Archives for October 2016

Why Opioid Maintenance Does Not Replace One Addiction with Another

Opioid addiction has been declared a national epidemic in America. President Obama called for $1.1 billion in new funding for opioid addiction treatment and research early in 2016.

Opioids are drugs that relieve physical and emotional pain. Opioids include opiates, which is an older term for drugs derived from opium, such as morphine. Common opioids include prescription painkillers such as OxyContin, hydrocodone, Percocet, methadone and Vicodin, as well as drugs like morphine and heroin. Opioids cause a rush of dopamine in the brain, conditioning the brain over time and altering pathways dealing with pleasure, memory, learning, and decision-making.

With continued use, the human body develops tolerance to opioids, which means the body no longer responds to the drugs unless the dose is increased. A person with a highly developed opioid tolerance may take doses to get high that would be lethal for a person without an opioid tolerance.

Unfortunately, people taking opioids illicitly may have an irregular supply, causing their tolerance to fluctuate. Illegal opioids are also of variable potency, and may be laced with stronger, faster-acting opioids like fentanyl. The combination of fluctuating tolerance and unpredictable potency creates a dangerous situation for people using illicit opioids. For example, someone using heroin whose tolerance has dropped may inject what they think is a manageable dose of heroin, not knowing it is laced with fentanyl; the added potency and reduced tolerance could cause an overdose, and this person could be at risk of dying.

Since 2000, opioid overdose deaths in the U.S. have increased 200%.

A nuanced discussion rather than a black-and-white debate

Some discussions about opioid maintenance involve black-and-white/good-or-bad thinking. Let’s explore the nuances of how opioid maintenance works for people with opioid addictions.

Why Opioid Maintenance Treatments Are the Best We Have

The opioid epidemic is alarming especially because so many people with families, dreams, and skills – like anyone else – are affected. People with opioid addictions are taxpayers and citizens of many races, religions, and backgrounds; they are people and they are valuable. How can we prevent them from dying?

Addiction is defined by NIDA as a chronic, relapsing brain disease characterized by repeated behavior despite negative consequences. Relapse rates for addiction are comparable to other chronic illnesses, such as diabetes and hypertension.

Given that relapse is likely and given that reduced tolerance is a primary risk factor for fatal overdose, it follows that maintaining tolerance would reduce overdose deaths. Sure enough, scientific research on opioid maintenance shows that stable doses of full or partial opioid agonists (drugs that completely or partially activate opioid receptors) maintain tolerance and reduce risk of death if a relapse occurs.

“If we really want to stop the overdose epidemic, we need to get serious about providing the only treatment known to reduce the death rate by 50 percent to 70 percent or more: indefinite, potentially lifelong, maintenance on a legal opioid drug like methadone or buprenorphine. The data on maintenance is clear. If you increase access to it, deathcrime and infectious disease drop; if you cut it short, all of those harms rise.”
– Maia Szalavitz, The public scorns the addiction treatment Prince was going to try. They shouldn’t.

How Opioid Maintenance Works

“The principle behind MAT is this: Because opioid addiction permanently alters the brain receptors, taking the drug completely out of someone’s system can leave them less able to naturally cope with physical or emotional stress…”
– Maia Szalavitz

Two drugs are supported by scientific evidence as effective opioid maintenance treatments: buprenorphine, and methadone. A continuous, prescribed dose of either buprenorphine or methadone prevents people from experiencing withdrawals, stabilizes them in recovery, and reduces risk of fatal overdose. These medications do this by maintaining tolerance to opioids. People who are in opioid maintenance programs are not high when they take doses as prescribed (also because of tolerance), and are quite capable of driving a vehicle, going to work, providing childcare, and otherwise living life. Pregnant women who are addicted to opioids are advised to take buprenorphine (Subutex) to stabilize themselves and their babies until delivery.

Buprenorphine

Buprenorphine is a partial opioid agonist, which means that it binds to opioid receptors in the brain with only partial efficacy compared to full agonists (like morphine, oxycodone, and fentanyl). Effects of buprenorphine also have a ceiling dose, beyond which higher doses have no effect. This ceiling effect also means overdose from buprenorphine is less likely. Buprenorphine also affects the mμ receptor, which reduces the effects of additional opioid use.

