Spirituality and recovery

Martin Nicolaus notices a not yet published study on the impact of spiritual guidance as part of treatment. There was no impact. In fact, the group with spiritual guidance by certified spiritual directors had worse outcomes on measures of depression and anxiety, though a group receiving spiritual guidance from their counselor did just as well as the other groups.

What's especially interesting about this study is that Bill Miller, the lead author, is very friendly to spirituality as an tool for facilitating change. He seems stumped but isn't questioning the study itself.

There is reason for confidence in the findings of this study. Outcome variables were carefully measured by independent interviewers, fidelity of interventions was good, and 82% of all possible follow-up interviews were completed. The studies were powered to detect a medium between-group effect size that would be sufficiently large to be of clinical interest ([Cohen, 1988] and Miller and Manuel (in press) Miller, W. R., and Manuel, J. K. (in press). How large must a treatment effect be before it matters to practitioners? An estimation method and demonstration. Drug and Alcohol Review.Miller and Manuel (in press)). Null findings were replicated across two study designs, and the direction of differences was, in many cases, opposite to prediction. We thus found no evidence for a beneficial effect of this spiritual counseling approach during the acute phase of addiction treatment. Different and more intensive spiritual counseling might increase daily spiritual practices, spiritual experience, and meaning and thereby influence substance use outcomes. Given the magnitude of changes that occur in early recovery, however, we believe that a more promising approach is to focus on spiritual development after a period of stabilization in which other basic needs have been addressed. Within a long-term care perspective, spiritual direction may fit better in later recovery, with a goal of maintaining and broadening the initial gains of sobriety.

It would be interesting to see more research on spirituality and recovery. I'm inclined to believe that spirituality can be a useful therapeutic tool. If nothing else, for people when enter treatment with spiritual beliefs, it might be used to increase engagement and participation in treatment. It might also be used as a long term source of support for change. (We do value a holistic approach, right?)

Along the lines of a stage dependent model, as Miller suggests, Project SAFE reported that many of the African American women in the study initiated their recovery in 12 step groups and sustained their recovery in churches.

The study said nothing of the participants' predisposition to spirituality. That seems important to me.

Other questions that might be interesting include:

• What forms of spirituality are helpful or unhelpful? Some clearly emphasize a stronger internal locus of control while others emphasize an external locus of control.
  
• Can helpful elements of the helpful forms of spirituality be unbundled?
• What are the non-spiritual paths to those helpful elements?
• There is a persistent assumption that all clients will benefit from spirituality. Is this true? Are these some who might benefit, others who are unaffected and some whose treatment outcomes are harmed?
• Along the lines of Miller's thinking, to what degree are these responses stage dependent?
  

DF employees - let me know if you want a copy of the study.

Early Exposure to Drugs and Alcohol

Interesting findings about the relationship between early substance use and troubled kids. It tries to answer whether substance use creates troubled kids or troubled kids engage in early substance use.

First, the prior consensus in child psychology and psychiatry has been that adolescents who go on to develop substance dependence are not normal adolescents who are experimenting with substances, but rather are highly likely to be adolescents with a prior history of conduct problems (Armstrong & Costello, 2002). If this is the case, the documented association between early substance exposure and adult outcomes would not be due to exposure per se, but instead would be the result of who is exposed (Wells, Horwood, & Fergusson, 2004). Prior research has not resulted in a consensus regarding the causal status of substance exposure (Agrawal, Neale, Prescott, & Kendler, 2004; Kandel, 2003; Lynskey et al., 2003; Prescott & Kendler, 1999). However, results from this study are consistent with a causal effect of early substance exposure among adolescents with no prior history of conduct problems. That is, early-exposed adolescents with no conduct-problem history, although they did not have an increased risk of failing to complete school, were more likely than their matched non-early-exposed counterparts to develop substance dependence, test positive for herpes, have an early pregnancy, and be convicted of criminal offenses.

Second, findings from this prospective study support a causal link between early substance exposure and a wide range of adult outcomes. Propensity-score-adjusted effects indicate that early substance exposure more than doubles the odds of adult substance dependence, herpes infection, early pregnancy, and criminal convictions.

Strangely, CADCA explains the study by describing some subjects as good kids and the others as bad kids.

[hat tip: Jess]

More on Methadone

My recent post on methadone prompted several comments, some making really great points. I decided to post all of them so that they would not be missed. The last 4 comments are great, you can guess what I think of the first 2.

armme said...

Your still working on the idea that addiction is some spiritual malady. Your way of thinking is in the DARK AGES, my friend. Your idea of recovery will soon be a thing of the past. It will be like performing an Exorcism on mental illness...once thought to be the ONLY form of treatment, but now considered completely irrational.

Your still trying to stop drug use...when you should be focusing how to get the addict to live a better life. Your treating an illness of endorphin dysfunction by taking away the only thing that corrects that dysfunction with stability.

You can continue to offer people your "exorcism approach" or you can learn the science behind opiate addiction and realize stopping people from using drugs doesn't stop the disease.

Do you want to treat the disorder so these people can have a better life--or do you just want them to stop using drugs no matter HOW miserable they have to be to do so?

Sometimes, MANY TIMES, you can't have both. Not with opiate addiction.

Anonymous said...

"counseling", while possibly helpful to some who may need referrals to things like job training, childcare, housing options, etc, is NOT the answer to most hardcore addiction problems. Science has shown clearly that addiction is a brain disease, a disruption of the brain chemistry. That is not something you can repair with a few hours of talk therapy. If talk therapy (or meetings or group therapy) worked even fairly well for addiction, there would have been no need to come up with something else to treat it--but it didn't and doesn't. We don't treat ANY other legitimate disease this way. People with schizophrenia, bipolar disorder, clinical depression, etc--all brain chemistry disorders--may receive some therapy sessions but it is almost always in conjunction with MEDICATION, which does the actual work of repairing and restabilizing the brain. Why should addiction be treated differently--especially when it has been clearly shown that abstinence based treatment has an extremely low effectiveness rate for addicts and particularly for opiate addicts?

Anonymous said...

As a recovering IV addict for more than 35 years, I continue to be appalled by these guys who push needles, methadone maintenance, etc. with their well-meaning efforts to "help us." Thankfully, none of you were around when I got clean - only people who assured me that I could in fact get clean and live a happy life.

The expectation that people like me are largely unable to find lasting clean time undermines our chances - and makes the way for the "experiments" by psychiatrists and others - naltrexone, methadone (now at new and much high doses!), acamprosate - hell, the Chinese drill out our limbic system with a Makita.

The lie is exposed - we CAN recover.

Anonymous said...

I too am a recovering IV user. I had the experience of being on maintenance several times and also of doing 21 day methadone detoxes in California a few times. My experience when I was using was that every time the methadone kicked in, the urge for CRACK became overwhelming. My problem is that I am a drug addict who has an allergy to drugs. When I get drugs in my system I want more and more and more. There is not enough methadone in the world to make me happy, or to fix whats wrong with me. I could drink a ton of methadone and be close to death but still be crawling across the floor trying to find more drugs. It doesn't work for me. Recovery after many years of using and living the lifestyle was not easy, but it did get better, and the alternative was way worse. I am SO glad that I was introduced to a program of abstinence based recovery and that the system did not give up on me by relegating me to a methadone clinic for the rest of my life. I am also quite sure that my family, the courts and everyone else on the road is glad as well. Recovery has changed my life!

Anonymous said...

You are SPOT ON in describing the "study" practices of those who want the world to believe that methadone is a miracle. Thanks for stating it this way.

The belief that methadone maintenance has a higher success rate than abstinance-based treatments is another huge lie these people use. They want to compare the people taking methadone to the people who have tried abstinance, without holding the same goals for each method. The maintenance population as about a quarter of the success rate at remaining abstinant as the other group after leaving mmt.

I personally think that nearly every sample used in these studies has a bias, and it is meant to be that way. The people conducting these "studies" have something to sell, and I think people should keep that in mind. It's little more that advertising in a free market economy, IMO...

Dr Dave said...

Nice critical appraisal of another tired study that does not help move things on at all. I couldn't agree more that low expectations of what opiate addicts might achieve is fundamental in ensuring that they don't achieve more.

