Vancouver mayor announces new program to fight drug addiction and crime

Vancouver mayor, Sam Sullivan, appears to be forging ahead with his plan to create drug maintenance programs for drug addicts. The plan is called CAST (Chronic Addiction Substitution Treatment). I've posted before on the subject here and here, so I won't repeat what I've already written. I will add, however, that Vancouver built a lot of support for its "four pillar" approach to addiction with the promise of treatment as one of the pillars. I suspect that this was not what many of those stakeholders had in mind.

If your from southeastern Michigan, you may be wondering how this is relevant to us. The answer is that Vancouver is frequently pointed to as an innovative model for responding to addiction.

Nicotine wars

Dr. Wes, a physician and blogger, offers his take on recent concerns over slowed progress on smoking cessation and low utilization of nicotine replacement therapy. He offers some pretty provocative opinions that are worth taking the time to read.

It still puzzles me that we use an incredibly addictive drug, nicotine, to help smokers quit their habit. It's like we've given up and decided that Nicorette gum is to the smoking addiction as methadone is to a heroin addiction. To make matters worse, it now seems that the pharmaceutical industry, in its press to promote its products, wants to limit the verbage on the warning label on the smoking cessation drugs.
...
Over-regulation as the cause for lack of utilization? How about the methadone/heroin analogy? Maybe the reason people aren't using these meds is because they're expensive and people don't like taking drugs - especially one that is powerfully addictive. And there are even researchers who question the efficacy of these drugs to stop the smoking habit in the first place.
...
The reality? We have been incredibly successful in the US at educating our population about the effects of smoking and reducing the number of individuals who smoke. Smoking bans have also been remarkably effective. Why make us smoke this lame excuse for "limited gains" of achieving our goals of smoking cessation in the interest of making pharmaceutical companies more money? Maybe, just maybe, the real reason that smoking cessation aides are producing only limited gains (in sales) is because fewer people are smoking.

There Is No Blame; There Is Only Love

From NPR's "This I Believe" series an essay from a mother of a young woman who has struggled with heroin addiction. After years of blaming herself and others, she now believes that there is no blame. Below is an excerpt, but follow the link and her the entire essay in her own voice.

You don't expect your child to grow up to be a heroin addict. From the moment of her birth, you have hopes and dreams about the future, but they never include heroin addiction. That couldn't happen to your child, because addiction is the result of a bad environment, bad parenting. There is most definitely someone or something to blame.

That's what I used to believe. But after failed rehab and long periods of separation from my heroin-addicted daughter, after years of holding my breath, waiting for another relapse, I now believe there is no blame.

...

I don't know why or how my daughter became addicted to heroin; I do know that it doesn't really matter. Life goes on, and Katie is still my daughter.

Katie and I meet for breakfast on Friday mornings now. We drink coffee and talk. I don't try to heal her. I just love her. Sometimes there is pain and sorrow, but there is no blame. I believe there is only love.

“You’ve Got to Stop”

A well done article about interventions with several quotes from our friend Jeff Jay. The article is from a Washington D.C. publication and gives special attention to the challenges of interventions with powerful and wealthy people.

The only passage that bothered me was this one:

A member of another DC-based group, Faces and Voices of Recovery, worries that George W. Bush’s solo effort to quit drinking sent the wrong message to those who think they can handle their addictions without help: “George Bush comes to town, and the impression they try to convey is that he just suddenly realized he had a problem and he stopped drinking and lived happily ever after.”

I'm no fan of Bush, but to suggest that his recovery narrative hurts the cause is silly. He doesn't present his path to recovery as the correct path and his message seems to affirm recovery in the broadest terms. As Bill White often says, "Recovery by any means necessary."

Ferguson Speaks From The Heart

Craig Ferguson on the Britney media frenzy and his own recovery:

NET for heroin gets boost in Scotland

A blog post on neuro-electric therapy (NET) in Scotland. Includes a link to the website of the manufacturer of NET equipment.

How Prohibition made Detroit a bootlegger's dream town

A little local history on prohibition in Detroit. Of special interest to anyone who knew Theresa M.

Is alcohol a "drug"? Why the question matters

Mark Kleiman offers a commentary about alcohol's cultural status as something other than a drug. I think he's guilty of a little hyperbole and condescension, but I find his point to be on the mark.

“In terms of its effects on the human body and psyche, alcohol is simply another psychoactive substance.” That sentence, with which Cook and Reuter begin their very able essay, embodies a proposition that will be taken as a truism by most readers of this journal, but would be regarded as a fallacy, an outrage, and an insult by many, if not most, ordinary citizens.

Why is that claim controversial, and why does the rejection of that claim matter?

It is controversial, I would submit, because the mood in which the public, its elected representatives, and their appointed officials consider drugs, drug-taking, and drug policy has little to do with the calm, evidence-based, policy-analytic tone taken by Cook and Reuter. The two scholars do not recite, because they do not believe, the basic credo underlying the international drug control regime, as well as the drug policies of most countries: outside a strictly medical context, drugs are fundamentally evil, drug-taking is both harmful and morally culpable, and drug-takers require some mixture of treatment and punishment. It is this credo that is threatened by any attempt to treat alcohol as a “drug.”

By contrast with any of the controlled drugs, alcohol use is neither statistically"

n particular, those who discuss drug policy (outside Islamic societies) have no obligation to pretend that they themselves are, nor any right to assume that their audiences are, abstinent from alcohol. Thus courtesy forbids even those who themselves do not drink, and disapprove of drinking, from referring to alcohol users generically as “drunkards” or “degenerates” or “slaves of the Demon Rum.” Problems with alcohol must therefore be treated, in Abraham Lincoln's formulation, as “the abuse of a good thing,” not “the use of a bad thing.”

But if alcohol is a drug, then “drug use” is normal, and not all drug use is abuse. That undercuts the entire project of stigmatization underlying much of what passes for “drug abuse prevention.” If smoking cannabis, snorting cocaine, swallowing MDMA (“ecstasy”), or even injecting heroin, are not different in principle from having a glass of wine, then the moral basis for treating cannabis-smokers, cocaine-snorters, rave-goers, and heroin-injectors as carriers of a deadly plague is called into question, and even suppliers of those drugs might be seen as regulatory violators rather than hostes humani generis (enemies of humankind) the modern incarnation of a legal category that used to cover pirates and slave-traders.

