Harm Reduction, Treatment, and Recovery in Scotland

Scotland may be on the verge of a very bold and exciting overhaul of their treatment system.

They have depended almost exclusively upon methadone maintenance. The majority of their clients have been expressed a preference for abstinence oriented treatment and they are poised to move toward a recovery oriented treatment system.

I had been thinking of this as an example of the failure of harm reduction as treatment. Not to say that there is not a place for harm reduction, rather to say that it is a poor substitute for treatment.

I had also been thinking about it as an example of the limitations of responding to addiction as a public health problem. A lot of treatment advocates argue that addiction should be treated as a public health problem instead of as a criminal problem, but I often feel I alone shudder at the idea. I tend to think of public health as advocating community (or, public) welfare even if it means that some individuals will suffer. I fear that addicts will too often end up on the losing side of this accounting exercise.

Interestingly, I was listening this morning to a lecture by Neil McKeganey. His observations suggest that some of the failures could be laid at the feet of harm reduction and public health, but his emphasis was on this as a failure of treatment-oriented treatment. He argues that the focus of services in Scotland has been to get people in treatment and keep people in treatment to the exclusion of helping people get well. The treatment system's belief was that the system was succeeding as long as people were continuing to take their methadone. The result was that people entered the system and never exited. The patient never achieved their goals, but the system gave itself a pat on the back for achieving its goals.

This raises one of the biggest dangers of framing addiction as a chronic disease. I suspect that this tension between recovery and addiction as a chronic illness is something that can't be resolved. The result is that we'll have to find a way to live on the slippery slope and be vigilant that we don't allow ourselves to slide in one direction or the other.

UPDATE: About my cringing at calls for a "public health" approach. I just fear approaches that put community welfare ahead of individual welfare. Here's a description of public health:

Most definitions share the premise that the subject of public health is the health of populations—rather than the health of individuals—and that this goal is reached by a generally high level of health throughout society, rather than the best possible health for a few. The field of public health is concerned with health promotion and disease prevention throughout society. Consequently, public health is less interested in clinical interactions between health care professionals and patients, and more interested in devising broad strategies to prevent, or ameliorate, injury, and disease.

I'm not sure what term I'd rather see people use instead. I'm reluctant to say we should call it a "medical problem" because I support addiction treatment as a specialty or categorically separate field. I'm not crazy about "behavioral health", but maybe that's the least bad option.

We should stop treating addiction as a criminal problem and start treating it as a behavioral health problem!

I'm not feeling it.

Explosive Increase in (Dutch) Cannabis Addiction

I won't speculate on what this means, but it will be an interesting subject to watch.

Court rules in favor of injection site

A Canadian court ruled that the Canadian goverment's prohibition of injection centers is unconstitutional.

There has been a great deal of passion and energy spent on both sides; the Feds trying to shut down the injection site, and the local goverment and researchers defending it. It would be nice to see everyone involved put a little of that energy into trying to help these addicts recover.

Hangover Time

From The New Yorker:

Hangovers also have an emotional component. Kingsley Amis, who was, in his own words, one of the foremost drunks of his time, and who wrote three books on drinking, described this phenomenon as "the metaphysical hangover": "When that ineffable compound of depression, sadness (these two are not the same), anxiety, self-hatred, sense of failure and fear for the future begins to steal over you, start telling yourself that what you have is a hangover. . . . You have not suffered a minor brain lesion, you are not all that bad at your job, your family and friends are not leagued in a conspiracy of barely maintained silence about what a shit you are, you have not come at last to see life as it really is." Some people are unable to convince themselves of this. Amis described the opening of Kafka's "Metamorphosis," with the hero discovering that he has been changed into a bug, as the best literary representation of a hangover.

[via Jim]

Different Roads

A commentary advocating for abstinence oriented treatment in England. It also bristles that the characterization of addition as a chronic illness appears set up arguments for drug maintenance and endless treatment.

I suppose context is important. We've (the U.S.) been operating in an environment where treatment has been getting increasingly less intense and shorter. While in the U.K., MMT has been the dominant response to opiate addiction.

Strong words:

There is an old saying about addiction treatment – ‘if you want drugs, go to treatment services; if you want to stop drugs, go nowhere near drug services’.

...

If you have workers in a system that is predicated on a belief of crime reduction and chronic disease management, the self-fulfilling pessimism permeates the client and the worker and generates limited goals.

The Spirituality of Recovery

NPR's Speaking of Faith has dedicated an episode to the spirituality of recovery. Susan Cheever talks about the spirituality of AA, her recovery, and her father's recovery.

The episode also devotes significant time to Buddhism and the 12 steps. They link to the Buddhist Recovery Network. Interestingly, Alan Marlatt is on their board.

Nothing scientific here, good for anyone who thinks AA is a Christian program.

It's worth a listen.

Methadone

The same reader on the days when methadone was one element of some comprehensive bio-psycho-social treatment programs:

The hospital where I trained had one of the original methadone pilot programs. They rounded up a bunch of addicts, provided counseling, educational assistance, housing assistance, employment assistance, health care, peer suppport and peer counselors, and oh yeah, methadone. Guess what, some of the "incurable sociopaths" got better, got jobs, rejoined their families, etc., so the methadone program seemed to be working. So they took away the counseling, educational assistance, housing assistance, employment assistance, health care, peer suppport and peer counselors, and left the clients with - methadone. Funny thing, it didn't seem to work as well any more.

This, of course, beg the queston of what is the effective ingredient. I'm guessing that this was also not a maintenance program. Of course the next part of the story is that, when these clients started doing poorly, rather than re-implement all the other services, they decided that all of them needed to be on methadone longer--maybe forever. Then, when they still did poorly, they decided that they needed to be on higher doses, and then ultra high doses. (The slide above is from this presentation.)

More on "the most dangerous place"

A reader response to my previous post:

That study was done in 2000. There are certainly major problems remaining with the ability of health care providers to recognize and provide appropriate referrals and/or treatment for addiction and addiction-related problems - but this is way improved since 2000. Assessment tools designed for medical offices, ER's and clincs are attaining wider use and "brief interventions" have been documented as effective in reducing AOD-related problems and are being taught to front-line health care providers. When I went to nursing school 35 years ago I was taught that cocaine was not addictive, that AA was a nice bandaid for alcoholics but only psychotherapy could "cure" alcoholism and alcoholics rarely wanted to be "cured;" and heroin addicts were untreatable sociopaths. When I floated to the "private" wards of the hospital I worked at and encountered patients experiencing impending DT's, I was often screamed at by their personal physicians for suggesting that their Very Important Patient might be an alcoholic (and then the physician would prescribe detox-level doses of ATC librium, magnesium sulfate and thiamine injections to "calm his nerves.") The nurses and doctors I encounter these days are way better educated and equipped. There is much progress in this area, and while more progress is needed I would hope that people would not be discouraged from seeking help and support from health care providers, in cooperation with whatever other help and support they need to recover, and that if their health care provider is not competent to provide appropriate support that they find one who is.

the "most dangerous place" for an alcoholic to seek help

The CEO of Betty Ford says it's your doctor's office:

An expert on alcoholism and addiction, Dr. Garrett O'Connor struggled for years with an alcohol problem of his own. He saw several doctors during that period but "the only person who ever said I might have a problem," he notes, "was my dentist." During some routine dental work "all my teeth fell out. I was going to sue [the dentist], until he pointed out my liver was deficient, not his skills." O'Connor claims his experience is far from unusual; many family doctors are still unequipped, he claims, to help patients with addiction.

There was a study done at Columbia University where they surveyed primary care physicians and found that 94 per cent were unable to diagnose addiction. They were diagnosing high blood pressure or depression. They were seeing only the symptoms of addiction, and not the disease itself. Sometimes, the most dangerous place for an addict or alcoholic to be looking for treatment is in a doctor’s office. It’s a terrible tragedy.

...alcohol is the great imitator of all diseases, because it goes to every cell in the body and can be present as a neurological disorder, a gastrointestinal one, a cardiac disorder, high blood pressure, a skin disorder, an eating disorder and as the whole raft of psychiatric disorders, including depression and bipolar disorder.

Hazy screens: Is Hollywood pushing marijuana?

Hazy screens: Is Hollywood pushing marijuana?:

There seem to be movies that are produced by a younger generation than the baby boomers, [by people] who seem to have had a lot of experience with marijuana,' says Jacob Sullum, senior editor at Reason magazine and author of 'Saying Yes: In Defense of Drug Use.'

