MDMA therapy

Mark Kleiman sees an opportunity for research on ecstasy for the treatment of PTSD.

Treatment reform in the U.K.

A direct challenge to the U.K. reliance on methadone.

I find it pretty easy to imagine similar circumstances in the U.S. if it weren't for the numbers of recovering people already in the field and the good fortune to have high profile recovery advocates like Senator Harold Hughes and Betty Ford in the right place at the right time.

Another article deconstructs the U.K.'s definition of recovery and offers some context.

In particular, the inclusion of "sustained control over substance use":

...in talking about voluntary exercised control there is a sense in which the thorny issue of drug user abstinence has been effectively sidestepped. But how is control in this context being defined? Does this definition mean that an individual continuing to use illegal drugs but in a more controlled way can be considered ‘in recovery’? Does it matter in terms of evaluating the effect of services if that element of control cannot actually be defined or measured? Does it matter if, as a result of this definition of recovery, we will not know whether the control that is being exercised is increasing, decreasing, or remaining the same over different lengths of time in treatment?

Aside from the difficulty of measuring the element of control, there is also the question of whose definition of control is going to apply in assessing whether the individual is indeed in more or less control of his or her drug use – that of the drug user, the doctor, or the addict’s family? Also what happens if these people disagree in terms of their assessment of how much control the individual is indeed exerting over his or her continued drug use?

Also the inclusion of "health and wellbeing and participation in the rights, roles and responsibilities of society":

These are grand terms, but what exactly do they mean? Do they mean that drug treatment services need to be enabling drug users to become good parents, to find work, to be housed, to vote, to understand current political issues, to be happier in themselves, to have better relationships with their families and friends, to not commit crime, to be greener in their lifestyle?

The list is potentially endless of the things that drug treatment services could see themselves doing which are all cumulatively about maximising an individual’s sense of health and wellbeing. But how well placed are drug treatment services to take on these additional challenges when they have found it so difficult to take on the challenge of enabling individuals to recover from their drug dependence?

I might have worded it differently, but this emphasis on recovery as something that is holistic is important. Addiction tends to infiltrate every aspect of the addict's life and it is not always self-correcting once abstinence is achieved. Good treatment and recovery support services must be prepared to address employment, family life, physical health, mental health, community involvement, etc. It is overwhelming, and we don't have to do it all ourselves (Much of it can be achieved through coordination of services--not just passive referrals.) , but the alternative is a system that fails and loses the confidence of addicts, their families, other professional helpers, and the public.When this confidence is lost, the stage is set for criminalization or a system that relies on methadone.

Dutch drug law changes

From Marginal Revolution:

1. As of July 1, the Netherlands will ban smoking in public places.
2. The smoking of cannabis and hashish, however, will be allowed, at least in licensed cafes.
3. The regulation will be that adding tobacco to the smoke (a popular practice) will be forbidden and that only "pure pot" will be allowed.

More here.

Kicking methadone in the U.K.

A great story of recovery and the professionals who didn't believe that it was possible. We get calls from people with the same experience here in the U.S., they want to get off methadone and the clinic treats it as noncompliance. They often feel that their only options are to get back on heroin or con a doctor into an opiate prescription, switch to the heroin or opiate Rx, and then detox themselves from the heroin or Rx opiates.

...I decided to look into rehab options. I met with my CAU key worker, explained that I wanted to get off the methadone as I wasn't using heroin anymore, and go to a rehab, I was told in no uncertain terms that she thought I wasn't ready for rehab and the local authority wouldn't be funding it.

As it happens that was probably for the best as I found a rehab myself, funded by housing benefit in Cardiff, that had a place for me. So I left hospital and went straight into LivingStones Rehab. I wanted to discuss reducing my methadone, so at this point I went to see my key worker again, really chuffed to be able to give my first negative urine sample(negative for heroin), She said that's great but I'd like to increase your methadone dose, just in case. I couldn't believe it, why raise it? I'd stopped taking heroin, was in a stable environment, with support and they wanted to raise my dose? After a lengthy discussion, she agreed to not increasing it but would have none of it when it came to talk of reducing it.

So I decided to write my own reduction plan, as I was on weekly pickup it was possible for me to measure it myself and discard the remainder. I decided on 10% drops every week, until I was completely off it. I let my key worker know my plan, accepted the flack she gave me and got on with it.

Every time I went in for an appointment after that I ended up being chastised for reducing myself,it was going smoothly but she still wouldn't agree to reducing as I wanted and would only drop it to the level I was on that day, so by the next week I was having to measure it and throw away the excess again. No matter what I said or how I explained it, the CAU would not reduce it for me, worse than that they put every barrier possible in front of me. This went on for months, in fact it wasn't until I was on 8ml/day that they realised I was serious about coming off methadone for good and actually started to reduce it for me when I asked.