I'm a doctor who is also a recovering opiate addict. At no point was methadone suggested as a treatment choice (apart from detoxification). The expectation was that I would recover with the right sort (and duration) of treatment. Now I adopt the same high expectation of my heroin addicted patients. They get better and stay better in the main. Our service is filled with reovered addicts who infectiously pass recovery on to their peers. Okay, so my recovery capital is arguably much higher, but we can increase the chances of success with some simple interventions (linking into recovery communities, providing housing and employment solutions, giving aftercare and long term management plans which focus on the client self-managing). We do it. It works. People get better.

Gone, baby, gone

It appears that opium harvests greatly exceed demand for heroin and no one seems to know where the excess heroin is.

More sentencing sense

I mentioned drug courts in a recent post. Well, the NY Times is reporting on drug courts.

Highlights:

Clearly, the courts do not help everyone. One of the most successful programs is in New York State, where about 1,600 offenders are in adult drug courts. Studies found that while 40 percent dropped out of the program along the way, those who started it, including both dropouts and graduates, had 29 percent fewer new convictions over a three-year period than a control group with similar criminal histories and no contact with drug courts, Mr. Berman said.

In other regions, half or more of those who start the program do not finish. And recidivism rates for participants are reduced by about 10 percent to 20 percent, depending upon the quality of the judges and treatment programs, said John Roman, a researcher at the Urban Institute, based on a recent study.

An earlier review of 57 “rigorous” drug court evaluations around the country, led by Steve Aos of the Washington State Institute for Public Policy, found that recidivism was reduced on average by only 8 percent, but with wide variation.

Yet even that modest reduction in crimes and prison yields cost benefits. The report this year by the Urban Institute found that, for 55,000 people in adult drug courts, the country spends about half a billion dollars a year in supervision and treatment but reaps more than $1 billion in reduced law enforcement, prison and victim costs. A large expansion would yield similar benefits, the report argued.

But some scholars, like Mark A. R. Kleiman, director of the Drug Policy Analysis Program at the University of California, Los Angeles, remain skeptical about the potential and the achievements. He suggests, for example, that success rates of some courts may be inflated because they take in offenders who are not addicted and entered this track only to avoid prison. Dr. Kleiman advocates a slimmed-down system that does not initially require costly treatment, as drug courts do, but simply demands that offenders stop using drugs, with the penalty of short stays in jail when they fail urine tests. Such an approach has shown promise with methamphetamine users in Hawaii, he said, and because it is far cheaper, it can be applied to far more offenders.

I'd like Kleiman's proposal if what he describes is a "pre-drug court" that would step addicts up into a full drug court.

There's something exciting and troubling about drug courts and health professional recovery programs in the context of the addiction treatment system. Exciting because there are important ways that they are succeeding in implementing some chronic disease management elements, namely long term monitoring and swift reintervention when relapse happens or appears imminent. Troubling because it seems that we are only implementing these strategies with involuntary involuntary clients and other systems are the ones implementing these programs for their own ends. (Not that there's anything wrong with this. In fact, it's great that these systems are approaching these problems in this way. But it should be cause for concern that these other systems are pulling us in this direction rather than us leading the way.) These programs get to be considerably more directive with these patients--they HAVE to go to treatment, they HAVE to get regular drug testing, they HAVE to attend recovery support groups, etc.

There will be a whole new set of challenges with voluntary clients. I suppose we'll face the same challenges that cardiac care and diabetes programs face every day.

How methadone research works

Start with the premise that opiate addicts don't get well. (Unless they're doctors.)

Perform a study offering only two variations of your preferred treatment. (Cheap and crime reducing.) One is high dose or long duration and the other low dose or short duration. Do not offer a recovery oriented option at all, or offer a recovery oriented option of inadequate duration and intensity.

Find that, when offering 2 lousy options, the lousy option with the longer duration or higher intensity reduces symptoms better at follow-up.

Run a headline of, "Methadone Detoxification Remains No Match for Methadone Maintenance, Even with Minimal Counseling." In the comments, declare, "Methadone maintenance is the preferred treatment approach for heroin dependence."

Bonus: "No difference between groups was found for cocaine use or depressive symptoms."

Bonus bonus: "Results for MM with standard counseling (2 hours a month) did not differ from those for MM with minimal counseling (15 minutes a month)."

Question: Do you think this will be used to justify offering even less counseling to methadone recipients?

UPDATE: I got some grief on this post. Here's my response:

Five points:

• First, a question. If methadone is a superior treatment option, why don't they use it for opiate addicted health professionals? Health professionals have high rates of opiate addiction and typically receive long term treatment with monitoring that lasts several years. Treatment is stepped up or down as needed. Guess what? They have great treatment outcomes. You might be inclined to chalk it up to a population with lots of recovery capital. To be sure, that plays a role, but surely a real chronic disease management approach plays a role too. 
  
• Second, is it coincidence that this study was done on poor black men? Why aren't studies like this done on young adults from affluent communities?
  
• Third, methadone used to be one component of some comprehensive bio-psycho-social treatment programs. I understand that there are still some programs that fit this description, but every program in my area is a dosing clinic and little more.
  
• Fourth, regarding misery, notice that there was no difference in depressive symptoms. 
  
• Fifth, heroin addicts in our long term programs do just as well as everyone else. It's all about hope and expectations. Beware of the subtle bigotry of low expectations.
  

All I want is a day when addicts are offered recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose.

What's possible

One Colorado community is taking the bull by the horns and adopting a 0.25% sales tax to establish a community detox and treatment services.

By the numbers
Larimer County Issue 1A on the November ballot would levy a 0.25 percent sales tax - or 25 cents on a $100 purchase - to build a facility that would provide treatment for people with mental-health and substance-abuse problems. Below are preliminary figures tied to the proposal:

> $12.5 million: Cost to build the facility
> $5.8 million: Staffing costs for new programs
> $1.3 million: Staffing costs to expand existing programs
> $750,000: Annual medication costs
> $350,000: Annual maintenance and utilities costs
> 41,000 square feet: Size of the building
> 1,200: People who would be served each year
> 72: Staff

An impressive vision. This is a county of 250,000.

Drug Czar = pointless, feckless, hopeless

The post of Drug Czar has become the very model of a modern major waste of time--a pointless, ineffective, reactionary bureaucratic construction.

Maybe it will become a verb, as in, "I've been Drug Czarred!"

Rats, cocaine, memory and volition

From Scientific American:

Scientists know that addictive drugs can mess with the brain’s circuitry and hijack its reward systems, but a July 31 rat study in the journal Neuron shows that psychological factors may be more instrumental in causing these changes than a drug’s chemical effects are. Cocaine use triggers long-lasting cellular memories in the brain, the study found—but only if the user consumes the drug voluntarily.

A team led by Billy Chen and Antonello Bonci, both at the University of California, San Francisco, trained three groups of rats to press levers that delivered cocaine, food or sugar. The researchers injected cocaine into a fourth group. When they examined the rats’ brain tissue, they found an increase in synaptic strength within the reward center in those rats that had self-administered sugar, food or cocaine. These cellular memories were short-lived in the sugar and food groups, but in rats that had self-administered cocaine they persisted for up to three months after consumption had stopped. Most interestingly, the brains of rats that had consumed cocaine involuntarily did not show such imprints.

The findings illustrate that the pharmacological effects of cocaine alone are not enough to create reward-associated memories, Bonci says. “Instead the motivation for taking the drug seems to be a key component in the process as well.”

The team is working to find ways to remove the long-term cellular memory left by voluntary cocaine use, which eventually could help treat addiction in humans by taking away the desire to actively seek the drug, Chen says.

I posted on this before, but missed this important finding--that the rats involuntarily receiving cocaine did not develop these memory imprints.

This is weird. Kind of ironic that volition had to be exercised for the deterioration of volitional control.

Can lab rats become addicted through involuntary cocaine consumption? Or, they just won't develop these imprints? Also worth noting is that behavior extinction had no impact on these cellular memory imprints.

Brain scan skepticism

I've had a gnawing fear that the brain scan research of the last two decades that has been used to support the disease model will be discredited by some new innovation in technology, or the realization that everything lights up the brain like the scans we're frequently shown. (I don't believe this, but I worry about it from time to time.)

Good news. This article by a brain scan skeptic says nothing that concerns me.

