Fighting HIV-AIDS One Syringe at a Time

A legislator makes a plea for an end to the federal needle exchange ban. I don't oppose lifting the ban, but his argument would be more compelling if he acknowledged the problems with many needle exchanges and called for standards for programs and increased access to treatment.

Abstinence and risk of overdose

We've known for some time that heroin addicts are at greatest risk for overdose when they reinitiate heroin use, including after detox or release from prison or jail. Some have argued that opiate maintenance is the answer to the problem. I would argue that it's a failure of acute care and that long term recovery management is the solution.

Drinking age (again)

Marginal Revolution points out that New Zealand lowered their drinking age to 18 and experienced serious problems, though not serious enough to raise the drinking age again.

Recovery Bill of Rights

Part of me wishes I could be more enthusiastic about this. They all seem like good points to make and I'm sure that they carefully developed using research and focus groups, but there's something about them that rubs me the wrong way. It sounds like the voice of the victimized. It talks about the right to strength-based services, but it doesn't speak with a voice of strength. There's something meek about it. It doesn't feel empowering.

At this moment in our culture, there seems to be fierce competition for aggrieved status. It seems to be the primary tool for promoting any kind of social change or consciousness raising. Think about it. How many times have you heard someone say, "In our country today, the only group you can make fun of is _______." You can fill in the blank with evangelicals, atheists, Catholics, obese people, southerners, cognitively impaired, little people, gay people, addicts, etc.

I have two problems with this approach for recovering people. First, I worry that it's bad strategy. There's a lot of competition for aggrieved status, the public is weary of this, and it may inspire more eye rolling than sympathy. Second, in terms of my personal recovery, I worry about any message that hints at adopting a victim stance or entitlement. No matter how well grounded, that position seems potentially toxic to my recovery.

If we really are mistreated, and we need to promote cultural change, what to do then? I can't say that I'm sure as I have not thought too deeply about this. However, I wonder if framing this as a call to action for recovering people would be more empowering and effective--"You have a responsibility to address these barriers for your still suffering brothers and sisters." Also, not to suggest a single pronged approach, but I'm convinced that the most powerful strategies will focus on reducing "otherness" and increasing "sameness" in public perceptions of addicts. Every time I take addicts to tell their story with churches and other community groups, the response is ALWAYS the same--we're not who they expect, we're just like some of their loved ones, they're often shocked by the sameness and want to do something to help. Unfortunately, that fades quickly. Strategies to capitalize on this window could be important.

Recovery Management

I was fortunate to get a peek at this monograph a while back. It, as Loran Archer noted, is sure to be the seminal document on recovery management. Over the last several years Bill White has been churning out papers that, one piece at a time, added flesh to bones of this model.

This document provides the big picture of recovery management in a way not previously offered. The references are exhaustive--804 references!!!

Quote for the day

"Recovery begins with hope, not abstinence..." - Michael Boyle

Craving

No wonder the rest of the world has such great difficulty understanding the power of addiction and craving. Addicts don't even appreciate craving's power when they're not in its grip.

Why is the Drinking Age 21?

Mental Floss provides a history of 21 year old drinking age.

More on drinking ages

Mark Kleiman, as usual, does a great job summarizing the drinking age quandary:

Setting the minimum legal drinking age at 21 saves lives by reducing drunk driving, and not just among the 18-to-21's; if 18-year-old high school seniors can buy beer at the supermarket, then 16-year-old high school sophomores have access to it. Common sense and evidence agree: drinking and driving by people who are both inexperienced drinkers and inexperienced drivers is really, really dangerous.

Setting the minimum legal drinking age at 21 also encourages disrespect for the law and encourages young adults to acquire and use false identification documents, which is not a social practice we want to encourage just right now. Moreover, that policy insultingly treats people who are adults for all other purposes as if they were still children, and deprives them of lawful access to an activity that forms part of the normal U.S. social scene and which some of them enjoy. And it may (the evidence isn't clear) lead those who are drinking illegally rather than legally to do so irresponsibly rather than responsibly.

Now, given those facts, what do you want to do about it?

His solution is to implement zero tolerance laws for drinking and driving for people under 21 and raise alcohol taxes.

