MDMA therapy

Mark Kleiman sees an opportunity for research on ecstasy for the treatment of PTSD.

Treatment reform in the U.K.

A direct challenge to the U.K. reliance on methadone.

I find it pretty easy to imagine similar circumstances in the U.S. if it weren't for the numbers of recovering people already in the field and the good fortune to have high profile recovery advocates like Senator Harold Hughes and Betty Ford in the right place at the right time.

Another article deconstructs the U.K.'s definition of recovery and offers some context.

In particular, the inclusion of "sustained control over substance use":

...in talking about voluntary exercised control there is a sense in which the thorny issue of drug user abstinence has been effectively sidestepped. But how is control in this context being defined? Does this definition mean that an individual continuing to use illegal drugs but in a more controlled way can be considered ‘in recovery’? Does it matter in terms of evaluating the effect of services if that element of control cannot actually be defined or measured? Does it matter if, as a result of this definition of recovery, we will not know whether the control that is being exercised is increasing, decreasing, or remaining the same over different lengths of time in treatment?

Aside from the difficulty of measuring the element of control, there is also the question of whose definition of control is going to apply in assessing whether the individual is indeed in more or less control of his or her drug use – that of the drug user, the doctor, or the addict’s family? Also what happens if these people disagree in terms of their assessment of how much control the individual is indeed exerting over his or her continued drug use?

Also the inclusion of "health and wellbeing and participation in the rights, roles and responsibilities of society":

These are grand terms, but what exactly do they mean? Do they mean that drug treatment services need to be enabling drug users to become good parents, to find work, to be housed, to vote, to understand current political issues, to be happier in themselves, to have better relationships with their families and friends, to not commit crime, to be greener in their lifestyle?

The list is potentially endless of the things that drug treatment services could see themselves doing which are all cumulatively about maximising an individual’s sense of health and wellbeing. But how well placed are drug treatment services to take on these additional challenges when they have found it so difficult to take on the challenge of enabling individuals to recover from their drug dependence?

I might have worded it differently, but this emphasis on recovery as something that is holistic is important. Addiction tends to infiltrate every aspect of the addict's life and it is not always self-correcting once abstinence is achieved. Good treatment and recovery support services must be prepared to address employment, family life, physical health, mental health, community involvement, etc. It is overwhelming, and we don't have to do it all ourselves (Much of it can be achieved through coordination of services--not just passive referrals.) , but the alternative is a system that fails and loses the confidence of addicts, their families, other professional helpers, and the public.When this confidence is lost, the stage is set for criminalization or a system that relies on methadone.

Dutch drug law changes

From Marginal Revolution:

1. As of July 1, the Netherlands will ban smoking in public places.
2. The smoking of cannabis and hashish, however, will be allowed, at least in licensed cafes.
3. The regulation will be that adding tobacco to the smoke (a popular practice) will be forbidden and that only "pure pot" will be allowed.

More here.

Kicking methadone in the U.K.

A great story of recovery and the professionals who didn't believe that it was possible. We get calls from people with the same experience here in the U.S., they want to get off methadone and the clinic treats it as noncompliance. They often feel that their only options are to get back on heroin or con a doctor into an opiate prescription, switch to the heroin or opiate Rx, and then detox themselves from the heroin or Rx opiates.

...I decided to look into rehab options. I met with my CAU key worker, explained that I wanted to get off the methadone as I wasn't using heroin anymore, and go to a rehab, I was told in no uncertain terms that she thought I wasn't ready for rehab and the local authority wouldn't be funding it.

As it happens that was probably for the best as I found a rehab myself, funded by housing benefit in Cardiff, that had a place for me. So I left hospital and went straight into LivingStones Rehab. I wanted to discuss reducing my methadone, so at this point I went to see my key worker again, really chuffed to be able to give my first negative urine sample(negative for heroin), She said that's great but I'd like to increase your methadone dose, just in case. I couldn't believe it, why raise it? I'd stopped taking heroin, was in a stable environment, with support and they wanted to raise my dose? After a lengthy discussion, she agreed to not increasing it but would have none of it when it came to talk of reducing it.

So I decided to write my own reduction plan, as I was on weekly pickup it was possible for me to measure it myself and discard the remainder. I decided on 10% drops every week, until I was completely off it. I let my key worker know my plan, accepted the flack she gave me and got on with it.

