Dopey, Boozy, Smoky—and Stupid

The National Interest has a lengthy article on drug policy by Mark A.R. Kleiman. I disagree with several of his points but this is exactly the kind of thoughtful contribution that the American drug policy debate needs more of.

I tend to see his perspective as hyper-rational (Possibly to balance the moral panic of drug crusaders and fetishization of drug culture by many legalization advocates.) and somewhat removed from both the suffering of addiction and the radical transformation that full recovery offers. I think he risks reducing policy issues to an accounting exercise but he expresses strong, well-informed opinions without and ideological ax to grind (Although there clear Libertarian themes.) and does so without characterizing and dismissing people who think differently.

After outlining the sad state of American drug policy he says:

These are depressing facts that cry out for a radical reform to solve the drug problem once and for all. But the first step toward achieving less awful results is accepting that there is no one “solution” to the drug problem, for essentially three reasons. First, the potential for drug abuse is built into the human brain. Left to their own devices, and subject to the sway of fashion and the blandishments of advertising, many people will wind up ruining their lives and the lives of those around them by falling under the spell of one drug or another. Second, any laws—prohibitions, regulations or taxes—stringent enough to substantially reduce the number of addicts will be defied and evaded, and those who use drugs in defiance of the laws will generally wind up poorer, sicker and more likely to be criminally active than they would otherwise have been. Third, drug law enforcement must be intrusive if it is to be effective, and enterprises created for the expressed purpose of breaking the law naturally tend toward violence because they cannot rely on courts to settle disputes or police to protect them from robbery or extortion.

Any set of policies will therefore leave us with some level of substance abuse—with attendant costs to the abusers themselves, their families, their neighbors, their co-workers and the public—and some level of damage from illicit markets and law enforcement efforts. Thus the “drug problem” cannot be abolished either by “winning the war on drugs” or by “ending prohibition.” In practice the choice among policies is a choice of which set of problems we want to have.

But the absence of a silver bullet to slay the drug werewolf does not mean we are helpless. Though perfection is beyond reach, improvement is not. Policies that pursued sensible ends with cost-effective means could vastly shrink the extent of drug abuse, the damage of that abuse, and the fiscal and human costs of enforcement efforts. More prudent policies would leave us with much less drug abuse, much less crime, and many fewer people in prison than we have today.

The reforms needed to achieve these ambitious goals are radical rather than incremental. But they are not simple, or all of a piece, or in any one of the directions defined by current arguments around American dinner tables, on American editorial pages or in American legislative chambers. The conventional division of drug programs into enforcement, prevention and treatment conceals more than it reveals. So does the standard political line between punitive drug policy “hawks” and service-oriented drug policy “doves.” Neither side is consistently right; some potential improvements in drug policy are hawkish, some are dovish, and some are neither.

I disagree with the hawk vs. doves dichotomy. The service-oriented doves are really divided into at least two camps. An older, more deeply entrenched group but shrinking group of treatment professionals who might be dovish relative to hawks, but generally support some form of prohibition. Then there is a newer group of doves who aren't all that service-oriented but are more radically dovish, advocating more radical decriminalization.

He offers five principles to guide policy decisions:

First, the overarching goal of policy should be to minimize the damage done to drug users and to others from the risks of the drugs themselves (toxicity, intoxicated behavior and addiction) and from control measures and efforts to evade them.

That implies a second principle: No harm, no foul. Mere use of an abusable drug does not constitute a problem demanding public intervention. “Drug users” are not the enemy, and a achieving a “drug-free society” is not only impossible but unnecessary to achieve the purposes for which the drug laws were enacted.

Third, one size does not fit all: Drugs, users, markets and dealers all differ, and policies need to be as differentiated as the situations they address.

Fourth, all drug control policies, including enforcement, should be subjected to cost-benefit tests: We should act only when we can do more good than harm, not merely to express our righteousness. Since lawbreakers and their families are human beings, their suffering counts, too: Arrests and prison terms are costs, not benefits, of policy. Policymakers should learn from their mistakes and abandon unsuccessful efforts, which means that organizational learning must be built into organizational design. In drug policy as in most other policy arenas, feedback is the breakfast of champions.

Fifth, in discussing programmatic innovations we should focus on programs that can be scaled up sufficiently to put a substantial dent in major problems. With drug abusers numbered in the millions, programs that affect only thousands are barely worth thinking about unless they show growth potential.

Finally, he offers an agenda for policy change. I doubt I could ever comfortably endorse some of these. Others, I find myself resisting, but in the context of radical change (rather than incremental), they may be more acceptable.

• Don’t fill prisons with ordinary dealers.
• Lock up dealers based on nastiness, not on volume.
• Pressure drug-using offenders to stop.
• Break up flagrant drug markets using low-arrest crackdowns.
• Deny alcohol to problem drinkers.
• Raise the tax on alcohol, especially beer.
• Eliminate the minimum drinking age.
• Prevent drug dealing among kids.
• Say more than “No.”
• Don’t rely on DARE.
• Encourage less risky forms of nicotine use.
• Let pot-smokers grow their own.
• Encourage problem drug users to quit without formal treatment.
• Expand opiate maintenance.
• Work on immunotherapies.
• Get drug enforcement out of the way of pain relief.
• Create a regulatory framework for performance-enhancing chemicals.
• Figure out what hallucinogens are good for, and don’t let the drug laws interfere with religious freedom.
• Stop sacrificing foreign policy and human rights objectives to drug control.

How kids can drink at home, legally

It was news to me that 31 states permit underage drinking with a parent:

"You can be 10 years old and drink in Virginia," said Beth Straeten, a spokeswoman for the state's Department of Alcoholic Beverage Control.

Surprised?

...Eleven states, Virginia among them, say providing alcohol to an underage son or daughter can only occur in the home. Twenty other states say parents can provide alcohol to their children anywhere.

The Virginia exception was passed during the 2006 legislature. It drew only two negative votes and won the signature of Gov. Timothy M. Kaine.

I was unable to find out what Michigan's law is. I'll post an update if anyone fills me in.

[Update: Jess found what appears to be the relevant Michigan law and there does not seem to be any language that would permit a minor to drink with a parent.]

Scientology Treatment Program for Prisoners Funded by Feds

Scientologists have scored a victory in New Mexico:

Federal tax dollars are helping to pay for a controversial addiction-treatment program for prisoners in New Mexico based on Scientology precepts...

The Second Chance program is billed as an alternative treatment program for nonviolent offenders and uses the principals of Scientology -- such as using saunas, diet, massage and vitamins to purge the body of toxins -- to fight addiction. In New Mexico, 24 of the state's 84 district judges have referred a total of 50 clients to the program since it opened last September.

Second Chance is the only Scientology-based treatment center for inmates in the U.S. A former chief district judge from Albuquerque, W. John Brennan, is a paid consultant hired to promote the program to his former colleagues. But the current chief district judge, William Lang, doesn't want judges to make referrals to the program, saying he is suspicious of its relationship with the Church of Scientology even though program officials say there is no link.

