Drugs and Disease: A Look Forward

First published 2/18/2014.

Former National Institute on Drug Abuse (NIDA) director Alan Leshner has been vilified by many for referring to addiction as a chronic, relapsing “brain disease.” What often goes unmentioned is Leshner’s far more interesting characterization of addiction as the “quintessential biobehavioral disorder.”

Multifactorial illnesses present special challenges to our way of thinking about disease. Addiction and other biopsychosocial disorders often show symptoms at odds with disease, as people generally understand it. For patients and medical professionals alike, questions about the disease aspect of addiction tie into larger fears about the medicalization of human behavior.

These confusions are mostly understandable. Everybody knows what cancer is—a disease of the cells. Schizophrenia? Some kind of brain illness. But addiction? Addiction strikes many people as too much a part of the world, impacted too strongly by environment, culture, behavior, psychology, to qualify. But many diseases have these additional components. In the end, the meaning of addiction matters less than the physiological facts of addiction.

One of the attractions of medical models of addiction is that there is such an extensive set of data supporting that alignment. Specifically, as set down in a famous paper by National Institute of Drug Abuse director Nora Volkow and co-author Joanna Fowler: “Understanding the changes in the brain which occur in the transition from normal to addictive behavior has major implications in public health…. We postulate that intermittent dopaminergic activation of reward circuits secondary to drug self-administration leads to dysfunction of the orbitofrontal cortex via the striato-thalamo-orbitofrontal circuit.” This cascade of events is often referred to as the “hijacking” of the brain by addictive drugs, but nothing is really being hijacked. Rather, the abusive use of drugs changes the brain, and that should come as no surprise, since almost everything we do in the world has the potential of changing the brain in some way. “Why are we so surprised that when you take a poison a thousand times, it makes some changes in your head?” said the former director of a chemical dependency treatment program at the University of Minnesota. “It makes sense that [addictive drugs] change things.”

Critics like Fernando Vidal object to a perceived shift from “having a brain” to “being a brain.” He is saying that he cannot see the point of “privileging” the brain as a locus for the study of human behavior. In “Addiction and the Brain-Disease Fallacy,” which appeared in Frontiers in Psychiatry, Sally Satel and Scott Lillienfeld write that “the brain disease model obscures the dimension of choice in addiction, the capacity to respond to incentives, and also the essential fact people use drugs for reasons (as consistent with a self-medication hypothesis).”

An excellent example of the excesses of the anti-brain discussions is an article by Rachel Hammer of Mayo Clinic and colleagues, in the American Journal of Bioethics-Neuroscience. “Many believed that a disease diagnosis diminishes moral judgment while reinforcing the imperative that the sick persons take responsibility for their condition and seek treatment.” But only a few paragraphs later, the authors admit: “Scholars have theorized that addiction-as-disease finds favor among recovering addicts because it provides a narrative that allows the person simultaneously to own and yet disown deviant acts while addicted.” Furthermore: “Addiction reframed as a pathology of the weak-brained (or weak-gened) bears just as must potential for wielding stigma and creating marginalized populations." But again, the risk of this potentially damaging new form of stigma “was not a view held by the majority of our addicted participants…”

And so on. The anti-disease model authors seem not to care that addicted individuals are often immensely helped by, and hugely grateful for, disease conceptions of their disorder, even though Hammer is willing to admit that the disease conception has “benefits for addicts’ internal climates.” In fact, it often helps addicts establish a healthier internal mental climate, in which they can more reasonably contemplate treatment. Historian David Courtwright, writing in BioSocieties, says that the most obvious reason for this conundrum is that “the brain disease model has so far failed to yield much practical therapeutic value.” The disease paradigm has not greatly increased the amount of “actionable etiology” available to medical and public health practitioners. “Clinicians have acquired some drugs, such as Wellbutrin and Chantix for smokers, Campral for alcoholics or buprenorphine for heroin addicts, but no magic bullets.” Physicians and health workers are “stuck in therapeutic limbo,” Courtwright believes.

“If the brain disease model ever yields a pharmacotherapy that curbs craving, or a vaccine that blocks drug euphoria, as some researchers hope,” Courtwright says, “we should expect the rapid medicalization of the field. Under those dramatically cost-effective circumstances, politicians and police would be more willing to surrender authority to physicians.” The drug-abuse field is characterized by, “at best, incomplete and contested medicalization.” That certainly seems to be true. If we are still contesting whether the brain has anything essential to do with addiction, then yes, almost everything about the field remains “incomplete and contested.”

Sociologists Nikolas Rose and Joelle M. Abi-Rached, in their book Neuro, take the field of sociology to task for its “often unarticulated conception of human beings as sense making creatures, shaped by webs of signification that are culturally and historically variable and embedded in social institutions that owe nothing substantial to biology.”

And for those worried about problems with addicts in the legal system, specifically, over issues of free will, genetic determinism, criminal culpability, and the “diseasing” of everything, Rose and Abi-Rached bring good news: “Probabilistic arguments, to the effect that persons of type A, or with condition B, are in general more likely to commit act X, or fail to commit act Y, hold little or no sway in the process of determining guilt.” And this seems unlikely to change in the likely future, despite the growing numbers of books and magazine articles saying that it will.

