…I do throw up my hands some when people say, oh, you know, this is just what the data says, this is what the model says, when it’s some human being or some set of human beings who designed the model, and if they make bad assumptions, they’ll be reflected in the model.

Nate Silver on Fresh Air

This is a little after the timeframe of this article, but what’s a discussion of alcohol, Detroit and history without reference to the Purple Gang?

The Detroit News offers a little history lesson on alcohol and temperance in Detroit. I guess we’ve always been a

In 1834 — with a population under 5,000 — 100 people were licensed dealers selling liquor in Detroit; there was no estimate of the unlicensed. It was said there was a bar for every 13 families.

A traveler from New Hampshire with a strong Puritanical eye, a Mr. Parker, noted in 1834: “The streets [of Detroit] near the water are dirty, generally having mean buildings, rather too many grog shops among them, and a good deal too much noise and dissipation. The taverns are not generally under the best regulations, although they were crowded to overflowing. I stopped at the Steamboat Hotel, and I thought enough grog was sold at that bar to satisfy any reasonable demand for the whole village.”

However, saloons and bars were not the entire picture. Pharmacies did substantial business packaging and selling liquor for medicinal purposes.

Throughout Detroit, but especially in Corktown and Germantown, whiskey also was sold through groceries to such an extent that many grocers distilled their own whiskey and had sit-down bars in their stores. The term “grocery” became synonymous with “saloon.”

Records of temperance groups of the day show the desire to “reduce the number of groceries in the city.” At the time, whiskey was sold in barrels, smaller kegs, or demijohns (jugs ranging anywhere from five gallons to half a gallon.)

Keep in mind that this is during the period of our “national binge”.

In 1825 the annual consumption of pure alcohol was 7 gallons per person over the age of 15. Today it’s 2.49 gallons annually, nearly two-thirds less.

(Photo credit: Wikipedia)

On the business interests involved in the push to legalize marijuana in Colorado.

He’s not just blowing smoke when he talks about selling out to the highest bidder. It’s already widely rumored that Philip Morris has leased warehouse space in the area. The company denies it, as do its top-tier competitors, but “I’ve heard a lot of talk about it,” says Keith Burdick, a partner at Xcalibur, one of the biggest independent generic-brand tobacco companies in the country. “You’re going to get cigarette companies in here. I’m sure of it,” says John Wickens, a real-estate agent who has sold or leased acres of commercial space to marijuana growers. Peter Bourne, the drug czar under Jimmy Carter, recently told Newsweek that tobacco executives shared their marijuana contingency plans with him.

The alcohol and tobacco industries traditionally get 80 percent of their profits from heavy users, and there’s every reason to believe that marijuana sellers will need the same ratio. That would mean Colorado’s burgeoning pot business could be the basis for a third huge, blood-sucking vice industry, dependent on converting kids and supporting heavy users. “No way,” says Arbelaez, when I raised this possibility with him. He talked passionately about medicine, and social progress, and it was moving, convincing stuff. “These people have families, and they employ families. They’re about helping people, not hurting people,” he said of his peers.

I want to believe him, but something happened after the board meeting. About eight of us went out for a drink. I found myself not in one of Denver’s dive bars, but the Churchill Bar, a smoking club inside the city’s poshest hotel, the Brown Palace. There, as a Bond-girl waitress delivered round after round of top-shelf conviviality and an electronic joint prototype appeared, it was easy to see my hosts 30 years from now, when legalization is here, sitting in the same woozy affluence—fatter, balder, and famously rich.

Related articles

• The Beginnings Of Big Bud? (andrewsullivan.thedailybeast.com)
• Colorado tax enforcer tells ’60 Minutes’: Weed beat the recession in Denver (rawstory.com)
• Colorado marijuana-legalization amendment spending tops $3 million (denverpost.com)

My job allows me to meet some really wonderful people. Sadly, I meet some of them under really terrible circumstances. Mark Rudolph is one of those people. He lost his son to opiate addiction 5 years ago and has chosen to make meaning of it by educating others about opiate addiction in the “safe” suburbs and supporting families dealing with addiction.

He just shared this video with me:

American Society of Addiction Medicine (Photo credit: Wikipedia)

From the ASAM blog:

…is there any evidence that the general public requires less treatment than do healthcare professionals and pilots? I would further ask, given the excellent outcomes generally obtained by PHPs and pilot recovery programs, why there have been no studies in which members of the lay public go through identical programs to determine what their long term outcome would be. Indeed, what happens when a non-healthcare professional or non-pilot goes through 90 days of rehab, and is then followed regularly by an addiction specialist physician while simultaneously attending twelve-step or similar self-help groups and being subject to random urine drug testing, all as the FAA requires of pilots requesting a special issuance medical, and as state medical boards generally require of physicians wanting to return to practice? Would they too have an 80-90% recovery rate?

