Addiction Inbox

Ten Drug Myths Exposed

noreply@blogger.com (Dirk Hanson) — Fri, 25 Jul 2008 20:15:00 +0000

Drug abuse vs. drug dependence.

As the neurobiology of addiction has come into clearer focus over time, our ability to separate fact from fiction in the field of drug dependence has grown rapidly. Beliefs that have been common wisdom for years--that anyone who uses cocaine or heroin inevitably becomes addicted to it, for example--can now be confidently replaced with insights gained from a decade or more of intense research on the biological causes and treatment of addiction.

Dr. Carlton Erickson, professor of Pharmacology/Toxicology and director of the Addiction Science Research and Education Center at the University of Texas, has assembled an intriguing list of such changes in thinking, based on his book, "The Science of Addiction: From Neurobiology to Treatment." The complete list can be found on his "Exploding Drug Myths" page at the University of Texas site.

With his kind permission, I offer a few of these emerging insights. Many of them, Dr. Erickson told me, are understandable only in the context of DSM-IV criteria for drug abuse and drug dependence as listed in "The Diagnostic and Statistical Manual of Mental Disorders."

The DSM table for drug abuse defines it as "A maladaptive pattern of drug use leading to impairment or distress" including one or more of the following symptoms: recurrent use leading to failure to fulfill major obligations; recurrent use which is physically dangerous; drug-related legal problems; continued use despite social or interpersonal problems.

In contrast, the DSM manual defines drug dependence as three or more of the following symptoms: drug tolerance; withdrawal; drug used more often than planned; inability to control drug use; effort expended to obtain the drug; drug use replaces other activities; drug use continues despite knowledge of a persistent problem.

With these definitions in mind--which correspond roughly to "problem drinker/user" in the former case, and "addict" in the latter--here are some of the myths:

MYTH: Therapeutic pain-killers (such as morphine) produce a high rate of addiction. "Since "addiction" means "dependence," writes Erickson, "the likelihood of becoming dependent on opioid pain-killers is actually quite low.... Most people given these pain-killers will go through withdrawal but will never want or need the drug again."

MYTH: Crack is more addicting than cocaine powder. "There is no pharmacological reason why the form of a drug or the route of administration should change the 'addiction' liability of a drug. In fact, science is beginning to realize that the drug is not the cause of 'addiction' rather, the susceptibility of the person to the drug determines how much 'addiction' (dependence) develops."

MYTH: "Substance abuse" is a scientifically valid term. "The word is a weak, wimpy, confusing, inaccurate, and misleading term when applied to drug problems."

MYTH: Alcoholics can drink socially. "There are a few scientific studies that suggest this. But most of these studies look at 'problem drinkers'....'Abusers' can drink socially (that is, under control), whereas truly dependent individuals cannot."

MYTH: All drugs damage brain cells. "Actually, relatively few have been shown to damage brain cells through a toxic effect. These include alcohol (high doses over a long time), 'inhalants'... methamphetamine and MDMA (shown in animal studies with high doses, but not yet in humans)."

MYTH: Drugs cause "addiction." "An interesting scientific question is: If drugs cause 'addiction,' then why doesn't everyone who uses drugs too much, too often, become dependent (addicted)? Scientists are looking into genetic and other unknown factors that cause some people to become dependent while sparing others of this brain pathology."

MYTH: It is possible to overdose on LSD. "LSD is a major hallucinogen and can cause people to jump from tall buildings (for example) in their hallucinogenic state. However, there is no known lethal dose in humans."

MYTH: The more a person is educated about drugs, the less likely they are to become "addicted". "This idea that chemical dependence is preventable is an old one. Strong indirect evident concerning the brain mechanisms involved in dependence tells us that 'addiction' cannot be prevented. If the above statement were true, physicians, nurses, and pharmacists would have a low rate of chemical dependence. Sadly, these health professionals have an incidence of dependence that is at least as high as the general population."

MYTH: Anyone who drinks too much, too often, is an alcoholic. "If the 'too much, too often' myth were true, then most college students would be alcoholics. In fact, most college students ABUSE alcohol, while only 10-15% show dependence on alcohol at some point in their drinking careers."

MYTH: Everyone "has what it takes" to become "addicted" to drugs. "If 'addiction' (dependence) is a chronic medical disease, then why should it be different from other medical diseases? Everyone doesn't 'have what it takes' to get sickle cell anemia, insulin-dependent diabetes, or AIDS."

Coffee and Cigarettes

noreply@blogger.com (Dirk Hanson) — Wed, 23 Jul 2008 20:54:00 +0000

Recovering alcoholics and their drugs.

It's no secret that alcohol and cigarettes go together. And it is common knowledge--and an AA truism--that recovering alcoholics take to strong black coffee like ducks to water.

Now comes a study of Alcoholics Anonymous participants in Nashville, to be published in the October issue of Alcoholism: Clinical and Experimental Research, which verifies the obvious, with a twist. Of 289 AA members interviewed by Dr. Peter R. Martin and coworkers at the Vanderbilt Addiction Center, 56.9% of respondents were cigarette smokers (approximately 20% of all adult Americans smoke cigarettes).

When it came to coffee, however, 88.5% of AA attendees were coffee drinkers, and a third of them drank more than 4 cups a day. "The most important finding," said Dr. Martin in a Vanderbilt University press release, "was that not all recovering alcoholics smoke cigarettes while almost all drink coffee."

Does all that coffee guzzling and cigarette smoking help or hinder recovering alcoholics in their quest for sobriety? The answer is: nobody quite knows. Dr. Martin, professor of psychiatry and pharmacology at Vanderbilt and lead investigator of the study, entitled "Coffee and Cigarette Consumption and Perceived Effects in Recovering Alcoholics Participating in Alcoholics Anonymous in Nashville, TN," put it this way in Science Daily: "Is this behavior simply a way to bond or connect in AA meetings, analogous to the peace pipe among North American Indians, or do constituents of these natural compounds result in pharmacological actions that affect the brain?"

"It's possible that coffee is even a gateway drug, with coffee drinking beginning at about the time persons begin using alcohol," said Robert Swift of the Brown University Medical School. "In addition, a potential negative interaction is coffee's known negative effects on sleep."

Selena Bartlett of the Ernest Gallo Clinic and Research Center of the University of California, San Francisco, offers the same concerns about cigarettes. A reliance on smoking by recovering alcoholics has a biological basis, she believes, and may increase the odds of relapse. In a HealthDay article by Steven Reinberg, Bartlett said: "My prediction would be that the relapse rates among smokers is higher." Since nicotine and alcohol addiction are so often found together, Bartlett thinks they should also be treated together, and is studying the anti-smoking drug Chantix for this purpose. "The drug inhibits the effect of nicotine, and by doing that, you may also reduce the euphoric effects of alcohol at the same time," she said. "We already have some evidence that it may work."

Varenicline, currently marketed by Pfizer for smoking cessation under the trade name Chantix, caught the attention of alcohol researchers when it dramatically curbed drinking in alcohol-preferring rats. The synthetic drug was modeled after a cytosine compound from the European Labumum tree, combined with an alkaloid from the poppy plant. An estimated 85 per cent of alcoholics are also cigarette smokers. (Chantix has lately been implicated, along with a dozen other anti-seizure medications, in suicidal ideation in some patients).

"I think it is important for alcohol researchers and clinicians to know that alcoholics, even those who do not use other illicit drugs, are not just addicted to alcohol, but use other psychotropic drugs like caffeine and nicotine," said Professor Swift of Brown University. "A second important aspect is the finding that rates of smoking are much higher in alcoholics in recovery than in the general population.... Yet, AA tolerates or otherwise does not address smoking in its members."

