Carl

 Christensen,  MD  PhD,  FASAM  

Associate  Professor,  Depts  OB  Gyn  &  
Pyschiatry  
Dawn  Farm  Spera  Center     http://public.me.com/ccmdphd  
Pain  Recovery  Solutions,  A2  
cchriste@med.wayne.edu  
 
 

Physiology of Addiction 2

Physiology of Addiction 3 Physiology of Addiction 4

  Physiologic  Dependence?     Tolerance:    requiring  increasing  amounts  of  

  Lack  of  willpower?   drug  to  get  the  same  effect  
  An   amoral  condition?  
  Withdrawal:    the  opposite  effect  of  the  drug  
  A  brain  disease?  
when  it  is  removed  

  NEITHER  of  these  imply  chemical  

dependency  (addiction)  

Physiology of Addiction 5 Physiology of Addiction 6

1
  100  people  are  treated  with  morphine  for  two  
weeks  after  an  accident.  
  Their  insurance  runs  out,  the  morphine  is  
suddenly  stopped.  
  95  of  them  will  have   the  flu  (physical  
withdrawal)  and  will  go  on  with  their  lives.  
  5  of  them  will  start  robbing  party  stores  to  
get  more  morphine!!!!    
  =  ADDICTION  

Physiology of Addiction 7 Physiology of Addiction 8

Physiology of Addiction 9 Physiology of Addiction 10

Physiology of Addiction 11 Physiology of Addiction 13

2
   Responds  to  dopamine  (DA)  
  Part  of  the  LIZARD  BRAIN  
  Responds  to  drugs  
  Responds  to  food  
  Responds  to  sex  
  Sends  signals  to  your  frontal  
cortex  
  THE  PLEASURE  CENTER  IS  
ABNORMAL  (DAMAGED)  IN  
ADDICTION  

Physiology of Addiction 14 Physiology of Addiction 15

Physiology of Addiction 16 Physiology of Addiction 17

Physiology of Addiction 18 Physiology of Addiction 19

3
   Do  some  people  develop  addiction  because  
they  have   reward  deficiency  
syndrome  (decreased  dopamine)  OR:  
 
  Do  people  with  addiction  have  low  dopamine  
because  they  have   burned  out  their  
pleasure  centers?  
 

Physiology of Addiction 21 Physiology of Addiction 25

  Those  who   enjoyed  methylphenidate  

(amphetamine)  had  LOWER  levels  of  
dopamine.  
  Those  who  found  it   unpleasant  had  
NORMAL  levels  of  dopamine  
  Conclusion?  
  -­‐addiction  is  an  abnormal  response  to  
reward  
Physiology of Addiction 26 Physiology of Addiction 31

  Women  who  have  an  abnormal  receptor  

  Decreased  Dopamine  receptors  
(brain  protein)  for  dopamine  had  brain  scans  
  Those  who  had  the  abnormal  receptor   =decreased  Dopamine  =
enjoyed  a  milkshake  LESS    Decreased Hedonic
  Were  more  likely  to  gain  weight!  
  Conclusion?   Tone
  -­‐addiction  is  an  DECREASED  response  to  
NORMAL  reward  
  Salsitz 2006
  If  you  don t  like  something  as  much,  you  need  to  
compensate!  
Grand Rounds Hutzel 4 17 07 33

Physiology of Addiction 32 Physiology of Addiction 33

4
   Alcoholics/addicts  who  finish  treatment  will  
often  relapse  when  they  re-­‐enter  society.  
  They  will  almost  ALWAYS  relapse  if  they  
undergo  quick  detox  and  re-­‐enter  society.  
  But:    their  withdrawal  is  gone.  
  SO:  why  do  they  relapse?????  

