Treatment for Meth OD May Harm Brain

New research on treatment of meth ODs:

According to experimental scientists a common antipsychotic drug used in emergency rooms to treat methamphetamine overdose can damage nerve cells in an area of the brain known to regulate movement.

Investigators from the Boston University School of Medicine used a rat model to determine that only the combination of the medication, haloperidol, and methamphetamine causes the destructive effects, not either one alone.

[Hat tip: Daily Dose]

Legacy Tobacco Documents Library

The American Legacy Foundation has created a digital library. The Legacy Tobacco Documents Library (LTDL) contains more than 7 million documents (40+ million pages) created by major tobacco companies related to their advertising, manufacturing, marketing, sales, and scientific research activities.
[Hat tip: Daily Dose]

Strawberry Quick and Cheese

I've been resisting posting about these reports. They feel like hype, but I've gotten several emails about them and they've been heavily reported. So, here you go.

More Canadian drug war fun

At least one of them resists questioning the motives of their opponents--something I haven't seen in American political debates for some time.

Point:

Last week, it was announced that the Conservative government will soon unveil a new national anti-drug strategy. The plan is said to feature a get-tough approach to illegal drugs, including a crackdown on grow-ops and drug gangs. And while it will also (wisely) include tens of millions for rehabilitation of addicts and for a national drug prevention campaign, it is said to retreat from safe-injection sites and other fashionable "harm-reduction" strategies introduced by the previous Liberal government.

To which we say: Good. This editorial column has long urged a softening of drug policy on marijuana and other non-addictive recreational substances. But heroin and similarly addictive drugs are a different story. Moreover, safe injection sites don't work. And they send the wrong message, too, promoting disrespect for the rule of law by having government facilitating the consumption of illegal substances.

Safe-injection sites (SIS)-- typically inner-city facilities where addicts may go to shoot up with clean needles under the watchful eye of medical specialists --are often said to work wonders. Benefits claimed on behalf of Insite, Canada's one and only SIS in Vancouver's Downtown Eastside since 2003, include reduced needle sharing, reduced spread of deadly diseases such as HIV and hepatitis, fewer needles discarded in surrounding neighbourhoods and fewer addicts overdosing in alleys. Lives have been saved, advocates claim, the "well-being of drug users improved," and all without increased street dealing around Insite.

Too bad most of the proof to back these positive claims come from SIS proponents or the academics who devise harm-reduction theories. Police here, and in Europe (where they have lots of experience with SISs) tell a very different tale.

When Insite applied to have its three-year licence renewed last fall, the RCMP told Health Canada it had "concerns regarding any initiative that lowers the perceived risks associated with drug use. There is considerable evidence to show that, when the perceived risks associated to drug use decreases, there is a corresponding increase in number of people using drugs."

That has certainly been the case in Europe. Currently there are more than three dozen major European cities on record against SISs. Most have had such facilities and closed them because they found that drug problems increased, not decreased.

After an injection site was opened in Rotterdam in the early 1990s, the municipal council reported a doubling of the number of 15- to 19-year-olds addicted to heroine or cocaine. Over the 1990s, the Dutch Criminal Intelligence Service reported a 25% increase in drug-related gun murders and robberies in neighbourhoods housing one of that country's 50 official methadone clinics or addict shelters. Zurich closed its infamous needle park in 1992, after the police and citizenry became fed up with public urination and defecation, prostitution, open sex, panhandling, drug peddling, loud fights and violent crimes.

...

But as much as we admire the good intentions behind SISs, drug consumption is the wrong business for government to be in. A government that funds safe havens for injecting illegal drugs on one hand will quickly find it is working against its efforts to reduce drug dealing on the other.

Counter-point:

Reports that the Harper government is preparing to announce changes to Canada's outdated 20-year-old national strategy on illicit drug use should be reason for optimism.

Instead, there are signs -- such as the Conservative distaste for safe-injection sites that are a key component of the "harm-reduction strategy" -- that Ottawa is tilting toward a more aggressive, U.S.-style war on drugs. If that is the case, it would be an unfortunate mistake with predictable and very disappointing outcomes.

While Washington from time to time trumpets bravely that it has scored a victory in the war on drugs, by all empirical measures it has been an abject failure.

Consider the record south of the border:

- Hundreds of billions of dollars have been spent. This year alone in the U.S., federal and state government have spent nearly $20.5 billion directly on counter-drug measures.

- There are nearly two million Americans in prison, about one-third of whom are locked up on charges for possession or low-level trafficking, costing tens of billions of dollars.

- Despite nearly 30 years of focused domestic and international measures, however, drugs are more available than they have ever been, largely because it is such a wildly profitable criminal industry. Virtually anyone who wants to buy drugs can, and it's easier than ever.

But what are the alternatives? This is a reasonable question. Just because the state can't beat the drug cartels doesn't mean it should join them.

One of the driving forces behind the U.S. war on drugs, especially under the Republican party, is Christianity. The religious right has placed "saving" people from the scourge of drugs as an important American value and tantamount to saving souls. It is one reason that successive administrations have continued to throw increasing resources at a fruitless war. The message, in essence, that the small number of those rescued from the grip of drugs justifies the billions used in the war.

Teen drinking

The skeptics at STATS.org catch some selective reporting:

There was a positive association between exposure to TV beer ads in the sixth grade and drinking which ranged from 1.43 to 1.48 depending on the type of television ad. In other words, the sixth graders where 43 to 47% percent more likely to drink in grade seven based on seeing beer ads on tv.

