Addicts are not criminals

An opinion piece arguing for more harm reduction and legalization:

...The answer is to stop treating any of them like criminals.

Decriminalizing or legalizing possession of hard drugs is not a decision to be taken lightly. We're not talking about marijuana, a substance that should be legalized because it does little harm to anyone. But it's explicitly because of the harm it currently does users that we need to reform our approach to heroin.

Study after study tells us that we can't force junkies to clean up; they have to be willing and able to do so themselves. In those cases, the best we can do is harm reduction. And that means pulling them out from underground - from flophouses with dirty shared needles, and back alleys where there's no one to help them when they overdose -- and into places like Insite [Vancouver's supervised injection center].

Reasonable people can disagree on these matters. However, while a few studies support his statement about coerced treatment, most do not. Proposition 36 in California appears to be reasonable compromise.

Vancouver has shortchanged treatment in it's response to drug problems, and Victoria, B.C. is looking at a supervised injection site when it's treatment system is in shambles.

Even if I accept that their motives are based on concern for the welfare of addicts themselves, I have a difficult time believing that there isn't an equal dose of pessimism about their ability to recover.

Most of the addicts we come in contact with would love to recovery. Their biggest barrier is lack of hope. What do we communicate to them when we're willing to invest in a supervised injection site but only give lip service to treatment and recovery support services?

Effects of substance use spans generations

A new study reaffirming the importance of intergenerational transmission of substance use problems:

In a long-term study conducted across three generations, researchers found that substance use in one generation was associated with problem behaviors and later substance use in the following generation. In turn, the substance use in the second generation was related to problem behaviors in the third generation.

The findings suggest that 'not only does parent's substance use affect their children but it also can affect their grandchildren,' study co-author Jennifer A. Bailey, of the University of Washington, in Seattle, Washington, told Reuters Health.

On the other hand, 'the benefits of successful intervention may also echo across generations,' Bailey and her co-authors write, so the findings highlight the importance of interrupting the intergenerational cycle.

Early Alcohol Dependence Linked to Reduced Treatment Seeking and Chronic Relapse

A new study with important implications for early onset alcoholism:

Individuals who become alcohol dependent before age 25 are less likely to ever seek treatment than those who become alcohol dependent at age 30 or older.... They also are more likely to have multiple dependence episodes, of longer duration, and to meet more dependence diagnostic criteria than those who become alcohol dependent later in life.

Study Offers Clues To Brain's Protective Mechanisms Against Alcoholism

A new study offers some possible insight into why some high risk people develop alcoholism and others don't:

In this study, researchers compared the number of dopamine D2 receptors in two groups: 16 nonalcoholic individuals with no family history of alcoholism and 15 nonalcoholic individuals who had a positive family history of alcoholism — an alcoholic biological father with early onset of alcoholism and at least two other first or second degree relatives (parent, child, sibling, grandparent, grandchild, cousin, aunt, uncle) with alcoholism. The latter group was at a very high risk of developing alcoholism. The researchers studied high-risk individuals rather than looking at people with drinking disorders because chronic alcohol abuse reduces the number of dopamine receptors, making comparisons difficult. Participants were scanned with positron emission tomography (PET) and were given two radioactive tracers to assess their dopamine D2 receptor levels and brain glucose — a marker of brain function.

The scans demonstrated high levels of dopamine D2 receptors in the brains of participants with a family history of alcoholism, particularly in their frontal regions — 10 percent higher, on average, than in the brains of those with no family history. These areas of the brain — including the caudate and ventral striatum — are involved in emotional reactions to stress and cognitive control of decisions about drinking.

At Least 17 People Have Died From Fentanyl Drug Overdose In New York City

The tragedies continue. Good to see that NYC heroin addicts are being urged to seek treatment.

For the geeks

First, a study identifying central nervous system proteins affected by alcohol exposure:

Researchers at the University at Buffalo studying the effects of alcohol on the brain, using zebrafish as a model, have identified several novel central nervous system proteins that are affected by chronic alcohol exposure...

"Identification of proteins that show selective changes in abundance after alcohol exposure has the potential to unlock new pathways both for understanding the mechanisms of alcoholism and alcohol toxicity, as well as its amelioration," said Richard A. Rabin, Ph.D., professor in the UB Department of Pharmacology and Toxicology and senior author on the study.

Next, a study exploring the interactions between certain genes and alcohol response:

"These findings suggest that there indeed might be a genetically influenced factor of a possible mildly increased LR to alcohol associated with the two genes that we studied," said Schuckit, "and that may decrease some people's risk for alcoholism slightly."

Schuckit said that these findings will likely change how he approaches his own research in the future. "In the kind of work that I'm doing, I had better evaluate people with those two gene forms of ADH separately, because I think they may wash out the effects of some of the other genes that I'm trying to look for. For the field in general, it's important for researchers to know that there are milder effects of alcohol-metabolizing enzymes similar to what's seen in Asians that might have an effect of slightly decreasing the risk for alcoholism."

He added that the implications of these findings go beyond significance for just researchers. "This is the sort of finding that reinforces the fact that genes impact on your response to alcohol, and impact on your risk for alcoholism," he said. "There are some people who think it's hard to see behavioral problems like alcoholism being impacted by genes, but of course it is, because genes affect what you were like before you took the alcohol, and also genes absolutely impact on how the alcohol will affect you. The clearest example we have of this are the alcohol-metabolizing genes."

Third, a study looking neurocognitive damage from alcohol consumption and the degree to which those problems are resolved with abstinence:

Alcoholism can cause neuropsychological deficits, that much is clear. There is much less clarity, however, concerning to what degree recovery may occur with abstinence from alcohol. New findings indicate that long-term abstinence from alcohol can resolve many - but not all - neurocognitive deficits.

Two reasons quitting smoking is hard

First, this research finding from Yale:

When cigarette smokers first stop smoking the number of nicotine receptors in the brain is significantly higher when compared to non-smokers, which may explain why it is so tough to quit...

Second, the tobacco companies are making it harder for you to quit:

All tobacco brands have been increasing the nicotine dosage in each cigarette steadily during the last six years, says a report from the Massachusetts Department of Public Health. The overall increase has been about 10% during 1998-2004.

Marlboro, the most popular brand, has been steadily raising the dosage in each cigarette. Kool, a popular menthol brand, has had its nicotine dose increased by 20% in six years.

Ethicist says safe-injection sites are obligation

An ethicist speaks up on Vancouver's safe-injection sites:

"In my view it would not be acceptable simply to say 'we don't agree with drug abuse," Somerville said Monday.

"It can't be simply, 'We have a political platform and our platform is nobody is going to be helped in any way in terms of drug addiction behaviour or illness.' That would be wrong in my view."

My impression of the criticism to the safe-injection center is that there are two camps. First, there are those who are indiferent to the fate of addicts and view addiction as a moral failing. The second group (I hope the bigger group.) are concerned about the center as a pessimistic response and wish to see recovery and treatment as the centerpeice of the response to addiction. They want to see more done, not less.

Her statement paints all critics as members of the first camp, unfairly, I think.

"In a lot of the cases we haven't been successful in use reduction," Somerville said. "They're going to use these drugs whether or not we try to stop them. And so the question becomes, 'If that's the case what do we need to do ethically in terms of harm reduction?'"

Haven't we been unsuccessful in harm reduction in a lot of cases? Haven't users of HR services died of their addiction, gotten sick, and made others sick?

Maybe the solution is to provide recovery-focused HR services and increase access to treatment and recovery support services.

NIH Researchers Complete Unprecedented Genetic Study That May Help Identify People Most at Risk for Alcoholism

The human genome mapping project has set the stage for advancing understanding of many illnesses. It's well established through twin and other studies that there are genetic components to addiction. Hopefully this article represents the beginning of similar advances in understanding the multiple genetic factors in addiction.

