What recovers in Recovery? – Cognitive Control over emotions?

 In recent blogs we have called for an increase in research into the neurobiology of recovery to add to the extensive research already published on the neurobiology of the addiction cycle.
There has been extensive research into the neurobiology of addiction, most of this has focused on reward and motivation networks of the brain.  In effect this suggests there is a pathological wanting in addicts, an excessive motivation towards drug taking over all other rewarding activities.
This view does not fully consider that this pathological wanting is in itself a product of dysregulated stress systems in the brain, many the product of neglect, abuse and maltreatment in childhood. These stress factors are also reflective of the role of emotional distress in the addiction cycle . This distress is we feel a product of the emotion processing and regulation deficits commonly seen in all addictive behaviours such as alcohol and substance addiction, eating and gambling disorders and sex addiction etc (and often reflective of childhood maltreatment).
In fact , this emotion processing and  regulation deficit is also apparent in certain children of alcoholics and may be a vulnerability to later alcoholism as these children demonstrate a deficit in impulsivity (common to alcoholics and addicts) and a decision making profile based on choosing now over later (short term gains based) and which recruits more subcortical and motor expressive (compulsive) parts of the brain rather than cortical and reflective/evaluative parts of the brain.
This means they make decisions to alleviate the distress of decisions (as undifferentiated emotions appear to be distressing) not via evaluative processes). This has obvious consequence for decision making over a life span.
This emotion dysregulation is also seen in active addicts and alcoholics and at the endpoint of addiction there is a fairly complete reliance of this compulsive decision making profile, which begs the question, does the decision making deficits seen in at risk children simply get worse in the addiction cycle via the neuro toxic effects of substance abuse?
This emotion (and stress) dysregulation also potentiates reward (makes things more rewarding) so alcohol is seen as more stimulating than for non risk children. This vulnerability may lead to the need  to regulate, especially negative, emotions ( and low self esteem ) via the stimulating and highly rewarding effects of alcohol make perpetuate the addiction cycle to it’s chronic endpoint where chronic emotional distress acts as a compulsive stimulus to the responding of chronic alcohol and drug use.
This emotion dysregulation also seems to play a huge part in relapse – so it begs the question does this emotion regulation improve in time via recovery, particularly long term recovery?
In the next two blogs we look at how the emotion regulation areas of the brain become reinforced, strengthened by the process of recovery or in other words we appear to develop the brain capacity for controlling and regulating our emotions more adaptively and this reduces the stress/distress which often prompts relapse.
Personally, I can wholeheartedly say, that the one main aspect I have developed in my recovery has been the awareness and skills in regulating/controlling emotions. Via recovery I have learnt to identify, label, describe by verbalising and sharing with others how I feel. This processes and regulates the emotions that used to cause me so much distress.
I have also developed a more acute awareness of the the emotional expression and needs of yours. These were previously aspects of my life which were completely lacking and frustrating/confusing as a result.
By emotionally engaging in with the world, by becoming more emotionally literate, I can converse with the world in a way that was previously beyond my capabilities.
The research we look at in the next two blogs asks the question – is cognitive control over emotions, lacking in active addiction, one of the main brain functions that improve in recovery?
A core aspect of alcohol dependence is poor regulation of behavior and emotion.
Alcohol dependent individuals show an inability to manage the appropriate experience and expression of emotion (e.g., extremes in emotional responsiveness to social situations, negative affect, mood swings) (1,2). Dysfunctional emotion regulation has been considered a primary trigger for relapse (1,3) and has been associated with prefrontal dysfunction.
While current alcohol dependence is associated with exaggerated bottom-up (sub-cortical) and compromised top-down (prefrontal cortex) neural network functioning, there is evidence suggesting that abstinent individuals may have overcome these dysfunctional patterns of network functioning (4) .
Neuro-imaging studies showing chronic alcohol abuse to be associated with stress neuroadaptations in the medial prefrontal and anterior cingulate regions of the brain (5 ), which are strongly implicated in the self-regulation of emotion and behavioral self-control (6).
One study (2) looking at how emotional dysregulation related to relapse, showed compared with social drinkers, alcohol-dependent patients reported significant differences in emotional awareness and impulse control during week 1 of treatment. Significant improvements in awareness and clarity of emotion were observed following 5 weeks of protracted abstinence.
Another study (7) which did not look specifically at emotional regulation but rather on the recovering of prefrontal areas of the brain known to be involved also in the inhibition of  impulsive behaviour and emotional regulation showed that differences between the short- and long-abstinence groups in the patterns of functional recruitment suggest different cognitive control demands at different stages in abstinence.

