Forgiveness

This might be a helpful resource for some clients. I wish the discussions of self-forgiveness had more about repentance. Lee Taft's model fleshes out repentance.

I'd also like to see more about the transition from victim to survivor. Along those lines, this interview from NPR has always stuck with me:

NEAL CONAN, host: This is TALK OF THE NATION. I’m Neal Conan in Washington.
On the 11th of September, Cheryle Sincock was among those killed when a hijacker crashed an airliner into the Pentagon. Her husband, Chief Warrant Officer Craig Sincock, joins us now on the line from his home in Virginia.
And thanks very much for speaking with us.
Chief Warrant Officer CRAIG SINCOCK: Thank you for having me this afternoon, Neal.
CONAN: This must be very difficult for you, especially over the holidays.
CWO SINCOCK: It has been difficult, and yet we really are filled with blessings, too.
CONAN: Filled with blessings. But I wonder, if you go back to September, were you angry after you learned of your wife’s death?
CWO SINCOCK: Neal, I was angry towards the end of that first day, about 11:00 that night, 11:30 when I got home. And I drove in my driveway and I was crying and I was angry at God for about 10 minutes. And then he and I did not have a very good relationship for about those 10 minutes, till I realized that it was not his fault. It was not him that had driven that plane in there. And a calm came over me that night, and I realized that it wasn’t God’s fault; it was something else. And not that I could understand it, but that I, you know, had to just continue on with my life and do the things I needed to do for somebody else at the time.
CONAN: When did you start thinking about forgiveness?
CWO SINCOCK: Actually, that was about the time I started the forgiveness. Actually about four hours after the attack the opportunity came to help somebody else who was in real trouble that day.
CONAN: Mm-hmm.
CWO SINCOCK: And as I was helping that other individual, I realized that when I got out of myself and I really thought about how to help somebody else—How could I say the right words? How could I just be there for somebody else?--the little problems that I had at the time, not knowing my wife—where she was, if she was alive or dead, if she was hurt, injured or whatever, you know. But getting outside of myself, that was a release to me. And then God gave me that same opportunity every single day from that point on and continues to every day, even today, to help somebody else. And getting outside of myself and helping somebody else has now lifted that burden of the fears and the frustration and the anger that I had originally.
CONAN: Does forgiving mean forgetting?
CWO SINCOCK: No, it does not. It’s kind of like you see a dog coming at you on the street, a mad dog, you know, you do something to protect yourself. I can’t forgive the dog. There’s nothing there to forgive, you know? But I have to, you know—I remember that and maybe I walk a different path the next time.
...
CONAN: You talked about this 10-minute period. How did you work through that anger? It must have been very difficult.
CWO SINCOCK: I kind of worked through it—and I hate to say logic because it really wasn’t logic. A calm came over me all of the sudden when I realized that what I was doing was wrong. I did not feel right. And when I don’t feel right, there’s something wrong with me. It’s not wrong with somebody else or something else or someplace else; it’s something wrong with me. I’ve learned that over the years about myself. And I just realized if I’m feeling this way and I’m angry and I’m frustrated and especially when I’m sitting there and I’m angry with God, there is something really wrong with myself. So I had to take a good, hard look that night and realize it was my fears, that fear of the unknown, that terrible fear of the unknown, of the impending doom of something I can’t control. And when I realized that, then I could say, ‘OK, God, you know, what do we do from this point on?’
CONAN: So you took responsibility.
CWO SINCOCK: That’s right. And in all things I have to end up taking—you know, I have to take the responsibility. It’s not the somebody else, it’s not the other people, places and things that get me. It’s usually me, just myself.
CONAN: Well, Craig Sincock, thank you so much for joining us. And again, on behalf of all of us, how sorry we all are for your loss.
CWO SINCOCK: Well, you know, there’s a lot of other people, a lot of other families out there that are still in that. You talked about earlier—you were talking about anger and hate and forgiveness. And what a terrible thing that is when we have to try to search for that and we don’t know how to grab ahold of that. We don’t understand what all those feelings are and those emotions. There’s a way of getting through that process. At least I’ve found a way, you know. And it’s more than just getting down on my knees and praying because I have to do some action, too.
I had one of the ministers or chaplains that was up at the Family Support Center early on after the incident ask me one day how I got through all my angers that he thought I should have. And I told him at that time that I thought anger led into the resentment. And resentment was the fact that when I get angry, that’s my anger.
CONAN: Mm-hmm.
CWO SINCOCK: You know, how dare you interrupt me in my anger? ‘Cause I feel so good feeling so angry.
CONAN: Yeah. You almost nurture it.
CWO SINCOCK: Yes. And the resentment, if I put an action to resentment, I have a revenge. And then if I go from that revenge state and I justify what I’m doing in revenge, I have vengeance. And what’s the only difference between me and my enemy, that person that flew that plane into the Pentagon? They had vengeance, but they had vengeance without a cause. I don’t dare go that far. I have to stop mine at the anger stage. I can’t afford to have that. Perhaps others can, but I cannot. So as I look down at my life and I say, ‘I really can’t afford to get the anger. If I can’t afford to get the anger—what causes my anger is fear. The thing that causes my fear is because I don’t want to forgive somebody for what I think they’ve done to me.’ And then I can say, you know, ‘It’s all right. I don’t understand what you did to me, but it’s OK. I’m going to protect myself a little different next time...’
CONAN: Mm-hmm.
CWO SINCOCK: ‘...but it’s OK.’
CONAN: Well, Craig Sincock, thanks very much.
CWO SINCOCK: I thank you for having me this afternoon.

Farm staff - this would make a great didactic.

One of us

The New Yorker published a profile of Kahlil Gibran. Turns out he's one of us:

He had another difficulty: alcoholism, a situation that may have developed soon after “The Prophet” was published, or while he was writing it. Robin Waterfield thinks that Gibran’s basic problem may have been a feeling of hypocrisy, in that his life so contradicted his pose as a holy man. In his last years, he stayed closed up in his apartment, occasionally receiving a worthy visitor but mostly drinking arak, a Syrian liquor that Marianna sent to him, apparently by the gallon. By the spring of 1931, he was bedridden, and one morning the woman who brought him his breakfast decided that his condition was dangerous. Gibran was taken to St. Vincent’s Hospital, where he died later that day. The cause of death was recorded as “cirrhosis of the liver with incipient tuberculosis.” Waterfield reports that Gibran’s admirers have greatly stressed the tuberculosis over the cirrhosis. “Nothing incipient kills people,” he objects. His speculation seems to be that Gibran drank himself to death out of a sense of fraudulence and failure.

[hat tip: http://newrecovery.blogspot.com]

Alcoholics Anonymous (AA) Recovery Outcome Rates: Contemporary Myth and Misinterpretation

A very interesting (and overdue) paper on AA's current and historical success rates:

This paper addresses an erroneous myth that AA is experiencing a 5% (or less) “success rate” today as opposed to either a 50%, 70%, 75%, 80% or 93% (take your pick) “success rate” it once reputedly enjoyed in the 1940s and 1950s. The term “myth” is used to emphasize that the low “success rates” promulgated are a product of imagination, invention and inattention to detail rather than fact-based research. Also noteworthy in the derivation of the mythical percentages, is the absence of fundamental academic disciplines of methodical research, corroborating verification and factual citation of sources. Regrettably, some of the advocates who are propagating the myth are AA members who purport to be “AA Historians” and appear to be advocating agendas that portray fiction as fact and hearsay as history.

Damaged brakes?

That the frontal cortex plays an import role in addiction is not news. However, if you're not familiar with the neurobiology of addiction, this is worth reading.

The Anti-Drug Drugs

Newsweek has a great overview of how immunotherapy for addiction might work.

A vaccine that would teach the immune system to attack and destroy cocaine before the drug reached the brain is poised to enter its first large-scale clinical trial in humans. The shot is years away from FDA approval, but the concept that it might someday be possible to inoculate those at risk of addiction has obvious appeal.

Each of the addiction vaccines now in development employs a similar medical strategy. Because the addictive drug molecules are small enough to evade the body's immune system, they can slip undetected from the respiratory and circulatory tracts that absorb them and make their way into the central nervous system, where they work their dark magic. But when attached to a larger molecule—like an inactivated protein from a cholera-causing bacterium—the addictive substances can't hide. The immune system develops antibodies that can latch on to the drugs when they are next ingested by themselves. Once attached to an antibody, a given drug cannot access its targets in the brain and is instead broken down by certain enzymes.

The medications now used to treat addiction do not prevent addictive drugs from entering the brain, as the vaccines would. Instead these treatments, known as small-molecule therapies, block the drugs' neural targets, so that when the drug reaches the brain it has no place to go. These treatments have met with limited success. For example, methadone, a drug used to treat heroin addiction, is itself a narcotic that has been associated with addiction. Naltrexone and Chantix, which treat alcohol and nicotine addiction, respectively, have been effective in only a small subset of patients. "In all three cases, the brain's receptors are still being manipulated, albeit with a replacement drug," explains Nora Volkow, director of the National Institute on Drug Abuse. In theory, says Volkow, anti-addiction vaccines would circumvent some of these problems by neutralizing the addictive substance before it reached the nervous system. And that means the drugs might someday be used to prevent substance abuse as well as treat it. "It would be great if we could give kids a vaccine that would make them impervious to the effects of alcohol and hard drugs," says Volkow. "In reality, we are still many years away from that."

