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Interviewer: How to treat addiction based on what we understand about the neuroscience of addiction. That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Eric Garland is a clinical researcher and practicing licensed psychotherapist at the University of Utah. Neuroscience is looking at a new way of thinking about addiction which then would guide how we would treat addiction. Give me a little background, how the school of thought in neuroscience treats addiction right now or thinks about addiction.

Eric: Sure. So there's really a way of understanding addiction that has emerged out of the past couple of decades, and there's been a lot of research and time and energy put into understanding this problem, and what we're coming to realize is that addiction is really a process of normal learning gone awry. The same processes in the brain that facilitate normal learning get hijacked by drugs of abuse.

Normally when we learn things, when we have an experience and the experience is rewarding, this tells the brain to do this thing again. And so we learn that that activity or that experience is valuable. We get some sort of pleasure or reward out of it.

In everyday life that might be good relationships with people that we care about, doing activities and hobbies that we love. It might be something simple like enjoying the pleasure of a tasty, healthy meal or a beautiful sunset or the snow on the mountains, but as a person becomes addicted, the effects of addictive drugs on the dopamine system in the brain cause changes in this normal learning pattern such that what was once rewarding becomes less rewarding and the brain becomes more and more dependent on drugs to receive the same amount of pleasure and reward.

Even drug use itself in the beginning is highly stimulating and rewarding to the brain. It produces a surge of dopamine release. But over time, the drug itself produces less reward and drug use becomes more and more of an automatic habit. People start to use drugs on automatic pilot without getting any pleasure out of it. It's just like any other habit we have that we do. The more you do it, the easier it becomes, the more automatic it becomes, the less you have to think about it, and that habit starts to become triggered by cues. For example, if you're an alcoholic driving past the bar or driving past a liquor store, or if you're a smoker and you smoke in social situations.

Interviewer: Or just even driving. I've known smokers that I could predict when they pull a cigarette out based on where we were in a trip.

Eric: Exactly.

Interviewer: By the time we hit the stop sign at the end of the street, a cigarette is going to be out. By the time we hit here, another cigarette's going to be out.

Eric: Exactly.

Interviewer: So wow, okay.

Eric: And they may not even intend to be smoking it. They may not even realize that they're smoking it. A lot of smokers have the experience of sort of looking down and seeing that half their cigarette's gone up and they don't even remember smoking it. It just becomes an automatic habit. It doesn't even give them pleasure anymore.

Interviewer: And then worse yet, the other things that didn't give them pleasure, don't give them pleasure anymore.

Eric: That's right.

Interviewer: So what do you do with that point? How do you break this cycle?

Eric: Right, and so the cycle, it gets worse because the things that used to give them pleasure are no longer giving them pleasure and the drug isn't giving them pleasure. The person is in a deficit. They're in a negative mood state and that really drives them to take higher and higher doses of the drug just to feel okay. And there's the addictive cycle right before you.

Interviewer: So how do you solve that?

Eric: Well, if this is the problem then it seems that we need treatments that can do two things. One, they can help a person become aware of the automatic habit of addiction, to become aware of when cues are triggering this automatic habit so that the person can begin to exercise some self-control over the automatic habit.

And then two, we need treatments that can help people to find a way to enjoy pleasure in life again, to teach the brain to relearn how to feel a sense of pleasure and reward from everyday activities that used to bring them pleasure.

Interviewer: And what are some of those things that you can do to start discovering pleasure in life again?

Eric: Yeah, so that is where a technique called mindfulness comes into play because mindfulness is really, although it's based on some ancient techniques for training the mind, we're coming to realize now with neuroscience that this approach actually strengthens both of those processes, both self-control over automatic habits as well as increasing attentional focus that might enhance the experience of reward.

Interviewer: Let me jump back for a second. So this is just one way of looking at addiction, what you've described to me. How sure are we that this is the way it is? I mean, how have they figured out this much?

Eric: There've been multiple millions of dollars invested by the National Institutes of Health, specifically the National Institute on Drug Abuse and the National Institute on Alcoholism devoted to this topic. These studies range from studies with animals, studies with humans and even studies down to the cellular level to understand how neurons communicate to each other and how drugs actually affect neurotransmission.

One simple way that this has been shown to be the case is by putting people in a brain scanner and watching how their brains respond when they're shown drug-related cues on a screen, for example, pictures of cigarettes, and showing activations in brain circuits in the reward center of the brain, and as addiction progresses seeing activations in the dorsal striatum which is the part of the brain that's involved in habit responses, and conversely seeing the opposite effects with regard to naturally rewarding queues.

So if you put somebody in a brain scanner and this person has developed addiction and you show them, for example, cues of smiling babies or beautiful sunsets or couples holding hands, the brain responds less sensitively to those cues.

