What is This Thing Called Neuroplasticity?

And how does it impact addiction and recovery?

Bielefeld, Germany—

The first in an irregular series of posts about a recent conference, Neuroplasticity in Substance Addiction and Recovery: From Genes to Culture and Back Again. The conference, held at the Center for Interdisciplinary Research (ZiF) at Bielefeld University, drew neuroscientists, historians, psychologists, philosophers, and even a freelance science journalist or two, coming in from Germany, the U.S., The Netherlands, the UK, Finland, France, Italy, Australia, and elsewhere. The organizing idea was to focus on how changes in the brain impact addiction and recovery, and what that says about the interaction of genes and culture. The conference co-organizers were Jason Clark and Saskia Nagel of the Institute of Cognitive Science at the University of Osnabrück, Germany.

One of the stated missions of the conference at Bielefeld’s Center for Interdisciplinary Research was to confront the leaky battleship called the disease model of addiction. Is it the name that needs changing, or the entire concept? Is addiction “hardwired,” or do things like learning and memory and choice and environmental circumstance play commanding roles that have been lost in the excitement over the latest fMRI scan?

What exactly is this neuroplasticity the conference was investigating? From a technical point of view, it refers to the brain’s ability to form new neural connections in response to illness, injury, or new environmental situations, just to name three. Nerve cells engage in a bit of conjuring known as “axonal sprouting,” which can include rerouting new connections around damaged axons. Alternatively, connections are pruned or reduced. Neuroplasticity is not an unmitigated blessing. Consider intrusive tinnitus, a loud and continuous ringing or hissing in the ears, which is thought to be the result of the rewiring of brain cells involved in the processing of sound, rather than the sole result of injury to cochlear hair cells.

The fact that the brain is malleable is not a new idea, to be sure. Psychologist Vaughn Bell, writing at Mind Hacks, has listed a number of scientific papers, from as early as 1896, which discuss the possibility of neural regeneration. But there is a problem with neuroplasticity, writes Bell, and it is that “there is no accepted scientific definition for the term, and, in its broad sense, it means nothing more than ‘something in the brain has changed.’” Bell quotes the introduction to the science text, Toward a Theory of Neuroplasticity: “While many scientists use the word neuroplasticity as an umbrella term, it means different things to different researchers in different subfields… In brief, a mutually agreed upon framework does not appear to exist.”

So the conference was dealing with two very slippery semantic concepts when it linked neuroplasticity and addiction. There were discussions of the epistemology of addiction, and at least one reference to Foucault, and plenty of arguments about dopamine, to keep things properly interdisciplinary. “Talking about ‘neuroscience,’” said Robert Malenka of Stanford University’s Institute for Neuro-Innovation and Translational Neurosciences, “is like talking about ‘art.’”

What do we really know about synaptic restructuring, or “brains in the wild,” as anthropologist Daniel Lende of the University of South Florida characterized it during his presentation? Lende, who called for using both neurobiology and ethnography in investigative research, said that more empirical work was needed if we are to better understand addiction “outside of clinical and laboratory settings.” Indeed, the prevailing conference notion was to open this discussion outwards, to include plasticity in all its ramifications—neural, medical psychological, sociological, and legal—including, as well, the ethical issues surrounding addiction.

Among the addiction treatment modalities discussed in conference presentations were optogenetics, deep brain stimulation, psychedelic drugs, moderation, and cognitive therapies modeled after systems used to treat various obsessive-compulsive disorders. Some treatment approaches, such as optogenetics and deep brain stimulation, “have the potential to challenge previous notions of permanence and changeability, with enormous implications for legal strategies, treatment, stigmatization, and addicts’ conceptions of themselves,” in the words of Clark and Nagel.

Interestingly, there was little discussion of anti-craving medications, like naltrexone for alcohol and methadone for heroin. Nor was the standard “Minnesota Model” of 12 Step treatment much in evidence during the presentations oriented toward treatment. The emphasis was on future treatments, which was understandable, given that almost no one is satisfied with treatment as it is now generally offered. (There was also a running discussion of the extent to which America’s botched health care system and associated insurance companies have screwed up the addiction treatment landscape for everybody.)

It sometimes seems as if the more we study addiction, the farther it slips from our grasp, receding as we advance. Certainly health workers of every stripe, in every field from cancer to infectious diseases to mental health disorders, have despaired about their understanding of the terrain of the disorder they were studying. But even the term addiction is now officially under fire. The DSM5 has banished the word from its pages, for starters.

Developmental psychologist Reinout Wiers of the University of Amsterdam used a common metaphor, the rider on an unruly horse, to stand in for the bewildering clash of top-down and bottom-up neural processes that underlie addictive behaviors. The impulsive horse and the reflective rider must come to terms, without entering into a mutually destructive spiral of negative behavior patterns. Not an easy task.

Addiction in the Spotlight at Neuroscience 2013

Testing treatments for nicotine, heroin, and gambling addiction.

Several addiction studies were among the highlights at last month’s annual meeting of the Society for Neuroscience (SfN) in San Diego. Studies released at the gathering including therapies for nicotine and heroin addiction, as well as some notions about the nature of gambling addiction.

And now, as they say, for the news:

— Transcranial Magnetic Stimulation (rTMS), the controversial technique being tested for everything from depression to dementia, may help some smokers quit or cut down, according to research coming in from Ben Gurion University in Israel. Abraham Zangen and colleagues used repeated high frequency rTMS over the lateral prefrontal cortex and the insula of volunteers. Participants who got the magnetic stimulation quit smoking at six times the rate of the placebo group over a six-month period. Work in this area is limited, but there is some preliminary evidence that some addictions may respond to this form of treatment. azangen@bgu.ac.il

—Speaking of the insula—a site deep in the frontal lobes where neuroscientists believe that self-awareness, cognition, and other acts of consciousness are partially mediated—research now suggests that out-of-control gamblers may be suffering, in part, from an overactive insula. People with damage to the insular region are less prone to both the “near-miss fallacy (where a loss is perceived as “almost” a win) and the “gambler’s fallacy (where a run of luck is “due” to a gambler after a string of losses). The volunteer gamblers played digital gambling games while undergoing functional MRIs. Luke Clark of the University of Cambridge, along with researchers from the University of Iowa and the University of Southern California, uncovered a “specific disruption of both effects” in a study group with insula damage. This ties in with earlier research demonstrating that smokers with insula damage lost interest in their habit. This one remains a puzzler, and further research, that brave cliché’, is needed, especially since disordered, or “pathological” gambling is now classified in the DSM5 as an addiction, not an impulse control disorder.  lc260@cam.ac.uk

—And speaking of stimulation, if you go deep with rat brains, you can stimulate a drug reward area and reduce the motivation for heroin in addicted rats. Deep brain stimulation (DBS), an equally controversial treatment approach, now in use as a treatment for Parkinson’s and other conditions, is a surgical procedure involving the implantation of electrodes in the brain. When Carrie Wade and others at the Scripps Research Institute and Aix-Marseille University in France electrically stimulated the subthalamic nucleus and got addicted rats to take less heroin and become less motivated for the task of bar pressing to receive the drug. Earlier work had demonstrated a similar effect in rats’ motivation for cocaine use. “This research takes a non-drug therapy that is already approved for human use and demonstrates that it may be an option for treating heroin abuse,” Wade said in a prepared statement.  clwade@scripps.edu

—Too much stimulation leads to stress, as we know. And George Koob, recently named the director of the National Institute on Alcohol Abuse and Alcoholism, discussed his work on the ways in which dysregulated stress responses might act as triggers for increased drug use and addiction. Koob focused on the negative reinforcement of stressful emotional states: “The argument here is that excessive use of drugs leads to negative emotional states that drive such drug seeking by activating the brain stress systems with areas of the brain historically known to mediate emotions and includes the stress/fear-mediating amygdala and reward-mediating basal ganglia.” For Koob, “stress can cause addiction and addiction can cause stress.” gkoob@scripps.edu

—Finally, hardcore gamblers show a boost in reward-sensitive brain areas when they win a cash payout, but less activation when presented with rewards involving food or sex. The study features more volunteers playing games inside fMRI machines, and purports to demonstrated that problem gamblers are less motivated by erotic pictures than by monetary gains, “whereas healthy participants were equally fast for both rewards.” This “blunted sensitivity” in heavy gamblers suggests the possibility of a marker for problem gambling, in the form of a distorted sensitivity to reward, said Guillaume Sescousse of Radboud University in The Netherlands, during a mini-symposium at the conference. “It is as if the brain of gamblers interpreted money as a primary reward…. for its own sake, as if it were intrinsically reinforcing.” g.sescousse@fcdonders.ru.nl

Will Power and Its Limits

How to strengthen your self-control.