Dr. Martin said that more detailed analyses of the results will help determine "whether these changes in coffee and cigarette use are predictive of recovery from alcoholism per se."

Photo credit: AA-Carolina.org

Drugs for Alcoholism

noreply@blogger.com (Dirk Hanson) — Mon, 21 Jul 2008 19:47:00 +0000

Different meds for different drinkers

Although there are still only three drugs officially approved by the FDA for the treatment of alcoholism, the research picture is beginning to change. In an article by Greg Miller published in the 11 April 2008 edition of Science, alcoholism researcher Stephanie O'Malley of Yale University said: "We have effective treatments, but they don't help everyone. There's lots of room for improvement."

The medications legally available by prescription for alcoholism are: disulfiram (Antabuse), naltrexone (Revia and Vivitrol), and acamprosate (Campral), the latest FDA-approved entry. A fourth entry, topiramate (Topamax), is currently only approved by the Food and Drug Administration (FDA) for use against seizures and migraine. The controversial practice of “off-label” prescribing—using a drug for indications that are not formally approved by the FDA—has become so common that Johnson & Johnson said it had no plans to seek formal approval for the use of Topamax as a medicine for addiction. (See my post,"Topamax for Alcoholism: A Closer Look").

Addiction experts are beginning to focus on which treatment drugs work best for different types of alcoholics. Two recent discoveries might help clarify the picture. Psychopharmacologist Charles O'Brien at the University of Pennsylvania reported that alcoholics with a specific variation, or allele, of a prominent opioid receptor gene were more likely to respond positively to treatment with naltrexone. Other work reported in the February 2008 Archives of General Psychiatry came to the same conclusion.

The second research insight builds on a lifetime of work by Robert Cloninger at Washington University in St. Louis. Cloninger discovered that alcoholics come in two basic flavors--Type 1 and Type 2. Type 1, the more common form, develops gradually, later in life, and does not necessarily require structured intervention. Type 1 alcoholics do not always experience the dramatic declines in health and personal circumstances so characteristic of acute alcoholism. These are the people often found straddling the line between alcoholic and problem drinker. In contrast, so-called Type 2 alcoholics are in serious trouble starting with their first taste of liquor during adolescence. Their condition worsens with horrifying speed. They frequently have a family history of violent and antisocial behavior, and they often end up in prison. They are rarely able to hold down normal jobs or sustain workable marriages for long. Type 2s, also known as “familial” or “violent” alcoholics, are likely to have had an alcoholic parent.

Type 1 drinkers, who only get in trouble gradually, are also known as "anxious" drinkers, and research suggests that they may respond better to medicines that alleviate alcohol-related anxiety, such as Lilly's new suppressor of stress hormones, known as LY686017. (See my post, "Drug That Blocks Stress Receptor May Curb Alcohol Craving "). Researchers at the National Institute of Alcohol Abuse and Alcoholism (NIAAA), working with colleagues at Lilly Research Laboratories and University College in London, announced the discovery of a drug that diminished anxiety-related drug cravings by blocking the so-called NK1 receptor (NK1R). The drug “suppressed spontaneous alcohol cravings, improved overall well-being, blunted cravings induced by a challenge procedure, and attenuated concomitant cortisol responses.”

The NIAAA researchers are making effective use of recent findings about the role played by corticotrophin-releasing hormone (CRH) in the addictive process. CRH is crucial to the neural signaling pathway in areas of the brain involved in both drug reward and stress. As it happens, NK1R sites are densely concentrated in limbic structures of the mid-brain, such as the amygdala, or so-called “fear center.”

Researchers are understandably excited about these developing insights. Psychopharmacologist Rainer Spanagel of Germany's Central Institute of Mental Health in Mannheim called such research "a milestone in pharmacogenetics." In Greg Miller's Science article, Willenbring of NIAAA predicted that the field is poised for a "Prozac moment," marked by the discovery of "a medication that's perceived as effective, that's well-marketed by a pharmaceutical company, and that people receive in a primary-care setting or general-psychiatry setting."

In "Days of Wine and Roses, " the 1960s film about alcoholism, Jack Lemmon played a character who embodied Type 2 characteristics--early trouble with alcohol, extreme behavioral dysregulation, poor long-term planning, and a hollow leg. His wife, played by Lee Remick, demonstrates the slower, more measured descent from problem drinking into clinical alcoholism that characterizes Type 1 alcoholics. Research now suggests that Lee Remick might do better on LY686017, while Jack Lemmon's character would be a promising candidate for treatment with naltrexone.

Photo credit: About Alcohol Information

Drugs for Cocaine Addiction

noreply@blogger.com (Dirk Hanson) — Wed, 16 Jul 2008 16:12:00 +0000

Researchers target GABA, noradrenaline.

According to Catalyst Pharmaceutical Partners, a company conducting research on drugs for the treatment of addiction, "The U.S. Food and Drug Administration has recognized that cocaine addiction is a 'serious, life-threatening condition for which there is no current drug treatment,' and the National Institute on Drug Abuse (NIDA) has stated that finding a pharmacological treatment for cocaine addiction is their number one research priority."

Other researchers view it differently, however. Allan Parry, a drug counsellor in Liverpool, U.K., told New Scientist that such work was "only likely to be relevant to a tiny minority of people. People often give up cocaine because their lifestyle changes or they just grow up."

Fighting fire with fire--using drugs to treat drug addiction--will likely remain a controversial approach for years to come.

What is the rationale for the use of drugs in the treatment of drug addiction? There are two basic approaches. Scientists look for medications that help patients initiate abstinence, and they look for drugs that help prevent relapse once the patient has achieved abstinence. The categories are not hard and fast. For example, a drug that effective reduces the reinforcing effects of cocaine by reducing the intensity of withdrawal can theoretically perform both functions at once. On the other hand, a drug that blunts the euphoric effects of cocaine--a drug that takes away the best of the buzz, no matter how much cocaine is ingested--can also succeed at the twin tasks of abstinence initiation and relapse prevention.

The search for medications with which to treat cocaine addiction has been in progress much longer than equivalent efforts aimed at methamphetamine addiction. One research target of long standing is modafinil, an odd-duck drug sold as Provigil for the treatment of narcolepsy. A mild stimulant, modafinil does a little bit of everything, pharmacologically tweaking dopamine, noradrenaline, anandamide and GABA receptor systems. Perhaps for this reason, the drug seemingly has been tried for almost everything, from Alzheimer's to atypical depression to jet lag. The U.S. military has reportedly shown some interest in it.

According to published research by Kyle M. Kampman in the June 2008 Addiction Science and Clinical Practice (PDF), modafinil-treated human subjects used less cocaine than placebo-using counterparts did in several recent small-scale studies. "In a double blind pilot trial with 62 cocaine-dependent patients, those who received modafinil submitted more cocaine-metabolite-free urine samples than placebo-treated patients (42 vs. 22 percent; Dackis et al., 2005)."

Propranolol, better known as the beta-blocker Inderal, works primarily by suppressing adrenaline and noradrenaline levels. In human studies to date, propranolol has shown itself most effective with the most severely cocaine-addicted patients. Studies by Kampman have shown that propanolol-treated patients stay in treatment longer than patients in control groups do.

