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Thanks to the Recovery Academy for including this blog in their newsletter.

Science can answer moral questions

Recently, I've had a few posts arguing that values are critical for making meaning of evidence and that values are embedded in scientific research. I suppose one point I've been making is that those who claim to be objective may believe that they are objective, but they are not.

Sam Harris argues for objectivity in morality and values.

Much of my worldview predisposes me to be sympathetic with his argument, but I find his sauce to be pretty weak. This may seem like a diversion, but isn't this often what we're talking about when we translate research to policy?

What he said...

I've tried several times to make the point that there is no such thing as "value free" interventions and policy decisions. This chapter makes the point better than I can:

Policy research is commonly presented as a value-free endeavour but, logically speaking, practical conclusions cannot be derived solely from facts. In research methodology, to attempt to do so is termed the `Naturalistic Fallacy.' Consequently, the term `evidence-based policy'--if interpreted literally--constitutes a contradiction in itself (oxymoron). This chapter will also deal with several other fallacies that are encountered in empirical addiction research, will reveal some popular concepts to be inconsistent and illogical advocacy tools, and will argue that the specific role of a researcher is completely incompatible with the role of an advocate for certain ideas and/or interest groups.

...

Statements can be dichotomised into descriptive statements (factual judgements about what is) and prescriptive statements (value judgements about what ought to be done). The latter are referred to as ethical judgements. It is well accepted in philosophy (Hume's Law) that ethical judgements cannot be derived logically from empirical facts alone. Any syllogism to arrive at ethical conclusions requires at least one ethical premise as well. The flawed idea of basing ethical conclusions purely on empirical facts was called the `Naturalistic Fallacy' by Moore, and has become a well-known term in research methodology. On the basis of facts, only factual conclusions can be derived. However, this does not mean that ethical issues cannot be a topic for empirical research--the opposite is true. It is essential to identify implicit value judgements and to make them explicit. Only if all implicit value judgements in our scientific reasoning are made explicit is it possible to analyse whether the ethical premises are consistent with each other,* with basic ethical principles and with factual evidence. I have previously termed the process of identifying and analysing implicit values in research `ethical evaluation', but this term is ambiguous since it could mean either `to conduct evaluations according to ethical standards' or `to evaluate the ethical content in research.' More precise is the term `evaluation of implicit ethics' or the almost synonymous `evaluation of implicit values.'

Odds Are, It's Wrong

Researchers' dirty little secret:

“There is increasing concern,” declared epidemiologist John Ioannidis in a highly cited 2005 paper in PLoS Medicine, “that in modern research, false findings may be the majority or even the vast majority of published research claims.”

Ioannidis claimed to prove that more than half of published findings are false, but his analysis came under fire for statistical shortcomings of its own. “It may be true, but he didn’t prove it,” says biostatistician Steven Goodman of the Johns Hopkins University School of Public Health. On the other hand, says Goodman, the basic message stands. “There are more false claims made in the medical literature than anybody appreciates,” he says. “There’s no question about that.”

...

Statistical problems also afflict the “gold standard” for medical research, the randomized, controlled clinical trials that test drugs for their ability to cure or their power to harm. Such trials assign patients at random to receive either the substance being tested or a placebo, typically a sugar pill; random selection supposedly guarantees that patients’ personal characteristics won’t bias the choice of who gets the actual treatment. But in practice, selection biases may still occur, Vance Berger and Sherri Weinstein noted in 2004 in ControlledClinical Trials. “Some of the benefits ascribed to randomization, for example that it eliminates all selection bias, can better be described as fantasy than reality,” they wrote.

Trauma, Chemical Use and Addiction

Can't make the Dawn Farm Education Series? Catch the most recent presentation, Trauma, with the slidecast below.

Trauma, Chemical Use and Addiction - March 2010

View more presentations from jschwartz.

tab dump

• Of Genes and Gin
• R. Gil Kerlikowske speaks on his job as nation's drug czar
• Not smart: Guardian misquotes

9 Medical Marijuana Ads

9 Medical Marijuana Ads

The Spread of Goodness

Jonah Lehrer reports on findings that human behavior is contagious whether it's obesity, optimism or generosity.

