Transcription:
The Science Behind Addiction

Melanie Cole (Host): Our topic today is opioid addiction and my guest is Dr. Nick Dewan. He’s the Chief Medical Officer in the Behavioral Health Division of BayCare Health System. Dr. Dewan how does addiction develop and what relationship is there to brain changes?

Nick Dewan, MD (Guest): Well that’s a pretty great question. The how does addiction develop – addiction is basically a compulsion to use a substance in great amounts than first warranted. And a compulsion to do anything you can to get ahold of that substance, no matter what the consequences to your life, to your family, to your wellbeing or anybody around you. Now, addiction develops first – the first part obviously is being exposed to a substance that supercharges what I would call your pleasure centers of the brain. So, we know that all addictive substances have what’s called a final common pathway. They are sort of what I would call the pleasure exit of the brain. And some substances stimulate that pleasure center at much greater capability than other substances and opioids as a drug, are super stimulators of that pleasure center. And because they are super stimulators of that pleasure center; one tends to want to use more and more and more and then one tends to only think about it, remember it, crave it, dream about it. One tends to change their entire life patterns of behavior to get it and then when one does not have it; instead of feeling just the absence of pleasure, there’s this awful pain, this sort of just terrible what I would call down in the dumps, just – and that’s the pain of withdrawal. And so, when people get down the road to where they are not seeking what I would call the super pleasure; but they are fighting against the super pain; that’s when you lose control of your life. And that’s when you start not caring about your family, not caring about your loved ones, not caring about a job. It’s the substance and the power of the substance that overtakes your brain, your body and your life. And that’s what’s called addiction. And that is what we are confronted with today in society. I hope that answers that question that you are asking.

Melanie: Wow, it certainly does Dr. Dewan. It’s a very powerful answer actually and you explained how addiction changes those life behaviors. What are some of the – so those would be short-term, but what are some of the long-term effects? I mean we are seeing skyrocketing use. We are seeing overdose and deaths. Can it actually change your body chemistry as you become addicted for a long period of time?

Dr. Dewan: Great – absolutely. So, let me – I’m going to get a little what I would call really cellular scientific on you. We all know that the brain has let’s say 93 billion neurons. And all these are just cells in your brain. There is the part of the brain that is the – called the pleasure center. That part has these neurons in there, these cells and these cells have gates on them. And they open and close and they open and close and there are genes that dictate what gates open and close. The more you get exposed to substances, it changes the gates that open and close. It may make a gate smaller. It may make another gate bigger. But those changes are permanent. So, you are permanently changing the architecture. It’s sort of like if you are doing some kitchen remodeling in your home or you are expanding a room in your home and you break down a few walls and that room is bigger. Well that’s a permanent change. It’s not going back the way it used to. So, because of those permanent changes – we have a lot of people say you know what, I can just do a little bit. It really won’t make me want to do more. Because I can handle it. Well, you might say that psychologically, but when that part of the brain has changed and those gates are not going to change; you can’t hold back because once those gates open; it’s like this massive domino affect where you hit the pleasure center, that pleasure center hits the memory center, the memory center say oh I remember how good this felt, that impacts the behavioral center. Then your judgement center doesn’t tell you to no this is not a good thing, remember you lost your job, you got arrested, you got problems with your kids, and your loved ones. All the judgement is gone once that brain part of that brain is changed because it’s linked to all these other things, the memory center, the judgement center, the behavioral center. And so, it does cause a change in the structure at the molecular cellular level and that change causes the ways and when I say dominoes, you can think of dominoes as little chemical circuits in the brain. And that domino trail changes as well. So, that’s what happens on what I would call the physical level. Does that help you?

Melanie: It certainly does.

Dr. Dewan: Did I answer your question, or did I miss something there?

Melanie: No, you absolutely did, and it really is fascinating and the biochemistry of it is fascinating, but this is a drug, medications, opioids that are used for so many different aspects of pain management. What had been the parameters or guidelines for the prescription of opioids in the past and what is different now when we look at stewardship?

Dr. Dewan: In the past, we didn’t think these medicines were so harmful. We actually in the past, when this became very popular, we in the medical field did not have all the tools that we could to help people reduce the suffering from pain. So, we thought we were doing a good deed. And that good deed was people are in pain, they are suffering, they can’t get along in life; let’s help them. The information at that time was, these things aren’t really that bad. They really aren’t that harmful. So, in the medical profession, you don’t want to do harm; you want to do good. But over time, we learned that these can be very harmful substances. But that took ten to twenty years and in the meantime, society and patients were expecting us to continue relieving their suffering so, to change from I’m sorry these medicines are and can be and will be harmful if you take them so long, let’s try different approaches to pain control. And that – we are going through that transition right now. We have to come up with ways that reduce the discomfort whether it’s a surgery, whether it’s an injury, whatever the cause of the pain in the body; we are having to come up with different strategies to address this whether it’s thinking through the pain, tolerating a little bit, doing some breathing, using more what I would call different medication approaches, combining say anti-inflammatories with other agents. So, there has been a lot of research and there is a lot of research going on in the country about what are different ways to address the suffering and distress in patients without giving them a substance that down the road could make them addicted and want more and more and more. So, we are going through that both in the short-term and the long-term right now.

