Thinking Differently About Treating Alcoholism, w/ Professor Bankole Johnson of the U of Maryland and HBO’s “Addiction” | EDB 113

(27 mins) In the first installment of a two part interview, Hackie Reitman, M.D. welcomes back Bankole A. Johnson, DSc, MD, MBChB, MPhil, FRCPsych, DFAPA, Dip-ABAM, Dip-ABDA, FACFEI, who heads the Brain Science Research Consortium Unit (BSRCU) at the University of Maryland School of Medicine, and is one of the world’s leading authorities on the subject of addiction. He is a leading neuroscientist and a pioneer in the development of medications for the treatment of alcohol abuse, and was featured on the HBO documentary series, “Addiction.” They discuss Professor Johnson’s his path to a career focusing on the neuroscience of addiction, the relationship between the gut and the brain in understanding addiction, and the importance of combining both new and traditional methods in treating alcoholism. 

FOR PART TWO, CLICK HERE

To find out more about Professor Bankole Johnson and the work he is doing with the Brain Science Research Consortium Unit (BSRCU), visit: medschool.umaryland.edu/bsrcu

For Professor Johnson’s personal site, visit: http://bankolejohnson.com/

For BSRCU’s newsletters, click here.

For the psychiatry department at the University of Maryland School of Medicine, visit: medschool.umaryland.edu/psychiatry

For information about the HBO Addiction project, for which Professor Bankole Johnson was a contributing expert, visit: www.hbo.com/addiction

And Professor Johnson can be followed on Twitter here: https://twitter.com/bankolekolej

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HACKIE REITMAN (HR): Hi I’m Dr. Hackie Reitman. Welcome to another episode of Exploring Different Brains. Today we have a returning guest. I am so excited and honored because it is my good friend, Dr. Bankole Johnson who is one of the world’s leading authorities on addiction and a million other things because he’s a real neuroscientist…He’s head of that whole brain contortion at the University of Maryland. He’s also a good writer too, but we will discuss that later. Welcome.

BANKOLE JOHNSON (BJ): I am so pleased to be here. Thank you for allowing me to come back.

HR: Are you kidding? And to have you here live at our Different Brains headquarters is a double honor.

BJ: Thank you, I am so grateful to be here, and it’s really good because it’s a little cold in Maryland today so it’s wonderful to be here in Florida.

HR: We are glad to have you…Just as a reminder to our audience because you have 42 degrees here…you have degrees from like every country in the world and everything else…but give our audience just a refresher on your background and introduce yourself.

BJ: Gosh, that gets tougher by time…but I went to medical school and in medical school and after medical school I decided I was probably going to verge off into sciences. So I started off doing a master degree, a master philosophy degree in statistics and computational math. The after that I went into a doctorate degree…this was done while I was at Oxford University and that was is psychopharmacology. As if I didn’t have enough punishment I did another doctorate at the University of Glasgow…and this time I did it in neuroscience and molecular genetics and aspects of brain psychopharmacology. So I’ve been in school a long time and it feels like I’ve never left school so I’m sure my mom must be proud.

HR: What is the favorite thing that you do now professionally?

BJ: Well I think the most fascinating thing is being able to go into work every day and talk to really bright people. The brain consortium which was really the genesis of what Dr. Albert Reese put together. A very clever man…and our idea was to bring together a lot of the brightest and best brains in anatomy, in neurosurgery, pharmacology, physiology, pharmacology to form this consortium in which we could come up with some really big ideas and pursue them just like the food project or a large project that would actually help to cure brain diseases. Most people don’t talk about curing brain diseases, but I think we’re getting to the point where we should really start thinking about curing brain diseases rather than just delaying their on send or providing some kind of management to their treatments.

HR: And it’s interesting because when we talk about brain disease, that’s one of the things we’re trying to do at Different Brains is to get everything under one roof which you seem to have done because it’s not just the neurological issues, it’s not just the developmental issues, it’s not just the mental health issues. It’s everything from autism, Alzheimer’s and all brains in-between and you have a handle on that. You see the commonality in the approach to much of this.

