Drugs and the Brain A bit of anatomy and physiology

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Drugs and the Brain A bit of anatomy and physiology




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Presentations text content in Drugs and the Brain A bit of anatomy and physiology

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Drugs and the Brain A bit of anatomy and physiology

Presented byElizabeth Diebold, ND, MPH, CHom

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Brain AnatomyThe nervous system is the body’s decision and communication centerControls every part of body movement and functionControls emotions and memoryThe central nervous system (CNS) is made up of the brain, spinal cord, and peripheral nervous systemNerves directly from the brain control movement and function of face, senses, and life support

Motor neurons from the brain to the body deliver instructions about what to do or action to takeNerves from the brain run through the spinal cord outward, controlling movement and functionThese nerve fibers also gather and send sensory information back to the brain for processingSensory neurons to the brain deliver messages about the environment to the brain for processing and response

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Brain AnatomyThe brain is comprised of three sections:ForebrainCerebrumThalamusHypothalamus (part of the limbic system)Midbrain

TectumTegmentumHindbrainPonsMedullaCerebellum

“brainstem”

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Brain AnatomyThe Cerebrum is the largest part of the brainLots of wrinkles means lots of surface area (and many neurons), which makes this area very efficientMostly made up of the neocortex, associated with more evolved animals and higher information processingAssociated with higher thought and action

Divided into four sections (lobes): Frontal lobe is associated with reasoning, planning, speech, movement, emotions, problem solvingParietal lobe is in charge of movement, orientation, recognition, and perception of environmental stimuliOccipital lobe is associated with processing visual information Temporal lobe rules auditory stimuli (including speech) and memory

A deep furrow divides the cerebrum in half, into left and right hemispheres with slightly different functionsThe right is more creative, the left more concerned with logicThe two sides are connected by the corpus callosum, a bundle of nerve cell connections

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Brain AnatomyThe Cerebellum (“little brain”) is associated with regulation and coordination of movement, posture, and balanceWhile similar in structure to the cerebrum, the cerebellum is (evolutionarily) much olderMeaning, it is well developed in less evolved animals, who do not have the neocortex of the cerebrum

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Brain AnatomyThe Limbic system (The emotional or “reptilian brain”) is buried deep within the cerebrumEvolutionarily, it is very oldContains:

Thalamus, which has sensory and motor functions Almost all sensory information enters the thalamus, where neurons send information to the overlying cortex.

Axons from every sensory system (except smell) synapse here as the last relay site before the cerebral cortex Hypothalamus is involved in homeostasis, emotion, thirst, hunger, circadian rhythms, and control of the autonomic nervous

system

Also

controls the

pituitary

Amygdala is located in the temporal lobe, and involved in memory, emotion, and

fear

Hippocampus is important for learning and

memory

Especially converting

short term memory to more permanent

memory

Vital for

recalling spatial relationships in the surrounding

environment

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Brain AnatomyThe Brain Stem lies beneath the limbic system, and is responsible for basic vital life functions such as breathing, heartbeat, and blood

pressure This is the simplest part of the human

brain, meaning it controls only basic functions and without conscious thoughtThe brains of lower animals’ brain stems look much the same as those of more highly evolved speciesComposed of:Midbrain (mesencephalon), involved in vision, hearing, eye and body

movement

Pons, which

is involved in motor control and sensory analysis

(e.g.,

information from the ear first enters the brain in the pons) and for level of consciousness and

sleep

Some

structures within the pons are linked to the cerebellum, thus are involved in movement and

posture

Medulla Oblongata is responsible for maintaining vital body functions, such as breathing and heart rate

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Brain Anatomy

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Brain FunctionThe adult brain weighs about three pounds, and is made up of billions of cellsThe brain controls everythingMovements of the body

Regulation of involuntary body functions (breathing, heartbeat, digestion, elimination)Senses (touch, smell, sight, taste, hearing)Memory, learning, emotionsThe brain presides over those experiences we consider humanThe brain manages behavior and actions, both conscious and unconsciousThe brain rules instinct and reflexive

actions and responses

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Brain Function

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Various functions are controlled by very specific areas of the brainThe brainstem, which connects the brain and

spinal cord, coordinates basic functions such as heart rate, breathing, digestion, and sleepThe cerebellum

coordinates skilled repetitive movements, and maintains balance and postureThe limbic

system

regulates emotions, motivation, and

mood, and is where the “reward system” is found

The

amygdala and hippocampus are part of the limbic system, and

are important for making memories

The diencephalon

is made up of the thalamus and hypothalamusThe thalamus oversees sensory

perception and

regulates movement

The

hypothalamus

regulates the

pituitary gland, which synchronizes the release of

hormones throughout the body

The cerebral cortex

is the

largest part of the

brain

Contains the areas

of the brain responsible for

thought, reasoning

,

perception

C

ontains areas dedicated to the senses (vision, hearing, touch, smell), making and understanding language, and movement

