When the Cure Is Not Worth the Cost

Maia Szalavitz weighs in against parity in today's NYT.

On its face, providing equal coverage for mental and physical illnesses sounds like a good idea, something only a managed-care bean counter could oppose....Unfortunately, this change would not be as benign as it appears. Unless mental health parity is tied to evidence-based treatment and positive outcomes, generous benefits may become a profit bonanza for providers that does little to help patients.

Thanks to research by the National Institutes of Health and academic scientists during the last three decades, we now have proven treatments for depression, addiction and other mental disorders. But all too often clinicians do not use them.

...

Without financial incentives to provide treatments that are known to work, many mental health professionals stick with what they know, or pick up on the latest fad, or even introduce their own untested innovations — which in turn are spread by testimonials and credulous news media coverage.

According to a review by the Institute of Medicine in 2006, only 10.5 percent of alcoholics received “care consistent with scientific knowledge” of the disorder; similarly, 43 percent of children in psychiatric hospitals are given antipsychotic medication despite not suffering from psychosis. Tough boot camps for troubled teenagers — which have been proven to be ineffective and potentially harmful — thrive, while “multisystemic family therapy,” which effectively treats teenagers at home, is available only through the juvenile justice system.

Hmmm, where to begin? Let's start with "generous benefits may become a profit bonanza." While we still need to pass federal parity laws, we have a lot of experience with parity in this country. Some states have passed sweeping parity laws, some large employers have implemented it and federal employees have had parity since the 1990s. I haven't seen any studies of provider profit, but there is a lot of research on increases in spending following the implementation of parity. The impact on spending for mental health and substance abuse services ranges from a 9% decrease in spending to a 4% increase in spending. Current estimates of increases from the Wellstone Mental Health and Addiction Equity Acts hover around 1%. Hardly a bonanza. The truth is, when parity is implemented, managed care practices are implemented to limit costs.

As for use of evidence based practices, I went to the Institute of Medicine review she mentioned. The quote she pulled was from a New England Journal of Medicine article reporting on a RAND study. The study based its ratings on compliance with quality indicators. There were 5 quality indicators for alcohol dependence and only 2 were offered as examples: "Assessment of alcohol dependence among regular or binge drinkers" and "Treatment referral for persons given a diagnosis of alcohol dependence". The problem with both was "underuse."

I was unable to find the other 3 indicators, but this paints a different picture than the NYT Op-Ed suggests. First, these indicators seem to assess primary care providers, not specialty treatment providers. Second, one could argue that the compliance problem with both of these indicators might be caused or worsened by the absence of parity. Local primary care physicians often don't assess and make referrals because adequate care is out of reach for many of their patients.

Finally, offering the TV show "Intervention", forcing patients to identify as alcoholics, and teen boot camps as examples of modern treatment is a bad faith argument. It's a little like characterizing journalists by talking about Stephen Glass, Jayson Blair and Jack Kelley.

The interventionists I know describe "Intervention" as hopelessly old school and dated, which makes for much more entertaining TV. No treatment program I know of in our area "force[s] [patients] to identify themselves as alcoholics." In fact all heavily rely on Twelve Step Facilitation, Motivational Enhancement Therapy, and Cognitive Behavioral Therapy--all evidence-based practices. Finally, I don't know of any treatment provider or social worker referring a child to a boot camp.

One more thing. While treatment could undoubtedly be improved with greater emphasis on demonstrating outcomes or utilizing evidence-based practices (I won't get into the politics of evidence-based practices.), we know that treatment, even "treatment as usual", helps people and is cost-effective.

America's Forgotten War

NPR recently ran a series entitled America's Forgotten War. It includes a brief historical overview of the war on drugs and some interviews with players and people affected by drugs.

Expert: Risky teen behavior is all in the brain

This has something to make everyone mad. It challenges the value of prevention programs and questions the neurobiological capacity of kids to evaluate risk. This expert's solution is to exercise greater control over kids.

A new review of adolescent brain research suggests that society is wasting billions of dollars on education and intervention programs to dissuade teens from dangerous activities, because their immature brains are not yet capable of avoiding risky behaviors.

The analysis, by Temple University psychologist Laurence Steinberg, says stricter laws and policies limiting their behaviors would be more effective than education programs.

"We need to rethink our whole approach to preventing teen risk," says Steinberg, whose review of a decade of research is in the April issue of Current Directions in Psychological Science. It's published by the Association for Psychological Science.

"Adolescents are at an age where they do not have full capacity to control themselves," he says. "As adults, we need to do some of the controlling."

Neurological researchers around the country, spearheaded by Jay Giedd of the National Institute of Mental Health, have in recent years found that the brain is not fully developed until after 18. The brain system that regulates logic and reasoning develops before the area that regulates impulse and emotions, the researchers say.

Studies by Steinberg and others have found that the mere physical presence of peers increased the likelihood of teens taking risks.

Now he's using brain imaging to better understand why teens are so susceptible to peer pressure. He has just begun pilot projects to study brain activity in teens when doing various tasks with their peers, compared with adults under similar circumstances.

Steinberg believes raising the driving age, increasing the price of cigarettes and more strongly enforcing underage drinking laws are among ways to really curb risky behavior.

"I don't believe the problem behind teen risky behavior is a lack of knowledge. The programs do a good job in teaching kids the facts," he says. "Education alone doesn't work. It doesn't seem to affect their behavior."

Michael Bradley, a Philadelphia-area psychologist and author specializing in teenagers, says U.S. culture tends to view teens as small adults when, neurologically, they are large children.

"Kids will sign drug pledges. They really mean that, but when they get in a park on a Friday night with their friends, that pledge is nowhere to be found in their brain structure. They're missing the neurologic brakes that adults have."

Bradley also is worried about the future now that risky behaviors have trickled to the preteen set.

"People look at risk statistics, and they're more or less steady. It looks like things aren't getting that bad. But risk behaviors have been ratcheted down to younger and younger ages," he says. "What the parents may have dealt with at ages 16 and 17, the kids are dealing with at 11, 12 and 13 — at the time when their brains are least able to handle complex decisions about risk behaviors."

Such policy talk — even from psychologists — sparks a useful conversation, says Isabel Sawhill, co-director of the Center on Children and Families at the Washington-based Brookings Institution.

"It is good research for policymakers to consider, but we shouldn't infer from this research that all our past efforts have been ineffective," she says. "I'm not in favor of just doing education, but I'm also not in favor of not doing it, either. We need to do some of both."

Experts such as Sawhill and Caterina Roman, a senior research associate at the Washington-based Urban Institute, say some educational programs do work. But the widely popular Drug Abuse Resistance Education program known as DARE, launched in the 1980s, was determined to be ineffective.

Roman believes that recent findings that the teen brain is not yet fully developed will spawn some of the restrictions Steinberg recommends.

"Ten years from now, the driving age will be higher than it is now. The price of cigarettes will increase," she predicts.

Steinberg says he's not advocating a police state. But he says parents must help their children make wise decisions.

"We've given them too much freedom," he says. "We don't monitor and supervise them carefully enough."

Violence linked to price of beer

Economists examine the relationship between the price of beer and violence:

A research report published in Applied Economics has found that the number of patients with violence-related injuries treated in hospital emergency rooms is related to the price of beer.

...

The researchers examined admissions to 58 hospital accident and emergency departments over a five year period and found that as the price of beer increased, violence-related injuries decreased.

In general, studies have found that alcohol consumption increases both the risk of being a victim of violence and the perpetrator of it.

There are three main theories on why alcohol and violence are linked: i) due to the drug effects on the brain; ii) because people use alcohol as an excuse for violent behaviour; iii) because people who use alcohol might be more likely to be violent, perhaps due to personality factors like sensation-seeking, impulsivity or risk-taking.

Of course, these theories are not in competition and all the factors are likely to have some influence, but researchers are keen to find out how they interact to better understand the problem.

Interestingly, the Applied Economics study also looked at a number of other factors linked to violence and found that increases in poverty, unemployment, diversity of ethnic population, the summer months and major sporting events also independently predicted an increase in violence.

This combination of an economic and psychological approach to understand violence is particularly important for designing and implementing government or health service policies.

California drug treatment mandate must have proper support

Check out this editorial on Prop 36 in California. It provides some updates on the status of it and some background on how it works.

Kids Dying From Drugs And Alcohol: It's All About Supply And Demand

Kids Dying From Drugs And Alcohol: It's All About Supply And Demand:

A third of deaths among young people in developed countries such as Canada are caused by alcohol and illicit drugs....

“The drug that’s killing the greatest amount of young people globally is alcohol—nearly 90 per cent of substance-related deaths in developed countries such as Canada are due to alcohol,” says Stockwell. “A substantial dent could be made in these figures by combining regulatory, early-intervention and harm reduction approaches.”

