Cash for safe drug injection "off mark"

How about getting these people into treatment? Do they have waiting lists for treatment in Australia?

...Jann Stuckey said the Queensland Injectors Health Network was distributing flyers headed: "Wanna make some cash?"

They offered $110 cash payments to intravenous drug users willing to teach others safe injecting techniques, or, "learn a bit, share a bit and make a bit".

Ms Stuckey said it was not a responsible way to deliver a harm minimisation program.

"To pay drug addicts in this manner, knowing that the $110 will almost certainly be their next hit, is grossly irresponsible," she told reporters on Tuesday.

Ms Stuckey said she believed the program was not effective because it did not focus on getting people off drugs.

"Without that support, these facilities are nothing more than needle hand-outs," she said.

"The public have for many years been led to believe these are needle exchanges, and sadly, this is not true."

Premier Anna Bligh said Queensland Health had ordered the advertisements be withdrawn at least six months ago.

She agreed the program, jointly funded by the state and commonwealth governments, would offend some people, but said "unconventional" methods were sometimes required.

"Sometimes they have to go to extreme lengths to engage with these people," Ms Bligh said.

Technorati Tags: harm_reduction, australia, addiction, hiv_aids

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A reader comment

"I was recently in Vancouver and witnessed a man shooting up on the sidewalk. There were articles in the paper about how the misery on the streets in Victoria is scaring the tourists away and in my brief time in Vancouver there was plenty of misery to be seen as well. They certainly don't look like they have found the solution."

Study in rats suggests moderate alcohol consumption improves recall

Moderate alcohol consumption may actually improve memory:

Among the normal rats, the animals that consumed moderate amounts of alcohol fared better on both tests compared with the teetotalers. Rats on a heavy alcohol diet did not do well on object recognition (and, in fact, showed signs of neurotoxicity), but they performed better than their normal brethren on the emotional memory task.

Bad news if you recently experienced something that you don't want to remember too vividly, like trauma:

"People often drink to 'drown sorrows,'" Kalev says. "Our results suggest that this could actually paradoxically promote traumatic memories and lead to further drinking, contributing to the development of alcoholism."

Technorati Tags: alcohol, brain, memory, trauma

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More criticism of Canadian drug policy plan

First off, I am not at all in favor a the war on drugs and I'm skeptical of this new plan. (In my limited understanding, it emphasizes criminalization.) However, I believe that these comments from Stephen Harper make a lot of sense:

Harper unveiled a $63.8-million, two-year drug strategy in Winnipeg Thursday, saying harm reduction is not a "distinct pillar" of the Conservative strategy.

Vancouver's safe injection site is "a second-best strategy at best," he said, "because if you remain a drug addict, I don't care how much harm you reduce, you're going to have a short and miserable life."
...
Harper said Thursday: "I remain a skeptic that you can tell people we won't stop the drug trade, we won't get you off drugs, we won't even send messages to discourage drug use, but somehow we will keep you addicted and yet reduce the harm just the same."

These comments have been met with accusations of ignorance:

Mark Townsend, director of the Portland Hotel Society in Vancouver, said Harper doesn't understand the scourge of drug addiction.

"It's depressing to see his [Harper's] lack of leadership on that and now he is out there trying to find a new study that will say the world is flat," Townsend said.

A columnist for the Victoria Times-Colonist rails against the plan:

The problems of ideology-based governance clearly must be more obvious from afar. Otherwise, Canadians wouldn't be able to bear the hypocrisy of railing against oppressive and backward regimes elsewhere in the world while committing ourselves anew to the folly of a war on drugs.

...

The real tragedy is that the misuse of drugs continues to cost us $40 billion a year in Canada in direct and indirect costs, and that's not even counting all the billions we've thrown away on misguided and ideologically driven attempts to do something about that.

Here's the thing: Health issues can't be resolved through ideology.

...

So why do we continue to let our elected politicians ignore the science when it comes to drug issues? Why should anybody's poorly informed position around drug use be the lens that we apply when trying to address complex health and social problems that are far too important to be left to political whim?

I respect the right of Stephen Harper and his MPs to believe that using illicit drugs is bad. It's a free country and they're welcome to their opinions, and never mind that alcohol is actually Canada's most dangerous and readily available drug by a long shot. (The social costs of alcohol use in Canada are more than double that of all illicit drugs combined and health-related costs are three times higher.)

But why would we want to base something as important as our national drug strategy on opinion and belief?

We've got six decades worth of scientific studies underlining the importance of an informed, health-based approach in reducing the harm and societal costs of drug use. Yet we're still letting vital public policy be decided by people who would rather maintain their personal fictions than take steps to fix the problems.

This complete rejection of the role of values in policy decisions can't be serious. What about torture? Is the only acceptable argument against torture and argument that it doesn't work? I don't know anything about this writer, but I suspect she believes it is wrong and would oppose any pro-torture policy on moral grounds--even if torture was scientifically proven to be effective.

Granted, there's a long distance between torture and drug policy. The point is that we base policy decisions on values and morals all the time, even in health care. Are Canada's universal health care policies and the U.S. SCHIP programs based in pragmatism? They're based on moral
convictions about providing access to health care. Furthermore, the argument that harm reduction activism is value-free and rooted only in science is folly. HR arguments are consistently value-laden. For example, common themes include:

• Drug use is not bad
• Self-determination and personal liberty trump competing concerns
• Drug experimentation is a normal developmental task for adolescents

Would it be so difficult to build a dialog on drug policy around values? For example:

• Drug use is bad for addicts
• Recovery is the ideal outcome and should never be abandoned as a goal
• No one should be incarcerated for simple personal possession or use
• If an addict refuses recovery, we should still provide assistance with basic needs
  

How much common ground could be developed? What policy initiatives might arise?

One other truth that activists on both sides need to accept is that any policy that does not enjoy broad and deep public support will always be in peril. The general public will never embrace a policy focused on incarceration or a policy focused on needle exchanges, safe injection centers and drug maintenance programs.

Technorati Tags: harm_reduction, canada, addiction, policy

John Walters, Milton Friedman and Libertarianism

A San Diego Union Tribune blog writer got to interview U.S. Drug Czar, John Walters, and ask him about Libertarian criticism of the drug war and Milton Friedman's arguments for legalization.

Worth reading, but unfortunately more of a soap box statement than a reporting of a meaningful exchange of ideas.

Kentucky sues makers of OxyContin

It will be interesting to see if any other states follow suit:

A lawsuit filed by Kentucky Attorney General Greg Stumbo and Pike County officials demands millions in compensation from drug maker Purdue Pharma.
...
The lawsuit seeks reimbursement for costs incurred in drug abuse programs, law enforcement and prescription payments through Medicaid and the Kentucky Pharmaceutical Assistance program.

In a statement, Purdue Pharma officials said OxyContin's packaging warns against the dangers of abusing the drug and that the company shouldn't be held responsible for individuals who choose to do so.

"We will defend this lawsuit vigorously and we expect to prevail," the statement said.
...
The company said it accepted responsibility for "past misstatements" by company officials.

