Quitting smoking -- a time in hospital can be a good time to start

A press release from the Cochrane Library:

For many people, going in to hospital provides an opportunity to stop smoking. A Cochrane Systematic Review has found that the chance of successfully quitting can be enhanced if patients receive smoking cessation counselling during their stay, and then have at least one month of supportive contact after going home.

Because hospitals are now smoke-free, any smoker has to stop temporarily while in hospital. People who are in hospital, especially those with smoking-related illnesses, are often highly receptive to the suggestion that they should try and break their habit. Consequently, they are a natural group of people to consider targeting with interventions that help them achieve this goal. Research carried out for the Cochrane Collaboration shows that this package of therapy can help smokers who go in to hospital for all conditions, even those that are not related to tobacco addiction.

This conclusion came from work that drew data from 33 trials involving a total of over 5600 people. The research showed that only intensive interventions with at least 30 minutes of counselling in the hospital and at least one-month of additional supportive care after the stay show any significant benefit; anything less, and the therapy tends to be ineffective.

They also found that adding nicotine replacement therapy or bupropion to intensive treatment plans had some additional effect in helping people stop smoking over providing the intensive counselling alone, although the difference was not statistically significant.

"High intensity behavioural interventions that begin during a hospital stay and include at least one month of supportive contact after discharge promote smoking cessation among hospitalised patients," says lead researcher Nancy Rigotti, MD, Associate Professor of Medicine at Harvard Medical School and Director of Tobacco Research and Treatment at Massachusetts General Hospital, Boston, USA.

"There is no evidence that less intensive counselling interventions, particularly those that do not continue after hospital discharge, are effective in promoting smoking cessation," says Rigotti.

I couldn't find the original review. I'll post it if there's anything else especially noteworthy.

Safer Cigarettes Coming Soon?

The FDA may soon regulate tobacco. (Can you think of anything else that you consume that isn't FDA regulated in some manner?)

A selling point is that regulation will make tobacco safer. That message is also a point of criticism. (Note: This group has credibility problems on many issues, but tobacco is not one of them.)

Drug addicts do not deserve our indulgence

An opinion piece from the Telegraph (U.K.):

...yo-yo addicts silt up the courts and the judiciary system, lower the quality of life and deplete medical funds that might otherwise be available for hip replacements and Alzheimer's drugs. Addicts mug old ladies to pay for their habit, then commit even more heinous crimes when off their faces on their beloved drugs.

The sympathetic, liberal portrayal of them as a luckless lot brought low by reduced circumstances and foreshortened futures is wearing very, very thin.

Ronnie and Gordon Ramsay shared a difficult, fractured upbringing, but while Gordon worked day and night to better himself and his situation, fragile Ronnie preferred the muffling embrace of the drug trance to the brisk slap of reality. So many do, when faced with a tough choice.

Yet everyone has problems, and the lives of most of us are storm-tossed in one way or another. It must not be forgotten that the root cause of drug use is the desire for enhanced pleasure; it might degenerate into self-inflicted misery at the end, but that's how it starts.

They get a high, everyone else gets a low. They want to cut out tedium and monotony, the rest of us just have to get on with it. In many ways, chronic drug addicts are even more selfish than suicides because - for their family and friends - the agony goes on and on.

For Ronnie Ramsay, the living will not be easy in a Far East prison. Not like here, where jailed addicts are to be given disinfectant tablets with which to clean their syringes, in an attempt to protect their human right not to suffer blood poisoning.

You would think they might have thought of that before they started filling their veins with Class A drugs, but reason has never been the strong point of druggies. They render themselves helpless through their vices, while expecting us to pick up the pieces.

What is there to say? I saw some of the same sentiment in the ABC Primetime episode focusing on Daniel Baldwin. The reporter was unable to conceal her contempt for the disease model and repeatedly suggested that addiction is a result of choice. (Although, it is possible to be an irresponsible creep and an addict.)

We have done a poor job of defining the balance volitional impairment and personal responsibility.

I suppose an important lesson is to consider the impact of interventions, not just on the target, but also on public attitudes.

Dead addicts are beyond treatment

A response to last week's National Post guest commentary. It makes a legitimate argument in favor of harm reduction (But fails to address the issue of prioritizing when resources are scarce.)

I love vigorous debate, but can't we all just get along? "Polemic", "illustrates her failure to recognize". Way to keep the door open for dialogue!

Why can't all addicts be treated like Navy pilots?

Great question. The same could be asked about doctors.

This overstates the impairment in the midbrain, but is roughly accurate.

Addicts are people with broken brains. That's the latest from experts on neuroscience and addiction studies at the University of Utah School on Alcoholism and Other Drug Dependencies this week. They're saying that genetics and early trauma can result in vulnerability to addiction.

But people with broken brains can get better. I'm hearing a lot of hope on that front. Kevin McCauley, the school's keynote speaker, was a Navy flight surgeon who helped administer the very successful "Keep 'em Flying!" approach for Navy pilots. McCauley says this approach resulted in a 95 to 97 percent rate of return to flying status for pilots suffering from alcoholism.

This high success rate occurs because of a comprehensive approach to treatment. Pilots are told that if they develop an alcohol problem, they can come to their superiors for the best available inpatient treatment; they will be returned to flying status as soon as possible; and they will receive long-term peer support. The pilots are treated like needed, valued members of the Navy community. Of course, they will also be tested regularly for drug use of any kind.

McCauley is convinced we could see an equally high recovery rate for other alcoholics and addicts if we offered them the same treatment. Today, only a handful of privileged addicts enjoy access to excellent inpatient treatment, a promise of return to high-status employment, and the mix of support and accountability provided to the Navy pilots.

Why don't we offer all addicted people this same winning combination?

For one thing, as a society, we're stuck on the idea that addiction is a moral failing and not a disease. The experts at the School on Alcoholism refute this convincingly. Defects in the midbrain - the part of the brain that regulates survival functions such as eating and self-defense - lead to an overpowering demand for a substance that will make the person feel better. Getting enough of the drug equates with the drive for survival in the addicted brain.

While the addicted person is busy getting and using drugs to placate the demanding midbrain, the person's prefrontal cortex - that part of the brain that deals with morality, spirituality, and other higher concerns - is shut down. No wonder addicts are known for immoral acts. Their instinctive brain is screaming for more drugs at any cost while their moral brain is on hold!

Memory suppression

A question from a reader:

How does the memory suppression relate to addiction? It seems to me like suppressing a memory might not be the best way to deal with it, please explain.

Two reasons.

First there's a relationship between trauma and addiction. The relationship probably isn't direct. Trauma may be more directly related to substance abuse. When substance abuse occurs in an immature brain it can increase risk for addiction through brain plasticity. Better strategies for addressing trauma could reduce substance abuse in trauma survivors and prevent the development of addiction in some cases.

