The Methadone/AA Link

Here's an interesting follow-up to my post about the Newsweek article.

This in an excerpt from a lecture by Vincent Dole, a pioneer in methadone maintenance:

In the early 1960’s I was honored (and puzzled) by an invitation to join the Board of Alcoholics Anonymous as a Class A (nonalcoholic) trustee. Under the Constitution of AA only seven nonalcoholic persons could occupy this position, while several hundred thousand regular members of AA had entered the Fellowship the hard way, by being alcoholics. I was afraid that they might have made a mistake, and so before accepting the position, I discussed my research with executives of the Fellowship and raised the question as to whether this appointment might involve a conflict of interest, or at least the appearance of one. Would it embarrass the Fellowship to have an investigator of chemotherapy for narcotic addiction included in the Board of AA? They insisted that they saw no problem since the objectives were parallel-namely providing the best treatment available to sick persons. They also pointed to AA’s Fifth Tradition, which states that the mission of AA is solely to help alcoholics, and firmly rules against taking a position on other issues. They were right. There never has been a problem in my association with AA, and my admiration for Bill Wilson and the dedicated AA members that I came to know has increased over the years.

Needless to say, I have gained far more from AA than the Fellowship did from me. It was my privilege to witness the healing force of personal service, group support and humility, while my only serious responsibility was to serve on a few committees and be an alert observer. As an organization, AA is the purest form of democracy. Major questions are submitted to the membership at the annual meetings of delegates representing all groups. Ultimately, questions of policy are resolved in a statement of the Group Conscience. The headquarters of AA, the General Services Office, is just what the name states. The secret of AA’s strength is service. It is a secret that certainly should be shared with the medical profession.

Throughout most of my time on the Board I continued to be puzzled by the original question: Why had I, specifically, been invited to serve? If a physician experienced in treatment of alcoholics had been needed for professional opinion, there were many persons with better qualifications than I. If an administrative advisor was sought, I would be near the bottom of any search list. My only qualification was caring. One answer gradually became clear: In the early years of AA Bill and the original trustees were acutely sensitive to the danger of the Fellowship being distorted by aggressive persons with dogmatic opinions. During my time on the Board, I never detected any sign of this happening, but perhaps that simply reflectedthe success of the Traditions in the mature organization, keeping the Fellowship on track. Anyway, I assumed that I had been brought in as sort of a smoke alarm, a canary in the mine.

A more specific answer, however, emerged in the late 1960s, not long before Bill’s death. At the last trustee meeting that we both attended, he spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many sheep who are lost in the dark world of alcoholism. He suggested that in my future research 1 should look for an analogue of methadone, a medicine that would relieve the alcoholic’s sometimes irresistible craving and enable him to continue his progress in AA toward social and emotional recovery, following the Twelve Steps. I was moved by his concern, and in fact subsequently undertook such a study.

Until its closure this year, my laboratory sought an analogue of alcoholism in mice so as to be able to test potential medicines that could benefit human alcoholics. We failed in this, but the work is only begun. Talented investigators in other laboratories are working on various aspects of the analogue problem. With the rapid advance in neurosciences, I believe that Bill’s vision of adjunctive chemotherapy for alcoholics will be realized in the coming decade.

Now let me describe a coincidence that linked my work with Bill’s in an unexpected way, and perhaps explains my reaction to the scenes on the 125th Street 30 years ago. In Bill’s biography, he recalls a time in the winter of 1940 when the future of AA looked bleak. There was no activity in the newly opened club on 24th Street, and he was resting upstairs. Someone called up that a bum had come in, asking for Bill. Stumping up the steps was a stooped man with a cane who identified himself as a Jesuit priest. He said that he had come to meet Bill because of his admiration for the Twelve Steps. They were, he said, remarkably similar to the precepts of St. Ignatius Loyola, the founder of his religious order. As Bill’s biographer put it, “thus began a conversation that lasted 20 years.”

My association with AA came much later, but my contact with Edward Dowling, the priest in this story, antedated Bill’s meeting with him by 15 years. He was my classroom teacher in first year high school at Loyola Academy in Chicago in the mid 1920’s. At that time he was a slim and vigorous young novitiate with jet black Irish hair and an intense manner. Among other subjects he discussed ethical conduct, not as an abstract thesis, but as a practical obligation toward others, and as a service that brings its own reward.

In his subsequent busy career as a priest Father Dowling lived what he had taught, friend and advisor to people in trouble, to young families, to students, to alcoholics. I saw him only infrequently in later years, but remember most clearly the contrast between his continued intellectual force and his deteriorating health. Medically, he had severe rheumatoid spondylitis. He became progressively more stooped, white haired, limited in travel. Yet he did not even seem to be aware of his disability. He was too occupied with the problems of others.

Marie Nyswander, Bill Wilson, and Edward Dowling are no longer with us, but their inspiration remains. For each, life was a continuing Twelve Step. They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected. They left a positive record of success in dealing with these problems. It is my privilege, as their student, to greet the Society for Addiction Medicine, and transmit the expectations that they surely would have had for its future. They would have welcomed the strength and scientific discipline that you bring to the field. They would expect you to study and debate the technical details of treatment while being united in compassion for addicts. They would look to you for leadership that rises above special interests and prejudice. They would hope that you could lead the way to rational measures of prevention, and a variety of effective, nonpunitive treatments for various addictions. Certainly they would expect you to be concerned with the enormous public health problem of addiction: tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated. It would be their fervent hope that you succeed.

This lecture was published in the journal Alcoholism: Clinical and Experimental Research in 1991.

What Addicts Need

In its latest issue, Newsweek devotes a lot of space to addiction and an what it describes as an imminent era of pharmacological treatments. It makes some interesting points, but also illustrates how difficult it is to write for the general public about addiction in a scientific and definitive way right now.

While the roots of addiction remain a dark tangle of factors—most experts agree that addicts trying to quit will always need psychological support—the old white-knuckle wisdom that addicts simply lack resolve passed out of fashion decades ago. The American Medical Association recognized addiction as a disease back in 1956. But only now are we beginning to see treatments that target the underlying biochemistry of that disease.

"most experts agree that addicts trying to quit will always need psychological support"--What does this mean? How does the author define "psychological support"? Is she referring to professional services? Or, could this support be provided by family and community supports? Is seems to imply the former, which experts do not agree on at all. There is growing interest and a growing body of research on natural or spontaneous recovery.

She also misrepresents AA's position on the use of medication:

It is also facing resistance from some elements in the addiction-treatment community, who are wedded to the 12-Step model pioneered by Alcoholics Anonymous in 1935. Twelve-Step programs traditionally discourage members from using any psychoactive substances, on the ground that addicts will simply trade one dependency for another.

Of course, there is some truth to this. Many AA members are skeptical of psychotropic medications or medications to treat addiction, but I suspect that they are now a minority. My experience with the recovering community is that many are on psychotropics and that antabuse is not frowned upon by most members. Of course, mood altering drugs like benzos and methadone are another story. Further, AA's official stance is pretty deferent to prescribing doctors.

The article does, however, present a good overview of the growing consensus that addiction is a chronic brain disease but it also paints a very clear picture of researcher enthusiasm for pharmacological treatments. Call me a cynic, but it's hard to imagine that their enthusiasm isn't coloring their judgment and reporting about the effectiveness of these treatments. (We've seen this recently here, here, here and here. There's also the laundry list of now-abandoned "best practices.")

The emerging paradigm views addiction as a chronic, relapsing brain disorder to be managed with all the tools at medicine's disposal. The addict's brain is malfunctioning, as surely as the pancreas in someone with diabetes. In both cases, "lifestyle choices" may be contributing factors, but no one regards that as a reason to withhold insulin from a diabetic. "We are making unprecedented advances in understanding the biology of addiction," says David Rosenblum, a public-health professor and addiction expert at Boston University. "And that is finally starting to push the thinking from 'moral failing' to 'legitimate illness'."

In laboratories run and funded by the National Institute on Drug Abuse (NIDA), fMRI and PET scans are forcing that infuriating organ, the addicted brain, to yield up its secrets. Geneticists have found the first few (of what is likely to be many) gene variants that predispose people to addiction, helping explain why only about one person in 10 who tries an addictive drug actually becomes hooked on it. Neuroscientists are mapping the intricate network of triggers and feedback loops that are set in motion by the taste—or, for that matter, the sight or thought—of a beer or a cigarette; they have learned to identify the signal that an alcoholic is about to pour a drink even before he's aware of it himself, and trace the impulse back to its origins in the primitive midbrain. And they are learning to interrupt and control these processes at numerous points along the way. Among more than 200 compounds being developed or tested by NIDA are ones that block the intoxicating effects of drugs, including vaccines that train the body's own immune system to bar them from the brain. Other compounds have the amazing ability to intervene in the cortex in the last milliseconds before the impulse to reach for a glass translates into action. To the extent that "willpower" is a meaningful concept at all, the era of willpower-in-a-pill may be just over the horizon. "The future is clear," says Nora Volkow, the director of NIDA. "In 10 years we will be treating addiction as a disease, and that means with medicine."

