Pre AA abstinence

More evidence that people with more severe alcohol problems benefit most from AA (from the firewalled full text):

The current findings support the hypothesis that 12-step self-help group attendance is most beneficial for patients who have not achieved abstinence. Specifically, among patients who had not achieved abstinence 1 year after treatment, those who attended 12-step self-help groups relatively frequently (10 meetings or more in a 3-month interval at year 1) were significantly more likely to be abstinent at long-term follow-up than were those who either did not attend self-help groups or attended them less frequently. In contrast, among patients who were abstinent at 1-year follow-up, those who did not attend 12-step self-help groups (or attended only infrequently) were about as likely to be abstinent at long-term follow-up as those who attended self-help groups relatively frequently.

A similar pattern of results emerged for improvement in SUD-related problems. Patients who were non-abstinent at 1 year and attended 12-step self-help groups relatively frequently in the first year improved significantly more than did non-abstinent patients who did not attend self-help groups. Patients who were abstinent at 1 year showed similar improvement regardless of whether they attended self-help groups more or less frequently. Thus, the overall influence of 12-step self-help group attendance was consistent for abstinence and for substance use problems. Importantly, the benefits of attending 12-step self-help groups for non-abstinent patients did not appear to be due to self-selection; this finding generalized across two large samples of patients.

...

These findings are consistent with the idea that a continuing SUD intervention is likely to have a stronger influence on individuals with more severe than on those with less severe continuing problems. In this regard, high levels of self-help group participation were more closely related to better 6-month outcomes among patients with more severe substance use problems than among those with less severe problems (Morgenstern et al., 2003). Similarly, AA attendance had a stronger positive influence on alcohol-related outcomes for outpatients in Project MATCH who had high-network support for drinking than for those with low-network support for drinking (Longabaugh et al., 1998 R. Longabaugh, P.W. Wirtz, A. Zweben and R.L. Stout, Network support for drinking, Alcoholics Anonymous, and long-term matching effects, Addiction 93 (1998), pp. 1313–1333. View Record in Scopus | Cited By in Scopus (84)Longabaugh et al., 1998).

Makes sense, no? AA has always claimed to be one solution for people who are unable to achieve abstinence, right?

More on the grim neurobiology of early drinking

Previous studies have begged the question, Alcoholism: Clinical & Experimental Research has a study that attempts to provide an answer:

"The key finding of this study was that people who started drinking before age 15, and to a lesser extent those who started drinking at ages 15 to 17, were more likely to become alcohol dependent as adults than people who waited until 18 or older to start drinking," said Dawson. "Past studies have often suggested that this association might result from common risk factors predisposing people to both early drinking and AUDs. Although the current study does not provide conclusive evidence that early drinking directly increases AUD risk, it suggests that it is premature to rule out the possibility of such a direct effect."

"By controlling for a variety of confounding risk factors in their analysis, Dawson and colleagues were able to demonstrate that ... early alcohol consumption itself, as a misguided choice or decision, is driving the relationship between early drinking and risk for development of later alcohol problems," observed Moss.

Tobacco regulation

The Washington Post makes the case for FDA regulation of tobacco:

The FDA regulates everything from vegetables to Viagra. But cigarettes, which lead to some 400,000 deaths in the United States each year and shorten a smoker's life by 10 years on average, have somehow escaped oversight. As a result, tobacco companies don't have to divulge the ingredients in their products. They also don't have to disclose the levels of nicotine in their cigarettes. This means they can label their products as "light" or "low tar" with few restrictions; smokers have no way of knowing whether such claims are true. The bill would prevent cigarette companies from using such labels. It would also curb cigarette advertising and forbid fruit-flavored cigarettes intended to lure new smokers. The legislation would fund a new program within the FDA to oversee Big Tobacco by imposing a user fee on cigarette companies.

And the specious arguments of opponents:

The bill's critics, including the Bush administration, say that FDA regulation could trick consumers into thinking cigarettes are approved by the agency. But a provision in the legislation would prohibit Big Tobacco from perpetuating such a misunderstanding.

Puhleaz!

Also, remember the post last week suggesting a tobacco sales ban in pharmacies? Well, Phillip Morris unsuccessfully fought such a ban in San Francisco.

Tobacco and pharmacies

Disease management care blog suggests that pharmacies should stop selling tobacco. Makes sense to me.

