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Brain Neuroplasticity and Addiction

For a long time there has been much research on addiction but there hasn’t been much research on the solution.  I like to talk about recovery, the solution.  Now for the first time there is exciting research about recovery.

Using addictive drugs can evolve from controlled social use into the compulsive relapsing disorder that characterizes addiction. This transition to addiction results from genetic, developmental, and sociological vulnerabilities, combined with pharmacologically induced plasticity in brain circuitry that strengthens learned drug-associated behaviors at the expense of adaptive responding for natural rewards. Advances over the last decade have identified the brain circuits most vulnerable to drug-induced changes, as well as many associated molecular and morphological underpinnings. This growing knowledge has contributed to an expanded understanding of how drugs usurp normal learning circuitry to create the pathology of addiction, as evidenced by involuntary activation of reward circuits in response to drug-associated cues and simultaneous reports of drug craving. This new understanding provides unprecedented potential opportunities for novel pharmacotherapeutic targets in treating addiction. There appears to be plasticity associated with the addiction phenomenon in general as well as changes produced by addiction to a specific class of addicting drugs. These findings also provide the basis for the current understanding of addiction as a chronic, relapsing disease of the brain with changes that persist long after the last use of the drug.1

You often see TV commercials that show how the balance of this neurochemical, or that neurochemical, is corrected by this drug or that drug. What does the balance do?  What we’ve begun to understand is that the brain chemistry studies are beginning to show that our brains are much more malleable and able to heal and adapt better than we ever thought.  I’ve been able to witness this in the recovery field first hand.  I’ve known people who have been in recovery from alcohol and drug problems for decades and today I see a person who has become a different person in the same body.  The brain has been transformed into a new personality and a new life with new values and attitudes that are different form the person trapped in active addiction.

The new concept in medicine, is brain neuroplasticity, and what we realize is that the brain is hugely adaptable to the world we expose it to and live in. So if a person lives in a world of drugs and alcohol, then their brain changes to become better able to survive in a world of drugs and alcohol and unable to survive in a world without drugs and alcohol.  That’s the negative part of the neuroplasticty.  When a person who has been in trouble with drugs and alcohol frees their brain of toxic chemicals, it’s initially like a fish out of water, but the important thing to know, and this is something we didn’t always understand, is that the brain does eventually heal itself.

The natural state of the brain is to live in an abstinent way, a state free of alcohol and drugs and the toxicity of chemicals.  Even though this is different in the beginning stage of withdrawal from toxic chemicals, the abstinent brain can grow back to provide a good healthy life.   In other words, the brain can mold itself in such a manner that allows a person to achieve things they never thought possible before.  Similar to the amputee who is able to run faster than normal people once he or she is given a prosthetic limb, people in healthy recovery can live above their old potential.  How does this happen? Like a fractured or broken bone, the brain can overcompensate under challenge.  If you break a bone, and you don’t splint it or take care of it, it never heals properly.  You never have a fully functional limb again.  However, if it’s splinted, if you get good nutrition, if there are stresses on the bone, it actually heals stronger than it was originally.  The brain, we now know, can heal in the same way and that’s why a sickness, a disease like alcoholism can heal.  With good scientific approaches that provide for abstinence in a person, with the help of recovery, family, friends and spiritual integration including things that people in 12 step program have used for years, the brain can heal stronger than it ever was before.

Sharon Begley in her book, Train Your Mind, Change Your Brain, speaks of how attention to what we are paying attention to changes your brain. This is an excerpt from an article that she wrote for the Wall Street Journal:

“Through attention, UCSF’s Michael Merzenich and a colleague wrote, “We choose and sculpt how our ever-changing minds will work, we choose who we will be the next moment in a very real sense, and these choices are left embossed in physical form on our material selves.”

The discovery that neuroplasticity cannot occur without attention has important implications. If a skill becomes so routine you can do it on autopilot, practicing it will no longer change the brain. And if you take up mental exercises to keep your brain young, they will not be as effective if you become able to do them without paying much attention.”

Living above your old potential is a new concept.  In most areas of medicine and mental health we live what I call below sea level.  Everything in the Diagnostic Statistical Manual (DSM) is a disease.  It’s all based on pathology.  Because of that it has been our believe, that when a person becomes a victim of an illness the best we can hope to do using the best medical science available to us is to bring people back up to sea level.   Recovery is a different paradigm where people can not only come back up to sea level; they can rise above it.

There are very few things in medicine that actually achieve this kind of goal but in addiction recovery we do that.  People who are in recovery not only overcome the sickness they’ve been treated for, but they achieve a life that goes into the positive far beyond what that person would have ever been capable of without recovery.  This is a new concept in medicine and the science of neuroplasticity is what allows this to happen.

The key elements for this to happen are an environment for healing and a controlled challenge that has to happen in order for healing to achieve greater strength.  This is a very different concept from the old mental health approach in which professionals always saw their patients as imprisoned by our emotions.

