The Neurobiology of Addiction Addiction 101 in Olson

Summary

This lecture delves into the neurobiology of addiction, emphasizing its status as a brain disease rather than a behavioral one. It outlines the disease model of addiction, affecting key brain areas like the frontal cortex and midbrain, leading to compulsive drug-seeking despite negative outcomes. The discussion highlights how drugs hijack the brain's reward system, causing a dysregulation in dopamine levels and resulting in a perpetual cycle of craving and use. The speaker advocates for a comprehensive treatment approach, including therapy, medication, and spiritual growth, to strengthen the frontal cortex and reestablish control over the midbrain's survival instincts.

Takeaways

• 🧠 Addiction is a brain disease, not a psychological one. It involves actual changes in the brain, particularly in the frontal cortex and midbrain.
• 🚫 The disease model of addiction fits the medical definition of a disease, with an organ (brain), a defect (neurological changes), and symptoms (loss of control, cravings).
• 👶 The midbrain, responsible for survival, is hijacked by drugs. It starts to believe it needs high levels of dopamine to survive, leading to addiction.
• 💊 Drugs of abuse, regardless of type, work in the midbrain and trigger the release of dopamine, which is the same neurotransmitter involved in natural rewards.
• 🔄 The brain's pleasure system gets dysregulated in addiction, causing a decrease in dopamine receptors and a higher threshold for experiencing pleasure.
• 🔄 Stress and trauma can lead to similar neurobiological changes as addiction, increasing the risk for addiction and relapse.
• 💭 Cravings are not just psychological; they are the result of an active midbrain sending physiological signals that the body interprets as needing the drug to survive.
• 🧘‍♂️ Treatment for addiction involves strengthening the frontal cortex through therapy, 12-step programs, and spirituality to overpower the midbrain's drive for drugs.
• 💊 Medication-assisted treatment helps to quiet the midbrain's cravings, allowing individuals to engage in therapy and recovery programs more effectively.
• 👥 Addiction treatment requires a team approach, combining therapy, support groups, and medication when appropriate, to address the complex nature of the disease.

Q & A

What is the main reason for discussing the neurobiology of addiction?

The main reason for discussing the neurobiology of addiction is to address the misconception that addiction is not treated as a disease despite being referred to as one. The lecture aims to reduce stigma and promote appropriate treatment by explaining the biological basis of addiction.

How does the disease model of addiction apply to the brain?

The disease model of addiction applies to the brain by identifying the organ affected as the brain itself, with a defect in its neurological functioning leading to addiction. This model is typically used in medicine to define diseases, where there's an organ, a defect in that organ, and symptoms resulting from that defect.

What are the two major parts of the brain involved in addiction according to the script?

The two major parts of the brain involved in addiction are the frontal cortex and the midbrain. The frontal cortex is associated with personality, values, ethics, morals, willpower, and conscious decision-making, while the midbrain is linked to survival instincts and is not under conscious control.

Why does the midbrain play a critical role in addiction?

The midbrain plays a critical role in addiction because it is responsible for the brain's reward system and survival instincts. Drugs of abuse work in the midbrain, releasing dopamine and creating a false sense of needing the substance to survive, which leads to addiction.

How does the brain's response to drugs of abuse differ from natural rewards like food?

The brain's response to drugs of abuse differs from natural rewards like food in the amount of dopamine released. While food releases dopamine to ensure survival, drugs of abuse release massive amounts of dopamine,远超 the brain's normal threshold for pleasure, leading to a dysregulation of the reward system and addiction.

What happens in the brain when someone is addicted that causes them to continue using despite negative consequences?

When someone is addicted, the midbrain erroneously believes it needs a high level of dopamine to survive, leading to cravings and loss of control. This results in persisting use despite negative consequences as the brain's reward system is dysregulated.

How does the script explain the role of dopamine in addiction?

The script explains that dopamine is the neurotransmitter responsible for the brain's reward system and pleasure. Drugs of abuse cause a massive release of dopamine,远超 the brain's normal threshold, leading to a downregulation of dopamine receptors and an increased threshold for pleasure, which is a key factor in addiction.

