Treatment for Problematic Drug Use Cogs 174: Drugs and Culture

1. Treatment for Problematic Drug UseCogs 174: Drugs and Culture C. Alexander Simpkins PhD Annellen M. Simpkins PhD

2. Treatment Helps with Drug Problems Statistics from the Substance Abuse and Mental Health Services Administration Reasons for discharge by types of service • 44% Completed treatment • 14% Transferred to another treatment • 25% dropped out

3. Specifics • Different Treatments have specific effects • Efficacy Studies show some therapies work better for some problems • CBT for Depression • Hypnosis for Anxiety and Fear • Recent neuroscience research shows that different therapies activate different areas of the brain • So the therapy used should address the needs of the client.

4. Non-Specific Ingredients of Treatment • History: Johns Hopkins Phipps Clinic Research Group (Frank et. al, 1978) • Some Key Non-specific factors (Frank, 1991) • Hope, faith, trust • Therapeutic relationship • Therapeutic rationale and rituals • Experiences of mastery of real skills

5. Evidence for Mind-Body Interactions: Expectancy and Placebo research • Mind and Body are linked • Cognitive processes (appraisals, beliefs, and expectancies) can elicit neurotransmitter action and brain activations and state changes • Expectancy research illustrates: • Expectancy plus pharmacological action 2 times larger when expectation is in line with phamacological action but weaker when expectancy is opposed (Luparello et. al, 1970) • Paradoxically expectancy can override pharmacological action (Frank & Frank, 1991)

6. Placebo Research • Although given placebo and told it is inert, responsive S’s still wanted refills! (Park and Covi, 1965) • For pain relief, similar to how opioids affect brain (Petrovic, et. Al. 2002) • Activation in rostral anterior cingulate gyrus (ACC) , right anterior insula (AI) and brainstem. Looping circuit: From limbic to brainstem to medial prefrontal areas • Connected to reward pathway: Placebo induced dopamine release in the ventral striatum (de la Fuente-Fernandez et. al, 2002) • Best results when people believe in their placebos: Appraisal matters (Seminowiecz, 2006)

7. Psychotherapies for Treatment of Drug Use • Some Basic Types • Cognitive Behavioral • 12 Steps • Meditation • Hypnosis • Work well together • Modern therapists identify with an approach but skilled practitioners use aspects from many methods

8. Psychotherapy Therapy vs Drug Therapy • Research shows best together or that psychotherapy is at least as effective or more so than drug therapy • With depression, found equally effective to Paxil, but had some opposite brain effects: Paxil increased PFC activations and decreased hippocampal activation, CBT decreased PFC activation & increased hippocampal activation (Goldapple, et. al, 2004) • Psychotherapy helped subjects decrease rumination • Less relapse • Mindfulness meditation prevents relapse (Witkiewitz, Marlatt, and Walker 2005)

9. CBT& RET: You Feel the Way You Think • Scientifically-based approach to therapy • Two Main Founders: Aaron Beck (b. 1921) & Albert Ellis (1913-2007) • Based on the concept that feelings and behaviors are caused by thoughts. Problematic patterns lead to problematic feelings • You may not be able to change circumstances but you can change how you think about them • You can be responsible for change • CBT for addictions • Recognize the triggers and take responsibility • Challenge faulty assumptions and resulting beliefs about drugs • Accept discomfort (Where is it written that you should always feel good? Albert Ellis)

10. CBT and the Brain • Sampling of studies showing CBT changes the brain • CBT increases gray matter for chronic fatigue sufferers (Lange, et. al., 2008). • Reappraisal tends to deactivate limbic regions and activate frontal executive functioning (co-varying relationship (Banks et. al, 2007). • Changes brain rapidly: 4 weeks for OCD (Saxena et. al, 2009).

11. Meditation: From Ancient Traditions to Modern Treatments • Yoga, Buddhism, Zen, & Daoism • Successfully used in drug treatment. • Meta-analysis of 198 independent studies showed meditation is as effective or more effective than standard treatments (Alexander, Robinson, & Rainforth, 1994). • Approaches and Techniques Include: • Mindfulness to become aware • Overcoming cravings • Activating Internal Energy to Rehabilitate the Body and Mind • Spirituality and enhanced well-being • Drugs often initially are taken when seeking a higher calling • Ultimately drugs lead people away from spirituality • Treatment involves satisfying the search for spiritual fulfillment without drugs

12. Meditation and Brain Research • Using more of the Brain • Higher gamma baseline on EEG across both hemispheres (Hankey, 2006) • Dual Effect • Increased beta waves for alertness and wakefulness along with slower alpha and theta associated with relaxation (Bhatia et. al., 2003). • Decoupling of attention and arousal for calmer, more receptive attention (Lutz, 2004) • Cortical thickening (Lazar et. al, 2005) • In right anterior insula and prefrontal cortex • Slowed normal thinning: The cortex of older meditators was as thick as 20-year old in these areas

