John Walters, Milton Friedman and Libertarianism

A San Diego Union Tribune blog writer got to interview U.S. Drug Czar, John Walters, and ask him about Libertarian criticism of the drug war and Milton Friedman's arguments for legalization.

Worth reading, but unfortunately more of a soap box statement than a reporting of a meaningful exchange of ideas.

Kentucky sues makers of OxyContin

It will be interesting to see if any other states follow suit:

A lawsuit filed by Kentucky Attorney General Greg Stumbo and Pike County officials demands millions in compensation from drug maker Purdue Pharma.
...
The lawsuit seeks reimbursement for costs incurred in drug abuse programs, law enforcement and prescription payments through Medicaid and the Kentucky Pharmaceutical Assistance program.

In a statement, Purdue Pharma officials said OxyContin's packaging warns against the dangers of abusing the drug and that the company shouldn't be held responsible for individuals who choose to do so.

"We will defend this lawsuit vigorously and we expect to prevail," the statement said.
...
The company said it accepted responsibility for "past misstatements" by company officials.

"We do not believe, however, that those misstatement were responsible for individuals' abuse of OxyContin," the statement said.

Predictors of Initiation of Alcohol Use Among US Adolescents

A new study from The Archives of Pediatric and Adolescent Medicine. Note what's protective (family dinners),what's not (self-esteem), and the risk factors (adults drinking in the home, underage sibling drinking, positive attitudes toward alcohol):

Results: Between 1998 and 1999, 611 girls (19%) and 384 boys (17%) initiated alcohol use. Older age, later maturational stage, smoking, adults drinking in the home, underage sibling drinking, peer drinking, possession of or willingness to use alcohol promotional items, and positive attitudes toward alcohol were associated with an increased likelihood of alcohol initiation. Girls who ate family dinner at home every day were less likely to initiate alcohol use than girls who ate family dinner only on some days or never (odds ratio, 0.66; 95% confidence interval, 0.50-0.87). Girls with higher social self-esteem and boys with higher athletic self-esteem were more likely to initiate alcohol use than those with lower self-esteem. Among teens who initiated alcohol use, 149 girls (24%) and 112 boys (29%) further engaged in binge drinking. Among girls, positive attitudes toward alcohol, underage sibling drinking, and possession of or willingness to use alcohol promotional items were associated with binge drinking; among boys, positive attitudes toward alcohol and older age were associated with binge drinking.

Conclusions: Eating family dinner at home every day may delay alcohol uptake among some adolescents. Alcohol promotional items appear to encourage underage alcohol initiation and binge drinking; this may warrant marketing restrictions on the alcohol industry.

Nicotine addiction mechanism identified

A new mechanism has been identified in nicotine addiction:

A new study reveals that, in rats, chronic nicotine use recruits a major brain stress system, the extrahypothalamic corticotropin releasing factor (CRF) system, which contributes to continued tobacco use by exacerbating anxiety and craving upon withdrawal. The researchers found that administering a compound that blocked the receptors involved in this stress system alleviated withdrawal symptoms.

Anorexia an addiction?

New research provides a peek inside the neurobiology of anorexia:

Scientists from France have found that anorexia and the highly addicting club-drug ecstasy activate some of the same brain pathways, a finding that may help explain the addictive nature of anorexia and other eating disorders and lead to new treatments.

In a paper published this week, Dr. Valerie Compan of Centre National de la Recherche Scientifique, Montpellier, and colleagues report that both anorexia and ecstasy reduce the drive to eat by stimulating the same subset of receptors for the neurotransmitter serotonin.

These so-called 5-HT4 receptors are located in a brain structure associated with feelings of reward called the nucleus accumbens.

In mice, Compan and colleagues stimulated these receptors, which are known to play a role in addictive behavior, and found that this led to anorexic-like behavior -- food-fed mice ate less and food-deprived mice showed a reduced drive to eat.

Stimulating these receptors in mice also boosted production of the same enzymes stimulated in response to cocaine and amphetamine use.

Blocking the receptors increased food intake in the animals and mice missing these receptors were less sensitive to the appetite-suppressant effects of ecstasy.

"Our data may converge to open the possibility that anorexia can be a reward-relating problem involving neuronal mechanisms," Compan told Reuters Health.

This research, she added, may have implications for the development of drug treatments for eating disorders. "Our studies over seven years now open the possibility that 5-HT4 receptor could represent an important therapeutic target to treat patients suffering from these disorders," Compan said.

