People in active addiction to alcohol and drugs use despite the harmful physical effects. Marvin D. Seppala, MD, joins host William C. Moyers to discuss the disease of addiction and the role of dopamine in the brain and other high risk factors.
0:01:13 William Moyers
Hello and welcome to Let's Talk, a series of podcasts produced by the Hazelden Betty Ford Foundation on the issues that matter to us and matter to you, too. Issues related to addiction, research, prevention, treatment and recovery support. I'm your host William Moyers and today we're joined by the Chief Medical Officer of the Hazelden Betty Ford Foundation, my friend and colleague, Dr. Marvin Seppala. Welcome, Marv.
0:00:40 Dr. Marv Seppala
Thanks, William, good to be back here.
0:00:41 William Moyers
Good to have you with us. And today we're going talk about the fact that addiction, as you and I know, is an illness of the mind and the body and the spirit. And we want to focus in this podcast on the mind and the body components of this dynamic illness. How do substances affect the body and the mind? Starting with the mind.
0:01:03 Dr. Marv Seppala
So we've come to understand the neurobiology of addiction really well this past 20 years or so. Although the research goes back into the seventies even. But we've identified through that research the two main parts of the brain involved. And it includes the reward center, which is described as subcortical or subconscious which would be another way of putting it. But it's not in a thinking part of the brain, it's kind of an automatic part of the brain. And the reward center's primary function is keeping us alive. It's all about survival. And the drugs that intoxicate us all affect the reward center by releasing dopamine. Now it's not the only neurotransmitter associated with addiction but it's the primary neurotransmitter. And dopamine is released whenever we do something rewarding. So, survival-based behaviors like sexual behaviors. It has to do with survival of the species.
0:01:59 William Moyers
0:02:00 Dr. Marv Seppala
Any species. You know and then food intake, water intake, personal/social interaction for human beings. All are survival-based. And keep us alive. And dopamine's released with all those activities. But, dopamine's released even more so by the drugs that we get intoxicated with, with alcohol as well. And way more so than natural reinforcers.
0:02:29 William Moyers
0:02:29 Dr. Marv Seppala
The only thing the parts of the brain in that reward center recognize is how much dopamine's released. And the more that's released, the more important the stimulus. So, I love dark chocolate. Probably releases a bunch of dopamine when I am even just preparing to eat it. But not that much, right? It's dark chocolate.
0:02:48 William Moyers
0:02:49 Dr. Marv Seppala
Or, you know, skiing. I love to ski and there's going to be some dopamine release but again, not that much. Neither are required for me to survive. Sexual behavior releases a lot of dopamine. But all the drugs of abuse, all the drugs we misuse, release way more. And so the stimulus, what's learned by the brain, is what's really important.
0:03:13 William Moyers
But it's out of whack.
0:03:14 Dr. Marv Seppala
Yeah, it's out of whack. And the brain doesn't know it's out of whack because of the stimulus, it only knows that there's a lot of dopamine associated with that stimulus.
0:03:21 William Moyers
0:03:22 Dr. Marv Seppala
So, I think I'll do that again.
0:03:24 William Moyers
0:03:25 Dr. Marv Seppala
And then those of us that become addicted, we cross this line from kind of a recognition in the brain that even though there's a lot of it, it's not going to alter the course of our lives. But those of us who become addicted, all of a sudden it starts to alter the course of our lives. And in fact, starts to re-prioritize those drive states. The drive states associated with survival and other rewarding activities. To the point that continued use of the drug becomes more important than life itself.
0:03:58 William Moyers
Nothing else matters. Except that next.
0:03:59 Dr. Marv Seppala
Nothing else matters. Yeah, the next high, that next bump, whatever it may be. And so we see when people are in the midst of addiction all the things they used to do, their hobbies, activities, they just go by the wayside.
0:04:13 William Moyers
Responsibilities. Relationships. Everything.
