Alcoholism, Family and the Limits of Love | World of Psychology

Bill White reviews the tv movie airing this Sunday, When Love is Not Enough:

When Love is Not Enough is clearly more than a love story, though it is surely that. Readers of Psych Central and the people they serve will discover in this movie six profound lessons about the impact of alcoholism and alcoholism recovery on intimate relationships and the family.

1. Prolonged cultural misunderstandings about the nature of alcoholism have left a legacy of family shame and secrecy.

2. Alcoholism is a family disease in the sense that it also wounds those closest to the alcohol dependent person; transforms family relationships, roles, rules, and rituals; and isolates the family from potential sources of extended family, social, and community support.

3. The family experience of alcoholism is often one of extreme duality.

4. Family recovery from alcoholism is a turbulent, threatening and life-changing experience.

5. We cannot change another person, only ourselves.

6. The wonder of family recovery.

How much do we know?

Clinical Evidence offers a pie chart that categorizes medical treatments (All medical treatments. This is not specific to addiction.) by their known effectiveness.

Use evidence-based approaches is important in all services, human and otherwise, but it's easy to forget that the concept is not that simple--there are political factors, publication bias, research bias, real world vs. research considerations, individual client factors, practitioner factors, environmental factors, etc. When thinking about evidence-based approaches in the context of behavioral health, it's also easy to lose sight of the larger medical context.

Figure 1 illustrates the percentage of treatments falling into each category. Dividing treatments into categories is never easy hence our reliance on our large team of experienced information specialists, editors, peer reviewers and expert authors. Categorisation always involves a degree of subjective judgement and is sometimes controversial. We do it because users tell us it is helpful, but judged by its own rules the categorisation is certainly of unknown effectiveness and may well have trade offs between benefits and harms. However, the figures above suggest that the research community has a large task ahead and that most decisions about treatments still rest on the individual judgements of clinicians and patients.

End Insanity Of The War on Drugs—Start With Decriminalizing Marijuana at The Federal Level

Ron Paul renews his call for marijuana decriminalization.

I'm not knee jerk about the matter, I don't think anyone should do jail time for simple possession, but these arguments would resonate more with me if they said something to address the social costs of drugs and alcohol. Alcohol prohibition was wrought with serious problems and I would never support its return, but alcohol consumption is tied to no small number of serious social problems and costs. (And it has an industry that's invested in shaping policy, beliefs and attitudes toward those problems and costs.)

As I've said before, a problem-free alcohol and drug policy is not possible. There will be problems with any policy. The question is which problems are we willing to live with and what can we do to mitigate them.

Tab Dump

• An Alcoholic’s Savior: God, Belladonna or Both? (Not news, but interesting. May say something about Bill Wilson's openness to LSD later in life.)
• Losing a voice of reason against ‘war on drugs’
  
• Soft war on drugs: Portugal shows how drug addiction, when treated as an illness and not as a crime, can be controlled effectively.
• Tanning bed usage can be as addictive as cannabis and alcohol (Ugh! I've said before that I worry about some of the neuroscience of drug addiction being replicated with all sorts of other compulsive behaviors. I don't believe that this will prove those behaviors are brain diseases or that addiction is not. Just that we understand less about the mechanisms of addiction than we think we do.)
• Reason.tv: 3 Reasons to Legalize Pot Now! (I find the first half of number one to be a terrible reason for legalization.)
• Why is Disulfiram Superior to Acamprosate in the Routine Clinical Setting? (Given the underwhelming evidence for disulfiram, what does this say about acomprosate? Can't get the full text yet.)

I give my autistic son pot

News from the medical marijuana front lines .

More on McLellan's departure

More on McLellan's departure.

Why Drug Addicts Are Getting Sterilized for Cash

Another story on Project Prevention. I've blogged about them before here and here.

What does it say that Time inserted this into the story?

(See the best and worst moms of all time.)

I think it speaks volumes about about the attitudes and stigma that this kind of program taps.

Think for a minute about the about the opening paragraphs:

When Joanne Chavarria's grandmother died last summer, she coped by turning to the bottle. "I started to drink. And then I started to smoke some weed. And then I started doing meth," says the 32-year old from Merced, California. Chavarria, who began abusing drugs at the age of 12, was eight months pregnant at the time. Last August, she gave birth to drug-addicted twins, and California's Child Protective Services took the infants, and Chavarria's three other children, into custody.

As with other addicts, the road to recovery for Chavarria began with counseling and a drug rehabilitation program. Less orthodox, however, was her decision to undergo a tubal ligation. "Addicts in my situation need to get their tubes tied," she says. "When you stop having kids it makes you think about what else you can do in life."

Chavarria had the procedure done after meeting with Project Prevention, a North Carolina-based charity that gives drug addicts $300 if they go on long-term birth control or undergo sterilization. The aim of Barbara Harris, 57, the organization's controversial founder, is to prevent addicts from having children they can't care for and reduce the number of babies born exposed to drugs.

"Last summer"?!?!?!

This article is dated April 17!

More concerns about DSM-V criteria

This concern speaks to some of my thoughts.

Others are more concerned, arguing that abuse should be thought of as a behavior and dependence as a disease, and by combining them it becomes easier for payers to deny clinically appropriate care. Even worse, it might signal a shift to the idea that any professional with "behavioral" health training would be eligible.

It's worth noting that is not an argument for the status quo. I've never been comfortable with abuse as a disorder.

The Joylessness of Drug Addiction

From Addiction Inbox:

The act of “liking” something is controlled by the forebrain and brain stem. If you receive a pleasant reward, your reaction is to “like” it. If, however, you are anticipating a reward, and are, in fact, engaging in behaviors motivated by that anticipation, it can be said that you “want” it. The wholly different act of wanting something strongly is a mesolimbic dopamine-serotonin phenomenon. We like to receive gifts, for example, but we want food, sex, and drugs. As Nesse and Berridge put it, “The ‘liking’ system is activated by receiving the reward, while the ‘wanting’ system anticipates reward and motivates instrumental behaviors. When these two systems are exposed to drugs, the “wanting” system motivates persistent pursuit of drugs that no longer give pleasure, thus offering an explanation for a core paradox in addiction.”

McLellan Resigning as ONDCP Deputy Director

Too bad. He's had a lot of family stuff going on. Sounds like a terrible time to start this kind of job. I wish him all the best.

Medical care in recovery

We're working on improving linkages between our clients and primary medical care. We've borrowed from these guidelines and have been discussing this with local primary care physicians. 

I drafted the document below for clients and I'm interested in your thoughts. Keep in mind that I'm trying to keep it brief so that people will actually read it. Please post comments or email me with your comments.

Thanks!

UPDATE: A few updates throughout the day. The most recent version can be viewed here.

=============

Medical care in recovery

It's been said that the doctors office can be one of the most dangerous places for a recovering alcoholic or drug addict.

Here are a couple of data points from studies on the subject:

• 29.5% of patients said their physicians knew about their addiction and prescribed psychoactive drugs such as sedatives or Valium, which could cause additional problems. (Source)
• 94% of primary care physicians fail to diagnose substance abuse when presented with early symptoms of alcohol abuse in an adult patient. (Source)
• In a study of third-year medical students, only 19% recognized alcoholism during a mock chart review examination, even though the alcoholism diagnosis, a family history of alcoholism, and a 10-year history of extensive alcohol use were included prominently throughout the chart. (Source)
• A national survey of residency program directors found only 56% of the programs require training in substance use disorders. Even when training is required, very little is provided—median curriculum hours ranged from 3 to 12. (Source)

We've seen countless relapses begin with a visit to the doctor's office. It can happen even when the recovering person is clear about their recovery status. We've heard time and time again from recovering people who go to the doctor for something like pain or sleep problems and the doctor insists that a drug like vicodin, ambien or ultram is "mild" or "safe".

