The soul of harm reduction

Several experts were asked "what harm reduction means to me."

Highlights below:

I regard harm reduction as a subversive way of performing medicine: doing outreach work, sharing knowledge with users, empowering them, care and cure in a more human, respectful and humble way, inventing a model which not only concerns drug use, but also transforms my whole practice

The magnificent work people who injected drugs in New York in the late 1970s and early 1980s did to figure out that they were under attack by an insidious disease - long before science figured it out.

Their success, in spite of continual assaults on their dignity and autonomy by media, politicians and police, in figuring out how to reduce their risk of acquiring or passing on this new disease - long before public health or others did much of anything.

The creativity of users (and their saying “We Are Human”) as they organised activist groups to pressure service providers and governments to help them when they need it and to respect their dignity and autonomy at all times.

To me, harm reduction means love, passion and care to all human beings who live with us ... I have graduated from university twice - once from a medical university in Shiraz (my home town) and once from the street university with all the people who use drugs and live with drugs. To me, the most efficient and noble experience was having the chance to be with people on the streets – to live with them and learn from them. Now they are my best friends and my best teachers whenever I need. I feel for the first time in my life that now I have a meaningful dream to live with

I had to smile when I was asked to write this short piece of what harm reduction means to me. Harm reduction for me has become more than something I do at work. It is a philosophy that I have adopted to guide how I deal with many sides of my life and I practice it not only professionally but maybe more importantly in my home. I am a single parent with three teenage children - two girls (11 and 15 years old) and a son of 13....

I have created a non-judgmental environment in my home where my children are comfortable sharing with me what is going on in their lives. HIV and drugs have been a regular topic of discussion in my kitchen for years! Condoms have always been around our house and are not seen as something weird or external - my children know what they are for. I have educated them to be peer educators in terms of drugs, sexual health, and HIV - so that when they hear misinformation from their friends they are able to provide the correct information. They know that I would rather that they did not use any substances, but we have also discussed each substance (including tobacco, ganja, crack and alcohol) and they know the harms associated with each. Instead of preaching sexual abstinence with my children, I have discussed with them the physical and mental health benefits of postponing intercourse to a later age and we have discussed other strategies for satisfying a partner through ‘outer-course’ (politically correct word for ‘mutual masturbation’ or ‘heavy petting’ - as it was called when I was 14!). If they chose penetrative sex, then they know that any boy who refuses to use a condom is not worth having sex with.

The age of sexual consent is 16 in Saint Lucia. As they turn 16, I will let them use the guest apartment under the house for their conjugal visits rather than have them go out to a car or beach where rape is a possibility.

For most drug users, harm reduction – not abstinence – is the only chance to survive. Harm reduction relieves them from the humiliating consequences of prohibition (at least those who have not been deterred). Harm reduction enables them to save their lives and live them free of contempt and humiliation. Harm reduction means to lead a constant fight against people’s need to reassure themselves of their superiority by stigmatising those who deviate from normality. Harm reduction forms a lively counterbalance to the exaggerated sense of duty and hostility to pleasure originating from puritan ideology. Harm reduction supports people who do not want to suffocate in a puritan corset but who strive for a life with intense experiences, even if their attempts often ended in failure.

Chantix and mental illness

Something to keep an eye on:

The August issue of the American Journal of Psychiatry included two letters reporting single cases of worsening of symptoms of schizophrenia and mania, while they were taking the new smoking cessation medication, Chantix (varenicline).

It's Not Fair. It's Not Working,

The ACLU has started a campaign to end the 100:1 crack cocaine sentencing disparity.

Diary Of A Mad Voter: In Search Of A Presidential Candidate Who Will “Just Say No”

DARE, the DEA, the War on Drugs, the presidential campaign, and apparently genuine concern about drug misuse. Jessica Peck Corry covers a lot of ground in this column.

Highlights:

While we don’t have the money to treat drug addiction, we do have the money to send users to prison.

...I respectfully request that the government refrain from putting a bong in the hands of my children.

The New Science of Addiction

A great educational website about addiction. It focuses on neurobiology but also covers a few other areas. Make sure to check out Mouse Party.
[Hat tip: Jim]

Anxiety, depression, and heavy drinking

From Addictive Behaviors:

Abstract

The Transtheoretical Stages of Change Model specifies that when the costs outweigh the benefits of substance abuse, the resulting discomfort can be a catalyst for change. The current study evaluated the roles of depression and anxiety in motivating readiness to change current drinking behaviors. Results from regression analyses of self-report data from 233 undergraduate hazardous drinkers indicated that higher levels of depression and anxiety were associated with elevated readiness to change. Additionally, study findings showed that when considered together, anxiety accounted for more of the individual differences in alcohol change readiness than depressive symptoms. Study results were discussed in the context of existing models of change readiness and implications for further research and clinical practice.

Not all that surprising if you follow the literature. In spite of trends to characterize every psychiatric symptom as a co-occurring disorder, these symptoms are not always noxious and may indicate intact reality testing and internal strengths rather than pathology.

Boozy Brits face disease timebomb

An update on British drinking habits and liver disease:

"There's been a frightening increase in alcoholic liver disease in recent years," said Dr. Ian Gilmore, president of the Royal College of Physicians.

Deaths from cirrhosis in Britain increased dramatically over the past two decades, while they fell steadily everywhere else in the Western world, according to government statistics.

In England and Wales, 17.5 deaths of every 100,000 men were due to cirrhosis in 2002, up from 8.3 in 1987. And in Scotland, the increase was even more dramatic: 16.9 cirrhosis deaths per every 100,000 men in 1987 to 45.2 per 100,000 in 2002.

By comparison, the overall U.S. cirrhosis rate has fallen from 15 deaths per 100,000 in 1973 to nine per 100,000 in 2004. In the European Union, the rate in the early 1980s was about 20 per 100,000 deaths; by 2004, it had fallen to 13 per 100,000. Neither the U.S. nor the EU provided a breakdown between men and women.

