More on the grim neurobiology of early drinking

Previous studies have begged the question, Alcoholism: Clinical & Experimental Research has a study that attempts to provide an answer:

"The key finding of this study was that people who started drinking before age 15, and to a lesser extent those who started drinking at ages 15 to 17, were more likely to become alcohol dependent as adults than people who waited until 18 or older to start drinking," said Dawson. "Past studies have often suggested that this association might result from common risk factors predisposing people to both early drinking and AUDs. Although the current study does not provide conclusive evidence that early drinking directly increases AUD risk, it suggests that it is premature to rule out the possibility of such a direct effect."

"By controlling for a variety of confounding risk factors in their analysis, Dawson and colleagues were able to demonstrate that ... early alcohol consumption itself, as a misguided choice or decision, is driving the relationship between early drinking and risk for development of later alcohol problems," observed Moss.

Tobacco regulation

The Washington Post makes the case for FDA regulation of tobacco:

The FDA regulates everything from vegetables to Viagra. But cigarettes, which lead to some 400,000 deaths in the United States each year and shorten a smoker's life by 10 years on average, have somehow escaped oversight. As a result, tobacco companies don't have to divulge the ingredients in their products. They also don't have to disclose the levels of nicotine in their cigarettes. This means they can label their products as "light" or "low tar" with few restrictions; smokers have no way of knowing whether such claims are true. The bill would prevent cigarette companies from using such labels. It would also curb cigarette advertising and forbid fruit-flavored cigarettes intended to lure new smokers. The legislation would fund a new program within the FDA to oversee Big Tobacco by imposing a user fee on cigarette companies.

And the specious arguments of opponents:

The bill's critics, including the Bush administration, say that FDA regulation could trick consumers into thinking cigarettes are approved by the agency. But a provision in the legislation would prohibit Big Tobacco from perpetuating such a misunderstanding.

Puhleaz!

Also, remember the post last week suggesting a tobacco sales ban in pharmacies? Well, Phillip Morris unsuccessfully fought such a ban in San Francisco.

Tobacco and pharmacies

Disease management care blog suggests that pharmacies should stop selling tobacco. Makes sense to me.

Nicotine delivery

I just stumbled upon these two nicotine delivery systems. (The WHO is alarmed about one of them.)

When reading about them, I couldn't help but think of Bill White's lecture on drug trends when he made this point:

The hypodermic syringe offers an interesting case study in innovation. This new instrument arrived with the promise to reduce morphine addiction by requiring smaller amounts of morphine via injection compared to oral use. But this new technology turned out to be a Trojan horse that would alter the history of addiction in unforeseen ways.

He also referenced the innovation of "rocking" cocaine with baking soda and offered a warning something to the effect of, "I can't tell you what the major drugs of abuse of tomorrow will be. But I can tell you that they are already here and that someone will discover a new way to use them."

I was about to write that it was hard to imagine nicotine as a major drug of abuse, but then realized how blind I can be to the fact that it is a major drug of abuse. At any rate, it's hard to imagine nicotine being used the way that heroin, cocaine and other illicit drugs are used but maybe with a new method of administration and in conjunction with another drug? 

Maybe. Maybe not. But I am convinced that Bill White is right--there are other trojan horses coming.

9 types of drinkers

I'll note that the article does not use the the words alcoholic or dependence, so it's intent may be limited to categorizing alcohol abusers, but it feels like the latest iteration of the psychogenic model of addiction.

Parity update

The platforms of both political parties endorse some form of parity, though the Republican platform does not specifically include access to addiction treatment. 

To be honest, I've grown a little weary of the struggle for parity. It's been 7 years since George Bush indicated that he'd sign parity legislation. For years, there have been enough votes to pass legislation but the Republican leadership refused to allow a vote.  Now the Democrats have been in power for more than a year and a half and we've watched it stall with nearly weekly advocacy calls for supporters to contact their legislators.

A parity law will be an important milestone, but it's clear that it does not mean that there will suddenly be easy access to care. Insurers will implement tight managed care protocols and, practically speaking, things may not be very different. Parity does not equal equity. This will be the next long struggle.  

Here's an overview of mental health parity I wrote several years ago.

More on Earth and Fire

Mark Keiman and Jacob Sullum have posted their responses to the Erowid argument for legalization.

Nothing too interesting. Kleiman does close with this:

We could reduce violence and drunken driving by raising alcohol taxes [Cook 2007, Cook forthcoming], we could shrink the illicit drug markets and reduce recidivism by using drug testing and swift, automatic, and mild sanctions to force probationers to stop using expensive illicit drugs [Kleiman 1998, Hawken and Kleiman 2007, Schoofs 2008], and we could break up street drug markets, thus protecting neighborhoods, with low-arrest drug crackdowns [Kennedy 2008, Schoofs 2008].

Inmates running the asylum...

Unsurprising FDA/drug company incest:

It seems that the Food and Drug Administration turned to “a non-profit run by a pharmaceutical industry advertising consultant to help design its new campaign to educate consumers about direct-to-consumer drug advertising. The FDA’s recently launched website, “Be Smart About Prescription Drug Advertising: A Guide for Consumers,” was developed by EthicAd, a non-profit run by Michael Shaw out of the offices of Atlanta-based Shaw Science Partners. Shaw’s firm claims credit for having helped launch over 25 pharmaceuticals, including Viagra, Celebrex, Zoloft, Cymbalta, and Rezulin, which was later withdrawn from the market because of safety concerns.”

All twelve step faciliation is not equal

Not a surprising outcome if you know much about twelve step facilitation:

Important findings from the current investigation of the relationship between services received and outcomes of chemical dependency treatment were that higher participation in optional or extracurricular 12-step meetings was associated with better treatment outcomes, whereas curricular involvement in 12-step groups (i.e., groups required as part of treatment) showed no association with treatment outcomes.

Get people to meetings does not necessarily equal connecting them with the community. All meetings are not equal. Getting them to a meeting where a thriving, welcoming community of recovery is essential for effective twelve step facilitation. It takes a kind of recovery cultural competence to effectively attend to these matters.

Other findings:

• ...weak effects for supplemental psychiatric, family, medical, and legal services: We found null associations between delivery of these services and the odds of 6-month sobriety across the board.
  
• The study also found associations between participation in sober recreational events at 2 and 4 weeks and better treatment outcomes at 6 months
  

Finally, another finding emphasizes the importance of recovery-oriented services, rather than treatment-oriented services:

We found that residential participants showed higher participation in curricular 12-step meetings at 2 weeks, relative to day-hospital participants and as expected; however, this effect was not maintained throughout follow-ups, and residential participants actually showed relatively lower rates of extracurricular 12-step meeting attendance and working with a sponsor through 4 weeks. These latter differences may be the consequence of residential clients' tightly scheduled time, intensive involvement in curricular 12-step meetings, and/or restrictions on leaving the treatment site.

Initial treatment focus

No difference in drinking, depression or retention for depressed alcoholics treated with cognitive behavioral therapy or twelve step facilitation.

Trauma, addiction treatment and iatrogenic harm

A frequent concern about trauma-focused models is the fear of iatrogenic harm. This study found that Seeking Safety didn't lead to adverse events. It's worth noting that Seeking Safety is a pretty low intensity approach emphasizing psychoeducation and coping skills.

When hope is lost...

...isolate the afflicted.

Responsible use not a foundation for policy

Oops. I was wrong in yesterday's post about responsible drug use. Jonathon Caulkins is from RAND, not Cato, and has posted a response to yesterday's Erowid post on responsible drug use at Cato Unbound. He starts off by identifying and challenging one of the underlying values:

The Erowids assert that “Modern humans must learn how to relate to psychoactives responsibly, treating them with respect and awareness, working to minimize harms and maximize benefits, and integrating use into a healthy, enjoyable, and productive life.” Most of that assertion is innocuous. Psychoactives are ubiquitous when the term is used so broadly as to include even caffeine. However some are quite dangerous, so as a class they should certainly be treated with respect. And working to minimize harms and maximize benefits is unobjectionable in most endeavors.