For this reason (and a couple others) it's important to recruit your doctor to support your recovery. 

Reasons to make your doctor a recovery ally

1. To help assure that your doctor will not prescribe you anything that might put your recovery at risk.
   
2. To help assure that you won't make a bad decision when you're scared, unhappy and/or in pain. When we're suffering we're at risk for making poor choices, we just want the pain to stop, we feel like we're going to go crazy if we don't get some sleep or if the anxiety doesn't stop. Everyone wants a quick, easy fix when their suffering, but the consequences are much more dire for us. This doesn't mean that we shouldn't take our symptoms seriously, we just need to be careful not to put our recovery at risk.
   
3. To help your doctor with diagnosis and treatment. Some symptoms of addiction (even in abstinence) can look like other medical and psychiatric problems. You want to be sure that the right problem is being treated. Your doctor can't make the right diagnosis if they don't have all the relevant information.
   
4. Addiction is a chronic illness and requires long term care, monitoring and support--longer than Dawn Farm can provide.
   
   Here's one way to think about it. If you get cancer, say Hodgkins, you are likely to go through a course of chemotherapy and radiation. If all goes well, within a period of months there will be no signs of cancer left in your body. Does your cancer treatment stop there? Let's hope not! Your doctor will probably want you to get periodic body scans for a period of around 5 years to be sure that a relapse is not occurring. If there is a relapse, the patient gets more treatment before the cancer get too bad. Why 5 years? Because recovery from the cancer is not considered stable until relapse rates drop below 15% and it takes about 5 years that to occur. It just so happens that it takes about 5 years for alcoholism relapse rates to drop below 15% and about 7 years for opiate addiction relapse rates to drop below 15%.
   
   For this reason is makes sense to make sure that you are getting recovery monitoring and support for a period of at least 5 years. A primary care physician is an ideal person to provide this monitoring and support.
   
5. It's your recovery and you're responsible for protecting it. There is tons of research that suggests this is important and there are thousands of stories that speak to its importance. 

What you can do

First, if you do not already have a doctor, choose a doctor that know something about addiction and recovery. We recommend the following:

Academic Internal Medicine 5333 McAuley Drive, Suite 4015 Ypsilanti, MI 48197 734.712.5300 (Sliding scale down to $0)	Corner Health Center 47 N. Huron Ypsilanti, MI 48197 734.484.3600 (22 and younger. Sliding scale down to $0)
Pain Recovery Solutions 4870 Clark Road Ypsilanti, MI 48197-1104 734.434.6600	Integrated Health Care 1290 South Main Street Chelsea, MI 48118-1454 734.475.1107

Second, make an appointment for a checkup. We have prepared a letter that you can send your doctor before your visit or bring with you to your appointment. It may seem corny or unnecessary, but it's important that it's in your file. You may end up working with other doctors and, let's face it, they are probably not going to remember.

Third, have your counselor prepare a release that allows your doctor and treatment staff to coordinate your care. Your counselor will then send them a letter letting them know that we are happy to help if they have any questions.

Fourth, bring it up with your doctor and let them know you'll welcome them asking how your recovery is going.

Fifth, keep in mind that it's likely you'll have to remind them when you come in for medical visits.

One more thought

All of this also applies to visits to the dentist too! It's easy to let your guard down and overlook the risks in a dental office then find yourself with a prescription for vicodin or offered nitrous oxide.

All of this may seem like overkill, but is it really? We're vigilant about all sorts of other things in our lives. All of us organize our lives around protecting things that are important to us, whether it's our job, family, health, creative outlets, faith--whatever. So much depends on our recovery. Shouldn't we be just as vigilant in protecting it?

The Future of AA, NA and Other Recovery Mutual Aid Organizations

Bill White's latest is up on Counselor Magazine's website. Two of the most interesting moments come in a section on the "Emerging science of recovery"

Science also will spark controversies by challenging prevailing beliefs of recovery fellowship members. Research on the potential value of medication-assisted recovery is challenging and softening many AA members’ views about medication. One of the most controversial issues within NA in the coming decade will be the science-driven push to re-evaluate local group policies on methadone and other medications (e.g., denial of the right of more than 265,000 persons in methadone maintenance in the United States to speak at NA meetings, chair a meeting, or head a service committee—even by individuals with prolonged stabilization, no secondary drug use, and achievement of global health and positive citizenship.) Some will attempt to avoid this debate by declaring that scientific studies on methadone maintenance are an “outside issue,” but the growing weight of science will exert enormous pressure on NA as an institution, as it will all recovery mutual aid fellowships.

All recovery mutual aid societies will be scientifically evaluated in the coming decades on such dimensions as accessibility, attraction, engagement (affiliation and retention rates), short- and long-term effects on the course of AOD problems, effects on global health and functioning and the potential social cost offsets from such participation. Some groups will face this scrutiny and actually achieve heightened scientific credibility (as has happened with AA in the past decade); others will not withstand the effects of such scrutiny.

An issue most critical to the survival of recovery mutual aid groups is the question of how long members should continue to participate. While 12 Step fellowships have implicitly encouraged sustained if not lifelong participation, many of the alternatives to 12 Step Fellowships do not expect sustained member participation. Among the latter, members are expected to avail themselves of sufficient support to initiate stable recovery and then leave and get on with their lives.

Science is actually revealing that this latter position may work at an individual level. Recent studies of AA reveal a population of positively disengaged individuals who initiated recovery within AA, then later ceased active participation but continued to sustain their sobriety and emotional health over time (Kaskutas, Ammon, Delucchi et al., 2005). An interesting outcome of this finding is that the actual societal impact of AA may have been grossly underestimated, as its contributions have generally been measured by its active membership numbers—a figure that ignores the existence of this larger community of people positively affected by but no longer actively participating in AA. The same is likely true for other recovery fellowships.

Interestingly, the “participate as long as and for only as long as you need to” policy may work at a personal level for many individuals but may doom a recovery mutual aid group’s organizational viability. The future of any recovery mutual aid organization rests on its leadership development and long-term meeting maintenance capacity. The personal recovery outcomes of a recovery support group will not always distinguish those groups that will survive and thrive from those that will stagnate and die or regress to the status of a small ideological cult or commercial platform.

Thanks Recovery Academy

Thanks to the Recovery Academy for including this blog in their newsletter.

Science can answer moral questions

Recently, I've had a few posts arguing that values are critical for making meaning of evidence and that values are embedded in scientific research. I suppose one point I've been making is that those who claim to be objective may believe that they are objective, but they are not.

Sam Harris argues for objectivity in morality and values.

Much of my worldview predisposes me to be sympathetic with his argument, but I find his sauce to be pretty weak. This may seem like a diversion, but isn't this often what we're talking about when we translate research to policy?

What he said...

I've tried several times to make the point that there is no such thing as "value free" interventions and policy decisions. This chapter makes the point better than I can:

Policy research is commonly presented as a value-free endeavour but, logically speaking, practical conclusions cannot be derived solely from facts. In research methodology, to attempt to do so is termed the `Naturalistic Fallacy.' Consequently, the term `evidence-based policy'--if interpreted literally--constitutes a contradiction in itself (oxymoron). This chapter will also deal with several other fallacies that are encountered in empirical addiction research, will reveal some popular concepts to be inconsistent and illogical advocacy tools, and will argue that the specific role of a researcher is completely incompatible with the role of an advocate for certain ideas and/or interest groups.

...