Specific research on relapse prevention strategies has focused on GABA-enhancing drugs that inhibit cocaine reinforcement by secondarily blocking the dopamine surge characteristic of cocaine intoxication. In addition to vigabatrin, discussed in the previous post, topiramate is another particularly well-suited candidate for relapse prevention. Known as Topamax, and prescribed for seizures and migraines, the drug has shown early promise: "In a 13-week, double-blind, placebo-controlled pilot trial of topiramate involving 40 cocaine-dependent patients.... more of those on topiramate achieved at least 3 weeks of continuous abstinence (59 vs. 26 percent)."

Surprisingly, the granddaddy of all anti-addiction drugs--Antabuse--has made a comeback as a subject of study for cocaine addiction, even though it has never been spectacularly effective in its original application as a relapse prevention drug for alcoholics. Disulfiram, as it is known chemically, causes unpleasant physical sensations, including vomiting, when combined with even small amounts of alcohol. It does so by inhibiting the enzymes responsible for degrading alcohol. Even a little becomes too much. In similar fashion, disulfiram retards the breakdown of cocaine, leading to extremely high levels that induce paranoia and anxiety rather than a pleasurable, if extreme, high. At least four published trials have demonstrated reduced cocaine use in disulfiram-treated patients, according to Kampman's paper . One important downside to using Antabuse for cocaine addiction is that serious complications might occur if alcohol is added to the mix.

Finally, and still well into the future, is the prospect of relapse prevention therapy by means of a vaccine--an entirely different mechanism of approach. Research has shown that it is possible to produce "cocaine-specific antibodies that bind to cocaine molecules and prevent them from crossing the blood-brain barrier, thereby blunting the drug's euphoric and reinforcing effects," Kampman's paper asserts. A vaccine called TA-CD has tested well in preliminary studies.

No Pill for Stimulant Addiction

noreply@blogger.com (Dirk Hanson) — Mon, 14 Jul 2008 02:12:00 +0000

Meth and cocaine continue to elude researchers.

Despite promising trials of several compounds, methamphetamine addiction remains largely impervious to anti-craving pills and other forms of drug treatment. According to a paper in the June issue of Addiction Science and Clinical Practice, "currently, no medications are approved by the FDA for the treatment of stimulant dependence. However, recent advances in understanding... have allowed researchers to identify several promising candidates."

The paper's author, Dr. Kyle Kampman of the University of Pennsylvania School of Medicine and Treatment Research Center, notes that "the demand for treatment for cocaine dependence remained roughly level from 1992 to 2005, while the demand for treatment for amphetamine dependence increased about eight-fold." (See chart above).

As I wrote earlier ("FDA Puts Coke/Meth Treatment on Fast Track"), the U.S. Food and Drug Administration (FDA) in January gave Fast Track designation to vigabatrin, sold as Sabril by Ovation Pharmaceuticals. Ovation is collaborating with the NIDA on Phase II studies to evaluate the safety of Sabril, with Phase III trials scheduled for the end of this year.

Vigabatrin, an anti-epilepsy drug called Gamma-vinyl-GABA, or GVG for short, showed early promise for use with cocaine addicts in a 60-day study and appears to increase GABA transmission. GABA has an inhibitory effect on dopamine and serotonin release.

Another entry in the vigabatrin sweepstakes, Catalyst Pharmaceuticals, is also testing its version of the drug, dubbed CPP-109, for the treatment of methamphetamine addiction in Phase II double-blind, placebo-controlled studies. Patrick J. McEnany, chief executive officer of Catalyst, commented, "We are excited to follow up on our cocaine trial with the initiation of our second, large-scale U.S. Phase II trial with CPP-109, this time as a potential treatment for methamphetamine addiction. As with cocaine, we believe that CPP-109 may offer the potential to provide patients suffering from methamphetamine addiction, as well as the physicians and clinicians that treat them, with a safe and effective pharmacotherapy option."

What, in essence, are such pills designed to accomplish? The primary avenue of research has centered upon medications that decrease the addict's experience of withdrawal and craving. According to Kampan, "several studies have demonstrated that patients who experience severe cocaine withdrawal symptoms... are twice as likely to drop out of treatment and less likely to attain abstinence in outpatient programs."

However, questions remain about the safety of vigabatrin. Although available abroad, it is not approved for use in the U.S., due to an association with serious visual effects after long-term use. The use of vigabatrin for stimulant addiction, if approved, might require associated eye examinations.

Buproprion, a drug that has shown some promise in the treatment of cocaine addiction, is also a candidate for meth addiction. The drug inhibits the reuptake of dopamine, thus allowing more dopamine to circulate in the brain. In addition, there are plans to test other drugs being investigated for cocaine craving, such as topiramate and modafinil.

According to the 2005 SAMHSA Survey on Drug Use and Health, an estimated 10.4 million people age 12 or older (4.3 percent of the population) have tried methamphetamine at some time in their lives. Approximately 1.3 million reported past-year methamphetamine use, and 512,000 reported current (past-month) use. Approximately 535,000 patients sought treatment for methamphetamine and other stimulant abuse in 2006.

Next post: Drugs for cocaine craving

Photo Credit: National Drug Intelligence Center

"Rogue Pharmacies" on the Internet

noreply@blogger.com (Dirk Hanson) — Thu, 10 Jul 2008 18:35:00 +0000

You've got drugs!

No prescription? No problem. Of 365 web sites advertising or selling controlled drugs, fully 85 percent do not require a written prescription, according to the 5th annual White Paper from the National Center on Addiction and Substance Abuse at Columbia University (CASA).

Although the overall number of drug-peddling web sites declined from 2007, the report found that benzodiazepines like Xanax and Valium were the most frequently offered online drugs, followed by painkillers like Oxycontin and Vicodin. 27 percent of the sites also offered Ritalin, Adderall, and other stimulants.

The paper, entitled "'You've Got Drugs!' V: Prescription Drug Pushers on the Internet," reported that only two of the 365 sites were certified by the National Association of Boards of Pharmacy, an official body which represents state pharmacy examination boards. The total number of drug sites was down from 581 such web sites in 2007.

"This problem is not going away," said Joseph A. Califano, Jr., chairman and president of CASA, and a former secretary of Health, Education and Welfare under President Jimmy Carter. "It is morphing into different outlets for controlled prescription drug trafficking like Internet script mills and membership sites that sell lists of online pharmacies, and different payment methods like eChecks, COD and money orders."

In addition, some of the sites sell "medical consultations" which can be used to procure controlled drugs without a formal prescription. In 2007, 80 percent of prescriptions filled by Internet pharmacies were for controlled substances. According to figures from the Drug Enforcement Administration (DEA), only 11 percent of business at traditional pharmacies involves scheduled drugs.

In April, the U.S. Senate passed a bill endorsed last year by the Senate Judiciary Committee, which seeks to control the Internet traffic in prescription drugs. The bill, introduced by Senators Diane Feinstein (D-CA) and Jeff Sessions (R-AL), now goes to the U.S. House. According to Senator Feinstein, "This [CASA] report emphasizes the need to take immediate action to stop rogue pharmacies on the Internet.... Our Internet pharmacy legislation has passed the Senate. It's time for the House to take action and pass this important bill."

Photo Credit: Next Thing

If the Genes Fit....

noreply@blogger.com (Dirk Hanson) — Sun, 06 Jul 2008 22:46:00 +0000

U.K psychiatrists agree addiction is "genetically determined."

Although the verdict is very little in doubt these days, the heritability of addictions was reaffirmed by the U.K.'s Royal College of Psychiatrists in London on July 4th.

In a presentation at the group's annual meeting, held at Imperial College, Professor Wim van den Brink of the University of Amsterdam's Academic Medical Center pinned the blame for addiction squarely on the absence of a sufficient number of dopamine receptors in the brain. "Addicts find it difficult to receive pleasure," he said. "They are not likely to enjoy most of the ordinary things most of us enjoy... they are looking for more stimulus."

