One of the Most Popular Podcasts in America Totally Botched Its Drug Addiction Episode by Peddling Miracle Pills
In an episode titled “The Fix,” the science podcast series Radiolab, announced: “This episode we take (sic) a sober look at the throbbing, aching, craving desire states that return people (again and again) to the object of their addiction … and the pills that just might set them free.”
Before I deconstruct this fantasy, let me say why I am so concerned to debunk such mishegas:
The idea that addiction is due to a single biological mechanism in the brain has been disproved time and again, not the least by neurochemical research: “Decades of spending on neuroscience have taught scientists mostly what they do not know, undermining some of their most elemental assumptions.” To continue this fantasy is to misunderstand addiction in a way that eludes the hard work of creating a better society and giving people the reasons and means for living their lives without addiction.
As we pursue these magic-bullet concepts, you may have noticed deaths involving heroin, pharmaceutical painkillers, and tranquilizers, tracked since 2000, simultaneously hit all time highs in 2014, according to the CDC (as reported in Time). Meanwhile, the massive government survey called NESARC measured a 50% increase in past-year alcohol-use disorders (from 8.5% to 14%) between 2001-2 and 2012-13.
How do you feel we’re doing? Yet the administration website trumpets the fantastic scientific progress we are making under National Institute on Drug Abuse director and neuroscientific guru, Nora Volkow: “Groundbreaking discoveries about the brain have revolutionized our understanding of drug addiction, enabling us to respond effectively to the problem.” Oh, Volkow, who is interviewed by Radiolab for her optimistic read on how we are solving addiction, assumed office in 2003, at the beginning of our steep climb in addiction and drug deaths.
In place of Volkow’s optimism, Ilse Thompson and I declare in Recover!: An Empowering Program to Help You Stop Thinking Like an Addict and Reclaim Your Life, “By reinforcing the myth that addiction is uncontrollable and permanent, neuroscientific models make it harder to overcome the problem, just as the 12-step disease model has all along. Telling yourself that you are powerless over addiction is self-defeating; it limits your capacity to change and grow.”
Here’s the Radiolab story: “Reporter Amy O’Leary was fed up with her ex-boyfriend’s hard-drinking, when she discovered a French doctor’s memoir titled The End of My Addiction. The fix that he proposed seemed too good to be true. But her phone call with the doctor left her, and us, even more intrigued. Could this malady – so often seen as moral and spiritual - really be beaten back with a pill?”
Skeptical are you? The Radiolab people made their way from the French doctor, who turned out to be rather opaque, to Anna Rose Childress, a psychiatric researcher at the University of Pennsylvania. The drug in question is naltrexone (NTX), a narcotic antagonist (meaning that it blocks narcotic receptors). The concept behind NTX is that it interferes with the effects, not only of opioids, but also alcohol.
This is all funny, because the leading psychiatric research program in the area of addiction is, like Childress, located at Penn (although Radiolab doesn’t seem to know about it). The University of Pennsylvania team is led by Charles O’Brien, the head of the substance use disorders group for the American Psychiatric Association’s diagnostic manual, DSM-5. O’Brien is universally recognized to be the leader, along with Volkow, in America’s neuromedical onslaught on addiction and alcoholism.
In 2015, O’Brien and his colleagues published in JAMA—Psychiatry the results of a major, extremely complex pharmacogenetic research study with alcoholics using NTX. Subjects in the study were divided according to variant opiate receptor genes (called alleles) and administered NTX for 12 weeks, without either the provider or the patient knowing whether the subject received the real drug or a placebo (called a double-blind study). Since the results of NTX therapy tend to be mixed, the researchers predicted that the two different genotypes would make subjects more or less responsive to the NTX.
But that didn’t happen. O’Brien et al.’s bottom-line finding: “There was no evidence of a genotype × treatment interaction on the primary outcome of heavy drinking.” In fact, “a significant reduction in heavy drinking occurred across all groups”—that is, with alcoholics receiving both NTX and placebo.
Wow, that’s a stunning finding. The leading drug candidate for reducing alcoholism, the one touted as a breakthrough on Radiolab, had been found no more effective than placebo by the leading research team at the same university as the podcast’s major academic source, more than a half year before the podcast aired in December (the study was published in March).
Let me back up a little. Since NTX reduces the impact of alcohol (which is itself a bit of a mystery, since NTX affects opiate receptor sites in the brain, and alcohol does not have specific receptor sites), it minimizes the effects of alcohol, making it less appealing to alcoholic and other drinkers. So they drink less. And that did happen for NTX recipients in this study. But it also happened exactly as much for those receiving placebos, whichever genotype the alcoholic was.
In the study results, It’s impossible to make out any difference between the frequency of drinking, or the amount consumed when drinking, by alcoholics receiving either NTX or the placebo. Furthermore, cravings were reduced about equally. In fact, the group reporting the least craving by the end of the 12 weeks of the study was one of the placebo groups!
Okay, one more wrinkle. Some NTX proponents (including those on Radiolab) swear by a specific method of NTX administration called The Sinclair Method. David Sinclair is an American psychologist who emigrated to Finland. (He died in 2015.) The Sinclair Method is a paired association learning technique in which subjects take Naltrexone, then drink alcohol, on a specified schedule. Since Naltrexone blocks alcohol’s effects, people unlearn the associations they had with drinking (a process called extinction) that had lead them to drink excessively.
For Sinclair proponents, the O’Brien et al. study failed because, stupid them, they neglected to employ the full Sinclair protocol. Here is one such study of the Sinclair method—sent to me, actually, by one of those proponents who denigrated the O’Brien et al. study. In this study by Sinclair and colleagues,* alcoholics received12 weeks of Naltrexone and 20 weeks of targeted Naltrexone with either supportive therapy, or with cognitive coping skills therapy.
And here were that study’s results:
With supportive therapy, “Naltrexone was not better than placebo in the supportive groups.”
Only in the coping group did Naltrexone do better than placebo, but still produced only a very small effect: “27% of the coping/naltrexone patients had no relapses to heavy drinking throughout the 32 weeks.”
Note that one group did no better than they did with placebo, and in the other, only 27% (and not 80%) did not relapse over a mere 32 weeks. Now, remember, 27% represents the combined effect of mind over matter (placebo) and the CBT therapy as well. So, perhaps, NTX contributed half the total effect for that group—that is, it might have led to 13.5% of subjects not relapsing over roughly half a year.
One last caveat. The vaunted Sinclair Method in this study involved patients being given Naltrexone for 12 weeks, then carrying the drug with them to use when they crave alcohol (“targeted medication”). Apparently, even the Sinclair people don’t believe that “extinction” (or unlearning) effect works on its own. So how is the Sinclair Method different from standard NTX, non-Sinclair protocols, where the drug is used as needed by alcoholics?
And, so, is it possible that perhaps Radiolab was premature in announcing the discovery of the cure for alcoholism and addiction?