Physiology of Addiction 34 Physiology of Addiction 36

High
blood
High flow
flow

Non users

Cocaine users, 10 days sober

Healthy Control Cocaine-dependent Low Low

flow blood
Gottschalk, 2001, Am J Psychiatry Cocaine Users, 100 days sober flow
Physiology of Addiction 37 Physiology of Addiction 38

  Tolerance       Great  deal  of  time  

  Withdrawal   spent  in  obtaining/
  Take  more/take   using  /recovering  
longer  than  intended     Important  activities  
given  up  2º  to  use  
  Can t  cut  down  or  
  Use  despite  physical/
control  use   psych  problem  

Physiology of Addiction 43 Physiology of Addiction 44

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  A  chronic  progressive  disease  characterized  by  the  following  
physical  and  psychological  symptoms  (the  four  (five)  C s):  

  Craving  
  Compulsion  
  Loss  of  Control  
  Continued  use  despite  consequences,  and  
  Chronic  use  

Physiology of Addiction 45 Physiology of Addiction 46

Physiology of Addiction 47 Physiology of Addiction 48

Physiology of Addiction 50 Physiology of Addiction 51

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   People  who  recover  from  alcoholism  may:  
  Gain  weight  
  Increase  their  smoking  
  Start  gambling  
  Become  involved  in  sexual  addiction,  internet  
addiction  

Physiology of Addiction 52 Physiology of Addiction 53

  People  who  undergo  gastric  bypass  surgery     You  are  worried  about  your  best  friend.  
may:     She  has  a  20  year  history  of  heavy  drinking  
  Become  alcoholics  
and  has  just  been  diagnosed  with  
hypertension  and  hyperlipidemia  (high  
  Develop  chronic  pain-­‐opiate  dependence  
cholesterol).  
  Gain  weight!     You  advise  her  to  quit.  
 

Physiology of Addiction 54 Physiology of Addiction 55

  You  went  to  the  Dawn  Farm  lecture  on     Failure  to  fulfill  work/school/social  obligations  
addiction  and  you  know  it  is  a  “disease”.     Continued  use  is  risky  situations  (ie,  drunk  
  To  your  surprise,  she  does  so,  without  any   driving)  
treatment.     Recurrent  legal  problems  (DUI)*  
  You  vow  never  to  waste  your  time  going  to     Continued  use  despite  social  or  interpersonal    
any  more  Dawn  Farm  lectures.   problems  (MOR)  
  How  did  she  do  it?????     Never  fit  the  criteria  for  dependence  

Physiology of Addiction 56 Physiology of Addiction 57

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  The  majority  of  patients  you  see  with  drug/   Most  people  who  have  
alcohol  problems  do  NOT  have  addiction   a  problem  with  alcohol  
  Most  people  with  drug/alcohol  problems  will   or  drugs  will  stop  on  
be  able  to  stop  on  their  own.  (William  White)   their  own  
  The  4Cs  helps  you  to  determine  which  ones     The  majority  of  people  
have  addiction!   who  stop  do  so  without  
treatment.  
  Even  many  heroin  
addicts  will   quit  
and  resume  normal  
lives.  
Physiology of Addiction 58 Physiology of Addiction 59

A  45  YEAR  OLD  WITH  AN   A  45  YEAR  OLD  WITH  AN  
OVARIAN  TUMOR.   OVARIAN  TUMOR.     Abuse  is  a  BEHAVIOR….  
  Addiction  is  a  DISEASE!!  

  Mark  Minestrina,  MD  

  Brighton  Hospital  

Physiology of Addiction 60 Physiology of Addiction 63

  anyone  can  quit  drinking……     Drug  triggered:     I  thought  I  could  (eat/

smoke/drink)  just  one….  

  Just  walk  up  and  hit  a  cop!  

  Stress  triggered:   I m  going  through  too  
much  right  now.    Gimme  that!  
 
▪  Herb  Malinoff,  MD  
  Cue  triggered:   Wet  faces  and  wet  places  

Physiology of Addiction 64 Physiology of Addiction 65

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Physiology of Addiction 66 Physiology of Addiction 67

Physiology of Addiction 68 Physiology of Addiction 69

  Hypertension:    the  most  common  cause  of  

essential  (unexplained)  hypertension  is  
alcohol.  
  Diabetes:  damage  to  the  pancreas  
(temporary  or  permanent)  
  Cholesterol:    LDL  (bad  cholesterol)  goes  up,  
triglycerides  (fat)  goes  up.  

