By Suzanne Riss

In 12-step meetings people are always saying, “After five years, you get your marbles back. After ten, you remember how to use them.” You also hear, “Don’t make any major decisions in your first year of recovery.” Some say it’s more like your first two years.

People in recovery often recognize that something mysterious is going on with their brains. They’re forgetful. They have trouble concentrating. They don’t think clearly.

Now doctors and scientists are gaining insight into what’s going on. They know that an addicted brain undergoes physical changes. And they know that the brain’s plasticity — its ability to change — allows it to heal over time. Now they can chart some of these changes using SPECT scan images, which can identify differences in blood flow in a normal brain and an addicted brain.

This information, according to some doctors and addiction specialists, can help them develop more effective treatment plans, allowing them to prescribe different medication that can compensate for the portion of the brain that has too much or too little activity. Those who use the scans say they deliver, at long last, a way to examine the target organ for the disease of addiction—the brain.

“If you’re not looking at the brain, you’re guessing and prescribing treatment based on symptoms,” says Dr. Daniel Amen, a pioneer in brain imaging. A physician, psychiatrist, brain imaging specialist and the CEO and medical director of Amen Clinic in Newport Beach, Calif., Amen has been using the scans for more than 20 years to target treatment for addicts and “help patients understand they’re dealing with brain illnesses rather than character problems.”

Though the biomedical community now agrees that addiction is a chronic brain disease, controversy surrounds the use of SPECT scans to treat the addicted brain. Opponents dismiss them as “SPECT scams” because of their inability to diagnose addiction and their $3,200 to $4,000 price tag. Many believe it’s premature to use SPECT clinically. Proponents, however, say that while more research needs to be done, the scans are useful treatment tools that work much like radar, providing insight that has never been available before into activity in different regions of an addict’s brain.

Brain envy
SPECT scan technology has been used in cardiology and other areas but its application to treat addiction is relatively new. In recent years, several leading addiction treatment facilities have purchased SPECT scan machines. “We’re changing what we’re doing therapeutically as a result of the information we get from SPECT scans,” says Dr. Barbara Krantz, Medical Director and Medical Director of Research at The Hanley Center, an addiction recovery facility in West Palm Beach, Fla. Since the center acquired a machine in 2010, every patient receives a scan. “The scans help us recommend more effective treatments, ask better questions and identify other brain-based disorders that affect addiction. They can also help us scientifically document what’s working in addiction treatment and what isn’t.”Sierra Tucson, a psychiatric hospital that treats addictions and behavioral disorders, purchased a SPECT machine in 2009. “The scans are very helpful in a variety of ways as they’re not used for something they can’t do, like make a diagnosis,” says Dr. Robert R. Johnson, medical director of the hospital, where about 25 percent of patients receive the scans. “There’s no signature image for addiction. Scans won’t tell you what substance is being abused, but they will show signs of a toxic brain.” Like Amen, he has found that the images can be great motivators. He’s seen patients break into tears after they see a scan of their brain. “It shifts the conversation from shame, guilt and lack of effort to a neuro-biological conversation,” he says. “It helps explain why it’s been such a struggle.”

The scans can not only show the damage that has been done but also can chart the progress of recovery. Plasticity, the capacity of the brain to change, means that the adult brain can create new neurons and new connections despite damage from addictive behavior. In other words, an addicted brain can rewire itself and heal. “This neuro-plasticity allows the brain to change in ways that engrain drug-seeking and drug-taking behavior,” says Kathryn A. Cunningham, Ph.D., director of the Center for Addiction Research at University of Texas Medical Branch Galveston, Texas, an academic health sciences center. “But this same property also allows the brain to correct and strengthen connections to improve neuro-degenerative and psychiatric disorders, including addiction.”

Addiction specialists say it would be a mistake to underestimate the brain’s ability to heal. “It’s always possible to compensate or stimulate other areas of brain,” says Dr. Ruben Baler, a scientist at the National Institute on Drug Abuse. “The message is very hopeful if you’re looking at the plasticity of brain,” he says. With Methamphetamine abuse, he has seen dopamine receptors coming back at least partially after 14 months. With alcohol abuse, he says the recovery time depends on the level of damage.

Johnson delivers this message of hope to patients at Sierra Tucson. He uses SPECT images and software to show patients what their brain will look like in 12 months if they stop using and what it will look like if they continue using. He then asks, “Which of these two brains do you want?” According to Amen, the scans “teach addicts to have brain envy. Then they’re more willing to engage in lifestyle changes.” The scans also increase awareness about the importance of taking care of your brain, Johnson says. “Most of us are not taught about the role the brain plays in sustaining healthy relationships or even keeping your job. It’s not just about recovery from addiction, it’s about leading a more fulfilling life.”