What is the significance of glutamate in the context of addiction as described in the script?

Glutamate is significant in addiction because it is responsible for memory formation. It acts like an executive assistant to dopamine, helping to create and store memories associated with dopamine release, which can lead to cravings and relapse when exposed to similar environments or cues.

How does stress relate to addiction according to the script?

Stress is related to addiction as it can lead to a downregulation of dopamine receptors, similar to the process in addiction. Chronic severe stress can increase the threshold for pleasure, making individuals more susceptible to the effects of drugs and potentially leading to addiction.

What are the three main factors that cause relapse in addiction as mentioned in the script?

The three main factors that cause relapse in addiction are dopamine exposure, stress, and exposure to drug cues. These factors can trigger the midbrain to seek out dopamine, leading to cravings and potentially relapse.

How does the script suggest treating addiction effectively?

The script suggests treating addiction effectively by using a combination approach that includes therapy, 12-step programs, group therapy, and medication if appropriate. The goal is to strengthen the frontal cortex to overpower the midbrain's cravings and to restore the brain's normal pleasure set point.

Outlines

00:00

🧠 Understanding Addiction as a Brain Disease

The speaker introduces the topic of addiction, emphasizing the need to treat it as a disease. They discuss the discrepancy between how addiction is viewed as a disease and how it is actually treated. The speaker is a board-certified expert in family and addiction medicine, with extensive experience in treating addiction. They explain the disease model of addiction, which is a framework used in medicine to define diseases based on organ defects and resulting symptoms. Using diabetes as an example, the speaker illustrates how addiction fits into this model as a brain disease, affecting the frontal cortex and midbrain. The frontal cortex is associated with personality, values, ethics, morals, and willpower, while the midbrain is linked to survival instincts. The speaker clarifies that addiction is a neurological issue, not a psychological one, and that the brain undergoes actual changes that result in addictive behavior.

05:01

🐭 The Neurological Basis of Addiction

The speaker delves into the neurological aspects of addiction, explaining how drugs of abuse affect the midbrain, which is responsible for survival instincts. They use the example of mice that will self-administer cocaine directly into their brains until death, demonstrating that addiction is not influenced by socioeconomic or cultural factors but is purely neurological. The midbrain's role is to ensure survival, and with repeated drug use, it starts to rely on high levels of dopamine to function, leading to addiction. The speaker explains that all drugs of abuse, regardless of their type, affect the same part of the brain and the same neurotransmitter system, hence there is no such thing as a specific drug addiction, but rather addiction in general. They also discuss how the brain's reward system is hijacked by drugs, leading to a constant search for the high levels of dopamine that drugs provide.

10:02

🧪 Dopamine, Pleasure, and the Brain's Set Point

This section explores the role of dopamine as the brain's pleasure chemical and how it is central to the brain's reward system. The speaker explains that the brain has a set point for pleasure, similar to how the body has a set point for temperature regulation. Drugs and alcohol can release excessive amounts of dopamine, causing the brain to down-regulate dopamine receptors, which in turn raises the threshold for pleasure. This leads to a decreased ability to experience joy from natural rewards, as the brain requires more dopamine to feel the same level of pleasure. The speaker also discusses the impact of chronic stress on dopamine receptors, which can lead to a similar down-regulation and increased pleasure threshold, setting the stage for addiction. They highlight the role of glutamate in memory formation and how it reinforces dopamine's effects, creating associations that can trigger cravings and relapse.

15:04

🚑 The Role of Cravings and the Midbrain in Addiction

The speaker discusses the concept of cravings as a manifestation of the midbrain's activation, which sends physiological signals to the body to seek relief. These signals can include sweating, chills, nausea, and restless legs, among others. The midbrain, in its quest for survival, will tap into the cortex to find reasons to use drugs, even if they are not warranted. This can lead to rationalizations and justifications for drug use, as the brain seeks to alleviate the discomfort caused by cravings. The speaker emphasizes that the outward behaviors associated with addiction, such as lying and manipulation, are symptoms of the underlying neurological changes and not simply a reflection of the person's character. They stress the importance of understanding these processes to effectively treat addiction.

