1. S. Alex Stalcup, M.D. New Leaf Treatment Center
251 Lafayette Circle, Suite 150
Lafayette, CA 94549
Tel:
Fax:

2. Trying to practice criminal law and not understanding addiction is like trying to be a mechanic and not understanding how to fix a flat tire.
Four of five criminal defendants meet one or more of these criteria:
Regular drug abuser
Was on drugs at the time of the offense
Committed the crime to support a habit
Charged with a drug-related offense.

3. What is a Drug?
A drug is a pleasure producing chemical. Drugs activate or imitate chemical pathways in the brain associated with feelings of well-being, pleasure and euphoria.

5. Functions of the Reward/Pleasure System of the Brain
Reward for pursuit of instinctive drives
(food, sex, nurture)
Focuses attention
Enjoyment
Rewards for social contact
Gives pleasure to sensations, emotions, thoughts (rewarding)
Assigns value (interest) to sensations, emotions, thoughts
Inhibits impulses via activation of the Pre-Frontal Cortex Executive Functions

6. The ventral tegmental area (VTA), and its efferent and afferent systems. ﾊ a | Human (left) and rat (right) brains, showing the mesolimbic and mesocortical dopamine (DA) pathways, which originate in the VTA and send ascending projections to the nucleus accumbens (NAc) and prefrontal cortex (PFC), respectively. These pathways are strongly activated by nicotine and are implicated in its rewarding and aversive psychological properties. The VTA also sends a descending projection to the tegmental pedunculopontine nucleus (TPP), a brain region that is involved in non-DA-mediated reward signalling. The rewarding effects of nicotine are blocked by lesions69 or GABA (-aminobutyric acid)-mediated inhibition78 of this nucleus. Ascending cholinergic and glutamatergic projections from the TPP also influence VTA neuronal activity and can regulate the activity of DA neurons in the VTA46, 47. b | Schematic showing the DA and GABA neuronal populations within the VTA. GABA neurons send descending projections to the TPP and provide inhibitory input to DA neurons. Both neuronal populations are activated by nicotine32, 33, 40. In addition, both neuronal populations receive excitatory glutamatergic inputs, which can regulate the relative activity of DA and GABA activity in the VTA.
Laviolette SR, vander Kooy D. The neurobiology of nicotine addiction: bridging the gap from molecules to behaviour.
Nature Reviews Neuroscience 5; (2004)

7. GABA Scale

8. Neuroadaptation, Tolerance, and Withdrawal
Neuroadaptation is the brain’s response to over stimulation from drugs. Drug-specific circuits cause a mixture of sedation and stimulation or intoxication.
Tolerance is the process by which the reward and pleasure centers of the brain adapt to high concentrations of pleasure neurotransmitters. In direct response to overstimulation, the brain regions decrease in sensitivity and become unresponsive (deaf) to normal levels of stimulation.
In addition to pleasure circuits each drug type affects other specific circuits. Other brain pathways overstimulated by drugs also neuroadapt and become under active, directly leading to anxiety, depression, and loss of energy.
Once neuroadaptation develops (tolerance), there will always be withdrawal symptoms that are the mirror image of the drug effects. Cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless, anxious, sleepless, and lacking energy
Under unstimulated conditions (without drugs) there is profound interference with the ability to experience normal pleasure. When sober, the user feels anhedonia, anxiety, anger, frustration and craving. The pleasure system remains impaired for months to years, interfering with sobriety, learning, and impulse inhibition.

9. Weighing consequences
Behavior Control: The Balance Concept
Forebrain
Decision Making
Logic
Drug Craving
Judgment
Cueing
Ethics
Hunger
Salience
(weighing value)
Greed
Lust
Weighing consequences
Fear
Rage
Jealousy
Midbrain

10. D2 Hypofrontality
Baseline metabolism falls in the prefrontal cortex secondary to decreased excitatory dopamine input.
Impaired decision making results from direct interference with reasoning, logic, and the ability to weigh consequences.
Drives, impulses, and craving are not inhibited because of direct compromise of brain reasoning ability.
The mind overvalues reward, fails to appreciate risk, and fails to activate systems that warn of impending danger.
The mind misjudges using as “worth it” by being unable to appreciate adverse consequences.

11. Drugs Induce Hypofrontality and Intensify Impulse
INTOXICATION Disturbance of perception
Impaired thought: rapid, over-focused, confused, disorganized
Impaired memory
Perseveration
BEHAVIORAL DISINHIBITION:
Failure of executive function to adequately restrain impulse, aggression, and/or belligerence
IRRITABILITY Lowered threshold for anger
Exaggerated anger response to stimulus
SLEEP DEPRIVATION Impaired memory, Dissociation, Derealization, and Depersonalization
PSYCHOSIS Delusion: Erroneous belief w/distortion or exaggeration of thought (paranoia)
Hallucination: A distortion or exaggeration of perception
Disorganization of speech and behavior
DELIRIUM Incoherent thought and speech
Awareness is dissociated from the environment
Internal preoccupation
ADDICTION Chronic hypofrontality, usually superimposed on underlying hypofrontality

12. Information Needed to Assess the Role of Drugs
Relative to the incident,
When did the client last use alcohol or other drugs ?
Does this use episode differ from client’s usual pattern of use ?
Was the client intoxicated or in a craving state ?
Was the client sleep deprived ?
What was the client’s mental state at the time of the incident ?
Is the client’s self reported mental state consistent with witnesses ?
Were blood/urine samples obtained from the client for analysis ?
If so, how long after the incident were the samples obtained ?

13. Information Needed to Assess the Role Of Drugs
Is the client an addict ?
Is the client physically dependent on any drug ?
The drug: amount used ?
route of administration ?
frequency of use ?
What is the client’s prior experience when using the drug ?
Under the influence of the drug, how does the client’s state differ from the sober state?
Does the client have prior experience with treatment for alcohol or other drugs ?