..."There's a lot of use of sauna with the idea that you sweat out toxins in the system," said addiction expert Bill Miller, who reviewed the program at the request of the city of Albuquerque. "I don't know of any scientific basis for that. It wasn't clear to me what sort of scientific basis there was even for the conception of the program to begin with."

The most troubling thing about Narconon and other Scientology-based programs is their consistent denials of any connection to the Church of Scientology. Offering a faith-based program is one thing, but misrepresenting themselves is another.

Stats.org weighed in on the WSJ's over-tentative reporting on matter. Unfortunately the author (Maia Szalavitz) appears to have forgotten to include Twelve Step Facilitation when mentioning evidence-based treatment strategies.

Why is it so hard to help drug-addicted criminals?

Here's a column about a rejected proposal (Hamilton, Ontario) to house an addiction counselor in the police department to intervene at the time of arrest throughout the judicial process. The goal is to capitalize on the crisis of being arrested and charged with a crime as an opportunity for active linkage to help rather than a passive referral.

It was shot down because they wanted prevention programs. It's an interesting idea that could be effective.

What's more interesting is what this (and programs like drug courts) says about systemic ownership of the problem of addiction. Over the last decade or so the criminal justice system has been realizing that the drug problem is not a simple criminal matter and they they are not equipped to respond in an effective and humane manner. The response has been to incrementally develop therapeutic responses within the criminal justice system, many with decent results. However, it seems that the real issue is what system(s) should "own" the problem.

There's a push right now to move ownership from the criminal justice system to the public health system (not necessarily the treatment system). If this movement was successful, I suspect that within a generation there would be renewed calls for ownership to be transferred back to the criminal justice system.

Right now I'm thinking that it doesn't have to be and either/or decision. It seems that there could be shared ownership to some extent--maintaining some reduced measure of prohibition (I know that the work prohibition freaks people out, but we prohibit everything from speeding to murder. Pretty broad continuum of enforcement approaches, no?) and rebuilding access to a treatment system with continuous recovery management.

The Short Road to Recovery

(click here to view)

Sage Stossel Atlantic Monthly Online Jan 27, 2007 EditorialCartoonists.com

Electric shock therapy for addicts

Scotland starts a new trial of ECT (source):

A radical new treatment for heroin addiction is to undergo its first clinical trial in Scotland, it was announced yesterday.

Neuro-electric therapy - NET - has been billed as a safer, more effective alternative to methadone, the heroin substitute which is both addictive and damaging to health.

The creators of NET believe their detoxification therapy not only reduces withdrawal symptoms but also removes cravings.

Readiness for change and drug use outcomes after treatment

Another study finding that the client's stage of change is a poor predictor of outcomes:

Results failed to support the hypothesis that taking steps should be associated with less frequent use of illicit opiates at follow-up. No statistically significant associations of any kind were found between readiness for change measures and use of opiates or stimulants at follow-up. A negative association was found between taking steps and benzodiazepine misuse. Readiness for change measures were correlated with heroin use and psychiatric symptom scores at treatment intake.

There has been high profile criticism that the rush to embrace the stages of change has outpaced the evidence. The question isn't whether the stages of change have any utility. The question is what are they useful for? Patient/family eduction, counselor education, conceptualizing interventions, matching treatments, etc.

The stages of change have undoubtedly changed the field for the better, but there are a lot of weak points that have not been adequately explained--failure to recognize the instability of motivation; disagreements about how to determine the client's stage of change; failure to account for stable, unplanned change; failure to explain for stable, initially coerced change. I've been especially concerned about practitioners relying on the stages of change for treatment placement and the inevitable post hoc deconstructions of treatment "failures" that blame the client's motivation and then conclude that we wasted money treating them (and suggest that better assessment would have led to the conclusion that the client wasn't motivated and a better referral).

Robert West, the editor of Addiction, has offered a new model for understanding change, he has called the PRIME theory.

More on the insula and smoking

I posted earlier on an exciting study on the relationship between the insula and nicotine addiction. Here's an article with a little more detail.
[via: New Recovery]

Singapore drug cases jump 42 pct on Subutex abuse

Singapore is reporting problems with buprenorphine misuse. It's too bad that the drug they've used is not Suboxone. Suboxone has naloxone added to reduce the potential for misuse. It will be interesting to see if the addition of naloxone is effective in reducing diversion.

Drug-abuse cases in Singapore soared last year, mainly because of a surge in the use of Subutex, a drug which was introduced to help wean drug addicts off heroin, Singapore's Central Narcotics Bureau (CNB) said.

Singapore introduced Subutex as a prescription medication five years ago to help wean addicts off heroin. But the narcotics agency said that 30 percent of abusers caught were hooked on Subutex, which is sometimes mixed with a tranquiliser or other drugs to produce a high.

But in mid-August, the government reclassified Subutex as an illegal drug. Since then, authorities have arrested a total of 347 people for abusing the drug. In all, Singapore has arrested 1,127 users last year, up 42 percent from 793 in 2005, the CNB said in a statement.

Spot in brain may control smoking urge

A stroke patient may have revealed a key to understanding craving:

Damage to a silver dollar-sized spot deep in the brain seems to wipe out the urge to smoke, a surprising discovery that may shed important new light on addiction. The research was inspired by a stroke survivor who claimed he simply forgot his two-pack-a-day addiction - no cravings, no nicotine patches, not even a conscious desire to quit.

"The quitting is like a light switch that went off," said Dr. Antoine Bechara of the University of Southern California, who scanned the brains of 69 smokers and ex-smokers to pinpoint the region involved. "This is very striking."

Clearly brain damage isn't a treatment option for people struggling to kick the habit.

But the finding, reported in Friday's edition of the journal Science, does point scientists toward new ways to develop anti-smoking aids by targeting this little-known brain region called the insula. And it sparked excitement among addiction specialists who expect the insula to play a key role in other addictions, too.

"It's a fantastic paper, it's a fantastic finding," said Dr. Nora Volkow, director of the National Institute on Drug Abuse and a longtime investigator of the brain's addiction pathways.

"What this study shows unequivocally is the insula is a key structure in the brain for perceiving the urges to take the drug," urges that are "the backbone of the addiction," Volkow added.

Why? The insula appears to be where the brain turns physical reactions into feelings, such as feeling anxious when your heart speeds up. When those reactions are caused by a particular substance, the insula may act like sort of a headquarters for cravings.

Mid-lifers most likely to have injected drugs

More evidence that the most serious drug problems are among middle-aged people:

Injection drug use is becoming less common among young people in the U.S., especially blacks, a new analysis of national data shows.

In fact, middle-aged men and women are more likely to have ever injected drugs than younger people -- or older people, for that matter...

Psychiatric disorders and substance misuse

Last night I posted an article about gender and substance misuse. I didn't realize that the Psychiatric Times had a special report section on psychiatric disorders and substance misuse. I haven't had time to read the whole thing yet. What I did read seemed okay other than a sky high prevalence estimate for borderline personality disorder in people with substance use disorders:

Nearly one third of those with a lifetime SUD diagnosis also have BPD (median, 27%; range, 5.2% to 74.0%).^16,20 BPD appears to be less prevalent in persons with alcohol use disorders (median, 16%; range, 3.2% to 27.4%) than in those with drug use disorders, especially cocaine and opioid abuse.^17,20 For example, Ross and colleagues¹⁷ found that almost half (47%) of individuals using heroin who entered treatment for SUD also had BPD.