Tom Hedrick, spokesperson for Partnership for a Drug Free America, says he worries that the uptick in such depictions makes the behavior appear too normal, creating bad role models.
...
"I think movies have a weird line to walk," says Wesley Morris, a film critic at The Boston Globe. "They derive a lot of entertainment from drug use and yet, at the same time, they go only so far in endorsing it. 'Harold and Kumar' … doesn't have anything to say negatively about drug use, but, at the same time, there is a stigma attached." In "Knocked Up," a lead character has to stop smoking marijuana because it gets in the way of him becoming a good father.
...
Legalization advocates argue that signs of societal tolerance, including decriminalization of possession of small amounts of marijuana, hint that casual pot use is widespread – something filmmakers are increasingly less afraid to portray.
...
But antidrug campaigners say it's time for Hollywood to tighten up.

"Is this the beginning of a major new reflection and glamorization in popular culture?" asks Hedrick. "I think it's too early to tell, but it worries us because it tends to portend, potentially, a return to attitudes that lead to more kids trying, and more kids using."

About 39% Of IDUs Living In Spain Are HIV-Positive, IHRA Report Says

Wow. Harm reduction isn't enough. Many of these people can become citizens who are great parents, business owners, neighbors, and contribute to every aspect of community life in meaningful ways.

Help keep them from contracting diseases, but that's no substitute for getting them well.

Obama on Medical Marijuana

Jacob Sullum compiles Obama's statements on medical marijuana,

More from Pat Deegan

When Help is Not Helpful

Help, and in particular toxic help, is not a topic that is discussed often in professional rehabilitation cultures. The nature of help is one of those topics about which we are often silent because we are too busy being helpful to stop to talk about it. But we must break that taboo. We must dare to talk about help because power, including the power to oppress, often disguises itself as help. Power-disguised-as-help is used to silence disabled people. Paolo Freire (1989) says that oppressive power submerges the consciousness of the oppressed into a culture of silence. Toxic help oppresses and silences people with disabilities.

Help isn't help if it's not helpful. Help that is not helpful can actually do harm. Being helpful requires that professionals ask us what we need. But asking is never enough. Professionals must also listen to what we say. In this way help becomes something that is co-created between the disabled person and the professional. When help is co-created as an explicit agreement between the professional and the individual, then silencing is avoided.

In my opinion, one of the best methods for amplifying the voice and values of those of us who are disabled is the shared decision making process. In this process, the clinician and service user come to agreement on *what the service need is, what the course of rehabilitation will be, what the desired outcomes of services are and what the respective responsibilities of each party will be in achieving those outcomes. It seems to me that the shared decision process is more than a method. It is an ethical obligation that makes explicit the power of the professional and brings it into alignment with the voice and directives of the disabled person.

Micro-Aggressions

[note: "Mentalism refers to the oppression of people who have been diagnosed with psychiatric disorders."]

Peer practitioners may encounter mentalism in all its forms when on the job. In its most obvious form, mentalism is a macro-aggression. A macro-aggression is obvious and easily identified by all who witness it as unfair, biased and/or discriminatory. An example of a mentalist macro-aggression is an emergency room automatically placing people with psychiatric diagnoses in restraints while waiting to be seen by a physician or having only clients (not staff) go through a metal detector at a local mental health center.

Another form that mentalism can take is called micro-aggression. Micro-aggressions are more subtle, not as obvious and therefore are harder to point out or confront. Mentalist micro-aggressions occur frequently and have a tendency to wear us down over time. Micro-aggressions tend to be “invisible” and we often experience the cumulative effect of them as tension between ourselves....

Most peer practitioners will encounter micro-aggressions on the job. How should staff handle these types of experiences and still remain within the role of the peer practitioner? The answer is that first peer practitioners must be able to identify micro-aggression when it happens. This requires consciousness raising and a supportive group of peer practitioners who can help us name mentalism when it is happening. Secondly, peer practitioners must support and validate for each other, the reality of mentalist micro-aggression when it is reported by a co-worker. Third, peer practitioners must learn to strategically respond to those people or policies that are oppressive, whether it was intentional or not.

Healing Relationships

Relationships are the cornerstone of the recovery process for most people. Relationships that are marked by kindness and compassion can heal. ... In a culture steeped in the belief that there is a “pill for every ill”, it can be important to remind ourselves of the healing power of human relationships.

The people I have interviewed mention certain important characteristics of people who were experienced as helpful in their recovery. Many said the helpful person showed fortitude, patience and love. For instance, John said:

“Relationships helped me. Patience. Sticking by you regardless. Like my wife. Sticking by you through thick and thin. Constant support. Constant encouragement from the outside. That's what I think a person needs the most. And love.”

Fidelity, patience and fortitude are evident when the helpful person is present during the most difficult of times and does not simply come around when recovery seems promising. People who are experienced as helpful are able to hold the relationship during times when the other does not reciprocate affection and care. This holding of love and relationship, even during the most barren and anguished winter of recovery, requires compassion. The word compassion comes from the Latin passio, to suffer and com, to be with. To be compassionate is to suffer with the person in distress. To be compassionate is a way of being with the other without an agenda to change them, to relieve their suffering or to suffer for them. Through compassion we can reach out to the other even when they refuse to reach back. With compassion we see the person, not the diagnosis or disorder....

Another characteristic of people who are helpful to the recovery process is that they believe in the person in distress, even when that person does not believe in themselves. Believing in the other is not expressed in optimistic rhetoric such as, “I just know that in time you will do better.” Shallow optimism ignores the challenges and difficulties that the person in distress faces. Optimism may help us feel better, but it leaves the other alone and distanced. Believing in someone, on the other hand, takes the form of a fundamental affirmation of that person's goodness. It is a hopeful stance that admits the the future is uncertain and ambiguous while simultaneously expressing a willingness to walk together into that unknown future....

People who are helpful to the recovery process are able to convey feelings and are experienced as being very human. No one reported that professional distance and demeanor were helpful. Instead, our own humanity is the bridge that connects us to people in distress. Sometimes humor can form a connection of warmth, joy and affection....

Relationship includes the idea of mutuality and reciprocity. This can be very healing for people who have been in the patient or client role for a long time. That is, being socialized into the role of a “good” mental patient often means learning to become preoccupied with matters pertaining to “me”. Socialization into self-preoccupation starts in the hospital where each day begins with a nurse asking you if your bowels are moving, if you slept that night, etc. Socialization into me-ness proceeds on through the years as each and every casemanager, therapist, residential worker or vocational rehabilitation counselor asks, “How are you doing?” Unlike normal social discourse in which 'how are you doing' acts as a perfunctory greeting, mental health discourse requires the client to take the question seriously and to answer by revealing more about “me”. In addition, in most mental health settings, clients are not encouraged to help each other or anyone else. In this sense, the currently popular term “consumer” seems apt. It conjures the image of a large mouth consuming and consuming without a hint that it would be possible to contribute something back.

Socialization into me-ness, self-preoccupation and being a consumer means that many people are denied the opportunity to discover they have something to offer to other people. This iatrogenic wounding is another reason relationships can be so healing. It is healing to learn that one needs and is needed, cares and is cared for, and can receive as well as give.

Recovery and the Conspiracy of Hope

I think Pat Deegan does a great job describing the cycle of despair in settings that don't facilitate or witness recovery. I think this translates very well to addiction treatment providers. What it misses is those who step in after hope is abandoned and ennoblize the suffering of patients--"accepting them as they are", but never accepting them for what they can become.

From Recovery and the Conspiracy of Hope:

From the outside it appears that the person just isn’t trying anymore. Very frequently people who show up at clubhouses and other rehabilitation programs are partially or totally immersed in this despair and anguish. On good days we may show up at program sites but that’s about all. We sit on the couch and smoke and drink coffee. A lot of times we don’t bother showing up at programs at all. From the outside we may appear to be among the living dead. We appear to be apathetic, listless, lifeless. As professionals, friends and relatives we may think that these people are “full of excuses”, they don’t seem to try anymore, they appear to be consistently inconsistent, and it appears that the only thing they are motivated toward is apathy. At times these people seem to fly into wishful fantasies about magically turning their lives around. But these seem to us to be only fantasies, a momentary refuge from chronic boredom. When the fantasy collapses like a worn balloon, nothing has changed because no real action has been taken. Apathy returns and the cycle of anguish continues.

Staff, family and friends have very strong reactions to the person lost in the winter of anguish and apathy. From the outside it can be difficult to truly believe that there really is a person over there. Faced with a person who truly seems not to care we may be prompted to ask the question that Oliver Sacks (1970, p. 113) raises: “Do you think William (he) has a soul? Or has he been pithed, scooped-out, de-souled, by disease?” I put this question to each of us here today. Can the person inside become a disease? Can schizophrenia pith or scoop-out the person so that nothing is left but the disease? Each of us must meet the challenge of answering this question for ourselves. In answering this question, the stakes are very high. Our own personhood, our own humanity is on the line in answering this question.

