In defense of SSRIs

A couple of attempts to defend SSRIs. First an editorial from The Times:

What is not warranted is a rush to judgment that these drugs are no good: policymakers and doctors should have sharply in mind that the people most likely to say that pills are pointless are the people who most need them.

Huh? Is this supposed to be a serious argument?

A blogger offers a slightly better argument: (note: She's previously written a very personal defense of antidepressants.)

The answer reveals a key flaw of randomized clinical trials and meta-analyses: when you are looking at aggregated data, huge individual differences can be washed out. For example, let’s imagine a drug that causes people with one genetic variation to have a profound positive effect-- but causes those with another to get dramatically worse and has little effect on everyone else.

...

Some people are strong responders to one drug-- but give them another in the same class, and they become actively suicidal. Most people have a slight positive effect; some have a slight negative effect. In aggregate, a drug that is a home run for one person and potentially fatal to another looks inert.

This question isn't whether these drugs are of any value. The relevant questions include whether, based on the evidence, there should be 40 million people on Prozac? Should 4.5 million people have been on it in the drug's first 5 years? Has acceptance outpaced the evidence? If the evidence for widespread use does not exist, how did we get here? Should it be a first line treatment, especially in light of our growing understanding of the withdrawal syndromes that these drugs can cause? Who are they effective for? Are there older (and cheaper) drugs that are more effective? Are there other treatments that are more effective? How can we reduce profit motives for overstating the effectiveness of drugs like this? How can we mitigate the influence of professional biases in what treatments are adopted as evidence-based?

Piling on antidepressants

While we're at it, I missed this earlier in the month. Looks like the manufacturer of Paxil may have failed to disclose that an early Paxil found that the drug was associated with increased risk of suicide:

An inappropriate analysis of clinical trial data by researchers at GlaxoSmithKline obscured suicide risks associated with paroxetine, a profitable antidepressant, for 15 years, suggest court documents (897kb, requires Acrobat Reader) released last month. Not until 2006 did GSK alert people to raised suicide risks associated with the drug, marketed as Paxil and Seroxat.

An analysis of internal GSK memos and reports, which were released to US lawyers seeking damages, suggests that the company had trial data demonstrating an eightfold increase in suicide risk as early as 1989. Harvard University psychiatrist Joseph Glenmullen, who studied the papers for the lawyers, says it's "virtually impossible" that GSK simply misunderstood the data - a claim the company describes as "absolutely false".

Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the FDA

Here's the actual study that an earlier referred to earlier:

Using complete datasets (including unpublished data) and a substantially larger dataset of this type than has been previously reported, we find that the overall effect of new-generation antidepressant medications is below recommended criteria for clinical significance. We also find that efficacy reaches clinical significance only in trials involving the most extremely depressed patients, and that this pattern is due to a decrease in the response to placebo rather than an increase in the response to medication.

Army of therapists to push aside pills for depression

England responds to questions about the efficacy of antidepressants:

The government yesterday released details of its £170m plan to train 3,600 more psychological therapists in the wake of a study showing that antidepressant drugs such as Prozac are no more effective than a placebo.

About 900,000 more people will be treated for depression and anxiety under the plan, according to the Department of Health, which predicts that 450,000 of them will be completely cured. The department also believes that 25,000 fewer people will claim sick pay and benefits because of mental health problems.

"The Improving Access to Psychological Therapies programme has already captured the imagination of primary care trusts up and down the country and is transforming the lives of thousands of people with depression and anxiety disorders in the areas that have been involved so far," said Alan Johnson, the health secretary.

A study published in the open access journal PLoS (Public Library of Science) Medicine on Tuesday revealed that Prozac, Seroxat and other antidepressants of the same class had performed no better than dummy pills in the earliest trials in the 1980s. No such analysis has been done before because of the reluctance of the pharmaceutical companies to hand over the full trial results.

Memoirs of Meth Addiction from a Father and a Son

A father and son have written parallel memoirs about the son's meth addiction. There's a glut of coverage about them:

• Here's a New York Times article about them.
• Here's audio of an interview with the two of them on NPR's Fresh Air.
• Here's an article by the father that evolved into his memoir.
• Here and here the New York Times book reviews of Beautiful Boy, the father's memoir.

I listened to the interview this afternoon and mixed feelings about some of it, but they did a good job illustrating how this is often a long haul for parents. Recovery doesn't come as easily or quickly as we'd like, and, sadly, there are no guarantees. But, more often than not, it does happen.

Prozac does not work in most depressed patients

Another study casts doubt on the efficacy of Prozac:

The antidepressant Prozac and related drugs are no better than placebo in treating all but the most severely depressed patients, according to a damaging assessment of the latest generation of antidepressants.

