Addiction and Recovery News

Does Alcohol Involvement Increase the Severity of Intimate Partner Violence?

2010-02-03T21:51:00.000-05:00

A pretty intuitive finding. That domestic violence is more severe when alcohol is present.

Study Says Drinking with Your Kids Doesn't Prevent Abuse

2010-02-03T21:47:00.000-05:00

Join Together reports:

Dutch teens who were allowed to drink alcohol at home drank more outside the home than their peers and -- along with other teens who drank -- were at increased risk of developing alcohol problems, according to researchers from Radboud University Nijmegen.
The study authors tracked 428 Dutch families with two children ages 13-15. They found that teens who drank at home also drank more on their own, and vice-versa, suggesting that teen drinking begets more teen drinking regardless of setting.
"The idea is generally based on common sense," said researcher Haske van der Vorst. "For example, the thinking is that if parents show good behavior -- here, modest drinking -- then the child will copy it. Another assumption is that parents can control their child's drinking by drinking with the child."
However, the study demonstrated that, "If parents want to reduce the risk that their child will become a heavy drinker or problem drinker in adolescence, they should try to postpone the age at which their child starts drinking," said van der Vorst.
The research was published in the January 2010 issue of theJournal of Studies on Alcohol and Drugs.

Injection center coverage

2010-02-03T21:11:00.001-05:00

Slate has a couple of dispatches on "Vancouver's experiment with helping addicts get high"

A commentary accuses opponents of "contempt for science"

I don't oppose harm reduction but, like this blogger, I see no reason why a recovery orientation could not be introduced in every harm reduction service.

The zeal for insite and contempt for critics make me wonder what their feeling would be about programs that distribute sleeping bags to homeless people to prevent frostbite and exposure deaths? These programs exist and there's one in my community.

Of course, there's one important difference. They engage in considerable advocacy, and not for more sleeping bags or tents, but for housing.

UPDATE: Peapod mentioned "evidence" below. Along the lines of his comment, we could produce studies and reams of evidence that sleeping bag distribution prevents frostbite and reduce exposure deaths, right? Does that make it the right thing to do? Maybe. Does that make it an adequate response? No. Does that mean that, in the establishment of priorities, it should trump other responses? No.

ONDCP talks recovery

2010-02-03T08:55:00.000-05:00

New Drug Policy Approach Focuses on the Vital Role of Recovery. See page 2.

Good news

2010-02-02T16:03:00.000-05:00

2010 Federal Budget Boosts Funding for Mental Health and Substance Abuse Programs

AA and depression

2010-02-02T14:18:00.000-05:00

From Addiction:

ABSTRACT
Rationale Indices of negative affect, such as depression, have been implicated in stress-induced pathways to alcohol relapse. Empirically supported continuing care resources, such as Alcoholics Anonymous (AA), emphasize reducing negative affect to reduce relapse risk, but little research has been conducted to examine putative affective mechanisms of AA's effects.

Methods Using lagged, controlled, hierarchical linear modeling and mediational analyses this study investigated whether AA participation mobilized changes in depression symptoms and whether such changes explained subsequent reductions in alcohol use. Alcohol-dependent adults (n = 1706), receiving treatment as part of a clinical trial, were assessed at intake, 3, 6, 9, 12 and 15 months.

Results Findings revealed elevated levels of depression compared to the general population, which decreased during treatment and then remained stable over follow-up. Greater AA attendance was associated with better subsequent alcohol use outcomes and decreased depression. Greater depression was associated with heavier and more frequent drinking. Lagged mediation analyses revealed that the effects of AA on alcohol use was mediated partially by reductions in depression symptoms. However, this salutary effect on depression itself appeared to be explained by AA's proximal effect on reducing concurrent drinking.

Conclusions AA attendance was associated both concurrently and predictively with improved alcohol outcomes. Although AA attendance was associated additionally with subsequent improvements in depression, it did not predict such improvements over and above concurrent alcohol use. AA appears to lead both to improvements in alcohol use and psychological and emotional wellbeing which, in turn, may reinforce further abstinence and recovery-related change.