Nicotine delivery

I just stumbled upon these two nicotine delivery systems. (The WHO is alarmed about one of them.)

When reading about them, I couldn't help but think of Bill White's lecture on drug trends when he made this point:

The hypodermic syringe offers an interesting case study in innovation. This new instrument arrived with the promise to reduce morphine addiction by requiring smaller amounts of morphine via injection compared to oral use. But this new technology turned out to be a Trojan horse that would alter the history of addiction in unforeseen ways.

He also referenced the innovation of "rocking" cocaine with baking soda and offered a warning something to the effect of, "I can't tell you what the major drugs of abuse of tomorrow will be. But I can tell you that they are already here and that someone will discover a new way to use them."

I was about to write that it was hard to imagine nicotine as a major drug of abuse, but then realized how blind I can be to the fact that it is a major drug of abuse. At any rate, it's hard to imagine nicotine being used the way that heroin, cocaine and other illicit drugs are used but maybe with a new method of administration and in conjunction with another drug? 

Maybe. Maybe not. But I am convinced that Bill White is right--there are other trojan horses coming.

9 types of drinkers

I'll note that the article does not use the the words alcoholic or dependence, so it's intent may be limited to categorizing alcohol abusers, but it feels like the latest iteration of the psychogenic model of addiction.

Parity update

The platforms of both political parties endorse some form of parity, though the Republican platform does not specifically include access to addiction treatment. 

To be honest, I've grown a little weary of the struggle for parity. It's been 7 years since George Bush indicated that he'd sign parity legislation. For years, there have been enough votes to pass legislation but the Republican leadership refused to allow a vote.  Now the Democrats have been in power for more than a year and a half and we've watched it stall with nearly weekly advocacy calls for supporters to contact their legislators.

A parity law will be an important milestone, but it's clear that it does not mean that there will suddenly be easy access to care. Insurers will implement tight managed care protocols and, practically speaking, things may not be very different. Parity does not equal equity. This will be the next long struggle.  

Here's an overview of mental health parity I wrote several years ago.

More on Earth and Fire

Mark Keiman and Jacob Sullum have posted their responses to the Erowid argument for legalization.

Nothing too interesting. Kleiman does close with this:

We could reduce violence and drunken driving by raising alcohol taxes [Cook 2007, Cook forthcoming], we could shrink the illicit drug markets and reduce recidivism by using drug testing and swift, automatic, and mild sanctions to force probationers to stop using expensive illicit drugs [Kleiman 1998, Hawken and Kleiman 2007, Schoofs 2008], and we could break up street drug markets, thus protecting neighborhoods, with low-arrest drug crackdowns [Kennedy 2008, Schoofs 2008].

Inmates running the asylum...

Unsurprising FDA/drug company incest:

It seems that the Food and Drug Administration turned to “a non-profit run by a pharmaceutical industry advertising consultant to help design its new campaign to educate consumers about direct-to-consumer drug advertising. The FDA’s recently launched website, “Be Smart About Prescription Drug Advertising: A Guide for Consumers,” was developed by EthicAd, a non-profit run by Michael Shaw out of the offices of Atlanta-based Shaw Science Partners. Shaw’s firm claims credit for having helped launch over 25 pharmaceuticals, including Viagra, Celebrex, Zoloft, Cymbalta, and Rezulin, which was later withdrawn from the market because of safety concerns.”

All twelve step faciliation is not equal

Not a surprising outcome if you know much about twelve step facilitation:

Important findings from the current investigation of the relationship between services received and outcomes of chemical dependency treatment were that higher participation in optional or extracurricular 12-step meetings was associated with better treatment outcomes, whereas curricular involvement in 12-step groups (i.e., groups required as part of treatment) showed no association with treatment outcomes.

Get people to meetings does not necessarily equal connecting them with the community. All meetings are not equal. Getting them to a meeting where a thriving, welcoming community of recovery is essential for effective twelve step facilitation. It takes a kind of recovery cultural competence to effectively attend to these matters.

Other findings:

• ...weak effects for supplemental psychiatric, family, medical, and legal services: We found null associations between delivery of these services and the odds of 6-month sobriety across the board.
  
