Catching up

Here are several articles I've been meaning to post about but have fallen behind:

Substance Abuse Benefits: Still Limited After All These Years

In 2005, approximately 22.2 million Americans age twelve or older were "dependent" on or "abused" illicit drugs or alcohol. Alcoholism alone is one of the ten leading U.S. causes of disability. Illicit drug users commit more than 60 percent of serious adult violent and property crimes in this country. In 2003, medical spending for substance abuse (SA) treatment constituted an estimated $20.7 billion--1.3 percent of health care spending.

More than 90 percent of people with SA problems do not seek medical attention, a figure that has changed little in recent years. Of the 37.5 percent of those who sought treatment and were unable to get it in 2002, cost was the key reason for not obtaining care.

Since the early 1990s, the public sector has assumed an increasing share of medical spending for substance abuse, while private payers' share has declined. From 1991 to 2003, all medical payments by private insurers (of which nearly 90 percent were for employer-based coverage) grew from 33 percent to 35 percent of national health care spending. In contrast, private insurance spending for SA services declined from 22 percent in 1991 to 10 percent in 2003. Yet about three of every four Americans with a drug or alcohol dependency were employed either full or part time in 2005.

Much of the decline in private insurance SA spending was concentrated in inpatient and residential services, although it also affected outpatient spending. Private insurance spending in all settings has declined, although the decline in inpatient spending has been longer and more substantial (Exhibit 1). It resulted in a falling share of inpatient, residential, and outpatient SA spending coming from private insurance between 1991 and 2003.

...

About 88 percent of insured employees had at least some coverage for SA treatment in 2006. To provide historical perspective, we compared 2006 data for workers in private firms who had health care coverage with similar historical information from the BLS. For 2000-03, 93-94 percent of workers in all private firms were enrolled in a plan with SA benefits, similar to the 93 percent recorded in our survey results for 2006. Earlier figures for 1995 and 1997 covering medium and large private establishments were only slightly higher (98 percent), in part because small private establishments, which typically provide less rich benefits, are not included. Concurrently, the use of limits on coverage of SA services became more pervasive: In 1989, 56 percent of employees with SA benefits had limits that were different from those applying to medical-surgical benefits. In 2006, 81 percent of covered employees belonged to plans that limit hospital inpatient days or office visits for SA treatment.

Patients' cost-sharing requirements for SA benefits remain higher than those for medical-surgical benefits--and it is well established that higher cost sharing reduces the use of services. In 2006, deductibles were 46 percent higher for SA services than for medical-surgical benefits (Exhibit 5). Employees are more likely to be subject to coinsurance as opposed to copayments for SA services than for medical-surgical services. According to the data presented in this paper, when employees face copayments, they are higher, on average, for SA benefits. When workers are subject to coinsurance, rates also are higher for SA than for medical-surgical services. Perhaps most important, plans that limit employees' out-of-pocket liability for medical-surgical services do not apply this protection for 44 percent of the employees with SA benefits.

Court ordered treatment reduces offending:

A new study from a team of researchers at the University of Kent and King's College London shows that court-ordered treatment for drug dependence can be effective in reducing offending and drug use.

The study, published this week in the British Journal of Criminology, suggests that, although treatment is effective in reducing offending by drug users, it can be equally effective for people who enter treatment as an alternative to imprisonment, leading to reductions of almost three quarters in the average frequency of offending.

...

Alex Stevens explained: 'Our research has shown that people on Drug Treatment and Testing Orders (DTTOs) were as likely to reduce their offending and drug use as people who entered treatment 'voluntarily'. On average, those sentenced to a DTTO reported a 71% reduction in the frequency of offending between the time of arrest and 18 months after they started treatment. The sharpest fall in offending occurred in the first six months of treatment. There were similar reductions in the frequency of drug use and in the money they spent on drugs.'

Experts Warn About Powdered Alcohol

They look harmless enough, the inconspicuous packets often next to the cashier at gas stations, convenience stores, beverage stores and bars. But according to consumer protection officials, that's what makes them all the more dangerous, since the powder inside contains alcohol, and a lot of it -- about 4.8 percent by volume. That is the equivalent of one to one-and-a-half glasses of liquor.

Vancouver mayor to lead campaign for injection site

Vancouver Mayor Sam Sullivan plans to lead an aggressive campaign to lobby for the continued operation of the country's only injection site for drug users.

In contrast to the last round of lobbying to keep the site open, where Sullivan used a quieter, back-door approach, the mayor said he plans to mount a public campaign that brings together injection-site supporters from every sector of the city.

He said that's because having the injection site open is key to bringing in the new kind of drug-treatment approach he has been advocating since he took office.

That approach, which he has labelled Chronic Addiction Substitution Treatment, will see legal substitutes for cocaine and heroin given to addicts.

"The CASTproject does require the supervised injection site as a site for recruitment. We are going to need to aggressively pursue this project," he said.

Sullivan's drug plan isn't the better way

As a former beat cop who spent more than seven years working in the Downtown Eastside, it was nice to see Jonathan Fowlie's article.

...

I can recall on many occasions when denizens of the poorest postal code in the country would approach me and say they wanted desperately to get into treatment and leave the drug life behind them.

However, adequate treatment didn't exist or there was a waiting list. When an addict reaches out for help, he or she must be removed from the Downtown Eastside and placed in a treatment facility immediately.

Supreme Court to review crack cocaine sentences

The Supreme Court agreed for the first time yesterday to reconsider the long prison terms meted out to the mostly black defendants who are convicted of selling crack cocaine.

At least 25,000 defendants per year are sent to federal prison on crack-cocaine charges, and their prison terms are usually 50 percent longer than drug dealers who sell powder cocaine.

This disparity, with its racial overtones, has been controversial for two decades since Congress ramped up the "war on drugs" in response to a crack-cocaine epidemic that was sweeping many cities.

Crack was targeted for stiffer penalties because it was viewed as more potent and dangerous than powder cocaine.

At the time, lawmakers set mandatory minimum prison terms for drug sellers based on the quantity of drugs sold. A sale of 5 grams of crack cocaine triggers the same five-year prison term as selling 500 grams of powder cocaine, even though they are the same substance.

Critics have said this 100-to-1 disparity is unfair and racially biased because dealers in crack cocaine are more often black, while powder cocaine is said to be sold more often to whites and by whites.

Put the Gangs Out of Business: Legalize Drugs

The street gang and associated drug trade problem in Canada won't be solved by a get-tough, criminal-justice-system response, nor should we expect young homies to just say no. Look to the United States for proof of this. Over the past 30 years, the U.S. has employed the most aggressive and expensive anti-drug and -gang measures ever conceived. In the process, 800,000 street gangsters under the age of 21 have been created. Moreover, more than two million Americans now call prison home, the majority of which are young black and Hispanic men. About half of them are serving time for relatively minor drug offences. Today, things are so bad that the FBI has made street gangs and the underlying drug trade their number one priority, even over domestic terrorism. The failure in this campaign is a testament to the abject failure of the U.S. war on drugs and gangs.

Canada has the opportunity, but perhaps not the courage, to employ a different approach on street gangs. To be sure, we must tackle the underlying socioeconomic causes of the street-gang problem, including poverty, income inequality and persistent discrimination. At the same time, we must equip our police agencies with the resources they need to take out the hardcore 20% or so of all street gangsters who are responsible for the majority of Canadian street violence. We must spend much more money on early prevention and diversion, because this is not a problem that we can arrest our way out of.

Finally, we need to embark upon drug legalization, which will starve gangs of their principal oxygen supply and serve to upset the attractive risk-reward proposition that every new gangster now faces.

Marlboro Snus: What is it?

Yesterday Philip Morris USA, the tobacco company that has around 50% of the total market for cigarettes in the USA, announced the launch a new product: “Marlboro Snus,” in a test market in the Dallas/Fort Worth area. So what type of product it this?

As this particular brand of snus won’t be launched until August we can’t yet tell much of the details of the product (e.g. how much nicotine it delivers or how much it will cost) so lets talk about what “snus” is generally, and why the biggest cigarette manufacturers in the US are test marketing an entirely different type of product.

Snus (pronounced “snooss”) is the Swedish word for snuff, and is a form of moist ground smokeless tobacco, that is usually sold in “sachet” form – each sachet looking like a small tea-bag. Each sachet is placed in the mouth (usually under the upper or lower lip) for about 30 minutes and the nicotine and tobacco taste is absorbed via the lining of the mouth. The main difference between snus products and other smokeless tobacco already available in the United States, is that snus is produced using a process like pasteurization in which it is heated with steam. This kills most of the microbes that can produce cancer-causing chemicals in tobacco. Traditional smokeless products like Skoal and Copenhagen are not pasteurized but are fermented - a process that facilitates the development of cancer-causing chemicals. So snus does not appear to cause oral cancer. Clearly smokeless products also don’t cause lung cancer or respiratory diseases like emphysema either. That’s not to say that snus is entirely safe. Long term use can cause white patches to appear on the lining of the mouth and erosion of the gum where it is placed, and decades of use may increase risks of pancreatic cancer and cardiovascular disease (e.g. stroke and heart attacks). The nicotine from this product will also harm the unborn baby when used by a pregnant woman. So neither snus nor any other form of smokeless tobacco is recommended for anyone who currently doesn’t smoke. But because the health risks from snus are much lower (about 90% lower) than from smoking this may be a step in the right direction for the smoker who wants to keep using tobacco but wants to avoid most of the health risks.

