Treatments that Work

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:

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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 best.

"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 enough."

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; empowerment.

"Warm turkey." Tapering down and "sobriety sampling" give addicts a chance to kick their habits and help them not give up if they fail.

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 abstinence.

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 lives.

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 neurotransmitters.

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 addicts.

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 profound.

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 pleasure.

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.

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