[hat tip: Herb]

Americans smoke opium in a Chinese-run opium den in New York City in 1925.

An antique collector has a new book about collecting opium smoking paraphernalia. Collector’s Weekly has an interview with the author:

What drew you to antique opium paraphernalia?

Steven Martin: There was something dark about it. People collect all sorts of weird things, like old torture mechanisms, just bizarre stuff. I think this falls into the same category. It had this outlaw-chic thing about it that attracted me right away.

This reminded me of Bill White’s line, “I can’t tell you what will be the next major drug of misuse will be, but I can tell you that it’s already here and someone will develop a new way to use it.”

What are the origins of opium smoking?

Martin: The interesting thing about opium is that until the Chinese invented this system for vaporization—sometime in the 18th century—there was no pleasurable way to ingest opium. People were eating it. People were smoking it, mixed with tobacco. But eating it causes really bad side effects, the worst being constipation for weeks. And burning it destroys certain alkaloids in the opium that make the intoxication enjoyable.

Then a Chinese inventor whose name is completely lost to history came up with a system for vaporizing it. That invention opened the door for opium to become a recreational drug. Suddenly, all the bad side effects were lessened. Vaporizing opium takes out a lot of the morphine content, which is the thing that makes you feel stupefied and out of it. Good-quality opium, smoked with the proper accoutrements, is energizing. It doesn’t put you on the floor. Well, you’re lying on the floor to do the actual smoking, but that’s just because it’s the most comfortable position to hold the pipe over the lamp. That’s the only reason the old photographs of opium dens show people lying down. It wasn’t because it made them so stoned they couldn’t stand up.

Though artists have certainly written good songs while in recovery, writing songs about the recovery process itself is a trickier matter. “They get very cheesy very fast. With that language you’re dealing with a bunch of clichés,” says singer-songwriter Justin Townes Earle, 29.

A few years ago, after a stretch in rehab that capped a spiral of homelessness and drug abuse, Mr. Earle started tinkering with a song about the experience. At the time he was staying with his father, the singer Steve Earle, who cratered in the mid-1990s with heroin and jail, then after cleaning up went into a prolific creative rebirth. Steve’s advice about the song: Don’t go there. If songwriting and recovery don’t remain separate, he counseled, “they can both suffer,” Justin says. “It was one of the very few suggestions from a father you pay attention to right off.”

Now the younger Earle broaches the subject in lyrics more obliquely. On his most recent album, “Harlem River Blues,” he sings, “Why do I try my luck? I should never touch the stuff” on the woozy blues tune “Slippin’ and Slidin.’”

“That was my realization song,” Mr. Earle recalls. It was written last summer when he was touring continuously, had already fallen off the wagon and was on his way to cutting the album in full relapse, marked by a diet of “vodka for breakfast and cocaine for dessert.” He had to keep his head, relatively speaking, in order to write and record the songs on “Harlem River Blues,” working on them during daylight hours when he was pacing his vodka intake. His productivity would cease around 5 p.m., “Usually by that time I was what most people call drunk, then I’d go out and get what I consider drunk.”

Last September, when Mr. Earle was touring in support of the album, his mounting alcohol and cocaine abuse erupted in a violent altercation with a club promoter in Indianapolis. He was arrested, spent the night in jail and soon after was packed off to a rehab facility in Tennessee.

…

Justin Townes Earle’s slowdown came abruptly. “I woke up with my girlfriend, my lawyer, my booking agent and some guy I’ve never seen before sitting around my bed getting ready to take me off to treatment,” Mr. Earle recalled in a telephone interview from Belfast in Northern Ireland. Following his September dust-up, he spent about a month in rehab. There, Mr. Earle wasn’t allowed to play guitar. Such rules are common in facilities where the goal is to strip away elements of outside life that may be associated with abuse.

Now Mr. Earle is back on tour. He recently performed on David Letterman’s show. He says he is sober, but maybe not for good. “I’m never going to say it’s not going to happen again. I’m smart enough to know that.”

[Thanks Billy!]

What’s so different and interesting about this study is that it followed the subjects for decades from a pretty young age. Their subjects were college sophomores when the study began and their selection was not based on any problems or characteristics. So, they studied them before, during and after their active alcoholism.

Here are a few of the better bits.

On alcoholism and recovery:

Q: What, then, are the great lessons to be drawn from the study?