Second, the brain's memory circuits seem to play important roles in developing addictions and relapse. Learning more about how to limit the power of certain memories could lead to helpful relapse prevention strategies.

Bad memories can be supressed

A new study suggests that people can be trained to suppress traumatic memories.

Nora Volkow on Fresh Air (part II)

I finally listened to the rest of the interview today. Two more thoughts.

First, on tobacco, she pointed out that nicotine elicits a relatively low dopamine response and indirectly attributed its addictive power to the unusual degree to which tobacco use is often woven into the user's life. She might make the same claim about alcohol. In my last post I noted nicotine's capture rate and suggested that there's got to be more to the story. The thing that jumped out at me today was the relationship between dopamine and pleasure. Nicotine, clearly, does not produce the kind of euphoria that other drugs produce. Yet, it has the highest capture rate and higher relapse rates. I'd really like to hear her discuss this in more detail.

The other discussion point that I've very curious about was related to food addictions. She stated that there are some important neurobiological similarities, but also some important differences. She did not elaborate. I'd also like to hear her discuss this in more detail.

She also discussed prevention and medical marijuana in a manner that seemed honest, thoughtful, and careful to avoid being alarmist.

The press loves pot

This post's title sounds snarky. I wasn't trying to be. These are all worthwhile stories but how many times can I use the title "Pot in the news"?

First, a story on the UN finding that Canadians used pot at rates higher than any other industrialized nation in 2004. (Quick quiz: Which countries report higher rates of past year use?)

Next, an article focuses on an experts claim that past year use rates don't mean much.

An editorial letter responds with a call for legalization.

Finally, the Australian Parliament published a report on pot and mental illness:

The evidence reviewed above suggests that cannabis use is associated with the development of mental disorders such as schizophrenia and depression. However, there is ongoing debate over exactly how this association should be characterised. In brief, it appears that while the majority of cannabis users will not develop mental illnesses as a consequence of their cannabis use, a "vulnerable minority appear to be at increased risk of experiencing harmful outcomes". As noted above, there is good evidence that young people and heavy users are particularly at risk.

The public-policy implications of this are complex. According to a recent review, the main challenge will be in communicating with young people about the probable risks of cannabis use:

This task will be complicated by the conflicting interpretations of the evidence on either side of the policy debate about the legal status of cannabis. We can expect those who defend current policy to support a strong causal interpretation of the evidence and proponents of cannabis liberalization to dismiss the evidence as the latest version of "reefer madness". These contrasting responses may amplify scepticism among young people about messages about the mental health risks of cannabis use.

In other words, it is crucial that emerging evidence about the links between cannabis use and mental-health problems is communicated clearly (particularly to those most at risk) and in a way that acknowledges the complexity of the issues involved without obscuring the level and gravity of the risks posed by cannabis use to vulnerable groups.

(Quiz answer: Zambia, Ghana, Papua New Guinea, and Micronesia)

50 years of drug addiction

Canada's National Post recently ran a scathing criticism of Vancouver's embrace of harm reduction:

Vancouver Mayor Sam Sullivan recently announced a supposedly innovative proposal to supply addicts with legal forms of illegal drugs (heroin, crack cocaine and crystal meth) in pill form. Sullivan naively claims the delivery system is the core of the addiction problem, and is determined to change the drug culture of "depending on needles."

This is innovative thinking, indeed. Common sense suggests the drug is the problem, and the culture of drug dependence is what needs to change. And the best way to change an epidemic rooted in a particular behaviour, is to change the behaviour.

But common sense isn't "innovative" enough for those who are charged with resolving Vancouver's drug problem, yet obsessed with doing anything they can to facilitate drug use.

The success of Sullivan's plan ultimately depends on how that is defined. If the end goal is to give addicts a new chance at life and help them to become functioning members of society, then it will fail. On the other hand, if the end goal is to keep an entire population of humans in a dysfunctional state, consumed by a need for drugs and wandering the streets in pharmaceutical oblivion, then it's exactly what Vancouver needs. Job done.

...

History shows that years of compassionate chatter and political solutions (that only give the appearance of doing something) have done little to evoke any real change in the DES. In 1959, there were just four detox beds available. In 2007, there are 23 beds available downtown and only six of those are for women. One organization has another 24 beds ready, but can't get government funding for operating costs.

The only way to change Vancouver's drug culture is through treatment. That means detox beds, long-term treatment centres located away from the DES, long-term social support and instruction in life skills and trades.

The last thing an addict needs is a substitute drug. It's a pathetic, callous alternative to implementing the meaningful measures that can transform both individuals and the DES into a functioning society. - Susan Martinuk is a Vancouver columnist.

Al Arsenault, a retired DES police officer who has made award-winning documentaries of life there, says the policy is "selling human potential down the road." He knows the addicts by name and says, "They don't need drugs, they need treatment. If Sullivan wants to change the drug culture, he has to fix the addict first."

I agree. Harm reduction waves the white flag of surrender, abandons an entire population to a lifetime of despair.

The Netherlands continues to deal with the partially living products of its state-sponsored harm reduction programs. It must now provide specialized housing for ageing addicts who, in their 30s and 40s, are experiencing medical problems common to those in their 80s. These "elderly addicts" are maintained on drugs while they wait for death to come.

Feds score against homegrown meth

Good news on meth production. It seems to fit with the anecdotal information I hear in Michigan. While use may not be down, it may slow increases in use.

Data show curbs working on making, not necessarily use, of drug in USA

Small, toxic methamphetamine labs that overwhelmed rural and suburban communities in the past several years are disappearing as ingredients to make the drug become more difficult to find, federal law enforcement agents say.

New statistics released by the Drug Enforcement Administration (DEA) show a 58% drop in meth labs and abandoned sites seized last year by police and U.S. agents, to 7,347. That indicator peaked nationwide in 2003, with 17,356 sites seized.

The DEA credits the decline to state and federal laws that restrict the sale of cold medicines and chemicals used to make methamphetamine and to increased law enforcement, spokesman Rusty Payne says.

"This is one time where the laws worked, and they worked quickly," DEA Senior Special Agent Philippa LeVine says.

Does food 'addiction' explain explosion of obesity?

I'm hearing more and more discussion about food addiction. As this article points out, serious people are giving the matter serious attention:

Obesity has long been blamed on weak willpower, overeating, genetics and lack of exercise. Now scientists increasingly are seeing signs that suggest there may be an additional contributor: food addiction.

Monday night and again today, dozens of the nation's leading researchers in obesity, nutrition and addiction planned to discuss whether food has addictive properties for some people. They're gathering in New Haven, Conn., at a meeting sponsored by Yale University's Rudd Center for Food Policy and Obesity.

