Is Addiction Always Permanent?

Recently, a colleague challenged what he perceived to be my "insistence that addiction is permanent." Here is my reply:

Dear John (not his real name):

As you know, I'm well aware of the studies regarding the life course of people who at some point in their lives meet dxic criteria for a SUD. And also, as you are aware, I've been talking about that, and therefore the need to have a wider continuum of care and to individualize approaches to SUDs for at least 10 years. In my presentation, Alcoholism Isn't What It Used to Be, which you frequently reference, I point out that 20 years after onset of DSM IV Alcohol Dependence, the most common outcome is low-risk drinking (40%), followed by abstinence (roughly 1/3), partial remission (about 20%) and then finally currently dependent (8%). So I'm not sure what the basis is for concluding that I have made blanket statements about ALL addicts in ALL circumstances.

 

What I do believe, and here I think the science and epidemiology are equally persuasive, is that in the case of severe addiction, there are brain neuroadaptations that are irreversible. For example, the likelihood of achieving non-abstinent recovery is inversely related to the severity of alcohol dependence. Conversely, abstinent outcomes become more likely as severity increases. This is as true in rodents as in humans. Since rehab and AA are populated almost exclusively by people at the very severe end of the spectrum, the likelihood of sustained non-abstinent recovery for current treatment seekers or AA members is relatively low. Thus, the AA stance is accurate for most AA members. Severity of dependence is the strongest predictor of AA affiliation, especially long-term affiliation, as opposed to a few weeks or months after a spell in rehab. Established heroin or other opioid addiction is another example; thus buprenorphine and methadone maintenance and the virtually complete failure of abstinence (or moderation) for treatment seekers. Those who could stop on the their own do so and therefore do not present for tx. That, of course, is a function of the awfulness, expense, stigmatization and disruption most current treatment includes.

 

At Alltyr Clinic, for example, I have seen many pts who come with a mild AUD who achieve non-abstinent recovery.

 

Just as abstinence is not a requirement for everyone who develops a SUD, neither is moderation possible for a sizeable proportion of them. The size varies by drug: Probably close to 100% of dependent smokers will require lifelong abstinence, whereas, most cannabis users will not, etc. Heroin, meth and cocaine addiction also probably have high to relatively high proportions where abstinence (which includes people taking opioid agonist therapy) is the only positive outcome option. In alcohol, I think it's probably somewhere in the middle, a large minority achieve non-abstinent recovery.

 

So the newer data simply seem to affirm the NESARC data, that conclusions have been based on clinical samples, and that if you look at community samples, the picture is very different. That's true for almost all common complex diseases, such as asthma or arthritis or even hypertension, the difference being that with SUDs there is a very high full remission rate, something that happens in very few other common complex diseases. Depression is very likely to be a pretty good analogue as well.

 

Finally, noting that many people have milder, self-limiting forms of SUDs doesn't mean they aren't brain disesases. How can you have a behavioral illness that doesn't include failures in brain regulation of behavior? It's just that in too many instances, people misinterpret "brain disease" to mean "permanent". Also, it hasn't helped that NIDA and SAMHSA keep stressing the chronicity of addiction, something I constantly fought against when i was at NIH. It's often not chronic. Neither is asthma, but I suspect you wouldn't have trouble thinking of mild, self-limited childhood asthma as a lung disease, or immune disease.

Study: Sex-Dependent Differences in Subjective Cannabis Effects (Do Women Enjoy Pot More Than Men?)

A new article by researchers at the New York State Psychiatric Institute and Department of Psychiatry at Columbia University explores the differences in the way men and women report their subjective experiences of the effects of cannabis. The authors reviewed data from four separate outpatient studies evaluating a range of cannabis-induced effects. In the final analysis, the subjects (35 men and 35 women) were all daily or near-daily cannabis users and their responses to standardized measures of mood, physical symptoms, and cannabis-related drug effects were recorded over time, beginning immediately after consumption.

It turns out, women were significantly more likely to report more feelings associated with enjoyment (and abuse liability) than men were:

According to the authors: "The results from this study demonstrate that when cannabis smokers are matched for use, ratings of cannabis’ subjective effects that are associated with abuse liability are higher in women compared to men. Although men and women significantly differed in body weight, sex differences were not observed for all subjective effects, including ratings of cannabis intoxication. "

In addition, cannabis use is more prevalent among men than women in the US (51.4% vs 37.4%, resp.). "Yet among cannabis smokers, women have a faster trajectory to cannabis-use disorders, which the current findings might in part explain." The authors call for more research to further explain the clinical significance of sex differences in the effects of cannabis and cannabis-use disorders.

