Culture and the placebo effect

Patrick Appel at The Daily Dish looks at the placebo effect and culture:

Wired says it's getting stronger:

[T]he placebo response is highly sensitive to cultural differences. Anthropologist Daniel Moerman found that Germans are high placebo reactors in trials of ulcer drugs but low in trials of drugs for hypertension—an undertreated condition in Germany, where many people pop pills for herzinsuffizienz, or low blood pressure. Moreover, a pill's shape, size, branding, and price all influence its effects on the body. Soothing blue capsules make more effective tranquilizers than angry red ones, except among Italian men, for whom the color blue is associated with their national soccer team—Forza Azzurri!

Mind Hacks parses. Another nugget:

[W]hy would the placebo effect seem to be getting stronger worldwide? Part of the answer may be found in the drug industry's own success in marketing its products.  Potential trial volunteers in the US have been deluged with ads for prescription medications since 1997, when the FDA amended its policy on direct-to-consumer advertising. The secret of running an effective campaign, Saatchi & Saatchi's Jim Joseph told a trade journal last year, is associating a particular brand-name medication with other aspects of life that promote peace of mind: "Is it time with your children? Is it a good book curled up on the couch? Is it your favorite television show? Is it a little purple pill that helps you get rid of acid reflux?" By evoking such uplifting associations, researchers say, the ads set up the kind of expectations that induce a formidable placebo response.

Technorati Tags: research, placebo, medication

Make a Gratitude Adjustment

A good article on the relationship between gratitude and happiness.

A psychology professor at the University of Michigan, Peterson regularly gave his students an unusual homework assignment. He asked them to write a "gratitude letter," a kind of belated thank-you note to someone in their lives. Studies show such letters provide long-lasting mood boosts to the writers. Indeed, after the exercise, Peterson says his students feel happier "100 percent of the time."

...The biggest bonuses come from experiencing gratitude habitually, but natural ingrates needn't despair. Simple exercises can give even skeptics a short-term mood boost, and "once you get started, you find more and more things to be grateful for," says Robert Emmons, a leading gratitude researcher at the University of California at Davis.

In gratitude letters like those penned by Peterson and his students, writers detail the kindnesses of someone they've never properly thanked. Read this letter aloud to the person you're thanking, Peterson says, and you'll see measurable improvements in your mood. Studies show that for a full month after a "gratitude visit" (in which a person makes an appointment to read the letter to the recipient), happiness levels tend to go up, while boredom and other negative feelings go down. In fact, the gratitude visit is more effective than any other exercise in positive psychology.

...Traumatic memories fade into the background for people who regularly feel grateful, Watkins's experiments show. Troublesome thoughts pop up less frequently and with less intensity, which suggests that gratitude may enhance emotional healing.

My first sponsor had me make gratitude lists daily for more than a year (until I moved away). I had been suffering from crippling depression and I believed that the suggestion of a gratitude list was dismissive of my suffering and indicated a failure to comprehend the complexity, seriousness and persistence of the problem. Was I wrong. Over time it was one of the most effective tools I've acquired in combating that episode and staving off potential episodes since then.

Technorati Tags: depression, trauma, gratitude, research

Depression's Evolutionary Roots

Researchers hypothesize that depression is an adaptation rather than dysfunction:

One reason to suspect that depression is an adaptation, not a malfunction, comes from research into a molecule in the brain known as the 5HT1A receptor. The 5HT1A receptor binds to serotonin, another brain molecule that is highly implicated in depression and is the target of most current antidepressant medications. Rodents lacking this receptor show fewer depressive symptoms in response to stress, which suggests that it is somehow involved in promoting depression. (Pharmaceutical companies, in fact, are designing the next generation of antidepressant medications to target this receptor.) When scientists have compared the composition of the functional part rat 5HT1A receptor to that of humans, it is 99 percent similar, which suggests that it is so important that natural selection has preserved it. The ability to “turn on” depression would seem to be important, then, not an accident.

This is not to say that depression is not a problem. Depressed people often have trouble performing everyday activities, they can’t concentrate on their work, they tend to socially isolate themselves, they are lethargic, and they often lose the ability to take pleasure from such activities such as eating and sex. Some can plunge into severe, lengthy, and even life-threatening bouts of depression.

