Mark Ambrose, M.D., a psychiatrist with Mercy Behavioral Health, explains addiction as a chronic, compulsive need to use any number of substances in spite of the consequences. “In other words,” he says, “repeatedly doing something that causes significant damage to their lives but continuing the use even in the face of that damage.”
There are two kinds of addictions: substance-based and behavioral. Substance-based addictions include alcoholism, drug abuse and nicotine use, while behavioral addictions cover gambling, shopping, eating, sexual activity, and—yes, it’s true—Internet addiction. Behaviors in the latter category, with the exception of gambling, are sometimes called “soft addictions,” although this is not an accepted clinical definition with the American Psychiatric Association or with the American Psychological Association. In fact, there is some question in the mental health and medical communities as to whether compulsive behaviors should be considered addictions at all
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Regardless of semantics, these conditions exist, often interfering with the participants’ normal functioning and creating havoc in their lives and in the lives of those around them.
Drugs and Alcohol
In days past, treating addictions was difficult at best. Traditional psychotherapy and 12-step support programs were thought to be the most effective means of getting and staying clean and sober. Antabuse, an alcohol aversion medication that causes people to become violently nauseated when they drink, was the only medication available to help. Fortunately, treatment modalities have changed and improved over time. Unfortunately, even in this time of mounting pharmacological advancements, there is still no elixir or potion that will make addictions disappear. But there is progress. Many comprehensive treatment programs now include drugs that work on brain receptors to help curb cravings and block the pleasurable effects of illicit drugs and alcohol. In fact, the National Institute on Alcohol Abuse and Alcoholism recently revised its treatment guidelines to encourage physicians to use drugs as an adjunct to psychosocial therapies for alcohol-dependent patients.
Naltrexone (ReVia) is part of a class of drugs known as opiate antagonists, and was originally used to help drug-addicted patients. Naltrexone was the first drug approved by the FDA for the treatment of alcoholism in 50 years. It works by blocking the euphoric feeling, or the “high,” that people experience when they use drugs or alcohol. “Naltrexone has been shown to reduce the quantity of alcohol consumed and increase the number of days that a person goes without drinking, if they are enrolled in a treatment program for problem drinking,” says Moore, who uses naltrexone as part of his overall patient-treatment plan, but not until a patient has relapsed. “And the actual amount of alcohol consumed is less over time for the group of people who take the medication.”
Another drug on the market is acamprosate calcium (Campral). “It’s only been out in this country for a year or two,” says Ambrose. “I’m not sure how it works. It may affect certain systems in the brain that alcohol can excite. If a person does relapse, it tends to decrease the amount that they drink during the relapse.” Ambrose adds that studies, which are limited in terms of time span, show that acamprosate is most effective in people who have had some psychotherapy and are sober when the medication is prescribed.
Ondansetron (Zofran) is an antinausea drug that has been shown to reduce binge drinking and help patients maintain abstinence. This drug appears to work best on people who developed alcohol problems before the age of 25.
Perhaps the most exciting drug in the pipeline is rimonabant (Acomplia), a sort of all-purpose medication with the potential to help curb obesity and alcoholism. “Rimonabant . . . may offer even more effectiveness than anything we’ve seen thus far,” says Moore. “It seems to play a role in regulating appetite or the desire to use a particular substance [and works] in the area of the brain where we experience satisfaction or fullness.” The trouble with promising new drugs, he adds, is that the effects often are not sustainable over time.
Along with naltrexone, a new drug, buprenorphine, can aid in the treatment of drug addiction. “Buprenorphine is a very nice medication that is used in opiate abuse,” says Ambrose, who explains that people on this medication most often significantly reduce or eliminate their opiate cravings.
Scientists are also working on a cocaine vaccine. “To my knowledge, it hasn’t been tested on humans,” says Moore. The idea behind the vaccine is to produce antibodies that bind to the cocaine and block its effects.
Both Moore and Ambrose agree that by themselves medications will not usually effectively treat drug and alcohol addiction and should be used in conjunction with education, group and individual therapy and psychiatric treatment, when needed. “In that context,” says Ambrose, “using certain drugs to help minimize cravings and other things can be helpful.”