Opponents of the disease model of addiction and other mental disorders are shocked, absolutely shocked, at the proliferation of “neuro” this and “neuro” that, particularly in the fields of advertising and self-improvement, where neurotrainers and neuroenhancing potions are the talk of the moment. Sociologists claim to see some new and sinister configuration of personhood, where a journalist might just see a pile of cheesy advertising and a bunch of fast-talking science hucksters maneuvering for another shot at the main chance. When has selling snake oil ever been out of fashion?

For harm reductionists, addiction is sometimes viewed as a learning disorder. This semantic construction seems to hold out the possibility of learning to drink or use drugs moderately after using them addictively. The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction. By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base. And that doesn’t help anybody find common ground.

Graphics Credit: http://www.docslide.com/disease-model/

Where Are All the New Anti-Craving Drugs?

The dilemma of dwindling drug development.

Drugs for the treatment of addiction are now a fact of life. For alcoholism alone, the medications legally available by prescription include disulfiram (Antabuse), naltrexone (Revia and Vivitrol)—and acamprosate (Campral), the most recent FDA-approved entry. A fourth entry, topiramate (Topamax), is currently only approved by the Food and Drug Administration (FDA) for other uses. But none of these are miracle medications, and more to the point, no bright new stars have come through the FDA pipeline for a long time.

New approvals for drugs in this category, like psychiatric drugs in general, have lately been confined to repurposed, “me-too” medications—which, insurance companies complain, are far too expensive. As health insurance giant Cigna explains on its website: “If anticraving medications are not covered by your insurance plan, keep in mind that the price of anticraving medications is usually small compared to the cost of alcohol and/or other drugs.” Perhaps so, but evidently not small enough for the expense to be routinely covered by the prescription portion of insurance policies.

Federal health officials have the same complaints. In a 2004 report entitled “Innovation or Stagnation: Challenge and Opportunity on the Critical Path to New Medical Products,” the U.S. Food and Drug Administration called for increased public-private collaboration and a “critical development path that leads from scientific discovery to the patient.”

As detailed by Professor Mary Jeanne Kreek, a senior attending physician at the Laboratory of the Biology of Addictive Diseases at Rockefeller University and one of the primary developers of methadone therapy:

Toxicity, destruction of previously formed synapses, formation of new synapses, enhancement or reduction of cognition and the development of specific memories of the drug of abuse, which are coupled with the conditioned cues for enhancing relapse to drug use, all have a role in addiction. And each of these provides numerous potential targets for pharmacotherapies for the future.

In other words, when an addiction has been active for a sustained period, the first-line treatment of the future is likely to come in the form of a pill. New addiction treatments will come—and in many cases already do come—in the form of drugs to treat drug addiction. Every day, addicts are quitting drugs and alcohol by availing themselves of pharmaceutical treatments that did not exist twenty years ago.

But things have changed. “This scientific stall may have seemed to come out of the blue,” writes Dr. Steven E. Hyman, Professor of Stem Cell and Regenerative Biology at Harvard University, in the Dana Foundation publication, Cerebrum. Hyman sketches a dismal picture:

The molecular and cellular underpinnings of psychiatric disorders remain unknown; there is broad disillusionment with the animal models used for decades to predict therapeutic efficacy; psychiatric diagnoses seem arbitrary and lack objective tests; and there are no validated biomarkers with which to judge the success of clinical trials. As a result, pharmaceutical companies do not see a feasible path to the discovery and development of novel and effective treatments…. progress for the many patients who respond only partially or not at all to current treatments requires the discovery of medications that act differently in the brain than the limited drugs that we now possess…. and regulatory agencies have given up their willingness to accept even more expensive new drugs.

Genes aren’t simple, and the kinds of studies that would lead to new anti-craving drugs are not cheap. Moreover, the medications themselves do not represent cures. Even if drugs that block dopamine receptors treat psychotic symptoms, Hyman writes, “it does not follow that the fundamental problem is excess dopamine any more than pain relief in response to morphine suggests that the original problem is a deficiency of endogenous opiates.”

What can change this picture for the better? “One exciting recent development is the emerging recognition that genes involved in schizophrenia, bipolar disorder, and autism do not represent a random sample of the genome,” Hyman writes. “Rather, the genes are beginning to coalesce into identifiable biochemical pathways and components of familiar neural structures…. Many researchers hope that such efforts will help attract the pharmaceutical industry back to psychiatry by demonstrating new paths to treatment development. The emerging genetic results may be the best clues we have ever had to the etiology of psychiatric disorders.”

Detractors worry, naturally enough, about the shrinking pie of funds available for this sort of endeavor. According to Steven Paul, president of Lilly Research Laboratories, “I am worried that obtaining the kind of molecular probes required for even in vivo testing may prove to be too time-consuming and expensive, and may divert precious NIH funds away from basic or clinical biomedical research.”

But Hyman remains optimistic, “based partly on the extraordinary vitality of neuroscience and perhaps, even more important, on the emergence of remarkable new tools and technologies to identify the genetic risk factors for psychiatric disorders, to investigate the circuitry of the human brain, and to replace current animal models that have failed to predict efficacious new drugs that act by novel mechanisms in the brain.”

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

Addiction Rehab: Everything is Broken

Down the rabbit hole in search of effective treatment.

When I first began researching drugs and addiction years ago, a Seattle doctor told me something memorable. “It’s as if you had cancer,” she said, “and your doctor’s sole method of treatment consisted of putting you in a weekly self-help group.”