Stockwell says regulating the price and physical availability of alcohol and tobacco is known to be highly effective. “These lessons could also be applied to the management of some other widely-used drugs such as cannabis,” he says. A previous CARBC study * showed cannabis is “very easy” to obtain in British Columbia and its use is more widespread among BC residents than the rest of Canadians.

Stockwell says another strategy is to reduce the demand for drugs by supporting young people and families at key stages in their development from before birth to teenage years. This includes educating parents on the dangers of using illicit substances during pregnancy and the risks associated with childhood exposure to second-hand smoke.

Harm reduction is another approach Stockwell highlights. Strategies such as random breath testing and graduated driver licensing have reduced the amount of driving-related deaths and injuries.

Barry R. McCaffrey: Methadone clinics are proven recovery tool for addicts

Barry McCaffrey weighs in on methadone in an opinion piece in a West Virginia paper. To his credit, he acknowledges being a board member of CRC Health Group, a for-profit corporation that claims to be the largest behavioral health care provider in the U.S. with more than $270 million in revenue last year and reported assets of $1.2 billion. They provide outpatient, residential and are a major methadone provider. It's also worth acknowledging that McCaffrey has been a methadone advocate for a long time.

Now to the substance. The column was written in response to community concerns about a clinic in the state. (CRC Health Group owns 7 of the 8 methadone programs in WV.) I don't have a problem with methadone being available to addicts who choose it, but I am troubled by the persistent myth that opiate addicts can't recover with drug-free treatment. We don't use methadone for opiate addicted health professionals. We use long-term treatment with intensive long-term monitoring and recovery support, and the outcomes are astonishing. Methadone is fine as one item on a comprehensive menu for clients to choose from, but I'm troubled by efforts to make methadone maintenance the default treatment. My experience in southeastern Michigan is that the complaints in the article above are credible.

This Week on Drugs

Here are some of the more absurd entries in The Stranger's This Week on Drugs:

Bad Medicine: DEA inaugurates 2005 meth law by busting man who bought seven boxes of Bronkaid.

Rough Rider: Woman gets DUI riding a horse.

Smooth Rider: Zamboni driver skates by DUI on thin ice.

Dairy Vows: Quit smoking.

Buds Bunny: Stuffed.

Interest Party: Guy nailed after applying for loan to buy crack.

Keith Richards: Not snorting family lines after all.

Law quells fear of aiding overdose victims : Local Politics : Albuquerque Tribune

After recently passing medical marijuana legislation, New Mexico passes a law providing partial immunity to people calling 911 for overdoses:

New Mexico has a new law aimed at encouraging those who overdose on drugs - and their friends, family or fellow partygoers - to call 911.

The measure, signed into law this week by Gov. Bill Richardson, provides limited immunity from prosecution for people who seek medical help for overdoses.

New Mexico is the first state to pass such a law, according to the National Conference of State Legislatures.

Tobacco as a model for illegal drugs

Two opinions that we should look to tobacco policy as a model for drug policy.

The first is from the Victoria Times Colonist:

We could have made tobacco illegal 20 years ago. But we chose a different approach -- managed use, with education and financial penalties to decrease smoking. And it's worked quite well.

So why not try the same approach with illicit drugs, or at least some of them? What if we say heroin and cocaine are like tobacco -- things we really wish people wouldn't use, but that we still accept some probably will.

Under that approach we would commit a lot of resources to making sure people didn't start, as we did with smoking. We'd target kids, but also vulnerable adults.

We'd make a big effort to help people quit, something we don't do today. And for people who wanted to keep using, we would prescribe heroin or cocaine or working substitutes. (The current half-hearted, restrictive methadone program really doesn't count.)

What are the downsides? It simply seems wrong to provide a drug like cocaine to people, for one thing. You could argue that others -- young people -- might see the practice as condoning drug use. (Though we've managed to allow controlled sale of tobacco products while condemning their use.)

Against those negatives, look at what we would gain. The people being prescribed the drugs wouldn't be stealing to get the money to buy them. Figure a 75-per-cent drop in property crime, conservatively, since Victoria police estimate up to 90 per cent of break-ins and thefts are drug-related. Police would be free to work on other problems and jails would be less crowded.

Organized criminals would lose a huge market. There would still be demand, but not enough to make the business attractive. Instead of spending their days and nights scrambling for money and drugs, users would have time to think about work and developing more stable lives.

Based on similar efforts in other countries, a significant number would seek treatment.

During a prescribed heroin trial in Switzerland, not only did crime by users plummet but about seven per cent quit during their time in the program.

Since people wouldn't be using drugs in alleys and dodgy settings, we'd save a fortune in health costs. Fewer overdoses, abscesses and infections. People with both mental health problems and addictions would get a chance to reduce the chaos in their lives and deal with their mental illness.

And all the while we'd be pushing for the same shift in attitudes toward drugs as we have achieved on smoking. It should be much easier. About 55 per cent of adults smoked in 1965, compared with 15 per cent in B.C. today. Only about two per cent of Canadians are heroin and cocaine users; if we can make the same relative gains, using the lessons from smoking, the number of addicts would be tiny.

That seems like a long list of benefits, with few costs. Yet instead, we push on with tactics and strategies that have failed to deal with prohibited substances for almost a century. We fight to reduce supply, unsuccessfully, and create crime and chaos and costs.

For whatever reason, we tried something different with tobacco. Maybe the big companies had too much clout, or there were just too many smokers. We didn't ban cigarettes or arrest people. We worked on reducing demand. And it worked.

Why not for other drugs?

I have a few reactions. First, I don't think his arguments are without any merit. As some states and other countries experiment with decriminalization, it will be worth watching which harms are reduced, which harms increase and what strategies are most effective in mitigating the undesirable effects of decriminalization. I've said several times in this blog that there is no such thing as a problem free drug policy. All of them will have problems associated with them, the question is this -- which problems are we willing to live with?

Second, I have concerns about the legalization and the combination of legal capitalism and addictive drugs. Marketing is a concern and lobbying power. Consider that tobacco is still not regulated by the FDA.

Third, in Michigan 23% of adults are regular smokers, and 52% of youth report having tried smoking with 16% of them before the age of 13. While tobacco policy has been successful in many ways, these numbers are still to high to offer comfort in moving towards tobacco as a model.

Fourth tobacco policy is in a state of rapid change. Who knows where it will be 5, 10 or 25 years from now? Is it inconceivable that some states or countries could be moving toward making tobacco sales illegal?

Finally, "During a prescribed heroin trial in Switzerland...about seven per cent quit during their time in the program." Talk about the soft bigotry of low expectations. The only kind of person who would point to this as an argument in favor of this policy is a person who believes that heroin addicts can't get well.

Another column from Newsday, "In the war on drugs, a tax plan that makes sense", raises inconsistencies in drug harms and their legality while arguing for higher tobacco taxes. He stops short of calling for any other drug policy change but he begs the question:

Will higher prices really push smokers to stop? Will $7 packs persuade kids not to start? Or is the lure of smoking and grip of addiction so all-powerful, the customers will pay whatever it costs?

Most of the research says that higher prices have the most impact on teenagers. They have less money in their pockets, even in the affluent 'burbs. At the same time, tax opponents warn about a rise in tax cheating, counterfeiting and illicit sales from Indian reservations, should higher taxes come in.

Only one thing is certain: This debate will never be settled on the facts. Addiction issues almost never are, and that certainly applies to the new suburban cigarette-tax debate.

Why is tobacco legal and marijuana not? Why is alcohol taxed, while cocaine and heroin are just available? Is it because some of these substances are more dangerous than others?

Of course not. We've never had a War on Drugs in America. We've always had a War on Some Drugs. And the teams were never chosen rationally.

The prestigious British medical journal The Lancet published a fascinating study last month.

Researchers from Oxford and Bristol universities set a straightforward challenge for themselves: Make a science-based assessment of the harm caused by various drugs, legal and illegal.

The researchers relied on three scales: the physical harm to the user, the drug's addictiveness, and its impact on the user's family and community.

Their data are hard to argue with: Alcohol and tobacco are more harmful than marijuana or ecstasy. Heroin and cocaine topped the list as most harmful. But there was hardly any connection at all, the scientists pointed out, between the harm a drug does and how the law has chosen to treat it.

Otherwise, pot would be legal. Tobacco and alcohol would not.

No one in the New York area yesterday was calling to make cigarettes illegal, even if they have now been banned from offices, restaurants, sports arenas and bars. (Suozzi did mention adding public parks to the no-smoking list.)

No one likes to pay more, even in a sin tax.

But if an extra $2 a pack will make some adults smoke less and persuade a few kids not to start, at least the change is connected to some kind of reality.

In this war, at this time, with these drugs, that's actually saying something.