BJ: Yes, I think one of the interesting things that has emerged as we have understood neuroplasticity more, is that the borders between what most people call physical versus mental disorders in the brain are actually quite intertwined and they tend to be co-localized. So, one of the analogies that I gave in our last meeting was of a guy who had a punch on his head and that the swelling of the brain could be due to why the person became depressed. Well it’s also possible that the psychological effects of being punched in the brain are pretty negative. Somebody wouldn’t want to have that happen to them again. But it shows you how intertwined they are…and they’re intertwined in so many ways, but the most important are of the intertwining. In recent times has been all the work in pain and addiction. You know pain and addiction are represented by areas of the brain that sort of co-localize. So it is not unusual for somebody to have a painful condition, to be given too many opiates and become addicted because they represented the same part of the brain.

HR: Now you have invented and patented medication approaches to addiction. Could you discuss that a bit?

BJ: Yes. This is really tricky work if I may say so myself. It started off in a small room at Oxford University where I was walking down the corridor. At Oxford the professor will just kind of pluck you to do things you know. So I was found wondering around the corridor and I was asked what I was going to do with my life, and I said, “Well, you know I was going to do pharmacology here.” He said, “You can’t do that, what you need to do is thing about your project and come back in about two years with your PhD and your job is to find a cure for alcoholism.” I said, “Gosh, you know thank you very much.”

HR: That’ll teach you to go wondering down the halls.

BJ: So after that I thought to myself how am I going to do this?

BJ: So I read some ideas that there was this large emphasis on serotonin in the brain. There’d been some initial studies done on serotonin in the brain at that point it had nine receptors and I was at that point in time saying to myself, gosh I can’t study all of these, I’m going to be here for about a hundred years. I’ll never get my PhD they’re going to throw me out long before that. I had read some work on this receptor called the 5 HT 3 receptor, serotonin 3 receptor and this serotonin 3 receptor is fascinating because it was the only one that was a ligand gated right channel. Which means that it took fasting pulses…and if you see when people drink, as they raise the glass to the lips they already begin to feel the effects of alcohol. So I said that could be something really fascinating to study and. So I started studying with the 5 HT 3 system basically on a hunch and I remember my Proctor coming back in about a week or two say you know what you are working on. This 5 HT 3. Do know the dose of the medications that you’re going to try and we going to start this first on all the humans in our lab. I said four and I have no idea why I said four. I thought four wasn’t a good answer. I said four and I’m so pleased he didn’t ask me four what? I presumed he thought I meant four milligrams or 40, but he hadn’t asked me.

We started off the experiments and it ended up being four micrograms per kilo twice a day…but what we found was when we brought in some individuals…we actually used 500 policemen who liked to drink heavily. We gave them this drug called ondansetron and goodness be, they could refuse alcohol. This is very interesting. I was then recruited to come over to the United States and I was very pleased to get a large grant from the National Institutes of Health to actually study this whole ondansetron…and the idea I had was very simple and I would say I spent a lot of time in bars in England but it was very obvious to me that there are some people after a few drinks they’re extremely happy and a few more and they’re about to quarrel and fight with people. Then another set of people a little bit more depressed, a little bit older who when they drink they get mellower. So this classification of two types, one driven primarily by impulses versus one that is more driven by affective mood disorder was the idea that I had. So we did this very large study of over 300 patients and by and large we got the individuals who are these early onset individuals to be able to reduce their drinking dramatically with ondansetron. Strangely enough, the people who had the late onset, who were more depressive, they didn’t get better at all. What that meant was that there was a very specific effect of the drug on certain types of alcoholism, but there wasn’t an effect on other times which meant that there was probably genetic basis. So the story continues and I took these results, they were published in a big journal I decided that what I was going to do was I had to find a genetic basis for this. The problem arose again, you know remember I came to this with some serendipity and we tried this. So again I said, well let’s try looking at a couple of molecular probes in these serotonin systems. I came up with this long short examination, which have been shown in other studies by people to have sub biological differences.