Marketing and resbonsibility

I've had a recent posts about alcohol marketing and teen drinking. If find these questions of marketing and personal responsibility difficult and I's suspicious of anyone with easy answers.
Marketer Seth Godin weighed in on responsibility and marketing today:

Marketing works.

Advertising and promotion and lobbying cost money. And organizations pay for it because, by and large, it works. Not all the time, and rarely as big as people hope, but sure, you can influence the public by spending money.

Which leads to the key question: are you responsible for what you market?

Some people will tell you that the market decides. They’ll remind you that most consumers are adults, spending their own resources and doing it freely. That people have a right to buy what they want, even if what they want isn’t good for them (right now, or in the long run). That’s what living in a free country is all about, apparently. Buy what you want.

But wait.

I thought we agreed that marketing works.

If marketing works, it means that free choice isn’t quite so free. It means that marketers get to influence and amplify desires. The number of SUVs sold in the United States is a bazillion times bigger than it was in 1962. Is that because people suddenly want them, or is it because car marketers built them and marketed them?

Cigarette consumption is way down. Is that because people suddenly don’t want them any more, or is it because advertising opportunities are limited?

Read the rest here.

‘Been There?’ Sometimes That Isn’t the Point

From Sally Satel in yesterday's NYT:

For other patients, though, the “Have you ever ...” question is less a therapeutic riddle to be solved — as it was in the case of Mr. B — than an expression of genuine skepticism that they can indeed be helped.

It is the kind of question asked by a person who believes his very soul has been warped by calamity. “Sometimes a patient expresses frustration that I can’t possibly help him because I never experienced the trauma that he did,” said Dr. Walter Reich, a professor of psychiatry at George Washington University and a former director of the United States Holocaust Memorial Museum, whose patients have included Holocaust survivors.

“Please tell me what happened, how you reacted to it then and how it lives in you now,” he will ask. He gently prods his patient to step out of his private world, “a chamber often filled with circular and self-devouring ruminations.” In the act of making his experience clear and complete to the therapist, the patient has to make it clear and complete to himself, Dr. Reich explains, adding that “in the process, he accepts into his being something that was once consuming it.”

Addiction, too, can be an intense and defining experience. “I have heard patients say that if you haven’t been there you can’t help me,” said Keith Humphreys, a Stanford psychologist. “So I tell them, ‘I can help you live a sober life because it’s all I have ever lived.’ ”

It’s true that having “been there” can endow a drug-abuse clinician with valuable authority and authenticity. There is just so much bluster a patient can get past a counselor who is a streetwise former junkie (which is why I, the forever-abstinent psychiatrist at a methadone clinic, often seek a second opinion from our counselors). Moreover, that recovered counselor inspires hope that addiction can be conquered.

But most of the time, therapist and patient do not share a history. And even if they do, there is no guarantee it will help. A mutual bond can paradoxically reinforce the patient’s sense of isolation from others. Also, commonality can lead the therapist to identify too closely with the patient, thus compromising objectivity.

In truth, the most relevant knowledge a clinician can possess is the experience of having known and treated many patients already. This is how he learns to become a skilled interpreter of the protean query “Have you ever...?”

Pain in the news

Maia Szalavitiz of STATS.org wrote a post that was very critical of a recent Newsweek article on pain management and opioids. It's good--addressing several common myths about addiction vs. dependence and opioids.

So, when I read the Newsweek article, I expected it to be crap. But it's pretty good too. It does a good job making the case for the importance of serious pain management and it illustrates the binds that myths and stigma put doctors and patients in. They could have done a better job with the issue of iatrogenic addiction, but I suspect that pain patients and doctors are better off for this article having been published.

Hyperthermia and Ecstasy: New Case Study Offers Possible Clue to Ecstasy-caused Deaths

This is from a press release from The Centre for Addiction and Mental Health:

Death caused by the drug ecstasy (mdma) is very rare compared to the high number of users. And the reasons why some ecstasy users are especially susceptible to a fatal drug reaction are not known, though these deaths often involve severe hyperthermia (increased body temperature).

A new case study in the Journal of Forensic Sciences points to a pre-existing defect affecting temperature regulation as one factor that might contribute to some ecstasy deaths.

Working with Centre of Forensic Sciences toxicologist Teri Martin and the Office of the Chief Coroner of Ontario, the Centre for Addiction and Mental Health (CAMH)’s Dr. Stephen Kish described a young woman who developed fatal hyperthermia after taking ecstasy. It was later discovered at autopsy that she had an overactive thyroid (hyperthyroidism), a condition that can make some people less tolerant to heat.

“This single case cannot prove that hyperthyroidism contributed to the death of the ecstasy user”, said Dr. Kish, Professor of Psychiatry and Pharmacology, University of Toronto, and Head, Human Neurochemical Pathology Laboratory, CAMH, “but it does suggest what many scientists have suspected - that a pre-existing problem in temperature regulation might increase the risk of an ecstasy-triggered death. This is supported by other data showing that experimental animals that are hyperthyroid are more likely to die when exposed to ecstasy.”

All that from one case? Can you say confirmation bias?

The Methadone Maze

A damning portrait of a methadone program in Maine:

For many people, the methadone program at Acadia Hospital has been a lifesaver, substituting a safe, monitored dose of liquid methadone for the dangerous and illegal street opiates abused by addicted clients.

In the best cases, these clients are able to resume their productive lives — finish their schooling, keep their jobs, care for their children. About 700 people are enrolled.

But attending the methadone clinic can be a daily exercise in frustration, anger and resentment. Brawling, harassment, intimidation and drug dealing are regular occurrences, some clients say, and the clinic staff rarely intervenes. This chaotic atmosphere at Acadia is a threat to their recovery, these clients allege — and it challenges public assumptions about the largely Medicaid-funded program.

But administrators at the hospital say that their clients’ antisocial and illegal activities are symptoms of the disease of drug addiction. Taking a hard line against such behavior would force too many clients out of treatment, they argue, undermining the goals of the program.

Speaking out

Danielle Eames-Powe, 22, has been a client at Acadia’s methadone clinic for two years. A drug user since she was 12, it was the birth of her daughter, Mabel, that made her seek treatment. She has been clean and sober for 2½ years now, she said, and works as a secretary for Bangor lawyer Joseph Baldacci.

Eames-Powe and her boyfriend, Bruce Raymond, also a client, told the Bangor Daily News that money and illicit drugs of all kinds change hands in the clinic’s waiting areas and parking lot. The staff looks the other way as these deals are made, they said, despite a largely unenforced rule that prohibits congregating, whispering or socializing on hospital property.

"A lot of them just make up their drug histories, so the clinic thinks they have a really big problem and gives them high doses of methadone," Eames-Powe said. Some clients — many, according to Raymond — who are entrusted with take-home doses sell their methadone to buy more potent drugs for their own use.

In the long hallway where dozens of clients may wait 45 minutes or longer to get their daily dose, they said, fistfights and shouting matches often break out. The language is often extremely offensive. Many clients bring their young children with them, and those children watch and listen as their parents and other clients take part in these violent encounters.

Mandatory counseling sessions are pointless, Raymond said. Some clinicians are apathetic and negative; others are overwhelmed by the number of clients they must see.

Clients can choose between individual therapy or group counseling; Eames-Powe said she always chooses individual sessions.

"I attended one of the groups and it was despicable," she said. "The people were nodding off, drooling, glorifying drugs, talking about how much they love getting high. I’ll never go to group again."

Individual sessions aren’t much more valuable, she said.

"I’ve had nine different counselors in two years," she said. "I just tell them the same story, my history. It doesn’t accomplish anything, but at least it’s confidential and you don’t have to sit next to a bunch of filthy people who are still using drugs."

Eames-Powe said she is "desperate" to get out of the Acadia program. But clinicians insist on weaning her so slowly that she fears she’ll never be free of the demoralizing daily visits.

Ironically, she said, despite her good behavior, consistently negative drug tests and evident commitment to recovery, she’s ineligible for take-home doses — she’s considered "unstable" because she is weaning.

Read the rest here.

The effects of alcohol on smoking cessation

Jonathan Foulds has two posts (here and here) on the relationship between drinking and alcohol consumption:

Not surprisingly, however, people with current alcohol problems tend to have poorer outcomes when it comes to quitting smoking. There is a fairly close association between smoking and problem drinking. For example, in a study published in 2000 based on a survey of almost 43,000 adults, Dr Deborah Dawson (National Institutes of Health) reported that the proportion of past-year smokers rose from 23.8% of those who never drank 5+ drinks on any drinking day to 61.8% of those who drank 5+ drinks weekly or more often. She also found that but drinking 5+ drinks at least once a month reduced the odds of smoking cessation by 42%.

A recent study by Leeman and colleagues from Yale University noted that many (46%) trials of medicines for smoking cessation exclude people with a current or post alcohol problem. It was also noticeable in their study that trials of new medicines were more likely to do so. Thus 45/125 (36%) trials of nicotine replacement therapies (gum, patch etc), 15/22 (68%) bupropion SR trials and 3/3 varenicline (Chantix) trials excluded participants with either current or recent alcohol problems. This is part of the reason that clinicians often want to wait for more studies when a new “wonder drug” comes out that appears to get better outcomes than previous medicines. Typically the first few studies of a new drug (usually sponsored by the company making the drug) include only “ideal” candidates for the drug, rather than typical patients who might use it in the real world.

So what does all this mean?

