Drug inflation

No mention of heroin or other opiates. My impression is that heroin prices are stable or down. Also, we've seen a downturn in cocaine admissions, continuing increases in heroin and other opiates, and we still see very few meth admissions.

Prices for cocaine and methamphetamine have risen for the fourth quarter in a row, a trend law enforcement officials say indicates supply has dropped.

The price for a pure gram of cocaine increased 47% since October 2006. The price of a pure gram of methamphetamine jumped 84%, says a report out Thursday by the Drug Enforcement Administration.

...

A gram of pure cocaine cost about $137 in September, up from $93 in October 2006, according to a DEA database that analyzes seized illegal drugs. A gram of pure methamphetamine cost $245 in September, up from $133 in October 2006. The DEA uses the database to gauge illegal drug markets. High prices and low purity generally indicate a short supply. Dealers often use filler ingredients to stretch a drug supply.

via dailydose.net

Landmark study on SUD and depression in teens

A breathless press release is hyping the findings in a new study:

The adolescents were randomly assigned to receive either 20 milligrams of fluoxetine daily or a placebo, along with cognitive behavioral therapy (CBT) focused on substance abuse rather than depression.

"The weekly, individual cognitive behavioral therapy helps adolescents improve their decision-making skills as well as their coping, communication, and drug-refusal skills," added Riggs. "It also helps adolescents learn ways to avoid high-risk situations and increase their motivation and involvement in pro-social activities that are incompatible with drug use."

The study found fluoxetine combined with CBT was well-tolerated and had greater efficacy than the placebo with CBT on the Childhood Depression Rating Scale-Revised but not on the Clinical Global Impression Improvement measure of treatment response. Drug use and conduct disorder symptoms decreased significantly in both the fluoxetine and placebo treatment groups but there was no difference between fluoxetine and placebo treatment on either variable. The rate of treatment retention/completion (84 percent) was higher and reduction in drug use similar to that reported for other evidence-based substance treatment modalities in adolescents with less psychopathology.

Then there's this pearl:

The higher than expected rate of treatment response (CGI-I) in the placebo + CBT (67 percent) as well as the fluoxetine + CBT (76 percent) treatment group may indicate that CBT contributed to depression treatment response, despite its focus on substance abuse. Adolescents whose depressions remitted (regardless of medication group assignment) significantly decreased their drug use whereas drug use did not decrease in those whose depressions did not remit.

Ton anyone who is familiar with the literature, it should be no shock that depression would respond to CBT, even if it's substance abuse focused CBT. Further, anyone familiar with the literature would know that depressive symptoms generally improve dramatically in the first 3 to 6 weeks of abstinence, without any treatment for mental illness.

A remarkable conclusion:

"An important clinical implication of these results may be that in the context of cognitive behavior therapy (substance abuse treatment), co-occurring depression may significantly improve or remit without antidepressant pharmacotherapy," said Riggs.

Given that conclusion, why isn't the headline, "CBT very effective for treating depression in youth with SUDs"? Or, "Fluoxetine provides modest benefit for depressed teens with SUDs"?

UPDATE: Other possible headlines: "Substance abuse treatment effective for depression in teens", "Psychiatric treatment unnecessary for most depressed teen substance abusers"

They're all accurate, right? They're all also very different. Does this demonstrate that scholarly journals are used professional advocacy tools? At minimum, it's evidence that they reflect the assumptions and biases of that discipline.

Virtual drug dens!

A new spin on cue extinction therapy.

Insomnia

More support for non-pharmacological treatment of insomnia--a common problem among recovering addicts:

For people with chronic insomnia, studies show that simple behavioral and psychological treatments work just as well, and sometimes better, than popular medications, according to a report in The Journal of Family Practice.

The medical journal Sleep last year reported on five high-quality trials that showed cognitive behavioral therapy helped people suffering from insomnia fall asleep sooner and stay asleep longer. Another American Journal of Psychiatry analysis of 21 studies showed that behavioral treatment helped people fall asleep nearly nine minutes sooner than sleep drugs. In other measures, sleep therapy worked just as well as drugs, but without any side effects.

The behavioral strategies for better sleep are deceptively simple, and that’s one reason why many people don’t believe they can make a difference. One of the most effective methods is stimulus control. This means not watching television, eating or reading in bed. Don’t go to bed until you are sleepy. Get up at the same time every day, and don’t nap during the day. If you are unable to sleep, get out of bed after 15 minutes and do something relaxing, but avoid stimulating activity and thoughts.