20:04

🛑 Treatment Approaches and the Path to Recovery

The final paragraph outlines various treatment approaches for addiction, focusing on the need for a combination of therapies, 12-step programs, and medication when appropriate. The speaker emphasizes the importance of strengthening the frontal cortex to regain control over the midbrain's cravings and survival instincts. They discuss the role of abstinence in quieting the midbrain and the use of medications to manage cravings and reduce harm. The speaker also highlights the need for coping skills and stress relief, as well as spiritual growth, to empower individuals in their recovery journey. They conclude by stating that no single person can treat addiction alone and that a team approach, including therapy, support groups, and medical intervention, is necessary for success.

Keywords

💡Neurobiology of Addiction

The neurobiology of addiction refers to the study of how addiction affects the brain and the underlying neurological processes that contribute to addictive behaviors. In the video, the speaker emphasizes that addiction is a brain disease, not just a psychological issue, and discusses the changes in the brain that result in addiction, such as alterations in the frontal cortex and midbrain.

💡Disease Model

The disease model is a framework used in medicine to conceptualize conditions as diseases, which typically involves identifying an organ affected by a defect that leads to symptoms. The speaker argues for addiction to be understood within this model, suggesting that the brain is the organ affected, with defects leading to compulsive drug-seeking behavior as the symptoms.

💡Frontal Cortex

The frontal cortex is a part of the brain associated with higher cognitive functions such as personality, decision-making, and willpower. In the context of the video, the speaker explains that addiction can impair the frontal cortex's function, leading to a 'weak Superman' analogy to describe how addicts might struggle with decision-making and impulse control.

💡Midbrain

The midbrain is described as the 'survival brain,' responsible for basic functions like eating, drinking, and procreation. The speaker notes that drugs of abuse hijack the midbrain's reward system, leading to a false belief that the brain needs drugs to survive, which is a core component of addiction.

💡Dopamine

Dopamine is a neurotransmitter associated with the brain's reward system and pleasure. The video explains how drugs of abuse artificially stimulate the release of dopamine, leading to a dysregulation of the brain's pleasure system and contributing to addiction. The speaker uses the example of how babies become addicted to food due to dopamine release to illustrate the mechanism.

💡Relapse

Relapse in the context of addiction refers to the recurrence of drug use after a period of abstinence. The speaker discusses various triggers for relapse, including exposure to drug cues, stress, and dopamine exposure, highlighting the complexity of maintaining sobriety for individuals with addiction.

💡Coping Skills

Coping skills are strategies individuals use to manage stress, negative emotions, or challenging situations. The video emphasizes the importance of developing and strengthening coping skills as part of addiction treatment to help individuals resist cravings and avoid relapse.

💡Spirituality

Spirituality in the video is presented as a key component of recovery, particularly within 12-step programs. It is described as a strength of the frontal cortex that can help overpower the midbrain's drive for drugs, providing a sense of purpose and meaning beyond the addictive cycle.

💡Medication-Assisted Treatment

Medication-assisted treatment (MAT) is a therapeutic approach that uses medications alongside counseling and behavioral therapies to treat substance use disorders. The speaker discusses how MAT can help quiet the midbrain's cravings, allowing individuals to engage in therapy and strengthen their frontal cortex to resist addiction.

💡Harm Reduction

Harm reduction is a public health approach that aims to minimize the negative consequences of drug use, rather than seeking to eliminate drug use entirely. The speaker mentions harm reduction in the context of medication, suggesting that while medications may not 'cure' addiction, they can reduce the harm caused by drug use, such as overdoses.

💡Prevention

Prevention in the context of addiction refers to strategies aimed at stopping the development of addiction before it starts. The speaker concludes the video by emphasizing the importance of prevention, suggesting that focusing on adolescents could be a key strategy in reducing the prevalence of addiction.