What distinguishes the Erowids is their assertion that modern humans must integrate psychoactive use into life. Apparently from their perspective, choosing abstinence, at either the individual or societal level, is inherently inconsistent with being modern.

Denying or denigrating an individual’s right to choose temperance is an extreme position not worth engaging.

He goes on to make the case for prohibition without being supportive of American prohibition:

While avoiding a full rehash of the by-now dull legalization debate, two points bear mention. First, American drug policy is easy to criticize as intrusive, ineffective, and mean-spirited. However, it does not follow that prohibition is necessarily a bad policy. Essentially every country in the world prohibits production and distribution of cocaine, crack, heroin, and methamphetamines for recreational use, even legalizers’ poster child, the Netherlands. Most affluent industrialized countries take a far less aggressive approach to their prohibitions than the United States does, yet they maintain prohibitions nonetheless. The problems with America’s prohibition stem primarily from particulars of its implementation, not from prohibition per se.

Second, the challenge is not in criticizing prohibition, but designing something better. To their credit, the Erowids offer specific suggestions in their “Fundamentals of Responsible Psychoactive Use.” I am skeptical that they constitute a practical framework for social policy, as distinct from being useful guidelines for individuals who choose to use psychoactive drugs. Note, though, that nothing about American alcohol policy precludes application of these principles. So if their advocates are successful in taming the rather considerable problems with legal alcohol, then I would take more seriously claims about the Principles’ universal efficacy with respect to all psychoactives, including, say, methamphetamine.

He then goes on to distill the issue to its most fundamental question:

What are the risks of trying the big four illegal drugs (marijuana, methamphetamine, cocaine—including crack—and heroin)? Statistics vary by drug, age of first use, and other variables, but among the myriad patterns of drug use, four are common: (1) limited experimentation, (2) ongoing controlled use, (3) ongoing use that is mostly controlled but punctuated by occasional abuse, and (4) escalation to dependent use.

...

To grossly simplify, about half of people who try illegal drugs stop with experimentation, and one in six end up in each of the other three categories (controlled use without and with occasional abuse and dependence). The proportions are slightly more favorable for those who only try cannabis, but less dramatically so than one might expect. At any given time, five times more people are dependent on marijuana than are incarcerated for drug-law violations, and the lifetime risk of abuse or dependence for cannabis use is on the order of one in ten.[1]

No one knows how legalization would change these probabilities. The Erowids might argue the risks would go down, particularly if their principles were applied. I would argue the opposite. The drugs would be cheaper, more easily available, and (likely) marketed aggressively; and their use would be less costly in terms of risk of arrest, loss of employment, and social approbation. In short, there would be fewer external constraints on use, and more frequent and heavier use increases the risk of dependence. For the sake of argument, let’s stick with the figure of a one-in-six risk that trying a drug will lead to dependence and associated harms.

Does society have a right to “protect” its citizens from a one-in-six risk of dependence, even though that “protection” denies five times as many people legal access to something pleasurable?

Early misuse of painkillers leads to addiction?

More research suggesting that opiate addiction can be aquired by early exposure:

No child aspires to a lifetime of addiction. But their brains might. In new research to appear online in the journal Neuropsychopharmacology this week, Rockefeller University researchers reveal that adolescent brains exposed to the painkiller Oxycontin can sustain lifelong and permanent changes in their reward system – changes that increase the drug’s euphoric properties and make such adolescents more vulnerable to the drug’s effects later in adulthood.

The research, led by Mary Jeanne Kreek, head of the Laboratory of the Biology of Addictive Diseases, is the first to directly compare levels of the chemical dopamine in adolescent and adult mice in response to increasing doses of the painkiller. Kreek, first author Yong Zhang, a research associate in the lab, and their colleagues found that adolescent mice self-administered Oxycontin less frequently than adults, suggesting that adolescents were more sensitive to its rewarding effects. These adolescent mice, when re-exposed to a low dose of the drug as adults, also had significantly higher dopamine levels in the brain’s reward center compared to adult mice newly exposed to the drug.

Gut-busters? New to me.

Jane Brody makes the case that local policies and alcohol sales practices are important contributors to binge drinking:

The Harvard School of Public Health College Alcohol Study, which began in 1993, has identified several environmental and community factors that encourage binge drinking. Dr. Wechsler, who directed the study, said in an interview that high-volume alcohol sales, for example, and promotions in bars around campuses encourage drinking to excess.

“Some sell alcohol in large containers, fishbowls and pitchers,” he said. “There are special promotions: women’s nights where the women can drink free; 25-cent beers; two drinks for the price of one; and gut-busters, where people can drink all they want for one price until they have to go to the bathroom. Sites with these kinds of promotions have more binge drinking.

“Price is an issue,” he added. “It can be cheaper to get drunk on the weekend than to go to a movie.”

Although it is a college’s duty to educate students about the effects of alcohol and the risks of drinking too much, “education by itself doesn’t work,” Dr. Wechsler said. “You must attack the supply side as well as the demand side.”

More than half the alcohol outlets surrounding colleges that participated in the Harvard study offered promotions with price discounts, and nearly three-fourths that served alcohol on the premises had price discounts on weekends.

The study found that the sites of heaviest drinking by college students were off-campus bars and parties held off-campus and at fraternity and sorority houses.

However, community policies and business practices can be just as critical in reducing binge drinking:

Community measures that helped to curtail binge drinking during the eight-year course of the study included a limit on alcohol outlets near campus, mandatory training for beverage servers, a crackdown on unlicensed alcohol sales and greater monitoring of alcohol outlets to curtail under-age drinking and excessive consumption by legal drinkers.

What would "responsible" drug use look like?

The keepers of Erowid offer a document advocating responsible drug use, primarily as a tool for achieving spritiual enlightenment.

They make some pretty provocative assertions about the state of American culture with respect to psychoactive substances:

Many people would agree that drug culture reform is needed, but we must recognize that “the drug culture” now includes everyone. Modern life involves daily decisions about psychoactives. The option of caffeine use is encountered multiple times a day. It is rare to watch an hour-long television show without seeing an advertisement for a mind altering pharmaceutical or a legal recreational drug. Late night coverage of the 2008 Summer Olympics was sponsored by Ambien, a popular sleep aid with memory-scrambling side effects whose commercials enticed audiences nationwide with comforting images of dreamy, refreshing, sedative-assisted sleep. A large portion of the population is exposed to the possibility of taking LSD, even if only 10-20% ever try it.[11,12] In today’s world, everyone must choose how they relate to innumerable psychoactive drugs. Whether or not one decides to use a specific drug, that decision should be made with skill, knowledge, and self-awareness, supported by accurate information.

And offer some fundamentals for responsible drug use:

Investigate the health risks and dangers of the specific psychoactive and of the class of drugs to which it belongs.


Learn about interactions with other recreational drugs, medications, supplements, and activities.


Review individual health concerns, predispositions, and family health history.


Choose a source or product carefully to help ensure correct identification and purity


(avoid materials with an unknown source or of unknown quality).


Know whether the drug is likely to reduce the ability to drive, operate equipment, or pay attention to necessary tasks.


Take oneself “off duty” from responsibilities that might be interfered with (job, child care, etc.), and arrange for someone else to be “on duty” for such responsibilities.


Anticipate reasonably foreseeable risks to oneself and others and employ safeguards to minimize those risks.


Choose an appropriate occasion and location for use.


Select and measure dosages carefully.


Begin with a low dose until individual reactions are known and thereafter use the minimum dose necessary to achieve the desired effects: lower doses are safer doses.


Reflect on and adjust use to minimize physical and mental health problems.


Note changes in health over time that may be related to use.


Modify use if it interferes with work or personal goals.


Check in with peers and family and accept feedback about one’s use.


Track reactions to specific drugs and dosages in order to avoid repeating mistakes.


Seek treatment if needed.


Decide not to use when the time isn’t right, the material is suspect, or the situation is otherwise problematic.