SSRIs, or selective serotonin reuptake inhibitors, were supposed to revolutionise care of depression – by treating symptoms without the side effects of older drugs, such as tricyclics.

But despite selling in vast quantities, a new meta-analysis of these drugs, from data presented to the US Food and Drug Administration (FDA), appears to suggest that for most patients they do not work. A previous study had indicated that the benefits of antidepressants might be exaggerated.

UK and US researchers led by Irving Kirsch of Hull University, UK, studied all clinical trials submitted to the FDA for the licensing of the four SSRIs: fluoxetine (Prozac), venlafaxine, nefazodone, and paroxetine (Seroxat or Paxil), for which full datasets were available.

They conclude that, "compared with placebo, the new-generation antidepressants do not produce clinically significant improvements in depression in patients who initially have moderate or even very severe depression".

They did detect some benefits in the most severely depressed patients. But conclude that in this group the small effect is "due to decreased responsiveness to placebo, rather than increased responsiveness to medication".

Substance use relapse rate low after transplant

Good news for alcoholics receiving liver transplants:

The average rate of alcohol relapse after transplantation was 5.6 cases per 100 patients per year, the researchers report in the medical journal Liver Transplantation, and the average rate of illicit drug relapse was 3.7 cases per 100 patients per year.

The only psychosocial factors affecting alcohol relapse were poor social support, a family history of alcohol abuse/dependence, and duration of abstinence before transplantation of 6 months or less.

The article doesn't address transplant screening methods. I'd imagine that all of the people who received a transplant had to at minimum offer some verbal commitment to abstinence.

Strategies to control bupe abuse outlined

From the Baltimore Sun:

Introduced in 2003, the drug known as "bupe" has been subject to increasing misuse and illegal sales as more of it is prescribed by physicians, The Sun reported in a series of articles beginning in December. Some patients sell it on the street; buyers use it to get high or hold off withdrawal symptoms until they can get their next heroin or painkiller hit.

...

The biggest problem, according to Schuster, is that some doctors are prescribing 30-day supplies of the pills to addicts after only a single visit. While that's legal, Schuster said, doctors should become comfortable that a patient is not abusing the drug before prescribing large amounts.

'A small minority of doctors are not practicing good medicine,' he said. 'That's a problem we need to be concerned with.'

Experts and officials identified other problems, including doctors who provide little counseling. An official with the NIDA said studies are showing that buprenorphine works better with pain-pill addicts, not heroin abusers.

The Methadone/AA Link

Here's an interesting follow-up to my post about the Newsweek article.

This in an excerpt from a lecture by Vincent Dole, a pioneer in methadone maintenance:

In the early 1960’s I was honored (and puzzled) by an invitation to join the Board of Alcoholics Anonymous as a Class A (nonalcoholic) trustee. Under the Constitution of AA only seven nonalcoholic persons could occupy this position, while several hundred thousand regular members of AA had entered the Fellowship the hard way, by being alcoholics. I was afraid that they might have made a mistake, and so before accepting the position, I discussed my research with executives of the Fellowship and raised the question as to whether this appointment might involve a conflict of interest, or at least the appearance of one. Would it embarrass the Fellowship to have an investigator of chemotherapy for narcotic addiction included in the Board of AA? They insisted that they saw no problem since the objectives were parallel-namely providing the best treatment available to sick persons. They also pointed to AA’s Fifth Tradition, which states that the mission of AA is solely to help alcoholics, and firmly rules against taking a position on other issues. They were right. There never has been a problem in my association with AA, and my admiration for Bill Wilson and the dedicated AA members that I came to know has increased over the years.

Needless to say, I have gained far more from AA than the Fellowship did from me. It was my privilege to witness the healing force of personal service, group support and humility, while my only serious responsibility was to serve on a few committees and be an alert observer. As an organization, AA is the purest form of democracy. Major questions are submitted to the membership at the annual meetings of delegates representing all groups. Ultimately, questions of policy are resolved in a statement of the Group Conscience. The headquarters of AA, the General Services Office, is just what the name states. The secret of AA’s strength is service. It is a secret that certainly should be shared with the medical profession.

Throughout most of my time on the Board I continued to be puzzled by the original question: Why had I, specifically, been invited to serve? If a physician experienced in treatment of alcoholics had been needed for professional opinion, there were many persons with better qualifications than I. If an administrative advisor was sought, I would be near the bottom of any search list. My only qualification was caring. One answer gradually became clear: In the early years of AA Bill and the original trustees were acutely sensitive to the danger of the Fellowship being distorted by aggressive persons with dogmatic opinions. During my time on the Board, I never detected any sign of this happening, but perhaps that simply reflectedthe success of the Traditions in the mature organization, keeping the Fellowship on track. Anyway, I assumed that I had been brought in as sort of a smoke alarm, a canary in the mine.