The article by Cooper & Haney can be viewed here:

http://www.drugandalcoholdependence.com/article/S0376-8716%2813%2900529-2/abstract

Oxytocin Shown to Block Alcohol Withdrawal

In a small, randomized, double-blind clinical trial, intranasal oxytocin blocked the effects of alcohol withdrawal on a population presenting to a hospital-based detoxification unit. Results from the study were published in the March edition of Alcoholism: Clinical and Experimental Research and are the first to confirm results obtained in other studies using non-human subjects.

In the study, participants (n=11) were given either lorazepam and oxytocin (n=7), or lorazepam and placebo (n=4), over three days of inpatient detox. They were then administered several standardized alcohol withdrawal measurements (CIWA, AWSC, ACVAS, POMS) and compared the two groups. Across the board, patients who were administered intranasal oxytocin scored significantly lower on withdrawal measures, while reporting significantly less craving and significantly better mood.
While the limitations of the study (small size) are clear, these findings are impressive and will lead to further research. In recent years, oxytocin has shown promise in the treatment of multiple disorders. Certainly, this research will add another voice to the chorus of oxytocin advocates.

Ants, Corporations, Complexity, Emergence

Heard on NPR Morning Edition:

Ants, bees, and other colonizing insects have complex organizations similar in many respects to modern corporations. Each ant has a specialized function that varies by age. The young ones tend the queen, middle-aged ants do clean up duty, and the older more experienced ants go out foraging for food. "The queen is really the only one with a dead-end job: laying eggs." Ants can jump over the clean up straight to foraging, similar to overachieving corporate managers. I don't know if the ants have to suck up to whoever is the ant CEO (this actually didn't come up) or not. Actually, it doesn't appear there is a CEO, the colonies are self-organizing. The scientist discussing this was asked about whether ants retire and her answer was that "ant retirement is not pretty." There is a specialized function for some ants, namely corpse disposal.

So in many ways, ant colonies are similar to corporations, but in addition to the presumed lack of a CEO or Board, there are other differences as well. Ant communication is much more efficient than in corporations. The ants communicate through chemical and other means than spread throughout the colony. "There is no email in an ant colony." (Lucky them, and presumably no Facebook or Twitter or texting either.) Another difference is that that there are no ants who get 400-500% more of the goodies than the median ant, while average CEO:median worker pay ratio is something like that. (According to Payscale.com, the Wal-Mart CEO is paid greater than 1000% more than the median worker there.) And presumably, ants don't get memberships in country clubs as part of their executive pay package.

The scientific principles here are complexity and emergence, an extremely important property of self-organizing systems, such as humans and the human "colony."  If you want to learn more, there is a fun site where you can set up your own ant colony. Just don't try to be the CEO.

MW

White House Announces Brain Mapping Initiative

Whew! Long drought! I was caught a bit off guard by the response to Jane Brody's column about Inside Rehab, which generated a lot of inquiries and new patients for Alltyr! All good things, plus opening the new office in downtown St. Paul and many other activities have left me a bit overwhelmed. Today's blog is written by Ian McLoone, a graduate student at the University of Minnesota Master of Professional Studies in Integrated Behavioral Health. Ian has been working with me learning about clinical work, as well as helping with Alltyr Clinic and other activities. He's going to be a regular contributor to Substance Matters.

MW

White House Announces Brain Mapping Initiative

President Obama announced on Tuesday plans to invest more than $100 million to develop and fund technology to map the human brain. The project, titled “Brain Research through Advancing Innovative Neurotechnologies”, or BRAIN Initiative, aims to improve our understanding of the human brain and, according to the White House, “uncover new ways to treat, prevent, and cure brain disorders like Alzheimer’s, schizophrenia, autism, epilepsy, and traumatic brain injury.”

Being hailed as the next Human Genome Project, the ambitious initiative will direct $50 million to the Defense Advanced Research Projects Agency (DARPA), $40 million to the National Institutes of Health (NIH), and another $20 million to the National Science Foundation (NSF). In addition, several private sector foundations and institutes have pledged significant contributions, each with specific goals in mind.

