Quitting smoking makes you happier

One more reason to quit smoking:

New survey results from Cancer Research UK, published today, should allay the fears of smokers who think giving up will make their lives a misery.

Of more than 850 ex-smokers surveyed, the vast majority reported feeling happier having beaten their addiction. Only a tiny fraction said they felt less happy.

Researchers Identify Alcoholism Subtypes

What's your type?

Analyses of a national sample of individuals with alcohol dependence (alcoholism) reveal five distinct subtypes of the disease, according to a new study by scientists at the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health (NIH).

“Our findings should help dispel the popular notion of the ‘typical alcoholic,’” notes first author Howard B. Moss, M.D., NIAAA Associate Director for Clinical and Translational Research. “We find that young adults comprise the largest group of alcoholics in this country, and nearly 20 percent of alcoholics are highly functional and well-educated with good incomes. More than half of the alcoholics in the United States have no multigenerational family history of the disease, suggesting that their form of alcoholism was unlikely to have genetic causes.”

“Clinicians have long recognized diverse manifestations of alcoholism,” adds NIAAA Director Ting-Kai Li, M.D, “and researchers have tried to understand why some alcoholics improve with specific medications and psychotherapies while others do not. The classification system described in this study will have broad application in both clinical and research settings.” A report of the study is now available online in the journal Drug and Alcohol Dependence.

Here are the subtypes:

Young Adult subtype: 31.5 percent of U.S. alcoholics. Young adult drinkers, with relatively low rates of co-occurring substance abuse and other mental disorders, a low rate of family alcoholism, and who rarely seek any kind of help for their drinking.

Young Antisocial subtype: 21 percent of U.S. alcoholics. Tend to be in their mid-twenties, had early onset of regular drinking, and alcohol problems. More than half come from families with alcoholism, and about half have a psychiatric diagnosis of Antisocial Personality Disorder. Many have major depression, bipolar disorder, and anxiety problems. More than 75 percent smoked cigarettes and marijuana, and many also had cocaine and opiate addictions. More than one-third of these alcoholics seek help for their drinking.

Functional subtype: 19.5 percent of U.S. alcoholics. Typically middle-aged, well-educated, with stable jobs and families. About one-third have a multigenerational family history of alcoholism, about one-quarter had major depressive illness sometime in their lives, and nearly 50 percent were smokers.

Intermediate Familial subtype: 19 percent of U.S. alcoholics. Middle-aged, with about 50 percent from families with multigenerational alcoholism. Almost half have had clinical depression, and 20 percent have had bipolar disorder. Most of these individuals smoked cigarettes, and nearly one in five had problems with cocaine and marijuana use. Only 25 percent ever sought treatment for their problem drinking.

Chronic Severe subtype: 9 percent of U.S. alcoholics. Comprised mostly of middle-aged individuals who had early onset of drinking and alcohol problems, with high rates of Antisocial Personality Disorder and criminality. Almost 80 percent come from families with multigenerational alcoholism. They have the highest rates of other psychiatric disorders including depression, bipolar disorder, and anxiety disorders as well as high rates of smoking, and marijuana, cocaine, and opiate dependence. Two-thirds of these alcoholics seek help for their drinking problems, making them the most prevalent type of alcoholic in treatment.

Does anyone else detect a whiff of countertransferance?

How Greenland curbed alcohol abuse

An interesting alcohol policy story from Greenland:

Alcohol abuse causes tremendous damage in Greenland...

But the solution chosen by Greenland's government for its most remote communities is not prohibition, which it acknowledges does not work, and only encourages bootlegging and the binge drinking of hard liquor. It's to ban hard liquor, but allow the sale of beer and wine.

Qaanaaq, a community of 800 near Thule on Green­land's west coast, is following this path after the government recently agreed to lift a two-month ban on alcohol.

The ban was prompted by a sociologist's report that described a community where alcohol abuse was so rampant children were often afraid to return home because their parents were drunk day and night.
...
Across Greenland, alcohol consumption has dropped dramatically since booze bans were lifted in many communities in 1982. At that time, residents consumed, on average, 22 litres of alcohol each year. That has since dropped to 13 litres.

That's still a lot compared to Canada, where the average resident drinks only eight litres of alcohol a year. But it's a huge improvement for Greenland, says Bodil Poulsen, an alcohol abuse worker with Greenland's health department.

Acetaminophen safe in abstinent alcoholics

From Reuters:

Alcoholics undergoing rehabilitation can safely use the maximum recommended daily dose of acetaminophen (Tylenol) without damaging their livers, study results suggest.

Isolated case reports have linked severe liver damage among alcoholics who abruptly stopped using alcohol and were treated with acetaminophen. Theoretically, the period of greatest risk would be right after they stopped drinking, based on various biochemical changes that take place.

...

"No participant suffered acetaminophen-related liver injury," the authors report.

Dart and his team point out that their findings can not be generalized to all alcoholic patients. They did not include patients with liver disease severe enough to impair liver function, patients who continued to drink alcohol, or individuals affected by either intentional or unintentional overdoses.

They worry that if told to avoid acetaminophen, patients who drink alcohol would be likely to use aspirin or other nonsteroidal anti-inflammatory medications, such as ibuprofen (Motrin, Advil), which are far more risky.

Psychiatrists Top List in Drug Maker Gifts

From the New York Times:

As states begin to require that drug companies disclose their payments to doctors for lectures and other services, a pattern has emerged: psychiatrists earn more money from drug makers than doctors in any other specialty.
...
Officials in Maine and Vermont said they would try to compare reports of payments to doctors with Medicaid records to explore how marketing practices might influence prescribing by doctors in ways that increased costs to taxpayers.

“What we want to be able to do is overlay the prescribing information that we have with the drug detailing information,” said Jude Walsh, special assistant to the governor of Maine, John E. Baldacci. “If we see that doctors in a certain southern county in the state are prescribing a lot of a drug and getting a lot of detailing for that drug, that could lead to some record reviews to see what’s happening.”

Addiction experts say video games not an addiction

Contrary to anecdotal evidence from college dorms and parents of adolescent boys, the APA makes a decision on video game "addiction". It appears that Super Mario will not need to be scheduled by the DEA.

Doctors backed away on Sunday from a controversial proposal to designate video game addiction as a mental disorder akin to alcoholism, saying psychiatrists should study the issue more.

Addiction experts also strongly opposed the idea at a debate at the American Medical Association's annual meeting.

Read the rest here.

The New York Times reports that global drug production and consumption is stable at the moment.
[hat tip: Matt]

Bong hits for Jesus

For those who don't know, the U.S. Supreme Court ruled that a school was within it rights to limit student speech when it confiscated a student's banner that said "bong hits for Jesus."

The Wall Street Journal highlighted some of Justice Stevens comments that compared the war on drugs, as it relates to marijuana, to prohibition:

...“Although this case began with a silly, nonsensical banner, it ends with the Court inventing out of whole cloth a special First Amendment rule permitting the censorship of any student speech that mentions drugs, at least so long as someone could perceive that speech to contain a latent pro-drug message,” he writes. “Our First Amendment jurisprudence has identified some categories of expression that are less deserving of protection than others—fighting words, obscenity, and commercial speech, to name a few.” Justice Stevens then mentions some “personal recollections” that have influenced his view that it’s unwise to create special rules for drug- and alcohol-related speech:

“. . . The current dominant opinion supporting the war on drugs in general, and our anti-marijuana laws in particular, is reminiscent of the opinion that supported the nationwide ban on alcohol consumption when I was a student. While alcoholic beverages are now regarded as ordinary articles of commerce, their use was then condemned with the same moral fervor that now supports the war on drugs. The ensuing change in public opinion occurred much more slowly than the relatively rapid shift in Americans’ views on the Vietnam War, and progressed on a state-by-state basis over a period of many years. But just as prohibition in the 1920’s and early 1930’s was secretly questioned by thousands of otherwise law-abiding patrons of bootleggers and speakeasies, today the actions of literally millions of otherwise law-abiding users of marijuana, and of the majority of voters in each of the several States that tolerate medicinal uses of the product, lead me to wonder whether the fear of disapproval by those in the majority is silencing opponents of the war on drugs. Surely our national experience with alcohol should make us wary of dampening speech suggesting —however inarticulately — that it would be better to tax and regulate marijuana than to persevere in a futile effort to ban its use entirely.

. . . In the national debate about a serious issue, it is the expression of the minority’s viewpoint that most demands the protection of the First Amendment. Whatever the better policy may be, a full and frank discussion of the costs and benefits of the attempt to prohibit the use of marijuana is far wiser than suppression of speech because it is unpopular.

Fentanyl: A Free Press Special Report

The Detroit Free Press is running a 15 part series on fentanyl in the Detroit area.

Smoking rate has plummeted in New York City

This is significant because there have been a lot of reports that smoking reduction efforts have hit a wall in recent years:

New York City's smoking rate has plummeted since a comprehensive program against smoking was launched in 2002, according to findings issued today in the national Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report (MMWR). The 2006 rate was nearly 20% lower than the 2002 rate -- a decline that represents 240,000 fewer smokers. The City's rate for 2006 is the lowest on record (17.5%), and lower than all but five U.S. states (California, Washington, Idaho, Utah and Connecticut). Over the past year, smoking decreased among men (from 22.5% to 19.9%) and among Hispanics (from 20.2% to 17.1%). These large declines followed a year-long ad campaign aimed at prompting more smokers to quit.