0:04:16 Dr. Marv Seppala
Yeah. Yeah, everything. Nothing's as important anymore. In that reward center. So imagine this: it's all about survival so it affects the rest of our brain and how we think, right? And there's all these connections to other parts of the brain. And we think with our prefrontal cortex. That's where we recognize a problem and plan out solutions and carry them out.
0:04:35 William Moyers
Where is that? [points to middle of forehead]
0:04:36 Dr. Marv Seppala
Yeah, up in the front part of our brain [gestures] and it's in the cortex itself. It's where we actually think. And could, you know, recognize a problem and take care of it. But, in the course of addiction, and they've shown this in brain scanning studies and in studies of neurotransmitter release, that both reward center and this prefrontal cortex are dysfunctional. They still work, they're just not working as well. So the dysfunction reward center is responding to those drugs, to that extra dopamine, by wanting more and more and more and limiting all these other activities because they're not as important. The prefrontal cortex is no longer functioning as well and can't recognize the problem. So what we call denial frequently is way more than denial. It's the actual brain dysfunction limiting the ability to even recognize or do anything about this problem.
0:05:29 William Moyers
So you mean there's a science to denial?
0:05:31 Dr. Marv Seppala
There sure is! Yeah.
0:05:32 William Moyers
0:05:33 Dr. Marv Seppala
A science to denial, a science to addiction, so if survival would be normally considered the most important drive.
0:05:41 William Moyers
0:05:42 Dr. Marv Seppala
But now it's superseded by this drive. And we see that all the time. People who've had six overdoses and have a seventh and die. The person who's drinking alcohol to the point that they have liver cirrhosis and don't stop. You know it's killing 'em and they can't stop. All these decisions that reveal that the risk to ourselves isn't as important as continued use of this substance is explained by how the reward center responds.
0:06:08 William Moyers
So then the science of addiction really comes down to the fact that these substances hijack the brain.
0:06:15 Dr. Marv Seppala
They really do hijack the brain.
0:06:18 William Moyers
What about when it comes to the substances and how they manifest themselves in the body?
0:06:25 Dr. Marv Seppala
So there's alcohol for example, kills brain cells, you know. So it can reduce the size of the brain even, what we used to call wet brain, has to do with the lower and lower number of brain cells there. And then the rest of that space filling with liquid. Alcohol is metabolized in the liver which the liver you know is just trying to clean the blood of all these different things in particular alcohol. And it damages the liver. So first it becomes more fatty. Just a lot of fat content in response to you know being damaged. Then it starts to get hard. Once it starts to get hard, it goes from what we call fatty liver in early aspects of alcohol use disorders to cirrhosis, alcoholic cirrhosis. Where it's really hard and starts to shrink. When it starts to shrink, the liver actually surrounds the vena cava which is the major vein returning blood from all over the body especially the lower extremities back to the heart. So it can go through the lungs and get oxygenated for energy and for use all around the body.
0:07:34 Dr. Marv Seppala
As it's going through the liver as the liver is shrinking, it eliminates the ability of enough blood to get back through that vena cava so all these other veins start to get bigger in response to that. Sometimes going up inside your esophagus. So when you hear about someone with alcoholism that has esophageal varices that burst and they have this horrible bleeding all of a sudden and can die from it, it's because their liver's so bad that they no longer have this main kind of expressway for blood to get back to the heart. And so that finds other routes.
0:08:10 Dr. Marv Seppala
And those sorts of things are really a problem. Alcohol is a solvent, it goes all over. So it actually affects all our organs throughout the body. It contributes to cancers, breast cancer is worse with people who drink regularly. Throat cancers, neck cancers, stomach cancers, all these things worsened by alcohol. Because it is a toxin to us. If you look at opioids by comparison. Opioids we have a natural internal opioid system. We don't have a natural internal alcohol system.
0:08:41 William Moyers
0:08:42 Dr. Marv Seppala
So the opioids they just hook on to opioid receptors already there waiting for 'em kinda. And the opioids don't hurt our brain cells.