Statements can be dichotomised into descriptive statements (factual judgements about what is) and prescriptive statements (value judgements about what ought to be done). The latter are referred to as ethical judgements. It is well accepted in philosophy (Hume's Law) that ethical judgements cannot be derived logically from empirical facts alone. Any syllogism to arrive at ethical conclusions requires at least one ethical premise as well. The flawed idea of basing ethical conclusions purely on empirical facts was called the `Naturalistic Fallacy' by Moore, and has become a well-known term in research methodology. On the basis of facts, only factual conclusions can be derived. However, this does not mean that ethical issues cannot be a topic for empirical research--the opposite is true. It is essential to identify implicit value judgements and to make them explicit. Only if all implicit value judgements in our scientific reasoning are made explicit is it possible to analyse whether the ethical premises are consistent with each other,* with basic ethical principles and with factual evidence. I have previously termed the process of identifying and analysing implicit values in research `ethical evaluation', but this term is ambiguous since it could mean either `to conduct evaluations according to ethical standards' or `to evaluate the ethical content in research.' More precise is the term `evaluation of implicit ethics' or the almost synonymous `evaluation of implicit values.'

Odds Are, It's Wrong

Researchers' dirty little secret:

“There is increasing concern,” declared epidemiologist John Ioannidis in a highly cited 2005 paper in PLoS Medicine, “that in modern research, false findings may be the majority or even the vast majority of published research claims.”

Ioannidis claimed to prove that more than half of published findings are false, but his analysis came under fire for statistical shortcomings of its own. “It may be true, but he didn’t prove it,” says biostatistician Steven Goodman of the Johns Hopkins University School of Public Health. On the other hand, says Goodman, the basic message stands. “There are more false claims made in the medical literature than anybody appreciates,” he says. “There’s no question about that.”

...

Statistical problems also afflict the “gold standard” for medical research, the randomized, controlled clinical trials that test drugs for their ability to cure or their power to harm. Such trials assign patients at random to receive either the substance being tested or a placebo, typically a sugar pill; random selection supposedly guarantees that patients’ personal characteristics won’t bias the choice of who gets the actual treatment. But in practice, selection biases may still occur, Vance Berger and Sherri Weinstein noted in 2004 in ControlledClinical Trials. “Some of the benefits ascribed to randomization, for example that it eliminates all selection bias, can better be described as fantasy than reality,” they wrote.

Trauma, Chemical Use and Addiction

Can't make the Dawn Farm Education Series? Catch the most recent presentation, Trauma, with the slidecast below.

Trauma, Chemical Use and Addiction - March 2010

View more presentations from jschwartz.

tab dump

• Of Genes and Gin
• R. Gil Kerlikowske speaks on his job as nation's drug czar
• Not smart: Guardian misquotes

9 Medical Marijuana Ads

9 Medical Marijuana Ads

The Spread of Goodness

Jonah Lehrer reports on findings that human behavior is contagious whether it's obesity, optimism or generosity.

He added this postscript with a reader comment. I suspect it's one explanation for the healing and sustaining power of communities of recovery:

Update: I've gotten a few emails wondering what this means for free will. After all, if our decisions are so determined by the decisions of others, then where is there space for human autonomy? My first reaction is that the new science of social networks still leaves plenty of elbow room for individual decisions. We're talking about risk factors and tendencies and statistical correlations. Just because we're influenced by others doesn't mean we can't reject those influences. I asked James Fowler a related question last year and this was his eloquent response:

Everyone always tells me that this research is so depressing and that it means we don't have free will. But I think they're forgetting to look at the flipside. Because of social networks, your actions aren't just having an impact on what you do, or on what your friends do, but on thousands of other people too. So if I go home and I make an effort to be in a good mood, I'm not just making my wife happy, or my children happy. I'm also making the friends of my children happy. My choices have a ripple effect.

AA “unethical” says SMART recovery founder

I saw this article yesterday and chose not to comment, but now that PeaPod has, I'll join his chorus. I had a similar reaction. I was disappointed in two things:

• It's too bad that this person can't just promote Smart Recovery as an alternative without bashing AA.
• The author adopted the critics language, presenting it as fact without context.

Oh well. It's nothing new and it won't be the last time. I recognize that people in twelve step recovery can be just as judgmental. More recovery is a good thing. Too bad we can't all just get along.

Evidence for what?

Stanley Fish:

While secular discourse, in the form of statistical analyses, controlled experiments and rational decision-trees, can yield banks of data that can then be subdivided and refined in more ways than we can count, it cannot tell us what that data means or what to do with it. No matter how much information you pile up and how sophisticated are the analytical operations you perform, you will never get one millimeter closer to the moment when you can move from the piled-up information to some lesson or imperative it points to; for it doesn’t point anywhere; it just sits there, inert and empty.

He is arguing that discussions about weighty matters fall apart in a secular context. I couldn't disagree more. Though I do think he's onto something. Evidence, by itself, leads nowhere. It needs context and something else to give it meaning. I believe that "something else" that animates these discussions are our values. Further, I believe that this is the case whether our values are recognized or not and that it's important for all parties to put their values on the table for examination and discussion.

America's largest service provider for addicts

Unsurprising news from CASA:

Of the 2.3 million inmates crowding our nations prisons and jails, 1.5 million meet the DSM IV medical criteria for substance abuse or addiction, and another 458,000, while not meeting the strict DSM IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation; or shared some combination of these characteristics, according to Behind Bars II: Substance Abuse and America’s Prison Population. Combined these two groups constitute 85 percent of the U.S. prison population.

Worst of the proposed DSM-V

The newly proposed substance use disorder diagnostic criteria made a "worst of" list for the DSM V.

Two takes on Insite and another on harm reduction

First, a columnist from the Calgary Herald says that Insite doesn't do enough to change addicts:

Corey Ogilvie wanted to document life in Vancouver's notorious downtown eastside (DTES) by spending 30 days living alongside the residents of North America's poorest, most destitute and drug-infested neighbourhood. Film clips of his journey are posted on the Internet and, as one would expect, are highly revealing.

In one clip, he determines he must do drugs to understand addiction. While coming down from a crack high, he decides to try heroin. So his street buddies send him to Insite, Vancouver's safe injection site.

Ogilvie's smuggled camera reveals Insite staff doing everything but stick the needle in his arm as they aid him in his quest. A staff member shows him how to prepare the heroin, fill the syringe and find a vein. He's clearly a novice and the worker asks the obvious question, "So, can I ask? Why the drug use?"

When Ogilvie fails to offer much of a response, the worker offers an upbeat, "It's OK. You don't have to say anything. It's not a big deal."

...

I was very impressed with the sincerity and concern that Insite staff have for those who come through their doors. They are truly kind and compassionate, and provide addicts with a very human (and humanizing) element to their day. For that, I offer kudos.

Yet I came away thinking that Insite's main gauge of success is engagement, not treating addiction, reducing numbers of addicts or providing addicts with a way out. Maybe social interaction is enough for some, but I remain unconvinced that facilitating drug injections and perpetuating a destructive lifestyle is the best way to afford someone their human dignity. These non-judgmental interactions may make addicts feel better about their behaviour, but I didn't sense that the Insite philosophy had any room for the notion that addicts could actually change their behaviour -- at least not the addicts in the DTES.

Insite does have 12 detox beds and 18 'transitional' beds for those who are hoping to get into treatment. They have daily programs such as yoga, health care or counselling for these residents. But, again, I never got the sense that they had much hope for addicts beyond the Insite facilities.

Insite leaders seemed uncertain about what treatment facilities existed and where they were located, but still insisted that they weren't the kind of facilities that would be a good fit for DTES addicts. I'm under no illusion that there are sufficient treatment facilities available, but isn't any addict going to be out-of-his-comfort zone in an addiction treatment facility? Since the intent is to change lifestyle patterns, I would certainly hope so.

