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CHRIS BUDNICK, MSW, LCSW, LCAS, CCS

FRIDAY JANUARY 23, 2015

Civil Commitment Training

SUBSTANCE USE DISORDERS AND RECOVERY

Initiating and Sustaining Recovery

Problem severity

Mild

Moderate

Severe

Initiating and Sustaining Recovery

Problem complexity Addiction

Addiction + Mental Illness

Addiction + Mental Illness – Housing – Social Supports

Recovery capital

Internal and external resources that can be mobilized

Access to appropriately designed services

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Many Paths Into Recovery

Solo (natural) recovery

Peer Assisted

Mutual Support groups (i.e. Alcoholics Anonymous)

Treatment Assisted

Emerging Evidence on Addiction

The mesolimbic dopamine system (reward

pathway)

Vulnerability for addiction

Why do some people develop problems with alcohol and

other drugs while other people don’t?

Long-term effects of addiction

How does this impact the recovery process

Addiction as a chronic illness

Mesolimbic Dopamine System

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Mesolimbic Dopamine System

This system is a collection of neurons that release the neurotransmitter dopamine.

Often called the reward pathway

This pathway is activated by things that are rewarding.

Mesolimbic Dopamine System

What behaviors are related to survival?

Food, water, sex and nurturing

They are rewarding and are considered “natural reinforcers”

because they are directly related to our survival

What assures that we will engage in these

behaviors?

The release of dopamine

Mesolimbic Dopamine System

Rewarding experiences tell the brain “do it again” so a behavior will be repeated

AOD increase dopamine at a much greater magnitude and duration than natural reinforcers (5 – 10 times greater)

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Understanding the Power of Dopamine

00

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00 11 22 33 44 5 hr5 hr

Time (min.)Time (min.)

% of Basal Release

% of Basal Release AmphetamineAmphetamine

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9009001000100011001100

00 11 22 33 44 5 hr5 hr

Time (min.)Time (min.)

% of Basal Release

% of Basal Release AmphetamineAmphetamine

Scale 0 – 1,100

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5050

100100

150150

200200

00 6060 120120 180180

Time (min)Time (min)

% o

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as

al Release

% o

f B

asal

Release

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BoxBox FeedingFeeding

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FoodFood

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00 6060 120120 180180

Time (min)Time (min)

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Scale 0 – 200

Mesolimbic Dopamine System

The probability of dopamine interacting with a

receptor is based upon how much dopamine is

released and how many receptors are available.

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Mesolimbic Dopamine System

Personal

Vulnerabilities

Vulnerability for Addiction

Genes and environment contribute to increased risk

for AOD problems or can serve as protective factors

against AOD problems

Developmental Vulnerabilities

The mean age of initiation of drinking alcohol in 

2005 was 14.2 years

What is happening in the adolescent brain when this

occurs?

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Developmental Vulnerabilities

Individuals who are not heavy users of alcohol or

other drugs during adolescence and into their early

20s are less likely to develop an addiction in later life

Biological Vulnerabilities

Differences between how individuals experience the

effects of alcohol and other drugs

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Group One

Usual or normal response

Group Two

Feelings of intoxication

Stimulation

Sedation

Happiness

3 times more likely to have a

family history of alcoholism

than members of Group One

3 times more likely to have a family history of alcoholismthan members of Group One

Alcohol

Other Biological Vulnerabilities

One of the dopamine receptors that has been shown

to be important in the reinforcing effects of alcohol

and other drugs is the dopamine D2 receptor

Dopamine Receptors

In one study, Ritalin was administered intravenously

to test subjects

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50% of the subjects experienced 

negative effects of the stimulant

50% of the subjects experienced 

positive effects of the stimulant

Heart rate

Sweating

Anxiety

Paranoia

Energy

Confidence

Euphoria

Those who experienced the pleasurable effects had fewer D2 receptors

D2 Receptors

A reduction in D2 receptors has been implicated in a

reduced sensitivity to rewards (“reward deficiency”)

Other Evidence

Animal studies have found that increasing D2

receptors significantly reduces alcohol and cocaine use

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D2 Receptor Comparison of Non-Alcoholics

Control Group

Non-alcoholic

No family history of

alcoholism

Experimental Group

Non-alcoholic with:

An alcoholic father

At least two 1st degree or 2nd

degree relatives who were

alcoholics

What has protected the

non-alcoholic from the

genetic risk factors?

