Pubdate: Wed, 10 Mar 1999
Source: San Diego Union Tribune (CA)
Copyright: 1999 Union-Tribune Publishing Co.
Contact:  http://www.uniontrib.com/
Forum: http://www.uniontrib.com/cgi-bin/WebX

NEW DRUGS PRESCRIBE SOBRIETY

Addiction treatment no longer has to be a "drug-free zone," thanks to
new therapies designed to soften the trauma of withdrawal and blunt
the cravings that often drive addicts back to drugs or booze or
cigarettes -- no matter how desperately they want to quit.

These new drugs, for everything from smoking to alcoholism, mark a new
path for addiction therapy. They act directly on the symptoms of
addiction, differing from earlier treatments, such as methadone, that
substituted one drug (albeit a less dangerous one) for another.

These new treatments are slowly becoming widely available. That is
due, in part, to a new understanding of the biology of addiction and,
perhaps in equal measure, to financial pressures to shorten expensive
treatment programs.

Even more of these new treatments are in the research pipeline. The
University of Miami School of Medicine is studying one drug to treat
alcoholism and another to make cocaine cravings disappear.

New therapies for addiction have the potential to affect millions
across the nation. About 14 million people -- an estimated 10 percent
of the U.S. adult population -- are believed to have a drinking
problem, and drinking contributes to more than 40 percent of the
nation's traffic fatalities. Nearly 30 percent of Americans smoke. And
both alcohol and cigarettes contribute to heart disease, stroke and
some types of cancers. The National Institutes of Health puts the cost
to the nation of addiction's direct and indirect factors (crime,
domestic violence, increased health-care costs and lost productivity
at work) at $276 billion a year.

Some in the treatment business warn that sobriety requires an overhaul
of the soul and will never be as simple as popping another pill. Even
proponents insist that the drugs can only ease a patient's path to a
new life, but will not work without therapy to address the problems
that lead people to addiction and the behaviors that trap them there.
Still, the possibilities can be irresistible, especially to those
fighting for sobriety.

Breaking the cycle

Consider Pat, a Plantation, Fla., woman who asked not to be identified
further because of her drinking problem. An experimental drug that
blocks the urge to drink has made sobriety far easier to sustain than
she ever expected. Recently, she said, she was even able to attend a
cocktail party without being tempted.

"I didn't have a problem at all with it," she said, a little
surprised. She talked about her situation during a visit to the
University of Miami, where she is enrolled in a clinical trial that
keeps her from knowing for certain which drug she is taking."

"It's kind of a miracle drug," she said. "In the past, I would be fine
for a week or two, and then something would come up and I would just
want a beer. And that would be it. I just wouldn't stop."

Some drugs that take this new approach have recently been approved and
are already available through doctors or treatment programs:

{} Zyban, a drug aimed at reducing the desire to smoke. It can be
prescribed by a doctor and is often used in combination with
over-the-counter nicotine patches to help smokers quit.

{} Naltrexone, sold under the trade name ReVia. It has been approved
by the U.S. Food and Drug Administration to help alcoholics stay sober
by reducing their urge to drink.

{} Ultra-rapid detoxification. It speeds naltrexone to rapidly
detoxify heroin addicts under sedation, to speed and ease their drug
withdrawal. {} Some of the newer antidepressants, such as Prozac.
These are being used to help drug addicts and alcoholics when their

substance abuse is thought to be related to an underlying mental illness.

Insurance coverage for these therapies varies, but most health plans
place strict limits on reimbursement for mental health and addiction
therapy. Most plans, for instance, will not cover Zyban, which is
specifically indicated for smoking cessation, though some doctors have
tried to work around this by prescribing a similar antidepressant.
Biological connection

The idea of treating an addiction with drugs results from scientists'
fast-growing understanding of substance abuse as a biological
affliction and not strictly a behavioral problem. Researchers are
finding new pieces to this complex puzzle all the time.

Basically, they now believe that addiction is a corruption of a bodily
system that evolution intended as a way to reward us for behaviors
that ensured the survival of the species -- most notably sex. There is
a reward pathway in the brain composed of nerve cells that signal
pleasure. These cells are particularly sensitive to a naturally
occurring chemical in the brain called dopamine, which is a
neurotransmitter -- it ferries signals between nerve cells.

New research suggests that dopamine may act in concert with other
neurotransmitters, but on a simple level, all enjoyable experiences --
whether a kiss or a fine piece of Belgian chocolate -- translate to a
rush of dopamine along this reward pathway in the brain.