Alcohol,The Brain & Insulin

One explanation for "wet brain"?

Teens Who Abuse Alcohol Or Drugs Are More Likely To Die Young

More reason to take teen drug use seriously. (Just don't hype it.)

"The fact that these were, to an extent, predictable deaths raises additional concerns about the hazards of alcohol and drug problems in teens and young adults," said Duncan B. Clark, M.D., Ph.D., associate professor of psychiatry and pharmaceutical sciences at the University of Pittsburgh School of Medicine and director of the Pittsburgh Adolescent Alcohol Research Center at the Western Psychiatric Institute and Clinic of UPMC.

Teens who abuse alcohol or drugs are more likely to die in early adulthood, according to a study by University of Pittsburgh researchers published in the current issue of the Journal of Adolescent Health.
...
The researchers studied 870 white and African-American adolescents, ages 12 through 18, recruited from both clinical and community settings. The subjects were followed for up to eight years, starting in 1990.

Among the 870 adolescents, researchers noted 21 deaths, or about 2 percent of the group, at an average age of nearly 25 years. Fourteen of those deaths occurred in males with SUDs, or more than 10 percent of that group. Among African-American males with SUDs, 23 percent had died by the age of 25. Males with SUDs in this study group had a mortality rate far in excess of the rate of 137 per 100,000 reported for young adult males in the U.S. general population.

Socioeconomic status was not a significant predictor of survival time. Causes of death for the young adults in the study ranged from homicide and suicide to drug overdose and motor vehicle accidents.

What drug poses the greatest threat?

This map shows how local law enforcement answered the question, "What drug poses the greatest threat to your area?" Blue is cocaine, red is methamphetamine, amber is heroin, and green is marijuana.

This map is from the National Drug Threat Survey. Even though I'm aware of the regional differences in drug use, it's still striking every time I see something like this. I'm surprised that there were not more mentions of heroin.
[hat tip: Addiction Inbox]

Pot potency commentary

A challenge to the ONDCP hype about pot potency. I support policies intended to keep kids from using drugs, but the ONDCP would really help themselves if they were less sensational and more honest. The result of this hype is that kids learn quickly that the ONDCP and CASA are not a reliable sources of information so they stop listening to anti-drug messages--then who are they listening to?

Social economics

Social economists are playing a larger role in drug policy discussions. There may be a lot of good reasons for them to have a place at the table, but this post, while not about addiction, does a great job illustrating why I believe social economists shouldn't be given too much sway.

They offer an intellectually stimulating perspective on many social problems that has the potential to stimulate some creative thinking, but they offer a very one dimensional perspective that seems indifferent to many elements of the social context.

The Historical Essence of Addiction Counseling

It struck me today that so many of the disagreements related to drug policy and services boil down to disagreements about the nature of the problem. Here's Bill White on the historical essence of addiction counseling:

If AOD problems could be solved by physically unraveling the person-drug relationship, only physicians and nurses trained in the mechanics of detoxification would be needed to address these problems. If AOD problems were simply a symptom of untreated psychiatric illness, more psychiatrists, not addiction counselors would be needed. If these problems were only a reflection of grief, trauma, family disturbance, economic distress, or cultural oppression, we would need psychologists, social workers, vocational counselors, and social activists rather than addiction counselors. Historically, other professions conveyed to the addict that other problems were the source of addiction and their resolution was the pathway to recovery. Addiction counseling was built on the failure of this premise. The addiction counselor offered a distinctly different view: "All that you have been and will be flows from the problem of addiction and how you respond or fail to respond to it."

Addiction counseling as a profession rests on the proposition that AOD problems reach a point of self-contained independence from their initiating roots and that direct knowledge of addiction, its specialized treatment, and the processes of long-term recovery provide the most viable instrument for healing and wholeness.

Opioid Maintenance Therapy Saves Lives

It's important to note the context of this finding. When your options are sub-optimal treatment, no treatment, or opioid maintenance, opioid maintenance saves lives. Findings like this get published, and we learn that, in the context of crappy options, which option is the least crappy. This option gets categorized as "the best option" or as an evidence-based practice. No one stops to suggest that, maybe, we should change the context.

Opioid-dependent patients are 13 times more likely to die than their age- and sex-matched peers in the general population. To examine predictors of long-term mortality, Australian researchers conducted a 10-year follow-up study of 405 heroin-dependent patients who had participated in a randomized trial comparing methadone and buprenorphine.

• Overall mortality was 8.8 deaths per 1000 person-years of follow-up (0.66 during opioid maintenance treatment and 14.3 while out of treatment).
• Each additional opioid maintenance treatment episode lasting more than 7 days decreased mortality by 28%.
• Subjects who were using more heroin at baseline had a 12% lower mortality rate overall, likely because they spent more time in opioid maintenance treatment.

