The Neuroscience of Addiction and Pharmacological Treatment

Dr. Bryon Adinoff, Distinguished Professor of Drug and Alcohol Abuse Research at the University of Texas Southwestern Medical Center and the Director of Research in Mental Health at the VA North Texas Health Care System, talks about the latest research on addiction and pharmacological or medication-assisted treatment, as well as how they can impact the criminal justice system.

The following is a transcript:

AVNI MAJITHIA-SEJPAL: Hello, and welcome to the New Thinking Podcast. This is MAJITHIA-SEJPALejpal. Today, we are at Reinvesting in Justice at the Dallas City Hall,l where I'm in conversation with Dr. Bryon Adinoff, the Distinguished Professor of Drug and Alcohol Abuse at the University of Texas Southwestern Medical Center and the director of research in mental health at the V.A. North Texas Healthcare System.

Dr. Adinoff, thanks for taking the time to speak with me.

BRYON ADINOFF: Good to be here.

MAJITHIA-SEJPAL: You just gave a very interesting talk about the neuroscience of addiction. For the benefit of our listeners at home, can you walk us through the highlights?

ADINOFF:The key thing about the neuroscience of addiction, it is a brain disease. It's a chronic medical illness just like other medical illnesses whether it's cardiovascular disease or pulmonary disease or epilepsy or schizophrenia or bipolar disease. There are many similar characteristics in that it's due to both specific genes that put you at risk, environments that put you at risk and in the case of substances of course, the use of substances often for a long time that develop the brain disease.

MAJITHIA-SEJPAL: More and more it seems that prosecutors and courts are seeking to link defendants with substance abuse issues to treatment programs. What is the latest research telling us? What do we know now about the addicted brain?

ADINOFF: It appears that what happens over time in the addicted brain is that the whole even though the drugs may be hitting particular parts of the brain involved in pleasure and reward, the whole brain becomes hijacked by this reward system. So that all of the parts of the brain particularly the prefrontal cortex that's involved in who we are, the way we plan things, the way we think about things. This part of the brain is hijacked by the reward system. We see many differences in people with addiction in their brain. We can certainly tell that, for instance, the brain is far more reactive to certain cues that remind them about using. That there's memories of use of things that they associate with using, whether it's a bottle of beer or a cocaine pipe or joint that become hardwired into the brain of people with addiction. It can be very difficult to put these memories away or make them quiet.

We found networks that work in the brain. All of our brains, we have networks of brain regions that talk to one another and that there's impairments, for instance, in these networks in the addicted brain. For instance the brain areas just at rest called the default mode network. These brain regions are active when we're not doing anything, we're just lying there thinking. This activity in people with addiction in this default mode network appear to be hyperactive. Maybe there's a loop of craving that they're not even aware of that is hyper-activated in addicts. Maybe they're scanning the environment without even thinking about it for addiction-related cues.

MAJITHIA-SEJPAL: You mentioned in your talk pharmacological treatment? One buzzword seems to be medication-assisted treatment. Are those two the same things?

ADINOFF: They are the same thing. I prefer not to use the term medication-assisted. We do not talk about insulin being medication-assisted treatment for diabetes even though the diabetic in addition to taking insulin needs to be watching their diet and exercise and also some other things, losing weight but they're all essential parts of treatment. Schizophrenia we don't talk about medication-assisted treatment when they're taking anti-psychotic. I think in the same way, for addiction disorders, we have medications that's very useful. We have talk therapies that are very useful. We have 12-step support groups that are very useful. They're all important treatments or interventions.

It can be very successfully used in the treatment of addiction. The pharmacologic approaches are medications that are helpful for the treatment of addiction.

MAJITHIA-SEJPAL: Can you expand on pharmacological treatments?

ADINOFF: There are many different good medications now for addictive disorders. For opiate disorders when opiates are drugs like heroin or Percocet or codeine, Oxycontin, Vicodin. These substances all hit opiate receptors in the brain. There's two major pharmacologic approaches. One is to use what's called an opiate agonist, where it replaces the effects of these other drugs on the brain. So instead of taking heroin in you would take methadone or suboxone or buprenorphine. What these medications do, they're also opiates and they hit the opiate receptor in the same way, that say, heroin might that replaces it, so the brain is no longer crying out demanding that it gets heroin. It's been satisfied or satiated with this other opiate agonist like suboxone or methadone.

Even though they're opiates and if you stop them suddenly you'd have withdrawal symptoms. They're legal. They take them once a day and they last for the full day and they take them by mouth so they can actually go on and function with regular life so they don't get in trouble with the law. They're not using needles. There's doctors I know who are on suboxone. There's a wide range of people that do very well on these medications.

