In the world of professional wrestling, everybody’s got a name. The name isn’t just an identifier of person but also of personality: Edge, Tank Abbot, Ultimo Dragon, etc. While most neruoscientists would shudder to think this, neuroscience has the same convention. In the case of addiction it’s always been presented that The Cortex is battling The Midbrain.

The Cortex evokes thoughts of calm deliberation, executive control, and the will. The Midbrain is the brain’s reward system and the seat of pleasure. Modern psychiatry and neuroscience understands addiction in terms of The Midbrain overpowering The Cortex when in fact it’s The Cortex who should be champ. While I think that’s a mistake, and I’ll tell you why in a bit, it is a vast improvement over what came before: The Cortex was the only one in the ring.

Before modern neuroscience and the understanding of the brain biology of addiction it was thought that addiction was a decision. Anyone who drank too much was a normal person who chose to drink too much because they were selfish and wanted more enjoyment than others had. There was no disorder, it was just the will of a selfish or bad person.

Then along came psychiatry that understood neurosis and disorders of the cortex. Addiction became understood as a disorder, but a disorder of a weakened cortex. People who used drugs or alcohol were those who wanted to stop but couldn’t because their cortex, the seat of decision making, was too weak. So psychiatry set about treating addiction as it did neurosis very early on. The answer was psychotherapy. Unfortunately it was a resounding failure, and people with addiction were then seen as untreatable. Most of medicine and psychiatry abandoned addicted patients at that point until the modern age of neuroscience.

Starting in the 1980s discoveries were made that showed that the root pathology of addiction lay in The Midbrain. In spite of all these discoveries modern neuroscience still has, as one target of addiction treatment, the idea of somehow increasing the power of The Cortex so that people can decide to stop. The corollary is that The Midbrain is too strong. It’s an interesting idea and appeals to concept of civilization taming the savage. Too bad it’s about as real as professional wrestling.

It seems that when we had to give up the idea that addiction is a illness of The Cortex and understood it as an illness of The Midbrain, we clung to the idea that the fix would be to turn it into a problem of The Cortex, because we know how to fix those. We really want this to become a matter of choice.

What’s always bothered me about this idea is that The Midbrain is designed by nature to be stronger than The Cortex so any fix for addiction that makes The Cortex stronger is like building a levee against a flood (I’m from New Orleans, so you get my point about the eventual outcome). The Midbrain is the part of our brain that makes us go get food when we haven’t eaten in 5 days. Even if The Cortex says, “We really shouldn’t steal food from that old lady. It isn’t right. It’s better to starve to death than hurt another person,” the Midbrain will just laugh and we’ll go get the food. If we weren’t designed that way, our ancestors never would have survived.

So it always bothered me from a philosophical position that the idea of making The Cortex stronger was just human hubris, but I had no evidence. I think I do now.

I recently received from a colleague the slides of a talk given last year by Dr. Nora Volkow, director of the National Institute of Drug Abuse. She pointed out in her slides the correlation between addiction and low density of dopamine receptors in The Midbrain. That is, in addiction The Midbrain is missing something. It’s not stronger, it’s missing something. She also noted that in 1993 and again in 2001 her group published studies showing that in cocaine “abusers” and methamphetamine “abusers” the lower the dopamine density in The Midbrain the lower the function of The Cortex. That means it’s the weakness of The Midbrain that causes the weakness of The Cortex. So the two wrestlers in opposition image has to go away, and I’ll stop capitalizing The Names.

It’s time for us to recognize that when we say addiction is an illness we mean it. It’s not in anyone’s control, and it isn’t going to be. There’s nothing we have that will change it from being an illness of the midbrain to a problem of the cortex. What that means is that someone with addiction will not be able to fix his problem with his own thinking and medicine will not be able to make him into someone who can fix his problem with his own thinking. That’s the essence of AA’s first step that’s worked better than my field has for 70 years. As medicine grows in the knowledge in neurobiology we shouldn’t forget the wisdom gained in addiction treatment while we were sitting on the sidelines.

