Friday, 8 February 2019

How brain science informs addiction treatment

Information is knowledge, and big tech companies know how important it is to collect and track data. When it comes to your health, it is now easy to measure and track all kinds of information. In the comfort of our homes we can check our weight, blood pressure, number of steps, calories, heart rate, and blood sugar. Recently some researchers have started to use an interesting marker for resilience and behavioral flexibility. It is called heart rate variability (HRV).

Have you ever wondered what the health impact of a stressful day was? Will you perform well during your long run tomorrow morning? Is there anything you can do today that would improve your ability to have a better day moving forward? HRV may be the piece of data that could help you answer these questions.
What is HRV?

HRV is simply a measure of the variation in time between each heartbeat. This variation is controlled by a primitive part of the nervous system called the autonomic nervous system (ANS). It works regardless of our desire and regulates, among other things, our heart rate, blood pressure, breathing, and digestion. The ANS is subdivided into two large components, the sympathetic and the parasympathetic nervous system, also known as the fight-or-flight mechanism and the relaxation response.

The brain is constantly processing information in a region called the hypothalamus. The hypothalamus, through the ANS, sends signals to the rest of the body either to stimulate or to relax different functions. It responds not only to a poor night of sleep, or that sour interaction with your boss, but also to the exciting news that you got engaged, or to that delicious healthy meal you had for lunch. Our body handles all kinds of stimuli and life goes on. However, if we have persistent instigators such as stress, poor sleep, unhealthy diet, dysfunctional relationships, isolation or solitude, and lack of exercise, this balance may be disrupted, and your fight-or-flight response can shift into overdrive.
Why check heart rate variability?

HRV is an interesting and noninvasive way to identify these ANS imbalances. If a person’s system is in more of a fight-or-flight mode, the variation between subsequent heartbeats is low. If one is in a more relaxed state, the variation between beats is high. In other words, the healthier the ANS the faster you are able to switch gears, showing more resilience and flexibility. Over the past few decades, research has shown a relationship between low HRV and worsening depression or anxiety. A low HRV is even associated with an increased risk of death and cardiovascular disease.

People who have a high HRV may have greater cardiovascular fitness and be more resilient to stress. HRV may also provide personal feedback about your lifestyle and help motivate those who are considering taking steps toward a healthier life. It is fascinating to see how HRV changes as you incorporate more mindfulness, meditation, sleep, and especially physical activity into your life. For those who love data and numbers, this can be a nice way to track how your nervous system is reacting not only to the environment, but also to your emotions, thoughts, and feelings.
How do you check your heart rate variability?

The gold standard is to analyze a long strip of an electrocardiogram, the test we frequently do in the medical office where we attach wires to the chest. But over the past few years, several companies have launched apps and heart rate monitors that do something similar. The accuracy of these methods is still under scrutiny, but I feel the technology is improving substantially. A word of caution is that there are no agencies regulating these devices, and they may not be as accurate as they claim. The easiest and cheapest way to check HRV is to buy a chest strap heart monitor (Polar, Wahoo) and download a free app (Elite HRV is a good one) to analyze the data. The chest strap monitor tends to be more accurate than wrist or finger devices. Check your HRV in the mornings after you wake up, a few times a week, and track for changes as you incorporate healthier interventions.
The bottom line

Tracking HRV may be a great tool to motivate behavioral change for some. HRV measurements can help create more awareness of how you live and think, and how your behavior affects your nervous system and bodily functions. While it obviously can’t help you avoid stress, it could help you understand how to respond to stress in a healthier way. There are questions about measurement accuracy and reliability. However, I am hoping an independent agency eventually identifies which devices and software provide data we can trust. In the meantime, if you decide to use HRV as another piece of data, do not get too confident if you have a high HRV, or too scared if your HRV is low. Think of HRV as a preventive tool, a visual insight into the most primitive part of your brain.
Stomachaches are incredibly common in children. Most of the time they are nothing serious at all. Most are just from a mild stomach bug, or some constipation, or hunger — or are a child’s way of getting out of something they don’t want to do. But a stomachache can sometimes be a sign of a more serious problem.
A stomachache worries doctors when…

1.  The pain is severe. By severe, I mean that the child cannot be distracted from it, and is crying or otherwise showing that they are extremely uncomfortable. Any severe pain warrants a trip to the doctor, whether it’s unrelenting or it comes and goes.