In sickness, if you look at the DSM, it’s all negative emotions, and in recovery the empowering element of recovery allows that negative to become positive.  If you go to a 12 Step meeting and nobody is nervous and nobody is depressed, it would really be a bad meeting.  The strength of a good recovery meeting is the challenge of weakness from those individuals coming in with problems.

Mike S. Logan, an online counselor, says:

“The key piece of recovery from drug addiction is to manage your thinking.  Capture and dispute automatic negative thoughts as Daniel Amen, MD, describes them, simply because it is your brain and you can do this.

In a sense automatic negative thoughts are like computer viruses. You install your 12 step filter, for example, and reboot the brain as you become aware of each negative thought. Soon you will be repeating thoughts which leave you feeling good, simply because you can and now your neuroplasticity is becoming effective in a positive way.

Change the thought, change the feeling, and soon your brain is moving towards a very healthy and relaxing pattern of thinking and internal chemistry.  Remember though, that we process sensory data and create thoughts about sensory data continuously, so this is an ongoing process.”

Stages of neuroplasticity in addiction. (a) Transient forms of neuroplasticity, typically involving the development of tolerance with repeated administration; potentially important in promoting social drug use. (b) Forms of plasticity that augment with repeated drug administration that diminish within hours to weeks after discontinuing drug administration; thought to be important in the transition from social to relapsing drug use. (c) Stable forms of plasticity emerging either during repeated drug use or during abstinence. In some instances, protein changes in this category progressively increase during abstinence, and are thought to contribute to the enduring vulnerability to relapse that is a cardinal feature drug addiction. Small arrows indicate repeated drug administration.

We take the power of the addiction, and through concepts of recovery that people incorporate into their lives and psyches, turn that power to promote health in recovery.  Anxiety becomes good because it gives me something to talk about and work on.  Just like putting pressure on a bone allows the calcium to form along the lines of stress and the bones become stronger, handling anxiety properly molds the brain around the problem in a way that produces a stronger psyche.

I have seen plenty of cases of people who have been poisoning their bodies with alcohol and drugs, where these people achieved more after their recovery than they ever hoped to achieve before their recovery.  Hemingway said, “Life breaks everyone, and a few are strong in the broken places.” Recovery is a solution to make many stronger in the broken places.

The concept of rising above your potential is actually compatible with a lot of other beliefs in our society; beliefs we already know are empowering.  We know spirituality is empowering even though it often works outside the medical arena.

Brain Development and Neuroplasticity

In humans much brain development happens after birth.  We notice this in children when they develop language and motor skills, particularly in the first two or three years of their lives.  But that brain development continues up until the person is an adult about 25 years of age.  This is one of the reasons, from a scientific perspective, where lowering the drinking age to 18 (and using medications, where we don’t yet understand the life-long implications), can be very dangerous because we’re intervening with toxic chemicals at a stage when the brain is not fully developed.

The brain has multiple functions and different parts of the brain develop at different rates. For example, there are times where the inhibitory centers of the brain will develop at a slower rate than the energizing areas of the brain.  An analogy would be, you’ve got a gas pedal and a brake pedal in your brain.  There are times when a child may look like they’re hyperactive and if we diagnose it out of context of the culture that child is living in, they may be given medications that could inhibit brain development so that the very thing the child needs to build, which are the brakes in the brains, never develop as they should because they’re no longer needed.  The gas and the brakes, and the development of these, it’s all a normal part of neuroplasticity, the same model used in recovery, that allows the brain to develop and rise to the challenge.

Let me give you a couple of really tangible examples of how our environments shape our brain.  I’m told that Eskimos can see 20 or 30 different shades of white.   I see only white and off-white because I grew up in a place where there were various colors and my life and survival didn’t depend on my distinguishing too many shades of white.

I tried to learn Russian one time and was a horrible student because there are several consonants in Russian that, to me, sound the same, yet my Russian tutor told me they were different sounds.  There are sounds in languages in Africa that you and I would interpret as just a bunch of clicks, yet every one of those subtle sounds are different words for somebody in that tribe who understands that language.  I had a friend who was in the military in Japan.  He had a daughter who stayed there her first two years of life.  They came back to America and she studied international business. When they went back to Japan the Japanese were shocked, that even though she had never spoken Japanese, she was able to learn the Japanese language as though she were a native to Japan.  Because she was there and exposed to hearing the sounds of the Japanese language those first two years in Japan, even though it was below the conscious level, the brain plasticity actually developed around those environmental influences so that when she went back to learn Japanese she already had the neuroplasticity network in place to easily learn the language.

The Success of Treatment

A lot of medical people and most of society erroneously believe treatment for addiction does not work – and I want to emphasize that treatment works very very well in addiction and recovery.  The results have been shown to be at least as good as, and often better, for addiction treatment, for alcoholism treatment, than for heart disease, cancer, diabetes, asthma and other chronic diseases.