Gambling
The American Psychiatric Association recognizes pathological gambling as a bona fide mental disorder. The condition is characterized as an uncontrollable urge to gamble and the inability to stop in spite of adverse consequences—financial devastation, loss of family and career ruin. While money plays a part in the reason for gambling, researchers say that compulsive gamblers are sometimes seeking the same heightened euphoric state that comes with using cocaine and other drugs. As tolerance grows, the stakes become higher in order to achieve the same desired result. “Some researchers believe that in predisposed individuals, external stimuli like gambling produce internal changes in the nervous system that are the same or similar to those produced by alcohol or other drugs,” says Moore.
A recent clinical trial has shown that nalmefene (Revex), an opiate antagonist used to treat drug abuse, reduces the urge to gamble. Nalmefene blocks the part of the brain that processes pathological pleasure and impedes the release of dopamine, a chemical released when the brain perceives a reward. A second study is under way.
Smoking
Tobacco use is the leading cause of death in the United States, with some 430,000 casualties each year from heart disease, cancer, emphysema and stroke. And because of the addictive nature of the chemical nicotine in tobacco products, it is difficult to quit smoking. Consumer Reports’ “Medical Guide” reports that, of every 100 people who try, only up to 10 percent succeed in quitting. “It’s probably easier to quit drinking than smoking,” says Moore.
Smoking cessation programs have been around for years and continue to be an effective means of support for people who are trying to quite smoking. (For programs in your county, visit nobutts.org.) Nicotine replacement therapy—nicotine gum, patches, nasal spray or inhalers—can ease withdrawal symptoms. Bupropion (Zyban) is an antidepressant thought to work on the neurotransmitters that affect dopamine and norepinephrine levels in the brain. Best of all, bupropion might prevent the weight gain associated with stopping smoking. But the newest medical weapon in the arsenal against smoking is varenicline (Chantix), a twice-daily pill recently approved by the FDA. Varenicline works by decreasing the pleasure of smoking and alleviating withdrawal symptoms.
Eating Disorders
There are three main eating disorders: anorexia nervosa, bulimia and binge eating, although the last is not recognized as a formal psychiatric disorder. There is also compulsive overeating. “What they have in common,” says Moore, “is an obsession with food that results in either an inability to eat normally or to take in calories to sustain a normal weight on one hand, or to engage in binging and purging behavior, which is bulimia.”
Anorexia nervosa is a serious medical condition in which people see themselves as overweight when in reality they are dangerously thin. The process of weight control becomes an obsession laden with compulsive exercise, measuring food and using laxatives, enemas and diuretics. Bulimia is characterized by recurrent episodes of eating large quantities of food and then purging (self-induced vomiting, laxatives, diuretics and enemas) at least twice a week for three months. Binging is defined as eating larger than normal amounts of high calorie foods in a given amount of time.
There is an addictive quality to all eating disorders. “Often, the eating disorder behavior is what becomes addictive,” says Lisa Loker, L.C.S.W., manager of the Eating Disorder Intensive Outpatient Program at Kaiser Permanente Sacramento. “Similar to other addictions, the behavior is a way of numbing feelings and responding to stressful situations and events in a person’s life.”
Depression, anxiety and substance abuse are not uncommon in patients with eating disorders.
Treatment for anorexia can involve inpatient treatment with intravenous feeding and careful food monitoring. Once weight gain has begun, psychotherapy begins. Bulimia is generally treated on an outpatient basis, with psychosocial intervention and nutritional rehabilitation. Treatment for binge eating disorder is managed through education, classes and group support. Antidepressants are commonly prescribed in all three situations. “Medication can most certainly be effective and helpful in treating eating disorders,” says Loker, “particularly with the obsessive thoughts around food and body image.” Antidepressants are not used with severe anorexic patients until their weight is stable. Scientists are currently looking for genes that predict a predisposition to eating disorders.