I’ve got nothing against weekly self-help groups, to be sure. But as Ivan Oransky, executive editor of Reuters Health and a blogger at Retraction Watch, told me as recently as least year, addiction treatment appeared to be “all selling and self-diagnosis. They’re selling you on the fact that you need to be treated.”

In his introduction to Inside Rehab by Anne M. Fletcher (pictured), treatment specialist and former deputy drug czar A. Thomas McLellan writes that the book is “filled with disturbing accounts of seriously addicted people getting very limited care at exhaustive costs and with uncertain results...”

A common notion about addiction treatment facilities, or rehabs, is they are commonly called, is that they are staffed by professional social workers, certified counselors, and family psychologists, as well as addiction specialists. However: “Of the twenty-one states that specify minimum educational requirements for program or clinical directors of rehabs, only eight require a master’s degree and just six require credentialing as an addiction counselor,” writes Fletcher. Neuroscience journalist Maia Szalavitz, who writes for Time Healthland and specializes in addiction and rehab, told Fletcher that “the addiction field has been about as effectively regulated as banking before the economic crisis in many states.” According to Tom McLellan, counselor and director turnover in addiction treatment programs is “higher than in fast-food restaurants.”

In the United States, where for-profit treatment is prevalent, money does not buy access to superior treatment. Fletcher, author of several self-help books on weight loss and alcoholism, doggedly documents what she learns from visiting treatment facilities and interviewing current and former staff and clients. One difficulty with a book of this kind, based primarily on first-hand accounts, is that the same treatment program can offer vastly contrasting experiences from one client to another. And Fletcher, no fan of the 12 Steps, wants AA and NA to account for themselves in a way those volunteer institutions were never designed to accomplish.

But let’s just say it: Addiction treatment in America is a disaster. Addicts get better despite the treatment industry as often as they get better because of it. How did it all go wrong? Part of the answer is that addiction, like depression, tuberculosis, and other chronic conditions, is a segregated illness, as McLellan explains in his introduction. Traditionally, chronic conditions like alcoholism “were not recognized as medical illnesses, and have only recently been taught in most medical schools and treated by physicians. They were seen as ‘lifestyle problems’ and care was typically provided by concerned, committed individuals or institutions not well connected to mainstream health care.”

For treatment of alcoholism and drug addiction, the work has historically fallen to addicts themselves, due to discrimination, segregation, and stigmatization. This prevailing condition is still seen today in many group treatment programs, which are often administered in large part by former addicts with little or no formal training, rather than medical or psychological professionals. Addiction, as the author’s husband wryly remarked, “is the only disease for which having it makes you an expert.”

Which brings up a central point: Where are all the M.D.s? Doctors aren’t helping, either, when they fail to screen for risky drinking or drug use, or when they automatically refer addicts rather than treating them.

If Christopher Kennedy Lawford’s new book, Recover to Live, is the pretty picture, then Fletcher’s Inside Rehab is the gritty picture, in which most addicts who recover don’t go to treatment, 28 days is not long enough to accomplish anything but detox, group counseling is not always the best way to treat addiction, the 12 Steps are not always essential to recovery, specialty drugs are often needed to treat drug addiction, and, perhaps the most troubling of all, most addiction programs do not offer state-of-the-art approaches to treatment that have been shown to be effective in scientific studies.

What clients get, for the most part, is “group, group, and more group,” Fletcher writes. And in many cases of residential or outpatient rehab, “the clients did most of the therapy.” The scientific evidence suggests that some addicts do better with an emphasis on individual counseling, rather than the constant reliance on group work that traditional rehabs have to offer. As one counselor put it: “If I made an appointment to see a therapist because I was depressed, would I be told I have to do a program with everyone else?”

Monthly residential treatment can easily cost $25,000 or more. But public, government funded rehab centers, which presumably have less incentive to treat clients like money, are frequently full. And since these programs run the bulk of prison-related treatment in this country, addicts often stand a better chance of getting into these less expensive programs if they commit a crime.

Even if you manage to get in, rehab rules all too often seem arbitrary and punitive: Recreational reading materials, musical instruments, cell phones, and computers are frequently not permitted. And there is a strong tendency to insist that use equals abuse in every circumstance. Rehab management—the business of what happens after formal treatment ends—is largely neglected in the treatment sphere.

Fletcher rails against the disease model, but mostly in response to how she believes this concept is presented by AA/NA. Like other critics, she dwells on the idea that the disease tag serves as a crutch and an excuse, rather than as an extremely empowering notion for many addicts. In fact, the disease model, as addiction scientists understand it, is seriously underrepresented in the treatment field. Too many mental health professionals continue to insist that “all you need to do is get to the bottom of the problem and the need to use substances to cope, will dissipate,” said an M.D. specializing in addiction. “However, there is absolutely no evidence that this approach works for people who are addicted to alcohol or drugs… The primary-secondary issue is moot and an artifact of the bifurcation of the treatment delivery system.”

A significant number of rehabs still oppose medication-assisted treatment, Fletcher makes clear. Hazelden made news recently for dropping its long-standing opposition to buprenorphrine as a maintenance drug for opiate addicts during treatment. Richard Saitz of Boston University’s School of Medicine says in the book that if addiction were viewed like other health problems, “patients addicted to opioids who are not offered the opportunity to be on maintenance medications would sue their providers and win.”

According to Dr. Mark Willenbring, former director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA): “No one wants to say, ‘Treatment as we’ve been doing it probably isn’t as effective as we thought, and we need more basic research to really come up with new tools. In the meantime let’s do what we can to help suffering people in the most cost effective way and strive to not harm them.’”

