Thursday, January 28, 2016

Dopamine: “The Anticipation Molecule”

by Peter R. Coleman, MD

For a long time, it has been known that dopamine is the pleasure molecule. After all, it is common knowledge that a large amount of dopamine is released in the nucleus accumbens area of the brain when we do pleasurable things - like eat food and have sex.  When the dopamine is released, we experience a strong sensation of pleasure and, of course, we are likely to want to repeat that experience.  We also know that all addictive drugs release massive amounts of dopamine in the nucleus accumbens - way more dopamine than we humans were ever meant to experience.  This heightened pleasure sensation is the biggest reason why people use addictive drugs.
But now, more light is being shed on just how complex are our brains and how different parts of the brain interact. Scientists are now also calling dopamine “the anticipation molecule” because it has been shown that dopamine is also released in large amounts when we anticipate a pleasurable experience.  We actually release dopamine in the nucleus accumbens and get a sensation of pleasure by just thinking about having one of these experiences. Actually, just thinking about having a pleasurable experience is not quite enough to release a lot of dopamine. The large amount of dopamine is released when two things happen - we both think about the pleasurable experience and there is a realistic opportunity that we will be able to have the pleasurable experience - true anticipation.
We can all relate to this and know that this is true. I’ll stick with the food example.  Let’s say we are quite hungry and someone brings out a plate of warm chocolate chip cookies.  We are suddenly presented with the opportunity to eat one of our favorite comfort foods.  In this situation our brains will actually release a small amount of dopamine and we will experience a thought - “maybe I should have one cookie”.  We start to process this situation and think about the different possibilities. We could refuse the temptation and not have the cookie, or maybe we think that we could have just one.   Our thoughts about the cookies begin to become a little more like a desire.  We analyze the pros and the cons.   Our thoughts are becoming more like a craving.   Our mind starts to swing towards making the decision that one cookie wouldn’t be so bad, and “What the heck - I deserve it”, or “Why not - I can go to the gym later”. As we allow these thoughts to build, we start to imagine what the cookie will taste like and how it will be amazingly delicious.  Our old memories kick in.  At this point, our pleasure center is releasing so much dopamine, we are getting very excited and we can’t wait to eat that cookie. We know how good it is going to be! We feel great!
And then, we bite into the cookie, and it happens - the cookie wasn’t that good.  It was an okay cookie, but it was not nearly as good as we had imagined. “The cookie lied to me!”  “Now I am going to get fat, and for what - a lousy cookie that didn’t even taste that good”.  It is amazing to know we actually got more dopamine from anticipating the cookie than we received from the cookie itself.
Drug addiction is just the same.  Even patients who are physically addicted to opiates have to go through all sorts of mind games each time they decide whether to use or not. They all know using drugs is bad, horrible, and they should stop.  But, once they have the opportunity to use, the dopamine kicks in so strongly that not using becomes almost impossible. And, frequently, it is just like the unsatisfying cookie - it wasn’t that satisfying.  Addiction is cruel for both the addicts and everyone around them.

Monday, January 4, 2016

6 Ways to Keep your Resolution for Sobriety

by Gabriella Pinto-Coelho

For those struggling with an addiction to alcohol or another substance, the end of the year can be a challenging time. Thanksgiving, Christmas, and New Year’s can bring up old temptations and triggers that can make your goal for sobriety seem out of reach. But now that the overindulgent holidays are past us, we can focus on the possibilities of the New Year that lies ahead.

Approximately 40% of Americans make resolutions, viewing the New Year as a fresh start, a symbolic transition. While setting resolutions can be a great way to get clear and motivated about your goals, only 40% of those who make resolutions actually go on to keep them. This 60% failure to keep a resolution can stem from a variety of things - unrealistic expectations, lack of discipline, loss of motivation, or something else. I personally think that some of the trouble with keeping resolutions lies in our cultural “all-or-nothing” attitude when it comes to resolutions. For example, say you have a friend who has made a resolution to eat healthier. But on a snow day in February, she eats 10 cookies. 

