Culture and alcohol

If anyone doubts the power of culture on problem drinking, I give you Wisconsin.

Genetic causality and addiction

Martin Nicolaus caught my attention a month ago when he made some bold statements about the genetics of addiction:

Modern genetic research has wiped away any basis for the idea that alcoholism is a genetically transmitted disease. The most that can be said is that some people appear to inherit a lower responsiveness to alcohol, so that if they drink, they must drink more to get the same high.
...
Much of the myth of genetic causality rests on twin studies.[emphasis mine]

A recent commentary in Addiction wrestles with the elusiveness of easy genetic causality but doesn't throw the baby out with the bath water, explaining the difficulty in identifying genetic markers for diseases:

...there are two main reasons why association studies may not identify genes for addiction.

First, as stated above, there is the absolute requirement of adequate exposure to the drug in question for addiction to occur. For most illegal drugs the majority of the population, from which the control group is drawn, have not been exposed to the drugs and they are, therefore, unscreened controls. (The effect this may have on statistical analysis of association studies is described below.)

Secondly, the required exposure to illegal drugs is not likely to be random, but due rather to genetic and environmental characteristics of the individuals who choose to seek out these drugs, or if offered to them, choose to experiment.

The problem is that many, perhaps most, linkage or association studies will result in finding genes which predispose people to start taking illegal drugs in the first place rather than genes involved in the addiction process. The genes they find may be involved in risk taking, sensation seeking, impulsivity, etc. It seems likely that these genes/variants may also predispose individuals to mountain climbing, race-car driving, extreme sports, etc. and are therefore not related to the biological processes involved in the development of addiction. This does not necessarily mean that identification of such genes are not helpful, but they are not likely to be related to the addiction process of any specific drug, nor of its treatment, which usually does not have alteration of personality as its goal.

Further, it explains that genetic effects can be divided into two categories:

...those which directly affect the process which is perturbed during drug addiction and those which modify the known environmental effect, i.e. the liability to take drugs in the first place.

The author goes on to explain the difficulty in defining and obtaining controls for genetic studies:

While the definition of the phenotype is a major problem for any genetic study of addiction, the definition of an unaffected control is at least as problematic. For most diseases a control subject is someone who has been exposed to the known specific environmental risk factors, such as passing a certain age in studies of Alzheimer's, but who is disease free. For addiction to drugs to occur, as stated above, at a minimum there is a requirement that the individual has taken the drug in question for a sufficient length of time and in sufficient quantities as to have become addicted should they have the propensity to become so, and has continued access to the drug. Buckland suggested previously that students, at least in the United Kingdom, would make good controls for alcohol addiction [36]. However, there is no evidence that students drink more than their peers, and in addition students are relatively young to manifest alcohol addiction. Given this, it is even less easy to find a sample who have been exposed sufficiently to other drugs and are clearly not addicted; for most purposes control groups must be considered to be unscreened. The power to detect an effect is lowered by the use of unscreened controls, the extent of this depending upon the population frequency of the underlying trait, but this can be compensated for by increasing the number used by twofold or more. A statistical study [44] shows two things of importance to this concept: first, to achieve the same power, if the population frequency of the trait is less than 10% then in general simply doubling the number of controls will be enough. However, above this population frequency, the required number of controls increases exponentially. Secondly, in general, the number of unscreened controls required to give equivalent power to one screened control increases as the odds ratio of the associated allele decreases, and therefore screening controls appears to be more important when studying small genetic effects with a high prevalence of the trait [44].

He sums up the challenges in his conclusion:

There are numerous reasons why it has proved far more difficult to find genes associated with complex illnesses than what was predicted in the early years of these studies. Only now are serious advances being made by using very large sample sizes; however, the genes for addiction may still be out of sight. There are two principal specific impediments to the identification of susceptibility variants for drug addiction.