So what could be so useful about depression? Depressed people often think intensely about their problems. These thoughts are called ruminations; they are persistent and depressed people have difficulty thinking about anything else. Numerous studies have also shown that this thinking style is often highly analytical. They dwell on a complex problem, breaking it down into smaller components, which are considered one at a time.

Read the whole thing. Pretty interesting.

Technorati Tags: depression, research

Even anesthesiologists

Amazing what happens when addicts are provided with high quality treatment of the appropriate duration and intensity.

Abstract

BACKGROUND: Anesthesiologists have a higher rate of substance use disorders than other physicians, and their prognoses and advisability to return to anesthesiology practice after treatment remain controversial. Over the past 25 yr, physician health programs (PHPs), created under authority of state medical regulatory boards, have become primary resources for management and monitoring of physicians with substance abuse and other mental health disorders.

METHODS: We conducted a 5-yr, longitudinal, cohort study involving 904 physicians consecutively admitted to 1 of 16 state PHPs between 1995 and 2001. This report analyzed a subset of the data involving the 102 anesthesiologists among the subjects and compared them with other physicians. The main outcome measures included relapse (defined as any unauthorized addictive substance use, including alcohol), return to anesthesiology practice, disciplinary actions, physician death, and patient harm.

RESULTS: Anesthesiologists were significantly less likely to enroll in a PHP because of alcohol abuse (odds ratio [OR] 0.4 [confidence interval {CI}: 0.2–0.6], P < 0.001) and much more likely to enroll because of opioid abuse (OR 2.8 [CI: 1.7–4.4], P < 0.001). Anesthesiologists had a higher rate of IV drug use, 41% vs 10% (OR 6.3 [CI: 3.8–10.7], P < 0.001). During similar periods of monitoring, anesthesiologists received more drug tests, 101 vs 82 (mean difference = 19 [CI: 3–35], P = 0.02); however, anesthesiologists were less likely to fail at least one drug test during monitoring, 11% vs 23% (OR 0.4 [CI: 0.2–0.9], P = 0.02). There was no statistical difference among rates of program completion, disciplinary actions, return to practice, or deaths, and there was no report of significant patient harm from relapse in any record.

CONCLUSIONS: Anesthesiologists in our sample treated and monitored for substance disorders under supervision of PHPs had excellent outcomes similar to other physicians, with no higher mortality, relapse rate, or disciplinary rate and no evidence in their records of patient harm. It is postulated that differences of study design account for contradictory conclusions from other reports.

Technorati Tags: research, physicians, treatment

My name is Roger...

Roger Ebert breaks his anonymity:

You may be wondering, in fact, why I'm violating the A.A. policy of anonymity and outing myself. A.A. is anonymous not because of shame but because of prudence; people who go public with their newly-found sobriety have an alarming tendency to relapse. Case studies: those pathetic celebrities who check into rehab and hold a press conference.

In my case, I haven't taken a drink for 30 years, and this is God's truth: Since the first A.A. meeting I attended, I have never wanted to. Since surgery in July of 2006 I have literally not been able to drink at all. Unless I go insane and start pouring booze into my g-tube, I believe I'm reasonably safe. So consider this blog entry what A.A. calls a "12th step," which means sharing the program with others. There's a chance somebody will read this and take the steps toward sobriety.

He responds to some of the most common criticisms (I know he doesn't recognize that many people are coerced.):

The God word. The critics never quote the words "as we understood God." Nobody in A.A. cares how you understand him, and would never tell you how you should understand him. I went to a few meetings of "4A" ("Alcoholics and Agnostics in A.A."), but they spent too much time talking about God. The important thing is not how you define a Higher Power. The important thing is that you don't consider yourself to be your own Higher Power, because your own best thinking found your bottom for you. One sweet lady said her higher power was a radiator in the Mustard Seed, "because when I see it, I know I'm sober."

Sober. A.A. believes there is an enormous difference between bring dry and being sober. It is not enough to simply abstain. You need to heal and repair the damage to yourself and others. We talk about "white-knuckle sobriety," which might mean, "I'm sober as long as I hold onto the arms of this chair." People who are dry but not sober are on a "dry drunk."

