Cocaine Treatment and the Stroop Test

Treatment dropouts do poorly on color/word match.

It’s commonly used to demonstrate behavioral inhibition, but it’s also a nifty parlor game. It is called the Stroop Test, and it plays off the fact that people are far better at reading words than they are at intentionally ignoring them. To prove it, John Ridley Stroop’s 1935 Ph.D. thesis showed how difficult it is to interfere with the automatic processing of words. In the basic Stroop test, a list of color names is presented. However, the word green might be printed in red ink, and the word red might be printed in blue ink. The task is to quickly name not the word itself, but the color of the word. As an example, for the word “green” printed in red ink, the correct verbal answer is “red.” Because of a phenomenon called directed attention, this is hilariously difficult to do. The subject must actively inhibit the automatic response—reading the word—in order to do something else.

What’s all this got to do with drug addiction?

Psychologists have known for some time that drug craving focuses attention on drug-related stimuli in the environment, and draws attention away from environmental cues unrelated to drugs. Naturally, researchers began to wonder whether the Stroop test could be brought to bear on the matter of addiction, and employed as a tool with which to predict the likelihood of relapse among the addict population. 

As researchers at the University of Wales have pointed out,  “Decisions about drinking and drug use can be highly automatic, with users being unaware of the factors that influence their decisions.” At the same time, addicts are hyper-aware of addiction-related environmental stimuli, compared to non-addicts. As a result, “the automatic processing of addiction-related stimuli might elicit conditioned responses such as withdrawal… or they might invoke automatic patterns leading to substance use.”

In a recent study of treatment dropouts among 74 cocaine-addicted subjects, published in Neuropsychopharmacology, Dr. Chris Streeter and coworkers at the Boston University School of Medicine and Harvard University provide strong evidence for the use of the Stroop Test as a diagnostic tool in addiction treatment.  Variations on the Stroop Test were better predictors of dropout than addiction severity, depression, and other clinical variables.  Dropouts took 24 per cent longer, on average, to finish the tests than cocaine addicts who stuck with treatment, the researchers reported.  “These finding suggest that the Stroop test can be used to identify cocaine-dependent subjects at risk for treatment dropout,” say the researchers, and that it can serve as another instrument with which to “identify and tailor interventions of at risk individuals in the hope of improving treatment compliance.”

Furthermore, other studies suggest that attentional bias may serve as a useful predictor of opiate relapse and smoking cessation failure as well.

Streeter, C., Terhune, D., Whitfield, T., Gruber, S., Sarid-Segal, O., Silveri, M., Tzilos, G., Afshar, M., Rouse, E., Tian, H., Renshaw, P., Ciraulo, D., & Yurgelun-Todd, D. (2007). Performance on the Stroop Predicts Treatment Compliance in Cocaine-Dependent Individuals Neuropsychopharmacology, 33 (4), 827-836 DOI: 10.1038/sj.npp.1301465

Photo Credit: http://www.edge.org

White House Releases New National Drug Strategy

The official press statement.


The White House
Office of the Press Secretary
For Immediate Release
May 11, 2010

WASHINGTON, DC – Today, President Obama released the Administration’s inaugural National Drug Control Strategy, which establishes five-year goals for reducing drug use and its consequences through a balanced policy of prevention, treatment, enforcement, and international cooperation.   The Strategy was developed by the Office of National Drug Control Policy (ONDCP) with input from a variety of Federal, State, and local partners.

“This Strategy calls for a balanced approach to confronting the complex challenge of drug use and its consequences,” said President Obama. “By boosting community-based prevention, expanding treatment, strengthening law enforcement, and working collaboratively with our global partners, we will reduce drug use and the great damage it causes in our communities.  I am confident that when we take the steps outlined in this Strategy, we will make our country stronger and our people healthier and safer.”

The 2010 Strategy highlights a collaborative and balanced approach that emphasizes community-based prevention, integration of evidence-based treatment into the mainstream health care system, innovations in the criminal justice system to break the cycle of drug use and crime, and international partnerships to disrupt transnational drug trafficking organizations.  

During a nationwide listening tour soliciting input for the development of the Strategy, National Drug Policy Director Gil Kerlikowske met with police and medical professionals, drug treatment providers and people in recovery, elected officials, corrections officials, academics, parents groups, faith leaders, and others.  Throughout the consultation process, significant themes emerged which connect the drug issue to major Administration policy priorities, including the economy, health care reform, youth development, public safety, military and veterans’ issues, and foreign relations.