Highlights

Addiction is discussed as a disease that is not treated as such, highlighting the need to address the stigma and treat people with addiction appropriately.

The speaker is board certified in family medicine and addiction medicine, with extensive experience in various treatment facilities.

The disease model of addiction is explained, requiring a defect in an organ leading to symptoms, with addiction being a brain disease.

The frontal cortex and midbrain are identified as the key brain areas involved in addiction, with the former being responsible for personality and the latter for survival instincts.

Drugs of abuse are shown to work in the midbrain, not the frontal cortex, contrary to previous beliefs.

The midbrain's role in addiction is to seek out high levels of dopamine, leading to a hijacking of the brain's reward system.

Addiction is described as a stress-induced hedonic dysregulation, causing a decrease in dopamine receptor activity and an increase in the pleasure threshold.

The importance of glutamate in memory formation and its role in reminding the brain of situations surrounding dopamine release is discussed.

Relapse triggers are identified as dopamine exposure, stress, and exposure to drug cues, which can cause a small release of dopamine and trigger cravings.

The midbrain's activation during cravings is described as sending physiological signals to the body to motivate drug-seeking behavior.

The need to strengthen the frontal cortex through therapy, 12-step programs, and medication is emphasized to help overpower the midbrain's drive for drugs.

Medication-assisted treatment is presented as a way to quiet the midbrain and reduce cravings, allowing for better engagement in therapy.

The ultimate goal of addiction treatment is described as a combination approach, including therapy, 12-step groups, and medication when appropriate.

Prevention is highlighted as a key strategy in addressing addiction, with a focus on adolescents to prevent the development of addiction.

The definition of addiction is summarized as a dysregulation in the pleasure system, leading to loss of control and persistent use despite negative consequences.