A "cult?" How can that be, when it's free, nobody profits and nobody is in charge? A.A. is an oral tradition reaching back to that first meeting between Bill W. and Doctor Bob in the lobby of an Akron hotel. They'd tried psychiatry, the church, the Cure. Maybe, they thought, drunks can help each other, and pass it along. A.A. has spread to every continent and into countless languages, and remains essentially invisible. I was dumbfounded to discover there was a meeting all along right down the hall from my desk.

The most remarkable things is that the comments are civil. (Even with several references to other paths to recovery.)

Technorati Tags: AA, cult, god

Dogma?

Tim Leighton takes on what he refers to as "Randomized Controlled Trial dogma."

Keep in mind he's writing from the U.K., where the treatment landscape is very different. To be sure, over the years various dogmas (12-step, psychiatrization, moral models, etc.) have stifled progress in effectively treating addictions. Unfortunately, some of the criticism of treatment and the recovery movement seem more like the assertion of a new dogma rather than constructive critical thinking.

What are dogmas for? They are doctrines which safeguard certain interests. People crave dogmatic authority because, as T.S. Eliot said, ‘human kind cannot bear too much reality’.

It is not hard to see what interests might be served by an insistence that only RCTs count as evidence in evaluating interventions for substance misuse problems. First, it saves a lot of time and effort, as this insistence precludes the necessity of evaluating more complex, difficult, often ambiguous evidence.

It serves commercial interests as it offers an opportunity to legitimate your product as ‘evidence-based’; it serves the interest of health-care rationing, as it severely curtails what will be made available; it serves the interest of many researchers and research institutes, particularly psychologists and medical researchers, who are trained in setting up and conducting randomised controlled trials, and who are keen to publish their work. It is much easier to get an RCT published in an addictions or psychology journal than any other kind of research (because of the orthodoxy – this may be changing, gradually).

Our field is in the view of quite a few people in the process of a paradigm shift. I agree. The thing about such a shift is that nobody can predict its exact form or timetable.

Technorati Tags: research, addiction, treatment

Autonomy, mastery, purpose and motivation

Dan Pink gave a talk on motivation and rewards at the TED conference. Of course, his talk has nothing to do with addiction, recovery or treatment. He is talking about management in the business world, not addiction treatment, but one can't help but wonder what lessons could be drawn from this.

He argues that "if/then" rewards work only for very simple tasks. Further, for more complicated tasks, ones that require creativity, rewards actually harm outcomes. He argues that for these more complicated tasks, an approach organized around autonomy, mastery and purpose are what leads to the best outcomes.

It seems like this philosophy would lend itself to motivational interviewing. It emphasizes tapping internal vs. external motivation. At one point he says that rewards are helpful for obtaining compliance but not engagement. If these lessons have any application to addiction treatment, this makes one wonder about the long term value of contingency management. Time will tell, but I found this to be a pretty interesting talk.

Technorati Tags: motivation, addiction, rewards, contingency management

Nevermind the teens...

New analysis from SAMHSA indicates that the drug use trends for boomers are far more troubling than the trends for youth.

Technorati Tags: drugs, boomers, trends, research

Early drinking, genetics and dependence

A new study offers some answers to the questions provoked by studies finding a strong relationship between early drinking and dependence later in life. Those questions center around the nature of this relationship: is the early drinking related to genetic or environmental factors that predispose the person for alcohol dependence? or, does early drinking change the brain in ways that leads to alcohol dependence?

This study determines that "genetic risk accounts in large part for this association."

Technorati Tags: alcoholism, research

More on heroin as treatment for heroin addiction

Mark Kleiman makes an important point about the heroin maintenance study released last week and the flaws in the coverage of the study. (Previous post here.)

John Tierney cites NYT reporter Benedict Carey for the claim that " treating hard-core heroin addicts with their drug of choice seems to work better than treating them with methadone." But neither Carey nor the paper Carey reports on makes any such claim. The study wasn't among "hard-core heroin addicts" generally, but among addicts who had already failed on methadone treatment.