Sadly, many people would throw in the towel at this point, thinking, “Today I went completely against my resolution, so I guess it’s over now.” In reality, keeping a resolution involves a less-than-perfect path. You might have days when you slip-up and others when you feel on top of the world. Doesn’t that sound a lot like the road to recovery? The point is, don’t give up on your resolutions when the going gets tough or when you take a few steps back. That’s life.

There are some other excellent ways to help yourself keep your resolution for sobriety in the New Year.

1.      Focus on what you are gaining from sobriety. When you frame your resolution as simply “not drinking,” you are making a negative statement. Instead, think and talk about your resolution as something like “freeing yourself from addiction.” Reframing your decision in a positive statement allows you to focus on the benefits that you get out of keeping your resolution.
2.      Forgive yourself for past mistakes and focus on making decisions you are proud of. Beating yourself up over what you did in the past will only create more pain and suffering in the present. Offering yourself some compassion and forgiveness will go a long way toward creating the life that you deserve.
3.      Let your friends and family know about your decision so you can develop a strong support system. Gathering the support of trusted loved ones allows you to get the encouragement that that you need as you navigate the road to recovery. It also holds you accountable to your resolution because the force of positive peer pressure can help keep you in check when you feel your motivation waning. Invest in relationships with the people that can be the helping hands you need.
4.      Do something altruistic. Volunteering not only helps those in need, but it can also give you a boost of self-esteem. When you feel good about yourself, you are more likely to take the necessary steps to take care of yourself.
5.      Face your demons in a healthy way. Many people start using alcohol and drugs as a way to escape their troubles. Whether it’s depression, anxiety, past trauma, insecurity, or something else, everyone has their demons.  Rather than self-medicating, make an appointment with a therapist and work through your issues. While therapy can be emotionally challenging, if you can attack the root cause of your addiction, you will set yourself up for long-term sobriety.

6.      Find clarity and meaning. Without drugs and alcohol clouding your outlook on life, you can start focusing on things that give you joy and meaning. Whether you decide to explore your faith, take up a hobby, learn a new language, travel, or something else, find something that gives you a sense of purpose. Living with intention will give you the attitude that you need to accomplish your resolution for sobriety.

Tuesday, December 22, 2015

After 5 Years of Recovery Are Patients Cured?

by Peter R. Coleman, MD

Recently, we have been hearing more and more about the idea that if people can sustain recovery for 5 years, they are (almost) cured. The concept is, just like a cancer diagnosis, if people can be free of their disease for five years, then the chance of the disease coming back is very unlikely - we can almost say they are cured. It is very unlikely that relapse will occur.

This idea appears to go beyond traditional thinking. We all know the saying - "once an alcoholic, always an alcoholic". We also refer to people in recovery as being "in recovery" and not "recovered", because we don't want to forget the fact that relapse is always possible, and recovering people need to protect their recovery. So, this new thinking is very bold, but maybe it is not so different after all.

I attended the American Society of Addiction Medicine (ASAM) annual conference earlier this year and some preliminary research was published that sheds some light on this situation.

A large study is looking at what happens to people if they are able to maintain 5 years of drug and alcohol free recovery. The results of the study so far indicate that if the patients were able to maintain 5 years of drug free recovery, then the relapse rate over the next five years was an amazingly low rate of only 3%. Fully 97% of people did not fall off the wagon. 

These are amazing results and very encouraging. When you think about it, the results are not as surprising as they first seem. If we think of nicotine dependence, another chemical addiction, then we would probably see very similar results. If people are able to stay off cigarettes for five years, they are very unlikely to pick up smoking again. Of course, they can relapse back to cigarette use if they make silly mistakes, but they are unlikely to do so. After 5 years of abstinence, people see themselves as non-smokers. They are no longer affected by triggers and they have learned how to deal with their emotions rather than just smoking cigarettes when they are bored, lonely, or frustrated. 

