Tag Archives: Treatment

A Different Path to Fighting Addiction

When their son had to take a medical leave from college, Jack and Wendy knew they — and he — needed help with his binge drinking. Their son’s psychiatrist, along with a few friends, suggested Alcoholics Anonymous. He had a disease, and in order to stay alive, he’d have to attend A.A. meetings and abstain from alcohol for the rest of his life, they said.

But the couple, a Manhattan reporter and editor who asked to be identified only by their first names to protect their son’s privacy, resisted that approach. Instead, they turned to a group of psychologists who specialize in treating substance use and other compulsive behaviors at the Center for Motivation and Change.

The center, known as the C.M.C., operates out of two floors of a 19th-century building on 30th Street and Fifth Avenue. It is part of a growing wing of addiction treatment that rejects the A.A. model of strict abstinence as the sole form of recovery for alcohol and drug users.

Instead, it uses a suite of techniques that provide a hands-on, practical approach to solving emotional and behavioral problems, rather than having abusers forever swear off the substance — a particularly difficult step for young people to take.

And unlike programs like Al-Anon, A.A.’s offshoot for family members, the C.M.C.’s approach does not advocate interventions or disengaging from someone who is drinking or using drugs. “The traditional language often sets parents up to feel they have to make extreme choices: Either force them into rehab or detach until they hit rock bottom,” said Carrie Wilkens, a psychologist who helped found the C.M.C. 10 years ago. “Science tells us those formulas don’t work very well.”

When parents issue edicts, demanding an immediate end to all substance use, it often lodges the family in a harmful cycle, said Nicole Kosanke, a psychologist at the C.M.C. Tough love might look like an appropriate response, she said, but it often backfires by further damaging the frayed connections to the people to whom the child is closest.

The center’s approach includes motivational interviewing, a goal-oriented form of counseling; cognitive behavioral therapy, a short-term form of psychotherapy; and harm reduction, which seeks to limit the negative consequences of substance abuse. The psychologists also support the use of anti-craving medications like naltrexone, which block the brain’s ability to release endorphins and the high of using the substance.

A 2002 study conducted by researchers at the University of New Mexico and published in the journal Addiction showed that motivational interviewing, cognitive behavioral therapy and naltrexone, which are often used together, are far more effective in stopping or reducing drug and alcohol use than the faith-and-abstinence-based model of A.A. and other “TSF” — for 12-step facilitation — programs. Results of an updated study have not yet been released.

Researchers elsewhere have come up with similar findings. In 2006, the Cochrane Library, a health care research group, reviewed four decades of global alcohol treatment studies and concluded, “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems.” Despite that research, A.A.’s 12-step model is by far the dominant approach to addiction in America.

Jack and Wendy’s son, who is in his early 20s, began drinking to alleviate crippling anxiety and ease persistent depression. His drinking, while worrisome, was not an entrenched pattern, his parents believed. Some of Jack’s friends suggested that if their son did not attend A.A. of his own volition, the only thing Jack and Wendy could do was attend Al-Anon.

“The implication was that there was no other solution,” Jack said. “There was a great deal of sadness on their part, empathetic sadness, which in some ways was frightening in itself.”

“A lot of people credit A.A. with saving their lives,” he added. “It’s understandable that they can’t dissociate themselves from a program that worked for them. But it’s an all-or-nothing commitment for life. That really freaked me out.”

In A.A.’s literature, “alcoholism” is defined as “a progressive illness that can never be cured.” Members describe themselves as being “in recovery,” which translates to lifelong abstinence and adherence to the 12 steps mapped out in the Big Book, published four years after the organization was founded in 1935. First among them is the obligation for members to admit their “powerlessness” over alcohol. It also relies heavily on faith; God is mentioned in five of the 12 steps.

On a warm evening last month, about a dozen parents gathered to hear Dr. Kosanke describe the center’s program for families, which goes by the acronym Craft, for Community Reinforcement and Family Training. It rejects, she said, the use of three words: “addict,” “alcoholic” and “enabling,” a term often used to describe the acts of loved ones that help perpetuate unhealthy behaviors.

Instead of addict or alcoholic, she prefers the terms favored by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or the DSM-V, which says that patients suffer from “alcohol use disorder” or “substance abuse disorder,” terms that convey a spectrum of severity.

