Why Don't They Just Say No?

Are addicts at fault for refusing to get well?

It often seems as if alcoholics and other drug addicts are at fault for perversely refusing to get well. Rarely do the treatment methods, or lack of them, come under question. The traditional view of the addict as an immature and irresponsible person, short on will power, low on self-esteem, and forever at the mercy of his or her “addictive personality,” works at cross-purposes with the goal of helping addicts recognize the need for treatment. Addicts have traditionally been taught to think of themselves the way Franz Kafka thought of himself in relation to his tuberculosis: “Secretly I don’t believe this illness to be tuberculosis, at least not primarily tuberculosis, but rather a sign of my general bankruptcy.”

Who is really at fault here—the patients, or the healers? Most of our current medical, legal, and psychiatric approaches to the prevention and treatment of drug addiction have failed—and are continuing to fail. As Susan Sontag has written: “Psychological theories of illness are a powerful means of placing the blame on the ill. Patients who are instructed that they have, unwittingly, caused their disease are also being made to feel that they have deserved it.”

In Samuel Butler’s classic utopian satire, Erewhon, sick people are thrown in prison, under a statute that makes it a crime to be ill. Is that our current approach to addiction? Does the drug problem belong in the Attorney General’s office, as it now stands, or in the Surgeon General’s office, where a growing number of researchers say it belongs? In light of new medical findings about addictive disorders, what is enlightened public policy, and what is not?

Recent research in neurophysiology, cell biology, and molecular genetics, coupled with breakthroughs in the science of brain imaging, have made it possible, for the first time, to venture a solid assault on the basic mysteries of addiction. The past fifteen years have been exhilarating times for biomedical researchers in general; a time when basic breakthroughs in the biomedical sciences have changed the way science approaches a variety of human afflictions. We have been used to thinking of such conditions as alcoholism, drug addiction, depression, and suicide in terms of causes rooted firmly in the environment. What events in a person’s life, what outside social factors, led to the problem? However, the new medicine is telling us that we have been looking in all the wrong places for causality.

When I first began following the scientific research on addiction and alcoholism, the field was small, the insights tentative, and the overall enterprise woefully underfunded. Today, more than a decade later, an interlocking maze of biomedical and psychiatric sub-specialties make up the world of addiction science. I can only hope to impart a sense of the important work being done in addiction science. What I had originally viewed as a series of potential breakthroughs in addiction research very rapidly became the tip of an enormous iceberg: brain science, and the revolutionary new directions represented by modern biological psychiatry. The brave new sciences strongly suggest that, when it comes to addiction, the place to look is inside the brain itself.

Photo Credit: Conversations on the Fringe

Ten Ways to Battle Coffee Addiction

Caffeine-free energy boosters

(From the mailbag)

Kelly Sonora at the Nursing Online Education Database (NOEDb) recently sent me an article by Christina Laun, entitled "50 Ways to Boost Your Energy Without Caffeine." The complete article is available on the NOEDb web site. If you are making an effort to decrease reliance on coffee, Laun writes, the suggestions will "give you a boost when you're feeling sleepy or prevent tiredness altogether."

Herewith, a sampling:

--Turn on the lights. Your body responds naturally to changes in light, so if it's unnaturally dark where you're working or sleeping it may make staying alert a lot harder. Try keeping your blinds open a bit so you'll wake up naturally in the morning or adding a few extra lights to your workspace to keep you from feeling sleepy throughout the day.

--Examine your emotions. Stress, depression and other negative emotions can take a heavy toll on your energy levels. Your exhaustion may have a lot to do with how you're feeling mentally, so take the time to deal with your emotions or get help if you need it.

--Don't linger in bed. Hitting the snooze button in the morning may delay the inevitable time when you do have to get up, but it's not doing you any favors in the long run. Challenge yourself to get up and move around for at least 10 minutes to see if you're still super tired. Chances are, once you get up you'll be ready to start your day.

--Eat smaller, more frequent meals. Eating meals that are infrequent can cause your blood glucose to spike and crash, leaving you tired and hungry. And digesting huge meals can steal energy you need for other things. Instead, eat smaller meals throughout the day so you can keep your energy level and keep yourself feeling great.

-- Cut down on alcohol. Alcohol may appear to make you sleepy, but it can actually ensure that you get a much lower quality of sleep than you would otherwise. Keep it in moderation so it won't affect your sleep and make you groggy the next day.

--Get out of the house. Sunlight can help wake you up and help you stay up, so take a trip outside to catch some rays and get some fresh air.

--Get away from your desk. Hours upon hours of sitting at your desk can start to sap your energy and make you plead for it to be 5 o'clock already. Give yourself a quick pick-me-up by stepping away from your desk for a bit for a trip to the water fountain, a walk around the office or just a short break.

--Listen to your favorite up-tempo songs. If you can listen to music at work, why not put on some tunes that will get your heart pumping and make you want to dance? It's a surefire way to beat the mid-afternoon slump.

--Stop slouching. Slumping down at your desk isn't doing you any favors in the alertness category. Sitting up at your desk, in an ergonomically friendly way, can make you feel more alert and ready to work.

--Avoid coworkers who sap your energy. Everyone has that one coworker who is so glum, negative or boring that they just suck the energy right out of you. When it's possible, keep this person away from you to save your energy and maybe your sanity too.

"Rogue Pharmacies" on the Internet

You've got drugs!

No prescription? No problem. Of 365 web sites advertising or selling controlled drugs, fully 85 percent do not require a written prescription, according to the 5th annual White Paper from the National Center on Addiction and Substance Abuse at Columbia University (CASA).

Although the overall number of drug-peddling web sites declined from 2007, the report found that benzodiazepines like Xanax and Valium were the most frequently offered online drugs, followed by painkillers like Oxycontin and Vicodin. 27 percent of the sites also offered Ritalin, Adderall, and other stimulants.

The paper, entitled "'You've Got Drugs!' V: Prescription Drug Pushers on the Internet," reported that only two of the 365 sites were certified by the National Association of Boards of Pharmacy, an official body which represents state pharmacy examination boards. The total number of drug sites was down from 581 such web sites in 2007.

"This problem is not going away," said Joseph A. Califano, Jr., chairman and president of CASA, and a former secretary of Health, Education and Welfare under President Jimmy Carter. "It is morphing into different outlets for controlled prescription drug trafficking like Internet script mills and membership sites that sell lists of online pharmacies, and different payment methods like eChecks, COD and money orders."

In addition, some of the sites sell "medical consultations" which can be used to procure controlled drugs without a formal prescription. In 2007, 80 percent of prescriptions filled by Internet pharmacies were for controlled substances. According to figures from the Drug Enforcement Administration (DEA), only 11 percent of business at traditional pharmacies involves scheduled drugs.

In April, the U.S. Senate passed a bill endorsed last year by the Senate Judiciary Committee, which seeks to control the Internet traffic in prescription drugs. The bill, introduced by Senators Diane Feinstein (D-CA) and Jeff Sessions (R-AL), now goes to the U.S. House. According to Senator Feinstein, "This [CASA] report emphasizes the need to take immediate action to stop rogue pharmacies on the Internet.... Our Internet pharmacy legislation has passed the Senate. It's time for the House to take action and pass this important bill."

Photo Credit: Next Thing

Addiction Treatment: Who is the Client?

The Overselling of Drug Rehab.

Professor David Clark, who runs the Wired In recovery website in the U.K., recently posted several passages from William L. White's "Slaying the Dragon: The History of Addiction Treatment and Recovery in America."

According to Professor Clark, "In highlighting [these quotes] on my Blog, I am not questioning the value of treatment. However, I am providing a word of caution to those who are trying to tell 'society' that the government-led treatment system is successful and is a panacea to some of society's problems."