Although not recognized as an addiction, compulsive overeating is a serious condition that can lead to obesity, heart disease, diabetes, hypertension, high cholesterol and depression. “Obesity is defined as a body mass index of greater than 30,” says Thomas Hopkins, M.D., co-director of the Sutter Bariatric Center in Sacramento.
Several FDA-approved drugs are on the market to aid in weight loss. “Meridia is a drug that suppresses appetite,” says Hopkins. “It increases a sense of fullness.” Phentermine, also is an appetite suppressant. “They are basically equally effective,” explains Hopkins. Orlistat (Xenical), available over the counter, blocks fat absorption so that ingested fat is excreted from the body. Rimonabant, the same drug that promises to help curb alcohol cravings, is also an appetite suppressant. It works by blocking chemicals in the brain called cannabinoids, which cause cravings and feelings of hunger. Rimonabant is in clinical trails.
Hopkins is quick to point out that drugs are only tools. “They are adjuncts to proper diet with caloric reduction, routine exercise and behavior changes,” he says.
A National Institute of Mental Health report says that researchers have found a complex network of nerve cells and molecular messengers called neuropeptides that regulate appetite and energy expenditure. This discovery could play a key role in the development of new pharmacological treatments for eating disorders.
The fastest growing procedure—from 10,000 to 150,000 in the United States in 10 years, according to the Centers for Disease Control—and perhaps the most surefire way to treat obesity and its comorbidities (diabetes, heart disease, et al.) is gastric bypass surgery. “This year, we project our volume to be between 300 and 350 cases,” says Mohamed Ali, M.D., director of minimally invasive surgery at the University of California, Davis Medical Center. “Next year, we project it to be between 350 and 400.” The two most common gastric bypass surgeries are vertical banded gastroplasty and the Roux-Y gastric bypass, the procedure used at UCDMC.
Gastric bypass surgery isn’t for everyone. NIH guidelines place a candidate’s BMI at 40 (235–270 pounds), with an exception for people with a BMI of 35 and serious medical considerations. Ali says UCDMC feels ethically bound to follow NIH criteria. “If we see a patient with a BMI of 34, we will refer that patient to medical weight loss,” he says.
NIH studies show that most patients who undergo the bypass procedure lose as much as 50 percent of their excess weight during the first six months after surgery, 77 percent during the first year, and maintain up to 60 percent of that loss 10 to 14 years later. The downside of gastric bypass is that many patients require plastic surgery to remove the sagging flaps of skin that result from drastic weight loss. The upside, says Ali, is “there is nothing more terrific than watching someone transform into a healthier, more confident, happier individual.”
“Soft Addictions”
If there is any doubt that so-called “soft” or behavioral addictions have a real impact on society, check out the list of 12-step recovery programs available—Debtors Anonymous, Shoplifters Anonymous, Sex Addicts Anonymous, Spenders Anonymous. And that doesn’t reflect the groups that offer help for gambling, drug and alcohol addictions and eating disorders. It seems the United States is becoming a nation of addicts whose lives are ruled by tanning booths, plastic surgery and cyberspace, a subject Karen Houseworth, a psychologist with Mercy Behavioral Health, knows something about. “There are a number of soft addictions,” she says. “The ones that I can speak to are the Internet and cell phones.” Internet addiction—a term Houseworth emphasizes is not a clinical diagnosis—has become so established that it has been broken down into three categories: cybersexual (porn-seeking), cyberrelational (example: MySpace.com) and Net gaming (where people congregate online to create alternate universes). The interesting thing is, while these conditions are proliferating, and while the consequences of these behaviors can interfere with a person’s life, the treatment has stayed the same—spending time in a therapist’s office. “We do short-term brief therapy, usually six to eight sessions, although it can go longer,” says Houseworth. “As with any treatment plan, it’s going to involve making changes and being committed to those changes over time. But if a person’s ready, you can do a lot of good work in six to eight sessions.”
From drug addiction treatment to helping people break compulsive cell phone habits, professionals agree that no one pill can make the behavior magically disappear. “Unfortunately,” says Ambrose, referring to drug and alcohol addiction, “there is no substitute in this field for good old-fashioned willpower.”
