Accepting Psychiatric Care May Be Dangerous for Homeless Women

An interesting take on homeless women's resistance to psychiatric diagnoses:

Most of the women Luhrmann interviewed said they believed that the uncertainty and danger of life on the streets drove some "crazy," and they believed that only those who were weak-willed succumbed to the harsh reality of life on the streets by becoming, for instance, psychotic, she told Psychiatric News.

"The women I interviewed, who themselves could be diagnosed with some kind of psychotic disorder, were motivated to say that they were not going to be driven crazy by life on the streets" and emphasized that they have a better chance of surviving by not seeking mental health services or social services that require a psychiatric diagnosis.

Some of the women at the center linked victimization with mental illness because the perception by others that they are mentally ill makes them vulnerable to attack, Luhrmann noted.

One woman Luhrmann interviewed mentioned that some of the women "talk to themselves.. .because they let the streets take over them.. .a lot of the women have been raped by the men here and.. .can't deal with it, so that just made them go haywire."

The author seems to present two reasons for their resistance. First, that it might make them a target for victimization. I see an implied second reason, that ,internalization of a psychiatric diagnosis might diminish their resilience.

Too bad the response is so patronizing:

In interactions with homeless women who have a psychotic disorder, "every effort should be made to avoid presenting the patient with an explicit psychiatric diagnosis," Luhrmann noted.

Parity Legislation Stalls

An update on the status of parity legislation:

The differences between the House and Senate negotiators have come down to three main areas: which types of mental illness should be covered, what out-of-network benefits will be offered, and what approach will allow the best preservation of stronger state laws.

Nonetheless, both bills require that insurance plans that include mental health benefits must cover those benefits at parity with in-network or out-of-network medical/surgical benefits. Thus, passage of either the Senate or House version, Meyers said, would constitute a major improvement over the current 1996 Mental Health Parity Act, which only guarantees equality in annual and lifetime payment limits.

One of the main differences over which negotiators remained deadlocked was that the House bill would require any plan that provides mental health parity coverage to recognize all illnesses in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The Senate measure would leave it up to health plans to determine the psychiatric conditions they would cover.
...
Negotiators also were unable to find common ground on differences in out-of-network benefits. The House bill would require any plans that include an out-of-network benefit to also offer out-of-network parity mental health coverage. The Senate version would allow plans to offer a medical/surgical out-of-network benefit without offering a corresponding mental health benefit. If the plans did offer an out-of-network mental health benefit, they would have to do so at parity.

African Americans Complete Alcohol Treatment at Lower Rates than Whites

A troubling finding from RAND.

For Debate - the COMBINE study

Read this before you are on the receiving end of a Vivitrex sales pitch:

The monumental study on combined pharmacotherapies and behavioural interventions for alcohol dependence (COMBINE) was set up ‘in order to determine if improvements in treatment outcome for alcohol dependence can be achieved by combining pharmacotherapy and behavioral interventions’ [1]. When the main results were published in May 2006 [2], it was clear that no such combining effect had been detected in the trial. Neither had the combination of the two pharmacological interventions—naltrexone and acamprosate—nor the combination of any or both of these with a behavioural intervention [combined behavioural intervention (CBI)], improved the outcome. At the same time, and in line with the results from other multi-site studies, all the nine different treatment interventions (combinations) showed a substantial reduction in drinking, including those who had received placebo pills. In general, the commentaries on these results, as well as the conclusions from the COMBINE study group, underlined one recommendation for clinical practice: support for the use of naltrexone in primary care settings. However, the empirical basis for this recommendation appears to be somewhat weak.
...
Given the fact that the magnitude of difference between the two pharmacological interventions is quite small at the end of treatment (i.e. 16 weeks), and basically disappears at the 1-year follow-up, it is possible to claim that the COMBINE study provides somewhat weak support for preferential use of either. In the same way, neither naltrexone nor acamprosate provide a better outcome than non-pharmacological interventions. In comparison with a group that received CBI and placebo (within the context of medical management), naltrexone in combination with CBI did not improve outcomes. Because the mechanisms behind the improvement of the CBI/placebo group must be mind-mediated and not of a neurochemical character, these findings indicate that there is an absence of any neurochemical effect associated with naltrexone which is additive to the psychological mechanisms at work in the CBI/placebo intervention. Although it is not logically necessary that specific pharmacological and placebo/psychological effects have to be additive [3], it does seem likely that they are. Why would a placebo produce a non-pharmacological effect while a pharmacological intervention, indistinguishable from the placebo, would not?
...
Along the same lines, the lack of empirical support for acamprosate is reported as surprising, but not discussed with any reference to the possibility that the mechanisms of action of acamprosate might not be there or, if there, not of any importance beyond the placebo effect. Given that researchers within the COMBINE study group have pointed previously to the fact that: ‘Despite its widespread use . . . and proven efficacy, the precise mechanism of action is unknown’ ([7], p. 60), it would have been interesting to see an elaboration of this theme in light of the lack of support for acamprosate in the COMBINE study.

