A Brief Commentary on Science and Stigma

Bill White recently released a new article expressing serious concern about the message of addiction as a brain disease without including information about recovery:

1. communicating the neuroscience of addiction without simultaneously communicating the neuroscience of recovery and the prevalence of long-term recovery will increase the stigma facing individuals and families experiencing severe alcohol and other drug problems, and
2. the longer addiction science is communicated to the public without conveying the corresponding recovery science, the greater the burden of that stigma will be.

...Campaigns that sought to reduce the stigma of mental illness by educating the public that mental illness was a brain disease inadvertently invoked perceptions that the mentally ill were less than human and invoked harsher behavior toward the mentally ill (Mehta & Farina, 1997; Corrigan & Watson, 2004). While such research has not been directly replicated in the addictions field, Crawford and colleagues (1989) did find that humanitarian attitudes toward the alcoholic (e.g., a sympathetic attitude and belief that treatment should be supported by public funds) were not directly related to whether alcoholism was or was not viewed as a disease.

The vivid brain scan images of the addicted person may make that person’s behavior more understandable, but they do not make the person whose brain is being scanned more desirable as a friend, lover, spouse, neighbor, or employee. In fact, in the public’s eye, there is short distance between the perceptual categories of brain diseased, deranged and dangerous. We should not forget that a century ago biological models of addiction provided the policy rationale for prolonged sequestration of addicted persons and their inclusion in mandatory sterilization laws (White, 1998). Further, christening addiction a CHRONIC brain disease—as I have done in innumerable presentations and publications, may, without accompanying recovery messages, inadvertently contribute to social stigma from a public that interprets “chronic” in terms of forever and hopeless (“once an addict, always an addict”)(See Brown, 1998 for an extended discussion of this danger).

Conveying that persons addicted to alcohol and drugs have a brain disease that alters emotional affect, compromises judgment, impairs memory, inhibits one’s capacity for new learning, and erodes behavioral impulse control are not communications likely to reduce the stigma attached to alcohol and other drug problems, UNLESS there are two companion communications: 1) With abstinence and proper care, addiction-induced brain impairments rapidly reverse themselves, and 2) millions of individuals have achieved complete long-term recovery from addiction and have gone on to experience healthy,
meaningful, and productive lives.

Drinking Often Spurs Move to Poorer Neighborhoods

An important finding:

"The more alcohol problems a man has, the more likely he is going to remain in, or migrate into, a disadvantaged neighborhood," according to a team of University of Michigan researchers. They report their findings in the September issue of Alcoholism: Clinical & Experimental Research.

"It can be kind of bleak when you look at it, but we know that alcoholics are prone to a whole range of negative consequences," added Ryan Trim, a research psychologist at the VA San Diego Health Care System who's familiar with the findings.

Experts have looked at the connections between neighborhoods and alcohol use in the past, but they've tended to focus on how bad neighborhoods might help produce alcoholism, Trim said.

He said the new study is unusual, because it looks at the link from the other direction: whether alcohol use makes people more likely to migrate to worse areas.

It's pretty obvious and confirms what most of us already believed. It's important
because studies on alcohol and poverty usually come at it from the other end--alcohol problems are more prevalent in poor areas, therefore poverty is an environmental cause of alcohol problems--these people are self-medicating their suffering from poverty.

This finding provides some important perspective on the matter. It also illuminates how researcher bias can lead to accurate but incomplete information.

Insite expands with Onsite detox centre for addicts

Vancouver's safe injection site makes a move in right direction. I wish I could say that I'm confident they'll embrace facilitating recovery.

In a previous post I was underwhelmed with the detox referral numbers that they were crowing about.

Industry worker drug use: Worker Substance Use by Industry

The latest installment of SAMHSA's drug and alcohol use by industry report.

Food service and construction have the highest rates of drug use while construction and entertainment have the highest rates of heavy drinking.

Education and utilities have the lowest rates of drug use, while health care and education have the lowest rates of heavy drinking.

Sewage tells tales about community-wide drug abuse

A new way to measure drug use community-wide.

Tanorexia--a real addiction?

