Not a Tiger Woods post

I've always struggled with how to talk about "process addictions" and other compulsive behaviors. More specifiically, how to distinguish them from AOD addiction.

A psychiatrist wrestles with sexual addiction and wonders if obsessive compulsive disorder (OCD) is the best way to conceptualize sexual addiction:

It seems difficult to me to distinguish OCD from so-called sexual addiction; perhaps the main difference would be that the individual is bothered by his behavior in one case (OCD) and not the other (addiction); yet this single minor subjective difference would seem to be a small feature upon which to base an entire diagnostic entity. Indeed, there appear to exist many cases of OCD without insight, that is, OCD in which the patient is not much bothered by his or her symptoms. OCD is not, traditional teaching notwithstanding, uniformly characterized by presence of insight (better phrasing than the old ego-dystonic term, in my view).

One reputable website defines sexual addiction as "a progressive intimacy disorder characterized by compulsive sexual thoughts and acts." DSM's definition, under paraphilias, as sexual disorders NOS includes the following ideas: "compulsive searching for multiple partners, compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships and compulsive sexuality in a relationship." This kind of definition seems quite hard to distinguish from OCD with sexual content.

Who are you calling square?

On more thought from the author of the book I referenced last night:

One of the things I’ve become most aware of while working on this book is the degree to which cultural critics inside and outside of the academy write about phenomena that reflect and reinforce their own tastes and worldviews. There’s a lot of writing out there about addiction, because addiction, despite its tragic dimension, retains a sheen of cool. Drug and alcohol use and abuse are dis-inhibiting; they de-stabilize social norms. Without too much effort, we can see them as heroic challenges to the staid routines of our uptight bourgeois lives.

Recovery culture, by contrast, is really square, both as aesthetics and as politics. ... It’s this squareness, I think, that has led critics to overlook the complexity of recovery—its existence as a cultural formation with a genuine intellectual and social history that both reflects and helps to construct the larger economic, political, and psychic realities around it.

Those who are predisposed to disagree will dismiss this (and vice versa), but I think that this speaks directly to the coolness many in recovery feel toward "empirical" knowledge of the issue. I think it also speaks to the appeal of harm reduction for many (not all, by any stretch) practitioners.

terra incognita?

A new book offers a wide ranging look at addiction as a cultural phenomena. The description of the tension with academia is interesting:

At another level, however, this book addresses a blind spot that seems particularly to affect academic researchers. Many recovering people have good reasons for not inquiring into the intellectual genealogies of their programs. For good or ill, their interests in recovery philosophy are primarily practical. Later chapters discuss the fact that they may even be urged by those around them not to take an overly analytical or intellectual view of their program lest they derail their quests for sobriety. The same is not true, however, for academics, whose lack of knowledge of and incuriosity about recovery is often so complete as to seem decidedly willful. While the well-educated humanist or qualitative social scientist is expected to have at least a passing familiarity with the standard premises of psychoanalysis, the recovery movement’s most basic history and its structuring ideas are, for all intents and purposes, a terra incognita to most such scholars. Therefore, a second aim of this book is to establish recovery—its history, its organizing principles, and its culture, among other things—as a legitimate subject for sustained scholarly analysis.

There are exceptions to this rule of academic neglect, of course. Existing scholarly research on recovery falls into two general categories, and though neither type of work has sought to answer the cultural questions that I find most compelling, I have drawn heavily on both while writing this book. First and not surprisingly, an abundant body of research has explored the medical/psychological and public health dimensions of 12-Step approaches to alcoholism and other addictions. Since it began to be generated during the late 1940s, the vast bulk of this scholarship has centered on questions of efficacy: does 12-Step recovery, with its focus on abstinence and spirituality, successfully break addictive habits? This practical question would seem well suited to empirical social scientific inquiry, but the ‘‘Anonymous’’ nature of 12-Step culture means that collecting meaningful data on the topic is and always has been difficult. Moreover, much research on this question is fiercely partisan, undertaken by scholars whose stakes in particular treatment protocols (and the private and governmental funds that legitimate them) often seem to predetermine their research outcomes. As a result, the question of whether, how, and to what degree 12-Step approaches to addiction are effective remains largely unresolved.

The Wisdom of Cochrane

The group that reached this conclusion:

The available experimental studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence compared with other treatments, but there were some limitations with these studies. Furthermore, many different interventions were often compared in the same study and too many hypotheses were tested at the same time to identify factors which determine treatment success.

strikes again:

Psychostimulants did not improve cocaine use, had an unclear beneficial effect over sustained cocaine abstinence and were not associated with higher retention in treatment. Psychostimulants did not increase risk of serious adverse events. It was found that psychostimulants could be efficacious for some groups of patients, such as methadone maintained dual heroin-cocaine addicts. Therefore, psychostimulants, though have not proved yet their efficacy for cocaine dependence, deserve further investigation.