"Previous studies established that alcoholism runs in families, but this research has given us the most extensive catalogue yet of the genetic variations that may contribute to the hereditary nature of this disease," says NIDA Director Dr. Nora D. Volkow. "We now have new tools that will allow us to better understand the physiological foundation of addiction."

NIDA researchers found genetic variations clustered around 51 defined chromosomal regions that may play roles in alcohol addiction. The candidate genes are involved in many key activities, including cell-to-cell communication, control of protein synthesis, regulation of development, and cell-to-cell interactions. For example, one gene implicated in this study the AIP1 gene is a known disease-related gene expressed primarily in the brain, where it helps brain cells set up and maintain contacts with the appropriate neighboring cells. Many of the nominated genes have been previously identified in other addiction research, providing support to the idea that common genetic variants are involved in human vulnerability to substance abuse.

Relapse often part of alcoholic's recovery

Here's a pretty good article on relapse and addiction as a chronic illness. It manages to avoid the typical "relapse is part of recovery" or "it's a relapsing illness."

Failing the addicted

Here is a tough article on the failure to serve addicts in Victoria, B.C. and a tougher column on the same subject.

These articles could be written about any community in southeastern Michigan.

Here are highlights from both pieces:

The Vancouver Island Health Authority has failed in its responsibility to provide addiction services, we suggested Saturday, and its failures have increased the homeless and panhandling on Victoria's streets...

The Archie Courtnall Centre, where Barale had been based, was opened almost two years ago to provide short-term services for all psychiatric patients needing urgent help. Instead it has been swamped with those struggling with addictions.

Those patients need to be stabilized and then referred to detox and treatment centres. But VIHA has only seven adult detox beds in the capital region, not nearly enough treatment spaces and no supported residential beds to help them stay sober, Barale says. (VIHA plans to open 30 supported residential living beds for people dealing with mental illness and addiction in the region this year.) The critique is damning and credible.

The concerns have all been raised by others, including the terrible cruelty involved in turning away addicts seeking treatment knowing that the result will be continued drug use.

Strung out on cocaine or crystal meth, they pile up in the comfortable waiting room chairs of the new Archie Courtnall psychiatric facility and wait for help.

Psychiatrists say they aren't qualified to deal with these patients' addictions, homelessness or diseases, and can't cope with their numbers. But they don't know what else to do.

"It's unethical to discharge them," Dr. Anthony Barale, departing clinical director of the Archie Courtnall Centre said Wednesday.

With only seven Victoria adult detox beds, which often have a waiting list, Barale said psychiatrists don't have anywhere to send the unexpected flood of addicted people.

When social workers and nurses can't find facilities in town to place the addicted patients, Barale said he just breaks the rules and lets them stay.

"We let them detox here, spend five, six, seven days even though the [four] beds are three-day placements [intended for the mentally ill]."

Sometimes these individuals just sleep or "wear it off" while sitting in the waiting room. Some are put in the facility's two secure rooms designed for mentally ill people who may harm themselves or others.

Rocks and Powder: Will Congress Fix Drug Sentencing?

A few weeks ago I wrote a post about a new bill designed to reduce the disparity between sentences for crack and powder cocaine possession.

Slate.com has a new article that focuses on the inter-branch governmental significance of the legislation. It provides some good background. Here are the highlights:

The 100-to-1 penalty ratio dates from 1986, when lawmakers established mandatory minimum sentences in response to widespread fear of a crack epidemic. For years judges have railed against the heavy crack sentences as unfair, and Congress has considered amending them before. What's different this time is that the judges are doing more than complaining. Seizing on a Supreme Court decision that expanded their discretion over sentencing, judges have justified less harsh punishments for some crack offenders by trumpeting the sentencing scale's many faults. And rather than ignoring the judges or trying to silence them, Congress may actually be listening, for a change...

Federal judges have long blasted the 100-to-1 ratio for punishing street-corner crack peddlers more harshly than major powder traffickers. But the biggest judicial gripe has been that the disproportionate penalties treat African-Americans unfairly. Blacks account for 80 to 90 percent of defendants convicted of crack offenses; whites and Hispanics for more than 70 percent of powder offenders. In 1992, one federal appellate judge said that the 100-to-1 ratio "makes the war on drugs look like a 'war on minorities.' "...

Then last year the Supreme Court issued a blockbuster ruling on sentencing, United States v. Booker. In Booker, the court found that mandatory sentencing guidelines violate a defendant's constitutional right to a jury trial (by requiring courts to assign a sentence based on facts found by judges, after the jury has issued a conviction). The federal sentencing guidelines, mandatory since they went into effect in 1987, became merely "advisory." Many trial judges saw Booker as authorization to renew the attack on the 100-to-1 ratio because of its impact on black defendants...

But three appellate courts around the country have refused to go along. They have thrown out the reduced sentences for crack offenders...

The proposed change to the crack-vs.-powder sentencing scale doesn't reflect a newfound lenient disposition. Recalibrating the 100-to-1 ratio is an easy call because the crack penalties have become an embarrassment. Still, it's nice to see a group of Republican and Democratic lawmakers taking a cue from the judiciary. The legitimacy of both branches is enhanced if they are seen as engaging each other rather than constantly clashing.

If you have any doubts about the importance of the issue, here are some highlights from an earlier post:

• Federal prison inmates whose most serious conviction was a drug crime rose from 4,749 in 1980 to 77,867 in 2004. (1540%) Source: Maguire, Kathleen and Ann L.Pastore, eds. Sourcebook of Criminal Justice Statistics. Available: http://www.albany.edu/sourcebook/ [Retrieved 7/3/05].
  
• State prison inmates whose most serious conviction was a drug crime rose from 19,000 in 1980 to 246,100 in 2001. (1195%) Source: Prisoners in 2002 & Prisoners in 1994, Bureau of Justice Statistics. Available: http://www.ojp.usdoj.gov/bjs/pubalp2.htm#Prisoners [Retrieved 7/3/05]
• Jail inmates whose most serious charge was a drug crime rose from 20,420 in 1983 to 155,249 in 2002. (660%) Source: Maguire, Kathleen and Ann L.Pastore, eds. Sourcebook of Criminal Justice Statistics. Available: http://www.albany.edu/sourcebook/ [Retrieved 7/3/05].
• From 1986 to 1999 the average term drug offenders entering prison could expect to serve rose from an average 30 months to 66 months. (120%) Source: Federal Drug Offenders, 1999 with Trends, 1984-99, Bureau of Justice Statistics. Available: http://www.ojp.usdoj.gov/bjs/abstract/fdo99.htm [Retrieved 7/3/05]

Cutting Alcohol's Cost

From Forbes:

What is striking is that the GWU researchers don't recommend counseling only alcoholics, who require years of treatment, but also people who aren't addicts but simply drink too much.

"Since there are so many more people who drink in hazardous or harmful amounts, about 60% of the costs of alcohol to society are from people who are not dependent," says Eric Goplerud, who heads an alcohol abuse program at GWU called Ensuring Solutions. "There are people who drink even though they have sore stomachs, or drink and get into a fight and get hurt or engage in unprotected sex."

Each year, alcohol abuse costs the United States an estimated $185 billion, according to the National Institute on Alcohol Abuse and Alcoholism. But only $26 billion, 14% of the total, comes from direct medical costs or treating alcoholics. Almost half, a whopping $88 billion, comes from lost productivity--a combination of all those hangovers that keep us out of work on Monday mornings, as well as other alcohol-related diseases.

The distinction that this article makes between dependence and misuse is rare. It's easy to hear reports about substance abuse, drug abuse and alcohol abuse and assume they are talking about addiction. You find the same thing with articles (even research) about co-occurring problems. (Ex. - 20% of people with [fill in the blank] also have alcohol problems.)

There's a big difference! The implications for the cause, pattern, duration and intervention are huge. Keep an eye on those terms and don't make assumptions.

