IS BREATHING AIR AN ADDICTION? (LinkedIN Group Discussion):

Thanks to Doc and Paul for pointing out the similarities between the normal function of our hypoxic drive receptors that regulate breathing by monitoring increased levels of CO2, and the defective down regulation of the mu opiate receptor that results in uncontrolled cravings for alcohol. Most of the debates on LinkedIn about the "causes" and treatments for alcoholism seem to be the result of confusion about the difference between a biologically imperative "drive" such as breathing, and a behavior pattern acquired by repetition rather than genetic pressure - such as toilet training or socially acceptable drinking. The issue that generates so much fraught debate seems to be - in which category do we place alcoholism? Are there sufficient cognitive emotional and spiritual abstract reason pathways to shut down the defective mu opiate receptor?  To whatever extent an alcoholic has inherited a defective regulatory mechanism, no amount of spiritual conditioning will supply sufficient negative feed back to turn off cravings completely or successfully in every instance when ever the receptor malfunctions. 

Everyone agrees that negative feedback from inhibitory pathways responsible for cognitive emotion and spiritual devotion cannot extinguish basic life functions. You can't pray hard enough or think clearly enough to stop yourself from eventually taking a breath while your head is being held underwater. The small number of neurons responsible for hypoxic drive cannot be completely influenced by the entire remainder of the human brain and nervous system.  Case closed.  No debate.  However, human strains that are susceptible to traditionally defined (Jellinek curve) alcoholism possess a genetically inherited control mechanism for craving alcohol through the mu opiate receptor.  Unlike the genetically controlled demand for air that is constant from birth, the opiate receptor has a life cycle of maturity and a daily circadian rhythm which can be influenced by environmental feedback - but not completely controlled, since, like breathing, the opiate receptor's circadian rhythm cannot be prayed or thought out of operation.      

ASAM - Operational Definition of Addiction - The Way Forward

The new ASAM Definition of Addiction sets the limiting parameters for what are and what are not legitimate areas of interest for anyone trying to talk about or do research on the previously non-specifically defined field of drug dependence. "Non-specific" being the operative element.  It would be naive to ignore the implications for the discussion that I am prosing for the blog on specifically the pathophysiology of alcoholism. I have recently noticed a number of references to the "ASAM Definition," without any one of them including any descriptive information.  Indeed the authors of this prodigious undertaking have been careful to include a nod to each of the various traditions that have been the subjects of LinkedIn Debates.  Here, we have the vede mecum from which we ought to discern the causes of, the natural history of, and the treatments for any a substance that fits the exclusionary criteria:

Inability to consistently [A]BSTAIN

Impairment of [B]EHAVIORAL control

[C]RAVING

[D]IMINISHED recognition of significant problems

Rather than offer comments or suggest interpretations, which would be hasty and even offensive to the brave men living and dead who struggled with this task, I would like to restrict our attention to only those parts of the 8 pages long "definition" that mention alcohol specifically. First things first. We need to relate symptoms to pathophysiology:[D]IMINISHED recognition of significant problems
Where in the brain are these functions localized - or what is the rate controlling process?

Why just alcohol? (From a LinkedIn duscussion)

