Obesity Predisposition Traced To The Brain's Reward System

I've previously expressed concern about erosion of the boundary integrity of the disease model undermining acceptance of addiction as an illness. Buy, if there's science to support it, no problem.

A new study suggests that obesity is linked to dopamine production:

"Baseline dopamine levels were 50 percent lower and stimulated dopamine release was significantly attenuated in the brain reward systems of obesity-prone rats, compared with obesity-resistant rats. Defects in brain dopamine synthesis and release were evident in rats immediately after birth," said Emmanuel Pothos, PhD, assistant professor in the department of pharmacology and experimental therapeutics at TUSM and member of the neuroscience program faculty of the Sackler School of Graduate Biomedical Sciences.

"Previous research has demonstrated that food intake leads to an increase in the release of dopamine, in the circuits that mediate the pleasurable aspects of eating," Pothos explains. "Also, chronic food deprivation resulting in decreased body weight leads to decreased dopamine levels. Therefore, increased food intake may represent a compensatory attempt to restore baseline dopamine levels."

Pothos says, "These findings have important implications in our understanding of the obesity epidemic. The notion that decreased dopamine signaling leads to increased feeding is compatible with the finding from human studies that obese individuals have reduced central dopamine receptors." He speculates that an attenuated dopamine signal may interfere with satiation, leading to overeating.

What I don't get is how these two statements go together:

Defects in brain dopamine synthesis and release were evident in rats immediately after birth

and

These findings have important implications in our understanding of the obesity epidemic.

Is there a new epidemic of babies being born with dopamine regulation problems at birth? We frequently attribute increases in obesity as a product of lifestyle changes. Is this suggesting that it's related to changes in brain function that are identifiable at birth?

Drinking Can Be Triggered By The Right Place And The Right Time

Everything old is new again. Remember those briefcases full of fake drugs for cue extinction therapy? Let's hope those aren't coming back.

Bullying a risk factor for SUDs?

Bullying a risk factor for substance use disorders?

Examining a group of nearly 9,600 U.S. students in grades 6 through 10, a pair of researchers led by Jorge Srabstein, M.D., of the Children's National Medical Center in Washington, D.C., found that 39 percent had been either a perpetrator of bullying, a victim, or both. These youths were at higher risk of any form of physical injury than were those youths not involved in any bullying activity.

Yet the researchers found that the group of perpetrators was at higher risk for some behaviors not seen in the group of victims. These behaviors included use of alcohol or any type of drug, as well as problems in the classroom.

Use before age of 13 down

Good news.

The percentage of high school students who first tried alcohol or cigarettes before the age of 13 has declined considerably over the last decade, according to recently released data from the national Youth Risk Behavior Survey (YRBS).

In 1997, 31% of high school students reported drinking more than a few sips of alcohol before age 13, compared to 24% in 2007. The percentage reporting smoking a whole cigarette for the first time before age 13 also declined, from 25% in 1997 to 14% in 2007. Marijuana initiation before age 13, however, did not change significantly over the same period.

Maybe this will offer an opportunity to learn more about the relationship between age of first use and dependence later in life. If this cohort has lower rates of dependence later in life, it might suggest that there is a cause and effect relationship between use in early adolescence and dependence later in life.

For and Against Insite....again

The National Post offers a point/counterpoint on harm reduction that completely misses the point.

From the pro-Insite piece:

"The belief," he says, "is that if health providers remove or lessen the harms of addicts' behaviour, addicts won't hit bottom and therefore won't have the motivation to go clean."

Does anyone really make this argument? This seems like a straw man argument.

"The issue is not whether the addict would be better off without his addiction--of course he would--but whether we are going to abandon him to illness or death if he is unable to give it up," says Dr. Gabor Mate

That's one issue. The other issue is, how far are we willing to go to help them get off drugs.

The anti harm reduction column is no better. It advocates the elimination of harm reduction services and offering only abstinence-based services.

How about both/and?

Medication deaths skyrocket

Fatal medication overdoses involving alcohol and street drugs skyrocket. The data also supports assertions that, despite conventional wisdom focusing on young people, baby boomers account for a significant portion of drug problems in the US:

According to background information in the paper, published in the July 28 issue of the Archives of Internal Medicine, there has recently been a dramatic shift in fatal overdoses away from inpatient settings to outpatient settings. More and more medications are taken outside of the hospital or clinic, with far less oversight from health-care professionals, the researchers said.

At the same time, more medications that once were available only by prescription are now bought over-the-counter, and more people are taking more than one medication.

All of this makes it easier for individuals to combine medications with alcohol and/or street drugs. But despite this shift, few if any studies have looked at drug errors outside clinical settings.

Almost 50 million death certificates were filed in the United States between Jan. 1, 1983, and Dec. 31, 2004, 224,355 of them involving fatal medication errors (FMEs). After examining all of these documents, the authors discovered that the overall death rate from fatal medical errors increased by 360.5 percent during that time period.

The surge in FMEs differed by type. FMEs occurring at home and combined with alcohol and/or street drugs increased the most, by 3,196 percent. [emphasis mine] FMEs not happening at home and not involving alcohol and/or street drugs showed the smallest increase, at 5 percent.

