Health Affairs, a leading journal of health policy in the United States, recently published a lengthy monograph in their Forefront series charting a path out of the opioid addiction crisis. The piece begins with a few sobering statistics:

• Nearly 10,000 people die every month in the U.S. from drug overdose

• 110,000 deaths due to drug overdose in 2023 is nearly double all U.S. deaths in the Vietnam War

• 99% of the world’s supply of the opiate hydrocodone is consumed in the U.S.

Then co-authors Paul J. Kenny, chair of the Nash Family Department of Neuroscience at the Icahn School of Medicine at Mount Sinai, and Eric J. Nestler, director of the Friedman Brain Institute at Mount Sinai, drop the hammer:

[T]here are no FDA-approved treatments for addiction to cocaine and other stimulants, and today’s available medication and behavioral treatments are not sufficiently effective for most people, who too often relapse.

This is our call to arms: We must craft public policy and increase support for biomedical science to reverse the devastating impact of drug addiction.

The authors then survey the most promising treatments before concluding with policy recommendations. The treatments examined include:

Addiction As a Genetic Disorder

The authors claim that 50% of addiction is due to heritability, meaning half of all addicts were born with a predisposition to substance abuse. Researchers have pinpointed three genes — OPRM1, CHRNA2, and CHRNA5, as receptors for opioids, alcohol, cocaine, nicotine, and THC. However, no drugs have yet been developed to target those genes.

Addiction As Brain Disorder

The authors state unequivocally that addiction is a brain disorder through which the brain’s functionality is altered by drug addiction. In particular, the authors state that “All addictive substances share the common ability to elevate levels of the neurotransmitter dopamine…” They zero in on the habenula, a region of the brain which “mediates drugs of abuse” and could possibly be stimulated to increase resistance.

The authors also commend new research based on fMRI scans allowing scientists to see pathways through which addiction interacts with the brain. Surprisingly, they do not provide citations to this research, though you will find plenty here at AddictionNews. They do cite other research on the role that receptors in the gut, heart and lungs play in the transmission of addictive chemicals throughout the body.

Addiction As a Behavioral Disorder

The authors note that substance use disorder is often comorbid with psychiatric disorders including depression and that both should be treated in a holistic fashion. It is unclear what they mean. If the root of addiction is a psychological disorder and not a substance-use disorder, where is the support for those studies? Some recent studies we have seen attribute nearly all the lasting success of substance use disorder treatments to cognitive behavioral therapy. Without CBT, drugs such as buprenorphine are ineffective at long-term recovery.

Policy Recommendations

The paper rather quickly jumps to policy recommendations, which start with a focus on adolescents and pre-adolescents. Limiting exposure to addictive drugs during the brain’s developmental years is the first line of defense against drug addiction. Among other suggestions, the authors recommend limiting social media and insisting on exercise.

Many people who become addicted to opioids first encounter them in a medical setting as a prescription for pain. The authors suggest restricting and closely monitoring the use of opioids as painkillers.

A major problem is that so few people are enrolled in treatment programs; the number is estimated at less than 10% of the 47 million Americans with substance use disorders. The authors blame in part that lack of medical insurance coverage and they call on the government to require all third-party payers to pay for “evidence-based” addiction treatment.

What these doctors want most of all is a push for new medications based on the ample science for treating substance use disorders. And why are there so few clinical trials?

Hesitancy by major pharmaceutical companies to invest in addiction-focused drug discovery programs is central to the dearth of addiction medications.

The authors call on federal and state authorities to fix the problem, but they don’t say how. Should the federal government force drug companies to do this research? Should the federal government or state governments take over clinical trials for addiction treatments and supercharge the funding? Why aren’t state-funded universities stepping into the breach and conducting this research on a larger scale?

We will keep digging out the stories about the people on the front lines of the science of addiction and recovery here at AddictionNews.

Written by Steve O’Keefe. First published July 16, 2024.

Sources:

“The Addiction Crisis: Science Charts A Path Forward,” Health Affairs, July 10, 2024.

Image of Mount Sinai Hospital Copyright: Billie-Grace Ward, used under Creative Commons license.