Substance Abuse Resources

Buprenorphine (Bup) effects;

1. Consider different-colored padlocks (Delta, Kappa, Mu1, Mu2, Nociception, Zeta.
   1. Agonist agents fit into the lock, turn and open (activate) the lock
   2. Antagonist fits into the lock but won’t turn/open/activate the lock.
      1. This prevents any other molecule from engaging the receptor—blocking it’s effect

• BUP is a mixed agonist/antagonist;
  1. Partial agonist/antagonist at Mu1àPain relief
  2. Antagonist of Kappa
  3. Mixed effects on other receptor subtypes
  4. Norbuprenorphine is a metabolite of BUP
     1. Norbuprenorphine also has psychotropic properties
  5. Blocks the Mu2 receptoràno euphoria (“high”); it BLOCKS getting “high”

1. 8 mg sl BUPà86% receptor blockade in opiate tolerate/dependent users
2. 16 mg sl BUPà94% blockade
3. 24 mg sl BUPà97% blockade
   1. The brain can tell the difference between 8 & 16 mg (86%-94%, or 8% receptor blockade)
   2. The brain cannot tell the difference between 16 mg & 24 mg (94%-97%, or 3% receptor blockade)
      1. However, 24 mg can be used short-term for acute pain syndromes if needed (Eg. After surgery)
   3. Remember, it blocks the euphoric effect
      1. “They sure don’t make heroin like they used to!”
   4. Prevents/relieves craving
   5. Stops pain; it’s used in open-heart surgery for pain control!
   6. Receptor half-life of 30 hours;
      1. Plasma half-life is 3-5 hours; high affinity means the receptor half-life is much longer.
      2. After 16 mg dose, in 30 hours, 8 mg still working…

• 30 more hours and 4 mg is still working and so on…

1. Strong affinity for the mu-2 opiate receptor.
   1. The BUP-Receptor bond at the Mu-2 receptor is >500 times stronger than the receptors affinity for morphine.
   2. This means it takes a much longer time for it to randomly bounce off the receptor than morphine or heroin would.
      1. It should be noted that molecules and atoms “bounce around”; they have energy and will eventually leave the receptor, the stronger the affinity the molecule has for the receptor, the longer it will stay on the receptor.

• This explains why having used BUP will ruin attempts to get high by using heroin for more than a day after the last full therapeutic use of BUP.

1. Transition from Methadone (MTD);
   1. This deserves special mention & review.
   2. Many “methadone clinics” put their patients on high doses of MTD whether they need it or not to control their addiction and/or pain.

• The best way to convert a patient from MTD to BUP is to start when the patient is down to 30 mg MTD/day.
  1. The patient may need to be slowly titrated down to this level, which may takes weeks.
  2. MTD has a prolonged and variable half-life of 8-60 hours
     1. It’s metabolized in the liver by the CytochromeP-450 CYP-3A4
     2. BUP is metabolized by the same liver enzymes.
  3. Converting patients from daily MTD doses >30 mg is possible but the patient will be uncomfortable—this is unavoidable.

1. Due to the long half-life of MTD in the body, it must be stopped for 2 days before BUP can be initiated, even then, there will probably be opiate withdrawal symptoms.
   1. Medications are prescribed to ease the withdrawal symptoms.
2. BUP treatment should be started when the patient is in early/mild opiate withdrawal.
   1. Starting this medication while the patient has high levels of other opiates (“pain pills”, heroin, MTD) can trigger opiate withdrawal/“cold turkey” symptoms.
3. BUP is not absorbed in the gut, it works well transmucosally (across moist surfaces such as the inside of the mouth).
   1. Dissolve it in the mouth
   2. Saliva, once swallowed will waste the drug

• Repeatedly spread the saliva with the drug around the inside of the mouth—it’s absorbed on the inside surfaces of the mouth; cheeks, tongue, under the tongue, gums, etc.

1. Try to keep the drug containing saliva in the mouth for 15 minutes
2. Do not smoke cigarettes or anything else before taking the medication and for as long as possible after the medication
3. Avoid brushing teeth before medicating and for as long as possible after medicating—some toothpastes contain astringents which can lessen absorption of the drug

1. Forms;

1. Naloxone is a rapid-acting opiate antagonist (blocker) that reverses/stops the effect of all opiates.
   1. Naloxone blocks ALL opiate activity
   2. This is especially useful in overdose when breathing stops
      1. It can restore breathing, blood pressure, etc.
      2. Evzio Autoinjector; (~$3,742.90 per dose)
      3. Narcan; (~$65.70 per dose)