In one study, the long-term abstinent group (n=9) had not consumed cocaine for on average 69 weeks, the short-term abstinent (SA) group (n=9) had an average 0f 2.4 weeks.

Relative to controls, abstinent cocaine abusers have been shown to have reduced metabolism in left anterior cingulate cortex (ACC) and right dorsolateral prefrontal cortex (DLPFC), and greater activation in right ACC.
In this study  the abstinent groups of cocaine addicts showed more elevated activity in the DLPFC ; a finding that has also been observed in abstinent marijuana users (8).
The elevation of frontal activity also appears to undergo a shift from the left to right hemisphere over the course of abstinence.  The right is used more in processing (labelling/identifying) of emotion.
Furthermore, the left inferior frontal gyrus (IFG) has recently been shown to be important for response inhibition (9) and in a task similar to that described here, older adults have been shown to rely more on left PFC (10). Activity observed in these regions is therefore likely to be response inhibition related.
The reliance of the SA group on this region suggests that early in abstinence users may adopt an alternative cognitive strategy in that they may recruit the LIFG in a manner akin to children and older adults to achieve behavioral results similar to the other groups.
In longer,  prolonged abstinence a pattern topographically typical of normal, healthy controls may emerge.
In short-term abstinence there was an increased inhibition-related dorsolateral and inferior frontal activity indicative of the need for increased inhibitory control over behaviour,  while long-term abstinence showed increased error-related ACC activity indicative of heightened behavioral monitoring.
The results suggest that the improvements in prefrontal systems that underlie cognitive control functions may be an important characteristic of successful long-term abstinence.
Another study (11) noted the loss of grey matter in alcoholism that last from 6–9 months to more than a year or, in some reports, up to at least 6 years following abstinence (12 -14).
It has been suggested cocaine abuse blunts responses in regions important to emotional regulation (15)
Given that emotional reactivity has been implicated as a factor in vulnerability to drug abuse (16)  this may be a preexisting factor that  increased the likelihood of the development and prolonging of drug abuse
If addiction can be characterized as a loss of self-directed volitional control (17),  then abstinence (recovery) and its maintenance may be characterized by a reassertion of these aspects of executive function (18)  as cocaine use has been shown to reduce grey matter in brain regions critical to executive function, such as the anterior cingulate, lateral prefrontal, orbitofrontal and insular cortices (19-24) .
The group of abstinent cocaine addicts (11) reported here show elevations in  (increased) grey matter in abstinence exceeded those of the healthy control in this study after 36 weeks, on average, of abstinence .
One possible explanation for this is that abstinence may require reassertion of cognitive control and behavior monitoring that is diminished during current cocaine dependence.
Reassertion of behavioral control may produce a expansion (25)  in grey matter  in regions such as the anterior insula, anterior cingulate, cerebellum, and dorsolateral prefrontal cortex .
All brain regions implicated in the processing and regulating of emotion. 
References
1. Berking M, Margraf M, Ebert D, Wupperman P, Hofmann SG, Junghanns K. Deficits in emotion-regulation skills predict alcohol use during and after cognitive-behavioral therapy for alcohol dependence. J Consult Clin Psychol. 2011;79:307–318.
2.  Fox HC, Hong KA, Sinha R. Difficulties in emotion regulation and impulse control in recently abstinent alcoholics compared with social drinkers. Alcohol Clin Exp Res. 2008;33:388–394.
3..Cooper ML, Frone MR, Russell M, Mudar P. Drinking to regulate positive and negative emotions: A motivational model of alcohol use. J Pers Soc Psychol. 1995;69:990
4. Camchong, J., Stenger, A., & Fein, G. (2013). Resting‐State Synchrony in Long‐Term Abstinent Alcoholics. Alcoholism: Clinical and Experimental Research37(1), 75-85.
5. Sinha, R., & Li, C. S. (2007). Imaging stress- and cue-induced drug and alcohol craving: Association with relapse and clinical
