Drug addiction: new therapies, old policies – Lancet

Copyright 1993 Information Access Company;
Copyright Lancet Ltd. 1993
The Lancet

July 31, 1993


LOAD-DATE-MDC: August 13, 1993

SECTION: Vol. 342 ; No. 8866 ; Pg. 297; ISSN: 0099-5355

LENGTH: 593 words

HEADLINE: Drug addiction: new therapies, old policies; Conference

BYLINE: Rowe, Paul M.

BODY: The link between the time course of drug effects on the brain and the damage done by a drug was a theme of the Second National Conference on Drug Abuse Research and Practice held by the National Institute on Drug Abuse in Washington on July 14-17. NIDA was recently reincorporated into the National Institutes of Health to facilitate cooperation in the fight against AIDS, but whether overall drug-control policy will shift much toward a medical approach from the current criminal justice approach is not yet clear. No one considers legalisation a serious possibility.

Rapid onset and offset of action, with extreme euphoria followed closely by a “crash”, not only results in rapid conditioning and the establishment of dependency, but can also lead to disruption of sexual function and of the stress and immune responses. Smoking and injection are the fastest routes to the brain, and smoking of crack cocaine is therefore much more dangerous than snorting the hydrochloride. Heroin is more damaging than morphine because heroin crosses the blood/brain barrier more rapidly. On the other hand, methadone, the standard therapeutic substitute for heroin addiction, is given orally, for slow onset, and one dose lasts all day. Methadone maintenance keeps the patient in a “normal” state, without euphoria or withdrawal, and can even block the euphoric effect of injected heroin, thereby helping to extinguish the conditioned mystique of the needle. By establishing a new stable set point for the opioid receptor system, methadone therapy restores adrenal, immune, and sexual function.

On July 9, the Food and Drug Administration approved a new drug for the treatment of opioid dependence, levo alpha-acetylmethadol. LAAM has an even slower onset and longer lifetime than methadone, and because it is a pro-drug, its onset is slower when given intravenously than when given orally. Thus its potential for abuse is nil.

Not all the new drug therapies being investigated are directed at the receptors targeted by the abused drug; cholecystokinin antagonists are being investigated as therapy for opioid withdrawal, and ibogaine, a mild hallucinogen from West Africa, seems to ease withdrawal from several drugs. Treatment of cocaine and opioid dependence with antidepressants has had only modest success, but this may have resulted from “premature randomisation” of subjects, because most heroin or cocaine abusers do suffer from depression, anxiety, or antisocial personality disorder. In most cases the disorder is thought to precede drug dependence, but even when it is secondary to drug use it may not disappear with detoxification alone, and may require specific therapy. Furthermore, dual diagnosis must guide treatment: the aggressive approaches successful with antisocial addicts will tend to drive depressed addicts away.

Policy analysts decried the draconian mandatory sentencing that overburdens the courts and prisons, and gives even non-violent first-time offenders the opportunity to learn about crime and drugs from more seasoned inmates. A warning was sounded that current US drug control policy focuses too heavily on reducing the prevalence of drug use, and not enough on reducing its harm. If prevalence is reduced greatly, some fear drug research and education may be replaced with official silence. This silence might not only mean less humane treatment for the remaining hard-core users, but it could also set up conditions for a future “discovery” of drugs as tools for personal development, as happened in the 1960s.

IAC-NUMBER: [Redacted]

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