S. Alex Stalcup, M.D.

1. S. Alex Stalcup, M.D. New Leaf Treatment Center 251 Lafayette Circle, Suite 150 Lafayette, CA 94549 Tel: 925-284-5200 Fax: 925-284-5204 alex@nltc.com www.nltc.com

3. Functions of the Reward/Pleasure System of the Brain Rewards pursuit of instinctive drives (food, sex, nurture) Attention Enjoyment Rewards social contact Give pleasure to sensations, emotions, thoughts (rewarding) Assigns value (interest) to sensations, emotions, thoughts

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

6. Neuroadaptation, Tolerance, and Withdrawal Neuroadaptation: The brain’s response to over stimulation from drugs. In direct response to overstimulation, the brain regions decrease in sensitivity and become unresponsive (deaf) to normal levels of stimulation. Tolerance: The process by which the reward and pleasure centers of the brain adapt to high concentrations of pleasure neurotransmitters. Withdrawal Symptoms: The mirror image of the drug effects will always appear when a tolerant user tries to stop use. Cessation of drug use leads to ‘inversion of the high’. 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. In addition to pleasure circuits each drug type affects other neurotransmitter circuits. These brain pathways overstimulated by drugs also neuroadapt and become under active, leading to anxiety, depression, and loss of energy.

7. 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.

8. Model for nicotine addiction cycle during daily cigarette smoking

9. C I M Model TreatmentCauses 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 inadequately treated or untreated • Stress equals craving

10. Environmental Cueing =Conditioned Craving Drug pleasure becomes associated with specific people, places, and things; to encounter any of those things in the environment is to trigger craving for the drug. Such triggers persist for decades after use.

12. 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.

13. END SEGMENT ONE

14. Nicotine Addiction • 75.5% ever try nicotine • 49.5% become daily smokers • 24.1% develop nicotine dependence • 50% of lifetime (daily + dependent) smokers die prematurely from nicotine-related diseases • Male smokers lose 13.2 years of life • Female smokers lose 14.5 years of life

16. Are you at Risk? BPSM The Bio-Psycho-Social Model EWMS Environment Withdrawal Mental Health Stress

17. 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

18. Drink+Smoke Darrell’s Family Drugs+Drink+Smoke Smoke

20. Percentage of U.S. Adults Aged 18 and Older Dependent on Alcohol, by Age of Drinking Onset

22. Inherited predisposition (genetics) Childhood trauma or abuse Unwanted sexual involvement before age 13 Mental Illness: depression, anxiety, personality disorder Attention Deficit Disorder (ADD) Learning disabilities/school failure Subjected to teasing, bullying Acne and/or obesity Other than heterosexual orientation Social rejection Early sexual involvement Onset of drug use before age 16 Enabling environment Ignorance No family history of addiction Good mental health Academic competence Positive relationship with an adult Family eats dinner together 5 days/wk Peer group participation (clubs) Participation in sports Participation in music, drama or dance Involvement in faith-based activities Taking care of pets Volunteer activities Social acceptance Environment disapproves of drug use Immediate, appropriate scaled consequences for alcohol/drug use. Early intervention for alcohol/drug use Addiction: Risk & Resilience

23. Nicotine EffectsReceptor Activation • Increase arousal • Heighten attention • Influence stages of sleep • Produce states of pleasure • Decrease fatigue • Decrease anxiety • Reduce pain • Lessen depression • Improve cognitive function

25. Nicotine Withdrawal • Anger • Anxiety • Difficulty with Concentration • Sadness • Hungry • Difficulty with Sleep • Craving

26. NICOTINE WITHDRAWAL ASSESSMENT KEY

27. Bio-Psycho-Social ModelAre you at Risk? Apply B P S M (bio-psycho-social model) to yourself: Family history of addiction? Do you have a tendency to boredom or ADHD? Are you anxious or depressed? Have you suffered sexual trauma? Do you use substances to reduce stress? Did drug and alcohol use enter your life at a difficult time? Are you surrounded by drug and alcohol users?

28. Bio-Psycho-Social ModelAre you in trouble? How can you tell if you are getting into trouble? Are you using more frequently and using greater amounts? Have you developed tolerance? Is your use causing adverse consequences: grades, friends, money, health, unwanted sexual behavior? Do you crave the drug under addiction conditions: Environment, Withdrawal, Mental Health, Stress (EWMS) If so, when you crave the drug, can you talk yourself into using it, even when you have resolved to not use? When you have resolved not to use, under known craving conditions, do you find yourself using: environmental cues, anxiety or blue, withdrawal (bored, irritable, sleep), or when you are stressed?

29. TRY THE “EXPERIMENT” Resolve not to use. Go about your usual daily activities. Put yourself around the drug and people using it. Each day, score how high or low your craving to use has been for that day. Bio-Psycho-Social ModelAre You an Addict?

31. C I M Model TreatmentQuestions about Craving • What is your craving score? • Why is your craving score high? or low? • How are you going to manage the craving? • How are you going to manage the craving for the rest of the day?

32. Were you able to not use? Did you find your mind talking you into using? Did you struggle not to use? Were you able to have pleasure without using? Did you have problems with boredom, depression or anxiety? Bio-Psycho-Social ModelAre You an Addict?