Chanting the mantra of harm reduction

About midway through the International AIDS Conference, Dr. Mark Wainberg, the bookish-looking AIDS scientist from Montreal and the meeting's co-chair, found himself in the thick of a chanting demonstration of prostitutes.

As the sex workers and their supporters, including a statuesque Indian transvestite, shouted out for legalization, Dr. Wainberg shouted along. As they punched the air in defiance, the respected microbiologist punched, too.

At this massive and extraordinary conference, supporting such causes is almost compulsory. As is speaking out for the rights of injection drug addicts, lamenting the plight of the overlooked transsexual and tolerating promiscuity, so long as that multiple-partner sex involves condoms.

I keep telling myself that I will lay off the HR stories for a while, but I can't stop myself from sharing stories like this. This was the International AIDS Conference and it gives an important peek into who drives drug policy discussions. With the drug warriors and these people dominating drug policy discussions, is there any hope?

Recovering people and loved ones of addicts need to step up to promote humane, recovery-oriented policies. I want injection drug user's human rights protected too, but a major component of that would be access to recovery and recovery support services.

Mayor Sullivan Wimps out on Drug Treatment

Finally. Someone calls Vancouver's mayor out on his apparent indifference to recovery.

Here's the mayor's attitude toward addiction recovery:

Now, addicts are like me. [Note: The mayor is quadrapalegic due to a skiing accident when he was 19.] They have a disability. And they will always have this disability. It is a waste of time and money to pretend to them and to ourselves that they will ever change. So what we should do is make them more comfortable! Remove the criminality, give them their drugs and let them choose what they do and want to do next.

Yesterday I posted a link to his comments about responding to street begging:

Because most of the people causing trouble in downtown Vancouver are those with drug addictions, said Sullivan, the backbone of his approach to the problem is innovative approaches to drug addiction.

"We know drug maintenance programs have worked fabulously in other jurisdictions to significantly reduce crime and street disorder," Sullivan said.

You may ask why I care about Vancouver when we live 3000 miles away? Well, Vancouver is seen as an innovator in responding to addiction. Local government officials and activists regularly point to Vancouver as a model for responding to addiction and it's manifestations in the community. Our fear all along has been that we'd experience exactly what is happening in Vancouver. In order to win acceptance of the harm reduction programs, lip service is given to treatment and recovery. Once the HR programs are created, momentum for anything else dies. People begin saying that addiction is an unsolvable problem and now that the once highly visible addicts are out of the community's hair, few people care.

It's not that we oppose HR programs in principle. We'd support recovery-oriented HR programs or programs that espouse gradualism. The biggest barrier is the context of the program. You can't have recovery-oriented HR if there are months long waiting lists for treatment and sober housing.

This was the first article in a three part series. The second shares his experience as the director of a treatment program. The third addresses the barriers to creating new treatment programs in B.C.

Crime, Incarceration and Addiction

Nora Volkow (Director of NIDA) has an Op-Ed in today's Washington Post on crime, addiction and treatment.

Psychiatric News has an article about the sad state of treatment for inmates.

Truth about ecstacy's unlikely trip from lab to dance floor

A history of ecstasy's pharmaceutical development and emergence as a misused substance. Dispells some oft repeated urban legends.

Recovery-Oriented Harm Reduction?

Between the 25 anniversary of AIDS and questions about the future of Vancouver's safe injection center, there are tons of articles on harm reduction lately. There's one characterizing opponents of needle exchanges as indifferent to addict deaths, another finding that a crack paraphernalia distribution program cut disease transmission but increased drug use, another proposing drug maintenance programs as a response to street begging, and a few in support of the safe injection center. (Here, here and here.)

These are just a fraction of the articles that have come through my inbox lately. I was thinking this morning about all of this and was experiencing my usual frustration at the consistent failure to mention recovery and treatment (in that order) in these articles. It occurred to me that the article Jim and I wrote a few years ago was really a call for recovery-oriented harm reduction. This should be non-controversial, no? I suppose that the big point of contention is that we have a big prerequisite--community conditions that support recovery.

Underage Binge Drinking Lowest in Areas of D.C., Detroit, Los Angeles, Utah, Tennessee, Maryland; Highest in Parts of North Dakot

I posted a link to this report recently, but I missed the fact that Detroit is one of the regions with the lowest underage drinking in the U.S.

I wonder how the suburbs fared. If my fuzzy memories of high school are any indication, not well.

Bloomberg Puts 125 Million Dollars Into Anti-Smoking

Michael Bloomberg has already been working to reduce smoking and second hand smoke in NYC by increasing tobacco taxes and implimenting smoking bans. Now he's donating $125 million to reduce smoking.

Illicit drug trade fuelling HIV infections

CTV.ca | Illicit drug trade fuelling HIV infections: expert:

There are also a range of drug rehabilitation programs, notably methadone for heroin users, that have proven successful, he said....

Wodak said the United States has the highest incidence of AIDS in the industrialized world, roughly five times greater than second-place Spain, in part because of its failure to control HIV among injection drug users.

Yet the opposition in the United States prevents these pragmatic approaches being spread throughout the world.

While progress is being made in the fight against HIV/AIDS, the disease is still spreading faster among injection drug users than harm reduction programs needed to slow transmission, he said.

To be sure, harm reduction is one important tool to reduce HIV transmission. However, reading this article would lead one to believe that injection drug use is the leading cause of HIV transmission in the U.S.--not true. Injection drug use accounts for 12% of infections and sex with an injection drug user accounts for 3%.

New Alcohol Test Promises Longer Detection Window -- But Not Precision

This new test could be a very important innovation for monitoring alcohol use. Jim King knows quite a bit about it and I'm sure that he would welcome questions.

Methadone survives four decades of tough politics

This article briefly chronicles four decades of public skepticism about methadone.

Bill White and others have argued that methadone has been a victim of unfair bias. It's hard to argue that they are wrong. However, I don't hear methadone advocates reflect on what criticisms may be legitimate. All critics tend to be characterized as irrational. Too often, particularly in southeastern Michigan, methadone treatment's focus is palliative rather than recovery-focused and therefore contributes to despair and stigma.

Exploring the Link Between Substance Use and Abortion: The Roles of Unconventionality and Unplanned Pregnancy

This is an interesting study and it challenges the stereotype that addicts are irresponsible baby mills. The study appears to find that unplanned pregnancy and abortion are related to "unconventionality" rather than substance use. They found that "unconventionality" was also related to substance use. An example of the saying that "correlation does not equal causation."

Addiction and the DSM-V

The journal Addiction has just released a special issue: Diagnostic Issues In Substance Use Disorders: Refining the Research Agenda--Guest editors: John B. Saunders and Marc A. Schuckit

The issue addresses diagnostic issues/controversies such as the impact of neurobiology, the impact of culture, the DSM vs. the ICD, co-occurring disorders, addiction subtypes, and non-substance "addictions." Lots of fun for addiction geeks!

Any DF staff should let me know if you would like reprints of any of the articles.

READERS RESPOND: War on Drugs (Part 1)

From JTO:

We received an unprecedented number of passionate, thoughtful responses to "Mission Accomplished" in War on Drugs? A representative sampling begins below, the first in a three-part series.

More on the "myth of the addict gene"

A reader comments on my last post:

The anti-disease concept crusaders seem to ignore that environmental/psycho-social influences are proven to change the biochemistry of the brain. E.g. PTSD and sexual abuse have been shown to produce some of the same biochemical markers in the brain nake-up and chemistry that are present in addiction so small wonder there’s a correlation.

