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Mindfulness, Meditation, and Drug and Alcohol Use

Mindfulness, Meditation, and Drug and Alcohol Use. Thomas Lyons, Ph.D. Loyola neuroscience seminar March 18, 2014. Mindfulness, Meditation and Drug and Alcohol Use. What is mindfulness? Enhancement of mindfulness through meditation training Neurobiology of meditation and drug addiction

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Mindfulness, Meditation, and Drug and Alcohol Use

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  1. Mindfulness, Meditation, and Drug and Alcohol Use Thomas Lyons, Ph.D. Loyola neuroscience seminar March 18, 2014

  2. Mindfulness, Meditation and Drug and Alcohol Use • What is mindfulness? • Enhancement of mindfulness through meditation training • Neurobiology of meditation and drug addiction • Mindfulness Based Relapse Prevention • Addiction and the criminal justice system: mindfulness programs in jails and prisons • Research program at Chicago State University • Summary and conclusions

  3. “Life is available only in the present moment.” ― ThíchNhấtHạnh

  4. What is mindfulness? • “Paying attention in a particular way; on purpose, in the present moment, and non-judgmentally.” (Kabat-Zinn) • Attention to thoughts, emotions and feelings in the present moment • Attitude of acceptance/non-reactivity and non-judgement • A very old concept • Sati in Sanskrit means “awareness”, also remembrance, an important concept in Buddhism • Came into Western languages in the 1970s through work of Vietnamese monk ThichNhatHanh and others

  5. What is mindfulness? • Can be conceptualized as • A mental state that varies from moment to moment in an individual • A personality trait or disposition perduring over time that can be measuring with personality inventories • The goal of mindfulness practice

  6. Five Facets Mindfulness Questionnaire (Baer et al 2006)

  7. Dispositional Mindfulness • Dispositional mindfulness is associated with adaptive functioning (Baer et al 2006). • Anxiety levels and history of depression (Grossman et al 2004) • less severe gambling outcomes (Lakey et al 2007). • diabetes self-management (Gregg et al 2007). • Many other cross-sectional studies • Difficulties with the construct of mindfulness as a trait (Grossman 2011) • Self reports may not be accurate • Experienced meditators may be more aware of their own limitations and rate themselves as less mindful

  8. Dispositional Mindfulness and Drug/Alcohol Use • Among college age drinkers, relationship to alcohol use is “paradoxical” (Eisenlohr-Moul et al 2012) • Higher levels of awareness • Lower levels of non-reactivity • Lower levels acting with awareness • Sample in drug treatment (Bowen and Enkema, 2014) • Mindfulness inversely related to severity of dependence

  9. Cultivating Mindfulness • Meditation • Types of meditation • Concentration or focused meditation, including TM • Insight or mindfulness meditation • Certain types of Hatha Yoga

  10. Insight Meditation • Various eastern traditions including Zen, Vipassana and Tibetan traditions can be grouped under mindfulness meditation • Often builds from awareness of the breath to awareness of the whole field of phenomena at the present moment • Can include sitting, walking meditation • Short demonstration: Mindfulness Based Cognitive Therapy (0:39:00) • Several short term or medium term interventions but for many, a lifetime practice http://www.youtube.com/watch?v=6-91LUJZoHo

  11. Neurobiology of meditation • Types of studies: • Measurement of brain state changes during meditation vs. rest or other activities • Cross sectional comparison between long term meditators, short term participants in interventions, and/or non-meditation control groups • Neural correlates of meditation/mindful states in these groups • Or response to a stimulus such as pain stimulus, emotional triggers • Longitudinal studies before and after meditation training • Comparisons to control group

  12. Neurobiology of meditation • Structural vs. functional studies • Healthy samples vs. clinical samples (with symptoms of depression, addiction etc) • Evidence from EEG, PET, fMRI, and SPECT

  13. Multiple brain structures affected • Prefrontal cortex • Somatosensory regions • Dorsolateral PFC • Hippocampus • Insulae • Amygdala • Functional networks • Eg insula plus somatosensory regions • Cortex plus limbic system

  14. Neurobiology of meditation • Cross sectional comparison of long term meditator vs non meditators show enhanced activity in the PFC, right anterior insula and right hippocampus (Chiesa & Seretti, 2010) • Eight week meditation training increases grey matter density in hippocampus, cerebellum compared to controls (Hölzel et al 2010) • Specific or non-specific effect?