"We believe that there is sufficient science to suggest there is something to this, so we are bringing the leading authorities together to decide whether food addiction is real and what the underlying psychology and biology might be," says Kelly Brownell, director of the Rudd Center.

"It's surprising that our field has overlooked this concept for so long," he says. "Society blames obesity only on the people who have it and has been close-minded to other explanations."

I'm increasingly open to the idea that some people have brain dysfunction similar to drug addiction that leads to food addiction.

However, this article seems to suggest that food addiction may be a cause of a growing obesity problem in the U.S. This strikes me as absurd. It would seem that some people may have a brain that produces food addiction but the rest of us just eat too much and exercise too little.

Mobile Meeting Finder

Find a 12 step group meeting in any zip code via text messaging. Pretty cool.
[via about.com]

Recovery-oriented care

Our friend Bill White is doing some exciting work in Philadelphia helping the city implement a recovery-oriented system of care. You can read about their efforts here.

Nora Volkow on Fresh Air

Nora Volkow was on NPR's Fresh Air today. I was in and out of the car and only heard about 1/3 of it. I'll listen to the podcast after they post it. I have a couple of reactions to what I did hear.

She's gotten better and better at explaining complex neurobiology and it was good to hear her in an unscientific forum.

She addressed the relative dopamine impact of various drugs with alcohol and tobacco being at or near the bottom. This is striking because she really emphasizes increased dopamine activity as a critical factor in addiction and tobacco has the highest capture rate of all drugs. (There was a new article this week highlighting this.) I would have loved to hear more discussion of this. Clearly, there's more to the story than dopamine. (I doubt she's argue with that point.)

She did go on to discuss that tobacco is about the only addictive drug that can be freely woven into all areas of person's life. She made the case that this is an important factor in the difficulty most smokers have when trying to quit.

Anti-Smoking Pill May Help Curb Drinking

A new use for Chantix?

The drug, called varenicline, already is sold to help smokers kick the habit. New but preliminary research suggests it could gain a second use in helping heavy drinkers quit, too.

Much further down the line, the tablets might be considered as a treatment for addictions to everything from gambling to painkillers, researchers said.

...

A study published Monday suggests not just nicotine but alcohol also acts on the same locations in the brain. That means a drug like varenicline, which makes smoking less rewarding, could do the same for drinking. Preliminary work, done in rats, suggests that is the case.

``The biggest thrill is that this drug, which has already proved safe for people trying to stop smoking, is now a potential drug to fight alcohol dependence,'' said Selena Bartlett, a University of California, San Francisco neuroscientist who led the study. Details appear this week in the journal Proceedings of the National Academy of Sciences.

...

More often than not, smoking and drinking go together - an observation pub-goers have made for hundreds of years. That a single drug could work to curb both addictions isn't a given - nor is it surprising, said Christopher de Fiebre, an associate professor of pharmacology and neuroscience at the University of North Texas Health Science Center at Fort Worth.

``This is an extremely important paper and hopefully it will convince the major funding agencies that they need to examine the interactions between nicotine and alcohol to a greater extent than they have done to date,'' said de Fiebre, who was not connected with the study.

In fact, the University of California researchers, together with the National Institute on Alcohol Abuse and Alcoholism, are now planning the first studies in humans of the drug's effectiveness in curbing alcohol cravings and dependence, Bartlett said. That the drug is already Food and Drug Administration-approved should speed things along.

"This is a drug that people are actually using. That's not trivial - not at all,'' said Mark Egli, co-leader of the medications development program at the NIAAA, part of the National Institutes of Health. ``There is plenty of animal research that looks pretty cool but there is no way those drugs are ever going to be used by human beings.''

[hat tip: Debbie]

Become an ex

Here's an interesting smoking cessation site that does a good job framing it as more than quitting--they frame it as an identity change. Your not just quitting. You're become an ex-smoker. It's more than stopping doing the behavior, it's learning to live differently.
[hat tip: Wendy]

How We Get Addicted

Time has an article that is one recovering addict's exploration of the neurobiology of addiction.

Alcoholics Anonymous Founder’s House Is a Self-Help Landmark

From the NYT, on the home of Bill and Lois Wilson:

For many visitors to Stepping Stones, the gracious Dutch colonial-style house where Mr. Wilson lived with his wife, Lois, for the last 30 years of his life before dying of emphysema in 1971, there is, indeed, something profoundly personal, even spiritual, about the experience. It has been open to the public since 1988, when Mrs. Wilson died at 97. With no children, she left it to the Stepping Stones Foundation, which she had set up in the hope that the site would educate and inspire future generations.

No room for drunks

A familiar story in Boulder. Clearly there needs to be a safe place for everyone, but I wouldn't pile on the dry shelters. Part of maintaining a safe place may mean excluding some people. The community just needs to create alternative spaces for those people or, where resources already exist, improve coordination to be sure that they get to the right place.

The death of three homeless men on the icy streets of Boulder last winter - including two who apparently had been barred from the county homeless shelter for drinking - has prompted an urgent effort to avoid a similar tragedy next winter.

Activists for the homeless in Boulder County have also been critical of the shelter's policy of excluding people who are drunk.

But Boulder is not alone. Nearly every shelter in the Denver area, citing the safety of other residents, bans intoxicated people.

Policies toward alcoholics vary among area shelters, but only the Denver Rescue Mission will take in people who are obviously drunk. Others, known as "damp" shelters, will allow people who have had a few drinks to stay.

Many, though, won't allow anyone inside who shows signs of drinking.

"Our shelter is sober," said Neal Hogan of the Salvation Army, which runs the 300-bed Crossroads shelter for single men. Hogan said many of his clients are struggling with addictions and didn't need to be exposed to drunkenness.

'Nothing is magical'

The Baltimore Sun has an interview with the new director of the Open Society Institute. Nothing earth-shattering here, but the institute has always gotten a lot of attention for its harm reduction efforts, so it's good to see him focus on treatment. He even expresses support for treatment as harm reduction.

My experience in the health department shows that if you treat addiction, you have all these other spillover effects, not just on crime, but on HIV rates, on hospitalizations, on emergency room visits. In Boston, something like 30 percent of the calls that came in for emergency medical services involved either mental health or addiction-related issues. They are brought to emergency rooms, which is an incredible inefficiency and waste. Imagine if someday the EMS system could accurately triage people and take those needing it to the mental health or addiction treatment systems.

Study Finds Cocaine, Pot in Rome's Air

I was going to make a crack about a celebrity hitting Rome, but decided it was in poor taste:

Researchers may have figured out what makes la vita so dolce in Rome. A report from Italy's National Research Council released Thursday found that there are traces of cocaine and cannabis in the air of the Eternal City.
Read the rest here.