So-called sleep hygiene is also part of sleep therapy. This includes regular exercise, adding light-proof blinds to your bedroom to keep it dark and making sure the bed and room temperatures are comfortable. Eat regular meals, don’t go to bed hungry and limit beverages, particularly alcohol and caffeinated drinks, around bedtime.

Finally, don’t try too hard to fall asleep, and turn the clock around so you can’t see it. Watching time pass is one of the worst things to do when you’re trying to fall asleep.

Pot, Tobacco and Youth

A new study challenges some assumptions about marijuana use by adolescents:

A study of more than 5,000 youngsters in Switzerland has found those who smoked marijuana do as well or better in some areas as those who don't, researchers said Monday.

But the same was not true for those who used both tobacco and marijuana, who tended to be heavier users of the drug, said the report from Dr. J.C. Suris and colleagues at the University of Lausanne.

The study did not confirm the hypothesis that those who abstained from marijuana and tobacco functioned better overall, the authors said.

In fact, those who used only marijuana were "more socially driven ... significantly more likely to practice sports and they have a better relationship with their peers" than abstainers, it said.

"Moreover, even though they are more likely to skip class, they have the same level of good grades; and although they have a worse relationship with their parents, they are not more likely to be depressed" than abstainers, it added.

It did not explain the reasons behind the apparent effect.

The researchers also found that those who smoked tobacco were more likely to be heavy users and that those who started before the age of 15 were more likely to be heavy users and misuse alcohol.

This has been trumpeted as proof that marijuana is harmless (here and here). Surely, its harm is hyped. But, this is one study, it appears to be something of an outlier, and skipping class and worse relationships with parents are not insignificant (I'm not suggesting that corelation is causation.). It would be interesting to see this done in a longitudinal study and to see if the findings hold. Of course it would also be good to see the study replicated.

Arch Pediatr Adolesc Med. 2007;161(11):1042-1047.

Recovery is everywhere

From the New York Times:

As he coaches one of the highest-ranked high school soccer teams in the country, Martin Jacobson also battles hepatitis C, a disease he contracted in an earlier life as a drug addict.

Mass. plans new heroin overdose program

It looks like Massachusetts is moving ahead with their narcan distribution plan. (Previous post here.)

Massachusetts officials next month will begin distributing kits to heroin addicts that include medication to treat overdoses.

Advocates say the kits will help treat overdoses quickly, safely and without fear of addiction, and will be beneficial in a state where more people die from heroin than firearms.

...

"It's a remarkably safe drug," said Dr. Peter Moyer, medical director for Boston's fire, police, and emergency medical services. "I've used gallons of it in my life to treat patients."

Heroin and other opiates killed 544 people in Massachusetts in 2005, more than double the number killed by firearms.

Strong demand and low prices make heroin a popular street drug in New England. At $5 or $6 for a small bag, heroin can cost less than a six-pack of beer.

"It's the perfect storm in all the wrong directions. We talk about availability, price, and potency of the drug," said Kevin Norton, president of CAB Health & Recovery Services, which will work with the state to provide Narcan in cities and towns on the North Shore.

State Public Health Commissioner John Auerbach, who started the Boston kit distribution program when he worked for the city, emphasized that treatment is still the state's priority.

What does it mean to say that treatment is still the state's priority? Do they have adequate treatment on demand?

Why You Should Be Skeptical About "Scientific" Studies

Bob Sutton offers a graphical explanation of why you should be skeptical of scientific studies:

Philly Needle-exchange angers neighbors

Another community voicing concern about a needle exchange.

This case might be interesting to watch. Philadelphia is in the process of transforming it's mental health and addiction treatment systems into a comprehensive, recovery-oriented system of care. If any community is capable of creating a recovery-oriented needle exchange, it might be Philly.

Passive smoking rates drop by 95% among hospitality workers

Early returns from an indoor smoking ban in England:

The study for charity Cancer UK and carried out by the Tobacco Control Collaborating Centre in Warwick found non-smoking hospitality workers had four times less cotinine - a byproduct of nicotine and an indicator of tobacco smoke exposure - in their saliva in August than they had in June.