• The study also found associations between participation in sober recreational events at 2 and 4 weeks and better treatment outcomes at 6 months
  

Finally, another finding emphasizes the importance of recovery-oriented services, rather than treatment-oriented services:

We found that residential participants showed higher participation in curricular 12-step meetings at 2 weeks, relative to day-hospital participants and as expected; however, this effect was not maintained throughout follow-ups, and residential participants actually showed relatively lower rates of extracurricular 12-step meeting attendance and working with a sponsor through 4 weeks. These latter differences may be the consequence of residential clients' tightly scheduled time, intensive involvement in curricular 12-step meetings, and/or restrictions on leaving the treatment site.

Initial treatment focus

No difference in drinking, depression or retention for depressed alcoholics treated with cognitive behavioral therapy or twelve step facilitation.

Trauma, addiction treatment and iatrogenic harm

A frequent concern about trauma-focused models is the fear of iatrogenic harm. This study found that Seeking Safety didn't lead to adverse events. It's worth noting that Seeking Safety is a pretty low intensity approach emphasizing psychoeducation and coping skills.

When hope is lost...

...isolate the afflicted.

Responsible use not a foundation for policy

Oops. I was wrong in yesterday's post about responsible drug use. Jonathon Caulkins is from RAND, not Cato, and has posted a response to yesterday's Erowid post on responsible drug use at Cato Unbound. He starts off by identifying and challenging one of the underlying values:

The Erowids assert that “Modern humans must learn how to relate to psychoactives responsibly, treating them with respect and awareness, working to minimize harms and maximize benefits, and integrating use into a healthy, enjoyable, and productive life.” Most of that assertion is innocuous. Psychoactives are ubiquitous when the term is used so broadly as to include even caffeine. However some are quite dangerous, so as a class they should certainly be treated with respect. And working to minimize harms and maximize benefits is unobjectionable in most endeavors.

What distinguishes the Erowids is their assertion that modern humans must integrate psychoactive use into life. Apparently from their perspective, choosing abstinence, at either the individual or societal level, is inherently inconsistent with being modern.

Denying or denigrating an individual’s right to choose temperance is an extreme position not worth engaging.

He goes on to make the case for prohibition without being supportive of American prohibition:

While avoiding a full rehash of the by-now dull legalization debate, two points bear mention. First, American drug policy is easy to criticize as intrusive, ineffective, and mean-spirited. However, it does not follow that prohibition is necessarily a bad policy. Essentially every country in the world prohibits production and distribution of cocaine, crack, heroin, and methamphetamines for recreational use, even legalizers’ poster child, the Netherlands. Most affluent industrialized countries take a far less aggressive approach to their prohibitions than the United States does, yet they maintain prohibitions nonetheless. The problems with America’s prohibition stem primarily from particulars of its implementation, not from prohibition per se.

Second, the challenge is not in criticizing prohibition, but designing something better. To their credit, the Erowids offer specific suggestions in their “Fundamentals of Responsible Psychoactive Use.” I am skeptical that they constitute a practical framework for social policy, as distinct from being useful guidelines for individuals who choose to use psychoactive drugs. Note, though, that nothing about American alcohol policy precludes application of these principles. So if their advocates are successful in taming the rather considerable problems with legal alcohol, then I would take more seriously claims about the Principles’ universal efficacy with respect to all psychoactives, including, say, methamphetamine.

He then goes on to distill the issue to its most fundamental question:

What are the risks of trying the big four illegal drugs (marijuana, methamphetamine, cocaine—including crack—and heroin)? Statistics vary by drug, age of first use, and other variables, but among the myriad patterns of drug use, four are common: (1) limited experimentation, (2) ongoing controlled use, (3) ongoing use that is mostly controlled but punctuated by occasional abuse, and (4) escalation to dependent use.

...

To grossly simplify, about half of people who try illegal drugs stop with experimentation, and one in six end up in each of the other three categories (controlled use without and with occasional abuse and dependence). The proportions are slightly more favorable for those who only try cannabis, but less dramatically so than one might expect. At any given time, five times more people are dependent on marijuana than are incarcerated for drug-law violations, and the lifetime risk of abuse or dependence for cannabis use is on the order of one in ten.[1]

No one knows how legalization would change these probabilities. The Erowids might argue the risks would go down, particularly if their principles were applied. I would argue the opposite. The drugs would be cheaper, more easily available, and (likely) marketed aggressively; and their use would be less costly in terms of risk of arrest, loss of employment, and social approbation. In short, there would be fewer external constraints on use, and more frequent and heavier use increases the risk of dependence. For the sake of argument, let’s stick with the figure of a one-in-six risk that trying a drug will lead to dependence and associated harms.