1. Tolerance, as defined by either of the following:
   1. A need for markedly increased amounts of the substance to achieve intoxication or the desired effect or
   2. Markedly diminished effect with continued use of the same amount of the substance
2. Withdrawal, as manifested by either of the following:
   1. The characteristic withdrawal syndrome for the substance or
   2. The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
3. The substance is often taken in larger amounts or over a longer period than intended (largely due to tolerance (a.).
4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
5. A great deal of time is spent in activities necessary to obtain the substance (such as visiting multiple doctors or driving long distances), use the substance (for example, chain-smoking), or recover from its effects.
6. Important social, occupational, or recreational activities are given up or reduced because of substance use.
7. The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (for example, current cocaine use despite recognition of cocaine-induced depression or continued abuse despite recognition that an ulcer was made worse by illicit consumption).
8. Legal problems related to abuse.
9. Medical problems related to abuse.

1. 41% Incidence of any use over the lifetime of any illicit drug.
   1. Admittedly 41% can include one-time use of a substance which is hardly addiction
2. 5% incidence of any use of illicit drug in the past month.
   1. Monthly use is much more regular use than use in the past year or lifetime.
   2. This information is obtained from surveys.
      1. Survey data often underestimates actual use
      2. Minimizing use is common among addicts.
      3. Minimizing is a form of denial.

• Considering the above, it’s quite possible that up to 10% of the population may have a problem with substance abuse (excluding tobacco)!

1. Incidence of use/abuse of drug within the US (total population age>12 years):

1. When one considers the scale of the use of psychoactive substances currently in the US and considers that addiction is often characterized by the abuse of multiple substances, there is a clear cause for concern.
2. Abuse of illicit substances costs the US $193,000,000,000 annually

Total substance abuse costs including alcohol and tobacco are >$700 billion/year.

1. Not only when high/stoned/abusing the drug, but even before the drug has EVER been tried.
2. Addicts/alcoholics “see things differently” and react differently.
3. The first use of the substance seems to “let the evil genie out of the bottle” accelerating the course of the disease of addiction.
4. Addicts use these distorted perceptions to make decisions.
   1. Their choices often lead to less than desirable results.
   2. Emotional growth is thought to stop at the age of first use of addicting agents.

• This is even more pronounced with drugs such as THC that affect the pre-fontal cortex where judgement and impulsivity control reside.

1. In short, addicts end up with changes in the brain that are best described as a form of brain damage.

1. “Two heads are better than one”; “collective brain power” can be a good defense, but where do you get the heads that can understand and reason with the addicted/afflicted?
   1. The “12-Step Meetings”
   2. Look for the group members with long-term sobriety!

• Get there well before the meeting starts for the informal “meeting before the meeting”

1. Stay afterwards for the “meeting after the meeting”
2. The folks who are going to meetings now are the same folks who used to be the “life of the party”
   1. They INSIST on having a good time
   2. They love to laugh and kid around
   3. They cannot keep their own gift of recovery without giving it away to newcomers whenever the opportunity arises
      1. Newcomers are helping them by showing up at meetings!
      2. They will insist that the above is true—they really mean it!
      3. Even if you’re not welcome anywhere else, they will welcome you warmly.

1. It’s important to understand the difference between Psychiatry and Psychology:
   1. Psychiatrists are physicians (MD or DO), they prescribe medications to correct abnormal brain chemistry as reviewed above, they tend to place emphasis on neurochemical modifications of one’s emotional and mental problems and state.
   2. Psychologists generally have a doctorate in what can be considered “talk therapy” which involves discussion with the patient, diagnosis forming and a variety of different types of talk therapy to help the patient come to an understanding of differing perspectives, ideas, beliefs & ultimately feelings and behaviors.
2. Psychological theories on why addiction happens;
   1. Addicts may engage in harmful behaviors because of concurrent mental illness.
   2. They may learn unhealthy behavior in response to their environment.

• Thoughts and believes create feelings….
  1. Which in turn determine behavior.
  2. If thoughts, beliefs & feelings are unrealistic/dysfunctional, behavior may be affected.

1. Psychologists assume these theories apply in some way to addiction.
2. People with these disorders might include cognitive difficulties, mood disturbances and other mental illnesses.
3. Addiction & other mental health disorders commonly occur together (co-morbidity).

• Half of the people seeking addiction treatment will have another significant mental health disorder (Miller, Forchimes & Sweben, 2011).
• Many who suffer from addiction have attempted to “self-treat” their mental illnesses with available psychoactive substances (drugs) to ease their suffering.