Melanie: So, you did just mention briefly a few other approaches and since addiction can – the treatment for addiction can require multiple different approaches; speak about the medications available for opioid dependence and Dr. Dewan, tell us why you want to provide this type of treatment because there are barriers I would assume and people have a lot of questions about medication assisted treatment.

Dr. Dewan: Absolutely. So, let’s talk about the how come you want to treat? What’s the real benefit? And there are three approaches today. and I will walk you through them very slowly. The first approach which is a very popular approach in terms of different – there are funding from different state legislatures, different organized bodies; something called naltrexone. And I’m not talking about the rescue drug naltrexone where you do the opiate reversal treatment. Okay. I’m talking about long acting blockers of opiates. So, remember when I started this conversation with you, I talked about those gates being wide open? And that the opiate would go through those gates and that would create that domino cascade throughout the brain and the body. Well, naltrexone blocks those gates. So, if somebody who is not taking opiates today and is let’s say has been in recovery or has abstained from opiates, if they have got that naltrexone long-acting in their body; that naltrexone is a gate blocker and if somebody were to take opiates and the gate is blocked; the pleasure is not felt. Therefore, the cascade, the domino effect of the addiction is stopped. And that’s the naltrexone. Now as a rescue drug, if let’s say the gates are open and the opiates are going through, and they are impacting somebody’s ability to breath; the naltrexone blocks the gate and doesn’t allow the opiates to continue blocking the respiration or going through those gates and impacting respiration. So, that’s how it works as a rescue drug and that’s how it works as a prevention drug. So, that’s naltrexone.

So, the two other approaches are what’s called methadone, and something called buprenorphine naloxone. And these are what’s called agonists. And the reason for using something that’s similar to opioids or other opioids is that you want to prevent harm, the downstream harm. Remember I said those gates were wide open? And sometimes you can’t block the gates. The gates have been busted down. And when they are busted down, instead of having somebody ruin their life, steal from other people, inject drugs, and infect others, infect their heart; you say let me give you something that will help you not be in the pain of withdrawal. It won’t make you high, it won’t give you substantial pleasure. It will just prevent the pain of withdrawal, so you don’t do these other harmful things. And that’s what medicines like buprenorphine, that’s what medicines like methadone are for. They are called agonists while the other one is called an antagonist. I hope that helps you understand this.

Melanie: It absolutely does, so very clearly Dr. Dewan. You are so good at this. What an educator you are. Tell us about some of the other ways that people can help in their recovery as far as spirituality or purpose in life or gratitude. There are so many other ways.

Dr. Dewan: Thank you so much for asking that. Remember, addiction changes your life patterns. It changes your purpose in life. It changes your life behaviors. So, part of treatment is reinventing your life. Means getting in touch with your spirituality, getting in touch with what’s important to you, getting in touch with raw human emotions like love, and gratitude, feeling connected to others, being able to do something to benefit others. All those what I would call positive social emotions and positive personal emotions that have basically been lost or forgotten because of the addiction. So, part of treatment is really reinventing life patterns and life behaviors and a life perspective. And that’s the joy of being in this field is you really get to help people make fundamental new changes in their life. It’s incredibly rewarding work for those of us who are in this.

Melanie: I would imagine that it is and as we wrap up Dr. Dewan, let the listeners know about your program at BayCare and how you can help those suffering from opiate addiction and the ones that they love and really what you want them to takeaway from this message of how people get addicted and how you can help them.

Dr. Dewan: Well I wish we had more programs, okay. We have so much demand, but we provide all the different options. We provide what’s called the blocker and I think we are really experts at that. We are expanding the other program in terms of giving the buprenorphine agonist and we are building those programs. We have partners that we work with to provide the other medicine and it really depends on the motivation of the patient, the willingness of them to be in treatment and their own personal preference in terms of which option would work for them. And so, we don’t have a cookie cutter approach. It’s really a personalized evaluation and I think there’s many of us that are in this field and we have many partners in this field. We are just not the only ones. And if we can’t provide a service for you, we will refer you to someone that can provide a service. And I think that’s – there’s so much distress and suffering out there, not one person or not one organization can do all the work. It really is a community and team effort. And that’s the way we look at this. This has happened, we all have a share in trying to make a difference and we will all work together to make a difference.

Melanie: What wonderful information and so beautifully put. I can hear the passion in you voice and how much you care Dr. Dewan. Thank you so much for joining us today and sharing your expertise on this very important topic. You’re listening to BayCare HealthChat. For more information please visit www.baycare.org, that’s www.baycare.org. This is Melanie Cole. Thanks so much for joining us.