Transcripts

so I'm going to talk about the

neurobiology of addiction or addiction

101 and the reason that I do this

lecture specifically is because we talk

about addiction as a disease but we

don't treat it as a disease and we

talked about how addiction affects

everyone and you know and we're saying

it's a disease process but nobody really

treats it like a disease process and

they say things to me like oh it's not

as bad as cancer right well known

disease as a disease and I think that

people need to understand that if we're

gonna get rid of the stigma and start

treating people with addiction

appropriately so essentially I am the

board certified in family medicine as

well as addiction medicine and I work in

a whole bunch of different treatment

facilities dealing with addiction all

day every day these are just some

objectives and disclosures you can read

at your own risk so it's the disease

model of addiction the disease model is

what we use in medicine so the disease

model essentially says that there is an

organ there's a defect defect in that

organ and there are symptoms because of

that defect so in order for something to

qualify as a disease it has to fit this

model diabetes the organ is the pancreas

the defect is a decrease in beta islet

cells the symptoms are high blood sugar

coma retinopathy etc so but all diseases

if we're calling them diseases fit this

model they have to fit this model and

there is no continuum it's just it's a

disease or not a disease so the question

becomes how do we get addiction to fit

this model so addiction is a brain

disease

we're starting at a disadvantage it is

not a purely psychological disease or

illness which is what everyone believed

previously it is a neurological disease

there's actual change in the brain that

occurs that results in addiction so

we're starting at a disadvantage because

the brain diseases often manifest this

behavior so you see someone with a brain

tumor or a lesion in the

brain they have personality changes they

behave differently they can become

impulsive or angry or difficult but we

excuse it because we know they have some

kind of tumor here they got hit in the

head or something but with addiction we

have a tendency to point at the addict

and say you're bad and this was your bad

choice but the disease is occurring in

the brain so in addiction we deal with

two major parts of the brain the frontal

cortex and the midbrain so the frontal

cortex is the part of our brain that

makes us us it makes you you it's where

your superpowers are it's your

personality your values your your ethics

your morals your willpower your sense of

choice it's all conscious that's where

you think and I use Superman to

represent it because it's your

superpower

a fully functioning frontal cortex like

everyone in this room right now is like

a fully functioning Superman an addict

or someone who is front frontal cortex

is not working properly is like weak

Superman I just need to simplify it with

pictures so the midbrain is the other

part of the brain we deal with and the

midbrain is your survival brain and it's

kept us alive for thousands and

thousands of years so it's doing a good

job but it is not conscious you have no

control over it you can't fix it or

change it or tell them what to do its

role in life is to keep you alive

that's it it doesn't wait consequences

it doesn't be like oh maybe this thing

no it says we're in danger we're gonna

die I have to take action to save the

life so I use the tiger it's more

primitive part of the brain so an angry

tiger no one in this room has right now

angry tiger is you're in the bear in the

woods and the Bears chasing you and

you're scared you're gonna die okay

angry tiger is an active midbrain so the

midbrain has three functions eat and

drink water to get nutrients fight or

flee from predator and procreate that's

it those are the only things it does so

when a baby is born one of the first

things we do is we feed it and the

reason that we feed it is because giving

the baby the nutrients releases dopamine

in the midbrain that active

the reward system and the baby

essentially becomes addicted to food we

have to get the baby addicted to food

because if the brain doesn't think it

needs it to survive the baby won't crave

food and it will die drugs of abuse work

in the midbrain and drugs and alcohol

for all intents and purposes are exactly

the same thing and I will explain why

okay but drugs the people abuse work in

the midbrain for years we thought they

worked in the frontal cortex because we

thought addictions of behavioral disease

but what we found is that if you put

probes into mice brains into the cortex

and into the midbrain and you give them

the option to hit a lever to administer

cocaine directly into their brain only

the mice that have the probes in the

midbrain will actually do it and they

will do it to the point of death they

will do it they will not eat they will

not sleep they won't do anything else

they will just administer cocaine until

they die so mice get addicted to drugs

but mice don't have you know like bad

families and they don't live in bad

neighborhoods and they didn't grow up in

the foster system and they don't have no

money

so this is not about you know anything

socioeconomically this is not about race

or culture this is simply about

neurology so what happens with repeated

use of a substance that's activating the

midbrain the midbrain starts to believe

erroneously that it now needs a high

level dopamine producing substance just

to survive so it gets hijacked basically

by drugs and so once it believes it

needs high level dopamine just to