The also, appropriately, take the US governemtn to task for dishonesty in reporting the potential consequences of drug use:

While the quality of government-sponsored sources has improved over the last decade, sites such as Freevibe.com, a youth-oriented website funded by the federal government, still include laughable exaggerations like “heart and lung failure“[27] as a general effect of hallucinogens—a deceptive claim they have made for more than eight years. Scientific literature reviews on the most common hallucinogens do not support their claims; most recently, Johns Hopkins researchers found that, “hallucinogens generally possess relatively low physiological toxicity and have not been shown to result in organ damage.”[28] Once people realize that a source is deceptive, as is the case for those teens visiting Freevibe who know someone who has tried LSD or psilocybin-containing (”magic”) mushrooms, they will be inclined to distrust all information from that source.

But what about groups like NORML? Is their information accurate? Do they engage in conduct that reports irresponsible drug use? Why focus exclusively on the ONDCP?

They focus heavily on psychedelics and argue that many users report benefits. What about cocaine and opiates? They really believe that adolescents should be supported in intentional responsible drug use? What are the potential consequences of this? Who can not engage in responsible drug use? Addicts? Pre-adolescents? Who else? They seem to dodge the more difficult questions.

They will have responses from Jacob Sullum, Robert Kleiman and another CATO (libertarian) fellow. I look forward to Kleiman's response.

Parachutes revisited -- Where's the evidence?

Satire of evidence-based medicine from BMJ:

What is already known about this topic

• Parachutes are widely used to prevent death and major injury after gravitational challenge
• Parachute use is associated with adverse effects due to failure of the intervention and iatrogenic injury
• Studies of free fall do not show 100% mortality

What this study adds

• No randomised controlled trials of parachute use have been undertaken
• The basis for parachute use is purely observational, and its apparent efficacy could potentially be explained by a "healthy cohort" effect
• Individuals who insist that all interventions need to be validated by a randomised controlled trial need to come down to earth with a bump

This is really funny stuff. Check this out:

One of the major weaknesses of observational data is the possibility of bias, including selection bias and reporting bias, which can be obviated largely by using randomised controlled trials. The relevance to parachute use is that individuals jumping from aircraft without the help of a parachute are likely to have a high prevalence of pre-existing psychiatric morbidity. Individuals who use parachutes are likely to have less psychiatric morbidity and may also differ in key demographic factors, such as income and cigarette use. It follows, therefore, that the apparent protective effect of parachutes may be merely an example of the "healthy cohort" effect.

And this:

It is often said that doctors are interfering monsters obsessed with disease and power, who will not be satisfied until they control every aspect of our lives (Journal of Social Science, pick a volume). It might be argued that the pressure exerted on individuals to use parachutes is yet another example of a natural, life enhancing experience being turned into a situation of fear and dependency. The widespread use of the parachute may just be another example of doctors' obsession with disease prevention and their misplaced belief in unproved technology to provide effective protection against occasional adverse events.

[hat tip: Freakonomics]

Recovery management

I recently had a conversation about disease management that got me very curious about what could be translated into recovery management. 

This person is involved in implementing pay-for-performance programs for primary care physicians. In the area of disease management, they are piloting a couple of programs for diabetics and cardiac disease. They are providing some diabetic patients with glucometers and cardiac patients with automated blood pressure cuffs. Nothing new about that, right? Here's what's innovative about them. These devices will transmit information to their medical record at their doctor's office. It will transmit the results of the test or transmit that the test was not completed. The doctor can call the patient in for a visit or testing if there is a concern, they can opt to skip a visit and just call in refills if everything is going smoothly, they can monitor compliance, they can also get a better sense of how various protocols are working with all of this additional information. 

Are there similar methods that we could employ in recovery management? What do you think?

A Sea Change in the Treatment of Alcoholism

More on recovery in a tribal community:

"Factors Associated with Remission From Alcohol Dependence in an American Indian Community Group," by Gilder et al. (1) is a well designed and carefully implemented study that provides valuable new information for American Indian communities but also for society at large. Perhaps the most salient finding is the relatively high rate of 6-month remission: 59% in an ethnic group whose remission rates 25 years ago ranged from 0% to 21% (2–4). Another study recently revealed a 41% 1-year full remission in 199 American Indian people with substance use disorder, confirming the salutary finding of Gilder and coworkers (1).

What has occurred over the last few decades in Native American communities to permit such a dramatic change? One factor lies in leadership: many tribal leaders have identified substance abuse as a major social and health problem (5). The fact that Gilder and coworkers could carry out such a study in Indian communities today bespeaks this critical political change. Second, many American Indian professionals and researchers have devoted their efforts to eliminating substance abuse from American Indian lives and communities (6, 7).

Upon reading this, the metaphor of the Healing Forest immediately came to mind. It also speaks to the potential of the recovery management approach.

This fifth principle, by affirming the inextricable link between personal health and community health, calls upon the addiction treatment agency and the addiction counselor to become actively involved in the communities within which their clients reside or to which they identify.

This person-community link is being conveyed to Native communities across the country within the cultural model of the Healing Forest. When a sick tree is removed from diseased soil, treated, and returned and replanted in the same diseased soil, it gets sick again. What is called for instead is a healing of the tree AND the replacement of diseased elements in the soil with nurturing elements (Red Road to Wellbriety, in press). Personal recovery flourishes best in a climate of family health, cultural vitality, political sovereignty, and economic security. What White Bison and other Native recovery advocacy organizations are trying to do is mobilize all segments of Native communities - the tribal councils, schools, churches, service programs, and political and cultural organizations - to forge and then actualize a healing vision for the community. The goal is to create a Healing Forest that creates a synergy between personal and community wellness. Such a synergy is reflected in the words of Andy Chelsea, who as the Shuswap tribal chief at Alkali Lake, declared, "The community is the treatment center" (Abbott, 1998).

Recovery in a tribal community

Interesting findings from a study of remission from alcoholism in a Native American community:

A surprising and novel finding of this study is that self-reported depression and anxiety symptoms do play a significant role in increasing and decreasing, respectively, the likelihood of remission. These are not depression and anxiety symptoms occurring in the context of alcohol withdrawal, because a similar question asking whether withdrawal had ever caused depression or anxiety symptoms did not appear in the final logistic regression model. Why self-reported depression and anxiety caused by drinking should be significantly associated with remission, especially in light of the absence of association of independent or substance-induced anxiety and affective disorders with remission, is unclear. It may be that insight about the nature of the relationship between drinking and depression and anxiety is a critical element in promoting or inhibiting remission. Why self-reported alcohol-induced depression would increase while self-reported alcohol induced anxiety would decrease the likelihood of remission is also unclear. The former is consistent with findings that insight promotes increased compliance with treatment and remission of other psychiatric disorders (37–39). The latter is consistent with the hypothesis that individuals with alcohol dependence and alcohol-induced anxiety symptoms are more likely to continue drinking, perhaps as a means to self-medicate those symptoms. Both raise the possibility that education about the depression and anxious effects of alcohol and alternative ways of dealing with anxiety symptoms that accompany alcohol dependence may have an important role in treatment and community prevention programs in this high-risk population.

We also tested whether factors associated with remission of alcohol dependence were also associated with the survival of alcohol dependence. Two factors significantly associated with remission (being married and having self-reported depression symptoms from drinking) were also significantly associated with a shorter duration of alcohol dependence, and two factors associated with nonremission (continuing to drink despite medical problems and having self-reported anxiety symptoms from drinking) were also significantly associated with a longer duration of alcohol dependence. Advancing age and younger age at onset of alcohol dependence were both associated with increased likelihood of remission. However, both advancing age and younger age at onset of alcohol dependence were associated with increased duration of alcohol dependence. These data are consistent with previous findings in this group that alcohol dependence runs a typical clinical course that includes duration as well as symptom profile (3). These data are not consistent with the notion that, from the standpoint of remission, there may be two groups of alcohol-dependent individuals: those with early onset who have a shorter course of alcoholism and those with later onset who have a longer course, which has been suggested for other populations (16, 40).

This is a study of a specific population and may not be tranferable to other groups of alcoholics. The finding is not shocking if you've read this blog.