...

So for this new paradigm to take hold, a lot of long-held prejudices will have to change. Doctors (and insurance companies) will have to get used to the idea of medicating their addicted patients, rather than handing them a brochure for AA, which a study published in 2005 in The New England Journal of Medicine found was the most common form of "treatment" offered. "If you have hypertension and it flares up, you go to a specialist," says psychologist Thomas McLellan of the University of Pennsylvania. "The specialist doesn't discharge you to a church basement. If he did, we would call it malpractice." Addicts, he adds, are by no means unique in their propensity to relapse. In a study comparing alcoholics and drug addicts to patients with diabetes, asthma and hypertension, McLellan found nearly identical rates of noncompliance and relapse; between 30 and 40 percent of each group failed to follow even half their doctors' guidelines.

As some of the statements above suggest, the article also foreshadows pressure on treatment providers and the recovering community to embrace these new treatments:

Volkow's vision of the future, however, is being greeted warily by big pharmaceutical companies, reluctant to develop products that would associate their brands with drug addicts. It is also facing resistance from some elements in the addiction-treatment community, who are wedded to the 12-Step model pioneered by Alcoholics Anonymous in 1935. Twelve-Step programs traditionally discourage members from using any psychoactive substances, on the ground that addicts will simply trade one dependency for another. That rationale has some unfortunate history on its side; both opium and cocaine were first introduced to the United States as cures for alcoholism in the late 1800s. More recently there is the example of methadone, the synthetic heroin that turned out to be addictive in its own right, and Antabuse, a drug that makes you throw up when you drink alcohol—which suffers from the shortcoming that an alcoholic planning a binge can just skip his dose.

...

The revolution these new drugs promise will have a huge impact on the addiction-treatment industry (or, as it prefers to think of itself, the "recovery movement"), which runs the gamut from locked psychiatric wards in big-city hospitals to spalike mansions in the Malibu Hills of California. And the reaction there is guarded; the people who run them have seen panaceas come and go over the years, and the same addicts return with the same problems. They also, of course, have a large investment in their own programs, which typically rely on intensive therapy and counseling based on the 12-Step model. "We need four or five more years to see how [Vivitrol] does," says staff psychiatrist Garrett O'Connor at the Betty Ford Center, in Rancho Mirage, Calif. "And we need to be very cautious, because a failed treatment will set a person back." The Ford Center and the Hazelden Foundation, in Minnesota, use drugs sparingly, and mostly just in the first days or weeks of recovery, the "detox" phase. "Hazelden will never turn its back on pharmaceutical solutions, but a pill all by itself is not the cure," says William Moyers, Hazelden's vice president of external affairs. "We're afraid that people are seeking a medical route that says treatment is the end, not the beginning." As for Alcoholics Anonymous and its imitators, they mostly do not forbid members to use medication but there are strong institutional biases against it. "I'm not judging others, but for myself, using something like Vivitrol or Camparal feels like a crutch," says one longtime AA member, who, following the organization's practice, asked not to be named. "It's not true sobriety."

The competing view is that of Lisa Torres, a New York lawyer who has been in recovery from heroin addiction for nearly 20 years, and continues to take methadone, which she regards as medication for a chronic condition, analogous to blood-pressure or cholesterol-lowering drugs. "It's a paradox that some of addicts' biggest advocates have been the most resistant to new treatments," she says. "But a lot of them come to the field after recovering from their own addictions, and they can be very stubborn about what works and what doesn't." More pointedly, she adds, "some people feel recovery from addiction should not be easy or convenient."

...

And addicts may need to change their thinking, too. For nearly 75 years, that thinking has been dominated by the principles laid down by Bill W., the founder of Alcoholics Anonymous. The amount of good AA has done in the world is incalculable; most people reading this article probably can think of someone they know who owes his or her life to it. Some readers themselves have surely benefited. But in 1935 AA was, essentially, the only legitimate option. There were "cures" of various sorts, including gold chloride injections, but there was virtually no modern neuroscience or psychopharmacology. Many people are now living in society with mental illnesses like schizophrenia and bipolar disorder that would have required institutionalization back then. Addicts, like the rest of the public, need to recognize the fact that we are entering a new era in addiction treatment. Viewing her condition as a chronic, recurring disease that could be treated was precisely what Dyess needed to return to sobriety. "In the past, when I would relapse," she says, "the thinking from 12-Step or from family was that I had failed. Now I know that if it happens, it happens, and I can pick myself up and move on, instead of assuming it's all over so I might as well keep drinking." The 12 Steps begin with a confession of powerlessness over addiction. But there's hope that science may some day help put that power within the reach of anyone who needs it. And then who would choose not to grasp it, and begin the long war for sobriety—a war without end, but one worth the fighting.

One more line from above provoked one more troubling thought:

Volkow's vision of the future, however, is being greeted warily by big pharmaceutical companies, reluctant to develop products that would associate their brands with drug addicts.

By working to reduce the stigma associated with addiction we will inevitably be removing barriers currently preventing others from entering the field. Some will probably have good motives and their presence will be helpful. Others will view it as a new market for profiteering. We've experienced this before. The article acknowledges this, but, in my opinion, naively dismisses these concerns because she believes science will be the basis of new treatments. Buyer beware.

Warning given over techno addicts

Please.

Physician group position on medical marijuana

The American College of Physicians recently released a position paper on medical use of marijuana. It appears to be a pretty sober approach to the issue and there's something to disappoint everyone. (nonsmoked) More states appear to be moving in the direction of legalizing medical marijuana (but the feds don't seem to be any where near considering it) and this could help address the many of the problems that have come up in California.

Position 1: ACP supports programs and funding for rigorous scientific evaluation of the potential therapeutic benefits of medical marijuana and the publication of such findings.
Position 1a: ACP supports increased research for conditions where the efficacy of marijuana has been established to determine optimal dosage and route of delivery.
Position 1b: Medical marijuana research should not only focus on determining drug efficacy and safety but also on determining efficacy in comparison with other available treatments.
Position 2: ACP encourages the use of nonsmoked forms of THC that have proven therapeutic value.
Position 3: ACP supports the current process for obtaining federal research-grade cannabis.
Position 4: ACP urges review of marijuana’s status as a schedule I controlled substance and its reclassification into a more appropriate schedule, given the scientific evidence regarding marijuana’s safety and efficacy in some clinical conditions.
Position 5: ACP strongly supports exemption from federal criminal prosecution; civil liability; or professional sanctioning, such as loss of licensure or credentialing, for physicians who prescribe or dispense medical marijuana in accordance with state law. Similarly, ACP strongly urges protection from criminal or civil penalties for patients who use medical marijuana as permitted under state laws.

[via dailydose.net]

Culturally Congruent Intervention

RAND just made an article available (previously published) on a culturally specific intervention for African American drug addicts. Bill White has written about several groups that frame addiction recovery as an act of cultural resistance. Locally, I've also seen the power of a minority faith community in holding culturally specific recovery events--Rabbi Yisrael Pinson holds monthly recovery Shabbat.

What I found interesting was the idea of doing the intervention over a meal. I'd imagine that this alone would have the potential to dramatically change the dynamics in all sorts of positive ways. Culture aside, this would be a fun model to experiment with.

The content and format of our intervention were designed to be congruent with cultural values of communalism and group process and to employ motivational intervention techniques appropriate for participants at the precontemplation or contemplation stage of change. We began with a traditional African American meal (fried chicken or ribs, greens, potatoes, red beans and rice), which served as a culturally specific frame for the intervention. For this meal, the participant was joined by an intervention team consisting of one counselor and a former drug user, whom we called a peer. This group then watched a 15-minute video, which combined voice-over with still photos, original and documentary footage, and clips from commercial films about African Americans. (Permission to use clips was obtained from holders of the copyrights.) The final step was a counseling session to review the participant’s interest in recovery and service needs. It was based on issues, thoughts, and emotions expressed by the participant during the meal or video.

In the video and counseling session, drug use was represented as both a personal problem and a community problem rooted in cultural and power disparities between the African American community and dominant institutions. Moreover, discussion acknowledged the totality of one’s life experience (e.g., racial prejudices, self-image issues, and job opportunities) not only as an individual but also as an African American. It was emphasized that behavior change is important not only for the individual but also for the collective good.