Among the observations from White's book:

Who is the client?

"Addiction treatment swings back and forth between a technology of personal transformation and a technology of coercion. When the latter dominates, counselors become, not helpers, but behavioral police. The fact that today’s treatment institutions often serve more than one master has created the ethical dilemma of “double agentry,” wherein treatment staff profess allegiance to the interests of the individual client, while those very interests may be compromised by the interests of other parties to whom the institution has pledged its loyalty.’

--White, p. 335.

On blaming

"Harold Hughes, the political Godfather of the modern alcoholism treatment system, often noted that alcoholism was the only disorder in which the patient was blamed when treatment failed.... For decades many addicts have been subjected to treatment interventions that had almost no likelihood of success; and when that success has indeed failed to materialize, the source of that failure has been attributed, not to the intervention, but to the addicts’ recalcitrance and lack of motivation. The issue is, not just that such mismatches do not work, but that such mismatches generate their own iatrogenic effects via increased client passivity, helplessness, hopelessness and dependence."

--White, p. 331.

Historical tendency to oversell what treatment can achieve

"The overselling of the ways in which addiction treatment could benefit the home, the workplace, the school, the criminal justice system, and the broader community during the 1970s and 1980s sparked a subsequent backlash. When time - the ultimate leveller – began to expose the fact that these benefits were not forthcoming at the level promised, a rising pessimism fueled the shift toward increased criminalization of addiction."

--White, p. 338

Photo Credit: Cliffside Malibu

Battling Addiction with Exercise

It helps you quit. Can it keep you from starting?

We've all heard the claim: Physical exercise helps addicts who are working their way through withdrawal and recovery. It is one of the most common prescriptions given out by doctors and health professionals, whether you are a recovering alcoholic or a chronic binge eater.

And it makes sense. Exercise has verifiable impacts on not just endorphin levels, but also on levels of circulating serotonin and dopamine. All three neurotransmitter systems are heavily implicated in both maintaining addiction and withdrawing from it. Countless drug addicts have extolled the virtues of vigorous exercise, and there seem to be no compelling reason to doubt them.

But is there reason to think that regular exercise can help prevent addiction from blossoming in the first place?

Dr. Nora Volkow, director of the National Institute on Drug Abuse (NIDA), thinks there is. She told the Cincinnati Enquirer: "It's something we could apply right away. Vaccines, we're not going to get those results in one or two years. It will take probably five, six years to results."

"Exercise has been shown to be beneficial in so many areas of physical and mental health," Volkow said recently at a NIDA-sponsored conference on addiction treatment and research in Cincinnati. "This cross-disciplinary meeting is designed to get scientists thinking creatively about its potential role in substance abuse prevention."

Dr. Bess Marcus of Brown University, who is working on a NIDA-funded study of exercise for smoking cessation, presented the scientific evidence for the addiction/exercise connection. Similarities in the effects on the reward pathways of the brain's limbic system--dopamine activity in particular--may tie the two behaviors together more directly than previously thought. Among the findings:

--Rats in cages with running wheels show less interest in amphetamine infusions than rats without exercise options.

--Baby monkeys who don't roughhouse with their peers have higher levels of impulse control problems and alcohol use when they get older.

--In humans, exercise is known to reduce stress and tension--and anxiety is a well-known side effect of withdrawal, from alcohol and cigarettes to heroin and speed.

--Physical activity may enhance cellular growth in key areas of the brain involved in addiction, thereby aiding the neural rewiring that takes place during detoxification and withdrawal from addictive drugs.

No one knows for sure whether this effect, if it exists, works only in the young, and declines with age, or whether it can be of benefit to anyone as a preventative measure to reduce drug craving. "Statistics indicate that teens who exercise daily are the least likely to report using drugs or alcohol," Volkow said.

However, there are numerous exceptions, one being the classic image of the hard-drinking athlete. "Now the kids who exercise the most actually drink the most," Dr. Lloyd Johnston of the University of Michigan told the Associated Press.

Neuroaddiction and the Reward Pathway

How addictive drugs fool Mother Nature

"The addicted brain is distinctly different from the nonaddicted brain,” writes Alan Leshner, the former director of the National Institute of Drug Abuse (NIDA). “Changes in brain structure and function is what makes it, fundamentally, a brain disease. A metaphorical switch in the brain seems to be thrown as a result of prolonged drug use.”

Addiction is both a cause and a consequence of these fundamental alterations in brain function. If physical abnormalities in the brain are at the root of the problem, then any treatment program worth its weight ought to be dealing—directly or indirectly--with these differences in brain state. Writing in Lancet, researcher Charles O’Brien has suggested a similar orientation: “Addiction must be approached more like other chronic illnesses--such as diabetes and chronic hypertension--than like an acute illness, such as a bacterial infection or a broken bone."

All of this suggests that we are not likely to win a war on drugs, achieve zero tolerance, or become chemical-free any time soon. The drug problem is an artifact of the basic design of the mammalian brain. Humankind is extraordinarily susceptible to drug abuse anywhere and everywhere certain drugs are widely available—and all because of a “design quirk” in the reward pathways of the central nervous system.

Any sufficiently powerful receptor-active drug is, in its way, fooling Mother Nature. This deceit means, in a sense, that all such drugs are illicit. They are not natural, however organic they may be. Yet, the human drive to use them is all-pervasive. We have no real built-in immunity to drugs that directly target specific receptors in the limbic and cortical pleasure pathways. The act of “liking” something is controlled by the forebrain and brain stem. If you receive a pleasant reward, your reaction is to “like” it.

If, however, you are anticipating a reward, and are, in fact, engaging in behaviors motivated by that anticipation, it can be said that you “want” it. The wholly different act of wanting something strongly is a mesolimbic dopamine-serotonin phenomenon. We like to receive gifts, for example, but we want food, sex, and drugs. As Nesse and Berridge put it, “The ‘liking’ system is activated by receiving the reward, while the ‘wanting’ system anticipates reward and motivates instrumental behaviors. When these two systems are exposed to drugs, the “wanting” system motivates persistent pursuit of drugs that no longer give pleasure, thus offering an explanation for a core paradox in addiction."

Under the biochemical paradigm, a runaway appetite for non-stop stimulation of the reward pathway is a prescription for disaster. The harm is physical, behavioral, and psychological--as are the symptoms. Peer pressure, disciplinary difficulties, contempt for authority--none of these conditions is necessary for drug addiction to blossom. What the drug itself does to people who are biologically vulnerable is enough. No further inducements are required.

Even this brief summation of the ways in which addictive drugs alter neurotransmission should serve to demonstrate that these substances have more in common than we ordinarily assume. All these drugs are of course rewarding, so it is perhaps not too surprising, for all their differences, that they work the limbic reward pathways. All these drugs share common mechanisms of action, which is why they are addictive.

--Excerpted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.


addiction drugs

Coffee Addiction

The pharmacology of caffeine

Recent studies have documented the existence of severe caffeine addicts who suffer significant depression and lessened cognitive capacity for several weeks or months following termination of coffee drinking. Balzac, the nineteenth century French writer, reportedly died of caffeine poisoning at roughly the 50-cup-per-day level.

At low doses, caffeine sharpens cognitive processes--primarily mathematics, organization, and memory--just as nicotine does. The results of a ten-year study, reported in the Archives of Internal Medicine, showed that female nurses between the ages of 34 and 59 who drank coffee were less likely to commit suicide than women who drank no coffee at all.

Until recently, coffee and tea were rarely thought of as drugs of abuse, even though it is certainly possible to drink too much caffeine. Are the xanthines, the family of compounds that includes caffeine, addictive?

