Addiction and its Rehabilitation - Lecture Notes PDF

Addiction and its Rehabilitation A Lecture for PSYU3344: Neuropsychology in Clinical Practice Clin A/Prof Jamie Berry Senior Clinical Neuropsychologist Outline Terminology Neuropsychology of alcohol and Substance Use Disorder...

Addiction and its Rehabilitation A Lecture for PSYU3344: Neuropsychology in Clinical Practice Clin A/Prof Jamie Berry Senior Clinical Neuropsychologist Outline Terminology Neuropsychology of alcohol and Substance Use Disorder methamphetamine use disorders Prevalence Rehabilitation of SUD Alcohol Use Disorder Cognitive Behavioral Therapy (CBT) Motivational Interviewing (MI) Comorbidity with mental illness 12 Step Programs Neurochemical mechanisms Therapeutic Communities The brain bases of tolerance and Cognitive Impairment in SUD withdrawal Prevalence Classifying substances Impact Substance Induced Neurocognitive Cognitive Impairment interventions Disorder Automatic processes Controlled processes Termninology (Kolb and Whishaw, 2022) Substance abuse is a pattern of drug use in which people rely on a drug chronically and excessively, allowing it to occupy a central place in their lives. A more advanced state of abuse is substance dependence, popularly known as addiction. Kolb, B., & Whishaw, I. Q. (2022). The Influence of Drugs and Hormones on Behavior. Terminology Addiction is a brain disorder characterized by compulsive engagement in rewarding stimuli despite adverse consequences. https://en.wikipedia.org/wiki/Addiction Addiction is a state of psychological or physical dependence (or both) on the use of alcohol or other drugs. The term is often used as an equivalent term for substance dependence and sometimes applied to behavioral disorders, such as sexual, Internet, and gambling addictions. https://dictionary.apa.org/addiction Addiction happens when someone compulsively engages in behaviour such as drug taking, gambling, drinking or gaming. Even when bad side effects kick in and people feel like they’re losing control, addicts usually can't stop doing the thing they’re addicted to without help and support. https://au.reachout.com/tough-times/addiction Terminology “Some clinicians will choose to use the word addiction to describe more extreme presentations, but the word is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation.” – (DSM 5, p485) A substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems A substance-induced disorder includes intoxication, withdrawal, and other substance/medication-induced mental disorders (e.g., substance-induced psychotic disorder, substance-induced depressive disorder) Substance Use Disorder (DSM – 5) A cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems Four categories of symptoms: impaired control (criteria 1-4) social impairment (criteria 5-7) risky use (criteria 8-9) pharmacological (criteria 10-11) As a general estimate of severity: a mild substance use disorder is suggested by the presence of two to three symptoms, moderate by four to five symptoms, and severe by six or more symptoms. Prevalence Individuals aged 18-24 years have relatively high prevalence rates for the use of virtually every substance. Slade et al (2009) Alcohol Use Disorder A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12- month period: Impaired Control 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. Social Impairment 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. Alcohol Use Disorder Risky use of the substance 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. Pharmacological criteria 10. Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b) A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol. b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms. Alcohol Use Disorder Prevalence In the United States, the 12-month prevalence of alcohol use disorder is estimated to be 4.6% among 12- to 17-year-olds and 8.5% among adults age 18 years and older in the United States. greater among adult men (12.4%) than among adult women (4.9%) Onset Late teens to early 20s Risk factors cultural attitudes toward drinking and intoxication availability of alcohol (including price) acquired personal experiences with alcohol stress levels (or poor coping strategies) 40%-60% of the variance of risk explained by genetic influences Comorbidity Marel et al (2016) Comorbidity Marel et al (2016) Neurochemical transmission Mechanisms 1. Synthesis 2. Storage 3. Release 4. Receptor interaction 5. Deactivation 6. Reuptake 7. Degradation Neurotransmission Opponent-Process Theory 1980 Brain aims for homeostasis – a steady state When neural activity is suddenly changed (e.g., increased or decreased), there is down- or up- Solomon and Corbit regulation