1. Examples of emotional/mental disorders commonly comorbid with addiction include;
   1. ADD/ADHD
   2. Anxiety
   3. Bipolar disorder
   4. Depression
   5. PTSD
   6. Trauma
2. Addictive personality;
   1. A set of personality traits that predispose an individual to developing addictions.
      1. This hypothesis states that there are common elements among people with varying addictions that relate to personality traits.
   2. There are several distinct personality disorders listed in the Diagnosis and Statistical Manual Edition 5 (DSM-5, the basic handbook of psychiatry and psychology that codifies all emotional/mental health disorders).
   3. Review of the Personality Disorders in the DSM-5R reveals the absence of an “addictive personality disorder”.
   4. There are basic/informal/not coded personality traits associated with addiction;
      1. Denial of obvious problems
      2. Problems with emotional regulation.
      3. Problems with impulse regulation.
   5. Psychotherapy attempts to identify and resolve underlying psychological disorders.
      1. Self-realizations and help from a qualified therapist can help uncover some of these issues.
      2. The “therapeutic relationship” of the patient with the therapist is critical to ensure enough trust is present that difficult issues can be explored.

• Absolute honesty and diligence is required for success in any such form of therapy.

1. Locus of control;
   1. Recognition and acceptance of personal responsibility for problems and their solutions bring to the surface deeper underlying issues.
      1. Do we see ourselves as internally directed, responsible for our own actions or…
      2. Externally directed; “things just happen because they happen”, we don’ have much responsibility for the major events of our lives “Fate or “Karma”-driven.
      3. A brief online test can help determine which locus of control you believe in.
      4. Nobody is entirely internally or externally directed, generally though, we all have a predominant belief in one vs. the other.
   2. Theories regarding responsibility for addiction;
      1. The “Medical Model”: People are not responsible for creating or solving their own problems.
      2. The “Compensatory Model”: People are not responsible for creating, but are responsible for solving their own problems.
      3. The “Moral Model”: People are responsible for creating and solving their own problems.
      4. The “Enlightenment Model”: People are responsible for creating, but not solving their own problems.

• What’s the best way to make sense of all of this?
  1. Since we’ve established the genetic/biologic/medical basis of addiction and the fact that none of us can choose our parents, it seems that the compensatory model fits…
  2. People are responsible for solving, but not creating, their own problems, thus the compensatory model…
  3. Yet, who among us hasn’t behaved in a manner that worsened our addiction, made poor choices, leaving us to consider other options. We’ve established the biological nature of the illness which makes the moral model less likely…
  4. Wouldn’t it be great if we were not solely responsible for fixing the mess that we’ve made of our lives?

1. This line of thought leads us to an answer…

1. Addiction has genetic underpinnings.
   1. If one parent is susceptible to addiction (whether they choose to “use” or not), there is a 50% chance that offspring will have the gene.
   2. If both parents carry the gene the chance of passing it on are closer to 100%

• The genetics of addiction probably involve numerous genes, are thus complex and not yet fully understood.

1. A review of family history will often reveal members of the family tree who were alcoholic, addicted, suffered from emotional/mental disorders or died early.
   1. Suicide is often associated with addiction.
   2. Recall that mental health is a very new field of study, even a generation ago somebody may have been considered “not right in the head” or avoided if not outright shunned and not talked about in family discussions.
2. Obviously, the addict’s behavior has wide-ranging effects on not only the immediate nuclear, but often on more extended family members as well.
3. Many families with a presence of addiction attribute addictive behavior to “normal”
   1. “It’s the only behavior we’ve ever known”.
4. Families and people are thought of to be “only as sick as their secrets”
   1. We learn at a tender young age that “there are certain things we just don’t talk about outside of our family”.
   2. This simply perpetuates the problem.
5. Codependence can be considered as another aspect of addiction.
   1. It can also be considered as an addiction all to itself
      1. One is addicted to the addict that they are enmeshed with in their codependence.
   2. Family members enable the addict(s) to continue their behavior in many ways

• “Calling in sick” for them when they’re unable to attend to their responsibilities due to effects of the substance/behavior or its withdrawal.

1. Tolerating and hiding unacceptable behavior
   1. “Accepting unacceptable behavior makes it acceptable”.
2. Divorce & failed relationships are often due directly or indirectly to addictive behaviors
   1. This may be frustration in dealing with the “ism” of alcoholism or “drugism”
   2. “…ism”= “I”, “Self” & “Me”
   3. “I’m not much but I’m all I think about”.
      1. Such behavior has its limits and is rarely tolerated forever.

1. Addiction encompasses alcohol and other drugs that are abused.
2. When attending an AA Meeting, it’s best to introduce yourself as an alcoholic
3. At an NA meeting the term “addict” is generally preferable.
4. A middle-of-the-road term; “I’m an alcoholic and drugs were part of my problem”.
5. Crossing the wrong term for the meeting attended may result in grumbled comments from a member of the group
6. We’re not in these meetings because we’re so healthy, we’re there because “we aren’t all ‘there’”!
7. There are a variety of other 12-step meetings as well;
   1. Sex & Love Addicts Anonymous; https://slaafws.org.
   2. Sex addicts anonymous; https://saa-recovery.org/.

