When hope heals

From Ode magazine:

An experiment: Two groups of rats receive transplants of malignant tumors and are given electric shocks. One of them can avoid the shocks by pushing on a lever; the other can't. In the group that can avoid the shocks, the immune system does its job, counterattacks and eliminates the cancer cells in 64 percent of the animals. In the other group, animals soon get discouraged, the immune cells are paralyzed and the cancer spreads in a few weeks. Only 23 percent of the rats reject the tumor.

Is that why Paul died—because he suddenly felt powerless to escape the "shocks" he got from his disease? [Paul, who had managed his illness for years, died 2 years after being told he had 2 years to live.] Cancer seems to develop faster and more aggressively in patients who have less control over the inevitable stress of existence, which seems to be one of the reasons support groups prolong survival. Now what could be more stressful than being told there's no hope of a cure? At the University of California, Los Angeles, Assistant Professor Steve Cole demonstrated that among AIDS patients on tri-therapy, the treatment benefits those who remain calm facing life's difficulties far more than those who have trouble controlling their stress. In the latter group, the virus spreads four times as fast.

But who will explain that to patients? Almost every week I hear patients tell me how they've received "death sentences" from their oncologists. These pronouncements are made with the greatest confidence, as if statistics were certainties. Studies like Cole's are almost never mentioned. Yet patients really need them. Because I've already made this mistake myself, I suspect doctors are more afraid of giving false hope than of talking about the worst that can happen. To guard against this Western-style voodoo, patients often need to know more than their doctors about what they can do to help themselves—beginning by placing more hope in their bodies than medicine is prepared to give them.

What role does hope play in addiction? An large role, I suspect. Scott Miller has found that expectancy accounts for 15% the variance in treatment outcomes.

“If you want to treat an illness that has no easy cure, first of all, treat them with hope” -- George Vaillant

Comments on Staying Alive

I got this comment about the CBC video:

Thank you so much for posting this! It really put some faces on all the talk we've had about harm reduction.

Don't get me wrong, I can see the importance of the social connections that Insite is providing for individuals. At the same time, what I found most disturbing was the situation with the woman, Shelley, who came to Insite to relapse.

I felt like with her life on the line, couldn't they do a little more to help her? Helping her get a hold of some pharmacies? Hooking her up with some non-methadone treatment?

I think one can be non-judgmental and say "You deserve sobriety" at the same time.

So, I finally watched the whole thing and here is my stream of consciousness:

Q: "How do you know if they're ready?"
A: "It's a judgment call. We know them..."

What does this mean? How about letting them tell you when their ready?

How on earth do people start recovery above the injection center? This place is the hub of the heroin user tribe of the culture of addiction.

Shelley - how about a little case management for Shelley? How about helping her get her prescription filled or a  getting her dose as an alternative to using heroin? Is it really reducing her harm when she predictably ends up tricking in the alley a day later? Was their passivity in the face of her relapse about her needs or about their personal philosophy? I'm not suggesting use of force, yelling or shaming, but she was in a temporary emotional crisis and was about to make a decision with profound long-term consequences.

Gabor Mate - "Addiction is not a moral failing" Correct. But our communal response to addiction is a moral failing. This place is a well equipped pit of despair. How can one offer hope in a place like this with people who expect you to fail at any attempt to recover.

The worker - I'm sorry. Maybe he's wonderful and in this for all the right reasons, but I can't shake the feeling that the work is self-ennoblizing, a source of vicarious excitement and is more about their world-view, their needs and their image. Acceptance of people "where they are at" does not mean treating them with the message that there's nothing wrong with staying where they are at forever. How about accepting them for what they can become?

Video fun

The A/V Geeks have posted scores of old videos, including the following:

[via kottke.org]

This is an emergency

One family writes about the impact of marijuana addiction in their family. (Skeptics - Stop focusing on the drug and think in terms of the response of the individual to the drug.)

Highlights here:

And for the last four years, this is how it's been. Two steps forward, two steps back. We effectively remain where we have been since it started.

This is cannabis. It stops you, it rips out normal reactions, normal kindness, normal motivation. It draws a line and you stand patiently behind it. And this is why we have broken one of the most serious prohibitions facing any writer. You Do Not Write About Your Children. Yes, your kids might enter your work now and then in charming disguise but you do not ever lay out their genuine, raw problems on the page. You fictionalise them, you do not present it up-front and true. There is a glass-fronted box in the corner of every writer's room, protecting the real lives of their children: Smash Only In Case Of Emergency.

...

Imagine if you could wave a wand and instantly all the spliffs and baggies were transformed into bottles of gin. You leave for work on Wednesday morning and suddenly you see kids on the way to school with a quarter of Gordon's sticking out their rucksack; at Thursday lunchtime, you see them sharing a swig of Tanqueray at the bus stop. And if you saw that daily, all around you, you would say there's a genuine problem. Except it's worse than that.

...

Their arguments - some ill-informed, some plain vitriolic - have all rested on an implicit belief that "a bit of pot" simply does not cause this kind of aggression, this sort of abuse. Yes, they say, if this was a heroin addict, nicking your stereo, your jewellery and flogging it down the pub, that would be credible. And they're right, you don't need to flog a stereo for a spliff - it costs less than a pint. And anyway, cannabis makes you mellow - stoners are hippies, laid back, docile to a fault. We used to smoke it, they imply, and we just giggled.

That was then. Skunk is GM cannabis. Evidence from the Forensic Science Service suggests that skunk cannabis (otherwise known as sinsemilla) is remarkably stronger than ever before. It is unquestionably different, definitely stronger. In skunk, the active ingredient, THC (tetrahydrocannabinol), has been ramped up significantly. But perhaps more importantly, this has been achieved at the cost of another component of naturally occurring cannabis, CBD (cannabidiol). And some scientists are starting to think that CBD has antipsychotic properties - something to offset the THC in old-fashioned marijuana but absent in skunk.

Heroin maintenance (again)

Is England considering adopting Denmark's heroin maintenance approach?

Some might think this initiative is not surprising in a country with a historical tradition of progressive, social democratic policies....

"Five years ago I decided I would not participate in yet another debate on drugs," recalls Preben Brandt, the chairman of the Council for Socially Marginalised People and an advocate of the policy. "It was too emotional, with different groups being very aggressive."

"The counter-argument was always 'you kill people by giving heroin' or 'with this initiative, you are telling people that taking heroin is OK'," he says. "It is very difficult to have a rational debate when you are arguing against beliefs."

The turning point came when results became available from experiments trialling the policy in other European countries, including Switzerland and the Netherlands. "The politicians became convinced that it could help those with the most severe drug problems," says Mads Uffe Pedersen, the head of the Centre for Alcohol and Drug Research at the University of Aarhus. "You could not argue against the (positive) findings."

"The debate became more practical," agrees Brandt. "It was about what policies worked and which ones did not. It was no longer about morality."

Attitudes towards drugs addicts improved too. "Drug addicts in Denmark are less stigmatised," says Brandt. "They are no longer perceived as criminals who are a danger to society. They're seen as patients who have a disease they need help with. The new scapegoats in Denmark are the foreigners."

I doubt this is near in England. And, call me crusty, but I find it difficult to believe that the motives here are to help addicts and that stigma has been reduced by a policy premised on the assumption that addiction is untreatable.

Involuntary treatment bill in West Virginia

I find this very frightening, though I empathize with families who wish they had this option.

Insite on CBC

CBC has a program on Vancouver's supervised injection center.

Drug War = Culture War?

A friend, Matt, wondered if the premise of this Frank Rich column will have implications for drug policy:

What has happened between 2001 and 2009 to so radically change the cultural climate? Here, at last, is one piece of good news in our global economic meltdown: Americans have less and less patience for the intrusive and divisive moral scolds who thrived in the bubbles of the Clinton and Bush years. Culture wars are a luxury the country — the G.O.P. included — can no longer afford.

