Another tribe

I just learned about Phoenix Multisport. I only know what it says on the website, but it looks like an amazing example of the diversity within and the potential of the recovering community. The recovering community (as wells as the tribes within it) never fails to inspire me.

Heroin's toll

The New York Times follows heroin's trail in Ohio:

Paul Coleman, the director of Maryhaven, the largest rehabilitation center in the region, said the percentage of patients reporting opiates, principally heroin, as their preferred drug — whether it is smoked, inhaled or injected — grew to 68 percent last year from 38 percent in 2002.
. . .
In Ohio, for instance, heroin-related deaths spread into 18 new counties from 2004 to 2007, the latest year for which statistics are available. Their numbers rose to 546 in that period, from 376 for 2000 to 2003.
. . .
The share of heroin-related prosecutions among federal drug cases in this region has also been climbing, reaching 15 percent of cases last year compared with 4 percent a decade ago.

Dawn Farm has seen an increase in heroin admissions at Detox (21% in 2002 to 30% in 2008) and residential treatment at the Farm (23% in 2002 to 39% in 2008).

Technorati Tags: heroin, opiates, overdose, trends, drugs. addiction

Shoveling Up II: The Impact of Substance Abuse on Federal, State and Local Budgets

CASA has pulled together a report that attempts to capture all of the costs of substance abuse in federal, state and local governments.

The report says that Michigan spends 18.2% its entire budget on substance abuse and addiction and its consequences. Only 0.2% goes to prevention and treatment.

If you line in another state, you can find its info here.

Technorati Tags: spending, treatment, prevention, michigan

their every truth...

...most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion. This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true. Their two is not the real two, their four not the real four: so that every word they say chagrins us and we know not where to begin to set them right. ~ Emerson

Oy. What is there to say about this? Where to begin?

New research?

Co-occurring disorders are proof that addiction isn't a disease?

That some people experience natural recovery is proof that it's not a disease?

That impaired pilots abstain at high rates is proof that there is no loss of control?

Technorati Tags: disease, addiction, choice

Pot Policy

More discussion of pot (and other drug) policy:

• Comment: Get real, drug czars by Robin Room
• What Would Happen if Marijuana Were Decriminalized? A Freakonomics Quorum
  

Technorati Tags: marijuana, policy

The recovery revolution: news from the front

Here's a presentation with audio from Bill White in the U.K.

I'm glad to see that he's addressing palliative care models. I've seen similar talks from him on several occasions and this is new to me. I mentioned in an earlier (and controversial) post that his description of MMT was different from my experience.

Treatment providers have long been troubled by the psychiatricizing of addiction. The mental health system is far larger and far more powerful. Fear of being "colonized and devoured" led to a kind of hunkering down that bred unhealthy skepticism (As opposed to healthy and appropriate skepticism.) of research, new treatment models, medications and any integration of mental health in addiction services. This response may have ensured the survival of a fraction of the addiction treatment system, but it stunted growth and was unsustainable. Bill's approach this problem was different than other treatment advocates. Rather than pile on mental health providers, he acknowledged the history and sought to engage the mental health system by offering a vision of a recovery-oriented system of behavioral health care. Offering recovery as the organizing paradigm had the potential to address what's wrong with both systems and minimize conflict over details by focusing everyone on facilitating recovery. This process is still unfolding, so we don't know how it will end but an attempt to maintain the status quo would have likely ended in a complete collapse of the specialty addiction treatment system.

Bill is clearly trying to do the same thing with MMT--sidestep the historic tensions by unifying drug-free and medication-assisted treatment providers around recovery. The addition of references to palliative care models seems to be a challenge to medication-assisted programs in the same manner he has challenged drug-free treatment providers to abandon acute care models.

Prescription Opioid-related Deaths Increased 114 Percent from 2001 to 2005

From the ONDCP:

Prescription Opioid-related Deaths Increased 114 Percent
from 2001 to 2005, Treatment Admissions Up 74 Percent in Similar Period; Young Adults Hardest Hit

(Washington, D.C.)—Today, Gil Kerlikowske, Director of National Drug Control Policy, released a report on the diversion and abuse of prescription drugs at the National Methamphetamine Pharmaceutical Initiative (NMPI) in Nashville. The report finds non-medical use of prescription drugs a serious threat to public health and safety, with unintentional deaths involving prescription opioids increasing 114 percent from 2001 to 2005, and treatment admissions increasing 74 percent in a similar four-year period.

