Robert L. DuPont, M.D.’s best advice for addiction treatment specialists is, perhaps, startling in its simplicity: listen to your patients, and they will teach you that the most successful way to treat addiction is not through burgeoning advances in genetics or pharmacology, but through good, old-fashioned behavior modification and implementation of strict, consistently enforced consequences to addictive behavior.

The noted addiction psychiatrist was one of several experts who addressed the annual "Medical Aspects of Addiction" conference in June in Myrtle Beach, S.C. DuPont, a clinical professor of psychiatry at Georgetown University School of Medicine, began his career in addiction medicine nearly 30 years ago.

He served as the White House drug policy advisor under President Richard Nixon, was the founding director of the National Institute on Drug Abuse, and for more 20 years has seen patients in private practice.

His presentation at last month’s conference, jointly sponsored by the American Society for Addiction Medicine, the South Carolina Society for Addiction Medicine, and the South Carolina Department of Alcohol and Other Drug Abuse Services, focused on addiction in older adults, including treatment issues.

To understand the best ways to reduce drug use and prevent future abuse, explained DuPont, one first has to understand the nature of addiction. This understanding has advanced greatly in the medical community over the last several years.

"Addiction," DuPont observed, "is a brain disease. . . .The key to addiction is reward, brain reward. It is the stimulation of the nucleus accumbens and the ventral tegmental area, the brain’s pleasure centers, where the neurotransmitter involved is dopamine, that leads to addiction."

Addiction specialists used to think that the phenomenon of addiction required an individual to experience withdrawal symptoms when the addictive substance was abruptly withheld. "Withdrawal," said DuPont, "has nothing to do with addiction. You can completely block withdrawal, and you still see addictive behavior.

Addiction in today’s older generation, which he defined as those over age 65, is largely limited to alcohol dependence, DuPont said. Addictive behavior, he explained, begins in the teen years, during a time of biological vulnerability. The brain centers that control impulsivity are not yet completely developed, so teens often have difficulty controlling pleasure-seeking behavior.

According to DuPont, about two-thirds of individuals have stable rates of alcohol use from age 40 to 60. Of the one-third with alcohol use that changes, two-thirds reduce intake, and one-third increase intake into their 60s. The two most common reasons for increasing their alcohol intake, he said, are the death of a spouse and retirement.

The pressure of retirement communities often mirrors that of today’s colleges, said DuPont.

"If you were designing a way of promoting alcohol and drug use," he told Psychiatric News, "you couldn’t improve on the modern American college. You take a homogenous age group of the highest risk, take away any responsibility for work, somebody else is paying the bills, and give them easy, cheap access." It’s the same problem in today’s retirement communities, he added.

As the current baby-boom generation continues to age, DuPont commented, more illicit drug abuse and addiction will be seen in seniors.

The elderly, said DuPont, are known to experience increased effects from a given amount of alcohol compared with younger people. This is due to a reduction in lean body mass as people age, a reduction in the enzymes that break down alcohol in the stomach, and potentially increased sensitivity because of decreased mental status due to other disease or disorders.

DuPont cautioned that with the elderly, clinicians must also consider the use of prescription and over-the-counter medications because many of these drugs increase the effects of alcohol.

Asking two important questions—"Do you drink alcohol?" and "How much do you drink, and how often?"—is the best way to screen elderly patients for alcohol abuse and dependence, according to DuPont. He cautioned, however, that most people report less than they actually drink.

"Bob DuPont’s Green Light Zone," he explained, "is straightforward: No more than two drinks in 24 hours, four drinks per week, and you’ve got a green light. With four drinks per day and nine drinks per week, you get a yellow light. Five or more drinks a day, or more than 10 drinks per week, and you’ve got a red light."

DuPont defines a person with a red light as not necessarily an alcoholic, but certainly at significant risk for alcoholism. A "drink" is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled liquor.

"Most elderly," DuPont told Psychiatric News, "will reduce their alcohol intake upon discussion with a respected, trusted health professional."

DuPont is a big proponent of the 12-step programs pioneered by Alcoholics Anonymous. He rarely uses pharmacological intervention, especially in his elderly patients, because, he said, it is not very effective. He advocates regular on-the-job drug testing and stiff penalties for drug use as two ways to make drugs less desirable to use. 

Most important, he continued, is individualization of treatment. Forty years of various treatment modalities, argued DuPont, have shown that when it comes to addiction treatment, one size does not fit all.