Addiction: The First Taste

From the introduction to The Chemical Carousel.

It was the late 1980s, and the “Decade of the Brain,” sponsored by the National Institute of Mental Health (NIMH) and the Library of Congress, was still a few years away. I was sitting in a Clement Street diner in San Francisco, reading a book called The Hidden Addiction, by a Seattle M.D. named Janice Keller Phelps, and trying to understand why I could not stop drinking. Dr. Phelps was saying that most of what I thought I knew about alcoholism and other addictions was completely wrong.

Years earlier, I had written a nonfiction book about the rise of Silicon Valley, so I was under no illusions about the scientific learning curve involved in writing a book about the dawn of addiction medicine. But I had the means and the motivation: a background as a science and technology journalist, and a solid addiction to alcohol and cigarettes.

We’re in Junior High, Randy and I, and it’s the weekend. We’re staying at Randy’s, after a successful performance at a state swimming meet, and Randy’s parent’s are out for the night. A typical sleepover, stupid movies and all the cokes you can drink.

But this Saturday night turned out differently, and to this day I can’t really say why. I remember Randy showing me his dad’s stash of liquor bottles underneath the kitchen sink, and us laughing about it, and what would you pick, Scotch or Gin, and what the hell was Vermouth?

Amazingly, I don’t recall what we picked, or exactly how much of it we drank. I remember that it went down okay, with the usual spluttering, and it was giggly and light-headed and fun.

And then, in my memory, a long, blurred period of time passing, and a sense of coming back into my body on a bed I did not recognize, face turned to the wall, Randy moaning quietly beside me. It was a sort of rolling blackout, sweet oblivion, the only one I have ever experienced. Suspended in time, as lost to ordinary chronology as I have ever been, before or since. And strangely, for all the drinking to come, I was never a blackout drinker again. No lost weekends, and no lost cars, dude.

“Come on,” I remember saying to my friend, as I came unsteadily to consciousness on the rocking bed, “let’s go have some more.” Unbelievable. Randy and I had already drunk ourselves into a stupor.

Let’s have some more. Good idea.

And then Randy saying, “Hi, mom,” in the way you say it when you’re trying to freak out your buddy and there’s nobody really there, like looking over his shoulder and pretending to see somebody when your buddy is copping a quick piss in the bushes, and saying in a deep voice, “Hi there, sir, how’s it going?” Just to watch him fumble with his zipper in a panic. So I roll over on the bed toward Randy, saying “Yeah, right, Randy, like I’m falling for that,” and in that instant seeing Randy’s mom standing speechless in the doorway of what turned out to be the master bedroom. Staring at us with shock. Or maybe I was the one who went into shock, as I remember very little of the rest of it. At some point Randy’s mother called my mother, naturally, despite my fervent prayers designed to produce an intercession, and my dad drove over and took me home, where I fell asleep (it was Saturday) for most of the day. I woke up feeling like hammered dogshit, as they say. My father was sitting in a chair in my bedroom. “Well,” he said, when I was as awake as I was going to get, “did you learn anything from this?”

Years later, I came across a study in the Archives of Pediatrics and Adolescent Medicine—“Age at Drinking Onset and Alcohol Dependence.” The conclusion of this cross-sectional survey of more than 43,000 adults was stark and straightforward: “Relative to respondents who began drinking at 21 years or older, those who began drinking before age 14 years were more likely to experience alcohol dependence ever and within 10 years of first drinking.”

Randy and I were 13 years old.

--Dirk Hanson

addiction drugs alcoholics anonymous smoking

Bulimia: What To Look For [Guest Post]

Signs and symptoms of a dangerous disorder.

