Category Archives: Policy

Abstinence—The Only Way to Beat Addiction?

StrawmanWhat killed Philip Seymour Hoffman? According to Anne Fletcher, it wasn’t the doctor who prescribed him the pain medication that began his relapse, it wasn’t the prescribers of the combination of meds found in his body, it wasn’t his discontinuing the behaviors that maintained his recovery for 23 years, it wasn’t a drug dealer, and it wasn’t addiction itself.

According to her it was 12 step groups for promulgating an alleged myth:

This is exactly what happened when Amy Winehouse, Heath Ledger, Corey Monteith, and most recently, Phillip Seymour Hoffman were found dead and alone. Scores of people most of us never hear about suffer a similar fate every year.

Why does this keep happening? One of the answers is that many people struggling with drug and alcohol problems have been “scared straight” into believing that abstinence is the only way out of addiction and that, once you are abstinent, a short-lived or even single incident of drinking or drugging again is a relapse. “If you use again,” you’re told, “you’ll pick up right where you left off.” Once “off the wagon,” standard practice with traditional 12-step approaches is to have you start counting abstinent days all over again, and you’re left with a sense that you’ve lost your accrued sober time.

She’s describing a theory often referred to as the “abstinence violation effect”. The argument is that the “one drink away from a drunk” message in 12 step groups is harmful and makes relapses worse than they might have been.

One problem. The theory is not supported by research. (See here and here. It hasn’t even held up with other behaviors.)

Two things are important here.

  • First, many people experience problems with drugs and alcohol without ever developing an addiction. Most of these people will stop and moderate on their own. These people are not addicts and their experience does not have anything to teach us about recovery from addiction.
  • Second, loss of control is the defining characteristic of addiction. The “one drink away from a drunk” message is a colloquial way of describing this feature of addiction.

Further, she characterizes AA as opposing moderation for problem drinkers, when AA literature itself says, “If anyone who is showing inability to control his drinking can do the right- about-face and drink like a gentleman, our hats are off to him.” 12 step groups believe that real alcoholics will be incapable of moderate drinking, but they are clear that they have no problem with people moderating, if they are able. This is a straw man.

We’re left to wonder why a best selling author and NY Times reporter would attack 12 step groups with a straw man argument and a long discredited theory.

via Abstinence—The Only Way to Beat Addiction? Part 1 | Psychology Today.

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Filed under Controversies, Harm Reduction, Policy, Research, Treatment

It will kill people as soon as it’s released

images (3)The upcoming release of Zohydro has been getting a lot of attention:

The hydrocodone-based drug is the latest in a long line of painkillers called opioid analgesics. The FDA approved the medication last fall to treat chronic pain, and it is set to become available to patients in March.

The drug was approved against the advice of the FDA’s own advisory board.

Despite a vote of 11 to 2 by an FDA panel to reject the powerful new drug, it was eventually given approval by the FDA for release.

There are concerns about the manufacturer’s access to the FDA.

Last fall, a series of emails were made public from a Freedom of Information Act request. They were emails between two professors who had, for a decade, organized private meetings between FDA officials and drug companies who make pain medicine. The drug companies pay the professors thousands of dollars to attend.

And here’s what has critics concerned. One of those companies was Zohydro’s original manufacturer, Elan Corp. Zogenix wasn’t in the picture yet but went on to partner with Elan.

One physician group isn’t mincing words about the impact of the drug.

“It’s a whopping dose of hydrocodone packed in an easy-to-crush capsule,” said Dr. Andrew Kolodny, president of the advocacy group Physicians for Responsible Opioid Prescribing. “It will kill people as soon as it’s released.”

Doctor Skeptic reviews the research on opioids as a pain management options and concludes with this:

The bottom line
1. Opioids may not be effective for chronic non-cancer pain, and their use in such patients is associated with side effects, tolerance, dependence, and addiction.
2. Despite this, prescription opioid use is increasing and with that, the rates of opioid abuse and opioid related death are also increasing.
3. Harms from prescription opioids are over-represented in the socially disadvantaged.

 

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Filed under Advocacy, Controversies, Policy, Research

Medication: The smart-pill oversell

Unlock-Your-PotentialGiven the simultaneous explosion in ADHD diagnosis, prescribed use of stimulants and non-medical use of stimulants, maybe it’s time to look at the cost/benefit ratio. We’ll it’s clear that the benefits aren’t all that. What to make of it?

Researchers are beginning to address this paradox. How can medication that makes children sit still and pay attention not lead to better grades?

One possibility is that children develop tolerance to the drug. Dosage could also play a part: as children grow and put on weight, medication has to be adjusted to keep up, which does not always happen. And many children simply stop taking the drugs, especially in adolescence, when they may begin to feel that it affects their personalities. Children may also stop treatment because of side effects, which can include difficulty sleeping, loss of appetite and mood swings, as well as elevated heart rate.

Or it could be that stimulant medications mainly improve behaviour, not intellectual functioning. In the 1970s, two researchers, Russell Barkley and Charles Cunningham, noted that when children with ADHD took stimulants, parents and teachers rated their academic performance as vastly improved9. But objective measurements showed that the quality of their work hadn’t changed. What looked like achievement was actually manageability in the classroom. If medication made struggling children appear to be doing fine, they might be passed over for needed help, the authors suggested. Janet Currie, an economist at Princeton University in New Jersey, says that she might have been observing just such a phenomenon in the Quebec study that found lower achievement among medicated students1.

