A dishonest political agenda

From the Honorary President of the International Harm Reduction Association (page 8) [via PeaPod]:

I am completely in favour of helping people who use drugs to stop, if that is what they want. I assume that is what is meant by ‘recovery’. Working with anyone who has problems with drugs must start where the individual is and could involve a range of strategies. Harm reduction should permeate the services available to drug users, which should be used on the basis of evidence of effectiveness, including cost-effectiveness, and on the basis of allocating scarce resources in the most effective way on a population base.

I wonder about the evidence for his first statement. How many people has he or his organization helped achieve drug-free recovery? How many of the people they serve want drug-free recovery, and how many people can't access services to achieve this goal? Do they track this information? Do they use it to advocate for more drug-free treatment services?

If so, great. We're on the same side. If not, stop giving lip service to helping people who use drugs stop.

The recovery agenda is a dishonest political agenda, by which some treatment agencies are positioning themselves for a seamless transition to a Conservative government. It ignores evidence and relies on faith. It is becoming evangelistic. It is dishonest because it is completely undeliverable financially and it raises false hopes. It is not a public health approach.

Whoa! I'm not there to see for myself, so I don't know if the U.K. recovery movement is a cabal of political conservatives or ideologues trying to exploit political conservatives. I see no political pandering on Wired in.

As a recovery advocate that is thousands of miles away, I see a frustrating parallel with discussions here. The HR advocates adopt a hyper-rational posture, denying that their values are reflected anywhere in their beliefs and practice while accusing recovery advocates of being close scientific cousins of intelligent design advocates.

What evidence do recovery advocates ignore? There is ample evidence that we can be as effective at treating addiction as we are with other chronic diseases like hypertension, diabetes and asthma. Should we reject the current treatments for those too?

Why is it undeliverable financially? Because the public doesn't support it? Isn't that the point of advocacy? Why quash advocacy work that is focused on improving the lives of the people you also advocate for? Why not collaborate to make sure a complete continuum is offered?

The basis of drugs work should always be harm reduction. It should always be public health-based and if it helps with public order that is fine with me.

Why is drug-free treatment incompatible with public health? I think it is, but it's also important to keep in mind some of the limitations of public health models--tension between prevention and treatment is common in these arguments, Public health approaches always include the application of some values (even when we say they don't), and they risk turning life and death decisions for entire classes of people into cold accounting exercises. For example, why do we cringe at a harm reduction/public health approach to female circumcision? (More here and here.)

One other observation. Mr. O'Hare did not the use of the word addiction or any its variants. Does that intimate something? It may be nothing (Really, I mean that.), but it make me wonder if he's invested in framing as something other than a disease.

[hat tip: PeaPod]

It's not on the list!!!

Mark Kleiman being interviewed about his new book. This segment focuses on drug policy:

A civil rights movement

Powerful language from wired in to recovery:

Many people would argue that the UK treatment system, in main, is simply managing symptoms and accepting long-term disability or discomfort of people with serious substance use problems.

These same people would not argue against the value of treatment per se, rather it needs to be provided in a different way.

The recovery movement is first and foremost a civil rights movement. It is about helping disadvantaged people, people with problems, improve their well-being.

It is about helping people with substance use problems (and often many other problems) reclaiming or claiming their right to a safe, dignified, meaningful and gratifying life in the community, sometimes despite their problems.

A recovery oriented system of care places the person with the problem at the centre of the system. It does not just build places where people go and get ‘treatment’ – it builds forms of support theroughout the community.

It accepts that the struggles of the person are not just with what is going on within their own body and mind – it is about their social struggles, which they experience because of the prejudice, discrimination, stigma and marginalisation that occurs in society.

Alcohol marketing and teen drinking

The finding from a study of the relationship between alcohol advertising and adolescent alcohol use:

Based on the consistency of findings across the studies, the confounders controlled for, the dose response relationships, as well as the theoretical plausibility and experimental findings regarding the impact of media exposure and commercial communications, it can be concluded from the studies reviewed that alcohol marketing increases the likelihood that adolescents will start to use alcohol, and to drink more if they are already using alcohol.

"Recovery is recovery"

Bill White interviews a medication assisted recovery advocate:

The problem with the methadone community is we have too many people who think methadone is a magic bullet for that disease—that recovery involves nothing more than taking methadone.

This view is reinforced by people who, with the best of intentions, proclaim, “Methadone is recovery.” Methadone is not recovery. Recovery is recovery. Methadone is a pathway, a road, a tool. Recovery is a life and a particular way of living your life. Saying that methadone is recovery let’s people think that, “Hey, you go up to the counter there, and you drink a cup of medication, and that’s it. You’re in recovery.” And of course, that’s nonsense. Too many people in the methadone field learn that opiate dependence is a brain disorder, and they think that that’s all there is to it. But just like any other chronic medical condition, it has a behavioral component that involves how you live your life and the daily decisions you make.

He bemoans the lack of recovery-oriented providers:

Bill: Do you see the methadone clinics in the United States developing more recovery-oriented philosophies in their service practices?

Walter: I wish I could say I did, but it’s a yes and no. I’ve been to all the AATOD conferences since 2001 and there are clearly people who are developing more recovery-oriented programs, but there are 1200 methadone programs in the U.S. How many are represented at the AATOD? 40? So yes, some of the programs are developing more recovery-oriented services, but many are not.

This will be a very interesting movement to watch. Read the rest here.

[via dailydose.net]

Tab dump

• Should Burden of Disease Estimates Include Cannabis Use as a Risk Factor for Psychosis?
• Mental Health Indicator Interaction in Predicting Substance Abuse Treatment Outcomes in Nevada
• Addiction recovery as TV drama: A&E’s “The Cleaner”
• Military Families Targeted by New Prevention Campaign

In 16 states, drug deaths overtake traffic fatals

From the Washington Post:

In 16 states and counting, drugs now kill more people than auto accidents do, the government said Wednesday. 

Experts said the startling shift reflects two opposite trends: Driving is becoming safer, and the legal and illegal use of powerful prescription painkillers is on the rise. 

Read the rest here.

