The Future of Addiction Treatment

Is there some way out of here?

Addictions are chronic diseases. They may require a lifetime of treatment. After a number of severe episodes of alcohol or drug abuse, the brain may be organically primed for more of the same. Long-term treatment is sometimes, if not always, the most effective way out of this dilemma. (The same is true of unipolar depression.)

We will need to learn a lot more about chemicals—the ones we ingest, and the ones that are produced and stored naturally in our bodies—if we plan to make any serious moves toward more effective treatment. What we have learned about the nature of pleasure and reward is a strong start. The guiding insight behind most of the work is that addiction to different drugs involves reward and pleasure mechanisms common to them all. The effects of the drug—whether it makes you sleepy, stimulated, happy, talkative, or delusional—constitute a secondary phenomenon. A good deal of earlier research was directed at teasing out the customized peculiarities of one drug of abuse compared to another. Now most addiction scientists agree that receptor alterations in response to the artificial stimulation produced by the drugs are the biochemical key, and that recovery occurs when the brain’s remarkable “plastic” abilities go to work at the molecular level, re-regulating and adjusting to the new, drug-free or drug-reduced status quo. An addict beats addiction by ceasing the constant and artificial manipulation of neuronal receptors, to be entirely unromantic for a moment about the nature of recovery.

But in order for that to happen most effectively, you have to stop taking the drugs.

Comparing our reservoir of pleasure chemicals to money in the bank, Dr. George Koob, Chairman of the Committee On The Neurobiology Of Addictive Disorders at the Scripps Institute in La Jolla, California, draws the following analogy:

We can expend that money over the course of a single weekend’s binge on cocaine or we can expend it over a two-week period in the normal pleasures of everyday life. If you spend these pleasure neurochemicals in one lump sum such as a crack binge, you use up your supply of pleasure for a certain period, and so you pay for it later.

Addicts vividly demonstrate a compulsive need to use alcohol and other drugs despite the worst kinds of consequences—arrest, illness, injury, overdose. What kind of euphoria could be worth such psychic pain? Even stranger, why continue when the drug no longers works as well as it once did due to tolerance? What makes these people eat their words, shred their best intentions, break their promises, and starting using or drinking again and again?

There really is no cheating in this game. The system has to self-regulate. Craving and drug-seeking behavior, once set in motion, disrupt an individual’s normal “motivational hierarchy.” How does this motivational express train come about? It happens at the point where casual experimentation is replaced by the pharmacological dictates of active addiction. It happens when the impulse to try it with your friends transforms itself into the drug-hungry monkey on your back.

 Formal medical treatment and intervention can work, but the results are inconsistent and often little better than no formal treatment at all. Most alcoholics and smokers and other drug addicts, it is frequently asserted, become abstinent on their own, going through detoxification, withdrawal, and subsequent cravings without benefit of any formal programs. Our health policy should not only encourage addicts to heal themselves, but must also help equip them with the medical tools they need in treatment. After all, behavioral habits as relatively harmless as nail biting can be all but impossible to break.

 As detailed by Dr. Mary Jeanne Kreek, a professor and senior attending physician at the Laboratory of the Biology of Addictive Diseases at Rockefeller University:

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. Sometimes medications work, and we all need to reacquaint ourselves with that notion. As more of the biological substrate is teased out, the search for effective medications narrows along more fruitful avenues. This is the most promising, and, without doubt, the most controversial development in the history of addiction treatment.

Fighting fire with fire is not without risk, of course. None of this is meant to deny the usefulness of talk therapy as an adjunct to treatment.  However, consider the risks involved in not finding more effective medical treatments. Better addiction treatment is, by almost any measure, a cost-effective proposition.

Photo: http://www.manorhouserehab.com/

The Strange and Secret Keeley Cure for Addiction

“Drunkenness is a disease and I can cure it.”