Addiction: Moral Failing or Disease?

ABC News provides some coverage of Senator Biden's efforts to change federal language related to addiction:

Under the Recognizing Addiction as a Disease Act of 2007, which Biden sponsored, the National Institute on Drug Abuse will become the National Institute on Diseases of Addiction, and the National Institute on Alcohol Abuse and Alcoholism will become the National Institute on Alcohol Disorders and Health.

However, it also reports on a pseudo-debate about the nature of addiction. Guess which experts question the disease model? Sally Satel and Scott Lilienfeld. (More here, here and here.)

There is no raging debate among experts. Overwhelmingly the disease model is accepted. There are a few gadflies like these two and Stanton Peele and Jeffrey Schaler who pop up every time the media needs to create conflict in a story.

Gone camping.

No blogging for a few days.

The Economics of Addiction

I understand the intellectual argument, but I don't understand how any human being can buy this.

Is rushing out to buy dope that killed your friend rational? Do they really believe that there's a rational dimension to using drugs so frequently in such large quantities that the addict loses his/her home, family, health, career, hopes, dignity, etc? Do they not get that people kill themselves in despair because of their inability to quit?

This seems to be a great theory if you place supreme value on cleverness or or if you are invested in believing that addiction is a choice.

Worker Substance Use and Workplace Policies and Programs

No surprise here. Food service and construction workers have the highest rates of drug and heavy alcohol use.

Faith-based initiative backfires

From the Christian Science Monitor:

Once upon a time God, with some federal funding, was going to do so much.

In his early years, President Bush promoted funding for faith-based groups in order to blast social problems with the power of religious belief by unleashing the "armies of compassion." Bush predicted that his faith-based initiative would be his great legacy. And it does send an estimated $2 billion to religious charities.

But the campaign, ignored by Congress and challenged in court, has dropped off the White House talking points. After a brief mention in the 2006 State of the Union address, it was left out entirely this year.

The initiative did leave another legacy: It gave spirituality a bad name in social-service circles.

Read the rest. It provides an interesting perspective on spirituality and treatment.

Addicted to prisons

California may be close to establishing a cap in their prison population. This has the potential to force serious drug policy reform.

On july 23, two U.S. District Court judges ordered the convening of a three-judge panel to consider releasing prisoners from California's alarmingly overcrowded state prison system. The judges' move raises the possibility that a specific cap on the state's prison population will come into place within the next few weeks or months.

...

The governor should order the early release of nonviolent parole violators and require parole officials to review whether community-based measures can address the risks posed by future technical violators. Special legislation to allow early release of nonviolent offenders who are within a few months of completing their sentences also should be considered.

Even these measures will not be enough to free the state from its chronic overuse of prison. To do this, the governor must come before the people and speak the truth about our penal code with his trademark frankness. These are laws written by and for "girlie men." We must learn to address serious social problems, like drug addiction, homelessness and threatening gang behavior, without indiscriminate recourse to prison. The governor should appoint a sentencing commission staffed with independent experts on crime and law enforcement to overhaul sentencing laws, with a mandate to reduce our reliance on prisons.

Which to treat first: Comorbid anxiety or alcohol disorder?

This article does a pretty good job outlining the problems and the potential relationships between symptoms:

The most common understanding of this comorbidity is that having an anxiety disorder predisposes one to develop an alcohol or substance use disorder via self-medication—using alcohol or drugs to modulate anxiety and negative affect. However, substance use disorder experts have argued that the social, occupational, and physiologic effects of substance use can generate new anxiety symptoms in vulnerable individuals. In other words, physiologic and/or environmental disruptions from chronic alcohol or substance use could promote conditions and circumstances in which anxiety symptoms are more likely to emerge or worsen.

Although DSM-IV-TR does not delve into the causes of mental disorders, it states that substance use can cause or “induce” an anxiety syndrome with symptoms that resemble or are identical to those of the various anxiety syndromes that are not related to substance disorder.

Alternatively, the idea that a third factor can serve as a common cause for both conditions fits with the view that substance use disorder and anxiety disorder can be phenotypic expressions of a common underlying genetic/physiologic liability.

Finally, these models are not mutually exclusive. Anxiety symptoms or substance use could cause or aggravate the other.

It also covers the possibilities in the sequence of symptoms (with a little psychiatric bias):

Anxiety disorder typically begins before a substance use disorder in comorbid cases, although some studies have reported the opposite pattern or roughly simultaneous onset of both disorders.

Using a prospective method in college students, we found that the risk of developing alcohol dependence for the first time as a junior or senior more than tripled among students who had an anxiety diagnosis as a freshman. We also found, however, that students who were alcohol dependent as freshman were 4 times more likely than other freshman to develop an anxiety disorder for the first time within the next 6 years.

In short, having either an anxiety or alcohol disorder earlier in life appears to increase the probability of developing the other later. This finding supports the idea that the types of associations that link pathologic anxiety and substance use vary among individuals and, perhaps, within individuals over time.

All of this seems to really come down to good, conservative diagnostic practice.

Today in pot history

The Freakonomics Blog acknowledges the 70th anniversary of the Marihuana Act of 1937.

Prisons and harm reduction--Deadly disregard?

The Journal of the Canadian Medical Association has an article entitled Deadly Disregard on the absence of needle exchanges in Canadian Prisons. It includes the following line:

Public comment commonly proceeds on the premise, sometimes stated but often assumed, that conviction removes all rights and that prisoners are entitled to little consideration once incarcerated.

Wow. People who object to the implementation of a needle exchange in a prison setting are simply indifferent to the human rights of prisoners?

How about responding the problem of addicted inmates in a manner other than an accounting exercise that reduces their well being to a count of infections? How about responding to the problem of addicted inmates with something other than the cheapest solution? (I suppose it really comes down to how you define the problem. Is it addiction, or disease transmission?)

Aren't prison and parole great opportunities for intervention. What about providing treatment on demand?