of receptor sites. (1974) The brain bases of tolerance and withdrawal Opponent processes These changes in receptor densities partly explain tolerance and withdrawal The withdrawal effect is often the opposite to the intoxication effect Alcohol intoxication and withdrawal symptoms Intoxication Withdrawal Relaxation Irritability / restlessness Drowsiness or sleepiness Agitation Disinhibition Anxiety / panic attacks Slowed thinking / reaction time Palpitations / sweating Loss of co-ordination Insomnia Unsteady gait Headache / migraine Slurred speech Hallucination / psychosis Loud, argumentative or aggressive Tremors behaviour Seizures Koob (2003) Allostasis is the ability to attain stability but at an altered, potentially pathologic set point Opponent Process Theory Solomon and Corbit (1974) Wanting and liking (incentive sensitization) theory (Robinson & Berridge, 1993) Wanting is equivalent to cravings for a drug Liking is the pleasure that drug taking produces. The theory proposes that with repeated drug use, tolerance for liking develops, and wanting sensitizes. Wanting and liking (incentive sensitization) theory (Robinson & Berridge, 1993) Separate neural systems are associated with wanting and liking. The dopamine system is the proposed neural basis for wanting (craving). The neural system for liking consists of a number of small liking “hot spots” within the regions to which dopamine neurons project. These hot spots may consist of neurons that use endogenous opioids as neurotransmitters. Koob, 2021: Drug Addiction: Hyperkatifeia / Negative Reinforcement as a Framework for Medications Development Addictions Neuroclinical Assessment (Kwako et al, 2016; 2017) Addictions Neuroclinical Assessment (Kwako et al, 2016; 2017) Classifying substances National Drug and Alcohol Research Centre (2017). A Quick Guide to Drugs & Alcohol, third edition Substance/Medication-Induced Neurocognitive Disorder A. The criteria are met for major or mild neurocognitive disorder. B. The neurocognitive impairments do not occur exclusively during the course of a delirium and persist beyond the usual duration of intoxication and acute withdrawal. C. The involved substance or medication and duration and extent of use are capable of producing the neurocognitive impairment. D. The temporal course of the neurocognitive deficits is consistent with the timing of substance or medication use and abstinence (e.g., the deficits remain stable or improve after a period of abstinence). E. The neurocognitive disorder is not attributable to another medical condition or is not better explained by another mental disorder. Mild Neurocognitive Disorder A. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual motor, or social cognition) based on: 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and 2. A modest impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. B. The cognitive deficits do not interfere with capacity for independence in everyday activities (i.e., complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required). C. The cognitive deficits do not occur exclusively in the context of a delirium. D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia). Neuropsychological effects of alcohol Acts on GABA, as well as serotonin and dopamine systems. Two distinct groups 1. Those with severe cognitive impairments (Alcohol Induced Major NCD) 10% of those with alcohol dependence Associated with Wernicke-Korsakoff syndrome Poor reversibility Risk increases with age and nutritional deficiencies 2. Those with mild to moderate cognitive impairments 45% of those with alcohol dependence Greater chance of reversibility Neuropsychological effects of alcohol Cortical atrophy Reduced cerebral blood flow in Reduced brain weight frontal and parietal areas Reduced white matter Esp. corpus callosum Loss of neurons in (superior) frontal cortex Shrinkage of neuronal cell bodies Increased cerebrospinal fluid spaces Ventricles Sulcal Neuropsychological effects of alcohol AUD  Neuropsychological effects of alcohol Wernicke-Korsakoff Syndrome Confusion/delirium, abnormal eye movements (ophthalmoplegia), gait ataxia Thiamine deficiency Haemorrhagic lesions in the brainstem, cell loss in periaqueductal and periventricular grey matter, thalamus, mammillary bodies and hippocampus Larger ventricles (esp. third ventricle) Associated with more permanent and severe memory impairment Neuropsychological effects of alcohol Deficits in: Relative sparing of: Executive functioning Intellect Cognitive flexibility Verbal skills Impulse control Abstract reasoning Problem-solving Learning and memory Encoding / storage Intrusion errors Esp. visual memory Visuo-spatial skills Constructional skills Motor skills Cognitive