Addiction in the Spotlight at Neuroscience 2013

Testing treatments for nicotine, heroin, and gambling addiction.

Several addiction studies were among the highlights at last month’s annual meeting of the Society for Neuroscience (SfN) in San Diego. Studies released at the gathering including therapies for nicotine and heroin addiction, as well as some notions about the nature of gambling addiction.

And now, as they say, for the news:

— Transcranial Magnetic Stimulation (rTMS), the controversial technique being tested for everything from depression to dementia, may help some smokers quit or cut down, according to research coming in from Ben Gurion University in Israel. Abraham Zangen and colleagues used repeated high frequency rTMS over the lateral prefrontal cortex and the insula of volunteers. Participants who got the magnetic stimulation quit smoking at six times the rate of the placebo group over a six-month period. Work in this area is limited, but there is some preliminary evidence that some addictions may respond to this form of treatment. azangen@bgu.ac.il

—Speaking of the insula—a site deep in the frontal lobes where neuroscientists believe that self-awareness, cognition, and other acts of consciousness are partially mediated—research now suggests that out-of-control gamblers may be suffering, in part, from an overactive insula. People with damage to the insular region are less prone to both the “near-miss fallacy (where a loss is perceived as “almost” a win) and the “gambler’s fallacy (where a run of luck is “due” to a gambler after a string of losses). The volunteer gamblers played digital gambling games while undergoing functional MRIs. Luke Clark of the University of Cambridge, along with researchers from the University of Iowa and the University of Southern California, uncovered a “specific disruption of both effects” in a study group with insula damage. This ties in with earlier research demonstrating that smokers with insula damage lost interest in their habit. This one remains a puzzler, and further research, that brave cliché’, is needed, especially since disordered, or “pathological” gambling is now classified in the DSM5 as an addiction, not an impulse control disorder.  lc260@cam.ac.uk

—And speaking of stimulation, if you go deep with rat brains, you can stimulate a drug reward area and reduce the motivation for heroin in addicted rats. Deep brain stimulation (DBS), an equally controversial treatment approach, now in use as a treatment for Parkinson’s and other conditions, is a surgical procedure involving the implantation of electrodes in the brain. When Carrie Wade and others at the Scripps Research Institute and Aix-Marseille University in France electrically stimulated the subthalamic nucleus and got addicted rats to take less heroin and become less motivated for the task of bar pressing to receive the drug. Earlier work had demonstrated a similar effect in rats’ motivation for cocaine use. “This research takes a non-drug therapy that is already approved for human use and demonstrates that it may be an option for treating heroin abuse,” Wade said in a prepared statement.  clwade@scripps.edu

—Too much stimulation leads to stress, as we know. And George Koob, recently named the director of the National Institute on Alcohol Abuse and Alcoholism, discussed his work on the ways in which dysregulated stress responses might act as triggers for increased drug use and addiction. Koob focused on the negative reinforcement of stressful emotional states: “The argument here is that excessive use of drugs leads to negative emotional states that drive such drug seeking by activating the brain stress systems with areas of the brain historically known to mediate emotions and includes the stress/fear-mediating amygdala and reward-mediating basal ganglia.” For Koob, “stress can cause addiction and addiction can cause stress.” gkoob@scripps.edu

—Finally, hardcore gamblers show a boost in reward-sensitive brain areas when they win a cash payout, but less activation when presented with rewards involving food or sex. The study features more volunteers playing games inside fMRI machines, and purports to demonstrated that problem gamblers are less motivated by erotic pictures than by monetary gains, “whereas healthy participants were equally fast for both rewards.” This “blunted sensitivity” in heavy gamblers suggests the possibility of a marker for problem gambling, in the form of a distorted sensitivity to reward, said Guillaume Sescousse of Radboud University in The Netherlands, during a mini-symposium at the conference. “It is as if the brain of gamblers interpreted money as a primary reward…. for its own sake, as if it were intrinsically reinforcing.” g.sescousse@fcdonders.ru.nl

Prohibition in Perspective

An essay on the Harrison Narcotic Act of 1914.

As the 20th Century began, America’s drinking habits were undergoing a thorough review. But In late 1914, five years before the prohibition of alcohol became the law of the land, the government also took aim at other drugs. The legal status of heroin and cocaine changed overnight with the passage of the Harrison Narcotic Act. The U.S. Congress, with the vociferous backing of William Jennings Bryan, the prohibitionist Secretary of State, voted to ban the “non-medical” use of opiates and derivatives of the coca plant.

Under the Harrison Act, physicians could be arrested for prescribing opiates to patients. “Honest medical men have found such handicaps and dangers to themselves and their reputation in these laws,” railed an editorial in the National Druggist, “that they have simply decided to have as little to do as possible with drug addicts...” The Harrison Act did have the effect of weeding out casual users, as opium became dangerous and expensive to procure. Housewives, merchants, salesmen, and little old ladies who had been indulging in the “harmless vice” now gave it up.