So, it makes sense that if people can achieve 5 years of abstinence from drugs and alcohol, they will also be unlikely to return to their former addictions.

Is five years the magic number? We do know that it takes a long time for the brain to heal after the drug use stops. I used to say that 12 months was a reasonable amount of time to assume the brain had returned to normal, but when it comes to opiates like prescription painkillers or heroin, I believe it takes a lot longer for all of the brain to heal. 

There is no other explanation for the fact that relapse is so common, even after very long periods of abstinence. The truth is most people who go to jail and are then released, will relapse virtually as soon as they get out. This seems to be true even when people are incarcerated for long periods of time. Clearly, the memory circuits in the brain and the systems responsible for cravings and impulse control have not fully healed.

We are now recommending treatment and follow up for five years. Using Naltrexone implants and injections for this first part of recovery is crucial. Transitioning to lesser levels of support can then be done when clinically indicated. If we treat this disease just like other medical conditions, we are much more likely to have favorable outcomes.

Tuesday, December 8, 2015


by Gabriella Pinto-Coelho

For some, the holiday season can be a time of year filled with love, family, and joy. And for others, it can be a total you-know-what-show. A lot of it depends on your family, and that’s no surprise. Family is the one place where you can regress 10, 20, 30 years without even realizing it. Family is the one place where you can feel simultaneously loved, loathed, hurt, rejected, and accepted. Everything that comes with reuniting with your family - from memories of bad haircuts to reminders that yes, your aunt is still crazy - can create a perfect storm to exacerbate both mental illness and the risks for substance abuse. Sometimes we get so caught up in the dread of returning home and the pressure of buying the best holiday gifts that we forget what the season is really about - love, gratitude, and peace.

Gratitude isn’t just something that’s good for Thanksgiving, Christmas, or New Year’s. Gratitude should be an everyday kind of thing. And if you don’t buy into that because it sounds too kumbaya, then consider the fact that science has proven gratitude might just be really effective medicine (and it just might help protect you from your crazy aunt and your desire to pick up the bottle). Here are seven reasons why gratitude is the best medicine:

1.   Gratitude creates more opportunities for new relationships. Showing your appreciation for someone isn’t just a pleasantry, it can actually lead to new friendships, according to a 2014 study published in Emotion. And it makes sense: if you are kind to someone and they thank you for your generosity, you’re a lot more likely to want to interact with them again. Especially if you have had to prune your group of friends after starting on the road to recovery, making new friends can be a really good thing.
2.   Gratitude improves your physical health. A 2012 study published in Personality and Individual Differences revealed that grateful people report feeling healthier than their less-grateful counterparts. Grateful people are also more likely to take care of their health, exercise more often, and have regular physicals with their doctor.
3.   Gratitude improves your psychological health. Do you want to be happier and less depressed? Practice gratitude! Gratitude is proven to reduce a number of negative emotions like envy, frustration, regret, and resentment.
4.   Gratitude heightens empathy and decreases aggression. A 2012 study out of the University of Kentucky proves that grateful people are more likely to exhibit pro social behavior even when others are unkind. I’m pretty sure that all of us could use a dose of that when it comes to dealing with family members that drive us up the wall.
5.   Grateful people sleep better. Most people know and appreciate the fact that getting adequate, deep sleep is an essential part of being healthy. A 2011 study published in Applied Psychology demonstrated that writing in a gratitude journal before bed can lead to better quality (and longer) sleep.
6.   Gratitude improves self-esteem. A 2014 study in the Journal of Applied Sports Psychology found that gratitude increased the self-esteem of athletes, which is an essential factor in their performance. Although this study focused specifically on athletes, I would argue that most of us do better at whatever we do when are confident in our abilities and have a healthy self-esteem. Gratitude is also shown to reduce social comparisons, like becoming resentful of others for having a bigger house or better job. That sounds like a pretty valuable skill during the gift-buying and gift-receiving of the holidays.
7.   Gratitude enhances mental strength & resilience. Research has demonstrated the power of gratitude in overcoming trauma. A 2006 study in Behavior Research and Therapy found that Vietnam War veterans with higher levels of gratitude were less likely to develop Post Traumatic Stress Disorder. A 2003 study in the Journal of Personality and Social Psychology found that gratitude contributed heavily to resilience after the September 11th terrorist attacks. Practicing gratitude even in the face of grave circumstances can help promote resilience. Those are some really encouraging results given the all that it takes to be in recovery.

