The Addicted Brain (26 page)

It is also possible to get information and even find help through the Internet. For example, the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have informative websites.
Table 13-2
lists many websites that were found in a recent search and includes some relevant comments about them. These organizations have people who are willing to assist people seeking treatment. Some are connected to a specific facility, and some offer to find treatment in the area where the patient lives. There are private programs where the patient pays either out of pocket, with insurance, or both, and there are free or low-cost programs such as state-funded programs. Note that the last entries are for sexual addiction. It is advisable to check the credentials and qualifications of any caregiver or professional. It is possible that some potential caregivers are bogus or misguided.

Table 13-2. Websites Offering Help

Drug abuse is a brain-based disorder like so many other illnesses such as anxiety and depression. Treatment, by qualified caregivers, is the solution for drug abuse and addiction. It is an ongoing, long-lasting
process,
rather than a specific event with an end. It actually saves money in addition to reducing misery. Substitute medications such as methadone are effective and successful. A barrier to treatment is the stigma associated with being a drug user, and the stigma must be overcome. Every person in this country can help by adjusting his or her own attitudes, and by helping others become more tolerant of and knowledgeable about addiction. The characteristics and components of good treatment are known. Preventing drug use from getting started is especially effective and an important goal for society.

¹
McLellan, A.T., Lewis, D.C., O’Brien, C.P. and Kleber, H.D.. “Drug Dependence, A Chronic Medical Illness.”
JAMA
284(13): 1689–1695, 2000. This is an example of a paper that describes drug abuse as a brain disorder deserving of routine standard medical care. It compares drug abuse to other chronic diseases including hypertension, asthma, and type 2 diabetes mellitus, and it finds similarities.

²
Summarized from Adler M. et al. “The Treatment of Drug Addiction: a Review.” In Graham et al,
Principles of Addiction Medicine
, Third edition, American Society of Addiction Medicine, p 419, 2003. The principles are also summarized from
Principles of Drug Addiction Treatment: A Research Based Guide
. Rockville MD: NIDA,
Chapter 2
, NIH Publication No. 99-4180. The wording of the second principle was changed slightly to make it a more positive statement.

³
See the article “Lower Rates of Cigarette and Marijuana Smoking Among Exercising Teens.”
NIDA Notes
, 22(4): 20, 2009.

⁴
O’Malley S.S. et al. “Naltrexone and Coping Skills Therapy for Alcohol Dependence.”
Arch Gen Psychiatry
, 49: 881–887, 1992.

⁵
Dole, V.P. “Implications of Methadone Maintenance for Theories of Narcotic Addiction.”
JAMA
, 260: 3025–3029, 1988. In this paper, Vincent Dole describes his work and experiences in the context of a receptor theory. This work is some of the most important in all of drug addiction research.

⁶
For example, Spoth R.L. et al. “Longitudinal Substance Initiation Outcomes for a Universal Preventive Intervention Combining Family and School Programs.”
Psychol Addict Behav
, 16: 129–134, 2002.

There are many themes in this book. One is that a drug addict is someone who has lost (at least some) control over his or her ability to seek and take drugs, and this loss of control leads to distress and problems for the drug user. Almost all drugs that humans abuse are also self-administered by animals, suggesting that drug taking is an innate drive that is widespread in many species. Moreover, many studies show that drug taking is involved with specific physiological systems in the brain. Because drug taking adversely alters brain chemistry, we can develop medications to reverse these negative changes; in fact, many useful medications have already been developed. Drug abuse produces long-lasting (months to years) changes in the brain, suggesting that these changes are the basis of the chronic and relapsing nature of drug addiction. Abstaining from drugs for a week or a month after long-term use is probably not enough time for the brain to return to normal and heal. The injury to the vulnerable brain increases the drive to take drugs. Drugs act through powerful systems in the brain, systems that have evolved to ensure the survival of our species. Drugs gain control of these natural systems and cause unnatural adaptations and effects. It is believed these factors, taken together, form the basis of drug addiction, a brain disorder or disease. Although many people can walk away from drugs on their own, many can’t. Some individuals are more vulnerable than others, and, realizing that they need help, seek professional treatment. Treatment for drug abuse is effective when done either voluntarily or by mandate, and it is geared to the specific needs of the individual. Great progress
has been made in this field, and more is needed. But, where is all this taking us? What does the future hold?

Many treatment providers feel that it would be wonderful if we could get what we already know about drug abuse into greater use. Public health would be served greatly if drug abuse prevention and treatment were integrated into primary care across the country. It would mean that a routine visit to the doctor would include screening, treatment if needed, and referrals as part of primary care. It sounds simple, but perhaps the stigma of drug addiction is part of the problem.

New and better treatments are also needed to reduce the costly burden of addiction in our society, and the cost is measured not only in money but also in misery. Studies of various treatments and treatment programs will reveal what is most effective in treatment, and these practices will be adopted by other programs. This approach works, but it will take time, money, and support. New medications are needed and will undoubtedly help in this effort. Although there are government-approved and medically accepted medications for treating smoking and alcohol abuse, there are none for treating psychostimulant abuse. Clearly, there are some gaps in addiction treatment that must be filled. Also, medications with fewer side effects are needed. In general, improvement in the treatment of drug abuse, one of our most costly disorders or diseases, is essential.