Cocaine Vaccine Hits Snag

2010-01-21T05:54:00.000-05:00

Over at Addiction Inbox, Dirk Hanson reports on findings from a trial of the new cocaine vaccine and provides a succint description of its mechanism:

Some cocaine addicts appear willing to risk overdose in order to defeat a new cocaine vaccine, a recent study has shown.

The study, which appeared in the Archives of General Psychiatry, demonstrated that the TA-CD vaccine could blunt the effects of cocaine in some, but not all, patients. The vaccine works by causing the production of antibodies, which attach themselves to cocaine molecules, making the molecules too big too pass effectively through the blood-brain barrier.

Of 115 addicts involved in the study, only 38 % produced sufficient antibodies to dull the effects of cocaine, Rachel Saslow of theWashington Post reported. And among the high-antibodies group, only 53 % stayed free of cocaine 50 % of the time. “Immunization did not achieve complete abstinence from cocaine use,” said Thomas Kosten of Baylor college of Medicine, one of the authors of the paper.

Moreover, in some of the study participants for whom antibodies made cocaine a disappointing high, researchers found cocaine levels in the body to be as much as ten times higher than previous levels of usage—an obvious attempt to overcome the vaccine’s effectiveness. There were no overdoses, according to Kosten.

Politics, Science and Harm Reduction

2010-01-20T11:23:00.000-05:00

Macleans has an interesting column making the case for the role of politics in decisions about programs like Insite:

...each person’s own opinions on federalism may not line up neatly with his views on drug policy. Indeed, if you are a strong centralist when it comes to Confederation AND you loathe the Harper government, or you’re just a centralizer who favours harm reduction, it seems to me that the Insite controversy has painted you into a rather awkward corner.

As far as I can tell, we are not having the kind of debate that would force such a person to say “I hate that those anti-science Conservative nutbars are trying to crush Insite, but they certainly have the right to do so.” Nor are we hearing from decentralizing socons who might say “I sure hate the idea of doctors getting paid good money to hover over diseased vermin while they irrigate their veins with poison, but as much as I like the Prime Minister, he should damn well stay out of B.C.’s business.”

I would add that this fundamental constitutional question is all the more important because, unlike many fellow libertarians and supporters of harm reduction, I don’t really believe that the value of safe-injection clinics is something that can be settled by a simple appeal to the authority of science. Science is well-placed to answer narrow, specific measurement questions about drug policy: “Did Insite reduce the number of overdose deaths in the region between years X and Y?”, for example. By answering such questions, it can provide the material for a broader assessment of the worth of such programs. But it cannot decide by fiat.

Insite has to be judged by its effects on many groups of citizens—not just the drug users who visit Insite, but the drug users who don’t and won’t; the families and loved ones of both groups of addicts; the dealers; the cops; the ordinary people who live near the clinic, and elsewhere in the region; the B.C. government, its treasury, and its taxpayers. (An environmentalist, or a Lorax, would even say that the non-human world should have a voice.) Within none of these groups are the effects simple or quantifiable by means of a single number, and all of the groups may have different claims to moral consideration, claims that there can be no universal agreement on. Moreover, the integrity of the criminal law and the public’s respect for it do count for something—maybe not much, but not zero—in this equation. The defender of Conservative policy would argue that this makes us all parties to the controversy, even outside B.C.

In short, science can’t provide us with a simple, scalar Benthamite answer to the net utility of Insite. To oppose Insite is not to be opposed to “science”, though a lot of scientists like Insite. Whether the clinic ought to exist is a question well-suited to be answered by political means: public and private argument, consensus-building, horse-trading, the consulting and balancing of moral principles, et cetera. Since this is the case, the question of what political unit should have the power to make the decision—the federation, or the province—is both crucial and urgent.