Does society have a right to “protect” its citizens from a one-in-six risk of dependence, even though that “protection” denies five times as many people legal access to something pleasurable?

Early misuse of painkillers leads to addiction?

More research suggesting that opiate addiction can be aquired by early exposure:

No child aspires to a lifetime of addiction. But their brains might. In new research to appear online in the journal Neuropsychopharmacology this week, Rockefeller University researchers reveal that adolescent brains exposed to the painkiller Oxycontin can sustain lifelong and permanent changes in their reward system – changes that increase the drug’s euphoric properties and make such adolescents more vulnerable to the drug’s effects later in adulthood.

The research, led by Mary Jeanne Kreek, head of the Laboratory of the Biology of Addictive Diseases, is the first to directly compare levels of the chemical dopamine in adolescent and adult mice in response to increasing doses of the painkiller. Kreek, first author Yong Zhang, a research associate in the lab, and their colleagues found that adolescent mice self-administered Oxycontin less frequently than adults, suggesting that adolescents were more sensitive to its rewarding effects. These adolescent mice, when re-exposed to a low dose of the drug as adults, also had significantly higher dopamine levels in the brain’s reward center compared to adult mice newly exposed to the drug.

Gut-busters? New to me.

Jane Brody makes the case that local policies and alcohol sales practices are important contributors to binge drinking:

The Harvard School of Public Health College Alcohol Study, which began in 1993, has identified several environmental and community factors that encourage binge drinking. Dr. Wechsler, who directed the study, said in an interview that high-volume alcohol sales, for example, and promotions in bars around campuses encourage drinking to excess.

“Some sell alcohol in large containers, fishbowls and pitchers,” he said. “There are special promotions: women’s nights where the women can drink free; 25-cent beers; two drinks for the price of one; and gut-busters, where people can drink all they want for one price until they have to go to the bathroom. Sites with these kinds of promotions have more binge drinking.

“Price is an issue,” he added. “It can be cheaper to get drunk on the weekend than to go to a movie.”

Although it is a college’s duty to educate students about the effects of alcohol and the risks of drinking too much, “education by itself doesn’t work,” Dr. Wechsler said. “You must attack the supply side as well as the demand side.”

More than half the alcohol outlets surrounding colleges that participated in the Harvard study offered promotions with price discounts, and nearly three-fourths that served alcohol on the premises had price discounts on weekends.

The study found that the sites of heaviest drinking by college students were off-campus bars and parties held off-campus and at fraternity and sorority houses.

However, community policies and business practices can be just as critical in reducing binge drinking:

Community measures that helped to curtail binge drinking during the eight-year course of the study included a limit on alcohol outlets near campus, mandatory training for beverage servers, a crackdown on unlicensed alcohol sales and greater monitoring of alcohol outlets to curtail under-age drinking and excessive consumption by legal drinkers.

What would "responsible" drug use look like?

The keepers of Erowid offer a document advocating responsible drug use, primarily as a tool for achieving spritiual enlightenment.

They make some pretty provocative assertions about the state of American culture with respect to psychoactive substances:

Many people would agree that drug culture reform is needed, but we must recognize that “the drug culture” now includes everyone. Modern life involves daily decisions about psychoactives. The option of caffeine use is encountered multiple times a day. It is rare to watch an hour-long television show without seeing an advertisement for a mind altering pharmaceutical or a legal recreational drug. Late night coverage of the 2008 Summer Olympics was sponsored by Ambien, a popular sleep aid with memory-scrambling side effects whose commercials enticed audiences nationwide with comforting images of dreamy, refreshing, sedative-assisted sleep. A large portion of the population is exposed to the possibility of taking LSD, even if only 10-20% ever try it.[11,12] In today’s world, everyone must choose how they relate to innumerable psychoactive drugs. Whether or not one decides to use a specific drug, that decision should be made with skill, knowledge, and self-awareness, supported by accurate information.

And offer some fundamentals for responsible drug use:

Investigate the health risks and dangers of the specific psychoactive and of the class of drugs to which it belongs.


