Tobacco smoking alone isn’t enough: More than smoking important in lung cancer death

Christopher Russell and Adi Jaffe

The tobacco epidemic already kills 5.4 million people a year from lung cancer, heart disease and other illnesses. By 2030, the death toll will exceed eight million a year. Unless urgent action is taken tobacco could kill one billion people during this century. (The World Health Organization Report on the Global Tobacco Epidemic, 2008)

These are some scary numbers, right? Cigarette smoking, according to the WHO, is the single most preventable cause of death in the world today, and in conveying these deadly statistics to the general public, cigarettes have come to be alternatively referred to by smokers and non-smokers as “cancer sticks”, “nicotine bullets”, and “coffin nails”.

But does smoking really ‘kill’ anybody in the literal sense with which we use this word?  To an epidemiologist, tobacco smoking (nor many other drugs of abuse for that matter) does not “kill” a person or “cause” illness or death in the way the words “kill” and “cause” are typically understood by the media and general public. For example, if I shoot someone in the head, stab another in the heart, and strangle a third till he stops breathing, it is reasonable to say that my actions were the direct, sole, and sufficient causes of death – I would have killed them. Smoking, however, is often neither a sole nor sufficient ‘cause’ of lung cancer, coronary heart disease, or myocardial infarction because non-smokers die from these diseases, and for example, because only 1 in 10 heavy smokers die from lung cancer when one looks at the overall numbers. Continue reading “Tobacco smoking alone isn’t enough: More than smoking important in lung cancer death”

Why the addiction-brain connection has to be part of the addiction treatment picture

Dr. Dodes recent article, apparently trying to blow up the myth of addiction as a neurophysiological disorder, sounded persuasive, although its underpinning was oversimplified and it’s understanding of the brain-science involved in addiction, and other associated mental health disorders, was lacking. Hopefully, by presenting a more complete picture of the evidence for a brain-aspect to addiction, I can un-bias the discussion somewhat. I, for one, don’t believe that neuroscience will ever be the only factor important in addiction – an individual’s environment, social influences, and other factors will always end up playing important parts as well – still, I think that to dismiss all of the evidence for biological factors at play in the development of addiction is foolhardy. Especially when there’s so much of it that was glossed over in Dr. Dodes’ introduction.

Pleasure center activation is only part of the picture in addiction

Firstly, supporters of the notion that addiction is, at least partly, an outcome of specific brain function point not only to pleasure center activation, but also to a whole host of findings showing genetic variability that is either protective from, or a risk factor for, dependence on drugs and likely also behavioral addiction like eating disorders, compulsive gambling, and maybe sex addiction as well (you can start out looking up ALDH2-2 variability and alcoholism and cocaine addiction, DRD4 and stimulant addiction, and many more).

While it is true that all those who consume addictive substance activate the brain similarly, there are considerable differences in the specific of that activation in reaction to drugs. Some release more dopamine while others have more “active” versions of specific important receptors; neurotransmitter recycling is quick in some, but not all, and drug metabolism is different in different individuals in ways that have been shown to be important not just for addiction risk, but also for the probability of treatment success. Just look at the nicotine and CPY26 literature for an example. It’s right there.

Additionally an entire body of literature exists that shows differential activation, as well as structural differences, between addicts and non-addicts in regions as varied as the OFC, PFC, Insula, and more. This is not to mention a slew of evidence that shows different behavioral test performance on risk-taking, impulsivity, and delay-discounting, all personality variables highly associated with addiction. If one simply ignore all of this evidence, it may be easy to believe that there is no biological explanation for these phenomena, but that’s just wrong.

To say that mesolimbic activation (what the good doctor called “pleasure centers”) is the only evidence for physiological factors in addiction is dismissive at best.

Drug addiction develops in only some drug users

The notion that not everyone who takes drugs becomes addicted is nothing close to evidence against a brain explanation for addiction. Everyone’s motor–cortex, striatum, and substantia nigra (the areas of the brain responsible for movement) activate in the same way during movement, but only a small group ends up suffering from Parkinson’s or Huntington’s disorders. One fact does not preclude the other but instead may specifically point to the fact the group which develops the disorder has somewhat different neurological functioning. Researchers aren’t concerned with explaining why all individuals can become addicted to drugs, but rather why that small subgroup develops compulsive behavior. A short reading of the literature makes that fact pretty clear. Additionally, while Dr. Dodes’ claims otherwise, imaging technology HAS produced evidence explaining this “mystery”, including differences in the ways addicted smokers respond to smoking-related triggers, and an increased dopamine response in cocaine addicts to cues, and well as to cocaine.

As mentioned in the motor disorder section above, ingestion of chemicals is not at all necessary for brain disorders to occur or indeed develop later in life. Dr. Dodes example of shifting addiction could be used as evidence for an underlying neurological difference just as well as it would serve to make his point… Or even better. If there’s a faulty basic mechanism attached to rewarding behaviors, it doesn’t really matter what the behavior is, does it? Sex addiction, gambling, and more can all be explained using a similar mechanism, though drugs of abuse may just have a more direct impact. I know, I’ve written about them all.