Every time I went in for an appointment after that I ended up being chastised for reducing myself,it was going smoothly but she still wouldn't agree to reducing as I wanted and would only drop it to the level I was on that day, so by the next week I was having to measure it and throw away the excess again. No matter what I said or how I explained it, the CAU would not reduce it for me, worse than that they put every barrier possible in front of me. This went on for months, in fact it wasn't until I was on 8ml/day that they realised I was serious about coming off methadone for good and actually started to reduce it for me when I asked.

Alcohol,The Brain & Insulin

One explanation for "wet brain"?

Teens Who Abuse Alcohol Or Drugs Are More Likely To Die Young

More reason to take teen drug use seriously. (Just don't hype it.)

"The fact that these were, to an extent, predictable deaths raises additional concerns about the hazards of alcohol and drug problems in teens and young adults," said Duncan B. Clark, M.D., Ph.D., associate professor of psychiatry and pharmaceutical sciences at the University of Pittsburgh School of Medicine and director of the Pittsburgh Adolescent Alcohol Research Center at the Western Psychiatric Institute and Clinic of UPMC.

Teens who abuse alcohol or drugs are more likely to die in early adulthood, according to a study by University of Pittsburgh researchers published in the current issue of the Journal of Adolescent Health.
...
The researchers studied 870 white and African-American adolescents, ages 12 through 18, recruited from both clinical and community settings. The subjects were followed for up to eight years, starting in 1990.

Among the 870 adolescents, researchers noted 21 deaths, or about 2 percent of the group, at an average age of nearly 25 years. Fourteen of those deaths occurred in males with SUDs, or more than 10 percent of that group. Among African-American males with SUDs, 23 percent had died by the age of 25. Males with SUDs in this study group had a mortality rate far in excess of the rate of 137 per 100,000 reported for young adult males in the U.S. general population.

Socioeconomic status was not a significant predictor of survival time. Causes of death for the young adults in the study ranged from homicide and suicide to drug overdose and motor vehicle accidents.

What drug poses the greatest threat?

This map shows how local law enforcement answered the question, "What drug poses the greatest threat to your area?" Blue is cocaine, red is methamphetamine, amber is heroin, and green is marijuana.

This map is from the National Drug Threat Survey. Even though I'm aware of the regional differences in drug use, it's still striking every time I see something like this. I'm surprised that there were not more mentions of heroin.
[hat tip: Addiction Inbox]

Pot potency commentary

A challenge to the ONDCP hype about pot potency. I support policies intended to keep kids from using drugs, but the ONDCP would really help themselves if they were less sensational and more honest. The result of this hype is that kids learn quickly that the ONDCP and CASA are not a reliable sources of information so they stop listening to anti-drug messages--then who are they listening to?

Social economics

Social economists are playing a larger role in drug policy discussions. There may be a lot of good reasons for them to have a place at the table, but this post, while not about addiction, does a great job illustrating why I believe social economists shouldn't be given too much sway.

They offer an intellectually stimulating perspective on many social problems that has the potential to stimulate some creative thinking, but they offer a very one dimensional perspective that seems indifferent to many elements of the social context.

The Historical Essence of Addiction Counseling

It struck me today that so many of the disagreements related to drug policy and services boil down to disagreements about the nature of the problem. Here's Bill White on the historical essence of addiction counseling:

If AOD problems could be solved by physically unraveling the person-drug relationship, only physicians and nurses trained in the mechanics of detoxification would be needed to address these problems. If AOD problems were simply a symptom of untreated psychiatric illness, more psychiatrists, not addiction counselors would be needed. If these problems were only a reflection of grief, trauma, family disturbance, economic distress, or cultural oppression, we would need psychologists, social workers, vocational counselors, and social activists rather than addiction counselors. Historically, other professions conveyed to the addict that other problems were the source of addiction and their resolution was the pathway to recovery. Addiction counseling was built on the failure of this premise. The addiction counselor offered a distinctly different view: "All that you have been and will be flows from the problem of addiction and how you respond or fail to respond to it."

Addiction counseling as a profession rests on the proposition that AOD problems reach a point of self-contained independence from their initiating roots and that direct knowledge of addiction, its specialized treatment, and the processes of long-term recovery provide the most viable instrument for healing and wholeness.

Opioid Maintenance Therapy Saves Lives

It's important to note the context of this finding. When your options are sub-optimal treatment, no treatment, or opioid maintenance, opioid maintenance saves lives. Findings like this get published, and we learn that, in the context of crappy options, which option is the least crappy. This option gets categorized as "the best option" or as an evidence-based practice. No one stops to suggest that, maybe, we should change the context.