In America in the late 1800s, curing alcoholism was a serious business—and for Dr. Leslie Keeley, a very lucrative one. Dozens of clinics and cures already existed, and some treatment centers had even experimented with franchising. For the late 19th Century alcoholic in search of treatment, what most of them had on offer was either outright patent medicine fraud, or else well intentioned if ultimately misguided “opium” cures. None of them, writes William L. White in Slaying the Dragon, “was more famous, more geographically dispersed, more widely utilized, and more controversial than Leslie Keeley’s Double Chloride of Gold Cure for the treatment of alcoholism, drug addiction, and the tobacco habit.”

The Irish-born Dr. Keeley served as a surgeon in the Civil War, and, as family lore would have it, started a treatment program for alcoholism in a Union hospital during the war. We do know that in 1879, he opened the first Keeley Institute in Dwight, Illinois, south of Chicago. His sales pitches were colorful and varied, but boiled down to this pledge: “Drunkenness is a disease and I can cure it.” He could cure it with a secret, specific formula, injected four times daily, about which all he would hint publically was that it contained, as one of its ingredients, gold. This was not so outlandish as it may seem. Gold, silver, strychnine, and other potentially poisonous ingredients were already employed in dozens of standard medicines—and, in many cases, still are. But everything else about Dr. Keeley’s magic elixir was as secret as the ingredients in Coke.

Nonetheless, something seemed to be working. He claimed an outlandish 95% success rate, bolstered by legions of enthusiastic followers who formed proto-AA groups with the catchy title of Bi-Chloride of Gold Clubs, better known as the Keeley Leagues. And Keeley himself employed the largest collection of formerly addicted doctors in the known world. There were no counselors at Keeley clinics. There were enough doctors on staff to go around, even though an estimated total of half a million alcoholics and other addicts eventually took the Keeley Cure.

Treatment consisted of the infamous injections, a liquid cordial every two hours, and, according to White, the following modalities: “daily rest, nutrition, mutual sharing, and alternative diversions worked to improve the patient’s physical and psychological health.” We can assume, from this regimen, that some alcoholics and addicts probably improved, regardless of what was in the medicine. And there was the frequent suggestion that, really, it was probably best not to ask too many questions about what was in the medicine, anyway.

“The atmosphere was informal and friendly at the clinics,” White writes, “with a marked absence of the bars and restraints that were typical in most inebriate asylums of the period.” There were, of course, some very vocal detractors. Dr. T. D. Crothers, a leader in the inebriate asylum movement, said: “There is no gold cure for inebriety. There are no facts to show that gold has any value in this disease. All the assertions and statements concerning gold as a remedy are delusions, and will not bear the test of critical examination.”  Perhaps not. But success was success, and soon, the marketplace saw the introduction of Dr. Haines Golden Remedy, the Geneva Gold Cure, the Boston Bichloride of Gold Company, and many other knockoffs. (Keeley proclaimed that his Double Chloride of Gold cured all forms of inebriety by “speeding up the restoration of poisoned cells to their pre-poisoned condition.”)

From 1892 through 1900, the Keeley Company pulled in almost $3 million, including mail-order business. There was a Keeley Day at the 1893 World’s Fair in Chicago. Here is an excerpt from the pamphlet, “To the Keeley Graduate,” given to every patient who completed treatment:

You are now numbered among thousands of men and women who have broken the shackles of alcohol and drug addictions by the Keeley method of treatment. Your cure will be as permanent as your life, you will never have any craving for alcohol or other sedative drugs as long as you live, unless you create it by returning to their use, thus re-poisoning your nerve cells.

But by 1900, the bloom was off the Keeley miracle, as insiders fought for financial control, and congressional investigators looked into the affairs of Keeley League president Andrew J. Smith.

Of course, if Keeley had really possessed a specific, replicable formula that took away the craving for alcohol, it would have been monstrously unethical to hold it a secret. And he was constantly accused of using harmful ingredients, such as codeine, strychnine, and cocaine in his magic injections.

Keeley wouldn’t say. And neither did any of his heirs or business partners. The only thing most court records agree on is that the injection didn’t contain any gold—too many possible side effects. According to the testimony of Keeley’s original business partner, “The only patient who ever received Keeley medicine that actually had gold in it almost died.”