survive it will seek out the high level

dopamine in any form which is why it

doesn't matter alcohol marijuana cocaine

and heroin there's no such thing as

heroin addiction or alcohol addiction

there's just addiction because if heroin

is what caused the change in the brain

alcohol will cause you to go back to

heroin that's it there's no it doesn't

matter that in the past you never had a

problem with alcohol it will lead to

relapse because it works in the same

exact place with the same exact chemical

so the example I always use for people

who are not addicts is if you're dying

of thirst in the desert and you're on

day 5 and your organs are shutting down

and you are about to die and I hand you

a bottle of water and I tell you I'm

gonna take your kids and your job and

your house and your family if you drink

the water you would take the water

everyone in this room would I don't care

how much you love your kids and your job

your house you would take the water

because the part of your brain that

values your children and your family and

your career is your cortex during times

of survival that's shut down your

midbrain is what has to keep you alive

and that doesn't care about your kids in

your job in your house and whatever so

you'll take the water drink it satiate

your midbrain and then your cortex comes

back online and goes oh my god I can't

believe it just gave up everything for

water and you try and manipulate me into

giving back your stuff so we can see on

a brain scan the difference between an

addict and someone who's just using

drugs there are people that just abuse

drugs they're not necessarily addicted

in order to be addicted bad things have

to happen because of your use and you

have to be unable to stop if you can put

it down and walk away

you were never addicted you've just used

drugs and maybe are a great choice maker

so if you put both people in a brain

scanner what you will see is for a true

addict you show them you put them in a

PET scan show them their drug of choice

brain scan will show midbrain lit up

frontal cortex dark take someone else

who just uses drugs put them in the

brain scan or show them the drug that

they like the most cortex lights up

their thinking about it I love it I hate

it whatever but their midbrain is dark

so you can see this you can actually see

this in brain scans and here's just some

examples of it so a non-user has a very

much more active cortex than an addict

and you can also see that it doesn't

matter even a hundred days abstinent

from a drug there's still less activity

in the cortex so the damage is is

long-standing and it takes a while to

get better

dopamine receptor activity is decreased

in the addicts so in the Attic the

midbrain dopamine receptors are down

regulated I'll explain why so addiction

is this broken pleasure sense it's our

reward system out of whack so here's how

our brains work in simple terms we

receive a signal from the environment

either chemical or electrical it comes

into neuron a he tells neuron a to

release neurotransmitter neuron a

releases the neurotransmitter into the

synapse and then that neurotransmitter

binds to neuron C which exerts an effect

I see a hole in the floor

I the electrical signal from the light

comes into my eyeball goes to my retina

it sends the signal it releases

acetylcholine or some other

neurotransmitter and then that tells

neuron C to move my leg so I step over

the hole whatever that's really simple

but that's essentially how our brains

work so with drugs the drug comes in it

binds to neuron a it releases dopamine

into the synapse dopamine binds to

neuron C and it says oh I'm really happy

or I'm really for a car I'm joyful or

whatever the effect of the drug is but

essentially it's not the drug that

matters it's the dopamine the dopamine

that was released into the synapse is

all that matters and it's the same

dopamine whether it was from alcohol

marijuana heroin crack methamphetamine

doesn't matter so it's not the drug that

matters its dopamine so the brain has

ten perceptual systems number ten is the

pleasure system that goes back to that

baby we have to become addicted to

certain things to survive so the reward

system is part of the pleasure system

also if you had no pleasure in life you

would have no desire to continue living

so things have to give you joy and

pleasure on a regular basis or we'd be

depressed and suicidal dopamine is the

pleasure chemical dopamine is what says

life is awesome this is great we're

having a great time I love this dopamine

is the neurotransmitter

mitr that we are addicted to or that

addicts are addicted to our brain has a

set point for pleasure just like we have

a set point for temperature for our body

regulation my body is the 98.5 degrees

because that's how I'm best most

optimally functioning I get exposed to a

bacteria or a virus my setpoint moves up

to 101 degrees because it knows it's

gonna kill off the bacteria at that

level once the bacteria is dead drops

back down to where it's happy 98.5

that's a fever that's how our bodies

work we have a set point in the brain

for pleasure the setpoint says that

things that release a certain amount of

dopamine are going to be viewed as

pleasurable so I can release dopamine

doing other things but if it doesn't

cross that threshold

I will not enjoy it so we have our

normal things like winning the lottery

or like getting married or something

exciting we release dopamine and we

think that's great drugs and alcohol

release massive amounts of dopamine just

massive amounts more than the brain

needs or really can tolerate so what

happens is the brain says we have all

