Addicts are often lumped into a single category, portrayed in the media as morally bankrupt and lacking in willpower. These preconceptions bleed out into the scathing arena of public opinion, especially when a celebrity dies of addiction-related causes. Some of the stigma has been fed by Alcoholics Anonymous and its many spin-offs, which claim to offer the best cure for the alcoholic/addict by holding him accountable and having him work the 12 steps. While AA undoubtedly does much good (it offers social sanctuary to those struggling with addiction), it also asserts that addiction is a disease while offering no medical treatment for it.
Meanwhile, emerging research reveals genetic and physiological roots of addiction, for which medical treatments are proving more effective than 12-step programs (though they can be done in conjunction). Plus, finally, all Americans have a legal right to receive substance-abuse treatment under the Affordable care Act.
ADDICTION IS ADDICTION, NO MATTER WHAT THE DRUG—AND IT'S NOT ABOUT WILLPOWER
While different substances have different effects on the body, the most commonly addictive drugs, from the licit (like alcohol and nicotine) to the illicit (including cannabis, cocaine, and opiates), all affect the brain’s reward circuitry in similar ways. Specifically, they trigger the mesolimbic dopamine system—the “reward” pathway—including an important area known as the nucleus accumbens. A recent study in the American Journal of Psychiatry finds that, when taken for prolonged periods, all these substances cause long-term changes to neurons that can lead to one or more of the four root states of addiction: tolerance, causing the person to require greater quantities of a drug to get the same effect; dependence, which causes uncomfortable and sometimes dangerous withdrawal symptoms; dysphoria, or excessively negative emotional states, which may contribute to greater likelihood of relapse; and sensitization, increased drug responsiveness to a particular dose, making the person more prone to relapse after extended withdrawal.
If all substances work in a similar way on the reward system, it nullifies the notion that a user of one substance has greater or lesser willpower than a user of another.
—"The Neural Basis of Addiction: A Pathology of Motivation and Choice," Kalivas, Peter et al. American Journal of Psychiatry, 2014.
GENES AFFECT YOUR PROPENSITY FOR ADDICTION, JUST AS THEY DO FOR ANY OTHER DISEASE
Genetics undoubtedly play a part in addiction as well. A review in Alcohol Research & Health that sifted the research on genetic addiction found that, in both alcohol and drug dependence, there is “extensive evidence” that genetic factors influence the risk of inheriting these disorders by about 50 to 60 percent. This research includes the largest twin study of the factors underlying psychiatric disorders, using identical twins who share 100 percent of the same genes. There was a higher instance of heritability for dependence in the case of an overlap between alcohol- and drug-dependence, whereby a person suffers a co-addiction. Researchers found genes that help shape an “addictive personality”; these genes can also help determine the likelihood of substance-dependence, transmission of nerve signals, and how alcohol, cannabinoids, and opioids are metabolized in the body. The genetic component in every phase of addictive behavior offers further notice that dependence isn't primarily a sign of weakness, or immorality—a stigma that can sometimes hamper recovery.
While genetics don’t necessarily predict who will become addicted, the research does open the door to eventual early detection as to who is predisposed, and possible early interventions and preventative approaches.
—“The Genetics of Alcohol and Other Drug Dependence,” Dick, D., and Agrawal, A., Alcohol Research & Health, 2008.
A RISE IN PRESCRIPTION OPIOIDS IS LINKED TO A SURGE IN HEROIN ABUSE
There remains a painful irony in how addicts are created by the very culture where they are later vilified. A study published this year in the Journal of Pain & Palliative Care Pharmacotherapy links the abuse of prescription opioid (PO) drugs to an increase in heroin abuse, which, the Centers for Disease Control and Prevention reports, has surged by 63 percent in the past 10 years. The origins of the PO surge stem from a 1992 report issued by the Agency for Healthcare Quality Research, which stated concerns that up to half of patients were not receiving adequate postsurgical pain treatment. This concern was later proven false, but it set in motion a massive uptick in opiod prescriptions as doctors rushed to “fix” this (perceived) error by offering more PO prescriptions. Between 1998 and 2007, prescriptions for hydrocodone increased by 198 percent, oxycodone by 588 percent, and methadone by 933 percent. Soon after, more people began bypassing their doctors altogether, getting their drugs from online pharmacies that either didn’t require a prescription or would accept obviously falsified ones.
POs, which bind to the same brain receptors as heroin, are considered “gateway” drugs, especially as heroin is less expensive (oxycodone, for example, can cost approximately $8 to $10/dose, whereas a whole 50mg bag of heroin, $9 to $10). As the CDC notes, 45 percent of people who have used heroin were also addicted to a proscription opioid. And people who are currently addicted to proscription opioids are 40 times more likely to become addicted to heroin.
Since addicts often suffer the shame of revealing their drug history to doctors, this epidemic suggests a greater need for more rigorous screening before patients are prescribed POs, including obtaining a detailed history of a person’s drug experience—and that of their family. The DEA made a move toward tighter control of POs as of October, 2014, when they re-classified hydrocodone-based drugs (like Vicodin and Percoset) from Schedule III to II under the controlled Substances Act, making these drugs difficult to obtain by phone; only written prescriptions will suffice, which usually requires an in-office visit.
—“The Epidemic of Prescription Opioid Abuse, the Subsequent Rising Prevalence of Heroin Use, and the Federal Response,” Kanouse, A., and Compton, P., Journal of Pain and Palliative Care Pharmacotherapy, 2015.
STRESS HORMONES CAN REDUCE HEROIN CRAVINGS
Further research in 2015 has shown that drug cravings can be reduced with medical intervention. In the case of heroin addicts, the stress hormone cortisol appears to reduce cravings. And since heroin is known to stimulate some of the most severe cravings among drugs, this offers potential for additional withdrawal therapy. Researchers at the University of Basel in Switzerland conducted a study on 29 heroin addicts undergoing heroin-assisted addiction treatment. They hypothesized that, since cortisol inhibits the brain’s ability to retrieve memories, it might also inhibit addiction-related memory—thereby weakening cravings, for heroin. In the Basel experiment, the cortisol was administered to the addicts before the heroin, and researchers saw a 25-percent decrease in cravings compared to a placebo. These lowered cravings, however, were only seen in low-dose heroin addicts, not those who were highly dependent.
This research further supports evidence that drugs alter the brain over time—and that these neural changes can, in fact, offer potential for reversing some of the effects of addiction.
—“Effects of Cortisol Administration on Craving in Heroin Addicts,” Walter, M. et al. Translational Psychiatry, 2015.
AND A SIMPLE MEDICATION CAN DRAMATICALLY DECREASE ALCOHOL DEPENDENCE—WHILE YOU'RE DRINKING
An alcohol-antagonist drug called naltrexone has shown to be one of the most effective methods of reducing dependence on alcohol by reducing cravings. The catch? A person has to be drinking alcohol at the same time as taking the naltrexone, or it won’t work. That’s because alcohol consumption causes the body to release endogenous—or naturally occurring—opioids. Naltrexone must bind to an opioid in order to enter the brain, and eventually block the opioids from binding to the brain’s receptors. In other words, you have to continue drinking in order for naltrexone to teach your body to stop craving the alcohol. The naltrexone approach to alcoholism has been shown to be more effective than going cold-turkey, once again lending weight to the idea that medical options may be more effective than 12-step programs.
—“Evidence About the Use of Naltrexone and Four Different Ways of Using It in the Treatment of Alcoholism,” Sinclair, J., Oxford Journal, 2001.
Five Studies is Pacific Standard’s biweekly column that identifies and analyzes the best academic research to deliver new insights on human behavior.