AddictionDoctor.Org

This is probably the second most important question in the field of addiction treatment, the first being whether or not addiction is an illness. I think it’s clear where I fall on the answer to that question, but once addiction is a illness, then comes the question of the role of medication in it’s treatment.

The field seems divided, but it’s always been divided. There are always been those that thought that any medication for an someone with addiction would interfere with recovery, and while anti-depressants have largely become acceptable to this crowd, there are still a few who think even this is too much. This seems to stem from two ideas as far as I can tell. The first is the belief that authentic suffering is required for true recovery and anything, even medication, that blunts that suffering will delay recovery. The other source seems to be the desire for “natural” recovery, I suppose stemming from the idea that it is the unnatural drugs that have caused the problem in the first place.

The second pole of the division is the group that has always advocated agonist maintenance treatment for addiction as a total treatment. This group seems based fundementally on the need to restore biological function as the only goal of treatment. The idea being that the illness is purely physical and once it’s fixed the person is normal. Of course there are many people in the middle, perhaps even most people, but these two poles seem to define the field.

I think these two groups have reached their polar opposite conclusions because of polar opposite views of the illness. The biological group sees a physiologic derangement that needs fixing. They historically have not paid enough attention to what happened to the person’s character structure during the years that the illness was active. The other group seems to be focused on the effect of the drug and gives little thought to the possibility of an underlying, even genetic, physiological derangement that caused the problem. With this background in mind, let’s look at how the two groups visualize drugs and medicine.

The “take no medicine” group sees any agent that acts at the same site or in a similar way to a drug as a drug and believe that it has no use in the treatment of addiction. The famous, or infamous, example of the day is Suboxone. It’s a partial opioid agonist and does what it does at the opioid receptor. Therefore this group says it is an opioid and therefore anyone who takes it is not “clean.” While this view is not mainstream, the belief system is influential and there are several treatment centers set up according to this philosophy.

The “medication is enough” group sees any agent that relieves suffering as a medication. It doesn’t matter where it’s used or if it is abusable, as long as some effort is made to limit the abuse. It doesn’t matter how it acts or how it relieves suffering. In the case of Suboxone, this group responds enthusiastically to the ability to provide opioid (partial) agonist treatment in an outpatient setting, releasing them from the restrictions of the methadone clinic. Again, while this view is not mainstream, the belief system is influential and there are several academic writers speaking about such “medication only” regimens. Their nod to psychosocial treatment is to have a nurse call once a week to make sure you’re taking your medication.

Of course both groups are wrong and their errors are based on ignorance and fear. The “no medicine” group is afraid that doctors will just load up addicts on other drugs that will lead to similiar if not larger problems in the future, not only delaying recovery, but doing actual harm. The medication only group is afraid that non-medical professionals will run the show requiring ideologies and belief systems of the patients and picking who lives and who dies according to who accepts the ideology of “the cult.” The examples that each group can site are real, but very rare.

As in all things a middle path must be found. I cannot tell you what “the” middle path is, I can only tell you mine. Is my path any less of an ideology than the extremes? I hope so. The evidence that leads me to this path is too voluminous to put here, but most of it is in previous posts and my book. For me a drug is what we use now to change how we feel now; it is the epitome of self will attempting to control nature. A medication is what I take no matter how it makes me feel acutely because it is a treatment for an illness; it is the epitome of surrender to a fact of nature. Is there any role for drugs in recovery? I don’t think so. That means there’s no role for overeating, smoking, compulsive sex, compulsive exercise, compulsive gambling or spending, etc in recovery, because once we have the disease of addiction we can use many if not all of those things as a drug. Is there a role for chemicals which act at the same site as some drugs? I think so. But to be medications they must be taken like medications. In my experience it is rarely the chemical in the medication that causes the problem but rather how it is used.

Medication is a tool, not a solution in the treatment of addiction. As long as both sides in the debate embrace the extremes we will see continued problems and confusion for patients and other stake holders. A good topical example is Suboxone. There is so much fear and hype around the medication that some doctors who are approved to use it refuse to write prescriptions for it because they are afraid of running afoul of the FDA or DEA. And, it’s not so out of the question either. The federal government must be open to comments by all citizens and, unfortunately, some of them are presenting hype and fear. Government, even governments that strive to be data driven, can be driven by political pressure no matter how divorced from reality the source of the pressure is. I know professionals in the field who will not speak their mind at professional meetings for fear of peer reaction. The result is that hundreds die of overdoses of full opioid agonists because the “no medicine” group can find and present in hysterical fashion a few cases of Suboxone abuse.

