Tab dump

• Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence - The metareview notes that there were few attempts to measure improvements in wellbeing.
• Alcohol-Induced Blackout - Are they predictive of dependence?
• Parity to Become Federal Law Despite Rule-Making Delay
• Policies to Prevent Drug Problems: A Research Agenda for 2010-2015 - Robert Wood Johnson's research agenda

Stigma and community

I read this Ta-Nehisi Coates post yesterday on domestic violence, responsibility, individual agency, community, shame, isolation and empowerment. It's really stuck with me. Very heavy, heady stuff in a very short post.

It got me thinking about some of the mechanisms of addiction and stigma, and the healing mechanisms of the recovering community. He points out the empowering aspects of a community of oppressed people and the responsibility this community confers upon its members.

Further along these lines, Bill White has a new paper on stigma, addiction and methadone. It poses some interesting challenges to the recovering community. How do we reduce the isolation of MMT patients trying to recover? What does recovery mean in the context of MMT? "Responsibility" in the paragraph above could be interchanged with standards. One of the healing mechanisms of the recovering community is imposing standards expectations (responsibility) on its members. Would bringing MMT patients into the community erode this? (There were similar fears with psychotropics.) Does this open a door for benzos and other meds? Clearly, these standards protect the recovering community, but they also constitute a barrier.

The conundrum here is that suspicion about MMT has been pretty persistent for good reason. The paper does a good job addressing the failure of MMT in facilitating recovery. Many members of the recovering community question whether its possible for large numbers of people to achieve and maintain recovery while on methadone--if methadone is such a helpful tool and isn't a barrier to recovery, then why, with the wide distribution of methadone clinics, haven't these people been able to form their own thriving tribe within the recovering community?

It would seem that the best way to test this (the degree to which intra-group stigmatization constitutes a barrier to recovery) would be to have these folks be welcomed into the arms of the recovering community and see how they do. But, how do we get there when this suspicion persists? And, how do we respect the role of these standards in the recovering community when considering the needs of MMT patients?

This challenge is not going away.

UPDATE: Maybe expectations would have been a better choice of words than standards?

Almost impossible to ignore

An interesting explanation of dopamine's function--distinguishing drive and motivation from pleasure and reward:

In the emerging view, discussed in part at the Society for Neuroscience meeting last week in Chicago, dopamine is less about pleasure and reward than about drive and motivation, about figuring out what you have to do to survive and then doing it. “When you can’t breathe, and you’re gasping for air, would you call that pleasurable?” said Nora D. Volkow, a dopamine researcher and director of the National Institute on Drug Abuse. “Or when you’re so hungry that you eat something disgusting, is that pleasurable?”

In both responses, Dr. Volkow said, the gasping for oxygen and the wolfing down of something you would ordinarily spurn, the dopamine pathways of the brain are at full throttle. “The whole brain is of one mindset,” she said. “The intense drive to get you out of a state of deprivation and keep you alive.”

Dopamine is also part of the brain’s salience filter, its get-a-load-of-this device. “You can’t pay attention to everything, but you want to be adept as an organism at recognizing things that are novel,” Dr. Volkow said. “You might not notice a fly in the room, but if that fly was fluorescent, your dopamine cells would fire.”

In addition, our dopamine-driven salience detector will focus on familiar objects that we have imbued with high value, both positive and negative: objects we want and objects we fear. If we love chocolate, our dopamine neurons will most likely start to fire at the sight of a pert little chocolate bean lying on the counter. But if we fear cockroaches, those same neurons may fire even harder when we notice that the “bean” has six legs. The pleasurable taste of chocolate per se, however, or the anxiety of cockroach phobia, may well be the handiwork of other signaling molecules, like opiates or stress hormones. Dopamine simply makes a relevant object almost impossible to ignore.

Lozenge/Patch Combo Best for Kicking Butts

Encouraging findings for people trying to quit smoking:

Smokers are more than twice as likely to quit if they use the nicotine patch along with nicotine lozenges—compared to lozenges or patches alone, buproprion (Xyban), buproprion plus the lozenges or placebo.  The trial was the largest study ever to compare these approaches head to head, and included 1,504 smokers.

All of the treatment groups did better than placebo—but the effect was strongest for the patch/lozenge combination, 40% of whom successfully kicked the habit.  Smokers using this combo were not only more likely to quit, but also less likely to have a “slip” prompt a return to regular smoking.