Firstly, if you think you may have a current alcohol problem you should get help with that immediately. If you scored in the “problem drinking” range on any of the questions mentioned above but still don’t think you have a problem, then here’s one more test. Starting tomorrow, go 30 consecutive days without drinking any alcohol. If you can do it, then fine, maybe your alcohol consumption isn’t currently a problem. If as soon as you think of it you perceive it to be too much trouble, or if you try it and can’t do it, take that as confirmation that you can’t control your alcohol consumption. You should then discuss this with your family doctor and attend a local AA meeting.

Secondly, whether or not you think you have a current alcohol problem, you should make plans to quit smoking. If you feel you would rather get the drinking under control first, that’s fine, but make a concrete plan to tackle the smoking very soon and mention this to your doctor and AA sponsor right from the start. More people with alcohol problems are killed by their smoking than their drinking, so this is not something to put on the back burner for long. Once you have 30 days without drinking under your belt then its time to talk to your doctor/sponsor again about quitting smoking and to set a quit date.

Dutch smoking ban to cover coffee shops

The end of Dutch cannabis cafes?:

A Dutch smoking ban will come into force in July next year for all restaurants and cafes -- including coffee shops where cannabis is the top attraction, the government decided on Friday.

"Coffee shops will be treated in the same manner as other catering businesses. They will be smoke-free," Prime Minister Jan Peter Balkenende told NOS television.

"It would have been wrong to move towards a smoke-free catering industry and then make an exception for coffee shops. People would not have understood that."

Establishments will not in fact have to be completely smoke-free. Proprietors will be allowed to set up a separate room or glass partition behind which people can smoke, but customers will not be served there to protect staff.

What's your color?

Am I getting old and prudish? Or, is there something creepy about the merger of pop culture iconography and harm reduction? Where are the lines between destigmatizing addiction, normalizing addiction and celebrating addition?

I don't consider myself anti-harm reduction, though I believe more aggressive forms of harm reduction should be done in the context of treatment on demand and I'm troubled by programs that pay little attention to creating opportunities to facilitate recovery.
[Hat tip: Matt]

Mayor pushes substitute drug program

Vancouver Mayor Sam Sullivan (previous posts here) says he was never committed to the safe injection site as a long term solution and would like to replace it with oral drug maintenance:

Vancouver will be able to close down its supervised-injection site for drug users once a new program for providing substitute legal drugs gets going, according to Vancouver Mayor Sam Sullivan.

...

"I would never see [the injection site] as a long-term solution," said Sullivan. "We know there's 90-per-cent Hep C and 30-per-cent HIV among injection drug users. The reality is needles are not a good way to take drugs."

In spite of all of his "meeting them where they are at" "realism", he fails to recognize that injecting drugs is a GREAT way to take drugs if your an active addict.

Sullivan's hope is that within 18 months a minimum of 1,000 people will be getting substitute drugs in five separate trials. Two of the trials will provide people with a new substitute for heroin; the other three will supply different kinds of drugs that are being proposed as substitutes for cocaine and crystal meth.

"I believe that 1,000 [people in these trials] will not make the supervised-injection site redundant, that it still has a very valuable service for society as we transition. It needs to be there as an essential recruitment site for [the substitution trials.] But I do believe it is a temporary measure."

...

He acknowledged that getting people to stop using needles may be difficult, because of the culture of drug-using in Vancouver that emphasizes "feel the steel."

"But now what we're asking is not that they 'just say no'.

"It's that they change the culture. It's much more possible to ask people to change the culture of their drug use versus stop their drug use."

...

Sullivan said he is spending a lot of his discretionary time and energy working on the project because "I see the payoffs for the citizens: dramatic reduction in crime, dramatic reduction in homelessness. I see many of the Project Civil City goals achieved in large part through [this]."

Needle Exchanges

Congress is considering legislation that would permit Washington D.C. to use city money to fund a needle exchange. The Washington Post weighs in today:

HIV-AIDS IS laying waste to Washington. The District has one of the worst infection rates in the country, and intravenous drug use is one of the primary modes of transmission. Yet the District -- unlike any other jurisdiction in the country -- is prohibited by Congress from using its own money to fund a needle-exchange program. Yesterday, Rep. Jose E. Serrano (D-N.Y.) took the first step toward ending this nuttiness.

The ban has been in place since 1998. That's when Rep. Todd Tiahrt (R-Kan.) succeeded in getting it attached to a bill governing the District's budget. With the Republicans in control, the prohibition on the District spending its own funds for needle-exchange programs survived every attempt to excise it from the House appropriations bill. But the Democrats are in charge now. Mr. Serrano, as chairman of the House Appropriations subcommittee on financial services and general government, which doles out federal money to the District, stripped the ban from legislation that passed unanimously yesterday. The action now moves to the full Appropriations Committee and then to the floor of the House, where opponents are expected to try to reinstate the prohibition.

"I do not dispute that drug addiction is a very real problem in this and other cities," Mr. Tiahrt told us via e-mail yesterday, "but [needle-exchange programs] have been proven in many studies to be ineffective and a threat to the surrounding community, especially to children." Yes, drug addiction is such a problem that there are now more than 210 syringe-swapping programs in 36 states. They constitute but one weapon in an arsenal of measures to help stem the tide of people converting from HIV-negative to HIV-positive. And they make it easier for outreach workers to talk to users about their addictions and then to get them into treatment.

The District is cautiously optimistic. City Administrator Dan Tangherlini told us that two departments (Human Services and Health) are beginning to work on a series of needle-exchange program options for Mayor Adrian M. Fenty (D) to consider. If all goes well, the District would be able to get something up and running for fiscal 2008. Congress should let it happen.

Track Money Flow to Stop Movement of Addictive Drugs

Keith Humphreys, the prolific researcher on AA, is advocating that financial transactions be used to track drug sales:

The drug dealer of the future is sleek, efficient, sophisticated - and WiFi enabled. As highlighted in a U.S. Senate Judiciary Committee hearing last week, the once-distinct worlds of drug dealing and the Internet are merging, resulting in unprecedented access to potent painkillers like Vicodin and Oxycontin for non-medical use. The fear this situation generates knows no partisan limits: liberal Sen. Dianne Feinstein and conservative Sen. Jeff Sessions are reaching across the aisle to promote greater controls on Internet drug trafficking.

Addictive and potentially lethal medications are available without prescription from over 2 million Web sites around the world, according to studies conducted by the Treatment Research Institute at the University of Pennsylvania. Many of them are based in countries that impose few legal controls on pharmaceuticals. A no-prescription pharmacy in Tajikistan or Tanzania - which might be little more than a truck with a well-stocked medicine cabinet and a wireless-enabled laptop computer - can sell painkillers to Americans with no fear of local law enforcement.

This growing phenomenon may be fueling the rising tide of prescription drug abuse among adolescents. The 2006 Monitoring the Future survey by the University of Michigan found that 12th graders are five times as likely to have used Oxycontin and 12 times as likely to have used Vicodin as they are to have used heroin in the past year. The average parent or teen probably considers abuse of these drugs less dangerous than heroin, but in fact they are pharmacologically quite similar, all being potent opiates with high risk of addiction and overdose.

Tech-savvy world

Most adolescents are more tech-savvy than their parents, and understandably have less fear of ordering a drug on their home computer or cell phone than they would of venturing out into the street to find a dealer. Many a teenager is home alone when the mail comes, and it only takes a few teens to supply a large number of young people with Internet-purchased drugs.

What to do? Feinstein and Sessions should be commended for taking the important first step of amending the Controlled Substances Act, which was originally passed when Steve Jobs and Bill Gates were 15 years old, to cover the Internet trade of abusable medications. The next step is to develop strategies that limit Internet trade in dangerous no-prescription drugs, while preserving the right of patients with legitimate prescriptions to purchase needed medications online.

The Drug Enforcement Agency has pursued the traditional law enforcement approach of arresting dealers and seizing drugs. This works well for pharmacies physically based in the United States, but most Web-based drug dealing originates in other countries. Even if we were fortunate enough to put all domestic illegal Internet pharmacies out of business, the traffic would simply shift entirely overseas at the speed of a few mouse clicks. Traditional border control methods likewise will have little impact: The Customs Service can't inspect more than a fraction of the foreign mail that enters the country each day.

Key difference

To succeed at suppressing this new form of drug dealing, we will have to recognize a fundamental difference between street and Internet drug deals. Tracking financial transactions on the street - for example, the names and addresses of all the people who contributed to the $5,000 in small bills found on an arrested drug dealer - is very difficult for law enforcement. In contrast, on the Internet, even the smallest financial transactions are electronic, creating a traceable record.

Law enforcement agents could pose as teenagers wanting to buy pain killers without prescription over the Internet, much the same way they currently catch online sexual predators. Once the phony transaction had been processed, the information on the seller could be immediately shared with the credit card company and its associated bank. These entities, in turn, could cancel the ability of the seller to do any further electronic transactions online. This involves some cost for the credit card companies and banks, but it will benefit them by getting them out of a dirty business.

Focusing policing on the financial transactions rather than the drugs themselves may seem an unusual departure from traditional enforcement approaches. But just as the Internet has demanded new ways of thinking about every other area of life, it will also require new ideas for combating dangerous drugs. Efforts to seize Internet-purchased drugs at the border or in far-off nations will have minimal effect, but we don't need those familiar tools to tackle this problem. The best approach was well-summarized by one of the witnesses at the Senate hearing, Dr. Thomas McLellan of the Treatment Research Institute: Just follow the money.


Keith N. Humphreys, Ph.D., is a Professor (Research) of Psychiatry and Behavioral Sciences at Stanford University School of Medicine.