If addiction is a disease, then we should treat it like one, and those that treat it should be treated like those that treat other diseases. They should be held to the same standards as others, not greater standards. The result of the fear and ignorance is that there are fewer people treating addicts than there could be because people who treat addicts in an attempt to stop abuse of drugs are held to a higher standard than those physicians who provide abusable drugs in an attempt to stop pain. As with most things we, as a society, are the source of our own problems.

I am very interested in organized medicine reworking the current definition of addiction. There are two problems with the definition as provided by DSM IV currently. The first is that the definition is limited to substance dependence and doesn’t allow for addiction using behaviors or what are commonly called process addictions. The second problem is that the definition is based on behavior rather than biological state. In the last entry I spoke of ASAM’s and ABAM’s use of the current defining ideas. Lately, in the healthcare debate, a lot of people have been looking at Canada, so I thought I would too as there is a Canadian Society of Addiction Medicine as well. Here’s the definition of addiction that they put on their website:

Addiction (Adopted 99.10.14) - A primary, chronic disease, characterized by impaired control over the use of a psychoactive substance and/or behaviour. Clinically, the manifestations occur along biological, psychological, sociological and spiritual dimensions. Common features are change in mood, relief from negative emotions, provision of pleasure, pre-occupation with the use of substance(s) or ritualistic behaviour(s); and continued use of the substance(s) and/or engagement in behaviour(s) despite adverse physical, psychological and/or social consequences. Like other chronic diseases, it can be progressive, relapsing and fatal.
Consider adding qualifiers such as full, partial remission, etc. based on DSM IV.

You can see right away that the CSAM doesn’t limit the idea of addiction to substances, and you know I’m happy to see that. Look at the date. This has been their definition for over 10 years. The other day I received a communication from a friend at ABAM who had read my last entry. He pointed out that while the current definition is limited to substances, they would be open to reviewing the limitation when evidence warrants. It looks like CSAM had enough evidence 10 years ago.

But here’s the problem. For those who don’t believe the current evidence for addiction involving behavior rather than substances, CSAM’s definition looks just as ideological as ASAM’s. It comes down to what you believe. That’s because CSAM’s definition lacks any biological focus as much as ASAM’s. It’s a very inclusive definition, but doesn’t exclude enough to be very useful. Any member of American Medicine can look at this definition and quickly decide it doesn’t offer more than the current one in use by ASAM. Progress generally happens when your neighbor one ups you, not when he doesn’t.

If I gave both definitions to a non-addiction physician, I doubt he or she would find either useful in terms of making a diagnosis in a biological sense. You can tell when you have a useful idea when everyone else starts to use it. I have a lot of friends in medicine who don’t practice Addiction Medicine, and they are not drawn to take either of these definitions as useful. That’s one of the reasons they mostly shy away from helping addicts. They have nothing to go on, and doctors like to know what they are doing.

CSAM’s definition is, I think, better than ASAM’s, but still has a way to go. My Canadian friends might take issue with what I feel is a lack of biological focus in their definition. They may point to the sentence that starts “Common features..,” but that’s just it. These are common features, not defining features. To be useful, the definition of an illness must be discriminating enough to tell the doctor what to do. While CSAM’s is better than ASAM’s in including more, it’s less than a helpful improvement because it includes too much. It would include those patients I’ve labeled as “Compulsive Use Syndrome” that are biologically driven to continue to use after first using but are not driven to restart once stopped. There aren’t many doctors who would find it useful to include both groups of patients in the same definition as the treatment would be entirely different.

I’m glad CSAM’s definition is different than ASAM’s. Diversity is good. When everyone is doing one thing in any environment, it’s the beginning to the road to extinction. That’s a big reason why we need definitions based on biological reality rather than someone’s interpretation of a patient’s behavior. DSM has created an ideology of addiction, not a clinical definition. And as the environment changes, the ideology can’t. That’s the end of the road to extinction. I wonder what the Mexicans think.

The American Board of Addiction Medicine just put out for comment its newly completed Scope of Practice for Addiction Medicine. (http://www.abam.net/files/Addiction_Medicine_Scope_of_Practicet_V1_2009.pdf) That document basically describes what Addiction Medicine physicians do. The document came to my attention when a colleague found fault with a recent media show on “addiction to plastic surgery” and pointed out that, to the positive, ABAM had finished its document. So I took a look. The question on my mind is whether or not ABAM will consider anything addiction if it doesn’t have to do with drugs or alcohol.

