique). Mental stress management techniques can also provide some temporary relief, as this study shows. A mistake many people make when trying to change their behavior is that they make an effort to give up the unhealthy actions, but fail to adequately plan for replacement behaviors. Beginning therapists also make this mistake by failing to adequately lay the groundwork for coping with the discomfort people will experience as they attempt to extinguish unhealthy behaviors, especially those based on addiction, or those with frequent reinforcement (for example, jealousy, where every time the person engages in a “checking” behavior, such as snooping through a call list, they are reinforcing the unhealthy behavior). Giving up something isn’t good enough, a person must have substitutes, or else the discomfort is very likely to lead to relapse. This study suggests the use of stress management techniques may aid that effort.

New Drug Treatment in Works for Alcoholism?

According to this article, researchers are examining a new type of therapy for alcoholics through the use of a brain protein. Administration of this protein has been used on rats, with the effect of preventing alcohol relapse, but without impacting other cravings, which has been a problem with previous medications. From the article:

The Gallo Center scientists set out to test the actions of GDNF in a brain site known as the Ventral Tegmental Area, or VTA, a region of the brain thought to be strongly involved in drug-seeking behavior. The first part of the study was designed to model both human social and excessive drinking. Researchers first trained rats to seek alcohol for two months. GDNF was then injected into the VTA brain region, and their motivation to drink in both models dropped significantly within as little as 10 minutes. The effect lasted at least three hours, the scientists reported.

In a second part of the study, rats had access to sugar water, and the scientists showed that after GDNF treatment, the animals still sought sugar -- convincing evidence that increased GDNF did not decrease other, related pleasure-seeking behaviors.

In a third research arm designed to model the risk of relapse behavior, the rats were trained to press a lever to get alcohol. Once they became highly motivated to seek alcohol, it was taken away. At first, they still pressed the lever to get their drink, but eventually they gave up - like people after rehab, Ron says. When alcohol was reintroduced, they relapsed, pressing for the same amount as before. But when they were treated with GDNF, they quickly lost their taste for alcohol.

Further in the article, the authors indicate they are looking to see if any current FDA-approved medications affect GDNF the same way. From a treatment perspective, this would be a very positive step forward in the treatment of alcoholism. Getting an individual to stop using alcohol is one thing, but maintenance often proves much harder. Generally speaking, once an alcoholic gives up drinking, they feel considerably worse for a period of time. It takes awhile for this to improve, as well as to start seeing some of the benefits of abstinence. If a treatment could be designed to reduce an individual’s desire to have a drink, this could buy valuable time for the treatment process to establish itself without having to deal with a relapse.

Aripiprazole May be Useful in Treatment of Alcoholism

Aripiprazole, a drug ordinarily used for the treatment of Bipolar Disorder ans Schizophrenia, may have a positive impact in the the treatment of alcoholism, according to this study.  The researchers found that the use of this medication made the alcohol have a "more sedating" effect, rather than a "stimulating effect," and the subjects became sleepier as a result of alcohol use.   The researchers also noted that Aripiprazole may also be more tolerable to a client (i.e. fewer side effects) than other anti-psychotic medications which have shown a similar effect, but are more difficult to tolerate.  Summary quote from the article:

"Aripiprazole is one of a growing list of medications that are being evaluated for the treatment of alcoholism," said Anton. "Readers should really see this as preliminary evidence and should be on the lookout for more studies to inform them of the potential treatment utility of aripiprazole by itself or in combination with other medications for alcohol-use disorders." He suggested that future research test aripiprazole on heavier drinkers and non-treatment-seeking alcoholics under longer-term dosing and natural drinking conditions, and also explore potential genetic predictors of its stimulatory versus sedation effects, with and without alcohol."