The secret ingredient was probably atropine—a powerful compound belonging to a very weird family of plant drugs known collectively as “anticholinergenic deliriants.”  Atropine is the active ingredient in Belladonna, aka Deadly Nightshade. Along with mandrake, henbane, and jimsonweed, the so-called Belladonna alkaloids are among the primary hallucinatory ingredients found in many a witch’s and sorcerer’s brew throughout the ages. Belladonna can cause terrifying hallucinations, feelings of flight or paralysis, blurred vision, impaired motor control, and other side effects usually experienced as highly unpleasant. It was likely Belladonna, not LSD, that served as the basic rocket fuel for the Manson’s family’s horrific activities, according to some accounts. More mundanely, atropine is familiar to armed forces personnel in the form of a self-injection device for serious wounds. Atropine has the ability to speed up a slowing or overworked heart. In ancient times, it was used as an anesthetic for surgery. Atropine is also a poison. (Scopolamine, used medically for motion sickness, is another.)

But one person’s unpleasant side effect is another’s chemical cure. Did the Keeley concoction just terrify the bejesus out of addicts, as some sort of ad hoc version of aversive therapy, or did it sedate his patients into a semi-catatonic, immobile haze, in which they could pass 3 weeks of detox in relative comfort, or at least immobility and minimal disruption? Probably both, depending on drug dosage, drug combination, and patient metabolism. There were widespread reports of Keeley patients who allegedly died or went insane.

“The pulp image of Dr. Leslie Keeley—that of the country physician who had stumbled onto a revolutionary cure for the inebriety problem that had stumped the best medical scientists,” was key to his success, White believes. “Keeley introduced an approach that carried an aura of scientific truth and all the emotional support and intensity of a revival meeting.”

“The likely ingredients of the Double Chloride of Gold remedy and tonics—alcohol, atropine, strychnia, apomorphine —did aid detoxification,” White concludes. And the graduation pamphlet went on to emphasize the importance of “sustaining the new Keeley habits: regular patterns of sleep, regular and balanced meals, regular consumption of water, abstinence from tobacco and caffeinated drinks, healthy recreation, and care in the selection of personal associates.”

If you skip the atropine injections, that series of admonitions remains the bedrock of drug and alcohol treatment programs everywhere.

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

Food Addiction

Carbohydrates on the Brain, Food Rehab in the Future

Earlier this month, Yale University hosted the first-ever conference on Food and Addiction. Dr. Nora Volkow of the National Institute on Drug Abuse told the collection of experts on nutrition, obesity and drug addiction that “commonalities in the brain’s reward mechanisms” linked compulsive eating with addictive drug use. “Impaired function of the brain dopamine system could make some people more vulnerable to compulsive eating,” Volkow said.

Moreover, animal studies and brain imaging research in humans strongly support the notion of food addiction. In particular, research has pointed toward a form of food addiction known as “carbohydrate-craving obesity.” Dr. Mark Gold, chief of addiction studies at the McKnight Institute at the University of Florida, and a well-known authority on cocaine abuse, argued that “failed diets and attempts to control overeating, preoccupation with food and eating, shame, anger, and guilt look like traditional addictions.”

Conference organizer Kelly Brownell, director of the Rudd Center for Food Policy and Obesity at Yale, conceded that “it wasn’t obesity experts who got interested in addiction, it was the addiction scientists who got interested in food.” Brownell suggested that psychologists have been slower to grasp the import of food addiction “in part because of a bias that obesity is all about failure and personal responsibility, so why look at biology?”

As Dr. Gold summed it up, “It turns out that food and drugs compete for the same reward system in the brain.”

SOURCES:

--“Yale Hosts Historic Conference on Food and Addiction.” Yale University Office of Public Affairs. July 9, 2007. http://www.yale.edu/opa/newsr/07-07-09-01.all.html

--Hellmich, Nancy. “Does food ‘addiction’ explain explosion of obesity?” USA Today, July 9, 2007.