[Hat tip: Jim]

Scientists find drug to banish bad memories

I've posted before about the role of memory circuits in addiction. It looks like there may have been another step forward in research to manage memory reconsolidation. More than a little creepy, but worth keeping an eye on.

It failed to bring Jim Carrey happiness in the award-winning film Eternal Sunshine of the Spotless Mind, but scientists have now developed a way to block and even delete unwanted memories from people's brains.

Researchers have found they can use drugs to wipe away single, specific memories while leaving other memories intact. By injecting an amnesia drug at the right time, when a subject was recalling a particular thought, neuro-scientists discovered they could disrupt the way the memory is stored and even make it disappear.

Read the rest here.

[via dailydose.net]

Quitting smoking makes you happier

One more reason to quit smoking:

New survey results from Cancer Research UK, published today, should allay the fears of smokers who think giving up will make their lives a misery.

Of more than 850 ex-smokers surveyed, the vast majority reported feeling happier having beaten their addiction. Only a tiny fraction said they felt less happy.

Researchers Identify Alcoholism Subtypes

What's your type?

Analyses of a national sample of individuals with alcohol dependence (alcoholism) reveal five distinct subtypes of the disease, according to a new study by scientists at the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health (NIH).

“Our findings should help dispel the popular notion of the ‘typical alcoholic,’” notes first author Howard B. Moss, M.D., NIAAA Associate Director for Clinical and Translational Research. “We find that young adults comprise the largest group of alcoholics in this country, and nearly 20 percent of alcoholics are highly functional and well-educated with good incomes. More than half of the alcoholics in the United States have no multigenerational family history of the disease, suggesting that their form of alcoholism was unlikely to have genetic causes.”

“Clinicians have long recognized diverse manifestations of alcoholism,” adds NIAAA Director Ting-Kai Li, M.D, “and researchers have tried to understand why some alcoholics improve with specific medications and psychotherapies while others do not. The classification system described in this study will have broad application in both clinical and research settings.” A report of the study is now available online in the journal Drug and Alcohol Dependence.

Here are the subtypes:

Young Adult subtype: 31.5 percent of U.S. alcoholics. Young adult drinkers, with relatively low rates of co-occurring substance abuse and other mental disorders, a low rate of family alcoholism, and who rarely seek any kind of help for their drinking.

Young Antisocial subtype: 21 percent of U.S. alcoholics. Tend to be in their mid-twenties, had early onset of regular drinking, and alcohol problems. More than half come from families with alcoholism, and about half have a psychiatric diagnosis of Antisocial Personality Disorder. Many have major depression, bipolar disorder, and anxiety problems. More than 75 percent smoked cigarettes and marijuana, and many also had cocaine and opiate addictions. More than one-third of these alcoholics seek help for their drinking.

Functional subtype: 19.5 percent of U.S. alcoholics. Typically middle-aged, well-educated, with stable jobs and families. About one-third have a multigenerational family history of alcoholism, about one-quarter had major depressive illness sometime in their lives, and nearly 50 percent were smokers.

Intermediate Familial subtype: 19 percent of U.S. alcoholics. Middle-aged, with about 50 percent from families with multigenerational alcoholism. Almost half have had clinical depression, and 20 percent have had bipolar disorder. Most of these individuals smoked cigarettes, and nearly one in five had problems with cocaine and marijuana use. Only 25 percent ever sought treatment for their problem drinking.

Chronic Severe subtype: 9 percent of U.S. alcoholics. Comprised mostly of middle-aged individuals who had early onset of drinking and alcohol problems, with high rates of Antisocial Personality Disorder and criminality. Almost 80 percent come from families with multigenerational alcoholism. They have the highest rates of other psychiatric disorders including depression, bipolar disorder, and anxiety disorders as well as high rates of smoking, and marijuana, cocaine, and opiate dependence. Two-thirds of these alcoholics seek help for their drinking problems, making them the most prevalent type of alcoholic in treatment.

Does anyone else detect a whiff of countertransferance?

How Greenland curbed alcohol abuse

An interesting alcohol policy story from Greenland:

Alcohol abuse causes tremendous damage in Greenland...

But the solution chosen by Greenland's government for its most remote communities is not prohibition, which it acknowledges does not work, and only encourages bootlegging and the binge drinking of hard liquor. It's to ban hard liquor, but allow the sale of beer and wine.

Qaanaaq, a community of 800 near Thule on Green­land's west coast, is following this path after the government recently agreed to lift a two-month ban on alcohol.

The ban was prompted by a sociologist's report that described a community where alcohol abuse was so rampant children were often afraid to return home because their parents were drunk day and night.
...
Across Greenland, alcohol consumption has dropped dramatically since booze bans were lifted in many communities in 1982. At that time, residents consumed, on average, 22 litres of alcohol each year. That has since dropped to 13 litres.

That's still a lot compared to Canada, where the average resident drinks only eight litres of alcohol a year. But it's a huge improvement for Greenland, says Bodil Poulsen, an alcohol abuse worker with Greenland's health department.

Acetaminophen safe in abstinent alcoholics

From Reuters:

Alcoholics undergoing rehabilitation can safely use the maximum recommended daily dose of acetaminophen (Tylenol) without damaging their livers, study results suggest.

Isolated case reports have linked severe liver damage among alcoholics who abruptly stopped using alcohol and were treated with acetaminophen. Theoretically, the period of greatest risk would be right after they stopped drinking, based on various biochemical changes that take place.

...

"No participant suffered acetaminophen-related liver injury," the authors report.

Dart and his team point out that their findings can not be generalized to all alcoholic patients. They did not include patients with liver disease severe enough to impair liver function, patients who continued to drink alcohol, or individuals affected by either intentional or unintentional overdoses.

They worry that if told to avoid acetaminophen, patients who drink alcohol would be likely to use aspirin or other nonsteroidal anti-inflammatory medications, such as ibuprofen (Motrin, Advil), which are far more risky.

Psychiatrists Top List in Drug Maker Gifts

From the New York Times:

As states begin to require that drug companies disclose their payments to doctors for lectures and other services, a pattern has emerged: psychiatrists earn more money from drug makers than doctors in any other specialty.
...
Officials in Maine and Vermont said they would try to compare reports of payments to doctors with Medicaid records to explore how marketing practices might influence prescribing by doctors in ways that increased costs to taxpayers.

“What we want to be able to do is overlay the prescribing information that we have with the drug detailing information,” said Jude Walsh, special assistant to the governor of Maine, John E. Baldacci. “If we see that doctors in a certain southern county in the state are prescribing a lot of a drug and getting a lot of detailing for that drug, that could lead to some record reviews to see what’s happening.”

Addiction experts say video games not an addiction

Contrary to anecdotal evidence from college dorms and parents of adolescent boys, the APA makes a decision on video game "addiction". It appears that Super Mario will not need to be scheduled by the DEA.