  15. Mindfulness Meditation as a Behavioral Therapy • “Third wave” of therapeutic interventions based on acceptance of negative thoughts and emotions rather than attempts to manage or control them. • Mindfulness-based Stress Reduction for chronic pain (Kabat-Zinn 1980) • Acceptance and Commitment Therapy for depression and anxiety (Hays et al 2006) • Mindfulness-based Cognitive Therapy for depression (Segal et al 2002) • Dialectical Behavior Therapy for borderline personality disorder (Hays et al 2004)

  16. Possible mechanisms of clinical benefit Strengthening connectivity between the cortex and limbic system (Chiesa, 2013) • Dampen automatic amygdala activation • stress response, • anxiety and other emotional states • pain perception • May be interpreted as an increased conscious control • Increasing grey matter density in specific regions (Hölzel et al 2010)

  17. Before meditation, high emotional reactivity is observed. The amygdala easily activates in response to negative stimuli and the PFC is not able to inhibit the amygdala. (Chiesa et al. 2010)

  18. After meditation training, amygdala activity is usually reduced. If amygdala activates in response to negative stimuli, PFC is engaged in order to dampen automatic amygdala responses. (Chiesa et al 2010)

  19. Neurobiology of addiction • Effect of drugs of abuse is related to the mesolimbic reward system: ventral tegmental area, ventral striatum, amygdala and medial PFC – the “reward circuit”. • Compulsive use also involves the dorsal striatum – “habit circuit” • Addiction also involves dysfunction in the cortex, including dlPFC and activation of subgenual ACC

  20. Effect of mindfulness meditation training • Mindfulness training primarily targets the cortex; at least initially, a “top down” process of improving control over functioning • Self referential thinking and rumination activate midline PFC areas in both depression and addiction (Brewer et al. 2009) • Mindfulness practice may shift activation from midline PCC to dlPCC – more objective awareness • Lateralization of brain activation

  21. Effect of a brief mindfulness meditation training • 47 treatment-seeking smokers (12-h abstinent from smoking) viewed images while undergoing fMRI (Westbrook et al 2011). • Passively vs. trained to engage in mindful attention • Mindful attention reduced neural activity in subgenual anterior cingulate cortex (sgACC) • Reduced connectivity with other craving related regions including insula and ventral striatum • Also reduced self-reported craving (Westbrook et al. 2011)

  22. Effect of a brief mindfulness meditation training • 47 treatment-seeking smokers (12-h abstinent from smoking) viewed images while undergoing fMRI (Westbrook et al 2011). • Passively vs. trained to engage in mindful attention • Mindful attention reduced neural activity in subgenual anterior cingulate cortex (sgACC) • Reduced connectivity with other craving related regions including insula and ventral striatum • Also reduced self-reported craving (Westbrook et al. 2011)

  23. Top-down or bottom-up process? • Experienced meditators exhibit changes in limbic system functioning during meditation that are independent of cortical control.(Chiesa et al 2013) • May depend on length of involvement in meditation • May depend on type of sample: healthy vs. clinical samples (eg smokers trying to quit)

  24. Mindfulness Based Relapse Prevention (Chawla et al 2011) • Based on Mindfulness Based Stress Reduction • An eight week course including meditation, yoga, and discussion of relapse, triggers, and relapse prevention • Designed for individuals coming out of drug treatment

  25. Mindfulness Based Relapse Prevention • In a randomized controlled trial (RCT), significant reductions in substance use and craving were observed in the MBRP group compared to treatment as usual (Bowen et al, 2009b) • A second RCT compared mindfulness meditation to cognitive behavioral therapy for substance use and found reduced craving and physiological stress indices in the treatment group (Zgierska et al 2010)