Reason in man obscured, or not obeyed,
Immediately inordinate desires,
And upstart passions, catch the government
From reason; and to servitude reduce
Man, till then free.
—John Milton, Paradise Lost

What is will power? Is it the same as delayed gratification? Why is will power “far from bulletproof,” as researchers put it in a recent article for Neuron? Why is willpower “less successful during ‘hot’ emotional states”? And why do people “ration their access to ‘vices’ like cigarettes and junk foods by purchasing them in smaller quantities,” despite the fact that it’s cheaper to buy in bulk?

 Everyone, from children to grandparents, can be lured by the pull of immediate gratification, at the expense of large—but delayed—rewards. By means of a process known as temporal discounting, the subjective value of a reward declines as the delay to its receipt increases. Rational Man, Economic Man, shouldn’t behave in a manner clearly contrary to his or her own best interest. However, as Crockett et. al. point out in a recent paper in Neuron “struggles with self-control pervade daily life and characterize an array of dysfunctional behaviors, including addiction, overeating, overspending, and procrastination.”

Previous research has focused primarily on “the effortful inhibition of impulses” known as will power. Crockett and coworkers wanted to investigate another means by which people resist temptations. This alternative self-control strategy is called precommitment, “in which people anticipate self-control failures and prospectively restrict their access to temptations.” Good examples of this approach include avoiding the purchase of unhealthy foods so that they don’t constitute a short-term temptation at home, and putting money in financial accounts featuring steep penalties for early withdrawal. These strategies are commonplace, and that’s because people generally understand that will power is far from foolproof against short-term temptation. People adopt strategies, like precommitment, precisely because they are anticipating the possibility of a failure of self-control. We talk a good game about will power and self-control in addiction treatment, but the truth is, nobody really trusts it—and for good reason.  The person who still trusts will power has not been sufficiently tempted.

The researchers were looking for the neural mechanisms that underlie precommitment, so that they could compare them with brain scans of people exercising simple self-control in the face of short-term temptation.

After behavioral and fMRI testing, the investigators used preselected erotic imagery rated by subjects as either less desirable ( smaller-sooner reward, or SS), or more highly desirable ( larger-later reward, or LL). The protocol is complicated, and the analysis of brain scans is inherently controversial. But previous studies have shown heightened activity in three brain areas when subjects are engaged in “effortful inhibition of impulses.” These are the dorsolateral prefrontal cortex (DLPFC), the inferior frontal gyrus (IFG), and the posterior parietal cortex (PPC). But when presented with opportunities to precommit by making a binding choice that eliminated short-term temptation, activity increased in a brain region known as the lateral frontopolar cortex (LFPC).  Study participants who scored high on impulsivity tests were inclined to precommit to the binding choice.

In that sense, impulsivity can be defined as the abrupt breakdown of will power. Activity in the LFPC has been associated with value-based decision-making and counterfactual thinking. LFPC activity barely rose above zero when subjects actively resisted a short-term temptation using will power.  Subjects who chose the option to precommit, who were sensitive to the opportunity to make binding choices about the picture they most wanted to see, showed significant activity in the LFPC. “Participants were less likely to receive large delayed reward when they had to actively resist smaller-sooner reward, compared to when they could precommit to choosing the larger reward before being exposed to temptation.”

Here is how it looks to Molly Crockett and her fellow authors of the Neuron article:

Precommitment is adaptive when willpower failures are expected…. One computationally plausible neural mechanism is a hierarchical model of self-control in which an anatomically distinct network monitors the integrity of will-power processes and implements precommitment decisions by controlling activity in those same regions. The lateral frontopolar cortex (LFPC) is a strong candidate for serving this role.

None of the three brain regions implicated in the act of will power were active when opportunities to precommit were presented.  Precommitment, the authors conclude, “may involve recognizing, based on past experience, that future self-control failures are likely if temptations are present. Previous studies of the LFPC suggest that this region specifically plays a role in comparing alternative courses of action with potentially different expected values.” Precommitment, then, may arise as an alternative strategy; a byproduct of learning and memory related to experiences “about one’s own self-control abilities.”

There are plenty of caveats for this study: A small number of participants, the use of pictorial temptations, and the short time span for precommitment decisions, compared to real-world scenarios where delays to greater rewards can take weeks or months. But clearly something in us often knows that, in the immortal words of Carrie Fisher, “instant gratification takes too long.” For this unlucky subset, precommitment may be a vitally important cognitive strategy. “Humans may be woefully vulnerable to self-control failures,” the authors conclude, “but thankfully, we are sometimes sufficiently far-sighted to circumvent our inevitable shortcomings.” We learn—some of us—not to put ourselves in the path of temptation so readily.

Crockett M., Braams B., Clark L., Tobler P., Robbins T. & Kalenscher T. (2013). Restricting Temptations: Neural Mechanisms of Precommitment, Neuron, 79 (2) 391-401. DOI: 10.1016/j.neuron.2013.05.028

Photo Credit: http://tommyboland.com/2011/05/27/white-knuckle-living/

Nature, Nurture, and Me

Which came first, the addiction or the trauma?

About a year ago, Jonathan Taylor, a professor at California State University in Fullerton, assigned his students some reading from my book, The Chemical Carousel, for his “Drugs, Politics, and Cultural Change” course. At the same time, the class watched an interview with Dr. Gabor Maté, author of In the Realm of Hungry Ghosts: Close Encounters with Addiction. In a letter written for his readers, Dr. Mate´ insists that addiction “is very close to the core of the human experience. That is why almost anything can become addictive, from seemingly healthy activities such as eating or exercising to abusing drugs intended for healing. The issue is not the external target but our internal relationship to it. Addictions, for the most part, develop in a compulsive attempt to ease one’s pain or distress in the world…. The more we suffer, and the earlier in life we suffer, the more we are prone to become addicted."

I find this perspective interesting, because I agree with so little of it. I do not believe that almost anybody can become involved in an addictive relationship with almost anything—not unless they have the genes for it. I do not believe that the genuine heart of addiction, its true root cause, is childhood abuse—although that is frequently and tragically a component of addiction, for many reasons. Overall, I see addiction as a biochemical disorder with strong behavioral attributes, mostly genetic in origin, influenced by—but not hostage to—environmental impacts, making it not so different from, say, diabetes or depression.

No doubt about it, there is a fair amount of distance between the doctor and your humble science journalist, from the nature/nurture point of view. And, students being students, they picked up on this, and wanted an explanation that would make some sense of these two seemingly opposite positions. Professor Taylor threw the question back to me:

My class was wondering how one would reconcile your and Mate’s views.  Both of you discuss the addicted brain and clearly view addiction as a brain disorder.  The fundamental difference is that Mate disputes the genetic component of addiction, or at least he says there is some genetic component but that the majority of the brain dysfunction and low levels of neurotransmitters found in addicted individuals relates to environmental influences during early childhood (or in the womb), rather than a genetic component…. In the book he discusses studies that indicate that insufficient maternal care, exposure to conflict etc. all lead to improper brain development which leads to increase susceptibility to addiction.  So while you write about “inherited susceptibility,” he seems to favor an “environmental induced susceptibility…. Any elucidation I can share with my students would be helpful.

So. I was well and truly on the hook. I kept my response short, for the obvious reasons, but there is no getting around the fact that it’s a damn good question. Here’s what I ended up telling the class:

-------------------------------------------------------------------------------------------------------------------------
Jon:

"Your students ask, quite rightly, how to reconcile the views expressed in The Chemical Carousel and In the Realm of Hungry Ghosts. Or, nature vs. nurture. Dr. Maté looks to environmental impacts during early childhood as the addiction trigger, while I advocate a view of addiction as a genetic disorder, expressed because of changes in DNA, not bad mothering. (It wasn’t very long ago that schizophrenia was firmly believed to be a result of bad mothering, too!) More to the point, Maté believes, for example, that ALL female heroin addicts were sexually abused as children. That is certainly not an assertion widely agreed upon or well supported by the scientific literature. In the most recent population study of addicts and non-addicted siblings, published in Science (Feb. 3 2012), when the researchers looked at the early lives of sibling pairs, they found all the same risk factors: both the addicts and their siblings had seen roughly equal amounts of trauma in childhood. 'We really looked at their childhoods,' says Karen Ersche, lead author of the study and group leader for human addiction research at the University of Cambridge in England, quoted at Time Healthland. 'There was a lot of domestic violence, there was sexual abuse — but both [groups] had that.'

