21 reduces alcohol dependence

More evidence for the argument that lowering drinking ages would lead to more alcohol and drug problems later in life. The point about age of first use vs. regular use is interesting and offers some interesting questions about goals and strategies for prevention programming.

Background: Many studies have found that earlier drinking initiation predicts higher risk of later alcohol and substance use problems, but the causal relationship between age of initiation and later risk of substance use disorder remains unknown.

Method: We use a "natural experiment" study design to compare the 12-month prevalence of Diagnostic and Statistical Manual, Fourth Edition, alcohol and substance use disorders among adult subjects exposed to different minimum legal drinking age laws minimum legal drinking age in the 1970s and 1980s. The sample pools 33,869 respondents born in the United States 1948 to 1970, drawn from 2 nationally representative cross-sectional surveys: the 1991 National Longitudinal Alcohol Epidemiological Survey (NLAES) and the 2001 National Epidemiological Study of Alcohol and Related Conditions. Analyses control for state and birth year fixed effects, age at assessment, alcohol taxes, and other demographic and social background factors.

Results: Adults who had been legally allowed to purchase alcohol before age 21 were more likely to meet criteria for an alcohol use disorder [odds ratio (OR) 1.31, 95% confidence intervals (95% CI) 1.15 to 1.46, p < 0.0001] or another drug use disorder (OR 1.70, 95% CI 1.19 to 2.44, p = 0.003) within the past-year, even among subjects in their 40s and 50s. There were no significant differences in effect estimates by respondent gender, black or Hispanic ethnicity, age, birth cohort, or self-reported age of initiation of regular drinking; furthermore, the effect estimates were little changed by inclusion of age of initiation as a potential mediating variable in the multiple regression models.

Conclusion: Exposure to a lower minimum legal purchase age was associated with a significantly higher risk of a past-year alcohol or other substance use disorder, even among respondents in their 40s or 50s. However, this association does not seem to be explained by age of initiation of drinking, per se. Instead, it seems plausible that frequency or intensity of drinking in late adolescence may have long-term effects on adult substance use patterns.

UPDATE: Oops. Here's the link.

The Sunday ritual

I'm not much of Mitch Albom fan, but good for him. Whether one agrees with him or not, it's something we all take for granted and it deserves discussion.

The video featured two attractive women.

It was shot by an onlooker.

It hit YouTube by storm.

You're no doubt thinking "sex," but let me assure you the women kept their clothes on. Unfortunately, that was the only ladylike thing about them.

On the video, they appeared intoxicated, swore like sailors, got in fights, then screamed, shoved and cursed until security finally took them away, one in handcuffs.

This was not a women's penitentiary. It was a Lions game. You can argue that watching the Lions might make anyone go ballistic. But I'm guessing these women, like many football fans, had another reason for their belligerence:

They were hammered before the game began.

And you could shoot this video every Sunday.

Look, it's bad enough that most NFL games begin at 1 p.m. and that people are buying beers before kickoff. But thanks to tailgating, many fans are blotto before they hand over their tickets. One day, we'll explain to Martians our tradition of arriving hours before a football game, sitting in cold parking lots in fold-up beach chairs, swigging beers and grilling fatty foods between bumpers of pickups (at which point the Martians will bolt to their spaceships).

...

I blame the tailgaters, but I also blame the teams -- pro and college. By encouraging a seven-hour drinking experience, football now sees its stadiums marred with behavior like this past week's wildly popular YouTube moment (billed as "Two Drunk Girls Kicked out of Vikings vs Lions Game").

Highlights from the conference "How AA and NA Work"

Presentations (hopefully video too) will be up next week. I'll post a link when they're up.

Sarah Zemore gave a great presentation on the evidence for the effectiveness of 12 step groups. It was powerful and well organized. I found a link to an identical presentation here.

She very effectively rebutted the Cochrane Review from a few years ago by making the following points. (These are based on notes I took and are incomplete. Hopefully they post video so that you can see her complete rebuttal for yourself.)

• It was limited only to randomized trials and ignored the overwhelming observational evidence.
• It included one of Zemore's studies which was NOT a randomized study of AA.
• She acknowledged that the randomized evidence is ambiguous.
  