Megan McArdle suggests adding special licenses for people who have been convicted of drunk driving and making it illegal to serve them alcohol.

In the "not always right, but always certain" department, a contributor to the Free Press offers these pearls:

The problem with asking at what age it ought to be legal to drink is that it is a fundamentally perverse question. The “logic” of law is that it allows government the power to punish actions deemed harmful while restraining government officials from singling out disfavored individuals or groups and imposing sanctions on them. The “rule of law” requires that all laws take the form of truly general rules of action, rules that provide punishment for anybody who takes the prohibited action.

Government decisions that just pick an individual and impose a sanction on that individual are bills of attainder, and our Constitution prohibits them. Rules that single out subsets of the population and punish them for actions which are not illegal when taken by other people are pseudo-laws, and legitimate government has no authority to enact them. (Example: Women cannot work as bartenders.)

To ask at what age it should be legal to drink, therefore, flies in the face of the inherent nature of law as a general rule of action. Either drinking must be legal for all, or illegal for all. The latter approach was tried during Prohibition, and it caused horrible results: organized crime, corruption, etc. Wisely, Prohibition was repealed by the 21st amendment in 1933.

Recipe for PTSD

The drug war horror story I posted about two weeks ago just hit Newsweek. Let's hope it continues to get attention.

Medical marijuana

The Los Angeles Times ran a pair of opposing pro/con pieces recently. I saw the headline for the con piece and thought it might be reefer madness rant, but thankfully it's much smarter than that. Acknowledging that marijuana's risks are relatively small, he argues that the FDA refuses to approve or yanks approval of drugs with fewer risks than marijuana.

I don't have a strong opinion on the matter and don't believe that anyone should do jail time for possession of marijuana in smallish quantities. I also don't think marijuana should get any special treatment from the FDA, in either direction--if it meets FFDA standards, approve it; if it doesn't meet FDA standards, deny approval. However, my impression is that most of the advocates of medical marijuana seem to be more interested in legalizing marijuana for their own use. I tend to find them pretty unpersuasive and they inspire a passive aggressive contrarian instinct in me.

Not quite an adult

The New York Times reports that the movement to lower the drinking age is gathering steam. On my other blog, I posted about this last year and said:

I have a few brief reactions. First, I don't have a strong opinion on the matter, other than I'd be troubled by 18 year old high-school students being able to buy alcohol.

In principle, the general idea of a less restrictive drinking law might appeal to Libertarians, but drinking licenses? That'll lose Libertarian support fast.

He makes an argument about current law criminalizing parents who try to teach their kids to drink responsibly. First, is serving alcohol necessary to do this? Second, as we saw a few weeks ago, this isn't illegal in 31 states. Third, when is the last time you heard of parents fined or arrested for allowing their teen to have a glass of wine with dinner?

Some of his arguments are a stretch -- for example, using SAMHSA's increased attention to underage drinking as an argument against the existing policy and implying that there's a relationship between the 21 year old drinking law and younger ages of first use.

The fact that we currently have problems, isn't necessarily a good argument against the status quo. Anyone who's honest with themselves will recognize that there is no such thing as a problem-free drug and alcohol policy. As I've said before in this blog, these drug policy questions are all about trade offs and, recognizing that every policy requires living with some problems, the questions you have to wrestle with are:

• Which problems are intolerable and which are you willing to tolerate?
• How do you make these decisions? (I'd suggest that even responses that purport to be value-free are value laden.)
• Which policy (or combination of policies) best balances these values?

It seems like these discussions would generate more light if people were a little more honest in acknowledging the problems inherent in their pet theory.

Ezra Klein offers his take here:

21 is, of course, a bizarre marker. Demanding that kids refrain from drinking for three years after they become legal adults and, in most cases, leave their parent's supervision, is a bit odd. "Welcome to adulthood, except when it comes to beverage choice!" But this could point the way towards a grand new education policy scheme: Drinking age is 18...if you attain a college-worthy GPA. Otherwise, 21. Implement that and you'll blow those other, way lamer, educational attainment proposals out of the water.