Tobacco Substitutes: Harm Reduction or Smokescreen?

The Public Library of Science Medicine editors want input on snus as a harm reduction strategy for smokers:

The editorial this month was triggered by a discussion among the editors at PLoS Medicine about whether or not we should, as a medical journal, be publishing papers on the use of smokeless tobacco (snus), the topic of the debate by Gartner, Chapman, and colleagues). At one end of the spectrum of views expressed, one editor argued that we should not give the topic room in the journal at all, because even discussion of the use of snus simply plays into the hands of the tobacco industry, which has a notorious history of doing anything it can to addict people to tobacco. At the other end of the spectrum, another editor pointed out that since snus is associated with less risk to health than cigarettes, a discussion of its use as a harm reduction measure is an appropriate topic for a medical journal. On this topic, the editors simply could not come to an agreement. (Another such topic, incidentally, is that of qualitative research, on which more in future.)

Don't journals have a duty to give all sides of a debate? That was certainly the argument that the BMJ put forward when it published a paper that concluded that harm caused by passive smoking had been overestimated. Unfortunately, that paper turned out not to be free of bias and may in fact have been part of the tobacco industry's ongoing attempt to discredit evidence of the harms caused by passive smoking. In trying to be fair, the BMJ may have been the victim itself of cynical maneuvering by an industry not known for its interest in playing by the rules in promotion of its products. By publishing papers such as the one on snus, could we be legitimizing a debate that at best can only shift tobacco dependence from one product to another? Should we only publish papers that point out the wrongdoing of the tobacco industry or advocate the abolition of all tobacco products?

No PLoS Medicine editor would argue that profiting from an addiction that severely impairs health is ethical, and none of us would dispute that ceasing to use tobacco is better than switching to snus. The issue is whether, in a world where many people die from their tobacco addiction without overcoming it, we should give room to the opinion that switching to snus, although not better than quitting, may be better in terms of short-term health outcomes than continuing to smoke.

In respect for honest differences of opinion, we are ending this editorial without a bottom line. Do papers on smokeless tobacco serve a legitimate public health interest? We'd like to seek the opinions of our readers: what do you think?

You can submit a response here.

South Florida Hospital Will No Longer Hire Smokers

Is this the next step for tobacco-free health care facilities?

(DF employees who are smokers--Do not freak out.)

Cannabis and conventional wisdom on co-occurring disorders

I haven't been looking and I've stumbled on two posts (here and here) that dismiss the recent cannabis findings. I'm sure I'd find more if I looked.

They argue that the correlation between smoking weed and an increased in risk for schizophrenia is best explained by self-medication--that people who are in the early stages of schizophrenia are self-medicating, rather than marijuana causing the onset of schizophrenia in small numbers of people.

I wonder if this is setting the stage for a little backlash against the psychiatrization of addiction. If addiction researchers have a hard time getting their research taken seriously maybe they'll start putting a little more effort into dispelling self-medication theories.

One can hope.

More on Satel and the Disease Model

Satel sent Lemonick a link to a longer article on the same subject:

My job is to help addicts quit heroin and not go back to it in the future. If this is a challenge for the clinician, it’s a monumental effort for the addict. Every so often a patient will ask me if I can “hypnotize” him out of his habit. One patient told me he wished there were an anti-addiction pill, “something to make me not want.” Indeed, that is the timeless quest of troubled addicts everywhere: not to want. It comes as no news to them, however, that recovery is very much a project of the heart and mind. Nor is it news that recovery is attainable.

This is why I chafe at the conventional scientific wisdom about addiction: namely, that it is “a chronic and relapsing brain disease.”[4] This view is much heralded by the National Institute on Drug Abuse, or NIDA, part of the National Institutes of Health. NIDA is funded at slightly over $1 billion a year and carries enormous authority on Capitol Hill, among grant-seeking scientists, and in medical schools. The “brain disease” idea is promoted at major rehab institutions such as the Betty Ford Center and Hazelden[5]; it is now a staple of anti-drug education in high schools and in counselor education. And, of course, lawyers play fast and loose with the brain disease rhetoric in courtrooms[6].

The brain disease concept sends a perilous public health message. First, it suggests that an addict’s condition is amenable to a medical cure (much as pneumonia is cleared with antibiotics). Second, it misappropriates language more properly used to describe conditions such as multiple sclerosis or schizophrenia—afflictions that are neither brought on by the sufferer himself nor modifiable by his desire to be well. Third, it carries a fatalistic theme, implying that users can never free themselves of their drug or alcohol problems.

The brain disease rhetoric also threatens to obscure the vast role of personal agency in perpetuating the cycle of use and relapse to drugs and alcohol. It sends a mixed message that undermines the rationale for therapies and policies that depend on recognizing the addict’s potential for self-governance.
...
We tend to think of the cocaine addict in the throes of a days-long binge. He frantically gouges himself with needles, jams a new rock into his pipe every 15 minutes, or hungrily snorts lines of powder. Or we think of the heroin junkie either nodding off or doubled over in misery from withdrawal, so desperate for the next hit that he’ll get the money any way he can. In the grip of such forces, an addict cannot be expected blithely to get up and walk away. These tumultuous states—with neuronal function severely disrupted—are the closest drug use comes to being beyond the user’s restraint.

Yet addicts rarely spend all of their time in conditions of such intense neurochemical siege. In the days between binges, for example, cocaine addicts make many decisions that have nothing to do with drug-seeking. Should they clean the apartment? Try to find a different job? Kick that freeloading cousin off their couch for good? Heroin-dependent individuals often function quite well as long as they have regular access to some form of opiate drug in order to prevent withdrawal symptoms[11]. Most of my own patients even hold jobs while pursuing their heroin habits, which typically entail use about every six to eight hours.