What differentiates drug testing in addiction from, say, drug testing in workplace drug use, is the presence of an illness. In doing drug testing to monitor an illness such as addiction, one is not trying to “catch” someone doing something wrong. One is monitoring one aspect of the illness. So rather than providing a means to a legal deterrent, drug testing becomes a medical tool, and I prefer to use the term Medical Monitoring for Adherence (MMA), where adherence refers to adherence to the plan of care, which includes abstaining from using drugs or alcohol.

Since we’re talking about a medical situation, let me give you another one to compare with. Let’s say you have an infection. The doctor tells you to take 10 days of antibiotics and cautions you not to stop before the 10 days are up. The reason you should take the whole course of 10 days is that some bacteria are more easily killed by the antibiotic than others, and if you just take it until you feel better most, but not all, of the bacteria will be dead. The only ones left will be those most resistant to the antibiotic, and they’ll grow to create an even worse infection if left alive. Now imagine there was a test that would measure the number of bacteria in the body, and you could do it every day during the 10 day course. When that number reached zero you could safely stop the antibiotic. What that test would do is give us patient specific information rather than population specific information. What we have now is the latter. The same is true with Medical Monitoring for Adherence in addiction.

Now, understanding that we are not yet into patient specific indicators for MMA, let’s look at two programs based on population that have documented success rates. Surprisingly, these two programs have much higher success rates than those reported for the general population and are considered the “gold standard.” Since they are very different they should give us some sense of what the important factors are. The first program is that of Navy pilots and the second is that of physicians.

The high rate of treatment success in these programs have been criticized as not being applicable to other populations because of the high educational achievement of the participants and the fact that they all have professional licenses (to fly or practice medicine) that gives coercive power over them. In fact, the physician monitoring programs have been replicated in less well educated populations with no significant decrease in effectiveness. In addition, illness, when understood as illness, provides its own coercive force on behavior. So I think these are good programs to look at.

Both Navy pilots and physicians have a greater than 90% five-year success rate at achieving and maintaining abstinence from drugs and alcohol. Both have 5 year MMA programs. Both have random testing. Both have wide panels including indicators for alcohol. Both utilize a tapering frequency of testing over the years of participation. Both programs require other behavioral changes in addition to abstinence. Both are still based on population; that is, there is no measure when someone is ready to leave the program at three years or needs to stay seven.

One might be tempted to look cynically at these programs and say, “Sure they’re sober for five years, but you’re testing them for five years.” What happens in year six? There is some evidence to suggest just that, and some state physician health programs are looking at extending their contracts to longer than 5 year periods of monitoring. However, this “monitoring period” idea is one of those vestigial aspects that no longer makes sense. When drug testing began, there was no understanding of addiction as a chronic illness; it was seen as a habit that you just had to break long enough to stay away from. The period came from what was necessary for the vast majority to “break the habit.”

But if we see addiction as a chronic illness then there’s no habit to break. The symptoms that caused the drug use in the first place are there until treated. So does that mean that if we had a medical treatment for addiction we wouldn’t need the monitoring? No, because there are behavioral aspects and no treatment is perfect, but a combination of medical treatment, MMA, and other medical surveillance should give us a more personalized approach to the length of time MMA is needed.

So let’s construct the “perfect” MMA program for medical treatment of addiction. We’ll have to compromise because of cost in some places, and for other reasons in other places, but “perfect” gives us something to shoot at.

Frequency: Frequency should start out at twice a week (because the most common things tested for can be detected at 3 to 4 days) and should be random. Each day should be liable for testing so that the person doesn’t know what’s coming. It should be truly random so that two days or even three in a row are possible.

Matrix: The matrix is the substance tested (urine, hair, saliva, etc). Urine is the perfect matrix for MMA as its collection is non invasive, it can be tested frequently with changes in state (unlike hair which doesn’t change much over time), and increases the time of detection (saliva can only detect what is there at present). There are some challenges to using urine: certain medical conditions, the fact that urine is chemically “dirty” because its a waste product, and others. Technology and modern lab techniques can overcome all of these challenges.