I stand by my earlier comments and I'm still concerned about about the relationship between legal drinking age, age of first use, and dependence later in life. However, it does seem that there is little cultural "buy in" for the current drinking age, particularly for 19 and 20 year olds--we're deeply ambivalent about it and this ambivalence turns into permissiveness that seems to drift downward toward high school aged teens. Parents excuse (and sometimes facilitate) underage drinking, police often do little more than dump alcohol, and no one feels strongly enough to challenge it directly or there is not enough consensus to challenge it effectively. If the drinking age was lowered to post-high school and there was broad consensus that this was important to enforce, maybe that would not be such a bad thing.

Suboxone addiction

I received a marketing email from this treatment program today. I don't know anything about the program and I don't mean for this post to endorse or criticize the program in any way.

What struck me is that it is marketing itself as a program specializing in suboxone addiction treatment. That treating addiction to suboxone, not treating opiate addiction with suboxone.

Suboxone has been a boon for opiate detox, but it seems to be freely prescribed for long term maintenance, we've been seeing people relapse by using suboxone, and we've seen been reading reports of misuse for some time (here, here, and here). Clearly, as we've known for a while, it's not as safe as we'd hoped. Still, it's potential for harm appears to be much lower than methadone.

Harm reduction is not enough

This study calls for treatment to improve compliance with HIV treatment guidelines.

Note that I'm not saying HR is bad or that it should be abolished. I'm saying that it is not enough.

Gone camping

The science of stigma

From Greater Good (pdf) magazine:

In my own lab, for example, we dug up dozens of images of societal groups that were identifiable in an instant: people with disabilities, older people, homeless people, drug addicts, rich businessmen, and American Olympic athletes. We asked research participants to tell us what emotions these images evoked in them; as we predicted, they reported feeling pity (toward the disabled and elderly), disgust (the homeless and drug addicts), envy (businessmen), and pride (athletes).

We then slid other participants into a functional MRI scanner to observe their brain activity as they looked at these evocative photos. Within a moment of seeing the photograph of an apparently homeless man, for instance, people's brains set off a sequence of reactions characteristic of disgust and avoidance. The activated areas included the insula, which is reliably associated with feelings of disgust toward objects such as garbage and human waste. Notably, the homeless people's photographs failed to stimulate areas of the brain that usually activate whenever people think about other people, or themselves. Toward the homeless (and drug addicts), these areas simply failed to light up, as if people had stumbled on a pile of trash.

We were surprised—not by the clear sign of disgust, but by how easy it was to achieve. These were photographs, after all, not smelly, noisy, intrusive people. Yet we saw how readily physical characteristics could evoke strong, immediate, and deep-seated emotional reactions.

The good news is that researchers have found that two factors can reduce this reaction, context and exposure. This affirms our anecdotal experience that public education that involves direct contact between addicts and the public can be powerful in reducing stigma.

Drug-linked mental illness

England reports that rates of drug related mental health problems have doubled.

The number of people admitted to hospital in England with mental illnesses linked to use of illegal drugs has doubled in the past decade, official figures revealed yesterday. The NHS Information Centre said 38,170 adults and children were admitted with drug-related mental and behavioural disorders in 2006-7, an increase of 101% since 1996-97.

Does the U.S. have any idea about the rates of drug related mental health problems?

I don't think so. One obvious reason that might be easier for them generate that that they have a single payer health care system that I imagine has a central data system. However, I suspect that the biggest barrier to the U.S. generating that kind of data is philosophical. There's considerable resistance to characterizing mental health problems as drug related. The conventional wisdom in the U.S. is that most people with substance use disorders have a mental illness and that both conditions are primary. (See principles 1 & 5.) Though it's not a listed principle, the U.S. system also operates on the assumption that all mental health problems are chronic.

The Healing Place

The Healing Place continues to gather steam as a model for responding to homelessness and addiction.

Rat and expectations

Productivity 501 offers more wisdom from rats:

There was an experiment where researchers were given a set of rats and told to rate their ability to learn mazes. They were told that certain rats were “smart rats” and had an abnormally high IQ. When the researchers tested the rats, their studies showed that the “smart rats” performed significantly better than the ordinary rats.

The experiment, however, wasn’t focused on the rats, it was testing the researchers. All of the rats were the same, but telling the researchers that some of the rats were smart caused them to rate the rats better, even though there was no difference.