Interviewer: It seems like some people are more prone to addiction. With this way of thinking, why would that be, or is that a false statement to begin with?

Eric: No, there's quite a bit of research looking into, for example, the genetic factors that predispose somebody to addiction, but in the line of discussion that we're talking about, people vary to the extent to which they're naturally sensitive to rewards. They vary to the extent to which they seek out novelty, they're sensation-seeking is the term, and they also vary to the extent to which they can control their impulses. Some people are just better naturally at stopping themselves and exerting self-control than others.

But my interest as a therapist is how people can train those capacities so that no matter where you start from, you can train your mind to strengthen self-control and strengthen your ability to experience pleasure in everyday life.

Interviewer: Are there any resources that if somebody wanted to learn more on their own that you could steer them towards?

Eric: There are a number of practitioners in the community that are practicing mindfulness-based therapies and there are also a number of providers in the community that are practicing other evidence-based treatments for addiction like motivational interviewing and cognitive behavioral therapy.

Interviewer: How is this way of treating being approached right now by the rest of the addiction community, people that don't subscribe to this philosophy?

Eric: This is a really hot topic right now in the addiction research field in terms of the importance of reward, the importance of sensitivity to natural reward as a predictor of addiction-related problems, but the idea that we could actually improve this capacity in somebody who is addicted and has lost the ability to feel pleasure in everyday life, this is a brand new thing. So it's a pretty hot topic and controversial.

Interviewer: Yeah, and not only overcoming addiction but actually maybe even be happier than they were ever before.

Eric: Exactly. It has a lot of applications to other issues, too, like depression or chronic pain and just improving the healthy response in life.

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Announcer: Navigating your way through med school can be tough. Wouldn't it be great if you had a mentor to help you out? Well, whether your first year or fourth year, we got you covered. The Med Student Mentor is on The Scope.

Interviewer: I'm here with Dr. Leana Wen, who is a Commissioner for the Baltimore City Health Department. She's also the author of, "When Doctors Don't Listen." Today our Podcast is going to be about stress, specifically about how to deal with stress. So Dr. Wen, how'd you deal with stress as a med student?

Dr. Wen: First of all, thank you for having me on your podcast. I think it's extremely important to talk about stress and to think about think about this, especially in medical training. Medical school and residency can be a really dehumanizing experience. You entered medicine, I think all of us entered medicine for the right reason is that we want to care for our patients, that we want to be there for our patients in their time of greatest need, and to be able to advocate for them, and for our communities.
But then we get into school and we begin doing all these things, and start studying, and taking tests, and we often become disconnected from the primary goals of why it is that we're in medicine, making it an even more stressful time because we lose track of that mission. And so, my biggest piece of advice, my single biggest piece of advice I think is to keep in mind, at all times, why it is that we're here.
We're not here to study and get the best grade, we're not here to study and learn just about diseases for the sake of learning about diseases, ultimately we want to care for people, and we want to help them figure out what it is that they have, and how they can get better.
So keeping in mind that mission, but also doing things actively around that mission, even when our day-to day lives involve just studying and taking tests, being involved in the community, being involved in outreach, these are ways to keep us connected to why we entered medicine, and I think it's the single most important thing for combating stress. That's what I did, and I think it really helped me avoid the burnout that is so easy to happen, especially early on in medical school.

Interviewer: So what resources did you take advantage of to get involved with the community?

Dr. Wen: There are so many opportunities. Every single medical school, and public health school, and nursing school, there are many organizations that are mainly student run, that are also interfaced with community organizations. And so, might involve for example, teaching reproductive health and teaching HIV AIDS to local middle schools and high school students. They might involve helping with the homeless. They might involve student free clinics.
The American Medical Student Association, which I was the National President of when I was a medical student, is also a great way to get involved on the regional as well as on the national and local levels. And I would highly encourage everyone to look into opportunities through AMSA, because those are good ways to not only make a difference in your communities, but also to form networks with like-minded peers.
And actually that would be my second piece of advice, another great way of avoiding stress and burnout is to find others who are like you who may also be sharing some of the concerns that you might have. And to develop networks with them, not just to complain about how difficult life is, but rather to see what are the things that you can do to make a difference in your medical education?

Interviewer: I'm a first year med student. What if I don't feel confident enough in my skills to actually go out in the community and actually get my hands on people?

Dr. Wen: I'm not suggesting that you go into the community and practice medicine on unsuspecting strangers. I don't think that that's the best way to go, but there are many things you can do without any medical background at all. You can teach kids literacy. You can volunteer in homeless shelters. There is so much you can do that may not even require medical training. And that's what I suggest as something that is absolutely critical to on medical education that we need to stay connected to the reason why we entered medicine in the first place, and keep in mind that social mission that's core of what it is that we're supposed to be doing in medicine. It's not just about learning new technology. It's not just about prescribing medications.
But what about this kid who comes in all the time saying that he has breathing difficulties, and it turns out that his parents cannot afford to buy him inhalers and that's why he keeps on coming back. Well, what can you do to help this kid from getting sick in the future? What are the implementations you can work on in the community to work on perhaps a better after-school program for him, encouraging this kid to do exercise, things that don't require a medical background per se but are critically important to people's health?