"We do not believe, however, that those misstatement were responsible for individuals' abuse of OxyContin," the statement said.

Predictors of Initiation of Alcohol Use Among US Adolescents

A new study from The Archives of Pediatric and Adolescent Medicine. Note what's protective (family dinners),what's not (self-esteem), and the risk factors (adults drinking in the home, underage sibling drinking, positive attitudes toward alcohol):

Results: Between 1998 and 1999, 611 girls (19%) and 384 boys (17%) initiated alcohol use. Older age, later maturational stage, smoking, adults drinking in the home, underage sibling drinking, peer drinking, possession of or willingness to use alcohol promotional items, and positive attitudes toward alcohol were associated with an increased likelihood of alcohol initiation. Girls who ate family dinner at home every day were less likely to initiate alcohol use than girls who ate family dinner only on some days or never (odds ratio, 0.66; 95% confidence interval, 0.50-0.87). Girls with higher social self-esteem and boys with higher athletic self-esteem were more likely to initiate alcohol use than those with lower self-esteem. Among teens who initiated alcohol use, 149 girls (24%) and 112 boys (29%) further engaged in binge drinking. Among girls, positive attitudes toward alcohol, underage sibling drinking, and possession of or willingness to use alcohol promotional items were associated with binge drinking; among boys, positive attitudes toward alcohol and older age were associated with binge drinking.

Conclusions: Eating family dinner at home every day may delay alcohol uptake among some adolescents. Alcohol promotional items appear to encourage underage alcohol initiation and binge drinking; this may warrant marketing restrictions on the alcohol industry.

Nicotine addiction mechanism identified

A new mechanism has been identified in nicotine addiction:

A new study reveals that, in rats, chronic nicotine use recruits a major brain stress system, the extrahypothalamic corticotropin releasing factor (CRF) system, which contributes to continued tobacco use by exacerbating anxiety and craving upon withdrawal. The researchers found that administering a compound that blocked the receptors involved in this stress system alleviated withdrawal symptoms.

Anorexia an addiction?

New research provides a peek inside the neurobiology of anorexia:

Scientists from France have found that anorexia and the highly addicting club-drug ecstasy activate some of the same brain pathways, a finding that may help explain the addictive nature of anorexia and other eating disorders and lead to new treatments.

In a paper published this week, Dr. Valerie Compan of Centre National de la Recherche Scientifique, Montpellier, and colleagues report that both anorexia and ecstasy reduce the drive to eat by stimulating the same subset of receptors for the neurotransmitter serotonin.

These so-called 5-HT4 receptors are located in a brain structure associated with feelings of reward called the nucleus accumbens.

In mice, Compan and colleagues stimulated these receptors, which are known to play a role in addictive behavior, and found that this led to anorexic-like behavior -- food-fed mice ate less and food-deprived mice showed a reduced drive to eat.

Stimulating these receptors in mice also boosted production of the same enzymes stimulated in response to cocaine and amphetamine use.

Blocking the receptors increased food intake in the animals and mice missing these receptors were less sensitive to the appetite-suppressant effects of ecstasy.

"Our data may converge to open the possibility that anorexia can be a reward-relating problem involving neuronal mechanisms," Compan told Reuters Health.

This research, she added, may have implications for the development of drug treatments for eating disorders. "Our studies over seven years now open the possibility that 5-HT4 receptor could represent an important therapeutic target to treat patients suffering from these disorders," Compan said.

Supreme Court Hears Arguments on Drug Case Sentencing

The Supreme Court of the United States is hearing cases with big implications for drug crime sentencing guidelines. Basically, they will decide whether sentencing guidelines are advisory or binding. Join Together suggests that these rulings will affect mandatory minimum sentencing laws, this article says the opposite. More here.

A better way to fight the drug war?

More on the Canadian drug policy debate. Wow!

Since nearly all the violence associated with the drug trade stems from turf wars between syndicates and gangs over who may make or sell drugs in which neighbourhoods, too little of this new money would appear to be earmarked to help police. All of it probably would not be enough to counter the well-armed, highly organized criminal networks that control much of our nation's drug trade. And since the hundreds of millions already spent by Canadian governments has done little to stem user demand for drugs, the 65% aimed at individuals may well be wasted.

Rather than declare that there are "no safe drugs," as Health Minister Tony Clement is expected to do when the anti-drug campaign is launched, the government should consider accepting that -- for good or bad -- drug use is a personal choice. As such, there is little it can do to prevent it. But given that it is a personal choice, society has little obligation to pay for the consequences of misuse. Legalize most drugs, but also declare no welfare for addicts. Let private charities supply relief and health care for those who abuse drugs. That would at least compel some users to confront the economic costs of their choices and might -- might -- discourage more Canadians from taking drugs than any preachy government advertising campaign or assault on casual drug use.

The does a great job illustrating that we're not operating from the same set of facts. Emerson summed it up well:

"Most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion. This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true. Their two is not the real two, their four not the real four; so that every word they say chagrins us, and we know not where to begin to set them right."

The Drug War

I'm not a regular reader of The Corner, but I was pleased to find a thoughtful post on drug policy. Jonah Goldberg discusses why he sees no easy answers:

One point I would like to make in response to a great many folks is the idea that simply because I'm in favor of keeping addictive narcotics illegal, I must think the current drug war is going well. I don't. I think it's a disaster. And while I'm very dubious of a lot of anti-drug war charges about our prisons being filled to the rafters with non-violent criminals, I think the overall indictment of the ongoing catastrophe is more accurate than not. But simply because I agree with a diagnosis doesn't mean I have to agree with the proposed remedy.

Indeed, this is a point often lost in political debates. Both conservatives and liberals are too often afraid to concede that the other side is pointing out real problems for fear of lending legitimacy to the opposition's proposed solutions....

Anyway, when it comes to the drug war, I'm willing to concede the point to the drug legalization crowd that the current war on drugs has all sorts of terrible consequences. I just think legalizing crack, heroin etc. will have even worse consequences, particularly in the short and mid term (i.e. the next decade or two). I believe that if you make drugs like crack cheaper, easier to get and more socially acceptable there will be more women like that cokehead mom discussed yesterday.

So what's my solution? Well the first answer has to be, I don't know. In fact, I'm not sure we can know. Some problems are hard and if not permanent certainly enduring. I don't have a solution to robbery, murder, or rape. All I have is an idea of how society should respond to such things in order to minimize their occurrence and to apply justice to those who perpetrate them (these are related but not identical issues).

Canada to adopt American style drug policies?

The Canadian government is announcing a new drug strategy that emphasizes tougher legal penalties and increased interdiction activities. Here are favorable and unfavorable articles.

Secondhand smoke law cuts heart attacks

New info on the impact of tobacco laws on public health:

A study released Thursday credits New York's 2003 Clean Indoor Air Act with an 8 percent drop in heart attacks statewide because of reduced exposure to secondhand smoke.

...