I think the cops are at the door

From Wired:

In the January issue of Neuropharmacology, which happens to have a marijuana theme, two teams of researchers tried to explain what causes some people to feel paranoid when they smoke weed.

If you think it's impossible to have too much of a good thing -- think again.

In the first sentence of their research paper, a group of Italian scientists explained that low doses of tetrahydrocannabinol -- the psychoactive chemical in marijuana -- tend to be calming while large amounts have the opposite effect.

Performance enhancing ritalin

I wonder how many high school athletes will start complaining of attention problems after this story gets a little more press.

Antidepressant Studies Unpublished

An unsurprising finding from the New England Journal of Medicine via The New York Times:

The makers of antidepressants like Prozac and Paxil never published the results of about a third of the drug trials that they conducted to win government approval, misleading doctors and consumers about the drugs’ true effectiveness, a new analysis has found.

In published trials, about 60 percent of people taking the drugs report significant relief from depression, compared with roughly 40 percent of those on placebo pills. But when the less positive, unpublished trials are included, the advantage shrinks: the drugs outperform placebos, but by a modest margin, concludes the new report, which appears Thursday in The New England Journal of Medicine.

Previous research had found a similar bias toward reporting positive results for a variety of medications; and many researchers have questioned the reported effectiveness of antidepressants. But the new analysis, reviewing data from 74 trials involving 12 drugs, is the most thorough to date. And it documents a large difference: while 94 percent of the positive studies found their way into print, just 14 percent of those with disappointing or uncertain results did.

Here's the results statment from the NEJM abstact:

Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published. Whether and how the studies were published were associated with the study outcome. A total of 37 studies viewed by the FDA as having positive results were published; 1 study viewed as positive was not published. Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive. Separate meta-analyses of the FDA and journal data sets showed that the increase in effect size ranged from 11 to 69% for individual drugs and was 32% overall.

Unfortunately, whenever you see a study demonstrating the effectiveness of a drug, you have to ask yourself, "what studies are they choosing not to publish?"

[via dailydose.net & Pain Recovery Solutions]

The History of Gay People in AA

I'm reading a great book that I wanted to share a little about. I'm only 4 chapters into The History of Gay People in AA but I can't recommend it highly enough for anyone interested in the history of AA or, more specifically, the history of gay people in AA. (Here's the Preface and Chapter 1)

I know about Marty Mann, but my understanding is that she was in the closet and I knew nothing else about gay people in early AA. I was surprised and pleased to learn that the history of gay membership in AA goes back to at least 1937. It turns out that this story from the 3rd tradition was about a gay man seeking help:

On the A.A. calendar it was Year Two. In that time nothing could be seen but two struggling, nameless groups of alcoholics trying to hold their faces up to the light. A newcomer appeared at one of these groups, knocked on the door and asked to be let in. He talked frankly with that group's oldest member. He soon proved that his was a desperate case, and that above all he wanted to get well. "But," he asked, "will you let me join your group? Since I am the victim of another addiction even worse stigmatized than alcoholism, you may not want me among you. Or will you?" There was the dilemma. What should the group do? The oldest member summoned two others, and in confidence laid the explosive facts in their laps. Said he, "Well, what about it? If we turn this man away, he'll soon die. If we allow him in, only god knows what trouble he'll brew. What shall the answer be - yes or no?" At first the elders could look only at the objections. "We deal," they said, "with alcoholics only. So went the discussion while the newcomers fate hung in the balance. Then one of the three spoke in a very different voice. "What we are really afraid of," he said, "is our reputation. We are much more afraid of what people might say than the trouble this strange alcoholic might bring. As we've been talking, five short words have been running through my mind. Something keeps repeating to me, `What would the Master do?'" Not another word was said. What more indeed could be said?"

The approach in those early days seemed to be, "the only thing we care about is that you're an alcoholic." The unfortunate corollary to this was social pressure to not discuss one's sexual identity (Unless, of course, you were heterosexual.) or stay in the closet. To be fair, this was still very progressive for the time and they took the same approach to many other "problems other than alcohol."

Also on the topic is this talk by Barry L. (author of Living Sober) about the influence of early gay members of AA on the development of the 3rd tradition.

