Monday, March 29, 2010

Science answers raise public policy questions on addiction

I've wondered in recent years if research by neuroscientists may eventually result in the conceptual uncoupling of addiction from criminality, forcing society to view it as a public health problem instead of reason for arrest and imprisonment. After all, nobody calls the cops when some tub of lard buys a grocery-cart full of junk food at the supermarket, but as it turns out a new study shows that:
high-fat, high-calorie foods affect the brain in much the same way as cocaine and heroin. When rats consume these foods in great enough quantities, it leads to compulsive eating habits that resemble drug addiction, the study found.

Doing drugs such as cocaine and eating too much junk food both gradually overload the so-called pleasure centers in the brain, according to Paul J. Kenny, Ph.D., an associate professor of molecular therapeutics at the Scripps Research Institute, in Jupiter, Florida. Eventually the pleasure centers "crash," and achieving the same pleasure--or even just feeling normal--requires increasing amounts of the drug or food, says Kenny, the lead author of the study.

"People know intuitively that there's more to [overeating] than just willpower," he says. "There's a system in the brain that's been turned on or over-activated, and that's driving [overeating] at some subconscious level."

So if addiction to cocaine and cheesecake relies on the same biological mechanism, will public policy eventually treat them similarly, and if so which path will we choose? Indeed, there are more similarities between junk food and controlled substances than first meets the eye, reports CNN:

The fact that junk food could provoke this response isn't entirely surprising, says Dr.Gene-Jack Wang, M.D., the chair of the medical department at the U.S. Department of Energy's Brookhaven National Laboratory, in Upton, New York.

"We make our food very similar to cocaine now," he says.

Coca leaves have been used since ancient times, he points out, but people learned to purify or alter cocaine to deliver it more efficiently to their brains (by injecting or smoking it, for instance). This made the drug more addictive.

According to Wang, food has evolved in a similar way. "We purify our food," he says. "Our ancestors ate whole grains, but we're eating white bread. American Indians ate corn; we eat corn syrup."

Obesity, like drug addiction, is both bad for the individual and costly for society. If both problems stem from the same source, will we change drug policy to treat controlled substances like we do fatty foods, where the emphasis is on personal freedom, tax policy and public education, or will we treat fatty foods like illegal drugs, policing individual consumption and enforcing penalties for producers and consumers of unhealthy products? Or are there distinctions besides brain chemistry that justify different legal approaches for heroin and Twinkies? What do you think?


Anonymous said...

Think about the enhancements under the law we can obtain. Lets see its any detectable amount and it's additives. We should be able to get a life sentence off of that last bite of the Twinkie dunked in milk.


Aaron_in_TO said...

Researchers at the Princeton Neuroscience Institute have shown that lab rats show all three of the required signs for addiction…to sugar

In addition to the effect of various brain chemicals, we also need to look at the effect insulin plays in the addictive nature of junk food

Anonymous said...

I see your point, but the reason drug addiction continues to be criminalized is directly related to the criminal behavior that goes along with drug/alcohol use and abuse. People who overeat are not going out burglarizing homes and businesses to get money buy more food. Criminal justice professionals nationwide understand that addiction fuels much of the assault, theft, burglary, and robbery behavior we see in our society.

Gritsforbreakfast said...

10:54 writes: "the reason drug addiction continues to be criminalized is directly related to the criminal behavior that goes along with drug/alcohol use and abuse"

Two problems with that statement: First, alcohol use is legal, so your distinction falls apart before finishing the sentence. Second, there is a correlation between sugar consumption and crime.

Anonymous said...

Sure, there is a correlation between sugar consumption in youths leading to criminal behavior later in life. However, adults (and kids alike) are not stealing and robbing and burglarizing to pay for their sugar binges the way drug addicts do. Also, alcohol use is not legal, it is restricted to those over the age of 21. And again, whereas it is legal to drink a soda while behidn the wheel, you cannot drink alcohol behind the wheel. And nobody ever goes on a "soda run" the way they go on a "beer run."

Anonymous said...

