Shocking article on cannabis policy

SHOCKING, I tell you. New Scientist published a thoughtful article about cannabis policy that attempts to present the evidence in a unsensational manner.

First U.S. Injection Site

San Francisco is about to open the first legal injection site in the country.

I've had a lot to say on the topic in the past. To sum up my view, context is key. A program like this can be an expression of despair, fear and/or contempt, or it can be a way to engage addicts and try to keep them healthier until the enter recovery.

Recovery is the key. I'd pose the following questions:

• Does treatment on demand exist? If not, does the facility consider it their responsibility to advocate for treatment on demand?
  
• Does the program view recovery as the ultimate goal?
  
• Does the facility believe that it's clients can achieve recovery?
  
• Are they capable of offering hope for recovery to their clients and the community?
  
• Does the program view drug use by addicts as a life style choice, or as a symptom of the treatable illness of addiction?
  
• Does the program represent the best use of scarce resources available to help addicts?

San Francisco does have a policy of treatment on demand, but it has never been anywhere near adequately funded.

Staying Sober, Reinventing Fun

A nice story from Weekend America about getting into recovery on a college campus and a campus recovery program.

About that recent Times article...

Something to piss everyone off and challenge the premise of that recent Times article. A meta-analysis of studies comparing "bona fide" treatments found "no evidence of differences among treatments for alcohol use disorders."

More interesting is this:

Although the variability of effects about zero was small, we also found evidence of an allegiance effect. Specifically, our analyses indicated that as allegiance to compared treatments became more unbalanced, the expected difference between treatments increased, in favor of the treatment forwhich there was researcher allegiance. Allegiance accounted for most of the variability in treatment differences in alcohol measures.

Not shocking to anyone who reads journals often. Researcher's findings strangely almost always support their hypothesis. It's worth noting that this study is no exception.

The authors suggest that the most important predictor of outcomes is the alliance between the helper and the client. I'm inclined to accept this, particularly with less severe substance use disorders and short term outcomes. They call for "research that focuses on developing models of the complex interactions that occur between patients", and I'd agree.

What I believe is missing from their formulation is the importance of factors like intensity and duration. I suspect that the most successful approaches will be those that respond to addiction as a chronic illness and recruit patients into managing their recovery over their life course.

Yes we cannabis!

This seems like wishful thinking to me. I could see him implementing more incremental reform, but not this:

Meanwhile, economists have been making the beer argument. In a paper titled "Budgetary Implications of Marijuana Prohibition," Dr. Jeffrey Miron of Harvard argues that legalized marijuana would generate between $10 and $14 billion in savings and taxes every year -- conclusions endorsed by 300 top economists, including Milton "Free Market" Friedman himself.

And two weeks ago, when the Obama team asked the public to vote on the top problems facing America, this was the public's No. 1 question: "Will you consider legalizing marijuana so that the government can regulate it, tax it, put age limits on it, and create millions of new jobs and a billion dollar industry right here in the U.S.?"

I'm ambivalent about marijuana's legal status, but I find this kind of thinking horrifying. I have no interest in criminalizing alcohol and tobacco, but they've been public health disasters, their lobbies have been much to powerful, and they've repeatedly targeted kids. Unleashing capitalism on the marijuana market and creating a marijuana industry would only create more problems. If marijuana is decriminalized, I would hope it's done in a way that minimized the commercial marketplace for it--like keeping sale illegal, but allowing people to grow and possess their own.

Cynicism recharge

Just in case the holiday spirit was dulling your cynical side, here's a story about white collar criminals and corrupt politicians are trying to save their skins with claims of addictions.

I've no doubt that some of them are truly addicts, but this pattern reinforces stigma associated with addiction being a convenient scheme to avoid accountability.

Life after...

Prevention initiatives in the U.S. have often had an anti-addict tone to them. Federal prevention initiatives often make me queasy because of the policies they espouse and the hysterical tone of their education efforts. However, it's good to see them start to embrace recovery. It's especially heartening with meth when one considers the history of the crack epidemic.