Birth defects from alcohol use in pregnancy going undiagnosed

There's been a lot written about the problems associated with increases in binge drinking in Britain. Here's another harm:

Far more babies may be damaged in the womb as a result of their mother's drinking habits than was assumed, the British Medical Association warned today as it backed the government's call for pregnant women and those trying for a baby to give up alcohol completely.

Only babies with full-blown foetal alcohol syndrome tend to be diagnosed and counted by doctors in the UK. But a BMA report published today called for data to be collected on a much wider and sometimes less obvious category of damage, called foetal alcohol spectrum disorders.

Around 0.2 per 1,000 UK babies suffer from foetal alcohol syndrome, which impairs the brain, causes abnormal facial features and leads to low birth weight. However, the wider foetal alcohol spectrum disorders were found to affect around 10 per 1,000 babies in Canada, one of the few countries to collect statistics on the latter category.

...

Babies born with the spectrum of disorders have some but not all of the problems that foetal alcohol syndrome brings. They may suffer from hyperactivity, be unable to concentrate, have a short attention span, or be slow to develop.

The BMA notes that there is still controversy in the UK about the existence even of foetal alcohol syndrome, which may explain, the report says, why data on the spectrum of disorders is not collected.

But, said Dr Nathanson, "it is so important that the discussions need to go on in parallel with getting women into treatment."

The BMA recognises that there is no evidence that a low level of drinking - one to two units a week - harmed the unborn child. But, said Dr Nathanson, "the fact that we haven't yet got the evidence doesn't mean that there isn't evidence of a link. It may be that it is just very difficult to get."

It has been shown that alcohol reaches the foetus across the placental barrier, and also that low levels of exposure to alcohol have an effect in animals.

...

The BMA report, titled Fetal Alcohol Spectrum Disorders, says it is very difficult for anybody to know how many units of alcohol they are drinking. Bottles of wine have risen from 8% to 12% proof and measures of wine and spirits vary considerably in pubs and restaurants. The BMA is calling for all bottles of alcohol and pub and restaurant drinks to be labelled with the number of units they contain.

[Hat tip: dailydose.net]

Boost care for mental illness

More of Patrick Kennedy's parity advocacy:

Just more than a year ago, after a late-night automobile accident and a nationally televised press conference, I got the treatment that changed my life. I was lucky to have good health insurance and access to treatment, but too many Americans do not have the same chance.

Most health plans put up barriers to mental health and addiction care. People seeking treatment for these diseases face higher copayments and deductibles, and arbitrary limits on the number of office visits or inpatient days covered. They pay the same premiums as everybody else, but when they get sick their insurance isn't there for them.

This year, I have been crisscrossing the country with my colleague, Rep. Jim Ramstad (R-Minn.), holding informal field hearings about mental health and addiction, and how Congress can help more people get well. We heard from consumers and providers, police chiefs and judges, business leaders and insurance executives, hospital presidents and public health officials. All of them see that equalizing benefits is crucial to addressing many goals -- around health care, public health, education, criminal justice, homelessness, and on and on.

But what it's really about -- what it's mostly about -- is the American Dream. Ending insurance discrimination is about whether our nation lives up to the ideals of the Declaration of Independence and the Constitution, promising every person the chance to reach his or her God-given potential.

It's about people like Amy Smith from Denver. She told us that when she meets people she knew 25 years ago, they are stunned she is still alive. She was in and out of jail and emergency rooms, unable to connect with other people, muttering to herself on the street, and unemployed. For 45 years, she says, she was a drain on society. Then she finally got the treatment she needed and now she's a taxpayer, holding down a good job.

Kevin Hines is a young man who told our hearing in Palo Alto about jumping off the Golden Gate Bridge in 2002. Unlike most jumpers, Kevin miraculously survived and he's getting married this summer. How many others who didn't survive could have found happiness and success had they had treatment?

The American Dream should not be rationed by diagnosis, and so Congress must pass the Paul Wellstone Mental Health and Addiction Equity Act to end insurance discrimination against Americans with mental illnesses and addictions. We know that improving mental health and addiction benefits can actually reduce health care costs by avoiding unnecessarily hospitalizations, controlling chronic physical diseases, and reducing emergency room visits. It improves productivity in the workplace and cuts down on law enforcement problems.

With that track record, a bipartisan majority of 268 declared House supporters, and strong endorsements from the entire House leadership, passing this insurance equity bill might seem easy. But there are 12 years worth of pent-up Democratic priorities. In Washington, the squeaky wheel gets the grease. And there will be those who ignore the evidence and claim the sky will fall on the health care system if we equalize health insurance benefits.

So Congress needs to hear from everyone who thinks it's time to bring fairness and equality to insurance coverage for mental illnesses and addictions. Representatives and senators need to know that passing the Paul Wellstone Mental Health and Addiction Equity Act is not just good policy, but good politics as well.

Rep. Patrick J. Kennedy (D-R.I.) is lead sponsor of the Paul Wellstone Mental Health and Addiction Equity Act.

Ritalin use doubles after divorce, study finds

An interesting finding out of Canada about Ritalin prescribing patterns:

Children from broken marriages are twice as likely to be prescribed attention-deficit drugs as children whose parents stay together, a Canadian researcher said on Monday, and she said the reasons should be investigated.

More than 6 per cent of 633 children from divorced families were prescribed Ritalin, compared with 3.3 per cent of children whose parents stayed together, University of Alberta professor Lisa Strohschein reported in the Canadian Medical Association Journal.

...

"It shows clearly that divorce is a risk factor for kids to be prescribed Ritalin," Strohschein said.

Other studies have shown that children of single parents are more likely to get prescribed drugs such as Ritalin. But is the problem caused by being born to a never-married mother, or some other factor?

"So the question was, 'is it possible that divorce acts a stressful life event that creates adjustment problems for children, which might increase acting out behavior, leading to a prescription for Ritalin?'" Strohschein said in a statement.

"On the other hand, there is also the very public perception that divorce is always bad for kids and so when children of divorce come to the attention of the health-care system - possibly because parents anticipate their child must be going through adjustment problems - doctors may be more likely to diagnose a problem and prescribe Ritalin."

[Hat tip: dailydose.net]

Let's buy Afghanistan's poppies?

The editorial page of Canada's National Post argues that the west should purchase Afghani opium for production of medical opiates:

Illicit poppy production is simultaneously a hard-to-replace source of income for thousands of small Afghan farmers and a valuable source of revenue for the enemies of NATO and the legitimate Afghan government. Over 90% of the world's illegal raw opium is thought to come from Afghanistan. Ultimately, its by-products go on to wreak havoc in cities around the world.

Consistent with the thinking that gave us Washington's failed "war on drugs," the preferred U.S. policy is to "eradicate" Afghan poppy fields through aerial spraying, which practically means driving the opium trade underground and hitting the small grow-ops hardest.

...

The basic idea is simple: Opium is medicine, so why destroy it? In an age of rising global prosperity and life expectancies, the medical demand for opioids such as codeine and morphine is rising all the time, and indeed is outstripping supply according to UN measures. Yet there are no legal arrangements for Afghan farmers to produce licensed opium legally for the international pharmaceutical market.

Nothing in international, Afghan or Islamic law stands in the way, and a similar program of pharmacization has already brought thousands of Turkish farmers in from the black market. The only thing missing in Afghanistan is the bridge between lawful authority and the areas in which poppies are now being grown illegally -- which is to say, the problem is that the war hasn't yet been won.

That's hardly a trivial hurdle to overcome, but there is a chicken-and-egg dynamic here: Isn't it just possible that NATO would find it easier to win hearts and minds in the lawless parts of Afghanistan if farmers there knew that NATO progress meant a big stake in a legal opium trade -- instead of the status quo, whereby government busybodies are trying to get everybody to burn their dollars-a-bushel poppies and grow pennies-a-bushel onions instead?

The real risk of a licensing regime is that it might end up being carelessly policed and prone to bribery, enabling some of the "legal" harvest to find its way into the illicit drug trade. But as the Council points out, that's where the entire harvest is ending up now.

Stephane Dion has come out in favour of looking at the Senlis plan, but when he notices that it implies seeing the war through to the end, as Ms. MacDonald has emphasized, he is likely to get cold feet. It's the Conservatives, the party of victory, that ought to give it the consideration it deserves.

Neil McKegany expresses concern about unintended consequences of such a policy:

In agreeing to that deal you would be sending out a powerful message to each and every country in the region that if they wanted a guaranteed income from the West then all they need to do is start farming opium. Far from stemming the drugs trade you could find yourself actually stimulating its growth. Those countries in particular who had already stemmed their opium production on the basis of international pressure might feel mightily irked by such a change in policy and decide themselves that it was no longer in their interests to so assiduously police
their own opium trade.

If you succeeded in persuading a local farmer to sell you his opium crop you would be placing them at enormous risk, because the gangs who currently run drug production are not going to sit around and watch their market disappear. Instead they are going to use whatever force is necessary to ensure that no matter who buys the drugs the money goes into their pockets. Such a policy then would require the capacity of the West not simply to buy the drugs from the farmers at source, but to provide the level of security that those farmers are going to require as a result of their decision to switch the sale of their product.
...
In the face of the continued failure to reduce the scale of opium production in Afghanistan, then aerial spraying may well come to be seen as the last but now needed option in tackling opium production. There is also a need, however, to show those who are dedicated to opium production that their choices in this respect are going to cost them dearly, whether in seized assets or further military intervention. Putting money into the hands of those who are involved in organised drug production is about as far from that strategy as it is possible to get.