...

However, when faced with a person lost in anguish and apathy, there are a number of more common responses than finding a way to establish an I-Thou relationship. A frequent response is what I call the “frenzied savior response”. We have all felt like this at one time or another in our work. The frenzied savior response goes like this : The more listless and apathetic the person gets, the more frenetically active we become. The more they withdraw, the more we intrude. The more willless they become, the more willful we become. The more they give up, the harder we try. The more despairing they become, the more we indulge in shallow optimism. The more treatment plans they abort, the more plans we make for them. Needless to say we soon find ourselves burnt out and exhausted. Then our anger sets in

...

Our anger sets in when our best and finest expectations have been thoroughly thwarted by the person lost in anguish and apathy. We feel used and thoroughly unhelpful. We are angry. Our identities as helping people are truly put to the test by people lost in the winter of anguish and indifference. At this time it is not uncommon for most of us to begin to blame the person with the psychiatric disability at this point. We say things like : “They are lazy. They are hopeless. They are not sick, they are just manipulating. They are chronic. They need to suffer the natural consequences of their actions. They like living this way. They are not mad, they are bad. The problem is not with the help we are offering, the problem is that they can’t be helped. They don’t want help. They should be thrown out of this program so they can 'hit bottom'. Then they will finally wake up and accept the good help we have been offering.”

During this period of anger and blaming a most interesting thing happens. We begin to behave just like the person we have been trying so hard to save. Frequently at this point staff simply give up. We enter into our own despair and anguish. Our own personhood begins to atrophy. We too give up. We stop trying. It hurts too much to keep trying to help the person who seems to not want help. It hurts too much to keep trying to help and failing. It hurts too much to keep caring about them when they can’t even seem to care about themselves. At this point we collapse into our own winter of anguish and a coldness settles into our hearts.

We are no better at living in despair than are people with psychiatric disabilities. We cannot tolerate it so we give up too. Some of us give up by simply quitting our jobs. We reason that high tech computers do as they are told and, besides, the pay is better. Others of us decide not to quit, but rather we grow callous and hard of heart. We approach our jobs like the man in the Dunkin Donuts commercial: “It’s time to make the donuts, it’s time to make the donuts”. Still others of us become chronically cynical. We float along at work like pieces of dead wood floating on the sea, watching administrators come and go like the weather; taking secret delight in watching one more mental health initiative go down the tubes; and doing nothing to help change the system in a constructive way. These are all ways of giving up. In all these ways we live out our own despair.

Additionally entire programs, service delivery systems and treatment models can get caught up in this despair and anguish as well. These systems begin to behave just like the person with a psychiatric disability who has given up hope. A system that has given up hope spends more time screening out program participants than inviting them in. Entry criteria become rigid and inflexible. If you read between the lines of the entry criteria to such programs they basically state: If you are having problems come back when they are fixed and we will be glad to help you. Service systems that have given up hope attempt to cope with despair and hopelessness by distancing and isolating the very people they are supposed to be serving. Just listen to the language we use: In such mental health systems we have “gatekeepers” whose job it is to "screen" and “divert” service users. In fact, we actually use the language of war in our work. For instance we talk about sending “front-line staff” into the “field” to develop treatment “strategies” for “target populations”.

Is there another alternative? Must we respond to the anguish and apathy of people with psychiatric disability with our own anguish and apathy? I think there is an alternative. The alternative to despair is hope. The alternative to apathy is care. Creating hope filled, care filled environments that nurture and invite growth and recovery is the alternative.

Remember the sea rose? During the cold of winter when all the world was frozen and there was no sign of spring, that seed just waited in the darkness. It just waited. It waited for the soil to thaw. It waited for the rains to come. When the earth was splintered with ice, that sea rose could not begin to grow. The environment around the sea rose had to change before that new life could emerge and come into being.

People with psychiatric disabilities are waiting just like that sea rose waited. We are waiting for our environments to change so that the person within us can emerge and grow.

Those of us who have given up are not to be abandoned as “hopeless cases”. The truth is that at some point every single person who has been diagnosed with a mental illness passes through this time of anguish and apathy, even if only for a short while. Remember that giving up is a solution. Giving up is a way of surviving in environments which are desolate, oppressive places and which fail to nurture and support us. The task that faces us is to move from just surviving, to recovering. But in order to do this, the environments in which we are spending our time must change. I use the word environment to include, not just the physical environment, but also the human interactive environment that we call relationship.

From this perspective, rather than seeing us as unmotivated, apathetic, or hopeless cases, we can be understood as people who are waiting. We never know for sure but perhaps, just perhaps, there is a new life within a person just waiting to take root if a secure and nurturing soil is provided. This is the alternative to despair. This is the hopeful stance. Marie Balter expressed this hope when asked, “Do you think that everybody can get better?” she responded: “It’s not up to us to decide if they can or can’t. Just give everybody the chance to get better and then let them go at their own pace. And we have to be positive - supporting their desire to live better and not always insisting on their productivity as a measure of their success”. (Balter 1987, p.153).

So it is not our job to pass judgment on who will and will not recover from mental illness and the spirit breaking effects of poverty, stigma, dehumanization, degradation and learned helplessness. Rather, our job is to participate in a conspiracy of hope. It is our job to form a community of hope which surrounds people with psychiatric disabilities. It is our job to create rehabilitation environments that are charged with opportunities for self-improvement. It is our job to nurture our staff in their special vocations of hope. It is our job to ask people with psychiatric disabilities what it is they want and need in order to grow and then to provide them with good soil in which a new life can secure its roots and grow. And then, finally, it is our job to wait patiently, to sit with, to watch with wonder, and to witness with reverence the unfolding of another person’s life.

Mad Pride: Mental illness and recovery

The NY Times has an article on anti-stigma efforts by mentally ill people.

This caught my attention in relation to all of the attention that harm reduction has been getting recently. There has also been a mental illness consumer advocacy movement demanding a recovery orientation in mental health services. This movement emerged in response to psychiatry's harmfully low expectations for people with serious mental illness.

I see a parallel.

The business of treatment

Apparently there has been some turmoil at Hazelden over a new CEO's modernization of their business practices. It doesn't offer much detail, but here's a little history:

It started in 1949 in a farmhouse where men followed a recovery program based on the Twelve Steps of Alcoholics Anonymous. Teams of psychologists, chaplains and clinicians developed an approach that was copied worldwide.

But by the time Jerry Spicer became chief executive in 1992, managed-care companies had decided they didn't like what had become known as the Minnesota Model, with its costly, long-term inpatient approach. They preferred cheaper short stays and outpatient care. Hazelden felt the cost pressure. Hundreds of other centers closed or downsized.

An outsider moves in

A decade later, Spicer's successor, health care executive Nick Hilger, lasted one year. In 2002, Breyer was plucked from Hazelden's board and made president and chief executive.

She had been vice president for marketing at Ryan Companies, a commercial real estate developer. Breyer brought an outsider's corporate sensibilities to the insular treatment field. Hazelden inked a contract with Blue Cross and Blue Shield of Minnesota, which now brings in about 30 percent of Hazelden's patient revenue.

That Blue Cross contract opened the floodgates to insured patients but squeezed out those at the high and low end. Therapists and alums used to referring patients wouldn't always get their self-paying patients in the door. At the opposite end, charity care fell.

Still, it was hard to argue with the numbers: In 2007, Hazelden had operating revenues of $109.3 million and a record 10,754 patients. Donors gave a record $12 million.

Despite Hazelden's traditional devotion to abstinence-based treatment, Breyer approved use of new pharmaceuticals to treat addiction.

She won some fans. "People generally thought highly of Ellen," said Jill Wiedemann-West, Hazelden's senior vice president and chief operating officer of clinical and recovery services. "She brought a vision."

...

In 2006, Breyer brought in the Hay Group, New York consultants who grouped Hazelden's activities into three "strategic" businesses: treatment, publishing and the graduate school. Fundraising was a fourth important area.

"Trying to get your hands around that organization was like trying to sort stuff out of cotton candy," Hunsicker said. "Ellen, for good, better or worse, rolled up her sleeves and said I'm going to build some accountability."

That year, the National Association of Addiction Treatment Providers named Breyer Administrator of the Year.

By the next year, Hazelden executives began leaving.

General counsel Ivy Bernhardson became a Hennepin County judge. Carol Falkowski, director of research communications, is now director of chemical health at the Minnesota Department of Human Services. Both declined to be interviewed.

Chief Medical Officer Dr. Marvin Seppala left to head an in-home treatment program. Vying to return as Hazelden's chief executive, he declined to talk.