Sentencing sense

The Washington Post reports that the U.S. Sentencing Commission is considering recommending some common sense on drug crime sentencing.

Astonishingly, the article fails to put the import of this in its proper perspective.









Given the state of American drug policy debates, drug courts seem to be the most pragmatic path to ending this insanity. There may come a day when we make more radical changes in drug policy, but, for the time being, drug courts balance concerns about public safety, drug control and the wanton incarceration of people whose primary crime is being an addict.

The future of treatment spending

Health Affairs looks at the future of substance abuse treatment spending. The future looks pretty grim:

Growth in SA spending is forecasted to average 5.0 percent between 2003 and 2014, slightly faster than the rate of 4.8 percent in the 1986-2003 historical period. Over the next decade, SA spending growth is expected to continue to increase at slower rates than MH health spending, mainly because pharmacotherapy, which has driven increases in MH spending, currently plays only a small role in SA treatment. This is expected to result in an SA share that falls from 1.3 to 1.0 percent of all-health spending. Moreover, growth in SA spending increases at a slower pace than growth in the economy, with the SA share of GDP falling slightly between 2003 and 2014.

Some of the analysis is already a bit dated, give the recent passage of parity legislation:

Historically, a dominating characteristic of private SA spending has been the lack of funding increases from private health insurance, which declined an average of 1.6 percent annually between 1986 and 2003. We expect private insurance SA spending growth to accelerate somewhat during the projection period--to 1.3 percent annually. However, actual spending in 2014 is anticipated to be below that estimated for 1986, and the private health insurance share of SA spending is expected to continue falling (from 10 percent in 2003 to 7 percent in 2014). Barriers to SA insurance coverage exist that are not present in medical/surgical coverage, including annual and lifetime limits for inpatient hospital stays and outpatient visits, and higher cost sharing through deductibles and coinsurance.

Specialty treatment settings are increasingly relied on as a share of spending, but, anecdotally, this makes no sense. Specialty treatment settings are disappearing and McClellan has documented the instability of the treatment system, including high rates of program closure. The definition for SSACs must be pretty inclusive.

Specialty SA centers (SSACs) have emerged as major providers in the delivery of SA treatment, with spending for their services increasing from 19 percent of SA spending in 1986 to a projected 42 percent in 2014. SSACs are multidimensional facilities that deliver services ranging from outpatient care to residential services. Programs can include those targeted to special populations (for example, people with HIV/AIDS or opiate addictions). SA spending on treatment in SSACs is forecasted to increase at a 5.3 percent average annual rate over the projection period, similar to the overall SA annual growth rate between 1993 and 2003.

Spending for SA hospital treatment fell from 48 percent of SA spending in 1986 to 24 percent in 2003, where the share is expected to remain in 2014. SSACs likely supplied the outpatient treatment venue for people who previously would have been treated in expensive hospital settings.

Parity has been passed since this paper was written and it's likely a lot more will change by 2013. It seems likely that some sort of universal coverage be enacted in the next 5 years and we can hope that decent addiction treatment will be covered.

Insite saves two to 12 lives a year, study says

Saving lives is important.

How many more lives would be saved adding recovery-oriented treatment on demand? How many more lives would be restored? Is Insite lobbying for the addition of these services?

It doesn't have to be either/or. It can be both/and.

Rhythms of despair

Provide poor/inadequate abstinence-oriented treatment ==>

Poor prognosis: client fails ==>

Conclusion: these people can't recover ==>

Organize treatment system and research around belief that addicts won't recover ==>

Public and helpers despair at the impotence of the system ==>

They look to research for answers, but research is organized around the assumption that addicts can't recover ==>

They reject the treatment system and the addict:

Street drugs are a lifestyle choice. Being a taxpayer is not; and it is harder to be tolerant of the rotten choices of others when one's hard-earned money is spent subsidizing them long-term.

The latest in harm reduction

Email goggles.

Some unknown circle of hell

The Washington Post runs a heartbreaking account of a parent trying to get help for Nicole, her heroin addicted daughter. Well worth the time to read.

Parity will mean that families with insurance will be able to access treatment but the insurer will implement restrictive protocols for accessing more expensive forms of treatment, like inpatient and residential.

[via dailydose.net]

Win the drug war?

Margret Kopala argues that the war on drugs is working. She points to a recent U.N. report, alcohol prohibition in the U.S., and Sweden's drug policy.

No doubt prohibition reduces drug use. The important question is, at what cost? We decided that the costs of alcohol prohibition were greater than our commitment to it could sustain.

The cost for the current drug war in the U.S. is high. I'm not an advocate of legalization, but any sensible person has to ask questions like:

• How can we mitigate the human costs associated with the war on drugs?
  
• What are we not doing, because we're investing enormous capital and energy in the war on drugs?
  
• Are there other strategies that might be effective in trying to achieve our goals?
  
• Are our goals realistic?
  

Further, Ms. Kopala resorts to characterizing supporters of harm reduction as part of a medical industrial complex. This suggests that HR advocates operate from bad motives. I disagree with many of them vigorously on many issues, but in most cases, their motives are good. (Just as advocates of recovery oriented systems of care are not zealots, pleasure police or motivated by moral panic.) However, their motives are rooted in an ideology that harms addicts in some ways (By lowering expectations and nurturing pessimism about prospects of recovery.) and has benefited addicts in other ways (Challenging the rest of us to work with active addicts, pay more attention to preventing illness and lower thresholds to receiving help.).

She's be more persuasive if didn't ascribe bad motives to those on the other side of the argument. Also, I get the impression that Sweden's policy has been successful. What are the challenges in replicating this policy elsewhere? What are the initial steps? Rather than tossing it off as a defense of the drug war status quo, how do we get there?

UPDATE: A reader appropriately took me to task for overlooking this

Nils Bejerot ... challenged the view ... that addiction was a health problem. ... Bejerot's argument that addiction was a learned behaviour made possible by the availability of drugs, time, money, user role models and a permissive ideology. This behaviour could be "unlearned," he said ...

She's right. It's absurd. Ideology is a problem on both sides of the street. It'll be nice when we manage to beyond this false dichotomy.

More on stigma

Addiction Inbox isn't buying SAMHSA's positive spin either.

Parity passes

Parity finally passed both branches of congress and was signed into law by the President.

This is a good and important step. Health Affairs explains what this means, what will happen next and what still needs to happen:

A thoughtful essay by Audrey Burnam and José Escarce in an earlier volume of Health Affairs contends that the debates around parity in insurance benefits are the latest manifestations of a longer-standing policy issue regarding equity of mental health care relative to general medical care. These authors argue that in an era of managed care, benefit parity is an insufficient mechanism for ensuring equity for those with a mental illness.26 Put another way, full benefit parity is an important "sequential" step toward the broader goal of ensuring that persons with a mental illness or addiction have the same opportunities for seeking and receiving appropriate treatment as those with a physical illness.

Importantly, a sequential approach to promoting treatment equity implies a recognition that full parity resolves some, but far from all, obstacles to access and use of appropriate services among persons with mental and addictive disorders. On the supply side, full parity generally indicates a nominal expansion of benefits. However, parity also has yielded increased management of care, and such management can be differentially applied in ways that produce unequal treatment opportunities (through either initial access or intensity and/or duration of services) for those with psychiatric versus general medical conditions. On the demand side, full parity results in the removal of arbitrary and inequitable limits to treatment. However, removal of these limits under parity may have little effect on the concomitant stigma that keeps many who need mental health and substance abuse services from seeking such care. In short, legislating full parity will promote, but not achieve, treatment equity for those with mental and addictive disorders. Nevertheless, without such action, the goal of equity will continue to remain elusive.

Recovery and stigma

SAMHSA did a survey of attitudes toward addiction and recovery. The press release paints a very optimistic picture, but the full report tells me that we have a long way to go.

30% of respondents said they'd think less of a friend with a drug problem and 18% said they'd think less of a friend in recovery. 66% said that they would be comfortable being friends with someone in recovery, 63% would be comfortable working with someone in recovery and 57% would be comfortable living next door to someone in recovery.

I'm not sure how to feel about this, but I suspect we're supposed to be thrilled. I don't find it very encouraging. Polls about attitudes toward gay people offer more optimistic numbers for gay rights activists and they still face considerable stigma and ballot initiatives in every election cycle.