The first paragraph is ambiguous to the point of whether or not addiction can involve something other than drugs or alcohol. It refers to the job of the Addiction Medicine physician as someone who cares “for persons with addiction, for the individual with substance-related health conditions, for persons who manifest unhealthy substance use, and for family members whose health and functioning are affected by someone’s substance use or addiction.”. This list leaves open the possibility that “persons with addiction” may include more than individuals with “substance-related health conditions.” The second paragraph is also ambiguous on this point. “Addiction medicine specialists often offer treatment for patients with addiction or unhealthy substance use” leaves open that the patients with addiction may not have unhealthy substance use but rather addiction using something other than substances. However it is in the third or last paragraph that I think the Board’s intention becomes clear.  “Some addiction medicine physicians limit their practice to patients with addiction or other patterns of unhealthy substance use.” This sentence tells me that addiction is a pattern of unhealthy substance use and is one among many patterns of unhealthy substance use. So it seems clear that ABAM, like ASAM, limits the idea of addiction to substances. I think this has great implications for what will happen to Addiction Medicine.

The public, as expressed in the “addiction to plastic surgery” media piece, does not seem to have the idea that addiction is limited to substances. It could be that they are using the word incorrectly. It could be that the word addiction has been so overused that it no longer means anything. It could be that people just mean “use too much” when they say addiction. It could be, so I asked a group of people for whom the word addiction is very meaningful, recovering addicts. Not one of the people with addiction that I asked was offended by the use of the term addiction to plastic surgery. Each understood that the pain of that person was as great as their own. None made fun of it. None thought that their addiction was limited to drugs or alcohol. None thought that addiction treatment should be limited to people with “unhealthy substance use.” But it could be that since I asked people with a brain illness that they may be mistaken. What does science have to say?

Much of the recent work in imaging has focused on the midbrain reward system. Several researchers have show that the same pattern of decreased dopamine receptor density exist in heroin addicts, compulsive overeaters, compulsive gamblers, alcoholics and other groups of addicts tested. Blocking dopamine increases craving in compulsive gamblers just as it does in smokers or alcoholics. It seems that what is important is not the substance or behavior but rather what that substance or behavior does to the midbrain dopamine tone. I have read nothing that convinces me that a scientific brain based definition of addiction would be limited to substances. While there are scientists who say that it is, I find glaring holes in their arguments which generally fall back to an appeal to authority rather than the data. But why would anyone be interested in limiting addiction to substances if it actually isn’t? Who benefits from that?

There is a large entrenched industry for addiction treatment. The origins of the industry are too complex to get into here, but the entanglements between the fight to have addiction treatment recognized as real treatment and addiction as a real disease have led to politics and finance sometimes pushing reality into the back seat. There are billions in government money in the budgets of the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. What if addiction was bigger than drugs and alcohol? We’d have to change the names. In fact, there was a push to do that but the websites for these institutes haven’t changed. The status quo would be greatly upset by expanding the idea of addiction to more than substances. The odd thing is that most people with addiction and their families aren’t so impressed with the status quo.

So where will it end? My prediction, and I hope I’m wrong, is that ASAM and ABAM will remain firmly in the camp of addiction being a substance use problem. The consumers however will begin demanding a greater breadth of services than is traditionally offered by Addiction Medicine. Where will they go? Probably to the people with the answers. But the road to the people with the answers will be not as straight or safe as they would be if they were part of Addiction Medicine. Because Addiction Medicine will not allow the concept of addiction to non-substances, patients will be more exposed to risk until they do find those with answers. And when they do find those with answers, the answers will put Addiction Medicine out of business. Organized Addiction Medicine is approaching its last chance to save itself from being overcome by events. It has one last chance to get on board with the rest of the world. Unfortunately it seems to be ignoring the opportunity.

I recently had the opportunity to hear Dr Trevor Robbins of Cambridge, an expert on cognitive neuroscience, speak about the neuropharmacology of cognition. His remarks have a lot to say about how Addiction and recovery are affected by and effect cognition.

Dr Robbins divided cognition into three parts: Input, Representation, and Executive Control. Input is exactly what we think it is, being alert and wakeful enough to perceive with our senses the world around us. Representation is what we do with the product of our senses, how we remember perceptions and link them to other perceptions in memory both long and short term. Executive Control, he broke down into three parts: decision making, decision shifting, and anti-impulsivity. Input first.

