Dopey, Boozy, Smoky—and Stupid

The National Interest has a lengthy article on drug policy by Mark A.R. Kleiman. I disagree with several of his points but this is exactly the kind of thoughtful contribution that the American drug policy debate needs more of.

I tend to see his perspective as hyper-rational (Possibly to balance the moral panic of drug crusaders and fetishization of drug culture by many legalization advocates.) and somewhat removed from both the suffering of addiction and the radical transformation that full recovery offers. I think he risks reducing policy issues to an accounting exercise but he expresses strong, well-informed opinions without and ideological ax to grind (Although there clear Libertarian themes.) and does so without characterizing and dismissing people who think differently.

After outlining the sad state of American drug policy he says:

These are depressing facts that cry out for a radical reform to solve the drug problem once and for all. But the first step toward achieving less awful results is accepting that there is no one “solution” to the drug problem, for essentially three reasons. First, the potential for drug abuse is built into the human brain. Left to their own devices, and subject to the sway of fashion and the blandishments of advertising, many people will wind up ruining their lives and the lives of those around them by falling under the spell of one drug or another. Second, any laws—prohibitions, regulations or taxes—stringent enough to substantially reduce the number of addicts will be defied and evaded, and those who use drugs in defiance of the laws will generally wind up poorer, sicker and more likely to be criminally active than they would otherwise have been. Third, drug law enforcement must be intrusive if it is to be effective, and enterprises created for the expressed purpose of breaking the law naturally tend toward violence because they cannot rely on courts to settle disputes or police to protect them from robbery or extortion.

Any set of policies will therefore leave us with some level of substance abuse—with attendant costs to the abusers themselves, their families, their neighbors, their co-workers and the public—and some level of damage from illicit markets and law enforcement efforts. Thus the “drug problem” cannot be abolished either by “winning the war on drugs” or by “ending prohibition.” In practice the choice among policies is a choice of which set of problems we want to have.

But the absence of a silver bullet to slay the drug werewolf does not mean we are helpless. Though perfection is beyond reach, improvement is not. Policies that pursued sensible ends with cost-effective means could vastly shrink the extent of drug abuse, the damage of that abuse, and the fiscal and human costs of enforcement efforts. More prudent policies would leave us with much less drug abuse, much less crime, and many fewer people in prison than we have today.

The reforms needed to achieve these ambitious goals are radical rather than incremental. But they are not simple, or all of a piece, or in any one of the directions defined by current arguments around American dinner tables, on American editorial pages or in American legislative chambers. The conventional division of drug programs into enforcement, prevention and treatment conceals more than it reveals. So does the standard political line between punitive drug policy “hawks” and service-oriented drug policy “doves.” Neither side is consistently right; some potential improvements in drug policy are hawkish, some are dovish, and some are neither.

I disagree with the hawk vs. doves dichotomy. The service-oriented doves are really divided into at least two camps. An older, more deeply entrenched group but shrinking group of treatment professionals who might be dovish relative to hawks, but generally support some form of prohibition. Then there is a newer group of doves who aren't all that service-oriented but are more radically dovish, advocating more radical decriminalization.

He offers five principles to guide policy decisions:

First, the overarching goal of policy should be to minimize the damage done to drug users and to others from the risks of the drugs themselves (toxicity, intoxicated behavior and addiction) and from control measures and efforts to evade them.

That implies a second principle: No harm, no foul. Mere use of an abusable drug does not constitute a problem demanding public intervention. “Drug users” are not the enemy, and a achieving a “drug-free society” is not only impossible but unnecessary to achieve the purposes for which the drug laws were enacted.

Third, one size does not fit all: Drugs, users, markets and dealers all differ, and policies need to be as differentiated as the situations they address.

Fourth, all drug control policies, including enforcement, should be subjected to cost-benefit tests: We should act only when we can do more good than harm, not merely to express our righteousness. Since lawbreakers and their families are human beings, their suffering counts, too: Arrests and prison terms are costs, not benefits, of policy. Policymakers should learn from their mistakes and abandon unsuccessful efforts, which means that organizational learning must be built into organizational design. In drug policy as in most other policy arenas, feedback is the breakfast of champions.