• Overeaters anonymous; https://oa.org/.

1. Gamblers anonymous; http://www.gamblersanonymous.org/.

1. Additionally, there are meetings for the loved ones of those addicted.
   1. These meetings usually end with “anon”
      1. Al Anon, Al A teen; http://www.al-anon.alateen.org/.
      2. Narc Anon; http://www.nar-anon.org.
      3. Adult Children of Alcoholics; http://www.adultchildren.org.
      4. Co Dependents Anonymous; http://coda.org/
   2. Co-dependence is the term used for those who have enabling behavior
      1. This is a form of behavior meant to be helpful, but in the long run is harmful for the addict.
      2. This can be thought of as another expression of addiction—that other person is hooked on the emotional state of the addict.
      3. An easy example would be a spouse calling in sick for the hung-over alcoholic so that he/she doesn’t get in trouble at work.
      4. The line between helpful and enabling is very thin and “moves” over time—it’s VERY helpful to have another person, ideally a sponsor in that program who is not emotionally invested in the addict help to navigate & determine the best course of action in various aspects of the disease of addiction and interactions with the beloved.

• These meetings for loved ones also have their own 12 steps, sponsors, etc. for the family to work with.

1. When attending a 12-step meeting, there will be a “meeting before the meeting” and a “meeting after the meeting” where folks hang out and chat before and after the meeting.
   1. This is the IDEAL time to share what’s going on in the newcomer’s life!
   2. It’s great to discuss problems, concerns and plans to resolve the issues.

• Typically, the longer a person has been sober, the better their overall mental health is.
  1. It’s a good idea to attend meetings with as much “long-term sobriety” as possible.
  2. Some meetings can have hundreds of years of sobriety collectively in each meeting.
     1. 20 attendees with 5 years of sobriety each = 100 sober years.
     2. 5 attendees with 20 years of sobriety each = 100 sober years.
     3. Ideally the most long-term sobriety (i.e. “b”) is preferred.
  3. Often, there is more long-term sobriety in AA than in NA meetings.
     1. But at the same time, triggers to relapse will be different between the two programs.
     2. There will be differences between addictions to various substances/activities.

• It’s best to include the meeting best suited to any given person’s predominant addiction.
  1. Many folks will have multiple addictions.
  2. Cross-addiction refers to stopping use of one addiction only to pick up another.

1. When an addict stops using a certain drug that does not mean that it’s OK to use other emotion/mind altering substances or behaviors.
   1. Cross-addicting to another substance or behavior is a very real danger.
   2. Even the opiate addict who hates alcohol can very easily become an alcoholic if they dabble in using alcohol occasionally

• Those addiction circuits in your brain are still there, dopamine, the “feel good” neurotransmitter is still the final common outcome neurotransmitter for all addictive substances and behaviors!

1. As important as meetings and sponsorship are, there wouldn’t be much hope without the 12 Steps of the Recovery Program.

1. Recovery is not about “not using”; it’s about having such a GREAT LIFE that you don’t WANT to use!
2. Imagine being able to attain the peace of mind and relaxation that in the past required using/abusing substances/behaviors, but being able to do so without abusing and to live peacefully in that state!
3. 12 Promises;
   1. We are going to know a new freedom & a new happiness
   2. We will not regret the past nor wish to shut the door on it.

• We will comprehend the word serenity.

1. We will know peace.
2. No matter how far down the scale we have done, we will see how our experience can benefit others.
3. The feelings of uselessness and self-pity will disappear.

• We will lose interest in selfish things and gain interest in our fellows.
• Self-seeking will slip away.

1. Our whole attitude and outlook on life will change.
2. Fear of people and of economic insecurity will leave us.
3. We will intuitively know how to handle situations which used to baffle us.

• We will suddenly realize that God is doing for us what we could not do for ourselves!

1. 12 Rewards of Recovery;
   1. Hope instead of desperation.
   2. Faith instead of despair.

• Courage instead of fear.

1. Peace of mind instead of confusion.
2. Self-respect instead of self-contempt.
3. Self-confidence instead of helplessness.

• The respect of others instead of their pity and contempt.
• A clean conscience instead of a sense of guilt.

1. Real friendships instead of loneliness.
2. A clean pattern of life instead of a purposeless existence
3. The love and understanding of our families instead of their doubts and fears.
4. The freedom of a happy life instead of the bondage of addictive obsession.