Here's a list of all the articles:

• The Link Between Psychotic Disorders and Substance Use By Emma Barkus, PhD
• Safe Treatment of Pain in the Patient With a Substance Use Disorder By Penelope P. Ziegler, MD
• Schizophrenia and Substance Abuse: Is There a Role for Atypical Antipsychotics? By Giovanni Caracci, MD
• Implications for Treatment and Prognosis of Borderline and Substance Use DisordersBy Ulrike Feske, PhD, Paul H. Soloff, MD, and Ralph E. Tarter, PhD
• Substance Abuse in Women: Does Gender Matter?By Sudie E. Back, PhD, Regana Contini, MD, and Kathleen T. Brady, MD, PhD

Alternative treatments give addicts a chance

An opinion piece on Sam Sullivan's (Vancouver's Mayor) proposal for stimulant maintenance programs. (Previous post here.) Grrrr.

Protecting fetuses from mothers who drink

Statin drugs may protect fetuses from maternal alcohol use.

Methadone in the news

Two recent stories on methadone. First, researchers may have identified a genetic marker that indicates the person's drug metabolism. They believe that these finding could be important in determining dosing for methadone. Second, a story about prison-based methadone programs.

Substance abuse in women: Does gender matter?

The Psychiatric Times runs a helpful review of gender differences in substance misuse. It covers several areas including epidemiology, comorbidity, diagnosis, course and neurobiology. From the section on treatment:

A number of studies indicate that women are less likely than men to enter treatment.¹ Reasons for lower rates of treatment entry may include sociocultural factors (eg, stigma, lack of partner/family support to enter treatment), socioeconomic factors (eg, child care), pregnancy, fears concerning child custody issues, and complexities associated with increased rates of co-occurring psychiatric disorders and the availability of appropriate dual-diagnosis treatments.^1,30,46 Furthermore, as previously stated, many women seek treatment at settings or clinics other than substance abuse clinics (eg, primary care, mental health).¹⁸

Those women who do enter substance abuse treatment receive similar benefits to those received by men. There are few, if any, consistent gender differences in treatment outcome, retention rates, or relapse rates across various types of substances, treatment settings, and types of treatment.^1,47,48 In studies that have found gender differences, women typically have better outcomes than men. For example, women have been found to have higher rates of abstinence at 6-month follow-up (79.3% of women vs 54% of men) and at 5 years (odds ratio, 1.9).^24,49,50 Women also demonstrate greater improvement in other domains (eg, medical problems⁵¹), have shorter relapse episodes,⁵² and are more likely to seek help following a relapse.^52,53

What a Long Strange Trip It's Been

Mentions of ecstasy as a therapeutic tool have popped up here and there for some time. Looks like we may be hearing more about it in the coming year:

This year, the drug MDMA, otherwise known as ecstasy, could take a step toward medical respectability. Researchers in South Carolina have begun experimenting with MDMA for patients with post-traumatic stress disorder. At Harvard, a long-awaited pilot study will begin on whether the drug can help relieve anxiety and pain in terminal cancer patients in connection with psychotherapy. And studies will also start in Switzerland and Israel, where a former chief psychiatrist of the Israel Defense Forces will oversee work with people whose PTSD stems from terrorism or war.

Vancouver mayor proposes 'revolutionary' plan for addicts

Vancouver's Mayor is promoting his plan for stimulant maintenance again and calling it treatment. This is the same guy who suggested that addicts and the public need to get real and accept addiction as a permanent disability, like his experience of having to accept his spinal cord injury and life in a wheel chair.

Vancouver Mayor Sam Sullivan is lobbying the federal government for an exemption from Canada's narcotics laws that would allow what he calls a "revolutionary" alternative drug-treatment plan to give substitute drugs to at least 700 cocaine and crystal-meth addicts.

If he is successful, Vancouver would be a global pioneer in running such a large-scale program of drug maintenance for stimulant-drug users.

Sullivan said the drug plan, along with three other key elements that have to come from Ottawa or Victoria, will eliminate most of Vancouver's problems with homelessness, panhandling and drug-dealing. Those are the three social problems he promised to reduce by half in time for 2010 in the Project Civil City initiative that he launched in November.

Do drug courts tame the meth monkey?

Utah's Governor starts a drug court push for meth addicted mothers and proposes significant investment in treatment:

Despite efforts to combat it, Utah's meth problem continues to grow - especially for women.
For five years, meth has been the top illegal drug of choice for Utahns entering public treatment. For women it surpasses even alcohol, the traditional front-runner, making it the only drug in history to have its female users outnumber males. Nearly half the women in treatment statewide have children.

Gov. Jon Huntsman Jr. has proposed investing $2 million in Utah's drug courts and $2.5 million to build two residential clinics in northern and southern Utah to treat 600 women, giving priority to those involved with the child welfare system. But Huntsman will have to convince lawmakers it's a wise investment, no easy task considering the stigma attached to addiction and a dearth of data on treatment, including how patients and drug court graduates fare over the longer term.

Helping Utah's women poses another challenge: transforming a system that wasn't built for them.

"Substance abuse treatment has been historically geared for white, middle-aged male alcoholics," said Salt Lake County substance abuse Director Patrick Fleming. "We're a hell of a lot better at treating women than 10 years ago, but there's room for improvement."

I'd challenge the "dearth of data" statement. We have a lot of data on the effectiveness of treatment and drug courts.

Lush Life: How Stars Make a Mockery Out of Rehab

More news coverage on treatment as havens for the rich.

More Nicotine Madness

Media critic Jack Shaeffer weighs in on the coverage of this week's Harvard nicotine level study. He shares the tobacco companies side of the story and says, "so what" about higher nicotine levels:

A substantial body of scientific research shows that smokers excel at milking cigarettes for the nicotine dose they desire, irrespective of how many milligrams of nicotine the actual cigarette they end up smoking contains. The well-known behavior is called "compensatory smoking." University of Waterloo professor David Hammond wrote in a sidebar to my piece last summer, "humans adjust the intensity of their smoking in response to the cigarette design and emission level. Therefore, 'lower nicotine' yield cigarettes are smoked systematically more intensely."
...

Whenever the press writes about nicotine yields, it invariably quotes some public-health advocate warning that even these incremental increases in nicotine automatically make cigarettes more addictive. But if that were true, wouldn't the press or somebody have saluted the tobacco industry for reducing the addictive potential of cigarettes whenever nicotine levels dropped? Indeed, between 1972 and 1983, the average measured nicotine (sales weighted) dropped from 1.39 milligrams per cigarette to 0.88 milligrams per cigarette. From 1989 to 1996, it dropped from 0.96 milligrams per cigarette to 0.88 milligrams per cigarette. (See this Federal Trade Commission PDF.) I don't recall hearing any cheering.

The nicotine-yield obsession blinds the press and some in the public-health establishment to the fact that, as Hammond wrote in the Slate sidebar last summer, there's enough nicotine in any commercially available cigarette "to promote and sustain addiction." All cigarettes are dangerous, no matter what their octane rating.