The moral of the story? Gratitude is good for everyone, but it might be even more beneficial for those of you on the road to or already in recovery. So when you’re sitting next to your crazy aunt at the Christmas table, do your best to think about all you have to be grateful for (even if it’s just good food at the table).

Friday, November 20, 2015

The Surprising Prevalence of Drug Abuse in America

by Gabriella Pinto-Coelho

A new study out of the National Institute on Alcohol Abuse and Alcoholism paints a bleak picture of drug addiction in the United States. Certain social factors like unemployment (which has a strong correlation to drug abuse) and the rise in prescription opioid use have contributed to the current state of drug use and abuse in our country.

The study from the NIAA analyzed data taken from a 2012-2013 national epidemiological survey. The research team focused on discovering the prevalence of drug use disorders (DUDs) as defined by the Diagnostic and Statistical Manual of Mental Disorders 5th edition. The DSM-5 serves as an encyclopedia and diagnostic tool for mental and behavioral health disorders.

The findings revealed that roughly 9.1 million, or 3.9%, of Americans had a DUD diagnosis based on their reported use in a 12-month period. Even more concerning is that 9.1% of Americans had a DUD diagnoses based on their reported lifetime use. The statistics on treatment for those with DUDS are more disheartening; only 24.6% of those with lifetime DUDs received treatment, and just 13.5% of those with 12-month DUDs received treatment.

The researchers identified demographic characteristics that put individuals at a higher risk of developing a DUD, including:
  • ·         Men
  • ·         Caucasians and Native Americans
  • ·         Young, and previously married or never married adults
  • ·         Individuals with lower levels of income and education
  • ·         Individuals who reside in the Western states

The results also linked a set of psychological factors related to the 12-month DUD diagnoses:
  • ·         Major depressive disorder
  • ·         Persistent mild depression
  • ·         Bipolar disorder
  • ·         Post-traumatic stress disorder
  • ·         Personality disorders

Finally, psychological risk factors for lifetime DUDs include:
  • ·         Generalized anxiety disorders
  • ·         Panic disorders
  • ·         Social phobias

This study didn’t even include information on drug abuse for institutionalized individuals like prisoners and active duty military personnel. Given the fact that the risk factors above are prevalent in the prison population (e.g. young, men, low income and education) and in the active military population (e.g. PTSD, young, men), I think that the statistics quoted by the researchers are lower than they actually are.

While these findings are a little bit depressing, we have to face the facts. As the researchers said, we are facing an urgent need to destigmatize drug abuse and focus on education, prevention, treatment, and support.

Friday, November 13, 2015

The Changing Demographics of Opioid Addictions

by Gabriella Pinto-Coelho

There’s no doubt that the population of individuals seeking treatment for opioid addictions now is vastly different than the same group profile in the 1990's or even early 2000's. A new study out of Canada has shed more light on this reality: the changing demographics in Canada, the U.S., and abroad highlights the importance of treatment programs to evolve to meet the needs of a new and unique group.

