The brain is a fickle creature. When it experiences something it likes, it bursts with dopamine, regardless of whether that thing is healthy or safe for us. Dr. Alta De Roo, Chief Medical Officer of the Hazeldon Betty Ford Foundation and Director-at-Large of the American Society of Addiction Medicine, joins us on the podcast to explain the science of addiction and why opioids are so good at making us chase a dopamine high.
Learn more:
- Purchase Ending the Crisis by Dr. Holly Geyer
- Learn more about pain management and safe opioid use on our Opioid Resource Center
- Comments or questions? Email us at mcppodcasts@mayo.edu.
- If you or a loved one are dealing with a substance use disorder, visit Substance Abuse and Mental Health Service Administration.
Read the transcript:
Dr. Benjamin Lai: Hello. Welcome to Ending the Opioid Crisis. I’m Dr. Dr. Benjamin Lai.
Dr. Holly Geyer: And I’m Dr. Dr. Holly Geyer.
Dr. Benjamin Lai: This is a podcast series aimed at getting a deeper understanding of the opioid crisis that has ravaged our country. Today, we’re thrilled to have Dr. Alta DeRoo joining our podcast. Dr. Alta DeRoo is a board certified addiction medicine physician and obstetrician gynecologist. She serves as chief medical officer of the Hazelden Betty Ford Foundation and is also director at large of the American Society of Addiction Medicine.
Dr. Alta DeRoo’s record of accomplishment includes a 24-year career in the U.S. Navy. She is one of the leading experts of maternal and fetal health complications related to substance use disorder and also an expert in medications for opioid use disorder during pregnancy. Welcome, Dr. Alta DeRoo.
Dr. Alta DeRoo: Thanks, Dr. Lai. And thank you, Holly, for having me today.
Dr. Holly Geyer: Thanks so much for joining us, Alta, we appreciate your time and the fact that you’d be able to join us for such an important topic. Today, what we want to address is what drives addiction. We recognize that so many friends and family members out there have loved ones, including the patients themselves, oftentimes see addiction primarily as a moral failure or as a societal problem or a criminal activity.
But we recognize the more we’ve studied it that it really has some biological drivers. And one of the first things that I thought we could talk about is terminology. Many people may have heard the term opioid use disorder. I was wondering if you might explain exactly what that is and how it relates to the concept of addiction.
Dr. Alta DeRoo: Opioid use disorder is definitely the preferred terminology for somebody who exactly has that: a medical use disorder to opioids. Opioids could be anywhere in the spectrum from pharmaceutically prepared opioids like Percocet, Vicodin, all the way to illicitly prepared opioids that now also include opioids such as buprenorphine or methadone. We choose to use the term OUD or opioid use disorder because it’s a medical disorder that’s actually a diagnosis within the psychiatry DSM five definition for Opioid Use Disorder.
It also uses the evidence to explain opioid use disorder as a true medical issue, a true disease, instead of you referring to what others may just interpret as a moral failing or a choice.
Dr. Holly Geyer: Thank you. As we think about biology that drives addiction, oftentimes most people don’t associate it with biological changes. Many friends and family and even patients assume that it stems from the desire to get high, to have fun, to enjoy that stimulation. Can you tell us what’s really going on in the brain that drives this perspective of it actually being a biological disorder?
Dr. Alta DeRoo: Initially when somebody uses an opioid they may get an increase in that euphoria that comes about by increasing the levels of dopamine in the brain. That may start out innocently, perhaps taking a pain medication as prescribed by your physician.
Eventually, when somebody feels that euphoria, after a while of taking that pain medication, opioid or even using another illicitly prepared opioid, that euphoria induces dopamine spikes in the brain. Dopamine is that neurotransmitter that makes us feel really good. Dopamine comes on after we breastfeed our children, after we have a really good fatty meal that makes us feel really good.
This euphoria that is induced by somebody taking this external drug increases the dopamine in our brain and it makes us feel really good. But after a while of taking that opioid that causes these dopamine spikes, no longer are they feeling that euphoria or it takes longer, or more medications, more opioids to get that euphoria. And eventually what happens is that the brain achieves new circuitry in the brain and is used to a certain amount of dopamine.
Unless that person is getting that drug to increase that dopamine, the brain’s not going to be satisfied. Instead of feeling this euphoria or this high feeling, a person is just going to use just to not go through withdrawal. That initial usage of opioids does induce that euphoria and people chase that high. But after a while, they’re not chasing that high anymore. What they’re doing is they’re using to not withdraw, is to not feel those withdrawal symptoms and get really super sick from the constant amount of opioids that they have in their body.
Dr. Holly Geyer: That’s so interesting. To understand how things change over time, could you talk a little bit about what a person who’s struggling with addiction might feel when they start doing everyday activities such as hugging your kid or eating ice cream? Are they getting the normal sensations they might have otherwise or have things changed in the brain?