Doctors backed away on Sunday from a controversial proposal to designate video game addiction as a mental disorder akin to alcoholism, saying psychiatrists should study the issue more.

Addiction experts also strongly opposed the idea at a debate at the American Medical Association's annual meeting.

Read the rest here.

The New York Times reports that global drug production and consumption is stable at the moment.
[hat tip: Matt]

Bong hits for Jesus

For those who don't know, the U.S. Supreme Court ruled that a school was within it rights to limit student speech when it confiscated a student's banner that said "bong hits for Jesus."

The Wall Street Journal highlighted some of Justice Stevens comments that compared the war on drugs, as it relates to marijuana, to prohibition:

...“Although this case began with a silly, nonsensical banner, it ends with the Court inventing out of whole cloth a special First Amendment rule permitting the censorship of any student speech that mentions drugs, at least so long as someone could perceive that speech to contain a latent pro-drug message,” he writes. “Our First Amendment jurisprudence has identified some categories of expression that are less deserving of protection than others—fighting words, obscenity, and commercial speech, to name a few.” Justice Stevens then mentions some “personal recollections” that have influenced his view that it’s unwise to create special rules for drug- and alcohol-related speech:

“. . . The current dominant opinion supporting the war on drugs in general, and our anti-marijuana laws in particular, is reminiscent of the opinion that supported the nationwide ban on alcohol consumption when I was a student. While alcoholic beverages are now regarded as ordinary articles of commerce, their use was then condemned with the same moral fervor that now supports the war on drugs. The ensuing change in public opinion occurred much more slowly than the relatively rapid shift in Americans’ views on the Vietnam War, and progressed on a state-by-state basis over a period of many years. But just as prohibition in the 1920’s and early 1930’s was secretly questioned by thousands of otherwise law-abiding patrons of bootleggers and speakeasies, today the actions of literally millions of otherwise law-abiding users of marijuana, and of the majority of voters in each of the several States that tolerate medicinal uses of the product, lead me to wonder whether the fear of disapproval by those in the majority is silencing opponents of the war on drugs. Surely our national experience with alcohol should make us wary of dampening speech suggesting —however inarticulately — that it would be better to tax and regulate marijuana than to persevere in a futile effort to ban its use entirely.

. . . In the national debate about a serious issue, it is the expression of the minority’s viewpoint that most demands the protection of the First Amendment. Whatever the better policy may be, a full and frank discussion of the costs and benefits of the attempt to prohibit the use of marijuana is far wiser than suppression of speech because it is unpopular.

Fentanyl: A Free Press Special Report

The Detroit Free Press is running a 15 part series on fentanyl in the Detroit area.

Smoking rate has plummeted in New York City

This is significant because there have been a lot of reports that smoking reduction efforts have hit a wall in recent years:

New York City's smoking rate has plummeted since a comprehensive program against smoking was launched in 2002, according to findings issued today in the national Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report (MMWR). The 2006 rate was nearly 20% lower than the 2002 rate -- a decline that represents 240,000 fewer smokers. The City's rate for 2006 is the lowest on record (17.5%), and lower than all but five U.S. states (California, Washington, Idaho, Utah and Connecticut). Over the past year, smoking decreased among men (from 22.5% to 19.9%) and among Hispanics (from 20.2% to 17.1%). These large declines followed a year-long ad campaign aimed at prompting more smokers to quit.

Read the rest here.

Is video game addiction a psychiatric disorder? AMA report seeks to declare it one

Oy vey.

Backlash on bipolar diagnoses in children

I tried to pull excerpts from this but had too difficult a time finding stuff to excise. Consider this a teaser and take the time to read the full article:

No one has done more to convince Americans that even small children can suffer the dangerous mood swings of bipolar disorder than Dr. Joseph Biederman of Massachusetts General Hospital.

From his perch as one of the world's most influential child psychiatrists, Biederman has spread far and wide his conviction that the emotional roller coaster of bipolar disorder can start "from the moment the child opened his eyes" at birth. Psychiatrists used to regard bipolar disorder as a disease that begins in young adulthood, but now some diagnose it in children scarcely out of diapers, treating them with powerful antipsychotic medications based on Biederman's work.

"We need to treat these children. They are in a desperate state," Biederman said in an interview, producing a video clip of a tearful mother describing the way her preschool daughter assaulted her before the child began treatment for bipolar disorder. The chief of pediatric psychopharmacology at Mass. General, he compares his work to scientific break throughs of the past such as the first vaccinations against disease.

But the death in December of a 4-year-old Hull girl from an overdose of drugs prescribed to treat bipolar disorder and attention deficit hyperactivity disorder has triggered a growing backlash against Biederman and his followers. Rebecca Riley's parents have been charged with deliberately giving the child overdoses of Clonidine, a medication sometimes used to calm aggressive children. Still, many wondered why a girl so young was being treated in the first place with Clonidine and two other psychiatric drugs, including one not approved for children's use. Riley's psychiatrist has said she was influenced by the work of Biederman and his protege, Dr. Janet Wozniak.

"They are by far the leading lights in terms of providing leadership in the treatment of children who have disorders such as bipolar," said J. W. Carney Jr., lawyer for Dr. Kayoko Kifuji, a Tufts-New England Medical Center psychiatrist who temporarily gave up her medical license after Riley died on Dec. 13, 2006. "Dr. Kifuji subscribes to the views of the Mass. General team."

Part of the criticism of Biederman speaks to a deeper issue in psychiatry: the extensive financial ties between the drug industry and researchers. Biederman has received research funding from 15 drug companies and serves as a paid speaker or adviser to seven of them, including Eli Lilly & Co. and Janssen Pharmaceuticals, which make the multi billion-dollar antipsychotic drugs Zyprexa and Risperdal, respectively. Though not much money was earmarked for bipolar research, critics say the resources help him advance his aggressive drug treatment philosophy.

Numerous psychiatrists say Riley's overdose suggests that bipolar disorder is becoming a psychiatric fad, leaving thousands of children on risky medications based on symptoms such as chronic irritability and aggressiveness that could have other causes. Riley's father, for example, had only recently returned to the home after being accused of child abuse, according to police. Since the girl's death, state officials have stepped up a review of the 8,343 children taking the latest antipsychotic medications under the Medicaid program for conditions including bipolar disorder, to be sure the treatment is appropriate.

Psychiatrists too often prescribe th
ese medications, which carry side effects such as weight gain and heart disease risk, without addressing problems in the children's lives, said Dr. Gordon Harper, director of child and adolescent services at the state Department of Mental Health. He likened the approach to "tuning the piano while the subway is going by."

