A reality check on drug use

George Will recently wrote a column on drug policy:

The Economist magazine says this means that more than 200 million people -- almost 5 percent of the world's adult population -- take illegal drugs, the same proportion as a decade ago. The annual U.S. bill for attempting to diminish the supply of drugs is $40 billion. Of the 1.5 million Americans arrested each year on drug offenses, half a million are incarcerated. "[T]ougher drug laws are the main reason why one in five black American men spend some time behind bars," the Economist said in March.

"There is no correlation between the harshness of drug laws and the incidence of drug-taking: citizens living under tough regimes (notably America but also Britain) take more drugs, not fewer." Do cultural differences explain this? Evidently not: "Even in fairly similar countries tough rules make little difference to the number of addicts: harsh Sweden and more liberal Norway have precisely the same addiction rates."

The good news is the progress America has made against tobacco, which is more addictive than most illegal drugs. And then there is alcohol.

In "Waking Giant: America in the Age of Jackson," historian David S. Reynolds writes that in 1820, Americans spent on liquor a sum larger than the federal government's budget. By the mid-1820s, annual per capita consumption of absolute alcohol reached seven gallons, more than three times today's rate. "Most employers," Reynolds reports, "assumed that their workers needed strong drink for stimulation: a typical workday included two bells, one rung at 11 a.m. and the other at 4 p.m., that summoned employees for alcoholic drinks."

The elderly Walt Whitman said, "It is very hard for the present generation anyhow to understand the drinkingness of those years. . . . it is quite incommunicable." In 1842, a Springfield, Ill., teetotaler named Lincoln said that liquor was "like the Egyptian angel of death, commissioned to slay, if not the first, the fairest born in every family." Which helps explain why the nation sobered up (somewhat -- these things are relative). One reason crack cocaine use has declined is that a generation of inner-city young people saw what it did to their parents and older siblings.

Undoubtedly culture changes are critical to changing these behaviors, though it's my understanding that one reason for those high rates of alcohol consumption was that alcoholic beverages were often safer to drink than the available water.

I'd like to better understand how that culture change happened. Can it occur without heavy moralizing and the formation of temperance societies? It would seem that this culture change eventually culminated in prohibition. Clearly not what George Will has in mind.

Bacon, cheesecake and Ho Hos, oh my!

Not sure what to make of this:

Junk food elicits addictive behavior in rats similar to the behaviors of rats addicted to heroin, a new study finds. Pleasure centers in the brains of rats addicted to high-fat, high-calorie diets became less responsive as the binging wore on, making the rats consume more and more food. The results, presented October 20 at the Society for Neuroscience’s annual meeting, may help explain the changes in the brain that lead people to overeat.

“This is the most complete evidence to date that suggests obesity and drug addiction have common neurobiological underpinnings,” says study coauthor Paul Johnson of the Scripps Research Institute in Jupiter, Fla.

It will be interesting to watch this research unfold. I worry about the the meaning of addiction as a brain disease being rendered meaningless by an ever-growing list of behaviors that are associated changes in the pleasure centers and dopamine production and response. I look forward to comparative research of these brain responses to better understand the differences.

Committed to treatment

Anchorage, AK is taking some very aggressive steps to address public drunkenness in their community:

The new mayor, Dan Sullivan, a Republican, has created a staff position and a task force devoted to addressing homelessness. The police recently gained the authority to dismantle homeless encampments with just 12 hours’ notice. Citizen groups are patrolling parks where homeless camps have been the site of rapes and other violence. But in perhaps the biggest and most controversial break from how the city has handled the problem in the past, a Salvation Army detoxification and alcohol abuse treatment center has begun accepting chronic inebriates who have been taken there essentially by force.

With $1.2 million in new state financing pushed through by one of Alaska’s more liberal Democrats, State Senator Johnny Ellis of Anchorage, the facility, the Clitheroe Center, is accepting people committed under a state law, Title 47. Under the law, a judge can order people into secure treatment for 30 days, and potentially for months, if the police, a doctor or family members convince the judge that the person’s abuse of alcohol has made them a threat to themselves and others. The person does not need to have committed a crime.

“Ten years ago, there would have been a community outcry that Johnny Ellis is locking up people with the disease of addiction,” Mr. Ellis said. “ ‘How can he do that and say he’s still a progressive?’ ”

Now, Mr. Ellis said, the problem has increased so much “that for various motivations people are saying let’s try something new.” He added, “The people dropping dead during the summertime really got this community paying attention.”