Because it is safer than methadone, buprenorphine can be prescribed by physicians as pills or sublingual films, often under the brand names Suboxone or Subutex. Subutex is buprenorphine alone, while Suboxone also contains naloxone, an opioid antagonist. Suboxone was created to discourage misuse. When Suboxone is taken orally as directed, the opioid partial-agonist effects of buprenorphine predominate. If Suboxone is injected, however, the naloxone blocks opioid receptors and prevents the person from getting high. In an opioid dependent individual, the naloxone precipitates withdrawal effects.

Methadone

Methadone is a full opioid agonist, and does not have ceiling effects like buprenorphine. For this reason, it is considered to have higher misuse potential and is only administered by SAMHSA-certified opioid treatment programs, usually methadone clinics. However, a 2014 Cochrane review of studies comparing methadone and buprenorphine determined that people are less likely to drop out of methadone programs.

Given the complexity of addiction, and the complexity of factors uniquely affecting each person, individuals with addiction need individualized treatment. Only the individual, in consultation with one or more physicians well-educated in opioid use disorder and its treatment, may decide.

“Extensive literature and systematic reviews show that maintenance treatment with either methadone or buprenorphine is associated with retention in treatment, reduction in illicit opiate use, decreased craving, and improved social function. … Further work is needed to directly compare each medication and determine individual factors that can assist in medication selection. Until such time, selection of medication should be based on informed choice following a discussion of outcomes, risks, and benefits of each medication.
Dr. Gavin Bart, 2012 (Emphasis added)

How Opioid Maintenance Treatments Discourage Misuse

Just as it is impossible to eliminate all supplies of illegal drugs, law enforcement and treatment providers cannot wholly prevent diversion and misuse of buprenorphine or methadone. In fact, in trying to reduce misuse of buprenorphine, authorities have restricted access to buprenorphine maintenance treatment, limiting the number of buprenorphine patients a doctor can treat at any one time.

Still, treatment providers, pharmaceutical manufacturers, legislators, and law enforcement continue to try to limit the potential negative impacts of opioid maintenance treatments. Methadone, for example, is only given in take-home doses if patients can provide drug-free urine for several months.

However, because Suboxone can be diverted to people who were not prescribed the medication, it can still be misused. People who do not have a tolerance for opioids can still get high on Suboxone, up to the ceiling effect. Arguably, it’s a safer high than heroin because it is less likely to cause fatal overdose, but it’s still an illegal high.

In this case, as citizens, we have to weigh the risks of the diversion of partial agonist, buprenorphine, with full agonists like heroin, morphine, fentanyl, and oxycodone. If the goal is to reduce overdose deaths and crime associated with the opioid epidemic, buprenorphine will remain an important tool despite diversion.

Why People Dependent on Drugs Are Not Addicted

People taking medicine for depression, diabetes, and many other chronic illnesses become physically, literally dependent on their drugs to stay healthy. In most of these cases, however, these people are not addicted to their medicines. Even chronic pain patients, who become physically dependent on their painkillers and suffer withdrawals without them, typically do not develop addiction – only 8-12% of chronic pain patients become addicted to pain medication.

Dependence and addiction are very different, and understanding this may sometimes make the difference between life and death. Addiction is defined by persisting in a behavior despite negative consequences. People who are only dependent on a drug suffer withdrawals, and are then free to continue their lives – they do not go looking for more of the drug or persist despite negative consequences. People who are dependent and addicted, however, will continue to seek the drug even after withdrawals are over.

In the case of opioid addiction, people are still at risk for relapse after withdrawals are through, and may die from a relapse if their tolerance drops. To treat opioid addiction, rather than only opioid dependence, opioid maintenance treatment – recommended by the World Health Organization, the Office of National Drug Control Policy, and others to be continued indefinitely, perhaps life-long – is necessary to keep people stable and to prevent fatal overdoses.

How Opioid Maintenance Disrupts Addiction Patterns

Addiction happens when people at risk due to trauma history, mental illness and other factors take a drug which they are predisposed to experience as extraordinarily rewarding. In the brain, when a person has an exciting new experience, the reward system responds with a release of dopamine and other neurotransmitters telling us it’s something we want to do again. Certain drugs are more likely to cause a magnified reward response in the brain, releasing far more dopamine than ordinary experiences.