The peer role was to share personal thoughts and experiences similar to those mentioned by the participant and to demonstrate to him or her that it was both safe and appropriate to speak honestly about one’s drug use experiences and one’s ambivalence regarding recovery. In addition, the peer converted the standard one-on-one format in which a counselor interviews a client to a culturally congruent group process format in which counselor and peer actively affirm the thoughts, feelings, and experiences invoked by the participant.

[via dailydose.net]

Sponsorship

From a friend:

My friend Bill White just ran across a ten year follow-up study that looked at the role of sponsorship in predicting post-treatment sobriety. Those who sponsored other AA members throughout the ten year study had a 91% end of study remission rate. The scientists are finally figuring out this helping other drunks is pretty powerful stuff.

Here's the citation:

Cross, G.M., Morgan, C.W., Mooney, A.J., Martin, C.A. & Rafter, J.A. (1990). Alcoholism treatment: A ten-year follow-up study. Alcoholism: Clinical and Experimental Research, 14, 169-173.

Identical twins not as identical as believed

A new snag in twin studies:

Contrary to our previous beliefs, identical twins are not genetically identical....

How can it be that one identical twin might develop Parkinson’s disease, for instance, but not the other? Until now, the reasons have been sought in environmental factors. The current study complicates the picture.

“Even though the genome is virtually identical in identical twins, our results show that there in fact are tiny differences and that they are relatively common. This could have a major impact on our understanding of genetically determined disorders,”

and YOU thought addiction was a disease ...

From a friend:

The Spiritual Science Research Foundation (SSRF) based in Melbourne, Australia has recently published breakthrough research about the causes of addictions ... 96% of all addictions are *caused due to possession by either ghosts or our departed ancestors.*

http://www.spiritualresearchfoundation.org/miscellaneous/pressreleases/


(and the best part - only THREE steps for a complete cure:)
http://www.spiritualresearchfoundation.org/spiritualresearch/mentalhealth/addiction/#611

SAMHSA sat on 'bupe' study

Misuse of bupe isn't news to us, but it's disappointing that SAMHSA sat on the info:

The federal agency that oversees buprenorphine treatment for narcotics addicts learned more than two years ago of illegal sales and abuse of the pills but did not reveal the findings as officials campaigned to expand use of the drug.

U.S. Substance Abuse and Mental Health Services Administration records show that in December 2005, Vermont health officials advised the federal agency of some patients crushing and injecting the pills called Suboxone, trading or peddling them on the street - even smuggling them into the state's prisons.

Agency officials hired consultants who confirmed those problems and others. Yet the agency didn't tell Congress or the U.S. Food and Drug Administration, which has the power to order tighter controls over prescription drugs. Agency officials waited until Jan. 28 of this year to disclose the findings, which were posted on the SAMHSA Web site as "new" and a "comprehensive report" of buprenorphine abuse nationwide.

The report, which characterizes abuse of the drug as a "small but persistent problem," is the first by the agency to provide detailed evidence of misuse as well as weaknesses in systems set up by Congress to guard against it.

The Battle Against Drugs

From a letter in the New York Times:

Accepting that we will never have a drug-free society, and that many drug users are unable to practice a sober lifestyle, does not preclude our ability to reduce the demand for drugs and help those who continue to use them.

This is what's wrong with too many harm reduction programs. How about, "many drug users are unable to practice a sober lifestyle now"?

[via dailydose.net]

OSI Treatment Initiative

Good news. George Soros, who has previously made large investments in harm reduction programs, has started a new treatment initiative.

Critics have often branded Soros and OSI as supporters of drug legalization based on their past funding support for groups like the Drug Policy Foundation. Capoccia -- who formerly led the Robert Wood Johnson Foundation's addiction treatment and prevention program area -- said it would be a mistake to associate the Closing the Addiction Treatment Gap program with drug-legalization groups. On the other hand, he noted, "Harm-reduction has always been a part of the continuum of care."

Asked if Closing the Treatment Gap constituted an effort by Soros and OSI to tackle addiction issues in a more "mainstream" fashion, Capoccia replied, "This is not a departure at all from the investments OSI and Soros have made, but rather an extension," adding: "It's mainstream on the one hand but radical on the other -- that everyone who needs treatment should have it. We've accepted things like waiting lists ... the radical dimension is that we should be accepting that."

RWJF's 2006 decision to end its addiction-related program area has left a substantial funding gap in the treatment and prevention community, but Capoccia said that OSI's intention is not to fill RWJF's shoes. "This is not a definition of new priorities for OSI," he stated. "This is more likely to be a focused effort."

Smoking bans and heart attacks

Another piece of evidence that smoking bans have significant impact on public health.

Crack sentence reform scare tactics

From Join Together:

U.S. Senate Judiciary Committee Chairman Patrick Leahy (D-Vt.) and others have rejected Attorney General Michael Mukasey's call for Congress to undo a recent decision by the U.S. Sentencing Commission, which retroactively reduced the penalties for crack-cocaine offenses, the Associated Press reported Feb. 12.

Mukasey requested that Congress pass a law to reverse the commission's decision before it goes into effect on March 3, claiming that the change in mandatory sentencing laws would result in the release of thousands of violent criminals. Representing the Justice Department, federal prosecutor Gretchen C.F. Shappert told the committee, "I am deeply concerned that the success we are experiencing in some of our most fragile, formerly crack-ravaged communities will be seriously interrupted if these communities are forced to absorb a disproportionate number of convicted felons."

The War on Drugs Starts Here

The New York Times weighs in on the President's new budget:

The Bush administration, which offers regular lectures on the superior logic of the free market, clearly doesn’t get this equation of supply and demand. Last October, Washington announced a new $1.4 billion assistance package for Mexico and Central America to combat the drug trade. Then the White House unveiled its 2009 budget, which calls for a 1.5 percent cut in spending on domestic drug prevention and treatment programs.

Yet the White House’s budget proposal for 2009 cuts the funding for the prevention and treatment of drug abuse to $4.9 billion. The budget for prevention programs — like the drug-free schools grants — was cut by 14.2 percent to just above $1.5 billion. After accounting for inflation, spending on prevention has fallen every year since 2002.

Making Pot Legal: We Can Do It -- Here's How

A blueprint for advocating cannabis legalization:

The long-expressed goals of the marijuana law reform movement to end the arrests of responsible adult pot smokers and enact a regulated system of cannabis access and sales are achievable. However, these goals will continue to remain unattainable unless this movement begins to better address the political and public hurdles that have plagued it for more than 30 years.

More on the subject.

In Adolescents, Addiction to Tobacco Comes Easy

Huh? I don't get it. This finding really challenges a lot of assumptions about addiction. It will be interesting to see follow-up studies. I'll take it more seriously once it's replicated. Could it be that there is some switch flipped in the limbic system that responds to environmental cues, even id they only occur once a week?

In the report that follows, Dr. Joseph R. DiFranza, a family health and community medicine specialist at the University of Massachusetts Medical School in Worcester, states that “very soon after that first cigarette, adolescents can experience a loss of autonomy over tobacco.”

Dr. DiFranza, who studies tobacco dependence, described a typical teenage smoker — a 14-year-old girl who smokes only occasionally, about three cigarettes a week. She admitted to having failed at several efforts to quit. Each time she tried, cravings and feelings of irritability drove her back to smoking.

“We have long assumed that kids got addicted because they were smoking 5 or 10 cigarettes a day,” Dr. DiFranza said in an interview. “Now we know that they risk addiction after trying a cigarette just once.”

Even occasional teenage smokers can experience the same symptoms of nicotine withdrawal that prompt adult smokers to light up again and again.

Robin J. Mermelstein, director of the Center for Health Behavior Research at the University of Illinois in Chicago and a longtime researcher on smoking behavior, said in an interview that Dr. DiFranza’s message was important. But, Dr. Mermelstein added, “the vast majority of teenagers who try one or two cigarettes don’t go on to become smokers.”

“Some kids experience withdrawal symptoms earlier than others,” she continued. “We still need to know how to predict who’s going to get hooked.”

Dr. DiFranza explained that a phenomenon called “dependence-related tolerance — how long after smoking a cigarette you can go before you need to smoke another one” — was long thought to be the same for adolescents and adults. But recent studies have shown that the brains of adolescents can become tolerant to nicotine after smoking fewer cigarettes than one a day, and it is tolerance that then drives them to smoke more often.

“The typical adult smoker begins to crave the next cigarette in 45 minutes to an hour after smoking,” he said. “But kids can be addicted and not need to smoke again for days, even weeks.”

Some adult smokers are no different from teenagers. One study found that adults who smoked only a few cigarettes a week found it hard to quit. “They experienced withdrawal symptoms, which some rated as unbearable,” Dr. DiFranza reported. “Most of these self-described ‘social smokers’ were addicted to tobacco.”

