In the past several months, I have returned to Martinsburg many times, and spoken with many addicts there. Lori Swadley is a portrait and wedding photographer in Martinsburg. When I looked at her Web site, she seemed to be in demand all over the area, and her photographs were lovely: her brides glowed in afternoon light, her high-school seniors looked polished and confident.
But what drew me to her was a side project she had been pursuing, called 52 Addicts—a series of portraits that called attention to the drug epidemic in and around Martinsburg. It was clear that Swadley had a full life: her husband, Jon, worked with her in the photography business, and they had three small children, Juniper, Bastian, and Bodhi.
Swadley is thirty-nine, tall and slender, and she looked elegant in jeans, a charcoal-colored turtleneck, and high boots. She and her husband had moved to Martinsburg in , she told me, looking for an affordable place to raise children close to where she had grown up, in the Shenandoah Valley. Soon after they arrived, they settled into a subdivision outside town, and Swadley started reading the Martinsburg Journal online.
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Because at that time it seemed like everybody else wanted to hide it. And, to me, that seemed like the worst thing you could do. I said that it seemed like an extraordinarily high number, especially for someone who was not an addict. She agreed, but there it was. All thirteen were young men—Swadley had met most of them when she was in her early twenties, and she had been a tomboy back then.
The first time she heard that a friend had died, she had been photographing a wedding for some mutual friends. They were sitting around a bonfire at the end of the day. When Swadley spoke of a crazy horror film that she and a guy named Jeremy had made in high school, somebody mentioned that he had recently died, from a heroin overdose. She threw up, and wrecked her car on the way home. At the time, Swadley was hanging out with her old crowd in bars and restaurants every weekend.
One by one, the group dwindled. As the overdoses piled up, she was appalled to find that sometimes she had trouble keeping track of which friends were dead. The funerals had a peculiar aspect. In January, , she started photographing addicts in recovery. For the first few portraits, Swadley reached out to her subjects, but soon people started coming to her. She took their pictures, asked them about their lives, and told their stories in a paragraph or so. There are now two dozen images in the series.
In one of the portraits, an E. A woman named Tiffany posed holding a snapshot of her younger sister, Tabby. Both women had started off on pills—Tabby had developed a problem after a gallbladder operation left her with a thirty-day supply of meds—and then became heroin addicts. Tiffany had received treatment, but Tabby had fatally overdosed while she was waiting for a rehab bed. Swadley took the portrait in a park where Tiffany had once begged Tabby to stop using.
When I called Tiffany, she told me that she had recently lost a second sister to heroin. Swadley hopes that her photographs will someday be displayed all around town—in coffee shops, restaurants, perhaps the library. I want to show people they deserve a chance. One day, Swadley told me about a local effort against heroin addiction, called the Hope Dealer Project.
It was run by three women: Tina Stride, who had a twenty-six-year-old son in recovery; Tara Mayson, whose close friend had gone through periods of addiction; and Lisa Melcher, whose son-in-law had died of an overdose, and whose thirty-two-year-old daughter, Christina, was struggling to overcome heroin addiction. All three had known addicts who wanted to get clean but had no place to go.
Last fall, like car-pool moms with a harrowing new mission, they had begun driving people to detox facilities all over the state—any place that could take them, sometimes as far as five hours away. The few with private insurance could get rehab anywhere in the country, and the Hope Dealer women were prepared to suggest options.
But most people in town had Medicaid or no insurance at all, and such addicts had to receive treatment somewhere in the state. Currently, the detox facility closest to Martinsburg is about two hours away. Stride works full time at the General Services Administration, in Washington, but spends up to twenty-four hours a week giving rides to drug users. The other two focus on reaching out to addicts and families.
When Stride and her client arrive at a detox facility, nurses are waiting at the door. For them to walk in those doors, that takes a lot. After five to ten days in detox, patients are released. If beds are all full, a lot of times they come back here to Martinsburg, because they have nowhere else to go. Stride usually drives clients to a detox center immediately after picking them up.
I tried to stay up, but I knew I had to drive four hours to the detox place, and four hours back. So I slept some. We were up at 4 a. Stride, who is forty-seven, wore her hair in a ponytail and had curly bangs; Mayson, who is forty-six, had long, sparkly nails. They had spent the previous day working on behalf of a woman and her twenty-one-year-old son, a heroin addict.
He had private insurance, so they had signed him up for rehab in New Hampshire. What do I do? Samantha Engelhardt right , a recovering addict, shows her newborn baby to the photographer Lori Swadley, who has been documenting the opioid epidemic in the Martinsburg area. Because I want to know he makes it. Mayson, who works at the Department of Veterans Affairs and has two adult children, said that the Hope Dealer women had become like sisters.
