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.

Americans Spending $100 Billion on Illegal Drugs Annually

The U.S. White House Office of National Drug Control Policy (ONDCP) commissioned the RAND Corporation to investigate how much Americans were spending on the four most common illegal drugs from 2000-2010. The study, published recently on the whitehouse.gov website, uses a variety of sources to develop an estimate in yearly spending by consumers of cannabis, heroin, cocaine (including crack), and methamphetamine. Their conclusion: over $100 billion is spent on just these four drugs, every year. Interestingly, this number has stayed relatively constant throughout the past decade, despite the $25.2 billion that was spent "to reduce drug use and its consequences" in the US in fiscal year 2014 alone (!).

Since 2002, spending on cocaine and marijuana has flipped. Researchers note that cocaine consumption has dropped by about half, while marijuana consumption has increased by around 40%. Heroin consumption has remained stable throughout the decade, with a small increase detected in the later years. Methamphetamine consumption, the authors note, has been harder to track, as "national datasets do not do a good job of capturing its use." Across the board, heavy users are the main drivers of spending and consumption, and are defined as folks who use at least 21 days/month.

The authors culled data from a variety of sources, including the National Survey on Drug Use and Health, the Arrestee Drug Abuse Monitoring Program, various law enforcement and seizure databases, and more. Despite the apparent rigor involved in the creation of these estimates, the authors caution about the inherent uncertainty in this type of data analysis - especially considering that the bulk of the data came from self-report surveys.

Nevertheless, the fact remains that despite the increasing public investments in the so-called War on Drugs, demand-side consumption and expenditures are constant or rising throughout the country. Could this be one reason the Attorney General has agreed to endorse changes to Federal drug sentencing? What do readers think about the current state of availability and expense?

You can read the full report here:

http://www.whitehouse.gov/ondcp/research-and-data/estimation-drug-expenditures-consumption-supply

"First Controlled Study of LSD-Assisted Psychotherapy in More Than 40 Years"

Researchers from Switzerland and the Multidisciplinary Association for Psychedelic Studies have conducted what they are calling the first study of its kind in over 40 years: a randomized, double-blind, active placebo-controlled study of LSD-assisted psychotherapy. The participants, 12 patients with anxiety related to life-threatening illnesses like metastatic cancer, non-Hodgkin's lymphoma, Parkinson's disease, etc., participated in drug-free therapy sessions as well as 2 LSD-assisted psychotherapy sessions over the course of the study. Follow-up interviews were conducted at 2- and 12-months post-treatment and indicated lasting, statistically-significant improvements in anxiety. The study is posted in its entirety for free online via The Journal of Nervous and Mental Disease.

The main outcome measures were scores on the State-Trait Anxiety Inventory (STAI). Exclusion criteria included current drug or alcohol disorders, primary psychotic, dissociative or bipolar 1 disorders, neurocognitive impairment or pregnancy/nursing. Participants in the experimental arm participated in 2 full-day LSD-assisted psychotherapy sessions, 2 to 3 weeks apart, that were "embedded within an ongoing process of [six]drug-free psychotherapy sessions for preparatory and integrative purposes." Subjects received doses of 200 micrograms of pure LSD and the day-long sessions lasted 8 hours, or until the effects of the medication wore off. Participants in the active placebo group received the exact same set of psychotherapy sessions, but were given 20-microgram doses of LSD. After the 2-month follow-up interview, these participants were informed of their place in the control group and were offered the full, open-label intervention.

The results indicate statistically significant STAI scores for both state and trait anxiety at 2 and 12 months for the experimental groups. The active placebo did not produce statistically-significant improvements. The researchers calculate the effect size at 1.1 for trait anxiety, and 1.2 for state anxiety. They also, as you would imagine, call for more research with larger controlled studies. Importantly, neither the experimental drug nor the placebo produced any serious adverse effects, leading the authors to seem confident in the safety of this type of therapy.

Considering the research on LSD ground to a halt by the 1970s, do readers think it's time to revisit this(or other psychedelics, for that matter) as a therapeutic tool? If you have experience with this, it would be fascinating to hear your take, too.

Interested to hear readers opinions on the matter...

Source:
http://journals.lww.com/jonmd/Documents/90000000.0-00001.pdf

Can Alcohol Dependent Patients Adhere to an ‘As-Needed' Medication Regimen? Yes: Study

According to researchers, AUD patients can benefit from as-needed medication regimens:

Abstract:

A pooled analysis of ‘as-needed medication use' data from 1,276 patients in two randomised, double-blind, placebo-controlled, parallel-group trials of nalmefene in the treatment of alcohol dependence was performed to explore whether an ‘as-needed' regimen is an acceptable and feasible strategy in patients seeking help for alcohol dependence. Adherence was defined as alcohol consumption and medication intake, or no alcohol consumption (with or without medication intake). Nalmefene was taken on approximately half of the study days; placebo was taken more often than nalmefene (52.8 vs. 64.5% of days, respectively). In each treatment group medication intake appeared to vary according to patients' needs in that intake correlated with the baseline drinking pattern. Sixty-eight percent of the nalmefene-treated patients (78% of the study completers) adhered to the as-needed treatment regimen on at least 80% of the study days. In conclusion, as-needed use is a feasible, patient-centred approach that engages patients with alcohol dependence in the active management of their illness. © 2014 S. Karger AG, Basel