“In following President Obama’s charge to seek a broad range of input in the Strategy, I gained a renewed appreciation of how deeply concerned Americans are about drug use,” said Director Kerlikowske. “It touches virtually all of us, whether we know a family member, a friend, or a colleague who suffers from addiction or is in recovery, a police officer working to protect the community, or a parent striving to keep a child drug free,” said Director Kerlikowske.

The 2010 Strategy establishes five-year goals to reduce drug use and its consequences, including:

• Reduce the rate of youth drug use by 15 percent;
• Decrease drug use among young adults by 10 percent;
• Reduce the number of chronic drug users by 15 percent;
• Reduce the incidence of drug-induced deaths by 15 percent; and
• Reduce the prevalence of drugged driving by 10 percent.

In addition, the Strategy outlines three significant drug challenges on which the Administration will specifically focus this year: prescription drug abuse, drugged driving, and preventing drug use.  Prescription drug abuse is the Nation’s fastest growing drug problem, driving significant increases of drug overdoses in recent years.   Drugged driving poses threats to public safety, as evidenced by a recent roadside survey which found that one in six drivers on weekend nights tested positive for the presence of drugs.  Preventing drug use before it starts is the best way to keep America’s youth drug-free.  In addressing each of these issues, the Strategy outlines a research-driven, evidence-based, and collaborative approach.

New Strategy elements also include a focus on making recovery possible for every American addicted to drugs through an expansion of community addiction centers and the development of new medications and evidence-based treatments for addiction.  Continued support for law enforcement, the criminal justice system, disrupting domestic drug traffic and production, working with partners to reduce global drug trade, and innovative community-based programs, such as drug courts, play a critical role in reducing American drug use and its effects.

For more information about the 2010 National Drug Control Strategy visit www.whitehousedrugpolicy.gov.

Photo Credit: http://www.whitehouse.gov

What Would a Genuine Drug War Look Like?

An essay on biomedicine and the body politic.

Millions of addicts in America want effective treatment, and cannot get it. Funds for research and treatment are still scarce, compared to money for interdiction and law enforcement. What would happen if we took the billions spent on interdiction and let it flow into addiction research and treatment? What would happen if we gave people truthful, accurate information about drugs, and trusted them to make intelligent decisions more often than stupid ones? Can it end up any worse that the present state of affairs?

Susan Sontag’s warnings about the danger of disease as metaphor still ring true. In modern American society, heart disease, cancer, AIDS, alcoholism, and cigarette addiction account for millions of deaths. They are all disease entities with strong psychological and behavioral components—complicated, multicellular, multi-organ disorders. But they have all been associated, at one time or another, with negative personality traits and moral flaws. The less we know about the mechanics of a human disorder, the more likely we are to view its external symptoms as signs of laziness, or neuralgia of the spirit, or as a form of damage caused by specific kinds of thoughts and emotions. Without a doubt, all kinds of flaws are sometimes expressed in the behavior of people who have these disorders. Yet none of these flaws can be considered the root cause of the diseases.

The genuine drug war is being fought in the arena of biomedicine. Addiction is being added to the roster of physical disorders once thought to be symptoms of insanity, but which are now seen to be physiological disease entities with mental components. The real crisis is the indisputable fact that there exists today an appalling shortage of funds for biomedical research. The cause of the dilemma is a fundamental misunderstanding among politicians and the public about how diseases can be understood and conquered. Research into the viral mechanisms of the common cold may ultimately yield more insights into AIDS then all of the directed research now underway. In biomedicine, there is no guarantee that goals can be reached through the front door, by a systematic assault akin to an engineering project. We cannot, for example, hope to cure addiction, or even the common cold, by means of the same methods we used to put a man on the moon.

There are, however, certain things we can do immediately, if we are serious about drug abuse. To begin with, we can attend to the staggering number of drug-related deaths, injuries, and hospitalizations caused by the abuse of prescription medications. The government itself has proven the case for this contention in numerous reports issued by the National Institute on Drug Abuse and other official bodies. According to the U.S. Department of Health and Human Services, older Americans account for more than half of all deaths from drug reactions, leading one to suspect that the majority of drug fatalities in this country stem from accidentally fatal overdoses by heavily medicated senior citizens. Our national fixation on illegal drugs has blinded us to the verifiable facts about prescription drug abuse.