By 1919, continued pressure from the alcohol temperance movement culminated in Congressional passage of the Volstead Act, which provided for federal enforcement of alcohol prohibition. The temperance activists had pulled it off, though there is nothing very “temperant” about total prohibition. A year later, the states ratified the 18th Amendment. Within a five-year period, morphine, cocaine, and alcohol had all been banned in America. The Prohibition Era had begun. At roughly the same time, alcohol prohibition movements were sweeping across Europe, Russia, and Scandinavia, as evidenced by this 1921 news photograph of Chinese Maritime Officers with 300 lbs of smuggled morphine confiscated in cylinders shipped from Japan.

Prohibition and the passage of the Harrison Narcotics Act coincided, as well, with a short-lived effort to prohibit cigarettes. Leaving no stone unturned in the battle to eliminate drugs and alcohol from American life, Henry Ford and Thomas Edison joined forces to wage a public campaign against the “little white slavers.” Edison had shown an earlier fondness for Vin Mariani, a French wine laced with prodigious amounts of cocaine, but he and Ford wanted to stamp out cigarette smoking in the office and the factory. Although that effort would have to wait another 75 years or so, and may yet become the next large-scale test of federal prohibition, New York City did manage to pass an ordinance prohibiting women from smoking in public.  Fourteen states eventually enacted various laws prohibiting or restricting cigarettes. By 1927, all such laws had been repealed.

As Prohibition continued, police and federal law enforcement budgets soared, and arrest rates skyrocketed, but no legal maneuvers served to make alcohol prohibition effective, once “respectable” citizens had chosen not to give up drinking. The experience was so repellent that even today, when drug legalization is considered a legitimate topic of debate, most American reformers are unwilling to argue the case for neo-prohibitionism. (America’s ambivalence over alcohol is still evident in some states, where “dry” counties have made the sale of liquor illegal from time to time.)

As the temperance crusaders faded away, politicians and the public turned their attention back to heroin addiction, as the opiates became the official villains again. However, one practice that remained quietly popular with an older generation of physicians well into the 1940s was the conversion of alcoholics into morphine addicts. The advantages of alcohol-to-morphine conversion were spelled out  by Lawrence Kolb, the Assistant Surgeon General of the U.S. Public Health Service at the time:  “...Drunkards are likely to be benefited in their social relations by becoming addicts. When they give up alcohol and start using opium, they are able to secure the effect for which they are striving without becoming drunk or violent.” Perhaps so, but there were plenty of doctors who did not believe that addiction of any kind fell within the scope of medical practice in the first place.

Subsequent laws tightened up the strictures of the Harrison Act. Mandatory life sentences were imposed in several states for simple possession of heroin. The first addict sentenced to life imprisonment under the new laws was a twenty-one year-old Mexican-American epileptic with an I.Q. of 69, who sold a small amount of heroin to a seventeen year-old informer for the FBI. (In 1962, the U.S. Supreme Court ruled that imprisonment for the crime of simply being an addict, in cases where the arrest involved no possession of narcotics, was cruel and unusual punishment in violation of the Bill of Rights.) 

The Prohibition Years also sparked a rise in marijuana use and marijuana black marketeering. To checkmate the migration toward that drug, Congress passed the Marihuana Tax Act of 1937, modeled closely after the Harrison Act. The American Medical Association opposed this law, as it had opposed the Harrison Act, but to no avail. The assault on marijuana was led by Harry J. Anslinger, the indefatigable U.S. Commissioner of Narcotics who served a Hoover-like stretch from 1930 to 1962. At one point, Anslinger announced that marijuana was being taken by professional musicians. “And I’m not speaking about good musicians,” he clarified, “but the jazz type.” Due in no small part to Anslinger’s tireless public crusade against “reefer madness,” additional state and federal legislation made marijuana penalties as severe as heroin penalties. The most famous early victim of Anslinger’s efforts was screen actor (and reputed jazz fan) Robert Mitchum, who was busted in 1948 and briefly imprisoned on marijuana charges.

One highly addictive drug that did not immediately fall under the proscriptions of the Harrison Act was a cocaine-like stimulant called amphetamine. Originally intended as a prescription drug for upper respiratory ailments and the treatment of narcolepsy (sleeping sickness), the drug was first synthesized in 1887 by a German pharmacologist. It was a British chemist named Gordon Alles, however, who showed everyone just what amphetamine could really do. There was no direct analog in the plant kingdom for this one. Alles, who also worked at UCLA and Caltech, documented the remarkable stimulatory effect of “speed” on the human nervous system—research that led directly to the commercial introduction of amphetamines in the late 1930s under the trade name Benzedrine. Once it became widely available over the counter in the form of Benzedrine inhalers for asthma and allergies, it quickly became one of the nation’s most commonly abused drugs, and remained so throughout the late 1950s and 1960s—with periodic comebacks.

