The toll from soaring rates of prescription drug abuse, including both psychiatric medications and drugs for pain, has begun to dwarf that of the usual illegal culprits. Hospitalizations related to prescription drugs are up fivefold in the last decade, and overdose deaths up fourfold. More high school seniors report recreational use of tranquilizers or prescription narcotics, like OxyContin and Vicodin, than heroin and cocaine combined.

via An Addiction Expert Faces a Formidable Foe – Prescription Drugs – NYTimes.com.

This article is more a profile Dr. Nora D. Volkow, the neurologist who heads the National Institute on Drug Abuse, than it is about the science of addition. It also touches on the politics of merging two bureaucracies within the federal National Institutes of Health: N.I.D.A and the National Institute on Alcohol Abuse and Alcoholism.

Abuse of prescription drugs presents a different kind of problem than illegal drugs: they have to be available for the medical benefits they bring, but be strictly controlled.

For instance, Dr. Volkow’s group showed several years ago that when cocaine addicts watched videos of people taking drugs, dopamine levels surged in the part of their brains associated with habit and learning, correlating with the intense drug cravings the subjects began to experience.

Her research and that of others has also shown that even after addicts are successfully detoxed and long clean, their dopamine circuits remain abnormally blunted. Substances that elevate dopamine levels in normal subjects had notably muted responses in ex-addicts.

This observation, experts say, may explain the intense difficulty addicts have staying clean, as the ordinary rewards of daily life may have little effect on the recovering brain. Only the drug of choice will send dopamine levels high enough for any kind of pleasure.

And interesting policy point, obvious once pointed out:

To the average doctor, … the addict’s brain is impenetrable. All that is visible is irrational, illegal and sometimes threatening behavior. Surveys show most doctors prefer to keep their distance from addiction and addicted patients.

The number of prescriptions written for potentially addictive pain medications has soared in the last decade, reaching more than 200 million in 2010, Dr. Volkow said. Surveys asking teenagers where they get pills find that relatively few buy from strangers. Many have their own prescriptions, often from dental work.

“Students and residents have gotten the message that pain is undertreated,” said Dr. Mitchell H. Katz, an internist who directs the Los Angeles County Department of Health Services. “So they just prescribe higher and higher doses.” Meanwhile, he said, there is no evidence that treatment with opioids for more than four months actually helps chronic pain, or that higher doses work where lower ones fail. There is good evidence, however, that higher doses raise the risk of overdose and death.