Wednesday, 26 September 2012

Does Brain Research Obscure Addiction’s Root Causes?


Did Dickens Get It Right?

Breathe the polluted air, foul with every impurity that is poisonous to health and life; and have every sense, conferred upon our race for its delight and happiness, offended, sickened and disgusted, and made a channel by which misery and death alone can enter. Vainly attempt to think of any simple plant, or flower, or wholesome weed, that, set in this foetid bed, could have its natural growth, or put its little leaves forth to the sun as God designed it. And then, calling up some ghastly child, with stunted form and wicked face, hold forth on its unnatural sinfulness, and lament its being, so early, far away from Heaven—but think a little of its having been conceived, and born, and bred, in Hell!

That’s how Charles Dickens chose to put the generational question, in his 1848 novel, Dombey and Son. Poverty and bad mothering (there was hardly any fathering) stunted a child’s “natural” inclinations toward normalcy and love. As the reed is bent, and so on. It is a forceful and memorable literary case for the debilitating effects of childhood deprivation, illness, and trauma. And quite timely, given the ongoing backlash against the “disease model” of addictions and mental illnesses. Did Dickens have it right, more than 150 years ago? Has the research associated with the disease model—the brain breakthroughs, the MRI scans, and the neurotransmitter studies—all been giant detours away from root causes?

You would think so, listening to the cacophony of voices seeking to discredit the notion of addictions and mental illnesses as medical diseases. Medical and psychiatric opinion appear to be revolving away from a strict study of mechanisms of the brain, and back toward the study of society and the environment as root causes of conditions like schizophrenia and drug addiction.

Assuming that we avoid the drastic road of looking beyond the brain entirely for addiction causes—which would represent a true return to the past—what seems to be called for is some sort of “third way” of threading between the determinism of DNA and the fuzzy humanism surrounding the question of social causation, even as many researchers and commentators have become frustrated with the pace of new drug discovery for treating addictive disease, and are threatening to throw out the baby with the bathwater.

Recently, during a lively dinner in Amsterdam, I raised some of these questions with neuroscientist Marc Lewis, Professor of Human Development and Applied Psychology at Radboud University in Nijmegen, The Netherlands, and author of Memoirs of an Addicted Brain: A Neuroscientist Examines his Former Life on Drugs.

“Addictive drugs convert the brain to recognize only one face of God, to thrill to only one suitor,” Lewis wrote in that excellent book. Dopamine becomes “specialized, stilted, inaccessible through the ordinary pleasures and pursuits of life, but gushing suddenly when anything associated with the drug comes into awareness…. I wish this were just an exercise in biological reductionism, or neuro-scientific chauvinism, but it’s not. It’s the way things really work.”

Nonetheless, even Dr. Lewis is unhappy with the idea of calling drug addiction a “disease.” But why? Dopamine, says Lewis, is about craving and attraction, and not just about pleasure. There is too much going on with addictive behavior to fit neatly into the disease category, Lewis believes. Lewis doesn’t argue that brain structure is not causal—much of his book is devoted to proving that it is—but rather that the early brain, in the first two years of life, is so malleable that parent-child experiences shape the style of that young brain, so to speak. “There must be neural correlates to addiction,” he said, “ but this can occur in early childhood, and not from innate genetics.”

This idea has sweeping ramifications. It suggests that a person could become a drug addict entirely independent of his or her inborn genetic predilections. It suggests that a biological propensity for addiction may not need to be innate in order for the disorder to develop. The neurobiological preconditions may develop in early childhood, or even in the womb, and an individual’s basic chromosomal endowment may not be as predictive or protective as we have previously concluded.

I am not yet convinced on this point. Certainly there is evidence that addicted people have often had traumatic childhoods. Or, as we now refer to them: ACEs, or adverse childhood experiences. But should we be spotlighting parents and social setting, as we did for most of the 20th Century, or should we be paying attention to the disordered central nervous system, with associated behavioral traits such as impulsivity, low harm avoidance, and difficulty imaging future consequences, that characterize the behavior and cause much of the frustration in dealing with chronically “bad” children?

