Cocaine self-medication for insomnia

"Addicted people may take cocaine to improve sleep-related cognitive functioning deficits—unaware that they are abusing, in part, to 'solve' these problems."

Huh? I suppose, if cocaine is part of one's life, one might use it instrumentally when tired--the way many of us use caffeine. But "unaware"?

Also, isn't this theory tautological? I go beyond his statement, but I think this speaks to much of the psychiatric conventional wisdom.

• Sleep problems are widespread among addicts.
• People self-medicate with stimulants to deal with impairments related to sleep problems.
• People self-medicate with sedatives to help them sleep when experiencing sleep problems.

Under what conditions is their drug use not self-medication? If it is self-medication, why are they unaware? If what they really seek is relief from sleep problems and psychiatric symptoms, why are they non-compliant with professionally directed treatments? Yet, they are so consistent with illicit drugs as self-medication when these drugs are poor treatments for the problem.

Two quotes come to mind:

Their every truth is not quite true. Their two is not the real two, their four not the real four: so that every word they say chagrins us and we know not where to begin to set them right. -- Ralph Waldo Emerson

If the only tool you have is a hammer, you tend to see every problem as a nail. -- Abraham Maslow

At any rate, the study focuses only on the first 17 days of abstinence in a non-treatment population. NIDA summarizes their findings as follows:

Sleep deficits—After 14 to 17 days of abstinence, the study group exhibited sleep deficits on several measures, relative to healthy, age-matched peers who participated in prior studies. For example, they had less total sleep time (336 versus 421-464 minutes) and took longer to fall asleep (19 versus 6-16 minutes).

Declines in sleep quantity and quality—The time participants took to fall asleep and their total time asleep transiently improved during the first week of abstinence, but then reverted to the patterns recorded on days of cocaine taking. On abstinence days 14-17, participants took an average of 20 minutes to fall asleep (from a low of 11) and slept for 40 minutes less than their minimum. Slow-wave sleep—a deep sleep that often increases following sleep deprivation—rose during the binge and on abstinence days 10-17.

Lack of awareness of their sleep problems—In contrast to the evidence of objective measures, the study participants reported steadily improving sleep from the beginning to the end of their days of abstinence.

Impairments in learning and attention—As with sleep quality, participants' performance on tests of alertness and motor-skills learning initially improved and then deteriorated. On abstinence day 17, they registered their lowest scores on alertness and ability to learn a new motor skill.

They then acknowledge the limitations of such a short study:

"Cocaine abusers who recognize their cognitive problems often report that it takes them 6 months to a year to turn the corner—a clinical observation that points to the need for longer term studies of sleep and treatment outcomes among this population."

They argue that they are relevant because other studies have found that early sleep problems predict relapse 6 months later, but neglect to mention that other studies have found that distress about sleep problems is a better predictor of relapse than objective sleep measures.

Not surprisingly, they are researching medications for sleep:

Dr. Morgan and his team are currently testing two medications, tiagabine (an anticonvulsant) and modafinil (a stimulant), to see if they can improve cocaine abusers' sleep and restore cognitive performance.

Why not try CBT (here and here) and looking at treatment populations?

Substance Use and Dependence Following Initiation of Alcohol or Illicit Drug Use

There is a new NSDUH report on the development of dependence upon a substance in the 2 years following substance use initiation as explained below.

For the purposes of this report, persons who initiated use of a substance 13 to 24 months prior to the interview are referred to as "year-before-last initiates." Year-before-last initiates were assigned to three mutually exclusive categories reflecting their substance use trajectories following initiation: those who had not used the substance in the past 12 months ("past year"), those who had used the substance during the past year but were not dependent on the substance during the past year, and those who had used the substance and were dependent on the substance during the past year.

The report provides a peek into two interesting statistics. The first is the 2 year capture rates for each drug. That is the percentage of people who develop DSM dependence upon a drug. Please note that dependence is only one harm associated with drug use.

Percentages of Year-Before-Last Initiates Who Were Dependent on the Initiated Substance in the Past Year, by Substance: 2004-2006

The second statistic is the percentage of people who used it for the first time 2 years ago, but have not used it at all in the last year.

Percentages of Year-Before-Last Initiates Not Using the Initiated Substance in the Past Year, by Substance: 2004-2006 Does this suggest that this is the rough percentage of people who experiment with a drug briefly and then do not use it again? Does the difference between these two statistics tell us the capture rate for casual use?

I'm not sure. It will be interesting to see more about this in coming years.