Learn about interactions with other recreational drugs, medications, supplements, and activities.


Review individual health concerns, predispositions, and family health history.


Choose a source or product carefully to help ensure correct identification and purity


(avoid materials with an unknown source or of unknown quality).


Know whether the drug is likely to reduce the ability to drive, operate equipment, or pay attention to necessary tasks.


Take oneself “off duty” from responsibilities that might be interfered with (job, child care, etc.), and arrange for someone else to be “on duty” for such responsibilities.


Anticipate reasonably foreseeable risks to oneself and others and employ safeguards to minimize those risks.


Choose an appropriate occasion and location for use.


Select and measure dosages carefully.


Begin with a low dose until individual reactions are known and thereafter use the minimum dose necessary to achieve the desired effects: lower doses are safer doses.


Reflect on and adjust use to minimize physical and mental health problems.


Note changes in health over time that may be related to use.


Modify use if it interferes with work or personal goals.


Check in with peers and family and accept feedback about one’s use.


Track reactions to specific drugs and dosages in order to avoid repeating mistakes.


Seek treatment if needed.


Decide not to use when the time isn’t right, the material is suspect, or the situation is otherwise problematic.

The also, appropriately, take the US governemtn to task for dishonesty in reporting the potential consequences of drug use:

While the quality of government-sponsored sources has improved over the last decade, sites such as Freevibe.com, a youth-oriented website funded by the federal government, still include laughable exaggerations like “heart and lung failure“[27] as a general effect of hallucinogens—a deceptive claim they have made for more than eight years. Scientific literature reviews on the most common hallucinogens do not support their claims; most recently, Johns Hopkins researchers found that, “hallucinogens generally possess relatively low physiological toxicity and have not been shown to result in organ damage.”[28] Once people realize that a source is deceptive, as is the case for those teens visiting Freevibe who know someone who has tried LSD or psilocybin-containing (”magic”) mushrooms, they will be inclined to distrust all information from that source.

But what about groups like NORML? Is their information accurate? Do they engage in conduct that reports irresponsible drug use? Why focus exclusively on the ONDCP?

They focus heavily on psychedelics and argue that many users report benefits. What about cocaine and opiates? They really believe that adolescents should be supported in intentional responsible drug use? What are the potential consequences of this? Who can not engage in responsible drug use? Addicts? Pre-adolescents? Who else? They seem to dodge the more difficult questions.

They will have responses from Jacob Sullum, Robert Kleiman and another CATO (libertarian) fellow. I look forward to Kleiman's response.

Parachutes revisited -- Where's the evidence?

Satire of evidence-based medicine from BMJ:

What is already known about this topic

• Parachutes are widely used to prevent death and major injury after gravitational challenge
• Parachute use is associated with adverse effects due to failure of the intervention and iatrogenic injury
• Studies of free fall do not show 100% mortality

What this study adds

• No randomised controlled trials of parachute use have been undertaken
• The basis for parachute use is purely observational, and its apparent efficacy could potentially be explained by a "healthy cohort" effect
• Individuals who insist that all interventions need to be validated by a randomised controlled trial need to come down to earth with a bump

This is really funny stuff. Check this out:

One of the major weaknesses of observational data is the possibility of bias, including selection bias and reporting bias, which can be obviated largely by using randomised controlled trials. The relevance to parachute use is that individuals jumping from aircraft without the help of a parachute are likely to have a high prevalence of pre-existing psychiatric morbidity. Individuals who use parachutes are likely to have less psychiatric morbidity and may also differ in key demographic factors, such as income and cigarette use. It follows, therefore, that the apparent protective effect of parachutes may be merely an example of the "healthy cohort" effect.

And this:

It is often said that doctors are interfering monsters obsessed with disease and power, who will not be satisfied until they control every aspect of our lives (Journal of Social Science, pick a volume). It might be argued that the pressure exerted on individuals to use parachutes is yet another example of a natural, life enhancing experience being turned into a situation of fear and dependency. The widespread use of the parachute may just be another example of doctors' obsession with disease prevention and their misplaced belief in unproved technology to provide effective protection against occasional adverse events.

[hat tip: Freakonomics]

Recovery management

I recently had a conversation about disease management that got me very curious about what could be translated into recovery management. 