But hold on – this was by no means the only factor to show such a positive association. The Times failed to mention that “Sports Activity” in the sixth grade delivered a higher odds ratio of drinking in the seventh – 1.60 or 60% more likely to drink. Low parental monitoring was greater than TV ads too (1.64), as was parental approval (1.69), and the approval of a friend almost doubled the chance of drinking (1.98). Deviant behavior (2.00) and peer drinking (3.20) were even greater predictors of beer consumption.

The Times also neglected to mention that the Rand researchers tried to account for the effect of these factors on one another in a series of complex calculations. The result, at least according to the tabular data in the study, shows that the odds ratio significantly diminished for all advertising (1.08 to 1.13 for TV ads). The factors most strongly influencing seventh graders to drink were, once again, peer drinking (1.40) sports activity (1.52), friend approval (1.53) deviance (1.54), and above all, whether they had drunk in the sixth grade (2.32).

I'm just as troubled by shoddy drug reporting, but there's something very off-putting about the zeal of STATS. I don't claim to know the impact of advertising, and even if it is effective with teens, I'm not sure I'd advocate restrictions. However, I find it difficult to believe that the alcohol industry's large advertising budgets are ineffective and sufficiently narrowly target to influence only adults. They sometimes seem to react to excessive certitude with excessive certitude.

Another study finds that there may be a relationship between teen drinking and something not mentioned in the previous study:

In a study of more than 10,000 15- and 16-year-olds, British researchers found that teens with larger allowances were more likely to drink frequently, binge or drink on street corners and other public places.

[hat tip: CCSA.ca and Shannon]

Because fentanyl is so powerful, overdosing occurs quickly, easily

Q & A about fentanyl patches in the Ann Arbor News. Prompted by 2 local deaths:

Michigan State Police at the Ypsilanti post have recently handled two overdoses in which victims chewed or sucked Fentanyl patches and stopped breathing.

New Insite numbers

Insite has been receiving negative attention since a change in government in Canada and recent critical review. Today, they released a report the value of Insite in moving users toward detox. They report that use of Insite is associated with a 30% increase in use of detox services. I'm not sure what to make of this. They previously reported that 18% of Insite users sought detox services over the course of a one year follow-up period.

• A 30% increase means that detox use went from what percentage to what percentage?
• What's the road not taken? Could increased access to detox have improved usage? (Vancouver only has 3 detox facilities.) Could simple street outreach have produced similar results?
  
• They had a follow-up rate in the neighborhood of 80%, but the cohort is huge. Did they factor any assumptions about the lost subjects? Are these numbers good.
  
• These numbers are based on a lot of assumptions. Are these reasonable assumptions? Might someone who's concerned enough about blood-borne pathogens to use Insite, be moving through the stages of change and be more likely to use detox services on their own? I don't know.
• What were the numbers for community-wide use of detox. Did that increase over this period? Detox admissions increased in Ann Arbor without Insite.
• What do the clients report as their reasons for entering detox? Do they credit Insite?
  

All the numbers are in statistical terms that make me wish I paid more attention to stats in college. Any DF staff wanting the full text can email me.

Medical marijuana use initiative launches in Michigan

An initiative that would allow seriously ill Michigan residents to use marijuana as a pain reliever without repercussions will be launched this week, The Coalition for Compassionate Care announced Wednesday.

Read the rest here. The initiative website is http://stoparrestingpatients.org. I wonder how many patients have been arrested. Seriously. I'm not just being a smart Alec.

How Normal Is Smoking? Teens Don't Know, But Their Guesses Affect Their Habits

More reason to be careful about how we present drug information to adolescents. It's possible to give kids the mistaken impression that drug use is much more common that it really is. This article highlights the dangers of this:

According to the study, nine out of 10 (93 percent) high school students overestimate the percentage of people who smoke in the United States. On average, they believe over half (56 percent) of Americans are smokers, while the actual figure is less than half that.

The study identifies three distinct ways to measure “normative beliefs” involving smoking, each of which it found to be significantly related to adolescents’ likelihoodof smoking. According to the study:

• The more an adolescent perceived that successful and elite people smoke cigarettes, the more likely that adolescent was to smoke.
• The more strongly an adolescent perceived that his or her parents or peers disapproved of smoking, the less likely that adolescent was to smoke.
• The more an adolescent overestimated the percentage of smokers in the general population, the more likely that adolescent was to smoke.

[Hat tip: Join Together]

Plant extract may block cannabis addiction

A plant compound reduced THC use in rats and interfered with dopamine release when using THC. More here.

Do rules hamper remedies for pain?

This article focuses of Washington state, but provides some needed background on opiate prescribing patterns. It appears opiates for pain relief are more readily available than they were 15 years ago.

Until about a decade ago, doctors reserved opioids largely for patients who had cancer. Wider use has come recently as doctors learn more about pain management and researchers have reported that only a small percentage of patients who properly take opioids ever become addicted.

The reigns on these drugs have tightened up over the last several years as there have been concerns about overdoses and prescribing patterns:

...[in] the late 1990s that Washington's workers'-compensation program began covering opioids.
advertising

Almost immediately, accidental deaths became a concern here and elsewhere in the nation. Between 1996 and 2002, 32 injured workers in Washington died after accidentally overdosing on opioids, according to state data.

In 1996, the state's typical workers'-compensation patient took 88 milligrams of morphine-equivalent doses a day. In 2005, the average daily dose was 151 milligrams -- a jump that state officials suspect is caused by an increased tolerance.

In response, some states, including Washington have started developing guidelines for opiate prescribing:

Some states already have opioids guidelines for people covered by state programs, such as starting doses for new patients. But Washington has gone further by setting a suggested daily-dosage ceiling.

