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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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Interviewer: Using mindfulness to overcome pain pill addiction. We'll tell you how, next on The Scope.

Announcer: Medical news and research from University of Utah Physicians and Specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: You or somebody you know suffers from chronic pain and as a result now has an addiction to the pain pills. Eric Garland is a clinical researcher and practicing licensed psychotherapist at the University of Utah, and there is a technique called mindfulness that could actually help get rid of the addiction and manage the pain as well. Tell me a little about that. First of all, does it really work?

Dr. Garland: It seems like it works. We have a body of research that's building that indicates that mindfulness is a really useful treatment for addiction. We're still actively studying this area, and really, it's an emerging research area, but there have been some pretty big well-controlled trials to show that it's helpful for this problem. I myself have done some of them.

Interviewer: I think sometimes people think of mindfulness and they think, "Oh, mind over matter. If it was only that easy." Right?

Dr. Garland: Right, and it's certainly not easy and I don't want to be flippant about it. This is tough stuff. We're talking about deeply entrenched habits. And it takes a lot of energy to change a deeply entrenched habit. But if you think about it, what mindfulness really is, it's a form of mental training.

So think of it this way. If you wanted to build up your bicep, you would curl a dumbbell and you have to put in a lot of energy, rep after rep, week after week, grueling workout after grueling workout to build the strength of your bicep. Well, if you want to build the strength of your mind to enhance your self-control over addictive habits, then you have to apply the same principle of repetition after repetition of mindfulness practice over and over again, day after day, week after week and you build up your mental strength through a very similar type of process.

Interviewer: So tell me, then, now. With somebody with pain pill addiction, how do they use mindfulness to overcome it? What would they do? Walk me through that process.

Dr. Garland: Yeah, let me walk you through the process. So let's assume that we have someone who's taking pain pills for a chronic pain condition but their use of the pain pills has sort of gotten out of control. One of the techniques we teach them is to practice mindful breathing before taking their opioid medicine. What that means is when the person is getting ready to take the opioids, instead of just popping the pill they stop, they pause, and they begin to focus on their breathing, and as they begin to focus on their breathing they begin to notice thoughts and feelings and urges, for example, the urge to take the pain medicine. In practicing mindfulness like this, the person may begin to realize whether their taking opioids is a means of alleviating pain or perhaps they're taking opioids as a means of getting rid of a craving, satisfying an urge as opposed to satisfying a genuine need for pain relief.

Interviewer: So then at that point what do you do? You just make the decision that wait, it is a craving. I'm not going to take this pill.

Dr. Garland: Well, in the case of somebody who is really dependent on opioids that would be dangerous to just stop taking the pill at that point, but by gaining that awareness the person might decide that they want to change their opioid use habit, so they might be able to work with their doctor to gradually decrease their dosage.

Now, if a person is really dependent and they start to decrease their dosage of opioids under a doctor's supervision, they may experience withdrawal or they may experience craving, and mindfulness techniques can be useful to help a person cope with the unpleasant feelings in their body and the unpleasant emotions in their mind during that process.

Interviewer: So it's really just kind of coming into touch with, "What am I feeling right now," and not just assuming that you're feeling pain or whatever, and then assessing that, and then deciding what you're going to do with that.

Dr. Garland: That's definitely a part of it. That's a big part of it. Another part of it is this process that we call mindful savoring, which is using your attention and your awareness to experience greater pleasure out of everyday activities and events. So again, as we discussed, from a neuroscience perspective addiction involves a process where the person becomes less sensitive to natural pleasure. When practicing mindfulness we can teach people to focus their attention on the positive and good aspects of their life so that they can actually enjoy it more. So let me give you an example of that.

In this mindfulness technique we have patients practice by focusing their attention on a bouquet of flowers. So they focus on the beautiful sights of the flowers, the colors, the textures, the touch of the pedals against their skin, the scent of the flowers, and whenever their mind wanders off to random thoughts they notice that their mind has wandered and they bring the focus of their attention back to the pleasant features of the flowers; the scent, the smell, the texture, the color. As they do this, they become aware of positive feelings in their mind and their body, and then the positive feelings and thoughts that arise in their mind and body become the focus of mindfulness practice. So we encourage the patient to focus their attention on any positive emotions or thoughts that come up.

This technique involves practice both in sessions with a therapist but also practice at home with other enjoyable things in the person's everyday life, and this technique is designed to help them to re-learn how to experience pleasure.

Interviewer: So with somebody with a pain pill addiction, the first thing that they would do is use mindfulness to just kind of become aware of, "Why am I popping this pill," and then if they've decided, "I want to do something different about that," you would recommend going to their physician and telling them, "I would like to get myself off these pain pills."

Dr. Garland: That's right

Interviewer: And a therapist would probably likely be involved as well with some mindfulness training.

Dr. Garland: That's right. So as the person goes to the process of reducing their use, they may experience craving for opioids, and mindfulness can be used to cope with the craving, again by first helping the person become aware of the sensations in their body, their craving-related thoughts and emotions. As the person becomes aware of the craving the feelings may start to get overwhelming, so they can use mindfulness techniques to focus on their breathing as a way to calm down the mind and relax the body to help the person to cope with the difficult thoughts and feelings without giving in to opioid use. And when this process is repeated over time, the craving can become weaker and weaker.

Interviewer: Any tips for somebody that's listening and they're convinced, "I want to do this". Do you have any tips for them, anything they should watch out for, anything they should absolutely do?

Dr. Garland: They should absolutely work with a trained and licensed therapist through this process. I don't think it's something that somebody could do so easily on their own in the beginning, but as a person learns these techniques with a skilled teacher they can begin to practice them at home alone by themselves, and that'll help them overcome the problem.

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