The Anthropology of Addiction

Can we ever integrate neuroscience and social science?

Bielefeld, Germany—
The last in a series of posts about a recent conference, Neuroplasticity in Substance Addiction and Recovery: From Genes to Culture and Back Again.  The conference, held at the Center for Interdisciplinary Research (ZiF)  at Bielefeld University, drew neuroscientists, historians, psychologists, philosophers, and even a freelance science journalist or two, coming in from Germany, the U.S., The Netherlands, the UK, Finland, France, Italy, Australia, and elsewhere. The organizing idea was to focus on how changes in the brain impact addiction and recovery, and what that says about the interaction of genes and culture. The conference co-organizers were Jason Clark and Saskia Nagel of the Institute of Cognitive Science at the University of Osnabrück, Germany.   Part One is here.   Part Two is here.  Part Three is here.


The disciplines of psychiatry and neurology are being brought intellectually closer to each other. One can foresee the day in the not-too-distance future when resident physicians in both disciplines will share a common year of training, comparable to the year of residency training in internal medicine for physicians who go on to specialize in widely different areas.
— Eric Kandel, In Search of Memory

Anthropology is arguably a perfect discipline within which to connect the two often-conflicting facets of addiction—its fundamental neuroarchitecture, and the socioenvironmental influences that shape this basic biological endowment. In The Encultured Brain, published by MIT Press, co-editors Daniel H. Lende and Greg Downey make an articulate call for a merger of interests, in an attempt to combine laboratory research with anthropological fieldwork. The term “neuroanthropology,” meant to denote this combination of anthropology and brain science, was evidently coined by Stephen Jay Gould. A number of thinkers have dipped into this arena over the years, including Melvin Konner, Sarah Hrdy, Norman Cousins, Robert Sapolsky, and Antonio Damasio. The term gained a more solid foothold when Lende and Downey began their Neuroanthropology blog, now at PLOS blogs. 

The term has the advantage of meaning exactly what it says: an integrative approach to the complicated matter of how our genetic endowment is influenced by our cultural endowment. Or vice versa, if you prefer. Here, from the introductory chapter, is the short definition of neuroanthropology: “Forms of enculturation, social norms, training regimens, ritual, language, and patterns of experience shape how our brains work and are structured…. Without material change in the brain, learning, memory, maturation, and even trauma could not happen…. Through systematic change in the nervous system, the human body learns to orchestrate itself. Cultural concepts and meanings become neurological anatomy.” From the point of view of actual study, there is no choice but to join these two when possible—a task make more difficult by the rampant “biophilia” found among anthropologists and sociologists, as well as the countering notion among biologists that anthropology does not make the cut as a “real” science.

Co-author Daniel Lende, an associate professor in the Department of Anthropology at the University of South Florida, was one of the presenters at the Bielenfeld conference. Lende did his Ph.D. work on adolescent substance abuse in Bogota, Colombia, and told the group that years of research “showed me that addiction is profoundly neuranthropological.” Lende told the audience that the “combination of neuroscience and ethnography revealed that addiction is a problem of involvement, not just of pleasure or of self.”

 This approach calls for applying a critical eye to strictly brain-based explanations that ignore both environmental influence and biochemical individuality. And it opens up the possibility that anthropologists may be incorporating neuroimaging technology into their working tool kit. While the neuroanthropology movement has been mostly a product of the anthropology side thus far, Lende said. But increasingly, cognitive scientists are joining in.

“As neuroanthropologists, we’re not trying to solve problems in the lab or in the clinic, but rather to take the results of that sort of work, and look at what’s happening to those brains in the wild,” Lende said.

Repeated patterning comes from social environments, he said. “We have to deal with how cultural practices and developmental experiences can shape and mold the brain, and how that has an effect on the production of human variation, not just sets of beliefs you can take on and put off.”  The cultural practice of skull shaping, for example, is “impossible to understand without taking into account both the cultural practices that drive it, and the early plasticity in bone formation that allows it biologically.”

Culture, said Dr. Lende, “can bring different elements into one package. It doesn’t have to be the biology side that does all the work. You can take the cultural strands and knit them into something really unusual that you wouldn’t necessarily see in the world. With cultural tools, we are using are brain in ways not necessarily built into it from the start.”

But attending to all of this requires thinking of neural plasticity in novel ways, Lende said. “Hardwiring isn’t quite as hard as we once thought. The lifespan of these circuits set early in life isn’t what we thought.” The brain can use sensory input in ways we don’t yet understand. Lende pointed to “significant recovery from stroke, which was not viewed as possible a couple of decades ago.”

“You have to be critical both of the neuroscience and some of its limitations, and also the anthropologists, who are sometimes saying, ‘it’s got to be all sociocultural.’ That’s not always a good explanation for something as complex as addiction.”

Lende believes that anthropology needs to pursue the impact of “biological embedding, or how experiences get under the skin” to alter human biological and developmental processes. “You can have differential vulnerabilities to biological embedding, coupled with differential environmental vulnerability.”

Dr. Lende points to the well documented clinical finding that exercise enhances neuroplasticity. “And exercising has been shown in various labs to reduce craving,” he said. “What’s important from my community-based orientation is, what sort of interventions or strategies can we have that are low cost and be used in non-professional settings. Can we motivate people to do it? What are the barriers?”

 Subjective experience is hard to get at, but that’s a problem anthropologists think about all the time. “I asked the kids in Columbia, if your drug use were a place, Lende said, “ then what sort of place would that be? Kids who’d never tried drugs didn’t get the question, but a kid with heavy cigarette use who had just quit, and who had recovered recently from using too much cocaine and crack, looked at his fingers, referring to cigarettes, and said, ‘a world in there? No. But with cocaine, yes.”