1. Step 1; Weadmitted we were powerless over drugs/alcohol—that our lives had become unmanageable.
   1. We this is a “we” program, nobody can get straight alone, we’re in this together!
   2. Admitted became aware, realized, recognized & let it be known to others.

• Powerless lack of control or ability to influence.

1. Drugs/Alcohol this is the only mention of substances/behaviors in any of the 12 steps
   1. The abuse is merely a symptom of our disease.
2. Unmanageable we are unable to cope, uncontrolled.

1. Step 2; Came to believe that a power greater than ourselves could restore us to sanity.
   1. Came
   2. Came to

• Came to believe

1. A power; something supernatural—back to the spiritual—but let’s not call it “God”.
   1. That term drives people who need help away, let’s use another term.
   2. “Higher Power” admits to the possibility of something transcendent, even if it’s only a “group of drunks”.
2. Restore to replace what was lost.
3. Sanity the ability to think and behave in a normal and rational manner, sound mental health.
   1. A trained behavioral scientist in 12-Step meetings can make diagnosis of virtually every mental illness imaginable.
   2. These diseases are all treated differently with medication and type of therapy.
   3. Yet they ALL improve by working the 12-Step program.
   4. By the same measure, it’s impossible to diagnose with certainty any mental illness in the disease of addiction until at least a year of recovery has happened.
      1. Another miracle of the program
   5. Addiction can manifest as every known form of mental illness.
      1. Addiction amplifies and exaggerates these diseases as well.
   6. This is yet another example of the distortion caused by addiction.
4. Step 3; Made a decision to turn our will and our lives over to the case of God as we understood Him.
   1. This is another key concept for recovery!
   2. Decision a choice that we freely make without coercion.

• Turn our will and our lives…
  1. This is HUGE; we’ve surrendered completely and given up trying to control our lives for ourselves.
  2. THIS is the ACCEPTANCE of God’s will in our life.

1. The care of God/Higher Power understanding that we are under His/It’s care and that He/It has care and concern for us, wishes us well and that no matter how bad things seem to get, it will ultimately be in our best interest.
   1. In the 12-Step programs, we share our experience, strength and hope.
      1. We don’t give advice or direction
   2. My personal experience has been that my Higher Power (whom I choose to address as “God”) allows me to go through difficulties in life.
      1. Growth often involves pain!
      2. I come out of these difficulties as a much stronger and better person than before the situation.
      3. Faith is stronger after such a test.
   3. We can choose to violate the decision and try to run away from the lesson—but it will find us and probably be repeated a few more times in our lives to ensure that we truly learned that lesson.
2. Since we’ve learned that addiction can mimic all known emotional & mental illness’, it can be useful to think of this as one of the many miracles provided by the Higher Power (whatever you conceive that to be, the one you agreed to the existence of in Step 2 above).
3. Once we truly decide to turn ourselves over, the miracles of the promises begin.

• The miracles will continue so long as the program is practiced and shared with others!

1. Step 4; Made a searching and fearless moral inventory of ourselves.
   1. This is the first “action step”, it involves pen & paper.
      1. It will take a lot of time, work, reflection and help from a good sponsor.
      2. Sometimes a good therapist may be helpful or required.
   2. This involves a thorough and complete moral inventory—the good and the bad.
      1. Not just what you did right or wrong, but why you did so.
         1. A good sponsor is essential for this step.
         2. This is about more than wrongdoing, it’s about the underlying reason for the wrongdoing.
         3. Without being completely thorough and honest, future relapse is likely.
         4. This will also form the basis for the 8^th and 9^th
      2. Step 5; Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
         1. God; it’s OK to use “Higher Power” if preferred.
         2. Another human being it’s essential to communicate this information, derived from Step 4 to another person.
            1. Often, but not necessarily your sponsor.
            2. Ideally/often, the other person (sponsor?) will share similar issues/experiences with the person doing the step (sponsee?).

• Exact nature involves not only the wrongdoing, but the underlying reason/motive behind it.

1. Step 6; Were entirely ready to have God remove all these defects of character.
   1. The Higher Power from Steps #2 & #3 is the source of this healing, restoration to sanity and revocation of mental illness.
   2. The compulsion to drink may be lifted with Step #3, sometimes persisting longer, if so it may resolve after Step #6.

• Entirely ready means without reservations, no matter what may come.

1. God (Higher Power) removes these defects, but only with our unreserved consent and cooperation.
2. Defects/faults/failures
3. Character our most basic moral character.

1. Step 7; Humbly asked him to remove our shortcomings.
   1. “When you have nowhere else to turn, and are on your knees, turning to your Higher Power, you are at your strongest!”
   2. This is done with the humble realization that we have not been able to heal ourselves.