Photo Credit: www.newworldencyclopedia.org

Steve Earle and the Ghost of Hank Williams

Book Review: I’ll Never Get Out of This World Alive

Musician Steve Earle made a solo name for himself with Guitar Town and Copperhead Road after playing in legendary country and bluegrass bands as a young prodigy. He was nominated for a Grammy, his reputations soared, he added rock and roll to his range—until 1991, when Earle put out the aptly named live album, Shut Up and Die Like An Aviator. Shortly thereafter, he was dropped by his record label for long-standing drug problems, and landed in prison with a heavy sentence for possession of heroin. He completed rehab successfully, earned his parole in 1994, and has gone on since then to make several highly successful albums, guest star in the TV series The Wire, and write music for the New Orleans-based series Treme.

And now he has written a novel called I’ll Never Get out of This World Alive, set mostly in San Antonio, with a main character who is an aging doctor and a heroin addict. Doc’s specialty is quick but relatively safe and sterile backroom abortions, commonly performed on illegal immigrants. His license to practice long ago taken away, Doc takes in enough to make his daily pilgrimage to the parking lot where his longtime dealer works the streets. The book’s title is taken from the name of a Hank Williams song, which is appropriate, because whether or not you enjoy this novel may depend upon your reaction to Hank’s ghost hanging around the main character, begging for a drink and some attention. Things get even stranger when a young Mexican girl, Graciela, falls under the doctor’s care, and begins to exhibit signs of stigmata and the power to heal drug addicts. Rather than choosing to tell his tale straightforwardly, Earle is working more in the tradition of Latin American magical realism. This is no One Hundred Years of Solitude, but a lot hangs on belief, and the power of unseen forces to organize events in unforeseen ways.

Earle has a fun, quick touch with character description and the telling anecdote, explaining, for example, that local narcotic detective Hugo Ackerman “rarely hurried even when attempting to catch a fleeing offender. He had worked narcotics for over a decade, and in his experience neither the junkies nor the pushers were going far. He caught up with everybody eventually.”

Set in 1963, the book carries us through the Kennedy assassination and other cultural events as background. And we get a nice, deft description of what starts the doctor down the road toward smackdom: “Then in the first year of his residency he befriended a crazy old pathologist who worked the midnight shift in the county morgue, and it was he who introduced Doc to the miracle of morphine. From that very first shot it was as if he’d discovered the one vital ingredient that God had left out when He’d send Doc kicking and screaming into the cold, cruel world.”

I won’t say that Mr. Earle should give up his day job on the basis of this outing, but I do think that critics who have dismissed his efforts have overlooked some of what the author is attempting to say about addiction, and about recovery--that recovery involves all kinds of intangibles like faith, hope and charity, and that these attributes can present themselves in myriad disguises. (And a lot of critics got it: Michael Ondaatje wrote that this “subtle and dramatic book is the work of a brilliant songwriter who has moved from song to orchestral ballad with astonishing ease.”)

I think this book is, in fact, written very much with addicts in mind. The shade of Hank Williams doesn’t dog Doc everywhere just because Steve Earle is a huge fan. Hank Williams was also a vicious, go-to-hell alcoholic and drug addict who could not make the turnaround Steve Earle has made, and therefore could not even get out of his twenties alive, let alone this world.  Earle has Doc stand in for him when it comes to lessons learned: “Doc was immediately sucked in by the big lie that all junkies want to believe in spite of daily evidence to the contrary, that this shot was going to be like that first shot all those years ago. He tied off, found the money vein in the back of his arm, well rested now because he had always reserved that one for the big shots, the teeth rattlers, and it stood at attention like a soldier on payday.”

I won’t give out any spoilers here, as the miraculous Graciela bleeds from her wounds and lays hands on dying addicts to save them. It’s the stuff of, well fiction—but fiction informed by the author’s firsthand voyage into heroin bondage. Steve Earle is living proof of the overarching theme of his book: redemption in its many guises.

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

A New/Old Treatment for Opiate Addiction

 

Gov makes naltrexone legit for heroin.

Last week, the government officially sanctioned the use of naltrexone, trade name Vivitrol, for use in the treatment of heroin addiction. Approved years ago by the FDA for use in the treatment of alcoholism, naltrexone is a long-acting opiate receptor antagonist that has been widely used for heroin detoxification, withdrawal, and maintenance for some time. In that light, the official approval was a bit of an anticlimax, and of less scientific interest than naltrexone’s earlier approval for alcohol dependence. 

