Prescription Opioid-related Deaths Increased 114 Percent from 2001 to 2005

From the ONDCP:

Prescription Opioid-related Deaths Increased 114 Percent
from 2001 to 2005, Treatment Admissions Up 74 Percent in Similar Period; Young Adults Hardest Hit

(Washington, D.C.)—Today, Gil Kerlikowske, Director of National Drug Control Policy, released a report on the diversion and abuse of prescription drugs at the National Methamphetamine Pharmaceutical Initiative (NMPI) in Nashville. The report finds non-medical use of prescription drugs a serious threat to public health and safety, with unintentional deaths involving prescription opioids increasing 114 percent from 2001 to 2005, and treatment admissions increasing 74 percent in a similar four-year period.

T he National Prescription Drug Threat Assessment (NPDTA) was prepared by the National Drug Intelligence Center (NDIC) in conjunction with the Drug Enforcement Administration (DEA). It synthesizes reports and data from law enforcement and public health officials to evaluate the threat posed by the distribution, diversion, and abuse of controlled prescription drugs in the United States. Non-medical use of prescription drugs (pain relievers, stimulants, tranquilizers, and sedatives) is most prevalent among young adults—individuals aged 18 to 25. From 2003-2007, approximately six percent of this age group reported non-medical prescription drug use in the past month.

Among the general population, nonmedical use of controlled prescription drugs was stable from 2003-2007, with 7 million Americans, aged 12 and older, reporting past month nonmedical use of prescription drugs. Pain relievers are the most widely diverted and abused, with one in five new drug abusers initiating with potent narcotics. Diversion and abuse of controlled prescription drugs cost public and private medical insurers an estimated $72.5 billion per year.

Director Kerlikowske released the report at NMPI, an annual ONDCP and High Intensity Drug Trafficking Area program initiative that gathers over 300 law enforcement officials to address methamphetamine and illicit pharmaceutical production and diversion through strategy development, intelligence sharing, and training. Diversion and abuse of prescription drugs are a threat to our public health and safety—similar to the threat posed by illicit drugs such as heroin and cocaine, said Director Kerlikowske. In 2006, the last year for which data are available, drug-induced deaths in the United States exceeded firearm-injury deaths and ranked second only to motor vehicle accidents as a cause of accidental death. Law enforcement and healthcare communities must work together to help address prescription drug abuse, addiction, and the public safety consequences of diversion.

In presenting the report to ONDCP, Michael T. Walther, NDIC Director stated, The National Prescription Drug Threat Assessment provides a comprehensive overview of the misuse and abuse of prescription drugs—a problem sometimes overlooked in the focus on illicit drug abuse. The report represents the first comprehensive assessment of emerging trends based on current law enforcement, intelligence, and public health reporting and data from Federal, state, and local agencies throughout the United Sates.

Today's report validates the disturbing trend of increasing prescription drug abuse within the United States, said DEA Acting Administrator Michele M. Leonhart. When abused, not only are these drugs dangerous in their own right, they often lead to the use of harder drugs, with life-altering consequences. We in law enforcement are committed to being part of a comprehensive solution, using tools such as the recently implemented Ryan Haight Online Pharmacy Consumer Protection Act, to defeat those who push diverted pharmaceuticals into the hands of those who abuse them.

Despite strident regulations for dispensing controlled substances, prescriptions drugs, especially pain relievers, are acquired illegally, most frequently from friends or family or by doctor-shopping, prescription fraud, and theft. Rogue Internet pharmacies are also a significant source of diverted prescription drugs, and increasingly, street gangs are involved in the illicit distribution of diverted pharmaceuticals.

Key Findings

Prescription Drug Abuse: Over 8,500 deaths nationwide involved prescription pain relievers in 2005, the latest year for which data are available, an increase of 114 percent since 2001. Emergency room visits for nonmedical use of pain relievers increased 39 percent from 2004 to 2006. Treatment admissions for prescription opioids increased 74 percent from 2002 to 2006. Nearly one third of individuals who began abusing drugs in the past year reported their first drug was a prescription drug: 19 percent indicated it was a prescription opioid. Thus, 1 in 5 new drug abusers are initiating use with potent narcotics, such as oxycodone, hydrocodone, and methadone.

Prescription Drug Diversion: Diverted controlled prescription drugs are often more readily available than heroin in all drug markets. Opioid pain relievers are the most commonly diverted. Diversion methods include prescription drug fraud, theft, rogue Internet pharmacies, and friends and relatives—the primary sources of controlled prescription drugs for most abusers.

Regional Deviations: Although diversion and abuse of controlled prescription drugs is highest in eastern states, violent and property crimes associated with prescription drug diversion and abuse have increased in all regions of the United States over the past 5 years.

Figure 1. Past Year Initiates for Specific Illicit Drugs Among Persons 12 or Older (2007)

In 2007, more than 2 million people who previously had not abused pain relievers reported misusing prescription opioids for the first time. This category of drugs includes powerful narcotics such as oxycodone, hydrocodone, and methadone.

The National Prescription Drug Threat Assessment 2009 can be found at
http://www.usdoj.gov/ndic/pubs33/33775/index.htm
http://www.usdoj.gov/ndic/pubs33/33775/33775p.pdf

Technorati Tags: opiates, rx, treatment, youth

Uber Hip Harm Reduction

via: dailydose.net

Technorati Tags: harm reduction, UK

Needle Exchange and Human Rights

How did needle exchanges get on the human rights agenda and why doesn't treatment access rank?

Technorati Tags: needle exchange, addiction, harm reduction, addiction

Addiction: Could it be a big lie?

Coming soon to 20/20.

A devotee of behavioral economics rips into addiction-as-a-disease. He will argue that when the costs become great enough, addicts quit. The basis for their skepticism is a disbelief in loss of control. More on that line of thought here and here.

The article does a good job stating the stakes of giving this fringe too much attention:

If hardly a controversial topic to those other than the small group of dissidents who want it to be, the semantic disease-or-not debate has important practical implications. How addiction is viewed affects how addicts are treated, by the public and by medical professionals, and how government allocates resources to deal with the problem.

UPDATE: The 20/20 reference is not referring to an actual upcoming show, just the fact that John Stossel's libertarian philosophy and disease model skepticism are sure to attract him to this book.

Technorati Tags: behavioral economics, addiction, choice

Not self-medication

Another study finds that depression tends to follow alcohol problems rather than cause alcohol problems. My guess is that the popularity of self-medication theories won't suffer at all. Why is that?

Conclusions - The findings suggest that the associations between AAD and MD were best explained by a causal model in which problems with alcohol led to increased risk of MD as opposed to a self-medication model in which MD led to increased risk of AAD.

This is a longitudinal study. I look forward to seeing more about the responses to treatment for alcoholism and depression.

Technorati Tags: depression, alcoholism, research

Another Vaillant project

The Atlantic has an article about George Vaillant's longitudinal study of the physical and mental well-being of a cohort that were Harvard sophomores in 1937. The article looks at some of the study's insights into happiness.

People unfamiliar with Vaillant are probably wondering what this has to do with the focus of this blog. This particular study has little to do with it but Vaillant id the author of The Natural History of Alcoholism, based on another longitudinal study of a alcoholism.

Technorati Tags: happiness, research

A hard question

The New York Times has a nice piece on the cognitive dissonance that a lot of baby boomers feel about marijuana legalization.

Technorati Tags: marijuana, drugs, policy, addiction

Obama and needle exchange

Looks like he's balking at lifting the ban.