The Relationship of Drug Abuse to Unexplained Sudden Death

Another hidden cost of addiction.

Drug Rehabilitation or Revolving Door?

The New York Times paints a dim view of addiction treatment and foreshadows a financial black hole once parity takes effect. The word recovery does not appear once, no mention of findings regarding the positive outcomes and cost-effectiveness of treatment, no mention of twelve step facilitation as an evidence based practice, no mention of duration of treatment as an important factor in outcomes, and, as Bill White has said, these arguments about MET vs. TSF vs. MET are all arguments within the acute care paradigm. Systems change needs to focus on long term recovery management strategies for chronic addicts.

[hat tip: Matt]

Tab dump

• Special Treatment: The rise of luxury rehab
• Something In the Air: When a Smoker Gets Lung Cancer, Sympathy Is Stained With Blame
• Law gives strength in fight against heroin
• College Students Say ADHD Drugs Help Them Study

Tobacco criminalization

Odd that there's growing cultural pressure toward greater criminalization of tobacco and decriminalization of marijuana and other drugs.

Michigan's Medical Marihuana Program

Michigan's Department of Community Health has fleshed out the medical marijuana program. It will be interesting to see how the role of caretaker takes shape.

Inhaling fear

This writer suggests that smoking warnings actually trigger cravings.

There's something a little too neat and a little too certain about his op-ed, particularly from a study of 32 subjects.

It's easy to imagine how a warning that contains the words cigarettes, tobacco or smoking might trigger craving. It's a little more difficult to understand how an image of a tumorous lung would provoke craving, unless subjects have been desensitized to the image and have developed an association between the image and a cigarette. The op-ed suggests that all warnings are useless, but only explicitly addresses subject response to the text warnings.

I tried to learn a little more about the author, but the Wikipedia page on his was deleted because it was deemed to be blatant advertising.

Misuse of legal drugs

A troubling trend continues:

15.4 percent of 12th-grade students reported nonmedical use of legal prescription or over-the-counter medications

This is particularly troubling for 2 reasons. First, as JAMA recently pointed out, overdose deaths associated with prescription drugs are skyrocketing in some areas. Second, people who develop problems with prescription opiates often end up switching to heroin because it's cheaper. They often start out by snorting heroin and end up switching to injecting.

Homelessness and crack use

A harm reduction group reports that half of the homeless people in Toronto use crack.

This seems difficult to believe. Worth watching.

More drug company chicanery

Celebrities and politicians aren't the only ones using ghostwriters.

Good news and bad news in British Columbia

Good news - drug deaths decline

Bad news - 1 in 10 drivers test positive for drugs, and 1 in 12 drivers test positive for alcohol

Doctors and addiction

Dirk Hanson makes several important points--that medical training on addiction is inadequate, that doctors don't respond well to patients with addiction, that the medical reimbursement system does not support a response to the problem, and that there are enormous barriers for doctors who do want to respond to addiction.

This is even more important as we attempt to implement recovery management approaches. Physicians are a natural point of contact for recovery checkups and long term monitoring.

Ramstad

I'm persuaded.

The other name I'd heard was Thomas McLellan. He was always my preference. Let's hope he gets it.

French Doctor Says Baclofen Cures Addiction

Hmmm.

The HBO Addiction documentary played like a baclofen ad. I honestly don't know much about it and don't have a lot to say, but I did admit someone who was treated with baclofen for neurological pain and used it to get high. The patient was eventually cut off by the prescribing physician because she overdosed on it several times and required hospitalization.

Pedophilia an addiction?

OMG. I'm speechless.

The Second Road

FYI - This blog is being cross-posted at The Second Road, a web-based community of recovery. They have several other blogs, videos and chats. Check them out when you get a chance.

Stuck on stupid

Mark Kleiman also takes on the drug warriors and sums up the drug policy freak show:

Walters and Nadelmann are like a pair of aging vaudeville comedians, still whacking away at each other with their slapsticks long after everyone in the audience has gotten bored with them.