A more specific answer, however, emerged in the late 1960s, not long before Bill’s death. At the last trustee meeting that we both attended, he spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many sheep who are lost in the dark world of alcoholism. He suggested that in my future research 1 should look for an analogue of methadone, a medicine that would relieve the alcoholic’s sometimes irresistible craving and enable him to continue his progress in AA toward social and emotional recovery, following the Twelve Steps. I was moved by his concern, and in fact subsequently undertook such a study.

Until its closure this year, my laboratory sought an analogue of alcoholism in mice so as to be able to test potential medicines that could benefit human alcoholics. We failed in this, but the work is only begun. Talented investigators in other laboratories are working on various aspects of the analogue problem. With the rapid advance in neurosciences, I believe that Bill’s vision of adjunctive chemotherapy for alcoholics will be realized in the coming decade.

Now let me describe a coincidence that linked my work with Bill’s in an unexpected way, and perhaps explains my reaction to the scenes on the 125th Street 30 years ago. In Bill’s biography, he recalls a time in the winter of 1940 when the future of AA looked bleak. There was no activity in the newly opened club on 24th Street, and he was resting upstairs. Someone called up that a bum had come in, asking for Bill. Stumping up the steps was a stooped man with a cane who identified himself as a Jesuit priest. He said that he had come to meet Bill because of his admiration for the Twelve Steps. They were, he said, remarkably similar to the precepts of St. Ignatius Loyola, the founder of his religious order. As Bill’s biographer put it, “thus began a conversation that lasted 20 years.”

My association with AA came much later, but my contact with Edward Dowling, the priest in this story, antedated Bill’s meeting with him by 15 years. He was my classroom teacher in first year high school at Loyola Academy in Chicago in the mid 1920’s. At that time he was a slim and vigorous young novitiate with jet black Irish hair and an intense manner. Among other subjects he discussed ethical conduct, not as an abstract thesis, but as a practical obligation toward others, and as a service that brings its own reward.

In his subsequent busy career as a priest Father Dowling lived what he had taught, friend and advisor to people in trouble, to young families, to students, to alcoholics. I saw him only infrequently in later years, but remember most clearly the contrast between his continued intellectual force and his deteriorating health. Medically, he had severe rheumatoid spondylitis. He became progressively more stooped, white haired, limited in travel. Yet he did not even seem to be aware of his disability. He was too occupied with the problems of others.

Marie Nyswander, Bill Wilson, and Edward Dowling are no longer with us, but their inspiration remains. For each, life was a continuing Twelve Step. They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected. They left a positive record of success in dealing with these problems. It is my privilege, as their student, to greet the Society for Addiction Medicine, and transmit the expectations that they surely would have had for its future. They would have welcomed the strength and scientific discipline that you bring to the field. They would expect you to study and debate the technical details of treatment while being united in compassion for addicts. They would look to you for leadership that rises above special interests and prejudice. They would hope that you could lead the way to rational measures of prevention, and a variety of effective, nonpunitive treatments for various addictions. Certainly they would expect you to be concerned with the enormous public health problem of addiction: tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated. It would be their fervent hope that you succeed.

This lecture was published in the journal Alcoholism: Clinical and Experimental Research in 1991.

What Addicts Need

In its latest issue, Newsweek devotes a lot of space to addiction and an what it describes as an imminent era of pharmacological treatments. It makes some interesting points, but also illustrates how difficult it is to write for the general public about addiction in a scientific and definitive way right now.

While the roots of addiction remain a dark tangle of factors—most experts agree that addicts trying to quit will always need psychological support—the old white-knuckle wisdom that addicts simply lack resolve passed out of fashion decades ago. The American Medical Association recognized addiction as a disease back in 1956. But only now are we beginning to see treatments that target the underlying biochemistry of that disease.

"most experts agree that addicts trying to quit will always need psychological support"--What does this mean? How does the author define "psychological support"? Is she referring to professional services? Or, could this support be provided by family and community supports? Is seems to imply the former, which experts do not agree on at all. There is growing interest and a growing body of research on natural or spontaneous recovery.

She also misrepresents AA's position on the use of medication:

It is also facing resistance from some elements in the addiction-treatment community, who are wedded to the 12-Step model pioneered by Alcoholics Anonymous in 1935. Twelve-Step programs traditionally discourage members from using any psychoactive substances, on the ground that addicts will simply trade one dependency for another.