recovery with abstinence from alcohol Neuropsychological recovery can continue for months or years after abstinence. Related to changes in brain morphology Reduced CSF spaces Related to increased white matter tissue volume on MRI Evident from 4-5 weeks post-abstinence May continue for a year Mechanism unclear but may be related to dendritic regrowth (evidence for this from animal models) Neuropsychological effects of methamphetamine Causes neurotoxicity via oxidative stress and hyperthermia, especially in nigrostriatal dopaminergic pathways Reduced cerebral blood flow and metabolism in frontal and striatal regions Neuropsychological effects of methamphetamine Acute effects Long term effects Enhanced attention 40% of those with dependence have Faster speed of information global cognitive deficits processing Processing speed Focussed and sustained attention Working memory Memory Executive functioning Response inhibition / impulse control Mental flexibility Decision making Problem solving Persist after several months of abstinence and probably indefinitely Poly substance use disorder The rule, not the exception! Effects on cognition more severe and widespread than single drug use. When assessed several weeks after abstinence, 40-50% polydrug users show impairments with cognition and motor functioning Cognition worse in this group with increasing age, poorer education and comorbid medical and developmental problems. Rehabilitation Cognitive Behavioral Therapy (CBT) Relapse prevention Contingency management Motivational Interviewing (MI) 12 Step Programs Therapeutic Communities Klimas et al (2018) – Cochrane Review Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users 7 studies (825 participants) cognitive-behavioural coping skills training (one study) twelve-step programme (one study) brief intervention (three studies) motivational interviewing (two studies) brief motivational interviewing (one study). “No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.” CBT - Relapse Prevention Larimer et al (1999) Contingency Management CM is a strategy used in alcohol and other drug (AOD) abuse treatment to encourage positive behavior change (e.g., abstinence) in patients by providing reinforcing consequences when patients meet treatment goals and by withholding those consequences or providing punitive measures when patients engage in the undesired behavior (e.g., drinking). Can be used for reducing AOD use; improving treatment attendance; and reinforcing other treatment goals, such as complying with a medication regimen or obtaining employment. Based on operant conditioning Contingency Management Source: https://images.app.goo.gl/KDEeyF29adXbzeKq7 Contingency Management Four central principles: 1. The clinician arranges for regular testing to ensure that the patient’s use of the targeted substance is readily detected. 2. The clinician provides agreed- upon tangible reinforcers when abstinence is demonstrated. 3. The clinician withholds the designated incentives from the patient when substance use is detected. 4. The clinician assists the patient in establishing alternate and healthier activities (e.g., a better paying job, improved family relations, enjoyable social and recreational activities) to compete with the reinforcement derived from the AOD-abusing lifestyle. Contingency Management Support from animal models For example, providing food, liquids, or novel environmental alternatives reduces AOD use in animals, just as providing entertainment or financial alternatives reduces AOD use in humans. Follow-up studies on the efficacy of CM have demonstrated beneficial long-term effects but have also found evidence of relapse in about the same proportion as is seen with other psychological treatments for AOD abuse disorders (Higgins et al. 1995) Transtheoretical Model of Change 1. Pre- Relapse contemplation 2. 6. Termination 5. Maintenance Contemplation 4. Action 3. Preparation Motivational Interviewing “Motivational interviewing is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change” Miller and Rollnick, 2009 (p137) Influenced by or co-evolved with: Cognitive dissonance (Festinger, 1957) Attribution theory (Kopel & Arkowitz, 1975) Transtheoretical stages of change model (Prochaska & DiClemente, 1982) Self-determination theory (Deci & Ryan, 1985) Social cognitive theory (Bandura, 1986) Motivational Interviewing Four principles of MI (Miller & Rollnick, 2002): 1. the practitioner expresses empathy for a patient, which creates an atmosphere of safety and promotes self-focus and disclosure 2. the practitioner develops discrepancy between the patient’s behavior and important goals or values 3. the practitioner avoids argumentation and rolls with resistance