Hazelden Offers Companion to the “Big Book”

New guide attempts a modest AA update.

The founders of AA published their book, Alcoholics Anonymous (The Big Book) back in 1939. The world has changed a great deal since then, so it’s not surprising that there have been periodic calls for an update. Barring an official revision, which is unlikely, Hazelden, the Minnesota treatment organization, has published an updated companion volume to the Big Book. (Narcotics Anonymous published their version of the basic text in 1962). “The core principles and practices offered in these basic texts hold strong today,” says Hazelden, “but addiction science and societal norms have changed dramatically since these books were first published decades ago.”

Hazelden’s book, Recovery Now, billed as an easy-to-follow guide to the teachings of Alcoholics Anonymous and Narcotics Anonymous, dispenses with the divisive question of medications for withdrawal straightaway. In a foreword by Dr. Marvin D. Seppala, chief medical officer at Hazelden, the doctor makes it clear: “I agree with the majority of treatment professionals who support using these meds to help with cravings when it is appropriate to do so. Addiction is a disease that calls for the best that science has to offer.” The unnamed authors of the “little green book” agree, stating that “for some mental health disorders, medications such as antidepressants are needed. These aren’t addictive chemicals and so professionals, as well as AA and NA, accept that we can take them and still be considered clean and sober (abstinent).” There are now, as well, specific Twelve Step groups for those with both addiction disorders and mental health disorders: Dual Diagnosis Anonymous and Dual Recovery Anonymous among them.

As Seppala points out in the foreword, when some alcoholics and other drug addicts hear about the research showing that addiction is similar to many other mental and physical disorders we call diseases, it reorients their thinking amid the shame, stigma, and negative emotional states associated with active addiction. For some, it opens the door to treatment.

Okay. Hazelden, Betty Ford, and many other major treatment providers are no longer fighting a rear-guard action against a host of medications, from buprenorphine to Zoloft. But two-thirds of the Big Book consists of stories of how people recognized and dealt with their sundry addictions. That’s really about it, which tracks well with AA’s core operating principle: one drunk helping another. AA believes that much of its success stems from the fact that the program is run by the members, without direct rule setting and intervention from organizations, including their own. (All statements hold for NA as well).

What else? Recovery Now takes on another sticking point for many: the fact that “the AA Big Book and other writings include traditional male-focused and religious language, like discussing God as a ‘he.’” And there is the matter of “the realities and stereotypes of the 1930s, which is why it contains a chapter titled ‘To the Wives.’” Hazelden continues the recent tradition of broadening acceptable interpretations of “higher power.” One example given is from Samantha, a young cocaine and alcohol addict: “My higher power is the energy of this group. I call her Zelda.”

The book presents some of the psychological aspects of the AA program as a sort of reverse cognitive behavioral therapy. CBT attempts to teach people how to unkink their thinking and turn harmful thoughts into helpful ones. AA attempts to convince people to first change their behavior—“fake it until you make it”—and helpful thoughts will follow.

Perhaps the genuine sea change lies in this passage, which can be contrasted with the faith and certainty with which the Big Book proclaims that AA will work for all but the most stubbornly self-centered. Even with the myriad of choices of AA groups now available, Hazelden acknowledges that “a group based on the Twelve Steps doesn’t work for all of us. Some of us have found help in recovery groups that offer alternatives to the Twelve Steps, such as SMART Recovery, Women for Sobriety, and Secular Organizations for Sobriety.”  This is a change of heart, given that groups like SMART Recovery don’t necessarily buy the idea of total abstinence, and often structure recovery as an exercise in controlled drinking. Hazelden also suggests that many of “us” have found the necessary ongoing support for recovery at churches, mental health centers, and nonreligious peer support groups.

As for anonymity, Recovery Now states: “While Twelve Step members do not reveal anything about another member of the group, any one of us may choose to go public with our own story.” Another promising development is the proliferation of Twelve Step meetings catering to specific populations—AA meetings for African Americans, Latinos, Native Americans, women, seniors, gays, and drug-specific (Cocaine Anonymous).

In the end, one of the best arguments for attendance at the AA program (free of charge) is that many addicts have “worn out our welcome” with families and friends, “and they have a hard time putting all that behind them and supporting us completely. But at most Twelve Step recovery meetings we can find the support we need.”

Addiction Books For the Beach

When 50 Shades of Grey doesn’t cut it.


The Science of Addiction: From Neurobiology to Treatment

Carlton K. Erickson
312 pages
Publisher: W. W. Norton and Company (2007)

Amazon Overview: Neuroscience is clarifying the causes of compulsive alcohol and drug use––while also shedding light on what addiction is, what it is not, and how it can best be treated––in exciting and innovative ways. Current neurobiological research complements and enhances the approaches to addiction traditionally taken in social work and psychology. However, this important research is generally not presented in a forthright, jargon-free way that clearly illustrates its relevance to addiction professionals. In The Science of Addiction, Carlton K. Erickson presents a comprehensive overview of the roles that brain function and genetics play in addiction.


The Addiction Solution: Unraveling the Mysteries of Addiction through Cutting-Edge Brain Science

David Kipper and Steven Whitney
304 pages
Publisher: Rodale Books (2010)

For decades addiction has been viewed and treated as a social and behavioral illness, afflicting people of “weak” character and “bad” moral fiber. However, recent breakthroughs in genetic technology have enabled doctors, for the first time, to correctly diagnose the disease and prove that addiction is an inherited, neuro-chemical disease originating in brain chemistry, determined by genetics, and triggered by stress. In their groundbreaking Addiction Breakthrough, David Kipper, MD, and Steven Whitney distill these exciting findings into a guide for the millions of adults who want to be free from the cycle of addiction, and for their loved ones who want to better understand it and to help.


