For example, said Gordis, a 30-year study of 10,000 veterans conducted by Charles O'Brien, Ph.D., M.D., at the University of Pennsylvania has helped fine-tune the distinctions between alcohol and other drug use, abuse, and addiction. Increasingly, addiction has come to be equated with loss of control, not necessarily daily use. "Unfortunately, this information has not gotten out to the community, including physicians," Gordis said.

Using this definition of addiction, the O'Brien study concluded that tobacco is the most-addictive drug used by humans: 31.9 percent of tobacco users become addicted to nicotine. That's more than double the percentage of drinkers who become addicted to alcohol, and significantly higher than the 23.1 percent of heroin users who become addicts.

Similarly, the work of researcher Tom McLellan, Ph.D., of the University of Pennsylvania has helped to reshape the science of outcome measurement. Rather than judging the success of addiction treatment programs solely on abstinence, McClellan says that a whole host of positive outcomes should be considered, including improvements in mental health, legal problems, employment status, and family relationships. "When we do treatment outcomes, we need to consider these other factors," said Gordis.

Advances in biological and genetic research and medication development also have the potential to change the fundamental nature of addiction treatment. "The human genome project probably will have a major impact on treatment," said Gordis, who pointed out that 40 percent of human genes have proteins that affect the nervous system. Researchers have determined that chromosomes #1 and #7 are both linked to alcoholism, he added. With the human genome now completely mapped, researchers will find it easier to develop medications that address the genetic underpinnings of addiction.

The development of medications to help fight addiction over the last decade has been driven in large part by research showing how various drugs of abuse affect the chemical systems of the brain. Unlike other drugs, however, alcohol works on many chemical receptor sites in the brain, not just one, making medication development especially challenging. "We're working to find the sensitive sections on receptors in order to fight alcoholism," said Gordis.

Cutting-edge addiction medications like naltrexone, acamprosate, and bupropion attempt to fight craving for drugs by impacting brain chemistry. The new federal COMBINE study is expected to provide valuable information about how well these drugs perform in combination with addiction counseling, which Gordis says is absolutely critical to success. "If you just give drugs, they will fail," he said.

As with treatment outcomes, however, research findings can be skewed if the bar for success is set artificially high. For example, Gordis noted that some naltrexone studies of alcoholics yield far more impressive results if the occasional "slip" is not counted as a treatment failure.

Another trouble spot for addiction treatment is noncompliance: patients who stop taking their medication or quit coming to therapy are considered failures. But Gordis points out that the National Center on Health Statistics estimates that half of all medical patients lie about compliance with their treatment regimen, and that noncompliance is a major factor in relapse for hypertension and asthma patients. "But nobody talks about not covering these diseases because of noncompliance," said Gordis. "The compliance rate in addiction is no different than with other diseases, but it is treated differently by the health-care system."

Relapse remains a significant problem in addiction treatment. One study on naltrexone, for instance, showed that addicted patients who took naltrexone for nine months did better than a placebo group. But by 18 months after treatment, the relapse rate among the naltrexone group had caught up to that of the patients who had never received the drug. One conclusion may be that people with addiction may require long-term drug therapy in order to sustain treatment gains.

Environmental cues, which Gordis said persist long after drug use stops, also play a surprisingly strong role in addiction relapse. "Research shows that video cues activated the brains of former cocaine users in a way similar to sexual arousal in young men, only moreso," he noted. "Drugs essentially hijack a part of the brain, so you can see that this is an incredibly enticing behavior."

NIAAA Chief Points to Advances in Knowledge of Addiction, Treatment. Original feature article, Join Together Online (www.jointogether.org), May 7, 2001.   

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