As mothers, they felt that they had a particular ability to communicate with women who needed help with their addicted children. I was devastated. On May 21st, I received an e-mail from Melcher, informing me that Christina, her daughter, had fatally overdosed on heroin. Christina, she said, had completed rehab several times, and had been clean for ninety days before relapsing.
Aldis is a family practitioner with a background in public health and tropical medicine. His mother taught nursing, and his father was an obstetrician. He spent most of his career in Asia and Africa, as a U. Navy physician and as a medical officer with the State Department. He retired in They filled it with art and antiques, acquired two Jack Russell terriers, and prepared for a quiet life filled with visits from their two daughters and the grandkids.
He took a job at the New Life Clinic, in Martinsburg, where he could prescribe Suboxone, one of the long-term treatments for opioid addiction. He found it enormously frustrating that addicts were often urged to quit heroin cold turkey or to stop taking Suboxone or methadone or naltrexone, the other drugs used to treat addiction and counteract withdrawal symptoms.
In his view, this was wholly unrealistic. Most addicts needed what is known as medication-assisted treatment for a long time, if not the rest of their lives. You could actually prescribe it to your patients. That might seem self-evident, but at this point in the opioid epidemic many West Virginians feel too exhausted and resentful to help. I remember one time, we had a kid who had O.
A call came over the radio—someone about his age had just died from an overdose. Then again, Poe mused, when most of your neighbors—not to mention your mom and your grandma—already knew that you used heroin, shaming might have little effect. This past winter, I watched Aldis teach two classes in Berkeley Springs, an Eastern Panhandle town, at a storefront church between a convenience store and a pawnshop.
The bare trees on the ridge above us were outlined like black lace against the twilight. Inside, a few dozen people, mostly women, sipped coffee from Styrofoam cups in an unadorned room with a low ceiling, tan carpeting, and rows of tan chairs. Aldis touched briefly on what an overdose looks like, but acknowledged that the attendees probably already knew.
At the first meeting I attended, in November, a few women began to cry when they heard that. At the second, in January, Aldis had some good news: the state had agreed to provide a hundred and eighty free kits. Aldis had been invited to Berkeley Springs by Melody Stotler, who ran a local organization for recovering addicts. Aldis introduced Kathy Williams, a former patient of his and the mother of two little girls.
She had twice saved people with Narcan. One time, while she was driving, she spotted a car on the side of the road, and a man lying on his back next to it. The other time, a neighbor in her apartment complex knocked on her door and said that a guy was overdosing in the parking lot. She saw a woman tending to a man. A woman named Tara, who was at the January meeting with her teen-age stepdaughter, told me that she had revived a guy who lived in the trailer park where she did some babysitting. Someone called the police.
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She was a recovering addict herself—seven years now. She was studying to be a medical assistant. John Aldis, at his home office in Shepherdstown. In , he became the first doctor in West Virginia to offer free public classes to teach anybody—not just first responders and health professionals—how to reverse opioid overdoses with the drug Narcan. Jason Chalmers loved his children, that was for sure. He crawled around on all fours, pretending to be a pony, to amuse his daughter, Jacey, and her younger brother, Liam. He submitted to Jacey whenever she wanted to cover his face with makeup. Liam was born in His mother, Angie, had struggled with an opioid problem, and had taken Suboxone to combat it during her pregnancy.
He was on morphine for two solid weeks in the hospital. Jason, who grew up in Martinsburg, was a heroin addict for most of his life, a fact that puzzled his family almost as deeply as it saddened them. He grew up in an attractive, wooded development on a country road, with horses and dogs, and a kindhearted mother. His grandparents lived in the development, too, and Jason and his two siblings waited for the school bus together on a wooden bench that a neighbor had carved for them. There were glimmers of an explanation here and there.
But who knew, really? It was the beginning of a self-destructive pattern. Sexual behavior is highly rewarding Tenk et al. Moreover, sexual experience induces neural plasticity in the NAc similar to that induced by psychostimulant exposure, including increased dendritic spine density Meisel and Mullins, ; Pitchers et al. Finally, periods of abstinence from sexual experience were found to be critical for enhanced Amph reward, NAc spinogenesis Pitchers et al. Naltrexone, a mu-opioid receptor antagonist approved by the US Food and Drug Administration for the treatment of alcoholism and opioid dependence, has shown efficacy in controlled clinical trials for the treatment of pathological gambling and kleptomania 76—79 , and promise in uncontrolled studies of compulsive buying 80 , compulsive sexual behavior 81 , internet addiction 82 , and pathologic skin picking Topiramate, an anti-convulsant which blocks the AMPA subtype of glutamate receptor among other actions , has shown promise in open-label studies of pathological gambling, compulsive buying, and compulsive skin picking 85 , as well as efficacy in reducing alcohol 86 , cigarette 87 , and cocaine 88 use.
