Pablo Iglesias

Is Suboxone a Wonder Drug that Helps Heroin Addicts Get Clean–Or Just Another Way to Stay High?

By Anna Merlan Wednesday, Oct 23 2013

Five months ago, Chris resolved that it was finally time to get clean.

Suboxone is “not being used in the context we’ve seen it to kick a habit or even to replace a narcotic dependence. It’s just a way to control your habit a little bit better.”

Sort of.

The 34-year-old Brooklyn real estate broker (who declined to be identified by his real name; “Chris” is a pseudonym) had begun using heroin and quit once before, in his late teens. But family problems and a few tough months caused him to relapse, and soon he was snorting the drug two or three times a week.

After nearly a year of using, the days between doses started to get dicey, and Chris got worried. On the off days, he says, “I was never myself. I was irritable, exhausted, had no motivation or desire to do things I once enjoyed doing. I wasn’t happy.”

So, in between bags of heroin, Chris scoredSuboxone, a prescription painkiller used to treat opiate addiction. He’d use it when he was making a halfhearted attempt to get sober, or when he just didn’t want to feel bad between bags. Thanks to its main ingredient, buprenorphine hydrochloride, Suboxone eliminated the agonizing heroin withdrawal, the “three days of complete hell” he had to go through every time he tried not to use.

Chris didn’t get Suboxone through a doctor, at first. He didn’t have to. It was easier and quicker to buy the drug from a friend who had a prescription and lots of leftovers, which he was willing to sell to Chris for $5 a pop. “Subs,” as people often shorthand the drug, come in paper-thin strips, a lot like theListerine kind, that melt under the tongue. Chris’s friend took half of a two-milligram strip each day and sold the extras to Chris.

Eventually, Chris decided he was spending too much money on the subs. He found a physician willing to prescribe him 24 milligrams a day—a “totally ridiculous” dose, he says, far too much for one person to take. (According to the drug’s manufacturer, U.K.–based Reckitt Benckiser, the recommended maintenance dose is anywhere from four to 24 milligrams.) He takes one or two strips each day, two to four milligrams, and sells the rest on Craigslist.

“I don’t work with everyone,” Chris says. “I’m probably more cautious than most.” He tries to weed out law enforcement by asking for Facebook or LinkedIn profiles to back up the buyer’s identity. “I’m not a full-blown addict. I do have a job. I have a lot to lose.” Besides, he adds, “I’d rather sell to someone who wants to get clean, rather than someone who just wants it in between their heroin binges. I’d rather help someone.”

Other dealers up and down the East Coast who sell buprenorphine take the same tack in their Craigslist sales, positioning themselves as stops on the road to recovery.

“If you’re trying to kick your diesel habit, then TEXT me asap!” writes one dealer. “Heroin is overwhelming here in New Jersey, so please do the right thing and get on Subutex asap!”

“Not LE here,” writes another dealer in Soho, using the shorthand for “law enforcement.” “Just a guy with a few extras and looking to help someone in need. Please be real about getting clean.”

“No bs and no le,” echoes a poster in upstate Montgomery County. “I’m just trying to help someone who needs to be off of pain medication.”

The technical term for what Chris and other dealers are doing is “diversion,” and it is, as you might guess, illegal. Selling your meds is a class C felony in New York, carrying a minimum of one year and a maximum of 10 in prison.

In the case of Suboxone and its generic equivalents, diversion is also increasingly common. Suboxone has been on the market in the U.S. since the late 1990s. Over the past two years, sales have skyrocketed, corresponding to a rise in heroin and (especially) painkiller addiction. The number of pain-pill prescriptions hovered around 209.5 million in 2010; the National Institute on Drug Abuse estimates that 5 million people in the U.S. abuse painkillers.

It’s hardly surprising that a drug that can help people get off opiates has become a runaway success. According to IMS Health, a company that collects data about the drugs U.S. doctors prescribe, Suboxone reached $1.4 billion in sales in the first quarter of 2012—nearly 10 times the figure from 2006. Seven years ago, Suboxone was the 198th-most commonly prescribed drug in the U.S. Today, it ranks 26th. In 2012, doctors wrote 9.3 million prescriptions for buprenorphine. From January to March of this year, they wrote 2.5 million more. A majority were for Suboxone, which controls about 70 percent of the buprenorphine market.

As the legal market for the drug expands, so does the black market pooling underneath. If Chris is too picky, Craigslist drug seekers can do business with 24-year-old Luis, who teams up with a friend with a prescription to sell the drug. Luis, who calls himself a “distributor,” is homeless and says he’s selling Suboxone to finance his move out of the shelters. That, and a desire to help folks.