One homeless person drowned. Another was hit by a car. One died from hypothermia. Most had been drinking, and several had four or even five times the blood-alcohol level above which a person is considered too drunk to drive. Experts say the problem of public drunkenness is part of a larger homeless problem that disproportionately affects Native Alaskans, particularly men who have moved in from rural parts of Alaska and lost their way in the city. The recession has also played a role.
Involuntary commitment of homeless alcoholics has been used elsewhere in the country. Some homeless advocates say it infringes on civil rights, and they question its effectiveness. Here in Anchorage, several longtime advocates said the severity of the situation had made them open to giving it a chance.

There is also a video about the story here.

Though court coerced treatment is common, commitment to treatment is unusual. Discussion of these matters in papers and blogs suggest we have two options: 1) harm reduction approaches that accept the person as they are, emphasize personal liberty and make no attempt to address the root cause of their suffering; or 2) lock-em up.

I suppose this approach represents a third way in these too often polarized debates and I suppose that's laudable. The cases discussed in the video and story clearly are seriously endangering themselves. However, the coercion involved in this approach should make everyone uncomfortable. I have a few thoughts about that.

• First, I'm skeptical of slippery slope arguments. Sometimes the slippery slope is the right place to be.
• The ethics of this seem to rest on questions of free will in addiction. If one believes the addict is not free, coercive interventions make sense. (More here, here, here, here, here, here and here.)
  
• Adopting this positive view of liberty opens the door to potential abuses by the state. Coercion should be a last resort.
• Attraction is preferable. This problem is not just a problem of individuals with a disease. It's likely a symptom of a system failure. Does a recovery-oriented system exist? One that encompasses the complete continuum from harm reduction to long term drug free treatment and recovery support? What if we added Project SAFE style recovery coaches engaged in aggressive outreach? Help support a vibrant recovering community that was capable of transmitting infectious hope and continuous peer support? How many could we attract voluntarily?
• That an alternative to palliative care and coercion exists, means that those would be justifiable only if voluntary attraction into recovery failed, or as a stopgap while implementing a voluntary system.
  
• This approach would require investing in more than just the squeaky wheels. It would mean investing in the well-being and recovery of all addicts.

Another recent study supporting the effectiveness of involuntary treatment offers some context.

Tab dump

• A brief history of scholastic inebriation (Too bad they missed Robert Smith whose U of M fraternity brothers called his father to fetch him because his drinking was out of hand.)
  
• Claims injection site dropped Downtown Eastside crime 'very much exaggerated,' say cops
• Battling Addiction With Those Who Know It Best
• New UK study suggests minimal relationship between cannabis and schizophrenia or psychosis
• Cocaine exposure during pregnancy leads to impulsivity in male, not female, monkeys

Drugs around the world

The Big Picture sets its lens on drug use across the globe.

Medical Marijuana Take Down

Chuck Lane writes a two post take down on medical marijuana.

As turned off as I am by anything that includes the word "druggie", he more or less states my position. Personal drug possession should be among the lowest enforcement priorities and should not result in incarceration. If there is or was a legitimate medical marijuana movement it's been co-opted by people whose goal is decriminalization of recreational use--a defensible position but a dishonest approach to achieving it. Finally, this just isn't the way we do medicine.

Phamacy reviews

An emerging market.

Same info, different reactions

I wonder what this means for addiction recovery and treatment messaging:

A study that will appear in the December issue of the American Journal of Public Health tracked the ways in which party affiliation related to people's responses to identical information on diabetes.

Participants in the study read a mock news article on the American Diabetes Association lobbying Congress for greater attention to Type 2 diabetes, the sixth-leading cause of death in the United States. Some people read a straight news report, with minimal mention of what causes diabetes. Others read one of three versions of the story: one that pegged the disease primarily to genetic factors; one that emphasized personal choices; and one that focused on social and environmental factors, such as access to safe places to exercise and affordable, healthy food.

The study's authors, University of Pennsylvania researcher Sarah E. Gollust, along with the University of Michigan's Paula M. Lantz and Peter A. Ubel, were most interested in how people responded to the notion that "social determinants" -- how easy it is to buy fresh vegetables or exercise, among other things -- are underlying causes of disease. Public health advocates have been promoting the importance of these factors, believing that the more people know about these circumstances, the more likely they are to want to help.

