Cocaine Vaccine Hits Snag

Over at Addiction Inbox, Dirk Hanson reports on findings from a trial of the new cocaine vaccine and provides a succint description of its mechanism:

Some cocaine addicts appear willing to risk overdose in order to defeat a new cocaine vaccine, a recent study has shown.

The study, which appeared in the Archives of General Psychiatry, demonstrated that the TA-CD vaccine could blunt the effects of cocaine in some, but not all, patients. The vaccine works by causing the production of antibodies, which attach themselves to cocaine molecules, making the molecules too big too pass effectively through the blood-brain barrier.

Of 115 addicts involved in the study, only 38 % produced sufficient antibodies to dull the effects of cocaine, Rachel Saslow of theWashington Post reported. And among the high-antibodies group, only 53 % stayed free of cocaine 50 % of the time. “Immunization did not achieve complete abstinence from cocaine use,” said Thomas Kosten of Baylor college of Medicine, one of the authors of the paper.

Moreover, in some of the study participants for whom antibodies made cocaine a disappointing high, researchers found cocaine levels in the body to be as much as ten times higher than previous levels of usage—an obvious attempt to overcome the vaccine’s effectiveness. There were no overdoses, according to Kosten.

Politics, Science and Harm Reduction

Macleans has an interesting column making the case for the role of politics in decisions about programs like Insite:

...each person’s own opinions on federalism may not line up neatly with his views on drug policy. Indeed, if you are a strong centralist when it comes to Confederation AND you loathe the Harper government, or you’re just a centralizer who favours harm reduction, it seems to me that the Insite controversy has painted you into a rather awkward corner.

As far as I can tell, we are not having the kind of debate that would force such a person to say “I hate that those anti-science Conservative nutbars are trying to crush Insite, but they certainly have the right to do so.” Nor are we hearing from decentralizing socons who might say “I sure hate the idea of doctors getting paid good money to hover over diseased vermin while they irrigate their veins with poison, but as much as I like the Prime Minister, he should damn well stay out of B.C.’s business.”

I would add that this fundamental constitutional question is all the more important because, unlike many fellow libertarians and supporters of harm reduction, I don’t really believe that the value of safe-injection clinics is something that can be settled by a simple appeal to the authority of science. Science is well-placed to answer narrow, specific measurement questions about drug policy: “Did Insite reduce the number of overdose deaths in the region between years X and Y?”, for example. By answering such questions, it can provide the material for a broader assessment of the worth of such programs. But it cannot decide by fiat.

Insite has to be judged by its effects on many groups of citizens—not just the drug users who visit Insite, but the drug users who don’t and won’t; the families and loved ones of both groups of addicts; the dealers; the cops; the ordinary people who live near the clinic, and elsewhere in the region; the B.C. government, its treasury, and its taxpayers. (An environmentalist, or a Lorax, would even say that the non-human world should have a voice.) Within none of these groups are the effects simple or quantifiable by means of a single number, and all of the groups may have different claims to moral consideration, claims that there can be no universal agreement on. Moreover, the integrity of the criminal law and the public’s respect for it do count for something—maybe not much, but not zero—in this equation. The defender of Conservative policy would argue that this makes us all parties to the controversy, even outside B.C.

In short, science can’t provide us with a simple, scalar Benthamite answer to the net utility of Insite. To oppose Insite is not to be opposed to “science”, though a lot of scientists like Insite. Whether the clinic ought to exist is a question well-suited to be answered by political means: public and private argument, consensus-building, horse-trading, the consulting and balancing of moral principles, et cetera. Since this is the case, the question of what political unit should have the power to make the decision—the federation, or the province—is both crucial and urgent.

The problem of free will in addiction

Philosophy bites has an interview with Thomas Pink on free will that I think touches on points important to thinking about addiction.

It's my anecdotal sense that much of the resistance to the disease model comes from concerns about free will. Specifically, that the disease model suggests a loss of free will (or, a kind of determinism), at least in this one area of the addict's life. The problem here is this: if the person is not in control of their behavior, how can we hold them accountable or assign blame for the bad things that they they do or that result from their AOD use? This isn't a small matter. This kind of accountability is an important social glue.