And it may simply be that drugs are not enough. Stimulant medications have two core effects: they help people to sustain mental effort, and they make boring, repetitive tasks seem more interesting. Those properties help with many school assignments, but not all of them. Children treated with stimulants would be able to complete a worksheet of simple maths problems faster and more accurately than usual, explains Nora Volkow. But where flexibility of thought is required — for example, if each problem on a worksheet demands a different kind of solution — stimulants do not help.

What about those non-medical users? Don’t they get a boost?

In people without ADHD, such as students who take the drugs without a prescription to help with school work, the intellectual impact of stimulants also remains unimpressive. In a 2012 study of the effects of the amphetamine Adderall on people without ADHD, psychologists at the University of Pennsylvania in Philadelphia found no consistent improvement on numerous measures of cognition, even though people taking the medication believed that their performance had been enhanced10.

via Medication: The smart-pill oversell : Nature News & Comment.

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Addicts and Disease

Dirk Hanson has a great post on resistance to the disease model.

I’m a believer in harm reduction as part of the continuum of addiction interventions, but there is often a chasm between the way harm reductionists and treatment providers frame the problem. This can make it difficult to work together. Dirk does a great job illuminating an element of the differences in frames.

For harm reductionists, addiction is sometimes viewed as a learning disorder. This semantic construction seems to hold out the possibility of learning to drink or use drugs moderately after using them addictively. The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction. By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base. And that doesn’t help anybody find common ground.

He also offers some historian David Courtwright’s perspective on resistance to the disease model.

Historian David Courtwright, writing in BioSocieties, says that the most obvious reason for this conundrum is that “the brain disease model has so far failed to yield much practical therapeutic value.” The disease paradigm has not greatly increased the amount of “actionable etiology” available to medical and public health practitioners. “Clinicians have acquired some drugs, such as Wellbutrin and Chantix for smokers, Campral for alcoholics or buprenorphine for heroin addicts, but no magic bullets.” Physicians and health workers are “stuck in therapeutic limbo,” Courtwright believes.

Interesting. Because medical practitioners have had a difficult time establishing a role for themselves, there’s a lot of resistance to recognizing it as a disease.

When we look at the chronic disease burden, does this lead to bias in favor of pills and procedures, and neglect of lifestyle medicine?

Dirk also gets into the ways addicts benefit from the disease model. Check out the whole post.

via Addiction Inbox: Addicts and Disease.

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The choice argument and pleasure cont’d

Pleasure-Island

The NY Times recently had a Room for Debate feature on addiction. They published opinions from 6 different people on addiction with one being a clear advocate for the disease model. This is a little like publishing a debate feature on climate change and having 1 of 6 experts believe that global climate change is occurring.

Two of the writers, Carl Hart (previous posts on Hart) and Gene Heyman (previous posts on Heyman), emphasized pleasure.

It’s well established that addiction is a disorder of the pleasure pathways. When other parts of the brain (related to, say, vision or movement) or other organs experience disorders, we don’t devote NY Times features to whether they really are a disease or whether choice is a factor in the illness. However, when pleasure enters the picture, we have a very difficult time surrendering the notion that we are, or should be, in full control of our behavior.

Kevin McCauley addresses the role of pleasure in advocacy for the choice argument:

Addiction is a disorder of the brain’s ability to properly perceive pleasure. I think it’s this moral loading of pleasure that makes it harder to accept that this is a disease process. It’s easier to just write addicts off as bad people who just want to feel good. In fact, that’s a corollary of the choice argument. It says exactly that, “Addicts don’t shoot gasoline into their veins, they shoot drugs into their veins! And, why? Because it feels good. Addicts do it because it feels good!”

In fact, there’s a sentence in the AA big book that says basically the same thing, “Men and women drink essentially because they like the effect produced by alcohol.” And that’s exactly right. What addiction is, is a defect in the brain’s like mechanism.  Pleasure is the capacity of the brain, and being a natural organ, the brain can break. And, addiction is, at it’s heart, a broken pleasure sense.

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Filed under Controversies, Policy

Sentences to ponder

by karola riegler photography

by karola riegler photography

The more than 16,000 overdose deaths from prescription opioids each year disproves the idea that it’s easy to regulate addictive drugs if they are produced and provided legally. We can reduce the violence in markets, but we’ve paid a real cost in public health harms and in safety failures from reckless corporate behavior.

via 100 Americans die of drug overdoses each day. How do we stop that?.

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Vancouver home to Canada’s first crackpipe vending machines

image (1)Vancouver is the home to Canada’s first-ever crackpipe vending machines, which were installed in the city’s troubled Downtown Eastside in a bid to curb the spread of disease among drug users.

Portland Hotel Society’s Drug Users Resource Centre operates two of the machines. They dispense Pyrex crackpipes for just 25 cents.

“For us, this was about increasing access to safer inhalation supplies in the Downtown Eastside,” Kailin See, director of the DURC, told CTV Vancouver.

She said the pipes are very durable and less likely to chip and cut drug users’ mouths, which helps stop the spread communicable diseases including HIV and hepatitis C.

The vending machines are part of a harm-reduction strategy introduced by InSite, North America’s only medically supervised safe injection site.

via Vancouver home to Canada’s first crackpipe vending machines | CTV News.

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