ADDICTION

Close to Home: Moyers on Addiction, produced and directed by Bill Moyers,
five 60-minute videos, including "Portrait of Addiction," "The Hijacked
Brain," "Changing Lives," "The Next Generation," and "The Politics of
Addiction," $229, Princeton, NJ, Films for the Humanities & Sciences, 1998.

Close to Home: Moyers on Addiction premiered on the Public Broadcasting
System on March 29, 30, and 31, 1998. This television and now video series
consists of five 1-hour focused videos entitled "Portrait of Addiction,"
"The Hijacked Brain," "Changing Lives," "The Next Generation," and "The
Politics of Addiction." The series provides a candid look at recent trends
in the "American disease" of addiction.

Our review examines the program not only from the professional and
provider's frame of reference, but also from the perspectives of the addict
and family members. We talked to medical students, house staff, patients,
and their families about their perceptions of the series. The Robert Wood
Johnson Foundation has called drug use and addiction the nation's number one
public health problem. The Moyers series documents the troubling finding of
increased drug use among our youth, despite increases in education and
prevention programs. While most physicians are aware of the prevalence of
addiction, many of our patient families were surprised at how this disease
infects all social strata without regard for age, race, sex, or income.

Moyers does a good job of redefining the concept of addiction. While
addiction has traditionally been thought of as physical dependence on a
drug, most experts now look at the disease as a complex set of maladaptive
behaviors that have their origin in brain neurochemistry.[1] Preoccupation
with the drug, compulsive use despite adverse consequences, and a pattern of
relapse over time help define addiction today as a pathological attachment
to a plant or drug, more accurate than physiological dependence alone. Loss
of control is a central part of all addiction theory, but, as important as
loss of control is, it is a mystery. Compulsive use does not necessarily
mean high volume or even repetitive use. Attachment to the drug defies
calculations of dose; frequency and duration provide more direction than
either measure alone. Detoxification, while a necessary first step on the
road to recovery, is in isolation of little use in the treatment of
addiction. This discussion of the concept of addiction can be instrumental
in helping families understand both the power and destructive force of this
disease.

In "The Hijacked Brain," Moyers examines how the addict forms a pathological
dependence on or attachment to the drug and continues using, seemingly
oblivious to the physical, emotional, and social consequences. This segment
cogently presents the neurobiological research conducted over the past 20
years that has identified the sites and mechanisms of drug action on the
brain.[2,3] The video makes clear that people smoke or use drugs because of
brain reward. No drug user smokes marijuana for its effects on the teeth,
gums, larynx, bronchi, or lungs. Opiates are targeted at the brain's
endogenous opioid systems, marijuana at the brain's endogenous cannabinoid
(tetrahydrocannabinol [THC]) systems, benzodiazepines and alcohol at the
brain's gamma-aminobutyric acid (GABA) receptor complex, and cocaine at the
brain's dopamine reuptake transporter. Regardless of specific target, all
drugs of abuse are similar in brain effect. This working neuroanatomy of
drug reward is more of a work in progress than a fait accompli.[4]

The series shows how drugs gain rapid access to the areas of the brain
(ventral tegmental area, nucleus accumbens) that produce intense pleasure
and reward. These hard-wired dopamine brain reward circuits, normally
activated by food and sex, can be stimulated by drugs of abuse.[5] While
first use of an illicit drug is voluntary, the user is motivated and goal
directed to reproduce that initial high. Subsequent use induces brain
changes, making additional use automatic and leading to the hypothesis that
addiction is an involuntary disease of the "hijacked brain."

Our patients and families found this discussion invaluable. One of the most
difficult things for the addict, family members, and society to accept is
the concept of substance abuse as a disease. The belief that alcoholism and
drug abuse are the result of moral decadence or personal weakness is both
powerful and pervasive. This belief, which still exists in the health
professions, has impeded the development of effective medical treatments for
this epidemic disease. Perhaps more than anything else, the Moyers series
frames addiction as a disease. The discussion in "The Hijacked Brain" helps
patients understand the disease concept of addiction. Behavior that was once
defined only as weakness, selfishness, or evil can now be understood in
terms of "chemical reactions," which, once activated, are difficult to
change. While none of our family members reported excusing the behavior of
the addict after watching the video, they did report a new understanding
that helped them prepare for future behavior and appreciate the enormity of
the treatment task. One mother reported that she now understands why her son
seemed to love cocaine more than her.

