Wasted: An Alcoholic Therapist's Fight for Recovery in a Tragically Flawed Treatment System (38 page)

Dr. Malenka thinks Mike, especially at the height of his disorder, would see cues he associated with booze, like a flashing “open” neon sign in the window of his favourite liquor store. He tells
Mike, “What I imagine happened is as you became addicted to alcohol, this entire circuitry was modified so that this cue, the neon sign, activated certain parts of your brain that communicated to your reward circuitry and just said ‘Man, I want that spike of dopamine. I really need it. I want it. I want it.’ Substances like alcohol maladaptively usurp the mechanisms in our brain that have evolved
for normal forms of learning and memory.”

So how much has Mike’s brain’s reward circuitry been hijacked? We got a chance to find out. The Medical University of South Carolina in Charleston has a reputation for excellence in researching substance use disorders. That’s where we met Dr. Joseph Schacht, an assistant professor and clinical psychologist at the Center for Drug and Alcohol Programs
in Psychiatry and Behavioral Sciences. He offered to scan Mike’s brain to see how much it craves alcohol. Mike was strapped into a magnetic resonance imaging machine, his head positioned in a football helmet-like device with a mirror attached. Dr. Schacht put a small sensor pad in his hand and explained that a series of images would be projected onto the space behind him, which Mike would watch
in the mirror. Over twelve minutes, Mike saw pictures of alcoholic drinks—sparkling wine with shimmery condensation creeping down the glass, a frosty mug of beer with a frothy head, a wide array of eye-catching cocktails—as well as non-alcoholic drinks like milk, Coke and orange juice. Using his hand sensor Mike was asked to rate the strength of his craving: none, mild, moderate, severe or extreme.

“The signal in his brain is independent—he can’t control it,” said Dr. Schacht, as he sat observing the different views of Mike’s brain on his console. When the task was complete and Mike was released from the machine, he revealed he’d felt very little craving and had hit the “none” response on his sensor pad the most, and “mild” a few times.

The next day, Dr. Schacht revealed the
results of the brain scan to Mike. And he was right: the brain doesn’t lie. First, he showed Mike images from previous scans of alcoholics’ brains. They were lit up like Christmas trees, glowing in vivid shades of orange, red and yellow, precisely in the areas neuroscientists associate with hijacked reward circuitry. Then Dr. Schacht showed Mike brain scans from non-alcoholics, which had very little
colour. Next, Mike’s scan.

Mike’s eyes popped. He swallowed hard as he took in the image, the bright splotches of orange, yellow and red, that placed him firmly in the group of alcoholics.

Leaving that meeting, Mike was quiet. I asked him how he felt when he saw that scan. “A whole bunch of reactions came to mind. First, relief. My brain really
is
different. Then, regret. I suffered
a lot, so did my family, because I kept hearing if I just had enough willpower, I could change this. That scan tells me it’s about so much more than willpower; it’s about biology, too.”

I realized, though, that there is a major upside to these brain scans. Once neuroscientists were able to map out usurped reward circuitry and discover the mechanism by which chronic use of alcohol and other
drugs can alter the brain, they could begin developing drugs to essentially alter and in some cases, block a substance’s effect.

Could one of those drugs prevent Mike’s recurrence from spiralling out of control?

• 44 •

WHEN MIKE WAS
first fighting to stay sober more than six years ago, his addictions doctor was not a fan of putting him on meds to help him with all the uncomfortable side effects of withdrawal. The exception was a drug called trazodone, an older antidepressant that helps people sleep. It didn’t do much for Mike. There’s a real
reluctance in some recovery circles to prescribe proven medication, the idea being, “You don’t use drugs to get off drugs.”

Attitudes toward using medication to treat addiction are complicated, according to Vancouver’s Dr. Evan Wood. He points out that many doctors are reluctant to prescribe certain drugs (such as methodone) due to their addictive nature, while others prescribe a “cocktail”
of psychoactive medication that is both unproven and possibly dangerous. “I also think old-school addiction doctors were not trained to use these new tools and other doctors (including primary care physicians) reach for
SSRI
s and other drugs that they are comfortable to prescribe,” he says.