In the Realm of Hungry Ghosts: Close Encounters with Addiction

Gabor Maté
520 pages
Publisher: North Atlantic Books (2010)

Based on Gabor Maté’s two decades of experience as a medical doctor and his groundbreaking work with the severely addicted on Vancouver’s skid row, In the Realm of Hungry Ghosts radically reenvisions this much misunderstood field by taking a holistic approach. Dr. Maté presents addiction not as a discrete phenomenon confined to an unfortunate or weak-willed few, but as a continuum that runs throughout (and perhaps underpins) our society; not a medical "condition" distinct from the lives it affects, rather the result of a complex interplay among personal history, emotional, and neurological development, brain chemistry, and the drugs (and behaviors) of addiction. Simplifying a wide array of brain and addiction research findings from around the globe, the book avoids glib self-help remedies, instead promoting a thorough and compassionate self-understanding as the first key to healing and wellness.


Memoirs of an Addicted Brain: A Neuroscientist Examines his Former Life on Drugs

Marc Lewis
336 pages
Publisher: PublicAffairs (2012)

Marc Lewis’s relationship with drugs began in a New England boarding school where, as a bullied and homesick fifteen-year-old, he made brief escapes from reality by way of cough medicine, alcohol, and marijuana. In Berkeley, California, in its hippie heyday, he found methamphetamine and LSD and heroin. He sniffed nitrous oxide in Malaysia and frequented Calcutta’s opium dens. Ultimately, though, his journey took him where it takes most addicts: into a life of addiction, desperation, deception, and crime. But unlike most addicts, Lewis recovered and became a developmental psychologist and researcher in neuroscience. In Memoirs of an Addicted Brain, he applies his professional expertise to a study of his former self, using the story of his own journey through addiction to tell the universal story of addictions of every kind.


The Chemical Carousel: What Science Tells Us About Beating Addiction

Dirk Hanson
472 pages
Publisher: BookSurge (2009)

A book for anyone concerned with the care and healing of addiction, substance abuse, and the latest advances in the area of addiction science. In The Chemical Carousel, science writer Hanson takes the reader on a voyage through the heady world of addiction science, from the lab to the clinic to the junky on the street. Hanson explains the workings of common neurotransmitters and documents the direct effect drugs and alcohol produce on the reward pathways of the brain. He shows how scientists and treatment professionals have finally given us an answer to the perennial question about addiction: Why can't those people just say no?


An Anatomy of Addiction: Sigmund Freud, William Halsted, and the Miracle Drug, Cocaine

Howard Markel
336 pages
Publisher: Vintage (2012)

Acclaimed medical historian Howard Markel traces the careers of two brilliant young doctors--Sigmund Freud, neurologist, and William Halsted, surgeon--showing how their powerful addictions to cocaine shaped their enormous contributions to psychology and medicine. When Freud and Halsted began their experiments with cocaine in the 1880s, neither they, nor their colleagues, had any idea of the drug's potential to dominate and endanger their lives. An Anatomy of Addiction tells the tragic and heroic story of each man, accidentally struck down in his prime by an insidious malady: tragic because of the time, relationships, and health cocaine forced each to squander; heroic in the intense battle each man waged to overcome his affliction.


How to Change Your Drinking: a Harm Reduction Guide to Alcohol

Kenneth Anderson
86 pages
Publisher: CreateSpace (2010)

This book is the first comprehensive compilation of harm reduction strategies aimed specifically at people who drink alcohol. Whether your goal is safer drinking, reduced drinking, or quitting alcohol altogether, this is the book for you. It contains a large and detailed selection of harm reduction tools and strategies which you can choose from to build your own individualized alcohol harm reduction program. There are many practical exercises to help people change their behaviors, including risk-ranking worksheets, drinking charts, goal choice worksheets, and many more. There are also innumerable practical tips from folks who "have been there" and have turned their drinking habits around for the better.


Rethinking Substance Abuse: What the Science Shows, and What We Should Do about It

William R. Miller and Kathleen M. Carroll
320 pages
Publisher: Guilford Press (2010)

While knowledge on substance abuse and addictions is expanding rapidly, clinical practice still lags behind. This state-of-the-art book brings together leading experts to describe what treatment and prevention would look like if it were based on the best science available. The volume incorporates developmental, neurobiological, genetic, behavioral, and social–environmental perspectives. Tightly edited chapters summarize current thinking on the nature and causes of alcohol and other drug problems; discuss what works at the individual, family, and societal levels; and offer robust principles for developing more effective treatments and services.

Writers On The Edge: 22 Writers Speak About Addiction and Dependency

Diana Raab and James Brown
204 pages
Publisher: Modern History Press (2012)

Writers On The Edge offers a range of essays, memoirs and poetry written by major contemporary authors who bring fresh insight into the dark world of addiction, from drugs and alcohol, to sex, gambling and food. Editors Diana M. Raab and James Brown have assembled an array of talented and courageous writers who share their stories with heartbreaking honesty as they share their obsessions as well as the awe-inspiring power of hope and redemption. Frederick & Steven Barthelme, Kera Bolonik, Margaret Bullitt-Jonas, Maud Casey, Anna David, Denise Duhamel, B.H. Fairchild, Ruth Fowler, David Huddle Perie Longo, Gregory Orr, Victoria Patterson, Molly Peacock, Scott Russell Sanders, Stephen Jay Schwartz, Linda Gray Sexton, Sue William Silverman, Chase Twichell, and Rachel Yoder

Photo Credit: http://www.readingkingdom.com/

Random Notes from the College on Problems of Drug Dependence

Opening day addresses at the annual meeting.

