Transcript here

Giving addiction its due*
Addiction what is the added value of the concept today?
The University of Helsinki Centre for Research on
Addictions
Gene M. Heyman
Dept. of Psychology, Boston College
October 15, 2012
* This is actually my 2nd talk
First talk: Some basic findings on drug use (among DSM
“addicts”)
Outline of topics
Context: What experts and addicts say about addiction,
policy, individual responsibility
Two questions:
– Is addiction a chronic disorder
– Does drug use become involuntary
Approach:
– Use DSM to distinguish addicts from drug users
– Look at the data
Why don’t they just quit?*
Is addiction like other psychiatric disorders?**
Views on addiction from experts: Alan Leshner & Nora
Volkow, past and present directors of US National Institute
on Drug Abuse (NIDA)
“Addiction is a brain disease . . . For most people, it
[addiction] is a chronic relapsing disorder . . . . addiction must
be approached more like other chronic illnesses.”
“A metaphorical switch in the brain [is] thrown as a result of
prolonged drug use. Initially, drug use is a voluntary behavior,
but when that switch is thrown, the individual moves into a
state of addiction, characterized by compulsive drug seeking
and use.” Leshner, Science, 1997.
“The key symptoms of addiction...are compulsive drug intake
and intense drive to take the drug....” “at the expense of lifepreserving activities.”Volkow, 1992, 2000
Views on Addiction: William Burroughs (19141998), author, counter culture hero, opiate addict
Junk yields a basic formula of “evil” virus: . . . A dope fiend
is a man in total need of dope. . . Dope fiends are sick
people who cannot act other than they do. A rabid dog
cannot choose but bite. Naked Lunch (1959)
Policy recommendations regarding insurance coverage and
individual responsibility for addiction
“. . effects of drug dependence treatment are optimized when
patients remain in continuing care and monitoring without limits or
restrictions on the number of days or visits covered.”
–
(A. T. McLellan, Recent Deputy Director of Drug Control Policy, Obama
Administration)
“Ten percent of [the] population [are] unknowingly vulnerable to
alcoholism when they drink. They can’t be held responsible for
developing that illness.”
– Dr. David Gastfriend, Recent Director of the Addiction Research Center at
Massachusetts General
“ I find it useful to conceptualize addiction as the cancer of behavior.
How else could one fathom the mother who buys cocaine for herself
instead of food for her children …”
– Dr. P. Martin in New England Journal of Medicine
One more account: Patty: Mother of two girls,
heavy cocaine user for 15 years, drug dealer
Oh, for a time my nose opened up when I went out
partying and drinking, but I learned how to handle it. You
know, I never really decided to quit using. I just quit
selling.
Once I stopped selling I didn’t have the money to buy it
anymore.
I would have literally had to say, “ Sorry, girls, you don’t
eat this week” to buy some. I would have exactly $80 for
two weeks of food. Waldorf et al. (1991)Cocaine
changes: The experience of using and quitting .
Some context, an example of human decision making: What to
eat when you have a severe food allergy
Ira Glass: “Barbara said . . .she got incredibly sick, throwing up, rushing to the
emergency room, getting an IV, an anti-nausea medication . . .”.
Barbara: “And being on vacation now, I've got a room full of popcorn and trail mix.”
Ira Glass: “You do? Right now? Wait, don't you think you're playing with fire?”
Barbara: “Well, you know, it's not going to kill me. And if it does, I won't know.”
Ira Glass: “Just a quick trip to the hospital, an IV, some medication.”
Ira Glass: This is Michelle DeVito, an emergency room doctor . . . she says that
nearly every day, she sees somebody with a food allergy who has eaten the food that
they're not supposed and ended up in her ER.
Michelle DeVito: “The ER is a virtual laboratory of dysfunctional behaviors and bad
choices. . . . much of the pathology we see in the ER is a result of bad choices. And
some of them, decades of bad choices.”
Some initial conclusions
The understanding of addiction has consequences for
public policy and tax dollars
Many cases (e.g., Burroughs) are consistent with the
disease/compulsive model (“rabid dogs”) ---but not all
– Real addicts vs. apparent addicts
– No “real” addicts?