This person is involved in implementing pay-for-performance programs for primary care physicians. In the area of disease management, they are piloting a couple of programs for diabetics and cardiac disease. They are providing some diabetic patients with glucometers and cardiac patients with automated blood pressure cuffs. Nothing new about that, right? Here's what's innovative about them. These devices will transmit information to their medical record at their doctor's office. It will transmit the results of the test or transmit that the test was not completed. The doctor can call the patient in for a visit or testing if there is a concern, they can opt to skip a visit and just call in refills if everything is going smoothly, they can monitor compliance, they can also get a better sense of how various protocols are working with all of this additional information. 

Are there similar methods that we could employ in recovery management? What do you think?

A Sea Change in the Treatment of Alcoholism

More on recovery in a tribal community:

"Factors Associated with Remission From Alcohol Dependence in an American Indian Community Group," by Gilder et al. (1) is a well designed and carefully implemented study that provides valuable new information for American Indian communities but also for society at large. Perhaps the most salient finding is the relatively high rate of 6-month remission: 59% in an ethnic group whose remission rates 25 years ago ranged from 0% to 21% (2–4). Another study recently revealed a 41% 1-year full remission in 199 American Indian people with substance use disorder, confirming the salutary finding of Gilder and coworkers (1).

What has occurred over the last few decades in Native American communities to permit such a dramatic change? One factor lies in leadership: many tribal leaders have identified substance abuse as a major social and health problem (5). The fact that Gilder and coworkers could carry out such a study in Indian communities today bespeaks this critical political change. Second, many American Indian professionals and researchers have devoted their efforts to eliminating substance abuse from American Indian lives and communities (6, 7).

Upon reading this, the metaphor of the Healing Forest immediately came to mind. It also speaks to the potential of the recovery management approach.

This fifth principle, by affirming the inextricable link between personal health and community health, calls upon the addiction treatment agency and the addiction counselor to become actively involved in the communities within which their clients reside or to which they identify.

This person-community link is being conveyed to Native communities across the country within the cultural model of the Healing Forest. When a sick tree is removed from diseased soil, treated, and returned and replanted in the same diseased soil, it gets sick again. What is called for instead is a healing of the tree AND the replacement of diseased elements in the soil with nurturing elements (Red Road to Wellbriety, in press). Personal recovery flourishes best in a climate of family health, cultural vitality, political sovereignty, and economic security. What White Bison and other Native recovery advocacy organizations are trying to do is mobilize all segments of Native communities - the tribal councils, schools, churches, service programs, and political and cultural organizations - to forge and then actualize a healing vision for the community. The goal is to create a Healing Forest that creates a synergy between personal and community wellness. Such a synergy is reflected in the words of Andy Chelsea, who as the Shuswap tribal chief at Alkali Lake, declared, "The community is the treatment center" (Abbott, 1998).

Recovery in a tribal community

Interesting findings from a study of remission from alcoholism in a Native American community:

A surprising and novel finding of this study is that self-reported depression and anxiety symptoms do play a significant role in increasing and decreasing, respectively, the likelihood of remission. These are not depression and anxiety symptoms occurring in the context of alcohol withdrawal, because a similar question asking whether withdrawal had ever caused depression or anxiety symptoms did not appear in the final logistic regression model. Why self-reported depression and anxiety caused by drinking should be significantly associated with remission, especially in light of the absence of association of independent or substance-induced anxiety and affective disorders with remission, is unclear. It may be that insight about the nature of the relationship between drinking and depression and anxiety is a critical element in promoting or inhibiting remission. Why self-reported alcohol-induced depression would increase while self-reported alcohol induced anxiety would decrease the likelihood of remission is also unclear. The former is consistent with findings that insight promotes increased compliance with treatment and remission of other psychiatric disorders (37–39). The latter is consistent with the hypothesis that individuals with alcohol dependence and alcohol-induced anxiety symptoms are more likely to continue drinking, perhaps as a means to self-medicate those symptoms. Both raise the possibility that education about the depression and anxious effects of alcohol and alternative ways of dealing with anxiety symptoms that accompany alcohol dependence may have an important role in treatment and community prevention programs in this high-risk population.