Sertraline Does Not Help Methamphetamine Abusers Quit

SSRIs are contraindicated for newly abstinent methamphetamine addicts.

Recovery will be key in new drugs strategy (Scotland)

I've posted before (here, here, here, here and here) about Scotland and the price of harm reduction being the basis of its drug policy. (To the exclusion of recovery or abstinence oriented approaches.) Good news. They've just announced that they are adopting a recovery-oriented approach:

The new report is published today as former Health Minister Susan Deacon chairs a conference in Glasgow looking at how the concept of 'recovery' might be applied to the field of drug addiction.

Mr Ewing said that the emerging focus on recovery represents 'a real opportunity to put a strategy in place that commands widespread professional, political and public support'.

Some of the main findings of the SACDM Sub-Group's Essential Care Report are:

• There is a need for a major change in the philosophy of care for people with problem substance use in Scotland
• Substance users are people with aspirations
• Policy makers, commissioners and services need to consider how they can help them recover
• Substance users have the right to the same quality of care as the rest of us

Mr Ewing said:

"The Essential Care report contains a number of welcome recommendations which are already being looked at as we develop our new drugs strategy.

"I believe we need to get better at encouraging each addict's personal vision of recovery by reducing practical barriers to services, while giving people hope by acknowledging that recovery is achievable.

"I have met former addicts who tell me that the key to believing in your own recovery is 'believing it can happen for you' - being optimistic that you can recover. The concept of recovery represents a significant shift in thinking and has happened in the field of mental health - why shouldn't people with drug problems believe they can recover too?

"That's the question that all the agencies working to tackle drug misuse need to ask themselves. If the answer isn't yet a straightforward 'yes' - then they need to challenge the approaches they are taking. We have a real opportunity to put a strategy in place that commands widespread professional, political and public support. I want us all to seize that opportunity.

"We will publish a new drugs strategy for Scotland before summer and its main focus will be recovery. It is essential that people experiencing drug problems have access to a range of wider services including employment, housing, and health that help them to move-on and rebuild their lives."

Heeeeeere’s Stanton

I'm not a fan of Stanton Peele and I usually don't read him because I find him to be more of a bomb-thrower than anything else.

While this article is full of his usual distortions, one line leaped out at me:

The typical program says, "Quit using before you enter, while you're here, and forever after." Good advice - if only people weren't addicted. (emphasis mine)

His argument is that abstinence is an unrealistic goal and that harm reduction is the only rational approach. I couldn't disagree more. While one could argue that it's dated, his point about the historical pre-treatment and treatment expectations of many programs is fair and it stings.

I'm proud that Dawn Farm has continued to work on ways to engage people who are still using and stay engaged when people relapse. I'm thinking of activities like outreach, recovery coaching, seamlessly stepping people up or down in treatment, and trying to be sure that getting discharged from one program (say, residential) does not mean that the person is discharged from our community of programs or that they are unable to re-enter the program if it makes sense at a later date.

'Cheese' Heroin Hooking Young Users in Dallas

As I've noted in the past, I'm a little reluctant devote space to something like this that has so much hype potential, but NPR has run a new story on "cheese" in Dallas:

"Reports that we were seeing were pretty striking. Kids as young as 9 or 10 years of age coming to the hospital emergency rooms or detox facilities in acute heroin withdrawal," says Dr. Carlos Tirado, a psychiatry professor at UT Southwestern Medical Center and medical director of a drug treatment center in Dallas.

"We didn't know what to do with a 9-year-old in opiate withdrawal, or what the treatment ramifications of that are," Tirado says. "Do you send a 9-year-old to an AA meeting?"

Can Sips at Home Prevent Binges?

A New York Times article examines the question of whether parents allowing teens to drink at home decreases alcohol problems later. (Note that they are not talking about parents hosting parties for their kids or buying them a 6 pack, they are talking about allowing some wine with dinner.)

Dr. Vaillant compared 136 men who were alcoholics with men who were not. Those who grew up in families where alcohol was forbidden at the table, but was consumed away from the home, apart from food, were seven times more likely to be alcoholics that those who came from families where wine was served with meals but drunkenness was not tolerated.

He concluded that teenagers should be taught to enjoy wine with family meals, and 25 years later Dr. Vaillant stands by his recommendation. “The theoretical position is: driving a car, shooting a rifle, using alcohol are all dangerous activities,” he told me, “and the way you teach responsibility is to let parents teach appropriate use.”