The problem of free will in addiction

2010-01-20T10:29:00.001-05:00

Philosophy bites has an interview with Thomas Pink on free will that I think touches on points important to thinking about addiction.

It's my anecdotal sense that much of the resistance to the disease model comes from concerns about free will. Specifically, that the disease model suggests a loss of free will (or, a kind of determinism), at least in this one area of the addict's life. The problem here is this: if the person is not in control of their behavior, how can we hold them accountable or assign blame for the bad things that they they do or that result from their AOD use? This isn't a small matter. This kind of accountability is an important social glue.

This podcast (18 minutes) does a good job exploring the matter of blame and free will, but, more importantly, addresses the apparent incompatibility between free will and determinism by suggesting that we conceptualize them improperly.

A helpful metaphor is offered: If a machine has two controllers (one controller representing deterministic factors and the other representing free will), does that mean that only one controller works? Or, is it possible that they both are capable of controlling the machine?

Here and Now with A. Thomas McLellan

2010-01-19T14:48:00.000-05:00

Here and Now has a good, brief interview with A. Thomas McLellan.Hea

Not on the same side

2010-01-19T08:09:00.000-05:00

Doctors criticise ‘reckless’ drug abuse guidance

"I Want Heidi Fleiss To Get Well ... But I Don't Think Celebrity Rehab Is The Solution"

2010-01-18T17:14:00.000-05:00

I don't usually post this kind of thing, but I've always had a soft spot for Juliana Hatfield. I think she's a little too kind to Dr. Drew.

I think money -- and the possibility of renewed visibility leading to future job offers -- is the only legitimate, honest motivation for anyone to go on "C.R." (Celebrity Rehab) I suspect that another reason people do go on the show -- disregarding the fact that they are so drug- and booze-addled that they simply cannot make any rational or intelligent decisions about anything -- is that they crave attention and fame. These people -- especially these people -- will never get clean unless they disappear; out of Hollywood, off of TV.

Addiction treatment afflicted with Baumol's cost disease

2010-01-18T09:48:00.001-05:00

I'd never heard of this guy or "Baumol's cost disease", but it makes a lot of sense and is has difficult implications for the future of of addiction treatment, particularly for providers that serve indigent populations or focus on offering affordable care.

Update: I got a few questions about this. The implication for programs is that, because there is little or no chance for gains in efficiency, programs must make more money every year just to maintain the status quo. Prices are just about the only lever that programs have.

Words used to describe substance-use patients can alter attitudes, contribute to stigma

2010-01-15T09:12:00.002-05:00

This study highlights something that's always troubled me about efforts to frame addiction as a chronic illness, that it could be more likely to increase stigma rather than decrease it.

Part of the appeal of the acute model is that it offers a narrative of permanent transformation. There are two concerns about the disease model that I hear over and over again that contribute to stigma.

The first concerns personal responsibility--that if we accept the disease model and destigmatize addiction, we're letting people off the hook for bad decisions. This concern focuses on behavior prior to recovery and the chronic model offers nothing new to address these concerns.

The second concern is that addicts and alcoholics don't change and that recovery either isn't a realistic possibility for most addicts or that recovery doesn't mean what advocates say it means. Some argue that alcoholics will never really quit, others might argue that the real problem is character and when you sober up a drunken horse thief you still have a sober horse thief. This fear of recidivism (or the expected persistence of anti-social behavior that's attributed to all addicts) contributes to disease model resistance and stigma. The acute model's narrative of permanent transformation, offers a (too often false) response to this fear. The chronic model's emphasis on lifelong vulnerability contributes to these fears that recovery is temporary and unstable.

Some will invest a lot of time in micro-examining word usage to improve "messaging". I don't think that this is the answer. I believe the problem is that our message is incomplete. What we say about the illness of addiction isn't the problem. The problem is that we have very little to say about recovery.