Facing Budget Cuts, ONDCP Refocuses Media Campaign

Facing Budget Cuts, ONDCP Refocuses Media Campaign

With federal research showing that its anti-drug media campaign isn't working with kids, and Congress calling for major cuts in the program, the White House Office of National Drug Control Policy (ONDCP) has unveiled a more modest effort that focuses on an emerging threat -- prescription-drug abuse -- and appeals to parents rather than youth.

Read the rest here.

2008 Elections Offer Special Opportunity for Recovery Advocates

2008 Elections Offer Special Opportunity for Recovery Advocates:

The Whole Health Campaign is reaching out to candidates, health policy advisors, and party delegates to promote the following three points:
(1) Ensure equitable and adequate mental health and addiction treatment coverage in all public and private health care plans.

(2) Support policies that promote individual and family recovery from mental illnesses and addiction as integral to overall health.

(3) Commit to investing in prevention, early intervention and research on mental illnesses and addiction.

Whole Health Campaign members want both parties’ platforms to reflect its three points. Yet they realize that a long-term strategy is also needed. “No one believes that the goals of the Campaign will be addressed or resolved by getting the right words in a candidate’s mouth,” said Dr. Goplerud. “Even if it’s not through the Whole Health Campaign itself, addiction and mental health groups need to be in this for the long haul.”

Read the rest here.

The effect of methadone maintenance treatment on alcohol consumption

From the Journal of Substance Abuse Treatment:

There is a high prevalence of alcohol use, abuse, and dependence in methadone maintenance treatment (MMT) programs. There have been reports that this may be a result of entry into methadone maintenance. Through a systematic review, this article attempts to determine whether alcohol consumption is affected during the course (from prior to treatment initiation to once on maintenance) of MMT. A literature search for publications addressing the issue of alcohol use while on MMT was conducted. Of 15 heterogeneous clinical studies that met inclusion criteria, three studies supported an increase in alcohol use, three supported a decrease in alcohol use, and nine supported no change in alcohol use. The studies varied in their methodology and in their definition of problematic alcohol use. This review found that alcohol use, although often problematic in methadone-using patients, likely does not change upon entering MMT. (emphasis added) We recommend routine screening and treatment for problematic alcohol use in patients on MMT.

Addiction and hunger connection

In interesting finding, but I'll remain pretty skeptical until I see more studies replicating the findings.

Oxy hype

STATS criticizes media coverage of Oxycontin (again). Has the media hyped the dangers of Oxycontin? Of course. They hype everything. I remember a recent Today Show segment on the hidden dangers of shopping carts.

The article argues that it's not a major drug of addiction:

The significance of this study is that it provides a powerful, random sample of drug addicts in the U.S. and finds that just 5% reported ever using OxyContin.

Among this group of 1,425 addicts, only 22% reported receiving OxyContin by way of prescription for a medical problem. But 86% reported using OxyContin, whether prescribed or not, to get high. Only eight (0.5%) used OxyContin exclusively. What this means is that the overwhelming majority of those abusing OxyContin were abusing other drugs as well (specifically, heroin, cocaine, methamphetamines and sedatives).

I've never been concerned about accidental addiction for pain patients. Rather, I've been more concerned about illicit use of Oxycontin by young people who become opiate addicts and switch to heroin because Oxycontin is so expensive. I don't think I've ever seen a client who's primary drug is Oxycontin, but I've seen scores whose opiate use began with Oxycontin experimentation. They probably would have become addicts anyway, but Oxycontin seems to have lowered the threshold for young people to start using opiates. The author does acknowledge that this study might not capture information about these trends.

Clearly we need to both look for ways to increase access to opiates when it's medically appropriate for pain management and find ways to reduce diversion.

Life cycle of ADHD

An interesting study on the course of ADHD:

Now a series of studies following 457 Finnish children from birth to ages 16 to 18 offers a glimpse of how the primary symptoms of ADHD typically evolve. At the same time, the studies raise provocative questions about the long-term effect of treating those symptoms with medication.

The studies focus on a subset of 188 Finnish teens considered to have "probable or definite ADHD" that will follow them into adulthood and 103 kids with conduct disorder -- behavior issues that fall short of an ADHD diagnosis but put kids at higher risk for similar problems. Those teens were compared with a group of Finnish teens with no ADHD diagnosis.

Researchers found it is the can't-sit-still kids -- the stereotype of the "ADHD generation" -- who are most likely to mature out of the disease. Among those with persistent ADHD, they also found, half have problems with cognitive skills that are key to success in adulthood, but half have no such deficits.

And when researchers compare the findings from Finland to studies of Americans with ADHD, an even more intriguing discovery emerges: By the time they're in their late teens, those who receive drugs for attention problems seem to fare about the same as those who do not.

That is sure to fuel a simmering debate over the extent to which American kids with ADHD receive medication, often with little other support. In Finland, medication for ADHD is extremely rare.

[via dailydose.net]

Narcan outrage

This NPR story about Narcan distribution has prompted outraged posts from Mark Kleiman and Matt Yglesias. (I posted about it earlier this month.)

I'm not a fan of Narcan programs(Which isn't to say I'd obstruct one.), mostly because they operate in environments that have little or no treatment, and don't make it their responsibility to facilitate recovery and advocate for recovery support.

Narcan programs are a symptom of our pathetic response to addiction. Given access to meaningful treatment (Not just once a week outpatient or methadone.), most addicts would prefer recovery. Addicts hate their lives, they just see no hope for a different life. Narcan distribution in the context of a system in which only the rich can access high quality treatment is a sad statement about our collective values. I'd have more respect for Narcan distribution advocates if they were working hard to facilitate recovery and advocating treatment on demand.

That Narcan distribution can save lives is important, but the unasked question is, "how many addicts want treatment, were unable to get meaningful treatment, and died during that period." Our response should be both/and.

Prop 215

Who wouldn't want to get their medication from a vending machine in a dispensary with a big poster of Tupac?

Phone-based peer recovery support

An excerpt from an interview about the Connecticut Community for Addiction Recovery's peer recovery support activities:

GREAT LAKES ATTC: You have recently started providing telephone-based recovery support services to people leaving Connecticut treatment programs. Could you describe the scope of this and what you’re learning from it?

PHIL VALENTINE: The Telephone Recovery Support premise is simple: a new recoveree receives a call once a week for 12 weeks from a trained volunteer (usually a person in recovery) to check up on their recovery. We have found, though, that after 12 weeks when we ask the recoveree if they still want to receive a phone call, most times the answer is “yes.” We now have people who have been receiving calls for 50 or more weeks, and they’re still in recovery. In our first full year of making these calls, CCAR volunteers and staff have made more than 3,100 outbound phone calls. We piloted the project for 90 days out of Willimantic, after meeting with Dr. Mark Godley from Chestnut Health Systems to refine our procedures (DMHAS supported this consultation through a Center of Excellence project). We tweaked the script a bit, and the process works amazingly well. Outcomes have been ridiculously good—our last quarterly report indicated that 88 percent of our recoverees were maintaining their recovery. Volunteers love making these calls; it helps them as well. It’s a win-win situation. We have trained dozens of people to make these calls out of all our locations. Anyone is eligible to receive a call—all you have to do is ask.

GREAT LAKES ATTC: Are all of your volunteers people in recovery?

PHIL VALENTINE: We thought the telephone recovery support would best be provided by people in recovery, but we have had some interns who weren’t in recovery who have done a great job in this role and have gotten the same results as our recovering people. I think it’s just the fact that the agency of CCAR, what we represent, is reaching out to them, and as representatives of CCAR, they really feel and understand that somebody cares for them. It may be more the institution and the relationship with the institution than the particular person who’s making that call. And I don’t even know if it’s the institution as much as the purpose. It’s the care, compassion, and love behind the call that seem to work.

GREAT LAKES ATTC: It’s hard to estimate the power of such contact.

PHIL VALENTINE: Early in my recovery, I was told to get a long list of names and phone numbers of people in recovery, and I did. I was a good boy. I had probably a couple hundred names. Did I ever call anybody? No. The idea of actually using the phone numbers was foreign to me. I couldn’t pick up the phone to call somebody, but when somebody called me, I would talk and talk and talk and talk and felt very grateful for the support.

GREAT LAKES ATTC: What keeps the volunteers coming back?

PHIL VALENTINE: It’s fulfilling. I sit here, and I listen to volunteers make telephone recovery support calls. I’m not ever sure who’s getting the most out of it, the volunteers or those they’re calling, but I see volunteers with eyes lit up, energized on the phone, really glad to hear from this person that they’re doing well, praising the person for all the good things they’re doing, being able to be a small part in maybe moving that person towards a life of recovery. There is nothing more rewarding in a volunteer position than playing a role in moving someone into a life in recovery.

