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