It is often said that Addiction is a disease of perception, but that’s not exactly correct according to Dr Robbins’ breakdown. We may perceive the stimulus accurately but are perhaps not paying enough attention. It’s not he eyes or ears that lack function in Addiction, but the brain areas that take the perceptions of the senses and process them. With too little dopamine in the midbrain we cannot adequately pay attention to stimuli. Every day I hear people tell me stories of how they thought they did something they didn’t do or did do something they don’t remember. Here’s an example. A man had the key for his AA meeting and was responsible for opening the door. He arrived a few minutes late so there was a crowd at the door. He unlocked it, set the door to be unlocked and went in with the others for the meeting. Several minutes later he was comfortably sitting in the meeting feeling he’d done a good job of unlocking the door when he heard a banging on the windows. The man when outside and found his sponsor standing by the locked door unable to get in. “I thought you had the key,” his sponsor said. “I do. I unlocked the door,” the man replied. “No, you didn’t,” was the obvious answer. The man thought he had unlocked the door. He had intended to unlock the door. He even remembered unlocking the door. Yet, he did not unlock the door. There was nothing wrong with his eyes or hands. But in his haste he did not pay adequate attention to what he was doing and therefore did not lay down an accurate memory of what he had done. This happens on a daily basis with Addiction. If we aren’t awake, alert, and attentive we will not perceive in our brain what our senses perceive of the world.

This example also has to do with memory which is the second part of Dr Robbins’ breakdown of cognition. He discussed representation of what we sense in our memories. Memory has two parts as he described it: working (or short term) and long term. Working memory is sort of what we do when we are figuring something out. We want to see how it works so we have to represent it in our minds, turn it around and see it from a different angle and at the same time keep the old angle in our minds in working memory. It’s what allows us to see the “whole picture” instead of just what’s in front of us. It often happens that people with Addiction cannot remember the other side of something that isn’t in front of them at the moment. That’s one of the reasons that a common AA slogan is, “This too shall pass.” It’s also the origin of some of the quick rush to judgement that people with Addiction exhibit. If all that’s there is what I see, then I know enough to make a decision. If I forget that there is more to it, I don’t see that I don’t yet know enough to make that decision. Long term memory is also impaired when we don’t have enough dopamine. People with Addicition seem to have difficulty with memory and memory of time.

Finally, executive control is, of course, impaired in Addiction. Decision making doesn’t seem to be much of a problem as noted above, but the second two, decision shifting and anti-impulsivity, are. Decision shifting is the mental flexability to change the decision when the inputs change. An example, “Cocaine makes me feel better for a little while, now cocaine has stopped making me feel better and makes me feel worse, but I’m still acting under the old rules using cocaine to try to feel better.” This happens in lots of life area for people with Addiction. Anti-impulsivity is such an obvious problem that it probably doesn’t need to be addressed except to say that it too is a low dopamine phenomenon.

So Addiction is not just a brain disease of “wanting” or “seeking” but also has symptoms and impairments in the cognitive aspects of life. It makes the need for treatment all the more important.

I’m at the ASAM State of the Art Conference in Washington and just heard 2 really good talks on Addiction where food is the drug or overeating is the process. Of course, the presenters didn’t put it quite that way. The first talk was by Gene-Jack Wang who has done a lot of the neuroimaging in Addiction and found a lot of evidence that Addiction is a single disease. Unfortunately, he interprets his findings differently and so titled his talk, “Overlapping Neural Circuits in Addiction and Obesity.” You can see from the title of the talk the focus on obesity still doesn’t look at the disease but the result; we might as well try to study diabetes by focusing on people who lost their feet. The other place I differ with Dr Wang’s conclusions is that he interprets his findings to mean that it’s the increased dopamine reward response that makes us eat more. I don’t think that’s true for most of the addicts I treat, and they are the target of his work.

The second talk was by Eric Stice called “Reward Circuitry Responsivity Predicts Weight Gain.” While Dr Wang’s talk was quite good, it’s Dr Stice’s talk that really gives us some information we didn’t have. He presented a number of studies that built a picture of determines who gains weight over the next year and who doesn’t.  Right there, you can see this is new because he’s not talking about rats and he’s not looking at people after the fact. He’s looking at the biology that determines their eating, not the biology caused by their eating. Rather than going into all the studies he presented, I want to just give you the pricture he presented as I see it.

