Tab dump

• AMA meeting: More to do on tobacco control
• Outpatient alcoholism treatment - 24-month outcome and predictors of outcome
• Healthcare Reform Must Prioritize Treatment for Addictions, Mental Health, Report Says
• Comparing retention in treatment and mortality in people after initial entry to methadone and buprenorphine treatment
  

Technorati Tags: tobacco, outpatient, treatment, policy, buprenorphine, methadone

Marlboro Country

Legal, taxed, regulated and still an enormous illicit industry.

21

I'm not dead set against lowering the drinking age, (see here) but I find it odd that in making the argument to lower the drinking age, John McCardell offers very troubling statistics without any serious interest in their cause:

at one major university, student visits to the emergency room for alcohol-related treatment have increased by 84 percent in the past three years. Between 1993 and 2001, 18-to-20-year-olds showed a 56 percent jump in the rate of heavy-drinking episodes. Underage drinkers now consume more than 90 percent of their alcohol during binges. These alarming rates have life-threatening consequences: each year, underage drinking kills some 5,000 young people and contributes to roughly 600,000 injuries and 100,000 cases of sexual assault among college students.

These increases occurred during a period with no changes in the legality of drinking for people under 21. Seems strange to blame the drinking age in that context, no? Particularly when countries with lower drinking ages are experiencing similar trends. One might argue that lowering the drinking age has little or no effect but, again, it seems inconsistent to blame it. Shouldn't be more interested/curious/concerned about the causes of this?

Interestingly, a study suggests that the 21 drinking age reduces binge drinking except in college students.

New research from Washington University School of Medicine in St. Louis has found substantial reductions in binge drinking since the national drinking age was set at 21 two decades ago, with one exception -- college students. The rates of binge drinking in male collegians remains unchanged, but the rates in female collegians has increased dramatically. The report was published in the July issue of the American Academy of Child and Adolescent Psychiatry. Core message: The drinking age is having a beneficial impact; reducing it would be a mistake.

Again, begging the question, "What's going on with college students to explain this 'dramatic increase' in recent years?"

Technorati Tags: alcohol, binge drinking, policy, underage drinking, amythest

THIQ all over again

A 2004 study carried out at the University of Colorado found that around 15 per cent of Caucasians have a genetic variant, known as the G-variant, that makes ethanol behave more like an opioid drug, such as morphine, with a stronger than normal effect on mood and behaviour. This variant seems randomly distributed among the population: it emerged through mutation, although the factors affecting its selection remain unknown since, like all genes, it does not operate in isolation. . . . The Colorado study tested the DNA of moderate-to-heavy drinking students to determine whether they had the G-variant gene. They were divided into two groups accordingly, before having alcohol injected directly into the bloodstream (to eliminate differences in absorption rate). Those with the G-variant produced a slightly different version of what is known as the mu-opioid protein, which elicits a stronger response in the brain. As a result they reported stronger feelings of happiness and elation after their shot of alcohol. This initial euphoria is usually followed by a longer state of relaxation, lasting several hours.

This feels a little too close to THIQ (#36). We'll see if it holds up to scientific scrutiny.

Technorati Tags: research, alcoholism, genetics

Ouch

I hate to say it, but I think we're going to be seeing more of this.

When I clicked the link, I was expecting to see it focus exorbitant salaries in boutique treatment programs. It's a little surprising that this is happening in the program with so much public funding. The current market is rewarding programs with entrepreneurial spirits and that is a double-edged sword. It can be good because it rewards programs that respond aggressively to community need rather than waiting for someone to hand them capital. The downside is obvious, from this article. It can foster an unhealthy emphasis on financial matters that has led to the demise of many programs over the last century.

