October 14th, 2012
Quitting smoking is hard, but that suggestion probably isn’t terribly exciting all on its own since most of our readers probably knew it already. Still, while we’ve talked about quitting smoking using nicotine replacement and medication, we haven’t really touched the subject of all those people out there who just decide to give quitting smoking a try one day without those patches, gums, or pills.
Since something like 95% of those who try their hand at quitting smoking relapse within one year, and most of these people try to quit unaided, I think this is an important topic to touch on. Fortunately, recent research conducted in the U.K. tried to assess the personality and cognitive aspects that end up predicting who will succeed, or fail, in their quit attempt.
The effects of expectation, motivation, and impulsivity when quitting smoking
Quite a bit of research has already shown that when smokers are trying to quit (so we’re talking early on during abstinence), their brains react differently to stimuli in the environment depending on the relationship between those stimuli and nicotine. Stimuli that aren’t associated with smoking (or some other form of nicotine intake) get less attention and show overall less activation of important brain circuits while nicotine associated cues light up the brain just as if nicotine was on board (even though participants were drug free at the time). Essentially, if a stimulus predicts getting a hit, the brain gets smokers to pay attention to it so that they can do whatever is necessary and get a little drug in. Throw in some of that reduced ability to control behavior that we talk about so much (like impulsivity), and which is common not only in smokers but in users of almost every other drug (heroin might be the exception) and you have a recipe for disaster, or at least for a good bit of smoking relapse. And yet if we want to fight the horrible health consequences of cigarettes, then quitting smoking has to be made easier, which nicotine replacement and medications like bupropion have done to some extent.
As part of this equation, knowing the specific predictors of early relapse in people who are quitting smoking may be useful so that professionals planning smoking interventions can do a better job of targeting the most important factors. The study recently published the journal Psychopharmacology tried to assess the relationship between the severity of smoking, the above-mentioned personality factors, and the success of the quitting attempt.
The cool thing about this study is that the 141 people who participated were assessed on a whole set of these cognitive tests twice – once after a smoking free night and a nicotine lozenge and another time after a smoking free night followed by a nicotine-free lozenge. While they couldn’t tell which was which, the procedure gave the researchers an assessment off how different participants’ reactions were with or without nicotine on board. Following the assessments participants were directed to begin their attempt at quitting smoking. While they were asked not to use nicotine replacement options or other medications, they were allowed to use any other resource available and were given a set of information pamphlets that explained expected side effects and likely difficulties during the quit attempt. They were then followed up after 1 week, 1 month, and 3 months. Quitting was identified as minimal smoking (less than 2 cigarettes per week) and was verified both by self report and cotinine testing. There was a small financial incentive to quitting, with people who relapsed after a week getting only £40 (about $60) and those who made it through month 3 getting £150 (about $250), though I’m pretty sure that if $200 was enough to make people quit we’d have just paid up already…
The first thing to note in the results was that 24% of the participants were still not smoking at the 33 month followup. This seems to be about on par with the usually low success rates at 1 year though I’m sure this research group will try to continue following these participants at least up to the 1 year mark and hopefully produce another paper.
The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interfering with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After the 1-week follow-up, at the 1 and 3 month assessment, the odds of quitting had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.
The take-home: Quitting smoking is hard for different reasons in the first week and later on
If you’ve ever tried to quit you’ve been told you that the first week is the hardest and that once you make it through that the rest is a piece of cake. While this research doesn’t necessarily support that notion, since about 25% of the sample relapsed between each of the followups, it does seem to indicate that the reasons for relapse change after that first week.
It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking seems to be associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward.
Overall, these findings suggest that the cognitive function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.
Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can reduce relapse numbers at 1 week we can have a more gradual fall-off for the following month resulting in significantly higher quit rates.
Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medications like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?
Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.
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The first thing to note in the results was the 24% of the participants were still not smoking at the 33 month followup. This seems to be about on track for the normally low success rates at 1 year though I’m sure this group will try to follow these individuals up at that point and hopefully produce another paper. The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interruption with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After that point, at the 1 and 3 month follow-ups, had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.
The take-home: Quitting smoking is hard for different reasons in the first week and later on
If you’ve ever tried to quit you’ve heard someone telling you that the first week is the hardest and once you make it through that the rest is a piece of cake. Well, this research doesn’t really support that notion since about 25% of the sample relapsed between each of the followups, but it does seem to indicate that the reasons for relapse change after that first week. It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking was associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward. Overall, these findings suggest that the brain function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.
Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can bring the relapse numbers down at 1 week we can have a more gradual fall-out for the following month resulting in significantly higher quit rates. Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medication like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power that nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?
Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.
|Posted in: Drugs, Education, Tobacco
Tags: abstinence, activation, brain function, bupropion, cognitive, cognitive interference, cotinine, expectation, experiment, impulsivity, medication, motivation, nicotine, nicotine assocciated cues, nicotine associated, nicotine replacement, quit, quit attempt, quitting, quitting smoking, quitting smoking hard, relapse, research, smokers, smoking
April 11th, 2011
A new article just published in JAMA (see here) reports a strong relationship between high-dose opiate prescribing and accidental overdose deaths. The authors focused on a sample of Veterans and found that those prescribed more than 50mg of morphine per day, or the equivalent of other opiate drugs, we much more likely to die of such overdose than patients being prescribed lower doses. Fortunately, only about 20% of the patient-months (a measure of how many people were prescribed a specific dose for how long) were prescribed these high doses but the rate of overdose for this group was 3 to 20 times higher! Read the rest of this entry »
|Posted in: Education
Tags: accidental death, Alcohol, benzo, benzodiazepines, Drugs, JAMA, marijuana, medication, Medications, nicotine, opiate, opiate presciption, overdose, overdoses, pain, patients, prescribed, prescription, veterans
February 22nd, 2011
ADHD In children and adults – Symptoms and tests
Children with attention deficit hyperactivity disorder (ADHD, formerly known also as ADD) are classically seen as the kids in class who have trouble staying in their seats and paying attention during long lessons. Underlying these problematic behaviors is a confluence of factors, with evidence pointing to genetics, neural function, and environmental factors (including parenting and lead exposure) that can all affect ADHD behavior. Many children diagnosed with ADHD seem to simply “grow out” of their symptoms. They may learn particularly effective strategies for managing inattention and disorganization (I myself am a notorious list maker), or learn to control some of the fidgeting and restlessness or channel that energy into sports or other activities. Read the rest of this entry »
|Posted in: Education
Tags: ADD, ADHD, attention deficit hyperactivity, attention deficit hyperactivity disorder, children, children adhd, high value, high value wrods, hyperactivity, hyperactivity disorder adhd, impulsivity, inattention, marijuana, memory, memory capacity, nicotine, planning, smoking, substance abuse, value, value words, words
January 17th, 2011
If you care about addiction you’re going to want to read our weekly update from across the globe. It’ll make you smarter – promise (at least when it comes to alcohol and drug abuse issues)!
Drug Abuse – Vaccines to treat addictions, and Sniffing Bath Salts
Medical News Today-A biochemical breakthrough by researchers at Cornell produces a unique vaccine that combines bits of the common cold virus with a particle that mimics cocaine. Researchers believe the vaccine could be tailored to treat other addictions, such as to nicotine, heroin, and methamphetamine. While similar to other vaccine discussions we’ve had here, the method and generalizability here are of specific interest.
BBC News-Publicity of scholastic journals back fired on Dr. David E. Nichols as drug makers profit off his research findings. Dr. Nichols says while some drugs can be manufactured in the kitchen the scale to which these “legal high” drugs are produced indicates some small companies are involved.
Fox News.com– A new “drug abuse” trend of sniffing bath salts to try to get high is emerging in Louisiana and is creating a issue for the Louisiana Poison Center. It appears that more kids are attempting this “trend” resulting in of paranoia, hallucinations, delusions, as well as hypertension and chest pain. The problem’s gotten so bad in the state that the Governor had to make the active ingredient in the bath salts illegal. The bath salts contain a chemical called “Mephadrone and Methylenedioxypyrovalerone or MDPV, which is known to be a stimulant that may also cause paranoia and hostility.
Alcoholism – Studies and Personal Stories about alcohol
Science Daily- A new study has been conducted which shows that midlife alcohol consumption may be related to dementia which is often assessed about 20 years later. The study found that both abstainers and heavy drinkers had a greater risk for dementia and cognitive impairment than light drinkers. Again, it seems that drinking no-alcohol is associated with risk factors and outcomes that are not as ideal as moderate consumption and somewhat similar to heavy drinking.
Counselor Magazine Blog- Everyone loves watching a good and inspirational movie from time to time. The new movie “Country Strong” deals with many issues that everyday individuals face such as alcoholism, mental illness, co-dependency, ageism, and grief. These are elements that a person goes through when they are dealing with alcoholism. The movie depicts that alcoholism is a family disease and does not affect just the alcoholic. Another great point that the movie shows is that if there are underlying issues that are often not resolved that relapse is very common.