• Randomized trials of AA are hard to do because some subjects in other groups end up participating in AA. This happened in Project MATCH.
• The Cochrane Review did not find Twelve-step Facilitation ineffective. It found it no more effective that CBT and MET.
• Finally, she cited 4 randomized studies of Twelve-step Facilitation: The outpatient arm of Project MATCH, a study by her colleague Kaskutas, and two others that I missed.

It was important for me because supporters of Twelve-step Facilitation are too often painted as the equivalent of intelligent design advocates. It's just not so and the evidence in this presentation made this unequivocally clear. Twelve-step Facilitation is not the only approach that works, but it's an evidence based practice.

Laudet made one self-evident point that jarred me because it is almost never made in professional circles. She pointed out that the subjects of one of her studies were infected with HIV at a rate of 22% and Hep C at a rate of 33%. She then said something to the effect of, "As a public health matter, we need to focus on keeping these people in recovery. If they relapse they are likely to spread these illnesses."

When's the last time you read anything about recovery as a strategy to reduce communicable disease?

Laudet (as did Zemore) attempted to deconstruct AA, so that it's mechanisms for change could be identified and still be offered to clients who prefer not to participate in AA or NA.

Bill White gave a rousing historical perspective of AA and NA's histories and pointed out the looming challenges that face twelve-step recovery groups. These challenges included matters like methadone maintenance patients as full NA members and the limitations of the 3rd tradition and singleness of purpose in AA. He noted that fewer that 18% of people entering treatment in the U.S. were primarily identified as alcohol dependent.

How AA/NA Work

The University of Michigan will host a conference tomorrow on How AA/NA Work and will stream it live here. The presenters include some very big names. Here's the agenda:

Friday, September 25, 2009
9:00 am - 4:00 pm

09:00-09:20	Introductions by John Traynor and Bob Zucker
09:20-10:00	Alcoholics Anonymous Effectiveness: Faith Meets Science by Sarah Zemore, PhD, Scientist, Alcohol Research Group, Public Health Institute
10:00-10:40	Twelve-step participation among polydrug users: Longitudinal patterns, effectiveness, and (some) lessons learned by Alexandre B. Laudet, Ph.D., Director, Center for the Study of Addictions and Recovery (C-STAR) and Deputy Director of the Institute for Treatment and Services Research, National Development and Research Institute
10:40-11:00	BREAK
11:00-11:40	The Varieties of recovery experience: AA, NA and the diversification of pathways and styles of long- term addiction recovery by William L. White, M.A., Senior Research Consultant, Chestnut Health Systems / Lighthouse Institute. Author of: Slaying the Dragon - The History of Addiction Treatment and Recovery in America
11:40-12:20	From iPod to iGod: Are 12-step Groups Hip Enough for Adolescents? by John F. Kelly, Ph.D., Associate Director, Mass. General Hospital/Harvard Center for Addiction Medicine, Director, Addiction Recovery Management Service (ARMS) at Mass. General Hospital, Assistant Professor of Psychiatry, Harvard Medical School
12:20-01:30	LUNCH
01:30-02:10	Alcoholics' perceptions of AA's helpfulness: Qualitative responses and association with drinking outcomes by Elizabeth A. R. Robinson, MSW, Ph.D., Research Assistant Professor, at the University of Michigan Department of Psychiatry Substance Abuse Section
02:10-02:30	BREAK
02:30-04:00	Panel Discussion

Cause, effect & underage drinking

Two interesting findings about underage drinking. The first on the relationship between early alcohol use and chronic alcohol problems later in life. The second looks at the relationship between early alcohol use and poor judgment later in life.

We've known for some time that there is a relationship between early drinking and alcohol problems later in life. What's been unclear is the nature of that relationship. Does early exposure to alcohol cause changes in the adolescent brain that lead to problems later in life? Does early exposure facilitate the expression of genes that are related to alcoholism? These two theories would suggest that early exposure to alcohol has the potential to cause alcohol problems later in life. Or, is early exposure an indicator of risk factors such as the environment the young person is in or risk taking behavior? These would suggest that there is no causal relationship.

A new study supports the gene expression theory:

Background: Research suggests that individuals who start drinking at an early age are more likely to subsequently develop alcohol dependence. Twin studies have demonstrated that the liability to age at first drink and to alcohol dependence are influenced by common genetic and environmental factors, however, age at first drink may also environmentally mediate increased risk for alcohol dependence. In this study, we examine whether age at first drink moderates genetic and environmental influences, via gene × environment interactions, on DSM-IV alcohol dependence symptoms.

