Ross Fitzgerald: Alcohol abuse is destroying youth, so let's de-glamorise it

An Australian Op-Ed calls for a tobacco-like public heath campaign on alcohol:

AS a nation we have never been more health conscious, yet we seem to be ignoring all the warnings about alcohol abuse.

Alcohol, our most widely used drug, is still ravaging the young, destroying indigenous communities, damaging the mentally ill and destroying lives, unabated. Perhaps some of the same zeal that has been applied to the anti-smoking cause could be enlisted in a concerted fight against alcohol abuse and misuse.
...
The ramifications of cigarette use are now seen on every pack: stained teeth, raw gums, gangrene from blocked arteries, heart disease and multiple cancers. In the West we have come a long way from the days when cigarettes could be promoted by white-coated doctors or, in one case, a smiling Ronald Reagan. Cigarette advertising is now banned, as it should be. In its place, on virtually every railway network, sporting venue, commercial television and radio program, advertisements and endorsement of alcohol have replaced advertisements for cigarettes.

How has alcohol escaped the Buga-up treatment, or something similar? Some argue that it's different, that many consumers can use alcohol sensibly and safely, while tobacco is highly addictive and every cigarette does damage.

Then the statistics are trotted out. In Australia, tobacco kills up to 19,000 people a year, alcohol 3000-plus - although that does not include those killed by drinkers in assaults, violence, accidents or through sheer negligence - and illicit drugs less than 1000. But cigarette smokers usually die later in life, whereas alcohol predominantly kills young drinkers, and others, from assaults, injuries, homicides, road trauma and domestic violence. Add to this the impoverishment of family and community life - a toxic social mix of violence, injury and neglect - well outside the calculus of tobacco harms.

It is instructive to learn that alcohol problems are escalating in the UK as drinking hours have been extended. The Royal College of Physicians, not exactly a radical group, recently recommended to the Blair Government a complete ban on alcohol advertising. They were responding to the doubling of alcohol-related deaths from 1991 to 2004.
...
Given successful litigation against tobacco transnationals, there soon may be a groundswell of opinion in favour of taking action against the makers, distributors and sellers of alcohol.

The hazards of alcohol misuse in environments of heavy drinking are well known and there are clearly many cases in which harm, both to the drinking person and to others, could have been reasonably foreseen and in which the suppliers of alcohol should have exercised due care and diligence. A recent survey of 500 Australians in the age group 18-24 found one in four had been drinking to the point of passing out.

Hat tip: dailydose.net

Addiction Community's Influence Over Corporate Responsibility Grows

From Join Together:

Anheuser-Busch's recent decision to pull its fruity Spykes drink mixers from the market represents the latest in a series of significant victories by the addiction field in confronting what advocates consider irresponsible marketing by big corporations.

After weeks of escalating complaints by public-health groups such as the Center for Science in the Public Interest (CSPI), the Marin Institute, Community Anti-Drug Coalitions of America and the Oregon Partnership, as well as a coalition of state attorneys general, Anheuser-Busch announced on May 17 that it was withdrawing Spykes from the market. The company continued to dispute assertions that Spykes was marketed to children, but company chairman August Busch acknowledged that parental concerns played a role in the decision to yank the product.

Many of the same groups were involved in a previous (and successful) advocacy campaign that resulted in Anheuser-Busch withdrawing "Bud Pong" games from the marketplace and ending its sponsorship of "Beer Pong" tournaments. Addiction activists complained that drinking games like Bud Pong, Beer Pong, and "Shots and Ladders" encouraged binge drinking and underage alcohol use.

The campaign, launched around the Christmas holidays, resulted in retailers like Target, Kohl's, and Linens n' Things halting sales of these games as well as another called "Drinko," an alcohol-fueled version of TV's "Plinko." The Oregon Partnership also spearheaded a campaign to get beer-related t-shirts pulled from the shelves of Macy's stores last October.

Read the rest here.

It's worth noting that none of the groups mention are recovery advocacy groups, they're all prevention groups.