--“Yale Hosts Historic Conference on Food Addiction.” Medical News Today. 11 July 2007. www.medicalnewstoday.com

--Hathaway, William. “Experts Chew Over Eating as Addiction.” The Hartford Courant. July 11, 2007. http://www.courant.com/news/health

What's Wrong With This Picture?

A bit of cognitive dissonance, perhaps?

The situation could easily be reversed, but cigarette manufacturers mostly advertise in magazines, not newspapers. Otherwise, we might be reading about the dangers of consuming too much alcohol in casinos, while looking at an ad for a new brand of cigarettes.

European Tree Yields New Alcoholism Treatment in Early Tests

Anti-Smoking Drug Also Curbs Alcohol Craving

A drug approved last year for smoking cessation has also shown promise for use against alcoholism, researchers at the University of California, San Francisco (UCSF), announced yesterday.

Varenicline, currently marketed by Pfizer for smoking cessation under the trade name Chantix, dramatically curbed drinking in alcohol-preferring rats, according to the study, which will be published online this week by “The Proceedings of the National Academy of Sciences.”

The synthetic drug was modeled after a cytosine compound from the European Labumum tree, combined with an alkaloid from the poppy plant.

Since an estimated 85 per cent of alcoholics are also cigarette smokers, varenicline could have an immediate effect on this common dual addiction. The drug has already been approved by the Food and Drug Administration (FDA) for human use, so Pfizer is likely to be granted a speedy approval for the new indication, sources say. The drug is likely to join Antabuse (disulfiram), Revia (naltrexone), and Campral (acamprosate) as FDA-approved treatments for alcoholism.

Selena Bartlett of the UCSF-affiliated Gallo Clinic and Research Center, a co-author of the study, said that the drug works by disrupting the neuronal “reward pathway” of the brain. Specifically, the drug binds to acetylcholine receptors, a neurotransmitter involved in arousal and attention. Through a cascade effect, stimulating these receptors causes a release of dopamine, one of the primary pleasure chemicals in the brain. Varenicline prevents alcohol and nicotine from causing a release of dopamine at those sites.

“Treatments for alcoholism today are like those for schizophrenia in the ‘60s,” Bartlett said. “People don’t talk about it. There are very few treatments, and most drug companies are not interested in it.”

Bartlett said she hoped the research would spur additional studies of drugs for alcoholism. “It’s a disease. If you’ve inherited a gene variant, of if some other cause leads you to alcohol dependence, it should be treated--like any disease.”

Sources:

“Drug to curb smoking also cuts alcohol dependence.” University of California, San Francisco, News Office. 09 July 2007. http://pub.ucsf.edu/newsservices/releases/200707063/

“Need a Cigarette and a Cocktail? Just Pop a Pill Instead.” ScientificAmerican.com July 09, 2007

Fearing Medicine

By Dirk Hanson

Have Americans become afraid of their doctors?

Once upon a time, Americans went to their doctors to get pills. Doctors complained that patients believed competent medical care consisted of being handed a prescription. In the absence of that piece of paper with the unintelligible signature, a patient was apt to claim that the doctor’s visit had been a waste of time. What was the point of seeing a doctor if the doctor didn’t give you anything that would cure what ailed you?

That was then. Patients now demand that doctors and pill makers come clean about the safety of the products they offer (long overdue), and that the pills themselves be absolutely benign in their effects (utterly impossible). In ever-greater numbers, Americans are coming to fear prescription drugs. This condition, in extremis, is a phobia with a recognized set of diagnostic criteria: pharmacophobia—an abnormal fear of medicine.

Today, Americans go to their doctors to be healthy and “drug-free.” If they are taking prescription medications, their goal is to get off them. Yesterday, patients demanded pills for conditions they didn’t have, or for which pills were ineffective. Today, patients are routinely filing lawsuits, demanding to know why their doctor gave them pills. Ironically, one of the major hindrances to health care, from a doctor’s point of view, is “patient non-compliance”—sick people often don’t take their pills properly. (This may be a good place to note that I do not work for, or with, or against Big Pharma, as the drug companies are now called. I don’t work for anybody.)