Aggressive treatment
Biederman's critics chide him for not speaking out against misuses of a diagnosis that he has helped inspire. Among leading authorities on bipolar disorder, the Mass. General team has proposed the most aggressive treatment for the broadest group of children, they say, and Biederman should take responsibility when treatment goes wrong. At a conference on bipolar disorder at Pittsburgh's Point Park University last weekend, one speaker, Dr. Lawrence Diller, a California behavioral pediatrician, contended that Biederman bears some blame for Riley's death.

"I find Biederman and his group to be morally responsible in part," said Diller, whose popular book, "Running on Ritalin," accused psychiatrists of over treating another childhood condition, attention deficit hyperactivity disorder. "He didn't write the prescription, but he provided all the, quote, scientific justification to address a public health issue by drugging little kids."

Biederman rejects the idea that Riley's death is a cautionary tale, accusing critics of exploiting a tragedy to fan fears about psychiatry, a profession that has long faced prejudice. "The fact that she had XY drug or XY treatment is irrelevant to what happened. . . . If this child had the same outcome from treatment for asthma or seizures, we wouldn't have this frenzy," said Biederman in an interview at Mass. General's Cambridge mental health clinic.

Though Biederman acknowledges that distinguishing bipolar disorder from ordinary crankiness and flights of fancy in young children is challenging, he insists there is no ambiguity in the patients at his practice. "People have to wait a long time to see me or my colleagues. . . . It's not that somebody comes to me after their child has a temper tantrum. They do things for years that are dangerous. These are things that profoundly affect the child," said Biederman, putting them at risk of academic failure or even suicide.

Biederman dismisses most critics, saying that they cannot match his scientific credentials as co author of 30 scientific papers a year and director of a major research program at the psychiatry department that is top-ranked in the "US News & World Report" ratings.

The critics "are not on the same level. We are not debating as to whether [a critic] likes brownies and I like hot dogs. In medicine and science, not all opinions are created equal," said Biederman, a native of Czechoslovakia who came to Mass. General in 1979 after medical training in Argentina and Israel. He now lives in Brookline.

Read the rest here.

Exploring the process of recovery through patient testimonials

Relapse predicted by profanity and unoriginal sharing? I guess my recovery is more miraculous than I realized.

Does Stimulant Treatment for ADHD Increase Risk of Drug Abuse?

It depends. (Keep in mind that lower levels of dopamine D2 receptors has been associated with addiction.):

After two months of treatment, and again after eight months, the scientists performed positron emission tomography (PET) scans to measure the levels of dopamine D2 receptors, a type of brain receptor important for experiencing reward and pleasure that has been linked to pleasure and drug abuse. After the eight-month treatment, animals were also tested for their propensity to self-administer cocaine.

Rats given the 2mg/kg dose of methylphenidate were significantly less likely to press a lever to self-administer cocaine, and received fewer self-initiated infusions of the drug following eight months of treatment than the lower-dose group or the control rats.

The changes observed in brain chemistry were specific to the age and duration of methylphenidate treatment: Specifically, after two months of treatment, brain scans revealed that both groups of treated rats had lower levels of dopamine D2 receptors in their brains than did control animals.

In contrast, after eight months of treatment, the brain scans revealed elevated levels of dopamine D2 receptors in treated rats compared with controls, with the higher-dose treatment group showing the highest level of D2 receptors. In the control group, D2 receptor levels declined with age. Research at Brookhaven and elsewhere has suggested that low levels of dopamine D2 receptors may increase the likelihood of drug abuse, while elevated levels of dopamine D2 receptors may attenuate the propensity to abuse drugs.

Read the rest here.

Substance abuse care environment "toxic" for people in recovery

Substance Abuse and Mental Health Care Environment "Toxic" for Persons in Recovery and Those Working in the Field (PDF, 1 page)
[hat tip: CCSA.ca]

Best anti-pot ad ever Redux

Message board reactions to The best anti-pot ad ever:

Anti-marijuana ads by stoners and for stoners? Bud-blazer Seth Stevenson gives the latest weed-whacking ads an "A" for effectiveness, declaring the newest campaign The Best Anti-Pot Ad Ever. He lauds these ads for steering away from the alarmism of previous spots, and sticking to the more modestly realistic claims that pot can cause aliens to steal your girlfriend or maybe disappoint your dog. Color me dubious that the same primal fears which sell toothpaste and deodorant—getting dumped and making a poor impression—will have any special cachet with the stoner set.

The merits of this argument, however, get lost in the haze of smoke rising from Slate's basement apartment, The Fray. Legions of readers seem to be lit up over the mere concept of opposing marijuana use. Rather than discouraging stoners, the ads have only incensed them. Buried among the tirades for legalization, there are some rather astonishing testimonials—one poster claims to have risen from his wheelchair and surfed the swells of hurricanes under the curative powers of the magic herb. I'm not saying he didn't... but his story lends credibility to mnloft's harrowing tale of a teenage son literally gone psycho under the influence of weed. Doesn't every stoner know one kid who couldn't quite hack it?

Amidst all the swirling color, some actual discussion of the article and the ads has taken place. First-time Frayster, eek223, provides a fairly representative reaction to the ads from a teenaged perspective—apparently, low-budget isn't "hip" with the upcoming generation. bluebird makes a solid point that all such commercials inspire the inevitable adolescent question: "Who's 'The Man' behind the curtain?" (If this point interests you, check out this post from Melvyl.) Based on her personal experience, queentutt figures mass-media might as well be broadcasting from the dark side of the moon, given how poorly it connects with contemporary kids. In a reasonably fair critique of Stevenson's article, figgyforcurt worries about short-term memory loss among anti-drug advertisers:

This article would've been better written if it explored the dilemma of sending mixed messages to kids by drastically changing "brand messaging." Think about it. One year ago, an anti-marijuana ad tells kids they're going to get high and kill a toddler, and the next year, an ad tells them they'll be uninteresting. If I were a teen and I'd seen both sets of ads, I'd dismiss both, because I'd see through the fact that a thinking man on the other end of the ad is trying to tell me why something is bad but can't figure out why exactly it is bad. This is the "fundamental mistake" this writer made in writing this article, dismissing the fact that those old ads do exist, and have impacted teens. Failing to consider that no matter how effective these ads appear, they must be considered as inconsistent in the larger framework of the anti-marijuana ad context.

Personally, I'd hope the best way to scare cynical teens straight would involve showing them the perils of earnest drug culture—NORML parties. In the meantime, responsible adults would be welcome in the Ad Report Card Fray. If you don't show up, someone's kids will be getting the unchallenged word on drugs from folks like this...GA …

The best anti-pot ad ever

From Slate.com:

Until recently, most anti-marijuana ads made the same fundamental mistake: They tried to link smoking weed with some sort of immediate physical danger. Think of the PSA in which a carful of stoners runs over a girl on a bicycle; or the one in which a fuzzy-brained pot smoker shoots his friend (oopsy daisy!) in the head. Melodramatic scare tactics like these may reassure the older, out-of-touch politicians who approve federal funding for anti-drug ads. But when it comes to a drug like weed, this message just doesn't ring true with the people it's meant to reach.