Technorati Tags: history, exploitation, treatment

U.N World Drug Report

The United Nations Office on Drugs and Crime World Drug Report was released yesterday. The section, "Confronting unintended consequences: Drug control and the criminal black market" is an interesting read. Section 2.1 "Why illicit drugs should remain illicit" squarely and intelligently takes on the pro-legalization argument. It paints a broader picture of the problem than any of the other policy articles I have seen. It also offers a holistic set of responses which are less focused on prosecuting individuals and more focused on macro interventions that address criminal consequences of prohibition at a systemic level. The report notes that "a small share of the user population appears to consume the bulk of the drug supply"; a perfect case for access to treatment for that small segment of the population .

A couple of highlights from the press release:

First, drug use should be treated as an illness. “People who take drugs need medical help,not criminal retribution,” said Mr. Costa. He appealed for universal access to drug treatment. Since people with serious drug problems provide the bulk of drug demand, treating this problem is one of the best ways of shrinking the market.

Second, he called for “an end to the tragedy of cities out of control.” In the same way that most illicit cultivation takes place in regions out of government control, most drugs are sold in city neighbourhoods where public order has broken down. “Housing, jobs,education, public services, and recreation can make communities less vulnerable to drugs and crime”.

Hijack the drug trade?

Does this strike anyone else as naive? In writing about the FDA's new powers to regulate tobacco, more specifically the FDA's power to regulate nicotine yields, Saletan says:

This is what drug warriors don't understand: There's always market competition, whether you like it or not. Prohibition just means that the competition is between legal and illegal products. To beat illegal products in an already-addicted market, you need sufficiently attractive legal alternatives. Then, by regulating and manipulating the legal products, you can ratchet down the harm and addiction. That's how you bring the market under control.

Come on. If we took this approach to other drugs there wouldn't be a massive black market? I suspect we'd end up with two markets, a legal one for adult recreational users and an illegal one for kids and addicts--kids because they couldn't buy it legally and addicts because they wouldn't be sated by the reduced yield stuff. We'd be back where we are.

BTW - I don't consider myself a "drug warrior". I generally don't think anyone should be incarcerated for personal use or possession. Drug courts are about as warrior-like as I get. But, I find myself asking, when did the options for drug policy become regulation or mass incarceration?

I also never cease to be astonished that none of these writers acknowledge the context inadequate access to adequate treatment.

Technorati Tags: drugs, policy, tobacco, regulation, FDA

The power of expectancy

A study of medications (and placebo) for alcoholism finds that expectancy is a better predictor of outcomes than the medication (or placebo) that they are prescribed:

Double-blind placebo-controlled trials are intended to control for the impact of expectancy on outcomes. Whether they always achieve this is, however, questionable.

Reanalysis of a clinical trial of naltrexone and acamprosate for alcohol dependence investigated this issue further. In this trial, 169 alcohol-dependent patients received naltrexone, acamprosate or placebo for 12 weeks. In addition to being assessed on various indices of alcohol dependence, they were asked whether they believed they received active medication or placebo.

While there were no differences in outcomes between treatment groups, those who believed they had been taking active medication consumed fewer alcoholic drinks and reported less alcohol dependence and cravings. That is, irrespective of actual treatment, perceived medication allocation predicted health outcomes.

My spin on this is that hope has significant influence on outcomes and that if you can't treat them with hope, you shouldn't treat them at all.

Technorati Tags: treatment, medication, alcoholism, expectancy, hope

The Myth of the Rational Market

This is the cure for our contemporary cultural worship of economics and hopefully for its creep into "behavioral economics" and thinking about addiction.

Technorati Tags: addiction, economics

Tab dump

• Assessing Parolees' Health Care Needs and Potential Access to Health Care Services in California (Health Care Needs Are High, but Mental Health and Drug Treatment Needs Are Even Higher)
• Advertising may lead to increased alcohol consumption
• More College Students Dying from Drinking, NIAAA Reports
  
• Dad's Drinking Predicts Teen Imbibing, Study Finds
  

Technorati Tags: prevention, parole, alcohol

A little Michigan context

This article in The Nation about the war on drugs offers a little context related to spending on incarceration in Michigan:

Over the past three decades, California has tripled the number of prisons it operates, has more than quintupled its prison population and has gone from spending $5 on higher education for every dollar it spent on corrections to a virtual dead-heat in spending. That puts it in the same boat as Michigan, Vermont, Oregon, Connecticut and Delaware--all of which, according to estimates by the Pew Charitable Trust, spend as much or more on prisons than on colleges. California is also under federal court order to implement costly improvements in the delivery of medical and mental healthcare services in prisons and to release close to a third of the prison population--about 55,000 inmates--to improve conditions for those remaining behind bars.