Crack-pipe project to be reviewed

I'd love to know more about the rate of disease transmission through crack pipes and respiratory illness resulting from inhaling brillo smoke:

The program's goal is to mitigate the spread of diseases, including HIV, hepatitis C and tuberculosis. The fresh mouthpiece prevents transfer of spit or blood from sores, and the screen discourages addicts from using a Brillo pad, which contains harmful ingredients.

And not a word about recovery.

Treatment for Meth OD May Harm Brain

New research on treatment of meth ODs:

According to experimental scientists a common antipsychotic drug used in emergency rooms to treat methamphetamine overdose can damage nerve cells in an area of the brain known to regulate movement.

Investigators from the Boston University School of Medicine used a rat model to determine that only the combination of the medication, haloperidol, and methamphetamine causes the destructive effects, not either one alone.

[Hat tip: Daily Dose]

Legacy Tobacco Documents Library

The American Legacy Foundation has created a digital library. The Legacy Tobacco Documents Library (LTDL) contains more than 7 million documents (40+ million pages) created by major tobacco companies related to their advertising, manufacturing, marketing, sales, and scientific research activities.
[Hat tip: Daily Dose]

Strawberry Quick and Cheese

I've been resisting posting about these reports. They feel like hype, but I've gotten several emails about them and they've been heavily reported. So, here you go.

More Canadian drug war fun

At least one of them resists questioning the motives of their opponents--something I haven't seen in American political debates for some time.

Point:

Last week, it was announced that the Conservative government will soon unveil a new national anti-drug strategy. The plan is said to feature a get-tough approach to illegal drugs, including a crackdown on grow-ops and drug gangs. And while it will also (wisely) include tens of millions for rehabilitation of addicts and for a national drug prevention campaign, it is said to retreat from safe-injection sites and other fashionable "harm-reduction" strategies introduced by the previous Liberal government.

To which we say: Good. This editorial column has long urged a softening of drug policy on marijuana and other non-addictive recreational substances. But heroin and similarly addictive drugs are a different story. Moreover, safe injection sites don't work. And they send the wrong message, too, promoting disrespect for the rule of law by having government facilitating the consumption of illegal substances.

Safe-injection sites (SIS)-- typically inner-city facilities where addicts may go to shoot up with clean needles under the watchful eye of medical specialists --are often said to work wonders. Benefits claimed on behalf of Insite, Canada's one and only SIS in Vancouver's Downtown Eastside since 2003, include reduced needle sharing, reduced spread of deadly diseases such as HIV and hepatitis, fewer needles discarded in surrounding neighbourhoods and fewer addicts overdosing in alleys. Lives have been saved, advocates claim, the "well-being of drug users improved," and all without increased street dealing around Insite.

Too bad most of the proof to back these positive claims come from SIS proponents or the academics who devise harm-reduction theories. Police here, and in Europe (where they have lots of experience with SISs) tell a very different tale.

When Insite applied to have its three-year licence renewed last fall, the RCMP told Health Canada it had "concerns regarding any initiative that lowers the perceived risks associated with drug use. There is considerable evidence to show that, when the perceived risks associated to drug use decreases, there is a corresponding increase in number of people using drugs."

That has certainly been the case in Europe. Currently there are more than three dozen major European cities on record against SISs. Most have had such facilities and closed them because they found that drug problems increased, not decreased.

After an injection site was opened in Rotterdam in the early 1990s, the municipal council reported a doubling of the number of 15- to 19-year-olds addicted to heroine or cocaine. Over the 1990s, the Dutch Criminal Intelligence Service reported a 25% increase in drug-related gun murders and robberies in neighbourhoods housing one of that country's 50 official methadone clinics or addict shelters. Zurich closed its infamous needle park in 1992, after the police and citizenry became fed up with public urination and defecation, prostitution, open sex, panhandling, drug peddling, loud fights and violent crimes.

...

But as much as we admire the good intentions behind SISs, drug consumption is the wrong business for government to be in. A government that funds safe havens for injecting illegal drugs on one hand will quickly find it is working against its efforts to reduce drug dealing on the other.

Counter-point:

Reports that the Harper government is preparing to announce changes to Canada's outdated 20-year-old national strategy on illicit drug use should be reason for optimism.