Fifth, in discussing programmatic innovations we should focus on programs that can be scaled up sufficiently to put a substantial dent in major problems. With drug abusers numbered in the millions, programs that affect only thousands are barely worth thinking about unless they show growth potential.

Finally, he offers an agenda for policy change. I doubt I could ever comfortably endorse some of these. Others, I find myself resisting, but in the context of radical change (rather than incremental), they may be more acceptable.

• Don’t fill prisons with ordinary dealers.
• Lock up dealers based on nastiness, not on volume.
• Pressure drug-using offenders to stop.
• Break up flagrant drug markets using low-arrest crackdowns.
• Deny alcohol to problem drinkers.
• Raise the tax on alcohol, especially beer.
• Eliminate the minimum drinking age.
• Prevent drug dealing among kids.
• Say more than “No.”
• Don’t rely on DARE.
• Encourage less risky forms of nicotine use.
• Let pot-smokers grow their own.
• Encourage problem drug users to quit without formal treatment.
• Expand opiate maintenance.
• Work on immunotherapies.
• Get drug enforcement out of the way of pain relief.
• Create a regulatory framework for performance-enhancing chemicals.
• Figure out what hallucinogens are good for, and don’t let the drug laws interfere with religious freedom.
• Stop sacrificing foreign policy and human rights objectives to drug control.

How kids can drink at home, legally

It was news to me that 31 states permit underage drinking with a parent:

"You can be 10 years old and drink in Virginia," said Beth Straeten, a spokeswoman for the state's Department of Alcoholic Beverage Control.

Surprised?

...Eleven states, Virginia among them, say providing alcohol to an underage son or daughter can only occur in the home. Twenty other states say parents can provide alcohol to their children anywhere.

The Virginia exception was passed during the 2006 legislature. It drew only two negative votes and won the signature of Gov. Timothy M. Kaine.

I was unable to find out what Michigan's law is. I'll post an update if anyone fills me in.

[Update: Jess found what appears to be the relevant Michigan law and there does not seem to be any language that would permit a minor to drink with a parent.]

Scientology Treatment Program for Prisoners Funded by Feds

Scientologists have scored a victory in New Mexico:

Federal tax dollars are helping to pay for a controversial addiction-treatment program for prisoners in New Mexico based on Scientology precepts...

The Second Chance program is billed as an alternative treatment program for nonviolent offenders and uses the principals of Scientology -- such as using saunas, diet, massage and vitamins to purge the body of toxins -- to fight addiction. In New Mexico, 24 of the state's 84 district judges have referred a total of 50 clients to the program since it opened last September.

Second Chance is the only Scientology-based treatment center for inmates in the U.S. A former chief district judge from Albuquerque, W. John Brennan, is a paid consultant hired to promote the program to his former colleagues. But the current chief district judge, William Lang, doesn't want judges to make referrals to the program, saying he is suspicious of its relationship with the Church of Scientology even though program officials say there is no link.

..."There's a lot of use of sauna with the idea that you sweat out toxins in the system," said addiction expert Bill Miller, who reviewed the program at the request of the city of Albuquerque. "I don't know of any scientific basis for that. It wasn't clear to me what sort of scientific basis there was even for the conception of the program to begin with."

The most troubling thing about Narconon and other Scientology-based programs is their consistent denials of any connection to the Church of Scientology. Offering a faith-based program is one thing, but misrepresenting themselves is another.

Stats.org weighed in on the WSJ's over-tentative reporting on matter. Unfortunately the author (Maia Szalavitz) appears to have forgotten to include Twelve Step Facilitation when mentioning evidence-based treatment strategies.

Why is it so hard to help drug-addicted criminals?

Here's a column about a rejected proposal (Hamilton, Ontario) to house an addiction counselor in the police department to intervene at the time of arrest throughout the judicial process. The goal is to capitalize on the crisis of being arrested and charged with a crime as an opportunity for active linkage to help rather than a passive referral.

