The Science and Spirituality of Addiction

1. The Science and Spirituality of Addiction Assoc Professor Alan Gijsbers Addiction Medicine RMH President ISCAST Australia

2. Drug Dependence Comparing ICD-10 and DSM-IV Criteria • In common • Withdrawal, tolerance and salience • ICD-10 • Rx withdrawal, compulsion, narrowing of repertoire, early relapse • DSM-IV • Lack of control 3 (greater use than intended, unsuccessful reductions, time on activity), use despite damage due to use

3. Science is More Than Phenomenology • Accurate observation leads to hypothesis testing especially asking the question, • Why is it so? • This leads to some theories about mechanisms, which if tested and found to be robust, become the established explanation.

4. Mind-altering Drugs • Pleasure Effect • Drugs of addiction enhance the limbic system (pleasure centre) of the brain. • “Artificial instant chemical pleasure” • Anaesthetic Effect • “...The need for chemical vacations from intolerable self-hood and repulsive environments will undoubtedly remain...” (A Huxley, 1953)

5. Neurobiological Circuits in Addiction “Circuits that serve to color an experience with emotion and direct the individual’s response to rewarding stimuli, including food, sex and social interaction.” Nestler EJ, Malenka RC. The addicted brain. Scientific American. March 2004;290:78-85

6. Reward Pathways Glutamate Excitatory Input Enkephalin or Dynorphin Inhibitory Neuron k Opioid Receptors Dopamine Receptors Enkephalin Inhibitory Neuron Dopamine Neuron GABA Neuron REWARD m Opioid Receptors GABA-A Receptors GABA Inhibitory Feedback Presynaptic Opioid Receptors (m, d?) GABA Inhibitory Neuron Ventral Tegmental Area (VTA) Nucleus Accumbens (NAc)

7. Addiction – More Than Just Reward? • Not just the pursuit of pleasure • But a drive to use – cravings and compulsions • Add drive, control and memory to the basic reward mechanisms

8. Localization of Addiction PathwaysVolkow ND. Fowler JS. Wang GJ. The addicted human brain: insights from imaging studies. [Review] Journal of Clinical Investigation. 2003;111:1444-51, • Control – prefrontal cortex and the anterior cingulate gyrus • Drive - Orbito-frontal cortex • Reward – Nucleus accumbens and the ventral pallidum • Memory – Amygdala and hippocampus

9. Integration of Pleasure Pathways

10. Not All Brains Are the Same • Varying responses to post-anaesthetic analgesia • Even those pain-killers that give pleasure do not necessarily lead to addiction • Not many patients in palliative care develop tolerance • Not all chronic pain patients develop tolerance

11. Different Responses to Acute Cocaine in Non-addicted Subjects

12. The Full Range of Issues? • Emotional circuits • Evolved to enhance relationships and social survival • Emotional dysregulation and interpersonal ineffectiveness seem to be dominant issues in patients with addictions • Emotions may even be more important than cravings

13. I don’t drink because I have cravings... “...I drink because I am angry, or I am pissed off...” “...I drink because the pressure of work is too much....” “...I drink because I want to get up my partner’s nose...” “...I drink to drown the memory of my abuse...” “...I drink to shut up the committee in my head...” “....I drink to relax...” “...I dunno, I just do.....”

14. Vaillant’s Positive Emotions Faith, love, hope, joy, forgiveness, compassion, awe and mystical illumination are important limbic system drivers of human flourishing Vaillant GE. Spiritual Evolution: how we are wired for faith, hope and love. Broadway books, New York. 2008.

15. Positive Emotions • Are parasympathetic and soothing as opposed to the negative emotions which are sympathetic and arousing • Are long-term and reach out • Negative emotions are immediate and protective • Positive emotions create relational bonds which build community rather than the negative emotions which protect the immediate individual

16. Emotions Humans thus seen are members of community rather than individuals and the emotions (especially the positive emotions) are designed to build community and the individual in that community

17. Thus Emotions are not just to be avoided but essential to being human Emotions predate verbal reasoning Vaillant then makes much of the spirituality of the positive emotions in contrast to the barren rationalism of fundamentalism Limbic is lyrical: Lexical is lame

18. Kandell’s Model - • Neurology is a function of gene expression, but gene expression changes according to mental (learning) input.

19. WHO MODEL OF DRUG USE SOCIAL AND INDIVIDUAL CONSEQUENCES SOCIAL AND INDIVIDUAL ANTECEDENTS Aversive Consequences e.g. toxic effects reduced drug effect organic damage psycho-social dysfunction Distal Antecedents e.g. peer groupsfamily interactionsparental drug use Immediate Antecedents e.g. licensing lawssocial pressuresavailabilitydemographic variables AvoidanceLearning SOCIAL Tolerance Dispositionto usedrug Drug Use Neuro Adaptive State Distal Antecedents e.g. early learningdrug experiencegenetic endowmentdevelopmental events Immediate Antecedents e.g. mood stateswithdrawal statesexpectations Withdrawal Symptoms INDIVIDUAL ApproachLearning Reinforcing Consequences e.g. mood enhancement psycho spcial facilitation avoidance of relief of withdrawl symptoms

20. Summary of the Science • Addictive behaviours • Mind-altering drugs affecting the reward mechanism • Drive, reward, memory and control • Heterogeneity of the brain • Complexity of neuroscience • Emotions and relationships • Regarded by some as spirituality....