The Third Way could well be epigenetics, defined as the study of how gene expression can be modified without making direct changes to the DNA. Writing in Science News, Tina Hesman Saey explains that "epigenetic mechanisms alter how cells use genes but don't change the DNA code in the genes themselves.... The ultimate effect is to finely tune to what degree a gene is turned on or off. Often the fine tuning is long-lasting, setting the level of a gene's activity for the lifetime of the cell."  From a scientific point of view, epigenetics opened the door for a new way of thinking about addiction.

 An addict, as Lewis told me, “is like a starving animal.” You cannot talk that animal out of stalking it prey. However, Lewis believes it is time to do away with the dominant role that the chase for specific genes has played in addiction science. The endeavor resembles a classic needle-in-the-haystack kind of search, and is unlikely to come up with something simple but significant. Lewis believes that in many cases “womb trauma and infant trauma during the first two years” is sufficient to create the innate biological architecture responsible for addiction. Is this true in every case? The research pictures strongly suggests that it isn’t—sorry, Dr. Maté. It seems clear that some people are hardwired for addiction in a way that transcends family environment and social circumstances. We have all heard of the perfect young man or woman, with every advantage, and a loving home life, who succumbs, mysteriously, to the lure of addictive drugs.

We also discussed an article Lewis wrote for Perspectives on Psychological Science, called “Dopamine and the Neural Now,” in which he argues that “the disease-versus-choice debate creates a false dichotomy: Neuroscience does not have to frame addiction as a disease. Rather, it can help explain how addicts make impulsive choices in the moment and distort appraisal and decision-making habits in the long run…. repeated dopamine enhancement modifies brain structures to maximize the appeal of addictive activities, minimize the appeal of competing rewards, and undermine the cognitive capacities necessary to choose between them. I conclude that addiction is not a monolithic state but a recurrent series of choices that permit negotiation, and sometimes cooperation, between immediate and long-range goals.”


Despite the growing popularity of ACE hypotheses for explaining addiction, Lewis insists that addiction is neither a disease of choice nor a genetic imperative. In some ways, it is a meta-disease, calling into question, as all “mental” illnesses do, the very notions of personhood and autonomy. But a Third Way of thinking about addiction; one that incorporates both the innate propensities of our genetic endowment and the many ways early experience can shape the expression of our DNA, may help draw the addiction field out of the “either/or” thinking that continues to shape many of the debates.

 As Saey wrote in Science News: “Such findings suggest that medicines that interrupt or reverse epigenetic changes… could one day prevent or cure addiction." Drugs to treat drug addiction are going to be a central feature of future addiction research, no matter how we rejuggle the relationship between nature and nurture.

Graphics Credit: http://news4geeks.net/

Tuesday, 18 September 2012

Alcohol Researchers Still Wary of Combined Addiction Institute

 
Why can’t we all just get along?

A long time ago, an intrepid institutional director named Francis Collins promised his minions (as former NIH director Harold Varmus had promised his) that he would unite the nation’s two mighty addiction research bodies, The National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), for the greater good of the entire kingdom—researchers and taxpayers alike.

Hasn't happened yet. 

Existing within the large institutional framework of the National Institutes of Health (NIH), the two agencies overlap sufficiently to make them prime candidates for a consolidation. Advocates of the merger, most of them advocates for NIDA, also suggest that the research itself will improve as a result of a decrease in “overlapping missions.”

However, as I wrote in 2010, the NIAAA has a long list of reasons why the merger—which looks, from the NIAAA point of view, more like an acquisition—is a bad idea. Alcohol use disorders are different than other drug addictions, researchers at NIAAA commonly propose. The genetics of alcoholism differs from the genetics of drug addiction, they say, and most people with “alcohol use disorders” don’t abuse other drugs. Furthermore, alcohol damages the brain and other organs in a consistent pattern “best suited to a single alcohol institute,” according to the NIAAA’s acting director.

At this stage, NIAAA’s heel dragging is patently obvious. The agency has always been the weaker sister in the addiction research family. With only half of NIDA’s billion-dollar budget, NIAAA deals strictly with alcohol research, even if the NIAAA has at times seemed unsure of what constitutes its main area of study—alcohol the addictive drug, or alcohol the healthy beverage. The merger would represent a recognition that alcohol is just another drug, albeit a legal one.

In a recent issue of Addiction Professional, Alison Knopf writes that “the alcoholism research field, which believes it would lose out under such a definition, is still fighting the reorganization. And some openly question whether the ‘merger’ ever will come to pass at all.”