T he National Prescription Drug Threat Assessment (NPDTA) was prepared by the National Drug Intelligence Center (NDIC) in conjunction with the Drug Enforcement Administration (DEA). It synthesizes reports and data from law enforcement and public health officials to evaluate the threat posed by the distribution, diversion, and abuse of controlled prescription drugs in the United States. Non-medical use of prescription drugs (pain relievers, stimulants, tranquilizers, and sedatives) is most prevalent among young adults—individuals aged 18 to 25. From 2003-2007, approximately six percent of this age group reported non-medical prescription drug use in the past month.

Among the general population, nonmedical use of controlled prescription drugs was stable from 2003-2007, with 7 million Americans, aged 12 and older, reporting past month nonmedical use of prescription drugs. Pain relievers are the most widely diverted and abused, with one in five new drug abusers initiating with potent narcotics. Diversion and abuse of controlled prescription drugs cost public and private medical insurers an estimated $72.5 billion per year.

Director Kerlikowske released the report at NMPI, an annual ONDCP and High Intensity Drug Trafficking Area program initiative that gathers over 300 law enforcement officials to address methamphetamine and illicit pharmaceutical production and diversion through strategy development, intelligence sharing, and training. Diversion and abuse of prescription drugs are a threat to our public health and safety—similar to the threat posed by illicit drugs such as heroin and cocaine, said Director Kerlikowske. In 2006, the last year for which data are available, drug-induced deaths in the United States exceeded firearm-injury deaths and ranked second only to motor vehicle accidents as a cause of accidental death. Law enforcement and healthcare communities must work together to help address prescription drug abuse, addiction, and the public safety consequences of diversion.

In presenting the report to ONDCP, Michael T. Walther, NDIC Director stated, The National Prescription Drug Threat Assessment provides a comprehensive overview of the misuse and abuse of prescription drugs—a problem sometimes overlooked in the focus on illicit drug abuse. The report represents the first comprehensive assessment of emerging trends based on current law enforcement, intelligence, and public health reporting and data from Federal, state, and local agencies throughout the United Sates.

Today's report validates the disturbing trend of increasing prescription drug abuse within the United States, said DEA Acting Administrator Michele M. Leonhart. When abused, not only are these drugs dangerous in their own right, they often lead to the use of harder drugs, with life-altering consequences. We in law enforcement are committed to being part of a comprehensive solution, using tools such as the recently implemented Ryan Haight Online Pharmacy Consumer Protection Act, to defeat those who push diverted pharmaceuticals into the hands of those who abuse them.

Despite strident regulations for dispensing controlled substances, prescriptions drugs, especially pain relievers, are acquired illegally, most frequently from friends or family or by doctor-shopping, prescription fraud, and theft. Rogue Internet pharmacies are also a significant source of diverted prescription drugs, and increasingly, street gangs are involved in the illicit distribution of diverted pharmaceuticals.

Key Findings

Prescription Drug Abuse: Over 8,500 deaths nationwide involved prescription pain relievers in 2005, the latest year for which data are available, an increase of 114 percent since 2001. Emergency room visits for nonmedical use of pain relievers increased 39 percent from 2004 to 2006. Treatment admissions for prescription opioids increased 74 percent from 2002 to 2006. Nearly one third of individuals who began abusing drugs in the past year reported their first drug was a prescription drug: 19 percent indicated it was a prescription opioid. Thus, 1 in 5 new drug abusers are initiating use with potent narcotics, such as oxycodone, hydrocodone, and methadone.

Prescription Drug Diversion: Diverted controlled prescription drugs are often more readily available than heroin in all drug markets. Opioid pain relievers are the most commonly diverted. Diversion methods include prescription drug fraud, theft, rogue Internet pharmacies, and friends and relatives—the primary sources of controlled prescription drugs for most abusers.

Regional Deviations: Although diversion and abuse of controlled prescription drugs is highest in eastern states, violent and property crimes associated with prescription drug diversion and abuse have increased in all regions of the United States over the past 5 years.

Figure 1. Past Year Initiates for Specific Illicit Drugs Among Persons 12 or Older (2007)

In 2007, more than 2 million people who previously had not abused pain relievers reported misusing prescription opioids for the first time. This category of drugs includes powerful narcotics such as oxycodone, hydrocodone, and methadone.