A: Some of the most important ones involved alcoholism. About 50 per cent of alcoholics recover, but a remarkable percentage of those do so with AA. The fact that this study followed up with these men on 60 different occasions with regard to their alcoholism over a period of 50 years did allow us to identify what made a difference.

You’ll have to read the Natural History of Alcoholism, because he didn’t expound on that in the interview.

On childhood unhappiness and alcoholism:

Q: A lot of long-held theories flew out the window over the decades thanks to your work.

A: One of the simplest examples was the notion that unhappy childhoods cause alcoholism. What a study like this shows is that, first, lots of alcoholics invent an unhappy childhood to justify their drinking. Second: if an alcoholic’s childhood is miserable, it’s because a blood relative has alcoholism. If the unhappy childhood is the result of an alcoholic step-parent, the person doesn’t drink to relieve the misery. So it’s the genetic component of alcoholism that matters.

On alcoholism’s toll (Too bad these lessons need to be re-learned!):

Q: You argue that alcohol abuse is the most ignored causal factor in modern social science. Why?

A: Because it’s much more fun to pay mind to nice people than to angry, passive-aggressive people, and the disease of alcoholism makes people angry and dishonest. If you look at the major books on marriage, alcoholism is mentioned nowhere in the index as a cause of unhappiness. Yet 57 per cent of all the divorces in the Harvard sample occurred when one or other spouse were drinking alcoholically. The alcohol abuse almost always preceded the trouble in the men’s life. Another dramatic example: depression does not lead to alcoholism, whereas alcoholism leads to depression. If you take 100 cases, you can find two or three exceptions, but that’s all. People didn’t really know that before the Grant study.

[hat tip: Jeff Jay]

Forbes (?!?!) covers Pat Deegan’s efforts

…I realized that we are at an important point in the history of medicine. Paper medical records are being replaced by digitized information organized into Electronic Health Records (EHRs). To my dismay, I observed that most EHRs were simply hard coding traditional clinical workflows. This isn’t the vision we started with when we saw the electronic future. The EHRs streamlined clinicians’ work and reflected what mattered to them, but patient priorities and perspectives were not taken into account in these EHRs, despite the fact it would be exceedingly simple to include them. For example, if a person is a recovering addict he or she might want to minimize opiate based pain medication after surgery. Where in the EHR is a place for that patient to voice that preference ? Where in the EHR are patients’ goals for treatment recorded and prominently displayed? If decision support information is available to doctors, why shouldn’t decision support materials be available to patients as well?

I began to realize that in this historic window of opportunity, those of us who are patients had to get at the table to insure that the EHR reflected our concerns, our strengths and views. Remember, patients are the other 50% of the healthcare equation. I thought about what would a truly person-centered EHR might look like. How can the patient’s voice best be accommodated in the EHR? What does bi-directional decision support look like? How can an EHR support informed medical decision making and shared decision making for people with long-term disorders. These are some of the important questions I developed the CommonGround web application to explore.

Primary care is a misnomer. Primary care happens in the context of daily life, not only in the physician’s office, but in the community and increasingly online. Traditionally, clinicians are gatekeepers of information, but if they don’t talk about recovery patients don’t hear about it. We decided to develop software with important information for current mental health patients provided by recovering patients. We start with the notion that those with mental disorders can and do recover, and we built a body of knowledge to help those currently struggling. The main thing for us is to help people be better informed about their conditions and their options for dealing with them in the broader context of functional and quality life.

The correlation phrase has become so common and so irritating that a minor backlash has now ensued against the rhetoric if not the concept. No, correlation does not imply causation, but it sure as hell provides a hint.

Related articles

• Correlation, Causation and Internet Comments (boingboing.net)
• The History of ‘Correlation Does Not Imply Causation’ (tech.slashdot.org)
• Slate Satisfies My Pet Peeve Quota For the Day (motherjones.com)
• Why do people love to say that correlation does not imply causation? (3quarksdaily.com)

English: This photo illustrates smoke in a pub, a common complaint for those concerned with passive smoking. (Photo credit: Wikipedia)

Apparently, Singapore was an early adopter of designated smoking areas and non-smoking areas. However, this wasn’t driven by health concerns. Rather, it was driven by aesthetic concerns–primarily smell.

In a fascinating paper published recently in Urban Studies, Qian Hui Tan observes that smokers are “purveyors of sensory pollution” – creating a scent that, like all odors, can invade and take over. When that space is public, the impact can be immense, segregating and stratifying public spaces.