Another reason to quit smoking

Phillip-Morris played a role in killing health care reform in 1994:

McCaughey's lies were later debunked in a 1995 post-mortem in The Atlantic, and The New Republic recanted the piece in 2006. But what has not been reported until now is that McCaughey's writing was influenced by Philip Morris, the world's largest tobacco company, as part of a secret campaign to scuttle Clinton's health care reform. (The measure would have been funded by a huge increase in tobacco taxes.) In an internal company memo from March 1994, the tobacco giant detailed its strategy to derail Hillarycare through an alliance with conservative think tanks, front groups and media outlets. Integral to the company's strategy, the memo observed, was an effort to "work on the development of favorable pieces" with "friendly contacts in the media." The memo, prepared by a Philip Morris executive, mentions only one author by name:

"Worked off-the-record with Manhattan and writer Betsy McCaughey as part of the input to the three-part exposé in The New Republic on what the Clinton plan means to you. The first part detailed specifics of the plan."

McCaughey did not respond to Rolling Stone's request for an interview.

Whatever your feelings about health care reform, is this the kind of interest we want secretly manipulating the debate?

21 reduces alcohol dependence

More evidence for the argument that lowering drinking ages would lead to more alcohol and drug problems later in life. The point about age of first use vs. regular use is interesting and offers some interesting questions about goals and strategies for prevention programming.

Background: Many studies have found that earlier drinking initiation predicts higher risk of later alcohol and substance use problems, but the causal relationship between age of initiation and later risk of substance use disorder remains unknown.

Method: We use a "natural experiment" study design to compare the 12-month prevalence of Diagnostic and Statistical Manual, Fourth Edition, alcohol and substance use disorders among adult subjects exposed to different minimum legal drinking age laws minimum legal drinking age in the 1970s and 1980s. The sample pools 33,869 respondents born in the United States 1948 to 1970, drawn from 2 nationally representative cross-sectional surveys: the 1991 National Longitudinal Alcohol Epidemiological Survey (NLAES) and the 2001 National Epidemiological Study of Alcohol and Related Conditions. Analyses control for state and birth year fixed effects, age at assessment, alcohol taxes, and other demographic and social background factors.

Results: Adults who had been legally allowed to purchase alcohol before age 21 were more likely to meet criteria for an alcohol use disorder [odds ratio (OR) 1.31, 95% confidence intervals (95% CI) 1.15 to 1.46, p < 0.0001] or another drug use disorder (OR 1.70, 95% CI 1.19 to 2.44, p = 0.003) within the past-year, even among subjects in their 40s and 50s. There were no significant differences in effect estimates by respondent gender, black or Hispanic ethnicity, age, birth cohort, or self-reported age of initiation of regular drinking; furthermore, the effect estimates were little changed by inclusion of age of initiation as a potential mediating variable in the multiple regression models.

Conclusion: Exposure to a lower minimum legal purchase age was associated with a significantly higher risk of a past-year alcohol or other substance use disorder, even among respondents in their 40s or 50s. However, this association does not seem to be explained by age of initiation of drinking, per se. Instead, it seems plausible that frequency or intensity of drinking in late adolescence may have long-term effects on adult substance use patterns.

UPDATE: Oops. Here's the link.

The Sunday ritual

I'm not much of Mitch Albom fan, but good for him. Whether one agrees with him or not, it's something we all take for granted and it deserves discussion.

The video featured two attractive women.

It was shot by an onlooker.

It hit YouTube by storm.

You're no doubt thinking "sex," but let me assure you the women kept their clothes on. Unfortunately, that was the only ladylike thing about them.

On the video, they appeared intoxicated, swore like sailors, got in fights, then screamed, shoved and cursed until security finally took them away, one in handcuffs.

This was not a women's penitentiary. It was a Lions game. You can argue that watching the Lions might make anyone go ballistic. But I'm guessing these women, like many football fans, had another reason for their belligerence:

They were hammered before the game began.

And you could shoot this video every Sunday.

Look, it's bad enough that most NFL games begin at 1 p.m. and that people are buying beers before kickoff. But thanks to tailgating, many fans are blotto before they hand over their tickets. One day, we'll explain to Martians our tradition of arriving hours before a football game, sitting in cold parking lots in fold-up beach chairs, swigging beers and grilling fatty foods between bumpers of pickups (at which point the Martians will bolt to their spaceships).

...

I blame the tailgaters, but I also blame the teams -- pro and college. By encouraging a seven-hour drinking experience, football now sees its stadiums marred with behavior like this past week's wildly popular YouTube moment (billed as "Two Drunk Girls Kicked out of Vikings vs Lions Game").

Highlights from the conference "How AA and NA Work"

Presentations (hopefully video too) will be up next week. I'll post a link when they're up.

Sarah Zemore gave a great presentation on the evidence for the effectiveness of 12 step groups. It was powerful and well organized. I found a link to an identical presentation here.

She very effectively rebutted the Cochrane Review from a few years ago by making the following points. (These are based on notes I took and are incomplete. Hopefully they post video so that you can see her complete rebuttal for yourself.)

• It was limited only to randomized trials and ignored the overwhelming observational evidence.
• It included one of Zemore's studies which was NOT a randomized study of AA.
• She acknowledged that the randomized evidence is ambiguous.
  
• Randomized trials of AA are hard to do because some subjects in other groups end up participating in AA. This happened in Project MATCH.
• The Cochrane Review did not find Twelve-step Facilitation ineffective. It found it no more effective that CBT and MET.
• Finally, she cited 4 randomized studies of Twelve-step Facilitation: The outpatient arm of Project MATCH, a study by her colleague Kaskutas, and two others that I missed.

It was important for me because supporters of Twelve-step Facilitation are too often painted as the equivalent of intelligent design advocates. It's just not so and the evidence in this presentation made this unequivocally clear. Twelve-step Facilitation is not the only approach that works, but it's an evidence based practice.

Laudet made one self-evident point that jarred me because it is almost never made in professional circles. She pointed out that the subjects of one of her studies were infected with HIV at a rate of 22% and Hep C at a rate of 33%. She then said something to the effect of, "As a public health matter, we need to focus on keeping these people in recovery. If they relapse they are likely to spread these illnesses."

When's the last time you read anything about recovery as a strategy to reduce communicable disease?