Instead, there are signs -- such as the Conservative distaste for safe-injection sites that are a key component of the "harm-reduction strategy" -- that Ottawa is tilting toward a more aggressive, U.S.-style war on drugs. If that is the case, it would be an unfortunate mistake with predictable and very disappointing outcomes.

While Washington from time to time trumpets bravely that it has scored a victory in the war on drugs, by all empirical measures it has been an abject failure.

Consider the record south of the border:

- Hundreds of billions of dollars have been spent. This year alone in the U.S., federal and state government have spent nearly $20.5 billion directly on counter-drug measures.

- There are nearly two million Americans in prison, about one-third of whom are locked up on charges for possession or low-level trafficking, costing tens of billions of dollars.

- Despite nearly 30 years of focused domestic and international measures, however, drugs are more available than they have ever been, largely because it is such a wildly profitable criminal industry. Virtually anyone who wants to buy drugs can, and it's easier than ever.

But what are the alternatives? This is a reasonable question. Just because the state can't beat the drug cartels doesn't mean it should join them.

One of the driving forces behind the U.S. war on drugs, especially under the Republican party, is Christianity. The religious right has placed "saving" people from the scourge of drugs as an important American value and tantamount to saving souls. It is one reason that successive administrations have continued to throw increasing resources at a fruitless war. The message, in essence, that the small number of those rescued from the grip of drugs justifies the billions used in the war.

Teen drinking

The skeptics at STATS.org catch some selective reporting:

There was a positive association between exposure to TV beer ads in the sixth grade and drinking which ranged from 1.43 to 1.48 depending on the type of television ad. In other words, the sixth graders where 43 to 47% percent more likely to drink in grade seven based on seeing beer ads on tv.

But hold on – this was by no means the only factor to show such a positive association. The Times failed to mention that “Sports Activity” in the sixth grade delivered a higher odds ratio of drinking in the seventh – 1.60 or 60% more likely to drink. Low parental monitoring was greater than TV ads too (1.64), as was parental approval (1.69), and the approval of a friend almost doubled the chance of drinking (1.98). Deviant behavior (2.00) and peer drinking (3.20) were even greater predictors of beer consumption.

The Times also neglected to mention that the Rand researchers tried to account for the effect of these factors on one another in a series of complex calculations. The result, at least according to the tabular data in the study, shows that the odds ratio significantly diminished for all advertising (1.08 to 1.13 for TV ads). The factors most strongly influencing seventh graders to drink were, once again, peer drinking (1.40) sports activity (1.52), friend approval (1.53) deviance (1.54), and above all, whether they had drunk in the sixth grade (2.32).

I'm just as troubled by shoddy drug reporting, but there's something very off-putting about the zeal of STATS. I don't claim to know the impact of advertising, and even if it is effective with teens, I'm not sure I'd advocate restrictions. However, I find it difficult to believe that the alcohol industry's large advertising budgets are ineffective and sufficiently narrowly target to influence only adults. They sometimes seem to react to excessive certitude with excessive certitude.

Another study finds that there may be a relationship between teen drinking and something not mentioned in the previous study:

In a study of more than 10,000 15- and 16-year-olds, British researchers found that teens with larger allowances were more likely to drink frequently, binge or drink on street corners and other public places.

[hat tip: CCSA.ca and Shannon]

Because fentanyl is so powerful, overdosing occurs quickly, easily

Q & A about fentanyl patches in the Ann Arbor News. Prompted by 2 local deaths:

Michigan State Police at the Ypsilanti post have recently handled two overdoses in which victims chewed or sucked Fentanyl patches and stopped breathing.

New Insite numbers

Insite has been receiving negative attention since a change in government in Canada and recent critical review. Today, they released a report the value of Insite in moving users toward detox. They report that use of Insite is associated with a 30% increase in use of detox services. I'm not sure what to make of this. They previously reported that 18% of Insite users sought detox services over the course of a one year follow-up period.

• A 30% increase means that detox use went from what percentage to what percentage?
• What's the road not taken? Could increased access to detox have improved usage? (Vancouver only has 3 detox facilities.) Could simple street outreach have produced similar results?
  
