One more reason to quit smoking

An explanation for the impact of continued smoking on recovery rates?

A study of alcoholics in treatment for their alcohol problems used brain scans to examine how performance on cognitive tests changes with abstinence from alcohol. Twenty-five alcoholics stopped drinking for six to nine months, but the 12 who smoked continued to smoke.

“We found that the smoking alcoholics over six to nine months of abstinence did not recover certain types of brain function as the non-smoking alcoholics did,” said study author Dieter J. Meyerhoff, a professor of radiology at the University of California, San Francisco. Decision-making skills, thinking speed, 3-D visualization and short-term memory were affected, calling into question the prospects of long-term sobriety, he noted.

And while smoking and non-smoking alcoholics improved on several other cognitive tests, such as learning and remembering words, smokers’ brain function, in general, took longer to recover.

[hat tip: jointogether.org]

Fixing National Drug Control Policy

A new drug policy brief is getting some attention:

Decades of research has taught us a good deal about the ingredients of a successful national drug control strategy. Achieving any measure of progress requires a comprehensive agenda involving treatment, prevention, domestic law enforcement, interdiction, and source country initiatives. But these ingredients are not all of equal value and represent very different returns on investment.

Attacking drugs at their source by focusing mostly on eradication is expensive and unproductive....

Investing in prevention and treatment is a more effective means of reducing drug demand and use. However, the scale and scope of substance abuse treatment must be greatly expanded to further mitigate drug use and addiction. Community based treatment programs, as well as prevention programs, such as Drug Free Communities and Weed and Seed, are particularly valuable in this regard. In addition, research shows that diversion programs, such as drug courts, that emphasize treatment over incarceration and use the coercive power of the criminal justice system in a productive way, are effective and should be greatly expanded.

A small portion of the drug-using population—specifically those who are addicted—consume well over two-thirds of the illicit drugs that law enforcement tries to prevent from entering the United States. Helping these individuals to stop using drugs would substantially reduce the quantity of drugs demanded by the marketplace. In other words: Good treatment policy is smart supply reduction policy.

The goals implicit in a national drug control strategy should drive the federal drug control budget....But instead we have a budget that over-weights source country and interdiction initiatives while under-weighting their domestic law enforcement, prevention, and treatment counterparts. According to the latest budget numbers, funding for supply reduction has increased by nearly 57 percent since federal fiscal year 2002 and now represents nearly two-thirds of the total federal drug control budget. By comparison, funding for demand reduction grew by less than 3 percent over this same period of time and now represents about one-third of the federal drug control budget. While resources for substance abuse treatment increased by 22 percent, resources for prevention programs actually declined by almost 25 percent.

The implications are clear: Any new administration must ensure that there is a match between the goals of the federal drug control strategy and the budget to support it.

Revisiting spiritual guidance in treatment

Bill White has a response to the Bill Miller study on the effectiveness (or lack of effectiveness) of spiritual guidance in an addiction treatment setting. He warns against throwing the baby out with the bath water and offers a series of questions about spiritual guidance, recovery and treatment:

• How are the following defined and delineated:spirituality, spiritual awakening, spiritual orientation,spiritual practices, and SG? What is the relationship between spirituality, life meaning and purpose, andquality of life?
• Does the essence of spiritual experience get lost in efforts to artificially define and replicate it within a professional treatment intervention? Are the ingredients of spiritually oriented professional interventions the same as the ingredients that people in long-term recovery self-report as transformative?
• Will individuals entering or leaving treatment voluntarily participate in a spiritually based intervention? It is unclear in the two SG studies whether the low participation rates (means of 2.9 and 4.8 sessions attended of 12 sessions) were a function of the characteristics of study subjects, the design, and content of the intervention offered or were influenced by staff or organizational factors.
• Are there dose, duration, and timing effects of spiritually oriented interventions? Would different outcomes of the SG studies have been achieved if the dose (number of sessions attended) had been larger or if SG had been delivered as a program for treatment alumni with at least 1 year of sobriety? Are the effects of spirituality and SG different across the long-term stages of recovery?
• What is the role of choice in the spirituality experience and the SG process? Does the “having had a spiritual awakening” effect of AA's 12 Steps result from the individual ingredients of the steps, the cumulative effects of such ingredients, or the sequence in which these actions were taken? Are there greater effects from a focused exposure to a single spiritual philosophy/practice or, as with the SG studies, self-choosing exposure to multiple spiritual practices?
• Is there an ecology of spiritual experience? The milieu of the SG studies (addiction treatment institution) is markedly different than the milieu of 12 Step and alternative recovery support groups (community of shared experience). What effects do physical and cultural environment exert on spiritual experience?
• Does the relational context matter? There is considerable difference between the professional–client relationship with professionals not having prior experience working with addicted and recovering people (as in the SG studies) and relationships in recovery support groups that are characterized by moral equality, mutual vulnerability, mutual support, and long continuity of relationships.
• Are there potential iatrogenic effects of SG as suggested by the slowed improvement of depression and anxiety when compared to controls in the first SG study? Could mild iatrogenic effects occur in an early stage of an SG intervention that could be followed by substantial improvements (e.g., increased anxiety and depression while going through Steps 4 and 5 of Alcoholics Anonymous with significant improvements in emotional health following completion of these steps)?