But that assumption doesn't hold up. When people who identified themselves as Democrats read specifically about the social factors that can lead to Type 2 diabetes, they expressed greater backing for public health policies aimed at addressing those factors; Republicans, by contrast, registered much lower levels of support.

"The take-home message is that people can walk away from the same information with different attitudes," Gollust says.

A tough approach to drug-using mothers

The LA Times paints a pretty sympathetic picture of Project Prevention, a program that pays addicticted women to get themselves sterilized or use long term birth control. It closes with the following:

Project Prevention makes sense to me. Although a few thousand IUDs might not make a dent in the problem, the bluntness of the gesture turns up the volume.

And it brings drug-using moms in on the dialogue. Thank you for helping me do the first responsible thing I've ever done with my addiction, one mother wrote in a letter to Harris, who solicits a life story from every client.

"They're not bad women," Harris told me. "They don't set out to have babies that are taken away. They feel regret about what they've done."

She's right. Demonizing the mothers doesn't help. They need counseling, not just contraception. Many were victims of childhood trauma and are prisoners of addiction now.

Some hope giving birth will redeem and stabilize their lives. "It's one of the few things they can do that they have control over," said retired social worker Glynis Morrow. "Then the realities of parenting hit. And they feel like failures. And that pain drives them back to drugs."

And we're right back where we started from.

So we can talk about women's rights or about the privilege of procreation. However we cast the conversation, there is one truth we can't avoid: We are helping mothers heal when we keep unwanted children from being born.

It doesn't "make a dent in the problem" but it "turns up the volume." Turns up the volume of what exactly? Bringing them "in on the dialogue"? Who's dialogue? "Helping mothers heal" by encouraging sterilization?

This is pessimism and stigma dressed up as compassion. It only reinforces the notion that addicts are hopeless, irresponsible social parasites. Indeed, the founder has previously said, "We don’t allow dogs to breed. We spay them. We neuter them. We try to keep them from having unwanted puppies, and yet these women are literally having litters of children …" She also previously distributed flyers saying, "Don't let getting pregnant get in the way of your drug habit."

I'm all for preventing unwanted pregnancies, but context matters. If this group was also lobbying for greater access to treatment for these women, that might be another matter. They give lip service to the welfare of the women but little more. Their statistics report only on the social costs of the addicts and offers no references to anything the program has done to improve the circumstances of the women--even activities like advocacy and treatment referrals which would cost nothing and be easy to track. One can only assume that they don't engage in these kinds of activities, collect data and report on it because they and their supporters don't care.

Tab dump

• Cocaine Vaccine for the Treatment of Cocaine Dependence in Methadone-Maintained Patients
• Cocaine use doubles in Mexico in six years
• The genetics of addiction

Treatment reduces criminal recidivism

Not surprising:

The 2009 Annual Report of the Office of Substance Abuse Treatment Services (OSATS), formerly the Division of Addiction and Recovery Services, includes return-to-custody data on offenders who paroled in Fiscal Year 2005-06 for a one-year and a two-year period. The return to custody rate after one year for offenders completing both in-prison and community-based treatment in FY 2005-06 was 21.9 percent compared to 39.9 percent for all offenders. The return to custody rate after two years for offenders completing both in-prison and community-based treatment in FY 2005-06 was 35.3 percent compared to 54.2 percent for all offenders.

For male offenders, the return-to-custody rate after one year for those who completed both in-prison and community-based substance abuse treatment in FY 2005-06 was 25.4 percent compared to 41.2 percent of all male offenders. The return-to-prison rate after two years for male offenders who completed both in-prison and community-based substance abuse treatment in FY 2005-06 was 40.4 percent compared to 55.6 percent of all male offenders.

Female offenders were especially responsive to substance abuse treatment. After one year, only 8.8 percent of female offenders who completed both in-prison and community-based substance abuse treatment in FY 2005-06 were returned to custody compared to 30.1 percent of all female offenders. The return-to-prison rate after two years for female offenders who completed both in-prison and community-based substance abuse treatment in FY 2005-06 was 16.5 percent compared to 43.7 percent of all female offenders.