He showed that one would normally expect a dopamine response in the brain from food and even from thinking about food. He’s the first scientist I’ve heard who has said what addicts have long known, that the problem is low dopamine in the brain, not the dopamine from the drug.

In the studies they looked at people who had two different forms of the dopamine receptor. One form has a lower response to seeing the brain’s dopamine and the other was normal. So those with the first form will presumably have a lower dopamine tone and need more of something to feel the dopamine release caused by it. The second form will feel normal dopamine release with a normal reward. Let’s call these two forms of the dopamine receptor A1 and A2.

For the A1 people the less their brain lit up when presented with food, the more likely they were to gain weight over the next year. That makes sense because they will need more food to feel the dopamine. For the A2 people it was just the opposite. For them, the more their brain responded to food the more likely they were to gain weight. Both groups can become obese.

The A2 people seem to act like Dr Wang expects; they far outnumber A1 people at about 75% to 25%, so he would mostly see the A2 people. The A1 people are the people I’m used to seeing that come for treatment for addiction regardless of what food or behavior they use.

For A2 people the more rewarding foods are the more they’ll gain weight - just like Dr Wang suggests. However for the A1 people it’s the less reward they feel from food, the more they’ll eat to feel normal and the more they’ll gain weight. So not every obese person has Addiction, it depends on why they’re obese. Just as I’ve suggested with alcohol.

Again we come to the importance of knowing our genetic makeup. It’s really important for us to know what risks there are in genes so we can know how to modify our lives. Also, it’s important for treatment Dr Stice’s A1 people need augmentation of their dopamine tone so that they can eat less food and the A2 people perhaps need attenuation of their dopamine tone so they can eat less and lose weight. I recommend to all my patients that they go to 23andme.com to get their genetic testing done.

By the time we learn to use words to describe things like medical interventions or public policy we’ve heard most of the words in other contexts, and we have our own idea of what they mean. Long before we heard the word Addiction in any adult setting we heard it as children. It’s meaning to us reflects our oldest understanding of the word. That is, we learned what we think Addiction is long before we learned about what it really is.

Most people I talk to about Addiction are talking about something else. They are talking about drug taking, or substance abuse or criminal behavior or just being bad. They are talking about will and decision, self-deception and lying. To be sure all of these things can be associated with Addiction, but none of them are Addiction.

I’ve written before here about separating out the core phenomena of the illness called Addiction from the surrounding epiphenomena that become associated with it. What keeps getting in the way are the definitions. Before we can actually discuss what we have learned scientifically we’re going to have to let go of our old definitions of words that we think we know the meaning to. Addiction is one of those words.

One colleague suggested that the word Addiction is so filled with false meaning to people that we need a new word to mean the illness that we treat. I came up with Subcortical Hedonic Attachment Syndrome, but there were two problems. First, it didn’t quite capture everything that is core to Addiction as an illness and second, SHAS is a stupid sounding acronym.

So here are some definitions of Addiction and related syndromes that I’ve put together for discussion and feedback. Perhaps we can get to a place of common ground starting from these:

ADDICTION: A permanent dysfunction of the midbrain reward system and resulting hypofrontality with characteristic symptoms relieved by the use of at least one rewarding substance or behavior and resulting in the compulsive use of that behavior.

It must be permanent – a temporary dysfunction brought about by combat or domestic violence is not addiction even if accompanied by attempts at self treatment with rewarding substances.

Resultant hypofrontality –  can be tested for by reward/risk test such as the Iowa Gambling Task and measures of impulsivity such as the Continuous Performance Task

Characteristic symptoms of midbrain reward system dysfunction include irritability, easily frustrated, relative anhedonia, poor focus, poor memory, difficulty making attachments to others, procrastination. Compulsive use of some substance without these symptoms would be a different syndrome such as a hypofunctioning GABAb input to the reward system leading over reactivity of the reward system and temporary production of these symptoms only in the case of drug use.

Substance or behavior must be used to control and be effective in controlling or mitigating at least some of the symptoms. Use cannot be solely for oblivion from some life situations, in response to external stressors or, in the case of anxiolytic substances, for the control of anxiety.

TEMPORARY REWARD SYSTEM DYSFUNCTION USE SYNDROME: The temporary production of symptoms of reward system dysfunction brought about by an environmental agent or situation leading to the compulsive use of a rewarding substance which completely resolves with the removal of the causative environmental agent or situation.