I honestly don't know if it's fair to characterize congressional reluctance to overturn the ban as pure politics or if it's still just fear of being cast as soft on drugs. I'm sure it's true of many. Maybe most.

I'd support overturning the ban, but it's a hard thing to muster much enthusiasm for. I look at the photo in story of disposed syringes at a needle exchange and it breaks my heart. It's hard not to see each of those needles as lost dreams, broken families, suffering communities, and pain and despair for countless people who are affected directly and indirectly.

I understand people being reluctant to purchase needles for someone to inject heroin, meth or cocaine. I understand feeling like it would be participating in someone's illness (rather than their recovery) or participating in their self-destruction. What's the alternative? To help people get well. We know how to do it. Programs for impaired health professionals serve large numbers of injection drug users with great outcomes. But, sadly, we haven't done that either. Effective treatment of adequate intensity and duration are out of reach for most people who need it. Instead, we seem to look away. We don't know how to help every one of those injection drug users recover, but we know how to help a lot of them. We CHOOSE not to do so.

I hope the ban is lifted. I hope that we're able to prevent addicts from getting Hepatitis C and HIV. Some people have bad reasons for opposing needle exchanges, but a lot of people have better reasons and still more just can't bring themselves to be pro-needle exchange. It seems to me that this message would have a lot more appeal if was about helping people get well, rather than just preventing them from getting sick. So, I hope that we do more than simply prevent them from contracting diseases. I hope we offer them an opportunity to recover--every one of them.

It's also worth noting that last time I looked (it's been a few years)
the number overdose deaths was three times the number of new cases of
HIV. 

We're not at war with people in this country

A welcome change in rhetoric:

The Obama administration's new drug czar says he wants to banish the idea that the U.S. is fighting "a war on drugs," a move that would underscore a shift favoring treatment over incarceration in trying to reduce illicit drug use.

In his first interview since being confirmed to head the White House Office of National Drug Control Policy, Gil Kerlikowske said Wednesday the bellicose analogy was a barrier to dealing with the nation's drug issues.

"Regardless of how you try to explain to people it's a 'war on drugs' or a 'war on a product,' people see a war as a war on them," he said. "We're not at war with people in this country."

Bill White on Methadone and Recovery

I love Bill and have enormous respect for him. This is not the first time I've heard him express these opinions and I respect where he's coming from, but it's just not been my 18 years experience in Southeastern and central Michigan. Just last week I admitted another 19 year old who had been going to a dosing clinic, getting no real counseling, no real recovery and little help when he asked to be detoxed so that he could pursue drug-free recovery. These are the kinds of stories I hear without exception. I recognize that my contact might be limited to a non-representative sample, but I've never even heard someone say something like, "Other people were doing well on it, but it wasn't for me." or "The people there really cared and treated me well, but I decided I needed something else." I've yet to meet a person on methadone at a professional conference as a success story. I've interviewed countless professionals seeking to leave methadone clinics--including people who don't have any connection to 12 step recovery. Methadone seems to be the dominant approach in the U.K. and it appears to be wrought with the same kinds of problems I see locally and the same pessimism about the capacity of opiate addicts to recover.

It's a crime if there are all sorts of great methadone recovery stories and stigma is preventing them from being heard, but I'm skeptical.

Bill has a history of doing a great job of delivering difficult messages to drug-free treatment providers. Methadone providers need to be challenged in the same manner. If drug-assisted treatment is ever to have a place in a recovery-oriented system of care, it seems to me that the providers in my area need a dramatic culture change.

UPDATE: Just to be sure that my position is understood. I'm not advocating the abolition of methadone.

Here's something I wrote in a previous post: "All I want is a day when addicts are offered recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose."

Another: "Once again, I'd welcome a day when addicts are offered recovery oriented treatment of an adequate duration and intensity and have the opportunity to choose for themselves."

It's also worth noting that there is a link between AA and methadone.

the Prozac moment

Mark Willenbring dreams of the day that addiction is treated by primary care docs:

...Dr. Willenbring, an expert on treating alcohol addiction, predicts that the day is not far off when giving a pill and five minutes of advice to an alcohol abuser will be all that is needed to keep drinking under control.
...
“We’re at the same place with alcohol abuse that the treatment of depression was at 40 years ago, when only psychiatrists treated it and most people with depression were never treated at all,” said Dr. Willenbring, the director the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism.

Then came Prozac, followed by similar antidepressants that took the treatment of depression out of mental hospitals and psychiatric offices and put it in homes and in the offices of primary care doctors.

“Now almost all of depression is treated in primary care,” Dr. Willenbring said, “and two-thirds to three-fourths of depression is getting treated.”

But with alcohol dependence, he said, only one person in eight receives professional treatment.

He acknowledges that this is not a likely possibility for the kind of people who currently enter residential and inpatient treatment:

“Those who get into treatment programs are the most severe alcoholics,” Dr. Willenbring said. “But the bulk of alcohol abusers have a more moderate form, with a better prognosis. Most could get well in primary care settings and not have to wait until they are at the end of their rope and forced to go into a rehabilitation program, which can be so stigmatizing.”

What is needed for controlling alcohol abuse early in the disease, he said, are drugs like Prozac that can be easily prescribed by primary care physicians to help people with moderate alcohol abuse. Several such drugs are now in the pipeline, Dr. Willenbring said.

The two already available — naltrexone and Topamax — are not yet the equivalent of Prozac for depression, but they can help many alcohol abusers learn to drink more moderately or abstain altogether.

I think he's got too much faith in antidepressants.

12 Step attendance and adolescent treatment outcomes

From the journal Addiction:

Aims  Twelve-Step affiliation among adolescents is little understood. We examined 12-Step affiliation and its association with substance use outcomes 3 years post-treatment intake among adolescents seeking chemical dependency (CD) treatment in a private, managed-care health plan. We also examined the effects of social support and religious service attendance on the relationship.

Design  We analyzed data for 357 adolescents, aged 13–18, who entered treatment at four Kaiser Permanente Northern California CD programs between March 2000 and May 2002 and completed both baseline and 3-year follow-up interviews.

Measures  Measures at follow-up included alcohol and drug use, 12-Step affiliation, social support and frequency of religious service attendance.

Findings  At 3 years, 68 adolescents (19%) reported attending any 12-Step meetings, and 49 (14%) reported involvement in at least one of seven 12-Step activities, in the previous 6 months. Multivariate logistic regression analyses indicated that after controlling individual and treatment factors, 12-Step attendance at 1 year was marginally significant, while 12-Step attendance at 3 years was associated with both alcohol and drug abstinence at 3 years [odds ratio (OR) 2.58, P < 0.05 and OR 2.53, P < 0.05, respectively]. Similarly, 12-Step activity involvement was associated significantly with 30-day alcohol and drug abstinence. There are possible mediating effects of social support and religious service attendance on the relationship between post-treatment 12-Step affiliation and 3-year outcomes.

Conclusions  The findings suggest the importance of 12-Step affiliation in maintaining long-term recovery, and help to understand the mechanism through which it works among adolescents.

Gil Kerlikowske, Drug Czar

From The Atlantic:

The U.S. government officially has a new drug czar: Seattle Police Chief Gil Kerlikowske sailed through his Senate confirmation process today on a 91-1 vote Thursday after passing un-contentiously through the Senate Judiciary Committee, which approved him without a recorded vote in a business meeting off the Senate floor in late April.

1990s treatment trend gets dinged

Acupuncture for detox was a hot trend in the mid 1990s. I have vague memories of it be promoted by NIDA or SAMHSA but I couldn't find a reference to it. Maybe my memory is failing me. Feel free to send me a reference if you know of one.

