Let’s Talk About Continuous Loops and Broken Links

Like many of you I heard about the Surgeon General’s report on addiction, “Facing Addiction in America,” this week. My post today is going to contain as few links as possible, in view of the many broken links out there on the internet. I’ll get to Dr. Vivek Murthy’s report later. First, I’d like to show you a side of Dr. Murthy you might not have heard about in the news and that’s his brief speech at The Gold Foundation Golden Thread Gala on November 1, 2016 in which he emphasized the importance of humanism in medicine. Because I can’t do justice to it without showing you the YouTube video of his presentation, I’m compelled to use the link which will embed it into this post.

I’ve been a Leonard Tow Humanism in Medicine pin recipient since 2007 and, I hope to receive the new pin the Gold Humanism Honor Society (GHHS) is distributing as a part of the organization’s rebranding. You can click the link in my blog menu to check out the Gold Foundation’s new web site. The new pin includes a Mobius loop “…as a symbol of the continuous bond of trust, respect, and communication that connects healthcare professionals with their patients when humanism is at the core of practice.”

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Dr. Murthy shows us we can create another continuous loop–between neuroscience and humanism. You can find the Surgeon General’s report on addiction by searching the web using the term “Facing Addiction in America.” Nope, I’m not dropping the link to it here. You have to do some of the work. However, I can copy one of the key findings, which is about the neurobiology of addiction:

  • Well-supported scientific evidence shows that addiction to alcohol or drugs is a chronic brain disease that has potential for recurrence and recovery.
  • Well-supported evidence shows that the addiction process involves a three-stage cycle: binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation. This cycle becomes more severe as a person continues substance use and it produces dramatic changes in brain function that reduce a person’s ability to control their substance use.
  • Well-supported scientific evidence shows that disruptions in three areas of the brain are particularly important in the onset, development, and maintenance of substance use disorders: the basal ganglia, the extended amygdala, and the prefrontal cortex. These disruptions:
    1. enable substance-associated cues to trigger substance seeking (i.e., they increase incentive salience)
    2. reduce sensitivity of brain systems involved in the experience of pleasure or reward, and heighten activation of brain stress systems
    3. reduce functioning of brain executive control systems, which are involved in the ability to make decisions and regulate one’s actions, emotions, and impulses
  • Supported scientific evidence shows that these changes in the brain persist long after substance use stops. It is not yet known how much these changes may be reversed or how long that process may take.
  • Well-supported scientific evidence shows that adolescence is a critical “at-risk period” for substance use and addiction. All addictive drugs, including alcohol and marijuana, have especially harmful effects on the adolescent brain, which is still undergoing significant development.

* “Well-supported”: when evidence is derived from multiple rigorous human and nonhuman studies; “Supported”: when evidence is derived from rigorous but fewer human and nonhuman studies.

The other loop is between patients and doctors and for that I tried to use the National Neuroscience Curriculum Initiative (NNCI). Just Google it. There is a “Talking Pathways to Patients: Addiction module on the reward pathway in the brain as it relates to addiction. However, the link to the video portion showing how the brain circuit works, which is also a loop by the way, leads you to this:

video-missing

I’m going to take another chance and drop another YouTube link to an alternative video from NNCI that probably accomplishes the same goal.

This also establishes a loop between residents and faculty in Psychiatry, including smokejumper consultants like me. We regularly collaborate with our fellow consultants in addiction medicine, seeing patients in the general hospital who struggle with comorbid psychiatric illness and addictions. I guess that’s yet another loop.

And how about the loop between psychotherapy and the brain? James Griffith and Lynn Gaby wrote about this in their November 28, 2014 Psychiatric Times article “Brief Psychotherapy at the Bedside: Existential Neuroscience to Mobilize Assertive Coping.” An excerpt:

Existential neuroscience offers a new perspective for conducting bedside psychotherapy that can contribute to its greater effectiveness, efficiency, and portability across clinical settings. Existential neuroscience studies brain operations that connect a person’s subjectivity and meaning-making with the capacity to act effectively within one’s relational world. It conceptualizes how experience is embodied within brain circuits and signaling pathways whose integrity opens or closes portals for a sense of coherence, hope, agency, purpose, or communion with others. Existential neuroscience provides an understanding of the neural infrastructure for assertive coping. This additional clinical map can further optimize the effectiveness of bedside interviews with demoralized patients, particularly when conditions for psychotherapy are adverse.

There is another loop which runs between psychopharmacology and mindfulness. This comes from a recent Psych Congress Network meeting in San Antonio at which a presentation was given, entitled “Two Tools Every Psychopharmacologist Should Use,” by Psych Congress steering committee members Rakesh Jain, MD, MPH, and Saundra Jain, MA, PsyD, LPC. Need a hint; give up? Neither is a drug and they’re exercise and mindfulness. An excerpt:

There are multiple brain-body pathways which are positively affected by physical exercise, and effects can last for as long as 4 days, said Dr. Rakesh Jain, a co-chair of Psych Congress and Clinical Professor at the Department of Psychiatry at the Texas Tech Health Sciences Center School of Medicine in Midland, Texas.

“This is not a homeopathic intervention. This is not a feel good,” he said. “It actually is quite a wonderful biological intervention.”

Dr. Rakesh Jain told attendees of a 2016 study in which researchers biopsied 30 mg of muscle tissue from participants’ quadriceps and found significantly elevated levels of multiple enzymes associated with exercise.

“The question is: Have we missed a peripheral antidepressant?” he said. “Have we completely ignored 30 to 50 pounds of flesh that resides on every individual that is a potent antidepressant?”

He encouraged clinicians to consider three elements when discussing exercise with patients: frequency, intensity, and duration. Twenty to 30 minutes is plenty, if patients are exercising frequently, he said.

Dr. Saundra Jain said mindfulness also has numerous proven benefits, from lowering inflammation levels to protecting against depression and anxiety, and its effects can be seen in changes to the brain.

Exercise and mindfulness are two of the components of the WILD 5 wellness program run by Drs. Jain. In a recent 30-day study involving 82 participants, they saw a 43 percent improvement in depression scores and a 40 percent improvement in anxiety scores.

“The data tells us as clinicians we must offer mindfulness meditation as an intervention. It has to be part of our practice toolkit in terms of what we offer our patients as a way to get better,” said Dr. Saundra Jain, an Adjunct Clinical Affiliate at the University of Texas at Austin School of Nursing.–story by Terri Airov, ref: “Two Tools Every Psychopharmacologist Should Utilize Even in a Medication-Based Practice: A Modern Update on Exercise and Mindfulness as Tools to Enhance Medication Outcomes.” Presented at the 29thAnnual U.S. Psychiatric & Mental Health Congress; October 20, 2016; San Antonio, TX.

You guys know how much exercise I typically get, which is an average of climbing 20 floors a day and 2-3 miles a day of walking…in a sort of loop between the rest of the general hospital and my office as a hit-and-run psychiatric consultant. And I’ve been practicing mindfulness for a little over 2 years now since taking the Mindfulness Based Stress Reduction course here at UIHC.

Boy, after all that I’m feeling a little loopy.

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