Pre frontal cortex damage or underdevelopment can be catastrophic especially when it is in addition to drug addiction. Understanding it and how to deal with it as a disease is critical to helping these loved ones as well as preventing it as our kids grow up. What causes it and what we can do about it.
As an opioid dependent person or a loved one watching a person with OUD, (Opioid Use Disorder) better known as Addiction, do you ever wonder, “why the hell did I, she, he, do that?” “That makes no sense” “that was so stupid” “didn’t you think about what could happen?” “How this would work out long term?” “What could go wrong and how will i deal with the consequences”?
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Every person has differing desires and abilities to think forward, to predict future consequences and outcomes and to see long term effects of actions. This ability has a direct correlation with a persons success in life in general. The ability to plan for successful long term outcomes and avoid problems setbacks and penalty is crucial.
You may have seen the studies (very simplified) of very young children being given the choice of one cookie now or two cookies later. Some take the reward immediately and some wait for the bigger reward later.
This is the essence of delayed gratification, the ability to reason and predict that if I sacrifice and don’t give in to my immediate impulse and desire now, I can have an even bigger reward later (or avoid penalty) and that reward will feel even better due to the sacrifice and waiting.
Any time that we can look into the knowable future and can see trends and ways to improve an outcome by waiting and or changing the direction of our choices, the reward will almost always be better. By planning for the bigger picture rather than an immediate nominal reward we think more clearly and can avoid some nasty pitfalls.
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Predictive and consequential thinking skills are one of the most critical life skills that we have and is a top predictor of success in almost all parts of life. It is also one of the fastest traits to be disappearing from our society for several reasons.
So many things that we would normally need to do some work to understand, we now can get someone else’s opinion on, in seconds, via the news, smart phone, Alexa or internet. We can also converse with someone across the world without ever seeing them or hearing their voice which begs the question, without non verbal cues, how do you know what they are really thinking and predict their actions or judge their reactions.
We also have many societal safety nets which enable people to mitigate the consequences of their actions and we also enable people in our families the same way by not allowing our loved ones to take the consequences of their poor decisions. We all understand why! We love and care for them and don’t want to see them suffer but without consequence there is no change or learning and in fact with the OUD population it usually gets worse before it gets better. Much worse.
To predict an outcome we must understand not only the goal but the facts about how something works and how it can change as its environment or situation changes. These skills are gained by direct experiences. We only touch a hot stove on purpose once, because we know from past experience about the burn. This translates into many simple cause and effect scenarios but when it comes to more complicated chains of events, much greater talent is needed. The more facts that are available to the predictor the more accurate the prediction.
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There are two perspectives I would like to tackle in this article. The first being how and when delayed gratification helps the prefrontal cortex in the developing brain to develop consequential and predictive thinking, thus enabling us to be better decision makers.
Second, how the damaged pre frontal cortex in OUD patients effects their behavior for the worse and how to attempt to heal and build/rebuild their ability to function normally and in their and their loved ones best interest.
Between the ages of about 14 until 22 our pre-frontal cortex is remodeling and adapting to the needs of its user so that by maturity we can function in our complicated world full of opportunities and pitfalls. During this time, if a person is using alcohol and/or drugs, especially drugs that effect Dopamine and Serotonin production and uptake, the growth and development of this critical area in the brain is stunted and less functional. We actually lose IQ.
By trial and error our brain will learn what works and what does not but does so in accordance with our unique particular situations.
If as a high school student, you decide to sleep in and be late to school several days a week and your parents do not punish you but allow you to go to great America that following weekend, that would be rewarding you for your bad behavior. Why would you do anything different? Not only are there no consequences but there is reward.
Now looking even farther down the road, always tardy = lesser grades = lesser opportunities for a good college = lesser chance for a good job = lesser chances of finding a good mate = higher potential of having trouble with your kids, mate and job and health. This of course is just an example, not an absolute, but hopefully you get the point that poor decisions early on translate into bad consequences down the road.
