Drug Legalization and Tax Revenue

Ugghh!

I hate this argument for legalization. I also think it's the wrong way to go about it if legalization were to come to pass.

Think for a moment about the power of the alcohol and tobacco lobbies. (In Michigan it's been impossible to raise liquor taxes.) Think about their marketing power. Think about their place in our culture.

Is that what we want for marijuana?

I fear that capitalism, legalization and out political system are likely to be an ugly combination.

If we were to legalize, I like Mark Kleiman's proposal to keep sale illegal and legalize people growing their own on a limited scale.

Salience

I've posted before about the role of salience in addiction. This is a great illustration:

More on recovery without abstinence

Oops. I meant to add more to that last post and didn't.

The commonly held belief about addiction is that addicts won't seek help without a gun held to their heads. Our experience just shatters that.

I meant to introduce the quote with the statement that Dawn Farm would say exactly the same thing. More than ever, I have faith that, given a menu that includes good options, addicts will migrate toward recovery--whatever that looks like for them. Some may be able to quit heroin and continue to drink while achieving the same quality of life as another who chooses to abstain completely. I believe that the former person is the exception to the rule and that it's a risky experiment--if this path doesn't work, they may not survive or their illness may progress in a manner that makes it more difficult to stabilize and achieve recovery the next time around. However, if a person chooses to pursue this path after reviewing the risks, it's their choice to make. What I fear is programs or systems that don't offer hope for recovery, don't offer accurate information, don't offer treatment/support of adequate duration and intensity and celebrate any positive change without encouraging addicts to keep moving in the direction of full recovery--whatever that means to them.

Recovery without abstinence

I'm not about to start recommending this as a path to recovery, but I really like the tone of this guy. Fascinating story.

The commonly held belief about addiction is that addicts won't seek help without a gun held to their heads. Our experience just shatters that.

The book that started it all

"more than 5 pounds"

only $13 a pound! 

That's cheaper than Starbucks Anniversary Blend!

Let's hope they offer a cheaper version in the near future. (They offer a more expensive version.)

Social network mapping and recovery facilitation

This begs some fascinating questions.

Could targeting specific roles in the culture of addiction bring others into recovery with them--a kind of domino effect?

How many of your friends drink alcohol? How many might say they used alcohol problematically? What about illicit drugs? Probably a smaller proportion of the people you know take drugs, but perhaps a few have experienced problems with drug use at some point in the life.

For the 160 current and former drug users who took part in the RSA’s User-Centred Drug Services Project survey, answers to these questions are, I presume, rather different to yours. ...30 per cent said that all of the people they know use drugs, with most of them using problematically. Similarly, around a third reported that all of the people they know used alcohol, and around half of them had problems because of it.

...The average probability of smoking, for example, is found to be 61 per cent higher if a friend smokes (one degree of separation), 29 per cent higher at two degrees of separation, and 11 per cent higher at three degrees of separation.

A recent RSA paper on problem drug use suggests that recovery may be ‘contagious’ in the same way. This is an important insight, but problematic: if all of the people you know take drugs, how do you get out of this networked influence that entrenches drug use? A study (external PDF) of drug user networks in Connecticut found that, on average, 85 per cent of the people in a drug user’s personal social network (or ego-network) used drugs. Piecing together the community-wide drug using network, the researchers found clustering of drug users into African American, Puerto Rican and White communities. Interestingly, the mapping also revealed who the key influencers were in the drug using network;  those ‘nodes’ at the centre of the network most strongly connected to large numbers of other users.

The RSA is extending its work on drugs to look at how we might similarly map drug using networks in Peterborough, with a view to identifying and working with these potential ‘recovery champions’ to transmit recovery through the network. There is good reason to try this: intervention programmes to tackle smoking and alcohol use that deliberately employ peer effects and social network ‘modification’ are found to be more effective than those that do not.

Stigma Unaffected by Acceptance of Disease Model, Study Finds

This doesn't surprise me. So much of what fuels stigma is fear. Calling addiction an illness or disease doesn't really get at the question, "Am I and my loved ones safe with you around us?"