Of course, there is some truth to this. Many AA members are skeptical of psychotropic medications or medications to treat addiction, but I suspect that they are now a minority. My experience with the recovering community is that many are on psychotropics and that antabuse is not frowned upon by most members. Of course, mood altering drugs like benzos and methadone are another story. Further, AA's official stance is pretty deferent to prescribing doctors.

The article does, however, present a good overview of the growing consensus that addiction is a chronic brain disease but it also paints a very clear picture of researcher enthusiasm for pharmacological treatments. Call me a cynic, but it's hard to imagine that their enthusiasm isn't coloring their judgment and reporting about the effectiveness of these treatments. (We've seen this recently here, here, here and here. There's also the laundry list of now-abandoned "best practices.")

The emerging paradigm views addiction as a chronic, relapsing brain disorder to be managed with all the tools at medicine's disposal. The addict's brain is malfunctioning, as surely as the pancreas in someone with diabetes. In both cases, "lifestyle choices" may be contributing factors, but no one regards that as a reason to withhold insulin from a diabetic. "We are making unprecedented advances in understanding the biology of addiction," says David Rosenblum, a public-health professor and addiction expert at Boston University. "And that is finally starting to push the thinking from 'moral failing' to 'legitimate illness'."

In laboratories run and funded by the National Institute on Drug Abuse (NIDA), fMRI and PET scans are forcing that infuriating organ, the addicted brain, to yield up its secrets. Geneticists have found the first few (of what is likely to be many) gene variants that predispose people to addiction, helping explain why only about one person in 10 who tries an addictive drug actually becomes hooked on it. Neuroscientists are mapping the intricate network of triggers and feedback loops that are set in motion by the taste—or, for that matter, the sight or thought—of a beer or a cigarette; they have learned to identify the signal that an alcoholic is about to pour a drink even before he's aware of it himself, and trace the impulse back to its origins in the primitive midbrain. And they are learning to interrupt and control these processes at numerous points along the way. Among more than 200 compounds being developed or tested by NIDA are ones that block the intoxicating effects of drugs, including vaccines that train the body's own immune system to bar them from the brain. Other compounds have the amazing ability to intervene in the cortex in the last milliseconds before the impulse to reach for a glass translates into action. To the extent that "willpower" is a meaningful concept at all, the era of willpower-in-a-pill may be just over the horizon. "The future is clear," says Nora Volkow, the director of NIDA. "In 10 years we will be treating addiction as a disease, and that means with medicine."

...

So for this new paradigm to take hold, a lot of long-held prejudices will have to change. Doctors (and insurance companies) will have to get used to the idea of medicating their addicted patients, rather than handing them a brochure for AA, which a study published in 2005 in The New England Journal of Medicine found was the most common form of "treatment" offered. "If you have hypertension and it flares up, you go to a specialist," says psychologist Thomas McLellan of the University of Pennsylvania. "The specialist doesn't discharge you to a church basement. If he did, we would call it malpractice." Addicts, he adds, are by no means unique in their propensity to relapse. In a study comparing alcoholics and drug addicts to patients with diabetes, asthma and hypertension, McLellan found nearly identical rates of noncompliance and relapse; between 30 and 40 percent of each group failed to follow even half their doctors' guidelines.

As some of the statements above suggest, the article also foreshadows pressure on treatment providers and the recovering community to embrace these new treatments:

Volkow's vision of the future, however, is being greeted warily by big pharmaceutical companies, reluctant to develop products that would associate their brands with drug addicts. It is also facing resistance from some elements in the addiction-treatment community, who are wedded to the 12-Step model pioneered by Alcoholics Anonymous in 1935. Twelve-Step programs traditionally discourage members from using any psychoactive substances, on the ground that addicts will simply trade one dependency for another. That rationale has some unfortunate history on its side; both opium and cocaine were first introduced to the United States as cures for alcoholism in the late 1800s. More recently there is the example of methadone, the synthetic heroin that turned out to be addictive in its own right, and Antabuse, a drug that makes you throw up when you drink alcohol—which suffers from the shortcoming that an alcoholic planning a binge can just skip his dose.

...