“People thank me,” he says earnestly. “I’m not doing a bad thing. I’m not selling drugs.”

In her line of work, Bridget Brennan sees—and busts—a lot of drug dealers. She’s immensely skeptical of the notion that anyone buying Suboxone on the street is taking it to get clean.

“To me, that seems highly unlikely,” she says. “You don’t need health insurance to go to a treatment center.”

Brennan is New York City’s Special Narcotics Prosecutor, and her office is responsible for prosecuting drug crimes. It was created by the city’s five district attorneys in the 1980s as a way to respond to a new epidemic of heroin and a corresponding citywide increase in violent crimes.

Brennan doesn’t seem surprised, or especially concerned, to learn that people are using Craigslist to sell their detox meds. She notes that Craigslist drug sales have transpired on and off for years. “Our focus is on more of the major suppliers,” she says. “But we do monitor Craigslist, and we do periodic sweeps there.”

Brennan says that, in her experience, most dealers carry Suboxone as a way to keep their clientele happy; in recent years, her office has busted several drug rings that stock it alongside heroin, Xanax, and Percocet. Addicts buy Suboxone when they can’t afford their drug of choice, or when they have a pressing social engagement that requires them not to turn up totally high.

“It’s not being used in the context we’ve seen it to kick a habit or even to replace a narcotic dependence,” she asserts. “What I’ve seen is not a real commitment to getting clean, it’s just a way to control your habit a little bit better.”

Mike Laverde agrees. He’s a former heroin addict himself, now nine years sober and an intervention specialist with a Chicago company called Family First Intervention. Like Brennan, he sees black-market Suboxone users as just another subspecies of addict.

“They think they can take the Suboxone and come off drugs themselves,” he says. “But they can’t. The problem in the drugs department is them.” Without actual treatment, Laverde says, addicts are very likely to fall back into dependence on their drug of choice. That practice—toggling back and forth between the drug you like and the drug that helps you avoid withdrawal—is known as “bridging.”

“People cycle on and off, absolutely,” says Jose Sanchez, a substance-use counselor at the nonprofit Lower East Side Harm Reduction Center. His clients, Sanchez explains, tell him they carefully plan out their drug use. “They’ll stop taking the Suboxone for a couple days, so that by the third day they’ll be able to feel that zing of the opiate, whether it’s heroin orOxycontin.”

It’s unlikely they’ll ever really get clean that way, he adds. “It certainly could work. But I think to be successful, you need every bit of support you can get”—i.e., counseling and a doctor’s supervision.

When someone self-medicates with Suboxone, Sanchez says, “You really can’t judge how well the medicine’s working for you. All you know is you feel good that day, and the next day you want to feel just as good.”

If you wanted to kick an opiate habit the aboveground way, you might visit a doctor likeDana Jane Saltzman, an internist who’s also one of the 1,600 doctors in New York State authorized to prescribe Suboxone. Her practice is hidden away in midtown, in a nondescript, five-story building not far from the marquee lights of the Ambassador Theater. She keeps two websites, one for her regular practice, and the other,NYCSuboxone.com, for people looking to get clean.

Saltzman’s building is a little down at the heels, but her clientele is anything but. Most of her Suboxone patients, she says, are Wall Street guys, “masters of the universe types” who find themselves with a pain-pill addiction and a pressing need to get sober without cutting into their 100-hour workweeks.

“I see a lot of young men, very high-functioning, very ambitious and upwardly mobile,” Saltzman says. Many of them are prescribed Oxycontin after they sustain sports injuries: shoulders, backs, knees. A client came to see her several weeks ago who’d been on the painkiller for two years before he realized he’d become dependent.

Buprenorphine is popular with Saltzman’s patients and other opiate addicts for one basic reason: It too is an opiate.

“It hits and stimulates the same receptors in the brain that are affected by heroin ormethadone,” explains Adam Bisaga. He’s a professor of clinical psychiatry at Columbia University and an addiction researcher at the New York State Psychiatric Institute.

Like other opiates, buprenorphine binds to certain receptors in the brain. It’s “stickier” than drugs like heroin, binding to those receptors faster and holding on longer: Morphine has a half-life of about two hours; buprenorphine’s is anywhere from 24 to 60 hours.

Buprenorphine is also a partial opioid agonist. It doesn’t fill up the brain’s receptors as completely as heroin or painkillers do, making its effects much more muted than the intense euphoria heroin offers.