Cori Bargmann of Rockefeller University and William Newsome of Stanford University will lead the NIH working group. They will be tasked with creating specific plans, goals, a time frame, and cost estimates for the project moving forward. Of course this begs the question: what goals or plans would blog readers like to see addressed in this process? Is this initiative too ambitious, or not ambitious enough, given its size and scope? Leave your comments after the jump.

Change: Continuous and Discontinuous

Recently I have several patients who have made remarkable progress in a short time. I would call this discontinuous change. That is, there is a prevalent notion that change occurs gradually, step by step. And sometimes that's how it happens. But then there are times when people change in multiple ways, on multiple dimensions, all at once. Change can be continuous or discontinuous. Now, in some ways this distinction requires some kind of arbitrary decision about what those terms mean. Ultimately, it's an issue of measurement. So, "continuous change" occurs at a smaller scale than the current measurement can detect, while "discontinuous change" occurs in a way that is distinct, a detectable change. Or, one could define it quantitatively or qualitatively. For example, "discontinuous change" could be defined as a change of a certain magnitude, or changes of a certain magnitude on multiple levels or in multiple scales.

But clinically, there are times when I'm simply blown away. A patient comes in who is hardly recognizable, and not simply because of cosmetic or clothing or grooming changes, although they may be a part of it. It's more that a different person walks through the door. Someone who thinks, speaks and otherwise behaves in multiple ways they have not previously. This happens with both substance use disorders and with psychiatric disorders. All of a sudden, everything is different. And no one, least of all the person who just transformed, has any idea why this happened now, at this moment in time. These events are not predictable with current knowledge and scientific methods. They may never be. (A part of me hopes and, of course, therefore predicts, that they never will be.) Anyway, in the past several weeks I have been completely blown away by progress in some of my patients.

What causes the change? There may be environmental events that have powerful effects, such as a DUI, hospitalization, serious medical illness, interpersonal experience, and so on. But these are not very reliable predictors and are not always present. I have patients who have had a DUI and then stopped drinking, and I have others where it doesn't seem to make a difference. Most often, my changed patients report to me that they have either "gotten sick and tired of being sick and tired," or "just decided," or "I just woke up and felt different." We don't have insight into how or why we make the most important decisions in our lives. Our reasons, by and large, are constructions designed to continue a cohesive narrative of our lives. We decide and then construct the reasons. Now sometimes it is the other way around. A slow, rational deliberation (System 2 in Daniel Kahneman's scheme) often plays an important role. But more often I think it's the other way around.

Here's my working hypothesis: complex dynamical systems (including us) tend to configure into a number of discrete, finite states, rather than an infinite number of slightly different ones. We tend to flip from one state to another, much like a tornado suddenly forms out of a certain set of optimal circumstances (but not always, and not easily specifically predicted.) And for us, these states include cognitive, affective (emotional), perceptive, behavioral, genomic, metabolomic, organ, organ system, organismal and social components that may all change at once on multiple levels.

And the thing is, there is only one thing happening even though it is happening at multiple levels. This is a hard one, an idea I finally developed when I was at NIH. In complex dynamical systems, an event occurs on many levels at once. Of course, there may be an instigating event, let's say an adverse social interaction that sets off a crusade of processes ending in severe depression and extremely heavy drinking. The response of a particular person (organism) involves all different levels of analysis essentially at once, because there are millions or billions or trillions of extremely rapidly interactive events that make up the whole. Everything happens on all levels at once: from particle physics up to global and beyond. However, we cannot examine the whole, we need to examine a part of it. We may talk to the involved person, ask them about their experience, perhaps ask them to fill out some scales. We may examine their social interactions and networks, or patterns of communication. We might put them in an fMRI or PET scanner to examine brain blood flow and metabolism, we might measure the output of a stress hormone such as cortisol in the blood, and so on. But we delude ourselves if we think that by looking at one level of analysis, we can say much about the system's behavior. It's not simply linear: A causes B which causes C. It requires a different type of mathematical modeling to help predict the behavior of the system as a whole. But this science is new and will take a long time to mature.

What about therapy or treatment? Sometimes, I think that by creating a safe, therapeutic environment and providing straight, often difficult, but always compassionate feedback, I may make a change like that possible. It often feels like a lifeline - I provide a secure support and anchor for taking chances and making changes. Some patients volunteer this information - that having me in their corner allowed them to make changes they were previously afraid to make, or that I provided a direction they had not seen before. Other times, I have no idea. A patient changed suddenly to the better, and I don't feel I had much if anything to do with it. This isn't false modesty; I'm talking about people I may see every 3 months for medication checks, but who suddenly undergo a big positive change. Most of the time, it's pretty hard to tell. Maybe I made a difference, maybe not. But it's enough to keep going, doing my best, trying to help people in any way I can. And I'm grateful for that opportunity. People let me into their lives in the most intimate ways imaginable, trusting me not to betray them, not to hurt them. I feel very privileged and humbled by that trust and I do my best to be deserving of it.