The article offers other interesting and hopeful findings:

In this study, the rate of 6-month full remission from DSM-III-R alcohol dependence with 1-month clustering of 59% is comparable to the U.S. epidemiological rate of 1 year prior to past year, full remission from DSM-IV alcohol dependence of 48% (14), the 1-year partial remission rate of 64% in a German representative population sample (17), and the 1-year full remission rate from alcohol abuse and dependence of 53% found in Ontario, Canada (16). Despite the high rate of 1-month clustered DSM-III-R alcohol dependence of 49% in this group, the rate of full remission is comparable to studies of predominantly European ancestry populations.

Several factors associated with full remission in this American Indian group are consistent with factors associated with full remission in the general U.S. population. Our findings are consistent with the findings of Dawson and colleagues (14) that abstinent and nonabstinent recovery in the general U.S. population are associated with female gender, increasing age, and being married, but not with tobacco use, dependent use of illicit drugs, and having any lifetime anxiety or affective disorder. Our findings are also consistent with Schuckit and colleagues (30), who found that episodes of 3-month abstinence in a mixed treatment and nontreatment group were associated with female gender, older age, ever having been married, and younger age of onset of alcohol dependence, but not with a primary diagnosis of antisocial personality disorder.

Increasing likelihood of remission with advancing age in this American Indian group is consistent with the "aging out" phenomenon described in the Navajo (5, 23). Why "aging out" occurs in American Indians and other ethnicities is unclear. Alcohol dependence may biologically run its course in a proportion of alcohol dependents, and/or the accumulating psychosocial burden of alcohol dependence may prompt increasingly successful attempts at cutting back on drinking. In addition, as age advances, individuals with alcohol dependence, as well as those without, may develop new work, social, and family networks (19) that play a role in reducing drinking. The consistent association of remission with marriage (14, 18, 36) suggests that the social support and limit setting that can come from a spouse are important factors in promoting remission.

Does this suggest that the high prevalence in tribal communities may be due to multiple pathways to addiction (not just genetic vulnerability) and that there may be multiple types of alcoholism at play? I'm not sure.  Maybe. This will be interesting to watch.

What makes nicotine so addictive?

There may be a very good reason why coffee and cigarettes often seem to go hand in hand. 

A Kansas State University psychology professor's research suggests that nicotine's power may be in how it enhances other experiences. For a smoker who enjoys drinking coffee, the nicotine may make a cup of joe even better. 

And that may explain why smoking is so hard to quit. 

I wonder if this will offer an answer to some of my questions about nicotine. 

I'm not sure. Some of this just doesn't sit well with me:

"The big picture is trying to figure out why people smoke," Palmatier said. "There are a lot of health risks, and the majority of smokers already know what they are. They want to quit but can't. It's not because nicotine is a potent drug; it doesn't induce significant amounts of pleasure or euphoria. Yet, it's just as difficult if not more difficult to quit than other drugs."

At K-State, Palmatier studies rats that are allowed to self-administer nicotine by pushing a lever. The main source of light in their testing environment shuts off when the rats earn a dose of nicotine. After about a minute, the light comes back on to signal that more nicotine is available.

By manipulating this signal, Palmatier and his colleagues found that the rats weren't really that interested in nicotine by itself.

"We figured out that what the rats really liked was turning the light off," Palmatier said. "They still self-administered the nicotine, but they took more of the drug when it was associated with a reinforcing light."

Palmatier and colleagues published a paper on their research in the August issue of Neuropsychopharmacology.

Palmatier has begun looking at how rats respond to sweet tastes after having nicotine. He said preliminary results show that nicotine has comparable effects on sweet tastes. That is, rats respond more for sugar-water solutions after getting nicotine.

"The taste aspect is really important because we can actually figure out how nicotine is increasing the subjects' behavior," Palmatier said. "If it makes a reward more pleasurable, then it may increase the palatability of a sweet taste."

If so, it would have to be soley on  a neurobiological level because on an oral taste level, because nothing tastes better with a cigarette.

I love Jesus, but I drink a little

A little comic relief:

[hat tip: Jim]

Alcohol

What do you do with the information provided in these two stories? I'm sure some will say that better education of potential binge drinkers and youth are the key, others will say that condoms should be available for free at bars and liquor stores. I'm not too optimistic.

It seems to me that problems like this are unlikely to be addressed without facilitating some kind of culture change related to alcohol mores. That our nation's largest prevention program is the designated driver campaign says something about how much we value drinking doesn't it? We don't tell people not to get drunk. We tell them to go ahead and get drunk, just don't drive. The campaign is constructed to protect something our culture values. There's also a strong association between this and weekends. It's deserved after a week of hard work, it's how we unwind,  and that it's part of the American dream to kick back with family and friends with a case of Bud, a bottle of wine, or an appletini. (In most cases this is not a drink with a meal.) 

BTW - While listening to the recent suggestions that lowering the age would lead to healthier drinking on college campuses, I kept coming back to this issue of alcohol's place in our culture. 

UPDATE - Of course, taxes could be an important tool for addressing underage drinking and binge drinking. However, a move in that direction would be an expression of values, and those are especially difficult to agree on in this area. Michigan has been in financial crisis for several years and proposed increases have been repeatedly killed. 

This map suggests a pretty strong relationship between alcohol taxes and alcohol related problems.

Medical marijuana???

Not what you're thinking.

Recovery coaching

Here's an interview with a Michael Boyle, the director of a pioneering program in recovery coaching. The interview is okay, but his recovery coaching manual is great.

A great recovery story

This is a great example of the love, support and generosity available in the recovering community:

Dale Ensor was desperate when he walked into a 12-step addiction recovery program five years ago. That's when he met a man named Dexter McElrath, who offered to help Ensor along the path to sobriety.

"Dexter took me under his wings and showed me the ropes," said Ensor, a 52-year-old self-employed painter who lives just north of Jackson. "I couldn't get it in my brain that there are people who care of me. The guy helped save my life. I would have died out there; I really would have."

At the time, neither could have known that this summer, Ensor would return the favor.

McElrath's kidneys began to fail in May 2007. The Ypsilanti Township resident went on dialysis for 14 months, expecting to wait the average three to five years for a transplant if he couldn't get a kidney from a friend or relative.

Two people offered a kidney, but one wasn't a match and McElrath wouldn't take the other because it would have meant postponing the donating woman's education.
McElrath was forced to cut way back on his hours as a construction worker because dialysis wore him out. Ensor watched his friend's health deteriorate and agreed to be tested.

"It was either that, or watch my friend die," he said. "All the cards were on the table. When it came to it, what kind of man am I? What am I going to do?"

At least she's predictable

From the same woman whose worldview dictates that stigmatizing addiction is good and addiction is not a disease. She chose to draw from a man with quite an agenda.

“It undermined their sense of themselves as individuals in control of their own destinies,” Mr. Sullum wrote in his 2003 book, “Saying Yes: In Defense of Drug Use.” “And so they stopped.”

I only read about these people. Patients who come to our methadone clinic are there, obviously, because they’re using. The typical patient is someone who has been off heroin for a while (maybe because life was good for while, maybe because there was no access to drugs, maybe because the boss did urine testing) and then resumed.

But the road to resumption was not unmarked. There were signs and exit ramps all along the way. Instead of heeding them, our patients made small, deliberate choices many times a day — to be with other users, to cop drugs for friends, to allow themselves to become bored — and soon there was no turning back.

Addiction does indeed discriminate. It “selects” for people who are bad at delaying gratification and gauging consequences, who are impulsive, who think they have little to lose, have few competing interests, or are willing to lie to a spouse.

Fighting HIV-AIDS One Syringe at a Time

A legislator makes a plea for an end to the federal needle exchange ban. I don't oppose lifting the ban, but his argument would be more compelling if he acknowledged the problems with many needle exchanges and called for standards for programs and increased access to treatment.

Abstinence and risk of overdose

We've known for some time that heroin addicts are at greatest risk for overdose when they reinitiate heroin use, including after detox or release from prison or jail. Some have argued that opiate maintenance is the answer to the problem. I would argue that it's a failure of acute care and that long term recovery management is the solution.

Drinking age (again)

Marginal Revolution points out that New Zealand lowered their drinking age to 18 and experienced serious problems, though not serious enough to raise the drinking age again.