Long-term use of opioids can pose hazards for both doctors and patients, said Dr. Jeffery Thompson, medical director of Washington Medicaid. For instance, high doses of it can actually exacerbate pain, which then can prompt doctors to prescribe even more.

Physicians who don't specialize in pain treatment "don't have the knowledge or all the tools," Thompson said. "These are very difficult clients."

The state created the opioids guidelines specifically for those primary-care physicians. The advisory is intended for patients with chronic pain, not for people with cancer or temporary pain or pain associated with terminal illnesses.

The guidelines do not dictate a limit on narcotics dosages, and there are no sanctions for exceeding the guidelines.

The biggest fear is that doctors simply will stop prescribing opioids to legitimate patients.

"Because it comes from a government agency, the guidelines could be perceived by many as imposing new restrictions," said Aaron Gilson, an associate director with the Pain & Policy Studies Group at the University of Wisconsin.

The state strongly recommends that patients rarely take more than 120 milligrams of morphine or its equivalent per day (for example, 800 milligrams of codeine is equivalent to 120 milligrams of morphine). For doses above that level, physicians are advised to send patients to pain specialists.

The state also advises doctors to ask patients to take random urine tests to verify that they're taking the prescribed medications, as well as to rule out illegal drug use.

I don't know enough to opine on the dosage guidelines. It seems to me that this is a case of tension between two real problems and we (the royal "we") are still in the process of trying to find balance. If it weren't for my history of addiction and recovery, I'd probably be pretty offended and resentful about having to submit to drug screens, but claims of Draconian restrictions seem to ignore that the prospects for pain patients are significantly better than 10 or 15 years ago.

It's too bad there's so much hyperbole in discussions about the matter, otherwise we might find some balance a little sooner.

Let's treat addiction like the disease it is

One writer's response to the firing/resignation of HBO's CEO, Chris Albrecht:

Addiction to drugs or alcohol is not an inconvenience, a lapse of willpower, a character flaw, anything to be ashamed of or any form of divine judgment. Addiction is not something that needs to be whispered about or shrouded in euphemisms when you are among polite company. Addiction is a progressive, incurable disease -- in the same way that diabetes and asthma are progressive and incurable diseases. If you have the illness of addiction or alcoholism and you stop treating that illness, you are guaranteed to have a relapse. If you relapse and you still don't treat your illness, you are guaranteed to die.

I can say this with such certainty because I am an addict and an alcoholic. Just like Albrecht, with his well-documented violent outbursts, my own life got pretty squalid and desperate for a while. At the end of my using, a high percentage of my days were being spent in bad behavior that was directly tied to my substance abuse. Then I went to jail for the night and had the same epiphany that every alcoholic and addict in recovery -- including Albrecht -- has had: If I don't quit using, I shall die a long, slow, horrible death, and I will hurt every person I come into contact with until that death.

I've happily been in recovery for years. Life, love and work are all good right now, but that goodness is entirely provisional on my continuing to treat my chronic disease of addiction. As part of this treatment, I insist on being myself in all situations. And what I am is a drunk and a pill popper, gratefully living a sober life today.

I'm lucky, because I am so not shy about my illness. I don't feel any need to hide in either my personal or professional life the fact that I am an addict and alcoholic . I make it a personal mission to help the people I work with understand that I'm perfectly "normal" as long as I don't drink or use. But I also make it clear that I don't have a choice about treating my disease: Doing what I need to do to stay sober has got to be the driving wheel of my daily life. For me, it's a matter of life and death. And it seems to me that Albrecht is only trying to do the same thing I do: Treat the disease that will wreck what's left of his life before that disease kills him.

This is what burns me about Americans and the illness of addiction: When Tony Snow announced he'd had a cancer relapse and took some time off from being our president's spokesman, the consensus seemed to be that he was a brave fighter who should be welcomed back to the Blue Room podium as soon as he felt up to standing behind it. Not that there's anything wrong with this. I, too, find Snow a very brave and appealing figure as he wages his perforce solitary war against his killer disease. But I find Albrecht to be an equally brave and appealing figure as he wages his own solitary war against his own killer disease of alcoholism.

Read the rest here. I agree with every word about attitudes toward addiction. I also appreciate his candor:

"I had been a sober member of Alcoholics Anonymous for 13 years," he wrote. "Two years ago, I decided that I could handle drinking again. Clearly, I was wrong."

However, this guy did commit an assault. (Not his first, either.) I don't think I'll describe him as brave, although I might, if he chose to start creating accountability for his violence by entering a batterer intervention program.

Childhood sexual abuse and alcohol problems

A new study looks for a relationship between childhood sexual abuse (CSA) and alcoholism. It finds that women who experienced CSA have elevated rates of alcohol use at 12-13 years old, but their rates of alcoholism are not any higher than people with similar adolescent alcohol use, though they are higher than the general population.

Two thoughts. First, CSA has been associated with higher rates of addiction. This suggests that CSA may not cause alcoholism, but may lead to early experimentation, which has been associated higher rates of addiction later in life. What's so interesting about this is that it supports CSA as a pathway to addiction and supports alcohol adolescent alcohol misuse as a response to CSA, but challenges the frequently circulated idea of addiction as self-medication for CSA.

Second, the study didn't look qualitatively at the CSA. It would have been interesting to see how the following "traumagenic factors" affected alcohol use and dependence: who committed the abuse (was it a trusted adult); did they report the abuse and where they believed; how invasive was the abuse; how many times were they abused; how many perpetrators were there?

If you are a DF employee and would like the full text, let me know.