“Substance use takes on a lot of different shapes and sizes,” Dr. Kosanke said. “There are real downsides to labeling a child with a lifetime identity, when that truly may or may not turn out to be the case.”

And calling caring behavior enabling, she said, has a way of turning even acts of kindness into something negative. “Our field hasn’t done a good job of defining it in a narrow way that’s appropriate,” she said. “If you give your kid money knowing he will go buy pot, that’s enabling. If you take your kid to soccer practice, you’re encouraging healthy behavior. That’s not ‘enabling.’ ”

Part of the Craft approach has parents take care of themselves, too, said Lorraine McNeill-Popper, who volunteers for the parent hotline at the Partnership for Drug-Free Kids, a nonprofit group devoted to recovery for young people. “If you are sleep-deprived and stressed out, how can you think clearly?” she said.

Ms. McNeill-Popper has her own family history of drug abuse. Her twin brother died of an overdose, and she adopted his son, who later became a heavy marijuana user and ended up in rehab. “I tell parents, ‘It’s like when you’re on an airplane, and they tell you to put the oxygen mask over yourself first. That way you can help with the others.’ ”

The center’s approach is controversial in the recovery world. David Rotenberg, executive vice president of treatment at the nonprofit Caron Treatment Centers, a large drug and alcohol rehabilitation provider with branches in several states, cautioned against approaches that do not set abstinence as a goal.

“The majority of people who are chemically dependent would love to be able to drink and drug in a more moderate fashion,” Mr. Rotenberg said. “Most drug addicts and alcoholics would love to drink just a couple of drinks, and they try to do so, with poor results.”

The C.M.C. doctors say treatment for young people needs to be tailored for them, since teenagers and young adults are neurologically, psychologically, socially and legally different from adults, and have different treatment needs.

Dr. Wilkens founded the center with a fellow psychologist, Jeffrey Foote, in 2003. The two had worked together in larger hospital-based treatment centers where they struggled to introduce evidence-based treatments, she said. When it opened, the C.M.C. was one of the few centers in the nation that were not tethered to the 12-step model, she said.

“It was our strong belief that you can work with people at any stage of change, ranging from ‘I’m not even sure I have a substance problem’ all the way to ‘I just got out of rehab and want to go to A.A. meetings every day,’ ” Dr. Wilkens said. “We don’t have a judgment on how you address your substance use problem. Maybe A.A. is helpful to you and you find everything you need there. If it’s not, we genuinely believe there are many strategies for helping to resolve them.”

In fact, a majority of college binge drinkers do not go on to become alcohol dependent, said Stanton Peele, a Brooklyn psychologist who has studied substance use for decades and is a longtime critic of the A.A. model. While binge drinking and other drug use are risky, multiple studies show that most people “mature out” of such recklessness when they begin to have increased responsibilities.

A federally financed study of 43,000 randomly selected Americans, called the National Epidemiologic Survey on Alcohol and Related Conditions, or Nesarc, found that 75 percent of those who are heavy drinkers eventually regain control without rehab or A.A., Dr. Peele said. The survey, which was conducted in the early 2000s and was designed to be representative of the larger United States population, was aimed at helping researchers understand high-risk drinking patterns, design better-targeted treatment programs and monitor recovery. It found that over half of those who recover managed to cut back instead of abstaining, Dr. Peele said.

“Isn’t it more encouraging to know that most people are going to outgrow these habits than to think they’re going to have a disease for the rest their lives?” Dr. Peele asked. “The data show that the odds are in your favor.”

Dr. Wilkens is familiar with that pattern. She was a college binge drinker herself and also struggled with bulimia. Once she left her home state of Kansas for New York City, where she attended Hunter College, she felt culturally stimulated and intellectually challenged, she said, and the drinking and disordered eating disappeared.

“When you focus on building up the world around you, you find stimulation and rewards that are very different from using drugs and alcohol. You find other ways of soothing yourself, and things can get better,” she said.

That is precisely what L.S. learned five years ago. L.S., a Manhattan lawyer in his early 30s who asked to be identified only by his initials to protect his privacy, spent nearly a decade as an episodic binge drinker. He began drinking as a student at his large Midwestern university, where he played rugby and where many of his best friends belonged to fraternities. Alcohol, he said, flowed freely through both subcultures. L.S. said he thought his drinking — weeks of no drinking followed by serious binges of a few dozen drinks over several days — would end after college. Yet the behavior did not fade. The morning after his wedding, he awoke with a hangover that lasted a day and a half.