While naltrexone has yet to become the huge treatment breakthrough for alcoholism that addiction researchers hoped for it, naltrexone did, in the end, prove to be the first anti-craving medication widely available for alcoholics. Using an opiate antagonist as an aid to the prevention of alcoholic relapse would have been unthinkable without the underpinnings of a neurophysiological model of addiction. Various investigators have also speculated that naltrexone, the drug used as an adjunct of heroin withdrawal therapy, may find use against symptoms of marijuana withdrawal in people prone to marijuana dependence

Naltrexone has something of a mixed reputation, however, in part due to its use in the highly controversial practice of “rapid detox.” Naltrexone, like methadone and buprenorphine, blocks the heroin high in a relatively neutral manner. It does so by knocking the opiate molecule off its receptors and replacing it with “dead weight,” so to speak. Naltrexone would seem to be the perfect drug for heroin addicts—but it is not. It does little to reduce cravings. Like acamprosate for alcohol, another blocking approach, its record of accomplishment is mixed, and the dropout rate is high. There is not even a mild drug-like effect to provide cross-tolerance and dampen the effects of withdrawal, as with methadone. Recently, naltrexone for heroin addiction has been offered as a form of rapid detoxification. The addict is anesthetized and placed on a respirator, then injected with naltrexone. The result: complete detoxification in a matter of hours, as the naltrexone molecules knock the opium molecules off their receptors. It can be lethal if not carefully controlled and supervised. The problem, as always, is that the detoxified addict is just as vulnerable to heroin addiction as before. Rapid detox does nothing to combat subsequent cravings, and relapse is frequent.

 Naltrexone combined with buprenorphine is marketed as Subutex, and represents another treatment modality for opiate addiction.  In addition, a University of Minnesota study of kleptomania—the compulsion to steal—showed that naltrexone drastically reduced stealing among a group of 25 shoplifters.

Naltrexone will be offered as a monthly injection, an approach that has not been widely tested on opiate addicts, but is potentially an advantage over frequent visits to methadone clinics or daily ingestion of other treatment drugs. Unfortunately, naltrexone is a potential problem for people with liver disease or hepatitis.  At high doses, naltrexone has been implicated in liver damage. More common adverse effects include dizziness, lethargy, and headache.

 Graphics Credit: http://www.cancercenter.ph/

Heroin in Vietnam: The Robins Study

Origins of the Disease Model of Addiction (Part 2).

In 1971, under the direction of Dr. Jerome Jaffe of the Special Action Office on Drug Abuse Prevention, Dr. Lee Robins of Washington University in St. Louis undertook an investigation of heroin use among young American servicemen in Vietnam. Nothing about addiction research would ever be quite the same after the Robins study. The results of the Robins investigation turned the official story of heroin completely upside down.

The dirty secret that Robins laid bare was that a staggering number of Vietnam veterans were returning to the U.S. addicted to heroin and morphine. Sources were already reporting a huge trade in opium throughout the U.S. military in Southeast Asia, but it was all mostly rumor until Dr. Robins surveyed a representative sample of enlisted Army men who had left Vietnam in September of 1971—the date at which the U.S. Army began a policy of urine screening. The Robins team interviewed veterans within a year after their return, and again two years later. 

After she had worked up the interviews, Dr. Robins, who died in 2009, found that almost half—45 per cent—had used either opium or heroin at least once during their tour of duty. 11 per cent had tested positive for opiates on the way out of Vietnam. Overall, about 20 per cent reported that they had been addicted to heroin at some point during their term of service overseas.

To put it in the kindest possible light, military brass had vastly underestimated the problem. One out of every five soldiers in Vietnam had logged some time as a junky. As it turned out, soldiers under the age of 21 found it easier to score heroin than to hassle through the military’s alcohol restrictions. The “gateway drug hypothesis” didn’t seem to function overseas. In the United States, the typical progression was assumed to be from “soft” drugs (alcohol, cigarettes, and marijuana) to the “hard” category of cocaine, amphetamine, and heroin. In Vietnam, soldiers who drank heavily almost never used heroin, and the people who used heroin only rarely drank. The mystery of the gateway drug was revealed to be mostly a matter of choice and availability. One way or another, addicts found their way to the gate, and pushed on through. 

“Perhaps our most remarkable finding,” Robins later noted, “was that only 5% of the men who became addicted in Vietnam relapsed within 10 months after return, and only 12% relapsed even briefly within three years.” What accounted for this surprisingly high recovery rate from heroin, thought to be the most addictive drug of all? As is turned out, treatment and/or institutional rehabilitation didn’t make the difference: Heroin addiction treatment was close to nonexistent in the 1970s, anyway. “Most Vietnam addicts were not even detoxified while in service, and only a tiny percentage were treated after return,” Robins reported. It wasn’t solely a matter of easier access, either, since roughly half of those addicted in Vietnam had tried smack at least once after returning home. But very few of them stayed permanently readdicted.