[Today’s guest post was contributed by Heidi Taylor. I include it here as part of a continuing series of guest posts having to do with the so-called “lifestyle addictions,” such as perceived addictions to gambling, sex, video games, or shopping—areas in which I can claim no special expertise, and diagnoses which remain controversial among addiction researchers. However, I do strongly believe that the case has been made for the addictive nature of certain eating disorders—bulimia and carbohydrate-craving obesity in particular—in which the ingested substance is food, not “drugs” as we commonly think of them. Eating is one of the most obvious ways in which we alter the neurochemistry of our brains every day. As for treatment, serotonin abnormalities are believed to be the culprit. Many bulimics improve on SSRI antidepressants.]
--Dirk Hanson

Detecting Bulimia in a Loved One

It’s not a disease that’s visible at first or even second sight, but even so, it is one that’s largely ignored and left untreated more because most people are not even aware of its existence. But bulimia, or to be exact, bulimia nervosa is an eating disorder that could end up having physical, psychological and sociological consequences that are hard to digest. Bulimics tend to eat more than they should – in fact, they gorge on food – and then force themselves to throw up using emetics, visit the toilet with laxatives, or go without food for the next day or so. In short, they compensate for their over-eating in ways that are neither healthy nor advisable.

While it may not seem like a dangerous disorder, bulimia can have devastating consequences if left unchecked – people affected are prone to suffer from an inflamed throat and neck glands, a torn esophagus, decaying and unhealthy teeth, acid reflux disorder, ruptured intestines, irritable bowels, dehydration and malfunctioning kidneys. Besides these physical symptoms, they’re also going to be obsessed with their weight, suffer from depression and anxiety, and face other mental and social problems. So if you suspect a loved one may be bulimic, here are a few symptoms that will help you detect the disorder and get them professional help as soon as possible:

• Eating more than the normal amount possible in a single meal or over the course of a few meals.
• Frequent visits to the toilet after a meal.
• A washed out and drained look that happens because they’re dehydrated and their body is low in minerals from all the purging and use of laxatives.
• Mood swings that seem to come on for no apparent reason.
• Sores in the mouth and/or on their fingers (because they may be sticking it in their throats to induce vomiting).
• Inflamed throats and bad teeth.
• Bouts of depression or uncalled for anxiety attacks.
• Exercising for a long time, at odd hours of the day and being obsessed with the way they look.
• It’s the women and the teenagers who are more susceptible to this disorder because of their obsession with their weight and the way they look. So if you have a daughter or a close female friend or relative who acts in a way that points suspicion to bulimia, talk to them and get them much-needed medical intervention before the situation worsens.

Even if you just suspect bulimia and are not really sure, you’d do well to talk to the person concerned and get them to see a doctor who can help. Remember, it may sound like a minor thing, but bulimia is a very serious disorder.
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This post was contributed by Heidi Taylor, who writes about the Masters in Healthcare. She welcomes your feedback at HeidiLTaylor006 at gmail.com

Graphics Credit: Graham Menzies Foundation

Phish Front Man Backs Drug Courts

Trey tells Congress about his addiction.

Trey Anastasio, lead guitarist and singer with the recently reunited rock band Phish, testified before Congress that drug courts may have saved his life. Without drug courts, he said, there might not have been a Phish reunion tour. Their lead guitarist might have been dead or in jail.

“My name is Trey Anastasio, and I’m a recovering alcoholic and a proud graduate of the Washington drug court program,” the musician testified, according to a Huffington Post report by Ryan Grim. “My life had become a catastrophe. I had no idea how to turn it around. My band had broken up. I had almost lost my family. My whole life had devolved into a disaster. I believe that the police officer who stopped me at three a.m. that morning saved my life.”

Anastasio, on behalf of the National Association of Drug Court Professionals (NADCP), called for drug courts as an alternative to prison for every American in need. Participants in drug courts receive mandated addiction treatment and other services, while submitting to regular drug tests. Those who fail their drug tests spend time in prison. Moreover, participants appear regularly before a specially trained judge to access their progress. A system of rewards and sanctions, plus treatment, replaces a lengthy jail sentence and little hope for effective treatment while imprisoned.