Recovery Bill of Rights

Part of me wishes I could be more enthusiastic about this. They all seem like good points to make and I'm sure that they carefully developed using research and focus groups, but there's something about them that rubs me the wrong way. It sounds like the voice of the victimized. It talks about the right to strength-based services, but it doesn't speak with a voice of strength. There's something meek about it. It doesn't feel empowering.

At this moment in our culture, there seems to be fierce competition for aggrieved status. It seems to be the primary tool for promoting any kind of social change or consciousness raising. Think about it. How many times have you heard someone say, "In our country today, the only group you can make fun of is _______." You can fill in the blank with evangelicals, atheists, Catholics, obese people, southerners, cognitively impaired, little people, gay people, addicts, etc.

I have two problems with this approach for recovering people. First, I worry that it's bad strategy. There's a lot of competition for aggrieved status, the public is weary of this, and it may inspire more eye rolling than sympathy. Second, in terms of my personal recovery, I worry about any message that hints at adopting a victim stance or entitlement. No matter how well grounded, that position seems potentially toxic to my recovery.

If we really are mistreated, and we need to promote cultural change, what to do then? I can't say that I'm sure as I have not thought too deeply about this. However, I wonder if framing this as a call to action for recovering people would be more empowering and effective--"You have a responsibility to address these barriers for your still suffering brothers and sisters." Also, not to suggest a single pronged approach, but I'm convinced that the most powerful strategies will focus on reducing "otherness" and increasing "sameness" in public perceptions of addicts. Every time I take addicts to tell their story with churches and other community groups, the response is ALWAYS the same--we're not who they expect, we're just like some of their loved ones, they're often shocked by the sameness and want to do something to help. Unfortunately, that fades quickly. Strategies to capitalize on this window could be important.

Recovery Management

I was fortunate to get a peek at this monograph a while back. It, as Loran Archer noted, is sure to be the seminal document on recovery management. Over the last several years Bill White has been churning out papers that, one piece at a time, added flesh to bones of this model.

This document provides the big picture of recovery management in a way not previously offered. The references are exhaustive--804 references!!!

Quote for the day

"Recovery begins with hope, not abstinence..." - Michael Boyle

Craving

No wonder the rest of the world has such great difficulty understanding the power of addiction and craving. Addicts don't even appreciate craving's power when they're not in its grip.

Why is the Drinking Age 21?

Mental Floss provides a history of 21 year old drinking age.

More on drinking ages

Mark Kleiman, as usual, does a great job summarizing the drinking age quandary:

Setting the minimum legal drinking age at 21 saves lives by reducing drunk driving, and not just among the 18-to-21's; if 18-year-old high school seniors can buy beer at the supermarket, then 16-year-old high school sophomores have access to it. Common sense and evidence agree: drinking and driving by people who are both inexperienced drinkers and inexperienced drivers is really, really dangerous.

Setting the minimum legal drinking age at 21 also encourages disrespect for the law and encourages young adults to acquire and use false identification documents, which is not a social practice we want to encourage just right now. Moreover, that policy insultingly treats people who are adults for all other purposes as if they were still children, and deprives them of lawful access to an activity that forms part of the normal U.S. social scene and which some of them enjoy. And it may (the evidence isn't clear) lead those who are drinking illegally rather than legally to do so irresponsibly rather than responsibly.

Now, given those facts, what do you want to do about it?

His solution is to implement zero tolerance laws for drinking and driving for people under 21 and raise alcohol taxes.

Megan McArdle suggests adding special licenses for people who have been convicted of drunk driving and making it illegal to serve them alcohol.

In the "not always right, but always certain" department, a contributor to the Free Press offers these pearls:

The problem with asking at what age it ought to be legal to drink is that it is a fundamentally perverse question. The “logic” of law is that it allows government the power to punish actions deemed harmful while restraining government officials from singling out disfavored individuals or groups and imposing sanctions on them. The “rule of law” requires that all laws take the form of truly general rules of action, rules that provide punishment for anybody who takes the prohibited action.

Government decisions that just pick an individual and impose a sanction on that individual are bills of attainder, and our Constitution prohibits them. Rules that single out subsets of the population and punish them for actions which are not illegal when taken by other people are pseudo-laws, and legitimate government has no authority to enact them. (Example: Women cannot work as bartenders.)

To ask at what age it should be legal to drink, therefore, flies in the face of the inherent nature of law as a general rule of action. Either drinking must be legal for all, or illegal for all. The latter approach was tried during Prohibition, and it caused horrible results: organized crime, corruption, etc. Wisely, Prohibition was repealed by the 21st amendment in 1933.

Recipe for PTSD

The drug war horror story I posted about two weeks ago just hit Newsweek. Let's hope it continues to get attention.

Medical marijuana

The Los Angeles Times ran a pair of opposing pro/con pieces recently. I saw the headline for the con piece and thought it might be reefer madness rant, but thankfully it's much smarter than that. Acknowledging that marijuana's risks are relatively small, he argues that the FDA refuses to approve or yanks approval of drugs with fewer risks than marijuana.

I don't have a strong opinion on the matter and don't believe that anyone should do jail time for possession of marijuana in smallish quantities. I also don't think marijuana should get any special treatment from the FDA, in either direction--if it meets FFDA standards, approve it; if it doesn't meet FDA standards, deny approval. However, my impression is that most of the advocates of medical marijuana seem to be more interested in legalizing marijuana for their own use. I tend to find them pretty unpersuasive and they inspire a passive aggressive contrarian instinct in me.

Not quite an adult

The New York Times reports that the movement to lower the drinking age is gathering steam. On my other blog, I posted about this last year and said:

I have a few brief reactions. First, I don't have a strong opinion on the matter, other than I'd be troubled by 18 year old high-school students being able to buy alcohol.

In principle, the general idea of a less restrictive drinking law might appeal to Libertarians, but drinking licenses? That'll lose Libertarian support fast.

He makes an argument about current law criminalizing parents who try to teach their kids to drink responsibly. First, is serving alcohol necessary to do this? Second, as we saw a few weeks ago, this isn't illegal in 31 states. Third, when is the last time you heard of parents fined or arrested for allowing their teen to have a glass of wine with dinner?

Some of his arguments are a stretch -- for example, using SAMHSA's increased attention to underage drinking as an argument against the existing policy and implying that there's a relationship between the 21 year old drinking law and younger ages of first use.

The fact that we currently have problems, isn't necessarily a good argument against the status quo. Anyone who's honest with themselves will recognize that there is no such thing as a problem-free drug and alcohol policy. As I've said before in this blog, these drug policy questions are all about trade offs and, recognizing that every policy requires living with some problems, the questions you have to wrestle with are:

• Which problems are intolerable and which are you willing to tolerate?
• How do you make these decisions? (I'd suggest that even responses that purport to be value-free are value laden.)
• Which policy (or combination of policies) best balances these values?

It seems like these discussions would generate more light if people were a little more honest in acknowledging the problems inherent in their pet theory.

Ezra Klein offers his take here:

21 is, of course, a bizarre marker. Demanding that kids refrain from drinking for three years after they become legal adults and, in most cases, leave their parent's supervision, is a bit odd. "Welcome to adulthood, except when it comes to beverage choice!" But this could point the way towards a grand new education policy scheme: Drinking age is 18...if you attain a college-worthy GPA. Otherwise, 21. Implement that and you'll blow those other, way lamer, educational attainment proposals out of the water.

I stand by my earlier comments and I'm still concerned about about the relationship between legal drinking age, age of first use, and dependence later in life. However, it does seem that there is little cultural "buy in" for the current drinking age, particularly for 19 and 20 year olds--we're deeply ambivalent about it and this ambivalence turns into permissiveness that seems to drift downward toward high school aged teens. Parents excuse (and sometimes facilitate) underage drinking, police often do little more than dump alcohol, and no one feels strongly enough to challenge it directly or there is not enough consensus to challenge it effectively. If the drinking age was lowered to post-high school and there was broad consensus that this was important to enforce, maybe that would not be such a bad thing.