Some limitations include the fact they do not appear to have the same effect on every one and that the immune response could be overwhelmed by high doses of drugs.

The Impact of Depressive Symptoms on Alcohol and Cigarette Consumption Following Treatment for Alcohol and Nicotine Dependence

This study found moderate and severe depression to be a predictor of drinking relapse, but not tobacco. Odd.

Here's the abstract and some reactions:

Abstract

Background: Although depression is common among alcohol and tobacco dependent patients, its impact on treatment outcomes is not well established. The purpose of this study was to examine the impact of depressive symptoms on abstinence from tobacco and alcohol after treatment for alcohol dependence and nicotine dependence.

Methods: The Timing of Alcohol and Smoking Cessation Study (TASC) randomized adults receiving intensive alcohol dependence treatment, who were also smokers, to concurrent or delayed smoking cessation treatment. The sample consisted of 462 adults who completed depression and substance use (alcohol and smoking) assessments at treatment entry and 6, 12, and 18 months posttreatment. Longitudinal regression models were used to examine the relationships between depression and subsequent abstinence from alcohol and tobacco after baseline characteristics, including alcohol and smoking histories, were considered.

Results: Depressive symptoms were prospectively related to nonabstinence from alcohol. Depressive symptoms at the previous assessment increased the odds of drinking at the subsequent time point by a factor of 1.67 (95% CI 1.14, 2.43), p <>

Conclusions: Depression is an important negative predictor of the ability to maintain abstinence from alcohol within the context of intensive alcoholism and smoking treatment. It may be important to include depression-specific interventions for alcohol and tobacco dependent individuals to facilitate successful drinking treatment outcomes.

It does a good job reviewing the mixed literature on the subject:

Several studies have suggested that patients with current or a past history of depression have less positive outcomes from alcohol treatment (Curran and Booth, 1999; Driessen et al., 2001; Hasin et al., 2002; Hodgins et al., 1999; Rounsaville et al., 1987). Others have found no relationship between depression and alcohol treatment outcomes (Burns et al., 2005; Davidson and Blackburn, 1998;Hunter et al., 2000; Miller et al., 1997; Sellman and Joyce, 1996).

Here's some more detail from the full text:

...the majority of participants who began the study with mild or no depressive symptoms, had no clinically significant depression at the follow-up assessments. However, most participants who entered the study with moderate or severe depression continued to report significant depressive symptomatology throughout the study.

...it is important to note that some of the variation in the existing literature may be related to differences in the way depression has been measured. For example, when we used just baseline depression scores (vs. the longitudinal, lagged model used in the present analyses) and examined their relationships to subsequent alcohol use, depression did not predict alcohol use beyond the 6-month assessment (data not presented).

It also found immediate smoking treatment to be a predictor of drinking:

Consistent with prior analyses (Joseph et al., 2004b), there was a significant effect of smoking treatment timing; those who had concurrent smoking treatment were more likely to drink over time [OR = 1.63, 95%CI (1.08, 2.47), p <>While it's presented as consistent with the literature, my impression is that this is very inconsistent with most research on the subject.

It says nothing about the treatment received and also found unemployment at baseline to be a predictor of drinking. To me this suggests the limitations of looking at drinking and mood in a vacuum.

The article seems pretty invested in self-medication for endogenous depression as an explanation for the relationship between alcohol and depression:

Our results suggest that depression is related to difficulty achieving 6 months of alcohol abstinence following treatment for alcohol and nicotine dependence. These findings are consistent with the findings from some, but not all, previous studies. For example, at least 1 study found no evidence that alcohol consumption reliably preceded a depressive episode or that depressive episodes reliably preceded the onset of alcohol relapse (Hodgins et al., 1999). However, several other studies have illustrated links between the remission of depression and alcohol or substance use (Hasin et al., 1996, 2002; Mueller et al., 1994; Sullivan et al., 2005). This fits with the model that negative mood states are precursors of relapse (Marlatt and Gordon, 1985) and the idea that negative reinforcement (drinking to reduce negative mood) may help to maintain drinking behavior. In fact, there is evidence that alcohol dependent subjects are more likely to report that alcohol relieved depressive symptoms than other psychiatric patients (Leibenluft et al., 1993).

Here's the predictable headline.

Co-occurring Social Anxiety and Alcohol Use Disorders

Abstract

Background: Individuals with social anxiety disorder and co-occurring alcohol problems report using alcohol to cope with anxiety symptoms. Interventions that reduce both social anxiety and drinking are needed. Paroxetine, an FDA-approved medication to treat social anxiety disorder, reduces anxiety in individuals with co-occurring alcohol problems.

Objectives: To examine whether effective treatment of social anxiety with paroxetine reduces drinking in dual-diagnosed individuals who endorse using alcohol to cope.

Methods: A 16-week, double-blind, randomized controlled trial of paroxetine was conducted. Participants (placebo n = 22; paroxetine n = 20) met DSM-IV diagnostic criteria for social anxiety disorder and alcohol abuse or dependence. Participants were seeking treatment for social anxiety, not for the alcohol problem. Alcohol use outcomes were measured with conventional quantity/frequency measures and novel measures of drinking to cope.

Results: Paroxetine improved social anxiety more than placebo. Paroxetine reduced self-reported reliance on alcohol for self-medication purposes, but was not different than placebo in changing quantity and frequency drinking or the proportion of drinking days that were identified as coping-related. Exploratory analyses revealed that for the placebo group, drinking during the trial was correlated with social anxiety severity, whereas for the paroxetine-treated group, drinking was uncoupled from social anxiety severity.

Conclusions: Successfully treating social anxiety symptoms with paroxetine does not reduce drinking in dual-diagnosed individuals who are not seeking treatment for alcohol problems. Paroxetine does, however, reduce reliance on alcohol to engage in social situations, and may change the reasons why one drinks (such that drinking occurs for other reasons besides coping with anxiety). These results have implications for staging of social anxiety and alcohol treatment in individuals with the co-occurring disorders presenting to a mental health or primary care provider.

Brief family treatment intervention in inpatient detoxification

Abstract

Two earlier studies showed that a brief family treatment (BFT) intervention for substance abusing patients in inpatient detoxification increased aftercare treatment post-detox. BFT consisted of meeting with the patient and a family member with whom the patient lived to review aftercare plans for the patient. A phone conference was used when logistics prevented an in-person family meeting. Based on the earlier research results, we trained a newly hired staff person to continue providing BFT. We monitored key process benchmarks derived from the earlier research studies to ensure ongoing fidelity in delivering BFT. This method proved successful in transferring BFT from delivery in a research study to ongoing delivery in routine clinical practice after the research ended. It also ensured that a high proportion of patients had their families contacted and included in planning the patients' aftercare.

Overdose Rescue Kits Save Lives

The article offers a feel-good national perspective on Narcan kits. Sadly and predictably, there is no mention that these programs are operating in the context of extremely limited access to treatment.

We need both/and.

Sexual Dysfunction Prior to First Drug Use Among Former Drug Addicts and Its Possible Causal Meaning on Drug Addiction

If the only tool you have is a hammer...

What's in a name?

An editorial in Addiction reviews the arguments for and implications of renaming the National Institute on Drug Abuse (NIDA) to the National Institute on Diseases of Addiction (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to the National Institute on Alcohol Disorders and Health (NIADH).

...an argument is put forward that the proposed name change for NIDA ‘removes the pejorative term "abuse"’ and thus separates abuse from ‘diseases of addiction’. Further, the name change links conceptually the concepts of disease with addiction and, as stated in the press release, ‘identifying addiction as a neurobiological disease will diminish . . . social stigma, discrimination, and personal shame . . .’.

For NIAAA, a different explanation is put forth in the Biden press release. The press release argues that NIAAA's current name is an awkward remnant of their organizational past, when the agency was housed within the former Alcohol, Drug Abuse and Mental Health Administration (ADAMHA). Today, NIAAA's research function is under the aegis of the National Institutes on Health (NIH). Moreover, there is a growing sense that ‘excessive alcohol use and alcohol dependence (alcoholism) are not separate diagnostic categories, but exist along a single continuum of alcohol-disorders associated with increased frequency of a harmful drinking pattern’. Thus, the proposed NIDA name change affirms the view that the term ‘abuse’ is no longer a useful or informative way to describe the goals or functions of the agency. In this regard, some have suggested that ‘alcohol abuse’ may not even appear in the next iteration of the DSM, which is due within the next 5 years.