It was shot down because they wanted prevention programs. It's an interesting idea that could be effective.

What's more interesting is what this (and programs like drug courts) says about systemic ownership of the problem of addiction. Over the last decade or so the criminal justice system has been realizing that the drug problem is not a simple criminal matter and they they are not equipped to respond in an effective and humane manner. The response has been to incrementally develop therapeutic responses within the criminal justice system, many with decent results. However, it seems that the real issue is what system(s) should "own" the problem.

There's a push right now to move ownership from the criminal justice system to the public health system (not necessarily the treatment system). If this movement was successful, I suspect that within a generation there would be renewed calls for ownership to be transferred back to the criminal justice system.

Right now I'm thinking that it doesn't have to be and either/or decision. It seems that there could be shared ownership to some extent--maintaining some reduced measure of prohibition (I know that the work prohibition freaks people out, but we prohibit everything from speeding to murder. Pretty broad continuum of enforcement approaches, no?) and rebuilding access to a treatment system with continuous recovery management.

The Short Road to Recovery

(click here to view)

Sage Stossel Atlantic Monthly Online Jan 27, 2007 EditorialCartoonists.com

Electric shock therapy for addicts

Scotland starts a new trial of ECT (source):

A radical new treatment for heroin addiction is to undergo its first clinical trial in Scotland, it was announced yesterday.

Neuro-electric therapy - NET - has been billed as a safer, more effective alternative to methadone, the heroin substitute which is both addictive and damaging to health.

The creators of NET believe their detoxification therapy not only reduces withdrawal symptoms but also removes cravings.

Readiness for change and drug use outcomes after treatment

Another study finding that the client's stage of change is a poor predictor of outcomes:

Results failed to support the hypothesis that taking steps should be associated with less frequent use of illicit opiates at follow-up. No statistically significant associations of any kind were found between readiness for change measures and use of opiates or stimulants at follow-up. A negative association was found between taking steps and benzodiazepine misuse. Readiness for change measures were correlated with heroin use and psychiatric symptom scores at treatment intake.

There has been high profile criticism that the rush to embrace the stages of change has outpaced the evidence. The question isn't whether the stages of change have any utility. The question is what are they useful for? Patient/family eduction, counselor education, conceptualizing interventions, matching treatments, etc.

The stages of change have undoubtedly changed the field for the better, but there are a lot of weak points that have not been adequately explained--failure to recognize the instability of motivation; disagreements about how to determine the client's stage of change; failure to account for stable, unplanned change; failure to explain for stable, initially coerced change. I've been especially concerned about practitioners relying on the stages of change for treatment placement and the inevitable post hoc deconstructions of treatment "failures" that blame the client's motivation and then conclude that we wasted money treating them (and suggest that better assessment would have led to the conclusion that the client wasn't motivated and a better referral).

Robert West, the editor of Addiction, has offered a new model for understanding change, he has called the PRIME theory.

More on the insula and smoking

I posted earlier on an exciting study on the relationship between the insula and nicotine addiction. Here's an article with a little more detail.
[via: New Recovery]

Singapore drug cases jump 42 pct on Subutex abuse

Singapore is reporting problems with buprenorphine misuse. It's too bad that the drug they've used is not Suboxone. Suboxone has naloxone added to reduce the potential for misuse. It will be interesting to see if the addition of naloxone is effective in reducing diversion.

Drug-abuse cases in Singapore soared last year, mainly because of a surge in the use of Subutex, a drug which was introduced to help wean drug addicts off heroin, Singapore's Central Narcotics Bureau (CNB) said.

Singapore introduced Subutex as a prescription medication five years ago to help wean addicts off heroin. But the narcotics agency said that 30 percent of abusers caught were hooked on Subutex, which is sometimes mixed with a tranquiliser or other drugs to produce a high.

But in mid-August, the government reclassified Subutex as an illegal drug. Since then, authorities have arrested a total of 347 people for abusing the drug. In all, Singapore has arrested 1,127 users last year, up 42 percent from 793 in 2005, the CNB said in a statement.