I don't think that the drug war has traditionally been part of the abortion/homosexuality/sexuality-in-pop-culture culture wars, but pro-legalization advocates seem to be enjoying a great deal of success in moving it to that category. I wince at this categorization--the culture wars tend to impose false binary choices and I suspect it would lead to very bad policy.

Conservative outcast David Frum wades into the matter, but his point seems to be to challenge hippie dope smoking peaceniks to consider the violence involved in the marijuana trade next time they light up. It's an old tune. Acknowledge some of the costs of the drug war, and frame drug use as an immoral decision without examining the morality of the policy itself.

I don't know what "the" solution is and I'm skeptical of anyone who claims to know. There are losts of changes we could make--shifting the the emphasis of our policy from incarceration to treatment and supervision. However, no drug policy is going to solve the drug problem, Every policy will bring new problems and decrease other problems. It really comes down to which problems we're willing to live with. A lot of us have strong opinions and would like to decide the right policy, but our political process requires some measure of concensus. (Even if it's limited.)  I suspect that the only way to get there is to identify the relevant values and debate how the options fit within these values. If the debate ends up getting framed in the context of the culture war, this will be impossible.

Anxiety and Alcohol

A new study focuses on the neurobiological relationship between anxiety and alcohol use.

It offers a possible mechanism for vicious cycle of alcohol use leading to anxiety and this anxiety leading to more alcohol use.

The researchers found that short-term alcohol exposure increased the number of dendritic spines in certain regions of the amygdala, producing anti-anxiety effects. Alcohol-dependent animals eventually developed a tolerance to the anxiety-lowering effects of alcohol.

The researchers traced the anti-anxiety effect to the production of a particular protein, Arc, in response to a nerve growth factor called BDNF that is stimulated by alcohol exposure. BDNF is vital in the functioning and maintenance of neurons.

When alcohol was withheld from animals that had been chronically exposed, they developed high anxiety. Levels of BDNF and Arc -- and the number of dendritic spines -- were decreased in the amygdala. But the researchers were able to eliminate the anxiety in the alcohol-dependent animals by restoring BDNF and Arc to normal levels.

Pandey suggested that an initial easing of anxiety may encourage people to begin to use alcohol, while for chronic users, a lack of alcohol provokes high anxiety, creating a need to continue drinking to feel normal.

I think we need to know a lot more about this anti-anxiety effect before going off the races with anxiety as a pathway to alcoholism.

Def Jam on Drug Policy

Russell Simmons praises moves by the New York legislature to roll back the Rockefeller Drug Laws.

Betty Ford

Alix at The Second Road gives us a heads up about a PBS show on Betty Ford.

Here's Bill White's salute to her from a couple of years ago:

In the decades following the repeal of Prohibition, American women faced a unique cultural double bind. They were targeted for unrelenting product promotion by the alcohol, tobacco, and pharmaceutical industries at the same time social stigma increased for addicted women. Only a few women of prominence (e.g., public health pioneer Marty Mann and actresses Lillian Roth and Mercedes McCambridge) braved such stigma to publicly acknowledge their recoveries from alcoholism, while women struggling with narcotic addiction, such as jazz singer Billie Holiday, broke into public visibility only when they were arrested or died.

In such a climate, unknown numbers of women lost their dreams and their lives to alcoholism and other addictions. Many sought help only in the latest stages of their illnesses, with many dying early in their recoveries as a result of medical disorders spawned from prolonged years of secret addiction to alcohol and other drugs. It could justifiably be claimed that these women died not from addiction, but from stigma.

Recovery advocates during the mid-20th century dreamed of a day when a woman of unprecedented prominence would go public with her recovery story and by doing so forever shatter America's stereotype of the alcoholic as a depraved skid row wino. That dream was about to come true in a way that would forever demarcate "before and after" in the history of addiction and recovery among American women.

Courageous announcement

In April 1978, former President and First Lady Gerald and Betty Ford announced to the nation that Mrs. Ford had sought treatment and was recovering from addiction to alcohol and other drugs. That moment stands as the height of destigmatization of alcohol and other drug problems in America. Here stood one of the most prestigious women in the United States and, at a more personal level, a woman deeply respected and revered by the American public for her independence, spunk, and candor. We had sensed earlier as a citizenry that this was a woman who cared about us and would tell us the truth. She had demonstrated those traits by openly sharing her battle with breast cancer and using that experience to educate us as a nation. And here she was again standing with her husband and family talking to us about recovery from alcoholism and drug dependence.

In doing so, Betty Ford and her family, as they had done before, found a way to elevate their personal crises to a higher level of meaning and purpose. In 1978, Betty Ford did for alcoholism what a few years later a famous actor, a beloved professional athlete, and a brave young boy would do for AIDS. She put a face on alcohol and drug dependency that shattered the public stereotype of the alcoholic and in that moment brought us all a step closer to telling the truth about how these problems had touched our own lives.

The manner in which Mrs. Ford initiated her recovery process was also significant in that it challenged the popular notion that nothing could be done to stop addiction until the person who was addicted had personally hit bottom and reached out for help. News that Betty Ford's daughter, Susan Ford, had initiated a formal family intervention process that resulted in Mrs. Ford's admission to treatment and opened the doorway to her recovery conveyed three crucial lessons to the nation: 1) There is hope for families facing addiction; 2) The family can play a catalytic role in the recovery process; and 3) Individual family members and the family as a whole need to recover from the effects of addiction. Mrs. Ford, President Ford, and Susan and the other Ford children offered themselves as living proof of those propositions.

Chicken or the Egg?

From a press release about a study in the Archives of General Psychiatry:

Although numerous studies have linked alcohol problems and depression, whether the relationship is causal or whether there is a common underlying factor remains unclear, they said.

To explore the issue, they examined data from the Christchurch Health and Development study, which followed 1,055 individuals born in New Zealand for 25 years from birth.

...

In an attempt to determine causality, the researchers tested three statistical models on the data:

• One in which both disorders increased risk of the other in a feedback loop
• One in which major depression caused alcohol problems
• One in which alcohol problems caused major depression

The model that fit best was the one that assumed that alcohol problems caused major depression.

"The underlying mechanisms that give rise to such an association are unclear," the researchers said. "However, it has been proposed that this link may arise from genetic processes in which the use of alcohol acts to trigger genetic markers that increase the risk of major depression."

"In addition," they said, "further research suggests that alcohol's depressant characteristics may lead to periods of depressed affect among those with alcohol abuse or dependence."

Stress related to social, financial, and legal problems stemming from alcohol use might also increase the risk of depression, they said.

Add the Economist's voice to the chorus

The Economist weighs in on drug prohibition. (Again.) Not surprising, given their Libertarian leanings.

I like that they refer to legalization as the "least bad" option. This frames the discussion in a more honest way, though their presentation of the risks/benefits are simplistic and suffer from excessive certitude. (Note that they're advocating the legalization of ALL drugs.)

They also make the assumptions that one would expect from a publication devoted to free markets:

Prohibition has failed to prevent the proliferation of designer drugs, dreamed up in laboratories. Legalisation might encourage legitimate drug companies to try to improve the stuff that people take.

I do not share their faith that free markets would be a good thing for the drug trade.

Something is clearly happening. Chatter on the topic is growing. Let's hope for reform, but let's hope it's done in a thoughtful and realistic way. The status quo is unacceptable, but the distance between the status quo and legalization is vast.

12 Steps to Stopping Terror

WTF???

CNBC?

CNBC has a gallery of medical marijuana.

Maybe major policy changes are closer than we think?