This Slate article offers biological evidence for tanning as an addiction:

A fundamental question in sun science is why we go on basking like lizards despite the obvious risks. Researchers have long suspected a connection between UV exposure and natural "feel good" molecules called beta-endorphins, which are also released during exercise. But for years, the evidence was ambiguous, as some scientists looking for it failed to find an endorphin surge in peoples' blood following exposure to ultraviolet light.

Last year, however, the field warmed up, so to speak. Steven Feldman, a dermatologist at Wake Forest University, gave eight frequent tanners a drug called naltrexone, which blocks the body's opioid receptors. These are sites in the body and brain where endorphins, as well as drugs like morphine and codeine, may attach. Feldman found that on naltrexone, half of the frequent tanners showed signs of withdrawal, like nausea and jitteriness, whereas none of the infrequent tanners did. He argues that with their opioid receptors blocked, the tanners "were deprived of their UV fix," because they'd developed a chemical dependency on the light.

David Fisher of the Dana Farber Cancer Institute in Boston thinks there may be an evolutionary rationale for the sun's draw. Maybe the endorphin release offered an adaptive advantage by reducing the pain associated with sunburn, or encouraged people living at high latitudes to spend time in the sun and thus avoid vitamin D deficiency. This spring, Fisher and his colleagues happened on a molecular connection between UV light, tanning, and endorphin release. In a paper published in March in Cell, they reported that UV damage directly causes the production of beta-endorphin in the skin.

No one knows exactly how this endorphin release might trigger chemical dependency—the molecules may or may not reach the bloodstream. But the door is now wide open to molecular sleuthing. Meanwhile, some indoor-tanning fans are also touting the endorphin findings, since it seems to prove chemically that tanning feels terrific (even as it kills you).

Kicking Butt

William Saletan argues that it's time to take a deep breath and consider whether we're going too far in the war on tobacco:

Despite studies showing it's far safer than cigarettes, most European countries allow smoking but prohibit snus. In the U.S., sponsors of legislation to regulate tobacco under the FDA are resisting amendments that would let companies tell consumers how much safer snus is. The president of the Campaign for Tobacco-Free Kids complains that snus will "increase the number of people who use tobacco," letting "the big companies win no matter what tobacco products people use." But the goal shouldn't be to stamp out tobacco or make companies lose. The goal should be to save lives.

The bill's opponents are no better. They'd rather stick with the idiotic current policy of letting the FDA regulate nicotine in gum and patches—its safest delivery vehicles—but not in cigarettes. They insist tobacco products can't be made safer or less addictive. That's just wrong. In addition to snus, one biotech company has already engineered tobacco plants that are almost nicotine-free.

A year ago, when a study showed an increase in cigarette nicotine levels, anti-smoking activists accused the tobacco industry of boosting its narcotic dosage to make people smoke more. But against the FDA bill, which would reduce nicotine levels, activists are making the opposite argument: that in order to get the same nicotine fix, people will be forced to smoke more cigarettes. Either way, they think manipulation is the problem. In the past, that was true. But today, manipulation is the solution.

Instead of indiscriminately vilifying tobacco, we should reengineer it. Bypass the combustion, purge the tar, dial down the nicotine—whatever serves public health. We could even use it to cure people. Two years ago, Henry Daniell, a biologist at the University of Central Florida, proved that an anthrax vaccine could be grown in genetically engineered tobacco. Tobacco was a logical vehicle, he said, because it was prolific and wouldn't end up in the food supply.

I get the argument, and I suppose it could work with FDA regulation, but I also understand the reluctance to enlarge the tobacco market.

Surviving the Pain and Sharing the Hope

The New York Times describes the outreach worker training system in New York.

Race and the war on drugs

Bradford Plumer explains that, while the effect of the war on drugs and the crack sentencing laws may be racist, the intent was clearly not racist:

The War on Drugs, which has contributed more to our mass-incarceration orgy than anything else, strikes me as more than just Jim Crow for the 21st century. After all, in 1989 even Jesse Jackson was talking about using "antiterrorist policies" on drug users and traffickers, and Charlie Rangel was constantly savaging Reagan for being too soft on the drug menace. The media hyped to high heaven an article by Robert Martinson showing that rehabilitation doesn't work, and yawned five years later when he recanted. (Martinson, depressed over what he had wrought, killed himself in 1980.) There seems to be a mass frenzy at work here that goes beyond race, even if that's how it started.