…

Tan visited some of these places and interviewed both smokers and non-smokers about how they think about the segregation of smokers to certain areas and the impact of smoking scents on people nearby.

Based on these conversations, Tan has compiled a collection of anecdotal evidence about smokers’ experiences being made to feel unclean or burdensome on those around them, and some of the efforts they take to reduce the olfactory impact their smoking on people they come into contact with. From smoking downwind to keeping more space from people after smoking, the smokers questioned said they had become sensitive to the way they are perceived after coming back from a smoke break.

…

And because of the invasive unavoidability of smell, the presence of cigarette smoke or its odor results in an inevitable “sensory appraisal” by others, according to Tan.

It doesn’t take a huge leap to imagine that this might be a non-significant factor in the relationship between smoking and relapse.

Caution Tape (Photo credit: Picture Perfect Pose)

A new article discussing the expanding use of medications in addiction treatment has the following sub heading:

Experts are pushing for a truly medical approach to treating addiction as a disease rather than relying solely on longtime unproven therapies like 12-step programs.

Unproven?

• Twelve Step Facilitation (TSF) is the treatment of choice for addicted physicians and they have excellent outcomes.
• There’s a lot of evidence for their effectiveness.
• TSP is recognized as an evidence based practice.

I’m certain a day will come when we have effective pharmacological tools to help addicts initiate and maintain recovery but, beyond detox, I find the current meds pretty underwhelming as a group and troubling in some cases.

When you hear the push for these “scientific”, “medical” and “evidence-based” treatments, keep these exhibits in mind:

A Doctor’s Dilemma: When Crucial New-Drug Data Is Hidden

The positive spin surrounding industry-funded studies — which are, after all, the studies that the government uses to approve drugs — isn’t the only ongoing problem. Goldacre further describes how drug companies hide data about medication risks that affect children, how they attempt to intimidate the employers of researchers who produce results they don’t like, and how they routinely withhold safety data in various other ways that do harm to patients.

A Call for Caution on Antipsychotic Drugs

You will never guess what the fifth and sixth best-selling prescription drugs are in the United States, so I’ll just tell you: Abilify and Seroquel, two powerful antipsychotics. In 2011 alone, they and other antipsychotic drugs were prescribed to 3.1 million Americans at a cost of $18.2 billion, a 13 percent increase over the previous year, according to the market research firm IMS Health….several recent large randomized studies, like the landmark Catie trial, failed to show that the new antipsychotics were any more effective or better tolerated than the older drugs.

It was also soon discovered that the second-generation antipsychotic drugs had serious side effects of their own, namely a risk of increased blood sugar, elevated lipids andcholesterol, and weight gain. They can also cause a potentially irreversible movement disorder called tardive dyskinesia, though the risk is thought to be significantly lower than with the older antipsychotic drugs.

Nonetheless, there has been a vast expansion in the use of these second-generation antipsychotic drugs in patients of all ages, particularly young people. Until recently, these drugs were used to treat a few serious psychiatric disorders. But now, unbelievably, these powerful medications are prescribed for conditions as varied as very mild mood disorders, everyday anxiety, insomnia and even mild emotional discomfort.

Top 10 Drug Company Settlements

Record-breaking multibillion-dollar settlements against big drug companies have become routine in the U.S. In recent years, pharmaceutical companies seem to have been playing a game of one-upmanship, each surpassing yet a new milestone of wrongdoing — fraudulently marketing their drugs or making misleading claims about their safety — and the threat of massive payouts appears to have offered little deterrent.

This study did not find a significant main effect of modafinil on the rate or duration of cocaine use among cocaine-dependent patients.

Now they decide to polish the turd:

Although these results are disappointing, we did find that modafinil-treated patients had nonsignificantly higher odds of attaining abstinence across all of the study time points, and those treated with 400 mg/day had significantly greater odds of attaining abstinence (p = .04) at the end of their 8-week medication trial (Visit 24). There was also a significant difference (p = .02) in the OR for abstinence at the final follow-up visit, suggesting the possibility that modafinil facilitated delayed clinical improvement that was not captured by our 8-week study design.

Back to reality:

Despite its ability to blunt cocaine-induced euphoria in three controlled human laboratory studies ( [Dackis et al., 2003], [Hart et al., 2008] and [Malcolm et al., 2006]), modafinil did not show overall success in this outpatient clinical trial.

Maybe these people are just too tough:

It is important to note that all of the patients in this study tested positive for cocaine at baseline. It is well established that patients who test positive for cocaine at study start have extremely poor clinical outcomes when compared with those who are able to produce a cocaine-negative urine sample ( [Ahmadi et al., 2009],[Kampman et al., 2001], [Patkar et al., 2002] and [Poling et al., 2007]). The reason for this finding is unclear, but it probably stems from greater addiction severity, less motivation for recovery, or both of these clinical features.

