The American addiction treatment landscape

Nothing too exciting in the treatment facility survey. A few interesting contrasts between methadone providers and other providers:

• Half (50 percent) of OTPs (opioid treatment programs) were operated by private for-profit organizations, compared to 29 percent of all substance abuse treatment facilities.
• Facilities with OTPs providing substance abuse treatment services were most likely to offer outpatient treatment (94 percent), but least likely to offer residential (non-hospital) or hospital inpatient treatment (7 percent each).

Another interesting data point:

• Over half (55 percent) of all OTPs provided both maintenance and detoxification. Thirty-seven percent provided maintenance only, and 8 percent provided detoxification only.

I don't know of any local programs offering detox. They're all maintenance. I wonder if they reported that they offer detox. There are either significant differences in OTPs in southeastern Michigan and the rest of the country, or there are differences between what they report offering and what they actually offer.

It also reported that 8% of facilities offer OTP, which is pretty stable. However, 23% of all clients received methadone (Am I reading that correctly?), up a little more than 2% over the last few years.

Comments on methadone posts here often complain that there is too little methadone treatment available, but what percentage of treatment seekers are opioid addicts and what percentage of those prefer methadone? Do they comprise more than 23% of all treatment seekers?

Another frequent complaint is that 95% of all treatment programs ram the 12 steps down clients throats. Here's a table that reports the clinical practices used by surveyed programs. 12-step approach was less popular than CBT and relapse prevention.

Alcohol use disorder prevalence

I saw this yesterday and feared that alcoholism research was going the same route as research on psychiatric prevalence--finding implausibly high rates of disorders.

A 20% lifetime rate of dependence for men would either be false or demonstrate the uselessness of dependence criteria. Reading the press release left me confused about whether that 20% figure was dependence or the sum of dependence AND abuse.

This Join Together research summary suggests that it is the latter. (Whew! Especially since Marc Schuckit is the lead author. I'd be very disappointed if his research began to look unreliable.)

Some data points of interest about early use and disorder onset:

• The usual age of first drinking, independently of the family, is about 15 years and has not changed much in decades. This age does not differ much for those who go on to develop alcohol-use disorders and those who do not, although an earlier onset of regular drinking is associated with a greater likelihood of later problems.
• The period of heaviest drinking is usually between 18 and 22 years of age, and also does not differ much between those with future alcohol-use disorders and the general population.
• More than 60% of teenagers, even those without alcohol-use disorders, have experienced drunkenness by the age of 18 years, and about 30% have either given up events such as school or work to drink, or have driven while intoxicated.
  
• The period of heaviest drinking is usually between 18 and 22 years of age, and also does not differ much between those with future alcohol-use disorders and the general population.
• Alcohol abuse and dependence often begin in the early to mid-20s, at a time when most people begin to moderate their drinking as their responsibilities increase.

An interesting point about depression and alcohol:

• Repeated heavy drinking in alcohol-use disorders is associated with a 40% risk of temporary depressive episodes...

On abstinence vs. moderation for dependent patients:

• Abstinence is the usual goal for treatment of dependence in the USA, although efforts to control drinking, or reduce harm, are more often deemed appropriate goals in the UK and other parts of Europe. Some studies have reported that about 20% of those with alcohol dependence were able to drink moderately without problems in the previous year, but this is often temporary, and other studies indicate that fewer than 10% ever develop long periods of non-problematic drinking.

On genetic risk:

• About 40-60% of the risk of alcohol-use disorders is explained by genes and the rest through gene-environment associations.
  

Themes in drug policy

Ed at The Second Road commented on my last post that "race of the person using the drug is probably playing a role in how the public perceives the danger of that drug."

Ed is very right, though the current methamphetamine hysteria puts a white twist on the pattern. William White wrote an article on this subject and identified these themes:

1. The drug is associated with a hated subgroup of the society or a foreign enemy.
   
   
2. The drug is identified as solely responsible for many problems in the culture, i.e., crime, violence, and insanity.
   
   
3. The survival of the culture is pictured as being dependent on the prohibition of the drug.
   
   
4. The concept of "controlled" usage is destroyed and replaced by a "domino theory" of chemical progression.
   
   
5. The drug is associated with the corruption of young children, particularly their sexual corruption.
   
   
6. Both the user and supplier of the drug are defined as fiends, always in search of new victims; usage of the drug is considered "contagious."
   
