Conversation with an addiction expert – Chris Evans, opiate master

Here at A3 we have already armed you with over 400 articles’ worth of knowledge on a wide variety of topics such as sex, gambling, and alcohol addictions. Our articles have in the past been written mostly by the team members at A3 (with a few notable guest pieces) based upon research findings and personal experience. Now we decided to expand our reach and get a different kind of perspective, broadening the knowledge we are able to provide to you and providing you expert opinion on commonly asked questions that the public often has about addiction.

Chris Evans, Ph.D.Our first expert is Christopher J. Evans (PhD) who is a professor in the David Geffen School of Medicine at UCLA. In addition to his work at the school of medicine, Evans is also a part of the UCLA Opioid Research Center, and Shirley and Stefan Hatos Center for Neuropharmacology. Evans is particularly interested in opioid drugs and is currently working on discovering the differential signaling at opioid receptors. Some of his past work has touched on withdrawal and on the theory of opponent processes involved in withdrawal, a counter to the theory that a rebound from over-activation is the whole story in the withdrawal process.

11 answers from an addiction expert

1 ) How did you become interested/specialized in addiction research?

Following my PhD studies in protein chemistry where I studied enkephalins and endorphins – opioids in our brains.

2 ) If you had to sum-up your “take” on substance use disorders in a few sentences, what would those be?

A sad disease where an obsession develops for an abused substance that creates fluctuating hedonic states. Increasingly there is decline to a negative hedonic state that can only be relieved by the abused drug.

3 ) What have been the most meaningful advances in the field in your view over the past decade?

The development of genetic models and imaging to begin to tease out circuits involved in liking a drug, withdrawal from a drug and drug craving.

4 ) What are the biggest barriers the field still needs to overcome?

Resolving the interaction of genetics and environment in creating phenotypes such as depression and anxiety leading to susceptibility to substance abuse.

5 ) What is your current research focused on?

Opioid drugs and the differential signaling at opioid receptors.

6 ) What do you hope to see get more research attention in the near future?

Inhalants and genetic studies aimed at behavioral phenotypes relevant to obsessive substance use .

7 ) How do you think the Health Care reform recently passed will affect addiction treatment?

It appears that there will be more attention paid to substance use disorders.  With increased access to health services the treatment of substance disorders is likely to become more of a focus.

8 ) What is your view regarding the inclusion of behavior/process addictions in the field?

They should be included.  Many of the process addictions have the same co-morbidities with substance use disorders and these are what need to be understood.

9 ) What is your view on the relative importance of Nature Vs. Nurture?

They are intertwined ? the interaction of nature with nurture directs our behaviors so neither should be considered more important than the other.  Either nature or nurture can be a disaster for a life.

10 ) In your view, what are some of the biggest misconceptions that the public still holds about addiction?

That addiction is driven solely by the acute rewarding effects of the drug and not by subsequent adaptations induced by the drug including dysphoria or memories of drug action.

11 ) What is the most common question you get from others (public?) when it comes to addiction?

Is marijuana harmful for you?

And there you go, a set of untouched, unedited answers about addiction and addiction research diretly from one of the masters. We hope you’ve enjoyed this and that you’ll look forward to more as All About Addiction continues a monthly exposure of what addiction research looks like from within.

People, places, and things – How important are drug-related triggers for addiction relapse?

In cognitive behavioral therapy they’re a big part of the “Five W’s” = When, Where, Why, With, and What. In the various 12-step programs they’re simply referred to as “People, places, and things.” But no matter how you refer to them, drug-associated cues, or “triggers” as they are more commonly known, obviously play a big role in reminding addicted individuals about their drug-seeking behavior, and they are often enough to restart old behavior, even among those who have been abstinent for a while and especially when unprepared for their effect.