Perverse incentives created by alcohol taxes

Here's a great example of the perverse incentives created by tax revenue from alcohol sales and a strong lobby that prevents increases in alcohol taxes.

Is this what we want for marijuana?

• In Georgia, Connecticut, Indiana, Texas, Alabama and Minnesota, lawmakers are considering legislation this year that would end the ban on Sunday liquor sales. All but 15 states sell booze on Sundays.
• In Nebraska, a state lawmaker has proposed allowing beer to be consumed in state parks as a way to boost tourism.
• Other states, including Utah, are considering allowing the sale of liquor on Election Day.

In fairness, the article does point out that several states are considering alcohol tax hikes, but the list includes California, which seems to have shot down the idea.

Pot polls

Nate Silver has a more sober and analytical take on the recent Rasmussen poll.

[via Andrew Sullivan]

Taxes, alcohol and drugs

A California Assemblyman is looking to a marijuana tax help address their budget woes. It's a common argument and I think it's a bad one. I've repeatedly made it clear that I'm not a marijuana alarmist, but commercialization and taxation of tobacco and alcohol have been wrought with serious problems. Their lobbies are extremely powerful and the alcohol lobby has been very successful at keeping taxes low. With all of California's budget problems, there is no alcohol tax increase in their budget accord. In Michigan, the worst economy in the country, the beer tax has not increased since 1966. Worse, they rely on problem drinkers and underage drinkers for a substantial portion of their profits.

If we eventually legalize and tax it, let's hope that they go for the moon and tax it high. There's lots of evidence that high taxes reduce alcohol consumption and alcohol related problems.

I've said it before, but I think Mark Kleiman has the best solution.

Pot legalization

Mark Kleiman directs us to a new poll on the subject with only a 6% margin against legalization.

His analysis of the poll:

Rasmussen doesn't give the wording, and the accompanying article is written largely from a pro-legalization viewpoint (Rasmussen tends to lean libertarian).

Under the circumstances, I'd be skeptical, but the CBS/NYT poll in January got comparable results: in response to "Do you think that the use of marijuana should be made legal or not?" 41% said "legal" and 52% said "not legal." Current support for legalization is at what seems to be an all-time high, but the numbers are consistent with the long-term trend in Gallup polling.

Predictions about Obama's policy direction:

Note that these numbers come against the backdrop of relentless official anti-pot propaganda: not just from the drug czar's office, DEA, and the DARE program, but even from the National Institute on Drug Abuse. That suggests that a President who decided to change the message might not hit a stone wall. And the age breakdown suggests that the trend is likely to continue as the cohorts that grew up without pot leave the voter pool.

Obviously, this isn't something the Obama Administration is going to jump on, but I wouldn't be surprised to see a big move late in a second Obama term or sometime in the term of his successor (assuming the Democrats keep winning elections). If I had to quote odds, I'd say about even money on legalization within fifteen years. As with the repeal of alcohol prohibition and the creeping legalization of gambling, I'd expect it to be presented at least in part as a revenue-raising measure.

His opinion on the matter:

Substantively, I'm not a big fan of legalization on the alcohol model; a legal pot industry, like the legal booze and gambling industries, would depend for the bulk of its sales on excessive use, which would provide a strong incentive for the marketing effort to aim at creating and maintaining addiction. (Cannabis abuse is somewhat less common, and tends to be somewhat less long-lasting, than alcohol abuse, and the physiological and behavioral effects tend to be less dramatic, but about 11% of those who smoke a fifth lifetime joint go on to a period of heavy daily use measured in months.) So I'd expect outright legalization to lead to a substantial increase in the prevalence of cannabis-related drug abuse disorder: I'd regard an increase of only 50% as a pleasant surprise, and if I had to guess I'd guess at something like a doubling.

So I continue to favor a "grow your own" policy, under which it would be legal to grow, possess, and use cannabis and to give it away, but illegal to sell it. Of course there would be sales, and law enforcement agencies would properly mostly ignore those sales. But there wouldn't be billboards.

That beautifully-crafted policy has only two major defects that I'm aware of: it wouldn't create tax revenue, and no one but me supports it. On the drug-warrior side of the argument, even those who can read the handwriting on the wall won't dare to deviate from the orthodoxy. As we did with alcohol, the country will lurch from one bad policy (prohibition) to another (commercial legalization). I just hope the sellers are required to measure the cannabinoid profiles of their products and put those measurements on the label.

The drug war and incarceration

Though this in no way justifies the drug war, it's contribution to the prison population is often overestimated:

Myth No. 2: Low-level drug offenders drive prison population growth. It is popular, perhaps almost mandatory, to blame the boom on the War on Drugs. But it is just not true. Only 20 percent of inmates in prisons (as opposed to jails) are locked up for drug offenses, compared with 50 percent for violent crimes and 20 percent for property offenses; most of the drug offenders are in prison for distribution, not possession. Twenty percent is admittedly much larger than approximately 3 percent, which was the fraction of prisoners serving time on drug charges in the 1970s. But if we were to release every prisoner currently serving time for a drug charge, our prison population would drop only from 1.6 million to 1.3 million. That's not much of a decline, compared with the total number of people in prison in the 1970s—about 300,000.

In fact, the war on drugs does play a role in the prisoner increase. But it's an indirect one. State "predicate felony" laws, for example, impose longer sentences on offenders with prior records: A drug conviction may not send someone to prison, but it will make him serve more time for any future crime he commits. This suggests that simply tackling long drug sentences, as reformers in New York state have done, may miss the real problem.

One interesting point for context: the number of people incarcerated for drug crimes is now approaching the total prison population in the 1970s.

4 takes on the new Drug Czar

The Stranger has 4 takes on the new drug Czar. Here's an excerpt from one:

Kerlikowske has also overseen a shift in drug policy from enforcement to treatment. Most notably, he allowed the Get Off the Streets program to hatch in the Central District in 2006. That year, then-lieutenant John Hayes (now a captain) set up a table in an open-air drug market where people with criminal warrants could visit for referrals to housing, health, and human services without risking arrest.

"That was, at that time, a very edgy approach, and the chief was willing to let one of his people staff the program," says City Council member Nick Licata, who soon pushed for legislation to fund the project. "It was at a stage where Gil could have stopped it, but he allowed it to go forward."

Although he isn't going to legalize pot, drug czar Kerlikowske could push to lift the federal ban on funding needle exchanges, stop the medical-pot raids in California, overhaul spending on antidrug commercials, and enthusiastically seek funding for drug-treatment programs.

The larger brilliance of Obama's pick for drug czar isn't just that Kerlikowske is open to new strategies, but that he is first and foremost a cop. Nobody can claim that Kerlikowske is a public-health nut who doesn't know the impact of drugs on the streets. Like many Americans, he agrees that drugs should be illegal. But he understands that both enforcement and public health have their place, and he's willing to take a look at new approaches when enforcement alone has failed.

[via Andrew Sullivan]

More on the power of gratitude

Bob Sutton posted a link to the abstract below:

This study tests whether gratitude predicts psychological well-being above both the domains and facets of the Five Factor Model. Participants (N=201) completed the NEO PI-R measure of the 30 facets of the Big Five, the GQ-6 measure of trait gratitude, and the Scales of Psychological Well-being. Gratitude had small correlations with autonomy (r = .17), and medium to large correlations with environmental mastery, personal growth, positive relationship, purpose in life, and self-acceptance (rs ranged from .28 to .61). After controlling for the 30 facets of the Big Five, gratitude explained a substantial amount of unique variance in most aspects of psychological well-being (requivalent = .14 to .25). Gratitude is concluded to be uniquely important to psychological well-being.

Gratitude also improves sleep quality.