MW

Determinism, Neuroscience and Free Will: A Conversation

I've recently been having a conversation with a colleague about implications of recent neuroscience research and free will (and therefore blameworthiness, or responsibility for our actions.)  Thought you might be interested. My colleague is Steven P. Gilbert, Ph.D., ABPP, LP. He is married to Anne Fletcher, who recently published a wonderful new book (more on that in a later post) called "Inside Rehab." If you haven't read it, you'll want to. There's nothing else like it on the planet.

MW

Mark,

Anne sent me your blog below about the frustrations of appealing to reason in argumentation.  I thought you might be interested in both the column I've included below entitled "Reasons Matter (When Intutitions Don't Object)" and the attached PDF, both by psychologist Jonathan Haidt.

I think Haidt's work is brilliant.  He demonstrates how evolutionary-based instincts shape our morality and thus our politics (see also  How Evolution Has Turned Us Into Liberals and Conservatives<http://blogs.telegraph.co.uk/news/edwest/100143941/how-evolution-turned-us-into-liberals-and-conservatives/>), and that reason is but a johnny-come-lately to the project.  He uses the analogy of an elephant and a rider -- the rider is our conscious reasoning and the elephant is our evolutionary-based emotions. Mostly, we use reason post-hoc to justify what our emotions "push" us to decide and conclude.

It all fits perfectly with Benjamin Libet's classic research in neuroscience which found that unconscious neuronal processes precede and potentially cause volitional acts which are retrospectively felt to be consciously motivated by the subject  (disturbing research because it challenges the notion of free will).

Steve

Steve, I couldn't agree more. I've always been an "intuitionist," as Haidt puts it, and I've always found much of academic psychology to be sterile and meaningless, in part because of the emphasis on rationality as the basis for decision-making. But my time at NIH is what really convinced me, as I became intimately acquainted with Kahneman's work, among many others, concerning Systems 1 and 2. Many years ago, I concluded that determinism is fundamentally correct, but irrelevant, because we still have to reason and act accordingly, it's how we're made. Also, it's irrelevant because quantum physics tells us that you can't know the precise location, mass and trajectory of every particle in the universe, because there isn't one. Therefore, you can't predict the future, although you could suggest probabilities of various outcomes (50% chance of showers today.)

Another body of work that convinced me of that, although I'm not truly familier with it, is that of social psychologists, who repeatedly find that our "freely made decisions" are strongly affected by our social, internal and external environments, although we are almost never conscious of that. 

That said, I'm concerned about the popularization of what is essentially another metaphor for the id, ego and superego, the idea that we have to tame the reptilian monster through reason and religion. Hair shirts, anyone, or flogging, perhaps?

Mark

Mark,

Your observation the indeterminism of quantum mechanics (which has outsed Newtonian determinism) opens the door to free will  –– is really interesting,  though at the outer limits of my conceptual abilities in both physics and philosophy!  Does knowing that God does in fact play dice, i.e., that there is always the possibility of Heisenbergian uncertainty (that no one can "determine" how I will act), really mean I have free will?    If our actions are caused by chance, we lack control and if we lack control, then we don't have free will, do we?

Re taming the reptilian monster, my readings in evolutionary psychology suggest that emotions are merely "evolution's executioners," to quote Robert Wright.  That is, emotions are essentially motivational dispositions which impel us to behave in adaptive ways, i.e. in ways which increase the likelihood of survival and reproduction (i.e., of having our genes replicated.)  Lust (more specifically, male desires for a partner with physical characteristics that signal health and fertility and female desires for a partner with physical and psychological characteristics which signal skill at resource acquisition and a willingness for commitment), maternal love, drives to understand the world, all  are in the service of our "selfish genes."  Admitedly reductionistic, but true nonetheless, I think!

