Heavy alcohol users Vs. Addicts – Stress response

I can’t even count how many times I’ve talked about the difference between alcohol or drug users and alcoholics or addicts (see here, here, and here for some examples and keep reading). The quick summary: Many people use drugs and many abuse them at times, a small percentage meet criteria for addiction at some point in their life and an even smaller percentage is the type of addict we’ve been taught to think of – chronically relapsing and seemingly incapable of quitting no matter how crappy their life gets.

One of the main reasons we study drug and alcohol abuse is because of the huge health impact of this stuff – we spend billions and billions of dollars every year on health-care that is directly or indirectly related to the abuse of nicotine, alcohol, and pretty much every other drug on earth (marijuana can certainly help some conditions but heavy use of marijuana can bring its own consequences). One of the major players in these health problems is the effect of alcohol and drug use on stress in the body. Stress increases death rates in several ways including: Heart attacks, strokes, cancer, and more.

Well, a recent study in Amsterdam looked at alcohol (yes, you read that right, the Dutch care about more than weed) consumption, alcohol addiction (alcoholism) diagnosis, and effects on the body’s stress system, also known as the HPA (Hypothalamic-Pituitary-Adrenal) Axis. If nothing else, the study helped confirm that an alcoholism diagnosis is not necessarily the same as an indication of heavy drinking and that excessive drinking is no bueno, regardless of whether it meets addiction criteria or not.

Alcohol drinking, alcoholism, and stress regulation

A very simple cortisol graph showing reduced levels during sleep with peaks upon wakingI’m not going to go into this in detail (look here and here for more) but just as our brains and bodies have systems for decision making, they also have complex stress management systems. The latter rely heavily on hormones, including Cortisol, to keep our bodies in the right states whether those be fight, flight, or reading a book before sleep (see figure on left for over-simplified cortisol levels throughout the day in a normal person). We’re supposed to have the most cortisol right upon waking with constant reductions throughout the day until we fall asleep, and back again. Individuals with mental health disorders like anxiety and depression have substantially different cortisol level patterns throughout the day and are less effective at regulating cortisol (in case you needed another reason why our biology affects our states of being and behavior).

The dutch study tested cortisol levels at 7 different times throughout the day after giving their subjects a 4 hour battery of tests. They also assessed their cardiac functioning by assessing different measures related to heart beat regulation that allows for adapting across challenging situations by affecting the sympathetic nervous system (excitatory processes) and parasympathetic nervous system (inhibitory processes).

They looked at these measures as a way of assessing the relative functioning of the HPA Axes’ of different groups. Specifically, they looked at:

  1. Non-drinkers
  2. Moderate drinkers (less than 3 drinks per day)
  3. Heavy drinkers (more than 3 drinks per day)
  4. Non alcoholics
  5. Remitted alcoholics (met criteria for alcoholism previously but not in past 12 months)
  6. Current alcoholics.

One of the most interesting findings, as far as I’m concerned, was that among remitted alcoholics the average amount of drinking was around 1.3 drinks per day with a lot of variability, a little higher than that of moderate drinkers (0.8 drinks per day) but lower than that of heavy drinkers (4.0 drinks per day). I see this as a little more proof that people who met criteria for alcoholism at one point don’t necessarily abstain forever and don’t necessarily continue to have drinking problems (per Moderation Management, spontaneous remission, or some other means of stopping their alcoholic drinking).*

You can blame improper diagnostic criteria, a continuum of addiction severity, or anything else as far as I’m concerned but as I pointed out in my first paragraph, we’ve talked about this topic repeatedly and I see no end coming soon. The bottom line is that meeting criteria for alcoholism at one point in life tells me something, but far from everything, about a person’s drinking habits or drinking problems later in life.

But back to stress. As you might have already guessed, since it is heavy drinking that causes serious dysregulation of the body’s stress response, what the researchers found was that meeting criteria for alcoholism now, or in the past, didn’t have any major effect over their participants’ HPA functioning. Instead, all that mattered was how heavy their drinking was now. Heavy drinkers had higher waking cortisol levels, higher night-time cortisol, and increased sympathetic (excitatory) control. In short – heavy drinkers were less able to regulate their stress and excitation response, likely leading to increased stress on their bodies.