At any rate, Addiction Inbox looks at a recent study of acupuncture for opiate detox and an article in Alcohol: Clinical and Experimental Research reviews studies of acupuncture for alcohol dependence. Not good.

When Brute Force Fails

Mark Kleiman has a forthcoming book on criminal justice policy titled, When Brute Force Fails. I found a report by the same name on the National Criminal Justice Reference Service. It contains exactly what you would expect from Kleiman--smart on crime policy ideas that are still criminal justice oriented. Here's one example from the chapter on drug policy:

In High Point, North Carolina, the unwilling home to a major drug market that was, as usual, a source of violence and disorder, and which had been resistant to sustained routine enforcement efforts. The market, though substantial compared to the size of the city, turned out to involve only about two dozen dealers. Instead of arresting them one by one, giving replacement a chance to work, the police in High Point patiently identified all of the dealers and made the “buys” required to prepare airtight cases against them. The dealers (and, in a brilliantly seriocomic touch, their mothers) were then invited to a meeting, at which they found a solid phalanx of enforcement and prosecution officials and a group of social-service providers. They also found a set of chairs with their names on them (plus three empty chairs), and a set of loose-leaf notebooks, also labeled with their names.

The head of the High Point enforcement effort then explained that the three empty chairs were for the three most violent dealers in town, all ofwhom had been arrested that day, and that the notebooks contained the evidence on which any of the twenty-five dealers in the room could be arrested and convicted with no further investigation necessary. The shocked dealers were also told that, as of that day, the open drug market was closed, and that any one of them so much as suspected of dealing from then on would be prosecuted on the evidence already gathered and in the notebook. The social-service providers were available for those who needed various kinds of help (literacy, drug treatment, job training, housing, tattoo removal) in turning their lives around.

The result, as reported by one of the designers of the initiative, was virtually magical: the drug market dried up overnight. Two new dealers who thought they could take advantage of the sudden supply shortage in the open market were promptly arrested. The effect on the volume of drug transactions and the extent of drug abuse in the High Point area is unknown, and may not have been substantial or lasting. But the contribution to crime reduction was dramatic.

Mechanisms of change in AA

Addiction Research and Theory published a review of mechanisms of behavior change in AA.

Here's an excerpt from their conclusions:

Why have spiritually-oriented organizations, like AA, become so popular among alcohol and other drug addicted individuals and not as popular among those suffering from other kinds of mental disorders? One reason perhaps is that the disinhibiting effects from heavy alcohol and drug use frequently generate deviations from one's own moral code or set of values. Repeated over and over this “Jekyll and Hyde” scenario can lead to a sense of profound moral failing, self-blame and self-loathing. As structural and functional brain alterations caused by continued alcohol use exacerbate impairment over the regulation of drinking behavior negative feelings may intensify and be deepened and reinforced further by the reproach of affected onlookers and significant others. For many, the sense of “salvation”, historically and implicitly embedded within AA philosophy and in many other recovery mutual-help societies throughout US history (White 1998), may feel cleansing and self-soothing, providing a framework for self-forgiveness. This may account for the rather odd AA mix of spirituality and, “alcoholism as a medical disease” (see the Doctors' Opinion, xxv; AA 1939, 2001), which may have been initially a purely pragmatic hybrid constructed to alleviate common feelings of guilt, shame, and self-loathing that serve as barriers to salutary change. The attenuation of these feelings and self-perceptions as a function of AA exposure may be more specific to the spiritual/disease framework of AA and worthy of future mechanisms research.

I cringe a little at the uncritical use of disinhibition and I consider the word "salvation" to be laden with a kind of religiosity that I don't find in 12 step groups. However, the article did a pretty good job of examining the program and placed a great deal of emphasis on the growth fostering relationships within the fellowship. It's worth noting that all 12 step meetings are not created equal and that there would probably be significant variance of these mechanisms between groups.

Farm staff who would like a copy can email me.

Free will and addiction

A commentary in Addiction Research and Theory offers a 3rd way for debates about whether addicts have control over their drug use:

Our view is that the debate about free will in addiction, like the broader debate about free will in all human behavior, is unlikely to be won by either extreme view (Baumeister 2008). Self-control is an important form of what people understand as free will, and the capacity for self-control is real but limited-thus neither complete nor completely lacking. The traditional notion of willpower may be useful here, especially if one understands willpower as a kind of psychological energy that fluctuates as people use it up and then re-charge it (Baumeister et al. 1998; Vohs and Heatherton 2000). Free will is a partial, sometime thing.

There is certainly room to incorporate biological and genetic vulnerabilities in such a model. People may vary as to the reward power of drugs and alcohol: Some people get more pleasure than others from them. Social factors and personal experiences may also contribute to individual differences in such propensities. Thus, some people end up with stronger cravings than others.

Still, some freedom remains. The wine does not pour itself into a glass and thence down the alcoholic's throat. The person thus makes a choice between competing impulses: indulging pleasure now versus abstaining for the sake of nonspecific but substantial delayed gains. Choosing the path of virtuous abstention depends on willpower, however. When willpower has been depleted (such as by other acts of self-control, or even by decision making in any context; see Vohs et al. 2008), their likelihood of choosing the immediate pleasure increases.

If a disease model for addiction is to be retained, we suggest abandoning the virus or germ models in favor of something more like Type II diabetes. One does not become infected with diabetes. Rather, a natural bodily vulnerability becomes exacerbated by experiences, many of which are based on personal choices. Many people will not become diabetics regardless of what they eat, but others will suffer diabetes to varying degrees as a function of diet and exercise. Moreover (and again unlike a virus), there is no definite boundary that separates the sick from the healthy. Diabetes, and by analogy addiction, is a continuum. Those who are constitutionally vulnerable move themselves along this continuum by virtue of the choices they make.

Such an approach might produce a more socially beneficial “mythology” of addiction. Our research findings have suggested that promoting disbelief in free will produces destructive, antisocial behaviors generally. We propose that similarly destructive effects are likely to come from depicting addiction as loss of free will. People who have made bad choices like to hear and to think that they did not really or freely make those choices. But catering to that view excuses their behavior and sometimes contributes to enabling them to continue making similar choices.

Instead, we advocate a view that biology is not destiny. Being born with a genetic receptivity to liking drugs or alcohol does not guarantee a life of addiction. It is perhaps a form of bad luck, but one that can be overcome with prudent though sometimes difficult choices. Difficult choices are difficult because they consume relatively large amounts of psychological energy. Depicting addiction in this way may encourage people to sustain belief in free will and to take responsibility for their own choices and actions. As our research findings suggest, such an attitude is likely to produce behaviors that are beneficial for both the individual and society.

I find this model useful and I think a lot of the field is already there.

However, the writers seem to neglect a couple of important aspects of their own framework.

If one is to frame addiction with a continuum of vulnerability, part of the continuum would be people who are doomed to become addicts regardless of their choices. Isn't that the case with Type II diabetes? That some will never develop it, some may or may not depending on their activity levels and diet, while others with develop it regardless of their diet and activity levels. 

Also, within the context of their metaphor of psychological energy, there might be times when a person has none and times when a person has no internal or external resources to replenish this energy.

Their closing paragraph seems to slight both of these considerations. Acknowleging these considerations does disavow the role of choice. Even on the end of the continuum where a person's biology and environment doom them to developing addiction, choices could influence the onset, course and severity. And, within the psychological energy metaphor, during periods of replenished energy a person may have the power to make choices that will protect or expend this energy in ways that preserve it (and initiate/maintain recovery) or diminish it (and lead to relapse).