Different triggers to reactivate old behavior

Research on relapse (what researchers call reinstatement) has long shown that there are a number of things that can return a person, or an animal, to drug seeking after they have been abstinent for a while. Stress, small drug doses, and the presentation of triggers are all very capable of doing this, even after months of abstinence and likely even years. It’s probably not surprising that giving drugs to an abstinent person can make them want the drug again. In fact, I would venture to guess that most readers believe that this is the most powerful way to induce a relapse (assuming the initial exposure was out of a person’s control and doesn’t count).

Well, recent research suggests that in actuality, triggers, or those people, places, and things, might be more powerful or at least longer lasting relapse risks than even taking drugs!

Triggers, not drugs, are shown to be longest lasting relapse risk

Researchers in Japan trained mice to press a lever for meth, getting them to poke their nose into a hole 60 times for a total of 30 meth administration per three hour session. Every time they poked their nose in the right hole they got a shot of meth and a little light above their nose-poke hole went on (this will become the trigger in the end). Once they were doing this reliably the researchers took away the meth and the animals learned, within 10-20 days, that pressing the lever no longer got them a drug and reduced their number of presses to less than 15 presses per session.

After all this the researchers gave the mice an injection of meth 30 minutes before putting them back in the box – leading the mice to start pressing again for the drug even though in the previous session they has pretty much stopped pressing knowing that no drug was coming. Obviously, the drug injection caused the mice to relapse back into their drug seeking. But, as you can see from the figure below (on the left side, the right side shows that the mice didn’t poke their nose into a hole that did nothing as a control), this little trick only worked once, and the next time the mice were given a shot of meth before being put in the box (after once again being taken through extinction training teaching them that pressing the lever did nothing), they didn’t press the lever any more and just around not doing much.

For the following part of the study the researchers once again took the animals through extinction training (and once again the mice stopped pressing the lever for meth) and then in a following session reintroduced the little light that used to go on every time the mice originally got meth. Just like they did with the meth the animals immediately went back to pressing the lever like crazy, hoping that now that the light was back, so was their meth. Just like with the drug relapse experiment above, the researchers repeated this whole process over two months later, only this time, the little light managed to re-trigger the lever pressing again, unlike the one-trick-pony meth. Seeing this, the researchers went for broke and tried another run of this with the same animals, now following up five months after the last time the animals received meth when they pressed the lever. Again the little light got the animals to increase their pressing, only this time it was a little less impressive than the first two tries (but still significantly higher). All in all, the little light managed to restart the lever pressing by the mice three times and a full five month after the meth-relapse experiment had failed!!!

Conclusion, thoughts, and implications about triggers, relapse, and addiction

In a completely different article I’d written that researchers found a number of different patterns of relapse among alcoholics who went to rehab and that in fact, the vast majority of those who did relapse never went back to the kind of heavy drinking that characterized their earlier problem (see here for One is too many, a thousand not enough). While this research touches on a different aspect of relapse, it once again challenges our thinking about the crucial factors in relapse prevention among addicts. Everyone knows that triggers are important, but the fact that they are at least as powerful and apparently longer lasting dangers than even being re-exposed to the addictive drug is a novel one. Still, this isn’t very surprising given the very long-lasting impact of drugs of abuse (especially stimulants like crystal meth) on learning mechanisms. In my opinion, and based on my own experience, those changes are essentially permanent and the only thing that makes an ex-user less likely to run back to pressing that drug lever when being re-triggered 10 years later is the life they’ve built, the experience they have, and the training they’ve undergone in reacting to those triggers. As you can see from the graph above, if a person runs back to the drugs and actually starts using again on that first, second, or third exposure to a trigger they are likely to start the whole cycle again, possibly making it ever more difficult to escape the next time.

Obviously preventing trigger-induced relapse should be a major strategy of addiction treatment and indeed, from CBT relapse prevention strategies to groundbreaking medications that have been shown to be effective for relapse rate reduction (like Vivitrol, Buprenorphine, Bupropion, and more), there is quite a bit of effort going exactly that way.

Citation:

Yijin Yan, Kiyofumi Yamada, Atsumi Nitta  and Toshitaka Nabeshima (2007). Transient drug-primed but persistent cue-induced reinstatement of extinguished methamphetamine-seeking behavior in mice. Behavioral Brain Research, 177, 261-268.