Brain Function

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Brain ChemistryCommunication between brain cells is the foundation of brain functionThe brain functions through a complex series of electric impulses and chemical reactionsElectrical impulses travel along nerve cellsChemical reactions occur in the area between nerve cells

There are two kinds of cells in the brain:Neurons (nerve cells) The basic unit of the brain (each brain contains about 1011 of them!)Interactions between neurons cause things to happenDendrites receive signals

from other nerves, axons transmit signals to other nerves

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Brain ChemistryThe axon ends in branches with swellings called presynaptic terminalsAxons are located near the dendrite of another neuron

Junction is called the synapseSpace between cells is where chemical messages occurGlial cells (glia)There are 10-50 times more glia than there are neurons in the central nervous systemAct as support elements (structure, myelin,

blood-brain barrier) and scavenger cells to remove cellular trashHelp regulate ion concentrations, remove neurotransmitters from intracellular space, guide neuron growth and migration

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NeurotransmittersA neurotransmitter is a chemical substance released at the end of a nerve fiber by the arrival of a nerve impulseBy diffusing across the synapse (aka, the junction), a neurotransmitter causes

the cell to transfer an impulse to another nerve fiber, muscle fiber, or some other structureEssential for proper brain (and so body) functions

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Neurotransmitters

Major Neurotransmitters in the Body

NeurotransmitterRole in the bodyAcetylcholineUsed by spinal cord motor neurons to cause muscle contraction and by many neurons in the brain to regulate memory.

In

most instances, acetylcholine is

excitatory

.

Dopamine

Produces feelings of pleasure when released by the brain reward system. Dopamine has multiple functions depending on where in the brain it acts. It is usually

inhibitory

.

GABA (gamma-

aminobutyric

acid)

The major inhibitory neurotransmitter in the brain.

Important

in producing sleep, reducing anxiety, and forming memories.

Glutamate

The most common

excitatory

neurotransmitter in the brain.

Important

in learning and memory.

Glycine

Used mainly by neurons in the spinal cord.

It

probably always acts as an

inhibitory

neurotransmitter.

Norepinephrine

Acts as a neurotransmitter and a hormone

.In the peripheral nervous system, it is part of the fight-or-flight response. In the brain, it acts as a neurotransmitter regulating blood pressure and calmness. Norepinephrine is usually excitatory, but it is inhibitory in a few brain areas.SerotoninInvolved in many functions including mood, appetite, and sensory perception.

In the spinal cord, serotonin is inhibitory in pain pathways.

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The Brain and Addiction Drug abuse/addiction carries consequences for individuals and a high cost to society Estimates of the total overall costs of substance abuse in the United States add up to more than $600 billion every year

This includes loss of productivity, impacted health and increased health care costs, and costs related to the crime which surrounds drug use and addictionNearly $200 billion of this figure is spent on the drugs themselvesAnother $200 billion goes to the purchase of tobacco, and nearly $250 billion to alcohol; these are often used concurrently, with or without the use of other drugs.Costs less measurable include the impact on public safety, as well as job loss and unemployment, educational failure, and the degeneration of families, domestic violence, and child abuseDrug addiction is a complex disease, and quitting takes more than good intentions and willpowerDrugs

change the brain in ways that foster compulsive drug use, making quitting difficult

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The Brain and Addiction Let’s review … what is addiction?Addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use, despite harmful consequences to the individual and to those around him/herAlthough

the initial decision to take drugs is voluntary, the brain changes that occur over time challenge an addicted person’s self control and impede his/her ability to resist impulses to take drugsSimilar to other chronic, relapsing diseases, such as diabetes, asthma, or heart disease, drug addiction can be managed successfully Much like other chronic diseases, it is common

for a person to relapse and use drugs again Reassurance and support are important, as relapse does not signal failureRather, it indicates that treatment should be

reinstated or

adjusted, and that alternative

treatments and tools are needed

to help the

individual

regain control

and be able to

sustain recovery

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Drugs Disrupt NeurotransmissionDrugs work by replacing natural brain chemicals with artificial ones that are more stimulating and longer acting, or by blocking natural brain chemicals to achieve a different effectThe reward system (part of the limbic system) regulates feelings of pleasure