Laudet (as did Zemore) attempted to deconstruct AA, so that it's mechanisms for change could be identified and still be offered to clients who prefer not to participate in AA or NA.

Bill White gave a rousing historical perspective of AA and NA's histories and pointed out the looming challenges that face twelve-step recovery groups. These challenges included matters like methadone maintenance patients as full NA members and the limitations of the 3rd tradition and singleness of purpose in AA. He noted that fewer that 18% of people entering treatment in the U.S. were primarily identified as alcohol dependent.

How AA/NA Work

The University of Michigan will host a conference tomorrow on How AA/NA Work and will stream it live here. The presenters include some very big names. Here's the agenda:

Friday, September 25, 2009
9:00 am - 4:00 pm

09:00-09:20	Introductions by John Traynor and Bob Zucker
09:20-10:00	Alcoholics Anonymous Effectiveness: Faith Meets Science by Sarah Zemore, PhD, Scientist, Alcohol Research Group, Public Health Institute
10:00-10:40	Twelve-step participation among polydrug users: Longitudinal patterns, effectiveness, and (some) lessons learned by Alexandre B. Laudet, Ph.D., Director, Center for the Study of Addictions and Recovery (C-STAR) and Deputy Director of the Institute for Treatment and Services Research, National Development and Research Institute
10:40-11:00	BREAK
11:00-11:40	The Varieties of recovery experience: AA, NA and the diversification of pathways and styles of long- term addiction recovery by William L. White, M.A., Senior Research Consultant, Chestnut Health Systems / Lighthouse Institute. Author of: Slaying the Dragon - The History of Addiction Treatment and Recovery in America
11:40-12:20	From iPod to iGod: Are 12-step Groups Hip Enough for Adolescents? by John F. Kelly, Ph.D., Associate Director, Mass. General Hospital/Harvard Center for Addiction Medicine, Director, Addiction Recovery Management Service (ARMS) at Mass. General Hospital, Assistant Professor of Psychiatry, Harvard Medical School
12:20-01:30	LUNCH
01:30-02:10	Alcoholics' perceptions of AA's helpfulness: Qualitative responses and association with drinking outcomes by Elizabeth A. R. Robinson, MSW, Ph.D., Research Assistant Professor, at the University of Michigan Department of Psychiatry Substance Abuse Section
02:10-02:30	BREAK
02:30-04:00	Panel Discussion

Cause, effect & underage drinking

Two interesting findings about underage drinking. The first on the relationship between early alcohol use and chronic alcohol problems later in life. The second looks at the relationship between early alcohol use and poor judgment later in life.

We've known for some time that there is a relationship between early drinking and alcohol problems later in life. What's been unclear is the nature of that relationship. Does early exposure to alcohol cause changes in the adolescent brain that lead to problems later in life? Does early exposure facilitate the expression of genes that are related to alcoholism? These two theories would suggest that early exposure to alcohol has the potential to cause alcohol problems later in life. Or, is early exposure an indicator of risk factors such as the environment the young person is in or risk taking behavior? These would suggest that there is no causal relationship.

A new study supports the gene expression theory:

Background: Research suggests that individuals who start drinking at an early age are more likely to subsequently develop alcohol dependence. Twin studies have demonstrated that the liability to age at first drink and to alcohol dependence are influenced by common genetic and environmental factors, however, age at first drink may also environmentally mediate increased risk for alcohol dependence. In this study, we examine whether age at first drink moderates genetic and environmental influences, via gene × environment interactions, on DSM-IV alcohol dependence symptoms.

Methods: Using data on 6,257 adult monozygotic and dizygotic male and female twins from Australia, we examined the extent to which age at first drink (i) increased mean alcohol dependence symptoms and (ii) whether the magnitude of additive genetic, shared, and nonshared environmental influences on alcohol dependence symptoms varied as a function of decreasing age. Twin models were fitted in Mx.

Results: Risk for alcohol dependence symptoms increased with decreasing age at first drink. Heritable influences on alcohol dependence symptoms were considerably larger in those who reported an age at first drink prior to 13 years of age. In those with later onset of alcohol use, variance in alcohol dependence was largely attributable to nonshared environmental variance (and measurement error). This evidence for unmeasured gene × measured environment interaction persisted even when controlling for the genetic influences that overlapped between age at first drink and alcohol dependence symptoms.

Conclusions: Early age at first drink may facilitate the expression of genes associated with vulnerability to alcohol dependence symptoms. This is important to consider, not only from a public health standpoint, but also in future genomic studies of alcohol dependence.

On the second matter, Scientific American [via 3 Quarks Daily] suggests that there is a causal relationship between early exposure to alcohol and poor judgement long after the effects of the alcohol wear off:

It's no secret that binge drinking and faulty decision-making go hand in hand, but what if poor judgment lingered long after putting the bottle down and sobering up? A new study with rats suggests that heavy alcohol consumption in adolescence could put people on the road to risky behavior.

Several studies have associated heavy drinking in youth with impaired judgment in adulthood, but these studies didn't resolve whether alcohol abuse actually predisposes people to develop bad decision-making skills, or if the people who indulged in excessive inebriation were risk-taking types to begin with. As Selena Bartlett, a director in the Ernest Gallo Clinic and Research Center at the University of California, San Francisco, explains, you cannot put adolescents in a room and ask them to consume alcohol to see what happens. But scientists can conduct these kinds of experiments with rats, an animal that Bartlett, who was not part of the study, says is "excellent for modeling changes in behavior" as a result of alcoholism.

In the new study published this week in Proceedings of the National Academy of Sciences, scientists at the University of Washington

(U.W.) in Seattle fed alcohol to a group of rats and found that their ability to make good decisions was impaired even long after they stopped consuming booze.

Harm Reduction Defined

From the International Harm Reduction Association:

‘Harm Reduction’ refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community.

Not bad for a definition developed by a committee.

[via drugscope]

Ending the war on drugs does not equal legalization

An interesting take on the growing chorus of calls to end the war on drugs.

The first problem I have with the op-ed is that she conflates ending the drug war with legalization, offering an fallacious binary choice. The piece is a hard sales pitch for her position.