Read the rest here.

Is video game addiction a psychiatric disorder? AMA report seeks to declare it one

Oy vey.

Backlash on bipolar diagnoses in children

I tried to pull excerpts from this but had too difficult a time finding stuff to excise. Consider this a teaser and take the time to read the full article:

No one has done more to convince Americans that even small children can suffer the dangerous mood swings of bipolar disorder than Dr. Joseph Biederman of Massachusetts General Hospital.

From his perch as one of the world's most influential child psychiatrists, Biederman has spread far and wide his conviction that the emotional roller coaster of bipolar disorder can start "from the moment the child opened his eyes" at birth. Psychiatrists used to regard bipolar disorder as a disease that begins in young adulthood, but now some diagnose it in children scarcely out of diapers, treating them with powerful antipsychotic medications based on Biederman's work.

"We need to treat these children. They are in a desperate state," Biederman said in an interview, producing a video clip of a tearful mother describing the way her preschool daughter assaulted her before the child began treatment for bipolar disorder. The chief of pediatric psychopharmacology at Mass. General, he compares his work to scientific break throughs of the past such as the first vaccinations against disease.

But the death in December of a 4-year-old Hull girl from an overdose of drugs prescribed to treat bipolar disorder and attention deficit hyperactivity disorder has triggered a growing backlash against Biederman and his followers. Rebecca Riley's parents have been charged with deliberately giving the child overdoses of Clonidine, a medication sometimes used to calm aggressive children. Still, many wondered why a girl so young was being treated in the first place with Clonidine and two other psychiatric drugs, including one not approved for children's use. Riley's psychiatrist has said she was influenced by the work of Biederman and his protege, Dr. Janet Wozniak.

"They are by far the leading lights in terms of providing leadership in the treatment of children who have disorders such as bipolar," said J. W. Carney Jr., lawyer for Dr. Kayoko Kifuji, a Tufts-New England Medical Center psychiatrist who temporarily gave up her medical license after Riley died on Dec. 13, 2006. "Dr. Kifuji subscribes to the views of the Mass. General team."

Part of the criticism of Biederman speaks to a deeper issue in psychiatry: the extensive financial ties between the drug industry and researchers. Biederman has received research funding from 15 drug companies and serves as a paid speaker or adviser to seven of them, including Eli Lilly & Co. and Janssen Pharmaceuticals, which make the multi billion-dollar antipsychotic drugs Zyprexa and Risperdal, respectively. Though not much money was earmarked for bipolar research, critics say the resources help him advance his aggressive drug treatment philosophy.

Numerous psychiatrists say Riley's overdose suggests that bipolar disorder is becoming a psychiatric fad, leaving thousands of children on risky medications based on symptoms such as chronic irritability and aggressiveness that could have other causes. Riley's father, for example, had only recently returned to the home after being accused of child abuse, according to police. Since the girl's death, state officials have stepped up a review of the 8,343 children taking the latest antipsychotic medications under the Medicaid program for conditions including bipolar disorder, to be sure the treatment is appropriate.

Psychiatrists too often prescribe th
ese medications, which carry side effects such as weight gain and heart disease risk, without addressing problems in the children's lives, said Dr. Gordon Harper, director of child and adolescent services at the state Department of Mental Health. He likened the approach to "tuning the piano while the subway is going by."

Aggressive treatment
Biederman's critics chide him for not speaking out against misuses of a diagnosis that he has helped inspire. Among leading authorities on bipolar disorder, the Mass. General team has proposed the most aggressive treatment for the broadest group of children, they say, and Biederman should take responsibility when treatment goes wrong. At a conference on bipolar disorder at Pittsburgh's Point Park University last weekend, one speaker, Dr. Lawrence Diller, a California behavioral pediatrician, contended that Biederman bears some blame for Riley's death.

"I find Biederman and his group to be morally responsible in part," said Diller, whose popular book, "Running on Ritalin," accused psychiatrists of over treating another childhood condition, attention deficit hyperactivity disorder. "He didn't write the prescription, but he provided all the, quote, scientific justification to address a public health issue by drugging little kids."

Biederman rejects the idea that Riley's death is a cautionary tale, accusing critics of exploiting a tragedy to fan fears about psychiatry, a profession that has long faced prejudice. "The fact that she had XY drug or XY treatment is irrelevant to what happened. . . . If this child had the same outcome from treatment for asthma or seizures, we wouldn't have this frenzy," said Biederman in an interview at Mass. General's Cambridge mental health clinic.

Though Biederman acknowledges that distinguishing bipolar disorder from ordinary crankiness and flights of fancy in young children is challenging, he insists there is no ambiguity in the patients at his practice. "People have to wait a long time to see me or my colleagues. . . . It's not that somebody comes to me after their child has a temper tantrum. They do things for years that are dangerous. These are things that profoundly affect the child," said Biederman, putting them at risk of academic failure or even suicide.

Biederman dismisses most critics, saying that they cannot match his scientific credentials as co author of 30 scientific papers a year and director of a major research program at the psychiatry department that is top-ranked in the "US News & World Report" ratings.

The critics "are not on the same level. We are not debating as to whether [a critic] likes brownies and I like hot dogs. In medicine and science, not all opinions are created equal," said Biederman, a native of Czechoslovakia who came to Mass. General in 1979 after medical training in Argentina and Israel. He now lives in Brookline.

Read the rest here.

Exploring the process of recovery through patient testimonials

Relapse predicted by profanity and unoriginal sharing? I guess my recovery is more miraculous than I realized.

Does Stimulant Treatment for ADHD Increase Risk of Drug Abuse?

It depends. (Keep in mind that lower levels of dopamine D2 receptors has been associated with addiction.):

After two months of treatment, and again after eight months, the scientists performed positron emission tomography (PET) scans to measure the levels of dopamine D2 receptors, a type of brain receptor important for experiencing reward and pleasure that has been linked to pleasure and drug abuse. After the eight-month treatment, animals were also tested for their propensity to self-administer cocaine.

Rats given the 2mg/kg dose of methylphenidate were significantly less likely to press a lever to self-administer cocaine, and received fewer self-initiated infusions of the drug following eight months of treatment than the lower-dose group or the control rats.

The changes observed in brain chemistry were specific to the age and duration of methylphenidate treatment: Specifically, after two months of treatment, brain scans revealed that both groups of treated rats had lower levels of dopamine D2 receptors in their brains than did control animals.

In contrast, after eight months of treatment, the brain scans revealed elevated levels of dopamine D2 receptors in treated rats compared with controls, with the higher-dose treatment group showing the highest level of D2 receptors. In the control group, D2 receptor levels declined with age. Research at Brookhaven and elsewhere has suggested that low levels of dopamine D2 receptors may increase the likelihood of drug abuse, while elevated levels of dopamine D2 receptors may attenuate the propensity to abuse drugs.

Read the rest here.

Substance abuse care environment "toxic" for people in recovery

Substance Abuse and Mental Health Care Environment "Toxic" for Persons in Recovery and Those Working in the Field (PDF, 1 page)
[hat tip: CCSA.ca]

Best anti-pot ad ever Redux

Message board reactions to The best anti-pot ad ever:

Anti-marijuana ads by stoners and for stoners? Bud-blazer Seth Stevenson gives the latest weed-whacking ads an "A" for effectiveness, declaring the newest campaign The Best Anti-Pot Ad Ever. He lauds these ads for steering away from the alarmism of previous spots, and sticking to the more modestly realistic claims that pot can cause aliens to steal your girlfriend or maybe disappoint your dog. Color me dubious that the same primal fears which sell toothpaste and deodorant—getting dumped and making a poor impression—will have any special cachet with the stoner set.

The merits of this argument, however, get lost in the haze of smoke rising from Slate's basement apartment, The Fray. Legions of readers seem to be lit up over the mere concept of opposing marijuana use. Rather than discouraging stoners, the ads have only incensed them. Buried among the tirades for legalization, there are some rather astonishing testimonials—one poster claims to have risen from his wheelchair and surfed the swells of hurricanes under the curative powers of the magic herb. I'm not saying he didn't... but his story lends credibility to mnloft's harrowing tale of a teenage son literally gone psycho under the influence of weed. Doesn't every stoner know one kid who couldn't quite hack it?