Ketamine relieves depression within hours

Ketamine may provide insight into new mechanisms for medication development for depression:

A drug used as a general anaesthetic may also work as a remarkably rapid antidepressant, according to a preliminary study.

The drug’s hallucinogenic side effects mean it is unlikely to be prescribed to patients, but it could pave the way to new faster-acting antidepressants, the researchers suggest.

Ketamine is used as an animal tranquiliser, but is perhaps better known as an illicit street drug, sometimes called “special K”. Now researchers have found the drug can relieve depression in some patients within just 2 hours – and continue to do so for a week.

In utero marijuana exposure alters infant behavior

The Journal of Pediatrics has a new study suggesting in utero marijuana exposure may cause behavior changes in newborns. I'll look forward to attempts to replicate these findings:

Infants exposed to marijuana in the womb show subtle behavioral changes in their first days of life, researchers from Brazil report.

These newborns were more irritable than non-exposed infants, less responsive, and more difficult to calm... They also cried more, startled more easily, and were more jittery. Such changes...have the potential to interfere with mother-child bonding.

Barros and her team looked at 561 infants born to adolescent mothers. Twenty-six of them had been exposed to marijuana, as revealed by tests on the mother's hair and the infant's stool. Just one of the mothers had reported smoking pot while pregnant.

Trained examiners, who did not know a child's marijuana exposure status, tested the neurobehavioral responses of all infants. On average, marijuana-exposed infants scored differently on measures of arousal, regulation and excitability compared to the non-exposed infants.

...

Marijuana's active ingredient, tetrahydrocannabinol (THC), does cross the placenta into the fetal circulation, Barros and her team point out. The drug also has been shown to trigger the expression of the neurotransmitter dopamine, they add, and this could result in long-term alterations in nervous system function.

"It is necessary to counter the misconception that marijuana is a 'benign drug' and to educate women regarding the risks and possible consequences related to its use during pregnancy," Barros and colleagues conclude.

U.S.-Style Rehabs Take Root in China As Addiction Grows

A shift in problem ownership of addiction from criminal justice to specialty treatment providers:

Half an hour outside this capital city in southwest China's Yunnan province, amid 100 acres of fruit trees and vineyards, three dozen recovering drug addicts stand every morning in a loose circle, their arms around each other's shoulders.

The voices that ring out do not recite the forced slogans and denouncements often heard in China's state facilities for drug users. Instead, the group reads aloud a mission statement that has been adopted from a New York-based drug treatment center:

"I am here because there is no refuge," the participants said in unison on a recent Saturday morning. ". . . Until I confront myself in the eyes and hearts of others, I am running."

That focus on individual responsibility and peer interaction is atypical for a drug treatment facility in China. Much more common are techniques used at the nearly 600 compulsory detoxification centers run by the police, or the even tougher techniques used by the Justice Department at reeducation campuses for repeat offenders. Both are military-like institutions that emphasize manual labor as part of their regimen.

Narcotic Meds for Back Pain Questioned

This caught my attention and has some practical application, for physicians treating back pain--they should engage in pretty tight follow-up of they are prescribing opiates on long term basis for back pain. What I found more interesting is that this figure of 24% matches previous "capture rate" data pretty closely.

While the pain may be relieved to some extent over the short-term (3 months), the risk of addiction and long-term effectiveness may override any temporary benefits.

Researchers from the Yale School of Medicine found use of opiods for short-term relief of chronic back pain lead to behaviors of opiod abuse in 24 percent of the cases reviewed.

Researchers Confirm Rising Nicotine Rates

Phillip-Morris denies it, but a new Harvard study confirms a study done earlier this year finding that nicotine levels in cigarettes have increased over the last decade:

Researchers at the Harvard School of Public Health say they have confirmed a study released last year by health officials in Massachusetts that found steadily increasing levels of nicotine in cigarettes sold in the state from 1997 to 2005. The analysis, based on data submitted to the Massachusetts Department of Public Health by cigarette manufacturers, found that increases in smoke nicotine yield per cigarette averaged 1.6 percent each year, or about 11 percent over a seven-year period.

Ending an Opium War: Poppies and Afghan Recovery Can Both Bloom

Washington Post columnist Anne Applebaum argues for the U.S. to start purchasing opium poppies from Afghanistan. She frames it through a lens of Afghan national stability and U.S. foreign policy interests. Her arguments are persuasive, unfortunately a couple toss away lines suggest a bias:

Of course it isn't fashionable right now to argue for any legal form of opiate cultivation.

...

The only good arguments against doing so -- as opposed to the silly, politically correct "just say no" arguments --...

What are the "just say no" arguments anyway? Am I silly for feeling queasy about the idea of further institutionalizing poppy farming and wondering if has the potential to increase international production?

I'd also challenge the "politically correct" and "unfashionable" feels spurious., she's hardly in the wilderness. Certainly, the White House is staunchly pro-war-on-drugs, but the media, academics, public health activists, and growing numbers of politicians and political thinkers on both ends of the spectrum are increasingly calling for radical changes in drug policy--including legalization

Public support for parity

Mental Health American (formerly the National Mental Health Association) released a poll on mental health and substance abuse parity this week. They are an advocacy group, so they have a clear bias, but the results they report are overwhelming:

Americans Think Health Coverage Should Include Mental Health and Substance Abuse... A large majority (74%) believe that insurance plans should cover substance abuse treatments at the same levels as treatments for general health issues. 23% feel that they should not be covered equitably. * The public demand for mental health equity is bipartisan -- 83% of Republicans and 92% of Democrats want equitable health insurance.

The other losing war

Commentary on the impact of the war on drugs in this hemisphere.

Big score holy grail for drug officers

A peak inside some of the culture problems in the narcotics unit in Atlanta. This article paints a picture of a unit that wants to make big busts but has so much pressure to generate arrests that they spend all their time arresting people with small quantities and sometimes cutting corners to get them. This is presented as the context for a shootout with a 92 year old woman that ended in her death.

'Drinko': Anatomy of an Advocacy Campaign

Join Together breaks down the campaign that get Target, Kohl's and Linens 'n Things to stop selling drinking games.

More on radical recovery

I got some strong responses to Radical Recovery and thought you might want some more on the subject. Here are two more articles on the tension between 12 step recovery's focus on self-change and social activism.

• Radicalizing Recovery: Addiction, Spirituality, And Politics
• Needed: a radical recovery
  

Kennedy, Ramstad hit the road to tout mental health measure

Substance abuse and mental health parity bills have been introduced several times in the last decade. Supporters reportedly have all the votes they need to pass it and President Bush has indicated that he would sign it, but Republican house leadership consistently blocked it from going to the floor for a vote. Hopefully this will be an opportunity to enact it.

Reps. Patrick Kennedy (D-R.I.) and Jim Ramstad (R-Minn.) will embark on a six-city tour today to tout legislation that would require insurance companies to treat mental illness and addiction just as they would any physical illness. The tour will kick off in Providence, R.I., then head to Ramstad’s district in Minnetonka, Minn., and continue on to Rockville, Md., Los Angeles and Vancouver, Wash.