The typical caffeine dose in a cup of coffee--between 50 and 200 milligrams, with an average of about 115 milligrams--is enough to produce a measurable metabolic effect. Supermarket coffee in a can has considerably more caffeine per brewed cup than gourmet blends. Robusta beans have more caffeine than Arabica varieties. Instant coffee is the most potent coffee of all. The side effects of overdose--excessive sweating, jittery feelings, and rapid speech--tend to be transient and benign. Withdrawal is another matter: Caffeine causes a surge in limbic dopamine and norepinephrine levels--but not solely at the nucleus accumbens. The prefrontal cortex gets involved as well.

Caffeine's psychoactive power and addictive potential are easily underestimated. The primary receptor site for caffeine is adenosine, which, like GABA, is an inhibitory neurotransmitter. Adenosine normally slows down neural firing. Caffeine blocks out adenosine at its receptors, and higher dopamine and norepinephrine levels are among the results. Taken as a whole, these neurotransmitter alterations result in the bracing lift, the coffee "buzz" that coffee drinkers experience as pleasurable.

Scientists at the National Institute of Mental Health (NIMH) have demonstrated that high doses of caffeine result in the growth of additional adenosine receptors in the brains of rats. In order to feel normal, the rats must continue to have caffeine. Take away the caffeine, and the brain, now excessively sensitized to adenosine, becomes sluggish without the artificial stimulation of the newly grown adenosine receptors. Like alcoholics and cocaine addicts, people with an impressive tolerance for coffee and tea may find themselves chasing a caffeine high in a losing battle against fluctuating neuroreceptor growth patterns.

Increased tolerance and verifiable withdrawal symptoms, the primary determinants of addiction, are easily demonstrated in victims of caffeinism. Even casual coffee drinkers are susceptible to the familiar caffeine withdrawal headache, which is the result of caffeine's ability to restrict blood vessels and reduce the flow of blood to the head. When caffeine is withdrawn, the arteries in the head dilate, causing a headache. Caffeine's demonstrated talent for reducing headaches is one of the reasons pharmaceutical companies routinely include it in over-the-counter cold and flu remedies. The common habit of drinking coffee in the morning is not only a quick route to wakefulness, but also a means of avoiding the headaches associated with withdrawal from the caffeine of the day before.

--Adapted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.

Photo Credit: Lifehacker
[Note: For my Russian readers, a translation of this post is available here: "Зависимость от кофе translated by Health Effects of Coffee"]

Ten Things to Know about Addiction

From "Rethinking Substance Abuse."

In the closing chapter of their 2006 book, "Rethinking Substance Abuse,” editors William R. Miller and Kathleen M. Carroll attempt to sum up what has been learned about the science of addiction. Their useful contribution, entitled Drawing the Science Together, offers "Ten Principles" that are designed to synthesize the welter of recent scientific research on addiction and help make sense of what we know.

In vastly truncated form, they are as follows:

1. Drug Use is Chosen Behavior

At least in the beginning, people choose to take drugs, as one of the behavioral options available to them.

2. Drug Problems Emerge Gradually

"Dependence emerges over time, as the person's life becomes increasingly centered on drug use," the authors write. "The diagnostic criteria for classifying people with 'drug abuse' and 'drug dependence' represent arbitrary cut points along a gradual continuum" (p.296).

3. Once Well Established, Drug Problems Tend to Become Self-Perpetuating

Once regular drug use has caused dysregulation of limbic reward systems, addictive behaviors "take on a life of their own," and become "surprisingly resistant to ordinary forces of persuasion, religion, punishment, and self-control. It can be challenging to destabilize such a self-organizing system" (p.296).

4. Motivation is Central to Prevention and Intervention

Miller and Carroll write: "Taking action also predicts change. Better outcomes follow from attending more sessions or staying longer in treatment, going to more 12-step meetings, adhering to treatment advice, or faithfully taking one's medication. It appears that actively doing something toward change may be more important than the particular actions that are taken" (p.297).

5. Drug Use Responds to Reinforcement

"Drug use tends to be associated with a foreshortening of time perspective, so that longer term delayed rewards are discounted in value.... People who more steeply discount delayed rewards are at higher risk for drug use and problems; moreover, drug use exacerbates discounting. Some effective medications reduce the reward value of drug use, which can enhance the appeal of alternative reinforcers" (p. 298).

6. Drug Problems Do Not Occur in Isolation, but as Part of Behavior Clusters

In young people, drug abuse often co-exists with mood disorders, behavioral problems at school or the job, and anti-social behaviors. As Miller and Carroll remind us, the same is true of adults. Family violence, health problems, unemployment, and child neglect are frequently associated with cases of active addiction.

7. There Are Identifiable and Modifiable Risk and Protective Factors for Problem Drug Use

"It is clear that heredity contributes to risk for alcohol problems, and evidence is mounting for genetic predispositions for or against other drug use" (p.299).

8. Drug Problems Occur within a Family Context

In addition to the evidence pointing to a direct genetic mode of transmission, parental drug use is also a risk factor. Anything that delays an addiction-prone young person from first use of alcohol or other drugs decreases the risk of long-term addiction.

9. Drug Problems Are Affected by a Larger Social Context

"Social isolation is both a promoter and a consequence of the progression of drug dependence, and social bonding with nonusers can be an antidote" (p.301).

10. Relationship Matters

In formal treatment settings, effectively matching counselor to client is crucial. Confrontational counselor styles are generally "countertherapeutic."

Graphics Credit: University of Utah, Genetic Science Learning Center

Amphetamine Blues

How meth addiction happens.

If alcohol’s impact on brain cells is wide-ranging and diffuse, and marijuana’s impact is selective and subtle, the impact of cocaine and amphetamine is much more straightforward. “There is certainly lots of evidence for common neurological mechanisms of reward across a wide variety of drugs,” said Dr. Robert Post, chief of the biological psychiatry branch at NIMH.

Animals will readily administer cocaine and amphetamine, Dr. Post once explained to me, but when researchers surgically block out areas of the brain that are dense with dopamine receptors, the picture changes dramatically. “The evidence definitely incriminates dopamine in particular,” said Dr. Post. “In animal models, if you make selective lesions in the dopamine-rich areas of the brain, particularly the nucleus accumbens in the limbic system, the animals won’t self-administer either amphetamine or cocaine.”

When you knock out large slices of the nucleus accumbens, animals no longer want the drugs. So, one cure for addiction has been discovered already—but surgically removing chunks of the midbrain won’t do, of course.

At the heart of the meth high is a chemical paradox. The entire range of stimulative effects hits the limbic system within seconds of being inhaled or inject, and the focused nature of the impact yields an astonishingly pleasurable high.

But the long-term result is exactly the opposite. The body’s natural stock of these neurotransmitters starts to fall as the brain, striving to compensate for the artificial flooding of the reward center, orders a general cutback in production. At the same time, the receptors for these neurotransmitters become excessively sensitive due to the frequent, often unremitting nature of the stimulation.

The release of dopamine and serotonin in the limbic structure called the nucleus accumbens lies at the root of active drug addiction. It is the chemical essence of what it means to be addicted. The pattern of neural firing that results from this surge of neurotransmitters is the “high.” Dopamine is more than a primary pleasure chemical—a “happy hormone,” as it has been called. Dopamine is also the key molecule involved in the memory of pleasurable acts. Dopamine is part of the reason why we remember how much we liked getting high yesterday.

One reason why amphetamine addicts will continue to use, even in the face of rapidly diminishing returns, is simply to avoid the crushing onset of withdrawal. Even though the drug may no longer be working as well as it once did, the alternative--the psychological and physical cost of withdrawal--is even worse. When addicts talk about “chasing a high,” the metaphor can be extended to the losing battle of neurotransmitter levels. In the jargon used by Alcoholics Anonymous, addicts generally have to get worse before they can get better.

