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Addiction Poorly Understood by Clinicians

Addiction Poorly Understood by Clinicians Bal Harbour, Fla—A patient with high blood pressure arrives at his annual checkup after another sedentary year. His physician, who has sketchy knowledge about hypertension, sees that the patient has gained 12 lbs and that his blood pressure remains high. She lectures the patient about the importance of willpower in overcoming his life-threatening shortcomings. Without a thought about prescribing one of the several effective antihypertensives, she dismisses the patient, shakes her head, and murmurs to herself about the seemingly hopeless plight of "those hypertensives." Such a scenario seems absurd—but insert "drug addiction" in place of "hypertension," and an all-too-common picture emerges, said scientists, clinicians, and other treatment specialists at the College for the Problems of Drug Dependency annual meeting held here in June. For all the lip service paid to the concept of addiction as a medical disease, the idea has yet to gain traction with a large proportion of physicians. They, like many others in society, often regard abuse of alcohol or drugs as a moral or behavioral problem, said several speakers. Addiction experts say that the widely held view of drug addiction as a moral or behavioral problem rather than a medical disease undermines treatment efforts. (Photo credit: Corbis) "Addiction is a brain disease," said Charles O'Brien, MD, PhD, a noted addiction specialist, during a keynote address at the meeting. "But when you say that to [an audience], people get very angry. It's something we have to continue selling." Bob Margolis, PhD, a psychologist who runs an adolescent drug and alcohol treatment program in Atlanta, related a story indicative of the problem. After delivering a presentation on addiction at a local hospital, several physicians approached him and said, "I wish someone [had] told me about this in medical school." Common myths Common myths According to Dispelling Myths About Addiction, a 1997 report from the Institute of Medicine, just 1% of the typical medical school curriculum is devoted to the subject. Surveys of physicians also consistently show that most fail to screen for alcohol or drug addiction; many believe that medical interventions are inappropriate and ineffective. Common myths Those who do see addiction as a medical problem tend to treat it as an acute, instead of chronic, disorder. And the idea that addiction is simply a consequence of willfulness still permeates the profession. O'Brien, a professor of psychiatry at the University of Pennsylvania School of Medicine, Philadelphia, and colleagues made these points in a review article three years ago (JAMA. 2000;284:1689-1695). Common myths "There is such prejudice in the community of doctors, severe prejudice," said National Institute on Drug Abuse Director Nora Volkow, MD, PhD, at an addiction studies program for journalists sponsored by Wake Forest University School of Medicine, Winston-Salem, NC, and held concurrently with the College for the Problems of Drug Dependency meeting. Common myths "How do we change this?" she asked. Addiction experts not only have to emphasize that addiction is a disease, but they also have to emphasize that addiction leads to other medical problems—it basically permeates medicine, Volkow explained. "We can prevent a lot of other problems by addressing addiction, but somehow we have failed to communicate that," she said. Common myths According to the National Institute on Drug Abuse, some $133 billion is spent each year treating the short- and long-term medical complications of addiction. Cocaine abusers die from sudden cardiac arrest; heroin and other intravenous drug users contract hepatitis C and human immunodeficiency virus; and many other illicit drug users endure damage to the kidneys or liver. Add billions more for treating cirrhosis and brain damage from alcoholism and lung cancer from smoking, and it becomes clear that addiction places a huge medical burden on society. Like other diseases Like other diseases As addiction medicine has evolved into its own isolated specialty over the past three decades, practitioners have continually buttressed their assertion that addiction is a disease. They like to point out that the natural history of and treatment strategies for addiction strongly resemble those of other chronic diseases, in particular diabetes, hypertension, and asthma. Like other diseases Scientists have uncovered a wealth of evidence that—much as the pancreas deteriorates in diabetes—the brain changes during addiction, trapped in an ever-deepening spiral of entrenched behavior. All drugs of abuse activate the dopamine reward circuit, a neural pathway essential to pleasure. This circuit is deeply connected to areas of the brain that control memory, emotion, and motivation. Any pleasurable activity—having sex, eating food, using drugs—activates