Speaker 0 00:00:02 Welcome friends to the Heart Rate Variability podcast. I am Matt, and I'm back here with our good friend, Anna. Anna. I think this is episode four or five, three. Yeah. Three, four. No, I think this is four. I think this is number four. So, uh, welcome back to the show. I can now officially call you Doctor, so congratulations. I know that's, uh, obviously it's a process. When I looked at it as a master's level student, I said, uh, no thank you. Uh, so I have a little bit of, uh, additional respect for the process, uh, that you are, you went through to, uh, call yourself that. And, uh, definitely I just wanted to start out with a, a huge congratulations, uh, to you for that accomplishment.
Speaker 1 00:00:53 Thank you. Yes. It's a long time coming. I remember being on your, on the first episode with you and I said, I think I was in my, I must've been in my third or fourth year. Yeah. So I'm cool to see that it actually ends up happening. We do graduate
Speaker 0 00:01:09 <laugh>. Yeah. And I remember talking to the optimal team right afterwards. I'm like, we can't let this Anna person escape our orbit. We, we gotta pull her in and keep her in, because I, I just remember both at the A A P P conference and then, uh, interviewing for podcast. It's like she's gonna teach me a lot moving forward. And, uh, I, I wanna, with this episode, talk about some of that teaching that, uh, you've given, uh, me specifically, uh, both in my, my wheelhouse and what I focus on. And I just think a really great, uh, way to look at research with your dissertation. So I'm excited to explore that with you a little bit. 'cause, uh, looking through it and yeah, chatting back and forth with you, um, about it. I'm just fascinated by it. So I, I would love for you to just give a little background on that and, uh, sort of share, start sharing with our listeners, uh, just sort of, uh, what got you interested in the topic. And, uh, let, let's then dive into some of the, the, the work that you did.
Speaker 1 00:02:15 Awesome. Yes. So it's interesting. When I came into grad school, I had or initially wanted to study the, uh, neurophysiology of, uh, substance use, different factors and characteristics among adolescents. Um, and then it progressed into, um, you know, my chair has asked me this, what guy interested in craving? And it's, you know, it's odd. I think I just got really fascinated by the idea of something that could be more, um, real life factor. 'cause we do a lot like self-report measures, but something that is so, um, hard to understand, hard to measure, hard to define. And you know, how the field of psychology is in neuroscience. We don't, we don't agree on anything. So <laugh>, um, and, and it's not because of any, an animosity, it's just that these factors and, uh, con or these, um, constructs are so complex. Yeah. So I was interested in substance craving, and then we were wondering how we wanted to go about that because there've been plenty primary studies.
Speaker 1 00:03:14 And then there were, um, studies that were looking at it from different forms of brain imaging, but then there was also, um, autonomic nervous system, uh, measurements as well, and to figure out which route I wanted to take with that. And my chair, um, Dr. Omar Al has soon he studied the neuropsych of different substance use disorders and meta-analysis. Uh, for those not familiar meta-analysis is a quantitative method to, uh, gather results of multiple studies and synthesize into one large study to hopefully identify consensus or discrepancies across, um, primary studies. And so I, um, wanted to use his skillset and his strengths as well as my curiosities in the areas that I wanted to learn to have the kind of the, um, most feasible, realistic, and for my own sake, interesting research. So, uh, we decided to look at doing a meta-analysis of Q reactivity across substance use disorders, and later narrowed that down to heroin versus alcohol. Um, and that was for various reasons, you know, alcohol and heroin have some similarities in terms of how they're both seen as depressants. Mm-hmm. <affirmative>, um, they're both highly addictive and both are, have very serious withdrawal effects, um, and very high relapse rates. Um, and also just seem to have across, uh, the craving research the most literature. And so the dissertation, I'll just read the name here is LONG is Functional Neuroanatomy of Craving and Opioid Use Disorder and Alcohol Use Disorder, voxel based Meta-Analysis of Functional Magnetic Resonance Imaging of Drug Cure Reactivity
Speaker 0 00:04:59 Tell you Doctor <laugh>
Speaker 1 00:05:01 The long name. So essentially what we're looking at is, if we're trying to think about this from what these participants went through in these studies is an individual, let's say, who has a substance use disorder with opioids or heroin mm-hmm. <affirmative>, in this case, all the participants, it was heroin. They go into an F M R I machine, and they're presented images of their substance of choice or paraphernalia. Um, and then they're presented neutral images, which can vary from gray screens, mosaic, just like where the picture's all chopped up. Yeah. Um, and then it can also include, um, food or different emotional states. So the neutral kind of varies quite a bit across the research. And then they are presented both of those at random, um, orders or different types of presentation. And they're looking to see what areas of the brain, um, have increased activation using, um, blood oxygen level dependent, uh, imaging.
Speaker 1 00:06:01 So we're looking at where increased blood flow is taking place. And so we were looking to see would that be similar with individuals with alcohol use disorder versus those with opioid use disorder. And we found in our research that there was a lot of overlap. They were definitely more similar than different. Um, however, opioid had some areas that were more distinct that alcohol didn't. Interesting. Um, yeah. And so it was pretty similar to regions that were proposed in like more theoretical papers, systematic reviews. Um, and it was in areas that are known for being associated with self-reported craving with different measurements. Hmm. It was also associated with increased activation areas that are associated with habit. Um, also with areas that would be called, um, how do you wanna say it? It would be inhibiting pre-one responses. So the inferior frontal gyrus, which would be kind of like right down here.