The National Prescription Drug Threat Assessment 2009 can be found at
http://www.usdoj.gov/ndic/pubs33/33775/index.htm
http://www.usdoj.gov/ndic/pubs33/33775/33775p.pdf

Technorati Tags: opiates, rx, treatment, youth

Uber Hip Harm Reduction

via: dailydose.net

Technorati Tags: harm reduction, UK

Needle Exchange and Human Rights

How did needle exchanges get on the human rights agenda and why doesn't treatment access rank?

Technorati Tags: needle exchange, addiction, harm reduction, addiction

Addiction: Could it be a big lie?

Coming soon to 20/20.

A devotee of behavioral economics rips into addiction-as-a-disease. He will argue that when the costs become great enough, addicts quit. The basis for their skepticism is a disbelief in loss of control. More on that line of thought here and here.

The article does a good job stating the stakes of giving this fringe too much attention:

If hardly a controversial topic to those other than the small group of dissidents who want it to be, the semantic disease-or-not debate has important practical implications. How addiction is viewed affects how addicts are treated, by the public and by medical professionals, and how government allocates resources to deal with the problem.

UPDATE: The 20/20 reference is not referring to an actual upcoming show, just the fact that John Stossel's libertarian philosophy and disease model skepticism are sure to attract him to this book.

Technorati Tags: behavioral economics, addiction, choice

Not self-medication

Another study finds that depression tends to follow alcohol problems rather than cause alcohol problems. My guess is that the popularity of self-medication theories won't suffer at all. Why is that?

Conclusions - The findings suggest that the associations between AAD and MD were best explained by a causal model in which problems with alcohol led to increased risk of MD as opposed to a self-medication model in which MD led to increased risk of AAD.

This is a longitudinal study. I look forward to seeing more about the responses to treatment for alcoholism and depression.

Technorati Tags: depression, alcoholism, research

Another Vaillant project

The Atlantic has an article about George Vaillant's longitudinal study of the physical and mental well-being of a cohort that were Harvard sophomores in 1937. The article looks at some of the study's insights into happiness.

People unfamiliar with Vaillant are probably wondering what this has to do with the focus of this blog. This particular study has little to do with it but Vaillant id the author of The Natural History of Alcoholism, based on another longitudinal study of a alcoholism.

Technorati Tags: happiness, research

A hard question

The New York Times has a nice piece on the cognitive dissonance that a lot of baby boomers feel about marijuana legalization.

Technorati Tags: marijuana, drugs, policy, addiction

Obama and needle exchange

Looks like he's balking at lifting the ban.

I honestly don't know if it's fair to characterize congressional reluctance to overturn the ban as pure politics or if it's still just fear of being cast as soft on drugs. I'm sure it's true of many. Maybe most.

I'd support overturning the ban, but it's a hard thing to muster much enthusiasm for. I look at the photo in story of disposed syringes at a needle exchange and it breaks my heart. It's hard not to see each of those needles as lost dreams, broken families, suffering communities, and pain and despair for countless people who are affected directly and indirectly.

I understand people being reluctant to purchase needles for someone to inject heroin, meth or cocaine. I understand feeling like it would be participating in someone's illness (rather than their recovery) or participating in their self-destruction. What's the alternative? To help people get well. We know how to do it. Programs for impaired health professionals serve large numbers of injection drug users with great outcomes. But, sadly, we haven't done that either. Effective treatment of adequate intensity and duration are out of reach for most people who need it. Instead, we seem to look away. We don't know how to help every one of those injection drug users recover, but we know how to help a lot of them. We CHOOSE not to do so.

I hope the ban is lifted. I hope that we're able to prevent addicts from getting Hepatitis C and HIV. Some people have bad reasons for opposing needle exchanges, but a lot of people have better reasons and still more just can't bring themselves to be pro-needle exchange. It seems to me that this message would have a lot more appeal if was about helping people get well, rather than just preventing them from getting sick. So, I hope that we do more than simply prevent them from contracting diseases. I hope we offer them an opportunity to recover--every one of them.

It's also worth noting that last time I looked (it's been a few years)
the number overdose deaths was three times the number of new cases of
HIV. 

We're not at war with people in this country

A welcome change in rhetoric:

The Obama administration's new drug czar says he wants to banish the idea that the U.S. is fighting "a war on drugs," a move that would underscore a shift favoring treatment over incarceration in trying to reduce illicit drug use.