"So, which came first, the trauma, or the trauma-prone personality? Where Dr. Maté sees childhood trauma, I tend to see behavioral dysregulation. Children born with an addictive propensity also carry with them the potential for various kinds of behavioral problems, impulsivity being a common one. And it is entirely likely that most addicts have had rocky childhoods, since, quite often, they have had alcoholics in the nuclear family, with all the attendant problems, including sexual violence. Or, their own behavioral template leads to problems—angst, worry, fights, trauma. In a sense, we can say that sooner or later, something, or someone, or a series of environmental impacts, will traumatize a child with addictive propensities, in the same way that latent schizophrenia is “switched on” by a traumatic or highly emotional event. Addicts feel like outsiders from an early age, and many of them sense that something is not quite right with them, long before they ever take a drink or a drug.

"Sorting out this chicken-egg problem is a major headache. And we haven’t even discussed the possibility of trauma in the womb. But I am willing to say that none of this is as settled or as straightforward as Dr. Maté would have it. On the matter of nature/nurture, I’m willing to put the odds of that mix at 60/40, which is a good deal less genetically loaded than my estimates used to be. The growing research field of epigenetics has brought the two views closer together by demonstrating that a person’s DNA can in some cases be modified, and genes turned off and on, by environmental impacts.

"Overall, it’s safe to say that Dr. Maté and I do agree on this: One of the best defenses against the scourge of addictive disease is a stable, loving, empathetic family."

Best,
Dirk

Photo Credit: http://lofalexandria.blogspot.com/

More Hard Facts About Addiction Treatment

“Yes, we take your insurance.”

Recent reportage, such as Anne Fletcher’s book, Inside Rehab, has documented the mediocre application of vague and questionable procedures in many of the nation’s addiction rehab centers. You would not think the addiction treatment industry had much polish left to lose, but now comes a devastating analysis of a treatment industry at “an ethics crossroads,” according to Alison Knopf’s 3-part series in Addiction Professional. Knopf deconstructs the problems inherent in America’s uniquely problematic for-profit treatment industry, and documents a variety of abuses. We are not talking about Medicaid, Medicare, or Block Grants here. Private sector dollars, Knopf reaffirms, do not “guarantee that the treatment is evidence-based, worth the money, and likely to produce a good outcome.” Even Hazelden, it turns out, is prepared to offer you “equine therapy,” otherwise known as horseback riding.

Knopf, who is editor of Alcoholism and Drug Abuse Weekly, was specifically looking at private programs, paid for by insurance companies or by patients themselves. Who is in charge of enforcing specific standards of business practice when it comes to private drug and alcohol rehabs? Does the federal government have some manner of regulatory control? According to a physician with the Substance Abuse and Mental Health Services Administration (SAMHSA), the feds rely on the states to do the regulating. And according to state officials, the states look to the federal agencies for regulatory guidance.

All too often, the states routinely license but do not effectively monitor treatment facilities, or give useful consumer advice. Florida state officials do not even know, with any certainty, exactly how many treatment centers are in operation statewide. And even if state monitoring programs were effective and aggressively applied, “just because something is legal doesn’t mean it’s ethical,” said the SAMHSA official.

“We see this as a pivotal time for the treatment field as we have come to know it,” said Gary Enos, editor of Addiction Professional, in an email exchange with Addiction Inbox. Enos said that “the Affordable Care Act (ACA) will move addiction treatment more into the mainstream of healthcare, and this will mean that treatment centers' referral and insurance practices will come under more scrutiny than ever before.”

 Among the questionable practices documented by Knopf:

—Paying bounties and giving gifts to interventionists in return for client referrals.

Under Medicare, paying interventionists for referrals is banned. “In the private sector,” says a California treatment official, “it’s not illegal. But it is unethical.” According to treatment lobbyist Carol McDaid, “kickbacks happen all the time. Treatment centers that are doing this will do so at their own peril in the future,” she told Knopf.

—Giving assurances that treatment will be covered by insurance even though only a portion of the cost is likely to be covered.

Under the Affordable Care Act (ACA), says the SAMHSA official, “We are trying to position people to know more about their benefit package. And the industry has to be more straightforward about what the package will cover.” John Schwarzlose, CEO of the Betty Ford Center, told Knopf that “it’s very hard for ethical treatment providers to compete against insurance bait-and-switch,” when patients are told their insurance is good—but aren’t told that the coverage ends after 7 days, or that the daily maximum payout doesn’t meet the daily facility charges.

—Billing patients directly for proprietary nutrient supplements, brain scans, and other unproven treatment modalities.

“Equine therapy, Jacuzzi therapy, those are nice things, and maybe they help with the process of engagement,” said one therapist. “But people need to recognize that these ancillaries aren’t the essence of getting sober.”

—Engaging in dubious Internet marketing schemes.

You see them on the Internet: dozens and dozens of addiction and rehab referral sites. They list private services in various states, and look, on the surface, like legitimate information resources for people in need. As the owner of a blog about drugs and addiction, I hear from them constantly, asking me for links. “Family members and patients frequently have no way of knowing that a treatment program was really a call center they got to by Googling ‘rehab,’ writes Knopf, “and that the call center gets paid for referring patients to the actual treatment center. They don’t know that a program that promises to ‘work with’ health insurance knows full well the insurance will cover only a few days at the facility, and the rest will have to be paid out of pocket.” She points to a 2011 Wired magazine article, which said the Internet marketing cost of key words like “rehab” and “recovery” can be stratospheric. But “by spending that money—not necessarily providing good service—treatment provides can come out on top on searches. It’s the new marketing to the desperate.”

The group with the most to lose from revelations of this nature is the National Association of Addiction Treatment Providers (NAATP), the association representing both private and non-profit rehab programs. The Betty Ford Center has discontinued its membership in NAATP, a move that reflects the turmoil of the industry today. “It’s crazy that we have treatment centers inviting interventionists and other referents on a cruise, and then giving everyone an iPad,” Schwarzlose said.

As one man who lost his son to an overdose said: “I don’t get it. There’s the American Cancer Society, but I look for drugs and alcohol and I can’t find anything. There’s no National Association for Addictive Disease. How can this be?”

The investigative series will be featured in Addiction Professional’s March/April print issue. Enos believes that “influential treatment leaders are more interested than ever to see this debate aired more publically,” and says that the online publication of Knopf’s articles for the magazine has sparked “a great deal of discussion in treatment centers and on social media, including comments about other questionable practices that harm the field’s reputation.”

Addiction Rehab: Everything is Broken

Down the rabbit hole in search of effective treatment.

When I first began researching drugs and addiction years ago, a Seattle doctor told me something memorable. “It’s as if you had cancer,” she said, “and your doctor’s sole method of treatment consisted of putting you in a weekly self-help group.”

I’ve got nothing against weekly self-help groups, to be sure. But as Ivan Oransky, executive editor of Reuters Health and a blogger at Retraction Watch, told me as recently as least year, addiction treatment appeared to be “all selling and self-diagnosis. They’re selling you on the fact that you need to be treated.”

In his introduction to Inside Rehab by Anne M. Fletcher (pictured), treatment specialist and former deputy drug czar A. Thomas McLellan writes that the book is “filled with disturbing accounts of seriously addicted people getting very limited care at exhaustive costs and with uncertain results...”

A common notion about addiction treatment facilities, or rehabs, is they are commonly called, is that they are staffed by professional social workers, certified counselors, and family psychologists, as well as addiction specialists. However: “Of the twenty-one states that specify minimum educational requirements for program or clinical directors of rehabs, only eight require a master’s degree and just six require credentialing as an addiction counselor,” writes Fletcher. Neuroscience journalist Maia Szalavitz, who writes for Time Healthland and specializes in addiction and rehab, told Fletcher that “the addiction field has been about as effectively regulated as banking before the economic crisis in many states.” According to Tom McLellan, counselor and director turnover in addiction treatment programs is “higher than in fast-food restaurants.”

In the United States, where for-profit treatment is prevalent, money does not buy access to superior treatment. Fletcher, author of several self-help books on weight loss and alcoholism, doggedly documents what she learns from visiting treatment facilities and interviewing current and former staff and clients. One difficulty with a book of this kind, based primarily on first-hand accounts, is that the same treatment program can offer vastly contrasting experiences from one client to another. And Fletcher, no fan of the 12 Steps, wants AA and NA to account for themselves in a way those volunteer institutions were never designed to accomplish.