The drug industry, one of the most tightly regulated industries in America, is the kind of corporate villain Americans understand. What particularly rankles many critics is that the drug companies advertise.

“Presumably,” Joseph Davis concedes in his jeremiad against drug advertising in the journal Hedgehog Review, “some percentage of those who identify their face and their feelings with those signified in the ads actually suffer from a debilitating condition. So much to the good.”

But of little significance, it seems. The central issue for Davis is: What if people who don’t need those pills are exposed to those ads? Normal people might think they need those pills—and they don’t! And very soon, as you can easily see, you’ve got trouble in River City. In the same issue of Hedgehog Review, biomedical ethics professor Leigh Turner professes similar shock, recounting with indignation “a world where a host of marketing strategies are used to package tidy, authoritative, and often profoundly misleading claims” about the safety and effectiveness of products. You can imagine how I felt when I learned that commercial advertisers were capable of doing that.

For lack of a better term, we will have to settle for calling it the real world, where soap, life insurance, housing, cars, psychiatric care, and legal advice are all marketed in misleading ways, to people who don’t always need them. And so it is with pills. However, where once patients desired this, they now resent the offer. Writing in the May 2007 issue of Harper’s, Gary Greenberg declares that “Under the agreement we’ve made—that they are doctors, that I am sick, that I must turn myself over to them so they can cure me—the medicine must be treated with the reverence due a communion wafer.”

Previously, patients wanted their communion wafers, and doctors were often accused of withholding them. Now, as Greenberg makes clear, patients fear doctors will drag them to the altar and force the holy wafers down their throats. One cannot help wondering what manner of pact Greenberg would like to arrive at with his treating physicians. His approach does not seem like a particularly promising step forward in doctor-patient relations.

Interestingly, Americans have shown little interest in a thorough examination of the adverse side effects of non-pharmaceutical approaches to health. Talk therapists and holistic practitioners of every stripe operate in a virtually regulation-free environment. Where, for example, can one find a list of common side effects associated with the practice of various forms of psychotherapy, from post-Freudian talk therapy to, say, the increasingly popular varieties of cognitive therapy? Where, I would like to know, is the list of unwanted side effects that can occur as the result of an on-air encounter with that manipulative bruiser, Dr. Phil?

Science writer Sharon Begley, in a June 18 Time column entitled “Get Shrunk at Your Own Risk,” declares: “What few patients seeking psychotherapy know is that talking can be dangerous, too—and therapists have not exactly rushed to tell them so.”

Among many other examples, Begley reminds us of the “recovered memory” therapies that tore families apart and sent innocent people to prison for the alleged sexual abuse of children. And “stress debriefing,” a method of re-experiencing traumatic events in an effort to eliminate Post Traumatic Stress Disorder, sometimes leads to increased stress and higher levels of anxiety, compared to PTSD victims who do not undergo such therapy. I’ll privilege an upset stomach and occasional loose stools from pills over that kind of deep-seated trauma any day.

Begley also cites a 2000 study of professional grief counseling which concluded that four out of ten people grieving for the death of a loved one through formal therapy would have been better off with no therapy at all. Compared to a control group, 40 per cent of mourners in professional therapy experienced increased depression and grief. (In some cases, the most benign contraindication is when the treatment doesn’t do anything at all.)

The side effects associated with talk therapies remain shrouded in mystery. “The number of people undergoing potentially risky therapies reaches into the tens of thousands,” Begley concludes. “Vioxx was yanked from the market for less.”

Does AA Work?

Bill W., co-founder of AA








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


Despite recent progress in the medical understanding of addictive disease, the amateur self-help group known as Alcoholics Anonymous, and its affiliate, Narcotics Anonymous, are still regarded by many as the most effective mode of treatment for the ex-addict who is serious about keeping his or her disease in remission. A.A. and N.A. now accept anyone who is chemically dependent on any addictive drug—those battles are history. In today’s A.A. and N.A., an addict is an addict. A pragmatic recognition of pan-addiction makes a hash of strict categories, anyway.