Speed, then, is diabolically well suited to the task of artificially stimulating the limbic reward pathway. Molecules of amphetamine displace dopamine and norepinephrine in the storage vesicles, squeezing those two neurotransmitters into the synaptic gap, and keeping them there, where they repeatedly stimulate their receptors. By mechanisms less well identified, cocaine accomplishes the same feat. Speed also interferes with the return of dopamine, norepinephrine, and serotonin molecules to their storage sacs, a procedure known as reuptake blocking—the same mechanism by which the so-called selective serotonin reuptake inhibitors (SSRI) antidepressants increase the availability of serotonin in the brain.

Adapted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.

addiction drugs

Drug Addiction and Dissociation

Where does the “self” go during active addiction?

Where does the everyday self go during active cycles of addiction? Addiction sometimes seems to resemble a waking trance, or autohypnosis. Psychologically, it is akin to a state of dissociation. The sense of self becomes impaired through the processes of intoxication, denial, neuroadaption, withdrawal, and craving. This impaired sense of self causes behavior that is baldly contradictory to the addict's core beliefs and values. Honest men and women will lie and steal in order to get drugs.

Webster’s Unabridged Dictionary defines dissociation, rather vaguely, as “the splitting off of certain mental processes from the main body of consciousness, with varying degrees of autonomy resulting.” How autonomous were you, consciousness-wise, the last time you got drunk and parked your car somewhere you couldn’t remember?

Dissociation may be part of the way consciousness itself adapts to chronic drug use. Richard S. Sandor, a thoughtful Los Angeles physician, helped to clarify many of these issues in an excellent essay some years ago in Parabola Magazine.

Sandor compares the addictive state to a form of hypnosis accompanied by posthypnotic amnesia. This automatism, this subsequent amnesia about the drugged “I” on the part of the sober “I,” is highly reminiscent of the consequences produced by state-dependent memory:

"A hypnotized subject is instructed to imagine that helium-filled balloons are tied to his wrist; slowly the wrist lifts off the arm of the chair. The subject smiles and says, ‘It’s doing it by itself!’ The ‘I’ that lifts the arm is unrecognized (not remembered) by the ‘I’ that imagines the balloons.... One part denies knowledge of what another part does. A cocaine addict, abstinent for a year, sees a small pile of spilled baking soda on a bathroom counter and experiences an overwhelming desire to use the drug again. Who wishes to get high? Who does not?"

“Interestingly,” Sandor says, “this type of amnesia is very similar to that seen in the multiple personality disorder (see Jekyll and Hyde), in which one entire ‘personality’ seems to be unaware of the existence of another. Even more interesting is the fact that confabulation, rationalization, and outright denial are also prominent features of the addictive disorders.” Dissociation, then, can occur without the intervention of anything as dramatic as hypnosis. The common quality is automaticity, the experience of “it doing it by itself.”

Sandor points to the inability of prevailing behavioral models to produce a comprehensive framework for effective addiction treatment. “None of the current treatment methods based upon the positivist scientific paradigm—be it psychodynamics (Freud, et al.) or behavioral (Pavlov, Watson, Skinner)—has demonstrated any particular superiority in the treatment of the ‘addictive disorders,’” he writes. “Many psychoanalysts readily admit the uselessness of that method for treating addicted individuals (the patient is regarded as being ‘unanalyzable’).”

In addition, says Sandor, “It appears that the most successful means of overcoming serious physical addiction is abstinence—very often supported by participation in one of the twelve-step groups based on the Alcoholics Anonymous model.... The basis of recovery from addiction in these nonprofessional programs is unashamedly spiritual.”

All addictions, Sandor argues, more closely resemble “the whole host of automatisms that we accept as an entirely normal aspect of human behavior than to some monstrous and inexplicable aberration.” Bicycle riding is a good example of an automatism, because once learned, “…it no longer requires the subjective effort of attention; more importantly, once learned, it cannot be forgotten. It is as though the organism says to itself, ‘Riding this thing could be dangerous! It’s much too important to trust that Sandor will pay close attention to it.’”

So what does the mind do? It creates a new state called bicycle riding:

"Number one priority in this state (after breathing and a few other things, of course) will be maintaining balance. In much the same way, the organism recognizes that mind- and mood-altering chemicals disturb the equilibrium of functions and are therefore potentially dangerous. In response, it may form a new state in which the ability to function is restored, but in which a new set of priorities exerts an automatic influence. Just as one’s only hope of not riding the bicycle again (if for some reason that is important) is to never again get on one, once a particular addictive state has developed, there is no longer any such things as “one” (drink, hit, fix, roll, etc.). Addicts begin again when they forget this fact (if indeed they have ever learned it) and/or when they become unable to accept the suffering that life brings and choose to escape it without delay. Addictions can be transcended--not eliminated."


--Excerpted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.

Paul Wellstone’s legacy

House passes Mental Health and Addiction Equity Act.

I live in Minnesota, so it is with great pride that I report that the U.S. House of Representatives recently passed mental health and addiction legislation named after the late U.S. Sen. Paul Wellstone of Minnesota, involving issues that were very close to his heart.

Wellstone, who died in a plane crash in northern Minnesota in 2002, was a two-term Democratic Senator who championed the cause of full medical insurance for the coverage of addiction treatment and mental illness. The Paul Wellstone Mental Health and Addiction Equity Act of 2007, sponsored by Rep. Patrick Kennedy of Rhode Island, passed the U.S. House on a vote of 268-148. The legislation will now be the subject of negotiations with the U.S. Senate, which earlier passed a similar but less stringent bill, sponsored by Rep. Patrick Kennedy’s father, Sen. Ted Kennedy.

Rep. Jim Ramstad of Minnesota, one of the bill’s key backers, and a recovering alcoholic, told Kevin Diaz of the Minneapolis Star Tribune: “This is not just another policy issue. It’s a matter of life and death for millions of Americans.”

The bill would require insurers to cover mental illness and addiction using the same guidelines as any other physical disease or ailment. Health insurance industry spokespeople said the bill goes too far, and would drive up health insurance premiums by mandating additional expensive treatments. The Senate version does not mandate mental health coverage, and offers exemptions for smaller group health plans.

But advocates of the Wellstone Act say that the provisions in the bill are long overdue. “We’re no longer going to allow people to languish in the shadows,” said Rep. Kennedy.

The House and Senate will also have to grapple with how the new bill will effect existing state legislation. According to Victoria Colliver in the San Francisco Chronicle, more than 25 states already have laws on the books mandating mental health coverage. Said California State Assemblyman Jim Beall Jr., who supports the Wellstone Bill: “If you don’t cover moderate mental problems or substance abuse, which often go together… you would not treat the person until their problems become acute—that’s not good health care.”

Marijuana Withdrawal Rivals Nicotine

Kicking pot or cigarettes leads to anxiety, sleep problems.

A small study in the journal Alcohol and Drug Dependence likened withdrawal from cannabis to that of withdrawal from nicotine, in the case of smokers addicted to either or both substances. The study gave further support to the growing body of evidence supporting the existence of a clinically significant marijuana withdrawal syndrome in heavy marijuana smokers.

As one cigarette smoker in withdrawal famously put it, “I cannot think, cannot concentrate, cannot remember.” Now it appears that heavy marijuana smokers who go cold turkey might be susceptible to the same symptoms of withdrawal from addiction.