Alcoholics and addicts not alexithymic?

A study in Addiction Research and Theory finds that newly abstinent addicts self-report alexithymia (the inability to articulate emotions) at very high rates, but, in tests with standardized instruments, researchers did not find evidence of actual alexithmia.

This is from the full text of the study:

Substance abusers were more likely than normal adults and psychiatric outpatients to say they had trouble identifying and describing their emotions (on the TAS-20), but showed no actual deficits in identifying and describing emotions (on the LEAS). Substance abusers performed as well on the LEAS as a college student sample, after controlling for age, gender, and IQ, and performed as well as a community adult sample. The observed differences between drug treatment and control groups on the self-report measure were highly statistically reliable, whereas the observed differences on the performance measure did not approach statistical significance. There are at least two potential explanations for this disassociation between self-report and performance.

The negative mood explanation: Negative mood was associated with self-reported alexithymia, which is consistent with what has been found in a normal sample (Haviland et al. 1994). Haviland et al. (1994) have suggested that negative emotional states (i.e., anxiety) may lead to increased alexithymia. Given that our drug treatment sample was experiencing much more negative affect than others, it is possible that the primary reason substance abusers are more alexithymic is because of this increased negative affect. Inconsistent with this view, psychiatric groups that might be expected to experience substantial negative affect (e.g., obsessive compulsive and simple phobia patients) do not report particularly high levels of alexithymia (about 13%; Taylor 2000). Future research should measure self-reported alexithymia and negative mood in both a substance abuse and control group, and then examine whether differences in alexithymia still exist after controlling for the effects of mood.

The inaccurate belief / low-motivation explanation: Substance abusers' self-reports were unrelated to their actual performance, which is inconsistent with a study of normal adults (Lane et al. 1996). This finding suggests that substance abusers' beliefs may be inaccurate. Even so, such beliefs may have a crucial impact on behavior. If people believe that they are not able to deal effectively with their emotions, they may be less motivated to do so. Less motivation may, in turn, lead to more alexithymic behavior. For this explanation to account for the disassociation between self-report and performance alexithymia, we would have to assume that something about the LEAS task motivated substance abuse participants to perform adequately (relative to our comparison groups). Such motivational factors may include the well-structured nature of the task, or the presence of a researcher.

I find these findings fascinating, but I don't find either of these explanations very satisfying. I wonder if the self-reported alexithymia is rooted in a perceived inability to make others adequately understand their emotional state--that others do not understand the intensity of their emotional state or an aspect of their emotional state that they believe to be unique. I'm able to tell you that I am mad or sad, but you still don't understand my suffering. This would fit nicely recovering community humor about "terminal uniqueness" and lend itself to cognitive behavioral therapy or rational emotive therapy to reduce these cognitive distortions.

Another possibility is that the subjects felt confused by their own emotional state and unable to construct an adequate narrative to explain their emotional state and therefore unable to adequately communicate their emotional state.

More on evidence-based practices

This is a re-post from last fall.

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]

When hope is lost

An article on how to open a wet day center. What a pathologizing, deficit-oriented article! Our detox works with this population every day in a drug and alcohol free setting and, while this population may behave badly in hospitals and other settings, we experience very few problems. (Fewer than 3% of admissions were asked to leave.)

One friend responded with this quote as a test for any intervention:
“If you want to treat an illness that has no easy cure, first of all, treat them with hope” -- George Vaillant

Pot polls

Mark Kleiman breaks down the latest polls of public sentiment regarding pot laws. Bottom line:

...I doubt that even the decrim question would have gotten that much support in any poll since the beginning of the second War on Drugs in 1979. This is clearly not an issue the Obama Administration intends to take up anytime soon, but when and if it does there seems to be some running room.

It Isn't All About Evidence-Based Practice

This article from Counselor does a good job pointing out some of the limitations of the push for evidence based practices.

The whole issue is a double-edged sword. Measuring your own outcomes is a good thing, but it's no small burden for a treatment provider. (Imagine if every doctor had to measure their outcomes.) The adoption of and evidence-based practice (with some measures to assure fidelity) could relieve providers of this burden, but it comes at the cost of autonomy--which no one likes. Providers also hate that the process for identifying evidence-based practices is so political. (Consider the case of MRT.)

Note the straw man hit job by the journalist in the comments:

Yeah, I'm skeptical of this resistance as well: the reason there's such a push for evidence-based practice is because the non-evidence-based practices in addiction-- like harsh confrontation, humiliation, one-true-wayism (particularly insistence that the alternative to AA is jailsinstitutionsdeath: way to give hope, guys!)-- are not only ineffective but harmful.

These practices are antithetical to therapeutic alliance and to most of the other things you say are important for treatment.

All evidence-based practices incorporate "best practices" like emphasizing therapeutic alliance and empathy and opposing one-true-way stuff-- so it's really rather absurd to argue against EBT's by saying that those things matter.

If the non-evidence-based stuff did that, this wouldn't be a huge issue, but it doesn't and harmful and ineffective practices continue to be widely utilized.

How did this turn into a sarcastic 12 step bashing moment? (By the way, 12 Step Facilitation is an evidence-based practice.) Why does she insist on painting treatment providers with such a broad brush?

Besides, a quick google search of the author of the article finds that that the guy wrote a book on controlled drinking--hardly a 12 step nazi. Another important point is that one of the biggest critics of the push for the adoption of evidence-based practices is Scott Miller--not a 12 stepper in ANY way. In fact, he's the biggest advocate of the notion that the therapeutic alliance is for more important than the treatment model and he uses lots of evidence to support his arguments--not just anecdotes and slurs against people who think differently.

So much for the false notion that questioning the push for adoption of evidence based practices means your a mindless, abusive treatment provider who can't bring yourself to give up "harsh confrontation, humiliation, one-true-wayism"!

NRT linked to cancer?

Do nicotine replacement gum and lozenges cause mouth and throat cancer? Of course, they'd still be lower risk than tobacco but it's an argument against long term maintenance on NRT.

Teens and marijuana self-medication

My inbox has been bombarded with stories based on this study. The qualitative study consisted of 20 (Yes, 20.) kids who were a subset of 63 and their reported reasons for smoking pot. These 20 were a subset of 63 pot smoking kids participating in a larger study. A quick read of the study reveals that the authors uncritically accept the premise that marijuana is an effective treatment for a myriad of problems and their citations reflect a bias for self-medication theories. The study looks like a conclusion in search of evidence. The reported reasons for use of marijuana by these kids included depression (6), stress/anxiety (12), sleep problems (9), focus/concentration (3) and physical pain (5). There was no confirmation of any prior diagnosis or treatment and no assessment and diagnosis as part of the study.

That a qualitative study of a subset of 20 kids has gotten so much attention and led to headlines like, "Teens Use Pot to Treat Health Problems", "Some teens smoke pot for medical needs", "Herbal Remedy: Teens Often Use Cannabis For Relief, Not Recreation, Study Finds" and "Some teens smoke pot for their health" is ridiculous. Of course, this will influence the assumptions of researchers and clinicians and yield more of the same.

Speaking of Kleiman...

From Foreign Policy:

There are two distinct "drug problems." First -- logically, not in importance -- is the damage that drug toxicity, intoxication, and addiction can do to people who consume drugs, and lead them to do to other people. That we might call the "drug problem" proper.

. . . illicit markets sometimes generate violence and disorder, and the higher prices they create stimulate income-producing crime by some drug users. The enforcement effort also generates harm: arrest, incarceration, bribery, gunfights between enforcers and dealers. The problem of the illicit market constitutes the second "drug problem."