Methods: Using data on 6,257 adult monozygotic and dizygotic male and female twins from Australia, we examined the extent to which age at first drink (i) increased mean alcohol dependence symptoms and (ii) whether the magnitude of additive genetic, shared, and nonshared environmental influences on alcohol dependence symptoms varied as a function of decreasing age. Twin models were fitted in Mx.

Results: Risk for alcohol dependence symptoms increased with decreasing age at first drink. Heritable influences on alcohol dependence symptoms were considerably larger in those who reported an age at first drink prior to 13 years of age. In those with later onset of alcohol use, variance in alcohol dependence was largely attributable to nonshared environmental variance (and measurement error). This evidence for unmeasured gene × measured environment interaction persisted even when controlling for the genetic influences that overlapped between age at first drink and alcohol dependence symptoms.

Conclusions: Early age at first drink may facilitate the expression of genes associated with vulnerability to alcohol dependence symptoms. This is important to consider, not only from a public health standpoint, but also in future genomic studies of alcohol dependence.

On the second matter, Scientific American [via 3 Quarks Daily] suggests that there is a causal relationship between early exposure to alcohol and poor judgement long after the effects of the alcohol wear off:

It's no secret that binge drinking and faulty decision-making go hand in hand, but what if poor judgment lingered long after putting the bottle down and sobering up? A new study with rats suggests that heavy alcohol consumption in adolescence could put people on the road to risky behavior.

Several studies have associated heavy drinking in youth with impaired judgment in adulthood, but these studies didn't resolve whether alcohol abuse actually predisposes people to develop bad decision-making skills, or if the people who indulged in excessive inebriation were risk-taking types to begin with. As Selena Bartlett, a director in the Ernest Gallo Clinic and Research Center at the University of California, San Francisco, explains, you cannot put adolescents in a room and ask them to consume alcohol to see what happens. But scientists can conduct these kinds of experiments with rats, an animal that Bartlett, who was not part of the study, says is "excellent for modeling changes in behavior" as a result of alcoholism.

In the new study published this week in Proceedings of the National Academy of Sciences, scientists at the University of Washington

(U.W.) in Seattle fed alcohol to a group of rats and found that their ability to make good decisions was impaired even long after they stopped consuming booze.

Harm Reduction Defined

From the International Harm Reduction Association:

‘Harm Reduction’ refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community.

Not bad for a definition developed by a committee.

[via drugscope]

Ending the war on drugs does not equal legalization

An interesting take on the growing chorus of calls to end the war on drugs.

The first problem I have with the op-ed is that she conflates ending the drug war with legalization, offering an fallacious binary choice. The piece is a hard sales pitch for her position.

She offers 2 reasons for these calls:

Two significant developments are contributing to the sudden surge in calls for reconsidering prohibition. The first is that drugs are now damaging long-term Western security interests, especially in Afghanistan and Mexico. The second is that production is migrating away from its traditional homes like Colombia and the Golden Triangle and moving into the heart of Western consumer areas like Canada, the Netherlands and Britain.

I don't have a global perspective, but, in the US, it seems to me that domestic policy is driving the reconsideration of drug policy. One factor is moral, the insane incarceration rates for drug offenders (From the early 1980s to the to the early 2000s, the number of inmates whose worst offense was a drug crime grew by 1540% in federal prisons and 1195% in state prisons.) The other is financial, with state budgets buckling under the recession and the cost of incarcerating all these people.

She goes on to make a humanitarian case based on the suffering in the developing world. Ironically, Antonio Maria Costa makes a humanitarian case against legalization based on the suffering it would cause in developing world.

At the moment, fewer than 5% of all adults in the world take drugs at least once a year, compared with around one-quarter who smoke tobacco and about a half who drink alcohol. Drugs kill about 200,000 people a year, tobacco 5 million and alcohol 1.8 million. Why open the floodgates to addiction by increasing access to drugs? Would the world really be a better place with a lot more people under the influence of drugs?

John Gray seems to think so. In last week's Observer he argued that the case for legalising all drugs is unanswerable. Yet who would answer for the havoc wrought on the vulnerable? Maybe western governments could absorb the health costs of increased drug use, if that's how taxpayers want their money to be spent.

But what about the developing world? Why unleash an epidemic of addiction in parts of the world that already face misery, and do not have the health and social systems to cope with a drug tsunami?