Speaker 1 00:07:01 That's gonna be an area that's gonna be trying to say, let's not, um, act on that impulse. Mm-hmm. And that would have increase activation. Interesting. So there was forming main clusters. Um, and we also found that there was areas of the brain associated with object recognition, um, and then visual attention. So I mean, it makes sense, right? Yeah. If it's a substance that they're, you know, familiar with using over time with classical conditioning, we know that, um, the more they see that spoon or, um, needle, that that's gonna increase that activation, it's more salient to the individual. So let,
Speaker 0 00:07:37 Let, yeah, let, let's, let's, uh, go back and, because I, I would love to get from you, uh, a definition and feel free to go wherever you want with this question of craving itself. Uh, is it like, on one hand, because having done some work in addiction, I know when I say like, I'm, I'm craving dessert or I'm craving chocolate. Yeah, maybe, but, but it's a whole sort of different kind of realm of, uh, that, that sort of sensation, uh, when I talk to people who are struggling with recovery or, uh, addiction, and we talk a lot about relapse triggers and that, uh, obviously has a lot to do with craving. So I would like, uh, you can go, uh, physiologically with this, psychologically with this, uh, what, what is our definition we're working with around the idea of craving itself?
Speaker 1 00:08:33 So craving has multiple definitions, unfortunately, but, um, they have really come to a consensus that it is not only a psychological reaction, there's a physiological reaction, um, a subjective reaction where the person just perceives that urge or that want to use. Um, and it can be associated with stress, associated with, um, those that have other current mental health conditions. That's something I'll bring up a little later is that, um, unfortunately with research that's gonna be on substance use disorders, they'll oftentimes isolate the participant sample to only substance use disorders and try to rule out any other mental health disorders. Oh, okay. And you and I both know as clinicians, that's not what it looks like. <laugh>. Right.
Speaker 0 00:09:18 Exactly.
Speaker 1 00:09:19 Um, and from a trauma, um, you know, trauma focused perspective, a lot of people are using substances to self-medicate or self-soothe, um, or to survive what have you. Yeah. Right. Um, and so substance use may be a way for them to see, even may have income to be able to manage the lifestyle that they have. And so it's, um, that's where craving can be kind of, can, can be kind of messy. 'cause it can be due to withdrawal, but it could also be due heightened stress. Mm-hmm. <affirmative>, it can be due to, um, like in my research, it's on a queue. So let's say someone's struggling with alcohol use and they live in the United States where booze commercials are everywhere. Yeah. Um, they're being essentially like, you know, triggered all the time. Yeah. Um, and that's why, you know, like in ours, our work with, you know, relapse prevention, it's really hard with alcohol because it's so socially acceptable mm-hmm. <affirmative>. Um, but then, you know, for a lot of individuals in different environments that might be different, like with heroin, if they might still be seen it quite a bit. Right. Um, and that doesn't even just mean the paraphernalia. It can be the houses they use and the individuals they use with, or different, um, clinics that they visited that can still be associated because that's how the brain, you know, organizes information. Yeah. So the
Speaker 0 00:10:34 Original I spell sounds, all that stuff could be, you know, a, a trigger for folks I've worked with in the past too, that it's just, it's, it's almost impossible to name all of them unless you've worked with somebody very intensely for almost years to, because they discover new ones themselves. I found, uh, yep. Too, which makes recovery. Like I said, when I look at recovery, you know, and I, I would say especially from something like heroin though, alcohol's so devastating, smoking's devastating as well. Like, it almost, and and you, I'll let you take over from here as the expert, but I almost see like it totally the mind, the physiology like almost wraps itself around the addiction and everything's about using. And so when you stop using, there's so many polls, I I think somebody called it like ghost synapses that exist there. And if you've ever tried to give up something you love, you know that when you relapse, it's spectacular until the shame and everything else kicks in, uh, as well.
Speaker 1 00:11:41 Absolutely. And that's, um, kind of going back to your comment about it's, you know, with substance use, it's so drastically maybe different than like if I'm craving a dessert, but actually then a lot of research shows pretty similar for people that have, it's mostly with those that have like food addiction or like more severe presentation with food related disorders. Um, but it is actually pretty similar because even different, you know, uh, chemicals that are in like dairy, like cheese, it's very similar to the effects that heroin has on the brain. Yeah. Um, sugar very similar to how cocaine acts on the brain. And so, um, that's where we see a lot of our individuals where, you know, they might find like a replacement, right? Yeah. Um, so that craving response may be very similar and they may resort, maybe we're trying at that point, help them kind of from like a harm reduction standpoint, look more for, you know, if they're using sugar, like that's okay for now.
Speaker 1 00:12:38 But, um, there's different, um, types of therapies they've tried, like q exposure therapy where they try to have the individual present with the, um, let's say paraphernalia for heroin use, and they want them to pair with not getting the substance after. So that disrupts that, um, paired, um, condition response to that condition stimuli. But what they found was it was helpful to reduce the salience of it, but it didn't quite reduce the intensity of that craving experience. Like you're talking about where like there's the increased heart rate increased, uh, sweat glands, um, the increased, um, actually the decreased temperature at her fingertips, all of that, right? Mm-hmm. <affirmative>, so they found that, pair it with, um, different forms of biofeedback, whether it's using skin conductance, biofeedback or H R V biofeedback, that that also allows them to cope with the craving response. And I think sometimes in the field we're trying to get rid of cravings, but the goal I have found clinically is that it's more of how can they manage cravings because it's wild.