Another explanation, not necessarily mutually exclusive from the first, is that NIDA and NIAAA are responding to pressures within the NIH to view their purpose and mission as primarily biomedical, or as stated in Biden's press release, ‘neurobiological’.

Without taking a position, the editorial points out that an outcome of this (possibly unintended) would be to institutionalize a micro approach to drug and alcohol problems.

What is notable about all the potential reasons for the name changes discussed above is that they all appear to produce a ‘win–win’ situation for those who see drug and alcohol issues exclusively through the quite narrow lens of addiction and disease. The ‘losers’ in this tale will be those who adhere to a broader public health framework that encompasses individual issues as well as larger, social policy and environmental concerns.

Childhood Sexual Abuse, Age of First Drink, and Onset of Alcohol Dependence

An interesting, but not very surprising finding from BASIS. Research in this area seems to consistently challenge common assumptions about childhood sexual abuse and addiction:

Contrary to expectation, CSA did not predict time to AD after adjusting for age at first drink. Drinking at an early age predicted a more rapid pace for AD development; however, both twins having AD was the best predictor of rapid onset of AD after their first drink, suggesting genetics and environment are greater risk factors for this effect than CSA. Future research could examine an early intervention’s effectiveness for reducing rates of later AD among early adolescents reporting CSA history.

Many Psychiatrists Self-Prescribe, Study Says

This story never says how many, "many" is. It also suggests that psychiatrists suffer Major Depression at rates higher than the general population and, interestingly, offers an environmental explanation for their depression that they are treating with meds.

The angle I was most interested in was what this means for patients, in terms of counter-transference and diagnostic patterns. This wasn't addressed.

[via: Matt]

If Tobacco Regulation Works, Why Not Regulate Marijuana?

I suppose it's possible that age of first use could decline if marijuana was regulated, rather than banned. However, please pardon my skepticism at the Marijuana Policy Project's concern about adolescent marijuana use. I'd guess that some of the factors associated with decreases in tobacco use include increased prices and shifts in cultural attitudes (it's gone from adult, cool and sophisticated to unhealthy, unsafe and dirty--from celebrated to tolerated) . In terms of cultural attitudes, perceptions of marijuana seem to be moving in the opposite direction, at least in part, due to the efforts of groups like the Marijuana Policy Project.

I don't begrudge them attacking the irrationality of American drug policy, but I don't trust their motives. I'm not convinced that "reducing harm" is their primary motivation. They earnestly believe legalization will reduce harm, but legalization is primary their primary goal and I suspect they would not change their position if new evidence emerged to challenge their beliefs (not that I'm predicting new evidence). Along these lines, with their consistent message that it's relatively harmless, I find it difficult to believe that they are very concerned about teen marijuana use.

One more thought--alcohol is regulated and widely used by teens. It's possible that, on balance, we'd be better off with different marijuana laws, but this is a pretty weak argument. All policy decisions are about trade-offs. There is no drug policy that will deliver us from all of our drug problems. Beware of people suggesting otherwise.

The notion that crack is far more dangerous than cocaine is widely disputed

More on the irrationality of the crack/powder cocaine sentencing disparity.

While I completely disagree with the sentencing disparity (and I don't think anyone should be incarcerated for personal use), crack is more dangerous than powder in that its addictive properties are changed by creating a cheap, easy way to freebase. It's a little like comparing chewed opium to injected opiates--the syringe dramatically changed the relationship between the drug and users. I suppose it depends on how you define "dangerous." They seem to be focusing on the effects on the body.

Network Support for Drinking and treatment matching

More Project MATCH follow-up:

Objective: The current study re-examined the Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) hypothesis that individuals with high network support for drinking would have the best treatment outcomes if they were assigned to twelve-step facilitation (TSF). Method: Drinking consequences, as measured by the Drinking Inventory of Consequences, was the primary outcome measure. Growth mixture models with multiple groups were used to estimate the drinking consequence trajectories of 952 outpatients during the 12 months following treatment for each of the three Project MATCH treatment conditions. Growth factors within latent trajectory classes were regressed on network support for drinking to assess whether treatment condition moderated the relationship between network support for drinking and drinking consequences over time. Results: Three latent classes were identified, representing low (n = 154, 16.2%), medium (n = 400, 42%), and high (n = 398, 41.8%) levels of drinking consequences. Classes did not differ across treatment groups. Greater network support for drinking predicted more drinking consequences over time but only for clients assigned to cognitive-behavioral therapy and motivational enhancement therapy, not TSF. Conclusions: This study provides further support for one of the original Project MATCH matching hypotheses: Clients with social networks supportive of drinking had better outcomes immediately after treatment if they were assigned to TSF. Because the original Project MATCH studies found this matching effect only at the 3-year follow-up, these results add validity to the network support for drinking matching effect. The study also provides additional evidence that accounting for heterogeneity in alcohol treatment outcomes is important for accurately estimating treatment effectiveness. (J. Stud. Alcohol Drugs 69: 21-29, 2008)

[via: alcohol reports]

Effectiveness of pretreatment interim support groups

This study might offer some ideas for managing waiting lists:

Decreasing state and federal budgets have led to shortages in public health funding for treatment programs to aid long-term users in recovery from methamphetamine abuse. These shortages have led to client “waiting lists” for government-subsidized treatment. Many of these “waiting list” individuals fail to show up for treatment when it is scheduled. The current study investigates the efficacy of “interim support groups” as a means of encouraging methamphetamine abusers to begin treatment programs (defined as attendance on the first day of treatment). A logistic regression revealed that interim group attendance predicted whether a methamphetamine abuser would show up for treatment. These results are discussed in terms of both the value of interim groups in facilitating treatment adherence and the role pretreatment support groups can play in facilitating a methamphetamine abuser's determination to engage in treatment.

Why'd I do that?

Shocking findings about emotional regulation and impulsivity in early recovery:

Background: Early abstinence from chronic alcohol dependence is associated with increased emotional sensitivity to stress-related craving as well as changes in brain systems associated with stress and emotional processing. The aim of the current study was to examine potential difficulties in emotion regulation during early alcohol abstinence using the recently validated Difficulties of Emotion Regulation Scale (DERS).

Method: Recently abstinent treatment-seeking alcohol abusers (n = 50) completed the DERS during their first week of inpatient treatment and at discharge (5 weeks later). These responses were compared to a group of social drinkers (n = 62).

Results: Compared with social drinkers, alcohol-dependent patients reported significant differences in emotional awareness and impulse control during week 1 of treatment. Significant improvements in awareness and clarity of emotion were observed following 5 weeks of protracted abstinence. However, significant difficulties with impulse control persisted until discharge.

Conclusion: Findings from the DERS indicate protracted stress-related impulse control problems in abstinent alcoholics, which may contribute to increased relapse vulnerability.

Presidential Candidates Weigh In

The Partnership for a Drug Free America posted candidate responses to their questions. Only 7 candidates responded.

Number of times the word "recovery" appears in all of the responses: 0
Number of times the word "treatment" appears from each candidate:

• Dodd - 1
• Obama - 2
• Edwards - 5
• Biden - 14
• Gravel - 1
• Huckabee- 2
• Richardson - 1
  

Number of times the words "prevention" or "prevent" appear from each candidate:

• Dodd - 4
  
• Obama - 2
• Edwards - 1
  
• Biden - 6
  
• Gravel - 0
  
• Huckabee- 0
  
• Richardson - 0
  

[via Jess]

A harm reduction trifecta

First, a columnist for the Vancouver Sun rightly complains that only two pillars of Vancouver's four pillar approach have been implemented. The writer promotes a big, audacious (and possibly goofy) idea. Here are the highlights:

The Four Pillars plan totters on only two -- harm reduction (which includes the safe injection site, the ever growing distribution of free needles, methadone and possibly free heroin) and the best enforcement Vancouver police can muster without completely abandoning the rest of the city.

...

Medical experts like Coleman define addiction as a war between two parts of the brain. The forebrain, which controls our intellectual or rational understanding, is not able to keep the mid-brain, the emotional centre, in check.

Addicts are, in Coleman's words, people who continue to use drugs or alcohol despite knowing the consequences are episodes of loss of control and an ongoing preoccupation with getting that next drink or fix.

...

So, what we're left with is this:

We can maintain the status quo, pouring millions of dollars into the Downtown Eastside and pretending that two pillars are four.

We can pack addicts off to the hinterlands and hope they don't come back as Martians.

Or, we can accept the medical evidence that recovery is a slow, hard process that's made easier if people get needed services in their own communities where, unimpaired, they can rebuild and resume their lives.

An Ottawa Citizen contributor defends Insite (Vancouver's safe injection room), characterizing it as a success. (Previous posts on Insite here.)

Finally, an ideologically motivated attack against ideologically motivated attacks against harm reduction. (Did you follow that?)
[via ccsa.ca]

Stimulant alcohol effects prime within session drinking behavior

Until recently, I don't recall seeing any research into stimulant properties of alcohol. However, James Milam wrote about as a powerful reinforcing aspect of alcoholism.