GAIN publications

The Lighthouse Institute has compiled all the publications based on GAIN data (Dawn Farm uses the GAIN in adolescent services). They have full text articles for many of them.

Very cool. Thanks Lighthouse!

Students for Recovery @ University of Michigan

Thanks Ivana. It's been needed for years.

For many students, moving to Ann Arbor to begin their careers at the University of Michigan is a time of excitement, curiosity and maybe a little bit of fear. But for School of Social Work graduate student Ivana Grahovac, the emotions were different.

As Grahovac prepared to start her time at the University, she was also recovering from a five-year addiction to heroin. Though she had been clean and sober for four-and-a-half years in her hometown of Bloomfield Hills, Mich., she wasn’t sure she could recreate that security in Ann Arbor.

Grahovac said coming to Ann Arbor was a “leap of faith” and that once she arrived, she felt her sobriety constantly threatened.

“I was constantly getting these e-mails about being invited to join people for keggers, drink night specials and pub-crawls,” she said. “There was just a real lack of understanding going on that maybe there are people for whom this would be a very bad choice and possibly cause some serious negative and tragic consequences to occur.”

It was in this environment that Grahovac decided to create Students for Recovery, a group aiming to support and provide provides information for students recovering from addiction. The group also helps students find sober programming as an alternative to the usual Friday night party filled with red Solo cups and alcohol.

Read the rest here.

A dishonest political agenda

From the Honorary President of the International Harm Reduction Association (page 8) [via PeaPod]:

I am completely in favour of helping people who use drugs to stop, if that is what they want. I assume that is what is meant by ‘recovery’. Working with anyone who has problems with drugs must start where the individual is and could involve a range of strategies. Harm reduction should permeate the services available to drug users, which should be used on the basis of evidence of effectiveness, including cost-effectiveness, and on the basis of allocating scarce resources in the most effective way on a population base.

I wonder about the evidence for his first statement. How many people has he or his organization helped achieve drug-free recovery? How many of the people they serve want drug-free recovery, and how many people can't access services to achieve this goal? Do they track this information? Do they use it to advocate for more drug-free treatment services?

If so, great. We're on the same side. If not, stop giving lip service to helping people who use drugs stop.

The recovery agenda is a dishonest political agenda, by which some treatment agencies are positioning themselves for a seamless transition to a Conservative government. It ignores evidence and relies on faith. It is becoming evangelistic. It is dishonest because it is completely undeliverable financially and it raises false hopes. It is not a public health approach.

Whoa! I'm not there to see for myself, so I don't know if the U.K. recovery movement is a cabal of political conservatives or ideologues trying to exploit political conservatives. I see no political pandering on Wired in.

As a recovery advocate that is thousands of miles away, I see a frustrating parallel with discussions here. The HR advocates adopt a hyper-rational posture, denying that their values are reflected anywhere in their beliefs and practice while accusing recovery advocates of being close scientific cousins of intelligent design advocates.

What evidence do recovery advocates ignore? There is ample evidence that we can be as effective at treating addiction as we are with other chronic diseases like hypertension, diabetes and asthma. Should we reject the current treatments for those too?

Why is it undeliverable financially? Because the public doesn't support it? Isn't that the point of advocacy? Why quash advocacy work that is focused on improving the lives of the people you also advocate for? Why not collaborate to make sure a complete continuum is offered?

The basis of drugs work should always be harm reduction. It should always be public health-based and if it helps with public order that is fine with me.

Why is drug-free treatment incompatible with public health? I think it is, but it's also important to keep in mind some of the limitations of public health models--tension between prevention and treatment is common in these arguments, Public health approaches always include the application of some values (even when we say they don't), and they risk turning life and death decisions for entire classes of people into cold accounting exercises. For example, why do we cringe at a harm reduction/public health approach to female circumcision? (More here and here.)

One other observation. Mr. O'Hare did not the use of the word addiction or any its variants. Does that intimate something? It may be nothing (Really, I mean that.), but it make me wonder if he's invested in framing as something other than a disease.

[hat tip: PeaPod]

It's not on the list!!!

Mark Kleiman being interviewed about his new book. This segment focuses on drug policy:

A civil rights movement

Powerful language from wired in to recovery:

Many people would argue that the UK treatment system, in main, is simply managing symptoms and accepting long-term disability or discomfort of people with serious substance use problems.

