THERAPIES USE DRUGS TO FIGHT ADDICTION

Addiction treatment no longer has to be a "drug-free zone," thanks to new
therapies designed to soften the trauma of withdrawal and blunt the cravings
that often drive addicts back to drugs or booze or cigarettes, no matter how
desperately they want to quit.

These new drugs -- for everything from smoking to alcoholism -- mark a new
path for addiction therapy. They act directly on the symptoms of addiction.
In that way, they differ from earlier treatments, such as methadone, that
substituted one drug, even if a less dangerous one, for another.

These new treatments are slowly becoming widely available here and
elsewhere. That's due, in part, to a new understanding of the biology of
addiction and, perhaps in equal measure, to pressures to shorten expensive
treatment programs.

Even more of these new treatments are in the research pipeline. Studies are
under way, for example, at the University of Miami School of Medicine on a
drug to treat alcoholism and on another to make cocaine cravings disappear.

New therapies for addiction have the potential to touch millions of people
across the nation. An estimated 10 percent of the U.S. adult population, for
example -- or about 14 million people -- are believed to have a drinking
problem. Nearly 30 percent of us smoke. Drinking contributes to more than 40
percent of the nation's traffic fatalities. Combined with cigarettes,
alcohol is a major contributor to leading killers like heart disease, stroke
and some cancers.

But even those with no direct connection stand to be affected by the
therapies, if they indeed can help fight drinking and drug abuse, which are
associated with crime, domestic violence, increased health-care costs and
lost productivity at work. The National Institutes of Health puts the cost
to the nation of all those direct and indirect factors at $276 billion a
year.

Some in the treatment business warn that sobriety requires an overhaul of
the soul and will never be as simple as popping another pill. Even
proponents insist that the drugs can only ease a patient's path to a new
life, but won't work without therapy to address the problems that lead
people to addiction and the behaviors that trap them there.

Still, the possibilities can be irresistible, especially to those fighting
for sobriety.

Easier to resist

Consider Pat, a Plantation woman who asked not to be identified because of
her drinking problem. An experimental drug that blocks the urge to drink has
made sobriety far easier to sustain than she ever expected. Recently, she
says, she was even able to attend a cocktail party without being tempted.

"I didn't have a problem at all with it," she says, a little surprised. She
talks about her situation during a visit to the University of Miami, where
she is enrolled in a clinical trial that keeps her from knowing for certain
which drug she is taking. "It's kind of a miracle drug . . . In the past, I
would be fine for a week or two, and then something would come up and I
would just want a beer. And that would be it. I just wouldn't stop."

Some drugs that take this new approach have recently been approved and are
already available through doctors or treatment programs:

Zyban, a drug aimed at reducing the desire to smoke. It can be prescribed by
a doctor and is often used in combination with over-the-counter nicotine
patches to help smokers quit.

Naltrexone, sold under the trade name Re Via. It is approved by the U.S.
Food and Drug Administration to help alcoholics stay sober by reducing their
urge to drink.

Ultra-rapid detoxification, which is available in South Florida only at
Mount Sinai Medical Center in Miami Beach. It uses the drug naltrexone to
rapidly detoxify heroin addicts under sedation, to speed and ease their drug
withdrawal.

Some of the newer antidepressants, like Prozac, currently used to fight
depression. These are now being used to help drug addicts and alcoholics
when their substance abuse is thought to be related to an underlying mental
illness.

Insurance coverage for these therapies varies, but most health plans place
strict limits on what they will reimburse for mental health and addiction
therapy. Most plans, for instance, will not cover Zyban, though some doctors
have tried to work around this by prescribing another, similar
antidepressant.

System gone wrong

The idea of treating an addiction with drugs results from scientists'
fast-growing understanding of substance abuse as a biological affliction,
and not strictly a behavioral problem. Researchers are finding new pieces to
this complex disease all the time.

Basically, they now believe that addiction is a corruption of a bodily
system that evolution intended as a way to reward us for behaviors that
ensured the survival of the species -- most notably sex. There is a reward
pathway in the brain composed of nerve cells that signal pleasure. These
cells are particularly sensitive to a naturally occuring chemical in the
brain called dopamine, which is a neurotransmitter -- it ferries signals
between nerve cells.

On a very simple level, all enjoyable experiences -- whether a kiss or a
fine piece of Belgian chocolate -- translate to a rush of dopamine along
this reward pathway in the brain.

Addictive substances distort this natural pleasure system, flooding the
brain with dopamine and causing a "high." Eventually -- and this is
especially so for cocaine and heroin addicts -- this flood of dopamine can
desensitize the brain to the chemical. The trickle of dopamine that's
triggered, say, by a kiss is no longer enough to produce pleasure.

The addict goes into a state similar to depression, in which it's no longer
possible to truly enjoy life. Even the drug no longer produces a high; it
simply fends off a more desperate low.

