Summer House

BBC News — Twin research projects have offered both present and future hope to people suffering from alcohol addiction.

US researchers say that epilepsy drug topiramate boosts general health as well as cutting the craving for drink.

A UK specialist said the potential side-effects of topiramate still merited caution.

A separate project showed that a single injection of a protein into the brains of rats almost immediately stopped them wanting alcohol.

Topiramate is not licensed in the UK for the treatment of alcohol addiction, although doctors are allowed to prescribe it if they wish, and occasionally do.

The latest study results, published in the journal Archives of Internal Medicine, could increase the number of doctors willing to do this.

Researchers from the University of Virginia analysed the results of the US-wide trial, which took 371 people with a heavy drinking problem, and gave them either topiramate or a placebo "dummy" drug.

They found, that over 14 weeks, those taking topiramate not only had fewer obsessive thoughts and compulsions about using alcohol, but had generally improving health.

Their weight, cholesterol and blood pressure dropped, and levels of liver enzymes linked to "fatty liver" disease, the forerunner of cirrhosis, also fell away.

Lead researcher Professor Bankole Johnson said: "What we’ve found is that topiramate treats the alcohol addiction, not just the ’symptom’ of drinking."

Side effects

Dr Jonathan Chick, a specialist in the psychiatry of addiction, welcomed the results, particularly the figures which proved better health, rather than relying on an estimate of reduced drinking levels, which could prove misleading.

He said: "There are other drugs which were originally developed to prevent epileptic seizures, which have also shown promise in reducing relapse in alcoholism, but topiramate is so far the most convincing."

However, he said that his own limited use of topiramate had been very carefully monitored to minimise the powerful side-effects of the drug.

In the other study, the Proceedings of the National Academy of Sciences Journal reported on a study in rats carried out at the University of California at San Francisco.

The scientists injected a brain protein called GDNF directly into a part of the brain called the ventral tegmental area, which is thought to be heavily involved in "drug-seeking" behaviour.

The rats were placed in an environment designed to mimic human social drinking, with a lever that could be pushed to deliver an alcoholic drink.

Rat rehab

The protein began working almost immediately, with effects noticed within 10 minutes.

The research also suggested that other cravings were unaffected, as the rats’ desire for their supply of sugary water continued unabated.

In addition, once treated with GDNF, rats seemed to be less likely to "relapse" to alcoholism after a "rehab" situation, in which the alcohol supply was cut off for a period of time, then reintroduced.

"Our findings open the door to a promising new strategy to combat alcohol abuse, addiction and especially relapse," said lead author Dr Dorit Ron.

Dr Chick said that there had been various attempts to interfere directly with the brain systems controlling alcohol cravings, although these had only achieved "mixed success" when transferred from experimental animals to humans.

ABC NEWS — A study at the University of Western Australia has found that heroin addicts with naltrexone implants are far less likely to return to heroin use than those taking oral tablets.

But critics are sceptical about the study and say that naltrexone is still a risky option for drug users trying to kick the habit.

Naltrexone is a drug which blocks the effects of heroin on the brain. It is usually taken as a tablet, but if heroin users stop taking the pill they often fall back into drug use.

That is why scientists have been working on an implant which automatically releases naltrexone into the body.

Gary Hulse from the University Of Western Australia is confident about the naltrexone’s success.

"It means that you’ve got a a one-stop shop. People can come in, they receive their treatment or implant and for five months or six months, they carry that treatment with them," he said.

The six-month trial involved 69 heroin users. Fifty-four completed the trial. Of the 28 participants who received a naltrexone tablet, 15 returned to regular heroin use. Of the 26 people who received a naltrexone implant, just two returned to heroin use.

Researchers like Mr Hulse say it is a good result for naltrexone implants.

"This is a relatively safe and a treatment which has good clinical outcomes," he said.

The study is yet to be published in a peer-reviewed medical journal, but the team at the University of Western Australia are confident the research will be well received.

"I’m not only confident that it’ll be published in a peer review but I would be surprised if this wasn’t accepted by one of the extremely high rating journals," said Mr Hulse.

But critics like Dr Alex Wodak, from the Alcohol And Drug Services at Vincents Hospital in Sydney, have little time for the new study.

"The paper hasn’t been published yet in a scientific journal and so therefore, it’s the equivalent of hearsay in a court of law. That is, it’s not really evidence," he said.

Naltrexone is a controversial drug. The implants are yet to be approved by Australia’s Therapeutic Goods Administration (TGA) and there have been mixed results for heroin users.

Some patients have stopped using heroin after receiving an implant. But others have cut them out of their body or suffered serious side effects.