these intertwined pathways and reinforces the pleasurable behaviors. Eventually, the dopamine circuit becomes blunted; with tolerance, a drug simply pushes the circuit back to normal, boosting the user out of depression but no longer propelling him or her toward euphoria. Imaging studies reveal the biology of addiction. Although the cerebellum is not often thought of as a participant in drug craving and reward, recent functional MRI studies have revealed activation of the cerebellar vermis in cocaine addicts watching cocaine-related videos. The color scale bar indicates relative signal intensity changes (from 0% to 0.6%) occurring when subjects watched neutral segments of video versus segments associated with cocaine use. Gray in the false color map indicates decreased signal intensity. (Photo credit: C.M. Anderson, M.J. Kaufman, et al/Brain Imaging Center, McLean Hospital) Like other diseases "If you continually bombard the body with a substance, you create a new allostasis," said Kent Vrana, PhD, who studies the genetics of alcoholism at Wake Forest. "And your body defends that. You literally ‘drink to feel normal,'" he said, quoting an hoary adage from recovery circles. Like other diseases Some of these brain changes appear to be long-lasting. Before joining the National Institute on Drug Abuse, Volkow spent years developing advanced imaging technology and techniques for the study of addiction. Among a host of findings, she reported that the dopamine system of cocaine users remains impaired for up to 3 months after their last snort. Other researchers have shown that formerly addicted individuals with long periods of abstinence experience powerful cravings when exposed to specific external cues, such as films of individuals using drugs. Evidence from animal studies Evidence from animal studies Perhaps the most powerful evidence that drug addiction is a physical disease springs from rodent and monkey studies. Evidence from animal studies "Animal behavior around drugs is remarkably similar to how people behave," said David Friedman, PhD, professor of physiology and pharmacology at Wake Forest. "It's a real low-level biological reaction. In a sense, you're stripping away all the higher reasoning, leaving just the survival instincts." Evidence from animal studies Addiction parallels diabetes, asthma, and hypertension in other ways, too. All worsen if left untreated; susceptibility can be inherited; medications ease symptoms but do not effect a cure; recurrence is routine; and each can be triggered or exacerbated by voluntary behavior—overeating, smoking, not exercising, having a drink, or using a drug. Evidence from animal studies But the one commonality that frustrates physicians more than any other is poor treatment compliance. Evidence from animal studies "The literature of compliance would literally fill this room," said Tom McClellan, PhD, director of the Treatment Research Institute at the University of Pennsylvania, and a speaker at the addiction studies program for journalists. "And it's filled with vitriol." Evidence from animal studies According to the JAMA review, individuals with diabetes adhere to their prescriptions about 60% of the time; they diet and exercise at about half that rate. Of individuals with asthma, only 30% to 40% use their inhalers or other medications as recommended. And of course, individuals struggling with addiction often return to their drug of choice. Evidence from animal studies In turn, many patients with chronic diseases require retreatment. Such care accounts for a huge proportion of medical spending in the United States. Evidence from animal studies "With diabetes, when someone comes back without changing their behavior, doctors point their finger and blame and so on, and guess what?" said McClellan. "It doesn't work." Evidence from animal studies So too it goes with addiction. The difference is that with addiction, the need for retreatment is seen as a failure—not only of the individual, but of the treatment as well. Re-evaluating addiction treatment "success" Re-evaluating addiction treatment "success" McClellan is critical of this double standard, which he says is at least partly rooted in a wrong-headed definition of "success." Virtually every study of addiction treatment measures success as abstinence at some point after completion of the treatment. To McClellan, this makes about as much sense as strapping a blood pressure cuff on a hypertensive patient who no longer takes his antihypertension medication, and then expecting a favorable reading. Re-evaluating addiction treatment "success" "It's wasteful to study outcomes 6 or 12 months posttreatment," he said. "It's expensive and it doesn't make sense. Evaluations should occur during treatment." In fact, said McClellan, the best studies of addiction treatment show that patients who receive 9 to 12 months of outpatient treatment plus continuing aftercare do much better than patients who receive 9 to 12 months of treatment