As a side note, this study also found that if anything, moderate drinking conferred health benefits when it came to stress over not-drinking at all – far from the first study to note this but another set of reinforcing evidence that drinking alcohol is not in itself bad for you while over-drinking is.

So – Drinking a lot of alcohol causes disruptions to your body’s stress regulation system that will likely increase the likelihood of heart problems, depression, anxiety, and more. Those disruptions are there whether you meet criteria for alcoholism or not.

Obviously, there are many alcoholics who drink a lot of alcohol, but there are also people who meet (now or in the past) criteria for alcoholism who are binge drinkers and therefore don’t drink daily and have lower “drink numbers.” As we mentioned before, addiction is not about quantity, in fact, the criteria for addiction barely mentions quantity – when it states that addicts consume “more than intended” or that tolerance creates a state where an person needs greater quantity to reach the same effect of the drug. Drinking or using a lot of drugs or alcohol does not an addict make.

*Note: Given the variability in the remitted-alcoholics groups their is little doubt that some of them had stopped drinking while others drank to excess. Additionally, it should be pointed out that alcohol abuse was not assessed in this sample, so it could still be a problem for at least some of those now-drinking past-alcoholics.

Citations:

Lynn Boschloo, Nicole Vogelzangs, Carmilla M.M. Licht, Sophie A. Vreeburg, Johannes H. Smit, Wim van den Brink, Dick J. Veltman, Eco J.C. de Geus, Aartjan T.F. Beekman, Brenda W.J.H. Penninx (2011). Heavy alcohol use, rather than alcohol dependence, is associated with dysregulation of the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. Drug and Alcohol Dependence 116, 170–176.

Heather M. Burke, Mary C. Davis, Christian Otte, David C. Mohr, (2005).  Depression and cortisol responses to psychological stress: A meta-analysis, Psychoneuroendocrinology, Volume 30, Issue 9, Pages 846-856.

Men and women are not the same: Sex differences in addiction research

You may not have realized it, but men and women are different. Really.

When ot comes to drugs, men and women are differentThough the statement may seem like the most unnecessary, obvious, expression since the dawn of time, it’s surprising how rarely the importance of these differences comes up when we talk about addiction. Still, there’s little doubt that if our hormones, brain development, and even our reaction the to exact same stories aren’t the same, the way we react to drugs, or to addiction treatment, are likely gender specific as well. In fact, while men are almost twice as likely to meet criteria for addiction, women seem to move from casual use to addiction more quickly. Let’s explore some addiction research findings that may tell us why.

Social stress, drug use, and addiction

If you’ve gone through high-school, you know that boys and girls have different sort of social interactions. Women develop tightly knit cliques that aim to protect them from being fully ostracized while keeping out those who may cause trouble within the fold.

Indeed, when researchers compared cocaine using men and women, they found much greater neural activation in the drug-seeking brain regions of women during social stress (things like exclusion, being put down, and such) than were found for men or for women who didn’t use drugs. Similar findings have been reported for a neuroprotective hormone called DHEAS, which was found to be lower in women and in cocaine addicts, signaling their increased vulnerability to stress-induced immune problems. It’s hard to tell which came first, but social stress “triggered” these women’s systems a lot more than it did men. And the differences change behaviors too – Research in monkeys found that while male monkeys used more cocaine if they were “losers” (lower on the social ladder), female monkeys who were “leaders” were found to use more cocaine when given a chance.

Obviously, social standing and events mean different things, and bring about different reactions to drugs, for men and women.

Drug use, the brain, and gender

Not only do men and women act differently when it comes to drugs, but differences have been found in the specific brain changes associated with drug exposure between the sexes!

Research in rats has shown that brain changes following prenatal (before birth) exposure to cocaine are different between males and females and that they interact with exposure to social stimulation. In humans, researchers found differences in brain volume, and its association with early trauma, emotional, and physical, neglect between boys and girls at risk for substance abuse problems. Other work found that the prenatal cocaine exposure was more greatly associated with memory problems in women than men.