Previous studies reported more dramatic results, including a 2003 study in Helena, Mont., that found heart attacks fell by about 40 percent after voters passed an indoor smoking ban. The rates returned to normal then the ban was lifted.

Another study found heart attack rates in Pueblo, Colo., dropped by 27 percent in the 18 months after a smoking ban was imposed in bars, restaurants and other public places.

Michael Seigel, a professor at Boston University's Social And Behavioral Sciences Department who reviews tobacco policies for the school, including smoking bans, questioned the conclusions of the New York study based on its limited scope.

"You can't conclude that that decline was due to the smoking ban," said Siegel, who has testified in New York City, Connecticut and Massachusetts about the value of indoor smoking bans. "Because it's possible that decline was happening everywhere, and without assessing data from every state, there's no way to know."

The New York study examined information from a 10-year span starting before the statewide smoking ban took effect. Researchers found that regulations by local governments that preceded the statewide ban also contributed to a downward trend for heart attacks.

SCHIP Bill Includes Parity Provisions

One more step in the direction of establishing mental health and addiction treatment parity. President Bush has previously stated that he would sign a parity bill. So, once President Bush and and congress reach an agreement on the bill, the parity provisions should be intact.

The children's health-insurance bill passed by the House and Senate this week not only raises federal tobacco taxes to pay for expanded health care but also requires state programs to treat addiction and mental-health disorders on par with physical illnesses.

Considering Health Insurance Parity: The Federal Experience

The APA offers commentary on parity:

The parity policy in the Federal Employees Health Benefits program began on Jan. 1, 2001, and offers comprehensive insurance coverage for mental disorders, including substance use disorders, on terms that are identical to the coverage of general medical conditions when the treatment is provided by in-network providers.

We compared seven Federal Employees Health Benefits plans with a matched set of plans that did not change benefits or management and did not have parity. We compared use and spending by enrollees in these plans for the 2 years before parity (1999 and 2000) and for the 2 years after parity began (2001 and 2002)....

We concluded that "parity of coverage of mental health and substance abuse services, when coupled with management of care, is feasible and can accomplish its objectives of greater fairness and improved insurance protection without adverse consequences for health care costs" (1, p. 1386).

The parity policy performed just as insurance should: it reduced costs from out-of-pocket payments with a small increase in plan payments (3). This could result in very small increases in insurance premiums without leading to an increase in the use of services. The Congressional Budget Office estimates a premium impact for group plans of a 0.4 percentage point increase (4), a figure that is identical to our estimate based on the Federal Employees Health Benefits experience.

We also looked at indirect measures of quality of behavioral health care in the Federal Employees Health Benefits plans during this same period. Parity was accomplished without increases in the hospitalization of patients and without a decline in the measures of quality of care that we studied, such as the likelihood of receiving follow-up care for depression or being referred for substance abuse treatment.

There was no use of or spending for (oft-parodied) trivial behavioral conditions under managed care plans. It is worth noting that the ICD contains a wide range of general medical conditions, such as scrapes and bruises, rashes, sprains, and the common cold, just as it includes sleep disorders, mild phobias, and mild learning problems. Managed care arrangements and "medical necessity" criteria control unnecessary use and spending for trivial cases of general medical conditions and mental disorders alike.

Governor unveils program to help combat meth addiction

Utah has a new public education campaign that avoid hype and treats drug users has human beings in need of, and deserving of, our help. Let's hope that this approach catches on.

A statewide methamphetamine public-awareness campaign — one without scare tactics and stereotypes — was unveiled today by Gov. Jon Huntsman Jr.

The campaign's newspaper ads and a series of television and radio commercials urge family members and friends to recognize the signs and help addicts, rather than judging people who use meth.

...

Contrary to awareness campaigns in other states — particularly Montana's time-lapse video of people emaciated by drug use — the Utah campaign focuses on debunking stereotypes of so-called drug users and urges loved ones to realize that a meth addict is "not a lost cause."

Defining Recovery

The latest issue of the Journal of Substance Abuse Treatment has a special section of defining recovery. I'll have more on it later. Any DF staff who want the articles can contact me.

Rep. Ramstad, Recovery Advocate, to Resign

Congress is losing its most dedicated parity advocate:

Rep. Jim Ramstad (R-Minn.), a nine-term member of Congress and longtime supporter of addiction treatment and recovery issues, has announced that he will retire at the end of his current two-year term in office

Family History Of Alcoholism Affects Response To Drug Used To Treat Heavy Drinking

As we learn more about genetic factors and brain science there is growing interest in developing typologies that might help in treatment decisions. Past attempts at this have been pretty shaky, so I'll believe it when I see a good evidence-base. Keep in mind that this looks very preliminary:

Naltrexone is one of four oral medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of alcoholism. A recent large multicenter research study of alcohol dependence supported by the National Institute of Alcoholism and Alcohol Abuse (NIAAA), the COMBINE Study, suggested that naltrexone produced a modest but significant benefit but another FDA-approved medication, acamprosate, was ineffective.

Perhaps consistent with its modest effects in COMBINE, naltrexone is not widely prescribed in the treatment of alcoholism. Yet, clinicians report that naltrexone may have significant benefits for individual patients.

John H. Krystal, M.D., one of the authors, notes that "When studied in large groups, naltrexone appears to have a rather small effect upon the ability to reduce drinking or remain abstinent from alcohol. However, there is growing evidence that there are subgroups of patients who show substantial benefit from naltrexone, even when naltrexone fails to work in the overall trial.*

"According to Suchitra Krishnan-Sarin, Ph.D., the lead author, "The results suggest that family history of alcoholism may be an important predictor of clinical response to naltrexone and could potentially be used to guide clinical practice." Dr. Krystal agrees, "These data suggest that family history might influence the optimal dosing of naltrexone and the nature of the clinical response."

Getting Better Numbers on Drugs

Time looks at the process of estimating drug use in the U.S.:

At least, that's what the numbers say. Though it's been more than 30 years since Richard Nixon famously announced America's "War on Drugs," it's hard to know exactly how far we are from victory, partly because the facts are so elusive: Who uses illegal drugs? Which drugs? How often? The answers come mainly from SAMHSA's national survey, a complex and carefully worded questionnaire administered continually throughout the year. It is one of the government's primary sources of statistical information on the use of illegal drugs by the U.S. population, but its data are far from perfect.

"The bottom line is, we learn about drug use by asking people about their behaviors," says Dr. Wilson Compton, director of the Division of Epidemiology Services and Prevention Research at the National Institute on Drug Abuse. "But because it's survey research, there are multiple ways it can be improved."

From FAVOR

CALL HOUSE SPEAKER NANCY PELOSI TUESDAY, September 18th

Help pass the Paul Wellstone Mental Health and Addiction Equity Act
(H.R. 1424) this year!

There are important new developments in our efforts to take the first step to end insurance discrimination faced by people with mental illness and addiction.

Help us end practices like higher co-pays and deductibles, restrictive day and visit limits and lower and annual lifetime caps on people seeking mental illness and addiction treatment and recovery services! Take Action next Tuesday!