Critics point out that vulnerable countries are the hardest hit by the crime associated with drug trafficking. Fair enough. But these countries would also be the hardest hit by an epidemic of drug use, and all the health and social costs that come with it. This is immoral and irresponsible.

He ends with the same kind of hard sell, resorting to an appeal to classism.

Let's be open-minded about how to improve drug control. But let's do it in a way that will improve the health and safety of our communities and not just make it easier for City bankers and high-street models to snort cocaine.

Ford + Hythiam = WTH?

As someone who lives in Michigan, I've been very interested in the welfare of the auto industry and I've been pretty hopeful about Ford. That is, until I read this. What the heck? (I'm trying to keep this blog PG.)

You can read more about Hythiam here.

9 components of recovery

David Clark at wiredin.org.uk expounds on a list of 9 components of recovery from the mental health recovery movement. They are:

1. Renewing hope and commitment to one’s life
2. Being supported by others
3. Finding one’s niche in the community
4. Redefining self or changing one’s identity
5. Incorporating illness
6. Managing symptoms.
7. Assuming control
8. Fighting stigma
9. Being an empowered citizen
   

Crime, crime, crime...

Today's UK papers have advocates and critics of heroin maintenance, but is anyone looking out for the addicts themselves? Where are the op-eds calling for an audacious recovery-oriented treatment initiative?

More on Mexico's drug policy reform

Five opinions on Mexico's recent move to decriminalize possession.

Too hot, too cold, just right...

They also make irreconcilable statements of fact.

Here are some of the highlights:

...if they asked me, will decriminalization of the possession of small amounts of drugs save a single life in Ciudad Juárez, where there have been about 3,200 murders in 21 months, my answer would be a rotund no.

But decriminalizing drug possession is in and of itself a change of, paradoxically, gigantic and modest proportions. Gigantic because it is a solid first step to pave the way for 1) distinguishing between drug use and drug abuse 2) paving the way for fully medicalizing abuse, that is, reinforcing the idea that we should treat drug addicts much as alcoholics and offer them help instead of prison time, and 3) focusing state resources on the production, trafficking and distribution networks. But modest because it still commits governments to continue their war on drugs, just not on the user.

Grrrr:

Drug users are not innocent. They support the vicious drug cartels. Without their demand for drugs, the supply side has no purpose. Since terrorists depend on the drug market to fund their activities, users are potentially aiding terrorism. Because drug traffickers are frequently linked with weapons and human trafficking, users are also supporting these activities.

I love you, Mom

Mama Zen offers a very short, simple and thought provoking post. Check it out.

How marijuana became legal

An interesting take on the history of the medical marijuana and it's role in a movement toward marijuana legalization:

This article is not another polemic about why it should or shouldn't be. Today, in any case, the pertinent question is whether it already has been -- at least on a local-option basis. We're referring to a cultural phenomenon that has been evolving for the past 15 years, topped off by a crucial policy reversal that was quietly instituted by President Barack Obama in February.

[via DrugScope]

Recovery and harm reduction

An interesting statement on harm reduction and recovery:

We believe that recovery is best defined by the individual seeking it, and that it is not for academics or treatment providers to tell anyone what recovery should mean to them. We assert that for some people, recovery can be medication assisted for a short or longer time (on maintenance) whilst the person achieves other gains in health, social care and reintegration (participation in the rights, roles and responsibilities of society).

I wonder how bread the agreement would be on this statement:

Being drug free is the ultimate goal of harm reduction.

Very broad, I hope.

[via DrugScope]

Eye movements reveal processing of hidden memories

Hmmmm. I've always been an EMDR skeptic but this suggests that there may be something to the theory behind it. Interesting.

Positive liberty and addiction

I saw a Facebook comment today referencing "freedom to" and "freedom from". It got me thinking about positive and negative liberty and harm reduction.

Negative liberty is the absence of obstacles, barriers or constraints. One has negative liberty to the extent that actions are available to one in this negative sense. Positive liberty is the possibility of acting — or the fact of acting — in such a way as to take control of one's life and realize one's fundamental purposes.
...
The reason for using these labels is that in the first case liberty seems to be a mere absence of something (i.e. of obstacles, barriers, constraints or interference from others), whereas in the second case it seems to require the presence of something (i.e. of control, self-mastery, self-determination or self-realization).