Understanding addiction research will require us to argue our corner but be flexible to change corners.

Hello everyone,

My name is Christopher Russell, I am a doctoral student in psychology at the University of Strathclyde in Glasgow, UK. My addiction research interests are wide and varied, but my core interests are in addiction theory (“why people do what they do”), the issue of freedom to control when using drugs, interpretations of addiction research evidence, and the use of licit and illicit drugs in the law.

Respect and rational debate of addiction research

Dr Adi Jaffe has very generously asked me to become a contributor to A3 and after reading about what A3 stood for (the mission and the abbreviation) and what Dr Jaffe is trying to achieve through A3, I am delighted to be a part of A3. Adi noted in a previous post that we do hold some different opinions about the nature and course of addiction. Above our differences, however, I respect that Dr Jaffe and I are able to debate addiction research rationally, respectfully, and vigorously without either of us resorting to ideological proclamations, disrespect for the alternative view, claiming a moral high ground or attacking each other’s moral character, or worst of all, name calling! Such people are hard to find in the academic world! The truth is that I, like Dr Jaffe, am still learning about addiction, and I’m not foolish enough to believe that my way is the way! If addiction research over the past 100 years has shown anything it is that a researcher would be foolish to hang his hat on any interpretation and proclaim it as fact – for example, for the past 200 years, masturbation was considered the most prevalent psychiatric disorder until it was replaced by drug use, and up until 1973, homosexuality was still diagnosed and treated as a form of mental illness! We must be willing to bend with the wind, to accept when addiction research evidence invalidates our beliefs, and to respond to falsifications by constructing models which stand up to our efforts to falsify them.

A3 and the fluid landscape of addiction research

The landscape of addiction research changes by about 50% each decade, as do many scientific ideas, so it is important that we all hold our beliefs about addiction lightly and be willing to consider that some dearly held addiction “truths” may not be as truthful as we had thought, perhaps hoped. Scientists are constantly revising what they thought they knew, changing their approach to measuring and conceptualising the problem, disseminating the latest findings to the public; like any good scientist, those who are involved with addiction, either personally or professionally, should always try to update their model, and sometimes, evidence can arise which causes us to question everything we thought we knew about the nature of a problem. Such evidence may require us to not merely adapt our exisitng models of the problem, but if called for, to abandon them in favour of more potent models which need not necessarily be liked or fully understood.

Hearing what addiction research is telling us, not what we want to hear

However, despite our pledges to be good scientists, our basic ways of thinking tend to get in the way of building better models of a problem. For example, a classic contribution of psychology research has been the finding that people prefer to try to discredit a new piece of evidence about a concept which doesn’t fit with their existing understanding of that concept rather than assimilate the new evidence into our understanding because it is cognitively easier to leave our belief structure as it is. This phenomenon is quite common in the addiction research community; some people just refuse to believe that addiction could be something other than what they had long thought it to be, and no amount of validated, replicable evidence to the contrary will move them to revise their beliefs. It is regrettably common that, for some, beliefs about addiction are based on an unwavering ideology rather than a science-grounded conclusion. Addiction researchers cannot afford to be this pompous, lazy, or inflexible; too many people are counting us to get the right answers to them, no matter who they come from or what form they come in. I know that my contributions to A3 are only useful to the extent to which they help get people from where they are to where they want to be. To achieve this, I must argue my corner but be willing to bend when the wind blows. We all must.

In the hope that I can be both teacher and student of A3, I believe that the value of my arguments will be measured by how well they hold up in the face of your most passionate, insightful criticism. Therefore, I invite all those who read my contributions to criticize, refute or support any of my arguments when you feel it is warranted. I will always try to give an intelligent answer and I swear to never resort to clichéd answers, bumper sticker answers, or the “it just is because it is” answer, which is in effect, no answer. And I will never resort to name calling (except when you really deserve it!).