I love the musing about the effect of this kind of service being delivered by alumni that have been out of treatment for a year. That opens up all sorts of interesting ideas, some having nothing to do with spiritual guidance. What about stage 2 recovery for those entering aftercare?

Who needs enemies...

...with friends (of treatment) like these?

McCain and Obama on drug policy

The Fort Wayne News-Sentinel reports on Obama's and McCain's positions on drug policy.

Addiction Inbox also has posts on both candidates.

Bottom line: McCain wants to continue the drug war and Obama wants to promote drug courts and alternatives to incarceration.

Things that make you go, "hmmm"

From Alcohol and Alcoholism:

Aims: Attention-deficit/hyperactivity disorder (ADHD) is of great clinical importance not only because of its high prevalence but also due to the frequent comorbid illnesses that are connected with this disorder. Several studies were able to demonstrate that ADHD constitutes a significant risk factor for the exacerbation of habit-forming illnesses, i.e. addictions. Methods: We conducted a study on 152 adult patients with alcohol dependence (n = 91) or multiple substance addiction (n = 61) to determine whether or not these patients were affected by ADHD. For retrospective assessment of childhood ADHD, the WURS-k was used as well as the DSM-IV symptom checklist for ADHD. The CAARS was used to assess the persisting symptoms of ADHD in adults. Results: 20.9% (WURS-k) or 23.1% (DSM-IV diagnostic criteria) of the alcohol-dependent patients showed evidence of retrospective ADHD affliction in childhood. With the help of CAARS, ADHD was proved to be persistent in 33.3% of the adult patients. In the group of substance-addicted patients 50.8% (WURS-k) and 54.1% (DSM-IV) presented with diagnostic criteria for ADHD in childhood and 65.5% (CAARS) showed evidence of ADHD persisting in adulthood. Conclusions: These results reveal that habit-forming illnesses can be associated with a high comorbidity with ADHD, expressed in the form of alcohol abuse and also in consumption of illegal drugs. The results underline the great importance of early and adequate diagnostics and therapy of ADHD for the prevention of habit-forming illnesses.

What I find remarkable is not the co-occurrence of ADHD and AOD problems. Rather, that this finding is accepted, and a finding of high intelligence among people with alcohol problems is met with such skepticism. What does this say about the researchers? What questions are they not asking, or at least taking seriously? Is this a case of the ladder of inference at work?

Narcotic Farm

From Scientific American:

From 1935 to 1975, just about everyone busted for drugs in the U.S. was sent to the United States Narcotic Farm outside Lexington, Ky. Equal parts federal prison, treatment center, research laboratory and farm, this controversial institution was designed not only to rehabilitate addicts, but to discover a cure for drug addiction.

...the institution became a premier center for research into drug addiction and treatment, advancing everything from the use of methadone to treat heroin withdrawal to drugs that blocked the action of opiates. Along the way, Narco was frequented by legendary jazz musicians such as Chet Baker and Sonny Rollins, as well as actor Peter Lorre and beat generation writer William S. Burroughs, who recounted his experience in his first novel, Junkie.

The documentary also chronicles how the Farm was shut down when Congress discovered that researchers there were using patients as human guinea pigs in CIA-funded experiments into LSD. Drug research on federal prisoners is now illegal.