Another approach is blocking the opiate receptors and there's a shot called Vivitrol and it has a drug in it called naltrexone that blocks these receptors for a month. Once you get that shot you no longer can use. If you use, say heroin, you won't get high. You're throwing your money down the drain and it's all that work to get the heroin for nothing. What that month does, it seems to get people the opportunity then to do their treatments so they have a whole month ahead of them for that treatment to kick in, and then they just have to make a commitment once a month to get that shot.

For alcohol, we have several other medications that hit different brain receptors or brain neurons that people that take these medications do better than people that take a placebo or don't take a medication at all.

MAJITHIA-SEJPAL: You would say that these are effective?

ADINOFF: They are. There's substantial literature on these medications. They're not cure-alls. They're not magic pills. We certainly always recommend that somebody taking these medications get their other therapy as well, but they do help.

MAJITHIA-SEJPAL: As someone who has done such extensive research on the subject, how do you address skepticism of pharmacological treatment that suggests that it merely replaces one drug for another?

ADINOFF: Well, in the case of the opiate agonist I mentioned like methadone and buprenorphine, they're opiate replacement therapy. They do in fact replace one drug with another. The difference is you're not getting high and that all the symptoms of addiction, the craving, the lost control, the consequences of use, the compulsive use, all those things if you take it every day as prescribed, they go away. So you don't have all the symptoms that make up an addiction. They work. I understand the philosophy of not wanting to replace one drug with another but in this position my goal is to help people get better. Other medications like I mentioned, the Vivitrol, are just medications. They don't replace the drug in the sense that we usually think about it. All other diseases that we think of, we use medications. It's not all we use but most diseases they're physiologic illnesses and we use medications with great success. Addictions are just another disease. They're chronic. They're marked by relapse. Again, just like all other chronic diseases, so it makes sense. Again, the biggest thing is people do better on them--and that's the ultimate goal.

MAJITHIA-SEJPAL: There was an interesting question that came up from an audience member in your talk about affordability and I was wondering whether you could talk about that a little bit. How accessible is pharmacological treatment to the average person?

ADINOFF: It's a great question and it certainly one concern in the addiction field as well as all other fields, whether it's chemotherapy or medication for schizophrenia or depression. The newer drugs are always way more expensive. The methadone is very inexpensive. It can be a pain to get. You have to go to special clinics but that's been around a long time and it's not expensive. Vivitrol is a shot and it is expensive. My understanding is the company that makes Vivitrol has actually given grants or given a lot of free Vivitrol to people that are in court systems. There's ways around it. For alcohol dependence, many of the medications are really old medications and are not that expensive.

When you consider how much an addiction, even if you're drinking, it really adds up very quickly and people put that money into getting the medication and other treatment--they probably come way out ahead in the long run.

MAJITHIA-SEJPAL: How can some of the research that you've been doing and citing inform and change the way the criminal justice system adjudicates addiction?

ADINOFF: I don't know that it can change it because I think the reasons for the drug laws that we presently have are political, social, cultural decisions that people have made and the government has made. Many of our laws for better or worse are not necessarily based on the science and it can take a long time for laws on the books to respond to the science. As a emotional issue, even though I believe, and I think many people now believe, addiction is a brain disease. There's something about people seemingly voluntarily taking drugs that is hard for us to really think of as a brain disease. I think that's changing is more and more people come out and say, "You know I've been addicted." I think gradually we're changing but it's very slow and not only in the community but in the field of medicine. Doctors are sometimes extremely slow to prescribe these medications that we were talking about.

It will take a while. As I mentioned in my talk in DSM IV--DSM is our psychiatric bible--legal problems was one of the ways we use to diagnose a substance disorder order, an addiction. And that was taken out for DSM V because they found being arrested for a substance use justice disorder had more to do with your race and your economic standing and your social standing than it did whether you were using or not. It really wasn't very good at helping you diagnose--it wouldn't good at all at helping you diagnose somebody with addiction or not. The laws that we've been using have not been effective in treating people with addiction or in decreasing the amount of use. We’ve certainly spent a lot of money on this country on the drug war. Again, it was understandable because these drugs can cause a great deal of harm to people and societies, but they haven't been effective. So this conference, it’s been great in trying to look at better ways to approach these problems other than incarcerating people.

MAJITHIA-SEJPAL: That brings us to the end of our conversation. Dr. Adinoff, thank you so much for taking the time to talk to me.

ADINOFF: It's been my pleasure.

MAJITHIA-SEJPAL: I'm MAJITHIA-SEJPALejpal and you've been listening to Dr. Bryon Adinoff about the latest research in the neuroscience of addiction and what it means for prosecuting drug crimes. To listen to more New Thinking Podcasts or to learn more about our work, you can visit our website at www.courtinnovation.org. Thanks for listening.