Nonetheless, under the biochemical paradigm of addiction, we have to ask whether the common A.A.-style of group rehabilitation, and its broader expression in the institutionalized form of the Minnesota Model, are nothing more than brainwashing combined with a covert pitch for some of that old-time religion. As Dr. Arnold Ludwig has phrased it, “Why should alcoholism, unlike any other ‘disease,’ be regarded as relatively immune to medical or psychiatric intervention and require, as AA principles insist, a personal relationship with a Higher Power as an essential element for recovery?”

The notion is reminiscent of earlier moralistic approaches to the problem, often couched in strictly religious terms. It conjures up the approach sometimes taken by fundamentalist Christians, in which a conversion experience in the name of Jesus is considered the only possible route to rehabilitation. But if all this is so, why do so many of the hardest of hard scientists in the field continue to recommend A.A. meetings as part of treatment? Desperation? Even researchers and therapists who don’t particularly like anything about the A.A. program often reluctantly recommend it, in the absence of any cheap alternatives.

In 1939, Bill Wilson and the fellowship of non-drinkers that had coalesced around him published the basic textbook of the movement, Alcoholics Anonymous. The book retailed for $3.50, a bit steep for the times, so Bill W. compensated by having it printed on the thickest paper available—hence its nickname, the “Big Book.” The foreword to the first printing stated: “We are not an organization in the conventional sense of the word. There are no fees or dues whatsoever. The only requirement for membership is an honest desire to stop drinking. We are not allied with any particular faith, sect or denomination, nor do we oppose anyone. We simply wish to be helpful to those who are afflicted.”

In short, it sounded like a recipe for complete disaster: naive, hopeful, objective, beyond politics, burdened with an anarchical structure, no official record
keeping, and a membership composed of anonymous, first-name-only alcoholics.
......................
Amid dozens of case histories of alcoholics, the Big Book contained the original Twelve Steps toward physical and spiritual recovery. There are also Twelve Traditions, the fourth one being, “Each group should be autonomous except in matters affecting other groups or A.A. as a whole.” As elaborated upon in Twelve Steps and Twelve Traditions, “There would be real danger should we commence to call some groups ‘wet’ or ‘dry,’ still others ‘Republican’ or ‘Communist’…. Sobriety had to be its sole objective. In all other respects there was perfect freedom of will and action. Every group had the right to be wrong. The unofficial Rule #62 was: “Don’t take yourself too damn seriously!”

As a well-known celebrity in A.A. put it: “In Bill W.’s last talk, he was asked what the most important aspect of the program was, and he said it was the principle of anonymity. It’s the spiritual foundation.” Co-founder Dr. Bob, for his part, believed the essence of the Twelve Steps could be distilled into two words—“love” and “service.” This clearly links the central thrust of A.A. to religious and mystical practices, although it is easily viewed in strictly secular terms, too.

Alcoholics Anonymous recounts a conversation “our friend” had with Dr. C.G. Jung. Once in a while, Jung wrote, “…alcoholics have had what are called vital spiritual experiences…. They appear to be in the nature of huge emotional displacements and rearrangements.” As stated in Twelve Steps and Twelve Traditions, “Nearly every serious emotional problem can be seen as a case of misdirected instinct. When that happens, our great natural assets, the instincts, have turned into physical and mental liabilities.”

Alcoholics Anonymous asserts that there are times when the addict “has no effective mental defense” against that first drink.

Bill Wilson wrote:
"Some strongly object to the A.A. position that alcoholism is an illness. This concept, they feel, removes moral responsibility from alcoholics. As any A.A. knows, this is far from true. We do not use the concept of sickness to absolve our members from responsibility. On the contrary, we use the fact of fatal illness to clamp the heaviest kind of moral obligation onto the sufferer, the obligation to use A.A.’s Twelve Steps to get well."