The reward system helps people to learn which experiences are good and which are bad. Because some people biologically experience some drugs as more rewarding than anything else, they learn to associate the drug, and any cues relating to its use (paraphernalia, locations, people, symbols) with immense reward. Their brains begin to respond to the cues, more even than the drug itself, which reinforces use.

Opioid maintenance does not involve the cues to which people with opioid addictions respond. Commuting to a methadone clinic is very different from shooting up heroin. Receiving one dose of Suboxone from a designated family member is very different from self-administering indefinite pills. The “people, places, and things” associated with use are changed when a person enters opioid maintenance. Opioid maintenance treatment helps keep neurocognitive cravings and physiological withdrawals at bay while the person rebuilds his or her life to remove cues for use.

In this way, opioid maintenance disrupts the addiction pattern of cue > pursuit of drug > use. Essentially, opioid maintenance attempts to replace an addiction with simpler dependence, rather than with another addiction. The difference between physical dependence and addiction is crucial to understanding why opioid maintenance does not replace one addiction with another.

How Opioid Maintenance Supports Healthy Recovery

At this point, it may seem overly simple to say that because opioid maintenance prevents people from dying, it supports lives in recovery. Still, this is a key truth. Beyond keeping people alive, opioid maintenance allows people to find enough stability to build new lives in recovery.

Many people believe that a person must abstain completely from all drugs in order to truly be in recovery. However, if a person in recovery from addiction needed medical treatment for diabetes and were prescribed insulin, that person would certainly not be expected to abstain from insulin for the ideal of abstinence. Nor would a person refuse needed antibiotics on the principle that they must not take any drugs if they are to be in recovery. Opioid maintenance is no different from these examples of medication for medical necessity.

A person in opioid maintenance treatment is not high. The steady dose of a partial or full-agonist opioid basically establishes a “new normal” biologically – biochemically – without which normalcy is disrupted. A person with depression who benefits from an anti-depressant is said to have a chemical imbalance, which is stabilized by the anti-depressant. Similarly, a person with an opioid addiction has a chemical imbalance from chronic opioid use, and may be unstable without some level of continued opioid administration.

People in recovery from opioid addictions will still need to do everything a healthy person must do to survive and succeed, such as keep a job, pay bills, provide child, pet, or elder care, or maintain a household. In order to be stable enough to manage all of these challenges and the attendant stress, people in recovery from opioid addictions need access to opioid maintenance.

To Sum it Up

  • People with opioid addictions are at risk of dying. As health professionals, concerned citizens, or families and friends, we owe it to people with opioid addictions to do what we can to prevent this.
  • Buprenorphine/methadone maintenance is the only evidence-based treatment that reduces death risk by 50%. To prescribe other treatments without considering maintenance is, frankly, malpractice.
  • People are not high when taking buprenorphine or methadone as prescribed. Opioids produce tolerance in the human body, such that consistent doses no longer make the person high.
  • Opioid maintenance treatments include measures to prevent or discourage misuse. Buprenorphine, as a partial agonist, has a “ceiling” dose, beyond which further amounts have no effect. Suboxone discourages injection misuse by the action of naloxone, which precipitates withdrawal symptoms in opioid dependent individuals. Methadone is primarily delivered in controlled, daily doses in a clinical setting.
  • Addiction is different from dependence. Addiction involves a learned behavior that continues despite negative consequences. Dependence is only the body’s physical adjustment to a drug, and can happen without addiction. Unlike addiction, dependence does not involve persisting in use despite negative consequences.
  • Maintenance disrupts addiction because doses are not rewarding and are not associated with addiction cues. People in opioid maintenance programs are receiving their stable doses of methadone or buprenorphine under very different circumstances than their usual addiction-related rituals. By disrupting the patterns of addiction and providing doses that are not rewarding (do not get the person high), maintenance maintains tolerance and dependence without maintaining or creating addiction.
  • Indefinite maintenance allows people to focus on improving their lives in recovery. Opioid maintenance treatments allow people to lead lives in recovery without worrying about coping with withdrawal symptoms or risking fatal overdose. In the event of a relapse, people can focus on learning which cues to avoid next time – how to prevent another relapse – rather than recovering from a severe overdose or dying.