Hi Howard.  thank you so much for your valuable insights.  I would like to restrict my blog to discussing a possible pharmacodynamic disease model for alcoholism for this reason.  Alcohol and alcohol addiction is unique in human history. Alcohol isn't just a feel good drug - or a poison.  Alcohol sterilizes water.  Literally, Western civilization could not have spread into Northern Europe if people did not seek alcohol laden liquids.  Western man became vulnerable to water born disease as soon as they stopped migrating and stayed in one place long enough to pollute their own water supplies. Only those who experienced twilight hour craving for alcohol, when, for millions of years, the men returned from the day time hunt back to the settlement, those who felt a desire to find their way back to a source of alcohol were assured of not contracting a fatal water born disease. Those who did not have that genetic variation, simply died out in a generation or two.  For what ever reason, our aldehyde sensor, that tells us when we turn acidotic from starvation, some how (random mutation highly selected for) got crossed with the resident endorphin Circadian rhythm generator on part of the opiate receptor. In plain English, when the other endocrine receptors peak at around 4 pm, we get a hyper-alert starvation warning which is either extinguished immediately with an ounce or so of alcohol or simply wears off gradually after a carbohydrate load that also satisfies that starvation alarm for another 24 hours.  Like all biosystems, there is a bell shaped distribution of receptor sensitivity (which we experience as craving intensity).  Some people have no mechanism to generate cravings for alcohol at all, but on the other end of the curve, some of us got stuck with a balky receptor that won't turn off with just one or two ounces of alcohol or even with a gluttonous carbo load. Our entire brain gets taken over until we find a pathway back to alcohol, which is the most efficient way to turn off the rogue receptor.  Even though the defect is just like a silent switch that we can't feel directly,every bit of brain matter at higher conscious levels (that we call the emotional and spiritual) is held hostage until that nasty receptor finally gets pickled enough to stop functioning.  Nomadic peoples, the Native Americans or Arabs, never had the survival pressure to develop this pattern. Orientals seem to have boiled everything since the dawn of their civilization, and hence, Chinese never were threatened with lethal water born illness.  They just get very flushed when they consume alcohol because they can't metabolize the aldehyde byproducts.  But neither Arabs, Native Americans nor Orientals have a turn off switch when they drink alcohol...they just keep on until they get cellular addiction. I have a lot more to suggest on this topic,which is why I decided to take those discussions to a more specifically technical blog, but I wanted to answer your question as part of this discussion because it does lead us to a very very important insight:  Now we can fit the physical level with the emotional and spiritual under one holistic model that easily accounts for the different observations that different discussants have been making.  Every one is totally correct at some time during the natural progression of the illness.

Is there a generally accepted physical mechanism that explains alcohol addiction?

I created this blog in response to an issue that kept arising in LinkedIn discussions about addiction;

What is the cause of alcohol addiction, and what can be done to treat the cause successfully?

Most of the LinkedIn discussions dealt with the 12 Step approach to treatment.  With those favoring 12 Step programs proclaiming that only strict obedience to the principals articulated in the Big Book of Alcoholics Anonymous could help alcoholics stay sober, and those opposed generally attacking the 12 Step approach for being quasi-scientific or for requiring acceptance of a Higher Being Who could and would relieve the alcoholic's addiction if He were accorded the correct propitiation.

As both a recovering alcoholic with over 13 years of daily attendance at 12 Step Meetings and as a psycho-pharmacologist with over 20 years research experience at Harvard Medical School, I realized that both pro and con arguments assumed that the basic defect causing some people to crave alcohol had to do with a "spiritual loss of values," thus making the  disease of alcoholism by definition an affliction of those who were ignorant of or who had rejected the moral imperatives of Christianity.

In essence, nearly all the LinkedIn discussions about alcohol addiction hinged on a system of beliefs rather than evidence about a disease process that results in devastating physical deterioration.  If alcoholics only suffered from inappropriate behaviors alone, or behaviors that a Christian would find repugnant - without any other characteristic psychophysiology - then accepting spiritual salvation would be the "cure" for the alcoholic without which no improvement could be possible. Furthermore, the obverse would also be true - that those who could not stay sober would have to be suffering from profound moral decay manifested by a definite pattern of seriously reckless and illegal behavior.  The physical manifestations would not be the defining characteristics of the illness.   The thought of a chronically relapsing alcoholic would who was not also a criminal would be unthinkable.

This is not far from the status quo for American alcoholics and those who abuse other substances that follow a pattern of cravings and relapses.  In America, addiction is definitely a moral/criminal issue.  We imprison and stigmatize those who cannot stay sober AS IF they were simply bad people who could be driven into submission by determined civil authorities with the power to imprison rather than an obligation to do biomedical research. 

The cynic in me wants to say that, here, we lock up our treatment failures.  We marginalize those who lack the financial means to live a law abiding life.  We disenfranchise anyone who has done jail time - for which the most common crime is possession of substances that have been made illegal by the same people who profit from running prisons and chasing down users.      

Cunning Baffling Powerful. . .