There seems to be two (maybe more) approaches to harm reduction. One that adopts what Scott Kellogg referred to as gradualism, (I've frequently discussed something I refer to as recovery-oriented harm reduction.) an approach that does not limit itself to the goal of the harm that results from addiction or other risky behaviors, but rather seeks to facilitate change away from active addiction or other risky behaviors. The other approach limits itself to reducing harm and often adopts and affirms the culture of tribes of drug users. The implicit message often seems to be that drug use is a lifestyle choice that is to be accepted, if not respected.

To a significant extent, many disagreements about harm reduction and legalization come down to this philosophical issue. Are these people free?

I say that they are not. However, Berlin, the philosopher who fleshed out the concept of negative vs. positive liberty, warned about the potential consequences of governments taking this view,

Once I take this view, I am in a position to ignore the actual wishes of men or societies, to bully, oppress, torture in the name, and on behalf, of their ‘real’ selves, in the secure knowledge that whatever is the true goal of man ... must be identical with his freedom.

To be sure, this a very real danger in adopting my view of the problem, but fear of infringing on another's liberty is not a reason to ignore this truth. Gradualism seems to navigate these waters well and, in a previous post, I put forth a set of principles for recovery-oriented harm reduction:

I've been thinking about a model of recovery-oriented harm reduction that would address the historic failings of abstinence-oriented and harm reduction services. The idea is that it would provide recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented provider:

• an emphasis on client choice--no coercion
• all drug use is not addiction
• addiction is an illness characterized by loss of control
• for those with addiction, full recovery is the ideal outcome
• the concept of recovery is inclusive -- can include partial, serial, etc.
• recovery is possible for any addict
• all services should communicate hope for recovery--recognizing that hope-based interventions are essential for enhancing motivation to recover
• incremental and radical change should be supported and affirmed
• while incremental changes are validated and supported, they are not to be treated as an end-point
• such a system would aggressively deal with countertransference--some people may impose their own recovery path on clients, others might enjoy vicarious nonconformity through clients

17 Killed in Mexican Rehab Center

What is there to say? Terrible.

Several masked men armed with automatic weapons stormed into a drug rehabilitation center in this violent border city on Wednesday night, lined up recovering drug addicts and alcoholics against a wall and opened fire at point-blank range, killing 17 people and wounding three.
...

In the past two years, gunmen suspected of ties with drug gangs have barged into rehab clinics in Juárez four times and started shooting. The death toll from these attacks on clinics is now about 32.

Sketches of the Drug Czars

A slideshow of drug war inspired art from Vanity Fair:

The United States spends nearly $50 billion each year on the war on drugs, to little avail: illegal drugs remain prevalent, and drug-funded groups continue to spread violence from Mexico to Afghanistan. The new White House drug czar, Gil Kerlikowske, says he wants to end the drug war, but other men in his position have tried and failed to do just that. In this illustrated history, Ricardo Cortes shows how science, politics, ego, and scandal transformed a public-health initiative into a century-long military campaign.

Technorati Tags: drug war, art

The Breathalyzer Behind the Wheel

A NYT contributor makes the case for ignition-interlock breathalyzers for drunk drivers.

People driving while intoxicated still cause about 13,000 deaths a year in the United States. And of the 1.4 million arrests made, one-third involve repeat offenders. The greatest potential of ignition interlocks is to reduce this recidivism.

These hand-held devices, typically attached to dashboards and connected to the ignition, use fuel-cell technology to measure the concentration of alcohol in a person’s breath. Although they are made by various companies, all ignition interlocks conform to strict standards of accuracy set by the National Highway Traffic Safety Administration. If too much alcohol is detected, the car will not start.

A person who has been drinking might naturally think of fooling the device by persuading a sober person to start the engine, but that is not enough to subvert the system, because the device requires breath samples while the person drives — at random intervals of five minutes to an hour. (At least one company is also integrating cameras with the interlocks to photograph the driver when he provides a breath sample.) The unit keeps a log of all tests, and it is sealed so that any attempts at tampering can be detected.

Ignition-interlock devices are not perfectly effective; a drunk can often borrow another car. But in one recent study they were found to reduce repeat drunk-driving offenses by 65 percent. If they were widely installed, the devices would save up to 750 lives a year, a recent National Highway Transportation Safety Administration report estimated.

Technorati Tags: drunk driving, courts