Any way you looked at it, too many soldiers had become addicted, many more than the military brass had predicted. But somehow, the bulk of addicted soldiers toughed their way through it, without formal intervention, after they got home. Most of them kicked the habit. Even the good news, then, took some getting used to. The Robins Study painted a picture of a majority of soldiers kicking it on their own, without formal intervention. For some of them, kicking wasn’t even an issue. They could “chip” the drug at will—they could take it or leave it. And when they came home, they decided to leave it.

However, there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty. And when they did, they had a very strong tendency to relapse. Frequently, they could not shake it at all, and rarely could they shake it for good and forever. Readers old enough to remember Vietnam may have seen them at one time or another over the years, on the streets of American cities large and small. Until quite recently, only very seriously addicted people who happened to conflict with the law ended up in non-voluntary treatment programs.

The Robins Study sparked an aggressive public relations debate in the military. Almost half of America’s fighting men in Vietnam had evidently tried opium or heroin at least once, but if the Robins numbers were representative of the population at large, then relatively few people who tried opium or heroin faced any serious risk of long-term addiction. A relative small number of users were not so fortunate, as Robins noted. What was the difference?

Quotes from: Robins, Lee N. (1994). “Lessons from the Vietnam Heroin Experience.” Harvard Mental Health Letter. December.

See also:

Robins, Lee. N. (1993) “Vietnam veterans' rapid recovery from heroin addiction: a fluke or normal expectation?” Addiction. 88(8), 1037 – 1167.

Origins of the Disease Model of Addiction (Part 1) can be found HERE.

Photo Credit:  soldiersupportproject.org

Drug Abuse Coverage Leaves Out the Science

How the media covers harm reduction.

Lewis Mehl-Madrona, a graduate of the Stanford University School of Medicine, recently wrote a piece for Futurehealth.org that zeroes in on a series of highly pertinent questions about the manner is which the America media tends to cover drug policy stories. Questions like: Why is the existence of credible scientific research rarely mentioned when drug controversies are in the headlines? Why does science not matter when it comes to the coverage of drug policy issues?

Mehl-Madrona cites the example of U.S. television coverage of Vancouver’s Insite project in Canada, which provides addicts with clean needles and a supervised injection room. Such “consumption rooms” are also available in Europe, and are being tried sporadically in the U.S. (See my earlier post on drug injection sites) Here is his reaction:

“The American TV was awash with criticisms of this policy, the primary one being that it promoted drug abuse and caused people to abuse drugs even more than they otherwise would. What amazed me was the complete lack of attention to data in the American media. Substantial research has been conducted on Insite and on harm reduction models. It is known that programs like Insite reduce the spread of HIV/AIDS and of hepatitis C and reduce drug overdose. No evidence exists to support its spreading drug abuse.”

One of the primary concerns raised by the media was whether the Insite facility would encourage addiction by making injections safer and easier. Yet a reliable study in the British Medical Journal showed no substantial increase in relapse or decrease in quit rates among a group of Insite users.

Another concern was that the Insite facility would discourage drug addicts from seeking treatment. However, a study published in the New England Journal of Medicine in 2006, involving more than 1,000 users of the facility, found that “individuals who used Insite at least weekly were 1.7 times more likely to enroll in a detox program than those who visited the centre less frequently,” according to Mehl-Madrona.

Moreover, the study confirmed that onsite addiction counselors were successfully increasing the number of addicts who signed up for detox. Rather than discouraging addicts from seeking treatment, the study confirmed that Insite was “facilitating entry into detoxification services among its clients.”

“I don't have an answer for why ideology trumps scientific evidence in the United States and its media” Mehl-Madrona writes. “Why are the opinions of ordinary people in cities across the United States considered more valid than three dozen rigorous scientific studies? Is this just the American way?”

Graphics Credit: http://abortmag.com

A Seaside Story of Love and Junkies

Documentary airs today on VBS.TV

A reminder that drug addiction is always, at bottom, about real people in the real world: The online video service VBS.TV is offering the first of a 6-part documentary on the underreported heroin epidemic in South Wales.

“Swansea Love Story,” according to its promoters, “follows the lives of a community of young heroin addicts living in an economically ravaged city of South Wales.”

Co-director Andy Kapper said in a press release: “I wanted to make this film because we were tired of seeing homeless young people being portrayed as little more than statistics. Documentaries about drug use often come out pious and fail to really get to know the people behind the drug usage. We wanted to show what it was like to live on the street, under the grip of heroin, as realistically as possible.”

The London Evening Standard called it “stunning, shocking, touching,  and deeply moving.”

I watched Part One. It's only seven minutes long, but it will sit you up straight.