I understand that this kind of process is important, but I sort of resent people even being asked whether they are comfortable with me. I don't really care if they're comfortable with me. What I do care about is whether they are willing to extend community help and support to the addict who is still suffering. Clearly, we're not there.

I also want to normalize recovery just as much as the next guy, but I'm a little worried that our advocacy of recovery may inadvertently reinforce stigma against active addicts by emphasizing, "We're in recovery! You have nothing to fear from us." As a person in recovery, I don't need anyone's acceptance and I wonder if promoting recovery is really the best way to soften attitudes toward active addicts.

Some of the more troubling findings included that about 40% respondents believe that addicts and alcoholics had only themselves to blame and 42% believe that illicit drug addicts can't recover.

I'm not sure what to make of the prevention attitudes. I suspect SAMHSA finds them encouraging, but I assume that they are more symptomatic of the belief that addiction has a lot to do with a person "losing their way", "getting hooked", or falling in with the wrong crowd."

One more question (to add to the meandering nature of this post). How might current efforts to define "recovery" in a specific, yet inclusive way, affect social attitudes toward addicts?

Okay, another question. Are the motivations to include non-abstinent addicts as "recovering" inclusive compatible with neurobiology and the stigma reduction agenda?

Pre AA abstinence

More evidence that people with more severe alcohol problems benefit most from AA (from the firewalled full text):

The current findings support the hypothesis that 12-step self-help group attendance is most beneficial for patients who have not achieved abstinence. Specifically, among patients who had not achieved abstinence 1 year after treatment, those who attended 12-step self-help groups relatively frequently (10 meetings or more in a 3-month interval at year 1) were significantly more likely to be abstinent at long-term follow-up than were those who either did not attend self-help groups or attended them less frequently. In contrast, among patients who were abstinent at 1-year follow-up, those who did not attend 12-step self-help groups (or attended only infrequently) were about as likely to be abstinent at long-term follow-up as those who attended self-help groups relatively frequently.

A similar pattern of results emerged for improvement in SUD-related problems. Patients who were non-abstinent at 1 year and attended 12-step self-help groups relatively frequently in the first year improved significantly more than did non-abstinent patients who did not attend self-help groups. Patients who were abstinent at 1 year showed similar improvement regardless of whether they attended self-help groups more or less frequently. Thus, the overall influence of 12-step self-help group attendance was consistent for abstinence and for substance use problems. Importantly, the benefits of attending 12-step self-help groups for non-abstinent patients did not appear to be due to self-selection; this finding generalized across two large samples of patients.

...

These findings are consistent with the idea that a continuing SUD intervention is likely to have a stronger influence on individuals with more severe than on those with less severe continuing problems. In this regard, high levels of self-help group participation were more closely related to better 6-month outcomes among patients with more severe substance use problems than among those with less severe problems (Morgenstern et al., 2003). Similarly, AA attendance had a stronger positive influence on alcohol-related outcomes for outpatients in Project MATCH who had high-network support for drinking than for those with low-network support for drinking (Longabaugh et al., 1998 R. Longabaugh, P.W. Wirtz, A. Zweben and R.L. Stout, Network support for drinking, Alcoholics Anonymous, and long-term matching effects, Addiction 93 (1998), pp. 1313–1333. View Record in Scopus | Cited By in Scopus (84)Longabaugh et al., 1998).

Makes sense, no? AA has always claimed to be one solution for people who are unable to achieve abstinence, right?

More on the grim neurobiology of early drinking

Previous studies have begged the question, Alcoholism: Clinical & Experimental Research has a study that attempts to provide an answer:

"The key finding of this study was that people who started drinking before age 15, and to a lesser extent those who started drinking at ages 15 to 17, were more likely to become alcohol dependent as adults than people who waited until 18 or older to start drinking," said Dawson. "Past studies have often suggested that this association might result from common risk factors predisposing people to both early drinking and AUDs. Although the current study does not provide conclusive evidence that early drinking directly increases AUD risk, it suggests that it is premature to rule out the possibility of such a direct effect."

"By controlling for a variety of confounding risk factors in their analysis, Dawson and colleagues were able to demonstrate that ... early alcohol consumption itself, as a misguided choice or decision, is driving the relationship between early drinking and risk for development of later alcohol problems," observed Moss.

Tobacco regulation

The Washington Post makes the case for FDA regulation of tobacco:

The FDA regulates everything from vegetables to Viagra. But cigarettes, which lead to some 400,000 deaths in the United States each year and shorten a smoker's life by 10 years on average, have somehow escaped oversight. As a result, tobacco companies don't have to divulge the ingredients in their products. They also don't have to disclose the levels of nicotine in their cigarettes. This means they can label their products as "light" or "low tar" with few restrictions; smokers have no way of knowing whether such claims are true. The bill would prevent cigarette companies from using such labels. It would also curb cigarette advertising and forbid fruit-flavored cigarettes intended to lure new smokers. The legislation would fund a new program within the FDA to oversee Big Tobacco by imposing a user fee on cigarette companies.

And the specious arguments of opponents:

The bill's critics, including the Bush administration, say that FDA regulation could trick consumers into thinking cigarettes are approved by the agency. But a provision in the legislation would prohibit Big Tobacco from perpetuating such a misunderstanding.

Puhleaz!

Also, remember the post last week suggesting a tobacco sales ban in pharmacies? Well, Phillip Morris unsuccessfully fought such a ban in San Francisco.

Tobacco and pharmacies

Disease management care blog suggests that pharmacies should stop selling tobacco. Makes sense to me.

Nicotine delivery

I just stumbled upon these two nicotine delivery systems. (The WHO is alarmed about one of them.)

When reading about them, I couldn't help but think of Bill White's lecture on drug trends when he made this point:

The hypodermic syringe offers an interesting case study in innovation. This new instrument arrived with the promise to reduce morphine addiction by requiring smaller amounts of morphine via injection compared to oral use. But this new technology turned out to be a Trojan horse that would alter the history of addiction in unforeseen ways.

He also referenced the innovation of "rocking" cocaine with baking soda and offered a warning something to the effect of, "I can't tell you what the major drugs of abuse of tomorrow will be. But I can tell you that they are already here and that someone will discover a new way to use them."

I was about to write that it was hard to imagine nicotine as a major drug of abuse, but then realized how blind I can be to the fact that it is a major drug of abuse. At any rate, it's hard to imagine nicotine being used the way that heroin, cocaine and other illicit drugs are used but maybe with a new method of administration and in conjunction with another drug? 

Maybe. Maybe not. But I am convinced that Bill White is right--there are other trojan horses coming.

9 types of drinkers

I'll note that the article does not use the the words alcoholic or dependence, so it's intent may be limited to categorizing alcohol abusers, but it feels like the latest iteration of the psychogenic model of addiction.

Parity update

The platforms of both political parties endorse some form of parity, though the Republican platform does not specifically include access to addiction treatment. 

To be honest, I've grown a little weary of the struggle for parity. It's been 7 years since George Bush indicated that he'd sign parity legislation. For years, there have been enough votes to pass legislation but the Republican leadership refused to allow a vote.  Now the Democrats have been in power for more than a year and a half and we've watched it stall with nearly weekly advocacy calls for supporters to contact their legislators.

A parity law will be an important milestone, but it's clear that it does not mean that there will suddenly be easy access to care. Insurers will implement tight managed care protocols and, practically speaking, things may not be very different. Parity does not equal equity. This will be the next long struggle.  

Here's an overview of mental health parity I wrote several years ago.

More on Earth and Fire

Mark Keiman and Jacob Sullum have posted their responses to the Erowid argument for legalization.

Nothing too interesting. Kleiman does close with this:

We could reduce violence and drunken driving by raising alcohol taxes [Cook 2007, Cook forthcoming], we could shrink the illicit drug markets and reduce recidivism by using drug testing and swift, automatic, and mild sanctions to force probationers to stop using expensive illicit drugs [Kleiman 1998, Hawken and Kleiman 2007, Schoofs 2008], and we could break up street drug markets, thus protecting neighborhoods, with low-arrest drug crackdowns [Kennedy 2008, Schoofs 2008].

Inmates running the asylum...