People will view what you do through their own set of prejudices. To a certain extent, your ability to succeed is determined by what people think of you ahead of time. When it comes to humans, very few things are actually objective.

By being aware of this, you can help yourself prepare for the future by nurturing positive impressions of yourself with those around you. If they expect you to succeed, you are more likely to (at least in their eyes) than if they expect you to fail.

That expectations influence perception has been demonstrated over and over again. The comments from the post referenced above include other examples. What is more important for professional helpers is that expectations influence not only perceptions about clients, but also influence outcomes. Consider this passage from an article by Arnold Washton.

A revealing study demonstrates how clinician expectancy can create a self–fulfilling prophecy. Counselors were told that according to sophisticated personality test profiles, certain alcoholic patients were likely to do very well in treatment.

These patients, who had actually been selected at random, were subsequently rated by the counselors as more motivated, more compliant, more punctual, more cooperative, and demonstrating more effort.

They actually showed significantly fewer absences and dropouts and had more sober days and fewer slips at one-year follow up. The counselor’s expectation of success in these “good prognosis” patients apparently led them to behave more therapeutically toward these patients.

Earlier posts about the role of expectations in recovery-oriented practice can be found here.

Memory interuption interupts addiction in rats

More exciting, yet creepy, progress in experiments that interrupt addiction by interfering with memory reconsolidation:

Barry Everitt, an experimental psychologist at the University of Cambridge in England, focused his group's efforts on proteins called NMDA-type glutamate receptors in rat brains. Previous work on addiction and post-traumatic stress has shown that these proteins—which are found on the surface of brain cells—are essential to memory formation. The receptors are also crucial to reconsolidating a memory—moving it from its storage area in long-term memory to brain regions that handle short-term memory.

The researchers—who report their findings in the Journal of Neuroscience—put rats in a cage with a lever in it for a couple of hours per day for a week. When the animals pushed the lever, a light would come on and a cocaine solution would be dispensed to the rat. The rats began to associate the light they saw with cocaine.

After a couple weeks of forced sobriety, the animals were returned to the cage. Before going back in, some of the rats received injections of experimental drugs that block NMDA-type glutamate receptors in the amygdala—a brain region that has been implicated in drug-associated memories.

Both treated and untreated animals, when back in the cage, would press the lever over and over again. The light would come on, but no cocaine would be served. Untreated animals continued unfazed, hoping cocaine would eventually come out.

For the treated animals, however, Everitt says, "They press the lever, but it doesn't do anything, so they stop." The animals seemed to forget that the light in the cage meant cocaine was on its way for up to four weeks after only a single treatment.

Scientists say that suggests that by disrupting the recollection of a drug-associated memory—a person one abuses drugs with, a place that one uses drugs at, for example—a therapeutic may be able to break the connection between cues in the environment and the need for drugs. Sometimes these cues can be quite close to home—a family member or loved one.

Related posts can be found here, here, here, here, here, and here.

CASA takes on parents

CASA takes an interesting approach in their new report. It seems to shame parents who are not monitoring their children's activities by characterizing them as "problem parents". It will interesting to see how this plays.

Problem parents -- those who fail to monitor their children's school night activities, safeguard their prescription drugs, address the problem of drugs in their children's schools, and set good examples -- increase the risk that their 12- to 17-year-old children will smoke, drink, and use illegal and prescription drugs, according to the National Survey of American Attitudes on Substance Abuse XIII: Teens and Parents, the 13th annual back-to-school survey conducted by The National Center on Addiction and Substance Abuse (CASA) at Columbia University.

"This year's survey reveals that too many mothers and fathers are problem parents who fail to take essential steps to prevent their kids from smoking, drinking or using drugs. By their actions -- and inactions -- by failing to become part of the solution, these parents become part of the problem of teen alcohol and drug abuse," said Joseph A. Califano, Jr., CASA's chairman and president and former U.S. Secretary of Health, Education, and Welfare. "Indeed, these problem parents enable -- some even encourage -- their 12- to 17-year-olds to use and abuse tobacco, alcohol, and illegal and prescription drugs."