Addicted to Bad Reporting

How should we cover drug dependence?

Journalists usually learn it early: Drug stories are crime stories. Articles about alcoholism and assorted “hard” drug addictions are typically sourced by law enforcement, and the frequently lurid results tend to dump recreational, illegal, and prescription drugs into the same stew.

This is a particular problem for patients on opioid substitution therapy, who take maintenance drugs such as methadone and buprenorphine (Suboxone). Both drugs are the subject of black markets the size of which is difficult to pin down, but the vast majority of users take the drugs under medical supervision in government-supervised health and social programs.

According to the World Health Organization (WHO), it is in everybody’s interest to get this straight. The U.N. agency reports that every dollar spent on drug treatment results in a savings of $7 in health and social costs. Treatment of opioid addiction with methadone or buprenorphine is now possible in 63 countries. “Substitution maintenance therapy is one of the most effective treatment options for opioid dependence,” says WHO. Such therapies reduce “heroin use, associated deaths, HIV risk behaviors and criminal activity.”

Nonetheless, the tendency among news writers to use phrases like “fake heroin,” “drug-using criminals,” and “giving drugs to drug users” led the International Harm Reduction Association (IHRA), with sponsorship from Schering-Plough, makers of the addiction treatment drug Suboxone, to suggest media reporting guidelines in a white paper issued earlier this year. In “Addicted to News: A Guide to Responsible Reporting on Opioid Dependence and its Treatment,” the authors reviewed 53 English-language articles about substitution therapy and discovered a continuing trend toward “sensationalist ‘tabloid’ stories’” leading to a “backlash against people with the condition, or an increase or exacerbation of the problem if it is glorified or publicized by a celebrity.”

Specifically, the IHRA identifies the following problems:

--Exaggerated terminology (“magic bullet,” “junkies,” “pharmaceutical narcotics”).

--Depiction of patients as criminals rather than people with a serious condition often requiring medical treatment.

--Undue emphasis on criminal activity related to substitution therapies.

--Assumption that the treatment has failed unless the patient is drug free.

--Portrayal of medical anti-craving drugs as indistinguishable from recreational drugs.

So what can a serious journalist do about it? IHRA is glad to provide some suggestions:

DO:

--Ask yourself, “what if this was me or someone close to me?’

--Use factual and correct terminology.

--Include balanced, up-to-date local statistics on treatment programs.

DON’T:

--Depend entirely on law enforcement as story sources.

--Use exaggerated or derogatory descriptions of patients in treatment.

--Try to localize a national or international story without close attention to its relevance to the local community.

--Allow celebrity news to warp the reporting of treatments available for this serious condition.

As the IHRA tirelessly points out, when patients are effectively treated, everybody benefits.

Graphics Credit: http://asp.cumc.columbia.edu

Heroin for Heroin Addiction

Getting your fix at the doctor’s office.

A group of Canadian researchers has demonstrated the truth of a practice commonly used in European countries like The Netherlands and Switzerland: Heroin can be an effective treatment for chronic, relapsing heroin addicts. Published in the New England Journal of Medicine, the study is “the first rigorous test of the approach performed in North America,” according to a New York Times article by Benedict Carey.

In the study, 226 patients were randomly assigned to oral methadone therapy or injectable diacetylmorphine, the primary active ingredient in heroin, over a 12-month period. The “rate of retention in addiction treatment” was 88 percent for the diacetylmorphine group, compared to 54 percent for the methadone group. The “reduction in rates of illicit-drug use” was 67 percent for the heroin group and 48 percent for the methadone group.

Using doctor-prescribed heroin has two advantages, some researchers believe. It gets around the problem of addicts who don’t like the effect of methadone and therefore don’t take it as prescribed. Moreover, as European countries have demonstrated, it brings treatment-resistant opiate addicts into regular contact with physicians and medical treatment professionals, thereby keeping them away from drug dealers and out of jail.

The downside is equally obvious. It keeps addicts hooked on heroin, and may even exacerbate their addiction by providing a higher quality drug. Furthermore, it runs against the prevailing North American notion that heroin should be illegal, period. Certainly, doctors have no business prescribing it to active addicts, critics argue. Furthermore, the risk of overdose or seizure is always present.

According to senior author Martin Schechter of the University of British Columbia’s School of Population and Public Health, as quoted in the New York Times: “The main finding is that for this group that is generally written off, both methadone and prescription heroin can provide real benefits.”

In an editorial accompanying the journal article, Virginia Berridge of the London School of Hygiene and Tropical Medicine cautioned that “the rise and fall of methods of treatment in this controversial area owe their rationale to evidence, but they also often owe more to the politics of the situation.”

At the end of the 19th Century in America, opium was widely prescribed as a cure for alcoholism. For opium addiction, the treatment was often alcohol.