Further reading:

Why We Have Wait Lists for Opioid Addiction Treatment

What the Opioid Epidemic Means in Virginia

How Ithaca, NY is Addressing America’s Opioid Epidemic

Addiction or Dependence: A Life and Death Difference

How to Talk with Someone About Getting Help with Addiction

This post was last updated on 10/27/16.

Addiction or Dependence: A Life and Death Difference

In the 1980s, when addiction science professionals sat down to agree on terminology for the DSM-IV, the room decided by only one vote to call addiction “dependence.” The issue did not rest there. The latest Diagnostic and Statistical Manual of Mental Disorders, DSM-5, labels addictions as “substance use disorders,” because “dependence” does not quite cover what addiction really is.

Addiction and Dependence : Apples and Oranges

Dependence is when a person becomes physically reliant on a substance, and experiences withdrawals without it. While dependence often happens as addiction develops, full addiction is much more complex, and is defined by continuing to use drugs or engage in behaviors despite negative consequences.

As an example, physical dependence can happen with many different medications. People who take antidepressants, for example, become dependent on them and undergo withdrawal symptoms if they stop taking the medications. In this case, these patients are dependent on antidepressants but are not addicted to them, and antidepressants are not considered to be addictive.

People in pain go to their doctors for relief, take pain medicine as prescribed, and if they take it long enough, their bodies get used to the medication, expect it, and throw a fit without it. When (if) their chronic or acute pain is over, doctors know to taper patients from pain medicine if physical dependence happens, and to treat withdrawal symptoms to ease the process. The patients may or may not know they are feeling sick because of withdrawal, but if they are otherwise happy in their lives they won’t bother with trying to find opioids illegally on the streets.

They do not persist in using the drug despite negative consequences, which defines addiction. They were dependent on the drug, but not addicted to it.

(Note: Among pain patients prescribed pain medication, only 8-12% develop addiction. Maia Szalavitz reports for Scientific American that “75 percent of all opioid misuse starts with people using medication that wasn’t prescribed for them—obtained from a friend, family member or dealer.”)

Addiction develops in 10-20% of people when multiple risk factors coincide with drug use (whether prescribed or recreational). If people have genetic predispositions, a history of trauma, and/or mental illness(es), they will be vulnerable to developing addiction. Even for these individuals, addiction takes time as they learn to associate the substance or activity with pleasure or relief, and the absence of the substance or activity with misery.

Individuals addicted to opioids are usually also physically dependent on them. Often a first line of treatment is to enter people with opioid substance use disorders into detox, where withdrawal symptoms may be treated while the person is monitored by medical staff. What happens next unfortunately depends on which doctor is managing the case (not all treatments are equally effective).

But to whatever treatment they are referred, individuals with opioid use disorder are at risk for relapse long after withdrawal symptoms are gone. This is why addictions, or substance use disorders, are very different from physical dependence. Once a person has gone through withdrawals and been abstinent from the substance for a period of time, the body readjusts and is no longer dependent on the substance. But people with substance use disorders still crave the drug.

Moreover, with certain drugs, like opioids, the body builds up tolerance with repeated use, which means the drug no longer affects the body unless the dose is increased. When a person enters a period of abstinence, their tolerance drops substantially.

Sadly, people with opioid use disorders often relapse and die when trying abstinence-based treatment, because they’re still addicted and their tolerance is gone. When they take the opioid at their usual dose, they overdose. What was once an okay amount is now fatal. Buprenorphine and methadone maintenance are recommended to keep people alive by keeping tolerance stable (without being high). Life-long maintenance may be necessary. If a person is tapered or otherwise terminates maintenance treatment, they are at higher risk of fatal overdose.

In the case of addiction, distinguishing between “substance use disorder” and “dependence” is a life and death debate. Understanding that substance use disorders – addictions – are more than physical dependence means we will help these individuals long after withdrawals are gone and for as long as they need treatment.

This post was last updated 5/4/17.

Are Twelve Step Approaches Evidence-Based for Addictions Recovery?

For a long time since Bill Wilson and Dr. Bob Smith founded Alcoholics Anonymous (AA) in 1935, AA’s twelve steps were the standard of care in addictions treatment. AA is a mutual help group for people with alcohol use disorders, guided by standard literature and twelve steps aimed at helping people make amends, develop spiritually, and connect with others in similar situations.