His father, who drinks socially, told him that people either were alcoholics or were not. But L.S. was unprepared to accept that label and began researching moderation on his own. He found a New York branch of Moderation Management, or M.M., a secular, peer-led support group that takes a cognitive behavioral approach.

In contrast to A.A., which stresses a drinker’s lack of power in the presence of alcohol, M.M. encourages personal responsibility for drinking. The group, founded in 1993, encourages members to start with an alcohol-free month, and then allows for the reintroduction of moderate amounts of alcohol. (Critics note that one of its founders, Audrey Kishline, was involved in a fatal accident while driving drunk. She left the group in January 2000 with the intention of joining A.A., and three months later, crashed head-on into another vehicle, killing the driver and his 12-year-old daughter.)

L.S. now attends hourlong meetings once a week at which he and about a dozen others discuss their goals for moderate drinking, as well as tips, challenges and progress on avoiding triggers. Since he began attending, L.S. limits himself to about five drinks a week, well below the 14 drinks M.M. advises as a safe limit for men.

L.S. is convinced that there is no single approach for all problem drinkers. “M.M. doesn’t profess to work for everybody. It has a scientifically based approach that works for some people,” he said.

The C.M.C. psychologists are blunt about the reasons many teenagers and young adults use drugs: When it comes to decreasing anxiety and relieving depression, substances tend to work for the short term. “Kids aren’t crazy for using them,” Dr. Wilkens said. “They have an effect that is reinforcing in some way. If you understand that, you can strategically work to support and reinforce other healthy, competing behaviors.”

That approach runs through the book she wrote with Dr. Foote and Dr. Kosanke, “Beyond Addiction: How Science and Kindness Can Help People Change.” It was published in February, just as the death of Philip Seymour Hoffman from a heroin overdose struck fear in the hearts of many parents whose children use drugs. It landed Dr. Wilkens on several talk shows and drew scores of calls to the center. (In addition to its New York office, the group has opened a residential treatment center in the Berkshires.)

Dr. Wilkens’s message struck a chord with Wendy. Her son had just left school, and the couple was exploring treatment options. Wired in the evenings with extreme anxiety, he drank excessively to get himself to sleep. Once in bed, he’d stay there till 5 p.m.

Before she read the book, Wendy said, she would stomp upstairs hourly to announce in an exasperated voice, “It’s 2 o’clock. You’ve got to get out of there.”

“I’d do that three or four more times and then be fuming,” she said. “I’d be fuming all day, at home doing my work and knowing he was upstairs sleeping off whatever he’d been drinking the night before.”

After learning the Craft approach, Wendy said, she stopped nagging, changing her negative, accusatory tone to a more pleasant one by asking open-ended questions.

Today, Wendy and Jack’s son is working with his psychiatrist and getting help for his depression and anxiety. He seems to be bingeing much less. When the family went out to dinner on a recent night, the parents each ordered a beer or a glass of wine and sipped slowly through dinner. “How will he learn moderation if he doesn’t see it modeled?” Wendy asked.

Ellie hopes her daughter, too, will be able to change her drinking patterns. Ellie is a New York editor, who asked that her last name be withheld to protect her family’s privacy. Her daughter, 23, has struggled with binge drinking since she was 16. While her daughter graduated from college and holds a responsible job, she still binges on weekends. “It’s so much a part of the culture, it’s everywhere,” Ellie said. “She says she’d have no social life if she stopped drinking.”

Ellie, who grew up in a home in which many relatives attended A.A., at first tried Al-Anon. “They talk about ‘disengaging,’ ” she said. “But it’s your child, and I’m not one of those people who can put her out on the street.”

While their daughter has resisted treatment so far, Ellie and her husband have begun seeing a therapist at the C.M.C. to better navigate their relationship.

“My child is much more than a label or a diagnosis,” she said. “She’s not a problem to be solved, but a child to be loved and guided toward a better life.”

Source:  The New York Times


New Addiction Treatments

Over the next decade, new treatments are likely to include “cocktails” of two or three old drugs and possibly a treatment vaccine. Why is the drug pipeline for this major public health problem stuck at a trickle?

Recovery from substance abuse can sometimes seem like an endless talkfest: therapy sessions, support groups, 12-step meetings and the like.