Sen. Biden Introduces Legislation to Help Erase Stigma of Addiction

Senator Biden proposes removing the unfortunate term "abuse" from federal addiction agencies:

Sen. Biden’s legislation (S. 1011) will change the name of the National Institute on Drug Abuse (NIDA) to National Institute on Diseases of Addiction, and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to the National Institute on Alcohol Disorders and Health.

“Addiction is a neurobiological disease – not a lifestyle choice – and it’s about time we start treating it as such,” said Sen. Biden. “We must lead by example and change the names of our Federal research institutes to accurately reflect this reality. By changing the way we talk about addiction, we change the way people think about addiction, both of which are critical steps in getting past the social stigma too often associated with the disease.”

Preventing Underage Drinking: Using Getting To Outcomes with the SAMHSA Strategic Prevention Framework to Achieve Results

Preventing Underage Drinking: Using Getting To Outcomes with the SAMHSA Strategic Prevention Framework to Achieve Results:

Underage drinking is a significant problem in the United States: Alcohol is the primary contributor to the leading causes of death among adolescents. As a result, communitywide strategies to prevent underage drinking are more important than ever. Such strategies depend on the involvement and education of adolescents, parents, law enforcement officials, merchants, and other stakeholders. This guide is designed to take communities through the process of planning, implementing, and evaluating strategies to prevent underage drinking and youth access to alcohol. The guide is structured according to the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Strategic Prevention Framework, a five-step prevention approach. Within the five steps, the guide adopts the Getting To Outcomes model of empowerment evaluation, results-based accountability, and continuous quality improvement. The result is a comprehensive, step-by-step manual for developing, implementing, and evaluating a high-quality communitywide plan to prevent underage drinking and its related consequences. Recommendations include the development of educational strategies for parents, adolescents, and alcohol merchants; attracting the involvement of civic leaders; working to reform legislation governing underage access to alcohol; and training law enforcement officials to be vigilant but safe in their efforts to police underage drinking in the community.

Reader Response: School Drug Testing

Reader responses from the NYT on school drug testing. I'm assuming that the paper made an attempt to keep the published letters representative of all that they received. I'm genuinely surprised at the number of responses that are supportive of testing. I support testing for cause, but random testing troubles me. Random or limited, my biggest concern is what we do with kids who test positive. Locally, there simply isn't help for them.

Opium for the people: Extraordinary move to legalise poppy crops (U.K.)

Tony Blair is considering call for legalizing Afghani opium crops:

The buds of millions of poppy flowers are swelling across Afghanistan. In the far southern provinces bordering Iran, the harvest will start later this month. By mid- May the fields around British military camps in Helmand will be ringing to the sound of scythes, rather than gunfire.

And this year's opium harvest will almost certainly be the largest ever. In the five years since the overthrow of the Taliban regime, land under cultivation for poppy has grown from 8,000 to 165,000 hectares.

The US wants to step up eradication programmes, crop-spraying from the air. But, desperate to win "hearts and minds" in Afghanistan and protect British troops, Tony Blair is on the brink of a U-turn that will set him on a collision course with President George Bush.

The Prime Minister has ordered a review of his counter-narcotics strategy - including the possibility of legalising some poppy production - after an extraordinary meeting with a Tory MP on Wednesday, The Independent on Sunday has learnt. Tobias Ellwood, a backbencher elected less than two years ago, has apparently succeeded where ministers and officials have failed in leading Mr Blair to consider a hugely significant switch in policy.

Supporters of the measure say it would not only curb an illegal drugs trade which supplies 80 per cent of the heroin on Britain's streets, but would hit the Taliban insurgency and help save the lives of British troops. Much of the legally produced drug could be used to alleviate a shortage of opiates for medicinal use in Britain and beyond, they say.

A Downing Street spokesman confirmed last night that Mr Blair is now considering whether to back a pilot project that would allow some farmers to produce and sell their crops legally to drugs companies. His change of heart has surprised the Foreign Office, which recently denied that licit poppy production was being considered. A freedom of information request has revealed that the Government looked carefully at proposals to buy up Afghanistan's poppy crop as early as 2000, under the Taliban. The removal of that regime - justified to both US and British voters partly in terms of a victory in the "war on drugs" - has made it politically difficult to financially reward poppy farmers.

New York City Is Hell for Pot Smokers

I don't have much to say about this. The racial disparity, particularly in sentencing is troubling:

Of the more than 395,000 defendants busted in New York City since 1980 for puffing or possessing pot in public, nearly 336,000 of them (85 percent) were either African-American or Hispanic. By contrast, African-Americans and Hispanics together comprise approximately half of the city's population.
...
The unequal treatment of minorities for misdemeanor pot crimes is not just limited to arrests, the study finds. Investigators also report that African-Americans were 2.66 times as likely as whites to be detained in jail pending arraignment while Hispanics were nearly twice as likely. In addition, both groups were twice as likely as whites to receive a conviction -- and criminal record -- for public pot possession. Compared to Caucasians, African-Americans were four times as likely and Hispanics were three times as likely to receive jail time.

The other reaction I have is that the relevant laws seem to already be pretty permissive:

(Although the possession of less than 25 grams of pot is punishable under state law by a fine-only civil citation, New York Statute 221.10 defines the possession or use of marijuana "open to public view" as a criminal misdemeanor punishable by up five days in jail.)

Possession is of less than 25 grams is subject to a fine? (That's one ounce of weed!) Smoking weed in public is subject to up to 5 days? As acknowledged frequently on this blog, reasonable people can disagree about whether pot should be legalized, but these laws are hardly draconian or oppressive. Is it so hard to smoke your weed in private?

I guess I had more to say than I thought.

UPDATE-I got the following comment from a friend:

Jason, I'm sorry but I had to laugh, because I'm guessing that to the average American who is not experienced with buying drugs - an ounce of weed sounds like enough for, not much, maybe a joint. I didn't comprehend how much an ounce of weed was until [someone I know] got busted with an ounce and the nice police officer explained why they tossed him in jail.

An ounce is a lot of weed. It's 30 to 60 joints depending on who you ask. According to Erowid, the price for an ounce varies from $120 to $480 and generally could get 160 to 240 people moderately high.

Cannabis-related Schizophrenia May Be Set To Rise, Say Researchers

A new study projects what might happen to the incidence of schizophrenia if there is a relationship between marijuana use and schizophrenia. It's worth noting that even people who believe that there is a relationship, believe that the risk is low.

If cannabis causes schizophrenia - and that remains in question - then by 2010 up to 25 per cent of new cases of schizophrenia in the UK may be due to cannabis, according to a new study by Dr Matthew Hickman of the University of Bristol and colleagues, published in Addiction journal.

Substantial increases in both prevalence and incidence of the disease are forecast by the end of the decade, with increases in schizophrenia starting earlier among young men in particular.

The research study matches historic trends in cannabis use and exposure from a national population survey against estimates of new occurrences of schizophrenia in three English cities (Nottingham, Bristol and the London Borough of Southwark).

The researchers assess what might happen to schizophrenia cases if we assume a causal link between cannabis use and onset of psychotic symptoms, an association widely recognised by some psychiatrists and researchers and considered recently by the Advisory Council on the Misuse of Drugs.

Exposure to cannabis grew fourfold over the thirty years to 2002, and its use among under-18s by 18-fold, say the researchers. If cannabis use causes schizophrenia, these increases in its use would lead to increases in overall schizophrenia incidence and prevalence of 29 per cent and 12 per cent respectively, between 1990 and 2010. (Incidence is defined as the frequency of new occurrences; and prevalence is the percentage of the population affected by the disease.)

The War on Drugs Is Really a War on Minorities

Ariana Huffington challenges the presidential candidates to address the issue of racial disparities in drug arrests, convictions and incarceration:

...African Americans make up an estimated 15% of drug users, but they account for 37% of those arrested on drug charges, 59% of those convicted and 74% of all drug offenders sentenced to prison. Or consider this: The U.S. has 260,000 people in state prisons on nonviolent drug charges; 183,200 (more than 70%) of them are black or Latino.

...

Maybe the president will suddenly wake up and decide to take on the issue five days before he leaves office. That's what Bill Clinton did, writing a 2001 New York Times Op-Ed article in which he trumpeted the need to "immediately reduce the disparity between crack and powder cocaine sentences" -- conveniently ignoring the fact that he had the power to solve it for eight years and did nothing.

When it mattered, he maintained an imperial silence. Then, when it didn't, he became Captain Courageous. And he lamented the failures of our drug policy as though he had been an innocent bystander rather than the chief executive (indeed, the prison population doubled on his watch).

The injustice is so egregious that a conservative senator, Jeff Sessions (R-Ala.), is now leading the charge in Congress to ease crack sentences. "I believe that as a matter of law enforcement and good public policy, crack cocaine sentences are too heavy and can't be justified," he said. "People don't want us to be soft on crime, but I think we ought to make the law more rational."