I recently attended an international seminar addressed by some of those who are involved in the Afghan counter-narcotics effort. Sitting next to me was a senior UK police officer who turned and said that part of the problem in tackling drugs production in countries like Afghanistan was the fact that you never knew whether the person you were speaking to was part of the problem or part of the solution: ‘We are expected to share our intelligence but you never know when you take out a group involved in opium production whether you have reduced supply or simply lowered the level of competition in the market.’ In a situation in which it is hard to tell whose side people are on, it is a risky strategy dolling out large amounts of government money.

Finally, The Institute for Peace and War Reporting reports on success in one province:

Muhammad Nazar is busily weeding his cotton fields. Last year at this time, he was engaged in harvesting poppy, but, like many landowners in Balkh province, has had a change of heart.

“The government has restricted poppy cultivation, and religious leaders have told us that growing poppy is haram [prohibited by Islam],” he said. “We should not go against our religion and the constitution.”

As he continued to work, he said, “I hope to get a good harvest, and the government has promised us a good price for cotton.”

Balkh province used to be the third-largest producer of opium poppy, after Helmand and Kandahar. But this year, the counter-narcotics programme has all but rid the province of the illegal crop.

Some farmers, like Nazar, say that they have switched to legitimate farming because of government strictures. But many others give a more pragmatic reason for decision.

“The price of poppy has been going down year by year,” said Noor Gul, a farmer in Charbolak, formerly the centre of Balkh’s poppy cultivation. “We couldn’t afford the expense of growing it, so we decided to plant something else instead.”

Dealers say that the price of opium has been declining due to overproduction. While in past years, a kilo of opium paste would fetch over 130 US dollars on the local market, it is now worth about half that.

Hat tip: dailydose.net and ccsa.ca

Ross Fitzgerald: Alcohol abuse is destroying youth, so let's de-glamorise it

An Australian Op-Ed calls for a tobacco-like public heath campaign on alcohol:

AS a nation we have never been more health conscious, yet we seem to be ignoring all the warnings about alcohol abuse.

Alcohol, our most widely used drug, is still ravaging the young, destroying indigenous communities, damaging the mentally ill and destroying lives, unabated. Perhaps some of the same zeal that has been applied to the anti-smoking cause could be enlisted in a concerted fight against alcohol abuse and misuse.
...
The ramifications of cigarette use are now seen on every pack: stained teeth, raw gums, gangrene from blocked arteries, heart disease and multiple cancers. In the West we have come a long way from the days when cigarettes could be promoted by white-coated doctors or, in one case, a smiling Ronald Reagan. Cigarette advertising is now banned, as it should be. In its place, on virtually every railway network, sporting venue, commercial television and radio program, advertisements and endorsement of alcohol have replaced advertisements for cigarettes.

How has alcohol escaped the Buga-up treatment, or something similar? Some argue that it's different, that many consumers can use alcohol sensibly and safely, while tobacco is highly addictive and every cigarette does damage.

Then the statistics are trotted out. In Australia, tobacco kills up to 19,000 people a year, alcohol 3000-plus - although that does not include those killed by drinkers in assaults, violence, accidents or through sheer negligence - and illicit drugs less than 1000. But cigarette smokers usually die later in life, whereas alcohol predominantly kills young drinkers, and others, from assaults, injuries, homicides, road trauma and domestic violence. Add to this the impoverishment of family and community life - a toxic social mix of violence, injury and neglect - well outside the calculus of tobacco harms.

It is instructive to learn that alcohol problems are escalating in the UK as drinking hours have been extended. The Royal College of Physicians, not exactly a radical group, recently recommended to the Blair Government a complete ban on alcohol advertising. They were responding to the doubling of alcohol-related deaths from 1991 to 2004.
...
Given successful litigation against tobacco transnationals, there soon may be a groundswell of opinion in favour of taking action against the makers, distributors and sellers of alcohol.

The hazards of alcohol misuse in environments of heavy drinking are well known and there are clearly many cases in which harm, both to the drinking person and to others, could have been reasonably foreseen and in which the suppliers of alcohol should have exercised due care and diligence. A recent survey of 500 Australians in the age group 18-24 found one in four had been drinking to the point of passing out.

Hat tip: dailydose.net

Addiction Community's Influence Over Corporate Responsibility Grows

From Join Together:

Anheuser-Busch's recent decision to pull its fruity Spykes drink mixers from the market represents the latest in a series of significant victories by the addiction field in confronting what advocates consider irresponsible marketing by big corporations.

After weeks of escalating complaints by public-health groups such as the Center for Science in the Public Interest (CSPI), the Marin Institute, Community Anti-Drug Coalitions of America and the Oregon Partnership, as well as a coalition of state attorneys general, Anheuser-Busch announced on May 17 that it was withdrawing Spykes from the market. The company continued to dispute assertions that Spykes was marketed to children, but company chairman August Busch acknowledged that parental concerns played a role in the decision to yank the product.

Many of the same groups were involved in a previous (and successful) advocacy campaign that resulted in Anheuser-Busch withdrawing "Bud Pong" games from the marketplace and ending its sponsorship of "Beer Pong" tournaments. Addiction activists complained that drinking games like Bud Pong, Beer Pong, and "Shots and Ladders" encouraged binge drinking and underage alcohol use.

The campaign, launched around the Christmas holidays, resulted in retailers like Target, Kohl's, and Linens n' Things halting sales of these games as well as another called "Drinko," an alcohol-fueled version of TV's "Plinko." The Oregon Partnership also spearheaded a campaign to get beer-related t-shirts pulled from the shelves of Macy's stores last October.

Read the rest here.

It's worth noting that none of the groups mention are recovery advocacy groups, they're all prevention groups.

Crack-pipe project to be reviewed

I'd love to know more about the rate of disease transmission through crack pipes and respiratory illness resulting from inhaling brillo smoke:

The program's goal is to mitigate the spread of diseases, including HIV, hepatitis C and tuberculosis. The fresh mouthpiece prevents transfer of spit or blood from sores, and the screen discourages addicts from using a Brillo pad, which contains harmful ingredients.

And not a word about recovery.

Treatment for Meth OD May Harm Brain

New research on treatment of meth ODs:

According to experimental scientists a common antipsychotic drug used in emergency rooms to treat methamphetamine overdose can damage nerve cells in an area of the brain known to regulate movement.

Investigators from the Boston University School of Medicine used a rat model to determine that only the combination of the medication, haloperidol, and methamphetamine causes the destructive effects, not either one alone.

[Hat tip: Daily Dose]

Legacy Tobacco Documents Library

The American Legacy Foundation has created a digital library. The Legacy Tobacco Documents Library (LTDL) contains more than 7 million documents (40+ million pages) created by major tobacco companies related to their advertising, manufacturing, marketing, sales, and scientific research activities.
[Hat tip: Daily Dose]

Strawberry Quick and Cheese

I've been resisting posting about these reports. They feel like hype, but I've gotten several emails about them and they've been heavily reported. So, here you go.

More Canadian drug war fun

At least one of them resists questioning the motives of their opponents--something I haven't seen in American political debates for some time.

Point:

Last week, it was announced that the Conservative government will soon unveil a new national anti-drug strategy. The plan is said to feature a get-tough approach to illegal drugs, including a crackdown on grow-ops and drug gangs. And while it will also (wisely) include tens of millions for rehabilitation of addicts and for a national drug prevention campaign, it is said to retreat from safe-injection sites and other fashionable "harm-reduction" strategies introduced by the previous Liberal government.

To which we say: Good. This editorial column has long urged a softening of drug policy on marijuana and other non-addictive recreational substances. But heroin and similarly addictive drugs are a different story. Moreover, safe injection sites don't work. And they send the wrong message, too, promoting disrespect for the rule of law by having government facilitating the consumption of illegal substances.

Safe-injection sites (SIS)-- typically inner-city facilities where addicts may go to shoot up with clean needles under the watchful eye of medical specialists --are often said to work wonders. Benefits claimed on behalf of Insite, Canada's one and only SIS in Vancouver's Downtown Eastside since 2003, include reduced needle sharing, reduced spread of deadly diseases such as HIV and hepatitis, fewer needles discarded in surrounding neighbourhoods and fewer addicts overdosing in alleys. Lives have been saved, advocates claim, the "well-being of drug users improved," and all without increased street dealing around Insite.

Too bad most of the proof to back these positive claims come from SIS proponents or the academics who devise harm-reduction theories. Police here, and in Europe (where they have lots of experience with SISs) tell a very different tale.

When Insite applied to have its three-year licence renewed last fall, the RCMP told Health Canada it had "concerns regarding any initiative that lowers the perceived risks associated with drug use. There is considerable evidence to show that, when the perceived risks associated to drug use decreases, there is a corresponding increase in number of people using drugs."

That has certainly been the case in Europe. Currently there are more than three dozen major European cities on record against SISs. Most have had such facilities and closed them because they found that drug problems increased, not decreased.

After an injection site was opened in Rotterdam in the early 1990s, the municipal council reported a doubling of the number of 15- to 19-year-olds addicted to heroine or cocaine. Over the 1990s, the Dutch Criminal Intelligence Service reported a 25% increase in drug-related gun murders and robberies in neighbourhoods housing one of that country's 50 official methadone clinics or addict shelters. Zurich closed its infamous needle park in 1992, after the police and citizenry became fed up with public urination and defecation, prostitution, open sex, panhandling, drug peddling, loud fights and violent crimes.