this dopamine we don't need all these

receptors for dopamine so it starts

pulling off receptors they down

regulates receptors and what happens

when you down regulate receptors is you

move the threshold up so as the

threshold moves up you need more

dopamine just to feel the same amount of

joy you used to which means that you

know going on family vacation winning

the lottery playing the guitar things

that used to give you pleasure they're

still releasing the same amount of

dopamine but it's not enough to cross

the threshold so you don't actually

experience pleasure anymore

and this is why addicts will tell you

all the time they used to love to play

the guitar they used to love to knit so

do stuff and they don't anymore

they really biologically don't anymore

they can't you joy from it stress works

just like addiction in the brain in that

with chronic severe stress there is a

release of corticotropin-releasing

factor which causes a down regulation of

dopamine receptors so essentially

chronic severe stress leads to the same

exact process as addiction it increases

the

thresholds now when we consider that one

out of every four addicts has a history

of trauma that's chronic severe stress

over time we can see that they're primed

for the first time when they use a drug

but that's the first time they're

experiencing any real joy because the

first time anything's crossing their

threshold and then continuing use of the

drug just exacerbates the process and it

becomes a vicious cycle and eventually

old pleasures just don't show up anymore

so addiction is a stress induced hedonic

dysregulation so it's a stress induced

pleasure deafness basically they can't

experience pleasure the other

neurotransmitter I talk about is

glutamate and glutamate is responsible

for memory formation and I always say

glutamates like the executive assistant

of dopamine so anytime you do something

enjoyable and dopamine comes out and

says yeah this is awesome glutamate

comes out and says I'll take note of it

and I'll keep it filed away and so

glutamate will start reminding you of

situations surrounding dopamine release

so you go on vacation in the same place

every year you enjoy it now when you're

packing your back sore that trip

glutamate is going whenever we pack our

bags like this we wind up in Disneyworld

and we like that and there's a lot of

dopamine so you start to get excited

even before you go right

so when addicts use drugs or alcohol in

the same exact place or environment and

with the same people in the same house

they drive down the same street to get

their drugs they go to the same bar

every day to get their alcohol glutamate

is taking know that that's where they

get the most dopamine so even driving

past their favorite bar can cause a

small amount of dopamine release and

trigger them 20 use the three things

that cause relapse in humans dopamine

exposure so go into an ER go into the

doctor getting a prescription for a

medication that releases a lot of

dopamine can trigger a relapse any

exposure heroin addict that goes out and

drinks alcohol at a family picnic gets a

lot of dopamine and suddenly can't

remember why they feel so Restless and

irritable and discontent and why am I

even clean and they wind up relapsing

stress anyone who ever knows an addict

who is

relapsed after a period of time clean

you ask him what happened they say

something stressful dog died wife left

lost my job something stressful happened

and exposure to drug cues people places

and things so running into an old dealer

an old friend used to use with running

into an old relationship where you used

to use these can cause relapse so the

midbrain knows it needs high-level

dopamine to survive how does it motivate

the person to behave in a way that's

counterintuitive to what they know how

does it get a soccer mom to bunt and

shoot heroin how does it get the prom

queen to go out and smoke crack

crazy craving is an active midbrain

that's really all it is the merge brain

is active thinks it's dying so it's

going to send out physiological signals

to the body so that the body thinks I

got to do something to make this go away

so it'll send out physical signals

sweating chills nausea restless legs

obsession tunnel vision inability to

think about anything but the discomfort

that I'm in that is what craving truly

is the craving will then tap into the

cortex and find a reason to use it'll go

into the library that is the cortex and

it will find a past reason that is

enough to make that person want to use

hey soccer mom remember when you have

that herniated just three years ago we

never took care of I think it's really

bad right now I think your pains awful

all right

hey prom queen remember you had social

anxiety in kindergarten I think we have

social anxiety again it's really bad

you're anxious you know you want to

leave the house and the craving the

midbrain will actually bring to the

consciousness these things causing the

person to now have give themselves

permission to want to use something I

can't live in this much pain I can't

live with this kind of anxiety they

don't know that's what's happening all

they know is they suddenly have worse

pain worse anxiety worse stress than

they ever did before and that's when

they start acting the way we see them

act the loss of control lying

manipulating well I have to manipulate I

have to see four different doctors if

none of them are going to treat

I paint we don't see all the other stuff

we don't see the down regulation of the

dopamine receptors or the craving or the

the suffering that's going on we see

this and we think that they're bad