Meanwhile, at-home FMEs not involving alcohol and/or street drugs increased by 564 percent, while at-home FMEs involving alcohol or street drugs increased by 555 percent.

Overall, the increase in FMEs was particularly pronounced among people aged 40 to 59, where the increase was 890.8 percent.

Counseling inflating Chantix outcomes?

The Disease Care Management Blog offers a take on Chantix that I had not yet heard.

The Disease Management Care Blog was struck by Wall Street Journal Health Blog’s (WSJHB) coverage of another varenicline (Chantix) peer review publication. Reported in Thorax, study participants were randomly assigned to Chantix or to a nicotine patch. While early abstinence rates favored Chantix, the one year quit rates (26% vs. 20%) failed to achieve statistical difference (p=.056)....

...

The DMCB took some additional time to review some other publications on Chantix here, here and here. What was striking about these studies was that Chantix’s success was always accompanied by multiple follow-up 10 minute tobacco cessation office visits. [emphasis mine] The DMCB interprets this as showing that Chantix’s quit rates are intertwined with a significant degree of ongoing counseling. In fact, we really don’t know how well Chantix works without counseling. What’s more, tobacco cessation guidelines echo the necessity of prescribing tobacco cessation medications in conjunction with close follow-up:

'There is a strong dose-response relationship between the intensity of tobacco dependence counseling and its effectiveness. Treatments involving person-to-person contact (ie, via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (eg, the number of minutes of contact). If the patient agrees to attempt cessation, the clinician should then assist in making a quit attempt and should arrange for follow-up contacts to prevent a relapse. The treatment of tobacco dependence, like the treatment of other chronic diseases, requires the use of multiple modalities. '

Focus on medical marijuana

Health Beat criticizes the recent New Yorker article on medical marijuana as unserious:

Clearly, there’s no shortage of real, substantive issues to discuss when it comes to medical marijuana. Is it a medically valid form of therapy? Should we be pursuing more research? Evidence strongly suggests that the answer is yes to both questions. Given this, it’s frustrating to read a 12,000 word piece that culminates with a ganja grower declaring that “you’re still subverting the Man. And you’re getting people high.” Reducing medical marijuana to stoner culture does the issue a real disservice.

Obviously The New Yorker doesn’t have some formal obligation to publish ‘big-picture’ pieces, nor is it a journal of medicine or policy. But given how much there is to say about medical marijuana as a health issue—and how the case for it is much stronger than you might think—it seems a waste to focus on the tics and philosophies of pot dealers.

When it comes to medical marijuana, this just isn’t the real story.

Medical marjuana's influence on the pot trade

The New Yorker offers a peek inside the marijuana trade in California:

It was now three o’clock in the afternoon, and Captain Blue was dozing after a copious inhalation of purified marijuana vapor. (His nickname is an homage to his favorite variety of bud.) His hair was black and greasy, and was spread across his pillow. On the front of his purple T-shirt, which had slid up to expose his round belly, were the words “Big Daddy.” With his arm wrapped around a three-foot-long green bong, he resembled a large, contented baby who has fallen asleep with his milk bottle.

Captain Blue is a pot broker. More precisely, he helps connect growers of high-grade marijuana upstate to the retail dispensaries that sell marijuana legally to Californians on a doctor’s recommendation.

...“Try Sour Diesel,” he told the client. “Take that and the Bubba Kush.” In addition to Sour Diesel and Bubba Kush, which are grown indoors, he also had AK Mist, an outdoor strain; Jedi, which is brown and fuzzy; Purple Urkel, whose hue is suggested by its name; O.G. Kush and L.A. Confidential, two particularly potent strains; and Lavender, a fragrant purple grown up North. Modern Kush plants are derived from a strain that is said to have originated in the Hindu Kush mountains, in Afghanistan and Pakistan, and, according to stoner lore, was imported to Southern California by some hippie surfers in the seventies, and then popularized in the late nineties by the Los Angeles rap group Cypress Hill. Stronger, better-tasting varieties of pot can sell for more than five thousand dollars per pound, more than double the price of average weed. The premium paid for designer pot creates a big incentive for growers and dealers to name their product for whatever strains happen to be fashionable that year. The variety of buds being sold as Kush has proliferated to the point where even the most catholic-minded botanist would be hard pressed to identify a common plant ancestor.

And some background on it's legal status:

In 2003, the California State Legislature passed Senate Bill 420. The law was intended to clear up some of the confusion caused by Proposition 215, which had failed to specify how patients who could not grow their own pot were expected to obtain the drug, and how much pot could be cultivated for medical purposes. The law permitted any Californian with a doctor’s note to own up to six mature marijuana plants, or to possess up to half a pound of processed weed, which could be obtained from a patients’ collective or coöperative—terms that were not precisely defined in the statute. It also permitted a primary caregiver to be paid “reasonable compensation” for services provided to a qualified patient “to enable that person to use marijuana.”