Original 12-Steps of Alcoholics Anonymous

AA’s model has been adopted by other groups such as Narcotics Anonymous (NA), Gambler’s Anonymous (GA), Overeater’s Anonymous (OA), and other variations. In each case, these groups continue to rely on the twelve steps, with minor adaptations, and have been generally known as 12-step support groups.

People in 12-step groups help each other with bits of collective wisdom beyond official literature, including the admonition to change “people, places, things” to remove triggers for use; the acronym HALT, reminding members never to get too Hungry, Angry, Lonely, or Tired; and the serenity prayer:

God, grant me the serenity to accept the things I cannot change,
Courage to change the things I can,
And wisdom to know the difference.

While meeting formats vary, they tend to include members sharing about their experiences and struggles while living in recovery and readings and discussions of the 12-step literature. Twelve-step groups also encourage members to find sponsors to provide advice based on their own recovery experience. Generally, people who have been abstinent for awhile become sponsors for other, newer members.

Many hundreds of people have testified that 12-step support groups saved their lives, and some scientific research seems to support the efficacy of 12-step groups (Humphreys et al., 2014Witbrodt et al., 2014; Moos & Moos, 2006).

Other people have criticized 12-step groups, pointing to the high rates of dropout, the heavy spiritual and moralistic emphasis, the inconsistent and contradictory logic in its literature, and the variability of groups depending on who is in them. Furthermore, about half of women who have participated in AA have experienced “13th-stepping,” the practice where group members, usually men, target new members, usually women, for dating or sex. In some cases this common practice has resulted in rape.

Despite their limitations, 12-step support groups remain an important part of many peoples’ lives in recovery, particularly if they feel belonging to their group. Research shows that social support is an important part of recovering from addiction. People who are a part of a strong group of people committed to sobriety are more likely to stay abstinent than people surrounded by old friends who may still be drinking or drugging.

Twelve-step groups are not the only addictions support group option, however. For people who want the social support without the spiritual emphasis, other mutual help groups exist, such as SMART Recovery (Self-Management and Recovery Training) and Moderation Management.

The Minnesota Model and Modern Rehab

The ubiquity of 12-step support groups was expanded to treatment in the 1950s by the Minnesota Model, a 12-step-based program developed by two people (not yet trained in addictions) working in a state mental hospital that was quickly adopted by the Hazelden Foundation, one of the oldest and most well-known rehab centers. The Minnesota Model is an intensive program including mandatory 12-step meetings, lectures, and counseling.

Rehab centers like Hazelden provide this type of care for 28-day periods on an inpatient basis. For many people with addiction, inpatient rehab may be their first contact with addictions treatment. Rehab centers have been criticized for high relapse rates, and for not following up with patients following discharge. Research on the efficacy of standard, 28-day rehab programs is notoriously scarce.

Twelve Step Facilitation (TSF)

Much later, in the 1990s, Twelve Step Facilitation was developed as a standardized adaptation of 12-step support groups, intended as an early, individual therapy delivered by a counselor. TSF helps to introduce many of the concepts of 12-step support groups, and encourages patients to engage in support groups following therapy. However, TSF is distinct from AA and other 12-step support groups.

“TSF is not officially related to or sanctioned by AA. It is available as a manual for standardized use by addiction treatment facilitators with a focus on abstinence as a treatment goal. Participation in AA meetings and other official AA activities (such as service and AA social events) is encouraged as a means to that end.” – Nowinski, Baker, & Carroll, 1999.

Some studies have demonstrated that Twelve Step Facilitation has helped people use 12-step support groups to support abstinent lifestyles, though when compared with TSF, cognitive behavioral therapy may be better for long-term support. As a first step toward engagement in 12-step support groups, TSF seems to be helpful and is often used in inpatient rehab settings.

Despite the ubiquity of 12-step groups and programs, scientific studies evaluating how well they work have not yet established, conclusively, whether 12-step-based approaches are effective. Reviews of the literature find mixed results, with some studies finding positive effects, some finding negative effects, and some detecting no statistically significant influence. Studies face methodological challenges (particularly self-selection bias), and most often do not distinguish between 12-step support groups, inpatient rehab, and TSF (perhaps because their content is so similar).