We also need to recognize the problem of underprescribing morphine and other addictive painkillers for children and adults in hospital settings. One of the great scandals to come out of the drug war is the growing understanding that potent painkillers are not being offered in sufficient amounts to patients suffering intractable and agonizing pain.

“There’s a certain amount of hysteria about narcotics among doctors,” maintains one researcher.

At least half of all cancer patients seen in routine practice report inadequate pain relief, according to the American College of Physicians. For cancer patients in pain, adequate relief is quite literally a flip of the coin.

A September 10 New York Times report highlights studies by the World Health Organization which amply document the ongoing scandal in pain management. At least 6 million cancer and AIDS patients currently receive no appropriate pain treatment of any kind. In addition, WHO estimates that four out of five patients dying of cancer are also suffering severe pain. The numbers of untreated patients suffering intractable, unrelieved pain from nerve damage, burns, gunshots, sickle cell anemia, and a host of other medical conditions can only be guessed at. Typically, non-addicted patients take morphine therapeutically for pain at doses in the 5 to 10 mg. range. But experienced morphine addicts regularly take several hundred milligrams a day—a huge difference. In many cases, pain relief is the one thing doctors can offer their patients, and the one thing they withhold

These outcomes, rather than flashy cocaine seizures at the border, represent the lasting fruits of the drug war.

Photo Credit: www.foreignpolicyjournal.com

Origins of the Disease Model of Addiction

Roger Williams and “deranged cellular metabolism.”

                                                  (with Linus Pauling, 1974-------------->)

The idea of addiction as a disease first began to gain a tentative foothold in scientific and government circles in the early 1960s, after the publication of E.M. Jellinek’s The Disease Concept of Alcoholism. Jellinek may not have invented the “alcohol science movement,” as he called it, and he may not have been much of a scientist himself (the evidence suggests that he faked his doctorate), but he was the first to describe the “disease syndrome” of alcoholism—chronic relapse leading to death by liver failure. A salesman by nature, Jellinek ardently presented the disease model of alcoholism to the world of the social sciences just as zealously as he had previously done banana research in Honduras for United Fruit, and biostatistics work for Worcester State Hospital in Massachusetts. The trouble was that the “science” part of alcohol science was murky at best. No real progress was made in loosening the grip that traditional psychology exerted upon the prevailing public view of addiction.

A few years earlier, in 1959, a colorfully maverick dissenter named Roger J. Williams, professor of chemistry at the University of Texas, had proposed a specific disease model of his own; one that went all but unnoticed at the time. The late Roger Williams was best known as the biochemist who discovered vitamin B-5, commonly known as pantothenic acid, one of the so-called “anti-stress” vitamins. This discovery produced a nice revenue stream for Williams’ home university through the patents he took out on various processes for synthesizing B-5.

 One of the problems with traditional theories of alcoholism, Williams believed, was that it was very difficult to identify the specific psychosocial pathologies psychiatrists insisted were behind alcoholism—such things as infantile regression and oral fixation. Those few researchers who did pay attention to alcoholism, he asserted, “have been so diverted by the rather vague and ill-defined personality disorders that alcoholics allegedly have that they have failed to concentrate upon the one thing that all alcoholics have—whether they are rich or poor... introverts or extroverts, dominant or submissive, repulsive or charming—namely, an excessive appetite for alcohol.”  The idea of appetite was, for Williams, the essential semantic shift. As Williams insisted in his book, Alcoholism: The Nutritional Approach:

“Alcohol is a physiological agent and the urge which the initial drink produces, in my opinion, arises because of deranged cellular metabolism. Except for the fact that derangement is involved, the urge is fundamentally similar to the urge we have for water when our tissues become dehydrated, for salt when our tissues become salt-hungry... or the unfortunate craving some diabetics have for sugar....”

Dr. Williams was saying that after a certain point, the burning urge for alcohol, or the insatiable craving for heroin became, for “addiction-prone” people, indistinguishable from the primal drives of food, thirst, or sex. “This is something that it is impossible to understand unless we take into account the tremendous biochemical individuality that exists.” If alcohol and addictive drugs didn’t effect you that way, well then, they just didn’t, and you thanked your lucky stars for it, the way you would be thankful for not having allergies or diabetes. Blood composition, enzyme levels, endocrine activities, excretion patterns, and nutritional needs all vary from person to person, argued Williams, and the effect of any given addictive drug was going to vary widely from person to person. This neglect of biochemical individuality, Williams was convinced, was the reason physicians had no medical treatment to offer. They had the wrong paradigm—they were focusing on the drugs themselves, and not on the bodies and brains of the users.