"The implants, I know for a fact, were at one stage required by the therapeutic goods administration to be stamped, not for use in human subjects, and the authors have conceded that to me in writing," said Dr Wodak.

But researchers such as Moira Sim from the Naltrexone Trial Independent Monitoring Committee say the implants used in the Perth trial were approved by the TGA.

"The committee reviewed all the processes that the trial went through and we are confident that they followed the correct processes that the data was collected properly, and therefore I’m very confident in the results of the trial," she said.

The researchers say the next step will be to conduct a trial comparing naltrexone implants with methadone and other drugs used to control heroin addiction.

Washington Post – When it comes to treatment, the experts think alcoholism needs to catch up to depression.

Three decades ago, long before the dawn of the Prozac Era, depression was a disease rarely treated in its mild form, reluctantly treated with drugs and usually treated by experts only. Today, signs of depression are actively sought, drugs are prescribed early and often, and most cases are handled by nonpsychiatrists.

With alcohol abuse, however, most physicians don’t go looking for trouble and don’t recognize it until it’s breathing in their face. Over-drinking patients often don’t think of looking for help even if they know they are heading in the wrong direction. And society as a rule looks at alcohol treatment as a last-chance, 90-degree corner taken only at high speed.

Simplify screening

All this will change if American physicians adopt the new guidelines for "Helping Patients Who Drink Too Much" promulgated by the National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health.

The idea is to simplify the screening for excessive alcohol use in general medical practice and to convince clinicians and patients that early intervention for drinking that hasn’t yet wreaked havoc is both possible and useful.

"We’re trying to increase the accessibility and attractiveness of treatment to a much broader spectrum of people," said Mark L. Willenbring, a psychiatrist who directs the Division of Treatment and Recovery Research at NIAAA.

Those especially targeted in the guidelines are heavy drinkers who are not yet physically dependent on alcohol but are at risk for becoming so.

"We know that that group responds very, very well to what we call facilitated self-change and brief motivational counseling. We could make that very widely available without much cost," Willenbring said.

A big part of the new strategy is to make primary care physicians — people without specialized training in addiction medicine — think about alcohol abuse the way many now think about depression, anxiety and obsessive-compulsive disorder. Which is to say, they need to think of it as something common, diagnosable and within their capacity to treat. The guidelines make this easy: The screening tool for alcohol problems consists of a single question. For men: How many days in the past year have you had five or more drinks? For women: How many days in the past year have you had four or more drinks?

"Most doctors don’t know how to make the diagnosis and don’t really try to do anything about it until it is so easy to diagnose that all you have to do is glance at the patient," said Charles P. O’Brien, a professor of psychiatry at the University of Pennsylvania who has been treating alcoholics for 38 years.

"It used to be said that you can’t treat somebody until they are down and out. But when they are down and out, they are really hard to treat," O’Brien said.

Willenbring concurs.

"I think there is a belief that people with more moderate levels of dependence don’t know they have a problem. I think they do. But they don’t think rehab is the model of treatment for them — and I don’t, either."

The sort of therapy both advocate does not involve magic bullets or easy answers or effortless behavior change. But it does enlist pills that help a little, quite a bit of talk and lots of self-discipline.

And what does it get a person?

Perhaps not surprisingly, there’s evidence that getting control of a drinking problem early can improve one’s health, completely apart from the social, psychological and familial benefits it brings.

Looking at death rates

A study published two years ago looked at the experience of 628 men and women who entered alcoholism treatment (either in residential rehab or as outpatients) in their mid-30s and were followed for 16 years.

Over that period, 121 died, or 1.2 percent a year. The average age of death was 48. But the chance of dying was significantly lower in people who after the first year were abstinent or had no drinking-related problems or symptoms.

So how successful is treatment, or at least how successful has it been?

Researchers in 2000 analyzed seven studies, one going back to the late 1970s, in which more than 8,000 people were treated for alcoholism in various ways, including with drugs. After a single course of treatment, one-fourth were abstinent for at least a year and one-tenth dramatically decreased their drinking. The rest, about two-thirds of the subjects, drank less often and in quantities averaging less than half of what they consumed before treatment. Mortality in the first year was 1.5 percent.

Some of those patients had a four-week stay in "rehab," but most did not. A long treatment-center admission as the optimal strategy to stop a serious drinking problem is much more the model of the 1980s than the 2000s. The newer one emphasizes outpatient treatment — occasionally after a brief hospital stay for acute detoxification, if necessary — with care provided by non-specialists in many cases.