Opioid-dependent patients are 13 times more likely to die than their age- and sex-matched peers in the general population. To examine predictors of long-term mortality, Australian researchers conducted a 10-year follow-up study of 405 heroin-dependent patients who had participated in a randomized trial comparing methadone and buprenorphine.

• Overall mortality was 8.8 deaths per 1000 person-years of follow-up (0.66 during opioid maintenance treatment and 14.3 while out of treatment).
• Each additional opioid maintenance treatment episode lasting more than 7 days decreased mortality by 28%.
• Subjects who were using more heroin at baseline had a 12% lower mortality rate overall, likely because they spent more time in opioid maintenance treatment.

Comments:
Often overlooked in the controversy over opioid substitution therapy is the reality that opioid dependence has a high fatality rate. The current study highlights that opioid maintenance treatment saves lives. The selection of the treatment episode as greater than 7 days strongly suggests that opioid maintenance, not detoxification, reduces mortality. The time is right to promulgate opioid maintenance therapy with either buprenorphine or methadone as the standard-of-care, first-line treatment for opioid dependence.
Peter D. Friedmann, MD, MPH

Reference:
Gibson A, Degenhardt L, Mattick RP, et al. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction. 2008;103(3):462–468.

This weed is the sh*t!!!

Literally. Salmonella too!

More on recovery in the U.K.

UPDATE: The author of the post linked to below believes that she was taken out of context. Her blog appears to be down at the moment. She was responding to this proposed definition of recovery:

‘The process of recovery from problematic substance use is characterised by voluntary sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.’

I believed that this would have been clear in the context of this blog (The previous post was on this subject and provided the definition.) and the link back to her blog. My apologies if this wasn't clear.

--------------------

A harm reduction advocate in the U.K. wrestles with the idea of a system organized around recovery:

So, hang on, if I'm a substance user who voluntarily controls my own substance use but who chooses not to have participation in the "rights and roles and responsibilities of society" I can't be in recovery? Who says so? What you going to do? Make voting and working and watching Eastenders mandatory for all ex users? Recovery is what I define it as.

Or say I want to participate in the "three R's" of society but every 6 months or so I have a binge. Am I not in Recovery? Don't I have any say in deciding that?

For me, defining Recovery as a process to be controlled by the individual, but then imposing a whole set of values and outcomes upon what "characterises" that recovery is to miss the point. You have to let me judge what my Recovery is. It is not up to you to normalise me. These are my choices, my hopes and my decisions. You make them yours, then you do exactly what those early mental health activists feared. You create "a cosmetic initiative that maintains the dependence of individuals on the system".

I suppose I understand the apprehension, that a recovery-oriented system just being a new set of parameters for doing the same old thing--controlling people. We've certainly had the experience of seeing systems earnestly describe themselves as recovery-oriented when, in practice, they still blame clients for the client's "failure to change" when, in truth, the system failed to provide the support the client needed. Also, there is some history of recovery advocates (before they were called recovery advocates) imposing one narrow path as THE way to recover.

Before I get into my reactions, let me say that I mean no disrespect. I see her blog post as a constructive attempt to articulate her concerns rather than dismiss or attack.

However, there's a way in which I bristle at the statement above. I think it paints a caricature of recovery advocates and addicts. The statement suggests that those who advocate recovery may be invested in forcing some sort of conformity onto addicts. I also believe that it hints at a view of addiction of a nonconformist lifestyle choice rather than an illness characterized by loss of control. The truth, in my experience, is that they're suffering terribly due to their addiction and often don't dare to hope for recovery. Once we impart some hope for recovery, (by offering success stories, hope-engendering relationships, respect and love) they want recovery. They may be concerned that we're asking them to give up their identity and become conformist but this is quickly dismissed by experiencing the recovering community first hand--it could hardly be characterized as conformist.