We also tested whether factors associated with remission of alcohol dependence were also associated with the survival of alcohol dependence. Two factors significantly associated with remission (being married and having self-reported depression symptoms from drinking) were also significantly associated with a shorter duration of alcohol dependence, and two factors associated with nonremission (continuing to drink despite medical problems and having self-reported anxiety symptoms from drinking) were also significantly associated with a longer duration of alcohol dependence. Advancing age and younger age at onset of alcohol dependence were both associated with increased likelihood of remission. However, both advancing age and younger age at onset of alcohol dependence were associated with increased duration of alcohol dependence. These data are consistent with previous findings in this group that alcohol dependence runs a typical clinical course that includes duration as well as symptom profile (3). These data are not consistent with the notion that, from the standpoint of remission, there may be two groups of alcohol-dependent individuals: those with early onset who have a shorter course of alcoholism and those with later onset who have a longer course, which has been suggested for other populations (16, 40).

This is a study of a specific population and may not be tranferable to other groups of alcoholics. The finding is not shocking if you've read this blog.

The article offers other interesting and hopeful findings:

In this study, the rate of 6-month full remission from DSM-III-R alcohol dependence with 1-month clustering of 59% is comparable to the U.S. epidemiological rate of 1 year prior to past year, full remission from DSM-IV alcohol dependence of 48% (14), the 1-year partial remission rate of 64% in a German representative population sample (17), and the 1-year full remission rate from alcohol abuse and dependence of 53% found in Ontario, Canada (16). Despite the high rate of 1-month clustered DSM-III-R alcohol dependence of 49% in this group, the rate of full remission is comparable to studies of predominantly European ancestry populations.

Several factors associated with full remission in this American Indian group are consistent with factors associated with full remission in the general U.S. population. Our findings are consistent with the findings of Dawson and colleagues (14) that abstinent and nonabstinent recovery in the general U.S. population are associated with female gender, increasing age, and being married, but not with tobacco use, dependent use of illicit drugs, and having any lifetime anxiety or affective disorder. Our findings are also consistent with Schuckit and colleagues (30), who found that episodes of 3-month abstinence in a mixed treatment and nontreatment group were associated with female gender, older age, ever having been married, and younger age of onset of alcohol dependence, but not with a primary diagnosis of antisocial personality disorder.

Increasing likelihood of remission with advancing age in this American Indian group is consistent with the "aging out" phenomenon described in the Navajo (5, 23). Why "aging out" occurs in American Indians and other ethnicities is unclear. Alcohol dependence may biologically run its course in a proportion of alcohol dependents, and/or the accumulating psychosocial burden of alcohol dependence may prompt increasingly successful attempts at cutting back on drinking. In addition, as age advances, individuals with alcohol dependence, as well as those without, may develop new work, social, and family networks (19) that play a role in reducing drinking. The consistent association of remission with marriage (14, 18, 36) suggests that the social support and limit setting that can come from a spouse are important factors in promoting remission.

Does this suggest that the high prevalence in tribal communities may be due to multiple pathways to addiction (not just genetic vulnerability) and that there may be multiple types of alcoholism at play? I'm not sure.  Maybe. This will be interesting to watch.

What makes nicotine so addictive?

There may be a very good reason why coffee and cigarettes often seem to go hand in hand. 

A Kansas State University psychology professor's research suggests that nicotine's power may be in how it enhances other experiences. For a smoker who enjoys drinking coffee, the nicotine may make a cup of joe even better. 

And that may explain why smoking is so hard to quit. 

I wonder if this will offer an answer to some of my questions about nicotine. 

I'm not sure. Some of this just doesn't sit well with me:

"The big picture is trying to figure out why people smoke," Palmatier said. "There are a lot of health risks, and the majority of smokers already know what they are. They want to quit but can't. It's not because nicotine is a potent drug; it doesn't induce significant amounts of pleasure or euphoria. Yet, it's just as difficult if not more difficult to quit than other drugs."

At K-State, Palmatier studies rats that are allowed to self-administer nicotine by pushing a lever. The main source of light in their testing environment shuts off when the rats earn a dose of nicotine. After about a minute, the light comes back on to signal that more nicotine is available.

By manipulating this signal, Palmatier and his colleagues found that the rats weren't really that interested in nicotine by itself.

"We figured out that what the rats really liked was turning the light off," Palmatier said. "They still self-administered the nicotine, but they took more of the drug when it was associated with a reinforcing light."

