Science Of Addiction: A JAMA Book Review

The Science of Addiction: From Neurobiology to Treatment

By Carlton K. Erickson, 288 pp, $32.
New York, NY, WW Norton Professional Books, 2007.
ISBN-13 978-0-3937-0463-1.

JAMA. 2007;298:809-810.

The term "addiction" commonly triggers stereotypic misperceptions about the compulsive, out-of-control use of illicit drugs resulting from a perceived amendable behavioral flaw. In 1988, the United States Supreme Court in a disputed decision declared alcoholism to be "willful misconduct." However, several decades of comprehensive genetic and neurobiological research have provided indisputable evidence that addiction is brain disease resulting from mesolimbic brain dysregulation that, if diagnosed in a timely fashion, can be properly treated. Addiction meets all characteristics of the disease concept, ie, (1) a clear biological basis; (2) unique, identifiable signs and symptoms; (3) a predictable course and outcome; and (4) the inability to control the cause of the disease.

In this context, Erickson's book provides a compelling overview of the "science of addiction" and superbly summarizes the state of the art of addiction medicine. In 10 easy-to-read chapters, the author guides the reader through basic neuroanatomy, neurobiology, and neurochemistry; the pharmacology of different drugs of abuse, including alcohol, depressants, and stimulants; current treatment algorithms; the strategies of addiction research; and the future outlook of the evidence-based research principles.

The text begins with a challenge of the terminology and characterization of "addiction," calling it unscientific, broad, too vague, and stigmatized. According to the author, the term provokes "pejorative misperceptions," and he uses the term "chemical dependence" instead to properly identify the impaired control over the drug use, the defining hallmark of this brain disease. He also suggests separating the colloquial term "addiction" from the scientific terminology of "chemical dependence," thereby not precluding its use but understanding its limitation. Erickson emphasizes that "the reluctance to define addiction as a disease stems partly from a desire to hold drug users accountable for their actions," and that "any approach that tries to understand addiction from a purist or unitary view misses other key components." Chemical dependence is a "compulsive, pathological, impaired control over drug use, leading to an inability to stop using drugs in spite of adverse consequences."

Drugs with a dependence liability not only produce a positive mood but trigger the mesolimbic dopamine system, resulting in an activation of the so-called "reward pathway." Neuroscientists believe that in some individuals the function of these neurotransmitter systems is disrupted due to genetic "miswiring," long-term exposure to a drug, or—more likely—a combination of genetic heritability, drug exposure, and environmental influences. This may explain why any drugs of abuse can induce dependence in susceptible individuals but not for every person who may use them occasionally or who has abused them during their lifetime.

The detailed review of the basic science of chemical dependence provides ample evidence that the dysregulation in the mesolimbic dopamine system constitutes the disease, just as poor dopamine function in the basal ganglia is the etiologic cause of Parkinson disease. Therefore, drug-seeking and drug-taking are only the symptoms of the disease, just as muscle rigidity and tremors are only the symptoms of Parkinson disease.

The author also provides a brief but comprehensive overview of the genetics of chemical dependence. Family, twin, and adoption studies demonstrate that genetic factors contribute to the risk of alcoholism. Scientists have identified some possible causative genes and certain risk genes which, in susceptible individuals exposed to drugs of abuse, may activate a cascade of neurochemical events leading to chemical dependence. The argument that chemical dependence is a brain disease, comparable to other brain diseases, begs the question about similar treatment approaches.

Erickson correctly emphasizes that any treatment approach cannot rely on pharmacological solutions alone. The treatment must be individualized and should take so-called harm reduction strategies, also known as harm minimization, into consideration. Such an approach includes methadone maintenance and needle-exchange programs that often ruffle the feathers of the proponents of abstinence-based programs.

In the last few years, new pharmacological treatments have broadened the opportunities for the outpatient management of patients with chemical dependencies. For example, anticraving, antirelapse, and abstinence-enhancing medications are now part of the treatment armamentarium for alcohol dependence and include naltrexone, acamprosate, and topiramate. The US Food and Drug Administration approval of buprenorphine for the treatment of opioid dependence extends the treatment outreach from federally approved methadone clinics to almost all physicians who have completed an 8-hour certification course.

In the remainder of the book, Erickson reviews the scientific methodology of addiction research and the exciting results of brain imaging studies in chemical dependence. These include positron emission tomography, functional magnetic resonance imaging, and single-photon emission computerized tomography. The imaging modalities illustrate that drug treatment as well as the anticipation of the active drug itself can trigger neurochemical changes and are valuable tools for studying the effectiveness and compatibility of interactional behavioral interventions and pharmacotherapy.

Unfortunately, the author has missed the opportunity to discuss the screening and brief intervention methods that can be incorporated into the clinical practice identifying patients at risk for chemical dependence. For example, the National Institute on Alcohol Abuse and Alcoholism has published valuable screening and brief intervention tools on its Web site1 that can assist health care professionals in risk stratification strategies for patients with chemical dependence. However, the book provides the knowledge that chemical dependence is a brain disease, and an understanding of this disease concept of addiction ensures that millions of individuals with chemical dependence can now receive appropriate and suitable treatments.

In summary, I recommend this excellent book as a "must-read" for any medical student, physician, or other allied health professional dedicated to the care of their patients with the treatable disease of addiction.

Financial Disclosures: None reported.

Bernd Wollschlaeger, MD, Reviewer
University of Miami
Miami, Florida
info@miamihealth.com


REFERENCES

1. National Institute on Alcohol Abuse and Alcoholism. A Pocket Guide for Alcohol Screening and Brief Intervention. http://pubs.niaaa.nih.gov/publications/Practitioner/PocketGuide/pocket_guide.htm. Accessibility verified July 18, 2007.

Book and Media Reviews Section Editor: John L. Zeller, MD, PhD, Contributing Editor.

Upcoming Events

Dear Friends and Colleagues;
I want to inform you about two upcoming events:

1. August 22-24th, 2007, Florida Alcohol And Drug Abuse Association, Orlando Florida

* Stacy Seikel, August 22nd,6:30PM - 10:00 PM Presentation about
"Prometa, A Treatment Program for Methamphetamine,Cocaine and Alcohol
Addiction"

1. August 24th-27th, 2007, FMA Annual Meeting, Hollywood, Florida

* Reference Committees will discuss three FSAM resolutions


Please call me for any questions or further information.
Yours

Bernd

California To end Physicians Monitoring Program

Dear Friends and Colleagues:
Attached some info regarding a very troublesome development in California.
Yours truly,
Bernd
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Calif. To End Program for Addicted Doctors
August 7, 2007
News Summary

The Medical Board of California has decided to end its diversion program for doctors who are grappling with addiction problems, the San Diego Union-Tribune reported Aug. 5.

The decision came in the wake of a report that concluded that the 27-year-old diversion program didn't do enough for addicted doctors and failed to protect patients. The program is scheduled to end next June unless the board decides to somehow overhaul it.

If the program ends, California would be the only state in the U.S. without a diversion mechanism for addicted doctors.

Under the program rules, doctors who confidentially sought help with addiction problems could keep their licenses if they attended treatment and self-help groups, and submitted urine tests. The Medical Board appoints a monitor to keep track of their progress, but the report said oversight was lacking.

Research showed that about 18 percent of doctors who entered the program completed treatment, far short of the 90 percent completion rate in North Carolina, for example.

Jeoffry Gordon, a past president of the Medical Board, said the state should offer some type of treatment to doctors. Others suggested that physicians be barred from practicing for six months while they get treatment.
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