Saturday, April 7, 2007

Substance Abuse: A Comprehensive Textbook

3rd Edition,, Joyce H. Lowinson, Pedro Ruiz, Robert B. Millman, John G. Langrod, eds. ISBN 0-683-18179-3

Notes and comments by Marty N.

(These informal notes were originally posted seriatim on Tom Shelley's LSRmail email list.)

The editors of the book (Lowinson, Ruiz, Millman and Langrod) say that "our goal is to provide the most authoritative and comprehensive resource on the subject of substance abuse and related areas. The book can serve as the definitive text for students in all professional disciplines ... as well as a source of information for scientists and clinicians working on drug, alcohol and other addictions." No false modesty here.

Also from the editors' preface, this point dear to the hearts of most secular recovering people:

"Each patient or client develops problems in unique ways and forms a unique relation to the substance of choice. Common sense dictates that treatment must respond to the needs of each individual." (p. xi.) For more on this theme, see Handbook of Secular Recovery, from LifeRing Press, Chapter 3.

By way of a quick overview: the gem of this book is the piece by Eliot Gardner, Brain Reward Mechanisms. If you read nothing else, read this. It's not easy going, but it's, well, very rewarding to the brain. Science writing at its best.


Enoch Gordis:

There are some interesting things in the foreword to this volume by Enoch Gordis, M.D., director of the National Institute on Alcohol Abuse and Alcoholism, of the National Institute of Health. He is one of the most prominent authorities in the field.
He says that the addictions field is in the process of evolution from its birth outside science and medicine to becoming part of them. There was a time when the chief qualification and "textbook" of counselors was their own recovery. Now (he claims) comprehensive professional training and standards are increasingly required, and workers in the field will have to study and master a large and quickly growing body of research in order to ply their trades.

In the process of becoming a part of science and medicine, alcoholism treatment has also had to change. Gordis quotes here from the 1958 speech of AA founder Bill W before the NY State Medical Society, where Bill W said that the medical people "have been achieving notable results for a long time, many of their patients have made good recoveries without any AA at all. It should be noted that some of the recovery methods employed outside AA are quite in contradiction to AA principles and practice. Nevertheless, we of AA ought to applaud the fact that certain of these efforts are meeting with increasing success...." (p. vii)

Gordis also says that AA in the late 1980s began publishing surveys showing "attrition in attendance at AA meetings after initial contact," and notes that twenty years earlier, such self-analysis by AA would have been unthinkable. Gordis suggests that in today's climate, no claims of success are accepted on faith. The funding sources want quality research on alcoholism treatment efficacy, the same as is required for other illnesses. Gordis sees the use of big-scale classical clinical research trials (such as
Project Match
) as one of the most significant advances in the field, a sure sign of the addiction field's maturing into an accepted branch of science and medicine.

The five big advances in alcohol science, according to Enoch Gordis:

1. "The clear demonstration that some of the vulnerability to alcoholism is inherited ..."
2. "The application of neuroscience to understanding drinking and the phenomenon of addiction ...."
3. "The acceptance of the study of 'mental processes' in alcohol action ... e.g. symptoms of alcohol intoxication produced by placebos;
4. Clearer understanding of how alcohol affects organs and how it impacts the fetus; 5. Application of classical large scale clinical trial methods to alcoholism and alcoholism treatment.

From the preface, pp. vii, viii.


Alan Leshner:

From the foreword by Alan I. Leshner, director of National Institute on Drug Abuse, National Institutes of Health:

"We now know that drug abuse is a preventable behavior and that drug addiction is, fundamentally, a treatable, chronic, relapsing disease of the brain... Research ... shows that addiction occurs as a result of the prolonged effects of abusable drugs on the brain -- and that addiction actually results in a changed brain. "Addiction ... is a special class of brain disease, one that is expressed in behavioral ways and within a social context. It is the quintessential biobehavioral disorder -- a brain disease with embedded behavioral and social context aspects...."

(From the Foreword, p. ix.)

So there goes our beloved disease debate up in smoke. Forget the argument whether it's organic or behavioristic. It's a "biobehavioral disorder." Drat, and we were having such fun.



Did you know:

"Heroin" was originally a trademark of the Bayer Company for its new morphine derivative designed as a cough suppressant. Introduced in 1898, it was thought to be less addictive than morphine ....
In the years before World War I, the United States had a greater per capita consumption of opium than any other nation in the world, including China, according to Dr. Hamilton Wright, the State Department's opium commissioner.
(From "Historical Perspectives" by David F. Musto, in the Lowinson textbook, pp. 1, 3.)