Mike Ranum, chief financial officer and chief administrative officer, joined an architectural firm in St. Paul. He did not return calls for comment. Nor did Tom Galligan, former market development chief.

All left, Breyer said, because of other opportunities. The departures "had very little, if anything, to do with me," she said.

Moyers, working on public policy, had become Hazelden's most recognizable public face. He also tried to leave last year but stayed after Hazelden funded a Center for Public Advocacy and put him in charge.

But to others, she represented a break from the Hazelden of old, where being in recovery was a credential as good as any fancy academic degree.

"The addiction field has been known for its warmth, its compassion, its affirmation," said Hunsicker. "Ellen brought with her a bit of an aloofness."

These are strange times in the field of addiction treatment. In the wake of the collapse of much of the addiction treatment system, many are seeing financial opportunity. Prometa, tv shows like Intervention and Celebrity Rehab, boutique treatment programs for the rich and famous, recovery coaches for hire, etc. There's a trade publication with cover stories like, "The King of Methadone" and "The Big Money Cometh". The magazine celebrates the business of addiction treatment, "high end" providers, and focuses one the scores of acquisitions that are creating some enormous companies with enormous profits.

It seems to be an era of entrepreneurship in addiction treatment and I find that pretty frightening.

The article didn't say much about what exactly is changing within Hazelden's culture. Smart business practices don't have to mean abandoning their mission, hopefully Hazelden will avoid some of the pitfalls that many other providers seem to be stepping in. Although, it's worth noting than many people think that Hazelden was one of the first providers to turn treatment and recovery into big business.

Science and Harm Reduction

I'm stepping into it here, but the rush of these articles (here and here are two examples) proclaiming Insite's empirical goodness (my word, not theirs) is getting on my nerves. The implication is that any critic is motivated by moral panic or some evangelistic impulse. (Many critics fit these characterizations. I'm bothered by them too.)

The first clue that something isn't quite kosher is this line, "A scientific review at the XVI International AIDS Conference in Toronto on August 15 became the scene of an emotional outpouring of support for Insite, Vancouver's supervised-injection site."

Let me be clear. I think that there can be a place for a program like Insite, especially in a city with HIV rates like Vancouver, but context matters.

"Success" depends on how one defines "success", doesn't it? Science supports the use of opioids to reduce pain in cancer patients. Is that an adequate response to cancer? We can create situaltions where the surgery is a success but the patient dies.

Many harm reduction advocates accuse critics of having a value-laden perspective on drug problems. I agree. I'm suggesting that values drive harm reduction activities as well. Public health has its values too. For example, it tends to focus on disease transmission, it tends to focus on communities rather than individuals, and can, at times, reduce decisions to an accounting exercise. One extreme example is medicalization of female circumcision.

I'd encourage all providers working with addicts to identify the values that drive their practices. We've done it, here.

So, Insite is fine with me, as long as it is used as a place to engage addicts and move them incrementally toward recovery. To do so, you have to have a lot of other pieces in place. I may be wrong, I'm 3000 miles away, but I get the sense that there is a lot more enthusiasm for harm reduction than for recovery.

These agruments might get put to rest if they tried a both/and approach.

Racial Inequity and Drug Arrests

A NY Times editorial on the insanity of the drug war and its disproportionate impact on communities of color.

Now, two new reports, by The Sentencing Project and Human Rights Watch, have turned a critical spotlight on law enforcement’s overwhelming focus on drug use in low-income urban areas. These reports show large disparities in the rate at which blacks and whites are arrested and imprisoned for drug offenses, despite roughly equal rates of illegal drug use.

Black men are nearly 12 times as likely to be imprisoned for drug convictions as adult white men, according to one haunting statistic cited by Human Rights Watch. Those who are not imprisoned are often arrested for possession of small quantities of drugs and later released — in some cases with a permanent stain on their records that can make it difficult to get a job or start a young person on a path to future arrests.

...

Between 1980 and 2003, drug arrests for African-Americans in the nation’s largest cities rose at three times the rate for whites, a disparity “not explained by corresponding changes in rates of drug use,” The Sentencing Project finds. In sum, a dubious anti-drug strategy spawned amid the deadly crack-related urban violence of the 1980s lives on, despite changed circumstances, the existence of cost-saving alternatives to prison for low-risk offenders or the distrust of the justice system sowed in minority communities.

Nationally, drug-related arrests continue to climb. In 2006, those arrests totaled 1.89 million, according to federal data, up from 1.85 million in 2005, and 581,000 in 1980. More than four-fifths of the arrests were for possession of banned drugs, rather than for their sale or manufacture. Underscoring law enforcement’s misguided priorities, fully 4 in 10 of all drug arrests were for marijuana possession.

One quibble. I do wish that these advocacy pieces would be consistent in distinguishing between arrests and incarceration. An arrest that results in a drug court, or a sentence to treatment and probation is very different that an arrest that results in a jail or prison sentence.

[hat tip: Matt Statman]

The American treatment system

A presentation from the Recovery Symposium I linked to the other day included this nugget.

Is Food Addictive?

From Slate:

As neuroscientists focus their attention on obesity, you can expect to see morestudies comparing food cravings to drug addiction. As these studies accumulate, you can expect to hear them cited in campaigns to regulate junk food.

Great Stuff

Here's a library of resources from the recent recovery conference in Philadelphia.

Of special note is this article: The Role of Clinical Supervision in Recovery-oriented Systems of Behavioral Health Care. It includes several references to Dawn Farm.

Powder cocaine comeback

This is certainly consistent with what I've been seeing in my intake interviews. I went years with very few mentions of recent powder cocaine use, but lately it's coming up every day.

Speedy Decline

A FEW years ago Pierce county, in Washington state, was in the grip of a methamphetamine epidemic. Toothless addicts roamed quiet rural roads, stealing everything that was not nailed down, ... “It was behind every bush,” she [the Sheriff] says.

The life cycle of the "meth epidemic" is an interesting story and I don't have my head wrapped around it yet, but the media's use of sensation and stigmatizing language has certainly colored attitudes and perceptions. The intro to this article makes it sounds like the film 28 Days Later.

I think that it's safe to conclude that there have been some successes in shortening the life cycle, but it's important to remember that drug use patterns are cyclical.

[via DailyDose.net]

Friend or foe? Drunk, the brain can’t tell

A new study exploring why people do risky things when they're drunk.

Housing First

There was an Op-Ed in today's USA Today advocating the housing first approach with "chronic public inebriates" (CPIs).

I have no objection to housing first is they continue to try to facilitate recovery. I'm uncomfortable with programs that place NO contingencies on the housing. I think there ought to be some expectation of at least minimal particiation in treatment or recovery support services. If a program opts not to place those contingencies on housing, they ought to at least continuously encourage use of those services/resources--looking for windows of opportunity. Housing is not enough.

The reason many programs seem to wince at this suggestion seems to be philosophical. They believe that addiction doesn't cause homelessness. Gentrification, racism, sexism, domestic violence, and other societal problems cause homelessness. That homelessness is not caused by individual factors, but community conditions. Therefore, to focus on their addiction is to blame the victim.

I also worry two other things. Financial considerations are important, but we shouldn't reduce these decisions to accounting exercises. We also need to be careful that these programs don't send messages to clients and the community that CPIs are hopeless and fan the flames of stigma.

Other posts on housing first here.

Albert Hofmann, the Father of LSD, Dies at 102

A little history lesson on LSD. Albert Hofmann, the scientist who discovered it, just died:

Dr. Hofmann first synthesized the compound lysergic acid diethylamide in 1938 but did not discover its psychopharmacological effects until five years later, when he accidentally ingested the substance that became known to the 1960s counterculture as acid.

He then took LSD hundreds of times, but regarded it as a powerful and potentially dangerous psychotropic drug that demanded respect. More important to him than the pleasures of the psychedelic experience was the drug’s value as a revelatory aid for contemplating and understanding what he saw as humanity’s oneness with nature. That perception, of union, which came to Dr. Hofmann as almost a religious epiphany while still a child, directed much of his
personal and professional life.

“It happened on a May morning — I have forgotten the year — but I can still point to the exact spot where it occurred, on a forest path on Martinsberg above Baden,” he wrote in “LSD: My Problem Child.” “As I strolled through the freshly greened woods filled with bird song and lit up by the morning sun, all at once everything appeared in an uncommonly clear light.

“It shone with the most beautiful radiance, speaking to the heart, as though it wanted to encompass me in its majesty. I was filled with an indescribable sensation of joy, oneness and blissful security.”

...

It was during his work on the ergot fungus, which grows in rye kernels, that he stumbled on LSD, accidentally ingesting a trace of the compound one Friday afternoon in April 1943. Soon he experienced an altered state of consciousness similar to the one he had experienced as a child.