Looking For the Science Behind the Twelve Steps

Transcendence, or nonsense?

What is it with the Twelve Steps? How, in the age of neuromedicine, do we account for the enduring concept of spiritual awakening available through “working the steps?” In Hijacking the Brain, Dr. Louis Teresi, former chief of neuroradiology at Long Beach Memorial Medical Center, along with Dr. Harry Haroutunian of the Betty Ford Center, sets themselves a formidable goal: “The sole intention of Hijacking the Brain is to connect the dots between an ‘organic brain disease’ and a ‘spiritual solution’ with sound physical, scientific evidence.” (For those who have grown weary of the overuse of “hijacked” brains in science writing, Teresi notes that an earlier term for the same idea was “commandeered.”)

Twelve Step programs remain popular, work for some addicts, and have their very vocal advocates in the recovery community. Outsiders are sometimes surprised to learn, writes Keith Humphreys, research scientist with the Veterans Health Administration and a professor at Stanford, that many of the people most profoundly and successfully affected by the 12-Step Program had “little or no interest in spirituality.”

The primary manifestation of this is the Twelve-Step Facilitation model (TSF), or Minnesota model, in honor of the Hazelden treatment facility in that state. Put simply, how do we go about explaining, in scientific terms, how a program like AA can have direct effects on a disease of the brain?

According to one strongly held view, we can’t. If there is something spiritual about recovery, it’s not anything that a medical doctor, who should have oversight of drug recovery and treatment programs, ought to be directly concerned with. Since the Twelve Step principles are explicitly spiritual in nature, how they apply to an organic brain disease is not at all clear. If you have cancer, your oncologists first line of thought is not usually, “why don’t you join a self-help group?” Writing for The Fix, health journalist Maia Szalavitz notes that “for no other medical disorder is meeting and praying considered reimbursable treatment: if a doctor recommended these religious or spiritual practices for the primary treatment of cancer or depression, you would be able to sue successfully for malpractice.” 

At an immediate level, the “power of the group,” which AA and other Twelve-Step Programs seems to tap into isn’t so hard to understand. Here are some of the obvious advantages of group work, as Teresi sees it:

--A reduction in the sense of isolation addicts feel.
--Useful information for addicts who are new to the processes of recovery.
--A way for people to see how others have dealt with similar problems.
--Additional structure and discipline for people whose living situations are often chaotic.

Teresi follows a common methodology, splitting the question into three dimensions: physical (an “allergy of the body driven by exaggerated limbic activity), mental (cognitive obsessions and compulsive drug use), and spiritual (an existential dilemma; a malady of the “soul”.) But the “spiritual awakening” that relieves this feeling and allows the addict to enter sobriety remains maddeningly ineffable: “The personality change sufficient to bring about recovery from alcoholism (addiction) has manifested itself among us in many different forms,” the Big Book cryptically affirms.

What makes it click for many addicts is what Teresi terms “empathic socialization,” defined as follows: “Positive socializing experiences received in support and therapeutic groups, such as praise, affection and empathic understanding, activate the brain’s reward centers as much as other natural rewards and similar to addictive substances. More importantly, belonging to an empathetic group reduces stress, a predominant cause and catalyst of addiction.”

Most people have only a hazy idea about what the Twelve Steps entail—something about admitting powerlessness over drugs, making amends for past wrongs, invoking a vague power higher than oneself. And the payoff? The reward for all the strenuous self-searching and personal honesty?

As Teresi sums it up: “inner peace, freedom, happiness, intuition, and alleviation of fear.” A heady package, indeed. All in return for achieving an emotional state called gratitude. Where are we to find the science in these claims?

Even though he doesn't solve the mystery, Dr. Teresi does offer  thoughts on some of the mechanisms in question, one of which is commonly referred to as an “attitude of gratitude” among Twelve-Step practitioners. “Gratitude for blessings received,” as it says the Big Book, is biochemically effective, Teresi argues. “In this regard,” Teresi writes, “grateful people show less negative coping strategies; that is, they are less likely to try to avoid the problem, deny there is a problem, blame themselves, or use mood-altering substances. Those with gratitude express more satisfaction with their lives and social relationships.”

And stress is where Dr. Teresi focuses his argument. More precisely, the working of the steps in Alcoholics Anonymous and kindred organizations involves “letting go” of high-stress states such as fear, guilt, self-loathing, and resentment. In Teresi’s thinking, the “power of the group” resides in its ability to reduce stress responses—and to raise levels of the “tend-and befriend” hormone, oxytocin. Oxytocin interacts with dopamine to increase maternal care, social attachments, and other affiliative behaviors and emotions. Thus, social rewards stir up a fair share of dopamine in reward centers of the brain, too. When alcoholics admit to powerlessness over alcohol, they are moving from a state of high autonomic nervous system tone to a more relaxed, “thank goodness that burden has been dropped” modality. This admission, when made as a conscious cognitive choice, and internalized through repetition and group motivation, lowers blood pressure and stress hormone levels, creating a more relaxed metabolic tone.

That is, in any event, how Teresi sees it. By confronting stress in this fashion, he believes that people with addictions can draw strength from group experience, even in the absence of personal religious belief.