Comments:
Often overlooked in the controversy over opioid substitution therapy is the reality that opioid dependence has a high fatality rate. The current study highlights that opioid maintenance treatment saves lives. The selection of the treatment episode as greater than 7 days strongly suggests that opioid maintenance, not detoxification, reduces mortality. The time is right to promulgate opioid maintenance therapy with either buprenorphine or methadone as the standard-of-care, first-line treatment for opioid dependence.
Peter D. Friedmann, MD, MPH

Reference:
Gibson A, Degenhardt L, Mattick RP, et al. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction. 2008;103(3):462–468.

This weed is the sh*t!!!

Literally. Salmonella too!

More on recovery in the U.K.

UPDATE: The author of the post linked to below believes that she was taken out of context. Her blog appears to be down at the moment. She was responding to this proposed definition of recovery:

‘The process of recovery from problematic substance use is characterised by voluntary sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.’

I believed that this would have been clear in the context of this blog (The previous post was on this subject and provided the definition.) and the link back to her blog. My apologies if this wasn't clear.

--------------------

A harm reduction advocate in the U.K. wrestles with the idea of a system organized around recovery:

So, hang on, if I'm a substance user who voluntarily controls my own substance use but who chooses not to have participation in the "rights and roles and responsibilities of society" I can't be in recovery? Who says so? What you going to do? Make voting and working and watching Eastenders mandatory for all ex users? Recovery is what I define it as.

Or say I want to participate in the "three R's" of society but every 6 months or so I have a binge. Am I not in Recovery? Don't I have any say in deciding that?

For me, defining Recovery as a process to be controlled by the individual, but then imposing a whole set of values and outcomes upon what "characterises" that recovery is to miss the point. You have to let me judge what my Recovery is. It is not up to you to normalise me. These are my choices, my hopes and my decisions. You make them yours, then you do exactly what those early mental health activists feared. You create "a cosmetic initiative that maintains the dependence of individuals on the system".

I suppose I understand the apprehension, that a recovery-oriented system just being a new set of parameters for doing the same old thing--controlling people. We've certainly had the experience of seeing systems earnestly describe themselves as recovery-oriented when, in practice, they still blame clients for the client's "failure to change" when, in truth, the system failed to provide the support the client needed. Also, there is some history of recovery advocates (before they were called recovery advocates) imposing one narrow path as THE way to recover.

Before I get into my reactions, let me say that I mean no disrespect. I see her blog post as a constructive attempt to articulate her concerns rather than dismiss or attack.

However, there's a way in which I bristle at the statement above. I think it paints a caricature of recovery advocates and addicts. The statement suggests that those who advocate recovery may be invested in forcing some sort of conformity onto addicts. I also believe that it hints at a view of addiction of a nonconformist lifestyle choice rather than an illness characterized by loss of control. The truth, in my experience, is that they're suffering terribly due to their addiction and often don't dare to hope for recovery. Once we impart some hope for recovery, (by offering success stories, hope-engendering relationships, respect and love) they want recovery. They may be concerned that we're asking them to give up their identity and become conformist but this is quickly dismissed by experiencing the recovering community first hand--it could hardly be characterized as conformist.

My response to the concern would be that a recovery-oriented system doesn't force anything, Can a client choose to use every six months and consider themselves in recovery? Sure. They're free to do whatever they want. Would I consider this recovery? If the binge is unintentional, I might characterize this as serial recovery but continue to work toward a more stable recovery. If the binge is planned, ("I'll just go on a binge once every 6 months!") I suppose I would not consider that recovery. I believe that part of recovery is participating in self-care to maintain recovery. However, if a person is capable of "tying one on" once every six months in a way that does not create problems in their life, I wouldn't consider that person an addict. My reaction is not some sort of moral reflex. I'd have the same reaction to a diabetic who goes on a sugar binge every six months and lands in the hospital. That person would not be in recovery from their diabetes. Now, does my judgment that this hypothetical is not recovery mean that I would try to coerce the client into my definition of recovery or abandon them? No. My response to this would be to try to be a fellow traveler and recognize that this is the client's journey.

Recovery is all about freedom. The freedom to live one's life in the way one chooses without being a slave to addiction or being controlled by treatment or criminal justice systems.

That is not to say that we cannot as professionals, service users and policy makers do what they did in mental health and begin to explore what we need to do to support Recovery, to define the conditions in which opportunities for people to achieve Recovery are optimised, or to find new ways of working which return the power to the service user and rebalance old inequalities. This is how Recovery became the dominant philosophy in the UK mental health field. I spent some time with an old friend last week who has spent years as a service manager working towards Recovery oriented mental health services. She told me that in the late 90's and early part of the century Recovery rapidly gained credence in mental health. Through the work of user groups and coalitions, the developmental work of NIMHE and other organisations across the field, and through live projects and action research, consensus was built around the Recovery model. She said the biggest challenge she faced was in changing the staff culture. No longer were people there to make decisions for people, to impose their will on people or even to ‘lead by example’. Staff had to find a new role, one that was about first of all helping people define their own ideas of what Recovery would mean – whether that was feeling completely well, or finding something they owned and understood in their own experience of illness (for example having a positive experience of hearing voices). But once that challenge had been dealt with, she said the battle was not over. Key for the success of the Recovery model was the ability of staff to empower service users to access the help and support they needed in the community.