Among the many unanswered questions are these, says Knopf: "The current portfolios for AIDS, fetal alcohol syndrome (FAS), liver disease and smoking—where the most money is at the two institutes—may or may not stay within the new institute. Also unknown to many is whether the new institute will cover all addictions (including those such as food and gambling) or will be devoted to the health effects of alcohol and drugs only."

The dark mutterings among alcohol researchers get even more specific in Knopf’s article. In one scenario, Fetal Alcohol Syndrome (FAS) “would go to the National Institute of Child Health and Development, liver disease and the entire organ damage portfolio would go to the National Institute of Diabetes & Digestive & Kidney Diseases, and cancer-related research would go to the National Cancer Institute (NCI). What would happen to drunk driving research is still unknown.”

Furthermore, “NIDA is worried about losing its AIDS funding, because it represents one-third of the institute’s budget.”

The NIH Substance Use, Abuse, and Addiction (SUAA) task force continues to wrestle with the question, which was originally to be decided by the end of the year. In the end, Knopf writes, one persistent rumor has stayed alive: The notion that “the alcohol beverage industry is lobbying Kentucky politicians, including U.S. Rep. Hal Rogers, chairman of the House Appropriations Committee, to keep the institutes separate because it doesn’t want alcohol to be associated with cocaine.”

Graphics Credit: http://www.puzzlemachine.com

Wednesday, 12 September 2012

Dutch Voters Leave Fate of “Weed Pass” Hanging


Clock Continues Ticking For Pot Tourists in The Netherlands.

AMSTERDAM—Voters in The Netherlands may have lost their final chance to block the nationwide imposition of the wietpas, or so-called "weed pass," as the law of the land in The Netherlands next year. On Wednesday, a crucial election in Holland determined the outline of a new coalition government under the narrowest of leads for the anti-immigration, anti-marijuana PVV party of Prime Minister Mark Rutte. The election featured a virtual tie with the center-left Labour Party (PvdA) upstart Diederik Samsom, who opposed the idea of closing marijuana shops to foreigners. 
 
But with 150 seats in the Dutch Parliament, experts say at least six parties will be involved in building a new coalition government. Cannabis advocates were hoping for a clear victory by the Labour Party and strong showings by other liberal parties.

Under legislation that came into effect in the south of the country in May, coffee shops effectively became private clubs, selling cannabis only to registered members, who must be Dutch, and able to prove it. The conservative government maintained that foreign drug criminals were replenishing inventory through the border shops, leading to violence and arrests.

As AP reported last week: “The center-left Labor Party [PvdA], which is surging in pre-election polls thanks to strong performances by its leader Diederik Samsom in televised debates, also advocates scrapping the pass and replacing it with legislation that would further enshrine tolerance of marijuana in Dutch law and regulate not only coffee shops but also growers. However, the coffee shops still have a fight on their hands – the conservative VVD party of outgoing Prime Minister Mark Rutte is topping polls and looks set to become the biggest single party.”

And that, more or less, is how it turned out. With a one-seat margin in various exit polls late Wednesday night in The Netherlands, the sitting VVD Prime Minister will want to stay the course and take marijuana out of the hands of foreigners, starting in January, 2013.

Dutch poll watchers had predicted a tight race between the conservative VVD and the liberal PvdA, with an additional dozen parties likely to land seats in a new coalition government. The VVD's election manifesto specifically supported the weed pass, as did other right-leaning parties in The Netherlands. 

"I don't want to apply for a pass because then everybody could see your personal information," one coffee shop owner told AP. "You don't have to do it in a bar to get alcohol, so why in a coffee shop?"

The only silver lining for pot tourists is a possible scenario in which a VVD-led coalition, having originally introduced the concept of the weed pass, winds up negotiating a centrist mashup in which all parties might be likely to barter away the weed pass in return for other policy favors. Moreover, the far-right PVV party led by Geert Wilders suffered heavy losses.
 
The Financieele Dagblad writes that in any case, voters will not be happy, "because any coalition is going to cause pain. The jigsaw that is a new cabinet will consist of many pieces. The results will be complex, just as in 2010."

Photo Credit: http://www.rnw.nl