Measures of Twelve-Step success will never be as precise as people would like. Not only does the national organization of AA generally avoid engaging in follow-ups, but the structure, or lack of it, works against precision measurements as well. As Teresi writes, “Anyone can start a Twelve-Step group by contacting the general service counsel of the organization of their interest, finding a meeting place (sometimes a person’s home) and adopting a readily available meeting protocol.” In fully monetized form, the Twelve Steps become Hazelden, or the Betty Ford Center. In supercharged upper income mode, it’s Passages and Promises. There is more going on here than simply a call to the pre-existing church-going addict. “AA,” says Keith Humphreys,  “is thus much more broad in its appeal than is commonly recognized.”

Teresi’s stated goal of connecting the dots isn’t an easy one. AA Twelve Steps and Twelve Traditions states unambiguously that the steps are “a group of principles, spiritual in their nature, which, if practiced as a way of life, can expel the obsession to drink and enable the sufferer to become happily and usefully whole.” In another passage, the Big Book refers to this as a personality change “sufficient to bring about recovery from alcoholism (addiction).” The explanations and definitions are maddeningly circular—unless you happen to be one of the people for whom the obsession to drink has been expelled through this practices.

Teresi believes it is possible to explore this terrain in a “belief neutral” manner, “with findings applicable to those who believe in a single God, multiple gods, or no God at all." Spiritual practices, Teresi believes, promote recovery in three ways. Meditation and some forms of prayer reduce stress levels. Techniques that lower stress have also been shown to stimulate limbic reward centers, “modulating emotion while strengthening attention and memory.” Finally, “spiritual practices, through improving morals and interpersonal behavior, foster closeness and a sense of community with one’s fellows and satisfy our instinctual need for social connection, also reducing stress.”

Nothing Organic About Rodale’s New Book on Addiction

Raw carrots won’t cut it.

How times have changed. You’ve heard of Rodale, the outfit that kicked off organic gardening in America, and publishes Prevention Magazine and Organic Gardening? Founded in 1947, the Rodale Institute’s mandate was to publicize J.I. Rodale’s personal vision of healthy soil and healthy food. So it was with great astonishment that I picked up The Addiction Solution: Unraveling the Mysteries of Addiction Through Cutting-Edge Brain Science, published by Rodale Books, heretofore famous for such perennials best sellers as The Rodale Book of Composting, The Rodale Whole Foods Cookbook, Diabetes Without Drugs, and The Organic Manifesto.

So what is the approach taken in this new paperback about addiction? Herbal treatments for alcoholism? Fresh air and sunshine for meth addiction? No. The “brain science” in the subtitle is really just that. Written by Dr. David Kipper, a Beverly Hills physician, and Steven Whitney, a former addict, the book states that addiction is… er… a brain disease, and not primarily a behavioral issue. It seems that Big Science has gotten its murderous dissecting hands around the Rodale organization at last. In neuroscience, not organic carrots, lies the future of addiction treatment, the book asserts. Is old man Rodale turning over in his grave? It gets worse. The Rodale organization is now saying, through this book, that if you are an addict, you might want to consider taking… more drugs.

Here it is, in a nutshell: “An inherited genetic flaw causes specific imbalances in brain chemistry, that, when impacted by stress, create biochemical ‘wantings,’ or needs, that show themselves as bad feelings, uncharacteristic behaviors, and/or addiction, which is medically treated by a new family of pharmaceutical medications that first regain and then stabilize the biochemical balance. During the rehabilitation of the brain chemistry, the patient enters a personalized recovery program featuring behavioral and other therapies.”

You can argue with certain specifics in that definition—“brain imbalance,” for example, is falling out of favor as a descriptor—but there is no denying that it represents an attempt at a strictly neurophysical definition of the condition.

Traditional addiction treatment, the book argues, hasn’t included any of this. The authors maintain that “traditional 28-day inpatient programs at treatment centers are now largely unnecessary. This is good news, since that kind of treatment costs from $50,000 to $100,000 per month.” [Editor’s note: perhaps in Beverly Hills.]

“In contrast,” the authors write, “the new medical paradigm is grounded in outpatient treatment, making it more affordable, especially with insurance and government benefits that define addiction as a medical disease. Thanks to the Mental Health Parity and Addiction Equity Act of 2008, insurers that offer substance abuse coverage must provide the same lifetime limits on payment as they provide for other medical diseases like diabetes, heart disease, and cancer.”

And what does all this accomplish? “More subtly, the new approach replaces the expectation of failure attached to the old, traditional treatment with a tangible opportunity for success, including raising an addict’s self-esteem.” Away with your old and traditional ways, says this Rodale title. If you are looking for an organic alternative to what is becoming the mainstream view of addiction, you will have to look elsewhere. Perhaps Prevention magazine might have something more in your line.

Graphics Credit: http://metalmother.com/

Why Drug Stigma Still Matters

More sinned against than sinning?

 “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.”

--Susan Sontag, Illness as Metaphor

Addiction is always a hot topic, in its way, if only because of an endless supply of fallible starlets. More seriously, valuable research is taking place in myriad directions—the psychology of addiction, the disease of addiction, the neurobiology of addiction, the neuropsychopharmacology of addiction, etc. What sometimes goes missing is any serious analysis of the stigmatization of drug addiction.

The UK Drug Policy Commission (UKDPC) is an independent research group comprised of 12 “expert commissioners” charged with providing objective analysis on drug policy matters. The group recently issued a paper authored by Charlie Lloyd of the University of York. In “Sinning and Sinned Against: The Stigmatisation of Problem Drug Users,” (PDF) Lloyd set out to pull together the evidence-based research on the effects of stigmatizing  “problem drug users.” The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) defines problem drug use as “injecting drug use or long-duration/regular use of opioids, cocaine and/or amphetamines.”