Physiology of Addiction 78 Physiology of Addiction 79

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  Fatty  liver:    from  drinking;  body  uses  alcohol     Your  friend  is  an  alcoholic.  His  family    left  him.  
rather  than  fat.    Fat  accumulates.     When  you  see  him  today,  he  denies  that  he  has  
  Alcoholic  Hepatitis:    inflammation  of  the   a  problem,  but  says  that  he  needs  to  "take  a  
liver;  fever,  jaundice,  pain,  nausea  and   break".  His  wife  left  him,  he  says,  because  of  
vomiting.   his  mother  in  law.  
  Viral  Hepatitis:    usually  hepatitis  C,  from     As  you  discuss  his  situation,  you  are  amazed  
sharing  needles,  straws  (cocaine),  sex.   by  his  ability  to:  
  Cirrhosis:    scarring  of  the  liver     Minimalize      -­‐Rationalize  
  Deny        -­‐Deflect  
Physiology of Addiction 80   Physiology of Addiction 81

  Recovering  addicts  make  bad  decisions  

  Ex:    3  weeks  into  recovery,  a  man  decides  to  
make  a  trip  to……  

  Q:    what  does  an  alcoholic  bring  on  a  2nd  

date?  
  A:      

Physiology of Addiction 82 Physiology of Addiction 84

  You  are  asked  to  see  him  in  the  hospital  several  
years  later.  
  He  says  he  knows  you,  but  cannot  remember  
your  name.    You  become  alarmed.  
  You  ask  him  who  the  president  is,  he  replies  
Who  cares?    They re  all  crooks .  
  He  walks  with  a  shuffling  broad-­‐based  gait  and  
has  to  hold  his  hand  on  the  wall  to  keep  his  
balance.  

Physiology of Addiction 85 Physiology of Addiction 86

10
  Immediately  after  stopping  drinking:     Confabulation:    make  things  up  
Wernike s  encephalopathy  (brain  disease)     Retrograde  amnesia:    can t  remember  what  
  Caused  by  thiamine  (B1)  deficiency   happened  in  the  past  
  Eye  muscles  are  paralyzed     Antegrade  amnesia:    can t  remember  info  
  Ataxia  (can t  walk  straight)   you  are  given  (remember  these  3  objects…)  
  Encephalopathy:    confusion,  agitation,     Polyneuropathy:    periperhal  nerve  damage  
restlessness  

Physiology of Addiction 87 Physiology of Addiction 88

  You  see  him    one  more  time,  several  years  later.    He     Hardening  of  the  liver  (scar  tissue)  
has  been  readmitted  for  vomiting  blood,  jaundice,  and     Causes  blood  to  back  up  in  the  veins  feeding  
encephalopathy.   the  liver:  
    He  is  given  multiple  transfusions.    He  has     Esophageal  varices:    vomit  blood  
esophageal  varices  from  his  cirrhosis.     Hemorrhoids:    rectal  bleeding  
    He  is  jaundiced.    He  says  that  he  is  asking  his  sister     Can t  metabolize  toxins:    encephalopathy  
to  pay  for  a  liver  transplant.    She  died  5  years  ago….     Can t  make  proteins:      
    When  he  are  speaking  to  him,  his  hands  will  
  bleeding  (coagulopathy)  
occasionally  flap.  
  Can t  hold  fluids:    ascites  

Physiology of Addiction 89 Physiology of Addiction 90

Physiology of Addiction 91 Physiology of Addiction 92

11
 Physiology of Addiction 93 Physiology of Addiction 94

  He  dies  several  weeks  later  of  liver  failure.  

  Jails,  institutions,  and  death  

▪  Narcotics  Anonymous  

Physiology of Addiction 95 Physiology of Addiction 96

High
blood
High flow
flow

Non users

Cocaine users, 10 days sober

Healthy Control Cocaine-dependent Low Low

flow blood
Gottschalk, 2001, Am J Psychiatry Cocaine Users, 100 days sober flow
Physiology of Addiction 97 Physiology of Addiction 98

12
 Physiology of Addiction 99 Physiology of Addiction 100

Physiology of Addiction 101 Physiology of Addiction 102

  We  have  driven  miles  in  the  dead  of  night  to  

satisfy  a  craving  for  food.    We  have  eaten  
food  that  was  frozen,  burnt,  stale,  or  even  
dangerously  spoiled.    We  have  eaten  food  off  
of  other  people s  plates,  off  the  floor,  off  the  
ground.    We  have  dug  food  out  of  the  
garbage  and  eaten  it.  