How often contemporary treatment succeeds was also explored in a complicated clinical trial of about 1,400 alcohol-dependent men and women, average age 44 and consuming 12 drinks a day, that was published in the Journal of the American Medical Association in 2006.

The researchers randomly assigned the patients to nine groups. Four of the groups got nine sessions, conducted by a doctor or nurse and lasting at least 20 minutes, that reviewed the health consequences of excessive drinking, encouraged abstinence and attendance at Alcoholics Anonymous meetings, and urged adherence to the study medicines. Four of the groups also got intensive counseling by alcohol-addiction experts — up to 20 hour-long sessions.

Drug therapy

Some of the patients were assigned to take a drug for three months: either naltrexone, which blocks opiate receptors in the brain that are involved in alcohol’s "reward pathways," or acamprosate, which works through so-called GABA receptors to decrease the anxiety and restlessness that can come with abstinence. Some got placebo pills.

A year later, there were no big differences among any of the groups, although there were some interesting small ones. (This was true even with what the researchers considered the placebo group, the people who received specialized alcohol counseling but no time with a physician and no pills.)

People who met regularly with a doctor or nurse and then got either naltrexone or the intensive counseling did equally well; about 66 percent were abstinent. People who had those sessions and got placebos did less well; 59 percent were abstinent. Those who got intensive counseling but no pills, neither active ones nor placebos, had an intermediate outcome, with 62 percent abstinent.

Unlike some other studies, this one showed no benefit from acamprosate. But that may not be the last word.

Interesting findings

A clinical trial not yet published showed the drug worked only when started during a period of abstinence, not while a person was still drinking. And last month researchers reported more evidence that GABA receptors play a role in alcohol addiction. Laboratory rats that got the drug gabapentin, which enhances the action of GABA, drank less — but only if they were already chronically exposed to alcohol. Those that used alcohol only occasionally did not show such an effect, suggesting the pre-existing state was crucial to the response.

Abstinence, in almost all practitioners’ minds, is always the goal. But its absence doesn’t signal abject failure.

"It is a fiction that the typical change process is a sudden transformation," Willenbring said. "The more common is a change process that lasts years and is characterized by lengthening periods of sobriety and shorter relapses until they are gone."

In that way, alcohol abuse is like depression. In another way, too.

"Recovery from depression requires effort. The same is true for alcohol dependence," he said.

And in both cases, he thinks they’re really worth the effort.

PARIS (AFP) — The drug buprenorphine is twice as effective as a rival treatment called naltrexone in helping heroin patients stay off the narcotic, a trial published in The Lancet on Friday said.

The two drugs, along with a dummy pill called a placebo, were tested for 22 months among 126 patients in Malaysia who had emerged from a detoxification and counselling programme, it said.

Buprenorphine, which is marketed as Temgesic or Buprenex, was twice as effective as naltrexone (branded as Revia, Depade or Vivitrol) and the placebo in terms of days of abstinence from heroin and a full-fledged relapse to the narcotic.

Indeed, buprenorphine proved to be so superior that the trial was halted early, as it would have been unethical to continue it to its scheduled end.

The study, led by Yale University’s Richard Schottenfeld, gives support for placing buprenorphine alongside methadone, and both of them over naltrexone, as pharmacological treatments for helping addicts stay off heroin.

The three drugs belong to a class called opioid antagonists.

These treatments are increasingly used to help ease heroin dependence but remain prohibited in some countries, amid suspicions that they are liable to be abused or simply substitute one addiction for another.

The study is important because it gives the first assessment of the relative effectiveness of two of the opioid antagonists.

Heroin and other illicit opiates were once a problem mainly confined to developed countries, but in the past few decades have spread to developing economies and nations of the former Soviet bloc.

China, India, Indonesia, Iran, Malaysia, Pakistan and Russia are among the countries where expansion of heroin use has risen fastest, according to a 2004 World Health Organisation (WHO) paper.

Times Union — Tatum O’Neal, the Oscar-winning actress, took a plea deal last week stemming from her June 1 arrest while supposedly trying to score some crack cocaine on the Lower East Side of Manhattan. She was initially charged with possession of a controlled substance and faced a year in prison if convicted. The court allowed her to plead out to a disorderly conduct charge and ordered her to attend two half-day drug treatment sessions. If she follows the court’s orders, the cocaine possession charges will be dismissed.

O’Neal has been open about her history of heroin addiction as outlined in her memoir, "A Paper Life." When she was arrested by undercover officers, they searched her and found two bags of cocaine along with an unused crack pipe. She had initially told police she was doing research for an acting role. Then she changed her story and told them that the death of her 16-year-old dog nearly triggered her into relapse.