But let’s just say it: Addiction treatment in America is a disaster. Addicts get better despite the treatment industry as often as they get better because of it. How did it all go wrong? Part of the answer is that addiction, like depression, tuberculosis, and other chronic conditions, is a segregated illness, as McLellan explains in his introduction. Traditionally, chronic conditions like alcoholism “were not recognized as medical illnesses, and have only recently been taught in most medical schools and treated by physicians. They were seen as ‘lifestyle problems’ and care was typically provided by concerned, committed individuals or institutions not well connected to mainstream health care.”

For treatment of alcoholism and drug addiction, the work has historically fallen to addicts themselves, due to discrimination, segregation, and stigmatization. This prevailing condition is still seen today in many group treatment programs, which are often administered in large part by former addicts with little or no formal training, rather than medical or psychological professionals. Addiction, as the author’s husband wryly remarked, “is the only disease for which having it makes you an expert.”

Which brings up a central point: Where are all the M.D.s? Doctors aren’t helping, either, when they fail to screen for risky drinking or drug use, or when they automatically refer addicts rather than treating them.

If Christopher Kennedy Lawford’s new book, Recover to Live, is the pretty picture, then Fletcher’s Inside Rehab is the gritty picture, in which most addicts who recover don’t go to treatment, 28 days is not long enough to accomplish anything but detox, group counseling is not always the best way to treat addiction, the 12 Steps are not always essential to recovery, specialty drugs are often needed to treat drug addiction, and, perhaps the most troubling of all, most addiction programs do not offer state-of-the-art approaches to treatment that have been shown to be effective in scientific studies.

What clients get, for the most part, is “group, group, and more group,” Fletcher writes. And in many cases of residential or outpatient rehab, “the clients did most of the therapy.” The scientific evidence suggests that some addicts do better with an emphasis on individual counseling, rather than the constant reliance on group work that traditional rehabs have to offer. As one counselor put it: “If I made an appointment to see a therapist because I was depressed, would I be told I have to do a program with everyone else?”

Monthly residential treatment can easily cost $25,000 or more. But public, government funded rehab centers, which presumably have less incentive to treat clients like money, are frequently full. And since these programs run the bulk of prison-related treatment in this country, addicts often stand a better chance of getting into these less expensive programs if they commit a crime.

Even if you manage to get in, rehab rules all too often seem arbitrary and punitive: Recreational reading materials, musical instruments, cell phones, and computers are frequently not permitted. And there is a strong tendency to insist that use equals abuse in every circumstance. Rehab management—the business of what happens after formal treatment ends—is largely neglected in the treatment sphere.

Fletcher rails against the disease model, but mostly in response to how she believes this concept is presented by AA/NA. Like other critics, she dwells on the idea that the disease tag serves as a crutch and an excuse, rather than as an extremely empowering notion for many addicts. In fact, the disease model, as addiction scientists understand it, is seriously underrepresented in the treatment field. Too many mental health professionals continue to insist that “all you need to do is get to the bottom of the problem and the need to use substances to cope, will dissipate,” said an M.D. specializing in addiction. “However, there is absolutely no evidence that this approach works for people who are addicted to alcohol or drugs… The primary-secondary issue is moot and an artifact of the bifurcation of the treatment delivery system.”

A significant number of rehabs still oppose medication-assisted treatment, Fletcher makes clear. Hazelden made news recently for dropping its long-standing opposition to buprenorphrine as a maintenance drug for opiate addicts during treatment. Richard Saitz of Boston University’s School of Medicine says in the book that if addiction were viewed like other health problems, “patients addicted to opioids who are not offered the opportunity to be on maintenance medications would sue their providers and win.”

According to Dr. Mark Willenbring, former director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA): “No one wants to say, ‘Treatment as we’ve been doing it probably isn’t as effective as we thought, and we need more basic research to really come up with new tools. In the meantime let’s do what we can to help suffering people in the most cost effective way and strive to not harm them.’”

How to Kick Everything

Christopher Kennedy Lawford on recovery.

Christopher Kennedy Lawford’s ambitious, one-size-fits-all undertaking is titled Recover to Live: Kick Any Habit, Manage Any Addiction: Your Self-Treatment Guide to Alcohol, Drugs, Eating Disorders, Gambling, Hoarding, Smoking, Sex, and Porn. That pretty much covers the waterfront, and represents both the strengths and the weaknesses of the book.

There’s no doubting Lawford’s sincerity, or his experiential understanding of addiction, or the fact that the raw ingredients were present in his case: bad genes and a traumatic early environment. He is related to Ted Kennedy, two of his uncles were publically murdered, and he started using drugs at age 12. But this book doesn’t dwell on his personal narrative. Lawford is a tireless supporter of the addiction recovery community, and Recover to Live is meant to be a one-stop consumer handbook for dealing with, as the title makes clear, any addiction.

To his credit, Lawford starts out by accurately pegging the addiction basics: A chronic brain disorder with strong neurological underpinnings. He cites a lot of relevant studies, and some questionable ones as well, but ultimately lands on an appropriate spot: “You can’t control which genes you inherited or the circumstances of your life that contributed to your disease. But once you know that you have the disease of addiction, you are responsible for doing something about it. And if you don’t address your problem, you can’t blame society or anyone in your life for the consequences. Sorry. That’s the way it works.”

Once you know, you have to treat it. “It can turn the most loving and nurturing home into a prison of anger and fear,” Lawford writes, “because there is no easy fix for the problem, and that infuriates many people.”

 Lawford includes good interviews with the right people—Nora Volkow, Herb Kleber, and Charles O’Brien among them. And he makes a distinction frequently lost in drug debates: “Nondependent drug use is a preventable behavior, whereas addiction is a treatable disease of the brain.” Due to our penchant for jailing co-morbid addicts, “our prisons and jails are the largest mental health institution in the world.” He also knows that hidden alcoholism and multiple addictions mean “rates of remission from single substances may not accurately reflect remission when viewed broadly in terms of all substances used.”

One nice thing about Lawford’s approach is that he highlights comorbidity, the elephant in the room when it comes to addiction treatment. Addiction is so often intertwined with mental health issues of various kinds, and so frequently left out of the treatment equation. The author is correct to focus on “co-occurring disorders,” even though he prefers the term “toxic compulsions,” meaning the overlapping addictions that can often be found in the same person: the alcoholic, chain-smoking, compulsive gambler being the most obvious example.

The curious inclusion of hoarding in Lawford’s list of 7 toxic compulsions (the 7 Deadly Sins?) is best explained by viewing it as the flipside of compulsive shoplifting, a disorder which is likely to follow gambling into the list of behavioral dependencies similar to substance addictions. In sum, writes Lawford, “If we are smoking, overeating, gambling problematically, or spending inordinate amounts of time on porn, we will have a shallower recovery from our primary toxic compulsion.” Lawford sees the exorcising of childhood trauma as the essential element of recovery—a theory that has regained popularity in the wake of findings in the burgeoning field of epigenetics, where scientists have documented changes in genetic expression beyond the womb.

But in order to cover everything, using the widest possible net, Lawford is forced to conflate an overload of information about substance and behavioral dependencies, and sometimes it doesn’t work. He quotes approvingly from a doctor who tells him, “If you’re having five or more drinks—you have a problem with alcohol.” A good deal of evidence suggests that this may be true. But then the doctor continues: “If you use illicit drugs at all, you have a problem with drugs.” Well, no, not necessarily, unless by “problem” the doctor means legal troubles. There are recreational users of every addictive substance that exists—users with the right genes and developmental background to control their use of various drugs. And patients who avail themselves of medical marijuana for chronic illnesses might also beg to differ with the doctor’s opinion.

Lawford attempts to rank every addiction treatment under the sun in terms of effectiveness (“Let a thousand flowers bloom”), an operation fraught with pitfalls since no two people experience addictive drugs in exactly the same way. Is motivational enhancement better than Acamprosate for treatment of alcoholism, worse than cognitive therapy, or about as good as exercise? Lawford makes his picks, but it’s a horse race, so outcomes are uncertain. Moderation management, web-based personalized feedback, mindfulness meditation, acupuncture—it’s all here, the evidence-based and the not-so-evidence based. Whatever it is, Lawford seems to think, it can’t hurt to give it a try, and even the flimsiest treatment modalities might have a calming effect or elicit some sort of placebo response. So what could it hurt.