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Another example could be, as an 18 year old if you are not in school and do not have a job but you can still live at home, have plenty to eat, an X-box, a TV, a paid for phone and a car of your own or to borrow, why would you want to change anything? (most people with a well functioning Pre Frontal Cortex will want to move out and have all the joys and challenges of independence). But as a person with poor PFC development due to drugs or other reasons, if our parents go ahead and pay for us anyway we have just been rewarded for another bad behavior and will probably continue it.
What would we guess would be the long-term action of that student? It would be to go ahead and blow off school, go to great America, live at home, not work and have someone else pay for it. They typically try to pull off the con in more and more different situations until they become the uncontrollable, lying, manipulative, relationship destroying addict that is so typical of these ill people. Please remember that they have a disease, (OUD) that is causing this and so we cannot think of them as vile terrible people, they are sick, they have a disease, they have chemically induced brain damage. We need to be caring, empathetic and purposeful in our interactions with them while staying strict and consequential in our tough love.
How does that translate into an adult life? If as an adult you have not positioned yourself for a decent job you might expect or hope that somebody else will help you make ends meet. This is part of the problem with what is called a nanny state in government. It is what our government sometimes does through so called safety net programs and what our loving families will actually do because they care and don’t want us to suffer. However, especially with a loved one who’s PFC is not functioning well, especially one addicted to drugs, it is not safe, sustainable or satisfying for anyone and will in most cases, make the situation worse.
To take this to another level, if a person does not have a job but needs a place to live and a car to use and their family will not pay for it, they only have a few choices. They must find a way to make some money so that they can get what they need. It will take longer to find a job, longer to make the money etc. and be functional but in the end they can go whenever and wherever they want and have the pride of doing it on their own. This is an example of delayed gratification.
This is why we must, as our children are growing through adolescence, have them work for the things that they want and only receive those things as rewards for their actions. They must learn that things are earned not given and learn to use tools that will help them to develop the brainpower to plan their actions in order to gain what they need in life. This is how we satisfy ourselves and build self esteem and pride and motivation to continue to move forward.
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So how do we build or rebuild the damaged pre-frontal cortex in OUD patients?
First they and their team must recognize and admit that they know there is chemical brain damage with real and serious side effects.
The patient, most often an adult, has the right to refuse treatment and may do so, not believing that they have a problem. If that is the case, they need to go it alone.
The patient must surrender, to some extent to someone that they trust to help guide them in making decisions toward healing.
Then activities designed to help develop predictive/consequential thinking skills should be pursued.
When OUD patients have decreased executive function, the results are usually that the patient is not able to see the long term benefit or consequences of their actions or lack thereof. There is a lack of motivation to do for themselves because, since their brain isn’t functioning properly, they cannot see the way forward and will default to an immediate reward.
Most often that default reward is back to drugs and the cycle repeats and strengthens itself.
This effects the patients behavior for the worse since they cannot plan their way out of trouble.
How then do we attempt to heal and build/rebuild their ability to function normally?
First is of course to stop using the destructive chemical which is not easy. There needs to be a way to fulfill their brains need for the drug and then we need to keep them comfortable so they wont relapse. This can be done with Suboxone.
Next, activities need to be started that stimulate the pre-frontal cortex.
This means anything which requires longer term outcome anticipation as well as blood oxygen level increases and Dopamine/Serotonin release.
Oxygen and Dopamine/Serotonin; Exercise, Sports (team and extreme), outdoor cycling etc.
Dopamine/Serotonin; Hobbies that are loved, especially the arts where they can go into “the zone” such as painting, photography, music etc and the solitary creative hobbies like gardening, design etc.
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Predictive/consequential; Chess, Writing, Life planning, Home design and structural rehabilitation, Business planning etc
Start by speaking with a Therapist for direction, motivation, guidance and structure. Get on and stay on the medications that will help you stay comfortable and stay close to people who support you, work and stay busy and absolutely avoid people whom you used to hang with while using. People who can help with the support portion are Therapists; PsyD’s, LCPC’s, LPC’s, OT’s. CADC’s and sobriety coaches amongst others.
At BRIGHTSIDE Clinic we can help educate, treat or help you find the right path to recovery.
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