(These are notes on research in progress, not findings written in stone).

--NIDA director Nora Volkow talked up buspirone (Buspar) as a treatment for cocaine addiction, and referred to favorable results on buspirone for cocaine self-administration in monkeys in a large clinical trial. Also, different vaccine strategies are in the works, including different pharmacological approaches to blocking specific dopamine transporter molecules.

--Edward Sellers of DL Global Partners, a drug research consulting firm, emphasized the importance of enzyme variations in smoking. Variants of the CYP2A6 enzyme of metabolization allow us to identify “slow metabolizers” who respond well to placebo or nicotine patch therapy, and other smokers who don’t.

--Sherry McKee of the Yale University School of Medicine reminded everyone that cigarette smokers—even very light smoking “chippers”— are far more likely to have concurrent drinking problems than non-smokers. Smoking helps drinkers drink more and longer. To demonstrate such “potentiated reinforcement,” she showed a delightful video of her child eating cookies, then craving a glass of milk, then succumbing to another round of cookie consumption…

--Jack Henningfield of Pinney Associates, and former NIDA research chief, said that the reason the National Institute on Alcohol Abuse and Alcoholism (NIAAA) became an agency focused on “one molecule” is because Senator Harold Hughes, recovering alcoholic from Iowa, and Bill W., co-founder of Alcoholics Anonymous, wanted it that way.

--David Penetar of Harvard Medical School and McLean Hospital added more evidence of the link between alcohol and cigarettes, noting that “90 per cent of smokers drink,” and that smokers are three times as likely to be alcoholics than non-smokers. He pointed to research documenting a disturbing “increased desire to drink” when wearing a nicotine patch. With a patch, subjects reported feeling the effects of alcohol sooner and longer.

Photo Credit: http://www.thejournalshop.com/

Addiction Doctors Pick Top Ten Journal Articles

A screen for problem gambling, medications for insomniac alcoholics, and more.

A group of addiction doctors presented a Top Ten List of peer-reviewed articles from 2011 at the American Society of Addiction Medicine’s Annual Medical-Scientific Conference in Richmond, VA. Dr. Michael Weaver presented the findings, noting that the list was “reached by consensus, and articles were selected not only for their quality but also to represent different areas of addiction medicine.” Dr. Weaver stressed that “not all published studies were done really well, and some may not apply to the patients treated by a particular clinician.”

According to Dr. Edward Nunes, with the Department of Psychiatry at Columbia University, the journal articles provide a "nice mixture on epidemiology and clinical outcome or clinical trials research,” which represent “the type of evidence most relevant to patient care."

Thanks to Catharine Zivkovic (@ccziv) for drawing attention to this list. The summaries are my own. Disclaimer: In some cases, these brief summaries are based solely on a reading of the journal abstracts.

1. 

Hsueh-Han Yeh, M.S. et al. (2011). Five-Year Trajectories of Long-Term Benzodiazepine Use by Adolescents: Patient, Provider, and Medication Factors. Psychiatric Services 62(8): 900–907.

 A Taiwanese study analyzing benzodiazepine prescription records came up with a simple solution: “Prescribers can reduce the risk of long-term use by assessing whether pediatric patients have received benzodiazepines from multiple doctors for various medical conditions.” Huh. Who’d have thought of that one, eh? But for various reasons, such checks, and the open records required to make them possible, are the exception rather than the rule in current health care systems. The study group found that for long-term users under 21, defined as anyone in receipt of a benzodiazepine prescription for 31 or more days in a calendar year, one in four patients fell into the categories of “accelerating or chronic users.” Specifically, “A history of psychosis or epilepsy, prescription by providers from multiple specialties, and receipt of benzodiazepines with a long half-life or mixed indications significantly increased one's risk of becoming a chronic or accelerating user.”

2. 

McBride, O, and Cheng, Hui G. (2011) Exploring the emergence of alcohol use disorder symptoms in the two years after onset of drinking: findings from the National Surveys on Drug Use and Health. Addiction 106(3): 555-563.

This study looked for clinical features of alcohol dependence and socially maladaptive drinking patterns during the first 24 months of alcohol use, based on stats from the 2004-2007 National Surveys on Drug Use and Health (NSDUH). Result: New alcohol users “frequently experienced problems relating to self-reported tolerance, spending a great deal of time recovering from the effects of alcohol and unsuccessful attempts at cutting down on drinking. The likelihood of experiencing the clinical features increased steadily in the first 9 months after use, but appeared to plateau or only gradually increase thereafter.” The researchers suggest there may be a window of opportunity during the 2nd year of drinking.

3.

Volberg, Rachel A., et al. (2011) A Quick and Simple Screening Method for Pathological and Problem Gamblers in Addiction Programs and Practices. The American Journal on Addictions. 20(3): 220-227.

Doctors, as these researchers point out, don’t often screen their patients for pathological gambling. To combat this, the investigators offer health professionals brief computer screenings they have developed for use in identifying problem gambling. “Given the high rates of comorbidity, routine and accurate identification of gambling-related problems among individuals seeking help for substance abuse and related disorders is important.” 

4.

Alford, Daniel. P., et al. (2011). Collaborative Care of Opioid-Addicted Patients in Primary Care Using Buprenorphine: Five-Year Experience. Archives of Internal Medicine 171(5):425-431.