A Review of Alcoholics Anonymous/ Narcotics Anonymous Programs for Teens

Recently published:

The investigation of the applicability of Alcoholics Anonymous/Narcotics Anonymous (AA/NA) for teens has only been a subject of empirical research investigation since the early 1990s. In the present review, the author describes teen involvement in AA/NA programming, provides an exhaustive review of the outcomes of 19 studies that used an AA/NA model as part of their formal teen substance abuse treatment programs, and provides data on the effects of AA/NA attendance on abstinence at follow-up, on which youth tend to become involved in AA/NA, and on mediation of the benefits of AA/NA participation. In addition, the author suggests the reasons for somewhat limited participation by teens in more informal, community-based 12-step meetings, and makes suggestions for maximizing participation at meetings in the community. The author concludes that AA/NA participation is a valuable modality of substance abuse treatment for teens and that much can be done to increase teen participation, though more research is needed.

Farm staff that want the entire article can email me.

Inside the "addiction cure"

What is there to say?

Putting substance "abuse" to rest

Bill White makes the case for ending the use of the word "abuse", as in substance abuse. He make's 5 arguments:

1. The term abuse applied to substance use disorders is technically inaccurate
2. The terms alcohol/drug/substance abuse/abuser reflect the misapplication of a morality-based language to depict a medical condition.
3. The terms abuse/abuser contribute to the social and professional stigma attached to substance use disorders and may inhibit help-seeking.
4. The terms abuse/abuser inaccurately portray the role of personal volition in substance use disorders.
5. The use of the abuse diagnosis by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) perpetuates and legitimizes the continued stigmatization of people with AOD problems.

CUOMO ANNOUNCES CHARGES AGAINST FORMER UB RESEARCHER FOR HIRING ACTORS TO TESTIFY DURING MISCONDUCT HEARING AND ATTEMPTING TO SIPHON $4 MILLION IN TAXPAYER FUNDS

Wow. This guy has written extensively on substance use disorders and domestic violence.

In September 2004, William Fals-Stewart, 48, of Eden, was accused of scientific misconduct for allegedly fabricating data in federally funded studies he was undertaking as an employee at the University at Buffalo and Research Institute on Addictions. According to court papers, the allegations were based upon discrepancies between the number of volunteers he reported to the National Institute for Drug Addiction relating to grants for which Fals-Stewart was the Principal Investigator, and the actual number of volunteers who participated in his studies.

According to the felony complaint, during a subsequent formal investigation launched by the University, three witnesses testified by telephone because Fals-Stewart claimed they were out of town. In reality, they were actors who thought they were taking part in a mock-trial. Fals-Stewart paid the actors to testify. He also provided them with scripts to use during the proceedings that were riddled with inaccuracies regarding his research. Fals-Stewart told the three actors, who he had hired before for legitimate training videos, that they would be performing in a mock trial training exercise. They were not aware that they were testifying at a real administrative hearing, nor did they know they were impersonating real people. Because of these false testimonies, Fals-Stewart was exonerated at the administrative hearing.

Claiming that the misconduct allegations tarnished his reputation, Fals-Stewart sued the University, seeking $4 million from the state in damages. The Office of the Attorney General, in its role of defending the University and the state in the court action, conducted a thorough investigation of the claims against the University. It was during this investigation that Cuomo’s office discovered the alleged fraud, forced Fals-Stewart to withdraw his lawsuit and initiated a criminal investigation.

Fals-Stewart was arrested today and charged in Buffalo City Court with Attempted Grand Larceny in the First Degree (class C felony); three counts of Perjury in the First Degree (class D felony); three counts of Identity Theft in the First Degree (class D felony); two counts of Offering a False Instrument for Filing in the First Degree (class E felony); and three counts of Falsifying Business Records in the First Degree (class E felony). The maximum permissible sentence for a class C felony is 15 years in prison.

The sociology of drinking

A lot of people have sent this to me. I don't know what to say about it.

I have an attraction/aversion thing with Gladwell. He's a great writer and fascinating, but I can't read him without thinking of this Mencken quote, "For every complex problem there is an answer that is clear, simple, and wrong."

I also tend to think this a situation of the exception proving the rule. Looking to an isolated culture with aberrant drinking patterns for universal truths doesn't seem to make a lot of sense.

It's a Bird, It's a Plane, It's... Methadone Man?

Hmmm.

I'm open to harm reduction, but I'm troubled by the culture of many harm reductionists.

Needle exchange raises weighty Catholic moral questions

It will be interesting to watch the Catholic church wrestle with the ethics of needle exchange.

Psychotropic prescribing

Two stories from recent news:

This NPR story reports that antipsychotics are Medicaid's largest drug expense. That's astonishing.

A friend sent this story on the potential for harm when people without severe depression are prescribed antidepressants:

Half of patients do not respond when they are given the medications, which can be powerful tool in helping the depressed to feel better. Instead of raising levels of a "happiness chemical", called serotonin, in their brain, they lower them.