Dr. Ryan Vandrey, a professor of psychiatry at Johns Hopkins School of Medicine, and principle author of the study, told Amy Norton of Reuters Health that marijuana withdrawal can cause symptoms similar to nicotine withdrawal, such as anxiety, irritability, difficulty concentrating, and sleep problems. Marijuana withdrawal, which typically affects only heavy smokers, has not been well studied or characterized in the scientific community. Some marijuana advocates view the idea of marijuana withdrawal with considerable skepticism. “These new findings give some idea of its significance,” Vandrey said, and will help inform heavy pot smokers about the symptoms they may face if they abruptly stop smoking.

In the journal article, “A within-subject comparison of withdrawal symptoms during abstinence from cannabis, tobacco, and both substances,” Vandrey and his co-authors conclude: “Overall withdrawal severity associated with cannabis alone and tobacco alone was of a similar magnitude. Withdrawal during simultaneous cessation of both substances was more severe than for each substance alone, but these differences were of short duration and substantial individual differences were noted.”

The authors argue that “cannabis withdrawal is clinically important and warrants detailed description in the DSM-V and ICD-11.” The DSM-V and the ICD-11 are standardized diagnostic classification systems used in the practice of psychiatry.

Participants in the study smoked marijuana at least four times a day, and cigarette smokers consumed 20 or more cigarettes daily.

Since, as Vandrey notes, the presence of withdrawal symptoms often leads to failure when smokers are attempting to quit, it is possible that many more people are trying—and failing—to quit marijuana than researchers have previously suspected. Dr. Vandrey suggested that since difficulty sleeping is one common symptom of withdrawal, sleep medications might be indicated in the case of severe marijuana withdrawal, but cautioned that more study is needed.

Along with insomnia and anxiety, heavy marijuana smokers often report an increase in the frequency and vividness of their dreams during withdrawal as well.

Photo: ©http://www.xes.cx/

See also: Marijuana Withdrawal nicotine

Addicts, Alcoholics Overwhelm Prison System

1 out of 100 Americans now in jail.

For the first time in American history, according to a study released by the Pew Center on the States, more than one in every 99.1 adult men and women are now in prison or in jail. States spent a total of $49 billion on prisons in 2007, compared to $11 billion 20 years ago. The United States incarcerates a larger percentage of its population than any other country. China ranks second.

“For all the money spent on corrections today, there hasn’t been a clear and convincing return for public safety,” according to Adam Gelb, director of the Pew Center’s Public Safety Performance Project. The report says that higher incarcerations rates have not been caused by increased crime or a corresponding surge in population numbers. Rather, stricter sentencing policies, such as “three-strikes” laws, as well as longer sentences, are behind the surge. A PDF version of the full report is available here.

A Newsweek article by Claudia Kalb notes that the number of drug offenders in the federal prison system leaped by 26 per cent between 2000 and 2006. In addition, more than one out of every three women in prison are serving time for drug-related crimes.

In 2000, fed-up California voters passed Proposition 36, designed to steer nonviolent drug offenders into treatment and job training programs--but funding has been precarious. Other states, including Texas, have resorted to specialized drug courts and greater drug treatment efforts to cope with the overflow of drug addicts in the legal system. As John Whitmire, a Texas State Senator, told the New York Times (Reg. required), “we weren’t smart about nonviolent offenders. The [Texas] Legislature finally caught up with the public.”

The Pew study reveals that addiction is as firmly criminalized as ever. The compressed essence of the war on drugs is simply to put as many people in jail as possible. Obviously, long prison terms will not cure addicts of their condition, any more than long prison terms for diabetics would cure that condition.

As a forced cold turkey treatment for addiction, perhaps some would view prison as harsh but necessary. Yet drugs are known to be widely available within the nation’s federal prison system. As an inmate in an Oklahoma federal prison wrote in a letter to Time magazine: “If the Government cannot stop people from using drugs in a few fenced-off acres over which it has total control, why should Americans forfeit any of their traditional civil rights in the hope of reducing the drug problem?”

The Sentencing Project, a Washington-based group that promotes alternatives to jail time, said recently that as of 2002, 45 per cent of all drug arrests were for marijuana. Simple possession is the rule--only one-sixth of the imprisonments involved charges of marijuana trafficking.

According to Reuters, the latest drug czar, George W. Bush’s man John Walters, alluded to new research showing that “marijuana use, particularly during the teen years, can lead to depression, thoughts of suicide and schizophrenia.” Even assuming this dubious statement to be true, it would seem to argue against prison and in favor of treatment.

The American criminal justice system cannot support the burden of a continual flood of minor drug possession cases. Plea-bargaining—the accommodation that keeps the legal edifice afloat—becomes the rule of the day. The legal system would break down in gridlock if every drug defendant insisted on his constitutional right to a jury trial. Prison sentences are bartered and sold like pork futures, and the jury trial has become an unaffordable luxury. For those accused of drug possession, pleading innocent sometimes looks like a risk they cannot afford to take.

Drug prohibition itself is a major part of the reason why the more potent and problematic refinements of plant drugs keep taking center stage. Since crack cocaine is more potent, more profitable, and more difficult to detect in transit, it replaces powdered cocaine, which, in its turn, replaced the chewing of cocoa leaves. Just as bootleggers switched from beer to hard liquor, so international drug dealers switch from cannabis to cocaine whenever the U.S. enforcement engine lumbers off in the direction of marijuana interdiction and eradication.

If addicted crack dealers sometimes receive stiffer sentences than wanton murderers (and they do), then it is a double irony, since people convicted of drug offenses are often good candidates for rehabilitation. However, public treatment programs are overbooked, and private programs are out of reach for those with little or no health insurance.

Photo Credit: California Dept. of Corrections and Rehabilitation

100 Million Killed By Tobacco

WHO estimates 1 billion more deaths in 21st century.

The World Health Organization (WHO) estimates that 100 million smokers died of tobacco-related causes in the 20th century, making cigarettes the leading preventable cause of death worldwide.

The agency estimates that as many as a billion people will die from tobacco in the 21st century, if present trends continue.

According to the WHO report, “Global Tobacco Epidemic 2008,” almost two-thirds of all smokers live in only ten countries, with China accounting for as much as 30 per cent of the total. Nearly 60 per cent of Chinese men smoke cigarettes, the report claims. The other leading countries, in order of consumption, are India, Indonesia, Russia, the U.S., Japan, Brazil, Bangladesh, Germany, and Turkey.

“The shift of the tobacco epidemic to the developing world will lead to unprecedented levels of disease and early death in countries where population growth and the potential for increased tobacco use are highest and where health care services are least available,” the report concluded. Or, as the Economist puts it, “the tobacco industry is getting the world’s poor hooked before governments can respond.”

The Economist reports that the most powerful prescription for fighting the trend is higher taxes: “Studies show that raising tobacco taxes by a tenth may cause a 4 per cent drop in consumption in rich countries, and an 8 per cent drop in poor ones, with tax revenue rising despite lower sales. The agency wants a 70 per cent increase in the retail price of tobacco, which is says could prevent up to a quarter of all tobacco-related deaths worldwide.”

The eradication of tobacco use will be as difficult as fighting insect-born diseases, WHO officials say. The WHO analysis strongly asserts that “partial bans on tobacco advertising, promotion and sponsorship do not work.”

In a soon-to-be-published paper by researchers at MIT and the University of California, cited by the Economist, the authors claim that “the monetary value of the health damage from a pack of cigarettes is over $35 for the average smoker, implying both that optimal taxes should be very large and that cigarette taxes are likely progressive.”

In a forward to the report, noting that 5.4 million people a year die from lung cancer and tobacco-related heart diseases, WHO Director-General Margaret Chan wrote that the world has reached “a unique point in public health history as the forces of political will, policies and funding are aligned to create the momentum needed to dramatically reduce tobacco use and save millions of lives by the middle of the century.”