In his first interview since being confirmed to head the White House Office of National Drug Control Policy, Gil Kerlikowske said Wednesday the bellicose analogy was a barrier to dealing with the nation's drug issues.

"Regardless of how you try to explain to people it's a 'war on drugs' or a 'war on a product,' people see a war as a war on them," he said. "We're not at war with people in this country."

Bill White on Methadone and Recovery

I love Bill and have enormous respect for him. This is not the first time I've heard him express these opinions and I respect where he's coming from, but it's just not been my 18 years experience in Southeastern and central Michigan. Just last week I admitted another 19 year old who had been going to a dosing clinic, getting no real counseling, no real recovery and little help when he asked to be detoxed so that he could pursue drug-free recovery. These are the kinds of stories I hear without exception. I recognize that my contact might be limited to a non-representative sample, but I've never even heard someone say something like, "Other people were doing well on it, but it wasn't for me." or "The people there really cared and treated me well, but I decided I needed something else." I've yet to meet a person on methadone at a professional conference as a success story. I've interviewed countless professionals seeking to leave methadone clinics--including people who don't have any connection to 12 step recovery. Methadone seems to be the dominant approach in the U.K. and it appears to be wrought with the same kinds of problems I see locally and the same pessimism about the capacity of opiate addicts to recover.

It's a crime if there are all sorts of great methadone recovery stories and stigma is preventing them from being heard, but I'm skeptical.

Bill has a history of doing a great job of delivering difficult messages to drug-free treatment providers. Methadone providers need to be challenged in the same manner. If drug-assisted treatment is ever to have a place in a recovery-oriented system of care, it seems to me that the providers in my area need a dramatic culture change.

UPDATE: Just to be sure that my position is understood. I'm not advocating the abolition of methadone.

Here's something I wrote in a previous post: "All I want is a day when addicts are offered recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose."

Another: "Once again, I'd welcome a day when addicts are offered recovery oriented treatment of an adequate duration and intensity and have the opportunity to choose for themselves."

It's also worth noting that there is a link between AA and methadone.

the Prozac moment

Mark Willenbring dreams of the day that addiction is treated by primary care docs:

...Dr. Willenbring, an expert on treating alcohol addiction, predicts that the day is not far off when giving a pill and five minutes of advice to an alcohol abuser will be all that is needed to keep drinking under control.
...
“We’re at the same place with alcohol abuse that the treatment of depression was at 40 years ago, when only psychiatrists treated it and most people with depression were never treated at all,” said Dr. Willenbring, the director the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism.

Then came Prozac, followed by similar antidepressants that took the treatment of depression out of mental hospitals and psychiatric offices and put it in homes and in the offices of primary care doctors.

“Now almost all of depression is treated in primary care,” Dr. Willenbring said, “and two-thirds to three-fourths of depression is getting treated.”

But with alcohol dependence, he said, only one person in eight receives professional treatment.

He acknowledges that this is not a likely possibility for the kind of people who currently enter residential and inpatient treatment:

“Those who get into treatment programs are the most severe alcoholics,” Dr. Willenbring said. “But the bulk of alcohol abusers have a more moderate form, with a better prognosis. Most could get well in primary care settings and not have to wait until they are at the end of their rope and forced to go into a rehabilitation program, which can be so stigmatizing.”

What is needed for controlling alcohol abuse early in the disease, he said, are drugs like Prozac that can be easily prescribed by primary care physicians to help people with moderate alcohol abuse. Several such drugs are now in the pipeline, Dr. Willenbring said.

The two already available — naltrexone and Topamax — are not yet the equivalent of Prozac for depression, but they can help many alcohol abusers learn to drink more moderately or abstain altogether.

I think he's got too much faith in antidepressants.

12 Step attendance and adolescent treatment outcomes

From the journal Addiction:

Aims  Twelve-Step affiliation among adolescents is little understood. We examined 12-Step affiliation and its association with substance use outcomes 3 years post-treatment intake among adolescents seeking chemical dependency (CD) treatment in a private, managed-care health plan. We also examined the effects of social support and religious service attendance on the relationship.

Design  We analyzed data for 357 adolescents, aged 13–18, who entered treatment at four Kaiser Permanente Northern California CD programs between March 2000 and May 2002 and completed both baseline and 3-year follow-up interviews.