13. Hypnosis • Uses an altered state to facilitate change • This can be attractive to drug users who like to alter consciousness • Helps alleviate pain and helps manage withdrawal symptoms • Hypnosis is well-researched for its pain reduction capacities (Boyle et. al, 2007) • Teaches people they can be responsible for feeling good • Doesn’t come from outside of themselves • Activates neurotransmitters already in the brain • Find inner resources for strength and calm within (Simpkins & Simpkins, 2005)

14. Hypnosis and the Brain • Researchers debate whether hypnosis is an altered state or a socio-psychological phenomenon, but there is growing evidence from neuroscience that it alters the brain (Barabasz & Barabasz, 2008) • Interaction between them creates the phenomenon • Changes in occipital region indicate a more flexible attentional style, a useful trait for therapeutic change (Davidson, et. al, 1976) • Activates anterior cingulate cortex involved in emotional regulation (Damasio, 1997) • Relaxation: Activates brainstem and hypothalamus areas involved in regulation of relaxation and sleep

15. The12 Steps • Turn to higher power to overcome the strong pull of drug use • Carefully laid out plan of steps to follow • Strong support system which continues to be available lifelong

16. Treatment Considerations • Harm Reduction • Self-Esteem • Finding pleasure in life not just in substances • Handle craving and discomfort • Dealing with guilt and responsibility • Learning to relax and self-soothe • Learning to release talent by their own ability which is perceived as enhanced through drug use • Eg. Immersion in performance by Jimmy Hendrix

17. Relapse Prevention • Working with Hospital Drug Treatment Programs • Become aware of and eliminate triggers • Avoid relationships associated with drug use • Stop pain killer use and any other drugs • Use non-alcoholic mouthwash, etc. • Linda and surgery for deviated septum

18. Begin with Awareness • To understand drug use, begin with a simple survey • How often do you use drugs? (daily, weekly?) • What drugs do you use? • Do you think you have a problem? • If so, what is it • Be specific

19. Illustrations with CasesHeroin • Bob: From crime and drugs to a life of fulfillment and honor • His father and uncle were in jail • Went into drug treatment program while seeing us for therapy • Former gang member he had harmed was also in rehab • Dealt with guilt in therapy and took responsibility • Years later returned to honorably pay for his treatment • Told us he had married a girl who had never been involved in drugs or crime • Had a responsible position as a manager

20. Methamphetamine The 30-year-old waiter with the heart of a 70-year-old man • Danny was a waiter who used methamphetamine regularly • When his doctor gave him the death sentence, he decided to try to stop using Methamphetamine, but feared he would not be able to succeed • He felt drug made him charming, competent, and socially adept • Without it he thought he was slow, sluggish, and nobody liked him • Through hypnosis he learned to awaken his positive qualities without drugs

21. Valium: The girl who learned to put her anxiety in her little finger • Berta was an attractive girl who had been prom queen of her high school • She became increasingly anxious, narrowing down her life to work in an ice cream parlor • She began deep hypnotherapy to overcome anxiety and her dependence on valium • In time she had the courage to enroll in classes to pursue her dream of becoming a dancer • Using hypnosis, she earned how to be calm when dancing: just shaking in her little finger • Teacher used her as an example of poise and calm • She worked on her conflicts unconsciously, doing automatic writing • She began gradually cutting down her use of valium. • One day she forgot her pills, never returned to them again

22. Alcoholism: The man who truly played golf • Dave had begun drinking many years ago as a manager for a well-known band • Enjoyed drinking with his wife and friends, at first. • But then lost his motivation. Suspected drinking was the cause • He was a golf enthusiast but he and his golfing friends drank while on the golf course • We taught him meditation and hypnosis. • He learned to find meaningful enjoyment in something other than the pleasure of indulging in alcohol, by focused involvement in technique and playing the game itself. • Discovered the satisfaction of mastery and experienced improvement of technique compared to playing while under the influence of alcohol • His natural feeling of motivation returned

23. The Best Trip Ever • During a brief stop while traveling, took a taxitour through a city. Unexpectedly, needed to cope with an entirely different kind of trip, the driver of the cab! • The driver disclosed after awhile that he was peaking on an acid trip and took a drive for the experience. He was driving erratically putting himself and us in danger. He asked us how he was driving. • Successful strategic use of guidance with focused meditation gave assistance.