I only wish I thought that the editors of the Wall Street Journal had deliberately chosen these two exercises in unreality to illustrate how completely what passes for the drug policy debate in political and journalistic circles is stuck on stupid. But I'm just about certain that they have been taken in by the illusion that they, in turn, foist on their readers, an illusion that the Walters drug-warrior crowd and the Nadelmann drug-legalizer crowd have done their best to foster because it's in their mutual interest: the illusion that there's no alternative to the War on Drugs other than a virtual free market in drugs with a few not-very-important regulations, more or less on the alcohol model.

The arguments for the drug war and for "an end to prohibition" are symmetrically nonsensical, only with opposite signs: rather like a particle and its anti-particle. Sadly, there's a difference; I see no hope that the "drug war" and "drug policy reform" might someday meet and disappear in a flash of photons. 

So it begins

The Hemp and Cannabis Foundation has come to Michigan!

Don't forget to visit the Church of Cognitive Therapy.

Prop 5

Join Together deconstructs the failure of Prop 5 in California. It seems to boil down to mistrust of the Drug Policy Alliance (DPA) and the DPA's failure to include others in developing the proposal.

It's not the cool thing to say these days, but my mistrust might have caused difficulty deciding how to vote. This explains why:

NORA supporter John DeMiranda, executive director of the National Association on Alcohol, Drugs and Disability and Pacific Southwest regional representative for Faces and Voices of Recovery, said that the treatment community in California "jumped on the bandwagon and talked about NORA as a treatment initiative," even though DPA mainly cast Prop 5 as a drug-policy reform effort.

I've never been able to shake the feeling that the DPA's support for treatment is more strategic than sincere.

Also, does FAVOR really want to get associated with aggressive decriminalization efforts?

"If we were to do our own initiative it would be very different, and the politics would be very different," said DeMiranda. However, he scorned the state's drug courts for failing to embrace the reforms embodied in NORA. "We need wholesale decriminalization, not retail decriminalization," said DeMiranda, noting the relatively small number of clients currently served by drug courts.

Feed your brain

Film Exchange on Alcohol & Drugs is pretty cool. Brief videos on policy, treatment and recovery.

A bad idea that won't go away

Time has an article lending credibility to the idea of treating stimulant addiction by placing addiction on a stimulant maintenance program. I've posted about this idea before.

What is there to say? Didn't we give up on treating alcoholism with benzos a long time ago?

It's argued that stimulant maintenance reduces drug use among participants and that abstinence-based programs only work for about a 1/3 of participants. This begs at least 2 questions:

• How many of those patients get treatment of an adequate duration and intensity?
  
• How many of the other 2/3 reduce their drug use? Is she using the same measuring stick for the two?
  

Ideas like this are rooted in despair, rather than hope. (see here, here, here) We get overwhelmed by the problem. (here) We're too cheap to offer adequate help. (here) We don't believe that these people can recover. We think they have no chance. We're scared that they'll hurt us and get us sick. (here)  So, we offer them these kinds of interventions. Often, these programs represented in the name of choice, (here) when, the addicts themselves, want better from us. (here, here) They actually want to get well, but often lose hope that it's possible for them. The system starts patting them on the head an encouraging them to be more realistic. (here, here, here) What they need from professional helpers is for us to lend them our hope to cultivate some of their own. (here, here) They need a system that stops talking about if they recovery and starts talking about when they recover. (here)

The article acknowledges that recovery rates for stimulant addicts are the same as for other drugs. We know what works. Recovery rates are very high when we offer long term treatment with longer term monitoring and swift re-intervention in the event of relapse. Some people respond, "Well, that's with addicted health professionals. It won't work with other addicts." How would we know? We don't try it.

If we truly tried everything and nothing worked for a sizable group of addicts, I might feel differently. But context matters, and the current context is ugly. We've had an explosion in incarceration and, in a period of explosive growth in health care spending, private spending on treatment has dropped and overall spending has grown at a rate much lower than other health care spending.

It's also worth noting that the writer is a frequent critic of treatment, AA, and the disease model. (I'm not suggesting that her criticism has no basis, but that she frequently paints with a broad brush and that there is a bias against specialty addiction treatment.)