Unsurprising FDA/drug company incest:

It seems that the Food and Drug Administration turned to “a non-profit run by a pharmaceutical industry advertising consultant to help design its new campaign to educate consumers about direct-to-consumer drug advertising. The FDA’s recently launched website, “Be Smart About Prescription Drug Advertising: A Guide for Consumers,” was developed by EthicAd, a non-profit run by Michael Shaw out of the offices of Atlanta-based Shaw Science Partners. Shaw’s firm claims credit for having helped launch over 25 pharmaceuticals, including Viagra, Celebrex, Zoloft, Cymbalta, and Rezulin, which was later withdrawn from the market because of safety concerns.”

All twelve step faciliation is not equal

Not a surprising outcome if you know much about twelve step facilitation:

Important findings from the current investigation of the relationship between services received and outcomes of chemical dependency treatment were that higher participation in optional or extracurricular 12-step meetings was associated with better treatment outcomes, whereas curricular involvement in 12-step groups (i.e., groups required as part of treatment) showed no association with treatment outcomes.

Get people to meetings does not necessarily equal connecting them with the community. All meetings are not equal. Getting them to a meeting where a thriving, welcoming community of recovery is essential for effective twelve step facilitation. It takes a kind of recovery cultural competence to effectively attend to these matters.

Other findings:

• ...weak effects for supplemental psychiatric, family, medical, and legal services: We found null associations between delivery of these services and the odds of 6-month sobriety across the board.
  
• The study also found associations between participation in sober recreational events at 2 and 4 weeks and better treatment outcomes at 6 months
  

Finally, another finding emphasizes the importance of recovery-oriented services, rather than treatment-oriented services:

We found that residential participants showed higher participation in curricular 12-step meetings at 2 weeks, relative to day-hospital participants and as expected; however, this effect was not maintained throughout follow-ups, and residential participants actually showed relatively lower rates of extracurricular 12-step meeting attendance and working with a sponsor through 4 weeks. These latter differences may be the consequence of residential clients' tightly scheduled time, intensive involvement in curricular 12-step meetings, and/or restrictions on leaving the treatment site.

Initial treatment focus

No difference in drinking, depression or retention for depressed alcoholics treated with cognitive behavioral therapy or twelve step facilitation.

Trauma, addiction treatment and iatrogenic harm

A frequent concern about trauma-focused models is the fear of iatrogenic harm. This study found that Seeking Safety didn't lead to adverse events. It's worth noting that Seeking Safety is a pretty low intensity approach emphasizing psychoeducation and coping skills.

When hope is lost...

...isolate the afflicted.

Responsible use not a foundation for policy

Oops. I was wrong in yesterday's post about responsible drug use. Jonathon Caulkins is from RAND, not Cato, and has posted a response to yesterday's Erowid post on responsible drug use at Cato Unbound. He starts off by identifying and challenging one of the underlying values:

The Erowids assert that “Modern humans must learn how to relate to psychoactives responsibly, treating them with respect and awareness, working to minimize harms and maximize benefits, and integrating use into a healthy, enjoyable, and productive life.” Most of that assertion is innocuous. Psychoactives are ubiquitous when the term is used so broadly as to include even caffeine. However some are quite dangerous, so as a class they should certainly be treated with respect. And working to minimize harms and maximize benefits is unobjectionable in most endeavors.

What distinguishes the Erowids is their assertion that modern humans must integrate psychoactive use into life. Apparently from their perspective, choosing abstinence, at either the individual or societal level, is inherently inconsistent with being modern.

Denying or denigrating an individual’s right to choose temperance is an extreme position not worth engaging.

He goes on to make the case for prohibition without being supportive of American prohibition:

While avoiding a full rehash of the by-now dull legalization debate, two points bear mention. First, American drug policy is easy to criticize as intrusive, ineffective, and mean-spirited. However, it does not follow that prohibition is necessarily a bad policy. Essentially every country in the world prohibits production and distribution of cocaine, crack, heroin, and methamphetamines for recreational use, even legalizers’ poster child, the Netherlands. Most affluent industrialized countries take a far less aggressive approach to their prohibitions than the United States does, yet they maintain prohibitions nonetheless. The problems with America’s prohibition stem primarily from particulars of its implementation, not from prohibition per se.

Second, the challenge is not in criticizing prohibition, but designing something better. To their credit, the Erowids offer specific suggestions in their “Fundamentals of Responsible Psychoactive Use.” I am skeptical that they constitute a practical framework for social policy, as distinct from being useful guidelines for individuals who choose to use psychoactive drugs. Note, though, that nothing about American alcohol policy precludes application of these principles. So if their advocates are successful in taming the rather considerable problems with legal alcohol, then I would take more seriously claims about the Principles’ universal efficacy with respect to all psychoactives, including, say, methamphetamine.

He then goes on to distill the issue to its most fundamental question:

What are the risks of trying the big four illegal drugs (marijuana, methamphetamine, cocaine—including crack—and heroin)? Statistics vary by drug, age of first use, and other variables, but among the myriad patterns of drug use, four are common: (1) limited experimentation, (2) ongoing controlled use, (3) ongoing use that is mostly controlled but punctuated by occasional abuse, and (4) escalation to dependent use.

...

To grossly simplify, about half of people who try illegal drugs stop with experimentation, and one in six end up in each of the other three categories (controlled use without and with occasional abuse and dependence). The proportions are slightly more favorable for those who only try cannabis, but less dramatically so than one might expect. At any given time, five times more people are dependent on marijuana than are incarcerated for drug-law violations, and the lifetime risk of abuse or dependence for cannabis use is on the order of one in ten.[1]

No one knows how legalization would change these probabilities. The Erowids might argue the risks would go down, particularly if their principles were applied. I would argue the opposite. The drugs would be cheaper, more easily available, and (likely) marketed aggressively; and their use would be less costly in terms of risk of arrest, loss of employment, and social approbation. In short, there would be fewer external constraints on use, and more frequent and heavier use increases the risk of dependence. For the sake of argument, let’s stick with the figure of a one-in-six risk that trying a drug will lead to dependence and associated harms.

Does society have a right to “protect” its citizens from a one-in-six risk of dependence, even though that “protection” denies five times as many people legal access to something pleasurable?

Early misuse of painkillers leads to addiction?

More research suggesting that opiate addiction can be aquired by early exposure:

No child aspires to a lifetime of addiction. But their brains might. In new research to appear online in the journal Neuropsychopharmacology this week, Rockefeller University researchers reveal that adolescent brains exposed to the painkiller Oxycontin can sustain lifelong and permanent changes in their reward system – changes that increase the drug’s euphoric properties and make such adolescents more vulnerable to the drug’s effects later in adulthood.

The research, led by Mary Jeanne Kreek, head of the Laboratory of the Biology of Addictive Diseases, is the first to directly compare levels of the chemical dopamine in adolescent and adult mice in response to increasing doses of the painkiller. Kreek, first author Yong Zhang, a research associate in the lab, and their colleagues found that adolescent mice self-administered Oxycontin less frequently than adults, suggesting that adolescents were more sensitive to its rewarding effects. These adolescent mice, when re-exposed to a low dose of the drug as adults, also had significantly higher dopamine levels in the brain’s reward center compared to adult mice newly exposed to the drug.

Gut-busters? New to me.

Jane Brody makes the case that local policies and alcohol sales practices are important contributors to binge drinking:

The Harvard School of Public Health College Alcohol Study, which began in 1993, has identified several environmental and community factors that encourage binge drinking. Dr. Wechsler, who directed the study, said in an interview that high-volume alcohol sales, for example, and promotions in bars around campuses encourage drinking to excess.

“Some sell alcohol in large containers, fishbowls and pitchers,” he said. “There are special promotions: women’s nights where the women can drink free; 25-cent beers; two drinks for the price of one; and gut-busters, where people can drink all they want for one price until they have to go to the bathroom. Sites with these kinds of promotions have more binge drinking.

“Price is an issue,” he added. “It can be cheaper to get drunk on the weekend than to go to a movie.”

Although it is a college’s duty to educate students about the effects of alcohol and the risks of drinking too much, “education by itself doesn’t work,” Dr. Wechsler said. “You must attack the supply side as well as the demand side.”

More than half the alcohol outlets surrounding colleges that participated in the Harvard study offered promotions with price discounts, and nearly three-fourths that served alcohol on the premises had price discounts on weekends.