She offers 2 reasons for these calls:

Two significant developments are contributing to the sudden surge in calls for reconsidering prohibition. The first is that drugs are now damaging long-term Western security interests, especially in Afghanistan and Mexico. The second is that production is migrating away from its traditional homes like Colombia and the Golden Triangle and moving into the heart of Western consumer areas like Canada, the Netherlands and Britain.

I don't have a global perspective, but, in the US, it seems to me that domestic policy is driving the reconsideration of drug policy. One factor is moral, the insane incarceration rates for drug offenders (From the early 1980s to the to the early 2000s, the number of inmates whose worst offense was a drug crime grew by 1540% in federal prisons and 1195% in state prisons.) The other is financial, with state budgets buckling under the recession and the cost of incarcerating all these people.

She goes on to make a humanitarian case based on the suffering in the developing world. Ironically, Antonio Maria Costa makes a humanitarian case against legalization based on the suffering it would cause in developing world.

At the moment, fewer than 5% of all adults in the world take drugs at least once a year, compared with around one-quarter who smoke tobacco and about a half who drink alcohol. Drugs kill about 200,000 people a year, tobacco 5 million and alcohol 1.8 million. Why open the floodgates to addiction by increasing access to drugs? Would the world really be a better place with a lot more people under the influence of drugs?

John Gray seems to think so. In last week's Observer he argued that the case for legalising all drugs is unanswerable. Yet who would answer for the havoc wrought on the vulnerable? Maybe western governments could absorb the health costs of increased drug use, if that's how taxpayers want their money to be spent.

But what about the developing world? Why unleash an epidemic of addiction in parts of the world that already face misery, and do not have the health and social systems to cope with a drug tsunami?

Critics point out that vulnerable countries are the hardest hit by the crime associated with drug trafficking. Fair enough. But these countries would also be the hardest hit by an epidemic of drug use, and all the health and social costs that come with it. This is immoral and irresponsible.

He ends with the same kind of hard sell, resorting to an appeal to classism.

Let's be open-minded about how to improve drug control. But let's do it in a way that will improve the health and safety of our communities and not just make it easier for City bankers and high-street models to snort cocaine.

Ford + Hythiam = WTH?

As someone who lives in Michigan, I've been very interested in the welfare of the auto industry and I've been pretty hopeful about Ford. That is, until I read this. What the heck? (I'm trying to keep this blog PG.)

You can read more about Hythiam here.

9 components of recovery

David Clark at wiredin.org.uk expounds on a list of 9 components of recovery from the mental health recovery movement. They are:

1. Renewing hope and commitment to one’s life
2. Being supported by others
3. Finding one’s niche in the community
4. Redefining self or changing one’s identity
5. Incorporating illness
6. Managing symptoms.
7. Assuming control
8. Fighting stigma
9. Being an empowered citizen
   

Crime, crime, crime...

Today's UK papers have advocates and critics of heroin maintenance, but is anyone looking out for the addicts themselves? Where are the op-eds calling for an audacious recovery-oriented treatment initiative?

More on Mexico's drug policy reform

Five opinions on Mexico's recent move to decriminalize possession.

Too hot, too cold, just right...

They also make irreconcilable statements of fact.

Here are some of the highlights:

...if they asked me, will decriminalization of the possession of small amounts of drugs save a single life in Ciudad Juárez, where there have been about 3,200 murders in 21 months, my answer would be a rotund no.

But decriminalizing drug possession is in and of itself a change of, paradoxically, gigantic and modest proportions. Gigantic because it is a solid first step to pave the way for 1) distinguishing between drug use and drug abuse 2) paving the way for fully medicalizing abuse, that is, reinforcing the idea that we should treat drug addicts much as alcoholics and offer them help instead of prison time, and 3) focusing state resources on the production, trafficking and distribution networks. But modest because it still commits governments to continue their war on drugs, just not on the user.

Grrrr:

Drug users are not innocent. They support the vicious drug cartels. Without their demand for drugs, the supply side has no purpose. Since terrorists depend on the drug market to fund their activities, users are potentially aiding terrorism. Because drug traffickers are frequently linked with weapons and human trafficking, users are also supporting these activities.

I love you, Mom

Mama Zen offers a very short, simple and thought provoking post. Check it out.

How marijuana became legal

An interesting take on the history of the medical marijuana and it's role in a movement toward marijuana legalization:

This article is not another polemic about why it should or shouldn't be. Today, in any case, the pertinent question is whether it already has been -- at least on a local-option basis. We're referring to a cultural phenomenon that has been evolving for the past 15 years, topped off by a crucial policy reversal that was quietly instituted by President Barack Obama in February.

[via DrugScope]

Recovery and harm reduction

An interesting statement on harm reduction and recovery:

We believe that recovery is best defined by the individual seeking it, and that it is not for academics or treatment providers to tell anyone what recovery should mean to them. We assert that for some people, recovery can be medication assisted for a short or longer time (on maintenance) whilst the person achieves other gains in health, social care and reintegration (participation in the rights, roles and responsibilities of society).

I wonder how bread the agreement would be on this statement:

Being drug free is the ultimate goal of harm reduction.

Very broad, I hope.

[via DrugScope]

Eye movements reveal processing of hidden memories

Hmmmm. I've always been an EMDR skeptic but this suggests that there may be something to the theory behind it. Interesting.

Positive liberty and addiction

I saw a Facebook comment today referencing "freedom to" and "freedom from". It got me thinking about positive and negative liberty and harm reduction.

Negative liberty is the absence of obstacles, barriers or constraints. One has negative liberty to the extent that actions are available to one in this negative sense. Positive liberty is the possibility of acting — or the fact of acting — in such a way as to take control of one's life and realize one's fundamental purposes.
...
The reason for using these labels is that in the first case liberty seems to be a mere absence of something (i.e. of obstacles, barriers, constraints or interference from others), whereas in the second case it seems to require the presence of something (i.e. of control, self-mastery, self-determination or self-realization).