The revolution these new drugs promise will have a huge impact on the addiction-treatment industry (or, as it prefers to think of itself, the "recovery movement"), which runs the gamut from locked psychiatric wards in big-city hospitals to spalike mansions in the Malibu Hills of California. And the reaction there is guarded; the people who run them have seen panaceas come and go over the years, and the same addicts return with the same problems. They also, of course, have a large investment in their own programs, which typically rely on intensive therapy and counseling based on the 12-Step model. "We need four or five more years to see how [Vivitrol] does," says staff psychiatrist Garrett O'Connor at the Betty Ford Center, in Rancho Mirage, Calif. "And we need to be very cautious, because a failed treatment will set a person back." The Ford Center and the Hazelden Foundation, in Minnesota, use drugs sparingly, and mostly just in the first days or weeks of recovery, the "detox" phase. "Hazelden will never turn its back on pharmaceutical solutions, but a pill all by itself is not the cure," says William Moyers, Hazelden's vice president of external affairs. "We're afraid that people are seeking a medical route that says treatment is the end, not the beginning." As for Alcoholics Anonymous and its imitators, they mostly do not forbid members to use medication but there are strong institutional biases against it. "I'm not judging others, but for myself, using something like Vivitrol or Camparal feels like a crutch," says one longtime AA member, who, following the organization's practice, asked not to be named. "It's not true sobriety."

The competing view is that of Lisa Torres, a New York lawyer who has been in recovery from heroin addiction for nearly 20 years, and continues to take methadone, which she regards as medication for a chronic condition, analogous to blood-pressure or cholesterol-lowering drugs. "It's a paradox that some of addicts' biggest advocates have been the most resistant to new treatments," she says. "But a lot of them come to the field after recovering from their own addictions, and they can be very stubborn about what works and what doesn't." More pointedly, she adds, "some people feel recovery from addiction should not be easy or convenient."

...

And addicts may need to change their thinking, too. For nearly 75 years, that thinking has been dominated by the principles laid down by Bill W., the founder of Alcoholics Anonymous. The amount of good AA has done in the world is incalculable; most people reading this article probably can think of someone they know who owes his or her life to it. Some readers themselves have surely benefited. But in 1935 AA was, essentially, the only legitimate option. There were "cures" of various sorts, including gold chloride injections, but there was virtually no modern neuroscience or psychopharmacology. Many people are now living in society with mental illnesses like schizophrenia and bipolar disorder that would have required institutionalization back then. Addicts, like the rest of the public, need to recognize the fact that we are entering a new era in addiction treatment. Viewing her condition as a chronic, recurring disease that could be treated was precisely what Dyess needed to return to sobriety. "In the past, when I would relapse," she says, "the thinking from 12-Step or from family was that I had failed. Now I know that if it happens, it happens, and I can pick myself up and move on, instead of assuming it's all over so I might as well keep drinking." The 12 Steps begin with a confession of powerlessness over addiction. But there's hope that science may some day help put that power within the reach of anyone who needs it. And then who would choose not to grasp it, and begin the long war for sobriety—a war without end, but one worth the fighting.

One more line from above provoked one more troubling thought:

Volkow's vision of the future, however, is being greeted warily by big pharmaceutical companies, reluctant to develop products that would associate their brands with drug addicts.

By working to reduce the stigma associated with addiction we will inevitably be removing barriers currently preventing others from entering the field. Some will probably have good motives and their presence will be helpful. Others will view it as a new market for profiteering. We've experienced this before. The article acknowledges this, but, in my opinion, naively dismisses these concerns because she believes science will be the basis of new treatments. Buyer beware.

Warning given over techno addicts

Please.

Physician group position on medical marijuana

The American College of Physicians recently released a position paper on medical use of marijuana. It appears to be a pretty sober approach to the issue and there's something to disappoint everyone. (nonsmoked) More states appear to be moving in the direction of legalizing medical marijuana (but the feds don't seem to be any where near considering it) and this could help address the many of the problems that have come up in California.

Position 1: ACP supports programs and funding for rigorous scientific evaluation of the potential therapeutic benefits of medical marijuana and the publication of such findings.
Position 1a: ACP supports increased research for conditions where the efficacy of marijuana has been established to determine optimal dosage and route of delivery.
Position 1b: Medical marijuana research should not only focus on determining drug efficacy and safety but also on determining efficacy in comparison with other available treatments.
Position 2: ACP encourages the use of nonsmoked forms of THC that have proven therapeutic value.
Position 3: ACP supports the current process for obtaining federal research-grade cannabis.
Position 4: ACP urges review of marijuana’s status as a schedule I controlled substance and its reclassification into a more appropriate schedule, given the scientific evidence regarding marijuana’s safety and efficacy in some clinical conditions.
Position 5: ACP strongly supports exemption from federal criminal prosecution; civil liability; or professional sanctioning, such as loss of licensure or credentialing, for physicians who prescribe or dispense medical marijuana in accordance with state law. Similarly, ACP strongly urges protection from criminal or civil penalties for patients who use medical marijuana as permitted under state laws.

[via dailydose.net]

Culturally Congruent Intervention

RAND just made an article available (previously published) on a culturally specific intervention for African American drug addicts. Bill White has written about several groups that frame addiction recovery as an act of cultural resistance. Locally, I've also seen the power of a minority faith community in holding culturally specific recovery events--Rabbi Yisrael Pinson holds monthly recovery Shabbat.