Test Panel: It should be very wide and constantly changing as new drugs become problems. The original drug test called the “DOT 5″ included THC, PCP, Benzodiazepines, Cocaine, and Barbituates. Developed when PCP was a growing problem, it made sense. Today PCP is something rarely used by itself, but most testing programs can’t stop looking for it because of it’s place in the canon of federal testing. Meanwhile, synthetic cannabinoids, a growing problem today, are not in most panels because they don’t change fast enough. As long as users have access to new drugs for significant periods before they are looked for, MMA will be limited in its effectiveness.

Testing Method: Some screening method to include screening for adulterants followed by Mass Spectrometry (MS) confirmation with quantification and normalization to individual hydration level with medical interpretation is the gold standard. Let’s take each of those factors in turn. “Screening followed by confirmation” – It may soon be possible to test for everything via confirmation testing but it is still more expensive and so we use screening techniques to find those samples most likely to be positive. The screening technique chosen should be overly sensitive so that positives aren’t missed. The confirmation gold standard is some kind of chromatography (liquid or gas) followed by MS which allows for the quantification of the various metabolites present. “Adulteration testing” – as long as there is MMA there will be those who try to defeat it by various methods. All screening should include screening for adulteration and dilution of urine in attempts to avoid monitoring. “Normalization” – in serial testing early in treatment or following a relapse into drug using behavior a dichotomous result becomes unimportant. It is necessary to do serial measurements to follow the falling level of metabolites in order to determine that drug using has stopped. This leads to the problem of nominal levels that rise because of concentration of the urine due to dehydration. Techniques have been developed to create normalized values to do serial comparisons. “Medical Interpretation” – MMA is a medical procedure and while other entities (courts, probation officers, employers, etc) have taken it on, it remains something best interpreted with the individual’s medical condition in mind. That is why federally regulated programs include a Medical Review Officer (MRO) and why all programs using MMA should have a physician interpret the results. Given the complexity of metabolic pathways, normalization coefficients, and interpretation algorithms, it is not likely that the layman can accurately interpret MMA results.

So now we have the “perfect” MMA scheme: daily randomization of twice weekly testing the first year, followed by two years of weekly testing, a year of monthly testing and a year of testing every two months. The panel should include: ETG/ETS (ethanol metabolites); THC; synthetic cannabinoids; amphetamine; methamphetamine (with the ability to test for d and l forms); cocaine; the substituted cathiones (bath salts); a list of benzos too long to list here; barbituates; opioids and opiates including buprenorphine, methadone, and oxycodone; the “Z-drugs”; and what ever addiction medication the person is taking. The confirmed, quantified, normalized results should be back in the office the next day with medical interpretation to allow for fast intervention.

Now back to reality. No one is going to go for more than once a week testing unless they are in intensive treatment. The most you’re going to get out of outpatients after treatment is weekly, and a true randomization scheme will aid in mitigating the decreased frequency. Some will say they can’t test weekly for the first year, and that may be so, but less frequent testing has not been shown to provide the behavioral fence around the illness that at least weekly testing has.

Some programs will say they can’t afford confirmatory quantified testing. They will always wonder if that positive was really positive, and when someone’s job or freedom is on the line, using non confirmed tests opens one up to considerable liability. Even in a pure treatment setting with no forensic implications, a non-confirmed test will open the program to losing the patient’s confidence by acting on a false positive. Some will say they need no medical interpretation, but they will also open themselves up to liability in interpreting the results if they get it wrong.

Labs focused on work place testing or pain clinic testing just don’t have the same focus or understanding what what an addiction treater needs in a lab. Personally, it’s taken me a long time to find a laboratory that is focused on helping those who treat addiction and need MMA. It’s taken a long time to find a lab that will pick up our samples and get the confirmed, quantified, interpreted results back to us quickly. The more people who treat addiction focus on what we need from a lab rather than settle for what the lab wants to give us the more prevalent will be the labs that can really help us treat patients.