In the past, while supporting the concept, Congress has made only meager sums available for the establishment of drug courts. “I would like every community in America to have the option of sentencing drug offenders to drug court,” Anastasio told members of Congress. “When we imprison people for minor drug offences, we waste money—and we waste lives. Prison will turn a person with a substance abuse problem into a lifetime felon.”

According to NADCP chief executive officer West Huddleston, “The scientific community has put drug courts under the microscope and concluded that drug courts significantly reduce drug abuse and crime and do so at less expense than any other justice strategy.”

Anastasio, who spend more than a year in drug court, told the congressional assembly that he had been sober for two and half years. “In August, my wife and I will celebrate our fifteenth wedding anniversary. My band is back together with a sold-out tour. And in September I’ll play a solo concert at Carnegie Hall with the New York Philharmonic.”

Photo Credit: WPT

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Acupuncture for Addiction: It Doesn't Look Good

Needles fail in latest study of opiate detox.

Acupuncture as a treatment for drug addiction took another punch recently in a study published in the Journal of Substance Abuse Treatment. In “Auricular acupuncture as an adjunct to opiate detoxification treatment,” the study authors investigated whether acupuncture would “add value” to a standard methadone-based detoxification process. For the two-week study, 82 opiate-addicted patients were randomly assigned to either ear acupuncture by qualified acupuncturists, or the attachment of ear clips by non-professionals. Each day, the study participants were tested for withdrawal severity and craving.

"On none of the 14 days,” the authors report, “were there statistically significant differences between patients allocated to ‘real’ acupuncture and the ‘sham’ treatment. Such statistically insignificant difference as there were favored the ‘sham’ treatment....”

The results, say the authors, “are consistent with the findings of other studies which failed to find any effect of acupuncture in the treatment of drug dependence.” Moreover, the authors conclude, this finding is “particularly disappointing as if anything the circumstances favored the acupuncture option,” since in contrast “the alternative may not have been seen as a convincing therapy.” Nevertheless, “like the featured study, previous studies of acupuncture in the treatment of opiate addiction have been unconvincing.... The ‘ineffective’ verdict on acupuncture extends to the treatment of cocaine dependence,” the authors maintain, while an attempt to replicate earlier positive findings on acupuncture for alcohol dependence found no benefits, either.

The authors also reflect on whether such offerings, though of dubious value, attract addicts to treatment centers. “The possibility remains that offering something concrete like acupuncture helps attract people to services, and that doing something both clients and staff believe is worthwhile (even if it is a ‘sham’ procedure) helps retain patients in treatment, and in doing so improves outcomes.”

Of course, this is only one study out of many, and acupuncture enthusiasts remain as optimistic as ever. Proponents of acupuncture treatment continue to petition the National Institute on Drug Abuse (NIDA) for endorsement. Most reports of success remain anecdotal. Nonetheless, the National Acupuncture Detoxification Association estimates that there are currently 200 acupuncture detoxification programs operating in the United States and Europe.


Photo Credit: The 217

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Guest Post: Things Go Better with Meth

The Pepsi Challenge with controlled substances.

[Today’s post comes to us from Neurological Correlates, a blog devoted to the neuroscience of dysfunctional behavior. It was written by Swivelchair, who refers to himself as “an anonymous biopharma worker." It’s an excellent blog, one of the few that focuses on the biological basis of addiction.]
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Things go better with meth, as compared to cocaine, if you’re dopamine transporter challenged, anyway.

By Swivelchair

Methamphetamine is taken up more quickly, and lasts longer than cocaine. (Fowler et al, Abstract below).

And here’s something from Microgram Bulletin, October 2008, Published by the Drug Enforcement Administration Office of Forensic Sciences Washington, D.C. 20537: The DEA South Central Laboratory (Dallas, Texas) recently received a submission of approximately 4972 fake “kidney beans” (total net mass 3,210 grams), all containing a fine tan powder, suspected heroin. The “beans” were actually small plastic packets that had been painted to resemble kidney beans... Analysis of the powder... confirmed 90.3% heroin hydrochloride.