“It stimulates the receptors, but only to 50 percent,” Bisaga explains. “At some point there’s a ceiling, and no matter how much you take, you’ll never get across that. It’s like an electronic block on your gas pedal in a sports car.”

To further limit its effects, Suboxone contains naloxone, an opiate blocker. The most famous naloxone-containing drug is Narcan, which can treat people during an overdose, and which has no known potential for abuse. Subutex, a Reckitt Benckiser-manufactured formulation that’s pure buprenorphine, is more potent—and in greater demand on the black market. Saltzman says she won’t prescribe it unless a patient has a proven allergy to naloxone.

Suboxone’s older cousin, methadone, is a full agonist, meaning that its effects, along with its getting-high and overdose potential, are that much stronger. But Suboxone offers users a powerful feature methadone can’t match: It’s designed to be taken at home, whereas by law methadone is required to be distributed at a clinic. (In New York, methadone patients can get take-home doses, but they’re tightly controlled; to get a six-day supply, a patient has to have been in treatment for at least three years.)

“You have to go to the clinic every day, and that has a little bit of a reputation,” Bisaga says. “Many people don’t like the idea.”

Buprenorphine was introduced as a treatment for opiate addiction in Belgium in 1983, in the form of little orange tablets that were placed under the tongue. Four years later, it was being used in France. Reckitt Benckiser won approval to distribute Suboxone in the U.S. in 1994, although it wasn’t released here until 2003. At the time, the Food and Drug Administration granted it “orphan” status, which is awarded to drugs that are meant to treat “rare diseases or conditions” and aren’t expected to be profitable. Orphan drugs qualify for generous tax credits, and the FDA can’t rescind the designation once it’s granted.

Suboxone retained orphan status until 2009, when the patent for the tablets expired. Several U.S. drugmakers promptly set to work making generic versions, two of which went on the market this past February. That month, analysts projected Reckitt’s annual pharmaceuticals profit would take as much as a 4 percent hit.

By 2006, Suboxone’s abuse potential had become pretty clear: A study of French buprenorphine users found that a lot of them were crushing up their tablets and injecting them. According to the European Opiate Addiction Treatment Association, the same problem soon turned up in England, Ireland, Scotland, New Zealand, Australia, Finland, and the Czech Republic. (A recent report in the daily Prague Post estimates that Subutex accounts for 70 to 80 percent of all drugs sold on the street.)

Also in 2006, the federal Substance Abuse and Mental Health Services Administration(SAMHSA) found the same issue cropping up in the U.S., noting that buprenorphine abuse appeared to be “concentrated unevenly in Northeastern and Southeastern regions.”

Seeing buprenorphine cross the Atlantic came as no surprise to Bisaga. “It’s a problem with every drug we have,” he says. “It was just a matter of time.”

Introduce a drug, and soon people will find a way to use it to get high.

According to SAMHSA figures, emergency-room visits involving buprenorphine use “increased substantially, from 3,161 in 2005 to 30,135 visits in 2010, as availability of the drug increased.” More than half of the people seen at the ER reported that they were using the drug “non-medically.”

The researchers who studied French buprenorphine injectors wrote that it seems “pharmacologically impossible” for anyone to get high from the drug. And yet, they say, the addicts did report feeling a “rush” after injecting it, which the researchers chalked up to the placebo effect.

The question for drug- and policy-makers alike is how to short-circuit any new drug’s potential for getting you high. Adding naloxone to buprenorphine hydrochloride is one way to limit abuse, Bisaga says. Another was to pull the tablets off the market and replace them with a film designed to be impossible to abuse. (According to several pharmacies theVoice contacted, brand-name Suboxone tablets are still available, at least in New York, though Reckitt Benckiser had notified the FDA in February 2012 that it would voluntarily discontinue the tablets. The company said at the time that the pills would be off the market by March 2012 at the latest. Reckitt Benckiser did not respond to several requests for comment for this story.)

People still try very hard to make the most of their Suboxone; Internet forums are full of tips and tricks about how to get high off the strips. Some users recommend melting them in water and injecting them, or offer instructions on how to “snort” them. Others insist the would-be stoners are wasting their time, that “bupe” won’t ever get you lifted.

Bisaga begs to differ. “People who are not in treatment, not taking it every day, can get high.” If you take it consistently and correctly, as part of a treatment plan, you probably won’t feel any euphoric effects, he says. But taken more sporadically, it’s possible: “You wouldn’t get as high as with heroin. It’s not such a powerful, instant, intense euphoria. But you’d still feel somewhat affected.”