They calculated that, on average, employees' exposure was the equivalent to smoking 190 cigarettes a year before the legislation, and that this had fallen to the equivalent of around 44 cigarettes since.

via dailydose.net

Opiate addiction in England

Two stories about opiate addiction in England. One that challenges the efficacy of methadone and another that suggests drug-free recovery is not possible.

via dailydose.net

Comment on "A rare head to head"

This comment from a friend seemed worth posting, just to make sure everyone sees it:

An important addition seems important here. Chantix + ongoing skill building and social support, is the combination that is getting results at 52 weeks. At 6 months, without any social support, the return to smoking rate remains high. I was just in the audience as Dr. Gonzales presented an unpublished study that showed a pattern of slips and relapses for up to 6 months, then stability.

The ongoing studies continue to show us that recovery from tobacco use is a process, not typically a "cessation" event. I think the time is ripe for addiction professionals to enter the tobacco treatment arena. We have much to offer.

Wendy Croze BA, CAC-R, TTS

Insula-palooza

More on the insula and addiction:

Abstract: We have investigated shape deformation of the insula to get a viewpoint of how chronic alcohol consumption affects the perisylvian region and compared the deformity pattern between the left and right hemisphere. A landmark-based structural and surface shape analysis of the insula was performed in 20 patients with alcohol dependence and 20 controls matched for age. The shape analysis revealed that the left and right insula follow distinct shape deformation patterns, which resulted in the reduction of left-right asymmetry. The shape deformity was most prominent in the central part of both insula. Our findings indicate that the right and left hemisphere are both affected but shows distinct patterns of deformation in alcohol dependence.

More brain science

Yesterday, I posted about recent findings related to the insular cortex and stimulants. I should have mentioned that this region was identified last year in a study of stroke patients who forgot to smoke.

Substance-Induced Versus Independent Depressions

A new study on substance-induced major depressive episodes (MDE) reaches a bold conclusion:

This study corroborates a high rate of substance-induced MDEs among alcoholics, with these disorders explaining about half of the lifetime depressive episodes.

Also worth noting, substance induced depressive episodes were no less severe:

...symptoms during the worst depressive episode were quite similar across [subjects with substance induced MDEs] and [subjects with independent MDEs].

More addiction brain research

Care to turn off your insular cortex?

Tests on amphetamine-addicted laboratory rats showed that when the insular cortex was deactivated by injecting a drug that halted brain cell activity, the rats showed no signs of addiction.

When the insular cortex was reactivated, the rats again showed signs of craving amphetamines, according to the research to be published in Friday's edition of the journal Science.

Cutbacks hit drug courts hard

Bad news for Michigan drug courts.

Parity

Health Affairs has a pretty comprehensive overview of the case for parity. Well worth the time it takes to read.

Emotions Run Amok in Sleep-Deprived Brains

More (probably unneeded) evidence for the wisdom of H.A.L.T.

A rare head to head

Chantix vs. Zyban vs. placebo:

Results showed that 22% of participants who used varenicline were able to remain abstinent for the full 52 weeks of the study, a rate two-and-a-half times that of the placebo.

S.F. injection center idea draws, support and doubt

San Francisco mulls Vancouver's experience.

Highlight:

"It's really been studied to death - it's time to move on," Kerr said. "It's obvious this is something that works."

I suppose it depends on your definition of "works." More here.

Too much cannabis 'worsens pain'

More isn't always better:

The pain-relieving qualities of cannabis have long been hailed, and several countries have made it available for medicinal purposes.

But quantity is key, according to the study in the journal Anesthesiology.

...those who had smoked the moderate dose said their pain was much better, while those who consumed high doses said it had got worse.

They did, however, feel "higher" than counterparts who had taken moderate doses.

Neurobiology of alcohol craving

I've seen several MRI studies of cocaine cravings, but I don't remember seeing the same for alcohol:

Aims: This study's purpose was to identify the neural substrates and mechanisms responsible for craving among subjects with alcohol use disorders (AUDs) using functional magnetic resonance imaging (fMRI). Methods: Alcohol abusers with AUD (n = 9) and demographically similar non-abusers (n = 9) participated in this study. After given 5 cc of alcohol, subjects were exposed to different types of stimuli [i.e. alcohol, non-alcoholic beverage, and visual control pictures and one rest (cross-hair)]. Craving levels were rated through self-report on a Likert scale immediately after the presentation of visual cues. Results: Brain activations in the fusiform gyri, temporal gyri, parahipocampal gyrus, uncus, frontal gyri, and precuneus were correlated with the level of craving among subjects with AUD in response to alcohol cues. Conclusions: In conclusion, specific brain regions were identified that are associated with craving among subjects with AUD.