Programs Let Addicted Docs Practice

It looks like California might actually end its health professional recovery program. This article discusses the issue in pretty sensational terms.

Nearly all states have confidential rehab programs that let doctors continue practicing as long as they stick with the treatment regimen. Nationwide, as many as 8,000 doctors may be in such programs, by one estimate.

These arrangements largely escaped public scrutiny until last summer, when California's medical board outraged physicians across the country by abolishing its 27-year-old program. A review concluded that the system failed to protect patients or help addicted doctors get better.

Opponents of such programs say the medical establishment uses confidential treatment to protect dangerous physicians.

"Patients have no way to protect themselves from these doctors," said Julie Fellmeth, who heads the University of San Diego's Center for Public Interest Law and led the opposition to California's so-called diversion program.

Most addiction specialists favor allowing doctors to continue practicing while in confidential treatment, as does the American Medical Association.

Supporters of such programs say that cases in which patients are harmed by doctors in treatment are extremely rare, and would pale next to the havoc that could result if physicians had no such option.

"If you don't have confidential participation, you don't get people into the program," said Sandra Bressler, the California Medical Association's senior director for medical board affairs.

California's program ends June 30. If no alternative program is adopted, the rules could revert back to the zero-tolerance policy in place before 1980, when doctors who were found by the medical board to have drug or alcohol problems were immediately stripped of their licenses.

No other state has followed California's lead. But the president of California's medical board, Dr. Richard Fantozzi, said that behind the scenes, regulators nationwide share his ambivalence toward such programs.

"To hide something from consumers, something so blatant ... it's unconscionable today," Fantozzi said.

I don't know anything about the situation in California, but I suspect that any state with a lousy program would be vulnerable to this kind of action. In that case, you'd have two options: to improve the program, or end the program. If the state has a good monitoring and enforcement program, patients shouldn't have anything to fear. The other advantage of a good program is that they usually have a voluntary program for health professionals who have not been reported by anyone, but are concerned about their own use.

Experts have no fear of crack ruling

Some helpful perspective on the Supreme Court's recent drug sentencing ruling. I'm surprised that this has not gotten more attention.

When the U.S. Sentencing Commission last week reduced sentences for imprisoned crack cocaine offenders — reversing years of policy that treated crack far differently from powder cocaine — the Justice Department and police groups bitterly criticized the action, warning of a flood of criminals rushing out onto America's streets.

The change "will make thousands of dangerous prisoners, many of them violent gang members, eligible for immediate release," predicted acting Deputy Attorney General Craig Morford. "These offenders are among the most serious and violent offenders in the federal system."

But many experts say the reality is not so dramatic. Fewer than 3,000 prisoners nationwide will be immediately eligible for the relief. All have already served considerable time. Each prisoner will have to petition the court for his freedom — and the Justice Department can oppose those petitions. Few offenders with violent histories are likely to be released.

[via dailydose.net]

Legislation to End Student Aid Penalty Stumbles

Your tax dollars at work.

9th Circuit on Abstention From Alcohol as Supervised Release Condition

If I understand this correctly, the 9th Federal Circuit Court ruled that a court can't impose an abstinence order if alcohol didn't play a role offense.

The 'bupe' fix

The Baltimore Sun just ran an article on buprenorphine diversion:

There's a new narcotic on the street in Baltimore and other communities - and taxpayers helped put it there.

The hexagonal orange pills some users call "bupe" are championed as an exceptional treatment for heroin and pain-pill addicts. Federal officials have spent millions of dollars to help create and promote buprenorphine, and are encouraging thousands of private doctors to prescribe it.

But making buprenorphine widely available has also made it easy for patients to sell the narcotic illegally, leading to growing abuse, an investigation by The Sun found. Some people have died after misusing it with other drugs.

Heroin addicts hardened by years on city streets, and youthful buyers in suburban and rural areas, are using it to get high - sometimes in dangerous combination with other substances - and to tide them over when they can't obtain heroin or other narcotics.

The drug, mainly prescribed in a form called Suboxone, is intended to be dissolved under the tongue. But some abusers are crushing the pills to snort or inject buprenorphine, a dangerous practice that medical experts believed could be deterred by a chemical safeguard in Suboxone.

[via jointogether.org]

Crack cocaine: It affects us all

The Muskegon Chronicle is running a series of posts on crack use in the community. (Look here and here.)

More co-occurring common sense

More from that special issue of the Journal of Substance Abuse Treatment. The points below may seem like it's stating the obvious, but for a major journal with leading researchers to be emphasizing these points is a big deal. The balance in this issue is refreshing.

...mixed findings echo the point ... Psychiatric diagnosis alone may be less relevant to addiction treatment failure than symptom severity.

Although, as a group, this population is often labeled as dual disordered,Q persons with co-occurring disorders are a heterogeneous lot, ranging from those with severe mental illnesses (e.g., schizophrenia) to those with mild or moderate psychiatric problems (e.g., dysthymia), as well as from those with severe substance-related disorders (e.g., dependence) to those with mild or moderate problems (e.g., misuse or abuse). In fact, most patients in addiction treatment programs with co-occurring disorders do not suffer from severe mental illnesses.

Co-occurring disorders in substance abuse treatment: Issues and prospects

The Journal of Substance Abuse Treatment has dedicated an issue to co-occurring disorders. This article stands out for balance and avoiding the myopic and psychiatry hyping findings often seen in articles on the subject.

First, is does a good job distinguishing between general population prevalence and clinical population prevalence. What it doesn't do (Because the research isn't there.) is distinguish between acute vs. chronic mental illness or abuse vs. dependence. Further, in discussing assessment, it acknowledges that real world conditions lead to overdiagnosis of mental illness in this population:

Ideally, the assessment of mental disorders would occur only after permitting a period of abstinence that extends up to a month or more to avoid the risk of confusing the client's presenting condition with the effects of his or her drug use ([Center for Substance Abuse Treatment, 2005], [Hasin et al., 1998] and [Quello et al., 2005]). The press of clinical programming often does not typically allow for such a deliberate strategy even where assessment does take place. Thus, in substance abuse treatment, clinicians may feel constrained to adapt practices to less-than-ideal conditions and accept the noise associated with the influence of substance use on assessment practices and results. One potential outcome of this less-than-ideal process is an overidentification of mental disorders, which may be a significant contributing factor to both the high prevalence rates reported by programs for CODs and findings of the effectiveness of single-disorder treatments for individuals identified as showing evidence of multiple disorders. To counter the risk of error in early diagnosis, it has been suggested that clinicians make use of multiple assessments conducted over time (Center for Substance Abuse Treatment, 2005) and rely on brief screening instruments at intake to determine if a later diagnostic assessment is warranted (cf. [Center for Substance Abuse Treatment, 2005] and [Quello et al., 2005]).

Another strength of the article is that it again, examines real world conditions and acknowledging that treatment as usual is effective for people with mild to moderate mental illness:

...it is important to take note of findings from several studies that individuals manifesting low to moderate levels of mental disorder in association with substance abuse appear to respond positively in terms of both drug use and psychiatric symptoms to the nonspecialized treatment provided in drug abuse programs. However, those same studies also point to the importance of specialized treatment specifically responsive to the needs and functioning of those showing moderate to severe levels of mental disorder.

Harm Reduction Round-Up

First, the Baltimore Sun apparently ran a column a while ago advocating the legalization of drugs. The author reports on the feedback he received from ex-users:

Drugs are part of a way of life - robbery, gangs, prostitution - that would persist even if the delivery method changed, the women said. "Addiction is not just getting high," said Felicia, who like the other addicts isn't especially proud of her past and didn't want her last name used. "It's the whole thing - copping [buying on the street], stealing, whatever you do."

Alcohol is legal, but "people out there will rob for a fifth of liquor because they can't get a dollar and 50 cents," she said. "They steal, they trick. They do the same thing. I've got friends that will go out there and hustle harder than me for a drink." Methadone also is legal, but plenty of methadone patients who are clean of heroin still break the law, she said.

Second, Addiction Inbox explores naloxone distribution.

Finally, Health Beat does a great job pointing out the increases in spending on incarceration at the same time as decreases in real health care spending:

Just take a look at history. According to a Health Affairs article from earlier this year, since 1987 public and private investment in substance abuse (SA) treatment has not kept pace with other health spending. From 1987 to 2003, the average annual total growth rate for SA treatment was 4.8 percent, while U.S. health care spending grew by 8.0 percent each year. Because of this mismatched growth rate, SA spending fell as a share of all health spending from 2.1 percent in 1986 to 1.3 percent in 2003.

Compare this drop in treatment spending to the increase in drug arrests: according to the Bureau of Justice Statistics, in 1987 drug arrests were 7.4 percent of all arrests reported to the FBI; by 2005, drug arrests had risen to 13.1 percent of all arrests. Our spending on SA treatment and the volume of drug arrests are moving in opposite directions. And for all the political pageantry surrounding yesterday’s report, President Bush’s FY 2008 budget calls for cutting $158.7 million from the Substance Abuse and Mental Health Services Administration (SAMHSA) budget and $278.9 million from the Safe and Drug-Free Schools and Communities (SDFS) program.