One more ally

Lindsey Graham goes on the record for parity and alternatives to incarceration.

Paroxetine reduces social anxiety in individuals with a co-occurring alcohol use disorder

This study found that Paxil reduces anxiety in drinkers. So did this experiment. (There's a wisecrack hidden here.)

Too bad the FDA lists alcohol abuse as a frequent adverse effect of Paxil. (See "nervous system".)

The internet is full of stories about the interactions between Paxil and alcohol.

Fund Rehab, Not Prisons, Taxpayers Say

Keep hope alive.

FDA fast-tracks first cocaine, meth addiction fighter

Another pharmacological treatment is on the way:

Deerfield-based Ovation Pharmaceuticals said Tuesday its drug vigabatrin, being developed to treat cocaine and methamphetamine dependence, has landed “fast track” designation from U.S. regulators potentially speeding up the process for market approval.

The drug would be the first approved by the U.S. Food and Drug Administration for treatment of the addictions.

The anticonvulsant drug, to be marketed under the brand name Sabril, is believed to block the craving and euphoria associated with cocaine and meth use.

Vermont hearing set on pot decriminalization

From the Boston Globe:

Vermonters get to weigh in this week on a bill before the Legislature that would decriminalize possession of small amounts of marijuana.

The history of drug diversion in America

A web exhibit on drug diversion.

Study finds disparities in jailing of whites, blacks

A rare opportunity to learn about local drug law enforcement relative to other regional and national numbers. The good news is that incarceration rates for drug crimes are low. The bad news is that there is troubling racial disparity in the rates.

Blacks are jailed on drug offenses in Washtenaw County at 42 times the rate of whites, placing the county within the top 10 nationwide in racial disparity, a recent study concluded.

The Justice Policy Institute study showed that, when broken down by race, nearly three white offenders per 100,000 residents are incarcerated on drug charges - compared to 112 black offenders per 100,000 residents.

But local officials are skeptical about the study's results and are compiling their own data as they study local trends in the criminal justice system.

Washtenaw was one of seven Michigan counties included in the study, titled the "Vortex: The Concentrated Racial Impact of Drug Imprisonment and the Characteristics of Punitive Counties." Washtenaw topped the other Michigan counties in terms of the racial disparity ratio.

...

Among the other findings of the study:

• Washtenaw is listed among the top 10 counties nationwide with lowest overall drug admission rates, at 17.05 per 100,000 residents.
• In 2002, 19.5 million Americans admitted to using drugs. During the same year, about 1.5 million were arrested on drug charges. Of those arrested, 175,000 were sentenced to prison, and more than half those were black.

Accepting Psychiatric Care May Be Dangerous for Homeless Women

An interesting take on homeless women's resistance to psychiatric diagnoses:

Most of the women Luhrmann interviewed said they believed that the uncertainty and danger of life on the streets drove some "crazy," and they believed that only those who were weak-willed succumbed to the harsh reality of life on the streets by becoming, for instance, psychotic, she told Psychiatric News.

"The women I interviewed, who themselves could be diagnosed with some kind of psychotic disorder, were motivated to say that they were not going to be driven crazy by life on the streets" and emphasized that they have a better chance of surviving by not seeking mental health services or social services that require a psychiatric diagnosis.

Some of the women at the center linked victimization with mental illness because the perception by others that they are mentally ill makes them vulnerable to attack, Luhrmann noted.

One woman Luhrmann interviewed mentioned that some of the women "talk to themselves.. .because they let the streets take over them.. .a lot of the women have been raped by the men here and.. .can't deal with it, so that just made them go haywire."

The author seems to present two reasons for their resistance. First, that it might make them a target for victimization. I see an implied second reason, that ,internalization of a psychiatric diagnosis might diminish their resilience.

Too bad the response is so patronizing:

In interactions with homeless women who have a psychotic disorder, "every effort should be made to avoid presenting the patient with an explicit psychiatric diagnosis," Luhrmann noted.

Parity Legislation Stalls

An update on the status of parity legislation:

The differences between the House and Senate negotiators have come down to three main areas: which types of mental illness should be covered, what out-of-network benefits will be offered, and what approach will allow the best preservation of stronger state laws.

Nonetheless, both bills require that insurance plans that include mental health benefits must cover those benefits at parity with in-network or out-of-network medical/surgical benefits. Thus, passage of either the Senate or House version, Meyers said, would constitute a major improvement over the current 1996 Mental Health Parity Act, which only guarantees equality in annual and lifetime payment limits.

One of the main differences over which negotiators remained deadlocked was that the House bill would require any plan that provides mental health parity coverage to recognize all illnesses in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The Senate measure would leave it up to health plans to determine the psychiatric conditions they would cover.
...
Negotiators also were unable to find common ground on differences in out-of-network benefits. The House bill would require any plans that include an out-of-network benefit to also offer out-of-network parity mental health coverage. The Senate version would allow plans to offer a medical/surgical out-of-network benefit without offering a corresponding mental health benefit. If the plans did offer an out-of-network mental health benefit, they would have to do so at parity.

African Americans Complete Alcohol Treatment at Lower Rates than Whites

A troubling finding from RAND.

For Debate - the COMBINE study

Read this before you are on the receiving end of a Vivitrex sales pitch:

The monumental study on combined pharmacotherapies and behavioural interventions for alcohol dependence (COMBINE) was set up ‘in order to determine if improvements in treatment outcome for alcohol dependence can be achieved by combining pharmacotherapy and behavioral interventions’ [1]. When the main results were published in May 2006 [2], it was clear that no such combining effect had been detected in the trial. Neither had the combination of the two pharmacological interventions—naltrexone and acamprosate—nor the combination of any or both of these with a behavioural intervention [combined behavioural intervention (CBI)], improved the outcome. At the same time, and in line with the results from other multi-site studies, all the nine different treatment interventions (combinations) showed a substantial reduction in drinking, including those who had received placebo pills. In general, the commentaries on these results, as well as the conclusions from the COMBINE study group, underlined one recommendation for clinical practice: support for the use of naltrexone in primary care settings. However, the empirical basis for this recommendation appears to be somewhat weak.
...
Given the fact that the magnitude of difference between the two pharmacological interventions is quite small at the end of treatment (i.e. 16 weeks), and basically disappears at the 1-year follow-up, it is possible to claim that the COMBINE study provides somewhat weak support for preferential use of either. In the same way, neither naltrexone nor acamprosate provide a better outcome than non-pharmacological interventions. In comparison with a group that received CBI and placebo (within the context of medical management), naltrexone in combination with CBI did not improve outcomes. Because the mechanisms behind the improvement of the CBI/placebo group must be mind-mediated and not of a neurochemical character, these findings indicate that there is an absence of any neurochemical effect associated with naltrexone which is additive to the psychological mechanisms at work in the CBI/placebo intervention. Although it is not logically necessary that specific pharmacological and placebo/psychological effects have to be additive [3], it does seem likely that they are. Why would a placebo produce a non-pharmacological effect while a pharmacological intervention, indistinguishable from the placebo, would not?
...
Along the same lines, the lack of empirical support for acamprosate is reported as surprising, but not discussed with any reference to the possibility that the mechanisms of action of acamprosate might not be there or, if there, not of any importance beyond the placebo effect. Given that researchers within the COMBINE study group have pointed previously to the fact that: ‘Despite its widespread use . . . and proven efficacy, the precise mechanism of action is unknown’ ([7], p. 60), it would have been interesting to see an elaboration of this theme in light of the lack of support for acamprosate in the COMBINE study.

I think the cops are at the door

From Wired:

In the January issue of Neuropharmacology, which happens to have a marijuana theme, two teams of researchers tried to explain what causes some people to feel paranoid when they smoke weed.

If you think it's impossible to have too much of a good thing -- think again.

In the first sentence of their research paper, a group of Italian scientists explained that low doses of tetrahydrocannabinol -- the psychoactive chemical in marijuana -- tend to be calming while large amounts have the opposite effect.

Performance enhancing ritalin

I wonder how many high school athletes will start complaining of attention problems after this story gets a little more press.

Antidepressant Studies Unpublished

An unsurprising finding from the New England Journal of Medicine via The New York Times:

The makers of antidepressants like Prozac and Paxil never published the results of about a third of the drug trials that they conducted to win government approval, misleading doctors and consumers about the drugs’ true effectiveness, a new analysis has found.

In published trials, about 60 percent of people taking the drugs report significant relief from depression, compared with roughly 40 percent of those on placebo pills. But when the less positive, unpublished trials are included, the advantage shrinks: the drugs outperform placebos, but by a modest margin, concludes the new report, which appears Thursday in The New England Journal of Medicine.