College Fraternity Sober Monitors

Fraternities and the university collaborate on a harm reduction approach to unsafe drinking at fraternity parties:

The Interfraternity Council is looking to bring a fresh approach to social responsibility through a redesigned Sober Monitor Training Program.

The program will provide members of the Greek community with the skills necessary to hold safer parties and handle alcohol-related situations that may arise at parties. At all fraternity parties a designated number of brothers is required to remain sober throughout the night. IFC president Ari Parritz said a priority of his will be to have most first-year members attend the program so they’ll know what to do when it’s their turn to be a sober monitor.

...
“My goal for this program is to have every new member — that is, the individuals generally responsible for the operation and conduct of our social events — complete it by February of 2010,” Parritz said in an e-mail interview. “Our community trusts these individuals with the safety and conduct of our social events; as such, they should be trained by professionals, and never be placed in a situation where they are unsure what to do.”

Desprez said there have been three training sessions so far this semester, with each session having between 10 and 40 people in attendance. There are plans to have eight to 12 sessions conducted by the end of the semester, she said.

The training program includes conversations and demonstrations on blood alcohol content, recognizing different levels of intoxication, alcohol-related laws, risk management issues, conflict management skills, and emergency protocol, Desprez said.

Nausea Drug Shows Promise Against Opioid Addiction

This could be good news. Buprenorphine has been a really good tool but we are seeing increasing misuse of it. Something that's effective in reducing suffering and has no misuse potential would be great.

The Limits of Shame

Andrew Sullivan picks up on a debate about shame's influence on behavior:

Adam Serwer responds to Dreher's post on stigmatizing having children out of wedlock:

Conservatives regularly overestimate the beneficial effects of shame. Shame provokes response in the form of impulse, not long term planning. A person who
is ashamed isn't going to think, "I'd better get a degree" or "I'd better get married," they're going to think in the short term about what they can do to rectify their sense of self-worth.

How do you see people--men in particular--act when they're ashamed? You rarely see them do something like get married or get a fantastic job; usually they're going to hurt or exploit someone, make them feel as low as they do--this is the lesson learned by the shamed from the shamer, regardless of the lesson the shamer thinks they're teaching the shamed.

I'm not sure it's possible to encourage beneficial social behavior without in some ways discouraging destructive behavior. The key is emphasis. And a little positive reinforcement often goes a long way.

I'm not interested in entering this debate (in this space any way), but this issue of shame is relevant. I've posted before on people like Sally Satel, who are worried that the disease model will erode stigma (that's a good thing!!!) and lower the threshold for people to misuse drugs and alcohol.

BTW - I've been watching the debate about Ta-Nehisi's posts unfold for the last week. Good reading.

More on the new Drug Czar candidate

The New York Times ran an article about the latest Drug Czar candidate. Not very quotable, so read the whole thing.

New residential treatment completion numbers

• Treatment completion among clients discharged from long-term residential treatment was also highest among those reporting primary alcohol abuse (46 percent), but lowest among those reporting primary cocaine abuse (33 percent) or primary opiate abuse (35 percent)
  
  
• As educational level increased, the proportion of client discharges completing either short-term or long-term residential treatment increased

Still making Dawn Farm look good.

What these numbers don't report is probably more important. I care a lot about how many people complete residential treatment at Dawn Farm, but that's only part of the picture.

What do they do after treatment? Do they maintain involvement in mutual aid groups? Do they attend aftercare?

What about the people who don't complete residential? Do we maintain a relationship with them? If residential was not a good fit for this person, at this time, do we connect them with another service that will better meet their needs and preferences? If residential was they right place for them, are we able to get them back into residential?

Addiction recovery is a long game, not a short one; addiction is a chronic illness, not an acute one. Successfully completing treatment is like successfully responding to a heart attack--it's a significant victory, but any long term success relies on taking medication, compliance with dietary guidelines and compliance with exercise recommendations. Completing treatment should be viewed in the same manner and treatment services should be structured to provide long-term support in maintaining recovery and long-term monitoring to help prevent relapse and re-intervene quickly when relapse does occur.

Neighborhood-based strategies

I often hear arguments that the cost of incarceration makes it sensible to invest in individuals and service delivery systems to keep people out of prison.

This suggests that neighborhood-based strategies could be a very effective strategy.

Nationwide, an estimated two-thirds of the people who leave prison are
rearrested within three years. A disproportionate number of them come
from a few urban neighborhoods in big cities. Many states spend more
than $1 million a year to incarcerate the residents of single blocks or
small neighborhoods.

Some of Mark Kleiman's points from yesterday's post lead in the same direction:

5. We can help by shrinking our domestic markets. Offenders under
criminal justice supervision account for half of all hard-drug
consumption. Hawaii's Judge Steven Alm has shown that frequent testing
and swift, automatic, but relatively mild sanctions can sharply reduce
methamphetamine use among probationers. This is a cheap solution that
also actually shrinks the population behind bars by reducing both
probation revocations and arrests for new crimes. But it works only if
the authorities can organize themselves to deliver the sanctions.

Carefully adapted to local conditions, testing-and-sanctions can be
extended nationwide, to every probationer and parolee, and everyone
released on bail, who has an illicit-drug problem. The current practice
of forcing large numbers of drug users into treatment, with
incarceration as the alternative, wastes resources. Voluntary treatment
should be more broadly provided. Coerced drug treatment should be
reserved for those who don't respond to the threat of short jail stays.

...

8. Flagrant retail drug markets still devastate too many American
neighborhoods, especially poor urban areas where African-Americans and
Latinos live. Imprisoning half the young men in those neighborhoods is
neither useful nor just, but that's the result of routine street-level
drug enforcement. Since every dealer arrested makes room for a
replacement, we're just running on a treadmill. "'Drug kingpins,"' too,
are replaceable. We now keep 500,000 drug dealers behind bars at any
one time; there wouldn't be a significant rise in drug abuse if that
number were halved. There are smarter and less brutal things to do.

9.One practical alternative to routine drug law enforcement is to
break up markets with as few arrests as possible. This was an approach
first used in High Point, North Carolina, and is now being tried out in
dozens of places nationwide. Identify all the dealers in a market,
build cases against them, and warn all of them, simultaneously, that
they have a choice of stopping -- right now -- or going to prison. If
that threat is made convincing, most dealers quit and there's enough
capacity to arrest and imprison the rest. When all the dealers in a
neighborhood quit or get sent away at once, the market is gone, and a
little bit of enforcement will keep it from coming back. Committed
users still get their drugs, discreetly, but crime drops and the
residents get their streets back. Can this general approach work
elsewhere? Try to find out.

Advice for the new Drug Czar

Here's an abridged list of suggestions from Mark Kleiman. (Please take the time to read the whole thing here.)

1. Talk to Americans as if we are thinking adults.

2. You'll be told that we have a national strategy resting on three legs: enforcement, prevention, and treatment. Don't believe it. There is no coherent strategy.

3. "Drug czar" is a silly title. We're not fighting a war, you don't have czar-like powers, and the last actual czar who fought an actual war got clobbered. You're stuck with the title. But don't get sucked in to the rhetoric of "'enemies"' and "'victory."' The drug problem isn't like that.

4.There are some real "'drug wars"' raging: in Afghanistan, in Colombia, and in northern Mexico.

5. We can help by shrinking our domestic markets. Offenders under criminal justice supervision account for half of all hard-drug consumption.

6. Treatment needs to be more accessible and more accountable.

7. Engage family doctors, internists, emergency room personnel, and mental health counselors to identify and address their patients' drug problems.

8. Flagrant retail drug markets still devastate too many American neighborhoods, especially poor urban areas where African-Americans and Latinos live. Imprisoning half the young men in those neighborhoods is neither useful nor just...