He added this postscript with a reader comment. I suspect it's one explanation for the healing and sustaining power of communities of recovery:

Update: I've gotten a few emails wondering what this means for free will. After all, if our decisions are so determined by the decisions of others, then where is there space for human autonomy? My first reaction is that the new science of social networks still leaves plenty of elbow room for individual decisions. We're talking about risk factors and tendencies and statistical correlations. Just because we're influenced by others doesn't mean we can't reject those influences. I asked James Fowler a related question last year and this was his eloquent response:

Everyone always tells me that this research is so depressing and that it means we don't have free will. But I think they're forgetting to look at the flipside. Because of social networks, your actions aren't just having an impact on what you do, or on what your friends do, but on thousands of other people too. So if I go home and I make an effort to be in a good mood, I'm not just making my wife happy, or my children happy. I'm also making the friends of my children happy. My choices have a ripple effect.

AA “unethical” says SMART recovery founder

I saw this article yesterday and chose not to comment, but now that PeaPod has, I'll join his chorus. I had a similar reaction. I was disappointed in two things:

• It's too bad that this person can't just promote Smart Recovery as an alternative without bashing AA.
• The author adopted the critics language, presenting it as fact without context.

Oh well. It's nothing new and it won't be the last time. I recognize that people in twelve step recovery can be just as judgmental. More recovery is a good thing. Too bad we can't all just get along.

Evidence for what?

Stanley Fish:

While secular discourse, in the form of statistical analyses, controlled experiments and rational decision-trees, can yield banks of data that can then be subdivided and refined in more ways than we can count, it cannot tell us what that data means or what to do with it. No matter how much information you pile up and how sophisticated are the analytical operations you perform, you will never get one millimeter closer to the moment when you can move from the piled-up information to some lesson or imperative it points to; for it doesn’t point anywhere; it just sits there, inert and empty.

He is arguing that discussions about weighty matters fall apart in a secular context. I couldn't disagree more. Though I do think he's onto something. Evidence, by itself, leads nowhere. It needs context and something else to give it meaning. I believe that "something else" that animates these discussions are our values. Further, I believe that this is the case whether our values are recognized or not and that it's important for all parties to put their values on the table for examination and discussion.

America's largest service provider for addicts

Unsurprising news from CASA:

Of the 2.3 million inmates crowding our nations prisons and jails, 1.5 million meet the DSM IV medical criteria for substance abuse or addiction, and another 458,000, while not meeting the strict DSM IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation; or shared some combination of these characteristics, according to Behind Bars II: Substance Abuse and America’s Prison Population. Combined these two groups constitute 85 percent of the U.S. prison population.

Worst of the proposed DSM-V

The newly proposed substance use disorder diagnostic criteria made a "worst of" list for the DSM V.

Two takes on Insite and another on harm reduction

First, a columnist from the Calgary Herald says that Insite doesn't do enough to change addicts:

Corey Ogilvie wanted to document life in Vancouver's notorious downtown eastside (DTES) by spending 30 days living alongside the residents of North America's poorest, most destitute and drug-infested neighbourhood. Film clips of his journey are posted on the Internet and, as one would expect, are highly revealing.

In one clip, he determines he must do drugs to understand addiction. While coming down from a crack high, he decides to try heroin. So his street buddies send him to Insite, Vancouver's safe injection site.

Ogilvie's smuggled camera reveals Insite staff doing everything but stick the needle in his arm as they aid him in his quest. A staff member shows him how to prepare the heroin, fill the syringe and find a vein. He's clearly a novice and the worker asks the obvious question, "So, can I ask? Why the drug use?"

When Ogilvie fails to offer much of a response, the worker offers an upbeat, "It's OK. You don't have to say anything. It's not a big deal."

...

I was very impressed with the sincerity and concern that Insite staff have for those who come through their doors. They are truly kind and compassionate, and provide addicts with a very human (and humanizing) element to their day. For that, I offer kudos.

