1. The Role of MFT in Addiction and
Chronic Pain
P. Joseph Frawley,M.D.

2. Principles of Addiction Medicine
• 1. Addiction is a disease of the Survival Brain
• 2. It is a chronic illness
• 3. It is fatal if left untreated
• 4. Treat it as a chronic
illness.
• 5. People can and do
recover

3. Ventral Tegmentum to Nucleus
Accumbens

4. Disease of Addiction
Survival Brain

5. Brain Reward Circuits

6. Natural History
•Addiction has a
Natural History

7. Natural History of Alcoholism
8 years in Clinic Sample Vaillant,1995
• 100 patients
• Ave age 45
• Prior Jail 71%
• Alone or street 50%
• Live with spouse 35%
• Reg Employment 27%
• Attended College 19%
• Stable Psyc/Soc 17%

8. Natural History of Alcoholism
Core City Sample Vaillant,1995
• Control Group for
Juvenile delinquent
Study.
• 456 Men follow up
• 150 had DSMIII alcohol
abuse at some point.
• 116 with alcohol abuse
followed through study

9. Natural History of Alcoholism
College Sample Vailant,1995
• Population of College
Graduates
• 268 Men Had Follow Up
• 46 Men had DSM III
Alcohol Abuse at some
point

10. What is the Natural History
of Opioid Dependence?
• 581 male addicts admitted to California
• Civil Addict Program in 1962-1964
• 33 year follow-up 48.9% dead
• Of the 242 interviewed
• 55.8% urine neg for opiates
• 14% incarcerated

11. 33 Year F/U Narcotic Addicts
Arch Gen Psych 58, May 2001 p. 503 (Hser et al)
• Compulsory Treatment
Program for Narcotic
Dependent Criminal
Offenders.
• Yr N Mean Age
• 1962 581 25.4
• 1974 439 36.8
• 1985 354 47.6
• 1996 242 57.4

12. Age of Drug Use Patterns

13. The Nature of Addiction
• 1. The Reward System
• 2. The Memory of Reward
• 3. The Triggers for Addiction
• 4. Tolerance and Withdrawal
• 5. Shame of loss of Control
• 6. Emotional Damage
• 7. Denial
• 8. Enabling

14. Animals will self stimulate the Reward
Center and forget other rewards

15. How The Survival Brain Works
Reward Center
Need
O2 Monitor Reward
Safety
Water
Food
Respect
Companionship

16. Brain Reward Center
1. Cells that monitor the Reward Center
status of needs Need
normally stimulate O2 Monitor Reward
these centers Safety
2. Meeting the needs will Water
stimulate reward
Food
3. Anticipation of reward
Respect
will highly stimulate
these centers Companionship

17. Memory Stores the Results of Action
and Strengthens Connections
Need is met
Memory Action Need
O2 Monitor Reward
Safety
Water
Food
Respect
Companionship

18. Brain Reward Center
When needs are not met Reward Center
we experience alarm: Need
Irritability O2 Monitor Reward
Tension Safety
Anxiety Water
Anger Food
Pain Respect
Companionship
Panic

19. Stages of Alarm to Threat
• Irritability
• Tension
• Anxiety
• Anger
• Pain
Panic

20. The Survival Brain motivates us to
change and stores the results
Reward Center
Need
O2 Monitor Reward
Safety
Water
Food
Respect
Companionship
Irritability Tension Anxiety Anger Pain Panic

21. Emotional Memory is layered
and is our emotional filter and reactor
• 0-5 5-10 10-15 15-20
Mixed Feelings
No confidence
Lots of confidence
• Tape Recorder that
plays back the past to
motivate and guide you
in the present-
• positively or negatively.