Conversely, labeling alcohol a “drug,” given the nasty connotations that word has been so carefully given, calls into question the presumptive innocence and innocuousness of drinking by responsible, non-alcoholic adults, and of the industry that supplies them, as it also supplies children, alcoholics, and those who become violent and imprudent under the influence of drink. To the analytically-minded it seems perverse that the one-eighth or so of diagnosable substance abuse disorder (other than nicotine dependency) that relates to the controlled drugs should receive much more attention (whether measured by rhetoric or control resources) than the seven-eighths in which the problem substance is alcohol.

Drug rape myth exposed as study reveals binge drinking is to blame

A sure to be controversial finding about date rape drug allegations in England. It's worth noting that this finding, if replicated in other countries, doesn't disprove the existence of date rape but does suggest that preventing binge drinking may be an important way to reduce date rape:

Doctors tested 75 women who claimed their drinks had been spiked by date rape drugs, not one tested positive

Women who claim to be victims of 'date-rape' drugs such as Rohypnol have in fact been rendered helpless by binge-drinking, says a study by doctors.

They found no evidence that any woman seeking help from emergency doctors because their drinks were allegedly spiked had actually been given these drugs.

Around one in five tested positive for recreational drugs while two-thirds had been drinking heavily.

The findings further erode the theory that there is widespread use of Rohypnol and GHB, another drug said to be favoured by predatory rapists.

Take Kids Away From Alcoholic Parents

Neil McKeganey, who's opinions I've tended to admire, has some strong words about intervening with alcoholic parents. I think I agree that there should not be disparity between drug addiction and alcohol addiction. However, I have real problems about any proposal to aggressively remove children from addicted parents. I think it's safe to assume that abuse or neglect is more common in an addicted home, but it seems to me that the same standards should be applied in all homes, addicted or not.

Alcoholic parents should have their kids taken from them in the same way as heroin addicts, one of Scotland's top addiction experts has claimed.

Professor Neil McKeganey, a former government adviser, has accused social services of double standards when dealing with heroin and alcohol addiction.

The respected academic has said children of parents who refuse to give up drink are suffering neglect as serious as those of drug addicts.

McKeganey, director of the Centre for Drug Misuse Research at Glasgow University, has warned the Scottish moralistic attitude to drugs means well-meaning social workers are failing thousands of Scots youngsters.

Social workers are often reluctant to remove children from the homes of alcoholics while the use of illegal drugs such as heroin is seen as far more serious.

Around 560 children are taken into care each year, the vast majority from parents who are drug addicts.

But as many as 100,000 children north of the Border are living in homes where alcohol abuse is affecting their welfare.

McKeganey believes alcohol problems result in more children being neglected.

It is feared a change in approach towards parental drink problems would see the beleaguered social services system swamped with cases.

But Professor McKeganey said alcoholism must now be treated in the same way as drug addiction in order to protect Scots children.

He said: "It is almost certainly the case that a child in a home with parental alcohol abuse is not being well looked after.

"If a parent cannot change their behaviour, they cannot be allowed to continue to harm their children.

"More should be removed from their homes, where parental alcohol use is affecting their health, than is currently the case.

"Social services are understandably extremely reluctant to remove children from the parental home. Often through a false sense of optimism they hope parents will resolve to start to look after their children.

"And yet that can often mean children remain within their families for far too long and suffer long-term harm as a result."

Here's a slightly more sober view:

Tom Wood, chairman of the Scottish Association of Alcohol and Drug Action, said: "We've been focused on the children of drug abusing parents, but children of alcohol abusing parents are as vulnerable.

"There are subtle differences between living in a home with an alcohol or drug problem but the same rules apply.

"Some cases will merit intervention - whether that is supervision in the home or, as a last resort, the child being taken into care.

"If you use drugs, bang, your child could be taken into care. But you can use alcohol. That's a moralistic view which I think is flawed."

The war on drugs, tobacco style

Here's an academic take from the perspective of an economist on the war on drugs. The post was inspired by an article about cigarette bans in prison driving prices to as high as $125 per pack.

Intensive care helps smokers quit, study finds

A new smoking cessation study finds promising long term outcomes:

An intensive stop-smoking program with at least three months of counseling and free drugs can help smokers kick the habit, U.S. researchers reported on Monday.

Their intensive care program helped 39 percent of smokers stay tobacco-free for two years, the team at Creighton University Cardiac Center in Omaha, Nebraska reported.

"What we have shown is that a very planned and organized approach to cessation of smoking, with careful follow-up, works much better than the current practice of simply advising them to quit smoking," said Dr. Syed Mohiuddin, who led the study.

The war within, killing ourselves

Lou Dobbs weighs in on the war on drugs:

We're fighting a war that is inflicting even greater casualties than the wars in Iraq and Afghanistan and, incredibly, costing even more money. We're losing the War on Drugs, and we've been in retreat for three decades.

That statement may come as a surprise to John Walters, Director of the White House Office of National Drug Control Policy, who spent last week trumpeting the Bush administration's anti-drug policies. He claims these policies have led to a decline in drug abuse and improvements in our physical and mental health.

While Walters focused on a marginal decline in drug use, he made no mention of the shocking rise in drug overdoses. The Centers for Disease Control and Prevention this week reported unintentional drug overdoses nearly doubled over the course of five years, rising from 11,155 in 1999 to 19,838 in 2004. Fatal drug overdoses in teenagers and young adults soared 113 percent.

More than 22 million Americans were classified with substance abuse or dependence problems in 2005, according to the Substance Abuse and Mental Health Services Administration. Nearly 8,000 people are trying drugs for the first time every day -- that's about 3 million a year. The majority of new users are younger than 18, and more than half of them are female.

Obviously, John Walters and I are not looking at the same statistics. There is simply no excuse for permitting the destruction of so many young lives.

How can anyone rationalize the fact that the United States, with only 4 percent of the world's population, consumes two-thirds of the world's illegal drugs?

Former President Richard Nixon first declared a modern-day war on the use of illicit substances, calling drugs "public enemy number one" and pushing through the Controlled Substances Act of 1970. Since then the government has waged a futile, three-decades-long war of attrition.

Illicit drug use costs the United States almost $200 billion a year, according to the National Institute on Drug Abuse. Include alcohol and tobacco-related costs along with health care, criminal justice and lost productivity and the figure exceeds $500 billion annually.

Even with new rehabilitation centers and clinics, less than 20 percent of drug and alcohol abusers receive the treatment they need and the cycle of drug-related crime continues unabated.