Needle exchange an unmitigated disaster

The Victoria Times Colonist recently published a description of what it's like to live near a needle exchange. Not to sound too cocky, but HR programs like this could do themselves a favor by reading and thinking about our position paper on HR. (Value number 5, in particular.)

Child killings challenge the drug war

Nolan Finley takes on the drug war:

You want to know why kids are being killed in Detroit? Because drug dealing is a $100 billion enterprise in the United States. All of that money moves through the criminal underground, where it is untaxed, unregulated and untraceable.

The only way to stop the drug trade from consuming our children and our communities is to take the profit out of selling dope.

For more than 30 years, we've tried to do that by kicking in doors, rounding up street corner dealers, cutting off international supply lines and filling our prisons. And it hasn't worked.

It will never work. Those determined to destroy themselves with drugs will find a way to do so, just as those who prefer to ruin their lives with alcohol or gambling, vices the government decided that, if we can't beat 'em, we might as well tax 'em.

So let's get the drugs off the street and into the pharmacies where they belong. Pick a variety of narcotics, from marijuana to heroin, and sell them in measured doses over-the-counter, like packaged liquor.

Move the drug money from the alleys to Wall Street. Let the pharmaceutical companies produce, sell and pay taxes on narcotics.

Perhaps we'll have more users when drugs are no longer illegal. But legalizing drugs will allow rehabilitation resources to be focused on those who truly have a problem, and create more funding for anti-drug education.

A drug-free America is an impossible dream. Our stubborn determination to press this lost cause is killing people.

If it were just the dope dealers who were dying, I'd say have at it. That's addition by subtraction.

But in Detroit we've seen the collateral damage of this misguided war.

When babies die in their beds, we have to start challenging the premises of the drug war, and asking whether the fight is worth the cost.

I've addressed these arguments before. (Imagine the power of the pharmaceutical, tobacco and alcohol industries being invested in legal opiates, cocaine and marijuana. Imagine what new drugs and methods of administration could be developed in corporate R & D departments.)

Why does this have to be a choice between the war on drugs and legalization? It doesn't.

Narcan handouts

The Boston Herald ran an article on a local Narcan handout program. Highlights:

Advertising with the glib phrase “Got Narcan? Need a refill?” plastered on the side of its needle exchange vans, the Boston Public Health Commission is stuffing the pockets of Hub junkies with the powerful prescription drug in hopes of countering heroin overdoses.

But front-line ambulance workers said giving addicts a powerful overdose remedy is a flat-out “stupid” practice that encourages uninhibited drug use and could even endanger their lives.

“The solution is for a health care professional to administer the drug, then offer them detox. These days you don’t know if the heroin is laced with something that can interact with it,” said Matt Carty, head of the Boston Police Patrolman’s Union/EMS Division. “It’s stupid, and you can quote me on that.”

The Public Health Commission, which oversees the emergency medical service, reports that since it began distributing Narcan a year ago, the drug has saved 50 addicts from overdoses.

Dr. Peter Moyer, the commission’s medical director, said the bottom line is that Narcan saves lives. It also keeps addicts returning to the city for services and counseling so that one day perhaps the addict will want to get off drugs, Moyer added.

“There’s really no downside to its use,” Moyer said. “They (addicts) do get training.”

What makes me nuts is not so much that they are handing our Narcan. It's that it's done in the context of no access to meaningful to treatment or recovery support services.

Sorting out protective and risk factors

Here's a study highlights how little we know about protective and risk factors:

The risky drinkers reported only slightly higher prevalence of experiencing child abuse or witnessing domestic violence compared to their non-risky drinking counterparts (see Table 1). However, those recruits who reported first drinking around 13 years were 5.5 times more likely to engage in riskier drinking behavior than recruits who reported first drinking after age 13. Other significant and anticipated predictors of young adult drinking were smoking, having a rural or small town background, having grown up with someone who was a problem drinker or having grown up with someone who suffered from mental illness. Some unexpected correlates of risky drinking were achieving a higher educational level, having more close family members or friends, and being raised by two parents.

...Young et al. (2006) provide support for the importance of age of onset to young adult drinking habits; however, they did not find adverse childhood experiences to be equally strong predictors of young adult drinking. Interestingly Young et al. (2006) noted that they did not expect to find that risky drinkers had a number of experiences that one might expect to be protective, such as, a higher number of close family and friends, a higher level of education, along with being slightly more likely to be raised by two parents. Young et al’s (2006) research shows that multiple and interactive factors, whether prototypically protective or detrimental, can be associated with harmful drinking behavior. The presence of protective childhood experiences does not guarantee a young adult life without substance abuse problems.