Predictors of overdose

A new study looked at OD following detox. The finding that the researchers emphasize is that recent depressive symptoms are a risk factor for OD. They also found that those with at least one prior OD were much more likely to have had an OD at follow-up. An unmentioned finding is that it appears detox may have lowered OD rates. Important because detox is usually not considered when discussing strategies to reduce OD.

If you are a DF employee and would like the full text, let me know.

Are Michigan kids being overdosed?

"Report shows that thousands of Michigan preschoolers are being prescribed psychiatric drugs."
[hat tip: daily dose]

Embracing the culture of recovery

Recovering people around the country are advocating for recovery. Some in big, high profile ways and others in smaller, quiet ways, but we all seem to be organizing around the same fundamental messages. Here's Joe Showalter from Crawfordsville, Indiana:

It has been said that addiction is a cunning enemy of life. (NA world Services) We all know people suffering from drug or alcohol addiction.

Many of us know several people who have attempted to recover from addiction with varying degrees of success. Somehow, though, unsuccessful attempts at recovery seem to garner more attention. Why do so many people return to active addiction after initially addressing their problem and receiving help? Were they unmotivated, unconvinced, under-treated or too far gone? A lot of the conventional wisdom concerning recovery from addiction seems to suggest that a person must hit some terrible ³bottom² before they are amenable to recovery. Often, this ³hitting bottom² entails the loss of the very resources needed to formulate a healthy recovery. Addiction gets progressively worse as it endures and it creates lies about itself along the way. Alcoholism and Addiction have been called the only diseases that tell you, you don¹t have it. I¹m sure many have watched abuse turn to addiction and wondered why the afflicted person doesn¹t appear to believe anything is wrong. Nobody wants to be an alcoholic or an addict. We don¹t want our loved ones to have ³those² problems. That is the very distortion of perception that allows the disease to progress untreated for so long and for so many.

The news is not all grim though. Recovery is possible. It happens all around us. Millions of Americans are in recovery from alcoholism and addiction. Just like the varying degrees of severity present in the problem, there are varying degrees of success and happiness in recovery.

One of the great hurdles springs from the fact that addiction becomes a lifestyle. Like any lifestyle, alcoholism and addiction become a culture unto themselves. This culture, complete with rituals, ceremonies and celebrations, dominates the social, leisure and community lives of those involved with it. A person who begins to seriously address the need for recovery often experiences a kind of ³culture shock². No longer is it safe to socialize in the same places, with the same people or in the same way.

Newly recovering people suddenly look up and they don¹t recognize their own lives. Boredom and isolation are very real enemies of recovery. It takes effort and dedication to reinvent a lifestyle. Fortunately those of us in recovery are not alone on this adventure.

There are many people in this community who have found a new way of life. Often we are where you might not expect to find us. We are in your church (maybe the basement), we are your co-workers, we¹re at the family reunion, the park, the theater, the concert, or maybe wandering the trails at Shades. We are taking an art class, a college course or shopping your garage sale. Many of us have found recovery through a variety of avenues. Support groups are well attended in C¹ville. Many seek help from our faith communities, and many thoughtful and caring professionals provide assistance. A lot of us find our way to recovery by making big mistakes and being held accountable for those mistakes. Our community is graced with a criminal justice system that understands the role addiction plays in the bad decisions that result in criminal behavior. Many alcoholics and addicts have their first exposure to recovery with firm encouragement from the legal system. One thing we all have in common is the need to abandon the culture of addiction and embrace the culture of recovery.

The culture of recovery is an adventure indeed. Social skills have to be re-learned without drugs or alcohol. Interests often have to be developed from scratch. Time management becomes a new concept for a lot of us. Courage to try new things and meet new people is different when your life depends upon it. A culture of recovery is not doing the same old things without the alcohol and drugs. A culture of recovery is about becoming excited about life. It is about rejoining the community and becoming a contributing member of society. When the dust settles we often wonder where we found the time to abuse alcohol and drugs. We begin to see new possibilities and discover a joy that few experience. It makes us want to give what we have found to others who want it. Truly we see that Fun Has Been Redefined.

Addiction illuminates concept of ‘free will’

Harvard Provost, Steven Hyman, recently gave a lecture titled “Compulsion and the Brain: Subverting the Concept of Self-Control.” He provided an easy to understand description of the neurobiological basis for addiction:

Hyman began by explaining what neuroscience has learned about the process by which humans choose among multiple goals and direct their behavior toward obtaining their choices. The part of the brain that manages this process is the prefrontal cortex.

Scientists first began to gain an understanding of the role of the prefrontal cortex in 1848 with the case of Phineas Gage. Gage, a hardworking and conscientious railroad employee, was the victim of a freak accident in which an explosion drove a steel rod through his skull.

Gage survived the accident but seemed to undergo an abrupt personality change.

“He retained his intelligence, but he was no longer sober and reliable. He could no longer conform his behavior to specific goals,” Hyman said.

Scientists now believe that the rod destroyed Gage’s orbital prefrontal cortex, the part of the brain in charge of encoding goals and assigning relative value to them.

Scientists have since identified other structures that perform functions such as holding goals in mind, monitoring behavior necessary to obtaining goals, and resolving conflicts that arise over conflicting goals.

Another essential aspect of the process of seeking and obtaining goals is the dopamine system. Dopamine is a neurotransmitter secreted into the nerve synapse by the presynaptic terminal vesicles, then reabsorbed back into the nerve cells.

Experiments with laboratory animals have shown that the release of dopamine signals the brain to expect a reward. After the reward is obtained, dopamine returns to the nerve cell. Thus, under normal conditions, dopamine is only involved in the process of pursuing a reward, not in the enjoyment of it. But this process can be distorted by the use of drugs such as heroin, cocaine, and amphetamine.