– Food allergies (and addiction): human nature/decision making
revealed?
How to proceed
Find a tool for identifying “addicts” then test if they are chronic,
compulsive (involuntary) drug users.
How to identify addicts
Use the American Psychiatric Association (DSM) criteria for
“substance dependence” to distinguish addicts from drug
users
Rationale:
– Official criteria for clinics, courts, & researchers
– Reliable/research based
– Divides drug users into meaningful categories
Key feature: persistence of drug use despite aversive
consequences
– High levels of drug use
– Use despite health & job risks
– Relapse & takes more than initially intended
Questions regarding DSM “addicts”
Are they chronic cases?
Do they become involuntary (compulsive) drug
users?
Overall
prevalence of
use and
dependence
100%
Ever Used
Ever Dependent
80%
* Anthony et al., 1994
NCS Replication
2D Graph 1
60%
Y Data
Heroin
40%
6
7
20%
ig
ar
et
te
s
Al
co
O
ho
th
l
er
D
ru
gs
M
ar
iju
an
a
C
oc
Am
ai
ne
ph
et
am
in
e
H
er
oi
n
0%
C
% of US Population,
National Comorbidity Study*
Lifetime Use and Lifetime
Dependence for Specific Drugs
8
Is addiction a chronic disorder, as so often claimed?
Remission in Representative Samples of
Dependent (Addicted) Drug Users (N approx. 2700)
% in Remission
100%
80%
60%
paraphrasing
O’Brien and
McLellan: “cure
is an unrealistic
hope, addiction
requires lifelong
treatment as
does “arthritis,
diabetes,
asthma”’
40%
20%
C
SA
R
NE
Rem% = (LT-C)/LT
20
01
-2
00
2
20
01
-0
3
NC
S
NC
S
19
90
-9
2
0%
Community
Studies
Textbook of
Clinical
Psychiatry: “for
addiction
patients
recovery is a
never-ending
process, the
term cure is
avoided.
High remission rates for
different drugs
Did type
of drug
matter?
90%
ECA Survey, 1981-198
NESARC Survey, 2001-2002
60%
45%
30%
Type Drug
s
t im
S
O
pi
od
s
15%
M
ar
ij
% Remission
75%
How long does
substance dependence
persist?
Cumulative Probability
of Remission
Cumulative Remission From Drug
Dependence & Their Best Fitting Curves
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Coc Rem = 0.98(1 - e-0.17Yr)
Mj Rem = 0.94(1 - e-0.13Yr)
Alc Rem = 0.95(1 - e-0.05Yr)
Cig Rem = "1.38"(1 - e-0.015Yr)
Fixed Asymtote = "1.38"(1 - e-0.024Yr)
0
10
20
30
40
50
60
Increasing
functions
suggest that
once addicts
quit, they
usually do
not resume
heavy drug
use
70
Years Since Dependence Onset
Yrs to 50% quit:
Cocaine: 4
Marijuana: 6
Alcohol: 16
Cigarettes: 31
Lopez-Quintero, 2010
Other methodological issues
Missing addicts?
Do high remission rates persist when self-report
is validated?
Why do we say that addiction is a “chronic”
disorder, when the data say otherwise?
Clinics as basis for understanding of addiction
But most addicts do not seek treatment
Berkson’s bias: those in clinic have more than one
disorder
Predictions:
– Drug use persists longer in clinic populations
– Clinic populations have more disorders (Berkson’s
bias)
Clinic results support received wisdom: “Addiction is a
chronic disorder”
Relapse Following Treatment
(Resumption of Drug Use)
% Relapse
75%
60%
Hunt et al., 1971
45%
Alcohol
Smoking
Heroin
30%
15%
0
Typical
clinic study
results
2
4
6
8
Months
10
12
Treatment Seeking is Corrrelated
With Higher Comorbidity*
80%
Drug Depend
& Tx Seeking
70%
60%
50%
40%
Drug Depend &
Not Tx Seeking
NotDrug
Dependent
30%
20%
10%
Tx
S
e
Tx ek
O
S
ee pi
a
Tx kCo te
S
ee cain
k
e
N An
y
ot
T x Dr
A g
N ny
ot
D
r
D
ru g
gD
ep
Freq of Additional
Psych Disorders
Berkson’s
bias
* Regier et al., 1990; Rounsaville et al., 1991
Is addiction a chronic disorder, according to the
data? Summary
Yes, for some (perhaps most) clinic populations
But most addicts do not seek/end up in treatment
Illicit drug addicts not in treatment tend to quit by age 30
(alcohol and cigarettes quit at lower rates)
One difference in the two groups: Additional medical
disorders
Is addiction a disease (meaning involuntary
drug use)?