N-acetyl cysteine, an amino acid that restores extracellular glutamate concentration in the nucleus accumbens, reduced gambling urges and behavior in one study of pathological gamblers 89 , and reduces cocaine craving 90 and cocaine use 91 in cocaine addicts. These studies suggest that glutamatergic modulation of dopaminergic tone in the nucleus accumbens may be a mechanism common to behavioral addiction and substance use disorders However, the components that are responsible for the heritability of characteristics that make an individual more susceptible to drug addiction in humans remain largely unknown given that patterns of inheritance cannot be explained by simple genetic mechanisms Cloninger et al.
The environment also plays a large role in the development of addiction as evidenced by great societal variability in drug use patterns between countries and across time UNODC, Therefore, both genetics and the environment contribute to an individual's vulnerability to become addicted following an initial exposure to drugs of abuse. The evidence presented here demonstrates that rapid environmental adaptation occurs following exposure to a number of stimuli. Epigenetic mechanisms represent the key components by which the environment can influence genetics, and they provide the missing link between genetic heritability and environmental influences on the behavioral and physiological phenotypes of the offspring.
Am J Psychiatry. Neuroscience Letters. Alcohol Health and Research World : 1— Retrieved 13 December I Want to Change My Life. Retrieved 17 September Retrieved 26 September Neuroscience and Biobehavioral Reviews. Adolescent Medicine. The International Journal of the Addictions. National Institute on Drug Abuse. Retrieved 15 December Substance Abuse and Mental Health Administration. Retrieved 19 December Archived from the original on 17 December Dual Diagnosis. This is known to occur on many genes including fosB and c-fos in response to psychostimulant exposure.
Chronic exposure to psychostimulants increases glutamatergic [signaling] from the prefrontal cortex to the NAc. Coincident and convergent input often induces plasticity on a postsynaptic neuron. The NAc integrates processed information about the environment from basolateral amygdala, hippocampus, and prefrontal cortex PFC , as well as projections from midbrain dopamine neurons. Previous studies have demonstrated how dopamine modulates this integrative process.
For example, high frequency stimulation potentiates hippocampal inputs to the NAc while simultaneously depressing PFC synapses Goto and Grace, KEGG Pathway. Retrieved 31 October Most addictive drugs increase extracellular concentrations of dopamine DA in nucleus accumbens NAc and medial prefrontal cortex mPFC , projection areas of mesocorticolimbic DA neurons and key components of the "brain reward circuit".
Amphetamine achieves this elevation in extracellular levels of DA by promoting efflux from synaptic terminals. Chronic exposure to amphetamine induces a unique transcription factor delta FosB, which plays an essential role in long-term adaptive changes in the brain. The net result is gene activation and increased CDK5 expression.
The net result is c-fos gene repression. Transcriptional mechanisms of addiction: role of DeltaFosB". Retrieved 10 April Short-term increases in histone acetylation generally promote behavioral responses to the drugs, while sustained increases oppose cocaine's effects, based on the actions of systemic or intra-NAc administration of HDAC inhibitors. Genetic or pharmacological blockade of G9a in the NAc potentiates behavioral responses to cocaine and opiates, whereas increasing G9a function exerts the opposite effect Maze et al. Such drug-induced downregulation of G9a and H3K9me2 also sensitizes animals to the deleterious effects of subsequent chronic stress Covington et al.
G9a appears to be a critical control point for epigenetic regulation in NAc, as we know it functions in two negative feedback loops. Also, G9a is induced in NAc upon prolonged HDAC inhibition, which explains the paradoxical attenuation of cocaine's behavioral effects seen under these conditions, as noted above Kennedy et al. GABAA receptor subunit genes are among those that are controlled by this feedback loop. Journal of Psychoactive Drugs. It has been found that deltaFosB gene in the NAc is critical for reinforcing effects of sexual reward.
Pitchers and colleagues reported that sexual experience was shown to cause DeltaFosB accumulation in several limbic brain regions including the NAc, medial pre-frontal cortex, VTA, caudate, and putamen, but not the medial preoptic nucleus. Next, the induction of c-Fos, a downstream repressed target of DeltaFosB, was measured in sexually experienced and naive animals. The number of mating-induced c-Fos-IR cells was significantly decreased in sexually experienced animals compared to sexually naive controls. Finally, DeltaFosB levels and its activity in the NAc were manipulated using viral-mediated gene transfer to study its potential role in mediating sexual experience and experience-induced facilitation of sexual performance.