Radical Recovery

For MLK day, here's an article by Bill White on "radical recovery." He describes a convergence of social activism and addiction recovery.

The article offers a model that goes well beyond the the interests of recovering people themselves and encourages advocacy in larger community contexts:

A radical recovery movement is now rising in America. That movement is flowing from the realization that addiction and its progeny of problems are visible everywhere, while recovery from addiction lies hidden. It is rising in the recognition that the stigma attached to AOD problems has increased in recent decades and has fueled the demedicalization and recriminalization of these problems. What started out as “zero tolerance” for drugs rapidly evolved into zero tolerance for people with AOD problems. It is in this regressive climate that a style of recovery is emerging that is radical in its scope (focus on environmental as well as personal transformation), radical in its inclusiveness (celebration of multiple pathways and styles of recovery), and radical in its synthesis of social responsibility and personal accountability. People in recovery are looking beyond their own addiction and recovery experiences to the broader social conditions within which AOD problems arise and are sustained. A radicalized vanguard of people in recovery is using personal transformation as a fulcrum for social change. They are living Gandhi’s challenge to become the change they wish to see in the world. Those who were once part of the problem are becoming part of the solution.

My Adventures in Psychopharmacology

A 23 year old women tells of her nightmarish experience with the psychiatric and addiction treatment system. She was prescribed 15 different drugs over a period of 5 years and, surprise, surprise, when treatment failed, she was blamed. The story ends with her being presumably correctly diagnosed and treated, but it's hard not to wonder if she has a chronic mentally illness at all.

Aside from the iatrogenic harm that professional hubris can cause, this story illustrates the hazards of a system that encourages rapid diagnosis.

Medication Nation

The Washington Post published a review of the recently published book, The Cult of Pharmacology by Richard DeGrandpre. DeGrandpre presents a pretty provocative premise:

Why isn't Nicorette gum a street drug? The Food and Drug Administration considers nicotine highly addictive. Tobacco companies seem to share this view when they manipulate the level of nicotine in cigarettes. But the gum, which packs a goodly dose of nicotine, appeals to almost no one. While we're at it, if nicotine dependence is what stands in the way of quitting, why do patched smokers -- their brains well-supplied with the substance -- still crave the next drag?

If these questions have an answer, it is that addiction is not a simple matter of chemical and receptor. Habit, ritual, social context and the means of delivery all affect how the brain processes a drug and how we experience it. As a result, drug research is replete with paradox.

...

Psychoactive compounds, he writes, function "as mere stimuli, with more or less the same, potentially great, powers as other stimuli one experiences and gives meaning to." DeGrandpre derides a set of beliefs that he groups under the infelicitous name "pharmacologicalism." This false ideology, he writes, holds that "drugs contain potentialities that lie within the drug's chemical structure . . . and when taken into the body, these potentialities take hold of and transform both brain and behavior." According to DeGrandpre, drugs do not work in any consistent, predictable way -- and we've been brainwashed if we think that they do.

The prevailing ideology, DeGrandpre argues, has another, equally insidious side. It causes us to attribute different powers to substances that are effectively identical. We demonize cocaine, a natural stimulant, but sanctify its synthetic counterpart, Ritalin. This benefits the "medicopharmaceutical industrial complex," which favors what can be patented and profited from. Ultimately, our confused beliefs lead to forms of social control, causing us to drug our children with stimulants while imprisoning consenting adults for taking nearly identical substances such as crystal meth.

The reviewer writes a thoughtful and effective critique of DeGrandpre's arguments:

The problem with DeGrandpre's argument is that he, more than his imagined opponents, ignores context. The findings of behavioral pharmacology are not unique; in medicine, environment often modifies physiology. Interferon, a medication used to treat certain cancers, causes depression, but it does so less in people who have social supports and more in patients who have had past depressive episodes. To show that the response is multifactorial hardly invalidates the claim that the drug triggers mood disorders.

Expectancy is powerful. Acupuncture is effective in pain relief. But so is sham acupuncture -- using shallow needles inserted at random points. Pain responds to placebos. It does not follow that pain lacks anatomical roots or that the use of aspirin for pain management amounts to a conspiracy.

Our drug policies, arising from puritanical moralizing as much as from the needs of corporations, are often irrational. Still, not every choice is without foundation. Like cocaine, Ritalin modulates dopamine transport in the brain. But schoolchildren who take Ritalin by mouth generally experience no high and develop no craving, while snorting cocaine famously does cause a rush. And crystal meth's minor chemical distinction -- it is water soluble and therefore easy to inject -- makes a major practical, and addictive, difference. That we allow Ritalin to be prescribed suggests that, as a nation, we pay attention both to drugs' chemical properties and to their customary usage -- hardly a sign of ideological rigidity.

It's too bad he throws in the drug policy statement. The suggestion that the motivations for U.S. drug policy are two-faceted and wholly insidious reveals his own ideology.

The needle and the damage done

This 2 year old article about the disciplinary of some British methadone maintenance physicians has been making the rounds today. It has a pretty clear bias for maintenance, but it offers quite a bit of history about the British opiate addiction treatment. It also illustrates how committed the British system has been to methadone. The whole debate is between methadone detox and methadone maintenance.

As the story of these doctors progresses, it includes drugs (obviously), Madonna, Hollywood and martial arts--what more could you want?

Three of the doctors involved were found guilty of misconduct and one was stripped of his license.

Benefit-Cost in the California Treatment Outcome Project: Does Substance Abuse "Pay for Itself?"

I think I posted a news article summarizing these findings, but this link includes a PDF of the journal article:

Results from a cost-benefit analysis of substance abuse treatment programs are presented. Sections of this article include: abstract; methods; results according to per diem substance abuse treatment costs, average cost and benefits associated with substance abuse treatment, pre-post changes in the individual sources of monetary benefit, sensitivity analyses; "inflating" the arrest data, multiple regression models, cohort, and varying treatment intensity across providers; and discussion. A ratio of 7:1 benefits to costs exists; a benefit of $11,487 to a cost of $1,583.

Tobacco report cards

The American Lung Association issued report cards for all 50 states on their tobacco policies. Michigan didn't fare too well:

REPORT CARD

STATE OF TOBACCO CONTROL 2006 MICHIGAN

Grades:
Smokefree Air - F
Youth Access - F
Tobacco Prevention and Control Spending - F
Cigarette Tax - A

US prison release a health risk: study

A new study reinforces the risks associated with overdose and release from prison:

Getting released from US prisons could be even more dangerous than being in them.

Death and prison records from Washington state show that 30,237 convicts released from 1999 to 2003 were 12 times more likely to die from a drug overdose and 10 times more likely to be murdered in a two-year period than the general population.

...

During the two-week period immediately after their release, compared to years later, the ex-cons were:

* 29 times more likely to die from cocaine;

* 34 times more likely to die from a heroin overdose;

* 15 times more likely to be killed by alcohol;

* more than twice as likely to be gunned down; and

* nearly 8 times more likely to commit suicide.

