Childhood Sexual Abuse, Age of First Drink, and Onset of Alcohol Dependence

An interesting, but not very surprising finding from BASIS. Research in this area seems to consistently challenge common assumptions about childhood sexual abuse and addiction:

Contrary to expectation, CSA did not predict time to AD after adjusting for age at first drink. Drinking at an early age predicted a more rapid pace for AD development; however, both twins having AD was the best predictor of rapid onset of AD after their first drink, suggesting genetics and environment are greater risk factors for this effect than CSA. Future research could examine an early intervention’s effectiveness for reducing rates of later AD among early adolescents reporting CSA history.

Many Psychiatrists Self-Prescribe, Study Says

This story never says how many, "many" is. It also suggests that psychiatrists suffer Major Depression at rates higher than the general population and, interestingly, offers an environmental explanation for their depression that they are treating with meds.

The angle I was most interested in was what this means for patients, in terms of counter-transference and diagnostic patterns. This wasn't addressed.

[via: Matt]

If Tobacco Regulation Works, Why Not Regulate Marijuana?

I suppose it's possible that age of first use could decline if marijuana was regulated, rather than banned. However, please pardon my skepticism at the Marijuana Policy Project's concern about adolescent marijuana use. I'd guess that some of the factors associated with decreases in tobacco use include increased prices and shifts in cultural attitudes (it's gone from adult, cool and sophisticated to unhealthy, unsafe and dirty--from celebrated to tolerated) . In terms of cultural attitudes, perceptions of marijuana seem to be moving in the opposite direction, at least in part, due to the efforts of groups like the Marijuana Policy Project.

I don't begrudge them attacking the irrationality of American drug policy, but I don't trust their motives. I'm not convinced that "reducing harm" is their primary motivation. They earnestly believe legalization will reduce harm, but legalization is primary their primary goal and I suspect they would not change their position if new evidence emerged to challenge their beliefs (not that I'm predicting new evidence). Along these lines, with their consistent message that it's relatively harmless, I find it difficult to believe that they are very concerned about teen marijuana use.

One more thought--alcohol is regulated and widely used by teens. It's possible that, on balance, we'd be better off with different marijuana laws, but this is a pretty weak argument. All policy decisions are about trade-offs. There is no drug policy that will deliver us from all of our drug problems. Beware of people suggesting otherwise.

The notion that crack is far more dangerous than cocaine is widely disputed

More on the irrationality of the crack/powder cocaine sentencing disparity.

While I completely disagree with the sentencing disparity (and I don't think anyone should be incarcerated for personal use), crack is more dangerous than powder in that its addictive properties are changed by creating a cheap, easy way to freebase. It's a little like comparing chewed opium to injected opiates--the syringe dramatically changed the relationship between the drug and users. I suppose it depends on how you define "dangerous." They seem to be focusing on the effects on the body.

Network Support for Drinking and treatment matching

More Project MATCH follow-up:

Objective: The current study re-examined the Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) hypothesis that individuals with high network support for drinking would have the best treatment outcomes if they were assigned to twelve-step facilitation (TSF). Method: Drinking consequences, as measured by the Drinking Inventory of Consequences, was the primary outcome measure. Growth mixture models with multiple groups were used to estimate the drinking consequence trajectories of 952 outpatients during the 12 months following treatment for each of the three Project MATCH treatment conditions. Growth factors within latent trajectory classes were regressed on network support for drinking to assess whether treatment condition moderated the relationship between network support for drinking and drinking consequences over time. Results: Three latent classes were identified, representing low (n = 154, 16.2%), medium (n = 400, 42%), and high (n = 398, 41.8%) levels of drinking consequences. Classes did not differ across treatment groups. Greater network support for drinking predicted more drinking consequences over time but only for clients assigned to cognitive-behavioral therapy and motivational enhancement therapy, not TSF. Conclusions: This study provides further support for one of the original Project MATCH matching hypotheses: Clients with social networks supportive of drinking had better outcomes immediately after treatment if they were assigned to TSF. Because the original Project MATCH studies found this matching effect only at the 3-year follow-up, these results add validity to the network support for drinking matching effect. The study also provides additional evidence that accounting for heterogeneity in alcohol treatment outcomes is important for accurately estimating treatment effectiveness. (J. Stud. Alcohol Drugs 69: 21-29, 2008)