Politics and Prison Reform

Interesting. The two most conservative candidates, Sam Brownback and Mike Huckabee, may be the two more vocal advocates of prison reform.

Huckabee on 3-strikes legislation and addiction:

Arkansas Governor Mike Huckabee is blunt when it comes to the three-strikes approach to justice: "It's the dumbest piece of public-policy legislation in a long time. We don't have a massive crime problem; we have a massive drug problem. And you don't treat that by locking drug addicts up. We're putting away people we're mad at, instead of the people we're afraid of."

More on Huckabee:

...he campaigns on a compassionate approach to wrongdoers, especially those whose crimes are the result of drug or alcohol addiction. At Philly's Finest, he condemned the "revenge-based corrections system," sounding every bit the sort of squishy liberal that the Bill O'Reillys of the world long ago scared into the shadows. "We lock up a lot of people we are mad at rather than the ones we are really afraid of," he said. "We incarcerate more people than anybody on earth." As governor, Huckabee pushed for drug treatment instead of incarceration for nonviolent offenders.

Brownback on the Second Chance Act:

The senator talks about how to achieve that goal by pointing to the program his audience knows well. IFI and other prerelease programs, says Brownback, can help inmates break their "bondage" to the past and prepare for a new life with people who can "pull you up, and not down." He also discusses his Second Chance Act, which would authorize $40 million to help newly released prisoners with housing, drug treatment, counseling, job training, and education. Brownback says reducing the recidivism rate is not only about turning around the lives of those who have committed crimes but also about "breaking the generational curse . . . so that it doesn't go to your kids and grandkids."

If there's bipartisan support for action, why is nothing happening? Conservative blogger Ross Douhat offers an explanation:

Prison reform is one of those impossible issues where all the incentives cut against changing the present system, because its injustices and cruelties are borne by a small percentage of the population, and its benefits are spread across the public as a whole.

Here's interesting analysis of the ineffectiveness and the racial injustice of it all:

Consider the tortured racial history of the War on Drugs. Blacks were twice as likely as whites to be arrested for a drug offense in 1975 but four times as likely by 1989. Throughout the 1990s, drug-arrest rates remained at historically unprecedented levels. Yet according to the National Survey on Drug Abuse, drug use among adults fell from 20 percent in 1979 to 11 percent in 2000. A similar trend occurred among adolescents. In the age groups 12–17 and 18–25, use of marijuana, cocaine, and heroin all peaked in the late 1970s and began a steady decline thereafter. Thus, a decline in drug use across the board had begun a decade before the draconian anti-drug efforts of the 1990s were initiated.

Of course, most drug arrests are for trafficking, not possession, so usage rates and arrest rates needn’t be expected to be identical. Still, we do well to bear in mind that the social problem of illicit drug use is endemic to our whole society. Significantly, throughout the period 1979–2000, white high-school seniors reported using drugs at a significantly higher rate than black high-school seniors. High drug-usage rates in white, middle-class American communities in the early 1980s accounts for the urgency many citizens felt to mount a national attack on the problem. But how successful has the effort been, and at what cost?

Think of the cost this way: to save middle-class kids from the threat of a drug epidemic that might not have even existed by the time that drug incarceration began its rapid increase in the 1980s, we criminalized underclass kids. Arrests went up, but drug prices have fallen sharply over the past 20 years—suggesting that the ratcheting up of enforcement has not made drugs harder to get on the street. The strategy clearly wasn’t keeping drugs away from those who sought them. Not only are prices down, but the data show that drug-related visits to emergency rooms also rose steadily throughout the 1980s and 1990s.

Entrepreneurial Addiction Recovery Centers

I didn't have time last night to provide context for this post. Here's a passage from Slaying the Dragon that provides some historical context for this trend:

In the 1980s, addiction treatment programs shifted their identities from those of service agencies to those of businesses. A growing number of for-profit companies that measured success in terms of profits and quarterly dividends--rather than treatment outcomes--entered the field.

...

Their self-images shifted from those of public servants to those of health-care entrepreneurs. For a time, a predatory mentality became so pervasive that it affected even some of the most service-oriented institutions. In this climate, alcoholics and addicts became less people in need of treatment more a crop to be harvested for their financial value. This evolving shift in in the character of the field left in its wake innumerable excesses that tarnished the public image of the field and set in motion a financial backlash that would lead to fundamental changes in the primary treatment modalities available to addicts and their families.