What are cigarette makers doing to combat these grim revelations? According to the Economist, “The tobacco industry is regrouping in order to focus on ‘promising’ markets and escape the pesky lawsuits it is likely to face in rich, litigious countries.”

photo credit: UCR/California Museum of Photography

Soros Funds Addiction Initiative

Urges insurance companies to close “treatment gap.”

In a move designed to jump-start a reluctant insurance industry, philanthropist George Soros is pushing an addiction initiative aimed at the estimated 20 million Americans who cannot afford treatment for substance abuse.

Through his New York-based Open Society Institute (OSI), Soros will award $10 million in grants to study “obstacles associated with addiction treatment.” Victor Capoccia, who previously ran community-based drug and alcohol treatment programs for the Boston Department of Health and Hospitals, will serve as director of OSI’s Initiative to Close the Addiction Treatment Gap. Capoccia also directed the addiction prevention effort at the Robert Wood Johnson Foundation.

Any future system of universal health care should provide coverage of addiction as a medical condition, the group believes. “We’re going to look at the role of the public sector, and ask government to pay for people who lack insurance, not as a replacement for what other insurance should be paying for,” Dr. Capoccia told Alcoholism and Drug Abuse Weekly. “We don’t want public funds subsidizing what should be an insurance responsibility for this health issue.”

Among the issues the initiative will explore are the expansion of Medicaid to cover science-based addiction treatment, an emphasis on early intervention and aftercare, and increased funding of treatment programs from a variety of sources. Backers of the Soros initiative maintain that drug addiction is a health issue that should fall within the general financing of existing health care delivery systems.

“People with a health condition ought to have that condition treated,” Capoccia told the Baltimore Sun in an article by Michael Hill. “They should not be jailed or shunned or put aside until their condition is so acute that they are a hopeless case.”

Capoccia described addiction as a chronic disease like diabetes and hypertension. “Using that chronic disease framework,” he told the Sun, “you realize that this is a condition you have to learn to manage. It is not a case of finding a cure, that it’s here today and gone tomorrow. It is a process of mitigation, of reducing the harmful effects, reducing the behaviors associated with those harmful effects.”

Capoccia pointed to Baltimore and San Francisco as communities where local governments have focused effectively on addiction treatment, and have “helped build a sense of collaboration…between health departments and law enforcement in really positive ways."

Addiction, said Capoccia, “has all these impacts, yet we decide to provide the resources so only one in 10 gets help. It’s laughable.”

Grants will be for $600,000. Specific information about the funding program is available at http://www.soros.org/initiatives/treatmentgap/focus_areas/guidelines

Photo Credit: The Washington Note

Fighting Fire with Fire

An introduction to anti-craving drugs

The early neurobehavioral research on addiction has been vindicated by the development of anti-craving drugs and new drugs for depression.

On the other hand, the psychopharmacology of addiction is not much studied in med school, and all but unknown among the general populace. Even the treatments now in existence are woefully underutilized. Moreover, there are good reasons to question whether these drugs are being prescribed with sufficient care and forethought in cases where they are being used. Legitimate, unanswered questions exist about pharmacotherapy for addictive disorders.

The most important effect--the reregulation of brain receptor arrays with time--is little understood. And we cannot say with certainty whether messing with Mother Nature’s receptors, in some cases, might disrupt other finely tuned immunological or neurological systems in the body. Finally, there is the possibility of side effects years down the road, which obviously cannot be predicted based on current studies. What we already know is that the “bodymind,” as Candace Pert refers to it, is a delicate and astonishingly complicated piece of organic machinery.

Researchers are confronted with the perpetual dilemma of designing out, or designing down, the side effects of any new class of drugs. The historical record of drugs like Thorazine, and darker cases like Oraflex and thalidomide, are reminders of the potential pitfalls of development races and corner-cutting practices in the pharmaceutical industry. The pharmacological sciences and the people who work in them are inextricably linked to the drug companies that sell the end products of any neurochemistry that yields marketable new medications. It cannot be otherwise: Market considerations drive much of the research. By 1990, the American pharmaceutical industry had surpassed the federal government’s National Institutes of Health as the world’s principal source of biomedical research and development funding. One of the stiffest challenges facing managed health care in the future will be the matter of evaluating the effectiveness of medications for addiction.

Fighting fire with fire brings scientists face to face with the problems posed by the blood-brain barrier, that superfine mesh of cells that protects the brain from unwelcome molecular intruders. Bacteriologists discovered the barrier more than two centuries ago, when they learned that dyes injected into the body stained all the organs except the brain. Normally, the capillary-rich barrier of cells is so densely packed that the only way to penetrate the tight junctions between them is by means of special transporter molecules. These specialized molecules act as chauffeurs for the amino acids, hormones, and other compounds that must pass regularly and consistently into the brain. These transporter molecules can be fussy about riders, and the only way around that is to use molecules so tiny that they are measured in units of atomic mass called “Daltons.”

Knowing this, biochemists have worked toward discovering extremely small molecules, and this is partly why so few effective psychoactive drugs come along. While scientists have had some luck with small-molecule approaches to treating epilepsy, schizophrenia, and certain mood disorders, there is no reason to assume a small molecule can always be found to fit the bill.

Current work centers on tricking existing transporter molecules into ferrying artificial cargos into the brain. Pills that easily penetrate the blood-brain barrier are rare, special, and capable of causing a host of problematic side effects. If Zyban demonstrated that there were good reasons to be hopeful about future anti-craving drugs, then the diet drugs Redux and “fen-phen” demonstrated to critics of the drug industry what seemed to be a reversion to type—unsafe drugs released to the public without sufficient attention to dangerous side effects. Eli Lilly’s earlier caution about moving forward with serotonin boosting drugs as anti-obesity medications—as anti-craving drugs for food addicts--soon came to look like a wise decision.

--Excerpted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.

Related posts:

Chantix and Suicide
What is Drug Craving?
Naloxone and "Receptorology"
Topamax for Alcoholism: A Closer Look

LSD and Serotonin

Early psychedelic research on alcoholism.

What did LSD do to the brain, exactly, in order to set off the fireworks that so fascinated brain scientists, hippies, and government spies? And why, after years of massive, unauthorized field-testing, so to speak, was there so little evidence implicating LSD as an addictive drug? Powerful as it was, LSD did not show any of the classic attributes of addiction, such as withdrawal or craving, although it was possible to build up a tolerance to its effects with repeated dosings.

Another novel brain chemical, discovered less than a year after Albert Hofmann's discovery of LSD, proved to be a crucial piece of the puzzle.

According to an early theory, the aberrant mental functioning produced by the tiniest dose of LSD was due to interference with normal levels of serotonin in the brain. In 1954, chemists D.W. Woolley and E. Shaw had published an article in Science strongly arguing that serotonin was the likely biochemical basis for major mental disorders. Wooley and Shaw confirmed that the most acutely serotonin-active substance known to man was the ergot derivative known as LSD. LSD’s chemical architecture looked eerily similar to that of serotonin.

While the idea of LSD as a “model” of psychosis did not hold up, the link between serotonin and mental disorders was there all along. The strongly serotonin-mediated mental disorders, researchers ultimately discovered, were depression, drug addiction, and alcoholism.

The psychedelic drugs, new and old, are not only among the most powerful ever discovered, but are also tremendously difficult to study and utilize responsibly. Nonetheless, these drugs have always played an important part of the story, even though they are not addictive. LSD, mescaline, DMT, psilocybin, Ibogaine, ayahuasca—none of these appeal to lab rats as a drug of abuse.