  26. Mindfulness Based Relapse Prevention • Might have particularly long-lasting effects on reducing drug use (Zgierska et al 2009). • However, strong evidence for effectiveness of mindfulness-based treatment for substance use disorders is still lacking. (Zgierska et al 2009)

  27. Difficulties with MM in drug treatment • Anxiety in early withdrawal (Vallejo et al 2009) • Restlessness/agitation • History of trauma • An adjunct, not a substitute for drug treatment • May require a period of abstinence from substances

  28. Research at Chicago State University • Urban Mindfulness and Addictions Research • MBRP in jail drug treatment • Mindfulness with case managers: enhancing the working alliance and therapeutic outcomes • Mindfulness, substance abuse, and medication adherence • Drug discovery program as adjunct to mindfulness therapy

  29. Addiction and the Criminal Justice System • More than 60% of prisoners are estimated to have a substance use disorder(National Center on Addiction and Substance Abuse 2010) • In Cook County the majority of detainees are charged with low level drug offenses(Lyons et al 2013)

  30. Addiction and the Criminal Justice System • Five fold growth in incarceration rates among people of color since 1980 has largely been a result of drug related arrests and convictions(Alexander 2010). • African Americans are 54% of those incarcerated for drug offenses and are 10 times more likely than whites to be sentenced to prison for a drug law violation(Human Rights Watch 2000). • Cycles of repeated arrest and imprisonment for drug related crimes often reflect untreated addiction(Langan and Levin 2002).

  31. Addiction and the Criminal Justice System • Much mindfulness meditation research has been with white, middle class patients. • No studies of mindfulness meditation that focus on cultural adaptations for African American men. • Meditation training in a jail context • Limited in duration • Linked to post-release services • Participants should be over the acute withdrawal stage

  32. Why meditation programs in jail? • 7x as many individuals released annually from jails as from prisons • Many jails have existing drug treatment programs • Enforced abstinence may promote benefit of mindfulness training • Mindfulness training may promote engagement in aftercare

  33. Goals of the study • Culturally tailor the MBRP intervention for an urban, primarily African American population of inmates • Test efficacy via a quasi-experimental clinical trial within a men’s drug treatment program at the Cook County Jail.

  34. Goals of the study • At 5-month intervals over the course of 36 months, successive cohorts will be given either mindfulness training or an attention control communication skills intervention. • Pre- and post-test assessments, at an equivalent interval, of mindfulness, psychological symptoms, and PTSD symptoms. • Participants in the experimental condition will be referred to post-release meditation groups

  35. Goals of the study • To assess the efficacy of the intervention, • rearrest and reincarceration data will be compared for the treatment and control groups at a minimum of 12 months post release. • Contact participants by telephone 3 months post release and obtain self reported substance use data • qualitative interviews with a subset of participants in the experimental group one month post-release will explore whether and how they implemented mindfulness

  36. Formative research to adapt intervention • Focus group • Working with African American, culturally competent trainers • Adapting and simplifying manual Mindfulness Based Relapse Prevention: A Clinician’s Guide (Chawla et al. 2011)

  37. Some conclusions • Mindfulness as an attentional state, personality trait, and goal of meditation practice • As a trait, mindfulness is probably important for understanding addiction, but research is just beginning • Related to deficits in executive functioning, impulsiveness, and sensation seeking

  38. Some conclusions • Meditation practice changes brain structure and functional circuits • Most studies cross sectional and involve small samples • Prospective studies with appropriate control groups needed • Meditation training may be a potent tool in drug addiction treatment • May have long lasting effects • Stage and context of recovery important • Linking behavioral and pharmacological treatment