This region is fully activated by drugs of abuse, which is what makes them so addictiveDrugs of abuse alter the communication between neurons that is mediated by the neurotransmitter dopamine in a number of waysExamples:Increase the amount of neurotransmitter releasedAlcohol, heroin, and nicotine indirectly excite dopamine-containing neurons so that they produce more action potentials, which increases the amount of dopamine released

Meth, crystal, crack, and other amphetamines cause the release of dopamine from storage areas independent of action potentials, which produces a quick and prolonged rise of dopamine levels

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Brain ChemistrySome drugs activate chemical receptors in synaptic transmission, others block themTHC and morphine activate specific receptors, which blocks a person from experiencing painCaffeine prevents the neurotransmitter adenosine (which has sedative properties), causing stimulation and arousalLSD stimulates some serotonin receptors while blocking others, impacting mental function in a very complex (and not fully understood) way

Slide20

Drug UseAlthough the influence of drugs on the brain’s reward pathways and alterations of

dopamine neurotransmission are central to continued use, there are other equally important factors at work:Genetics impact a person’s drug sensitivity, how drugs are metabolized, and their tendency toward addiction Environmental factors, such as stress, trauma, and (especially in teens) unhappiness can impact an individual’s willingness to experiment with drug use or give in to continued use

Dose and route of administration are critical factorsA dose can be anywhere from low (no effect) to toxic (overdose)Not everyone responds to the same dose in the same way, or the same way every time to a particular doseResponses can be influenced by age, gender, genetics, emotional state, and past experience with drugs (including prescription drugs)

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Drug UseRoutes of administration have a huge impactDrugs enter the brain by different routes, and the route of administration can make a dramatic difference to onset, intensity, and duration of action for a drugA drug which is inhaled reaches the brain very quickly, as it will go directly from the lungs to the heart to the brain

Effect may be less intense because some of the drug will be exhaled and some may not pass through the blood-brain barrier in sufficient amountsA drug injected intravenously travels quickly and intact, causing a rapid onset and high risk of overdoseSnorting or snuffing a drug brings a less intense action because it takes longer to get the drug to the brain; the same is true of oral ingestion, as both must be metabolized in the body first

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Drug Use: Routes of Administration

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Addiction: Nature or Nurture?In 1994, Mickey Mantle checked into The Betty Ford Clinic after being told by doctors that his liver was on its last leg. His wife and sons had already completed treatment for their own alcoholism and drug addiction, and they urged him to go.

This man -- this legend – who had survived osteomyelitis in his youth and gone on to set world records in baseball, was here getting sober with his family. A family which consisted of

two alcoholic parents and their four children.

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Addiction: Nature or Nurture?Studies of identical twins suggest that up to half of an individual's risk of becoming addicted to nicotine, alcohol, or other drugs depends on his or her genes Genes provide information that directs the body’s

basic cellular activities Research on the human genome has shown that the DNA sequences of any two individuals are 99.9% identical That 0.1% variation is profoundly important, contributing to visible individual differences, like height and hair color, and to invisible differences, such as increased risk or protection from heart attack, stroke, diabetes, and

addictionSome diseases are caused by an error in a single gene (e.g., sickle cell anemia, cystic fibrosis, Huntington’s disease)Other diseases – including addiction – are more complicated, and variations in many different genes lead to increased risk or resistance to a particular disorder

Slide25

Addiction: Nature or Nurture?Research shows that individual health is the result of dynamic interactions between genes, familial customs, and environmental conditionsIn other words,

In many cases, genetic effects persist throughout a person's lifeThink about risk for high blood pressure, heart disease, or diabetes, or even sunburn, obesity, all of which can be managed or alleviated through personal choices and a healthy lifestyleResearch suggests that genes can also influence how a person responds to his or her environment, placing some individuals at higher risk than

others even under the best of circumstances if they are not very carefulThis means that they must be educated!