versus imposing change strategies 4. the practitioner supports a patient’s self-efficacy to resolve problems MI vs CBT Motivational Interviewing Promotes internal, rather than external, motivation to change MI and traditional behavioural approaches are potentially at odds Behavioural approaches better suited to more acute/severe cases where there is some control over the contingencies (e.g., inpatient admissions) MI associated with greater long-term change 12 Step Programs Self-help groups E.g., Alcoholics Anonymous, Narcotics Anonymous One of the oldest treatment approaches to alcoholism (1930s) Ferri, Amato and Davoli (2006) – Cochrane Review N = 3,417 “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems.” 12 Steps (https://www.alcohol.org/alcoholics-anonymous/) 1. We admitted we were powerless over alcohol—that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory and when we were wrong promptly admitted it. 11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs. AA Agnostica – secular 12 steps Therapeutic Communities Therapeutic communities emphasise a Recovery: holistic approach to treatment and requires establishment or renewal of address the psychosocial and other issues personal values, such as honesty, self- behind substance abuse. The reliance, and responsibility to self and “community” is thought of as both the others context and method of the treatment involves learning or re-establishing the model, where both staff and other behavioural skills, attitudes and values residents assist the resident to deal with associated with community living his or her drug dependence. involves personal development and lifestyle change consistent with shared community SUD is viewed as: values. a complex condition combining social, psychological, behavioural and physiological dimensions a symptom of underlying social, NSW Health (2007) psychological or behavioural issues that need to be addressed if recovery is to occur. Cognitive Impairment Prevalence in AOD services The prevalence of cognitive impairment among clients accessing AOD treatment has been estimated to be between 30% and 80% – (Copersino, et al., 2009) Marceau et al (2016). Using a Brief Screening Tool to assess Cognitive Impairment in residents of an Alcohol and other drug Therapeutic Community. Journal of Substance Abuse Treatment Marceau et al (2016) Residents of an AOD therapeutic community N=128 Non-substance using control group N=37 All administered the MoCA 43.8% AOD treatment clients met criteria for cognitive impairment Marceau et al (2016) 67.2% of AOD sample had sustained a traumatic brain injury 50% of the AOD sample required hospitalisation for their head injury History of head injury was a significant predictor of cognitive impairment Executive functioning (combination of trail-making, phonemic fluency, verbal abstraction, cube-copying and clock-drawing) was the domain that differed most between the groups. Impact of CI in AOD Treatment Brorson et al (2013). Drop-out from addiction treatment: A systematic review of risk factors. Clinical Psychology Review 1. Cognitive Impairment 2. Younger Age 3. Personality Disorder Impact of CI in AOD Treatment Decreased treatment retention Poorer treatment outcomes Decreased abstinence Less likely to engage in therapeutic interventions for change Less treatment adherence, engagement, readiness to change, self- efficacy and insight Greater denial of addiction Impact of CI in AOD Treatment To overcome SUD, clients need to: integrate new information formulate goals establish new behavioural strategies and plan for the future = Executive Functioning “those capacities that enable a person to engage successfully in independent, purposive, self-directed, and self-serving behavior” – Lezak et al (2012) Sofuoglu et al (2013) CBM (Mucic & Hilty, 2016) Action tendency bias – a greater tendency to approach disorder- related stimuli Participants react to a feature of the stimulus unrelated to the contents, for example, the format or a little tilt left or right Cognitive Bias Modification Participants are instructed to respond to pictures of alcohol making an avoidance movement (pushing the joystick) and to respond to pictures of soft drinks making an approach movement (pulling the joystick) (Wiers, 2013). Between 4 and 12 x 20 min training sessions. CBM has shown to reduce alcohol relapse up to one year after the training measured via the Timeline Followback interview (TLFB), showing moderate effect sizes compared to sham training and no-training (Wiers et al., 2011; Eberl et al., 2013). the neural mechanism relevant to CBM effects in alcohol use disorders is the down-regulation of the salience/impulsive system, reflected in training- related reductions of medial prefrontal cortex and amygdala responsivity to alcohol cues (Wiers et al., 2015a, 2015b).  