2.  There is blood in the stool. Most of the time, we see blood in the stool with constipation, which is usually not serious and can be easily treated. But a bad stomachache with blood in the stool can be a sign of a serious infection, inflammatory bowel disease, or another intestinal problem. So any time your child has a stomachache and blood in the stool, give your doctor a call to be on the safe side.

3.  The child vomits blood. As with blood in the stool, this isn’t always a sign of something serious. Children who have been vomiting a lot can sometimes vomit some blood, and children who have nosebleeds, or bleeding from a lost tooth or some other problem of the mouth, may vomit that blood back up. But as with blood in the stool, any stomachache with vomiting blood requires a call to the doctor.

4.  There is green vomit. Green vomit can be a sign of a blockage in the intestine. Sometimes people vomit some yellow-green material when they have vomited up everything else, but stomach pain and green vomit should never be ignored.

5.  The child has hives, looks pale, complains of dizziness, or has swelling of the face. Anaphylaxis, the most serious kind of allergic reaction, can cause stomach pain, often with vomiting. For this one, you should call 911. If your child has a known allergy and you have epinephrine at home, give it while you wait for the ambulance to arrive.

6.  The stomach pain is in the right lower side of the belly. That’s where the appendix is. Early on, the stomachache of appendicitis is usually around the belly button, but then it moves to what we doctors call “the right lower quadrant.” Constipation can cause pain there, and girls who get periods can have pain there when they ovulate, but we don’t like to miss appendicitis. So, any pain in that part of the belly should get checked out.

7.  The child has a fever and a bad cough. Pneumonia can sometimes cause a stomachache. Now, many viruses can cause a stomachache along with a cough, but if the cough is particularly bad, or the stomachache is getting worse, or the child seems to be breathing quickly or otherwise differently, call the doctor.

8.  The child says it hurts to urinate. Sometimes a stomachache can be a sign of a urinary tract infection.

9.  The child has a high fever or seems much sleepier than usual. Stomachaches can be seen in serious infections — and being very sleepy when you are in pain can be a sign not just of infection but of low blood pressure or blood loss. High fevers and extra sleepiness should always be checked out, but especially if there is a stomachache too.

10.  The child is losing weight. It’s not uncommon for a child to lose a little weight from vomiting or diarrhea. Usually they gain it back once they feel better. But if a child who gets stomachaches is steadily losing weight — for example, their clothes no longer fit — they should be thoroughly checked out by the doctor.
What to do if none of the above is true

This doesn’t mean that every other stomachache is fine — but if none of the above is true, it’s less likely to be something serious. Try rest, fluids, and a bland diet (or extra fiber in the diet if your child is constipated). If your child isn’t getting better, especially if your child has vomiting or diarrhea that isn’t getting better, call your doctor. If your child has recurrent stomachaches, it’s incredibly helpful when parents keep a diary of the stomachaches, along with details of things like what they ate that day, what their stool was like, how they acted, etc. This information can go a long way toward helping the doctor figure out what is going on, and how to help.

The American College of Cardiology and the American Heart Association certainly grabbed the attention of us busy primary care physicians with the recent release of their updated blood pressure guidelines. These organizations had piqued interest by declaring the release date and labeling it as “highly anticipated.” I pooh-poohed all that drama, but upon reading through the 114-page executive summary PDF with 21 authors and almost a thousand references, I have to say, I am duly impressed.

The definition of the diagnosis of high blood pressure and the decision-making process surrounding treatment have traditionally been quite individualized (read: all over the place). Personally, I invite these stricter measures, because they are accompanied by solid research, logistical guidance, and useful management strategies.

However, a whole heck of a lot of people just got pulled into a significant medical diagnosis.

Let’s review what’s new.
A new definition of high blood pressure (hypertension)

(Please note that all numbers refer to mm Hg, or, millimeters of mercury.) The guidelines, in a nutshell, state that normal blood pressure is under 120/80, whereas up until Monday, normal was under 140/90.

Now, elevated blood pressure (without a diagnosis of hypertension) is systolic blood pressure (the top number) between 120 and 129. That used to be a vague category called “prehypertension.”

Stage 1 high blood pressure (a diagnosis of hypertension) is now between 130 and 139 systolic or between 80 and 89 diastolic (the bottom number).

Stage 2 high blood pressure is now over 140 systolic or 90 diastolic.