Spot in brain may control smoking urge

A stroke patient may have revealed a key to understanding craving:

Damage to a silver dollar-sized spot deep in the brain seems to wipe out the urge to smoke, a surprising discovery that may shed important new light on addiction. The research was inspired by a stroke survivor who claimed he simply forgot his two-pack-a-day addiction - no cravings, no nicotine patches, not even a conscious desire to quit.

"The quitting is like a light switch that went off," said Dr. Antoine Bechara of the University of Southern California, who scanned the brains of 69 smokers and ex-smokers to pinpoint the region involved. "This is very striking."

Clearly brain damage isn't a treatment option for people struggling to kick the habit.

But the finding, reported in Friday's edition of the journal Science, does point scientists toward new ways to develop anti-smoking aids by targeting this little-known brain region called the insula. And it sparked excitement among addiction specialists who expect the insula to play a key role in other addictions, too.

"It's a fantastic paper, it's a fantastic finding," said Dr. Nora Volkow, director of the National Institute on Drug Abuse and a longtime investigator of the brain's addiction pathways.

"What this study shows unequivocally is the insula is a key structure in the brain for perceiving the urges to take the drug," urges that are "the backbone of the addiction," Volkow added.

Why? The insula appears to be where the brain turns physical reactions into feelings, such as feeling anxious when your heart speeds up. When those reactions are caused by a particular substance, the insula may act like sort of a headquarters for cravings.

Mid-lifers most likely to have injected drugs

More evidence that the most serious drug problems are among middle-aged people:

Injection drug use is becoming less common among young people in the U.S., especially blacks, a new analysis of national data shows.

In fact, middle-aged men and women are more likely to have ever injected drugs than younger people -- or older people, for that matter...

Psychiatric disorders and substance misuse

Last night I posted an article about gender and substance misuse. I didn't realize that the Psychiatric Times had a special report section on psychiatric disorders and substance misuse. I haven't had time to read the whole thing yet. What I did read seemed okay other than a sky high prevalence estimate for borderline personality disorder in people with substance use disorders:

Nearly one third of those with a lifetime SUD diagnosis also have BPD (median, 27%; range, 5.2% to 74.0%).^16,20 BPD appears to be less prevalent in persons with alcohol use disorders (median, 16%; range, 3.2% to 27.4%) than in those with drug use disorders, especially cocaine and opioid abuse.^17,20 For example, Ross and colleagues¹⁷ found that almost half (47%) of individuals using heroin who entered treatment for SUD also had BPD.

Here's a list of all the articles:

• The Link Between Psychotic Disorders and Substance Use By Emma Barkus, PhD
• Safe Treatment of Pain in the Patient With a Substance Use Disorder By Penelope P. Ziegler, MD
• Schizophrenia and Substance Abuse: Is There a Role for Atypical Antipsychotics? By Giovanni Caracci, MD
• Implications for Treatment and Prognosis of Borderline and Substance Use DisordersBy Ulrike Feske, PhD, Paul H. Soloff, MD, and Ralph E. Tarter, PhD
• Substance Abuse in Women: Does Gender Matter?By Sudie E. Back, PhD, Regana Contini, MD, and Kathleen T. Brady, MD, PhD

Alternative treatments give addicts a chance

An opinion piece on Sam Sullivan's (Vancouver's Mayor) proposal for stimulant maintenance programs. (Previous post here.) Grrrr.

Protecting fetuses from mothers who drink

Statin drugs may protect fetuses from maternal alcohol use.

Methadone in the news

Two recent stories on methadone. First, researchers may have identified a genetic marker that indicates the person's drug metabolism. They believe that these finding could be important in determining dosing for methadone. Second, a story about prison-based methadone programs.

Substance abuse in women: Does gender matter?