Scientific advances, however, have put forward a medical model of addiction as a disease rooted less in the mind than in the brain. A new consensus is emerging that medical treatments will be the go-to for getting and staying sober, as is the case with depression in the age of Prozac. Sharing and caring in one meeting or another will remain significant supports, but combinations of psychoactive drugs or even treatment vaccines will do the heavy lifting to reclaim your “hijacked” brain from addiction.

The addiction drug pipeline has never looked so good; it has gone from a drip-drop to a trickle. But substance abusers can look forward to some new treatments over the next decade. None are likely to be a breakthrough on the order of Prozac. Like Vivitrol (naltrexone injections) for alcohol and opiate abuse, they will work well for some people but offer only modest benefits to most.

Addiction is the most neglected disease in drug development, even though it is one of the nation’s leading public health problems. Why the neglect? First, basic research into the brain mechanisms of addiction—neurotransmitters, pathways, etc.—is still full of unknowns. Second, Big Pharma, which alone has deep pockets to bring new drugs to market, has given addiction the cold shoulder, partly because many addicts are poor, uninsured, hard to reach and not especially health conscious. Nor is this highly regulated industry crazy about associating its brand with people who use illegal drugs. But at bottom the neglect stems from the pervasive social stigma of addiction, according to many top researchers.

The drug industry makes one exception: nicotine addiction. As proven by the $750 million annual sales of varenicline (Chantix), the only drug on the market to help smokers quit, drug companies are spending big bucks to back R&D for a global market made up of hundreds of millions of people. Cigarettes are, of course, legal. Dozens of experimental compounds are in clinical trials.

For all the buzz about addiction as a brain disease, treatment vaccines hold the most promise of a breakthrough—and they do not even target the brain. Like preventative vaccines that protect you against, say, the flu, treatment vaccines prime your body’s immune system to produce antibodies that recognize the invading pathogens, destroy it, and then “remember” it in the event of future exposures. But treatment vaccines, as the name suggests, help control a disease that you already have. When applied to addiction, vaccines aim to produce an immune response not to an infectious pathogen but to the substance of abuse. Treatment vaccines prevent you from getting high by preventing the molecule of cocaine, say, or heroin from reaching your brain, where it has its effects.

Vaccine research for substance abuse is appealing partly because vaccines are tried and true; they are pretty simple to make; and they do not muck around with brain processes. But there are plenty of challenges. Most drug molecules are too small for the immune system to recognize. So scientists attach other, harmless molecules to the vaccine agent (the drug molecule) in order to add bulk in order to spark an antibody response. For instance, Thomas Kostens, MD, psychiatry and neuroscience professor at Baylor College of Medicine in Houston—and a leading addiction treatment researcher—fused bits of deactivated cholera bacteria to cocaine molecules to get the attention of the immune system. Its antibodies are big fat proteins; once they glom onto the cocaine-cholera combo, the resulting conglomeration cannot pass through the blood-brain barrier. Blunting the effect of the coke would, in theory, support your effort to quit using. In 2009, Kosten’s vaccine provided the first evidence that this approach could work in people.

There are many experimental vaccines currently in test tubes and early studies of animals. Very few will make it to clinical trials in humans. So far, the most promising, like Kosten’s, have gone bust in human tests.

At the center of the addiction vaccine enterprise is the prestigious Scripps Research Institute, a private nonprofit in La Jolla, Calif. Its Committee on Neurobiology of Addictive Disorders (CNAD) has six of the nation’s top addiction scientists studying the intersection of the brain, emotion, stress and addiction; the same six are also members of Scripps’ Pearson Center for Alcoholism and Addiction Research, which “translates” CNAD’s lab discoveries into experimental treatments.

In the early 1980s, when a vaccine for addiction struck most researchers as absurd, “the stars of two research programs at Scripps aligned,” says George Koob, MD, the scientist who chairs CNAD. At the time, Koob’s lab was doing basic research, and Kim Janda, MD, was hunting for a chemical that might put a dent in cocaine addiction. When the two teams began collaborating, the synergy was “momentous.”

Since then, Janda has tried to develop vaccines against nicotine, alcohol, marijuana, heroin, cocaine and methamphetamine. His failures have blazed trails. Most recently, his experimental coke vaccine, created by cobbling together a cold virus particle and the cocaine molecule, got as far as Phase III clinical trials before failing. Yet the trial showed some success: Addicts who had the strongest immune response did not get high when they used and had a longer period of abstinence. But one-fourth of the subjects produced no antibodies to the vaccine.