Perhaps if sugar cost as much as heroin or coke, a 'sugar addict' would commit crimes. As it is, they can buy a pound of sugar and eat it by the spoonfuls if they just want to get an instant rush. What's sugar cost these days?

Great Post Scott and proof of a theory I've always believed.

Gritsforbreakfast said...

11:41 writes: "adults (and kids alike) are not stealing and robbing and burglarizing to pay for their sugar binges the way drug addicts do"

Neither are most drug addicts "stealing and robbing and burglarizing." Addicts may be more likely to engage in such activities, but there are many, MANY more addicts than there are thieves, robbers and burglars.

And alcohol use IS legal. Saying otherwise is absurd. Limiting it to adults and banning it behind the wheel is all part of the legal regulatory structure, but the folks making Budweiser and Lone Star are legal businesses, not outlaw cartels. Also, just as with drugs, not everyone using alcohol is "stealing and robbing and burglarizing." Surely you know that, but you're conflating all these issues in ways that don't jibe with reality.

12:50 - excellent point on pricing sugar.

ckikerintulia said...

Make sugar illegal, then watch the price of it go out of sight and out of reach, then see what happens to the sugar related crime rate.

Anonymous said...

Many kids steal from their parents to buy sugar products. Are they going to jail for this NO1 Will they groe up to steal and have an addition to drugs
Who knows!! Are we rats No!

Don said...

Addictions professionals have long known that eating disorders were addictions. I couldn't vouch for the truth in the notion that sugar addicts don't go on soda runs. I have a daughter who would go to some pretty dire measures when out of Dr. Pepper. (the real kind, of course, not the wimpy diet stuff). New York has a new "sugar tax" don't they? Or at least it's being considered.

Don said...

"So if addiction to cocaine and cheesecake relies on the same biological mechanism, will public policy eventually treat them similarly, and if so which path will we choose?"

Well, Scott, judging by our history and the trajectory of our social policy evolution, I would opine that we would probably opt for jailing the cheesecake fiends. Don't you think?

tommy wilson said...

re: sugar pricing. let us not forget how much we subsidize the sugar industry in this country (i.e. corn). if we threw an equal amount of cash on cocaine, you could grind your teeth into dust for a few dollars a week...

Anonymous said...

same mechanism but just imagine how much cheesecake you would have to eat!

Scott this is just silly. The realities small amounts of alcohol and cocaine can have mind altering effects that frequently result in injuries to others. Just cause they have the same mechanism doesn't mean that they have the same impact. It's like comparing a single horsepower engine to a ferrari. There was time when you didn't need speed limits either.

Gritsforbreakfast said...

8:31 writes: that this is like "comparing a single horsepower engine to a ferrari"

Except, last I checked, a Ferrari and a moped must both follow speed limits, stop at traffic lights, etc.. Just because you drive a Ferrari doesn't mean the same rules of the road don't apply, so your analogy actually supports my point instead of disputing it. Do we make special road rules for Ferraris? That would be silly. The rules should be based on general principles, not which type of car you drive or, in this case, which addiction you've succumbed to.

Also, anyone who thinks sugar and processed foods are not "mind altering" has never raised children.

And you're wrong about processed food having relatively minimal impact: There are plenty of serious harms and societal costs - higher taxes, higher insurance premiums, soaking up emergency room resources - that far outweigh (so to speak) those from drug abuse in the big picture because the issue affects so many more people.

Don said...

Anonymous 6:38: You obviously know a lot about addiction, and I agree with most of what you said. But it was the long way around to get to your point, which obviously was to take a swipe at 12-step programs. With some people, 12-step programs are not all that's needed, but they can be a complement to other treatment. It's not necessarily an either-or thing. And I'm not sure "society" shuns the treatments you mention and urges opiate addicts to choose AA/NA only. Don't think "society" knows or cares, generally speaking.

Anonymous said...

Don, thanks for your comments. The fact is, however, that 97% of the rehabilitation facilities in the USA use the 12 step model of abstinence based treatment. The success rate for this model is very very low--and particularly so for those with heavy opiate addictions. In fact, AA's own triennial survery of it's membership showed that of those who came into the program, only 5% were still there, sober, a year later.

