Wednesday, April 25, 2012
ADDICTION: BRAIN IMAGING, DIAGNOSIS, LEGAL & SPIRITUAL IMPLICATIONS
This is a paper that I submitted last year in a college course
ADDICTION: BRAIN IMAGING, DIAGNOSIS, LEGAL & SPIRITUAL IMPLICATIONS
I started out wanting to find out if there was a way to diagnose addiction by brain imaging. I hoped I might find information useful to some of my friends in my OA program, because such images might be help them decide that they really need to work the program or might have helped one of them avoid jail time. After talking to an expert in the field, I concluded that that such diagnosis was not yet possible, so I just read various documents about addiction, imaging the addict brain, use of images in court, and diagnosis of addiction without imaging.
I became interested in the subject of addiction after I joined Overeaters Anonymous (“OA”) in October of 2004. [i]
In 2005, I read C. Brownlee, “Food Fix: Neurobiology highlights similarities between obesity and drug addiction” Science News, Sept. 3, 2005; Vol. 168, No. 10, p. 155 This article had portions relating to locations and functions of the brain associated with addiction. In the summer of 2007, Time Magazine ran an issue featuring addiction on the front cover. This article had very impressive images purporting to show what cravings looked like in the brain. There is a simplified version of this article at “Addiction and the Brain” http://www.time.com/time/interactive/0,31813,1640235,00.html I thought I had copies of both of these articles stored in my computer, but now I cannot find them, only citations to them; however, the point is that they caused me to become curious about imaging the brain to diagnose addiction.
I hoped such imaging could be useful in two areas.
First, my experience in OA is that most people who are addicts are unable to admit to themselves that they have this problem, that they cannot control their behavior. Generally, if a person does not believe s/he is addicted, s/he will not seek treatment. It seemed to me that an actual imaging diagnosis would be helpful in convincing addicts that they do in fact have this disease and therefore need treatment.[ii]
Second, I had a sponsee[iii] who was also a drug addict, who kept getting thrown in jail for her drug use. When in jail, she relapsed into her food bingeing behavior, because she was taken away from her support group. The common belief in the twelve step rooms is that addiction is a disease. A disease cannot be cured by imprisonment, normally. It seemed to me, as an attorney, that -- if one could prove by brain imaging that she had a mental illness that caused her drug behaviors -- then she could not be considered to have the mens rea[iv] necessary for conviction of a crime and would not be able to be imprisoned,[v] and therefore would not be taken away from her support group.
Those first articles led me to suppose that if I looked through the literature, I might find more articles that would show how to diagnose addiction based on brain imaging. I downloaded a large number of articles that had images of brains of drug addicts. Most of these articles were over my head. Many of them referred to a team of researchers at Brookhaven Laboratories on Long Island, which caught my attention, because my father used to work there. I decided to call one researcher whose name I saw several times, Dr. Joanna Fowler. She was very kind and actually called me back. She said that the research is not there yet. There are patterns that tend to be typical of addicts, but they overlap with patterns seen in the general population, and therefore cannot be the basis of a definitive diagnosis. [vi]
This sort of took the wind out of my sails, so I am just going to try to summarize some articles I found.
First I downloaded a huge number of academic articles, most of which I find incomprehensible, unfortunately, because they refer to tiny obscure parts and chemistry of the brain and many of them deal with only a single drug or the effects of the drug after use, as opposed to diagnosing addiction There are copies of them in this notebook, though.
