From Alcohol to Opioids, Can Doctors Successfully Treat Addiction?

Bret S. Stetka, MD

Disclosures

February 12, 2020

Editorial Collaboration

Medscape &

Lloyd Sederer, Adjunct professor in the Department of Epidemiology at the Columbia University School of Public Health

As former chief medical officer for the New York State Office of Mental Health, psychiatrist Lloyd Sederer has firsthand experience battling our country's rising rates of addiction and drug overdoses. Sederer, who is also an adjunct professor in the Department of Epidemiology at the Columbia University School of Public Health, recently spoke with Medscape about addiction neuroscience and how clinicians can approach substance abuse and misuse in their patients.

Addiction has pervaded human culture since civilization began, and probably long before that in hunter-gatherer societies. How do you define addiction and why is it so pervasive in humans?

There is no society on earth that does not use intoxicants. In order for us to understand addiction, we have to understand why people use drugs. And the reason is actually very basic: People use drugs because they work. They are powerful and immediate in terms of affecting people's physical pain, psychic pain, turmoil, trauma, even just transporting them away from the everyday grind. That is what drugs do.

That is why they are so popular. They work until they don't work anymore. But any approach to addiction needs to start with an appreciation that people are using the substance—opioids or whatever it is—because it serves them. It's the best solution that they have found to address their pain or problem, and as doctors and clinicians, we're in a position to help people suffering from addiction find other solutions.

These days, among drug addictions, we hear mostly about the opioid and heroin epidemic. This problem is not new, but what is contributing to the continued rise in opioid overdoses?

The most troublesome marker of an epidemic is death. Opioid-related deaths continue to increase every year despite our interventions—we have not caught up with it. It's quite ubiquitous. There has been a lot of recent focus on opioids among middle-aged, high school–educated men; they have spent their lives in the trades so they have arthritis, back problems, and pain and are jobless with little prospects for their kids. This is the kind of environment that invites the use of opioids as a solution to feel better.

We see opioid use in the Midwest, the South, and New England; we're also now seeing an increase in methamphetamine use among opioid users. But opioids remain a huge problem in cities, inner cities, and among people of color, and also with soldiers and vets coming back. It's all over the place and the conditions make a difference. Conditions of scarcity, the experience of trauma, and hopelessness about the future are all risk factors that breed addiction because people are in pain and are looking for a solution.

Like Churchill said, we need to do the right thing.

What approaches to addressing addiction have clinicians and policymakers tried in the past?

As Winston Churchill said, "You can rely on Americans to do the right thing after they've tried everything else." That is basically the history of how this country has handled addiction epidemics. Remember prohibition? That was a huge failure (and a huge opportunity for the mafia). Another is criminalization of drugs. We've loaded our jails and prisons disproportionately with people of color because of criminalization related to substance use. This has done nothing to reduce the epidemic.

Another thing we've got wrong is interdiction—capturing drugs at the border. Time and time again we try it, and time and time again it fails. If people want them, drugs will find their way in. These are supply-side approaches.

Another approach is exhortation. Exhortation is when we say to somebody, "Don't you know that this is destroying your life? Don't you know that you are losing your job?" This has absolutely no effect. In fact, it usually drives a person away.

These are four approaches that we need to stop. Like Churchill said, we need to do the right thing.

What approaches to treating addictions have worked? And what is the role of medication?

To understand how we need to treat addiction, it helps to take a tour of the brain. There are four specific brain regions in particular that are involved in addiction. If we can touch those areas in one way or another, we can make a difference. We can better combat addiction and help people toward recovery.

The first is the reward center, the ventral tegmental area and nucleus accumbens. This is where dopamine is released in response to pleasurable experiences. It fires like an accelerator, mobilizing the brain toward pleasure seeking. We have very effective US Food and Drug Administration–approved interventions that act on the reward center. We can quell cravings with a medication called buprenorphine, an agonist which is often life-saving in that it prevents overdoses. Then we have antagonists which prevent somebody from having that dopamine burst. The two antagonists are naloxone, which is a lifesaver when someone is in an overdose, and naltrexone, which is best delivered in monthly injections for abstinence maintenance. These are the medication-assisted addiction treatments. At the moment they are really underutilized.

The second addiction center is our memory center, the amygdala and hippocampus. This is where we encode the memory of, "Boy, that felt really good." Remember Pavlov's dogs? He trained dogs to salivate to the bell, not to food. This is a conditioned response, and conditioned responses are among the strongest, most powerful risk factors for relapse. If someone with an addiction who is in recovery has a friend who calls and is high, this could be a cue for relapse triggered by the memory center. They see a drug deal going down on the street, Prince dies of an overdose. These are all cues. We have approaches, particularly cognitive-behavioral therapy, that are effective in helping people not respond to those cues and helping them prevent relapse.

The third center is the orbital frontal cortex. This is where neuroscientists believe motivation resides. Motivation means, "Oh, I really liked that stuff. I want more of it." How can we tip the balance in somebody? We have techniques called motivational interviewing and motivational enhancement which are readily learned, not just by addiction doctors or psychiatrists, but by all doctors because it's an approach of getting behind the patient's need and helping the patient begin to seek help.

The fourth center is our prefrontal cortex. This is where we can put the brakes on things. The problem is, it's not a very powerful brake. So how can we enhance it? Support groups, 12-step groups, individual psychotherapy, and family interventions are all reinforcers of the prefrontal cortex and can be effective in helping patients overcome their addictive urges.

If we intervene at each of these four areas, we're giving somebody much more of an opportunity to recover. These are additive interventions.

There has been a resurgence in studying psychedelic compounds for a variety of mental health disorders, including posttraumatic stress disorder and severe depression. Is there a role for psychedelic compounds in treating addiction?

It's one of the most promising approaches that we have. Psilocybin is found in magic mushrooms, but it is also being synthesized and shows promise. There have been a lot of studies using it in people with terminal illness, and it's approaching use for problems such as addiction, severe depression, and obsessive-compulsive disorder. We do not have any other treatment or intervention in psychiatry and medicine where one intervention—one trip—actually changes how somebody feels.

This has been proven in very large studies in people who are in distress about dying. They take one or two trips and it affects the default mode network, a batch of inhibitory centers in the brain. Psilocybin inhibits the inhibitory centers. It releases our minds to appreciate that we are part of a universe, [and makes us feel] awe and wonder the way that we did when we were children. And that has a tremendously transformative effect on a whole variety of conditions. I'm not suggesting that you or anybody go out and get a hold of some psilocybin tonight, but instead that we keep an open mind to it. Psychedelics have been prohibited in research since the '60s, but they are coming back and may be the most promising nonaddictive, one-time treatment we have.

What messages do you have for Medscape readers?

Thank you for asking that question. There are a couple of important stances that we need to have as doctors, as clinicians, as people working with families. The first is to be nonjudgmental. The moment that we start to get judgmental—that we take the attitude that there is something bad or wrong about a person—we lose them. That person runs away from us and then we don't have a patient or someone to ally with in terms of making them successful in getting over their addiction.

The second message, and maybe the more important of the two, is having hope. We see that people who have addiction to opioids or alcohol have relapses. These are chronic, relapsing conditions, and each time a person experiences a relapse, it depletes them of their own confidence. Their family begins to wonder whether this is ever going to change. Their clinicians wonder if they can stand by the person. That is the moment where we have to keep hope alive because there is overwhelming evidence that, over time, people recover from addictions to alcohol, opioids, even tobacco. But we don't know when. So, when those relapses occur, we need to keep hope alive.

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