The counties of California were allowed to amend the state guidelines, and the result was a patchwork of rules and regulations. Upstate in Humboldt County, the heartland of high-grade marijuana farming in California, the district attorney, Paul Gallegos, decided that a resident could grow up to ninety-nine plants at a time, in a space of a hundred square feet or less, on behalf of a qualified patient. The limited legal protections afforded to pot growers and dispensary owners have turned marijuana cultivation and distribution in California into a classic “gray area” business, like gambling or strip clubs, which are tolerated or not, to varying degrees, depending on where you live and on how aggressive your local sheriff is feeling that afternoon. This summer, Jerry Brown, the state’s attorney general, plans to release a more consistent set of regulations on medical marijuana, but it is not clear that California’s judges will uphold his effort. In May, the state Court of Appeal, in Los Angeles, ruled that Senate Bill 420’s cap on the amount of marijuana a patient could possess was unconstitutional, because voters had not approved the limits.

Most researchers agree that the value of the U.S. marijuana crop has increased sharply since the mid-nineties, as California and twelve other states have passed medical-marijuana laws. A drug-policy analyst named Jon Gettman recently estimated that in 2006 Californians grew more than twenty million pot plants. He reckoned that between 1981 and 2006 domestic marijuana production increased tenfold, making pot the leading cash crop in America, displacing corn. A 2005 State Department report put the country’s marijuana crop at twenty-two million pounds. The street value of California’s crop alone may be as high as fourteen billion dollars.

According to Americans for Safe Access, which lobbies for medical marijuana, there are now more than two hundred thousand physician-sanctioned pot users in California. They acquire their medication from hundreds of dispensaries, collectives that are kept alive by the financial contributions of their patients, who pay cash for each quarter or eighth of an ounce of pot. The dispensaries also buy marijuana from their members, and sometimes directly from growers, whose crops can also be considered legal, depending on the size of the crop, the town where the plants are grown, and the disposition of the judge who hears the case.

California’s encouragement of a licit market for pot has set off a low-level civil war with the federal government. Growing, selling, and smoking marijuana remain strictly illegal under federal law. The Drug Enforcement Administration, which maintains that marijuana poses a danger to users on a par with heroin and PCP, has kept up an energetic presence in the state, busting pot growers and dispensary owners with the coöperation of some local police departments.

In the past five years, an unwritten set of rules has emerged to govern Californians participating in the medical-marijuana trade. Federal authorities do not generally bother arresting patients or doctors who write prescriptions. Instead, the D.E.A. pressures landlords to evict dispensaries and stages periodic raids on them, either shutting them down or seizing their money and marijuana. Dispensary owners are rarely arrested, and patient records are usually left alone. Through trial and error, dispensary owners have learned how to avoid trouble: Don’t advertise in newspapers, on billboards, or on flyers distributed door to door. Don’t sell to minors or cops. Don’t open more than two stores. Any Californian who is reasonably prudent can live a life centered on the cultivation, sale, and consumption of marijuana with little fear of being fined or going to jail.

Foil!

A new approach to harm reduction with injection heroin users.

Gates, Bloomberg launch $375M anti-smoking campaign

Wow:

The $250 million from Bloomberg and $125 million from Gates will support projects that raise tobacco taxes, help smokers quit, ban tobacco advertising and protect nonsmokers from exposure to smoke. It will also aid efforts to track tobacco use and better understand tobacco control strategies.

...

Bloomberg, who built his fortune from the financial information company he founded in the 1980s, is adding $250 million to an anti-smoking initiative he funded with $125 million in 2006. That money goes toward tobacco-fighting campaigns in low- and middle-income countries, most specifically China, India, Indonesia, Russia and Bangladesh. Bloomberg Philanthropies is also conducting a survey to better understand smoking in those countries.

...

Bloomberg quit cigarettes about 30 years ago and has crusaded against smoking as a public official. In his first term he banned smoking in bars and restaurants and his health department has an aggressive, ongoing campaign to help New Yorkers kick the habit.

Tobacco Free Treatment

New York takes the leap.

Chronic disease management boring?

This is from a blog on medical disease management:

It is difficult to overestimate the mostly good and sometimes bad influence of medical training on attitude, values and career choices. One of the most pervasive outcomes of med school and residency however, is the enculturation of young trainees toward an acute care focus. We become addicted to the thrill of spotting a diagnosis and tailoring a successful treatment. That’s not necessarily bad: physicians are needed first and foremost to care for sick patients. After many rewarding years of helping patients in extremis, prevention - the art and science of non-events - is, well, so boring.

This contrast between chronic care ennui and acute care excitement has gone unexamined as one cause of the widespread lapses in health care quality. But the DMCB thinks it is out there.
...

The DMCB appreciates there are other forces at play. Physicians lack time, trust in the system, training, incentives and support. On the other hand, when physicians really want to effect change, it appears they have the means to do so.

I wonder how much of a role this plays in the dominance of the acute care model in addiction treatment. I also wonder to what degree the seductive power of the diagnostic process and boredom with disease management might lead to finding additional things wrong with patients.

That's better

Here's much smarter diavlog on drug prohibition. Though Kleiman is someone who's taken the time to learn something about drug policy and has thought deeply about it. I don't agree with him on a lot, but I always find him thought provoking.

Esteemed Ignorance on Display

Why pundits should have no role in shaping drug policy.

MCARDLE: In my experience, getting addicted to drugs is something that happens to people who are already screwed up. I've rarely seen someone seized by drugs and alcohol who didn't have something else going on in their lives.
COATES: Hmmmm. Yeah. Who would have been fine otherwise.