Previous research had found a similar bias toward reporting positive results for a variety of medications; and many researchers have questioned the reported effectiveness of antidepressants. But the new analysis, reviewing data from 74 trials involving 12 drugs, is the most thorough to date. And it documents a large difference: while 94 percent of the positive studies found their way into print, just 14 percent of those with disappointing or uncertain results did.

Here's the results statment from the NEJM abstact:

Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published. Whether and how the studies were published were associated with the study outcome. A total of 37 studies viewed by the FDA as having positive results were published; 1 study viewed as positive was not published. Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive. Separate meta-analyses of the FDA and journal data sets showed that the increase in effect size ranged from 11 to 69% for individual drugs and was 32% overall.

Unfortunately, whenever you see a study demonstrating the effectiveness of a drug, you have to ask yourself, "what studies are they choosing not to publish?"

[via dailydose.net & Pain Recovery Solutions]

The History of Gay People in AA

I'm reading a great book that I wanted to share a little about. I'm only 4 chapters into The History of Gay People in AA but I can't recommend it highly enough for anyone interested in the history of AA or, more specifically, the history of gay people in AA. (Here's the Preface and Chapter 1)

I know about Marty Mann, but my understanding is that she was in the closet and I knew nothing else about gay people in early AA. I was surprised and pleased to learn that the history of gay membership in AA goes back to at least 1937. It turns out that this story from the 3rd tradition was about a gay man seeking help:

On the A.A. calendar it was Year Two. In that time nothing could be seen but two struggling, nameless groups of alcoholics trying to hold their faces up to the light. A newcomer appeared at one of these groups, knocked on the door and asked to be let in. He talked frankly with that group's oldest member. He soon proved that his was a desperate case, and that above all he wanted to get well. "But," he asked, "will you let me join your group? Since I am the victim of another addiction even worse stigmatized than alcoholism, you may not want me among you. Or will you?" There was the dilemma. What should the group do? The oldest member summoned two others, and in confidence laid the explosive facts in their laps. Said he, "Well, what about it? If we turn this man away, he'll soon die. If we allow him in, only god knows what trouble he'll brew. What shall the answer be - yes or no?" At first the elders could look only at the objections. "We deal," they said, "with alcoholics only. So went the discussion while the newcomers fate hung in the balance. Then one of the three spoke in a very different voice. "What we are really afraid of," he said, "is our reputation. We are much more afraid of what people might say than the trouble this strange alcoholic might bring. As we've been talking, five short words have been running through my mind. Something keeps repeating to me, `What would the Master do?'" Not another word was said. What more indeed could be said?"

The approach in those early days seemed to be, "the only thing we care about is that you're an alcoholic." The unfortunate corollary to this was social pressure to not discuss one's sexual identity (Unless, of course, you were heterosexual.) or stay in the closet. To be fair, this was still very progressive for the time and they took the same approach to many other "problems other than alcohol."

Also on the topic is this talk by Barry L. (author of Living Sober) about the influence of early gay members of AA on the development of the 3rd tradition.

If you are a Dawn Farm staff and you're interested in borrowing the book, let me know.

Heroin anyone?

BMJ has pro/con commentaries on the subject of heroin maintenance.

Opioid maintenance treatment generally seems to be well justified for treating this disease. And if maintenance is generally justifiable as a form of treatment, why should heroin not be used as one such pharmacological agent? ... Overall, we see no convincing reason why heroin assisted maintenance treatment should not be part of a comprehensive treatment system for opioid dependence.

No convincing reason? Obviously, they've taken a position, but they don't think that ANY of the arguments have ANY merit? At least they offer this caveat...

However, the development of an overall integrated treatment system is crucial.

Neil McKeganey responds with an argument against:

Prescribing heroin to heroin addicts is a strategy beloved by top police officers and successive home secretaries. It is a strategy, though, borne of utter frustration at our seeming inability to tackle an escalating drug problem. If you cannot stop addicts committing crimes to fund their drug habit then, so the argument goes, the next best thing is to provide them with the drugs that are the reason they are committing the crimes in the first place. The logic may seem faultless, but at the back of your mind is the nagging question, "Is it treatment or is it social problem prescribing?"

I think he makes right argument. Opponents of HR strategies are often accused of moral panic. I think the moral argument is one of the most persuasive, but not trying to turn drug use or addiction into a moral issue. Rather, the way we respond to suffering addicts is a moral issue. Further, are our interventions motivated by despair or hope, and, who are they intended to serve?

Prescribing heroin to heroin addicts, however, makes sense only if your primary concern is to treat not their drug dependency but the consequences of their drug use. You may want to reduce their use of street drugs, the risks to health from HIV or hepatitis C virus, the risks of overdose, or their criminality. With all of these aims in mind you may conclude that it makes sense to provide addicts with a prescription for the drug that they have become dependent on. And yet the reason they are committing those crimes, and taking such enormous and persistent risks with their health, is because the drugs have become more important than life itself—that is the nature of drug addiction. And that is the problem that drug treatment services need to tackle.

In the commentary, McKeganey makes the case for the efficacy of treatment. The problem is not that addiction doesn't response to treatment, rather that we continually treat it with sub-optimal doses and duration and then despair at the intractability of the problem.

Along these lines, if the issue for advocates is really that we don't have widely effective treatments (an argument that I don't buy), why don't they ever advocate these programs as a temporary stopgap until more effective treatments are developed?

But do addicts coming forward for treatment actually want heroin to be prescribed to them? A study of over 1033 drug users starting treatment in 2001 asked participants what they wanted to get from the drug treatment services they were contacting. Most of those questioned said that they wanted the services to help them become drug free.

America's Love-Hate Relationship with Drugs

I'm truly sympathetic to arguments against the war on drugs, but is it really possible that the author this naive?

In 2004 Miami Dolphins running back Ricky Williams announced that he had found marijuana to be 'ten times more helpful than Paxil' for his anxiety and depression. What made Williams's declaration difficult to ignore was that he had been a celebrity spokesman for GlaxoSmithKline, manufacturer of Paxil.

Neuroscientist Pankaj Sah notes, 'It's worth considering that people who constantly use cannabis may be doing it for other reasons than just to 'get high' -- perhaps they are experiencing some emotional problems which taking cannabis alleviates. Much the same way as some people drink alcohol to relieve anxiety.'

[via dailydose.net]

From the Ashtray of History

The Atlantic uses their archives to offer a little historical perspective on tobacco in the U.S.. Here's the lede:

For decades, scientists have noted a strong correlation between smoking, lung cancer, and high death rates. But only recently has government at both the national and local levels taken aim at the practice of smoking. Why, one might wonder, has it taken so long? As this collection of Atlantic articles—spanning more than a century—makes clear, the debate on that seemingly straightforward question is older and more complex than one might think.

They also provide a timeline on anti-tobacco movements going back to 1624.

Brief Screening by Docs Reduces Drinking

Physician screening and brief counseling offers some bang for very few minutes:

A 10-minute screening and talk with a doctor about problem drinking delivers almost as much bang for the buck to the health system as childhood immunization and advice about taking aspirin to prevent stroke and heart attack, according to a new systematic review — but just 8.7 percent of problem drinkers report receiving such information.

The review, which appears in the February issue of the American Journal of Preventive Medicine, included data from 10 randomized controlled trials of alcohol problem screening and advice by primary care doctors.

...

The review found that screening and brief counseling reduced problem drinking by 17.4 percent over a period that varied from six months to two years among studies. This means that more than one in six problem drinkers who received these brief interventions no longer fit that definition six months to two years later.

[via dailydose.net]

Forgiveness

This might be a helpful resource for some clients. I wish the discussions of self-forgiveness had more about repentance. Lee Taft's model fleshes out repentance.