  39. Thank you! tlyons20@csu.edu

  40. References • Alexander, M. (2010). The new Jim Crow: Mass incarceration in the age of colorblindness. New York: New Press. • Baer, R. A., Hopkins, J., Krietemeyer, J., Smith, G. T., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27-45. • Bowen, S., & Enkema, M. C. (2014). Relationship between dispositional mindfulness and substance use: Findings from a clinical sample. Addictive Behaviors, 39, 3, 532-537. • Bowen S, Marlatt A. (2009a) Surfing the Urge: Brief Mindfulness-Based Intervention for College Student Smokers. Psychology of Addictive Behaviors 2009;23(4):666-671. • Bowen S., Chawla N., Collins S.E., Hsu S., Grow J., Clifasefi S., et al. (2009b) Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse 2009;30(4):295-305. • Chiesa A., Serretti A. A systematic review of neurobiological and clinical features of mindfulness meditations. Psychological Medicine 2010;40(8):1239-1252. • Chiesa A, Serretti A, Jakobsen JC. Mindfulness: Top–down or bottom–up emotion regulation strategy? Clinical Psychology Review 2013;33(1):82-96. • Eisenlohr-Moul T.A., Walsh E.C., Charnigo Jr. R.J., Baer R.A., Lynam D.R. The "What" and the "How" of Dispositional Mindfulness: Using Interactions Among Subscales of the Five-Facet Mindfulness Questionnaire to Understand Its Relation To Substance Use. Assessment 2012;19(3):276-286. 29 • Gregg, J., Callaghan, G. Improving diabetes self-management through acceptance, mindfulness and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology. 2007. Vol. 75. No. 2 336-343. • Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res. 2004 Jul; 57(1):35-43. • Grossman, P., & Van, D. N. T. (May 01, 2011). Mindfulness, by any other name…: trials and tribulations of sati in western psychology and science. Contemporary Buddhism, 12, 1, 219-239. • Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and Commitment Therapy: Model, processes and outcomes. Behav Res Ther 2006;44(1):1-25. • Hayes SC, Follette VM, Linehan M. Mindfulness and acceptance : expanding the cognitive-behavioral tradition. New York: Guilford Press; 2004.

  41. References • Hölzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S. W. (January 01, 2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research, 191, 1, 36-43 • Human Rights Watch. Punishment and prejudice: Racial disparities in the war on drugs. 2000. Retrieved from http://www.hrw.org/reports/2000/05/01/punishment-and-prejudice-racial-disparities-war-drugs • Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry 1982;4(1):33-47. • Lakey, Campbell, W., Brown, K. Goodi, A. Dispositional mindfulness as a predictor of the severity of gambling outcomes. Personality and Individual Differences. 2007. Vol. 43: 1698–1710 • Langan PA, Levin DJ, United States. Bureau of Justice Statistics. Recidivism of prisoners released in 1994. 2002; . • National Center on Addiction and Substance Abuse. Behind bars II : substance abuse and America's prison population. New York, NY: National Center on Addiction and Substance Abuse at Columbia University; 2010. • Lyons T, Lurigio A, Roque L, Rodriguez P. Racial Disproportionality in the Criminal Justice System for Drug Crimes: A State Legislative Response to the Problem. Race and Justice 2013;3(1):83-101. • Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression : a new approach to preventing relapse. New York: Guilford Press; 2002. • Thorsten, B., Duggan, D., Griffith, J. Dispositional mindfulness moderates the relation between neuroticism and depressive symptoms. Pers Individ Dif. 2011 December; 51(8): 958–962. • Vallejo Z, Amaro H. Adaptation of Mindfulness-Based Stress Reduction Program for Addiction Relapse Prevention. Humanistic Psychologist 2009;37(2). • Westbrook C, Creswell JD, Tabibnia G, Julson E, Kober H, Tindle HA. Mindful attention reduces neural and self-reported cue-induced craving in smokers. Social Cognitive and Affective Neuroscience 2011(12). • Zgierska A., Rabago D., Kushner K., Chawla N., Marlatt A., Koehler R. Mindfulness meditation for substance use disorders: A systematic review. Substance Abuse 2009;30(4):266-294.

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