“If you are taught to drink in a ceremonial way with food, then the purpose of alcohol is taste and celebration, not inebriation,” he added. “If you are forbidden to use it until college then you drink to get drunk.”

The article focuses on the matter in a very micro manner--avoiding questions alcohol's status as a celebrated drug in our culture and questions of drinking age. (If we strongly believe that alcohol should be prohibited for people under the age of 21, why are we so permissive with 19 and 20 year olds? If we don't think it's a problem for 19 and 20 year olds, why do we maintain this law?)

Gay Youth Report Higher Rates Of Drug And Alcohol Use

The odds of substance use for lesbian, gay and bisexual (LGB) youth are on average 190 percent higher than for heterosexual youth, according to a study by University of Pittsburgh researchers published in the current issue of Addiction. What's more, for some sub-populations of LGB youth, the odds were substantially higher, including 340 percent for bisexual youth and 400 percent for lesbians, researchers found.

This will be interesting to watch. The study was a meta-analysis of research from 1994 to 2006. While homophobia is alive and well, in some communities, the landscape for LGB youth has changed dramatically for the better over that period. No? Will disparities decrease as homophobia decreases?

"Make Room for Serious Criminals" bill

Barney Frank has announced plans to file a bill to remove all federal penalties for the possession or use of small amounts of marijuana.

The Healing Place

Kentucky's Healing Place focuses on 12 step facilitation as a response to homeless alcoholic men. It's become a model for 10 new programs in Kentucky and other programs around the country.

Addicts 'not second-class people'

Pressure continues to grow to rethink Scotland's emphasis on methadone.

[via dailydose.net]

Bill Wison on YouTube

Someone has posted video on YouTube of Bill & Lois Wilson telling Bill's Story, the first meeting with Dr. Bob and history of the Traditions.

Essential viewing for anyone with an interest in 12 step recovery.

NOTE: Some of the "related videos" slander Dr. Bob. Be warned.

The Wire's War on the Drug War

From the writers of The Wire:

...we offer a small idea that is, perhaps, no small idea. It will not solve the drug problem, nor will it heal all civic wounds. It does not yet address questions of how the resources spent warring with our poor over drug use might be better spent on treatment or education or job training, or anything else that might begin to restore those places in America where the only economic engine remaining is the illegal drug economy. It doesn't resolve the myriad complexities that a retreat from war to sanity will require. All it does is open a range of intricate, paradoxical issues. But this is what we can do — and what we will do.

If asked to serve on a jury deliberating a violation of state or federal drug laws, we will vote to acquit, regardless of the evidence presented. Save for a prosecution in which acts of violence or intended violence are alleged, we will — to borrow Justice Harry Blackmun's manifesto against the death penalty — no longer tinker with the machinery of the drug war. No longer can we collaborate with a government that uses nonviolent drug offenses to fill prisons with its poorest, most damaged and most desperate citizens.

Jury nullification is American dissent, as old and as heralded as the 1735 trial of John Peter Zenger, who was acquitted of seditious libel against the royal governor of New York, and absent a government capable of repairing injustices, it is legitimate protest.

[hat tip: Jim]

What Research Tells Us About the Reasonableness of the Current Priorities of National Drug Control

RAND released a new report on American drug policy and takes the gloves off.

On federal prevention strategies (emphasis added):

So in light of the well-documented failure of the National Youth Anti-Drug Media Campaign, ONDCP’s continued promotion of this as a cornerstone of its prevention policy is puzzling. If coupled with the broad adoption of evidence-based drug prevention curricula in the classrooms it would make more sense, but the current National Drug Control Strategy does not propose such a coordinated approach. In fact, there is no discussion about using school-based drug education as part of a comprehensive strategy, and funds supporting school-based programs continue to be fragmented across Federal agencies.

ONDCP has thus missed an opportunity to demonstrate leadership in promoting school-based drug prevention curricula. Research clearly shows school-based drug prevention curricula can be effective, cost-effective, and socially beneficial due to the societal savings generated from reduced consumption of illicit drugs, alcohol and tobacco (Caulkins et al., 2002; Caulkins et al., 1999). Moreover, some studies show that particular programs have demonstrated improvements in general academic performance and school success in addition to diminishing substance abuse among youth (LoSciuto et al., 1996; Eggert et al, 1994).

Basically, there are strategies with an evidence-base and we insist on using strategies that have been proven to be ineffective. Why? It doesn't even appear to be philosophy--there are philosophically compatible options. I suspect it has more to do with the purpose of prevention campaigns--making adults feel like we're doing something.