In other words, there is room for other choices. These addicts could go to a Narcotics Anonymous meeting, for example, or enter treatment if they have private insurance, or register at a public clinic if they don’t. And yes, they could even stop cold turkey. I’ve interviewed scores of opiate addicts who have done it. They take lots of Valium-type drugs to handle withdrawal and suffer through a few days of vomiting, diarrhea, and cramping.
...
I am a clinician. I treat real-life patients. As a pragmatist, I can’t see the advantage of conceptualizing addiction as a “chronic and relapsing brain disease.” At the same time, no reasonable person would disagree that addiction is mediated through the dopamine system of the brain. Or that intense activation of the dopamine system makes it more difficult for users to quit. Or that genetic factors influence the intensity of the effect that users derive from substances, the rapidity with which they develop compulsive use, the potency of their cue-related craving, and the severity of withdrawal symptoms.
...
I prefer the language of self-agency because it is the one that translates best into efforts to prevent, treat, and overcome addiction. Perhaps one day discoveries unearthed by brain science will oblige me to reconsider, and talking about addiction in the idiom of neurobiology will be more fruitful in the clinical domain. But for now, people like me must engage a patient in a consideration of himself—his anxieties and aspirations—not his brain.

It's worth reading the whole thing. She does a good job articulating the arguments against the disease model, which are worth knowing if you have any interest in defending it.

What I find especially ironic is that she works in a methadone clinic. First, if there's not a brain disease, why is preventing withdrawal important? Why not just detox them? Second, she's concerned about the disempowering effects of the disease model but works in a methadone clinic? It may work for some, but as long as we're using anecdotes, I hear from scores of methadone recipients who describe it as slavery.

Lemonick's response is here.

Cannabis data comes to the crunch

The Guardian science section picks apart the recent study linking cannabis to an increased risk of schizophrenia and other psychotic illness.

Early Abstinence in Cocaine Dependence: Influence of Comorbid Major Depression

From the American Journal on Addictions.

Abstract
Cocaine dependence (CD) is often accompanied by major depressive disorder (MDD). The comorbid condition (CD + MDD) is especially difficult to treat, with relapse possibly made more likely by intensified dysphoria during abstinence in the setting of MDD. We studied treatment-seeking CD + MDD volunteers, currently depressed, and a comparison CD group over three days of inpatient monitored abstinence. At admission, Beck Depression Inventory (BDI) and anxiety scores differed significantly between groups. By Day 3, BDI scores improved for both CD and CD + MDD groups. The mood response to cocaine cessation among CD + MDD individuals resembled that of CD participants, contrary to some expectations.

Not "contrary to [your] expectations" if you've read our position paper on co-occurring mood disorders.

Cannabis use linked to 40% rise in risk of schizophrenia

The risk of schizophrenia and other psychosis is small but real:

The overall additional risk to cannabis smokers is small, but measurable. One in 100 of the general population have a chance of developing severe schizophrenia; that rises to 1.4 in 100 for people who have smoked cannabis.

But the risk of developing other psychotic symptoms among people who smoke large quantities or are already prone to mental illness is significant, the researchers say.

People who smoke cannabis daily have a 200% increased risk of psychosis. They estimate that 14% of 15- to 34-year-olds currently suffering schizophrenia are ill because they smoked cannabis, a figure previously thought to be between 8% and 10%. According to the current diagnosis rates about 800 people would have been spared schizophrenia if they had not smoked cannabis.

The journal article is here.

Addiction is NOT a Disease???

The author of the recent Time Magazine article on addiction has posted a retort to Satel here:

This clueless pair doesn't argue that the neurochemistry of an addict's brain is no different from that of a non-addict. They can't, because it demonstrably is. Instead, they offer gems of wisdom like this:

Characterizing addiction as a brain disease misappropriates language more properly used to describe conditions such as multiple sclerosis or schizophrenia—afflictions that are neither brought on by sufferers themselves nor modifiable by their desire to be well.

This presumes that there's no underlying neurological basis that predisposes someone to addiction. Those who actually know something about it know this is a false presumption. Addiction, as Satel and Lilienfeld have somehow failed to learn, is not simply the behavior of abusing drugs—if it were, then all of the college students who drink too much would be alcoholics. Most aren't; they grow out of it.

Addiction is actually a disorder in which the brain's reward system is conditioned to value the reward of getting high over pretty much anything else. It's a disorder, in other words, in which the brain is malfunctioning. And it malfunctions even when the addict isn't actively using the drug. Satel and Lilienfeld would have you believe that the decision to use a drug when the addict knows full well it will lead to disaster, as it has every other time--a behavior every addict is all too familiar with—is just a habit. Like throwing your socks on the floor instead of into the laundry hamper, maybe.

Sure, recovery from addiction requires some change in behavior. So does Type 2 diabetes, which requires the sufferer to avoid sugar and simple carbohydrates, but who nevertheless (unless Satel and Lilienfeld beg do differ) has a disease. An addict has to choose not to use, which is overwhelmingly difficult. It's overwhelmingly difficult but not impossible for someone with depression to get out of bed and put on a good face. But Satel and Lilienfeld don't harangue people with depression to change their "bad habits." Or..maybe they do, come to think of it. It wouldn't surprise me. If medications can help an addict resist the urge to use, why, precisely, is this something to avoid?

and here is a response to some comments from his first post:

We've had a bunch already, some thoughtful, some not so much. Here's a thoughtful one. Tom writes:

To call addiction a disease only validates the feelings of powerlessness that addicts feel. It undermines the fact that behavioral change is the only solution to their condition, and allows them to deny responsibility for their condition. Beating addiction is incredibly hard as it is, and the last thing drug counselors need is people coming to them with the belief that they have a disease which is beyond their control. If you believe your addiction is beyond your control to change, then you might as well be dead already because you're never going to do what you have to do to beat it.