Meanwhile, a blogger for Phoenix House gives them the benefit of the doubt:

...when I looked at Insite’s website, I was encouraged by the fact that the facility is actually part of a larger organization that provides “a complete continuum of services,” including prevention, opioid replacement therapy, residential treatment, and housing support. An addiction counselor is part of Insite’s staff and, in its second year of operation, it made 2,000 referrals to other services. A New England Journal of Medicine study found that, because Insite removes barriers to treatment, its clients—who may not be well connected to the health care system—have increased their use of detox and withdrawal programs.

If Insite’s advocates want a real shot at challenging critics, they should emphasize that it is not a stand-alone operation, but a “rung on the ladder” from “chronic drug addiction to recovery.” People suffering the devastating effects of substance abuse cannot change their lives overnight. But, getting off the street and coming to a place like Insite—where medical professionals can help them get the care they need—may be the first step in the process. I hope future media coverage of Insite offers this perspective.

Finally, the blog, The Art of Life Itself, describes ab approach to harm reduction that embraces recovery.

Low-Tech Treatment May Be Best for Addiction

This Newsweek piece offers a little perspective on pharmacology and behavioral treatments for addiction:

Freud was a disaster for psychiatry, but not because his theory of the mind inspired his acolytes to exclude physical and chemical processes from explanations of thoughts, emotion, and behaviors. No, the disaster has been the extreme backlash against that nonmaterialist, touchy-feely approach. As neuroscience has blossomed in the last two decades, it has left virtually everything that smacks of psychiatry in the dust. In a nutshell, and not to get too Cartesian, but the brain has replaced the mind.
...

Consider the excitement over cocaine vaccines. Composed of a bacterial protein plus a molecule that is a coke look-alike, they train the immune system to produce antibodies against both. The antibodies also bind to cocaine, preventing it from entering the brain and causing a high. The good news is that the vaccine makes crack less pleasurable, notes Meg Haney of Columbia University, who led a 2010 vaccine study. That suggests the vaccine indeed kept the drug out of the brain. The bad news is that the level of antibodies in the volunteers (55 coke users in a 2009 study, 10 crack users in Haney's) varied widely. Only 38 percent of the coke users produced enough antibodies to dull the effects of cocaine, and, of those, only half stayed clean more than half the time.

In contrast, a 2008 analysis of 34 studies of behavioral treatments for addiction to cocaine, marijuana, and other drugs showed impressive efficacy. "There is still no generally effective [medication]" for coke, pot, and meth addictions, notes psychiatry professor Kathleen Carroll of Yale University. "But the behavioral therapies we have are quite good," bringing a 67 percent improvement. Yet that research gets the response of the proverbial tree falling in an empty forest.

...the National Institute on Drug Abuse, which has been terrific in funding behavioral approaches to addiction. It has had so much success in developing and validating behavioral therapies "that we don't need more research to show they work," says NIDA director Nora Volkow. Consider a new study she led with colleagues at Brookhaven National Laboratory. They showed cocaine users pictures of coke and coke paraphernalia, which usually makes activity in the brain's limbic (emotion) regions spike, causing intense craving. The scientists taught the users to suppress that activity. That success, says Volkow, "provides enormous hope," implying that cognitive interventions might enable cocaine abusers to "block the drug-craving response to help them avoid relapse." The problem is implementation, and Volkow is "trying to direct more funding to that." One wonders how much more could be accomplished if it got more than table scraps. Especially if cognitive and behavioral approaches can overcome their lack of sex appeal.

It's not too late to save 'normal'

A chairperson from the DSM-IV makes a plea to avoid what she has now concluded were mistakes:

Our panel tried hard to be conservative and careful but inadvertently contributed to three false "epidemics" -- attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many "patients" who might have been far better off never entering the mental health system.

The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.

Willpower as an exhaustible resource

A new book called Switch targeting business types has a lot of food for thought about addiction.

First, the authors explore the tension between the emotional brain and the rational brain:

The unavoidable conclusion is this: Your brain isn’t of one mind.

...

But, to us, the duo’s tension is captured best by an analogy used by University of Virginia psychologist Jonathan Haidt in his wonderful book The Happiness Hypothesis. Haidt says that our emotional side is an Elephant and our rational side is its Rider. Perched atop the Elephant, the Rider holds the reins and seems to be the leader. But the Rider’s control is precarious because the Rider is so small relative to the Elephant. Anytime the six-ton Elephant and the Rider disagree about which direction to go, the Rider is going to lose. He’s completely overmatched. Most of us are all too familiar with situations in which our Elephant overpowers our Rider.

You’ve experienced this if you’ve ever slept in, overeaten, dialed up your ex at midnight, procrastinated, tried to quit smoking and failed, skipped the gym, gotten angry and said something you regretted, abandoned your Spanish or piano lessons, refused to speak up in a meeting because you were scared, and so on. Good thing no one is keeping score.

The weakness of the Elephant, our emotional and instinctive side, is clear: It’s lazy and skittish, often looking for the quick payoff (ice cream cone) over the long-term payoff (being thin). When change efforts fail, it’s usually the Elephant’s fault, since the kinds of change we want typically involve short-term sacrifices for long-term payoffs. (We cut back on expenses today to yield a better balance sheet next year. We avoid ice cream today for a better body next year.) Changes often fail because the Rider simply can’t keep the Elephant on the road long enough to reach the destination.

The Elephant’s hunger for instant gratification is the opposite of the Rider’s strength, which is the ability to think long-term, to plan, to think beyond the moment (all those things that your pet can’t do).

But what may surprise you is that the Elephant also has enormous strengths and that the Rider has crippling weaknesses. The Elephant isn’t always the bad guy. Emotion is the Elephant’s turf—love and compassion and sympathy and loyalty. That fierce instinct you have to protect your kids against harm—that’s the Elephant. That spine-stiffening you feel when you need to stand up for yourself—that’s the Elephant.

And even more important if you’re contemplating a change, the Elephant is the one who gets things done. To make progress toward a goal, whether it’s noble or crass, requires the energy and drive of the Elephant. And this strength is the mirror image of the Rider’s great weakness: spinning his wheels. The Rider tends to overanalyze and overthink things. Chances are, you know people with Rider problems: your friend who can agonize for twenty minutes about what to eat for dinner; your colleague who can brainstorm about new ideas for hours but can’t ever seem to make a decision.

If you want to change things, you’ve got to appeal to both. The Rider provides the planning and direction, and the Elephant provides the energy. So if you reach the Riders of your team but not the Elephants, team members will have understanding without motivation. If you reach their Elephants but not their Riders, they’ll have passion without direction. In both cases, the flaws can be paralyzing. A reluctant Elephant and a wheel-spinning Rider can both ensure that nothing changes. But when Elephants and Riders move together, change can come easily.

They then frame willpower as an "exhaustible resource":

To see this point more clearly, consider the behavior of some college students who participated in a study about “food perception” (or so they were told). They reported to the lab a bit hungry; they’d been asked not to eat for at least three hours beforehand. They were led to a room that smelled amazing— the researchers had just baked chocolate-chip cookies. On a table in the center of the room were two bowls. One held a sampling of chocolates, along with the warm, fresh-baked chocolate-chip cookies they’d smelled. The other bowl held a bunch of radishes.

The researchers had prepped a cover story: We’ve selected chocolates and radishes because they have highly distinctive tastes. Tomorrow, we’ll contact you and ask about your memory of the taste sensations you experienced while eating them.