So we tried that in a prospective way dividing people by genetic profile, and guess what? We found that these individuals with these long alleles who basically have an interaction between the allele and said parts of the brain were the ones that responded to ondansetron the best…and we’ve expanded that to show that there’s now a five panel system of genetics, which affects about 33% of people who drink for which ondansetron is highly good at reducing the desire to drink and the amount they drink. It doesn’t work for the other 67%, but here’s the fascinating thing about this. This pharmacogenetics panel can be done by taking a blood test and also it could be a biomarker for drinking. So in the future, if this drug is used this way, not only can you be given the drug but you don’t need to ask someone whether they’re drinking a lot. You can take blood samples, you can look at their mRNA, you can take pictures of the brain and you can tell if they’re drinking. So it takes the whole technology of alcohol treatment from what in which somebody is saying well did you drink five drinks a day, or ten drinks a day, or twenty drinks. You can just say I’m going to take a blood test, I’m going to do a brain scan, and I’ll tell you how you’re getting better. So that to me is science of now, the immediate now, and the interim now to the future. As we know more about Molecular Genetics, we are going to be able to find other drugs that will affect the other 67% of individuals. One of the final anecdotes to the story is that the genetic pattern is very interesting. So this combination is very low in Asian, very low in Japanese people. It’s roughly about 3 to 4 percent these alleles. So and that way it’s helped us to also explain why some Asians have a lot of protective factors, as well, against drinking…but it’s very high in Americans, it was about 33 to 36 percent…buts extremely high as you go to the Nordic countries like Russia and Scandinavia, rates that are about 50%. So they have a different type of genetic pattern.

HR: You just mentioned several geographic locations to their respective diets when you get into the gut brain interactions and the genetic interactions therein. Do you suspect any relation to that or not really?

BJ: Wow you do ask some great questions. So yes I do but let me answer the question in two ways. One of the things that’s very good about serotonin is it’s the oldest mudra mean in the brain. Therefore there is almost an ancestral way of tracking people as they’ve moved out of the Olduvai Gorge in Africa and they’ve spread out into Europe. So you can see that with that migration, you can also look at the migration to how those traits are actually exhibited and I’ll just finish off by telling a small story. I did my doctorate with a guy who was from Denmark’s I used to call it my Viking friend. He actually liked drinking so I feel that at some point I ended up going all the way back to my Viking friend saying and trying to understand why the Vikings might’ve been the way they were. Like you know in historical or of drinking but that’s that’s probably just on the side…but the gut brain is very important because we did not understand, for a long time, how the gut and the brain can actually be connected, but a lot of serotonin to your body actually sits in your gut it doesn’t sit in your brain. Well we now know that you could get signaling of these dealer transmitters of the brain by various mechanisms and they affect the brain in different ways. The important thing about alcohol is alcohol seems to affect specific parts of the bowel very differently. It doesn’t affect just the large colon, it affects the small intestine and we did some really fascinating experiments now at the University of Maryland, trying to pay point why that is exactly and why there are specific genetic clues all the way in our gut that will tell you why these drugs might be particularly useful to reduce alcohol drinking. So this story is nowhere near the end. We may find out that may be the effect our own specific gut microbes or specific neurotransmitters that are being modulated to the small intestine and these are having an affected on the brain…and you know like every theory, in theory has to be modified with time

HR: You were part of the team that won Emmy Awards for the HBO feature documentary, Addiction.

BJ: Yes.

HR: Would you share with our audience your involvement with that and what that was like.

BJ: Oh that was that was a fascinating project and it was watched by about 27 million Americans. I was glad to be included in the program because someone had heard about this work we were doing on another medication called powermade. So the producer said to me that they were not going to allow me to choose my own patients. They were going to find the patient, and they didn’t want to find me a patient in the same town because they didn’t want me to be able to influence the patient. They found two patients. One of these patients had to be brought to us by lever and I said only need to be able to give him the medicine and meet him for 15-20 minutes. They didn’t think 15 minutes was a long time but I assured them it was. So they brought out these folks they filmed them at home, they filmed over their background, and then they filmed them going through the transition. They only saw me for 15 minutes they put a timer on it and happily for them and I suppose luckily for me (I’m just joking because I did expect the medicine to work very well). They did very well their lives were transformed…and I think that this was part of a watershed in giving people hope, that the treatment of alcohol is not futile. The problem which practitioners have in treating people with alcoholism is that individuals turn up 50 to 20 years too late…but it’s really a very treatable disorder in a lot of people with the right medication, in the right hands, with both behavioral and the right pharmacology. It’s actually quite a crying shame that a lot of people did not have access to treatment. Early treatment should be started at the level of the family practitioner not wait15-20 years where the person has lost their job, their marriage, or their friends. It should start or the person starts to drink excessively.

HR: Now have you been getting pushback in the similar fashion where the natural medicine people fight against the traditional medicine people instead of getting together for integrative medicine. Do you get pushback from the it’s all behavioral versus any kind of medical approach? Where you say, look let’s give the medicine and let’s take the behavioral approach and let’s combine the best of both worlds for the benefit of the patient. Are you getting pushed back from say the 12-stepcommunity you know?