1). The House Ways and Means Committee's Health Subcommittee will be considering or “marking-up” H.R. 1424 next Wednesday, September 19th. After this mark-up, the only remaining hurdle before the House can vote on the bill is for the House Committee on Energy and Commerce to act.

2). According to Congressional Quarterly magazine, “the Congressional Budget Office released a surprisingly low estimate late last week of the cost impact of House legislation to put mental health care benefits on par with those for treatments of other kinds of illnesses. The estimate of the cost of the bill (HR 1424) could stiffen the resolve of the House bill's backers to stick with the more sweeping provisions of the House measure, which is expected to see floor action this fall.”

ACT SEPTEMBER 18th
—TIME IS RUNNING OUT IN CONGRESS TO PASS HR 1424!

NATIONAL CALL-IN DAY TO
END INSURANCE DISCRIMINATION

Tuesday, September 18th
9:00 am – 6:00 pm Eastern

Call House Speaker Nancy Pelosi Toll-Free

at 877.978.9996*

Our Message:

“Please schedule a vote on H.R. 1424, the Paul Wellstone Mental Health and Addiction Equity Act of 2007, by mid-October. The time has come for mental illness and addiction to be treated the same as other illnesses. Thank you for your help in making this long overdue action a reality.”

* When you dial 877.978.9996 an operator will be standing by to assist you.

Thanks for all of your advocacy that has helped continue to build momentum for passage of The Paul Wellstone Mental Health and Addiction Equity Act this year!

This Is Your (Father’s) Brain on Drugs

I never really get what this guy is saying.

Is he saying that adolescence is not "a time of heightened vulnerability for risky behavior"? That there is no such process as brain maturation or plasticity?

I can accept an argument that there's hype around adolescents and risky behaviors, but does it not have some basis in fact?

I can accept an argument that adults 35 to 54 should be of much greater concern. Does this mean that we shouldn't be concerned about adolescents?

What exactly does he suggest?

Free cocaine for addiction study subjects

Clearly, a case can be made for this kind of research if it is highly likely to lead to effective treatments for addiction. What troubles me is that there was no mention of treatment in this article. I would hope that and IRB would require a study of this type to try to engage participants into treatment--really try to engage them into treatment of adequate duration and intensity that addresses all of their barriers to recovery.

Drug Tests Part of the Curriculum at Recovery High

NPR profiles a recovery high school.

More on the subject here.

Crystal mess

"People have a low threshold for BS." I couldn't have said it better.

Disturbing Facts about Sexual Abuse

Much less surprising to professional helpers, but interesting because I've never seen these kinds of numbers:

From research by economists J.J. Prescott and Jonah Rockoff, here are a few current statistics on sex offenses reported to the police:

1. 25 percent of victims are 10-14 years old; 23 percent are nine or younger.
2. 22.5 percent of the offenders are family members. Only 8 percent are strangers.
3. 25 percent of sex offenses reported to the police lead to an arrest.

And these are only the offenses reported to the police. Stranger sex offenses must be much more likely to be reported to the police than family abuse.

Using this data, I estimate that six out of every 1,000 10- to 14-year-old girls are victims of sex offenses which are reported to the police each year. The actual victimization rate is surely much higher.

Can In Utero Exposure to Alcohol Lead to Alcohol Disorders During Early Adulthood?

Another argument for not drinking during pregnancy. I'd caution that correlation does not equal causation.

Drug Recovery Program Honors San Quentin Inmates

There are a lot of things I like about the idea of of training inmates to to provide recovery support and basic treatment in prison. (Although it shouldn't be a replacement for experienced professionals.) I feel a little queasy about prisons being a workforce recruitment and development center:

Nine inmates in the Addiction Counselors Training (ACT) program, which began training inmates to become certified drug and alcohol counselors in 2005, were honored at the event. Working under clinical supervision by experienced addiction treatment professionals, the inmate counselors provide peer counseling, case management and education services to other inmates in the Addiction Recovery Counseling (ARC) program while in custody and will receive job placement counseling and referrals for employment in the addictions treatment field when they are paroled, prison officials reported.

"Are you suicidal?"

Troubling findings about suicide crisis lines:

Two of the unprecedented studies involved eavesdropping on suicide hot-line calls - in which the researchers heard things like that terrifying rifle shot - and two main conclusions came out of the work: One, many crisis-line callers are indeed in suicidal distress (and not just lonely or sad) and they are helped by talking to an empathetic fellow human being. And two, the call centers fail, with alarming regularity, to ask some very basic questions: Are you suicidal? Do you have a plan? Do you have the tools at hand to carry it off? Are you alone and drinking?

Is bipolar disorder overdiagnosed among patients with substance abuse?

A new study found a 57% false positive rate:

The study was performed at a residential treatment facility for patients with known substance abuse or dependence. All consecutive patients who presented to the psychiatrist affiliated with the facility with a request for ongoing psychiatric care for a previous diagnosis of BD were asked to participate. To qualify for the study, patients had to have either a history of treatment for BD by a psychiatrist or be in current treatment for BD as an outpatient. In other words, all subjects had to have been diagnosed or treated for bipolar illness by a psychiatrist.

...

All potential subjects participated. A total of 21 patients were interviewed....Only 9 of the 21 (42.9%) participants met DSM-IV criteria for BD.

They hate us

From a local research center:

Heroin-dependent volunteers who also use cocaine are needed for an eight-week research study.

The purpose is to study how certain factors, including drug dose, the amount of work effort and medication dose affect opiate and cocaine drug choice. Short-term maintenance on buprenorphine (an alternate to methadone) is included but this is not a treatment study. This requires reporting ... every day to receive the medication.

Volunteers must be willing to live for at least 22 and up to 26 consecutive nights on a residential unit, during which time they will participate in 12 experimental sessions that involve different doses of a medication (sustained release amphetamine) and choices between different drug does and money. Candidates will be thoroughly medically and psychiatrically screened. Only volunteers who are in good health, from 18 to 55 years old, and not seeking treatment will be accepted.

Volunteers can earn up to $50 for screening and from $880 to $1,328 for completing the study.

I wonder what will happen when you take a group of heroin addicts, give the bupe to help keep them off heroin during the study, give them stimulants for 3 weeks, give them a large sum of money, and then send them on their way?

At best, it's a set-up for a self-destructive binge. At worst, it's a set-up for an overdose.

This made it through a human subjects committee. They hate us.

UPDATE: Someone questioned whether "they" really hate us. I believe that this could only happen in a climate of contempt and dehumanization. If it's not hatred, it's depraved indifference.

Parolees can't be forced into Alcoholics Anonymous, court rules

More here. Just stupid, given all of the recovery support options available in California.

Michigan treatment and prevention cuts

As the Michigan legislature tries to hammer out final budget agreements, there is ongoing concern that there will be PA2 fund cuts to the Substance Abuse Coordinating Agencies (SACA). The SACAs have not had a funding increase in 17 years and the proposed cuts may amount to as much as 20%.