The study found that the sites of heaviest drinking by college students were off-campus bars and parties held off-campus and at fraternity and sorority houses.

However, community policies and business practices can be just as critical in reducing binge drinking:

Community measures that helped to curtail binge drinking during the eight-year course of the study included a limit on alcohol outlets near campus, mandatory training for beverage servers, a crackdown on unlicensed alcohol sales and greater monitoring of alcohol outlets to curtail under-age drinking and excessive consumption by legal drinkers.

What would "responsible" drug use look like?

The keepers of Erowid offer a document advocating responsible drug use, primarily as a tool for achieving spritiual enlightenment.

They make some pretty provocative assertions about the state of American culture with respect to psychoactive substances:

Many people would agree that drug culture reform is needed, but we must recognize that “the drug culture” now includes everyone. Modern life involves daily decisions about psychoactives. The option of caffeine use is encountered multiple times a day. It is rare to watch an hour-long television show without seeing an advertisement for a mind altering pharmaceutical or a legal recreational drug. Late night coverage of the 2008 Summer Olympics was sponsored by Ambien, a popular sleep aid with memory-scrambling side effects whose commercials enticed audiences nationwide with comforting images of dreamy, refreshing, sedative-assisted sleep. A large portion of the population is exposed to the possibility of taking LSD, even if only 10-20% ever try it.[11,12] In today’s world, everyone must choose how they relate to innumerable psychoactive drugs. Whether or not one decides to use a specific drug, that decision should be made with skill, knowledge, and self-awareness, supported by accurate information.

And offer some fundamentals for responsible drug use:

Investigate the health risks and dangers of the specific psychoactive and of the class of drugs to which it belongs.


Learn about interactions with other recreational drugs, medications, supplements, and activities.


Review individual health concerns, predispositions, and family health history.


Choose a source or product carefully to help ensure correct identification and purity


(avoid materials with an unknown source or of unknown quality).


Know whether the drug is likely to reduce the ability to drive, operate equipment, or pay attention to necessary tasks.


Take oneself “off duty” from responsibilities that might be interfered with (job, child care, etc.), and arrange for someone else to be “on duty” for such responsibilities.


Anticipate reasonably foreseeable risks to oneself and others and employ safeguards to minimize those risks.


Choose an appropriate occasion and location for use.


Select and measure dosages carefully.


Begin with a low dose until individual reactions are known and thereafter use the minimum dose necessary to achieve the desired effects: lower doses are safer doses.


Reflect on and adjust use to minimize physical and mental health problems.


Note changes in health over time that may be related to use.


Modify use if it interferes with work or personal goals.


Check in with peers and family and accept feedback about one’s use.


Track reactions to specific drugs and dosages in order to avoid repeating mistakes.


Seek treatment if needed.


Decide not to use when the time isn’t right, the material is suspect, or the situation is otherwise problematic.

The also, appropriately, take the US governemtn to task for dishonesty in reporting the potential consequences of drug use:

While the quality of government-sponsored sources has improved over the last decade, sites such as Freevibe.com, a youth-oriented website funded by the federal government, still include laughable exaggerations like “heart and lung failure“[27] as a general effect of hallucinogens—a deceptive claim they have made for more than eight years. Scientific literature reviews on the most common hallucinogens do not support their claims; most recently, Johns Hopkins researchers found that, “hallucinogens generally possess relatively low physiological toxicity and have not been shown to result in organ damage.”[28] Once people realize that a source is deceptive, as is the case for those teens visiting Freevibe who know someone who has tried LSD or psilocybin-containing (”magic”) mushrooms, they will be inclined to distrust all information from that source.

But what about groups like NORML? Is their information accurate? Do they engage in conduct that reports irresponsible drug use? Why focus exclusively on the ONDCP?

They focus heavily on psychedelics and argue that many users report benefits. What about cocaine and opiates? They really believe that adolescents should be supported in intentional responsible drug use? What are the potential consequences of this? Who can not engage in responsible drug use? Addicts? Pre-adolescents? Who else? They seem to dodge the more difficult questions.

They will have responses from Jacob Sullum, Robert Kleiman and another CATO (libertarian) fellow. I look forward to Kleiman's response.

Parachutes revisited -- Where's the evidence?

Satire of evidence-based medicine from BMJ:

What is already known about this topic

• Parachutes are widely used to prevent death and major injury after gravitational challenge
• Parachute use is associated with adverse effects due to failure of the intervention and iatrogenic injury
• Studies of free fall do not show 100% mortality

What this study adds

• No randomised controlled trials of parachute use have been undertaken
• The basis for parachute use is purely observational, and its apparent efficacy could potentially be explained by a "healthy cohort" effect
• Individuals who insist that all interventions need to be validated by a randomised controlled trial need to come down to earth with a bump

This is really funny stuff. Check this out:

One of the major weaknesses of observational data is the possibility of bias, including selection bias and reporting bias, which can be obviated largely by using randomised controlled trials. The relevance to parachute use is that individuals jumping from aircraft without the help of a parachute are likely to have a high prevalence of pre-existing psychiatric morbidity. Individuals who use parachutes are likely to have less psychiatric morbidity and may also differ in key demographic factors, such as income and cigarette use. It follows, therefore, that the apparent protective effect of parachutes may be merely an example of the "healthy cohort" effect.

And this:

It is often said that doctors are interfering monsters obsessed with disease and power, who will not be satisfied until they control every aspect of our lives (Journal of Social Science, pick a volume). It might be argued that the pressure exerted on individuals to use parachutes is yet another example of a natural, life enhancing experience being turned into a situation of fear and dependency. The widespread use of the parachute may just be another example of doctors' obsession with disease prevention and their misplaced belief in unproved technology to provide effective protection against occasional adverse events.

[hat tip: Freakonomics]

Recovery management

I recently had a conversation about disease management that got me very curious about what could be translated into recovery management. 

This person is involved in implementing pay-for-performance programs for primary care physicians. In the area of disease management, they are piloting a couple of programs for diabetics and cardiac disease. They are providing some diabetic patients with glucometers and cardiac patients with automated blood pressure cuffs. Nothing new about that, right? Here's what's innovative about them. These devices will transmit information to their medical record at their doctor's office. It will transmit the results of the test or transmit that the test was not completed. The doctor can call the patient in for a visit or testing if there is a concern, they can opt to skip a visit and just call in refills if everything is going smoothly, they can monitor compliance, they can also get a better sense of how various protocols are working with all of this additional information. 

Are there similar methods that we could employ in recovery management? What do you think?

A Sea Change in the Treatment of Alcoholism

More on recovery in a tribal community:

"Factors Associated with Remission From Alcohol Dependence in an American Indian Community Group," by Gilder et al. (1) is a well designed and carefully implemented study that provides valuable new information for American Indian communities but also for society at large. Perhaps the most salient finding is the relatively high rate of 6-month remission: 59% in an ethnic group whose remission rates 25 years ago ranged from 0% to 21% (2–4). Another study recently revealed a 41% 1-year full remission in 199 American Indian people with substance use disorder, confirming the salutary finding of Gilder and coworkers (1).

What has occurred over the last few decades in Native American communities to permit such a dramatic change? One factor lies in leadership: many tribal leaders have identified substance abuse as a major social and health problem (5). The fact that Gilder and coworkers could carry out such a study in Indian communities today bespeaks this critical political change. Second, many American Indian professionals and researchers have devoted their efforts to eliminating substance abuse from American Indian lives and communities (6, 7).

Upon reading this, the metaphor of the Healing Forest immediately came to mind. It also speaks to the potential of the recovery management approach.

This fifth principle, by affirming the inextricable link between personal health and community health, calls upon the addiction treatment agency and the addiction counselor to become actively involved in the communities within which their clients reside or to which they identify.

This person-community link is being conveyed to Native communities across the country within the cultural model of the Healing Forest. When a sick tree is removed from diseased soil, treated, and returned and replanted in the same diseased soil, it gets sick again. What is called for instead is a healing of the tree AND the replacement of diseased elements in the soil with nurturing elements (Red Road to Wellbriety, in press). Personal recovery flourishes best in a climate of family health, cultural vitality, political sovereignty, and economic security. What White Bison and other Native recovery advocacy organizations are trying to do is mobilize all segments of Native communities - the tribal councils, schools, churches, service programs, and political and cultural organizations - to forge and then actualize a healing vision for the community. The goal is to create a Healing Forest that creates a synergy between personal and community wellness. Such a synergy is reflected in the words of Andy Chelsea, who as the Shuswap tribal chief at Alkali Lake, declared, "The community is the treatment center" (Abbott, 1998).