Prevention, which includes education of the public about drugs, is also effective, and more and better preventive measures are needed. As with treatment, studies of prevention will reveal the best prevention methods. Studies of vulnerability will reveal which groups are the most likely to abuse certain drugs, and these are the groups that can be targeted by improved prevention techniques.

Drugs produce changes in the brain, and these changes are in the levels and activity of various molecules in certain neurons. For example, drugs seem to reduce the levels of D2 dopamine receptors, which have been discussed previously. These and other changes form the cellular and molecular bases of addictive behavior. Therefore, knowledge of these molecular events is critical for understanding drug addiction. Understanding a disease does not necessarily mean we can cure it, but it at least defines the problem. This understanding also sets the stage for a possible cure when new techniques and approaches develop over time.

The story of dopamine has been told to illustrate how brain chemicals mediate addiction. But dopamine is not the only important neurotransmitter. We have mentioned others including glutamate, GABA, serotonin, enkephalins, and anandamide. Addiction is complex and involves systems and circuits of neurons with many neurotransmitters. In the future, we hope to better specify the neurotransmitters and the specific neurons that are critical for addiction. We have made progress on this, but more remains to be done. In addition to neurotransmitters, a number of larger molecules such as proteins (transporters, receptors, and so on) are important for addiction. Again, we have learned much but much remains to be discovered.

As detailed in previous chapters, we know something about the genes involved in addiction, and we know something about the various molecules that are involved as well. We are learning about the important new science, epigenetics, and how drugs cause epigenetic changes in gene expression. As described in
Chapter 5
, “The Dark Side Develops!,” epigenetic changes in neurons in the brain change the levels of various proteins in the nerve cells, such as the mesolimbic neurons. We know a little bit about the drug-induced changes in gene expression and various molecules. But this knowledge needs to be extended and refined. Significant advances are likely in this area in the future. Someday, this knowledge will be translated into gains in new medications and treatments.

Vaccines are major public health tools that are responsible for the eradication of smallpox, the prevention of childhood diseases, and the control of many injurious illnesses. Treatment with a vaccine results in the development of antibodies specific for some target, known as an antigen. The antigen can be a virus, for example, but it is really a protein that is part of the virus. When the antibody binds to the protein on the virus, the virus is prevented from infecting the cells of the vaccinated host. Antibody molecules are Y-shaped proteins that bind to the antigen at the tip of the two arms of the Y. The binding is highly specific for the antigen in the vaccine, and the antibody can be thought of as a specific deactivator or blocker. Although we most often think of antibodies as protecting us against infectious diseases, antibodies can also be made against specific drug molecules.

In 1973, Drs. B. Wainer, F. Fitch, R. Rothberg, and C.R. Schuster published a paper in
Nature
showing that antibodies against morphine blocked the action of morphine on a functioning, contracting tissue.
¹
Traditionally, antibodies are made against large molecules like proteins, and the generation of effective antibodies against a small molecule like morphine was a significant achievement. Not only were the antibodies produced, they were active in that they bound morphine and prevented morphine from having a biological effect. A simple analogy is restraining someone from reaching and doing something injurious to another person. The antibody binds and restrains the molecule so that it can’t do anything. From this seminal study, the idea of producing vaccinations against addicting drugs took hold. For example, it has been shown that vaccinating someone with a protein that has many cocaine molecules attached to it can result in the body producing antibodies against cocaine. The antibody is in the blood of the vaccinated individual (see
Figure 14-1
). It has been shown that this vaccination procedure is effective in reducing the behavioral effects produced by cocaine. Vaccines against addicting drugs (cocaine, nicotine, phencyclidine [PCP], and methamphetamine) are not yet
routinely available but are currently in development. In clinical trials, these vaccines have been effective and shown promise. For example, in a recent study of the cocaine vaccine, the patients that produced the most antibodies against cocaine used less of this drug, presumably because they experienced little reward from taking cocaine. Without these rewarding effects, the act of taking the drug is not reinforced. It will be important to develop better vaccines and procedures that maximize the benefits of this therapeutic approach.

Figure 14-1. Antibodies prevent drugs from entering the brain. Consider the top half of the diagram. There are four frames from left to right showing the sequence for a drug. In the left frame, there are no cocaine molecules (circles) and the blood and brain compartments are shown without drug. The next frame shows cocaine entering the blood, the third frame shows cocaine in the blood about to enter the brain, and the fourth frame shows cocaine diffusing from the blood into the brain where it will produce its effects. Now examine the lower half of the diagram. In the left frame, the blood has antibodies, either from vaccination or from direct injection. The second frame shows antibodies going into the blood (Y-shaped molecules) and cocaine entering the blood either from ingestion or injection. The third frame shows the critical event—the antibodies bind to the cocaine in the blood so that the drug cannot get into the brain, or only a small amount gets in as shown in the fourth frame. In the case of vaccines, the patient’s immune system has been recruited to produce an antibody that prevents or reduces cocaine’s effects. Dr. Thomas Kosten, his colleagues and others have been carrying out this work. (From Whitten, L. “Cocaine Vaccine Helps Reduce Drug Use.”
NIDA Notes
, Vol. 23, December 2010.)