Nature

AND

Nurture

AND

Slide26

Addiction: Nature or Nurture?Scientists of pharmacogenomics are currently using genomic information to improve treatments for a number of diseases, including some very interesting work in addiction therapyClinicians have found substantial variability in how individual patients respond to treatment, particularly drug treatment

Part of that variability is due to genetics: Genes influence the numbers and types of receptors in the brain, how quickly the body metabolizes drugs, and the response an individual has to different medicationsThis can have huge implications on how likely it is that an individual becomes addicted, and how they are subsequently treated

Two dangers in this approach:The trial and error phase can be long, tedious, and deadlySubstituting one substance (or behavior) for another

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Addiction: Nature or Nurture?There is a distinct interaction of factors that leads to an addiction-prone individual becoming an addict

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Drug Use: Implications for TreatmentWhen drug use is present, brain neurotransmitters are impactedWhen neurotransmitters are impacted, behavior and physicality are changedCravings are exacerbated by imbalances in the brain’s neurotransmitter chemicals, which can be caused by the use of psychotropic drugs of any kind

Re-balancing brain chemistry and neurotransmitters will allow the patient to manage mood disturbances and cravings

Slide29

Drug Use: ConsequencesThe consequence of drug abuse are vast and varied, and affect people of all ages and socioeconomic areas.

What we are doing, and how we do it, matters.

Slide30

Trends in the SWFrom the National Institute on Drug Abuse, the following trends are seen in NM (as of 2012):Drug overdose deaths rates for Bernalillo County (Albuquerque) and New Mexico increased in 2011There was a dramatic increase in methocarbamol (Robaxin

, a muscle relaxant) poison control center cases from 2011Synthetic cannabinoids increased substantially in numbers of poison control center cases and in numbers of reports identified from drug items seized and analyzed A large increase occurred in reported naloxone overdose reversals in Bernalillo County over the previous yearDrug overdose deaths continue to increase

throughout NMIn 2010, New Mexico had the second highest drug overdose death rate in the Nation, a rate which increased by 66% in 2011 (nearly 40% in ABQ), which represents nearly 30 deaths per 100,000 peopleWhile drug overdose as the primary diagnosis decreased in 2011, drug overdose death rates increased as a secondary diagnosis, as well as deaths involving

prescription opioids. Overdose death rates were stable for methamphetamines/amphetamines.

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Trends in the SW(continued)In Albuquerque, 2012:21.2% of drug seizures in Albuquerque were for heroin20.6% involved methamphetamines18.7% involved marijuana

seizures16.3% involved cocaineAccording to the Youth Risk and Resiliency Survey, drug use among youth in NM remains high, although it has declined in recent years for all substancesApproximately 26.5% of high school students reported using marijuana during the past 30 days10.2% reported having used painkillers to get high6.1% were reported as current users of

inhalantsAccording to the National Survey of Drug Use and Health, 11.4% age 12 and older reported current marijuana use, and 5.76% reported current nonmedical use of prescription pain relieversOverall, sales of prescription opioids have increased only slightly (<1% in ABQ, 5.8% in NM), with the highest volume being of oxycodone

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Trends in the SWAs of 2013:High levels of heroin and methamphetamine/amphetamine continue to be seized in ABQ and Bernalillo CountyHeroin and prescription opioids/opiates other than heroin were overtaken in primary treatment admissions data by methamphetamine/amphetamines and marijuana The proportion of primary methamphetamine/amphetamine treatment admissions increased from 2010 to

2012Percentages of marijuana/cannabis seizures increased, but remain lower than national dataTreatment admissions in which marijuana was the primary drug of choice increased in 2012 from 2010The proportion of drug reports for cocaine in the ABQ area were

lower than the national data, and decreased in the first half of 2013Primary cocaine treatment admissions declined from 2010 to 2012

Slide33

NM in the NewsFrom the Trust for America’s HealthNew Mexico has the Second Highest Drug Overdose Mortality Rate in the United States New Mexico Scored 10 out of 10 on New Policy Report Card of Promising Strategies to Help Curb Prescription Drug Abuse What NM is doing right:Educate the public to understand the risks of prescription drug use to avoid misuse in the first place;

Ensure responsible prescribing practices, including increasing education of healthcare providers and prescribers to better understand how medications can be misused and to identify patients in need of treatment(cont…)