Photo Credit: www.steps2rehab.com

addiction drugs

How Brain Science Began

Civilization’s debt to opium.

The history of brain science probably began about 4,000 B.C., somewhere in Sumeria, when human beings first discovered the extraordinary effects of the unripened seed pods of the poppy plant. Modern neuroscience owes a great debt of gratitude to this tame-looking plant drug and its sticky, incredibly potent byproduct called opium. Neuropharmacology—the study of the action of drugs on the nervous system—would never have advanced so quickly without it.

Historically, the emphasis has been on opium’s cash value, not its value to science. A trade staple on the Silk Route for centuries, opium was very nearly the perfect business. The present-day drug companies, known collectively as Big Pharma, are not the first capitalists in the world to exert an unprecedented grip on drug retailing.

From roughly 1720 to the late 1800s, the merchants of the British East India Company ran a brisk and lucrative opium business with the Oriental “heathens.” In 1839, the British went to war with China to maintain unlimited trading rights. The British won the war, retained the right to market opium in the Orient, and picked up the island of Hong Kong in the bargain.

Opium’s effects are concentrated at specific receptor sites, while alcohol’s range of action is more diffuse. Nonetheless, the two drugs have similar effects along the limbic reward pathway. Morphine comes right from the source, isolated from the crude opium resin found on Papaver somniferum—the opium poppy. Morphine is known as a “pure mu agonist,” meaning it locks securely into the “mu” subset of endorphin receptors, and activates them. This alters the transmission of pain messages, and induces a contented, euphoric state of relaxation. Codeine, another natural painkiller, is found in opium in very small concentrations. Most medical codeine is synthesized from morphine.

The body’s own opiates are referred to as endogenous opioids. Endorphins and enkephalins are interchangeable terms for these chains of amino acids. An important mechanism of action in this process is morphine’s inhibitive effect on GABA. By inhibiting the inhibitor, so to speak, neurotransmitter levels increase down the line, particularly in the nucleus accumbens. Hence, feelings of pleasure.

Alcohol stimulates the mu receptor as well, so we are back to the same basic chain of limbic activation triggered by drinking. GABA is the bridge that connects the alcohol high and the heroin high.

Rapid cellular tolerance is the hallmark of opiate addiction. Brain cells quickly become less responsive to the same doses of the drug. “The body’s natural enkephalins are not addicting because they are destroyed rapidly by peptide-degrading enzymes as soon as they act at opiate receptors,” writes Solomon Snyder. “Therefore, they are never in contact with receptors long enough to promote tolerance…. As analgesics, the enkephalin derivatives developed by drug companies have not been superior to morphine, or even as good as morphine.” Even the brain’s own morphine is not as good as morphine. Nothing is as good as morphine.

Recent evidence for the heritability of opiate addiction looks strong. “Harvard did some really superb studies using a huge cohort of military recruits in the U.S. Army,” according to Mary Jeanne Kreek, a specialist in opiate addiction at Rockefeller University in New York. “Heroin addiction has even a larger heritable component than any of the other addictions, so that up to 54% of heroin addictions seem to be on a genetic basis or a heritable basis.” Estimates of alcohol’s heritability generally run to 40 or 50 per cent.

--Excerpted from The Chemical Carousel: What Science Tells Us About Beating Addiction. (Spring 2009).

Heroin Overdose Kits: The Debate Goes On

More states back naloxone programs, but Feds aren’t convinced.

Since the first trial run in Chicago several years ago, efforts to provide heroin addicts with naloxone overdose kits has gained ground in Baltimore, New York, Boston, and several other cities and states. As reported here at Addiction Inbox last month, Dr. Peter Moyer, medical director of Boston’s fire, police and emergency services, applauded the recent Massachusetts decision to expand the Boston program to the entire state and offer Massachusetts heroin addicts the overdose reversal kit. Approved by the Food and Drug Administration (FDA) 35 years ago, Naloxone, or Narcan, is the standard emergency room treatment for heroin overdose. Naloxone instantly reverses life-threatening overdoses by crowding out heroin molecules at the brain receptor sites where they bind.

Predictably, the Office of National Drug Control Policy in the White House does not support the Massachusetts program. Drug Policy officials do not like the idea of addicts medically treating other addicts and have argued repeatedly against distribution of the naloxone kits, claiming that distributing the Narcan antidote will only encourage heroin use and delay treatment.

But the move among states and cities for direct naloxone distribution to addicts continues to gain momentum. In Baltimore, assistant commissioner of health Richard W. Matens maintains that the direct-to-addicts model had been “extremely successful” in his city. Death by heroin overdose reached its lowest level in a decade in 2005, and Matens says the naloxone distribution program played an important role in that reduction.