More on prohibition

Mark Kleiman has a great post in response to Ethan Nadelmann's Wall Street Journal op-ed:

As Talleyrand said about the restored Bourbons, the
anti-prohibitionists have learned nothing and forgotten nothing in
thirty years of making exactly the same points in exactly the same way.
Ethan Nadelmann's op-ed in Friday's Wall Street Journal
doesn't admit that "an end to prohibition" means increased
availability, and that one of the consequences of increased
availability is increased abuse. (It's not true that "booze flowed as
readily" during the Noble Experiment as it did before and after;
cirrhosis deaths plunged by 2/3.)


Of course that isn't where the argument ends; maybe the increased level
of abuse is a price worth paying to avoid the bad consequences of the
illicit market, and of enforcement. But that's where any honest
argument has to start: how much more abuse are we going to have as a
result of a given change in the laws? And that's where Nadelmann &
Co. relentlessly refuse to start it. Their "vigorous and informed
debate" refuses to face the basic trade-off involved.

As I keep saying, there is no ideal or problem-free drug policy. The real question is what problems are we most willing to tolerate and how do we minimize them.

Note that, in spite of the false binary world of Nadelmann and others, Kleiman is not a neo-prohibitionist or a drug warrior. He wants strategies that don't clog the criminal justice system and jails with possession cases or low level dealers.

That's the honest debate we ought to be having: just what should we
permit and what should we prohibit, and how should we go about
enforcing those prohibitions, to steer between the Scylla of drug abuse
and the Charybdis of prohibition side-effects?



David Kennedy has shown in North Carolina that it's possible to break up street drug markets, thus protecting neighborhoods, with a very small number of arrests. Steve Alm has shown in Hawai'i that it's possible to keep probationers off meth and out of jail with frequent tests and reliable but mild sanctions. Phil Cook persuasively argues that alcohol is now grossly under-taxed in the U.S. and that we are all "paying the tab" for cheap booze.
Yet the Drug Policy Alliance has been conspicuously silent on all of
this, and Nadelmann keeps writing the same essay he's been writing
since the mid-70s.

Choice and addiction

I just listened to this podcast on choice. I'm only half way through and, so far, it has said nothing about addiction, but it's content is very relevant to addiction.

First, a little background. We know that the limbic system and frontal cortex both play important roles in addiction. The limbic system (The primitive part of the brain that controls drives for food and sex. It's the "go" part of the brain.) responds very strongly to drug cues in drug addicts, and the frontal cortex (The rational part of the brain that weighs the pros and cons of decisions. It might be thought of as your brain's brakes that help prevent you from making impulsive decisions.) appears to be impaired in drug addicts. Loss of control is attributed to this disrupted balance between the limbic system and the frontal cortex.

Back to the radio show. In the first segment, it talked about an experiment that seems to demonstrate the power of this disrupted balance. Subjects were led into a room one by one and given a number to remember. One group was given a 2 digit number and the other group was given a 7 digit number. They were asked to report to another room down the hall and recite the number to the researcher in the other room. On their way to the other room they were stopped by someone offering them a snack--a choice between a piece of chocolate cake and an apple. The subjects who were given a 2 digit number overwhelmingly chose an apple and the subjects who were given a 7 digit number overwhelmingly chose the cake.

Why? Here are 3 assumptions that the researchers made when explaining the results:

1. That cake is the prefered snack of the "emotional brain"--it's tasty and sweet. I'm assuming that emotional brain and the limbic system are the same or overlap.
2. That an apple is the preferred snack of the rational brain--it's healthy and you won't have any regrets.
3. The remembering 7 digits places demands on the rational brain. It is the part of the brain involved in remembering this kind of information on a short term basis.

The researchers believe that the subjects trying to remember 7 digits chose chocolate cake because their rational brain was focused on remembering the numbers and was not able to fully engage in the snack decision to steer the person toward the healthy low-regret snack.

Think about that for a minute.

