We look at alternative aspects of treatment, such as the Buddhist 12-step program, and issues of “drunk-dreaming” as well as a new study review of anti-depression medication studies, the placebo effect and the FDA drug approval process.
Transcript (edited):
Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions.
CNS: There are some interesting things in the news this week that talk about different aspects of treatment that we havent looked at before. The Buddhist approach to the 12-step program that was in the Huffington Post recently and an article by one of their regular commentators talking about drunk dreams experienced by people in recovery. They do okay during the day, but apparently at night theyre tortured to some extent by their dreams.
DARRYL: The concept of alternative treatment or complementary medicine as it relates to addiction is getting more attention and I think treatment programs should take a closer look. Things like yoga have good evidence based studies that show it is effective in helping maintain recovery. Buddhist meditation, mindfulness meditation or just mindfulness is also proving to be as effective as a 12-step program. Acupuncture is considered alternative treatment and shows tremendous usefulness in the treatment of addiction. So, what is considered alternative or complementary can help addicts. Equine therapy, pet therapy, aroma therapy and energy focused techniques like tapping are beginning to show evidence that they are effective.
In regards to dreams, you can have two types or maybe multiple types, but the two types the article refers to were dreams about getting high. People experience euphoric effects in their dreams – wake up and are triggered into missing their drug. Thats something that mindfulness meditation and Buddhism could be really helpful for because in Buddhism you dont shut out or get rid of your thoughts, your thoughts are there and what you do is learn how not to react to them in a negative way. You learn to be aware of your thoughts, but not to react to them. The other types of using dreams are nightmares. They are terrifying dreams. Theyre dreams in which you are back in relapse, suffering a tremendous amount of negative effects but not getting high at all; or youre at home and the cops are breaking in and youre paralyzed. You cant move a muscle to swallow your stash or flush it down the toilet and so youre going to get busted. Those are terrifying nightmares of a user past even though they can be useful because they help reinforce how far some one has come and how much they have accomplished and what they need to do to stay focused on recovery. The problem dreams referred to in the article are euphoric dreams. The euphoric dreams recall the feeling of being high, you dream youre stoned.
CNS: This can act as a trigger and according to the article, it provoked guilt and fear that they were losing track of their recovery.
DARRYL: Dreams are an access to the subconscious and theyre generated by what we call the memory spikes or the memory bumps that have formed in the brain from the use and involvement with drugs. And, as far as I know, you never lose those memory bumps, those memory spikes, theyre always there. The brain of a person in recovery doesnt use or access those memories so they become weaker, less prominent. This forces the brain to form loose networks of communication links that bypass those memories. But when you are in a sleep state, in a dream state, the access of memory is through the unconscious and through the networks that access the memory bumps associated with drugs. That can be extremely dangerous as weve seen with the stop paradigm in the control circuitry of the brain. Once an addict initiates an action, those memories and those bumps will cause an addict to want to use again and almost nothing is going to stop them because of the dysfunctional control circuitry of an addicts brain. There are reports of people who have been 10 years, 20 years, maybe even 30 years in continuous recovery, having a using dream, waking up, and almost on a subconscious basis, picking up a hit. The next thing you know theyre in a full scale relapse. So its something we need to pay more attention to, to help addicts plan a strategy that will prevent them from using if they experience one of these dreams.
CNS: Another interesting story comes from Newsweek recently about the efficacy of placebos in contrast to antidepressant drugs. A new study indicates that 75% of the people participating in a couple of studies responded positively to sugar pills as opposed to serious antidepressant medication. What are your thoughts about placebos in general?