Read my mind
It turns out that addicts have a lot in common. Indeed, researchers are finding similarities between individuals suffering from a variety of addictions. “All addictive substances affect similar pathways in brain,” says Dr. Susan Forster, vice president and director of policy research and analysis at the National Center on Addiction and Substance Abuse at Columbia University. “The reward pathways get compromised by significant substance use.” Regardless of the substance, the same brain pathways are involved – most involve the neuro chemical dopamine, a neurotransmitter that helps control the brain’s reward and pleasure centers.

“If you think about the brain in terms of the parts that drive you to experience pleasure and parts that say, ‘wait a minute, let think about the consequences,’ when a brain becomes addicted, that brake isn’t applied,” Forster says. “It’s overridden by the part of brain that says there’s a reward.” In effect, the brain is hijacked by continued use of an addictive substance. The brains of people with addictive disorders reflect similar functional and structural changes, she adds. “When those changes happen, you see characteristic behavior: compulsive use of substances in spite of negative consequences.”

Despite the similarities, there are also individual histories and unique differences in which regions of the brain are impacted, Amen says. “SPECT allows us to target treatment to the individual type of brain being examined.” While a CT or MRI looks at brain anatomy, SPECT (“single photon emission computed tomography”) looks at brain activity. If you have your brain scanned after suffering a concussion in a car accident, a CT scan or an MRI would take pictures of your brain’s structure. If you have your brain scanned after years of abusing alcohol, a SPECT scan can produce images of the blood flow in your brain. These pictures of the brain in action result from having radioactive tracers injected into the patient that concentrate where the brain is active.

“SPECT scans basically tell us three things,” says Amen, “areas of the brain that work well, the areas that are low in activity and the areas high in activity. Once we know how the brain works, the goal of treatment is to balance brain function, such as calm the overactive areas and enhance the under active ones.” As an example, an alcoholic may have too much activity in the anxiety centers of the brain. “When we see this on the scan, we can find ways to calm down those parts of the brain. Or if there’s too little activity in the front part of brain, it may need stimulation. We can also see instances of prior brain trauma due to a fall during a blackout or someone getting hit over the head with a beer bottle in a bar fight.”

Amen finds the scans add the most value when treatment is failing. “I put imaging in the protocol when things are confusing,” he says. “There could be an underlying problem that the scan can point to.”

The scans of addicts often reveal what appear to be dents in the brain’s surface that make it look like Swiss cheese. These apparent holes, which would not be visible on a CT scan or MRI, represent areas of the brain with reduced activity due to low blood flow. Begin to heal these areas, which Krantz says is usually possible in a matter of months, and you begin to heal the patient. By contrast, the surface of a normal brain is smooth. When Krantz did a pilot program with nine patients to test out the scan machines, she saw interesting commonalities. “Every person had a significant decrease in blood flow in the prefrontal cortex of brain, which governs impulse control,” she says. “That area of the brain wasn’t getting enough blood to function properly.”

Customized treatment
For those who wonder why recovering addicts continually relapse, SPECT scans provide insights, Krantz says. These patients can’t stop using drugs or alcohol because they can’t control their impulsivity, she says. “It’s not lack of willpower,” she says. “It’s just that the part of the brain that tells most people to stop is damaged in addicts.”

The compulsion to drink or pop pills despite losing a marriage, having repeated DUIs or getting fired from a job is all evidenced in the prefrontal cortex, she says. “This is why we see patients who have been in 10 different treatment centers yet continue to relapse,” she says. “I always wondered what we were missing, how we could do a better job.” Krantz believes that SPECT scans are beginning to help provide some answers. How does this information influence treatment? “Impulsivity was a big issue for these patients, so I might put them on anti-craving medication early in the process to make sure they don’t walk out or relapse yet again,” she says. For another patient, it might mean prescribing antidepressants to enhance recovery.

Krantz believes that she can target medication more effectively when she knows precisely which area of the addict’s brain is over active or under active. “The scans take out a lot of the guesswork,” she says. “If patients come in with alcoholism and bipolar disorder, there are certain patterns that we believe we are seeing on the SPECT scan.”

SPECT scans have uncovered significant similarities in the varied patient population at Sierra Tucson, says Johnson. “We draw patients from all over the country and the world, and we have a very diverse patient mix. Many have failed multiple programs in the past. SPECT has helped highlight the effects of traumatic brain injury, which can have a big physiological effect.”