The Vietnam vet heroin story used by Dr. Dodes as evidence that emotional, rather than physiological, factors are responsible for addiction actually fits right in line with the notion of predisposition and underlying differences, and I’m surprised to hear a physician point to group differences as an indicator of no neurobiological basis. Indeed, when it comes to the emotional reactivity associated with drug associated cues, normal learning literature, as well as drug-specific learning research, has revealed over and over that drug-related stimuli activate brain regions associated with drug reward in the same way that natural-reward predictors do for things like food and sex. Once again, these facts are part of the basic understanding of the neuroscience of learning, with or without drug abuse involvement.

My own dissertation work shows that it is very likely that only a subsection of those exposed to nicotine will develop abnormal learning patterns associated with that drug. However, among those, learning about drug-related stimuli (as in “triggers”) continues in an exaggerated manner long after the other “normal” animals have stopped learning. That sort of difference can lead to a seriously problematic behavioral-selection problem whereby drug-related stimuli are attended to, and pursued, more so than other,  non-drug-related ones. If that sounds familiar, it should, since drug users continuously pursue drug-associated activities and exposures in a way that seems irrational to the rest of the world. It just might be due to such a mechanism and others like it.

Some important points about science in Dr. Dodes’ article

One very true fact about mental health pointed out by Dr. Dodes is that diseases like schizophrenia, which used to be explained simply as demon possession and evidence of witchcraft can now be, to a large extent, explained by the study of behavioral neuroscience and cognition. The same is true for bipolar disorder, depression, ADHD, and a host of other such conditions. In fact, the study of psychology has only been able to rely on technological advances that allow us to “see” brain function for a few short decades, leading to incredible advances in the field that I think will continue. The thinking that no such advances have, or will continue to be, made in the study of addiction is, in my opinion short sighted.

As I mentioned above, I don’t for a second think that the entire explanation for drug abuse and addiction will come from neurophysiological evidence. The doctor points out that “If we could take a more accurate image of addiction in the brain, it would encompass much of the history and many of the events that make us who we are.” I agree that we need to advance our technology as well as expand our understanding, but I think that to discount neuroscientific explanations completely is a big mistake.

Drug use isn’t the problem – Addiction and the question of legalization or decriminalization

I don’t keep it a secret that I used to have a very serious drug problem. If you haven’t read it by now, my drug use started early on along with a whole bunch of high-school friends. They smoked weed, I wanted to fit in, and the rest is history.

But guess what? Most of them turned out fine.

Drug use versus addiction

Only about 3 of us ended up screwing up a major part of our lives because of our drug use. One friend died 8 years later from AIDS after finding out way too late about an HIV infection he got from shooting up heroin. Another dropped out of college and never made it back. I developed a massive habit that only grew bigger when I shifted from simply using drugs to selling them. Then I got arrested, served a year in jail and went to rehab. That sucked.

The thing is that I don’t think drugs were the source of our problem.

I’m pretty sure I’m going to get my own genetic code sequenced some time in the near future in order to certify this, but I think we all had way too much of the impulsive, rush-seeking in us to allow the rules of society to keep us down. If it wasn’t for the drugs, something else would have probably gotten us sooner or later. I know that, to date, my own love for speed (as in miles per hour) and motorcycles already got me in 3 pretty serious accidents.

What I know now is that once you start using drugs on a regular basis the issue of how you got there no longer matters. Your brain controls your behavior and when drugs control your brain, you’re out of luck without help.

Is the answer legalization or decriminalization?

I think legalization is a mistake. Making a drug legal gives the impression that the state sanctions its use. Heroin, cocaine, crystal meth, ecstasy, and yes, even marijuana cause problems for people. I think that sending any other message is dangerous.

It’s not a coincidence that most people with substance abuse problems in this country (about 15 million) are pure alcoholics. Want a guess at the second biggest group? The marijuana dependent group is about 5 million strong. The rest of the drugs pick up only a few millions in total. Any move towards the legalization of any new drugs will most likely increase their use and therefore the number of addicts.

Still, decriminalization could be the answer. I’ve been meaning to write a post about Portugal’s decriminalized system for a while and haven’t gotten around to it. The bottom line? People found with illegal drugs are given a ticket and sent before a committee. The more visits one has in front of the committee the more forceful the push towards treatment. Still, unless a drug user commits another crime aside from the  possession of drugs they aren’t sent to jail.

As it stand right now, 30%-40% of our prisoners are in for simple drug offenses. That means not only billions in wasted incarceration costs every year, but also billions and billions more useless dollars thrown away at future sentences, court costs, and more (health care, probation and on and on). As it stands now recidivism rates, especially within the addict population are at 70% or higher! Unless these people get treatment, they will go back to jail! It’s that simple. Really.

So what should we do?

Many people aren’t going to like my view point. Those of us in the addiction field are supposed to scream as loudly as possible that drug are bad and that their eradication should be a major goal of our system. I disagree. Sue me.

I think we need to put the money we’re putting into jailing drug addicts into treatment. Even if it saves no money in the present (it will) we’ll be seeing huge savings over time as less of these people go to jail, more of them earn wages and pay taxes, and less of them make wasteful use of other resources like emergency rooms and social services.

And guess what? It will make our society better. We’ll start taking care of our citizens instead of locking them up. We’ll be showing Americans that we believe they can overcome rather than telling them we’d rather see them rot in jail than help them. We’ll be cutting down the number of single parent households and along with them god only knows how many more seemingly endless problems.

That’s my story, an I’m sticking to it.