I did find Nora Volkow, a prominent addiction expert, saying essentially what I thought about the topic of imprisoning drug addicts, on line at “Addiction is a brain disease. I'd send them to treatment, not prison.“ NORA D. VOLKOW, director of the National Institute on Drug Abuse, supporting the Vienna Declaration, a statement that calls for drug users to be spared arrest and offered clean needles and methadone instead July 10, 2010 http://www.time.com/time/quotes/0,26174,2006052,00.html I had seen her name on several articles in my searching. I also found an article about Volkow: M. Duenwald, “A Scientists’s Lifetime of Study into the Mysteries of Addiction,” New York Times, 8/19/03 p. F5. It turns out that she’s written hundreds of articles on addiction and is a great grand-daughter of Leon Trotsky[vii]
In J. Rosen, “The Brain on the Stand,” New York Times 3/11/07 p. E48, I learned that my idea about using brain images to to exonerate or attempt to exonerate criminals or reduce their sentences was not at all new. The most common such use is in capitol punishment cases to attempt to avoid the death sentence, for instance by identifying a cyst in the arachnoid membrane around the brain or by showing how the adolescent brain is less responsible for crimes committed than an adult brain would be. In another case, a researcher testified that injury to the amygdala of a perpetrator resulted in him becoming a serial rapist & murderer. Drug addiction was mentioned in passing as an example of where images might show loss of conscious control. Avenues of research for using brain imaging in court included monitoring brain reactions of potential jurors to attempt to determine which would be best for a case; and as a more reliable type of lie detectors.
The article described the philosophical and ethical issues that arise from the idea of brain function exonerating the criminal. There is still the possibility that it will turn out that no one has rational control of any behavior, that reason is a post hoc illusion[viii]. In such a case, the entire criminal law might be eviscerated.
The National Institute for Drug Abuse and Addiction, has some helpful summary articles about addiction e.g. at “Why do People Abuse Drugs?” http://www.nida.nih.gov/pubs/teaching/Teaching6/Teaching3.html and “Drug Use Changes the Brain”http://www.nida.nih.gov/pubs/teaching/Teaching6/Teaching4.html. These articles include
• a simplified diagram of the brain, which I am including as an appendix, showing regions involved in the craving process -- those regions being the prefrontal cortex, the anterior cingulate gyrus, the orbitofrontal cortex, the subcallosal cortex, the nucleus accumbens, the ventral pallidum, the hippocampus, and the amygdala[ix]; and
• a diagrams relating to the role of addiction in the dopamine process at the synapses in the brain..
The latter diagrams look very similar to diagrams that we had in class with respect to acetylcholine at synapses, except that dopamine is being studied rather than acetylcholine. I wish I had had this NIDA material before I tried to read the academic articles, but I wonder about the simplified approach, as the book I looked at, Koob & Moal,The Neurobiology of Addiction Elsevier 2006 (“Koob & Moal”) listed 19 different “Neurocircuitry Theories of Addiction” in chapter 9 -- each with lovely illustrations, just like our textbook has, but none apparently being considered definitive at least at the time of publication of the book. Granted this book is more than four years old and the NIDA website could be current, but I suspect that, given what Joanna Fowler said, the NIDA website is oversimplified.
I gather from several of the documents I’ve read, at least one central mechanism in addiction is that initial exposure to the addictive substance creates pleasure by stimulating more dopamine or D2. After a while, the body develops tolerance and the number of D2 receptors declines, so that the addict has to take more of the substance just to feel normal.
In that vein, Dunn et al, “Decreased dopamine type 2 receptor availability after bariatric surgery: Preliminary findings,” Brain Research 1350 (2010) 123-130. [x] documented physiological changes in the patients’ bodies that made them want to eat less after bariatric surgery. In particular, some of the damage to the dopamine system present in obesity seemed to be reversed by the surgery, so that patients enjoyed their food more, felt more satisfied, and therefore ate less.
Given that I gave up on finding imaging based diagnosis of addiction, I looked at how addiction is diagnosed, absent an imaging diagnosis. Koob & Moal, in their chapter 1, reviewed definitions of drug abuse and dependence from various sources. One was DSM IV from the American Psychiatric Association in 1994. Another was ICD-10 from the World Health Organization. They summarized these with the terms: clustering criterion, tolerance, withdrawal, impaired control, neglect of activities, time spent, continued use despite problems, and compulsive use. However, there were other views, which included
• “Psychiatric View of Addiction,” including aspects of impulse control and compulsive disorders;
• “Psychodynamic View of Addiction,” which included disordered emotions, disordered self care, disordered self-esteem, and disordered relationships leading to self-medication.