The Lancet and drug harms: missing the bigger picture

The Transform Drug Policy Foundation offers a response to the recent Lancet article that ranked drugs by harm. The writer suggest that the article is flawed in two important ways. First he argues that it fails to consider harms caused by the illegal status of the drug. Second, he says that the nature of the paper lends itself to criminalization of the drugs judged to be more harmful.

I'll use this as an opportunity share an opinion I didn't share in my original post--it's impossible to separate values from these kinds of decisions. Values influence which harms are identified, how those harms are ranked, who's opinion is sought, the intended use influences the design, etc.

UPDATE: I received the following comment from a reader:

"Values influence which harms are identified". Yes that is a description of what happens at present but is shouldn't be a prescription for what should happen. If we are to base drug classification on scientific evidence then the aim should be to get as close to objectivity as possible.

Let me clarify. In an ideal world I'd agree with the comment, we could objectively quantify harms and know that there is one set of facts for us to operate from. My judgment is that this is fantasy. For example, purportedly objective American harm reduction discussions tend to very heavily emphasize HIV/AIDS. Why? Because the early American harm reduction advocates were HIV/AIDS advocates.

Other tough questions:

• Should growing up with an addicted parent be considered a harm? Beyond child protective service cases? If yes, how should this be quantified? If not, why?
  
• How about the emotional pain experienced by other family members? If the answer is yes, how should these be weighted relative to the harms caused to children?
  
• Should the malaise cast over communities be considered a harm? If one looks at certain communities, American Indian reservations for example, the despair due to alcohol (a legal drug) goes well beyond unemployment. Should the pall addiction can cast over an affected community be considered?
• Should harms to non-users be weighted more heavily? Based on the belief that the user is exercising personal liberty and assumes risks in doing so?
• When it comes to making harm reduction policy decisions, one harm reduction strategy can reduce harm to one population and increase risk of harm for another.

Don't get me wrong, I'm glad this study was done and I look forward to more studies like it. I'm just convinced that values can't honestly be eliminated from the equation. It might be helpful to integrate scientific evidence and a discussion the values like liberty, safety, etc.

The cannabis debate - Round 2

The British cannabis debate continues. The Independent ran responses to criticisms of last weeks change in editorial position on legalization. This week their coverage included an overview of the criticism of their position change (The cannabis debate) and a story looking at the concerns surrounding skunk weed (So how dangerous is skunk?).

The Transform Drug Policy Foundation has a response to The Independent's responses.

As someone who detests the war on drugs but is ambivalent about radical policy changes, I'm enjoying the debate. Policy reform advocates advocates often point to alcohol--it's more harmful and we tried prohibition which created horrible problems and no one regrets abandoning it. The alcohol arguments hardly stir motivation for drug reform. Alcohol is associated with significant public health and social problems with addicted and social users, the alcohol and tobacco industries lobbies' are powerful and noxious, they have powerful promotional machines with dubious histories, and it's reasonable to speculate that age of first use might drop further.

I'm interested in hearing more analysis about the position change of The Independent. They said the following to explain their position change:

We quote John Maynard Keynes in our defence: "When the facts change, I change my mind. What do you do, sir?"

No one seems to be accusing them of bad motives, just stupidity. I'd like to hear more analysis about their decision making process and whether others agree that the facts have changed significantly.

Alcohol, tobacco among riskiest drugs

This paper is getting a lot of attention. It is thoughtful and provocative, It would be nice if it provoked some thoughtful dialogue, but I suspect that is hoping for too much. Any DF staff interested in a copy of the paper should ask me for one.

New "landmark" research finds that alcohol and tobacco are more dangerous than some illegal drugs like marijuana or Ecstasy and should be classified as such in legal systems, according to a new British study.

In research published Friday in The Lancet magazine, Professor David Nutt of Britain's Bristol University and colleagues proposed a new framework for the classification of harmful substances, based on the actual risks posed to society. Their ranking listed alcohol and tobacco among the top 10 most dangerous substances.

Nutt and colleagues used three factors to determine the harm associated with any drug: the physical harm to the user, the drug's potential for addiction and the impact on society of drug use. The researchers asked two groups of experts — psychiatrists specializing in addiction and legal or police officials with scientific or medical expertise — to assign scores to 20 different drugs, including heroin, cocaine, Ecstasy, amphetamines and LSD.

Nutt and his colleagues then calculated the drugs' overall rankings. In the end, the experts agreed with each other — but not with the existing British classification of dangerous substances.

Heroin and cocaine were ranked most dangerous, followed by barbiturates and street methadone. Alcohol was the fifth-most harmful drug and tobacco the ninth most harmful. Cannabis came in 11th, and near the bottom of the list was Ecstasy.

‘Current drug system is ill thought-out’
According to existing British and U.S. drug policy, alcohol and tobacco are legal, while cannabis and Ecstasy are both illegal. Previous reports, including a study from a parliamentary committee last year, have questioned the scientific rationale for Britain's drug classification system.

"The current drug system is ill thought-out and arbitrary," said Nutt, referring to the United Kingdom's practice of assigning drugs to three distinct divisions, ostensibly based on the drugs' potential for harm. "The exclusion of alcohol and tobacco from the Misuse of Drugs Act is, from a scientific perspective, arbitrary," write Nutt and his colleagues in The Lancet.

Tobacco causes 40 percent of all hospital illnesses, while alcohol is blamed for more than half of all visits to hospital emergency rooms. The substances also harm society in other ways, damaging families and occupying police services.

Here's the complete list of drugs assessed in the paper. I'm a little surprised that solvents are so low.

Research recently published in the medical journal The Lancet rates the most dangerous drugs (starting with the worst) as follows:

1. Heroin

2. Cocaine

3. Barbiturates

4. Street methadone

5. Alcohol

6. Ketamine

7. Benzodiazepines

8. Amphetamine

9. Tobacco

10. Buprenorphine

11. Cannabis

12. Solvents

13. 4-MTA

14. LSD

15. Methylphenidate

16. Anabolic steroids

17. GHB

18. Ecstasy

19. Alkyl nitrates

20. Khat

The National Center for Trauma-Informed Care

SAMHSA has created a National Center for Trauma-Informed Care

Brain Scans Reveal Cause of Smokers' Cravings

An article with good brain images of regions involved in nicotine craving.

Proposals for Mental Health Parity Pit a Father’s Pragmatism Against a Son’s Passion

Father and son Kennedys introduce competing parity legislation:

It’s Kennedy versus Kennedy as two members of Congress from the same family face off over competing versions of legislation that would require many health insurance companies and employers to provide more generous benefits to people with mental illness.

Representative Patrick J. Kennedy, Democrat of Rhode Island and chief sponsor of the House bill, has criticized as inadequate the Senate bill introduced by his father, Senator Edward M. Kennedy, Democrat of Massachusetts. Representative Kennedy is trying to mobilize mental health advocates to lobby for what he describes as “the stronger of the two bills, the House bill.”

Both bills seek to end discrimination against people with mental disorders by requiring insurers and employers to provide equivalent coverage, or parity, for mental and physical illnesses.

That would be a huge change. For decades, insurers have charged higher co-payments and set stricter limits on coverage of mental health services. For example, insurers often refuse to cover more than 20 visits a year to a psychotherapist. And a patient may have to pay 20 percent of the cost for visiting a cancer specialist, but 40 percent or more for a mental health specialist.

The differences between the Kennedys’ bills reflect different views about what is possible and what is politically feasible.

Senator Kennedy said he was taking a pragmatic approach and had made a number of compromises to win the support of business and insurance groups. These compromises, he said, greatly increased the chances that a bill would become law, protecting millions of Americans in group health plans.

Insurers and employers had opposed similar proposals in the past, saying the plans would drive up costs. This year, however, Senator Kennedy invited employers and insurers to help write the legislation, along with mental health groups, and they have endorsed the bill that he introduced with Senator Pete V. Domenici, Republican of New Mexico. The bill was recently approved in a Senate committee by a vote of 18 to 3.

How the Independent on Sunday got it horribly wrong on Cannabis

I knew that this was coming. A harm reduction group tackles the Independent on Sunday's reversal on pot.
They make the following points:

1. The facts are all over the place.
2. They fail to understand how drugs are used.
3. We haven't suddenly 'discovered' that cannabis is related to mental health problems.

Even if it's all true - what exactly is the IOS recommending?
Even if it's all true - what exactly is the IOS recommending? Ignore all other tedious witterings above for a moment and let's assume that cannabis really is 25 time stronger than 10 years ago and this really has led to a ten fold increase in teen cannabis addiction (whatever that might be). What does the IOS then recommend in its leader as a response to the policy disaster under which this skunk apocalypse has emerged?

Nothing: They say the the current policy is 'about right'.

Do we get an exploration of policy alternatives or a consideration of progressive policy in other European countries where the problems are markedly smaller? No. Instead we are told that the 'the fact possession of cannabis - and other drugs - is illegal acts as a important social deterrent'.