First, it is likely that a greater portion of the genetic variance in drug abuse originates from effects which are non-specific to any one drug, or to drug abuse in general, than from genetic variance which underlies the specific addiction process.

Secondly, when compared to other complex phenotypes, addiction to drugs is far less well defined, the structure of the phenotype is not fully understood, controls are effectively unscreened and heritability is relatively low.

Both of the above suggest that far larger cohorts of probands are required for genetic studies in addiction compared to other complex illnesses. Unfortunately, the largest study to date of any drug of abuse has used numbers of samples an order of magnitude fewer than are being used currently in comparative studies.

What does all this mean? Clearly, establishing the extent and specifics of genetic causality is proving far more difficult that most of us anticipated and it is pretty clear that no single gene will exert a very strong influence and that it will be certain combinations of genes that predict addiction.

I've always thought that there is a lot for us to learn about typologies of addiction. Maybe learning more about the genetic combinations that contribute to addiction will help us understand who is more or less susceptible to multi-drug addictions. We may also learn more about shared genetic traits with some process addictions. We'll know more in a decade.

Farm staff who want a copy, let me know.

More heroin maintenance drama

The heroin/methadone death match continues. Pretty troubling, of accurate.

Remember, DeVlaming is a methadone advocate. I like his use of quotation marks around the word treatment in reference to the heroin maintenance approach.

Capitalism and pharmacology

I don't expect altruism, but this and this are creepy.

Back to the future

Unfortunately, access to longer term treatment is often limited to those who can afford to pay out of pocket, but it looks like long term treatment may be making a comeback:

In fact, data suggest 30 days aren't nearly enough.

• Research published in 1999 by Bennett Fletcher, a senior research psychologist at the National Institute on Drug Abuse, has shown that though 90 days isn't a magic number, anything less than that tends to increase the chances of relapse. One study, of 1,605 cocaine users, looked at weekly cocaine use in the year after treatment. It found that 35% of people who were in treatment for 90 days or fewer reported drug use the following year compared with 17% of people who were in treatment for 90 days or longer. The study was published in the Archives of General Psychiatry.
• Another study, part of an NIDA-funded project called Drug Abuse Treatment Outcome Studies, followed 549 patients who had several problems in addition to their drug use and who entered a long-term residential program. Those who dropped out of treatment before 90 days had relapse rates similar to those who stayed in treatment only a day or two. After 90 days, however, relapse rates dropped steadily the longer a person stayed in treatment.
• Studies of youth also reflect the connection between longer care and a greater chance of recovery. A 2001 UCLA study of 1,167 adolescents receiving substance-abuse treatment found that those in treatment for 90 days or more had significantly lower relapse rates than teens in programs of 21 days.

One bit of advice we've always given people is to investigate what treatment physicians with your problem receive. Well, here you go:

Some of the earliest evidence emerged from high success rates in treatment of addicted health professionals, says Haroutunian: The Federation of State Physician Health Programs has long recommended 90-day treatments and continued follow-up care for doctors who abuse drugs.

Fortunately, Dawn Farm and other programs are finding ways to offer this support in cost effective ways by bundling treatment and recovery support services.

[hat tip: jointogether.org]

Same old, same old

Oy vey.

What is there to say. More of the freak show.

Truth is, most addicts will tell you that they started with tobacco or alcohol. For several years, I've been seeing more young clients report pot as the first drug they tried. Now, it looks like pain relievers may be overtaking pot for initiation into illicit drug use.

Denying autonomy in order to create it

The new issue of Addiction has a provocative editorial on mandated treatment. It's an issue that I'm very interested in and posted about recently.

The writer makes the case that autonomy is usurped by addiction, making it ethically justifiable to coerce treatment for the purpose of restoring autonomy.

The author then goes on to propose naltrexone as a candidate for mandated treatment. He proposes that mandated addicts could regain their autonomy by complying with involuntary treatment. Kafkaesque, no?