14. Definition of Addiction
Compulsion: loss of control
The user can’t not do it s/he is compelled to use.
Compulsion is not rational and is not planned.
Continued use despite adverse consequences
An addict is a person who uses even though s/he knows it is causing problems.
Addiction is staged based on adverse consequences.
Craving: daily symptom of the disease
The user experiences intense psychological preoccupation with getting and using the drug.
Craving is dysphoric, agitating and it feels very bad.
Denial/hypofrontality: distortion of cognition caused by craving
Under the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using.

15. Addiction Effects on Behavioral Control
CRAVING
Hijacks brain drive machinery, Suppresses awareness of threat, Suppresses awareness of wrong, Impairs recall of adverse consequences, Overvalues necessity of goal
HYPOFRONTALITY
Direct compromise of judgment by the disease process
IMPULSIVITY
Acting without consideration, reflection, appreciation of consequences
LOSS OF RATIONAL CONTROL OVER BEHAVIOR
Especially drug seeking and drug use

16. “Diseased Decisions”
Concepts like “willingly use”, “intend”, “choose to use” do not apply to addiction:
Decisions by addicts are part of a disease process, and are not rational application of “free will.”
Reflection, deliberation, and consideration are precluded in addictive behavior.

17. Loss of Control Addicts do not choose to use:
Control over behavior is a target of the disease process of addiction.
Drug use by a person with the disease of addiction is not VOLITIONAL use; it is compulsive, the absence of choice.
Reflection, consideration of right and wrong, weighing consequences, are all DISEASED in addicts.

18. Risk of Addiction Positive and Negative Reinforcement
If, in addition to producing pleasure
(positive reinforcement), a drug is more
addicting if it relieves negative states:
boredom, anxiety, depression or stress
(negative reinforcement).

19. Addiction Risk and Perpetuation
BPSM
The Bio-Psycho-Social Model
EWMS
Environment
Withdrawal
Mental Health
Stress

20. Bio-Psycho-Social Model
Predisposition
Genetics
Childhood Sexual Abuse
Mental Illness
Acquired Hypofrontality
in utero alcohol/drug exposure low birth weight
perinatal asphyxia head injury
The Drug / Circumstances of First Use
Enabling System

21. C I M Model Treatment Causes of Craving
E W M S
Environmental cues (Triggers)
immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiences
Drug Withdrawal
inadequately treated or untreated
Mental illness symptoms
Stress equals craving

22. Abuse versus Addiction
Substance Abuse is distinguished from Addiction by the appearance of tolerance and withdrawal, leading to loss of control over use.
Substance abusers require motivation to stop.
Addicts require treatment to stop.

23. Residential Treatment
Monitoring and Treatment
In-custody Treatment
Residential Treatment
IOP + Sober Living
Intensive Outpatient
IOP
Addict
Re-entry
Monitoring
Random UDS 6 months
(Positive UDS)
Entry
Assessment
Monitoring
Random UDS
6 tests/90 days ?
Discharge
Unsure
Discharge

24. C I M Model Treatment Components of Treatment
Initiation of Abstinence: Stopping Use
Drug Detoxification: Use of medications to control withdrawal symptoms
Avoidance Strategies: Measures to protect the client from environmental cues
Schedule: Establishing times for arising, mealtimes, and going to bed
Mental Health Assessment and Treatment
Relapse Prevention
Drug Detoxification: Continued use of medications to control withdrawal
Avoidance Strategies: Controlled re-entry to cue-rich environments
Schedule: Adherence to a regular daily lifestyle
HUNGRY Three regularly spaced meals each day
ANGRY Separate feelings of anger from losing control of behavior
LONELY One positive social contact per day minimum
TIRED Daily practice of sleep hygiene
Tools: Behaviors that dissipate craving
Exercise Spiritual Practice Talk Peer Support Groups Counseling Having Fun
Mental Health Treatment

25. Causes of Addiction Treatment Failure
Exposure to environmental cues
Failure to provide withdrawal management
Failure to concurrently treat co-occurring mental illness
Failure to teach a balanced lifestyle and to manage craving caused by stress.

26. Predictors of Treatment Outcome
Negative (clean) drug test results are the best objective measure of sobriety.
Length of time in treatment
Less than 3 months in treatment has no effect.
After treatment for months 68% achieve sobriety.
Retention in treatment is a primary factor influencing outcome.
Drug Court participation doubles the number of clients retained in treatment.

27. Meth-free subjects at 6 month and 12 month Follow-up
Methamphetamine treatment project data.
This data indicates that methamphetamine dependence is a highly treatable disease. Participants who were legally-involved had better outcomes. The “legal hook” which compels participation in treatment helps participants stay sober. The treatment effect lasts beyond 12 months and perhaps as long as five years.

28. REFERENCES
Benowitz N. Neurobiology of nicotine addiction: implications for smoking cessation treatment. American Journal of Medicine. 121(4A) S3-S10 (2008).
Bechara A. Decision making, impulse control and loss of willpower to resit drugs: a neurocognitive perspective. Nature Neuroscience. 8: (2005)
Dackis C, O’Brien C. Neurobiology of addiction: treatment and public policy ramifications. Nature Neuroscience. 8(11): (2005).
Nestler EJ, Malenka RC. The addicted brain. Scientific American.com February 9, 2004.
Stalcup SA, Christian D, Stalcup JA, Brown M Galloway GP. A treatment model for craving identification and management. Journal of Psychoactive Drugs. 38:235-44, 2006
Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. Journal of Clinical Investigation. 111(10: (2003).
Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in progress. National Campaign to Prevent Teen Pregnancy. June 2005.

29. THE END