Half the participants were asked to eat two or three cookies and some chocolate candies, but no radishes. The other half were asked to eat at least two or three radishes, but no cookies. While they ate, the researchers left the room, intending, rather sadistically, to induce temptation: They wanted those poor radish-eaters to sit there, alone, nibbling on rabbit food, glancing enviously at the fresh-baked cookies. (It probably goes without saying that the cookie-eaters experienced no great struggle in resisting the radishes.) Despite the temptation, all participants ate what they were asked to eat, and none of the radish-eaters snuck a cookie. That’s willpower at work.

At that point, the “taste study” was officially over, and another group of researchers entered with a second, supposedly unrelated study: We’re trying to find who’s better at solving problems, college students or high school students. This framing was intended to get the college students to puff out their chests and take the forthcoming task seriously.

The college students were presented with a series of puzzles that required them to trace a complicated geometric shape without retracing any lines and without lifting their pencils from the paper. They were given multiple sheets of paper so they could try over and over. In reality, the puzzles were designed to be unsolvable. The researchers wanted to see how long the college students would persist in a difficult, frustrating task before they finally gave up.

The “untempted” students, who had not had to resist eating the chocolate-chip cookies, spent 19 minutes on the task, making 34 well-intentioned attempts to solve the problem. The radish-eaters were less persistent. They gave up after only 8 minutes—less than half the time spent by the cookie-eaters—and they managed only 19 solution attempts. Why did they quit so easily?

The answer may surprise you: They ran out of self-control. In studies like this one, psychologists have discovered that self-control is an exhaustible resource. It’s like doing bench presses at the gym. The first one is easy, when your muscles are fresh. But with each additional repetition, your muscles get more exhausted, until you can’t lift the bar again. The radish-eaters had drained their self-control by resisting the cookies. So when their Elephants, inevitably, started complaining about the puzzle task—it’s too hard, it’s no fun, we’re no good at this—their Riders didn’t have enough strength to yank on the reins for more than 8 minutes. Meanwhile, the cookie-eaters had a fresh, untaxed Rider, who fought off the Elephant for 19 minutes.

Book Review: Thinking Simply About Addiction

Dirk Hansen reviews Thinking Simply About Addiction: A Handbook for Recovery and describes its interesting spin on the concept of powerlessness:

While acknowledging that addiction is “correctly understood as a disease,” Sandor diverges a bit from the mainstream disease theory of addiction, believing that addictions are “diseases of automaticity—automatisms—developments in the central nervous system that cannot be eliminated but can be rendered dormant.”

As examples of simple automatisms, Sandor cites bicycle riding and swimming, two behaviors it is impossible to “unlearn.” Consider swimming: If, for some reason, it became extremely dangerous for you to swim (pollution, a heart condition, sharks), the problem is that “you literally cannot choose not to swim. Your only reliable choice is to stay out of the water, to become abstinent.”

Much of the confusion over addiction, the author maintains, is that “we miss the essential quality that defines addiction as a disease: Something someone has rather than something they’re doing.”

What his addicted patients frequently tell him, Sandor writes, is that “the core experience of being addicted is powerlessness, the experience of having lost control over the use of alcohol or a drug.” As one addiction expert put it, addicts “have lost the freedom to abstain.” Like other forms of rehabilitation, says Sandor, “treatment doesn’t work or not work. The patient works. It seems obvious. If the very nature of addiction is automaticity—the loss of control—then recovery is the restoration of choice, not handing choices over to someone else.”

Not a Tiger Woods post

I've always struggled with how to talk about "process addictions" and other compulsive behaviors. More specifiically, how to distinguish them from AOD addiction.

A psychiatrist wrestles with sexual addiction and wonders if obsessive compulsive disorder (OCD) is the best way to conceptualize sexual addiction:

It seems difficult to me to distinguish OCD from so-called sexual addiction; perhaps the main difference would be that the individual is bothered by his behavior in one case (OCD) and not the other (addiction); yet this single minor subjective difference would seem to be a small feature upon which to base an entire diagnostic entity. Indeed, there appear to exist many cases of OCD without insight, that is, OCD in which the patient is not much bothered by his or her symptoms. OCD is not, traditional teaching notwithstanding, uniformly characterized by presence of insight (better phrasing than the old ego-dystonic term, in my view).

One reputable website defines sexual addiction as "a progressive intimacy disorder characterized by compulsive sexual thoughts and acts." DSM's definition, under paraphilias, as sexual disorders NOS includes the following ideas: "compulsive searching for multiple partners, compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships and compulsive sexuality in a relationship." This kind of definition seems quite hard to distinguish from OCD with sexual content.

Who are you calling square?

On more thought from the author of the book I referenced last night:

One of the things I’ve become most aware of while working on this book is the degree to which cultural critics inside and outside of the academy write about phenomena that reflect and reinforce their own tastes and worldviews. There’s a lot of writing out there about addiction, because addiction, despite its tragic dimension, retains a sheen of cool. Drug and alcohol use and abuse are dis-inhibiting; they de-stabilize social norms. Without too much effort, we can see them as heroic challenges to the staid routines of our uptight bourgeois lives.

Recovery culture, by contrast, is really square, both as aesthetics and as politics. ... It’s this squareness, I think, that has led critics to overlook the complexity of recovery—its existence as a cultural formation with a genuine intellectual and social history that both reflects and helps to construct the larger economic, political, and psychic realities around it.

Those who are predisposed to disagree will dismiss this (and vice versa), but I think that this speaks directly to the coolness many in recovery feel toward "empirical" knowledge of the issue. I think it also speaks to the appeal of harm reduction for many (not all, by any stretch) practitioners.

terra incognita?

A new book offers a wide ranging look at addiction as a cultural phenomena. The description of the tension with academia is interesting:

At another level, however, this book addresses a blind spot that seems particularly to affect academic researchers. Many recovering people have good reasons for not inquiring into the intellectual genealogies of their programs. For good or ill, their interests in recovery philosophy are primarily practical. Later chapters discuss the fact that they may even be urged by those around them not to take an overly analytical or intellectual view of their program lest they derail their quests for sobriety. The same is not true, however, for academics, whose lack of knowledge of and incuriosity about recovery is often so complete as to seem decidedly willful. While the well-educated humanist or qualitative social scientist is expected to have at least a passing familiarity with the standard premises of psychoanalysis, the recovery movement’s most basic history and its structuring ideas are, for all intents and purposes, a terra incognita to most such scholars. Therefore, a second aim of this book is to establish recovery—its history, its organizing principles, and its culture, among other things—as a legitimate subject for sustained scholarly analysis.

There are exceptions to this rule of academic neglect, of course. Existing scholarly research on recovery falls into two general categories, and though neither type of work has sought to answer the cultural questions that I find most compelling, I have drawn heavily on both while writing this book. First and not surprisingly, an abundant body of research has explored the medical/psychological and public health dimensions of 12-Step approaches to alcoholism and other addictions. Since it began to be generated during the late 1940s, the vast bulk of this scholarship has centered on questions of efficacy: does 12-Step recovery, with its focus on abstinence and spirituality, successfully break addictive habits? This practical question would seem well suited to empirical social scientific inquiry, but the ‘‘Anonymous’’ nature of 12-Step culture means that collecting meaningful data on the topic is and always has been difficult. Moreover, much research on this question is fiercely partisan, undertaken by scholars whose stakes in particular treatment protocols (and the private and governmental funds that legitimate them) often seem to predetermine their research outcomes. As a result, the question of whether, how, and to what degree 12-Step approaches to addiction are effective remains largely unresolved.