Anyone who witnesses the suffering and insanity of addiction first hand can easily find themselves thinking, "If only we could get this person in treatment and make it impossible for them to leave until their addiction is no longer holding them hostage."

All this might be wonderful if there wasn't a history of horrific professional abuse of addicts and alcoholics.

Bill White also recently wrote about choice in the context of treatment and recovery and wrestled with the issue of impairment of volitional control and self-determination:

One way to partially reconcile the dilemma between the traditional and emerging views of choice is to first acknowledge that free will in addiction and recovery is not an all or none phenomena. The capacity for volitional control over AOD use and related decisions is variable across individuals (as a function of the interaction between problem severity/complexity and recovery capital) and is dynamic (shifts incrementally on a continual basis within the same individual through both addiction and recovery processes). Recovery can be viewed as progressive rehabilitation or reclamation of the will — the power to reclaim personal choice (Smith, 2005). There are times the recovery process may involve consciously not choosing — relying on resources and relationships outside the self, and times that the next recovery steps require an assertion of self. At a practical level, this means that the first hours of acute detoxification are not the best time to rely exclusively on client choice. And yet, long-term recovery is not possible without choice. If there is no rehabilitation of the power to choose and encouragement of choice, we are left with, not sustainable recovery, but superficial treatment compliance. 

To effectively apply a philosophy of choice requires great skill on the part of the addiction professional, particularly where a client’s immaturity, cellular craving, impulsivity, psychiatric symptoms and impaired judgment severely limit choice generation, choice analysis and the capacity to stick with any personal resolution. In such cases, we must carefully plot a path between complete autonomy (total choice and clinical abandonment) and paternalism (no choice and intrusive control). Most clients have a sense of this need as well.

The import question is, if the addict is denied his or her right to choose, who gets to choose? Their family, a doctor, counselor? Under what conditions. What treatments can be involuntarily ordered?

We already accept coerced treatment with the courts and impaired health professional monitoring bodies, but these people still have a choice. They've committed a crime or practiced in a way that endangers patients, and they being offered an alternative to incarceration or loss of their license. There is a great distance between coerced treatment as a sentencing alternative and involuntary treatment "for your own good."

I understand that well-intentioned people might be drawn to this idea, but there is far too much history of abuse and far too much stigma and pessimism among modern professional helpers.

Besides, how could we ever consider such a thing when treatment isn't even accessible to millions of addicts and alcoholics? We don't even know what would happen if addicts had access to high quality treatment of adequate duration and intensity. When we offer every addict the same treatments we offer doctors, maybe...maybe we could discuss something like this, but we have a long, long way to go first.

BTW-In the case naltrexone, what happens if the person gets into a car accident or needs emergency surgery and needs opiates for pain management? 

Sexual abuse and treatment outcomes in men

I don't remember seeing a study looking at sexual abuse in men and its impact on treatment outcomes. The findings look a lot like what studies of women have found:

Men with a history of physical or sexual abuse had more severe drug problems at intake, but by 6 months, there were no group differences in drug use. However, relative to men without an abuse history, men with a sexual abuse history had more severe psychiatric problems at all three time points and were more likely to report significant suicidality at intake and 6 months. Findings suggest that men with a history of sexual abuse benefit from SUD treatment, but additional intervention may be warranted to remedy persisting psychiatric distress.

Next steps in pot policy

NORML's planning it's next steps:

This week, Massachusetts became the 13th state in the country to decriminalize marijuana when voters approved Question 2 on the ballot, which made getting caught with less than an ounce of marijuana punishable by a civil fine of $100.

The change in the law means someone found carrying multiple joints will no longer be reported to the state's criminal history board. The law will require those younger than age 18 to complete a drug awareness program and community service, and for those who don't, the fine will increase to as much as $1,000.

The vote in Massachusetts follows a form of decriminalization that passed seven years ago in Nevada, where it remains a felony for anyone under age 21 to possess marijuana. The other states - Maine, New York, California, North Carolina, Oregon, Ohio, Arizona, Colorado, Minnesota, Mississippi, Nebraska - decriminalized marijuana in the 1970s, according to NORML.