Yet I came away thinking that Insite's main gauge of success is engagement, not treating addiction, reducing numbers of addicts or providing addicts with a way out. Maybe social interaction is enough for some, but I remain unconvinced that facilitating drug injections and perpetuating a destructive lifestyle is the best way to afford someone their human dignity. These non-judgmental interactions may make addicts feel better about their behaviour, but I didn't sense that the Insite philosophy had any room for the notion that addicts could actually change their behaviour -- at least not the addicts in the DTES.

Insite does have 12 detox beds and 18 'transitional' beds for those who are hoping to get into treatment. They have daily programs such as yoga, health care or counselling for these residents. But, again, I never got the sense that they had much hope for addicts beyond the Insite facilities.

Insite leaders seemed uncertain about what treatment facilities existed and where they were located, but still insisted that they weren't the kind of facilities that would be a good fit for DTES addicts. I'm under no illusion that there are sufficient treatment facilities available, but isn't any addict going to be out-of-his-comfort zone in an addiction treatment facility? Since the intent is to change lifestyle patterns, I would certainly hope so.

Meanwhile, a blogger for Phoenix House gives them the benefit of the doubt:

...when I looked at Insite’s website, I was encouraged by the fact that the facility is actually part of a larger organization that provides “a complete continuum of services,” including prevention, opioid replacement therapy, residential treatment, and housing support. An addiction counselor is part of Insite’s staff and, in its second year of operation, it made 2,000 referrals to other services. A New England Journal of Medicine study found that, because Insite removes barriers to treatment, its clients—who may not be well connected to the health care system—have increased their use of detox and withdrawal programs.

If Insite’s advocates want a real shot at challenging critics, they should emphasize that it is not a stand-alone operation, but a “rung on the ladder” from “chronic drug addiction to recovery.” People suffering the devastating effects of substance abuse cannot change their lives overnight. But, getting off the street and coming to a place like Insite—where medical professionals can help them get the care they need—may be the first step in the process. I hope future media coverage of Insite offers this perspective.

Finally, the blog, The Art of Life Itself, describes ab approach to harm reduction that embraces recovery.

Low-Tech Treatment May Be Best for Addiction

This Newsweek piece offers a little perspective on pharmacology and behavioral treatments for addiction:

Freud was a disaster for psychiatry, but not because his theory of the mind inspired his acolytes to exclude physical and chemical processes from explanations of thoughts, emotion, and behaviors. No, the disaster has been the extreme backlash against that nonmaterialist, touchy-feely approach. As neuroscience has blossomed in the last two decades, it has left virtually everything that smacks of psychiatry in the dust. In a nutshell, and not to get too Cartesian, but the brain has replaced the mind.
...

Consider the excitement over cocaine vaccines. Composed of a bacterial protein plus a molecule that is a coke look-alike, they train the immune system to produce antibodies against both. The antibodies also bind to cocaine, preventing it from entering the brain and causing a high. The good news is that the vaccine makes crack less pleasurable, notes Meg Haney of Columbia University, who led a 2010 vaccine study. That suggests the vaccine indeed kept the drug out of the brain. The bad news is that the level of antibodies in the volunteers (55 coke users in a 2009 study, 10 crack users in Haney's) varied widely. Only 38 percent of the coke users produced enough antibodies to dull the effects of cocaine, and, of those, only half stayed clean more than half the time.

In contrast, a 2008 analysis of 34 studies of behavioral treatments for addiction to cocaine, marijuana, and other drugs showed impressive efficacy. "There is still no generally effective [medication]" for coke, pot, and meth addictions, notes psychiatry professor Kathleen Carroll of Yale University. "But the behavioral therapies we have are quite good," bringing a 67 percent improvement. Yet that research gets the response of the proverbial tree falling in an empty forest.