If this is an issue you care about, contact your State Representative and State Senator.

Here's what I might write:

Dear [Legislator]:

As you consider additional cuts to the state budget, please do not cut the PA2 funds currently allocated to the Regional Substance Abuse Coordinating Agencies. Cuts in addiction treatment and drug prevention will actually lead to increased costs to the state. Medicaid healthcare costs will increase. Emergency departments will be flooded. Jails and prisons costs will rise. These cuts would not be fiscally responsible.

More than 600 scientific papers have concluded that treatment for drug addiction works. Relapse rates for addiction treatment are lower than treatment for asthma and hypertension, and equivalent to relapse rates in type 2 diabetes. Patient compliance rates for addiction treatment are better than patient compliance rates in the treatment of asthma and hypertension. Treatment is also cost effective. Studies by the RAND Corporation and UCLA have both found that every $1 spent on addiction treatment saves $7 in other costs like medical, human service and criminal justice system costs.

Unfortunately, treatment remains out of reach for most people. More than 1.2 million Americans wanted treatment but did not receive it; nearly 38% tried to enter treatment but were unable due to costs.

Please do not cut PA2 funding to the Regional Substance Abuse Coordinating Agencies. Lives and families depend on access to addiction treatment.

Sincerely,

Jason Schwartz

One tip. If you plan to email your legislators and you work for a treatment program, you may not want to use your work email account.

Michigan addiction professional requirements

The Michigan Office of Drug Control Policy (ODCP) recently announce new requirements for all treatment agencies receiving funding through the Regional Substance Abuse Coordinating Agencies.

All treatment specialists (Basically, any counselor.) must obtain a CAC-M, CAAC-M, CAC-R, CAAC, or CCJP credential from MCBAP. In addition, all treatment supervisors must obtain a CCS (Certified Clinical Supervisor) credential from MCBAP. These requirements apply regardless of professional licensure. (With the exception of ASAM and APA certifications specializing in addiction.)

These changes are to be effective October 1, 2008.

I plan to contact the ODCP to share my opinion on this requirement. If you have an opinion, you should too.

Here's their email address: MDCH-ODCP@michigan.gov

Michigan Co-occurring Numbers

Don Allen, Michigan's Director of the Office of Drug Control Policy, reported today that 33% of people served in Michigan's public substance abuse treatment system have a co-occurring psychiatric disorder.

Hardly an expectation.

It's worth noting that this number is not too far from the 27% identified in the NSDUH.

Pain relievers surpass marijuana

From the 2006 National Survey on Drug Use & Health:
I've also posted on this before, but this graph shows that marijuana has been replaced by pain relievers (non medical use) as the drug most often tried for the first time.

Tsk, tsk, tsk, baby boomers

From the 2006 National Survey on Drug Use & Health:
I've posted on this before. This graph shows that young baby boomers are the demographic with the fastest growing rates of drug use.

Dual diagnosis is an expectation?

From the 2006 National Survey on Drug Use & Health:

Meeting the criteria for SPD indicates that the respondent endorsed having symptoms at a level known to be indicative of having a mental disorder (i.e., any disorder such as an anxiety or mood disorder).

Am I missing something? It's also worth noting that this makes no attempt to distinguish between primary and secondary problems.

A two question asessment?

From Alcohol, Other Drugs, and Health: Current Evidence:

• Among subjects in the developmental sample, 2 criteria*—recurrent drinking in physically hazardous situations and drinking more or for longer than intended—had a sensitivity of 96% and a specificity of 85% for current alcohol use disorders.
• Among all subjects in the 3 validation samples, the criteria had a sensitivity of 72% to 94% and a specificity of 80% to 95%.

Risk factors for non-fatal overdose

From Alcohol, Other Drugs, and Health: Current Evidence:

an overdose more than 6 months before study entry (odds ratio [OR], 28.6)

younger age (e.g., OR, 7.2 for subjects 18–24 versus those 45 and older)

cocaine use in the last 6 months (OR, 2.1)

serious withdrawal symptoms in the last 2 months (OR, 2.7)

alcohol use in the last 6 months (OR, 1.9)

Alcohol Use Disorders: Chronic or Not?

From Alcohol, Other Drugs, and Health: Current Evidence:

Alcohol Use Disorders: Chronic or Not?
Interviews of a representative sample of 43,093 U.S. adults provide new information on the usual course of alcohol use disorders (abuse or dependence).

• Approximately 5% of adults had past-year abuse while 4% had past-year dependence. Lifetime prevalences were 18% and 13%, respectively.
• Of those with lifetime alcohol dependence, only 24% reported ever having received alcohol treatment, even though treatment was defined broadly and included (but was not limited to) participation in 12-step programs, care in an emergency department, and assistance by clergy or other professionals.
• The mean age of onset of an alcohol use disorder was 22 years.
• Most patients with lifetime abuse or dependence had only 1 episode (72%). Those with more than 1 episode had a mean of 5 episodes. The mean duration of the longest episode was about 3 years for abuse and 4 years for dependence.

Comments:
This nationally representative survey tells us that alcohol use disorders begin in young adulthood and usually go untreated. They are characterized by recurrence for relatively few patients (though patients with recurring episodes are the ones that physicians are most likely to encounter and remember). More commonly, alcohol use disorders consist of 1 symptomatic episode, even when not treated, lasting up to several years.

Richard Saitz, MD, MPH

So, alcohol use disorders are generally not chronic. What would be nice to know is what the breakdown looks like for abuse versus dependence.

Study: Romantic love affects brain like drug addiction

A very interesting look at the neurobiology of love. Surprise! There are some striking similarities to addiction:

Her front brain is telling her he's trouble. Look at the facts, it says. He's never made a commitment, he can't keep a job.

But her middle brain won't listen. Man, it swoons, he looks great in those jeans, his black hair curls onto his forehead so adorably. His front brain is lecturing, too: She's flirting with every guy, and she can drink you under the table, it says. His mid-brain is unresponsive, distracted by her come-hither stare.

"What could you be thinking?" their front brains demand.

Their middle brains, each on a quest for reward, pay no heed.

Alas, when it comes to choosing mates, smart neurons can make dumb choices.

...

That initial spark can flash and fade. Or it can become a flame and then a fire, a rush of exhilaration and sense of union that scientists know as passionate love.

Key to this state of seeing a person as a soul mate instead of a one-night stand is the limbic system, nestled deep within the brain between the neocortex (the region responsible for reason and intellect) and the reptilian brain (responsible for primitive instincts). Altered levels of dopamine, norepinephrine and serotonin – neurotransmitters also associated with arousal – wield influence.

But passionate love is also "a drive to win life's greatest prize, the right mating partner," Dr. Fisher says. It is, she says, an addiction.

People in the early throes of passionate love, she says, can think of little else. They describe sleeplessness, loss of appetite and feelings of euphoria, and they're willing to take exceptional risks. Brain areas governing reward, obsession, recklessness and habit all play their part in the trickery.