people so the question becomes how do we

fix it how do we bring this cortex back

online well after we get through the

medical part of detoxing them we have to

focus on strengthening the cortex so we

have to change this idea that the drug

is survival that the drug is the only

thing that will keep us alive and so we

have a couple of tasks going on one we

have to remain abstinent because that's

what's gonna quiet the midbrain over

time and two we have to work on coping

skills and stress relief and we have to

work on spiritual growth spirituality in

the frontal cortex is the only part of

the brain that is capable of becoming

strong enough to overpower in a midbrain

so that's why we focus on spirituality

in the 12-step programs and in in most

treatment centers because we know that

that part of the brain has the ability

to overpower a midbrain not religion I'm

not talking about religion talking about

spirituality but coping skills stress

truth the second you use a drug that

releases dopamine you instantly forget

all of your coping skills and stress

release instantly so we have to reteach

those behavioral therapy and 12-step

meetings they work on the frontal cortex

they are strengthening that frontal

cortex which is the ultimate goal in

addiction treatment medications work in

the midbrain okay we need sometimes to

quiet the midbrain because they can take

up to a year for the thresholds for

pleasure to come back down to normal

with just abstinence and most people

can't live a year never experiencing any

joy or pleasure they just can so unless

they're in jail they're probably not

going to make it that year so how do we

accelerate the process well we work on

the frontal cortex the harder we work on

that the quicker the process occurs but

in the meantime we may need to quiet the

midbrain

so the idea of a high-end traditional

therapy 12-step therapy group therapy

behavioral therapy is simply to take a

weak frontal cortex and strengthen it in

the face of cravings in an active

midbrain that's the idea so over time

with abstinence and even with medication

because the medication that we use keeps

us consistent level of dopamine in the

system with overtime that threshold will

move back down now it's friable meaning

that the second it's exposed to dopamine

again it'll move back up okay it's not

even if it took twenty five years for it

to get here in the first place it will

only take one use for it to start moving

back up again

the idea behind medication assisted

treatment is simply to quiet the tiger

in the face of a weak frontal cortex so

I always say that back eighty years ago

when Alcoholics Anonymous was founded

you had a bunch of 65 year-old gentleman

who had been through several career

changes lost their wives their children

they're desperate and they walk into a

room and they sit sit down shut up and

listen and they go alright I'll do

whatever you say because I've lost

everything you know I'll do whatever

today we have 19 year olds who lost

their job at Taco Bell and mom will let

them drive the car anymore they don't

understand desperation how do you get

them to sit into in a room with a bunch

of old guys go and sit down shut up and

listen it's almost impossible unless you

can quiet their midbrain if you can

quiet that craving and keep that under

control they will listen they will do

what you tell them so the medications we

use obviously for alcohol and abuse

Carol now trucks on these help with

cravings nothing really stops drinking

antabuse is a negative reinforcement

they'll throw up if they take this and

then drink alcohol we know negative

reinforcement does not work for a long

term but it may be helpful in the

beginning stages of recovery and the

other ones help cravings which may or

may not reduce drinking for opiates we

replace them or we block them those are

our choices we can replace them which

quiets the midbrain or we can block them

prevents the midbrain from getting them

but the problem with opiate with these

medications obviously is they do nothing

for cocaine or benzos or marijuana or

alcohol and so for not actively working

in the frontal cortex we're not actively

reminding them that they're addicts the

drugs useless and that's what I just

talked about and so basically the idea

behind medication is harm reduction we

have to reduce the amount of harm

they're doing decrease the amount of

overdoses by giving them this medication

saying this is not the treatment this is

simply helping you get to the treatment

so the definition of addiction is

essentially a dysregulation in the

pleasure system a broken reward system

and it results in loss of control which

is that foolish behavior we see the

craving and the persisting use despite

negative consequences something bad

happens you keep using it's a problem

and that is how we get it to fit into

the disease model so the organ is the

midbrain the defect is this

dysregulation of the pleasure system and

the symptoms are loss of control

cravings and persisting use despite

negative consequences and the ultimate

toolbox is really a combination approach

we look at therapy we look at 12-step

groups we look at medication if it's

appropriate and we and we work together

as a team

nobody can treat addiction on their own

nobody not one single person can't do it

you need a team and the only way we're

ever gonna really fix this is to prevent

it so we really need to start at the

level of the adolescents we're now we're

going to treat it to extinction I don't

know how we do that I don't have an

answer for that but that's how what we

have to focus on that's that

yeah a lot of information