The month of September is dedicated to raising awareness about recovery from drug and alcohol addiction. This month, we interviewed Dana Alliance member Charles O’Brien, M.D., Ph.D., who founded the University of Pennsylvania’s Center for Addiction Treatment. For more than thirty years, O’Brien has worked to improve addiction treatment and has made many breakthroughs regarding the clinical aspects of addiction and the neurobiology of relapse.
In your opinion, what is the most common misconception about drug and alcohol addiction?
Most physicians learn very little about addictive disorders in medical school or residency. Rather than being considered a disease of the brain, most see it as bad behavior. They don’t know that there are FDA approved medications and that patients do respond to treatment, even though “cures” are rare.
In the USA, Alcoholics Anonymous is the only “treatment” that is well known but it is not a professional treatment. It can supplement treatment under the guidance of a trained professional, but most doctors simply refer patients to an AA group. Less than 10% of people seeking help receive an FDA approved medication. Frequently, AA sponsors discourage the use of any medication. This includes anti-craving medication as well as other meds such as mood stabilizers, neuroleptics, or anti-depressants. Evidence-based treatment is seldom used.
According to NIH, the rate of relapse (i.e. how often symptoms recur) for someone who has drug addiction is very similar to the rates of other medical illnesses, such as hypertension, asthma, and diabetes. What is the most effective method for someone with a drug or alcohol addiction to handle relapse?
Long term treatment is essential. Medication-assisted treatment, depending on the type of drug use disorder, must be continued. If relapse occurs, increased frequency of visits and involvement of the family may be helpful. Hypertension is a good model: While there are no cures, continued treatment, usually medication, and rehab programs are helpful in combination with medication.
As founder of the Center for Studies of Addiction, can you talk about some of your current research?
We discovered in the 1980s that alcohol activates the endogenous opioid system, and blocking opioid receptors with an antagonist–such as naltrexone–reduces drug craving and blocks some of the high from alcohol. Most studies demonstrate that naltrexone reduces heavy drinking and makes the patient more amenable to rehab, including counseling or psychotherapy. Unfortunately some therapists are against the use of medication even when they have seen evidence of benefit. An extraordinary example of this was demonstrated in a CNN special called “Addiction: Life on the Edge.” The only patient who did well was taking naltrexone, but when the journalist showed the recording of the interview to the counselors at the anti-medication treatment programs, they responded, “We never use medications here.” At least one of the programs in the series later announced that they were beginning the use of medications to prevent relapse, but they are in the minority. Most addiction treatment programs don’t even consider the use of medication.
An interesting current study involves the use of extended release naltrexone which protects the patient from opioid relapse for 30-40 days after a single injection. We did a multi-city study of parolees with a history of opioid addiction recently released from prison, who almost always relapse. We randomly assigned 308 of them to either treatment as usual (TAU) or 6 monthly injections of extended release naltrexone. There were 7 opioid overdoses in the comparison group but none in the naltrexone group. There was significantly less relapse to opioid drugs during the six months of naltrexone treatment but after the naltrexone stopped, the use of opioids gradually returned. We think that more than six months of naltrexone maintenance is needed, and we are currently doing a cost benefit analysis comparing the cost of naltrexone to the savings in lack of crime and incarceration. Incidentally, this study was started with the help of a grant from the Dana Foundation. [More on this study in a 2011 interview with Dr. O’Brien, “Ignorance and the Undertreatment of Addiction: Lessons from Prison.”]
Do you have any advice on how to care for a friend or relative who is trying to recover from addiction?
Stick with the person in need of treatment. Don’t give up. Addiction saps your free will and produces a compulsion to relapse against your will. Think of the intelligent friends you have who continually relapse to smoking even though they know the health risks. Recovery from addiction can be a very long process. Even years after the last dose, drug related cues can still awaken changes in the brain that we and others have demonstrated to underlie craving. These are physical changes in the brain that produce strong craving and increase the likelihood of relapse and are largely outside of the patient’s control.
– Seimi Rurup