Clinically will look like Addiction and will be differentiated from it by history.

Temporary Reward System Dysfunction Use Syndrome can become Addiction with continued use and resulting damage to the midbrain reward system.

COMPULSIVE USE SYNDROME: The temporary compulsive use of a substance or rewarding behavior brought about only in the aftermath of a rewarding stimuli not accompanied by chronic symptoms of midbrain reward system dysfunction and hypofrontality.

Temporary – often seen as repeated binging episodes and not present between episodes until triggered by another reward powerful enough to cause a high and resultant crash leading to compulsive use

Between episodes there are no symptoms of reward system dysfunction  or hypofrontality.

Compulsive Use Syndrome can become Addiction with continued use and resulting damage to the midbrain reward system.

ANXIETY INDUCED SUBSTANCE USE: The use, compulsive or otherwise, of any anxiolytic substance, rewarding or otherwise, to quell the symptoms of anxiety, even when done in spite of adverse consequences, coupled with an absence of symptoms of midbrain reward system dysfunction.

Use must be solely for relief of anxiety and not for relief of symptoms of midbrain reward system dysfunction. There must be no symptoms of midbrain reward system dysfunction except in the immediate aftermath of a rewarding anxiolytic substance.

Anxiety induced substance use can become Addiction with continued use and resulting damage to the midbrain reward system.

SUBSTANCE OR REWARDING BEHAVIOR ABUSE: The recurrent, non-compulsive use of a substance, in spite of knowledge of possible adverse consequences, for purposes of experimentation, fitting in with peers, to avoid social stigma or other social reason without evidence of compulsive use, anxiety relief from use or symptoms of midbrain reward system dysfunction.

SUBSTANCE OR REWARDING BEHAVIOR USE: The occasional, voluntary, and non-problematic use of rewarding substances or behaviors in socially acceptable situations without compulsive use, symptoms, or symptom relief.

It’s everybody’s dream. Don’t just treat the illness, or even find a cure for the illness; prevent the illness. It’s a wonderful dream, and with regard to addictions it seems easy to fulfill. Don’t ever drink and you won’t get addicted to alcohol. Don’t allow cocaine in the country and no one will ever get addicted to cocaine. To quote Hemingway, “Isn’t it pretty to think so.”

We’ve got to ask ourselves, “How long have we been at this? And when is it going to work?” Surely, if this were true prohibition in the twenties would have gotten rid of much of Addiction if Addiction could be prevented by preventing use of the drug. However, as I show in Questions and Answers on Addiction, while prohibition temporarily decreased the amount of alcohol used in the US it just caused a switch to another drug. Drinking went down but not Addiction.

I keep asking my Addiction Medicine colleagues to show me one study that shows that any preventive measures aimed at Addiction as a whole have ever worked. I’ve put this challenge out numerous times to the leadership of Addiction Medicine and have yet to get a single response. I get lots of responses about preventing alcoholism or cocaine abuse, but nothing that shows prevention of Addiction as a whole.

Of course, no one has to worry about my thesis on this if they don’t believe Addiction is an illness. If they believe that alcoholism or cocaine dependence is an illness, but that they are different illnesses, then I can be safely shunted aside. It’s probably more convenient for a lot of people treating Addiction to not see the single disease. It’s hard to see your own overeating as a form of the illness while telling someone else to stop drinking.

It also helps when you’re making drug policy not to have to look at Addiction as an illness. It’s hard to get an illness to change by making a policy; it’s so much easier to have a policy about a drug. We’ve had “drug policy” for a long time in this country and spent billions of dollars to implement it. At this point one would have to conclude that either the original thesis of the policy was incorrect or that the implementation was completely botched. Generation after generation of administrations have been able to point to their predecessor and claim a botched implementation, thereby preventing anyone from having to critically look at the original premise.

So if I’m right, can Addiction be prevented? Sure, about as well as Diabetes is prevented or Hypertension. These are largely genetic, chronic illnesses with lifestyle and behavioral components just like Addiction. We can have tertiary prevention and secondary prevention, but primary prevention of a largely genetic illness is going to be hard.

What would we have to prevent to have primary prevention of the Addiction that isn’t genetically derived? We’d have to prevent anyone feeling less than anyone else. We’d have to prevent anyone from feeling isolated from others. In short we’d have to prevent bigotry, prejudice, poverty, inequality, and the list goes on. Really, it’s much easier to just shoot down drug smugglers.