While support groups can be extremely helpful in learning to manage a variety of diseases, they are not usually considered "treatment" for that disease--unless the disease is addiction.

Now that science has discovered, and is continuing to discover more about the relationship between addictive behavior and brain chemistry, we have more tools in the toolbox to treat the diseases than they did back in the 1930's when 12 step programs were born. At that time, abstinence was thought to be the only path to recovery, and addiction was treated as a "character defect" or a "spiritual malady" which could only be treated by a "spiritual awakening".

However, even though we now know that many people require medication to normalize their brain chemistry, societal acceptance of that idea has a loooooong way to go.

Here's an example. When an AA or NA group decides to open up, no one protests. They often meet in churches, libraries, even in school buildings off hours. They are generally viewed favorably by the community, despite the fact that there are often attendees that are either not yet sober/clean or have relapsed and are using, may have drugs on them, and may even be selling/delivering them to other members, and driving to and from the meetings in an impaired state. But one seldom hears of a community turning out to protest such group meetings in their neighborhood.

But let a methadone clinic try to open, and it's Armageddon. Townspeople pour out in droves to cry "Not In My Backyard!". People state that they fear the dangerous junkies will "stumble down the street in a stupor", or that they will "have to push drug addicts aside to get through the doors of nearby businesses" (direct statements from a recent article). The town councils in many places have preemptively changed their zoning ordinances to make it literally impossible for a clinic to locate there, in direct violation of the ADA, and when they pass the ordinances they make comments such as "We're taking back our town!" and "that's one for the little guy!".

Even though in almost every case the clinics, when they finally finish the requisite court battles to locate, turn out to be good neighbors, and the patients turn out to be actual human beings from all walks of life, the same scene is repeated ad nauseum every single time one tries to open. The success rates of methadone treatment FAR surpass those of abstinence based treatment, making it FAR more likely that MMT patients will be free of illicit drugs than addicts who are in abstinence based treatment--yet they are shunned for seeking evidence based treatment.

I feel there is a real place for support groups, but they are not treatment. Until addiction is recognized as a MEDICAL disease--one that often requires MEDICAL intervention--rather than a character issue or a criminal justice issue, things will remain status quo. New treatments are being found for alcoholism, stimulant addiction, etc as well

People accept with equanamity the need for medication, along with therapy, to successfully treat most cases of major depression, schizophrenia, bipolar disorder, etc--all disease of the brain chemistry--yet they resist it's use in addiction treatment, in spite of the high success rates and all supporting science--why is this?

Don said...

Anon: 10:45
Once again I agree with most of what you say, particularly when you frame it in terms mostly regarding opiate addiction, and the public's opinion of AA/NA vs. methadone clinics. Where I live, I don't think anyone has tried open a methadone clinic lately. We used to have one in conjunction with MHMR but frankly, I'm not sure if it's still operational. And I agree with you that these type programs are more effective than AA/NA with opiate addicts. (For what it's worth, I'm a semi-retired addictions counselor of 23 years). And though what you say is true about being able to start an AA/NA group just about anywhere, and there is a stigma about opiate addiction, actually neither population causes much of a problem within a community, far as I can tell. It's just the perception.
What I do disagree with you about is that you suggest that AA/NA holds itself out to be a treatment program, and that is not, never has been, the case. On an official level, they have always been very careful to emphasize that it is NOT treatment. There could be some groups that are not really in tune with 12-step dogma that would refer to their programs as treatment, but that certainly is not the official stance. I have worked in most treatment venues, and I guess I agree that most of them are 12 step based, but that doesn't mean that's ALL they do. But once again, there is nothing about a 12-step group that resembles the definition of Treatment. It's apples and oranges.

Anonymous said...

Don, sounds as though you may live in the Austin area from your reference to MHMR? If so, yes that clinic is still operational, and Austin also has two private pay clinics. And yes, you are absolutely correct that neither 12 step meetings nor MMT clinics cause problems in the communities they are in, speaking generally.