Keep in mind that these are people who have written for The Atlantic, a prestigious and influential magazine. They also both presented at the Aspen Ideas Festival. They may not be household names, but they are up-and-coming opinion makers.

Black in America

This weekend I watched a little of CNN's Black in America series and, while listening to them discuss the role of hope in education for young black men, I was struck by the parallels with helping people find recovery:

JABALI SAWICKI, EXCELLENCE CHARTER SCHOOL: So, the key here is incentive. I think the reality is -- our young boys, our children need to believe in school and they need to be able to celebrate their success in the school. So whether it is financial incentive, whether it is a school that can associate academic success with being an African American male or African American female. That's what we have to do.

The challenge how can we motivate and inspire our children to once again believe that school is a magical place, that school is a place empowerment and overcome the sense of disenfranchisement and disenchantment that many of them feel everyday. At Excellence, which is our school we have a 99 percent African American population of all males. Every single day our teachers, our leaders in he school he to find a way to convince these children, these scholars that school is an empowering place for them to succeed in life.

O'BRIEN: And what's that way, how do you take a kid who may say I don't know anybody who finished 11th grade. Why do I have to finished 11th grade?

SAWICKI: The key is there are people that are successful. But we a school have the ability to bring in adults who absolutely believe that every single one of our scholars can go to college. So college becomes the message of the school. When scholars walk through the door in kindergarten, every single adult is talking about college not as an if, but a when. And by positive messaging by creating opportunities to create a self-esteem and to give them belief and show them models of academic success we feel that we're situated to provide something real and tangible that they can buy into.

Our clients need a system that talks about recovery "not as an if, but a when" and connects them with success stories.

One of the panelists, Roland Fryer, was extremely impressive. He's even more impressive once you read his life story. In 2006, Fryer published a study of the impact of crack cocaine in the black community. It provides a brief history of the trajectory of the crack cocaine epidemic and it's disparate impact on violence, child welfare and arrests.

Our index of crack is strongly correlated with a range of social indicators. We find that the rise in crack from 1984-1989 is associated with a doubling of homicide victimizations of Black males aged 14-17, a 30 percent increase for Black males aged 18-24, and a 10 percent increase for Black males 25 and over, and thus accounts for much of the observed variation in homicide rates over this time period. The rise in crack can explain 20-100 percent of the observed increases in Black low birth weight babies, fetal death, child mortality, and unwed births in large cities between 1984 and 1989. In contrast, the measured impact of crack on Whites is generally small and statistically insignificant. We estimate that crack is associated with a 5 percent increase in overall violent and property crime in large U.S. cities between 1984 and 1989.

Obama on the war on drugs

From Rolling Stone:

The War on Drugs has cost taxpayers $500 billion since 1973. Nearly 500,000 people are behind bars on drug charges today, yet drugs are as available as ever. Do you plan to continue the War on Drugs, or will you make some significant change in course?

Anybody who sees the devastating impact of the drug trade in the inner cities, or the methamphetamine trade in rural communities, knows that this is a huge problem. I believe in shifting the paradigm, shifting the model, so that we focus more on a public-health approach. I can say this as an ex-smoker: We've made enormous progress in making smoking socially unacceptable. You think about auto safety and the huge success we've had in getting people to fasten their seat belts.

The point is that if we're putting more money into education, into treatment, into prevention and reducing the demand side, then the ways that we operate on the criminal side can shift. I would start with nonviolent, first-time drug offenders. The notion that we are imposing felonies on them or sending them to prison, where they are getting advanced degrees in criminality, instead of thinking about ways like drug courts that can get them back on track in their lives — it's expensive, it's counterproductive, and it doesn't make sense.

[via Transform Drug Policy Foundation and Jess]

More Kids Dying

From the New York Times:

Despite a decline in overall drug use, the rate at which young Americans between the ages of 15 and 24 have been dying from drug overdoses has jumped dramatically — more than doubling between 1999 and 2005. In the same period, according to the Centers for Disease Control and Prevention, “accidental poisoning deaths” in this age group, mostly drug overdoses, have jumped from 849 to 2,355.

Instead of rushing to save these young people, state governments are actually shortchanging them. Only a tiny fraction of the money that Washington sends to the states under the Substance Abuse and Prevention and Treatment Block Grant program is aimed at young drug abusers. This cannot go on.

Addiction, recovery and baseball

The MLB all-star game had a great story of recovery. An Alternet writer uses this story to make a point about the availability of treatment.

Let's hope he keeps taking care of his recovery. It's got to be tough with all that attention, money and time on the road.

Recovery Kentucky

I've been watching the Recovery Kentucky initiative with interest. Without talking to people on the ground, it's hard to know what to make of an initiative like this.

They've just published an outcome report. I looked over them quickly and was surprised to see that they appear to have had large numbers of abstinent people entering treatment. I don't know what to make of this, but the rest of the numbers seem to make a good case for a state investing in access to treatment. At any rate, it's good to see a state making the issue a priority.

HIV travel ban repealed

Not directly related to addiction, but seems worth mentioning. Congress voted last night to repeal the HIV travel ban.