   
7. Policy options are presented as total prohibition or total access.
   
   
8. Anyone questioning any of the above assumptions is bitterly attacked and characterized as part of the problem that needs to be eliminated.

Crack Babies - The Epidemic That Wasn't

It's important to remember how wrong we can be. America has a long history of drug hype that leads to bad policy.

When the use of crack cocaine became a nationwide epidemic in the 1980s and ’90s, there were widespread fears that prenatal exposure to the drug would produce a generation of severely damaged children. Newspapers carried headlines like “Cocaine: A Vicious Assault on a Child,” “Crack’s Toll Among Babies: A Joyless View” and “Studies: Future Bleak for Crack Babies.”

But now researchers are systematically following children who were exposed to cocaine before birth, and their findings suggest that the encouraging stories of Ms. H.’s daughters are anything but unusual. So far, these scientists say, the long-term effects of such exposure on children’s brain development and behavior appear relatively small.

“Are there differences? Yes,” said Barry M. Lester, a professor of psychiatry at Brown University who directs the Maternal Lifestyle Study, a large federally financed study of children exposed to cocaine in the womb. “Are they reliable and persistent? Yes. Are they big? No.”

Cocaine is undoubtedly bad for the fetus. But experts say its effects are less severe than those of alcohol and are comparable to those of tobacco — two legal substances that are used much more often by pregnant women, despite health warnings.

[hat tip: dailydose.net]

More on alcohol taxes

Powerful evidence about the social costs associated with alcohol:

Carpenter and Dobkin then electronically examined the death certificates of every 19- to-22-year-old who died in the United States between 1997 and 2005.

Young people’s alcohol consumption increases by over 20 percent as they hit their 21st birthday. Meanwhile, death rates increase by 9 percent exactly at age 21. Carpenter and Dobkin traced this further, finding that the mortality jump was largest for motor vehicle accidents, suicides, and other causes plausibly linked with alcohol use. The correlation isn’t a slam dunk, but it is close. The authors estimate that reducing the minimum drinking age by one year--as some propose--would cause 408 additional deaths every year among 20-year-olds.

...Over the past 50 years, Cook reports, the inflation-adjusted value of federal liquor taxes declined by a factor of six while the inflation-adjusted value of federal beer taxes declined by a factor of 3.6. Both taxes are well below what is required to recoup the alcohol-related “externalities” problem drinking imposes on the community.

This is crazy. Cook argues that a 10-cent tax per ounce of ethanol (the amount contained in two drinks) would reduce ethanol sales by 12 percent and would reduce motor vehicle fatalities by about 7 percent. An estimated 80 percent of these taxes would be paid by the 13 percent of American adults who are heavy drinkers. I’m not happy to impose this burden. Yet this is the very group which causes great social harm.

Medical marijuana raids

Obama said that he would end medical marijuana raids, so this story is getting some attention on the internet.

As I've said before, I'm not a medical marijuana alarmist and I don't think this is a good use of resources, but this continues to feel like an incredibly phony issue.

Here are some reviews of the "medical marijuana dispensary:

Veronica G. says "With the price of gas nowadays, not everyone can make the drive up to SF from the Peninsula. Cheers to a large healthy rotating selection that can please even some of the most descerning of medicators* (or at least raise an eyebrow or two). Props also for having in mind the "stoner on a budget" or the "day before payday" if you will, by selling in incriments as small as a gram or get the bang for your blunt buck from some shake

Not that I'd know or anything...."

Versace Shade says "No one medicates more than me. All I can say is that this spot provides high quality, top nodes of the best specifically Kens OG and Kens Purple.

BIG Fan of TRICHome K!!"

DT says "If you are on the bay grapes hype this is the club for you. Holistic Solutions always have a good selection of the best grapes in the bay.. at a good price too.. $45 an eigth will get you some dank grapes and sometimes they have some specials from like 50 - 55 .. never seen higher than that, but they usually have some amazing color or taste.