Non‐AlcoholicFamily history of alcoholism

Non‐AlcoholicNo Family history of alcoholism

D2 receptors

The Role of Environment

One study looked at environment, D2 receptors and AOD use.

PET scans of 20 individually housed monkeys were used to determine D2 receptor availability

Monkeys moved from individual housing into social housing with groups of 4 monkeys

Social hierarchies were allowed to develop

PET scans were used to capture the availability of D2

receptors 3 months after they were assigned to social groups

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Lighter colors represent increases in D2 functioning (Source NIDA Notes)

Individually Housed

SociallyHoused

Dominant20% increase in D2

receptors when socially housed

SubordinateNo change in D2 receptors when socially housed

The Role of Environment

cocaine use among dominant monkeys

cocaine use among subordinate monkeys

Recent study in humans has supported these findings (related to social status and social support)

Implications for AOD Problems

Individuals with low levels of D2 receptors are more vulnerable for AOD problems because the experience is pleasurable

Individuals with high levels of D2 receptors may protect against AOD use since the experience tends to be unpleasant or aversive

Environment can affect neurobiology Nurturing

Stability

Consistency

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Mesolimbic Dopamine System

Personal

Vulnerabilities

Neurobiological

Consequences

Neurobiological Consequences

Prolonged AOD use in vulnerable individuals

changes brain functioning:

Related to memory

Related to judgment/decision making

Related to the ability to find natural rewards “rewarding”

Related to delaying gratification

The Role of Memory

Memory plays a significant role in:

Continued use

Attempts to achieve and sustain abstinence

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The Role of Memory in Addiction

The brain records the pleasurable experience through

connections to memory and emotion in the amygdala

and hippocampus (euphoric recall)

As a result, dopamine activity increases, not only during a

rewarding or pleasurable experience, but also in anticipation

of one

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• Slides were presented randomly for 33 msecfollowed by 467 msecneutral slides

• 33 msec escapes conscious detection

• Despite no conscious recognition, the limbic system showed activation in response to the slides.

Normal BrainBrain of Meth User

1 month abstinent

Brain of Meth User

14 months abstinent

Recovery of Brain Functioningwith Prolonged Abstinence

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Dopamine D2 Receptor Availability

ComparisonSubject

Cocaine

Methamphetamine

Alcohol

AddictedPerson

Brain

Reward System

1. Thickness

2. Surface Area

3. Volume

Non-smoking,

light-drinking

controls

Individuals

who relapsed

after treatment

Individuals

who remained

abstinent after

treatment

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Results

• Highest cortical thickness of three groups

Non-smoking, light-drinking

controls

• Lower cortical thicknessAbstinent after

treatment

• Lower cortical thickness• Lower total brain reward system surface area• Lower volume in certain areas of the brain

Relapsed after treatment

Conclusions

Those who relapsed had greater abnormalities

in areas of the brain associated with:

Decision making

Emotions

Reward processing

Regulation of internal drives

Mesolimbic Dopamine System

Personal

Vulnerabilities

Neurobiological

ConsequencesAddiction as a

Chronic Illness

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Addiction as a Chronic Illness

Should addiction be considered a chronic

illness, similar to hypertension or diabetes?