A reasonable argument, but I don't agree. Diabetes is a disease, but people who have it can and do change their behavior to keep the symptoms of the disease at bay. For addiction, twelve-step groups like AA take the position that "we are powerless over alcohol"—i.e. that they have no responsibility for the underlying condition—and then provide practical steps to help them deal with that powerlessness by staying away from alcohol. I strongly believe that the underlying addiction itself is beyond personal control. But the behavior that will help you beat it is quite the opposite.

Addiction isn't a brain disease

Disease model gadfly Sally Satel has a piece in Slate challenging addiction's status as a brain disease. It even has an Aldous Huxley reference!

Satel and her co-author criticize the disease model by blowing it up into a reefer madness caricature and then disproving their caricature by pointing out that the addiction does not have complete control of the addict.

They go on to express fear that it lets addicts off the hook, disempower addicts, will reduce healthy stigma, and dismiss brain imagery studies, not on the basis of the studies themselves, rather because the gullible public tends to believe just about anything prefaced with the statement, "brain scans indicate...":

As a psychiatrist who treats heroin addicts and a psychologist long interested in the philosophical meaning of disease, we have chafed at the "brain disease" rhetoric [emphasis added] since it was first promulgated by NIDA in 1995. Granted, the rationale behind it is well-intentioned. Nevertheless, we believe that the brain disease concept is bad for the public's mental health literacy.

Characterizing addiction as a brain disease misappropriates language more properly used to describe conditions such as multiple sclerosis or schizophrenia—afflictions that are neither brought on by sufferers themselves nor modifiable by their desire to be well. Also, the brain disease rhetoric is fatalistic, implying that users can never fully free themselves of their drug or alcohol problems. Finally, and most important, it threatens to obscure the vast role personal agency plays in perpetuating the cycle of use and relapse to drugs and alcohol.

It is true that a cocaine addict in the throes of a days-long binge or a junkie doubled over in misery from withdrawal can't reasonably be expected to get up and walk away.

Yet addicts rarely spend all of their time in the throes of an intense neurochemical siege. In the days between binges, cocaine addicts make many decisions that have nothing to do with drug-seeking. Should they try to find a different job? Kick that freeloading cousin off their couch for good? Register for food stamps? Most of the patients one of us treats hold jobs while pursuing their heroin habits.

In other words, there is room for other choices. These addicts could go to a Narcotics Anonymous meeting, enter treatment if they have private insurance, or register at a public clinic if they don't. Self-governance, in fact, is key to the most promising treatments for addiction. For example, relapse prevention therapy helps patients identify cues—often people, places, and things—that reliably trigger a burst of desire to use. Patients rehearse strategies for avoiding the cues if they possibly can and managing the craving when they cannot. In drug courts (a jail-diversion treatment program for nonviolent drug offenders), offenders are sanctioned for continued drug use (perhaps a night or two in jail) and rewarded for cooperation with the program. The judge holds the person, not his brain, accountable for setbacks and progress.

The brave new world of brain scanning figures prominently in the new disease rhetoric. During imaging experiments in which an addict is shown drug paraphernalia, the reward centers in his brain light up like a Christmas tree. It's easy to be misled into believing that these colorful images prove that the addict is helpless to change his behavior. In a powerful experiment, Deena Weisberg, a doctoral candidate at Yale University, and her colleagues presented nonexperts with flawed explanations for psychological phenomena. They were adept at spotting the errors—until, that is, these explanations were accompanied by "Brain scans indicate … " With those three words, Weisberg's participants suddenly found the flawed explanations compelling. Yet in truth, at least at this stage of the technology, we rarely learn as much by visualizing addicts' brains than by asking them what they are experiencing and what they desire.

Telling the public that addiction is a "chronic and relapsing brain disease" suggests that an addict's disembodied brain holds the secrets to understanding and helping him. It implies that medication is necessary and that interventions must be applied directly at the level of the brain. But that's not how people recover. For actress Jamie Lee Curtis, for example, quitting painkillers was a spiritual matter. When she appeared on Larry King Live recently, the guest host asked her, "What made you get clean?" She responded, "Well, you know what, that turning point was a—was really a moment between me and God. I never went to treatment. I walked into the door of a 12-step program and I have not walked out since."

Finally, dare we ask: Why is stigma bad? It is surely unfortunate if it keeps people from getting help (although we believe the real issue is not embarrassment but fear of a breach of confidentiality). The push to destigmatize overlooks the healthy role that shame can play, by motivating many otherwise reluctant people to seek treatment in the first place and jolting others into quitting before they spiral down too far.

Satel has written some columns that I've liked and linked to. (here and here) I don't think she's an awful person or anything, but she's got a world view that informs her opinion. (She's a fellow at AEI.)

So much for the alcohol-sensing anklet

Salon reviews the Lindsey Lohan media coverage and highlights our own Jim Balmer:

The Detroit Free Press was among the few who put Lohan's rather spectacular relapse in the context of real-life recovery. For one thing, relapse is common to begin with, according to the National Institute on Drug Abuse. "It's tough enough to recover from an addiction. To have to do it in a fishbowl, it's daunting," said Jim Balmer, president of Dawn Farm, a treatment center in Ypsilanti, Mich. "Celebrity stints in rehab centers often seem to be little more than public relations stunts, more geared toward rehabbing a star's image than dealing with an addiction. That doesn't help with public understanding of addiction recovery," the Freep added. (Some people also question the effectiveness of resortlike rehab centers; L.A.'s ABC affiliate pointed out that fancy digs are usually the only way to prune away excuses and lure celebrities in. That way they can't say, "I can't go there because it's a dump," said one facility director.) The Freep also makes clear that people don't leave treatment centers "cured." Rather, that's when the process of learning to manage their problem in the real world begins.

Drug users to get shop vouchers

England implements a large contingency management pilot.

Questions:

• If the numbers suggest it's an effective strategy to keep people in treatment and the post-treatment numbers look good, but the public resents the program and it engenders more stigma, is it the right thing to do?
• Why are we not talking about this kind of intervention with non-compliant patients in cardiac care units, diabetes clinics, weight loss programs, etc.?
  (UPDATE: I was going to resist responding to my own question but I'm weak. Is it because we respect them too much to offer gift certificates for following their treatment plan.)
  