Steve

Steve,

Re your first paragraph:

My primary point was that IMO the question of free will is moot, because we have to act as if we have it even if we don't in theory. That is, accepting determinism, how does one make a decision? "I" still have to "make a decision," and since no one can predict or understand all the pre-determinants, even if "my decision" was pre-determined, it doesn't change anything. Even trying to implement determinism doesn't work. For example, you could say, "It doesn't matter what "I" think because "my decision" is already determined. Therefore, I will flip a coin for every "choice" that "I" have to make" still doesn't help, because that is a "choice" itself, and "my mind" can (and probably will) change. I don't think there's a way out of this loop. If that's so, then we have "no choice" but to act as if we do have choice and make decisions. I think the recursive nature of consciousness and rational thought (system 2) is an evolutionary development. We don't need consciousness to have language, make calculations, or do anything else. So it could be argued (and has, by Skinner) that consciousness is simply an epiphenomenon, perhaps something that came along for the ride with some other more essential evolutionary development, and that we simply respond to reinforcement. I suspect that consciousness evolved because it does have evolutionary value, probably by monitoring System 1 and allowing non-instinctual decision-making. However, it also unleashed the uniqueness of human evils, by freeing us of the constraints of purely instinctive behavior. Wolves will typically fight fiercely for dominance, but when one of them surrenders, the dominant wolf will generally not kill the other one. Humans feel humiliation and shame, and go on killing sprees to punish those perceived as causing the humiliation. So whether consciousness will turn out to be advantageous in the long run remains to be seen.

Along those lines and pursuant to your second para, I've also come to believe that we are motivated to maintain homeostasis in our interoception, our awareness of our internal state, and that this drives all behavior. Emotions are combinations of thoughts and physical sensations, and there are other internal states This appears to be localized in the insular cortex, but it's not an area we hear much about in terms of research.

Mark

How to Save $30,000 and Get Better Results

I have had numerous patients who have been pressured by their families to "go away" to some residential treatment program, usually it seems in another state (than Minnesota). Florida, Arizona and California seem to have a concentration of these, especially "Executive Programs" with gourmet food, precious handling, "equine therapy," "golf therapy," yoga, life coaching, and of course first class accommodations. They run from $20,000 to $70,000 for a month. These are people who have severe, recurrent addictions, usually to alcohol but some are addicted to opioids like heroin. Almost all have been through some sort of rehab multiple times before. Many but not all have money. Often enough, it's a family member who is coughing up the big bucks.

What do they get? One patient relapsed on the plane on the way home. Not a single one had any lasting benefit. Almost all relapsed within weeks, often days after returning home. In other circumstances, patients and families, and in Minnesota, state government, will pay for lengthy stays, 90, 120, 180 days in some "recovery environment." Again, it's plenty costly. But do they get any benefit? The vast majority do not.

It's an uphill battle to try to convince family members that sending their loved one away for some period of time to some "special place" is very unlikely to change their long-term outcomes. People just do not want to believe it. And admittedly, it's a hard pill to swallow. After all, the chemical dependency treatment industry has done a commendable job of spreading the idea that anyone can recover "if they really want to." And of convincing people that they have some unique answer to an ancient problem that defies easy resolution. The really difficult fact is this: all of our treatments (yes, that includes 12 Step treatment programs and AA) have modest effects at best. (The exception to this generalization is for opioid maintenance therapy with Suboxone or methadone for addiction to opioids such as Oxycontin or heroin. Opioid maintenance therapy is extremely effective and more cost-effective than almost any medical intervention other than vaccination.) Too many people do not respond to any available treatment. And they die of their illness. They die of a hereditary, brain-based behavioral disorder that makes them vulnerable to compulsive use of alcohol, opioids, cocaine, meth or cigarettes. It's not that they aren't motivated to change. I have to say, this is one of the cruelest things that rehabs do: people are told they could stop the process if they wanted to. But guess what? Some people can't. No matter how hard they try to "work the program." No matter what they do. Even if they go 90x90, or attend 1000 12-step meetings a year. They are mystified. "Why do I keep doing this? I'm not stupid! I know what will happen, but I do it anyway." This is the mystery of addiction.

In other chronic severe diseases, health care providers constantly experience failure of available treatments, and are able to accept it. People die of heart disease, cancer, diabetes, stroke, multiple sclerosis, dementia. But in the rehab industry, staff members are protected from experiencing treatment failure. First, treatment is time limited. So, instead of having to live with patients who come back with recurrent illness when the treatment doesn't work, staff members don't have to live with (and struggle to help) people who don't respond to treatment. Second, the entire industry (and unfortunately, too many 12-step program members) believe without doubt that "treatment doesn't fail patients, patients fail treatment." Try telling that to someone with metastatic cancer, end-stage liver failure, Parkinson's disease or chronic obstructive liver disease. But because we continue to stigmatize people with addiction, we get by with it, we are told to reject them, to use "tough love," to let them "bottom out." In my experience, in too many people "bottom" is 6 feet under ground. We condemn family members who don't abandon their loved ones as "enablers." What could be more cruel than this?