. . . Both no-brainer "solutions" to the drug problem --"a drug-free society" and "ending the drug war" -- are equally delusional. The two drug problems are both here to stay. Let's learn to deal with that fact.

Another legalization op-ed

This time in the Wall Street Journal. More of the same. The growing chorus of voices calling for legalization, regulation and taxation makes one ask, where are the other Kleimans calling for something other than the status quo or legalization?

More on Portugal

More on Portugal's drug policy. Again, it's worth noting that Cato is a Libertarian think tank and has a strong point of view on the issue:

Limitations of Utilitarianism

A post about the limitation of Utilitarianism uses drug policy as an example:

But the big problem, the world-breaking problem, is that sticking everything good and bad about something into one big bin and making decisions based on whether it's a net positive or a net negative is an unsubtle, leaky heuristic completely unsuitable for complicated problems.

...

In the hopes of using theism less often, a bunch of Less Wrongers have agreed that the War on Drugs would make a good stock example of irrationality. So, why is the War on Drugs so popular? I think it's because drugs are obviously BAD. They addict people, break up their families, destroy their health, drive them into poverty, and eventually kill them. If we've got to have a category "drugs"³, and we've got to call it either "good" or "bad", then "bad" is clearly the way to go. And if drugs are bad, getting rid of them would be good! Right?

So how do we avoid all of these problems?

I said at the very beginning that I think we should switch to solving moral problems through utilitarianism. But we can't do that directly. If we ask utilitarianism "Are drugs good or bad?" it returns: CATEGORY ERROR. Good for it.

Utilitarianism can only be applied to states, actions, or decisions, and it can only return a comparative result. [emphasis mine]

Utilitarianism is often cited in support of harm reduction programs that I object to (I don't object to all, or even most, harm reduction programs.) and drug legalization. However, as this post argues, the real question is, "X is better than what?"

The argument is limited by which options the person making the argument has chosen to compare. Too often, this lends itself to straw man arguments and reduces complex problems to false binary decisions.

[via Andrew Sullivan]

Out of your head

A nonalcoholic writer writes about a month of sobriety:

I am not an alcoholic. I don’t get sick, fall down or start my day with tots of whiskey. But I do love wine. I am entranced by the socio-historical and chemical properties of the vine. It is, for me, an intellectual pursuit–albeit one that is also literally intoxicating.

The threshold of addiction is a foggy place. You more or less know when you’re dependent, and you know when you're independent. But most of us stumble around somewhere in between: we’ll just have one more; we don’t need it, we just like it; we could stop anytime. My social life runs on alcohol like a bicycle on its tyres: it could keep moving without it, but the ride would be bumpy and uncomfortable and I would worry about looking foolish.

So I decided to give up drinking for a month. How hard could it be? Not that I thought it would be easy: not only do I enjoy drinking, but also I am good at it. I merrily buy fine wine and hold it well. Yet given my lack of discipline, going completely without seemed easier than moderation. I believe La Rochefoucauld had it right when he said, "Moderation is the feebleness and sloth of the soul, whereas ambition is the warmth and activity of it."

    Supportive friend:  "Seriously? For a whole month? Wow. You should write about it. People love to read about the misery of others."

    Less supportive friend:  "In January? Are you mad? What other joys are there at this time of year?"

    Even less supportive friend:  "I’m just off out for a lovely evening of dinner, chat and lots of red wine. Oh, and martinis. Envious?"

So I did it. It’s not difficult. Just dull. I felt unsociable. I missed the glow of self-satisfaction that alcohol brings, and the clear division it offers between work and recreation.
...
So what else did I learn after a month of stone-cold sobriety? That it's over-rated. There is a reason why people drink proportionally more the less they like themselves: alcohol takes you, as so much slang for drunkenness has it, out of your head. I’m no self-loathing Hemingway or Parker, but a month is a long time in your own uninterrupted company. Nobody wants to spend that much time with me--not even me. This is despite the fact that I found abstinence to be good for my self-esteem, not the other way round. People keep asking me if I feel healthier. I don't, particularly. But I do feel smug.

Wow. What a great job explaining the difficulty of quitting drinking for someone who simply likes drinking--for someone whose brain hasn't even been hijacking to seeking alcohol as a survival need.

It also does a great job of explaining some of the ways in which a tribe within mainstream culture can offer many of the same barriers that are face by people who identify with a tribe the culture of addiction.

Pot and cancer tumors

In case you heard that recent story about marijuana as a potential treatment for cancer tumors and wondered what to make of it, here's an apparent expert offering their view on it.

New ONDCP appointment

Obama's Drug Czar nominee seems to be well on his way to confirmation and now we learn that A. Thomas McLellan has been nominated for Deputy Director of the ONDCP. McLellan founded the Treatment Research Institute, co-authored a landmark paper making the argument that addiction is a chronic illness and, more recently, has been working closely with Bill White and others on implementing a recovery-oriented system of care in Philadelphia. (Here's something that they wrote together.)

This seems to be very good news. Hopefully they'll get the latitude that they need to initiate meaningful reforms.

Why do they stay?

A little off topic, but this is a great post on why victims of domestic violence often stay with the perpetrator.

5 Years After: Portugal's Drug Decriminalization Policy Shows Positive Results

This offers a very important opportunity to examine the effects of decriminalization. In terms of public health, the effects appear to have been very good. I'd be interested to watch indicators like age of first use, overall use rates, treatment admission rates, other crimes that are often drug-related, other harms that are often drug related (child welfare, etc.) and if there are any adverse or positive effects on specific communities. Aside from the legal status of the drug, it would be great to see a country shift its emphasis from criminalization of addicts to a wellness or recovery facilitation approach.

Keep in mind that the source has an avowed bias.

Abstinence too dangerous?

Interesting reading about professional helpers' fear of abstinence at wired in to recovery.

Peapod says, "While the ‘it’s too dangerous to try for abstinence’ argument is widespread in treatment settings, my own belief is that it is a rationalisation for maintaining the status quo."

I think it goes beyond the status quo issue. The context is much different here in the States, harm reduction and methadone are not dominant here, but there are very similar sentiments among those providers here. I believe that it comes down to a few common core beliefs in many (not all) workers in these field:

• that addicts can't or won't achieve full recover
• that drug use (including addiction) is voluntary or a lifestyle choice and that the liberty to choose drug use should trump other values
  
• to encourage recovery is to moralize

These discussions always remind me of a friend describing an NA t-shirt from a conference years ago. The shirt says, "The lie is exposed--we can recover."

Sober housing

Bill White reflects on the historical significance of sober housing (and recovery support services in general):

Congress has just mandated that health insurance companies must cover mental illness and substance abuse with the same standards they use to pay for other illnesses (The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (PL 107- 1434)). Passage of this legislation is, in some ways, a step “back to the future” since many health insurance companies in the 1970s and early 1980s covered addiction treatment as they covered payment for other illnesses. Such reimbursement was restricted or eliminated in the late 1980s and early 1990s because of treatment industry excesses (e.g., inappropriate admissions, excessive lengths of stay) and growing alarm about patterns of chronic relapse and treatment recycling. It is important in the face of this new legislation that the treatment field avoids replication of this earlier history. The use of Oxford Houses and other non-clinical, peer-based recovery support services can enhance the likelihood of recovery without relapse and can help prevent the future loss of the parity that has just been legislatively restored. 

Polishing a terd

Hythiam Announces Results Of Two Double-Blind, Placebo-Controlled Studies On Impact Of Prometa(R) Treatment Program For Alcohol Dependence

Marijuana derangement syndrome

Mark Kleiman debunks the some of the latest pro-legalization hysteria. (Read Kleiman's entire post.)