The ban was enacted in 1987 with the passage of the "Helms amendment" to a bill to increase access to AIDS treatment medications. Placing restrictions on travel for people with communicable diseases falls under the purview of the Department of Health and Human Services. HIV was the only illness for which congress created a specific ban.

An American Pastime: Smoking Pot

From Time:

The Netherlands, with its permissive marijuana laws, may be known as the cannabis capital of the world. But a survey published this month in PLoS Medicine, a journal of the Public Library of Science, suggests that the Dutch don't actually experiment with pot as much as one would expect. Despite tougher drug policies in the U.S., Americans were twice as likely to have tried marijuana than the Dutch, according to the survey. In fact, Americans were more likely to have tried marijuana or cocaine than people in any of the 16 other countries, including France, Spain, South Africa, Mexico and Colombia, that the survey covered.

Possible explanations offered include affluence, perceived risk, and baby boomer culture.

The ONDCP complains that statistics on lifetime use are no way to judge the effectiveness of drug policy (hahaha). He probably has a point, but would past year or past month numbers really look a lot better?

Professional Pessimism

A comment in a recent post exemplifies the reasons for my queasiness about many harm reduction programs and practitioners (emphasis mine):

I work with a Chicago agency engaged in needle exchange. The high rate of HIV, hepatitis and the like transmitted by dirty needles would indicate a need for more harm reduction - not less. It's simply ridiculous to imply that providing clean needles in any way promotes drug use. Harm-reductionists soft-pedal recovery so as not to alienate active users. By engaging the user over time, harm-reductionists create opportunities for steering users to the treatment and social services they need. Certainly, they reduce the time between when a user decides he wants to quit to when he actually does something about it. There's another reality: statistically, most addicts never do recover, regardless of what they or social agencies do. Harm-reduction addresses this reality. The harm reduced is not only for that of the user, but for society as a whole. It's simply in everyone's best interest to reduce the transmission of disease by dirty needles, because this also reduces transmission to the general population by sexual activity and other means. All of us in the recovery business are saddened by conditions we see. But, we also believe, where there's life, there's hope. Many do recover - me, for example, and just about everyone I know working in the trenches. We've been there. Believe me, we know what we're doing.

Set aside from the straw man argument that, "It's simply ridiculous to imply that providing clean needles in any way promotes drug use."

What statistics show that most addicts never recover? Even if it's true for the people that this worker comes in contact with, why don't they recover? Is is because they're incapable? Because the professional helpers they come in contact with believe that they won't recover? Because the system would only offer them suboptimal treatment?

It's true that some addicts will never recover. However, I've been doing this for 14 years and I am completely incapable of predicting who will recover and who won't. Clients with no recovery capital recover and go back to school, start a business, reconcile with their loved ones, become wonderful neighbors, spouses, parents, and on and on. Others with everything going for them crash an burn. Because I am incapable of determining who will recover and who won't recover, I have to treat them all as though they can recover.

For multiple problem clients, hope-engendering relationships are key to treatment engagement and recovery initiation. One cannot offer a hope-engendering relationship if one believes that most addicts won't recover. If one can't participate in this conspiracy of hope, that person should not work with this population.

If one is able to offer authentic and bold hope, then one would be obliged to vigorously advocate for a system that offers more than harm reduction--a system that also offers adequate recovery-oriented treatment and recovery support on demand.

Artifact: Using Heroin Safely

From New York magazine, a "...a clean-injection kit and syringe (which can be used for heroin, cocaine, meth—basically, anything that can be mixed with water) from Housing Works’ Harm Reduction Place"
[hat tip: Anna]

Sick of watching people die

Harsh criticism of harm reduction:

Vancouver is famous for its innovative approaches to drug treatment. Twenty years ago, it launched a bold experiment to tackle the problems of the notorious Downtown Eastside. The guiding idea was harm reduction. If you couldn't cut off the drug supply or jail all the addicts, then at least you could reduce the secondary damage – HIV, hepatitis and the like – by giving people clean needles. You would surround them with medical and social services. Addiction, all agreed, was an illness, and addicts deserved compassion and respect.
...
Vancouver's needle exchange, the first in North America, opened in 1989. That first year, about 128,000 needles were handed out. Today, the streets are flooded with more than three million free needles each year. The sick and malnourished, many of them with open sores, freely inject drugs. Between 5,000 and 10,000 addicts live within these eight square blocks. The HIV rate hovers around 40 per cent; hepatitis-C rate is 85 per cent. There are more than 150 social services located in the area, offering everything from counselling and shelter to free lunch and art supplies. But there are virtually no treatment beds.

Mark Steinkampf, who heads the Downtown Eastside detail, has worked this beat for 18 years. He cares about the people, and wants to get a message out: Harm reduction – the philosophy that has come to dominate drug policy – doesn't work. Just the opposite. It digs the pit of addiction deeper and wider.
...
They also need a far more aggressive push into treatment and recovery – something they don't get from the many, many helpers who are busy finding them housing and giving them free needles. “Harm reduction without a treatment component is a failed policy,” he says.

Today, rehabilitation is the treatment of last, not first resort. “Rehabilitation” and “recovery” are terms you don't hear from advocates of harm reduction. What you do hear, over and over again, is the word “safe” – a word that many addictions doctors take issue with.