As a healer, one of the hardest things I do is to stay engaged with someone who dies of addiction. To not reject them. To not condemn them. To understand they are in the grips of something neither they nor I nor anyone else can control or stop, short of imprisoning them (and even then, prisons and mental hospitals are usually full of drugs.) To accept the limitations of our available treatments. To be compassionate even as death approaches. In the last year alone, in my part-time clinical practice, I have lost 6 patients to addiction.

It's not actually different than dying of diabetic renal failure, or of multiple sclerosis, or cancer. We can accept those illnesses as "not the person's fault." But when it's a brain-based disease, we cannot fathom that a brain can become dysregulated to the degree that someone loses control of their behavior to such an extent that they die from it. It's too frightening. We can't stand the thought that we aren't in full control of our lives. That we can't control our own behavior completely.

And yet, we all know better. We all have areas of problem, non-optimal behavior. We smoke. We drink too much. We don't exercise enough. We can't get our behavior right with our spouse or partner or children. We lose it. We shop too much. We can't handle money. We eat too much. We don't take good care of ourselves when we have a chronic illness. We lose our tempers. We work too hard, or not hard enough. We ignore important things. We procrastinate.

Yet we cling to the illusion of control. Of self-determination. We control our fates. Why can't "they"?

Just to be clear, I am not advocating that people with brain-based behavioral disorders not be held responsible for their behavior. For example, I am not advocating that people who commit crimes while intoxicated should be found innocent because of their addiction. As we move further into understanding the brain mechanisms underlying destructive and/or illegal behavior, this question looms large. But I have concluded that even though brain dysregulation might underlie much of this type of behavior, society only works if we hold people responsible for their behavior in spite of that fact. Individual responsibility for behavior is a social and political necessity that cannot be sorted out by science. In this blog, I am addressing how to provide health care for people with addiction and nothing else.

It's terrifying to think of having a behavior so out of control that it kills us. Anorexia nervosa. Depression. Bipolar disorder. Schizophrenia. Addictions. Antisocial and borderline personality disorders. All have substantial mortality rates. People with serious mental illness die 25 years early on average! Is it because people don't care if they die? I know that's not true, I've worked with too many of them. No, it's because the brain is a flesh-and-blood organ that can get sick, dysregulated, in specific ways that the individual cannot have insight into and cannot control. And it kills them. We have to come to grips with this grim reality if we have any hope of overcoming these dread diseases.

One thing I do know is this: some short-term high-end expensive rehab program is not going to change anything. The best hope is long-term care management with an experienced and qualified clinician or team of clinicians. That's what we do for diabetes, heart disease, cancer, stroke, arthritis. That's the best we can do for people with severe addictions. And it is a heck of a lot cheaper besides. Give me $30,000; I'll see you daily for a year! Geez, with 8 patients, I could make $240,000 a year!

I can obtain better results at a fraction of the price than any high-end time-limited treatment program. I guarantee it! And yet, I have to accept that despite all of my best efforts, and theirs, and their families', some of my patients will not respond. And some will die as a result. And they deserve our compassion, not condemnation.

What do you think? Please spread this around, comment on it, argue, agree or do something else. These are incredibly important questions.

MW

More NIDA Hype: Vaccines for Addictions (NYT, 10/4/11)

The New York Times today published a story about research on vaccines to prevent or treat substance addictions. The tantalizing title: "An Addiction Vaccine, Tantalizingly Close." The problem? It's not only not close, it's looking more and more unlikely as time goes on. The article details the research career of Kim Janda, an immunologist at the Scripps Institute. Unfortunately, his dedicated quest to develop an effective vaccine for nicotine, alcohol, cocaine, methamphetamine or even obesity have all been dead ends. Often, research in rodents is tantalizing but then human studies are inevitably disappointing. Yet, he is said to be at the "vanguard of addiction research." No less a luminary than the inevitably quoted Drug War General and Director of the National Institute on Drug Abuse (NIDA) Nora Volkow naturally endorses this research, which they funded. Ummmhhh. What am I missing here? I wish that this research offered more promise than it appears to, but I'm afraid I see it on the back burner more than the vanguard.