This podcast (18 minutes) does a good job exploring the matter of blame and free will, but, more importantly, addresses the apparent incompatibility between free will and determinism by suggesting that we conceptualize them improperly.

A helpful metaphor is offered: If a machine has two controllers (one controller representing deterministic factors and the other representing free will), does that mean that only one controller works? Or, is it possible that they both are capable of controlling the machine?

Here and Now with A. Thomas McLellan

Here and Now has a good, brief interview with A. Thomas McLellan.Hea

Not on the same side

Doctors criticise ‘reckless’ drug abuse guidance

"I Want Heidi Fleiss To Get Well ... But I Don't Think Celebrity Rehab Is The Solution"

I don't usually post this kind of thing, but I've always had a soft spot for Juliana Hatfield. I think she's a little too kind to Dr. Drew.

I think money -- and the possibility of renewed visibility leading to future job offers -- is the only legitimate, honest motivation for anyone to go on "C.R." (Celebrity Rehab) I suspect that another reason people do go on the show -- disregarding the fact that they are so drug- and booze-addled that they simply cannot make any rational or intelligent decisions about anything -- is that they crave attention and fame. These people -- especially these people -- will never get clean unless they disappear; out of Hollywood, off of TV.

Addiction treatment afflicted with Baumol's cost disease

I'd never heard of this guy or "Baumol's cost disease", but it makes a lot of sense and is has difficult implications for the future of of addiction treatment, particularly for providers that serve indigent populations or focus on offering affordable care.

Update: I got a few questions about this. The implication for programs is that, because there is little or no chance for gains in efficiency, programs must make more money every year just to maintain the status quo. Prices are just about the only lever that programs have.

Words used to describe substance-use patients can alter attitudes, contribute to stigma

This study highlights something that's always troubled me about efforts to frame addiction as a chronic illness, that it could be more likely to increase stigma rather than decrease it.

Part of the appeal of the acute model is that it offers a narrative of permanent transformation. There are two concerns about the disease model that I hear over and over again that contribute to stigma.

The first concerns personal responsibility--that if we accept the disease model and destigmatize addiction, we're letting people off the hook for bad decisions. This concern focuses on behavior prior to recovery and the chronic model offers nothing new to address these concerns.

The second concern is that addicts and alcoholics don't change and that recovery either isn't a realistic possibility for most addicts or that recovery doesn't mean what advocates say it means. Some argue that alcoholics will never really quit, others might argue that the real problem is character and when you sober up a drunken horse thief you still have a sober horse thief. This fear of recidivism (or the expected persistence of anti-social behavior that's attributed to all addicts) contributes to disease model resistance and stigma. The acute model's narrative of permanent transformation, offers a (too often false) response to this fear. The chronic model's emphasis on lifelong vulnerability contributes to these fears that recovery is temporary and unstable.

Some will invest a lot of time in micro-examining word usage to improve "messaging". I don't think that this is the answer. I believe the problem is that our message is incomplete. What we say about the illness of addiction isn't the problem. The problem is that we have very little to say about recovery.

For this reason, Bill White wrote a piece calling for research into the neurobiology of recovery. It's well worth the time to read it.

Fear Mongers Attack a NYC Harm Reduction Pamphlet that Saves Lives

Earlier this week I predicted that critics of injection drug using instructions would be accused of moral panic. I was a little off, the accusation is fear mongering.

As I said, I can imagine circumstances where this could have some value in preventing illness and facilitating recovery, but I suspect that the people producing these materials do not share my goal of recovery.

I do not oppose harm reduction, if it's aligned with the goal of facilitating recovery.

I understand that there is scientific evidence demonstrating that HR reduces disease transmission and other health problems, but some of these advocates are very tone deaf. While accusing others of moral panic or fear mongering, they fail to comprehend the way many of us view addiction--as something akin to slavery due to compromised free will where drug use is concerned.

Would there be a basis of for criticizing programs targeting slaves to enhance their health and life satisfaction? On its face, helping improve health and wellbeing is a good thing, but wouldn't it be better to also be an abolishionist?

Some more narrow public health examples might be programs to educate and provide sterile cutting equipment to people who engage in self-mutilation or communities that practice female circumcision.