“I saw a patient the other day who's still injecting two or three times a week,” says Dr. de Vlaming. “I explained that there's no safe way of injecting drugs. He said, ‘No one's ever told me that.' ”

“Safe injection is a misnomer,” says Milan Khara, another veteran addictions doctor. “Insite is a supervised injection site. Injections inevitably lead to medical complications.”
...
“Look around!” he says afterward, gesturing at the dishevelled men with their shopping carts and the ravaged women who look 60, but are 30. “And they're calling this fucking mess a success? Anyone can see it has failed utterly.”

I don't like a lot of the language in the column--"free lunch" and "enabling" in particular. I was not surprised to learn that she's politically right of center and has some history of intemperate remarks. This contribution seems to represent more of the freak show.

She's right that any drug policy and service system organized around harm reduction is incomplete. She's wrong that harm reduction is the problem. The problem is the context. Harm reduction makes sense as one approach within a comprehensive system to respond to drug and alcohol problems and the constellation of secondary problems.

Preventing illness is important and creating low threshold opportunities for addicts and heath professionals to connect is a good thing. However, it too often amounts to infection control and palliative care when the primary problem is treatable. It represents a standard of care that we wouldn't tolerate for any other population.

Origins of the Serenity Prayer

The New York Times reports on new controversy surrounding the authorship of the Serenity Prayer:

For more than 70 years, the composer of the prayer was thought to be the Protestant theologian Reinhold Niebuhr, one of modern Christianity’s towering figures. Niebuhr, who died in 1971, said he was quite sure he had written it, and his wife, Ursula, also a prominent theologian, dated its composition to the early 1940s.

His daughter Elisabeth Sifton, a book editor and publisher, wrote a book about the prayer in 2003 in which she described her father first using it in 1943 in an “ordinary Sunday service” at a church in the bucolic Massachusetts town of Heath, where the Niebuhr family spent summers.

Now, a law librarian at Yale, using new databases of archival documents, has found newspaper clippings and a book from as far back as 1936 that quote close versions of the prayer. The quotations are from civic leaders all over the United States — a Y.W.C.A. leader in Syracuse, a public school counselor in Oklahoma City — and are always, interestingly, by women.

Some refer to the prayer as if it were a proverb, while others appear to claim it as their own poetry. None attribute the prayer to a particular source. And they never mention Reinhold Niebuhr.

[hat tip: Dave O.]

Setting the bar low

41% of MMT recipients (on MMT for an average of 5 years) receiving employment counseling reported obtaining ANY paid employment over a period of 6 months. This is evidence of the efficacy of the employment counseling program. Shameful.

I understand that people involved in this project are probably full of good intentions, but tinkering with a system that is failing these people is not the answer. Change the system! The glue holding this together is the belief that these patients are incapable of doing any better.

drinking-->abstinence-->depression

An interesting take on the relationship between depression and alcohol problems:

...new research shows that stopping drinking -- including at moderate levels -- may lead to health problems including depression and a reduced capacity of the brain to produce new neurons, a process called neurogenesis.

...

"Our research in an animal model establishes a causal link between abstinence from alcohol drinking and depression," said study senior author Clyde W. Hodge, Ph.D., professor of psychiatry and pharmacology in the UNC School of Medicine. "In mice that voluntarily drank alcohol for 28 days, depression-like behavior was evident 14 days after termination of alcohol drinking. This suggests that people who stop drinking may experience negative mood states days or weeks after the alcohol has cleared their systems,"

...

"This research provides the first evidence that long-term abstinence from moderate alcohol drinking -- rather than drinking per se -- leads to a negative mood state, depression," Hodge said.

The study also found that the emergence of depression was associated with a profound reduction in the number of neural stem cells (cells that will become neurons) and in the number of new neurons in a brain region known as the hippocampus. This brain region is critical for normal learning and memory, and recent studies show that the development of neurons in the hippocampus may regulate mood, Hodge said.

...

But the study also found that treatment with an antidepressant drug during 14 days of abstinence prevented the development of depression and restored the capability of the brain to produce new cells.

"Treatment with antidepressant drugs may help people who suffer from both alcoholism and depression by restoring the brain's ability to form new neurons," Hodge said. "Moreover, this research provides an animal model of alcohol-related depression with which we can begin to fully understand the neurobiology underlying co-occurring alcoholism and depression, and thereby develop successful treatment options. At this point it appears that blunted neurogenesis may underlie the effects of abstinence from alcohol drinking on mood, but understanding the mechanisms by which this occurs is a key challenge for future research."

Don't get in your patients' boats

From the New York Times on providing therapy to the super rich:

A couple of years ago, Dr. Karasu received a call on behalf of an entertainment executive who wanted to reschedule an appointment at the last minute.

Dr. Karasu said the only time he had available that week was at 7 one night. The executive’s assistant said: “He’s having dinner then. How about 10 p.m.? He’s flying out to the Hamptons, but we’ll send a car for you and you can ride with him and do therapy on the helicopter, and then we’ll send you home in the morning.”

On and on it went. “If I would say I am busy on Saturday, the assistant would offer to pay me extra, as if that would be the answer,” Dr. Karasu said, adding that he declined the request. “For the average patient, the 45 minutes with a therapist is the most precious time. For this patient, it was just another activity superimposed on his schedule, and the therapist has to accommodate his way of being — like his trainer, his cook, his pilot, his administrative staff.”