“These drugs are Trojan horses,” said Hyman. “Each of them contains a chemical that is enough like the neurotransmitter that they increase the amount of dopamine in the brain.”

When dopamine continues to be released beyond the normal period, the brain is thrown into a perpetual state of “wanting,” which is the essence of addiction.

Long-term use of addictive drugs, Hyman said, creates processes in the nerve cells that “literally rewire the brain. The circuitry becomes deranged, which elicits automatic drug craving and drug seeking.”

These changes in the brain’s circuitry and the resulting loss of control over the normal goal-setting and goal-seeking process are what makes it so difficult for addicts to recover and return to normal lives.

“I’m not saying that these people are zombies,” Hyman said. “They can grab hold of themselves and regain control of their behavior, but they are at a high risk of relapse.”

What are the policy implications for this model of addiction? One of them, Hyman said, is that because the addicts’ brains are so compromised, it is necessary for others — families, friends, and institutions — to fill in and act almost like “a prosthesis” for the brain functions that are missing or disabled. In order to succeed, however, they must be “absolutely relentless,” added Hyman.

“Drug addiction is a very dramatic form of compulsion,” he said. “We are probably a little less in control than we’d like to believe we are.”

Nevertheless, Hyman believes that addicts should still be held responsible for their actions.

“The fiction that they are responsible may be what gets them to change their behavior,” he said. “A society that errs on the side of holding people responsible is better than a society that errs on the side of giving people excuses.”

There are actually clinically proven reasons for holding people responsible for their actions, Hyman said. Experiments have shown that people function better and are more able to deal with stress when they feel that they are in control.

“We are wired for personal responsibility, even if it’s a bit fictional.”

But “punitive moral opprobrium” and overly harsh prison sentences for minor drug offenses do not serve any useful purpose, Hyman added.

ADHD and Alcoholism

A new study finds a strong relationship between ADHD and alcoholism. It seems to beg the question of what observable symptoms of alcoholism exist before the person has consumed alcohol or before they've developed DSM symptoms of alcoholism. We know that impairment in the frontal cortex plays an important role in addiction and this part of the brain regulates behavior. Are some youth with primary ADHD diagnoses really demonstrating early symptoms of alcoholism?

Molina noted that for adolescents who had previously been diagnosed with ADHD, the risk for heavy drinking or drinking problems began at around age 15. For example, the teens aged 15 to 17 with childhood ADHD reported being drunk an average of 14 times in the previous year versus 1.8 times for those without an ADHD diagnosis.

Approximately 14 percent of those who had been diagnosed with ADHD were diagnosed upon follow-up with alcohol abuse or dependence, and none of the 15- to 17-year-olds without childhood ADHD had alcohol problems.

The researchers also found that those with ADHD and co-existing conduct disorder as adolescents had significantly higher rates of alcohol abuse than did those with ADHD alone: for instance, 20.7 percent of those with ADHD and concurrent conduct disorder as adolescents were diagnosed with alcohol abuse, compared with 4.8 percent of those with ADHD alone.

Molina also found that 10.3 percent of adolescents with ADHD and concurrent conduct disorder met criteria for alcohol dependence, compared with 1.6 percent of those with only ADHD.

For those assessed in early adult hood (aged 18 to 25), Molina found that 42 percent of those with ADHD and antisocial personality disorder met criteria for alcohol abuse or dependence as compared with less than 20 percent of those with only ADHD.

Pain Killers

From artist Chris Jordan. His new collection is called Running the Numbers: An American Self-Portrait. It "looks at contemporary American culture through the austere lens of statistics."

His piece Pain killers "depicts 213,000 Vicodin pills, equal to the number of emergency room visits yearly in the US related to misuse or abuse of prescription pain killers."


Click for partial zoom:

Click for detail at actual size:


Hat tip: Andrew Sullivan

From addict to physician -- a determined life

From Jim:

I've actually met this guy and heard him talk. Interesting commentary on the way the old therapeutic communities put a low emphasis on drinking - thus he didn’t actually get sober until 1993...

'Every last gram of cocaine is soaked with innocent blood'

Scottish police are starting a new public education campaign about drugs. It seems to attempt to change cultural attitudes toward drugs by focusing on the social justice implications of drug production. They're trying to define drug trade and drug use as unethical, not just bad. I suppose it could be effective in changing cultural attitudes toward drug use and could reduce casual drug use, but it's unlikely to impact addictive use. [hat tip: Jim]

Oxycontin coverage

STATS.org fellows Maia Szalavitz and Trevor Butterworth pick apart media coverage of last week's oxycontin verdict.

I share Maia's concern about pain patients getting adequate pain management, but the narrative she offers doesn't fit with my experience. The people that I have contact with who are concerned about oxycontin are parents. They don't see it as a "bad" drug, and their concern is not that doctors are getting people addicted. They are concerned their kids getting prescription opiates from friends who get them from someone's medicine cabinet. Their focus is on raising parental and community awareness about the problem and to encourage people to secure their meds and dispose of them properly when they are no longer needed. They're not especially sophisticated about drugs or medicine, so it would surprise me if they're very unusual. Hardly marauding "drug warriors."

She also points to low treatment admission rates for primary oxycontin dependence. This misses the point. It's not that I'm seeing people present with oxycontin as their primary problem. (It's too expensive on the street.) The problem is that we're seeing more young people presenting with heroin or Rx opiate addiction who initiated their opiate use with oxycontin or a similar drug. Granted, the number of people who will develop an addiction is small and the fact that some people will develop addiction doesn't mean it should be made inaccessible to pain patients. However, with 12% of 18 to 25 year olds reporting non-medical use of Rx pain relievers in the last year, it's not a small problem.