But we have a lot we can do about secondary and tertiary prevention whether something is genetic or not. We can find it quickly and intervene before it gets worse. We can treat it as an illness rather than as a social problem that we hope goes away. We can make sure that people who don’t get better get more treatment, not less. But in order to do any of these things that can be good secondary and tertiary prevention of Addiction, we have to recognize that we can’t do primary Addiction prevention by getting rid of drugs and alcohol. Unless of course you can show me that study, but I’m still waiting.

Growing up, I was taught that Jewish people couldn’t be alcoholics. That was a bit of wishful thinking. The people who taught me this rationalized it by saying that the Sabbath Kiddush socialized us in such a way as alcohol became something used only in a religious way. This never made sense to me as several Christian religions have sacramental use of wine and they didn’t report lower frequencies of alcoholism. So I just passed the whole thing off as a cultural myth and went about my business.

It turns out that Jews do have a lower frequency of alcoholism, but it has nothing to do with the religion or the culture. It’s in the genes.

As alcohol is processed in the body it is first turned from ethanol to ethylaldehyde on it’s way to becoming acetic acid. Ethylaldehyde, like formaldehyde, is not something the body likes, but it isn’t there long or in great quantities when the average person takes a drink. However a point mutation in the enzyme that turns ethanol into ethylaldehyde makes the enzyme run very fast and makes more ethylaldehyde than the body can process. It also gets rid of the ethanol more quickly. So someone with that mutation gets less enjoyment from alcohol and more of the aldehyde with its negative effects, it would sort of be like taking antabuse.

This point mutation is very rare in Europeans, occuring in less than 5%. In east Asians it is very common with more than 90% of Japanese and Chinese having at least one copy of the mutated gene. In Jews the prevalence is greater than 20% or more than 4 times higher than a European population. In fact more and more genetic studies are coming out showing Jews of European ancestry to be genetically more like a Middle Eastern population than a European one. (A professor from Jerusalem is hoping to ignite a grassroots peace process by showing that the Palestinian population are actually the Jews left by the Romans to man the farms in the area. It’s a fascinating topic with a lot of evidence but too much to get into here.)

So as Europeans go, a greater percentage of Ashkenazi Jews than normal “get no kick from Champagne.” This really would lower the prevelence of alcoholism in the Jewish population. However it doesn’t say much about Addiction in general.

If you look at Addiction as the addictions, depending on what drug the person uses, all you need to do is avoid the drug and you can’t get the addiction. But what if Addiction is one disease with multiple drugs? What if compulsive overeating and heroin addiction have the same common cause in the brain? That would mean that being protected from over drinking doesn’t protect someone from the illness called Addiction. This has become an important idea because recent findings at the National Institute of Drug Abuse show the same PET scan results in obese compulsive overeaters, alcoholics, cocaine addicts and heroin addicts.

There is no evidence that the disease of Addiction, taken together in all it forms, varies from population to population. The drug used does and some of that is genetic, but the genetic causes of Addiction seem to be old enough and strong enough to span across all human populations equally.

I had always intended to write more frequently here about what was happening with addiction medicine and addiction treatment. The last several months have been very hectic, and my attention has gone elsewhere. Most of the time has been spent with my business, Townsend.

My business partner and I bought 5 clinics in south Louisiana from our former employer when that company closed. The first several months were spent just keeping it going and handling the usual start up problems that any company faces. Recently though, my energies have gone to completing a new book for patients to be used to guide our treatment program. Because our model of treatment is so different from that taught to most students of counseling, I also wrote a book for the counselors. Both books are finished now. I was also invited to speak at the 4th Annual Neuroscience Meets Recovery conference in Las Vegas next month and it took a good bit of time to create three 90-minute talks.

So the upshot is that I haven’t done much reading and have a large stack of journals to go through. Consequently, I haven’t had much to write about here. I’ll now have time to get both of those done.

Therapy fixes things. Something’s wrong, you go to therapy, you get it fixed, you graduate. Congratulations, you’re well. It works great for neurotics.

The problem is that addicts aren’t neurotics and Addiction isn’t neurosis. You can go to therapy, figure out why you’re an addict, change the thing that caused you to be an addict, graduate, and go out and get drunk that day. Addiction doesn’t go away, and you can’t fix it; you have to learn to live with it. Trying to fix Addiction with therapy is like trying to treat blindness with therapy. You may know why you’re blind, but you’ll still be blind.