Measures  Measures at follow-up included alcohol and drug use, 12-Step affiliation, social support and frequency of religious service attendance.

Findings  At 3 years, 68 adolescents (19%) reported attending any 12-Step meetings, and 49 (14%) reported involvement in at least one of seven 12-Step activities, in the previous 6 months. Multivariate logistic regression analyses indicated that after controlling individual and treatment factors, 12-Step attendance at 1 year was marginally significant, while 12-Step attendance at 3 years was associated with both alcohol and drug abstinence at 3 years [odds ratio (OR) 2.58, P < 0.05 and OR 2.53, P < 0.05, respectively]. Similarly, 12-Step activity involvement was associated significantly with 30-day alcohol and drug abstinence. There are possible mediating effects of social support and religious service attendance on the relationship between post-treatment 12-Step affiliation and 3-year outcomes.

Conclusions  The findings suggest the importance of 12-Step affiliation in maintaining long-term recovery, and help to understand the mechanism through which it works among adolescents.

Gil Kerlikowske, Drug Czar

From The Atlantic:

The U.S. government officially has a new drug czar: Seattle Police Chief Gil Kerlikowske sailed through his Senate confirmation process today on a 91-1 vote Thursday after passing un-contentiously through the Senate Judiciary Committee, which approved him without a recorded vote in a business meeting off the Senate floor in late April.

1990s treatment trend gets dinged

Acupuncture for detox was a hot trend in the mid 1990s. I have vague memories of it be promoted by NIDA or SAMHSA but I couldn't find a reference to it. Maybe my memory is failing me. Feel free to send me a reference if you know of one.

At any rate, Addiction Inbox looks at a recent study of acupuncture for opiate detox and an article in Alcohol: Clinical and Experimental Research reviews studies of acupuncture for alcohol dependence. Not good.

When Brute Force Fails

Mark Kleiman has a forthcoming book on criminal justice policy titled, When Brute Force Fails. I found a report by the same name on the National Criminal Justice Reference Service. It contains exactly what you would expect from Kleiman--smart on crime policy ideas that are still criminal justice oriented. Here's one example from the chapter on drug policy:

In High Point, North Carolina, the unwilling home to a major drug market that was, as usual, a source of violence and disorder, and which had been resistant to sustained routine enforcement efforts. The market, though substantial compared to the size of the city, turned out to involve only about two dozen dealers. Instead of arresting them one by one, giving replacement a chance to work, the police in High Point patiently identified all of the dealers and made the “buys” required to prepare airtight cases against them. The dealers (and, in a brilliantly seriocomic touch, their mothers) were then invited to a meeting, at which they found a solid phalanx of enforcement and prosecution officials and a group of social-service providers. They also found a set of chairs with their names on them (plus three empty chairs), and a set of loose-leaf notebooks, also labeled with their names.

The head of the High Point enforcement effort then explained that the three empty chairs were for the three most violent dealers in town, all ofwhom had been arrested that day, and that the notebooks contained the evidence on which any of the twenty-five dealers in the room could be arrested and convicted with no further investigation necessary. The shocked dealers were also told that, as of that day, the open drug market was closed, and that any one of them so much as suspected of dealing from then on would be prosecuted on the evidence already gathered and in the notebook. The social-service providers were available for those who needed various kinds of help (literacy, drug treatment, job training, housing, tattoo removal) in turning their lives around.

The result, as reported by one of the designers of the initiative, was virtually magical: the drug market dried up overnight. Two new dealers who thought they could take advantage of the sudden supply shortage in the open market were promptly arrested. The effect on the volume of drug transactions and the extent of drug abuse in the High Point area is unknown, and may not have been substantial or lasting. But the contribution to crime reduction was dramatic.

Mechanisms of change in AA

Addiction Research and Theory published a review of mechanisms of behavior change in AA.