At the New York State Health Department, which oversees 20 naloxone distribution programs in New York City, Dan O’Connell told the New York Times (reg. required) that from a public health perspective, heroin overdose kits were “a no-brainer.” O’Connell, director of the department’s H.I.V. prevention division, said: “For someone who is experiencing an overdose, naloxone can be the difference between life and death.”

Wisconsin, Minnesota, Connecticut, New Mexico, Rhode Island, and several other states are also embarking on naloxone distribution programs. Thousands of lives are likely to be saved if the idea continues to gain ground.

So what could be the worm in the apple?

“It is not based on good scientific data,” contends Dr. Bertha Madras, deputy director with the White House Office of National Drug Control Policy, which continues its steadfast opposition to such programs. “It’s based on what some people would consider the right thing to do. But the studies supporting it are so sparse it’s painful.” As evidence, Madras and other federal substance abuse officials point to a survey of San Francisco drug addicts done in 2003, the year San Francisco first began funding naloxone distribution. About one-third of the addicts in the survey said they might use more heroin if they had naloxone to protect against overdose. “In the absence of scientific evidence,” Madras told the Times, “we don’t engage in policies that would bring more harm than benefit.”

However, a more recent survey of San Francisco addicts casts major doubt on those findings. In 2005, when the city began a trial program giving out two free needles loaded with naloxone, local officials claimed that fatal overdoses began to fall markedly, and city officials were soon claiming that heroin overdose deaths were at their lowest mark in ten years. California programs train addicts in the use and administration of naloxone. “I’m glad they’re showing us this stuff,” one addict said. “I don’t want to just sit there if someone ends up in a bad situation.”

According to figures reported by the Harm Reduction Coalition, 3,691 California drug users died of overdose in 2003, the latest year of official records. This represents an increase of 42 per cent since 1998, resulting in an annual death rate greater than that from firearms, homicides, and A.I.D.S.

But so far, states are on their own, as Federal drug policy officials continue to maintain that naloxone should only be prescribed and administered by doctors. And yet, many doctors refuse to treat heroin addicts, on the grounds that there is nothing that can be done for them, or that they are recalcitrant patients.

Dan Bigg, director of the Chicago Recovery Alliance, told the New York Times he has seen firsthand that such overdose kits are effective. “What we have here is an antidote to the problem [of heroin overdose],” Bigg said. “Now we just have to convince people it’s worth it.”

Naloxone and “Receptorology”

The power of the opiates revealed

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

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

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

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

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

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

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

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

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

Overdose Kits for Heroin Addicts

Massachusetts to offer Narcan nasal spray

Noting that heroin overdoses kill more people in Massachusetts each year than firearms, Dr. Peter Moyer, medical director of Boston’s fire, police and emergency services, applauded the state’s decision to offer addicts an overdose reversal kit. The package contains two nasal doses of naloxone, known as Narcan, a drug that reverses heroin overdose and saves uncounted lives (many victims of heroin overdose never see a hospital) when administered quickly enough. “It’s a remarkably safe drug,” said Dr. Moyer. “I’ve used gallons of it in my life to treat patients.”

Predictably, other health authorities aren’t so sure. “You give them the Narcan, where is their motivation to change?” said Michael Gimbel, director of substance abuse for Baltimore County, Maryland. “Giving Narcan might give them that false sense that ‘I can live forever,’ which is not what we want,” he told the Associated Press. Although similar programs have met with success in Chicago and New York City, the Massachusetts program is not supported by the Office of National Drug Control Policy in the White House. Drug Policy officials do not like the idea of addicts medically treating other addicts. Other officials argue against distribution of the kits, as they have frequently argued against needle distribution programs—in the belief that distributing the Narcan antidote will encourage heroin use and delay treatment for addicts.

Almost no one disputes the fact that heroin is currently popular throughout New England due to low prices and a surge in demand. “It’s the perfect storm in all the wrong directions. We talk about availability, price and potency,” said Kevin Norton of CAB Health & Recovery Services, one of the state-designated Narcan overdose kit providers.

The state-sponsored overdose kits were first tried in a pilot program in Boston, where Public Health Commissioner John Auerbach decided to go statewide after the kits were used to save 66 overdoses in the Boston area. “Narcan’s been around for a long time,” according to Cindy Champagne, director of nurses at the Greater New Bedford Community Health Center. Nonetheless, Champagne expressed some reservations about the drug “being out there for addicts to use,” noting its powerful effects and the rapid reversal of overdose, which leaves some addicts “combative.”

But Joanne Newton of the Seven Hills Behavioral Health Center of New Beford, another of the administrators of the program chosen by the Massachusetts Department of Public Health (DPH) cautioned that the program is carefully regulated, and will not increase the likelihood of addict overdoses. “There will be protocols and policies,” she said. “We’ll have to see what DPH’s plan is.”