implications. Drug and Alcohol Review, 26(1), 25−31.
6. Beauregard, M., Lévesque, J., & Bourgouin, P. (2001). Neural correlates of conscious self-regulation of emotion. Journal of
Neuroscience, 21(18), RC165
7. Connolly, C. G., Foxe, J. J., Nierenberg, J., Shpaner, M., & Garavan, H. (2012). The neurobiology of cognitive control in successful cocaine abstinence. Drug and alcohol dependence121(1), 45-53.
8.  Tapert SF, Schweinsburg AD, Drummond SP, Paulus MP, Brown SA, Yang TT, Frank LR. Functional MRI of inhibitory processing in abstinent adolescent marijuana users.Psychopharmacology (Berl.) 2007;194:173–183.[PMC free article]
9. Swick D, Ashley V, Turken AU. Left inferior frontal gyrus is critical for response inhibition. BMC Neurosci. 2008;9:102.[PMC free article]
10. Garavan H, Hester R, Murphy K, Fassbender C, Kelly C. Individual differences in the functional neuroanatomy of inhibitory control. Brain Res. 2006;1105:130–142
11. Connolly, C. G., Bell, R. P., Foxe, J. J., & Garavan, H. (2013). Dissociated grey matter changes with prolonged addiction and extended abstinence in cocaine users. PloS one8(3), e59645.
12. Chanraud S, Pitel A-L, Rohlfing T, Pfefferbaum A, Sullivan EV (2010) Dual Tasking and Working Memory in Alcoholism: Relation to Frontocerebellar Circuitry. Neuropsychopharmacol 35: 1868–1878 doi:10.1038/npp.2010.56.
13.  Wobrock T, Falkai P, Schneider-Axmann T, Frommann N, Woelwer W, et al. (2009) Effects of abstinence on brain morphology in alcoholism. Eur Arch Psy Clin N 259: 143–150 doi:10.1007/s00406-008-0846-3.
14.  Makris N, Oscar-Berman M, Jaffin SK, Hodge SM, Kennedy DN, et al. (2008) Decreased volume of the brain reward system in alcoholism. Biol Psychiatry 64: 192–202 doi:10.1016/j.biopsych.2008.01.018.
15, Bolla K, Ernst M, Kiehl K, Mouratidis M, Eldreth D, et al. (2004) Prefrontal cortical dysfunction in abstinent cocaine abusers. J Neuropsychiatry Clin Neurosci 16: 456–464 doi:10.1176/appi.neuropsych.16.4.456.
16.  Piazza PV, Maccari S, Deminière JM, Le Moal M, Mormède P, et al. (1991) Corticosterone levels determine individual vulnerability to amphetamine self-administration. Proc Natl Acad Sci USA 88: 2088–2092. doi: 10.1073/pnas.88.6.2088
17.  Goldstein RZ, Volkow ND (2002) Drug addiction and its underlying neurobiological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry 159: 1642–1652. doi: 10.1176/appi.ajp.159.10.1642
18. Connolly CG, Foxe JJ, Nierenberg J, Shpaner M, Garavan H (2012) The neurobiology of cognitive control in successful cocaine abstinence. Drug Alcohol Depend 121: 45–53 doi:10.1016/j.drugalcdep.2011.08.007.
19.  Liu X, Matochik JA, Cadet JL, London ED (1998) Smaller volume of prefrontal lobe in polysubstance abusers: a magnetic resonance imaging study. Neuropsychopharmacol 18: 243–252 doi:10.1016/S0893-133X(97)00143-7.
20.  Bartzokis G, Beckson M, Lu P, Nuechterlein K, Edwards N, et al. (2001) Age-related changes in frontal and temporal lobe volumes in men – A magnetic resonance imaging study. Arch Gen Psychiatry 58: 461–465. doi: 10.1001/archpsyc.58.5.461
21. Franklin TR, Acton PD, Maldjian JA, Gray JD, Croft JR, et al. (2002) Decreased gray matter concentration in the insular, orbitofrontal, cingulate, and temporal cortices of cocaine patients. Biol Psychiatry 51: 134–142. doi: 10.1016/s0006-3223(01)01269-0
22.  Matochik JA, London ED, Eldreth DA, Cadet J-L, Bolla KI (2003) Frontal cortical tissue composition in abstinent cocaine abusers: a magnetic resonance imaging study. NeuroImage 19: 1095–1102. doi: 10.1016/s1053-8119(03)00244-1
23.  Lim KO, Wozniak JR, Mueller BA, Franc DT, Specker SM, et al. (2008) Brain macrostructural and microstructural abnormalities in cocaine dependence. Drug Alcohol Depend 92: 164–172 doi:10.1016/j.drugalcdep.2007.07.019.
24.  Ersche KD, Barnes A, Jones PS, Morein-Zamir S, Robbins TW, et al. (2011) Abnormal structure of frontostriatal brain systems is associated with aspects of impulsivity and compulsivity in cocaine dependence. Brain 134: 2013–2024 doi:10.1093/brain/awr138.
25.  Ilg R, Wohlschlaeger AM, Gaser C, Liebau Y, Dauner R, et al. (2008) Gray matter increase induced by practice correlates with task-specific activation: A combined functional and morphometric magnetic resonance Imaging study. J Neurosci 28: 4210–4215 doi:10.1523/JNEUROSCI.5722-07.2008.