Physiology of Addiction 103 Physiology of Addiction 104

13
   Waist  Circumference  
  35F  40M  
  Triglycerides   THE  SOLUTION?  
   >150  
  HDL  
   <40F  35M  
  Blood  pressure  
   >130/85  
  Fasting  glucose  
   >100  

Physiology of Addiction 106

  Medical  
  Behavioral  
  Spiritual  
  Surgical    

Physiology of Addiction 112

  Agonists:    similar  to  the   drug     Antagonists:    opposite  effect  of  the  drug  
  Suboxone  for  opiate  dependence     Naltrexone  for  opiate  dependence  
  Methadone  for  opiate  dependence   ▪  Oral:    Rivea  
  Nictotine  patches  for  tobacco  dependence   ▪  Injectable:    Vivitrol  

  THC  for  marijuana  dependence     Naltrexone  for  alcohol  dependence:    Vivitrol  

  Dilaudid  for  heroin  dependence!    (Canada)     Disulfiram  (Antabuse)  for  alcohol  dependence  
  Rimonabant  for  obesity  

Physiology of Addiction 113 Physiology of Addiction 114

14
   Behavior  (drinking)  is  due  to  false  beliefs  (I  
can’t  stop)  
  Change  the  false  beliefs,  change  the  
behavior.  
  Apologies  to  therapists  everywhere……  

Physiology of Addiction 115 Physiology of Addiction 116

DRINKING! Behavior

  Alcoholics  Anonymous:  
734  482  5700    
PITIFUL, INCORMPREHENSIBLE Mood
www.aa-­‐semi.org    
DEMORALIZATION

I’M JUST GOING TO USE Thoughts

Flawed Beliefs/
Thinking
Beliefs
THERE S NO WAY THAT
I CAN STOP USING.
Physiology of Addiction 120 Physiology of Addiction 121

      ?  
Physiology of Addiction 122 Physiology of Addiction 123

15
   Gastric  Bypass  for  eating  disorders  
  Liver  transplant  for  cirrhosis  
  ETOH  and  Hepatitis  C:    most  common  indication  
  Brain  surgery  for  addiction?  
  Destroy  the  nucleus  accumbens  (China,  Russia)  
  Accidental  injury  to  the  insula:    quit  smoking!  

Physiology of Addiction 126 Physiology of Addiction 127

  Only  about  40%  of  patients  will  be  abstinent  at  one  
year  after  treatment.  
  Failure  rates  may  be  due  to  lack  of  aftercare,  often  
due  to  insurance  difficulties  
  Low  economic  status,  psych  comorbidity  and  lack  
of  family/social  supports  also  predict  relapse.  
  Relapse  is  often  viewed  as  “inevitable”  and  drug  
dependence  as  “hopeless”*  

130 131

  ONLY  60%  OF  TYPE  I  DIABETICS  ADHERE  TO     If  you  were  to  stop  taking  your  insulin,  and  you  
MEDICATION  SCHEDULE   wound  up  in  a  coma  in  the  ICU,  your  doctor  would  
  LESS  THAN  40%  OF  ASTHMATICS  ADHERE  TO   say:      
TREATMENT  REGIMEN     “you  need  to  go  back  on  insulin!    You  could  have  
  LESS  THAN  40%  OF  HYPERTENSIVES  ADHERE  TO   died!”  
THEIR  TREATMENT  REGIMEN     If  you  were  to  stop  your  Suboxone/methadone/12  
  DRUG  DEPENDENCE  =40  TO  60%  ADHERENCE   step  treatment,  and  wind  up  in  the  ICU,  your  doctor  
would  say:  
  “You’re  an  addict.    You’re  hopeless!!!!!”  

132 133

16
   Decreased  HIV  infection  rates  
  Decreased  incarceration     “There  is  little  evidence  of  effectiveness  from  
  Decreased  drug  use   detoxification  or  short-­‐term  stabilization  
  Decreased  mortality   alone  without  maintenance  or  monitoring  
such  as  in  (opioid)  maintenance  or  AA.”  

  McLellan,  2000  

134 135

  Obesity  
  Hypertension  
  Diabetes  
  Asthma  
  Addiction        

136 Suboxone lecture 2 5 07 Physiology of Addiction 137

  ccmdphd@mac.com  
  http://public.me.com/ccmdphd    
  Voice  mail:    734  448  0226  
  Fax:    313  447  2244  
  Pain  Recovery  Solutions  (A2):    
   734  434  6600  

Physiology of Addiction 144

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