Alcohol and Suicide

N.Y.T. article on the relationship between alcohol and suicide. It is interesting to note the suicide rate in the military and the prevalence of alcohol abuse.

Tab dump

Public support

• Addiction touches almost everyone
• Poll: Americans Want Addiction Treatment in Healthcare Reform

Harm Reduction

• “Recovery should also be a goal, not simply harm reduction”
• Handing heroin to addicts
• Heroin addicts’ families in Southampton get emergency drug kits

Policy

• A Drug War Inside the Government
  
• Addicts commit crime to get help
• War on tobacco is merely posturing
• A Drug War Truce? 
• Calif. Legalization Advocates Focus on 2010 Ballot
  

Families

• Heroin addicts’ families in Southampton get emergency drug kits
• Addiction affects others, particularly family members
• Parental Involvement in Preventing Youth Substance Use
  

Treatment

• Addicts commit crime to get help
• Emerging Issues in the Use of Methadone
• Help for addicts may come in form of questions
• “Hijacking recovery” and learning from mental health
  

Control

I found this article interesting. I am hesitant to compare addiction to a concentration camp or to the financial crisis, but there are some parallels with regard to loss of control. The article helps explain the often elusive and difficult task of accepting the loss of control of AOD use and the powerlessness identified in the 12 steps. It reaffirms the need for client involvement in the treatment process and touches on the illusion of control that many of us struggle with. It also prompted me to think about the control issues that clients deal with in residential treatment. The author notes that “a false sense of control can be beneficial.” I would also add that it can kill you.

Drugs Won

In his Sunday op-ed piece in the NYT titled “Drugs Won the War” , Kristof joins the growing mass of voices calling for drastic rethinking of our current archaic and ineffective drug policy. He emphasizes three points; the enormous prison population, the empowering of the criminal enterprise and the huge financial cost associated with our failed policy. He voices a need for a “liberalization” of narcotics policy. In his blog, On the Ground, he presents a more concise summary of his viewpoint, in which he admits that he does not know which policies he favors, but that decriminalization and then perhaps legalization and taxation should be explored.

He does mention lack of treatment briefly in discussing the disparity between the funds we spend on interdiction, policing and imprisonment and the money we spend on treatment. He suggests that prevention policy similar to the public health campaigning that we have used with cigarettes should be examined as is proposed by the former presidents of Mexico, Brazil and Colombia in their Drugs and Democracy policy paper.

It is great that this is getting coverage in the main stream media. The growing consensus is that a drastic change is needed, yet it is hard not to be cynical about our ability to make meaningful one, just look at the healthcare debate.

I am no expert. This is a tough policy area, and as Jason has frequently mentioned, there is no perfect solution. The options that are most frequently presented seem almost always to emphasize legalization and taxation or decriminalization. Why not more emphasis on treatment, prevention, community building etc…? Let’s start discussing the human costs along with the financial ones.

No One Deserves to Die by Overdose

No One Deserves to Die by Overdose . . . so true.

But it is also true that everyone deserves an opportunity to recover--the help they need, when they need it and a community/system that treats them with HOPE as well as compassion.

• Number of times the word treatment appears in this article=0
• Number of times the word recovery appears in this article=0

The writer says, "We need to accept the reality that people will always use drugs. . .". Again, true. However, why is Alternet so averse to acknowledging the reality that we are letting people die of untreated/undertreated addiction? If we were talking about suffering/harm related to treatable cancer, would it be enough to advocate for pain management but not treatment? Why is palliative care enough for this population? Why?