According to Lloyd’s analysis of the research literature, the groups most frequently referred to as stigmatized are the disabled, the mentally ill, minority ethnic groups—and drug addicts. To make matters worse, multiple problems often attach to addicts: “Problem drug users frequently report suffering from other stigmas: being black, female, Hepatitis C or HIV positive, disabled, or suffering from a mental disorder. However, research shows that problem drug user status is the most stigmatising.” The stigma is continuously cemented in place by rhetoric about the “war on drugs.” There is no comparable public war on disability, or mental illness, or ethnicity—at least not overtly.

I cannot vouch for Lloyd’s analysis, but a good deal of it smacks of common sense at the street level. Others have suggested it is logical to assume that the stigma attached to hard drug addiction serves, by example, to deter others. “However,” Lloyd writes, “attempts to scare young people away from drug use have not proved effective. The evidence reviewed here suggests that stigma keeps users away from treatment.”

So this is not a theoretical concern. Stigmatization “may be a major stumbling block to successful rehabilitation.” Health professionals and hospital staff “can be distrustful and judgmental in dealing with problem drug users but drug users can themselves be aggressive and manipulative. In the United States staff who choose to work in hospitals serving the most deprived, inner-city populations appear to be more compassionate and patient.”

The prevailing public view, Lloyd writes, is that problem drug users tend to be “dangerous, deceitful, unreliable, unpredictable, hard to talk with and to blame for their predicament. Young people may have more negative views in this respect than adults.”

Of course, drug addicts can be all those things at one time or another. Drug abusers often stigmatize themselves. For the user, these conflicted feelings lead some of them to feel that “the very act of seeking treatment serves to cement an ‘addict’ or ‘junkie’ identity, which can lead to further rejection from family and friends.” This is most commonly experienced by users on methadone maintenance treatment, “who feel particularly stigmatised, in comparison to other treatment types.” Lloyd notes that a lifetime stigma sometimes attaches to heroin and cocaine addiction, continuing “to haunt such ex-users, preventing access to good housing and employment.” As he trenchantly observes, there is plenty of room “to stigmatise users less, without rendering heroin or crack-cocaine significantly more attractive.”

Lloyd concludes that the primary culprit, the complicating factor, is “blame.” Compared to “blameless groups” such as the disabled and the mentally ill, problem drug users, he writes, “are blamed for taking drugs in the first place and are also perceived to have a choice whether or not to take drugs in the future.”

If public and professional stigma has the power to prevent addicts from entering treatment (as it formerly held a similar power over the mentally ill, and before that, the disabled), what can be done about it? Lloyd makes several concrete suggestions, most of which center, predictably, on education:

--Drug education in schools should focus on the causes and the consequences of active addiction, rather than relying on scare stories.

--It’s time to teach health care and pharmacy staff about the medical, social, and psychological aspects of drug addiction.

--Treatment agencies need to focus on the whole person, “and not see problem drug users as solely problem drug users. Some drug addicts are also bird-watchers.”

--Users themselves, as well as their families, often benefit from a greater understanding of the mechanisms of addiction. This can have the effect of reducing “the self-blame felt by many drug user’s parents.”

--Finally, “police need to reflect on their practice in policing problem drug users at street level.” ‘Nuff said on that.

DrugScope, a leading U.K. charity with a membership drawn in part from the ranks of drug treatment and education workers, praised the report as “timely and insightful.” Martin Barnes, chief executive of DrugScope, said that the report effectively “evidences stigma as a barrier to recovery and reintegration.”

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

Treating Addictions [Guest Post]

The ABCs of rehab.

[Journalists like me tend to get immersed in the scientific and medical aspects of addiction. Not a bad thing, to be sure—but sometimes a simpler rendition puts a finer point on the matter. Today’s guest post was contributed by Susan White, who writes on the topic of Becoming a Radiologist.  She welcomes your comments at her email id: susan.white33@gmail.com.]

It’s very easy to find fault and assign blame when you’ve never been in the other person’s shoes; how often have we found ourselves judging people for their bad habits? Why can’t he stop that obnoxious habit? Oh, she’s not strong at all, she cannot stop drinking! I would never sink to the drug-induced state he is in, not even if the worst things were to happen to me – it’s easy to say all these things because we don’t know what an addiction feels like and how hard it is for people to quit. They’re just like you and me; they don’t like the way they are, but their substance abuse controls their bodies, minds and everything they do or say.

To understand an addiction, you need to understand that the body goes through changes, both physiological and psychological. If the addiction is to alcohol, drugs or any other chemical substance, the high euphoric feeling is what makes you go back again and again. But as time goes by, the high decreases and you begin to take in more of the abusive substance in your quest for that initial euphoria. It’s a vicious cycle that feeds itself, and if you stop, you feel withdrawal symptoms because your body is so used to its daily or even hourly fix.

It takes a supreme effort to admit that you have a problem and seek help. Rehab centers work because they make the addict quit cold turkey; they are cloistered and controlled environments where addicts have no access to the abusive substance. The sudden withdrawal causes abnormal reactions in your body, and you’re treated with medicines that help soothe your frayed nerves. When the initial craving subsides, you’re put in therapy and other forms of rehabilitation. Your diet is regulated, and your body slowly starts to recover and rejuvenate. 