Sex (gender) and drugs – the takeaway

So, men and women are not the same. Not a big surprise I know, but the specific ways in which the two sexes react to the intake of drugs and the differences in their responses to stress that may motivate them to use at different times can become important factors to consider both in prevention AND in addiction treatment setting. For instance, it seems that we’d want to look at the possibility that drug prevention efforts should look at social-standing among adolescents when determining might need the most attention. Also, if exposure to drugs affects the brain differently in the different sexes because of differences in the concentration of protective hormones, it’s possible that the specific aspects of treatment that require focus might be different too.

Some food for thought…

Will you get addicted? Signs of drug abuse

Everyone wants to know if they can become addictedEveryone wants to know if they, or someone they love will get addicted to alcohol or drugs.

• Parents want to know if their children are likely to become addicts, especially if there is a family history of addiction.

• Teens wonder if trying a drug will lead to a life of crime and shame.

So what are the signs of drug abuse?!

Unfortunately, I have to start with the answer you probably don’t want to hear: no single factor can be said to fully predict substance abuse. Instead, the equation can be thought of as an interplay of risk-factors and protective-factors.

Having family members with alcohol- or drug-abuse problem is an example of a risk-factor. The more risk-factors a person has the more likely it is that person will become addicted. Some risk factors interact to make the likelihood of addiction much greater than either factors alone.

Protective-factors are life events or experiences that reduce or moderate the effect of exposure to risk factors. Some examples of protective factors are: parental-monitoring, self-control, positive relationships, academic competence, anti-drug use policies, and neighborhood attachment.

Risk Factors Vs. Protective factors – An implicit battle

There are five categories of risk and protective factors including individual, school, peer, community and family. Examples of protective factors within the individual category include social skills and responsiveness, emotional stability, positive sense of self, problem solving skills, flexibility, and resilience.

Other aspects of the individual category include the gender and ethnicity of a person. Men are generally more likely to become addicted (likely because they are less prone for internalizing issues like depression). American-Indians are genetically more sensitive to the effects of alcohol, while about 20% of the Jewish population may have genetic variations that protect them against alcoholism. Overall, estimates regarding the genetic influence on addiction risk range from 40% to 80%. Much of that genetic risk lies in changes related to the functioning of neurotransmitters that play a part in the development of addiction such as GABA, serotonin, dopamine, NMDA. Those with mental disorders of all types are at an increased risk for developing an addiction.

Some factors, like stress, can be considered part of multiple categories. Individual variability in stress response (via the HPA Axis) would be part of the individual category, while levels of environmental stress can be part of the other four categories.

questioning-terrierThe home and school life of a child (part of the non-individual categories) can play a large role as either risk-, or protective-factors. If a child sees elders using drugs, they may view drugs as harmless, but children who are well prepared by their parents may better resist peer-pressure to use drugs. As we stated before, the earlier a person begins to use drugs, the more susceptible they are to harmless effects on brain structures and other bodily functions.

Certain methods of using drugs can also be considered risk-factors. Smoking or injecting a drug causes it to be more quickly absorbed into the bloodstream, producing an almost instantaneous high when compared with eating or drinking a drug. However, the quick rush of euphoria may soon dissipate and leave the user feeling the “rebound effect” making them crave the high again. This quick, short lasting, cycle is believed to encourage the user to want to the drug again in hopes of reaching that high.

Overall there is no one thing that can predict or protect against addiction. Instead, a combination of factors are always at play and the more aware a person is of these factors the more able they are to protect themselves.

Co-authored by: Jamie Felzer

Citations:

http://www.psychiatry.ufl.edu/aec/courses/501/risk%20and%20protective%20factors.pdf

http://www.drugabuse.gov/scienceofaddiction/addiction.html

http://www.aadac.com/documents/profile_youth_risk_protective_factors.pdf

 

People, places, and things – How important are drug-related triggers for addiction relapse?