Methadone is only part of the problem

Here's a passionate and effective argument against methadone.

Too bad his solution is prescription heroin.

A legal duty to call 911

From the Ann Arbor News:

When Christopher Stamper died of a prescription drug overdose in 2005, his grandfather asked local authorities to charge the people who were with Stamper that night for failing to call for help.

But there is no law in Michigan to hold people accountable for not calling 911. So, John Mercer has spent the past 20 months lobbying state legislators to adopt such a law in memory of his grandson, who was 27 years old when he died.

"He was my boy,'' Mercer said recently at his home in Ypsilanti Township. "I raised him since he was 6 months old.''

Mercer's efforts could pay off this summer.

State Rep. Alma Wheeler Smith, D-Salem Township, plans to introduce a "duty to assist'' bill in the Legislature this month that would require people to call 911 in case of an emergency. Violation of the law would be a misdemeanor punishable by six months in jail or a $500 fine. The idea is to encourage people to provide reasonable help, Smith said. The law would protect them from liabilities, she said.

[hat tip: Matt]

House Committee Approves Addiction/Mental Health Parity Bill

From Join Together:

In a historic move, the House Education and Labor Committee voted 33-9 to approve a strong mental-health and addiction parity bill, setting the stage for a possible House floor vote on the measure this fall.

The vote marks the first time a House committee has approved parity legislation. The bill, H.R. 1424, The Paul Wellstone Mental Health and Addiction Equity Act of 2007, is cosponsored by Rep. Patrick Kennedy (D-R.I.) and Rep. Jim Ramstad (R-Minn.). It would require group health plans with 50 members or more to cover addiction and mental health problems (as defined in the DSM-IV, the "bible" of healthcare diagnosis) on par with other illnesses.

The coverage provisions in the legislation are modeled after the Federal Employees Health Benefit Program and include out-of-network care. "This bill is about treating people equally," said Kennedy. "If you can get care for heart disease or cancer or diabetes out of network, but you can't get care for alcoholism or depression or PTSD out of network, that's not equal."

During committee debate, supporters of the parity bill beat back an attempt to amend the measure to conform with a Senate bill -- cosponsored by Kennedy's father, Sen. Ted Kennedy (D-Mass.) -- that field advocates say is weaker than the House version. Unlike the House bill, the Senate parity bill (S-558) would preempt stronger state parity legislation and give health plans the power to determine coverage levels.

"The Senate bill is the product of two years of bipartisan negotiations between a broad, well-respected group of senators, mental-health advocates, providers and business groups, who represent virtually all interests in the debate," said Rep. John Kline (R-Minn.), who sponsored the defeated amendment, CQ Today reported Sept. 18. "The House bill starts to immediately unravel support of the Senate compromise."

But Kennedy called the committee vote "a strong, bipartisan endorsement of fairness, equal opportunity, and common sense.

"It's a first step towards ensuring that anybody who pays their premiums can get the care they've paid for," he said.

Andrew McKetchnie, a spokesperson for Ramstad, told Join Together that further action on the bill probably won't occur before Congress takes its August recess, but that both the Energy and Commerce and Ways and Means Committees have pledged to act on the bill when lawmakers return in September, if not before.

If the bill clears those committees, as expected, the measure could get a vote in the full House this fall, and the margin of victory in the Education and Labor committee "bodes well for the vote on the floor," said McKetchnie.

Pat Taylor, director of the advocacy group Faces and Voices of Recovery, said she was "very excited by this important step."

"We're looking forward to passage of a strong bill," she said.

The biggest obstacle to that occurring will likely come in negotiations with the Senate, where the weaker parity bill has been endorsed by a number of prominent mental-health advocacy groups, including the National Alliance for the Mentally Ill.

Experts say that opponents of parity fall into a few main camps: people who see addiction as a moral failure; and self-insured business groups and health insurers, who think that parity will hurt their bottom line. "At this point, we have all the empirical data we need," said McKetchnie. "If people are opposing parity now, they probably will never support it."

Carol McDaid, a lobbyist for Capital Decisions who works on behalf of treatment providers and the American Society of Addiction Medicine, said the key to the measure's fate in the Senate may be "how much will the business groups be willing to give once the House passes a stronger bill?"

David Wellstone, co-chair of Wellstone Action -- an advocacy group dedicated to carrying on the work of the late Sen. Wellstone -- said he was "ecstatic" about the committee's passage of his father's namesake bill.

"I think we're going to pass this bill. I think we have some momentum," he said. "I hope the Senate will see this bill and asks why don't we get a stronger bill with better consumer protections."

Wellstone acknowledged that significant differences remain between the House and Senate bills, but showed little inclination to back down on the preemption language -- which he called "unacceptable" because it could result in up to half the states having to adopt weaker parity laws -- or using the DSM-IV to determine which conditions insurers should be required to cover.

"Health plans are looking at their quarterly investor reports," said Wellstone. "I'm looking at kids who have died."

Former first ladies Betty Ford and Rosalynn Carter called for passage of a parity law in similarly strong language in a July 18 op-ed in the Washington Times.

"As it stands now, health insurers offer coverage and reimbursement if you need cancer therapy or treatment for Parkinson's disease, heart disease, diabetes or any other physical illness," they wrote. "But if you are diagnosed with a mental illness or need treatment for an addiction, you are likely to face unequal and unfair insurance barriers that can be catastrophic to your health, your financial security and even your life. This is unconscionable. Patients affected by these disorders should be treated with the same urgency and diligence as patients with any other disease, and should receive the same healthcare options and coverage."

Smoking Ban Is Proposed in Drug Centers

New York would become the first state requiring all addiction treatment programs to help their clients quit smoking under a proposed rule to be announced today.

