Addiction to Drugs, Revolutionary New Treatments
Written by: Richard Gracer, M.D., San Ramon, California
Posted by: Ron Kennedy, M.D., Santa Rosa, California
“You what?” I said. “Did I hear that you totaled your car? Are you all right?” It was unexpected, but I was not surprised.
“I was lonely. Just had one drink. I know that I can never just have one, and I didn’t. I barely remember what happened, but I’m lucky that I wasn’t hurt too badly and that I didn’t kill someone else. My new $35,000 Saab is gone and I had to spend the night in jail. I’m so ashamed. This is it this time. I‘m done with drinking. You know the worst part? I want a drink right now!”
Susan is a 45 year old scientist whose family is riddled with alcoholism and opiate addiction. We started seeing her about a year ago when her husband brought her into the clinic. She had been drinking up to 2 bottles of wine per day for over a year and it had finally caught up with her. She had developed severe abdominal pain, but even that didn’t stop her. I put her the hospital for a couple of days to “dry her out”. We suggested the Prometa protocol for alcohol, but Susan was hesitant because it was expensive and new. Instead she entered into therapy with Steve Peterson, the Program Director for our medical group, under my medical supervision. We used antidepressants, along with Campral and Vivitrol, FDA approved, efficacious medications for alcoholism. We entered her into the Intense Outpatient Treatment Program (IOT) at New Connections, our partner. She would not go to AA because it was “too public and too religious”. Susan tried very hard. She knew it was important, but she had to deal with severe cravings almost every day. Her drinking drastically decreased, although she did have an occasional binge. Her work performance improved and her marriage got better. Steve and I were overall pleased with her progress, but really had some underlying anxiety that her physical cravings might take over. This is exactly what happened.
“After this incident you have to reconsider your decision not to go through the Prometa protocol.”, I told her. “The next time you might kill yourself or even worse, someone else.”
Susan gave me a rueful grin and said, “Now I wish that I had taken your advice in the first place. Let’s do it.”
Within days we started the three IV Prometa treatments, along with the other medications that comprise the protocol. By the third day Susan’s head was clear and she told us that the cravings were gone. It is now about six weeks since the treatment and Susan has “zero cravings”. This is a remarkable change that I would think a fluke if we hadn’t seen the same reaction in almost all of the patients that we have treated with Prometa. In fact, going over our data for the past 18 months we have close over a 2/3 success rate for our Prometa and buprenorphine patients.
Addiction is a Brain Disease
While the choice to use drugs, especially by genetically susceptible individuals, may start the problem, it sets in motion a cascade of events that leads to long lasting and even permanent neural damage. Unfortunately the way that this problem is usually viewed and treated in our society is as a social failing that can be conquered by strong will and faith. This model was developed in the early 20th century, a time when there was only rudimentary insight into the workings of the brain and also a time when there was no methamphetamine epidemic. There was no real treatment for serious psychiatric illnesses such as bipolar disorder, which often co-exist with substance abuse and dependence. Medicine has come a long way since those days, but the treatment of substance abuse is still based on twelve step programs and other social interventions, which are important, but are not, as is often thought, “The only thing that works.”
There are two important medical treatments that I believe will revolutionize the treatment of the most important drug addictions: opiates, alcohol, cocaine, and methamphetamine. Before you can appreciate how they work, you first have to understand how the brain changes with drug addiction. The limbic system in the brain regulates our emotions. The main chemical that induces relaxation is gamma amino butyric acid (GABA). When GABA receptors are stimulated we feel happy and enjoy ourselves. GABA also increases the amount of dopamine in the limbic system, which gives pleasure and even euphoria. When these chemicals are depleted, we feel anxious, depressed, achy, nauseated, and irritable. This is what happens in drug withdrawal. The brain gets used to being heavily stimulated by drugs and loses its ability to produce enough dopamine in the limbic system to feel good or even feel normal without them. This condition can last for months, years, or even indefinitely (especially with meth). Withdrawing addicts can feel as if they are going to die. It is no wonder that they relapse so often. Unless this feeling is treated, the relapse rate will stay 85% of more. In our community a patient told me today that the recurrence rate for methamphetamine at the best and busiest detox and intensive care center in our upscale middle class community is 96%!!