Spirituality Aids Alcohol Recovery

Spirituality Aids Alcohol Recovery:

Incorporating spirituality and a sense of purpose into the alcohol recovery process has been an integral rehabilitation component for years. A new research study explores this aspect of the process documenting how spirituality changes during recovery may influence a person’s chance of succeeding in the quest for sobriety.

The study by University of Michigan Addiction Research Center researchers is found in the March issue of the Journal of Studies on Alcohol and Drugs.

Study authors show that many measures of spirituality tend to increase during alcohol recovery and they also demonstrate that those who experience increases in day-to-day spiritual experiences and their sense of purpose in life are most likely to be free of heavy drinking episodes six months later.

...results suggest that “proactive and experiential” dimensions of spirituality, rather than cognitive ones, were contributing to the recovery and decrease in drinking in the first six months.

They note that this pattern is consistent with two AA slogans: “Bring your body, your mind will follow,” and “Fake it ‘til you make it.”

In other words, changes in core beliefs and values don’t have to occur in order for someone to be more open to spiritual experiences or to take part in more spiritual activities.

These findings suggest that including spirituality of all kinds into the delivery of recovery services for alcoholism may indeed help. Many individual faiths or religious institutions have offered recovery services, and some advocates have suggested that faith-based recovery is most effective for all. But Robinson notes that the spirituality seen in the study was not necessarily a matter of believing in one interpretation of God, or even belief in a God of any kind.

Each individual’s own spirituality, and the ability to experience growth in that spirituality, appears to be paramount, the authors suggest. So, each individual alcoholic might do best by searching for a recovery program that best matches his or her existing belief system.

Medical marijuana: Governor calls bill 'right thing to do'

Presidential candidate Bill Richardson has signed a medical marijuana bill:

Democratic Gov. Bill Richardson, poised to sign a bill making New Mexico the 12th state to legalize medical marijuana, said Thursday that he realizes his action could become an issue in the presidential race.

"So what if it's risky? It's the right thing to do," said Richardson, one of the candidates in the crowded 2008 field. "What we're talking about is 160 people in deep pain. It only affects them."

The legislation would create a program under which some patients -- with a doctor's recommendation -- could use marijuana provided by the state Health Department. Lawmakers approved the bill Wednesday. The governor is expected to sign it in the next few weeks.

Cannabis: An apology

The left-leaning Independent on Sunday changes its editorial position on marijuana:

In 1997, this newspaper launched a campaign to decriminalise the drug. If only we had known then what we can reveal today...

Record numbers of teenagers are requiring drug treatment as a result of smoking skunk, the highly potent cannabis strain that is 25 times stronger than resin sold a decade ago.

More than 22,000 people were treated last year for cannabis addiction - and almost half of those affected were under 18. With doctors and drugs experts warning that skunk can be as damaging as cocaine and heroin, leading to mental health problems and psychosis for thousands of teenagers, The Independent on Sunday has today reversed its landmark campaign for cannabis use to be decriminalised.

A decade after this newspaper's stance culminated in a 16,000-strong pro-cannabis march to London's Hyde Park - and was credited with forcing the Government to downgrade the legal status of cannabis to class C - an IoS editorial states that there is growing proof that skunk causes mental illness and psychosis.

The decision comes as statistics from the NHS National Treatment Agency show that the number of young people in treatment almost doubled from about 5,000 in 2005 to 9,600 in 2006, and that 13,000 adults also needed treatment.

The skunk smoked by the majority of young Britons bears no relation to traditional cannabis resin - with a 25-fold increase in the amount of the main psychoactive ingredient, tetrahydrocannabidinol (THC), typically found in the early 1990s. New research being published in this week's Lancet will show how cannabis is more dangerous than LSD and ecstasy. Experts analysed 20 substances for addictiveness, social harm and physical damage. The results will increase the pressure on the Government to have a full debate on drugs, and a new independent UK drug policy commission being launched next month will call for a rethink on the issue.

The findings last night reignited the debate about cannabis use, with a growing number of specialists saying that the drug bears no relation to the substance most law-makers would recognise. Professor Colin Blakemore, chief of the Medical Research Council, who backed our original campaign for cannabis to be decriminalised, has also changed his mind.

He said: "The link between cannabis and psychosis is quite clear now; it wasn't 10 years ago."

Many medical specialists agree that the debate has changed. Robin Murray, professor of psychiatry at London's Institute of Psychiatry, estimates that at least 25,000 of the 250,000 schizophrenics in the UK could have avoided the illness if they had not used cannabis. "The number of people taking cannabis may not be rising, but what people are taking is much more powerful, so there is a question of whether a few years on we may see more people getting ill as a consequence of that."

"Society has seriously underestimated how dangerous cannabis really is," said Professor Neil McKeganey, from Glasgow University's Centre for Drug Misuse Research. "We could well see over the next 10 years increasing numbers of young people in serious difficulties."

Politicians have also hardened their stance. David Cameron, the Conservative leader, has changed his mind over the classification of cannabis, after backing successful calls to downgrade the drug from B to C in 2002. He abandoned that position last year, before the IoS revealed that he had smoked cannabis as a teenager, and now wants the drug's original classification to be restored.

Court: Dying can be charged for using marijuana

A blow to medical marijuana:

A California woman whose doctor says marijuana is the only medicine keeping her alive is not immune from federal prosecution on drug charges, a federal appeals court ruled Wednesday.

The case was brought by Angel Raich, an Oakland mother of two who suffers from scoliosis, a brain tumor, chronic nausea and other ailments. On her doctor's advice, she eats or smokes marijuana every couple of hours to ease her pain and bolster a nonexistent appetite as conventional drugs did not work.

The Supreme Court ruled against Raich two years ago, saying that medical marijuana users and their suppliers could be prosecuted for breaching federal drug laws even if they lived in a state such as California where medical pot is legal.

Because of that ruling, the issue before the 9th U.S. Circuit Court of Appeals was narrowed to the so-called right to life theory: that marijuana should be allowed if it is the only viable option to keep a patient alive.

Raich, 41, began sobbing when she was told of the decision and said she would continue using the drug.

"I'm sure not going to let them kill me," she said. "Oh my God."

Will a New Study Force Changes in Drug Law?

AlterNet has published a well written reaction to the release of the British RSA drug policy report. The author has a clear bias but he is right that this offers a useful framework for discussion.

I question his near Utopian characterization of England--as this blog frequently posts, they're having problems of their own.

While I agree that we need major changes in drug policy, he paints the shedules in the U.S. Controlled Substances Act as irrational (almost deliberately so). Those schedules are based on a combination of abuse potential and accepted medical utility--this may or may not be the best way to classify drugs, but it's not all that irrational. It might be helpful to revisit the drug schedules, but the real problem seems to lie in penalties.

Finally, reform advocates who seek decriminalization seek to present the possibility of drug policy decisions as wholly rational and something akin to an accounting exercise. Considering the harms that drugs cause and ranking those harms is impossible to do objectively--this has to be a subjective exercise, and values will inevitably enter the equation.

After two years of research, this panel of experts and laypeople came to a number of conclusions so sensible and so obvious that it's astonishing how consistently our elected leaders have avoided confronting them. In particular:

• The notion of a drug-free society is "almost certainly a chimera. ... People have always used substances to change the way they see the world and how they feel, and there is every reason to think they always will." Therefore, "[t]he main aim of public policy should be to reduce the amount of harms that drugs cause." A policy based on total prohibition "is bound to fail."
  
  
• The concept of "drugs" should include tobacco and alcohol. "Indeed, in their different ways, alcohol and tobacco cause far more harm than illegal drugs." These substances should be brought into a unified regulatory framework "capable of treating substances according to the harm they cause."
  
  
• The heart of this new regulatory framework must be an index of substance-related harms. "The index should be based on the best available evidence and should be able to be modified in light of new evidence."
  
  
• We need a new way of evaluating the efficacy of drug policies. "In our view, the success of drugs policy should be measured not in terms of the amounts of drugs seized or in the number of dealers imprisoned, but in terms of the amount of harms reduced."

As an example of the sort of harms index they envision, the RSA Commission points to an index developed by a pair of British scientists, David Nutt and Colin Blakemore, and published in a House of Commons report last year.

Based on scientific evaluations of physical harms (e.g., acute and chronic toxicity), likelihood of dependence, and social harms (including damage done to others, health care costs, etc.), Nutt and Blakemore ranked 20 different classes of drugs, both legal and illegal. Not surprisingly, heroin was at the top of the harm scale, followed by cocaine and barbiturates. Alcohol and tobacco were rated as significantly more harmful than marijuana and several other illegal substances.

While not specifically endorsing the Nutt/Blakemore index, the RSA Commission clearly considered these rankings a good example of what they have in mind, using them as a starting point for illustrations of how such an index might translate into law. Marijuana, they wrote, "should continue to be controlled. But its position on the harms index suggests that the form this control takes might have to correspond far more closely with the way in which alcohol and tobacco are regulated."