Since Addiction can’t be fixed, what’s the goal of treatment? The goal of treatment is to learn to live with the condition and still be happy without using. I read a study recently that tells us exactly why therapy won’t work and teaching someone to live with the condition will.

Loran Nordgren at Northwestern University Kellogg School of Management and his colleagues included 4 studies in a paper entitled “Restraint Bias: how the illusion of self-restraint promotes impulsive behavior.” I really like papers like this. Their idea, restraint bias, is that people’s inflated sense of self-restraint will actually put them at greater risk of impulsive behavior because they’ll be more likely to go into risky situations.

What I like about this paper is that it presents a simple central idea and then tests it, not with one experiment, but a robust suite of studies that look at it from different angles. They base the idea of restraint bias on earlier work on something called the “empathy gap.”

The empathy gap is not about empathy towards others; it’s the difference in feeling someone has in a “hot” state such as craving and a “cold” state when they can no longer remember how it felt to be in the hot state. It’s basically a lack of empathy with yourself in a former state. As old as this idea is (1996), Alcoholics Anonymous discussed it even earlier, “We are unable at certain times to bring into our consciousness with sufficient force the memory of the suffering and humiliation of even a week or a month ago. We are without defense against the first drink.”

From the idea of the empathy gap, Nordgren and his colleagues supposed that in a “cold” state people will take more risks and be more likely to be impulsive because they don’t have an empathy with the “hot” state and overestimate their ability to refrain from action. You may wonder why business school researchers are interested in this, but think of the fact that mechanical stock traders who follow rules generally do better than those that go by their “gut.” The most successful stock traders I have heard of are the ones that know that their own brain is their worst enemy. So Nordgren’s work isn’t just applicable to addicts, the restraint bias is a universal human phenomenon. But for addicts, it’s particularly dangerous, because to take the first drink or drug or bite or bet can be catastrophic.

Their first study had to do with students and their study habits when tired. The second had to do with snack choices when hungry. The third and fourth studies looked at smokers, so lets concentrate there.

In their third study, the split the group into those who believed they had high self control and those with a belief that they had low self control. They then asked both groups to watch a movie that would cue them to smoke without having a cigarette. The kicker is that people would get a monetary reward for not smoking during the film and they got to choose the reward in advance. If they left their cigarettes in another room during the film, they could win 2 Euros. If they left their cigarettes on the desk in the cubicle they could win 4 Euros. Holding it throughout the film got them 6 Euros, or holding it unlit in their mouth could get them 8 Euros. As predicted smokers in the high control group exposed themselves to more risk than did the low control group. In the high control group, which took greater risks, 33% of the subjects smoked, while in the low control group taking less risk, it was only 11%.

The fourth study also had to do with smokers, in this case, smokers who had quit and were past nicotine withdrawal. Again they self divided into those that believed they had good control and those who thought they had a lower level of control. Four months later when they were followed up. As expected, smokers who felt they had high control reported less avoidance of cigarettes, and a greater percentage of those that had less avoidance of cigarettes relapsed.

In their discussion they refer to a recent study of heroin addicts who are asked what price they would pay for a buprenorphine pill. The study found that addicts in withdrawal would value it more highly than those not in withdrawal. While that might seem like common sense, the authors point out that all of the addicts not in withdrawal had been in withdrawal before and knew it was likely that they’d be in withdrawal again, but because they were in a “cold” state, they just couldn’t remember how bad that would be.

So why did I start this off about therapy? It has to do with what therapists are taught. We are taught that self-efficacy is critical to self-control. We are taught that people should be empowered to achieve what they want to achieve. This has always been at odds with AA’s insistence on powerlessness as the path to recovery. What Nordgren’s work shows is that, for addiction anyway, those that embrace the fact of their powerlessness will be more likely to not use and more likely to stay in recovery. It’s always been my experience and it’s always a point of contention when I’m discussing patients with colleagues who treat a more general population than addicts.

Now we have behavioral scientists agreeing with what AA and other 12-step programs have said for 70 years. Perhaps this is why there is no psychological treatment for addiction that has been shown to work any better than 12-step facilitation treatment where the patient is encouraged to get into 12-step recovery. Perhaps going to meetings reminds us of that “hot” state without getting into it because while we can’t empathize with our former selves, we can perhaps empathize with the person sitting next to us now.