The Wisdom of Cochrane

The group that reached this conclusion:

The available experimental studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence compared with other treatments, but there were some limitations with these studies. Furthermore, many different interventions were often compared in the same study and too many hypotheses were tested at the same time to identify factors which determine treatment success.

strikes again:

Psychostimulants did not improve cocaine use, had an unclear beneficial effect over sustained cocaine abstinence and were not associated with higher retention in treatment. Psychostimulants did not increase risk of serious adverse events. It was found that psychostimulants could be efficacious for some groups of patients, such as methadone maintained dual heroin-cocaine addicts. Therefore, psychostimulants, though have not proved yet their efficacy for cocaine dependence, deserve further investigation.

A Review of Alcoholics Anonymous/ Narcotics Anonymous Programs for Teens

Recently published:

The investigation of the applicability of Alcoholics Anonymous/Narcotics Anonymous (AA/NA) for teens has only been a subject of empirical research investigation since the early 1990s. In the present review, the author describes teen involvement in AA/NA programming, provides an exhaustive review of the outcomes of 19 studies that used an AA/NA model as part of their formal teen substance abuse treatment programs, and provides data on the effects of AA/NA attendance on abstinence at follow-up, on which youth tend to become involved in AA/NA, and on mediation of the benefits of AA/NA participation. In addition, the author suggests the reasons for somewhat limited participation by teens in more informal, community-based 12-step meetings, and makes suggestions for maximizing participation at meetings in the community. The author concludes that AA/NA participation is a valuable modality of substance abuse treatment for teens and that much can be done to increase teen participation, though more research is needed.

Farm staff that want the entire article can email me.

Inside the "addiction cure"

What is there to say?

Putting substance "abuse" to rest

Bill White makes the case for ending the use of the word "abuse", as in substance abuse. He make's 5 arguments:

1. The term abuse applied to substance use disorders is technically inaccurate
2. The terms alcohol/drug/substance abuse/abuser reflect the misapplication of a morality-based language to depict a medical condition.
3. The terms abuse/abuser contribute to the social and professional stigma attached to substance use disorders and may inhibit help-seeking.
4. The terms abuse/abuser inaccurately portray the role of personal volition in substance use disorders.
5. The use of the abuse diagnosis by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) perpetuates and legitimizes the continued stigmatization of people with AOD problems.

CUOMO ANNOUNCES CHARGES AGAINST FORMER UB RESEARCHER FOR HIRING ACTORS TO TESTIFY DURING MISCONDUCT HEARING AND ATTEMPTING TO SIPHON $4 MILLION IN TAXPAYER FUNDS

Wow. This guy has written extensively on substance use disorders and domestic violence.

In September 2004, William Fals-Stewart, 48, of Eden, was accused of scientific misconduct for allegedly fabricating data in federally funded studies he was undertaking as an employee at the University at Buffalo and Research Institute on Addictions. According to court papers, the allegations were based upon discrepancies between the number of volunteers he reported to the National Institute for Drug Addiction relating to grants for which Fals-Stewart was the Principal Investigator, and the actual number of volunteers who participated in his studies.

According to the felony complaint, during a subsequent formal investigation launched by the University, three witnesses testified by telephone because Fals-Stewart claimed they were out of town. In reality, they were actors who thought they were taking part in a mock-trial. Fals-Stewart paid the actors to testify. He also provided them with scripts to use during the proceedings that were riddled with inaccuracies regarding his research. Fals-Stewart told the three actors, who he had hired before for legitimate training videos, that they would be performing in a mock trial training exercise. They were not aware that they were testifying at a real administrative hearing, nor did they know they were impersonating real people. Because of these false testimonies, Fals-Stewart was exonerated at the administrative hearing.

Claiming that the misconduct allegations tarnished his reputation, Fals-Stewart sued the University, seeking $4 million from the state in damages. The Office of the Attorney General, in its role of defending the University and the state in the court action, conducted a thorough investigation of the claims against the University. It was during this investigation that Cuomo’s office discovered the alleged fraud, forced Fals-Stewart to withdraw his lawsuit and initiated a criminal investigation.

Fals-Stewart was arrested today and charged in Buffalo City Court with Attempted Grand Larceny in the First Degree (class C felony); three counts of Perjury in the First Degree (class D felony); three counts of Identity Theft in the First Degree (class D felony); two counts of Offering a False Instrument for Filing in the First Degree (class E felony); and three counts of Falsifying Business Records in the First Degree (class E felony). The maximum permissible sentence for a class C felony is 15 years in prison.

The sociology of drinking

A lot of people have sent this to me. I don't know what to say about it.

I have an attraction/aversion thing with Gladwell. He's a great writer and fascinating, but I can't read him without thinking of this Mencken quote, "For every complex problem there is an answer that is clear, simple, and wrong."

I also tend to think this a situation of the exception proving the rule. Looking to an isolated culture with aberrant drinking patterns for universal truths doesn't seem to make a lot of sense.

It's a Bird, It's a Plane, It's... Methadone Man?

Hmmm.

I'm open to harm reduction, but I'm troubled by the culture of many harm reductionists.

Needle exchange raises weighty Catholic moral questions

It will be interesting to watch the Catholic church wrestle with the ethics of needle exchange.

Psychotropic prescribing

Two stories from recent news:

This NPR story reports that antipsychotics are Medicaid's largest drug expense. That's astonishing.

A friend sent this story on the potential for harm when people without severe depression are prescribed antidepressants:

Half of patients do not respond when they are given the medications, which can be powerful tool in helping the depressed to feel better. Instead of raising levels of a "happiness chemical", called serotonin, in their brain, they lower them.

The researchers found with some brain cells "the more antidepressants try to increase serotonin production, the less serotonin (they) actually produce,” said Dr Rene Hen, from Columbia University in New York and a researcher at the New York State Psychiatric Institute, who led the study.

Substance-Related Disorders | APA DSM-5

The APA is planning to eliminate substance dependence and substance abuse from the DSM-5 and is planning to replace them with "[insert drug name]-use disorder". Here are the proposed alcohol-use disorder criteria.

They propose severity specifiers, which is interesting. However, at first glance, I'm concerned about putting abuse and dependence on the same continuum, though I was always pretty ambivalent about abuse as a diagnosis anyway.

Your thoughts?

UPDATE: Let's hope they don't group "internet addiction" and opiate addiction:

Among the work group’s proposals is the recommendation that the diagnostic category include both substance use disorders and non-substance addictions. Gambling disorder has been moved into this category and there are other addiction-like behavioral disorders such as “Internet addiction” that will be considered as potential additions to this category as research data accumulate.

Does Alcohol Involvement Increase the Severity of Intimate Partner Violence?

A pretty intuitive finding. That domestic violence is more severe when alcohol is present.

Study Says Drinking with Your Kids Doesn't Prevent Abuse

Join Together reports:

Dutch teens who were allowed to drink alcohol at home drank more outside the home than their peers and -- along with other teens who drank -- were at increased risk of developing alcohol problems, according to researchers from Radboud University Nijmegen.

The study authors tracked 428 Dutch families with two children ages 13-15. They found that teens who drank at home also drank more on their own, and vice-versa, suggesting that teen drinking begets more teen drinking regardless of setting.

"The idea is generally based on common sense," said researcher Haske van der Vorst. "For example, the thinking is that if parents show good behavior -- here, modest drinking -- then the child will copy it. Another assumption is that parents can control their child's drinking by drinking with the child."

However, the study demonstrated that, "If parents want to reduce the risk that their child will become a heavy drinker or problem drinker in adolescence, they should try to postpone the age at which their child starts drinking," said van der Vorst.

The research was published in the January 2010 issue of theJournal of Studies on Alcohol and Drugs.

Injection center coverage

Slate has a couple of dispatches on "Vancouver's experiment with helping addicts get high"

A commentary accuses opponents of "contempt for science"

I don't oppose harm reduction but, like this blogger, I see no reason why a recovery orientation could not be introduced in every harm reduction service.