• They had a follow-up rate in the neighborhood of 80%, but the cohort is huge. Did they factor any assumptions about the lost subjects? Are these numbers good.
  
• These numbers are based on a lot of assumptions. Are these reasonable assumptions? Might someone who's concerned enough about blood-borne pathogens to use Insite, be moving through the stages of change and be more likely to use detox services on their own? I don't know.
• What were the numbers for community-wide use of detox. Did that increase over this period? Detox admissions increased in Ann Arbor without Insite.
• What do the clients report as their reasons for entering detox? Do they credit Insite?
  

All the numbers are in statistical terms that make me wish I paid more attention to stats in college. Any DF staff wanting the full text can email me.

Medical marijuana use initiative launches in Michigan

An initiative that would allow seriously ill Michigan residents to use marijuana as a pain reliever without repercussions will be launched this week, The Coalition for Compassionate Care announced Wednesday.

Read the rest here. The initiative website is http://stoparrestingpatients.org. I wonder how many patients have been arrested. Seriously. I'm not just being a smart Alec.

How Normal Is Smoking? Teens Don't Know, But Their Guesses Affect Their Habits

More reason to be careful about how we present drug information to adolescents. It's possible to give kids the mistaken impression that drug use is much more common that it really is. This article highlights the dangers of this:

According to the study, nine out of 10 (93 percent) high school students overestimate the percentage of people who smoke in the United States. On average, they believe over half (56 percent) of Americans are smokers, while the actual figure is less than half that.

The study identifies three distinct ways to measure “normative beliefs” involving smoking, each of which it found to be significantly related to adolescents’ likelihoodof smoking. According to the study:

• The more an adolescent perceived that successful and elite people smoke cigarettes, the more likely that adolescent was to smoke.
• The more strongly an adolescent perceived that his or her parents or peers disapproved of smoking, the less likely that adolescent was to smoke.
• The more an adolescent overestimated the percentage of smokers in the general population, the more likely that adolescent was to smoke.

[Hat tip: Join Together]

Plant extract may block cannabis addiction

A plant compound reduced THC use in rats and interfered with dopamine release when using THC. More here.

Do rules hamper remedies for pain?

This article focuses of Washington state, but provides some needed background on opiate prescribing patterns. It appears opiates for pain relief are more readily available than they were 15 years ago.

Until about a decade ago, doctors reserved opioids largely for patients who had cancer. Wider use has come recently as doctors learn more about pain management and researchers have reported that only a small percentage of patients who properly take opioids ever become addicted.

The reigns on these drugs have tightened up over the last several years as there have been concerns about overdoses and prescribing patterns:

...[in] the late 1990s that Washington's workers'-compensation program began covering opioids.
advertising

Almost immediately, accidental deaths became a concern here and elsewhere in the nation. Between 1996 and 2002, 32 injured workers in Washington died after accidentally overdosing on opioids, according to state data.

In 1996, the state's typical workers'-compensation patient took 88 milligrams of morphine-equivalent doses a day. In 2005, the average daily dose was 151 milligrams -- a jump that state officials suspect is caused by an increased tolerance.

In response, some states, including Washington have started developing guidelines for opiate prescribing:

Some states already have opioids guidelines for people covered by state programs, such as starting doses for new patients. But Washington has gone further by setting a suggested daily-dosage ceiling.

Long-term use of opioids can pose hazards for both doctors and patients, said Dr. Jeffery Thompson, medical director of Washington Medicaid. For instance, high doses of it can actually exacerbate pain, which then can prompt doctors to prescribe even more.

Physicians who don't specialize in pain treatment "don't have the knowledge or all the tools," Thompson said. "These are very difficult clients."

The state created the opioids guidelines specifically for those primary-care physicians. The advisory is intended for patients with chronic pain, not for people with cancer or temporary pain or pain associated with terminal illnesses.

The guidelines do not dictate a limit on narcotics dosages, and there are no sanctions for exceeding the guidelines.

The biggest fear is that doctors simply will stop prescribing opioids to legitimate patients.

"Because it comes from a government agency, the guidelines could be perceived by many as imposing new restrictions," said Aaron Gilson, an associate director with the Pain & Policy Studies Group at the University of Wisconsin.