"It's easy to do ads about drugs like heroin and meth, and the awful consequences that manifest," says Tom Riley, director of public affairs at the Office of National Drug Control Policy. "It's harder to make ads about marijuana. 'Marijuana's gonna melt your face off' isn't really a credible thing to say to teens."

This realization—the result, according to Reilly, of stepped-up research into the mindset of the 13- to 17-year-old target market (though I could have saved them a pile of money if they'd just asked me)—has led to a far more soft-pedal approach of late. Consider "Pete's Couch": In this anti-pot PSA, the major immediate danger posed by smoking weed is that you might sit around on your sofa for 11 hours straight. The ad won points with me for its honesty (I've blazed away a few couch-bound afternoons of my own). But I doubt the specter of inactivity is a deterrent for the average teen. With the advent of instant messaging, on-demand digital cable, and really awesome video games, I get the sense that modern youth sees no downside to spending entire fortnights immobile on an overstuffed cushion.

This new campaign opts for slightly scarier scare tactics. Again, though, the nature of the threat is subtler and more realistic. (Well, as realistic as an ad that features space aliens can be.) There's no fatal car crash or gun accident—that kind of acute disaster would never enter into the cost/benefit analysis a teen might run before getting high. Instead, the frightening possibility posited here is that smoking weed will make you boring to be around. The animated lass in the ad described above seems fed up with her stoner boyfriend—her one line of dialogue is the ad's title: "Not again"—and she's quick to ditch him when that straight-edge alien dude happens along.

Read the rest here.

The ads themselves can be viewed here and here.

When Is a Pain Doctor a Drug Pusher?

The NYT ran an exhaustive article today on a the recent conviction of a pain management doctor for his prescribing practices. The article provides a lot of background and wrestles with many of the big questions:

...most doctors prescribe opioids conservatively, and many patients and their families are just as cautious as their doctors. Men, especially, will simply tough it out, reasoning that pain is better than addiction.

It’s a false choice. Virtually everyone who takes opioids will become physically dependent on them, which means that withdrawal symptoms like nausea and sweats can occur if usage ends abruptly. But tapering off gradually allows most people to avoid those symptoms, and physical dependence is not the same thing as addiction. Addiction — which is defined by cravings, loss of control and a psychological compulsion to take a drug even when it is harmful — occurs in patients with a predisposition (biological or otherwise) to become addicted. At the very least, these include just below 10 percent of Americans, the number estimated by the United States Department of Health and Human Services to have active substance-abuse problems. Even a predisposition to addiction, however, doesn’t mean a patient will become addicted to opioids. Vast numbers do not. Pain patients without prior abuse problems most likely run little risk. “Someone who has never abused alcohol or other drugs would be extremely unlikely to become addicted to opioid pain medicines, particularly if he or she is older,” says Russell K. Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center in New York and a leading authority on the treatment of pain.

I've had several recent posts on opioids and pain and have wondered how common these prosecutions are. The article offers some perspective on the question:

How typical is McIver’s case? On the D.E.A.’s Web site the agency lists some of the doctors who have been prosecuted, and their crimes. There are some strikingly obvious and egregious cases of shady dealings: a doctor who wrote prescriptions in a gas station for a person who wasn’t present; one who sold blank prescription forms; one who dispensed drugs to people who then shared them with him.

But not every doctor’s intent to deal drugs is as clear. McIver was a crusader for high-dose opioids, credulous with patients and sloppy with documentation — a combination unwise in the extreme. But some of his patients said he was the only doctor who ever brought them relief. Prosecutors never brought any evidence that he intended to write prescriptions to be abused or sold. They never accused him of profiting from his patients’ diversion except in collecting office fees. His patients who diverted or abused their opioids all testified they got their prescriptions by consistently lying to him. Nor is it convincing that his prescriptions killed Larry Shealy.

No one has analyzed the various prosecutions of pain doctors, so it is hard to determine how many of them look like McIver’s. The D.E.A.’s list is incomplete. There have been many cases like McIver’s, and most of these cases are not listed on the D.E.A.’s Web site. (One possible reason for this omission is that some of these cases are still being appealed.) And many cases that do appear on the list detail only vague crimes: convictions for prescribing “beyond the bounds of acceptable medical practice” or “dispensing controlled substances . . . with no legitimate medical purpose” — which is how the agency will most likely describe the McIver case if it ever includes the case on the list.

The D.E.A. claims that it is not criminalizing bad medical decisions. For a prosecutable case, Caverly, the D.E.A. officer, told me: “I need there to be no connection of the drug with a legitimate medical condition. I need the doctor to have prescribed the drug in exchange for an illegal drug, or sex, or just sold the prescription or wrote prescriptions for patients they have never seen, or made up a name.”

I read this statement to Jennifer Bolen, a former federal prosecutor in drug-diversion cases who trained other prosecutors and now advises doctors on the law. “That’s a good goal,” she said. “I don’t think they have yet reached that goal.” McIver’s case had no such broken connection, and in many cases the government has not produced testimony of intent to push drugs, providing evidence only of negligence or recklessness.

The author provides some recomendations for law enforcement and medical review:

The dilemma of preventing diversion without discouraging pain care is part of a larger problem: pain is discussed amid a swirl of ignorance and myth. Howard Heit, a pain and addiction specialist in Fairfax, Va., told me: “If we take the fact that 10 percent of the population has the disease of addiction, and if we say that pain is the most common presentation to a doctor’s office, please tell me why the interface of pain and addiction is not part of the core curriculum of health care training in the United States?” Will Rowe, the executive director of the American Pain Foundation, notes that “pain education is still barely on the radar in most medical schools.”

The public also needs education. Misconception reigns: that addiction is inevitable, that pain is harmless, that suffering has redemptive power, that pain medicine is for sissies, that sufferers are just faking. Many law-enforcement officers are as in the dark as the general public. Very few cities and only one state police force have officers who specialize in prescription-drug cases. Charles Cichon, executive director of the National Association of Drug Diversion Investigators (Naddi), says that Naddi offers just about the only training on prescription drugs and reaches only a small percentage of those who end up investigating diversion. I asked if, absent Naddi training, officers would understand such basics as the whether there is a ceiling dose for opioids. “Probably not,” he said.

There is another factor that might encourage overzealous prosecution: Local police can use these cases to finance further investigations. A doctor’s possessions can be seized as drug profits, and as much as 80 percent can go back to the local police.

