HUNGRY FOR THE NEXT FIX

Behind The Relentless, Misguided Search For A Medical Cure For Addiction

As director of the National Institute on Drug Abuse (NIDA), Alan
Leshner toured the country with a Powerpoint presentation featuring
brain scans. The show was a slightly more sophisticated version of the
Partnership for a Drug-Free America's famous ad showing an egg frying
in a pan. As he flashed MRI images on a screen, Leshner would say, in
effect, "This is your brain on drugs."

Leshner's message was threefold: First, certain drugs are inherently
addictive. Second, scientists have discovered the neurochemical
processes through which these drugs cause addiction. Third, that
understanding will make it possible to develop drugs that cure or
prevent addiction. Leshner's traveling Powerpoint show epitomized
NIDA's reductionist approach to drug abuse: Take a brain, add a
chemical, and voila, you've got substance dependence.

Leshner left NIDA at the end of November. Coincidentally, Enoch
Gordis, head of the National Institute on Alcohol Abuse and Alcoholism
(NIAAA) since 1986, retired around the same time. Like Leshner, Gordis
sees addiction as a biological problem with a pharmaceutical solution.
He believes scientists have "the ability based on new knowledge from
neuroscience research to develop pharmacologic treatments that act on
brain mechanisms involved in alcohol dependence."

The view of addiction espoused by Leshner and Gordis is at odds with
what we know about the actual behavior of drug users and
drinkers including evidence from government-sponsored research. These
studies indicate that treatment is neither necessary nor sufficient
for overcoming addiction. The main factor in successful resolution of
a drug or alcohol problem is the ability to find rewards in ordinary
existence and to form caring relationships with people who are not
addicts. By looking instead for a magical elixir just over the
horizon, NIDA and the NIAAA give short shrift to the individual
circumstances that are crucial to understanding why some people abuse
drugs.

`A Medical Illness'

NIDA's official mission is "to lead the Nation in bringing the power
of science to bear on drug abuse and addiction." Leshner, who has a
Ph.D. in physiological psychology, took the agency's helm in 1994.
During his tenure NIDA's budget doubled to $781 million, money devoted
mainly to biological research that approaches addiction as a disease.

Although drug use "begins with a voluntary behavior," Leshner said in
a 2001 interview with The Journal of the American Medical Association,
it ceases to be voluntary after it repeatedly affects the "pathway
deep within the brain" common to all drug addiction. "There's no
question it's a medical illness," he said, "and once you have it, it
mandates treatment. It's a myth that millions of people get better by
themselves."

Leshner's model of addiction emphasizes the special power of drugs.
After all, he did not travel around the country with MRI images
showing how shopping, gambling, or eating potato chips affects the
brain. Thus it was startling to see him concede that drug abuse may be
fundamentally similar to excessive involvements with other activities
that give pleasure or relieve stress. "Over the past 6 months," he
said in the November 2 issue of Science, "more and more people have
been thinking that, contrary to earlier views, there is a commonality
between substance addictions and other compulsions." Some of us have
been making this point for years, and it does not fit very well with
the idea that drugs create addicts by transforming their brains.

As evidence for this view, Leshner would point to MRI scans of
experienced drug users, which he claimed differed in characteristic
ways from images of ordinary brains. He also cited studies of
drug-induced brain changes in animals. He liked to display a
map reminiscent of a phrenology chart showing which areas of the
brain are involved in drug use and addiction.

But Leshner's seemingly scientific claims have never jibed with
reality. Consider what the sociologist Lee Robins and the psychiatrist
John Helzer found when they headed a team that interviewed veterans
who had been addicted to heroin in Vietnam. Only one in eight became
readdicted at any time during the three years after they came home.
This was not because the rest were abstinent: Six in 10 used a
narcotic after returning to the U.S., and a quarter of the previously
addicted men used heroin regularly. Yet only one in five of those who
used a narcotic after they got home, including only half of those who
used heroin regularly, became readdicted.

The Vietnam situation, of course, was unique. Young men were torn from
their homes, sent to a strange and dangerous environment, and offered
easy access to heroin. Then they returned to normal life. Still, the
results surprised Robins and her associates, who commented: "It is
uncomfortable presenting results that differ so much from clinical
experience with addicts in treatment. But one should not too readily
assume that differences are due to our special sample. After all, when
veterans used heroin in the United States...only one in six came to
treatment." In other words, looking only at addicts who are treated
provides a skewed view of addiction. Indeed, the vets who were treated
after they got home actually were more likely to pick up the habit
again.