I asked Andrew Sullivan to publish the number of incarcerations for marijuana possession in quantities consistent with personal use. (Because I honestly didn't know and he give lip service to bringing rationality to matter.) Rather, he's opted to go with the umpteenth installment of "The Cannabis Closet". (Why does such a smart guy embrace this crap? Does he feel the same way about people saying, "Dude, I'm gonna pound a case a beer tonight. I've got a beautiful beer bong that can hold 72oz and deliver it in 4 seconds!"?) I don't really care if he wants to spark up every night, but the he celebrates it is getting pretty grating.

Kleiman reports that there are 30,000 inmates whose worst offense was marijuana crime. Another site reports that the number is 37,500, with 15,400 of them convicted of possession rather than trafficking. Too many, worthy of attention for reform, but not what the hyperbole would lead one to believe. Keep in mind that there is a lot of distance between current practices and legalization.

Webb on prison reform

Glenn Greenwald commends Senator Jim Webb for trying to bring attention to our incarceration rates and the need for prison reform. (Though I'm sick of the blogosphere hyperventilating over Obama's response to the question about pot legalization.) Here's an excerpt from a speech Webb gave last week:

The elephant in the bedroom in many discussions on the criminal justice system is the sharp increase in drug incarceration over the past three decades. In 1980, we had 41,000 drug offenders in prison; today we have more than 500,000, an increase of 1,200%. . . .

In many cases these issues involve people’s ability to have proper counsel and other issues, but there are stunning statistics with respect to drugs that we all must come to terms with. African-Americans are about 12% of our population; contrary to a lot of thought and rhetoric, their drug use rate in terms of frequent drug use rate is about the same as all other elements of our society, about 14%. But they end up being 37% of those arrested on drug charges, 59% of those convicted, and 74% of those sentenced to prison by the numbers that have been provided by us. . . .

It's a great post. Too difficult to pull quotes from. Take the time to read the whole thing.

Bill White in the UK

Bill White recently visited with some recovery advocates in the UK. There are several reactions posted at Wired in to recovery. Here's an interesting one on the cultural gap between the US and the UK:

I think I am right is saying that being welfare dependent carries more social stigma in the US than it does here. I think what I am trying to say is that there is a different social context for self-help and mutal aid and therefore recovery.

In the UK’s welfare state, there is a large body of middle class professionals (including drugs workers) who are charged with managing the lower orders of addicts. They may unwittingly “infantilse” the people in their care when they say things like, “You’re not ready for detox”.

I was reminded of something that was said to me a few years ago in a heated debate about harm reduction. “Sometimes, liberal minded people do the wrong things for the right reasons and their conservative opposites end up doing the right things for the wrong reasons”.

I'm still chewing on this and I don't really buy the right/wrong reasons--I think there are people with good and bad motives on both ends of the political spectrum. I started to write more, but I'll leave it at that.

Mexico's drug war

The Boston Globe's photo blog, the big picture, has a collection of imaged from Mexico's drug war.

No kidding

Sleep Drug, Sometimes Used as Study Aid, Might Be Addictive

Grow your own

Mark Kleiman modifies his grow your own proposal for pot policy:

That then suggests yet another option: in addition to allowing production for one's own use or for gift, perhaps the law could allow the formation of consumer-owned co-operatives, limited in size, barred from advertising and from selling other than by mail-order. Each co-op would be required to produce its own material rather than buying it from manufacturers or wholesalers. That system would provide much though not all of the convenience, choice, and potential tax revenue of the alcohol model, without creating an another addiction-promotion industry.

He also explains his rationale. Read the whole thing.

Creative solutions

What is there to say? I would really like to stop posting this stuff.

Every day, in the shadow of Parliament Hill, 30 homeless alcoholics are fed, housed and served drinks, each hour on the hour, between early morning and evening.

That this "managed alcohol" program run by Ottawa's Inner City Health Inc. in the ByWard Market, is effective, is beyond dispute. For one thing, it has saved the local health-care system in the neighbourhood of $3.5 million by reducing or eliminating its clients' frequent visits to hospital emergency rooms. For another, it has dramatically improved the quality of life for a group of people many would view as beyond hope.
...
It may seem counterintuitive to give addicts what is making them sick, but the Inner City Health program demonstrates it can help them live healthier, happier and less disruptive lives. Despite the fact that they are kept "buzzed" all day as a Citizen reporter put it, they are actually drinking less -- maybe two-thirds less -- than they would have been on the street. They can't panhandle while on the program and must meet strict requirements, which they agree to. And the fact is many homeless alcoholics can't quit. The best that can be done is to manage their addiction.
...
Many people think residential treatment is the only option for drug addicts. Muckle disagrees. "We have to change the assumptions and provide other kinds of help than we do." For some, residential treatment programs will be entirely ineffective, she says, mainly because they don't last long enough to make a real difference. A long, slow process that includes group therapy, harm reduction programs and some place to live, would have a better chance of succeeding.

One more thought about this and Staying Alive. The people give lip service to recovery, but all they talk about is how few people will recover, how damaged these people are and how the rest of us just don't get it. How can they really advocate for recovery when they have so little hope for the people they work with?

I honestly don't go looking for it. I rely on saved searches for keywords like substance abuse, drugs, alcohol, addiction, etc. This stuff just keeps coming.

Call for stories

From The Second Road:

April is Alcohol Awareness month. The Second Road will showcase a recovery story everyday during the month of April. They want to applaud those living in recovery while helping to bring awareness to addiction and to also make people aware of the strong community of support that exists.

TSR wants to salute the people who are battling alcoholism; as a child, a parent, a spouse, sibling, or as an addict. Be it 22 years or 2 days, they want to hear from the people making the decision to start a new path?to take the second road. TSR hopes this showcase will inspire not only those who are living in desperation, wrestling with the will to get sober, but also encourage those already working a program.

Community, support and inspiration are necessary on the road to recovery. If we can heighten the awareness of this disease, hopefully we can lower the amount of people living in pain.
Please, make YOUR voice heard. Submit your story to alix@thesecondroad.org.

TSR will feature more than one story a day, granted they receive enough submissions. If anyone would like to videotape their story, TSR will also showcase it on their YouTube page, with the other recovery speakers, at http://www.youtube.com/user/thesecondroad.

The power of expectancy

A study of naltrexone, acamprosate and placebo found that the treatment group they were in did not predict outcomes. What did predict outcomes was whether they believed that they were receiving an actual drug rather than placebo.

Background: Double-blind placebo-controlled trials are intended to control for the impact of expectancy on outcomes. Whether they always achieve this is, however, questionable. Methods: Reanalysis of a clinical trial of naltrexone and acamprosate for alcohol dependence investigated this issue further. In this trial, 169 alcohol-dependent patients received naltrexone, acamprosate or placebo for 12 weeks. In addition to being assessed on various indices of alcohol dependence, they were asked whether they believed they received active medication or placebo. Results: While there were no differences in outcomes between treatment groups, those who believed they had been taking active medication consumed fewer alcoholic drinks and reported less alcohol dependence and cravings. That is, irrespective of actual treatment, perceived medication allocation predicted health outcomes. Conclusions: These results highlight the differences between treatment administration in clinical trials and standard medical practice, a discrepancy that may sometimes decrease the validity of these types of trials.

You could also refer to expectancy as hope.