Psychiatric fads

Allen Frances, Chair of the DSM-IV Task Force, deconstructs the  phenomena of psychiatric fads:

To become a fad, a psychiatric diagnosis requires 3 preconditions: a pressing need, an engaging story, and influential prophets. The pressing need arises from the fact that disturbed and disturbing kids are very often encountered in clinical, school, and correctional settings. They suffer and cause suffering to those around them--making themselves noticeable to families, doctors, and teachers. Everyone feels enormous pressure to do something. Previous diagnoses (especially conduct or oppositional disorder) provided little hope and no call to action. In contrast, a diagnosis of childhood Bipolar Disorder creates a justification for medication and for expanded school services. The medications have broad and nonspecific effects that are often helpful in reducing anger, even if the diagnosis is inaccurate. 

The "epidemic" of childhood Bipolar Disorder fed off the engaging storyline that it: 

1. Is extremely common
2. Was previously greatly under-diagnosed
3. Presents differently in children because of developmental factors
4. Can explain the variety of childhood emotional dysregulation
5. Has diverse presenting symptoms (eg, irritability, anger, agitation, aggression, distractibility, hyperactivity, and conduct problems)

The prophets were "thought leading" researchers who encouraged child psychiatrists to ignore the standard bipolar criteria and instead to make the diagnosis in a free-form, over-inclusive way. Then enter the pharmaceutical industry-- not very good at discovering new drugs, but extremely adept at finding new markets for existing ones. The expanded reach of childhood Bipolar Disorder created an inviting target. The bandwagon was further advanced by advocacy groups, the media, the internet, and numerous books aimed at suffering parents. 

[hat tip: David Mee-Lee]

Hope

This comment on a previous post caught my attention:

Drugoholism is a field, a combination of various processes, internal and external. "As the twig is bent the branch doth grow." is an old adage. I have realised that IN PRACTICE this is true for many. At times the only PRACTICAL solution, apart from the exceptional few is amelioration.

I'm reminded of this post from a few years ago:

Ideas like this are rooted in despair, rather than hope. (see here, here, here) We get overwhelmed by the problem. (here) We're too cheap to offer adequate help. (here) We don't believe that these people can recover. We think they have no chance. We're scared that they'll hurt us and get us sick. (here)  So, we offer them these kinds of interventions. Often, these programs represented in the name of choice, (here) when, the addicts themselves, want better from us. (here, here) They actually want to get well, but often lose hope that it's possible for them. The system starts patting them on the head an encouraging them to be more realistic. (here, here, here) What they need from professional helpers is for us to lend them our hope to cultivate some of their own. (here, here) They need a system that stops talking about if they recovery and starts talking about when they recover. (here)

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

Smoking and recovery

PeaPod just posted on one of my pet causes--smoking among recovering people.

The situation is very similar in the U.S. and we are trying hard to address this within Dawn Farm for a few key reasons:

• In Michigan, 23% of the population smokes while 85% of our clients smoke.
• Addicts and alcoholics have a harder time quitting than other smokers.
• Addicts and alcoholics experience greater physical harm from smoking than other smokers.
• Quitting smoking at the initiation of recovery is associated with improved treatment outcomes. Quitting smoking is good for recovery.
• 15% of nonsmokers who enter programs that allow smoking become smokers by the time they leave treatment.   

One of our handouts is available here.

A slidecast is available here.

Ecstasy, meth and marijuana

New drug use survey findings.

Stuck on ... dopamine

In attempting to explain attention and ADHD, Jonah Lehrer explains dopamine's salience function:

But the caricature of dopamine as simply the chemical of hedonism is woefully incomplete. For instance, studies have shown that the dopamine reward pathway is also extremely active when people are forced to eat something disgusting, or when a subject is gasping for air after holding their breath. These are intensely unpleasant experiences, and yet our dopamine neurons are pumping out neurotransmitter. This leaves two possibilities: 1) We are all secret masochists, and take pleasure in pain or 2) Dopamine is really about attention and motivation, and is not just the chemical of pleasure and rewards.