Suboxone addiction

I received a marketing email from this treatment program today. I don't know anything about the program and I don't mean for this post to endorse or criticize the program in any way.

What struck me is that it is marketing itself as a program specializing in suboxone addiction treatment. That treating addiction to suboxone, not treating opiate addiction with suboxone.

Suboxone has been a boon for opiate detox, but it seems to be freely prescribed for long term maintenance, we've been seeing people relapse by using suboxone, and we've seen been reading reports of misuse for some time (here, here, and here). Clearly, as we've known for a while, it's not as safe as we'd hoped. Still, it's potential for harm appears to be much lower than methadone.

Harm reduction is not enough

This study calls for treatment to improve compliance with HIV treatment guidelines.

Note that I'm not saying HR is bad or that it should be abolished. I'm saying that it is not enough.

Gone camping

The science of stigma

From Greater Good (pdf) magazine:

In my own lab, for example, we dug up dozens of images of societal groups that were identifiable in an instant: people with disabilities, older people, homeless people, drug addicts, rich businessmen, and American Olympic athletes. We asked research participants to tell us what emotions these images evoked in them; as we predicted, they reported feeling pity (toward the disabled and elderly), disgust (the homeless and drug addicts), envy (businessmen), and pride (athletes).

We then slid other participants into a functional MRI scanner to observe their brain activity as they looked at these evocative photos. Within a moment of seeing the photograph of an apparently homeless man, for instance, people's brains set off a sequence of reactions characteristic of disgust and avoidance. The activated areas included the insula, which is reliably associated with feelings of disgust toward objects such as garbage and human waste. Notably, the homeless people's photographs failed to stimulate areas of the brain that usually activate whenever people think about other people, or themselves. Toward the homeless (and drug addicts), these areas simply failed to light up, as if people had stumbled on a pile of trash.

We were surprised—not by the clear sign of disgust, but by how easy it was to achieve. These were photographs, after all, not smelly, noisy, intrusive people. Yet we saw how readily physical characteristics could evoke strong, immediate, and deep-seated emotional reactions.

The good news is that researchers have found that two factors can reduce this reaction, context and exposure. This affirms our anecdotal experience that public education that involves direct contact between addicts and the public can be powerful in reducing stigma.

Drug-linked mental illness

England reports that rates of drug related mental health problems have doubled.

The number of people admitted to hospital in England with mental illnesses linked to use of illegal drugs has doubled in the past decade, official figures revealed yesterday. The NHS Information Centre said 38,170 adults and children were admitted with drug-related mental and behavioural disorders in 2006-7, an increase of 101% since 1996-97.

Does the U.S. have any idea about the rates of drug related mental health problems?

I don't think so. One obvious reason that might be easier for them generate that that they have a single payer health care system that I imagine has a central data system. However, I suspect that the biggest barrier to the U.S. generating that kind of data is philosophical. There's considerable resistance to characterizing mental health problems as drug related. The conventional wisdom in the U.S. is that most people with substance use disorders have a mental illness and that both conditions are primary. (See principles 1 & 5.) Though it's not a listed principle, the U.S. system also operates on the assumption that all mental health problems are chronic.

The Healing Place

The Healing Place continues to gather steam as a model for responding to homelessness and addiction.

Rat and expectations

Productivity 501 offers more wisdom from rats:

There was an experiment where researchers were given a set of rats and told to rate their ability to learn mazes. They were told that certain rats were “smart rats” and had an abnormally high IQ. When the researchers tested the rats, their studies showed that the “smart rats” performed significantly better than the ordinary rats.

The experiment, however, wasn’t focused on the rats, it was testing the researchers. All of the rats were the same, but telling the researchers that some of the rats were smart caused them to rate the rats better, even though there was no difference.

People will view what you do through their own set of prejudices. To a certain extent, your ability to succeed is determined by what people think of you ahead of time. When it comes to humans, very few things are actually objective.

By being aware of this, you can help yourself prepare for the future by nurturing positive impressions of yourself with those around you. If they expect you to succeed, you are more likely to (at least in their eyes) than if they expect you to fail.

That expectations influence perception has been demonstrated over and over again. The comments from the post referenced above include other examples. What is more important for professional helpers is that expectations influence not only perceptions about clients, but also influence outcomes. Consider this passage from an article by Arnold Washton.

A revealing study demonstrates how clinician expectancy can create a self–fulfilling prophecy. Counselors were told that according to sophisticated personality test profiles, certain alcoholic patients were likely to do very well in treatment.

These patients, who had actually been selected at random, were subsequently rated by the counselors as more motivated, more compliant, more punctual, more cooperative, and demonstrating more effort.

They actually showed significantly fewer absences and dropouts and had more sober days and fewer slips at one-year follow up. The counselor’s expectation of success in these “good prognosis” patients apparently led them to behave more therapeutically toward these patients.

Earlier posts about the role of expectations in recovery-oriented practice can be found here.

Memory interuption interupts addiction in rats

More exciting, yet creepy, progress in experiments that interrupt addiction by interfering with memory reconsolidation:

Barry Everitt, an experimental psychologist at the University of Cambridge in England, focused his group's efforts on proteins called NMDA-type glutamate receptors in rat brains. Previous work on addiction and post-traumatic stress has shown that these proteins—which are found on the surface of brain cells—are essential to memory formation. The receptors are also crucial to reconsolidating a memory—moving it from its storage area in long-term memory to brain regions that handle short-term memory.

The researchers—who report their findings in the Journal of Neuroscience—put rats in a cage with a lever in it for a couple of hours per day for a week. When the animals pushed the lever, a light would come on and a cocaine solution would be dispensed to the rat. The rats began to associate the light they saw with cocaine.

After a couple weeks of forced sobriety, the animals were returned to the cage. Before going back in, some of the rats received injections of experimental drugs that block NMDA-type glutamate receptors in the amygdala—a brain region that has been implicated in drug-associated memories.

Both treated and untreated animals, when back in the cage, would press the lever over and over again. The light would come on, but no cocaine would be served. Untreated animals continued unfazed, hoping cocaine would eventually come out.

For the treated animals, however, Everitt says, "They press the lever, but it doesn't do anything, so they stop." The animals seemed to forget that the light in the cage meant cocaine was on its way for up to four weeks after only a single treatment.

Scientists say that suggests that by disrupting the recollection of a drug-associated memory—a person one abuses drugs with, a place that one uses drugs at, for example—a therapeutic may be able to break the connection between cues in the environment and the need for drugs. Sometimes these cues can be quite close to home—a family member or loved one.

Related posts can be found here, here, here, here, here, and here.

CASA takes on parents

CASA takes an interesting approach in their new report. It seems to shame parents who are not monitoring their children's activities by characterizing them as "problem parents". It will interesting to see how this plays.

Problem parents -- those who fail to monitor their children's school night activities, safeguard their prescription drugs, address the problem of drugs in their children's schools, and set good examples -- increase the risk that their 12- to 17-year-old children will smoke, drink, and use illegal and prescription drugs, according to the National Survey of American Attitudes on Substance Abuse XIII: Teens and Parents, the 13th annual back-to-school survey conducted by The National Center on Addiction and Substance Abuse (CASA) at Columbia University.

"This year's survey reveals that too many mothers and fathers are problem parents who fail to take essential steps to prevent their kids from smoking, drinking or using drugs. By their actions -- and inactions -- by failing to become part of the solution, these parents become part of the problem of teen alcohol and drug abuse," said Joseph A. Califano, Jr., CASA's chairman and president and former U.S. Secretary of Health, Education, and Welfare. "Indeed, these problem parents enable -- some even encourage -- their 12- to 17-year-olds to use and abuse tobacco, alcohol, and illegal and prescription drugs."

Another point of interest is the fact that only 9% of kids who misused prescription drugs reported getting them from a drug dealer--challenging the notion of many parents that predatory "pushers" get kids hooked on drugs. Most kids get drugs and alcohol at home or from another fresh-faced kid in their community.

What works in prevention

Join Together posted a pair of articles today that are interesting because of their contrast.

One on the ineffectiveness of anti-tobacco scare tactics:

The Cancer Council study also found that the labels were highly recognized among youths, with 77 percent of students saying they had seen the cigarette packaging with the graphic images.