I'd also like to see more about the transition from victim to survivor. Along those lines, this interview from NPR has always stuck with me:

NEAL CONAN, host: This is TALK OF THE NATION. I’m Neal Conan in Washington.
On the 11th of September, Cheryle Sincock was among those killed when a hijacker crashed an airliner into the Pentagon. Her husband, Chief Warrant Officer Craig Sincock, joins us now on the line from his home in Virginia.
And thanks very much for speaking with us.
Chief Warrant Officer CRAIG SINCOCK: Thank you for having me this afternoon, Neal.
CONAN: This must be very difficult for you, especially over the holidays.
CWO SINCOCK: It has been difficult, and yet we really are filled with blessings, too.
CONAN: Filled with blessings. But I wonder, if you go back to September, were you angry after you learned of your wife’s death?
CWO SINCOCK: Neal, I was angry towards the end of that first day, about 11:00 that night, 11:30 when I got home. And I drove in my driveway and I was crying and I was angry at God for about 10 minutes. And then he and I did not have a very good relationship for about those 10 minutes, till I realized that it was not his fault. It was not him that had driven that plane in there. And a calm came over me that night, and I realized that it wasn’t God’s fault; it was something else. And not that I could understand it, but that I, you know, had to just continue on with my life and do the things I needed to do for somebody else at the time.
CONAN: When did you start thinking about forgiveness?
CWO SINCOCK: Actually, that was about the time I started the forgiveness. Actually about four hours after the attack the opportunity came to help somebody else who was in real trouble that day.
CONAN: Mm-hmm.
CWO SINCOCK: And as I was helping that other individual, I realized that when I got out of myself and I really thought about how to help somebody else—How could I say the right words? How could I just be there for somebody else?--the little problems that I had at the time, not knowing my wife—where she was, if she was alive or dead, if she was hurt, injured or whatever, you know. But getting outside of myself, that was a release to me. And then God gave me that same opportunity every single day from that point on and continues to every day, even today, to help somebody else. And getting outside of myself and helping somebody else has now lifted that burden of the fears and the frustration and the anger that I had originally.
CONAN: Does forgiving mean forgetting?
CWO SINCOCK: No, it does not. It’s kind of like you see a dog coming at you on the street, a mad dog, you know, you do something to protect yourself. I can’t forgive the dog. There’s nothing there to forgive, you know? But I have to, you know—I remember that and maybe I walk a different path the next time.
...
CONAN: You talked about this 10-minute period. How did you work through that anger? It must have been very difficult.
CWO SINCOCK: I kind of worked through it—and I hate to say logic because it really wasn’t logic. A calm came over me all of the sudden when I realized that what I was doing was wrong. I did not feel right. And when I don’t feel right, there’s something wrong with me. It’s not wrong with somebody else or something else or someplace else; it’s something wrong with me. I’ve learned that over the years about myself. And I just realized if I’m feeling this way and I’m angry and I’m frustrated and especially when I’m sitting there and I’m angry with God, there is something really wrong with myself. So I had to take a good, hard look that night and realize it was my fears, that fear of the unknown, that terrible fear of the unknown, of the impending doom of something I can’t control. And when I realized that, then I could say, ‘OK, God, you know, what do we do from this point on?’
CONAN: So you took responsibility.
CWO SINCOCK: That’s right. And in all things I have to end up taking—you know, I have to take the responsibility. It’s not the somebody else, it’s not the other people, places and things that get me. It’s usually me, just myself.
CONAN: Well, Craig Sincock, thank you so much for joining us. And again, on behalf of all of us, how sorry we all are for your loss.
CWO SINCOCK: Well, you know, there’s a lot of other people, a lot of other families out there that are still in that. You talked about earlier—you were talking about anger and hate and forgiveness. And what a terrible thing that is when we have to try to search for that and we don’t know how to grab ahold of that. We don’t understand what all those feelings are and those emotions. There’s a way of getting through that process. At least I’ve found a way, you know. And it’s more than just getting down on my knees and praying because I have to do some action, too.
I had one of the ministers or chaplains that was up at the Family Support Center early on after the incident ask me one day how I got through all my angers that he thought I should have. And I told him at that time that I thought anger led into the resentment. And resentment was the fact that when I get angry, that’s my anger.
CONAN: Mm-hmm.
CWO SINCOCK: You know, how dare you interrupt me in my anger? ‘Cause I feel so good feeling so angry.
CONAN: Yeah. You almost nurture it.
CWO SINCOCK: Yes. And the resentment, if I put an action to resentment, I have a revenge. And then if I go from that revenge state and I justify what I’m doing in revenge, I have vengeance. And what’s the only difference between me and my enemy, that person that flew that plane into the Pentagon? They had vengeance, but they had vengeance without a cause. I don’t dare go that far. I have to stop mine at the anger stage. I can’t afford to have that. Perhaps others can, but I cannot. So as I look down at my life and I say, ‘I really can’t afford to get the anger. If I can’t afford to get the anger—what causes my anger is fear. The thing that causes my fear is because I don’t want to forgive somebody for what I think they’ve done to me.’ And then I can say, you know, ‘It’s all right. I don’t understand what you did to me, but it’s OK. I’m going to protect myself a little different next time...’
CONAN: Mm-hmm.
CWO SINCOCK: ‘...but it’s OK.’
CONAN: Well, Craig Sincock, thanks very much.
CWO SINCOCK: I thank you for having me this afternoon.

Farm staff - this would make a great didactic.

One of us

The New Yorker published a profile of Kahlil Gibran. Turns out he's one of us:

He had another difficulty: alcoholism, a situation that may have developed soon after “The Prophet” was published, or while he was writing it. Robin Waterfield thinks that Gibran’s basic problem may have been a feeling of hypocrisy, in that his life so contradicted his pose as a holy man. In his last years, he stayed closed up in his apartment, occasionally receiving a worthy visitor but mostly drinking arak, a Syrian liquor that Marianna sent to him, apparently by the gallon. By the spring of 1931, he was bedridden, and one morning the woman who brought him his breakfast decided that his condition was dangerous. Gibran was taken to St. Vincent’s Hospital, where he died later that day. The cause of death was recorded as “cirrhosis of the liver with incipient tuberculosis.” Waterfield reports that Gibran’s admirers have greatly stressed the tuberculosis over the cirrhosis. “Nothing incipient kills people,” he objects. His speculation seems to be that Gibran drank himself to death out of a sense of fraudulence and failure.

[hat tip: http://newrecovery.blogspot.com]

Alcoholics Anonymous (AA) Recovery Outcome Rates: Contemporary Myth and Misinterpretation

A very interesting (and overdue) paper on AA's current and historical success rates:

This paper addresses an erroneous myth that AA is experiencing a 5% (or less) “success rate” today as opposed to either a 50%, 70%, 75%, 80% or 93% (take your pick) “success rate” it once reputedly enjoyed in the 1940s and 1950s. The term “myth” is used to emphasize that the low “success rates” promulgated are a product of imagination, invention and inattention to detail rather than fact-based research. Also noteworthy in the derivation of the mythical percentages, is the absence of fundamental academic disciplines of methodical research, corroborating verification and factual citation of sources. Regrettably, some of the advocates who are propagating the myth are AA members who purport to be “AA Historians” and appear to be advocating agendas that portray fiction as fact and hearsay as history.

Damaged brakes?

That the frontal cortex plays an import role in addiction is not news. However, if you're not familiar with the neurobiology of addiction, this is worth reading.

The Anti-Drug Drugs

Newsweek has a great overview of how immunotherapy for addiction might work.

A vaccine that would teach the immune system to attack and destroy cocaine before the drug reached the brain is poised to enter its first large-scale clinical trial in humans. The shot is years away from FDA approval, but the concept that it might someday be possible to inoculate those at risk of addiction has obvious appeal.

Each of the addiction vaccines now in development employs a similar medical strategy. Because the addictive drug molecules are small enough to evade the body's immune system, they can slip undetected from the respiratory and circulatory tracts that absorb them and make their way into the central nervous system, where they work their dark magic. But when attached to a larger molecule—like an inactivated protein from a cholera-causing bacterium—the addictive substances can't hide. The immune system develops antibodies that can latch on to the drugs when they are next ingested by themselves. Once attached to an antibody, a given drug cannot access its targets in the brain and is instead broken down by certain enzymes.

The medications now used to treat addiction do not prevent addictive drugs from entering the brain, as the vaccines would. Instead these treatments, known as small-molecule therapies, block the drugs' neural targets, so that when the drug reaches the brain it has no place to go. These treatments have met with limited success. For example, methadone, a drug used to treat heroin addiction, is itself a narcotic that has been associated with addiction. Naltrexone and Chantix, which treat alcohol and nicotine addiction, respectively, have been effective in only a small subset of patients. "In all three cases, the brain's receptors are still being manipulated, albeit with a replacement drug," explains Nora Volkow, director of the National Institute on Drug Abuse. In theory, says Volkow, anti-addiction vaccines would circumvent some of these problems by neutralizing the addictive substance before it reached the nervous system. And that means the drugs might someday be used to prevent substance abuse as well as treat it. "It would be great if we could give kids a vaccine that would make them impervious to the effects of alcohol and hard drugs," says Volkow. "In reality, we are still many years away from that."

Some limitations include the fact they do not appear to have the same effect on every one and that the immune response could be overwhelmed by high doses of drugs.

The Impact of Depressive Symptoms on Alcohol and Cigarette Consumption Following Treatment for Alcohol and Nicotine Dependence

This study found moderate and severe depression to be a predictor of drinking relapse, but not tobacco. Odd.