I look forward to providing you with thought pieces, philosophical contributions, reviews of evidence, and most of all, interacting with you the readers, the lifeblood of A3.

Christopher

Biology versus Choice: Is a simple explanation of addiction enough?

At the recent Addictions conference, held in D.C. and sponsored by Elsevier, a well known academic publishing house, I got myself into one of those long debates with a fellow addiction researcher. The question we were debating was whether addiction is primarily biological or if it is mostly a matter of personal choice. We ran through research evidence, the notion of stigma, and more, making us late for the afternoon session of talks – but it was worth it.

My take on it was that one can’t separate biology from choice, a point I have made over and over (see my choice Vs. control talk), and that ignoring the biology of addiction is therefore impossible. My opponent across the stage (or lunch table as it were) was Christopher Russell, a graduate student at the University of Strathclyde in the United Kingdom who is a bigger believer in the choice view of addiction, along with people like Dr. Bruce Alexander of Rat Park fame and Dr. Gene Heyman who wrote “Addiction is a disorder of choice.”

I like good debates and at as far as I understand it Christopher and I ended-up agreeing that as usual neither biology, nor choice, do a good enough job of explaining a complex disorder like substance abuse and addiction. I’ve been making that point for a while, so I’m pretty comfortable with the final conclusion – Biology, environment, and choice (cravings) all factor into addiction as I understand it. Without understanding the machinery and how genetics and behavior affect it, I think the rest of the discussion is moot, but it is pretty much as pointless without addressing environmental influences and the role of choice.

I liked debating with Christopher so much that we’re going to be bringing him on a writer on A3. He’ll help us keep on top of the most recent addiction research and news while bringing in another voice on the topic that I think will help move our discussion forward. So please help me welcome Christoper Russell from the U.K., and look ahead for his contribution as well as a likely ongoing debate about the importance of biology versus personal choice.

Releasing the motivation bottleneck – Helping addicts by making recovery easier

My friend Patrick as SpiritualRiver reminded me of an issue that I think is somewhat obvious to many drug addiction researchers but may not be to others.

The way I see it, there is a specific reason behind much of the research into medications, or other interventions, that will help drug addicts in their transition to recovery:

If we can figure out a way to reduce the extreme hold that drugs have over addicts, we may just make it possible for a much larger proportion of them to get their life back and succeed in addiction treatment.

Long term drug use causes some serious alterations in the neurological functioning, and therefore the behavior, of substance abusers. As it stands, it requires a great deal of motivation, support, and perseverance to overcome a serious drug habit.

Still, if we can somehow make it easier, either by intervening earlier, or by somehow speeding up the brain’s recovery, or by creating the kind of functioning needed for the person to be able to make deliberate, informed decisions, we could just even the playing field a little. Right now, there are some medications out there that do just that, and as far as i’m concerned, regardless of what people say about substituting one addiction for another (which they do for methadone and buprenorphine), if we can get addiction back on the road to a functioning, contributing, life – that’s recovery too. Harm reduction is just that, a way to make people’s lives easier even if they can’t, or aren’t ready, to completely give up drugs. I for one don’t understand why so many people are insisting that it’s all or nothing. In case you haven’t figured it out, that’s not how life normally works, in recovery or anywhere else.

And by the way, that’s definitely not the only way to intervene – medication like modafinil and other pharmacotherapies that help addicts make better, less impulsive choices, also work; add to that bupropion (an antidepressant and a nicotine addiction medication that has a low abuse potential), as well naltrexone (good for opiate overdose but also for alcoholism treatment) and you begin to see that this area of treatment is getting better at providing solutions that are meant to supplement, not replace, traditional treatment modalities.

The end goal is to help the addict and as I’ve said before, I think we should use all our tools.

How doctors treat doctors with drug use problems: Addiction treatment that works

Physician Health Programs (PHP) are reporting an astonishing success rate when it comes to providing addiction treatment for addicted doctors:

  • Only about 20% of doctors ever test positive after being admitted to the program within a 5 year period.