Amidst all the swirling color, some actual discussion of the article and the ads has taken place. First-time Frayster, eek223, provides a fairly representative reaction to the ads from a teenaged perspective—apparently, low-budget isn't "hip" with the upcoming generation. bluebird makes a solid point that all such commercials inspire the inevitable adolescent question: "Who's 'The Man' behind the curtain?" (If this point interests you, check out this post from Melvyl.) Based on her personal experience, queentutt figures mass-media might as well be broadcasting from the dark side of the moon, given how poorly it connects with contemporary kids. In a reasonably fair critique of Stevenson's article, figgyforcurt worries about short-term memory loss among anti-drug advertisers:

This article would've been better written if it explored the dilemma of sending mixed messages to kids by drastically changing "brand messaging." Think about it. One year ago, an anti-marijuana ad tells kids they're going to get high and kill a toddler, and the next year, an ad tells them they'll be uninteresting. If I were a teen and I'd seen both sets of ads, I'd dismiss both, because I'd see through the fact that a thinking man on the other end of the ad is trying to tell me why something is bad but can't figure out why exactly it is bad. This is the "fundamental mistake" this writer made in writing this article, dismissing the fact that those old ads do exist, and have impacted teens. Failing to consider that no matter how effective these ads appear, they must be considered as inconsistent in the larger framework of the anti-marijuana ad context.

Personally, I'd hope the best way to scare cynical teens straight would involve showing them the perils of earnest drug culture—NORML parties. In the meantime, responsible adults would be welcome in the Ad Report Card Fray. If you don't show up, someone's kids will be getting the unchallenged word on drugs from folks like this...GA …

The best anti-pot ad ever

From Slate.com:

Until recently, most anti-marijuana ads made the same fundamental mistake: They tried to link smoking weed with some sort of immediate physical danger. Think of the PSA in which a carful of stoners runs over a girl on a bicycle; or the one in which a fuzzy-brained pot smoker shoots his friend (oopsy daisy!) in the head. Melodramatic scare tactics like these may reassure the older, out-of-touch politicians who approve federal funding for anti-drug ads. But when it comes to a drug like weed, this message just doesn't ring true with the people it's meant to reach.

"It's easy to do ads about drugs like heroin and meth, and the awful consequences that manifest," says Tom Riley, director of public affairs at the Office of National Drug Control Policy. "It's harder to make ads about marijuana. 'Marijuana's gonna melt your face off' isn't really a credible thing to say to teens."

This realization—the result, according to Reilly, of stepped-up research into the mindset of the 13- to 17-year-old target market (though I could have saved them a pile of money if they'd just asked me)—has led to a far more soft-pedal approach of late. Consider "Pete's Couch": In this anti-pot PSA, the major immediate danger posed by smoking weed is that you might sit around on your sofa for 11 hours straight. The ad won points with me for its honesty (I've blazed away a few couch-bound afternoons of my own). But I doubt the specter of inactivity is a deterrent for the average teen. With the advent of instant messaging, on-demand digital cable, and really awesome video games, I get the sense that modern youth sees no downside to spending entire fortnights immobile on an overstuffed cushion.

This new campaign opts for slightly scarier scare tactics. Again, though, the nature of the threat is subtler and more realistic. (Well, as realistic as an ad that features space aliens can be.) There's no fatal car crash or gun accident—that kind of acute disaster would never enter into the cost/benefit analysis a teen might run before getting high. Instead, the frightening possibility posited here is that smoking weed will make you boring to be around. The animated lass in the ad described above seems fed up with her stoner boyfriend—her one line of dialogue is the ad's title: "Not again"—and she's quick to ditch him when that straight-edge alien dude happens along.

Read the rest here.

The ads themselves can be viewed here and here.

When Is a Pain Doctor a Drug Pusher?

The NYT ran an exhaustive article today on a the recent conviction of a pain management doctor for his prescribing practices. The article provides a lot of background and wrestles with many of the big questions:

...most doctors prescribe opioids conservatively, and many patients and their families are just as cautious as their doctors. Men, especially, will simply tough it out, reasoning that pain is better than addiction.

It’s a false choice. Virtually everyone who takes opioids will become physically dependent on them, which means that withdrawal symptoms like nausea and sweats can occur if usage ends abruptly. But tapering off gradually allows most people to avoid those symptoms, and physical dependence is not the same thing as addiction. Addiction — which is defined by cravings, loss of control and a psychological compulsion to take a drug even when it is harmful — occurs in patients with a predisposition (biological or otherwise) to become addicted. At the very least, these include just below 10 percent of Americans, the number estimated by the United States Department of Health and Human Services to have active substance-abuse problems. Even a predisposition to addiction, however, doesn’t mean a patient will become addicted to opioids. Vast numbers do not. Pain patients without prior abuse problems most likely run little risk. “Someone who has never abused alcohol or other drugs would be extremely unlikely to become addicted to opioid pain medicines, particularly if he or she is older,” says Russell K. Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center in New York and a leading authority on the treatment of pain.

I've had several recent posts on opioids and pain and have wondered how common these prosecutions are. The article offers some perspective on the question:

How typical is McIver’s case? On the D.E.A.’s Web site the agency lists some of the doctors who have been prosecuted, and their crimes. There are some strikingly obvious and egregious cases of shady dealings: a doctor who wrote prescriptions in a gas station for a person who wasn’t present; one who sold blank prescription forms; one who dispensed drugs to people who then shared them with him.

But not every doctor’s intent to deal drugs is as clear. McIver was a crusader for high-dose opioids, credulous with patients and sloppy with documentation — a combination unwise in the extreme. But some of his patients said he was the only doctor who ever brought them relief. Prosecutors never brought any evidence that he intended to write prescriptions to be abused or sold. They never accused him of profiting from his patients’ diversion except in collecting office fees. His patients who diverted or abused their opioids all testified they got their prescriptions by consistently lying to him. Nor is it convincing that his prescriptions killed Larry Shealy.

No one has analyzed the various prosecutions of pain doctors, so it is hard to determine how many of them look like McIver’s. The D.E.A.’s list is incomplete. There have been many cases like McIver’s, and most of these cases are not listed on the D.E.A.’s Web site. (One possible reason for this omission is that some of these cases are still being appealed.) And many cases that do appear on the list detail only vague crimes: convictions for prescribing “beyond the bounds of acceptable medical practice” or “dispensing controlled substances . . . with no legitimate medical purpose” — which is how the agency will most likely describe the McIver case if it ever includes the case on the list.

The D.E.A. claims that it is not criminalizing bad medical decisions. For a prosecutable case, Caverly, the D.E.A. officer, told me: “I need there to be no connection of the drug with a legitimate medical condition. I need the doctor to have prescribed the drug in exchange for an illegal drug, or sex, or just sold the prescription or wrote prescriptions for patients they have never seen, or made up a name.”

I read this statement to Jennifer Bolen, a former federal prosecutor in drug-diversion cases who trained other prosecutors and now advises doctors on the law. “That’s a good goal,” she said. “I don’t think they have yet reached that goal.” McIver’s case had no such broken connection, and in many cases the government has not produced testimony of intent to push drugs, providing evidence only of negligence or recklessness.

The author provides some recomendations for law enforcement and medical review:

The dilemma of preventing diversion without discouraging pain care is part of a larger problem: pain is discussed amid a swirl of ignorance and myth. Howard Heit, a pain and addiction specialist in Fairfax, Va., told me: “If we take the fact that 10 percent of the population has the disease of addiction, and if we say that pain is the most common presentation to a doctor’s office, please tell me why the interface of pain and addiction is not part of the core curriculum of health care training in the United States?” Will Rowe, the executive director of the American Pain Foundation, notes that “pain education is still barely on the radar in most medical schools.”

The public also needs education. Misconception reigns: that addiction is inevitable, that pain is harmless, that suffering has redemptive power, that pain medicine is for sissies, that sufferers are just faking. Many law-enforcement officers are as in the dark as the general public. Very few cities and only one state police force have officers who specialize in prescription-drug cases. Charles Cichon, executive director of the National Association of Drug Diversion Investigators (Naddi), says that Naddi offers just about the only training on prescription drugs and reaches only a small percentage of those who end up investigating diversion. I asked if, absent Naddi training, officers would understand such basics as the whether there is a ceiling dose for opioids. “Probably not,” he said.

There is another factor that might encourage overzealous prosecution: Local police can use these cases to finance further investigations. A doctor’s possessions can be seized as drug profits, and as much as 80 percent can go back to the local police.

There are ways to prevent diversion without imprisoning doctors who have shown no illegal intent. They are increasingly used — but state authorities and doctors need to push even harder. The majority of states, South Carolina among them, do not yet have prescription monitoring — a central registry of prescriptions, which could help catch people getting opioids from several different doctors and pharmacies. Doctors should use more urine and blood tests, including screens that can tell quantities of drug present.

Last year, state medical boards took 473 actions against doctors for misdeeds involving prescribing controlled substances. In many cases, their licenses were pulled. Physicians can also lose their D.E.A. registration, and with it the right to prescribe controlled substances. A few dozen do every year, although there is considerable overlap with medical-board actions. Washington is the first state to recommend that only pain specialists handle high-dose opioids; other states are likely to follow.

This article seemed to have a bias, but generally seemed to do a good job of providing multidimensional context. However, including this line without context bothered me:

There is another factor that might encourage overzealous prosecution: Local police can use these cases to finance further investigations. A doctor’s possessions can be seized as drug profits, and as much as 80 percent can go back to the local police.

How often does this happen? I'm sure it happens but it paints a rather sinister picture of police and prosecutors. If the practice is widespread enough to mention, some context seems appropriate.