• Social Psychological/self-regulation view of addiction, with lapses leading to distress leading to further failures
Another interesting thing I learned from this book is that brain imaging is not fast enough to get actual movement of information in the brain, but only indicates regions that are active.[xi]
An article I found particularly interesting was Avena et al, “Evidence for sugar addiction: Behavioral and neurochemical effects of intermittent, excessive sugar intake”, Neuroscience and Biobehavioral Reviews 32 (2008) 20-39[xii]. This article looked for four main symptoms as evidence of addiction: bingeing, withdrawal, craving, and sensitization. The authors found that rats who were exposed to excessive sugar intermittently developed these four symptoms, while rats who had continuous exposure to sugar did not. For me, this tended to confirm my suspicion that dieting can lead to food addiction, but the rats studied were quite different from people in that the ones who binged did not necessarily get fat as they were able to regulate their total calorie intake, which is not at all the case with many people.
In my program, I have learned from Alcoholics Anonymous (Alcoholics Anonymous World Service, Inc. 2001 4th ed.) (aka “Big Book”) to define addiction in terms of an “allergy of the body,” p.xxviii, which is not a histamine allergy, but an abnormal reaction of the body which results in the “phenomenon of cravings” p. xxix upon exposure to the addictive substance; and a “peculiar mental twist” p.33, which results in the repeated finding of an “insanely trivial excuse” p.37 to pick up the addictive substance despite having resolved not to do so -- though the various definitions reviewed by Koob & Moal all have familiar aspects.
The Big Book encourages the addict to look for recovery in a “vital spiritual experience.” p. 27 This has has given me a long term interest in the research of Richard Davidson at the University of Wisconsin, Madison. He has been studying the brains of experienced Buddhist meditators, particularly Tibetan Buddhist. I sometimes go to Madison, because I am originally from there and my father was a professor there, so I once went by Professor Davidson’s office, after being unsuccessful in contacting him by e-mail. I left him a long, hand-written letter trying to encourage him to look into using his research for the treatment of addiction, but I never heard back from him. I also once spoke to a neuroscience researcher at Columbia University and asked him to look into this. When I spoke with Dr. Fowler this semester, it turned out she had never heard of Professor Davidson’s research, so I sent her a copy of P. B. Reiner, “Meditation on Demand: New research reveals the cell mechanisms underlying a meditative state,” Scientific American Mind (November/December 2009) p. 64-67. I hope she read it and that finally there will be some connection in the scientific research community between addiction research and meditation research.
I. I have to make more modest objectives for myself when trying to write a ten page paper for a freshman biology class -- scaling back not being an easy undertaking for me.
II. Diagnosis of addiction from brain imaging is likely going to be possible, but not yet.
III. Brain imaging diagnosis could help exonerate addicts from addiction related crimes in courts of law.
IV. Some drug addiction experts agree with me that imprisonment is not the best way to help addicts recover.
V. Diagnosis of addiction, without images, is ambiguous at best, which is not very helpful to people who need to know whether they are really addicted in order to motivate themselves to get treatment, or who keep getting thrown in prison for crimes they are unable to stop themselves from committing
VI. While 12-steppers generally believe that prayer and meditation are useful in addiction treatment, scientific researchers do not seem to be looking into the scientific implications of that.
Bibliography (in order of appearance)
• C. Brownlee, “Food Fix: Neurobiology highlights similarities between obesity and drug addiction” Science News, Sept. 3, 2005; Vol. 168, No. 10, p. 155
• “Addiction and the Brain” Time magazine online http://www.time.com/time/interactive/0,31813,1640235,00.html
• Vienna Declaration excerpt, July 10, 2010 http://www.time.com/time/quotes/0,26174,2006052,00.html
• M. Duenwald, “A Scientists’s Lifetime of Study into the Mysteries of Addiction,” New York Times, 8/19/03 p. F5
• J. Rosen, “The Brain on the Stand,” New York Times 3/11/07 p. E48
• “Why do People Abuse Drugs?” http://www.nida.nih.gov/pubs/teaching/Teaching6/Teaching3.html
• Dunn et al, “Decreased dopamine type 2 receptor availability after bariatric surgery: Preliminary findings,” Brain Research 1350 (2010) 123-130
• Koob & Moal,The Neurobiology of Addiction Elsevier 2006
• Avena et al, “Evidence for sugar addiction: Behavioral and neurochemical effects of intermittent, excessive sugar intake”, Neuroscience and Biobehavioral Reviews 32 (2008) 20-39
• Alcoholics Anonymous (Alcoholics Anonymous World Service, Inc. 2001 4th ed.)