On the following Monday, he deliberately swallowed a dose of LSD and rode his bicycle home as the effects of the drug overwhelmed him. That day, April 19, later became memorialized by LSD enthusiasts as “bicycle day.”

Dr. Hofmann’s work produced other important drugs, including methergine, used to treat postpartum hemorrhaging, the leading cause of death from childbirth. But it was LSD that shaped both his career and his spiritual quest.

“Through my LSD experience and my new picture of reality, I became aware of the wonder of creation, the magnificence of nature and of the animal and plant kingdom,” Dr. Hofmann told the psychiatrist Stanislav Grof during an interview in 1984. “I became very sensitive to what will happen to all this and all of us.”

...

But he was also disturbed by the cavalier use of LSD as a drug for entertainment, arguing that it should be treated in the way that primitive societies treat psychoactive sacred plants, which are ingested with care and spiritual intent.

After his discovery of LSD’s properties, Dr. Hofmann spent years researching sacred plants. With his friend R. Gordon Wasson, he participated in psychedelic rituals with Mazatec shamans in southern Mexico. He succeeded in synthesizing the active compounds in the Psilocybe mexicana mushroom, which he named psilocybin and psilocin. He also isolated the active compound in morning glory seeds, which the Mazatec also used as an intoxicant, and found that its chemical structure was close to that of LSD.

During the psychedelic era, Dr. Hofmann struck up friendships with such outsize personalities as Timothy Leary, Allen Ginsberg and Aldous Huxley, who, nearing death in 1963, asked his wife for an injection of LSD to help him through the final painful throes of throat cancer.

...

Though Dr. Hofmann called LSD “medicine for the soul,” by 2006 his hallucinogenic days were long behind him, he said in the interview that year.

“I know LSD; I don’t need to take it anymore,”...

Bill introduced in U.S. House to legalize marijuana

Dirk Hanson at Addiction Inbox has the details on a new bill by Barney Frank that would legalize marijuana.

Drug Policy extremes

How to have a crappy debate about drug policy.

Just pick two ideologues. In this case, someone from the Heritage Foundation and someone from Reason Magazine, owned by the Reason Foundation. All heat and no light.

Stigma

800 people attend a meeting to obstruct the establishment of an addiction treatment program.

An unintended consequence of an Vancouver's emphasis on harm reduction with the message that addicts can't and/or don't want to recover?

Risk of depression dims hopes for anti-addiction pills

Unsuprising news about unintended effects of pharmacotherapies for addiction.

The pills worked in a novel way, by blocking pleasure centers in the brain that provide the feel-good response from smoking or eating. Now it seems the drugs may block pleasure too well, possibly raising the risk of depression and suicide.

More on HR

Last week I missed an op-ed weighinh in against HR. The writer closes with this thought:

Many organizations offer the rationalization that drug use is part of our lives and will not go away. That is probably true, as it is true that most people who use recreational drugs or drink will not become addicted.

But there are those who are addicted and whose lives are in trouble. For them, continued use can and will ultimately prove to be disastrous.

It is a courageous act for an individual to face their problems and attempt to make the changes necessary to break free of their addiction. It's not an easy transition to make.

We, as a society, should do everything possible to assist them on their road to recovery. Everything, except create the illusion that only going half way down that road is all it takes.

Today, another writer offers a less certain opinion:

...I have come to realize, slowly and painfully, that complete abstinence may be out of reach for some. The all-or-nothing approach of abstinence advocates neglects the needs of many substance users who may fall somewhere in between.

This is obviously true--some people with addiction, even those who recieve treatment, will die of their addiction. The problem is that we don't know who will recovery and who will not. After 14 years in this field, I am unable to predict those who will recover and those who will not. Further, my instincts are repeatedly proven wrong. This being the case, the only solution is to treat all addicts as though they can recover. This is not an argument against HR, rather it's an argument in favor of making recovery-oriented services available to all who want them. It is also important that systems recognize that many who do not want recovery-oriented services may be making this decision due to an absence of hope, and it is the system's responsibility impart hope and encourage clients to seriously consider all of the best treatments available. (Just as we would do with a cancer patient facing difficult treatment with uncertain outcomes.)

The writer does maintain a conclusion that I can agree with:

All said, I am still not sure where I stand on harm reduction. I know that abstinence is the ideal.

I appreciate someone talking about their struggle with the matter. I've steadily grown more wary of people expressing what Anne Lamont referred to as "excessive certitude".

Point/Counterpoint on Legalization

I'm afraid to say I don't find either of these very persuasive.

Sullum assumes that alcohol prohibition has been a great success. I'm not advocate of prohibition, but clearly, we suffer from a lot of alcohol-related problems. Stimson argues that Reagan's drug policy has been a success? He's being gamey with the 50% number. I'm not sure where he gets it, but it's very misleading. Does he think skyrocketing incarceration rates for drug crimes is a sign of success?

Too bad we keep getting this Crossfire style of debate by the ideological extremes. I'm more and more convinced that there is no problem-free (or, even low-problem) drug policy. Every drug policy brings problems with it. The questions are which problems we're willing to live with and how we can best minimize those problems.

Abstinence vs. Harm Reduction redux

Sara McGrail sent a kind comment to yesterday's post. I thought I'd post her entire comment to make it more visible:

Hey, thanks for blogging my blog - and you're right, I am an exponent of harm reduction. I totally agree with your assertion about raising expectations - as long as those expectations that we strive for are the clients and not just the service's or the worker's. For me, the difficulties in raising aspiration in any sustainable way while labelling the individual an addict or considering their drug use solely an illness are manifest

The context and orientation of services is as you say, critical. While the impetus for change is directed from a political level, its all too easy to negate the choices made by the individual. A focus on criminalising or pathologising drug use is problematic and shifts the emphasis away from individual aspiration, hope and recovery. This is sadly the environment within which many services operate - and in my view a continuing block to a full menu of useful interventions (and particularly those focussed on reintegration) for many individuals experiencing problems with substance use.

Harm reduction is a dynamic philosophy that I do not in any way see being in opposition to abstinence. Good harm reduction requires at its core a recognition of individual volition and self direction as well as an understanding of the impact of environment and culture on the choices available. However the philosophy of harm reduction is vulnerable when there is a shift in the definition of harm from an individual one to a societal or political. Community wide gains from harm reduction are best achieved incrementally through numerous successful individual interventions rather than centrally mandated programmes. Centrally funded harm reduction initiatives need to be cautiously managed to ensure the drive for acceptance of the philosophy (ie through attaching crime outcomes) does not overpower the individual intervention. These comments are of course specifically relevant to the UK situation where harm reduction has been accepted for some time. Where harm reduction is less well developed, different approaches may be more appropriate.

Going to feed the dog now. Have a grand weekend.

Sara

I agree that it is important that we not view all heavy drinking or illegal drug use as addiction. The U.S. had its excesses with this in the 1980s when every kids who's Mom found a bag of weed in their sock drawer was diagnosed with substance dependence. I also agree that the clinician should not be prescribing goals, however when we offer clients services that are filled with hope and success stories, they choose recovery. (Skeptics should visit our detox facility.) As for the difficulty of raising aspirations within the context of addiction as an illness, I don't see it. We don't see hope as incompatible with other illnesses and I don't see a nonjudgemental review of the diagnostic criteria as harmful labeling. Personally, I think that viewing an addict outside of that framework frames them as self-destructive hedonists, making it more a matter of character than health.

However, I think she's put her finger on the crux of much of the tension between many HR advocates and recovery advocates. If you view drug users as engaging in a lifestyle choice, recovery advocates look like evangelical temperance zealots driven by moral judgement and panic. If you view it as brain disease characterized by loss of control, then long-term strategies that are focused on controlled use or limited to reducing harm constitute professional neglect--similar to treating only the symptoms of a serious chronic illness when treatments to facilitate full recovery (Even if only for a sizable portion.) are available.

The super adventure club helps kids say "no"

Score one for Scientology. I feel a little queasy.

Abstinence vs. harm reduction

Though this writer presents herself as having no attachment to a particular treatment approach, she's clearly a harm reduction advocate. However, she does a good job making the both/and argument and recognizes that motivation and client preferences often change frequently.

What she fails to address is that context and the culture of services have enourmous influence on the addict's choices and motivation. Does the system subtly and patronizingly discourage abstinence as unrealistic? Does the system reject and judge clients who are unwilling to embrace lifelong abstinence? Does is offer unwaivering hope for full recovery and honestly review options with clients?

Drug-free treatment has historically failed to accept addicts who were not ready to embrace abstinence and harm reduction providers too often define the addict by their illness and place so much emphasis on accepting them as they are that there is no emphasis on what they can become. We know that radical transformation is possible--we see it every day. A system should accept and provide services to support incremental change, but it must not damn them with low expectations, it must not be satisfied with reducing risk for harm, and must offer hope and support for full recovery.