CausesAlcohol

Related

Problems

Asthma Diabetes

High

Blood

Pressure

Controllable

Risk Factors

Yes

Limit drinking 

Yes

Limit exposure

to allergens

Yes

Limit food intake

Exercise regularly 

Yes

Limit fat & salt

Intake/Diet

Exercise

regularly 

Uncontrollable

Risk FactorsYes  Yes  Yes  Yes 

Estimated Genetic

Influence

50% – 60%  36% ‐ 70% 30% – 55% Type I

80% Type II 25% ‐ 50% 

TreatmentAlcohol

Related

Problems

Asthma Diabetes

High

Blood

Pressure

Cure No No No No

Clear Diagnostic Criteria Yes Yes Yes Yes

Research Based Treatment Guidelines and Protocols

Yes Yes Yes Yes

Effective Patient and Family Education

Yes Yes Yes Yes

% Who Follow Treatment Regimens Faithfully 40% ‐ 60% 30%  30%  30% 

% Who Relapse Within a Year 40% ‐ 60%  50% ‐ 70%  30% ‐ 50%  50% ‐ 70% 

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Treatment Adherence & Outcomes

McLellan et. al (2000) found that the most important

predictors of poor adherence and poor treatment

outcome, for all illnesses, were:

Low socioeconomic status

Lack of family or social supports

Co-occurring psychiatric problems

Addiction as a Chronic Illness

Historically, treatment of severe and persistent AOD

problems has resembled interventions for acute health

conditions (e.g., traumatic injuries, bacterial

infections)

Implications

For persons with hypertension & diabetes

A recurrence of symptoms (relapse) following treatment cessation is considered evidence of treatment effectiveness

This is used to justify devoting resources to continuing treatment

For persons with alcoholism and addiction

A recurrence of symptoms (relapse) following treatment cessation is considered evidence of treatment failure

This is used to justify not investing further resources into treatment

Treatment needs to shift from an acute care model to recovery oriented systems of care

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Lawyer Assistance Program

LAP services are free, paid for by state bar dues

LAP handles everything from career counseling to stress, depression, substance use disorders and mental health issues

LAP services are COMPLETELY confidential, subject to attorney/client privilege

info@nclap.org

References

Childress A. R., Ehrman, R.N., Wang, Z., Li, Y., Sciortino N, et al (2008) Prelude to Passion: Limbic Activation by ‘‘Unseen’’ Drug and Sexual Cues. PLoS ONE 3(1): e1506.doi:10.1371/journal.pone.0001506

Durazzo, T. C., Tosun, D., Buckley, S., Gazdzinski, S., Mon, A., Fryer, S. L. & Meyerhoff, D. J. (2006). Cortical Thickness, Surface Area, and Volume of the Brain Reward System in Alcohol Dependence: Relationships to Relapse and Extended Abstinence. Alcoholism: Clinical and Experimental Research, 35(6).

Farmer, R. L. (2009). Neuroscience and Social Work Practice: The Missing Link. Los Angeles: SAGE.

Fowler, J. S., Volkow, N. D., Kassed, C. A., & Chang, L. (2007). Imaging and the Addicted Human Brain. Science & Practice Perspectives, 3(2) 4 – 16.

References

Goldstein, R. Z. & Volkow, N. D. (2002). Drug Addiction and Its Underlying Neurobiological Basis: Neuroimaging Evidence for the Involvement of the Frontal Cortex. American Journal of Psychiatry, 159(10), 1642 – 1652.

Gordh, A. & Soderplam, B. (2011). Healthy Subjects with a Family History of Alcoholism Show Increased StimulativeSubjective Effects of Alcohol. Alcoholism: Clinical and Experimental Research, 35(8), 1 – 9.

Harvard Mental Health Letter (2007). Addiction and the problem of relapse. January.

Martinez, D., Orlowska, D., Narendran, R., Slifstein, M., Liu, F., Kumar, D., Broft, A., Van Heertum, R., Kleber, H. D. (2010). Dopamine Type 2/3 Receptor Availability in the Striatum and Social Status in Human Volunteers. Biological Psychiatry, 67(3), 275 – 278.

