WARNING: Unless treatment is supervised and implemented by professionals who themselves have a strong 12-Step background, any other treatment will be contaminated with subliminal inducements for recovering addicts to obliterate rather than solve problems or tolerate uncertainty. 

The prospect of millions of addicts recovering 

with

only the learned behavior of addiction 

to guide them

is horrifying.

Why this is so, I can explain biologically. 

What matters is that I can prove it.

After four years, I must update my understanding: A"cure" is relative only to specific symptoms of alcohol or opioid dependence. Over the past four years, since I set up EdwardsVoice, Inc. a private non-profit 501(c)(3) corporation, I have observed at close range, hundreds of people with varying degrees of alcohol/opioid dependence and their responses to traditional treatments. For the most part, they have suffered in silence, relapsed and disappeared. Those who remain abstinent attribute their success to Divine intervention that they found through adherence to the same program that has not helped nearly all others. Epidemics do not respect people's passionate regard for a philosophy or a lifestyle choice. The dead have been heard.

Recently, the Institute of Medicine published a position paper that sanctions home induction of blocking agents, approves of the concurrent use of benzos, and suggests that brief counseling is helpful but might not be necessary. The paper will have a profound effect on the future of addiction treatment well into the 21st Century.  The Institute does not speak with such authority unless there is a medical crisis.  According to the Institute of Medicine, the only response that has a hope of success in combatting the current opioid crisis requires overturning decades of traditional thinking.  Saving the lives of each and every addict is the goal that has not been reached by ANY currently available treatment.

Must we throw out the baby with the bathwater? How much do 12-Step programs currently matter? Consistently, 2 million people claim affinity with a 12-Step program. That amounts to one-half of one percent (0.55%) of the population.  About 9% suffer from addiction.  This means that 6% of all addicts have an affinity for a 12-Step Program. To achieve the same 65% remission rate that the Institute of Medicine proposes to achieve with home induction of blocking agents would mean that 12-Step programs would have to expand their membership by a factor of by 968%. Yet, the profound commitment that people (too many of them on their way to death) have for building spiritual lives cannot and must not be ignored. The transcendent devotion of the 12-Step adherent is the essential glue for sticking in gratitude where there was rancor and serenity where there was unrelenting turmoil. I have seen this happen in hundreds of recovering addicts under the care of a dedicated group of professionals with a firm grounding in  12-Step principles. Is this logical?

Addiction does not pertain to just one neurotransmitter. Evey level of cerebral function is affected, except for a small area in the parietal cortex that has increased metabolic output when the subject reports praying or meditating.  The justification for the inclusion of and the necessity for 12-Step programs in sustained recovery is to preserve and expand the functioning of this small piece of tissue in the parietal cortex, which does not have any inputs from the mu opioid receptor and therefore is the seat of long-term recovery potential. Blocking the mu opioid receptor not only saves lives but also opens the door to cortical rehabilitation under the protection of a strong parietal cortex that can only be enhanced by a 12-Step program approach along with medical interventions for conflicting chemical imbalances such as major depression, bipolar illness, panic disorder/agoraphobia, attention deficits, and fits due to closed head trauma.

The Institue reasons that cravings result when the mu opioid receptor malfunctions.  This is settled science. Unchecked cravings stimulate memory pathways that guide the addict back to her drug of choice. This "look, see, GO" reasoning is not subject to mid-brain moderation. Shortcuts result from the frenzied brain looking for the substance that has allowed functioning to be maintained despite chemical imbalances that have gone unrecognized or untreated.

This is fancy language that explains why low-bottom drunks and addicts will continue seeking drugs. Jackpots do not matter. Even the suggestion that this addictive pattern can be altered raises up powerful defenses - so strong that every current treatment has a "back door" to guard the mu opioid receptor against interference - of any sort.

Only in the throes of imminent death will the layers of biological protection drop so that another human can take over temporarily.  Help comes only after the addict has a spontaneous remission - an event that permits the addict to cry out for HELP. Blocking agents keep the mu opioid receptor in a chemically-induced remission (similar to the alteration in cell growth factors that is brought about by chemotherapies that can arrest cancer.)  The logic and the evidence are irrefutable. Blocking the mu opioid receptor ends cravings.

Open Letter:  October 02, 2014

For Martha Coakley, Attorney General

Commonwealth of Massachusetts

You are my hero.

             When I heard you talk about your brother Edward and how he died needlessly, I knew that at last someone understood what it’s like not to be able to communicate. Over the past few years you helped me get the document that so many others in your office have denied or suppressed – the proof that I was robbed of my livelihood to satisfy the interests of corrupt prosecutors and tainted witnesses.  And, how those corrupt officials had such wanton disregard for human life that they caused over 200 desperately sick patients who, like Edward, were unable to speak for themselves, to be forced from care to die or to commit crimes – to cost the State millions just to advance the careers of conspirators who were at the time in the Office of the Medicaid Fraud Prosecutor, the Board of Registration in Medicine, and even my own attorney who was suborned to commit perjury to keep the judge’s order suppressed and gain more favorable treatment for future cases. 

             When I heard you talk about Edward, I started to piece together the evidence we need to bring these miscreants to justice – or to consider other options --- like helping those who still suffer rather than subjecting a very long list of professional people to a draconian exposé.

             In honor of Edward and all that he stands for, I plan to found a not for profit organization to give Edward his voice for all time: The Voice of Edward will have a mission to promote effective medical care and legal protection for all the Edwards who suffer with depression, and other conditions that impair communication – the alcoholics and drug addicts that I helped until ignorance and greed stopped me, and the post trauma and concussion patients who are unable to express their own pain.

             But above all you are OUR hero.  You know that immense power comes from the bottom of the pyramid, while those at the top have lost the capacity to govern.  You will bring a new awareness to the electorate -- an edict in destiny to replace fear and shame with treatment and education. To give those who were doomed to struggle the power to earn and thrive.

             I will soon record and publicize a message announcing that The Voice of Edward will launch as soon as our status becomes legally compliant.  Since it has been several months since you designated Mr. Bedrosian to head an investigation, I will also send him a copy along with the identities and evidence of the conspirators who deserve his scrutiny.

             May God bless the Commonwealth of Massachusetts and her governor-to-be.

William A. Rohde, M.D., M.B.A., M.Sc.

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......