It's estimated about half of the more than two million inmates in our nation's prisons meet the clinical criteria for drug or alcohol dependence, and yet fewer than one-fifth of these offenders receive any kind of treatment. Studies show successful treatment cuts drug abuse in half, reduces criminal activity by as much 80 percent and reduces arrests by up to 64 percent.

As NIDA reports, "Treatment not only lowers recidivism rates, it is also cost-effective. It is estimated that for every dollar spent on addiction treatment programs, there is a $4 to $7 reduction in the cost of drug-related crimes. With some outpatient programs, total savings can exceed costs by a ratio of 12:1."

In the midst of the global war on terror along with wars in Iraq and Afghanistan, we have forgotten about the brutal effects of narcotics trafficking on millions of American lives. We must end the abuse of drugs and alcohol, and provide successful treatment for Americans whose addictions are destroying their own lives and wounding our families and society.

Whatever course we follow in prosecuting other wars, we must commit ourselves as members of this great society to only one option in the War on Drugs -- victory.

How many drinks is too many? | The Daily Telegraph

I've been in a couple discussions over the past few days about federal drinking guidelines and what constitutes risky drinking. It just happens that Australia is reviewing their drinking guidelines. Of special concern are pregnant women and young women. Their drinking guidelines for healthy people between 18 and 64 are as follows:

For men: No more than 4 Standard Drinks a day on average and no more than 6 Standard Drinks on any one day. One or two alcohol-free days per week.

For women: No more than 2 Standard Drinks a day on average and no more than 4 Standard Drinks on any one day. One or two alcohol-free days per week.

*These drinks should be spread over several hours. For example, men should have no more than 2 standard drinks in the first hour and 1 per hour after that. Women should have no more than 1 standard drink per hour.

Special report: Under-age drinking (U.K.)

Independent Online Edition >England is also experiencing problems with underage drinking. In England 18 year olds can purchase alcohol and 16 year olds can drink alcohol in s restaurant, if the alcohol was purchased by a parent.

Amid growing concerns over 24-hour drinking, soaring rates of liver disease and police forces unable to cope with drunken disturbances on the streets, an exclusive Independent on Sunday investigation today reveals the dramatic rise in children admitted to hospital because of alcohol-related illnesses.

The biggest increase is seen among girls under 16 years old, with a 25 per cent increase between 2002/03 and 2004/05. And the problem is getting worse: hospital admissions for under-18s are at their highest since records began, and the average amount children are drinking every week has doubled since 1990.

Professor Mark Bellis, director of the Centre for Public Health at Liverpool John Moores University and a government adviser on alcohol-related issues, said: "The numbers of underage drinkers in hospital for alcohol-related conditions are substantial but it is only the tip of the iceberg. Many more children are admitted for problems not recorded as alcohol. The admissions include everything from being involved in violence to teenage pregnancies. For every one youth admitted due to alcohol consumption there are many more whose health suffers through excessive alcohol consumption."

The ages of children admitted to hospital for alcohol-related problems are getting lower. The number of eight-year-old-boys who drink has doubled from 5 per cent in 1995 to 10 per cent in 2005. The number of 11-year-old girls who drink has increased from 15 per cent in 1995 to 25 per cent in 2005. Many experts believe country is in the grip of a hidden epidemic - one that, like alcoholics themselves, the country is in denial about.

...

Last year police introduced exclusion zones around the beaches of Polzeath and Rock after residents complained of underage drinking and fighting. Dubbed the "Costa del Sloane", the beaches are a magnet for children from public schools.

A senior policeman with Devon and Cornwall constabulary also spoke out about the underage drinking culture after a mob of 100 youths - some as young as 12 - were caught at a mass boozing session in Falmouth.

The startling rise in underage drinking is already beginning to have repercussions on public health and will continue to do so for future generations unless something is done to curb the alcohol consumption of British children, campaigners say.

Frank Soodeen of the charity Alcohol Concern said: "A recent government report on alcohol-related deaths showed that the biggest group was men and women aged 35-54 - which is far younger than ever before. Clearly it's beginning to catch up at an earlier stage, which is very worrying. Generally the highest proportion a few years ago was well above that age group."

The most serious of these health problems is liver cirrhosis. People in their 20s and 30s are now ending up with serious liver problems which, until recently, were normally seen in people twice those ages.

Professor Ian Gilmore, president of the Royal College of Physicians and a liver specialist at the Royal Liverpool Hospital, said: "Cirrhosis of the liver has increased tenfold since the 1970s. There is a big concern about the rise in deaths from cirrhosis among young people. I think we are going to see big increases in people in their 20s and 30s being diagnosed with liver cirrhosis."

David Mayer, chair of the UK Transplant Liver Advisory Group, warned that young drinkers are storing up a problem for the future and are likely to require his services in years to come. "People have more money and more opportunity to drink from an earlier age and therefore their livers are exposed to chronically high alcohol levels. We are concerned that it's becoming an epidemic. It does take many years to develop cirrhosis, but if you start drinking at an early age you are going to see problems sooner rather than later."

With such a marked increase in child drinking, campaigners are furious over the lack of provision offered to young people such as Hayley in helping to tackle their problems. There are even calls for drying-out clinics to be set up specially for young people.

But Professor Bellis argues that we need to help children long before it reaches that stage. "Waiting until children develop alcohol problems means their health, their education and ultimately their life prospects have already begun to suffer. We need a major shift in our national attitudes towards alcohol."

Caroline Flint, the public health minister, last week claimed that the Government is tackling the problem through "targeted enforcement" - reducing sales to under-18s by bars, off-licences and retailers - as well as education on substance abuse.

But campaigners blame the drinks industry for promoting alcohol as "sexy" to the young. Mr Soodeen said: "The drinks industry plays a big part in the whole issue. We really need to be cutting off the supply to young people. Unfortunately, the drinks industry has been very effective in persuading the Government that a 'voluntary health' approach is the way forward. We find it odd that so much of the packaging on alcopops seems juvenile and the alcohol industry has yet to come up with a credible explanation."