That's what Bill W. called alcoholism "cunning, baffling, powerful.....no power on earth can remove this viscious preditor....."  That was in 1936.  The major killers of people in the civilized world were pneumonia, heart failure, tubercolosis, and cancer.  Syphilis was incurable. Gonorrhea caused female sterility.  Malnutrition was endemic during the Great Depression.  And, no one expected any of these dread diseases to ever be conquored. The recommended treatments for "depression" were either five to seven years of psychoanalytic treatment, one hour per day, five days per week, or lengthy "rest" cures that often involved long stays in sanatoria, lengthy ocean cruises, or chronic hospitalization often for life when the episodes became severely disabling. Schizophrenia was treated with "hydrotherapy" tubs where patients would be restrained for hours every day in swirling warm water.  The mechanisms of disease were basically understood: bad humor explanations had given way to bacteriology and the rudiments of public health.  But there were no "cures" for any dread disease except for "tincture of time."  The greatest physician of the time, Sir William Osler, recognized the terrible toll that alcoholism took on every body system. He set aside 25% of his teaching beds at The Johns Hopkins Hospital reserved for the treatment of male alcoholics - principally from delerium tremens, liver failure, kidney disease and Korsakoff psychosis - the end stage of mental deterioration from chronic relapse. 

Given this context, Bill W.'s observations were realistic and conservative. Since time immoemorial, physicians had known that mobilizing "spiritual" strength was extremely helpfrul to combat fatal illness.  Furthermore, the very idea that people could or should demand  a "cure" for any of these conditions was unthinkable. 

Today, people still die of the same conditions, but the rule has shifted - toward survival, even from cancer.  People demand "cures" for life threatening illness, and in the case of HIV, those demands stimulated an entire industry to create effective treatments that do not involved living in sanatoria, spending 5 hours per week laying on an anaylst's couch, of sitting in a hot tub for hours every day. Why do we still describe alcoholism the same way we did in 1936?  Before we delve into a techincal discussion, it is worth while to speciulate about this  bizarre anachronis,: is alcoholism the disease that dare not ask to be cured?  Why aren't alcoholics thronging their health care providers demanding a "cure" just like HIV victims did so effectively. Even tubercular patients rioted at the Bayer GMBH laps inGermany demanding a cure for tuberculisis - which they got eventually, from INH and streptomuycin. 

Is alcoholism really so different fron other major killers of mankind that were thought to be uncurable 80 years ago?  Or not?  Post your cumments......  

Is there a generally accepted physical mechanism that explains alcohol addiction?

In May and June 2011, I participated in a number of LinkedIn discussions with self-proclaimed addiction specialists - dealing with a number of topics that had to do with alcohol addiction and treatment.  As a group, everyone who participated was very experienced treating alcoholics, and had hands-on experience with implementing treatments based on at least one of three loosely aligned models of the disease process.

To get this blog rolling, I want to post my own interpretation of the three dominant viewpoints that seemed to dominate the LinkedIn discussions:
1) LEARNING MODEL: Motivational learning model - based on the assumption that alcoholism represented learned behavior that can, therefore, be unlearned or reconfigured using cognitive behavioral methods.
2) SELF-HELP MODEL: All of the LinkedIn discussants were very familiar with the Program of Alcoholics Anonymous.  While AA does recognize physical and emotional components of alcoholism, the differentiating focus is on the recognition and correction of the alcoholics impaired value system - the spiritual submission that leads toward profound character change and away from environmental triggers.
3) MEDICAL MODEL:  This was the least talked about and most universally maligned view point that takes the position that alcoholism is an error of metabolism that has less to do with learning and values than with defective bio regulatory systems.

PLEASE COMMENT ON THESE 3 THEORIES IN YOUR OWN TERMS AND EXPERIENCES.   

As we gather information about these separate approaches, we must bear in mind that all of them are probably significant and contributory to some important aspect of alcoholism.  The question we will ultimately try to confront is to identify pivotal defect(s) that materially causes the addict to crave alcohol and have irrational relapses into uncontrollable drinking.  To talk of a "cure" is to talk about a critical phase of the illness, that, if modified, would  reduce the risk of morbidity and mortality for every patient, prevent further outbreakes to such an extent that remission could be sustained with minimal intervention and without any appreciagble risk of endangerment either to the former alcoholic or to his ecology.     

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