Scripps presses on, producing a new vaccine candidate almost seasonally. In May, Koob’s lab announced that a heroin vaccine showed efficacy in rat studies. Each substance presents its own particular challenge to a vaccine approach. Heroin quickly breaks down in the body into two other chemicals: 6-acetylmorphine and morphine. An effective smack vaccine would have to target both at once, and the new Scripps candidate fits the bill.

Scripps is also making progress with a vaccine against methamphetamine. Meth’s particular challenge is that its active molecule’s structure is so generic that meth-primed antibodies can mistake many other molecules for it. Scripps’ Michael Taffe, PhD, and his team are testing MH6, one of six potential meth vaccines developed in Janda’s lab. In a soon-to-be-published rat study, MH6 decreased the critters’ symptoms of meth addiction.

Scripps doesn’t have a monopoly on addiction vaccine research. Baylor’s Kosten and S. Michael Owens, PhD, the head of the Center for Alcohol and Drug Abuse at the University of Arkansas for Medical Sciences, are leaders in the field. Kosten has spearheaded research into the neuroscience of addiction and trauma for decades and has studied a wide range of treatments and would-be treatments, including a cocaine vaccine, immunotherapy for hallucinogens, buprenorphine (Suboxone) for opioid dependence and disulfiram (Antabuse) for cocaine abuse.

Owens is currently in the race for a methamphetamine vaccine, with one of his anti-meth shots already in human tests for safety. Owens’ innovative approach is very different from Taffe’s more traditional one, however. Owens is synthesizing methamphetamine-primed antibodies in the lab and then injecting them into patients. Rather than waiting to see if your body produces its own antibodies, “we can give you enough antibody and we can do it fast and at the right dose, just like any other medication,” Owen says.

A major problem with all addiction vaccines is that their effect is short-lived. A decent immune response typically requires a series of injections over a month or so, but the response may fade in a matter of weeks. But to overcome addiction, many people need long-term, even lifetime, treatment. The costs and complications of a vaccine that must be administered every few months would probably be prohibitive for both patients and health insurance companies.

Ironically, Scripps’ most significant contribution to addiction treatment is not a vaccine at all but a pill that has been around for years. Researchers have shown that gabapentin (Neurontin), originally approved to treat seizures, has modest effectiveness against alcoholism during acute withdrawal and early abstinence. While vaccines prevent the substance from entering the brain, conventional drugs like gabapentin are chemicals that “block the brain effect, not just the substance effect,” Koob says.

The Center for Studies of Addiction (CSA), at the University of Pennsylvania’s School of Medicine, may be our best hope for getting effective treatments into addicts’ bodies in the near term. Because CSA not only researches new treatment options but actually works with people with substance abuse problems, they have established a unique program of clinical trials of psychoactive drugs already approved for other conditions to see if they can help curb addiction. This is one of the most economical ways to bring an addiction treatment to market. Most of these drugs have been around for years, so their safety issues are well known; they can go directly into human trials.

No one expects any of these drugs to be a game-changer. Because each will likely offer, at best, only modest benefits, CSA is banking on the “cocktail” model of treatment: Use two or three partially effective drugs together to target different receptors and pathways at the same time.

CSA’s program includes testing two medications for alcohol abuse: naltrexone, an old anti-craving drug, and Seroquel, a bipolar treatment. Trials are up and running for the dual addiction of alcohol and cocaine with a combination of naltrexone and modafinil, a non-amphetamine stimulant that has not exactly won raves in previous anti-cocaine studies. Nonetheless, CSA is doing its own modafinil-for-coke-addiction trial, adding the anti-nicotine drug Chantix. The program has a certain throw-it-against-the-wall-and-see-if-it-sticks rationale, but some of these drugs will likely stick for some addicts.

Kyle Kampman, MD, medical director of CSA’s Addiction Treatment and Medication Development Division and principal investigator of a project in the Cocaine Medication Development Center, reports that his lab just completed a trial of a cocaine vaccine (the data are still being analyzed). Substance abuse vaccines fit the “cocktail” model perfectly. Because vaccines do not affect the brain, a cocaine addict could take both the vaccine and psychoactive drugs that do target the brain; a heroin addict could do a vaccine-Suboxone cocktail. Pile on the pills!