The study adds support to a growing body of research that suggests that offering addicts access to drugs similar to their drug of choice—or even that drug itself—can actually help them quit or at least dramatically reduce the harm associated with their addiction.

Placing this in the context of offering drug replacements to addicts is interesting food for thought. One important bit of context is that these were people who were trying to quit and the overarching goal of helping professionals with smokers is to try to help them quit, not reduce use. The nicotine addicts I know want full recovery. They want to be completely smoke free, and the few people I know who have been on nicotine replacement for years still really want to stop but can't. The system encourages their moves toward quitting completely and supports gradual change. That seems to be an important part of any lessons drawn from treatment for nicotine addiction. The focus of heroin maintenance is not to stabilize people while moving them toward quitting, it's to maintain them because we've concluded that they can't quit.

Gemini and Granny Growers

A mini pot tab dump:

• Baby Boomers and retirees are plunging into the medical marijuana business
• A short history of Gemini Dream

Recovery pandemic

holy cow, it’s happening to you too.

Androcles writes a nice post on the infectious nature of recovery and hope.

Substance Abuse Prevention Dollars and Cents

From a recent government report:

1.1. Costs of Substance Abuse
Studies have shown the annual cost of substance abuse to the Nation to be $510.8 billion in 1999 (Harwood, 2000). More specifically,

• Alcohol abuse cost the Nation $191.6 billion;
• Tobacco use cost the Nation $167.8 billion;
• Drug abuse cost the Nation $151.4 billion.

Substance abuse clearly is among the most costly health problems in the United States. Among national estimates of the costs of illness for 33 diseases and conditions, alcohol ranked second, tobacco ranked sixth, and drug disorders ranked seventh (National Institutes of Health [NIH], 2000). This report shows that programs designed to prevent substance abuse can reduce these costs.

1.2. Savings From Effective School-Based Substance Abuse Prevention
If effective prevention programs were implemented nationwide, substance abuse initiation would decline for 1.5 million youth and be delayed for 2 years on average. It has been well established that a delay in onset reduces subsequent problems later in life (Grant & Dawson, 1997; Lynskey et al., 2003). In 2003, an estimated:

• 5.6 percent fewer youth ages 13–15 would have engaged in drinking;
• 10.2 percent fewer youth would have used marijuana;
• 30.2 percent fewer youth would have used cocaine;
• 8.0 percent fewer youth would have smoked regularly.

The average effective school-based program in 2002 costs $220 per pupil including materials and teacher training, and these programs could save an estimated $18 per $1 invested if implemented nationwide. Nationwide, full implementation of school-based effective programming in 2002 would have had the following fiscal impact:

Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis

• Saved State and local governments $1.3 billion, including $1.05 billion in educational costs within 2 years;
• Reduced social costs of substance-abuse-related medical care, other resources, and lost productivity over a lifetime by an estimated $33.7 billion;
• Preserved the quality of life over a lifetime valued at $65 billion.

Although 80 percent of American youth reported participation in school-based prevention in 2005 (SAMHSA, 2004), only 20 percent were exposed to effective prevention programs (Flewelling et al., 2005).

Massive, Risky and Expensive

Mark Kleiman responds to pushback on some of his alternatives to incarceration:

The suggestion that various non-punitive programs might control crime, and that doing so was preferable, ceteris paribus, to controlling crime by inflicting damage on offenders, met with an especially furious response, mostly centered on the phrase “liberal social engineering.”  But the project of putting 1% of the adult population behind bars — an incarceration rate five times as high as any other advanced democracy, and five times as high as the U.S. ever had before 1975 — is itself a massive, massively risky, and expensive  social-engineering project, and no less massive, risky, or expensive for never having been thought through.   It also involves a completely unprecedented expansion of the power of the state over the individual.

If all taxation is theft, then the $200 billion required to support the current policing, adjudication, and corrections systems is just as much “stolen” as the much smaller sums that might be usefully expended on improving parental performance by poor young first-time mothers, removing lead from the environment, or improving classroom discipline.  If people who call themselves fiscal conservatives understood that a sentence of life without parole imposed on an 18-year-old represented a present-value expenditure of $1 million, the enthusiasm for “throwing away the key” might be diminished.  (An execution, including the due process required — but not sufficient — to prevent the execution of the innocent, costs more.)