I would definitely recommend anything with the name ken in it... his granddaddy is hella tasty.. they have a cool variety of hash too.. from 15 - 80 a gram.. a couple different kindas.. right now they got:

humboldt hash for 15/g
buddha kush hash for 40/g
granddaddy kief 30/g
sour diesel high concentrate 80/g

All pretty dank."

Only one review puts it in the context of medication in any serious way.

I don't doubt that this is a serious issue for some people, but, for many, the medical angle is just that--an angle. So, instead, it would be nice if they advocated for decriminalization rather than hiding behind the medical angle.

Here's a smart take on the issue from Mark Kleiman. It's too nuanced for me to pull a quote. Read the whole thing.

Tab dump

Accurate Native history is critical to sobriety and recovery, program finds

The Drug Capitals Of America

Responsibility and Choice in Addiction

Technology improves treatment options for drug users

Pain, opiates and addiction

This is not news, but there's no reason to fear treating pain patients with opiates. Few pain patients develop problems with the drugs.

However, I'd add two side concerns that could/should be addressed in ways that do not result in inadequate pain treatment.

First, diversion is a huge problem. 12% of 18 to 25 year olds reported nonmedical use of pain relievers in the last year. This problem could be addressed without depriving patients of treatment.

Second, physicians need to be educated about addiction. I can't tell you how many clients have gone to the ER for minor injuries and were prescribed Vicodin even after they explained that they are a recovering addict and do not want anything mood altering.

Methadone provocation

Rowdy Yates makes some provocative points about cognitive impairment associated with methadone, methadone's legal status and it's social purpose (treatment vs. social control).

Enjoy.

Tylenol risks

Alix Bryan puts together a striking collection of statistics about the way Americans use over the counter medications.

More proof about the effects of alcohol taxes

They are effective at reducing alcohol related problems.

What's holding us back? These discussions get bogged down in "nanny state" and other libertarian arguments, but we never talk about how much our culture values alcohol. Certainly, that plays as much of a role as the philosophical political arguments. That never enters the conversation. Why?

[hat tip: Lawrence at Second Road]

What if you knew your child had the "alcoholic gene"

Etta at Second Road posted a great question:

What if there were an alcoholic gene? Anyone who had this gene was sure to be an alcoholic. What if you were informed your child had it?  What would you think? What would you do?

I’ve thought a lot about it and my son is now 2 years younger than I was when I took my first drink.

Clearly, there isn’t one gene that causes it. More likely there are
multiple genes that contribute to the risk of developing an addiction.

In spite of giving it a lot of thought, I haven’t come up with a whole lot.

• I’ll do what I can to postpone drinking and drug use as much as possible. Once experimentation begins, I’ll do what I can to not be an alarmist but will still minimize it in terms of frequency and quantity. Early use is associated with an increased risk of problems.
• I’ll be open and honest about my recovery–trying to normalize recovery and model a path if either of my kids develop problems.
• I’ll do what I can to foster the development of recovery capital (Recovery capital is the quantity and quality of internal and external resources that one can bring to bear on the initiation and maintenance of recovery) before they develop a problem. Hopefully, if they develop a problem, this will minimize the duration of it and the losses associated with it.
• Most of all, I'll just try to love them and recognize that this is one of those areas where my influence is limited. I just have to accept that.
  

Bill White wrote a great article calling for research in this area, you can find it here.

Moderation Management works for some

A study suggests that Moderation Management may work for people with "less severe dependence". I'd like to see them flesh out what "less severe" means. Technorati Tags: research, mutual_aid

Separate and unequal

Addicted physicians have terrific recovery rates. We know what works. Why does this two tiered approach to treatment and recovery support persist?

Abstract - A sample of 904 physicians consecutively admitted to 16 state Physicians' Health Programs (PHPs) was studied for 5 years or longer to characterize the outcomes of this episode of care and to explore the elements of these programs that could improve the care of other addicted populations. The study consisted of two phases: the first characterized the PHPs and their system of care management, while the second described the outcomes of the study sample as revealed in the PHP records. The programs were abstinence-based, requiring physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At post-treatment follow-up 72% of the physicians were continuing to practice medicine. The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence.

Freebase caffeine

Eek. Talk to your sponsor before you look at this.