Lawford’s “Seven Self-Care Tools” with which to combat the Seven Toxic Compulsions vary widely in usefulness. The evidence is controversial for Tool 1, Cognitive Behavioral Therapy. Tool 2, 12-Step Programs, is controversial and not to everybody’s taste, but used as a free tool by many. Tool 3 is Mindfulness, which is basically another form of cognitive therapy, and Tool 4 is Meditation, which invokes a relaxation response and is generally recognized as safe. Tool 5, Nutrition and Exercise, is solid, but Tool 6, Body Work, is not. Treatments like acupuncture, Reichian therapy, and other forms of “body work” are not proven aids to addicts. Tool 7, Journaling, is up to you.

One of the more useful lists is NIDA director Nora Volkow’s “four biggest addiction myths."

First: “The notion that addiction is the result of a personal choice, a sign of a character flaw, or moral weakness.”

Second: “In order for treatment to be effective, a person must hit ‘rock bottom.’”

Third: “The fact that addicted individuals often and repeatedly fail in their efforts to remain abstinent for a significant period of time demonstrates that addiction treatment doesn’t work.”

Fourth: “The brain is a static, fully formed entity, at least in adults.”

Finally, Lawford puts a strong emphasis on an important but rarely emphasized treatment modality: brief intervention. Why? Because traditional, confrontational interventions don’t work. The associate director of a UCLA substance abuse program tells Lawford: “I haven’t had a drink now in 25 years, and this doctor did it without beating me over the head with a big book, without chastising me, or doing an intervention. What he did was a brief intervention. Health professionals who give clear information and feedback about risks and about possible benefits can make a huge difference. A brief intervention might not work the first time. It might take a couple of visits. But we need more doctors who know what the symptoms of alcohol dependence are and know what questions to ask.”

If your knowledge of addiction is limited, this is a reasonable, middle-of-the-road starting point for a general audience.

The Encultured Brain: A Book Review

How biology and culture jointly define us.

Anyone who follows academia knows that the broad category of courses known as the Liberal Arts has been going through major changes for some time now. In a sort of collegiate scrum to prove relevance and fund-worthiness, disciplines like sociology, anthropology, human ecology, cultural psychology, and even English, have been subjected to a winnowing process. The clear winner seems to anthropology, which has expanded its own field by connecting with modern findings in neuroscience while simultaneously swallowing up what was left of sociology.

It makes sense. Take addiction for an example. Anthropology is a natural and accessible discipline within which to connect the two often-conflicting facets of addiction—its fundamental neuroarchitecture, and the socioenvironmental influences that shape this basic biological endowment. In The Encultured Brain, published this year by MIT Press, co-editors Daniel H. Lende and Greg Downey call for a merger of anthropology and brain science, offering ten case histories of how that might be accomplished. The case histories are lively, ranging from the somatics of Taijutsu martial arts in Japan, to the presence of humor among breast cancer survivors. These attempts to combine laboratory research with anthropological fieldwork are important early efforts at a new combinatory science—one of the hot new “neuros” that just might make it.

I have corresponded with Daniel Lende, one of the book’s co-editors, and I am happy to disclose a mention in the book’s acknowledgements as one of the many people who formed a “rolling cloud of online discussion” with respect to neuroscience and the new anthropology. I am pleased to see that the thoughts of Lende and Downey and others on the emerging science of neuroanthropology are now available as a textbook.

The term “neuroanthropology” was evidently coined by Stephen Jay Gould. A number of prominent thinkers have dipped into this arena over the years: Melvin Konner, Sarah Hrdy, Norman Cousins, Robert Sapolsky, and Antonio Damasio, to name a random few, but the term didn’t seem to get a foothold of note until Lende and Downey began their Neuroanthropology blog, now at PLOS blogs.

The term has the advantage of meaning exactly what it says: an engagement between social science and neuroscience. Lende and Downey look ahead to a time when field-ready equipment will measure nutritional intake, cortisol levels, prenatal conditions, and brain development in the field. As such, neuroanthropology fits somewhere in the vicinity of evolutionary biology and cultural psychology. As a potential new synthesis, it is brilliant and challenging, representing an integrative approach to that ancient problem—how our genetic endowment is influenced by our cultural endowment, or vice versa, if you prefer.

 Lende is no functionalist when it comes to the neuroscience he wants to see incorporated in anthropology. His approach calls for applying a critical eye to any and all strictly brain-based explanations that ignore both environmental influence and biochemical individuality. The possibility that anthropologists may be incorporating neuroimaging technology into their working tool kit is a heady notion indeed. Anthropology may be a “soft” science, but it has always been about the study of “brains in the wild.”

Here, from the introductory chapter, is the short definition of neuroanthropology by Lende and Downey: “Forms of enculturation, social norms, training regimens, ritual, language, and patterns of experience shape how our brains work and are structured…. Without material change in the brain, learning, memory, maturation, and even trauma could not happen…. Through systematic change in the nervous system, the human body learns to orchestrate itself. Cultural concepts and meanings become neurological anatomy.” From the point of view of actual study, there is no choice but to join these two when possible—a task make more difficult by the rampant “biophilia” found among anthropologists and sociologists, as well as the countering notion among biologists that anthropology does not make the cut as a “real” science.

We have come a long way from the simplified view of the brain as some sort of solid-state computer, or, alternatively, a lump of custard waiting to be endowed with functionality by selective pressures from “outside.” We know by now that neural resources are frequently reallocated; that “physiological processes from scaling to connectivity shape what brains can do and why.”  We need to stop viewing culture as “merely information that is transmitted over evolutionary time and recognize that enculturation is, equally, the ways that our interaction with each other shapes our biological endowment, and has been doing so for a very long time,” Lende writes.

At bottom, says Lende, it is a simple notion: “Biology and culture jointly define us.” For example, Lende points to the way tool use affects cortical organization. Monkeys trained to use rakes to fetch food “evidence increasing cortex dedicated to visual-tactile neurons.” Lende wants us to incorporate neuroscience into the broader study of man. He writes that “the activation of neural reward centers, such as the mesolimbic dopaminergic system, is inherently bound up in sociocultural contexts, social interactions, and personal meaning-making.”

As an example, Lende contributes a chapter on “Addiction and Neuroanthropology,” in which he describes research he conducted on drug abuse among young people during a decade he spent in Colombia. Lende found that the addictive spiral “was not merely a neurological transformation, but a shift in habits, clothing, friends, hangouts, and other external factors that re-cued drug seeking behavior, drove addicts to take drugs, even when the young people sought to stay clean. Addiction is not simply in the brain, but in the way that the addict’s brain and world support each other.” And now, he writes, “This combination of neuroscience and ethnography revealed that addiction is a problem of involvement, not just of pleasure or of self. That decade showed me that addiction is profoundly neuroanthropological.”

In other words, tolerance and withdrawal aren’t enough. It is fiendishly complex: “The parts of the brain where addiction happens are not single, isolated circuits—rather, these areas handle emotion, memory, and choice, and are complexly interwoven to manage the inherent difficulty of being a social self in a dynamic world.”

Trying to pick apart the relative influences of nature and nurture comes to look, ultimately, like a fool’s game, “because changes in behavior exposed users to situations in which specific neurophysiological effects were cued with greater frequency; both environment and biology were moving together into a cycle of addiction.”

In a chapter titled “Collective Excitement and Lapse in Agency: Fostering an Appetite for Cigarettes," Peter G. Stromberg of the University of Tulsa argues that the dissociative environment in which college students often try cigarettes for the first time can lead to the loss of “the sense of agency,” meaning that people sometimes carry out activities without taking full responsibility for the decision to do so. As Stromberg writes, “Early smoking experiences typically occur in effervescent social gatherings marked by a high level of excitement and highly rhythmic activities, such as conversation and dancing." Cigarettes acquire a “symbolic valence” in such settings, and the ability to handle a cigarette adroitly confers what Stromberg terms “erotic prestige.” Furthermore, “As anyone who has ever been in a conga line can attest, we humans can be strongly motivated to entrain with rhythmic activities, even if those activities might be judged as unappealing in other contexts.”

If young people smoke at parties for many of the same reasons that they dance at parties—a “desire to increase status” and enter into “joint rhythmic play”—then potential nicotine addicts will be gently nudged into a position of associating party feelings with cigarette feelings, regardless of the actual physiology of nicotine. And, by fostering a dissociative mode of consciousness, college parties help foster the conviction that the use of cigarettes is not completely under one’s volitional control (“I was going to leave, but we danced all night.” Or, “the next thing I knew, the pack was empty”). The smoker may falsely attribute these feelings to the direct effect of the drug, rather than the set and setting.