This is the key. We've struggled mightily with maintaining a professional culture that is focused on recovery. It often conflicts with human nature and the instincts of professional helpers, so we have to accept that it will be a constant struggle. On the subject, we contributed to this paper.

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
  

1000 posts

My last post with my 1000th post. This blog started out as a way for me to share information with Dawn Farm employees and now has 150 to 300 readers a day. Thanks for your interest.

UPDATE: I neglect to mention that any commentary I make that's worth reading is due to the staff and clients of Dawn Farm. We talk every day about barriers to recovery, great and small, everything from international policy to helping a client in financial crisis get food for his dog.

Thanks for your hard work, thoughtfulness and inspiration. You make it easy to get out of bed every day and join you in helping people not just end their suffering, but transform their lives in truly incredible and inspiring ways.

A very U.K. definition of recovery

‘The process of recovery from problematic substance use is characterised by voluntary sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.’

A definition only a committee could love. Seriously though, it's good that England is re-examining its treatment system, trying to be more client centered, and trying to develop a vision of recovery. Also, I recognize how difficult the task is. Agreeing on a definition of recovery in an organization would be difficult, let alone across organizations and systems.

Two things leap out at me. The word maximize seems to hedge and leave some room for clinical pessimism. The other thing I found striking is the use of the phrase "sustained control". It's hard to imagine an American consensus statement with that phrase. In fact, one of the participants stated, "very uneasy with the words recovery and sobriety – it all sounded very American", bu that they are "words everyone understands." The concepts of powerlessness from 12 step groups, and loss of control from the DSM are pretty widely accepted here. It's worth noting that sustained control could mean abstinence or non-problematic use.

It seems to me that an important determinant of the definition of recovery would be the definition of the problem. My impression is that the disease concept is not widely accepted and drug problems are thought to be lifestyle choices.

Why Is Mom in Rehab?

The New York Times on recent increases in treatment admissions for 40+ year old women:

The actress Tatum O’Neal was arrested recently on charges of buying crack cocaine from a man on the street near her New York City home. She is a 44-year-old mother of three. She has spent years in and out of drug abuse treatment (which she chronicled in her 2004 memoir), and according to her publicist she will continue to “attend meetings” for drug and alcohol abuse.

Ms. O’Neal illustrates a disturbing trend among those being admitted to substance abuse treatment services: a growing percentage of older women are being treated for harder drugs.

Data from the Substance Abuse and Mental Health Services Administration revealed that the total number of admissions to treatment services from 1996 to 2005 (the last year for which detailed data are available) stayed about the same among people under 40, but jumped 52 percent among those 40 and older. Of the 40 and older group, the rise in admissions among men was 44 percent. Among women, it was 82 percent.

Early Drinking and Adult Alcohol Dependence Increases Among Americans

I've posted before on the relationship between early drinking and dependence later in life. Here's a summary of another study on the subject:

A study of individuals born between 1934 and 1983 found that more Americans began drinking alcohol at an early age over the decades, especially women, and that those who did drink at a younger age were more likely to be alcohol-dependent as adults.

Reuters reported June 9 that researcher Richard A. Grucza of the Washington University School of Medicine and colleagues said that the study doesn't prove that early drinking leads to dependence, "but what [it] does show is that early drinking does not simply reflect a genetic vulnerability to alcohol dependence."

Earlier onset of drinking and increased alcohol dependence in adulthood was true for both men and women, but the changes were more significant in women. Women who were born between 1934 and 1943 began drinking at age 22, on average, while those who were born after 1963 started drinking at an average age of 17. The rate of lifetime alcohol dependence was 9 percent among women born between 1934 and 1943 but rose to 22 percent among those born after 1963.

Grucza noted that while the study found that the decrease in women's average age of first alcohol use and rise in alcohol dependence occurred over the course of a few decades, human "genes don't change in that amount of time."

New Report Finds Highest-Ever Levels Of THC in U.S. Marijuana

It's so hard to believe anything that these guys say. I seem to remember them saying the same kind of thing in 2000. (And, their new chart certainly doesn't support that claim.) One thing that makes this a little more credible is that we're getting similar reports from other countries.

Program Treats Addicts in Health Care

Amazing what happens when you provide treatment in an adequate dose and intensity, and provide long term monitoring.

Family history and alcoholism

It appears that looking beyond parents is important in assessing familial risk for developing alcohol problems.