A lecturer I heard at a neonatal/pediatric pain management conference I attended a few years is a pioneer in neonatal pain research (Dr. Anand.) In one of his rat studies he demonstrated that rat pups exposed to minor but repetitive pain stimuli (i.e. neonatal stress) had many brain changes and associated behaviors as adult rats. One of the brain changes was a marked increase in the NMDA receptors (know to be associated with addiction as well as ADHD) and one of the behavior changes was a MARKED increase in alcohol preference – from 10% in the control to 90% (or as he put it in his melifluously accented voice, “The rats were really hitting the bottle.”) Sure sounds like a brain phenomena to me, whether it’s environmentally and/or genetically and/or otherwise induced.

There clearly is concensus building about the brain being central to addiction. However, the question that I rarely see address is this--assuming that addiction is a brain problem, are addicts born with a different brain, or is it created by drug use, life experience, etc?

My biggest problem with the trend I addressed in the previous post is the motives of the critics. If you're offended by the war on drugs, attack that. If you want social mores and policy to create space for social drug use, make that case. It's not neccesary to attack the disease model to make their case. (I've got the same problem with people who characterize all excessive drug or alcohol use as a disease.) If they really question the disease model on scientific evidence, by all means, speak up. However, I suspect that too often there are other motives.

AlterNet: DrugReporter: The Myth of an 'Addict Gene'

The alternative liberal media has been running more and more articles like this one about the "myth of the addict gene." I suspect that there the following are at least a few reasons for these criticisms of the disease model, 12 step recovery, and any legal restrictions on drug possession or use:

• First, there is a strong anti-drugwar sentiment. Many of these writers and activists are rightly horrified by the appalling increases in incarceration for drug offenses. They want to shift policy toward harm reduction and decriminalization of drug use and possession.
• Second, there is anger at social mores and drug policy that characterizes all drug use as pathology and/or criminality. I'm of the opinion that they go too far in the other direction and seek to characterize all drug use as a lifestyle choice.
• Third, there is suspicion of 12 step group's spirituality.
• Fourth, there are privacy concerns about all genetic testing.

There's a way in which the article is a straw man argument. I don't know of anyone who argues that there is a single gene that wholly determines whether one becomes an addict. We know from twin studies that genetics play an important role in the etiology of addiction. Evidence that addiction is a brain disease continues to grow, as well as evidence that multiple genes are involved. Even advocates of addiction as a purely biogenic problem would concede that environmental factors influence the onset, course, severity and treatment response of addiction.

Oliver Stone's movie and how the 9/11 rescue really happened

This article about Oliver Stone's 9/11 movie tells an interesting story that didn't make it into the movie. Recovery is everywhere:

Whatever the filmmakers' reasons, they missed one of the more remarkable aspects of this rescue story. Chuck Sereika, a man with no training in collapsed-building rescue and extrication, risked his life that day for men he had never met. Sereika said he was sure he would die when he crawled in. Unlike the police and firefighters who without hesitation sacrificed everything—and I in no way discount their selfless acts—Sereika was not called to duty by his unit. He arrived on his own accord. He was a paramedic, but his license had expired and he had left that life behind as he sought treatment for addiction problems. But he grabbed his medic sweatshirt and his cell phone and headed down to Ground Zero to see if he could apply a few splints or perform minor triage. He never imagined that he would be involved in one of the few and most memorable rescues of Sept. 11.

Substate Estimates from the 2004 NSDUH, SAMHSA Office of Applied Studies

This document looks at drug and alcohol use by 340 regions withing the U.S. I've skimmed it and here are a couple if interesting findings:

• Of the 15 regions with the highest rates of illicit drug use, three are in Michigan.

• The region with the highest percentage of people consuming alcohol is Washington D.C.'s wealthiest ward. (politicians?)

Challenge one: Deciding to fight addiction Challenge two: Paying for it

This is another article in the Silent Treatment series that I linked to earlier this week. This article discusses the erosion of insurance coverage for treatment. Unfortunately, it doesn't address the barriers facing uninsured addicts.

Demystifying CBT: Effective, easy-to-use treatment for depression and anxiety

Here is a good primer on CBT for depression and anxiety.

Checkup System Catches Relapse Early and Facilitates Return to Treatment

This is an important article that supports our approach of maintaining engagement and reconnecting clients with services when it's needed:

Supplementing regular recovery checkups with motivational interviewing and active linking to treatment can get relapsing patients back into treatment sooner and help them stay longer, report NIDA-funded researchers. In the 2 years following treatment, patients who received the additional interventions were three times as likely to reenter treatment as others who received assessments only.

Court-Mandated Treatment Works as Well as Voluntary

Regardless of their impetus for participating in drug treatment—internal drive or external pressure—men had similar outcomes in the long term.

This has been found over and over again. It's a big wrinkle in the idea that treatment needs to be matched to the stages of change.

Nicotine shows promise as treatment against Parkinson's disease

Nicotine may be good for something after all.

Imaging Study May Help Point Toward More Effective Smoking Cessation Treatments

This study may help explain why nicotine has the highest "capture rate" of commonly used drugs.

Results of a new imaging study, supported in part by the National Institute on Drug Abuse (NIDA), National Institutes of Health, show that the nicotine received in just a few puffs of a cigarette can exert a force powerful enough to drive an individual to continue smoking. Researchers found that the amount of nicotine contained in just one puff of a cigarette can occupy about 30 percent of the brain’s most common type of nicotine receptors, while three puffs of a cigarette can occupy about 70 percent of these receptors. When nearly all of the receptors are occupied (as a result of smoking at least 2 and one-half cigarettes), the smoker becomes satiated, or satisfied, for a time. Soon, however, this level of satiation wears off, driving the smoker to continue smoking throughout the day to satisfy cigarette cravings.

Smoking marijuana in public: the spatial and policy shift in New York City arrests, 1992-2003

This article about marijuana arrests in NYC got a lot of attention yesterday. I recently posted a link to an article bemoaning the state of drug policy research. I conceded that it's a problem but argued that it cuts both ways. This paper is an example of that. It is full of speculation and heavily laden with the ideology of the writers.

For example, they seem skeptical of the quality-of-life policing approach in NYC (often referred to as the broken windows model) and equate it with zero-tolerance. This is a pretty reductionist description that is often used by critics and "tough on crime" politicians. The broken windows approach is a policing strategy that strategically focuses on relatively minor, highly visible offences that contribute an atmosphere of disorder (turnstyle jumping, graffiti, prostitution, litter, etc.). The theory asserts that reducing these crimes will result in reductions in more serious crimes. This approach was used in NYC and is credited with huge drops in crime. The approach was adopted by the transit authority in 1990 and then by the NYC police department in 1993, explaining the study's finding that arrest shifted from the transit police to the NYPD. Critics argue that the NYC drops in crime were during a period where crime dropped nationwide and reductions are due to multiple interacting factors rather than one law enforcement approach. Supporters argue that NYC experienced a far larger reduction in crime than other big cities and that the difference is largely due to the application of the broken windows model. Two books that look at the issue from different perspectives are Freakonomics and The Tipping Point.

At any rate, considering the publication and the tenor of the article, I suspect that they authors are advocates of decriminalization and view marijuana use as a lifestyle choice the the government shouldn't interfere with. Reasonable people can disagree on these issues. (Personally, I'm concerned about potential increases in early exposure and applying Budweiser's marketing strategies to newly legalized marijuana.) I'd hope that the kinds of legal penalties that are enforced are relatively mild (fines?) but I also support addressing public consumption of marijuana.

Bill seeks to cut disparity in cocaine case sentences

Four senators have introduced the Drug Sentencing Reform Act of 2006 which would reduce the disparity between mandatory minimum sentences for crack and powder cocaine:

That disparity in federal sentencing guidelines is currently 100-to-1. It would be reduced to 20-to-1 under a measure introduced yesterday by Republican Sens. Jeff Sessions of Alabama and John Cornyn of Texas and Democratic Sens. Mark Pryor of Arkansas and Ken Salazar of Colorado.