22. Emotional Brain is quicker and faster
than the Slower Creative Intellect

23. However, as humans we come to
conclusions about our experience so
we can plan
• These can be called
cognitions, beliefs,
viewpoints, etc.
• During development,
parental guidance is
essential in healthy
development in this
area.
• These are our cognitive
filters

24. As we learn, we form cognitions about
what we need to do to survive
Cognition Memory Action
Reward Center
Need
O2 Monitor Reward
Safety
Water
Food
Respect
Companionship

25. Addictive Drugs are Mimics of our own
Reward Chemistry: They Lie to Us
Opiates Endorphin
Speed Dopamine/
Adrenaline
Valium GABA
THC Anandamide
Alcohol Several
systems
Genetics influences how
well they work and how
we adapt to them

26. How Addictive Drugs Addict the
Person- The Good
1. The drug stimulates the Reward Center
reward center according Need Monitor Reward
to its chemical action, O2
state of the system and
genetics. Safety DRUG
2. The message is Drug Water
Works! Food
3. The meaning can be: The Respect
drug is a new/better way Companionship
to feel good

27. Dopamine and Reward

28. How Addictive Drugs Addict the
Person-The Bad
1. The drug suppresses the normal monitor Reward Center
and reward systems according to its
chemical action ,state of the system and
genetics. Monitor Reward
2. The brain adapts:
tolerance People
physical dependence Places DRUG
Activities
3. There is a shift in people, places and Need
activities towards getting the drug. O2
Safety
Water
4. The meaning can be:
Apparent balance is progression of disease
Food
Coping Skills lag in development
Emotional memory is lied to
Respect
Cognitions are distorted
Companionship

29. How Addictive Drugs Addict the
Person-The Ugly
1. When the drug is gone, Reward Center
the normal system does Need Monitor Reward
not work depending on O2
drugs chemical action
,state of the system and Safety DRUG
genetics. Water
2. The brain adapts: Food
withdrawal Respect
Companionship
3. The meaning is:
The drug is needed to
Survive

30. Drug Works-I Don’t Work
In withdrawal we Reward Center
experience alarm and Need Monitor Reward
we learn our own
system doesn’t work:
Memory Action O2 Drug Craving
Irritability Safety
Tension Water
Anxiety Food
Anger Respect
Companionship
Pain
Panic

31. Brain Imaging shows suppression
• After use of cocaine
there is suppression of
dopamine receptors

32. Positive Emotional Drug Memory can
also stimulate the reward center
=CRAVING
Drug Memory
People
Places

33. Anxiety and Mood Disorders often
begin in Teens and Young Adult hood

34. In Dual Diagnosis There are several
mechanisms for anxiety and
depression
Cognition Memory Skills Needs Biochemical
O2
Safety
Food
H2O
Respect
Companionship

35. In Dual Diagnosis the drugs carry a
bigger impact and development stops
Cognition Memory Skills Needs Biochemical
O2
Safety Drug
Food
H2O
Respect
Companionship

36. The Disease Progresses
• Tolerance, Physical
Dependence
• 5-7 years of struggle for
control
• Craving for the drug
during attempts to quit
• Denial because I need
the drug so much
• Shame at not being able
to be in control

37. The Family Disease Progresses

38. Denial and Enabling
I can’t conceive living
without it
It is what I need
It is my number one
priority
I didn’t drink or use
that much
It doesn’t bother them

39. Recovery Needs and Problem Drinking
ScoresVaillant,1995

40. Shame of Loss of Control of Illness
• Alcoholics spend 5-7
years struggling for
control
• They don’t know
how to respect
themselves with
being out of control
• They have an illness

41. Getting to Treatment
• It is hard and scary
to change
• If the addict takes a
first step then we
need to meet
him/her there and
facilitate their
progress.
• The addict may need
intervention

42. We can Help the Process Along
• Each stage has appropriate interventions

43. The Team Approach

44. Detoxification
We taper medications over Reward Center
time to allow the Need Monitor Reward
nervous system to
stabilize
Memory Action O2 Drug tapering
Safety
Water
Food
Respect
Companionship

45. Opiate Stabilization
Some people stay too Reward Center
agitated when coming Need Monitor Reward
off opiates and need to
be stabilized on them
Memory Action O2 Drug Stabilization
Safety
Water
Food
Respect
Companionship

46. Swedish Randomized Trial
The Lancet 361,Feb 22,2003 (Kakko et al)
• Heroin Dependence by
DSM IV
• Placebo Bupr
• ASI 1.84 2.11
• Yrs Heroin 4.8 5.8
• Hep B 35% 35%
• Hep C 80% 60%
• HIV 0 1

