Welcome, Professor Monti. Tell us about when you first arrived at Brown University.
50 years ago I saw an advertisement for a job at Brown as a project coordinator. Having just received my Ph.D., it looked like an interesting opportunity, so I took it and worked on a pharmacotherapy trial. I thought I was going to be around for a year doing that, and here I am 50 years later, not able to find a real job otherwise.
That must have been quite a study!
We were studying a group of psychiatric patients with a variety of diagnoses, and substance misuse was emerging as a theme in our work. A lot of studies involving psychiatric patients were eliminating people who had alcohol use disorders. They were looking at this as a nuisance variable. If they were, for example, studying depression, they didn't want to study people who were drinking because drinking would interfere with the study of depression. Well, when you do that, you eliminate vast chunks of the population.
We decided that they were throwing the baby out with the bathwater and we decided to focus in on the substance use, particularly alcohol, at that time. We began to forge a research program around alcohol, eventually, with people with alcohol use disorder. That's how it evolved.
Somebody else's nuisance variable turned out to be the thing that enamored us most and captured our attention. That led to a variety of pilot studies and ultimately, we approached the National Institute on Alcohol Abuse and Alcoholism for funding and received our first grant, to take a look at craving and alcohol use disorder (AUD).
Your work on craving turned out to be a major advancement.
Yes, we stumbled on what has become a major mechanism in the field. In order to measure craving as an endophenotype, if you will, we devised a phenomenon referred to as cue reactivity. We happened upon this quite serendipitously. I was doing coping skills training, which is what I had been writing about, and we were trying to make role-plays for people who had alcohol use disorder as realistic as possible. So we introduced a prompt of beverage alcohol in the role-play. So for example, if somebody was doing a role play of refusing a drink, we would hold up a glass to them and say, ‘Here, you take this drink, I'll grab myself another,’ and the participant, the person with alcohol use disorder, was supposed to come up with an effective way to refuse that drink.
Well, what we found is that we were getting a pretty big bang for our buck with the prop there. It was just a prop to make the thing more realistic, but it took us down the path toward this endophenotype measuring craving in the context of the cue reactivity. We did a number of studies showing that alcoholics, severe alcoholics, differed from people with minor drinking problems in terms of their reaction to the cues. And to this day, the phenomenon of craving as measured in the endophenotype of cue reactivity is being used.
A few months ago in Science Magazine they were talking about the new magic bullet for diabetes, the popular drug Ozempic. It seems they’ve stumbled upon the fact that people who had diabetes, who were put on this drug, were not only losing weight, but were also reporting less interest in alcohol. And lo and behold, they're using our cue reactivity protocol to measure craving in people who are on or off Ozempic.
So it's gratifying that we uncovered this serendipitously almost 40 years ago now, and to this day it's being used in the scientific study of craving.
Fifty years ago, the popular view of alcohol dependence was very different than it is today.
The scene was shifting at that time, yes. (Alcohol use disorder) was initially seen, in the 1930s and 40s, as moral failure. We began getting some scientific bulk around the notion that it was a coping problem, and maybe a brain disease. To this day, it's still probably a combination of both, but clearly, at that time, we were emerging from where it was seen as moral failure, to more of a medical or psychiatric or psychological social problem, if you will.
But that former way of thinking contributed to stigma that still persists today.
People who suffer from a variety of addictive disorders are almost uniformly subject to stigma. Understanding this, not only from a social perspective, but from a clinical perspective, I think is very important. It is a disorder that is found largely in underserved populations. Certainly the wealthy are not immune to it, but for people who are underserved, who haven't been treated fairly and are under a great deal of stress, both psychological stress, pharmacological stress, that needs to be acknowledged when approaching their respective addictions. Not to do so misses the mark.