0:08:51 William Moyers
Even though they can kill us.
0:08:52 Dr. Marv Seppala
Yeah, they could kill us by overriding the brainstem, our respiratory center where breathing is controlled. And it overrides it to slow it down, slow it down, slow it down 'til we stop breathing. So it can do that to us. But it doesn't kill those cells it just alters how they function. Opioids in general when you read about people that have had decades of opioid addiction, you don't usually see damage from the opioid itself. Those people have medical illnesses, all kinds of them, usually from IV use from injecting and bacteria you know all kinds of infections. You know a lot of high rates of Hepatitis C, HIV, those sorts of things. So other viruses causing the problems in their bodies associated with their use. But not caused by the drug itself.
0:09:49 Dr. Marv Seppala
You know the stimulants methamphetamine harms brain cells doesn't necessarily kill them. And does so a lot with brain cells associated with memory and undermine the ability to remember new information. So we had a physician actually in our facility out in Oregon, Hazelden Newberg, who was in his forties and started using methamphetamine 'cause he was dating a woman who used methamphetamine. And he wasn't, he never was a drinker, he never used other drugs, pretty clean-cut guy. Until this relationship. And all of a sudden he was off and running. And he was working in a hospital up until the day he was admitted to our facility. So that's an important part of the story because he gets into our facility, he stops the methamphetamine and there's only one men's hallway in that facility, in that residential facility. And so all their rooms are down that hallway. Couldn't find his room. Day in and day out. Couldn't remember where his room was. He could write beautifully and he'd write this significant event sheet about what he learned that day, every day. And not even remember what he wrote by noon. He had no, you know, recall of new information. And that can take six to twelve or more months to return to normal. This guy couldn't go back to the hospital and work for a long time. Because his brain wasn't functioning correctly because of that damage.
0:11:23 Dr. Marv Seppala
Cocaine doesn't do that, but it does other things. So cocaine can cause heart attacks. It can even cause strokes. You know if you're smoking cocaine, crack cocaine especially, it vaporizes kinda goes into a gaseous state. And if it gets to your brain fast enough it can start to recrystallize there in these teeny little arteries and block 'em off. Causing micro strokes and things, and so all kinds of different aspects of these different drugs that affect us physically and harm us. And marijuana, you know affects how we learn. Affects our memory, our concentration, and can cause psychosis and even schizophrenia. So there's a lot of different ways these drugs play a role in our bodies. But when we talk addiction to them, when people cross the line into addiction, it's all identical. It's like a final common pathway. It's just those two parts of the brain.
0:12:31 William Moyers
So the point being that all of those substances have an effect on the mind and on the body, but they don't always affect people the same way. It's only a small percentage of people who become actually addicted to them, correct?
0:12:44 Dr. Marv Seppala
Correct. Yeah. [nods]
0:12:45 William Moyers
And so there's a genetic component too.
0:12:47 Dr. Marv Seppala
Absolutely. So we say the major risk factor associated with addiction is genetic. It is at least 40 to 60 percent of the risk associated with addiction. Much like many other illnesses. Where you've got a genetic component and an environmental component. And for addiction, the genetic component's big, it's the major risk factor. But environmental components also play a role. So if you've had a history of trauma let's say at 13 you were raped by somebody.
0:13:18 William Moyers
0:13:18 Dr. Marv Seppala
A lot more likely to become addicted. If you have another psychiatric illness that can put you at higher risk for addiction.
0:13:26 William Moyers
0:13:27 Dr. Marv Seppala
You know, those sorts of things also alter the course of this disease. But you know in my case and I'm a hundred percent Finnish and I've had--
0:13:35 William Moyers
Finnish as in from Finland. Right.