There are ways to prevent diversion without imprisoning doctors who have shown no illegal intent. They are increasingly used — but state authorities and doctors need to push even harder. The majority of states, South Carolina among them, do not yet have prescription monitoring — a central registry of prescriptions, which could help catch people getting opioids from several different doctors and pharmacies. Doctors should use more urine and blood tests, including screens that can tell quantities of drug present.

Last year, state medical boards took 473 actions against doctors for misdeeds involving prescribing controlled substances. In many cases, their licenses were pulled. Physicians can also lose their D.E.A. registration, and with it the right to prescribe controlled substances. A few dozen do every year, although there is considerable overlap with medical-board actions. Washington is the first state to recommend that only pain specialists handle high-dose opioids; other states are likely to follow.

This article seemed to have a bias, but generally seemed to do a good job of providing multidimensional context. However, including this line without context bothered me:

There is another factor that might encourage overzealous prosecution: Local police can use these cases to finance further investigations. A doctor’s possessions can be seized as drug profits, and as much as 80 percent can go back to the local police.

How often does this happen? I'm sure it happens but it paints a rather sinister picture of police and prosecutors. If the practice is widespread enough to mention, some context seems appropriate.

The article closes with an anecdote that provides some perspective on the aggressive, unorthodox practices of Dr. McIver:

With his typical imprudence, McIver told Ben: “You don’t worry about it, take whatever you need to be pain-free, if it takes 2 pills or 10 pills. If you’re taking too much and slurring your words, you know to back off. Use some common sense.” At McIver’s request, Ben kept a diary of what he took and how much. He reached a top dosage of five 80-milligram pills of OxyContin four times a day — more opioids than Shealy was taking at the time of his death. “I never felt high,” he said. “They helped my pain. I could get out and work, use the bulldozer. I was working a 250-head cattle herd. I was doing everything relatively pain-free because of the drugs. They gave me my life back.”

[hat tip: Matt]

Is cocaine back?

From the NYT:

Drug-abuse experts say the blasé attitude toward cocaine use is a result of “generational amnesia.”

“There seems to be less of a stigma about” cocaine, said Dr. Herbert Kleber, director of the division of substance abuse at the New York State Psychiatric Institute in Manhattan. As part of his oversight of research into cocaine addiction and treatment, and in his private clinical practice, Dr. Kleber hears stories about the drug’s use. “People don’t feel nearly as much the need to hide it,” he said. “They feel that they can use it in a more open fashion.”

The visibility of cultural markers — and the absence of cautionary tales — leads to the assumption that coke is not as harmful, say, as heroin (which was associated with the high-profile overdoses of River Phoenix and Kurt Cobain in the 90s), or methamphetamine, whose recent popularity in the gay community has led to a targeted campaign against it, said Perry N. Halkitis, a professor of applied psychology at New York University who studies behavior, the AIDS epidemic and drug abuse.

“If you’re a 19-year-old and you go out and party and you’re offered meth, you say no because you’ve heard these bad things,” he said. “But you’re offered coke, you say yes because you assume it’s safe.” And, he added, as the authorities crack down on meth, “people are going to tend to go to cocaine, which has similar, if not identical properties” as a stimulant.

STATS.org responds:

This is the problem with having a demon drug of the moment: all of them can’t possibly be “the worst” and “most addictive” and “most dangerous,” but if you look at the news coverage of each new scare, that’s exactly what the coverage claims. When crack came out, it was “more addictive than heroin,” (the previous worst drug ever), now meth allegedly makes crack look like “child’s play.”

Different drugs certainly do carry different risks—but that’s not what the media or the government wants to explore. To do that would mean admitting that some really are more harmful than others and that the relative harm has little to do with drugs’ legal status. For the media, it would mean that these drug trend stories have far less news value—because the truth is that some drug is always in and it’s not always worse than the one that went before it.

Exploring the varying risks of addiction related to these drugs would also mean having to actually understand addiction and why some people are at greater risk than others and what “more addictive” really means. It would mean recognizing that addiction is not an equal opportunity problem—that levels of it are much higher amongst the poor and unemployed than amongst the middle classes (and probably also higher amongst the extremely rich).

And it would also mean trying to understand whether the people who fall prey to one type of drug are only at risk for that sort of addiction—or whether the trends really don’t matter much and sweep up the at-risk people no matter what drug is in fashion.

Bringing life to Wellstone's dream

From the Star Tribune:

Stuck in traffic on an April morning in 2002, Paul Wellstone got to talking. "You know," he said of his fellow lawmakers, "party affiliation counts for less than I once guessed. There are decent folks on both sides of the aisle. Take Jim Ramstad. The guy is -- well, really, he's a total mensch."

With trademark sentence fragments and Wellstonian gestures, the professor-turned politician expressed a surprising certainty about the future.

"Jim and I have fought, like, forever to win equal treatment for mental illness and addiction -- and I'm telling you, he's just not giving up. He's a recovering alcoholic. He knows this stuff. No big-bucks insurance lobby will ever get him to back down. I mean, we're definitely passing these bills next year -- no question -- but if it takes another 10 years, that guy won't quit. And neither will I."

Wellstone's words might have been entirely on the mark but for a poorly piloted plane. But though his death in October of 2002 stalled the parity quest, his assessment of the Republican named Ramstad was apt. More than a decade after joining Wellstone in this project, Ramstad is as resolute as ever. This year he enlisted Rep. Patrick Kennedy, D-R.I., to push a revamped bill, which wisely demands that both mental and addictive disorders be treated under the same rules as physical illnesses.

Entitled the Paul Wellstone Mental Health and Addiction Equity Act, the new bill merely changes federal law to reflect scientific fact: Mental illness and addiction -- like Alzheimer's disease and epilepsy -- are brain disorders treatable by medical care. There's no reason to set them apart, and the Ramstad-Kennedy bill thus would bar health insurers from doing so. The measure would end the higher copayments, deductibles and out-of-pocket costs that patients with such brain disorders now pay. It would also nix tighter limits on hospital stays and office visits for these illnesses than for other ailments.

The plan makes a world of sense, and its House sponsors insist this is the year to write it into law. Though the measure's Senate companion -- sponsored by Pete Domenici, R-N.M., and Ted Kennedy, D-Mass. -- is meeker, there's reason to expect the more compelling House bill to prevail. Hopes have risen enough to draw Wellstone's son David -- no ordinary lobbyist -- to Washington to make the case for parity.

After all this time, surely lawmakers can grasp the logic: Pretending that brain diseases aren't "real" illnesses requiring medical care is harmful, not thrifty. It keeps sick people sick, hurts families and deprives society of contributions from citizens helped to recovery.

If lawmakers still don't get it, perhaps they should call in an expert. Their best bet is Paul Wellstone's old friend Jim Ramstad -- a fiscal conservative who happens to be a recovering alcoholic -- not to mention a mensch.

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.