The article closes with an anecdote that provides some perspective on the aggressive, unorthodox practices of Dr. McIver:

With his typical imprudence, McIver told Ben: “You don’t worry about it, take whatever you need to be pain-free, if it takes 2 pills or 10 pills. If you’re taking too much and slurring your words, you know to back off. Use some common sense.” At McIver’s request, Ben kept a diary of what he took and how much. He reached a top dosage of five 80-milligram pills of OxyContin four times a day — more opioids than Shealy was taking at the time of his death. “I never felt high,” he said. “They helped my pain. I could get out and work, use the bulldozer. I was working a 250-head cattle herd. I was doing everything relatively pain-free because of the drugs. They gave me my life back.”

[hat tip: Matt]

Is cocaine back?

From the NYT:

Drug-abuse experts say the blasé attitude toward cocaine use is a result of “generational amnesia.”

“There seems to be less of a stigma about” cocaine, said Dr. Herbert Kleber, director of the division of substance abuse at the New York State Psychiatric Institute in Manhattan. As part of his oversight of research into cocaine addiction and treatment, and in his private clinical practice, Dr. Kleber hears stories about the drug’s use. “People don’t feel nearly as much the need to hide it,” he said. “They feel that they can use it in a more open fashion.”

The visibility of cultural markers — and the absence of cautionary tales — leads to the assumption that coke is not as harmful, say, as heroin (which was associated with the high-profile overdoses of River Phoenix and Kurt Cobain in the 90s), or methamphetamine, whose recent popularity in the gay community has led to a targeted campaign against it, said Perry N. Halkitis, a professor of applied psychology at New York University who studies behavior, the AIDS epidemic and drug abuse.

“If you’re a 19-year-old and you go out and party and you’re offered meth, you say no because you’ve heard these bad things,” he said. “But you’re offered coke, you say yes because you assume it’s safe.” And, he added, as the authorities crack down on meth, “people are going to tend to go to cocaine, which has similar, if not identical properties” as a stimulant.

STATS.org responds:

This is the problem with having a demon drug of the moment: all of them can’t possibly be “the worst” and “most addictive” and “most dangerous,” but if you look at the news coverage of each new scare, that’s exactly what the coverage claims. When crack came out, it was “more addictive than heroin,” (the previous worst drug ever), now meth allegedly makes crack look like “child’s play.”

Different drugs certainly do carry different risks—but that’s not what the media or the government wants to explore. To do that would mean admitting that some really are more harmful than others and that the relative harm has little to do with drugs’ legal status. For the media, it would mean that these drug trend stories have far less news value—because the truth is that some drug is always in and it’s not always worse than the one that went before it.

Exploring the varying risks of addiction related to these drugs would also mean having to actually understand addiction and why some people are at greater risk than others and what “more addictive” really means. It would mean recognizing that addiction is not an equal opportunity problem—that levels of it are much higher amongst the poor and unemployed than amongst the middle classes (and probably also higher amongst the extremely rich).

And it would also mean trying to understand whether the people who fall prey to one type of drug are only at risk for that sort of addiction—or whether the trends really don’t matter much and sweep up the at-risk people no matter what drug is in fashion.

Bringing life to Wellstone's dream

From the Star Tribune:

Stuck in traffic on an April morning in 2002, Paul Wellstone got to talking. "You know," he said of his fellow lawmakers, "party affiliation counts for less than I once guessed. There are decent folks on both sides of the aisle. Take Jim Ramstad. The guy is -- well, really, he's a total mensch."

With trademark sentence fragments and Wellstonian gestures, the professor-turned politician expressed a surprising certainty about the future.

"Jim and I have fought, like, forever to win equal treatment for mental illness and addiction -- and I'm telling you, he's just not giving up. He's a recovering alcoholic. He knows this stuff. No big-bucks insurance lobby will ever get him to back down. I mean, we're definitely passing these bills next year -- no question -- but if it takes another 10 years, that guy won't quit. And neither will I."

Wellstone's words might have been entirely on the mark but for a poorly piloted plane. But though his death in October of 2002 stalled the parity quest, his assessment of the Republican named Ramstad was apt. More than a decade after joining Wellstone in this project, Ramstad is as resolute as ever. This year he enlisted Rep. Patrick Kennedy, D-R.I., to push a revamped bill, which wisely demands that both mental and addictive disorders be treated under the same rules as physical illnesses.

Entitled the Paul Wellstone Mental Health and Addiction Equity Act, the new bill merely changes federal law to reflect scientific fact: Mental illness and addiction -- like Alzheimer's disease and epilepsy -- are brain disorders treatable by medical care. There's no reason to set them apart, and the Ramstad-Kennedy bill thus would bar health insurers from doing so. The measure would end the higher copayments, deductibles and out-of-pocket costs that patients with such brain disorders now pay. It would also nix tighter limits on hospital stays and office visits for these illnesses than for other ailments.

The plan makes a world of sense, and its House sponsors insist this is the year to write it into law. Though the measure's Senate companion -- sponsored by Pete Domenici, R-N.M., and Ted Kennedy, D-Mass. -- is meeker, there's reason to expect the more compelling House bill to prevail. Hopes have risen enough to draw Wellstone's son David -- no ordinary lobbyist -- to Washington to make the case for parity.

After all this time, surely lawmakers can grasp the logic: Pretending that brain diseases aren't "real" illnesses requiring medical care is harmful, not thrifty. It keeps sick people sick, hurts families and deprives society of contributions from citizens helped to recovery.

If lawmakers still don't get it, perhaps they should call in an expert. Their best bet is Paul Wellstone's old friend Jim Ramstad -- a fiscal conservative who happens to be a recovering alcoholic -- not to mention a mensch.

Catching up

Here are several articles I've been meaning to post about but have fallen behind:

Substance Abuse Benefits: Still Limited After All These Years

In 2005, approximately 22.2 million Americans age twelve or older were "dependent" on or "abused" illicit drugs or alcohol. Alcoholism alone is one of the ten leading U.S. causes of disability. Illicit drug users commit more than 60 percent of serious adult violent and property crimes in this country. In 2003, medical spending for substance abuse (SA) treatment constituted an estimated $20.7 billion--1.3 percent of health care spending.

More than 90 percent of people with SA problems do not seek medical attention, a figure that has changed little in recent years. Of the 37.5 percent of those who sought treatment and were unable to get it in 2002, cost was the key reason for not obtaining care.

Since the early 1990s, the public sector has assumed an increasing share of medical spending for substance abuse, while private payers' share has declined. From 1991 to 2003, all medical payments by private insurers (of which nearly 90 percent were for employer-based coverage) grew from 33 percent to 35 percent of national health care spending. In contrast, private insurance spending for SA services declined from 22 percent in 1991 to 10 percent in 2003. Yet about three of every four Americans with a drug or alcohol dependency were employed either full or part time in 2005.

Much of the decline in private insurance SA spending was concentrated in inpatient and residential services, although it also affected outpatient spending. Private insurance spending in all settings has declined, although the decline in inpatient spending has been longer and more substantial (Exhibit 1). It resulted in a falling share of inpatient, residential, and outpatient SA spending coming from private insurance between 1991 and 2003.

...

About 88 percent of insured employees had at least some coverage for SA treatment in 2006. To provide historical perspective, we compared 2006 data for workers in private firms who had health care coverage with similar historical information from the BLS. For 2000-03, 93-94 percent of workers in all private firms were enrolled in a plan with SA benefits, similar to the 93 percent recorded in our survey results for 2006. Earlier figures for 1995 and 1997 covering medium and large private establishments were only slightly higher (98 percent), in part because small private establishments, which typically provide less rich benefits, are not included. Concurrently, the use of limits on coverage of SA services became more pervasive: In 1989, 56 percent of employees with SA benefits had limits that were different from those applying to medical-surgical benefits. In 2006, 81 percent of covered employees belonged to plans that limit hospital inpatient days or office visits for SA treatment.

Patients' cost-sharing requirements for SA benefits remain higher than those for medical-surgical benefits--and it is well established that higher cost sharing reduces the use of services. In 2006, deductibles were 46 percent higher for SA services than for medical-surgical benefits (Exhibit 5). Employees are more likely to be subject to coinsurance as opposed to copayments for SA services than for medical-surgical services. According to the data presented in this paper, when employees face copayments, they are higher, on average, for SA benefits. When workers are subject to coinsurance, rates also are higher for SA than for medical-surgical services. Perhaps most important, plans that limit employees' out-of-pocket liability for medical-surgical services do not apply this protection for 44 percent of the employees with SA benefits.

Court ordered treatment reduces offending:

A new study from a team of researchers at the University of Kent and King's College London shows that court-ordered treatment for drug dependence can be effective in reducing offending and drug use.

The study, published this week in the British Journal of Criminology, suggests that, although treatment is effective in reducing offending by drug users, it can be equally effective for people who enter treatment as an alternative to imprisonment, leading to reductions of almost three quarters in the average frequency of offending.

...