0:13:37 Dr. Marv Seppala
From Finland, yeah, yeah. And the Finnish government about ten, twelve years ago announced that the number one cause of death was alcoholism. So big genetic load among Finns. It is the first country to admit this and beat the Irish, you know. [both chuckle softly] And as a result, I have a pretty big genetic load for addiction. I have four siblings none of whom developed addiction.
0:14:04 William Moyers
0:14:05 Dr. Marv Seppala
Which is kinda weird, but I did.
0:14:06 William Moyers
0:14:07 Dr. Marv Seppala
And I had it really severe from the very start.
0:14:10 William Moyers
At a young age.
0:14:10 Dr. Marv Seppala
Yeah at a really young age. And so I had what would be described as a real genetic aspect to addiction.
0:14:17 William Moyers
0:14:18 Dr. Marv Seppala
Whereas someone else let's say someone else has just a little bit of that genetic load but they have multiple traumas in their adolescence. You know that genetic load puts them at some risk but the trauma kinda puts it over the edge. With a high genetic load you may not need any other factor.
0:14:39 William Moyers
We only have about a minute left. I want to just get to this and maybe we'll have to have another podcast when we talk about the mind and the body as it relates to addiction. But also the mind and the body as it relates to recovery. And in the short time we have for now Dr. Seppala, talk just a little bit about where you think the science of addiction is taking us in terms of the treatment of addiction and the recovery from addiction.
0:15:07 Dr. Marv Seppala
So right now, the main place that science is taking us has to do with that neurobiology of addiction and the effects of these substances on our brains to come to understand it better and to try to figure out tools to address addiction and help people get into recovery. And the primary focus of like the National Institute of Health being you know National Institute of Drug Abuse, National Institute of Alcohol Abuse and Alcoholism is medications. So they're funding other types of research but that's their primary focus. And so that's where we'll probably really see the advances over time. And maybe, you know, well, I know this is actually factual. One of the genetic alterations associated with addiction has to do with a metabolic pathway in the brain associated with a B vitamin.
0:16:00 William Moyers
Mmm. [nodding vigorously, intrigued]
0:16:01 Dr. Marv Seppala
And that actually ultimately turns into dopamine and several other neurotransmitters. And so you can get a blood test that shows whether you have both or one of these two genes that are altered. And so I did that. I went, I had the blood test just to check, I have alteration on both of 'em. So I really do have a high genetic load. And as a result, probably have a lower dopamine level than most people.
0:16:26 William Moyers
Oh! Yeah. [nods]
0:16:26 Dr. Marv Seppala
So it's just kinda [gestures with hands] This is theoretical, but, a lower dopamine tone it's called, so lower amount of dopamine in general in my brain would have left me at risk for addiction from first use because it bumped it up.
0:16:42 William Moyers
0:16:41 Dr. Marv Seppala
To the normal range. And I probably felt better and normal with use than I did without.
0:16:49 William Moyers
0:16:50 Dr. Marv Seppala
Yeah. And someday we'll be able to use these tests and simple tools. Like L-methylfolate, a B vitamin, is used to fix that issue I just described. Just a regular B vitamin.
0:17:03 William Moyers
0:17:04 Dr. Marv Seppala
And may limit people's relapse. But we haven't had the research yet to support what I just said. So it's theoretical but really likely.
0:17:13 William Moyers
It's complex, addiction is complex, the science of addiction is involved. That means then that the science of recovery and how the body responds to not using substances and how the body responds to treatment is not as simple as just getting better, right? It takes time. Talk to us about the process of recovery in the context of the science.
0:17:37 Dr. Marv Seppala
There's some information about recovery and not enough. You know, we focused on the pathology in the research trying to figure out what causes this and how can we address it and less on recovery. But we know some things. So, like alcohol causes memory problems. Within about a month you get 80/90 percent of that memory back. Within six, probably that's gonna be what you get. [gestures with hands to show gap] Some people have done enough brain damage that you know after that month everyone's going wow, look, she's doing so much better. But then at six months, it's not that much different than that one month. And so, that's kind of the factor with alcohol. With the methamphetamine, six, twelve, eighteen months before memory starts really coming around.