They argue that crack is more dangerous and should be more severely punished than powder cocaine:

The crack/powder sentencing disparity -- which has resulted in higher incarceration rates for blacks convicted of drug crimes -- long has been targeted by groups such as the Leadership Conference on Civil Rights and the American Civil Liberties Union.
In 2000, more than 84 percent of those sentenced for crack cocaine distribution were black, while 9 percent were Hispanic and 5 percent were white. By contrast, 30 percent of those sentenced for powdered cocaine were black, 50 percent were Hispanic and 15 percent were white.

The senators are trying to reduce the sentencing disparity between crack and powdered cocaine, but not remove it.

"Crack is a more dangerous commodity," Mr. Sessions said. Although powdered cocaine is usually snorted, crack is usually smoked. Mr. Sessions said crack is more addictive and causes more paranoia and violence than powdered cocaine.

It's good to see the disparity reduced, but maintaining any disparity makes little sense to me. Historically, we know that societal beliefs about which drugs are dangerous are influenced by factors other than science and objectivity.

Road to recovery

This story is part of a collection of articles developed by a program named silent treatment.

It's a public education project that focuses on raising awareness about addiction, treatment and recovery. They have written a series of stories that they are offering to newspapers for publication. Hopefully we'll be seeing more of them.

College Students Play it Safe: New Study Shows Protective Behaviors Reduce Risk of Injury

This study celebrates the fact that a majority of college students employ "protective behaviors"

The NCHA contains a list of 10 potentially protective behaviors, including alternating non-alcohol with alcohol beverages; determining, in advance, not to exceed a set number of drinks; choosing not to drink alcohol; using a designated driver; eating before and during drinking; having a friend keep track of consumption; keeping track of one's own consumption; pacing drinks to one or fewer per hour; avoiding drinking games; and drinking non-alcohol look-alikes.

If someone showed me evidence, I'd be willing to beleive that concerns about binge drinking on campuses may have been hyped in recent years. But show me some numbers that alcohol related harms have been stable or decreased. The use of these protective factors as an indication of the state of campus drinking is pretty underwhelming.

"Mission Accomplished" in War on Drugs?

Seven previous drug czars say that the war on drugs has been won.

Self-medication?

This study looked at sex, drug use and depression in adolescents:

"Overall, sex and drug behavior predicted an increased likelihood of depression, but depression did not predict behavior. Among girls, both experimental and high-risk behavior patterns predicted depression. Among boys, only high-risk behavior patterns increased the odds of later depression. Depression did not predict behavior in boys, or experimental behavior in girls; but it decreased the odds of high-risk behavior among abstaining girls (RRR=0.14) and increased the odds of high-risk behavior (RRR=2.68) among girls already experimenting with substance use"

Fentanyl-Laced Heroin Demand Reduction Forum - ONDCP

Very disappointing. I was pleased to see that the spate of fentanyl ODs prompted a demand reduction forum. From a quick review of the notes, it looks like this focused on fentanyl as a prescription drug (weren't these people heroin addicts?), pharmacology and interdiction. No discussion of the current treatment shortage.

Drugs and prohibition

A commentary on drug policy as a magnet for bad research.
Very true, research on addiction and drug policy does consistently appear to reflect the biases of the writer. This writer focuses on the anti-drug warriors, but the problem clearly runs in both directions and right that the root of the problem is people reductionist approach the problem, usually in a way that's suited to their worldview.

Antidepressant Discontinuation Syndrome

I thought that these articles might be helpful for a lot of you. Both are on "Antidepressant Discontinuation Syndrome." The first is scholarly and the second is a patient handout.

Some skeptical of new anti-drug campaign

This article reports that The Partnership for a Drug Free America has recently started an ad campaign to raise awareness about addiction as a disease and reduce stigma. It's being criticized for characterizing addiction as a disease.

Not a big surprise. The Partnership's message often seems to fuel the drug hysteria that created and maintains the war on drugs. However, this campaign is clearly focused on stigma reduction and appears right on target.

What I found striking in this article was one of the sources of criticism. I expected to see Stanton Peele, he's a frequent, strident and highly visible critic of the disease model. I was surprised to see Ethan Nadelmann from the Drug Policy Alliance, a big advocacy organization that seeks to end the war on drugs be decriminalizing drug use. It is also the country's largest harm reduction advocacy organization. Here's what he says:

"If we define drug addiction as a disease, does that mean that every cigarette smoker has a disease?" asked Ethan Nadelmann, executive director of the Drug Policy Alliance, which seeks to end the war on drugs.

Addiction, Nadelmann said, typically occurs when someone's dependence on a substance causes problems for themselves and others. The line between recreational use and addiction is too open for interpretation in his book.

"Right now some people say one to two drinks a day if you're over 50 is great for the heart," he said. "On the other hand, others say if you need one to two drinks a day, you're addicted."

What reputable expert or organization says that one or two drinks a day means your addicted? What a ridiculous straw man argument! I was surprised to see Nadelmann taking such a public position against the disease model. He usually seems to avoid these issues and sticks to advocating harm reduction and decriminalization. We've always suspected that much of their advocacy work is based on the believe that what we call addiction is really just a lifestyle choice that should be respected.

Recovery From Comorbid Illness More Common Than Expected

Findings from an evaluation of 10-year outcomes show that despite some conventional—and professional—wisdom to the contrary, patients with schizophrenia and substance abuse can recover over time.

Stimulant maintenance is a good beginning

More on the Mayor of Vancouver's proposal to start a stimulant maintenance program.

A new report on ASA discharges

This report provides some analysis of national data about people who left treatment against professional advice in 2003.

Methadone Pioneer Dr. Vincent P. Dole Dies

Methadone pioneer Dr. Vincent P. Dole died this week. It's worth remembering that methadone started out as one component of some comprehensive bio-psycho-social treatment programs. Unfortunately, many (especially in our area) have devolved into dosing clinics that offer no meaningful treatment and no vision of recovery.

Mayor seeks drug maintenance for drug addicts (Vancouver, BC)

The mayor of Vancouver is calling for a stimulant maintenance program. I've heard calls for heroin maintenance programs, but this is the first time I've seen a call from a politician for a stimulant maintenance program.

Vancouver has a "four pillar" response to their drug problem. It's good that they are espousing a comprehensive approach to the problem, but they seem to be much more invested in the harm reduction pillar than the treatment and recovery pillar. These programs are often promote in the name of choice, unfortunately they don't offer any more choices than the abstinence focused programs that they criticize.

Amid heroin deaths, authorities debate drug that stops overdose

At least we're not alone. The fentanyl OD deaths have hit Boston. They're considering distributing naloxone, but not a word about treatment.

U.S. Cigarette Sales Reach Lowest Point in More Than 50 Years

U.S. smoking continues to decline. However, over 85% of our clients smoke, and research consistently demonstrates that it negatively impacts their recovery.

Once-Weekly Opiate Treatment with Buprenorphine/Naloxone Called Effective

Once a week Buprenorhine found effective.

New Recovery Management Monographs

The Northeast Addiction Technology Transfer Center just released two new recovery management monographs. The first is about linking treatment to communities and the second is on building resilience.

IV Drug Users Don't Cope Well When Others Overdose, Study Finds

Here's a summary of a study examining responses to overdoses:

A study of IV drug users in Baltimore found that more than two-thirds had witnessed an overdose. But only two-thirds of those called 911 for emergency medical help, and even then, they delayed making the call by five minutes or more.

Often, witnesses to an overdose tried their own remedies, such as walking the victim around, shaking them or inflicting pain, and one in four injected a home-made solution of salt water in an attempt to reverse the overdose, said Robin Pollini, Ph.D., lead author of the study, which appears in the September issue of the American Journal of Preventive Medicine.

Most witnesses did not call 911 promptly because they thought the victim could be revived without help, but many reported fearing involvement by the police

Two Studies on 12-Step Groups

A new study finds that mentally ill alcoholics and religious skeptics benefit equally from 12-Step Programs.