Animals with DeltaFosB overexpression displayed enhanced facilitation of sexual performance with sexual experience relative to controls. In contrast, the expression of DeltaJunD, a dominant-negative binding partner of DeltaFosB, attenuated sexual experience-induced facilitation of sexual performance, and stunted long-term maintenance of facilitation compared to DeltaFosB overexpressing group.
Together, these findings support a critical role for DeltaFosB expression in the NAc in the reinforcing effects of sexual behavior and sexual experience-induced facilitation of sexual performance. Malenka Nature Reviews Neuroscience. Lin; M Brodsky Bibcode : Sci Current Opinion in Pharmacology. Edinburgh: Churchill Livingstone. The American Journal of Psychiatry. Cerebral Cortex. British Journal of Pharmacology. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences. Here I discuss how mesocorticolimbic mechanisms generate the motivation component of incentive salience.
Incentive salience takes Pavlovian learning and memory as one input and as an equally important input takes neurobiological state factors e. Neurobiological state changes can produce unlearned fluctuations or even reversals in the ability of a previously learned reward cue to trigger motivation. Such fluctuations in cue-triggered motivation can dramatically depart from all previously learned values about the associated reward outcome. Associative learning and prediction are important contributors to motivation for rewards. Learning gives incentive value to arbitrary cues such as a Pavlovian conditioned stimulus CS that is associated with a reward unconditioned stimulus or UCS.
Learned cues for reward are often potent triggers of desires. For example, learned cues can trigger normal appetites in everyone, and can sometimes trigger compulsive urges and relapse in addicts. This is a signature feature of incentive salience. This cue attraction is another signature feature of incentive salience Sydor A, Brown RY eds. VTA DA neurons play a critical role in motivation, reward-related behavior Chapter 15 , attention, and multiple forms of memory.
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This organization of the DA system, wide projection from a limited number of cell bodies, permits coordinated responses to potent new rewards. Thus, acting in diverse terminal fields, dopamine confers motivational salience "wanting" on the reward itself or associated cues nucleus accumbens shell region , updates the value placed on different goals in light of this new experience orbital prefrontal cortex , helps consolidate multiple forms of memory amygdala and hippocampus , and encodes new motor programs that will facilitate obtaining this reward in the future nucleus accumbens core region and dorsal striatum.
In this example, dopamine modulates the processing of sensorimotor information in diverse neural circuits to maximize the ability of the organism to obtain future rewards. The brain reward circuitry that is targeted by addictive drugs normally mediates the pleasure and strengthening of behaviors associated with natural reinforcers, such as food, water, and sexual contact. Dopamine neurons in the VTA are activated by food and water, and dopamine release in the NAc is stimulated by the presence of natural reinforcers, such as food, water, or a sexual partner.
As previously mentioned, the activity of dopaminergic neurons in the VTA appears to be linked to reward prediction. The NAc is involved in learning associated with reinforcement and the modulation of motoric responses to stimuli that satisfy internal homeostatic needs. The shell of the NAc appears to be particularly important to initial drug actions within reward circuitry; addictive drugs appear to have a greater effect on dopamine release in the shell than in the core of the NAc. If motivational drive is described in terms of wanting, and hedonic evaluation in terms of liking, it appears that wanting can be dissociated from liking and that dopamine may influence these phenomena differently.
Differences between wanting and liking are confirmed in reports by human addicts, who state that their desire for drugs wanting increases with continued use even when pleasure liking decreases because of tolerance. Reinforcement principles for addiction medicine; from recreational drug use to psychiatric disorder. Brain Res. Progress in Brain Research. An important dimension of reinforcement highly relevant to the addiction process and particularly relapse is secondary reinforcement Stewart, Secondary reinforcers in many cases also considered conditioned reinforcers likely drive the majority of reinforcement processes in humans.
In the specific case of drug addition, cues and contexts that are intimately and repeatedly associated with drug use will often themselves become reinforcing A fundamental piece of Robinson and Berridge's incentive-sensitization theory of addiction posits that the incentive value or attractive nature of such secondary reinforcement processes, in addition to the primary reinforcers themselves, may persist and even become sensitized over time in league with the development of drug addiction Robinson and Berridge, Drug Alcohol Depend.
Psychosom Med. National Institute of Mental Health. Retrieved 17 June Fortschr Neurol Psychiatr in German. Addictive disorders are chronic relapsing conditions marked by compulsive and often uncontrolled use of psychotropic substances or stimuli. In this review, we present and discuss the current specific psychosocial interventions for addictive disorders and their effectiveness.