[via: alcohol reports]

Effectiveness of pretreatment interim support groups

This study might offer some ideas for managing waiting lists:

Decreasing state and federal budgets have led to shortages in public health funding for treatment programs to aid long-term users in recovery from methamphetamine abuse. These shortages have led to client “waiting lists” for government-subsidized treatment. Many of these “waiting list” individuals fail to show up for treatment when it is scheduled. The current study investigates the efficacy of “interim support groups” as a means of encouraging methamphetamine abusers to begin treatment programs (defined as attendance on the first day of treatment). A logistic regression revealed that interim group attendance predicted whether a methamphetamine abuser would show up for treatment. These results are discussed in terms of both the value of interim groups in facilitating treatment adherence and the role pretreatment support groups can play in facilitating a methamphetamine abuser's determination to engage in treatment.

Why'd I do that?

Shocking findings about emotional regulation and impulsivity in early recovery:

Background: Early abstinence from chronic alcohol dependence is associated with increased emotional sensitivity to stress-related craving as well as changes in brain systems associated with stress and emotional processing. The aim of the current study was to examine potential difficulties in emotion regulation during early alcohol abstinence using the recently validated Difficulties of Emotion Regulation Scale (DERS).

Method: Recently abstinent treatment-seeking alcohol abusers (n = 50) completed the DERS during their first week of inpatient treatment and at discharge (5 weeks later). These responses were compared to a group of social drinkers (n = 62).

Results: Compared with social drinkers, alcohol-dependent patients reported significant differences in emotional awareness and impulse control during week 1 of treatment. Significant improvements in awareness and clarity of emotion were observed following 5 weeks of protracted abstinence. However, significant difficulties with impulse control persisted until discharge.

Conclusion: Findings from the DERS indicate protracted stress-related impulse control problems in abstinent alcoholics, which may contribute to increased relapse vulnerability.

Presidential Candidates Weigh In

The Partnership for a Drug Free America posted candidate responses to their questions. Only 7 candidates responded.

Number of times the word "recovery" appears in all of the responses: 0
Number of times the word "treatment" appears from each candidate:

• Dodd - 1
• Obama - 2
• Edwards - 5
• Biden - 14
• Gravel - 1
• Huckabee- 2
• Richardson - 1
  

Number of times the words "prevention" or "prevent" appear from each candidate:

• Dodd - 4
  
• Obama - 2
• Edwards - 1
  
• Biden - 6
  
• Gravel - 0
  
• Huckabee- 0
  
• Richardson - 0
  

[via Jess]

A harm reduction trifecta

First, a columnist for the Vancouver Sun rightly complains that only two pillars of Vancouver's four pillar approach have been implemented. The writer promotes a big, audacious (and possibly goofy) idea. Here are the highlights:

The Four Pillars plan totters on only two -- harm reduction (which includes the safe injection site, the ever growing distribution of free needles, methadone and possibly free heroin) and the best enforcement Vancouver police can muster without completely abandoning the rest of the city.

...

Medical experts like Coleman define addiction as a war between two parts of the brain. The forebrain, which controls our intellectual or rational understanding, is not able to keep the mid-brain, the emotional centre, in check.

Addicts are, in Coleman's words, people who continue to use drugs or alcohol despite knowing the consequences are episodes of loss of control and an ongoing preoccupation with getting that next drink or fix.

...

So, what we're left with is this:

We can maintain the status quo, pouring millions of dollars into the Downtown Eastside and pretending that two pillars are four.

We can pack addicts off to the hinterlands and hope they don't come back as Martians.