Supreme Court Hears Arguments on Drug Case Sentencing

The Supreme Court of the United States is hearing cases with big implications for drug crime sentencing guidelines. Basically, they will decide whether sentencing guidelines are advisory or binding. Join Together suggests that these rulings will affect mandatory minimum sentencing laws, this article says the opposite. More here.

A better way to fight the drug war?

More on the Canadian drug policy debate. Wow!

Since nearly all the violence associated with the drug trade stems from turf wars between syndicates and gangs over who may make or sell drugs in which neighbourhoods, too little of this new money would appear to be earmarked to help police. All of it probably would not be enough to counter the well-armed, highly organized criminal networks that control much of our nation's drug trade. And since the hundreds of millions already spent by Canadian governments has done little to stem user demand for drugs, the 65% aimed at individuals may well be wasted.

Rather than declare that there are "no safe drugs," as Health Minister Tony Clement is expected to do when the anti-drug campaign is launched, the government should consider accepting that -- for good or bad -- drug use is a personal choice. As such, there is little it can do to prevent it. But given that it is a personal choice, society has little obligation to pay for the consequences of misuse. Legalize most drugs, but also declare no welfare for addicts. Let private charities supply relief and health care for those who abuse drugs. That would at least compel some users to confront the economic costs of their choices and might -- might -- discourage more Canadians from taking drugs than any preachy government advertising campaign or assault on casual drug use.

The does a great job illustrating that we're not operating from the same set of facts. Emerson summed it up well:

"Most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion. This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true. Their two is not the real two, their four not the real four; so that every word they say chagrins us, and we know not where to begin to set them right."

The Drug War

I'm not a regular reader of The Corner, but I was pleased to find a thoughtful post on drug policy. Jonah Goldberg discusses why he sees no easy answers:

One point I would like to make in response to a great many folks is the idea that simply because I'm in favor of keeping addictive narcotics illegal, I must think the current drug war is going well. I don't. I think it's a disaster. And while I'm very dubious of a lot of anti-drug war charges about our prisons being filled to the rafters with non-violent criminals, I think the overall indictment of the ongoing catastrophe is more accurate than not. But simply because I agree with a diagnosis doesn't mean I have to agree with the proposed remedy.

Indeed, this is a point often lost in political debates. Both conservatives and liberals are too often afraid to concede that the other side is pointing out real problems for fear of lending legitimacy to the opposition's proposed solutions....

Anyway, when it comes to the drug war, I'm willing to concede the point to the drug legalization crowd that the current war on drugs has all sorts of terrible consequences. I just think legalizing crack, heroin etc. will have even worse consequences, particularly in the short and mid term (i.e. the next decade or two). I believe that if you make drugs like crack cheaper, easier to get and more socially acceptable there will be more women like that cokehead mom discussed yesterday.

So what's my solution? Well the first answer has to be, I don't know. In fact, I'm not sure we can know. Some problems are hard and if not permanent certainly enduring. I don't have a solution to robbery, murder, or rape. All I have is an idea of how society should respond to such things in order to minimize their occurrence and to apply justice to those who perpetrate them (these are related but not identical issues).

Canada to adopt American style drug policies?

The Canadian government is announcing a new drug strategy that emphasizes tougher legal penalties and increased interdiction activities. Here are favorable and unfavorable articles.

Secondhand smoke law cuts heart attacks

New info on the impact of tobacco laws on public health:

A study released Thursday credits New York's 2003 Clean Indoor Air Act with an 8 percent drop in heart attacks statewide because of reduced exposure to secondhand smoke.

...

Previous studies reported more dramatic results, including a 2003 study in Helena, Mont., that found heart attacks fell by about 40 percent after voters passed an indoor smoking ban. The rates returned to normal then the ban was lifted.

Another study found heart attack rates in Pueblo, Colo., dropped by 27 percent in the 18 months after a smoking ban was imposed in bars, restaurants and other public places.

Michael Seigel, a professor at Boston University's Social And Behavioral Sciences Department who reviews tobacco policies for the school, including smoking bans, questioned the conclusions of the New York study based on its limited scope.

"You can't conclude that that decline was due to the smoking ban," said Siegel, who has testified in New York City, Connecticut and Massachusetts about the value of indoor smoking bans. "Because it's possible that decline was happening everywhere, and without assessing data from every state, there's no way to know."