Another point of interest is the fact that only 9% of kids who misused prescription drugs reported getting them from a drug dealer--challenging the notion of many parents that predatory "pushers" get kids hooked on drugs. Most kids get drugs and alcohol at home or from another fresh-faced kid in their community.

What works in prevention

Join Together posted a pair of articles today that are interesting because of their contrast.

One on the ineffectiveness of anti-tobacco scare tactics:

The Cancer Council study also found that the labels were highly recognized among youths, with 77 percent of students saying they had seen the cigarette packaging with the graphic images.

The newspaper spoke to service station owners who confirmed that young people often ask for packs with specific images when they purchase cigarettes. Benton added about one of the images, "If you cut out the picture of the rotten mouth you can stick it over your own teeth; it's a good joke."

And, another on the move toward social norms strategies on college campuses:

At Virginia Commonwealth University, although surveys have shown that 25 percent of students don't drink at all and 70 percent don't drink at high-risk levels, many students believe the highly visible unhealthy behaviors they sometimes encounter reflect a wider phenomenon on campus.

"The majority who don't get hammered don't get seen," said Linda Hancock, director of the university's Wellness Resource Center.

Olympic lessons for recovery management

Disease Care Management Blog draws some lessons from the story of Michael Phelps. How might these be applicable to recovery management?

• Role-appropriate listening and helping: According to an ABC news interview, she said "I've been there not to dictate or guide. I'm there to listen to what he wants to do and try to help him problem-solve and make a wise decision…”
• Willingness to accept risky suggestions:Michael wanted to stop his ADHD drugs. Deborah Phelps agreed.
• Let experts handle the things that experts handle:Michael has access to a number of expert coaches and other advisors.Deborah Phelps stays out of their way.
• Recognize talent and build on it:Michael was not very good at math, but his swimming prowess quickly declared itself.Guess which skill was the focus of Mrs. Phelps?
• Stay in the background:Watch Deborah Phelps in an interview and it’s clear that she rarely talks about herself. If forced, she portrays herself as just a mom.

Shooting weed

This post includes videos of experiments designed to better understand the roles of what are believed to be the 2 active ingredients in marijuana.
[via Andrew Sullivan]

POPAGSV!!!

Passed Out Persons Against Google Street View

Hey hey, ho ho. Google street view has got to go! Hey hey, ho ho. Google street view has got to go!

Anthrax and 42 CFR Part 2

Turns out that the alleged anthrax killer had a substance abuse counselor. (Though she wasn't exactly a poster child for the profession--she had a 2007 OUIL.)

This story raises a very interesting point. If my understanding of 42 CFR Part 2 is correct, there is no "duty to warn" provision in the law. This being the case, the recommended practice is to make a non-disclosing report--an anonymous report that does not explicitly or implicitly identify the client as a recipient of addiction treatment services. (More info here.)

Clearly, this is a case where a worker (or agency) has to imagine his or herself on the witness stand defending a decision to disclose (or not to disclose). If you believe that a guy is going to kill his co-workers you want to report it in a way that assures the police will intervene and take it seriously.

The story, as told in the Washington Post, which may, or may not, be 100% accurate, raises a few questions about whether the situation could have been handled better:

• She waited overnight. Should she have made the report sooner?
  
• Was a supervisor or the agency director involved?
• Did she identify herself as an addiction counselor or calling from an agency that provides addiction treatment services?
  
• Should she have made the call from a non-agency phone? Does making the call from an agency phone turn, an otherwise non-disclosing report, into a disclosing report?

Just to be clear, I'm not criticizing her. It's just a good opportunity to brush up on the law and learn from an actual case.

Nicotine buzz

I remember it well:

Anyone who has ever tried smoking probably remembers that first cigarette vividly. For some, it brought a wave of nausea or a nasty coughing fit. For others, those first puffs also came with a rush of pleasure or "buzz."

Now, a new study links those first experiences with smoking, and the likelihood that a person is currently a smoker, to a particular genetic variation. The finding may help explain the path that leads from that first cigarette to lifelong smoking.

He was an aggressive licker :-(

Whatever your feelings about the legality of marijuana, it's hard to disagree with those concerned about the absurd excesses in law enforcement raids.