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NM in the NewsIncrease understanding about safe storage of medication and proper disposal of unused medications, such as through "take back" programsMake sure patients do receive the pain and other medications they need, and that patients have access to safe and effective drugsImprove, modernize and fully-fund Prescription Drug Monitoring Programs, so they are real-time, interstate and incorporated into Electronic Health Records, to quickly identify patients in need of treatment and connect them with appropriate care and identify doctor shoppers and problem

prescribersMake rescue medications more widely available by increasing access for at-risk individuals to naloxone and provide immunity for individuals and others seeking helpExpand access to and availability of effective treatment options as a key component of any strategy to combat prescription drug abuse

Slide35

What’s Being Done in the SWUNM: Center on Alcoholism, Substance Abuse, and Addictions (CASAA)Studies in the areas of behavior, pharmacological, and integrated behavioral and pharmacological treatment interventions Studies across a broad range of treatment settings and diversified patient populationsEastern NM University

Research and training in biological, social, and psychological aspects of addiction, and in efficacy of various counseling techniquesSpecial studies of “special populations,” including women, minorities, youth, and persons with concomitant physical and mental disabilities/disordersPacific Coast Research CenterMultidisciplinary study in the areas of criminal justice, drug abuse, and implementation, partnering with other states and agencies and focusing on organizational and system processes

Slide36

Some Favorite Tools for ChangePlanningStudies in behavior change show that taking the time and effort to make a plan is a powerful motivator in changing one’s actionsUse a calendar, chart, or daily list, and include details of the planFormulate a long-term plan to maintain sight of the “Big Picture,” then set aside time each week to make a detailed weekly plan

Be sure to note down-time and rewards to keep you motivatedInclude a few minutes every day to re-play how the day wentOffers feedback, and allows for adjustments to behaviorAllows us to feel more in control and confident, and thus more prepared for the next move, the next dayVisualizingFive minutes a day will do the trick!Envision yourself in brilliant detail acting as you want to, carrying out the behaviors you aspire to, and being the person you want to be/become

See yourself taking the

next best step

Slide37

Some Favorite Tools for ChangeMeditationThe simplest form of meditation is one sitting quietly and concentrating on the breathOnce mastered, meditation can be used for stress control and to ease cravings (be they drugs, food, or behavior)Five minutes in the morning and before bed, and just a minute or two whenever a “time out” is neededJournalingJournaling serves to get the spiraling thoughts out of your head and into a place where they can be dealt with and put to rest

The journal can be as simple (a spiral notebook or computer document) or as fancy as you like. Make certain that the journal, in whatever form, is completely privateRewardsEver go to Disneyland? Participate in a group event? Rewards, big or small, and powerful motivatorsSmall rewards, such as stickers, charms, or chips should come regularly, and for even the smallest victoriesLarge rewards, such as a trip, new bicycle, or day at the spa can come with larger goals reached – such as time clean

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Some Favorite Tools for ChangeReview progress dailyAsk yourself …Did you have the day you planned to have?Name one thing, large or small, that you are proud of todayWhat challenges did you face today? How did you do? Why?

How can what happened today help me tomorrow? What can I change? How can I better be prepared?Feedback, not failure!Use what is learned in these exercises to change behaviors, adjust the plan, and re-commit to goalsForgive and move onThere are bound to be slips and slides; make a note of them and then forgive yourself so you can move onLook forward, not backWhatever today looked like, look forward to a better tomorrow

Use the “coin analogy”One coin does not make one rich – but that is where it beginsAdding one coin at a time does not make one rich – but is how wealth is builtMany coins, collected over time, leads to riches, just as many small steps leads to goals met, behaviors changed

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For more information or answers to questions,

Call Dr Diebold at 505-410-2840 or email chance@drdiebold.com

Questions?

Slide40

Cases in Addiction

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Cases: Famous People’s AddictionsKurt CobainThe lead singer of the world’s biggest rock band of the 1990s was a lifelong heroin addict, a problem that only worsened as fame grew. Unable to handle the pressures that accompany success, Cobain secluded himself in his sprawling Washington estate, overdosed on

heroin, then committed suicide via a self-inflicted gunshot wound.River PhoenixRiver Phoenix enjoyed a meteoric rise to stardom during his short life, and participated in habitual cocaine and heroin use from his early teens. Phoenix would succumb to a drug overdose from a speedball (cocaine and heroin mixture) outside of the famous Viper Room nightclub on the Sunset Strip in

LA.Tim AllenDuring the 1990s, Tim Allen was one of the most beloved stars on television, with his hit show Home Improvement rating number every season of its existence. During this time, Allen overcame a very serious cocaine addiction, one that led him to trouble with law enforcement, before enjoying mainstream success. Tim Allen is an excellent example of a celebrity who had the strength and support

to

overcome drug addiction in a setting that makes recovery very difficult

.