...

But as much as we admire the good intentions behind SISs, drug consumption is the wrong business for government to be in. A government that funds safe havens for injecting illegal drugs on one hand will quickly find it is working against its efforts to reduce drug dealing on the other.

Counter-point:

Reports that the Harper government is preparing to announce changes to Canada's outdated 20-year-old national strategy on illicit drug use should be reason for optimism.

Instead, there are signs -- such as the Conservative distaste for safe-injection sites that are a key component of the "harm-reduction strategy" -- that Ottawa is tilting toward a more aggressive, U.S.-style war on drugs. If that is the case, it would be an unfortunate mistake with predictable and very disappointing outcomes.

While Washington from time to time trumpets bravely that it has scored a victory in the war on drugs, by all empirical measures it has been an abject failure.

Consider the record south of the border:

- Hundreds of billions of dollars have been spent. This year alone in the U.S., federal and state government have spent nearly $20.5 billion directly on counter-drug measures.

- There are nearly two million Americans in prison, about one-third of whom are locked up on charges for possession or low-level trafficking, costing tens of billions of dollars.

- Despite nearly 30 years of focused domestic and international measures, however, drugs are more available than they have ever been, largely because it is such a wildly profitable criminal industry. Virtually anyone who wants to buy drugs can, and it's easier than ever.

But what are the alternatives? This is a reasonable question. Just because the state can't beat the drug cartels doesn't mean it should join them.

One of the driving forces behind the U.S. war on drugs, especially under the Republican party, is Christianity. The religious right has placed "saving" people from the scourge of drugs as an important American value and tantamount to saving souls. It is one reason that successive administrations have continued to throw increasing resources at a fruitless war. The message, in essence, that the small number of those rescued from the grip of drugs justifies the billions used in the war.

Teen drinking

The skeptics at STATS.org catch some selective reporting:

There was a positive association between exposure to TV beer ads in the sixth grade and drinking which ranged from 1.43 to 1.48 depending on the type of television ad. In other words, the sixth graders where 43 to 47% percent more likely to drink in grade seven based on seeing beer ads on tv.

But hold on – this was by no means the only factor to show such a positive association. The Times failed to mention that “Sports Activity” in the sixth grade delivered a higher odds ratio of drinking in the seventh – 1.60 or 60% more likely to drink. Low parental monitoring was greater than TV ads too (1.64), as was parental approval (1.69), and the approval of a friend almost doubled the chance of drinking (1.98). Deviant behavior (2.00) and peer drinking (3.20) were even greater predictors of beer consumption.

The Times also neglected to mention that the Rand researchers tried to account for the effect of these factors on one another in a series of complex calculations. The result, at least according to the tabular data in the study, shows that the odds ratio significantly diminished for all advertising (1.08 to 1.13 for TV ads). The factors most strongly influencing seventh graders to drink were, once again, peer drinking (1.40) sports activity (1.52), friend approval (1.53) deviance (1.54), and above all, whether they had drunk in the sixth grade (2.32).

I'm just as troubled by shoddy drug reporting, but there's something very off-putting about the zeal of STATS. I don't claim to know the impact of advertising, and even if it is effective with teens, I'm not sure I'd advocate restrictions. However, I find it difficult to believe that the alcohol industry's large advertising budgets are ineffective and sufficiently narrowly target to influence only adults. They sometimes seem to react to excessive certitude with excessive certitude.

Another study finds that there may be a relationship between teen drinking and something not mentioned in the previous study:

In a study of more than 10,000 15- and 16-year-olds, British researchers found that teens with larger allowances were more likely to drink frequently, binge or drink on street corners and other public places.

[hat tip: CCSA.ca and Shannon]

Because fentanyl is so powerful, overdosing occurs quickly, easily

Q & A about fentanyl patches in the Ann Arbor News. Prompted by 2 local deaths:

Michigan State Police at the Ypsilanti post have recently handled two overdoses in which victims chewed or sucked Fentanyl patches and stopped breathing.

New Insite numbers

Insite has been receiving negative attention since a change in government in Canada and recent critical review. Today, they released a report the value of Insite in moving users toward detox. They report that use of Insite is associated with a 30% increase in use of detox services. I'm not sure what to make of this. They previously reported that 18% of Insite users sought detox services over the course of a one year follow-up period.

• A 30% increase means that detox use went from what percentage to what percentage?
• What's the road not taken? Could increased access to detox have improved usage? (Vancouver only has 3 detox facilities.) Could simple street outreach have produced similar results?
  
• They had a follow-up rate in the neighborhood of 80%, but the cohort is huge. Did they factor any assumptions about the lost subjects? Are these numbers good.
  
• These numbers are based on a lot of assumptions. Are these reasonable assumptions? Might someone who's concerned enough about blood-borne pathogens to use Insite, be moving through the stages of change and be more likely to use detox services on their own? I don't know.
• What were the numbers for community-wide use of detox. Did that increase over this period? Detox admissions increased in Ann Arbor without Insite.
• What do the clients report as their reasons for entering detox? Do they credit Insite?
  

All the numbers are in statistical terms that make me wish I paid more attention to stats in college. Any DF staff wanting the full text can email me.

Medical marijuana use initiative launches in Michigan

An initiative that would allow seriously ill Michigan residents to use marijuana as a pain reliever without repercussions will be launched this week, The Coalition for Compassionate Care announced Wednesday.

Read the rest here. The initiative website is http://stoparrestingpatients.org. I wonder how many patients have been arrested. Seriously. I'm not just being a smart Alec.

How Normal Is Smoking? Teens Don't Know, But Their Guesses Affect Their Habits

More reason to be careful about how we present drug information to adolescents. It's possible to give kids the mistaken impression that drug use is much more common that it really is. This article highlights the dangers of this:

According to the study, nine out of 10 (93 percent) high school students overestimate the percentage of people who smoke in the United States. On average, they believe over half (56 percent) of Americans are smokers, while the actual figure is less than half that.

The study identifies three distinct ways to measure “normative beliefs” involving smoking, each of which it found to be significantly related to adolescents’ likelihoodof smoking. According to the study:

• The more an adolescent perceived that successful and elite people smoke cigarettes, the more likely that adolescent was to smoke.
• The more strongly an adolescent perceived that his or her parents or peers disapproved of smoking, the less likely that adolescent was to smoke.
• The more an adolescent overestimated the percentage of smokers in the general population, the more likely that adolescent was to smoke.

[Hat tip: Join Together]

Plant extract may block cannabis addiction

A plant compound reduced THC use in rats and interfered with dopamine release when using THC. More here.

Do rules hamper remedies for pain?

This article focuses of Washington state, but provides some needed background on opiate prescribing patterns. It appears opiates for pain relief are more readily available than they were 15 years ago.

Until about a decade ago, doctors reserved opioids largely for patients who had cancer. Wider use has come recently as doctors learn more about pain management and researchers have reported that only a small percentage of patients who properly take opioids ever become addicted.

The reigns on these drugs have tightened up over the last several years as there have been concerns about overdoses and prescribing patterns:

...[in] the late 1990s that Washington's workers'-compensation program began covering opioids.
advertising

Almost immediately, accidental deaths became a concern here and elsewhere in the nation. Between 1996 and 2002, 32 injured workers in Washington died after accidentally overdosing on opioids, according to state data.

In 1996, the state's typical workers'-compensation patient took 88 milligrams of morphine-equivalent doses a day. In 2005, the average daily dose was 151 milligrams -- a jump that state officials suspect is caused by an increased tolerance.

In response, some states, including Washington have started developing guidelines for opiate prescribing:

Some states already have opioids guidelines for people covered by state programs, such as starting doses for new patients. But Washington has gone further by setting a suggested daily-dosage ceiling.

Long-term use of opioids can pose hazards for both doctors and patients, said Dr. Jeffery Thompson, medical director of Washington Medicaid. For instance, high doses of it can actually exacerbate pain, which then can prompt doctors to prescribe even more.

Physicians who don't specialize in pain treatment "don't have the knowledge or all the tools," Thompson said. "These are very difficult clients."

The state created the opioids guidelines specifically for those primary-care physicians. The advisory is intended for patients with chronic pain, not for people with cancer or temporary pain or pain associated with terminal illnesses.

The guidelines do not dictate a limit on narcotics dosages, and there are no sanctions for exceeding the guidelines.

The biggest fear is that doctors simply will stop prescribing opioids to legitimate patients.

"Because it comes from a government agency, the guidelines could be perceived by many as imposing new restrictions," said Aaron Gilson, an associate director with the Pain & Policy Studies Group at the University of Wisconsin.

The state strongly recommends that patients rarely take more than 120 milligrams of morphine or its equivalent per day (for example, 800 milligrams of codeine is equivalent to 120 milligrams of morphine). For doses above that level, physicians are advised to send patients to pain specialists.

The state also advises doctors to ask patients to take random urine tests to verify that they're taking the prescribed medications, as well as to rule out illegal drug use.

I don't know enough to opine on the dosage guidelines. It seems to me that this is a case of tension between two real problems and we (the royal "we") are still in the process of trying to find balance. If it weren't for my history of addiction and recovery, I'd probably be pretty offended and resentful about having to submit to drug screens, but claims of Draconian restrictions seem to ignore that the prospects for pain patients are significantly better than 10 or 15 years ago.

It's too bad there's so much hyperbole in discussions about the matter, otherwise we might find some balance a little sooner.