[via: Alcohol and Drugs History Society]

An Honest Conversation About Alcohol

From Inside Higher Ed:

Two months after he finished up as president of Middlebury College in 2004, John M. McCardell Jr. wrote a column for The New York Times called “What Your College President Didn’t Tell You.” In the piece, he discussed how he was “as guilty as any of my colleagues [as presidents] of failing to take bold positions on public matters that merit serious debate.” Taking advantage of his new emeritus status, he proceeded to take a few such positions. Among other things, he wrote that the 21-year-old drinking age is “bad social policy and terrible law,” and that it was having a bad impact on both students and colleges....

The current law, McCardell said in an interview Thursday, is a failure that forces college freshmen to hide their drinking — while colleges must simultaneously pretend that they have fixed students’ drinking problems and that students aren’t drinking. McCardell also argued that the law, by making it impossible for a 19-year-old to enjoy two beers over pizza in a restaurant, leads those 19-year-olds to consume instead in closed dorm rooms and fraternity basements where 2 beers are more likely to turn into 10, and no responsible person may be around to offer help or to stop someone from drinking too much.

I have a few brief reactions. First, I don't have a strong opinion on the matter, other than I'd be troubled by 18 year old high-school students being able to buy alcohol.

In principle, the general idea of a less restrictive drinking law might appeal to Libertarians, but drinking licenses? That'll lose Libertarian support fast.

He makes an argument about current law criminalizing parents who try to teach their kids to drink responsibly. First, is serving alcohol necessary to do this? Second, as we saw a few weeks ago, this isn't illegal in 31 states. Third, when is the last time you heard of parents fined or arrested for allowing their teen to have a glass of wine with dinner?

Some of his arguments are a stretch -- for example, using SAMHSA's increased attention to underage drinking as an argument against the existing policy and implying that there's a relationship between the 21 year old drinking law and younger ages of first use.

The fact that we currently have problems, isn't necessarily a good argument against the status quo. Anyone who's honest with themselves will recognize that there is no such thing as a problem-free drug and alcohol policy. As I've said before in this blog, these drug policy questions are all about trade offs and, recognizing that every policy requires living with some problems, the questions you have to wrestle with are:

• Which problems are intolerable and which are you willing to tolerate?
• How do you make these decisions? (I'd suggest that even responses that purport to be value-free are value laden.)
• Which policy (or combination of policies) best balances these values?

It seems like these discussions would generate more light if people were a little more honest in acknowledging the problems inherent in their pet theory.

Drugs, Brains, and Behavior: The Science of Addiction

From NIDA:

"Drugs, Brains, and Behavior: The Science of Addiction" was unveiled today by the National Institute on Drug Abuse (NIDA), a component of the National Institutes of Health. The 30-page full-color booklet explains in layman's terms how science has revolutionized the understanding of drug addiction as a brain disease that affects behavior. NIDA hopes this new publication will help reduce stigma against addictive disorders.

"Thanks to science, our views and our responses to drug abuse have changed dramatically, but many people today still do not understand why people become addicted to drugs or how drugs change the brain to foster compulsive drug abuse," said NIDA Director Dr. Nora D. Volkow. "This booklet aims to fill that knowledge gap by providing scientific information about the disease of drug addiction in language that is easily understandable to the public."

The "Science of Addiction" booklet discusses the reasons people take drugs, why some people become addicted while others do not, how drugs work in the brain, and how addiction can be prevented and treated. Like diabetes, asthma or heart disease, drug addiction is a chronic disease that can be managed successfully. Treatment helps to counteract addiction's powerful disruptive effects and helps people regain control of their lives. The new booklet points out that just as with other chronic diseases, relapses can happen. The publication further explains that relapse is not a signal of treatment failure - rather, it indicates that treatment should be reinstated or adjusted to help the addict fully recover.

A Toxic Brew

Psychology Today has an article on ACOAs. Something I haven't seen in a while:

If alcoholism seems like a lot to handle, imagine growing up with addicted parents. The alcoholic family is one of chaos, inconsistency, unclear roles, and illogical thinking. Arguments are pervasive, and violence or even incest may play a role. Children in alcoholic families suffer trauma as acute as soldiers in combat; they also carry the trauma like an albatross throughout their lives....

Tobacco, tobacco tobacco

Three recent articles on tobacco. First, The Boston Globe reports on the effectiveness of pharmacological treatments for nicotine addiction. The article presents a pretty pharmacological treatments as an essential part of a smoking cessation plan.

Philip Quartier, a 64-year-old stockbroker from Mission Hill, had been smoking a pack of cigarettes a day for 45 years when he quit for the first time. After five clean years, an impulse led him to pick up another cigarette eight months ago, and the biking enthusiast, who has lung disease, was frustrated to be back to his old habit.

Determined to quit for good, he dug out the subliminal motivation tapes he'd used the first time around, went back on the nicotine patch, bought a self-help book, and joined a counseling group, but several months into the process, he was getting nowhere. So in November, he got a prescription for Chantix (varenicline), a six-month-old drug that is the first new quit-smoking treatment in a decade.

The pills don't work for everyone but quickly diminished Quartier's cravings. "By the eighth day I was absolutely ready" to give cigarettes up again, he said.

Though most smokers try to quit without help, nicotine-free treatments including Chantix and longtime staples like nicotine gum and patches are more effective than trying to quit "cold turkey," according to experts and research.

Next, Dr. Wes questions the federal push toward pharmacological treatments and provides some compelling arguments:

Well it seems that nicotine patches are now part of the federal guidelines regarding smoking cessation issued by the Public Health Service, a division of the Department of Health and Human Services. But an interesting twist to these guidelines was revealed yesterday (WSJ, subscription):

(Doctor) Michael Fiore is in charge of revising federal guidelines on how to get smokers to quit. He also runs an academic research center funded in part by drug companies that make quit-smoking aids, and he personally has received tens of thousands of dollars in speaking and consulting fees from those companies. ... Dr. Fiore, a University of Wisconsin professor of medicine, headed the 18-member panel that created those guidelines. He and at least eight others on it had ties to the makers of stop-smoking products.

Those opposed to urging medication on most quitters note that cold turkey is the method used by the vast majority of former smokers. They fear the federal government's campaign could discourage potential quitters who don't want to spend money on quitting aids or don't like the idea of treating their nicotine addiction with more nicotine.

"To imply that medications are the only way is inappropriate," says Lois Biener, a senior research fellow at the University of Massachusetts at Boston who has surveyed former smokers in her state. "Most people don't want them. Most of the people who do quit successfully do so without them."