In an experiment published in the 2006 book Evolutionary Cognitive Neuroscience, Dr. Fisher found 17 people who were in relationships for an average of seven months. All said they'd feel deep despair if their lover left, and they yearned to know all there was to know about the loved one.

She put them in an FMRI to see what areas of their brains got active when they saw a photograph of their beloved ones.

"We saw activity in the ventral tegmental area and other regions of the brain's reward system associated with motivation, elation and focused attention," she said. It's the same part of the brain that presumably is active when gamblers think they're going to win.

...

Lucy Brown, professor of neuroscience at the Albert Einstein College of Medicine, has also taken FMRI images of people in the early days of a new love. In a study reported in the July 2005 Journal of Neurophysiology, she too found key activity in the ventral tegmental area. "That's the area that's also active when a cocaine addict gets an IV injection of cocaine," Dr. Brown says. "It's not a craving. It's a high."

Biologically, the cravings and pleasures unleashed are as strong as any drug. Certain brain regions, scientists have found, are being deactivated, such as within the amygdala, associated with fear. Excited brain messages reach the caudate nucleus, a dopamine-rich area where unconscious habits and skills, such as the ability to ride a bike, are stored.

A 40-fold increase in bipolar?

This is a little outside my usual areas of focus, but Michelle Cottle from The New Republic does a great job summarizing a very troubling story from the New York Times:

There's a disturbing front-pager in today's New York Times about the sharp increase in the diagnosis of bipolar disorder among U.S. children.

According to a study in this month's Archives of General Psychiatry, between 1994 and 2003, the number of bipolar diagnoses for Americans under the age of 20 rose from 20,000 to 800,000. As the Times calculates it, the disorder now affects about 1 percent of the under-20 population, making it more common than garden-variety depression.

These findings strike me as deeply troubling, not because I think today's kids are dramatically more disordered than they were a decade ago, but because--this being America--the rise in diagnoses is naturally being accompanied by a rise in the prescription of powerful drugs.

Whatever your views on America's psychopharmaceutical habit, you have to admit we have an unfortunate (and accelerating) tendency to respond to any unpleasant behavior with medication. So be it. But ostensibly well-informed, responsible adults dosing themselves willy-nilly is one thing. Dosing their kids is another matter entirely.

For starters, as psychiatric experts told the Times, diagnosing biploar disorder in kids is an iffy business, in part because it tends to manifest itself differently in children than in adults. Worse still, the meds used to treat the disorder apparently have few proven benefits in children and can prompt some pretty nasty side effects (including tremors and rapid weight gain). As we saw with certain antidepressants' tendency to raise the risk of suicide in kids, assuming that what's good for Mom and Dad is also good for Junior can be flat-out dangerous.

One might argue that no parent would dose their beloved offspring with a brain-altering drug unless the kid's behavior was so terrible that there was no doubt but that he was seriously ill. (And yes, more often than not, the child in question is a he: two-thirds of bipolar patients are boys.) But I think exactly the opposite is true: Parents understandably cannot bear to sit helplessly by and watch their children suffer--Why is he so angry? Why is he so sad? Why does he get into so much trouble at school? We want answers. We want a plan of action. We want desperately to be told by some nice doctor that the nightmare will end with the proper combination of pills. (Besides, who has the time, energy, and comprehensive insurance coverage for longer-term treatment options?)

A Brief Commentary on Science and Stigma

Bill White recently released a new article expressing serious concern about the message of addiction as a brain disease without including information about recovery:

1. communicating the neuroscience of addiction without simultaneously communicating the neuroscience of recovery and the prevalence of long-term recovery will increase the stigma facing individuals and families experiencing severe alcohol and other drug problems, and
2. the longer addiction science is communicated to the public without conveying the corresponding recovery science, the greater the burden of that stigma will be.

...Campaigns that sought to reduce the stigma of mental illness by educating the public that mental illness was a brain disease inadvertently invoked perceptions that the mentally ill were less than human and invoked harsher behavior toward the mentally ill (Mehta & Farina, 1997; Corrigan & Watson, 2004). While such research has not been directly replicated in the addictions field, Crawford and colleagues (1989) did find that humanitarian attitudes toward the alcoholic (e.g., a sympathetic attitude and belief that treatment should be supported by public funds) were not directly related to whether alcoholism was or was not viewed as a disease.

The vivid brain scan images of the addicted person may make that person’s behavior more understandable, but they do not make the person whose brain is being scanned more desirable as a friend, lover, spouse, neighbor, or employee. In fact, in the public’s eye, there is short distance between the perceptual categories of brain diseased, deranged and dangerous. We should not forget that a century ago biological models of addiction provided the policy rationale for prolonged sequestration of addicted persons and their inclusion in mandatory sterilization laws (White, 1998). Further, christening addiction a CHRONIC brain disease—as I have done in innumerable presentations and publications, may, without accompanying recovery messages, inadvertently contribute to social stigma from a public that interprets “chronic” in terms of forever and hopeless (“once an addict, always an addict”)(See Brown, 1998 for an extended discussion of this danger).

Conveying that persons addicted to alcohol and drugs have a brain disease that alters emotional affect, compromises judgment, impairs memory, inhibits one’s capacity for new learning, and erodes behavioral impulse control are not communications likely to reduce the stigma attached to alcohol and other drug problems, UNLESS there are two companion communications: 1) With abstinence and proper care, addiction-induced brain impairments rapidly reverse themselves, and 2) millions of individuals have achieved complete long-term recovery from addiction and have gone on to experience healthy,
meaningful, and productive lives.

Drinking Often Spurs Move to Poorer Neighborhoods

An important finding:

"The more alcohol problems a man has, the more likely he is going to remain in, or migrate into, a disadvantaged neighborhood," according to a team of University of Michigan researchers. They report their findings in the September issue of Alcoholism: Clinical & Experimental Research.

"It can be kind of bleak when you look at it, but we know that alcoholics are prone to a whole range of negative consequences," added Ryan Trim, a research psychologist at the VA San Diego Health Care System who's familiar with the findings.

Experts have looked at the connections between neighborhoods and alcohol use in the past, but they've tended to focus on how bad neighborhoods might help produce alcoholism, Trim said.

He said the new study is unusual, because it looks at the link from the other direction: whether alcohol use makes people more likely to migrate to worse areas.

It's pretty obvious and confirms what most of us already believed. It's important
because studies on alcohol and poverty usually come at it from the other end--alcohol problems are more prevalent in poor areas, therefore poverty is an environmental cause of alcohol problems--these people are self-medicating their suffering from poverty.

This finding provides some important perspective on the matter. It also illuminates how researcher bias can lead to accurate but incomplete information.

Insite expands with Onsite detox centre for addicts

Vancouver's safe injection site makes a move in right direction. I wish I could say that I'm confident they'll embrace facilitating recovery.

In a previous post I was underwhelmed with the detox referral numbers that they were crowing about.

Industry worker drug use: Worker Substance Use by Industry

The latest installment of SAMHSA's drug and alcohol use by industry report.