Speaker 1 00:13:50 Some of my patients have felt as if it was their fault that they had cravings. Yeah. And teaching them this physiology helps 'em understand that it's not their fault. They're not morally, um, broken or, I mean, obviously the chronic substance use changes the chemistry of the brain and the physiology of the body where reward thresholds do change. And we know that from research. And that doesn't mean that when you have crazy that that's your fault, that's just 'cause your body wants that substance and it's had it for years. Right. So I, I had a gentleman, a veteran where he just was, came up to me and he said, Ann, I'm so sorry, I I you're gonna be so disappointed. I just have had cravings all morning. I was like, oh man, that's not your fault. That's 'cause your brain loves that heroin <laugh>. Yeah. And I said, that's not your fault. And I explained it to my bra, my brain model, and I explained to him, um, what areas of the brain are being activated and how that has been seen across the research. And he goes, oh, so it's not my fault. I go, no, but how do we manage it? Right. Right. And they have like suboxone, naltrexone, naloxone, methadone, yeah. Where that the idea is to reduce the intensity of cravings, but they may still happen. So I encourage people to learn how to manage it.
Speaker 0 00:15:05 Yeah. So I'd love to hear more, you know, about, you know, what, what you found, but also maybe just with your expertise thoughts on especially the H R V, uh, biofeedback. 'cause one of the, one of my teachers, uh, on addiction and trauma, Dr. Gabriel Matte, I, I thought, and he is not the first to say it, but he, I love what he does. 'cause it kind of simplifies a lot is like for addiction to be there. Obviously, oftentimes behind the, the cravings is like, you gotta have a, a organism that can live a human body, basically a substance or behavior that can be addictive and then stress. And so that, that to me is like, oh, that all makes sense. And then all the trauma stuff on top of that, obviously being a type of stress and the, the, uh, the life people lives. I, I think it's AA who does a good job of saying there's those, all those, like if you're hungry, if you're didn't get a good night's sleep, you know, like four or five different things that, uh, you gotta be really careful about if you're angry. Absolutely. That absolutely. That you lead to that as well. So we obviously know, and our audience knows, uh, biofeedback mindfulness helps the stress response, but love for you to dive. What, what do you think's, uh, kind of going on there? What'd you find around the biofeedback, uh, pieces?
Speaker 1 00:16:28 So I'm glad you brought that up because, um, Dr. And his student, uh, Dr. Andrew Nicks, they had his dis, or it was Andrew Nick's dissertation on H R V biofeedback, substance and substance cravings and an outpatient setting in San Diego. And the, I was lucky enough to, um, put together a poster using their data collection and their synthesis and presented at A A P V at the first conference. And I think they did a really good job of really talking about how we can, like what H R V biofeedback is doing for these people. Right. Because, you know, the goal a lot of times in H R V biofeedback might be to increase H R V mm-hmm. <affirmative>, um, and seasonal a allergies as usual. Um, anyways, so they will be, um, you know, like an individual as we've kind of talked about, they're not as well-versed in H R V, like an increase in H R V might not for them be as meaningful as what it's paired with.
Speaker 1 00:17:30 Mm-hmm. Right. So if they're having increased H R V, but it's also paired with they feel like they're doing really well Yeah. Then that data becomes meaningful to them. Right. So, you know, some people are like, oh, hire H R V, what does that mean? Right. So we have to find a way to make that data meaningful. So in this study they had, I believe it was 22 participants in the H R V biofeedback group, plus treatment as usual. Then they had, um, 21 in the treatment as usual group completely, um, without any H R V biofeedback, and I believe it was a five week study. And what they were looking for is that they would get education on, on IC nervous system, how stress can influence cravings mm-hmm. <affirmative>. And then they wanted to look at, um, would their self-report, uh, craving scores go down.
Speaker 1 00:18:20 Yeah. And because what was tricky is five weeks, if were, you know, it's not super long for maybe drastic changes in H R V, but maybe they can have some meaningful change in terms of their, um, self-report cravings. And that doesn't mean necessarily that their cravings are bad or good, it's just more so, um, how intense or how severe it is. Yeah. And so they were trained on how to do the breathing. They gathered their initial H R V and they were more so asking them to self-report their training, just kind of saying, did I do it or not? Yeah. Which we'll get to that, where I think a lot of our research is gonna change with having our more, uh, user-oriented, um, mobile apps. Mm-hmm. Um, having our home, um, readers, because again, with this one, it's, these people are going through a lot, they're in intensive outpatient.
Speaker 1 00:19:13 Um, it's not their, it's not their fault if they're not doing every day, but, you know, it'd be nice to know if they are <laugh>. Yeah. Yep. So no judgment, just so, so that we know Yes. Like maybe there's a, something to do with adherence or not. Right. However, when they did, the group that had the H I V biofeedback did have clinically significant, statistically significant as well. Um, lower craving scores at five weeks and the treatment as usual group, um, did that mean that they relapse or return to use? That is unknown, unfortunately. But that might mean that that's a helpful thing to have in a treatment program. Um, so that they can have, um, the way that, uh, Dr. Nicks incorporated in his post, or I just love, I wrote it down here, is, um, the H R V biofeedback not only helps to possibly increase H R V, but it helps the individual to increase sense of self-efficacy to manage cravings.