Buprenorphine remains an underused but often effective treatment for opiate addiction, the authors of this study maintain. The cohort being studied was a group of addicted patients under the dual care of general physicians and nurse care managers. “Of patients remaining in treatment at 12 months, 154 of 169 (91.1%) were no longer using illicit opioids or cocaine based on urine drug test results,” the investigators report. However, dropout rates were high. The researchers did find that the nurse-doctor model was workable: “Collaborative care with nurse care managers in an urban primary care practice is an alternative and successful treatment method for most patients with opioid addiction that makes effective use of time for physicians who prescribe buprenorphine.”

5. 

Kolla, B.P., et. al. (2011) Pharmacological Treatment of Insomnia in Alcohol Recovery: A Systematic Review. Alcohol and Alcoholism 46: 578-585.

In this Mayo Clinic review of drugs used for sleep problems in alcohol recovery, the authors combed through more than 1,200 articles and reported that, of all the old and new drugs being used, an old and rarely used medication—trazadone—improved sleep measures as reliably as anything else that was tested. Gabapentin got good but equivocal marks due to questions about testing and inclusion criteria. Topiramate and carbamazepine helped in some cases. Furthermore, “in single, small, mostly open-label studies, quetiapine, triazolam, ritanserin, bright light and magnesium have shown efficacy, while chlormethiazole, scopolamine and melperone showed no difference or worsening. Conclusion: Trazodone has the most data suggesting efficacy.”

6.

Bohnert, A.S., et. al. (2011). Association between opioid prescribing patterns and opioid overdose-related deaths. Journal of the American Medical Association 305: 1315-1321.

Accidental prescription overdose deaths are on the rise, and this group of university researchers in Ann Arbor and Indianapolis thinks it may have something to do with how the dosing instructions are usually worded.  They set out to investigate “the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among patients with cancer, chronic pain, acute pain, and substance use disorders.” They found from VHA hospital records that “the frequency of fatal overdose over the study period among individuals treated with opioids was estimated to be 0.04%.” The risk for overdose was directly related to the “maximum prescribed daily dose of opioid medication.” And patients who stuck with regular dosages, or took opioids “as needed,” were not at any elevated risk for overdose. Another obvious but frequently overlooked conclusion: “Among patients receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of opioid overdose death.”

7. 

Allsop, D.J. et al. (2011). The Cannabis Withdrawal Scale development: patterns and predictors of cannabis withdrawal and distress. Drug and Alcohol Dependence 19(1-2):123-9.

Rates of treatment for marijuana abuse and addiction are increasing, say these Australian authors, along with relapse rates. They have devised a Cannabis Withdrawal Scale that measures such withdrawal effects as associated distress, strange dreams, trouble sleeping, and angry outbursts—common manifestations of withdrawal from weed. The scientists maintain that their “Cannabis Withdrawal Scale can be used as a diagnostic instrument in clinical and research settings where regular monitoring of withdrawal symptoms is required.”

8.

West, R., et al. (2011) Placebo-Controlled Trial of Cytisine for Smoking Cessation. New England Journal of Medicine 365: 1193-1200.

This important study assessed the effectiveness of the drug cytisine in smoking cessation programs, and a potential star was born. In a single-center, randomized, double-blind, placebo-controlled trial, the journal paper concluded that “cytisine was more effective than placebo for smoking cessation. The lower price of cytisine as compared with that of other pharmacotherapies for smoking cessation may make it an affordable treatment to advance smoking cessation globally.”

9. 

Elkashef A., et al. (2011) Topiramate for the treatment of methamphetamine addiction: a multi-center placebo-controlled trial. Addiction Published online 12/16.

Conducted at eight medical centers across the U.S., this study found that for most of the 140 methamphetamine-dependent adults under scrutiny, use of topiramate produced “abstinence from methamphetamine during weeks 6-12.” That’s the good news. Unfortunately,  “secondary outcomes included use reduction versus baseline, as well as psychosocial variables… topiramate did not increase abstinence from methamphetamine during weeks 6-12.” That’s the bad news. And here’s the silver lining, as far as the investigators are concerned: “Topiramate does not appear to promote abstinence in methamphetamine users but can reduce the amount taken and reduce relapse rates in those who are already abstinent.”

10.

Levina. A., et al. (2011). Molecular Mechanism for a Gateway Drug: Epigenetic Changes Initiated by Nicotine Prime Gene Expression by Cocaine. Science Translation Medicine 3(107) 107-109.

There really is s a gateway drug. In fact, there are two of them in our culture. Almost every potential addict starts out with alcohol or cigarettes or both. Because they are legal and easily available. So is cocaine and marijuana, once you get the hang of it, but in the beginning, and all around us, it’s booze and cigs. The amazing premise of this final study is this: “Pretreatment of mice with nicotine increased the response to cocaine, as assessed by addiction-related behaviors and synaptic plasticity in the striatum, a brain region critical for addiction-related reward.” Nicotine primes subjects for cocaine addiction, in effect. “These results from mice prompted an analysis of epidemiological data, which indicated that most cocaine users initiate cocaine use after the onset of smoking and while actively still smoking, and that initiating cocaine use after smoking increases the risk of becoming dependent on cocaine, consistent with our data from mice. If our findings in mice apply to humans, a decrease in smoking rates in young people would be expected to lead to a decrease in cocaine addiction.”

Photo Credit: www.flickr.com/

From Their Mouth to Your Ear: Researchers Talk Drugs

A collection of five-question interviews.

I’ll be away from the Addiction Inbox office this week, attending the big TEDMED health and medicine powwow in Washington, D.C.

In the meantime, here’s a summation (with links) of the interviews I’ve been doing recently in the “five-question interview” series. I’ve been very lucky to nab some state-of-the-art thinkers, working at the top of their fields, from psychiatry to pharmacology to neuroscience.