Dr. Alta DeRoo: Those normal activities that would have previously given us a spike in dopamine to make us feel satisfied, aren’t going to be as effective anymore. The brain, in a way, says: “you know, I’m used to this higher level of dopamine that you’re giving me from this external drug” that’s going into the brain. So breastfeeding or exercising or eating that good meal is not going to produce the same type of satisfaction that you would have had before.
The circuitry has been re-engineered in the brain to expect a certain dopamine spike. You’re not going to get those same dopamine spikes from just doing natural activities because now your dopamine is coming from extra natural, supernatural ways. So once you start taking the opioids, the things that used to make you satiated or pleasurable in the past, it’s not going to be as effective.
Dr. Holly Geyer: Before I got into the field of medicine I thought of the brain, I thought of a giant pan of linguini; a bunch of tubes and systems and noodles going in every direction, but not necessarily organized or complex. As I went through medical training, I realized that this is a highly specialized organ with each part of the brain serving a very particular function and responsibilities. Could you talk about the different parts of the brain that might be changed over time in the setting of addiction, particularly with opioids?
Dr. Alta DeRoo: One of the major parts of the brains that are affected is what we call in medicine the prefrontal cortex. Also referred to as the frontal lobe, the front part of the brain. That front part of the brain isn’t done forming until the mid-twenties.
There’s a lot of dopamine receptors in that frontal cortex. Those change over time when you’re exposed to opioids. In that frontal brain, that prefrontal cortex is involved in decision making, or measuring risk, or doing complicated things like higher orders of math. It’s what makes humans able to do the higher order executive functioning in our brain.
After a while, it’s subjected to higher levels of dopamine. The receptors are very sensitive in that prefrontal cortex. Then there’s this new pathway where a person may not be able to use their prefrontal cortex in a way that enables them to do normal risk taking analysis. They may have a problem with controlling themselves, or have impulse control.
We see that remodeling of the circuitry, that linguini, so to speak, that you mentioned. That’s very difficult to undo until a person has stopped using opioids. So that’s where we see a major part of this research is happening.
Dr. Holly Geyer: I had the opportunity to look at an image once and it was on a certain type of MRI that allows different parts of the brain to highlight. It was fascinating to see the connection systems that differed between addiction, even in the resting state, of someone who did not have a history of drug use. The way it was explained to me is that what happens with chronic opioid use is that parts of the brain that were thoroughly connected before, or had minimal connections, kind of like bike paths, were now turning into four lane freeways over time.
One of the questions friends and family and patients might have about this is what degree of reversal is there with treatment of opioid use disorder? Can you get to where they were before?
Dr. Alta DeRoo: There are pathways that you’re probably referring to are the nucleus accumbens sending pathways or signals to the prefrontal cortex. Those are all big, jumbly medical words, saying that the nucleus accumbens is the pleasure seeking place. Like with the prefrontal cortex and judgment. Eventually, when somebody stops using opioids, they’re going to go through this post-acute withdrawal syndrome that makes them a little less functional than they used to be.
That can last up to about 18 months where people may have depression, inability to pay attention, may have cravings, that type of thing. But one thing that’s really wonderful about treatment, behaviorally approached and/or medically approached is that these can be reset and a person’s neural pathways can be restored. But they’ll always have that possibility of returning to use again if they reintroduce that drug.
It’s definitely difficult in that post-acute withdrawal syndrome time frame, 12 to 16 months. But after that, with behavioral treatment and or medication assisted treatment to help them along, you can rework these pathways, you can undo some of these four lane freeways that have been paved.
Dr. Holly Geyer:Every 8 minutes, someone in the US dies of an opioid overdose. The drugs we have long trusted to help kill pain are now killing us. But what if we were equipped with the information to use opioids wisely, store them safely, avoid their risks and reverse their problems? What if we could help loved ones misusing opioids and support them as they seek treatment?
My book, Ending the Crisis, shares Mayo Clinic’s collective insight into the lives of every person struggling to understand opioids and their role in managing pain, or dealing with the complications caused by these powerful drugs. Visit the link in the notes of this episode, or visit mcpress.mayoclinic.org/opioids to get your copy today.
Dr. Holly Geyer: You mentioned you got a background in addiction medicine and you work with the American Society of Addiction Medicine. I’m a big fan of that organization. When you look up the definition of addiction by that organization, they’ve got this classic label and they call it a chronic medical disease involving complex interactions amongst the brain circuits, just like you talked about, but also genetics and the environment and life experiences. It sounds like the concept of addiction is touching not just the biological domain, but other domains. Would you mind talking a little bit about how it reaches into these other areas of our lives?