Buprenorphine for Opiate Addiction
Buprenorphine works by stimulating the opiate Mu receptors in the brain in a similar way to opiates themselves. Stimulation of these receptors produces pain relief and relaxation. With drugs such as hydrocodone (Vicodin and Norco), oxycodone (Oxycontin), morphine, and heroin, these effects rise steadily as the dose increases. Increasing doses lead to desensitization of the brain and the physical changes of drug addiction. Too much drug can result in overdose and death. Buprenorphine only partially stimulates the Mu receptor, enough to eliminate drug cravings, but not enough to desensitize the brain. It is also very long acting so that the patient only has to use it once or twice daily. After a certain dose more buprenorphine has no more effect. This makes overdose or abuse very unlikely. Buprenorphine also blocks another opiate receptor, the kappa receptor, which is the cause of many withdrawal symptoms. The result is elimination of cravings, and the ability to slowly decrease the dose, completely stopping the drug most times. Some patients need to stay on buprenorphine in very small doses indefinitely. My opiate addicted patients tell me that they have never felt as good as when they are in this medication. Inappropriate drug use stops and they begin living normal lives.
Prometa Protocol for Cocaine, Methamphetamine, and Alcohol Addiction
The Prometa protocol concentrates on “fixing” the GABA receptor. With addiction the GABA receptor actually physically changes, markedly reducing normal stimulation. The only way to get enough GABA action to stay comfortable is by taking drugs. This, along with other physical changes in the limbic dopamine system, cause long lasting symptoms that can last indefinitely. Flumazanil is a medication that is used to block the GABA receptor and is usually used to treat benzodiazepine (Valium, Ativan, and others) overdose in the operating or emergency room. GABA receptors (and in fact all cell receptors) are constantly being taken into nerve cells and then regenerated. When given intravenously in a very specific protocol flumazanil blocks the GABA receptor at the time it is regenerated. When a blocked receptor is recycled it regenerates as the normal form. This basically eliminates the problem. Patients feel much better almost immediately. They almost all say that they think clearer and even more importantly, the cravings disappear. The beauty of this treatment is that it is completed over one to 3 weeks with lasting results.
Before Prometa there was no effective treatment for methamphetamine and cocaine cravings. There is simply nothing else that works. Without this treatment, patients feel tired, irritable, and depressed indefinitely. No wonder that almost all meth addicts eventually relapse. After Prometa these feelings are gone. One study of 50 methamphetamine addicts showed that almost 90 percent got significant positive effects. In my practice we see the same results. The patient stories are amazing.
These treatments are not cure alls. They will only be fully successful when used as part of a comprehensive program, such as the one I describe in my book, A New Prescription for Addiction. We also encourage twelve step programs for patients who will use them. There are barriers to getting these treatments to the people who need them. Buprenorphine can only be prescribed by physicians who have a special federal waiver and then each of these physicians can treat no more than 100 patients. Prometa is only available at licensed centers and it is very expensive. There is very limited insurance coverage for Prometa at this time, pending completion of university based double blind studies, which should be completed in late 2007. The major obstacle, however, is the attitude of society and unfortunately, many members of the addiction treatment community, towards this problem.
One thing is clear. Unless we treat physical cravings, we will never be able to get a handle on this terrible problem. What other treatment would be considered successful if 85% of patients failed?
Richard I. Gracer, MD, Certified in Addiction by ASAM
Gracer Medical Group
San Ramon, California
Author of A New Prescription for Addiction, published May 2007
Learn more about these treatments and others from my website: http://www.gracermedicalgroup.com/
For Prometa see: http://www.hythiam.com/
For buprenorphine see: http://www.naabt.org/
Read another article by Dr. Gracer: Detox-Rehab Cycles and Why They Fail In The Treatment of Addiction
You can order Dr. Gracer’s new book from: A New Prescription for Addiction
Getting a loved one to undergo drug abuse treatment becomes so much easier if the addict realizes the need for it.