 Dr. Janda commented that because there is so little available to help some of these addicts, people are desperate to hear something that gives them hope. I am sympathetic to the suffering of individuals with addiction and their loved ones, and I understand their desperation. I see it every day in my practice. Indeed as a physician I experience it, having to give them some pretty bad news about the dearth of highly effective treatments for stimulant addictions. (Note: contingency management, where patients are given rewards for staying abstinent and attending sessions is effective at improving engagement and retention. Whether those effects last very long is still unclear. Also high quality cognitive behavior therapy given to better prognosis addicts is beneficial. However, neither of these treatments is available in the community. The 12-step rehab widely available in the community probably has little if any long term effectiveness.) My interpretation is that non-treatment factors (legal sanctions, accumulating adverse consequences, pressure from others, growing up) are more important than treatment of any kind in determining whether a person will stop.

 Just to be clear, none of this is to say that funding basic and clinical research which has not yet yielded much in the way of clinical breakthroughs is not unique to addiction, and not a reason to decrease funding for it. For all of the billions of dollars put into research on treating solid cancers, for example, there is not much to show for it. In many cases, like cancer of the pancreas, brain or lung, there have been no significant advances at all. We still have no effective way to prevent or treat obesity or osteoarthritis. And yes, new treatments in these other areas that offer modest if any net benefit are also touted by a press looking for something big. So this type of thing seems pretty common in a society that looks to technological solutions for problems where changes in policy and regulation would arguably yield more. But I am concerned when the importance of research findings for treating addiction are exaggerated. I think giving hope that something new may become available has its place here as it does in other diseases. But I also think we have to be careful so we don't lose credibility among a public that is not accustomed to looking to science for an answer for addiction since the most widespread treatment is based on a spiritual transformation.

 One more quick note: Dr. Janda also made the unfortunate comment about addicts needing to "want to stop." In my experience, all addicts want to stop because being addicted is so miserable. But breaking up with cocaine is hard to do. Changing behavior of any type is very hard to do. We aren't very good at it, and we are overall pretty poor at helping others change health behavior and maintain the change. It's possible, it happens more often than we might even expect, but when it doesn't happen it's just too easy to blame the victim as "not wanting to change." And it's too scary to realize that sometimes it's impossible to change even when your life depends on it. Just ask the smokers inhaling through their tracheostomy tubes after having treatment for throat cancer. How terrifying is it to watch yourself die of a behavioral disorder that you abhor and despise and want desperately to change?

 MW

OK, So What's With the Hype About the "Drunk Protector" Drug?

Recently there have been some breathless reports about an experiment conducted by Mark Hutchinson, a scientist at the University of Adelaide, Australia. Hutchinson targeted a novel receptor, TLR4, that is involved in modulating the immune system. It is possible that this receptor is involved in some of the symptoms of drunkenness, like imbalance and slurred speech. Hutchinson gave alcohol to mice who were either normal mice ("wild type") or who had been genetically modified to lack genes encoding two different receptors involved in the TLR4 cascade. They also used a medication that blocked opioid receptors, naltrexone as a comparison group. In addition, they conducted some studies on cell cultures rather than live animals. One of the findings was that mice without these genes had shorter durations of imbalance on two difference measures when given alcohol, compared to mice who were genetically normal. This is what led to the media hype. So does this mean that we are close to a pill that allows people to drink and not get drunk, as media reports suggest? No, of course not. First, this is a very complex experiment that could only be understood by someone steeped in the neurobiology of brain transmission and alcohol's effects on various types of receptors and cells. Second, it has no current or near-term impact. It's meaning only be discerned by other neuroscientists, and it has not even been replicated by another investigator, let alone been translated into a treatment. So, don't get excited, college students! That said, the immune system is something of a trendy thing right now in just about every malady known to humankind, from diabetes to heart disease, stroke to depression. There's no question it is involved in and affected by alcohol consumption. Some effects might be positive, such as a reduced risk of diabetes or Alzheimer's Disease in moderate drinkers, and some might be negative, such liver fibrosis and dysfunctional brain neurotransmission. Here is the website for the original report, for those of you who are undaunted by lots of scientific jargon: http://onlinelibrary.wiley.com/doi/10.1111/j.1476-5381.2011.01572.x/pdf MW