In cognitive behavioral therapy they’re a big part of the “Five W’s” = When, Where, Why, With, and What. In the various 12-step programs they’re simply referred to as “People, places, and things.” But no matter how you refer to them, drug-associated cues, or “triggers” as they are more commonly known, obviously play a big role in reminding addicted individuals about their drug-seeking behavior, and they are often enough to restart old behavior, even among those who have been abstinent for a while and especially when unprepared for their effect.

Different triggers to reactivate old behavior

Research on relapse (what researchers call reinstatement) has long shown that there are a number of things that can return a person, or an animal, to drug seeking after they have been abstinent for a while. Stress, small drug doses, and the presentation of triggers are all very capable of doing this, even after months of abstinence and likely even years. It’s probably not surprising that giving drugs to an abstinent person can make them want the drug again. In fact, I would venture to guess that most readers believe that this is the most powerful way to induce a relapse (assuming the initial exposure was out of a person’s control and doesn’t count).

Well, recent research suggests that in actuality, triggers, or those people, places, and things, might be more powerful or at least longer lasting relapse risks than even taking drugs!

Triggers, not drugs, are shown to be longest lasting relapse risk

Researchers in Japan trained mice to press a lever for meth, getting them to poke their nose into a hole 60 times for a total of 30 meth administration per three hour session. Every time they poked their nose in the right hole they got a shot of meth and a little light above their nose-poke hole went on (this will become the trigger in the end). Once they were doing this reliably the researchers took away the meth and the animals learned, within 10-20 days, that pressing the lever no longer got them a drug and reduced their number of presses to less than 15 presses per session.

After all this the researchers gave the mice an injection of meth 30 minutes before putting them back in the box – leading the mice to start pressing again for the drug even though in the previous session they has pretty much stopped pressing knowing that no drug was coming. Obviously, the drug injection caused the mice to relapse back into their drug seeking. But, as you can see from the figure below (on the left side, the right side shows that the mice didn’t poke their nose into a hole that did nothing as a control), this little trick only worked once, and the next time the mice were given a shot of meth before being put in the box (after once again being taken through extinction training teaching them that pressing the lever did nothing), they didn’t press the lever any more and just around not doing much.

For the following part of the study the researchers once again took the animals through extinction training (and once again the mice stopped pressing the lever for meth) and then in a following session reintroduced the little light that used to go on every time the mice originally got meth. Just like they did with the meth the animals immediately went back to pressing the lever like crazy, hoping that now that the light was back, so was their meth. Just like with the drug relapse experiment above, the researchers repeated this whole process over two months later, only this time, the little light managed to re-trigger the lever pressing again, unlike the one-trick-pony meth. Seeing this, the researchers went for broke and tried another run of this with the same animals, now following up five months after the last time the animals received meth when they pressed the lever. Again the little light got the animals to increase their pressing, only this time it was a little less impressive than the first two tries (but still significantly higher). All in all, the little light managed to restart the lever pressing by the mice three times and a full five month after the meth-relapse experiment had failed!!!

Conclusion, thoughts, and implications about triggers, relapse, and addiction

In a completely different article I’d written that researchers found a number of different patterns of relapse among alcoholics who went to rehab and that in fact, the vast majority of those who did relapse never went back to the kind of heavy drinking that characterized their earlier problem (see here for One is too many, a thousand not enough). While this research touches on a different aspect of relapse, it once again challenges our thinking about the crucial factors in relapse prevention among addicts. Everyone knows that triggers are important, but the fact that they are at least as powerful and apparently longer lasting dangers than even being re-exposed to the addictive drug is a novel one. Still, this isn’t very surprising given the very long-lasting impact of drugs of abuse (especially stimulants like crystal meth) on learning mechanisms. In my opinion, and based on my own experience, those changes are essentially permanent and the only thing that makes an ex-user less likely to run back to pressing that drug lever when being re-triggered 10 years later is the life they’ve built, the experience they have, and the training they’ve undergone in reacting to those triggers. As you can see from the graph above, if a person runs back to the drugs and actually starts using again on that first, second, or third exposure to a trigger they are likely to start the whole cycle again, possibly making it ever more difficult to escape the next time.