For this reason, Bill White wrote a piece calling for research into the neurobiology of recovery. It's well worth the time to read it.

Fear Mongers Attack a NYC Harm Reduction Pamphlet that Saves Lives

2010-01-09T07:21:00.002-05:00

Earlier this week I predicted that critics of injection drug using instructions would be accused of moral panic. I was a little off, the accusation is fear mongering.

As I said, I can imagine circumstances where this could have some value in preventing illness and facilitating recovery, but I suspect that the people producing these materials do not share my goal of recovery.

I do not oppose harm reduction, if it's aligned with the goal of facilitating recovery.

I understand that there is scientific evidence demonstrating that HR reduces disease transmission and other health problems, but some of these advocates are very tone deaf. While accusing others of moral panic or fear mongering, they fail to comprehend the way many of us view addiction--as something akin to slavery due to compromised free will where drug use is concerned.

Would there be a basis of for criticizing programs targeting slaves to enhance their health and life satisfaction? On its face, helping improve health and wellbeing is a good thing, but wouldn't it be better to also be an abolishionist?

Some more narrow public health examples might be programs to educate and provide sterile cutting equipment to people who engage in self-mutilation or communities that practice female circumcision.

Is it unreasonable to question these responses to these problems? Is it too much to ask that the professional helpers participating in these responses seek to facilitate an end to the behavior? Why is that so controversial?

On the other hand, a reader offered the following comment:

Unfortunately the tone and language of the article would seem to suggest that some "critics" do seem guilty of judgmentalness, if not exactly "moral panic"
"offers dope fiends such useful advice"
"spells out how junkies should ready their fix"
if the article was describing advice for hypertensives or diabetics the language would likely be a little more respectful.

Jane Doe :)

NIAAA Official Says Alcoholism 'Isn't Usually' a 'Chronic, Relapsing Disease'

2010-01-06T20:00:00.004-05:00

Jacob Sullum enjoys a gotcha moment with Mark Willenbring.

After reading the original article, I don't see this as the Perry Mason moment that Sullum does. The article suffers from the same problem that many articles on the subject do--it does a poor job of distinguishing when we're talking about DSM dependence and when we're talking about DSM abuse. The implications for each are vastly different. Most people with DSM abuse will find that their problems eventually resolve on their own or when other primary problems are resolved. For those with DSM dependence, the conventional wisdom has been that they all need professional treatment and that they all need professional treatment and they all need to abstain completely. We're learning more about how this is not universal. Part of the problem has been categorization of problem drinkers. People with temporary, rather than chronic, alcohol problems may meet diagnostic criteria for dependence and then "mature out". The example that most easily comes to mind are college students who engage in frequent heavy drinking and then moderate when they graduate, get married, or decide that it will interfere with their goals. That's what this article examines.

What I find very interesting is the libertarian hostility toward the disease model of alcoholism. I read this a few days ago and was wondering if the objection was that the model challenges individual agency. A peek at the comments this morning suggests that the objections do coalesce around three issues:

An objection to the notion that free will (and, therefore, personal responsibility) is compromised.
The spirituality of AA.
That framing heavy drinking as something other than a personal choice opens the door to medical and state interference in a person's life.
That treatment doesn't look like treatment for the medical conditions that come to mind.

Heroin for dummies

2010-01-05T12:16:00.004-05:00

Responses to this will be interesting to watch. I'm certain that people who object will be accused of moral panic or something like it.

I'm open to non-judgmental outreach harm reduction for the purpose of building relationships and gradually engaging people into recovery.

I'd like to know how these materials are being used. Are they in the hands of hopeful recovery-informed outreach workers who are building relationships and building motivation to recover? Or, something else?

I've posted about gradualism and recovery-oriented harm reduction before.