I have to confess, I have no little trouble fathoming how on earth we have ended up here, once again engaged in the obsessive navel gazing that is the debate about whether the focus of treatment should be abstinence or maintenance?

Its just not a question that I can identify with, because people experiencing drug treatment need the opportunity to choose the interventions that work best for them. This might change through someone’s drug using career, with needle exchange, drop in, prescribing, inpatient and community detox and residential or community rehabilitation services coming into play at different points for different people. Sometimes, as we know, people will not move through these interventions in any convenient linear mapable way, but may well drift in and out of treatment over a protracted period of time

Of course as long as they stay for at least 13 weeks we’re all absolutely cool about it.

So is the aim abstinence? Yes. Is it maintenance? Yes. Do we need Harm Reduction? Yes. Is prevention important? Yes.

There is no right or wrong answer and really there should be no debate about this. There is no “one size fits all” solution to the problems people who use drug face. I have as little time for people who say everyone needs a script as I do for those who say everyone needs to go to a fellowship group.

Limbic System Preconsciously Activated by Drug and Sexual Cues

An explanation of why recovering people can't count on being able to see a relapse coming:

The human brain responds to recognizable signals for sex and drugs of addiction by activating the limbic reward circuitry. To determine whether the brain responds in similar ways to these signals even when they are "unseen" -- i.e., presented in a way that prevents their conscious recognition -- researchers in an NIDA-funded study tested the brain response to cocaine, sexual, aversive, and neutral cues (33 milliseconds duration each) in 22 male patients with cocaine dependence. Brain response to each visual cue was measured by magnetic resonance imaging (MRI).

• Cocaine-related images triggered the emotional centers of the brains of patients, even when subjects were unaware they had seen anything.
• Greater brain activity to “unseen” cocaine cues predicted a stronger positive response to visible versions of the same stimuli in later testing.

Comments by Tommie Ann Bower, MA
Results of this study supports years of anecdotal evidence that relapse can be triggered outside of awareness. As with any new finding, the generalizability of these results will depend on additional studies. In the long run, the complicated nature of craving in the brain must be further understood. In the short run, clinicians must redouble efforts to educate patients about the specific triggers for craving, to activate awareness, and to redirect impulses to use.

Increasing D2 Receptors Works On Cocaine, As On Alcohol

Addiction has been linked to a deficiency of dopamine D2 receptors. It appears that scientists have found a way to increase the number of these receptors in the brains of rats:

"By increasing dopamine D2 receptor levels, we saw a dramatic drop in these
rats' interest in cocaine," said lead author Panayotis (Peter) Thanos, a
neuroscientist with Brookhaven Lab and the National Institute on Alcohol Abuse
and Alcoholism (NIAAA) Laboratory of Neuroimaging. "This provides new evidence
that low levels of dopamine D2 receptors may play an important role in not just
alcoholism but in cocaine abuse as well. It also shows a potential direction for
addiction therapies."

The D2 receptor receives signals in the brain triggered by dopamine, a
neurotransmitter needed to experience feelings of pleasure and reward. Without
receptors for dopamine, these signals get "jammed" and the pleasure response is
blunted. Previous studies at Brookhaven Lab have shown that chronic abuse of
alcohol and other addictive drugs increases the brain's production of dopamine.
Over time, however, these drugs deplete the brain's D2 receptors and rewire the
brain so that normal pleasurable activities that stimulate these pathways no
longer do - leaving the addictive drug as the only way to achieve this
stimulation.

The current study suggests that cocaine-dependent individuals may have
their need for cocaine decreased if their D2 levels are boosted. Thanos' lab
previously demonstrated dramatic reductions in alcohol use in alcohol-preferring
rats infused with dopamine D2 receptors (see: http://www.bnl.gov/discover/Winter_06/alcohol_1.asp). Thanos
hypothesized that the same would hold true with other addictive drugs.

The researchers tested this hypothesis by injecting a virus that had been
rendered harmless and altered to carry the D2 receptor gene directly into the
brains of experimental rats that were trained to self-administer cocaine -- the
same technique used in the earlier alcohol study. The virus acted as a mechanism
to deliver the gene to the nucleus accumbens, the brain's pleasure center,
enabling the cells in this brain region to make receptor proteins themselves.

The scientists examined how the injected genes affected the rats'
cocaine-using behavior after they had been taking cocaine for two weeks. After
receiving the D2 receptor treatment, the rats showed a 75 percent decrease in
self-administration of the drug. This effect lasted six days before their
cocaine self-administration returned to previous levels.

Gratitude lists

AA sponsors have known about the power of gratitude lists for decades. (Thank goodness mine did.) This study had participants list 5 items daily for 13 days.

The effect of a grateful outlook on psychological and physical well-being was examined. In Studies 1 and 2, participants were randomly assigned to 1 of 3
experimental conditions (hassles, gratitude listing, and either neutral life events or social comparison); they then kept weekly (Study 1) or daily (Study 2) records of their moods, coping behaviors, health behaviors, physical symptoms, and overall life appraisals. In a 3rd study, persons with neuromuscular disease were randomly assigned to either the gratitude condition or to a control condition. The gratitude-outlook groups exhibited heightened well-being across several, though not all, of the outcome measures across the 3 studies, relative to the comparison groups. The effect on positive affect appeared to be the most robust finding. Results suggest that a conscious focus on blessings may have emotional and interpersonal benefits.

[via: cognitive daily]

New Calif. Ballot Initiative Expands Treatment, Builds on Prop 36

I've noticed lately that the Drug Policy Alliance appears to be trying to balance their agenda with the concerns of people who are sympathetic to their message on criminalization of addiction, but fear radical decriminalization.

This looks like another very big step in that direction. It's good to see them taking a both/and approach.

Recovering the Oxford House

New funding for Oxford Houses in Illinois. Researcher Leonard Jason is the leading researcher of this kind of sober housing:

The two studies released by the group in 2006 showed drug abstinence rates
of 65 to 87 percent among recovering addicts who lived communally in the
self-supporting Oxford House system. The results bucked prior notions that a
majority of recovering substance users relapsed after treatment.

Jason’s reasoning is simple. "If you have someone who is dealing with
substances and drugs and then they get released back to the same family and
neighborhoods that might have high levels of substance abuse and you don’t
provide them any types of support, the likelihood is that many of those people
will relapse," he said. "If you provide housing, opportunities for employment,
peer support—you can reduce that rate by half."

Ferrari, a Vincent DePaul Distinguished Professor, credited the Oxford
House system’s success to the reality that "a sense of home is very important
for people" and that the method respects the "individuality and dignity" of each
person who lives in an Oxford House.

The article also offers this mouthful:

"Oxford Houses are controversial because they are showing that people can take
care of themselves. [Oxford House residents] don’t need the medical community."

Couldn't the same be said for much of the professional resistance to 12 step programs?

The Neurobiology of Free Will and Drug Addiction

Norah Volkow on the evolving understanding of the neurobiology of addiction.

A good headline is worth 1000 words

Scientists Say Methadone-Like Treatment for Cocaine Addiction Possible

Free trade and Drug Policy

I'm so glad the ONDCP is apolitical, aren't you?

[via dailydose.net]

Campus recovery center provides 'sober support'

University of Texas' innovative (but long-standing) student support program is explained in this article. Why don't any Michigan universities have a program like this?

After an attempted suicide, stints in a hospital and psychiatric ward, substance abuse, a nervous breakdown and two months in a rehabilitation center, Britney Salyer found sobriety at UT.

The marketing senior got involved in University Health Services' Center for Students in Recovery when she returned to UT after leaving a rehabilitation center.

"I went into rehab with no intentions of quitting anything," she said. "But I got introduced to the program, stuck around at UT and got back into the swing of things."

The center provides counseling services and sober social networks for University students, whether they are in treatment, have gone through rehabilitation or need sober support to avoid addiction.

Substance abusers become acclimated to dealing with life and relationships with drugs or alcohol. Laura Jones-Swann, the center's alcohol and drug education coordinator, said the program teaches life skills that help students mend relationships.

"I used to not be able to do class presentations without downing a drink," Salyer said. "It took me a while to regain my steam, but now I don't feel overwhelmed or nervous at all."

UT is one of seven universities in the country that provides programs for recovering students. The program

began in 2002 with seven students and now has 50, but Jones-Swann said she still knows all of the students' names.

"I stay connected to the students through our Wednesday night meetings where we talk about relationships and just get really, extremely honest with each other," she said.

If a student is absent from the meetings for more than two weeks, she said, she sends them an e-mail to check in.