0:18:26 William Moyers
Wow. [shaking head]
0:18:27 Dr. Marv Seppala
And we don't have the long-term studies yet. We did a study, Hazelden Betty Ford, with University of Minnesota doing brain scans--
0:18:35 William Moyers
0:18:35 Dr. Marv Seppala
--on folks with cocaine use disorders. And looking at that comin' back in recovery. And I don't remember the details. Six to twelve months things are really lookin' good. The way I look at it often is more behaviorally. When I know people in recovery over time. And really see them comin' around, you know. They're interacting with people again, they look happy and joyful, you know. They're doing things with their life and they kinda come alive again. And that takes months and sometimes years. It can be altered by depression, anxiety, other mental illnesses.
0:19:13 William Moyers
0:19:13 Dr. Marv Seppala
You know co-morbid sort of things that get in the way. But in general, it takes a long time. And when you look at some of the statistics associated with long-term recovery, if you believe everyone's sober in a treatment sample of a couple hundred people, which may or may not be true.
0:19:36 William Moyers
0:19:37 Dr. Marv Seppala
But you know they're in treatment. There's old studies that show, especially done with alcohol, that right off the bat, first six months, the relapse rates are tremendously high. You know. There's diminished recovery rates. And by twelve months, it's really stabilizing. And by eighteen months to two years, there's hardly any relapse. So if you can get through that first year to 18 months, you've got a really good chance of recovery. And we know from other research that the longer you're involved in treatment, the higher the likelihood of recovery. And that probably is just the same thing going on. That the longer you're involved, the more likely you'll be sober. 'Cause you stayed involved. And as a result, you're lasting long enough to be able to get into good long-term recovery.
0:20:26 William Moyers
0:20:27 Dr. Marv Seppala
And that doesn't mean no one relapses after a certain point by any means, but, the bulk of the issue's right off the bat.
0:20:33 William Moyers
0:20:33 Dr. Marv Seppala
And I don't think we do enough about that. We need to do a lot more. One of the things behind COR-12®, our program for those folks with opioid use disorders, was keep them engaged.
0:20:45 William Moyers
0:20:46 Dr. Marv Seppala
Long-term. Because we wanna keep 'em alive, you know at a minimum, we wanna keep 'em growing in recovery. And ultimately no longer needing our services. And the medications help keep 'em engaged and all of the psychosocial therapies help keep 'em engaged. And getting the Twelve Step programs or other means of support in recovery keeps them engaged and keeps them doing the things they need to do to stay sober.
0:21:13 William Moyers
Well and no wonder the phrase that's often uttered in recovery 'A day at a time' really does stick. Because if you can take it a day at a time, you can move beyond those days into those weeks and into those months since your last use. And you can gain that traction in recovery. That is as relevant to the process as the science of addiction is on the front end as well.
0:21:34 Dr. Marv Seppala
Absolutely. And it's such a great way of looking at it. 'Cause you know if I can just make it today.
0:21:39 William Moyers
0:21:40 Dr. Marv Seppala
Or make it you know, early, this hour. You know or get past this old friend who's got whatever in his pocket [laughing], you know, just getting to the next goal.
0:21:51 William Moyers
0:21:52 Dr. Marv Seppala
Whatever it may be is so important. And focusing on today. And not just to stay sober today after a period of time it's no longer about sobriety. It's living my life to the best of my ability.
0:22:04 William Moyers
0:22:05 Dr. Marv Seppala
0:22:05 William Moyers
Right. Well thank you, Dr. Seppala, for bringing your incredibly professional expertise and your personal passion to the science of addiction and looking at it as it relates to the mind and the body. I know we'll have another conversation around spirituality of recovery when you join us for another edition of Let's Talk, a series of podcasts produced by the Hazelden Betty Ford Foundation on the issues that matter to all of us. Thank you for joining us today and we'll see you another time.