Pointing to the high number of tobacco-related deaths among former addicts, the state’s Office of Alcoholism and Substance Abuse Service said that by July 24 of next year, all facilities treating drug or alcohol addiction would have to have programs in place to encourage clients to stop smoking. Under the plan, all treatment centers would have to be smoke-free, and staff members would also have to abide by the ban.

Treatment for nicotine addiction, including drugs to relieve cravings, would have to be offered to all patients, and provided free to those without insurance. Patients who refuse to quit smoking could still be treated for other addictions, but they would not be allowed to smoke at the treatment centers.

New Jersey has required residential addiction programs to treat nicotine addiction and be smoke-free since 2001, but officials in New York say it would be the first state to require smoking cessation efforts in outpatient programs, which account for two-thirds of the 1,100 treatment programs in the state. Programs in New York that failed to comply with the smoking regulations could lose state certification and would have to stop treating clients.

Read the rest here.

Soberfest proves there's fun at end of addiction

Wow. What is Flint's recovering community doing right? Can this all be attributed to the UAW?

Sponsored by UAW Local 598 and the support group Maintaining Our Sobriety Together, Sunday marked the 13th year for the event held at the Union City Ball Field on Torrey Road.

A crowd of about 1,500 - many of them families with children - enjoyed food, games, pony rides, a trout pond, dunk tank and more during the all-day fest that organizers hope will make recovery a little smoother.

"Things become easier when they realize that they don't need alcohol as a social lubricant, that they can have a good time and don't need alcohol or drugs to make that happen," said Bob McKamie, a work/family representative for Local 598.

Examining parents' role in teen drinking

A tragedy prompts an evaluation of parental responsibility and teen drinking. Debates about these matters often turn into a battle of statistics, but these cases aren't about the "parents drinking with their children" scenario that defenders often bring up.

Let's assume we can agree that reasonable people can disagree about whether it's wise to allow your teen a glass of wine with dinner. Are we in theoretical agreement? Great. However, it seems difficult to argue that there's nothing wrong with a parent #1 permitting parent #2's children to drink without parent #2's knowledge. Shouldn't this be beyond debate? Especially when we're talking about large groups of teens?

"Our kids have been educated almost ad nauseam through DARE and other programs about drinking and drugs," said Vicki Ettelson, who attended the trial and has a 16-year-old son at Deerfield High School. "We feel it's time to offer solutions and strategies [to parents] to combat teenage drinking."

Parents must be part of the solution because, as was shown in the Hutsell case, some of them are part of the problem, Ettelson said. The Hutsells and their attorneys could not be reached for comment on Sunday.

A Lake County jury Saturday found the Hutsells, both 53, knew 20 to 30 teens were drinking alcohol in their basement and did nothing to stop it. The couple also were convicted of endangering the life of a child and lying to police investigating the crash, but they were acquitted of a count of destroying evidence. Their sentencing is scheduled for Sept. 11.

On Vacation. Light blogging this week.

Seeking Recovery, Finding Confusion

This story sickens me and breaks my heart. One of the great things about AA is its lack of enforced structure, it also leaves it vulnerable to this kind of deviance.

Normally 13th stepping is a one way ticket to loserville. The rest of the community views the person as not working the program and as a predator. Newcomers are typically warned to stay away from him. In this case, it looks like this guy established a cult of personality around himself that insulated him from the typical response.

I've seen a handful of groups over the years that seemed to be established to nourish the ego of one member and I've seen one CA group that had patterns similar to what was described in the article. Fortunately, all of these groups stayed small and none of them lasted a year. In the case of the worst group, the local recovering community immediately identified the group as "cultish", warned people to stay away from it, reached out and expressed concern to young members, and confronted the senior members.

Usually the recovering community functions as it should and these kinds of groups tend to fizzle out as quickly as they start. This one seems pretty large and pretty entrenched.

As I said earlier, when a group goes off the rails, other groups and members go out of their way to distance themselves from the group. This situation is made worse by the fact that someone like Clancy weighs in and minimizes these serious problems with statements that sound like a cult apologist who even suggests blame for the victims:

..."there probably have been some excesses, but they have helped more sober alcoholics in Washington than any other group by far."

Imislund, who speaks frequently to AA groups across the country, said he concluded that if sexual relations between older men and young girls "ever did take place, it's not taking place now. It had been an issue, but wherever you have a lot of young, neurotic people, they're going to cling to each other."

Although Imislund portrayed parents of young people in Midtown as "immensely grateful that this group has managed to get their children sober when no one else could,"...

Let's hope this group burns out soon and other "elder statesmen" don't pop out of the woodwork to defend them.

Methadone in Scotland

Methadone has been the primary response to opiate addiction in Scotland. It sounds as though the treatment system there could be fairly characterized as dosing clinics. Their national health service and public appear to have reached the conclusion that their system isn't working. They're not discontinuing methadone, but they're talking about tripling their treatment spending and requiring the provision of additional treatment services focused on getting people drug-free.

I'm not sure they'll be successful, but it will be interesting to watch and learn.

More here and here.

Private Insurance Paying Less for Substance Abuse Treatment

A recent study confirms something we already knew:

On average, private insurance payments for substance abuse treatment fell 1.6 percent each year. In 1986, private insurance paid $2.8 billion for drug and alcohol treatment; by 2003, it funded $2.1 billion in treatment - a 24 percent decline. The share of total substance abuse treatment costs paid by private insurance declined from 30 percent to 10 percent.

I was surprised by the out-of-pocket spending drop. I would have expected out-of-pocket to be a small, but growing share of spending to compensate for reductions in private insurance spending.

The shift from private insurance to public funding is troubling for a lot of reasons. Anecdotally, treatment seekers in the public system often fall into one of the following categories:

• People who have never had much recovery capital.
• People who once had private insurance and were unable to get help. They've lost private insurance (Usually attached to their job.) and are now seeking help with a much more advanced AOD problem and less recovery capital.