There will be evidence, dammit!

Despite our negative study, we believe it is premature to dismiss modafinil as a potential treatment for cocaine dependence.

These findings

Findings from multivariate analyses initially showed no association between treatment enrollment and employment transitions. However, when a distinction was made between MMT and other addiction treatment modalities, it became clear that the relationship between addiction treatment and employment outcomes for IDU in this setting was contingent upon the type of addiction treatment: enrollment in non-MMT forms of treatment increased the odds of making an employment transition, whereas MMT enrollment had the inverse effect. This mode-specific association was echoed in analyses of transitions into temporary, informal, and under-the-table work, which had no association with MMT enrollment but also saw a strong positive association with non-MMT forms of addiction treatment.

Possible explanations?

We’re expecting too much of these poor folks:

The observed systematic differences in employment outcomes might plausibly be related to individual-level characteristics or circumstances that either inhibit transitions to employment and systematically apply to those individuals enrolled in MMT or lead to both MMT enrollment and nonemployment. For example, in contrast to abstinence-based forms of treatment, MMT is geared toward stabilized maintenance (Ward, Mattick, & Hall, 1994) and aimed at reducing the major risks, costs, and harms associated with untreated opiate addiction ( [Rosenbaum et al., 1996], [Ward et al., 1999] and [World Health Organization, 2004]). It may therefore be a part of the early stages of addiction treatment and rehabilitation, and the initiation of labor market activity might not be expected to follow MMT enrollment in the same way that it would for other treatment modalities.

Cognitive impairment?

…methadone has been shown to impair cognitive performance (Darke, Sims, McDonald, & Wickes, 2000) and may impact capacities to undertake work.

Another variation on the idea that we’re expecting too much.

Elsewhere, explanations for differences in labor market outcomes among people with substance use disorders, such as lower education levels, work histories, or motivation (Svikis et al., 2012), may be disproportionately prevalent among those enrolled in MMT. As with non-drug-using populations (Dooley, Fielding, & Levy, 1996), individuals may also have differing capacities related to physical or mental health that inhibit their ability to seek and find employment.

Maybe it’s because they’re still getting high.

Finally, the common presence of concurrent and ongoing drug use by individuals enrolled in MMT ( [Barnas et al., 1992] and [DeMaria et al., 2000]) may preclude transitions into employment or temporary, informal, or under-the-table income generation.

Watch the whole film here.

UPDATE: Matt reminded me of some reasons it seems a little silly for these findings to be considered so counterintuitive. From our buprenorphine maintenance position paper:

Amato L, M. S. (2011). Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database of Systematic Reviews.;

Schwartz RP, Kelly SM, O’Grady KE, Gandhi D, Jaffe JH. (2011). Interim methadone treatment compared to standard methadone treatment: 4-month findings. J Subst Abuse Treat. 41(1):21-9.;

Helwick C (2010, May 24) For Prescription Opioid Dependence, Relapses Associated With Shorter Treatment Course. Retrieved October 25, 2011 from, 
http://www.medscape.com/viewarticle/722342
;

Fiellin DA, Pantalon MV, Chawarski MC, Moore BA, Sullivan LE, O’Connor PG, Schottenfeld RS. (2006). Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med. 355:365-374

Amato et al.’s meta-analysis of methadone maintenance treatment (MMT) found no benefit from added psychosocial support. Schwartz et al. compared interim methadone (IM) patients receiving no counseling with standard methadone (SM) patients receiving counseling. IM patients tested positive for illicit drugs at the same rate but engaged in less criminal activity and spent less money on drugs. These findings suggest that MMT patients are not “available” to benefit from these interventions which are the mainstay of abstinence based recovery. Helwick reported similar findings from a presentation by Roger Weiss, MD on the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study. Patients receiving buprenorphine and counseling fared no better than patients without the counseling. Fiellin, et al. reported similar findings. Again, suggesting that ORT patients are not “available” to benefit from these interventions which are the mainstay of abstinence based recovery.

Ironies abound.

(Photo credit: Blazenhoff)

Keith Humphreys and Mark Kleiman offer some great commentary on marijuana legalization and what a legal marijuana market might look like.

First, Humphreys:

About eighty percent of the market is “commercial grade” cannabis, which has a THC content of about 5% and sells for $70 to $230 per ounce, depending on how far a buyer is from the producing farm and in what amount he or she buys. If that level of potency and price surprises you, you are probably an observer or participant in the small, nationally unrepresentative marijuana “upmarket“.