From "Epidemiology" by Charles Winick, p. 13.
Some basic population statistics for recent years in the US:
Number of cigarette smokers: 60 million. Number of illicit drug users: 13 million Of these: marijuana users: 10 million, cocaine 1.4 million
Number of people who used alcohol at all: 140 million Number of heavy drinkers (5 drinks per session 5 sessions per month): 13 million
Per cent who are chronic drinkers (60 drinks in previous month): 2.98 per cent.
Share of total US alcohol consumption drunk by the top 2.5 per cent of drinkers: 31-36 per cent.
Share of total US alcohol consumption drunk by the top 5 per cent of drinkers: 45-50 per cent.

Hey, the alcohol industry would've gone broke without us. The comparative handful of us who made up the top five per cent of drinkers all by ourselves drank half or almost half of all the liquor sold in the United States.
Shouldn't we get some kind of industry recognition -- medals, awards, something?


Drug Policy

From "Drug Policy," by Mathea Falco, p. 19.
In recent years, fewer than 1000 out of the 41,000 prisoners in federal prisons who had drug abuse problems had intensive drug treatment programs available.
More than three quarters of all state prison and county jail inmates are drug abusers, but less than 10 per cent receive any drug treatment at all.
A field of opium poppies 25 square miles in area would be sufficient to supply the US demand for heroin for one year. Three DC-3A cargo planes could carry the annual supply in one trip.
To supply the annual demand for cocaine would take a plantation covering 300 square miles; three Boeing 747 cargo planes could carry the year's supply.



The chapter on "Genetics" by Robert Anthenelli and Marc A. Schuckit is a review of the genetic research into alcoholism. After surveying twenty years of family, twin and adoption studies of alcoholism, the authors say that "although these investigations are not unanimous in their results, they provide compelling evidence for the importance of genetic factors in this disorder." (p. 41 of the textbook). One of the principal findings in support of the genetic thesis is that the sons of alcoholic fathers demonstrate at the outset a greater tolerance to alcohol than sons of nonalcoholics. This difference exists subjectively, in the degree of intoxication the subjects report, and also objectively, in observations of muscular steadiness and in EEG patterns. (45-47)

However, the studies do not support the idea that all alcoholism is genetically rooted. On the contrary, the authors refer to alcoholism as a "group of disorders with multifactorial origins." (41) They see a picture of "etiological heterogeneity" which is far from being sorted out. (43).

The authors distinguish broadly between primary alcoholism, where alcoholism is the individual's underlying problem and various psychiatric disorders may arise on top of that; and secondary alcoholism, where a major psychiatric illness came first and the alcoholism came later, e.g. as a form of self-medication. Since the psychiatric illnesses may also have their own genetic transmission mechanisms, it becomes important for the researchers to disentangle them from the alcoholism; no easy task. (43)

One clear genetic finding is that about 50 per cent of Asians lack a certain liver enzyme that processes alcohol. When they drink, they get facial flushing, tachycardia and a burning sensation in the stomach; as a result they tend to avoid alcohol and have low rates of alcoholism. The other half of Asians have the enzyme. (44)

There are many suggestions in the article about how a possible "test" for alcoholism (or for the susceptibility to alcoholism) might be constructed. Levels of certain brain chemicals, certain DNA patterns, even brainwave patterns are being investigated as possible markers. On the other hand, studies have found no significant differences in the cognitive abilities or in the personality profiles of genetically alcoholism-susceptible individuals. (44-45)

Genetic studies of other drugs provide only slight evidence because the sample is too small and often short-lived for meaningful large-scale and long-term studies. The exception is cigarette smoking, which has been thoroughly studied and where a genetic influence has also been found. (48)

The authors emphasize that the genetic research on addictions is still in its infancy. A large multidisciplinary effort called the Collaborative Study on the Genetics of Alcoholism (COGA) has recently been launched.
Among the policy implications, they write that "the stigma once associated with the view of alcoholism as a 'moral weakness' is fading with the accumulation of evidence supporting the importance of biological factors." (48)

I'm amazed as I grind through this textbook at the amount of research literature that exists in this field. The Genetics chapter by itself has 142 footnotes, and that's on the low side. The chapter on Brain Reward Mechanisms, which is next, has 767 -- fifteen and a half pages of footnotes! I can't wait ... pant, pant ....


Brain Reward Mechanisms, by Eliot L. Gardner.

This is an article about why rats do drugs. The author is director of the Laboratory of Behavioral Neuropharmacology at Albert Einstein College of Medicine. He reviews fifty years of laboratory studies on drug use in rats and other mammals.