My response to the concern would be that a recovery-oriented system doesn't force anything, Can a client choose to use every six months and consider themselves in recovery? Sure. They're free to do whatever they want. Would I consider this recovery? If the binge is unintentional, I might characterize this as serial recovery but continue to work toward a more stable recovery. If the binge is planned, ("I'll just go on a binge once every 6 months!") I suppose I would not consider that recovery. I believe that part of recovery is participating in self-care to maintain recovery. However, if a person is capable of "tying one on" once every six months in a way that does not create problems in their life, I wouldn't consider that person an addict. My reaction is not some sort of moral reflex. I'd have the same reaction to a diabetic who goes on a sugar binge every six months and lands in the hospital. That person would not be in recovery from their diabetes. Now, does my judgment that this hypothetical is not recovery mean that I would try to coerce the client into my definition of recovery or abandon them? No. My response to this would be to try to be a fellow traveler and recognize that this is the client's journey.

Recovery is all about freedom. The freedom to live one's life in the way one chooses without being a slave to addiction or being controlled by treatment or criminal justice systems.

That is not to say that we cannot as professionals, service users and policy makers do what they did in mental health and begin to explore what we need to do to support Recovery, to define the conditions in which opportunities for people to achieve Recovery are optimised, or to find new ways of working which return the power to the service user and rebalance old inequalities. This is how Recovery became the dominant philosophy in the UK mental health field. I spent some time with an old friend last week who has spent years as a service manager working towards Recovery oriented mental health services. She told me that in the late 90's and early part of the century Recovery rapidly gained credence in mental health. Through the work of user groups and coalitions, the developmental work of NIMHE and other organisations across the field, and through live projects and action research, consensus was built around the Recovery model. She said the biggest challenge she faced was in changing the staff culture. No longer were people there to make decisions for people, to impose their will on people or even to ‘lead by example’. Staff had to find a new role, one that was about first of all helping people define their own ideas of what Recovery would mean – whether that was feeling completely well, or finding something they owned and understood in their own experience of illness (for example having a positive experience of hearing voices). But once that challenge had been dealt with, she said the battle was not over. Key for the success of the Recovery model was the ability of staff to empower service users to access the help and support they needed in the community.

This is the key. We've struggled mightily with maintaining a professional culture that is focused on recovery. It often conflicts with human nature and the instincts of professional helpers, so we have to accept that it will be a constant struggle. On the subject, we contributed to this paper.

I've been thinking about a model of recovery-oriented harm reduction that would address the historic failings of abstinence-oriented and harm reduction services. The idea is that it would provide recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented provider:

• an emphasis on client choice--no coercion
• all drug use is not addiction
• addiction is an illness characterized by loss of control
• for those with addiction, full recovery is the ideal outcome
• the concept of recovery is inclusive -- can include partial, serial, etc.
• recovery is possible for any addict
• all services should communicate hope for recovery--recognizing that hope-based interventions are essential for enhancing motivation to recover
• incremental and radical change should be supported and affirmed
• while incremental changes are validated and supported, they are not to be treated as an end-point
• such a system would aggressively deal with countertransference--some people may impose their own recovery path on clients, others might enjoy vicarious nonconformity through clients
  

1000 posts

My last post with my 1000th post. This blog started out as a way for me to share information with Dawn Farm employees and now has 150 to 300 readers a day. Thanks for your interest.

UPDATE: I neglect to mention that any commentary I make that's worth reading is due to the staff and clients of Dawn Farm. We talk every day about barriers to recovery, great and small, everything from international policy to helping a client in financial crisis get food for his dog.

Thanks for your hard work, thoughtfulness and inspiration. You make it easy to get out of bed every day and join you in helping people not just end their suffering, but transform their lives in truly incredible and inspiring ways.

A very U.K. definition of recovery

‘The process of recovery from problematic substance use is characterised by voluntary sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.’

A definition only a committee could love. Seriously though, it's good that England is re-examining its treatment system, trying to be more client centered, and trying to develop a vision of recovery. Also, I recognize how difficult the task is. Agreeing on a definition of recovery in an organization would be difficult, let alone across organizations and systems.

Two things leap out at me. The word maximize seems to hedge and leave some room for clinical pessimism. The other thing I found striking is the use of the phrase "sustained control". It's hard to imagine an American consensus statement with that phrase. In fact, one of the participants stated, "very uneasy with the words recovery and sobriety – it all sounded very American", bu that they are "words everyone understands." The concepts of powerlessness from 12 step groups, and loss of control from the DSM are pretty widely accepted here. It's worth noting that sustained control could mean abstinence or non-problematic use.

It seems to me that an important determinant of the definition of recovery would be the definition of the problem. My impression is that the disease concept is not widely accepted and drug problems are thought to be lifestyle choices.

Why Is Mom in Rehab?

