Better science may revolutionize treatment.
Listen deeply to anyone with an addiction and you’ll hear many threads to the story. The Rubik’s cube puzzle may seem to have far more than six faces, lining up in various ways.
All patients are individuals. “It would be a miracle if standardized treatment strategies would work for everyone at every stage and that patients with the same diagnosis would respond in the same way," observes Jaap van der Stel, a professor of mental health at the University of Applied Sciences in Leiden, Germany. But this may be especially true for people struggling with addictions.
Personalized medicine therefore holds the promise of transforming the field. In his 2015 overview, “Precision in Addiction Care: Does It Make a Difference?” van der Stel goes on to say, “There are great opportunities for more precision in psychiatry and addiction care… [with a] targeted focus on the patient’s individual characteristics and a better selection of treatment strategies.”
Resistance to oversimplification — “I’m different from other addicts” — is one of the most common reasons people give for staying away from medical treatment. That doesn't mean they are doomed: the common idea that addictions always get worse without professional treatment simply isn’t true. Many get better — on their own, over time. They escape bad circumstances or grow into other coping methods.
The hope is that treatment can speed things up, and that people will be more likely to overcome shame and other reasons for resisting help if they see options fine-tuned to their own needs. Ideally, everyone could choose among support groups, medication, specialized therapy, and other social services that make a difference.
The most immediate applications of personalized medicine may be with medication. Many drugs, typically with other current uses — among them, naltrexone, acamprosate, topiramate, disulfiram, baclofen, N-acetylcysteine, and bupropion — all seem to have some power to reduce cravings. But not for everyone. Naltrexone, for example, seems to prevent a relapse of drinking for up to 75 percent of people recovering from alcoholism who try it. You’re a good candidate if you have strong alcohol cravings, a family history of alcoholism — and it turns out, if you like spicy foods.
Similarily, genetic markers have been linked to success with acamprosate. Another potential anti-craving drug, especially for smokers and drinkers, is varenicline; research into associated genetic markers is underway. Meanwhile, researchers are on the trail of effective meds for behavioral addictions; again, the more we know about the people most likely to benefit the better: the population that may have a habit deemed a behavioral addiction at any point in time is much bigger than you might guess.
One day we may offer closely targeted therapy as well, instead of sending everyone to a group using the 12-step formula. Some research, for example, suggests that younger teens with a marijuana problem and a rebellious streak do better with family therapy than cognitive behavioral therapy, which teaches them to think more clearly. On the other hand, 17- and 18-year-olds may do better with cognitive behavioral therapy. It’s even possible that brain scans may one day help pinpoint the trait or skill that most needs a boost.
Obviously it will help to know the patient as well as possible. Many people with addictions are depressed or have other psychiatric issues. It’s a sadly common (and self-defeating) scenario for drinkers to get a prescription for an antidepressant — and keep drinking. Personalized medicine means addressing both the addiction and depression: antidepressants alone don’t stop substance abuse. One small study reported that depressed drinkers who received both sertraline and naltrexone did better than people treated with either drug alone or a placebo.
Patients in the end will free themselves, finding ways to avoid relapses, which may require both persistence and experimentation: twisting and turning that Rubik’s cube. Better, more personalized, treatment is essential.
March 31, 2020
Christopher Nystuen, MD, MBA