Professor van den Brink also made clear the importance of environmental interactions for gene expression: "You might start off smoking or taking cocaine, and that first introduction is very much determined by your environment. But to stick with it and become dependent on it is genetically determined."

The self-defeating nature of addiction is graphically illustrated by the overall decrease in the number of pleasure receptors for dopamine and serotonin over time, as drug use escalates. Moreover, addicts show a striking deficiency in the ability to engage in long-term thinking. This behavioral link, the Royal College maintained, is the reason addicts fail to realistically differentiate between short-term pleasure and long-term negative effects.

This inability of drug addicts to engage in effective long-term thinking is well summarized in the old Reverend Gary Davis song: "Cocaine's for horses and it's not for men/Doctor said it kill you, but he didn’t say when."

Photo Credit: National Institute on Drug Abuse

Pain Patients Sue State of Washington

noreply@blogger.com (Dirk Hanson) — Tue, 01 Jul 2008 00:42:00 +0000

Do doctors suffer from "opiophobia?"

The opium family of painkillers has always been a bane and a boon to the human race, as evidenced by nurses injecting morphine into agonizingly wounded soldiers, and street junkies selling the clothes off their back for another fix.

However, as I wrote in an earlier post, "The Morphine Scandal," the ironies fly thick and fast: In many cases, pain relief is the one thing doctors can offer their patients, and the one thing they withhold. Studies show that 70 per cent of patients present with painful conditions. 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.

Now, a lawyer for a pain relief advocacy group has filed suit against the state of Washington, claiming that overly stringent guidelines on prescription pain medications have had a negative effect on pain management across the country. Attorney Laura D. Cooper, who filed the suit on behalf of a group of Washington residents being treated for pain, said in an Associated Press article by Donna Gordon Blankinship that the state's regulations were comparable to setting a limit on the amount of insulin a doctor could prescribe for diabetic patients. Cooper alleged that the Washington standards have been used as guidelines by insurance companies and workman's compensation boards.

The AP article also quoted Siobhan Reynolds of the Internet-based Pain Relief Network: "The ramifications are enormous. You never see on a death certificate that people died of pain, but people die of pain all the time."

The lawsuit features an excerpt from a University of Wisconsin textbook on pain medicine, Bonica's Management of Pain, 3rd edition:

"Opiophobia is the syndrome of failure to administer adequate opioid analgesics because of the fear of producing addiction or toxicity. The etiology of opiophobia is multifactorial: Peer pressure (provider and patient), regulatory agency pressure (real or perceived), and lack of education on opioids and the fundamentals of pain management all contribute to its persistence.... All of these factors contribute to the underuse of these relatively simple and very effective medications, due to no fault of the patients. "

According to Drug Law Blog, the complaint "asks the court to declare that the state guidelines 'do not constitute enforceable law of any kind and should be stricken and removed from all state publications of every variety,' and seeks other additional relief, including an injunction against enforcement."

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

Photo Credit: Opioid.org

[Guest Post] Internet Addiction: A Novel Disease?

noreply@blogger.com (Dirk Hanson) — Fri, 27 Jun 2008 17:04:00 +0000

Or a reflection of the new world order?

[Editors Note: Addiction Inbox has not covered the so-called behavioral or non-traditional addictions--Internet addiction, video game addiction, compulsive shopping and compulsive gambling--because I am not yet convinced that such behaviors show the same chemical and often inheritable propensities associated with alcoholism and other drug addictions. Nonetheless, I am pleased to offer an alternative view, and to welcome guest blogger Elizabeth Dillon, who contributes a thought-provoking post on internet addiction.] --Dirk Hanson

By Elizabeth Dillon

It is impossible to deny the incredible significance of the internet and the effects its development has had on the world. Today the internet touches nearly every aspect of our daily lives; we shop online, we keep in touch through email, banking and credit can be taken care of through one click of a mouse, news from all over the world blinks up at us from the screen every time we log on, and communities of people from all over the planet are connected. Despite its obvious countless advantages, there is a rising concern regarding the overuse of the internet on a personal level. There are more and more people each day who feel a compulsive need to be connected to the internet, a need that some scientists and psychiatrists have begun to consider an addiction. This issue drew major media attention in March of this year when Dr. Jerald Block published an editorial in the American Journal of Psychiatry arguing that “Internet Addiction” should be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a handbook published by the American Psychiatric Association of recognized psychological conditions. Block raised the question of whether this new phenomenon should be classified as a disease or written off as a bad habit.

The traditional view of addiction generally applies to substances like drugs or alcohol and is seen as a result of a combination of genetic and social influences. However, in recent years the definition of addiction has expanded to include different behaviors like gambling and over-eating. The question that remains to be seen is if there are enough similarities between traditional addiction and this so called internet addiction to warrant its acceptance as a disease by the mental health community. For now it is officially titled Internet Addictive Disorder (IAD) or Internet Overuse Syndrome (IOS) and not recognized by the American Psychiatric Association.

Block argues that Internet addiction is characterized by the same four factors as traditional addiction: excessive use, withdrawal, tolerance, and negative repercussions. He contends that users are on the internet for so much time that they are unaware of how many hours have gone by, and neglect other basic human desires, often forgetting to eat or use the bathroom. Users feel angry, depressed, and tense when access to the internet is limited and frequently need better tools and more time of use to experience the original satisfaction. Internet addicts also face such harmful consequences as social isolation and poor achievement.

The statistics regarding the prevalence of internet addiction in the U.S. vary widely. A random telephone survey estimated 0.3-0.7% of Americans are afflicted, while Maressa Hecht Orzack of McLean Hospital in Massachusetts, estimates that nearly 10% of Americans have experienced some sort of internet dependency. Higher rates of addiction are seen mostly in Asian nations like South Korea and China where the popularity of internet cafes is high and the condition is easier to track because of its public nature. In fact, data from 2006 stated that approximately 210,000 South Korean children (2.1%) were afflicted with internet addiction with about 80% requiring treatment that included the use of psychotropic medication. Another interesting aspect of IAD is that most often individuals who suffer from it also are battling another mental illness. In particular, mood, anxiety, impulse control and substance abuse disorders are common in conjunction with internet overuse.

Research has traced other behavioral addictions like gambling and shopping to biological foundations; however the current research on internet addiction merely distinguishes it as a growing issue and draws parallels to other types of addictions. More studies need to be performed on this new phenomenon in order to properly characterize it as an addiction or as simply a destructive behavior.

While the internet may not officially be an addiction, there are still many individuals out there who would benefit from treatment. There are currently no proven forms of effective treatment and no available psychotropic medications for IAD. However, like with other addictive habits, cognitive behavioral therapy may be effective. Cognitive therapy is essentially a method that identifies and helps a person to correct specific errors in what he or she is thinking that produces negative or painful feelings. According to Dr. Allison Conner of Cognitive Therapy Associates, an internet addiction could be treated similarly to other addictions. She asserts that, “so many changes need to occur in the person's lifestyle (mental, emotional, physical, social), and support is crucial. A guide or coach is often essential to help ensure success, but most important is the willingness of the addicted person to get real with themselves and stay committed to the goal of recovery.”

While we may not see Internet Addiction in the DSM-V handbook anytime soon, the issue is controversial and becoming ever more widespread. Ironically enough, you can even look up online resources if you feel you need help.

Elizabeth Dillon is the Director of Communications Management for Cognitive Therapy Associates.