47. The Work of Recovery
Cognition Memory Skills Needs Biochemical
O2
Safety Drug
Food
H2O
Respect
Companionship

48. Safe Environment
• The patient needs to be • This will help determine
in a safe environment to the level of care that
feel calm enough to they need.
begin to learn new • 1. Hospital
skills, ways of thinking • 2. Sober Living
and to experience
feeling better. • 3. Intensive Outpatient
• The addiction is still • 4. Outpatient
very reactive. • 5. 12 Steps

49. The Biochemical
• 1. Detoxification/taper/ • Close communication
maintenance between the team is
• 2. Stabilize Mood important.
• 3. Stabilize Anxiety • 1. Symptoms vs Disease
states
• 4. Reduce Craving
• 2. Reactive vs
biochemical imbalance
• 3. Pain vs function

50. Medications
• Antabuse- • Reduces impulsive use
• Campral • Reduce Craving (mild
effect)
• Naltrexone • Block reward of drinking
or using opiates
• Provigil/Nuvigil • Help with stimulant
withdrawal/ADD

51. The Needs
• Safety • 1. The most essential
• Respect aspect of a program is
• Companionship safety.
• 2. Respect needs to be
modeled and starts with
• These have often been acknowledgement.
severely damaged. Part
of treatment is to • 3. Sober friends and
provide a systematic family and meetings
structure to help form the initial
restore them. community of recovery.

52. The Skills
• 1. Managing Craving • Recovery is like learning a
sport or to dance
• 2. External Triggers • Patients will make
mistakes and lose
• 3. Internal Triggers confidence
• They may relapse
• 4. Communication Skills • They may get frustrated
• 5. Setting Boundaries It is not what they
know but how they
• 6. Dealing with the past react.

53. The Emotional Memory
• Time has no meaning • 1. In addition to the life
to the emotional memories that are
memory stored there (good and
• It records and it replays bad) it has been lied to
• It is primitive but by the addictive drug.
powerful • 2. It has to go through
• It is influenced by retraining.
current status of needs • 3.We have to have
and cognitive filters compassion for it, for it
is sick

54. Cognitions
• Denial • Cognitive Skills and
• Shame Creativity
• Core Beliefs
• Cognitive Distortions 1. Mood Logs
2. Untwisting one’s
thinking
3. New Perspectives and
Options

55. Chronic Pain
Low Back Pain Migraine
Fibromyalgia Headache

56. Prior Trauma and PTSD and Chronic Pain
• 1. Common Histories
a. Adultified Child
b. Abused Child
2. High Anxiety
a. If I set boundaries I will be rejected
b. I can’t say no.
c. I must succeed
d. Past intrudes into the present
3. Persona vs Person
a. What I do defines/hides me

57. Trauma and Vulnerability to Pain
• N=520 Traumatized subjects: assessed for-
• PTSD,dissociation,somatization, affect
• No PTSD<lifetime PTSD<Current PTSD
• disaster victims<adult interpersonal
trauma<childhood trauma
• Conclusions: PTSD,dissociation,
somatization,affect dysregulation co-occur
• (Covington,2004)

58. Chronic Pain Predisposition
Reward Center
Need
O2 Monitor Reward
Safety
Water
Food
Respect
Companionship
Irritability Tension Anxiety Anger Pain Panic

59. Limbically Augmented Pain
Syndrome
• Patients w/ depression, behavioral
dysfunction, heightened sensitivity to
internal and external stimuli
• Pain: chronic,often atypical, resistant to
analgesics
• Assoc w/ disturbed mood, sleep, energy,
libido, memory/concentration/behavior
• Amplification,spontaneity,anatomic
spreading,cross sensitization.(Covington,2004)

60. Wind-Up in Fibromyalgia
Staud,R. Arthritis Research & Therapy 2006,8:208
Windup pain ratings of
normal control (NC) and
fibromyalgia syndrome (FM)
patients. All subjects received
15 mechanical stimuli (taps
(T)) to the adductor pollicis
muscles of the hands at
interstimulatory intervals of 3
s and 5 s. FM patients showed
mechanical hyperalgesia
during the first tap and
greater temporal summation
than NCs at both
interstimulatory intervals. A
numerical pain scale was used
(0 to 100). The shaded area
represents pain threshold.