The first mandate of medical treatment is to do no harm. Because some studies have found 12-step programs to be detrimental to people, and because their effects are otherwise inconsistent and inconclusive, 12-step-based treatments cannot be considered to be evidence-based. Evidence-based treatments for addiction do exist, and include cognitive behavioral and dialectical behavior therapies, mindfulness training, and a range of pharmaceutical treatments. Typically, addictions treatments must be individualized, and must account for the type of substance or behavior used, co-occurring mental disorders, and trauma history.

With a scarcity of evidence, treatment providers must decide on a case-by-case basis whether 12-step groups, inpatient rehab, TSF, or some alternative is best for a person in recovery. Twelve-step groups and facilitation do work for many people, but they are not for everyone.

The primary benefit of 12-step support groups and programs is subjective, depending on the quality of the human relationships in a given group and on the importance of spirituality to the person in recovery. Social support is recommended for people in recovery from addictions, but other mutual help groups may provide this without the problematic aspects of the 12-step approach.

After extensive research, the most balanced recommendation I can make is if you are a person in recovery, consult your doctor first, and choose the treatments that work for you. The goal is to create a stable and positive life in recovery, and if a treatment is not adding to this goal, it is not for you. In this case, if the medicine tastes bad, it is bad.

If you are a treatment provider or a drug court judge, please be advised that 12-step groups and programs are not evidence-based, may sometimes do harm, and therefore, if recommended at all, should be one of many treatment and recovery support options offered.

I wrote this post following a discussion with Anne Giles, in which she requested balanced research on the efficacy of and difference between 12-step support groups, inpatient rehab, and Twelve Step Facilitation. The positions I take in this post are mine, and cannot speak for her, or for Handshake Media, Inc. 

Applications of Neuroscience Findings to Addictions Treatment

The article annotated and excerpted below, published in 2013, offers a conceptual framework through which to apply the findings of neuroscience to addictions treatment. It may be explosively important. Translating its offerings into practical applications will be difficult. The article is lengthy, written in highly technical language, weighs in at 9,300+ words, and cites 182 sources.

My intention is to attempt, however, to do just that. The work by Eric Garland, et al. – new research funding was just announced 9/6/16 –  could have weighty implications for individuals with substance use disorders (SUDs) and for SUD treatment professionals. My intention is to continue writing about addiction and addictions treatment as simply and directly as I can.

To that end, I have excerpted, annotated, added explanatory links to, and re-formatted the conclusion from Mindfulness Training Targets Neurocognitive Mechanisms of Addiction at the Attention-Appraisal-Emotion Interface and intend to link to this post from other writings.

We offer the following speculative, hypothetical account [demonstrating the conceptual framework described in this paper that applies findings of neuroscience to addictions treatment] based on our clinical and research experience using MBIs [mindfulness-based interventions] to treat persons diagnosed with substance use disorders.

When a recovering addict with a history of using drugs to cope with negative emotions encounters a cue associated with past drug-use episodes while in the context of a stressful environment (e.g., walking past a bar after getting in an argument with a work supervisor), this encounter may activate cortico-limbic-striatal circuits subserving drug-use action schemas. [In other words, the encounter may activate brain structures related to feelings, thoughts and behaviors associated with drug use. The authors write, “The urge to seek intoxication from addictive substances is driven, in part, by reactivity to substance-related stimuli [cues] which have been conferred incentive salience [priority importance], and is magnified by negative affective states.” The authors define “drug-use schemas” as “memory systems that drive drug seeking and drug use through automatized sequences of stimulus-bound, context-dependent behavior.”].

After completing a course in mindfulness training, the addict may become more aware of the automatic addictive habit as it is activated, allowing for top-down regulation of the precipitating negative emotional state and the bottom-up [brain structured-based reactivity] appetitive urge. [“Top-down regulation” is not to be confused with “willpower” or  “suppression” which, according to neuroimaging research, actually results in “hypoactivation in cognitive control circuits.” Attempts to suppress urges, paradoxically, result in 1) increased urges, 2) decreased resilience with regard to emotionally stressful events which is correlated with return to use, and 3) depletion of cognitive resources, thus increasing the likelihood of a return to automatic behavior to use vs. conscious behavior to abstain.]

