Because addiction has no solitary cause, the new view toward it
demands that single-minded approaches to drug treatment be abandoned. At
least four studies, according to William Miller, have found no
differences between groups of alcoholics assigned to Alcoholics Anonymous
and to no treatment at all. AA simply doesn't work for a lot of people.
Consistently negative findings have also come from controlled studies of
in-sight-oriented psychotherapies, antipsychotic drugs, confrontational
counseling, most forms of aversion therapy, educational lectures, group
therapy, psychedelics, and hospitalization.
"A rather remarkable amount of research has been conducted on the
effectiveness of several dozen approaches to the treatment of substance
abuse," says New Mexico's Miller. But sadly, he says, the chug treatment
community has been curiously resistant to using what works. His
colleague, Reed Hester, after a review of treatment outcomes from 1980 to
1990, concluded that "despite much more knowledge of what works,
treatment for substance abuse hasn't changed much in 40 years."
Plenty of things, however, do appear to work--some simple, some
complicated, and some novel. Some samples:
Brief intervention. According to Miller, studies show conclusively
that very brief treatment, if designed properly, is highly successful
against even moderately severe addictions.
"We found this out the hard way," he recalls. In 1976, in one of
his studies of controlled drinking, Miller separated his subjects into
two groups. The treatment group got a variety of treatments, including
counseling and disulfiram (Antabuse). The control group was given only a
brief self-help manual and told to go home, read it, and do their
"To our amazement, people in the control group did just as well as
the treatment group. We thought we had really messed up the study so we
repeated it twice again and got the same results.
"Then we went looking for what was really happening. We gave one
group the manual and another group no manual. The manual turned out to be
the variable that was the potent treatment. But why? We knew it wasn't
the effect of our initial interview with the subjects, or some difference
in the patient groups.
"The key was that we had inadvertently motivated the control group
and in spite of our expectations, the addicts changed and moderated their
drinking. Simply giving them the manual, saying to them that we believed
they could help themselves, could handle it, you can do this, was
Since then, Miller and other therapists have refined and modified
"motivational interviewing" and brief-intervention therapy. More than 30
studies in 14 countries have affirmed the value of its key components,
dubbed FRAMES: Feedback--specific and tailored to the individual, not
general; Responsibility--it's up to you, your choice, you are not a
helpless victim of a disease; Advice--firm and clear recommendations;
Menu--there are different ways to work this out; Empathy--the best
therapists have this and are neither pushy nor confrontational, but
supportive and warm; and Self-efficacy--you can do it;
"Warm turkey." Tapering down and "sobriety sampling" give addicts a
chance to kick their habits and help them not give up if they
In the hands of trained therapists, this and other forms of
"relapse prevention" teaches addicts skills for coping with mistakes and
setbacks. These methods also allow for moderate continuation of some
addictions for some people, rather than insisting on total
Pharmacologic treatment. Drug treatments for addictions have
historically been the least successful and the least available. Except
for methadone (which many experts feel largely failed because
accompanying social services and counseling were not given to addicts)
and Antabuse for alcoholics, there has not been much to offer.
However, several groups of scientists are conducting studies
looking for a methadone-style treatment for cocaine addiction. Now that
neurobiologists and neurochemists have pinpointed those parts of the
brain and the neurotransmitter system where cocaine exerts its effect,
they plan to develop drugs that block it.
As Childers explains: "Cocaine activates dopamine by inhibiting a
mechanism that pushes dopamine back into nerve endings that release it.
This pump, known as a dopamine transporter protein, is so inhibited by
cocaine that dopamine is released in relatively huge amounts."
In the past 18 months, George Uhl, M.D., Ph.D., of the NIDA
Addiction Research Center, and other scientists, using the gene cloned
for the dopamine transporter protein, located specific areas where
dopamine and cocaine both act in the brain.
Childers says the goal is to develop "designer drugs," man-made
molecules that can block cocaine receptors without shutting down the
dopamine transport system. (These are known as "antagonists" because they
block the receptors.) Another strategy is to develop drugs that bind
lightly to cocaine receptors, producing a very mild form of cocaine
"rush" but also blocking cocaine itself. These drugs are known as mixed
agonist/antagonists, or long-acting agonists.