with no aftercare. Re-evaluating addiction treatment "success" Further, nearly half of all money spent on addiction treatment in the United States goes to acute detoxification with no follow-up, a sure sign that addiction is wildly misunderstood. Addiction specialists are nearly unanimous that 2 or 3 days of detoxification will never cure addiction; it simply prepares patients for continuing outpatient or inpatient care. Re-evaluating addiction treatment "success" Contrary to perception, this principle has been well documented. In fact, researchers have been compiling information about what constitutes effective drug treatment for 30 years. In 1999, an expert panel convened by the National Institute on Drug Abuse, including O'Brien and McClellan, codified this knowledge in Principles of Drug Addiction Treatment, a 56-page manual. Re-evaluating addiction treatment "success" Some of the manual's 13 principles are intuitive: treatment needs to be readily available; no single treatment is appropriate for everyone; and possible drug use during treatment needs to be monitored. Others are perhaps less obvious: addicted individuals with comorbid mental illnesses need to receive integrated treatment for both disorders; treatment does not need to be voluntary to be effective; and recovery from addiction is a long-term process that often requires multiple treatment episodes. Not a choice Not a choice The final myth that ignites addiction specialists is the idea that individuals simply choose to continue abusing drugs despite negative consequences. Not a choice "In 15 years, I've never met [a patient] who . . . wanted to be an addict," said Volkow. "Sure, they started out wanting to take a drug. But the problem is we don't know who will become addicted." Not a choice McClellan put it like this: "Drinking is voluntary, but your reaction is not." Not a choice According to a 1999 Institute of Medicine report on medical marijuana, 32% of individuals who try tobacco become dependent, as do 23% of those who try heroin, 17% of those who try cocaine, 15% of those who try alcohol, and 9% of those who try marijuana (Marijuana and Medicine: Assessing the Science Base. Washington, DC: National Academies Press; 1999). Not a choice The genetics behind these figures is slowly being unraveled. Alcoholism is the best studied addiction; about 40% of the risk for the disease appears inherited, said Vrana. The Consortium on the Genetics of Alcoholism, a group of researchers studying families with strong histories of the disease, is at work tracing several dozen candidate genes that may help confer this risk. Not a choice The most promising single candidate, so far, is the gene for aldehyde dehydrogenase, an enzyme that metabolizes alcohol. Asian populations tend to carry a variation of the gene that protects them from alcoholism by producing a less active enzyme that struggles to break down even small amounts of alcohol. As acetaldehyde accumulates in the bloodstream, the drinker experiences more and more unpleasant effects, the so-called flush response. Disulfiram, a drug sometimes prescribed to individuals with severe alcoholism, works by inhibiting aldehyde dehydrogenase; when taking the drug, one alcoholic drink can cause flushing, throbbing headache, and vomiting. Not a choice But as the knowledge of addiction's biological origins grows, specialists are hearing an increasingly vociferous backlash from those who say that labeling addiction a medical condition deletes personal responsibility from the equation. Not a choice In fact, the best addiction treatments, said Volkow, teach patients the biological origins of their disease while helping them understand how their behavior affects the individuals around them. Not a choice "Calling it a disease does not absolve personal responsibility. They aren't mutually exclusive," said Volkow. "It's a prejudice we constantly battle." For More Information For More Information The College on Problems of Drug Dependence, a large professional society founded in 1929. The group's annual meeting attracts more than 1000 diverse addiction specialists. Available at: http://www.cpdd.vcu.edu. Dispelling the Myths About Addiction: Strategies to Increase Understanding and Strengthen Research, is a 1997 report from the Institute of Medicine, published by National Academies Press. Available at: http://www.nap.edu/catalog/5802.html. Principles of Drug Addiction Treatment, a 56-page summary of 13 research-based principles, is available from the National Institute on Drug Abuse at: http://www.nida.nih.gov/PODAT/PODATindex.html. September is National Recovery Month, sponsored by the Center for Substance Abuse Treatment at the Department of Health and Human Services. Available at: http://www.recoverymonth.gov/. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Addiction Poorly Understood by Clinicians

Vastag, Brian
JAMA , Volume 290 (10) – Sep 10, 2003
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Publisher