9.One practical alternative to routine drug law enforcement is to break up markets with as few arrests as possible.

10. Prescription pain-killers and stimulants are now traded hand-to-hand among middle school and high school students. So far, no one has a convincing idea about how to deal with the problem. Get someone thinking about it.

11. All these measures bring one common injunction: Take public management seriously.

12. Our data collection systems are pathetically ill-matched to the actual drug problem.

New Drug Czar

This is the first I've seen about Seattle Police Chief Gil Kerlikowske being appointed as Drug Czar.

The article says almost nothing about his positions on drug policy.

Girls more resilient than boys in troubled households

Here's a brief report on a study finding that girls are 4 times more resilient than boys in overcoming adversity at home, such as a heroin addicted parent.

The details are sketchy and the study isn't posted on the journal's webpage yet. I'll try to get more info and do another post on it.

Contingency Management for Smokers

I've bristled before at the use of incentives for addicts. I worry that it smacks of "the subtle bigotry of low expectations."

However, I saw this post on incentives for smokers and was confronted with the fact that we use a financial incentives for employees at Dawn Farm and have for more than 15 years.

I'll have to digest this for a while.

Rockefeller Laws: An End in Sight

Good news:

The New York Legislature finally seems poised to overturn the infamous Rockefeller drug laws. The impending change comes too late for the tens of thousands of low-level, nonviolent drug offenders who wasted away in prison because of mandatory sentencing policies when they should have been given treatment and leniency. But after years of building support for reform, legislative leaders now have it within their power to make wholesale changes in this profoundly destructive law.

Read the rest here.

Foundation advocates heroin maintenance

This is why a trial in some far off place matters.

[hat tip: dailydose.net]

Bad news

Last week I noted that, in spite of spending on health care, the stimulus bill offered little for treatment advocates to get excited about.

One bit of good news in the bill was increases in Byrne grants. These grants are often used to fund drug courts. The new compromise bill has eliminated those increases.

"Culture-wars Kabuki"

Mark Kleiman dissects the medical marijuana fight.

Economy Killing Abusive Teen Programs

From Mother Jones:

In just the last few weeks, the notorious Tranquility Bay program in Jamaica, Spring Creek Lodge in Montana, and Pathway Family Center in Detroit and Ohio have all been shuttered.

No darvocet for you!

An FDA panel recommends that it be pulled off the market.

UPDATE: CNN appeared to have removed the story. Here's another story from the Washington Post.

Amphetamines vs. Methamphetamines

Mental Floss explains (kind of) the difference between amphetamines and methamphetamines.

Dual diagnosis is an expectation, not an exception?

It's been conventional wisdom in the U.S. that most addicts and alcoholics also have a mental illness.

Not so in Canada.

Researchers 'Astonished' by Anorexia Death Rates

Researchers followed a cohort of 6000 patients with anorexia:

Out of the cohort studied, 265 died during the 30-year follow-up. The most frequent causes of death were suicide (responsible for 32 percent of the deaths), anorexia (19 percent of the deaths), and cancer (11 percent of the deaths). The remaining 38 percent of deaths were caused by other illnesses or by homicide. The average age at death for the 265 anorexia patients who died was 34.

The researchers also compared findings for their anorexia patients during the 30-year follow-up period with those of the general Swedish population. For example, compared with the general population during this time, anorexia subjects were 19 times more likely to have died from psychoactive substance use, primarily alcohol use, 14 times more likely to have died from suicide; 12 times more likely to have died from respiratory diseases, 11 times more likely to have died from urogenital diseases, five times more likely to have died from gastrointestinal diseases, and two times more likely to have died from either cardiovascular disease or from cancer.

Altogether, anorexia patients were six times more likely to have died during the 30-year follow-up period than was the general population.

Smoking May Prime Adolescents for Depression

From jointogether.org:

New animal research from Florida State University suggests that smoking during adolescence may increase the risk of depression during adulthood, Medical News Today reported Jan. 29.

Researcher Carlos Bolaños-Guzmán and colleagues injected adolescent rats with either nicotine or saline solution for 15 days, then tested the rats' responses to stressful and rewarding situations both during and after exposure.

The study showed that even a single day's worth of nicotine exposure during adolescence led to rats experiencing lower sensitivity to natural rewards and enhanced sensitivity to stressful situations.

Administering either nicotine or antidepressants during adulthood caused the depression symptoms to disappear, the researchers found.

"These data suggest that adolescent exposure to nicotine results in a negative emotional state rendering the organism significantly more vulnerable to the adverse effects of stress," Bolaños said.

The results were published online Dec. 17, 2008 in the journal Neuropsychopharmacology.

Let'em go?

This week's Newsweek has a story on an out-of-the-box approach to low level drug dealers:

In a 2004 experiment in High Point, N.C., Kennedy got the cops to try a new way of cleaning up the corners. They rounded up some young dealers; showed a videotape of them dealing drugs; and readied cases, set for indictment, that would have meant hard time in prison. Then they let the kids go. Working with their families, the police helped the dope dealers find job training and mentors. The message, which spread quickly through the neighborhood, was that the cops would give kids a second chance—but come down aggressively if they didn't take it. The police won back trust they had lost long ago (if they ever had it). After four years, police in High Point had wiped the drug dealers off the corner. They compared the numbers to the prior four years and found a 57 percent drop in violent crime in the targeted area.

[via: jointogether.org]

Medical marijuana DEA raids to end

Obama brings some sense DEA priorities, though I don't understand the need to wait for a new DEA head:

White House Spokesman Nick Shapiro reacted to new Drug Enforcement Administration (DEA) raids at medical cannabis collectives in California, saying he expects President Obama to end that policy when a new DEA Administrator is seated. “The president believes that federal resources should not be used to circumvent state laws, and as he continues to appoint senior leadership to fill out the ranks of the federal government, he expects them to review their policies with that in mind," Shapiro said.

No treatment stimulus

I avoid politics here and I can't begin to wrap my head around the stimulus bill, but, if you're spending a lot on health care, it seems like it would make sense to invest in a long neglected sector that can expect an increase in demand during a economic downturn.

The American addiction treatment landscape

Nothing too exciting in the treatment facility survey. A few interesting contrasts between methadone providers and other providers:

• Half (50 percent) of OTPs (opioid treatment programs) were operated by private for-profit organizations, compared to 29 percent of all substance abuse treatment facilities.
• Facilities with OTPs providing substance abuse treatment services were most likely to offer outpatient treatment (94 percent), but least likely to offer residential (non-hospital) or hospital inpatient treatment (7 percent each).

Another interesting data point:

• Over half (55 percent) of all OTPs provided both maintenance and detoxification. Thirty-seven percent provided maintenance only, and 8 percent provided detoxification only.

I don't know of any local programs offering detox. They're all maintenance. I wonder if they reported that they offer detox. There are either significant differences in OTPs in southeastern Michigan and the rest of the country, or there are differences between what they report offering and what they actually offer.

It also reported that 8% of facilities offer OTP, which is pretty stable. However, 23% of all clients received methadone (Am I reading that correctly?), up a little more than 2% over the last few years.

Comments on methadone posts here often complain that there is too little methadone treatment available, but what percentage of treatment seekers are opioid addicts and what percentage of those prefer methadone? Do they comprise more than 23% of all treatment seekers?

Another frequent complaint is that 95% of all treatment programs ram the 12 steps down clients throats. Here's a table that reports the clinical practices used by surveyed programs. 12-step approach was less popular than CBT and relapse prevention.

Alcohol use disorder prevalence

I saw this yesterday and feared that alcoholism research was going the same route as research on psychiatric prevalence--finding implausibly high rates of disorders.

A 20% lifetime rate of dependence for men would either be false or demonstrate the uselessness of dependence criteria. Reading the press release left me confused about whether that 20% figure was dependence or the sum of dependence AND abuse.