This is only one example of the many ways in which a combination of neurobiology and anthropology can lead to new questions and fresh approaches. Where might all this be heading? “As research continues,” write Lende and Downey, “greater recognition of neural diversity as a fundamental part of human variation will surely become an even more substantive part of the neuroanthropological approach.”

Science, Academia, and Tobacco

A review of The Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition

Part III

Academic collaborations come in many flavors. Just because the money is corporate doesn’t mean the studies that are funded are flawed by definition. But the cigarette industry’s academic philanthropy set new records for hubris, writes Robert Proctor, professor of history at Stanford University, in his new book, The Golden Holocaust. Duke University and Bowman Gray School of Medicine, both in North Carolina, are named for tobacco magnates.

Harvard has a long and dubious history of tobacco largesse.  Harvard’s Tobacco and Health Research Program kicked off in 1972 with a generous tobacco grant from the Tobacco Institute, who dreamed up the program in the first place. “The Harvard project made the industry look good and so was handsomely endowed, absorbing $7 million over an eight-year period.” Also in 1972, Harvard anthropologist Carl Seltzer testified for the industry in numerous public hearings, stating: “We do not know whether or not there is a causal relationship between smoking and heart disease.” In 2002, Harvard’s School of Public Health declared it would no longer undertake research sponsored by the cigarette industry. Many universities had already gone cold turkey, and after Harvard, bans were put in place by the Karolinska Institute, Johns Hopkins University, Emory University, and many others.

Proctor informs us that “Washington University in St. Louis has been another big sponge for tobacco money." In 1971, the university set a new world record for an industry grant to a single institution, and “millions more were eventually funneled into the School of Medicine, turning it into a hotbed of cigarette-friendly activism.” The irony of taking money from Big Tobacco to fund research on lung cancer is not lost on Proctor. A good deal of the research was aimed away from tobacco and toward possible causes like viruses. “The goal was clearly more than cancer cures,” he writes. “The industry also hoped to generate good PR and academic allies.” The industry was able to garner  sympathetic headlines, like “Helping in Fight against Cancer,” in the St. Louis Globe-Democrat.

The other academic hotbed thoroughly penetrated by Big Tobacco was UCLA, according to Proctor. “Tobacco collaborators at UCLA have attracted their fair share of criticism from public health advocates, and for understandable reasons.” The university picked up its own multimillion-dollar grant from cigarette makers for the Program on Tobacco and Health in 1974, and that wasn’t the first tobacco money the university had taken. “As with all such projects,” Proctor writes, “industry lawyers… played a key role in the decision to fund—with the companies also conceding that the decision ‘should be based more on public relations than on purely scientific grounds.’” The end came in 2007, when “UCLA’s dance with the devil” garnered a ton of unwanted press. Reports showed that UCLA had taken more than $6 million from Philip Morris for research “to compare how children’s brains and monkey brains react to nicotine.”

Proctor admits that singling out Harvard, Washington University and UCLA is somewhat misleading, “given that scholars throughout the world have gorged themselves on tobacco money. Indeed it may well be the rare institution that has NOT at one time or another dipped into this pot.”

Including Stanford, where Proctor teaches. Plenty of Stanford researchers have undertaken contract work and served as expert witnesses for the industry right in Proctor’s own backyard, where “at least eighteen faculty members have received monies (in the form of sponsored research) from the Council for Tobacco Research, with at least two of these—Judith Swain and Hugh McDevitt from the medical school—serving on its Scientific Advisory Board. Stanford pharmacologists were assisting the industry with its diethylene glycol studies as early as the 1930s…”

In the conclusion to his densely researched but surprisingly readable work, Proctor returns to the controlling irony of the book: “Our bizarre starting point is the well-stocked shelf of cigarettes, to which we respond by begging people not to purchase them.” He presents the dream of a world in which cigarettes have been abolished. To do so, he admits, would require a leap. “If phasing out tobacco seems out of reach, this is only because our imaginations are impoverished.” And he has scant patience for the “Prohibition failed” argument. It failed, he says, because people like to drink. “Tobacco presents us with a very different situation. Nicotine is not a recreational drug. Most people who smoke wish they didn’t, and most smokers (90 percent) regret ever having started.”

Graphics Credit: http://www.prwatch.org/node/7004

The Tobacco Industry as Disease Vector

A review of The Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition

Part II

The famous Surgeon General’s Report of 1964, officially warning Americans about the dangers of smoking, and publicizing the cancer connection, is typically seen as a triumphal moment in American medical history. But according to Stanford history professor Robert Proctor in his book, The Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition, the report was “flawed in a number of interesting respects.” [The author, above, with paraphernalia] For one thing, members of the advisory committee consulting on the report, many of them congressman friendly to the tobacco cause, succeeded in their attempts to have smoking referred to as a “habit” rather than as addiction—a shameful Orwellian turn that went uncorrected for 25 years.

Meanwhile, the industry continued to fund new institutes, and continued to give out research grants for “red herring” research. As an example, the highest-ranking officer of the American Heart Association received money from one of the industry’s fraudulent research arms.

As late as the early 80s, most smokers believed they suffered from a bad habit, rather than an addiction—even though a majority of them wished they didn’t smoke. That is an odd kind of consumer “choice.” Cigarette makers have spent millions to perpetuate this myth. Proctor views tobacco industry executives and lawyers as a unique form of disease vector, spreading the pernicious health consequences of smoking across the globe.

The 2008 World Health Organization (WHO) Report on the Global Tobacco Epidemic fleshes out this metaphor, suggesting that all epidemics have a means of contagion, “a vector that spreads disease and death. For the tobacco epidemic, the vector is not a virus, bacterium or other microorganisms—it is an industry and its business strategy.”

In an email exchange, I asked Professor Proctor to expand on this notion of a disease vector:

“We tend to divide "communicable" from "non-communicable" diseases,” Proctor told me, “when the reality is that many "non-communicable" diseases are in fact spread by communications.”

Examples? “Through ignorance and propaganda, for example, which can spread like a virus,” Proctor wrote. “We don't count the anthropogenic communications, oddly enough, even though these can be just as dangerous, and just as deadly. And just as preventable--by changing our exposure environments.”

In a recent article for Tobacco Control, Proctor laid out how the calculus of the disease vector plays out. We know, for example, that smoking will cause roughly 6 million deaths in 2015. And about a third of those will be from lung cancer. We know that 25 acres of tobacco plants will result in about 10 lung cancer deaths per year, starting 20 or 30 years down the road. Here’s a sick equivalence: “A 40 ft container of the sort shipped overseas or trucked by highway houses 10 million cigarettes, which means that each container will cause about 10 deaths.” Proctor works out the numbers for the value of a human life:

“Cigarette companies make about a penny in profit for every cigarette sold, or about $10,000 for every million cigarettes purchased. Since there is one death for every million cigarettes sold (or smoked), a tobacco manufacturer will make about $10,000 for every death caused by their products…. The value of a human life to a cigarette manufacturer is therefore about $10,000.” 

Proctor has even produced a “factories of death” chart, illustrating that arguably the world’s most lethal production plant is Philip Morris’s Richmond cigarette facility, which churned out 146 billion cigarettes in 2010, which adds up to about 146,000 deaths per year.

By 1964, researchers at Harvard had already identified the presence of radioactivity in the form of polonium 210 in cigarette smoke, and the cry went up for safety. As for the notion of safer cigarettes, Proctor says all cigarette filters function the same way—“basically like drinking through a somewhat thinner straw.” He goes even further, arguing that “filters have reduced smoke particle size, producing cancers deeper in the lungs, making them harder to identify and harder to treat.” (Scientists determined that the radiation source was the newer “superphosphate” fertilizers being used heavily on tobacco plants.)

 Next came mandated “tar and nicotine numbers,” which turned out to be misleading measures obtained from smoking robots. Then, “an opportunity presented itself to game the system, as we find in the brilliant trick of ventilation.” Manufacturers pricked tiny holes in the paper near the mouthpiece of cigarettes brands like Carlton and True, which consumers got around by covering the holes with fingers or with “lipping” behavior. “Low tars were a fraud, just as “lights” would be,” Proctor writes. Smokers just smoked harder, or differently, or more frequently. In 1983, pharmacologist Neal Benowitz at UCSF broke the official news in the New England Journal of Medicine: Smokers got just as much nicotine, whether they smoked high-, low-, filtered, unfiltered, regular, light, or ultra-light.  The industry itself had known this for more than 20 years. “Nicotine in the actual rod was rarely allowed to drop below about 10 milligrams per cigarette,” Proctor asserts, “and no cigarette was ever commercially successful with much less than this amount.” (A Philip Morris psychologist compared nicotine-free cigarettes to “sex without orgasm.”)