Let's treat addiction like the disease it is

One writer's response to the firing/resignation of HBO's CEO, Chris Albrecht:

Addiction to drugs or alcohol is not an inconvenience, a lapse of willpower, a character flaw, anything to be ashamed of or any form of divine judgment. Addiction is not something that needs to be whispered about or shrouded in euphemisms when you are among polite company. Addiction is a progressive, incurable disease -- in the same way that diabetes and asthma are progressive and incurable diseases. If you have the illness of addiction or alcoholism and you stop treating that illness, you are guaranteed to have a relapse. If you relapse and you still don't treat your illness, you are guaranteed to die.

I can say this with such certainty because I am an addict and an alcoholic. Just like Albrecht, with his well-documented violent outbursts, my own life got pretty squalid and desperate for a while. At the end of my using, a high percentage of my days were being spent in bad behavior that was directly tied to my substance abuse. Then I went to jail for the night and had the same epiphany that every alcoholic and addict in recovery -- including Albrecht -- has had: If I don't quit using, I shall die a long, slow, horrible death, and I will hurt every person I come into contact with until that death.

I've happily been in recovery for years. Life, love and work are all good right now, but that goodness is entirely provisional on my continuing to treat my chronic disease of addiction. As part of this treatment, I insist on being myself in all situations. And what I am is a drunk and a pill popper, gratefully living a sober life today.

I'm lucky, because I am so not shy about my illness. I don't feel any need to hide in either my personal or professional life the fact that I am an addict and alcoholic . I make it a personal mission to help the people I work with understand that I'm perfectly "normal" as long as I don't drink or use. But I also make it clear that I don't have a choice about treating my disease: Doing what I need to do to stay sober has got to be the driving wheel of my daily life. For me, it's a matter of life and death. And it seems to me that Albrecht is only trying to do the same thing I do: Treat the disease that will wreck what's left of his life before that disease kills him.

This is what burns me about Americans and the illness of addiction: When Tony Snow announced he'd had a cancer relapse and took some time off from being our president's spokesman, the consensus seemed to be that he was a brave fighter who should be welcomed back to the Blue Room podium as soon as he felt up to standing behind it. Not that there's anything wrong with this. I, too, find Snow a very brave and appealing figure as he wages his perforce solitary war against his killer disease. But I find Albrecht to be an equally brave and appealing figure as he wages his own solitary war against his own killer disease of alcoholism.

Read the rest here. I agree with every word about attitudes toward addiction. I also appreciate his candor:

"I had been a sober member of Alcoholics Anonymous for 13 years," he wrote. "Two years ago, I decided that I could handle drinking again. Clearly, I was wrong."

However, this guy did commit an assault. (Not his first, either.) I don't think I'll describe him as brave, although I might, if he chose to start creating accountability for his violence by entering a batterer intervention program.

Childhood sexual abuse and alcohol problems

A new study looks for a relationship between childhood sexual abuse (CSA) and alcoholism. It finds that women who experienced CSA have elevated rates of alcohol use at 12-13 years old, but their rates of alcoholism are not any higher than people with similar adolescent alcohol use, though they are higher than the general population.

Two thoughts. First, CSA has been associated with higher rates of addiction. This suggests that CSA may not cause alcoholism, but may lead to early experimentation, which has been associated higher rates of addiction later in life. What's so interesting about this is that it supports CSA as a pathway to addiction and supports alcohol adolescent alcohol misuse as a response to CSA, but challenges the frequently circulated idea of addiction as self-medication for CSA.

Second, the study didn't look qualitatively at the CSA. It would have been interesting to see how the following "traumagenic factors" affected alcohol use and dependence: who committed the abuse (was it a trusted adult); did they report the abuse and where they believed; how invasive was the abuse; how many times were they abused; how many perpetrators were there?

If you are a DF employee and would like the full text, let me know.

Predictors of overdose

A new study looked at OD following detox. The finding that the researchers emphasize is that recent depressive symptoms are a risk factor for OD. They also found that those with at least one prior OD were much more likely to have had an OD at follow-up. An unmentioned finding is that it appears detox may have lowered OD rates. Important because detox is usually not considered when discussing strategies to reduce OD.

If you are a DF employee and would like the full text, let me know.

Are Michigan kids being overdosed?

"Report shows that thousands of Michigan preschoolers are being prescribed psychiatric drugs."
[hat tip: daily dose]

Embracing the culture of recovery

Recovering people around the country are advocating for recovery. Some in big, high profile ways and others in smaller, quiet ways, but we all seem to be organizing around the same fundamental messages. Here's Joe Showalter from Crawfordsville, Indiana:

It has been said that addiction is a cunning enemy of life. (NA world Services) We all know people suffering from drug or alcohol addiction.

Many of us know several people who have attempted to recover from addiction with varying degrees of success. Somehow, though, unsuccessful attempts at recovery seem to garner more attention. Why do so many people return to active addiction after initially addressing their problem and receiving help? Were they unmotivated, unconvinced, under-treated or too far gone? A lot of the conventional wisdom concerning recovery from addiction seems to suggest that a person must hit some terrible ³bottom² before they are amenable to recovery. Often, this ³hitting bottom² entails the loss of the very resources needed to formulate a healthy recovery. Addiction gets progressively worse as it endures and it creates lies about itself along the way. Alcoholism and Addiction have been called the only diseases that tell you, you don¹t have it. I¹m sure many have watched abuse turn to addiction and wondered why the afflicted person doesn¹t appear to believe anything is wrong. Nobody wants to be an alcoholic or an addict. We don¹t want our loved ones to have ³those² problems. That is the very distortion of perception that allows the disease to progress untreated for so long and for so many.

The news is not all grim though. Recovery is possible. It happens all around us. Millions of Americans are in recovery from alcoholism and addiction. Just like the varying degrees of severity present in the problem, there are varying degrees of success and happiness in recovery.

One of the great hurdles springs from the fact that addiction becomes a lifestyle. Like any lifestyle, alcoholism and addiction become a culture unto themselves. This culture, complete with rituals, ceremonies and celebrations, dominates the social, leisure and community lives of those involved with it. A person who begins to seriously address the need for recovery often experiences a kind of ³culture shock². No longer is it safe to socialize in the same places, with the same people or in the same way.

Newly recovering people suddenly look up and they don¹t recognize their own lives. Boredom and isolation are very real enemies of recovery. It takes effort and dedication to reinvent a lifestyle. Fortunately those of us in recovery are not alone on this adventure.

There are many people in this community who have found a new way of life. Often we are where you might not expect to find us. We are in your church (maybe the basement), we are your co-workers, we¹re at the family reunion, the park, the theater, the concert, or maybe wandering the trails at Shades. We are taking an art class, a college course or shopping your garage sale. Many of us have found recovery through a variety of avenues. Support groups are well attended in C¹ville. Many seek help from our faith communities, and many thoughtful and caring professionals provide assistance. A lot of us find our way to recovery by making big mistakes and being held accountable for those mistakes. Our community is graced with a criminal justice system that understands the role addiction plays in the bad decisions that result in criminal behavior. Many alcoholics and addicts have their first exposure to recovery with firm encouragement from the legal system. One thing we all have in common is the need to abandon the culture of addiction and embrace the culture of recovery.

The culture of recovery is an adventure indeed. Social skills have to be re-learned without drugs or alcohol. Interests often have to be developed from scratch. Time management becomes a new concept for a lot of us. Courage to try new things and meet new people is different when your life depends upon it. A culture of recovery is not doing the same old things without the alcohol and drugs. A culture of recovery is about becoming excited about life. It is about rejoining the community and becoming a contributing member of society. When the dust settles we often wonder where we found the time to abuse alcohol and drugs. We begin to see new possibilities and discover a joy that few experience. It makes us want to give what we have found to others who want it. Truly we see that Fun Has Been Redefined.

Addiction illuminates concept of ‘free will’

Harvard Provost, Steven Hyman, recently gave a lecture titled “Compulsion and the Brain: Subverting the Concept of Self-Control.” He provided an easy to understand description of the neurobiological basis for addiction:

Hyman began by explaining what neuroscience has learned about the process by which humans choose among multiple goals and direct their behavior toward obtaining their choices. The part of the brain that manages this process is the prefrontal cortex.

Scientists first began to gain an understanding of the role of the prefrontal cortex in 1848 with the case of Phineas Gage. Gage, a hardworking and conscientious railroad employee, was the victim of a freak accident in which an explosion drove a steel rod through his skull.

Gage survived the accident but seemed to undergo an abrupt personality change.

“He retained his intelligence, but he was no longer sober and reliable. He could no longer conform his behavior to specific goals,” Hyman said.

Scientists now believe that the rod destroyed Gage’s orbital prefrontal cortex, the part of the brain in charge of encoding goals and assigning relative value to them.

Scientists have since identified other structures that perform functions such as holding goals in mind, monitoring behavior necessary to obtaining goals, and resolving conflicts that arise over conflicting goals.

Another essential aspect of the process of seeking and obtaining goals is the dopamine system. Dopamine is a neurotransmitter secreted into the nerve synapse by the presynaptic terminal vesicles, then reabsorbed back into the nerve cells.

Experiments with laboratory animals have shown that the release of dopamine signals the brain to expect a reward. After the reward is obtained, dopamine returns to the nerve cell. Thus, under normal conditions, dopamine is only involved in the process of pursuing a reward, not in the enjoyment of it. But this process can be distorted by the use of drugs such as heroin, cocaine, and amphetamine.