The measurements must have been obtained from at least two careful readings on at least two different occasions. What does careful mean? The guidelines provide a six-step tutorial on how, exactly, to correctly measure a blood pressure, which, admittedly, is sorely needed. My patients often have their first blood pressure taken immediately after they have rushed in through downtown traffic, as they’re sipping a large caffeinated beverage. While we always knew this could result in a falsely elevated measurement, it is now officially poor clinical technique resulting in an invalid reading.
New recommendations on monitoring blood pressure

The new guidelines also encourage additional monitoring, using a wearable digital monitor that continually takes blood pressure readings as you go about your life, or checked with your own cuff at home. This additional monitoring can help to tease out masked hypertension (when the blood pressure is normal in our office, but high the rest of the time) or white coat hypertension (when the blood pressure is high in our office, but normal the rest of the time). There are clear, helpful directions for setting patients up with a home blood pressure monitor, including a recommendation to give people specific instructions on when not to check blood pressure (within 30 minutes of smoking, drinking coffee, or exercising) and how to take a measurement correctly (seated comfortably, using the correct size cuff). The home blood pressure cuff should first be validated (checked in the office, for accuracy).
If you now have high blood pressure, you may not need meds… yet

The guidelines also outline very clearly when a diet-and-lifestyle approach is the recommended, first-line treatment, and when medications are simply just what you have to do. Thankfully, the decision is largely based on facts and statistics. For the elevated blood pressure category, medications are actually not recommended; rather, a long list of evidence-based, non-drug interventions are. What are these interventions? Things that really work: a diet high in fruits and vegetables (such as the DASH diet, which is naturally high in potassium); decreased salt and bad fats; more activity; weight loss if one is overweight or obese; and no more than two alcoholic drinks per day for men, and one for women. Simply changing what you eat can bring down systolic blood pressure by as much as 11 points, and each additional healthy habit you adopt can bring it down another four to five points.

For people with stage 1 hypertension who don’t have cardiovascular disease and are at low risk for developing it (less than 10% risk of an event within 10 years), lifestyle changes are still the way to go. (Risk is determined using a well-researched, widely used formula available here.)

However, if a patient has any kind of cardiovascular disease and stage 1 hypertension (a blood pressure over 130 systolic or 80 diastolic), or no existing cardiovascular disease but a significant risk of developing it (over 10% risk within the next 10 years), then lifestyle changes plus medications are recommended. And, even if someone has less than a 10% risk, if their blood pressure is over 140 systolic or 90 diastolic, which is now stage 2 high blood pressure, they ought to be treated with medication as well.
Optimizing treatment of high blood pressure

The authors bring several evidence-based yet progressive concepts into the guidelines, the first of which is that high blood pressure should be treated using a team approach. This makes sense, as science supports more and better patient education around self-monitoring, nutrition, and lifestyle changes, as well as stress management. Telehealth is emphasized as a cost-effective method of ongoing monitoring that is more convenient for patients than frequent office visits.
And why should this all matter to you?

Mountains of research over time have shown a very clear link between high blood pressure and cardiovascular disease. A 20-point higher systolic blood pressure or a 10-point higher diastolic blood pressure is associated with double your risk of death from a heart attack, stroke, or other cardiovascular complication (like abdominal aortic aneurysm or heart failure). What many people don’t realize is that those who survive these events find their lives permanently altered by disability and medical complications.

Much is being made of the fact that the new definitions of high blood pressure will mean roughly half of all US citizens will be considered to have high blood pressure, but when you really look at the numbers, as cardiologists already have, not that many more people will actually be advised to take medications. Although the public has good reason to be suspicious of “big pharma,” that’s not what this is about.

Diet and lifestyle changes are powerful medicine. Even if your blood pressure is normal now, you can help to prevent it from becoming elevated starting today. Eat more fruits, veggies, and whole grains, and limit foods high in sodium and unhealthy fats. Be as physically active as possible.

There is a lot more in the very long, detailed executive summary, including specific guidance for various populations, myriad diseases, and special circumstances, but this is the gist of it. The document is free, and available here. But, it’s also one of the first things to fall by the wayside in times of stress, especially for those who are primary caregivers. This includes parents, people caring for elderly relatives, healthcare providers, and first responders. These are the people who often put the well-being of others above themselves.

This is a big problem.
Why is self-care important?

Well, we can’t function very well if we aren’t very well. If it is important to us to be able to take care of others, then we must pay attention to our own well-being.