Another reviews studies on AA and concludes that 12 Step Facilitation is no more effective than other treatment methods. Here's an article providing a little background discussion.

Principles of Drug Abuse Treatment for Criminal Justice Populations

The National Institute of Drug Abuse (NIDA) has just released a now booklet on treating people in the criminal justice system.

Interventions to Facilitate Smoking Cessation

This article provides a good overview of smoking cessation interventions. It's got a handy table that provides information on the evidence base and quit rates for various interventions.

More on methadone

An article I linked to in my last post referred to Neil McKeganey as a critic of methadone. I wasn't sure that was a fair characterization, but this editorial makes it clear that he is a critic. While he's sometimes dismissed as a critic, I haven't seen criticism of the methodology of his studies. This editorial is worth a read. Here's an excerpt:

Methadone will undoubtedly continue to play a role in our drug-treatment services, but not as a drug provided for ever-increasing numbers of users for ever-lengthening periods, with little or no expectation of their eventual recovery.There is in the world of drug-abuse treatment a division between public knowledge and private knowledge, exemplified in the following conversation. I was speaking recently with one of the UK's top medical advisers on drug addiction. We were discussing methadone when he said that if his daughter had a heroin problem, he would do all he could to get her into a residential programme.

"When I am prescribing methadone in my day-to-day work," he said, "I know in my heart of hearts it is not a solution to the individual's drug problem but the only option I have for the majority of addicts I am seeing".

There is a simple truth here but one that is rarely shared, namely that methadone has all too easily become the drug-addiction treatment for the masses. There are no superstar heroin addicts or drug-dependent doctors signing themselves up for long-term methadone programmes. Residential rehabilitation is the gold-standard treatment for those who can afford it or those who are lucky enough to get it on the state.

Our masses, however, need more than the cheapest treatment if they are to live a life that is not dictated by the rhythms of their drug addiction. What they need are fewer drugs and greater support in their attempts at remaining drug free. And that is no quick fix.

Injecting crack cocaine is surprisingly common

While we're talking about a relatively small number of people, I've definitely been hearing more clients report injecting crack cocaine in intake interviews over the last year.

Methadone: Curse or cure?

This article does a decent job of presenting one addict's experience with methadone and a couple professional's opinions on it. Unfortunately the discussion is limited to opinions. One statement that leaped out at me is this:

"I hear that from a lot of health-care professionals too, who don't have a lot of faith in it, you know, because (addicts) want that methadone. But, you know, they're not sticking something in their arm. There's so much hepatitis and HIV out there and it's dangerous. So, maybe it is another drug. The harm-reduction drug works very effectively for the majority of people," she says.

Opposition to it is based on addicts wanting it? That's a pretty reductionist characterization of those who don't have faith in it. It's also based on an assumption that could well be false. A U.K. study found that 60% of methadone clients would prefer to be in abstinence focused treatment.

Anti-heroin project transforms towns

A story about the impact of treatment on a drug ravaged community. It's pretty vague about the treatment provided. I suspect it's methadone but could be naltrexone or buprenorphine.

PRESS RELEASE: Free Site Offers Real Help for Friends and Loved Ones Hooked on Drugs

I saw this press release and wanted to take this opportunity to give you a heads up about press releases like this and the occasional news stories based on them.

I can't confirm it yet, but I suspect that this press release is linked to Narconon (they have a program in Michigan), a treatment program tied to the Church of Scientology. The address was previously used by a Scientology linked business, Scientology has a large base in Clearwater, and the name listed in the press release (although it is a pretty common name) is associated with Scientology.

Narconon and the church issue dozens of press releases like this every year, they also have dozens of websites. Many of these press releases and website appear to hide their association to Narconon and try to get you to call an 800 number. Even when you talk with someone, you can't count on getting straight answers. I once took a call from Stone Hawk and they denied any affiliation or basis in Scientology.

I also see this press release strategy used by Hythiam. The company that has licensed PROMETA, a protocol of prescription drugs and nutritional supplements.

It's easier to be skeptical of a press release, but these press releases are often written as news stories and sometimes lazy journalists or publications will print them with little or no editing.

Pot doesn't lead to heroin

More discussion of the recently published studies on marijuana.

Telephone counselling for smoking cessation

More good news about a simple, cost effective way to help people stop smoking:

Authors' conclusions:Proactive telephone counselling helps smokers interested in quitting. There is evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increases the odds of quitting compared to a minimal intervention such as providing standard self-help materials, brief advice, or compared to pharmacotherapy alone. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness.

Homeless Admissions to Substance Abuse Treatment: 2004

SAMHSA just released a report on homeless admissions to treatment in 2004. No surprises.

• Homeless admissions are up from 10% in 2000 to 13% in 2004.
• Homeless people were more than twice as likely to have ad 5 prior treatment admissions.

State may face dearth of drug and alcohol counselors

A story from Columbus, Ohio on the the coming shortage of addiction counselors.

On the same subject, here's a Bill White article about a coming leadership crisis in addiction treatment.

Homeless Alcoholics in Seattle Find a Home

Here's an NPR story the program that houses drinking alcoholics in Seattle. The story makes it clear that they've given up hope that these people can get better. I'm all for housing them, but put some expectations on the client (participation in some form of treatment and/or mutual aid groups) and keep working to facilitate recovery.

Impact of practitioner's training in the management of alcohol depende

This study finds marked differences in outcomes between doctors with training in alcoholism versus those without. The average amount of training among the group of trained doctors was only 10 hours.

Trained GPs proved better i) in the attempt at abstinence, with 67% patients becoming sober vs. 47% in a comparison sample and ii) in repeat attempt at abstinence in the event of relapse, with an average 2.99 vs. 1.31 attempts per patient.

Companies Must Stop Fraudulently Promoting Laser Therapy as a Treatment to Quit Smoking, Public Citizen Tells FDA

Public Citizen is asking the FDA to prevent the promotion of laser therapy as a smoking cessation treatment. More here.

Help Seeking Quadruples Likelihood of Abstinence; Dawson

Here's a summary of a recent study on the impact of seeking help on the likelihood of abstinence. People who sought help had more severe and more numerous problems, but they were significantly more likely to recover than people who did not seek help. I went to the article and founce no mention of whether the person sought help because of external pressures (like courts).

Even though they had more comorbidity and therefore were at risk for worse outcomes, seekers of formal and informal treatment had better odds of recovery from alcohol dependence.

Searching for Strategies to Help the Homeless

NPR's Morning Edition is running a series on chronic homelessness. Today's segment talked about the importance of supportive housing and addressing "root causes of homelessness" like mental illness and addiction. This was a controversial assertion in Ann Arbor 10 years ago, it is less controversial now. A representative from the Rockefeller Foundation talked about what a mistake it is to provide housing without also addressing these root causes.

Tomorrow's segment is on the housing program in Seattle that I posted about recently. It provides permanent housing for chronic alcoholics, apparently without any expectations that they try to recover.

Addiction careers and the natural history of change

The British National Treatment Agency for Substance Misuse (NTA) recently released a research report about addiction careers and natural change. Looking at addiction careers is a pretty new area of research and represents a shift toward looking at addiction as a chronic condition. When one starts to look at addiction this way, one possible outcome of treatment is a reduction in addiction careers.

Highlights from the report include:

• A table of the "capture rates" of different drugs. How many people that try it eventually become addicted.
• Discussion of the concept of natural recovery.
• Discussion of the impact on maintenance interventions on careers.
• The impact of treatment on careers.

It's a great primer on "natural recovery." We known for years that most people recover without treatment, we're just now beginning to explore how these people change and why others are unable to change without help.

BTW - The NTA website is building a library of reports like this. Many are very good and concise. Worth browsing.