Speaker 1 00:20:11 Hmm. A lot of times they just feel like they are, like you said, I am addicted. Like the drug kind of runs me, or the alcohol runs me. Um, help them just in general self-regulate their autonom nervous system, help them improve their interceptive awareness. We know interceptive awareness is a really strong variable for helping individuals have increased insight to managing challenging obstacles or managing things in their body. Um, and then he also mentioned that improving autonomic nervous system and regulation, the H P A axis may also help reduce the rate of relapse because there is research to suggest that when individuals have higher craving scores, they're more likely to have a higher risk of relapse or return to use. And if we have lower scores and cravings, which may be associated with improved regulation, that might ultimately reduce the chance of relapse. Um, but I think, like you and I have talked about from a trauma-informed approach, re turning to use or, um, relapse doesn't mean a failure. Right. Right. I think what we're gonna need in the research moving forward is quality of life. Um, there perceived, um, future their oriented or their orientation towards their current lifestyle because we can have people do really well and still have slips or return to use. Yeah.
Speaker 1 00:21:35 So I think by having this tool and having other ways to look for outcomes in a way that is looking at the whole picture for the individual is what's gonna be helping us to move forward.
Speaker 0 00:21:46 Awesome. I would love to get your insight on, because I, you know, on one hand, I mean, I, I might even have a little trouble if somebody asks me. The question I'm gonna ask you, um, is the, the connection between stress specifically and cravings. 'cause I would under, I could understand, I mean, I, I get like, Hey, I've, I mean we have this thing, uh, I know I've been to San Diego called Happy Hour. So go to work all day and get stressed out. Go have a drink or two, you know, your drug dealer at the quarter bar is gonna sell you drugs, uh, for cheaper than normal so you can feel better and be happy. But mm-hmm. <affirmative>, you know, so I, I'm kind of wondering in your mind, because craving seems like a psychological phenomena that could be viewed as, uh, distinct from stress where maybe I just am stressed out.
Speaker 0 00:22:44 So I want to use just to feel better. Might not cross over to what I call craving, but I, I just, I, I, like you said, I, I couldn't give a good answer. So I wonder just kind of how you're thinking about, you know, a biological pull to use, which again, I, as I, what I know about addiction, you know, really crafts the dopamine, endorphins, serta, all those receptors are ready to use. So you got all that, but then stress comes in there as another variable. And just kind of the, the idea and how you conceptualize that, that relationship between stress and cravings.
Speaker 1 00:23:25 Yeah. So I think the, the phrase that kept going through my head when you first started that question was what is the, the con or what is the stimulus that triggers the craving? Great, great. Yeah. Right. So I think it comes down to, uh, like for example, in my dissertation, they were looking at Q induced craving. So it's if they see something risk that is associated with their substance use. And here's the thing, it might vary 'cause maybe they had really pleasant experiences. 'cause like when they've, you know, evaluated like social drinkers, it might not necessarily be a negative thing for them. Right. They just think a cold beer that's has condensation, it sounds real good. Yep. Um, but then there's also, um, Q induced where they see that substance and it might remind them of withdrawal. And the thing about F M R I research with this study was that they, there's usually six second delay from when they see it and then what the brain, uh, imaging is going to represent.
Speaker 1 00:24:19 Mm-hmm. Um, so it's unclear how much of it is like, um, automatic versus they had time to reconcile it. So let's say they see the picture and they go, oh, I don't, I don't like seeing that. Like, that reminds me of bad times. That might be too long of a response and that might've been different. Versus if there's a six second delay, maybe we're just seeing the automatic reaction that's been classically conditioned. So like how much of it is like in their conscious awareness versus autonomic. Um, so there is that for when it comes to q I think from a standpoint that substance use has comorbid with so many mental health and, and physical health conditions that, um, I was reading about this morning actually that like chronic pain, if they have a pain flare up, they might have increased distress, which may distress might be associated with using.
Speaker 1 00:25:11 So their craving goes up. Hmm. So I see it more as like craving is like the conditioned response to a stimuli that's associated with, uh, their substance use. That's how I've been able to conceptualize it. Yeah. I'm not saying that that's across the field, but when I explain it to patients, like, let's say I have a, for example, I had a gentleman who was a pretty heavy drinker. And um, even when he would see like a glass bottle, he would notice like his heart rate would go up. Yeah. And so for some people craving for their own perception is very physiological. And then for some of them it's a little bit more cerebral where they think, you know, that sounds like a way to get out of how I'm feeling. Yeah. And some of 'em will say, I didn't even remember that space of time that I was using before I knew what happened.
Speaker 1 00:26:03 Yeah. So I think it depends on what the research was saying too, is it depends on the severity. Because what we'll see too is some people will have increased activation in the brain that's associated with more, um, like areas in the brain with like balance and coordination and um, mo oh, what's it called? The muscle memory where it's like, you know, remembering to ride a bike. Like it's just that automatic. Yeah. So I think it depends on the severity. It depends on what their cues are going to be or what their, um, triggers are going to be. And so like chronic pain, it might be seeing medication bottle or it might be having a flare up in pain. So I think craving really is that conditioned response to that factor or that cue, um, that elicits it for them. And so what I've seen for most people, it seems to be, um, stressors in general.
Speaker 1 00:27:01 Right. And the thing too with our society is we very much normalize that if you're stressed, get rid of it, unfortunately. Mm-hmm. <affirmative>. Yeah. <laugh>. And we're trying, we're trying to help the, um, I don't know, sounds kind of ambitious, but like the nation and the world understand that it's how you manage stress. 'cause we all need stress important. Yeah. But a lot of times with people that have abused substances, any type of stress or any type of discomfort or even eustress Yeah. Like positive stress, um, they use with it. 'cause that's just, um, been their lifestyle that they've saw it in their family, they saw it in those they grew up with, they see it on the media. Yeah. So I think a lot of it comes down to what I do with patients is we, like you said, it might take multiple sessions or years to really figure out what brings it up for you. Yeah. And the goal is not to get rid of those cues 'cause they're gonna be there. It's, it's to be just aware.