This fiasco looks likely to raise awareness:

When the shooting stopped, two dogs lay dead. A mayor sat in his boxers, hands bound behind his back. His handcuffed mother-in-law was sprawled on the kitchen floor, lying beside the body of one of the family pets that police had killed before her eyes.

After the raid, Prince George's County police officials who burst into the home of Berwyn Heights' mayor last week seized the same unopened package of marijuana that an undercover officer had delivered an hour earlier.

What police left behind was a house stained with blood and a trail of questions about their conduct. No other evidence of illegal activity was found, and no one was arrested at Mayor Cheye Calvo's home in this small bedroom community near College Park.

Addiction and free will

This one slipped by me late last year. It offers a great description of the neurobiological processes involved in addiction. It also tries to tackle frequently neglected questions about free will and addiction. All of this is great, but the description of the client with a "secondary" addiction and their intervention (rather, the absence of any intervention) leaves me wanting.

In the early stages of addiction, the free will of someone like Jack is relatively intact. I say relatively because emerging research suggests that Jack probably had a decreased number of D₂ dopamine receptors, and this state of hypodopaminergic function increased his risk to excessively respond to the suprathreshold dopamine stimulation of drugs of abuse.⁴ As the addiction progresses, the main brain engines of free will are damaged and begin to malfunction, including the attentional and self-control mechanism of the anterior cingulate gyrus; the crucial orbital prefrontal cortex that associates emotional and motivational valence with environmental stimuli and cues; and the dorsolateral prefrontal cortex, the seat of executive function and as such, the true decision maker.

In the later stages of addiction, Volkow cautions, free will may be virtually devastated: "We have come to see addiction as a disease that involves the destruction of multiple systems in the brain that more or less are able to compensate for one another. When the pathology erodes the various systems, you disrupt the ability to compensate, and the addictive disease erodes and destroys the life of the individual."⁵

In the new conceptualization, addiction is not so much a matter of dysregulation of the pleasure systems but of a distortion of goal direction expressed by the term "salience." Evolution has wired the brain to seek out and respond to environmental factors, such as sex, food, money, and affection, that improve the chance of the survival and even thriving of the species. All of these natural incentives release dopamine, not so much to satisfy desire as once thought but as a way of neurochemically cementing the salience of these stimuli (ie, potentiating learning).

Tragically, drugs and alcohol have a massively more potent dopaminergic action than even the best gourmet meal, a good run on a beautiful fall morning, or the devotion of a wife and children. These new neurobiological explanations of addiction give molecular weight to the phenomenological DSM-IV-TR criteria for "continued [substance] use despite adverse consequence" by a dependent person.⁶ Given the extreme biological response to drugs of abuse compared with daily life and work, it is no wonder that "time spent in obtaining the substance replaces social, occupational or recreational activity."⁶ Jack had a family who loved him, and he was resourceful enough to have been successful had he only employed the immense energy he spent on substance use in the service of more productive aims.

So complete is drugs' usurpation of human priorities that what were once semivoluntary actions and reactions become conditioned responses. In an elegant experiment, Volkow and colleagues⁷ measured dopamine metabolism in 18 cocaine-dependent patients while they watched a nature video and a video of persons using cocaine. Not only was there a substantial dopaminergic surge in the addicted patients when watching the cocaine film, but even more alarming, it corresponded to their subjective experience of craving, which itself is a measure of the compulsive quality of addiction.

These results obviously underscore the challenge of relapse prevention when even otherwise neutral cues can elicit the intensity of intoxication. But more ominously for free will, what Volkow calls the plastic changes in brain structure and function suggest the entire apparatus of self-determination may have been commandeered.⁸

Internet rehab

Sometimes I hate that I'm such a cynic, but it's hard for me to not see this as a two-fer. Eroding the disease model and profiteering. (I'm assuming that they don't accept unfunded clients.)

More on prohibition

A couple of smart takes (old takes) from Mark Kleinman.

On why legalize alcohol, but criminalize other drugs?

...if the line between legal and illegal drugs needs to track some imagined line between "good drugs" and "bad drugs," drug policy is profoundly incoherent. But there's no need for such a link. There are, among intoxicants, no "good" or "bad" drugs. Both alcohol and cocaine are consumers' goods with a peculiar mix of risks, including both the risks due to intoxication (loss of self-command over behavior in the short run) and addiction (chronic loss of self-command with respect to consuming the drug itself).

