• Document: The Brain and Recovery An Update on the Neuroscience of Addiction Kevin McCauley, MD January 2015 The most evil disease imaginable Wouldn t look like a disease at all Genetic, but with var...
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The Brain and Recovery An Update on the Neuroscience of Addiction Kevin McCauley, MD January 2015 The most evil disease imaginable … •  Wouldn’t look like a “disease” at all •  Genetic, but with variable penetrance (genotype ≠ phenotype) •  Repulsive symptoms easily confused with “willful badness” •  Self-deception as a clinical feature •  Poor prognosis in many, but most will get better •  Chronic and relapsing condition (not acute, rarely “cured”) •  Culturally & politically divisive (would tap into society’s deepest prejudices, stigma, superstitions and attack its core values) •  Would only submit to “weird” solutions: peer support, patient accountability, personal evaluation, and spiritual growth (not just a medication or surgery) Leading Causes of Death 1.  Heart Disease ADDICTION 2.  Cancer ADDICTION 3.  Chronic Lower Pulmonary Disease ADDICTION 4.  Hypertension/Stroke ADDICTION 5.  Accidents ADDICTION 10. Suicide ADDICTION 12. Liver Disease/Cirrhosis ADDICTION Murphy SL, Xu JQ, Kochanek KD. Deaths: Preliminary Data for 2010. National Vital Statistics Reports; vol 60 no 4. Hyattsville, MD: National Center for Health Statistics. 2012 Big Questions •  How does heredity fit in? •  Why do addicts put drugs over things that really matter? •  How do we define addiction? (Who is an addict?) •  Why do addicts relapse? •  What is the primary cause of addiction? •  Where did the child/spouse/friend/employee that I love/value go? Is Addiction Really a “Disease?” “Choice” vs. “Disease” •  Free Will exists •  No Free Will •  Responsibility •  No Responsibility •  Can stop •  Can’t stop •  Punishment and •  Punishment and Coercion DO work Coercion DON’T work •  BEHAVIORS •  SYMPTOMS The Prosecutors Challenges 1. The Outrage Argument How dare you call addiction a “disease” – addicts are liars, cheats and thieves 2. The Disease Nosology Argument Pedophiles have a disease – they suffer from pedophilia 3. The “Punishment Works” Argument Most people quit when the consequences get bad enough 4. The Accountability Argument What’s to keep the addict from running to “disease” as an excuse for bad behavior? 5. The “First Choice” Argument The addict never should have taken that first drug/drink 6. The Problem of Evil Argument You’re just trying to explain away bad behavior A “Disease” of Volition •  Could such a thing exist? (ontologic argument) •  What would happen if such a thing existed? (teleologic argument) •  What is the nature of volition/free will/choice? •  Is there something special (non-material) about “choice?” •  If so, what is it? •  If not, how is “choice” realized in the brain? What goes into a “choice?” •  Valuation •  Risk Taking •  Novelty-seeking •  Impulsivity •  Empathy/Narcissism •  Memory/Stress/Trauma •  Social Status Ways to define “Disease” •  By “fiat” •  Normative •  Biostatistical •  Pathophysiological a disease is a cellular defect in an organ or organ system that leads to observable, measurable signs and symptoms The “Disease Model” If ever we could fit addiction into this model, then it would win admission into ”The Disease Club” . . . And now, we finally can … ASAM Addiction Definition (Aug 2011) A stress-induced (HPA axis), genetically-mediated (polymorphisms, epigenetic mechs.) primary, chronic and relapsing brain disease of reward (nucleus accumbens), memory (hippocampus & amygdala), motivation and related circuitry (ACC, basal forebrain) that alters motivational hierarchies such that addictive behaviors supplant healthy, self-care behaviors Addiction fits the “Disease Model!” Addiction is a disorder of … 5. … CHOICE (motivation) 4. … STRESS (anti-reward system) 3

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