June 2013 Newsletter

After a busy two months I have finally managed to produce a newsletter. I recently gave a talk on the emerging divide between those who believe that opioid substitution is a treatment in itself, and those who believe that it is not really recovery. My talk, Opioid Substitution Therapy: Treatment vs. Recovery can be found here. This was prior to me being aware of the DSM qualification of "on maintenance therapy" for those in remission from Substance Use Disorders. I think we will see this argument developing in the States, and opinions will remain polarised. Hopefully we will see a more balanced approach in the South African setting. Comments are most welcome.

In this month's newsletter we talk about: Agonist Therapy for Stimulant Addiction, Is addiction a Disease?, The Anti-Reward System, Stimulant Addiction and Gray Matter, The Most Important Treatment Studies Matrix, Chris Arnade, Mindfulness and Improved RCTs in addiction.

Agonist Therapy for Stimulant Addiction?
If we thought opioid maintenance therapy was controversial, how about dopamine agonist therapy (okay, well indirect agonist, to be precise!). Many stimulant users will tell you that methamphetamine use all but stopped their cocaine use, and now science is agreeing, suggesting that methylphenidate (Ritalin) may be good for the treatment of cocaine addiction. But don't get too excited, the study published in JAMA by a group of researchers, including Volkow and Goldstein, is based only on fMRI and not on actual treatment studies. The study showed that after methylphenidate administration there was a reduction in the abnormally strong connectivity of the ventral striatum and dorsal stratium that is seen in after cocaine administration, and at the same time there was a strengthening in the corticolimbic and corticocortical connections. This could theoretically translate into increased top-down control, and in conjunction with behavioural therapies, could help in the treatment of cocaine and other stimulant use disorders. We wait for the debate to start!

Brain Disease or Not?
These days when we hear that addiction is a brain disease we all nod our heads. I have advocated that this may not be the most useful approach when treating patients. To see addiction only from the disease model runs the risk of narrowing treatment options. We all know Leshner's seminal article Addiction is a Brain Disease and it Matters. In the latest issue of Frontiers in Psychiatry, Levy writes Addiction is Not a Brain Disease (and it Matters). Indeed, Levy is not alone in this criticism of addiction as a brain disease. Marc Lewis, Stanton Peele and Lance Dodes have all been critical, to lesser or greater degrees, of the disease model. Another article that questions the disease model is to be found in Inquiry. The article called Addiction: An Emergent Consequence of Elementary Choice Principles, argues that "normal" processes in nature can lead to extreme events, and as such, addiction is an extreme manifestation of a normal process, and could be seen as a function of the rules of everyday choice.

An interesting article on the hyping of neuroscience in the Guardian is worth a read: Human Behaviour: Is it all in the Brain - or the Mind?. In it Sally Satel and Scott O Lilienfield have this to say about addiction:
"Understanding the biological basis of pleasure leads us to fundamentally rethink the moral and legal aspects of addiction," writes neuroscientist David Linden. This is popular logic among addiction experts; yet, to us, it makes little sense. Granted, there may be good reason to reform the way the criminal justice system deals with addicts, but the biology of addiction is not one of them. Why? Because the fact that addiction is associated with neurobiological changes is not, in itself, proof that the addict is unable to choose. Just look at American actor Robert Downey Jr.
He was once a poster boy for drug excess. "It's like I have a loaded gun in my mouth and my finger's on the trigger, and I like the taste of gunmetal," he said. It seemed only a matter of time before he'd meet a horrible end. But Downey Jr entered rehab and decided to change his life. Why did Robert Downey Jr use drugs? Why did he decide to stop and to remain clean and sober? An examination of the brain, no matter how sophisticated, cannot tell us that at this time, and probably never will. The key problem with neurocentrism is that it devalues the importance of psychological explanations and environmental factors, such as familial chaos, stress and widespread access to drugs in sustaining addiction."

 As for me, when I am asked "what is addiction? Is it a disease or a behavioural condition? Is it a social construct or the result of environmental influences? Perhaps it is self-medication or a learned condition?" - my clear and unequivocal answer is "Yes!".

The Anti-Reward System
We often hear about the reward system, and sometimes how it is hi-jacked in the case of addiction. A recent New York times article suggests that it is time to retire the phrase and to look at addiction from the view of both choice and disease. George Koob and others propose a new hypothesis that turns the "Hi-jacked reward system" concept around and concludes "The recruitment of anti-reward systems provides a powerful neurochemical basis for the negative emotional states that are responsible for the dark side of addiction." I, and others, have long described the move from use to addiction as a move from "positive" reinforcement towards "negative" reinforcement. Or from impulsive to compulsive. The writers describe "Addiction as a Stress Surfeit Disorder" in the paper published in the June edition of Neuropharmacology. They propose "brain stress response systems are hypothesized to be activated by acute excessive drug intake, to be sensitized during repeated withdrawal, to persist into protracted abstinence, and to contribute to the development and persistence of addiction." Berridge would also agree that these same mechanisms could also play a significant role in the reinstatement of drug use.