I've been thinking about a model of recovery-oriented harm reductionthat would address the historic failings of abstinence-oriented and harm reduction services. The idea is that it would provide recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented provider:
an emphasis on client choice--no coercion
all drug use is not addiction
addiction is an illness characterized by loss of control
for those with addiction, full recovery is the ideal outcome
the concept of recovery is inclusive -- can include partial, serial, etc.
recovery is possible for any addict
all services should communicate hope for recovery--recognizing that hope-based interventions are essential for enhancing motivation to recover
incremental and radical change should be supported and affirmed
while incremental changes are validated and supported, they are not to be treated as an end-point
such a system would aggressively deal with countertransference--some people may impose their own recovery path on clients, others might enjoy vicarious nonconformity through clients

Comparing Outcomes of ‘Voluntary’ and ‘Quasi-Compulsory’ Treatment of Substance Dependence in Europe

2010-01-05T12:16:00.002-05:00

Another study finding that coerced treatment is just as effective as voluntary treatment.

This is important for drug courts, employers and families.

It also raises important questions about the utility of the stages of change for treatment placement. The conventional wisdom is that less motivated people should not be provided higher levels of care. These findings suggest that treatment outcomes are not a good argument for this approach.

This should be of limited comfort, though. The treatment system fails to attract too many people and relies too much on external coercion.

Charlie Sheen blames drinking for attack on wife, but is that really the cause?

2010-01-05T12:13:00.001-05:00

Short answer, "no!"

We've written a lot on the subject. More here:

Rising alcohol addiction costs 'could cripple the NHS'

2010-01-01T10:37:00.000-05:00

A reader (thanks Foppe) shared this article with me about the burden addiction is placing on Britain's NHS.

I have a couple of reactions. This could be looked at as a simple reporting of facts on a public health issue. But, why do we never hear stories about cardiac disease crippling health systems? Cancer? Other diseases?

The answers that pop into my mind are that the health system (and society) doesn't consider addiction as being under their purview, they don't feel ownership of the problem. There are a lot of reasons for this, including the existence of a categorically segregated and that, beyond detox, treatment does not look like traditional medical treatment. (Though the emergence of disease management protocols has expanded the role of the medical system and recovery management seeks to integrate primary care into addiction treatment.)

The other answer that comes into my mind is that it's an expression of stigma--passive-aggressive whining about how much "those people" are costing the rest of us.

The dangers of overconfidence

2009-12-19T19:55:00.001-05:00

Support for twelve-step programs' emphasis on powerlessness?

It doesn't end there. In a third study, the researchers contrived to influence beliefs about self-control by giving student smokers a bogus implicit test of impulse control. Later, the students were challenged to watch the film "Coffee and Cigarettes" whilst abstaining from smoking. They were promised a greater cash reward the more difficult they made the challenge for themselves. In this case, students given bogus test feedback indicating they had high self-control were more likely to opt for greater temptation - holding the cigarette in their hand rather than having it on the desk - and they were more likely to give in to that temptation.

Finally, Nordgren's team tested the idea that "restraint bias" could explain why drug addicts are so prone to relapse. They recruited 55 participants through a smoking-cessation programme, all of whom had been smoke free for at least three weeks. Those who said they had more impulse control also tended to say they wouldn't be trying so hard to avoid temptation, such as the company of other smokers. Four months' later, those with the inflated sense of impulse control were more likely to have relapsed.

"The restraint bias suggests that people are willing to experiment with addictive drugs simply because they believe they can overcome the addiction," the researchers said. "An urgent task for future research is to test whether enduring shifts in impulse-control beliefs can be created."

Who me?

2009-12-18T16:33:00.002-05:00

Discouraging news in terms of attraction to treatment:

A lack of perceived need for treatment is still a key reason for the low rate of treatment in people with alcohol-use disorder and for the lack of progress in reducing the scale of this problem, according to an analysis of recent large surveys in the United States.

In the National Survey on Drug Use and Health (NSDUH) dataset, 7,009 respondents met the diagnostic criteria for an alcohol-use disorder (dependence or abuse), among whom 89.6 percent said they did not perceive a need for treatment or counseling for their alcohol use in the prior 12 months. In the 3,305 participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) who met the criteria for alcohol-use disorder, a similar rate of 89 percent said they did not think they needed treatment for alcohol-use treatment.