New Style of Entrepreneurial Addiction Recovery Centers Becoming Main Stream

Oy vey.

Harm Reduction

A few people have asked for thoughts about yesterday's harm reduction post. I held back, intending to let it speak for itself and avoid appearing mean, but here goes.

I thought it did a great job illuminating the differences between Dawn Farm (drug-free, recovery-oriented services) and them. Not to say that we can't learn anything from them, but from our perspective, I thought that their comments communicated the following:

• a belief in addiction as a lifestyle choice (rather than loss of control or enslavement to a brain disease)
  
• overwhelming skepticism about the capacity of addicts to recover
• a fetishization of drug culture
• vicarious derivation of "coolness" from contact and identification with addicts
• a reduction of addicts to a culturally liberated hedonist caricature
• the subtle bigotry of low expectations
• enoblizing the suffering of addicts

This shouldn't be perceived as an attempt to generally disparage harm reduction. I can support most harm reduction activities if they are conducted in a recovery-oriented manner. Those comments don't reflect any interest in facilitating recovery.

Disability payments may spur drug abuse

This is old news to our detox staff:

Paying out certain types of government aid in a monthly lump sum appears to fuel a spate of harmful and often fatal drug binges, according to a new study in a forthcoming issue of the Journal of Public Economics that links the monthly arrival of disability checks with a sharp rise in drug related hospitalizations and deaths. The findings by researchers at the University of California, Santa Cruz and Texas A&M University suggests that spreading out aid payments over several weeks could be a way to relieve some of the stress on hospitals and health care workers who struggle to handle the monthly surge.

The analysis found that in California, the 23 percent increase in drug-related hospital admissions that occurs in the first five days of any given month is driven largely by the arrival of Supplemental Security Income (SSI) and Social Security Disability Income (DI) payments. In particular, hospital deaths among SSI recipients increase 22 percent at the beginning of the month.

Quitting on Impulse May Be Smokers' Best Bet

What does this mean for the transtheoretical stages of change?

Smokers are often told the best way to nix their habit is to have a game plan, including a quit day and a quit strategy. But could that advice be counterproductive?

In a recent study putting that question to the test, smokers who quit spontaneously -- without advance planning -- had a greater chance of succeeding than those who planned ahead. The results, published in the British Medical Journal, seem to flout traditional smoking-cessation guidance.

Dr. Michael Siegel, a professor of social and behavioral sciences at Boston University who examines tobacco control policies and smoking behavior, said the findings make a lot of sense.

"Planned quit attempts are implemented gradually and thus the level of motivation is probably rather low," he said. "But these unplanned, sudden attempts probably reflect some sentinel event or great tension that precipitates a very high level of motivation to quit. And thus these attempts are more successful," he reasoned.

Study authors Robert West and Taj Sohal liken the unplanned quit attempt to what mathematicians call "catastrophe theory." The idea is simply this: As tensions build up, even small triggers can lead to sudden and dramatic shifts in action. In nature, such forces might lead to, say, an avalanche. In much the same way, a smoker becomes disgusted with his habit, creating tension that, eventually, triggers a split decision to kick the habit.

...

Thomas Glynn, director of cancer science and trends and director of international tobacco programs at the American Cancer Society in Washington, D.C., said the research is intriguing.

"What this study does is certainly require us to take a step back and look at different decision-making styles that people have," he said. But without further study bearing out these results, the cancer society would not consider revisiting its smoking cessation advice. "We certainly wouldn't want to do it on the basis of one study, particularly one that's based on retrospective data," he added.

For their study, the researchers compared data on 918 smokers who had made at least one quit attempt with the experiences of 996 successful former smokers. Almost half -- 48.6 percent -- of smokers said their most recent quit attempts were made without previous planning, and these spontaneous attempts were more likely to succeed for at least six months.

In fact, the odds of quitting successfully for at least six months were higher for unplanned quit attempts than for those that involved some pre-planning.

Presuming their theory is correct, the researchers propose that public health campaigns focus on what they dub the "3 Ts" -- creating motivational tension in smokers, triggering action in those who are on the cusp of change, and supporting them with treatment, such as nicotine patches and counseling.