Palmatier and colleagues published a paper on their research in the August issue of Neuropsychopharmacology.

Palmatier has begun looking at how rats respond to sweet tastes after having nicotine. He said preliminary results show that nicotine has comparable effects on sweet tastes. That is, rats respond more for sugar-water solutions after getting nicotine.

"The taste aspect is really important because we can actually figure out how nicotine is increasing the subjects' behavior," Palmatier said. "If it makes a reward more pleasurable, then it may increase the palatability of a sweet taste."

If so, it would have to be soley on  a neurobiological level because on an oral taste level, because nothing tastes better with a cigarette.

I love Jesus, but I drink a little

A little comic relief:

[hat tip: Jim]

Alcohol

What do you do with the information provided in these two stories? I'm sure some will say that better education of potential binge drinkers and youth are the key, others will say that condoms should be available for free at bars and liquor stores. I'm not too optimistic.

It seems to me that problems like this are unlikely to be addressed without facilitating some kind of culture change related to alcohol mores. That our nation's largest prevention program is the designated driver campaign says something about how much we value drinking doesn't it? We don't tell people not to get drunk. We tell them to go ahead and get drunk, just don't drive. The campaign is constructed to protect something our culture values. There's also a strong association between this and weekends. It's deserved after a week of hard work, it's how we unwind,  and that it's part of the American dream to kick back with family and friends with a case of Bud, a bottle of wine, or an appletini. (In most cases this is not a drink with a meal.) 

BTW - While listening to the recent suggestions that lowering the age would lead to healthier drinking on college campuses, I kept coming back to this issue of alcohol's place in our culture. 

UPDATE - Of course, taxes could be an important tool for addressing underage drinking and binge drinking. However, a move in that direction would be an expression of values, and those are especially difficult to agree on in this area. Michigan has been in financial crisis for several years and proposed increases have been repeatedly killed. 

This map suggests a pretty strong relationship between alcohol taxes and alcohol related problems.

Medical marijuana???

Not what you're thinking.

Recovery coaching

Here's an interview with a Michael Boyle, the director of a pioneering program in recovery coaching. The interview is okay, but his recovery coaching manual is great.

A great recovery story

This is a great example of the love, support and generosity available in the recovering community:

Dale Ensor was desperate when he walked into a 12-step addiction recovery program five years ago. That's when he met a man named Dexter McElrath, who offered to help Ensor along the path to sobriety.

"Dexter took me under his wings and showed me the ropes," said Ensor, a 52-year-old self-employed painter who lives just north of Jackson. "I couldn't get it in my brain that there are people who care of me. The guy helped save my life. I would have died out there; I really would have."

At the time, neither could have known that this summer, Ensor would return the favor.

McElrath's kidneys began to fail in May 2007. The Ypsilanti Township resident went on dialysis for 14 months, expecting to wait the average three to five years for a transplant if he couldn't get a kidney from a friend or relative.

Two people offered a kidney, but one wasn't a match and McElrath wouldn't take the other because it would have meant postponing the donating woman's education.
McElrath was forced to cut way back on his hours as a construction worker because dialysis wore him out. Ensor watched his friend's health deteriorate and agreed to be tested.

"It was either that, or watch my friend die," he said. "All the cards were on the table. When it came to it, what kind of man am I? What am I going to do?"

At least she's predictable

From the same woman whose worldview dictates that stigmatizing addiction is good and addiction is not a disease. She chose to draw from a man with quite an agenda.

“It undermined their sense of themselves as individuals in control of their own destinies,” Mr. Sullum wrote in his 2003 book, “Saying Yes: In Defense of Drug Use.” “And so they stopped.”

I only read about these people. Patients who come to our methadone clinic are there, obviously, because they’re using. The typical patient is someone who has been off heroin for a while (maybe because life was good for while, maybe because there was no access to drugs, maybe because the boss did urine testing) and then resumed.

But the road to resumption was not unmarked. There were signs and exit ramps all along the way. Instead of heeding them, our patients made small, deliberate choices many times a day — to be with other users, to cop drugs for friends, to allow themselves to become bored — and soon there was no turning back.

Addiction does indeed discriminate. It “selects” for people who are bad at delaying gratification and gauging consequences, who are impulsive, who think they have little to lose, have few competing interests, or are willing to lie to a spouse.