addiction mechanics, a neurobiological understanding focussing on alcohol addiction.....

1. Addiction-Medicine: An
Overview
Ramkumar G. S. MD
Dept. of Psychiatry.

2. Slide 2 of 25
Over view of presentation
 Why do people take drugs and why some of
them become addicted?
 Neurobiological understanding of addiction.
 Alcohol Use Disorder.
 Treatment processes in deaddiction care/
drugs used/psychotherapy.

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Why use drugs?
 Is it simply a search for
fun?
Image courtesy: Google images

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Why use drugs?
 many people also take drugs to feel
comfortably numb.
 Feel pleasantly drowsy.
 Feel full of energy and confidence.
 As a self administered medicine for negative
emotional states, aversive states like drug
withdrawal
 Feel normal
 Peer pressure

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Why use drugs?
 Individual development (Thrill seeking
predispositions, impulsive temperament)
 Social background.
 Unidentified disorders of mood.
 Unopposed and chronic stress responses.
 Genetic predisposition.

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Why use drugs?
 In a “Drug using career” different motivations
may become dominant at different point of
time.
 Different perspectives – molecular, genetic,
pharmacological, psychological, Social.

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Alcoholism
 Substance use.
 Problematic use.
 Substance misuse.
 Abuse.
 Harmful use.
 Addiction
Dependence Spectrum

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Addiction/Dependence
 PHYSICAL vs Psychological Dependence
 Conditioning to Pathological
neuroadaptation…..

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Neurobiology of addiction.
Reward circuitry
Neurotransmitters
involved Dopamine,
Endogenous opoids
+ve reinforcement,
compulsive drug seeking
behaviour
Pleasure seeking
Neuroadaptive process…
an altered biological
homeostasis
Involvement of stress
hormones like NYP and
CRP
-ve reinforcement,
craving, tolerance,
salience in drug usage

11. Neuroadaptation (+ve reinforcement) in
Chronic alcohol use
Slide 11 of 25

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Mu opoid receptor

13. Neuroadaptation (-ve reinforcement) in
Chronic alcohol use
Slide 13 of 25
CRF/Glutamate
tone is
upregulated
NYP/GABA
is down
regulated.
Alcohol is neuro inhibitory/
depressant/ anxiolytic
Glutamate is excitatory
GABA is inhibitory
CRF stress promoting
NYP stress reducing

14. Changing pattern of motivation in a “drug
using career”
Slide 14 of 25

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AUD
 Heterogenous disorder eg. Type 1 and 2
 Course: remission and relapse.
 Disease management approach rather than
the cure approach in acute illness.
 Chronic illness needing long term long
intensity treatment with brief high intensity
treatment for relapse and on the front end of
the abstience process.

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Treatment approach
Detoxification Pharmacological
detoxification treatment.
Psychological Treatment.
Pharmacology for
reversing pathological
neuroadaptation.
Maintenance treatment

17. Containing the withdrawal response by
detoxification
Slide 17 of 25
 Withdrawal symptoms arise
when alcohol is being used
regularly and withdrawn rapidly.
 Excitatory glutamatergic tone.
 Delerium tremens
 Treatment is via sedation with
adequate dosage of
benzodiazepines, Thiamine
supplementation.

18. Reversing pathological neuroadaptation.
 With appropriate help, withdrawing from
alcohol is not the dependent drinkers’s main
difficulty.
 The main difficulty is avoiding relapse into
further problematic drinking or dependence.
 Differentiation of physical vs psychological
dependence as therapeutic implications.
Slide 18 of 25

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Drugs.

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Psychological therapy
 Motivational enhancement therapy.(MET)
 12 Step facilitation program/ AA group.
 Relapse prevention.
 Craving management.
 Cognitive Behavioural therapy ( dealing with
high risk situation, contingency management,
community reinforcement techniques)
 Social skills training, Behavioural contracting,
Behavioral Family therapy.

21. MET (stages of changer model- Miller)
Slide 21 of 25

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Off label drugs in AUD
 Topiramate
 Buspirone
 Fluoxetine
 Ondansetron
 Baclofen

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Summary.
 Addiction which sets in because of the conditioning
effects of the self reinforcing reward sensations
associated with substance use.
 It is maintained by the underlying neuro-adaptive
process that sets in.
 There are biological, psychological and social
vulnerabilities that directly influence it in addition to
the environment.
 Effective treatment takes on a bio-psycho-social-spiritual
approach.
 Matching treatment to the person.

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Sources:
 Oxford textbook of Psychiatry.
 Medscape Psychiatry, July 22,2014, What is
Addiction? by Denck E Vergne MD
 Psychiatric Times, Nov 2, 2012, Advances
and challenges in treating alcohol
dependence by Hellen M Pattinatti PhD
 Other internet resources.