The researchers found with some brain cells "the more antidepressants try to increase serotonin production, the less serotonin (they) actually produce,” said Dr Rene Hen, from Columbia University in New York and a researcher at the New York State Psychiatric Institute, who led the study.

Substance-Related Disorders | APA DSM-5

The APA is planning to eliminate substance dependence and substance abuse from the DSM-5 and is planning to replace them with "[insert drug name]-use disorder". Here are the proposed alcohol-use disorder criteria.

They propose severity specifiers, which is interesting. However, at first glance, I'm concerned about putting abuse and dependence on the same continuum, though I was always pretty ambivalent about abuse as a diagnosis anyway.

Your thoughts?

UPDATE: Let's hope they don't group "internet addiction" and opiate addiction:

Among the work group’s proposals is the recommendation that the diagnostic category include both substance use disorders and non-substance addictions. Gambling disorder has been moved into this category and there are other addiction-like behavioral disorders such as “Internet addiction” that will be considered as potential additions to this category as research data accumulate.

Does Alcohol Involvement Increase the Severity of Intimate Partner Violence?

A pretty intuitive finding. That domestic violence is more severe when alcohol is present.

Study Says Drinking with Your Kids Doesn't Prevent Abuse

Join Together reports:

Dutch teens who were allowed to drink alcohol at home drank more outside the home than their peers and -- along with other teens who drank -- were at increased risk of developing alcohol problems, according to researchers from Radboud University Nijmegen.

The study authors tracked 428 Dutch families with two children ages 13-15. They found that teens who drank at home also drank more on their own, and vice-versa, suggesting that teen drinking begets more teen drinking regardless of setting.

"The idea is generally based on common sense," said researcher Haske van der Vorst. "For example, the thinking is that if parents show good behavior -- here, modest drinking -- then the child will copy it. Another assumption is that parents can control their child's drinking by drinking with the child."

However, the study demonstrated that, "If parents want to reduce the risk that their child will become a heavy drinker or problem drinker in adolescence, they should try to postpone the age at which their child starts drinking," said van der Vorst.

The research was published in the January 2010 issue of theJournal of Studies on Alcohol and Drugs.

Injection center coverage

Slate has a couple of dispatches on "Vancouver's experiment with helping addicts get high"

A commentary accuses opponents of "contempt for science"

I don't oppose harm reduction but, like this blogger, I see no reason why a recovery orientation could not be introduced in every harm reduction service.

The zeal for insite and contempt for critics make me wonder what their feeling would be about programs that distribute sleeping bags to homeless people to prevent frostbite and exposure deaths? These programs exist and there's one in my community.

Of course, there's one important difference. They engage in considerable advocacy, and not for more sleeping bags or tents, but for housing.

UPDATE: Peapod mentioned "evidence" below. Along the lines of his comment, we could produce studies and reams of evidence that sleeping bag distribution prevents frostbite and reduce exposure deaths, right? Does that make it the right thing to do? Maybe. Does that make it an adequate response? No. Does that mean that, in the establishment of priorities, it should trump other responses? No.

ONDCP talks recovery

New Drug Policy Approach Focuses on the Vital Role of Recovery. See page 2.

Good news

2010 Federal Budget Boosts Funding for Mental Health and Substance Abuse Programs

AA and depression

From Addiction:

ABSTRACT
Rationale Indices of negative affect, such as depression, have been implicated in stress-induced pathways to alcohol relapse. Empirically supported continuing care resources, such as Alcoholics Anonymous (AA), emphasize reducing negative affect to reduce relapse risk, but little research has been conducted to examine putative affective mechanisms of AA's effects.

Methods Using lagged, controlled, hierarchical linear modeling and mediational analyses this study investigated whether AA participation mobilized changes in depression symptoms and whether such changes explained subsequent reductions in alcohol use. Alcohol-dependent adults (n = 1706), receiving treatment as part of a clinical trial, were assessed at intake, 3, 6, 9, 12 and 15 months.

Results Findings revealed elevated levels of depression compared to the general population, which decreased during treatment and then remained stable over follow-up. Greater AA attendance was associated with better subsequent alcohol use outcomes and decreased depression. Greater depression was associated with heavier and more frequent drinking. Lagged mediation analyses revealed that the effects of AA on alcohol use was mediated partially by reductions in depression symptoms. However, this salutary effect on depression itself appeared to be explained by AA's proximal effect on reducing concurrent drinking.

Conclusions AA attendance was associated both concurrently and predictively with improved alcohol outcomes. Although AA attendance was associated additionally with subsequent improvements in depression, it did not predict such improvements over and above concurrent alcohol use. AA appears to lead both to improvements in alcohol use and psychological and emotional wellbeing which, in turn, may reinforce further abstinence and recovery-related change.