American Medical Association
Copyright
Copyright © 2003 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.290.10.1299
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Abstract

Bal Harbour, Fla—A patient with high blood pressure arrives at his annual checkup after another sedentary year. His physician, who has sketchy knowledge about hypertension, sees that the patient has gained 12 lbs and that his blood pressure remains high. She lectures the patient about the importance of willpower in overcoming his life-threatening shortcomings. Without a thought about prescribing one of the several effective antihypertensives, she dismisses the patient, shakes her head, and murmurs to herself about the seemingly hopeless plight of "those hypertensives." Such a scenario seems absurd—but insert "drug addiction" in place of "hypertension," and an all-too-common picture emerges, said scientists, clinicians, and other treatment specialists at the College for the Problems of Drug Dependency annual meeting held here in June. For all the lip service paid to the concept of addiction as a medical disease, the idea has yet to gain traction with a large proportion of physicians. They, like many others in society, often regard abuse of alcohol or drugs as a moral or behavioral problem, said several speakers. Addiction experts say that the widely held view of drug addiction as a moral or behavioral problem rather than a medical disease undermines treatment efforts. (Photo credit: Corbis) "Addiction is a brain disease," said Charles O'Brien, MD, PhD, a noted addiction specialist, during a keynote address at the meeting. "But when you say that to [an audience], people get very angry. It's something we have to continue selling." Bob Margolis, PhD, a psychologist who runs an adolescent drug and alcohol treatment program in Atlanta, related a story indicative of the problem. After delivering a presentation on addiction at a local hospital, several physicians approached him and said, "I wish someone [had] told me about this in medical school." Common myths Common myths According to Dispelling Myths About Addiction, a 1997 report from the Institute of Medicine, just 1% of the typical medical school curriculum is devoted to the subject. Surveys of physicians also consistently show that most fail to screen for alcohol or drug addiction; many believe that medical interventions are inappropriate and ineffective. Common myths Those who do see addiction as a medical problem tend to treat it as an acute, instead of chronic, disorder. And the idea that addiction is simply a consequence of willfulness still permeates the profession. O'Brien, a professor of psychiatry at the University of Pennsylvania School of Medicine, Philadelphia, and colleagues made these points in a review article three years ago (JAMA. 2000;284:1689-1695). Common myths "There is such prejudice in the community of doctors, severe prejudice," said National Institute on Drug Abuse Director Nora Volkow, MD, PhD, at an addiction studies program for journalists sponsored by Wake Forest University School of Medicine, Winston-Salem, NC, and held concurrently with the College for the Problems of Drug Dependency meeting. Common myths "How do we change this?" she asked. Addiction experts not only have to emphasize that addiction is a disease, but they also have to emphasize that addiction leads to other medical problems—it basically permeates medicine, Volkow explained. "We can prevent a lot of other problems by addressing addiction, but somehow we have failed to communicate that," she said. Common myths According to the National Institute on Drug Abuse, some $133 billion is spent each year treating the short- and long-term medical complications of addiction. Cocaine abusers die from sudden cardiac arrest; heroin and other intravenous drug users contract hepatitis C and human immunodeficiency virus; and many other illicit drug users endure damage to the kidneys or liver. Add billions more for treating cirrhosis and brain damage from alcoholism and lung cancer from smoking, and it becomes clear that addiction places a huge medical burden on society. Like other diseases Like other diseases As addiction medicine has evolved into its own isolated specialty over the past three decades, practitioners have continually buttressed their assertion that addiction is a disease. They like to point out that the natural history of and treatment strategies for addiction strongly resemble those of other chronic diseases, in particular diabetes, hypertension, and asthma. Like other diseases Scientists have uncovered a wealth of evidence that—much as the pancreas deteriorates in diabetes—the brain changes during addiction, trapped in an ever-deepening spiral of entrenched behavior. All drugs of abuse activate the dopamine reward circuit, a neural pathway essential to pleasure. This circuit is deeply connected to areas of the brain that control memory, emotion, and motivation. Any pleasurable