Addictive substances distort this natural pleasure system, flooding
the brain with dopamine and causing a "high." Eventually -- and
especially so for cocaine and heroin addicts -- this flood of dopamine
can desensitize the brain to the chemical. The trickle of dopamine
that's triggered, say, by a kiss is no longer enough to produce
pleasure. The addict goes into a state similar to depression,  in
which it's no longer possible to truly enjoy life. Even the drug no
longer  produces a high; it simply fends off a more desperate low.

"At first, it's like a cerebral orgasm: The first few hits are so
pleasurable, they keep chasing that rush," says Deborah Mash, a
University of Miami researcher who is working on a drug called
ibogaine to treat cocaine and other  addictions. "They can't derive
pleasure from anything in life, not love, nothing. The only time they
feel good is when they have the crack pipe in their  hands."

Reducing cravings

Ibogaine is derived from an African plant. It's being tested on
addicts with  several addictions, though results have varied. The drug
seems to detoxify  addicts with few withdrawal pains, and it also
seems to stay in the body long  enough to reduce their cravings for
several months. Mash hopes eventually to  develop a patch based on an
ibogaine derivative that cocaine addicts could wear  to reduce their
cravings, much as smokers wishing to quit can wear a nicotine  patch.

The University of Miami is also conducting several studies of drugs
that could help alcoholics who cannot tolerate naltrexone. It recently
tested a French drug, acamprosate, which is widely available in Europe
and is now being reviewed by the Food and Drug Administration for
approval in the United States.

At Nova Southeastern University in Fort Lauderdale, Fla., Jose A. Rey,
an assistant professor in the College of Pharmacy, is studying whether
a drug currently used to treat Parkinson's disease -- which is another
type of malfunction of the dopamine system -- might also stave off
cravings in cocaine addicts.

"There's a lot of people throwing darts and doing research on a host
of drugs," said Rey. "I haven't seen any cure-all. We're still in an
age of exploration."

No quick fix

One of the most common tactics is to give antidepressants to addicts.
The idea is to treat underlying depression that can lead people to
abuse alcohol, drugs, even cigarettes. Recent research has indicated
that about a third of all smokers are depressed and may turn to
nicotine as a way of self-medicating. So doctors are using mild

antidepressants like Zyban to help smokers quit.

But some fear that such approaches might tempt addicts to forgo the
hard work of behavioral therapy, thinking that they can solve their
problems with the quicker fix of anti-craving medications.

Doctors at Mount Sinai Medical Center in Miami use drugs to speed drug
or alcohol detoxification, reasoning that it helps addicts who have
the will to quit but cannot get past their fear of the terrors of
withdrawal. But the doctors are cautious about the prospect of drugs
to reduce the desire for an addictive substance.

"This is a physical disease with a spiritual remedy," said Dr. John C.
Eustace, medical director of the Fletcher Addiction Treatment Program
at Mount Sinai. "There's a physical part to this disease, but then
there's the mental, emotional, social aspects of this kind of life. A
pill isn't going to make a long-term change in an addictive
personality. We can't write a prescription for serenity."

Getting less

Proponents argue that these medications have a practical value because
they seem to boost the effectiveness of today's pared-down therapy
programs. Years ago, it was standard practice to treat alcoholics and
drug addicts with intensive inpatient therapy that lasted about a
month -- long enough to clear their systems of drugs and help them
through the first, most difficult weeks of sobriety.

Financial pressures, largely stemming from cutbacks in the age of
managed care, have changed that. Today, most addiction therapy is on
an outpatient basis, perhaps after a brief hospitalization to clear
the system of drugs. This can be harder on patients because they don't
get as much support during the toughest period of sobriety; in
addition, because they are outside a hospital setting, they continue
to have access to whatever substance they have been abusing.

So doctors reason that if they can develop a drug that reduces the
desire to drink or take drugs, they can improve the odds that an
addict will stay sober.

It seems to work that way for alcoholism. Studies indicate that
naltrexone does seem to reduce relapses for recovering alcoholics by
dampening -- though not necessarily eliminating -- the desire to
drink. People who previously could not stop drinking after their first
beer are no longer compelled to keep going until they are drunk. "We
have a better three-month relapse rate than patients who started out
with traditional 28-day inpatient programs," said Barbara Mason,
director of the Alcohol Disorders Research Unit at the University of
Miami. Mason is testing two drugs that she hopes will help alcoholics
stay sober with fewer side effects than naltrexone, which can cause
nausea and liver problems. Studies indicate that these drugs seem to
help about 20 percent more patients stay sober for at least three
months than those who just get traditional therapy, she says. That is
important, because the longer a person stays sober, the more likely he
or she is to make a permanent change.

The University of Miami is also testing combination therapies to help
alcoholics who smoke quit both addictions at the same time.

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