13 states have similar laws? Where possession of small amounts is punishable by fine only? I didn't know it was that many. If this is accurate and there are 11 states with similar laws dating back to the 1970s, why aren't we hearing more about the impact (ot lack thereof) of state law on use by young people and age of first use?

They [advocates] cited a bill introduced in the spring by Representative Barney
Frank, which would decriminalize possession of marijuana in amounts of
3.5 ounces or less anywhere in the United States. The bill, if it
became law, would end federal prosecution of such crimes, but it would
not supersede state laws.

The advocates said they hope the bill would lead to hearings and spark more support from fellow lawmakers in the coming session.

"We
anticipate the bill will be reintroduced fairly early in the next
session," said Keith Stroup, legal counsel and founder of the National
Organization for the Reform of Marijuana Laws (NORML), which has long
lobbied for the legalization and decriminalization of marijuana. "Then
what we expect is that we will be able to get legislative hearings this
session, and maybe a vote on the floor of the House."

He said his organization, which helped Frank draft his bill, is looking for a sponsor in the Senate.

Drug Policy in the Obama Era

Ethan Nadelmann looks forward to drug policy reform opportunities under the Obama administration:

"...he has said that America should start treating drug use as a health issue instead of a criminal justice issue. He supports repealing the federal syringe ban and ending the DEA's raids on medical marijuana patients. He is also co-sponsor of Senator Biden's bill to eliminate the 100-to-1 crack/powder cocaine sentencing disparity."

All great news. I'm hopeful about the new administration, but I believe he may be more pragmatic than many people think. We'll see. Know hope.

Penny wise and pound foolish

What is there to say? This is just sad.

No recidivism rates were offered to provide context?

In Michigan, the two year recidivism rate for parolees is almost 50% and Washtenaw County is around 75%.

Three months of residential treatment costs about $8000 and they can then move into sober housing and pay their own way. Three months of outpatient treatment costs about $500. A year of prison costs $30,000. You do the math.

What drives this insanity? First we send them to prison in staggering numbers rather than offer help. Doing prison time assures that they lose nearly every shred of recovery capital and then we release them (Locally, often to the homeless shelter.) and cut back on treatment?

It's easy to explain this by pointing to short-sighted bureaucracies, but that explanation doesn't cut it. The truth is that they view it as willful misconduct and they hate addicts.

Recovery capital

A primer on recovery capital just became available.

Meth by powerpoint

Powerpoint presentations and other files from the Global Methamphetamine Conference are here.

The social cost of smoking

Tobacco use is continuing its transition from celebrated to tolerated and is slinking in the direction of prohibition.

Election roundup

Join Together has put together a roundup of the election ballot proposals.

Looks like it was a good day for marijuana advocates and mixed day for other areas of the drug war.

A Peek Inside Heroin Maintenance

Robert's story:

Long-time addict Robert Vincent says he's living proof that getting free, daily heroin can improve the quality of a drug user's life, possibly steering him closer to recovery.

"I wasn't waking up in the middle of the night worrying where I was going to get the money to get my fix," said Mr. Vincent, who speaks with a slight lisp, the result of large gaps between his teeth. "I started to eat better, regain my appetite."

Mr. Vincent, 36, was one of 115 men and women, all diehard heroin addicts, who were part of a groundbreaking but controversial Canadian medical trial, called NAOMI - the North American Opiate Medication Initiative - which doled out free heroin for a year to addicts in Vancouver and Montreal. Others in the study received methadone or hydromorphone, a prescription painkiller.

Its preliminary results were released last month, with researchers concluding that most addicts committed fewer crimes and took better care of themselves when they didn't have to steal and panhandle to support their pricey heroin habits. They say they will use the results to press the government to consider free heroin as a treatment option for incurable addicts.