Speaker 0 00:27:54 And so one of the things that, that I, I just, I'm fascinated with, and I I I've come to some of my own conclusions, but I realize I might be wrong because, uh, neuroscientists a lot of them come to different conclusions and I really respect their work too. It, it's sort of that idea of like the brain being, in some ways hardwired, that once variables hit in some ways the outcome, if you knew it got enough information, you could predict the outcome at a hundred percent accuracy. Like if you've got somebody who sees somebody they you with, you know, that that's probably gonna re lead to use themselves or a relapse situation. And I've always been fascinated, especially with my work around like change and motivational interviewing is what about us as human beings that might not always show up on a brain scan, can sort of start to act in a catch yourself, I guess is the thing is that I'm looking for here is like, okay, when I've been in this situation every time for the last 15 years, I end up using this time all a sudden.
Speaker 0 00:29:10 And, and this is where I kind of go back to mindfulness. I'm able to kind of catch my cravings, so to speak, before it leads to behavior. And I'm not sure if, uh, this come, came out in your research at all, but I, you can speculate, I'll give you full runway to do so. Like folks that again, may have been used 10 years every day, we both know body mind, that whatever you wanna call it is program to use around that addiction. And all of a sudden they start to find ways to make different choices. Do, do you have ideas of where that volitional control, if it does actually exist? Kind of where that comes from. And I'll just leave that very vague to see where you wanna go with it. Or just tell me to shut up. Um, <laugh>.
Speaker 1 00:30:04 Um, so I'll say this is gonna not be based off my research. However, in terms of the hardwired part, there is a lot of research on, uh, F M R Q reactivity. So like the paradigm that was in the studies that I used that would look at pre and post some type of an intervention and there would be changes in levels of activation and areas of the brain that were associated with craving or, I mean, you know, a lot of it's like correlation, right? So they're looking at, you know, if there's increased activation here is at a higher risk for relapse. And there's a lot of, I think, um, so I mean different things like medication, you know, a lot of people do really well with different, um, uh, medications to reduce cravings like suboxone, Naloxone, um, speaking from a research standpoint, um, I think also it is something that they talked about too.
Speaker 1 00:31:06 Um, let's see. You know, VCO is a really prominent researcher in substance use and neurobiology. And she talks about how, you know, what do we do with this information? Can it be changed? Mm-hmm. <affirmative>. Um, and so there's studies to show the changes, but I don't think we'll ever have something definitive, at least in the near future. Um, I would say that it comes to the, I think it's gonna be very bio-psychosocial. I think it's gonna come down to the individual's perception of their self-efficacy. Um, you know, do they have some type of alternative self-soothing method? You know, just like, oh, just take away the thing that's helped you feel safe, your whole life feel when you've been experiencing multiple adversive uh, traumas and events. So I think a lot of it comes down to we have to look at the individual, right. Their, their culture, their perspective, and it be a very much of a multi-pronged approach.
Speaker 1 00:32:12 Yeah. And I think what it comes down to too, as the individual having that readiness to do it, because I think, you know, there has to be this desire to change too. Like probably know for motivational interviewing. You know, if they have no consideration whatsoever, there's only so much motivational interviewing you can do. Um, and so to answer your question, I think a lot of it is being person focused, um, helping the person find reasons to achieve some form of sobriety if that is the outcome they're going for. And something that comes to my mind when I think of this too, is they, so for example, they have done studies where they look at, let's say they present a substance and then something that would normally bring, um, like a pleasure response for somebody. So like a beautiful tray of food Yeah. Or um, a gorgeous landscape of a sunrise.
Speaker 1 00:33:11 Right. And they actually had sometimes hypo activation and areas that are associated with pleasure reward. And over time though, they would see that change and then the group that didn't have the substance use disorder would actually have like increased activation in those areas because the individuals that are using the substance are artificially increasing their reward threshold to a point that is kinda like not, uh, realistic given our like natural rewards that we have. Yeah. But they did find though that it, over time, if you pair, like let's say they, they talked about, I included my dissertation that if you have them like doing exercise and they have a positive experience with it, okay, then over time that becomes a more enjoyable experience. And you see in the recovery world a lot, all of 'em want their gym memberships or Yes. They're working out nonstop. Yeah.
Speaker 1 00:34:02 Um, so I think it's finding alternative ways to get that natural reward, but there, it's giving the individual an understanding that, you know, it might not be reaching that threshold that you've had in the past. Um, over time the brain does adapt to not having that substance. It takes time. So it's a tricky question, but I think a lot of it comes to me, the individual where they're at having a supportive environment, um, a reason to achieve sobriety and a way to manage any kind of eustress or distress. Um, so that they feel not only that they are feel like they're going to use, but they feel like, you know what, even if I wanna use, I don't have to. Right. So I think, and I think that comes to like having again, um, I watch this documentary, I'm a not <laugh>, I love it.
Speaker 1 00:34:54 It's called Stutz. And he talks about the life force and he says that, um, you know, the physical body needs to be in check, right? So if they're, like you said, they're hungry, tired, and Yeah. And just agitated. That's asking for a recipe for disaster. All of us wanna do something that's not super healthy when we're in that state. Yeah. And then it's meaningful social connections, helping them build relationships for people. They can see that hey, they wanted to use at one point and they stayed sober. Mm-hmm. <affirmative>. So I think it's having some form of inspiration, accountability. And then the top level was, um, relationship with the self and helping them to find a reason and purpose. Right. If they have such a long like, legal history and they have so many medical conditions, they might feel like at a point like, why do I stop using my life is so hard.