Baclofen for cocaine addiction

:-(

Spontaneous vs. planned attempts to quit

Robert West, the editor of Addiction and critic of the stages of change, has published another study finding that the stages of change are not a prerequisite for change. One of the important implications of this is dinging the predictive value of the the stages of change.

I view this as important because faith in the predictive value of the stages of change has become a post hoc way to blame the client for failure or blame the system for not guarding the gate well enough and create justifications for new barriers to anything more intensive that traditional outpatient care.

. . . the odds of a "spontaneous" quit attempt lasting for 6 months or longer were twice that of preplanned attempts.

20 years later

A recently published study paints a pretty grim picture (for men in particular) and reinforces an abstinence orientation:

AIMS: The aim of this study was to evaluate long-term outcomes in alcohol-dependent patients following outpatient treatment and gender differences in drinking outcome and mortality. METHODS: A 20-year longitudinal prospective study was done with interim analyses at 1, 5 and 10 years. Of the original sample of 850 patients, 767 (90%) were located 20 years later and 393 of these were interviewed. 273 (32%) patients died during the intervening period and 101 (12%) no longer wished to participate in the study. Drinking status was assigned based on the 12 months prior to the follow-up interview. RESULTS: At the 20-year follow-up, 277 (32.6%) of the 393 patients for whom drinking status could be assigned were abstinent (defined never drinking or drinking on less than occasion per month and never more than four drinks/drinking occasion.), 29 (3.4%) were controlled drinkers and 87 (10.2%) were heavy drinkers. Controlled drinking was the least stable category, with 23% continuing from year 5 to year 10 in that category, and 10% continuing in that category from year 10 to year 20. Mortality was higher (39.1%) in those who had been categorized at year 5 as heavy drinkers compared to those who had been categorized as controlled drinkers or abstinent. Abstinent patients reported fewer alcohol-related problems and better psychosocial functioning than heavy drinkers. Women achieved higher abstinence rates (47.2% versus 29.0%, P = 0.005) and had lower mortality (22.4% versus 34.5%, P = 0.03) than men. CONCLUSIONS: Over the long-term, abstinence is the most frequent and stable drinking outcome achieved and is associated with fewer problems and better psychosocial functioning. Controlled drinking is rarely achieved and sustained. Women appear to do better than men in the long term.

Addicts have made a choice

Now Gene Heyman has become the go to guy for anyone with an ideological aversion to addiction as a disease.

What's most troubling is that many of his fans have much more broad readership that the Journal of Substance Abuse Treatment.

A waste . . .

. . . of time and capital.

What do I tell my kids?

The truth.

Technorati Tags: prevention, recovery, kids, parenting

We're not on the same side

"Nice People Use Drugs"

What is there to say? Of course it's true. But there are a lot of statements that are true but make for terrible public education slogans. I suspect this agency is very concerned about HIV prevention. (I am too and have no problem with condom distribution.) What would they think of the slogan, "Condom users get HIV"? It's true that some condom users still get STDs, and it's probably even true that most people who acquire HIV through sex used condoms sometimes, but it's a terribly misleading statement isn't it?

It's clear that they view drug use as a lifestyle choice. Surely, for some people, they are. For the addicted, they are not a choice, they are a form of holistic enslavement, and addictive drug use occurs in the context of terrible personal and social costs. The drug problem is a serious, complicated problem. The status quo is unacceptable. Serious reform is needed. However, the triteness of this slogan has got to be very troubling to anyone who cares deeply about the suffering caused by drugs.

If they really just want to reduce stigma, how many other messages could they have tried? What does choosing this message say about their values.

Technorati Tags: policy, drugs, harm reduction, england

Confused

One of our staff, who is also an officer at the local jail, received some well deserved attention for her guided meditation and other work in the "therapeutic block" at the jail.

I loved this thought:

“This uniform confuses people,” Wilson says in an interview. And by “people,” she means the people who wear the uniforms. “It confuses your ego.” Civilians, she says, “outrank” police officers. “We’re here to provide a service.”