My favorite analogy for this is clichéd, but accurate. When you get on an airplane and the flight attendant gives that safety spiel, when they get to the part about the oxygen masks, the first thing they tell you is: “If you’re traveling with children or others who need assistance, put your oxygen mask on first.”

Think about it. Let’s say you don’t do that and you fall unconscious due to lack of oxygen, then no one gets the help they need. Lose/lose situation there. It’s the same deal in everyday life. When we don’t take care of ourselves, no one wins.

And yet there is a pervasive cultural pressure to keep pushing ourselves, to ignore the physical needs of our bodies and the emotional needs of our souls, which invariably leads to chronic stress, burnout, depression. Data show that burned-out healthcare providers provide crappy service, depressed parents can’t effectively parent, and the list goes on.

When I talk with my patients about self-care, I often hear things like “But I don’t have time!” or “I’ll feel like I’m being selfish!”

As one of two working parents with two small children, I can empathize greatly with these patients. So, the advice I give is the same advice that I follow.

I know that it can be difficult to fit in self-care when time is at a premium and demands on you are high, but here are four easy things you can consider.
4 things to help revive and nourish body and soul

Be physically active. Exercise busts stress, boosts the mood, and elevates our energy level, not to mention the heart health benefits. Believe it or not, you can exercise just about anywhere, anytime. It doesn’t have to be at the gym. It doesn’t have to be a scheduled class. And it doesn’t have to be more than a few minutes a day. All activity counts. I encourage patients to think of an activity that they enjoy. Anything. Think about how that enjoyable activity can fit into your life: maybe you can ride your bike to work, or take your kids on an easy hike, or get the whole family to rake leaves with you. Let’s brainstorm about activities that will fit into your life: Maybe make your next meeting a walking one, or take a brisk walk at lunchtime. Try a few minutes on the exercise bike in the kitchen, or dancing around your living room in your socks. On my very busy days, I make sure I take the stairs whenever I have the option. I park farther away than I need to and walk a little more. If I’m going to the grocery store and I only need a few things, I use a hand basket instead of a cart. It. All. Counts. And the more, the better.

Eat well. That means eat healthy. The mountain of studies supporting a whole-foods, plant-based diet for our health is almost as large as the exercise one. Stay away from inflammatory, sugar-spiking, insulin-releasing foods like processed carbohydrates (think all added sugars and anything made with flour). Aim for things that grew on plants or trees. The more colorful the fruits or vegetables, the more vitamins, minerals, and antioxidants they have and the healthier they are. Vitamin pills and other supplements just don’t work as well. Not going vegetarian to save your life? Got it. Just get colorful fruits and veggies into your diet wherever you can. We don’t have to be perfect, but the more plant-based our diets are, the better.

Calm your mind. We all have stressors in our lives. What varies is how much we let the stressors stress us. What can we do? Yes, meditation works. The relaxation response works. Yoga works. But for those patients who stare at me blankly when I mention these, I talk about other calming activities. This can mean knitting, baking, walking, swimming. Anything quiet and peaceful, when one can take deep breaths and be calmly, enjoyably focused. Me? I try to do a few favorite yoga stretches at the end of the day, right before bed. This is usually after the kids fall asleep, and I can’t even be bothered to find my yoga mat. I just get right to it on the carpet in my daughter’s room: downward dog, plank, cobra, and then some of my own moves, to stretch out my back.

Sleep well. Aim for a refreshing amount of sleep. While this will differ for everyone, generally it’s about eight hours. It’s tempting to stay up late to cram in those last household chores or answer email, but really, the world won’t end if the laundry is dirty for another day, or the dishes are piled up in the sink. Sleep deprivation causes irritability, poor cognition, impaired reflexes and response time (think: car accidents!), and chronic sleep deprivation can contribute to depression and anxiety. Create a short, easy bedtime routine. Stretching or yoga, prayer, or reading a book can be relaxing. But stay away from your smartphone, tablet, or laptop, as the light interferes and interrupts the natural sleep onset. Alcohol near bedtime also interferes with sleep, and is a common cause of nighttime or early-morning awakening. As a neuroscientist I have been trained to think in a certain way, almost like a car mechanic, who “looks under the hood” at the brains of laboratory rats exposed to drugs. If we can figure out exactly which genes, proteins, brain regions, and neural connections go awry in substance use disorders (SUDs), we can fix those “broken” parts in the brain and design better long-term approaches to addiction treatment. While there is great promise in this approach, it’s not so easy to get under the hood of people who desperately need help with a SUD. It’s very different from working with lab rats. And it can take a long time — often decades — between discovering a way to redirect the addicted brain and an approved treatment.
Neuroscientists and practicing clinicians need to be partners in advancing treatment for SUDs