The newspaper spoke to service station owners who confirmed that young people often ask for packs with specific images when they purchase cigarettes. Benton added about one of the images, "If you cut out the picture of the rotten mouth you can stick it over your own teeth; it's a good joke."

And, another on the move toward social norms strategies on college campuses:

At Virginia Commonwealth University, although surveys have shown that 25 percent of students don't drink at all and 70 percent don't drink at high-risk levels, many students believe the highly visible unhealthy behaviors they sometimes encounter reflect a wider phenomenon on campus.

"The majority who don't get hammered don't get seen," said Linda Hancock, director of the university's Wellness Resource Center.

Olympic lessons for recovery management

Disease Care Management Blog draws some lessons from the story of Michael Phelps. How might these be applicable to recovery management?

• Role-appropriate listening and helping: According to an ABC news interview, she said "I've been there not to dictate or guide. I'm there to listen to what he wants to do and try to help him problem-solve and make a wise decision…”
• Willingness to accept risky suggestions:Michael wanted to stop his ADHD drugs. Deborah Phelps agreed.
• Let experts handle the things that experts handle:Michael has access to a number of expert coaches and other advisors.Deborah Phelps stays out of their way.
• Recognize talent and build on it:Michael was not very good at math, but his swimming prowess quickly declared itself.Guess which skill was the focus of Mrs. Phelps?
• Stay in the background:Watch Deborah Phelps in an interview and it’s clear that she rarely talks about herself. If forced, she portrays herself as just a mom.

Shooting weed

This post includes videos of experiments designed to better understand the roles of what are believed to be the 2 active ingredients in marijuana.
[via Andrew Sullivan]

POPAGSV!!!

Passed Out Persons Against Google Street View

Hey hey, ho ho. Google street view has got to go! Hey hey, ho ho. Google street view has got to go!

Anthrax and 42 CFR Part 2

Turns out that the alleged anthrax killer had a substance abuse counselor. (Though she wasn't exactly a poster child for the profession--she had a 2007 OUIL.)

This story raises a very interesting point. If my understanding of 42 CFR Part 2 is correct, there is no "duty to warn" provision in the law. This being the case, the recommended practice is to make a non-disclosing report--an anonymous report that does not explicitly or implicitly identify the client as a recipient of addiction treatment services. (More info here.)

Clearly, this is a case where a worker (or agency) has to imagine his or herself on the witness stand defending a decision to disclose (or not to disclose). If you believe that a guy is going to kill his co-workers you want to report it in a way that assures the police will intervene and take it seriously.

The story, as told in the Washington Post, which may, or may not, be 100% accurate, raises a few questions about whether the situation could have been handled better:

• She waited overnight. Should she have made the report sooner?
  
• Was a supervisor or the agency director involved?
• Did she identify herself as an addiction counselor or calling from an agency that provides addiction treatment services?
  
• Should she have made the call from a non-agency phone? Does making the call from an agency phone turn, an otherwise non-disclosing report, into a disclosing report?

Just to be clear, I'm not criticizing her. It's just a good opportunity to brush up on the law and learn from an actual case.

Nicotine buzz

I remember it well:

Anyone who has ever tried smoking probably remembers that first cigarette vividly. For some, it brought a wave of nausea or a nasty coughing fit. For others, those first puffs also came with a rush of pleasure or "buzz."

Now, a new study links those first experiences with smoking, and the likelihood that a person is currently a smoker, to a particular genetic variation. The finding may help explain the path that leads from that first cigarette to lifelong smoking.

He was an aggressive licker :-(

Whatever your feelings about the legality of marijuana, it's hard to disagree with those concerned about the absurd excesses in law enforcement raids.

This fiasco looks likely to raise awareness:

When the shooting stopped, two dogs lay dead. A mayor sat in his boxers, hands bound behind his back. His handcuffed mother-in-law was sprawled on the kitchen floor, lying beside the body of one of the family pets that police had killed before her eyes.

After the raid, Prince George's County police officials who burst into the home of Berwyn Heights' mayor last week seized the same unopened package of marijuana that an undercover officer had delivered an hour earlier.

What police left behind was a house stained with blood and a trail of questions about their conduct. No other evidence of illegal activity was found, and no one was arrested at Mayor Cheye Calvo's home in this small bedroom community near College Park.

Addiction and free will

This one slipped by me late last year. It offers a great description of the neurobiological processes involved in addiction. It also tries to tackle frequently neglected questions about free will and addiction. All of this is great, but the description of the client with a "secondary" addiction and their intervention (rather, the absence of any intervention) leaves me wanting.

In the early stages of addiction, the free will of someone like Jack is relatively intact. I say relatively because emerging research suggests that Jack probably had a decreased number of D₂ dopamine receptors, and this state of hypodopaminergic function increased his risk to excessively respond to the suprathreshold dopamine stimulation of drugs of abuse.⁴ As the addiction progresses, the main brain engines of free will are damaged and begin to malfunction, including the attentional and self-control mechanism of the anterior cingulate gyrus; the crucial orbital prefrontal cortex that associates emotional and motivational valence with environmental stimuli and cues; and the dorsolateral prefrontal cortex, the seat of executive function and as such, the true decision maker.

In the later stages of addiction, Volkow cautions, free will may be virtually devastated: "We have come to see addiction as a disease that involves the destruction of multiple systems in the brain that more or less are able to compensate for one another. When the pathology erodes the various systems, you disrupt the ability to compensate, and the addictive disease erodes and destroys the life of the individual."⁵

In the new conceptualization, addiction is not so much a matter of dysregulation of the pleasure systems but of a distortion of goal direction expressed by the term "salience." Evolution has wired the brain to seek out and respond to environmental factors, such as sex, food, money, and affection, that improve the chance of the survival and even thriving of the species. All of these natural incentives release dopamine, not so much to satisfy desire as once thought but as a way of neurochemically cementing the salience of these stimuli (ie, potentiating learning).

Tragically, drugs and alcohol have a massively more potent dopaminergic action than even the best gourmet meal, a good run on a beautiful fall morning, or the devotion of a wife and children. These new neurobiological explanations of addiction give molecular weight to the phenomenological DSM-IV-TR criteria for "continued [substance] use despite adverse consequence" by a dependent person.⁶ Given the extreme biological response to drugs of abuse compared with daily life and work, it is no wonder that "time spent in obtaining the substance replaces social, occupational or recreational activity."⁶ Jack had a family who loved him, and he was resourceful enough to have been successful had he only employed the immense energy he spent on substance use in the service of more productive aims.

So complete is drugs' usurpation of human priorities that what were once semivoluntary actions and reactions become conditioned responses. In an elegant experiment, Volkow and colleagues⁷ measured dopamine metabolism in 18 cocaine-dependent patients while they watched a nature video and a video of persons using cocaine. Not only was there a substantial dopaminergic surge in the addicted patients when watching the cocaine film, but even more alarming, it corresponded to their subjective experience of craving, which itself is a measure of the compulsive quality of addiction.

These results obviously underscore the challenge of relapse prevention when even otherwise neutral cues can elicit the intensity of intoxication. But more ominously for free will, what Volkow calls the plastic changes in brain structure and function suggest the entire apparatus of self-determination may have been commandeered.⁸

Internet rehab

Sometimes I hate that I'm such a cynic, but it's hard for me to not see this as a two-fer. Eroding the disease model and profiteering. (I'm assuming that they don't accept unfunded clients.)

More on prohibition

A couple of smart takes (old takes) from Mark Kleinman.

On why legalize alcohol, but criminalize other drugs?

...if the line between legal and illegal drugs needs to track some imagined line between "good drugs" and "bad drugs," drug policy is profoundly incoherent. But there's no need for such a link. There are, among intoxicants, no "good" or "bad" drugs. Both alcohol and cocaine are consumers' goods with a peculiar mix of risks, including both the risks due to intoxication (loss of self-command over behavior in the short run) and addiction (chronic loss of self-command with respect to consuming the drug itself).