See below for the story thus far:



David Kroll, former Professor and Chair of Pharmaceutical Science at North Carolina Central University in Durham, is now Science Communications Director for the Nature Research Center at the North Carolina Museum of Natural Sciences.

“The attraction to users was, until recently, that Huffman cannabis compounds (prefixed with "JWH-" for his initials) could not be detected in urine by routine drug testing. Hence, incense products containing these compounds have been called ‘probationer's weed.’" MORE

Vaughan Bell is a Senior Research Fellow at the Institute of Psychiatry, King’s College, London. He is also honorary professor at the Universidad de Antioquia in Medellín, Colombia.

"I was very struck by the appearance of classic Kluver form constants [after taking ayahuasca], geometric patterns that are probably caused by the drug affecting the visual neurons that deal with basic perceptual process (e.g. line detection)." MORE

Jon Simons, a cognitive neuroscientist, is a lecturer in the Department of Experimental Psychology at the University of Cambridge, UK, and principal investigator at the University’s Memory Laboratory.

“If you’re at a party and happen to drunkenly strike up conversation with Angelina Jolie (or Brad Pitt, if you prefer) and, bowled over by your charm and witty repartee, she tells you her phone number, you may well not remember it when you wake up sober the next morning. However, the evidence suggests that you would have a better chance of recalling the number if you got drunk again." MORE

Bankole Johnson is professor and chairman of the University of Virginia’s Department of Psychiatry and Neurobehavioral Sciences.

“With growing and clear acceptance of the neurobiological underpinnings of addiction, our work on pharmacogenetics promises to provide effective medications—such as ondansetron—that we can deliver to an individual likely to be a high responder, based on his or her genetic make up." MORE

Michael Farrell is the director of the National Drug and Alcohol Research Centre (NDARC) at the University of New South Wales in Sydney, Australia. Before that, he was Professor of Addiction Psychiatry at the Institute of Psychiatry at Kings College, London.

“The near complete absence of methadone or buprenorphine treatment in American prisons is hard to understand, when you see what a great contribution US research and treatment with methadone and buprenorphine has had globally. Now there are over 300,000 people on methadone in China as part of HIV and AIDS prevention." MORE

Deni Carise is a clinical psychologist who serves as senior vice president and chief clinical officer at Phoenix House, a leading U.S. non-profit drug treatment organization with more than 100 programs in 10 states.

“Those in recovery see the disease of alcoholism or addiction as a moral obligation to get well. If you know you have this disease and the only way to keep it under control is not to use alcohol or drugs, then that’s what you have to do." MORE


Keith Laws is professor of cognitive neuropsychology and head of research in the School of Psychology at the University of Hertfordshire, UK.

"Some may tolerate 100s or even 1000s of E tablets, but for others far fewer may lead to memory problems. We can predict that 3 in 4 users will develop memory problems, but not which 3 or after how many tablets." MORE

photo credit: http://www.startawritingbusiness.co.uk

Essay: The Genuine Drug War is in Biomedicine

Knowledge, not firepower, is the key to the future.

In modern American society, heart disease, cancer, HIV\AIDS, diabetes, alcoholism, and cigarette addiction account for millions of deaths. They are all disease entities with strong psychological and behavioral components—complicated, multicellular, multi-organ disorders. But they have all been associated, at one time or another, with negative personality traits and moral flaws. The less we know about the mechanics of a human disorder, the more likely we are to view its external symptoms as signs of laziness, or neuralgia of the spirit, or as a form of damage caused by specific kinds of thoughts and emotions. Without a doubt, all kinds of flaws are sometimes expressed in the behavior of people who have these disorders. Yet none of these flaws can be considered the root cause of the diseases.

Addiction is being added to the roster of physical disorders once thought to be symptoms of insanity, but which are now seen to be disease entities with strong mental components, like most diseases. As Professor Felton J. Earls of the Harvard School of Public Health argued almost twenty years ago: “Until we have an Institute of Addictive Behaviors, we are not going to get very far on the public-policy issues because we will not have our science-policy issues properly aggregated and organized in order to move forward on the issues in any meaningful way.”  Witness the tangle over merging NIDA and the NIAAA, and you’ll have a good idea of how far we still have to go in this respect.

The genuine drug war is being fought in the arena of biomedicine. The New York State Division of Substance Abuse Services in Albany  estimated several years ago that the annual bill for successfully treating a single drug addict is $3,850, compared with $14,000 in estimated annual expenses— health, welfare and law enforcement costs—associated with one untreated addict. The real crisis is the indisputable fact that there exists today an appalling shortage of funds for biomedical research—ironically one of the fields of scientific endeavor in which the U.S. holds a clear lead.

The cause of the dilemma is a fundamental misunderstanding among politicians and the public about how diseases can be understood and conquered. Cross-fertilization among scientific disciplines yields unexpected results. Targeted research, such as the much-ballyhooed war on cancer, or the crash program to find a cure for A.I.D.S., is not necessarily the most desirable way to proceed. Insights come from unexpected places, in serendipitous ways. As the scientific understanding of cells and receptors deepens, diseases and disorders once thought to have unrelated causes are seen to have common and entirely unanticipated origins. Research into the viral mechanisms of the common cold may ultimately yield more insights into AIDS then all of the directed research now underway. In biomedicine, there is no guarantee that goals can be reached through the front door, by a systematic assault akin to an engineering project. We cannot, for example, hope to cure addiction, or even the common cold, by means of the same methods we used to put a man on the moon.