This is an important challenge for providers. How do we attract people who are not coerced and/or late stage? It's time for providers to take responsibility for this.

It would be more meaningful if they separated dependence and abuse.

What happens when free treatment is offered?

2009-12-18T16:30:00.002-05:00

Early returns from a Massachusetts initiative offering free smoking cessation treatment:

When Massachusetts began offering virtually free treatments to help poor residents of the state stop smoking in 2006, proponents hoped the new Medicaid program would someday reap benefits.

But state officials never expected it would happen so soon.

New state data show a steep drop in the smoking rate among poor people. When the program started, about 38 percent of poor Massachusetts residents smoked. By 2008, the smoking rate for poor residents had dropped to about 28 percent, a decrease of about 30,000 people in two and a half years, or one in six smokers, said Lois Keithly, director of the state’s Tobacco Cessation and Prevention Program.

There are also indications that the drop has lowered rates of hospitalization for heart attacks and emergency room visits for asthma attacks, she said.

The data has not yet been peer-reviewed. But the numbers have already grabbed national attention, with several United States senators and antismoking advocates using the data to push for similar new Medicaid coverage for tobacco addiction in the national health care legislation.

Mental-health parity laws require oversight

2009-12-18T16:25:00.002-05:00

Findings from the implementation of mental health parity in California:

Costs associated with parity were in line with, or even below, the projections.
Most health plans responded to the parity law by lifting limits on the annual number of days allowed for inpatient treatments and the number of visits allowed for outpatient treatment.
Concerns arose over the use of "medical necessity" clauses to authorize treatments and control costs. Medical necessity is typically defined as the need to supply a service for a condition that could endanger life or cause significant illness, suffering or disability and for which there is no adequate, less costly alternative available.
Consumers also complained about being referred to lists of mental-health providers only to find out that providers on the list were not taking new patients.
Health insurance providers felt the list of diagnoses covered under the parity law was arbitrary in excluding certain diagnoses.
Some doctors reported that they chose a parity diagnosis for a patient in order to ensure insurance coverage although it wasn't the most accurate diagnosis. Some doctors said they had little flexibility to change a client's diagnosis if he or she improved because they believed the health plan would then stop providing coverage for continuing care or care for a lesser diagnosis.
Nearly half of Californians polled in focus groups were unaware of the parity law.

an abuse of human rights

2009-12-16T09:42:00.004-05:00

An opinion piece in the Guardian makes a powerful indictment of the use of methadone in U.K. prisons. (I'm not clear whether the controversy is about methadone maintenance or methadone detox in prisons. I see both referenced.)

In a jail recently, I watched a slow, shuffling queue of men in the rain. The sight of these addicts lining up outside the dispensary for their drugs must be one of the saddest and most shameful in our prison estate, yet giving them drugs is now the cornerstone of policy throughout western Europe – the argument being that we should accept that the addicted will always be with us and, instead of trying to change them, we should limit the damage they can do to society. Just get them on a programme of controlled drug use and the public will be protected from the crime and chaos that are the bedfellows of addiction.
...
Maybe you have to live with your own addiction and go through the various methods of so-called treatment to understand the truth: that the methadone programme is an abuse of human rights. Every addict should be given the chance to recover. Most addicts do not believe it is possible to lead a fulfilling and drugs-free life. Their world is out of control and underpinned by the belief that they must commit crime to get drugs, or wait for the doctor to hand them over. It is shameful that our public services reinforce this view, instead of giving individuals the help they need to change.

It seems that recovery could offer an organizing paradigm to diffuse some of the tension here. If the MMTs in question adopted a recovery-oriented approach and evaluated themselves with recovery-oriented outcomes, it might offer a path to progress in this dispute.