activity—having sex, eating food, using drugs—activates these intertwined pathways and reinforces the pleasurable behaviors. Eventually, the dopamine circuit becomes blunted; with tolerance, a drug simply pushes the circuit back to normal, boosting the user out of depression but no longer propelling him or her toward euphoria. Imaging studies reveal the biology of addiction. Although the cerebellum is not often thought of as a participant in drug craving and reward, recent functional MRI studies have revealed activation of the cerebellar vermis in cocaine addicts watching cocaine-related videos. The color scale bar indicates relative signal intensity changes (from 0% to 0.6%) occurring when subjects watched neutral segments of video versus segments associated with cocaine use. Gray in the false color map indicates decreased signal intensity. (Photo credit: C.M. Anderson, M.J. Kaufman, et al/Brain Imaging Center, McLean Hospital) Like other diseases "If you continually bombard the body with a substance, you create a new allostasis," said Kent Vrana, PhD, who studies the genetics of alcoholism at Wake Forest. "And your body defends that. You literally ‘drink to feel normal,'" he said, quoting an hoary adage from recovery circles. Like other diseases Some of these brain changes appear to be long-lasting. Before joining the National Institute on Drug Abuse, Volkow spent years developing advanced imaging technology and techniques for the study of addiction. Among a host of findings, she reported that the dopamine system of cocaine users remains impaired for up to 3 months after their last snort. Other researchers have shown that formerly addicted individuals with long periods of abstinence experience powerful cravings when exposed to specific external cues, such as films of individuals using drugs. Evidence from animal studies Evidence from animal studies Perhaps the most powerful evidence that drug addiction is a physical disease springs from rodent and monkey studies. Evidence from animal studies "Animal behavior around drugs is remarkably similar to how people behave," said David Friedman, PhD, professor of physiology and pharmacology at Wake Forest. "It's a real low-level biological reaction. In a sense, you're stripping away all the higher reasoning, leaving just the survival instincts." Evidence from animal studies Addiction parallels diabetes, asthma, and hypertension in other ways, too. All worsen if left untreated; susceptibility can be inherited; medications ease symptoms but do not effect a cure; recurrence is routine; and each can be triggered or exacerbated by voluntary behavior—overeating, smoking, not exercising, having a drink, or using a drug. Evidence from animal studies But the one commonality that frustrates physicians more than any other is poor treatment compliance. Evidence from animal studies "The literature of compliance would literally fill this room," said Tom McClellan, PhD, director of the Treatment Research Institute at the University of Pennsylvania, and a speaker at the addiction studies program for journalists. "And it's filled with vitriol." Evidence from animal studies According to the JAMA review, individuals with diabetes adhere to their prescriptions about 60% of the time; they diet and exercise at about half that rate. Of individuals with asthma, only 30% to 40% use their inhalers or other medications as recommended. And of course, individuals struggling with addiction often return to their drug of choice. Evidence from animal studies In turn, many patients with chronic diseases require retreatment. Such care accounts for a huge proportion of medical spending in the United States. Evidence from animal studies "With diabetes, when someone comes back without changing their behavior, doctors point their finger and blame and so on, and guess what?" said McClellan. "It doesn't work." Evidence from animal studies So too it goes with addiction. The difference is that with addiction, the need for retreatment is seen as a failure—not only of the individual, but of the treatment as well. Re-evaluating addiction treatment "success" Re-evaluating addiction treatment "success" McClellan is critical of this double standard, which he says is at least partly rooted in a wrong-headed definition of "success." Virtually every study of addiction treatment measures success as abstinence at some point after completion of the treatment. To McClellan, this makes about as much sense as strapping a blood pressure cuff on a hypertensive patient who no longer takes his antihypertension medication, and then expecting a favorable reading. Re-evaluating addiction treatment "success" "It's wasteful to study outcomes 6 or 12 months posttreatment," he said. "It's expensive and it doesn't make sense. Evaluations should occur during treatment." In fact, said McClellan, the best studies of addiction treatment show that patients who receive 9 to 12 months of outpatient treatment plus continuing aftercare do much better