If you take a look at the President’s 2008 drug control budget, it may look as if it emphasizes treatment over enforcement, since it claims a 3.4 percent increase (the most of any other sector of drug control) from 2007. But take this number with a grain of salt—there are a lot of questions marks beneath the surface. In 2001 The Boston Globe reported that drug officials had no methodology to formulating the drug control budget, admitting that “we made it up” and that budget reports did not reflect how money was actually being spent through drug policy. Since 2003, there have been worries that the Office of National Drug Control Policy (ONDCP) budget inflates its commitment to treatment by including alcohol and tobacco in its numbers for SAMHSA, even though by statute ONDCP is excluded from dealing with those substances. Worse, since 2003 the ONDCP drug budget hasn’t reported incarceration costs and costs related to the prosecution of drug cases, resulting in an artificial parity between enforcement and treatment.

Health Beat goes on to discuss Insite in a way that frames arguments against it as pro-enforcement. She offers an explanation of why enforcement approaches seem to always win in political discourse:

More often than not, treatment is going to lose out because it lacks the populist, kick-you-in-the-gut political salaciousness of punishment.

To me it seems that the debate is actually between enforcement, treatment and HR. Unfortunately HR and enforcement seem to be the squeaky wheels and treatment loses out. These debates don't have to be framed as enforcement OR treatment OR HR. We could do all three. Couldn't we?

Male Admissions with Co-occurring Psychiatric and Substance Use Disorders: 2005

These new federal numbers suggest that either people Minkoff are grossly overestimating rates of mental illness or practitioners completing the federal reporting forms are grossly underestimating the prevalence of mental illness.

Of the approximately 544,800 male admissions in these 26 States in 2005, 16 percent (86,500) were admissions with co-occurring substance use and psychiatric disorders (hereafter referred to as co-occurring disorders). This report compares the characteristics of male admissions with co-occurring disorders and male admissions without co-occurring disorders.

Why not legalize?

A very smart post on legalizing drugs:

Ethan points out that alcohol and nicotine do more damage than most of the illicit drugs. He could have stated that more strongly: alcohol alone does more damage than all illicit drugs combined. I can't figure out why that counts as an argument for legalization; if the drug we legalized does more harm than the drugs we still prohibit, doesn't that suggest that legalization tends to increase harm by increasing the number of problem drug users?

...

Both the drug warriors pursuing their fantasy of a drug-free society (not including their favorite drug, alcohol) and the legalization agitators imagine that there's a simple way out of this mess. There isn't. There are many useful things to do, but none of them fits on a bumper sticker

As I've said here before, anyone who suggests that legalization or better enforcement will solve (or dramatically improve) our drug problem is dishonest or deluded. While our current policy provides the worst of all worlds, which alternative policy to pursue comes down to which problems we want to live with.

Monitoring the Future data released

Good news. Here are the highlights:

The drugs most responsible for this year’s modest decline in illicit drug use are marijuana and various stimulant drugs, including amphetamines, Ritalin (a specific amphetamine), methamphetamine, and crystal methamphetamine.

...

A number of illicit drugs showed little change this year. Many of them are at rates well below their recent peak levels of use, however. These include cocaine, crack cocaine, LSD, hallucinogens other than LSD, heroin, and most of the prescription-type psychoactive drugs used outside of medical supervision, including sedatives, tranquilizers, narcotics other than heroin, OxyContin specifically, and Vicodin specifically. (Both OxyContin and Vicodin are narcotic drugs.)

...

The only drug showing signs of an increase in use is MDMA (ecstasy).

...

The use of alcohol by teens, like their use of many of the illicit drugs, has declined since the mid-1990s.

...

30-day smoking rates continued a gradual decline in grades 8 and 10 in 2007—statistically significant for 8th grade only.

More on Prometa

I've posted before about Hythiam and their Prometa protocol. I'm glad to see that they are under renewed scrutiny. 60 Minutes did a story on them and several newspapers are running this Chicago Tribune story.

Cocaine sentencing ruling

In a decision with pretty sweeping implications, the SCOTUS ruled that judges can deviate from the sentencing guidelines. The ruling stemmed from a judge's decision to deviate from the 100:1 crack/cocaine sentencing guidelines, because they were "ridiculous".

The big question now is what congress will do. There is broad support for closing the gap, but some proposals do this by raising powder cocaine sentences. The other question facing congress is whether to adjust sentences retroactively. There is a lot of support for this, but they will need support from many of the "tough on crime" Democrats (Like Hillary Clinton).

The other question I have is whether this ruling so dramatically changes the landscape that congress has no longer has a significant role in correcting the problem.

Parenting in addiction

Here's a qualitative study of the impact of opiate addiction on parenting. It examined several areas, including, effects of use, emotional availability, physical availability, financing of addiction, socialization, depression/ irritability, imprisonment, and, interestingly, treatment.

Here are some of the closing comments:

Implications for children's well-being and development

The psychological consequences for children of low levels of parental involvement, including low or erratic levels of emotional responsiveness, separation from parents and unstable or inconsistent caregiving environments have been well-researched, though not specifically in the context of parental drug misuse. Low levels of involvement by parents who are present in the home, such as minimal supervision and monitoring, has been linked with a range of negative outcomes for children, and especially risk for conduct and emotional problems (Patterson and Stouthamer-Loeber 1984; Simons et al. 1994).

Parental emotional responsiveness has been identified as an important predictor of positive social development. Across childhood, sensitive attunement of parents to children's capabilities and to their developmental tasks seems to promote emotional security, behavioural independence and social competence, as well as intellectual achievement (Demo and Cox 2000). Responsive caregiving has been found to act as a mediator of the effects of adversity on children's well being (Egeland et al. 1993). Low parental emotional responsiveness, on the other hand, has potentially negative implications for children's development and welfare and for the security of attachment relationships (De Wolff and van Ijzendoorn 1997). These relationships need to be investigated in the context of parental drug misuse, where the physiological and psychological effects of drug intake and withdrawal, as well as the social context may have particular implications for children's risks and outcomes.

Finally, it has long been recognised that instability and discontinuity of care-giving pose threats to children's emotional well-being. Recent literature suggests that family instability may have a negative impact on children's sense of emotional security in the family and sense of control over their immediate environment (Ackerman et al. 1999). The particular implications for children being reared in the context of parental opiate dependence, which may be chronically relapsing, need investigation. The significance of separations that occur in the context of parental drug use, and its correlates, such as imprisonment, hospitalisation and death of parents due to drug misuse, needs urgent attention from researchers. The impact on parent-child relationships of the enforced separation brought about by parental incarceration, under the constraints of prison visiting policies, which may limit parent-child physical contact, and in the context of parental drug use and its associated stigma, is an important avenue for future research.

Implications for support

The clearest implication arising from this study is that support should be targeted at families as systems, rather than at drug users as individuals. It should focus on ensuring continuity, not only of instrumental caregiving, but also of emotional caregiving to children, particularly through periods of critical transitions associated with the changing lifestyle and patterns of drug use and treatment of their parents when parental ability to sustain positive involvement may be especially low. This research also highlights areas of particular vulnerability in the course of daily life, such as early mornings. Programmes are needed that target these periods and that help reduce risks for children. Such programmes should recognise that opiate dependence may be chronic, with periods of more intense support needs.

Social services need to be alert to the risk that children may be in need of substitute parental care at short notice and/or for unpredictable lengths of time and make suitable arrangements with extended family members or professional carers. Interviews with professionals linked to these families, reported in Hogan and Higgins (2001a), revealed a concern amongst professionals that grandparents were being expected to pick up the pieces very often and that they were often themselves in need of support. Sometimes grandparents were reluctant to let their drug using son or daughter resume their parental role or there was conflict between the parent and the grandparents. Hogan and Higgins conclude that 'family support is often a complex issue that requires greater understanding' (2001a, p 27).

The children in this sample were not receiving any counselling or support which was geared specifically to helping them to deal with their parent's addiction. Such support might be needed in many cases. Also parents who are addicts may need advice and support around their parenting role and the consequences of their addiction for their children. Since some parents and children are coping well most of the time, an open door service might be well suited to the needs of many parents and children. Such a service should be oriented towards the family not just the addict. The need for more intense, individual interventions may be expressed or identified more easily when parents and children have ready access to a family-oriented service, which does not seek to pathologise their behaviour or their experience.

Conclusions

Parents' reports indicate that drug misuse affects parenting in specific ways, which have a negative impact on parental capacity to be emotionally available and responsive to their children on a stable basis over time. The implications for children's well-being and development need further study. Future research should explore children's subjective experiences of family relationships in the context of parental drug misuse, and especially children's experiences of security and closeness within their families. Support services should be family-oriented and designed to provide long-term support for families, with the capacity to provide increased support during periods of particular vulnerability.