Alex Stevens explained: 'Our research has shown that people on Drug Treatment and Testing Orders (DTTOs) were as likely to reduce their offending and drug use as people who entered treatment 'voluntarily'. On average, those sentenced to a DTTO reported a 71% reduction in the frequency of offending between the time of arrest and 18 months after they started treatment. The sharpest fall in offending occurred in the first six months of treatment. There were similar reductions in the frequency of drug use and in the money they spent on drugs.'

Experts Warn About Powdered Alcohol

They look harmless enough, the inconspicuous packets often next to the cashier at gas stations, convenience stores, beverage stores and bars. But according to consumer protection officials, that's what makes them all the more dangerous, since the powder inside contains alcohol, and a lot of it -- about 4.8 percent by volume. That is the equivalent of one to one-and-a-half glasses of liquor.

Vancouver mayor to lead campaign for injection site

Vancouver Mayor Sam Sullivan plans to lead an aggressive campaign to lobby for the continued operation of the country's only injection site for drug users.

In contrast to the last round of lobbying to keep the site open, where Sullivan used a quieter, back-door approach, the mayor said he plans to mount a public campaign that brings together injection-site supporters from every sector of the city.

He said that's because having the injection site open is key to bringing in the new kind of drug-treatment approach he has been advocating since he took office.

That approach, which he has labelled Chronic Addiction Substitution Treatment, will see legal substitutes for cocaine and heroin given to addicts.

"The CASTproject does require the supervised injection site as a site for recruitment. We are going to need to aggressively pursue this project," he said.

Sullivan's drug plan isn't the better way

As a former beat cop who spent more than seven years working in the Downtown Eastside, it was nice to see Jonathan Fowlie's article.

...

I can recall on many occasions when denizens of the poorest postal code in the country would approach me and say they wanted desperately to get into treatment and leave the drug life behind them.

However, adequate treatment didn't exist or there was a waiting list. When an addict reaches out for help, he or she must be removed from the Downtown Eastside and placed in a treatment facility immediately.

Supreme Court to review crack cocaine sentences

The Supreme Court agreed for the first time yesterday to reconsider the long prison terms meted out to the mostly black defendants who are convicted of selling crack cocaine.

At least 25,000 defendants per year are sent to federal prison on crack-cocaine charges, and their prison terms are usually 50 percent longer than drug dealers who sell powder cocaine.

This disparity, with its racial overtones, has been controversial for two decades since Congress ramped up the "war on drugs" in response to a crack-cocaine epidemic that was sweeping many cities.

Crack was targeted for stiffer penalties because it was viewed as more potent and dangerous than powder cocaine.

At the time, lawmakers set mandatory minimum prison terms for drug sellers based on the quantity of drugs sold. A sale of 5 grams of crack cocaine triggers the same five-year prison term as selling 500 grams of powder cocaine, even though they are the same substance.

Critics have said this 100-to-1 disparity is unfair and racially biased because dealers in crack cocaine are more often black, while powder cocaine is said to be sold more often to whites and by whites.

Put the Gangs Out of Business: Legalize Drugs

The street gang and associated drug trade problem in Canada won't be solved by a get-tough, criminal-justice-system response, nor should we expect young homies to just say no. Look to the United States for proof of this. Over the past 30 years, the U.S. has employed the most aggressive and expensive anti-drug and -gang measures ever conceived. In the process, 800,000 street gangsters under the age of 21 have been created. Moreover, more than two million Americans now call prison home, the majority of which are young black and Hispanic men. About half of them are serving time for relatively minor drug offences. Today, things are so bad that the FBI has made street gangs and the underlying drug trade their number one priority, even over domestic terrorism. The failure in this campaign is a testament to the abject failure of the U.S. war on drugs and gangs.

Canada has the opportunity, but perhaps not the courage, to employ a different approach on street gangs. To be sure, we must tackle the underlying socioeconomic causes of the street-gang problem, including poverty, income inequality and persistent discrimination. At the same time, we must equip our police agencies with the resources they need to take out the hardcore 20% or so of all street gangsters who are responsible for the majority of Canadian street violence. We must spend much more money on early prevention and diversion, because this is not a problem that we can arrest our way out of.

Finally, we need to embark upon drug legalization, which will starve gangs of their principal oxygen supply and serve to upset the attractive risk-reward proposition that every new gangster now faces.

Marlboro Snus: What is it?

Yesterday Philip Morris USA, the tobacco company that has around 50% of the total market for cigarettes in the USA, announced the launch a new product: “Marlboro Snus,” in a test market in the Dallas/Fort Worth area. So what type of product it this?

As this particular brand of snus won’t be launched until August we can’t yet tell much of the details of the product (e.g. how much nicotine it delivers or how much it will cost) so lets talk about what “snus” is generally, and why the biggest cigarette manufacturers in the US are test marketing an entirely different type of product.

Snus (pronounced “snooss”) is the Swedish word for snuff, and is a form of moist ground smokeless tobacco, that is usually sold in “sachet” form – each sachet looking like a small tea-bag. Each sachet is placed in the mouth (usually under the upper or lower lip) for about 30 minutes and the nicotine and tobacco taste is absorbed via the lining of the mouth. The main difference between snus products and other smokeless tobacco already available in the United States, is that snus is produced using a process like pasteurization in which it is heated with steam. This kills most of the microbes that can produce cancer-causing chemicals in tobacco. Traditional smokeless products like Skoal and Copenhagen are not pasteurized but are fermented - a process that facilitates the development of cancer-causing chemicals. So snus does not appear to cause oral cancer. Clearly smokeless products also don’t cause lung cancer or respiratory diseases like emphysema either. That’s not to say that snus is entirely safe. Long term use can cause white patches to appear on the lining of the mouth and erosion of the gum where it is placed, and decades of use may increase risks of pancreatic cancer and cardiovascular disease (e.g. stroke and heart attacks). The nicotine from this product will also harm the unborn baby when used by a pregnant woman. So neither snus nor any other form of smokeless tobacco is recommended for anyone who currently doesn’t smoke. But because the health risks from snus are much lower (about 90% lower) than from smoking this may be a step in the right direction for the smoker who wants to keep using tobacco but wants to avoid most of the health risks.

Marketing and resbonsibility

I've had a recent posts about alcohol marketing and teen drinking. If find these questions of marketing and personal responsibility difficult and I's suspicious of anyone with easy answers.
Marketer Seth Godin weighed in on responsibility and marketing today:

Marketing works.

Advertising and promotion and lobbying cost money. And organizations pay for it because, by and large, it works. Not all the time, and rarely as big as people hope, but sure, you can influence the public by spending money.

Which leads to the key question: are you responsible for what you market?

Some people will tell you that the market decides. They’ll remind you that most consumers are adults, spending their own resources and doing it freely. That people have a right to buy what they want, even if what they want isn’t good for them (right now, or in the long run). That’s what living in a free country is all about, apparently. Buy what you want.

But wait.

I thought we agreed that marketing works.

If marketing works, it means that free choice isn’t quite so free. It means that marketers get to influence and amplify desires. The number of SUVs sold in the United States is a bazillion times bigger than it was in 1962. Is that because people suddenly want them, or is it because car marketers built them and marketed them?

Cigarette consumption is way down. Is that because people suddenly don’t want them any more, or is it because advertising opportunities are limited?

Read the rest here.

‘Been There?’ Sometimes That Isn’t the Point

From Sally Satel in yesterday's NYT:

For other patients, though, the “Have you ever ...” question is less a therapeutic riddle to be solved — as it was in the case of Mr. B — than an expression of genuine skepticism that they can indeed be helped.

It is the kind of question asked by a person who believes his very soul has been warped by calamity. “Sometimes a patient expresses frustration that I can’t possibly help him because I never experienced the trauma that he did,” said Dr. Walter Reich, a professor of psychiatry at George Washington University and a former director of the United States Holocaust Memorial Museum, whose patients have included Holocaust survivors.

“Please tell me what happened, how you reacted to it then and how it lives in you now,” he will ask. He gently prods his patient to step out of his private world, “a chamber often filled with circular and self-devouring ruminations.” In the act of making his experience clear and complete to the therapist, the patient has to make it clear and complete to himself, Dr. Reich explains, adding that “in the process, he accepts into his being something that was once consuming it.”

Addiction, too, can be an intense and defining experience. “I have heard patients say that if you haven’t been there you can’t help me,” said Keith Humphreys, a Stanford psychologist. “So I tell them, ‘I can help you live a sober life because it’s all I have ever lived.’ ”

It’s true that having “been there” can endow a drug-abuse clinician with valuable authority and authenticity. There is just so much bluster a patient can get past a counselor who is a streetwise former junkie (which is why I, the forever-abstinent psychiatrist at a methadone clinic, often seek a second opinion from our counselors). Moreover, that recovered counselor inspires hope that addiction can be conquered.

But most of the time, therapist and patient do not share a history. And even if they do, there is no guarantee it will help. A mutual bond can paradoxically reinforce the patient’s sense of isolation from others. Also, commonality can lead the therapist to identify too closely with the patient, thus compromising objectivity.

In truth, the most relevant knowledge a clinician can possess is the experience of having known and treated many patients already. This is how he learns to become a skilled interpreter of the protean query “Have you ever...?”