I suspect that there is little to this, but whenever I see anything like this I am reminded of a talk by Bill White on drug trends. He closed by saying something like, "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 they will become a problem when someone develops new ways to use them."

School drug testing outcomes

Not good:

Overall, drug testing was accompanied by an increase in some risk
factors for future substance use. More research is needed before random
drug and alcohol testing is considered an effective deterrent for
school-based athletes.

Hope for addicts

From the new White House website:

• Reduce Crime Recidivism by Providing Ex-Offender Support: President Obama and Vice President Biden will provide job training, substance abuse and mental health counseling to ex-offenders, so that they are successfully re-integrated into society. Obama and Biden will also create a prison-to-work incentive program to improve ex-offender employment and job retention rates.
• Eliminate Sentencing Disparities: President Obama and Vice President Biden believe the disparity between sentencing crack and powder-based cocaine is wrong and should be completely eliminated.
• Expand Use of Drug Courts: President Obama and Vice President Biden will give first-time, non-violent offenders a chance to serve their sentence, where appropriate, in the type of drug rehabilitation programs that have proven to work better than a prison term in changing bad behavior.

It's a start.

The Amethyst Initiative

A while back I wrote about efforts to lower the drinking age.

Here's a thoughtful, but somewhat ambivalent argument for lowering the drinking age to 18.

Twenty-nine states lowered their minimum age by 1975. I and a colleague analyzed the effects on highway fatalities, finding that the relevant age group experienced about a 10% increase in states that lowered their age for all beverage types from 21 to 18, compared with states that didn’t change their law. Other research documented this and other indications of increased abuse. President Reagan appointed a commission that documented the problems (with some exaggeration) and ultimately sold Congress on establishing a national minimum.

(Note that we analysts could recite all the theoretical reasons why an age-based prohibition could have perverse effects on health and safety. Those arguments have some truth, but were ultimately trumped by the data. The net effect of lowering the minimum age was to increase alcohol abuse.)

...

Yet giving 18-20 year olds the right to drink has a lot going for it. After all, 18 year olds currently can vote, serve on juries, and hold most public offices, enlist in the military or work at any job without parental consent, undertake contractual obligations including marriage, and legally purchase lottery tickets, cigarettes, and shotguns. They are held fully accountable for criminal acts and are too old to receive the protection of the statutory rape laws.

It is also true that while the minimum age law does some good, it’s widely violated – in fact, it’s hard to think of another law that is so widely scoffed at. The great majority of older teens choose to drink, with whatever effect that may have on their respect for the law generally.

It's good to see someone wrestling with the subject in an intellectually honest manner.

I doubt that there will be movement in this direction, but if there is, I'd hope that the requirement would be lowered to 18 with a high school diploma and 19 without. This might help reduce access for high school students.

 

Trauma and parental responses to homosexuality

Here are a couple of links to loosely related topics. Loosely related because rates of substance use disorders (SUDs) are higher among LGBT people and people with PTSD.

First, a post about a researcher who theorizes that playing Tetris shortly after a traumatic experience may reduce the incidence of PTSD. The idea is that occupying the parts of the brain that play a role in memory consolidation will interfere with traumatic memories becoming so entrenched and powerful.

One earnest question. Would playing Tetris during study breaks interfere with remembering studied material?

Next, a post about the damage cause by parental rejection of homosexual children:

The odds ratios reported indicate that a homosexual youth experiencing high levels of rejection by family have a risk of attempting suicide as much as 8 times more than those experiencing little or no rejection by family. Looking at the raw numbers, this means as many as 67 percent of study subjects in the high rejection group had attempted suicide by age 25! Illicit drug use, substance abuse disorders, and risky sexual behaviors are also similarly increased in this group. The apparent effect of family rejection is devastating.

Needle Exchanges Save Lives but May Imperil Workers

From the Wall Street Journal:

Pete Morse devoted his life to saving the lives of heroin users. A dreadlocked community activist with a Ph.D in history, he bore a tattoo that read: "Injury to one is an injury to all."

So his friends and colleagues were shocked when he was found unconscious in 2007 on a bathroom floor with a needle by his side. Doctors pronounced the 36-year-old Mr. Morse dead from an overdose of heroin, alcohol and cocaine.