What is interesting is the way the government makes these recommendations: based on clinical trials. And who is better equipped to perform clinical trials than drug companies? (Bias 1). Further, all of the individuals in clinical trials must sign consent, and therefore have to be willing to take a drug (Bias 2). So these "clinical trials" are, by their very nature, skewed toward those willing to take a drug.

But in the interest of revealing effectiveness of these smoking cessation drugs in the real world, another type of study, an observational population trial that looks at all comers to the smoking cessation party, found this:

Studies of quitters outside clinical trials have shown no consistent advantage for medicine over cold turkey, the pharmaceutical industry's primary competitor. An unpublished National Cancer Institute survey of 8,200 people who tried quitting found that at three months, users of the nicotine patch and users of bupropion (Wellbutrin) remained abstinent at higher rates than did users of no medication. But at nine months, the no-medication group held an advantage over every category of stop-smoking medicine. The study was presented at a world tobacco conference last summer.

Finally, a recent Biological Psychiatry commentary addresses the links between alcohol and nicotine addiction, including the genetic links, shared neurobiological mechanisms, shared behaviors and treatment.

Epidemiologic data confirm that: (1) heavy drinking may stimulate smoking; (2) cessation of smoking may enhance abstinence from alcohol; and (3) combined treatment for dual addiction may achieve the most beneficial treatment outcome.

Teen drinking laws update

A couple of weeks ago I posted about laws that allow teens to drink with their parents and asked for info on Michigan law. Brian, a student of mine who is also a juvenile probation officer sent this:

I checked into the laws governing underage drinking related to parents here at the courthouse. There are no laws that allow for parents to let their kids drink in any circumstance. However, there are limited exceptions. One is allowed for religious purposes in a religious setting. Another is for educational purposes like in a culinary class for cooking. If a parent provides or allows a kid to drink they can be charged with contributing to the delinquency of a minor or furnishing alcohol to a minor.

Thanks Brian!

Charity records 13% rise in post-Christmas abortions

A publicity seeking stunt? Or, a little mentioned harm associated with excessive drinking?

The family planning service Marie Stopes International said today that it performed a record number of UK abortions last month.

The charity carried out nearly 6,000 abortions at its nine centres across the UK in January, the highest number in its 32-year history. This was a rise of 13% on January last year.

The charity's UK director, Liz Davies, blamed the surge in abortions on excess drinking over the Christmas season.

[Hat tip: New Recovery]

Three takes on weed

First, USA Today did it's best to create the impression that there is still a raging debate about marijuana and the gateway theory:

Most users of more addictive drugs, such as cocaine or heroin, started with marijuana, scientists say, and the earlier they started, the greater their risk of becoming addicted.

Many studies have documented a link between smoking marijuana and the later use of "harder" drugs such as heroin and cocaine, but that doesn't necessarily mean marijuana causes addiction to harder drugs.

"Is marijuana a gateway drug? That question has been debated since the time I was in college in the 1960s and is still being debated today," says Harvard University psychiatrist Harrison Pope, director of the Biological Psychiatry Laboratory at Boston's McLean Hospital. "There's just no way scientifically to end that argument one way or the other."

That's because it's impossible to separate marijuana from the environment in which it is smoked, short of randomly assigning people to either smoke pot or abstain — a trial that would be grossly unethical to conduct.

"I would bet you that people who start smoking marijuana earlier are more likely to get into using other drugs," Pope says. Perhaps people who are predisposed to using a variety of drugs start smoking marijuana earlier than others do, he says.

Besides alcohol, often the first drug adolescents abuse, marijuana may simply be the most accessible and least scary choice for a novice susceptible to drug addiction, says Virginia Tech psychologist Bob Stephens.

No matter which side you take in the debate over whether marijuana is a "gateway" to other illicit drugs, you can't argue with "indisputable data" showing that smoking pot affects neuropsychological functioning, such as hand-eye coordination, reaction time and memory, says H. Westley Clark, director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration.

The article ends up hedging its bets and qualifies just about everything she says. I find it hard to argue with the facts presented, but the emphasis and the selective inclusion suggest that the writer might be guilty of hype.

Next, a Canadian publication advocates legalizing and regulating marijuana:

Because of crimes that are related to the drug trade—most notably the killing of the four police officers in Mayerthorpe two years ago—many have been pushing for increased punishment for drug-related crimes recently. While a tactic such as increased jail time would theoretically make criminals think twice before becoming involved in the trade, there’s no statistical evidence that supports this claim.

The fact remains that it’s just too profitable an industry to be deterred by harsher punishment. Instead we need to end this failed experiment called prohibition and regulate most, if not all, drugs.

...The regulated sale of drugs would mean that one of the biggest dangers of drug use, drugs that are laced with more dangerous substances, would be systematically eliminated. As well, it would allow people to find a more accurate description of what they are taking, what it does to them, recommended doses and possible negative side effects. A more honest approach on the effect of these drugs would work better than just saying that drugs kill.

If there’s a demand for illicit drugs, like any other product, why should criminal elements be the ones who profit from it? Marijuana, for example, is more profitable than any other crop in Canada. Instead of letting criminals sell it, using the profits for other nefarious purposes, why doesn’t the Canadian government make it and sell it, eliminating the criminal element in the process? People are still going to buy it either way, after all.

Variations of this proposal a published frequently. At least this version eliminates profit potential. Most versions of this proposal suggest legalizing and regulating private sale, which raises the specter of a marijuana industry with the promotional and lobbying power of the alcohol and tobacco industries. While all variations of legalization models have an uphill battle, one that puts the government in the role of manufacturer and sales seems DOA.

Finally, STATS was riled by the USA Today article. They make several strong rebuttals to the points in the USA Today - if there is a gateway drug it's alcohol; alcohol causes more harm; there's lots of evidence against the gateway theory; most marijuana users experience little or no harm, etc. However, she also inserts her bias and misrepresents the USA Today article:

So, where’s the evidence that marijuana is more harmful than other substances?

The USA Today article didn't argue that marijuana is more harmful, just that it's not harmless. There were enough problems with the article that the straw man tactics we're needed.

Ultra Abstinence Approach?

I'm glad I'm not a drug addict in Ireland:

Two doctors specialising in treating substance abuse in Dublin have called for new thinking in treatment services and say doctors need to be aware that the evidence-base shows that abstinence in opiate drug addiction treatment does not work.

...Dr Quig­ley believes some doctors take an “ultra abstinence approach” which doesn’t necessarily work in drug addiction.