In my view, crime at current levels is such a social problem that even substantial increase in the $200 billion criminal-justice budget would be justified by even modest decreases in crime.  If we can spend an extra $10 billion a year to have reduced crime and reduced incarceration, so much the better.

Now for the specifics:

1.  Evidence about the capacity of nurse-family partnerships to reduce offending by more than 50% (based on a randomized controlled trial) is here.

2.  Evidence about the impact of lead on crime takes two forms:  individual-level studies, and econometric studies. The results are consistent, and the effect sizes are large. Moreover, the biology is understood: lead, even at low levels, damages cognitive function, and lower-level cognitive functioning reduces deterrability, thus increasing crime. Moreover, lead does specific damage to impulse control.

Therefore, lead causes crime, and removing lead reduces crime.  It does so more cost-effectively than increasing incarceration, and it has side-benefits rather than side-costs.

3. I have no doubt that a minimum legal drinking age of 21 reduces drinking among minors, and that relaxing that rule would increase drinking (and drinking-related problems) in that population. It also generates massive disobedience and the mass acquisition of false ID.   Increased alcohol taxes are effective in reducing drinking, and especially in reducing heavy, problem drinking (since an extra tax of a dime a drink wouldn’t much bother someone who averages a drink a day). The biggest impacts are on heavy drinking by minors, whose incomes tend to be limited.  A combination of relaxing the age restriction and raising the price could reduce heavy drinking while avoiding the criminalization of mass behavior.

British Drug Classification

Andrew Sullivan offers a clear and concise summary of the an initiative to reclassify drugs (the classifications are used to determine criminal penalties).

Take the question of alcohol and tobacco out of the discussion and it seems quite sensible. Add alcohol and tobacco back and you have a firestorm. Is this about being too soft on drugs, or is this about protecting the status of alcohol and tobacco?

Wounded Systems of Care

We spend a lot of time talking about recovery-oriented systems of care. Important, but should we first look at facilitating recovery for our systems of care?

Peapod writes about healing treatment systems (systems, not clients). She draws from a recent Bill White document about the Philadelphia experience and describes a critical juncture:

In Philadelphia in 2004, they decided to tackle the things that were wrong in their services. They did a giant exercise in information gathering, something they called a ‘fearless inventory’ after the AA fourth step. You can see the detail here:

They uncovered that some unhealthy stuff was going on. Organisations were not talking to each other. They existed like islands connected by drawbridges that ‘were permanently up’.

Focus groups uncovered “an underlying tone of paternalism, disrespect and, at times, outright contempt.”

The right sentence

The Washington Post looks toward the end of the crack/powder cocaine sentencing disparity with some ambivalence. It appears that they failed to consider whether prison sentences are an effective tool for addressing the harm associated with crack use.

IN THE 1980s, entire communities were devastated by the addiction and violence that accompanied crack, a smokable form of cocaine. Congress reacted by passing extraordinarily tough laws, including one that mandated a minimum prison sentence of five years for those in possession of as little as five grams of crack. Those arrested with 50 grams were automatically slapped with a 10-year sentence.

This supposed solution, backed at the time by many in the Congressional Black Caucus, turned out to be destructive also. Tens of thousands of black men -- many of them first-time offenders with no history of violent crime -- found themselves behind bars for inordinately long periods. White and Hispanic offenders -- those most often collared for powder cocaine violations -- had to be caught with 100 times the amount of powder to trigger the same mandatory minimum sentences.

. . .


smoking crack delivers a faster, more intense high than snorting powder and that this high is more short-lived, thus compelling most crack users to seek additional doses of the drug. The differences in addiction rates between crack and powder are not enormous, but they are real, and the study also notes that crack users often experience faster rates of physical deterioration than do those who consume powder. The report notes that roughly one-fourth of crack offenders are associated with violence, and that this rate exceeds that for powder cocaine offenders. As in the 1980s, predominantly African American communities continue to bear the brunt of the crime and addiction brought on by this awful drug.

These facts suggest that there should be some difference in the penalties for crack and powder cocaine, but how much? This is a difficult question to answer with precision, so perhaps the best solution would be to eliminate the mandatory minimums for both crack and powder and build into the sentencing guidelines tougher penalty ranges for crack that judges could apply on a case-by-case basis