There seems to be two (maybe more) approaches to harm reduction. One that adopts what Scott Kellogg referred to as gradualism, (I've frequently discussed something I refer to as recovery-oriented harm reduction.) an approach that does not limit itself to the goal of the harm that results from addiction or other risky behaviors, but rather seeks to facilitate change away from active addiction or other risky behaviors. The other approach limits itself to reducing harm and often adopts and affirms the culture of tribes of drug users. The implicit message often seems to be that drug use is a lifestyle choice that is to be accepted, if not respected.

To a significant extent, many disagreements about harm reduction and legalization come down to this philosophical issue. Are these people free?

I say that they are not. However, Berlin, the philosopher who fleshed out the concept of negative vs. positive liberty, warned about the potential consequences of governments taking this view,

Once I take this view, I am in a position to ignore the actual wishes of men or societies, to bully, oppress, torture in the name, and on behalf, of their ‘real’ selves, in the secure knowledge that whatever is the true goal of man ... must be identical with his freedom.

To be sure, this a very real danger in adopting my view of the problem, but fear of infringing on another's liberty is not a reason to ignore this truth. Gradualism seems to navigate these waters well and, in a previous post, I put forth a set of principles for recovery-oriented harm reduction:

I've been thinking about a model of recovery-oriented harm reduction that would address the historic failings of abstinence-oriented and harm reduction services. The idea is that it would provide recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented provider:

• an emphasis on client choice--no coercion
• all drug use is not addiction
• addiction is an illness characterized by loss of control
• for those with addiction, full recovery is the ideal outcome
• the concept of recovery is inclusive -- can include partial, serial, etc.
• recovery is possible for any addict
• all services should communicate hope for recovery--recognizing that hope-based interventions are essential for enhancing motivation to recover
• incremental and radical change should be supported and affirmed
• while incremental changes are validated and supported, they are not to be treated as an end-point
• such a system would aggressively deal with countertransference--some people may impose their own recovery path on clients, others might enjoy vicarious nonconformity through clients

17 Killed in Mexican Rehab Center

What is there to say? Terrible.

Several masked men armed with automatic weapons stormed into a drug rehabilitation center in this violent border city on Wednesday night, lined up recovering drug addicts and alcoholics against a wall and opened fire at point-blank range, killing 17 people and wounding three.
...

In the past two years, gunmen suspected of ties with drug gangs have barged into rehab clinics in Juárez four times and started shooting. The death toll from these attacks on clinics is now about 32.

Sketches of the Drug Czars

A slideshow of drug war inspired art from Vanity Fair:

The United States spends nearly $50 billion each year on the war on drugs, to little avail: illegal drugs remain prevalent, and drug-funded groups continue to spread violence from Mexico to Afghanistan. The new White House drug czar, Gil Kerlikowske, says he wants to end the drug war, but other men in his position have tried and failed to do just that. In this illustrated history, Ricardo Cortes shows how science, politics, ego, and scandal transformed a public-health initiative into a century-long military campaign.

Technorati Tags: drug war, art

The Breathalyzer Behind the Wheel

A NYT contributor makes the case for ignition-interlock breathalyzers for drunk drivers.

People driving while intoxicated still cause about 13,000 deaths a year in the United States. And of the 1.4 million arrests made, one-third involve repeat offenders. The greatest potential of ignition interlocks is to reduce this recidivism.

These hand-held devices, typically attached to dashboards and connected to the ignition, use fuel-cell technology to measure the concentration of alcohol in a person’s breath. Although they are made by various companies, all ignition interlocks conform to strict standards of accuracy set by the National Highway Traffic Safety Administration. If too much alcohol is detected, the car will not start.

A person who has been drinking might naturally think of fooling the device by persuading a sober person to start the engine, but that is not enough to subvert the system, because the device requires breath samples while the person drives — at random intervals of five minutes to an hour. (At least one company is also integrating cameras with the interlocks to photograph the driver when he provides a breath sample.) The unit keeps a log of all tests, and it is sealed so that any attempts at tampering can be detected.

Ignition-interlock devices are not perfectly effective; a drunk can often borrow another car. But in one recent study they were found to reduce repeat drunk-driving offenses by 65 percent. If they were widely installed, the devices would save up to 750 lives a year, a recent National Highway Transportation Safety Administration report estimated.

Technorati Tags: drunk driving, courts

Culture and the placebo effect

Patrick Appel at The Daily Dish looks at the placebo effect and culture:

Wired says it's getting stronger:

[T]he placebo response is highly sensitive to cultural differences. Anthropologist Daniel Moerman found that Germans are high placebo reactors in trials of ulcer drugs but low in trials of drugs for hypertension—an undertreated condition in Germany, where many people pop pills for herzinsuffizienz, or low blood pressure. Moreover, a pill's shape, size, branding, and price all influence its effects on the body. Soothing blue capsules make more effective tranquilizers than angry red ones, except among Italian men, for whom the color blue is associated with their national soccer team—Forza Azzurri!

Mind Hacks parses. Another nugget:

[W]hy would the placebo effect seem to be getting stronger worldwide? Part of the answer may be found in the drug industry's own success in marketing its products.  Potential trial volunteers in the US have been deluged with ads for prescription medications since 1997, when the FDA amended its policy on direct-to-consumer advertising. The secret of running an effective campaign, Saatchi & Saatchi's Jim Joseph told a trade journal last year, is associating a particular brand-name medication with other aspects of life that promote peace of mind: "Is it time with your children? Is it a good book curled up on the couch? Is it your favorite television show? Is it a little purple pill that helps you get rid of acid reflux?" By evoking such uplifting associations, researchers say, the ads set up the kind of expectations that induce a formidable placebo response.

Technorati Tags: research, placebo, medication

Make a Gratitude Adjustment

A good article on the relationship between gratitude and happiness.

A psychology professor at the University of Michigan, Peterson regularly gave his students an unusual homework assignment. He asked them to write a "gratitude letter," a kind of belated thank-you note to someone in their lives. Studies show such letters provide long-lasting mood boosts to the writers. Indeed, after the exercise, Peterson says his students feel happier "100 percent of the time."

...The biggest bonuses come from experiencing gratitude habitually, but natural ingrates needn't despair. Simple exercises can give even skeptics a short-term mood boost, and "once you get started, you find more and more things to be grateful for," says Robert Emmons, a leading gratitude researcher at the University of California at Davis.