In 1619, Robert Harris described habitual
drunkenness as this “Dropsilike disease.”
In 1628, William Prynne notes that drunkenness is
a “dangerous dropsie and disease.”
John Bury (1677) writes: “drunkenness is a
disease so epidemical that all the Physicians in
England know not how to stop it.”
Who are these early commentators and
what were they thinking?
British clergymen
Basis of diagnosis (1609): those who addict
themselves . . . turn delight into necessitie . . .
yet against all rules of reason . . . they will not
leave their drunkenness
Drinking seemed irrational therefore it was a
disease (assumption: voluntary behavior is
rational)
Additional, more recent explanations: addiction is a
disease because it has a biological basis: genes
and drug-induced changes in the brain
Genetic etiology: “the evidence of this physical basis
(genes) has significantly advanced the acceptance of
alcoholism (addiction) as a disease.” Miller & Chappel
(1991)
Drugs change the brain: “That addiction is tied to
changes in brain structure and function is what makes it,
fundamentally, a disease.” Alan Leshner, Science (1997)
Changes in nucleus accumbens and
cortex produce a “recipe for addiction.”
Fig. 5. Photographs of three examples of
apparently anomalous apical dendrites
on Cg3 pyramidal cells in rats that selfadministered cocaine (see text).
Robinson et al., 2001, Synapse…
Given Access to Saccharin, Preference
Shifts toSaccharin Following
Escalated Cocaine Intake
% Preference for Saccharin
Cocaine Intake Escalates
When It Is Only Option
mg Cocaine/Day
25
20
15
10
5
Day 1
Day 21
Days
100
80
60
40
20
0
1
2
3
4
5
6
7
8
9 10
Days
Motor sensitization (3x a much cocaine as in
Perhaps as much as 15
Robinson study); saccharin linked to lower DA
g/day for humans (or
release) Recall Volkow : “at expense of life
about 1-2 wk supply for
preserving activities”)
heavy user).
The proper question
All psychological phenomena vary as a function
of variation in genes and brain structure/function
Thus, we can ask: do genes and drug- induced
neural adaptations insulate drug use in addicts
from the determinants of choice?
Does biology of addiction lead to involuntary
drug use?
Criteria for the voluntary/involuntary
continuum
Not free will
Different causal relations: elicited vs. feedback
Elicited: reflexes, instincts
Feedback: Values, sanctions, opinion of others,
costs benefits, punishment, reward, etc.
Examples and difficult cases
Contrasts
–
–
–
–
–
Patellar reflex vs. kick
Blush vs. rouge
Blink vs. wink
Ballistic missile vs. guided missile
Sneezing vs. spitting
Difficult cases: OCD symptoms, compelled
crimes (e.g., kidnap victim forced to rob bank)
Do the factors that influence choice help bring drug
use to a halt in addicts (and can the same be said
for symptoms of other psychiatric disorders?)