The hardest part of rehab however comes when you step out of the cocoon of the de-addiction center and enter the real world. You have to face the demon that had its tentacles around you and fight it down, and for some people, this is where they suffer a relapse. Once they are surrounded by temptation, they succumb and are soon back to their decadent and sorry state. Others however, are made of sterner stuff. They know that they cannot afford to lose control again and they are disciplined enough to say no when they come face to face with temptation.

Addiction, be it to a substance, person or thing, is not something to be taken lightly. Unless admitted to and treated at the earliest, it could end up having serious physical and mental consequences. 

Graphics Credit: http://www.nida.nih.gov/

The Rehab Scandal: Relapse Rates

If 8 out of 10 addicts fail, is it really treatment?

The British drug treatment and recovery community has been squabbling recently over annual figures published by the National Treatment Agency (NTA) showing a marked increase in the number of people in drug treatment programs in Britain.

BBC home editor Mark Easton dug into the data and found that, of 202,000 people in treatment, a total of 7,324 “left the treatment programme drug free last year.” Ergo, “Just 3.6 % of those in treatment were discharged free of illegal drugs. “

Andrew Brown, a writer who covers addiction and substance abuse, cited studies showing relapse rates of 80 % or more, and wrote in the UK Telegraph that residential treatment advocates “can be fervent, and persuasive, in their enthusiasm, especially those individuals for whom rehab represents the turning point in their battle with addiction. But the fact is that the expected outcome from most people who enter a treatment centre remains—relapse.”

In the current issue of Newsweek, science writer Sharon Begley gives us some inadvertent clues. Since most residential treatment therapy revolves around individual and group counseling by psychologists, not M.D.s or prescribing psychiatrists, it is unnerving to discover, in a study highlighted by Begley, that clinical psychologists in general practice do not necessarily use “the interventions for which there is the strongest evidence of efficacy.” In other words, where’s the science?

This is an argument that severely rankles psychologists, naturally enough. But Begley writes that because of rigorous clinical trials, we know, for example, that cognitive behavioral therapy can be effective against depression, OCD, bulimia, and other strongly serotonin-mediated disorders. “Neuroscience,” writes Begley, “has identified the brain mechanisms by which these interventions work, giving them added credibility.”

What, then, do we find being used as therapeutic tools in such situations by psychotherapists in the trenches, including those in addiction treatment facilities? The answer, according to Begley, is likely to be “chaotic meditation therapy, facilitated communication, dolphin-assisted therapy, eye-movement desensitization....”

Begley could have added sacral cranial therapy, electric acupuncture, and a host of other questionable practices now subsumed under the broad rubric of clinical psychology. The point is obvious: With more than a thousand brands of psychotherapy currently being practiced, it is safe to say that the field is rife with conflicting opinions about what works.

The problem is that the addicted person has no way of knowing whether the clinical therapy on offer during treatment is backed up by enough sound scientific evidence to warrant participation.

As long as clinics are showing relapse rates not unlike those shown by alcoholics and other addicts going it alone, patients and those involved in their recovery have every reason to view addiction therapy programs with a critical eye.

addiction drugs alcoholics anonymous

National Alcohol and Drug Addiction Recovery Month

Obama's September proclamation.

Recovery Month, an annual September observance highlighting the benefits of substance abuse treatment, kicked off on August 31 when President Obama issued a proclamation, excerpted below:

"Every year, Americans across the country overcome their struggles with addiction. With personal determination and the support of family and friends, community members, and health professionals, they have turned the page on an illness and sought the promise of recovery.

"As a Nation, we must work together to provide access to effective services that reduce substance abuse and promote healthy living. Without effective treatment, abuse of alcohol, illicit drugs, or prescription medications can devastate the mind and body. With treatment, substance use disorders can be managed, giving individuals the effective tools necessary to address their addiction.

"During National Alcohol and Drug Addiction Recovery Month, we also pay special tribute to the dedicated professionals and everyday citizens who, with skill and empathy, guide people through the treatment and recovery process. Across America, they are offering a message of hope and understanding. These compassionate individuals remind us that the strength of our character derives not from the mistakes we make, but from our ability to recognize and address them."

More information on Recovery Month is available HERE.

This year's theme--"Join the Voices for Recovery: Together We Learn, Together We Heal"-- is intended to "emphasize the need to use all available resources, in our communities and on the Internet, to educate people about the disease and to help those with substance use disorders, and those close to them, get support," according to the Recovery Month website.

The U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration (SAMHSA) and its Center for Substance Abuse Treatment (CSAT) created the materials being distributed for Recovery Month. President Obama's proclamation is available HERE.

addiction drugs

Addiction Touches Almost Everyone

75% of Americans know someone who is addicted.

A new survey by Lake Research Partners, sponsored by George Soros’s Open Society Institute and presented at the June 16 Conference of Mayors meeting in Providence, R.I., reveals that three of every four people surveyed said that they personally knew someone who has been addicted to alcohol or drugs.

More ominously, half of Americans “say they could not afford treatment if they or a family member needed it. They are also concerned that people addicted to alcohol or drugs may not be able to get treatment because of cost or lack of insurance coverage – a concern likely heightened by the current economic recession.” Moreover, financial concerns about treatment are highest among Americans with incomes less than $50,000. 67% of that income group said they would not be able to afford addiction treatment.