If you are a Dawn Farm staff and you're interested in borrowing the book, let me know.

Heroin anyone?

BMJ has pro/con commentaries on the subject of heroin maintenance.

Opioid maintenance treatment generally seems to be well justified for treating this disease. And if maintenance is generally justifiable as a form of treatment, why should heroin not be used as one such pharmacological agent? ... Overall, we see no convincing reason why heroin assisted maintenance treatment should not be part of a comprehensive treatment system for opioid dependence.

No convincing reason? Obviously, they've taken a position, but they don't think that ANY of the arguments have ANY merit? At least they offer this caveat...

However, the development of an overall integrated treatment system is crucial.

Neil McKeganey responds with an argument against:

Prescribing heroin to heroin addicts is a strategy beloved by top police officers and successive home secretaries. It is a strategy, though, borne of utter frustration at our seeming inability to tackle an escalating drug problem. If you cannot stop addicts committing crimes to fund their drug habit then, so the argument goes, the next best thing is to provide them with the drugs that are the reason they are committing the crimes in the first place. The logic may seem faultless, but at the back of your mind is the nagging question, "Is it treatment or is it social problem prescribing?"

I think he makes right argument. Opponents of HR strategies are often accused of moral panic. I think the moral argument is one of the most persuasive, but not trying to turn drug use or addiction into a moral issue. Rather, the way we respond to suffering addicts is a moral issue. Further, are our interventions motivated by despair or hope, and, who are they intended to serve?

Prescribing heroin to heroin addicts, however, makes sense only if your primary concern is to treat not their drug dependency but the consequences of their drug use. You may want to reduce their use of street drugs, the risks to health from HIV or hepatitis C virus, the risks of overdose, or their criminality. With all of these aims in mind you may conclude that it makes sense to provide addicts with a prescription for the drug that they have become dependent on. And yet the reason they are committing those crimes, and taking such enormous and persistent risks with their health, is because the drugs have become more important than life itself—that is the nature of drug addiction. And that is the problem that drug treatment services need to tackle.

In the commentary, McKeganey makes the case for the efficacy of treatment. The problem is not that addiction doesn't response to treatment, rather that we continually treat it with sub-optimal doses and duration and then despair at the intractability of the problem.

Along these lines, if the issue for advocates is really that we don't have widely effective treatments (an argument that I don't buy), why don't they ever advocate these programs as a temporary stopgap until more effective treatments are developed?

But do addicts coming forward for treatment actually want heroin to be prescribed to them? A study of over 1033 drug users starting treatment in 2001 asked participants what they wanted to get from the drug treatment services they were contacting. Most of those questioned said that they wanted the services to help them become drug free.

America's Love-Hate Relationship with Drugs

I'm truly sympathetic to arguments against the war on drugs, but is it really possible that the author this naive?

In 2004 Miami Dolphins running back Ricky Williams announced that he had found marijuana to be 'ten times more helpful than Paxil' for his anxiety and depression. What made Williams's declaration difficult to ignore was that he had been a celebrity spokesman for GlaxoSmithKline, manufacturer of Paxil.

Neuroscientist Pankaj Sah notes, 'It's worth considering that people who constantly use cannabis may be doing it for other reasons than just to 'get high' -- perhaps they are experiencing some emotional problems which taking cannabis alleviates. Much the same way as some people drink alcohol to relieve anxiety.'

[via dailydose.net]

From the Ashtray of History

The Atlantic uses their archives to offer a little historical perspective on tobacco in the U.S.. Here's the lede:

For decades, scientists have noted a strong correlation between smoking, lung cancer, and high death rates. But only recently has government at both the national and local levels taken aim at the practice of smoking. Why, one might wonder, has it taken so long? As this collection of Atlantic articles—spanning more than a century—makes clear, the debate on that seemingly straightforward question is older and more complex than one might think.

They also provide a timeline on anti-tobacco movements going back to 1624.

Brief Screening by Docs Reduces Drinking

Physician screening and brief counseling offers some bang for very few minutes:

A 10-minute screening and talk with a doctor about problem drinking delivers almost as much bang for the buck to the health system as childhood immunization and advice about taking aspirin to prevent stroke and heart attack, according to a new systematic review — but just 8.7 percent of problem drinkers report receiving such information.

The review, which appears in the February issue of the American Journal of Preventive Medicine, included data from 10 randomized controlled trials of alcohol problem screening and advice by primary care doctors.

...

The review found that screening and brief counseling reduced problem drinking by 17.4 percent over a period that varied from six months to two years among studies. This means that more than one in six problem drinkers who received these brief interventions no longer fit that definition six months to two years later.

[via dailydose.net]

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.