As for Public Citizen, they're in the business of providing accountability for corporate fraud or mistreatment of consumers. Isn't a case of misleading marketing like this exactly what they exist for?

Butterworth says that the data provides a basis for concern about misuse of the drug but blames the media for the problem:

Yet the real data on OxyContin makes a strong argument for holding the media responsible for the rise in OxyContin abuse. According to the Drug Abuse Warning Network, the number of times OxyContin was recorded in an emergency department visit due to drug abuse or a suicide attempt went from zero in 1996 to four in 1997 to 527 in 1998 to 1,178 in 1999. The most dramatic increase occurred between 2000 and 2002, when the number of mentions went from 2,772 to 9,998 in 2001 and then to 14, 087 in 2002.

This shows a correlation between the media’s frenetic coverage of OxyContin, which began during the February 2001 sweeps, and the sharp increase in emergency room mentions of abuse during and after this time period. Naturally, reporters explained how to defeat OxyContin’s time delay mechanism so as to get high. As the Washington Post’s Tom Shales observed in a 2001 article in Electronic Media:

"...in the course of 'reporting' on abuse of the drug, they've all aired how-to pieces that include handy, easy-to-follow instructions on the correct abuse procedure. They tell you how to get high. Then the correspondents do follow-up reports expressing shock and dismay that the abuse is becoming more popular."

But while the manufacturer of OxyContin can be taken to court for misbranding, the major source of information about how to actually abuse the drug not only remains free of accountability – many of its practitioners continue to mislead the public on a drug whose value to people suffering acute, chronic pain is beyond medical dispute.

"the drug-testing business has never been better"

Apparently, drug-test sales to parents have never been better. This article provides a little discussion of the costs.

Smoking bans

The Toledo Blade reports that Ohio's new smoking ban is resulting in an increase in enrollment in smoking cessation services.

Meanwhile, the Guardian has a point/counterpoint commentary on smoking bans. Christopher Hitchens writes in opposition to bans in his usual style.

Pocket Shot | Goes Anywhere - New Packaging Category

This packaging/marketing strategy of a "flask on the fly" will appropriately raise eyebrows. [hat tip: Jim via Alcohol Reports]

Pope: God Will Punish Drug Dealers

You'd hope that a papal visit to a treatment program would result in a headline focused on hope and recovery rather than vengeance. Let's hope that the headline doesn't accurately reflect the content of the visit. [hat tip: Matt]
[Update: link was broken and I was unable to find the original article. This one discusses he broader concerns about Brazilian culture, but is similar. It appears that he also gave the program $100,000. 5/13/07]

Canada's Cracked-Out Capital

An audio slideshow from the Toronto Globe and Mail. [hat tip Anna]

The crisis that never came

A good reminder of how intense and how wrong the "crack baby" hype was.

Interesting public policy finding?

An alcohol ban in some Canadian provincial parks resulted in big reductions in complaints, vandalism and damages:

...the number of individuals evicted from parks was down by 84%; public complaints were down by 91%; vandalism was reduced by 96%; and, cost of damages was down by 97%.

I wonder is this generalizable or if it was related to a local problem.

Spiritual beliefs, practices may help smokers quit

Shocking. Spiritual smokers, who are trying to quit, believe that their spirituality may be helpful in their attempt to quit.

OxyContin maker misled on addiction risks

OxyContin maker misled on addiction risks:

The maker of the powerful painkiller OxyContin and three of its current and former executives pleaded guilty Thursday to misleading the public about the drug’s risk of addiction, a federal prosecutor and the company said.

Purdue Pharma L.P., its president, top lawyer and former chief medical officer will pay $634.5 million in fines for claiming the drug was less addictive and less subject to abuse than other pain medications, U.S. Attorney John Brownlee said in a news release.

The plea agreement comes two days after the Stamford, Conn.-based company agreed to pay $19.5 million to 26 states and the District of Columbia to settle complaints that it encouraged physicians to overprescribe OxyContin.

"Be in charge of your drug use!"

This article exemplifies what's wrong with a lot of harm reduction activism and (unfortunately) the reporting of the alternative press.

• The anecdotal report of a program focusing on 12 to 23 year old sex workers from Chicago is presented as "shooting down" hype around the Monitoring the Future survey.
• They present any increase in use of painkillers as prescribed medical use. Past year non-medical use of painkillers by 18-25 year olds is at 11.9%. I find that shockingly high.
• They characterize drug use and sex work by the women in the story as a simple lifestyle choice. I'm all for reducing stigma, but let's treat these women the way we'd want our sisters and daughters treated. Treat them with acceptance and compassion--and get them help. Some of these girls are in their early teens.
• Talking about how great it is that these kids are better educated about the drugs they are using.
  
• Telling a 13 year old to "be in charge of [her] drug use."

Self-Esteem not a predictor of relapse

A new study finds that self-esteem is not a predictor of relapse:

This study investigates whether self-esteem is associated with clinical and demographic characteristics, self-efficacy expectancies, and post-treatment drinking outcomes. Forty-one (40.6%) women and 60 (59.4%) men were recruited during inpatient alcohol dependence treatment. At baseline, lower self-esteem was significantly associated with current depression and other psychiatric disorders. Self-esteem was not related to gender, relapse, other one-year drinking outcomes, or self-efficacy. Age and psychiatric disorders were strong predictors of self-esteem at follow-up. This study suggests that different perceptions of the self have unique roles in recovery from alcohol use disorders.