This idea you don’t use drugs to get off drugs is particularly popular in some
AA
circles, but it’s
not condoned by
AA
. In fact,
AA
has a little pamphlet about medications that tells members not to play doctor—basically, don’t tell anyone to stop taking their medication. “And yet,” Dr. Keith Humphreys says, “you find members of
AA
who think true recovery means you’re not allowed to take your antidepressant.”

The end result of “you don’t use drugs to get off drugs” is a lot of people
not getting—and taking—the proper medications to treat a difficult disorder. And let’s not forget: a sizable portion of those battling substance use disorders
also
battle another mental illness.

It’s an attitude that is particularly troubling, since the new understanding about brain reward circuitry has lead to the development of medications that are saving lives. The drug Suboxone (a
combination of buprenorphine and naloxone) is now used at Hazelden Betty Ford to help get people off opioids like heroin, morphine and OxyContin.

If your problem is alcohol, there are only three medications approved for use in Canada: naltrexone, acamprosate (Campral) and disulfiram, known commonly as Antabuse. In the U.S., the thirty-day injectable form of naltrexone, Vivitrol, is also
available.

Because researchers now understand the neuroscience of our brain’s reward circuitry, several drugs that have been used to treat other conditions are now being repurposed for use in substance use disorders because they work on the same neural pathways. Some doctors and hospitals are already prescribing these medications off-label because they reduce the suffering associated with
battling alcohol use disorders. However, there is a problem with physicians not adequately trained in addiction medicine over-prescribing unproven medications—it can raise the risk of overdose. A doctor that’s skilled in addiction medicine needs to manage these drugs.

A few of the promising new drugs:

• Gabapentin was originally marketed as an anticonvulsant and neuropathic pain medication,
  but because it acts on the reward pathway involved in alcohol addiction, it has been tested in that context. In trials at the Scripps Research Institute in La Jolla, California, gabapentin significantly improved rates of alcohol abstinence, with more than four times the success as a placebo in high enough doses, around 1800 mg, for example. It also significantly reduced bouts of heavy drinking
  in those who did not abstain.
  1
  
• Topiramate, like gabapentin, is an anticonvulsant. In recent studies it has been shown to reduce alcohol craving and consumption.
  2
  It may also help with cocaine addiction.
  
• Baclofen, a muscle relaxant, has produced or decreased alcohol craving in clinical trials.
  3
  Many addiction institutions, like Canada’s Centre for Addiction and Mental Health and some
  American rehabs, already prescribe it.
  

The idea that you don’t use drugs to get off drugs ends up killing people with serious substance use disorders—many commit suicide, drink themselves to death, or overdose. And it hurts those suffering from concurrent disorders the most. Mike’s brother Roger stayed in a Canadian treatment centre for a year. He got sober all right, but as a condition
of staying in the program, he had to come off all meds, including drugs to treat his bipolar disorder. He was catatonic and suicidal before he got real mental health attention and addiction treatment at St. Paul’s Hospital in Vancouver. His disorder properly medicated, Roger now attends weekly support meetings and has never been happier, or healthier, in his life.

And there’s even a new
treatment in the pipeline for pot addiction.

People make jokes about pot addiction. Yet we all know someone whose addiction to marijuana has destroyed their motivation to live a productive life. Now researchers have found that a simple amino acid called N-acetylcysteine (or
NAC
) helps people kick the cannabis habit.

Dr. Peter Kalivas, a neuroscientist and distinguished professor
at the Medical University of South Carolina, brought
NAC
to early clinical trials, and
NAC
is now in large-scale clinical trials in six cities. It is a well-known dietary supplement believed to boost the body’s antioxidant stores. It’s been used in treatment of cystic fibrosis and acetaminophen overdose, and is now being explored in treating all manner of psychiatric disorders that are characterized
by intrusive thoughts, including addiction,
PTSD
and depression, and obsessive compulsive disorder.

Dr. Kalivas explains how
NAC
works in addiction. “What happens in addiction is: you can describe to me all the error messages you are getting, ‘My family is falling apart,’ ‘My job is falling apart,’ ‘My health is going downhill,’ and yet you can’t use those error messages to change your
habitual drug-seeking behaviour.”

NAC
dampens destructive, intrusive thoughts and has allowed some long-term users to return to productive lives.