In particular cognitive behavioral therapy, motivational interviewing, relapse prevention, the community reinforcement approach, and contingency management were found to be effective. For these psychotherapeutic treatments, mostly moderate effect sizes have been found. Their effectiveness seems to be highest in cannabis dependence.
Empirical evidence for dependence on "hard" drugs is largest for contingency management, while for alcohol dependence motivational interviewing and the community reinforcement approach show the largest effect sizes. Presumably, combinations of different approaches as well as online interventions will bring further progress in the psychosocial treatment of addictive disorders in the future. Environmental Enrichment In humans, non-drug rewards delivered in a contingency management CM format successfully reduced drug dependence In general, CM programs promote drug abstinence through a combination of positive reinforcement for drug-free urine samples.
For instance, voucher-based reinforcement therapy in which medication compliance, therapy session attendance, and negative drug screenings reinforced with vouchers to local business e. Physical Exercise There is accelerating evidence that physical exercise is a useful treatment for preventing and reducing drug addiction In some individuals, exercise has its own rewarding effects, and a behavioral economic interaction may occur, such that physical and social rewards of exercise can substitute for the rewarding effects of drug abuse.
The value of this form of treatment for drug addiction in laboratory animals and humans is that exercise, if it can substitute for the rewarding effects of drugs, could be self-maintained over an extended period of time. Work to date in [laboratory animals and humans] regarding exercise as a treatment for drug addiction supports this hypothesis. However, a RTC study was recently reported by Rawson et al. Animal and human research on physical exercise as a treatment for stimulant addiction indicates that this is one of the most promising treatments on the horizon.
Neurosci Biobehav Rev. Exercise also produces neuroadaptations that may influence an individual's vulnerability to initiate drug use. Consistent with this idea, chronic moderate levels of forced treadmill running blocks not only subsequent methamphetamine-induced conditioned place preference, but also stimulant-induced increases in dopamine release in the NAc Chen et al. Exercise has been proposed as a treatment for drug addiction that may reduce drug craving and risk of relapse. Although few clinical studies have investigated the efficacy of exercise for preventing relapse, the few studies that have been conducted generally report a reduction in drug craving and better treatment outcomes see Table 4.
Taken together, these data suggest that the potential benefits of exercise during relapse, particularly for relapse to psychostimulants, may be mediated via chromatin remodeling and possibly lead to greater treatment outcomes. Am J Drug Alcohol Abuse. The limited research conducted suggests that exercise may be an effective adjunctive treatment for SUDs.
In contrast to the scarce intervention trials to date, a relative abundance of literature on the theoretical and practical reasons supporting the investigation of this topic has been published. As briefly reviewed above, a large number of human and rodent studies clearly show that there are sex differences in drug addiction and exercise. The sex differences are also found in the effectiveness of exercise on drug addiction prevention and treatment, as well as underlying neurobiological mechanisms. The postulate that exercise serves as an ideal intervention for drug addiction has been widely recognized and used in human and animal rehabilitation.
In particular, more studies on the neurobiological mechanism of exercise and its roles in preventing and treating drug addiction are needed. Expert Opinion on Pharmacotherapy. Current Psychiatry Reports. American Family Physician. Exp Clin Psychopharmacol. Cannabis is the most widely used illicit substance in the world, and demand for effective treatment is increasing.
However, abstinence rates following behavioral therapies have been modest, and there are no effective pharmacotherapies for the treatment of cannabis addiction. Biol Psychiatry , — A pioneering study revealing both positive and negative modulatory effects of beta-arrestin2 on THC tolerance. By demonstrating that tolerance to antinociception is reduced whereas tolerance to catalepsy is enhanced in beta-arrestin2 knockout mice, authors suggest that development of cannabinoid agonists that minimize interactions between CB1Rs and beta-arrestin2 might produce improved cannabinoid analgesics with reduced motor suppression, and be therapeutically beneficial.
Am J Health Syst Pharm. Nicotinic receptor antagonists as treatments for nicotine abuse. Advances in Pharmacology. Health Technol Assess. Drug Development Research. Eur Addict Res. CNS Drugs. Expert Rev Clin Pharmacol. Despite concerted efforts to identify a pharmacotherapy for managing stimulant use disorders, no widely effective medications have been approved. Cochrane Database Syst.
To date, no pharmacological treatment has been approved for [addiction], and psychotherapy remains the mainstay of treatment. Decision Making. The Psychology of Depression. Exchange Vocabulary Tool. Ingredients of Happy and Healthy Living. How to Deal with Backsliding. Forward Steps to Recovery.
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