Or, we can accept the medical evidence that recovery is a slow, hard process that's made easier if people get needed services in their own communities where, unimpaired, they can rebuild and resume their lives.

An Ottawa Citizen contributor defends Insite (Vancouver's safe injection room), characterizing it as a success. (Previous posts on Insite here.)

Finally, an ideologically motivated attack against ideologically motivated attacks against harm reduction. (Did you follow that?)
[via ccsa.ca]

Stimulant alcohol effects prime within session drinking behavior

Until recently, I don't recall seeing any research into stimulant properties of alcohol. However, James Milam wrote about as a powerful reinforcing aspect of alcoholism.

Programs Let Addicted Docs Practice

It looks like California might actually end its health professional recovery program. This article discusses the issue in pretty sensational terms.

Nearly all states have confidential rehab programs that let doctors continue practicing as long as they stick with the treatment regimen. Nationwide, as many as 8,000 doctors may be in such programs, by one estimate.

These arrangements largely escaped public scrutiny until last summer, when California's medical board outraged physicians across the country by abolishing its 27-year-old program. A review concluded that the system failed to protect patients or help addicted doctors get better.

Opponents of such programs say the medical establishment uses confidential treatment to protect dangerous physicians.

"Patients have no way to protect themselves from these doctors," said Julie Fellmeth, who heads the University of San Diego's Center for Public Interest Law and led the opposition to California's so-called diversion program.

Most addiction specialists favor allowing doctors to continue practicing while in confidential treatment, as does the American Medical Association.

Supporters of such programs say that cases in which patients are harmed by doctors in treatment are extremely rare, and would pale next to the havoc that could result if physicians had no such option.

"If you don't have confidential participation, you don't get people into the program," said Sandra Bressler, the California Medical Association's senior director for medical board affairs.

California's program ends June 30. If no alternative program is adopted, the rules could revert back to the zero-tolerance policy in place before 1980, when doctors who were found by the medical board to have drug or alcohol problems were immediately stripped of their licenses.

No other state has followed California's lead. But the president of California's medical board, Dr. Richard Fantozzi, said that behind the scenes, regulators nationwide share his ambivalence toward such programs.

"To hide something from consumers, something so blatant ... it's unconscionable today," Fantozzi said.

I don't know anything about the situation in California, but I suspect that any state with a lousy program would be vulnerable to this kind of action. In that case, you'd have two options: to improve the program, or end the program. If the state has a good monitoring and enforcement program, patients shouldn't have anything to fear. The other advantage of a good program is that they usually have a voluntary program for health professionals who have not been reported by anyone, but are concerned about their own use.

Experts have no fear of crack ruling

Some helpful perspective on the Supreme Court's recent drug sentencing ruling. I'm surprised that this has not gotten more attention.

When the U.S. Sentencing Commission last week reduced sentences for imprisoned crack cocaine offenders — reversing years of policy that treated crack far differently from powder cocaine — the Justice Department and police groups bitterly criticized the action, warning of a flood of criminals rushing out onto America's streets.

The change "will make thousands of dangerous prisoners, many of them violent gang members, eligible for immediate release," predicted acting Deputy Attorney General Craig Morford. "These offenders are among the most serious and violent offenders in the federal system."

But many experts say the reality is not so dramatic. Fewer than 3,000 prisoners nationwide will be immediately eligible for the relief. All have already served considerable time. Each prisoner will have to petition the court for his freedom — and the Justice Department can oppose those petitions. Few offenders with violent histories are likely to be released.

[via dailydose.net]

Legislation to End Student Aid Penalty Stumbles

Your tax dollars at work.

9th Circuit on Abstention From Alcohol as Supervised Release Condition

If I understand this correctly, the 9th Federal Circuit Court ruled that a court can't impose an abstinence order if alcohol didn't play a role offense.

The 'bupe' fix

The Baltimore Sun just ran an article on buprenorphine diversion:

There's a new narcotic on the street in Baltimore and other communities - and taxpayers helped put it there.

