You may have seen Nora in the HBO special on addiction a couple of years ago. (Here’s an interview with Nora on the HBO page for the documentary.)  

Joan reminded me that Nora is the great-granddaughter of Russian revolutionary/exiled Soviet politician Leon Trotsky. She was raised in Mexico City in the home where he was assassinated.

The New York Times, which also noted her lineage, called her “A General in the Drug War.” Joan mentioned she was an early proponent of the Reward Deficiency theory originated by Dr. Kennth Blum. It was Nora who pioneered the use of brain imaging to better understand how drug addiction affects the brain.

Nora is constantly quoted, as in this USA Today article. Here’s her bio, which describes her illustrious career and wide-ranging career interests. For years she has studied and educated people about dopamine, a neurotransmitter that plays a role in reward-seeking and thus addiction. In May she addressed a group of drug experts about prescription pill abuse, according to The New York Times article. And she writes, too. One of her articles I found especially interesting is Physical Activity May Prevent Substance Abuse.

NIDA and National Institute on Alcohol Abuse and Alcoholism are due to be merged, and the NYT article says Volkow approves of the idea.

“…[S]he is all for the merger, calling the current structure ‘an artificial division with many missed opportunities,’ like having an institute for every particular variety of cancer. Addictions tend to move together, she said, sharing many triggers and a great deal of biology.”

You will remember that in 1990, when Dr. Kenneth Blum, PhD and Dr. Ernest Noble, PhD found the first official link between genetics and addiction, they were focused on the DRD2 gene, originally called the “alcoholic gene” by the media but correctly called the “reward gene” in their "Journal of American Medical Association" article. Many years of additional research have stemmed from that seminal study, confirming the original findings.

The results of a pilot study were published in the current edition of "Alcohol and Alcoholism".  Research scientists from the Department of Psychology at Sweden’s University of Gothenburg, studied the relapse rate of adults diagnosed as “alcohol dependent.”  The number of people studied was small -- 10 women and 40 men recruited from two Swedish 12 Step programs.  All 50 participants were required to provide blood for genotyping, and to be without severe on-going physical and psychiatric disorders other than alcohol and nicotine dependence.

Variations of a gene are called polymorphisms.  In this study only the Taq1A polymorphism of DRD2 “alcoholic” gene was studied. 

18 of the 50 alcoholics were found to carry the Taq1 1A polymorphism.  The other 32 alcoholics were not carriers.

The study found that after one and a half years, 33 of those who participated in the study had relapsed.  16 of the relapsers carried the Taq 1 1A polymorphism -- meaning that only 2 of the 18 genetically pre-disposed to addiction did not relapse. In other words  89% of the subjects that carried the DRD2 A1 allele relapsed. That is a very big and sad number.

By comparison only 53% of those who do not carry the gene (17 of the 32) relapsed.

None of those who relapsed were found to have been triggered by the influence of psychological or socio-demographics.  Additionally the study revealed no differences between those who relapsed and those who did not in terms of self-efficacy, mental health, stress, personality, and cravings.

The University of Gothesburg authors concluded that their study suggests an association between the DRD2 gene and relapse.  They suggest that other polymorphisms of the DRD2 gene now be studied.

The authors of the study wrote:  “The reason for the increased relapse rate in the carriers of the [“alcoholic gene”] remains to be elucidated.” 

Additionally – and this is important -- they cite two recent studies.  One demonstrated that carriers of  the same gene variant have a “diminished drinking refusal self-efficacy" (translation:  a diminished capacity to stop drinking). The other demonstated that healthy individuals who are carriers of the gene show “impairment in reversal learning situations. “

The authors concluded:  “The two studies suggest that alcohol-dependent individuals who carry the ”alcoholic gene” can benefit from more intensive psychological treatment aimed to improve drinking refusal self-efficacy and learning to focus on maintenance of abstinence.    The importance of improving treatment of the alcohol-dependent subjects who are carriers of the gene is seriously underscored by the findings of the highly increased mortality rate of those subjects.”

We agree.  To achieve long term sobriety, alcoholics predisposed to addiction need to not only become part of the fellowship of Alcoholics Anonymous, but to seek treatment of their dopaminergic dysfunction.

NOTE:  After I posted this blog Dr. Blum told me that the DRD2 gene has 7 polymorphisms, 4 of which occur frequently enough to be the subject of ongoing clinical testing about the relationship between the gene and relapse.  He said he has identified more than 30 additional genes which show predisposition to addiction, some or all of which would also be important candidates for the studies on the likelihood of relapse.

Do you ever wonder what doctors think about their patients who drink or abuse other drugs? There’s an online publication called www.medpagetoday.com  that says it’s “PUTTING BREAKING MEDICAL NEWS INTO PRACTICE^®.” I get the organization’s email newsletter. It also offers a couple of blogs written by the staff, many of whom are doctors.

Recently one of the blogs by a doctor who calls himself Shadowfax caught my eye. The title of his blog is “Movin’ Meat: The Accidental Blog of a Semi-Accidental ER Doc Living in the Pacific Northwest.” The name of the particular post I read was “Just Another Drunk.” 

He wrote about an older homeless alcoholic who ended up in his ER. We never learn the man’s name. Someone had found him passed out in a bush and had called an ambulance. The man, who had been in jail recently, was in the bush in the first place because he’d had too much to drink and couldn’t find his way back to the bridge he lived under. Shadowfax laments the fact that there’s nothing the ER can do for this man, and marvels that he has lived to age 75.

The doctor asks the man if he has any family and waits as he hesitates for a minute and then says no. It’s the hesitation that grabs the doctor’s attention and makes him try to imagine this man’s life and the family he may have had at one time. Did each of his loved ones drop off along the way? Did he once have friends?  Then the doctor makes it personal, talking about his own family which includes uncles who were lost to alcoholism and what it did to their families. The doctor is yet another person touched by alcoholism, illustrating once again the reach that this disease has.

Shadowfax was sympathetic to this man’s plight and didn’t judge. But I’ve read that there are some doctors who still judge alcoholics, who think that drinking is a moral failure instead of a brain disease. Hard to believe when they’re in the medical field. But that was before the HBO Addiction series appeared on TV, so let’s hope the doctors who still think that way saw the program and it changed their attitude.

I wonder how many other people have a family member who was homeless at one time or maybe still is. I especially like his last line: “Of all the sad things we see in the ER -- and there are plenty -- this seems to me to be one of the saddest and least appreciated, and by far among the most common.”