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References

McLellan, A. T., Lewis, D. C., O'Brien, C. P., & Kleber, H. D. (2000). Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance and Outcomes Evaluation. Journal of the American Medical Association, 284(13), 1689 – 1695.

National Institute on Drug Abuse Slide Teaching Packets. Retrieved September 5, 2005 from http://www.nida.nih.gov/pubs/teaching/default.html.

National Institute on Drug Abuse (2003). Social Environment Appears Linked to Biological Changes in Dopamine System, May Influence Vulnerability to Cocaine Addiction. NIDA Notes, 17(5).

Oscar-Berman, M. & Bowirrat, A. (2004). Relationship between dopaminergic neurotransmission, alcoholism, and reward deficiency syndrome. American Journal of Medical Genetics, 132B(1), 29 – 37.

References

Ray, L. A., & Hutchison, K. E. (2004). A Polymorphism of the μ-Opioid Receptor Gene (OPRM1) and Sensitivity to the Effects of Alcohol in Humans. Alcoholism: Clinical and Experimental Research. 28(12), p. 1789 – 1795.

Volkow, N. D., Fowler, J. S., & Wang, G. J. (2003). The addicted human brain: insights from imaging studies. The Journal of Clinical Investigation, 111(10), 1444 – 1451.

Volkow, N. D. (2004). Imaging the Addicted Brain: From Molecules to Behavior. The Journal of Nuclear Medicine, 45(11), 13N – 24N.

Volkow, N. D., Wang, G. J., Begleiter, H., Porjesz, B., Fowler, J. S., Telang, F., Wong, C., Ma, Y., Logan J., Goldstein, R., Alexoff, D., Thanos, P. K. (2006). High levels of dopamine D2 receptors in unaffected members of Alcoholic families: Possible protective factors. Archives of General Psychiatry, 63(9), 999-1008.

One of the free resources available to you asa State Bar member is the Lawyer AssistanceProgram (LAP). From time to time, lawyersencounter a personal issue that, leftunaddressed, could impair his or her ability topractice law. Accordingly, the LAP was createdby lawyers for lawyers to assure that free,confidential assistance is available for anyproblem or issue that is impairing or might leadto impairment.

Lawyers at Particular RiskOf all professionals, lawyers are at the

greatest risk for anxiety, depression, alcoholism,drug addiction, and even suicide. As many asone in four lawyers are affected. This means itis likely that you, an associate, a partner, or oneof your best lawyer friends will encounter oneof these issues. Whether you need to call theLAP for yourself or to refer a colleague, allcommunications are completely confidential.

Anxiety and DepressionAnxiety and depression often go hand-in-

hand. These conditions can be incapacitatingand can develop so gradually that a lawyer isoften unaware of the cumulative effect on hisor her mood, habits, and lifestyle. Eachcondition is highly treatable, especially in theearly stages. Asking for help, however, runscounter to our legal training and instincts. Mostlawyers enter the profession to help others andbelieve they themselves should not need help.

The good news is that all it takes is a phonecall. The LAP works with lawyers exclusively.The LAP has been a trusted resource forthousands of lawyers in overcoming theseconditions.

Alcohol and Other SubstancesOften a lawyer will get depressed and self-

medicate the depression with alcohol. Alcoholis a central nervous system depressant but actslike a stimulant in the first hour or two ofconsumption. The worse you feel, the more youdrink initially to feel better, but the more youdrink, the worse you feel. A vicious cycle begins.On the other hand, many alcoholic lawyers whohave not had depression report that theirdrinking started normally at social events andincreased slowly over time.