This new recognition of the effects of drugs on brain chemistry has allowed
us to understand the sites for withdrawal and develop a host of new,
approved treatments to help reduce relapse. Medications like naltrexone
(ReVia) block the effects of opiates and alcohol. Methadone, buprenorphine,
and the opioid agonist L-alpha-acetylmethadol (LAAM) prevent opiate relapse.
Bupropion-SR (Zyban) reduces cigarette smoker relapse, and acamprosate can
reduce alcohol relapse.[6]

In "Changing Lives," we see how these medical treatments can be combined
with traditional interventions to increase the likelihood of a successful
outcome. Addicts report how traditional interventions, such as 12-step
fellowships, provide hope, structure, and support necessary for lifelong
abstinence. Indeed, 80% of alcoholics who report being abstinent 5 years or
longer are regular attendees at Alcoholics Anonymous.

These discussions provide both the addict and the affected family with hope.
Acceptance of substance abuse as a chronic illness prepares the person for
the long journey in which "recovery" is a process and not a place.

While the Moyers series provides a rationale for understanding addiction and
a basis of hope for millions of people, it also provides a warning for the
future. As noted above, drug use is highest in the most vulnerable segment
of our society, our youth. According to data from the University of
Michigan, while 19.4% of eighth graders smoked cigarettes in 1991, 36.5%
were smoking before graduation in 1997. Similar findings are being reported
for alcohol and other drugs, such as heroin, cocaine, amphetamines, and LSD.
Nationwide, in 1997, an incredible 22.6% of eighth graders had already
learned inhalation of drug vapors by smoking marijuana. While some kids are
learning how to analyze complex equations, others are learning how to inhale
marijuana, tobacco, or cocaine. "The Next Generation" examines this trend
and looks at the process of preventing addiction. However, while Moyers
starts the argument, this program fails to help us understand why smoking of
tobacco and marijuana are increasing at a dramatic rate when prevention
efforts and new research and treatments are so widespread.[7] While many
have focused on smoking,[8] the importance of smoking as a gateway to other
drugs and as a major vehicle in brain training and hijacking is not
emphasized in this series.

The next step in prevention involves the training of physicians in the
treatment of substance abuse. While it has been noted that physicians are in
an ideal position to address the subject, formal medical education has not
prepared them for helping users of tobacco, alcohol, and other drugs.[9]
Physicians have been trained to recognize that substance abuse is a major
source of hepatitis B infection, human immunodeficiency virus infection,
hypertension, bacterial pneumonia, tuberculosis, sexually transmitted
diseases, cirrhosis, and so on. However, they have little training in the
early identification of the addictive process and rarely make a diagnosis
early in the course of the addictive illness.

In conclusion, the Moyers series on addiction is a valuable adjunct for the
understanding, treatment, and prevention of substance abuse. While
physicians who are active in diagnosing and treating chemical dependency
will find little new from the program, those who have been only peripherally
involved will receive a cogent update. The series will also provide the
physician with a perspective on the consequences of addiction beyond the
office setting. The series, however, will likely have its most profound
impact upon the addict and family coping with the disease of addiction. The
information in the series is not only accurate but is presented so as to
increase the knowledge, ameliorate the guilt, and provide hope for those
having to contend with substance abuse. We recommend using the series in
trying to help families understand the disease of addiction. Virtually all
of the family members we spoke to described the program as informative and
therapeutic. While not a replacement for 12-step programs or support groups
like Al-Anon, the Moyers series provides a comprehensive, cost-effective
method to help the general public understand the pernicious disease of
addiction.

Mark S. Gold, MD Michael J. Herkov, PhD University of Florida College of
Medicine Gainesville

References

1. DuPont RL, Gold MS. Withdrawal and reward: implications for
detoxification and relapse prevention. Psychiatr Ann. 1995;25:663-668.

2. Koob GF, Nestler EJ. The neurobiology of drug addiction. J
Neuropsychiatry Clin Neurosci. 1997;9:482-497.

3. Wise RA. Neurobiology of addiction. Curr Opin Neurobiol. 1996;6:243-251.

4. Rocha BA, Scearce-Levie K, Lucas JJ, et al. Increased vulnerability to
cocaine in mice lacking the serotonin-1B receptor. Nature. 1998;393:175-178.

5. Dackis CA, Gold MS. New concepts in cocaine addiction: the dopamine
depletion hypothesis. Neurosci Biobehav Rev. 1985;9:469-477.

6. Gold MS. Drug abuse. In: Rakel RE, ed. Conn's Current Therapy.
Philadelphia, Pa: WB Saunders Co; 1998:1123-1132.

7. Gold MS, Herkov MJ. Tobacco smoking and nicotine dependence: biological
basis for a pharmacotherapy from nicotine to treatments that prevent
relapse. J Addict Dis. 1998;17:7-22.

8. Gold MS, Gleaton TJ. Tobacco and marijuana use increases in junior and
senior high school students. Biol Psychiatry. 1996;39:629. 9. Lewis, DC. The
role of the generalist in the care of the substance-abusing patient. Med
Clin North Am. 1997;81:831-843.

(JAMA. 1998;280:2046-2047)

Checked-by: Rolf Ernst