There are, however, certain things we can begin to do immediately, if, as a nation, we are serious about drug abuse. As a society, Americans have not done a very good job of laying the groundwork for an objective look at addiction and recovery. To begin with, we must attend to the staggering number of drug-related deaths, injuries, and hospitalizations caused by the abuse of prescription medications. The government itself has proven the case for this contention in numerous reports issued by the National Institute on Drug Abuse and other official bodies. According to the U.S. Department of Health and Human Services, “Older Americans account for more than half of all deaths from drug reactions,” leading one to suspect that the majority of drug fatalities stem from accidentally fatal overdoses by heavily medicated senior citizens. Our national fixation on illegal drugs has blinded us to certain verifiable facts about prescription drug abuse.

We also need to recognize the problem of underprescribing opiates and other addictive painkillers for children and adults in hospital settings. If we continue to stringently prohibit the use and sale of synthetic and designer drugs like methadone, morphine, amphetamines, and barbiturates, we will have to make one important exception: pain abatement in medical applications. One of the great scandals to come out of the drug war is the growing understanding that potent painkillers are not being offered in sufficient amounts to patients suffering intractable and agonizing pain.

“There’s a certain amount of hysteria about narcotics among doctors,” maintains one researcher. At least half of all cancer patients seen in routine practice report inadequate pain relief, according to the American College of Physicians. For cancer patients in pain, adequate relief is quite literally a flip of the coin.

At least 6 million cancer and AIDS patients currently receive no appropriate pain treatment of any kind. In addition, WHO estimates that four out of five patients dying of cancer are also suffering severe pain. The numbers of untreated patients suffering intractable, unrelieved pain from nerve damage, burns, gunshots, sickle cell anemia, and a host of other medical conditions can only be guessed at.

Figures gathered by a different U.N. agency, the International Narcotics Control Board, make clear that “citizens of rich nations suffer less.” To put it starkly, the use of morphine per person in the United States is 17,000 times higher than per person usage in Sierra Leone. Doctors in Africa paint a grim picture of patients hanging themselves or throwing themselves in front of trucks as an alternative to life without pain relief. The U.S., Canada, Britain, France, Germany, and Australia together account for roughly 80 per cent of the world’s medicinal morphine use. Other countries, particularly the poor and undeveloped nations, scramble for what’s left.

In many cases, pain relief is the one thing doctors can offer their patients, and the one thing they withhold.

--Adapted from The Chemical Carousel, by Dirk Hanson

Photo Credit: http://www.eurac.edu 

NIDA on Drugs, Brain, and Behavior

How Science Has Revolutionized the Understanding of Drug Addiction.

Addiction to alcohol, nicotine, and other drugs costs Americans as much as half a trillion dollars a year, according to the National Institute on Drug Abuse. Since the 1930s, when the science of addiction got its start, scientists have consistently battled against a prevailing view of addicted individuals as morally flawed and lacking in willpower. In an effort to dispel myths and keep drug arguments on track, NIDA has released an updated 2010 version of its valuable publication, “The Science of Addiction.” The report is available as a PDF for download.

As a disease that affects both brain and behavior, addiction is indeed the “cunning, baffling and powerful” disease described by Bill W., the founder of AA. Dr. Nora Volkow, director of NIDA, said that despite the plethora of scientific advances being made in addiction medicine, “many people today do not understand why individuals become addicted to drugs or how drugs change the brain to foster compulsive drug abuse. This booklet aims to fill that knowledge gap by providing scientific information about the disease of drug addiction, including the many harmful consequences of drug abuse and the basic approaches that have been developed to prevent and treat the disease.”

Dr. Volkow exhorted Americans to “adopt science-based policies and programs that reduce drug abuse and addiction in their communities, and support scientific research that improves the Nation's well-being.”

Today, "thanks to science,” writes Volkow, “our views and our responses to drug abuse have changed dramatically. Groundbreaking discoveries about the brain have revolutionized our understanding of drug addiction, enabling us to respond effectively to the problem.”

Noteworthy Recent Posts on Drugs and the Brain

A few good articles.

Teasing Out the Effects of Environment on the Brain.

By Moheb Costandi

The Dana Foundation

Antidepressants: Are They Effective or Just a Placebo?

By Maia Szalavitz

Time Magazine

SSRIs and Suicide.

By Neuroskeptic

Neuroskeptic blog

Cannabis and mental health – two new studies give the “wrong” results!

UKCIA Newsblog

Under the Microscope: How does caffeine work?

By Professor Andrew Smith.

UK Independent

Photo Credit: http://degweb.org/

My Interview with Santa Fe Public Radio

Addiction science gets a little air time.

Been doing some publicity for my book, The Chemical Carousel. This radio interview with Diego Mulligan on KSFR in Santa Fe is from August 26th, and it turned out to be reasonably listenable.

The interview runs 18 minutes.

CLICK HERE FOR THE INTERVIEW.

addiction drugs

What’s a Neurotransmitter, Anyway?

A brief guide for the perplexed.

A neurotransmitter is a chemical substance that carries impulses from one nerve cell to another. Neurotransmitters are manufactured by the body and are released from storage sacs in the nerve cells. A tiny junction, called the synaptic gap, lies between brain cells. (Think of Michelangelo’s Sistine Chapel, with the finger of Adam and the finger of God not quite touching, yet conveying energy and information.)

Neurotransmitters squirt across the synaptic gap, and this shower of chemical messengers lands on a field of tiny bumps attached to the surface of the nerve cell on the other side of the synaptic gap. These bumps are receptors, and they have distinctive shapes. Picture these receptors, brain researcher Candace Pert has suggested, as a field of lily pads floating on the outer oily surface of the cell.