• Admitted that our issues have been shortcomings.

1. Step 8; Made a list of all persons we had harmed and became willing to make amends to them all.
   1. After having done Step #4, with the realization of the harms done by our moral failings and faults, it’s now time to start contemplating being able to make appropriate amends and to whom.
   2. This also requires review with a good sponsor.
      1. It’s not about making amends, it’s about becoming ready and willing to do so.

• Made this is another action step.

1. A list of all persons everybody and the list will include 2^nd generation harms, we may have caused somebody to harm another due to the harm that we di to them.
2. Become willing in part because of having done the 5^th Step, willing to make amends to them all.

1. Step 9; Made direct amends to such people wherever possible, except when to do so would injure them or others.
   1. Amend; make better, improve.
      1. The US Constitution has 27 amendments.
         1. None start with an apology!
      2. Imagine driving a huge railroad spike into the middle of an expensive polished mahogany conference table.
         1. An apology would entail removing the spike, leaving a large hole
         2. An amend is to fix the table in a matter satisfactory to the owner of the table.
      3. Except when to do so would involve injury to them or (especially) others.
         1. An example would be undiscovered infidelity.
            1. If the victimized spouse was ignorant of the wrongdoing, to expose it would cause that spouse pain.
            2. If there has truly been a change and future transgressions are quite unlikely, then there would be nothing positive to gain by exposing the prior error.
         2. The amends process is to heal you, not the other person.
            1. It releases you from a spiritual bondage/guilt toward that other person.
         3. Step 10; Continued to take personal inventory, and when we were wrong, promptly admitted it.
            1. Continued means that this is an ongoing process, often done at the end of each day, with a daily review/reflection, especially regarding any problems that may have occurred and how I responded.
            2. When we were wrong recognized when we had committed a transgression

• Promptly admitted it without delay and made amends as soon as possible.

1. Step 11; Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
   1. Sought we continue daily to pursue our Higher Power in Whom we’ve entrusted ourselves without reserve.
   2. Prayer & meditation
      1. Prayer can be thought of as our transmission upward, an upload of sorts, to our Higher Power.
      2. Meditation is our reception, or download from our Higher Power

• Improve our conscious contact acknowledges that we do have a conscious contact with our Higher Power; this is the essence of spirituality.

1. As we understood Him remember, this is our own personal Higher Power.
   1. The same One we chose & defined for our self in our 2^nd
   2. The same One we turned our lives over to.
   3. The same One we chose to heal us.
   4. The same One who removed our shortcomings, including our compulsion to use and Who gave us the gift of recovery!
2. Knowledge of His will for us we are to pray only for that which He wants for us.
   1. We turned ourselves over to Him in Step #3. This reinforces that decision!
   2. We acknowledged that He alone knows what is best for us.
3. And the power to carry that out.
   1. He alone gives us the power to do His will.
   2. He will provide us with the power to do His will.
   3. He is the “Miracle Department”.
   4. He has better plans for our life than we have for our life!
4. Step 12; Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affirs.
   1. Had
      1. We have already
      2. It’s a done deal!
      3. There is no more doubt about it being possible, it’s an established fact by now!
   2. Spiritual awakening
      1. Established and continued to enhance and maintain our relationship with
         1. The Transcendent
         2. My Higher Power (God?)
            1. While many agnostics enter the 12-Step programs, within 5 years, few of these folks continue to describe themselves as agnostic.
            2. Faith grows!

• Result of these steps
  1. Clearly, this is the outcome.
  2. Of all the work that we’ve done to date and…
  3. Our sacrifice of “self” to our Higher Power’s will

1. Carry this message
   1. Carry;
      1. To maintain with me, myself and
      2. To convey to others.
   2. This message;
      1. The gift of recovery.
         1. Steps
         2. Meetings

• Sponsorship

1. Service work
2. Fellowship

1. To anybody & everybody who wants it.
   1. This program is for those who want it, not those who need it!
   2. We ourselves are living proof of this.
2. Therefore, the newcomer is the most important person in any meeting and in the program in general.
3. Therefore, you must continue this hospitality!

1. Practice these principles in all our affairs.
   1. We practice these daily, this is what we do.
   2. These principles are the 12-Step Program.
   3. In all our affairs.
      1. We don’t pick and choose.
      2. This is our new way of life.
      3. Likely much different from our former way of life!