When hope heals

From Ode magazine:

An experiment: Two groups of rats receive transplants of malignant tumors and are given electric shocks. One of them can avoid the shocks by pushing on a lever; the other can't. In the group that can avoid the shocks, the immune system does its job, counterattacks and eliminates the cancer cells in 64 percent of the animals. In the other group, animals soon get discouraged, the immune cells are paralyzed and the cancer spreads in a few weeks. Only 23 percent of the rats reject the tumor.

Is that why Paul died—because he suddenly felt powerless to escape the "shocks" he got from his disease? [Paul, who had managed his illness for years, died 2 years after being told he had 2 years to live.] Cancer seems to develop faster and more aggressively in patients who have less control over the inevitable stress of existence, which seems to be one of the reasons support groups prolong survival. Now what could be more stressful than being told there's no hope of a cure? At the University of California, Los Angeles, Assistant Professor Steve Cole demonstrated that among AIDS patients on tri-therapy, the treatment benefits those who remain calm facing life's difficulties far more than those who have trouble controlling their stress. In the latter group, the virus spreads four times as fast.

But who will explain that to patients? Almost every week I hear patients tell me how they've received "death sentences" from their oncologists. These pronouncements are made with the greatest confidence, as if statistics were certainties. Studies like Cole's are almost never mentioned. Yet patients really need them. Because I've already made this mistake myself, I suspect doctors are more afraid of giving false hope than of talking about the worst that can happen. To guard against this Western-style voodoo, patients often need to know more than their doctors about what they can do to help themselves—beginning by placing more hope in their bodies than medicine is prepared to give them.

What role does hope play in addiction? An large role, I suspect. Scott Miller has found that expectancy accounts for 15% the variance in treatment outcomes.

“If you want to treat an illness that has no easy cure, first of all, treat them with hope” -- George Vaillant

Comments on Staying Alive

I got this comment about the CBC video:

Thank you so much for posting this! It really put some faces on all the talk we've had about harm reduction.

Don't get me wrong, I can see the importance of the social connections that Insite is providing for individuals. At the same time, what I found most disturbing was the situation with the woman, Shelley, who came to Insite to relapse.

I felt like with her life on the line, couldn't they do a little more to help her? Helping her get a hold of some pharmacies? Hooking her up with some non-methadone treatment?

I think one can be non-judgmental and say "You deserve sobriety" at the same time.

So, I finally watched the whole thing and here is my stream of consciousness:

Q: "How do you know if they're ready?"
A: "It's a judgment call. We know them..."

What does this mean? How about letting them tell you when their ready?

How on earth do people start recovery above the injection center? This place is the hub of the heroin user tribe of the culture of addiction.

Shelley - how about a little case management for Shelley? How about helping her get her prescription filled or a  getting her dose as an alternative to using heroin? Is it really reducing her harm when she predictably ends up tricking in the alley a day later? Was their passivity in the face of her relapse about her needs or about their personal philosophy? I'm not suggesting use of force, yelling or shaming, but she was in a temporary emotional crisis and was about to make a decision with profound long-term consequences.

Gabor Mate - "Addiction is not a moral failing" Correct. But our communal response to addiction is a moral failing. This place is a well equipped pit of despair. How can one offer hope in a place like this with people who expect you to fail at any attempt to recover.

The worker - I'm sorry. Maybe he's wonderful and in this for all the right reasons, but I can't shake the feeling that the work is self-ennoblizing, a source of vicarious excitement and is more about their world-view, their needs and their image. Acceptance of people "where they are at" does not mean treating them with the message that there's nothing wrong with staying where they are at forever. How about accepting them for what they can become?

Video fun

The A/V Geeks have posted scores of old videos, including the following:

[via kottke.org]

This is an emergency

One family writes about the impact of marijuana addiction in their family. (Skeptics - Stop focusing on the drug and think in terms of the response of the individual to the drug.)

Highlights here:

And for the last four years, this is how it's been. Two steps forward, two steps back. We effectively remain where we have been since it started.

This is cannabis. It stops you, it rips out normal reactions, normal kindness, normal motivation. It draws a line and you stand patiently behind it. And this is why we have broken one of the most serious prohibitions facing any writer. You Do Not Write About Your Children. Yes, your kids might enter your work now and then in charming disguise but you do not ever lay out their genuine, raw problems on the page. You fictionalise them, you do not present it up-front and true. There is a glass-fronted box in the corner of every writer's room, protecting the real lives of their children: Smash Only In Case Of Emergency.

...

Imagine if you could wave a wand and instantly all the spliffs and baggies were transformed into bottles of gin. You leave for work on Wednesday morning and suddenly you see kids on the way to school with a quarter of Gordon's sticking out their rucksack; at Thursday lunchtime, you see them sharing a swig of Tanqueray at the bus stop. And if you saw that daily, all around you, you would say there's a genuine problem. Except it's worse than that.

...

Their arguments - some ill-informed, some plain vitriolic - have all rested on an implicit belief that "a bit of pot" simply does not cause this kind of aggression, this sort of abuse. Yes, they say, if this was a heroin addict, nicking your stereo, your jewellery and flogging it down the pub, that would be credible. And they're right, you don't need to flog a stereo for a spliff - it costs less than a pint. And anyway, cannabis makes you mellow - stoners are hippies, laid back, docile to a fault. We used to smoke it, they imply, and we just giggled.

That was then. Skunk is GM cannabis. Evidence from the Forensic Science Service suggests that skunk cannabis (otherwise known as sinsemilla) is remarkably stronger than ever before. It is unquestionably different, definitely stronger. In skunk, the active ingredient, THC (tetrahydrocannabinol), has been ramped up significantly. But perhaps more importantly, this has been achieved at the cost of another component of naturally occurring cannabis, CBD (cannabidiol). And some scientists are starting to think that CBD has antipsychotic properties - something to offset the THC in old-fashioned marijuana but absent in skunk.

Heroin maintenance (again)

Is England considering adopting Denmark's heroin maintenance approach?

Some might think this initiative is not surprising in a country with a historical tradition of progressive, social democratic policies....

"Five years ago I decided I would not participate in yet another debate on drugs," recalls Preben Brandt, the chairman of the Council for Socially Marginalised People and an advocate of the policy. "It was too emotional, with different groups being very aggressive."

"The counter-argument was always 'you kill people by giving heroin' or 'with this initiative, you are telling people that taking heroin is OK'," he says. "It is very difficult to have a rational debate when you are arguing against beliefs."

The turning point came when results became available from experiments trialling the policy in other European countries, including Switzerland and the Netherlands. "The politicians became convinced that it could help those with the most severe drug problems," says Mads Uffe Pedersen, the head of the Centre for Alcohol and Drug Research at the University of Aarhus. "You could not argue against the (positive) findings."

"The debate became more practical," agrees Brandt. "It was about what policies worked and which ones did not. It was no longer about morality."

Attitudes towards drugs addicts improved too. "Drug addicts in Denmark are less stigmatised," says Brandt. "They are no longer perceived as criminals who are a danger to society. They're seen as patients who have a disease they need help with. The new scapegoats in Denmark are the foreigners."

I doubt this is near in England. And, call me crusty, but I find it difficult to believe that the motives here are to help addicts and that stigma has been reduced by a policy premised on the assumption that addiction is untreatable.

Involuntary treatment bill in West Virginia

I find this very frightening, though I empathize with families who wish they had this option.

Insite on CBC

CBC has a program on Vancouver's supervised injection center.

Drug War = Culture War?

A friend, Matt, wondered if the premise of this Frank Rich column will have implications for drug policy:

What has happened between 2001 and 2009 to so radically change the cultural climate? Here, at last, is one piece of good news in our global economic meltdown: Americans have less and less patience for the intrusive and divisive moral scolds who thrived in the bubbles of the Clinton and Bush years. Culture wars are a luxury the country — the G.O.P. included — can no longer afford.