The state strongly recommends that patients rarely take more than 120 milligrams of morphine or its equivalent per day (for example, 800 milligrams of codeine is equivalent to 120 milligrams of morphine). For doses above that level, physicians are advised to send patients to pain specialists.

The state also advises doctors to ask patients to take random urine tests to verify that they're taking the prescribed medications, as well as to rule out illegal drug use.

I don't know enough to opine on the dosage guidelines. It seems to me that this is a case of tension between two real problems and we (the royal "we") are still in the process of trying to find balance. If it weren't for my history of addiction and recovery, I'd probably be pretty offended and resentful about having to submit to drug screens, but claims of Draconian restrictions seem to ignore that the prospects for pain patients are significantly better than 10 or 15 years ago.

It's too bad there's so much hyperbole in discussions about the matter, otherwise we might find some balance a little sooner.

Let's treat addiction like the disease it is

One writer's response to the firing/resignation of HBO's CEO, Chris Albrecht:

Addiction to drugs or alcohol is not an inconvenience, a lapse of willpower, a character flaw, anything to be ashamed of or any form of divine judgment. Addiction is not something that needs to be whispered about or shrouded in euphemisms when you are among polite company. Addiction is a progressive, incurable disease -- in the same way that diabetes and asthma are progressive and incurable diseases. If you have the illness of addiction or alcoholism and you stop treating that illness, you are guaranteed to have a relapse. If you relapse and you still don't treat your illness, you are guaranteed to die.

I can say this with such certainty because I am an addict and an alcoholic. Just like Albrecht, with his well-documented violent outbursts, my own life got pretty squalid and desperate for a while. At the end of my using, a high percentage of my days were being spent in bad behavior that was directly tied to my substance abuse. Then I went to jail for the night and had the same epiphany that every alcoholic and addict in recovery -- including Albrecht -- has had: If I don't quit using, I shall die a long, slow, horrible death, and I will hurt every person I come into contact with until that death.

I've happily been in recovery for years. Life, love and work are all good right now, but that goodness is entirely provisional on my continuing to treat my chronic disease of addiction. As part of this treatment, I insist on being myself in all situations. And what I am is a drunk and a pill popper, gratefully living a sober life today.

I'm lucky, because I am so not shy about my illness. I don't feel any need to hide in either my personal or professional life the fact that I am an addict and alcoholic . I make it a personal mission to help the people I work with understand that I'm perfectly "normal" as long as I don't drink or use. But I also make it clear that I don't have a choice about treating my disease: Doing what I need to do to stay sober has got to be the driving wheel of my daily life. For me, it's a matter of life and death. And it seems to me that Albrecht is only trying to do the same thing I do: Treat the disease that will wreck what's left of his life before that disease kills him.

This is what burns me about Americans and the illness of addiction: When Tony Snow announced he'd had a cancer relapse and took some time off from being our president's spokesman, the consensus seemed to be that he was a brave fighter who should be welcomed back to the Blue Room podium as soon as he felt up to standing behind it. Not that there's anything wrong with this. I, too, find Snow a very brave and appealing figure as he wages his perforce solitary war against his killer disease. But I find Albrecht to be an equally brave and appealing figure as he wages his own solitary war against his own killer disease of alcoholism.

Read the rest here. I agree with every word about attitudes toward addiction. I also appreciate his candor:

"I had been a sober member of Alcoholics Anonymous for 13 years," he wrote. "Two years ago, I decided that I could handle drinking again. Clearly, I was wrong."

However, this guy did commit an assault. (Not his first, either.) I don't think I'll describe him as brave, although I might, if he chose to start creating accountability for his violence by entering a batterer intervention program.

Childhood sexual abuse and alcohol problems

A new study looks for a relationship between childhood sexual abuse (CSA) and alcoholism. It finds that women who experienced CSA have elevated rates of alcohol use at 12-13 years old, but their rates of alcoholism are not any higher than people with similar adolescent alcohol use, though they are higher than the general population.