1. If we are casual with this phase of our development, we will be using before we are half-way through.
2. We are going to know a new imprisonment and a new misery.
3. We will relive the past and won’t be able to shut the door on it.
4. We will comprehend the word CONFLICT and we will know PAIN.
5. No matter how far down the scale we have gone, we’ll sink even lower.
6. That feeling of uselessness and self-pity will deepen. 
7. We will gain interest in selfish things and lose interest in our fellows. 
8. Self-esteem will slip away.
9. Our whole attitude and outlook upon life will SUCK.
10. Fear of people, and of economic insecurity will multiply.
11. We will intuitively know how to run from situations which never used to bother us.
12. We will suddenly realize that God would never have done to us what we are doing to ourselves.
    1. Are these extravagant promises?
       1. We think not!
       2. They are being fulfilled among those of us who are still drinking; sometimes quickly, sometimes slowly…..
       3. IF WE USE FOR THEM! 

(Orientation: This is the brain, sliced in half, from top to bottom dividing right & left sides, this is the view of the “inside” of the right half of the brain.)

(Orientation: This is the brain, sliced in half, from top to bottom dividing right & left sides, this is the view of the “inside” of the right half of the brain.)

1. New neural pathways form as addiction progresses
   1. They also form in withdrawal
   2. But those prior pathways are “circuits ready to be re-energized at a moment’s notice”
      1. Therefore, when folks relapse, they don’t start out their addictive disease at the level of when they first became addicted…
      2. They typically relapse to a degree of use that was greater than what they were using when they had most recently stopped using
         1. Even if it was decades ago!
         2. Those pesky neural circuits still exist
            1. Think of a superhighway that was built, used for awhile then for whatever reason falls into disuse—very little traffic but many available lanes available and able to carry a lot of traffic.
         3. Addiction changes brain structure and function
            1. Impaired decision making
            2. Impulsivity is controlled by the pre-frontal cortex, which changes in addiction.

• Compulsivity in the pre-frontal cortex changes in addiction leading to…
  1. Drug-seeking behaviors
  2. Cravings
  3. Habit formation
  4. Relapse triggers
  5. Stress dysregulation
  6. Withdrawal (with other more primitive brain areas)

1. The pre-frontal cortex can be thought of as a “braking system” for impulsivity & compulsivity
2. Addiction involves numerous structural changes in the brain such as the dopamine-2 allele in the locus ceruleus and other areas in those with addictive diseases.
3. Mesolimbic system pathways are critical in the neurobiology ofaddiction:
   1. Located in the brainstem, the area essential for our basic survival.
   2. The Ventral Tegmental Area (VTA) is located at the front of the mesolimbic center.

• The VTA projects to the nucleus accumbens, the “reward center” of the brain.

1. The main mesolimbic neurotransmitter is dopamine, the “feel good” neurotransmitter.
   1. Dopamine is released when we engage in activities that help further our survival and the survival of the human species (which involves sex!).
      1. This helps ensure our survival as a species; it makes us feel that good!
      2. ALL addictive drugs and activities release dopamine into the nucleus accumbens.
         1. Stimulant-type drugs release more than the other classes.
         2. Dopamine is associated with pleasure seeking and drug seeking/craving.
            1. GABA & Glutamate are also involved in pleasure-seeking.
            2. Dopamine is also involved in drug craving.
         3. Habituation; natural cravings (food, water, sex) lessen over time and with satiation.
            1. Dopamine activity decreases with habituation; once satisfied, enough is enough with “natural cravings”.
            2. Addiction is another matter; this is an unnatural desire.
            3. Tolerance happens as people need to increase the dose and frequency of their drug of choice to maintain the pleasurable effect/amount of dopamine which wears off after time and continued exposure to drugs.
               1. Tolerance leads to increased drug craving/compulsion to use
               2. This drives the addictive process forward
               3. As addiction progresses, cravings (compulsion) gradually replace pleasure seeking (impulsive), this is worsened with drugs such as opiates that have severe withdrawal symptoms in addition to craving.
               4. Craving is an attempt to avoid or relieve unpleasant symptoms.
               5. So, addiction starts with pleasure-seeking and ends up in the trap of using to relieve craving.
               6. Eventually the relief of craving becomes its own form of pleasure.
            4. As drug use or addictive activity escalates, the involvement of various brain regions associated with our emotional state also increases.
               1. The brain region most often associated with our emotional state is the extended amygdala, part of the limbic system (where our emotions “live”).
                  1. Interestingly, the olfactory bulb is located right next to the amygdala.
                  2. Scents/smells often have a strong impact on our emotional state for this reason.
               2. Scientists think this brain region plays an important role in addiction because of its association with emotions and stress.

• The amygdala processes emotions and memory.
  1. When the brain forms these memories, it stores the memory of the event along with the emotions that accompanied the memory.
  2. The memory of engaging in the addiction is stored with a pleasant emotional state (positive memory).
  3. Thus, the pleasing memories of engaging with an addiction can lead to repeating those behaviors and a habit forms.