This Join Together research summary suggests that it is the latter. (Whew! Especially since Marc Schuckit is the lead author. I'd be very disappointed if his research began to look unreliable.)

Some data points of interest about early use and disorder onset:

• The usual age of first drinking, independently of the family, is about 15 years and has not changed much in decades. This age does not differ much for those who go on to develop alcohol-use disorders and those who do not, although an earlier onset of regular drinking is associated with a greater likelihood of later problems.
• The period of heaviest drinking is usually between 18 and 22 years of age, and also does not differ much between those with future alcohol-use disorders and the general population.
• More than 60% of teenagers, even those without alcohol-use disorders, have experienced drunkenness by the age of 18 years, and about 30% have either given up events such as school or work to drink, or have driven while intoxicated.
  
• The period of heaviest drinking is usually between 18 and 22 years of age, and also does not differ much between those with future alcohol-use disorders and the general population.
• Alcohol abuse and dependence often begin in the early to mid-20s, at a time when most people begin to moderate their drinking as their responsibilities increase.

An interesting point about depression and alcohol:

• Repeated heavy drinking in alcohol-use disorders is associated with a 40% risk of temporary depressive episodes...

On abstinence vs. moderation for dependent patients:

• Abstinence is the usual goal for treatment of dependence in the USA, although efforts to control drinking, or reduce harm, are more often deemed appropriate goals in the UK and other parts of Europe. Some studies have reported that about 20% of those with alcohol dependence were able to drink moderately without problems in the previous year, but this is often temporary, and other studies indicate that fewer than 10% ever develop long periods of non-problematic drinking.

On genetic risk:

• About 40-60% of the risk of alcohol-use disorders is explained by genes and the rest through gene-environment associations.
  

Themes in drug policy

Ed at The Second Road commented on my last post that "race of the person using the drug is probably playing a role in how the public perceives the danger of that drug."

Ed is very right, though the current methamphetamine hysteria puts a white twist on the pattern. William White wrote an article on this subject and identified these themes:

1. The drug is associated with a hated subgroup of the society or a foreign enemy.
   
   
2. The drug is identified as solely responsible for many problems in the culture, i.e., crime, violence, and insanity.
   
   
3. The survival of the culture is pictured as being dependent on the prohibition of the drug.
   
   
4. The concept of "controlled" usage is destroyed and replaced by a "domino theory" of chemical progression.
   
   
5. The drug is associated with the corruption of young children, particularly their sexual corruption.
   
   
6. Both the user and supplier of the drug are defined as fiends, always in search of new victims; usage of the drug is considered "contagious."
   
   
7. Policy options are presented as total prohibition or total access.
   
   
8. Anyone questioning any of the above assumptions is bitterly attacked and characterized as part of the problem that needs to be eliminated.

Crack Babies - The Epidemic That Wasn't

It's important to remember how wrong we can be. America has a long history of drug hype that leads to bad policy.

When the use of crack cocaine became a nationwide epidemic in the 1980s and ’90s, there were widespread fears that prenatal exposure to the drug would produce a generation of severely damaged children. Newspapers carried headlines like “Cocaine: A Vicious Assault on a Child,” “Crack’s Toll Among Babies: A Joyless View” and “Studies: Future Bleak for Crack Babies.”

But now researchers are systematically following children who were exposed to cocaine before birth, and their findings suggest that the encouraging stories of Ms. H.’s daughters are anything but unusual. So far, these scientists say, the long-term effects of such exposure on children’s brain development and behavior appear relatively small.

“Are there differences? Yes,” said Barry M. Lester, a professor of psychiatry at Brown University who directs the Maternal Lifestyle Study, a large federally financed study of children exposed to cocaine in the womb. “Are they reliable and persistent? Yes. Are they big? No.”

Cocaine is undoubtedly bad for the fetus. But experts say its effects are less severe than those of alcohol and are comparable to those of tobacco — two legal substances that are used much more often by pregnant women, despite health warnings.

[hat tip: dailydose.net]

More on alcohol taxes

Powerful evidence about the social costs associated with alcohol:

Carpenter and Dobkin then electronically examined the death certificates of every 19- to-22-year-old who died in the United States between 1997 and 2005.

Young people’s alcohol consumption increases by over 20 percent as they hit their 21st birthday. Meanwhile, death rates increase by 9 percent exactly at age 21. Carpenter and Dobkin traced this further, finding that the mortality jump was largest for motor vehicle accidents, suicides, and other causes plausibly linked with alcohol use. The correlation isn’t a slam dunk, but it is close. The authors estimate that reducing the minimum drinking age by one year--as some propose--would cause 408 additional deaths every year among 20-year-olds.

...Over the past 50 years, Cook reports, the inflation-adjusted value of federal liquor taxes declined by a factor of six while the inflation-adjusted value of federal beer taxes declined by a factor of 3.6. Both taxes are well below what is required to recoup the alcohol-related “externalities” problem drinking imposes on the community.

This is crazy. Cook argues that a 10-cent tax per ounce of ethanol (the amount contained in two drinks) would reduce ethanol sales by 12 percent and would reduce motor vehicle fatalities by about 7 percent. An estimated 80 percent of these taxes would be paid by the 13 percent of American adults who are heavy drinkers. I’m not happy to impose this burden. Yet this is the very group which causes great social harm.

Medical marijuana raids

Obama said that he would end medical marijuana raids, so this story is getting some attention on the internet.

As I've said before, I'm not a medical marijuana alarmist and I don't think this is a good use of resources, but this continues to feel like an incredibly phony issue.

Here are some reviews of the "medical marijuana dispensary:

Veronica G. says "With the price of gas nowadays, not everyone can make the drive up to SF from the Peninsula. Cheers to a large healthy rotating selection that can please even some of the most descerning of medicators* (or at least raise an eyebrow or two). Props also for having in mind the "stoner on a budget" or the "day before payday" if you will, by selling in incriments as small as a gram or get the bang for your blunt buck from some shake

Not that I'd know or anything...."

Versace Shade says "No one medicates more than me. All I can say is that this spot provides high quality, top nodes of the best specifically Kens OG and Kens Purple.

BIG Fan of TRICHome K!!"

DT says "If you are on the bay grapes hype this is the club for you. Holistic Solutions always have a good selection of the best grapes in the bay.. at a good price too.. $45 an eigth will get you some dank grapes and sometimes they have some specials from like 50 - 55 .. never seen higher than that, but they usually have some amazing color or taste.

I would definitely recommend anything with the name ken in it... his granddaddy is hella tasty.. they have a cool variety of hash too.. from 15 - 80 a gram.. a couple different kindas.. right now they got:

humboldt hash for 15/g
buddha kush hash for 40/g
granddaddy kief 30/g
sour diesel high concentrate 80/g

All pretty dank."

Only one review puts it in the context of medication in any serious way.

I don't doubt that this is a serious issue for some people, but, for many, the medical angle is just that--an angle. So, instead, it would be nice if they advocated for decriminalization rather than hiding behind the medical angle.

Here's a smart take on the issue from Mark Kleiman. It's too nuanced for me to pull a quote. Read the whole thing.

Tab dump

Accurate Native history is critical to sobriety and recovery, program finds

The Drug Capitals Of America

Responsibility and Choice in Addiction

Technology improves treatment options for drug users

Pain, opiates and addiction

This is not news, but there's no reason to fear treating pain patients with opiates. Few pain patients develop problems with the drugs.

However, I'd add two side concerns that could/should be addressed in ways that do not result in inadequate pain treatment.

First, diversion is a huge problem. 12% of 18 to 25 year olds reported nonmedical use of pain relievers in the last year. This problem could be addressed without depriving patients of treatment.