Two thoughts. First, CSA has been associated with higher rates of addiction. This suggests that CSA may not cause alcoholism, but may lead to early experimentation, which has been associated higher rates of addiction later in life. What's so interesting about this is that it supports CSA as a pathway to addiction and supports alcohol adolescent alcohol misuse as a response to CSA, but challenges the frequently circulated idea of addiction as self-medication for CSA.

Second, the study didn't look qualitatively at the CSA. It would have been interesting to see how the following "traumagenic factors" affected alcohol use and dependence: who committed the abuse (was it a trusted adult); did they report the abuse and where they believed; how invasive was the abuse; how many times were they abused; how many perpetrators were there?

If you are a DF employee and would like the full text, let me know.

Predictors of overdose

A new study looked at OD following detox. The finding that the researchers emphasize is that recent depressive symptoms are a risk factor for OD. They also found that those with at least one prior OD were much more likely to have had an OD at follow-up. An unmentioned finding is that it appears detox may have lowered OD rates. Important because detox is usually not considered when discussing strategies to reduce OD.

If you are a DF employee and would like the full text, let me know.

Are Michigan kids being overdosed?

"Report shows that thousands of Michigan preschoolers are being prescribed psychiatric drugs."
[hat tip: daily dose]

Embracing the culture of recovery

Recovering people around the country are advocating for recovery. Some in big, high profile ways and others in smaller, quiet ways, but we all seem to be organizing around the same fundamental messages. Here's Joe Showalter from Crawfordsville, Indiana:

It has been said that addiction is a cunning enemy of life. (NA world Services) We all know people suffering from drug or alcohol addiction.

Many of us know several people who have attempted to recover from addiction with varying degrees of success. Somehow, though, unsuccessful attempts at recovery seem to garner more attention. Why do so many people return to active addiction after initially addressing their problem and receiving help? Were they unmotivated, unconvinced, under-treated or too far gone? A lot of the conventional wisdom concerning recovery from addiction seems to suggest that a person must hit some terrible ³bottom² before they are amenable to recovery. Often, this ³hitting bottom² entails the loss of the very resources needed to formulate a healthy recovery. Addiction gets progressively worse as it endures and it creates lies about itself along the way. Alcoholism and Addiction have been called the only diseases that tell you, you don¹t have it. I¹m sure many have watched abuse turn to addiction and wondered why the afflicted person doesn¹t appear to believe anything is wrong. Nobody wants to be an alcoholic or an addict. We don¹t want our loved ones to have ³those² problems. That is the very distortion of perception that allows the disease to progress untreated for so long and for so many.

The news is not all grim though. Recovery is possible. It happens all around us. Millions of Americans are in recovery from alcoholism and addiction. Just like the varying degrees of severity present in the problem, there are varying degrees of success and happiness in recovery.

One of the great hurdles springs from the fact that addiction becomes a lifestyle. Like any lifestyle, alcoholism and addiction become a culture unto themselves. This culture, complete with rituals, ceremonies and celebrations, dominates the social, leisure and community lives of those involved with it. A person who begins to seriously address the need for recovery often experiences a kind of ³culture shock². No longer is it safe to socialize in the same places, with the same people or in the same way.

Newly recovering people suddenly look up and they don¹t recognize their own lives. Boredom and isolation are very real enemies of recovery. It takes effort and dedication to reinvent a lifestyle. Fortunately those of us in recovery are not alone on this adventure.

There are many people in this community who have found a new way of life. Often we are where you might not expect to find us. We are in your church (maybe the basement), we are your co-workers, we¹re at the family reunion, the park, the theater, the concert, or maybe wandering the trails at Shades. We are taking an art class, a college course or shopping your garage sale. Many of us have found recovery through a variety of avenues. Support groups are well attended in C¹ville. Many seek help from our faith communities, and many thoughtful and caring professionals provide assistance. A lot of us find our way to recovery by making big mistakes and being held accountable for those mistakes. Our community is graced with a criminal justice system that understands the role addiction plays in the bad decisions that result in criminal behavior. Many alcoholics and addicts have their first exposure to recovery with firm encouragement from the legal system. One thing we all have in common is the need to abandon the culture of addiction and embrace the culture of recovery.