1. Emotional memory has another role in the development of addiction called due anticipation.
   1. Cue anticipation refers to environmental cues that can initiate or elevate cravings. Cravings often lead to relapse.
2. For this reason, these cues are often called relapse triggers.
   1. These environmental cues (relapse triggers) can be anything that is associated with the addiction.
3. The brain may also form an association between unpleasant emotions and a memory (forming a “bad” memory).
   1. The negative emotional memory of anxiety becomes associated with the physical signs of withdrawal.
   2. As withdrawal begins, the symptoms trigger an unpleasant emotional memory.
   3. This increases the negative experience of withdrawal.
   4. This acts as a “feed-forward) or amplification loop within the neural circuitry.

• Withdrawal avoidance (via returning to the addiction) often becomes the cornerstone of addiction in the later stages.
• Thus, in the earlier stages of addiction, the pleasurable experience of the drug motivates a repetition of that behavior (impulsive).
  1. In the later stages, (compulsive) relief of withdrawal symptoms (physical and/or emotional discomfort) achieves pleasure.
  2. The pleasurable relief from withdrawal symptoms continues to motivate the repetition of that behavior.
     1. Addiction is like dancing with an 800-pound gorilla.
        1. Exciting at first (impulsive).
        2. Then a habit that you do (compulsive).

• Finally, you’re exhausted, but you’re not done dancing until the gorilla is done dancing!

1. Stress and the role of the hypothalamus;
   1. The hypothalamus regulates body temperature, hunger, thirst, sleep and our response to stress.
      1. The hypothalamus signals the pituitary gland to release hormones (endocrine system) which affect distant parts of the body, not just within the brain as neurotransmitters do.
         1. Think of the “fight or flight” of the autonomic/sympathetic nervous system.
      2. These hormones can also act as neuromodulators within the brain, like a neurotransmitter acts.
      3. A medical intuitive, gifted with a sixth-sense regarding disease and healing refers to the hypothalamus as the “location of our soul”.
   2. Stress is a major trigger for relapse
      1. Relapse is a bigger problem than withdrawal for addiction patients
      2. Stress and psychostimulants cross-react with each other, promoting relapse
         1. Psychostimulants (amphetamines, cocaine, methamphetamine) are more difficult to get off of than other addictive drugs due to this cross-reactivity at the neurotransmitter level.
      3. Withdrawal also causes stress.
         1. This creates an unfortunate cycle.
         2. Efforts to stop using create stress.
         3. Stress triggers release of stress hormones from the hypothalamus.
         4. Dopamine and serotonin activity in the nucleus accumbens actually decrease with stress early in recovery.
            1. These calming neurotransmitters normally help reduce stress.
            2. This is a disruption of the normal stress response that occurs with addiction & withdrawal.

• The dopamine and serotonin neurotransmitters should increase to help cope with the stress.

1. Stress triggers addictive behavior (use).
2. Thus, withdrawal causes stress, which can trigger more addictive use, which causes stress to the addict who is unable to stop using the drugs in a vicious cycle in which the normal calming/“braking” serotonin/dopamine activity from the nucleus accumbens is lost!

4. Recovery is the process of breaking this cycle.
   1. It takes a lot of motivation!
   2. Medication help, but recovery still requires effort!
   3. The brain is very adaptable; it learns!
      1. This is what the brain was designed to do—learn!
      2. Recovery is a process of learning!

• Learning involves forming new circuits/pathways in the brain.

1. Many recovering addicts will testify that the first effort at recovery is much easier than recovery after numerous slips or relapses.
   1. The first is a gift.
   2. It’s progressively harder to recover after the first attempt.

• This is one of the spiritual axioms of recovery.

1. Addiction related brain areas neurotransmitters and their functions;
   1. The negative emotional memory in the amygdala is associated with drug withdrawal.
   2. The positive emotional memory in the amygdala is associated with drug cues.

• Hypothalamic and nucleus accumbens serotonin (calming) & dopamine (feel good) disruption occurs due to stress de-regulation.

1. The pleasurable relief from withdrawal symptoms that occurs by resuming drug use or addictive activities reduce stress/sooth the hypothalamus.

1. Opioidsinhibit the firing of neurons in the locus ceruleus.
   1. When opioid consumption is stopped, the increased activity of the locus ceruleus contributes to the symptoms of opiate withdrawal.
   2. The alpha2 adrenoceptor agonist clonidineis used to counteract this withdrawal effect by decreasing adrenergic neurotransmission from the locus ceruleus.^[14]
2. Alcoholics & addicts have altered Dopamine-2 Alleles in the Locus ceruleus.

Comprehensive Overview of Addiction and the Process of Recovery