What I found interesting was the idea of doing the intervention over a meal. I'd imagine that this alone would have the potential to dramatically change the dynamics in all sorts of positive ways. Culture aside, this would be a fun model to experiment with.

The content and format of our intervention were designed to be congruent with cultural values of communalism and group process and to employ motivational intervention techniques appropriate for participants at the precontemplation or contemplation stage of change. We began with a traditional African American meal (fried chicken or ribs, greens, potatoes, red beans and rice), which served as a culturally specific frame for the intervention. For this meal, the participant was joined by an intervention team consisting of one counselor and a former drug user, whom we called a peer. This group then watched a 15-minute video, which combined voice-over with still photos, original and documentary footage, and clips from commercial films about African Americans. (Permission to use clips was obtained from holders of the copyrights.) The final step was a counseling session to review the participant’s interest in recovery and service needs. It was based on issues, thoughts, and emotions expressed by the participant during the meal or video.

In the video and counseling session, drug use was represented as both a personal problem and a community problem rooted in cultural and power disparities between the African American community and dominant institutions. Moreover, discussion acknowledged the totality of one’s life experience (e.g., racial prejudices, self-image issues, and job opportunities) not only as an individual but also as an African American. It was emphasized that behavior change is important not only for the individual but also for the collective good.

The peer role was to share personal thoughts and experiences similar to those mentioned by the participant and to demonstrate to him or her that it was both safe and appropriate to speak honestly about one’s drug use experiences and one’s ambivalence regarding recovery. In addition, the peer converted the standard one-on-one format in which a counselor interviews a client to a culturally congruent group process format in which counselor and peer actively affirm the thoughts, feelings, and experiences invoked by the participant.

[via dailydose.net]

Sponsorship

From a friend:

My friend Bill White just ran across a ten year follow-up study that looked at the role of sponsorship in predicting post-treatment sobriety. Those who sponsored other AA members throughout the ten year study had a 91% end of study remission rate. The scientists are finally figuring out this helping other drunks is pretty powerful stuff.

Here's the citation:

Cross, G.M., Morgan, C.W., Mooney, A.J., Martin, C.A. & Rafter, J.A. (1990). Alcoholism treatment: A ten-year follow-up study. Alcoholism: Clinical and Experimental Research, 14, 169-173.

Identical twins not as identical as believed

A new snag in twin studies:

Contrary to our previous beliefs, identical twins are not genetically identical....

How can it be that one identical twin might develop Parkinson’s disease, for instance, but not the other? Until now, the reasons have been sought in environmental factors. The current study complicates the picture.

“Even though the genome is virtually identical in identical twins, our results show that there in fact are tiny differences and that they are relatively common. This could have a major impact on our understanding of genetically determined disorders,”

and YOU thought addiction was a disease ...

From a friend:

The Spiritual Science Research Foundation (SSRF) based in Melbourne, Australia has recently published breakthrough research about the causes of addictions ... 96% of all addictions are *caused due to possession by either ghosts or our departed ancestors.*

http://www.spiritualresearchfoundation.org/miscellaneous/pressreleases/


(and the best part - only THREE steps for a complete cure:)
http://www.spiritualresearchfoundation.org/spiritualresearch/mentalhealth/addiction/#611

SAMHSA sat on 'bupe' study

Misuse of bupe isn't news to us, but it's disappointing that SAMHSA sat on the info:

The federal agency that oversees buprenorphine treatment for narcotics addicts learned more than two years ago of illegal sales and abuse of the pills but did not reveal the findings as officials campaigned to expand use of the drug.

U.S. Substance Abuse and Mental Health Services Administration records show that in December 2005, Vermont health officials advised the federal agency of some patients crushing and injecting the pills called Suboxone, trading or peddling them on the street - even smuggling them into the state's prisons.

Agency officials hired consultants who confirmed those problems and others. Yet the agency didn't tell Congress or the U.S. Food and Drug Administration, which has the power to order tighter controls over prescription drugs. Agency officials waited until Jan. 28 of this year to disclose the findings, which were posted on the SAMHSA Web site as "new" and a "comprehensive report" of buprenorphine abuse nationwide.

The report, which characterizes abuse of the drug as a "small but persistent problem," is the first by the agency to provide detailed evidence of misuse as well as weaknesses in systems set up by Congress to guard against it.

The Battle Against Drugs

From a letter in the New York Times:

Accepting that we will never have a drug-free society, and that many drug users are unable to practice a sober lifestyle, does not preclude our ability to reduce the demand for drugs and help those who continue to use them.