In gratitude letters like those penned by Peterson and his students, writers detail the kindnesses of someone they've never properly thanked. Read this letter aloud to the person you're thanking, Peterson says, and you'll see measurable improvements in your mood. Studies show that for a full month after a "gratitude visit" (in which a person makes an appointment to read the letter to the recipient), happiness levels tend to go up, while boredom and other negative feelings go down. In fact, the gratitude visit is more effective than any other exercise in positive psychology.

...Traumatic memories fade into the background for people who regularly feel grateful, Watkins's experiments show. Troublesome thoughts pop up less frequently and with less intensity, which suggests that gratitude may enhance emotional healing.

My first sponsor had me make gratitude lists daily for more than a year (until I moved away). I had been suffering from crippling depression and I believed that the suggestion of a gratitude list was dismissive of my suffering and indicated a failure to comprehend the complexity, seriousness and persistence of the problem. Was I wrong. Over time it was one of the most effective tools I've acquired in combating that episode and staving off potential episodes since then.

Technorati Tags: depression, trauma, gratitude, research

Depression's Evolutionary Roots

Researchers hypothesize that depression is an adaptation rather than dysfunction:

One reason to suspect that depression is an adaptation, not a malfunction, comes from research into a molecule in the brain known as the 5HT1A receptor. The 5HT1A receptor binds to serotonin, another brain molecule that is highly implicated in depression and is the target of most current antidepressant medications. Rodents lacking this receptor show fewer depressive symptoms in response to stress, which suggests that it is somehow involved in promoting depression. (Pharmaceutical companies, in fact, are designing the next generation of antidepressant medications to target this receptor.) When scientists have compared the composition of the functional part rat 5HT1A receptor to that of humans, it is 99 percent similar, which suggests that it is so important that natural selection has preserved it. The ability to “turn on” depression would seem to be important, then, not an accident.

This is not to say that depression is not a problem. Depressed people often have trouble performing everyday activities, they can’t concentrate on their work, they tend to socially isolate themselves, they are lethargic, and they often lose the ability to take pleasure from such activities such as eating and sex. Some can plunge into severe, lengthy, and even life-threatening bouts of depression.

So what could be so useful about depression? Depressed people often think intensely about their problems. These thoughts are called ruminations; they are persistent and depressed people have difficulty thinking about anything else. Numerous studies have also shown that this thinking style is often highly analytical. They dwell on a complex problem, breaking it down into smaller components, which are considered one at a time.

Read the whole thing. Pretty interesting.

Technorati Tags: depression, research

Even anesthesiologists

Amazing what happens when addicts are provided with high quality treatment of the appropriate duration and intensity.

Abstract

BACKGROUND: Anesthesiologists have a higher rate of substance use disorders than other physicians, and their prognoses and advisability to return to anesthesiology practice after treatment remain controversial. Over the past 25 yr, physician health programs (PHPs), created under authority of state medical regulatory boards, have become primary resources for management and monitoring of physicians with substance abuse and other mental health disorders.

METHODS: We conducted a 5-yr, longitudinal, cohort study involving 904 physicians consecutively admitted to 1 of 16 state PHPs between 1995 and 2001. This report analyzed a subset of the data involving the 102 anesthesiologists among the subjects and compared them with other physicians. The main outcome measures included relapse (defined as any unauthorized addictive substance use, including alcohol), return to anesthesiology practice, disciplinary actions, physician death, and patient harm.

RESULTS: Anesthesiologists were significantly less likely to enroll in a PHP because of alcohol abuse (odds ratio [OR] 0.4 [confidence interval {CI}: 0.2–0.6], P < 0.001) and much more likely to enroll because of opioid abuse (OR 2.8 [CI: 1.7–4.4], P < 0.001). Anesthesiologists had a higher rate of IV drug use, 41% vs 10% (OR 6.3 [CI: 3.8–10.7], P < 0.001). During similar periods of monitoring, anesthesiologists received more drug tests, 101 vs 82 (mean difference = 19 [CI: 3–35], P = 0.02); however, anesthesiologists were less likely to fail at least one drug test during monitoring, 11% vs 23% (OR 0.4 [CI: 0.2–0.9], P = 0.02). There was no statistical difference among rates of program completion, disciplinary actions, return to practice, or deaths, and there was no report of significant patient harm from relapse in any record.

CONCLUSIONS: Anesthesiologists in our sample treated and monitored for substance disorders under supervision of PHPs had excellent outcomes similar to other physicians, with no higher mortality, relapse rate, or disciplinary rate and no evidence in their records of patient harm. It is postulated that differences of study design account for contradictory conclusions from other reports.

Technorati Tags: research, physicians, treatment

My name is Roger...

Roger Ebert breaks his anonymity:

You may be wondering, in fact, why I'm violating the A.A. policy of anonymity and outing myself. A.A. is anonymous not because of shame but because of prudence; people who go public with their newly-found sobriety have an alarming tendency to relapse. Case studies: those pathetic celebrities who check into rehab and hold a press conference.

In my case, I haven't taken a drink for 30 years, and this is God's truth: Since the first A.A. meeting I attended, I have never wanted to. Since surgery in July of 2006 I have literally not been able to drink at all. Unless I go insane and start pouring booze into my g-tube, I believe I'm reasonably safe. So consider this blog entry what A.A. calls a "12th step," which means sharing the program with others. There's a chance somebody will read this and take the steps toward sobriety.

He responds to some of the most common criticisms (I know he doesn't recognize that many people are coerced.):

The God word. The critics never quote the words "as we understood God." Nobody in A.A. cares how you understand him, and would never tell you how you should understand him. I went to a few meetings of "4A" ("Alcoholics and Agnostics in A.A."), but they spent too much time talking about God. The important thing is not how you define a Higher Power. The important thing is that you don't consider yourself to be your own Higher Power, because your own best thinking found your bottom for you. One sweet lady said her higher power was a radiator in the Mustard Seed, "because when I see it, I know I'm sober."

Sober. A.A. believes there is an enormous difference between bring dry and being sober. It is not enough to simply abstain. You need to heal and repair the damage to yourself and others. We talk about "white-knuckle sobriety," which might mean, "I'm sober as long as I hold onto the arms of this chair." People who are dry but not sober are on a "dry drunk."