Logical implications of high remission rates plus nonclinic recovery in community samples
Correlates of recovery:
– Information: Surgeon General’s Report on smoking (1964)
– Historical events: Harrison narcotics tax act (1914)
/Prohibition (alcohol)
– Biographies: values and practical concerns
Common themes in biographical accounts of
quitting:
Stories are laced with explicit and implicit values:
–
–
–
–
:“I wasn’t put on earth to be an addict”
“I wanted my parents to be proud of me again”
“I didn’t want to embarrass my children”
“I was sick of the hassles”
Ordinary concerns
– Fear of arrest
– Finances and occupational concerns
– Family pressures
If drug use is voluntary, why don’t addicts just quit? Drug is
the better choice from a local perspective (1)
Addictive drugs are behaviorally “toxic”---they
undermine the value of competing activities
Benefits are immediate; costs are delayed
No direct self-satiating mechanisms as with most
other rewarding activities
Intoxicating, whereas moderation depends on
judgment
If drug use is voluntary why don’t addicts
just quit? (2)
Intoxication, depression, anxiety and other
emotional states reduce the frame of reference
to “now”
Lifestyle associated with drug use may not
include activities with long time horizons, thereby
promoting local frame of reference
Is addiction like other mental disorders
Yes, e.g., analogous to OCD: symptom provides
immediate reward, resisting symptom provides delayed
larger reward
No:
– Addiction’s unique idioms
– Addiction’s unique correlates of recovery: legislation,
opinion of others, AA
– Importance of cohort
0.16
*National Comorbidity Study
0.12
0.08
0.04
Year of Birth
19
66
-1
97
5
19
56
-1
96
5
19
46
-1
95
5
0.00
19
36
-1
94
5
Probability that Drug Use Leads
to Dependence by Age 20
Historical Variation in the Transition
From Drug Use to Drug Dependence*
Differences in Likelihood of Psychiatric Disorders
as Function of Differences in Year of Birth (ECA)
10%
on
si
ep
re
s
0%
Psychiatric Disorder
Sc
hi
zo
D
C
O
ni
c
Pa
M
an
ia
2%
An
4%
xie
ty
6%
D
8%
Af
f
D ect
is iv
or e
de
r
Likelihood
12%
Born 1917-1936
Born 1952-1963,
Ab
D us
ep e/
14%
The original talk summarized:
“Addiction” is a useful label
Addiction as compulsion is not in accord with the
research
Addiction as a psychiatric disorder is
questionable
The talk that there is not time for: Why are we so
susceptible to the idea that addicts are compulsive
drug users?
Recall William Burroughs
Junk yields a basic formula of “evil” virus: . . . A
dope fiend is a man in total need of dope. . .
Dope fiends are sick people who cannot act
other than they do. A rabid dog cannot choose
but bite.
From: Naked Lunch (1959)
Burroughs redux
His allowance from home stops (at age 40)
“I stood there with my last check in my hand and
realized that it was my last check. I took the next
plane to London [to enter “treatment”].”
– From Naked Lunch…(1959)
Graph is consistent with Amer. Psych Assoc. definition of addiction: Persistence of
drug use despite negative consequences
Local Frame
(Drug vs. NonDrug)
400V
15V
Drug (Choice Dependent
Decreases in Value)
12V
Value
Global Frame
(Drug+ NonDrug Market Baskets)
Equilibrium
9V
350V
x Drug Days + (30 - x)
Non-Drug Days
300V
Equilibrium
6V
Equilibrium
250V
200V
Value of Non-Drug
Undermined by Drug Effects
3V
150V
100V
0V
0
3
6
9 12 15 18 21 24 27 30
0
3
6
9 12 15 18 21 24 27 30
Number of Drug (e.g., heroin)
Choices In Last 30 Days
Graph is consistent with temporal pattern of addiction:
alternating periods of drug use and abstinence
Retail Vouchers
ReduceCocaine Use
% Continuously
Abstinent
100%
Explicit test of
incentives
Prosocial Incentives
for Abstinence
12-Step (Narcotic Anon.)
Program
80%
60%
40%
20%
0%
1
2
3
4
5
6
7
8
9
Week of Treatment
10 11 12
% Cocaine Abstinent
Choice-based voucher treatment: Cocaine
dependent users
Incentives and
drug use in
cocaine addicts
100%
80%
Vouchers
Counseling
Higgins et al.
1995
60%
40%
20%
0%
6
9
12
Months Since Treatment
Abstinence When Positive Drug Tests
Can Result in Job Loss
% Abstinent or
"Doing Well"
100%
No Monitoring
80%
60%
40%
20%
0%
1a 1b 2
3
4
5
6
7 8a 8b 9 10
Remission Rates for Psychiatric Disorders
NCS (1990-1992)
60%
All psychiatric disorders,
not counting drug and
alcohol dependence.