The zeal for insite and contempt for critics make me wonder what their feeling would be about programs that distribute sleeping bags to homeless people to prevent frostbite and exposure deaths? These programs exist and there's one in my community.

Of course, there's one important difference. They engage in considerable advocacy, and not for more sleeping bags or tents, but for housing.

UPDATE: Peapod mentioned "evidence" below. Along the lines of his comment, we could produce studies and reams of evidence that sleeping bag distribution prevents frostbite and reduce exposure deaths, right? Does that make it the right thing to do? Maybe. Does that make it an adequate response? No. Does that mean that, in the establishment of priorities, it should trump other responses? No.

ONDCP talks recovery

New Drug Policy Approach Focuses on the Vital Role of Recovery. See page 2.

Good news

2010 Federal Budget Boosts Funding for Mental Health and Substance Abuse Programs

AA and depression

From Addiction:

ABSTRACT
Rationale Indices of negative affect, such as depression, have been implicated in stress-induced pathways to alcohol relapse. Empirically supported continuing care resources, such as Alcoholics Anonymous (AA), emphasize reducing negative affect to reduce relapse risk, but little research has been conducted to examine putative affective mechanisms of AA's effects.

Methods Using lagged, controlled, hierarchical linear modeling and mediational analyses this study investigated whether AA participation mobilized changes in depression symptoms and whether such changes explained subsequent reductions in alcohol use. Alcohol-dependent adults (n = 1706), receiving treatment as part of a clinical trial, were assessed at intake, 3, 6, 9, 12 and 15 months.

Results Findings revealed elevated levels of depression compared to the general population, which decreased during treatment and then remained stable over follow-up. Greater AA attendance was associated with better subsequent alcohol use outcomes and decreased depression. Greater depression was associated with heavier and more frequent drinking. Lagged mediation analyses revealed that the effects of AA on alcohol use was mediated partially by reductions in depression symptoms. However, this salutary effect on depression itself appeared to be explained by AA's proximal effect on reducing concurrent drinking.

Conclusions AA attendance was associated both concurrently and predictively with improved alcohol outcomes. Although AA attendance was associated additionally with subsequent improvements in depression, it did not predict such improvements over and above concurrent alcohol use. AA appears to lead both to improvements in alcohol use and psychological and emotional wellbeing which, in turn, may reinforce further abstinence and recovery-related change.

Cocaine Vaccine Hits Snag

Over at Addiction Inbox, Dirk Hanson reports on findings from a trial of the new cocaine vaccine and provides a succint description of its mechanism:

Some cocaine addicts appear willing to risk overdose in order to defeat a new cocaine vaccine, a recent study has shown.

The study, which appeared in the Archives of General Psychiatry, demonstrated that the TA-CD vaccine could blunt the effects of cocaine in some, but not all, patients. The vaccine works by causing the production of antibodies, which attach themselves to cocaine molecules, making the molecules too big too pass effectively through the blood-brain barrier.

Of 115 addicts involved in the study, only 38 % produced sufficient antibodies to dull the effects of cocaine, Rachel Saslow of theWashington Post reported. And among the high-antibodies group, only 53 % stayed free of cocaine 50 % of the time. “Immunization did not achieve complete abstinence from cocaine use,” said Thomas Kosten of Baylor college of Medicine, one of the authors of the paper.

Moreover, in some of the study participants for whom antibodies made cocaine a disappointing high, researchers found cocaine levels in the body to be as much as ten times higher than previous levels of usage—an obvious attempt to overcome the vaccine’s effectiveness. There were no overdoses, according to Kosten.

Politics, Science and Harm Reduction

Macleans has an interesting column making the case for the role of politics in decisions about programs like Insite:

...each person’s own opinions on federalism may not line up neatly with his views on drug policy. Indeed, if you are a strong centralist when it comes to Confederation AND you loathe the Harper government, or you’re just a centralizer who favours harm reduction, it seems to me that the Insite controversy has painted you into a rather awkward corner.

As far as I can tell, we are not having the kind of debate that would force such a person to say “I hate that those anti-science Conservative nutbars are trying to crush Insite, but they certainly have the right to do so.” Nor are we hearing from decentralizing socons who might say “I sure hate the idea of doctors getting paid good money to hover over diseased vermin while they irrigate their veins with poison, but as much as I like the Prime Minister, he should damn well stay out of B.C.’s business.”

I would add that this fundamental constitutional question is all the more important because, unlike many fellow libertarians and supporters of harm reduction, I don’t really believe that the value of safe-injection clinics is something that can be settled by a simple appeal to the authority of science. Science is well-placed to answer narrow, specific measurement questions about drug policy: “Did Insite reduce the number of overdose deaths in the region between years X and Y?”, for example. By answering such questions, it can provide the material for a broader assessment of the worth of such programs. But it cannot decide by fiat.

Insite has to be judged by its effects on many groups of citizens—not just the drug users who visit Insite, but the drug users who don’t and won’t; the families and loved ones of both groups of addicts; the dealers; the cops; the ordinary people who live near the clinic, and elsewhere in the region; the B.C. government, its treasury, and its taxpayers. (An environmentalist, or a Lorax, would even say that the non-human world should have a voice.) Within none of these groups are the effects simple or quantifiable by means of a single number, and all of the groups may have different claims to moral consideration, claims that there can be no universal agreement on. Moreover, the integrity of the criminal law and the public’s respect for it do count for something—maybe not much, but not zero—in this equation. The defender of Conservative policy would argue that this makes us all parties to the controversy, even outside B.C.

In short, science can’t provide us with a simple, scalar Benthamite answer to the net utility of Insite. To oppose Insite is not to be opposed to “science”, though a lot of scientists like Insite. Whether the clinic ought to exist is a question well-suited to be answered by political means: public and private argument, consensus-building, horse-trading, the consulting and balancing of moral principles, et cetera. Since this is the case, the question of what political unit should have the power to make the decision—the federation, or the province—is both crucial and urgent.

The problem of free will in addiction

Philosophy bites has an interview with Thomas Pink on free will that I think touches on points important to thinking about addiction.

It's my anecdotal sense that much of the resistance to the disease model comes from concerns about free will. Specifically, that the disease model suggests a loss of free will (or, a kind of determinism), at least in this one area of the addict's life. The problem here is this: if the person is not in control of their behavior, how can we hold them accountable or assign blame for the bad things that they they do or that result from their AOD use? This isn't a small matter. This kind of accountability is an important social glue.

This podcast (18 minutes) does a good job exploring the matter of blame and free will, but, more importantly, addresses the apparent incompatibility between free will and determinism by suggesting that we conceptualize them improperly.

A helpful metaphor is offered: If a machine has two controllers (one controller representing deterministic factors and the other representing free will), does that mean that only one controller works? Or, is it possible that they both are capable of controlling the machine?

Here and Now with A. Thomas McLellan

Here and Now has a good, brief interview with A. Thomas McLellan.Hea

Not on the same side

Doctors criticise ‘reckless’ drug abuse guidance

"I Want Heidi Fleiss To Get Well ... But I Don't Think Celebrity Rehab Is The Solution"

I don't usually post this kind of thing, but I've always had a soft spot for Juliana Hatfield. I think she's a little too kind to Dr. Drew.

I think money -- and the possibility of renewed visibility leading to future job offers -- is the only legitimate, honest motivation for anyone to go on "C.R." (Celebrity Rehab) I suspect that another reason people do go on the show -- disregarding the fact that they are so drug- and booze-addled that they simply cannot make any rational or intelligent decisions about anything -- is that they crave attention and fame. These people -- especially these people -- will never get clean unless they disappear; out of Hollywood, off of TV.