  • More than 70% maintain their license and continue working within the same 5 year period.

These are the kind of addiction treatment results we want!

I’ve been saying for a long time that I believe in the theory promoted by Dr. McLellan, who until recently was the deputy-director of the Office of National Drug Control Policy (ONDCP). Doctor McLellan promotes a long-term view of addiction treatment, more like a chronic disease than anything that can be cured in a few visits (although this view only holds for some addicts).

I’ve also known for a while that the American Medical Association is supposed to be having great success at addiction treatment for addicted doctors. I’ve been meaning to contact someone at the AMA to find out how they did it. Now I don’t need to thanks to this recent bit of addiction research.

Addiction research on treatment for addicted doctors

A recent research article surveyed the vast majority of PHP’s and found that, not surprisingly, the things that we know work in addiction treatment do indeed produce results. The solution may not be easy, but it’s pretty simple:

  • Early detection and assessment brings the addicted doctor, their family members, colleagues, and employers together. Getting the problem out in the open early makes it easier to deal with than having to be secretive about it. The doctors get  an option, leave the profession or sign up for a 5 year treatment program to deal with their addiction.
  • Formal addiction treatment using the most appropriate and effective treatment centers In contrast to our criminal justice addiction pipeline, the majority of physicians (69%) receive 90 day residential treatment, while the rest receive intensive outpatient treatment. The PHPs also receive frequent status reports on each physician in treatment to assure adherence. To find treatment that works, use our Rehab-Finder.
  • Long-term support and monitoringAfter treatment, the physicians continue with aftercare that includes 12-step support, regular counseling meetings, and monitoring that includes random drug testing.

That’s it!  So simple yet so effective.

As addiction research continues to improve, I’m sure we’ll be able to bring these numbers up even higher than the 70% success rate currently reported. Still, you have to admit, 70% is amazing!!!

So if you want to know how to stop drinking and drugging, do like the doctors do and commit to long-term addiction treatment.

There are obvious differences between most addicts and the doctors in these programs (most people don’t have such a clear distinction between losing their livelihood and getting help), but the solution is most likely very similar.

More proof we need more money for addiction treatment:

We need to press our representatives to increase funding for addiction treatment and addiction research so that we can find the most efficient, yet effective, way to offer this kind of addiction treatment to the general population. By reducing the problems, we’d be able to cut into the $500 Billion a year drag addiction is putting on our economy. The effort will pay back for itself in no time.

Citation:

DuPont, R.L., Carr, G., Gendel, M., McLellan, A.T., Skipper, G.E. (2009). How are addicted physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment, 37, 1-7.

Like advancements in medical care and science? Then support animal research

There was a Pro-Test for Science rally on the UCLA Campus today.  The goal of the rally was to spread awareness about the utility of animal-research and to help combat extremists and prove to the community and world that the ethical use of animals for biomedical research is absolutely vital to the progress and success of advancements in science.

Many of the treatments that we discuss on this site are available because of extensive research with animals. In fact, many scientific discoveries have been possible largely because animal research is an available tool for researchers. Immunizations, medical treatments for Parkinson’s, Alzheimer’s, and diabetes treatments have all been advanced greatly through the use of biomedical research with animals. Of course, great care is always taken to ensure humane treatment of the animals used.  Animals prove a vital part of advancements in medicine, genetics and other research.

Biomedical scientists endure many trials in order to become experts in the type of research techniques we’re talking about here, including extensive schooling, years of training and of course many thousands of hours spent in a lab, all for the benefit of humanity.  They should not have to additionally endure the harassment of extremists and fear for their safety and the safety of their loved ones who often are caught in the middle.

Debate is healthy; discussion is good. But the harassment and terrorizing of researchers must stop if we’re to consider ourselves an open, educated, society. All biomedical researchers want is to better society by finding cures for the many things that plague our world today, so what everyone should really be doing is thanking them.

Co-authored by Jamie Felzer