What Addicts Need

In its latest issue, Newsweek devotes a lot of space to addiction and an what it describes as an imminent era of pharmacological treatments. It makes some interesting points, but also illustrates how difficult it is to write for the general public about addiction in a scientific and definitive way right now.

While the roots of addiction remain a dark tangle of factors—most experts agree that addicts trying to quit will always need psychological support—the old white-knuckle wisdom that addicts simply lack resolve passed out of fashion decades ago. The American Medical Association recognized addiction as a disease back in 1956. But only now are we beginning to see treatments that target the underlying biochemistry of that disease.

"most experts agree that addicts trying to quit will always need psychological support"--What does this mean? How does the author define "psychological support"? Is she referring to professional services? Or, could this support be provided by family and community supports? Is seems to imply the former, which experts do not agree on at all. There is growing interest and a growing body of research on natural or spontaneous recovery.

She also misrepresents AA's position on the use of medication:

It is also facing resistance from some elements in the addiction-treatment community, who are wedded to the 12-Step model pioneered by Alcoholics Anonymous in 1935. Twelve-Step programs traditionally discourage members from using any psychoactive substances, on the ground that addicts will simply trade one dependency for another.

Of course, there is some truth to this. Many AA members are skeptical of psychotropic medications or medications to treat addiction, but I suspect that they are now a minority. My experience with the recovering community is that many are on psychotropics and that antabuse is not frowned upon by most members. Of course, mood altering drugs like benzos and methadone are another story. Further, AA's official stance is pretty deferent to prescribing doctors.

The article does, however, present a good overview of the growing consensus that addiction is a chronic brain disease but it also paints a very clear picture of researcher enthusiasm for pharmacological treatments. Call me a cynic, but it's hard to imagine that their enthusiasm isn't coloring their judgment and reporting about the effectiveness of these treatments. (We've seen this recently here, here, here and here. There's also the laundry list of now-abandoned "best practices.")

The emerging paradigm views addiction as a chronic, relapsing brain disorder to be managed with all the tools at medicine's disposal. The addict's brain is malfunctioning, as surely as the pancreas in someone with diabetes. In both cases, "lifestyle choices" may be contributing factors, but no one regards that as a reason to withhold insulin from a diabetic. "We are making unprecedented advances in understanding the biology of addiction," says David Rosenblum, a public-health professor and addiction expert at Boston University. "And that is finally starting to push the thinking from 'moral failing' to 'legitimate illness'."

In laboratories run and funded by the National Institute on Drug Abuse (NIDA), fMRI and PET scans are forcing that infuriating organ, the addicted brain, to yield up its secrets. Geneticists have found the first few (of what is likely to be many) gene variants that predispose people to addiction, helping explain why only about one person in 10 who tries an addictive drug actually becomes hooked on it. Neuroscientists are mapping the intricate network of triggers and feedback loops that are set in motion by the taste—or, for that matter, the sight or thought—of a beer or a cigarette; they have learned to identify the signal that an alcoholic is about to pour a drink even before he's aware of it himself, and trace the impulse back to its origins in the primitive midbrain. And they are learning to interrupt and control these processes at numerous points along the way. Among more than 200 compounds being developed or tested by NIDA are ones that block the intoxicating effects of drugs, including vaccines that train the body's own immune system to bar them from the brain. Other compounds have the amazing ability to intervene in the cortex in the last milliseconds before the impulse to reach for a glass translates into action. To the extent that "willpower" is a meaningful concept at all, the era of willpower-in-a-pill may be just over the horizon. "The future is clear," says Nora Volkow, the director of NIDA. "In 10 years we will be treating addiction as a disease, and that means with medicine."

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So for this new paradigm to take hold, a lot of long-held prejudices will have to change. Doctors (and insurance companies) will have to get used to the idea of medicating their addicted patients, rather than handing them a brochure for AA, which a study published in 2005 in The New England Journal of Medicine found was the most common form of "treatment" offered. "If you have hypertension and it flares up, you go to a specialist," says psychologist Thomas McLellan of the University of Pennsylvania. "The specialist doesn't discharge you to a church basement. If he did, we would call it malpractice." Addicts, he adds, are by no means unique in their propensity to relapse. In a study comparing alcoholics and drug addicts to patients with diabetes, asthma and hypertension, McLellan found nearly identical rates of noncompliance and relapse; between 30 and 40 percent of each group failed to follow even half their doctors' guidelines.