Sexual Abuse and the Outcome of Addiction Treatment

This study's conclusion is surprisingly frequent. The first time I saw a study with this finding, I assumed it was an abberation, but I continue to see similar findings published:

The objective of this prospective follow-up study was to examine the effects of sexual abuse on substance use disorder patients' clinical presentation and course in treatment. Consecutive admissions to the MUHC's Addictions Unit were assessed at intake (N = 206) and six-month follow-up (n = 172). Assessments evaluated socio-demographic and psychiatric characteristics, addiction severity, and physical and/or sexual abuse histories. Upon entering treatment, 23% reported prior sexual abuse with or without physical abuse. Patients with a sexual abuse history had higher rates of psychological problems, stronger family histories of substance use disorders, and more impaired family relationships. At six months, there were no differences between patients with and without sexual abuse histories in their response to treatment, or their utilization of treatment services. The current study failed to show that prior sexual abuse compromised short-term treatment outcomes.

Treatments for patients with dual diagnosis: a review

A research review finds evidence for intregrated treatment wanting:

BACKGROUND: Comorbid substance use and mental illness is prevalent and often results in serious consequences. However, little is known about the efficacy of treatments for patients with dual diagnosis. METHODS: This paper reviews both the psychosocial and medication treatments for those diagnosed with a substance-related disorder and one of the following disorders: (a) depression, (b) anxiety disorder, (c) schizophrenia, (d) bipolar disorder, (e) severe mental illness, and (f) nonspecific mental illness. We made no restriction of study design to include all published studies, due to the dearth of studies on treatments of patients with dual diagnosis. RESULTS: Fifty-nine studies were identified (36 randomized-controlled trials; RCT). Limited number of studies, especially RCTs, have been conducted within each comorbid category. This review did not find treatments that had been replicated and consistently showed clear advantages over comparison condition for both substance-related and other psychiatric outcomes. CONCLUSIONS: Although no treatment was identified as efficacious for both psychiatric disorders and substance-related disorder, this review finds: (1) existing efficacious treatments for reducing psychiatric symptoms also tend to work in dual-diagnosis patients, (2) existing efficacious treatments for reducing substance use also decrease substance use in dually diagnosed patients, and (3) the efficacy of integrated treatment is still unclear. This review provides a critique of the current state of the literature, identifies the directions for future research on treatment of dual-diagnosis individuals, and calls for urgent attention by researchers and funding agencies to conduct more and more methodologically rigorous research in this area.

Any DF employee who would like the full text should email me.

With friends like these...

From The Canadian Journal of Psychiatry:

In what amounts to a historical anomaly, the mental health community was (and in many jurisdictions still is) disenfranchised as the primary and rightful custodian for the treatment of this disease.

...

For the minority of “addicts” with access to addiction treatment, such treatment is often exceedingly costly and representative of inequitable practices that may be fraudulent, unaccountable, or perhaps even dangerous. Programs are frequently delivered by individuals in addiction recovery themselves, with limited training except by virtue of their own experience. Compounding this, many addiction workers (without formal psychiatric training) remain distrustful of psychiatry because of the use of what they perceive to be mind-altering drugs, and some see psychopathology as merely a direct manifestation of drug use. The general lack of attention to minimum standards for education and training, credentialing, addiction-treatment expenditures, and outcome measurement are all symptomatic of the system’s failure.

The status quo creates unrealistic expectations for the health care system to deliver curative interventions instead of prevention.

Not a whole lot to say is there? I'm not very familiar with the Canadian addiction treatment system, but this article exemplifies my fears of service integration--that service integration will never be a merger of equals, rather it will be the mental health system devouring the addiction treatment system.

Alcohol: the solution

Robin Room is probably the most respected expert on drug policy in the world. I haven't looked hard, but it seems that it's rare to get his thoughts in brief, digestible pieces. This article includes some of his thoughts about Australian alcohol policy. It appears that much of what's said could also apply to the U.S.:

There is a recurring problem in the attempt to reduce alcohol harm. "What's popular doesn't work and what works isn't popular," according to internationally renowned alcohol policy researcher Professor Robin Room, the president of the Alcohol and Other Drugs Council of Australia.

High-profile media campaigns urging the public to drink responsibly are far less effective than reducing density of alcohol outlets, restricting trading hours and increasing taxes, he argues.

But despite international evidence proving the success of such measures, the industry is not supportive.

"I don't think it helps that the Federal Government put $5 million into Drinkwise, an industry-funded organisation meant to educate the public about responsible alcohol use. Fundamentally, the industry's interest is in channelling any concerns about alcohol into strategies that won't affect their bottom line," said Professor Room.

Breaking down Federal Government guidelines on safe drinking by age group has also been suggested.

The guidelines recommend no more than four standard drinks a day and no more than 28 standard drinks over a week for men. Women should have an average of no more than two a day and no more than 14 over a week. One or two alcohol-free days a week are recommended.

"The national guidelines are based on people of average size under 65. As people get older, their body mass and muscle decline and they may well be in ill health and on medication. Should the national guidelines apply? We don't know," said Professor Steve Allsop, director of the National Drug Research Institute.

Alcohol Abuse Is All in the Family But Not for Expected Reason

Alcoholism and love:

One of the more interesting findings to emerge from this analysis was that 38 percent of substance abusers had a spouse who abused substances, compared with only 12 percent of controls. In contrast, only 24 percent of individuals with signs of an anxiety disorder had a spouse who also appeared to have an anxiety disorder, which was comparable to the 20 percent rate for spouses in the control group.

So it looked as though substance abusers often were married to abusers and that the chances of this happening seemed to be greater than the chances of people with serious anxiety being married to spouses with serious anxiety.