Progress in basic research and clinical trials is slow and expensive—witness the ongoing failures of Scripps’ many experimental vaccines. Both Scripps and CSA are funded mainly by the federal government and pharmaceutical companies. But money is tight. Scripps’ Kroob says that their promising heroin vaccine is in limbo until he finds financial backers to pay for more animal studies. “This kind of money would usually come from pharma companies,” he says. “But there’s a stigma associated with working with drug addiction.”

The drug industry has calculated that the market for addiction treatments, especially vaccines, is too small to be profitable. A large number of clinicians would have to prescribe the treatment. But only some 3,500 physicians in the US specialize in addiction. Many physicians do not see addiction as a legitimate medical condition and have no interest in treating addicts. Others look at the high failure rate of all addiction therapies and recoil.

Obamacare might somewhat improve the situation. Many poor and uninsured people with substance abuse will become eligible for Medicaid. The Affordable Care Act mandates that Medicaid and all health insurance for newly eligible adults starting in 2014 must include services for substance use disorders. Yet whether the coverage offered by Medicaid and the exchanges will prove adequate remains to be seen. Medicaid has a lifetime cap for methadone and Suboxone that covers only five months of treatment. Yet controlling substance abuse with long-term medication is cost-effective. “Look at any emergency room,” Koob says. “Half of the patients are there because of addiction-related issues.”

By default, the financial burden of addiction drug research has largely fallen to the federal government, especially the National Institutes of Health (NIH). “That’s why the NIH is so important,” says Donald Vereen, MD, the director of the University of Michigan Substance Abuse Research Center. Vereen served at the NIH during the Clinton and Bush II administrations; he was also deputy drug czar. The NIH, Vereen says, often partners with pharmaceutical companies to move promising compounds through trials and to market. Indeed, buprenorphine (Suboxone) owes its success to this collaboration. (The drugmaker gets all the profits, however.) The National Institute on Drug Abuse (NIDA) also has a medication development division—a sign, Vereen says, of private industry’s neglect of the field.

“Nobody wants to work on developing drugs for addicts,” he says, echoing the sentiments of other top researchers. Why? Because of social stigma and the criminalization of substance use. In the end, these are bigger deterrents to progress than the limits of neuroscience and the cost/benefit analyses of Big Pharma.

“The lack of treatment for addicts is ultimately a civil rights issue,” Vereen says. That is not a problem that gets solved by scientists in labs.

Oscar de la Hoya goes to rehab

Oscar De La Hoya has admitted himself to a treatment facility as he continues to fight substance abuse.

The former boxer issued a statement Tuesday saying he voluntarily admitted himself to an unnamed facility. The move comes on the eve of the biggest fight of the year for his promotion company in a fight expected to be one of the richest in boxing history.

“I will not be at the fight this Saturday to cheer Canelo to victory since I have voluntarily admitted myself into a treatment facility,” De La Hoya said in his statement. “I explained this to Canelo and he understood that my health and long term recovery from my disease must come first.”

Alvarez said De La Hoya called him on Monday to tell him he wouldn’t be at the fight.

“I support him in the great battle he has in his life,” Alvarez said. “I’m sure he’s going to win his battle and I’m going to win my battle.”

Mayweather, who beat De La Hoya in 2007 but has been at odds with him in recent years, said he wished him well.

“Hopefully he can get better and pull through like a true champion,” Mayweather said.

De La Hoya first admitted two years ago that he was an alcoholic and drug user and had been in treatment. He told the Los Angeles Times last month that he sometimes attends Alcoholics Anonymous meetings six days a week, but had slipped at times in his treatment.

“The fight life, that was easy,” he told the paper. “This is a battle I have every day.”

De La Hoya is a partner in Golden Boy Promotions, which promotes Alvarez and is promoting the fight against Mayweather. He appeared several times on Showtime’s “All Access” show cheering on Alvarez in what is expected to be one of the richest fights in boxing history.

Golden Boy CEO Richard Schaefer said he did not try to talk De La Hoya out of going into rehab before the fight, even though he is active in the promotion.

“It’s not perfect timing,” Schaefer said. “But they say that the show must go on and it will.”

De La Hoya won world titles in six classes and an Olympic gold medal in 1992. He retired in December 2008 after being stopped by Manny Pacquiao in his last fight.