I don't think that the drug war has traditionally been part of the abortion/homosexuality/sexuality-in-pop-culture culture wars, but pro-legalization advocates seem to be enjoying a great deal of success in moving it to that category. I wince at this categorization--the culture wars tend to impose false binary choices and I suspect it would lead to very bad policy.

Conservative outcast David Frum wades into the matter, but his point seems to be to challenge hippie dope smoking peaceniks to consider the violence involved in the marijuana trade next time they light up. It's an old tune. Acknowledge some of the costs of the drug war, and frame drug use as an immoral decision without examining the morality of the policy itself.

I don't know what "the" solution is and I'm skeptical of anyone who claims to know. There are losts of changes we could make--shifting the the emphasis of our policy from incarceration to treatment and supervision. However, no drug policy is going to solve the drug problem, Every policy will bring new problems and decrease other problems. It really comes down to which problems we're willing to live with. A lot of us have strong opinions and would like to decide the right policy, but our political process requires some measure of concensus. (Even if it's limited.)  I suspect that the only way to get there is to identify the relevant values and debate how the options fit within these values. If the debate ends up getting framed in the context of the culture war, this will be impossible.

Anxiety and Alcohol

A new study focuses on the neurobiological relationship between anxiety and alcohol use.

It offers a possible mechanism for vicious cycle of alcohol use leading to anxiety and this anxiety leading to more alcohol use.

The researchers found that short-term alcohol exposure increased the number of dendritic spines in certain regions of the amygdala, producing anti-anxiety effects. Alcohol-dependent animals eventually developed a tolerance to the anxiety-lowering effects of alcohol.

The researchers traced the anti-anxiety effect to the production of a particular protein, Arc, in response to a nerve growth factor called BDNF that is stimulated by alcohol exposure. BDNF is vital in the functioning and maintenance of neurons.

When alcohol was withheld from animals that had been chronically exposed, they developed high anxiety. Levels of BDNF and Arc -- and the number of dendritic spines -- were decreased in the amygdala. But the researchers were able to eliminate the anxiety in the alcohol-dependent animals by restoring BDNF and Arc to normal levels.

Pandey suggested that an initial easing of anxiety may encourage people to begin to use alcohol, while for chronic users, a lack of alcohol provokes high anxiety, creating a need to continue drinking to feel normal.

I think we need to know a lot more about this anti-anxiety effect before going off the races with anxiety as a pathway to alcoholism.

Def Jam on Drug Policy

Russell Simmons praises moves by the New York legislature to roll back the Rockefeller Drug Laws.

Betty Ford

Alix at The Second Road gives us a heads up about a PBS show on Betty Ford.

Here's Bill White's salute to her from a couple of years ago:

In the decades following the repeal of Prohibition, American women faced a unique cultural double bind. They were targeted for unrelenting product promotion by the alcohol, tobacco, and pharmaceutical industries at the same time social stigma increased for addicted women. Only a few women of prominence (e.g., public health pioneer Marty Mann and actresses Lillian Roth and Mercedes McCambridge) braved such stigma to publicly acknowledge their recoveries from alcoholism, while women struggling with narcotic addiction, such as jazz singer Billie Holiday, broke into public visibility only when they were arrested or died.

In such a climate, unknown numbers of women lost their dreams and their lives to alcoholism and other addictions. Many sought help only in the latest stages of their illnesses, with many dying early in their recoveries as a result of medical disorders spawned from prolonged years of secret addiction to alcohol and other drugs. It could justifiably be claimed that these women died not from addiction, but from stigma.

Recovery advocates during the mid-20th century dreamed of a day when a woman of unprecedented prominence would go public with her recovery story and by doing so forever shatter America's stereotype of the alcoholic as a depraved skid row wino. That dream was about to come true in a way that would forever demarcate "before and after" in the history of addiction and recovery among American women.

Courageous announcement

In April 1978, former President and First Lady Gerald and Betty Ford announced to the nation that Mrs. Ford had sought treatment and was recovering from addiction to alcohol and other drugs. That moment stands as the height of destigmatization of alcohol and other drug problems in America. Here stood one of the most prestigious women in the United States and, at a more personal level, a woman deeply respected and revered by the American public for her independence, spunk, and candor. We had sensed earlier as a citizenry that this was a woman who cared about us and would tell us the truth. She had demonstrated those traits by openly sharing her battle with breast cancer and using that experience to educate us as a nation. And here she was again standing with her husband and family talking to us about recovery from alcoholism and drug dependence.

In doing so, Betty Ford and her family, as they had done before, found a way to elevate their personal crises to a higher level of meaning and purpose. In 1978, Betty Ford did for alcoholism what a few years later a famous actor, a beloved professional athlete, and a brave young boy would do for AIDS. She put a face on alcohol and drug dependency that shattered the public stereotype of the alcoholic and in that moment brought us all a step closer to telling the truth about how these problems had touched our own lives.

The manner in which Mrs. Ford initiated her recovery process was also significant in that it challenged the popular notion that nothing could be done to stop addiction until the person who was addicted had personally hit bottom and reached out for help. News that Betty Ford's daughter, Susan Ford, had initiated a formal family intervention process that resulted in Mrs. Ford's admission to treatment and opened the doorway to her recovery conveyed three crucial lessons to the nation: 1) There is hope for families facing addiction; 2) The family can play a catalytic role in the recovery process; and 3) Individual family members and the family as a whole need to recover from the effects of addiction. Mrs. Ford, President Ford, and Susan and the other Ford children offered themselves as living proof of those propositions.

Chicken or the Egg?

From a press release about a study in the Archives of General Psychiatry:

Although numerous studies have linked alcohol problems and depression, whether the relationship is causal or whether there is a common underlying factor remains unclear, they said.

To explore the issue, they examined data from the Christchurch Health and Development study, which followed 1,055 individuals born in New Zealand for 25 years from birth.

...

In an attempt to determine causality, the researchers tested three statistical models on the data:

• One in which both disorders increased risk of the other in a feedback loop
• One in which major depression caused alcohol problems
• One in which alcohol problems caused major depression

The model that fit best was the one that assumed that alcohol problems caused major depression.

"The underlying mechanisms that give rise to such an association are unclear," the researchers said. "However, it has been proposed that this link may arise from genetic processes in which the use of alcohol acts to trigger genetic markers that increase the risk of major depression."

"In addition," they said, "further research suggests that alcohol's depressant characteristics may lead to periods of depressed affect among those with alcohol abuse or dependence."

Stress related to social, financial, and legal problems stemming from alcohol use might also increase the risk of depression, they said.

Add the Economist's voice to the chorus

The Economist weighs in on drug prohibition. (Again.) Not surprising, given their Libertarian leanings.

I like that they refer to legalization as the "least bad" option. This frames the discussion in a more honest way, though their presentation of the risks/benefits are simplistic and suffer from excessive certitude. (Note that they're advocating the legalization of ALL drugs.)

They also make the assumptions that one would expect from a publication devoted to free markets:

Prohibition has failed to prevent the proliferation of designer drugs, dreamed up in laboratories. Legalisation might encourage legitimate drug companies to try to improve the stuff that people take.

I do not share their faith that free markets would be a good thing for the drug trade.

Something is clearly happening. Chatter on the topic is growing. Let's hope for reform, but let's hope it's done in a thoughtful and realistic way. The status quo is unacceptable, but the distance between the status quo and legalization is vast.