Interviewer: Going out into the community seems to be a very important theme in your work. Do you think that it's just as important to go out and globally affect different communities? Not only here in the United States but abroad?

Dr. Wen: Actually, I don't. And here's the reason, so many students now I here talking about the importance of global health work, and having done a lot of global health myself, in general I think that we have to focus more as a country, as a society on other people around us, and not just think about Ebola and other problems as being over there, that we don't want to deal with problems over there, we as a society should do that.
However, medical students, there is a limited amount of things you can do as a student, and if you're going abroad maybe you can work there for two weeks, maybe you can work there for a month, but I see so many students waiting to get involved in something until they can work on say, HIV in Africa. Well, you know what, there is plenty of HIV in your backyard. Here in Washington, D.C., we have one of that highest infection rates in the country of HIV.
So when I hear students at our medical school talking about how they're waiting until they can go to Africa to work on HIV, I think that's really hypocritical. If you really want to work on this issue, work on it now, here in your backyard. And that's the issue that I have with encouraging students to do international work. Certainly, it's important to think about international issues and if you have the opportunity take advantage of it, but don't wait until you can go abroad to start making a difference, because you can do that every day here in our communities.

Interviewer: Another thing that's really stressful about medical school is this constant need for assessment. And so, with these regularly based tests, we have tests almost every week here at the University of Utah, how do you schedule in these kind of involvement opportunities?

Dr. Wen: It's important to get good enough grades that you can advance. I mean, I'm certainly not recommending to people to slack off and not do well. But you know, all of us who enter medicine on some level we have these Type A personalities. We're used to doing extremely well, we're used to getting the straights A's, and really who's going to care about your medical school grades? At the end of the day, does it really matter whether you get a 97 percentile or 92 percentile?
And so, what I'm saying is instead of focusing on that extra several points on your tests, why not spend that extra time focusing on why it is that you wanted to be a doctor in the first place? By no means, of course, am I suggesting that medical school isn't stressful inherently. There's so much information to learn, and I also thing that we put extra pressure on ourselves to learn so that we can take good care of our patients. And I think that's good, we should be learning to take care of our patients. There are always tradeoffs in time, and in what we can do. And I would say that the vast majority of students trade off the service component in exchange for studying when it should be the other way around.

Interviewer: Medical school's inherently stressful. And so we've talked about ways to kind of reduce that stress, but ultimately that stress is always going to be there. How have you been able to channel the stress to be more productive?

Dr. Wen: My advice is to just come back and know yourself, and keep on reflecting, and find others who are like you in processing these issues. And be open to talking about them. Don't see vulnerability, and don't see being scared or being uncertain as a failure, but rather embrace those feelings, and be open to thinking about these feelings and talking about these feelings. Because that's what's going to make you connected to yourself, and that's what's going to make you connected to your patients at the end of the day.

Interviewer: So do you still reflect on kind of this origin of your motivations practicing as an attending physician at George Washington University?

Dr. Wen: Absolutely, every day I do. So first of all, I am an attendee and I do teach medical students and residents every day. And so, I see their struggles with it all the time. But I'd say that it's also stressful in academia, in private practice, in whatever people choose to do later in practice as well, that you still face challenges of time, whether its challenges of setting time with family, or with other commitments, with research, with admin, along with clinical practice. And ultimately, it's still about being reflective about why it is that we're here. If anything I see burnout happen even more among attendees than I do among students and resident. And I think the way to mitigate against this, is again to remind ourselves of why we're here.

Interviewer: Do you think that the reason why is different for every individual? Or is there a commonality?

Dr. Wen: I hope that there's a commonality, otherwise why is it that people are in medicine? I mean, I would hope that we're all here because we want to serve our patients and serve our communities.

Interviewer: So you mentioned that you see a lot of burnout in residents. Has that reflection process kind of helped them, or are there any other techniques beyond reflection that have helped them to overcome that kind of stress?

Dr. Wen: There are certainly techniques that I see that can be helpful. So things that I'm sure others have talked about, spending time with family, having a hobby, being able to get away from medicine one in a while to maintain balance in your lives. But ultimately, I still think that the most important thing is to find out your core mission, and then take charge of what you can do to get there.

Interviewer: Do you have any last final thoughts?

Dr. Wen: Only that it is a special privilege and honor to be a physician and a special privilege and honor that we worked really hard to get to where we are. And so, don't lose track of your motivation because ultimately that is what's going to get you through both the good times and the hard times.

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