Obviously medical and mental health clinicians treat SUDs from the perspective of patient care. They are presented with real people who have very real, very immediate needs. These individuals have often lost their families, their jobs, and their basic health. Their lives may be in jeopardy because of the risk of overdose. The goal is to first detoxify the patients, then work with them, through initial recovery from the crisis and beyond, to prevent relapse. This is critically important work, but so is searching for potentially permanent solutions to SUDs. And the place to start is the brain.

Over the past 30-plus years, basic laboratory and translational research has expanded our understanding of the brain’s reward circuitry — specifically how dopamine, a neurotransmitter that is important in both our ability to feel pleasure and our brain’s ability to learn strong associations between cues in our daily lives that predict pleasure, operates. We now understand that the brain’s reward circuitry regulates both the “feel good” effects of a drug as well as the extreme physical and emotional discomfort experienced during withdrawal. The emotional signs of withdrawal can flare up for months or even years after attempts to quit, and these factors play into drug taking, craving, and relapse.
Neuroscience has already contributed to SUD treatment

Here are two examples of SUD treatments that regulate, directly or indirectly, dopamine’s role in the brain reward pathway.

Buprenorphine (Subutex): Like methadone, buprenorphine is considered an opioid replacement therapy because it activates the same parts of the brain that opioids like heroin and oxycodone do. The difference is that it activates at a much lower level and doesn’t jolt the brain’s reward pathway, causing a surge of dopamine release like heroin or oxycodone would. It can help ease withdrawal symptoms and can be used for both initial recovery periods and maintenance of abstinence.

Bupropion (Wellbutrin, Zyban): It has several pharmacological actions in the brain, all of which combine to make bupropion an effective treatment for nicotine addiction (e.g., smoking or chewing tobacco). Its main action is to increase levels of available dopamine in the brain. Since a drop in dopamine is partly responsible for symptoms of nicotine withdrawal, bupropion can prevent this drop, and thus mitigate the strong cravings people experience when they try to quit smoking.
And neuroscience holds promise for better and safer treatments

Here are examples of newer approaches:

Transcranial magnetic stimulation (TMS): TMS uses magnetic fields to strategically stimulate parts of the brain. The FDA approved TMS for some neurological conditions in 2009. Since then the number of conditions for which TMS has shown positive effects has skyrocketed. For people with SUDs, the prefrontal cortex, the part of the brain that helps us not act on every impulse, is often sluggish. Scientists have shown that an underactive prefrontal cortex can set the stage for impulsive and compulsive behavior observed in SUDs. Recently, it was shown that using TMS to stimulate the prefrontal cortex of the human brain might help quell those insatiable urges to take a drug.

Kappa opioid receptor antagonists: These compounds, which block the actions of the naturally occurring neuropeptide dynorphin, can help prevent drug withdrawal from causing low dopamine levels. Here’s how: many drugs that can lead to substance use disorders, if taken long enough, increase dynorphin in the dopamine reward system, which inhibits dopamine release in the brain’s reward circuitry — and the person doesn’t feel good. However, blocking dynorphin receptors with synthetically designed compounds prevents this effect. Currently there are several ongoing clinical trials testing kappa receptor antagonists in SUDs.
Where do we go from here?

The good news is that carefully collected and analyzed laboratory data from preclinical studies have led to numerous treatment options for people with SUDs. But in real life, it’s never as simple as in the laboratory. Each person struggling with a substance use disorder has his or her unique constellation of social, genetic, and psychological factors that make some treatments more or less effective than others. But the better we understand the brain science of addiction, the more likely we will come up with an array of treatments that can help a broader range of those with SUDs.

To me, this means my brain-mechanic work looking under the hood of the brains of rats exposed to drugs is essential to the ultimate process of helping people suffering from SUDs, but only if I take the time to look up and discuss my findings with clinical colleagues. Likewise, the clinicians’ overwhelming job of helping people with immediate, life-threatening needs is essential, but only if they pause periodically to listen to our new brain discoveries that might revolutionize SUD treatments.

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