Dr. Alta DeRoo: We have seen through DNA analysis, brain analysis, that there is a genetic predisposition up to about 60% to somebody to acquire addiction. So that means if our parents or grandparents were unfortunately suffering from alcohol use disorder, or opioid use disorder, the children can be genetically predisposed to that. They may have a shorter interval to developing some type of use disorder when it comes to those drugs or that alcohol. That would account for about 60% of the genetic variation. However, the environmental part of it is that if a person is never introduced to alcohol or opioids, then they’re not going to develop this disorder. If they’ve never had an opportunity for their brain to be affected by it, then they’re not going to develop it. So the introduction of this drug to the person is highly influential, especially considering age.
Before I talked about how that prefrontal cortex is not fully formed until your mid-twenties, if you introduced this drug; opioids, alcohol, marijuana to the developing brain, you’re really going to remap that circuitry before it’s well-established and mature. And unfortunately, this is going to hijack that brain. And so these folks are highly susceptible to addiction when they’re fully formed brains aren’t even able to establish the circuitry that was meant to be before it’s disrupted by this introduction to drugs.
The third thing that you touched upon was the introduction of this drug and the kind of drug. Like we discussed previously, that dopamine, you can have spikes in dopamine by doing just normal activities that make you feel good; again running, cardiovascular activity, working out, having a great meal, laughing, loving, those things that make that dopamine go up.
That’s a natural increase. But we found that those drugs that a person introduces into their system, that causes an abnormally high spike in dopamine, is going to cause a use disorder more quickly. So we take a look at smoking, that increases the dopamine a little, alcohol use increases the dopamine a little. But we find that with opioids, cocaine, and methamphetamines, they cause very high dopamine spikes in a short period of time.
It’s those fast-acting drugs that affect our brain that causes an increase, a high increase, in dopamine that are more habit-forming. Even though alcohol may be habit-forming, cigarettes may be, tobacco may be habit forming, they may induce a dopamine spike that is long. It lasts for a long time, several hours, several days. But it’s those dopamine spikes that are fast, fast-acting, that may be for one or two hours, that really increases that propensity to developing a substance use disorder.
Of those drugs that I just mentioned, methamphetamine is the biggest culprit. Increases a huge, supraphysiologic increase in dopamine that rewires that circuitry quickly. Even by patient reports and by brain MRI’s, we see that those dopamine spikes change the circuitry and increase someone’s risk for addiction or habit-forming use to that drug even more than these other habit-forming drugs like alcohol or tobacco.
Wrapping this up in just plain easy speak, it’s those drugs that make you feel really good, really fast are the ones that are more addictive.
Dr. Holly Geyer: I had seen a chart, it was about a year ago, that they had done a study and they showed that a morphine infusion, a quick push was about a 300% increase in the dopamine output from what you normally produce. But methamphetamine, it was a 1,000% increase. Imagine doing that day after day, hour after hour, year after year.
It’s not surprising that people end up in the lifestyles that we see and it can overtake your life so quickly. I want to transition a little bit about what life looks like when you’re in that state of addiction and why comprehensive treatment is so key to managing the whole addiction experience.
Dr. Alta DeRoo: When somebody is in the active disease of addiction and their brain is hijacked by this circuitry now, that does impair our choices and it does impair our decision making. What happens is that the brain considers this drug very salient, and that’s often a word that we use to describe addiction. It’s so salient and meaningful that the brain puts so much emphasis on needing this drug that folks may not be making the decisions that they would have made before using the drug. They’ll do anything to get that drug.
They will use resources to get money to pay for these drugs in ways that they wouldn’t have before. We’re not talking about moral choices or I choose to behave this way, but they’re a victim of the brain who says, I must get this drug and I will do anything that I need to do to get this drug. Then that’s where our prefrontal cortex is compromised.
You ask what it’s like for this person who is actively using this. It’s almost like they’re not in control anymore of their decisions. They’ve lost control. That’s when the treatment, medication or behaviorally, becomes important. The behavioral part of that treatment allows for that recircuitry, the reeducation of decisions, the relapse prevention, as we call it, not putting ourselves in risky situations, abstinence of the drug and then counseling, positive reinforcement about non risk-taking behaviors combined with medications can be a powerful tool for recovery.
Now, the medications, at least for opioid use disorder, come into effect because they satisfy that opioid receptor partially so that the person can engage in this therapy. This behavioral therapy, 12 step meetings, any type of one on one psychotherapy they can engage in more wholly to be present because they’re not suffering from this constant distraction of a craving. These medications, such as buprenorphine, buprenorphine, naloxone, help satisfy that receptor so that the person doesn’t have this craving to go out and use again.
Behavioral treatment complements this medical treatment, and it’s nice when you can use them together. Medication alone, there is some evidence to show that not everybody needs psychotherapy, but using psychotherapy or that one on one approach with positive reinforcement in good habits complements it very well.