Some say O’Neal was treated with a slap on the wrist. Others say she did not deserve to do any jail time because of her addiction. This raises a critical question that we as a society need to address. Should we treat drug addiction as a criminal matter, or as a medical problem?

For most people, treatment is a much more effective approach than imprisonment for successfully breaking their addictions, yet our prisons are full of individuals whose only crime is their drug addiction.

According to Justice Department statistics, the United States has more prisoners than any country in the world, 2.5 million and rising. In 2006, the Justice Department recorded the largest increase since 2000 in the number of people in prisons and jails. Criminal justice experts attribute the exploding prison population to harsh sentencing laws and record numbers of drug law violators entering the system, many of whom have substance abuse problems.

Nonviolent drug offenders like Tatum O’Neal should be given an opportunity to receive treatment, not jail time, for their drug use. This would be a more effective (not to mention much more affordable) solution for both the individual and the community. Prosecutors in many states, most notably New York, have leeway to recommend a defendant to treatment instead of incarceration. More than likely, however, they will not do it. This is because it would not be considered a victory for them. The system does not reward prosecutors for doing the compassionate thing.

O’Neal can be an example for millions of young people. One can only hope that her experiences with addiction and the realities of the drug war will encourage her to join the movement to reform U.S. drug policy. If she decides to take up the cause of treatment, she could help change laws across the country. After all, if treatment instead of jail is good enough for her as she struggles with her addiction, surely it is good enough for the thousands of others just like her who struggle with their own substance abuse problems.

Like depression, addiction affects tens of millions of Americans. How best to treat it is a serious a question we need to explore. Rich or poor, young or old, addiction has no boundaries. But the drug war does. Our long war on drugs has stifled the open debate society should be having about the nature of addiction and how best to deal with it. It is time to treat addiction for what it is — a medical problem, not a criminal one.

NEW YORK (Reuters Health) - Infants born to women with substance abuse problems will fare better if their mothers undergo treatment for these problems early in pregnancy, according to the largest study to date to investigate this issue.

In fact, they did just as well as babies born to mothers who didn’t have issues with drug or alcohol use on nearly all of the measures the researchers looked at, Dr. Nancy C. Goler of The Permanente Medical Group in Vallejo, California, and her colleagues found.

"It is time for our nation to look at the issue of substance abuse in pregnancy with a non-judgmental, coordinated, effective intervention that all pregnant women can easily access," they write in the Journal of Perinatology. Such treatment should become the "national standard," Goler and her team urge.

Kaiser Permanente Northern California (KPNC) screens pregnant members for substance abuse with questionnaires and urine tests and offers "state of the art" treatment through its Early Start program, the researchers explain in their report. Women identified as having problems receive care from a specialist in both prenatal care and substance abuse treatment who is based at her local Woman’s Health Clinic.

To evaluate the program’s effectiveness, the researchers looked at outcomes for 49,985 women who underwent screening at KPNC clinics from January 1, 1999 to June 1, 2003. They compared four groups: the 46,553 women who screened negative for substance abuse problems (control group); 2,073 who screened positive and underwent treatment; 1,203 with substance abuse problems who were assessed as part of the Early Start program but weren’t treated; and 156 who tested positive for substance abuse but weren’t assessed or treated.

Most women in each of the four groups received the same amount of prenatal care, but the control and treatment groups were more likely to begin prenatal care before 13 weeks of pregnancy than women in the other two groups.

The rates of 8 of the 10 maternal or fetal complications the researchers evaluated were similar for the control group and the group of women who received treatment. However, infants born to treated women were slightly more likely to be low birth weight or to require admission to the newborn intensive care unit.

Infants born to women treated for substance abuse were less likely to require assistance in breathing shortly after birth than babies born to women with substance abuse issues who weren’t assessed or treated, Goler and her colleagues found. And fewer of these infants were preterm or low birth weight.

Rates of these and other complications for babies born to mothers who were assessed but not treated for substance abuse were generally between those of the treated women and those who weren’t assessed or treated.

Substance-abusing women who weren’t assessed or treated were significantly more likely than any other women in the study to develop a serious pregnancy complication called placental abruption. Their risk was nearly seven times as great as that for women in the control group. The fetuses of these women also were 16 times more likely to die in utero compared to the control group, while rates of fetal death for women who were assessed or assessed and treated weren’t significantly different from the control group.

Before KPNC initiated its Early Start program, Goler and her team point out, women diagnosed with substance abuse issues were referred to outside treatment programs, but typically didn’t show up for these appointments.

The Early Start model of care "affords women easy access to the program by removing both the physical and emotional barriers that can be overwhelming in pregnancy," the researchers conclude.