There were, Williams insisted, periodic references in the literature to what he called the “X” factor—some particular defect, or excess, or absence, that was present in alcoholics, but absent in moderate drinkers and abstainers. The hunt for the X Factor, for Substance H, was fast becoming the Holy Grail of addiction research.

Williams thought the X factor was genetic.

Photo Credit: http://bioinst.cm.utexas.edu

Five Science Blogs You Should Know About

(If you don’t already).

Mind Hacks

“Neuroscience and psychology tricks to find out what's going on inside your brain.”

Mind Hacks was originally a book by Tom Stafford and Matt Webb, subtitled “Tips and Tools for Using Your Brain.” Mind Hacks the blog has top-notch coverage of everything you can think of having to do with the brain. On Fridays, Vaughan Bell writes a weekly post, “Spike Activity,” which summarizes and links to the worldwide blogodome’s best posts about mind, brain, and culture from the preceding week.  Truly one of my first stops when it’s time to surf. Refreshingly, the site does not take ads or sponsored links.

Brain Blogger

“Topics from Multidimensional Biopsychosocial Perspectives.”

Dr. Shaheen Lakhan, editor of Brain Blogger and executive director of the Global Neuroscience Initiative Foundation, writes: “When we started blogging a few years ago, there were excellent science and medicine blogs, but none that truly captured the multidimensional aspects of health from biological, psychological, sociological, technological, and economical perspectives.” Topics covered include mental health stigmatization, living with a brain disorder, deep brain stimulation for depression, and addiction issues. Disclosure: I occasionally write articles for Brain Blogger.

Research Blogging

“ResearchBlogging.org is a system for identifying the best, most thoughtful blog posts about peer-reviewed research.”

According to information posted on the site, “Since many blogs combine serious posts with more personal or frivolous posts, our site offers a way to find only the most carefully-crafted posts about cutting-edge research, often written by experts in their respective fields.” Posts that meet the blog’s guidelines are displayed in easy-to-follow lists, and there are also weekly roundups.  Bloggers are able to mark their submitted posts with a Research Blogging icon for easy visibility on their own site. More or less exactly what you want out of a science blog aggregator.

The Corpus Callosum

Psychiatry, biology, medicine and mental health posts from an anonymous psychiatrist working “at a small community hospital somewhere in the USA.”

At The Corpus Callosum, editor Joseph puts up detailed, scrupulously accurate posts about everything from predicting antidepressant-related suicidality to post-traumatic stress disorder, and does so in a calm, measured tone of authority.  Another favorite of mine.

The Frontal Cortex

 “Jonah Lehrer is a contributing editor at Wired. He's also written for The New Yorker, Seed, Nature, and the New York Times and is a contributor to Radiolab.”

The hyperkinetic Jonah Lehrer is also the author of Proust Was A Neuroscientist and How We Decide. The former Rhodes scholar recently published a thought-provoking look at depression in the New York Times Magazine. On his blog, he’s likely to post about anything that catches his eye, and he’s got a good eye.

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

The Bong Water Case Revisited

Minnesota v. Peck.

Astute readers will recall the Great Bong Water Decision of 2009, in which the Minnesota Supreme Court determined, 4-3, that water used in a water pipe can be considered a “drug mixture.” Twenty five grams or more of this water, the court ruled, qualified the possessor for a first-degree criminal conviction and up to 30 years in prison.

The decision made the Minnesota Court the punch line in a worldwide joke, but things didn’t turn out so funny for defendant Sara Peck, who was sentenced to a year in jail, with six months suspended, after she pleaded guilty to Controlled Substance violations.  The quirk in the case was that the drug dissolved in the bong water wasn’t marijuana, but methamphetamine--a strange circumstance to say the least.

Nonetheless, Minneapolis criminal attorney Thomas Gallagher thinks that the ruling basically meant that, under the new interpretation, water could enhance the severity of a drug crime: “If trace amounts of criminalized drugs in bong water could be a crime based upon the weight of the water ‘mixture,’ then would not trace amounts of illegal drugs in our drinking water also be a crime to possess?”