Mr. Morse spent more than 10 years working in drug-addiction programs that follow the principle of harm reduction. This philosophy argues that the best way to save users' lives isn't to force them off illegal drugs. Instead, its adherents teach safer ways to use drugs -- supplying clean needles to prevent the spread of disease, for example, or teaching how to avoid overdosing. The programs are credited with saving lives in cities across the U.S.

To my mind, this is no indictment of harm reduction per se. I see this as a symptom of one of my biggest reservations about many harm reduction programs--that they don't view addictive drug use as an illness. Rather, many programs treat it as a lifestyle choice and that to promote recovery is to moralize.

Because harm-reduction programs don't force their clients to quit, making employees do so would be "completely hypocritical," said Ms. McQuie, the West Coast director of the Harm Reduction Coalition, a New York-based nonprofit that trains workers to run needle exchanges and other harm-reduction programs....

...Mr. Morse never stopped identifying as a user. In counseling with clients, the tattooed and dreadlocked Mr. Morse listened silently and, based on his own use and drug knowledge, explained how certain prescription drugs interact with heroin, recalls Kirk Read, who worked with Mr. Morse gathering data for a drug-user study for the University of California.

I'm sure that some will disagree with me, but is it possible to for a program like this to effectively encourage recovery? I'm sure it gives lip service to recovery, but I can't imagine it's interested in doing so, and I doubt that it could if it wanted to.

It's unlikely that I'll be taken seriously, given that I'm viewed as an enemy of harm reduction, but harm reduction has a lot of house cleaning to do. (Just as abstinence oriented programs did when harm reduction began its ascension.) I hope to see more programs adopting recovery-oriented harm reduction approaches.

Sharing our stories

Fighting stigma is important to me. I believe stigma is the most powerful barrier we face.

• It drives professionals to develop "treatments" based on the expectation that we cannot recover.
  
• It drives families to give up on us.
  
• It makes our communities to fear us and choose to protect themselves by locking us up.
  
• It makes financial interests decide that providing care to us is a waste of money.
• It makes faith communities define the problem as sin.
• It makes us turn on our own. How many addicts have you seen share at tables about their powerlessness and addiction as an illness, but then treat chronic relapsers with scorn and disdain, telling them that they "just don't want it" or "haven't made a decision".

Like any other stigmatized group, we need to reduce our "otherness". It seems that the best way to reduce our "otherness" is to tell our stories, let other people know that we are their sons, daughters, fathers, mothers, nieces, nephews, cousins, neighbors, employees, employers, PTA parents, parishioners, doctors, lawyers, teachers, mechanics, plumbers, etc.

So, I know that we need to tell our stories, but I think we need to be careful about the way we tell our stories. There is so much danger of self-enoblization(sp?), narcissism, fetishization, etc. There's constant risk of making ourselves a spectacle rather than humanizing addicts and normalizing recovery.

I keep coming across links to these books and I've resisted linking to them. I don't know enough about them to judge them, but the stylized, dramatic photos for one of them make me squeamish.

So, how do we tell our stories in ways that minimize this risk? I'm not sure I know the answer. I think that drunkalogues do little to help us. I suspect that modesty and humility when sharing our recovery are important. Maybe to keep in mind that the purpose of telling our stories is to illuminate addiction and recovery rather than aggrandizing ourselves and our struggle.

In any event, I'm excited about this:

From Billboards

Drug Companies & Doctors: A Story of Corruption

Ezra Klein directs us to a NY Times Book Review piece on doctors, research, evidence-based medicine and drug companies:

Conflicts of interest affect more than research. They also directly shape the way medicine is practiced, through their influence on practice guidelines issued by professional and governmental bodies, and through their effects on FDA decisions. A few examples: in a survey of two hundred expert panels that issued practice guidelines, one third of the panel members acknowledged that they had some financial interest in the drugs they considered. In 2004, after the National Cholesterol Education Program called for sharply lowering the desired levels of "bad" cholesterol, it was revealed that eight of nine members of the panel writing the recommendations had financial ties to the makers of cholesterol-lowering drugs. Of the 170 contributors to the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), ninety-five had financial ties to drug companies, including all of the contributors to the sections on mood disorders and schizophrenia. Perhaps most important, many members of the standing committees of experts that advise the FDA on drug approvals also have financial ties to the pharmaceutical industry.

Combine this with my recent posts about publication bias and researcher allegiance effects and it's enough to make a cynic wonder if they've mustered sufficient skepticism. Oy.

Most popular posts in 2008

1. Alcoholics Anonymous (AA) Recovery Outcome Rates: Contemporary Myth and Misinterpretation
2. Heroin Anyone?
3. The History of Gay People in AA
4. FDA fast-tracks first cocaine, meth addiction fighter
5. The super adventure club helps kids say "no"
6. What Addicts Need
7. Narcan outrage
8. More on recovery in the U.K.
9. Co-occurring Social Anxiety and Alcohol Use Disorders
10. More from Pat Deegan
11. Cocaine self-medication for insomnia
12. Kicking methadone in the U.K.
13. Sick of watching people die
14. Recovery and the Conspiracy of Hope
15. Drug policy freak show

Loose associations

People who know me well know that I often make loose associations that leave other people scratching their heads. Here are two loosely related articles that I wanted to draw your attention to.

First, an article on batterer's intervention programs that provides an overview of some of the history and the philosophical tensions that exist among programs.

Second, an article on happiness as a social phenomena.

While there are many determinants of happiness, whether an individual is happy also depends on whether others in the individual’s social network are happy. Happy people tend to be located in the centre of their local social networks and in large clusters of other happy people. The happiness of an individual is associated with the happiness of people up to three degrees removed in the social network. Happiness, in other words, is not merely a function of individual experience or individual choice but is also a property of groups of people. Indeed, changes in individual happiness can ripple through social networks and generate large scale structure in the network, giving rise to clusters of happy and unhappy individuals. These results are even more remarkable considering that happiness requires close physical proximity to spread and that the effect decays over time.

The findings could be understood as an affirmation of the importance of communities of recovery. It also might provide more concrete support for advice to "stick with the winners". [hat tip: wired in]

Helping heals

More evidence for the healing power of one alcoholic helping another.

Oww, Oww...Ahhh

How many addicts do you know that love spicy food? I know quite a few.

TASTELESS, colourless, odourless and painful, pure capsaicin is a curious substance. It does no lasting damage, but the body’s natural response to even a modest dose (such as that found in a chili pepper) is self-defence: sweat pours, the pulse quickens, the tongue flinches, tears may roll. But then something else kicks in: pain relief. The bloodstream floods with endorphins—the closest thing to morphine that the body produces. The result is a high. And the more capsaicin you ingest, the bigger and better it gets.

Publication bias

PLoS has an article taking an economist's look at the publication process for pharmacological studies. The paper offers some potential remedies:

Potential Competing or Complementary Options and Solutions for Scientific Publication

1. Accept the current system as having evolved to be the optimal solution to complex and competing problems.
2. Promote rapid, digital publication of all articles that contain no flaws, irrespective of perceived “importance”.
3. Adopt preferred publication of negative over positive results; require very demanding reproducibility criteria before publishing positive results.
4. Select articles for publication in highly visible venues based on the quality of study methods, their rigorous implementation, and astute interpretation, irrespective of results.
5. Adopt formal post-publication downward adjustment of claims of papers published in prestigious journals.
6. Modify current practice to elevate and incorporate more expansive data to accompany print articles or to be accessible in attractive formats associated with high-quality journals: combine the “magazine” and “archive” roles of journals.
7. Promote critical reviews, digests, and summaries of the large amounts of biomedical data now generated.
8. Offer disincentives to herding and incentives for truly independent, novel, or heuristic scientific work.
9. Recognise explicitly and respond to the branding role of journal publication in career development and funding decisions.
10. Modulate publication practices based on empirical research, which might address correlates of long-term successful outcomes (such as reproducibility, applicability, opening new avenues) of published papers.

Happy New Year!

It could be media hype (Hard to know from thousands of miles away, but reports have been consistent and objective measures, like cirrhosis rates, seem to support it.), but something seems to be very wrong with England's drinking culture.

What's up with this? American discussions about binge drinking seem to focus on college-aged drinkers and drinking age. Clearly not the issue in England.