Mr. Vincent, they say, is an example of how an addict's life can improve when freed from the constraints of scrounging for money to feed a costly, illegal habit. While on the study, Mr. Vincent left the street, found an apartment, landed a job and gained 30 pounds.

But then the free heroin stopped.

Today, he is back living on the street, delving through back-alley garbage bins for returnable bottles to earn money to buy drugs. He said he uses street-purchased morphine and hydromorphone. The day after an initial interview with The Globe and Mail, Mr. Vincent failed to show up for a follow-up meeting. He was spotted a few hours later standing outside Vancouver's supervised injection site, his eyes fluttering and his chin drooped on his chest. He was clearly high.

To be sure, Robert's crash will be presented as evidence for and against the effectiveness of heroin maintenance. What I found most revealing was this line: "...researchers...say they will use the results to press the government to consider free heroin as a treatment option for incurable addicts."

Who knows whether the researchers used the word incurable, but the reporter was given that impression. Says it all, doesn't it? What treatments have or haven't been tried for these incurable addicts? What do they want?

Strange bedfellows. A methadone advocate weighs in:

"There is a fine line between harm reduction and enabling," said Stanley deVlaming, who has treated addicts in Vancouver's Downtown Eastside for years. Dr. deVlaming believes the study, which he says was based largely on self-reporting, was politicized. Severely addicted people knew that if they responded positively to the free heroin, it could bolster the chances of receiving the illegal drug down the road.

Dr. deVlaming argues that the best way to treat heroin addiction is with methadone, a synthetic drug that helps prevent withdrawal sickness but does not induce euphoria.

"For many of these patients, if I hand them their heroin, if I make it easier for them to stay addicted, am I doing them any favours?" Dr. deVlaming asked. "When I treat a patient, I often say that I am treating two sides of that person. There's one side that's trying to get better and there's that side of them, the addicted side, that wants to stay addicted. I try to align myself with the side of them that wants to get better."

From another physician:

Another Vancouver addiction physician, Milan Khara, said doctors who speak against the effectiveness of the heroin trials have been harassed, as have those who have criticized another so-called harm-reduction initiative, Vancouver's supervised injection site.

Dr. Khara criticized the NAOMI results, saying he too thinks the participants in the heroin study were motivated to report positive results.

"At the end of the day, these individuals have an addiction," he said. "If they believe their answers are going to lead to a lifetime of free heroin, their answers become highly unreliable.

PICC lines anyone?

Dr. deVlaming says he has concerns too with any treatment that involves daily injections, which often cause serious infections in the heart, spine or bones. "There is nothing safe about repeated daily injections directly into your veins," he said.

From a research subject:

Greg Liang, an addict who was part of the heroin trial, says the program helped stabilize his life. Mr. Liang felt tremendous relief at not having to hustle for money to buy drugs. The NAOMI heroin was pure and uncut, providing a longer high than street heroin. "It was quite delicious," he said in an interview at a Vancouver coffee shop.

But Mr. Liang, 41, who began using drugs at 18, says the free heroin made him complacent about his addiction. Other addicts, he says, took advantage of the free heroin, even competing for how much they could consume each day. For some, their habits grew worse. "They were heroin pigs," he said, shaking his head.

After nine months on the heroin trial, Mr. Liang says, he switched to methadone because he knew it would be hard to stop cold turkey when the study ended.

Today, Mr. Liang is still using heroin and cocaine. He says he's not sure if the heroin program helped his addiction. Like Mr. Vincent, his quality of life improved for a period. He began volunteering for the city of Vancouver, helping addicts. It eventually became a paid, part-time position.

But Mr. Liang says his life is still controlled by drugs. A stressful day can set off a binge. He thinks the only way to quit drugs is to move far from Vancouver's Downtown Eastside, where there are scores of services for addicts.

I want to repeat what Mr. Liang said, "the only way to quit drugs is to move far from Vancouver's Downtown Eastside, where there are scores of services for addicts."