Prescription Drug abuse and death
Reuters- A new study has found that an increasing amount of individuals are dying from abusing and misusing prescription drugs as well as illegal drugs. In recent times deaths from “accidental poisonings” or overdose are more than ten times higher than they were in the late 1960s. This increase in drug deaths is higher across almost all age groups than it was in previous decades, especially amongst white Americans.
Chicago Sun Times- Prescription drug abuse is a growing problem in our country, and deaths from unintentional drug overdoses in the US have increased five-fold over the last two decades. The drugs that are commonly causing these deaths are particularly painkillers such as OxyContin (oxycodone), Vicodin (hydrocodone) and fentanyl. What many individuals do not realize is prescription drugs can be much more deadly than illegal drugs. In 2007 alone, abuse of prescription painkillers was responsible for more overdose deaths than heroin and cocaine combined. Prescription painkillers, most of which are opioids, are synthetic versions of opium used to relieve moderate to severe chronic pain, however in large and excessive quantities, they can suppress a person’s ability to breathe and are very dangerous when they are mixed with alcohol or other drugs.
|Posted in: Education
Tags: about addiction, addiction, Alcohol, alcoholism, bath salts, BBC, cocaine, Country Strong, crystal meth, death, drug, drug abuse, Drugs, heroin, illegal drugs, methamphetamine, new study, nicotine, opiates, overdose, prescription, prescription drug, prescription drug abuse, prescription drugs, sniffing bath salts, stories, vaccine
January 11th, 2011
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. Read the rest of this entry »
|Posted in: Drugs, Education, prevention, Tobacco, Treatment
Tags: biological heredity, cancer, cancer sticks, death, died lung cancer, dying lung cancer, genetic, heart disease, heredity, high, high heredity, high risk, low biological heredity, lung, lung cancer, lung cancer death, nicotine, risk, risk factor, risk factors, smokers high heredity, smoking, tobacco, who
November 21st, 2010
By Christopher Russell
In 2003, the US Department of Health and Human Services (USDHHS) set a goal of reducing cigarette smoking among US adults (18 years +) to 12% by 2010, which if achieved would halve the adult smoking prevalence rate reported in 1998 (24%). Achieving this current smoking reduction may depend on the extent to which health care providers (doctors, nurses, and such), who are charged with promoting smoking cessation and dissuading the uptake of smoking among to the general public, are themselves current smokers. For example, health care providers’ anti-smoking and pro-quit messages will likely be more persuasive and credible to the smoking public when the messengers practice what they preach about smoking. Such messages may also better motivate quit efforts if the health care providers have had personal success in quitting smoking using the methods and information they are now endorsing. Conversely, smokers may intuit that when health care providers advise quitting but continue to smoke themselves despite enjoying ready access to all the resources, information, and tools which should facilitate quitting, then smokers, without this luxury of access to education and resources, will be even less likely to successfully stop smoking.
Therefore, significant strides in increasing the number of quit smokers and never smokers in the general population may somewhat depend on reducing current smoking among the health care providers who act as both educators and trusted role models to the general public. It is therefore important to know how the prevalence of smoking among health care providers compares to the prevalence of smoking in the general population, which health care providers are charged to reduce.
Current smoking among health care providers
Using US population survey data, a recent study published in Nicotine and Tobacco Research reports estimated changes in the prevalence of current smokers, former smokers, and never smokers among eight groups of health care provider – physician, physicians assistant, registered nurse (RN), licensed practical nurse (LPN), pharmacist, respiratory therapist, dentist, and dental hygienist – between 2003 and 2006/07. While the majority of these health care providers have never smoked a single cigarette, the authors report that, in 2006/07, approximately one in every five licensed practical nurse (20.55%) and respiratory therapist (19.28%) was a current smoker. Current smoking rates among LPNs and respiratory therapists were marginally higher than the rate of current smoking in the general population (18.01%) and near double the Healthy People 2010 goal of 12% current smoking in the general population. Four groups of health care provider – physicians (2.31%), dentists (3.01%), pharmacists (3.25%), and registered nurses (RNs) (10.73%) were all on course to be below the 12% prevalence goal. Furthermore, seven of these eight health care groups in 2006/07 showed higher quit rates than was found in the general population (52%) – only LPNs had a lower quit rate (46%). However, the concern from a public health perspective, is that while current smoking rates among these health care groups and in the general population have dropped considerably when compared to data reported in a similar cohort study in 1990/91, these decreases in current smoking appear to have leveled off in recent years; current smoking did not significantly decrease in any health care profession or in the general population between 2003 and 2006/07.
