Pubdate: Fri, 18 Dec 1998 Source: Journal of the American Medical Association (US) Contact: http://www.ama-assn.org/public/journals/jama/ Copyright: 1998 American Medical Association. ADDICTION Close to Home: Moyers on Addiction, produced and directed by Bill Moyers, five 60-minute videos, including "Portrait of Addiction," "The Hijacked Brain," "Changing Lives," "The Next Generation," and "The Politics of Addiction," $229, Princeton, NJ, Films for the Humanities & Sciences, 1998. Close to Home: Moyers on Addiction premiered on the Public Broadcasting System on March 29, 30, and 31, 1998. This television and now video series consists of five 1-hour focused videos entitled "Portrait of Addiction," "The Hijacked Brain," "Changing Lives," "The Next Generation," and "The Politics of Addiction." The series provides a candid look at recent trends in the "American disease" of addiction. Our review examines the program not only from the professional and provider's frame of reference, but also from the perspectives of the addict and family members. We talked to medical students, house staff, patients, and their families about their perceptions of the series. The Robert Wood Johnson Foundation has called drug use and addiction the nation's number one public health problem. The Moyers series documents the troubling finding of increased drug use among our youth, despite increases in education and prevention programs. While most physicians are aware of the prevalence of addiction, many of our patient families were surprised at how this disease infects all social strata without regard for age, race, sex, or income. Moyers does a good job of redefining the concept of addiction. While addiction has traditionally been thought of as physical dependence on a drug, most experts now look at the disease as a complex set of maladaptive behaviors that have their origin in brain neurochemistry.[1] Preoccupation with the drug, compulsive use despite adverse consequences, and a pattern of relapse over time help define addiction today as a pathological attachment to a plant or drug, more accurate than physiological dependence alone. Loss of control is a central part of all addiction theory, but, as important as loss of control is, it is a mystery. Compulsive use does not necessarily mean high volume or even repetitive use. Attachment to the drug defies calculations of dose; frequency and duration provide more direction than either measure alone. Detoxification, while a necessary first step on the road to recovery, is in isolation of little use in the treatment of addiction. This discussion of the concept of addiction can be instrumental in helping families understand both the power and destructive force of this disease. In "The Hijacked Brain," Moyers examines how the addict forms a pathological dependence on or attachment to the drug and continues using, seemingly oblivious to the physical, emotional, and social consequences. This segment cogently presents the neurobiological research conducted over the past 20 years that has identified the sites and mechanisms of drug action on the brain.[2,3] The video makes clear that people smoke or use drugs because of brain reward. No drug user smokes marijuana for its effects on the teeth, gums, larynx, bronchi, or lungs. Opiates are targeted at the brain's endogenous opioid systems, marijuana at the brain's endogenous cannabinoid (tetrahydrocannabinol [THC]) systems, benzodiazepines and alcohol at the brain's gamma-aminobutyric acid (GABA) receptor complex, and cocaine at the brain's dopamine reuptake transporter. Regardless of specific target, all drugs of abuse are similar in brain effect. This working neuroanatomy of drug reward is more of a work in progress than a fait accompli.[4] The series shows how drugs gain rapid access to the areas of the brain (ventral tegmental area, nucleus accumbens) that produce intense pleasure and reward. These hard-wired dopamine brain reward circuits, normally activated by food and sex, can be stimulated by drugs of abuse.[5] While first use of an illicit drug is voluntary, the user is motivated and goal directed to reproduce that initial high. Subsequent use induces brain changes, making additional use automatic and leading to the hypothesis that addiction is an involuntary disease of the "hijacked brain." Our patients and families found this discussion invaluable. One of the most difficult things for the addict, family members, and society to accept is the concept of substance abuse as a disease. The belief that alcoholism and drug abuse are the result of moral decadence or personal weakness is both powerful and pervasive. This belief, which still exists in the health professions, has impeded the development of effective medical treatments for this epidemic disease. Perhaps more than anything else, the Moyers series frames addiction as a disease. The discussion in "The Hijacked Brain" helps patients understand the disease concept of addiction. Behavior that was once defined only as weakness, selfishness, or evil can now be understood in terms of "chemical reactions," which, once activated, are difficult to change. While none of our family members reported excusing the behavior of the addict after watching the video, they did report a new understanding that helped them prepare for future behavior and appreciate the enormity of the treatment task. One mother reported that she now understands why her son seemed to love cocaine more than her. This new recognition of the effects of drugs on brain chemistry has allowed us to understand the sites for withdrawal and develop a host of new, approved treatments to help reduce relapse. Medications like naltrexone (ReVia) block the effects of opiates and alcohol. Methadone, buprenorphine, and the opioid agonist L-alpha-acetylmethadol (LAAM) prevent opiate relapse. Bupropion-SR (Zyban) reduces cigarette smoker relapse, and acamprosate can reduce alcohol relapse.