Dr. Karasu and several of his peers voiced a concern that a rich person today was ever more inclined to view his or her psychotherapist as nothing more than a highly skilled member of his personal army.

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Dr. Karasu acknowledged that he was not immune from taking satisfaction in the success and fame of his patients. “Wealthy people bring about a degree of awe, even in their therapists sometimes,” he said. “This is the biggest problem I see in the doctors I supervise. And these are fully practicing doctors, doctors making $400, $500 an hour.”

He added: “It’s King Ludwig Syndrome. In the 19th century, Bernhard von Gudden was the psychiatrist for the Bavarian royal family and began to treat King Ludwig II, who was psychotic. In the end, the two of them drowned in a boat. So I teach my people who are treating wealthy people, ‘Don’t get in your patients’ boats.’ ”

Medications

A couple of medication findings yesterday.

First, a meta-analysis of methadone and buprenorphine:

Low dose methadone is more likely to retain patients than low dose buprenorphine (RR= 0.67; 95% CI: 0.52 - 0.87). Medium dose buprenorphine does not retain more patients than low dose methadone, but may suppress heroin use better. There was no advantage for medium dose buprenorphine over medium dose methadone in retention (RR=0.79; 95% CI:0.64 - 0.99) and medium dose buprenorphine was inferior in suppression of heroin use.

Second, a report concluding that naltrexone and acomprosate enhance abstinence rates:

Alcohol-dependent individuals who consistently took prescribed medications to prevent withdrawal symptoms and craving had better treatment outcomes than those who didn't take their medication, even among patients receiving behavioral counseling, researchers say.

HealthDay News reported June 20 that data from the National Institute on Alcohol Abuse and Alcoholism's Combine study found that those patients who adhered to the medication regimen for naltrexone or acamprosate as well as taking part in medical-management (MM) or combined behavioral intervention (CBI) programs had more abstinent days and avoided heavy drinking more successfully than those who didn't take their prescribed drugs as ordered.

"High medication adherents fared better than low medication adherents across all combinations of behavioral and pharmacological treatment conditions," said researcher Allen Zweben of Columbia University.

The researchers also reported that CBI seemed to help even patients who took a placebo, but did not appear to affect relapse rates among naltrexone patients who didn't take their medications.

I don't know about you, but I don't find this too persuasive. Isn't it likely that medication adherence is an artifact of motivation? The carefully couched language suggests that the intent to treat analysis didn't find that participants receiving medication did any better patients receiving placebo.

Losing the war on drugs -- follow-up

Last week I linked to a New York Times editorial that criticized the war on drugs. Here are the published letters to the editor. Interestingly, there are no defenders. Disagreements seem to be about where to dedicate dollars and energy.

Suicide

An article in the New York Times Magazine suggests that a large portion of suicides in the U. S. are impulsive and challenges the notions that these people are suicidal for periods of days, weeks or months and that they will simply switch methods if their first choice becomes unavailable or more difficult:

The National Institute of Mental Health says that 90 percent of all suicide “completers” display some form of diagnosable mental disorder. But if so, why have advances in the treatment of mental illness had so little effect? In the past 40 years, whole new generations of antidepressant drugs have been developed; crisis hotline centers have been established in most every American city; and yet today the nation’s suicide rate (11 victims per 100,000 inhabitants) is almost precisely what it was in 1965.
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in 2005, approximately 32,000 Americans committed suicide, or nearly twice the number of those killed by homicide.
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In the late 1970s, Seiden set out to test the notion of inevitability in jumping suicides. Obtaining a Police Department list of all would-be jumpers who were thwarted from leaping off the Golden Gate between 1937 and 1971 — an astonishing 515 individuals in all — he painstakingly culled death-certificate records to see how many had subsequently “completed.” His report, “Where Are They Now?” remains a landmark in the study of suicide, for what he found was that just 6 percent of those pulled off the bridge went on to kill themselves. Even allowing for suicides that might have been mislabeled as accidents only raised the total to 10 percent.

“That’s still a lot higher than the general population, of course,” Seiden, 75, explained to me over lunch in a busy restaurant in downtown San Franciso. “But to me, the more significant fact is that 90 percent of them got past it. They were having an acute temporary crisis, they passed through it and, coming out the other side, they got on with their lives.”

In Seiden’s view, a crucial factor in this boils down to the issue of time. In the case of people who attempt suicide impulsively, cutting off or slowing down their means to act allows time for the impulse to pass — perhaps even blocks the impulse from being triggered to begin with. What is remarkable, though, is that it appears that the same holds true for the nonimpulsive, with people who may have been contemplating the act for days or weeks.

“At the risk of stating the obvious,” Seiden said, “people who attempt suicide aren’t thinking clearly. They might have a Plan A, but there’s no Plan B. They get fixated. They don’t say, ‘Well, I can’t jump, so now I’m going to go shoot myself.’ And that fixation extends to whatever method they’ve chosen.
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In a 1985 study of 30 people who had survived self-inflicted gunshot wounds, more than half reported having had suicidal thoughts for less than 24 hours, and none of the 30 had written suicide notes. This tendency toward impulsivity is especially common among young people — and not only with gun suicides. In a 2001 University of Houston study of 153 survivors of nearly lethal attempts between the ages of 13 and 34, only 13 percent reported having contemplated their act for eight hours or longer. To the contrary, 70 percent set the interval between deciding to kill themselves and acting at less than an hour, including an astonishing 24 percent who pegged the interval at less than five minutes.