The reason for the current dominance of commercial grade pot is simple: It’s an inexpensive product for a price-sensitive population.

But, he argues price would likely drop and …

The cannabis-using population would experience a vast increase in average drug potency. Caulkins and colleagues estimate that in the past 15 years, average potency of marijuana in the U.S. has doubled. But after legalization, with the 80% commercial grade market share being almost completely supplanted by sinsemilla, average potency would roughly triple very rapidly.

This increase in exposure to highly potent cannabis is one of the mechanisms through which legalization would result in a higher prevalence of addiction (Some of the other mechanisms are discussed here). It at first seems reasonable to assume that experienced users would simply titrate their dose of higher-potency pot, making higher or lower doses equivalent from a biological viewpoint. But surprisingly, laboratory studies of experienced marijuana users show that they are in fact poor at judging the potency of cannabis.

Kleiman isn’t so certain. Here are a few of his reasons. Read the entire post for the rest of his thinking:

• Even if high-potency product were legal, it could be heavily taxed, as whiskey is heavily taxed compared to beer.
• In the current illicit market, “quality” and “potency” are conflated in consumers’ minds. Post-legalization, …THC could be extracted from the vegetable matter and used to “fortify” pot to any desired potency. That may push consumers’ ideas of “quality” away from potency and toward other factors.
• Unlike alcoholic beverages, which mostly contain only a single psychoactive, cannabis contains a mix. Some consumers will want lower-THC, higher-CBD product.

Alcohol remains our one experiment with legalization of an intoxicant. Two-thirds of the alcohol consumed in the U.S. is taken in the form of beer rather than higher-potency forms.

As is so often the case, the answer here is “Hard to say; it depends.”

Related articles

• High-Potency Pot Would Dominate a Legal Marijuana Market (washingtonmonthly.com)
• Does Hemp Matter? (washingtonmonthly.com)

(Photo credit: Wikipedia)

Keith Humphreys on findings that link marijuana, tobacco and alcohol use with opiate use:

The researchers used data from 2006 to 2008 from the National Survey on Drug Use and Health, an annual study representative of the U.S. population, to study 18- to 25-year-olds’ drug use behavior. They found that 12 percent of the survey population reported misusing prescription opioids around the time the survey was conducted.

They also found that both men and women who had smoked marijuana between the ages of 12 and 17 were more than two times more likely to later abuse prescription drugs than those who had not. Young men who drank or smoked cigarettes as teens were 25 percent more likely to abuse prescription drugs — though this link was not found in women surveyed. Fiellin said there was no clear-cut reason why the results differed for men and women.

Keith Humphreys, professor of psychiatry at the Stanford Medical Center, said that this association between “gateway drugs” and prescription pain medication was significant regardless of the exact mechanism behind the link.

“Some people believe the ‘gateway effect’ exists because early drug use primes the human brain for more drug-seeking, others argue that the friends you make using drugs as a youth are a ready source for other drugs later, and still others argue that there are factors, like impulsivity, that causes both early and later drug use,” Humphreys said. “Which camp is correct? Probably, all of them.”

Related articles

• Debating the “Gateway Effect” of Youth Drug Use (samefacts.com)
• Debating the “Gateway Effect” of Youth Drug Use (washingtonmonthly.com)
• Is Alcohol or Marijuana the Gateway Drug? Perhaps It Is Both. (myteensavers.wordpress.com)
• Yale study: Alcohol’s gateway effect much larger than marijuana’s (rawstory.com)

Love First linked to this article on the role of non-medical interventions in treating addiction.

I’m more and more convinced that the key to managing costs and improving outcomes for all chronic diseases are behavioral or lifestyle strategies. We’ve got a lot to learn about helping people make important changes in their lives that will help prevent relapses in cardiac care, joint replacements, weight loss, respiratory care, depression, etc. We’ve got even more to learn about helping people maintain these changes for decades.

Addiction treatment is ahead of the curve on a lot of this. We have a lot to offer the rest of medicine and I’m certain we’ll have a lot of opportunities to learn from their research and innovations.

Related articles

• 11 Chronic Disease Technologies to Watch (thielst.typepad.com)
• “Disease” and recovery (addictionandrecoverynews.wordpress.com)
• Rethinking Everything We Thought About Addiction (psychologytoday.com)

Heard this on Fresh Air last week. A cool story about a recovering alcoholic who spent much of his life an active alcoholic working in a paper mill:

…I’d been divorced twice, I’d filed bankruptcy. When I got sober I was living in this little, very small apartment above this garage. It was about the size of a motel room and I’d been living there for about four or five years. I owned a black-and-white TV that my sister had given me and I had this old ’76 Chevy that had the whole side of it smashed in. And that was it.