Food service and construction have the highest rates of drug use while construction and entertainment have the highest rates of heavy drinking.

Education and utilities have the lowest rates of drug use, while health care and education have the lowest rates of heavy drinking.

Sewage tells tales about community-wide drug abuse

A new way to measure drug use community-wide.

Tanorexia--a real addiction?

This Slate article offers biological evidence for tanning as an addiction:

A fundamental question in sun science is why we go on basking like lizards despite the obvious risks. Researchers have long suspected a connection between UV exposure and natural "feel good" molecules called beta-endorphins, which are also released during exercise. But for years, the evidence was ambiguous, as some scientists looking for it failed to find an endorphin surge in peoples' blood following exposure to ultraviolet light.

Last year, however, the field warmed up, so to speak. Steven Feldman, a dermatologist at Wake Forest University, gave eight frequent tanners a drug called naltrexone, which blocks the body's opioid receptors. These are sites in the body and brain where endorphins, as well as drugs like morphine and codeine, may attach. Feldman found that on naltrexone, half of the frequent tanners showed signs of withdrawal, like nausea and jitteriness, whereas none of the infrequent tanners did. He argues that with their opioid receptors blocked, the tanners "were deprived of their UV fix," because they'd developed a chemical dependency on the light.

David Fisher of the Dana Farber Cancer Institute in Boston thinks there may be an evolutionary rationale for the sun's draw. Maybe the endorphin release offered an adaptive advantage by reducing the pain associated with sunburn, or encouraged people living at high latitudes to spend time in the sun and thus avoid vitamin D deficiency. This spring, Fisher and his colleagues happened on a molecular connection between UV light, tanning, and endorphin release. In a paper published in March in Cell, they reported that UV damage directly causes the production of beta-endorphin in the skin.

No one knows exactly how this endorphin release might trigger chemical dependency—the molecules may or may not reach the bloodstream. But the door is now wide open to molecular sleuthing. Meanwhile, some indoor-tanning fans are also touting the endorphin findings, since it seems to prove chemically that tanning feels terrific (even as it kills you).

Kicking Butt

William Saletan argues that it's time to take a deep breath and consider whether we're going too far in the war on tobacco:

Despite studies showing it's far safer than cigarettes, most European countries allow smoking but prohibit snus. In the U.S., sponsors of legislation to regulate tobacco under the FDA are resisting amendments that would let companies tell consumers how much safer snus is. The president of the Campaign for Tobacco-Free Kids complains that snus will "increase the number of people who use tobacco," letting "the big companies win no matter what tobacco products people use." But the goal shouldn't be to stamp out tobacco or make companies lose. The goal should be to save lives.

The bill's opponents are no better. They'd rather stick with the idiotic current policy of letting the FDA regulate nicotine in gum and patches—its safest delivery vehicles—but not in cigarettes. They insist tobacco products can't be made safer or less addictive. That's just wrong. In addition to snus, one biotech company has already engineered tobacco plants that are almost nicotine-free.

A year ago, when a study showed an increase in cigarette nicotine levels, anti-smoking activists accused the tobacco industry of boosting its narcotic dosage to make people smoke more. But against the FDA bill, which would reduce nicotine levels, activists are making the opposite argument: that in order to get the same nicotine fix, people will be forced to smoke more cigarettes. Either way, they think manipulation is the problem. In the past, that was true. But today, manipulation is the solution.

Instead of indiscriminately vilifying tobacco, we should reengineer it. Bypass the combustion, purge the tar, dial down the nicotine—whatever serves public health. We could even use it to cure people. Two years ago, Henry Daniell, a biologist at the University of Central Florida, proved that an anthrax vaccine could be grown in genetically engineered tobacco. Tobacco was a logical vehicle, he said, because it was prolific and wouldn't end up in the food supply.

I get the argument, and I suppose it could work with FDA regulation, but I also understand the reluctance to enlarge the tobacco market.

Surviving the Pain and Sharing the Hope

The New York Times describes the outreach worker training system in New York.

Race and the war on drugs

Bradford Plumer explains that, while the effect of the war on drugs and the crack sentencing laws may be racist, the intent was clearly not racist:

The War on Drugs, which has contributed more to our mass-incarceration orgy than anything else, strikes me as more than just Jim Crow for the 21st century. After all, in 1989 even Jesse Jackson was talking about using "antiterrorist policies" on drug users and traffickers, and Charlie Rangel was constantly savaging Reagan for being too soft on the drug menace. The media hyped to high heaven an article by Robert Martinson showing that rehabilitation doesn't work, and yawned five years later when he recanted. (Martinson, depressed over what he had wrought, killed himself in 1980.) There seems to be a mass frenzy at work here that goes beyond race, even if that's how it started.

Politics and Prison Reform

Interesting. The two most conservative candidates, Sam Brownback and Mike Huckabee, may be the two more vocal advocates of prison reform.

Huckabee on 3-strikes legislation and addiction:

Arkansas Governor Mike Huckabee is blunt when it comes to the three-strikes approach to justice: "It's the dumbest piece of public-policy legislation in a long time. We don't have a massive crime problem; we have a massive drug problem. And you don't treat that by locking drug addicts up. We're putting away people we're mad at, instead of the people we're afraid of."

More on Huckabee:

...he campaigns on a compassionate approach to wrongdoers, especially those whose crimes are the result of drug or alcohol addiction. At Philly's Finest, he condemned the "revenge-based corrections system," sounding every bit the sort of squishy liberal that the Bill O'Reillys of the world long ago scared into the shadows. "We lock up a lot of people we are mad at rather than the ones we are really afraid of," he said. "We incarcerate more people than anybody on earth." As governor, Huckabee pushed for drug treatment instead of incarceration for nonviolent offenders.

Brownback on the Second Chance Act:

The senator talks about how to achieve that goal by pointing to the program his audience knows well. IFI and other prerelease programs, says Brownback, can help inmates break their "bondage" to the past and prepare for a new life with people who can "pull you up, and not down." He also discusses his Second Chance Act, which would authorize $40 million to help newly released prisoners with housing, drug treatment, counseling, job training, and education. Brownback says reducing the recidivism rate is not only about turning around the lives of those who have committed crimes but also about "breaking the generational curse . . . so that it doesn't go to your kids and grandkids."

If there's bipartisan support for action, why is nothing happening? Conservative blogger Ross Douhat offers an explanation:

Prison reform is one of those impossible issues where all the incentives cut against changing the present system, because its injustices and cruelties are borne by a small percentage of the population, and its benefits are spread across the public as a whole.

Here's interesting analysis of the ineffectiveness and the racial injustice of it all:

Consider the tortured racial history of the War on Drugs. Blacks were twice as likely as whites to be arrested for a drug offense in 1975 but four times as likely by 1989. Throughout the 1990s, drug-arrest rates remained at historically unprecedented levels. Yet according to the National Survey on Drug Abuse, drug use among adults fell from 20 percent in 1979 to 11 percent in 2000. A similar trend occurred among adolescents. In the age groups 12–17 and 18–25, use of marijuana, cocaine, and heroin all peaked in the late 1970s and began a steady decline thereafter. Thus, a decline in drug use across the board had begun a decade before the draconian anti-drug efforts of the 1990s were initiated.