Second, physicians need to be educated about addiction. I can't tell you how many clients have gone to the ER for minor injuries and were prescribed Vicodin even after they explained that they are a recovering addict and do not want anything mood altering.

Methadone provocation

Rowdy Yates makes some provocative points about cognitive impairment associated with methadone, methadone's legal status and it's social purpose (treatment vs. social control).

Enjoy.

Tylenol risks

Alix Bryan puts together a striking collection of statistics about the way Americans use over the counter medications.

More proof about the effects of alcohol taxes

They are effective at reducing alcohol related problems.

What's holding us back? These discussions get bogged down in "nanny state" and other libertarian arguments, but we never talk about how much our culture values alcohol. Certainly, that plays as much of a role as the philosophical political arguments. That never enters the conversation. Why?

[hat tip: Lawrence at Second Road]

What if you knew your child had the "alcoholic gene"

Etta at Second Road posted a great question:

What if there were an alcoholic gene? Anyone who had this gene was sure to be an alcoholic. What if you were informed your child had it?  What would you think? What would you do?

I’ve thought a lot about it and my son is now 2 years younger than I was when I took my first drink.

Clearly, there isn’t one gene that causes it. More likely there are
multiple genes that contribute to the risk of developing an addiction.

In spite of giving it a lot of thought, I haven’t come up with a whole lot.

• I’ll do what I can to postpone drinking and drug use as much as possible. Once experimentation begins, I’ll do what I can to not be an alarmist but will still minimize it in terms of frequency and quantity. Early use is associated with an increased risk of problems.
• I’ll be open and honest about my recovery–trying to normalize recovery and model a path if either of my kids develop problems.
• I’ll do what I can to foster the development of recovery capital (Recovery capital is the quantity and quality of internal and external resources that one can bring to bear on the initiation and maintenance of recovery) before they develop a problem. Hopefully, if they develop a problem, this will minimize the duration of it and the losses associated with it.
• Most of all, I'll just try to love them and recognize that this is one of those areas where my influence is limited. I just have to accept that.
  

Bill White wrote a great article calling for research in this area, you can find it here.

Moderation Management works for some

A study suggests that Moderation Management may work for people with "less severe dependence". I'd like to see them flesh out what "less severe" means. Technorati Tags: research, mutual_aid

Separate and unequal

Addicted physicians have terrific recovery rates. We know what works. Why does this two tiered approach to treatment and recovery support persist?

Abstract - A sample of 904 physicians consecutively admitted to 16 state Physicians' Health Programs (PHPs) was studied for 5 years or longer to characterize the outcomes of this episode of care and to explore the elements of these programs that could improve the care of other addicted populations. The study consisted of two phases: the first characterized the PHPs and their system of care management, while the second described the outcomes of the study sample as revealed in the PHP records. The programs were abstinence-based, requiring physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At post-treatment follow-up 72% of the physicians were continuing to practice medicine. The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence.

Freebase caffeine

Eek. Talk to your sponsor before you look at this.

I suspect that there is little to this, but whenever I see anything like this I am reminded of a talk by Bill White on drug trends. He closed by saying something like, "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 they will become a problem when someone develops new ways to use them."

School drug testing outcomes

Not good:

Overall, drug testing was accompanied by an increase in some risk
factors for future substance use. More research is needed before random
drug and alcohol testing is considered an effective deterrent for
school-based athletes.

Hope for addicts

From the new White House website:

• Reduce Crime Recidivism by Providing Ex-Offender Support: President Obama and Vice President Biden will provide job training, substance abuse and mental health counseling to ex-offenders, so that they are successfully re-integrated into society. Obama and Biden will also create a prison-to-work incentive program to improve ex-offender employment and job retention rates.
• Eliminate Sentencing Disparities: President Obama and Vice President Biden believe the disparity between sentencing crack and powder-based cocaine is wrong and should be completely eliminated.
• Expand Use of Drug Courts: President Obama and Vice President Biden will give first-time, non-violent offenders a chance to serve their sentence, where appropriate, in the type of drug rehabilitation programs that have proven to work better than a prison term in changing bad behavior.

It's a start.

The Amethyst Initiative

A while back I wrote about efforts to lower the drinking age.

Here's a thoughtful, but somewhat ambivalent argument for lowering the drinking age to 18.

Twenty-nine states lowered their minimum age by 1975. I and a colleague analyzed the effects on highway fatalities, finding that the relevant age group experienced about a 10% increase in states that lowered their age for all beverage types from 21 to 18, compared with states that didn’t change their law. Other research documented this and other indications of increased abuse. President Reagan appointed a commission that documented the problems (with some exaggeration) and ultimately sold Congress on establishing a national minimum.

(Note that we analysts could recite all the theoretical reasons why an age-based prohibition could have perverse effects on health and safety. Those arguments have some truth, but were ultimately trumped by the data. The net effect of lowering the minimum age was to increase alcohol abuse.)

...

Yet giving 18-20 year olds the right to drink has a lot going for it. After all, 18 year olds currently can vote, serve on juries, and hold most public offices, enlist in the military or work at any job without parental consent, undertake contractual obligations including marriage, and legally purchase lottery tickets, cigarettes, and shotguns. They are held fully accountable for criminal acts and are too old to receive the protection of the statutory rape laws.

It is also true that while the minimum age law does some good, it’s widely violated – in fact, it’s hard to think of another law that is so widely scoffed at. The great majority of older teens choose to drink, with whatever effect that may have on their respect for the law generally.

It's good to see someone wrestling with the subject in an intellectually honest manner.

I doubt that there will be movement in this direction, but if there is, I'd hope that the requirement would be lowered to 18 with a high school diploma and 19 without. This might help reduce access for high school students.

 

Trauma and parental responses to homosexuality

Here are a couple of links to loosely related topics. Loosely related because rates of substance use disorders (SUDs) are higher among LGBT people and people with PTSD.

First, a post about a researcher who theorizes that playing Tetris shortly after a traumatic experience may reduce the incidence of PTSD. The idea is that occupying the parts of the brain that play a role in memory consolidation will interfere with traumatic memories becoming so entrenched and powerful.

One earnest question. Would playing Tetris during study breaks interfere with remembering studied material?

Next, a post about the damage cause by parental rejection of homosexual children:

The odds ratios reported indicate that a homosexual youth experiencing high levels of rejection by family have a risk of attempting suicide as much as 8 times more than those experiencing little or no rejection by family. Looking at the raw numbers, this means as many as 67 percent of study subjects in the high rejection group had attempted suicide by age 25! Illicit drug use, substance abuse disorders, and risky sexual behaviors are also similarly increased in this group. The apparent effect of family rejection is devastating.

Needle Exchanges Save Lives but May Imperil Workers

From the Wall Street Journal:

Pete Morse devoted his life to saving the lives of heroin users. A dreadlocked community activist with a Ph.D in history, he bore a tattoo that read: "Injury to one is an injury to all."

So his friends and colleagues were shocked when he was found unconscious in 2007 on a bathroom floor with a needle by his side. Doctors pronounced the 36-year-old Mr. Morse dead from an overdose of heroin, alcohol and cocaine.

Mr. Morse spent more than 10 years working in drug-addiction programs that follow the principle of harm reduction. This philosophy argues that the best way to save users' lives isn't to force them off illegal drugs. Instead, its adherents teach safer ways to use drugs -- supplying clean needles to prevent the spread of disease, for example, or teaching how to avoid overdosing. The programs are credited with saving lives in cities across the U.S.

To my mind, this is no indictment of harm reduction per se. I see this as a symptom of one of my biggest reservations about many harm reduction programs--that they don't view addictive drug use as an illness. Rather, many programs treat it as a lifestyle choice and that to promote recovery is to moralize.