...the National Institute on Drug Abuse, which has been terrific in funding behavioral approaches to addiction. It has had so much success in developing and validating behavioral therapies "that we don't need more research to show they work," says NIDA director Nora Volkow. Consider a new study she led with colleagues at Brookhaven National Laboratory. They showed cocaine users pictures of coke and coke paraphernalia, which usually makes activity in the brain's limbic (emotion) regions spike, causing intense craving. The scientists taught the users to suppress that activity. That success, says Volkow, "provides enormous hope," implying that cognitive interventions might enable cocaine abusers to "block the drug-craving response to help them avoid relapse." The problem is implementation, and Volkow is "trying to direct more funding to that." One wonders how much more could be accomplished if it got more than table scraps. Especially if cognitive and behavioral approaches can overcome their lack of sex appeal.

It's not too late to save 'normal'

A chairperson from the DSM-IV makes a plea to avoid what she has now concluded were mistakes:

Our panel tried hard to be conservative and careful but inadvertently contributed to three false "epidemics" -- attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many "patients" who might have been far better off never entering the mental health system.

The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.

Willpower as an exhaustible resource

A new book called Switch targeting business types has a lot of food for thought about addiction.

First, the authors explore the tension between the emotional brain and the rational brain:

The unavoidable conclusion is this: Your brain isn’t of one mind.

...

But, to us, the duo’s tension is captured best by an analogy used by University of Virginia psychologist Jonathan Haidt in his wonderful book The Happiness Hypothesis. Haidt says that our emotional side is an Elephant and our rational side is its Rider. Perched atop the Elephant, the Rider holds the reins and seems to be the leader. But the Rider’s control is precarious because the Rider is so small relative to the Elephant. Anytime the six-ton Elephant and the Rider disagree about which direction to go, the Rider is going to lose. He’s completely overmatched. Most of us are all too familiar with situations in which our Elephant overpowers our Rider.

You’ve experienced this if you’ve ever slept in, overeaten, dialed up your ex at midnight, procrastinated, tried to quit smoking and failed, skipped the gym, gotten angry and said something you regretted, abandoned your Spanish or piano lessons, refused to speak up in a meeting because you were scared, and so on. Good thing no one is keeping score.

The weakness of the Elephant, our emotional and instinctive side, is clear: It’s lazy and skittish, often looking for the quick payoff (ice cream cone) over the long-term payoff (being thin). When change efforts fail, it’s usually the Elephant’s fault, since the kinds of change we want typically involve short-term sacrifices for long-term payoffs. (We cut back on expenses today to yield a better balance sheet next year. We avoid ice cream today for a better body next year.) Changes often fail because the Rider simply can’t keep the Elephant on the road long enough to reach the destination.

The Elephant’s hunger for instant gratification is the opposite of the Rider’s strength, which is the ability to think long-term, to plan, to think beyond the moment (all those things that your pet can’t do).

But what may surprise you is that the Elephant also has enormous strengths and that the Rider has crippling weaknesses. The Elephant isn’t always the bad guy. Emotion is the Elephant’s turf—love and compassion and sympathy and loyalty. That fierce instinct you have to protect your kids against harm—that’s the Elephant. That spine-stiffening you feel when you need to stand up for yourself—that’s the Elephant.

And even more important if you’re contemplating a change, the Elephant is the one who gets things done. To make progress toward a goal, whether it’s noble or crass, requires the energy and drive of the Elephant. And this strength is the mirror image of the Rider’s great weakness: spinning his wheels. The Rider tends to overanalyze and overthink things. Chances are, you know people with Rider problems: your friend who can agonize for twenty minutes about what to eat for dinner; your colleague who can brainstorm about new ideas for hours but can’t ever seem to make a decision.

If you want to change things, you’ve got to appeal to both. The Rider provides the planning and direction, and the Elephant provides the energy. So if you reach the Riders of your team but not the Elephants, team members will have understanding without motivation. If you reach their Elephants but not their Riders, they’ll have passion without direction. In both cases, the flaws can be paralyzing. A reluctant Elephant and a wheel-spinning Rider can both ensure that nothing changes. But when Elephants and Riders move together, change can come easily.