The New York study examined information from a 10-year span starting before the statewide smoking ban took effect. Researchers found that regulations by local governments that preceded the statewide ban also contributed to a downward trend for heart attacks.

SCHIP Bill Includes Parity Provisions

One more step in the direction of establishing mental health and addiction treatment parity. President Bush has previously stated that he would sign a parity bill. So, once President Bush and and congress reach an agreement on the bill, the parity provisions should be intact.

The children's health-insurance bill passed by the House and Senate this week not only raises federal tobacco taxes to pay for expanded health care but also requires state programs to treat addiction and mental-health disorders on par with physical illnesses.

Considering Health Insurance Parity: The Federal Experience

The APA offers commentary on parity:

The parity policy in the Federal Employees Health Benefits program began on Jan. 1, 2001, and offers comprehensive insurance coverage for mental disorders, including substance use disorders, on terms that are identical to the coverage of general medical conditions when the treatment is provided by in-network providers.

We compared seven Federal Employees Health Benefits plans with a matched set of plans that did not change benefits or management and did not have parity. We compared use and spending by enrollees in these plans for the 2 years before parity (1999 and 2000) and for the 2 years after parity began (2001 and 2002)....

We concluded that "parity of coverage of mental health and substance abuse services, when coupled with management of care, is feasible and can accomplish its objectives of greater fairness and improved insurance protection without adverse consequences for health care costs" (1, p. 1386).

The parity policy performed just as insurance should: it reduced costs from out-of-pocket payments with a small increase in plan payments (3). This could result in very small increases in insurance premiums without leading to an increase in the use of services. The Congressional Budget Office estimates a premium impact for group plans of a 0.4 percentage point increase (4), a figure that is identical to our estimate based on the Federal Employees Health Benefits experience.

We also looked at indirect measures of quality of behavioral health care in the Federal Employees Health Benefits plans during this same period. Parity was accomplished without increases in the hospitalization of patients and without a decline in the measures of quality of care that we studied, such as the likelihood of receiving follow-up care for depression or being referred for substance abuse treatment.

There was no use of or spending for (oft-parodied) trivial behavioral conditions under managed care plans. It is worth noting that the ICD contains a wide range of general medical conditions, such as scrapes and bruises, rashes, sprains, and the common cold, just as it includes sleep disorders, mild phobias, and mild learning problems. Managed care arrangements and "medical necessity" criteria control unnecessary use and spending for trivial cases of general medical conditions and mental disorders alike.

Governor unveils program to help combat meth addiction

Utah has a new public education campaign that avoid hype and treats drug users has human beings in need of, and deserving of, our help. Let's hope that this approach catches on.

A statewide methamphetamine public-awareness campaign — one without scare tactics and stereotypes — was unveiled today by Gov. Jon Huntsman Jr.

The campaign's newspaper ads and a series of television and radio commercials urge family members and friends to recognize the signs and help addicts, rather than judging people who use meth.

...

Contrary to awareness campaigns in other states — particularly Montana's time-lapse video of people emaciated by drug use — the Utah campaign focuses on debunking stereotypes of so-called drug users and urges loved ones to realize that a meth addict is "not a lost cause."

Defining Recovery

The latest issue of the Journal of Substance Abuse Treatment has a special section of defining recovery. I'll have more on it later. Any DF staff who want the articles can contact me.

Rep. Ramstad, Recovery Advocate, to Resign

Congress is losing its most dedicated parity advocate:

Rep. Jim Ramstad (R-Minn.), a nine-term member of Congress and longtime supporter of addiction treatment and recovery issues, has announced that he will retire at the end of his current two-year term in office

Family History Of Alcoholism Affects Response To Drug Used To Treat Heavy Drinking

As we learn more about genetic factors and brain science there is growing interest in developing typologies that might help in treatment decisions. Past attempts at this have been pretty shaky, so I'll believe it when I see a good evidence-base. Keep in mind that this looks very preliminary:

Naltrexone is one of four oral medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of alcoholism. A recent large multicenter research study of alcohol dependence supported by the National Institute of Alcoholism and Alcohol Abuse (NIAAA), the COMBINE Study, suggested that naltrexone produced a modest but significant benefit but another FDA-approved medication, acamprosate, was ineffective.

