According to the National Household Survey on Drug Abuse (overseen by the Substance Abuse and Mental Health Services Administration), about 3 million Americans have used heroin. Of these, one in 10 report using the drug in the last year, and one in 20 say they've used it in the past month. The percentages for cocaine are similar. In both cases, daily use is so rare that the government does not provide figures for it. These findings indicate that the vast majority of heroin and cocaine users either never become addicted or, if they do, soon manage to moderate their use or abstain.
This pattern has been confirmed again and again by government-sponsored research. At NIDA, however, studies of human behavior have taken a back seat to research involving brain scans, special breeds of rats, and monkeys tethered to drug-dispensing catheters.
Given NIDA's biological orientation, it may seem odd that the main form of treatment the agency advocates (pending development of a wonder drug for addiction) involves adopting a new set of quasi-religious beliefs and meeting regularly with like-minded individuals. But NIDA's take on addiction has much in common with the view promoted by Alcoholics Anonymous (A.A.) and its imitators. Both see addiction as a disease involving loss of control that can be overcome only through abstinence.
NIDA's support for drug treatment based on A.A.-like principles, the dominant approach in the United States, flies in the face of its avowed commitment to rigorous science -- a conflict illustrated in the last issue of NIDA's newsletter published under Leshner. A front-page article announced the disastrous long-term consequences of heroin use, based on a study that followed a group of addicts for more than 30 years. "The death rate among the members of the group is 50 to 100 times the rate among the general population of men in the same age range," the article said.
"Even among surviving members of the group," the lead researcher added, "severe consequences such as high levels of health problems, criminal behavior and incarceration, and public assistance were
associated with long-term heroin use."
Yet the subjects of this study were criminal offenders in California who were forced to attend abstinence-oriented, A.A.-style group sessions between 1962 and 1964. In other words, they benefited from just the sort of treatment NIDA advocates. Undaunted, Leshner began his column in the same issue of the newsletter with the cheery news that "NIDA's quarter century of research has produced a basic unequivocal message -- drug addiction is a treatable brain disease." Yet today's preferred treatment is indistinguishable from the programs those California convicts attended in the 1960s.
Sugar: The Miracle Cure
If Leshner and Gordis are right, A.A.-style therapy will ultimately be replaced, or at least supplemented, by drugs that block addiction. The leading candidate so far is naltrexone, which is reputed to curb the urge for both heroin and alcohol. Naltrexone has been approved for treatment of alcohol dependence, and Gordis, an M.D., promoted the drug as the first in the pharmacopoeia he envisioned for alcoholism.
A study published in December made that prospect seem unlikely. The researchers divided 600 alcoholics into three groups: One received naltrexone for a year, another was given naltrexone for three months followed by nine months of sugar pills, and the third group took just the placebo. The subjects began the study drinking, on average, on two out of every three days, 13 drinks on each occasion. One year after their treatment began, these men were drinking one-quarter as frequently and consuming somewhat less when they did drink. But the reduction was about the same for the men who took the fake pills as it was for those who were given naltrexone.
Announced in The New England Journal of Medicine, these findings were incomprehensible to anyone who accepts the view of alcoholism promoted by the NIAAA. Aside from the evidence against naltrexone's effectiveness, it was stunning that sugar pills enabled severe alcoholics to reduce their drinking without abstaining completely, which alcoholism experts in the United States teach is impossible. Yet every major study of alcoholism carried out during Gordis' tenure at the NIAAA yielded the same sort of results. It's just that Gordis spent much of his energy denying what his own agency had found.
In 1992 the NIAAA surveyed more than 42,000 randomly selected Americans in the National Longitudinal Alcohol Epidemiologic Survey. Census Bureau interviewers questioned each respondent about his or her lifetime drug and alcohol use. Of special interest were 4,585 respondents who at some time in their lives were "alcohol dependent" (what most people call alcoholic). Of this group, only about a quarter were ever treated for alcoholism (including A.A. as treatment). But the treated group was no more likely to have improved, as measured by either abstinence or drinking without abuse. In fact, more treated (33 percent) than untreated alcoholics (28 percent) were continuing to abuse alcohol.
One reason untreated alcoholics did better was that many more of them reduced their drinking without abstaining. Among people who at some point in their lives had qualified as alcohol dependent but were never treated, nearly "6 in 10" or "more than half" (58 percent) in the untreated group were drinking without a diagnosable problem. Including all the treated and untreated alcoholics in this random sample of Americans, half were drinking without abusing alcohol.
Driven Not to Drink
The NIAAA sponsored another ambitious study -- the largest trial of psychotherapy ever conducted. Completed in 1996, the study was known as Project MATCH because it was aimed at determining whether different treatments could be "matched" to specific types of alcoholics to produce optimum results. One of the therapies, based on A.A.'s 12 steps, was called "12-step facilitation." A second was dubbed "coping skills therapy." The third was "motivational enhancement therapy." Nearly half of the 1,700 or so subjects underwent hospital treatment first; the rest entered the MATCH treatments directly.
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