A "cult?" How can that be, when it's free, nobody profits and nobody is in charge? A.A. is an oral tradition reaching back to that first meeting between Bill W. and Doctor Bob in the lobby of an Akron hotel. They'd tried psychiatry, the church, the Cure. Maybe, they thought, drunks can help each other, and pass it along. A.A. has spread to every continent and into countless languages, and remains essentially invisible. I was dumbfounded to discover there was a meeting all along right down the hall from my desk.

The most remarkable things is that the comments are civil. (Even with several references to other paths to recovery.)

Technorati Tags: AA, cult, god

Dogma?

Tim Leighton takes on what he refers to as "Randomized Controlled Trial dogma."

Keep in mind he's writing from the U.K., where the treatment landscape is very different. To be sure, over the years various dogmas (12-step, psychiatrization, moral models, etc.) have stifled progress in effectively treating addictions. Unfortunately, some of the criticism of treatment and the recovery movement seem more like the assertion of a new dogma rather than constructive critical thinking.

What are dogmas for? They are doctrines which safeguard certain interests. People crave dogmatic authority because, as T.S. Eliot said, ‘human kind cannot bear too much reality’.

It is not hard to see what interests might be served by an insistence that only RCTs count as evidence in evaluating interventions for substance misuse problems. First, it saves a lot of time and effort, as this insistence precludes the necessity of evaluating more complex, difficult, often ambiguous evidence.

It serves commercial interests as it offers an opportunity to legitimate your product as ‘evidence-based’; it serves the interest of health-care rationing, as it severely curtails what will be made available; it serves the interest of many researchers and research institutes, particularly psychologists and medical researchers, who are trained in setting up and conducting randomised controlled trials, and who are keen to publish their work. It is much easier to get an RCT published in an addictions or psychology journal than any other kind of research (because of the orthodoxy – this may be changing, gradually).

Our field is in the view of quite a few people in the process of a paradigm shift. I agree. The thing about such a shift is that nobody can predict its exact form or timetable.

Technorati Tags: research, addiction, treatment

Autonomy, mastery, purpose and motivation

Dan Pink gave a talk on motivation and rewards at the TED conference. Of course, his talk has nothing to do with addiction, recovery or treatment. He is talking about management in the business world, not addiction treatment, but one can't help but wonder what lessons could be drawn from this.

He argues that "if/then" rewards work only for very simple tasks. Further, for more complicated tasks, ones that require creativity, rewards actually harm outcomes. He argues that for these more complicated tasks, an approach organized around autonomy, mastery and purpose are what leads to the best outcomes.

It seems like this philosophy would lend itself to motivational interviewing. It emphasizes tapping internal vs. external motivation. At one point he says that rewards are helpful for obtaining compliance but not engagement. If these lessons have any application to addiction treatment, this makes one wonder about the long term value of contingency management. Time will tell, but I found this to be a pretty interesting talk.

Technorati Tags: motivation, addiction, rewards, contingency management

Nevermind the teens...

New analysis from SAMHSA indicates that the drug use trends for boomers are far more troubling than the trends for youth.

Technorati Tags: drugs, boomers, trends, research

Early drinking, genetics and dependence

A new study offers some answers to the questions provoked by studies finding a strong relationship between early drinking and dependence later in life. Those questions center around the nature of this relationship: is the early drinking related to genetic or environmental factors that predispose the person for alcohol dependence? or, does early drinking change the brain in ways that leads to alcohol dependence?

This study determines that "genetic risk accounts in large part for this association."

Technorati Tags: alcoholism, research

More on heroin as treatment for heroin addiction

Mark Kleiman makes an important point about the heroin maintenance study released last week and the flaws in the coverage of the study. (Previous post here.)

John Tierney cites NYT reporter Benedict Carey for the claim that " treating hard-core heroin addicts with their drug of choice seems to work better than treating them with methadone." But neither Carey nor the paper Carey reports on makes any such claim. The study wasn't among "hard-core heroin addicts" generally, but among addicts who had already failed on methadone treatment.

I've devoted a lot of posts to this issue. In spite of what's been suggested in comments, I'm not a one-wayist, but it's hard to see this as anything other than an approach rooted in the idea that these people are beyond help and untreatable. Much of the analysis I've read focuses on social benefits rather than benefits to the individual. When they've tried treating these people with the same methods we've offered physicians and failed, then, maybe, there's a case for experimenting with this kind of approach.

Technorati Tags: heroin, harm reduction, recovery, addiction

Major Mexican reform

They've decriminalized possession of small amounts.

Mexico has enacted a controversial law that decriminalizes possession of small amounts of marijuana, cocaine and heroin.

The law defines "personal use" amounts for those drugs, as well as LSD and methamphetamines.

It says people found with those amounts will not face criminal prosecution, but that if caught a third time they will be required to complete treatment programs, though no punishment is specified to enforce that.

Technorati Tags: Mexico, decriminalization, policy

Drunk driving arrests of women increase

Hard to know what to make of this. It would help if they provided a little context. What are the general trends in drunk driving arrests? In alcohol consumption?

Arrests for women driving under the influence jumped by nearly 30 percent during the decade ending in 2007, according to a study released Wednesday by the U.S. Transportation Department.

I suppose it should be too much of a surprise give we've been seeing increases in binge drinking by girls.

Technorati Tags: alcohol, drunk driving, women

Fraud!

Eric Sterling takes the positions that pot should be legal and that it has medical value but the practice of medical marijuana in California amounts to fraud:

...the ease with which basically healthy persons are able to acquire marijuana in the guise of being ill is offensive. It is hard to avoid judging what appears to be a scam because the scam threatens to produce a backlash or reaction that may result in denying cannabis medicine to those who suffer and should be able to use it. The scam perception creates a another stigma for those who are seriously ill and use cannabis. Stigma one -- you are breaking the law. Stigma two -- you are a scam artist.

Technorati Tags: medical marijuana, legalization, marijuana, pot

Recovery?

Heroin better for addicts in recovery. Really? Recovery? Really?

Here's the abstract.

Raises some interesting questions about the future of the word recovery.