The Psychiatric Times runs a helpful review of gender differences in substance misuse. It covers several areas including epidemiology, comorbidity, diagnosis, course and neurobiology. From the section on treatment:

A number of studies indicate that women are less likely than men to enter treatment.¹ Reasons for lower rates of treatment entry may include sociocultural factors (eg, stigma, lack of partner/family support to enter treatment), socioeconomic factors (eg, child care), pregnancy, fears concerning child custody issues, and complexities associated with increased rates of co-occurring psychiatric disorders and the availability of appropriate dual-diagnosis treatments.^1,30,46 Furthermore, as previously stated, many women seek treatment at settings or clinics other than substance abuse clinics (eg, primary care, mental health).¹⁸

Those women who do enter substance abuse treatment receive similar benefits to those received by men. There are few, if any, consistent gender differences in treatment outcome, retention rates, or relapse rates across various types of substances, treatment settings, and types of treatment.^1,47,48 In studies that have found gender differences, women typically have better outcomes than men. For example, women have been found to have higher rates of abstinence at 6-month follow-up (79.3% of women vs 54% of men) and at 5 years (odds ratio, 1.9).^24,49,50 Women also demonstrate greater improvement in other domains (eg, medical problems⁵¹), have shorter relapse episodes,⁵² and are more likely to seek help following a relapse.^52,53

What a Long Strange Trip It's Been

Mentions of ecstasy as a therapeutic tool have popped up here and there for some time. Looks like we may be hearing more about it in the coming year:

This year, the drug MDMA, otherwise known as ecstasy, could take a step toward medical respectability. Researchers in South Carolina have begun experimenting with MDMA for patients with post-traumatic stress disorder. At Harvard, a long-awaited pilot study will begin on whether the drug can help relieve anxiety and pain in terminal cancer patients in connection with psychotherapy. And studies will also start in Switzerland and Israel, where a former chief psychiatrist of the Israel Defense Forces will oversee work with people whose PTSD stems from terrorism or war.

Vancouver mayor proposes 'revolutionary' plan for addicts

Vancouver's Mayor is promoting his plan for stimulant maintenance again and calling it treatment. This is the same guy who suggested that addicts and the public need to get real and accept addiction as a permanent disability, like his experience of having to accept his spinal cord injury and life in a wheel chair.

Vancouver Mayor Sam Sullivan is lobbying the federal government for an exemption from Canada's narcotics laws that would allow what he calls a "revolutionary" alternative drug-treatment plan to give substitute drugs to at least 700 cocaine and crystal-meth addicts.

If he is successful, Vancouver would be a global pioneer in running such a large-scale program of drug maintenance for stimulant-drug users.

Sullivan said the drug plan, along with three other key elements that have to come from Ottawa or Victoria, will eliminate most of Vancouver's problems with homelessness, panhandling and drug-dealing. Those are the three social problems he promised to reduce by half in time for 2010 in the Project Civil City initiative that he launched in November.

Do drug courts tame the meth monkey?

Utah's Governor starts a drug court push for meth addicted mothers and proposes significant investment in treatment:

Despite efforts to combat it, Utah's meth problem continues to grow - especially for women.
For five years, meth has been the top illegal drug of choice for Utahns entering public treatment. For women it surpasses even alcohol, the traditional front-runner, making it the only drug in history to have its female users outnumber males. Nearly half the women in treatment statewide have children.

Gov. Jon Huntsman Jr. has proposed investing $2 million in Utah's drug courts and $2.5 million to build two residential clinics in northern and southern Utah to treat 600 women, giving priority to those involved with the child welfare system. But Huntsman will have to convince lawmakers it's a wise investment, no easy task considering the stigma attached to addiction and a dearth of data on treatment, including how patients and drug court graduates fare over the longer term.

Helping Utah's women poses another challenge: transforming a system that wasn't built for them.

"Substance abuse treatment has been historically geared for white, middle-aged male alcoholics," said Salt Lake County substance abuse Director Patrick Fleming. "We're a hell of a lot better at treating women than 10 years ago, but there's room for improvement."

I'd challenge the "dearth of data" statement. We have a lot of data on the effectiveness of treatment and drug courts.

Lush Life: How Stars Make a Mockery Out of Rehab

More news coverage on treatment as havens for the rich.