• P. B. Reiner, “Meditation on Demand: New research reveals the cell mechanisms underlying a meditative state,” Scientific American Mind (November/December 2009) p. 64-67
Second Bibliography (not well formatted)
This is a list of articles that I glanced at, but did not cite directly above:
W.3.03 Brain imaging studies in human addicts M.R.C. Daglish, D.J. Nutt. Psychopharmacology Unit,
University of Bristol, UK
Modelling human drug abuse and addiction with dedicated small animal positron emission tomography
Jeffrey W. Dalley a, b, c, *, Tim D. Fryer a, d, Franklin I. Aigbirhio a, d, Laurent Brichard a, d, Hugh K. Richards a, e, Young T. Honga,d, Jean-Claude Barona,d,f, Barry J. Everitta,b, Trevor W. Robbinsa Neuropharmacology 56 (2009) 9–17
Individual differences in prefrontal cortex function and the transition from drug use to drug dependence
Olivier George∗, George F. Koob Neuroscience and Biobehavioral Reviews 35 (2010) 232–247
“Junk Food and Obesity” http://healthcomments.info/2011/03/13/junk-food-addiction-and-obesity.aspx
Human brain imaging and substance abuse Anne Lingford-Hughes Current Opinion in Pharmacology 2005, 5:42–46
E. London et al., “Orbitalfrontal Cortex: Human Drug Abuse: Functional Imaging”, Cerebral Cortext, March 2000, 10:334-342
Decision-making and addiction (part I): impaired activation of somatic states in substance dependent individuals when pondering decisions with negative future consequences Antoine Bechara∗, Hanna Damasio Neuropsychologia 40 (2002) 1675–1689
Cocaine addiction: Diffusion tensor imaging study of the inferior frontal and anterior cingulate white matter Maria J. Romeroa,b, Samuel Asensioa, Carmina Palauc, Amparo Sancheza, Francisco J. Romeroa,⁎Psychiatry Research: Neuroimaging 181 (2010) 57–63 (after the fact)
Hyperinsulinemic obesity and carbohydrate addiction: the missing link is the carbohydrate frequency factor R.F. Heller , a and Rachael F. Hellera Medical Hypotheses Volume 42, Issue 5, May 1994, Pages 307-312 (abstract only)
Neural mechanisms underlying obesity and drug addiction Richard Trinkoa, Robert M. Searsa, Douglas J. Guarnieria and Ralph J. DiLeone Physiology & Behavior Volume 91, Issue 5, 15 August 2007, Pages 499-505 (abstract only)
Mitral Valve Prolapse and Addictions JON CHRISTOPHER STRINGER, MD ANIS OBEID, MD
ELEANOR O’SHEA, RN, CNP November 1, 1985 THE AMERICAN JOURNAL OF CARDIOLOGY Volume 56 pp. 808-9 (interesting to me, because I have mitral valve prolapse, at least when I don’t have enough water & salt)
Thalamo-cortical dysfunction in cocaine abusers: Implications in attention and perception
Dardo Tomasia,⁎, Rita Z. Goldsteina, Frank Telanga, Thomas Malone Psychiatry Research: Neuroimaging 155 (2007) 189–201
Cognitive control of drug craving inhibits brain reward regions in cocaine abusers Nora D. Volkow a,b,⁎, Joanna S. Fowler c, Gene-Jack Wang c, Frank Telang b, Jean Logan c, Millard Jayne b, Yeming Ma b, Kith Pradhan c, Christopher Wong c, James M. Swanson d NeuroImage 49 (2010) 2536–2543
The addicted human brain viewed in the light of imaging studies: brain circuits and treatment strategies
Nora D. Volkow a,b,c,, Joanna S. Fowler d, Gene-Jack Wangc Neuropharmacology 47 (2004) 3–13
Volkow & Fowler, “Addiction: A Disease of Compulsion & Drive: Involvement of the orbito-frontal cortex,” Cerebral Cortex, March 2000, 10:318-328
Reward, dopamine and the control of food intake: implications for obesity Nora D. Volkow1, Gene-Jack Wang2 and Ruben D. Baler1 Published by Elsevier Ltd. doi:10.1016/j.tics.2010.11.001 Trends in Cognitive Sciences, January 2011, Vol. 15, No. 1 (review of a book)
Overlapping neuronal circuits in addiction and obesity: evidence of systems pathology Nora D. Volkow1,2,*, Gene-Jack Wang3, Joanna S. Fowler3 and Frank Telang2 Phil. Trans. R. Soc. B (2008) 363, 3191–3200