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Cases: Famous People’s AddictionsStephen King“As the tall, thin man in his mid-40s lay unconscious on the floor of his office, his eyes shut tight and his shirt-front soaked with blood, the silence of the night all around him was broken only by the shrieks of the bats which haunted the rafters of his vast Victorian mansion.” The scene was like something out of a novel by that master of the macabre Stephen King, ironic given that the comatose figure was none other than King himself - dead to the world after drinking countless cans of beer and snorting so much cocaine that his ravaged nose had become a gushing crimson fountain.

An unhappy child, King learned to medicate himself with drugs and alcohol as a college student. He finally began recovery in 1988 – which he struggles with to this day.Elvis PresleyWhen Elvis was young, he was a polite, clean cut young man. Although many parents saw his hip gyrations and racy and his lyrics signs of a collapse of society, he was actually quite tame by modern standards.

When Elvis went into the US Army, he began taking amphetamines. When he returned to civilian life, he developed a prescription drug addiction that included practically every drug found a pharmacist’s shelf. After decades of drug dependence, Elvis died of an overdose with a shocking fourteen different drugs in his system.

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Cases: Not so Famous AddictsJohn“My goal in life wasn't living...it was getting high. I was falling in a downward spiral towards a point of no return. Over the years, I turned to cocaine, marijuana, and alcohol under a false belief it would allow me to escape my problems. It just made things worse.

I had everything, a good job, money, a loving family, yet I felt so empty inside. As if I had nothing. Over twenty years of using, I kept saying to myself, I’m going to stop permanently after using this last time. It never happened. There were even moments I had thought of giving up on life.” 

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Cases: Not so Famous AddictsBen“It started with the weed, then the pills (Ecstasy) and acid, making cocktails of all sorts of drugs, even overdosing to make the rushes last longer. I took copious amounts of these chemicals every day for as long as two years until I had a bad trip one night and went into toxic psychosis. I prayed and cried for this feeling to go away, I had voices in my head, had the shakes and couldn't leave home for six months. I became very withdrawn and thought everyone was watching me. I couldn’t walk in public places. Man! I couldn’t even drive.

“I ended up homeless and on the streets, living and sleeping in a cardboard box, begging and struggling to find ways to get my next meal.“I asked myself if this is rock bottom, and I believe that it was. While observing these homeless people I decided that I had had enough. Yes I wanted drugs, but I realized that I could want life more.” 

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Cases: Not so Famous AddictsMichael“I have had a rough life. I don’t know my real father. The only person I have ever even called dad died when I was nine years-old. My mom is a drug addict and is in prison now, as she was pretty much my whole life. I only have maybe one or two friends who I can really count on, and I have always lived with my grandmother since birth.On my 13th birthday, I was at a friend’s house. Now I knew that he and his family smoked pot, but I had never tried it and then my friend asked me if I wanted to try it. I was hesitant, but I said sure and so started my addiction with drugs.

I knew I was already hooked right after the first hit. I fell in love with it, but little did I know how much trouble it would cause me later down the road. So, I went home the next day, and I paced back and forth for about thirty minutes. I didn’t know what was wrong with me, then it hit me that I needed to have more. So almost everyday after school I went over to his house just to get a quick high.

Slide46

Remember …Mental illnesses of any kind does not define the individual– people are wholistic beings, living in unique environments with families, friends, jobs (or not), and lifestyle habits, with feelings, emotions, and dreams that are central to who they are … It is ALL of these things that must be addressed in order for anyone – including addicts and others with mental illnesses - to regain a healthy wholenessLife is not predestined to be an ever downward-spiraling path, so let’s not enable people to believe that it is in any way

Teach skills to enable addicts to live a functional life, find success and happiness, and pursue their dreams in the real worldVary your approach! Each person you deal with will come from a different place, have a unique outlook, a distinctive set of genes, and need specific information to be successful in their wellness journeyStrive for greatness – anyone can live an exemplary and fulfilling life, so never let an individual slide by without trying!

Slide47


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