Indeed, almost every design modification put in place by tobacco companies over the past century, from flue-curing to filters, has served to make cigarettes deadlier than before. “Talk of ‘safer cigarettes’ is rather like talking about safer terrorism, or safer smallpox, or safer forms of drowning,” Proctor concludes.

And the industry testing continues. The point of tobacco-sponsored research is not simply to discredit an individual researcher’s work, but to create an aggregate bias in the pattern of research—a lot of “noise” in the signal. In other words, “you basically fund lots of research to dispute a hazard, then cite this same research to say that lots of scholars dispute it.” We are told about “mucociliary escalators,” which dredge the tar up and out of smokers’ lungs. We learn that “a rabbit will scream if nicotine is introduced into the eye.” We read excerpts from anguished letters to tobacco companies: “Do you suppose if I continue to smoke Camel Ultra Light Cigarettes and I should develop cancer it will be ‘Ultra Light Cancer?’”

Proctor brings us up to date: Harm reduction, he writes, has become the industry’s new mantra. “The companies now want us to believe that less hazardous products can be and are being made and marketed.” Proctor thinks harm reduction “may end up causing even greater harm” if products touted as “safer” make smokers less likely to quit. As for public health campaigns, “consumers are encouraged to stop consuming,” Proctor writes, “but producers are never discouraged from producing.” Or, as Louis Pasteur once wrote: “When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it.”

So, what comes next? A glimpse of the future may already be here, in the form of cinnamon- and mint-flavored Camel Orbs, “which look like Tic Tac candy and contain about a milligram of nicotine in a highly freebased form.”

As for the industry’s success in corrupting scientists and academics through various means, the story is just as bad as you think it is: “It would take many thousands of pages to chronicle the full extent of Big Tobacco’s penetration of academia; the scale of such collaborations is simply too vast. From 1995 to 2007 alone, University of California researchers received at least 108 awards totaling $37 million from tobacco manufacturers….”

Part II of III.

Photo Credit: http://theloungeisback.wordpress.com/

The Hidden Story of How Big Tobacco Invented Freebasing

Review of The Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition.

Part I

It’s easy to think of cigarettes, and the machinations of the tobacco industry, as “old news.” But in his revealing 737-page book, The Golden Holocaust, based on 70 million pages of documents from the tobacco industry, Stanford professor Robert N. Proctor demonstrates otherwise. He demonstrates how Big Tobacco invented freebasing. He shows how they colluded in misleading the public about “safe” alternatives like filters, “low-tar,” and “ultra-lights.” We discover in Lorillard’s archives an explanation of menthol’s appeal to African Americans: It is all part of a desire by “negroes” to mask a “genetic body odor.” Radioactive isotopes were isolated in cigarette smoke, and evidence of the find was published, as early as 1953. He reveals that the secret ingredient in Kent’s “micronite filter” was asbestos. And he charges that the “corruption of science” lies behind the industry’s drive to continue its deadly trade. “Collaboration with the tobacco industry,” writes Proctor, “is one of the most deadly abuses of scholarly integrity in modern history.”

Half of all cigarette smokers will die from smoking—about a billion people this century, if present trends continue. In the U.S., this translates into roughly two jumbo jets crashing, killing everyone onboard, once daily. Cigarettes kill more people than bullets. The world smokes 6 trillion of them each year. (The Chinese alone account for about 2 trillion). Some people believe that tobacco represents a problem (more or less) solved, at least in the developed West.

All of this represents a continuing triumph for the tobacco industry. The aiders and abettors of tobacco love to portray the tobacco story as “old news.” But as Stanford Professor Robert M. Proctor writes in The Golden Holocaust, his exhaustive history of tobacco science and industry: “Global warming denialists cut their teeth on tobacco tactics, fighting science with science, creating doubt, fostering ignorance.”

Checking in at 737 pages, The Golden Holocaust is nobody’s idea of a light read, and at times its organization seems clear only to the author. But what a treasure trove of buried facts and misleading science Proctor has uncovered, thanks to more than 70 million pages of industry documents now online (http://legacy.library.ucsf.edu) as part of the Master Settlement Agreement of 1998. Once the material was finally digitized and available online, scholars like Proctor could employ full-text optical character recognition for detailed searchability. Ironically, this surreal blizzard of documentation was meant to obscure meaningful facts, not make them readily available, but tobacco executives seem not to have factored in digital technology when they turned over the material.

The single most important technological breakthrough in the history of the modern cigarette was flue-curing, which lowers the pH of tobacco smoke enough to make it inhalable. The reason few people inhale cigars, and very few used to inhale cigarettes, is that without some help, burning tobacco has a pH too high for comfortable inhalation. It makes you cough. But flue-curing lowered pH levels, allowing for a “milder,” less alkaline smoke that even women and children could tolerate.

World War I legitimized cigarettes in a major way. Per capita consumption in the U.S. almost tripled from 1914 to 1919, which Proctor considers “one of the most rapid increases in smoking ever recorded.” After World War II, the Marshall Plan shipped a staggering $1 billion worth of tobacco and other “food-related items.” (The U.S. Senator who blustered the loudest for big postwar tobacco shipments to Europe was A. Willis Robertson of Virginia, the father of televangelist Pat Robertson.)

The military, as we know, has historically been gung-ho on cigarettes. And Proctor claims that “the front shirt pocket that now adorns the dress of virtually every American male, for example, was born from an effort to make a place to park your cigarette pack.” In addition, cigarette makers spent a great deal of time and effort convincing automakers and airline manufacturers to put ashtrays into the cars and planes they sold. Ashtrays were built into seats in movie theaters, barbershops, and lecture halls. There was even an ashtray built into the U.S. military’s anti-Soviet SAGE computer in the 50s.

In the early 50s, research by Ernest Wynder in the U.S. and Angel Roffo in Argentina produced the first strong evidence that tobacco tars caused cancer in mice. Roffo in particular seemed convinced that tobacco caused lung cancer, that it was the tar rather than the nicotine, and that the main culprits were the aromatic hydrocarbons such as benzpyrene. Curiously enough, it was influential members of Germany’s Third Reich in the 40s who first took the possibility of a link seriously. Hans Reiter, a powerful figure in public health in Germany, said in a 1941 speech that smoking had been linked to human lung cancers through “painstaking observations of individual cases.”

In the December 1953 issue of Cancer Research, Wynder, et al. published a paper demonstrating that “tars extracted from tobacco smoke could induce cancers when painted on the skins of mice.” As it turns out, the tobacco industry already knew it. Executives had funded their own research, while keeping a close eye on outside academic studies, and had been doing so since at least the 30s. In fact, French doctors had been referring to cancers des fumeurs, or smokers’ cancers, since the mid-1800s. All of which knocks the first leg out from under the tobacco industry’s classic position: We didn’t know any stuff about cancer hazards until well into the 1950s.

Only weeks after the Wynder paper was published, tobacco execs went into full conspiracy mode during a series of meetings at the Plaza Hotel in New York, “where the denialist campaign was set in motion.” American Tobacco Company President Paul Hahn issued a press release that came to be known as the “Frank Statement” of 1954. Proctor calls it the “magna carta of the American’s industry’s conspiracy to deny any evidence of tobacco harms.” How, Proctor asks, did science get shackled to the odious enterprise of exonerating cigarettes? The secret was not so much in outright suppression of science, though there was plenty of that: In one memorable action known as the “Mouse House Massacre,” R.J. Reynolds abruptly shut down their internal animal research lab and laid off 26 scientists overnight, after the researchers began obtaining unwelcome results about tobacco smoke. But the true genius of the industry “was rather in using even ‘good’ science, narrowly defined, as a distraction, something to hold up to say, in effect: See how responsible we are?”

Entities like the Council for Tobacco Research engaged in decoy research of this kind. As one tobacco company admitted, “Research must go on and on.”

A good deal of the industry’s research in the 50s and 60s was in fact geared toward reverse engineering competitors’ successes. Consider Marlboro. Every cigarette manufacturer want to know: How did they do it? What was the secret to Marlboro’s success?