The study focused on a large group of both men and women at 13 methadone clinics in Canada. All study participants were seeking treatment for an opioid dependence disorder and were attending methadone clinics for their treatment. Researchers found that the majority (52%) of women and 38% of men had their first contact with opioids from a doctor’s legitimate prescription. Researchers aren’t entirely sure why women were so vulnerable to opioid dependence originating from a doctor’s prescription. One hypothesis is that women are more likely to seek medical care in general. Furthermore, the women in the study were more likely to have both physical and mental health issues, a family history of psychiatric illness, and childcare responsibilities. Meanwhile, the men were more likely to hold jobs and smoke cigarettes. Interestingly, the average age of patients seeking treatment is 38, though they began using opioids at an average age of 25.

This profile is very different than the profile of patients seeking treatment in the 1990's; the average age at treatment was 25, while age at first use fell to 21. Patients seeking treatment in the 90's were predominantly male, injecting heroin, and without childcare or employment responsibilities. The unfortunate fact is that many current treatment methodologies are still based on this outdated model that has shifted in recent years. More and more women are seeking treatment for opioid addiction in Canada, the U.S., and other countries, and many treatment programs do not consider the impact of childcare and employment responsibilities on the lives of both women and men seeking help.

Given this shortage of patient-centered treatment programs, it comes as no surprise that programs like The Coleman Institute’s accelerated, outpatient detox are growing in popularity; it's private, compassionate, comfortable, and relatively quick detox programs seem to be appealing to people who are eager to get back to work, family, and other life responsibilities.

Thursday, November 5, 2015

A "Wild" Transformation

by Peter R. Coleman, M.D.

I recently watched the movie “Wild” starring Reese Witherspoon as Cheryl Strayed - a young woman who was having serious problems and felt like the best solution was to go hike on the Pacific Crest Trail. I was expecting a fairly boring movie showing some struggles and perseverance and then she would finally make it to the end and live happily ever after. What I saw instead was the story of an amazing transformation in a young woman’s’s life.

Cheryl grew up with some significant dysfunction – an alcoholic, abusive father, who was so abusive the family was bundled up and had to escape late at night. Her mother then seemed to run away from all of life and not deal with things in healthy way. It was very painful for Cheryl and her brother. Cheryl escaped with a young boyfriend, then drugs, and ultimately became horribly addicted to heroin. When she was at the end of her rope, she happened to notice a beautiful photograph of a landscape hanging on the wall of an office.

It was a photograph of a section of the Pacific Crest Trail (PCT). A little voice inside her told her that if she could just tune into this beauty and follow a different path, things would turn out alright. She surrendered to this voice without quite knowing why or what lay ahead. With only the minimum of preparation, she set out. The early days were very difficult but she persevered. In the end, she hiked over 1,000 miles. 

She conquered enormous obstacles and put up with what, at the time, seemed unbearable pain. Along the way, she was able to evaluate her past experiences and how she had handled them. Cheryl was able to feel and experience her pain – both physical pain and emotional pain. Ultimately, she was able to accept her past and forgive herself and others. She came out a transformed woman.

What struck me about this true story is that the journey Cheryl embarked on is so similar to the journey of substance abuse recovery. She just did it in an unconventional way. She first gave up the drugs and alcohol and then, she was able to think and feel clearly. She nurtured her body and soul with good exercise, good food, and beautiful surroundings. She overcame challenges. She sat through pain without giving up. She started to look at her patterns of thinking and behavior that got her into trouble. Cheryl looked back at the influences of her past and was able to get past judgement and blame. She became able to see her parents as real people who did the best they could – even if that wasn’t very good. She was able to forgive herself and them. Over time, she found a new passion for living – writing, sharing her stories, and helping others.

Finally, as she neared the end of the trail, she found a way she could reintegrate and live in the real world in a safe way that would not trigger her to return to drug use.

Since the “Wild” walk, Cheryl Strayed married and raised a family. She has written books, shared her stories, and inspired others. Last week, I saw a reference to a talk that Cheryl will be giving soon. Over 15 years later, she is still growing in her recovery, still following her passion, and still helping others.