24. Upcoming Books

25. Bibliography • Alexander, C.N., Robinson, P., & Rainforth, M. 1994. Treating and preventing alcohol, nicotine, and drub abuse through Transcendental Meditation: A review and statistical meta-analysis. Alcoholism Treatment Quarterly. 11, 1-2, 13-87. • Banks, S. J., Eddy, K. T., Angstadt, M., Nathan, P. J., & Phan, K. L. (2007). Amygdala-frontal connectivity during emotion regulation. Soc Cogn Affect Neurosci. 2, 4, 303-312. • Barabasz, A. F. & Barabasz, M. (2008). Hypnosis and the brain. In M. Nash & A. Barnier,, Eds. The Oxford handbook of hypnosis. London: Oxford U. Press. pp. 337-363. • Boly, M. Faymonville, M., Vogt, B. A., Maquet, P, & Laureys, S. (2007). Hypnotic regulation of consciousness and the pain neuromatrix. in G. A. Jamieson, Ed. Hypnosis and conscious states: The cognitive neuroscience perspective. Oxford, England: Oxford University Press. • Damasio, A. R. (1997). Towards a neuropathology of emotion and mood. Nature. 386, 769-70. • Davidson, R., Goleman, D., & Schwartz, G. 1976. Attentional and affective concomitants of meditation: A cross-sectional study. Journal of Abnormal Psychology. 85. 235-308. • de la Fuente-Fernandez, R. Schulzer, M., Stoessi, A., (2002). Placebo mechanisms and reward circuitry: clues from Parkinson’s disease. Biological Psychiatry. 56, 2, 67-71. • Frank, J. D., & Frank, J. B. (1991). Persuasaion & Healing. Baltimore: The Johns Hopkins University Press. • Frank, J. D., Hoehn-Saric, R., Imber, S., Liberman, B., Stone, A. (1978). Effective Ingredients of successful psychotherapy. New York: Brunner/Mazel. • Goldapple, K., Segal, Z., Garson, C., Lau, M., Bieling, P., Kennedy, S., Mayberg, H. (2004). Modulation of cortical-limbic pathways in major depression: Treatment-specific effects of cognitive behavior therapy. Arch Gen Psychiatry, 61, 1, 34-41. • Lange, F. P., Koers, A. K. , Kalkman, J. S., Bleijengerg, G., Hagoort, P., van der Meer, J. W. M., & Toni, I. (2008). Increase in prefrontal cortical volume following cognitive behavioural therapy in patients with chronic fatigue syndrome. Brain, 131, 2172–80.

26. Bibliography Continuted • Lazar, S. W., Kerr, C. E., Wasserman, R. H., Gray, J.R. Greve, M., Treadway, T., MCGarvey, M., Quinn, B.T., Dusek, J. A., Benson, H., Rauch, S.L, Moore, C. L.and Fishi, B. (2005.) Meditation experience is associated with increased cortical thickness. NeuroReport. 16, 17, 1893-1897. • Lutz, A. Gretschar, L.L., Rawlings, N., Ricard, M., & Davidson, R.J. 2004. Long-term meditators self-induce high-amplitude gamma synchrony during mental practice.Neuroscience. 101. 46. 16369-16373. • Luparello, t. J., Leist, N., Sourie, C. H., & Sweet, P. (1970). The interaction of psychologic stimuli and pharmacoligic agents on airway reactivity in ashmatic subjects. Psychosom. Med. 32, 509-13. • Park, L. C., & Covi, I. (1965). Non-blind placebo trial: An exploration of neurotic patients’ responses to placebo when its inert content is disclosed. Arch. Gen Psychiatry. 12, 336-45. • Petrovic, P. Kalso, E. K. M. Petersson, , Ingvar, M. (2002). Placebo and Opioid Analgesia-- Imaging a Shared Neuronal Network. Science, 295, 5560, 1737-1740. • Saxena, S., Gorbis, e., O’Neill, J., Baker, S. K., Mandlkern, M. A., Maidment, K. M., Chang, S., Salamon, N., Brody, A. L., Schwartz, J. M. & London, E. D. (2009). Rapid effects of brief intensive cognitive-behavioral therapy on brain glucose metabolism in obsessive-compulsive disorder. Molecular Psychiatry. 14, 197-205. • Seminowicz, D. (2006). Believe in your placebo. Journal of Neuroscience. 26, 17, 4453-4454. • Simpkins, C. A. & Simpkins, A. M. (2005). Effective self hypnosis with CD. San Diego: Radiant Dolphin Press • Simpkins, C. A., & Simpkins, A. M. (2009). Meditation for therapists and their clients. New York: W. W. Norton. • Simpkins, C. A. & Simpkins, A. M. (2009). The Dao of neuroscience. New York: W. W, Norton. • Witkiewitz, K, Marlatt, G.A., & Walker, D. (2005). Mindfulness-based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy. 19. 3, 211-228.