Some patients in treatment report that the drug has mood-lifting properties. “People often feel good on Suboxone,” notes Saltzman, the Suboxone specialist. “Many people say they feel better than they have in their lives.”

Saltzman has seen the rise of Suboxone abuse firsthand. She has had a license to prescribe it since 2000; in the past few years, the number of patients she suspects are diverting the drug is increasing.

“There’s a constant wave of diversionary tactics in here,” she says. “It’s constant and unending. It’s just piling up.”

She tries to weed out the drug-seekers from the people who are genuinely eager to get sober. She requires patients to attend group therapy and one-on-one sessions with a counselor, and she encourages them to enroll in a 12-step program like Narcotics Anonymous. She also drug-tests them every time they come in to have their prescription refilled.

“If someone doesn’t want to give a urine sample, that’s always a bad sign,” she says. “That may mean their last prescription was sold on the street.”

Saltzman is quick to add that most of her patients—including the ones who relapse or sell their prescriptions—genuinely want to get better. She acknowledges, too, that her treatment is too expensive for many: $400 for the initial visit and $250 for every visit thereafter. The medication itself is covered by insurance, but the office visits aren’t.

That’s by design, Saltzman says. Otherwise “we’d have lines out the door. It would be a whole different thing. Making people pay is about getting their full attention. It’s very intense work, and it’s not at all like primary care.” (By law, Suboxone doctors can only treat a maximum of 100 patients.) A couple of low-cost clinics in the city don’t charge for the initial visit, but most Suboxone doctors’ rates are as steep as Saltzman’s.

As for the price of the drug itself, at a CVS pharmacy, the estimated price for an uninsured person to get 30 days’ worth of Suboxone tablets is $295. At Duane Reade, it’s $315. At Rite Aid, it’s $283. Insurance brings down the price substantially: United Healthcare’s rate is $60 ($25 for the generic). Blue Cross Blue Shield‘s is about $40; Aetna‘s, $75.

Chris, the real estate broker and Craigslist dealer, routinely gets e-mails from people who say the price is what prevents them from procuring the drug legally.

“im interested in yr add,” a recent would-be buyer wrote. “recently lost insurance, and the cost of a doctor/script is just too much fr me right now. very serious about getting off, without getting too sick to work. Im a professional honest guy with a family you can look me up on facebook, just search [redacted] in new york, there is a drawing of a rabbit as my main photo. Please keep it discreet and profess. and i will do the same.”

Motive and legality aside, how harmful is “bridging” with Suboxone? Every dose of buprenorphine is a dose of heroin (or the like) not taken. And a person is far less likely to die from using buprenorphine. According to Joshua Lee, a professor at New York University Medical Center and an attending physician at Bellevue Hospital, buprenorphine has “less overdose potential” than methadone. In particular, it’s less likely to cause “respiratory depression”—the physical state when breathing becomes so shallow as to no longer provide the body with oxygen.

“As doctors prescribing it, we’re very concerned with this,” Lee says of black-market use. “And we discourage people from doing that. But from a public-health, harm-reduction standpoint, we acknowledge that diversion of buprenorphine seems different than diversion of oxycodone, say, or Xanax.”

“So many people who cannot afford the medications from legitimate sources are basically buying it on the street to treat themselves,” offers Bisaga, the Columbia professor and addiction researcher. “I don’t think these people are doing it to get high—although certainly there are people like that. I think most of them are just trying to get treated at low cost, which is obviously a tragedy. Most developed countries in the world have free treatment for drug addicts and this is no longer an issue.”

A few months after he began selling his prescription on Craigslist, Chris has decided to stop for good. “I pulled all my ads down,” he says.

Chris is muscular and pale, and he looks exhausted. He’s wearing a V-neck sweater and jeans, and carrying a shoulder bag that looks like something a doctor making house calls might use. He says he saw “many, many” people in the few months he was selling—including attorneys, fellow real estate brokers, and even one addiction counselor.

Chris says he got himself off Suboxone, a process he describes as “brutal.” He did it by transitioning to the painkiller Percocet, then weaning himself off that.

The experience of detoxing left Chris with mixed feelings about Suboxone. “On the one hand, it is a good thing,” he says. “It keeps people from stealing and robbing and overdosing. But it really just masks the issue: the addiction. From heroin withdrawals, you move onto Suboxone, and then you have to go through those withdrawals. It’s something that’s going to happen, but a lot of us choose to prolong it.”