The hexagonal orange pills some users call "bupe" are championed as an exceptional treatment for heroin and pain-pill addicts. Federal officials have spent millions of dollars to help create and promote buprenorphine, and are encouraging thousands of private doctors to prescribe it.

But making buprenorphine widely available has also made it easy for patients to sell the narcotic illegally, leading to growing abuse, an investigation by The Sun found. Some people have died after misusing it with other drugs.

Heroin addicts hardened by years on city streets, and youthful buyers in suburban and rural areas, are using it to get high - sometimes in dangerous combination with other substances - and to tide them over when they can't obtain heroin or other narcotics.

The drug, mainly prescribed in a form called Suboxone, is intended to be dissolved under the tongue. But some abusers are crushing the pills to snort or inject buprenorphine, a dangerous practice that medical experts believed could be deterred by a chemical safeguard in Suboxone.

[via jointogether.org]

Crack cocaine: It affects us all

The Muskegon Chronicle is running a series of posts on crack use in the community. (Look here and here.)

More co-occurring common sense

More from that special issue of the Journal of Substance Abuse Treatment. The points below may seem like it's stating the obvious, but for a major journal with leading researchers to be emphasizing these points is a big deal. The balance in this issue is refreshing.

...mixed findings echo the point ... Psychiatric diagnosis alone may be less relevant to addiction treatment failure than symptom severity.

Although, as a group, this population is often labeled as dual disordered,Q persons with co-occurring disorders are a heterogeneous lot, ranging from those with severe mental illnesses (e.g., schizophrenia) to those with mild or moderate psychiatric problems (e.g., dysthymia), as well as from those with severe substance-related disorders (e.g., dependence) to those with mild or moderate problems (e.g., misuse or abuse). In fact, most patients in addiction treatment programs with co-occurring disorders do not suffer from severe mental illnesses.

Co-occurring disorders in substance abuse treatment: Issues and prospects

The Journal of Substance Abuse Treatment has dedicated an issue to co-occurring disorders. This article stands out for balance and avoiding the myopic and psychiatry hyping findings often seen in articles on the subject.

First, is does a good job distinguishing between general population prevalence and clinical population prevalence. What it doesn't do (Because the research isn't there.) is distinguish between acute vs. chronic mental illness or abuse vs. dependence. Further, in discussing assessment, it acknowledges that real world conditions lead to overdiagnosis of mental illness in this population:

Ideally, the assessment of mental disorders would occur only after permitting a period of abstinence that extends up to a month or more to avoid the risk of confusing the client's presenting condition with the effects of his or her drug use ([Center for Substance Abuse Treatment, 2005], [Hasin et al., 1998] and [Quello et al., 2005]). The press of clinical programming often does not typically allow for such a deliberate strategy even where assessment does take place. Thus, in substance abuse treatment, clinicians may feel constrained to adapt practices to less-than-ideal conditions and accept the noise associated with the influence of substance use on assessment practices and results. One potential outcome of this less-than-ideal process is an overidentification of mental disorders, which may be a significant contributing factor to both the high prevalence rates reported by programs for CODs and findings of the effectiveness of single-disorder treatments for individuals identified as showing evidence of multiple disorders. To counter the risk of error in early diagnosis, it has been suggested that clinicians make use of multiple assessments conducted over time (Center for Substance Abuse Treatment, 2005) and rely on brief screening instruments at intake to determine if a later diagnostic assessment is warranted (cf. [Center for Substance Abuse Treatment, 2005] and [Quello et al., 2005]).

Another strength of the article is that it again, examines real world conditions and acknowledging that treatment as usual is effective for people with mild to moderate mental illness:

...it is important to take note of findings from several studies that individuals manifesting low to moderate levels of mental disorder in association with substance abuse appear to respond positively in terms of both drug use and psychiatric symptoms to the nonspecialized treatment provided in drug abuse programs. However, those same studies also point to the importance of specialized treatment specifically responsive to the needs and functioning of those showing moderate to severe levels of mental disorder.