Because harm-reduction programs don't force their clients to quit, making employees do so would be "completely hypocritical," said Ms. McQuie, the West Coast director of the Harm Reduction Coalition, a New York-based nonprofit that trains workers to run needle exchanges and other harm-reduction programs....

...Mr. Morse never stopped identifying as a user. In counseling with clients, the tattooed and dreadlocked Mr. Morse listened silently and, based on his own use and drug knowledge, explained how certain prescription drugs interact with heroin, recalls Kirk Read, who worked with Mr. Morse gathering data for a drug-user study for the University of California.

I'm sure that some will disagree with me, but is it possible to for a program like this to effectively encourage recovery? I'm sure it gives lip service to recovery, but I can't imagine it's interested in doing so, and I doubt that it could if it wanted to.

It's unlikely that I'll be taken seriously, given that I'm viewed as an enemy of harm reduction, but harm reduction has a lot of house cleaning to do. (Just as abstinence oriented programs did when harm reduction began its ascension.) I hope to see more programs adopting recovery-oriented harm reduction approaches.

Sharing our stories

Fighting stigma is important to me. I believe stigma is the most powerful barrier we face.

• It drives professionals to develop "treatments" based on the expectation that we cannot recover.
  
• It drives families to give up on us.
  
• It makes our communities to fear us and choose to protect themselves by locking us up.
  
• It makes financial interests decide that providing care to us is a waste of money.
• It makes faith communities define the problem as sin.
• It makes us turn on our own. How many addicts have you seen share at tables about their powerlessness and addiction as an illness, but then treat chronic relapsers with scorn and disdain, telling them that they "just don't want it" or "haven't made a decision".

Like any other stigmatized group, we need to reduce our "otherness". It seems that the best way to reduce our "otherness" is to tell our stories, let other people know that we are their sons, daughters, fathers, mothers, nieces, nephews, cousins, neighbors, employees, employers, PTA parents, parishioners, doctors, lawyers, teachers, mechanics, plumbers, etc.

So, I know that we need to tell our stories, but I think we need to be careful about the way we tell our stories. There is so much danger of self-enoblization(sp?), narcissism, fetishization, etc. There's constant risk of making ourselves a spectacle rather than humanizing addicts and normalizing recovery.

I keep coming across links to these books and I've resisted linking to them. I don't know enough about them to judge them, but the stylized, dramatic photos for one of them make me squeamish.

So, how do we tell our stories in ways that minimize this risk? I'm not sure I know the answer. I think that drunkalogues do little to help us. I suspect that modesty and humility when sharing our recovery are important. Maybe to keep in mind that the purpose of telling our stories is to illuminate addiction and recovery rather than aggrandizing ourselves and our struggle.

In any event, I'm excited about this:

From Billboards

Drug Companies & Doctors: A Story of Corruption

Ezra Klein directs us to a NY Times Book Review piece on doctors, research, evidence-based medicine and drug companies:

Conflicts of interest affect more than research. They also directly shape the way medicine is practiced, through their influence on practice guidelines issued by professional and governmental bodies, and through their effects on FDA decisions. A few examples: in a survey of two hundred expert panels that issued practice guidelines, one third of the panel members acknowledged that they had some financial interest in the drugs they considered. In 2004, after the National Cholesterol Education Program called for sharply lowering the desired levels of "bad" cholesterol, it was revealed that eight of nine members of the panel writing the recommendations had financial ties to the makers of cholesterol-lowering drugs. Of the 170 contributors to the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), ninety-five had financial ties to drug companies, including all of the contributors to the sections on mood disorders and schizophrenia. Perhaps most important, many members of the standing committees of experts that advise the FDA on drug approvals also have financial ties to the pharmaceutical industry.

Combine this with my recent posts about publication bias and researcher allegiance effects and it's enough to make a cynic wonder if they've mustered sufficient skepticism. Oy.

Most popular posts in 2008

1. Alcoholics Anonymous (AA) Recovery Outcome Rates: Contemporary Myth and Misinterpretation
2. Heroin Anyone?
3. The History of Gay People in AA
4. FDA fast-tracks first cocaine, meth addiction fighter
5. The super adventure club helps kids say "no"
6. What Addicts Need
7. Narcan outrage
8. More on recovery in the U.K.
9. Co-occurring Social Anxiety and Alcohol Use Disorders
10. More from Pat Deegan
11. Cocaine self-medication for insomnia
12. Kicking methadone in the U.K.
13. Sick of watching people die
14. Recovery and the Conspiracy of Hope
15. Drug policy freak show

Loose associations

People who know me well know that I often make loose associations that leave other people scratching their heads. Here are two loosely related articles that I wanted to draw your attention to.

First, an article on batterer's intervention programs that provides an overview of some of the history and the philosophical tensions that exist among programs.

Second, an article on happiness as a social phenomena.

While there are many determinants of happiness, whether an individual is happy also depends on whether others in the individual’s social network are happy. Happy people tend to be located in the centre of their local social networks and in large clusters of other happy people. The happiness of an individual is associated with the happiness of people up to three degrees removed in the social network. Happiness, in other words, is not merely a function of individual experience or individual choice but is also a property of groups of people. Indeed, changes in individual happiness can ripple through social networks and generate large scale structure in the network, giving rise to clusters of happy and unhappy individuals. These results are even more remarkable considering that happiness requires close physical proximity to spread and that the effect decays over time.

The findings could be understood as an affirmation of the importance of communities of recovery. It also might provide more concrete support for advice to "stick with the winners". [hat tip: wired in]

Helping heals

More evidence for the healing power of one alcoholic helping another.

Oww, Oww...Ahhh

How many addicts do you know that love spicy food? I know quite a few.

TASTELESS, colourless, odourless and painful, pure capsaicin is a curious substance. It does no lasting damage, but the body’s natural response to even a modest dose (such as that found in a chili pepper) is self-defence: sweat pours, the pulse quickens, the tongue flinches, tears may roll. But then something else kicks in: pain relief. The bloodstream floods with endorphins—the closest thing to morphine that the body produces. The result is a high. And the more capsaicin you ingest, the bigger and better it gets.

Publication bias

PLoS has an article taking an economist's look at the publication process for pharmacological studies. The paper offers some potential remedies:

Potential Competing or Complementary Options and Solutions for Scientific Publication

1. Accept the current system as having evolved to be the optimal solution to complex and competing problems.
2. Promote rapid, digital publication of all articles that contain no flaws, irrespective of perceived “importance”.
3. Adopt preferred publication of negative over positive results; require very demanding reproducibility criteria before publishing positive results.
4. Select articles for publication in highly visible venues based on the quality of study methods, their rigorous implementation, and astute interpretation, irrespective of results.
5. Adopt formal post-publication downward adjustment of claims of papers published in prestigious journals.
6. Modify current practice to elevate and incorporate more expansive data to accompany print articles or to be accessible in attractive formats associated with high-quality journals: combine the “magazine” and “archive” roles of journals.
7. Promote critical reviews, digests, and summaries of the large amounts of biomedical data now generated.
8. Offer disincentives to herding and incentives for truly independent, novel, or heuristic scientific work.
9. Recognise explicitly and respond to the branding role of journal publication in career development and funding decisions.
10. Modulate publication practices based on empirical research, which might address correlates of long-term successful outcomes (such as reproducibility, applicability, opening new avenues) of published papers.

Happy New Year!

It could be media hype (Hard to know from thousands of miles away, but reports have been consistent and objective measures, like cirrhosis rates, seem to support it.), but something seems to be very wrong with England's drinking culture.

What's up with this? American discussions about binge drinking seem to focus on college-aged drinkers and drinking age. Clearly not the issue in England.