Obviously preventing trigger-induced relapse should be a major strategy of addiction treatment and indeed, from CBT relapse prevention strategies to groundbreaking medications that have been shown to be effective for relapse rate reduction (like Vivitrol, Buprenorphine, Bupropion, and more), there is quite a bit of effort going exactly that way.

Citation:

Yijin Yan, Kiyofumi Yamada, Atsumi Nitta  and Toshitaka Nabeshima (2007). Transient drug-primed but persistent cue-induced reinstatement of extinguished methamphetamine-seeking behavior in mice. Behavioral Brain Research, 177, 261-268.

About Addiction: Sex and Drugs, and Addiction’s impact on children and stress

Have questions about addiction? You should browse our content and check out the links in this article and all the others we’ve written. It’s a great quick stop for 30 minutes of information!

Sex and Drugs

Science Centric– What a great way to help others! A peer based outreach service have been developed to aid sex workers resolve their drug problems. The program is lead by current and former sex workers and is helping to increase entry to detox and residential drug treatment programs among women in sex work.

Take Part– A male porn star has tested positive to having HIV. This positive test has put a halt to production of new sex tapes. This article provides five things that individuals should know about the porn industry. It is a great read!

Addiction inbox- Spice has been marketed as a synthetic cannabis. It can get a person high but at the same time will allow individuals to pass a drug urinalysis. That fact is making spice very common in places like police stations, fire department, and army bases.

Breaking the Cycles– Everyone knows how hard it is to break a habit, it often takes time and it is a struggle to maintain the new behavior. This is the same when an addict or alcoholic successfully makes it through their rehab. The hard part however comes when individuals are trying to prevent relapse.  SAMHSA (Substance Abuse and Mental Health Services Administration) suggests that to prevent relapse individuals should think about doing something as opposed to not doing something. This allows individuals to create an anti-drug and anti-drink. This article follows the pattern of our earlier writing on relapse prevention by replacement.

Addiction’s impact on children and stress

Sober teens online- This is not a typical article post that we love to provide you, however it is no doubt very moving. This site displays artwork which depicts the emotions of foster children who are victimized by addiction.

Stress and addiction– Does stress cause addiction? Does addiction cause stress? That’s a popular question when people are trying to figure out the causes of addiction. It is no surprise that stress and addiction have a reciprocal relationship with each other. Stress can cause an individual to start drinking or taking drugs, and stress often triggers addict to use drugs or alcohol. Stress such as early childhood trauma may cause an individual to become an addict when they are older. This article examines the interplay of stress and addiction and also offers a great video about stress and addiction.

About Addiction: Addiction Treatment, distress, kids with drugs, and your brain

This week our wrap-up includes articles about addiction, sometimes in kids, and the stress that can often accompany them As usual, we’ll educate you in 30 seconds flat and give you a window to this week’s hot stories.

Addiction treatment access

Boston Globe – Read about the often sad reality of American soldiers who become addicted to medications prescribed to them during service by medical staff and are then left holding the tab when it comes time to pay. Hopefully this practice is a thing of the past now that TRICARE, the military’s heath-insurance provider is allowing for future claims.  This should speed up the process and reimburse addicted service members for the out-of-pocket costs they have previously owed when they were using these drugs.

Addiction Inbox– Check out Charlie Lloyd’s account of the devastating effect of drug addiction stigma on treatment seeking. If we want to help, and not simply reinforce, the problem we must focus on education about addiction and not scare tactics.

Youth and drugs/addiction

Fox News– A two year old Indonesian boy has finally kicked his habit of smoking two packs a cigarettes a day. The toddler apparently first obtained the cigarettes from his father and became addicted quickly. Gives a whole new meaning to starting early…

The Vancouver Sun– Lindsey Lohan has opened up about her addiction in an interview with Vanity Fair. Lindsay conducted this interview before she went to serve her jail sentence and admitted that her actions were irresponsible and that she is addicted to prescription pills. LiLo would like to put the past behind her and get her career back. Good luck.