45%
30%
Al
lD
is
U
or
de
rs
se
15%
Su
bs
t
% in Remission
75%
Do all
psych
disorders
have high
remission
rates?
Competing Motives
Delay, Incentive, and Choice
200
Incentive Value
180
160
140
120
Reward Value = Amount/(1 + k Delay)
Green Amount = 200
Red Amount = 100
Green Delay = D + 5
Red Delay = D
k=1
100
80
60
40
20
Delay to
Smaller Reward
10
8
6
4
2
0
15 13 11
Delay to
Larger Reward
9
7
5
3
Time to Reward
0
150
NonDelayed
Choice
Benefits
Costs
100
Overall Value of Cigarette =s
(Benefits - Penalites)= (100 -150 units of value)
Value
50
0
-50
-100
-150
Benefits of Cigarette Now
vs Penalties Later
150
Overall Value of Cigarette =s
(Benefits - Penalties =s)
(100 - 25 units of value)
100
Value
50
Moment Cigarette is
Available
0
-50
-100
-25
Moment Neg.
Consq.Take
Effect
Discounted
Value of
Neg. Conseq.
-150
10
9
8
7
6
5
4
Delay
3
2
1
0
How can we justify interventions to aid addicts, if
they so often quit on their own?
We can shorten the period of self-destructive
drug use
Likelihood of quitting depends on alternatives
and judgment.
– Drug user may have few alternatives
– Assuming a better alternative to drug use exists, it
may take sober effort to achieve it
Missing Addicts?
Perhaps addicts who keep using are missing?
Assume most addicts remain addicts but go missing. Thus real % no
longer showing symptoms is 20% not 80%. How many missing
addicts are there?
Let 80% = True % of current addicts = (Current Addicts + X)/(X +
Lifetime Addicts), where X = number of missing addicts.
X = 3 x Current lifetime addicts (or about 12 % of Americans were
addicted to an illicit drug at some time in their life---and 75% of this
population (>20 M) cannot be found and are still addicted or dead
Remission in studies that include repeated,
Remission
% for Opiate
Addiction:
face-to-face
interviews,
back-up
validation
"Prospective, Intensive" Studies
methods
80%
60%
40%
20%
S
In t Lo
ne u
r C is
it y
0%
% of "Cases" Who No Longer
Met Criteria for Drug Dependence
100%
80%
60%
40%
20%
2
01
-0
-0
3
20
01
20
C
S
N
ES
A
R
C
N
C
S
19
90
-9
2
0%
N
% Cases Remitted
V
ie
V tna
et m
s
Does type
of study
matter?
% in Remission
100%
Political Attitudes In
Twins Living Apart*
Correlation (Similarity)
80
The logic behind the
genetic argument:
(1)Addiction has a
genetic basis.
60
(2) You do not choose
your genes.
40
20
(3) Therefore, drug use
in addicts is involuntary
Tw
ins
ra
te
rn
al"
"F
Id
en
t ic
*McCourt et al., 1999
al
T
wi
ns
0
But as this graph shows voluntary
behavior has a genetic basis also
(4) Sensible argument if
voluntary behaviors do
not have a biological
basis
(5) Yet…see graph
Brain plasticity is inherent to all psychological
phenomena, particularly learning and voluntary acts.
That addiction is
tied to changes in
brain structure and
function is what
makes it,
fundamentally, a
disease.
Alan Leshner,
Science (1997)
But all learning is
tied to changes in
brain structure and
function…
VVVVolkow et al., Synapse, 1993, 14:169-177.
Summary:
In accordance with the idioms that distinguish addiction from
chronic illnesses, research reveals
Most addicts stop using drugs and usually do so without
professional assistance
The primary factors that bring drug use to a halt are those that
influence decisions: familial concerns, economics, values
We cannot make a similar summary for “chronic illnesses”
Although addiction has a biological basis, these differences
are important and too large to overlook: Thus, addiction, is not
“Really like chronic diseases”