Their experience will be characterized by the following pattern:

• They will require higher intensity treatment, in a larger dose for a longer time.
• They probably won't receive the treatment they need.
• They will relapse in large numbers.
• Many of them will seek help again.
• They still will not get the treatment they need.
• They will relapse in large numbers.
• They will require more expensive care, like medical detox and hospital admissions for AOD related problems.

Community responses will be characterized be the following pattern:

• Professional helpers and the public observe this cycle and conclude that these people can't be helped, or that they don't want to be helped.
• Professional helpers and the public conclude that treatment is a waste of money.
• Efforts to facilitate drug-free recovery are characterized as Quixotic and moralistic. There are calls for more pragmatic solutions.
  
• Societal responses to addiction will shift from facilitating recovery to mitigating the societal damage, primarily crime and disease.

What did I miss?

Mexico tightens restrictions on pseudoephedrine sales to combat meth production

Recent reports suggest that U.S. efforts to reduce domestic meth production have been successful. However, Mexico imports have made up for the drop in domestic production.

Mexico is now following suit and going further.

Program for heroin addicts is lauded

Baltimore and the State of Maryland have started a push to make buprenorphine more accessible.

U.S. Mayors Declare Drug War a Failure

From Join Together:

The mayors of America's large cities have unanimously approved a resolution stating that the drug war "has failed" and calling for a harm-reduction oriented approach to drug policy that focuses on public health.

The U.S. Conference of Mayors adopted the resolution during its June 21-26 annual meeting in Los Angeles, calling for a "new bottom line" in drug policy that "concentrates more fully on reducing the negative consequences associated with drug abuse, while ensuring that our policies do not exacerbate these problems or create new social problems of their own; establishes quantifiable, short- and long-term objectives for drug policy; saves taxpayers money; and holds state and federal agencies responsible."

Sponsored by Salt Lake City Mayor Rocky Anderson, the resolution states that the drug war costs $40 billion annually but has not cut drug use or demand. It slams the Office of National Drug Control Policy's (ONDCP) drug-prevention programs -- specifically, the agency's national anti-drug media campaign -- as "costly and ineffective," but called drug treatment cost-effective and a major contributor to public safety because it prevents criminal behavior.

"This Conference recognizes that addiction is a chronic medical illness that is treatable, and drug treatment success rates exceed those of many cancer therapies," the document states.

The resolution condemns mandatory minimum sentences and incarceration of drug offenders, particularly minorities, and called for more control of anti-drug spending and priorities at the local level, where the impact is most acutely felt.

"U.S. policy should not be measured solely on drug-use levels or number of people imprisoned, but rather on the amount of drug-related harm reduced," according to the resolution. The document calls for more accountability among federal, state and local drug agencies, with funding tied to performance measures, more treatment funding and alternatives to incarceration, and lifting the federal funding ban for needle-exchanges.

The resolution, which will be used to guide the U.S. Conference of Mayors' Washington lobbying on addiction issues, passed with minimal debate, clearing two committees and the general assembly by unanimous votes.

Read the rest here.

Weekly pot news roundup

After downgrading the classification of pot 2 years ago, England is reviewing its classification again and considering returning it the classification that includes methamphetamine.

The Victoria Times Colonist makes a reasonably thoughtful argument for eliminating criminal penalties for possessing less than a half ounce of marijuana.

Meanwhile, conservative Orange County approves medical marijuana, and some North Dakotans hope to legalize industrial hemp.

Let's Talk Recovery Radio Network's New Host

It's much worse than you think. With friends like this...

Pediatric Ritalin Use May Affect Developing Brain, New Study Suggests

A new study identifies neurochemical changes from ritalin use:

Use of the attention deficit/hyperactivity disorder (ADHD) drug Ritalin by young children may cause long-term changes in the developing brain, suggests a new study of very young rats by a research team at Weill Cornell Medical College in New York City.

The study is among the first to probe the effects of Ritalin (methylphenidate) on the neurochemistry of the developing brain. Between 2 to18 percent of American children are thought to be affected by ADHD, and Ritalin, a stimulant similar to amphetamine and cocaine, remains one of the most prescribed drugs for the behavioral disorder.

"The changes we saw in the brains of treated rats occurred in areas strongly linked to higher executive functioning, addiction and appetite, social relationships and stress. These alterations gradually disappeared over time once the rats no longer received the drug," notes the study's senior author Dr. Teresa Milner, professor of neuroscience at Weill Cornell Medical College.

It will be interesting to see more research on the subject, particularly as we learn more about brain plasticity in adolescents.

Drugs and the death penalty

Amnesty International weighs in on death sentences for drug-crimes in 16 Asian nations.

Buprenorphine maintenance: A new treatment for opioid dependence

I'm sure we'll be seeing more about this.

It begs all sorts of questions:

• Under what conditions is maintenance appropriate?
• Under what conditions is it inappropriate?
• Is part of maintenance's attraction that we so rarely provide treatment of appropriate duration, intensity and type?
• Will maintenance be acceptable for opioid addicted doctors? Why or why not?
• This will raise questions about the definition of recovery. Is this recovery...full recovery? Why or why not?
  

NRT in hospital settings

From a reader:

For many people, going in to hospital provides an opportunity to stop smoking ... 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.

Might be a bad idea - this study was written up in one of my critical care nursing journals recently: http://www.medicalnewstoday.com/articles/55094.php

Lee and colleagues examined the safety of NRT in the ICU ... Among the patients who received NRT, 18 deaths (16.1%) occurred, compared with the 3 deaths (2.7%) in the control group. The hospital mortality rate was 21.4% for the NRT group, compared with 5.4% in the control group. Furthermore, when researchers controlled for severity of illness, NRT was found to be an independent risk factor for mortality (odds ratio 17.0)

Nicotine (inhaled or transdermal or whatever form) has many deleterious effects on the cardiovascular system, and probably on blood flow patterns, wound healing, immune response and other factors significant to people who are hospitalized vs. people who are not experiencing acute health problems.

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]