Here's the abstract and some reactions:

Abstract

Background: Although depression is common among alcohol and tobacco dependent patients, its impact on treatment outcomes is not well established. The purpose of this study was to examine the impact of depressive symptoms on abstinence from tobacco and alcohol after treatment for alcohol dependence and nicotine dependence.

Methods: The Timing of Alcohol and Smoking Cessation Study (TASC) randomized adults receiving intensive alcohol dependence treatment, who were also smokers, to concurrent or delayed smoking cessation treatment. The sample consisted of 462 adults who completed depression and substance use (alcohol and smoking) assessments at treatment entry and 6, 12, and 18 months posttreatment. Longitudinal regression models were used to examine the relationships between depression and subsequent abstinence from alcohol and tobacco after baseline characteristics, including alcohol and smoking histories, were considered.

Results: Depressive symptoms were prospectively related to nonabstinence from alcohol. Depressive symptoms at the previous assessment increased the odds of drinking at the subsequent time point by a factor of 1.67 (95% CI 1.14, 2.43), p <>

Conclusions: Depression is an important negative predictor of the ability to maintain abstinence from alcohol within the context of intensive alcoholism and smoking treatment. It may be important to include depression-specific interventions for alcohol and tobacco dependent individuals to facilitate successful drinking treatment outcomes.

It does a good job reviewing the mixed literature on the subject:

Several studies have suggested that patients with current or a past history of depression have less positive outcomes from alcohol treatment (Curran and Booth, 1999; Driessen et al., 2001; Hasin et al., 2002; Hodgins et al., 1999; Rounsaville et al., 1987). Others have found no relationship between depression and alcohol treatment outcomes (Burns et al., 2005; Davidson and Blackburn, 1998;Hunter et al., 2000; Miller et al., 1997; Sellman and Joyce, 1996).

Here's some more detail from the full text:

...the majority of participants who began the study with mild or no depressive symptoms, had no clinically significant depression at the follow-up assessments. However, most participants who entered the study with moderate or severe depression continued to report significant depressive symptomatology throughout the study.

...it is important to note that some of the variation in the existing literature may be related to differences in the way depression has been measured. For example, when we used just baseline depression scores (vs. the longitudinal, lagged model used in the present analyses) and examined their relationships to subsequent alcohol use, depression did not predict alcohol use beyond the 6-month assessment (data not presented).

It also found immediate smoking treatment to be a predictor of drinking:

Consistent with prior analyses (Joseph et al., 2004b), there was a significant effect of smoking treatment timing; those who had concurrent smoking treatment were more likely to drink over time [OR = 1.63, 95%CI (1.08, 2.47), p <>While it's presented as consistent with the literature, my impression is that this is very inconsistent with most research on the subject.

It says nothing about the treatment received and also found unemployment at baseline to be a predictor of drinking. To me this suggests the limitations of looking at drinking and mood in a vacuum.

The article seems pretty invested in self-medication for endogenous depression as an explanation for the relationship between alcohol and depression:

Our results suggest that depression is related to difficulty achieving 6 months of alcohol abstinence following treatment for alcohol and nicotine dependence. These findings are consistent with the findings from some, but not all, previous studies. For example, at least 1 study found no evidence that alcohol consumption reliably preceded a depressive episode or that depressive episodes reliably preceded the onset of alcohol relapse (Hodgins et al., 1999). However, several other studies have illustrated links between the remission of depression and alcohol or substance use (Hasin et al., 1996, 2002; Mueller et al., 1994; Sullivan et al., 2005). This fits with the model that negative mood states are precursors of relapse (Marlatt and Gordon, 1985) and the idea that negative reinforcement (drinking to reduce negative mood) may help to maintain drinking behavior. In fact, there is evidence that alcohol dependent subjects are more likely to report that alcohol relieved depressive symptoms than other psychiatric patients (Leibenluft et al., 1993).

Here's the predictable headline.

Co-occurring Social Anxiety and Alcohol Use Disorders

Abstract

Background: Individuals with social anxiety disorder and co-occurring alcohol problems report using alcohol to cope with anxiety symptoms. Interventions that reduce both social anxiety and drinking are needed. Paroxetine, an FDA-approved medication to treat social anxiety disorder, reduces anxiety in individuals with co-occurring alcohol problems.

Objectives: To examine whether effective treatment of social anxiety with paroxetine reduces drinking in dual-diagnosed individuals who endorse using alcohol to cope.

Methods: A 16-week, double-blind, randomized controlled trial of paroxetine was conducted. Participants (placebo n = 22; paroxetine n = 20) met DSM-IV diagnostic criteria for social anxiety disorder and alcohol abuse or dependence. Participants were seeking treatment for social anxiety, not for the alcohol problem. Alcohol use outcomes were measured with conventional quantity/frequency measures and novel measures of drinking to cope.

Results: Paroxetine improved social anxiety more than placebo. Paroxetine reduced self-reported reliance on alcohol for self-medication purposes, but was not different than placebo in changing quantity and frequency drinking or the proportion of drinking days that were identified as coping-related. Exploratory analyses revealed that for the placebo group, drinking during the trial was correlated with social anxiety severity, whereas for the paroxetine-treated group, drinking was uncoupled from social anxiety severity.

Conclusions: Successfully treating social anxiety symptoms with paroxetine does not reduce drinking in dual-diagnosed individuals who are not seeking treatment for alcohol problems. Paroxetine does, however, reduce reliance on alcohol to engage in social situations, and may change the reasons why one drinks (such that drinking occurs for other reasons besides coping with anxiety). These results have implications for staging of social anxiety and alcohol treatment in individuals with the co-occurring disorders presenting to a mental health or primary care provider.

Brief family treatment intervention in inpatient detoxification

Abstract

Two earlier studies showed that a brief family treatment (BFT) intervention for substance abusing patients in inpatient detoxification increased aftercare treatment post-detox. BFT consisted of meeting with the patient and a family member with whom the patient lived to review aftercare plans for the patient. A phone conference was used when logistics prevented an in-person family meeting. Based on the earlier research results, we trained a newly hired staff person to continue providing BFT. We monitored key process benchmarks derived from the earlier research studies to ensure ongoing fidelity in delivering BFT. This method proved successful in transferring BFT from delivery in a research study to ongoing delivery in routine clinical practice after the research ended. It also ensured that a high proportion of patients had their families contacted and included in planning the patients' aftercare.

Overdose Rescue Kits Save Lives

The article offers a feel-good national perspective on Narcan kits. Sadly and predictably, there is no mention that these programs are operating in the context of extremely limited access to treatment.

We need both/and.

Sexual Dysfunction Prior to First Drug Use Among Former Drug Addicts and Its Possible Causal Meaning on Drug Addiction

If the only tool you have is a hammer...

What's in a name?

An editorial in Addiction reviews the arguments for and implications of renaming the National Institute on Drug Abuse (NIDA) to the National Institute on Diseases of Addiction (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to the National Institute on Alcohol Disorders and Health (NIADH).

...an argument is put forward that the proposed name change for NIDA ‘removes the pejorative term "abuse"’ and thus separates abuse from ‘diseases of addiction’. Further, the name change links conceptually the concepts of disease with addiction and, as stated in the press release, ‘identifying addiction as a neurobiological disease will diminish . . . social stigma, discrimination, and personal shame . . .’.

For NIAAA, a different explanation is put forth in the Biden press release. The press release argues that NIAAA's current name is an awkward remnant of their organizational past, when the agency was housed within the former Alcohol, Drug Abuse and Mental Health Administration (ADAMHA). Today, NIAAA's research function is under the aegis of the National Institutes on Health (NIH). Moreover, there is a growing sense that ‘excessive alcohol use and alcohol dependence (alcoholism) are not separate diagnostic categories, but exist along a single continuum of alcohol-disorders associated with increased frequency of a harmful drinking pattern’. Thus, the proposed NIDA name change affirms the view that the term ‘abuse’ is no longer a useful or informative way to describe the goals or functions of the agency. In this regard, some have suggested that ‘alcohol abuse’ may not even appear in the next iteration of the DSM, which is due within the next 5 years.

Another explanation, not necessarily mutually exclusive from the first, is that NIDA and NIAAA are responding to pressures within the NIH to view their purpose and mission as primarily biomedical, or as stated in Biden's press release, ‘neurobiological’.

Without taking a position, the editorial points out that an outcome of this (possibly unintended) would be to institutionalize a micro approach to drug and alcohol problems.

What is notable about all the potential reasons for the name changes discussed above is that they all appear to produce a ‘win–win’ situation for those who see drug and alcohol issues exclusively through the quite narrow lens of addiction and disease. The ‘losers’ in this tale will be those who adhere to a broader public health framework that encompasses individual issues as well as larger, social policy and environmental concerns.