In the longer term, he adds, the drug also made him feel “like total shit.”

“My girl always says I couldn’t even formulate sentences,” he explains. “I was not articulate. I couldn’t fuck her, excuse my language. I was just totally like a zombie. And then my feet were constantly uncomfortable. I couldn’t sleep without it. My eyeballs would turn into like these huge dishes, big pupils like Mickey Mouse.”

To his dismay, Chris realized that he initially felt even worse when trying to pull back on the Suboxone than when he experienced heroin withdrawal. “You’re exhausted for a very long time. It takes forever to get out of your system,” he says.

He believes now that his doctor didn’t adequately warn him that the detox drug had the potential to be addictive, nor about its “sticky” properties. “The doctor I was seeing—it was literally five or 10 minutes—he sits there and gives his typical speech about how bad drugs are, et cetera, and then he writes a scrip, and I’m gone. He gets paid, I go fill it, and that’s it.”

Saltzman says some Suboxone doctors operate as little more than drug mills. “I had one of them get arrested right in front of me on 57th Street the other day,” she says. In part, she goes on, the problem may have to do with how Suboxone doctors get their licenses. Ten years ago, in order to be able to prescribe the drug, she was required to complete a two-day class at Mount Sinai Hospital. These days, she says, “it’s an Internet course that takes a couple of hours.”

Chris also was disturbed to hear his doctor tell him that he might have to use buprenorphine for the rest of his life. “It made me feel like a loser,” he says.

Adam Bisaga takes a different view. “This is the push that they hear from [12-step programs],” the Columbia professor says. “That recovery with medication is something inferior. That you’re not truly in recovery until you take nothing. It’s not science. It’s just ideology from a 12-step movement that makes them vulnerable to relapse.” (Responds a spokesman for Narcotics Anonymous: “The experience of NA members is that being clean means complete abstinence from all mood- and mind-altering drugs. That said, NA welcomes everyone. Ultimately, we’re not in the business of telling people blanket statements about whether they’re clean or not.”)

“On the other hand,” Bisaga adds, “you do hear the stories of the pharmaceutical industry pushing people to stay on as much medication as possible. Depending on where you stand in this conversation, you can hear arguments on both sides. We rely on science and effective treatments, and we’d like patients to make informed decisions on their future.”

Saltzman says some of her patients are, for all practical purposes, on the drug permanently, but she doesn’t encourage it. “I don’t like that idea. It’s not a healthy way to live,” she says. “To me it speaks to someone not wanting to look at themselves.”

Chris gazes out a window and rubs his legs, which sometimes still hurt. “At some point,” he says, “you have to pay the piper. There’s no easy way out with opiate addiction.”

Asked how long he’s been clean, he smiles, looking both proud and more tired. “Two weeks,” he says.

amerlan@villagevoice.com

By Join Together Staff | September 12, 2013 |

The number of people seeking addiction treatment could double under the Affordable Care Act, the Associated Press reports. Under the new law, four million people with drug and alcohol problems will become eligible for insurance coverage. The surge of new patients is likely to strain the substance abuse treatment system, the AP notes.

How many new patients will seek addiction treatment will depend in part on how many states decide to expand their Medicaid programs.

“There is no illness currently being treated that will be more affected by the Affordable Care Act than addiction,” Tom McLellan, CEO of the nonprofit Treatment Research Institute, told the AP. “That’s because we have a system of treatment that was built for a time when they didn’t understand that addiction was an illness.”

The new law designates addiction treatment as an “essential health benefit” for most commercial insurance plans, meaning the plans must cover it.

Substance abuse treatment is to a large extent publicly funded, and run by counselors who have limited medical training, according to the article. Programs are already running over capacity in many places, and have been hit by government budget cuts. The increase in patients could result in long waiting lists, treatment agencies warn.

According to the 2012 National Survey on Drug Use and Health, 23.1 million people ages 12 and older needed treatment for an illicit drug or alcohol use problem last year, but only 2.5 million received treatment at a specialty facility. About one-quarter of those who need treatment but do not receive it lack insurance, according to the article.

NIH study finds chronic alcohol use shifts brain’s control of behavior

Chronic alcohol exposure leads to brain adaptations that shift behavior control away from an area of the brain involved in complex decision-making and toward a region associated with habit formation, according to a new study conducted in mice by scientists at the National Institutes of Health.