Harm Reduction Round-Up

First, the Baltimore Sun apparently ran a column a while ago advocating the legalization of drugs. The author reports on the feedback he received from ex-users:

Drugs are part of a way of life - robbery, gangs, prostitution - that would persist even if the delivery method changed, the women said. "Addiction is not just getting high," said Felicia, who like the other addicts isn't especially proud of her past and didn't want her last name used. "It's the whole thing - copping [buying on the street], stealing, whatever you do."

Alcohol is legal, but "people out there will rob for a fifth of liquor because they can't get a dollar and 50 cents," she said. "They steal, they trick. They do the same thing. I've got friends that will go out there and hustle harder than me for a drink." Methadone also is legal, but plenty of methadone patients who are clean of heroin still break the law, she said.

Second, Addiction Inbox explores naloxone distribution.

Finally, Health Beat does a great job pointing out the increases in spending on incarceration at the same time as decreases in real health care spending:

Just take a look at history. According to a Health Affairs article from earlier this year, since 1987 public and private investment in substance abuse (SA) treatment has not kept pace with other health spending. From 1987 to 2003, the average annual total growth rate for SA treatment was 4.8 percent, while U.S. health care spending grew by 8.0 percent each year. Because of this mismatched growth rate, SA spending fell as a share of all health spending from 2.1 percent in 1986 to 1.3 percent in 2003.

Compare this drop in treatment spending to the increase in drug arrests: according to the Bureau of Justice Statistics, in 1987 drug arrests were 7.4 percent of all arrests reported to the FBI; by 2005, drug arrests had risen to 13.1 percent of all arrests. Our spending on SA treatment and the volume of drug arrests are moving in opposite directions. And for all the political pageantry surrounding yesterday’s report, President Bush’s FY 2008 budget calls for cutting $158.7 million from the Substance Abuse and Mental Health Services Administration (SAMHSA) budget and $278.9 million from the Safe and Drug-Free Schools and Communities (SDFS) program.

If you take a look at the President’s 2008 drug control budget, it may look as if it emphasizes treatment over enforcement, since it claims a 3.4 percent increase (the most of any other sector of drug control) from 2007. But take this number with a grain of salt—there are a lot of questions marks beneath the surface. In 2001 The Boston Globe reported that drug officials had no methodology to formulating the drug control budget, admitting that “we made it up” and that budget reports did not reflect how money was actually being spent through drug policy. Since 2003, there have been worries that the Office of National Drug Control Policy (ONDCP) budget inflates its commitment to treatment by including alcohol and tobacco in its numbers for SAMHSA, even though by statute ONDCP is excluded from dealing with those substances. Worse, since 2003 the ONDCP drug budget hasn’t reported incarceration costs and costs related to the prosecution of drug cases, resulting in an artificial parity between enforcement and treatment.

Health Beat goes on to discuss Insite in a way that frames arguments against it as pro-enforcement. She offers an explanation of why enforcement approaches seem to always win in political discourse:

More often than not, treatment is going to lose out because it lacks the populist, kick-you-in-the-gut political salaciousness of punishment.

To me it seems that the debate is actually between enforcement, treatment and HR. Unfortunately HR and enforcement seem to be the squeaky wheels and treatment loses out. These debates don't have to be framed as enforcement OR treatment OR HR. We could do all three. Couldn't we?

Male Admissions with Co-occurring Psychiatric and Substance Use Disorders: 2005

These new federal numbers suggest that either people Minkoff are grossly overestimating rates of mental illness or practitioners completing the federal reporting forms are grossly underestimating the prevalence of mental illness.

Of the approximately 544,800 male admissions in these 26 States in 2005, 16 percent (86,500) were admissions with co-occurring substance use and psychiatric disorders (hereafter referred to as co-occurring disorders). This report compares the characteristics of male admissions with co-occurring disorders and male admissions without co-occurring disorders.