The question, drug-by-drug and comprehensively, is what mix of policies would minimize aggregate damage, net of benefit. (This elides the distinction between harm to self and harm to others, which strikes me as a reasonable thing to do in the face of an activity where individuals can't be assumed to be good stewards of their own well-being.) In some cases that least-cost solution will look like prohibition; in others it will look like regulation and taxation. It's a practical problem, to be handled by practical means-ends reasoning, not by the enunciation of profound truths about human nature or the role of the state.

Even believing that alcohol, on balance, creates a net social deficit, I don't actually believe that alcohol should be prohibited. Given the enormous user base for alcohol, its prohibition would be operationally nightmarish as well as politically infeasible. Instead, why not ban its sale to those previously convicted of alcohol-induced violence or repeated drunken driving? That ban wouldn't be perfectly obeyed, but it would have some good effect nonetheless, and wouldn't create another huge illicit market.

And on arguments to legalize cocaine with a very high excise tax:

The hypothetical licit cocaine market, by offering users a product of known composition, available in safe surroundings from non-criminal suppliers, and without the risk of legal sanctions at the price illicit dealers charge for product with none of those attractive qualities, would represent a substantial hedonic price decrease compared to the current situation. Moreover, legality, and the associated marketing activity, would tend to change current attitudes and opinions in a direction favorable to cocaine use.

Therefore, one would expect a fairly large increase in the number of people trying cocaine. Some proportion of them would become habituated, and some proportion of that group would find the habit difficult to break and become chronic heavy users. For them, the high legal price would mean that their cocaine habits, though legal, would be ruinous financially, and some would be likely to turn to crime to finance continued cocaine purchases. In addition, of course, they would face many, though not all, of the health and psychological risks attendant on heavy cocaine use as we now know it.

So I conclude that legalization at a high price is probably a loser, even if one adjusts for what would certainly be benefits to supplier and transit countries and some marginal reduction in resources available to terrorist organizations. That even someone as smart as Levitt could have been taken in testifies both to the peculiarities of drugs as consumers' goods and to the strength of the persistent hope that our seemingly intractable drug problems might be made to yield to some simple piece of ingenuity.

[Legalization at a low price would probably succeed in reducing overall crime, and might well be a substantial boon to poor minority neighborhoods now wracked by cocaine dealing, though at what would very probably be a very high cost in increased cocaine abuse. It is even possible, though I doubt it, that low-price legalization would represent a net improvement over today's version of prohibition.]

Tobacco crusades

Addiction Inbox offers a little perspective on Bill Gates and Michael Bloomberg's anti-tobacco efforts. The best thing about the post is the British anti-smoking ad.

Prohibition

Mental Floss offers a brief take on alcohol prohibition as part of it's 20 greatest mistakes in history. Here's an excerpt:

It certainly seemed like a great idea at the time: Just outlaw liquor and, bam!, goodbye social ills of every stripe—from the Germans to the Irish. Yes, pandering to xenophobia was the favorite tactic among Prohibition crusaders, who painted saloons as a filthy underworld brimming with undesirable foreigners. Ultimately, however, the event that probably did the most to push America toward Prohibition was the country’s 1917 entry into World War I. Prohibitionists began arguing that all of America’s resources were needed to fight the German menace, using the logic that, if the government needed to maximize agricultural production to win the war, then it couldn’t waste all that grain on booze. Apparently, their message worked. By the end of 1917, the majority of Americans were living in alcohol-free states or counties.

It appears that Mental Floss's facts are wrong. This article presents a contrary view:

First, the regime created in 1919 by the 18th Amendment and the Volstead Act, which charged the Treasury Department with enforcement of the new restrictions, was far from all-embracing. The amendment prohibited the commercial manufacture and distribution of alcoholic beverages; it did not prohibit use, nor production for one's own consumption. Moreover, the provisions did not take effect until a year after passage -plenty of time for people to stockpile supplies.

Second, alcohol consumption declined dramatically during Prohibition. Cirrhosis death rates for men were 29.5 per 100,000 in 1911 and 10.7 in 1929. Admissions to state mental hospitals for alcoholic psychosis declined from 10.1 per 100,000 in 1919 to 4.7 in 1928.