He feels his only hope is to get away from the professionals that are trying to help addicts!!! (Read our position paper on harm reduction. Note that it's not against harm reduction.)

A closing thought from the lead researcher:

Martin Schechter, NAOMI's chief investigator, said researchers have no qualms about giving addicts free heroin and denied the program helped enable their addictions.

"This is a way of providing a maintenance therapy that allows them to get out of the street cycle of illicit drugs because these people are injecting heroin right now," Dr. Schechter said. "It's not like we're starting them on heroin. They're on it now. So the question is: Who do you want prescribing it? You have the black market or doctors or nurses."

I'd like to hear more about the values that drive his practice. Maybe the next trial should include PICC lines?

Online recovery support

I've been waiting for a large treatment program to implement a web-based recovery support program. I've been curious to see what it might look like and how they would navigate privacy issues.

MORE is hardly innovative. We'll see what future iterations look like.

Extended vs Short-term Buprenorphine for Young Opiate Addicts

In a study with subjects receiving low intensity outpatient treatment, those who received buprenorphine for 12 weeks did significantly better than those receiving it for 2 weeks.

The difference in retention is striking 70% for extended detox, compared with 20% for short term detox. There were also improved short term and 12 month outcomes in opiate and cocaine use. Outcomes related to alcohol and marijuana use were comparable and pretty low in both groups.

One of the reported limitations was this:

We had no way to compare these results with intensive outpatient therapy, residential treatment, therapeutic community, or naltrexone. It was impossible to design a random assignment study including the first 3 options because they are in limited supply, and the programs we contacted did not feel comfortable using an agonist medication with this population except for short-term detoxification.

What, exactly, was responsible for the improved outcomes? I suspect that most of the benefits, particularly long term, are related to enhanced treatment retention. (As a treatment provider, of course I'd think this!)

Other questions:

• To what degree are these benefits a function of the low intensity of treatment?
• What would the disparity be like if more recovery support been provided? If they were provided intense treatment?
• Unfortunately, we have to ask, what have unpublished studies found?
  

Lip balm addiction

Fox is winning the race to render the term addiction meaningless.

Michigan's medical marijuana proposal

Michigan has a ballot proposal that, if passed, will legalize medical marijuana. It looks like it will easily pass. Moreover, it seems to be getting very little attention--it's noncontroversial.

How did we get here? I think it's safe to say that this proposal would have been a major flashpoint 8 years ago. In fact, I attended a treatment provider meeting 8 years ago only to suffer through a presentation by a local prosecutor about a marijuana ballot proposal in which he repeatedly referred to George Soros and others as "crack daddies."

This time around most people seem to be barely aware of the proposal and few people seem to have strong feelings. Yesterday is the first time I remember seeing a commercial. I've seen no serious analysis of the proposal. No one seems to be seriously wrestling with questions like the following:

• Is marijuana good medicine?
• Does this proposal integrate lessons from other states like California?
• has legalization of medical marijuana led to increased marijuana use by teens or lowered the age of first use?
• Are there other options (like Savitex) that are better?
• Instead of changing state constitutions one at a time, should we pressing for unbiased clinical trials and if those trials merit it, have the FDA seriously review it for approval? 
• Are there legitimate reasons for the FDA to withhold approval? If so, is this a good way to make medical policy?
• How many cancer or MS patients have been arrested for using marijuana?

My suspicion is that the reason there's no serious discussion of these questions is because it's too difficult to trust what anyone has to say on the subject. We've all been held hostage by the drug policy freak show with the ONDCP on one side and legalization advocates on the other. We know the drug war is a disaster but we're not comfortable with decriminalization and we hate the drug policy war too. It's spilled beyond drug enforcement policy and is polluting discussion of treatment and prevention. We feel like we can't trust what anyone says, so we just tune it all out. 

In this way, the drug war is the gift that keeps on giving.