Speaker 0 00:35:41 Yeah. Why would I feel wor Why would I stop doing something that, you know, and one of my, my things that really helped when I got in the neurobiology is I would often hear, I use now to feel normal. I, I heard that so often. What, what I didn't appreciate from a trauma perspective is I always, I, you know, when I, when I do this, when I teach people this now, I always like use a life satisfaction scale is my normal is probably if, if 10 is you're waking up every day and you're just in love with every minute of every, nobody's kind of, there is, you know, if I, my normal's an eight, which I'm fortunate enough to kind of probably be in the eights if you'd asked me that question, that's my normal. So I thought they were using to get to an eight where a lot of folks like you mentioned, have had so many life struggles that contribute and then are exacerbated per the use and addiction is that they're kind of using to get back to a three on that life satisfaction scale, where maybe the first time they use, they shot up to a nine, which just increased motivation to use again.
Speaker 0 00:36:50 'cause it's the best they ever felt. And I don't care if it's you, me, or anybody, we pull off the street, if I take something that makes me feel twice as good as I've ever felt in my life, I might wanna do it again. Right. Absolutely. Especially if I'm escaping that pain. So that, that to me is like that the addiction can be so evil in that way is that, you know, and my whole misperception initially was, oh, they feel like I do when I wake up in the morning when they use, that's their normal. But it's still this, uh, state for so many people that's, I I think if you just put us in that state, would be pretty, feel pretty traumatic and devastating. Uh Right.
Speaker 1 00:37:33 And I think what you're talking about with that level of satisfaction too is some of them might be trying to get to a three 'cause that's what they're used to, but some of them might think they're supposed to get to a 10. Yes.
Speaker 0 00:37:43 And
Speaker 1 00:37:44 I had an individual who he's, he would be in the groups and they, they, the therapist would go around asking all of them, um, what's your level of craving on a zero to 10? And um, the veterans would all say things like, like 10 being the worst, right? Yeah. So they would, they'd say like, 0 1, 0 2, 1. And I asked, and the individual I had, I was standing for individual therapy and I said, what did you tell him your number was? And he is like, well, if I say too high of a number, they're gonna think I'm doing something wrong. Yeah. Um, and then I'm gonna feel like I'm doing something wrong. And I said, but you're lying to yourself. Right. Like that's part of interceptive awareness is being aware with your body and then part of mindfulness is being non-judgmental of what that experience is. Yeah.
Speaker 1 00:38:31 And so, um, sometimes when I would run the groups, I would go, I know some of y'all are gonna tell me zeros and one, but we're in a rehab facility. No bullshit y'all. Yeah. Like, come on, what are we actually on? They're like seven, eight nines, tens. And I was like, and are you using right now because you have a nine or a 10? They said no. And I go, exactly. So that physical, it's a lot of that education of invalidating that just 'cause you have this high of a cream does not mean you're gonna run out that door and get a beer.
Speaker 0 00:38:59 Exactly.
Speaker 1 00:39:01 And that for them, they're like, oh yeah. Like it is down the road, isn't it? I'm like, sure is if you wanna go get it, you can. Yeah. And it's imp that's the self-efficacy where they can say, I'm sitting here, I wanna use so bad that my body's shaking. I'm so uncomfortable and I don't have to, that's where you start breaking that condition, um, response. Right? Yeah. That having that craving experience, which is very different from many people, um, can, does not equal using it, can predict it. But I think they have to understand that, um, even like what I tell 'em is, you working a solid recovery program and having cravings does not mean you're doing something wrong necessarily. That's just an opportunity for you to look in your body and go, what am I needing? What is something I can do to maybe help myself? Maybe that's helping somebody else. Maybe that's eating something that's a little bit more clean, not so inflammatory, whatever <laugh>. So, um, it's, I think a lot of it comes to mindfulness and being aware of it instead of saying, oh no, I have cravings so I have to use
Speaker 0 00:40:10 Yeah, absolutely. And that, that kind of, that idea of that window of tolerance from Sal Ogden and their work, like that's where I think the H R v biofeedback I've, I've seen it in, in my, my life and my use of it being fortunate and privileged enough not to deal with, uh, addictive struggles like that. But, you know, not perfect in any way, shape or form as well is like I, you know, is is really opening that that tolerance. Building resiliency is a, is a, I know a, a loaded word, but you know, I'm, I'm increasing my capacity to handle maybe some cravings, maybe stress, and I've got room or capacity to catch myself before absolutely automatic, you know, because almost once people get on these, the trigger can often show like trigger a cascade of behaviors that lead to then relapse. And depending on your drug of choice, that can be easy or hard.
Speaker 0 00:41:11 But it almost, right. Almost even if you gotta get in the car and go somewhere, it's still almost like you're on, people tell me this. It's like, like you said, I don't even remember what happened next. 'cause there's almost this automatic processes flooding of those emotions and, you know, the, the heart rate variability, biofeedback with that ventral vagal break, you know, could be giving, you know, again, I'm, I'm, I'm really making jumps, uh, from what you're saying, uh, admittedly, but gives a little bit more of that capacity to bring that mindful awareness to say, okay, a craving doesn't mean I have to use, I don't want to follow right through. This is a craving. I can name it. I can own it and it doesn't have to control me. And even with that, sometimes I eat the thing I know I shouldn't eat. You know, the tear tots are on the menu. I know I should have a salad, but the tots look so good. So, you know, and I, my my, uh, my desire for tots is nothing like the folks you're talking about with heroin or alcohol. Uh, I love 'em, but not Right. Gonna compare those two in any way, shape, or form.