Technorati Tags: alcohol prevention abuse adolescent

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A tale of two cities...

Two recent articles about harm reduction plans in two cities.

I have lots of thoughts, but here's one quick one about the San Francisco story. Placing an injection center in the area with the highest OD rates seems obvious. But, would such a program (As opposed to a recovery oriented program.) further institutionalize addiction in this struggling community? Also, I've heard that the Tenderloin district is becoming gentrified. What might this do to plans for an injection center? What does that say about treatment of socio-economic classes?

Rethinking confrontation

I posted on this when it came out, but Bill White and Bill Miller recently published an article on confrontation that was just made available on the Counselor Magazine website. It makes a terrific point on confrontation as a therapeutic goal in contrast to confrontation as a therapeutic style:

In its etymology, the word “confront” literally means “to come face to face.” In this sense, confronting is a therapeutic goal rather than a counseling style: to help clients come face to face with their present situation; reflect on it; and decide what to do about it. Once confronting is understood as a goal, then the question becomes how best to achieve it. Getting in a person’s face is rarely the best way to help them open up to new perspectives. There is, as Hazelden observed in its 1985 recanting of aggressive confrontation, “a better way.” People are most able and likely to re-evaluate reality within safe, empathic, supportive and nonjudgmental interpersonal relationships that do not necessitate defensiveness.

One unrelated thought...what is up with the photos that Counselor chooses? Is it just me, or do they make addicts look like dangerous, crazy and volatile psychopaths?

"war on drugs"

The first time the New York Times used the phrase "war on drugs":

June 14, 1919

Health Commissioner Copeland Defends His War On Drugs
According to a statement given out yesterday by the Bureau of Narcotic Research, representing in its membership a number of philanthropists and medical men interested in the drug problem…the question that is interesting the doctors is how far the municipal and State authorities are seeking to interfere with the private practitioner’s efforts in curing drug addicts. Any amendments to the sanitary code as have been proposed that will aim to treat as a single class the thousands of persons addicted to the use of narcotics will be vigorously resisted by the doctors, says the bureau’s statement.

It also states that, according to figures compiled by the Police Department, there are at present some 250,000 addicts in New York. Of this number only about 15 percent are of the criminal or underworld classes, it says, and 212,500 of the total are making every effort to be cured.

via Mental Floss

Amsterdam's Magic Mushroom Tourists May Trip on Sales Crackdown

Drug tourists may be losing a destination:

Paul arrived in Amsterdam looking forward to a weekend with his friends. Instead, the 24-year-old Australian stayed holed up in his hotel room, too frightened to walk the streets after taking magic mushrooms.

"We had to lock ourselves up in case we would do something crazy,'' said Paul, who asked that his last name not be used because he didn't want acquaintances to know about his drug use. "There is no way this should be legal.''

In Amsterdam, where the fungi are sold in so-called smart shops, local officials agree. The city council last month approved a three-day waiting period to cut down on tourist use. The national government is considering an outright ban after a French teenager leapt to her death in March. Health Minister Ab Klink will release a statement on the hallucinogens this week.

Technorati Tags: drugs, policy, europe, legalization, hallucinogens

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Helping other alcoholics in alcoholics anonymous and drinking outcomes

This isn't a new article, but seemed worth sharing. Researchers demonstrate what mutual aid groups have known for decades. Helping other alcoholics helps the helper stay sober.

OBJECTIVE: Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholics in the world, its specific mechanisms that mobilize and sustain behavior change are poorly understood. The purpose of this study is to examine prospectively the relationship between helping other alcoholics and relapse in the year following treatment for alcohol use disorders. METHOD: Data were derived from Project MATCH, a longitudinal prospective investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence. Kaplan-Meier survival estimates were used to calculate probabilities of time to alcohol relapse. To identify the unique value of helping other alcoholics when controlling for the number of AA meetings attended, proportional hazards regressions were conducted to determine whether the likelihood of relapse was lower for those who were helping other alcoholics. RESULTS: There were no demographic differences that distinguished participants in regard to involvement in helping other alcoholics, with the exception of age; those who were helping other alcoholics were, on average, 3 years older than those who were not helping alcoholics. Those who were helping were significantly less likely to relapse in the year following treatment, independent of the number of AA meetings attended. CONCLUSIONS: These findings provide compelling evidence that recovering alcoholics who help other alcoholics maintain long-term sobriety following formal treatment are themselves better able to maintain their own sobriety. Clinicians who treat persons with substance abuse disorders should encourage their clients to help other recovering alcoholics to stay sober.