You know, for 14 years of working there that’s what I had. And so, you know, there was that sense, I guess, of me just being a failure.

After he got sober he decided to pursue writing.

Donald Ray Pollock … didn’t become a writer until he put in over 30 years at the local paper mill and got sober. But once he did start writing he was noticed. After the publication of his first book, a collection of short stories called “Knockemstiff,” he received the 2009 PEN/Robert W. Bingham Fellowship.

You never know what recovery will unlock.

Points is publishing a series on methadone and offers a case for methadone without resorting to describing it as “the most effective treatment for opiate addiction.”

It’s a pretty fair piece. I had only one quibble with the facts of the story. This is unusual and very welcome. However, the author and I disagree starkly about the context and meaning of those facts. (As I pointed out last week, we seem to lower the bar for these addicts.)

It opens with this statement:

…there is one treatment that offers real hope.

Okay hope is good. Hope for what?

Reduced Crime

One of methadone’s biggest strengths is reducing this criminal behavior. The vast majority of research shows a marked decrease in crime following methadone treatment.  One particularly large study, involving over 600 patients, showed a 70.8 percent decline in “crime days” – a 24 hour period in which an individual commits one or more crimes – during the first 4 months of methadone maintenance treatment.

Reduced HIV Transmission

The post erroneously reports that, “More than 36% of new A.I.D.S. cases are attributed to intravenous drug abuse.” The report they cite actually says:

Since the epidemic began, injection drug use has directly and indirectly accounted for more than one-third (36%) of AIDS cases in the United States. This disturbing trend appears to be continuing. Of the 42,156 new cases of AIDS reported in 2000, 11,635 (28%) were IDU-associated.

These numbers includes people whose only exposure was IDU and people who reported possible IDU transmission AND male-to-male sexual transmission. A more recent report puts these new case transmission numbers significantly lower. Among men, IDU transmission was reported in 7% of cases. (IDU and male-to-male exposure was reported in another 4% of new male cases.) Among women, IDU transmission was reported in 14% of new cases. The total for all 3 groups would be 5594 new IDU-associated cases.

At any rate, the argument is as follows:

Even though methadone does not stop some addicts from continuing IV drug abuse, it reduces that needle share rate to 1/5.   In addition to reducing H.I.V. infections, methadone reduces prostitution by addicts, another major cause of new infections.

Reduced Drug Use

When measuring whether a treatment is effective or not, the primary concern is whether addicts stop or use fewer drugs than before they started treatment.  Methadone succeeds in this regard.  Drug use declines dramatically in those who undergo treatment, and it continues to decline as addicts spend more time in treatment.  Relatively new research shows that addicts who receive higher doses (measured as 80-100 milligrams) use even fewer opiates than the traditional treatment population, who are usually maintained on a sub-optimal dose.

A Couple of Qualifiers

First:

However, the majority of patients drop out within a year.

Second:

Nearly 40 percent of patients drop out of methadone programs during their first year of treatment due to incarceration.

What about Abstinence?

Abstinence is dismissed as absolutist and simplistic.

Defining success is of critical importance when assessing any treatment’s effectiveness.  The simplistic view looks at whether a treatment stops an addict from using their drug of choice.  This absolutist approach is problematic for a number of reasons.

Related articles

• Two stories of methadone (addictionandrecoverynews.wordpress.com)
• Methadone’s cognitive effects (addictionandrecoverynews.wordpress.com)
• Prolonged Methadone Treatment Can Affect The Nerve Cells, Behaviour (medicalnewstoday.com)

Match (Photo credit: matthewgriff (EmmGee))

Writing about physician burnout and expressing concern about financial incentives to improve care, Richard Gunderman puts his finger on something we try hard to attend to at Dawn Farm:

To promote burnout … it is only necessarily to subvert their professional and personal priorities, so that they spend all their time on little things and suffer continually from a growing sense that they are neglecting the ones that really matter.

First,

DEATHS among drug users have hit a record high in Scotland, increasing by a fifth in 2011, the latest government figures reveal.

Last year 584 people died from drug use, which means that drugs now account for one in every 100 deaths in Scotland.

The heroin substitute, methadone, was at the heart of the increase, with almost half of the drugs-related deaths involving the prescription drug.