Brain dopamine and obesity Gene-Jack Wang, Nora D Volkow, Jean Logan, Naomi R Pappas, Christopher T Wong, Wei Zhu, Noelwah Netusil, Joanna Fowler THE LANCET • Vol 357 • February 3, 2001
Exposure to appetitive food stimuli markedly activates the human brain Gene-Jack Wang,a,* Nora D. Volkow,a,1 Frank Telang,a Millard Jayne,a Jim Ma,a Manlong Rao,b Wei Zhu,b Christopher T. Wong,a Naomi R. Pappas,a Allan Geliebter,c and Joanna S. Fowlerd NeuroImage 21 (2004) 1790– 1797
[i] OA is a 12 step program that treats overeating as a manifestation of an addiction, and is modeled on the program of Alcoholics Anonymous. At the time I joined, I weighed 190 lbs and I now weigh somewhere around 140, plus or minus 5 lbs, most of the time.
[ii] I had one friend who died in 2009, top weight 800 lbs,, who was still unable to admit that he could not control his eating behavior; something that was perfectly apparent to anyone else. Alcoholics Anonymous cited below has an ominous portion relating to the issue of convincing addicts that they have this problem. It says, at p. 30, “The idea that he will some day be able to control and enjoy his drinking is the great obsession of every abnormal drinker. The persistence of this illusion is astonishing. Many pursue it into the gates of insanity or death,” something I saw in my friend.
[iii] A person I was helping with the OA program
[iv] mental state. Criminal law generally requires “mens rea” for conviction of a crime.
[v] When I started this paper, I believed that this particular sponsee was dead or in prison, because I had not heard from her. Since then I did hear from her and learned that she has been clean of both illegal drugs and bingeing on food for more than a year, so I am moderating my opinion somewhat as to whether imprisonment was effective in helping her; but the point was that my initial opinion was that imaging might be useful in her situation, which helped get me started here.
[vi] but cf “HANLEY CENTER ACQUIRES THE EAST COAST’S FIRST SPECT SCANNER TO TREAT ADDICTION: Groundbreaking Images Demonstrate That Addiction Is A Brain Illness; Helps Predict Patient Relapse (5/25/10) http://hanleycenter.org/pdf/SPECT-Scan-release.pdf This article purports to do some sort of diagnosis of addiction from images, but it is somewhat vague. It sounds more like they’re still trying to figure out how to use these images.
[vii] She is not political herself, but spent time in Paris where she met Trotskyites. I was an exchange student in Paris, myself, and had several friend who were Trotskyites there.
[viii] That is certainly my impression of my own functioning, that I have little or no choice as to what I do and am constantly frustrated by my choices for use of my time.
[ix] i just sent this diagram to a sponsee and asked her to focus her meditations on the areas pictured, to see if that helped her cravings. I think that kind of visualization helped me.
[x] In OA, we only see bariatric surgery failures, people who gain back the weight they lost through surgery. I know one person who has had bariatric surgery twice and is gaining the weight back a second time. I heard a friend of friend story of someone back up at 500 lbs not too long after surgery, because he figured out how to drink a lot of frappes. I know another person whose 23 year old daughter died 5 days after the lap band surgery leaving a 2 year old daughter. I always am a bit surprised by the assertions in articles like this that the surgery is typically successful, because that is not my experience in OA, but of course we have a self-selecting sample.
[xi] This is something that I want to find out more about later, because another topic of interest to me is designing biofeedback techniques to stop addictive behavior, which it seems to me might require actually seeing information movement in the brain.
[xii] I sent a copy to a sponsee who wondered how on earth I had found time to locate such an article.