The finding provides a biological mechanism that helps to explain compulsive alcohol use and the progression to alcohol dependence. A report appears online in the Proceedings of the National Academy of Sciences (PNAS).

The brain’s prefrontal cortex is involved in decision-making and controlling emotion, while the dorsal striatum is thought to play a key role in motivation and habit formation. Past studies have shown that alcohol dependent individuals show problems with skills mediated by the prefrontal cortex such as impulse control. These same individuals often show exaggerated neural response in the dorsal striatum to alcohol-related cues.

To investigate whether changes in the dorsal striatum might account for these observations, researchers led by Andrew Holmes, Ph.D., in the Laboratory of Laboratory of Behavioral and Genomic Neuroscience at NIAAA, measured changes in the brains of mice that were chronically exposed to alcohol vapors.

He and his colleagues found profound changes in the dorsal striatum of these mice, including the expansion of neuronal dendrites, the branching projections of the nerve cell that conduct signals. Such changes are also seen with chronic exposure to drugs such as amphetamine. These structural changes were associated with changes in synaptic plasticity, the brain’s ability to change in response to experience, and reduced activity of endocannabinoid receptors, which are part of a signaling system that may play a role in sensation, mood, and memory.

“These findings give important insight into how excessive drinking affects learning and behavioral control at the neural level,” said Kenneth R. Warren, Ph.D., acting director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). “The shift to increased striatal control over behavior may be a critical step in the progression of alcoholism.”

“The changes we observed suggest that the manner in which the dorsal striatum signaled and adapted to environmental information has been altered by alcohol,” said senior author Dr. Andrew Holmes. “The findings imply that chronic drinking may set up a concerted set of adaptions in this key brain region that produce a bias for striatal control over behavior.”

Such changes could contribute to the emergence of habitual and compulsive patterns of behavior in alcohol abuse, and suggest that treatments designed to normalize striatal function may be an important approach for alcohol treatment.

Dr. Holmes and his colleagues add that their findings suggest that drug abuse doesn’t simply impair brain functions, but instead produces a complex set of adaptations that tamp down the function of some brain regions while dialing up the function of others.

Indeed, the researchers found that chronic alcohol actually improved the ability of mice to learn to make choices on a touchscreen.

“Improved performance on learning tasks that we know depend on the dorsolateral striatum is particularly interesting because it suggests that alcohol could prime the brain to favor other dorsal striatal behaviors – including things like habit formation, which may foster addictive patterns of behavior,” said Dr. Holmes.

The National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health, is the primary U.S. agency for conducting and supporting research on the causes, consequences, prevention, and treatment of alcohol abuse, alcoholism, and alcohol problems. NIAAA also disseminates research findings to general, professional, and academic audiences. Additional alcohol research information and publications are available athttp://www.niaaa.nih.gov.

About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visitwww.nih.gov.

NIH…Turning Discovery Into Health^®

Reference

Chronic alcohol produces neuroadaptations to prime dorsal striatal learning. DePoy L, Daut R, Brigman JL, MacPherson K, Crowley N, Gunduz-Cinar O, Pickens CL, Cinar R, Saksida LM, Kunos G, Lovinger DM, Bussey TJ, Camp MC, Holmes A. PNAS. 2013 Aug 20. [Epub ahead of print]

Jarret Liotta

for National Geographic

Published August 9, 2013

Science has never revealed as much about addiction—potential genetic causes, influences, and triggers, and the resultant brain activity—or offered as many opportunities and methods for initial treatment as it does now.

Even so, the grassroots 12-step program remains the preferred prescription for achieving long-term sobriety.

Since the inception of Alcoholics Anonymous (A.A.)—the progenitor of 12-step programs—science has sometimes been at odds with the notion that laypeople can cure themselves.

Yet the success of the 12-step approach may ultimately be explained through medical science and psychology. Both offer substantive reasons for why it works.

Climbing the Steps to Recovery

The “miracle” of A.A. can be traced to the evening of June 10, 1935, when a struggling alcoholic named Bill Wilson, fighting to stay dry while on a business trip to Akron, Ohio, met with an apparently hopeless drinker named Bob Smith in order to quell his own thirst.

It had been suggested to Wilson, through a religious organization called the Oxford Group, that talking to wet drunks about his experiences and trying to help them get sober would, in turn, help him stay dry. Smith, once a respected physician in the community, was referred to him as someone at bottom, beyond help.

Their discussion sparked the insight that the best hope for sobriety was a daily reprieve from alcohol, which stood with the singular practice of helping others.