33. Bio-Psycho-Social ModelWhat to do Get out of the using environment. Find alternative sources of pleasure. Work on balancing stress. Seek help for mental health issues and other personal stresses.

34. Inherited predisposition (genetics) Childhood trauma or abuse Unwanted sexual involvement before age 13 Mental Illness: depression, anxiety, personality disorder Attention Deficit Disorder (ADD) Learning disabilities/school failure Subjected to teasing, bullying Acne and/or obesity Other than heterosexual orientation Social rejection Early sexual involvement Onset of drug use before age 16 Enabling environment Ignorance No family history of addiction Good mental health Academic competence Positive relationship with an adult Family eats dinner together 5 days/wk Peer group participation (clubs) Participation in sports Participation in music, drama or dance Involvement in faith-based activities Taking care of pets Volunteer activities Social acceptance Environment disapproves of drug use Immediate, appropriate scaled consequences for alcohol/drug use. Early intervention for alcohol/drug use Addiction: Risk & Resilience

35. END SEGMENT TWO

36. Overview Bio-Psycho-Social factors Genetics: Does alcoholism or drug addiction run in your family? Were you truly bored in school? Were you hyperactive? Can you hold your liquor better than others? Childhood Abuse: Did you suffer trauma (physical or sexual abuse) during your childhood? Did you experience any other life-changing difficulties? Mental Illness: Do you have a parent or grandparent who is has a mental illness: depression, anxiety, bipolar disorder or schizophrenia? Have you been diagnosed with a mental health problem? Do you become really anxious, depressed, or unable to sleep when you stop using alcohol or drugs? The Drug: How old were you when you first started using alcohol or drugs? How long did it take before you used regularly? Circumstances of First Use: What was going on in your life when you first began using? Was it a good time or a bad time? What benefits did using give you? Enabling System: How easy was it for you to get alcohol/drugs? Did your parents and peers approve or disapprove of your use?

37. Bio-Psycho-Social ModelAssessment Goal: Develop an assessment of risk for becoming addicted Develop a family tree, noting all inherited diseases, school failure, mental illnesses, and protective factors Are symptoms of the addiction present in family or individual? If you are concerned, screen Mental Health using Beck Depression Inventory and Beck Anxiety Inventory Assess circumstances of first use

39. Drink+Smoke Darrell’s Family Drugs+Drink+Smoke Smoke

40. Bio-Psycho-Social ModelAnalysis of Early Drug Use Analysis: 1. Age of onset, time to regular use, use patterns, dosage form (eat, snort, smoke, inject) presence or absence of intoxication resistance. Circumstances of early use: difficult or positive time in life, awareness of drug effect beyond getting high What else did the drug do for you beside make you high, e.g., promote sleep, relieve depression or anxiety or boredom, help fit in, lose weight, make stronger?

41. Assessment Questions Have you ever used alcohol or other drugs ? • Have you ever felt guilty about your use of substances? • Have ever been criticized by other for your use of substances? • Have you ever had legal difficulties related to substance use, such as a DUI or wet and reckless? • Do you have history of addiction to alcohol/other substances? • If so, when did the addiction start and what has happened since then? • Have you ever received formal treatment for addiction or attended peer support, such as 12-step meetings?

42. C I M Model TreatmentCauses 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 inadequately treated or untreated • Stress equals craving

43. C I M Model Treatment Environmental Assessment Environmental Cueing immediate, high intensity craving caused by exposure to people, places, things, and events the user associates with getting and using alcohol or other drugs. People: Can you stay away from people you drank or used with? Places: Can you stay away from places where you drank or used? Things: Is your home a safe place? No alcohol? No drugs? No drug paraphernalia? Events: Do you have any upcoming events where people will be drinking or using?

44. C I M Model Treatment Cessation: Environmental Control Goal: to prepare home, school, and social environment to protect from exposure to environmental cues Cleaning out environments of ashtrays, paraphernalia, the drug, smell Rehearsing asking friends and family to discontinue use around client.

45. C I M Model TreatmentDetoxification Use of medications to treat withdrawal symptoms.

46. Nicotine Withdrawal • Mentally sluggish • Inattentive • Insomnia • Boredom and dysphoria • Fatigue • Anxiety • Increased pain sensitivity • Depression • Diminished cognitive function

47. C I M Model TreatmentMental Health Assessment Goal: to monitor whether mental health symptoms are exacerbated by abstinence. Monitor sleep, boredom, depression, anxiety, irritability Use test instruments to formally assess symptoms Develop access to medical assessment and treatment Monitor impact of treatment on symptoms and abstinence

48. Personal stressors Relationship conflict Financial problems Work school issues Parenting conflicts Legal issues Lifestyle stressors Hunger Anger Loneliness Tired C I M Model TreatmentAssessment for Stressors STRESS EQUALS CRAVING

49. Stress Management Goal: to develop alternatives to drug use that are pleasureable and reduce boredom and stress Practice effect of exercise, music, sports, social contact, fun activities on craving scores Experiment with scheduling day as stress response technique Practice fun alternative to use

50. Promoting Resilience • Positive relationship with an adult or supportive friend/family • Positive peer group activities • Involvement in faith-based activities • Participation in Drama or Music or Dance • Taking care of pets • Volunteer activities • Keep goal of one pleasureable activity per day • Strict adherence to a carefully balanced lifestyle