Second,

How I Learned to Stop Worrying and Love Methadone

Just like ex-junkie Russell Brand, I used to believe that “maintenance” was as bad—if not worse—than active addiction. Here’s how I came to understand how fatally wrong I was.

I have no quarrel with any addict receiving methadone maintenance, IF they’ve been provided with accurate information and quality drug-free treatment.

I wish that, rather than describing methadone as, “the most effective treatment for opioid addiction,” they would be more specific about what they mean by effective:

…study after study shows that when methadone prescribing increases, addict deaths drop. It is superior to abstinence-only treatment in terms of fighting HIV and overdoses, and many studies find it superior in cutting crime.

Those things are important, but methadone is not the only way to achieve those goals and they’re not the only things that are important.

Of course, as we’ve pointed out many times, there is one group of opiate addicts that are not treated with opiate maintenance. Doctors are not treated with opiate maintenance and they have terrific outcomes.

Are we really denying addicted doctors “the most effective treatment for opioid addiction”?

Of course not. We’ve decided that, for them, we’re going to aim a little higher than reducing overdose risk, crime and HIV.

Related articles

• Methadone’s cognitive effects (addictionandrecoverynews.wordpress.com)
• Methadone to blame for one-third of US prescription painkiller deaths, CDC says – CBS News (cbsnews.com)
• Prolonged Methadone Treatment Can Affect The Nerve Cells, Behaviour (medicalnewstoday.com)

English: Methadone structure, animation (Photo credit: Wikipedia)

Another study on methadone’s cognitive effects:

In one study, on the day after the last exposure to methadone, there was a significant reduction (around 70 per cent) in the level of a signal molecule which is important in learning and memory, in both the hippocampus and in the frontal area of the brain. This reduction supports findings from a previous study (Andersen et al., 2011) where impaired attention in rats was found at the same time. At this time, methadone is no longer present in the brain. This indicates that methadone can lead to cellular changes that affect cognitive functioning after the drug has left the body, which may be cause for concern.

The study was done on rats, not people, but it’s findings aren’t isolated.

Patients and their loved ones may decide that the potential benefits outweigh the costs, but they should be made aware of the costs and know the alternatives.

Related articles

• Prolonged Methadone Treatment Can Affect The Nerve Cells, Behaviour (medicalnewstoday.com)
• Dawn Farm’s Position on Buprenorphine Maintenance

They interviewed a guy who wrote a book and gave a TED talk on the topic.

During the interview he discussed the concept of the adjacent possible and it’s importance in forming new ideas. During the interview, he described it as the building blocks of new ideas. Without the right building blocks, any innovation is not possible. He described it another way in a WSJ article:

The adjacent possible is a kind of shadow future, hovering on the edges of the present state of things, a map of all the ways in which the present can reinvent itself.

The strange and beautiful truth about the adjacent possible is that its boundaries grow as you explore them. Each new combination opens up the possibility of other new combinations. Think of it as a house that magically expands with each door you open. You begin in a room with four doors, each leading to a new room that you haven’t visited yet. Once you open one of those doors and stroll into that room, three new doors appear, each leading to a brand-new room that you couldn’t have reached from your original starting point. Keep opening new doors and eventually you’ll have built a palace.

During the interview, he pointed out that it doesn’t matter how smart one is, it was not possible to invent a microwave in 1650, because the building blocks, the adjacent possible, just wasn’t there.

One factor is that the physical building blocks did not exist. The other factor is that the imaginative/inspiration building blocks did not exist.

This reminded me of a metaphor Bill White once used when talking about hope-engendering relationships offering kindling for hope.

I think this helps explain the resistance some recovery advocates have to interventions focused on something other than drug-free recovery. There’s a sense of how precious this adjacent possible is, and how easy it is to imagine a world where drug-free recovery is not possible because the adjacent possible has been lost.

English: Human Rights Watch logo Русский: Логотип Хьюман Райтс Вотч (Photo credit: Wikipedia)

Not sure what to make of this:

A Chinese research team’s study of drug addiction treatments published inScience on 13 April is coming under fire from Human Rights Watch (HRW), the New York City-based advocacy group. This week’s issue of Science contains a letter from the group accusing the Chinese team of not making it clear whether their research subjects were held ”without due process” in compulsory treatment centers and subjected to “forced labor.” But a response from the study authors describes their considerable efforts to ensure that the research was conducted in an ethical manner, and bioethicists based in both the United States and China have also defended the Chinese researchers, calling the accusations unfair.

Related articles

• Human Rights Group Questions Ethics of Chinese Drug Treatment Study (news.sciencemag.org)
• China prisoners exploited in US-sponsored medical study? (rt.com)