Recovery in a tribal community

Interesting findings from a study of remission from alcoholism in a Native American community:

A surprising and novel finding of this study is that self-reported depression and anxiety symptoms do play a significant role in increasing and decreasing, respectively, the likelihood of remission. These are not depression and anxiety symptoms occurring in the context of alcohol withdrawal, because a similar question asking whether withdrawal had ever caused depression or anxiety symptoms did not appear in the final logistic regression model. Why self-reported depression and anxiety caused by drinking should be significantly associated with remission, especially in light of the absence of association of independent or substance-induced anxiety and affective disorders with remission, is unclear. It may be that insight about the nature of the relationship between drinking and depression and anxiety is a critical element in promoting or inhibiting remission. Why self-reported alcohol-induced depression would increase while self-reported alcohol induced anxiety would decrease the likelihood of remission is also unclear. The former is consistent with findings that insight promotes increased compliance with treatment and remission of other psychiatric disorders (37–39). The latter is consistent with the hypothesis that individuals with alcohol dependence and alcohol-induced anxiety symptoms are more likely to continue drinking, perhaps as a means to self-medicate those symptoms. Both raise the possibility that education about the depression and anxious effects of alcohol and alternative ways of dealing with anxiety symptoms that accompany alcohol dependence may have an important role in treatment and community prevention programs in this high-risk population.

We also tested whether factors associated with remission of alcohol dependence were also associated with the survival of alcohol dependence. Two factors significantly associated with remission (being married and having self-reported depression symptoms from drinking) were also significantly associated with a shorter duration of alcohol dependence, and two factors associated with nonremission (continuing to drink despite medical problems and having self-reported anxiety symptoms from drinking) were also significantly associated with a longer duration of alcohol dependence. Advancing age and younger age at onset of alcohol dependence were both associated with increased likelihood of remission. However, both advancing age and younger age at onset of alcohol dependence were associated with increased duration of alcohol dependence. These data are consistent with previous findings in this group that alcohol dependence runs a typical clinical course that includes duration as well as symptom profile (3). These data are not consistent with the notion that, from the standpoint of remission, there may be two groups of alcohol-dependent individuals: those with early onset who have a shorter course of alcoholism and those with later onset who have a longer course, which has been suggested for other populations (16, 40).

This is a study of a specific population and may not be tranferable to other groups of alcoholics. The finding is not shocking if you've read this blog.

The article offers other interesting and hopeful findings:

In this study, the rate of 6-month full remission from DSM-III-R alcohol dependence with 1-month clustering of 59% is comparable to the U.S. epidemiological rate of 1 year prior to past year, full remission from DSM-IV alcohol dependence of 48% (14), the 1-year partial remission rate of 64% in a German representative population sample (17), and the 1-year full remission rate from alcohol abuse and dependence of 53% found in Ontario, Canada (16). Despite the high rate of 1-month clustered DSM-III-R alcohol dependence of 49% in this group, the rate of full remission is comparable to studies of predominantly European ancestry populations.

Several factors associated with full remission in this American Indian group are consistent with factors associated with full remission in the general U.S. population. Our findings are consistent with the findings of Dawson and colleagues (14) that abstinent and nonabstinent recovery in the general U.S. population are associated with female gender, increasing age, and being married, but not with tobacco use, dependent use of illicit drugs, and having any lifetime anxiety or affective disorder. Our findings are also consistent with Schuckit and colleagues (30), who found that episodes of 3-month abstinence in a mixed treatment and nontreatment group were associated with female gender, older age, ever having been married, and younger age of onset of alcohol dependence, but not with a primary diagnosis of antisocial personality disorder.

Increasing likelihood of remission with advancing age in this American Indian group is consistent with the "aging out" phenomenon described in the Navajo (5, 23). Why "aging out" occurs in American Indians and other ethnicities is unclear. Alcohol dependence may biologically run its course in a proportion of alcohol dependents, and/or the accumulating psychosocial burden of alcohol dependence may prompt increasingly successful attempts at cutting back on drinking. In addition, as age advances, individuals with alcohol dependence, as well as those without, may develop new work, social, and family networks (19) that play a role in reducing drinking. The consistent association of remission with marriage (14, 18, 36) suggests that the social support and limit setting that can come from a spouse are important factors in promoting remission.

Does this suggest that the high prevalence in tribal communities may be due to multiple pathways to addiction (not just genetic vulnerability) and that there may be multiple types of alcoholism at play? I'm not sure.  Maybe. This will be interesting to watch.

What makes nicotine so addictive?

There may be a very good reason why coffee and cigarettes often seem to go hand in hand. 

A Kansas State University psychology professor's research suggests that nicotine's power may be in how it enhances other experiences. For a smoker who enjoys drinking coffee, the nicotine may make a cup of joe even better. 

And that may explain why smoking is so hard to quit. 

I wonder if this will offer an answer to some of my questions about nicotine. 

I'm not sure. Some of this just doesn't sit well with me:

"The big picture is trying to figure out why people smoke," Palmatier said. "There are a lot of health risks, and the majority of smokers already know what they are. They want to quit but can't. It's not because nicotine is a potent drug; it doesn't induce significant amounts of pleasure or euphoria. Yet, it's just as difficult if not more difficult to quit than other drugs."

At K-State, Palmatier studies rats that are allowed to self-administer nicotine by pushing a lever. The main source of light in their testing environment shuts off when the rats earn a dose of nicotine. After about a minute, the light comes back on to signal that more nicotine is available.

By manipulating this signal, Palmatier and his colleagues found that the rats weren't really that interested in nicotine by itself.

"We figured out that what the rats really liked was turning the light off," Palmatier said. "They still self-administered the nicotine, but they took more of the drug when it was associated with a reinforcing light."

Palmatier and colleagues published a paper on their research in the August issue of Neuropsychopharmacology.

Palmatier has begun looking at how rats respond to sweet tastes after having nicotine. He said preliminary results show that nicotine has comparable effects on sweet tastes. That is, rats respond more for sugar-water solutions after getting nicotine.

"The taste aspect is really important because we can actually figure out how nicotine is increasing the subjects' behavior," Palmatier said. "If it makes a reward more pleasurable, then it may increase the palatability of a sweet taste."

If so, it would have to be soley on  a neurobiological level because on an oral taste level, because nothing tastes better with a cigarette.

I love Jesus, but I drink a little

A little comic relief:

[hat tip: Jim]

Alcohol

What do you do with the information provided in these two stories? I'm sure some will say that better education of potential binge drinkers and youth are the key, others will say that condoms should be available for free at bars and liquor stores. I'm not too optimistic.

It seems to me that problems like this are unlikely to be addressed without facilitating some kind of culture change related to alcohol mores. That our nation's largest prevention program is the designated driver campaign says something about how much we value drinking doesn't it? We don't tell people not to get drunk. We tell them to go ahead and get drunk, just don't drive. The campaign is constructed to protect something our culture values. There's also a strong association between this and weekends. It's deserved after a week of hard work, it's how we unwind,  and that it's part of the American dream to kick back with family and friends with a case of Bud, a bottle of wine, or an appletini. (In most cases this is not a drink with a meal.) 

BTW - While listening to the recent suggestions that lowering the age would lead to healthier drinking on college campuses, I kept coming back to this issue of alcohol's place in our culture. 

UPDATE - Of course, taxes could be an important tool for addressing underage drinking and binge drinking. However, a move in that direction would be an expression of values, and those are especially difficult to agree on in this area. Michigan has been in financial crisis for several years and proposed increases have been repeatedly killed. 

This map suggests a pretty strong relationship between alcohol taxes and alcohol related problems.

Medical marijuana???

Not what you're thinking.

Recovery coaching

Here's an interview with a Michael Boyle, the director of a pioneering program in recovery coaching. The interview is okay, but his recovery coaching manual is great.