Here's an excerpt from their conclusions:

Why have spiritually-oriented organizations, like AA, become so popular among alcohol and other drug addicted individuals and not as popular among those suffering from other kinds of mental disorders? One reason perhaps is that the disinhibiting effects from heavy alcohol and drug use frequently generate deviations from one's own moral code or set of values. Repeated over and over this “Jekyll and Hyde” scenario can lead to a sense of profound moral failing, self-blame and self-loathing. As structural and functional brain alterations caused by continued alcohol use exacerbate impairment over the regulation of drinking behavior negative feelings may intensify and be deepened and reinforced further by the reproach of affected onlookers and significant others. For many, the sense of “salvation”, historically and implicitly embedded within AA philosophy and in many other recovery mutual-help societies throughout US history (White 1998), may feel cleansing and self-soothing, providing a framework for self-forgiveness. This may account for the rather odd AA mix of spirituality and, “alcoholism as a medical disease” (see the Doctors' Opinion, xxv; AA 1939, 2001), which may have been initially a purely pragmatic hybrid constructed to alleviate common feelings of guilt, shame, and self-loathing that serve as barriers to salutary change. The attenuation of these feelings and self-perceptions as a function of AA exposure may be more specific to the spiritual/disease framework of AA and worthy of future mechanisms research.

I cringe a little at the uncritical use of disinhibition and I consider the word "salvation" to be laden with a kind of religiosity that I don't find in 12 step groups. However, the article did a pretty good job of examining the program and placed a great deal of emphasis on the growth fostering relationships within the fellowship. It's worth noting that all 12 step meetings are not created equal and that there would probably be significant variance of these mechanisms between groups.

Farm staff who would like a copy can email me.

Free will and addiction

A commentary in Addiction Research and Theory offers a 3rd way for debates about whether addicts have control over their drug use:

Our view is that the debate about free will in addiction, like the broader debate about free will in all human behavior, is unlikely to be won by either extreme view (Baumeister 2008). Self-control is an important form of what people understand as free will, and the capacity for self-control is real but limited-thus neither complete nor completely lacking. The traditional notion of willpower may be useful here, especially if one understands willpower as a kind of psychological energy that fluctuates as people use it up and then re-charge it (Baumeister et al. 1998; Vohs and Heatherton 2000). Free will is a partial, sometime thing.

There is certainly room to incorporate biological and genetic vulnerabilities in such a model. People may vary as to the reward power of drugs and alcohol: Some people get more pleasure than others from them. Social factors and personal experiences may also contribute to individual differences in such propensities. Thus, some people end up with stronger cravings than others.

Still, some freedom remains. The wine does not pour itself into a glass and thence down the alcoholic's throat. The person thus makes a choice between competing impulses: indulging pleasure now versus abstaining for the sake of nonspecific but substantial delayed gains. Choosing the path of virtuous abstention depends on willpower, however. When willpower has been depleted (such as by other acts of self-control, or even by decision making in any context; see Vohs et al. 2008), their likelihood of choosing the immediate pleasure increases.

If a disease model for addiction is to be retained, we suggest abandoning the virus or germ models in favor of something more like Type II diabetes. One does not become infected with diabetes. Rather, a natural bodily vulnerability becomes exacerbated by experiences, many of which are based on personal choices. Many people will not become diabetics regardless of what they eat, but others will suffer diabetes to varying degrees as a function of diet and exercise. Moreover (and again unlike a virus), there is no definite boundary that separates the sick from the healthy. Diabetes, and by analogy addiction, is a continuum. Those who are constitutionally vulnerable move themselves along this continuum by virtue of the choices they make.

Such an approach might produce a more socially beneficial “mythology” of addiction. Our research findings have suggested that promoting disbelief in free will produces destructive, antisocial behaviors generally. We propose that similarly destructive effects are likely to come from depicting addiction as loss of free will. People who have made bad choices like to hear and to think that they did not really or freely make those choices. But catering to that view excuses their behavior and sometimes contributes to enabling them to continue making similar choices.

Instead, we advocate a view that biology is not destiny. Being born with a genetic receptivity to liking drugs or alcohol does not guarantee a life of addiction. It is perhaps a form of bad luck, but one that can be overcome with prudent though sometimes difficult choices. Difficult choices are difficult because they consume relatively large amounts of psychological energy. Depicting addiction in this way may encourage people to sustain belief in free will and to take responsibility for their own choices and actions. As our research findings suggest, such an attitude is likely to produce behaviors that are beneficial for both the individual and society.

I find this model useful and I think a lot of the field is already there.

However, the writers seem to neglect a couple of important aspects of their own framework.

If one is to frame addiction with a continuum of vulnerability, part of the continuum would be people who are doomed to become addicts regardless of their choices. Isn't that the case with Type II diabetes? That some will never develop it, some may or may not depending on their activity levels and diet, while others with develop it regardless of their diet and activity levels. 

