November 29, 2007 8:29

The Addiction Wars

I wrote a post a few weeks back on a paper that described a step forward in understanding the neurobiological basis of addiction. In it, I mentioned the fact that understanding the underlying biology could help lead to new medications to treat the problem—and the comments have been raging ever since.

The most prolific poster by far, Nathan, took me to task for touting medication as a cure-all:

Addiction is not something that can be prevented by taking a pill, nor is it simply the result of dopamine saturation. If it was, why is it that some are much more susceptable to addiction than others? Why can addiction be traced through the family tree? Billions of people can have a drink and not become addicted. There are genetic vulnerabilities involved in the equation; its not just alcohol.

Which is true of course, and I don't mean to suggest medication can necessarily cure addiction. But like insulin, which isn't a cure for diabetes, medication could very plausibly help an addict recover, and make relapse less likely.

Nathan goes on:

Now we have doctors that treat mental health by the bottle without advocating therapy, even though medication should only be used as a last resort, and ONLY for the short term. The patients want the quick fix, and the doctors want pharma's money. You can artificially modify the chemicals of the brain and shift someones personality out of depression, but it doesn't "fix" anything; it's a patch. I have no doubt that eventually someone will create a pill to do the same thing for addiction, but its like giving someone crutches for a broken leg and declaring him healed.

Most of the mental-health experts I know would agree that simply handing a patient a pill and declaring him or her cured is totally irresponsible. Most would also agree that telling someone with a broken leg "no crutches for you" would be equally so. The suggestion about what medication is ONLY good for, however, is not nearly as settled as Nathan suggests.

He continues:

I cringe every time I hear about research being conducted with the end goal of developing more medication. Most addiction treatment centers use the disease model, which gives people the false impression that it can be "cured" with a pill.

Most treatment professionals, and lay groups like AA, use the disease model but explicitly say it can not be cured. Rather, they say it can be held in remission--again, like diabetes. The fact that there's no cure for diabetes shouldn't, however, make people cringe at the news that researchers are trying to find one. Seems to me that it should be the same with addiction, no?

Another of Nathan's key concerns is that there aren't enough long-term studies of psychiatric drugs to be sure of their safety—and he's right to be concerned. But then he asks:

Which is more important, developing better therapy techniques or developing more effective medication?

To which I answer: why do I have to choose one? I also wonder what "developing better therapy techniques" even means. Every so often, someone comes up with a new type of therapy, and at least one—cognitive behavioral therapy—has become widely endorsed by therapists in the bast 25 years or so, for a wide range of problems. But I don't know much about active programs to develop new therapies. Maybe someone can enlighten me on that. I'm all for it.

November 14, 2007 10:09

Another Insight into Addiction

A couple of months ago, I wrote this cover story on the new science of addiction, and one of the things I talked about was the key role of the neurotransmitter dopamine. Among other things, dopamine governs the brain's reward system—it tells you "that feels good" when you do something pleasurable.

It's already known that addictive drugs, including alcohol, trigger a rush of dopamine. Getting that literal rush is such a powerful reward that it's a big part of the reason addicts go back to drugs, even though they know objectively that it's a truly bad idea.

Now comes a paper in the Journal of Neuroscience that adds another key piece to the addiction puzzle. Nora Volkow, director of the National Institute on Drug Abuse, along with several colleagues, used brain-imaging studies to look at the dopamine responses of alcoholics—not to alcohol, but to a different drug, methylphenidate, better known by its trade name Ritalin. In normal subjects, the drug causes a spike in dopamine in the brain's prefrontal cortex.

But in alcoholics, the study found, that spike is significantly muted. Says Volkow: "It could explain why alcoholics encounter a decrease in the ability to experience pleasure from everyday activities." In essence, they've been overstimulating their dopamine systems for so long with alcohol that their brains have become numb. It also explains why so many relapse into drinking; it's the one way they can experience any sort of pleasure.

That's the bad news. The good news is that any gain in our understanding of the underlying biochemistry of addiction can give researchers clues about new treatments. As Volkow told TIME back in July: "Addiction is a medical condition. We have to recognize that medications can reverse the pathology of the disease."

This one more step toward that crucial goal. Here's a link to a really useful book on addiction.