Pain in the news

Maia Szalavitiz of STATS.org wrote a post that was very critical of a recent Newsweek article on pain management and opioids. It's good--addressing several common myths about addiction vs. dependence and opioids.

So, when I read the Newsweek article, I expected it to be crap. But it's pretty good too. It does a good job making the case for the importance of serious pain management and it illustrates the binds that myths and stigma put doctors and patients in. They could have done a better job with the issue of iatrogenic addiction, but I suspect that pain patients and doctors are better off for this article having been published.

Hyperthermia and Ecstasy: New Case Study Offers Possible Clue to Ecstasy-caused Deaths

This is from a press release from The Centre for Addiction and Mental Health:

Death caused by the drug ecstasy (mdma) is very rare compared to the high number of users. And the reasons why some ecstasy users are especially susceptible to a fatal drug reaction are not known, though these deaths often involve severe hyperthermia (increased body temperature).

A new case study in the Journal of Forensic Sciences points to a pre-existing defect affecting temperature regulation as one factor that might contribute to some ecstasy deaths.

Working with Centre of Forensic Sciences toxicologist Teri Martin and the Office of the Chief Coroner of Ontario, the Centre for Addiction and Mental Health (CAMH)’s Dr. Stephen Kish described a young woman who developed fatal hyperthermia after taking ecstasy. It was later discovered at autopsy that she had an overactive thyroid (hyperthyroidism), a condition that can make some people less tolerant to heat.

“This single case cannot prove that hyperthyroidism contributed to the death of the ecstasy user”, said Dr. Kish, Professor of Psychiatry and Pharmacology, University of Toronto, and Head, Human Neurochemical Pathology Laboratory, CAMH, “but it does suggest what many scientists have suspected - that a pre-existing problem in temperature regulation might increase the risk of an ecstasy-triggered death. This is supported by other data showing that experimental animals that are hyperthyroid are more likely to die when exposed to ecstasy.”

All that from one case? Can you say confirmation bias?

The Methadone Maze

A damning portrait of a methadone program in Maine:

For many people, the methadone program at Acadia Hospital has been a lifesaver, substituting a safe, monitored dose of liquid methadone for the dangerous and illegal street opiates abused by addicted clients.

In the best cases, these clients are able to resume their productive lives — finish their schooling, keep their jobs, care for their children. About 700 people are enrolled.

But attending the methadone clinic can be a daily exercise in frustration, anger and resentment. Brawling, harassment, intimidation and drug dealing are regular occurrences, some clients say, and the clinic staff rarely intervenes. This chaotic atmosphere at Acadia is a threat to their recovery, these clients allege — and it challenges public assumptions about the largely Medicaid-funded program.

But administrators at the hospital say that their clients’ antisocial and illegal activities are symptoms of the disease of drug addiction. Taking a hard line against such behavior would force too many clients out of treatment, they argue, undermining the goals of the program.

Speaking out

Danielle Eames-Powe, 22, has been a client at Acadia’s methadone clinic for two years. A drug user since she was 12, it was the birth of her daughter, Mabel, that made her seek treatment. She has been clean and sober for 2½ years now, she said, and works as a secretary for Bangor lawyer Joseph Baldacci.

Eames-Powe and her boyfriend, Bruce Raymond, also a client, told the Bangor Daily News that money and illicit drugs of all kinds change hands in the clinic’s waiting areas and parking lot. The staff looks the other way as these deals are made, they said, despite a largely unenforced rule that prohibits congregating, whispering or socializing on hospital property.

"A lot of them just make up their drug histories, so the clinic thinks they have a really big problem and gives them high doses of methadone," Eames-Powe said. Some clients — many, according to Raymond — who are entrusted with take-home doses sell their methadone to buy more potent drugs for their own use.

In the long hallway where dozens of clients may wait 45 minutes or longer to get their daily dose, they said, fistfights and shouting matches often break out. The language is often extremely offensive. Many clients bring their young children with them, and those children watch and listen as their parents and other clients take part in these violent encounters.

Mandatory counseling sessions are pointless, Raymond said. Some clinicians are apathetic and negative; others are overwhelmed by the number of clients they must see.

Clients can choose between individual therapy or group counseling; Eames-Powe said she always chooses individual sessions.

"I attended one of the groups and it was despicable," she said. "The people were nodding off, drooling, glorifying drugs, talking about how much they love getting high. I’ll never go to group again."

Individual sessions aren’t much more valuable, she said.

"I’ve had nine different counselors in two years," she said. "I just tell them the same story, my history. It doesn’t accomplish anything, but at least it’s confidential and you don’t have to sit next to a bunch of filthy people who are still using drugs."

Eames-Powe said she is "desperate" to get out of the Acadia program. But clinicians insist on weaning her so slowly that she fears she’ll never be free of the demoralizing daily visits.

Ironically, she said, despite her good behavior, consistently negative drug tests and evident commitment to recovery, she’s ineligible for take-home doses — she’s considered "unstable" because she is weaning.

Read the rest here.

The effects of alcohol on smoking cessation

Jonathan Foulds has two posts (here and here) on the relationship between drinking and alcohol consumption:

Not surprisingly, however, people with current alcohol problems tend to have poorer outcomes when it comes to quitting smoking. There is a fairly close association between smoking and problem drinking. For example, in a study published in 2000 based on a survey of almost 43,000 adults, Dr Deborah Dawson (National Institutes of Health) reported that the proportion of past-year smokers rose from 23.8% of those who never drank 5+ drinks on any drinking day to 61.8% of those who drank 5+ drinks weekly or more often. She also found that but drinking 5+ drinks at least once a month reduced the odds of smoking cessation by 42%.

A recent study by Leeman and colleagues from Yale University noted that many (46%) trials of medicines for smoking cessation exclude people with a current or post alcohol problem. It was also noticeable in their study that trials of new medicines were more likely to do so. Thus 45/125 (36%) trials of nicotine replacement therapies (gum, patch etc), 15/22 (68%) bupropion SR trials and 3/3 varenicline (Chantix) trials excluded participants with either current or recent alcohol problems. This is part of the reason that clinicians often want to wait for more studies when a new “wonder drug” comes out that appears to get better outcomes than previous medicines. Typically the first few studies of a new drug (usually sponsored by the company making the drug) include only “ideal” candidates for the drug, rather than typical patients who might use it in the real world.

So what does all this mean?

Firstly, if you think you may have a current alcohol problem you should get help with that immediately. If you scored in the “problem drinking” range on any of the questions mentioned above but still don’t think you have a problem, then here’s one more test. Starting tomorrow, go 30 consecutive days without drinking any alcohol. If you can do it, then fine, maybe your alcohol consumption isn’t currently a problem. If as soon as you think of it you perceive it to be too much trouble, or if you try it and can’t do it, take that as confirmation that you can’t control your alcohol consumption. You should then discuss this with your family doctor and attend a local AA meeting.

Secondly, whether or not you think you have a current alcohol problem, you should make plans to quit smoking. If you feel you would rather get the drinking under control first, that’s fine, but make a concrete plan to tackle the smoking very soon and mention this to your doctor and AA sponsor right from the start. More people with alcohol problems are killed by their smoking than their drinking, so this is not something to put on the back burner for long. Once you have 30 days without drinking under your belt then its time to talk to your doctor/sponsor again about quitting smoking and to set a quit date.

Dutch smoking ban to cover coffee shops

The end of Dutch cannabis cafes?:

A Dutch smoking ban will come into force in July next year for all restaurants and cafes -- including coffee shops where cannabis is the top attraction, the government decided on Friday.

"Coffee shops will be treated in the same manner as other catering businesses. They will be smoke-free," Prime Minister Jan Peter Balkenende told NOS television.

"It would have been wrong to move towards a smoke-free catering industry and then make an exception for coffee shops. People would not have understood that."

Establishments will not in fact have to be completely smoke-free. Proprietors will be allowed to set up a separate room or glass partition behind which people can smoke, but customers will not be served there to protect staff.

What's your color?

Am I getting old and prudish? Or, is there something creepy about the merger of pop culture iconography and harm reduction? Where are the lines between destigmatizing addiction, normalizing addiction and celebrating addition?

I don't consider myself anti-harm reduction, though I believe more aggressive forms of harm reduction should be done in the context of treatment on demand and I'm troubled by programs that pay little attention to creating opportunities to facilitate recovery.
[Hat tip: Matt]

Mayor pushes substitute drug program

Vancouver Mayor Sam Sullivan (previous posts here) says he was never committed to the safe injection site as a long term solution and would like to replace it with oral drug maintenance:

Vancouver will be able to close down its supervised-injection site for drug users once a new program for providing substitute legal drugs gets going, according to Vancouver Mayor Sam Sullivan.

...

"I would never see [the injection site] as a long-term solution," said Sullivan. "We know there's 90-per-cent Hep C and 30-per-cent HIV among injection drug users. The reality is needles are not a good way to take drugs."

In spite of all of his "meeting them where they are at" "realism", he fails to recognize that injecting drugs is a GREAT way to take drugs if your an active addict.