Students who experience organizational hazing, particularly episodes of forced binge drinking, often seek services at UHS.

The most recent study of alcohol-related deaths on college campuses, conducted in 2001, found that 1,700 college students died from unintentional alcohol-related injuries and deaths that year. UT officials said this emphasizes the importance of preventative measures taken by the University.

After 26 months of sobriety, death is not an alternative for Salyer, as it once was.

"It took either rehab, jail or death to get me to quit," she said. "As long as I am willing enough to go into the program and be open about things, then I'll be OK."

Alcohol across the lifespan

The National Institute on Alcohol Abuse and Alcoholism has posted a 5 year plan to address alcohol use across the lifespan.

Alcohol and Other Drug Abuse Among First-year College Students

This document examines the problem of problem drinking among freshman college students. It looks at the scope of the problem and potential responses. While it's focus is pretty narrow, it offers a lot of helpful information for other communities as well.

National surveys find that about two in five U.S. undergraduates engage in heavy drinking, which is typically defined as having five or more drinks in a row at least once in a two-week period. According to survey data compiled by the Core Institute in 2004, 45.3 percent of freshmen nationally can be classified as heavy drinkers. The same data indicate that 17.7 percent are heavy and frequent drinkers, meaning that they engaged in at least one episode of heavy drinking in the previous two weeks and drank on three or more occasions per week.

The negative consequences associated with college alcohol use are legion, including personal injury, physical illness, high-risk sexual behavior, and death. Research estimates that 1,700 college students ages 18–24 die annually from alcohol related unintentional injuries. Nearly 80 percent of those deaths are associated with driving after drinking. In 2001, just over 10 percent of college students reported being injured, while 8 percent reported having unprotected sexual intercourse because of their drinking.

It also offers detailed guidelines for keeping first year students safe:

Provide Alcohol-free Options.

• Create and promote alcohol-free events for fi rst-year students.
• Support student clubs and organizations that are substance-free.
• Create and promote service learning and volunteer opportunities.
• Require community service work as part of the academic curriculum.
• Open or expand hours at a student center, recreation facilities, or other alcohol-free settings.
• Promote consumption of nonalcoholic beverages and food at events.

Create a Healthy Normative Environment.

• Offer a greater number of substance-free residence halls.
• Promote faculty-student contact.
• Require students to meet regularly with academic adviser.
• Require students to meet regularly with resident assistant.
• Employ older resident assistants.
• Prohibit fraternity and sorority rush for fi rst-year students.
• Require students to take more morning and Friday classes.

Restrict Alcohol Availability.

• Require all social events during orientation to be “dry.”
• Require fi rst-year students to live on campus.
• Disseminate responsible host guidelines for both on- and off-campus parties.
• Install a responsible beverage service program.
• Train alcohol servers and managers to stop service to underage or intoxicated students.
• Train alcohol servers and managers in the latest techniques and technologies for recognizing false IDs.
• Eliminate residence hall delivery of alcohol purchases.
• Advertise food and activities, such as dancing or sports, rather than drinking as the focus of the event.

Restrict Marketing and Promotion of Alcohol.

• Ban alcohol promotions with special appeal to underage drinkers.
• Ban advertising of high-risk promotions.

Strengthen Policy Development and Enforcement.

• Review campus alcohol and other drug policies and strengthen where necessary.
• Disseminate campus alcohol and other drug policies and publicize their enforcement.
• Require on-campus functions to be registered.
• Impose tough penalties for possessing a fake ID.
• Enforce minimum legal drinking age laws.

Increase ID checks at on-campus functions and parties.

Use decoy operations at campus pubs and on-campus functions.

Increase ID checks at off-campus bars and liquor stores.

Use decoy operations at retail alcohol outlets.

Enforce seller penalties for sale of liquor to minors.

• Support local and state enforcement in imposing driver’s license penalties for minors violating alcohol laws, and in changing driver’s licensing procedures and formats.
• Notify parents of their children’s rules violations.

The sting of poverty

This article is a little off topic for this blog, but it addresses what many of Dawn Farm's client's confront. We talk a lot about our clients as "multiple problem clients", and that one of the reasons they end up in our programs is because of the number of problems they face as well as their intensity and complexity.

Imagine getting A bee sting; then imagine getting six more. You are now in a position to think about what it means to be poor...

When we're poor, Karelis argues, our economic worldview is shaped by deprivation, and we see the world around us not in terms of goods to be consumed but as problems to be alleviated. This is where the bee stings come in: A person with one bee sting is highly motivated to get it treated. But a person with multiple bee stings does not have much incentive to get one sting treated, because the others will still throb. The more of a painful or undesirable thing one has (i.e. the poorer one is) the less likely one is to do anything about any one problem. Poverty is less a matter of having few goods than having lots of problems.

Poverty and wealth, by this logic, don't just fall along a continuum the way hot and cold or short and tall do. They are instead fundamentally different experiences, each working on the human psyche in its own way. At some point between the two, people stop thinking in terms of goods and start thinking in terms of problems, and that shift has enormous consequences. Perhaps because economists, by and large, are well-off, he suggests, they've failed to see the shift at all.

If Karelis is right, antipoverty initiatives championed all along the ideological spectrum are unlikely to work - from work requirements, time-limited benefits, and marriage and drug counseling to overhauling inner-city education and replacing ghettos with commercially vibrant mixed-income neighborhoods. It also means, Karelis argues, that at one level economists and poverty experts will have to reconsider scarcity, one of the most basic ideas in economics.

"It's Econ 101 that's to blame," Karelis says. "It's created this tired, phony debate about what causes poverty."

Cocaine self-medication for insomnia

"Addicted people may take cocaine to improve sleep-related cognitive functioning deficits—unaware that they are abusing, in part, to 'solve' these problems."

Huh? I suppose, if cocaine is part of one's life, one might use it instrumentally when tired--the way many of us use caffeine. But "unaware"?

Also, isn't this theory tautological? I go beyond his statement, but I think this speaks to much of the psychiatric conventional wisdom.

• Sleep problems are widespread among addicts.
• People self-medicate with stimulants to deal with impairments related to sleep problems.
• People self-medicate with sedatives to help them sleep when experiencing sleep problems.

Under what conditions is their drug use not self-medication? If it is self-medication, why are they unaware? If what they really seek is relief from sleep problems and psychiatric symptoms, why are they non-compliant with professionally directed treatments? Yet, they are so consistent with illicit drugs as self-medication when these drugs are poor treatments for the problem.

Two quotes come to mind:

Their every truth is not quite true. Their two is not the real two, their four not the real four: so that every word they say chagrins us and we know not where to begin to set them right. -- Ralph Waldo Emerson

If the only tool you have is a hammer, you tend to see every problem as a nail. -- Abraham Maslow

At any rate, the study focuses only on the first 17 days of abstinence in a non-treatment population. NIDA summarizes their findings as follows:

Sleep deficits—After 14 to 17 days of abstinence, the study group exhibited sleep deficits on several measures, relative to healthy, age-matched peers who participated in prior studies. For example, they had less total sleep time (336 versus 421-464 minutes) and took longer to fall asleep (19 versus 6-16 minutes).

Declines in sleep quantity and quality—The time participants took to fall asleep and their total time asleep transiently improved during the first week of abstinence, but then reverted to the patterns recorded on days of cocaine taking. On abstinence days 14-17, participants took an average of 20 minutes to fall asleep (from a low of 11) and slept for 40 minutes less than their minimum. Slow-wave sleep—a deep sleep that often increases following sleep deprivation—rose during the binge and on abstinence days 10-17.

Lack of awareness of their sleep problems—In contrast to the evidence of objective measures, the study participants reported steadily improving sleep from the beginning to the end of their days of abstinence.

Impairments in learning and attention—As with sleep quality, participants' performance on tests of alertness and motor-skills learning initially improved and then deteriorated. On abstinence day 17, they registered their lowest scores on alertness and ability to learn a new motor skill.

They then acknowledge the limitations of such a short study:

"Cocaine abusers who recognize their cognitive problems often report that it takes them 6 months to a year to turn the corner—a clinical observation that points to the need for longer term studies of sleep and treatment outcomes among this population."

They argue that they are relevant because other studies have found that early sleep problems predict relapse 6 months later, but neglect to mention that other studies have found that distress about sleep problems is a better predictor of relapse than objective sleep measures.

Not surprisingly, they are researching medications for sleep:

Dr. Morgan and his team are currently testing two medications, tiagabine (an anticonvulsant) and modafinil (a stimulant), to see if they can improve cocaine abusers' sleep and restore cognitive performance.

Why not try CBT (here and here) and looking at treatment populations?