Sources:

Block, Jerald J. (2008). Issues for DSM-V: Internet Addiction. The American Journal of Psychiatry, 165, 306-307.

Goldsborough, Reid, (2008). Internet Addiction Afflicting a Growing Number of Web Surfers. Community College Week, Vol. 20 Issue 11, 0, 22-22.

Shaw, Martha Black, Donald W. (2008). Internet Addiction. CNS Drugs, Vol. 22, Issue 5, 13, 353-365.

Dr. Allison Conner can be contacted through her website:
http://www.cognitive-therapy-associates.com/ or at (212)-258-2577.

Addiction Treatment: Who is the Client?

noreply@blogger.com (Dirk Hanson) — Wed, 25 Jun 2008 16:24:00 +0000

The Overselling of Drug Rehab.

Professor David Clark, who runs the Wired In recovery website in the U.K., recently posted several passages from William L. White's "Slaying the Dragon: The History of Addiction Treatment and Recovery in America."

According to Professor Clark, "In highlighting [these quotes] on my Blog, I am not questioning the value of treatment. However, I am providing a word of caution to those who are trying to tell 'society' that the government-led treatment system is successful and is a panacea to some of society's problems."

Among the observations from White's book:

Who is the client?

"Addiction treatment swings back and forth between a technology of personal transformation and a technology of coercion. When the latter dominates, counselors become, not helpers, but behavioral police. The fact that today’s treatment institutions often serve more than one master has created the ethical dilemma of “double agentry,” wherein treatment staff profess allegiance to the interests of the individual client, while those very interests may be compromised by the interests of other parties to whom the institution has pledged its loyalty.’

--White, p. 335.

On blaming

"Harold Hughes, the political Godfather of the modern alcoholism treatment system, often noted that alcoholism was the only disorder in which the patient was blamed when treatment failed.... For decades many addicts have been subjected to treatment interventions that had almost no likelihood of success; and when that success has indeed failed to materialize, the source of that failure has been attributed, not to the intervention, but to the addicts’ recalcitrance and lack of motivation. The issue is, not just that such mismatches do not work, but that such mismatches generate their own iatrogenic effects via increased client passivity, helplessness, hopelessness and dependence."

--White, p. 331.

Historical tendency to oversell what treatment can achieve

"The overselling of the ways in which addiction treatment could benefit the home, the workplace, the school, the criminal justice system, and the broader community during the 1970s and 1980s sparked a subsequent backlash. When time - the ultimate leveller – began to expose the fact that these benefits were not forthcoming at the level promised, a rising pessimism fueled the shift toward increased criminalization of addiction."

--White, p. 338

Photo Credit: Cliffside Malibu

Battling Addiction with Exercise

noreply@blogger.com (Dirk Hanson) — Sat, 21 Jun 2008 21:01:00 +0000

It helps you quit. Can it keep you from starting?

We've all heard the claim: Physical exercise helps addicts who are working their way through withdrawal and recovery. It is one of the most common prescriptions given out by doctors and health professionals, whether you are a recovering alcoholic or a chronic binge eater.

And it makes sense. Exercise has verifiable impacts on not just endorphin levels, but also on levels of circulating serotonin and dopamine. All three neurotransmitter systems are heavily implicated in both maintaining addiction and withdrawing from it. Countless drug addicts have extolled the virtues of vigorous exercise, and there seem to be no compelling reason to doubt them.

But is there reason to think that regular exercise can help prevent addiction from blossoming in the first place?

Dr. Nora Volkow, director of the National Institute on Drug Abuse (NIDA), thinks there is. She told the Cincinnati Enquirer: "It's something we could apply right away. Vaccines, we're not going to get those results in one or two years. It will take probably five, six years to results."

"Exercise has been shown to be beneficial in so many areas of physical and mental health," Volkow said recently at a NIDA-sponsored conference on addiction treatment and research in Cincinnati. "This cross-disciplinary meeting is designed to get scientists thinking creatively about its potential role in substance abuse prevention."

Dr. Bess Marcus of Brown University, who is working on a NIDA-funded study of exercise for smoking cessation, presented the scientific evidence for the addiction/exercise connection. Similarities in the effects on the reward pathways of the brain's limbic system--dopamine activity in particular--may tie the two behaviors together more directly than previously thought. Among the findings:

--Rats in cages with running wheels show less interest in amphetamine infusions than rats without exercise options.

--Baby monkeys who don't roughhouse with their peers have higher levels of impulse control problems and alcohol use when they get older.

--In humans, exercise is known to reduce stress and tension--and anxiety is a well-known side effect of withdrawal, from alcohol and cigarettes to heroin and speed.

--Physical activity may enhance cellular growth in key areas of the brain involved in addiction, thereby aiding the neural rewiring that takes place during detoxification and withdrawal from addictive drugs.

No one knows for sure whether this effect, if it exists, works only in the young, and declines with age, or whether it can be of benefit to anyone as a preventative measure to reduce drug craving. "Statistics indicate that teens who exercise daily are the least likely to report using drugs or alcohol," Volkow said.

However, there are numerous exceptions, one being the classic image of the hard-drinking athlete. "Now the kids who exercise the most actually drink the most," Dr. Lloyd Johnston of the University of Michigan told the Associated Press.

Meth to the West, Cocaine to the East, Pot in the Middle

noreply@blogger.com (Dirk Hanson) — Tue, 17 Jun 2008 17:04:00 +0000

The geography of drug use.

To paraphrase an old tune by Gerry Rafferty, we got meth to the left of us, cocaine to the right, and here we are, stuck in the middle with pot.

The National Drug Threat Survey of 2007, a product of the National Drug Intelligence Center (NDIC) at the Department of Justice, illustrates the stark nature of regional variation when it comes to illegal drugs of choice in the United States. The map at the right represents the responses of state and local law enforcement agencies to the question: "What drug poses the greatest threat to your area?" Blue indicates cocaine, red indicates methamphetamine, and green stands for marijuana. (Click map for larger image.)

According to the Oregonian in Portland, reporting on similar numbers from the U.S. Substance Abuse and Mental Health Services Administration: "The politics of methamphetamine have been shaped by geography. Lawmakers from the East, Midwest and South focused on cocaine--the most heavily abused drug by far in their home states. By contrast, more than 90 percent of people treated for meth abuse live west of the Mississippi River."

The NDIC's stated mission is "to provide strategic drug-related intelligence, document and computer exploitation support, and training assistance to the drug control, public health, law enforcement, and intelligence communities of the United States...." NDIC obtains its data through direct surveys of federal, state and local law enforcement and intelligence agencies, as well as information from court documents, news sources, and public health agencies.

The NDIC has produced a National Drug Threat Survey annually since 2000, and began deriving state-level estimates in 2003. Federal, state and local government agencies use the statistical estimates as guidelines for promulgating drug legislation and enforcement strategies.

Graphics Credit: National Drug Intelligence Center

Obama and McCain on Addiction Treatment

noreply@blogger.com (Dirk Hanson) — Fri, 13 Jun 2008 21:49:00 +0000

Candidates differ on medical marijuana.

A drug and alcohol policy group has released a study of positions on drug policy by the presidential candidates, concluding that "neither John McCain or Barack Obama can really be considered a leader in the drug-policy area."

In an article published on the Join Together website, author Bob Curley notes that Obama has admitted to youthful marijuana and cocaine use, and McCain has admitted to youthful alcohol abuse. Both candidates are former cigarette smokers, Obama having quit only recently. Curley write that "both appear to have a broader and more nuanced understanding of addiction issues than their White House predecessor."