More than fifty years ago it was discovered that laboratory animals could readily become addicts. An early researcher, Spragg, described chimpanzees who "would drag the researcher to the cupboard where the morphine, syringes, and needles were stored, and voluntarily assume the proper position to receive the injections." (p. 52) More than thirty years ago researchers first implanted an intravenous drug rig in laboratory rats, such that the animal got a hit of drug whenever it pressed a lever. Researchers ever since have been varying the parameters of this basic experiment to test different hypotheses.

If given unlimited quantities of the drug (one lever press = one dose), the animals' response depends on the drug. With opiates (morphine, heroin etc.) they will settle on a "moderate and measured self-administration of modest doses without voluntary abstinence periods." (p. 53) With stimulants (cocaine, amphetamines, caffeine) they will alternate between binging and abstaining. During the binging, they will go into frenzies of using, during which they ignore food, water and sleep; then they will lay off for some time before resuming. Alcohol produces a similar binge-and-abstain cycle. Given unlimited doses, animals commonly consume so much of the drugs that they make themselves sick or die.

When the researchers limit the doses, for example by requiring twice as many lever presses for each consecutive dose (1, 2, 4, 8 presses, etc.), a drug hierarchy appears. At some point for each drug, the animal gives up. At the top of the scale is cocaine. Most lab animals "will spend most of their waking hours self-administering the drug ... to the point of starvation and death, even if hundreds or thousands of lever-presses are needed to obtain one dose of the drug." (53)

All the addictive substances studied have in common the chemical property that they (at least at first) enhance the "reward" effect in the brain's dopamine system, either by increasing the amount of the reward effect or by lowering the threshold at which rewards are registered. The dopamine (DA) system is a set of brain organs and circuits which form a subset of the mesolimbic system that runs in the core of the brain. There are diagrams at pp. 57 and 70.

About forty years ago researchers discovered that behavior identical to drug addiction could be produced by implanting electrodes in certain parts of the brain, and giving the animals a small electrical jolt (instead of a drug) when they pressed the lever. Implanted in the right spots, the electrodes proved to be a reward as powerful as cocaine. Hungry animals ignore food, thirsty ones ignor water, and all will endure pain, to get it. They will press the lever more than 100 times per minute to get the electrical buzz. A few tests of this setup have been done on humans; they report feelings "of intense subjective pleasure or euphoria." (55).

A very extensive experimental effort has gone into mapping the brain regions where electrical and chemical reward-seeking behavior can be stimulated, and trying to construct the exact function and interrelation of these regions. Much of the article examines this topic at a microscopic scale of chemical and anatomical detail. The pleasure systems stimulated by drugs and electric impulses are not special, but appear to be the same ones that normally operate to reward such functions as eating. At least three stages in the reward circuit have been identified. Different subgroups of drugs "hit" different regions within the system. (59) The brain areas involved in the reward system are distinct from those that govern drug dependence and withdrawal symptoms. (59).

There is evidence that the "reward" circuits also send out a slower and longer-acting "opponent" signal which creates the "down" feelings that follow the "ups." (68) The dopamine reward mechanisms in the brain also are connected with and interact with many other areas of the brain and are modulated by numerous other non-"drug" chemical substances found naturally in the brain. (65)

Laboratory animals can be bred for a greater or lesser propensity to self-administer drugs. One strain of rats, the "Lewis" strain, has been bred for its superior propensity to use alcohol and cocaine. This strain is also hot for tetrahydrocannabinol and for any other drugs it can get its paws on. Lewis rats turn out to have a dysfunctional dopamine system; their brain plumbing cannot delive enough dopamine naturally, and it is theorized that they resort to drug use to compensate for the deficiency. The identical behavior and dopamine dysfunction can be induced in non-Lewis rats, i.e. in rats that are not genetically vulnerable, by chronic drug administration. (65).

There is a discussion of human parallels and other genetic research on human subjects at pp. 65-66, with specific reference to the work of Blum and associates on the "reward deficiency syndrome."

Human users typically experience cravings when exposed to "triggers" such as the street corner where they scored, or paraphernalia, or advertisements for liquor, etc. Researchers have modeled this kind of craving in the laboratory by rewarding rats with drugs in one kind of environment, say, with stripey walls, but giving them only water in another kind of setting, say with plain walls. They then get the rats clean and let them choose environments, with the expected results. Researchers then interfere surgically or chemically with the rats' brains to see what it takes to extinguish their preference for the druggy environment. This research is one of the many unfinished areas to which the article points.

Long-term chronic use of each of the drugs, or combinations of them, tends to produce dopamine deficiencies or higher dopamine thresholds. Dopamine dysfunction seems to be the common denominator of all the addictive drugs, and seems to supply the neuro-pharmacological meaning of the word "addiction." (68).