“These drugs are Trojan horses,” said Hyman. “Each of them contains a chemical that is enough like the neurotransmitter that they increase the amount of dopamine in the brain.”

When dopamine continues to be released beyond the normal period, the brain is thrown into a perpetual state of “wanting,” which is the essence of addiction.

Long-term use of addictive drugs, Hyman said, creates processes in the nerve cells that “literally rewire the brain. The circuitry becomes deranged, which elicits automatic drug craving and drug seeking.”

These changes in the brain’s circuitry and the resulting loss of control over the normal goal-setting and goal-seeking process are what makes it so difficult for addicts to recover and return to normal lives.

“I’m not saying that these people are zombies,” Hyman said. “They can grab hold of themselves and regain control of their behavior, but they are at a high risk of relapse.”

What are the policy implications for this model of addiction? One of them, Hyman said, is that because the addicts’ brains are so compromised, it is necessary for others — families, friends, and institutions — to fill in and act almost like “a prosthesis” for the brain functions that are missing or disabled. In order to succeed, however, they must be “absolutely relentless,” added Hyman.

“Drug addiction is a very dramatic form of compulsion,” he said. “We are probably a little less in control than we’d like to believe we are.”

Nevertheless, Hyman believes that addicts should still be held responsible for their actions.

“The fiction that they are responsible may be what gets them to change their behavior,” he said. “A society that errs on the side of holding people responsible is better than a society that errs on the side of giving people excuses.”

There are actually clinically proven reasons for holding people responsible for their actions, Hyman said. Experiments have shown that people function better and are more able to deal with stress when they feel that they are in control.

“We are wired for personal responsibility, even if it’s a bit fictional.”

But “punitive moral opprobrium” and overly harsh prison sentences for minor drug offenses do not serve any useful purpose, Hyman added.

ADHD and Alcoholism

A new study finds a strong relationship between ADHD and alcoholism. It seems to beg the question of what observable symptoms of alcoholism exist before the person has consumed alcohol or before they've developed DSM symptoms of alcoholism. We know that impairment in the frontal cortex plays an important role in addiction and this part of the brain regulates behavior. Are some youth with primary ADHD diagnoses really demonstrating early symptoms of alcoholism?

Molina noted that for adolescents who had previously been diagnosed with ADHD, the risk for heavy drinking or drinking problems began at around age 15. For example, the teens aged 15 to 17 with childhood ADHD reported being drunk an average of 14 times in the previous year versus 1.8 times for those without an ADHD diagnosis.

Approximately 14 percent of those who had been diagnosed with ADHD were diagnosed upon follow-up with alcohol abuse or dependence, and none of the 15- to 17-year-olds without childhood ADHD had alcohol problems.

The researchers also found that those with ADHD and co-existing conduct disorder as adolescents had significantly higher rates of alcohol abuse than did those with ADHD alone: for instance, 20.7 percent of those with ADHD and concurrent conduct disorder as adolescents were diagnosed with alcohol abuse, compared with 4.8 percent of those with ADHD alone.

Molina also found that 10.3 percent of adolescents with ADHD and concurrent conduct disorder met criteria for alcohol dependence, compared with 1.6 percent of those with only ADHD.

For those assessed in early adult hood (aged 18 to 25), Molina found that 42 percent of those with ADHD and antisocial personality disorder met criteria for alcohol abuse or dependence as compared with less than 20 percent of those with only ADHD.

Pain Killers

From artist Chris Jordan. His new collection is called Running the Numbers: An American Self-Portrait. It "looks at contemporary American culture through the austere lens of statistics."

His piece Pain killers "depicts 213,000 Vicodin pills, equal to the number of emergency room visits yearly in the US related to misuse or abuse of prescription pain killers."


Click for partial zoom:

Click for detail at actual size:


Hat tip: Andrew Sullivan

From addict to physician -- a determined life

From Jim:

I've actually met this guy and heard him talk. Interesting commentary on the way the old therapeutic communities put a low emphasis on drinking - thus he didn’t actually get sober until 1993...

'Every last gram of cocaine is soaked with innocent blood'

Scottish police are starting a new public education campaign about drugs. It seems to attempt to change cultural attitudes toward drugs by focusing on the social justice implications of drug production. They're trying to define drug trade and drug use as unethical, not just bad. I suppose it could be effective in changing cultural attitudes toward drug use and could reduce casual drug use, but it's unlikely to impact addictive use. [hat tip: Jim]

Oxycontin coverage

STATS.org fellows Maia Szalavitz and Trevor Butterworth pick apart media coverage of last week's oxycontin verdict.

I share Maia's concern about pain patients getting adequate pain management, but the narrative she offers doesn't fit with my experience. The people that I have contact with who are concerned about oxycontin are parents. They don't see it as a "bad" drug, and their concern is not that doctors are getting people addicted. They are concerned their kids getting prescription opiates from friends who get them from someone's medicine cabinet. Their focus is on raising parental and community awareness about the problem and to encourage people to secure their meds and dispose of them properly when they are no longer needed. They're not especially sophisticated about drugs or medicine, so it would surprise me if they're very unusual. Hardly marauding "drug warriors."

She also points to low treatment admission rates for primary oxycontin dependence. This misses the point. It's not that I'm seeing people present with oxycontin as their primary problem. (It's too expensive on the street.) The problem is that we're seeing more young people presenting with heroin or Rx opiate addiction who initiated their opiate use with oxycontin or a similar drug. Granted, the number of people who will develop an addiction is small and the fact that some people will develop addiction doesn't mean it should be made inaccessible to pain patients. However, with 12% of 18 to 25 year olds reporting non-medical use of Rx pain relievers in the last year, it's not a small problem.

As for Public Citizen, they're in the business of providing accountability for corporate fraud or mistreatment of consumers. Isn't a case of misleading marketing like this exactly what they exist for?

Butterworth says that the data provides a basis for concern about misuse of the drug but blames the media for the problem:

Yet the real data on OxyContin makes a strong argument for holding the media responsible for the rise in OxyContin abuse. According to the Drug Abuse Warning Network, the number of times OxyContin was recorded in an emergency department visit due to drug abuse or a suicide attempt went from zero in 1996 to four in 1997 to 527 in 1998 to 1,178 in 1999. The most dramatic increase occurred between 2000 and 2002, when the number of mentions went from 2,772 to 9,998 in 2001 and then to 14, 087 in 2002.

This shows a correlation between the media’s frenetic coverage of OxyContin, which began during the February 2001 sweeps, and the sharp increase in emergency room mentions of abuse during and after this time period. Naturally, reporters explained how to defeat OxyContin’s time delay mechanism so as to get high. As the Washington Post’s Tom Shales observed in a 2001 article in Electronic Media:

"...in the course of 'reporting' on abuse of the drug, they've all aired how-to pieces that include handy, easy-to-follow instructions on the correct abuse procedure. They tell you how to get high. Then the correspondents do follow-up reports expressing shock and dismay that the abuse is becoming more popular."

But while the manufacturer of OxyContin can be taken to court for misbranding, the major source of information about how to actually abuse the drug not only remains free of accountability – many of its practitioners continue to mislead the public on a drug whose value to people suffering acute, chronic pain is beyond medical dispute.

"the drug-testing business has never been better"

Apparently, drug-test sales to parents have never been better. This article provides a little discussion of the costs.

Smoking bans

The Toledo Blade reports that Ohio's new smoking ban is resulting in an increase in enrollment in smoking cessation services.

Meanwhile, the Guardian has a point/counterpoint commentary on smoking bans. Christopher Hitchens writes in opposition to bans in his usual style.

Pocket Shot | Goes Anywhere - New Packaging Category

This packaging/marketing strategy of a "flask on the fly" will appropriately raise eyebrows. [hat tip: Jim via Alcohol Reports]

Pope: God Will Punish Drug Dealers

You'd hope that a papal visit to a treatment program would result in a headline focused on hope and recovery rather than vengeance. Let's hope that the headline doesn't accurately reflect the content of the visit. [hat tip: Matt]
[Update: link was broken and I was unable to find the original article. This one discusses he broader concerns about Brazilian culture, but is similar. It appears that he also gave the program $100,000. 5/13/07]

Canada's Cracked-Out Capital

An audio slideshow from the Toronto Globe and Mail. [hat tip Anna]

The crisis that never came

A good reminder of how intense and how wrong the "crack baby" hype was.

Interesting public policy finding?

An alcohol ban in some Canadian provincial parks resulted in big reductions in complaints, vandalism and damages:

...the number of individuals evicted from parks was down by 84%; public complaints were down by 91%; vandalism was reduced by 96%; and, cost of damages was down by 97%.

I wonder is this generalizable or if it was related to a local problem.

Spiritual beliefs, practices may help smokers quit

Shocking. Spiritual smokers, who are trying to quit, believe that their spirituality may be helpful in their attempt to quit.

OxyContin maker misled on addiction risks

OxyContin maker misled on addiction risks:

The maker of the powerful painkiller OxyContin and three of its current and former executives pleaded guilty Thursday to misleading the public about the drug’s risk of addiction, a federal prosecutor and the company said.

Purdue Pharma L.P., its president, top lawyer and former chief medical officer will pay $634.5 million in fines for claiming the drug was less addictive and less subject to abuse than other pain medications, U.S. Attorney John Brownlee said in a news release.

The plea agreement comes two days after the Stamford, Conn.-based company agreed to pay $19.5 million to 26 states and the District of Columbia to settle complaints that it encouraged physicians to overprescribe OxyContin.