Rats vs. People

Any doubts about the relevance of the Vietnam veterans study are
allayed by findings from long-term studies of drug users in the United
States. Long-term cocaine users, for example, generally do not become
addicts. And when they do go through periods of abuse, they typically
cut back or quit on their own. They may not do so as rapidly as others
(and they themselves) wish they would. But addicts act very much like
other human beings: They pursue pleasure or relief, and most will
change their behavior when it causes them serious harm, so long as
they have reasonable alternatives.

According to the National Household Survey on Drug Abuse (overseen by
the Substance Abuse and Mental Health Services Administration), about
3 million Americans have used heroin. Of these, one in 10 report using
the drug in the last year, and one in 20 say they've used it in the
last month. The percentages for cocaine are similar. In both cases,
daily use is so rare that the government does not provide figures for
it. These findings indicate that the vast majority of heroin and
cocaine users either never become addicted or, if they do, soon manage
to moderate their use or abstain.

This pattern has been confirmed again and again by
government-sponsored research. At NIDA, however, studies of human
behavior have taken a back seat to research involving brain scans,
special breeds of rats, and monkeys tethered to drug-dispensing catheters.

Given NIDA's biological orientation, it may seem odd that the main
form of treatment the agency advocates (pending development of a
wonder drug for addiction) involves adopting a new set of
quasi-religious beliefs and meeting regularly with like-minded
individuals. But NIDA's take on addiction has much in common with the
view promoted by Alcoholics Anonymous and its imitators. Both see
addiction as a disease involving loss of control that can be overcome
only through abstinence.

NIDA's support for drug treatment based on A.A.-like principles, the
dominant approach in the United States, flies in the face of its
avowed commitment to rigorous science a conflict illustrated in the
last issue of NIDA's newsletter published under Leshner. A front-page
article announced the disastrous long-term consequences of heroin use,
based on a study that followed a group of addicts for more than 30
years. "The death rate among the members of the group is 50 to 100
times the rate among the general population of men in the same age
range," the article said. "Even among surviving members of the group,"
the lead researcher added, "severe consequences such as high levels of
health problems, criminal behavior and incarceration, and public
assistance were associated with long-term heroin use."

Yet the subjects of this study were criminal offenders in California
who were forced to attend abstinence-oriented, A.A.-style group
sessions between 1962 and 1964. In other words, they benefited from
just the sort of treatment NIDA advocates. Undaunted, Leshner began
his column in the same issue of the newsletter with the cheery news
that "NIDA's quarter century of research has produced a basic
unequivocal message drug addiction is a treatable brain disease." Yet
today's preferred treatment is indistinguishable from the programs
those California convicts attended in the 1960s.

Sugar: The Miracle Cure

If Leshner and Gordis are right, A.A.-style therapy will ultimately be
replaced, or at least supplemented, by drugs that block addiction. The
leading candidate so far is naltrexone, which is reputed to curb the
urge for both heroin and alcohol. Naltrexone has been approved for
treatment of alcohol dependence, and Gordis, an M.D., promoted the
drug as the first in the pharmacopoeia he envisioned for alcoholism.

A study published in December made that prospect seem unlikely. The
researchers divided 600 alcoholics into three groups: One received
naltrexone for a year, another was given naltrexone for three months
followed by nine months of sugar pills, and the third group took just
the placebo. The subjects began the study drinking, on average, on two
out of every three days, 13 drinks on each occasion. One year after
their treatment began, these men were drinking one-quarter as
frequently and consuming somewhat less when they did drink. But the
reduction was about the same for the men who took the fake pills as it
was for those who were given naltrexone.

Announced in The New England Journal of Medicine, these findings were
incomprehensible to anyone who accepts the view of alcoholism promoted
by the NIAAA. Aside from the evidence against naltrexone's
effectiveness, it was stunning that sugar pills enabled severe
alcoholics to reduce their drinking without abstaining completely,
which alcoholism experts in the United States teach is impossible. Yet
every major study of alcoholism carried out during Gordis' tenure at
the NIAAA yielded the same sort of results. It's just that Gordis
spent much of his energy denying what his own agency had found.

In 1992 the NIAAA surveyed more than 42,000 randomly selected
Americans in the National Longitudinal Alcohol Epidemiologic Survey.
Census Bureau interviewers questioned each respondent about his or her
lifetime drug and alcohol use. Of special interest were 4,585
respondents who at some time in their lives were "alcohol dependent"
(what most people call alcoholic). Of this group, only about a quarter
were ever treated for alcoholism (including A.A. as treatment). But
the treated group was no more likely to have improved, as measured by
either abstinence or drinking without abuse. In fact, more treated (33
percent) than untreated alcoholics (28 percent) were continuing to
abuse alcohol.