Problem-free drinking over 16 years among individuals with alcohol use disorders

A new study suggests that abstinence is the best goal for most problem drinkers. The description immediately begs the question of how many members of the study group only met criteria for DSM abuse. I went to the full text and it looks like this group was composed of pretty heavy drinkers. They averaged 12.5 drinks per drinking episode.

Results - In the 6 months prior to the 1-year assessment, 36% (n = 152) of participants reported abstinence from alcohol, 48% (n = 200) reported drinking with problems, and 16% (n = 68) reported non-problem drinking. At each follow up, 16–21% of the sample reported non-problem drinking. Compared to individuals in the abstinent and problem-drinking groups, individuals who were drinking in a problem-free manner at 1 year had reported, at baseline, fewer days of intoxication, drinks per drinking day, alcohol dependence symptoms, and alcohol-related problems, less depression, and more adaptive coping mechanisms. Over time, 48% of participants who engaged in non-problem drinking at 1 year continued to report positive outcomes (either non-problem drinking or abstinence) throughout the long-term follow-up, whereas 77% of those abstaining at 1 year reported positive outcomes throughout the same time period. Additionally, 43% of individuals with problematic alcohol consumption at 1 year reported positive outcomes over the remaining follow-up interval, a rate that was not significantly different from the rate of positive outcomes of 48% observed in those with initial problem-free drinking.

Conclusions - Although some individuals report non-problem drinking a year after initially seeking help, this pattern of alcohol use is relatively infrequent and is less stable over time than is abstinence. An accurate understanding of the long-term course of alcohol use and problems could help shape expectations about the realistic probability of positive outcomes for individuals considering moderate drinking as a treatment goal.

Trazodone Improves Sleep, but Decreases Abstinence in Recovering Alcoholics

Here's bad news for a widely used treatment strategy for sleep disturbance in early recovery:

"We were really surprised that, if anything, trazodone made things worse with respect to drinking," said Dr. Swift. "The sleep was better. The drinking was not."

"Wired" Recovering Alcoholics

Sleep disturbances are common among patients in recovery from alcoholism, said Dr. Swift, affecting 25% to 50% of patients who are in the early stages of detoxification. Fatigue might be related to relapse, he added.

Off-label prescribing of trazodone, a weak sedating antidepressant, is the most common pharmaceutical treatment for insomniac alcoholic patients in the early stages of detoxification, according to a survey of addiction medicine physicians done by Dr. Friedman and colleagues (J Addict Dis 2003; 22:91-103).

In 2006, there were 16 million prescriptions for trazodone in the United States, said Dr. Swift, speculating that a lot of these prescriptions were for sleep disorders. In laboratory studies, 1 of trazodone's metabolites — m-chlorophenylpiperazine — was found to increase alcoholic cravings.

The group wanted to determine whether trazodone reduces drinking and improves sleep quality among alcoholic patients who have recently undergone detoxification.

They hypothesized that among alcoholic patients in early recovery, the administration of trazodone would increase days of abstinence, reduce heavy drinking days, reduce drinks per drinking day, and improve sleep quality.

They screened more than 2400 people who were admitted to the state-run detoxification program in Rhode Island. To be included in the study, individuals had to be 18 years or older and meet DSM criteria for alcohol dependence but not for any other drug except nicotine or cannabis. They also had to have sleep problems during previous abstinence periods or have a self-reported global Pittsburgh Sleep Quality Index score of >5 (indicating disturbed sleep).

Most potential subjects were excluded because they abused other drugs. A total of 173 patients were randomized to trazodone 50 to 150 mg (n=88) or to placebo (n=85) for 12 weeks. All patients received a sleep hygiene booklet. Assessments were made at baseline, 1 month, 3 months (study end), and 6 months (follow-up).

Outcome variables included Pittsburgh Sleep Quality Index scores, percentage of abstinent days, drinks per drinking day, and percent of heavy drinking days (5 for men, 4 for women).

Very Heavy Drinkers

The participants had a mean age of 21 years, and women made up less than 10% of the study sample. The group reported heavy drinking in the previous 3 months (a mean of 22 drinks per drinking day, and a mean of 71 heavy drinking days).

Individuals in the trazodone group had less improvement in percentage of abstinent days, a smaller decrease in heavy drinking days, and an increase in drinks per drinking day after the study medicine was stopped.

Trazodone was associated with a greater improvement in sleep quality, but once the medication was stopped, sleep quality was the same as with placebo.

Study limitations include that it was a relatively small sample in a single site and that subjects were all very heavy drinkers.

The group concluded that despite a short-term benefit in sleep quality with trazodone, the drug might impede improvements in alcohol consumption in the postdetoxification period and might lead to increased drinking when stopped.

"Until further studies have established benefits and safety, trazodone for sleep disturbances cannot be recommended after detoxification from alcoholism," said Dr. Swift.

[via http://alcoholreports.blogspot.com]

Forced 12-step attendance

An email about the following line from and article I posted about earlier:

Twelve-step programs can work for people who choose that option, she said, but it’s not effective for people who are forced into such programs.

The question was whether this was an empirical statement. I haven't seen replicated research on the subject. AA is full of people who were court-ordered and coerced by families and employers. There are all sorts of reasonable arguments against coerced attendance--that it changes AA in undesirable ways; that it might be less effective for people who are forced than for people who go voluntarily; that, for people who are unwilling, it might be less effective than alternatives; that it's unconstitutional; that it's wrong or unjust; that 12-step groups aren't for everyone; etc.

Clearly, 12-steps groups sometimes doesn't work for people who go voluntarily and sometimes works for people who are coerced/forced.

Personality disorders and alcoholism treatment

A counter-intuitive finding: "Diagnosis of personality disorder did not adversely affect alcohol outcomes"

While addicted people with BPS may be at ongoing risk for other problems, these findings, with respect to drinking and drug use outcomes, are not an aberration. (See here, here and here.)

[via alcoholreports.blogspot.com]

Europeans are lushes

Just kidding. However, 14 of the 15 heaviest drinking countries are in Europe. (Australia is the lone non-European country on the list.)

This begs questions about whether these higher consumption rates result in greater alcohol related harm. Unfortunately, the article doesn't answer that question.

Also, the article suggests that cultural tolerance and acceptance are the reason for these consumption patterns. If that's the case, does that pattern hold for drugs?

Hide the hand sanitizer!

You know you're powerless when...

Forced 12-step loses in court (again)

Another ruling that court ordered 12-step attendance is a violation of the persons rights.

[via jointogether.org]

Nicotine helps cognitive function in alcoholics

All you smokers have a new excuse. Fortunately, the patch appears to have the same benefits. One question though, if smoking is associated with relapse, does NRT carry the same risks?

• Alcoholics in early recovery tend to have impaired cognitive functioning.
• Nicotine is known to have beneficial effects under certain circumstances.
• New findings show that nicotine patches may enhance cognitive functioning among newly recovering alcoholics with a history of smoking.

[via jointogether.org]

Drug War Wars

It didn't take long. The Rolling Stone article that I just posted about, has already prompted prompted at least one call for legalization:

Wallace-Wells' skillful illustration of the international repercussions of the repressive Nixon-Reagan-Bush-Clinton-Bush war on drugs, which threatens to turn Peru and Mexico into narco-states, inspired me to revisit economist David R. Henderson's findings on the effects of stringent drug control. In a working paper circulated in the late 1970s and finally in a 1991 paper published in the University of California-Davis Law Review (1991. 24: 655-676) titled "A Humane Economist's Case for Drug Legalization," Henderson shows how increased penalties never have the effects on drug markets predicted by governments.

Henderson looks at drug markets as rational, which they are, and writes that increased drug penalties tend to drive "more civilized dealers" out of the market and reduce supply. "Competition by buyers for a lessened supply must cause the price to rise," he writes, and as "the price rises, profits will increase and in the long run eventually will return to their precriminalization levels." As the civilized dealers exit, the most vicious dealers rise. He continues:

Profits of dealers will look higher than normal because the cost of imprisonment, fines, and bribes is not subtracted. Also, profits of successful dealers who are never caught will be higher than normal, just as profits of lottery winners are higher than normal. Looking only at the profits of dealers who successfully avoid capture, however, and concluding on that basis that the illegal drug business is abnormally profitable is like looking at the fortunes of only lottery winners and concluding that buying a lottery ticket is abnormally profitable.

Henderson's insights help explain the phenomenal violence of the cocaine trade described by the Rolling Stone piece.

How America Lost the War on Drugs

Rolling Stone has a terrific article chronicling the failures of American drug policy over the last 14 years. Here's one lost opportunity:

"At the beginning of the Clinton administration," Cañas tells me, "the War on Drugs was like the War on Terror is now." It was, he means, an orienting fight, the next in a sequence of abstract, generational struggles that the country launched itself into after finding no one willing to actually square up and face it on a battlefield. After the Cold War, in the flush and optimism of victory, it felt to drug warriors and the American public that abstractions could be beaten. "It was really a pivot point," recalls Rand Beers, who served on the National Security Council for four different presidents. "We started to look carefully at our drug policies and ask if everything we were doing really made sense." The man Clinton appointed to manage this new era was Lee Brown.