Perhaps consistent with its modest effects in COMBINE, naltrexone is not widely prescribed in the treatment of alcoholism. Yet, clinicians report that naltrexone may have significant benefits for individual patients.

John H. Krystal, M.D., one of the authors, notes that "When studied in large groups, naltrexone appears to have a rather small effect upon the ability to reduce drinking or remain abstinent from alcohol. However, there is growing evidence that there are subgroups of patients who show substantial benefit from naltrexone, even when naltrexone fails to work in the overall trial.*

"According to Suchitra Krishnan-Sarin, Ph.D., the lead author, "The results suggest that family history of alcoholism may be an important predictor of clinical response to naltrexone and could potentially be used to guide clinical practice." Dr. Krystal agrees, "These data suggest that family history might influence the optimal dosing of naltrexone and the nature of the clinical response."

Getting Better Numbers on Drugs

Time looks at the process of estimating drug use in the U.S.:

At least, that's what the numbers say. Though it's been more than 30 years since Richard Nixon famously announced America's "War on Drugs," it's hard to know exactly how far we are from victory, partly because the facts are so elusive: Who uses illegal drugs? Which drugs? How often? The answers come mainly from SAMHSA's national survey, a complex and carefully worded questionnaire administered continually throughout the year. It is one of the government's primary sources of statistical information on the use of illegal drugs by the U.S. population, but its data are far from perfect.

"The bottom line is, we learn about drug use by asking people about their behaviors," says Dr. Wilson Compton, director of the Division of Epidemiology Services and Prevention Research at the National Institute on Drug Abuse. "But because it's survey research, there are multiple ways it can be improved."

From FAVOR

CALL HOUSE SPEAKER NANCY PELOSI TUESDAY, September 18th

Help pass the Paul Wellstone Mental Health and Addiction Equity Act
(H.R. 1424) this year!

There are important new developments in our efforts to take the first step to end insurance discrimination faced by people with mental illness and addiction.

Help us end practices like higher co-pays and deductibles, restrictive day and visit limits and lower and annual lifetime caps on people seeking mental illness and addiction treatment and recovery services! Take Action next Tuesday!

1). The House Ways and Means Committee's Health Subcommittee will be considering or “marking-up” H.R. 1424 next Wednesday, September 19th. After this mark-up, the only remaining hurdle before the House can vote on the bill is for the House Committee on Energy and Commerce to act.

2). According to Congressional Quarterly magazine, “the Congressional Budget Office released a surprisingly low estimate late last week of the cost impact of House legislation to put mental health care benefits on par with those for treatments of other kinds of illnesses. The estimate of the cost of the bill (HR 1424) could stiffen the resolve of the House bill's backers to stick with the more sweeping provisions of the House measure, which is expected to see floor action this fall.”

ACT SEPTEMBER 18th
—TIME IS RUNNING OUT IN CONGRESS TO PASS HR 1424!

NATIONAL CALL-IN DAY TO
END INSURANCE DISCRIMINATION

Tuesday, September 18th
9:00 am – 6:00 pm Eastern

Call House Speaker Nancy Pelosi Toll-Free

at 877.978.9996*

Our Message:

“Please schedule a vote on H.R. 1424, the Paul Wellstone Mental Health and Addiction Equity Act of 2007, by mid-October. The time has come for mental illness and addiction to be treated the same as other illnesses. Thank you for your help in making this long overdue action a reality.”

* When you dial 877.978.9996 an operator will be standing by to assist you.

Thanks for all of your advocacy that has helped continue to build momentum for passage of The Paul Wellstone Mental Health and Addiction Equity Act this year!

This Is Your (Father’s) Brain on Drugs

I never really get what this guy is saying.

Is he saying that adolescence is not "a time of heightened vulnerability for risky behavior"? That there is no such process as brain maturation or plasticity?

I can accept an argument that there's hype around adolescents and risky behaviors, but does it not have some basis in fact?

I can accept an argument that adults 35 to 54 should be of much greater concern. Does this mean that we shouldn't be concerned about adolescents?

What exactly does he suggest?

Free cocaine for addiction study subjects

Clearly, a case can be made for this kind of research if it is highly likely to lead to effective treatments for addiction. What troubles me is that there was no mention of treatment in this article. I would hope that and IRB would require a study of this type to try to engage participants into treatment--really try to engage them into treatment of adequate duration and intensity that addresses all of their barriers to recovery.