Can't the same be said of getting letters after your name? (MSW, CAC, etc.)

New Peer-based Recovery Support Monograph

Bill White has published another comprehensive monograph, this time it's Peer-based Addiction Recovery Support: History, Theory, Practice, and Scientific Evaluation. This, along with the his monograph, Recovery Management and Recovery Oriented Systems of Care: Scientific Rationale and Promising Practices should be considered essential reading for anyone in the field.

I may have more to say after an opportunity to dig into it.

Technorati Tags: addiction, recovery, AA, research

Why does alcohol get a pass?

A reminder of the social costs of alcohol.

Not to be interpreted as a call for prohibition, but keep this in mind the next time someone points to the success of alcohol legalization and regulation as a model for drugs.

Technorati Tags: alcohol, policy

Marijuana legalization pro and con

Pro and con.

Same old, but less freak show-ish

Technorati Tags: marijuana, policy, legalization, decriminalization, drugs

Recovery is everywhere

Who'd of thought?

Technorati Tags: addiction, recovery

Empower Yourself--with naloxone

Empower yourself? With naloxone?

This can only be serious within a palliative framework or one that views addiction as a lifestyle choice. In this framework, even a worker's hope for freedom from addiction is considered judgment-laden.

From the presentation: "For many of our clients overdose is a fact of life..."

Preventing death is a good thing, but there is NOTHING about recovery or treatment in the presentation. NOTHING.

It reminds me of a story last year about Vancouver, where a client said, "the only way to quit drugs is to move far from Vancouver's Downtown Eastside, where there are scores of services for addicts." He feels his only hope is to get away from the professionals that are trying to help addicts!!!

Time also has an article on naloxone in the U.S. Again, no mention of recovery or the need for treatment. Presenting the matter without the context that decent treatment is unavailable to most people fails to give readers the frame of reference needed to consider policy and social issues involved. Not surprising, given that the writer has been pretty plain about her biases. She is a frequent critic of treatment, AA, and the disease model.

Technorati Tags: addiction, harm reduction, naloxone

Tab Dump

• New National Report Shows Substantial Disparities in the Levels of Substance Abuse and Mental Illness Problems Experienced among the States
• Could Youth Drug Use Be Making a Comeback?
• Report: Smoking declines as alcohol, drug use hold steady
• Anti-Cocaine Drug Fails in Trial
  
• Addict on methadone for 18 years

Technorati Tags: research, prevention, policy, prevalence, vaccine, methadone

Which came first?

Another study finding that psychiatric problems typically follow alcohol problems rather than the other way around. This suggests that, more often than not, psychiatric problems are secondary to alcohol problems.

Technorati Tags: mental illness, dual duagnosis, alcohol

More on the predictive power of the Stages of Change

This study surveyed medical inpatients receiving treatment for a medical problem other than alcoholism. Among risky drinkers, higher Perception of Problems scores were associated with more drinking at follow-up, while higher Taking Action scores were associated with less drinking.

This is interesting, has some limitations, in my view. First, the subjects were offered treatment. I suspect that those with higher Taking Action scores accepted the offer of treatment. If so, were their improvements an artifact of readiness to change or participation in treatment? Second, the study appears to lump people meeting criteria for DSM Abuse and DSM Dependence. Are these outcomes a product of people with more severe problems doing more poorly? This would be likely. Dependence is harder to treat than Abuse, and Abuse is probably likely to improve following a medical crisis. Third, I'm always interested in seeing these kinds of studies in a treatment population. Treatment studies allow us to find out of readiness is a predictor of treatment outcomes. Many studies have found that this isn't the case.

The findings do highlight the importance of hope (self-efficacy) in promoting change. While problem awareness wasn't predictive, one wonders if it offers an essential intermediary step that creates a foundation for other factors more directly predictive of change. Again, a treatment study would be interesting to see if these factors are predictive as pre-treatment factors and to see how treatment influences them and then how predictive they are at discharge.

Technorati Tags: research, TSOC, alcohol