Everything above makes a lot of sense but the ellipses replaced this:

Siegel said the study points to the need to focus on motivating smokers to want to quit. He said there's been too much emphasis on promoting pharmaceutical aids to help people quit. "If we can get smokers motivated enough, they will succeed in quitting, regardless of the mechanism."

Really? The reason people are unsuccessful quitting is that they are not sufficiently motivated? This doesn't doesn't fit countless anecdotal experiences and seems to suggest that the blame lie with the addict.

Herbal sleeping pills contain prescription meds

One more reason for those in recovery to be careful about herbal remedies.

Why do drug dealers live in their mother's basements?

This doesn't have much to do with addiction, but the author of Freakonomics pokes holes in our cultural mythology about drug dealers and wealth.

The syringe in the sandbox

A call for needle exchange reform in San Francisco. More background info here.

The soul of harm reduction

Several experts were asked "what harm reduction means to me."

Highlights below:

I regard harm reduction as a subversive way of performing medicine: doing outreach work, sharing knowledge with users, empowering them, care and cure in a more human, respectful and humble way, inventing a model which not only concerns drug use, but also transforms my whole practice

The magnificent work people who injected drugs in New York in the late 1970s and early 1980s did to figure out that they were under attack by an insidious disease - long before science figured it out.

Their success, in spite of continual assaults on their dignity and autonomy by media, politicians and police, in figuring out how to reduce their risk of acquiring or passing on this new disease - long before public health or others did much of anything.

The creativity of users (and their saying “We Are Human”) as they organised activist groups to pressure service providers and governments to help them when they need it and to respect their dignity and autonomy at all times.

To me, harm reduction means love, passion and care to all human beings who live with us ... I have graduated from university twice - once from a medical university in Shiraz (my home town) and once from the street university with all the people who use drugs and live with drugs. To me, the most efficient and noble experience was having the chance to be with people on the streets – to live with them and learn from them. Now they are my best friends and my best teachers whenever I need. I feel for the first time in my life that now I have a meaningful dream to live with

I had to smile when I was asked to write this short piece of what harm reduction means to me. Harm reduction for me has become more than something I do at work. It is a philosophy that I have adopted to guide how I deal with many sides of my life and I practice it not only professionally but maybe more importantly in my home. I am a single parent with three teenage children - two girls (11 and 15 years old) and a son of 13....

I have created a non-judgmental environment in my home where my children are comfortable sharing with me what is going on in their lives. HIV and drugs have been a regular topic of discussion in my kitchen for years! Condoms have always been around our house and are not seen as something weird or external - my children know what they are for. I have educated them to be peer educators in terms of drugs, sexual health, and HIV - so that when they hear misinformation from their friends they are able to provide the correct information. They know that I would rather that they did not use any substances, but we have also discussed each substance (including tobacco, ganja, crack and alcohol) and they know the harms associated with each. Instead of preaching sexual abstinence with my children, I have discussed with them the physical and mental health benefits of postponing intercourse to a later age and we have discussed other strategies for satisfying a partner through ‘outer-course’ (politically correct word for ‘mutual masturbation’ or ‘heavy petting’ - as it was called when I was 14!). If they chose penetrative sex, then they know that any boy who refuses to use a condom is not worth having sex with.

The age of sexual consent is 16 in Saint Lucia. As they turn 16, I will let them use the guest apartment under the house for their conjugal visits rather than have them go out to a car or beach where rape is a possibility.

For most drug users, harm reduction – not abstinence – is the only chance to survive. Harm reduction relieves them from the humiliating consequences of prohibition (at least those who have not been deterred). Harm reduction enables them to save their lives and live them free of contempt and humiliation. Harm reduction means to lead a constant fight against people’s need to reassure themselves of their superiority by stigmatising those who deviate from normality. Harm reduction forms a lively counterbalance to the exaggerated sense of duty and hostility to pleasure originating from puritan ideology. Harm reduction supports people who do not want to suffocate in a puritan corset but who strive for a life with intense experiences, even if their attempts often ended in failure.

Chantix and mental illness

Something to keep an eye on:

The August issue of the American Journal of Psychiatry included two letters reporting single cases of worsening of symptoms of schizophrenia and mania, while they were taking the new smoking cessation medication, Chantix (varenicline).