The authors of the study characterized these results as surprising. I'm not sure why it should be surprising. It's well known that substance use problems occur in around 80% of inmates and that addicts are at greatest risk for overdose after a period of abstinence, especially involuntary abstinence. Additionally, people who end up in prison are probably among those with the greatest number of co-occurring problems. They get placed in a toxic environment, get little or no treatment and (locally) are often released into conditions that make relapse and recidivism nearly inevitable.

Facts on the new smoking cessation medication

A new fact sheet on Varenicline (the generic name for Chantix), the newly approved smoking cessation drug. It's the first drug to target nicotine receptors.

Study: H.S. Teenage Binge Drinking Common Link To Greater Risky Behaviors

A new report on the prevalence of teen binge drinking and the harms associated with it:

The latest study published in the January issue of "Pediatrics" based on the Centers for Disease Control (CDC) study indicates that binge drinking is common among high school students and is linked to a greater participation in several other risky behaviors.

The new study conducted by CDC scientists, Binge Drinking and Associated Health Risk Behaviors Among High School Students, found that 45 percent of high school students admittedly reported to alcohol consumption within the last month. The survey found that 64 percent of these students also reported binge drinking.

Binge drinking is defined as consuming five or more alcoholic drinks in a row within a few hours of time.

The study found that the probability of teenage binge drinkers to be tempted to get involved in other risky behaviors was much higher than that of the nondrinking teens.

These risky behaviors included sexual activity, smoking and physical fighting to name a few.

Although those students who denied any binge drinking were involved in many of the other risky behaviors, the extent to which they were involved was much lower than those students who admitted to binge drinking.

According to CDC researcher, Jacqueline Miller, MD, "Our study clearly shows that it's not just that students drink alcohol, but how much they drink that most strongly affects whether they experience other health and social problems."

The CDC researchers indicated the following comparisons between nondrinking and binge drinking teenagers from their study, with teen binge drinkers being:

• Greater than five times more likely to be sexually active with one or more partners.
• Smokers with 19 times more likelihood to smoke cigarettes.
• Almost four times as likely to engage in physical fights.
• Eleven times more likely to become a passenger in a vehicle being driven by another who has been drinking alcohol.
• Almost four times more likely to date rape or a victim of violence by the opposite sex.
• Four times more likely to attempt suicide.
• At greater risk to use drugs, such as marijuana and cocaine.

The survey also indicated that binge drinking among these teenagers was more common with boys than girls.

The binge drinkers self-admittedly reported poorer grades in school as well.

Overall, the survey included reports of both public and private school students across the entire U.S.

Assertive Continuing Care effectiveness

More evidence for the effectiveness of assertive continuing care (ACC) in adolescents. It's an important emerging recovery management approach:

ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence.

Advocates Renew Push for Mental Health 'Parity' Bill

This NPR story suggests that there is a good opportunity right now for passing parity legislation. The story never mentions addiction treatment. In the past, every time they get close to passing comprehensive parity (mental health and addiction), they drop addiction. We'll see what happens with this go-round.

Memory’s Link to Recovering from Addiction

A pretty clear explanation of one of the neurobiological mechanisms of addiction:

New research on the brain is showing that addiction is a matter of memories, and recovery is a slow process in which the influence of those memories is diminished...

Studies have shown that addictive drugs stimulate a reward circuit in the brain. The circuit provides incentives for action by registering the value of important experiences. Rewarding experiences trigger the release of the brain chemical dopamine, telling the brain “do it again.” What makes permanent recovery difficult is drug-induced change that creates lasting memories linking the drug to a pleasurable reward.

High school drug use predicts job-related outcomes at age 29

A new study finds a relationship between adolescent drug use and job status 10 years later:

Overall, the results suggest that adolescent drug use is linked with poorer occupational and job quality outcomes as much as 10 years after high school. Interestingly, which job-related outcomes are affected by early hard drug use varies by gender. Females who use hard drugs as adolescents end up in lower skill, lower status jobs while males who use hard drugs as adolescents are more likely to end up in jobs with fewer benefits (e.g., health, retirement).

Youngest Drinkers Likelier To Use Alcohol For Stress Relief As Adults

A new study reports on the impact of one risk factor for problem substance use:

The younger someone starts drinking alcoholic beverages, the more likely he or she is to reach for a drink to relieve stress when older, a large new study suggests.

...

Respondents were asked whether they had experienced 12 different types of stressful events in the previous year, such as death of a family member or close friend, unemployment for more than a month, financial crises, legal problems or disruption of a marriage or romantic relationship.

Average daily consumption of alcohol increased by 19 percent with each additional stressful event experienced among those who started drinking at 14 or younger compared with 3 percent among those who took their first drink at 18 or older.

After adjusting for other factors that might be related to the amount of alcohol consumed, the researchers said "the association between stress and volume of consumption was significant only for early initiators."

Encouraging Posttreatment Self-Help Group Involvement to Reduce Demand for Continuing Care Services

A new study on 12 step involvement as continuing care:

Background: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients' health care costs in the first year after treatment, but such initially impressive effects may wane over time. This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up.

Methods: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step–based (n=887 patients) or cognitive-behavioral (CB, n=887 patients) treatment programs. The 12-step–based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs. The 2-year follow-up assessed patients' substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs.

Results: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) versus CB (37.0%) programs. Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs. In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p=0.01).

Conclusions: Promoting self-help group involvement appears to improve posttreatment outcomes while reducing the costs of continuing care. Even cost offsets that somewhat diminish over the long term can yield substantial savings. Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

This article focuses on cost savings, so the abstract is limited to this narrow area. Here's an additional finding from the study:

Both 12-step and CB program patients experienced substantial and comparable improvements in substance-related problems and psychiatric outcomes and required less ongoing professional treatment between 1 and 2 years than they had in the year after discharge. However, patients treated in 12-step treatment programs achieved substantially better abstinence rates (49.5 vs 37.5% in CB). This difference is actually slightly larger than that identified at 1-year follow-up (45.7% in 12-step vs 36.2% in CB

It's worth noting that, while the authors are supporters of 12 step groups, they suggest that this outcome may have more to do with mutual aid group involvement than with the specific mutual aid group.

Bias in co-occurring research

An interesting new study on drinking and depression:

"Not all studies have found a significant relationship between drinking and depression," said Kathryn Graham, senior scientist at the Centre for Addiction and Mental Health, "and some have found a relationship for one gender but not the other. In our study, we included two quite different types of measures of depression. We also used four clearly different types of alcohol consumption measures that examined both drinking pattern as well as overall consumption." Graham is the corresponding author for the study.

I hate to sound jaded, but when I read this it felt a little like a search for conclusive proof of a strong relationship between the two and self-medication as the probable explanation. I figured I was just too jaded and read on...

Results indicate that measurement and gender are key issues in interpreting findings on the relationship between alcohol and depression. Specifically, depression is primarily related to drinking larger quantities per occasion, is unrelated to drinking frequency, and these effect are stronger for women than for men.

"Depression is most strongly related to a pattern of binge drinking," said Graham. "A pattern of frequent but low quantity drinking is not associated with depression. In fact, those who usually drink less than two drinks per occasion and never drink as much as five drinks are less depressed -- for both measures of depression -- than former drinkers. This relationship with drinking pattern is greater for women than for men."