DARRYL: Well, first of all, Howard, the study does not surprise me at all. People should never short change or under appreciate the placebo effect. The medications that are developed to treat depression, to treat any kind of mental health issue, as well as any process in the brain, are simply mimicking or interfering or interacting with natural brain chemicals. We already have this whole pharmacy in our brain that consists of natural chemicals that serve as anti depressants, that manages excitement, fear and things like that. Placebos access that natural chemistry without actually using a drug. Its the expectation of an effect or an expectation of some sort of benefit that causes a person to actually benefit from their own chemistry. Placebos create a true and powerful physiological reaction in people. I participated in placebo experiments as a student at University of California in Dr. Fields laboratory. He had a lot of pharmacy, medical, and nursing students participate by taking a pill, which contained one of 3 possible drugs. All the pills were exactly the same so we didnt know what we were getting and he didnt know what he was giving us. This was a regular pharmacology double-blind crossover type of study, which is the Gold standard in terms of doing research on the efficacy of pharmacological substances. We got either 10 mg of methamphetamine, or 60 mg of codeine or milk sugar, the placebo. And it profoundly affects me to this day to remember that in this research, where nobody knew what they were getting, we had to measure our reaction our blood pressure, pulse rate, our reaction ability, our ability to coordinate our muscles and our equilibrium. We had to do all these studies 30 or 40 minutes after the pill was absorbed through the stomach to see what would happen. Later on the code was broken, showing which student got which drug or the placebo and it was amazing to me that about 1/3 of the people who got only milk sugar had such dramatic physical reactions. Their blood pressure changed. Their heart rate changed. They experienced all kinds of physiological responses. I remember some people were actually hallucinating and experiencing a whole array of mental issues when in fact they got a placebo. Placebos are powerful in their real responses.
The second thing the Newsweek article pointed out is that we dont have a good way of really evaluating medication. Double-blind crossover studies are designed to be used at the mid-point of research. For example, patient A who got pill #1 will get pill #2 at the crossover and patient B will switch from pill #2 to pill #1. This allows the researcher to get clarity on whether the patient is really reacting to the medication, to the placebo or to some other artifact of the study. The problem with crossover double-blind studies is they sometimes present an ethical question. That actually came up once during a syphilis study. The question was could a cynical compound or antibiotic treat syphilis. Placebos were given and it became a huge ethical issue. If someone has this debilitating, horrible disease and they receive milk sugar, their disease could get worse and worse and the person could suffer tremendous biological or medical problems. So is that something we should be doing? When a crossover design is not applied properly there is no way of determining the benefits from the pill. Is it a true antidepressant or are we seeing it as a partial placebo effect or a combination of placebo and antidepressant effects?
CNS: Another question addresses the FDA process which can take a long time and can keep drugs off the market here when they are in use already in Europe.
DARRYL: America is restricted from a lot of medications that might be effective for people who are suffering a disease. Is the push to get them approved as quickly as possible for the benefit of the patient or the company with a vested interest in getting it approved? The faster they get approval, the more time they have to benefit from their patent. A patent runs for 17 years after a drug is first registered. This includes development as well as the time the drug is put through the scrutiny process to determine its efficacy and its safety. The longer it takes to do that, the less time a drug company has an exclusive patent on the medication and the less money they will make. So, there are those two conflicting problems and I can see both sides. I can see the economic interests winning out sometimes in the pharmaceutical industry, but I also see the clinical issue. The FDA gets a lot of heat for the restrictions and difficulty in getting a medication approved that has the potential to ease suffering and save lives there are people suffer or die waiting for drugs to be approved. There are two sides to this coin and we may have to find a way to strengthen our ability to address both sides so medications can be approved quickly enough, but at the same time be sure that the medication is going to do what it says it will and be extremely safe and not cause more harm.
CNS: Back to efficacy of the antidepressant medication. In many cases, it is the primary care physician, not the psychiatrists who are treating a patient for depression and it is easier for them to prescribe a pill rather than explore a whole range of things that might be most efficacious.
DARRYL: That is a concern, I think in psychiatry and in all the medicine. The majority of anti-psychotic, antidepressant, mood stabilizing drugs are prescribed by non-psychiatrists – by people who have very little training in regards to these medications and what they do, but more importantly very little training in the whole mental health diagnosis, prognosis and treatment alternative processes. Thats something that has to be more effectively addressed because I do think we are not as effective as we can be in addressing the mental health treatment needs.
CNS: Treatment is certainly on the front burner here in terms of a topic that is important and thats going to be increasingly in the news as we see the mental health parody act go into effect.
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