They then frame willpower as an "exhaustible resource":

To see this point more clearly, consider the behavior of some college students who participated in a study about “food perception” (or so they were told). They reported to the lab a bit hungry; they’d been asked not to eat for at least three hours beforehand. They were led to a room that smelled amazing— the researchers had just baked chocolate-chip cookies. On a table in the center of the room were two bowls. One held a sampling of chocolates, along with the warm, fresh-baked chocolate-chip cookies they’d smelled. The other bowl held a bunch of radishes.

The researchers had prepped a cover story: We’ve selected chocolates and radishes because they have highly distinctive tastes. Tomorrow, we’ll contact you and ask about your memory of the taste sensations you experienced while eating them.

Half the participants were asked to eat two or three cookies and some chocolate candies, but no radishes. The other half were asked to eat at least two or three radishes, but no cookies. While they ate, the researchers left the room, intending, rather sadistically, to induce temptation: They wanted those poor radish-eaters to sit there, alone, nibbling on rabbit food, glancing enviously at the fresh-baked cookies. (It probably goes without saying that the cookie-eaters experienced no great struggle in resisting the radishes.) Despite the temptation, all participants ate what they were asked to eat, and none of the radish-eaters snuck a cookie. That’s willpower at work.

At that point, the “taste study” was officially over, and another group of researchers entered with a second, supposedly unrelated study: We’re trying to find who’s better at solving problems, college students or high school students. This framing was intended to get the college students to puff out their chests and take the forthcoming task seriously.

The college students were presented with a series of puzzles that required them to trace a complicated geometric shape without retracing any lines and without lifting their pencils from the paper. They were given multiple sheets of paper so they could try over and over. In reality, the puzzles were designed to be unsolvable. The researchers wanted to see how long the college students would persist in a difficult, frustrating task before they finally gave up.

The “untempted” students, who had not had to resist eating the chocolate-chip cookies, spent 19 minutes on the task, making 34 well-intentioned attempts to solve the problem. The radish-eaters were less persistent. They gave up after only 8 minutes—less than half the time spent by the cookie-eaters—and they managed only 19 solution attempts. Why did they quit so easily?

The answer may surprise you: They ran out of self-control. In studies like this one, psychologists have discovered that self-control is an exhaustible resource. It’s like doing bench presses at the gym. The first one is easy, when your muscles are fresh. But with each additional repetition, your muscles get more exhausted, until you can’t lift the bar again. The radish-eaters had drained their self-control by resisting the cookies. So when their Elephants, inevitably, started complaining about the puzzle task—it’s too hard, it’s no fun, we’re no good at this—their Riders didn’t have enough strength to yank on the reins for more than 8 minutes. Meanwhile, the cookie-eaters had a fresh, untaxed Rider, who fought off the Elephant for 19 minutes.

Book Review: Thinking Simply About Addiction

Dirk Hansen reviews Thinking Simply About Addiction: A Handbook for Recovery and describes its interesting spin on the concept of powerlessness:

While acknowledging that addiction is “correctly understood as a disease,” Sandor diverges a bit from the mainstream disease theory of addiction, believing that addictions are “diseases of automaticity—automatisms—developments in the central nervous system that cannot be eliminated but can be rendered dormant.”

As examples of simple automatisms, Sandor cites bicycle riding and swimming, two behaviors it is impossible to “unlearn.” Consider swimming: If, for some reason, it became extremely dangerous for you to swim (pollution, a heart condition, sharks), the problem is that “you literally cannot choose not to swim. Your only reliable choice is to stay out of the water, to become abstinent.”

Much of the confusion over addiction, the author maintains, is that “we miss the essential quality that defines addiction as a disease: Something someone has rather than something they’re doing.”

What his addicted patients frequently tell him, Sandor writes, is that “the core experience of being addicted is powerlessness, the experience of having lost control over the use of alcohol or a drug.” As one addiction expert put it, addicts “have lost the freedom to abstain.” Like other forms of rehabilitation, says Sandor, “treatment doesn’t work or not work. The patient works. It seems obvious. If the very nature of addiction is automaticity—the loss of control—then recovery is the restoration of choice, not handing choices over to someone else.”