A great recovery story

This is a great example of the love, support and generosity available in the recovering community:

Dale Ensor was desperate when he walked into a 12-step addiction recovery program five years ago. That's when he met a man named Dexter McElrath, who offered to help Ensor along the path to sobriety.

"Dexter took me under his wings and showed me the ropes," said Ensor, a 52-year-old self-employed painter who lives just north of Jackson. "I couldn't get it in my brain that there are people who care of me. The guy helped save my life. I would have died out there; I really would have."

At the time, neither could have known that this summer, Ensor would return the favor.

McElrath's kidneys began to fail in May 2007. The Ypsilanti Township resident went on dialysis for 14 months, expecting to wait the average three to five years for a transplant if he couldn't get a kidney from a friend or relative.

Two people offered a kidney, but one wasn't a match and McElrath wouldn't take the other because it would have meant postponing the donating woman's education.
McElrath was forced to cut way back on his hours as a construction worker because dialysis wore him out. Ensor watched his friend's health deteriorate and agreed to be tested.

"It was either that, or watch my friend die," he said. "All the cards were on the table. When it came to it, what kind of man am I? What am I going to do?"

At least she's predictable

From the same woman whose worldview dictates that stigmatizing addiction is good and addiction is not a disease. She chose to draw from a man with quite an agenda.

“It undermined their sense of themselves as individuals in control of their own destinies,” Mr. Sullum wrote in his 2003 book, “Saying Yes: In Defense of Drug Use.” “And so they stopped.”

I only read about these people. Patients who come to our methadone clinic are there, obviously, because they’re using. The typical patient is someone who has been off heroin for a while (maybe because life was good for while, maybe because there was no access to drugs, maybe because the boss did urine testing) and then resumed.

But the road to resumption was not unmarked. There were signs and exit ramps all along the way. Instead of heeding them, our patients made small, deliberate choices many times a day — to be with other users, to cop drugs for friends, to allow themselves to become bored — and soon there was no turning back.

Addiction does indeed discriminate. It “selects” for people who are bad at delaying gratification and gauging consequences, who are impulsive, who think they have little to lose, have few competing interests, or are willing to lie to a spouse.

Fighting HIV-AIDS One Syringe at a Time

A legislator makes a plea for an end to the federal needle exchange ban. I don't oppose lifting the ban, but his argument would be more compelling if he acknowledged the problems with many needle exchanges and called for standards for programs and increased access to treatment.

Abstinence and risk of overdose

We've known for some time that heroin addicts are at greatest risk for overdose when they reinitiate heroin use, including after detox or release from prison or jail. Some have argued that opiate maintenance is the answer to the problem. I would argue that it's a failure of acute care and that long term recovery management is the solution.

Drinking age (again)

Marginal Revolution points out that New Zealand lowered their drinking age to 18 and experienced serious problems, though not serious enough to raise the drinking age again.

Recovery Bill of Rights

Part of me wishes I could be more enthusiastic about this. They all seem like good points to make and I'm sure that they carefully developed using research and focus groups, but there's something about them that rubs me the wrong way. It sounds like the voice of the victimized. It talks about the right to strength-based services, but it doesn't speak with a voice of strength. There's something meek about it. It doesn't feel empowering.

At this moment in our culture, there seems to be fierce competition for aggrieved status. It seems to be the primary tool for promoting any kind of social change or consciousness raising. Think about it. How many times have you heard someone say, "In our country today, the only group you can make fun of is _______." You can fill in the blank with evangelicals, atheists, Catholics, obese people, southerners, cognitively impaired, little people, gay people, addicts, etc.

I have two problems with this approach for recovering people. First, I worry that it's bad strategy. There's a lot of competition for aggrieved status, the public is weary of this, and it may inspire more eye rolling than sympathy. Second, in terms of my personal recovery, I worry about any message that hints at adopting a victim stance or entitlement. No matter how well grounded, that position seems potentially toxic to my recovery.

If we really are mistreated, and we need to promote cultural change, what to do then? I can't say that I'm sure as I have not thought too deeply about this. However, I wonder if framing this as a call to action for recovering people would be more empowering and effective--"You have a responsibility to address these barriers for your still suffering brothers and sisters." Also, not to suggest a single pronged approach, but I'm convinced that the most powerful strategies will focus on reducing "otherness" and increasing "sameness" in public perceptions of addicts. Every time I take addicts to tell their story with churches and other community groups, the response is ALWAYS the same--we're not who they expect, we're just like some of their loved ones, they're often shocked by the sameness and want to do something to help. Unfortunately, that fades quickly. Strategies to capitalize on this window could be important.

Recovery Management

I was fortunate to get a peek at this monograph a while back. It, as Loran Archer noted, is sure to be the seminal document on recovery management. Over the last several years Bill White has been churning out papers that, one piece at a time, added flesh to bones of this model.

This document provides the big picture of recovery management in a way not previously offered. The references are exhaustive--804 references!!!

Quote for the day

"Recovery begins with hope, not abstinence..." - Michael Boyle

Craving

No wonder the rest of the world has such great difficulty understanding the power of addiction and craving. Addicts don't even appreciate craving's power when they're not in its grip.

Why is the Drinking Age 21?

Mental Floss provides a history of 21 year old drinking age.

More on drinking ages

Mark Kleiman, as usual, does a great job summarizing the drinking age quandary:

Setting the minimum legal drinking age at 21 saves lives by reducing drunk driving, and not just among the 18-to-21's; if 18-year-old high school seniors can buy beer at the supermarket, then 16-year-old high school sophomores have access to it. Common sense and evidence agree: drinking and driving by people who are both inexperienced drinkers and inexperienced drivers is really, really dangerous.

Setting the minimum legal drinking age at 21 also encourages disrespect for the law and encourages young adults to acquire and use false identification documents, which is not a social practice we want to encourage just right now. Moreover, that policy insultingly treats people who are adults for all other purposes as if they were still children, and deprives them of lawful access to an activity that forms part of the normal U.S. social scene and which some of them enjoy. And it may (the evidence isn't clear) lead those who are drinking illegally rather than legally to do so irresponsibly rather than responsibly.

Now, given those facts, what do you want to do about it?

His solution is to implement zero tolerance laws for drinking and driving for people under 21 and raise alcohol taxes.

Megan McArdle suggests adding special licenses for people who have been convicted of drunk driving and making it illegal to serve them alcohol.

In the "not always right, but always certain" department, a contributor to the Free Press offers these pearls:

The problem with asking at what age it ought to be legal to drink is that it is a fundamentally perverse question. The “logic” of law is that it allows government the power to punish actions deemed harmful while restraining government officials from singling out disfavored individuals or groups and imposing sanctions on them. The “rule of law” requires that all laws take the form of truly general rules of action, rules that provide punishment for anybody who takes the prohibited action.

Government decisions that just pick an individual and impose a sanction on that individual are bills of attainder, and our Constitution prohibits them. Rules that single out subsets of the population and punish them for actions which are not illegal when taken by other people are pseudo-laws, and legitimate government has no authority to enact them. (Example: Women cannot work as bartenders.)

To ask at what age it should be legal to drink, therefore, flies in the face of the inherent nature of law as a general rule of action. Either drinking must be legal for all, or illegal for all. The latter approach was tried during Prohibition, and it caused horrible results: organized crime, corruption, etc. Wisely, Prohibition was repealed by the 21st amendment in 1933.

Recipe for PTSD

The drug war horror story I posted about two weeks ago just hit Newsweek. Let's hope it continues to get attention.

Medical marijuana

The Los Angeles Times ran a pair of opposing pro/con pieces recently. I saw the headline for the con piece and thought it might be reefer madness rant, but thankfully it's much smarter than that. Acknowledging that marijuana's risks are relatively small, he argues that the FDA refuses to approve or yanks approval of drugs with fewer risks than marijuana.

I don't have a strong opinion on the matter and don't believe that anyone should do jail time for possession of marijuana in smallish quantities. I also don't think marijuana should get any special treatment from the FDA, in either direction--if it meets FFDA standards, approve it; if it doesn't meet FDA standards, deny approval. However, my impression is that most of the advocates of medical marijuana seem to be more interested in legalizing marijuana for their own use. I tend to find them pretty unpersuasive and they inspire a passive aggressive contrarian instinct in me.