Arrests for public drunkennness and disorderly conduct declined 50 percent between 1916 and 1922. For the population as a whole, the best estimates are that consumption of alcohol declined by 30 percent to 50 percent.

Third, violent crime did not increase dramatically during Prohibition. Homicide rates rose dramatically from 1900 to 1910 but remained roughly constant during Prohibition's 14 year rule. Organized crime may have become more visible and lurid during Prohibition, but it existed before and after.

Fourth, following the repeal of Prohibition, alcohol consumption increased. Today, alcohol is estimated to be the cause of more than 23,000 motor vehicle deaths and is implicated in more than half of the nation's 20,000 homicides. In contrast, drugs have not yet been persuasively linked to highway fatalities and are believed to account for 10 percent to 20 percent of homicides.

Prohibition did not end alcohol use. What is remarkable, however, is that a relatively narrow political movement, relying on a relatively weak set of statutes, succeeded in reducing, by one-third, the consumption of a drug that had wide historical and popular sanction.

The suggestion that alcohol prohibition was all bad is just as silly as suggesting that nothing good could come of decriminalization of marijuana. Each policy has problems. As I've said before the important question is which problems you want to live with.

Heavy drinking and the risk of assualt

A new study suggests a staggering increase in the risk of experiencing sexual aggression by young women when they drink heavily:

According to researchers at the University at Buffalo's Research Institute on Addictions (RIA), the odds of 18-19 year old college women experiencing sexual aggression are 19 times greater when they binge drink than when they don't drink. Binge drinking or heavy drinking was defined as drinking four or more drinks on a drinking occasion.

...

...The odds of experiencing sexual aggression were 19 times greater on heavy drinking days compared to non-drinking days. ...The odds of experiencing physical aggression were 12 times greater on heavy drinking days compared to non-drinking days.

One big caveat about the researchers methods. 76% of the women who are described as experiencing sexual aggression denied experiencing sexual aggression. Their responses to questions indicated that they met the researcher's definition of sexual aggression, but when asked, "have you experienced sexual aggression?", most of them said "no."

Stoner bigotry

The outrage...

Three months

Another study finds that important reversals in addiction related brain adaptations occur in the first 90 days of recovery.

It has been hypothesized that persistent drug seeking alters the brain's natural reward and motivational system. The current study focuses on how drug seeking alters the communication between brain cells in this critical circuitry. In the normal processes of learning and memory formation there is a well documented strengthening of communication between brain cells, this process is known as "long-term potentiation" (LTP). The new study reports that LTP was similar in the rats that had learned to self administer cocaine, food or sucrose, but with a critical distinction. The increase in LTP due to cocaine persisted for up to three months of abstinence, but the increase in response to natural rewards dissipated after only three weeks. Importantly, the nature of the cocaine experience had a strong effect on the outcome, since rats exposed to cocaine when they did not expect it (passive infusions) displayed no LTP, neither transient nor long lasting. Finally, the study showed that LTP in rats that self-administered cocaine persisted after they were trained to stop drug self-administration behaviors. This indicates that, once established, it is very difficult to reverse the "memory trace" associated with drug reward.

Dealing and entrepreneurship

A strength to be harnessed from life in the drug culture?

Fairlie was interested in entrepreneurship in the black market and how it relates to legitimate entrepreneurship. So he looked at data regarding drug dealers, and he found that they were 10 to 11 percent more likely to become self-employed in legitimate businesses than people who weren't drug dealers.

He goes on to make an argument about legalization:

So I'll go ahead and ask what Shane seems to be hinting at: Does drug prohibition change the incentives such that potential entrepreneurs pursue lives of crime rather than legitimate businesses?

On one hand, those who call for the legalization or decriminalization of drugs have long argued that the drug war directly fuels the crime around the drug trade that it seeks to fight by creating a massive black market. The high profits in this black market attract people who might otherwise become legitimate entrepreneurs to deal drugs.

In the chapter, Why do Drug Dealers Live with Their Mothers?, didn't Freakonomics assert that average drug dealer makes very little money and could make more at McDonalds?

[via dailydose.net]