"At first, it's like a cerebral orgasm: The first few hits are so
pleasurable, they keep chasing that rush," says Deborah Mash, a University
of Miami researcher who is working on a drug called ibogaine to treat
cocaine and other addictions. "They can't derive pleasure from anything in
life, not love, nothing. The only time they feel good is when they have the
crack pipe in their hands."

Ibogaine is derived from an African plant. It's being tested on addicts with
several different addictions, though results have varied. The drug seems to
detoxify addicts with few withdrawal pains, and it also seems to stay in the
body long enough to reduce their cravings for several months. Mash hopes
eventually to develop a patch based on a substance derived from ibogaine
that cocaine addicts could wear to reduce their cravings, much as smokers
wishing to quit can wear a nicotine patch to reduce their own cravings.

Alternative for alcoholics

The University of Miami is also conducting several studies of drugs to treat
alcoholism that should provide help to those who can't tolerate naltrexone.
The university was also involved with recent tests of a French drug,
acamprosate, widely available in Europe and now under review by the FDA for
possible approval in the United States.

At Nova Southeastern University in Davie, Jose A. Rey, an assistant
professor in the college of pharmacy, is studying whether a drug currently
used to treat Parkinson's disease -- which is another type of malfunction of
the dopamine system -- might also stave off cravings in cocaine addicts.

"There's a lot of people throwing darts and doing research on a host of
drugs," says Rey. "I haven't seen any cure-all . . . We're still in an age
of exploration."

One of the most common tactics being employed is to give antidepressants to
addicts. The idea is to treat underlying depression that can lead people to
abuse alcohol, drugs, even cigarettes. Recent research has indicated that
about a third of all smokers are depressed and may turn to nicotine as a way
of self-medicating. So doctors are using antidepressants like Zyban, which
was recently approved by the FDA and is also believed to reduce cravings, to
help smokers quit. Scientists have also found that antidepressants can help
depressed alcoholics sober up, though they don't do much good for those who
don't suffer from depression.

But some fear that such approaches might tempt addicts to forgo the hard
work of behavioral therapy, thinking they can solve their problems with the
quicker fix of anti-craving medications. Even doctors at Mount Sinai in
Miami Beach -- who use drugs to speed drug or alcohol detoxification,
reasoning that it helps addicts who have the will to quit but can't get past
their fear of the terrors of withdrawal -- are cautious about the prospect
of drugs to reduce the desire to drink or abuse a drug.

"This is a physical disease with a spiritual remedy," says Dr. John C.
Eustace, medical director of the Fletcher Addiction Treatment Program at
Mount Sinai. "There's a physical part to this disease, but then there's the
mental, emotional, social aspects of this kind of life. A pill isn't going
to make a long-term change in an addictive personality. We can't write a
prescription for serenity."

Pared-down therapy

But proponents argue that these medications have a practical value because
they seem to boost the effectiveness of today's pared-down therapy programs.
Years ago, it was standard practice to treat alcoholics and drug addicts
with intensive inpatient therapy that lasted about a month -- long enough to
clear their systems of drugs and help them through the first, most difficult
weeks of sobriety.

Financial pressures, largely stemming from cutbacks in the age of managed
care, have changed that. Today, most addiction therapy is on an outpatient
basis, perhaps after a brief hospitalization to clear the system of drugs.
This can be harder on patients because they don't get as much support during
the toughest period of sobriety, and being outside a hospital setting, they
continue to have access to whatever substance they've been abusing.

So doctors reason that if they can develop a drug that reduces the desire to
drink or take drugs, they can improve the odds that someone will stay sober.

It seems to work that way for alcoholism, at least. Studies indicate that
the drug naltrexone does seem to reduce relapses for recovering alcoholics.
It seems to dampen the desire to drink, though not necessarily to eliminate
it. People who previously could not stop drinking after their first beer no
longer are compelled to keep going until they are drunk.

"We have a better three-month relapse rate than patients who started out
with traditional 28-day inpatient programs," says Barbara Mason, director of
the Alcohol Disorders Research Unit at the University of Miami.

Reducing side effects

Mason is testing two drugs she hopes will also someday help alcoholics stay
sober with fewer side effects than naltrexone, which can cause nausea and
liver problems. Studies indicate that these drugs seem to help about 20
percent more patients stay sober for at least three months than those who
just get traditional therapy, she says. That's important because the longer
a person stays sober, the more likely they are to make a permanent change,
experts agree.

UM is also testing combination therapies to help alcoholics who smoke quit
both addictions at the same time.

But one thing all these medications have in common: They don't work on their
own. They need to be combined with psychotherapy.

For Pat, the Plantation woman enrolled in the UM trial, that means a weekly
visit to a therapist who's helped her develop strategies for resisting the
urge to drink by substituting other activities at times when she used to
drink and by helping her learn to fight off cravings. The pills she takes
are only intended to make that process easier. She has been sober for more
than three months, she says, a record for her.

"Sometimes, it just seems like it's too easy," says Pat, 47, whose sisters
are watching her progress because they may seek similar help with their
drinking if she succeeds. "I had some struggles at first, but now it really
isn't that bad."