Both the United States and Britain now have drug laws that rank drugs into a series of classifications. The problem -- well, at least one problem -- is that these classifications have little connection to what the science actually tells us about the dangers (or lack thereof) of different substances. Britain's version, the commission noted, "is driven more by 'moral panic' than a practical desire to reduce harm. ... It sends people to prison who should not be there. It forces people into treatment who do not need it (while, in effect, denying treatment to people who do need it)."

And Britain's law is, on at least one key point, far more rational than the U.S. Controlled Substances Act. The British classify marijuana in the lowest of three classes of illicit drugs -- still illegal, but treated as less dangerous than cocaine, heroin or methamphetamine. Simple possession, without aggravating circumstances, is generally a "nonarrestable" offense.

Our CSA ranks marijuana in Schedule I, the worst class of drugs -- considered not only to be at high risk of abuse but also to be unsafe for use even under medical supervision -- along with heroin and LSD. Amazingly, cocaine and meth are in Schedule II -- considered acceptable for use under medical supervision. That such a ranking is insane should not need to be stated.

There are plenty of specifics in the RSA report about which reasonable people can disagree. But the important thing is not what they say about any specific drug -- and indeed, the report is careful not to advocate specific legal changes for particular drugs. What's important is that it suggests a framework that's far more rational than what now exists in the United States, Britain and most other countries: A reality-based approach rooted in sound science, focusing on how to reduce harm.

Man Who Sent Apology Sentenced for Rape

The man who was charged with rape after offering 9th step amends to his victim (earlier post here) has been sentenced:

A man who sexually assaulted a University of Virginia student in 1984 and apologized to her two decades later as part of the Alcoholics Anonymous program was sentenced to 18 months in prison Thursday.

Flawed research equates placebo to cold turkey

Why placebo should not be equated with cold turkey:

...can people who volunteer to test a drug, but who are randomly assigned to get a placebo instead of the drug they wanted, reasonably be compared to people who decide to quit smoking without drugs? A growing chorus of independent experts and health advocates are expressing concern that the pharmaceutical industry has either divorced itself from common sense or is intentionally deceiving smokers.

"Pharmacotherapy in general is over-emphasized," asserts Dr. Michael Siegel, a physician and professor at Boston University School of Public Health. "Most smokers who quit successfully long-term are those who quit cold turkey without any particular pharmaceutical aids."

Stupid drug story of the week: A strange cocktail mixed by the Times

Jack Shafer vents his spleen over a NYT story I posted about earlier this week. His criticism that this story may be hyped is probably fair. However, he also reveals his bias:

Not that long ago, every reporter knew his way around the bottle. He kept a pint in his bottom drawer at work, adjourned to bars for lunch, and as often as not, went to bed with a slight buzz on. But in today's puritanical newsroom, alcohol has become as verboten as methamphetamine, heroin, marijuana, cocaine, and MDMA. Reporters, who could once file dispassionate stories on the topic, have become as hysterical as 12-steppers falling off the wagon when assigned to write a booze story.

Wasting the Best and Brightest

From CASA:

The report finds that from 1993 to 2005 there has been no real decline in the proportion of students who drink (70 to 68 percent) and binge drink (40 to 40 percent). However, the intensity of excessive drinking and rates of drug abuse have jumped sharply:

• Between 1993 and 2001 the proportion of students who binge drink frequently is up 16 percent; who drink on 10 or more occasions in a month, up 25 percent; who get drunk at least three times a month, up 26 percent; and who drink to get drunk, up 21 percent.
• Between 1993 and 2005 the proportion of students abusing prescription drugs increased:
• 343 percent for opioids like Percocet, Vicodin and OxyContin;
• 93 percent for abuse of stimulants like Ritalin and Adderall;
• 450 percent for tranquilizers like Xanax and Valium;
• 225 percent for sedatives like Nembutal and Seconal.
• Between 1993 and 2005, the proportion of students who:
• Use marijuana daily more than doubled to 310,000.
• Use cocaine, heroin, and other illegal drugs (except marijuana), is up 52 percent to 636,000.

This may be a good argument for better typology within the use/misuse/dependence continuum.

Lawmakers Consider Less Crack Penalties

Congress finally looks to address the crack/powder sentencing disparity. However, Reason Magazine reports that Sessions' bill would reduce crack penalties and increase powder penalties. Let's hope that the legislative process brings a little sanity. Does anyone really think that we're too lenient with powder cocaine penalties?

Momentum is building in Congress to ease crack cocaine sentencing guidelines, which the American Civil Liberties Union and other critics say have filled prisons with low-level drug dealers and addicts whose punishments were much worse than their crimes.

Federal prison sentences for possessing or selling crack have far exceeded those for powder cocaine for two decades. House Crime Subcommittee chairman Robert Scott, D-Va., a longtime critic of such sentencing policies, plans to hold hearings on crack sentences this year. In the Senate , Republican Jeff Sessions of Alabama is drawing bipartisan support for his proposal to ease crack sentences.

"I believe that as a matter of law enforcement and good public policy that crack cocaine sentences are too heavy and can't be justified," Sessions says. "People don't want us to be soft on crime, but I think we ought to make the law more rational."

The mandatory federal sentencing guidelines passed by Congress in 1986 require a judge to impose the same sentence for possession of 5 grams of crack as for 500 grams of powder cocaine: five years in prison.

...

"We're going to address all the mandatory minimums," said Scott, chairman of the House Judiciary Committee's Subcommittee on Crime, Terrorism and Homeland Security. "The crack cocaine is probably the most egregious because of its draconian number of years for relatively small amounts."

Opposition to weaker sentences has come from police, prosecutors and law enforcement agencies such as the Justice Department and the Drug Enforcement Administration.

"We believe the current federal sentencing policy and guidelines for crack cocaine offenses are reasonable," Justice spokesman Dean Boyd says.

Higher penalties for crack offenses reflect its greater harm, he says, adding that crack traffickers are more likely to use weapons and have more significant criminal histories than powder cocaine dealers.

"Congress thought by having very harsh sentences, it would deter the spread of crack into the inner cities and around the country," Sessions says. "The truth is, it didn't stop it. It spread very rapidly. Now we need to ask ourselves, what is the right sentence for this bad drug. I think it's time to adjust. I think it's past time to do this."

Brain cue response predicts relapse

From NIDA:

...investigators recruited 17 men and women who were participating in a trial of an antidepressant—sertraline—that is being evaluated as a possible treatment for cocaine addiction. The participants reported abusing cocaine 20 days, on average, during the month before the study. All met standard clinical criteria for cocaine addiction and had abused the drug for 6 years, on average. Most were new to treatment.

After being cocaine-free for 5 days, on average, each participant underwent functional magnetic resonance imaging (fMRI) while watching two 4-minute videotapes. The first minute of each tape reported on vegetable prices, and the participants' brain activity while hearing this emotionally neutral information served as a baseline for comparison. During the last 3 minutes, an actor pretended to smoke cocaine and experience a "rush." Immediately after viewing the tapes, each participant rated peak cocaine craving intensity on a scale from 0 to 10. After the imaging session, participants began taking either sertraline or a placebo daily and completed 2 weeks of residential treatment. During the 10-week outpatient phase of the trial, they were to continue their medication regimen, receive weekly individual cognitive-behavioral therapy, and submit urine samples three times a week.

Nine of the 17 participants relapsed, defined by the investigators as submitting fewer than 15 of a possible 30 cocaine-free samples during the study and not completing outpatient treatment. Participants taking sertraline were just as likely as those taking the placebo to relapse. Relapsers and nonrelapsers reported cue-induced cravings of comparable intensity. The two groups differed, however, on brain activation during the first 30 seconds of the cocaine-cue videotapes. Relapsers showed greater cue-induced activation than nonrelapsers in several areas of the cortex: the left precentral (movement control), right superior temporal (auditory processing), right lingual and right inferior occipital (visual processing), and the left posterior cingulate cortices. The cingulate cortex is integral to attention, response inhibition, emotional regulation, and decisionmaking.

The definition of relapse inspires a lot of confidence, no?

For U.S. Troops at War, Liquor Is Spur to Crime

A troubling about U.S. troops, liquor and crime (Requires free registration. If you don't wish to register, you can use www.bugmenot.com.):

Alcohol, strictly forbidden by the American military in Iraq and Afghanistan, is involved in a growing number of crimes committed by troops deployed to those countries. Alcohol- and drug-related charges were involved in more than a third of all Army criminal prosecutions of soldiers in the two war zones — 240 of the 665 cases resulting in convictions, according to records obtained by The New York Times through a Freedom of Information Act request.

Seventy-three of those 240 cases involve some of the most serious crimes committed, including murder, rape, armed robbery and assault. Sex crimes accounted for 12 of the convictions.