Over the next five years, a non-denominational program emerged that drew much of its spiritual doctrine from Christian practices. It embodied an action plan in the form of 12 “steps” that are essentially guidelines for right living, including taking a personal inventory of one’s strengths and shortcomings, making restitution for past wrongs, and helping others find sobriety.

A.A. reports that more than two million members worldwide currently stay sober by regularly attending meetings and implementing these steps.

In recent decades, the 12 steps have been applied to other addictions—everything from drugs, food, and other substances to various compulsive behaviors around gambling or sex.

Psychic Solution

Most addicts receive less than 30 days of inpatient treatment. But they must also accept that they need ongoing outside help.

The 12-step approach, said Paul Gallant, an interventionist with 27 years of sobriety, is “so popular with treatment centers because it’s proven to work. When a person completes treatment, they have a place to go.

“Self-knowledge is not a sufficient treatment for alcoholism,” continued Gallant. “I’ve worked with people who have had years and years of psychotherapy and intensive analysis, but it’s brought them no closer to ongoing abstinence.”

However, experiencing what Gallant called a “psychic change,” which in the 12-step world is linked to the marvel of a “spiritual awakening,” often results in a distinct personality and behavioral transformation that leads to long-term sobriety.

“The not-drinking is really just a part of it,” Gallant said. “It’s not drinking and changing as a person. That psychic change needs to come from a program of spiritual development, and so far the greatest success has been Alcoholics Anonymous.”

Community Spirit(ual)

Established treatment facilities like Sierra Tucson offer everything from traditional medicine to such alternative approaches as equine therapy and healing circles.

According to Nia Sipp, staff psychiatrist with Sierra Tucson, the goal is not just removing the substance or behavior but also facilitating self-reflection and creating social systems. “Oftentimes people feel that it’s about God and other things,” Sipp said. But she believes that the A.A. concept is more about “the spirit of community.”

Rev. Jack Abel, director of spiritual care at Caron Treatment Centers, agreed. “When we say spirituality, we’re talking about connection. People who are addicted become disconnected. And spirituality, as it’s emphasized in the program of the 12 steps, is profoundly reconnecting.”

According to Marvin Seppala, chief medical officer at Hazelden and sober 37 years, attending 12-step meetings does more than give an addict warm, fuzzy feelings.

The unconscious neurological pull of addiction undermines healthy survival drives, causing individuals to make disastrous choices, he said. “People will regularly risk their lives—risk everything—to continue use of a substance.”

Addicts don’t want to engage in these behaviors, but they can’t control themselves. “The only way to truly treat it is with something more powerful,” he said—something, like the 12 steps, that can change patterns in the brain.

Left Brain, Right Brain

Andrew Newberg studies neurotheology—the science of how spiritual practices affect the brain.

He avoids theological opinions, noting that the positive mental and emotional effects that might come from believing in God are real to the individual. “Irrespective of whether God truly exists or not,” Newberg said, “the brain is less interested in the accuracy of reality than the adaptability of how we respond.”

Bill Wilson had a famous “white light” experience in a hospital room, where he was recovering from what would be his last alcoholic bender. He claimed it was a spiritual awakening that not only changed his outlook but also removed his desire to drink.

Newberg said that “large-scale, existential-type crises” such as Wilson’s can bring instant changes to the brain. New neuronal pathways are activated or reactivated. This instant rewiring, Newberg said, generates a sudden and intense “aha” moment.

Newberg speculates that such an event may occur because of differences between the brain’s left and right hemispheres, which approach problems differently. The left side struggles to work through a problem from an analytical, black-and-white perspective.

But the right side may suddenly kick in and apply a very different, more holistic solution. In such a moment, the neurons of the brain are immediately realigned, spurred on by intense emotion relating to the crisis.

This same experience, sometimes described as a “eureka!” moment—or a cognitive insight phenomenon—is often referenced in relation to creative breakthroughs.

One 2008 study found that when the left side of the person’s brain dwells on a problem, it produces an excessive amount of obstructive gamma waves. The more the person ruminates on the problem, the harder it becomes to solve.

Conversely, when concentration is relaxed—or as Newberg said, when the person manages to quiet the left side of the brain and involve the right—the sudden appearance of new answers and insights can feel profound.

Neglected Realm

David Shurtleff, acting deputy director of the National Institute on Drug Abuse (NIDA), described addiction as a mainstream medical problem suffering from a lack of coordinated efforts.