The New York Times on recent increases in treatment admissions for 40+ year old women:

The actress Tatum O’Neal was arrested recently on charges of buying crack cocaine from a man on the street near her New York City home. She is a 44-year-old mother of three. She has spent years in and out of drug abuse treatment (which she chronicled in her 2004 memoir), and according to her publicist she will continue to “attend meetings” for drug and alcohol abuse.

Ms. O’Neal illustrates a disturbing trend among those being admitted to substance abuse treatment services: a growing percentage of older women are being treated for harder drugs.

Data from the Substance Abuse and Mental Health Services Administration revealed that the total number of admissions to treatment services from 1996 to 2005 (the last year for which detailed data are available) stayed about the same among people under 40, but jumped 52 percent among those 40 and older. Of the 40 and older group, the rise in admissions among men was 44 percent. Among women, it was 82 percent.

Early Drinking and Adult Alcohol Dependence Increases Among Americans

I've posted before on the relationship between early drinking and dependence later in life. Here's a summary of another study on the subject:

A study of individuals born between 1934 and 1983 found that more Americans began drinking alcohol at an early age over the decades, especially women, and that those who did drink at a younger age were more likely to be alcohol-dependent as adults.

Reuters reported June 9 that researcher Richard A. Grucza of the Washington University School of Medicine and colleagues said that the study doesn't prove that early drinking leads to dependence, "but what [it] does show is that early drinking does not simply reflect a genetic vulnerability to alcohol dependence."

Earlier onset of drinking and increased alcohol dependence in adulthood was true for both men and women, but the changes were more significant in women. Women who were born between 1934 and 1943 began drinking at age 22, on average, while those who were born after 1963 started drinking at an average age of 17. The rate of lifetime alcohol dependence was 9 percent among women born between 1934 and 1943 but rose to 22 percent among those born after 1963.

Grucza noted that while the study found that the decrease in women's average age of first alcohol use and rise in alcohol dependence occurred over the course of a few decades, human "genes don't change in that amount of time."

New Report Finds Highest-Ever Levels Of THC in U.S. Marijuana

It's so hard to believe anything that these guys say. I seem to remember them saying the same kind of thing in 2000. (And, their new chart certainly doesn't support that claim.) One thing that makes this a little more credible is that we're getting similar reports from other countries.

Program Treats Addicts in Health Care

Amazing what happens when you provide treatment in an adequate dose and intensity, and provide long term monitoring.

Family history and alcoholism

It appears that looking beyond parents is important in assessing familial risk for developing alcohol problems.

Obama and McCain on drug policy

Read it here. The 10 second version is that Obama has a decent sized list of predictable progressive pledges and McCain was an early champion of tobacco policy reform and has said little on drug policy recently. The article does look at McCain's positions that are indirectly related to drug policy.

Drug testing coming to Detroit high school

My gut reaction to this is very negative. Id be interested in visiting a school where this is already happening and hear about the impact, positive and negative.

Finney High School in Detroit received a federal grant Wednesday to start randomly testing some of its students for drug use as early as this fall.

Kanzoni Asabigi, the deputy director of substance abuse prevention at the Detroit Department of Health and Wellness Promotion, said the three-year pilot program could lead to random drug testing at all public high schools in Detroit.

It's also ironic that this pretty drastic action is being taken when, last I checked, underage drinking and drug use was a bigger problem in the suburbs.

A Genetic Clue to Quitting Smoking

An new direction for pharmacotherapy:

Reporting this week in the Archives of General Psychiatry, scientists describe for the first time a set of genes, about 100 in all, that seem to predict how well a smoker will respond to two different types of quitting programs — nicotine replacement or bupropion (Zyban). Nicotine-replacement methods, including the patch, pill and gum, work by weaning the smoker off nicotine gradually, usually over a period of weeks or months. Bupropion, on the other hand, is an antidepressant, which does not contain nicotine; instead, it works to curb nicotine cravings by interfering with the reward circuit in the brain, where addictions — to nicotine and other drugs, or behaviors — are reinforced. Nationally, about 70% to 80% of smokers say they want to quit, but any single attempt, regardless of the quitting method, is on average only 30% successful.

Society pays a high price for the bad choices of a few

This writer has an interesting take on the Insite controversy.

Some of his beliefs about addiction are deeply flawed:

I recognize, though, that the advantages of life are not universally shared. I recognize that some people have more choices than others. I recognize, too, that some people have stronger wills than others, and an instinct not to throw their lives down the drain.