Is it unreasonable to question these responses to these problems? Is it too much to ask that the professional helpers participating in these responses seek to facilitate an end to the behavior? Why is that so controversial?

On the other hand, a reader offered the following comment:

Unfortunately the tone and language of the article would seem to suggest that some "critics" do seem guilty of judgmentalness, if not exactly "moral panic"

• "offers dope fiends such useful advice"
• "spells out how junkies should ready their fix"

if the article was describing advice for hypertensives or diabetics the language would likely be a little more respectful.

Jane Doe :)

NIAAA Official Says Alcoholism 'Isn't Usually' a 'Chronic, Relapsing Disease'

Jacob Sullum enjoys a gotcha moment with Mark Willenbring.

After reading the original article, I don't see this as the Perry Mason moment that Sullum does. The article suffers from the same problem that many articles on the subject do--it does a poor job of distinguishing when we're talking about DSM dependence and when we're talking about DSM abuse. The implications for each are vastly different. Most people with DSM abuse will find that their problems eventually resolve on their own or when other primary problems are resolved. For those with DSM dependence, the conventional wisdom has been that they all need professional treatment and that they all need professional treatment and they all need to abstain completely. We're learning more about how this is not universal. Part of the problem has been categorization of problem drinkers. People with temporary, rather than chronic, alcohol problems may meet diagnostic criteria for dependence and then "mature out". The example that most easily comes to mind are college students who engage in frequent heavy drinking and then moderate when they graduate, get married, or decide that it will interfere with their goals. That's what this article examines.

What I find very interesting is the libertarian hostility toward the disease model of alcoholism. I read this a few days ago and was wondering if the objection was that the model challenges individual agency. A peek at the comments this morning suggests that the objections do coalesce around three issues:

• An objection to the notion that free will (and, therefore, personal responsibility) is compromised.
• The spirituality of AA.
• That framing heavy drinking as something other than a personal choice opens the door to medical and state interference in a person's life.
  
• That treatment doesn't look like treatment for the medical conditions that come to mind.

Heroin for dummies

Responses to this will be interesting to watch. I'm certain that people who object will be accused of moral panic or something like it.

I'm open to non-judgmental outreach harm reduction for the purpose of building relationships and gradually engaging people into recovery.

I'd like to know how these materials are being used. Are they in the hands of hopeful recovery-informed outreach workers who are building relationships and building motivation to recover? Or, something else?

I've posted about gradualism and recovery-oriented harm reduction before.

I've been thinking about a model of recovery-oriented harm reductionthat 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

Comparing Outcomes of ‘Voluntary’ and ‘Quasi-Compulsory’ Treatment of Substance Dependence in Europe

Another study finding that coerced treatment is just as effective as voluntary treatment.

This is important for drug courts, employers and families.

It also raises important questions about the utility of the stages of change for treatment placement. The conventional wisdom is that less motivated people should not be provided higher levels of care. These findings suggest that treatment outcomes are not a good argument for this approach.

This should be of limited comfort, though. The treatment system fails to attract too many people and relies too much on external coercion.

Charlie Sheen blames drinking for attack on wife, but is that really the cause?

Short answer, "no!"

We've written a lot on the subject. More here:

• Guidelines for working with batterers
• Guidelines for working with survivors
• Barriers Preventing Effective Communication Between Domestic Violence and Addiction Professionals
• But I was drunk!

Rising alcohol addiction costs 'could cripple the NHS'

A reader (thanks Foppe) shared this article with me about the burden addiction is placing on Britain's NHS.

I have a couple of reactions. This could be looked at as a simple reporting of facts on a public health issue. But, why do we never hear stories about cardiac disease crippling health systems? Cancer? Other diseases?

The answers that pop into my mind are that the health system (and society) doesn't consider addiction as being under their purview, they don't feel ownership of the problem. There are a lot of reasons for this, including the existence of a categorically segregated and that, beyond detox, treatment does not look like traditional medical treatment. (Though the emergence of disease management protocols has expanded the role of the medical system and recovery management seeks to integrate primary care into addiction treatment.)

The other answer that comes into my mind is that it's an expression of stigma--passive-aggressive whining about how much "those people" are costing the rest of us.