These same people would not argue against the value of treatment per se, rather it needs to be provided in a different way.

The recovery movement is first and foremost a civil rights movement. It is about helping disadvantaged people, people with problems, improve their well-being.

It is about helping people with substance use problems (and often many other problems) reclaiming or claiming their right to a safe, dignified, meaningful and gratifying life in the community, sometimes despite their problems.

A recovery oriented system of care places the person with the problem at the centre of the system. It does not just build places where people go and get ‘treatment’ – it builds forms of support theroughout the community.

It accepts that the struggles of the person are not just with what is going on within their own body and mind – it is about their social struggles, which they experience because of the prejudice, discrimination, stigma and marginalisation that occurs in society.

Alcohol marketing and teen drinking

The finding from a study of the relationship between alcohol advertising and adolescent alcohol use:

Based on the consistency of findings across the studies, the confounders controlled for, the dose response relationships, as well as the theoretical plausibility and experimental findings regarding the impact of media exposure and commercial communications, it can be concluded from the studies reviewed that alcohol marketing increases the likelihood that adolescents will start to use alcohol, and to drink more if they are already using alcohol.

"Recovery is recovery"

Bill White interviews a medication assisted recovery advocate:

The problem with the methadone community is we have too many people who think methadone is a magic bullet for that disease—that recovery involves nothing more than taking methadone.

This view is reinforced by people who, with the best of intentions, proclaim, “Methadone is recovery.” Methadone is not recovery. Recovery is recovery. Methadone is a pathway, a road, a tool. Recovery is a life and a particular way of living your life. Saying that methadone is recovery let’s people think that, “Hey, you go up to the counter there, and you drink a cup of medication, and that’s it. You’re in recovery.” And of course, that’s nonsense. Too many people in the methadone field learn that opiate dependence is a brain disorder, and they think that that’s all there is to it. But just like any other chronic medical condition, it has a behavioral component that involves how you live your life and the daily decisions you make.

He bemoans the lack of recovery-oriented providers:

Bill: Do you see the methadone clinics in the United States developing more recovery-oriented philosophies in their service practices?

Walter: I wish I could say I did, but it’s a yes and no. I’ve been to all the AATOD conferences since 2001 and there are clearly people who are developing more recovery-oriented programs, but there are 1200 methadone programs in the U.S. How many are represented at the AATOD? 40? So yes, some of the programs are developing more recovery-oriented services, but many are not.

This will be a very interesting movement to watch. Read the rest here.

[via dailydose.net]

Tab dump

• Should Burden of Disease Estimates Include Cannabis Use as a Risk Factor for Psychosis?
• Mental Health Indicator Interaction in Predicting Substance Abuse Treatment Outcomes in Nevada
• Addiction recovery as TV drama: A&E’s “The Cleaner”
• Military Families Targeted by New Prevention Campaign

In 16 states, drug deaths overtake traffic fatals

From the Washington Post:

In 16 states and counting, drugs now kill more people than auto accidents do, the government said Wednesday. 

Experts said the startling shift reflects two opposite trends: Driving is becoming safer, and the legal and illegal use of powerful prescription painkillers is on the rise. 

Read the rest here.

Another reason to quit smoking

Phillip-Morris played a role in killing health care reform in 1994:

McCaughey's lies were later debunked in a 1995 post-mortem in The Atlantic, and The New Republic recanted the piece in 2006. But what has not been reported until now is that McCaughey's writing was influenced by Philip Morris, the world's largest tobacco company, as part of a secret campaign to scuttle Clinton's health care reform. (The measure would have been funded by a huge increase in tobacco taxes.) In an internal company memo from March 1994, the tobacco giant detailed its strategy to derail Hillarycare through an alliance with conservative think tanks, front groups and media outlets. Integral to the company's strategy, the memo observed, was an effort to "work on the development of favorable pieces" with "friendly contacts in the media." The memo, prepared by a Philip Morris executive, mentions only one author by name:

"Worked off-the-record with Manhattan and writer Betsy McCaughey as part of the input to the three-part exposé in The New Republic on what the Clinton plan means to you. The first part detailed specifics of the plan."

McCaughey did not respond to Rolling Stone's request for an interview.

Whatever your feelings about health care reform, is this the kind of interest we want secretly manipulating the debate?