Second, the overall relationship between depression and alcohol consumption is stronger for women than for men, but only when depression is measured as meeting a clinical diagnosis of major depression. Conversely, there is no gender difference when depression is measured as recent depressed feelings, which is commonly done in research on this topic.

The first conclusion is interesting--it makes a lot of sense that depression would be more strongly associated with heavy drinking episodes rather than the frequency of drinking. The second finding also is not surprising, women self-report depressive symptoms at higher levels then men, and the study is based on a phone survey.

Finally comes the self-medication hypothesis:

"This pattern of associations is more consistent with women using alcohol to counteract depression -- by high-quantity drinking and intoxication -- than with chronic alcohol consumption tending to make women depressed," said Wilsnack. "However, a vicious circle could possibly begin with drinking in response to depression....

The bottom line, said Wilsnack, is that "clinical depression may encourage some women to drink large amounts of alcohol in hopes of numbing depressed feelings, with risks of alcohol abuse and dependence. Therefore, clinicians treating women for depression really need to be concerned about women's use of alcohol, because of the risks that women may try to medicate their moods with alcohol."

This in spite of the fact that the source article itself says "these cross-sectional data do not provide information about temporal ordering or causation".

Drug Wars in the blogosphere

Matthew Yglesias offers an interesting deconstruction of an all or nothing agrument against the war on drugs:

I guess this is something liberals and libertarians are supposed to agree about, but I consistently find it bizarre that there are some people who seem to think it would be a good idea if you could just walk into your local convenience store and pick up some heroin or crack along with your Fritos and Diet Coke. At times, people taking this line seem to argue that drug prohibition couldn't possibly be having any beneficial effects because, after all, you can still find heroin. Naturally enough, you don't see anyone proposing that the "war on mugging" be ended simply because mugging-prohibition has failed to actually eliminate the proscribed activity. That said, like any reasonable person I think many aspects of current crime-control and drug-control policy in the United States don't make sense. So I have a hard time knowing what to make of things like this from Jerry Taylor:

While it should be obvious to any fair-minded observer that our increasingly brutal war on drugs is a losing proposition on all counts, few of us seem to be fair minded observers. So allow me to pose a question to those of you still clinging to this benighted enterprise: Exactly what would it take to convince you that the drug war was causing more harm than good? Is there any bit of data, any hypothetical fact, or anything at all that would cause you to give up the policy ghost? Because if there is not, then we are in the realm of religious belief — and that’s about all that I can find to support this cruel, costly, and counterproductive jihad.

I mean, I'm not even clear on what question's being asked here. Do I think the status quo is preferable to total deregulation of currently prohibited drugs? I would say so. But considering how heavily regulated the use of alcohol and tobacco is, one hardly imagines that a heroin free-for-all (ads after school cartoons, for sale out of ice cream trucks) is a likely alternative policy. So, I don't know. What is the "war on drugs" exactly? Does it do more harm than good compared to what?

Recovery: The bridge to integration?

Bill White and Larry Davidson suggest that shifts toward recovery orientation models in mental health and addiction services could serve as a bridge toward integration:

“Recovery-oriented system transformation” is becoming an umbrella concept for integrating behavioral healthcare and creating systems of care that are culturally competent, trauma-informed, evidence-based, inclusive of families, based on strengths, and connected to communities (as indigenous sources of recovery support). Leading the call for such system transformation are new recovery advocacy movements in both the addictions and mental health fields. These movements, led by people in recovery, their families, and visionary professionals, are demanding that care be focused on the processes of long-term recovery and anchored within natural supports and local communities.

Theoretically, I don't disagree at all. My fear is that this process will not be a merger between equals, my experience (admittedly limited to southeastern Michigan) is of watching mental health systems devour addiction treatment systems. This fear is compounded by the fact that, at least in our region, mental health agencies are well-organized and well-connected governmental behemoths while addiction treatment programs are small, unstable and diffused.

Consider these historical reflections from some of Bill's other works:

The Segregation/Integration Pendulum
American history is replete with failed efforts to integrate the care of alcoholics and addicts into other helping systems. These failed experiments are followed by efforts to move such care into a categorically segregated system that, once achieved, is followed with renewed proposals for service integration. After fighting 40 years to be born as an autonomous field of service, addiction treatment is once again in the throes of service-integration mania. This cynical evolution in the organization of addiction treatment services seems to be part of two broader pendulum swings in the broader culture, between specialization and generalization and between centralization and decentralization. Once we have destroyed most of the categorically segregated addiction treatment institutions in America, a grassroots movement will likely arise again to recreate them. When the 21^st century once again gives birth to specialized addiction treatment, perhaps this “new” institution will be given a colorful name fitted to its form and function – perhaps something like inebriate asylum.

Diffusion and Diversion
Diffusion and diversion constitute two of the most pervasive threats in the history of addiction treatment institutions and mutual-aid societies. Diffusion is the dissipation of an organization’s core values and identity, most often as a result of rapid expansion and diversification. Diffusion creates a porous organization (or field) that is vulnerable to corruption and consumption by people and institutions in its operating environment. Diversion occurs when an organization follows what appears to be an opportunity, only to discover in retrospect that this venture propelled the organization away from its primary mission.

The current absorption of addiction treatment into the broader identity of behavioral health is an example of a diffusion process that might replicate two earlier periods – the absorption of inebriate asylums into insane asylums and the integration of alcoholism and drug-abuse counseling into community mental health centers in the 1960s. This diffusion-by-integration has generally led to two undesirable consequences: 1) the erosion of core addiction treatment technologies; and 2) the diversion of financial and human resources earmarked to support addiction treatment into other problem arenas.

A Panicked Field In Search of Its Soul and Its Future
In the face of such threats (managed care, facility closures, merger mania & integration into behavioral health systems), the field is experiencing a strange phenomenon. As the core of the addiction treatment field shrinks, the field is growing at the periphery. Where the total amount allocated to residential and inpatient treatment services is shrinking, the numbers of outpatient services is actually increasing, as is a growing number of new specialty programs that extend addiction treatment services into allied fields. The growth zone of the addiction treatment industry is not at the traditional core but in the delivery of addiction treatment services into the criminal justice system, the public health system (particularly AIDS related projects), the child welfare system, the mental health system, and the public-welfare system. If one looks at these trends as a whole, what is emerging in the 1990s is a treatment system less focused on the goal of long-term personal recovery than on social control of the addict. The goal of this evolving system is moving from a focus on the personal outcome of treatment to an assurance that the alcoholic and addict will not bother us and will cost us as little as possible.

The fate of the field will be determined by its ability to redefine its niche in an increasingly turbulent health-care and social-service ecosystem. That fate will also be dictated by more fundamental issues – the ability of the field to: 1) reconnect with the passion for service out of which it was born; 2) re-center itself clinically and ethically; 3) forge new service technologies in response to new knowledge and the changing characteristics of clients, families, and communities; and 4) the ability of the field to address the problem of leadership development and succession.