This excruciating state of moral and physical sickness—this “incomprehensible demoralization”—is known in A.A. as hitting bottom. “Why is it,” asks Dr. Arnold Ludwig, “that reasonably intelligent men and women remain relatively immune to reason and good advice and only choose to quit drinking when they absolutely must, after so much damage has been wrought? What is there about alcoholism, unlike any other ‘disease’ in medicine except certain drug addictions, that makes being in extremis represent a potentially favorable sign for cure?”

Hitting bottom may come in the form of a wrecked car, a wrecked marriage, a jail term, or simple the inexorable buildup of the solo burden of drug-seeking behavior. While the intrinsically spiritual component of the A.A. program would seem to be inconsistent with the emerging biochemical models of addiction, recall that A.A.’s basic premise has always been that alcoholism and drug addiction are diseases of the body and obsessions of the mind.

When the shocking moment arrives, and the addict hits bottom, he or she enters a “sweetly reasonable” and “softened up” state of mind, as A.A. founder Bill Wilson expressed it. Arnold Ludwig calls this the state of “therapeutic surrender.” It is crucial to everything that follows. It is the stage in their lives when addicts are prepared to consider, if only as a highly disturbing hypothesis, that they have become powerless over their use of addictive drugs. In that sense, their lives have become unmanageable. They have lost control.

A.A.’s contention that there is a power greater than the self can be seen in cybernetic terms—that is to stay, in strictly secular terms. The higher power referred to in A.A. may simply turn out to be the complex dynamics of directed group interaction, i.e., the group as a whole. It is a recognition of holistic processes beyond a single individual—the power of the many over and against the power of one.

“The unit of survival—either in ethics or in evolution—is not the organism or the species,” wrote anthropologist Gregory Bateson, “but the largest system or ‘power’ within which the creature lives.” In behavioral terms, A.A. enshrines this sophisticated understanding as a first principle.

alcoholics anonymous

Vaccinating Against Vices

Developing a pill or a vaccine for a specific drug addiction has long been one of the tantalizing potential rewards of addiction research. Now a company in Florida has garnered national attention, a spate of clinical trails, and a positive response from the National Institute on Drug Abuse (NIDA) with a compound called NicVAX, aimed at nicotine addiction. In addition, Celtic Pharma in Bermuda is working on a similar product for cocaine addiction.

The idea of vaccinating for addictions is not new. If you want the body to recognize a heroin molecule as a foe rather than a friend, one strategy is to attach heroin molecules to a foreign body--commonly a protein which the body ordinarily rejects--in order to switch on the body’s immune responses against the invader. The idea of a vaccine for cocaine, for example, is that the body’s immune system will crank out antibodies to the cocaine vaccination, preventing the user from getting high. A strong advantage to this approach, say NIDA researchers, is that the vaccinated compound does not enter the brain and therefore is free of neurological side effects.

Preliminary research at the University of Minnesota showed that a dose of vaccine plus booster shots markedly reduce the amount of nicotine that reaches the brain. Animal studies have shown the same effect. NicVAX, from Nabi Biopharmaceuticals, consists of nicotine molecules attached to a protein found in a species of infectious bacteria. When smokers light up, antibodies attack the protein-laden nicotine molecules, which, further encumbered by these antibodies, can no longer fit through the blood-brain barrier and allow the user to enjoy his smoke.

That, at least, is the idea. It is a difficult and expensive proposition, the closest thing to a miracle drug for addiction, but it does not specifically attack drug craving in addicted users. The idea of vaccination is that, once a drug user cannot get high on his or her drug of choice, the user will lose interest in the drug.

This assertion is somewhat speculative, in that users of the classic negative reinforcer, Antabuse, have found ways to circumvent its effects--primarily by not taking it. There remain a wealth of questions related to the effects of long-lasting antibodies. And it is sometimes possible to “swamp” the vaccine by ingesting four or five times as much cocaine or nicotine as usual.

Drugs that substantially reduce the addict’s craving may yet prove to be a more fruitful avenue of investigation. While several anti-craving medications have been approved for use by the Food and Drug Administraton (FDA), no vaccines have made it onto the approved least yet.

For more on pharmaceutical approaches to fighting drug addiction, see my website at http://www.dirkhanson.org