1. Today’s class 1. Housekeeping  Moodle  Did you email me your statement for HW 1? 2. Lecture – Brain disease or public health challenge? 3. Dr. Volkow’s talk Ted Talk on why brains get addicted 4. What is epigenetics? (The Ghost in your Genes) 5. Writing tip – how to organize your thoughts for an essay 6. Review for Quiz 1

2. brain stem – controls basic functions critical to life (e.g., heart rate, breathing, sleeping). cerebral cortex - different areas process information from our senses, enabling us to see, feel, hear, and taste. The frontal cortex, or forebrain, is the thinking center of the brain; it powers our ability to think, plan, solve problems, and make decisions. limbic system - the brain’s reward circuit, this area controls and regulates our ability to feel pleasure. Feeling pleasure motivates us to repeat behaviors that are critical to our existence. The limbic system is activated by healthy, life-sustaining activities such as eating and socializing—but it is also activated by substances. In addition, the limbic system is responsible for our perception of other emotions, both positive and negative, which explains the mood-altering properties of many substances. https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction

3. The brain undergoes dramatic changes during adolescence and continues to develop into adulthood. Introducing drugs during this period of development may cause brain changes that have profound and long- lasting consequences. https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction The prefrontal cortex enables us to assess situations, make sound decisions, and keep our emotions and desires under control.

4. To send a message, a brain cell (neuron) releases a chemical (neurotransmitter) into the space (synapse) between it and the next cell. The neurotransmitter crosses the synapse and attaches to proteins (receptors) on the receiving brain cell. This causes changes in the receiving cell—the message is delivered. Substances are chemicals that affect the brain by tapping into its communication system and interfering with the way neurons normally send, receive, and process information. Marijuana and heroin mimic natural transmitters. Amphetamine and cocaine cause release of abnormal amount of neurotransmitters, or prevent normal recycling. https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction..

5. Most substances target the brain’s reward system by flooding the circuit with dopamine. Dopamine is a neurotransmitter present in regions of the brain that regulate movement, emotion, motivation, and feelings of pleasure. When activated at normal levels, this system rewards our natural behaviors. Overstimulating the system with substances, however, produces euphoric effects, which strongly reinforce the behavior of substance use— teaching the user to repeat it. https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction.. How do substances produce pleasure?

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7. Q: Why is addiction a “brain disease”? A: Long-term substance use changes brain structures and functioning. https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction

8. Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp. 8417-8422, October 15, 1998. Decreased dopamine transporter binding in methamphetamine users resembles that in Parkinson ’ s Disease (PD) Control Meth PD

9. 9 The brain after cessation of substance use DA = Days Abstinent Partial Recovery of Dopamine Transporters After Prolonged Abstinence Normal Control Meth user (1 month abstinent) Meth user (36 months abstinent)

10. In what way is addiction a brain disease? Ted Talk by Dr. Nora Volkow “Why do our brains get addicted? http://www.tedmed.com/talks/show?id=309096

11. In what way is addiction a brain disease? l Brain imaging studies of people with addiction show a reduction in dopamine 2 receptors – these are used to exert self-control. In other words, the ability to control urges has been compromised. How does this happen? l Dopamine is released when you see or experience a reward (“conditional stimuli”)  image of a reward signals “reward” to the brain, dopamine is released, the urge increases. l When the substance is used, the urge is met and a person feels satiated. l But repeated use leads to a loss of dopamine receptors, which leads to an inability to feel satiated and thus an inability to control urges. l Note - people are less able to resist the urge when in a state of deprivation or when surrounded by stimuli. Notes from the Ted Talk by Dr. Nora Volkow “Why do our brains get addicted? http://www.tedmed.com/talks/show?id=309096

12. Reflect 1. Why does Dr. Volkow intertwine drug addiction with obesity and eating behaviors? 2. What was effective about Dr. Volkow’s talk? What could have been improved and how? 3. Dr. Volkow ends by focusing on food environments – suggesting that to prevent obesity we need to create options and alternatives. How do we use these concepts to prevent addiction, help people to avoid relapse, and improve treatment/interventions?

13. Making upstream the mainstream A man and a woman are fishing downstream… A child floats down, struggling… The woman rescues the child…

14. Making upstream the mainstream But then, another child floats down, and then a man and a woman, and then more children… … the rescuers are getting tired.

15. Making upstream the mainstream Eventually they ask, why are all of these people drowning in the river? They walk upstream to find out. People are drawn to the ledge. There is no safe place to look. Some people cannot swim. Children are unattended. Few people have been trained on how to safely float down a river. To prevent drowning the community could____________________________________.

16. Lessons from the Parable Instead of expending all resources and energy on rescuing each drowning person, why not “go upstream” and prevent the drowning from happening? Prevention may not eliminate drownings, but there may be fewer people to rescue. Prevention must address individual attitudes, knowledge, and behavior but also environmental and structural forces too.

17. Key Public Health Concepts Public health approach describes efforts to prevent disease or injury for a population. It is different from medicine. Population-based health considers a wide array of factors Behavioral Environmental Economic Social and cultural Social justice It addresses both risk factors and protective factors A risk factor is a behavior or condition that, on a basis of scientific evidence, is thought to increase vulnerability to a specific condition. A protective factor reduces vulnerability.

18. Levels of Prevention Primary - stop the problem from happening in the first place. Secondary - identify those who are already affected but still at an early stage. Tertiary – focus on people who have already experienced the problem. Build a viewing platform so people cannot fall in. Add a net so people who fall do not hit the water. Rescue people as soon as they hit the water. Teach people to swim and how to float down a river safely. Rescue drowners.

19. Rehabilitation Public health perspective of alcohol use and disorders Use & Problems Modality None 1º Prevention 2º Prevention Moderate Severe Chronic Disease management

20. One approach

22. Facilitated self change Heavy drinking only Chronic Disease management Brief motivational counseling Medical management + pharmaco tx or cognitive behavioral intervention Specialized remission- oriented treatment Increased quantity, frequency & consequencesof alcohol use Harmful drinking Dependence Extended Continuum

23. Let’s take a public health approach to addiction What are some “upstream” factors that influence the development or course of addiction? What would it mean to “make the upstream the mainstream” when we think about efforts to prevent or ameliorate addiction? Which population and problem would you focus on? Which risk factors and protective factors would you target? Which level of prevention would you address? Primary Secondary Tertiary

24. Epigenetics What is epigenetics? How can the environment impact health, and in ways that are passed on to our children and grandchildren? What implications do these ideas have for the prevention or treatment of substance use disorders?

25. Review for Quiz 1 1. Compare and contrast two definitions of SUD. 2. Compare and contrast two theories of the etiology of SUD. 3. What key findings emerged from the marshmallow experiment regarding self-control and delayed gratification? What implications might this science have for understanding why people continue to use substances even when they do not want to? 4. Define risk factor and protective factor. Provide at least one example of each and explain how they relate to the chances of developing a SUD. 5. What is meant by the term “social determinant of health”? Provide one example and how it relates to development of a SUD. 6. What is childhood adversity? How could it “cause” addiction? 7. How can health care better treat people with SUD who have had traumatic life experiences? What are two do’s and two don’ts? 8. In what way is addiction a brain disease? 9. How do substances produce pleasure, according to the brain science? 10. What does it mean to take a public health approach to addiction?