The culture of recovery is an adventure indeed. Social skills have to be re-learned without drugs or alcohol. Interests often have to be developed from scratch. Time management becomes a new concept for a lot of us. Courage to try new things and meet new people is different when your life depends upon it. A culture of recovery is not doing the same old things without the alcohol and drugs. A culture of recovery is about becoming excited about life. It is about rejoining the community and becoming a contributing member of society. When the dust settles we often wonder where we found the time to abuse alcohol and drugs. We begin to see new possibilities and discover a joy that few experience. It makes us want to give what we have found to others who want it. Truly we see that Fun Has Been Redefined.

Addiction illuminates concept of ‘free will’

Harvard Provost, Steven Hyman, recently gave a lecture titled “Compulsion and the Brain: Subverting the Concept of Self-Control.” He provided an easy to understand description of the neurobiological basis for addiction:

Hyman began by explaining what neuroscience has learned about the process by which humans choose among multiple goals and direct their behavior toward obtaining their choices. The part of the brain that manages this process is the prefrontal cortex.

Scientists first began to gain an understanding of the role of the prefrontal cortex in 1848 with the case of Phineas Gage. Gage, a hardworking and conscientious railroad employee, was the victim of a freak accident in which an explosion drove a steel rod through his skull.

Gage survived the accident but seemed to undergo an abrupt personality change.

“He retained his intelligence, but he was no longer sober and reliable. He could no longer conform his behavior to specific goals,” Hyman said.

Scientists now believe that the rod destroyed Gage’s orbital prefrontal cortex, the part of the brain in charge of encoding goals and assigning relative value to them.

Scientists have since identified other structures that perform functions such as holding goals in mind, monitoring behavior necessary to obtaining goals, and resolving conflicts that arise over conflicting goals.

Another essential aspect of the process of seeking and obtaining goals is the dopamine system. Dopamine is a neurotransmitter secreted into the nerve synapse by the presynaptic terminal vesicles, then reabsorbed back into the nerve cells.

Experiments with laboratory animals have shown that the release of dopamine signals the brain to expect a reward. After the reward is obtained, dopamine returns to the nerve cell. Thus, under normal conditions, dopamine is only involved in the process of pursuing a reward, not in the enjoyment of it. But this process can be distorted by the use of drugs such as heroin, cocaine, and amphetamine.

“These drugs are Trojan horses,” said Hyman. “Each of them contains a chemical that is enough like the neurotransmitter that they increase the amount of dopamine in the brain.”

When dopamine continues to be released beyond the normal period, the brain is thrown into a perpetual state of “wanting,” which is the essence of addiction.

Long-term use of addictive drugs, Hyman said, creates processes in the nerve cells that “literally rewire the brain. The circuitry becomes deranged, which elicits automatic drug craving and drug seeking.”

These changes in the brain’s circuitry and the resulting loss of control over the normal goal-setting and goal-seeking process are what makes it so difficult for addicts to recover and return to normal lives.

“I’m not saying that these people are zombies,” Hyman said. “They can grab hold of themselves and regain control of their behavior, but they are at a high risk of relapse.”

What are the policy implications for this model of addiction? One of them, Hyman said, is that because the addicts’ brains are so compromised, it is necessary for others — families, friends, and institutions — to fill in and act almost like “a prosthesis” for the brain functions that are missing or disabled. In order to succeed, however, they must be “absolutely relentless,” added Hyman.

“Drug addiction is a very dramatic form of compulsion,” he said. “We are probably a little less in control than we’d like to believe we are.”

Nevertheless, Hyman believes that addicts should still be held responsible for their actions.

“The fiction that they are responsible may be what gets them to change their behavior,” he said. “A society that errs on the side of holding people responsible is better than a society that errs on the side of giving people excuses.”

There are actually clinically proven reasons for holding people responsible for their actions, Hyman said. Experiments have shown that people function better and are more able to deal with stress when they feel that they are in control.

“We are wired for personal responsibility, even if it’s a bit fictional.”

But “punitive moral opprobrium” and overly harsh prison sentences for minor drug offenses do not serve any useful purpose, Hyman added.