I'm not aware that there are gangs, wielding syringes, roaming our streets and delivering the first fix that is said to begin addiction. I don't know what it is that forces thinking and aware people to become junkies if they don't have to.

I understand there may be some pre-existing medical condition that requires substances that are proscribed because there's nothing else available -- drugs that can make a partial life bearable.

But, he does make some interesting points:

I think it's commendable that our society tries to treat those who are addicted and get them off drugs, tries to prevent others from being hooked and tries to enforce laws that it deems appropriate to punish traffickers and those who commit other crimes to feed their self-destructive habit.

It's also commendable that society tries to reduce the collateral damage of addiction -- things like the spread of disease and the risk of harm, including death from overdose, to users.

This last bit is where Vancouver's Insite fits in. It's been an experiment with very modest results that are merely collateral to drug addiction and are measured in negatives. No one has died on the premises.

Based on the opinion of its supporters among medical practitioners and authorities and the less universal endorsement of police, there should be Insites in every city and town across Canada.

There aren't for two reasons: There are far greater medical priorities in the country, and our society is uncomfortable providing places for people to break the law and supplying professional backup to ensure they can do so safely.

...

Surely more is accomplished in treating addicts, trying to get them off the stuff and giving them a little hope than by idly standing by to "supervise" their self-destruction and then allowing them out to crawl in the filth again.

The idea that people have a constitutional entitlement to be rescued by the state while continuing to harm themselves, under the guise of the right to life, liberty and security of the person, surely is absurd. I hope a higher court declares it so.

This seems like someone who would be open to a both/and response if either side was offering one.

Fertilizer for your brain

This is a little creepy:

Drugs that encourage the growth of new neurons in the brain are now headed for clinical trials. The drugs, which have already shown success in alleviating symptoms of depression and boosting memory in animal models, are being developed by BrainCells, a San Diego-based start-up that screens drugs for their brain-growing power. The company hopes the compounds will provide an alternative to existing antidepressants and says they may also prove effective in treating cognitive disorders, such as Alzheimer's.

The Brain on (Lots of) Marijuana

An interesting finding:

Marijuana's effect on the brain is far from understood, but Australian research published Monday in the Archives of General Psychiatry suggests that very heavy long-term smoking might be associated with structural changes in two areas of the brain rich in receptors to the drug. The hippocampus, believed to regulate emotion and memory, and the amygdala, which plays a role in aggression and fear, were smaller—12 percent and 7 percent, respectively—in a group that smoked at least five joints daily for at least the past 10 years (and, on average, 20 years) when compared to a nonsmoking group.

Users also showed more signs of sub-threshold psychotic symptoms compared with those in the group that abstained. And on tests of memory and verbal ability, they performed more poorly. "Our findings suggest that everyone is vulnerable to potential changes in the brain, some memory problems, and psychiatric symptoms if they use heavily enough and for long enough," says lead author Murat Yucel of the ORYGEN Research Centre and Melbourne Neuropsychiatry Centre at the University of Melbourne.

With a caveat:

But it's way too early for parents to conclude that pot deteriorates the brain, cautions Scott Swartzwelder, professor of psychiatry and behavioral sciences at Duke University whose own research focuses on substance abuse and the adolescent brain. "Scientifically, it's a very limited set of data," he says. The study was tiny—it covered only 15 pot smokers and 16 abstainers—and looked at extreme behavior, so "I'm not sure how relevant it is to the general public," says Swartzwelder, who is coauthor of Just Say Know: Talking to Kids About Drugs and Alcohol and Buzzed: The Straight Facts About the Most Used and Abused Drugs From Alcohol to Ecstasy (an updated third edition is being released in August). [NOTE: A great book with dispassionate and reliable information.]

Aging doesn't stop drug use

From Scientific American:

Writing in the journal Neuropsychopharmacology, Gay­athri J. Dowling, Susan R. B. Weiss and Timothy P. Condon warn that many aging baby boomers, long accustomed to using illicit drugs for recreation and medicinals of all kinds for treating whatever ails them, will carry their love affair with drugs into old age. Medicine is only beginning to appreciate the consequences.

