10th August 2004
Here is the rest of it....
Last year, only 5 out of 43 patients at Dr. McDowell's center had relapsed after their first six months on buprenorphine, an 88 percent success rate; on methadone, treatment programs for most forms of drug addiction have less than a 50 percent success rate after six months, he said. In France, where buprenorphine has been on the market less than 10 years, fatal overdoses from heroin and other opiates have fallen almost 80 percent. ''In the field of addiction treatment, those figures are just unbelievable,'' he said.
Doctors in the United States wrote 80,000 prescriptions for buprenorphine in 2003, a number that is expected to soar in the coming years. Lured by the prospect of privacy, many heroin and opiate abusers are seeking help for the first time. Others are switching from methadone.
Dr. Chadd A. Herrmann, a psychiatrist in Manhattan, said he has received about 20 telephone calls in the last three weeks from people looking for buprenorphine. He had to turn them away, he said, because he was still awaiting authorization to prescribe it. In New York, doctors who want to prescribe buprenorphine are required to take an eight-hour training course and then receive approval from the state.
Dr. Herrmann, whose practice is on Fifth Avenue, said many of the people who called did so ''because of my address.'' He added, ''They make it really clear that they don't want to be in a program or clinic in some other part of the city.''
Perhaps buprenorphine's biggest draw, said Roberta P. Sales, a nurse coordinator at the Columbia program, is that it frees addicts from the methadone clinic. With a prescription, they can get a month's supply of the medication at the pharmacy. The cost is about $5 to $10 a day.
''How can you possibly work or go to school when the primary focus of your day is going to a methadone program?'' she said. ''With buprenorphine, I've had patients literally break down and cry because they can travel to another state and see their family for the first time in years.''
For all its promise, buprenorphine, whose use is confined to opiates, will help only a fraction of the Americans who abuse drugs. Researchers say their focus now is on finding new treatments for a wide variety of drugs. They hope to find medications that are not simply chemical substitutes but eliminate dependence altogether. In some laboratories, researchers are working on developing medications that do away with the cravings that make abstinence from any drug a struggle.
''It's never as simple as just washing the drug out of your body,'' said Dr. Anna Rose Childress, a research associate professor of psychology at the University of Pennsylvania medical school.
The shift toward treating cravings came largely from imaging studies. Researchers found that when a recovering addict was shown slight cues or reminders of an old drug habit -- an antidrug advertisement, for example, a cigarette or a syringe -- it set off intense activity in the brain's reward circuitry, and produced an urge to relapse.
''Often, this is what pulls people back in,'' Dr. Dackis said.
Campral, the anticraving medication, made by Merck and approved for alcoholism by the F.D.A. last week, appears to dampen that response by elevating levels of GABA, the brain's major inhibitory neurotransmitter. Dr. Childress believes that GABA helps rein in the reward circuitry that drives people to seek drugs and other pleasurable experiences. Campral has been used in Europe for several years.
At least two other drugs that increase GABA, topiramate and baclofen, seem to curb cravings for cocaine, heroin, cigarettes and alcohol. Dr. Childress, who is involved in clinical trials of baclofen for cocaine, said the medications may even help conquer compulsive behaviors like pathological gambling and sexual compulsion. Scientists have also found that the prescription medication modafinil, used for sleep disorders, can blunt the euphoria of cocaine.
Still other scientists are trying to solve two problems common among substance abusers: They often forget to take their medications, and even those who stay in recovery end up ''slipping'' periodically.
Vaccines, some researchers believe, may provide answers to these problems.
At Yale and Columbia, for example, researchers are testing a vaccine that uses molecules of cocaine bound to harmless pathogens. When the vaccine is injected into the body, the immune system responds by producing antibodies to the cocaine and to the pathogen it is paired with. After a handful of immunizations over the course of three months, the user has enough antibodies to prevent at least three times the typical dose of cocaine from reaching the brain.