Also, within the context of their metaphor of psychological energy, there might be times when a person has none and times when a person has no internal or external resources to replenish this energy.

Their closing paragraph seems to slight both of these considerations. Acknowleging these considerations does disavow the role of choice. Even on the end of the continuum where a person's biology and environment doom them to developing addiction, choices could influence the onset, course and severity. And, within the psychological energy metaphor, during periods of replenished energy a person may have the power to make choices that will protect or expend this energy in ways that preserve it (and initiate/maintain recovery) or diminish it (and lead to relapse).

Alcoholics and addicts not alexithymic?

A study in Addiction Research and Theory finds that newly abstinent addicts self-report alexithymia (the inability to articulate emotions) at very high rates, but, in tests with standardized instruments, researchers did not find evidence of actual alexithmia.

This is from the full text of the study:

Substance abusers were more likely than normal adults and psychiatric outpatients to say they had trouble identifying and describing their emotions (on the TAS-20), but showed no actual deficits in identifying and describing emotions (on the LEAS). Substance abusers performed as well on the LEAS as a college student sample, after controlling for age, gender, and IQ, and performed as well as a community adult sample. The observed differences between drug treatment and control groups on the self-report measure were highly statistically reliable, whereas the observed differences on the performance measure did not approach statistical significance. There are at least two potential explanations for this disassociation between self-report and performance.

The negative mood explanation: Negative mood was associated with self-reported alexithymia, which is consistent with what has been found in a normal sample (Haviland et al. 1994). Haviland et al. (1994) have suggested that negative emotional states (i.e., anxiety) may lead to increased alexithymia. Given that our drug treatment sample was experiencing much more negative affect than others, it is possible that the primary reason substance abusers are more alexithymic is because of this increased negative affect. Inconsistent with this view, psychiatric groups that might be expected to experience substantial negative affect (e.g., obsessive compulsive and simple phobia patients) do not report particularly high levels of alexithymia (about 13%; Taylor 2000). Future research should measure self-reported alexithymia and negative mood in both a substance abuse and control group, and then examine whether differences in alexithymia still exist after controlling for the effects of mood.

The inaccurate belief / low-motivation explanation: Substance abusers' self-reports were unrelated to their actual performance, which is inconsistent with a study of normal adults (Lane et al. 1996). This finding suggests that substance abusers' beliefs may be inaccurate. Even so, such beliefs may have a crucial impact on behavior. If people believe that they are not able to deal effectively with their emotions, they may be less motivated to do so. Less motivation may, in turn, lead to more alexithymic behavior. For this explanation to account for the disassociation between self-report and performance alexithymia, we would have to assume that something about the LEAS task motivated substance abuse participants to perform adequately (relative to our comparison groups). Such motivational factors may include the well-structured nature of the task, or the presence of a researcher.

I find these findings fascinating, but I don't find either of these explanations very satisfying. I wonder if the self-reported alexithymia is rooted in a perceived inability to make others adequately understand their emotional state--that others do not understand the intensity of their emotional state or an aspect of their emotional state that they believe to be unique. I'm able to tell you that I am mad or sad, but you still don't understand my suffering. This would fit nicely recovering community humor about "terminal uniqueness" and lend itself to cognitive behavioral therapy or rational emotive therapy to reduce these cognitive distortions.

Another possibility is that the subjects felt confused by their own emotional state and unable to construct an adequate narrative to explain their emotional state and therefore unable to adequately communicate their emotional state.

More on evidence-based practices

This is a re-post from last fall.

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]

When hope is lost

An article on how to open a wet day center. What a pathologizing, deficit-oriented article! Our detox works with this population every day in a drug and alcohol free setting and, while this population may behave badly in hospitals and other settings, we experience very few problems. (Fewer than 3% of admissions were asked to leave.)

One friend responded with this quote as a test for any intervention:
“If you want to treat an illness that has no easy cure, first of all, treat them with hope” -- George Vaillant

Pot polls

Mark Kleiman breaks down the latest polls of public sentiment regarding pot laws. Bottom line:

...I doubt that even the decrim question would have gotten that much support in any poll since the beginning of the second War on Drugs in 1979. This is clearly not an issue the Obama Administration intends to take up anytime soon, but when and if it does there seems to be some running room.