21. Spirituality • Left brain definition of right brain activity [limbic activity]? • Describe the indescribable? • Raises questions of the scientific evaluation of what’s going on!

22. Spirituality Publications 1975–2001

23. Addiction and Spirituality Publications 1981–2001

24. Spirituality “Spirituality simply means the direct experience of something special in life and living.”- S.Biddolph

25. Relatedness Transcendence Humanity Core/force/soul Meaning/Purpose Authenticity/Truth Values Non-materiality (Non)-religiousness Wholeness Self-knowledge Creativity Consciousness Domains of SpiritualityCCH Cook. Addictions. 2004;99:539-551

26. Spirituality as Drive/Life • Spirit = Breath = Life = Liveliness= Enthusiasm • Spirited person, spirited defence, spirited horse • Inspired • Expired • Dispirited

27. Eudaemonia • Eu = balance • Daemon = One's genius; a tutelary spirit or internal voice; as, the demon of Socrates. [Often written d[ae]mon.]drive • Eudaemonia = Balance of the drives = Aristotle’s ideals for which one strived • Addiction could then be described as dysdaemonia (!)

28. Spirituality • Meaning • Purpose • Relationships

29. Relationships • To self • Insight • Acceptance • To the environment • Which feeds and breathes us • Which touches us aesthetically • To other humans • Partner • Family • Friends • Community • Society • Enemy • To the Higher power • Imago dei • Strength [spirit] to live

30. Spirituality • Meaning Faith • Purpose Hope • Relationships Love

31. Faith • Asking what are the core understandings that shape a person’s attitudes to life. • Spiritual attitudes are sometimes shaped by a person’s faith in God, but there are other ways of expressing a person’s core beliefs and attitudes • Modern secular society however discourages the exploration of these dimensions (Taylor C, Ethics of Authenticity).

32. Hope • Frankl’s work, relationships and suffering. • Aristotle’s pursuit of the goods – eudaemonia Taylor’s Hypergoods – the core commitments which shape other commitments. • Without meaning and purpose life if hopeless, lacks momentum, and lacks drive. • Addiction is about the pursuit of immediate pleasure irrespective of the long-term consequences.

33. Love • Self • Others • Natural environment • A higher power • Supernatural forces • One of the dimensions of addiction is alienation and recovery focuses on reconnection

34. What About? • Truth...(embodied and personified)? • Justice and righteousness? • Failure and forgiveness?

35. Spirituality • Drive to life and liveliness • Meaning purpose and relationships • Truth, justice and mercy

36. Aspect of the Individual Difficult to delimit – transcendent Can be stifled by religious rituals and practices Socially organised structure By definition boundaried - beliefs, practices, governance and rituals Spirituality and Religion (WR Miller)

37. Contrast Religion and Spirituality

38. Spiritus Contra Spiritum • “You see, "alcohol" in Latin is "spiritus" and you use the same word for the highest religious experience as well as for the most depraving poison. The helpful formula therefore is: spiritus contra spiritum.” CG Jung Letter to Bill W http://www.sober.org/CarlJung.html

39. Flesh vs Spirit • Dominant ethic in Pauline writings (Rom 6-8, Gal 5:1-23). • Spirit – human spirit or Divine spirit indwelling humans? • Divine power to put to death the deeds of the flesh and to live a new life of freedom and love. • Fruits of the spirit contrasted with the deeds of the flesh.

40. AA Spirituality • Based on the Buchman’s Oxford Group Movement (Moral Rearmament) of the 1930’s • Buchman came into deeper experience of God at a Keswick Convention in about 1909 • No doubt initially Christian based • Current tension between a generic spirituality on the one hand and the Christian Right on the other

41. Powerless Power available Surrender to that Power Moral inventory Admit wrongs Ready to remove defects Ask Him to remove shortcomings List persons harmed Make amends Continue inventory Prayer to improve conscious contact Spread message of spiritual awakening AA Spirituality – 12 Steps

42. Spirituality and Our Patients • The spirituality gap • Respect for the patient’s integrity • Aware of need and hence the ability to meet it • Start them on a journey looking at meaning, purpose, power, relationships • Compassionate care expresses our spirituality

43. D&A Spiritual Change • From salience to perspective • Bondage to freedom • Powerlessness to power • Indiscipline to discipline • Self-centredness to other-centredness

44. D&A Spiritual Change • Fear to trust • Sinfulness to goodness • Disorder to order • Despair to hope • Grace: an unconditional acceptance yet a maintenance of standards

45. From My Practice “You know after your session [on spirituality] I realised I was totally dispirited...I have no spirit...can you help?”

47. That Afternoon • Found a book in a secular bookshop Secrets of a Bullet Proof Spirit.

48. Conclusion • Science and spirituality interact in the field of addiction and a comprehensive program of recovery calls for a radical re-ordering according to a patient’s core values and hyper-goods. It also calls for relational repair. Spiritual input is thus crucial as people work through their pain and reach out for radical healing.

49. Harm Minimization vs Abstinence • Abstinence from mind-altering drugs is the bottom line in addiction therapy • Harm minimization recognises the reality of ongoing drug use and seeks to reduce the degree of harm causes by use eg • Substitution pharmacotherapy • Needle and syringe exchange programs • Injecting rooms • Supply of clean opioids in a supervised situation • Abstinence is the best form of harm minimisation but carries greater risk of significant harm

50. DOLE & NYSWANDER’S ORIGINAL TRIAL NEJM 1969;280:1372-1375