Ouch

In a talk about the genetics of addiction, an expert makes the following point:

"Addicts find it difficult to receive pleasure," said Prof van den Brink. "They are not likely to enjoy most of the ordinary things most of us enjoy, experiences such as a day at the beach or night at a club. They are looking for more and more stimulus."

This trait in me is the bane of my wife's existence.

Drug enforcement and drug consumption. No relationship?

From libertarian drug policy expert Jacob Sullum:

With the U.S. Drug Enforcement Administration celebrating its 35th birthday this week, the publication of a new study estimating drug use rates across countries is well-timed. Of the 17 countries surveyed by the World Health Organization, China has the lowest rate of illegal drug use (cannabis and cocaine combined), followed by Japan, while the United States has the highest rate, followed closely by New Zealand. (Here is a comparison table.) "Globally," the researchers report, "drug use is not distributed evenly and is not simply related to drug policy, since countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones." It may be that the United States has especially stringent drug policies partly because it has especially high levels of drug use. But it seems clear, after you look at drug use not only across countries but over time in the U.S., that the ebbs and flows have little to do with the intensity of drug law enforcement (which is not to say that prohibition itself has no impact).

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Getting back to the WHO study, it's striking that the lifetime marijuana use rate in the U.S. (42.4 percent) is more than twice as high as the rate in the Netherlands (19.8 percent), despite the latter country's famously (or notoriously, depending on your perspective) tolerant cannabis policies. The difference for lifetime cocaine use is even bigger: The U.S. rate (16.2 percent) is eight times the Dutch rate (1.9 percet). Do these results mean that draconian drug laws promote drug use, while a relatively laid-back approach discourages it? Not necessarily; that would be a hell of a "forbidden fruit" effect. But one thing that's clear is the point made by the WHO researchers: Drug use "is not simply related to drug policy." If tinkering with drug policy (within the context of prohibition) has an impact, it is hard to discern, and it's small compared to the influence of culture and economics.

As one of the commenter points out, his focus on drug policy (in this post, anyway) is limited to policies related to legality of use and possession--not access to treatment or other demand reduction efforts.

Also take the time to check out his post from the previous day. It reviews the undeniable lack of progress in high school drug use since the inception of the DEA.

Treatment in Iran

Iran's surprisingly progressive approach to addiction:

Iran’s theocratic government has encouraged and financed a vast expansion in the number of drug treatment centers to help users confront their addictions and to combat the spread of H.I.V., the virus that causes AIDS, through shared needles.

The center in central Tehran, which is called Congress 60 and is run by a private nonprofit agency, is one of 600 centers that provide drug treatment across the country with help from government money. An additional 1,250 centers offer methadone, free needles and other services for addicts who are not ready to quit, including food and treatment for H.I.V. and other sexually transmitted infections.

Iran’s government, trying to curb addiction’s huge social costs, has been more supportive of drug treatment than any other government in the Islamic world, according to the United Nations Office on Drugs and Crime.

It was not always this way. After the 1979 revolution, the government tried a more traditional approach: arresting drug users and putting them in jail.

But two decades later, it recognized that this approach had failed. A sharp increase in the crime rate and the number of people infected with H.I.V., both directly linked to a surge in narcotics use, persuaded the government to shift strategies.

“We have realized that an addict is a social reality,” said Muhammad-Reza Jahani, the vice president for the Committee Combating Drugs, which coordinates the government’s efforts to fight drug addiction and trafficking. “We don’t want to fight addicts; we want to fight addiction. We need to manage addiction.”

Motivation to change and homelessness

Local conventional wisdom is that homeless addicts and alcoholics are significantly less motivated to change than other addicts and alcoholics. This study in Addictive Behaviors used a emergency department visits as an opportunity to compare the readiness to change in homeless and non-homeless patients with substance use disorders:

Substance-using homeless persons frequent emergency departments and hospitals often. However, little is known about how homelessness affects when they seek care and their motivation for substance abuse treatment (SAT). We surveyed homeless (N = 266) and non-homeless (N = 104) substance-using adults sequentially admitted to an urban hospital medicine service, comparing demographics, readiness for change (URICA), and motivating reasons for SAT. Homeless respondents were more likely to be younger, uninsured, have hepatitis B/C, and < style="font-weight: bold; font-style: italic;">although more homeless respondents were in an action stage. They also had similar motivating reasons for wanting SAT, although being homeless was an additional motivator for the majority of homeless respondents. Almost half reported that being homeless caused them to delay seeking health care; paradoxically those citing physical health as a SAT motivator were 3.4 times more likely to have delayed care. While acutely ill homeless persons were at least as motivated for SAT, these data suggest the challenge is getting them to care in a timely manner and tailoring interventions during the care episode to avail of this motivation.

Losing the war on drugs

Drug policy focused on supply is not working.