Of course, most drug arrests are for trafficking, not possession, so usage rates and arrest rates needn’t be expected to be identical. Still, we do well to bear in mind that the social problem of illicit drug use is endemic to our whole society. Significantly, throughout the period 1979–2000, white high-school seniors reported using drugs at a significantly higher rate than black high-school seniors. High drug-usage rates in white, middle-class American communities in the early 1980s accounts for the urgency many citizens felt to mount a national attack on the problem. But how successful has the effort been, and at what cost?

Think of the cost this way: to save middle-class kids from the threat of a drug epidemic that might not have even existed by the time that drug incarceration began its rapid increase in the 1980s, we criminalized underclass kids. Arrests went up, but drug prices have fallen sharply over the past 20 years—suggesting that the ratcheting up of enforcement has not made drugs harder to get on the street. The strategy clearly wasn’t keeping drugs away from those who sought them. Not only are prices down, but the data show that drug-related visits to emergency rooms also rose steadily throughout the 1980s and 1990s.

Entrepreneurial Addiction Recovery Centers

I didn't have time last night to provide context for this post. Here's a passage from Slaying the Dragon that provides some historical context for this trend:

In the 1980s, addiction treatment programs shifted their identities from those of service agencies to those of businesses. A growing number of for-profit companies that measured success in terms of profits and quarterly dividends--rather than treatment outcomes--entered the field.

...

Their self-images shifted from those of public servants to those of health-care entrepreneurs. For a time, a predatory mentality became so pervasive that it affected even some of the most service-oriented institutions. In this climate, alcoholics and addicts became less people in need of treatment more a crop to be harvested for their financial value. This evolving shift in in the character of the field left in its wake innumerable excesses that tarnished the public image of the field and set in motion a financial backlash that would lead to fundamental changes in the primary treatment modalities available to addicts and their families.

New Style of Entrepreneurial Addiction Recovery Centers Becoming Main Stream

Oy vey.

Harm Reduction

A few people have asked for thoughts about yesterday's harm reduction post. I held back, intending to let it speak for itself and avoid appearing mean, but here goes.

I thought it did a great job illuminating the differences between Dawn Farm (drug-free, recovery-oriented services) and them. Not to say that we can't learn anything from them, but from our perspective, I thought that their comments communicated the following:

• a belief in addiction as a lifestyle choice (rather than loss of control or enslavement to a brain disease)
  
• overwhelming skepticism about the capacity of addicts to recover
• a fetishization of drug culture
• vicarious derivation of "coolness" from contact and identification with addicts
• a reduction of addicts to a culturally liberated hedonist caricature
• the subtle bigotry of low expectations
• enoblizing the suffering of addicts

This shouldn't be perceived as an attempt to generally disparage harm reduction. I can support most harm reduction activities if they are conducted in a recovery-oriented manner. Those comments don't reflect any interest in facilitating recovery.

Disability payments may spur drug abuse

This is old news to our detox staff:

Paying out certain types of government aid in a monthly lump sum appears to fuel a spate of harmful and often fatal drug binges, according to a new study in a forthcoming issue of the Journal of Public Economics that links the monthly arrival of disability checks with a sharp rise in drug related hospitalizations and deaths. The findings by researchers at the University of California, Santa Cruz and Texas A&M University suggests that spreading out aid payments over several weeks could be a way to relieve some of the stress on hospitals and health care workers who struggle to handle the monthly surge.

The analysis found that in California, the 23 percent increase in drug-related hospital admissions that occurs in the first five days of any given month is driven largely by the arrival of Supplemental Security Income (SSI) and Social Security Disability Income (DI) payments. In particular, hospital deaths among SSI recipients increase 22 percent at the beginning of the month.

Quitting on Impulse May Be Smokers' Best Bet

What does this mean for the transtheoretical stages of change?

Smokers are often told the best way to nix their habit is to have a game plan, including a quit day and a quit strategy. But could that advice be counterproductive?

In a recent study putting that question to the test, smokers who quit spontaneously -- without advance planning -- had a greater chance of succeeding than those who planned ahead. The results, published in the British Medical Journal, seem to flout traditional smoking-cessation guidance.

Dr. Michael Siegel, a professor of social and behavioral sciences at Boston University who examines tobacco control policies and smoking behavior, said the findings make a lot of sense.

"Planned quit attempts are implemented gradually and thus the level of motivation is probably rather low," he said. "But these unplanned, sudden attempts probably reflect some sentinel event or great tension that precipitates a very high level of motivation to quit. And thus these attempts are more successful," he reasoned.

Study authors Robert West and Taj Sohal liken the unplanned quit attempt to what mathematicians call "catastrophe theory." The idea is simply this: As tensions build up, even small triggers can lead to sudden and dramatic shifts in action. In nature, such forces might lead to, say, an avalanche. In much the same way, a smoker becomes disgusted with his habit, creating tension that, eventually, triggers a split decision to kick the habit.

...

Thomas Glynn, director of cancer science and trends and director of international tobacco programs at the American Cancer Society in Washington, D.C., said the research is intriguing.

"What this study does is certainly require us to take a step back and look at different decision-making styles that people have," he said. But without further study bearing out these results, the cancer society would not consider revisiting its smoking cessation advice. "We certainly wouldn't want to do it on the basis of one study, particularly one that's based on retrospective data," he added.

For their study, the researchers compared data on 918 smokers who had made at least one quit attempt with the experiences of 996 successful former smokers. Almost half -- 48.6 percent -- of smokers said their most recent quit attempts were made without previous planning, and these spontaneous attempts were more likely to succeed for at least six months.

In fact, the odds of quitting successfully for at least six months were higher for unplanned quit attempts than for those that involved some pre-planning.

Presuming their theory is correct, the researchers propose that public health campaigns focus on what they dub the "3 Ts" -- creating motivational tension in smokers, triggering action in those who are on the cusp of change, and supporting them with treatment, such as nicotine patches and counseling.

Everything above makes a lot of sense but the ellipses replaced this:

Siegel said the study points to the need to focus on motivating smokers to want to quit. He said there's been too much emphasis on promoting pharmaceutical aids to help people quit. "If we can get smokers motivated enough, they will succeed in quitting, regardless of the mechanism."

Really? The reason people are unsuccessful quitting is that they are not sufficiently motivated? This doesn't doesn't fit countless anecdotal experiences and seems to suggest that the blame lie with the addict.

Herbal sleeping pills contain prescription meds

One more reason for those in recovery to be careful about herbal remedies.

Why do drug dealers live in their mother's basements?

This doesn't have much to do with addiction, but the author of Freakonomics pokes holes in our cultural mythology about drug dealers and wealth.

The syringe in the sandbox

A call for needle exchange reform in San Francisco. More background info here.

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.