Low-tech treatments work better.
Freud was a disaster for psychiatry, but not because his theory of the mind inspired his acolytes to exclude physical and chemical processes from explanations of thoughts, emotion, and behaviors. No, the disaster has been the extreme backlash against that nonmaterialist, touchy-feely approach. As neuroscience has blossomed in the last two decades, it has left virtually everything that smacks of psychiatry in the dust. In a nutshell, and not to get too Cartesian, but the brain has replaced the mind.
And that's a problem, especially in addiction. To be sure, some of the most exciting advances in addiction research have come from neurobiology, such as the discovery of brain circuits that underlie dependence and craving, and the dopamine and other neurochemicals that fuel it; fMRIs have shown the spike in activity in the reward circuits of an addict's brain when he sees drugs, proving that addiction is a brain disease, not a moral failing. The discovery that addicts' brains are deficient in the neurochemical GABA has put addiction on a firm biological footing, showing that drug craving is no more an addict's fault, in a willpower sense, than low blood glucose is a diabetic's.
The biological discoveries have been so much more illuminating than the Freudian notion that addiction stems from "dependency needs" dating to childhood. It's understandable, then, that more funding, and seemingly all the excitement, has gone to discover medications and vaccines for addiction, not to implement behavioral therapies. And although the media laud the smallest steps toward a cocaine vaccine, when a study shows—yawn—that rewarding abstinence can get addicts off meth, that couples counseling can treat alcoholism, or that cognitive-behavior therapy can break the grip of coke addiction … silence.
Consider the excitement over cocaine vaccines. Composed of a bacterial protein plus a molecule that is a coke look-alike, they train the immune system to produce antibodies against both. The antibodies also bind to cocaine, preventing it from entering the brain and causing a high. The good news is that the vaccine makes crack less pleasurable, notes Meg Haney of Columbia University, who led a 2010 vaccine study. That suggests the vaccine indeed kept the drug out of the brain. The bad news is that the level of antibodies in the volunteers (55 coke users in a 2009 study, 10 crack users in Haney's) varied widely. Only 38 percent of the coke users produced enough antibodies to dull the effects of cocaine, and, of those, only half stayed clean more than half the time.
In contrast, a 2008 analysis of 34 studies of behavioral treatments for addiction to cocaine, marijuana, and other drugs showed impressive efficacy. "There is still no generally effective [medication]" for coke, pot, and meth addictions, notes psychiatry professor Kathleen Carroll of Yale University. "But the behavioral therapies we have are quite good," bringing a 67 percent improvement. Yet that research gets the response of the proverbial tree falling in an empty forest.
The track record of addiction meds shows their limits. Naltrexone blocks the effects of heroin, and Antabuse the effects of alcohol, but we still have junkies and lushes. Addiction is a behavior, with social and psychological causes, so behavioral therapies that target those causes last longer than medication and are better at preventing relapse. "You can't expect a medication or vaccine alone to take care of addiction," says Haney. "I am entirely humble about that."
So is the National Institute on Drug Abuse, which has been terrific in funding behavioral approaches to addiction. It has had so much success in developing and validating behavioral therapies "that we don't need more research to show they work," says NIDA director Nora Volkow. Consider a new study she led with colleagues at Brookhaven National Laboratory. They showed cocaine users pictures of coke and coke paraphernalia, which usually makes activity in the brain's limbic (emotion) regions spike, causing intense craving. The scientists taught the users to suppress that activity. That success, says Volkow, "provides enormous hope," implying that cognitive interventions might enable cocaine abusers to "block the drug-craving response to help them avoid relapse." The problem is implementation, and Volkow is "trying to direct more funding to that." One wonders how much more could be accomplished if it got more than table scraps. Especially if cognitive and behavioral approaches can overcome their lack of sex appeal.