It would be interesting to look at two more things:

• If these finding hold up in other mutual aid groups. I suspect they would.
• We know that mutual aid group involvement is a better predictor of recovery than attendance. 12 step work is frequently identified as an indicator of involvement. It would be interesting to see if the benefits of helping are are different or more powerful than other forms of mutual aid group involvement.
  

Technorati tags: recovery, alcoholism, aa, mutual_aid, research, addiction

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Europe: Curing, not punishing, addicts

This Op-Ed is a little simplistic, but does a decent job illuminating the difference in approaches. However, I find the headline to be the most striking thing about it. The problem I have with drug policy in some European countries isn't their lack of enforcement, it's the overemphasis on maintenance and harm reduction. Curing, as the headline suggests, does not appear to be a goal at all.

via dailydose.net

Technorati Tags: policy, harm_reduction, drugs, america, europe, addiction, drugs

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Five Myths About Crack

A Washington Post Op-Ed contributor offers some guidance to the supreme court in the form of 5 myths about crack:

1. Crack is different than cocaine.
2. Crack is instantly and inevitably addicting.
3. The "plague" of crack use spread quickly into all sectors of society.
4. Crack is the direct cause of violent crime.
5. Harsh sentences for crack are necessary to deter "serious" and "major traffickers."

Technorati Tags: cocaine, crack, policy, criminalization, addiction

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Seizure Drug May Treat Alcoholism

Topiramate has been used to treat alcoholism for a little while now and was featured in the HBO Addiction series. This story has been very widely reported over the last few days. It may become a useful tool for a small number of alcoholics, but I find the results reported in this article pretty underwhelming:

Compared with placebo treatment, treatment with Topamax was associated with an 8 percent greater reduction in the percentage of heavy drinking days during the trial, the researchers reported.

Researcher Bankole Johnson, MD, tells WebMD that alcoholics in the trial who took Topamax went from the equivalent of drinking a bottle and a half of wine a day to about 3 1/2 glasses of wine.

"I think that is a big difference," he says. "Most people can manage that amount of alcohol without getting into too much trouble."

The researchers reported that Topamax users had a greater rate of achieving 28 or more days of continuous nonheavy drinking during the study and 28 days of continuous abstinence.

The manufacturer has also been accused of promoting off-label use:

But in a letter to the FDA, the consumer interest group Public Citizen accused the company of illegally promoting use of the drug for this purpose.

While doctors can legally prescribe FDA-approved drugs for nonapproved conditions, it is illegal for the companies that market the drugs to promote these so-called "off label" uses.

The Public Citizen complaint involved a question-and-answer sheet distributed to the media before publication of the study, which specifically discussed the drug's potential "off label" use for alcohol dependence.

Kara Russell of Ortho-McNeill tells WebMD that the company knew nothing about the question-and-answer sheet until the Public Citizen letter became public."

Ortho-McNeil Neurologics does not support any reference to off label use of its products and only promotes the use of Topamax in the approved indication of migraine and epilepsy treatment," Russell says.

I'm not surprised. I've wondered what arrangement led to the prominent placement of topiramate in the HBO series. It was practically an infomercial and led the lay people I know to grossly overestimate the effectiveness of the drug.




Technorati Tags: topiramate, addiction, alcoholism, treatment, research, medication

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More on the new Canadian drug plan

65% for prevention and treatment (including culturally specific treatment) doesn't exactly sound Draconian:

The Conservative government's new $63.8-million, two-year drug strategy could be worse, but it could be better.Fully half the money will go toward beefing up treatment for addicts. Since health and social services are mainly a provincial responsibility, however, that money will go mainly to development of national benchmarking - so that evaluations can be consistent across the country - and extra programs for aboriginals. The main burden of helping addicts remains with the provinces.Another $10 million will go to prevention - ad campaigns and brochures to remind people, especially young people, how damaging addiction is. "Drugs are dangerous and destructive," Prime Minister Stephen Harper said, unveiling the plan. "If drugs do get hold of you, there will be help to get you off them."

Based on American experience, mandatory minimum sentences don't seem like a wise move, but why not start lobbying and negotiating instead of calling them idiots.


Technorati Tags: canada, addiction, treatment, prevention, policy

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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?)