The perhaps undeniable point: probably the self-selecting population of people who are first drawn to drugs, and then become irretrievably addicted, are those who lack sufficient dopamine transport to feel fulfilled (or other insufficiency, depending on the choice of drug). They are, in essence, self-medicating, rather than using drugs for recreational use. I mean, you don’t load up kidney beans for recreational drug users.

I’m reminded of a friends’ younger brother, from a locally well-known family, whose arrest was reported as bringing in “the largest amount” of cocaine in those parts. His remark: He was a wholesaler, and the newspaper quoted street (”retail”) values, so the report inflated his inventory value. This was purely about money for him — he made far more money selling coke than any job he was qualified to do (which was, well, probably none, unless being a bon vivant and sparkling raconteur with insufficient money to fund a high rent party lifestyle qualifies as a profession, which it may). If the US were to decriminalize drug use, and fund a program to make an agonist which was not addictive (a la the whole methadone thing), probably we could solve much of the crime problem in the Western Hemisphere.
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“Fast uptake and long-lasting binding of methamphetamine in the human brain: comparison with cocaine.” Fowler JS, Volkow ND, Logan J, et. al. Medical Department, Brookhaven National Laboratory, Upton, NY 11973

Abstract from Neuroimage. 2008 Dec; 43(4):756-63.

“Methamphetamine is one of the most addictive and neurotoxic drugs of abuse. It produces large elevations in extracellular dopamine in the striatum through vesicular release and inhibition of the dopamine transporter. In the U.S. abuse prevalence varies by ethnicity with very low abuse among African Americans relative to Caucasians, differentiating it from cocaine where abuse rates are similar for the two groups. Here we report the first comparison of methamphetamine and cocaine pharmacokinetics in brain between Caucasians and African Americans along with the measurement of dopamine transporter availability in striatum.

Methamphetamine’s uptake in brain was fast (peak uptake at 9 min) with accumulation in cortical and subcortical brain regions and in white matter. Its clearance from brain was slow (except for white matter which did not clear over the 90 min) and there was no difference in pharmacokinetics between Caucasians and African Americans. In contrast cocaine’s brain uptake and clearance were both fast, distribution was predominantly in striatum and uptake was higher in African Americans. “Among individuals, those with the highest striatal (but not cerebellar) methamphetamine accumulation also had the highest dopamine transporter availability suggesting a relationship between METH exposure and DAT availability. Methamphetamine’s fast brain uptake is consistent with its highly reinforcing effects, its slow clearance with its long-lasting behavioral effects and its widespread distribution with its neurotoxic effects that affect not only striatal but also cortical and white matter regions. The absence of significant differences between Caucasians and African Americans suggests that variables other than methamphetamine pharmacokinetics and bioavailability account for the lower abuse prevalence in African Americans.”

Related Links

PET studies of d-methamphetamine pharmacokinetics in primates: comparison with l-methamphetamine and ( –)-cocaine. [J Nucl Med. 2007] PMID:17873134

Long-term methamphetamine administration in the vervet monkey models aspects of a human exposure: brain neurotoxicity and behavioral profiles. [Neuropsychopharmacology. 2008] PMID:17625500

Graphics Credit: methamphetaminetx.com

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NIDA'S Updated Guide Book Emphasizes Science

Drug addiction treatment trends.

Favoring objective medicine over moral exhortation, the National Institute on Drug Abuse (NIDA) has updated one of its primary research guides, continuing the trend toward focusing on the scientific aspects of drug and alcohol addiction.

In the preface to the updated 2nd Edition of Principles of Drug Addiction Treatment, available here, NIDA Director Nora D. Volkow writes:

“Addiction affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. Some individuals are more vulnerable than others to becoming addicted, depending on genetic makeup, age of exposure to drugs, other environmental influences, and the interplay of all these factors.”

Looking toward the future, Volkow writes that “we will harness new research results on the influence of genetics and environment on gene function and expression (i.e., epigenetics), which are heralding the development of personalized treatment interventions.”

