Saturday, April 28, 2007

Changing Attitudes about Addiction

In the 1960s, Dr. Marie Nyswander, a trained Freudian psychoanalyst, and Dr. Vincent Dole, a metabolic disease specialist who was chair of the NYC Health Research Council's Committee on Narcotics (not a job he particularly wanted) established the first methadone maintenance clinics in NY for heroin addicts. In the late fifties, Nyswander had begun working with jazz musicians addicted to heroin. The prevailing Freudian theory of heroin addiction at that time hypothesized that these male artists were actually homosexuals who used heroin to over-activate the superego and suppress the id. The overall understanding of drug addiction in the 60s was that there was an "addictive personality" type that took drugs to escape reality in order to conceal inadequacies. Frustrated by her experience with her patients' propensity to relapse, Nyswander accepted a position at the Rockefeller Center offered by Dole and the two began a collaboration to discover both the nature of addiction and possible treatments. In 1965, they were the first to establish methadone treatment clinics. In 1967, Dole and Nyswander published a groundbreaking theory that heroin addicts had undergone permanent metabolic changes, and that abstinence was an unrealistic expectation - maintenance in the form of methadone replacement was the goal. It brought into prominence the existing but previously unpopular theory that drug addiction was a physical disease and not a moral failing, as Drs. Nyswander and Dole saw no correlation between sociopathic tendencies and addiction once addicts were being treated. They were one of the first to refer to the disease of addiction as "persistent neurochemical disturbance," though the theory can be dated (without scientific support) to the 20s. In personal gossip, in 1965 Nyswander abruptly ditched her writer husband and married Dole.

More info about methadone: it is a long-lasting mu opioid receptor agonist. It reduces craving and withdrawal symptoms, but does not produce euphoria unless doses are very high. If heroin is administered while methadone is on board, it prevents the euphoria associated with heroin. Its use as a replacement therapy is controversial and affected by general attitudes and perceptions about drug addiction. The late 70s especially saw strong demand to not open more methadone clinics, as punitive measures against drug addicts again became popular. Its controlled substance status prevents it from being administered by a personal physician, and it can only be given at one of these special clinics (it also is rarely allowed to be self-administered at home). I believe the Drug Enforcement Agency, and not a health care organization, is still the group that operates methadone clinics.

More about heroin: Heroin is converted into morphine in the brain, and acts at μ-opioid receptors on GABA inhibitory interneurons in the ventral tegmental area. This activation may close N-type calcium channels, possibly through G-protein interactions or inhibition of adenylyl cyclase. These interneurons are therefore inhibited. The resulting disinhibition at the post-synaptic cell leads to increased firing of dopaminergic cells that are usually inhibited by these interneurons.

The first epidemic of opiate addiction in the U.S. occurred after the Civil War - it is estimated that up to 400,000 soldiers were addicted to morphine (the infamous "skin-poppers," - morphine administered subcutaneously). The next time opiate addiction was widely publicized in this country was after the Vietnam War; where it's estimated that up to 50% of American soldiers used heroin regularly while in Vietnam, and 20% returned to the U.S. addicted. This was also around the time when cocaine was touted as "the perfect drug" by a weekly news magazine, a "non-addictive party drug," because of the lack of physical withdrawal symptoms from repeated cocaine use - it was believed then that addicts took drugs to alleviate withdrawal symptoms. Thirty years later, the anhedonia hypothesis has largely been discredited.


matt said...

I read a while back that until the 1980's, the UK actually allowed doctors to prescribe small amounts of heroin to addicts as a sort of 'maintenance', which was very common, and indeed many highly functional people were maintained in that way (I recall that one of the founders of Johns Hopkins University was one such, though of course that is a completely different time period). Then under the Reagan administration, the US put pressure on the UK to change to the methadone-clinic methodology, banning heroin maintenance altogether, and the results were terrible: addiction rates soared as people who had been able to wean themselves off the heroin "maintenance" were not able to keep functioning under a methodone "maintenance" schedule, and resorted to getting high from street dealers' heroin, in larger doses and with dangerous impurities.

Had you heard about any of this? It seems like, contrary to intuition, giving doctors the ability to prescribe small amounts of heroin to addicts might be the best solution.

AG said...

I don't know much about the history of drug policy in the UK, though a quick review does indicate that heroin maintenance therapy (as opposed to methadone maintenance therapy - MMT) was used for awhile in the 60's and 70's.

I'm a bit suspicious of addiction worsening as a result of a switch to MMT from heroin. Methadone has a longer half-life than heroin, and patients on methadone do not experience the euphoric effects of heroin, so as in the U.S. it may be more likely that the doses of methadone used were insufficient for maintenance. Other problems In the U.S. include the location of methadone clinics (the fact that methadone cannot be prescribed by a general practicioner and can only be obtained at a methadone clinic adds to the stigma of MMT), the pressure on physicians to NOT be part of such a maintenance therapy, the stigma against anything other than total abstinence when it comes to addiction, and as stated above, that the small number of physicians who are authorized to distribute methadone are under a tremendous amount of pressure to keep doses as low as possible - the average methadone dose given currently in the U.S. is below therapeutic levels. I'm unsure whether or not there are similar problems in the UK with MMT.

In the U.S. in the late 80s and early 90s, methadone dosage declined as purer forms of heroin that could be smoked or snorted hit the streets. This created a HUGE problem as the number of heroin addicts dramatically increased and maintenance therapy was called "ineffectual" although, of course, any drug treatment is going to be "ineffectual" when administered below the recommended dosage. By the way, purer forms of heroin available in southeast Asia in the 60s and 70s contributed to the addiction of U.S. soldiers. Many of the soldiers (most of whom smoked or snorted the drug) who were diagnosed with heroin addiction did not continue to use once back in the U.S. - probably because of the impurity of the heroin available in the U.S. at the time (necessitating injection for the same high, the stigma of i.v. injections, and the lack of drug-paired cues (my own research interest). Those who continued to use heroin tended to have used drugs prior to their tours of Vietnam, or were in other risk categories that made the propensity of abuse more likely.

I can't imagine (if it were a good solution) ever returning to a time when doctors would be able to prescribe schedule 1 or 2 drugs at their own discretion - there are simply too many risks involved for the doctors (most don't want to do it, both out of malpractice concerns and ethical/moral concerns that addicts should not be "maintained" on drugs of addiction) and the DEA watches doctors who are authorized to prescibe such treatments very very carefully.

In the political world conservative movements, which tend to favor abstinence programs instead of harm reduction in a whole host of behaviors, have really affected drug policy. I'm sure the UK's own conservative movement, with or without pressure from the Reagan administration, would have been in favor of instituting such changes, but I don't really know.

ranjini said...

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