Addiction treatment afflicted with Baumol's cost disease

I'd never heard of this guy or "Baumol's cost disease", but it makes a lot of sense and is has difficult implications for the future of of addiction treatment, particularly for providers that serve indigent populations or focus on offering affordable care.

Update: I got a few questions about this. The implication for programs is that, because there is little or no chance for gains in efficiency, programs must make more money every year just to maintain the status quo. Prices are just about the only lever that programs have.

Words used to describe substance-use patients can alter attitudes, contribute to stigma

This study highlights something that's always troubled me about efforts to frame addiction as a chronic illness, that it could be more likely to increase stigma rather than decrease it.

Part of the appeal of the acute model is that it offers a narrative of permanent transformation. There are two concerns about the disease model that I hear over and over again that contribute to stigma.

The first concerns personal responsibility--that if we accept the disease model and destigmatize addiction, we're letting people off the hook for bad decisions. This concern focuses on behavior prior to recovery and the chronic model offers nothing new to address these concerns.

The second concern is that addicts and alcoholics don't change and that recovery either isn't a realistic possibility for most addicts or that recovery doesn't mean what advocates say it means. Some argue that alcoholics will never really quit, others might argue that the real problem is character and when you sober up a drunken horse thief you still have a sober horse thief. This fear of recidivism (or the expected persistence of anti-social behavior that's attributed to all addicts) contributes to disease model resistance and stigma. The acute model's narrative of permanent transformation, offers a (too often false) response to this fear. The chronic model's emphasis on lifelong vulnerability contributes to these fears that recovery is temporary and unstable.

Some will invest a lot of time in micro-examining word usage to improve "messaging". I don't think that this is the answer. I believe the problem is that our message is incomplete. What we say about the illness of addiction isn't the problem. The problem is that we have very little to say about recovery.

For this reason, Bill White wrote a piece calling for research into the neurobiology of recovery. It's well worth the time to read it.

Fear Mongers Attack a NYC Harm Reduction Pamphlet that Saves Lives

Earlier this week I predicted that critics of injection drug using instructions would be accused of moral panic. I was a little off, the accusation is fear mongering.

As I said, I can imagine circumstances where this could have some value in preventing illness and facilitating recovery, but I suspect that the people producing these materials do not share my goal of recovery.

I do not oppose harm reduction, if it's aligned with the goal of facilitating recovery.

I understand that there is scientific evidence demonstrating that HR reduces disease transmission and other health problems, but some of these advocates are very tone deaf. While accusing others of moral panic or fear mongering, they fail to comprehend the way many of us view addiction--as something akin to slavery due to compromised free will where drug use is concerned.

Would there be a basis of for criticizing programs targeting slaves to enhance their health and life satisfaction? On its face, helping improve health and wellbeing is a good thing, but wouldn't it be better to also be an abolishionist?

Some more narrow public health examples might be programs to educate and provide sterile cutting equipment to people who engage in self-mutilation or communities that practice female circumcision.

Is it unreasonable to question these responses to these problems? Is it too much to ask that the professional helpers participating in these responses seek to facilitate an end to the behavior? Why is that so controversial?

On the other hand, a reader offered the following comment:

Unfortunately the tone and language of the article would seem to suggest that some "critics" do seem guilty of judgmentalness, if not exactly "moral panic"

• "offers dope fiends such useful advice"
• "spells out how junkies should ready their fix"

if the article was describing advice for hypertensives or diabetics the language would likely be a little more respectful.

Jane Doe :)

NIAAA Official Says Alcoholism 'Isn't Usually' a 'Chronic, Relapsing Disease'

Jacob Sullum enjoys a gotcha moment with Mark Willenbring.

After reading the original article, I don't see this as the Perry Mason moment that Sullum does. The article suffers from the same problem that many articles on the subject do--it does a poor job of distinguishing when we're talking about DSM dependence and when we're talking about DSM abuse. The implications for each are vastly different. Most people with DSM abuse will find that their problems eventually resolve on their own or when other primary problems are resolved. For those with DSM dependence, the conventional wisdom has been that they all need professional treatment and that they all need professional treatment and they all need to abstain completely. We're learning more about how this is not universal. Part of the problem has been categorization of problem drinkers. People with temporary, rather than chronic, alcohol problems may meet diagnostic criteria for dependence and then "mature out". The example that most easily comes to mind are college students who engage in frequent heavy drinking and then moderate when they graduate, get married, or decide that it will interfere with their goals. That's what this article examines.

What I find very interesting is the libertarian hostility toward the disease model of alcoholism. I read this a few days ago and was wondering if the objection was that the model challenges individual agency. A peek at the comments this morning suggests that the objections do coalesce around three issues:

• An objection to the notion that free will (and, therefore, personal responsibility) is compromised.
• The spirituality of AA.
• That framing heavy drinking as something other than a personal choice opens the door to medical and state interference in a person's life.
  
• That treatment doesn't look like treatment for the medical conditions that come to mind.

Heroin for dummies

Responses to this will be interesting to watch. I'm certain that people who object will be accused of moral panic or something like it.

I'm open to non-judgmental outreach harm reduction for the purpose of building relationships and gradually engaging people into recovery.

I'd like to know how these materials are being used. Are they in the hands of hopeful recovery-informed outreach workers who are building relationships and building motivation to recover? Or, something else?

I've posted about gradualism and recovery-oriented harm reduction before.

I've been thinking about a model of recovery-oriented harm reductionthat would address the historic failings of abstinence-oriented and harm reduction services. The idea is that it would provide recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented provider:

• an emphasis on client choice--no coercion
• all drug use is not addiction
• addiction is an illness characterized by loss of control
• for those with addiction, full recovery is the ideal outcome
• the concept of recovery is inclusive -- can include partial, serial, etc.
• recovery is possible for any addict
• all services should communicate hope for recovery--recognizing that hope-based interventions are essential for enhancing motivation to recover
• incremental and radical change should be supported and affirmed
• while incremental changes are validated and supported, they are not to be treated as an end-point
• such a system would aggressively deal with countertransference--some people may impose their own recovery path on clients, others might enjoy vicarious nonconformity through clients

Comparing Outcomes of ‘Voluntary’ and ‘Quasi-Compulsory’ Treatment of Substance Dependence in Europe

Another study finding that coerced treatment is just as effective as voluntary treatment.

This is important for drug courts, employers and families.

It also raises important questions about the utility of the stages of change for treatment placement. The conventional wisdom is that less motivated people should not be provided higher levels of care. These findings suggest that treatment outcomes are not a good argument for this approach.

This should be of limited comfort, though. The treatment system fails to attract too many people and relies too much on external coercion.

Charlie Sheen blames drinking for attack on wife, but is that really the cause?

Short answer, "no!"

We've written a lot on the subject. More here:

• Guidelines for working with batterers
• Guidelines for working with survivors
• Barriers Preventing Effective Communication Between Domestic Violence and Addiction Professionals
• But I was drunk!

Rising alcohol addiction costs 'could cripple the NHS'

A reader (thanks Foppe) shared this article with me about the burden addiction is placing on Britain's NHS.

I have a couple of reactions. This could be looked at as a simple reporting of facts on a public health issue. But, why do we never hear stories about cardiac disease crippling health systems? Cancer? Other diseases?

The answers that pop into my mind are that the health system (and society) doesn't consider addiction as being under their purview, they don't feel ownership of the problem. There are a lot of reasons for this, including the existence of a categorically segregated and that, beyond detox, treatment does not look like traditional medical treatment. (Though the emergence of disease management protocols has expanded the role of the medical system and recovery management seeks to integrate primary care into addiction treatment.)

The other answer that comes into my mind is that it's an expression of stigma--passive-aggressive whining about how much "those people" are costing the rest of us.