This is what's wrong with too many harm reduction programs. How about, "many drug users are unable to practice a sober lifestyle now"?

[via dailydose.net]

OSI Treatment Initiative

Good news. George Soros, who has previously made large investments in harm reduction programs, has started a new treatment initiative.

Critics have often branded Soros and OSI as supporters of drug legalization based on their past funding support for groups like the Drug Policy Foundation. Capoccia -- who formerly led the Robert Wood Johnson Foundation's addiction treatment and prevention program area -- said it would be a mistake to associate the Closing the Addiction Treatment Gap program with drug-legalization groups. On the other hand, he noted, "Harm-reduction has always been a part of the continuum of care."

Asked if Closing the Treatment Gap constituted an effort by Soros and OSI to tackle addiction issues in a more "mainstream" fashion, Capoccia replied, "This is not a departure at all from the investments OSI and Soros have made, but rather an extension," adding: "It's mainstream on the one hand but radical on the other -- that everyone who needs treatment should have it. We've accepted things like waiting lists ... the radical dimension is that we should be accepting that."

RWJF's 2006 decision to end its addiction-related program area has left a substantial funding gap in the treatment and prevention community, but Capoccia said that OSI's intention is not to fill RWJF's shoes. "This is not a definition of new priorities for OSI," he stated. "This is more likely to be a focused effort."

Smoking bans and heart attacks

Another piece of evidence that smoking bans have significant impact on public health.

Crack sentence reform scare tactics

From Join Together:

U.S. Senate Judiciary Committee Chairman Patrick Leahy (D-Vt.) and others have rejected Attorney General Michael Mukasey's call for Congress to undo a recent decision by the U.S. Sentencing Commission, which retroactively reduced the penalties for crack-cocaine offenses, the Associated Press reported Feb. 12.

Mukasey requested that Congress pass a law to reverse the commission's decision before it goes into effect on March 3, claiming that the change in mandatory sentencing laws would result in the release of thousands of violent criminals. Representing the Justice Department, federal prosecutor Gretchen C.F. Shappert told the committee, "I am deeply concerned that the success we are experiencing in some of our most fragile, formerly crack-ravaged communities will be seriously interrupted if these communities are forced to absorb a disproportionate number of convicted felons."

The War on Drugs Starts Here

The New York Times weighs in on the President's new budget:

The Bush administration, which offers regular lectures on the superior logic of the free market, clearly doesn’t get this equation of supply and demand. Last October, Washington announced a new $1.4 billion assistance package for Mexico and Central America to combat the drug trade. Then the White House unveiled its 2009 budget, which calls for a 1.5 percent cut in spending on domestic drug prevention and treatment programs.

Yet the White House’s budget proposal for 2009 cuts the funding for the prevention and treatment of drug abuse to $4.9 billion. The budget for prevention programs — like the drug-free schools grants — was cut by 14.2 percent to just above $1.5 billion. After accounting for inflation, spending on prevention has fallen every year since 2002.

Making Pot Legal: We Can Do It -- Here's How

A blueprint for advocating cannabis legalization:

The long-expressed goals of the marijuana law reform movement to end the arrests of responsible adult pot smokers and enact a regulated system of cannabis access and sales are achievable. However, these goals will continue to remain unattainable unless this movement begins to better address the political and public hurdles that have plagued it for more than 30 years.

More on the subject.

In Adolescents, Addiction to Tobacco Comes Easy

Huh? I don't get it. This finding really challenges a lot of assumptions about addiction. It will be interesting to see follow-up studies. I'll take it more seriously once it's replicated. Could it be that there is some switch flipped in the limbic system that responds to environmental cues, even id they only occur once a week?

In the report that follows, Dr. Joseph R. DiFranza, a family health and community medicine specialist at the University of Massachusetts Medical School in Worcester, states that “very soon after that first cigarette, adolescents can experience a loss of autonomy over tobacco.”

Dr. DiFranza, who studies tobacco dependence, described a typical teenage smoker — a 14-year-old girl who smokes only occasionally, about three cigarettes a week. She admitted to having failed at several efforts to quit. Each time she tried, cravings and feelings of irritability drove her back to smoking.

“We have long assumed that kids got addicted because they were smoking 5 or 10 cigarettes a day,” Dr. DiFranza said in an interview. “Now we know that they risk addiction after trying a cigarette just once.”

Even occasional teenage smokers can experience the same symptoms of nicotine withdrawal that prompt adult smokers to light up again and again.

Robin J. Mermelstein, director of the Center for Health Behavior Research at the University of Illinois in Chicago and a longtime researcher on smoking behavior, said in an interview that Dr. DiFranza’s message was important. But, Dr. Mermelstein added, “the vast majority of teenagers who try one or two cigarettes don’t go on to become smokers.”