than patients who receive 9 to 12 months of treatment with no aftercare. Re-evaluating addiction treatment "success" Further, nearly half of all money spent on addiction treatment in the United States goes to acute detoxification with no follow-up, a sure sign that addiction is wildly misunderstood. Addiction specialists are nearly unanimous that 2 or 3 days of detoxification will never cure addiction; it simply prepares patients for continuing outpatient or inpatient care. Re-evaluating addiction treatment "success" Contrary to perception, this principle has been well documented. In fact, researchers have been compiling information about what constitutes effective drug treatment for 30 years. In 1999, an expert panel convened by the National Institute on Drug Abuse, including O'Brien and McClellan, codified this knowledge in Principles of Drug Addiction Treatment, a 56-page manual. Re-evaluating addiction treatment "success" Some of the manual's 13 principles are intuitive: treatment needs to be readily available; no single treatment is appropriate for everyone; and possible drug use during treatment needs to be monitored. Others are perhaps less obvious: addicted individuals with comorbid mental illnesses need to receive integrated treatment for both disorders; treatment does not need to be voluntary to be effective; and recovery from addiction is a long-term process that often requires multiple treatment episodes. Not a choice Not a choice The final myth that ignites addiction specialists is the idea that individuals simply choose to continue abusing drugs despite negative consequences. Not a choice "In 15 years, I've never met [a patient] who . . . wanted to be an addict," said Volkow. "Sure, they started out wanting to take a drug. But the problem is we don't know who will become addicted." Not a choice McClellan put it like this: "Drinking is voluntary, but your reaction is not." Not a choice According to a 1999 Institute of Medicine report on medical marijuana, 32% of individuals who try tobacco become dependent, as do 23% of those who try heroin, 17% of those who try cocaine, 15% of those who try alcohol, and 9% of those who try marijuana (Marijuana and Medicine: Assessing the Science Base. Washington, DC: National Academies Press; 1999). Not a choice The genetics behind these figures is slowly being unraveled. Alcoholism is the best studied addiction; about 40% of the risk for the disease appears inherited, said Vrana. The Consortium on the Genetics of Alcoholism, a group of researchers studying families with strong histories of the disease, is at work tracing several dozen candidate genes that may help confer this risk. Not a choice The most promising single candidate, so far, is the gene for aldehyde dehydrogenase, an enzyme that metabolizes alcohol. Asian populations tend to carry a variation of the gene that protects them from alcoholism by producing a less active enzyme that struggles to break down even small amounts of alcohol. As acetaldehyde accumulates in the bloodstream, the drinker experiences more and more unpleasant effects, the so-called flush response. Disulfiram, a drug sometimes prescribed to individuals with severe alcoholism, works by inhibiting aldehyde dehydrogenase; when taking the drug, one alcoholic drink can cause flushing, throbbing headache, and vomiting. Not a choice But as the knowledge of addiction's biological origins grows, specialists are hearing an increasingly vociferous backlash from those who say that labeling addiction a medical condition deletes personal responsibility from the equation. Not a choice In fact, the best addiction treatments, said Volkow, teach patients the biological origins of their disease while helping them understand how their behavior affects the individuals around them. Not a choice "Calling it a disease does not absolve personal responsibility. They aren't mutually exclusive," said Volkow. "It's a prejudice we constantly battle." For More Information For More Information The College on Problems of Drug Dependence, a large professional society founded in 1929. The group's annual meeting attracts more than 1000 diverse addiction specialists. Available at: http://www.cpdd.vcu.edu. Dispelling the Myths About Addiction: Strategies to Increase Understanding and Strengthen Research, is a 1997 report from the Institute of Medicine, published by National Academies Press. Available at: http://www.nap.edu/catalog/5802.html. Principles of Drug Addiction Treatment, a 56-page summary of 13 research-based principles, is available from the National Institute on Drug Abuse at: http://www.nida.nih.gov/PODAT/PODATindex.html. September is National Recovery Month, sponsored by the Center for Substance Abuse Treatment at the Department of Health and Human Services. Available at: http://www.recoverymonth.gov/.

Journal

JAMA – American Medical Association

Published: Sep 10, 2003

Keywords: addictive behavior

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