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No aspect of today’s medicine could succeed without the solid scientific research that advances the prevention, diagnosis, and treatment of the true underlying causes of illness. Addiction medicine is no different.
Last week, Caron and the Penn State College of Medicine together hosted the Third Annual Addiction Research Symposium, bringing together psychiatrists, psychologists, behavioral health therapists, addiction therapists, physicians, and other healthcare practitioners in an informative day that showcased the latest evidence-based practices, treatment models, and cutting-edge research in addiction medicine.
For me, the day highlighted how far we have come in our understanding of addiction, and how far we still must go. Yes, addiction is a chronic disease that can be successfully managed, but we lack many of the tools we need to manage it with any degree of precision.
With diabetes, physicians can use hemoglobin A1C, fasting blood sugar, and a myriad of other blood tests to see where a patient is objectively. Same for COPD, where pulmonary function studies, MRIs, and other tools track the disease objectively. With addiction, everything is subjective. Addiction is a brain disease, and it is difficult to get real-time data on the brain.
Much more research is needed to help us prevent, diagnose, treat, and manage this illness. There are four areas we should focus our efforts on:
Even though evidence-based methodologies are making great strides in the successful treatment of addiction, there are many treatment providers that still hold to outdated, ineffective, and unsafe approaches to treatment. We need to be able to hold treatment providers accountable for their outcomes. That is, it is not enough to go through the motions; a treatment provider must be judged by the results – how many patients remain in recovery a year after leaving treatment, etc.
Right now, there is no universally agreed-upon standard of care in addiction medicine, no clearly defined outcomes.
Healthcare in general has evolved towards greater accountability regarding outcomes. For example, for knee replacements, every patient who has knee replacement surgery is put into a registry and followed to ensure long-term success of the procedure. There’s a clear standard of care and a clear expectation around outcomes for knee replacements. We need something similar in addiction medicine, and research is the way to get there. Across all patients receiving addiction treatment services, we should be following people for a year after leaving treatment, getting toxicology verification of their sobriety, doing detailed assessment. Armed with this data, we will gain a greater understanding of the critical factors involved in long-term recovery.
Predicting Relapse and Adjusting Treatment
We know a certain percentage of patients are going to relapse. In fact, we often say that relapse is just a normal part of recovery. But it would be better if we were able to predict those who are most at risk for relapse, or able to detect an impending relapse before it occurs.
One possible approach is to use real-time neuroimaging to monitor changes in brain activity, using the results of the tests to change treatment plans and lengths of stay. Caron is currently participating in two relapse prediction research studies. One uses Functional Near-Infrared Spectroscopy (fNIRS) during treatment, and the research showed the technique is 80 percent accurate in identifying patients who would eventually relapse, both for alcohol use disorder and opioid use disorder. We’re also in the early phase of research utilizing Electroencephalogram (EEG) technology in a similar fashion to investigate its predictive value around relapse.
Another potential area of research is in the effectiveness of medication assisted treatment (MAT), particularly in understanding how MAT works in the brain. MAT is the standard of care in addiction medicine – the data is clear about that -- but we don’t have answers for which type of medication assisted treatment works best, for whom, and how long. Nor do we understand how the brain reacts to MAT. Does the brain respond differently to MAT than it does to the substance of choice, or is MAT simply substituting the effect? More research can tell us so much.
The Genetics of Addiction
There is clearly a genetic component to addiction, certainly for alcohol, but we don’t know enough yet to put that knowledge into clinical practice. We need more research on the genetics of addiction, so we can be more precise in our treatment and, more importantly, identify those who have a genetic proclivity to develop an addiction.
Addiction is multi-genomic, involving the interplay of several genes. It’s even much more complicated than that because of epigenetic factors, those life experiences that trigger the expression or suppression of different genes. Childhood trauma, for example, is an epigenetic phenomenon that increases the risk of addiction seven times more than the general population who did not suffer trauma. Moreover, experiences in one generation can be passed on, to some extent, to the next generations through epigenetics.
People who have parents who are alcoholics or addicts are at greater risk of becoming alcoholics or addicts themselves. One parent, four times the risk. Two ends up being seven times the risk. This is likely due to epigenetic factors, and research is needed to figure out why this is happening and whether we can use it in either prevention or treatment of substance use disorder.
Addiction is the single most preventable chronic disease. It’s more curable and preventable than diabetes. Those at risk for diabetes must eat -- there is no way to live without eating. Those at risk for substance use disorder, if they know they are at risk, can take steps to avoid the environmental triggers that cause it to progress. But, we need research to help us determine who is at risk and what are the triggers.
I often compare the state of research into addiction to that of HIV and AIDS. A diagnosis of AIDS was once tantamount to a death sentence. The country made a commitment to AIDS research, and Federal funding for preventing, researching, and treating HIV has grown significantly from just a few hundred thousand in 1982 to more than $32 billion in FY 2017. Because of this investment into medical and scientific research, HIV infection has become a manageable chronic illness, with a life expectancy close to that of the general population.
We no longer think of AIDS and HIV infection in moral terms. Unfortunately, many still apply a moral code to substance use disorder, seeing it as a failure of character or willpower. This misperception keeps us from addressing addiction for what it is -- a disease of the brain. We can do great work if we’re given the opportunity through research and prevention efforts if we treat it like every other chronic disease.