• 45 •

BASED ON OUR
research for the film, the most obvious drug for Mike to try is naltrexone. It’s not a new drug. It was given
FDA
approval in the United States in 1994, two decades ago. It’s been available for a long time in Canada too. It’s estimated to help diminish agitation and cravings in somewhere between one and four and one in
eight people, yet doctors rarely prescribe it, which frustrates Dr. Wood. He explains a term used in medicine called, “the number needed to treat.” For some heart medications, for example, that’s one in fifty. Fifty patients need to be treated before you’d expect to prevent a heart attack for one. Dr. Wood says doctors have no trouble prescribing those heart medications. Yet naltrexone, which actually
works on a much more favourable ratio of patients, is rarely prescribed.

Besides unpleasant side effects like nausea, there is one other major problem with oral naltrexone: it won’t work if the patient doesn’t take it. That’s why in addiction medicine circles, there’s considerable excitement about Vivitrol, the thirty-day injectable version of naltrexone.

When we interviewed him
at Stanford, Dr. Humphreys explained why Vivitrol can be so effective. “You get the shot and then for the next thirty days, you have that medication in your body. And in a sense what you’re doing is tying the hands of your future self. ‘I know at this moment I sincerely want to stop drinking but when Friday night rolls around, there’ll be another guy running the show and he’s going to make a different
decision.’”

Vivitrol was approved for use in the U.S. in 2006 for treating alcohol dependence and in 2010 for treating opioid addictions in adults. The drug is prescribed for addiction to heroin and prescription painkillers such as Vicodin and OxyContin, which is a rising problem nationally, as well as for alcoholism. A large randomized trial published in the
Journal of the American Medical
Association
reported Vivitrol reduced heavy drinking in alcoholics by twenty-five per cent. In a study published in the
Lancet
, the well-known British medical journal, ninety per cent of heroin users given Vivitrol became abstinent, compared to thirty-five per cent given the placebo.
1

The medication is not approved in Canada and is currently the subject of a trial at St. Paul’s Hospital
in Vancouver. After what happened tonight at the party, the more I read about Vivitrol, the more I think it
may be
what Mike needs to get well again.

• 46 •

MIKE WAS UNABLE
to succeed at
AA
or twelve-step programs in no small part due to his great difficulty admitting powerlessness over alcohol. That’s why he’s intrigued by how much something called motivational interviewing has gained traction in treating addiction. Where
AA
insists one admit powerlessness over alcohol, motivational interviewing
actually does the opposite. It’s rooted in the belief that we all have the capacity within ourselves to change. As defined by its founders, “motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.” The counsellor guides the process by using open-ended questions, affirmations, reflective listening and summary statements.
It focuses on a client’s strengths and the assumption that people hold a lot of their own wisdom within and have the power to change themselves.

In most of the drug trials we filmed, participants were also offered a variety of therapies, most often either motivational interviewing or cognitive behavioural therapy. Cognitive behavioural therapy is a structured approach that looks at how
thoughts, feelings and behaviours are interconnected, and posits that by changing the way we think and behave we can change the way we feel. In fact, we interviewed one man in a trial of gabapentin who is convinced he is doing much better. But he can’t discern whether it’s the gabapentin or the motivational interviewing that’s responsible for the change. He considers the motivational interviewing
transformative.

Dr. Bill Miller is widely known as the father of motivational interviewing. He describes it as a photographic negative of where addiction treatment was in the 1980s: “Shut up and listen, you don’t know anything. I’m the expert, you’re in denial, let me tell you the truth.” Meanwhile, of motivational interviewing, he says: “It’s like guiding. It’s that middle ground between
an authoritarian approach and a really passive, good listening approach—that’s where motivational interviewing lives.” Although motivational interviewing requires a great deal of therapist skill and training, the word “interviewing” can be a bit misleading because it is not so much about the questions the therapist asks, it’s more about the connection and spirit of the therapeutic relationship.
Most people battling a substance use disorder confront profound ambivalence. They recognize their drinking or drug-taking has negative consequences, but there are obvious upsides, too: a feeling of euphoria, more confidence, reduced depression—at least at the beginning—and diminished anxiety, to name a few. In motivational interviewing, a skilled and trusted counsellor guides the client through
the process of change, listens intently, picks up on client’s cues, deftly avoids arguments and direct confrontation, adjusts to resistance rather than opposing it directly.