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Craving

Craving. Karen Drexler, M.D. Emory University School of Medicine. Overview. What is craving? Why is it so compelling? What are the neural mechanisms that drive craving? How does knowing neurobiology inform my clinical practice?. Features. Intense desire Many components 3 types

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Craving

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  1. Craving Karen Drexler, M.D. Emory University School of Medicine

  2. Overview • What is craving? • Why is it so compelling? • What are the neural mechanisms that drive craving? • How does knowing neurobiology inform my clinical practice?

  3. Features • Intense desire • Many components • 3 types • Withdrawal-induced • Drug-induced • Cue-induced • Compels drug-seeking in dependentindividuals

  4. DSM-IV Dependence 3 or more of the following: • Tolerance • Withdrawal • Larger amountsthan intended • Persistent efforts to cut downor control • A great deal of time spent gettingthe substance, taking it, or recovering • Important activitiesgiven up • Continued use despite psychological or physical problemexacerbated by use

  5. Desire Corresponds With Drug Use Liking Wanting Craving Non-problematic use Abuse Dep

  6. Overview • What is craving? • Why is it so compelling?

  7. Why is Craving So Compelling? • Correlates with other measures of substance dependence • Better understanding may lead to better treatment

  8. Overview • What is craving? • Why is it so compelling? • What are the neural mechanisms that drive craving?

  9. Neural Mechanisms

  10. Mesocorticolimbic Pathway Anterior cingulate Subcallosal cortex Nucleus accumbens Ventral tegmental area

  11. Prefrontal - Limbic Inhibition Dorsolateral PFC Lateral Orbitofrontal cortex Nucleus accumbens

  12. Amygdala – Limbic Connections Medial PFC Nucleus accumbens Amygdala

  13. Neural Mechanisms

  14. Neuroimaging in Humans • Confirm these hypotheses • Two types of provocation • Drug-induced • Cue-induced

  15. Drug-induced Craving High Craving

  16. Drug-induced Craving

  17. Cue-induced Craving • Widely distributed cortical activations • Temporal lobe (Amygdala) • Frontal cortex (DLPFC, OFC) • Less often mesolimbic pathway

  18. Cue-induced Craving

  19. Cue-induced Craving Associated  in BOLD fMRI Dorsolateral Prefrontal Ant Cingulate Medial Prefrontal Post Cingulate Garavan et al, 2000

  20. Amygdala Activation to Ethanol Cues Before and After Treatment Amygdala Before treatment After treatment Schneider et al, 2001

  21. Neural Correlates of Cocaine Cue-induced Craving Left Right insula -34 mm +34 mm anterior cingulate amygdala -19 mm +19 mm -9 mm +9 mm subcallosal cortex nucleus accumbens area

  22. Drug-induced vs Cue-induced Craving

  23. Overview • What is craving? • Why is it so compelling? • What are the neural mechanisms associated with craving? • How does this affect my clinical practice?

  24. Implications for Treatment • Appreciation that substance dependence is a brain disease • Cognitive behavioral therapy • Medications

  25. Craving Summary • Intense desire that compels use in dependent individuals • Associated neural circuits involved in: • Reward • Cognitive control • Learning • Treatment targeting craving may improve outcome

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