The 240 cases involved a roughly equal number of drug and alcohol offenses, although alcohol-related crimes have increased each year since 2004.

Despite the military’s ban on all alcoholic beverages — and strict Islamic prohibitions against drinking and drug use — liquor is cheap and ever easier to find for soldiers looking to self-medicate the effects of combat stress, depression or the frustrations of extended deployments, said military defense lawyers, commanders and doctors who treat soldiers’ emotional problems.

“It’s clear that we’ve got a lot of significant alcohol problems that are pervasive across the military,” said Dr. Thomas R. Kosten, a psychiatrist at the Veterans Affairs Medical Center in Houston. He traces their drinking and drug use to the stress of working in a war zone. “The treatment that they take for it is the same treatment that they took after Vietnam,” Dr. Kosten said. “They turn to alcohol and drugs.”

Exec’s private pain fuels HBO’s ‘Addiction’

This HBO series' (debut's Thursday at 9pm) promotional machine is amazing--there are ads everywhere. More evidence that parents and other loved ones are the key to changing drug policy and treatment access:

HBO unleashed some of the industry’s best documentary filmmakers to take on the subject of addiction, a project born from the frustration of a top HBO executive whose son has struggled with alcohol and cocaine problems.
...

It all began with the realization by Sheila Nevins of HBO that she understood little about the problems bedeviling her son David.

...

All of the documentaries will be available to download for free off HBO’s Web site. HBO also timed the series to air on one of its periodic weekends where the service is offered for free to entice new viewers.

The series strongly communicates the message of addiction as a brain disease, which is not entirely accepted by the public or even the medical community, said Nora Volkow, director of the National Institute on Drug Abuse.

“We need to create an empathy so we don’t react with anger and a stigma to the person who is addicted, which doesn’t help anyone — the person or society,” Volkow said.

HBO has done a handful of campaigns like this in the past, on issues like AIDS and cancer, and supported Nevins’ efforts here.

While still exploring the idea, HBO brought groups of people together to talk about addiction to hear their attitudes and experiences. A key moment in moving forward came when Nevins heard the story of one woman and her two children, one who had epilepsy and another who was an addict. The woman cared for the child with epilepsy and kicked the addict out of her house.

Now she has only one child — the addict is dead — and the decision not to seek medical help haunts her to this day.

“It gives dignity to the addict,” Nevins said of the HBO project. “They are responsible for seeking treatment, not responsible for the disease.”

Anti-Drug Spending Would Decline Under Bush Budget, Analysts Say

Join Together reports that the President's new budget calls for increases in spending on law enforcement and interdiction at the expense of treatment and prevention.

For the first time in about 20 years, spending on federal anti-drug programs would actually decline on a year-over-year basis if the Bush administration's 2008 drug budget is adopted, according to an analysis by Carnevale Associates.

The administration's proposed $12.961 billion drug-control budget not only represents a $166.7-million decline from 2007 spending levels, it also cuts prevention spending while continuing to increase funding for overseas and interdiction programs -- a puzzling strategy when major drugs of abuse -- prescription drugs and marijuana -- are mostly domestically produced," noted the Carnevale Associates policy brief.

"Perhaps most puzzling, however, the FY 2008 budget trend goes against well-established principles of effective drug-control policy, including the need for a comprehensive balanced approach between interdiction, law enforcement, overseas programs, and prevention and treatment programming," the report says. "Specifically, the FY 2008 budget request continues the Bush administration's long-term trend of shifting resources away from demand reduction ... toward supply reduction."

Since 2002, supply reduction has gone from 55 percent of the federal drug budget to a proposed 64 percent in 2008, according to Carnevale's analysis. Over this time span, funding for drug interdiction programs rose 72 percent, domestic law-enforcement funding rose 27 percent, and overall supply-reduction efforts received 42 percent more federal funding.

Meanwhile, the administration's FY2008 request -- if approved by Congress -- highlights the far less generous trends in funding for demand-reduction activities. While treatment funding rose a modest 9 percent from 2002 to the proposed 2008 funding levels, prevention will have declined by 3 percent from FY2002 to FY2008. "The decline in demand reduction is driven entirely by a reduction for substance-abuse prevention," which would receive 21 percent less federal funding in 2008 than it did in 2002 under the administration's proposal, according to the Carnevale report. Cuts to the Safe and Drug-Free Schools and Communities program and the budget of the Center for Substance Abuse Prevention account for most of the funding decline.

According to Carnevale, the FY2008 budget flies in the face of a series of campaign promises made by President Bush in 2001, including big spending increases for addiction treatment for teenagers (entirely unfunded to date), drug courts (down to $7 million in 2007 from $50 million in 2002), drug-free schools (cut drastically in recent years), and drug-free workplaces (unfunded).

"Had ONDCP followed through on these promises for treatment, education, drug-free communities, and drug courts, the share of the budget devoted to demand reduction would have been approximately 42 percent in FY 2008, rather than the 36 percent currently budgeted," Carnevale noted.

A new British drug classification report

A British government report with recommendations about drug classifications was released last week. Here are a couple of articles on the report (here and here.)

I'm sympathetic to arguments that drug classifications have been based on panic, racism, demagoguery, and false dichotomies. However, drug policy advocates who insist on characterizing the masses as unenlightened, guilty of "moral panic" and just persistently stupid are every bit as maddening as the drug war proponents. There are important ways in which they are right, but they fail to recognize the ways in which their "opponents" are right, or at least legitimately concerned. The argument that some people use heroin, have a steady relationship, are employed and have children is not very persuasive. It may be true, but it's misleading. (Transparently misleading, at that.)

I suspect that most people would be open to the arguments of many of these policy advocates if they weren't so absolutist and narrowly focused. I think most people are willing to go for drug reclassification, alternatives to incarceration and many harm reduction strategies. They're just not willing to go for those ideas alone. They also want to be sure that their children are safe and they want to make sure we treat people suffering from addiction. I'm not a fan of his, but look at this segment from Lou Dobbs (about 2/3 down the page). He looks like he may be open to reconsidering his advocacy for widespread adolescent drug testing, he's supportive of some harm reduction strategies and doesn't want to see people simply sent off to prison/jail. BUT, he also wants interdiction, treatment and, I assume, some form of criminalization. (Probably without knee-jerk incarceration.) The point is that most people are not willfully ignorant--listening is as important as advocacy.

An open trial of CBT for insomnia comorbid with alcohol dependence

Good news about the effectiveness of CBT for insomnia in alcoholics:

Results:
Diary-rated sleep latency [F (2, 10) = 14.4, p < .001], wake after sleep onset [F (2, 10) = 7.7, p = .009], and sleep efficiency [F (2, 10) = 28.3, p < .001] improved as did patient-rated and clinician-rated Insomnia Severity Index (ISI) and the Dysfunctional Beliefs and Attitudes about Sleep – Short Form (DBAS-SF). Compared to pre-treatment, significant post-treatment improvements were found on scales measuring depression and anxiety symptoms, fatigue, and quality of life. No one relapsed to alcohol during treatment.

Conclusions:
Cognitive-behavioral insomnia therapy may benefit recovering alcoholics with mild to moderate insomnia by improving sleep and daytime functioning. Effects on relapse remain to be determined. Findings need to be interpreted cautiously due to the uncontrolled design and lack of follow-up assessments.

Doctors: School drug testing a bad idea - Kids & Parenting - MSNBC.com

The American Academy of Pediatrics weighs in on drug testing kids, saying that they are unreliable and can create a climate of distrust suspicion and fear.

Subjecting children to drug testing is usually a bad idea for a host of reasons, including often inaccurate results and loss of the child’s trust, a leading pediatricians’ group said on Monday.

Increasingly, schools are embarking on drug testing, particularly of student-athletes, following a 2002 U.S. Supreme Court ruling that declared the practice legal.

Parents may also be tempted by newly available home drug screening kits in an effort to catch the problem early.

But the American Academy of Pediatrics, updating its decade-old policy statement on the issue, said screening for illicit drugs is a complicated process prone to errors and cheating, and has not been shown to curtail youngsters’ drug use.

Drug testing also creates a counterproductive climate of “resentment, distrust and suspicion” between children and their parents or school administrators, a committee of experts wrote in the March issue of the group’s journal, Pediatrics.

False-positive results can arise from eating poppy seeds or ingesting certain cold medications, and test results may need to be confirmed with expensive further testing, it said.

Many students are also likely to be aware of Web sites that offer methods of defeating drug testing.

In addition, several illegal drugs are undetectable in urine more than 72 hours after use, and standard tests do not detect often abused substances such as alcohol, Ecstasy and inhalants. Some youngsters may respond to testing by avoiding drugs such as marijuana and instead abuse less-detectable, but more dangerous, drugs, the statement said.