These are subjects with healthy, normal limbic systems and frontal cortexes. This relatively minor distraction had a significant impact on subject choices. Imagine people with ramped up emotional brains and impaired rational brains. The loss of control in addiction becomes easier to comprehend.

Alcohol prohibition = drug criminalization?

I've recently expressed a preference for a shift from a focus on medical to a more honest debate on legalization.

Well, here it is.

I've posted extensively about this subject before. (Look here and here.) Here are a few thoughts:

• Prohibition did reduce alcohol use. This point isn't to defend alcohol prohibition, rather to suggest that legalization of drugs will result in increased drug use.
• Why is alcohol policy pointed to as a model. Doe we really want the ubiquitous marketing and consumption of alcohol to be replicated with drugs?
• He offers a false choice between the status quo of insane incarceration rates and legalization. There's a lot of room in between.
• All drug policies will bring problems, the question is, which problems are we willing to live with and how can we minimize them?
• Developing a dependence on tax revenue from the sale of drugs strikes me as a pretty bad idea.
  
• I'd like to end use of the phrase "war on drugs" (WOD), but the failure of the current tactics in the WOD to end drug use isn't really a good argument for ending the WOD. It's an argument for revisiting the tactics and goals, but it does not mean that the goals should be abandoned. For example, of we have a war on organized crime and organized crime persists, does it mean that the goal of minimizing or eliminating organized crime should be abandoned?
  

Giving addicts $ for research participation

I don't know what to think about this. The researchers found that giving subjects money for participating in research on cocaine addiction does not increase cocaine use in the days following the study. They gave the subjects between $150 and $300.

I'm kind of skeptical, but open to having my assumptions challenged if larger future repeat these outcomes.

A couple of subject traits seem important to me. For obvious reasons, the severity and pattern of their dependence might be important, and their income or access to money might be important. If having $150 to $300 is no big deal, then it seems a lot less likely to lead to increased use. The subjects of this study report an average 10 to 12 days of cocaine use per month, and average of $50 to $100 per day of use, and total monthly use of $600 to $1000. (Ranges are because of differences in subject groups.) This is less than what a typical cocaine addict reports at admission to residential treatment at Dawn Farm. Also, more than half were employed. These data points don't suggest manipulation, but leave room for questions about response differences.

If these outcomes are supported in chronic, severe cocaine addicts, doesn't this raise big questions about our understanding of addiction--that you can hand a cocaine addict $300 and that are not very likely to buy cocaine with it?

It's worth noting that these researchers have an interest in finding that this kind of compensation does not adversely affect participants.



 

Parity

The National Association of Addiction Treatment Providers has issued a new document offering some pretty detailed analysis (but not too long) of what the new parity law will mean.

I'm glad it finally passed. It won't mean equity, but it's a step in the right direction.

1 in 5 young adults has personality disorder

Come on. 20% of young people have a personality disorder? Wikipedia (not my favorite source, but I'm short on time.) offers this definition of personality disorders:

Personality disorders are defined by the American Psychiatric Association (APA) as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it". ^[1] These patterns, as noted, are inflexible and pervasive across many situations, due in large part to the fact that such behavior is ego-syntonic (i.e., the patterns are consistent with the ego integrity of the individual), and therefore, perceived to be appropriate by that individual.

8% with obsessive compulsive personality disorder? 12% with anxiety disorders?

Counting substance abuse, the study found that nearly half of young people surveyed have some sort of psychiatric condition, including students and non-students.

So, if a young person is seated in from of a psychiatrist, they have a 1 in 2 chance of being diagnosed with a psychiatric condition?

If the only tool you have is a hammer, everything starts to look like a nail.

Medical marijuana victory

The U.S. Supreme Court declined to hear a California case on the matter.

Beginnings, projects, designs and expectations

I saw Joe Biden quote Emerson at a Governor's conference today. The quote referred to the U.S. as, "a country of beginnings, of projects, of designs, and expectations."

The expression really caught my imagination. Isn't that what a good addiction treatment or outreach program needs to be?

More posts on hope here.