This Is Your Brain on Drugs, Dad

In an Op-Ed in the New York Times, Mike Males calls for an end to "the obsession with hyping teenage drug use." I have the same reaction every time I read something from him. He always does a good job arguing that we while our attention is on drugs, sex and violence among youth, the biggest problems in these area are adults.

Among Americans in their 40s and 50s, deaths from illicit-drug overdoses have risen by 800 percent since 1980, including 300 percent in the last decade. In 2004, American hospital emergency rooms treated 400,000 patients between the ages 35 and 64 for abusing heroin, cocaine, methamphetamine, marijuana, hallucinogens and “club drugs” like ecstasy.

Equally surprising, graying baby boomers have become America’s fastest-growing crime scourge. The F.B.I. reports that last year the number of Americans over the age of 40 arrested for violent and property felonies rose to 420,000, up from 170,000 in 1980. Arrests for drug offenses among those over 40 rose to 360,000 last year, up from 22,000 in 1980. The Bureau of Justice Statistics found that 440,000 Americans ages 40 and older were incarcerated in 2005, triple the number in 1990.

...

In 1972, the University of Michigan researchers who carry out Monitoring the Future found that just 22 percent of high school seniors had ever used illegal drugs, compared to 48 percent of the class of 2005. Yet as that generation has aged, it has been afflicted by drug abuse and its related ills — overdoses, hospitalizations, drug-related crime — at far higher rates than those experienced by later generations at the same ages.

However, I get the sense that his intention is for the reader to be more alarmed about adult behavior and less alarmed about youth behaviors. I tend to be more alarmed about both young people and adults. He also (unintentionally?) makes the case that the problem is worse than we realize:

When releasing last week’s Monitoring the Future survey on drug use, John P. Walters, the director of the Office of National Drug Control Policy, boasted that “broad” declines in teenage drug use promise “enormous beneficial consequences not only for our children now, but for the rest of their lives.” Actually, anybody who has looked carefully at the report and other recent federal studies would see a dramatically different picture: skyrocketing illicit drug abuse and related deaths among teenagers and adults alike.

While Monitoring the Future, an annual study that depends on teenagers to self-report on their behavior, showed that drug use dropped sharply in the last decade, the National Center for Health Statistics has reported that teenage deaths from illicit drug abuse have tripled over the same period [emphasis added]. This reverses 25 years of declining overdose fatalities among youths, suggesting that teenagers are now joining older generations in increased drug use.

Everything I've read by Males is thought provoking and worth reading. I just always feel that he's successful in making his case about adults but fails to persuade me that we're overly concerned about young people.

Alcoholics forced into hospital treatment

Australia is piloting a program that commits their most severe addicts and alcoholics for 28 days. Interesting in light of Australia's embrace of harm reduction:

HEAVILY-addicted drug users and alcoholics will be forced to have treatment in hospital under a two-year pilot proposed by the New South Wales Government.

The trial, with up to 28 days of involuntary care at Nepean Hospital, would be a "circuit breaker" for the most severely addicted, state Health Minister John Hatzistergos said today.

"The four-bed service at Nepean Hospital will aim to break the addiction cycle for alcoholics and long-term entrenched drug users, before they are referred to longer-term treatment and rehabilitation with community support and follow-up," he said.

"We expect up to 50 patients a year from western Sydney will be treated in the four-bed secure unit."

The Government is drafting changes to the Inebriates Act 1912 to enable the trial to take place.

The changes would allow medical practitioners to seek a court order referring a severely drug- or alcohol-dependent person to compulsory treatment.

Good news from the new Congress

The new Congress appears interested in revisiting the 100 to 1 disparity (see this post for an explanation) in powder vs. crack cocaine sentencing guidelines:

Key lawmaker Rep. John Conyers (D-Mich.), chair of the House Judiciary Committee, and Rep. Robert Scott (D-Va.) have signaled their intention to hold hearings on mandatory sentences for nonviolent offenses. Conyers said that the current sentencing disparity between crack and powdered cocaine offenses -- crack offenders face much harsher penalties -- is the "most outrageous example of the unfairness of mandatory minimums."

Marijuana Policy

This morning's post on the evolving sentiment toward marijuana policy reminded me of this interview with Bill White from Bill Moyer's Close to Home PBS series. I always thought that medical marijuana advocacy was a joke was an ineffective way to promote policy change, but I now think that they're having success in changing who we associate with marijuana.

White: ...you would be hard-pressed to build the case why in certain cultures opiates are celebrated and in other cultures alcohol is celebrated. I would suggest that it has little to do with science or pharmacology in either culture. It has much more to do with the historical niche that a drug fills within that culture. Most importantly, drug policy depends on whom we associate with that drug [emphasis added]. We almost always confuse our feelings about drugs with our feelings about the people we believe to use those drugs.

...

Moyers: How, then, were our drug laws developed?

White: They grew out of racial and class struggles, particularly on the West Coast and in the South. The first state laws were based on this sort of "dope fiend" caricature -- showing somebody of a different race and a different culture. In California, it was Chinese railway workers smoking opium; in the South, it was black men using cocaine. The reality is that the vast majority of people addicted to narcotics in the late 19th century were white affluent women, who were primarily addicted through traditional medicine or over-the-counter "patent" medicines. The caricature which drove the prohibition campaigns in the late 19th century bore little resemblance to reality. And, to give you a modern version of that, in the mid-1980s, when cocaine was overwhelmingly a white phenomenon in America, the images which began to appear on television were overwhelmingly of African-Americans, particularly young African-Americans enjoying crack cocaine on a street corner. If you look at all the exposes of drug exposed infants, we see young African-American infants, trembling in neonatal intensive care units. But that image was not the reality of cocaine addiction in the United States in 1985.

Moyers: Why?

White: At that exact point in time, those who were addicted to this drug were overwhelmingly white and affluent. The best predictors of cocaine use at that point were education and income. As years of education went up and annual income went up, the probable use of cocaine went up. Yet the image was and still is that we have poor inner-city African-Americans involved in all of these criminal illegal markets. Much of the anti-coke rhetoric and the changing of laws it generated was based on that early image. But in 1985, it had little relationship with reality.

Weed, weed, weed.

The LA Times reports on the DEA's efforts to target California's large, higher profile "medical" marijuana businesses.

The conservative Washington Times runs a UPI story that these larger business are claiming that they are unfairly targeted.

The conservative Pittsburgh Tribune-Review ran a scathing anti-drug war editorial and a letter to the editor on the recent NORML report about marijuana as the U.S.'s largest cash crop.

Finally, a DEA press release from earlier this year on some dealer's creative packaging of marijuana. Includes photos.

I've seen some year-end commentary on failures in efforts to change marijuana policy in 2006, but I think there's little doubt that it gained traction as a political issue. Growing numbers of conservative ideologues are joining libertarians and liberal ideologues in calling for radical reform in drug policy. The issue may be placed on the back burner as we approach a presidential election cycle, but I don't see it fading. What's interesting about this is that the conservatives involved see it as a conservative issue, liberals involved see it as a liberal issue, and libertarians see it as a libertarian issue. If these groups can form a functional coalition, they could be pretty effective in advocating greater latitude for states to experiment with drug policy and organizing support for state-level legislation and ballot initiatives.