“A key issue at the heart of the drug-testing dilemma is the lack of developmentally appropriate adolescent substance abuse and mental health treatment” in many communities, it said, noting existing programs designed for adults may be unsuitable for children.

The report suggested parents suspicious that a child is abusing drugs or alcohol consult the child’s primary care doctor rather than rely on school-based drug screening or home kits to check their concerns.

Vancouver teens lead in drug and alcohol use

Is this a consequence of Vancouver's drug policy?:

A new survey has found that people between 16 and 25 in this city are more likely to experiment with alcohol and drugs than young people elsewhere in Canada.

The Vancouver Coastal Health Authority says it found 54 per cent of young people who were surveyed had smoked marijuana or cigarettes in the past year, while nine out of 10 had drunk alcohol.

Young men are more likely to try pot, mushrooms and cocaine, while young women use ecstasy more.

One-third said they tried drugs because they were curious and most think pot is the least risky drug.

HBO's Addiction Series

I went to a premiere of the new HBO addiction series last night and have a few thoughts.

On the positive side:

• A really good segment on the latest in brain imaging. The also used a helpful way of explaining the role of dysfunction in limbic system and the frontal cortex. They described the limbic system as the "go" center of the brain and the frontal cortex as the "stop" center of the brain.
• There was a very powerful segment on insurance parity advocacy efforts in Pennsylvania.
• There was an inspiring segment about a steamfitter labor union local that became self-insured to avoid managed care restrictions on treatment access, developed recovery support groups for members, and developed a strong EAP program to intervene with and support union members.

On the down side:

• It was not as hopeful as I would have liked. The emphasis was on addiction and treatment, rather than recovery. I thought that someone without much knowledge or experience might leave with the impression that recovery is the exception to the rule. I also thought that it presented treatment as the only viable pathway to recovery.
  
• There was very little diversity. Almost all of the people depicted were white.
• There was a lot of attention to pharmacotherapies and no portrayal of mutual aid groups.
• One expert from a treatment program in Maine stated that 90% of opiate addicts are unable to achieve recovery without drug maintenance therapy. He went on to state that buprenorphine may be effective for people who are mildly addicted or only addicted to prescription medication, but that injection opiate addicts require methadone maintenance.

It was definitely worth seeing. My impression is that this 90 minute episode will air on March 15th and thirteen shorter episodes will follow. Hopefully the additional episodes will address some of the weak points in the first episode.

Funding treatment programs can save much pain, greater expenses down the road

From the Detroit Free Press:

Gov. Jennifer Granholm says the state needs to raise money for a better future while cutting spending for the present. But there's also a way to invest in the present that could save a fortune now -- and down the road.

Take a slice of the governor's proposed tax increase on liquor, add a piece of the higher taxes that also should be imposed on beer, and pour the money into treatment programs for drug and alcohol abusers. Cut into the physical damage these folks do and the crimes they commit and you get huge savings in health care, law enforcement, courts and prisons, where 80% of the inmates have histories of drugs or alcohol abuse. Intercept chemically addled people on their inevitable downward spiral and you can make them productive taxpayers, instead of a burden. Intervene early enough with a young person headed for trouble and you save not only millions of dollars but also a life. Lives, even, when you count the innocent victims of drunken drivers.

And yet, despite a conservative estimate of $2.7 billion in annual costs from addiction, Michigan ranks last among the 50 states in the share of the state budget spent for substance abuse programs.

Michigan does have treatment programs and diversion projects and sobriety or drug-abuse courts that have impressive results, but the state doesn't attack addiction the way it does other diseases. Why not? Well, the booze business, which now advertises more than ever, seems to think that it's doing enough with those "drink responsibly" tags on the commercials. And the public, despite overwhelming evidence to the contrary, doesn't buy drug or alcohol addiction as a disease, seeing it instead as a personal problem, a lack of willpower, even a shame.

In Detroit, that false notion will be attacked this month as part of a national effort that local treatment advocates hope will result in more public money dedicated to fight an enormously costly problem. (By the way, if setting aside some of the beer and liquor taxes won't work, what about some of the money from unclaimed can and bottle deposits, an estimated $50 million a year now split between the state and beverage retailers?)

Some Brains May Be Predisposed to Substance Abuse

We've known for some time that dopamine D2 receptors play an inportant role in addiction, but this is news:

Do the brain changes noted in drug addicts help cause their addiction, or are they the result of drug abuse?

A new study might solve that chicken-and-egg puzzle - pointing to new ways of preventing and treating addiction, researchers say.

The rat study suggests that "some individuals may be predisposed to the effects of cocaine on the brain," making them more likely to try the drug and become addicts, said lead researcher Dr. Jeffrey Dalley, of Cambridge University's Behavioural and Clinical Neuroscience Institute in the United Kingdom.

Specifically, rats that went on to compulsively self-administer cocaine intravenously were more likely to have fewer brain cell-surface receptors for the neurotransmitter dopamine in an area of the brain called the nucleus accumbens, compared to rodents that were less prone to addiction.

"The study is the first to conclusively demonstrate that changes in dopamine receptors in the nucleus accumbens pre-date cocaine use," Dalley said. That means that these brain changes are not caused by cocaine exposure but may encourage use of the drug.

Medical pot cuts pain, study finds

A recent study finds that marijuana is effective at relieving neuropathy pain in AIDS patients.

I'm not opposed to medical marijuana is it really is an effective medical treatment and it goes through the same approval process as any other drug. (However, it would seem to be important to find a route of administration better than smoking.) Unfortunately, all the competing political and social agendas make all the information suspect. The result is that I'm suspicious of everyone. As drug warriors often allege, many medical marijuana advocates appear to be guilty of hiding other agendas behind compassionate medical arguments. As harm reduction and medical marijuana advocates often allege, opponents are often guilty of irrational hysteria and hiding moral judgments behind bad science.

Doctors at San Francisco General Hospital reported Monday that HIV-infected patients suffering from a painful nerve condition in their hands or feet obtained substantial relief by smoking small amounts of marijuana in a carefully constructed study funded by the state of California.

Although the study was small, it is the first of its kind to measure the therapeutic effects of marijuana smoking while meeting the most rigorous requirements for scientific proof -- a randomized, double-blind placebo-controlled trial.

As such, the results of the trial are being hailed by medical marijuana advocates as the most solid proof to date that smoking the herb can be beneficial to patients who might otherwise require opiates or other powerful painkillers to cope with a condition known as peripheral neuropathy.

The federal government has taken a hard line against marijuana use for medical purposes, maintaining that smoking it is harmful and that there is no scientific evidence to support its legitimacy for treatment in the United States. The U.S. Supreme Court in 2005 ruled that medical marijuana patients can be prosecuted by the government, even in states like California where medical use has been legalized.

"It's time to wake up and smell the data," said Bruce Mirken, spokesman for the Marijuana Policy Project, a group advocating the legalization of the drug for medicinal purposes. "The claim that the government keeps making that marijuana is not a safe or effective medicine doesn't have a leg to stand on."

The study found that most volunteers who were given three marijuana cigarettes a day experienced a significant drop in the searing pain of peripheral neuropathy, which patients liken to a stabbing or burning sensation, usually on the bottoms of their feet. HIV patients are not the only group to experience peripheral neuropathy -- many types of the condition have been identified, and it can also afflict diabetics, cancer patients and people with injuries or infections that affect nerve tissue.

On average, the experiment's participants reported at the start that their pain was roughly at midpoint on a 100-point scale, where zero was no pain at all and 100 was "the worst pain imaginable."

At least half the volunteers who smoked the active marijuana experienced a 72 percent reduction in pain after their first cigarette on the first day of the trial. Over five days, the median reduction in pain reported by the marijuana smokers was 34 percent, compared with 17 percent reported by those who smoked placebo cigarettes that had the active ingredient THC removed in a process akin to decaffeinating coffee.

"This is evidence, using the gold standard for clinical research, that cannabis has some medicinal benefits for a condition that can be severely debilitating," said Dr. Donald Abrams, lead author of the study released Monday by the journal Neurology.

You Can Have Free Drugs, but Only If You Don't Behave Yourself

A libertarian (and disease model skeptic) response to the Vancouver plan to offer drug maintenance for cocaine and methamphetamine addicts:

The rhetorical and policy contortions produced by prohibition are something to behold. Instead of allowing adults to obtain oral stimulants for whatever purpose they like (which was the situation in the U.S. until the government started requiring a prescription for amphetamines in 1954 and even for a decade or so afterward, when prescriptions were easy to come by), the government drives them into the black market and then allows the select few who are sufficiently fucked up to get oral stimulants at taxpayers' expense. Meanwhile, doctors commonly prescribe stimulants to people who have trouble focusing and paying attention, a condition that used to be self-treated but nowadays is recognized as a disease requiring professional diagnosis. If you take these drugs without that diagnosis, you also have a disease—drug dependence—that one day, if we're lucky, may be treated by giving you the drugs.