The article also quotes William Cope Moyers, vice president of external affairs at Hazelden treatment center, who says he has "never been more hopeful that addiction treatment will begin to get the attention it deserves, because we at least have two candidates who are aware of the issue." Obama's admission of drug use is already on the table as a potential campaign issue, while McCain purportedly had an alcoholic father, and his wife went through treatment for an addiction to painkillers in the 1990s.

Senator McCain has been active in efforts to regulate tobacco advertising, and advocates smoking cessation programs in the workplace. At other times, he has advocated tougher sentencing for drug crimes and capital punishment for international drug traffickers.

For his part, Senator Obama supported the Second Chance Act of 2007, which aimed at reintroducing veteran drug defenders to society. He has called for greater use of drug courts and rehabilitation programs in lieu of lengthy prison sentences. He is opposed to efforts to lower the drinking age to 18.

McCain is against marijuana legalization, and opposes the use of marijuana for medical purposes. He said he "would not support medical marijuana because I don't think that the preponderance of medical opinion in America agrees...."

Obama, according to the Join Together article, while not ready to let people grow their own, told a reporter in March that "my attitude is that if it's an issue of doctors prescribing medical marijuana as a treatment for glaucoma or as a cancer treatment, I think that should be appropriate because there really is no difference between that and a doctor prescribing morphine or anything else."

Smoking Rates Fall 18% in Indiana

noreply@blogger.com (Dirk Hanson) — Fri, 06 Jun 2008 16:32:00 +0000

What's their secret?

Addiction is a tough disease, and smoking grabs hold of the addiction-prone with a speed and ferocity that remains impressive even in a world of crack cocaine and ice amphetamine. Zyban may help, and there is the ever-controversial Chantix, as well as a plethora of nicotine replacement products. They are valuable and frequently effective additions to the arsenal of medical approaches to nicotine addiction.

Yet there remains one universally effective--if equally controversial--method of lowering smoking rates in a given population. You can increase the price.

Last year, Indiana boosted state taxes on cigarettes by a whopping 44 cents per pack. The result? Cigarette sales fell in Indiana by almost 18 per cent in the nine months since the new tax was put into effect, according to a June 3 Associated Press report. That percentage represents a decrease in sales of roughly 80 million packs of cigarettes, according to state health experts.

"This is exactly what we predicted, " Dr. Judith Monroe, the state health commissioner, told AP. "We've got to remember that smoking is an addiction... not just a bad habit."

In an editorial, the Indianapolis Star put the matter straightforwardly: "In Indiana and nationally, the research in unequivocal: Taxes reduce smoking, especially among the young. So does serious spending on smoking prevention and cessation. The state used to do the latter, and has paid the price for slacking off."

Indiana currently ranks 6th highest in the nation for smoking prevalence. In 1999, under terms of the state-by-state settlement with the tobacco industry, Indiana used its money entirely for smoking reduction programs. After seeing significant declines in smoking, the state legislature nonetheless diverted the remaining settlement money to other programs in 2003. At which point, according to the Indianapolis Star, "smoking rose again, up to second-highest in the nation," making Indiana "one of the unhealthiest states."

"More than one million Hoosiers use tobacco," Karla Sneegas of Indiana Tobacco Prevention and Cessation told the Associated Press. "But we know from our data that approximately 90 percent of those people want to quit and 30 percent are ready to quit right now."

Photo Credit: SavingAdvice.Com

The Biology of Bulimia

noreply@blogger.com (Dirk Hanson) — Mon, 02 Jun 2008 20:09:00 +0000

The binge-and-purge addiction.

By 2000, the biological substrate unifying alcoholism, addiction, depression, and certain eating disorders had become irrefutable. Population surveys had shown that nearly half of alcoholic patients had a long history of coexisting depression and/or anxiety disorders. Overall, about a third of patients with depression or panic disorder have had lifelong problems with drug abuse. These are estimates, best clinical guesses, but associating depression and addiction is no longer a speculative venture.

As with more familiar forms of addiction, bulimia was coming to be seen as another serotonin/dopamine-mediated medical condition. As noted, serotonin is involved in both the binge and the purge. Once researchers began performing the necessary double blind, placebo-controlled studies, it became clear that serotonin-boosting drugs dramatically lessened bulimic behavior in general, and associated carbohydrate binging in particular, in a large number of diagnosed bulimics. (Anorexia nervosa, another eating disorder, does not show the same serotonin affinities in action.)

Bulimics often maintain a normal weight, but can suffer serious physical consequence—heart rhythm irregularities, electrolyte imbalances, low blood pressure, and damage to the esophagus. Once the binge-purge cycle has been established, some researchers believe, drug-like changes in serotonin 5HT receptor distributions help reinforce the pattern. It is not surprising to learn that Prozac and other serotonin reuptake inhibitors such as dexfenfluramine were prominent among the drugs being tested against bulimia in the 1990s. By 1995, a paper presented at the National Social Science Association Conference in San Diego stated: “The serotonin hypothesis of bulimia nervosa suggests that bulimia is the behavioral manifestation of functional underactivity of serotonin in the central nervous system.”

In 1997, Prozac became the first drug ever licensed by the Food and Drug Administration (FDA) for the treatment of bulimia nervosa, as this chronic disorder is officially known. The drug’s formal approval was based on three clinical studies showing median reductions in binging of as much as 67 per cent for Prozac, compared with 33 per cent for placebo. Vomiting was reduced by 56 per cent, compared to 5 per cent for female placebo users. (About 10 per cent of diagnosed bulimics are males.) There is often a family history of alcoholism and/or eating disorders. The locus of “serotonergic dysfunction” appears to be the hypothalamus. Low levels of serotonin and dopamine metabolites have been documented in the cerebrospinal fluid of bulimic patients. Evidence exists for the involvement of norepinephrine as well.

Bulimia, like alcoholism and other drug addictions, has its psychosocial side, but twins studies show that there is very probably a genetics of bulimia to be pursued. In one influential study, an identical twin stood a one-in-four chance of developing bulimia, if the other twin was diagnosed with the disorder. A combination of SSRI drugs and some form of structured cognitive therapy is the recommended approach.

--Excerpted from
Addiction: The Search for a Cure © Dirk Hanson 2007

Photo Credit: Graham Menzies Foundation

Epigenetics and Addiction

noreply@blogger.com (Dirk Hanson) — Fri, 30 May 2008 18:13:00 +0000

Turning off the genes for substance abuse.

If psychiatric disorders, including depression and addiction, are rooted in nature, but modified by nurture, some better way of viewing the interaction between genes and the environment is desperately needed.

Enter "epigenetics," defined as the study of how gene expression can be modified without making direct changes to the DNA. Writing in Science News, Tina Hesman Saey explains that "epigenetic mechanisms alter how cells use genes but don't change the DNA code in the genes themselves.... The ultimate effect is to finely tune to what degree a gene is turned on or off. Often the fine tuning is long-lasting, setting the level of a gene's activity for the lifetime of the cell."

A common form of epigenetic modification involves adding molecules to the DNA structure. Adding molecules from a methyl group or an acetyl group can change the manner in which genes interact with a cell's transcribing system. Cells can "mark" specific genes by attaching a methyl group consisting of three hydrogen atoms and one carbon atom to cytosine in the DNA base, effectively turning genes on or off without making major alterations to genetic structure. (Gene mutations or insertions, on the other hand, are capable of fundamentally altering the DNA protein structure.)

Scientists have learned that epigenetic changes can be caused by environmental impacts, but the details are not well understood. We have not yet reached the point of being able to link a specific experience of stress or infection or chemical exposure to specific epigenetic alterations.