Brown had been a cop for almost thirty years when Clinton tapped him to be the nation's drug czar in 1993. He had started out working narcotics in San Jose, California, just as the Sixties began to swell, and ended up leading the New York Police Department when the city was the symbolic center of the crack epidemic, with kids being killed by stray bullets that barreled through locked doors. A big, shy man in his fifties, Brown had made his reputation with a simple insight: Cops can't do much without the trust of people in their communities, who are needed to turn in offenders and serve as witnesses at trial. Being a good cop meant understanding the everyday act of police work not as chasing crooks but as meeting people and making allies.

"When I worked as an undercover narcotics officer, I was living the life of an addict so I could make buys and make busts of the dealers," Brown tells me. "When you're in that position, you see very quickly that you can't arrest your way out of this. You see the cycle over and over again of people using drugs, getting into trouble, going to prison, getting out and getting into drugs again. At some point I stepped back and asked myself, 'What impact is all of this having on the drug problem? There has to be a better way.' "

In the aftermath of the Rodney King beating, this philosophy - known as community policing - had made Brown a national phenomenon. The Clinton administration asked him to take the drug-czar post, and though Brown was skeptical, he agreed on the condition that the White House make it a Cabinet-level position. Brown stacked his small office with liberals who had spent the long Democratic exile doing drug-policy work for Congress and swearing they would improve things when they retook power. "There were basic assumptions that Republicans had been making for fifteen years that had never been challenged," says Carol Bergman, a congressional staffer who became Brown's legislative liaison. "The way Lee Brown looked at it, the drug war was focused on locking kids up for increasing amounts of time, and there wasn't enough emphasis on treatment. He really wanted to take a different tactic."

Brown's staff became intrigued by a new study on drug policy from the RAND Corp., the Strangelove-esque think tank that during the Cold War had employed mathematicians to crank out analyses for the Pentagon. Like Lockheed Martin, the jet manufacturer that had turned to managing welfare reform after the Cold War ended, RAND was scouting for other government projects that might need its brains. It found the drug war. The think tank assigned Susan Everingham, a young expert in mathematical modeling, to help run the group's signature project: dividing up the federal government's annual drug budget of $13 billion into its component parts and deciding what worked and what didn't when it came to fighting cocaine.

Everingham and her team sorted the drug war into two categories. There were supply-side programs, like the radar and ships in the Caribbean and the efforts to arrest traffickers in Colombia and Mexico, which were designed to make it more expensive for traffickers to bring their product to market. There were also demand-side programs, like drug treatment, which were designed to reduce the market for drugs in the United States. To evaluate the cost-effectiveness of each approach, the mathematicians set up a series of formulas to calculate precisely how much additional money would have to be spent on supply programs and demand programs to reduce cocaine consumption by one percent nationwide.

"If you had asked me at the outset," Everingham says, "my guess would have been that the best use of taxpayer money was in the source countries in South America" - that it would be possible to stop cocaine before it reached the U.S. But what the study found surprised her. Overseas military efforts were the least effective way to decrease drug use, and imprisoning addicts was prohibitively expensive. The only cost-effective way to put a dent in the market, it turned out, was drug treatment. "It's not a magic bullet," says Reuter, the RAND scholar who helped supervise the study, "but it works." The study ultimately ushered RAND, this vaguely creepy Cold War relic, into a position as the permanent, pragmatic left wing of American drug policy, the most consistent force for innovating and reinventing our national conception of the War on Drugs.

When Everingham's team looked more closely at drug treatment, they found that thirteen percent of hardcore cocaine users who receive help substantially reduced their use or kicked the habit completely. They also found that a larger and larger portion of illegal drugs in the U.S. were being used by a comparatively small group of hardcore addicts. There was, the study concluded, a fundamental imbalance: The crack epidemic was basically a domestic problem, but we had been fighting it more aggressively overseas. "What we began to realize," says Jonathan Caulkins, a professor at Carnegie Mellon University who studied drug policy for RAND, "was that even if you only get a percentage of this small group of heavy drug users to abstain forever, it's still a really great deal."

Thirteen years later, the study remains the gold standard on drug policy. "It's still the consensus recommendation supplied by the scholarship," says Reuter. "Yet as well as it's stood up, it's never really been tried."

To Brown, RAND's conclusions seemed exactly right. "I saw how little we were doing to help addicts, and I thought, 'This is crazy,' " he recalls. " 'This is how we should be breaking the cycle of addiction and crime, and we're just doing nothing.' "

The federal budget that Brown's office submitted in 1994 remains a kind of fetish object for certain liberals in the field, the moment when their own ideas came close to making it into law. The budget sought to cut overseas interdiction, beef up community policing, funnel low-level drug criminals into treatment programs instead of prison, and devote $355 million to treating hardcore addicts, the drug users responsible for much of the illegal-drug market and most of the crime associated with it. White House political handlers, wary of appearing soft on crime, were skeptical of even this limited commitment, but Brown persuaded the president to offer his support, and the plan stayed.

Still, the politics of the issue were difficult. Convincing Congress to dramatically alter the direction of America's drug war required a brilliant sales job. "And Lee Brown," says Bergman, his former legislative liaison, "was not an effective salesman." With a kind of loving earnestness, the drug czar arranged tours of treatment centers for congressmen to show them the kinds of programs whose funding his bill would increase. Few legislators came. Most politicians were skeptical about such a radical departure from the mainstream consensus on crime. Congress rewrote the budget, slashing the $355 million for treatment programs by more than eighty percent. "There were too many of us who had a strong law-and-order focus," says Sen. Chuck Grassley, a Republican who ­opposed the reform bill and serves as co-chair of the Senate's drug-policy caucus.

For some veteran drug warriors, Brown's tenure as drug czar still lingers as the last moment when federal drug policy really made sense. "Lee Brown came the closest of anyone to really getting it," says Carnevale, the longtime budget director of the drug-control office. "But the bottom line was, the drug issue and Lee Brown were largely ignored by the Clinton administration." When Brown tried to repeat his treatment-centered initiative in 1995, it was poorly timed: Newt Gingrich and the Republicans had seized control of the House after portraying Clinton as soft on crime. The authority to oversee the War on Drugs passed from Rep. John Conyers, the Detroit liberal, to a retired wrestling coach from Illinois who was tired of drugs in the schools – a rising Republican star named Dennis Hastert. Reeling from the defeat at the polls, Clinton decided to give up on drug reform and get tough on crime. "The feeling was that the drug czar's office was one of the weak areas when it came to the administration's efforts to confront crime," recalls Leon Panetta, then Clinton's chief of staff.

What I find encouraging is that I see no reason to believe the window of opportunity for that 1995 plan was permanently closed. In fact, it seems that it may be opening again right now. There seems to be a growing bipartisan consensus that the drug war's emphasis on incarceration has been a disaster. It seems to me that the only reason we haven't changed course is that Washington doesn't see a politically viable alternative. Public interest in relatively low, I suspect that this is because the public also doesn't see any good options. The time may be right for a sensible alternative to emerge from the din of the legalization and tough on crime crowds. Obama and Huckabee have laid some groundwork but other candidates are more wary.

The Peace Drug (MDMA)

The Washington Post recently ran a story on a researcher looking at ecstasy as a treatment for PTSD:

THE CAPSULES RESIDE IN A SAFE, armed with an alarm and bolted to the floor of Mithoefer's office, a 1950s-vintage cottage on the road between downtown Charleston and Sullivans Island. It's been tastefully remodeled to create a softly lit, high-ceilinged sanctuary in the back, scattered with art and furnished with, among other things, the ever-so-slightly inclined futon where Donna got crooked.

The elaborate security is occasioned by what is inside the capsules: MDMA, a synthetic compound that is a chemical cousin to both mescaline and methamphetamine. Unabbreviated, MDMA is a real mouthful -- 3,4-methylenedioxymethamphetamine -- but it is far better known by its street name, ecstasy, millions of doses of which are synthesized in criminal labs from the oil of the sassafras plant. At one point, Mithoefer recounts, agents of the Drug Enforcement Administration, there to inspect the security arrangements, inquired about the therapist who rents the office adjoining the safe room.

"I guess they were concerned she might drill through the wall into the safe and steal the MDMA," Mithoefer says. "Though there's such a small amount in there, and it's so readily available on the street in such large quantities, I don't see how that would be worth the effort, even if she were so inclined."