The first four years of medical school routinely provide doctors with only a few hours of instruction on addiction. Shurtleff said his agency would like to see more training for primary care physicians, including equipping them with a standardized assessment to diagnose addiction. “We do the best we can,” he said, “but it’s an uphill fight.”

Meanwhile, brain science marches on. Understanding of addiction at the cellular level continues to yield revelations that seem to cast light on why 12-step meetings succeed.

Power of Dopamine Receptors

D2 dopamine receptors connect dopamine, a key neurotransmitter, to neurons. When these receptors are not functioning—or there are too few of them available to connect the dopamine to neurons—memory, mood, and thinking may all be impaired.

A shortage of D2 receptors, some researchers surmise, could predispose a person to addiction.

Nora Volkow, NIDA’s director, led two studies that involved artificially increasing the number of D2 receptors in rats by administering adenoviral vectors directly into their brains. Viral vectors transmit their genetic material and makeup into foreign cells, in this case increasing the number of D2 receptors in the new cells to match their own.

In one study involving rats and alcohol, the increased number of D2 receptors led the rodents to consume less alcohol, compared with their baseline intake.

In the other study, the D2-receptor increase caused rats to significantly reduce their intake of cocaine.

Michael Nader, a researcher at Wake Forest School of Medicine, is investigating ways to raise D2-receptor levels naturally. One experiment he helped conduct focused on five separate groups of four monkeys. Each had been self-administering cocaine to the point of habit and were then deprived of the drug for an eight-month period. To create a picture of D2-receptor availability, the monkeys were given a radioactive tracer that competes with dopamine for receptors.

The monkeys were then randomly put in social groups of four and given the opportunity to self-administer the drug again.

Positron emission tomography (PET) imaging of the monkeys over time showed fluctuations in dopamine levels, which allowed the researchers to estimate the changing numbers of available D2 receptors. After only three months, the socially dominant monkeys in each group had naturally increased their numbers of D2 receptors.

There was no increase in the subordinate monkeys. Further, the subordinate monkeys reverted to using cocaine at much higher levels than the dominant monkeys.

“There is an interesting relationship between D2-receptor numbers and vulnerability to drug addiction,” Nader said. “It appears that individuals with low D2 measures are more vulnerable compared to individuals with high D2-receptor numbers.”

Why did the socially dominant monkeys show D2-receptor increases? “One hypothesis,” Nader said, “is environmental enrichment.” For the monkeys, it seems, being dominant was the enriching trigger.

One physiological consequence of involvement in 12-step meetings, therefore, could be an increase in the natural production of D2 receptors. “That’s another whole area to be studied beyond the animal world,” Shurtleff said.

Need for Attachment

Philip Flores, author of Addiction as an Attachment Disorder, said the human need for social interaction is a physiological one, linked to the well-being of the nervous system.

When someone becomes addicted, he said, mechanisms for healthy attachment are “hijacked,” resulting in dependence on addictive substances or behaviors.

Some believe that addicts, even before their disease kicks in, struggle with knowing how to form emotional bonds that connect them to other people. Co-occurring disorders, such as depression and anxiety, make it even harder to build those essential emotional attachments.

“We, as social mammals, cannot regulate our central nervous systems by ourselves,” Flores said. “We need other people to do that.”

While it’s commonly understood that early childhood attachments to parents and family are necessary for healthy development, Flores maintains that emotional attachments remain necessary throughout adulthood.

This is where a 12-step program becomes valuable.

It’s not enough, Flores said, to remove the addiction, which in itself has become an object of unhealthy emotional and physical attachment. To achieve long-term well-being, addicts need opportunities for forging healthy emotional attachments.

“What A.A. does on the basic level is what good psychotherapy does,” Flores said. It provides “a community for people to break their isolation and to start to connect on an emotional level with other people.”

Helping Heals

Lee Ann Kaskutas, a scientist with the Alcohol Research Group, has faced skepticism from colleagues for studying A.A., in part because of the numerous spiritual references that go with the 12-step program. It puts A.A. on “the fringe” in the minds of many scientists, Kaskutas said.

Kaskutas, a self-proclaimed atheist, said that the 12 steps bear fruit regardless of one’s spiritual beliefs. “If you don’t believe in God, the way it weasels in is in the help and behaviors that the 12-step group inculcates.”

Helping others, Kaskutas said, “is the internal combustion engine of A.A. I think that is the connection to spirituality.”

People feel better about themselves after helping someone else, Kaskutas said. “So it’s reinforcing—when you help somebody, I think your brain chemistry changes.”

—Follow Jarret Liotta on Facebook.