Speaker 1 00:42:20 Right. But you can understand how, even though you recognize it, that sometimes it's, um, it comes to like, maybe you were lacking salt or you were wanting some different fats, whatever. So it's just like that curiosity, that awareness even after it happened. Right. So, um, a lot of times addiction and many mental health conditions are perpetuated by, um, unaddressed shame and guilt. And so if they can target the shame and guilt and look at more from like, you know, our compassionate approach or self-compassion practices to say like, although I may have returned to use or although I've had cravings. Yeah. Um, or maybe I'm not as active in my recovery program, you know, that doesn't mean I'm doomed. It means like, what can we kind of, or what can we do to kind of recalibrate and readjust what we're doing here? Um, people can just be, and all of us and me and clue we can just be so hard on ourselves.
Speaker 1 00:43:15 Yeah. And, um, I think part of this too, and part of uh, even just a lot of people experience trauma and P t ss D and different trauma related conditions is, um, they might kind of almost invalidate themselves for what they're experiencing. And so I do, my biggest part is educating them on the impact of chronic substance use on their body. And so that they don't, that's one area that hopefully they don't blame themselves as much for and then educating their families. And I think that's when I was, before getting, or before logging onto this, I was thinking about how so much of research is not as accessible to people. Right. Right. And how this is such an honor and privilege to actually spread that information. Uh, because you know, I I, I've had so many families where I talked to their spouse or their friend or whatever it may be, and I explained to 'em some of the physiology of what they're going through.
Speaker 1 00:44:09 And that if they have cravings is that does not mean you need to like panic. It's just to be there with them and talk with them. And they're shocked by the fact that it's not just because they are avoiding conflict or because they're a jerk or whatever. They're like, oh, like that's something that their body's conditioned to do every time they see a bottle or every time they see a spoon or what have you. And so the education's so important and then I'm working on this, is making that education, uh, understandable. Yeah. Um, because it's heavy. It's a lot of information. It is. Yeah. I always thought it was funny how we, you know, in rehab centers, we teach the patients so much about neurobiology, but they're just trying to detox still <laugh>.
Speaker 0 00:44:49 Yeah. Well, and then to me too, like my, my, my work in, you know, and I love, and, and it hasn't picked up as much after Covid that I like it to, but I training people that are in those, those scenarios and, and are in the, the struggle of recovery, whatever that means, uh, for them working on that. And it is like, to me, once they, if I can communicate the complexity, and I, I've, I've really found that, uh, I had somebody, uh, in one of my very first talks say, you know, you won't find, and these were his words, I don't use the word addict to describe anybody, but I'll, I'll quote him. You don't find dumb addicts like there there's no dumb addicts 'cause they die. You know, very crash way to say it. Like I said, I words I would not use from, uh, any perspective I take.
Speaker 0 00:45:38 But, you know, just getting into that in a way that's, do we have to get into the different lobes of the prefrontal cortex? Not necessarily, but like, I, I just remember like my first time I, I talked to folks, it's like two pieces of feedback that have just resonated. I realize I'm not a bad person. Like, and you know, as like a therapist, if I do really good therapy and somebody thinks they're a horrible person who's weak and just, you know, this, that or the other, you know, that might be two to three months worth of work depending on trauma. That was like a 45 minute presentation and people understanding why they might need treatment and support, because I, that idea of being a weak broken person has so much shame in it, but understanding that, yeah, these are biological reactions. Probably your addiction was a reaction to stress or trauma or with the opiate addiction.
Speaker 0 00:46:33 I deal with so much with my work around the country, a a really broken, uh, unethical medical system, uh, that that has its own, you know, uh, role to play in this. Just that realization that I'm not a bad person. Uh, just such a powerful, uh, insight for folks have doesn't mean it's over for them. The work, it's still a lot of hard work, but boy, if we can remove that shame, to me that's such a barrier to change. Um, that, that I just see over and over addiction, homelessness, uh, intimate partner violence, well, whatever, uh, disordered eating all those things, just like it's such a barrier to getting to, to the life. Maybe they can see it, but such a barrier to that, that change process.
Speaker 1 00:47:21 Absolutely. And I think that's where you have individuals who say like, am I worth recovering? Or their family members or the world unfortunately has said you're once, they'll say things like, once an addict, always an addict. Yeah. And you know that yes, they may have that, um, long-term or lifelong recovery doesn't mean that they're going to always fail. And I say in quotes for their listening audio. And yes, I say that it's um, that's what I think is, you know, a lot of people say like, well what is all the neurobiology of addiction research? What is that going to do? How do we use that to help people? Yeah. And I think a lot of it is reducing or hopefully eliminating stigma and understanding that it does have medical impacts and long-term physical impacts. And we see in the research too, the cure activity research, which if I haven't clarified, I apologize, is cure activity is the, um, measurement for craving using F M R I.