Outcome research is very difficult in addiction.  One of the reasons is because we have set the bar differently from the way we measure success with other illnesses.  In diabetes we stabilize people.  We give them treatment and then, as their treatment is shown to work, we monitor for problems that may occur because of their diabetes.  We do the same thing for hypertension.  You take someone with high blood pressure and when their blood pressure gets better, when it lowers, you don’t stop the treatment. But in the addiction field we often approach with a different mentality because we have so much guilt and shame.  People think, “I want to get my treatment behind me and I want to get on with life” and when they feel better they give up doing what made them feel better.  That’s part of what I call “addictive thinking” which we don’t see as much with diabetes and high blood pressure.  But if your doctor did stop treatment for these illnesses like high blood pressure, once they had stabilized, the doctor would be guilty of malpractice.  The blood pressure pills helped your blood pressure so you need to continue to get this treatment.  The same is true for treatment for addiction.

I don’t know why that’s such a difficult concept for people who have trouble with alcohol and drugs to understand, but it is.  Most of our professional organizations that deal with people who have been in trouble like the LAP program have realized that long term monitoring is a crucial part of success in recovery.  Not in a punitive way, but in a supportive way because there are a lot of things that come up in recovery that a person who’s there might not be able to recognize and attend to just like there are things in blood pressure that a person may not be able to recognize.  I don’t care how smart you are you cannot tell me what your blood pressure is.  It has to be monitored.  When you have a heart attack, there are things you need to do for your heart the rest of your life.  And now we’re beginning to accept that the same is true for addiction.

In addiction, what we’ve done in the past is send people to detox and then to a 28 day program.  After that they wouldn’t be in treatment.  A doctor would come back a year later and say ‘how you doing?’ Imagine if we gave a diabetic insulin for a week and then went back a year later and said ‘how you doing?  They’d probably be dead.  And yet that’s exactly what we were doing in the addiction field.

So this whole monitoring idea is something that’s part of how you treat chronic diseases and now we’re beginning to faithfully apply it in the addiction world.  If you have cancer you will really want it to be monitored for its return.  And now we’re beginning to see that, just like any other disease, alcoholism and addiction need to be monitored if we expect to overcome the problems in a life-long way.

Fortunately, through some enlightened researchers we are now looking at measuring results while people are still in the treatment process.  In mutual support group people come together in a way which allows the group to empower one other, with strength beyond what any individual has.  We know that empowerment and the emotional aspect of recovery is a very powerful influence, and not just in recovery from alcohol and drugs.  It’s being used now for diabetes and cancer.  It’s a way to take advantage of the brain’s mechanism of healing, bringing people together with similar problems.

I’ve actually helped conduct research of my own on this topic.  At Willingway Hospital we followed people over ten years in recovery. We found in our study that after about ten years alcoholics and drug addicts tend to be either dead or doing well in recovery.  There’s very little in between.  Most of the people who were doing well, who remained in recovery, were involved in 12 step recovery.  So trying to help other people actually fuels a person’s personal progress in recovery and that was an important outcome finding in our study.

Illustration of the relationship between neuroplasticity, motivated learning, brain circuitry, and the stages of addiction. (a) The phases of addiction from the development of addiction (social use) to vulnerability to relapse (transitioning from regulated to compulsive). Also shown is the proposed use of pharmacotherapeutics and pharmacology and behavioral interventions. (b) Mapping normal motivated learning processes and the relevant dopaminergic and glutamatergic circuitry onto the stages of addiction.

One of the best outcome studies I’ve seen on the importance of long term care and monitoring, was an unpublished study conducted by the Federal Aviation industry on pilots in their recovery program.    If seven to ten percent of the population are alcoholics, there is about a seven to ten percent chance that you you’ll get into an airplane with an alcoholic pilot at the cockpit.  If you walk into that plane and say ‘are you an alcoholic’ and ‘are you involved in the recovery program’ and you get a ‘yes’ there’s essentially a zero chance that you’re gonna have any problem with an active alcoholic in the cockpit. Ninety five percent of the people who sign up for the recovery program within the FAA’s jurisdiction are abstinent and in recovery.

If you go to my colleagues around the country and say how many alcoholics and addicts get sober and maintain life long recovery you’ll get answers like 25-30 percent, or maybe 30 or 50 percent.  A ninety-five percent recovery by a program that is totally abstinence based includes incentives for good treatment, good monitoring, and AA involvement.  When you put all these things together that program has shown the recovery rate to go up to about 95 percent, and about 85 percent of those people never relapse.  That program alone has shown that there’s a lot of success in alcoholism treatment with the right kind of long term car and monitoring.  The brain’s neuroplasticity is what makes this high level of successful treatment possible.

– by Dr. Al Mooney*

1Neuropsychopharmacology. 2008 Jan;33(1):166-80. Epub 2007 Sep 5 Kalivas PW,O’Brien C.

 

*Al Mooney, M.D., is  a Lawyer Assistance Program Board member and former Medical Director at Willingway Hospital.  He is co-author of “The Recovery Book.”

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