Source: http://www.karger.com/Article/FullText/357865

Maintenance, not abstinence, will save addicts' lives

Read Dr W's Op-Ed in this week's Star Tribune:

http://www.startribune.com/opinion/commentaries/246619891.html

Researchers Take a Novel Approach to Vivitrol Induction

Researchers and clinicians at Duke University performed a small, open label study to test a new induction protocol for opioid detoxification in an outpatient setting. Much has been written about the pros and cons of antagonist medication for opioid dependence, with most evidence supporting agonist medications like buprenorphine or methadone. One of the most difficult aspects of maintenance antagonist treatment is the detoxification and induction phases of treatment, considering the intolerability of the experience to most patients - especially those in outpatient settings. So, the authors of a new study, published recently in Drug and Alcohol Dependence, sought to make this experience a little more tolerable. The administered increasing doses of naltrexone and decreasing doses of buprenorphine to treatment-seeking opioid addicts until their first dose of extended-release injectable naltrexone (Vivitrol). The results were encouraging:

Abstract

BACKGROUND

The approval of extended release injectable naltrexone (XR-NTX; Vivitrol®) has introduced a new option for treating opioid addiction, but studies are needed to identify its place within the spectrum of available therapies. The absence of physiological opioid dependence is a necessary and challenging first step for starting XR-NTX. Outpatient detoxification gives poor results and inpatient detoxification is either unavailable or too brief for the physiological effects of opioids to resolve. Here we present findings from an open label study that tested whether the transition from opioid addiction to XR-NTX can be safely and effectively performed in an outpatient setting using very low dose naltrexone and buprenorphine.

METHODS

Twenty treatment seeking opioid addicted individuals were given increasing doses of naltrexone starting at 0.25 mg with decreasing doses of buprenorphine starting at 4 mg during a 7-day outpatient XR-NTX induction procedure. Withdrawal discomfort, craving, drug use, and adverse events were assessed daily until the XR-NTX injection, then weekly over the next month.

RESULTS

Fourteen of the 20 participants received XR-NTX and 13 completed weekly assessments. Withdrawal, craving, and opioid or other drug use were significantly lower during induction and after XR-NTX administration compared with baseline, and no serious adverse events were recorded.

CONCLUSIONS

Outpatient transition to XR-NTX combining upward titration of very low dose naltrexone with downward titration of low dose buprenorphine was safe, well tolerated, and completed by most participants. Further studies with larger numbers of subjects are needed to see if this approach is useful for naltrexone induction.

Mean opioid withdrawal and craving scores during induction and after naltrexone extended release administration (Days 1-9), using SOWS (Subjective Opioid Withdrawal Scale), COWS (Clinical Opioid Withdrawal Scale) and VAS (Visual Analog Scale) for craving. Time point scores are the results of the mean score of each day of treatment, error bars represent + -1 SEM. Number of participants is reported on the X-axis.

In-treatment proportion of opioid positive urine samples (Day1-9, N = 20).

Source:

http://www.sciencedirect.com/science/article/pii/S0376871614000568

Computerized Vs In-Person Brief Intervention for Drug Misuse: RCT

We have written much about the challenges of widespread implementation of SBIRT in the US. Well, authors of a new study, published online this month in the journal, Addiction, have suggested a novel tool which they believe could help ensure that scores of additional patients are being screened: computerized brief intervention. And according to their study, it works as well and the in-person version:

Abstract

Background and aims

Several studies have found that brief interventions (BIs) for drug misuse have superior effectiveness to no-treatment controls. However, many health centers do not provide BIs for drug use consistently due to insufficient behavioral health staff capacity. Computerized BIs for drug use are a promising approach, but their effectiveness compared with in-person BIs has not been established. This study compared the effectiveness of a computerized brief intervention (CBI) to an in-person brief intervention (IBI) delivered by a behavioral health counselor.

Methods

Two-arm randomized clinical trial, conducted in two health centers in New Mexico, USA. Participants were 360 adult primary care patients with moderate-risk drug scores on the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) who were randomly assigned on a 1:1 basis to a computerized brief intervention (CBI) or to an in-person brief intervention (IBI) delivered by a behavioral health counselor. Assessments were conducted at baseline and 3-month follow-up, and included the ASSIST and drug testing on hair samples.

Results

The IBI and CBI conditions did not differ at 3 months on global ASSIST drug scores (b=-1.79; 95% CI=-4.37,-0.80) or drug-positive hair tests (OR=.97; 95% CI= 0.47,1.94). There was a statistically significant advantage of CBI over IBI in substance-specific ASSIST scores for marijuana (b=-1.73; 95% CI= -2.91,-0.55; Cohen's d=.26; p=.004) and cocaine (b= -4.48; 95% CI= -8.26,-0.71; Cohen's d=.50; p=.037) at 3 months.

Conclusions

Computerized brief intervention can be an effective alternative to in-person brief intervention for addressing moderate drug use in primary care.

What do you think - could computerized brief interventions be the key to widespread SBIRT implementation?

Source: http://onlinelibrary.wiley.com/doi/10.1111/add.12502/abstract