Neurotransmitter molecules bind themselves tightly to these receptors. The fact that certain drugs of abuse also lock tightly into existing receptors, and send messages to nerve cells in the brain, is the key to the mystery of addiction.

The fact that certain drugs essentially “fool” receptors into receiving them is one of the most important and far-reaching discoveries in the history of modern science. It is the reason why even minute amounts of certain drugs can have such powerful effects on the human nervous system. The lock-and-key arrangement of neurotransmitters and their receptors is the fundamental architecture of action in the brain. Glandular cells are studded with receptors, and many of the hormones have their own receptors as well. If the drug fits the receptor and elicits a response, it is called an agonist. If it simply blocks the receptor site without stimulating a response, it is an antagonist. Still other neurotransmitters have only a secondary effect, causing the target cell to release other kinds of neurotransmitters and hormones.

Two of the most important neurotransmitters are serotonin and dopamine. The unfolding story of addiction science, at bottom, is the story of what has been learned about the nature and function of such chemicals, and the many and varied ways they effect the pleasure and reward centers in our brains.

In 1948, three researchers—Maurice Rapport, Arda Green, and Irvine Page—were looking for a better blood pressure medication. Instead, they managed to isolate a naturally occurring compound in beef blood called serotonin (pronounced sarah-tóne-in), and known chemically as 5-hydroxytryptamine, or simply 5-HT. The researchers determined that serotonin was involved in vasoconstriction, or narrowing of the blood vessels, and in that respect resembled another important chemical messenger in the brain—epinephrine, better known as adrenaline.

Even though there is at most 10 milligrams of the substance in our bodies, serotonin turned out to be one of nature’s signature chemicals—a chemical of thought, movement and behavior, as well as digestion, ejaculation, and evacuation. The body’s all-purpose neurotransmitter, involved in sleep, mood, appetite, among dozens of other functions. The cortex, the limbic system, the brain stem, the gut, the genitals, the bowels: serotonin is a key chemical messenger in all of it.

Another key neurotransmitter—dopamine—is considered to be one of the brain’s primary “pleasure chemicals,” and is found in areas of the brain linked to experiences of joy and reward.

Dopamine pathways play a role in carrying signals related to attention, movement, problem solving, pleasure, and the anticipation of rewarding experiences. Dopamine is one of the reasons why, after you have a pleasurable experience with food, drink, sex, or certain drugs, you are likely to feel a desire to repeat the experience. Dopamine is implicated in not just the drug high, but in the craving that accompanies withdrawal as well.

Feelings of pleasure, or joy, are natural drug highs. The fact that they are produced by chemical alterations in brain state does not make the fear or the pleasure feel any less real.

Excerpted from The Chemical Carousel: What Science Tells Us About Beating Addiction by Dirk Hanson © 2008


Photo Credit: NIDA

addiction drugs dopamine

Naloxone and “Receptorology”

The power of the opiates revealed

The breakthrough that laid the groundwork for the first truly scientific understanding of addictive drugs took place in 1972, when researchers discovered the existence of specific receptor sites in the brain for the opium molecule.

At roughly the same time, emergency room doctors were baffled to discover that timely injections of a drug called naloxone completely reversed the effects of heroin intoxication. Minutes after an injection of naloxone, heroin addicts were awake, fully recovered, and instantly into the rigors of heroin withdrawal. Naloxone, and a similar drug called naltrexone, rescued O.D. victims from respiratory failure. Like a magic bullet, naloxone--trade name Narcan-- blocked the effects of heroin.

At Johns Hopkins University School of Medicine in Baltimore, Dr. Solomon Snyder and a young doctoral candidate named Candace Pert devised a method for testing this theory. By making molecules of naloxone radioactive, and following the course of the molecules with the aid of a radiation counter, Snyder and Pert were able to show that naloxone attached itself very specifically to certain neurons in certain parts of the brain. If naloxone molecules were capable of locking into specific sites, then presumably these were the same sites in the brain where the opiates did their work.

The sites in question were mean for naturally occurring painkillers called endorphins. The only reason opium worked so dramatically to relieve pain was because a part of the opium molecule was similar in shape to the naturally occurring endorphins. Heroin “fooled” the receptors designed for the shape of an endorphin molecule. Not only that, but heroin and the other opiates stimulated these receptors just as effectively as the natural endorphins did.

The stunning power of the opiates had been revealed as an architectural quirk of nature.

Naloxone was a heroin antagonist—it blocked the effect of the drug at specific sites on nerve cells in the brain. (If the drug fits the receptor and elicits a response, it is called an agonist. If it simply blocks the receptor site without stimulating a response, it is an antagonist.)

The naloxone molecule also bore an uncanny resemblance to the shape of natural endorphin molecules, and when doctors gave an O.D. victim a shot of naloxone, the naloxone molecules knocked the opium molecules right off their receptors. Then they bound themselves to the endorphin sites even more tightly than the heroin molecules did. Naloxone was capable of snapping onto the receptor sites without triggering the release of endorphin.

The brain scans developed for studying this chemical activity were produced by introducing radioactive atoms into naloxone. Wherever naloxone stuck to a receptor site in the brain of a rat, the “hot” connection lit up on special film. These maps of receptor geography in the brain led Dr. Pert and her colleagues to christen the new science “receptorology.” Likening these snapshots to “tiny sparkling grains in a sea of colorfully stained brain tissue,” Pert was helping to invent a new field of study.

“Receptorology” came to be known as neuroscience, or neuropharmacology, and operated under a deceptively simple premise: If it is a drug, and if it has an effect on the brain, then it must have a brain receptor site to which it binds. Find its site of action, and you find out what it is, what it does, and where it does it.