Among the survey’s other findings:

--Three‐quarters (75%) of Americans are concerned that people who are addicted to alcohol or drugs may not be able to get treatment because they lack insurance coverage or cannot afford it. Concerns about the affordability of and access to addiction treatment emerge throughout the survey results. Four in ten (41%) are very concerned.

--Nearly three‐quarters (73%) support including alcohol and drug addiction treatment as part of national health care reform to make it more accessible and affordable. This support cuts across all demographic groups. Lake Research Partners notes that this figure is quite high, “given the current economic climate and public concerns about government spending." One‐quarter (26%) oppose increased funding.

--Two‐thirds of Americans (68%) also support increasing federal and state funding for alcohol and drug prevention, treatment, and recovery services.

--Finally, more than nine in ten (96%) support providing specialized prevention, treatment, and recovery support to veterans and military returning from active duty (78% strongly support this effort).

The poll was sponsored by Closing the Addiction Treatment Gap , a program of the Open Society Institute. This program seeks to raise awareness around alcohol and drug addiction and its effects on family and communities. The telephone survey was conducted May 29-June 1, 2009 among a nationally‐representative sample of N = 1,001 adults 18 and older. The margin of sampling error is + 3.1 percentage points.

Graphics Credit: http://naturalpatriot.org/category/education/

addiction drugs

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

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.

Obama and McCain on Addiction Treatment

Candidates differ on medical marijuana.

A drug and alcohol policy group has released a study of positions on drug policy by the presidential candidates, concluding that "neither John McCain or Barack Obama can really be considered a leader in the drug-policy area."

In an article published on the Join Together website, author Bob Curley notes that Obama has admitted to youthful marijuana and cocaine use, and McCain has admitted to youthful alcohol abuse. Both candidates are former cigarette smokers, Obama having quit only recently. Curley write that "both appear to have a broader and more nuanced understanding of addiction issues than their White House predecessor."

The article also quotes William Cope Moyers, vice president of external affairs at Hazelden treatment center, who says he has "never been more hopeful that addiction treatment will begin to get the attention it deserves, because we at least have two candidates who are aware of the issue." Obama's admission of drug use is already on the table as a potential campaign issue, while McCain purportedly had an alcoholic father, and his wife went through treatment for an addiction to painkillers in the 1990s.

Senator McCain has been active in efforts to regulate tobacco advertising, and advocates smoking cessation programs in the workplace. At other times, he has advocated tougher sentencing for drug crimes and capital punishment for international drug traffickers.

For his part, Senator Obama supported the Second Chance Act of 2007, which aimed at reintroducing veteran drug defenders to society. He has called for greater use of drug courts and rehabilitation programs in lieu of lengthy prison sentences. He is opposed to efforts to lower the drinking age to 18.

McCain is against marijuana legalization, and opposes the use of marijuana for medical purposes. He said he "would not support medical marijuana because I don't think that the preponderance of medical opinion in America agrees...."

Obama, according to the Join Together article, while not ready to let people grow their own, told a reporter in March that "my attitude is that if it's an issue of doctors prescribing medical marijuana as a treatment for glaucoma or as a cancer treatment, I think that should be appropriate because there really is no difference between that and a doctor prescribing morphine or anything else."

medical marijuana

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

Drug That Blocks Stress Receptor May Curb Alcohol Craving

Anxiety, drugs, and the brain’s “fear center.”

A brain receptor for a neurotransmitter involved in stress and anxiety has become a primary target in the scientific war on alcoholism—the only kind of drug war that really matters.

Researchers at the National Institute of Alcohol Abuse and Alcoholism (NIAAA), working with colleagues at Lilly Research Laboratories and University College in London, announced that a drug that blocks the so-called NK1 receptor (NK1R) reduced alcohol cravings in a study of 25 detoxified alcoholic inpatients. The drug “suppressed spontaneous alcohol cravings, improved overall well-being, blunted cravings induced by a challenge procedure, and attenuated concomitant cortisol responses.”

The study, published in the current issue of Science magazine, (look here for abstract) demonstrates that investigators continue to work toward more effective anti-craving drugs from a variety of angles. The NIAAA researchers are making effective use of recent findings about the role played by corticotropin-releasing hormone (CRH) in the addictive process. CRH is crucial to the neural signaling pathway in areas of the brain involved in both drug reward and stress.

Another neurotransmitter of this type is substance P, together with its preferred receptor, NK1R. As it happens, NK1R sites are densely concentrated in limbic structures of the mid-brain, such as the amygdala, or so-called “fear center.” The experimental drug, known as LY686017, blocks NK1R receptors, shutting off substance P, which in turn diminishes anxiety-related drug cravings.

Other researchers had previously demonstrated that deletion of NK1R sites eliminated opiate use in animal models. It has also been known for some time that alcohol and the opiates share certain common chemical pathways in the brain. And in humans, at least one earlier study showed decreased stress and anxiety reactions in human subjects taking a drug that blocked the Neurokinin 1 receptors.

The authors of the study suggest that “blockade of NK1Rs might modulate stress- and reward-related processes of importance for excessive alcohol use and relapse.”

According to NIAAA director Dr. Ting-Kai Li, “These findings advance our understanding of the link between stress and alcohol dependence and raise the prospect of a new class of medications for treating alcoholism.”

The early finding will require more research. “To our knowledge,” the authors conclude, “no data are presently available to address this hypothesis.”

graphic credit: http://www.ibiblio.org/rcip/ptsdmemory.html

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.”