Substance Use and Dependence Following Initiation of Alcohol or Illicit Drug Use

There is a new NSDUH report on the development of dependence upon a substance in the 2 years following substance use initiation as explained below.

For the purposes of this report, persons who initiated use of a substance 13 to 24 months prior to the interview are referred to as "year-before-last initiates." Year-before-last initiates were assigned to three mutually exclusive categories reflecting their substance use trajectories following initiation: those who had not used the substance in the past 12 months ("past year"), those who had used the substance during the past year but were not dependent on the substance during the past year, and those who had used the substance and were dependent on the substance during the past year.

The report provides a peek into two interesting statistics. The first is the 2 year capture rates for each drug. That is the percentage of people who develop DSM dependence upon a drug. Please note that dependence is only one harm associated with drug use.

Percentages of Year-Before-Last Initiates Who Were Dependent on the Initiated Substance in the Past Year, by Substance: 2004-2006

The second statistic is the percentage of people who used it for the first time 2 years ago, but have not used it at all in the last year.

Percentages of Year-Before-Last Initiates Not Using the Initiated Substance in the Past Year, by Substance: 2004-2006 Does this suggest that this is the rough percentage of people who experiment with a drug briefly and then do not use it again? Does the difference between these two statistics tell us the capture rate for casual use?

I'm not sure. It will be interesting to see more about this in coming years.

Sertraline Does Not Help Methamphetamine Abusers Quit

SSRIs are contraindicated for newly abstinent methamphetamine addicts.

Recovery will be key in new drugs strategy (Scotland)

I've posted before (here, here, here, here and here) about Scotland and the price of harm reduction being the basis of its drug policy. (To the exclusion of recovery or abstinence oriented approaches.) Good news. They've just announced that they are adopting a recovery-oriented approach:

The new report is published today as former Health Minister Susan Deacon chairs a conference in Glasgow looking at how the concept of 'recovery' might be applied to the field of drug addiction.

Mr Ewing said that the emerging focus on recovery represents 'a real opportunity to put a strategy in place that commands widespread professional, political and public support'.

Some of the main findings of the SACDM Sub-Group's Essential Care Report are:

• There is a need for a major change in the philosophy of care for people with problem substance use in Scotland
• Substance users are people with aspirations
• Policy makers, commissioners and services need to consider how they can help them recover
• Substance users have the right to the same quality of care as the rest of us

Mr Ewing said:

"The Essential Care report contains a number of welcome recommendations which are already being looked at as we develop our new drugs strategy.

"I believe we need to get better at encouraging each addict's personal vision of recovery by reducing practical barriers to services, while giving people hope by acknowledging that recovery is achievable.

"I have met former addicts who tell me that the key to believing in your own recovery is 'believing it can happen for you' - being optimistic that you can recover. The concept of recovery represents a significant shift in thinking and has happened in the field of mental health - why shouldn't people with drug problems believe they can recover too?

"That's the question that all the agencies working to tackle drug misuse need to ask themselves. If the answer isn't yet a straightforward 'yes' - then they need to challenge the approaches they are taking. We have a real opportunity to put a strategy in place that commands widespread professional, political and public support. I want us all to seize that opportunity.

"We will publish a new drugs strategy for Scotland before summer and its main focus will be recovery. It is essential that people experiencing drug problems have access to a range of wider services including employment, housing, and health that help them to move-on and rebuild their lives."

Heeeeeere’s Stanton

I'm not a fan of Stanton Peele and I usually don't read him because I find him to be more of a bomb-thrower than anything else.

While this article is full of his usual distortions, one line leaped out at me:

The typical program says, "Quit using before you enter, while you're here, and forever after." Good advice - if only people weren't addicted. (emphasis mine)

His argument is that abstinence is an unrealistic goal and that harm reduction is the only rational approach. I couldn't disagree more. While one could argue that it's dated, his point about the historical pre-treatment and treatment expectations of many programs is fair and it stings.

I'm proud that Dawn Farm has continued to work on ways to engage people who are still using and stay engaged when people relapse. I'm thinking of activities like outreach, recovery coaching, seamlessly stepping people up or down in treatment, and trying to be sure that getting discharged from one program (say, residential) does not mean that the person is discharged from our community of programs or that they are unable to re-enter the program if it makes sense at a later date.

'Cheese' Heroin Hooking Young Users in Dallas

As I've noted in the past, I'm a little reluctant devote space to something like this that has so much hype potential, but NPR has run a new story on "cheese" in Dallas:

"Reports that we were seeing were pretty striking. Kids as young as 9 or 10 years of age coming to the hospital emergency rooms or detox facilities in acute heroin withdrawal," says Dr. Carlos Tirado, a psychiatry professor at UT Southwestern Medical Center and medical director of a drug treatment center in Dallas.

"We didn't know what to do with a 9-year-old in opiate withdrawal, or what the treatment ramifications of that are," Tirado says. "Do you send a 9-year-old to an AA meeting?"

Can Sips at Home Prevent Binges?

A New York Times article examines the question of whether parents allowing teens to drink at home decreases alcohol problems later. (Note that they are not talking about parents hosting parties for their kids or buying them a 6 pack, they are talking about allowing some wine with dinner.)

Dr. Vaillant compared 136 men who were alcoholics with men who were not. Those who grew up in families where alcohol was forbidden at the table, but was consumed away from the home, apart from food, were seven times more likely to be alcoholics that those who came from families where wine was served with meals but drunkenness was not tolerated.

He concluded that teenagers should be taught to enjoy wine with family meals, and 25 years later Dr. Vaillant stands by his recommendation. “The theoretical position is: driving a car, shooting a rifle, using alcohol are all dangerous activities,” he told me, “and the way you teach responsibility is to let parents teach appropriate use.”

“If you are taught to drink in a ceremonial way with food, then the purpose of alcohol is taste and celebration, not inebriation,” he added. “If you are forbidden to use it until college then you drink to get drunk.”

The article focuses on the matter in a very micro manner--avoiding questions alcohol's status as a celebrated drug in our culture and questions of drinking age. (If we strongly believe that alcohol should be prohibited for people under the age of 21, why are we so permissive with 19 and 20 year olds? If we don't think it's a problem for 19 and 20 year olds, why do we maintain this law?)

Gay Youth Report Higher Rates Of Drug And Alcohol Use

The odds of substance use for lesbian, gay and bisexual (LGB) youth are on average 190 percent higher than for heterosexual youth, according to a study by University of Pittsburgh researchers published in the current issue of Addiction. What's more, for some sub-populations of LGB youth, the odds were substantially higher, including 340 percent for bisexual youth and 400 percent for lesbians, researchers found.

This will be interesting to watch. The study was a meta-analysis of research from 1994 to 2006. While homophobia is alive and well, in some communities, the landscape for LGB youth has changed dramatically for the better over that period. No? Will disparities decrease as homophobia decreases?

"Make Room for Serious Criminals" bill

Barney Frank has announced plans to file a bill to remove all federal penalties for the possession or use of small amounts of marijuana.

The Healing Place

Kentucky's Healing Place focuses on 12 step facilitation as a response to homeless alcoholic men. It's become a model for 10 new programs in Kentucky and other programs around the country.

Addicts 'not second-class people'

Pressure continues to grow to rethink Scotland's emphasis on methadone.

[via dailydose.net]

Bill Wison on YouTube

Someone has posted video on YouTube of Bill & Lois Wilson telling Bill's Story, the first meeting with Dr. Bob and history of the Traditions.

Essential viewing for anyone with an interest in 12 step recovery.

NOTE: Some of the "related videos" slander Dr. Bob. Be warned.

The Wire's War on the Drug War

From the writers of The Wire:

...we offer a small idea that is, perhaps, no small idea. It will not solve the drug problem, nor will it heal all civic wounds. It does not yet address questions of how the resources spent warring with our poor over drug use might be better spent on treatment or education or job training, or anything else that might begin to restore those places in America where the only economic engine remaining is the illegal drug economy. It doesn't resolve the myriad complexities that a retreat from war to sanity will require. All it does is open a range of intricate, paradoxical issues. But this is what we can do — and what we will do.

If asked to serve on a jury deliberating a violation of state or federal drug laws, we will vote to acquit, regardless of the evidence presented. Save for a prosecution in which acts of violence or intended violence are alleged, we will — to borrow Justice Harry Blackmun's manifesto against the death penalty — no longer tinker with the machinery of the drug war. No longer can we collaborate with a government that uses nonviolent drug offenses to fill prisons with its poorest, most damaged and most desperate citizens.

Jury nullification is American dissent, as old and as heralded as the 1735 trial of John Peter Zenger, who was acquitted of seditious libel against the royal governor of New York, and absent a government capable of repairing injustices, it is legitimate protest.

[hat tip: Jim]