Otherwise, we'd invest more energy in alcohol consumption and an obvious place to start would be to challenge adults to examine the way our culture celebrates drinking. To be clear, I'm not anti-alcohol. I've got no problem at all with adults drinking, but if we wanted to take underage drinking seriously, we'd have to encourage families to ask themselves questions like, "Why do so many family parties (child birthday parties, wakes, first communion, baptism, etc.) involve alcohol? And, what message does this send to our kids?" We'd also have to ask ourselves to clarify what we believe about drinking by 18 to 21 year-olds. Do we really think it should be illegal? If not, how do we change the laws and protect high school aged kids? If so, why do our responses to it communicate such ambivalence?

On treatment:

treatment remains a relatively under-funded tool, as indicated by a variety of different measures including its small budget share, its slower growth rate vis-à-vis drug enforcement strategies, and the persistently large number of dependent users who remain in need of treatment in the United States.

Conclusions:

Research at RAND and elsewhere indicates that a greater emphasis placed on treating the chronic users in our mature drug markets and tracking measures of our success with this group would be more effective at addressing this nation’s drug problems. Today, too much emphasis is placed on supply-side strategies that offer too little of a return given the stage of the epidemic we are in with cocaine, heroin and marijuana. Enforcement strategies targeting methamphetamine and prescription drugs are likely to provide high returns, given that these markets are less endemic, but the mix of strategies needs to be thoughtfully considered in light of the nuances of these markets.

...

The Strategy in its current form is neither balanced nor cost-effective, and as such, suggests a need for Congress to carefully scrutinize the structure of the budget request. By cutting the budget for programs lacking scientific support or strong analytic arguments and reallocating those funds to program areas that are known to be effective, the nation will have a much better chance of successfully reducing substance abuse and its many costs on society. This would produce a Strategy that more closely addresses the drug situation that exists here in the United States. I would be happy to answer any questions you may have at this time.

Parity Bill Passed by U.S. House of Representatives

Good news via Join Together. Keep in mind that parity does not equal equity. In states that have implemented parity, insurers end up implementing managed care strategies to keep costs down, but at least the lifetime limits, excessive co-pays, etc. are gone.

Parity Bill Passed by U.S. House of Representatives
March 6, 2008

News Feature
By Bob Curley


In a major victory for addiction treatment and recovery advocates, the U.S. House of Representatives has passed a bill that would mandate that insurers cover addiction and mental illness on par with other illnesses.

"We've waited 12 long years for this historic day," said Rep. Jim Ramstad (R-Minn.), co-chair of the Congressional Addiction, Treatment and Recovery Caucus with Rep. Patrick Kennedy (D-R.I.). "I am grateful that the House has taken this important step to end the discrimination against people who need treatment for mental illness and chemical addiction." Ramstad, who is retiring from the House, cosponsored the parity bill with Kennedy, who said he hoped passage of the legislation "will help to erase the stigma associated with mental illness and substance abuse."

The House voted 268 to 148 in favor of H.R. 1424, the Paul Wellstone Mental Health and Addiction Equity Act, rebuffing attempts to substitute a version of parity legislation previously approved by the Senate generally considered by advocates to be weaker than the House legislation. Pelosi said that ensuring that Americans have equal access to addiction and mental-health treatment has economic benefits and also would benefit returning veterans.

"Illness of the brain must be treated like illness anywhere else in the body," said Pelosi, who called the Wellstone Act "a comprehensive bill to help end discrimination against those who seek treatment for mental illness."

Parity supporters sought -- and received -- a strong bipartisan vote in favor of the bill to back their case for adoption of the House legislation in negotiations with the Senate, which passed the Mental Health Parity Act of 2007 by unanimous consent on Sept. 18. 2007. The House bill received critical support from Speaker Nancy Pelosi (D-Calif.), who appeared at a pre-vote rally on the steps of the Capitol and spoke in favor of the measure during the floor debate on March 5.

Congress Needs Meeting of Minds

The two houses of Congress will now need to meet and reach a compromise on parity if the legislation is to move swiftly toward a vote in a legislative calendar shortened by the presidential election season.

"The Paul Wellstone Mental Health and Addiction Equity Act of 2007 is the right solution to ending insurance discrimination facing people with alcohol and drug problems and their families," said Merlyn Karst, chair of the Faces & Voices of Recovery Board of Directors. "We urge the Congress to come together and hammer out the differences between the strong bill that the House passed today and the Senate-passed version of the parity legislation, S. 558."