The Road to Recovery

Following on from our recent blog on “So what is Recovery?” we now look at the process of recovery itself and important changes that contribute to successful recovery.

Many recovering persons report quitting drugs because they are ‘sick and tired’ of the drug life. Recovery is the path to a better life but that path is often challenging and stressful.

However, the main message from this study (1) is that those individuals who manage to get to 5 or more years abstinence have an 86% chance of long term recovery !

Not only do the recovering persons benefit in many ways but families and societies also see major benefits of recovery too. The initial cost of recovery, i.e. if via treatment facilities, is offset by increased employment, less penal costs, financial contributions to society of recovering persons etc.

Not only does it make ethical, moral and medical sense to spend much more on treatment facilities it makes makes very obvious financial sense.

“Although substance use disorders are increasingly recognized as chronic relapsing conditions that often span decades and require multiple episodes of treatment and/or self-help (Anglin, Hser, and Grella 1997; Anglin et al. 2001; Dennis, Scott et al. 2003; Dennis and Scott [in press]; Hser et al. 1997; Hser et al. 2001; McAweeney et al. 2005; McLellan et al. 2000; Moos and Moos 2005, 2006; Scott, Foss, and Dennis 2005a, 2005b; Simpson, Joe, and Broome 2002; Vaillant 1988; Weisner, Matzger, and Kaskutas 2003; White 1996), approximately 60% of the people with lifetime substance disorders do eventually reach a state of sustained abstinence (Cunningham 1999a, 1999b; Dawson 1996; Dennis et al. 2005; Kessler 1994; Robins and Regier 1991).

This has led to multiple calls to define and better understand and study “recovery” in terms of not only abstinence but improvements in health, mental health, coping, housing, social and spiritual support, illegal activity, and vocational engagement (Betty Ford Consensus Panel [in press]; Laudet, Morgen, and White 2006; Laudet, White, and Storey [in press]; White 2005).

Using data from 1,162 adults living in a large metropolitan area who sought substance abuse treatment in 1998 and who were subsequently interviewed annually between Years 2 and 8 (greater than 94% follow-up rate each year), this study addresses the following four questions:

1. How do health, mental health, and coping vary by duration of abstinence?

2. How do illegal activity, incarceration, employment, and family income vary by duration of abstinence?

3. How do housing, clean and sober friends, recovery environment, self-efficacy to resist relapse, and social and spiritual support vary by duration of abstinence?

4. How does the likelihood of sustaining abstinence another year vary by the duration of abstinence?

Health, mental health, and coping. Abstinence is generally associated with better health, mental health, and coping. Among people in the community, less substance use is associated with lower rates of chronic health and psychiatric problems, which are in turn associated with high societal costs and death (Mokdad et al. 2004).

Abstinence is also associated with less “avoidance” coping styles, such as cognitive avoidance and emotional discharge, as well as more “approach” coping styles, such as logical analysis, seeking guidance, problem solving, seeking alternative rewards, and positive reappraisal (Carpenter and Hasin 1999; Chung et al. 2001; Finney and Moos 1995; Holahan et al. 2003; Moggi et al. 1999; Moos and Moos 2005).