The baby boomers, the generation born between 1946 and 1964, make up 29 percent of the U.S. population today. By 2030 this “pig in the python” of the nation’s age-distribution profile will swell the number of people aged 65 and older to 71 million. The baby boomers, of course, became well known in the 1960s for their significantly higher use of illicit drugs than that of preceding generations. At one time, investigators were convinced that as people aged, they would “grow out of” the use of recreational drugs. There is little evidence that any such thing has taken place today.

Dowling and his colleagues cite hospital data that record the number of people aged 55 and older who sought emergency-room treatment and mentioned using various drugs. The number of cocaine mentions rose from 1,400 in 1995 to almost 5,000 in 2002, an increase of 240 percent. Similarly, mentions of heroin increased from 1,300 to 3,400 (160 percent), marijuana from 300 to 1,700 (467 percent) and amphetamine from 70 to 560 (700 percent).

Data from the National Survey on Drug Use and Health corroborate those trends. In 2002 some 2.7 percent of adults between 50 and 59 admitted to illicit drug use at least once in the preceding year. By 2005 that number had increased significantly, to 4.4 percent. The investigators attribute the rise to the aging baby boomers, as well as to enhanced longevity coupled with people’s tendency to retain their long-held patterns of drug use as they grow older. Those numbers will put substantial new strains on the medical system: by one estimate, the number of adults aged 50 and older treated for drug abuse will rise from 1.7 million in 2000 and 2001 to 4.4 million in 2020.

The article goes on to discuss differences in metabolism and dangers as one ages and continues to use drugs.

Drug policy freak show

A scathing criticism of the Canadian federal government's opposition to Insite.

Complete with serious flaws when reporting history...

A major factor in the court's thinking was the widespread belief at the time that addiction could be cured easily thanks to a marvelous treatment invented by Charles B. Towns, a failed stockbroker. Unfortunately, it was realized not long after the ruling that Towns was a quack. But by then, it was too late. All maintenance programs had been shut down and the drug problems we are now so familiar with -- black markets, violence, disease -- sprouted in American cities.

...and idealized reporting of drug policy and other countries...

I've seen it at work in the Netherlands. Imagine healthy heroin addicts. With jobs. And apartments. And families. Addicts who are not a blight on the community. It's all thanks to an array of harm reduction programs which this country is too timid to even try.
...
In the United Kingdom, by contrast, maintenance remained the central policy for another 45 years. In all that time, the underworld drug scene scarcely existed.

...and insults for those the writer disagrees with...

The government's handling of drug policy is so ignorant and foolish it is a challenge to explain why in a newspaper column. To expound on stupidity of this magnitude requires a very long book.

I thought for some time about whether to post anything about this column. It's so hostile to those who disagree and it is dripping with what Anne Lamott once called "excessive certitude". I didn't want to give it any attention, but it exemplifies two things that I'd like to draw attention to. First, as I've written before, there is no problem-free drug policy. Any drug policy will have problems, probably serious problems. The important questions are:

• Which problems are we most unwilling to live with?
  
• Which problems are we most willing to tolerate?
• What strategies will help us achieve these goals while maintaining concern for all problems?

Of course, of equal importance is our willingness to regularly re-assess policy to improve our response and address unanticipated problems.

The second point I wanted to make is that drug policy dicussion has devolved in a way that is similar to American political discourse. In his book, The Way to Win, Mark Halperin describes the phenomena of the political "freak show" where media is shining the spotlight on the extreme poles of political thought. These voices get more attention and often eventually intensify their rhetoric to keep the spotlight on them. These voices get framed as "the debate" when most people are somewhere in the middle or adopt positions that are not represented at all. Discourse gets uglier and uglier, and the voices on the poles intensify their rhetoric (often getting increasingly intellectually lazy and/or dishonest) while everyone else withdraws.

I see something similar happening in drug policy debates. There is a lot that reasonable people can disagree about. Where we have disagreements, we should disagree and disagree vigorously. But, we should try to keep in mind that all of us come into these discussions with our own priorities and values. We should be willing to identify our own priorities and values and be willing to listen to those of other people. There's a strong public health case for Insite and other HR programs--and that abstinence-oriented providers were not responsive enough to the needs of pre-contemplative addicts and public health concerns. There's a strong libertarian case for treating drug use as a matter of personal liberty--and that we should all be troubled by incarceration rates and that we should be thoughtful and cautious in the use of coercion to get people into treatment. There is also strong case that drug policy is too often focused on the needs of people other than the addict and is too often based on beliefs that addicts don't want help, can't get well, and are of questionable character. All of these positions offer important perspectives, but none of them capture the whole picture.