I've devoted a lot of posts to this issue. In spite of what's been suggested in comments, I'm not a one-wayist, but it's hard to see this as anything other than an approach rooted in the idea that these people are beyond help and untreatable. Much of the analysis I've read focuses on social benefits rather than benefits to the individual. When they've tried treating these people with the same methods we've offered physicians and failed, then, maybe, there's a case for experimenting with this kind of approach.

Technorati Tags: heroin, harm reduction, recovery, addiction

Major Mexican reform

They've decriminalized possession of small amounts.

Mexico has enacted a controversial law that decriminalizes possession of small amounts of marijuana, cocaine and heroin.

The law defines "personal use" amounts for those drugs, as well as LSD and methamphetamines.

It says people found with those amounts will not face criminal prosecution, but that if caught a third time they will be required to complete treatment programs, though no punishment is specified to enforce that.

Technorati Tags: Mexico, decriminalization, policy

Drunk driving arrests of women increase

Hard to know what to make of this. It would help if they provided a little context. What are the general trends in drunk driving arrests? In alcohol consumption?

Arrests for women driving under the influence jumped by nearly 30 percent during the decade ending in 2007, according to a study released Wednesday by the U.S. Transportation Department.

I suppose it should be too much of a surprise give we've been seeing increases in binge drinking by girls.

Technorati Tags: alcohol, drunk driving, women

Fraud!

Eric Sterling takes the positions that pot should be legal and that it has medical value but the practice of medical marijuana in California amounts to fraud:

...the ease with which basically healthy persons are able to acquire marijuana in the guise of being ill is offensive. It is hard to avoid judging what appears to be a scam because the scam threatens to produce a backlash or reaction that may result in denying cannabis medicine to those who suffer and should be able to use it. The scam perception creates a another stigma for those who are seriously ill and use cannabis. Stigma one -- you are breaking the law. Stigma two -- you are a scam artist.

Technorati Tags: medical marijuana, legalization, marijuana, pot

Recovery?

Heroin better for addicts in recovery. Really? Recovery? Really?

Here's the abstract.

Raises some interesting questions about the future of the word recovery.

There's been discussion in recent years about being more inclusive with concept of recovery to make room for medication-assisted recovery, serial recovery, partial recovery, 12-step, faith based, secular, solo, etc. To be sure, many had defined it too narrowly. But, at what point does it lose its meaning? Could we get to the point where people using their drug of choice under medical supervision are considered to be in recovery? Is this headline an indication that it is already losing its meaning?

Time magazine had a piece a while ago on Baclofen and the possibility of it turning some problem drinkers into "normal" (nonproblem) drinkers. If it lives up to the hype, (I'm skeptical.) it will be a good thing. But, are those people "in recovery"? They're well, they're better, etc.

This is bound to be a woefully incomplete discussion of the concept (I'm trying to get out of the house.), but I'll get the ball rolling. "In recovery" has taken on a certain cultural meaning for people in and out of recovery--that a person had experienced the devastating and consuming effects of addiction to drugs and/or alcohol and has now organized multiple dimensions of their life around recovering from the illness and the devastation caused by the illness. (Like, say, someone who suffers a heart attack and changes their diet, starts to exercise, takes meds, takes responsibility for monitoring their health, etc.) Does someone who's problem is solved by simply taking a pill qualify? Is it important that there be a label and a distinction?

Technorati Tags: heroin, baclofen, recovery, addiction, alcoholism

I had no idea you felt that way...

From the LA Times:

Of the many things that long-term alcohol addiction can steal -- careers, lives, health, memory -- one of its most heartbreaking tolls is on relationships. Alcoholics, researchers have long known, have a tendency to misread emotional cues, sometimes taking offense when none was intended or failing to pick up on a loved one's sadness, joy, anger or disappointment.

The misunderstandings can result in more drinking, and more deterioration of relationships and lives.

How does alcohol do all that? A new study finds that the brains of long-term alcoholics, even those who have long abstained, often differ from nonalcoholics' in ways that make them poorer judges of facial expressions. In particular, alcoholics register less intensity in the amygdala and hippocampus (collectively known as the limbic system) when observing faces. [emphasis mine]

Technorati Tags: alcoholism, brain

Dawn Farm's kindred spirit

Two acres of hope for recovering addicts

Legal Prostitution in Australia a "Failure"

I wonder if there are lessons here for drug legalization? Maybe not, but what might the unintended consequences be? As I've said, you could change law enforcement priorities without changing the legal status of drugs.