The question, drug-by-drug and comprehensively, is what mix of policies would minimize aggregate damage, net of benefit. (This elides the distinction between harm to self and harm to others, which strikes me as a reasonable thing to do in the face of an activity where individuals can't be assumed to be good stewards of their own well-being.) In some cases that least-cost solution will look like prohibition; in others it will look like regulation and taxation. It's a practical problem, to be handled by practical means-ends reasoning, not by the enunciation of profound truths about human nature or the role of the state.

Even believing that alcohol, on balance, creates a net social deficit, I don't actually believe that alcohol should be prohibited. Given the enormous user base for alcohol, its prohibition would be operationally nightmarish as well as politically infeasible. Instead, why not ban its sale to those previously convicted of alcohol-induced violence or repeated drunken driving? That ban wouldn't be perfectly obeyed, but it would have some good effect nonetheless, and wouldn't create another huge illicit market.

And on arguments to legalize cocaine with a very high excise tax:

The hypothetical licit cocaine market, by offering users a product of known composition, available in safe surroundings from non-criminal suppliers, and without the risk of legal sanctions at the price illicit dealers charge for product with none of those attractive qualities, would represent a substantial hedonic price decrease compared to the current situation. Moreover, legality, and the associated marketing activity, would tend to change current attitudes and opinions in a direction favorable to cocaine use.

Therefore, one would expect a fairly large increase in the number of people trying cocaine. Some proportion of them would become habituated, and some proportion of that group would find the habit difficult to break and become chronic heavy users. For them, the high legal price would mean that their cocaine habits, though legal, would be ruinous financially, and some would be likely to turn to crime to finance continued cocaine purchases. In addition, of course, they would face many, though not all, of the health and psychological risks attendant on heavy cocaine use as we now know it.

So I conclude that legalization at a high price is probably a loser, even if one adjusts for what would certainly be benefits to supplier and transit countries and some marginal reduction in resources available to terrorist organizations. That even someone as smart as Levitt could have been taken in testifies both to the peculiarities of drugs as consumers' goods and to the strength of the persistent hope that our seemingly intractable drug problems might be made to yield to some simple piece of ingenuity.

[Legalization at a low price would probably succeed in reducing overall crime, and might well be a substantial boon to poor minority neighborhoods now wracked by cocaine dealing, though at what would very probably be a very high cost in increased cocaine abuse. It is even possible, though I doubt it, that low-price legalization would represent a net improvement over today's version of prohibition.]

Tobacco crusades

Addiction Inbox offers a little perspective on Bill Gates and Michael Bloomberg's anti-tobacco efforts. The best thing about the post is the British anti-smoking ad.

Prohibition

Mental Floss offers a brief take on alcohol prohibition as part of it's 20 greatest mistakes in history. Here's an excerpt:

It certainly seemed like a great idea at the time: Just outlaw liquor and, bam!, goodbye social ills of every stripe—from the Germans to the Irish. Yes, pandering to xenophobia was the favorite tactic among Prohibition crusaders, who painted saloons as a filthy underworld brimming with undesirable foreigners. Ultimately, however, the event that probably did the most to push America toward Prohibition was the country’s 1917 entry into World War I. Prohibitionists began arguing that all of America’s resources were needed to fight the German menace, using the logic that, if the government needed to maximize agricultural production to win the war, then it couldn’t waste all that grain on booze. Apparently, their message worked. By the end of 1917, the majority of Americans were living in alcohol-free states or counties.

It appears that Mental Floss's facts are wrong. This article presents a contrary view:

First, the regime created in 1919 by the 18th Amendment and the Volstead Act, which charged the Treasury Department with enforcement of the new restrictions, was far from all-embracing. The amendment prohibited the commercial manufacture and distribution of alcoholic beverages; it did not prohibit use, nor production for one's own consumption. Moreover, the provisions did not take effect until a year after passage -plenty of time for people to stockpile supplies.

Second, alcohol consumption declined dramatically during Prohibition. Cirrhosis death rates for men were 29.5 per 100,000 in 1911 and 10.7 in 1929. Admissions to state mental hospitals for alcoholic psychosis declined from 10.1 per 100,000 in 1919 to 4.7 in 1928.

Arrests for public drunkennness and disorderly conduct declined 50 percent between 1916 and 1922. For the population as a whole, the best estimates are that consumption of alcohol declined by 30 percent to 50 percent.

Third, violent crime did not increase dramatically during Prohibition. Homicide rates rose dramatically from 1900 to 1910 but remained roughly constant during Prohibition's 14 year rule. Organized crime may have become more visible and lurid during Prohibition, but it existed before and after.

Fourth, following the repeal of Prohibition, alcohol consumption increased. Today, alcohol is estimated to be the cause of more than 23,000 motor vehicle deaths and is implicated in more than half of the nation's 20,000 homicides. In contrast, drugs have not yet been persuasively linked to highway fatalities and are believed to account for 10 percent to 20 percent of homicides.

Prohibition did not end alcohol use. What is remarkable, however, is that a relatively narrow political movement, relying on a relatively weak set of statutes, succeeded in reducing, by one-third, the consumption of a drug that had wide historical and popular sanction.

The suggestion that alcohol prohibition was all bad is just as silly as suggesting that nothing good could come of decriminalization of marijuana. Each policy has problems. As I've said before the important question is which problems you want to live with.

Heavy drinking and the risk of assualt

A new study suggests a staggering increase in the risk of experiencing sexual aggression by young women when they drink heavily:

According to researchers at the University at Buffalo's Research Institute on Addictions (RIA), the odds of 18-19 year old college women experiencing sexual aggression are 19 times greater when they binge drink than when they don't drink. Binge drinking or heavy drinking was defined as drinking four or more drinks on a drinking occasion.

...

...The odds of experiencing sexual aggression were 19 times greater on heavy drinking days compared to non-drinking days. ...The odds of experiencing physical aggression were 12 times greater on heavy drinking days compared to non-drinking days.

One big caveat about the researchers methods. 76% of the women who are described as experiencing sexual aggression denied experiencing sexual aggression. Their responses to questions indicated that they met the researcher's definition of sexual aggression, but when asked, "have you experienced sexual aggression?", most of them said "no."

Stoner bigotry

The outrage...

Three months

Another study finds that important reversals in addiction related brain adaptations occur in the first 90 days of recovery.

It has been hypothesized that persistent drug seeking alters the brain's natural reward and motivational system. The current study focuses on how drug seeking alters the communication between brain cells in this critical circuitry. In the normal processes of learning and memory formation there is a well documented strengthening of communication between brain cells, this process is known as "long-term potentiation" (LTP). The new study reports that LTP was similar in the rats that had learned to self administer cocaine, food or sucrose, but with a critical distinction. The increase in LTP due to cocaine persisted for up to three months of abstinence, but the increase in response to natural rewards dissipated after only three weeks. Importantly, the nature of the cocaine experience had a strong effect on the outcome, since rats exposed to cocaine when they did not expect it (passive infusions) displayed no LTP, neither transient nor long lasting. Finally, the study showed that LTP in rats that self-administered cocaine persisted after they were trained to stop drug self-administration behaviors. This indicates that, once established, it is very difficult to reverse the "memory trace" associated with drug reward.

Dealing and entrepreneurship

A strength to be harnessed from life in the drug culture?

Fairlie was interested in entrepreneurship in the black market and how it relates to legitimate entrepreneurship. So he looked at data regarding drug dealers, and he found that they were 10 to 11 percent more likely to become self-employed in legitimate businesses than people who weren't drug dealers.

He goes on to make an argument about legalization:

So I'll go ahead and ask what Shane seems to be hinting at: Does drug prohibition change the incentives such that potential entrepreneurs pursue lives of crime rather than legitimate businesses?

On one hand, those who call for the legalization or decriminalization of drugs have long argued that the drug war directly fuels the crime around the drug trade that it seeks to fight by creating a massive black market. The high profits in this black market attract people who might otherwise become legitimate entrepreneurs to deal drugs.

In the chapter, Why do Drug Dealers Live with Their Mothers?, didn't Freakonomics assert that average drug dealer makes very little money and could make more at McDonalds?

[via dailydose.net]