Specifically, the individual may engage in mindful breathing to first disengage from and then restructure negative cognitive appraisals, thereby reducing limbic (e.g., amygdala) activity, autonomic reactivity, and dysphoric emotions related to the stressor. Concurrently, the individual may become aware of when his attention has been automatically captured by the sight of people drinking in the window of the bar, and, through formal mindfulness practice, activate fronto-parietal mediated attentional networks to disengage and shift focus onto the neutral sensation of respiration.

During this process, as sensations of craving arise, the individual may engage in metacognitive [the ability to become aware of, and direct, one’s thoughts] monitoring of these sensations, and in so doing, facilitate prefrontal down-regulation of limbic-striatal activation. [Author Maia Szalavitz uses the metaphor of a “volume control” to explain a person’s ability to up-regulate or down-regulate his or her own inner state.] As mindfulness of craving is sustained over time without drug-use, the sensations of craving may abate, promoting extinction learning to weaken associative linkages between conditioned addiction-related stimuli and the attendant conditioned appetitive response. [If “appetite” for drinking or using is present, but is not satiated with the anticipated reward, the tie between use and the reward lessens over time.]

Once working memory has been cleared of active representations of substance use, the individual may shift attention to savor non-drug related rewards, such as the sense of accomplishment that may arise from successfully resisting the temptation to drink (i.e., self-efficacy), appreciating the beauty of the sunset on the walk home without being clouded by inebriation, or the comforting touch of a loved one upon returning home safe and sober. [“Savoring” is defined by the authors as “selective attention to positive experience.”]

Through repeated practice of regulating addictive responses and extracting pleasure from life in the absence of substance use, the individual may re-establish healthy dopaminergic tone [to replace atrophy resulting from substance use] and foster neuroplasticity in brain areas subserving increased dispositional mindfulness. [“Dispositional mindfulness” is defined as awareness of, and attention to, what one is feeling and thinking in the moment.]

Ultimately, mindfulness may facilitate a novel, adaptive response to the canonical “people, places, and things” that tend to elicit addictive behavior as a scripted, habitual reaction. In so doing, the practice of mindfulness may attenuate [reduce the power of] stress reactivity and suppression while disrupting addictive automaticity, resulting in an increased ability to regulate and recover from addictive urges.

Posts that link to this post:

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Want to Help Our Community? Volunteer for SMART Recovery

For those beginning to discover they’re doing something they want to stop – or have tried stopping something and are having trouble – SMART Recovery welcomes all. Whether one struggles with alcohol and other drugs, smoking, gambling addiction, Internet addiction, sexual addiction, self-injury, problematic eating behavior, problematic relationships, or issues with other substances and activities, SMART Recovery meetings are the place to gather and talk with people addressing similar challenges.

What science is telling us and we know from personal experience is that we do better making changes with support from others!

If you’re interested in helping your community address its challenges with addiction, I invite you to train to become a SMART Recovery discussion host.

Based on my professional and personal assessment, holding SMART Recovery meetings is the closest we can get to community-wide, evidence-based, group-based addictions recovery assistance using resources already in place.

Welcome to SMART Recovery!

If we can, as a community, host SMART Recovery meetings every day at different times all over the area, we can provide free, near-treatment-level assistance to our people with addiction challenges. We don’t need to form task forces, write grants, or lobby public officials. We just need community members to do the training and sign up as hosts with SMART Recovery, and for community organizations with buildings to offer spaces for meeting locations.

  • SMART Recovery discussion meetings are free and open to anyone in the community.
  • Volunteers hosts DO NOT have to be in recovery from addiction to serve. Any community member – from the mayor to the maki maker to the mechanic – can serve as a discussion meeting host.
  • While discussion meetings are not generally facilitated by experts or licensed professionals, meetings focus on learning skills termed “tools” and are guided by trained hosts, thus extending the therapeutic value beyond more sharing-oriented support group meetings.

Here’s more information:

If you’d like to experience in-person what a SMART Recovery meeting is like, this meeting is open to all and you are welcome to attend:

Sundays, 4:00 PM, New River Valley Community Services, 700 University City Boulevard, Blacksburg, Virginia.

We’re compiling local recovery support resources here.

If you have any questions, feel free to contact, Anne Giles, [email protected], 540-808-6334.

(If you email me and don’t receive a reply, please check your spam folder. If you don’t see a reply in your spam folder, please phone or text me and we’ll connect that way!)

Hope to join you in volunteering with SMART Recovery!