An important methodological note about this study is that results reflect weighted population estimates (WPE), not actual data. WPEs allow researchers to make inferences about an entire population group given only some data for that group simply by scaling up the actual data, (i.e. data reported by around 4000 health care providers in each collection year were used to estimate smoking statuses for over 2 million actual individuals). Of course, this technique likely overgeneralizes behavior in the sampling group, but is nonetheless a standard, valuable tool of health epidemiologists when they want to make inferences about how entire populations are behaving. Indeed, many of our health policies have derived from WPEs.
Current smoking among licensed practical nurses
Among the most important findings of this study is that one in five licensed practical nurses in the US is currently smoking. Of the estimated 754,000 LPNs in the US, this equates to roughly 155,000 current smokers in this profession, illustrating that health campaigns designed to depict smoking as socially unacceptable, readily available access to education and empirical research on the health consequences of smoking, working in smoke-free health care campuses, and being charged with task of persuading clients to stop smoking, all appear insufficient to reduce current smoking among LPNs and respiratory therapists to below the rate of current smoking in the general population.
In contrast, 10.73% of registered nurses are current smokers. The discrepancy between LPNs and RNs begs two questions: why are LPNs nearly twice as likely as RNs to be current smokers, and should we expect RNs will be better able than LPNs to persuade current smokers to quit and dissuade smoking to would-be smokers? Certainly, researchers should now ask whether a health care provider’s smoking status is related to his ability to produce cessation in health care recipients. If we assume that health care workers have a central role to play in producing mass behaviour change of whatever kind, then it is plausible to reason that reducing smoking prevalence at the national level will significantly depend on first reducing smoking prevalence among health care providers, our first responders to public health concerns. Testing this hypothesis seems the logical extension to capitalise on these smoking prevalence data.
Why are licensed practical nurses twice as likely as registered nurses to be currently smoking?
If one’s smoking status is important for persuading change in others, we need to know why smoking is more prevalent among LPNs than RNs, why LPNs have a lower quit ratio than the general population, and so, which factors should be addressed to reduce current smoking among LPNs to below the 12% level. The authors of this study suggested that LPNs’ fewer years in education and lower annual income may be associated with their current smoking status since they mirror socioeconomic factors known to associate with higher smoking rates. Comparably large proportions of LPNs and RNs are female, thus ruling out an important effect of gender. In my opinion, given that nicotine produces positively reinforcing psychoactive effects and that smokers commonly report smoking to alleviate affective distress, another consideration may be that LPNs and RNs differ in their exposure to stressful work events and environments, and/or differ in their emotional reactivity and sensitivity to these events, and/or differ in their bias to perceive work events as stressful. Furthermore, as smoking staus is known to be associated with socioeconomic status and socioeconomic status is known to be associated with many health and wellbeing factors including stress, then stress may be important both as a direct influence on smoking behavior and indirectly as a mediator of the effects of socioeconomic variables on smoking behavior. A good start to exploring these hypotheses would be to simply ask LPNs and RNs of their main reasons for smoking in short open-ended interviews; if reliable differences in smoking attributions emerge then we may begin the harder task of counseling LPNs to think of smoking in ways which alter their reasons to smoke, the reasons which may currently be maintaining smoking in one in five LPNs.
Questions for the reader; please give your comments below
1) Why do you think current smoking is more prevalent among licensed practical nurses than in the general population?
2) Does a health care provider’s status as a current smoker make him/her more or less able to persuade smoking cessation in others?
3) Will reducing current smoking nationally depend on reducing current smoking among health care providers?
U.S. Department of Health and Human Services. (2003). Healthy People 2010, Retrieved from http://www.healthypeople.gov/
This report is free to download at: http://www.healthypeople.gov/document/pdf/uih/2010uih.pdf
Sarna, L., Bialous, S. A., Sinha, K., Yang, Q., & Wewers, M. E. (in press). Are health care providers still smoking? Data from the 2003 and 2006/2007 Tobacco Use Supplement-Current Population Surveys. Nicotine and Tobacco Research.
|Posted in: Education, Tobacco, Treatment
Tags: current, current smokers, current smoking, doctors, education, general population, health, health care, healthcare providers, licensed practical nurses, nicotine, nurses, prevalence, quit, quitting, quitting smoking, smoking
October 29th, 2010
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.
|Posted in: Education, Opinions
Tags: addiction, alcoholism, ALDH2, Brain, disease, DRD4, drug, drug related, drug related stimuli, drug use, drug users, environemtn, evidence, gambling, gene, genetic, genetics, impulsivity, Insula, mechanism, metabolism, neuroscience, nicotine, OFC, personality, PFC, pleasure center, predisposition, reiak-taking, science, sex addiction, social influences, treatment, vietnam