Psychedelics have been exhorted, and occasionally deployed, as specific anti-craving medications for more than 50 years now. The psychedelic experience seems to assist some addicts in their efforts to remain sober and abstinent. However, the risks of casual experimentation with these substances should be obvious. Recent research on Ecstasy only makes this point more emphatically.

In the 1950s, along with Aldous Huxley and others, Al Hubbard came to believe that the more mystical or “transpersonal” experiences LSD sometimes afforded might hold considerable psychotherapeutic potential. With LSD provided by Hubbard, Canadians Abram Hoffer, Ross Mclean, and Humphrey Osmond pursued the idea of LSD as a treatment for alcoholism. In the U.S, Oscar Janiger, Sanford Unger, and others undertook research on LSD and alcoholism on the West Coast.

Throughout this period, there were LSD clinics operating in England and Europe. European LSD therapists tended to use very low doses as an adjunct to traditional psychoanalytic techniques. But North American researchers took a different, bolder approach. When “psychedelic” therapy began to catch on in Canada and the United States, therapists typically gave patients only one or two sessions at very high doses. These early efforts were aimed at producing spontaneous breakthroughs or recoveries in alcoholics through some manner of religious epiphany or inner conversion experience. The only other quasi-medical approach of the day, the Schick Treatment Center’s brand of “aversion therapy,” was not seen to produce very compelling long-term recovery rates, and subsequently fell out of favor.

In this light, the early successes with LSD therapy, sometimes claimed to be in the 50-75 per cent range, looked noteworthy indeed. However, the design and criteria of the LSD/alcoholism studies varied so widely that it has never been possible to draw definitive conclusions about the work that was done, except to say that LSD therapy seemed to be strikingly effective for certain alcoholics. Some patients were claiming that two or three trips on LSD were worth years of conventional psychotherapy—a claim not heard again until the advent of Prozac thirty years later.

“I’ve taken lysergic acid several times, and have collected considerable information about it,” Bill Wilson, the co-founder of Alcoholics Anonymous, disclosed in a private letter written in 1958. “At the moment, it can only be used for research purposes. It would certainly be a huge misfortune if it ever got loose in the general public without a careful preparation as to what the drug is and what the meaning of its effects may be.” Like many others, Wilson was excited by LSD’s potential as a treatment for chronic alcoholism. Even Hollywood was hip to the new therapy. Cary Grant, among others, took LSD under psychiatric supervision and pronounced it immensely helpful as a tool for psychological insight. Andre Previn, Jack Nicholson, and James Coburn agreed. (It could be argued that the human potential movement began here).

But the early addiction research was stuck in an impossible situation. Some of the best tools available to scientists for studying the workings of the human brain were the very drugs that were increasingly prohibited under state and federal law--drugs like heroin, cocaine, PCP, LSD, and marijuana.

By the early 1970s, meaningful research involving any of these substances had virtually ground to a halt, and grants for clinical work had dried up completely.

--Excerpted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.


Photo Credit: Albert Hofmann Foundation

Related posts: Ibogaine and Addiction

Serotonin and Dopamine: A Primer




alcoholics anonymous drugs

Marijuana Withdrawal Revisited

Is cannabis addictive?

See also Marijuana Withdrawal


Until recently, there was very little evidence in animal models for marijuana tolerance and withdrawal, the classic symptoms of addiction. For at least four decades, million of Americans have used marijuana without clear evidence of a withdrawal syndrome. Most recreational marijuana users find that too much pot in one day makes them lethargic and uncomfortable. Self-proclaimed marijuana addicts, on the other hand, report that pot energizes them, calms them down when they are nervous, or otherwise allows them to function normally. They feel lethargic and uncomfortable without it. Heavy marijuana users claim that tolerance does build. And when they withdraw from use, they report strong cravings.

While the scientific evidence weighed in against the contention that marijuana is addictive, there were a few researchers who were willing to concede the possibility. “Probably not, for most people,” a researcher at the University of Minnesota’s Chemical Dependency Program told me in the late 1990s. “But there may be some small percentage of people who are on the same wavelength with it chemically, and who end up in some way hooked to it physically. It’s a complicated molecule.”

The difference between animal models and humans may be the difference between pure THC and naturally grown marijuana. Despite the fact that rats and monkeys find whopping doses of synthesized THC aversive in the lab, psychopharmacologist Ronald Siegel, in his book Intoxication, has documented numerous instances of rodents feeding happily on wild marijuana plants in the field. There are apparently other components in the psychoactive mix that makes marijuana what it is. When the lab version of THC is hundreds of times more potent that the genuine article, it is hard to know exactly what the research is telling us.

Some of the mystery of cannabis was resolved after researchers demonstrated that marijuana definitely increased dopamine activity in the ventral tegmental area of the brain. Some of the effects of pot are produced the old-fashioned way—by means of neurotransmitter alterations along the limbic system’s reward pathway.

A report prepared for Australia’s National Task Force on Cannabis put the matter straightforwardly:

There is good experimental evidence that chronic heavy cannabis users can develop tolerance to its subjective and cardiovascular effects, and there is suggestive evidence that some users may experience a withdrawal syndrome on the abrupt cessation of cannabis use. There is clinical and epidemiological evidence that some heavy cannabis users experience problems in controlling their cannabis use, and continue to use the drug despite experiencing adverse personal consequences of use.

The U.S. government’s essentially unchanged opposition to marijuana research has meant that, until quite recently, precious few dollars were available for pot research. This official recalcitrance is one of the reasons for the belated recognition and characterization of marijuana’s distinct withdrawal syndrome.

To pluck one statistic out of many, representing estimates made in the late 1990s, more than 11 million Americans smoked marijuana regularly in the NIDA-sponsored “National Household Survey on Drug Abuse.” What NIDA has learned about cannabis addiction, according to the principal investigator of a recent NIDA study, was that “we had no difficulty recruiting dozens of people between the ages of 30 and 55 who have smoked marijuana at least 5,000 times. A simple ad in the paper generated hundreds of phone calls from such people” (This would be roughly equivalent to 14 years of daily pot smoking).

There now exists a nice body of clinical trials showing that mice and dogs show evidence of cannabis withdrawal. (For THC-addicted dogs, it is the abnormal number of wet-dog shakes that give them away.) Today, scientists have a much better picture of the jobs performed by anandamide, the body’s own form of THC. This knowledge helps explain a wide range of THC withdrawal symptoms. Among the endogenous tasks performed by anandamide are pain control, memory blocking, appetite enhancement, the suckling reflex, lowering of blood pressure during shock, and the regulation of certain immune responses.

These functions shed light on common hallmarks of cannabis withdrawal, such as anxiety, chills, sweats, flu-like physical symptoms, and decreased appetite. At Columbia University’s National Center on Addiction and Substance Abuse, where a great deal of NIDA-funded research takes place, researchers have found that abrupt marijuana withdrawal leads to symptoms similar to depression and nicotine withdrawal.

In a 2003 research report entitled “Nefazodone Decreases Anxiety During Marijuana Withdrawal in Humans,” published in Psychopharmacology, researchers at the New York State Psychiatric Institute used Serzone (nefazodone) to decrease some symptoms of marijuana withdrawal in human subjects who had been regularly smoking six joints of pot per day. Anxiety and muscular discomfort were reduced, but Serzone had no effect on other symptoms, like irritability and sleep problems. The drug did not alter the perceived effects of marijuana intoxication (the SSRIs didn’t, either). Serzone is another antidepressant, a modest inhibitor of serotonin and norepinephrine, but its mechanism of action is ill defined. It is not in the SSRI or tricyclic families.

To date, there is no effective anti-craving medication approved for use against the marijuana withdrawal syndrome, for addiction-prone individuals unlucky enough to suffer from it.