Still, the filmmakers note accomplishments at the institution remain milestones in addiction science and treatment. Its most important contribution might be how it transformed the way society views addicts—"as people suffering from a chronic, relapsing disorder that affects public health," says book co-author Nancy Campbell, an associate professor at Rensselaer Polytechnic Institute in Troy, N.Y., who studies the history of drug addiction research.

About the lower image:

The original caption for this photo, which appeared in a 1951 New York World-Telegram & Sun series on the Narcotic Farm, read: "This desperate narcotics addict, caught like his fellows in the revolving door of law enforcement, will probably go back to his habit when he is free."

Complete slide show here.

Info on the film here.

Info on the book.

UPDATE: The original article has since issued the following correction:

Correction (posted October 25, 2008): When originally posted, this story suggested that a Congressional investigation into the Narcotic Farm had led to its closure. In fact the main reason Narco was closed was that its centralized form of institutional care was supplanted by a national network of local treatment centers. Its closure coincided with the Congressional investigation into LSD research. Scientific American regrets the error.

Local policy news

The Ann Arbor News suggests that they would like to endorse a medical marijuana proposal, but this one isn't it.

"unexpected findings"

I don't attribute a lot of significance to this, but I find it amusing that they state 3 times in this very brief press release that these findings are contrary to their expectations. It just CAN'T be true. Further examination is need.

NEW YORK (Reuters Health) - Contrary to expectations, higher intelligence scores at age 10 may be associated with higher levels of alcohol intake and alcohol-related drinking problems during adulthood, study findings suggest.

Moreover, these associations appear "markedly stronger among women than among men," Dr. G. David Batty, from the University of Glasgow in Scotland, and colleagues report in the American Journal of Public Health.

However, "given that these findings ran counter to our expectations," the investigators call for further examination of this relationship.

Batty's team assessed associations between mental ability scores obtained when 8170 boys and girls were 10 years old and their alcohol intake and alcohol problems when they were about 30 years old.

Of the 3895 men and 4148 women who reported drinking alcohol as adults, those with higher average scores on childhood mental ability tests were also more likely to have indications of alcohol problems in adulthood.

The association between higher mental ability in childhood and adulthood problem drinking became stronger among women than among men after allowing for socioeconomic factors such as social class during both childhood and adulthood.

Specifically, for every 15-point increase in childhood mental ability score, the likelihood of drinking problems increased 1.38 times for women, and 1.17 times fro men

These unexpected findings, and the lack of other research in this area, indicate the need for "further examination of the relation between childhood IQ and adult drinking patterns," the investigators conclude.

SOURCE: American Journal of Public Health, October 2008

[Thanks Jess]

Local sentencing sense

The Ann Arbor News reports on the Washtenaw County Sobriety Court and our friend Judge Creal:

The defendant, who had been arrested for drunken driving, stood before 15th District Judge Julie Creal.

But unlike a typical sentencing, Creal asked questions of a more personal nature - wondering whether the death of a relative would impact the man's sobriety.

"I'm dealing with it," he said. "It's a tough time for me."

Creal asked how long he'd been sober.

"Sixteen months sober on Tuesday," he replied.

The nearly two dozen people stuffed in Creal's small courtroom for Washtenaw County's Sobriety Court broke into applause.

"Fabulous," Creal said as she clapped.

A judge who applauds? A group of defendants cheering each other's successes?

That's Sobriety Court, created by Creal four years ago to help repeat drunken drivers get treatment. Representatives from the prosecutor's office, city attorney's office, law enforcement and probation department also are present.

People who enter a voluntary, 18-month program and successfully complete it can avoid jail time and save about $1,000 in fines and fees. The program includes random testing at home, attendance at 12-step meetings, making small payments and staying sober.

Since it started, 157 people have entered the program. Of those who are no longer in the system, 60 have completed it successfully - a rate of about 76 percent.

The focus of the program is really about owning up to a problem.

I posted last week about how drug courts and health professional recovery programs are leading the way for the rest of us.

Methadone maintenance as palliative care

David Clark sticks his neck out on MMT:

As I have said many times before, I have nothing against methadone substitution therapy per se, but I feel strongly about it being used with clients being offered no, or only minimal other, support. I have written:

'Due to the approach adopted by much of the UK treatment system, this generally leads people from one addiction to another without providing a realistic opportunity to attain recovery.

Whilst methadone (and Subutex) have an important role to play in helping people take the chaos out of a heroin-using lifestyle, they should not be prescribed in isolation or with minimal other support.

The majority of heroin users actually want to get off drugs completely, not be “left” long-term on methadone or other substitute drugs. They must be provided with the choice of, and help in, finding a path to recovery, rather than just being helped to live with addiction. Much of the treatment system shows a shocking paucity of ambition for its clients. If cancer patients were only offered what amounts to a form of palliative care, it would be seen as a scandal.'

This issue of palliative care gets to the very crux of the issue doesn't it?

From Wikipedia:

The term "palliative care" may be used generally to refer to any care that alleviates symptoms, whether or not there is hope of a cure by other means;

It really comes down to whether once believes addiction is a treatable illness doesn't it?

I'd add that it might be possible for a methadone program to have a recovery orientation, rather than a palliative orientation, but it's not what I see.

Once again, I'd welcome a day when addicts are offered recovery oriented treatment of an adequate duration and intensity and have the opportunity to choose for themselves.

Transformed...beyond hope

What is there to say?

The NAOMI study was funded by an $8.1-million research grant from the Canadian Institutes of Health Research.

The heroin and hydromorphone participants received three doses a day from health-care professionals in downtown clinics. Most participants - 192 - were from Vancouver. Fifty-nine were from Montreal.

After one year, 90 per cent of the addicts being provided heroin were still in the program and 54 per cent in the methadone program remained - much higher than the retention rates for conventional treatment, Dr. Schechter said.

Researchers said they found a decrease in criminal activity and use of street drugs, and an improvement in health among participants.

Participants must have been addicted to heroin for at least five years and attempted treatment twice in the past.

"This is a group that society has written off as beyond hope," Dr. Schechter said.

Once again, Emerson comes to mind:

This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true. Their two is not the real two, their four not the real four ; so that every word they say chagrins us and we know not where to begin to set them right.

Two failed treatments and the best we can hope for is reduced crime, some improvements in health and persistence in showing up to receive free heroin? All for only $32,270 per participant?

Spirituality and recovery

Martin Nicolaus notices a not yet published study on the impact of spiritual guidance as part of treatment. There was no impact. In fact, the group with spiritual guidance by certified spiritual directors had worse outcomes on measures of depression and anxiety, though a group receiving spiritual guidance from their counselor did just as well as the other groups.

What's especially interesting about this study is that Bill Miller, the lead author, is very friendly to spirituality as an tool for facilitating change. He seems stumped but isn't questioning the study itself.

There is reason for confidence in the findings of this study. Outcome variables were carefully measured by independent interviewers, fidelity of interventions was good, and 82% of all possible follow-up interviews were completed. The studies were powered to detect a medium between-group effect size that would be sufficiently large to be of clinical interest ([Cohen, 1988] and Miller and Manuel (in press) Miller, W. R., and Manuel, J. K. (in press). How large must a treatment effect be before it matters to practitioners? An estimation method and demonstration. Drug and Alcohol Review.Miller and Manuel (in press)). Null findings were replicated across two study designs, and the direction of differences was, in many cases, opposite to prediction. We thus found no evidence for a beneficial effect of this spiritual counseling approach during the acute phase of addiction treatment. Different and more intensive spiritual counseling might increase daily spiritual practices, spiritual experience, and meaning and thereby influence substance use outcomes. Given the magnitude of changes that occur in early recovery, however, we believe that a more promising approach is to focus on spiritual development after a period of stabilization in which other basic needs have been addressed. Within a long-term care perspective, spiritual direction may fit better in later recovery, with a goal of maintaining and broadening the initial gains of sobriety.

It would be interesting to see more research on spirituality and recovery. I'm inclined to believe that spirituality can be a useful therapeutic tool. If nothing else, for people when enter treatment with spiritual beliefs, it might be used to increase engagement and participation in treatment. It might also be used as a long term source of support for change. (We do value a holistic approach, right?)

Along the lines of a stage dependent model, as Miller suggests, Project SAFE reported that many of the African American women in the study initiated their recovery in 12 step groups and sustained their recovery in churches.

The study said nothing of the participants' predisposition to spirituality. That seems important to me.

Other questions that might be interesting include:

• What forms of spirituality are helpful or unhelpful? Some clearly emphasize a stronger internal locus of control while others emphasize an external locus of control.
  
• Can helpful elements of the helpful forms of spirituality be unbundled?
• What are the non-spiritual paths to those helpful elements?
• There is a persistent assumption that all clients will benefit from spirituality. Is this true? Are these some who might benefit, others who are unaffected and some whose treatment outcomes are harmed?
• Along the lines of Miller's thinking, to what degree are these responses stage dependent?
  

DF employees - let me know if you want a copy of the study.

Early Exposure to Drugs and Alcohol

Interesting findings about the relationship between early substance use and troubled kids. It tries to answer whether substance use creates troubled kids or troubled kids engage in early substance use.

First, the prior consensus in child psychology and psychiatry has been that adolescents who go on to develop substance dependence are not normal adolescents who are experimenting with substances, but rather are highly likely to be adolescents with a prior history of conduct problems (Armstrong & Costello, 2002). If this is the case, the documented association between early substance exposure and adult outcomes would not be due to exposure per se, but instead would be the result of who is exposed (Wells, Horwood, & Fergusson, 2004). Prior research has not resulted in a consensus regarding the causal status of substance exposure (Agrawal, Neale, Prescott, & Kendler, 2004; Kandel, 2003; Lynskey et al., 2003; Prescott & Kendler, 1999). However, results from this study are consistent with a causal effect of early substance exposure among adolescents with no prior history of conduct problems. That is, early-exposed adolescents with no conduct-problem history, although they did not have an increased risk of failing to complete school, were more likely than their matched non-early-exposed counterparts to develop substance dependence, test positive for herpes, have an early pregnancy, and be convicted of criminal offenses.

Second, findings from this prospective study support a causal link between early substance exposure and a wide range of adult outcomes. Propensity-score-adjusted effects indicate that early substance exposure more than doubles the odds of adult substance dependence, herpes infection, early pregnancy, and criminal convictions.

Strangely, CADCA explains the study by describing some subjects as good kids and the others as bad kids.

[hat tip: Jess]

More on Methadone

My recent post on methadone prompted several comments, some making really great points. I decided to post all of them so that they would not be missed. The last 4 comments are great, you can guess what I think of the first 2.

armme said...

Your still working on the idea that addiction is some spiritual malady. Your way of thinking is in the DARK AGES, my friend. Your idea of recovery will soon be a thing of the past. It will be like performing an Exorcism on mental illness...once thought to be the ONLY form of treatment, but now considered completely irrational.

Your still trying to stop drug use...when you should be focusing how to get the addict to live a better life. Your treating an illness of endorphin dysfunction by taking away the only thing that corrects that dysfunction with stability.

You can continue to offer people your "exorcism approach" or you can learn the science behind opiate addiction and realize stopping people from using drugs doesn't stop the disease.

Do you want to treat the disorder so these people can have a better life--or do you just want them to stop using drugs no matter HOW miserable they have to be to do so?

Sometimes, MANY TIMES, you can't have both. Not with opiate addiction.

Anonymous said...

"counseling", while possibly helpful to some who may need referrals to things like job training, childcare, housing options, etc, is NOT the answer to most hardcore addiction problems. Science has shown clearly that addiction is a brain disease, a disruption of the brain chemistry. That is not something you can repair with a few hours of talk therapy. If talk therapy (or meetings or group therapy) worked even fairly well for addiction, there would have been no need to come up with something else to treat it--but it didn't and doesn't. We don't treat ANY other legitimate disease this way. People with schizophrenia, bipolar disorder, clinical depression, etc--all brain chemistry disorders--may receive some therapy sessions but it is almost always in conjunction with MEDICATION, which does the actual work of repairing and restabilizing the brain. Why should addiction be treated differently--especially when it has been clearly shown that abstinence based treatment has an extremely low effectiveness rate for addicts and particularly for opiate addicts?

Anonymous said...

As a recovering IV addict for more than 35 years, I continue to be appalled by these guys who push needles, methadone maintenance, etc. with their well-meaning efforts to "help us." Thankfully, none of you were around when I got clean - only people who assured me that I could in fact get clean and live a happy life.

The expectation that people like me are largely unable to find lasting clean time undermines our chances - and makes the way for the "experiments" by psychiatrists and others - naltrexone, methadone (now at new and much high doses!), acamprosate - hell, the Chinese drill out our limbic system with a Makita.

The lie is exposed - we CAN recover.

Anonymous said...

I too am a recovering IV user. I had the experience of being on maintenance several times and also of doing 21 day methadone detoxes in California a few times. My experience when I was using was that every time the methadone kicked in, the urge for CRACK became overwhelming. My problem is that I am a drug addict who has an allergy to drugs. When I get drugs in my system I want more and more and more. There is not enough methadone in the world to make me happy, or to fix whats wrong with me. I could drink a ton of methadone and be close to death but still be crawling across the floor trying to find more drugs. It doesn't work for me. Recovery after many years of using and living the lifestyle was not easy, but it did get better, and the alternative was way worse. I am SO glad that I was introduced to a program of abstinence based recovery and that the system did not give up on me by relegating me to a methadone clinic for the rest of my life. I am also quite sure that my family, the courts and everyone else on the road is glad as well. Recovery has changed my life!

Anonymous said...

You are SPOT ON in describing the "study" practices of those who want the world to believe that methadone is a miracle. Thanks for stating it this way.

The belief that methadone maintenance has a higher success rate than abstinance-based treatments is another huge lie these people use. They want to compare the people taking methadone to the people who have tried abstinance, without holding the same goals for each method. The maintenance population as about a quarter of the success rate at remaining abstinant as the other group after leaving mmt.

I personally think that nearly every sample used in these studies has a bias, and it is meant to be that way. The people conducting these "studies" have something to sell, and I think people should keep that in mind. It's little more that advertising in a free market economy, IMO...

Dr Dave said...

Nice critical appraisal of another tired study that does not help move things on at all. I couldn't agree more that low expectations of what opiate addicts might achieve is fundamental in ensuring that they don't achieve more.

I'm a doctor who is also a recovering opiate addict. At no point was methadone suggested as a treatment choice (apart from detoxification). The expectation was that I would recover with the right sort (and duration) of treatment. Now I adopt the same high expectation of my heroin addicted patients. They get better and stay better in the main. Our service is filled with reovered addicts who infectiously pass recovery on to their peers. Okay, so my recovery capital is arguably much higher, but we can increase the chances of success with some simple interventions (linking into recovery communities, providing housing and employment solutions, giving aftercare and long term management plans which focus on the client self-managing). We do it. It works. People get better.

Gone, baby, gone

It appears that opium harvests greatly exceed demand for heroin and no one seems to know where the excess heroin is.

More sentencing sense

I mentioned drug courts in a recent post. Well, the NY Times is reporting on drug courts.

Highlights:

Clearly, the courts do not help everyone. One of the most successful programs is in New York State, where about 1,600 offenders are in adult drug courts. Studies found that while 40 percent dropped out of the program along the way, those who started it, including both dropouts and graduates, had 29 percent fewer new convictions over a three-year period than a control group with similar criminal histories and no contact with drug courts, Mr. Berman said.

In other regions, half or more of those who start the program do not finish. And recidivism rates for participants are reduced by about 10 percent to 20 percent, depending upon the quality of the judges and treatment programs, said John Roman, a researcher at the Urban Institute, based on a recent study.

An earlier review of 57 “rigorous” drug court evaluations around the country, led by Steve Aos of the Washington State Institute for Public Policy, found that recidivism was reduced on average by only 8 percent, but with wide variation.

Yet even that modest reduction in crimes and prison yields cost benefits. The report this year by the Urban Institute found that, for 55,000 people in adult drug courts, the country spends about half a billion dollars a year in supervision and treatment but reaps more than $1 billion in reduced law enforcement, prison and victim costs. A large expansion would yield similar benefits, the report argued.

But some scholars, like Mark A. R. Kleiman, director of the Drug Policy Analysis Program at the University of California, Los Angeles, remain skeptical about the potential and the achievements. He suggests, for example, that success rates of some courts may be inflated because they take in offenders who are not addicted and entered this track only to avoid prison. Dr. Kleiman advocates a slimmed-down system that does not initially require costly treatment, as drug courts do, but simply demands that offenders stop using drugs, with the penalty of short stays in jail when they fail urine tests. Such an approach has shown promise with methamphetamine users in Hawaii, he said, and because it is far cheaper, it can be applied to far more offenders.

I'd like Kleiman's proposal if what he describes is a "pre-drug court" that would step addicts up into a full drug court.

There's something exciting and troubling about drug courts and health professional recovery programs in the context of the addiction treatment system. Exciting because there are important ways that they are succeeding in implementing some chronic disease management elements, namely long term monitoring and swift reintervention when relapse happens or appears imminent. Troubling because it seems that we are only implementing these strategies with involuntary involuntary clients and other systems are the ones implementing these programs for their own ends. (Not that there's anything wrong with this. In fact, it's great that these systems are approaching these problems in this way. But it should be cause for concern that these other systems are pulling us in this direction rather than us leading the way.) These programs get to be considerably more directive with these patients--they HAVE to go to treatment, they HAVE to get regular drug testing, they HAVE to attend recovery support groups, etc.

There will be a whole new set of challenges with voluntary clients. I suppose we'll face the same challenges that cardiac care and diabetes programs face every day.

How methadone research works

Start with the premise that opiate addicts don't get well. (Unless they're doctors.)

Perform a study offering only two variations of your preferred treatment. (Cheap and crime reducing.) One is high dose or long duration and the other low dose or short duration. Do not offer a recovery oriented option at all, or offer a recovery oriented option of inadequate duration and intensity.

Find that, when offering 2 lousy options, the lousy option with the longer duration or higher intensity reduces symptoms better at follow-up.

Run a headline of, "Methadone Detoxification Remains No Match for Methadone Maintenance, Even with Minimal Counseling." In the comments, declare, "Methadone maintenance is the preferred treatment approach for heroin dependence."

Bonus: "No difference between groups was found for cocaine use or depressive symptoms."

Bonus bonus: "Results for MM with standard counseling (2 hours a month) did not differ from those for MM with minimal counseling (15 minutes a month)."

Question: Do you think this will be used to justify offering even less counseling to methadone recipients?

UPDATE: I got some grief on this post. Here's my response:

Five points:

• First, a question. If methadone is a superior treatment option, why don't they use it for opiate addicted health professionals? Health professionals have high rates of opiate addiction and typically receive long term treatment with monitoring that lasts several years. Treatment is stepped up or down as needed. Guess what? They have great treatment outcomes. You might be inclined to chalk it up to a population with lots of recovery capital. To be sure, that plays a role, but surely a real chronic disease management approach plays a role too. 
  
• Second, is it coincidence that this study was done on poor black men? Why aren't studies like this done on young adults from affluent communities?
  
• Third, methadone used to be one component of some comprehensive bio-psycho-social treatment programs. I understand that there are still some programs that fit this description, but every program in my area is a dosing clinic and little more.
  
• Fourth, regarding misery, notice that there was no difference in depressive symptoms. 
  
• Fifth, heroin addicts in our long term programs do just as well as everyone else. It's all about hope and expectations. Beware of the subtle bigotry of low expectations.
  

All I want is a day when addicts are offered recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose.

What's possible

One Colorado community is taking the bull by the horns and adopting a 0.25% sales tax to establish a community detox and treatment services.

By the numbers
Larimer County Issue 1A on the November ballot would levy a 0.25 percent sales tax - or 25 cents on a $100 purchase - to build a facility that would provide treatment for people with mental-health and substance-abuse problems. Below are preliminary figures tied to the proposal:

> $12.5 million: Cost to build the facility
> $5.8 million: Staffing costs for new programs
> $1.3 million: Staffing costs to expand existing programs
> $750,000: Annual medication costs
> $350,000: Annual maintenance and utilities costs
> 41,000 square feet: Size of the building
> 1,200: People who would be served each year
> 72: Staff

An impressive vision. This is a county of 250,000.

Drug Czar = pointless, feckless, hopeless

The post of Drug Czar has become the very model of a modern major waste of time--a pointless, ineffective, reactionary bureaucratic construction.

Maybe it will become a verb, as in, "I've been Drug Czarred!"