One reason untreated alcoholics did better was that many more of them
reduced their drinking without abstaining. Among people who at some
point in their lives had qualified as alcohol dependent but were never
treated, nearly six in ten (58 percent) were drinking without a
diagnosable problem. Including all the treated and untreated
alcoholics in this random sample of Americans, half were drinking
without abusing alcohol.

Driven Not to Drink

The NIAAA sponsored another ambitious study the largest trial of
psychotherapy ever conducted. Completed in 1996, the study was known
as Project MATCH because it was aimed at determining whether different
treatments could be "matched" to specific types of alcoholics to
produce optimum results. One of the therapies, based on A.A.'s 12
steps, was called "12-step facilitation." A second was dubbed "coping
skills therapy." The third was "motivational enhancement therapy."
Nearly half of the 1,700 or so subjects underwent hospital treatment
first; the rest entered the MATCH treatments directly.

All the therapies performed equally well, but one was considerably
simpler than the others: Motivational enhancement involved four
sessions with each alcoholic, compared to 12 for the two other types
of therapy (although, on average, subjects attended only two-thirds of
the sessions scheduled for any of the therapies). Motivational
enhancement brings into focus and strengthens the individual's own
drive for sobriety, but it leaves the mechanics of sobriety to the
alcoholics themselves.

Although the Project MATCH subjects had few counseling sessions
(especially in motivational enhancement therapy), their drinking was
periodically assessed following treatment. These interactions with the
project, intended solely for research purposes, seem to have had the
effect of keeping alcoholics focused on controlling their drinking.

Whatever treatment alcoholics received in Project MATCH, few abstained
for even a year. Gordis and his colleagues instead emphasized dramatic
reductions in drinking by the subjects. Whereas they averaged 25 days
of drinking a month prior to treatment, after a year they were
drinking only six days out of the month. Moreover, the average number
of drinks they consumed each time they drank dropped from 15 to three.

In all three of these prominent studies the naltrexone trial, the
NIAAA's national survey, and Project MATCH the results were essentially
the same. Even with clinical alcoholics, minimal treatments were as
successful as more elaborate ones, and the best indicator of success
was the alcoholics' ability to cut back their drinking rather than
quit altogether. But how can sugar pills or a few sessions of
motivational enhancement help alcoholics control their drinking? The
basic ingredients for successful treatment are 1) identifying a
problem with the agreement of the addict, 2) believing change is
possible, 3) placing primary responsibility on the addict for carrying
out the change, 4) accepting reductions in use as well as abstinence,
and 5) following up to let addicts know someone cares and wants to
make sure they stay on course.

Beyond Abstinence

In the face of studies that cast doubt on traditional notions about
alcoholism, Gordis seemed to consider it his duty to explain why they
actually confirmed the conventional wisdom. Project MATCH in
particular presented a serious P.R. problem for the NIAAA: It spent
more than $30 million without fulfilling its purpose of identifying
principles for matching alcoholics to treatments. This is how Gordis
spun the results: "The good news is that treatment works. All three
treatments...produced excellent overall outcomes."

Although Gordis relied on reduced drinking as a measure of success to
put the best gloss on Project MATCH, he has always quashed any
revision of the abstinence-oriented goals that characterize virtually
all American alcoholism treatment. Responding to a 1997 U.S. News and
World Report story on Moderation Management, a program for reducing
alcohol consumption among problem drinkers, Gordis sternly warned that
"current evidence supports abstinence as the appropriate goal for
persons with the medical disorder `alcohol dependence'
(alcoholism)."

While abstinence may be a desirable goal for these individuals, not
many accomplish it. Project MATCH engaged the top clinical
practitioners and researchers in the United States in designing and
supervising treatment for alcoholics. As a result of this attentive,
sophisticated care, which is unlikely to be matched by any program an
alcoholic could find in the real world, about a quarter of the
subjects abstained for as long as a year.

Gordis' attitude seems to be: "Most alcoholics won't abstain after
treatment, but they should! And we are not going to accept anything
less than this worthy, if unreachable, goal." His attitude is
especially disturbing since Project MATCH found that reductions in
drinking were beneficial. The subjects' liver functioning typically
improved, and they displayed fewer problems associated with drinking.
Surely, better health and less destructive behavior are worthy goals.
Since Gordis spoke for the U.S. alcohol treatment establishment, his
rigidity condemned American alcoholics to limp along, most continuing
to drink, with little chance of finding assistance in limiting their
drinking or reducing its negative consequences. We will never
eliminate drinking and drug use. But we might be able to reduce the
harm they sometimes cause if we could eliminate the pseudoscientific
moralism dispensed by the likes of Leshner and Gordis.