BJ: Well I do get push back. The good thing is, as a scientist, it’s always good for something to charge your ideas. So the best thing about science is that you could write an experiment and see whether you’re correct or that they’re correct. We ran a very large study ran by Dyson C’s of Health called Our Combined. That looked at both naltrexone and chemprocide with various types of behavioral treatment including one cell, which is call called cell 9, in which individuals got every behavioral and psychological intervention that they wanted. You wanted family therapy, you got it, you want motivation you got that thrown in. So you got mega therapy in cell 9. The others received medication and light behavioral treatment, you know motivational interviewing and guess what? The individuals who had the mega therapy in cell 9 had the worst outcomes. Even individuals who received placebo and brief interact in a brief intervention actually did slightly better than individuals who just had the mega therapy. To me it’s thought that doesn’t tell you that behavioral treatments don’t work. What it tells me is that behavioral treatments have specific ways of working just like medicines do and you can get an overdose of psychological treatment just like you can have an overdose of a pharmacological treatment. Overdosing people in therapy doesn’t help them very much and this idea of matching the right amount of psychological help with a right amount of medicine is really, I think, very much a key to getting the best treatments. So to readdress your other piece about behavioral treatment and pushback in a different way. Alcohol, the alcohol disease is primarily a biological disorder.

We now know that it’s almost 60% of the capacity is inherited. So about 40% of it is if you like non-biological or environmental…but even those environmental factors affect the brain because they modify the genes of the brain and they also create different expression levels of an appreciation for alcohol. So here’s the way I would put it if you were dropped into a desert and you are thirsting for water. You came upon this oasis, this oasis was full of water but the water was poisoned in some way and you knew it was poisoned. You knew that drinking this water was going to kill you but you’re still very thirsty and the thirst is your alcohol. Well I might be able to resist for a day or two but if you’re dependent on alcohol then you’re going to drink that water and it’s good to kill you. So the biological compulsion is very high. The other piece, to this, is we know that people, who have purely behavioral treatments, relapse often and they tend to replace very quickly. It’s up to 70 percent of people will relapse in six months and that is a pretty strong relapse rate. So having a medication and a behavioral component is the best way to ensure they actually get adequate treatment. It’s really a shame that almost 90% of people in the United States, who drink excessively, don’t get treatment. Of those 10% who get treatment, you know that 10% of those get a medicine and that is really too bad. That is really not optimizing medicine and we haven’t probably done a great job of educating the public to say this is a treatable condition. It could be bad just like if you have heart disease or blood pressure or diabetes and these treatments should be available to your doctor.

HR: How can our Different Brains audience learn more about you?

BJ: Well gosh, you know there’s a lot about me already on various websites but probably going to the University of Maryland website the School of Medicine website, they’ll be able to get a bio of my work the things that I do. Hopefully they will also take a look at the other members of the brain science research consortium unit. A group of very talented and very clever scientists of the University of Maryland and see what they’re doing. We’re doing some fascinating work on focused ultrasound, its being used for the treatment of neurological disorders at the moment. It may be useful for treatments of cancers, be able to be useful the treatment of affective disorder maybe even addiction. We’re doing some fascinating work of the gut brain access to look at schizophrenia and alcohol to determine whether we could change these microbes in a way that if you like healthy choice treatments for alcohol and other just mental disorders. They’re just so many fascinating things going on and every day is just a thrill. Sometimes it’s exhausting because I have to keep up because there’s so many brilliant people in the room, I have to-do a lot more reading than I probably used to but I should probably not admit that…but I have to do a lot more reading to try and understand our evidence.

HR: Well I got to tell you it’s a great thrill for me to be able to learn all of this from you. You’ve devoted your whole life to this really. You’re always at the cutting edge and what you’ve done and what the University of Maryland have done and again getting everything under one roof with the brain consortium is nothing short of epic and very much needed. It’s been a pleasure having you back.

HR: We’ve had the pleasure again on another episode of Exploring Different Brains to have my friend Dr. Benkole Johnson, from the University of Maryland, one of the world’s great addiction experts if not the addiction expert and also neuroscientist, he does it all. He is one of the leading authorities about the brain in general and thank you so much for being here today.

BJ: Thank you and I appreciate your invitation and it’s wonderful to see you in person. Thank you for having me.

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