There is no perfect picture of the alcoholic oraddicted lawyer. It may be surprising to learnthat he or she probably graduated in the topone-third of the class. Also surprising, lawyersmay find themselves in trouble with addictiondue to the overuse or misuse of certainprescription medications that were originallyprescribed to address a temporary condition.Use of these kinds of medications, combinedwith moderate amounts of alcohol, greatlyincreases the chances of severe impairmentrequiring treatment. The LAP knows the besttreatment options available, guides lawyersthrough this entire process, and provides on-going support at every stage.

info@nclap.org

An Important Free Resource for Lawyers

www.NCLAP.org

FREE l SAFE l CONFIDENTIAL

LAP recognizes alcoholism, addiction, and mental illness as diseases, not moral failures. The only stigma attached to these illnesses is

the refusal to seek or accept help.

Confidentiality

All communications with the LAP arestrictly confidential and subject to theattorney-client privilege. If you call to seekhelp for yourself, your inquiry is confidential.If you call as the spouse, child, law partner,or friend of a lawyer whom you suspectmay need help, your communication is alsotreated confidentially and is never relayedwithout your permission to the lawyer forwhom you are seeking help. The LAP has acommittee of trained lawyer volunteerswho have personally overcome theseissues and are committed to helping otherlawyers overcome them. If you call a LAPvolunteer, your communication is alsotreated as confidential.

The LAP is completely separate from thedisciplinary arm of the State Bar. If youdisclose to LAP staff or to a LAP volunteerany misconduct or ethical violations, it isconfidential and cannot be disclosed. SeeRules 1.6(c) and 8.3(c) of the Rules ofProfessional Conduct and 2001 FEO 5. TheLAP works because it provides anopportunity for a lawyer to get safe, free,confidential help before the consequencesof any impairment become irreversible.

Know the signs. Make the call.You could save a colleague’s life.

TAKE THE TEST FOR DEPRESSION

YES NO

q q 1. Do you feel a deep sense of depression, sadness, or hopelessness most of the day?

q q 2. Have you experienced diminished interest in most or all activities?

q q 3. Have you experienced significant appetite or weight change when not dieting?

q q 4. Have you experienced a significant change in sleeping patterns?

q q 5. Do you feel unusually restless...or unusually sluggish?

q q 6. Do you feel unduly fatigued?

q q 7. Do you experience persistent feelings of hopelessness or inappropriate feelings of guilt?

q q 8. Have you experienced a diminished ability to think or concentrate?

q q 9. Do you have recurrent thoughts of death or suicide?

If you answer yes to five or more of these questions(including questions #1 or #2), and if the symptomsdescribed have been present nearly every day for twoweeks or more, you should consider speaking to a healthcare professional about treatment options for depression.

Other explanations for these symptoms may need to beconsidered. Call the Lawyer Assistance Program.

Adapted from American Psychiatric Association: Diagnosticand Statistical Manual of Mental Disorders. Fourth Edition.Washington, DC. American Psychiatric Association: 1994.

TAKE THE TEST FOR ALCOHOLISM

YES NO

q q 1. Do you get to work late or leave early due to drinking?

q q 2. Is drinking disturbing your home life?

q q 3. Do you drink because you are shy with other people?

q q 4. Do you wonder if drinking is affecting your reputation?

q q 5. Have you gotten into financial difficulties as a result of drinking?

q q 6. Does drinking make you neglect your family or family activities?

q q 7. Has your ambition decreased since drinking?

q q 8. Do you often drink alone?

q q 9. Does drinking determine the people you tend to be with?

q q 10. Do you want a drink at a certain time of day?

q q 11. Do you want a drink the next morning?

q q 12. Does drinking cause you to have difficulty sleeping?

q q 13. Do you drink to build up your confidence?

q q 14. Have you ever been to a hospital or institution because of drinking?

q q 15. Do family or friends ever question the amount you drink?

If your answer is yes to two or more of these questions youmay have a problem. Call the Lawyer Assistance Program.

FREE l SAFE l CONFIDENTIAL

Western RegionCathy Killian 704.910.2310

Piedmont RegionTowanda Garner 919.719.9290

Eastern RegionNicole Ellington 919.719.9267