Says Dr Quigley: “As we have gone along with the metha­done programme we have abandoned some previous processes like attempting to pressure addicts to detox. On the basis of medical evidence, that just doesn’t work and creates more difficulties.”

Dr McGovern supports this view: “Unfortunately, evidence doesn’t support this [abstinence] approach and very few would remain free of opiates, and with any illicit substance, relapse is the norm.”

Both doctors say most general adult psychiatrists seem to advocate an abstinence ap­proach for opioids, and say the historical approach of abstinence and Alcoholics Anony­mous for alcoholism simply does not work in drug addiction treatment. “If you bring that sort of thinking in automatically into drug addiction, you are liable to get it wrong. You have to leave that approach outside the door of the surgery,” Dr Quigley adds. He also expresses concern about the abstinence ap­proach taken by the country’s forensic psychiatry services. “The Central Mental Hospital is strongly abstinent in orientation and that is where the problem arises with retaining dangerous addicts in treatment,” says Dr Quigley.

If that doesn't convince you that they've got an addiction stigma problem, it appears that they have a problem finding treatment for all of the violent drug addicts:

While there is a debate over whether patients who are violent should be excluded from treatment, either for a period, or for good, Dr McGovern says he believes that the patients who are violent are the very ones who most need treatment.

Both doctors believe the lack of services in which to refer violent patients on to is a major flaw in the system.

Dr Quigley adds: “Some people threaten the medical staff, and smash our vehicles or assault us. If they manifest that, we have to be able to pick up the phone [to the central treatment centre in Trinity Court]. If you can’t say that, and have to say ‘you’re barred from the clinic,’ you’re likely to be assaulted personally.”

Dr McGovern calls for better training for staff in dealing with violence. “Such patients need to be treated in a unit that is safe for both staff and other patients. The unit needs to be staffed by professionals who have specialist forensic psychiatric experience. I also believe that treating patients in a secure unit is only half the battle. Patients need to be offered treatment that ad­dresses aggressive behaviour.”

But often, no help is available to violent drinkers, says Dr Quigley. “They are getting no help because the addiction services that exist are not attractive to them, they are too rigid and not geared to people who are still drinking,” adds Dr Quigley.

While working in an agency that's treated over 10,000 of the poorest and most severely addicted people in our region, this has never been more than a rare problem.

Meth Addicts Demand Government Address Nation's Growing Spider Menace

From the Onion:

Following the tragic falling death of 32-year-old methamphetamine addict Phillip Diggs, who was reportedly attacked by spiders while scaling a large construction crane near Palo Alto, CA, thousands of outraged and confused meth addicts marched frenetically on Washington as part of a week of activities urging the federal government to address the nation's growing spider epidemic.

"Something needs to be done and it needs to be done soon—these spiders are everywhere," said Rich Harlowe, event organizer and founder of Tweakers' Rights NowNowNowNowNowNowNowNowNow!, in testimony before a Senate committee Tuesday. "The government must address this problem before the situation gets out of hand and these poisonous, acid-shooting spiders develop the powers of mind control or—God forbid—flight."

"America cannot afford to ignore this any crisis any longer," Harlowe added.

The rally drew addicts from every part of the country, many traveling on foot through the night, trading sex with truck drivers for rides, or stealing their brothers-in-law's bicycles. At dozens of rambling public speeches, organizers decried the fact that it took the spider-related death of an innocent meth addict to raise awareness of the issue, while lauding the bravery of meth addicts, and methamphetamines themselves.

A 45,000-word proposal was drafted by members of TRN during a marathon, 72-hour meeting under the Roosevelt Bridge, and presented twice to the Senate Indian Affairs Committee. The document, which includes schematics for the development of a giant "spider bomb" the size of Rhode Island, concludes repeatedly that the problem would best be combated with large quantities of methamphetamines and steel wool.
Meth Addicts Jump

"This very morning, I saw a small child completely covered in hairy, bloodsucking, screaming tarantulas while his parents stood by and did nothing," said protester Joe Lopez, pausing to spit out a black and decayed tooth. "I was appalled. I shouted horrible profanities and incantations at them, but they ignored me."

"I, I, I don't—this is just, just, just—I, I, I—guh, ah," he added.

A Small Part of the Brain, and Its Profound Effects

More on the insula and nicotine addiction. (Requires free registration. If you don't wish to register, you can use www.bugmenot.com.)

According to neuroscientists who study it, the insula is a long-neglected brain region that has emerged as crucial to understanding what it feels like to be human.

They say it is the wellspring of social emotions, things like lust and disgust, pride and humiliation, guilt and atonement. It helps give rise to moral intuition, empathy and the capacity to respond emotionally to music.

Its anatomy and evolution shed light on the profound differences between humans and other animals.

The insula also reads body states like hunger and craving and helps push people into reaching for the next sandwich, cigarette or line of cocaine. So insula research offers new ways to think about treating drug addiction, alcoholism, anxiety and eating disorders.

Of course, so much about the brain remains to be discovered that the insula’s role may be a minor character in the play of the human mind. It is just now coming on stage.

The activity of the insula in so many areas is something of a puzzle. “People have had a hard time conceptualizing what the insula does,” said Dr. Martin Paulus, a psychiatrist at the University of California, San Diego.

If it does everything, what exactly is it that it does?

For example, the insula “lights up” in brain scans when people crave drugs, feel pain, anticipate pain, empathize with others, listen to jokes, see disgust on someone’s face, are shunned in a social settings, listen to music, decide not to buy an item, see someone cheat and decide to punish them, and determine degrees of preference while eating chocolate.

Damage to the insula can lead to apathy, loss of libido and an inability to tell fresh food from rotten.

Plan to vaccinate babies against drugs

The U.K.'s Daily Mail recently ran a story on a plan to vaccinate children for cocaine, heroin and tobacco. The vaccine would prevent any effects from the drugs and therefore prevent any addiction.

A group called the Transform Drug Policy Foundation has written a response on their blog. They argue that: Drug vaccines don’t really work; Giving drug vaccines to children is profoundly unethical; Even if vaccines worked it wouldn’t prevent problematic drug use, or offending.

I find it pretty unlikely that there would be any significant steps in this direction in the near future. I think it's far more likely that drugs like this will be tried with people who have developed problems before their used in preventative strategies.

Pseudophedrine restrictions a boon to Mexican cartels

Recent efforts may have been successful at reducing American meth production, but it appears Mexican cartels may be picking up the slack.

The Combat Methamphetamine Act of 2005, which trumps laws that had already been passed in many states, made stores move their cold medicines containing the decongestant pseudoephedrine - which can be extracted and used to make methamphetamine - behind the counter, limit the amount that consumers can purchase and require purchasers to present photo identification. Stores must also keep personal information about these customers in a logbook for two years.
The regulations lend an illicit air to a legitimate attempt to banish a stuffy nose. Many cold meds now include phenylephrine, which doesn't carry the same restrictions - or efficacy....

But if consumers view this new counter ritual as a small sacrifice to keep meth off the streets, they may be disappointed to see that tough restrictions at the drugstore have failed to dent availability of the illegal drug. Restricting pseudoephedrine may have shut down small-time neighborhood meth cookeries, but Mexican cartels have seized the opportunity to swoop into unconquered territory and make those meth customers their own.

According to the National Drug Intelligence Center's 2007 National Drug Threat Assessment, "Marked success in decreasing domestic methamphetamine production through law enforcement pressure and strong precursor chemical sales restrictions has enabled Mexican (drug trafficking organizations) to rapidly expand their control over methamphetamine distribution - even in eastern states - as users and distributors who previously produced the drug have sought new, consistent sources."
Additionally, the flow of "ice" - highly concentrated meth that is usually smoked - from Mexico has increased sharply, most likely creating more addicts because of the better high it creates, states the report.

So while lawmakers have focused on regulating sniffling customers at drugstore counters, Mexican cartels have monopolized the gaps left in the meth market, bringing their goods - and guns - across a porous border. "Now, approximately 80 percent of all meth purchased in the U.S. originates from Mexican labs,"

This has gotten some attention on some blogs, but feels like they're trying to have it both ways: "Look! The boneheaded drug warriors have created a crisis. They've given a gift to those vicious Mexican drug cartels, who are invading thanks to our porous borders."; and "Look! The boneheaded drug warriors are hyping meth use. There's no crisis and there never was!"

This particular columnist is politically conservative and has previously written at least a few articles on immigration. Is this just an opportunity to raise alarm at illegal immigration?

About That Methedemic

Jack Shafer gives Newsweek a big TOLD YA SO!

Last Friday, Jan. 26, the federal National Survey on Drug Use and Health released results from a survey that showed meth use had "declined overall between 2002 and 2005" and that the number of "initiates"— people using the drug for the first time in the 12 months before the survey—had "remained relatively stable between 2002 and 2004, but decreased between 2004 and 2005."

Homelessness a cause, not a result of drug abuse

This article has gotten a lot of attention today. It runs counter to my admittedly biased experience and the experience of colleague who work in settings focused on homelessness. Note that it uses the term substance abuse rather than dependence. It's easy to believe that people with a diagnosis of substance abuse may have developed problems after becoming homeless. I find it more difficult to believe that people with substance dependence would have developed their problem only after becoming homeless.

It will be interesting to see the actual report and analysis of it:

A report on homelessness in Melbourne has shattered two key myths: that substance abuse and mental illness are the major reasons why people become homeless....

About 43 per cent had problems with substance use while 30 per cent reported mental health problems. Of these, 66 per cent and 53 per cent respectively had developed the problems after becoming homeless.

Activists Plan 'Safe Site' for Drug Smokers

Another article on calls for a "safe inhalation site" in Vancouver:

Addicts who smoke hard drugs will have an indoor place to get their fix if a Vancouver drug users group is able to open North America's first safe inhalation site later this year....

Such an unsanctioned facility would provide a supervised location for addicts to smoke crack cocaine and heroin, in much the same way that Insite -- Vancouver's legally sanctioned three-year-old safe injection site -- provides services to addicts who inject the same drugs.

Smoking manners

Japanese tobacco companies are doing their part to encourage good manners on the part of smokers. This is apparently a real ad campaign and frequently place on trains. I don't remember seeing these ads, but I do remember a similar public service warning painted on a sidewalk. It was a graphic of a cigarette poking a child in her eye. Enjoy.

Home at Last

PBS's series NOW had a segment on a housing first approach with a man named Footie who is chronically homeless and an alcoholic. He's clearly a late stage alcoholic, frequently has seizures and may have some cognitive impairment due to years of heavy drinking and seizures. (Streaming video of the entire episode is available at the link above.)

The story made a pretty compelling case for this approach with this him, arguing that it was impossible to address his higher order needs when his physiological and safety needs were not being addressed. Footie was provided an apartment with no contingencies. The approach could make a lot of sense in many cases--the question is which cases and under what conditions?

I had several reactions to the segment. First, had Footie ever been provided with comprehensive treatment of and adequate dosage, duration? Why no contingencies? Maybe his housing shouldn't be contingent upon abstinence, but how about participation in treatment? If the fear is that this might be a set-up, how about reviewing it at monthly or quarterly intervals so that a bad week does not put him back on the street? Why not at least make it recovery-focused? If this approach is good for Footie and raises his functioning and quality of life to his potential, who's functioning and quality of life might be reduced to something below their potential? At Dawn Farm, we see some clients who would probably benefit greatly from a recovery-focused housing program that is not contingent upon abstinence. However, how many of clients who are currently in full recovery would have settled into an apartment like Footie's and never achieved stable recovery and a full, satisfying life? Many, I think.

UPDATE: This isn't to say it shouldn't be done, but rather how to go about it in a way that doesn't lower the bar for all homeless addicts and fail to address what caused their homelessness. Maybe one way to approach it is to ask, "Absent their addiction, would this person still be likely to be homeless?" In the case of Footie, the answer is "probably so". In the case of most of our homeless clients, the answer is "unlikely".

Of course, another big question is how to prioritize services in the context of scarce resources.

Stop-smoking efforts reaching out to homeless

Homeless shelters are beginning to look at addressing nicotine addiction. The discussion sounds lot like those that have taken place among treatment centers for the last decade:

Following successful anti-tobacco campaigns geared toward pregnant women, teenagers, African-Americans, Latinos and other groups, homeless people...may be the next target.

Amid broad skepticism, nascent campaigns to get the homeless off cigarettes are bubbling up in Chicago and across the country.

A Humboldt Park shelter is holding regular meetings where the homeless can discuss their addiction to tobacco. In New York City, Zyban and other anti-smoking pills will be distributed over the next few months at homeless shelters, where 6,000 workers also will be trained in tobacco physiology. Nicotine patches have been offered at shelters in Seattle since last fall and are on the way to others in Wisconsin.