The University of Queensland Working Group on Human Trafficking recently released a report stating that the prostitution laws in Australia had failed.  Since 1999, women in Australia have had the option of working legally in licensed brothels or on their own.  The hope was that women with an entrepreneurial spirit and a passion for commercial sex would set up their own businesses, and make everything safe, legal, and regulated.  That hasn't happened.

What has happened, instead, is entrepreneurial pimps have lured and trafficked Asian women to Australia and set up illegal brothels with lower prices. Trafficking is "booming" in Queensland, and there are few laws to help protect women who are lured or coerced into prostitution against their will. And as legal brothels try and compete with the trafficking boom, they cut costs, which often involves cutting freedom and benefits for women.  Even in the legal, liscenced brothels of Queensland, women have reported being coerced into working under unfair conditions or against their will.

Technorati Tags: legalization

On a completely different note...

This post is a little off topic for this blog, but bear with me.

My family lost my cousin, Matt, to suicide 5 years ago. Matt was a wonderful person. Just weeks away from graduating from Rutgers and had lined up an internship with a major labor union. He was also a musician and had a wicked sense of humor. He left behind many devastated friends and family who loved him dearly and were shocked at his death. He had a bright future and was taken far too early.

I'm asking for your help to prevent other families from suffering this kind of loss.

I will be joining with thousands of people nationwide this fall to walk in AFSP's Ann Arbor Walk 2009 Out of the Darkness Community Walk to benefit the American Foundation for Suicide Prevention. I would appreciate any support that you give me for this worthwhile cause.

The American Foundation for Suicide Prevention is at the forefront of research, education and prevention initiatives designed to reduce loss of life from suicide. With more than 33,000 lives lost each year in the U.S. and over one million worldwide, the importance of AFSP's mission has never been greater, nor our work more urgent.

I hope you will consider supporting my participation in this event. Any contribution will help the work of AFSP, and all donations are 100% tax deductible.

Donating online is safe and easy! Just visit my fundraising page and click the "Support This Participant" button on this page.

Thank you!

Priorities, Priorities, Priorities

Matt Yglesias on drug legalization:

Tactics like the High Point Initiative appear to work as ways of shutting down overt drug markets. If a city can do that in its most problematic areas, the best thing to do seems to me to be to have its police . . . move on to worrying about something else. If people are selling drugs in a manner that’s not a nuisance for their neighbors and doesn’t involve violence, why not turn a blind eye? The knowledge that drug dealers who aren’t making problems for others will be left alone should encourage people to try to find less destructive business models. That’s still a far cry from saying that there should be heroin at the corner store, while CrackCo International hires the top marketing minds and lobbyists in the country to dream up exciting new ways of turning kids into addicts.

Technorati Tags: legalization, enforcement, policy

Neil McKeganey on safe injecting centres

Neil McKeganey thoughtfully shares his ambivalence about safe injecting centers in this video. talks about them as places of despair that, in the existing context, may be better than not creating them. He goes on to talk about what a woefully inadequate response they are and that they do not call for the rest of us to give ourselves a pat on the back.

This is a very good thing

Let's hope he's given the power to align policy research from places like TRI and Lighthouse:

The Senate yesterday confirmed University of Pennsylvania psychologist A. Thomas McLellan as deputy director of the White House Office of National Drug Control Policy.

The vote, by unanimous consent, means that McLellan will be the No. 2 to Gil Kerlikowske, the former police chief of Seattle, who was confirmed this year as the office's director, better known as the drug czar.

McLellan, a leading researcher in addiction and treatment, will be charged with reducing the nation's demand for drugs.

Until his nomination by President Obama in April, McLellan, 60, was executive director of the Treatment Research Institute, a nonprofit he cofounded in Philadelphia 17 years ago to study and compare treatments and to translate scientific findings into clinical practice and public policy.

Technorati Tags: policy, addiction, drugs, ONDCP