As for 12 step holding itself out to be treatment--while the groups themselves do not do so, the rehabs that utilize twelve step, which most do, tend to center their treatment around the 12 step "model". Patients are generally given a Big Book when they enter treatment, and usually a series of workbooks based on the twelve steps, to complete while in treatment. They attend 12 step meetings, Big Book studies, lectures on aspects of the steps, "spirituality" classes, etc. If you go online and look at the weekly schedule for Austin Recovery Center, for example, you will see that the vast majority of classes, groups, etc are about the 12 steps.

There is no denying the extreme prevalence of the 12 step model in USA rehabs, and I have to disagree with you regarding it's use as treatment. While I am very familiar with AA's traditions, etc, I also know, from long experience in the field, that in fact, the program IS used as treatment in most places. They may also toss in some cognitive therapy, Behavior modification, or individual counseling, but the emphasis is on the 12 steps, i.e., "work the steps or die!", a motto frequently repeated in NA as well as in rehab.

If they were simply used as a support group--i.e., patients were taken to a meeting once a week or something, I would have no problem--but that is not the case. In many, if not most rehabs, almost the entirety of treatment is focused on the steps--lectures on the steps, workbooks on the steps, requirements that patients work steps 1-5 before leaving treatment, Big Book studies , required reading of and reporting on 12 step literature, and so on.

And then we have the court system, or CPS, or Employee Assistance programs, or Licensing Boards, all of whom either currently or in the very recent past required 12 step attendance, with proof thereof, as evidence that the person was "working a program of recovery"--this despite the fact that the Supreme Court has ruled that AA/NA is religious in nature and that the government cannot require people to attend.

At any rate, I feel strongly that people should be offered a range of treatment options so that they can see what works for them. Not only do I see pushing of the 12 step program, I also witness pushing of, for example, Suboxone over methadone, etc--and there is just no need, unless it is from a purely capitalistic viewpoint, to push one method over another.

I may have gone a bit off track here--but my primary motivation is to open the minds of the general public towards evidence based treatment, and towards treating addiction as a medical disease rather than a crime, or a character defect or "spiritual malady". Support groups have a definite place--but they need to be support groups, not support groups masquerading as treatment--and again, the fault may lie with the rehabs that utilize it as such, and some are worse than others about this.

Don said...

6:47: As I told you, I have worked in MANY treatment programs. Most of them were what you would term as 12-step based. (By the way, I don't live in Austin, but in the Lubbock area). Anyway, again, I am mostly agreeing with you, but have some sticking points. ALL of the programs that I have worked in gave me, as an LCDC, a lot of leeway to counsel the way I saw fit. Even though I like 12-steps, I never saw it as something I needed to limit my counseling to. I got a degree and a professional license so I wouldn't be limited to being an AA sponsor, or harping on the 12 steps. I don't think that's what treatment is. I didn't just "throw some cognitive in there", RET and RBT and CBT were what I did. And going to a meeting or two each week, as you described, was the adjunct.
I also know that you are correct that some treatment programs are mostly AA programs, but I don't know if I would say 90% are. If that's the case, I don't know how I missed so many of them when I worked in probably at least 10 different centers, including free-standing, hospital based, MHMR, and Criminal Justice. It could be a geographical thing, or it could be that I just didn't drink the Kool-Aid.
I am familiar with Austin Recovery Center and it is not a good example of the way things are everywhere. The CEO (Fr. Bill Wigmore), is a dyed-in-the-wool AA enthusiast, (euphemism for AA nut) and I believe you when you say that's about the size of it, as far as their treatment is concerned. But that's them.
Now, here is something that I most DEFINITELY agree with you on. That is the "sentencing" to AA/NA that the courts do. That is a gross injustice, not only to the sick person, but to AA itself. It totally disregards several AA traditions, and living in a rural area of Texas, I have seen it completely destroy at least AA chapter, and severely damage many more. I have harped on that for all of my 23 years in the field. I've told Probation Officers, Judges, Prosecutors, and everybody else who would listen how wrong this is, all to no avail. They don't care; it gets them something to put in a file, and they can say they did their job. NOT!
Anyway, I have enjoyed the dialogue. You are a very knowledgeable person on this subject. As I said, I agree with you about 99%. And, like you, wish the general public cared enough about this to actually learn a few basics.