Speaker 1 00:48:20 But they'll also use cure activity using like heart rate and other things. But when I say cure activity, I'm referring to how they measure craving. And so I think it's fascinating that we can say that they're, you know, they look at, you know, if you have family history of it, you might have different cure activity and you might have never even excessively used a substance. Yeah. They've looked at, um, those that have had trauma history and the interaction of substance use and those studies, I, you know, that was hard for the meta-analysis was I had to really try to control for internal validity so that the, we're looking at the impact of the chronic substance use. Right. So I was, you know, unfortunately eliminating things if there was like a diagnosis of P T S D and anxiety depression. And so like that interaction is, I mean it's the realistic clinical world and it's also possibly very much exacerbating it because most, um, I was reading about it this morning too, just 'cause um, healthy eustress where I'm trying to just get some fun facts for the podcast.
Speaker 1 00:49:19 Right. And so I was reading about how the, the comorbidity of different, um, mental health and physical conditions with substance use, I mean, one could argue that, you know, if the individual has, um, well I guess what I was gonna say was that there's not as much research on H R V back feedback for substance use. There is some for narrow feedback. Um, but there is a lot of h I v biofeedback research for anxiety disorders. P ts d Yeah. Chronic pain, gastrointestinal, um, panic disorder. And so then I thought, okay, if there's some research for those, then there must be, we could consider that there's a likelihood that if the individual has that disorder, they probably are also possibly misusing a substance. Yeah. And it's true. And like the prevalence we have aren't great. Like I, they're, they're, the range is like 20 to like 80, you know?
Speaker 1 00:50:09 Yeah. But yeah. Um, we do know, like, I think the highest ones they said are, like with P T S D, depression, anxiety. Mm-hmm. Chronic pain. I think they looked at a, like it was a super large sample for chronic pain, but it was like over, I wanna say like 40% had some type of substance use disorder if they had had a chronic pain conditions. Yeah. So I think we can, you know, use it not as a sole approach, but we can use it as an adjunctive service in our approaches. I think also just measuring H R V to have additional data to, um, evaluate their progress and their recovery. 'cause there's mixed research on the long-term impacts of certain substances on H R V. Like some people have lower H R V if they chronically use a substance, but some substances doesn't impact it as much. Um, and so I think it's more so like what we tell individuals, find your own baseline work from there.
Speaker 0 00:51:06 Excellent. I, I, I just wanna give you, uh, because I, I could talk to you about this all day long. Uh, is there any other, uh, as we kind of wrap up here, any other insights you've had, any other, like, I always like to ask people who've done especially meta studies, 'cause they're so time intensive and boy, I can't even imagine how many, uh, journal articles you looked at during this process. Any generalizations too, even though I'm not gonna ask to be back, but just kind of in your own head, like epiphanies that might not be exactly related to this, but larger epiphanies or any other insights, uh, you'd like to share as, as we start to wrap up here?
Speaker 1 00:51:50 I guess I would say is that, um, there's a level for individuals that are not as familiar with peer reviewed research to have healthy skepticism, because that's what you learn in meta-analysis is, um, and I say that not in a negative way, say that as a, a perspective to have mm-hmm. <affirmative>. So just because, you know, the, across the research in our DA data analysis that these areas showed increased activation, um, and let's say those areas are associated with higher risk of relapse does not mean that is the destiny. Yeah. Um, and so I think a lot of this more so is to educate ourselves as clinicians so that we are also being aware of our own stigma that we have with substance use because it's a hard field because we see a, it's, you know, it's a really, um, I think there's really low percentages of individuals that achieve one year sobriety.
Speaker 1 00:52:49 Not that that's the only outcome, but it's, it's a really hard, um, and really tragic, um, area to help with. And very rewarding too because you see people get their lives back. Um, so I think with my dissertation, I gathered that, um, to, uh, to read things with curiosity, to read literature with, um, looking for details, looking for the methodology, looking at the participants, right. And reminding ourselves too that, um, we're working with, from like a clinical psychologist who's gonna be primarily doing clinical work now is remember that you're working with the individual mm-hmm. <affirmative>. Um, and that just because we have some consensus from different meta-analyses, um, they can be helpful in our case conceptualization, they can be helpful in education with our patients. Um, and at this time they're not really used as like treatment indicators, but maybe in the future they will.
Speaker 1 00:53:47 They, they always put that in the future research, use these as treatment indicators, but fmri machines are expensive. So yes, they're, um, but I think it's to use it for those reasons and to remember that you're working with an individual and individuals, we are all complex. Yeah. Um, and that's something I learned not only in my dissertation, but this year internship was that, um, you know, we are not working with just lab rats. And I say that ironically because I love animals, but I mean, yeah. You know, humans also have culture and they have, you know, event history and there's a lot of factors that don't fit in a box like we can do in some of our research. So to remember that although we have such incredible findings in our research world to remember the individual is there needing help and that we're there to help them, that's kind of my biggest takeaway, honestly. <laugh>.
Speaker 0 00:54:34 Well, that was beautiful. So I will not ruin that. Uh, we'll put some information about, uh, Anna in the show notes. Uh, she is a, uh, valued member of the optimal team. So it's just been great to work with you, my friend. Uh, congratulations. Uh, uh, you know, as we were talking about, I think you've been through four or five, like major exciting yet, you know, big, big, uh, moved across the country. We can call you doctor, change of jobs, all kind, relationship, excitement, all kinds of stuff. So, uh, it's great to, uh, be on this journey with you. Thanks for all that you do, and thanks for sharing your work with our audience. Uh, I know it'll be greatly appreciated.
Speaker 1 00:55:22 Of course. Pleasure and an honor. Thank you.
Speaker 0 00:55:24 Awesome. And as long as you can find more
[email protected] and, uh, we will see you next week.