''The people that make significant amounts of antibodies say that cocaine isn't what it used to be, and the people who make the highest levels of antibodies stop using it altogether,'' said Dr. Thomas Kosten, a professor of psychiatry and medicine at the Yale medical school.
In Australia, scientists are experimenting with a similar vaccine that blocks nicotine.
It may be years, experts concede, before the promise of vaccines, anticraving drugs and other new treatments can be fully realized. And if the prospect of a world without drug addiction seems too good to be true, it just might be. None of the drugs is a magic bullet. Psychotherapy will still be needed to help addicts repair frayed relationships and overcome psychological dependence. Moreover, an addict who is determined to get high, experts say, can counteract even the most effective medication -- by not taking it.
''In the drug abuse field you have to be humble,'' said Dr. Margaret Haney, a researcher at the New York State Psychiatric Institute who is involved in clinical trials of the cocaine vaccine. ''There is nothing that is going to work for everyone, but we're just hoping to increase the odds that someone will be able to stay clean and have just enough time to get their lives back in order.''
CAPTIONS: Photos: Serious drug addiction afflicts more than 10 million Americans. Hard-core narcotics like heroin and cocaine have a notoriously stubborn hold on addicts, and relapse rates are high. (Photo by Murdo Macleod); (Photo by Lalena Fisher/The New York Times)(pg. F1); Roberta P. Sales and Dr. David M. McDowell, at left, and Dr. Charles A. Dackis are involved in new treatment programs for drug addiction. (Photos by Nancy Siesel/The New York Times, left; Bradley C. Bower for The New York Times); (Photo by Bill Marsh/The New York Times)(pg. F6)
Chart: ''A Lesser High''
A new drug for opiate abuse imitates heroin, but only to a degree.
Heroin molecules fit into opiate receptors on brain cells, or neurons. They stop the neuron from emitting a molecule that regulates dopamine between cells, so that dopamine floods the brain, causing a high.
Buprenorphine fits into the opiate receptors, blocking heroin and yielding a limited high.
Last year, only 5 out of 43 patients at Dr. McDowell's center had relapsed after their first six months on buprenorphine, an 88 percent success rate; on methadone, treatment programs for most forms of drug addiction have less than a 50 percent success rate after six months, he said. In France, where buprenorphine has been on the market less than 10 years, fatal overdoses from heroin and other opiates have fallen almost 80 percent. ''In the field of addiction treatment, those figures are just unbelievable,'' he said.
Doctors in the United States wrote 80,000 prescriptions for buprenorphine in 2003, a number that is expected to soar in the coming years. Lured by the prospect of privacy, many heroin and opiate abusers are seeking help for the first time. Others are switching from methadone.
Dr. Chadd A. Herrmann, a psychiatrist in Manhattan, said he has received about 20 telephone calls in the last three weeks from people looking for buprenorphine. He had to turn them away, he said, because he was still awaiting authorization to prescribe it. In New York, doctors who want to prescribe buprenorphine are required to take an eight-hour training course and then receive approval from the state.
Dr. Herrmann, whose practice is on Fifth Avenue, said many of the people who called did so ''because of my address.'' He added, ''They make it really clear that they don't want to be in a program or clinic in some other part of the city.''
Perhaps buprenorphine's biggest draw, said Roberta P. Sales, a nurse coordinator at the Columbia program, is that it frees addicts from the methadone clinic. With a prescription, they can get a month's supply of the medication at the pharmacy. The cost is about $5 to $10 a day.
''How can you possibly work or go to school when the primary focus of your day is going to a methadone program?'' she said. ''With buprenorphine, I've had patients literally break down and cry because they can travel to another state and see their family for the first time in years.''
For all its promise, buprenorphine, whose use is confined to opiates, will help only a fraction of the Americans who abuse drugs. Researchers say their focus now is on finding new treatments for a wide variety of drugs. They hope to find medications that are not simply chemical substitutes but eliminate dependence altogether. In some laboratories, researchers are working on developing medications that do away with the cravings that make abstinence from any drug a struggle.