Smoking To Blame For More Than Half Of Difference In Men's Mortality Risk Across Class Lines

Quit smoking to stick it to the man!:

The direct correlation between lower socioeconomic status and mortality risk is well known, but a new study by the University of Toronto and the University of Oxford is the first to determine that more than half the difference in risk of death between men in the highest social strata and those in the lowest can be attributed to smoking.

My Marijuana Post

A reader makes a fair criticism:

Just a comment that from a prevention advocate's point of view (the ones who are creating the "firestorm",) the potential innate harm of a drug is not limited to or defined by whether or not someone becomes addicted to it. E.g. It's well documented that cannabis impairs driving skills, esp the ability to stay in a lateral lane. If my son smoked dope and was killed or injured in a car accident, or was hit by someone who had been smoking dope, all I would care about is that my son was injured or killed; I wouldn't much care whether or not the use resulted from a chemically dependent limbic system or a poor choice. [Some friends] once did a workshop for parents on marijuana, and several legalization advocates showed up to argue and it was turning into a circus until a local student who was attending as part of a class assignment stood up and said she had a 2 year old son she had not planned to have and she ever would have slept with the father if she hadn't been high on marijuana. Those are the kinds of consequences that are hard to measure and do not result only from addiction, they result from use.

My point (poorly made), was not that addiction is the only harm or only important harm that might result from marijuana use. Rather, that both sides seize upon these kinds of findings and stretch the truth to make their case.

Cannabis in the News

A recent marijuana study concluded that there was no link between smoking marijuana and lung cancer. This set off a firestorm - cannabis advocates argued that it's safe; anti-drug activists argued that it's still dangerous. One of the recent studies that they seized upon concluded that marijuana use in rats was linked to heroin use. This brought retorts criticizing these activists of reviving the "gateway theory". Now there's a new study linking marijuana smoking to pre-cancerous cells in smokers' lungs.

My problem with all of this is that it focuses far too much on the drug (the drug's dangerous - the drug's not dangerous) and not enough on the relationship between the drug and the brain of the user. Clearly, most adults who use marijuana are not and will not become addicted. However, people with the wrong limbic system will develop problems.

Safe Injection Rooms in the News

There have been several recent articles about supervised injection centers. Here's a recent one praising an Australian center and another from today asking hard questions about the same center.

Personally, I'm underwhelmed with the referral rates. The first article cites more referrals than the second, I'm not sure where the discrepancy comes from. They also don't clearly define "referral." Is it a passive referral, "call this number"; or an active referral, "we'll take you directly to the detox center right now"? There's a big difference. Whatever the definition or the number, the best scenario is a 1.7% referral rate. I don't know what a good referral rate would be, but I'm not impressed.

In Vancouver, there's concern about the future of the supervised injection center because its license is about to expire and the new prime minister opposes the site. At the same time, there have been several articles about the addition of 30 beds to the site. I don't have a clear understanding of their purpose. They say they are for people waiting for treatment. I guess it would operate like a shelter for them? But, isn't an injection center a lousy place to shelter someone who's decided to stop using? Don't they have any social detoxes or shelters with recovery support services?

First recovery center breaks ground in Kentucky

The State of Kentucky has broken ground on a women's recovery center. This is part of Governor Fletcher's "Recovery Kentucky" initiative. (Here's an NPR story on it.) He plans to open 10 regional recovery centers that provide sheltering, transitional housing and recovery support for up to 2 years.

Colorado University-Boulder creates the Center for Students in Recovery

Colorado University-Boulder creates the Center for Students in Recovery. College recovery support programs are beginning to pop up around the country. Texas Tech was the pioneer.

From an older story about the Texas Tech program:

Since the inception of the program, only one student out of 600 who have received scholarship aid has flunked out. Even more impressive is the fact that these recovering students maintain a grade point average of 3.58, well above the university-wide average of 2.85, and 95 percent of the participants have stayed clean and sober.

New study emphasizes the importance of relationships

A study published in the August 2006 issue of the journal Addiction attempted to study the impact of treatment program relationships on treatment outcomes. No suprise, it found that treatment relationships based on acceptance and constructive social relationships resulted in better outcomes. Here are the highlights from the abstract. Let me know if you want a copy of the entire article:

Aims This study presented and tested a model of behavior change in long-term substance use disorder recovery, the acceptance and relationship context (ARC) model. The model specifies that acceptance-based behavior and constructive social relationships lead to recovery, and that treatment programs with supportive, involved relationships facilitate the development of these factors.

Conclusions Patients from treatment programs with an affiliative relationship network are more likely to respond adaptively to internal states associated previously with substance use, develop constructive social relationships and achieve long-term treatment benefits.

Park to be site of sober revelry - Ann Arbor

Soberfest 2006! Sunday! Sunday! Sunday! See you there!

Join Together withdraws PROMETA article

On July 3rd I posted an entry about a study using Hythiam's PROMETA protocol for methamphetamine addiction. I told you about their sketchy sales tactics and to expect to hear more about them. Well, this morning's Join Together email included the announcement below stating that they withdrew their summary of the study from their site.

EDITOR'S NOTE
The June 30 research summary Anti-Anxiety Drug Said to Help Meth Addicts, which appeared in the July 3 edition of JT Direct, has been withdrawn from our service. It reports preliminary uncontrolled results from off label use of a medication approved for a condition that is not addiction. The FDA has not approved this treatment modality, nor has it been supported by peer reviewed NIH research.

Project Prevention

Project Prevention just announced its "2006 In '06" campaign. Project Prevention was formerly known as CRACK (Children Requiring A Caring Kommunity). Their goal for 2006 is to pay 2006 addicts to get sterilized or get some form of long term birth control. According to their website, they have a chapter in Detroit.

The group's founder, Barbara Harris, is reported to have said:

We don’t allow dogs to breed. We spay them. We neuter them. We try to keep them from having unwanted puppies, and yet these women are literally having litters of children …

She's also quoted as saying the following:

My mind has changed as far as the women go. When I first started the program I was just so angry with these women. I thought they were scum. But during these years I've had the opportunity to meet many of these women, and eventually realized that my anger is more toward society. If the government had common sense, they would spend more money on drug treatment—then they'd be spending less on caring for these babies. People tell me I should be spending my money on treatment programs and I tell them for every [addicted child] I can prevent from being conceived, there's four million dollars that can be used for drug treatment.

I'm all for preventing drug affected pregnancies. However, we know that the biggest barriers to a meaningful community response are stigma and hopelessness. It seems clear to me that this group's reductionist message - that addicted women are irresponsible, unloving baby machines - only makes the problem worse.

New and improved SAMHSA website

Substance Abuse and Mental Health Services Administration overhauled their website. It was badly needed. Hopefully their wealth of materials will be easier to sort through.

The Not-Quite-So-Grim Neurology of Teenage Drinking

Here is another perspective on the story about the impact of age of first use from a few days ago. The writer argues that the early drinking and future alcohol dependence is caused by environmental factors and hereditary predisposition rather than early drinking cause future alcohol problems.

The author has a pretty strong bias against the disease model and believes that most addiction is self-medication (listen to minute 33:45).

I think she's right that the coverage of this overstates the likelyhood that alcoholism can be "caught" by early exposure. But, she is probably just as guilty of understating the potential impact of early exposure, completely excluding any mention of research on early drug exposure and brain plasticity.

Chantix Quadruples Smoker's Chances Of Quitting Successfully

A new drug from Pfizer shows promising results. The results don't include comparison to nicotine replacement therapy. The results seem to underscore that whatever your method, there's hope for quitting smoking.

The study lasted one year. Here are some facts from that study:

-- 44% of those on Chantix were not smoking at 12 weeks
-- 29.5%% of those on Zyban were not smoking at 12 weeks
-- 18% of those on a placebo were not smoking at 12 weeks
-- 22% of those on Chantix did not smoke from week 9 to 52
-- 16% of those on Zyban did not smoke from week 9 to 52
-- 8.4% of those on a placebo did not smoke from week 9 to 52

Another study, from the Unversity of Wisconsin included 1,027 volunteers, all of them smokers who wanted to quit. Results were almost the same as the ones above.