But actually what were the chances? When the researchers undertook further analyses, they found that such a likelihood was significant: the chance of spouses of substance abusers also being substance abusers was eight times greater than the chance of the spouses of nonabusers being substance abusers. Moreover, this finding meshed with those of previous investigations that found an odds ratio for spousal concordance in substance abuse of between 3 and 12. In contrast, Low and her colleagues could find no spousal agreement for anxiety disorders. Previous inquiries that looked for such a link also failed to find one.

So if substance abusers are often married to substance abusers, the question is why. Low and her colleagues found that 71 percent of individuals who had substance abuse problems had developed them before "tying the knot," and that 64 percent of spouses who abused substances had also done so before marrying the current partner. This finding implied that one abusing partner did not "infect" the other, but rather that there was something about their premarital status that brought them together. But what was it? A shared passion for alcohol or some other substance? A mutual expectation that heavy drinking or other substance abuse was a part of life, therefore making them feel at ease with each other? Perhaps, Low told Psychiatric News, but it is also possible that abusers may end up paired with abusers because nonabusers shun them as partners.

Not news to anyone familiar with the concept of a culture of addiction.

SSRIs and CBT

First, a review of data on SSRIs finds that benefits outweigh the risks:

"Antidepressants are effective in treating disorders such as anxiety, obsessive-compulsive disorder, and depression," said David Brent, M.D., one of the study's investigators, in an interview with Psychiatric News. While he said that they found a small risk associated with developing suicidal thoughts or behaviors in children and adolescents, he noted, "it would be much riskier not to treat them with these medications."

Placebo works pretty well for depression too.

Another study finds CBT is as effective in treating depression, but was less accepted by patients as a treatment option:

Less than one-third of subjects in a federally funded study of depression treatment consented to try cognitive therapy after discontinuing the antidepressant citalopram either because the medication was not effective or because side effects were intolerable. However, the outcomes among those who did consent to cognitive therapy and who were ultimately randomized into it proved to be comparable to those of all the pharmaceutical options.

Insite strikes back!

Insite strikes back:

Dr. Thomas Kerr, a research scientist at the B.C. Centre for Excellence in HIV/AIDS, said Thursday that a study in the new online Journal of Global Drug Policy and Practice is merely a commentary about Insite, North America's first such facility.

"He writes opinion pieces, he doesn't do research," Kerr said of Colin Mangham, who authored the study published Wednesday.

Depression and the Initiation of Alcohol and Other Drug Use among Youths Aged 12 to 17

Kids who have had an episode of depression are more likely to initiate drug use than kids who have not experienced an episode of depression. It suggests there's a sequence, but doesn't explicitly say so--I suspect that it is not reporting on a sequential pattern but kids who reported depression and substance use initiation in the past year.

Clinical importance of caffeine dependence and abuse

A new journal article makes the case that caffeine dependence exists and is clinically significant. That'll generate some eye rolls.

I'd love to see some meaningful research on the impact (or lack of impact) of caffeine use on recovery. Please send it if you're aware of any.

Report suggests B.C.'s safe-injection site a failure

A new, highly critical, paper has been published about the safe injection center (INSITE) in Vancouver. The author has a clear bias against harm reduction and for treatment and primary prevention. His approach in the paper is to pick apart the pro-INSITE bias in research and media coverage.

In my opinion, he's pretty effective. One gripe I have about it is that both sides assume a posture of besieged minority. Both sides have some points and my biases lean in one direction, but it's really pretty tiresome. Here's a news article about the paper. Here's the paper itself.

Pain Doctor Is Guilty of Drug Trafficking

This conviction is getting a lot of attention and is being painted as a very important and influential verdict. I don't know enough to express an informed opinion, but this doctor is being painted as a criminal drug dealer and alternately as a noble servant of unwanted and neglected patients.

Cocaine Prices Dropping, Purity Rising, ONDCP Admits

Troubling, from the ONDCP. First, the spin of the ONDCP is always troubling. Second, in the mid-1990s, heroin purity increased and price dropped. This led to greater use and experimentation among young people. Heroin no longer needed to be injected for any significant effect, it could be smoked or snorted, lowering the initiation threshold.

So-called low-risk drinking isn't

It looks like the benefits of moderate drinking are hyped:

Focusing their findings on Canadian statistics, researchers found that while more than 800 premature deaths were prevented each year due to the benefits of moderate drinking, that same type of consumption caused 2,800 premature deaths.

That means a net of 2,000 people die of so-called low-risk drinking annually in Canada, Stockwell said. Add to that 5,300 deaths a year due to high-risk drinking and it turns out more than 7,000 people die prematurely each year due to the ill-effects of alcohol use.

Those deaths include such things as motor vehicle accidents, alcohol-related cancers and liver disease.

Low-risk drinking is defined by researchers as no more than an average of two standard drinks for women, three for men.

I checked out the source, just to see if they were ideologically motivated group. Turns out they are very active in harm reduction activities.

Pot news roundup

First, there are are new studies looking at the effects of two of the major chemical agents in weed. Not surprisingly, THC induced psychotic symptoms in subjects. These were particularly pronounced in schizophrenic subjects. However, another chemical, cannabidiol (CBD), had antipsychotic properties without the side effects of commonly used antipsychotics. What's interesting is the attention that the CBD findings get in various news reports. Some report on these findings as a potential breakthrough, while others emphasize the harmful effects of THC and simply describe CBD as having a relaxing effect.

The Transform Drug Policy Foundation blog has a post on the potency hype promulgated by UK and US government agencies.

Finally, Join Together reports on a recent article about the challenges for parents who smoke pot when responding to their teens who are smoking pot. The article seems to highlight the youth oriented harm reduction approach of the Drug Policy Alliance.