The range of what we think and do is limited by what we fail to notice. And because we fail to notice that we fail to notice, there is little we can do to change, until we notice how failing to notice shapes our thoughts and deeds.

Ronald Laing

Alcoholics Anonymous and Narcotics Anonymous benefit adolescents who attend

Recently, some questions have been raised about the appropriateness of 12 step facilitation with adolescents. It's been suggested that it's an ineffective strategy and, worse, that it's harmful to adolescents.

First, let me address the use of 12 step facilitation with adolescents at Dawn Farm. First, we only employ 12 step facilitation with clients who meet diagnostic criteria for dependence and can be characterized as having chronic, high severity problems with alcohol and other drugs. There is some history of treatment providers indiscriminately employing 12 step facilitation with every client who walks through their doors. Second, Washtenaw county is fortunate to have a large, vibrant, and welcoming community of young people in 12 step recovery. It may be harmful to refer a 16 year old to 12 step groups in communities where they will be the youngest person in the room by 10 to 20 years. Thirdly, are treatment strategies are not limited to 12 step facilitation. We work with clients to identify other strategies and communities to support their recovery.

It just so happens that an upcoming issue of the journal Alcoholism: Clinical and Experimental Research has a study on the subject. Here's an excerpt from a press release:

“AA and NA are explicitly focused on abstinence and addiction recovery, they are widely available across most communities, they provide entry to a social network of recovery-specific support and sober events that can be accessed ‘on demand’ – particularly at times of high-relapse risk such as evenings and weekends, the services are free, and AA/NA can be attended as intensively, and for as long, as individuals desire,” he said.

However, he added, despite growing evidence that adults benefit from AA and NA, little is known about how these abstinence-focused organizations help youth, and what is known lacks scientific rigor.

“This knowledge gap is particularly noteworthy given that adolescents and young adults face more barriers to AA and NA than older adults and yet appear to be referred there just as frequently by treatment providers,” said Kelly. “Youth tend to have less severe addiction problems, on average, and consequently do not feel a strong need to stop using alcohol and/or drugs. ‘Why should they bother to go to abstinence-oriented organizations like AA and NA, and would they benefit even if they did go?’” These are the questions Kelly and his colleagues wanted to address.

The researchers recruited 160 adolescent inpatients (96 males, 64 females), with an average age of 16 years, who were enrolled at two treatment centers in California having a focus on abstinence and based on a 12-step model. The study participants’ length of stay ranged from four to six weeks, after which they were re-assessed on a number of clinical variables at six months, and one, two, four, six, and eight years.

“We found that most of the youth attended at least some AA/NA meetings post-treatment,” said Kelly. “Those patients with severe addiction problems and those who believed they could not use alcohol/drugs in moderation attended the most. The NA and AA focus on abstinence/recovery probably resonates better with these more severely dependent individuals who also typically need ongoing support.”

Even though many of the youth discontinued AA/NA after time, they nonetheless appeared to benefit from attendance.

“We found that patients who attended more AA and/or NA meetings in the first six months post-treatment had better longer term outcomes, but this early participation effect did not last forever – it weakened over time,” said Kelly. “The best outcomes achieved into young adulthood were for those patients who continued to go to AA and/or NA. In terms of a real-world recovery metric, we found that for each AA/NA meeting that a youth attended they gained a subsequent two days of abstinence, independent of all other factors that were also associated with a better outcome.”

A little can go a long way, he added. “During the first six months post-treatment,” said Kelly, “even small amounts of AA/NA participation – such as once per week – was associated with improved outcome, and three meetings per week was associated with complete abstinence. This suggests youth may not need to attend as frequently as every day, sometimes recommended clinically, to achieve very good outcomes.”

Kelly believes that part of the reason for the success of AA/NA among adolescents who attend meetings is related to their developmental needs.

“Given the need for social affiliation and peer-group acceptance outside of the family at this stage of life, peers can exert strong influence on the behavior of young people,” he noted. “When you couple this fact with the reality that most adolescents and young adults are experimenting with, or heavily using, alcohol and other drugs, it may be hard to find suitable peer contexts that can facilitate recovery. In fact, we know that most youth relapses are connected with social contexts where alcohol/drugs are present; unlike adults, youth rarely relapse alone. So, organizations such as AA/NA may provide support, and encourage and provide alternatively rewarding sober social activities.”

The article will be published in the August issue.