What does any of this have to do with drug addiction or depression? One of the environmental impacts researchers have linked to epigenetic changes is drug addiction. The DNA double helix is packaged in proteins collectively called chromatin. One set of proteins, the histones, is a frequent site of epigenetic modification. In a study published in Neuron, Eric Nestler and co-workers in the Southwestern Medical Center at the University of Texas found that alterations in chromatin packaging were tied up with the dopamine release caused by cocaine addiction. The researchers concluded that chronic cocaine use was influenced by "chromatin remodeling." Specifically, modulating histone activity "alters locomotor and rewarding responses to cocaine."

How does this work? As Saey writes in Science News: "Another gene, known as delta-FosB, also switches on when a wave of dopamine washes over the nucleus accumbens.... Delta-FosB teams up with other transcription factors and recruits enzymes that acetylate histones and remodel control regions of some genes..... Such findings suggest that medicines that interrupt or reverse epigenetic changes caused by drugs of abuse could one day prevent or cure addiction."

Image Credit: Science in School

Annals of Addiction: Richard Lewis

noreply@blogger.com (Dirk Hanson) — Thu, 29 May 2008 18:37:00 +0000

From The Harder They Fall

"It's hard to know exactly when I became an alcoholic. What I do know is that growing up I felt misunderstood, not appreciated, and needing validation. I didn't feel I was getting it from important people in my life. They had their problems, their own concerns. I felt sort of invisible....

"Drinking made me feel not as miserable. It was a great Band-Aid. It progressed, but it didn't stop me in my career. I've done well, and I was an alcoholic at the height of my career, when I really hit. When alcohol really got me by the throat, I quit stand-up comedy. Acting was easier. Easier to stay sober most of the time, do my work, and know I'm off for three days.....

"There were tip-offs, even way early. I remember getting some sort of sexually transmitted disease that was going to last for a week. I had to take certain antibiotics, and I remember the doctor very nonchalantly saying, 'Oh, by the way, you can't drink for five days.' I was going to New York to appear on the Letterman show, and all I thought about was, 'Oh my God, there I am in first class, five-and-a-half hours in an airplane, without booze. There I am in New York with my friends and no booze. I can't even have a couple of glasses of wine in my hotel room to relax before the show.' That's all I thought about. I wasn't thinking of my career. I wasn't thinking about anything but 'I can't believe I can't drink.' It was horrifying. And that was thirteen years before I bottomed.

"I was hallucinating. I was emaciated. Holed up doing coke for six nights.... I was ashamed to waste my life, given all the blessings I had. That I would throw away my life needlessly. To have a disease that I could stop giving myself, if I surrendered, finally.....

"One reason I love being sober is that I thought about this guy I saw who slipped last week, who I spoke to this morning.... I wouldn't have been able to do that if I was drinking. I couldn't have helped this guy.... If I'm going to leave any kind of legacy, making people laugh is fine, but to help somebody get the darkness from out of their eyes and to turn their life around, it's the most important aspect of my life."

Excerpted from:

The Harder They Fall, by Gary Stromberg and Jane Merrill. Center City, MN: Hazelden.

Photo Credit: Pearlies of Wisdom

Annals of Addiction: Grace Slick

noreply@blogger.com (Dirk Hanson) — Wed, 28 May 2008 14:50:00 +0000

From The Harder They Fall

"There's a whole bunch of alcoholics on both sides of my family, but they function in the sense that everybody kept their jobs. There were no divorces, except for my grandmother, but she's not an alcoholic. She was just a wild child like I was. Our alcoholics all kept their jobs and stayed married....

"The Airplane became famous as the original psychedelic band, but personally, I was more of a drinker. Anything that was around and easy I took--marijuana was very easy to score, but alcohol was my drug of choice. That's the genetic deal going on, where I'm an addict in the sense that anything I like I'm all over. Like flies on shit! And sometimes that works out fine. Right now I'm a painter. That's how I make my living and pay the mortgage....

"In 1970, when I became pregnant with China, I wasn't conscious of addiction. My life was all just sex, drugs and rock and roll. But I'm not a moron, so I knew that what you put into your face goes into your body, and part of your body is what's living in there--the child....

"Life is now fine. My daughter is sober. China came in a couple of weeks after me. Into the same rehab. My sponsor was amused. She had never seen a mother-daughter combination in the same rehab....

"I always felt very close to the story of Alice in Wonderland for a real good reason. If you remember what happened to her, she came from a very straight-laced Episcopalian Republican background, and at some point between twelve and twenty-four--mine at about eighteen or so--you go down the rabbit hole."

Excerpted from:
The Harder They Fall, by Gary Stromberg and Jane Merrill. Center City, MN: Hazelden.

Photo Credit: Donna E. Natale Planas/Miami Herald

Annals of Addiction: Malcolm McDowell

noreply@blogger.com (Dirk Hanson) — Mon, 26 May 2008 21:28:00 +0000

From The Harder They Fall

"My father was an alcoholic, so I never really drank much. I kept away from it, but I didn't realize that cocaine was really the same thing. Alcohol eventually started getting a little out of control, but in the form of 'fine wine.' That was my excuse....

"So I didn't consider wine a problem, but cocaine was a problem, and that got out of hand quite fast. It had a very bad effect on my marriage. The lies and deceit and everything that goes with addiction. I went from snorting it occasionally to now smoking it, doing freebase. Doing as much as I could. Finish a batch at four in the morning. Driving around the San Fernando Valley looking for some more of it. Driving while completely stoned, of course. How I was never in an accident, I just don't know....

"The using ended because I went down to the Betty Ford Center.... I didn't thank God at the time time, however. I felt I'd lost a great friend or mistress, that I'd lost the one thing that I could totally trust--all that bullshit! It wasn't until I started to work on myself at Betty Ford, which is a wonderful place as is any place that gets you sober....And, of course, it's hard work, recovery. Less and less hard as the years have gone by, but you know, the way we live our lives is all recovery in one sense or another. We go through a shattering experience like that, and everything we do in life from then on is in a way influenced by what we've been through."

Excerpted from:
The Harder They Fall, by Gary Stromberg and Jane Merrill. Center City, MN: Hazelden.

Photo Credit: MTV News

The Chemistry of Cocaine Addiction

noreply@blogger.com (Dirk Hanson) — Mon, 19 May 2008 17:40:00 +0000

Crack, free-base, and powder

The cocaine high is a marvel of biochemical efficiency. Cocaine works primarily by blocking the reuptake of dopamine molecules in the synaptic gap between nerve cells. Dopamine remains stalled in the gap, stimulating the receptors, resulting in higher dopamine concentrations and greater sensitivity to dopamine in general.

Since dopamine is involved in moods and activities such as pleasure, alertness and movement, the primary results of using cocaine--euphoria, a sense of well being, physical alertness, and increased energy—are easily understood. Even a layperson can tell when lab rats have been on a cocaine binge. The rapid movements, sniffing, and sudden rearing at minor stimuli are not that much different in principle from the outward signs of cocaine intoxication among higher primates.

Chemically, cocaine and amphetamine are very different compounds. Psychoactively, however, they are very much alike. Of all the addictive drugs, cocaine and speed have the most direct and most devastatingly euphoric effect on the dopamine systems of the brain. Writing in the November 2004 issue of Synapse, Jonathan D. Brodie and colleagues at the New York University School of Medicine reported that “A rapid elevation in nucleus accumbens dopamine characterizes the neurochemical response to cocaine, methamphetamine, and other drugs of abuse."

