“But the size of the addiction research enterprise is dwarfed by a $35 billion a year or so treatment industry in this field. This is a booming entrepreneurial world, where treatment centers charge people tens of thousands of dollars for various offerings. And despite all the investment in science, few of those treatments make much use of the scientific advances in the area of addiction. In fact, treatment approaches have not changed much at all over the past quarter century.” — Markus Heilig

This week our featured book is The Thirteenth Step: Addiction in the Age of Brain Science, by Markus Heilig. To open the week’s feature, Heilig has written a powerfully argued guest post in which he contrasts the advances in the science of addiction and the stagnation in the way that addiction is actually treated.

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Why have breakthroughs in addiction research not changed addiction treatment?
By Markus Heilig

The US taxpayers fund the overwhelming majority of addiction research in the world. Every year, Congress channels about $1 billion to the National Institute on Drug Abuse (NIDA). An additional almost 0.5 billion is separately given to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), my own workplace for the past decade. That may sound impressive, and in many ways it is. With the help of these resources, there have been truly amazing advances in the understanding of how addiction works. “Brain reward systems” have become part of the general parlance. The NIDA director has become a celebrity who has appeared on 60 Minutes. New findings on how alcohol and drugs get people hooked have shown a rare ability to fascinate people far outside the circle of scientists. And there has been perhaps a more modest, but still significant progress in figuring out better treatments.

But the size of the addiction research enterprise is dwarfed by a $35 billion a year or so treatment industry in this field. This is a booming entrepreneurial world, where treatment centers charge people tens of thousands of dollars for various offerings. And despite all the investment in science, few of those treatments make much use of the scientific advances in the area of addiction. In fact, treatment approaches have not changed much at all over the past quarter century. If someone were to be pulled out of a 12-step meeting then and transported through time to one today, he or she would probably not notice much of a difference. Here is, perhaps unsurprisingly then, something that the investment in research has not bought us: Any measurable dent in the damage done by addictions.

Some basic facts: Alcohol continues to kill about 80,000 Americans each year. Death from prescription pain killers adds almost 20,000 more, and has been on the rise for over a decade. As we have begun clamping down on these prescriptions, heroin has become resurgent instead. Why is it that all the passionate research efforts by dedicated scientists have such a hard time producing much of a change in the lives of real people with addictions? Only about one in 10 people with alcoholism ever receive treatment. For most of those, that is synonymous with joining Alcoholics Anonymous (AA), a movement formed three-quarters of a century ago, when medicine had little to offer addicts beyond perhaps treating the shakes of acute alcohol withdrawal.

As I wrote in an op-ed in the Washington Post almost two years ago, we now know that the effects of behavioral treatments for alcoholism are modest at best. The favored therapy in the US, 12-step treatment, fares even less well in scientific evaluations. A rigorous analysis by the Cochrane Collaboration, the original source of the evidence based medicine concept, found that “available . . . studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence compared with other treatments.” In fact, AA’s own surveys have indicated that for every 100 alcoholics entering their first meeting, only about 30 will be attending and sober a year later. That is very close to the spontaneous relapse rates consistently found by research over the past four decades.

Addiction, in its more severe forms, is simply very hard to treat. On a good day, AA-groups still offer a lot that is simply priceless for people who otherwise have little: A community, a context, and the support of others. But given how hard addiction is to treat, one would think the arrival of science-based addiction medications would be greeted with great enthusiasm. Yet nothing could be further from the truth. Let’s for a moment forget the Lasker-award winning advance, methadone maintenance for heroin addiction, or its younger cousin buprenorphine. These, after all, would require us to discuss the trade-off between lives saved, and the provision of medications that are addictive themselves, a worthy topic for another day. But the FDA determined already in 1994 that naltrexone (Revia) is an effective treatment for alcoholism. And naltrexone is completely non-addictive, safe, well-tolerated and cheap. It is by no means a panacea, but reduces the risk of heavy drinking by about 20 percent, even more in the right patient. Yet fewer than 10% of patients with alcoholism receive a prescription for naltrexone or, for that matter, any alcoholism medication. Medications that target brain function simply continue to be viewed unfavorably in most 12-step programs. Because of this, patients lose out on the benefits of treatment. Meanwhile, the pharmaceutical industry gets a clear message to stay away from investing in alcoholism therapies. What then, one might ask, is the point of devoting so much research to addictive disorders?

To change this, some of us doing the science will have to get out of the lab and try to get a public conversation going. If not before, this was clear to me some 7 years ago, when I saw a broadcast of Larry King Live. This was years after the FDA had determined that naltrexone is beneficial in treating alcoholism. That did not prevent Susan Ford Bales, then-chair of the Betty Ford Center, from bluntly dismissing it. “We do not use [these medications] at the Betty Ford Center,” she pronounced, as if that fact was its own justification. There is no other area of medicine where disregarding easily available evidence would be tolerated.

Equally problematic, as recently pointed out in a beautiful piece in The Atlantic by Gabrielle Glaser, is the uncompromising AA tenet that “once an alcoholic, always an alcoholic.” Its implication that abstinence is the only worthwhile treatment outcome continues to feed catastrophic thinking and a sense of being powerless when people slip, instead of promoting self-efficacy, learning, and harm-reduction. Sure – many alcoholics remain highly susceptible to relapse for life. Abstinence is always the safest bet. But many patients are not ready to pursue abstinence. Attempting to impose on them a treatment goal they are not ready for goes against reports from solid behavioral research, and turns people away from treatment.

As I wrote in my Washington Post piece: The system is broken. It must be fixed before too many more people die. The first step toward fixing it is trying to bring together what science has taught us about addiction over the past quarter century with the everyday experiences of people with addictions, their families, and their treatment providers. That is what I have attempted to do in my book.