“Some kids experience withdrawal symptoms earlier than others,” she continued. “We still need to know how to predict who’s going to get hooked.”

Dr. DiFranza explained that a phenomenon called “dependence-related tolerance — how long after smoking a cigarette you can go before you need to smoke another one” — was long thought to be the same for adolescents and adults. But recent studies have shown that the brains of adolescents can become tolerant to nicotine after smoking fewer cigarettes than one a day, and it is tolerance that then drives them to smoke more often.

“The typical adult smoker begins to crave the next cigarette in 45 minutes to an hour after smoking,” he said. “But kids can be addicted and not need to smoke again for days, even weeks.”

Some adult smokers are no different from teenagers. One study found that adults who smoked only a few cigarettes a week found it hard to quit. “They experienced withdrawal symptoms, which some rated as unbearable,” Dr. DiFranza reported. “Most of these self-described ‘social smokers’ were addicted to tobacco.”

Facing Budget Cuts, ONDCP Refocuses Media Campaign

Facing Budget Cuts, ONDCP Refocuses Media Campaign

With federal research showing that its anti-drug media campaign isn't working with kids, and Congress calling for major cuts in the program, the White House Office of National Drug Control Policy (ONDCP) has unveiled a more modest effort that focuses on an emerging threat -- prescription-drug abuse -- and appeals to parents rather than youth.

Read the rest here.

2008 Elections Offer Special Opportunity for Recovery Advocates

2008 Elections Offer Special Opportunity for Recovery Advocates:

The Whole Health Campaign is reaching out to candidates, health policy advisors, and party delegates to promote the following three points:
(1) Ensure equitable and adequate mental health and addiction treatment coverage in all public and private health care plans.

(2) Support policies that promote individual and family recovery from mental illnesses and addiction as integral to overall health.

(3) Commit to investing in prevention, early intervention and research on mental illnesses and addiction.

Whole Health Campaign members want both parties’ platforms to reflect its three points. Yet they realize that a long-term strategy is also needed. “No one believes that the goals of the Campaign will be addressed or resolved by getting the right words in a candidate’s mouth,” said Dr. Goplerud. “Even if it’s not through the Whole Health Campaign itself, addiction and mental health groups need to be in this for the long haul.”

Read the rest here.

The effect of methadone maintenance treatment on alcohol consumption

From the Journal of Substance Abuse Treatment:

There is a high prevalence of alcohol use, abuse, and dependence in methadone maintenance treatment (MMT) programs. There have been reports that this may be a result of entry into methadone maintenance. Through a systematic review, this article attempts to determine whether alcohol consumption is affected during the course (from prior to treatment initiation to once on maintenance) of MMT. A literature search for publications addressing the issue of alcohol use while on MMT was conducted. Of 15 heterogeneous clinical studies that met inclusion criteria, three studies supported an increase in alcohol use, three supported a decrease in alcohol use, and nine supported no change in alcohol use. The studies varied in their methodology and in their definition of problematic alcohol use. This review found that alcohol use, although often problematic in methadone-using patients, likely does not change upon entering MMT. (emphasis added) We recommend routine screening and treatment for problematic alcohol use in patients on MMT.

Addiction and hunger connection

In interesting finding, but I'll remain pretty skeptical until I see more studies replicating the findings.

Oxy hype

STATS criticizes media coverage of Oxycontin (again). Has the media hyped the dangers of Oxycontin? Of course. They hype everything. I remember a recent Today Show segment on the hidden dangers of shopping carts.

The article argues that it's not a major drug of addiction:

The significance of this study is that it provides a powerful, random sample of drug addicts in the U.S. and finds that just 5% reported ever using OxyContin.

Among this group of 1,425 addicts, only 22% reported receiving OxyContin by way of prescription for a medical problem. But 86% reported using OxyContin, whether prescribed or not, to get high. Only eight (0.5%) used OxyContin exclusively. What this means is that the overwhelming majority of those abusing OxyContin were abusing other drugs as well (specifically, heroin, cocaine, methamphetamines and sedatives).

I've never been concerned about accidental addiction for pain patients. Rather, I've been more concerned about illicit use of Oxycontin by young people who become opiate addicts and switch to heroin because Oxycontin is so expensive. I don't think I've ever seen a client who's primary drug is Oxycontin, but I've seen scores whose opiate use began with Oxycontin experimentation. They probably would have become addicts anyway, but Oxycontin seems to have lowered the threshold for young people to start using opiates. The author does acknowledge that this study might not capture information about these trends.

Clearly we need to both look for ways to increase access to opiates when it's medically appropriate for pain management and find ways to reduce diversion.