In the late 1990s, scientists at Johns Hopkins and NIDA had shown that opiate receptors play a role in cocaine addiction as well. PET scans demonstrated that cocaine addicts showed increased binding activity at mu opiate receptors sites in the brain during active cocaine addiction. Take away the cocaine, and the brain must cope with too many empty dopamine and endorphin receptors.

Cocaine and amphetamine produce rapid classical conditioning in addicts, demonstrated by the intense cravings touched off by such stimuli as the sight of a building where the user used to buy or sell. Environmental impacts of this nature can produce marked blood flow increases to key limbic structures in abstinent addicts.

When the crack "epidemic" first became news, it was clear that the old specialty of free-basing was now within reach of existing cocaine users. No paraphernalia needed except for a small pipe; no more butane and mixing; no muss, no fuss. Like basing, smoking crack was a drug dealer’s dream. The “rush” from smoking crack was more potent, but even more transient, than the short-lived high from nasal ingestion

Both the cocaine high and the amphetamine high are easily augmented with cigarettes or heroin. These combinations result in “nucleus accumbens dopamine overflow,” a state of neurochemical super saturation similar to the results obtained with the notorious “speedball”—heroin plus cocaine.

It has been clear for more than a decade that most cocaine treatment programs are failures. In the case of the newly arrived crack cocaine, relapse rates after formal treatment sometimes approach one hundred per cent. Clearly, a piece of the puzzle has been missing. If receptors were the sites that controlled how drugs affected the mind, and if genes controlled how receptors were grown, then one implication of all the receptor theories was that sensitivity to addictive drugs could conceivably have a genetic basis. It was a large step in the right direction, because there were already good reasons for seeing alcoholism and other addictions as inherited dysfunctions in brain chemistry.

--Excerpted from Addiction: The Search for a Cure © Dirk Hanson 2007

Photo Credit: Legal Drug Alternatives

Take the Alcohol Test

noreply@blogger.com (Dirk Hanson) — Sat, 17 May 2008 17:57:00 +0000

CAGE questionnaire still a useful tool

Despite the time, labor, and expense that have gone into the search for a better way to diagnose alcoholism, researchers have yet to outdo what may be the simplest, most accurate test for alcoholism yet devised. A set of four simple, relatively non-controversial questions, first devised in 1970 by Dr. John A. Ewing, still serve as a useful predictive tool for alcoholism.

Neurobiology has taught us that addictive drugs cause long-lasting neural changes in the brain. The problems start when sustained, heavy drinking forces the brain to accept the altered levels of neurotransmission as the normal state of affairs. As the brain struggles to adapt to the artificial surges, it becomes more sensitized to these substances. It may grow more receptors at one site, less at another. It may cut back on the natural production of these neurotransmitters altogether, in an effort to make the best of an abnormal situation. In effect, the brain is forced to treat alcoholic drinking as normal, because that is what the drinking has become.

The likelihood that many alcoholics and other drug addicts have inherited a defect in the production and distribution of serotonin and other neurotransmitters is a far-reaching finding. While it is difficult to measure neurotransmitter levels directly in brains, there are indirect ways of doing so. One such method is to measure serotonin’s principle metabolic breakdown product, a substance called 5-HIAA, in cerebrospinal fluid. From these measurements, scientists can make extrapolations about serotonin levels in the central nervous system as a whole.

However, testing for serotonin levels is imprecise and impractical in the real world of the doctor's office and the health clinic. Despite all the promising research on neurotransmission, what can physicians and health professionals do today to identify alcoholics and attempt to help them? For starters, physicians could look beyond liver damage to the many observable “tells” that are characteristic patterns of chronic alcoholism—such manifestations as constant abdominal pain, frequent nausea and vomiting, numbness or tingling in the legs, cigarette burns between the index and middle finger, jerky eye movements, and a chronically flushed or puffy face. Such signs of acute alcoholism are not always present, of course. Many practicing alcoholics are successful in their work, physically healthy, don’t smoke, and came from happy homes.

The CAGE test takes less than a minute, requires only paper and pencil, and can be graded by test takers themselves. It goes like this:

1. Have you ever felt the need to (C)ut down on your drinking?

2. Have you ever felt (A)nnoyed by someone criticizing your drinking?

3. Have you ever felt (G)uilty about your drinking?

4. Have you ever felt the need for a drink at the beginning of the day—an “(E)ye opener?

People who answer “yes” to two or more of these questions should seriously consider whether they are drinking in an alcoholic or abusive manner.

--Excerpted from Addiction: The Search for a Cure © Dirk Hanson 2007

Neuroaddiction and the Reward Pathway

noreply@blogger.com (Dirk Hanson) — Fri, 16 May 2008 01:22:00 +0000

How addictive drugs fool Mother Nature

"The addicted brain is distinctly different from the nonaddicted brain,” writes Alan Leshner, the former director of the National Institute of Drug Abuse (NIDA). “Changes in brain structure and function is what makes it, fundamentally, a brain disease. A metaphorical switch in the brain seems to be thrown as a result of prolonged drug use.”

Addiction is both a cause and a consequence of these fundamental alterations in brain function. If physical abnormalities in the brain are at the root of the problem, then any treatment program worth its weight ought to be dealing—directly or indirectly--with these differences in brain state. Writing in Lancet, researcher Charles O’Brien has suggested a similar orientation: “Addiction must be approached more like other chronic illnesses--such as diabetes and chronic hypertension--than like an acute illness, such as a bacterial infection or a broken bone."

All of this suggests that we are not likely to win a war on drugs, achieve zero tolerance, or become chemical-free any time soon. The drug problem is an artifact of the basic design of the mammalian brain. Humankind is extraordinarily susceptible to drug abuse anywhere and everywhere certain drugs are widely available—and all because of a “design quirk” in the reward pathways of the central nervous system.

Any sufficiently powerful receptor-active drug is, in its way, fooling Mother Nature. This deceit means, in a sense, that all such drugs are illicit. They are not natural, however organic they may be. Yet, the human drive to use them is all-pervasive. We have no real built-in immunity to drugs that directly target specific receptors in the limbic and cortical pleasure pathways. The act of “liking” something is controlled by the forebrain and brain stem. If you receive a pleasant reward, your reaction is to “like” it.

If, however, you are anticipating a reward, and are, in fact, engaging in behaviors motivated by that anticipation, it can be said that you “want” it. The wholly different act of wanting something strongly is a mesolimbic dopamine-serotonin phenomenon. We like to receive gifts, for example, but we want food, sex, and drugs. As Nesse and Berridge put it, “The ‘liking’ system is activated by receiving the reward, while the ‘wanting’ system anticipates reward and motivates instrumental behaviors. When these two systems are exposed to drugs, the “wanting” system motivates persistent pursuit of drugs that no longer give pleasure, thus offering an explanation for a core paradox in addiction."

Under the biochemical paradigm, a runaway appetite for non-stop stimulation of the reward pathway is a prescription for disaster. The harm is physical, behavioral, and psychological--as are the symptoms. Peer pressure, disciplinary difficulties, contempt for authority--none of these conditions is necessary for drug addiction to blossom. What the drug itself does to people who are biologically vulnerable is enough. No further inducements are required.

Even this brief summation of the ways in which addictive drugs alter neurotransmission should serve to demonstrate that these substances have more in common than we ordinarily assume. All these drugs are of course rewarding, so it is perhaps not too surprising, for all their differences, that they work the limbic reward pathways. All these drugs share common mechanisms of action, which is why they are addictive.

--Excerpted from Addiction: The Search for a Cure © Dirk Hanson 2007