It follows logically that “every citizen of Minnesota [is] a drug criminal” if they use tap water, since trace amounts of dozens of prescription drugs are routinely present in tap water (I live in Minnesota, but, as the fates would have it, draw my water from a well, which should protect me from prosecution).

A bill introduced in the Minnesota House is designed to correct the situation. The bill would have the state determine the volume of illegal drugs in an arrest by “weighing the residue of a controlled substance” rather than the entire weight of the compound or mixture the drugs might be a part of.  (I can already envision a legal argument regarding the possession of unsmokable, discardable marijuana plant stems, by far the majority component of high-volume pot busts.)

The problem is obvious: “The Minnesota Bong Water case has helped undermine what public confidence there was in criminal drug laws and their enforcement,” writes Gallagher, citing a portion of the written dissent in the original court ruling in the Peck case:

“The majority’s decision to permit bong water to be used to support a first-degree felony controlled-substance charge runs counter to the legislative structure of our drug laws, does not make common sense, and borders on the absurd.”

Photo Credit: http://www.pigginempire.co.uk

A Shot for Cigarette Addiction?

NIDA’s Nora Volkow on addiction vaccines.

Nora Volkow, director of the National Institute on Drug Abuse (NIDA), predicted in a telephone interview on Friday that a vaccine for cigarettes could be available in as little as three years, if two large ongoing Phase 3 trials—the last major FDA hurdle—prove as successful as earlier studies.

NicVax (Nicotine Conjugate Vaccine) from Nabi Biopharmaceuticals, with a boost from a $40 million up-front cash infusion from GlaxoSmithKline Biologicals SA, is poised to become the first of a new kind of science-based addiction treatment—an avenue of approach that brings with it great promise, and a significant number of problems.

I asked Dr. Volkow if the NicVax studies had shown evidence that the effects could be overcome with greater levels of smoking. This is a hurdle that has plagued early research on a promising cocaine vaccine, as reported in the Archives of General Psychiatry (See my post "Cocaine Vaccine Hits Snag").  In the cocaine studies, researchers found that users could overcome the blunting effects of cocaine antibodies by ingesting as much as ten times their normal level of cocaine—clearly a dangerous outcome that could enhance the possibility of lethal overdose.  (See discussions at Neurotopia  and DrugMonkey).

“I am very sensitive to that issue,” Volkow said during a conference call from NIDA's Eighth Annual Blending Conference in Albuquerque, NM, where she was a featured speaker. “But the data we have give no evidence that smokers increase their cigarettes to overcome the antibodies. It was that piece of the data that led me to approve funding.”

In fact, said Volkow, “craving decreased after these vaccinations, so we would not necessarily expect smokers to try to overcome the effects. We’ve also seen a dramatic decrease in cocaine administration in animal models.” The matter of defeating a vaccine by overindulging remains a theoretical rather than an established risk, Volkow believes. 

Vaccines may operate somewhat differently that we think, she explained, by helping to extinguish the conditioned responses to craving cues as well. “We did not expect to see [anti-craving effects],” she said. “Craving is a product of memory, associated stimuli, the anticipation of a pleasant response. With cigarettes, if you feel nothing, the brain mechanism of conditioning that drives craving starts to weaken.”

The vaccine itself “is not totally stopping all of the drug from getting into the brain. But it affects the pharmacological properties, so users don’t get the expected outcome.  Nobody knows exactly how this might accelerate the extinction process—we haven’t done the studies. It’s going to be intriguing to have a product that has the capacity to make extinction much more universal.”

Volkow admitted that “we need to get a wider response,” since a significant number of smokers and cocaine users do not form antibodies from the vaccines. In addition, “we need longer-lasting responses so we don’t have to re-vaccinate.” The cocaine vaccine under study is in Phase 2 trials, and it will be several years before more definitive results are in.

The Blending Conference Volkow was attending was titled “Blending Addiction Science and Practice: Evidence-Based Treatment and Prevention in Diverse Populations and Settings.” Despite her emphasis on science-based treatments, Volkow stated firmly that social intervention and psychological treatment can be equally important, and characterized the supposed line between physical addiction and psychological addiction as an “obsolete distinction.” It is important to remember, she said, that “psychosocial interventions make biological changes in the brain” as well.

“People are desperate, and vaccines will be very helpful to those who develop antibodies. People want these magic bullets, but we don’t yet know how these vaccines will effect the therapeutic landscape.”

Graphics Credit: http://www.attcnetwork.org/