Changing the prescription for addicts

by Shari Roan

A call for change is afoot in the difficult and often heartbreaking world of addiction treatment.

For decades, 12-step programs and a medication-free approach have dominated the recovery industry. But now doctors and scientists and the leader of the National Institute on Abuse are pushing for broad recognition of addiction as a disease and more medical approaches to therapy.

In the last couple of years, a top addiction society officially declared addiction a "brain disorder." A specialty substance-abuse training program for doctors has been ushered into medical schools. The federal government has announced the creation of new resources to help guide patients, families and doctors toward science-based , and more drugs to treat addiction are entering the pipeline.

In June, Gil Kerlikowske, director of the Office of National Drug Control Policy and President Barack Obama's top adviser on drug policy, declared in a speech at the Betty Ford Center in Rancho Mirage that addiction "is not a moral failing on the part of the individual. It's a chronic disease of the brain that can be treated."

About 21 million Americans have a substance-abuse disorder for which they need specialty treatment, according to 2010 statistics from the government-funded National Survey on Drug Use and Health. Deaths from drug overdoses now exceed .

Nine out of 10 people addicted to drugs other than nicotine receive no treatment, and most of those who do get it are put through unproven programs run by people without medical training, according to a 500-plus-page report released by Columbia University in June. Solid data on effectiveness of the most popular recovery approach - 12-step programs - are lacking, the report said.

Much of the reason for the disconnect is rooted in the recovery movement's history: Addicts, shunned by the , received their help from those outside of it, a trend that continues to this day.

"Drug abuse treatment developed outside mainstream medicine," said Dr. Walter Ling, a leading addiction specialist at UCLA. "We're still suffering from that."

And yet decades of basic laboratory science has revealed that addiction is a bone fide medical problem involving profound brain alterations. Alcohol, opiates, cocaine and other substances increase levels of the chemical dopamine in the reward pathway of the brain. With repeated use, baseline dopamine levels wane to compensate and a drug becomes less pleasurable, requiring ever-larger doses.

Even when people are weaned from a drug, their brains don't return to normal. So they remain vulnerable to its draw, suffering mood swings and profound urges to use again.

Such discoveries are filling science journals at a prodigious rate, adding weight to the position taken by National Institute on Drug Abuse chief Dr. Nora Volkow - that addiction is a chronic disorder that will require multiple rounds of therapy to reduce the risk of relapse and to lengthen drug-free intervals.

Several drugs to treat addictions have been approved in recent years, adding to the modest collection already in limited use, such as methadone for heroin addiction, Antabuse for alcoholism and a handful of others.

To Volkow's mind, the new medications are important for two reasons. First, recovery from addiction is hard and patients need every tool that medicine can offer them. But there is another potential benefit: The growing availability of medical treatments will encourage doctors to treat their patients' drug problems, just as they would a patient's out-of-control blood sugar or high cholesterol.

"You are killing two birds with one stone - giving tools to improve outcomes for the patient and giving tools to the physician, increasing the likelihood they will incorporate substance abuse disorders into their practice," she said.

One of the most important new developments has been the emergence of long-acting drugs to reduce cravings that persist even in people who are highly committed to abstinence. Freeing addicts from summoning the willpower to take their medications each day - as well as the temptation to sell them on the street - eases their burden in the challenging first months of recovery, Ling said.

The medication naltrexone, a pill to treat alcohol dependence, was reformulated into a monthly injection called Vivitrol in 2006 and was approved for opioid addiction in 2010. In studies, 36 percent of the opioid-addicted patients on Vivitrol were able to stay in a treatment program for the full six months, compared with 23 percent of the patients receiving a placebo injection. That is a significant improvement for addiction, experts said.

Titan Pharmaceuticals of South San Francisco plans to seek Food and Drug Administration approval of an implant that would provide continuous delivery of the drug buprenorphine - known as Suboxone in its pill form - for six months to people attempting recovery from dependence on heroin or prescription painkillers.

In advanced studies led by UCLA's Ling, nearly 66 percent of patients who had the implant inserted under the skin in the upper arm stuck with treatment, compared with only 31 percent of those who received a placebo implant. They had higher rates of clean urine tests and lower rates of withdrawal symptoms and cravings.

The National Institute on Drug Abuse is also putting considerable effort into developing vaccines to fight addiction to nicotine, cocaine, heroin and methamphetamine, Volkow said. The aim is to trigger an immune response to a drug of abuse so it can't reach the brain and elicit a "high," causing cravings for the drug to erode over time.

The move to treat addiction as a disease may receive a boost from the Affordable Care Act, which mandates treatment for substance abuse disorders and is likely to push services away from nonmedical treatment centers toward mainstream medicine, a Medicare official wrote last year in the journal Health Affairs.

But many U.S. drug treatment centers shun medications, or offer them only sparingly.

A 2011 survey of 345 directors of drug treatment centers in the Journal of Addiction Medicine found little interest in medications: Among programs with access to a medical doctor, fewer than half had adopted all available addiction treatments. Despite the availability of three prescription drugs approved to treat alcoholism, only 24 percent said they offered them.

Medications don't address the lifestyle, relationship and spiritual problems that lie at the heart of addiction, said John Schwarzlose, president and chief executive of the Betty Ford Center, one of the oldest and most highly regarded inpatient treatment facilities.

"That's why the Betty Ford Center has the 12-step program as the core philosophy," said Schwarzlose, who added that doctors at his center prescribe addiction medications on a case-by-case basis.

Volkow said she wasn't proposing that behavioral, psychosocial and spiritual approaches be kicked out of treatment programs - only that the best that science can offer be thrown at this highly intractable problem.

" is a very aggressive disease," she said. "We need to treat it aggressively. We do that for other diseases."

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