Even cessation proponents acknowledge that small gains will be seen as a victory, considering that 80 percent of the chronically homeless are addicted to smoking.

The goal, experts say, is to change the culture in shelters and possibly save millions each year in Medicaid payments for smoking-related illnesses.

Increasingly, the homeless themselves are pushing the subject. At Humboldt Park Social Services, which operates in one of the Chicago's poorest neighborhoods, residents sit around a folding table during regular meetings to discuss tobacco.

"We started talking about what can kill you, talking about AIDS and STDs, but they didn't want to hear that anymore. . . . Our clients were tired of it," said Noemi Avelar, director of operations. "They wanted to talk about smoking. They said this is what we do every day, so let's take a look at it."

Addressing addictions to heroin, cocaine and marijuana remain priorities, but tobacco use will be added to the list beginning this year, said Avelar.

So far, few shelters have jumped on the anti-smoking wagon. Most cite higher priorities among their clients, including serious psychological problems or addictions to alcohol, heroin, methamphetamines and crack.

..."We have more people addicted to nicotine than heroin, and the cigarettes can be harder to quit," Harden said. "We'd love to address smoking along the way, but right now there isn't much out there that would do much good."

The executive director of Aurora's only permanent emergency shelter said tobacco addiction is a very low priority.

"I hate tobacco, but there are a lot more serious issues I have to deal with, starting with funding," said Ryan Dowd of Hesed House. "Sure, smoking is bad and causes all sorts of health problems. So does sleeping outside and not having anything to eat."

Randal Syverson, 56, a resident at Hesed House, was openly skeptical of cessation programs.

"No house, no job, no family--a cigarette can be the only joy I'll have today," he said.

I understand the reluctance of the program staff. Locally, they're underfunded and overwhelmed with the number of clients and the broad scope of their problems. An all out push toward smoking cessation doesn't fit neatly within their mission and their clients are clearly facing larger barriers to achieving stable housing. However, shelters perform all sorts of secondary public health functions and they can at least begin to change the culture among the homeless and in shelters--from one that celebrates tobacco to one that tolerates tobacco.

At the very least, providers should begin asking clients if they want to quit, said Janet Porter, program director for the National Network on Tobacco Prevention and Poverty.

"I think we've all been surprised by the number of the homeless who say, `yes,'" Porter said.

..."What's good for someone working at a big upscale law firm is just as good for people living in the street," said Roger Valdez, manager of the county's tobacco-prevention program. "Everyone deserves clean water, air and the same chance to beat this addiction."

The Intellidrug tooth implant

A future drug delivery method?

Now EU researchers are developing a better, more accurate and more convenient way – a dental prosthesis capable of releasing accurate dosages into the mucous membranes in the mouth.

...

“The dental prosthesis consists of a drug-filled reservoir, a valve, two sensors and several electronic components,” explains Dr. Oliver Scholz of the Fraunhofer Institute for Biomedical Engineering IBMT in St. Ingbert, where the sensors and electronics were developed.

“Saliva enters the reservoir via a membrane, dissolves part of the solid drug and flows through a small duct into the mouth cavity, where it is absorbed by the mucous membranes in the patient’s cheeks.”

The duct is fitted with two sensors that monitor the amount of medicine being released into the body. One is a flow sensor that measures the volume of liquid entering the mouth via the duct, while the other measures the concentration of the agent contained in the liquid. Based on the measurement results, the electronic circuit either opens or closes a valve at the end of the duct to control the dosage. If the agent has been used up, the electronic system alerts the patient via a remote control, which was also developed at the IBMT. This control permits wireless operation of Intellidrug, and can be used by the patient or doctor to set the dosage required.

The patient has to have the agent refilled every few weeks. »This could be done using a deposit system whereby the patient swaps the empty prosthesis for a newly refilled one. At the same time, the battery could be replaced and the device could be serviced,« says Scholz.

Hand sanitizer: a good buzz?

Ethanol -based hand sanitizer will now be contraband in treatment programs, jails and prisons:

Prison officials and poison control centers can add a new substance to their list of intoxicants -- hand sanitizer. A usually calm 49-year-old prisoner prompted a call to the Maryland Poison Control Center after guards found him red-eyed, combative and "lecturing everyone about life." Other inmates and staff reported the unidentified prisoner had been drinking from a gallon container of hand sanitizer, which is more than 70 per cent alcohol, or over 140 proof

Does marijuana contribute to psychotic illness?

Current Psychiatry on marijuana and schizophrenia:

Cannabis and psychosis: 4 clinical pearls Cannabis use increases the risk of developing psychosis and is estimated to double the risk for later schizophrenia (5 to 10 new cases per 10,000 person-years) The association is not an artifact of confounding factors such as prodromal symptoms or concurrent use of other substances (including amphetamines) The risk increases with the frequency and length of use (a dose-effect relationship) Self-medication is not the connection between cannabis use and schizophrenia, according to empiric evidence

I'll keep an eye out for responses to this. It's so hard to know what to trust on something like this. This article seems reasonable, but it feels a little reminiscent of Reefer Madness. Also, the increased risk of schizophrenia may be statistically significant but I find it difficult to get too alarmed about the risk going from 1 in 2000 to 1 in 1000. (Maybe I should be more alarmed. I suppose that you start talking about large numbers when you multiply these numbers by large numbers of users.)

Methylphenidate for Amphetamine Dependence

The American Journal Psychiatry ran a recent study on the effectiveness of methylphenidate for speed addiction. Could this be a future evidence-based practice? Let's hope not.

No Child Left Untested?

The ONDCP is starting a new push for random drug testing of athletes in schools. A truly awful idea. This article includes Q & A with representatives from the Drug Policy Alliance and ONDCP. It's a shame that the fringes get the spotlight.

The Michigan High School Athletic Association has weighed in against drug testing.

Potent drug blamed for death rise

It looks like we now have a final count for drug deaths in Wayne County in 2006:

The Wayne County Department of Health and Human Services reported that 542 people died from drugs from Jan. 1 through Dec. 10, 2006. That is up 19 percent from the 457 drug deaths reported for all of 2005.

Of the 2006 deaths, 178 were specifically attributed to fentanyl, 197 to heroin and 204 to cocaine. Because those drugs often are mixed, the numbers don't add up exactly...