''It's never as simple as just washing the drug out of your body,'' said Dr. Anna Rose Childress, a research associate professor of psychology at the University of Pennsylvania medical school.
The shift toward treating cravings came largely from imaging studies. Researchers found that when a recovering addict was shown slight cues or reminders of an old drug habit -- an antidrug advertisement, for example, a cigarette or a syringe -- it set off intense activity in the brain's reward circuitry, and produced an urge to relapse.
''Often, this is what pulls people back in,'' Dr. Dackis said.
Campral, the anticraving medication, made by Merck and approved for alcoholism by the F.D.A. last week, appears to dampen that response by elevating levels of GABA, the brain's major inhibitory neurotransmitter. Dr. Childress believes that GABA helps rein in the reward circuitry that drives people to seek drugs and other pleasurable experiences. Campral has been used in Europe for several years.
At least two other drugs that increase GABA, topiramate and baclofen, seem to curb cravings for cocaine, heroin, cigarettes and alcohol. Dr. Childress, who is involved in clinical trials of baclofen for cocaine, said the medications may even help conquer compulsive behaviors like pathological gambling and sexual compulsion. Scientists have also found that the prescription medication modafinil, used for sleep disorders, can blunt the euphoria of cocaine.
Still other scientists are trying to solve two problems common among substance abusers: They often forget to take their medications, and even those who stay in recovery end up ''slipping'' periodically.
Vaccines, some researchers believe, may provide answers to these problems.
At Yale and Columbia, for example, researchers are testing a vaccine that uses molecules of cocaine bound to harmless pathogens. When the vaccine is injected into the body, the immune system responds by producing antibodies to the cocaine and to the pathogen it is paired with. After a handful of immunizations over the course of three months, the user has enough antibodies to prevent at least three times the typical dose of cocaine from reaching the brain.
''The people that make significant amounts of antibodies say that cocaine isn't what it used to be, and the people who make the highest levels of antibodies stop using it altogether,'' said Dr. Thomas Kosten, a professor of psychiatry and medicine at the Yale medical school.
In Australia, scientists are experimenting with a similar vaccine that blocks nicotine.
It may be years, experts concede, before the promise of vaccines, anticraving drugs and other new treatments can be fully realized. And if the prospect of a world without drug addiction seems too good to be true, it just might be. None of the drugs is a magic bullet. Psychotherapy will still be needed to help addicts repair frayed relationships and overcome psychological dependence. Moreover, an addict who is determined to get high, experts say, can counteract even the most effective medication -- by not taking it.
''In the drug abuse field you have to be humble,'' said Dr. Margaret Haney, a researcher at the New York State Psychiatric Institute who is involved in clinical trials of the cocaine vaccine. ''There is nothing that is going to work for everyone, but we're just hoping to increase the odds that someone will be able to stay clean and have just enough time to get their lives back in order.''
CAPTIONS: Photos: Serious drug addiction afflicts more than 10 million Americans. Hard-core narcotics like heroin and cocaine have a notoriously stubborn hold on addicts, and relapse rates are high. (Photo by Murdo Macleod); (Photo by Lalena Fisher/The New York Times)(pg. F1); Roberta P. Sales and Dr. David M. McDowell, at left, and Dr. Charles A. Dackis are involved in new treatment programs for drug addiction. (Photos by Nancy Siesel/The New York Times, left; Bradley C. Bower for The New York Times); (Photo by Bill Marsh/The New York Times)(pg. F6)
Chart: ''A Lesser High''
A new drug for opiate abuse imitates heroin, but only to a degree.
Heroin molecules fit into opiate receptors on brain cells, or neurons. They stop the neuron from emitting a molecule that regulates dopamine between cells, so that dopamine floods the brain, causing a high.
Buprenorphine fits into the opiate receptors, blocking heroin and yielding a limited high.