There's been discussion in recent years about being more inclusive with concept of recovery to make room for medication-assisted recovery, serial recovery, partial recovery, 12-step, faith based, secular, solo, etc. To be sure, many had defined it too narrowly. But, at what point does it lose its meaning? Could we get to the point where people using their drug of choice under medical supervision are considered to be in recovery? Is this headline an indication that it is already losing its meaning?

Time magazine had a piece a while ago on Baclofen and the possibility of it turning some problem drinkers into "normal" (nonproblem) drinkers. If it lives up to the hype, (I'm skeptical.) it will be a good thing. But, are those people "in recovery"? They're well, they're better, etc.

This is bound to be a woefully incomplete discussion of the concept (I'm trying to get out of the house.), but I'll get the ball rolling. "In recovery" has taken on a certain cultural meaning for people in and out of recovery--that a person had experienced the devastating and consuming effects of addiction to drugs and/or alcohol and has now organized multiple dimensions of their life around recovering from the illness and the devastation caused by the illness. (Like, say, someone who suffers a heart attack and changes their diet, starts to exercise, takes meds, takes responsibility for monitoring their health, etc.) Does someone who's problem is solved by simply taking a pill qualify? Is it important that there be a label and a distinction?

Technorati Tags: heroin, baclofen, recovery, addiction, alcoholism

I had no idea you felt that way...

From the LA Times:

Of the many things that long-term alcohol addiction can steal -- careers, lives, health, memory -- one of its most heartbreaking tolls is on relationships. Alcoholics, researchers have long known, have a tendency to misread emotional cues, sometimes taking offense when none was intended or failing to pick up on a loved one's sadness, joy, anger or disappointment.

The misunderstandings can result in more drinking, and more deterioration of relationships and lives.

How does alcohol do all that? A new study finds that the brains of long-term alcoholics, even those who have long abstained, often differ from nonalcoholics' in ways that make them poorer judges of facial expressions. In particular, alcoholics register less intensity in the amygdala and hippocampus (collectively known as the limbic system) when observing faces. [emphasis mine]

Technorati Tags: alcoholism, brain

Dawn Farm's kindred spirit

Two acres of hope for recovering addicts

Legal Prostitution in Australia a "Failure"

I wonder if there are lessons here for drug legalization? Maybe not, but what might the unintended consequences be? As I've said, you could change law enforcement priorities without changing the legal status of drugs.

The University of Queensland Working Group on Human Trafficking recently released a report stating that the prostitution laws in Australia had failed.  Since 1999, women in Australia have had the option of working legally in licensed brothels or on their own.  The hope was that women with an entrepreneurial spirit and a passion for commercial sex would set up their own businesses, and make everything safe, legal, and regulated.  That hasn't happened.

What has happened, instead, is entrepreneurial pimps have lured and trafficked Asian women to Australia and set up illegal brothels with lower prices. Trafficking is "booming" in Queensland, and there are few laws to help protect women who are lured or coerced into prostitution against their will. And as legal brothels try and compete with the trafficking boom, they cut costs, which often involves cutting freedom and benefits for women.  Even in the legal, liscenced brothels of Queensland, women have reported being coerced into working under unfair conditions or against their will.

Technorati Tags: legalization

On a completely different note...

This post is a little off topic for this blog, but bear with me.

My family lost my cousin, Matt, to suicide 5 years ago. Matt was a wonderful person. Just weeks away from graduating from Rutgers and had lined up an internship with a major labor union. He was also a musician and had a wicked sense of humor. He left behind many devastated friends and family who loved him dearly and were shocked at his death. He had a bright future and was taken far too early.

I'm asking for your help to prevent other families from suffering this kind of loss.

I will be joining with thousands of people nationwide this fall to walk in AFSP's Ann Arbor Walk 2009 Out of the Darkness Community Walk to benefit the American Foundation for Suicide Prevention. I would appreciate any support that you give me for this worthwhile cause.

The American Foundation for Suicide Prevention is at the forefront of research, education and prevention initiatives designed to reduce loss of life from suicide. With more than 33,000 lives lost each year in the U.S. and over one million worldwide, the importance of AFSP's mission has never been greater, nor our work more urgent.

I hope you will consider supporting my participation in this event. Any contribution will help the work of AFSP, and all donations are 100% tax deductible.

Donating online is safe and easy! Just visit my fundraising page and click the "Support This Participant" button on this page.

Thank you!

Priorities, Priorities, Priorities

Matt Yglesias on drug legalization:

Tactics like the High Point Initiative appear to work as ways of shutting down overt drug markets. If a city can do that in its most problematic areas, the best thing to do seems to me to be to have its police . . . move on to worrying about something else. If people are selling drugs in a manner that’s not a nuisance for their neighbors and doesn’t involve violence, why not turn a blind eye? The knowledge that drug dealers who aren’t making problems for others will be left alone should encourage people to try to find less destructive business models. That’s still a far cry from saying that there should be heroin at the corner store, while CrackCo International hires the top marketing minds and lobbyists in the country to dream up exciting new ways of turning kids into addicts.

Technorati Tags: legalization, enforcement, policy

Neil McKeganey on safe injecting centres

Neil McKeganey thoughtfully shares his ambivalence about safe injecting centers in this video. talks about them as places of despair that, in the existing context, may be better than not creating them. He goes on to talk about what a woefully inadequate response they are and that they do not call for the rest of us to give ourselves a pat on the back.

This is a very good thing

Let's hope he's given the power to align policy research from places like TRI and Lighthouse:

The Senate yesterday confirmed University of Pennsylvania psychologist A. Thomas McLellan as deputy director of the White House Office of National Drug Control Policy.

The vote, by unanimous consent, means that McLellan will be the No. 2 to Gil Kerlikowske, the former police chief of Seattle, who was confirmed this year as the office's director, better known as the drug czar.

McLellan, a leading researcher in addiction and treatment, will be charged with reducing the nation's demand for drugs.

Until his nomination by President Obama in April, McLellan, 60, was executive director of the Treatment Research Institute, a nonprofit he cofounded in Philadelphia 17 years ago to study and compare treatments and to translate scientific findings into clinical practice and public policy.

Technorati Tags: policy, addiction, drugs, ONDCP