As some of the statements above suggest, the article also foreshadows pressure on treatment providers and the recovering community to embrace these new treatments:

Volkow's vision of the future, however, is being greeted warily by big pharmaceutical companies, reluctant to develop products that would associate their brands with drug addicts. It is also facing resistance from some elements in the addiction-treatment community, who are wedded to the 12-Step model pioneered by Alcoholics Anonymous in 1935. Twelve-Step programs traditionally discourage members from using any psychoactive substances, on the ground that addicts will simply trade one dependency for another. That rationale has some unfortunate history on its side; both opium and cocaine were first introduced to the United States as cures for alcoholism in the late 1800s. More recently there is the example of methadone, the synthetic heroin that turned out to be addictive in its own right, and Antabuse, a drug that makes you throw up when you drink alcohol—which suffers from the shortcoming that an alcoholic planning a binge can just skip his dose.

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The revolution these new drugs promise will have a huge impact on the addiction-treatment industry (or, as it prefers to think of itself, the "recovery movement"), which runs the gamut from locked psychiatric wards in big-city hospitals to spalike mansions in the Malibu Hills of California. And the reaction there is guarded; the people who run them have seen panaceas come and go over the years, and the same addicts return with the same problems. They also, of course, have a large investment in their own programs, which typically rely on intensive therapy and counseling based on the 12-Step model. "We need four or five more years to see how [Vivitrol] does," says staff psychiatrist Garrett O'Connor at the Betty Ford Center, in Rancho Mirage, Calif. "And we need to be very cautious, because a failed treatment will set a person back." The Ford Center and the Hazelden Foundation, in Minnesota, use drugs sparingly, and mostly just in the first days or weeks of recovery, the "detox" phase. "Hazelden will never turn its back on pharmaceutical solutions, but a pill all by itself is not the cure," says William Moyers, Hazelden's vice president of external affairs. "We're afraid that people are seeking a medical route that says treatment is the end, not the beginning." As for Alcoholics Anonymous and its imitators, they mostly do not forbid members to use medication but there are strong institutional biases against it. "I'm not judging others, but for myself, using something like Vivitrol or Camparal feels like a crutch," says one longtime AA member, who, following the organization's practice, asked not to be named. "It's not true sobriety."

The competing view is that of Lisa Torres, a New York lawyer who has been in recovery from heroin addiction for nearly 20 years, and continues to take methadone, which she regards as medication for a chronic condition, analogous to blood-pressure or cholesterol-lowering drugs. "It's a paradox that some of addicts' biggest advocates have been the most resistant to new treatments," she says. "But a lot of them come to the field after recovering from their own addictions, and they can be very stubborn about what works and what doesn't." More pointedly, she adds, "some people feel recovery from addiction should not be easy or convenient."

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And addicts may need to change their thinking, too. For nearly 75 years, that thinking has been dominated by the principles laid down by Bill W., the founder of Alcoholics Anonymous. The amount of good AA has done in the world is incalculable; most people reading this article probably can think of someone they know who owes his or her life to it. Some readers themselves have surely benefited. But in 1935 AA was, essentially, the only legitimate option. There were "cures" of various sorts, including gold chloride injections, but there was virtually no modern neuroscience or psychopharmacology. Many people are now living in society with mental illnesses like schizophrenia and bipolar disorder that would have required institutionalization back then. Addicts, like the rest of the public, need to recognize the fact that we are entering a new era in addiction treatment. Viewing her condition as a chronic, recurring disease that could be treated was precisely what Dyess needed to return to sobriety. "In the past, when I would relapse," she says, "the thinking from 12-Step or from family was that I had failed. Now I know that if it happens, it happens, and I can pick myself up and move on, instead of assuming it's all over so I might as well keep drinking." The 12 Steps begin with a confession of powerlessness over addiction. But there's hope that science may some day help put that power within the reach of anyone who needs it. And then who would choose not to grasp it, and begin the long war for sobriety—a war without end, but one worth the fighting.

One more line from above provoked one more troubling thought:

Volkow's vision of the future, however, is being greeted warily by big pharmaceutical companies, reluctant to develop products that would associate their brands with drug addicts.

By working to reduce the stigma associated with addiction we will inevitably be removing barriers currently preventing others from entering the field. Some will probably have good motives and their presence will be helpful. Others will view it as a new market for profiteering. We've experienced this before. The article acknowledges this, but, in my opinion, naively dismisses these concerns because she believes science will be the basis of new treatments. Buyer beware.