The other part of that, a solution to a great recovery is family support. There’s lots of evidence to show that family support, mother, father, husbands, wives, that family support and that social support is incredibly important to the success of somebody who’s in treatment.
Dr. Holly Geyer: As we look towards the world where buprenorphine will now be offered by many more people, we hope we’ll probably see a change in our society. Would you mind just sharing some of your hopes if there’s physicians listening in our audience as to what you think would set our patients up for best success as we enter this era where just about any doctor can now offer buprenorphine to their patients?
Dr. Alta DeRoo: It’s wonderful that the waiver for buprenorphine has been eliminated. Previously I only specialized physicians that had this special XDR waiver with 8 hours of training could prescribe buprenorphine. In this game this unnecessary stigma and barrier to buprenorphine that, in my opinion, wasn’t necessary. It made people view buprenorphine as this risky medication that you would get. In actuality, it’s only a partial agonist.
It’s very difficult to overdose on something like buprenorphine, but the same physicians who may be concerned about buprenorphine are also prescribing or have a history of prescribing opioids, morphine, Percocet, Vicodin, those are full agonists. Somebody can overdose from that. The literature shows it’s very uncommon to overdose from buprenorphine unless it’s combined with something like a benzodiazepine.
I’m very hopeful in that by eliminating this DEA waiver that more physicians can see that it’s not so risky to prescribe this medication, can encourage them to learn more about it, and then prescribe it more easily instead of thinking to themselves that this was a medicine that they couldn’t prescribe because it was only for a certain special population of physicians to prescribe.
With the idea of buprenorphine, now not needing a special waiver to prescribe, I’m hoping that more physicians will feel a little more comfortable with prescribing that.
Dr. Holly Geyer: One can only hope. We’re definitely in a day and age where we need it, don’t we?
Dr. Alta DeRoo: Absolutely.
Dr. Holly Geyer: Dr. Lai, do you have any thoughts or comments on today’s discussion?
Dr. Benjamin Lai: I’ve learned so much just listening to you. I work in primary care and I have a couple of questions and I’m asking for my patients, and I’m sure our listeners may have similarly. At the very top of the hour, we talked about that change in the brain circuitry, the spaghetti I think you and Dr. Geyer referred to.
I actually have some patients that come in and say: “Gosh, doc, you know, I’m scheduled for surgery. My surgeon is probably going to prescribe me opioids. I don’t want to be addicted to it.” They have significant hesitations about taking opioids for perhaps the right reasons.
How would you counsel those patients? I think those patients are more concerned about how long it is that they take themedicine before a potential addiction could develop? Any thoughts on that?
Dr. Alta DeRoo: Not every surgery needs to be treated with post-op opioids. That has been our go to it has been an opioid. We’ve gone with morphine, either IV or Vicodin, Percocet, Tramadol. But not every surgery needs to be treated with opioids. I would say if a person has a genetic disposition or perhaps they’re in recovery, let’s try Motrin, Tylenol, maybe a little Gabapentin before we jump to the opioid, and in general, I still do surgery, and I find that even with large abdominal procedures that somebody’s opioid use really does not need to extend beyond one or two weeks. After beyond one or two weeks, at high doses, or if you feel like you’re escalating your doses, or using your opioid even when you’re not in pain, that’s a risky situation, should be a red flag to you.
If somebody legitimately has a concern about an addiction to an opioid because they’re prescribed it as post-op, just remember, not all pain needs to be remedied by an opioid. There’s powerful evidence to show that if you alternate your NSAID, something like Ibuprofen, Motrin with Tylenol, and you combine a little bit of Gabapentin, which can be a powerful pain reliever, you’re going to need less opioids to recover.
Often with my large abdominal cases, I may give patients a prescription of 12 or 14 pills. The reason why I limit it to such a low dose is because if a patient is still having persistent pain, after that one or two weeks, as their surgeon I want to know about it. I want to know because it’s not normal to have that type of pain that needs opioid treatment two weeks later.
I may want to investigate their abdomen for something out of the ordinary. By limiting that number of pills that I’m giving for opioids, of course we’re decreasing our risk for any type of diversion, decreasing our risk for addiction, but then we’re also inviting that patient to come back and see me if you still have pain persisting past two weeks.
Dr. Benjamin Lai: That’s great. Thank you so much.
Dr. Alta DeRoo: Great questions.
Dr. Benjamin Lai: That is all from us on today’s episode of Ending the Opioid Crisis, you can check at our website at mcpress.mayoclinic.org/opioids for more episodes of our podcast series and other resources for safe opioid use. If you or someone you know are struggling with an opioid or another substance use disorder, we recommend speaking with your health care provider or going to the substance abuse and Mental Health Services Administration website.
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