[6] In "Changing Lives," we see how these medical treatments can be combined with traditional interventions to increase the likelihood of a successful outcome. Addicts report how traditional interventions, such as 12-step fellowships, provide hope, structure, and support necessary for lifelong abstinence. Indeed, 80% of alcoholics who report being abstinent 5 years or longer are regular attendees at Alcoholics Anonymous. These discussions provide both the addict and the affected family with hope. Acceptance of substance abuse as a chronic illness prepares the person for the long journey in which "recovery" is a process and not a place. While the Moyers series provides a rationale for understanding addiction and a basis of hope for millions of people, it also provides a warning for the future. As noted above, drug use is highest in the most vulnerable segment of our society, our youth. According to data from the University of Michigan, while 19.4% of eighth graders smoked cigarettes in 1991, 36.5% were smoking before graduation in 1997. Similar findings are being reported for alcohol and other drugs, such as heroin, cocaine, amphetamines, and LSD. Nationwide, in 1997, an incredible 22.6% of eighth graders had already learned inhalation of drug vapors by smoking marijuana. While some kids are learning how to analyze complex equations, others are learning how to inhale marijuana, tobacco, or cocaine. "The Next Generation" examines this trend and looks at the process of preventing addiction. However, while Moyers starts the argument, this program fails to help us understand why smoking of tobacco and marijuana are increasing at a dramatic rate when prevention efforts and new research and treatments are so widespread.[7] While many have focused on smoking,[8] the importance of smoking as a gateway to other drugs and as a major vehicle in brain training and hijacking is not emphasized in this series. The next step in prevention involves the training of physicians in the treatment of substance abuse. While it has been noted that physicians are in an ideal position to address the subject, formal medical education has not prepared them for helping users of tobacco, alcohol, and other drugs.[9] Physicians have been trained to recognize that substance abuse is a major source of hepatitis B infection, human immunodeficiency virus infection, hypertension, bacterial pneumonia, tuberculosis, sexually transmitted diseases, cirrhosis, and so on. However, they have little training in the early identification of the addictive process and rarely make a diagnosis early in the course of the addictive illness. In conclusion, the Moyers series on addiction is a valuable adjunct for the understanding, treatment, and prevention of substance abuse. While physicians who are active in diagnosing and treating chemical dependency will find little new from the program, those who have been only peripherally involved will receive a cogent update. The series will also provide the physician with a perspective on the consequences of addiction beyond the office setting. The series, however, will likely have its most profound impact upon the addict and family coping with the disease of addiction. The information in the series is not only accurate but is presented so as to increase the knowledge, ameliorate the guilt, and provide hope for those having to contend with substance abuse. We recommend using the series in trying to help families understand the disease of addiction. Virtually all of the family members we spoke to described the program as informative and therapeutic. While not a replacement for 12-step programs or support groups like Al-Anon, the Moyers series provides a comprehensive, cost-effective method to help the general public understand the pernicious disease of addiction. Mark S. Gold, MD Michael J. Herkov, PhD University of Florida College of Medicine Gainesville References 1. DuPont RL, Gold MS. Withdrawal and reward: implications for detoxification and relapse prevention. Psychiatr Ann. 1995;25:663-668. 2. Koob GF, Nestler EJ. The neurobiology of drug addiction. J Neuropsychiatry Clin Neurosci. 1997;9:482-497. 3. Wise RA. Neurobiology of addiction. Curr Opin Neurobiol. 1996;6:243-251. 4. Rocha BA, Scearce-Levie K, Lucas JJ, et al. Increased vulnerability to cocaine in mice lacking the serotonin-1B receptor. Nature. 1998;393:175-178. 5. Dackis CA, Gold MS. New concepts in cocaine addiction: the dopamine depletion hypothesis. Neurosci Biobehav Rev. 1985;9:469-477. 6. Gold MS. Drug abuse. In: Rakel RE, ed. Conn's Current Therapy. Philadelphia, Pa: WB Saunders Co; 1998:1123-1132. 7. Gold MS, Herkov MJ. Tobacco smoking and nicotine dependence: biological basis for a pharmacotherapy from nicotine to treatments that prevent relapse. J Addict Dis. 1998;17:7-22. 8. Gold MS, Gleaton TJ. Tobacco and marijuana use increases in junior and senior high school students. Biol Psychiatry. 1996;39:629. 9. Lewis, DC. The role of the generalist in the care of the substance-abusing patient. Med Clin North Am. 1997;81:831-843. (JAMA. 1998;280:2046-2047) - --- Checked-by: Rolf Ernst