In conclusion, the author again takes up the hypothesis of Blum to the effect that some substance abusers suffer from a genetically transmitted neuropharmacological "reward deficiency syndrome." If this is true, he suggests, it follows that "our goals are not only to acutely rescue addicts from the clutches of their addictions, but also more importantly to restore their reward systems to a level of functionality that will enable them to 'get off' on the real world." (70).



Notes from the chapter "Psychodynamics" by Nancy M. Brehm and Edward J. Khantzian, p. 90
Freud wrote: "Masturbation is the one major habit, the 'primary addiction,' and it is only as a substitute and replacement for it that the other addictions -- to alcohol, morphine, tobacco and the like -- come into existence." (p. 90)
Abraham theorized that men drank to express their homosexuality in a socially acceptable way.
Glover described addiction as a defense against paranoid-sadistic tendencies and psychosis. Knight saw alcoholism as "the regressive acting out of unconscious libidinal and sadistic drives," and found the cause for it in overindulgent mothers and aggressive fathers.
The more modern psychological theories, according to the author, tend to depict addiction as a "progressive effect" that may actually reverse "regressive states" such as feelings of rage, shame and abandonment. (92). Several theorists see drug use as self-medication of emotional disorders, and the "co-occurrence" of depression, personality disorders and alcoholism is noted. The literature "emphasizes the addict's tragic suffering and this person's attempts to alleviate or control his or her emotional state." (93)
Many observe that addicts suffer deficits in self-care, vulnerabilities in self-development and self-esteem, and in relationships. (94-95) There are various models of the "development" of addiction from infantile neuroses. (96)
The "treatment implications," according to the authors, are first to teach the patient to control his or her drinking, rather than to abstain. (97) During that period, the patient is referred to AA or NA to recognize "powerlessness," unless the patient's "personality structure is too rigid to accept the AA/NA message of 'surrender -- belief in a higher power,' etc." (97) Abstinence is offered as an option later. Self-regulation, self-care, repair of self-esteem, rebuilding relationships and modulating affect are subsequent objectives. (97-98).
Summary: the "psychodynamic" approach "focuses on understanding addictions as adaptive attempts to alleviate emotional suffering and repair self-regulatory deficiencies." (99).
Comment: This review of psychoanalytic theories of aggression reminds me of the game of pinata, where blindfolded children whack away at a paper-mache effigy with long sticks, and pounce on the candies that fall from its belly. I found a lot of well-turned phrases and valid observations about one or another aspect of the life of addicted and recovering people I have known, including myself. I found nothing that struck me as a defensible and coherent theory of addiction, and very little even that resembled a testable hypothesis. Almost none of the writers cited seemed to be aware of research findings in the physiological basis of addiction. While the older theories (e.g. Freud) appear silly but harmless, some of the newer work of the "self-medication" school tends to make addiction seem rational and sympathetic. There is little insight into the hell that opens up once the voluntary dose of "medicine" turns into the chemically compulsory fix. The developmental theorizing about the etiology of addiction in childhood neuroses and inadequate parenting is IMHO a diversion to rack up couch fees. Finally, the idea of treating an addict by first trying to teach controlled use rather than abstinence strikes me as indefensibly dimwitted and irresponsible. If you never read this article you didn't miss anything.


Individual Psychotherapy

Re my recent screed against the "Psychodynamics" article, I feel vindicated by the following:
Newer treatment approaches, including 12-step, group therapy, methadone maintenance and others "derived their popularity from the failures of dynamically informed ambulatory individual psychotherapy when it was used as the sole treatment for drug abusers. The problems reported for this form of treatment were premature termination, reaction to anxiety-arousing interpretations with resumption of drug use, erratic attendance at sessions, difficulties posed by attending sessions while intoxicated, and failure to pay fees because money was spent on drugs."
In other words, I'm not the only one who thought that the "Psychodynamics" approach was shaky to say the least.
The quote is from: "Individual Psychotherapy" by Bruce J. Rounsaville and Kathleen M. Carroll, in the Lowinson textbook, p. 430. The authors go on to outline a much more informed and practical approach to individual psychotherapy for drug abusers than the one in the "Psychodynamics" article.
Among the passages that brought my pencil down to the paper:
"It has been observed in clinical situations and demonstrated in laboratory conditions that most abused drugs such as opioids or cocaine are capable of producing constellations of symptoms that mimic psychiatric syndromes such as depression, mania, anxiety disorders, or paranoia. Many of these symptomatic states are completely drug-induced and resolve spontaneously when substance abuse is stopped. It is frequently the therapist's job to determine whether or not presenting symptoms are part of an enduring, underlying psychiatric condition or a transient, drug-induced state. If the former, then simultaneous treatment of the psychiatric disorder is appropriate; if the latter, reassurance and encouragement to maintain abstinence are usually the better course." (p. 432).

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