Theoretically, says Childers, such drugs would break the
behavioral-chemical links, the cycle that keeps cocaine addicts craving
the drug. "We so far have only a long-acting agonist. That would still
help clinically, the way methadone does, and those addicted to cocaine
binges or overdoses would be helped. It might give a hard-core crack
addict a way to come off his high slowly and perhaps not have the
terrible withdrawal and craving."
Another pharmacologic approach that is drawing interest and
controversy is the African hallucinogen ibogaine, made from the shrub
Tabernanthe iboga, which grows in Gabon. Anecdotal evidence and a few
animal studies suggest that ibogaine can cure opiate addictions. It's
banned in the U.S., but a white powder made from it is available in
Holland and many American junkies have gone abroad to get it.
Some patients claim it not only stops cravings for long periods
without withdrawal, but also suppresses all desire for any drugs and
generates an emotional confrontation with their own thoughts and
feelings, during which they are inspired to reorganize their
Scientists at NIDA say there is no evidence that it works, even
over the long haul. Studies at Johns Hopkins have shown that ibogaine
interrupts dopamine release and stimulates other
Still, most experts say the long-term effects reported by some
users probably have more to do with the desire addicts have to kick their
habits and to their expectation that it will work. At Johns Hopkins, Mark
Molliver, M.D., and his team have also found ibogaine kills brain cells
in a part of the brain--the orbital frontal cortex--linked to obsessive
behavior. At present, neuroscientists at the University of Miami have the
go-ahead to test ibogaine at low doses for safety, but not yet on
Transformational psychology. The new view of addiction and some new
ideas about treatment have been fed from such unusual sources as
religion, philosophy, and literature. Recent research conducted on abrupt
personality change is a case in point. The investigators, William Miller
and Catherine Baca, M.D., of the University of New Mexico's Center on
Alcoholism, Substance Abuse and Addictions, credit their study of Joan of
Arc, Malcolm X, Alcoholics Anonymous cofounder Bill Wilson, Saint Paul,
Buddha, Kierkegaard, and Dicken's A Christmas Carol for suggesting means
by which some addicts might kick their habits overnight--much the way
Ebenezer Scrooge went from wretched skinflint to kindly benefactor after
a bad dream.
Whether or not their "transformational psychology" research
translates into a practical treatment for addictive behavior, its
publication this year by the American Psychological Association and
presentation at international drug and alcohol research conferences
reflect a shift in thinking about how people become addicted and how they
might get free. Until now, says Miller, behavioral scientists have stuck
to the conviction that real change, if it happens at all, is gradual and
painstaking. Now, says Miller, we know that "relatively sudden and
profound changes can and do occur, at least occasionally." If that
capability could be harnessed, the impact on addiction could be
Aversion therapy. Toni Farrenkopf uses aversion conditioning to
treat addictions, particularly those involving gambling and sexual
behavior. He's worked with patients for whom a single incident of
voyeurism, or indecent exposure, sometimes at a very early age, was so
arousing that the addiction held for decades.
"What we've learned is that people who are voyeurs and exposers are
addicted to the rush they get from contemplating, planning, and doing the
behavior, not necessarily from sexual release itself. With pedophiles,
other factors drive the addiction. But in all cases, you want to try and
countercondition the behavior."
Aversive therapy works by introducing negative consequences
immediately after the pleasurable experience occurs. One reason that many
people don't become addicted is that they rarely experience the worst
consequences of their behavior soon enough to override the
Farrenkopf uses covert sensitization with imagery. He'll show a
sexual addict arrest scenarios--being handcuffed, jailed, searched--10
seconds after an erotic exposure and do this repeatedly. Or he'll expose
them to a noxious odor or painfully snap a rubber band on a wrist. "I
help the patients experience all of the painful things that happen when
they are caught, or have to confront their families after getting
caught," he says. "It works for many."
In a related therapy for gamblers and others "addicted to thrills,"
Farrenkopf makes them do an inventory of how people are hurt by their
behavior, and visualize how their family would feel if they were killed
or maimed, how humiliating it would be for a professional to be arrested
for drunk driving.
Behavioral shaping. A recent study by NIDA researcher Kenzie
Preston, Ph.D., uses this method to ease inner-city cocaine addicts off
the drug; they get increasing rewards in the form of redeemable vouchers
to encourage abstinence. At the end of his first 12-week trial, nearly
half the subjects had stayed free of coke for at least seven weeks. Among
the rewards purchased with the vouchers: tennis shoes, tires, clothing,
and a lawyer's fee.