Abstinence has generally been associated with reductions in illegal activity, incarceration, poverty, and improvements in vocational activity. Reductions in substance use are associated with relatively rapid reductions in illegal activity and illegal income (Dismuke et al. 2004; Scott, Foss et al. 2003).

Although this often involves some period of residential treatment or incarceration, such costs are typically offset by reductions in other costs to society, increased employment, and increased productivity (Bray et al. 2000; French, Salome, and Carney 2002; McCollister and French 2003; Rajkumar and French 1997; Single et al. 1998).

Abstinence is generally associated with being housed and having some friends, fewer problems in the recovery environment, and more personal, family, social, and spiritual support.

Risks (e.g., substance use among family, friends, and victimization) and protective factors (e.g., treatment and self-help participation, peers in recovery) in the recovery environment and self-efficacy to resist relapse were also among the major predictors of transitions from using to recovery and relapse (Humphreys, Moos, and Cohen 1997; Schutte et al. 2001; Scott et al. 2005b).

The general association between relapse and stress has also been found to be moderated by the extent of support one gets from self-perceived personal strengths, family, and social peers (Jessor, Turbin, and Costa 1998, Laudet et al. 2004; Miller 1998; Miller et al. 1996; Procidano and Heller 1983; Schutte et al. 2001).

We found no studies to date using the “duration of abstinence” to predict the likelihood of sustaining abstinence for another year. However, a recent extensive review by Moos and Moos (2007) found one or more of four dozen studies reporting that the odds of sustaining abstinence was positively associated with abstinence self-efficacy, approach coping styles, vocational engagement, income, having clean and sober friends, and having social and spiritual support and inversely related to an avoidance approach coping style.

Findings – This study demonstrates that duration of abstinence is related to changes in other aspects of recovery but at different rates and times.

Use of coping mechanisms started out high and decreased as the number of years of abstinence increased, suggesting that the high rates of these coping strategies previously reported by others (see Moos and Moos 2007) may actually be a characteristic of early abstinence. Mental health problems peaked during 1 to 3 years of abstinence and decreased thereafter.

The rapid decrease in illegal activity and illegal income sustained across varying lengths of abstinence was consistent with the literature given that many of the crimes were drug related. Following 1 year of abstinence, the number of days worked and legal income generated significantly increased and days with financial problems decreased. After 3 years of abstinence, there were also significant reductions in the percentage of families living below the poverty line, which indicates continued gains in financial status.

Consistent with the literature, the duration of abstinence was associated with reduced environmental risks and increased number of clean and sober friends, level of social support, spiritual support, and self-efficacy to resist relapse.

The odds of sustaining abstinence increased dramatically during the first 3 years and then leveled off. Among people with 5 or more years of abstinence, there was still some risk of relapse (14%) – but equally a 86% chance of remaining in recovery!

Consistent with earlier findings by Grella et al. (Grella, Scott, and Foss 2005; Grella et al. 2003; Grella et al. [in press]) that women were more likely to enter and stay in recovery.

Implications for Practice, Policy, and Research

Findings suggest the need for a shift from focusing on acute episodes of treatment to the management of recovery during longer periods of time.

Most of the drug abuse treatment research to date has focused on reducing days of use or abstinence in the first 6 to 12 months after treatment (Dennis and Scott [in press]; Prendergast et al. 2002). More health services research is needed on managing long-term recovery, both in terms of how to deliver it in ways that are both effective and cost effective for multiple years. This includes research on ways to integrate these other kinds of services, minimize some of the negative trends (e.g., the early peak in mental health problems), and accelerate the positive trends (e.g., more positive recovery environment and vocational activity).

Conclusion

Although much of the research on substance abuse treatment outcomes has focused on abstinence in the first 6 to 12 months after treatment, this article suggests that initial abstinence and the initial time period do not fully represent the changes associated with long-term recovery. This research shows that risk of relapse is particularly problematic in the first 3 years of abstinence and never completely goes away, suggesting the need for promoting strategies and programs that support the long-term management of recovery.

References

1. Dennis, M. L., Foss, M. A., & Scott, C. K. (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), 585-612.