Mithoefer became a psychiatrist in 1991, after a decade as an emergency room doctor -- he had found himself less interested in the bodily traumas his patients suffered than the psychological traumas that so often preceded their appearance in the emergency room. He's got that mellow, empathic vibe that they just can't teach at therapy school. He always seems moments away from a sympathetic chuckle, an understanding murmur or a sage observation. A fit 61, with a brown ponytail and relaxed dress code, Mithoefer has become the accidental point man of a movement to revive medical research into psychedelic drugs. His Food and Drug Administration-approved PTSD study that began with Donna Kilgore in April 2004 is now nearly completed, with 18 of 21 subjects having undergone the double-blind sessions. Two Iraq veterans with war-related PTSD, the study's first, are cleared to begin. Close behind are similar studies in Switzerland and Israel. At Harvard's McLean Hospital, researchers are set to evaluate MDMA therapy as a way to alleviate acute anxiety in terminal cancer patients. In Vancouver, Canada, the effectiveness of an ongoing program to treat drug addiction with another potent psychedelic drug, ibogaine, is under scrutiny. There is a proposal, based on case histories, to study the ability of LSD to defuse crippling cluster headaches.

All of these studies are directly or indirectly funded by a surprisingly robust organization whose roots stretch back 40 years to the psychedelic movement of the 1960s. Before Harvard lecturer Timothy Leary started channeling aliens and urging college kids to turn on and drop out, an intense cadre of doctors and researchers had come to believe that psychedelic drugs would revolutionize psychiatry, providing those with a wide spectrum of psychological problems -- or even just ordinary life difficulties -- the ability to, basically, heal themselves.

But Leary's bizarre career, which morphed from doing research on psychedelics to cheerleading their widespread abuse, obscured whatever medical potential the drugs may have had. Instead, authorities focused on the risks, and often exaggerated them. Richard Nixon famously called Leary "the most dangerous man in America." After a slow start, regulators and legislators cracked down hard. Millions of dollars in enforcement efforts were unable to end abuse of psychedelic drugs, but they effectively stamped out sanctioned research into their healing potential.

A small group of psychedelic researchers and therapists willing to break the law continued their work clandestinely. A much larger group did not flout the law, but waited in the wings and is now emerging. Experience had convinced these therapists that psychedelics, along with significant risks, had potential for even more significant benefits.

This may have been especially true of MDMA.

Mithoefer states the case in an article he wrote for a book of scholarly essays, Psychedelic Medicine: Social, Clinical and Legal Perspectives:"The reported results [of early therapeutic use] include decreased fear and anxiety, increased openness, trust and interpersonal closeness, improved therapeutic alliance, enhanced recall of past events with an accompanying ability to examine them with new insight, calm objectivity and compassionate self-acceptance."

In short, a therapist's dream. Or is it a hallucination?

THE PROMISE OF A BLOCKBUSTER TREATMENT, one that doesn't just address symptoms but defuses underlying causes, is a particularly seductive vision right now. A report issued last month by the National Academy of Sciences' Institute of Medicine emphasizes the uncertain effectiveness of current PTSD treatments, and the urgent need of returning soldiers who will suffer from it.

To a non-scientist, the very preliminary results of Mithoefer's study would suggest that MDMA might be just what the doctors ordered. Of the subjects who have been through both the MDMA-assisted therapy and the three-month post-experiment follow-up tests, Mithoefer reports, every one showed dramatic improvement.

But scientists are a cautious lot. "It's potentially nice to hear those things," says Scott Lilienfeld, an associate professor of psychology at Emory University. But until results are statistically analyzed and peer-reviewed for publication, "you can't really judge them. The plural of anecdote is not data." Especially with a drug that has considerable risk, Lilienfeld cautions, it pays to be skeptical.

A.C. Parrott, a psychologist at Swansea University in Britain who has devoted a large part of his career to studying the dangers of MDMA, is far more than skeptical. "MDMA is a very powerful, neurochemically messy and potentially damaging drug," he says. The government "should never have given it a license for these trials. Certainly I would not give it a license for any further trials."

But one of the nation's premier PTSD researchers, Roger K. Pitman, a professor of psychiatry at Harvard Medical School, disagrees. Morphine is a powerful, potentially damaging drug, Pitman says, "and we use it to treat the pain of cancer patients. Sound medical reasons should trump."

Current treatment for PTSD is "partial at best," he says. "There's a lot of room for improvement, and we need to be looking for novel treatments."

Though Pitman calls the MDMA study "a fringe hypothesis" -- "I've never heard anybody talk about it at any PTSD meeting I've ever attended in 25 years" -- he also observes that, based solely on a description of the preliminary results, "this seems worth further study. A lot of new ideas meet with rejection and skepticism, and we need to be careful not to be prejudiced against something just because it seems wacky. If it has a 5 percent chance, or even a 1 percent chance, of being effective in treatment of PTSD, it's worth pursuing."

This isn't new, I posted about this back in January.

[hat tip: Don Phillips]

Club drugs inflict damage similar to traumatic brain injury

I read headlines like this on and roll my eyes that it is an ONDCP hype job. However, Mark Gold has a good reputation.

University of Florida researchers say both may trigger a similar chemical chain reaction in the brain, leading to cell death, memory loss and potentially irreversible brain damage.

A series of studies at UF over the past five years has shown using the popular club drug Ecstasy, also called MDMA, and other forms of methamphetamine lead to the same type of brain changes, cell loss and protein fluctuations in the brain that occur after a person endures a sharp blow to the head, according to findings a UF researcher presented at a Society for Neuroscience conference held in San Diego this month.

“Using methamphetamine is like inflicting a traumatic brain injury on yourself,” said Firas Kobeissy, a postdoctoral associate in the College of Medicine department of psychiatry. “We found that a lot of brain cells are being injured by these drugs. That’s alarming to society now. People don’t seem to take club drugs as seriously as drugs such as heroin or cocaine.”

Working with UF researchers Dr. Mark Gold, chief of the division of addiction medicine at UF’s McKnight Brain Institute and one of the country’s leading experts on addiction medicine, and Kevin Wang, director of the UF Center for Neuroproteomics and Biomarkers Research, Kobeissy compared what happened in the brains of rats given large doses of methamphetamine with what happened to those that had suffered a traumatic brain injury.

The group’s research has already shown how traumatic brain injury affects brain cells in rats. They found similar damage in the rats exposed to methamphetamine. In the brain, club drugs set off a chain of events that injures brain cells. The drugs seem to damage certain proteins in the brain, which causes protein levels to fluctuate. When proteins are damaged, brain cells could die. In addition, as some proteins change under the influence of methamphetamine, they also begin to cause inflammation in the brain, which can be deadly, Kobeissy said.

Kobeissy and other researchers in Gold’s lab are using novel protein analysis methods to understand how drug abuse alters the brain. Looking specifically at proteins in the rat cortex, UF researchers discovered that about 12 percent of the proteins in this region of the brain showed the same kinds of changes after either methamphetamine use or traumatic brain injury. There are about 30,000 proteins in the brain so such a significant parallel indicates that a similar mechanism is at work after both traumatic brain injury and methamphetamine abuse, Kobeissy said.

Alcohol sales and violence

A while back, England wrestled with how to reduce violence after closing hours for the pubs and decided to allow 24 hour alcohol sales. Early returns were positive, the second wave of reports look negative.

Brazil is a different country with a different culture, but the results of this study don't look too promising:

Objective. We investigated whether limiting the hours of alcoholic beverage sales in bars had an effect on homicides and violence against women in the Brazilian city of Diadema. The policy to restrict alcohol sales was introduced in July 2002 and prohibited on-premises alcohol sales after 11 PM.

Methods. We analyzed data on homicides (1995 to 2005) and violence against women (2000 to 2005) from the Diadema (population 360 000) police archives using log-linear regression analyses.

Results. The new restriction on drinking hours led to a decrease of almost 9 murders a month. Assaults against women also decreased, but this effect was not significant in models in which we controlled for underlying trends.

Conclusions. Introducing restrictions on opening hours resulted in a significant decrease in murders, which confirmed what we know from the literature: restricting access to alcohol can reduce alcohol-related problems. Our results give no support to the converse view, that increasing availability will somehow reduce problems.

The Addiction Wars

Time science writer Michael Lemonick blogs an exchange with a commenter who resists the suggestion that addiction will eventually be treated with a pill.

Abortion linked to drugs, alcohol abuse

Another harm associated with drug addiction:

Young women who have abortions are more likely to drink heavily and abuse hard drugs, an Australian study has found.

...

The study tracked 1,122 young women who were born at the Mater hospital in the early 1980s, finding that 21 years on, about one-third had an abortion.

Those who had an abortion were three times more likely to also abuse hard drugs, like heroin, methamphetamines and glue, than the women who had either had no pregnancy or those who had a child.

They were also twice as likely to be a binge drinker or an alcoholic, and 1.5 times more likely to suffer depression, delegates at the World Psychiatric Association (WPA) conference in Melbourne were told.

Sleepiness drug 'helps ice addicts'

Back to the future! A stimulant to treat stimulant addiction.

Next they'll be researching the effectiveness of benzos for treating alcoholism.

Tale of Three Medics

ABC News has a story on soldiers developing drug and alcohol problems as they return to the U.S. The story will also air on 20/20 this Friday night.