Stimulant Addiction and Gray Matter
In our January newsletter I reported on Dr Karen Ersche's work that suggests that brain structure may predict vulnerability to cocaine addiction. In a new paper in Current Opinion in Neurobiology, she conducts a "Meta-analysis of structural brain abnormalities associated with stimulant drug dependence and neuroimaging of addiction vulnerability and resilience". Gray matter decline in various brain areas is well documented in cases of addictive stimulant use as this paper shows. What is less well researched is to what extent the low density preceded or was caused by the drug use.

What has been even less researched, and is of particular interest to me, is what happens with prolonged abstinence? Does the patient regain the density of a "normal" brain? This is exactly what Connolly, Bell, Foxe, and Garavan have researched in their paper "Dissociated Grey Matter Changes with Prolonged Addiction and Extended Abstinence in Cocaine Users". What is amazing, is that in certain areas, after 35 weeks of abstinence, the gray matter density of a recovering addict exceeds that of a drug naive subject. Not only this, but  there is asymmetry between the losses and gains, pre and post use. This would imply that recovery does not simply reverse the affects of drug use but involves distinct neurological processes. The implications of this are profound, and I hope to do further reading and writing around this issue.

The Most Important Treatment Studies Matrix: Fantastic Resource
The Effectiveness Bank and the Substance Misuse Skills Consortium in the UK have created a fantastic resource. They have created a matrix of addiction treatment approaches with corresponding research and the settings in which they are relevant. There is also a separate matrix for alcohol use disorders. Having had a brief look at this, I would highly recommend it to anyone in the field as a starting point when doing research into various treatment modalities. I'm sure that there will be much future debate regarding the particular research they have referenced, but no matter what our thoughts are, this is a great idea - well thought out and well executed.

 Personality of the Month
Chris Arnade is not directly involved in the addiction treatment field, but he comes face to face with addiction on a daily basis. Chris received a PhD in Physics from Johns Hopkins University and then went to work on Wall Street. He left his job as a trader on the Emerging Markets trading desk to start telling the stories of the people of Hunts Point. Chris says: "What I am hoping to do, by allowing my subjects to share their dreams and burdens with the viewer and by photographing them with respect, is to show that everyone, regardless of their station in life, is as valid as anyone else."

Any clinican working with the disenfranchised/homeless population should follow Chris's facebook page. I have been doing so for a while now, and no matter where you are in the world, addictive disorders have the same effect on this population: The use of drugs both frees the individual from the reality of their existence, while simultaneously often preventing them from rising above their situation. Chris catches this contradiction in a way that shows empathy and respect for his subjects. By following this page I believe a clinician can begin to gain an understanding of what their patients are really going through. It is easy to intellectualize, moralize and give advice. Chris's photos bring a healthy dose of reality into the mix. I find it interesting the juxtaposition between Chris's Faces of Addiction project and the well-known faces of Meth project. Chris's pictures educate, elucidate and encourage empathy, while the Faces of Meth have become a freak-show parody of the "evils" of drugs.

Mindfullness  and Addiction

My e-mail friend, neuroscientist Marc Lewis, author of Memoirs of an Addicted Brain, is off to see the Dalai Lama in October. It's part of the Mind and Life initiative - the group that organizes the Dalai Lama's interactions with scientists. The meeting will be entitled "Craving, Desire and Addiction." Also present will be Nora Volkow and Kent Berridge, so this is a pretty heavy-weight delegation. You can catch up with Marc's experiences by reading his blog: Memoirs of an Addicted Brain.

All this got me thinking about mindfulness and its increasing role in addiction treatment. I touched on it during some studies last year, and have found mindfulness to be very valuable in recovery. Most of the people I see moving from active drug use towards recovery from their disorder move from a state of reaction to considered response. They stop being driven by their impulses and compulsions, and rather learn to accept the present moment as passing. This is at the centre of mindfulness practices. I decided to have a look at some of the research and found this useful article on mindfulness based relapse prevention: Retraining the Addicted Brain: A Review of Hypothesized Neurobiological Mechanisms of Mindfulness-Based Relapse Prevention.

I also found this article on neuroplasticity and mindfulness pretty interesting: Cognitive-Affective Neural Plasticity following Active-Controlled Mindfulness Intervention

Improving Randomized Control Trials in Addiction Research
A collaboration between the Centre for Evidence Based Intervention and the Centre for Outcomes Research and Effectiveness, as well as the Institute of Child Care Research in association with CONSORT Group aims to create new guidelines for RCTs in the addictions field. This will be referred to as CONSORT-SPI (an extension for Social and Psychological Intervention). As they say in the latest issue of Addiction: "RCTs of addiction interventions are particularly challenging to report clearly and comprehensively. These interventions are often complex; they include multiple, interacting components at several levels and have various relevant outcomes. RCTs of these interventions are often reported insufficiently to understand internal validity (bias) and external validity (the applicability of a study's results in other settings or populations). To use the evidence provided by RCTs for developing and disseminating these interventions, the quality of reporting must be addressed."

 You can have your say and get involved in this process by going here: Oxford university Department of Social policy and Intervention.

Quote of the Month
This adaption of a statement attributed to Goethe comes from Dexter, Season 7, and I felt it was rather apt for those of us in the addiction field, and more so for our patients:
" Trust those who seek the truth, but never those who claim to have found it!"

Til next time.