The third study involved people in seven countries - 1,900 smokers who wanted to quit. All of them took Chantix for the first 12 weeks, after which 1,236 (65%) were still not smoking. The 1,236 quitters were then divided into two groups: One group continued taking Chantix while the other took a placebo. This continued for another 12 weeks. At the end of the 24-week period:

-- 70.5% of those on Chantix were not smoking
-- 49.6% of those on a placebo were not smoking

Cellphone prevents drunk dialing

Does this qualify as harm reduction?

The disparity on crack-cocaine sentencing

This compelling Op-Ed calls for reforming the cocaine sentencing disparity created by the Anti Drug Abuse Act:

Defendants convicted with just 5 grams of crack cocaine, the weight of 5 sugar packets, were subject to a five-year mandatory minimum sentence. The same penalty was triggered for powder cocaine only when an offense involved at least 500 grams.

Twenty years later, the aftermath of these laws is sobering. More than 80 percent of the defendants prosecuted for a crack offense are African-American, despite the fact that more than two-thirds of crack users are white or Hispanic. By and large, these defendants are not the kingpins of the drug trade. Data from the US Sentencing Commission document that 73 percent of crack defendants had only low-level involvement in drug activity, such as street-level dealers, couriers, or lookouts. The commission also has found that crack cocaine sentences are the single most significant factor contributing to racial disparity in federal sentencing.

The Grim Neurology of Teenage Drinking

A new study (NY Times registration is free. If you don't want to register, go to www.bugmenot.com.) affirms what we've learned over the last 10 to 15 years about the importance of postponing age of first use:

47 percent of those who begin drinking alcohol before the age of 14 become alcohol dependent at some time in their lives, compared with 9 percent of those who wait at least until age 21. The correlation holds even when genetic risks for alcoholism are taken into account.

"We definitely didn't know 5 or 10 years ago that alcohol affected the teen brain differently," said Dr. White, who has also been involved in research at Duke on alcohol in adolescent rats. "Now there's a sense of urgency. It's the same place we were in when everyone realized what a bad thing it was for pregnant women to drink alcohol."

Homeless Alcoholics Receive a Permanent Place to Live, and Drink

Take the time to read this. (NY Times registration is free. If you don't want to register, go to www.bugmenot.com.) It's a very sad story.

It talks about the application of the "housing first" approach with chronic alcoholics. Reasonable people can disagree on the merits of using the approach with this population, but whatever one's ideology, this is a difficult thing to imagine celebrating. The article made no reference to any efforts to facilitate recovery among the people in the apartments. I hope that there are some efforts and that the reporter failed to include those efforts in the story. Again, reasonable people can disagree about the merits of a "housing first" approach with these people, but it would be unconscionable to give up on trying to help them recover.

Meth addicts reduce drug use with new treatment

This article* PROMETA. PROMETA is a protocol for combining certain prescription drugs and nutritional supplements. PROMETA protocols are owned and sold by Hythiam, Inc. Hythiam is in the midst of a major publicity and sales push.

Dawn Farm and the local drug court have had several very aggressive sales calls. They've gotten so aggressive, pushing and smarmy that I had to ask the sales person to stop calling and not to come to our facilities. It's worth noting that a lot of their sales pitch was focused on the value of their stock.

You're going to see their name popping up everywhere. PROMETA may represent the best pharmacology available today, but it appears that all of their drugs could be precribed by any knowledgeable doctor.

* Post updated 7/4/06 due to bad link. The story was corrected after it was initially posted.

Remission and Relapse in the General Population

This study suggests that most people who develop alcohol problems resolve them without any professional help. Keep in mind that this is a non-clinical population.

Panel Calls for States to Take Lead on Addiction Policy

Michael Dukakis is chairing a panel of government officials, treatment providers and recovery advocates. They recently released a report that calls for states to take lead on addiction policy:

...states bear many of the costs of alcohol and other drug addiction, spending an estimated 13 percent of their budgets on addiction-related problems.

However, the report noted, 'Less than four percent of this is spent on prevention and treatment, while more than 96 percent pays for the avoidable social and physical consequences that result from our failure to apply what we know about how to prevent and treat substance-use problems.' These costs include child-welfare, prison, court, police, and Medicaid expenditures for treating medical problems related to addictive illnesses.

recommendations include that states do the following:

develop a statewide strategy that includes all agencies affected by drug and alcohol problems

increase accountability for all state agencies working on issues related to addiction

educate lawmakers about the costs of alcohol and other drug addiction to improve their participation in policymaking

train judges to address alcohol and other drug use among defendants and improve coordination with treatment services

create a state alcohol and other drug policy advisory board, answerable to the governor and lawmakers, that includes representatives from the recovering community and civic leaders

The whole report is available here. It's not an exciting read, but it is worth downloading.

Reports suggest declines in drug production and use

I'm of the opinion that we focus too much on supply and enforcement, nut here's some good news on those fronts:

• DEA meth lab seizures are down 30%.
• Job applicant drug tests suggest meth use is down and overall positive tests are at a 17 year low.
• The United Nations reports that opium poppy production is down 22%.
• The U.N. also reports that cocaine consumption is down in North and South America, but up in Europe.

Addicts need treatment: Given proper help and support, most will recover

The Ann Arbor News ran an Other Voices piece by me. It was really visible - above the fold, a big headline and a big graphic. Hopefully it will motivate some people to take some action.

Lawmakers back jail terms for drug offenders despite Prop. 36

I wrote something about this a few weeks back. Proposal 36 in California was passed by California voters in 200 and required that the state offer treatment as an alternative to jail or prison for most nonviolent drug offenders.

Ballot mandated funding for Prop. 36 ended this year and the California legislature had to decide what to do. They've passed new funding for it but want to allow short, instant jail sentences for probation violators. The Drug Policy Alliance is prepared to fight them on any incarceration for relapses.

Alcohol-related Liver Disease Numbers Double In Ten Years, UK

Over the past couple of years, there has been a lot of coverage of drinking problems in England. It's been hard to know how much of it is hysteria and how much of the concern is legitimate. This article provides some hard data suggesting that there is significant growth in alcohol related problems.

• Alcohol-related liver disease hospital admissions in the UK have doubled in ten years
• total deaths related to alcoholic liver disease rose by 37%, according to NHS figures.
• In 2004/5 35,400 people were admitted to hospital with an alcohol-related liver disease.
• In 2004/5 21,700 people were admitted to hospital for alcoholic poisoning, versus 13,600 in 1994/5.
• in 2005 25% of 11-15 year old children had had an alcoholic beverage during the previous seven days of being surveyed.
• 33% of men and 25% of women, aged 16-24 had been on a binge drink once during the previous seven days of being surveyed.

I was unable to find precisely analogous numbers for the U.S. I did find that the numbers for past 30 days use of alcohol is 17% for 8th graders and 33% for 10th graders.

Cognitive Behavioral Therapy Appears More Effective Than Sleep Medication For Treating Insomnia

This study provides more good news for people suffering from insomnia (a relatively common problem for people in early recovery). The study supports the findings from a Harvard study that was published last year. Cognitive behavioral therapy appears to be a safe, effective treatment for many people suffering from insomnia.

Ten-Year Recovery Outcomes for Clients With Co-Occurring Schizophrenia and Substance Use Disorders

This study finds good news for schizophrenics with alcohol problems. At 10 year follow up 65% had no signs of a substance use disorder.

The study is much more focused on mental illness than on substance use problems. As usual it's also vague about the nature of the substance use problems. I went to the full article and it does not specify DSM abuse vs. dependence. Either way, this study offers hope.

One other interesting note:

"clients who received clozapine during the early years of the study experienced highly significant improvements in substance abuse outcomes compared with those on other antipsychotic medications."