Here are excerpts from a section of the updated guide titled “Principles of Effective Treatment.”

--No single treatment is appropriate for everyone.

“Matching treatment settings, interventions, and services to an individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.”

--Treatment needs to be readily available.

“Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.”

-- Remaining in treatment for an adequate period of time is critical.

“Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment. Recovery from drug addiction is a longterm process and frequently requires multiple episodes of treatment.”

-- Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

“For example, methadone and buprenorphine are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opioid-addicted individuals and some patients with alcohol dependence. Other medications for alcohol dependence include acamprosate, disulfiram, and topiramate.”

-- Many drug-addicted individuals also have other mental disorders.

“Because drug abuse and addiction—both of which are mental disorders—often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co-occur, treatment should address both (or all), including the use of medications as appropriate.”

-- Treatment programs should assess patients for the presence of HIV/ AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.

“Typically, drug abuse treatment addresses some of the drug-related behaviors that put people at risk of infectious diseases. Targeted counseling specifically focused on reducing infectious disease risk can help patients further reduce or avoid substance-related and other high-risk behaviors.”

Graphics Credit: NIDA

How Junk Food Works

Ex-FDA chief offers clues to food addiction.

It is a perplexingly common experience: You open a bag of cookies, intending to have one or two. An hour later, the bag is empty, and your self-loathing is at its peak.

But compulsive overeating is not a character flaw, according to David Kessler, former head of the Food and Drug Administration. It is, rather, a “biological challenge.”

Readers may remember Kessler from his anti-cigarette and food product labeling crusades during the Clinton administration. In his forthcoming book, The End of Overeating: Taking Control of the Insatiable American Appetite, Kessler notes that while food took over his brain, the foods in question were not carrots, apples and green leafy vegetables. “Conditioned overeating,” as Kessler dubs it, is driven by a biological drive to eat high-fat, high-sugar foods even when we are not hungry. Moreover, such foods are cheaper than more healthy alternatives.

What Kessler describes in his book is a system of reward-driven eating abetted by a food industry fully aware of the biological attraction exerted by salt, fat, and sugar. Kessler himself is no stranger to this attraction. “I have suits in every size,” Kessler writes, according to a report by Lauren Neergaard for AP. “Once you know what’s driving your behavior, you can put steps in place.”

Kessler has also served as dean of the medical schools at Yale and the University of California at San Francisco. On the book’s Amazon site, Michael Pollan, author of In Defense of Food, calls Kessler’s book “a fascinating account of the science of human appetite, as well as its exploitation by the food industry.”

It is becoming increasingly clear that fat and sugar in combination are capable of producing a dopamine-driven surge of intense pleasure in people with a propensity for addictive behavior. Mice that have been genetic altered so that they lack the ability to taste sweet foods still prefer sugar water to regular water. (See my post on Dopamine and Obesity.) Kessler provides additional evidence that certain forms of overeating qualify as legitimate drug addictions. Just as it is with, say, cocaine addicts, the supersaturated reward pathways of the brain do not have effective mechanisms for signaling: “That’s enough. Stop eating.”

It may seem obvious in retrospect that the same mechanisms that make it so difficult for many drug addicts to “just say no” would also function in the case of addicted overeaters. What happens is similar to the flooding of reward circuitry that occurs in cases of what we might call “compulsive overdrugging,” otherwise known as addiction. The food industry, according to Kessler, has figured out what works, has packaged fat-and-sugar foods in products that scarcely even have to be chewed, and it has priced these products to move.

Yale university conducted studies in which “hypereaters” were given the odor of chocolate during an MRI scan. Normal eaters get used to the odor and habituate rapidly. Hypereaters find that the odor of chocolate becomes more demanding and overpowering with time. And even drinking a complete chocolate milkshake did not quell the craving.

According to Publisher’s Weekly, Kessler’s book, set to be released on April 28, “provides a simple food rehab program to fight back against the [food] industry’s relentless quest for profits while an entire country of people gain weight and get sick.”

Photo Credit: Neurological Correlates