I don’t know about you, but I’m betting on hypothesis number two. I think there’s a growing body of evidence suggesting that the real purpose of the dopamine is to help us efficiently assess the outside world. Many dopamine researchers, for instance, refer to the chemical as our “neural currency,” since it allows us to quickly assign a value to the multitudes of things and ideas we perceive. (In other words, dopamine is the price tag of sensory information, and it attaches hefty prices to things that are delicious, beautiful, or reflect some urgent homeostatic need.) When we see something we want  - and it doesn’t matter if it’s a chocolate cupcake or a glass of water – the mere sight of the object triggers a wave of emotional desire, which motivates us to act. (Emotion and motivation share the same Latin root, movere, which means “to move.”) The world is full of possibilities, and it is our dopaminergic urges that help us choose between them.

Put simply, dopamine's salience function makes certain stimuli nearly impossible to ignore.

Previous posts here.

Is abstinence best? redux

The link I posted to Peapod's post about abstinence prompted a few comments on this blog and several on Wired In.

Many of the comments could be summarized as, "abstinence is best for some, for other's it's not."

I think this misses the forest for some of the trees.

The real questions is, in general, what goal should the treatment system treat as the ideal, achievable outcome--abstinence or maintenance?

To me, if the choice is between elimination of symptoms or management of symptoms, the choice is clear.

To be fair, a maintenance advocate might reframe the question this way, "which treatment is likely to lead to the most improved quality of life for the most people?"

I think, as Peapod pointed out, Laudet's research responds to this question:

“We conducted a study among former substance users, the Pathways Project, to examine the question. 289 participants had had a severe history ofDSM-IV dependence to crack or heroin lasting on average 18.7 years, and had not used any illicit drugs for an average (mean) of 31 months when they entered the study. They were asked to select the statement best corresponding to their personal definition of recovery – 86.5% endorsed total abstinence (Laudet, 2007).

Because the treatment system in the US is strongly influenced by 12-step ideology (McElrath, 1997), we repeated the study in Melbourne, Australia, where the approach to substance user services focuses on a harm-minimisation ideology. Australian participants were also people who had experienced a long and severe history of dependence, mostly to heroin, but who had not used any drugs recently. 73.5% of Australian participants endorsed total abstinence from both drugs and alcohol as their personal definition of recovery (Laudet & Storey, 2006).”

Further, whenever I'm confronted with a health question (for myself or a loved one), my first question is this, "what treatment do doctors with this problem receive?"

In the case of addiction, the answer to that question is abstinence oriented treatment, recovery support and monitoring that lasts years. And, the outcomes are outstanding.

Why would we focus on a different goal for other populations?

Is abstinence best?

I'm in a time crunch, so no time to write anything about it, but this post from Peapod is a must-read.

Parental drug use and adolescent treatment outcomes

A study of juvenile drug court participants finds one powerful predictor of poor outcomes:

Results indicated that youth whose caregivers reported illegal drug use pretreatment were almost 10 times as likely to be classified into the nonresponder trajectory group. No other variable significantly distinguished drug use trajectory groups.

Meta-analysis of acamprosate

Money quote:

Compared to placebo, acamprosate increased the number of days drinkers stayed abstinent by about 11%, and reduced the odds of their return to drinking by 9% during a 3- to 12-month follow-up period. Combining naltrexone and acamprosate increased the odds of sobriety by 30% — but this drug cocktail had so many side effects that many patients simply dropped out.

A well defended smoker

As a former smoker, I can relate to irritation when my smoking was brought up, but I think it's only going to get worse for smokers in the public eye.

Alcohol first aid

The British Red Cross is recommending that alcohol first aid be taught to school age kids.

Makes sense to include in any first aid course, and looks like it's part of comprehensive first aid education. I like that aspect.

Drug problems and domestic violence screening

This study found that patients with diagnoses related to alcohol and other drug problems were MUCH less likely to be screened for interpersonal violence. Why is that?

Crash course on dopamine and addiction

Crash course on dopamine and addiction:

First, Nora Volkow:


Next, Adam Kepecs: