Tab dump

• Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence - The metareview notes that there were few attempts to measure improvements in wellbeing.
• Alcohol-Induced Blackout - Are they predictive of dependence?
• Parity to Become Federal Law Despite Rule-Making Delay
• Policies to Prevent Drug Problems: A Research Agenda for 2010-2015 - Robert Wood Johnson's research agenda

Stigma and community

I read this Ta-Nehisi Coates post yesterday on domestic violence, responsibility, individual agency, community, shame, isolation and empowerment. It's really stuck with me. Very heavy, heady stuff in a very short post.

It got me thinking about some of the mechanisms of addiction and stigma, and the healing mechanisms of the recovering community. He points out the empowering aspects of a community of oppressed people and the responsibility this community confers upon its members.

Further along these lines, Bill White has a new paper on stigma, addiction and methadone. It poses some interesting challenges to the recovering community. How do we reduce the isolation of MMT patients trying to recover? What does recovery mean in the context of MMT? "Responsibility" in the paragraph above could be interchanged with standards. One of the healing mechanisms of the recovering community is imposing standards expectations (responsibility) on its members. Would bringing MMT patients into the community erode this? (There were similar fears with psychotropics.) Does this open a door for benzos and other meds? Clearly, these standards protect the recovering community, but they also constitute a barrier.

The conundrum here is that suspicion about MMT has been pretty persistent for good reason. The paper does a good job addressing the failure of MMT in facilitating recovery. Many members of the recovering community question whether its possible for large numbers of people to achieve and maintain recovery while on methadone--if methadone is such a helpful tool and isn't a barrier to recovery, then why, with the wide distribution of methadone clinics, haven't these people been able to form their own thriving tribe within the recovering community?

It would seem that the best way to test this (the degree to which intra-group stigmatization constitutes a barrier to recovery) would be to have these folks be welcomed into the arms of the recovering community and see how they do. But, how do we get there when this suspicion persists? And, how do we respect the role of these standards in the recovering community when considering the needs of MMT patients?

This challenge is not going away.

UPDATE: Maybe expectations would have been a better choice of words than standards?

Almost impossible to ignore

An interesting explanation of dopamine's function--distinguishing drive and motivation from pleasure and reward:

In the emerging view, discussed in part at the Society for Neuroscience meeting last week in Chicago, dopamine is less about pleasure and reward than about drive and motivation, about figuring out what you have to do to survive and then doing it. “When you can’t breathe, and you’re gasping for air, would you call that pleasurable?” said Nora D. Volkow, a dopamine researcher and director of the National Institute on Drug Abuse. “Or when you’re so hungry that you eat something disgusting, is that pleasurable?”

In both responses, Dr. Volkow said, the gasping for oxygen and the wolfing down of something you would ordinarily spurn, the dopamine pathways of the brain are at full throttle. “The whole brain is of one mindset,” she said. “The intense drive to get you out of a state of deprivation and keep you alive.”

Dopamine is also part of the brain’s salience filter, its get-a-load-of-this device. “You can’t pay attention to everything, but you want to be adept as an organism at recognizing things that are novel,” Dr. Volkow said. “You might not notice a fly in the room, but if that fly was fluorescent, your dopamine cells would fire.”

In addition, our dopamine-driven salience detector will focus on familiar objects that we have imbued with high value, both positive and negative: objects we want and objects we fear. If we love chocolate, our dopamine neurons will most likely start to fire at the sight of a pert little chocolate bean lying on the counter. But if we fear cockroaches, those same neurons may fire even harder when we notice that the “bean” has six legs. The pleasurable taste of chocolate per se, however, or the anxiety of cockroach phobia, may well be the handiwork of other signaling molecules, like opiates or stress hormones. Dopamine simply makes a relevant object almost impossible to ignore.

Lozenge/Patch Combo Best for Kicking Butts

Encouraging findings for people trying to quit smoking:

Smokers are more than twice as likely to quit if they use the nicotine patch along with nicotine lozenges—compared to lozenges or patches alone, buproprion (Xyban), buproprion plus the lozenges or placebo.  The trial was the largest study ever to compare these approaches head to head, and included 1,504 smokers.

All of the treatment groups did better than placebo—but the effect was strongest for the patch/lozenge combination, 40% of whom successfully kicked the habit.  Smokers using this combo were not only more likely to quit, but also less likely to have a “slip” prompt a return to regular smoking.

The study adds support to a growing body of research that suggests that offering addicts access to drugs similar to their drug of choice—or even that drug itself—can actually help them quit or at least dramatically reduce the harm associated with their addiction.

Placing this in the context of offering drug replacements to addicts is interesting food for thought. One important bit of context is that these were people who were trying to quit and the overarching goal of helping professionals with smokers is to try to help them quit, not reduce use. The nicotine addicts I know want full recovery. They want to be completely smoke free, and the few people I know who have been on nicotine replacement for years still really want to stop but can't. The system encourages their moves toward quitting completely and supports gradual change. That seems to be an important part of any lessons drawn from treatment for nicotine addiction. The focus of heroin maintenance is not to stabilize people while moving them toward quitting, it's to maintain them because we've concluded that they can't quit.

Gemini and Granny Growers

A mini pot tab dump:

• Baby Boomers and retirees are plunging into the medical marijuana business
• A short history of Gemini Dream

Recovery pandemic

holy cow, it’s happening to you too.

Androcles writes a nice post on the infectious nature of recovery and hope.

Substance Abuse Prevention Dollars and Cents

From a recent government report:

1.1. Costs of Substance Abuse
Studies have shown the annual cost of substance abuse to the Nation to be $510.8 billion in 1999 (Harwood, 2000). More specifically,

• Alcohol abuse cost the Nation $191.6 billion;
• Tobacco use cost the Nation $167.8 billion;
• Drug abuse cost the Nation $151.4 billion.

Substance abuse clearly is among the most costly health problems in the United States. Among national estimates of the costs of illness for 33 diseases and conditions, alcohol ranked second, tobacco ranked sixth, and drug disorders ranked seventh (National Institutes of Health [NIH], 2000). This report shows that programs designed to prevent substance abuse can reduce these costs.

1.2. Savings From Effective School-Based Substance Abuse Prevention
If effective prevention programs were implemented nationwide, substance abuse initiation would decline for 1.5 million youth and be delayed for 2 years on average. It has been well established that a delay in onset reduces subsequent problems later in life (Grant & Dawson, 1997; Lynskey et al., 2003). In 2003, an estimated:

• 5.6 percent fewer youth ages 13–15 would have engaged in drinking;
• 10.2 percent fewer youth would have used marijuana;
• 30.2 percent fewer youth would have used cocaine;
• 8.0 percent fewer youth would have smoked regularly.

The average effective school-based program in 2002 costs $220 per pupil including materials and teacher training, and these programs could save an estimated $18 per $1 invested if implemented nationwide. Nationwide, full implementation of school-based effective programming in 2002 would have had the following fiscal impact:

Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis

• Saved State and local governments $1.3 billion, including $1.05 billion in educational costs within 2 years;
• Reduced social costs of substance-abuse-related medical care, other resources, and lost productivity over a lifetime by an estimated $33.7 billion;
• Preserved the quality of life over a lifetime valued at $65 billion.

Although 80 percent of American youth reported participation in school-based prevention in 2005 (SAMHSA, 2004), only 20 percent were exposed to effective prevention programs (Flewelling et al., 2005).

Massive, Risky and Expensive

Mark Kleiman responds to pushback on some of his alternatives to incarceration:

The suggestion that various non-punitive programs might control crime, and that doing so was preferable, ceteris paribus, to controlling crime by inflicting damage on offenders, met with an especially furious response, mostly centered on the phrase “liberal social engineering.”  But the project of putting 1% of the adult population behind bars — an incarceration rate five times as high as any other advanced democracy, and five times as high as the U.S. ever had before 1975 — is itself a massive, massively risky, and expensive  social-engineering project, and no less massive, risky, or expensive for never having been thought through.   It also involves a completely unprecedented expansion of the power of the state over the individual.

If all taxation is theft, then the $200 billion required to support the current policing, adjudication, and corrections systems is just as much “stolen” as the much smaller sums that might be usefully expended on improving parental performance by poor young first-time mothers, removing lead from the environment, or improving classroom discipline.  If people who call themselves fiscal conservatives understood that a sentence of life without parole imposed on an 18-year-old represented a present-value expenditure of $1 million, the enthusiasm for “throwing away the key” might be diminished.  (An execution, including the due process required — but not sufficient — to prevent the execution of the innocent, costs more.)

In my view, crime at current levels is such a social problem that even substantial increase in the $200 billion criminal-justice budget would be justified by even modest decreases in crime.  If we can spend an extra $10 billion a year to have reduced crime and reduced incarceration, so much the better.

Now for the specifics:

1.  Evidence about the capacity of nurse-family partnerships to reduce offending by more than 50% (based on a randomized controlled trial) is here.

2.  Evidence about the impact of lead on crime takes two forms:  individual-level studies, and econometric studies. The results are consistent, and the effect sizes are large. Moreover, the biology is understood: lead, even at low levels, damages cognitive function, and lower-level cognitive functioning reduces deterrability, thus increasing crime. Moreover, lead does specific damage to impulse control.

Therefore, lead causes crime, and removing lead reduces crime.  It does so more cost-effectively than increasing incarceration, and it has side-benefits rather than side-costs.

3. I have no doubt that a minimum legal drinking age of 21 reduces drinking among minors, and that relaxing that rule would increase drinking (and drinking-related problems) in that population. It also generates massive disobedience and the mass acquisition of false ID.   Increased alcohol taxes are effective in reducing drinking, and especially in reducing heavy, problem drinking (since an extra tax of a dime a drink wouldn’t much bother someone who averages a drink a day). The biggest impacts are on heavy drinking by minors, whose incomes tend to be limited.  A combination of relaxing the age restriction and raising the price could reduce heavy drinking while avoiding the criminalization of mass behavior.

British Drug Classification

Andrew Sullivan offers a clear and concise summary of the an initiative to reclassify drugs (the classifications are used to determine criminal penalties).

Take the question of alcohol and tobacco out of the discussion and it seems quite sensible. Add alcohol and tobacco back and you have a firestorm. Is this about being too soft on drugs, or is this about protecting the status of alcohol and tobacco?

Wounded Systems of Care

We spend a lot of time talking about recovery-oriented systems of care. Important, but should we first look at facilitating recovery for our systems of care?

Peapod writes about healing treatment systems (systems, not clients). She draws from a recent Bill White document about the Philadelphia experience and describes a critical juncture:

In Philadelphia in 2004, they decided to tackle the things that were wrong in their services. They did a giant exercise in information gathering, something they called a ‘fearless inventory’ after the AA fourth step. You can see the detail here:

They uncovered that some unhealthy stuff was going on. Organisations were not talking to each other. They existed like islands connected by drawbridges that ‘were permanently up’.

Focus groups uncovered “an underlying tone of paternalism, disrespect and, at times, outright contempt.”

The right sentence

The Washington Post looks toward the end of the crack/powder cocaine sentencing disparity with some ambivalence. It appears that they failed to consider whether prison sentences are an effective tool for addressing the harm associated with crack use.

IN THE 1980s, entire communities were devastated by the addiction and violence that accompanied crack, a smokable form of cocaine. Congress reacted by passing extraordinarily tough laws, including one that mandated a minimum prison sentence of five years for those in possession of as little as five grams of crack. Those arrested with 50 grams were automatically slapped with a 10-year sentence.

This supposed solution, backed at the time by many in the Congressional Black Caucus, turned out to be destructive also. Tens of thousands of black men -- many of them first-time offenders with no history of violent crime -- found themselves behind bars for inordinately long periods. White and Hispanic offenders -- those most often collared for powder cocaine violations -- had to be caught with 100 times the amount of powder to trigger the same mandatory minimum sentences.

. . .


smoking crack delivers a faster, more intense high than snorting powder and that this high is more short-lived, thus compelling most crack users to seek additional doses of the drug. The differences in addiction rates between crack and powder are not enormous, but they are real, and the study also notes that crack users often experience faster rates of physical deterioration than do those who consume powder. The report notes that roughly one-fourth of crack offenders are associated with violence, and that this rate exceeds that for powder cocaine offenders. As in the 1980s, predominantly African American communities continue to bear the brunt of the crime and addiction brought on by this awful drug.

These facts suggest that there should be some difference in the penalties for crack and powder cocaine, but how much? This is a difficult question to answer with precision, so perhaps the best solution would be to eliminate the mandatory minimums for both crack and powder and build into the sentencing guidelines tougher penalty ranges for crack that judges could apply on a case-by-case basis

A reality check on drug use

George Will recently wrote a column on drug policy:

The Economist magazine says this means that more than 200 million people -- almost 5 percent of the world's adult population -- take illegal drugs, the same proportion as a decade ago. The annual U.S. bill for attempting to diminish the supply of drugs is $40 billion. Of the 1.5 million Americans arrested each year on drug offenses, half a million are incarcerated. "[T]ougher drug laws are the main reason why one in five black American men spend some time behind bars," the Economist said in March.

"There is no correlation between the harshness of drug laws and the incidence of drug-taking: citizens living under tough regimes (notably America but also Britain) take more drugs, not fewer." Do cultural differences explain this? Evidently not: "Even in fairly similar countries tough rules make little difference to the number of addicts: harsh Sweden and more liberal Norway have precisely the same addiction rates."

The good news is the progress America has made against tobacco, which is more addictive than most illegal drugs. And then there is alcohol.

In "Waking Giant: America in the Age of Jackson," historian David S. Reynolds writes that in 1820, Americans spent on liquor a sum larger than the federal government's budget. By the mid-1820s, annual per capita consumption of absolute alcohol reached seven gallons, more than three times today's rate. "Most employers," Reynolds reports, "assumed that their workers needed strong drink for stimulation: a typical workday included two bells, one rung at 11 a.m. and the other at 4 p.m., that summoned employees for alcoholic drinks."

The elderly Walt Whitman said, "It is very hard for the present generation anyhow to understand the drinkingness of those years. . . . it is quite incommunicable." In 1842, a Springfield, Ill., teetotaler named Lincoln said that liquor was "like the Egyptian angel of death, commissioned to slay, if not the first, the fairest born in every family." Which helps explain why the nation sobered up (somewhat -- these things are relative). One reason crack cocaine use has declined is that a generation of inner-city young people saw what it did to their parents and older siblings.

Undoubtedly culture changes are critical to changing these behaviors, though it's my understanding that one reason for those high rates of alcohol consumption was that alcoholic beverages were often safer to drink than the available water.

I'd like to better understand how that culture change happened. Can it occur without heavy moralizing and the formation of temperance societies? It would seem that this culture change eventually culminated in prohibition. Clearly not what George Will has in mind.

Bacon, cheesecake and Ho Hos, oh my!

Not sure what to make of this:

Junk food elicits addictive behavior in rats similar to the behaviors of rats addicted to heroin, a new study finds. Pleasure centers in the brains of rats addicted to high-fat, high-calorie diets became less responsive as the binging wore on, making the rats consume more and more food. The results, presented October 20 at the Society for Neuroscience’s annual meeting, may help explain the changes in the brain that lead people to overeat.

“This is the most complete evidence to date that suggests obesity and drug addiction have common neurobiological underpinnings,” says study coauthor Paul Johnson of the Scripps Research Institute in Jupiter, Fla.

It will be interesting to watch this research unfold. I worry about the the meaning of addiction as a brain disease being rendered meaningless by an ever-growing list of behaviors that are associated changes in the pleasure centers and dopamine production and response. I look forward to comparative research of these brain responses to better understand the differences.

Committed to treatment

Anchorage, AK is taking some very aggressive steps to address public drunkenness in their community:

The new mayor, Dan Sullivan, a Republican, has created a staff position and a task force devoted to addressing homelessness. The police recently gained the authority to dismantle homeless encampments with just 12 hours’ notice. Citizen groups are patrolling parks where homeless camps have been the site of rapes and other violence. But in perhaps the biggest and most controversial break from how the city has handled the problem in the past, a Salvation Army detoxification and alcohol abuse treatment center has begun accepting chronic inebriates who have been taken there essentially by force.

With $1.2 million in new state financing pushed through by one of Alaska’s more liberal Democrats, State Senator Johnny Ellis of Anchorage, the facility, the Clitheroe Center, is accepting people committed under a state law, Title 47. Under the law, a judge can order people into secure treatment for 30 days, and potentially for months, if the police, a doctor or family members convince the judge that the person’s abuse of alcohol has made them a threat to themselves and others. The person does not need to have committed a crime.

“Ten years ago, there would have been a community outcry that Johnny Ellis is locking up people with the disease of addiction,” Mr. Ellis said. “ ‘How can he do that and say he’s still a progressive?’ ”

Now, Mr. Ellis said, the problem has increased so much “that for various motivations people are saying let’s try something new.” He added, “The people dropping dead during the summertime really got this community paying attention.”

One homeless person drowned. Another was hit by a car. One died from hypothermia. Most had been drinking, and several had four or even five times the blood-alcohol level above which a person is considered too drunk to drive. Experts say the problem of public drunkenness is part of a larger homeless problem that disproportionately affects Native Alaskans, particularly men who have moved in from rural parts of Alaska and lost their way in the city. The recession has also played a role.
Involuntary commitment of homeless alcoholics has been used elsewhere in the country. Some homeless advocates say it infringes on civil rights, and they question its effectiveness. Here in Anchorage, several longtime advocates said the severity of the situation had made them open to giving it a chance.

There is also a video about the story here.

Though court coerced treatment is common, commitment to treatment is unusual. Discussion of these matters in papers and blogs suggest we have two options: 1) harm reduction approaches that accept the person as they are, emphasize personal liberty and make no attempt to address the root cause of their suffering; or 2) lock-em up.

I suppose this approach represents a third way in these too often polarized debates and I suppose that's laudable. The cases discussed in the video and story clearly are seriously endangering themselves. However, the coercion involved in this approach should make everyone uncomfortable. I have a few thoughts about that.

• First, I'm skeptical of slippery slope arguments. Sometimes the slippery slope is the right place to be.
• The ethics of this seem to rest on questions of free will in addiction. If one believes the addict is not free, coercive interventions make sense. (More here, here, here, here, here, here and here.)
  
• Adopting this positive view of liberty opens the door to potential abuses by the state. Coercion should be a last resort.
• Attraction is preferable. This problem is not just a problem of individuals with a disease. It's likely a symptom of a system failure. Does a recovery-oriented system exist? One that encompasses the complete continuum from harm reduction to long term drug free treatment and recovery support? What if we added Project SAFE style recovery coaches engaged in aggressive outreach? Help support a vibrant recovering community that was capable of transmitting infectious hope and continuous peer support? How many could we attract voluntarily?
• That an alternative to palliative care and coercion exists, means that those would be justifiable only if voluntary attraction into recovery failed, or as a stopgap while implementing a voluntary system.
  
• This approach would require investing in more than just the squeaky wheels. It would mean investing in the well-being and recovery of all addicts.

Another recent study supporting the effectiveness of involuntary treatment offers some context.

Tab dump

• A brief history of scholastic inebriation (Too bad they missed Robert Smith whose U of M fraternity brothers called his father to fetch him because his drinking was out of hand.)
  
• Claims injection site dropped Downtown Eastside crime 'very much exaggerated,' say cops
• Battling Addiction With Those Who Know It Best
• New UK study suggests minimal relationship between cannabis and schizophrenia or psychosis
• Cocaine exposure during pregnancy leads to impulsivity in male, not female, monkeys

Drugs around the world

The Big Picture sets its lens on drug use across the globe.

Medical Marijuana Take Down

Chuck Lane writes a two post take down on medical marijuana.

As turned off as I am by anything that includes the word "druggie", he more or less states my position. Personal drug possession should be among the lowest enforcement priorities and should not result in incarceration. If there is or was a legitimate medical marijuana movement it's been co-opted by people whose goal is decriminalization of recreational use--a defensible position but a dishonest approach to achieving it. Finally, this just isn't the way we do medicine.

Phamacy reviews

An emerging market.

Same info, different reactions

I wonder what this means for addiction recovery and treatment messaging:

A study that will appear in the December issue of the American Journal of Public Health tracked the ways in which party affiliation related to people's responses to identical information on diabetes.

Participants in the study read a mock news article on the American Diabetes Association lobbying Congress for greater attention to Type 2 diabetes, the sixth-leading cause of death in the United States. Some people read a straight news report, with minimal mention of what causes diabetes. Others read one of three versions of the story: one that pegged the disease primarily to genetic factors; one that emphasized personal choices; and one that focused on social and environmental factors, such as access to safe places to exercise and affordable, healthy food.

The study's authors, University of Pennsylvania researcher Sarah E. Gollust, along with the University of Michigan's Paula M. Lantz and Peter A. Ubel, were most interested in how people responded to the notion that "social determinants" -- how easy it is to buy fresh vegetables or exercise, among other things -- are underlying causes of disease. Public health advocates have been promoting the importance of these factors, believing that the more people know about these circumstances, the more likely they are to want to help.

But that assumption doesn't hold up. When people who identified themselves as Democrats read specifically about the social factors that can lead to Type 2 diabetes, they expressed greater backing for public health policies aimed at addressing those factors; Republicans, by contrast, registered much lower levels of support.

"The take-home message is that people can walk away from the same information with different attitudes," Gollust says.

A tough approach to drug-using mothers

The LA Times paints a pretty sympathetic picture of Project Prevention, a program that pays addicticted women to get themselves sterilized or use long term birth control. It closes with the following:

Project Prevention makes sense to me. Although a few thousand IUDs might not make a dent in the problem, the bluntness of the gesture turns up the volume.

And it brings drug-using moms in on the dialogue. Thank you for helping me do the first responsible thing I've ever done with my addiction, one mother wrote in a letter to Harris, who solicits a life story from every client.

"They're not bad women," Harris told me. "They don't set out to have babies that are taken away. They feel regret about what they've done."

She's right. Demonizing the mothers doesn't help. They need counseling, not just contraception. Many were victims of childhood trauma and are prisoners of addiction now.

Some hope giving birth will redeem and stabilize their lives. "It's one of the few things they can do that they have control over," said retired social worker Glynis Morrow. "Then the realities of parenting hit. And they feel like failures. And that pain drives them back to drugs."

And we're right back where we started from.

So we can talk about women's rights or about the privilege of procreation. However we cast the conversation, there is one truth we can't avoid: We are helping mothers heal when we keep unwanted children from being born.

It doesn't "make a dent in the problem" but it "turns up the volume." Turns up the volume of what exactly? Bringing them "in on the dialogue"? Who's dialogue? "Helping mothers heal" by encouraging sterilization?

This is pessimism and stigma dressed up as compassion. It only reinforces the notion that addicts are hopeless, irresponsible social parasites. Indeed, the founder has previously said, "We don’t allow dogs to breed. We spay them. We neuter them. We try to keep them from having unwanted puppies, and yet these women are literally having litters of children …" She also previously distributed flyers saying, "Don't let getting pregnant get in the way of your drug habit."

I'm all for preventing unwanted pregnancies, but context matters. If this group was also lobbying for greater access to treatment for these women, that might be another matter. They give lip service to the welfare of the women but little more. Their statistics report only on the social costs of the addicts and offers no references to anything the program has done to improve the circumstances of the women--even activities like advocacy and treatment referrals which would cost nothing and be easy to track. One can only assume that they don't engage in these kinds of activities, collect data and report on it because they and their supporters don't care.