As it turns out, they did it by increasing nicotine’s kick. And they accomplished that, in essence, by means of freebasing, a process invented by the cigarette industry. Adding ammonia or some other alkaline compound transforms a molecule of nicotine from its bound salt version to its “free” base, which volatilizes much more easily, providing low-pH smoke easily absorbed by body tissue. And there you have the secret: “The freebasing of cocaine hydrochloride into ‘crack’ is based on a similar chemistry: the cocaine alkaloid is far more potent in its free base form than as a salt, so bicarbonate is used to transform cocaine hydrochloride into chemically pure crack cocaine.” Once other cigarette makers figured out the formula, they too began experimenting with the advantages of an “enhanced alkaline environment.”
  
(End of Part I)

Photo Credit: http://theloungeisback.wordpress.com/

What It Means to Say Alcoholism is Genetic

One woman’s journal.

From Insanity to Serenity, by Tommi Lloyd

Excerpts:

"I was born in 1963 in Toronto, Canada, to a family struggling long before I arrived. My dad was an alcoholic, born in Wales in 1921. His father and namesake was also an alcoholic who died at age 28…. My oldest sibling and only brother, Harry, entered a treatment centre at age 36 and has been sober for more than 20 years…. My Uncle Griff died from alcoholism when I was 10 years old…. There were no reprieves by which we spent a day or two in a sober environment. Dad drank from morning until night…. Christmas, Thanksgiving, and Easter—these were some of the worst days of the year…. Santa started leaving a carton of cigarettes next to my stocking at Christmas and I thought it was great.

"I yearned for some quality time before his drinking took center stage for the day… he drank from the minute he got up to the minute he passed out. At the height of his addiction, he was drinking more than 40 ounces of vodka a day…. There were many times when I would walk into the bedroom and see him guzzling the vodka straight from the bottle. It made me feel physical ill and utterly helpless.

"I too, am an alcoholic. In addition to alcohol, my teenage love of marijuana turned into a 30-year affair…. I have two nephews who are addicted to marijuana…. Rather than being sloppy drunks, my nephews opted for the mellow alternative that’s not addictive, (so we like to think) and you can pay for your habit by selling it to your friends.

"By age 11 I tried drinking for the first time…. I recall Susie telling us we could try drinking, but it had to be done quickly so as not to get caught. We poured some very strong rum and cokes and I guzzled mine down by holding my nose with my free hand…. As soon as I lay down on my bed the room started spinning and it wasn’t long before I was throwing up. Mom fussed over me, concluding I had the flu and I recall feeling both happy and guilty at the same time. I loved the attention but felt badly for the cause of my illness. I didn’t drink again for a few years….

"There is nothing more validating for me as a mother than to know I’m an inspiration to my children. I could not have asked for a better gift. This is what sobriety and a renewed spiritual life has brought my children and me…. Intellectually, I recognize how my childhood experiences and the disease of alcoholism molded a lot of my behavior and have been the root of much of my struggle with self-esteem. But self-knowledge does not change our circumstances, action does."

“Addiction Fiction”

Coming-of-Age Drug Novels

Call it “addiction fiction.” In the past few years we have seen a blossoming of this genre, where the private eye goes to 12-Step meetings, and one day your sponsor may just save your life by gunning down a rival in the street. Or, where the wise-beyond-their-years prep school drug addicts engage in Brett Easton Ellis-style sex and ennui.

Fiction readers of a certain age will recall that this is not a new thing under the sun. From Junky to The Man With the Golden Arm, from Naked Lunch to Less Than Zero, drug novels have always been with us. Addiction fiction has two distinct subgenres: addicts with money, and addicts without money. For obvious reasons, the latter genre is the prevailing one—Trainspotting and Requiem for a Dream come to mind. But the wealthy end of the spectrum is not without representation. Consider The Basketball Diaries, or Bright Lights, Big City.

As an example of the first type of book, the one where the addict has no money, we have Spoonful, by first-time author Chris Mendius. As for the upscale second type, there is the recently released novel, No Alternative,  by William Dickerson, a budding film director with an MFA. I would judge both authors to be well south of the age of 40, making both of them pure examples of Generation X. 

Ah, the 90s. As time passes, it seems clear that the death of Kurt Cobain has been added to the touchstones of American youth culture, in a tradition going back to the 60s. Where were you when Kennedy died? When Lennon died? When Cobain died? This last question matters, since Nirvana and Cobain are threaded thematically through both of these new novels. As Chris Willman wrote at Stop the Presses: “April 5 is to many contemporary rock fans what November 22 is to older baby boomers: the day you can almost certainly remember where you were or what you were doing when you heard that ___ died. That's not to say that Kurt Cobain's suicide represented a loss of national innocence in the same way that JFK's assassination did. For one thing, Cobain's whole life and career already symbolized lost innocence, long before he died.”

In Generation X drug novels, lost innocence isn’t lost—there was never any innocence in the first place.

Michael, the narrator of Spoonful, is the kind of drug addict with no money. Michael is forthright, if not one to probe the philosophical ironies of his condition: “Nobody ever says, ‘When I grow up, I want to be a junkie.’” End of story. Well, the beginning, really. In this well-written junky novel, author Chris Mendius brings his tragic characters to life in a manner that calls to mind Hubert Selby, Jr.’s stark New York classics of addiction without redemption.

Set in Chicago’s Wicker Park area, young Michael and his pal Sal find their way to heroin in a hurry. They also quickly learn the flip side of the illness—the sickness of withdrawal, “like having a debilitating combination of food poisoning and the flu, with periodic muscle cramps.” No matter. “Once we made it through all that, we decided to stay off dope. A month passed with no discernible improvement in our lives and we promptly resumed getting high.”

It’s heroin he craves. Michael is no fan of cocaine: “You’re up all night, running your mouth, jaw twitching, nose burning. You might want to fuck but you can’t. All you can do is keep going. Before you know it, the birds are chirping and the garbage trucks are rolling. You’re out hundreds of dollars and for what?” And they scoff at pharmaceutical efforts at non-addictive synthetic opiates, “engineered to not let anyone feel a moment of undeserved pleasure.” One character likens kicking methadone to “getting your skin pulled off with pliers.”

The debate over freely distributing the drug naloxone as an anti-OD safety measure is referred to obliquely: “That’s the thing with smack. It’s a fine line between the time of your life and the end of your life…. More often than not, the difference between life and death was having someone there to revive you or call somebody who could.”

Mendius is good at drawing a picture of the addict’s endless grind: “Finding the ways and means to score is a twenty-four-seven gig. You might get lucky and hit it big now and then but you’re always looking ahead. Plotting. Planning. No matter how much you get or how close the scrape, you always gotta keep at it. Day in and day out.”

Michael never quits for long, and when he is off heroin, he buries himself in marijuana and booze. There is no redemptive ending. He walks off into the sunset.

From seedy Chicago to the upper reaches of Westchester, New York. Like Spoonful, No Alternative by William Dickerson features characters whose collective memory goes back no farther than the 80s. Which sucked, as we all know, and as Thomas, the narrator, never tires of telling us. Thomas and his friends are drug and alcohol abusers with money. The drugs of choice are prescription medications, not heroin or cocaine, for these products of Fordham Prep. 

It is 1994, and the grunge youth of Yonkers, the children of Vietnam vets and hippies, are rootless and confused. “There was no clear-cut path beckoning them. No modus operandi.” It was a generation, Dickerson writes, that “earned a label that was just about as vague as their sense of what to do with their lives: Generation X.” In this version, not much has changed since the crack-crazy L.A. 80s of Brett Easton Ellis. The names and the drugs have been altered, but otherwise the trappings are indistinguishable: high disposable income and excessive ennui.

Thomas supports his crazy little sister Bridget, who becomes a white rapper named Bri Da B. His sister’s drug of choice is cutting herself: “She was determined to be in control. If she was going to bleed, it was going to be a decision, it was going to be controlled, and she was going to bleed everywhere, not just from the abyss between her legs. If pain was to be a constant, might as well get used to it and build up a tolerance.”

No Alternative is readable enough, but it does not carry the campy forward motion of other rich-kid addiction books. It is more measured, dry, and there is an odd hitch in the narration, which is resolved, rather shakily, at the end, with a big Reveal that distracts the reader from the central relationships in the story.

So, two early novels, by promising young writers, about drugs and what they do to you. It will be interesting to find out what becomes of these authors, and what manner of new work they get up to in the future. The story never ends where you think it does.