UPI– A Hawaiian man is suing a video games creator claiming that it lead to an addiction that left him unable to bathe, eat, dress, or wake during the day. Smallwood claims he spent more than 20,000 hours on his addiction and believes that the game should issue a warning that it may cause addiction because Smallwood still has a “compulsive urge and need” to play the game.

Body, brain, (di)stress, and death

Psypost – Young adults who get fewer than eight hours of sleep have a greater risk of developing  psychological mental  distress as well as depression and anxiety. This distress increased 14% for each hour lost in a night’s sleep. Get those ZZZZZZZZ’s !!!

Neurodynamics – A great read if you want to learn about the way in which the brain responds to stress. The amygdala,  the hippocampus, and the prefrontal cortex all play important parts, and this article will help you understand why and how.

Time– Abstainers apparently have shorter life expectancies than moderate drinkers. While the effect is similar to the reduced life-span of heavy drinkers, it’s a quirky finding that keeps showing up. There are a slew of suggestions and interesting ideas if you follow this article all the way to the study itself. The bottom line – Light and moderate drinkers likely do better than abstainers or heavy drinkers (alcoholics?) in the long run, even when a whole bunch of other factors are accounted for.

Breaking the cycles-What would you do if a police officer pulled you over and arrested you for driving under the influence if you BAC was not .08? This is a reality and the reason for the DUI is  the inability to drive a car with the same caution characteristic of a sober person. This inability to drive as carefully as a sober person is determined by the manner in which the car was driven, the physical signs and symptoms of the driver and the driver’s performance on field sobriety tests. This definitely give a new meaning to being careful when you have a few drinks and drive home.

Women, Trauma and HIV Transmission

Co-authored by Jamie Felzer

Just how much can the events of a traumatic childhood affect the likelihood of contracting HIV or other serious diseases in later life? Unfortunately, recent research shows that the effect can be profound, especially for women.The silver lining may be in our ability to reduce later HIV transmission by providing better intervention services post-trauma.

Childhood Trauma, Women and HIV/AIDS

In ways both surprising and predictable, it seems that even very early childhood trauma can be firmly linked to high risk behaviors and a higher risk of contracting HIV. And with AIDS now reported by the US Department of Heath & Human Services as the leading cause of death for African-American women between the ages of 25-34 (and the perhaps even more sobering H&HS assessment that African-American women are a staggering 21 times more likely to die from AIDS compared to non-Hispanic white women), this crisis has a particular impact on women of color.

The obvious conclusion is that those subjected to childhood trauma are more likely to engage in risky behavior in an attempt to relieve some of the chronic stress that often accompanies such experiences. Drug use, unprotected sex, heavy drinking and other accompanying behaviors can all seem like appropriate responses to mental and emotional stress, but that stress can also inhibit one’s ability to make safe choices in this context. This naturally leads to an increased risk for contracting sexually transmitted diseases and blood-borne pathogens. Factor in the simple biological reasons why women may be at an elevated risk of contracting HIV through any one encounter, and it becomes clear that many at-risk young women are not receiving adequate education on how to protect themselves against this threat.

Many young women with a history of trauma and elevated lifetime stress from sexual assault, violence or any of the myriad stressors that accompany low socioeconomic status may be inadvertently putting themselves at greater risk for contracting HIV and AIDS. As mentioned, these risks can commonly come from unsafe sex and the abuse of unknown drugs, potentially with non-sterile needles. Without a strong support system to help them adequately process the short and long-term effects of trauma, many young women end up developing symptoms of chronic anxiety and depression, conditions that can alter behavior and even ultimately lead to demonstrated higher rates of mortality. That these conditions also often co-exist with other health issues linked to lower socioeconomic status such as obesity and heart disease serves to further compound this risk. Stress has even been shown to speed the progression of the AIDS virus, making the disease itself more deadly.

And with a full 1/3 of the female population having reported some form of sexual assault or similar violent trauma, the sad reality is that the risks for contracting HIV among young women are, if anything, growing. It seems that one way to attack the HIV pandemic is by improving prevention, as well as intervention, services, for women affected by such early trauma. It might be a way to kill two, or even more, birds with one stone.