61. After Central Sensitization
• after central sensitization has been established
only minimal nociceptive
input is required for the maintenance of the
chronic pain state.
• Additional, factors, including pain related
negative affect and poor sleep have been
shown to significantly contribute to clinical FM
pain
• Arthritis research & therapy.; 2006 1 1;8(3)

62. The Work of Recovery from Chronic Pain
• 1. Acknowledgement of the injury and its effect upon the person at
all levels.
• 2. Acknowledgement of the emotional state of the person’s
reaction to the injury, the level of pain experienced by the person
and their perceptions of their options.
• 3. Management of the pain at all three levels of pain.
• a. Injury Site
• b. Nervous System augmentation
• c. Limbic System
• 4. Management of grief and co-occurring mental health disorders
and /or chemical dependency if present.

63. Pain Recovery Skills
• 1. Pacing • 1. Respecting who you
are, not who you were
• 2. Setting Boundaries • 2. Respecting one’s
limits
• 3. Learning how to • 3. Communication Skills
manage anger and options
• 4. Learning how to • 4. Learning how to feel
manage anxiety safe
• 5. Connecting to people • 5. Persona vs Self
in a new way

64. Moving from Rejection to Respect
• The drugs reject
reality.
• Recovery is a return
to respect for reality
and oneself and
ones relationships
with others

65. The Twelve Steps-
• STEP 1 • How do respect your
self with this?
• Powerless over alc/drug
• Life has become • Answer:
Unmanageable • You share it and receive
respect from others
• You come to learn you
have an illness

66. The Twelve Steps
• Step 2 • How do we respect
• Came to believe that a ourselves when we
Power greater than don’t have the answer?
ourselves that could
restore us to sanity • Answer:
• Humility is the
beginning of Wisdom

67. The Twelve Steps
• Step 3 • What does God look
like?
• Made a decision to turn
our will and our lives • Answer:
over to God as we • He/She cannot be a
understand him human being.

68. Alcoholics Anonymous And Spirituality
• The emergence of AA as a potent vehicle for
personal transformation has been influential,
as it has brought the term spirituality to the
attention of both the general public as well as
the mental health and addiction treatment
providers.

69. Practical Spirituality
• Learning how to respect oneself as a limited
person who has limited control and is not
perfect
• Drugs can disconnect the person from feeling
one’s limits. Drugs are able to say “shut up” to
parts of self the person doesn’t know how to
deal with.
• In recovery the person goes from rejection to
respect for these parts of self

70. The Balance of Spirituality and
Psychology
• INVESTMENT-> • No Time
CARING • No Money
• No Understanding
• No Knowledge
• Etc.
• When caring
is blocked. = Stress

71. The Balance of Spirituality and
Psychology
• No Time
• CARING
• No Money
• No Understanding
• No Knowledge
• Etc
Drugs take the
caring away =No Stress

72. The Balance of Spirituality and
Psychology(the Serenity Prayer)
CARING Accept what can’t be
changed
Courage to change
the things can be
Wisdom to know the difference
Time Out, Sharing, Asking for help = Managed Stress

73. Thank You-Team!

76. Treatment of Addiction
• 1. 12 step programs
• 2. Counseling programs
• 3. Medication
• 4. Residential Treatment

79. How Addictive Drugs Addict the
Person- Dual Diagnosis
1. The drug stimulates the Reward Center
reward center according Need Monitor Reward
to its chemical action O2
,state of the system and
genetics. Safety DRUG
2. The message is Drug Water
Works! Food
3. The meaning can be: Respect
The drug is a better way to Companionship
Feel Good

80. How Addictive Drugs Addict the
Person- Dual Diagnosis
1. The drug stimulates the Reward Center
reward center according Need Monitor Reward
to its chemical action O2
,state of the system and
genetics. Safety DRUG
2. The message is Drug Water (_)
Works! Food
3. The meaning can be: Respect
The drug is a new/better Companionship
way to Feel Good

81. Stages of Alarm and Defense
involve both feeling and action
• Irritability Annoyance more than fear
• Tension Alert to question of danger
• Anxiety A feeling of needing to escape
• Anger A need to stay and defend
• Pain The boundary has been crossed
• Panic There is no escape

82. The Survival Brain is a teaching
machine that stores its results
Reward Center
Need
O2 Monitor Reward
Safety
Water
Food
Respect
Companionship
Irritability Tension Anxiety Anger Pain Panic