From Research to Recovery: Linking Science and Treatment in Addiction Medicine Sean Koon, MD Chemical Dependency Recovery Program Kaiser Permanente, Fontana

The Dichotomy of our Science and Practice  At conferences such as this, we often delve deeply into cell biology and neuroscience to understand this disease process  Yet, many of us will return a world of group therapy, recovery slogans, surrender, denial, relapse, 12-steps, and even issues of spirituality

Neuroscience and the Commerce of Choice  Motivational neural circuits – reward us for life sustaining behaviors  Drugs of abuse have a substantial effect on brain pathways of motivation and learning

Neuroscience and the Commerce of Choice  Homeostasis vs. Allostasis and compulsion in addiction  Conflict between logical value and the urgency of immediate value

Neuroscience and the Commerce of Choice VS. Maslow’s Hierarchy of Needs

“Millstones” and the Angst of Addiction  A painful discord between the patient’s core values and their behaviors, resulting from compulsion and “poor trades”  Between these opposing “millstones”, integrity, self-esteem and hope suffer: INCOMPREHENSIBLE DEMORALIZATION

“Millstones” and the Angst of Addiction  How do you relieve this friction? –DENIAL –CODEPENDENCY (get by with a little help from your friends) –MORE USE  If personal loss “outpaces” the effectiveness of these three, then “rock bottom” is felt  If these three are effective, rock bottom is not felt until greater loss occurs “Rock Bottom” “Sick and tired of being sick and tired”

Incomprehensible Demoralization  The addiction grows and demoralization continues –Despair –Concealment –Isolation

Addiction and the Ripple Effect  In the brain, compulsion begins to win over good judgment in the commerce of choice  The addict suffers between these “millstones” of values and compulsions

Addiction and the Ripple Effect  The enablers are caught between the millstones of their co-dependency needs vs. their personal suffering

Addiction and the Ripple Effect  The community is conflicted between marginalization of the addict vs. intervention

Addiction and the Ripple Effect  Even the government has its own millstones: justice vs. mercy

Addiction and the Ripple Effect  With roots in biology, it becomes a disorder with moral, social, family, spiritual, mental health, legal, and medical elements  Ironically, each of the above disciplines also contributes to the solution

Why Treatment?  Medical: Addresses medical consequences and educates the patient  Mental Health: Treats organic or substance induced mood disorders  Family: Engages and treats the family system. Treats codepency.  Occupational: helps employers assess and deal with workers with addiction  Legal: Cooperates with the legal system and provides an effective alternative to incarceration in non-violent offenders  Spiritual: addresses spirituality, shame, and demoralization  Social: deals with isolation and engages the patient into recovery community. Encourages resocialization

WHY 12 Step Program SlogansResearch Correlates “Old Playmates and Old Playgrounds” Conditioned place preference, associative learning “H.A.L.T.” “Gratitude is an attitude” Negative affective states increase propensity to relapse “One drink is too many and a thousand is not enough” Priming effect “Stinking thinking”Cognitive distortions increase probability of relapse. CBT “Get out of the drivers seat”Impaired decision making in addiction “A drug is a drug is a drug”Cross addiction “Easy does it” “One day at a time” Stress as a precipitant to relapse

Why Spirituality ?  Spirituality at it’s core implies connection within (integrity of value and action) as well as a connection without (community and “higher power”).  Addiction is a disease of disconnection, it causes a rift within the addict, as well as a rift between the addict and everything else

How it works: The Cast of Recovery  Unmanageability  Honesty, openness, willingness allows the faulty inclinations to be exposed  Community: –Accepts –Forms around –Aligns and redirects the impaired choices –Continues to Support Surrender, sponsorship, group therapy, “one alcoholic helping another”

Treatment is Excessively Beneficial: You get more than you came for…

Foundations of Addiction Medicine “Evidence and Art” CSAM 2004