CBM group – portrait images always contained images of alcoholic drinks (e.g., wine bottles, beer) and landscape images always contained pictures of nonalcoholic beverages, including soft drinks, juice, milk, and water. Control group – sham training involving kitchenware (portrait) and stationery (landscape) images Both groups trained to push joystick when presented with portrait images and pull joystick when presented with landscape images. 4 sessions of CBM (120 trials over 15 minutes) over 4 consecutive days resulted in significantly higher abstinence in the CBM versus sham treatment group (75% vs 45%). Manning et al (2021) N=300 Abstinence rates were 42.5% in controls and 54.4% in CBM participants, yielding an 11.9% (95% CI, 0.04%-23.8%; P =.04) difference in abstinence rates. In a per-protocol analysis including only those who completed 4 sessions of training and the follow- up, the difference in abstinence rate between groups was 17.0% (95% CI, 3.8%-30.2%; P =.008). Working Memory Training Repetitive mental exercises (e.g. letter and digit strings, visual searches, mental arithmetic tasks, N-back tasks) are used to strengthen information maintence, manipulation and updating, often using computerized applications Applications: Cogmed, PSSCogRehab, Cogpack, Lumosity, mHealth Bickel et al (2011) n = 27 adults in treatment for stimulant use were randomly assigned to receive either working memory training or control training according to a yoked experimental design 4 to 15 training sessions, and 1 posttraining session. The range of time lapsed between pre- and posttraining sessions was 9 to 44 days, with a mean of 25 days. Outcome measure – delay discounting participants chose between an immediate, smaller and a later, larger amount of money. Results: Delay discounting was reduced in the training, relative to the control group Goal-Directed Training Altogether, the extant findings suggest that goal-directed interventions improve some executive functions (working memory −2 studies, and cognitive control and decision-making −1 study) in substance dependent populations. The extent to which these effects generalise to alcohol and drug use outcomes still needs to be determined. Verdejo-Garcia (2016) Verdejo-Garcia (2016) The two training classes map onto the core deficits of the “addicted brain”: (1) an overactive bottom-up impulsive system; and (2) a poor top-down executive system (Goldstein and Volkow, 2002, 2011; Bechara 2005). The emerging cognitive training research has revealed meaningful interactions between these two systems. For example, CBM training taps into cognitive biases related to the impulsive system (Coskunpinar and Cyders, 2013), but the retraining of stimulus-action biases can also facilitate learning of novel stimulus- outcome associations via executive mechanisms (Sonuga-Barke and Fairchild, 2012).  Ecologically Valid Sample 527 Participants were included in the study 44% Methamphetamine from 10 SUD sites 38% Alcohol Ecologically valid sample – No exclusion criteria (includes OST, court-ordered treatment, 7% Cannabis comorbidities) 4% Heroin Mean Age = 36.49 (SD=10.84) 2% Cocaine Range 18-70 62% Male 1.3% Opioids Mean Years of Education = 10.70 (SD=2.08) 2.7% Other Range 5-17 Stepped Wedge Randomised Trial Staggered introduction of Cognitive N=234 participants provided data Remediation (CR) at 2+ time points Comparison of periods of treatment as usual (TAU) and periods of CR Primary outcomes Self-reported executive functioning (BRIEF-A) Higher scores = more difficulties Length of Stay and Graduation data Results – intention to treat Intention-to-treat analysis did Unadjusted average GEC over not find significant differences time (by sequence) for executive functioning (mean difference = −2.49, 95%CI [−5.07, 0.09], p =.059) Investigation of CR attendance data showed that a considerable number of participants (n=70; 22%) who were allocated to sites running CR did not attend any sessions. High dropout from the intention- to-treat sample (56%)  Per protocol Results – per protocol results 9 8 8.18 A post-hoc analysis was 7 conducted using a per protocol BRIEF-A GEC Improvements approach 6 5.76 CR was associated with improved 5 executive functioning (mean 4 difference = −3.33, 95%CI [−6.10, −0.57], p =.019) 3 3.03 2 TAU Partial CR Full CR Improvement in GEC T-Scores over time (Inverted) Graduation Graduation Rate (%) 100 Rate 90 80 70 63.1 The adjusted odds of 60 graduating from 50 treatment after engaging in CR was 40 34.2 2.43 times greater 30 than the odds of 20 graduating from TAU 10 treatment (95% CI 0 1.43 to 4.11; TAU ACE p