Sullivan's hope is that within 18 months a minimum of 1,000 people will be getting substitute drugs in five separate trials. Two of the trials will provide people with a new substitute for heroin; the other three will supply different kinds of drugs that are being proposed as substitutes for cocaine and crystal meth.

"I believe that 1,000 [people in these trials] will not make the supervised-injection site redundant, that it still has a very valuable service for society as we transition. It needs to be there as an essential recruitment site for [the substitution trials.] But I do believe it is a temporary measure."

...

He acknowledged that getting people to stop using needles may be difficult, because of the culture of drug-using in Vancouver that emphasizes "feel the steel."

"But now what we're asking is not that they 'just say no'.

"It's that they change the culture. It's much more possible to ask people to change the culture of their drug use versus stop their drug use."

...

Sullivan said he is spending a lot of his discretionary time and energy working on the project because "I see the payoffs for the citizens: dramatic reduction in crime, dramatic reduction in homelessness. I see many of the Project Civil City goals achieved in large part through [this]."

Needle Exchanges

Congress is considering legislation that would permit Washington D.C. to use city money to fund a needle exchange. The Washington Post weighs in today:

HIV-AIDS IS laying waste to Washington. The District has one of the worst infection rates in the country, and intravenous drug use is one of the primary modes of transmission. Yet the District -- unlike any other jurisdiction in the country -- is prohibited by Congress from using its own money to fund a needle-exchange program. Yesterday, Rep. Jose E. Serrano (D-N.Y.) took the first step toward ending this nuttiness.

The ban has been in place since 1998. That's when Rep. Todd Tiahrt (R-Kan.) succeeded in getting it attached to a bill governing the District's budget. With the Republicans in control, the prohibition on the District spending its own funds for needle-exchange programs survived every attempt to excise it from the House appropriations bill. But the Democrats are in charge now. Mr. Serrano, as chairman of the House Appropriations subcommittee on financial services and general government, which doles out federal money to the District, stripped the ban from legislation that passed unanimously yesterday. The action now moves to the full Appropriations Committee and then to the floor of the House, where opponents are expected to try to reinstate the prohibition.

"I do not dispute that drug addiction is a very real problem in this and other cities," Mr. Tiahrt told us via e-mail yesterday, "but [needle-exchange programs] have been proven in many studies to be ineffective and a threat to the surrounding community, especially to children." Yes, drug addiction is such a problem that there are now more than 210 syringe-swapping programs in 36 states. They constitute but one weapon in an arsenal of measures to help stem the tide of people converting from HIV-negative to HIV-positive. And they make it easier for outreach workers to talk to users about their addictions and then to get them into treatment.

The District is cautiously optimistic. City Administrator Dan Tangherlini told us that two departments (Human Services and Health) are beginning to work on a series of needle-exchange program options for Mayor Adrian M. Fenty (D) to consider. If all goes well, the District would be able to get something up and running for fiscal 2008. Congress should let it happen.

Track Money Flow to Stop Movement of Addictive Drugs

Keith Humphreys, the prolific researcher on AA, is advocating that financial transactions be used to track drug sales:

The drug dealer of the future is sleek, efficient, sophisticated - and WiFi enabled. As highlighted in a U.S. Senate Judiciary Committee hearing last week, the once-distinct worlds of drug dealing and the Internet are merging, resulting in unprecedented access to potent painkillers like Vicodin and Oxycontin for non-medical use. The fear this situation generates knows no partisan limits: liberal Sen. Dianne Feinstein and conservative Sen. Jeff Sessions are reaching across the aisle to promote greater controls on Internet drug trafficking.

Addictive and potentially lethal medications are available without prescription from over 2 million Web sites around the world, according to studies conducted by the Treatment Research Institute at the University of Pennsylvania. Many of them are based in countries that impose few legal controls on pharmaceuticals. A no-prescription pharmacy in Tajikistan or Tanzania - which might be little more than a truck with a well-stocked medicine cabinet and a wireless-enabled laptop computer - can sell painkillers to Americans with no fear of local law enforcement.

This growing phenomenon may be fueling the rising tide of prescription drug abuse among adolescents. The 2006 Monitoring the Future survey by the University of Michigan found that 12th graders are five times as likely to have used Oxycontin and 12 times as likely to have used Vicodin as they are to have used heroin in the past year. The average parent or teen probably considers abuse of these drugs less dangerous than heroin, but in fact they are pharmacologically quite similar, all being potent opiates with high risk of addiction and overdose.

Tech-savvy world

Most adolescents are more tech-savvy than their parents, and understandably have less fear of ordering a drug on their home computer or cell phone than they would of venturing out into the street to find a dealer. Many a teenager is home alone when the mail comes, and it only takes a few teens to supply a large number of young people with Internet-purchased drugs.

What to do? Feinstein and Sessions should be commended for taking the important first step of amending the Controlled Substances Act, which was originally passed when Steve Jobs and Bill Gates were 15 years old, to cover the Internet trade of abusable medications. The next step is to develop strategies that limit Internet trade in dangerous no-prescription drugs, while preserving the right of patients with legitimate prescriptions to purchase needed medications online.

The Drug Enforcement Agency has pursued the traditional law enforcement approach of arresting dealers and seizing drugs. This works well for pharmacies physically based in the United States, but most Web-based drug dealing originates in other countries. Even if we were fortunate enough to put all domestic illegal Internet pharmacies out of business, the traffic would simply shift entirely overseas at the speed of a few mouse clicks. Traditional border control methods likewise will have little impact: The Customs Service can't inspect more than a fraction of the foreign mail that enters the country each day.

Key difference

To succeed at suppressing this new form of drug dealing, we will have to recognize a fundamental difference between street and Internet drug deals. Tracking financial transactions on the street - for example, the names and addresses of all the people who contributed to the $5,000 in small bills found on an arrested drug dealer - is very difficult for law enforcement. In contrast, on the Internet, even the smallest financial transactions are electronic, creating a traceable record.

Law enforcement agents could pose as teenagers wanting to buy pain killers without prescription over the Internet, much the same way they currently catch online sexual predators. Once the phony transaction had been processed, the information on the seller could be immediately shared with the credit card company and its associated bank. These entities, in turn, could cancel the ability of the seller to do any further electronic transactions online. This involves some cost for the credit card companies and banks, but it will benefit them by getting them out of a dirty business.

Focusing policing on the financial transactions rather than the drugs themselves may seem an unusual departure from traditional enforcement approaches. But just as the Internet has demanded new ways of thinking about every other area of life, it will also require new ideas for combating dangerous drugs. Efforts to seize Internet-purchased drugs at the border or in far-off nations will have minimal effect, but we don't need those familiar tools to tackle this problem. The best approach was well-summarized by one of the witnesses at the Senate hearing, Dr. Thomas McLellan of the Treatment Research Institute: Just follow the money.


Keith N. Humphreys, Ph.D., is a Professor (Research) of Psychiatry and Behavioral Sciences at Stanford University School of Medicine.

Birth defects from alcohol use in pregnancy going undiagnosed

There's been a lot written about the problems associated with increases in binge drinking in Britain. Here's another harm:

Far more babies may be damaged in the womb as a result of their mother's drinking habits than was assumed, the British Medical Association warned today as it backed the government's call for pregnant women and those trying for a baby to give up alcohol completely.

Only babies with full-blown foetal alcohol syndrome tend to be diagnosed and counted by doctors in the UK. But a BMA report published today called for data to be collected on a much wider and sometimes less obvious category of damage, called foetal alcohol spectrum disorders.

Around 0.2 per 1,000 UK babies suffer from foetal alcohol syndrome, which impairs the brain, causes abnormal facial features and leads to low birth weight. However, the wider foetal alcohol spectrum disorders were found to affect around 10 per 1,000 babies in Canada, one of the few countries to collect statistics on the latter category.

...

Babies born with the spectrum of disorders have some but not all of the problems that foetal alcohol syndrome brings. They may suffer from hyperactivity, be unable to concentrate, have a short attention span, or be slow to develop.

The BMA notes that there is still controversy in the UK about the existence even of foetal alcohol syndrome, which may explain, the report says, why data on the spectrum of disorders is not collected.

But, said Dr Nathanson, "it is so important that the discussions need to go on in parallel with getting women into treatment."

The BMA recognises that there is no evidence that a low level of drinking - one to two units a week - harmed the unborn child. But, said Dr Nathanson, "the fact that we haven't yet got the evidence doesn't mean that there isn't evidence of a link. It may be that it is just very difficult to get."

It has been shown that alcohol reaches the foetus across the placental barrier, and also that low levels of exposure to alcohol have an effect in animals.

...

The BMA report, titled Fetal Alcohol Spectrum Disorders, says it is very difficult for anybody to know how many units of alcohol they are drinking. Bottles of wine have risen from 8% to 12% proof and measures of wine and spirits vary considerably in pubs and restaurants. The BMA is calling for all bottles of alcohol and pub and restaurant drinks to be labelled with the number of units they contain.