These brain injuries can include everything from falling while skate boarding or skiing to football injuries or falling down while drunk. He says initial data showed that 40 percent of Sierra Tucson patients have had symptomatic brain injuries, and many have had more than one. “The scans showed more instances of traumatic brain injury than we thought,” he says. “What this speaks to is impaired frontal lobe functioning or the ability to say no to temptation. When the prefrontal cortex is impaired, it’s hard to maintain recovery.”

A personal mission
Today we have a much better understanding of the neurobiology of the brain than we did 30 years ago, when Krantz herself was in recovery. As a young mom trying to keep up with her 6-month old and a busy medical practice, Krantz started getting pounding migraines. When her neurologist gave her a shot of Demerol, she was relieved to find that a sweeping euphoria replaced the debilitating headaches. Soon she was injecting Demerol daily. She eventually entered a program for addicted physicians. During her recovery, she struggled.

“My brain wasn’t back,” she says. “I didn’t feel right. None of the doctors who treated me could answer my questions about what was going on with my brain. It was very disturbing.” Krantz says she became an addiction specialist to help answer these questions. Had SPECT scans been in use to treat addiction at the time, Krantz believes they would have helped her. “My scan would have shown a lot of emotionally charged memories,” she says. “My treatment could have been more focused. It would have made more sense to me.”

In AA comes the promise that, “We will intuitively know how to handle situations which used to baffle us.” This ability to think more clearly is the result of a healed brain, says Krantz. In fact, she has noticed that many AA slogans are now finding a scientific basis. “It’s amazing that AA knew, for example, to advise those in recovery to HALT,” she says, referring to the recommendation that you don’t allow yourself to get too Hungry, Angry, Lonely or Tired. “We are finding out 50 years later that those are all functions of the lateral hypothalamus in the reward pathway for the disease of addiction.”

A lot of hoopla?
Not all treatment centers embrace SPECT scan machines. Promises Treatment Centers, the alcohol rehab and drug rehab addiction treatment facilities in Malibu and Los Angeles, do not.  “SPECT scan are not treatment and have limited diagnostic validity,” says Dr. David Sack, M.D., CEO of Promises. His primary complaints are the lack of data and the scans’ inability to predict which treatments will work.

“When you look beyond the hoopla, how much useful clinical information is there? I think very little,” says Sack. “The scans are not harming people but when they start to believe that they can guide their treatment, it’s misleading.” For Sack, until the scans can tell doctors how to treat patients, he doesn’t see the value.

Dr. Hal Urschel, a psychiatrist and author of Healing the Addicted Brain, believes it will be another five to eight years before SPECT data are analyzed and understood. “There’s still a long way to go,” he says. “It will be a better tool in the future.” Urschel sees SPECT as a possible piece of a treatment plan but “not necessarily critical.” The price of a scan and evaluation “could buy a lot of medications to control the cravings,” he says.

Those who embrace SPECT are the first to admit that more study is needed. The Hanley Center is currently analyzing the data it has been gathering to see what patterns emerge. “We need evidence-based data,” Krantz says. “We are starting to see patterns but need more research and statistical analysis and mapping.” Though repeated scans have shown improvement in blood flow to impaired areas, Krantz says it’s too soon to tell the success rates. However, she remains an optimist about the future potential of the scans: “I believe the scans will give us predictive severity measures that will impact treatment planning.”

There’s a growing consensus that neuro imaging is playing an important role in research and clinical practice with addiction medicine and psychiatric illness, says Johnson of Sierra Tucson. “We’re moving away from traditional symptom driven, syndrome categories to genetic and neuro biological imaging.” Part of the resistance to SPECT scans, he says, is that they require that clinicians make a mental shift that isn’t always easy. “They need to shift to what’s happening in the brain of the person in front of them and not just default to a diagnosis,” he says. When SPECT scans were discussed at a recent American Psychiatric Association symposium in Honolulu, the majority of critics “were won over when they heard about the data and clinical efficacy and practice,” he says.

For Amen, the naysayers are nothing new. “We’ve been at this for 20 years,” he says. “People said we were crazy when we started out. Initially there was a lot of resistance. People said the scans were nonsense. They’re not. We think they’re really important.”

Suzanne Riss is a writer and editor who specializes in health and women’s issues. Most recently she was Editor-in-Chief of Working Mother magazine. Her first book, The Working Mom Survival Guide, was published by Weldon Owen in October.