Pat Taylor, executive director of Faces and Voices of Recovery, said that while there are "significant differences" between the two bills, "we think they can be worked out." Unlike the Senate bill, for example, the House legislation requires that out-of-plan addiction and mental-health treatment be covered by insurers if plans do so for other illnesses, and that insurers include coverage of all illnesses listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the "bible" of the mental-health field. That's the same standard used in the Federal Employees Health Benefits Plan.

"I think we may have some Senate Democrats who had supported the Senate bill now come out in support of the House bill," said Dave Wellstone, son of the late senator from Minnesota and a parity advocate for the group Wellstone Action. Wellstone predicted that Congress would reach a compromise on parity
that "looks a little more like the House bill" than the current Senate legislation. "There are better patient protections in the House bill and the costs are the same, so there's no need, in my mind, to pass a weaker bill just because that's what insurers want," he said.

The Bush administration, the U.S. Chamber of Commerce, and some health insurers are among the opponents of the House legislation, although Bush has not threatened to veto the measure. The trade group America's Health Insurance Plans (AHIP) has supported the Senate bill, sponsored by Sens. Edward Kennedy (D-Mass.) and Pete Dominici (R-N.M.) but not the House bill.

"Health insurance plans support the bipartisan mental-health parity legislation (S. 558) that passed the Senate by unanimous consent because it is a balanced approach that would preserve access to health plans' medical management and quality improvement programs," said Karen Ignagni, president and CEO of AHIP. "Unfortunately, the House legislation would turn back the clock on advances in the quality of care and impose excessive costs on patients and employers. Though well-intentioned, this legislation would undermine the progress that has been achieved in improving behavioral-health benefits through coordinated-care strategies."

Generational tsunami

From the New York Times:

“We have different health issues, different emotional issues, different grief issues,” said Patrick Gallagher, 66, who was treated here for a dual addiction to pain medication and alcohol. “We need more peace and quiet and a different pace.”

Hmmmm...

From Chicago:

Tiny plastic bags used to sell small quantities of heroin, crack cocaine, marijuana and other drugs would be banned in Chicago, under a crackdown advanced Tuesday by a City Council committee.

Ald. Robert Fioretti (2nd) persuaded the Health Committee to ban possession of "self-sealing plastic bags under two inches in either height or width," after picking up 15 of the bags on a recent Sunday afternoon stroll through a West Side park.

Lt. Kevin Navarro, commanding officer of the Chicago Police Department's Narcotics and Gang Unit, said the ordinance will be an "important tool" to go after grocery stores, health food stores and other businesses. The bags are used by the thousand to sell small quantities of drugs at $10 or $20 a bag.

Navarro referred to the plastic bags as "Marketing 101 for the drug dealers." Many of them have symbols, allowing drug users to ask for "Superman" or "Blue Dolphin" instead of the drug itself, he said.

Prior to the final vote, Ald. Walter Burnett (27th) expressed concern about arresting innocent people. He noted that extra buttons that come with suits, shirts and blouses -- and jewelry that's been repaired -- come in similar plastic bags.

Burnett was reassured by language that states "one reasonably should know that such items will be or are being used" to package, transfer, deliver or store a controlled substance. Violators would be punished by a $1,500 fine.

Health Committee Chairman Ed Smith (28th) said the ban is part of a desperate effort to stop what he called "the most destructive force" in Chicago neighborhoods.

"We need to use every measure that we possibly can to stop it because it is destroying our kids," he said.

Insite on HDNet

Dan Rather reports on Vancouver's Insite program. (Warning: If seeing people shoot up is going to bother you, don't watch it.)



I had understood that Vancouver had serious problems with addiction and high HIV rates. It helps me understand the impulse for a radical response. However, in light of the severity of the problem, their response is not radical--it's pathetic and constitutes abandonment. In a situation as dire as Vancouver, a radical response is needed, but that radical response should be to flood the community with comprehensive harm reduction AND treatment services. I understand that there may be real world limitations and tough decisions must be made, but I don't hear anyone advocating for recovery-oriented services.

The video presents Insite as treatment inducement site, however, Insite's own website reports that they've made 368 referrals to withdrawal management, a number that constitutes 5% of the unduplicated count of persons served. They also make reference to 1632 referrals to treatment, but the wording makes it sounds a little gamey--that, at best, they are passive referrals rather than an active linkage.

Bill White recently warned about the potential stigmatizing effects of our efforts to define addiction as a neurobiological disease without also describing the neurobiology of recovery. Several of the comments in the video do a great job illustrating his warning.