For more, see earlier posts:

Marijuana Withdrawal

Is Marijuana Addictive?

Photo credit: 2nd International Cannabis and Mental Health Conference Programme

Chantix and Suicide

Anti-smoking pill joins the list—but is the risk real?

The U.S. Food and Drug Administration fired both barrels last week, announcing that a variety of anti-seizure medications—as well as the anti-smoking pill, Chantix—may increase the risk of suicidal thoughts in patients who take them. The FDA will require new label warnings for a total of 11 drugs used for epilepsy.

New label warnings are also in the works for Chantix, the nicotine cessation aid being widely used by people attempting to quit smoking cigarettes. In a public health advisory issued last Friday, the FDA declared it “increasing likely” that Chantix may be associated with psychiatric problems. A month earlier, the FDA had advised that Chantix users should be monitored for the onset of suicidal urges, but backed off from making a strict cause-and-effect connection.

The FDA reviewed clinical data on anti-epileptic medications, including Pfizer’s Neurontin and Ortho-MacNeil’s Topamax, and concluded that “patients who are currently taking or starting on any anti-epileptic drug should be closely monitored for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression.” Topamax has shown additional promise as an anti-craving medication for alcoholism.

This follows on the heels of earlier warnings about increased suicide risk in adolescents taking SSRI antidepressants.

In the case of Chantix, the FDA’s Bob Rappaport, in a conference call with reporters, said the agency had “no definitive evidence there is a causal relationship here, they are just strongly appearing to be related.” Rappaport, quoted at WSJ.com, also said that “Chantix has proven to be effective in smokers motivated to quit,” and that the new warnings would help doctors and patients “make an informed decision regarding whether or not to use this product.”

A spokesman for Pfizer, quoted at Bloomberg.com, said that “no causal relationship has been established. There are some post-marketing reports and you cannot exclude those. We go by our scientific data, and from our clinical trial data we have not seen this.”

Discussions about a possible link between Chantix and suicide were fueled by the death last year of New Bohemians lead singer Carter Albrecht, who was shot while attempting to break into a house in Dallas. His girlfriend told authorities that his behavior had been erratic since he began taking Chantix in an effort to stop smoking.

In no case are the numbers of suicides linked to any of the drugs alarmingly high. The FDA study of epilepsy medications appears to demonstrate, as summed up by the San Francisco Chronicle’s Bernadette Tansey, “2.1 more people for every 1,000 on the medications exhibited suicidal thoughts or behavior, compared with every 1,000 on placebo.”

Note that the FDA is not discussing an increased risk of suicide, but rather an increased risk of suicidal thoughts or feelings. This is called “suicidal ideation.” The FDA usually refers to it as “suicidality.” Unlike an actual suicide attempt, suicidal ideation is the act of contemplating the act—a sort of “what if.” It is the difference, as a mental patient once put it, between buying the rope, and contemplating buying the rope

Persistent suicidal ideation is obviously not a desirable state of mind. But it does not downplay this behavior to note that it is, by nature, often fleeting and difficult to quantify. Moreover, the act of going cold turkey itself can cause heavily addicted people to feel temporarily suicidal—to ideate about killing themselves without killing themselves. These and other factors make it difficult to reach firm statistical conclusions about such risks.

For a Chantix user's point of view on the debate, visit www.stopsmokingcigs.com

Photo Credit: eNews 2.0
nicotine smoking

Ibogaine and Addiction

Can a psychedelic shrub diminish drug cravings?

In 1957, two scientists in the research department of CIBA Pharmaceutical Products in New Jersey reported on “an indole alkaloid with central-stimulant properties” used by native peoples in the Congo: “The crude extracts of Tabernanthe iboga caused a feeling of excitement, drunkenness, mental confusion, and, possibly, hallucinations.” The CIBA researchers were working from early reports by French and Belgian explorers in the 1800s, which had noted the use of this remarkable shrub in the Congo and surrounding regions.

Years later, a few researchers had begun to wonder whether ibogaine might not harbor properties that could be used in psychiatry and the treatment of addiction. It was the beginning of an unlikely renaissance in the study of psychedelic drugs.

A little-noticed article in the journal Brain Research in 1994 detailed the results of work with ibogaine at Albany Medical College in New York. Certain mysterious alkaloids—ibogaine in particular—decreased the self-administration of cocaine in rats--presumably through effects on the “dopaminergic mesolimbic system.” It was later determined that ibogaine also exhibited a weak affinity for one of the less common opiate sites, the kappa opiate receptor.

The active ingredient in ibogaine does not produce a classic psychedelic high, even at peak dosages. It is a state more like waking REM sleep, accompanied by hypnagogic images. Some users feel nothing at all, except intense nausea, palsy, and the sound of rushing water in their ears.

In an unexpected return to the psychedelic solution, an odd assortment of ex-hippies, AIDS activists, addiction treatment experts, and maverick scientists fell in behind the use of the African plant drug as a powerful agent for “addiction interruption.” Ibogaine, a drug that Hunter S. Thompson made famous when he joked that it might have been responsible for the downfall of Edmund Muskie’s 1972 presidential campaign, has been cited by some scientists for its ability to free certain cocaine and heroin addicts from their cravings. Initial underground experimentation was aimed at heroin addicts, but the hallucinogenic plant was also tried on alcoholics, cigarette smokers, and cocaine addicts. (The unlikely saga of ibogaine is related in The Ibogaine Story, self-published by Paul De Rienzo and Dana Beal).

Recently, ibogaine gained renewed attention in the usual way—by attenuating alcohol intake in various strains of alcohol-preferring rats. In the January 19 issue of The Journal of Neuroscience, researchers at the University of California-San Francisco (UCSF) reported that ibogaine substantially decreased alcohol consumption in alcohol-preferring rats. It did so by increasing the levels of a brain protein known as GDNF, or glial cell line-derived neurotrophic factor. “By identifying the brain protein that ibogaine regulates to reduce alcohol consumption in rats, we have established a link between DGNF and reversal of addiction,” according to Dorit Ron, the principal investigator of the study.

“On the basis of word of mouth, the ibogaine scene has quadrupled in the last five years,” Ken Alper of the New York University School of Medicine told Science News. In a report published in the Journal of Ethnopharmacology, Alper reported that an estimated 850 people had taken ibogaine in 2001. By 2006, the number had risen to almost 5,000, says Alper—and almost 70 per cent of users had taken the drug for its anti-addiction properties.

Recognition of anti-craving potential for this drug has been understandably slow to reach the mainstream science world. For one thing, ibogaine remains illegal in the United States. No so in Canada, Mexico, and other countries, where ibogaine clinics have begun to appear.

Emerging insights in the brain sciences had changed the field considerably, and, unlikely as it may seem, the proponents of ibogaine managed to catch NIDA’s ear this time around. They also got a running start on some straightforward clinical research from Dr. Deborah Mash of Miami University, who gained approval for clinical trials of ibogaine for the treatment of heroin addiction. Dr. Mash now runs an ibogaine treatment clinic for heroin addicts on the island of St. Kitts.

Taking Ibogaine or any other psychedelic is a strenuous undertaking, involving altered mental states wholly unlike other drug experiences There has never been anything predictable about the results of a psychedelic trip. Since outcomes can vary so markedly, depending upon set and setting, personality, and behavioral traits, studies are difficult to design, and always have been. In the Science News article by Brian Vastag, Frank Vocci, director of anti-addiction drug development at the National Institute of Drug Abuse (NIDA), said that “The idea of trying to push this into pharmaceutical development is a tough nut."

Photo credit: http://www.chm.bris.ac.uk/motm/ibogaine/ibogainej.htm