[Hat tip: dailydose.net]

Boost care for mental illness

More of Patrick Kennedy's parity advocacy:

Just more than a year ago, after a late-night automobile accident and a nationally televised press conference, I got the treatment that changed my life. I was lucky to have good health insurance and access to treatment, but too many Americans do not have the same chance.

Most health plans put up barriers to mental health and addiction care. People seeking treatment for these diseases face higher copayments and deductibles, and arbitrary limits on the number of office visits or inpatient days covered. They pay the same premiums as everybody else, but when they get sick their insurance isn't there for them.

This year, I have been crisscrossing the country with my colleague, Rep. Jim Ramstad (R-Minn.), holding informal field hearings about mental health and addiction, and how Congress can help more people get well. We heard from consumers and providers, police chiefs and judges, business leaders and insurance executives, hospital presidents and public health officials. All of them see that equalizing benefits is crucial to addressing many goals -- around health care, public health, education, criminal justice, homelessness, and on and on.

But what it's really about -- what it's mostly about -- is the American Dream. Ending insurance discrimination is about whether our nation lives up to the ideals of the Declaration of Independence and the Constitution, promising every person the chance to reach his or her God-given potential.

It's about people like Amy Smith from Denver. She told us that when she meets people she knew 25 years ago, they are stunned she is still alive. She was in and out of jail and emergency rooms, unable to connect with other people, muttering to herself on the street, and unemployed. For 45 years, she says, she was a drain on society. Then she finally got the treatment she needed and now she's a taxpayer, holding down a good job.

Kevin Hines is a young man who told our hearing in Palo Alto about jumping off the Golden Gate Bridge in 2002. Unlike most jumpers, Kevin miraculously survived and he's getting married this summer. How many others who didn't survive could have found happiness and success had they had treatment?

The American Dream should not be rationed by diagnosis, and so Congress must pass the Paul Wellstone Mental Health and Addiction Equity Act to end insurance discrimination against Americans with mental illnesses and addictions. We know that improving mental health and addiction benefits can actually reduce health care costs by avoiding unnecessarily hospitalizations, controlling chronic physical diseases, and reducing emergency room visits. It improves productivity in the workplace and cuts down on law enforcement problems.

With that track record, a bipartisan majority of 268 declared House supporters, and strong endorsements from the entire House leadership, passing this insurance equity bill might seem easy. But there are 12 years worth of pent-up Democratic priorities. In Washington, the squeaky wheel gets the grease. And there will be those who ignore the evidence and claim the sky will fall on the health care system if we equalize health insurance benefits.

So Congress needs to hear from everyone who thinks it's time to bring fairness and equality to insurance coverage for mental illnesses and addictions. Representatives and senators need to know that passing the Paul Wellstone Mental Health and Addiction Equity Act is not just good policy, but good politics as well.

Rep. Patrick J. Kennedy (D-R.I.) is lead sponsor of the Paul Wellstone Mental Health and Addiction Equity Act.

Ritalin use doubles after divorce, study finds

An interesting finding out of Canada about Ritalin prescribing patterns:

Children from broken marriages are twice as likely to be prescribed attention-deficit drugs as children whose parents stay together, a Canadian researcher said on Monday, and she said the reasons should be investigated.

More than 6 per cent of 633 children from divorced families were prescribed Ritalin, compared with 3.3 per cent of children whose parents stayed together, University of Alberta professor Lisa Strohschein reported in the Canadian Medical Association Journal.

...

"It shows clearly that divorce is a risk factor for kids to be prescribed Ritalin," Strohschein said.

Other studies have shown that children of single parents are more likely to get prescribed drugs such as Ritalin. But is the problem caused by being born to a never-married mother, or some other factor?

"So the question was, 'is it possible that divorce acts a stressful life event that creates adjustment problems for children, which might increase acting out behavior, leading to a prescription for Ritalin?'" Strohschein said in a statement.

"On the other hand, there is also the very public perception that divorce is always bad for kids and so when children of divorce come to the attention of the health-care system - possibly because parents anticipate their child must be going through adjustment problems - doctors may be more likely to diagnose a problem and prescribe Ritalin."

[Hat tip: dailydose.net]

Let's buy Afghanistan's poppies?

The editorial page of Canada's National Post argues that the west should purchase Afghani opium for production of medical opiates:

Illicit poppy production is simultaneously a hard-to-replace source of income for thousands of small Afghan farmers and a valuable source of revenue for the enemies of NATO and the legitimate Afghan government. Over 90% of the world's illegal raw opium is thought to come from Afghanistan. Ultimately, its by-products go on to wreak havoc in cities around the world.

Consistent with the thinking that gave us Washington's failed "war on drugs," the preferred U.S. policy is to "eradicate" Afghan poppy fields through aerial spraying, which practically means driving the opium trade underground and hitting the small grow-ops hardest.

...

The basic idea is simple: Opium is medicine, so why destroy it? In an age of rising global prosperity and life expectancies, the medical demand for opioids such as codeine and morphine is rising all the time, and indeed is outstripping supply according to UN measures. Yet there are no legal arrangements for Afghan farmers to produce licensed opium legally for the international pharmaceutical market.

Nothing in international, Afghan or Islamic law stands in the way, and a similar program of pharmacization has already brought thousands of Turkish farmers in from the black market. The only thing missing in Afghanistan is the bridge between lawful authority and the areas in which poppies are now being grown illegally -- which is to say, the problem is that the war hasn't yet been won.

That's hardly a trivial hurdle to overcome, but there is a chicken-and-egg dynamic here: Isn't it just possible that NATO would find it easier to win hearts and minds in the lawless parts of Afghanistan if farmers there knew that NATO progress meant a big stake in a legal opium trade -- instead of the status quo, whereby government busybodies are trying to get everybody to burn their dollars-a-bushel poppies and grow pennies-a-bushel onions instead?

The real risk of a licensing regime is that it might end up being carelessly policed and prone to bribery, enabling some of the "legal" harvest to find its way into the illicit drug trade. But as the Council points out, that's where the entire harvest is ending up now.

Stephane Dion has come out in favour of looking at the Senlis plan, but when he notices that it implies seeing the war through to the end, as Ms. MacDonald has emphasized, he is likely to get cold feet. It's the Conservatives, the party of victory, that ought to give it the consideration it deserves.

Neil McKegany expresses concern about unintended consequences of such a policy:

In agreeing to that deal you would be sending out a powerful message to each and every country in the region that if they wanted a guaranteed income from the West then all they need to do is start farming opium. Far from stemming the drugs trade you could find yourself actually stimulating its growth. Those countries in particular who had already stemmed their opium production on the basis of international pressure might feel mightily irked by such a change in policy and decide themselves that it was no longer in their interests to so assiduously police
their own opium trade.

If you succeeded in persuading a local farmer to sell you his opium crop you would be placing them at enormous risk, because the gangs who currently run drug production are not going to sit around and watch their market disappear. Instead they are going to use whatever force is necessary to ensure that no matter who buys the drugs the money goes into their pockets. Such a policy then would require the capacity of the West not simply to buy the drugs from the farmers at source, but to provide the level of security that those farmers are going to require as a result of their decision to switch the sale of their product.
...
In the face of the continued failure to reduce the scale of opium production in Afghanistan, then aerial spraying may well come to be seen as the last but now needed option in tackling opium production. There is also a need, however, to show those who are dedicated to opium production that their choices in this respect are going to cost them dearly, whether in seized assets or further military intervention. Putting money into the hands of those who are involved in organised drug production is about as far from that strategy as it is possible to get.

I recently attended an international seminar addressed by some of those who are involved in the Afghan counter-narcotics effort. Sitting next to me was a senior UK police officer who turned and said that part of the problem in tackling drugs production in countries like Afghanistan was the fact that you never knew whether the person you were speaking to was part of the problem or part of the solution: ‘We are expected to share our intelligence but you never know when you take out a group involved in opium production whether you have reduced supply or simply lowered the level of competition in the market.’ In a situation in which it is hard to tell whose side people are on, it is a risky strategy dolling out large amounts of government money.

Finally, The Institute for Peace and War Reporting reports on success in one province:

Muhammad Nazar is busily weeding his cotton fields. Last year at this time, he was engaged in harvesting poppy, but, like many landowners in Balkh province, has had a change of heart.

“The government has restricted poppy cultivation, and religious leaders have told us that growing poppy is haram [prohibited by Islam],” he said. “We should not go against our religion and the constitution.”

As he continued to work, he said, “I hope to get a good harvest, and the government has promised us a good price for cotton.”

Balkh province used to be the third-largest producer of opium poppy, after Helmand and Kandahar. But this year, the counter-narcotics programme has all but rid the province of the illegal crop.

Some farmers, like Nazar, say that they have switched to legitimate farming because of government strictures. But many others give a more pragmatic reason for decision.

“The price of poppy has been going down year by year,” said Noor Gul, a farmer in Charbolak, formerly the centre of Balkh’s poppy cultivation. “We couldn’t afford the expense of growing it, so we decided to plant something else instead.”

Dealers say that the price of opium has been declining due to overproduction. While in past years, a kilo of opium paste would fetch over 130 US dollars on the local market, it is now worth about half that.

Hat tip: dailydose.net and ccsa.ca