“ceaseless reinvention leading to overlapping solutions”

0_A_winding_roadRead this last night on the brain’s “ceaseless reinvention leading to overlapping solutions” and it got me thinking about the long and challenging road ahead of us in developing a really solid understanding of addiction as a brain disease.

For centuries, neuroscience attempted to neatly assign labels to the various parts of the brain: this is the area for language, this one for morality, this for tool use, color detection, face recognition, and so on. This search for an orderly brain map started off as a viable endeavor, but turned out to be misguided.

The deep and beautiful trick of the brain is more interesting: it possesses multiple, overlapping ways of dealing with the world. It is a machine built of conflicting parts. It is a representative democracy that functions by competition among parties who all believe they know the right way to solve the problem.

As a result, we can get mad at ourselves, argue with ourselves, curse at ourselves and contract with ourselves. We can feel conflicted. These sorts of neural battles lie behind marital infidelity, relapses into addiction, cheating on diets, breaking of New Year’s resolutions—all situations in which some parts of a person want one thing and other parts another.

These are things which modern machines simply do not do. Your car cannot be conflicted about which way to turn: it has one steering wheel commanded by only one driver, and it follows directions without complaint. Brains, on the other hand, can be of two minds, and often many more. We don’t know whether to turn toward the cake or away from it, because there are several sets of hands on the steering wheel of behavior.

Take memory. Under normal circumstances, memories of daily events are consolidated by an area of the brain called the hippocampus. But in frightening situations—such as a car accident or a robbery—another area, the amygdala, also lays down memories along an independent, secondary memory track. Amygdala memories have a different quality to them: they are difficult to erase and they can return in “flash-bulb” fashion—a common description of rape victims and war veterans. In other words, there is more than one way to lay down memory. We’re not talking about memories of different events, but different memories of the same event. The unfolding story appears to be that there may be even more than two factions involved, all writing down information and later competing to tell the story. The unity of memory is an illusion.

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Asking the right questions in the right way

021-640x480Recovery Review directs our attention to a presentation by Jim Orford called Time to Ask the Right Questions in the Right Way: A New Direction for Addiction Treatment Research?. He suggests that comparisons between MET, CBT and TSF follow from us asking the wrong questions.

Here’s one of his suggestions.

Stop studying named techniques [CBT/MET/TSF] and focus instead on studying change processes and developing good, general addiction change theories

  • Need to change, can’t do it alone, ‘surrender’
  • Commitment, ‘self-liberation’
  • Incentives
  • Helper who is: credible, knowledgeable, efficient, concerned, working alliance
  • Communication, self-disclosure
  • Pledge, change statements
  • Social support for change
  • Coping with craving, negative emotions, etc.
  • Persistence
  • New identity

He offers the following tentative conclusions for this area:

Effective treatments have in common some basic process elements:

  • A knowledgeable, efficient, likeable and encouraging helper(s)
  • Who help(s) reinforce the feeling of need for change (e.g. encourage ‘discrepancy’)
  • Help(s) develop commitment to change (e.g. ‘pledges’, ‘change statements’)
  • Help(s) develop self-efficacy (e.g. ‘self liberation’, ‘seeing the benefits’)
  • And help(s) build social support for change

Under another suggestion he suggests that research look beyond primary treatment to include looking at the impact of:

  • What happened before
  • Entry procedures
  • The whole organisation
  • Mutual-help, faith communities and others
  • Families and social networks
  • The wider community

This is such a profound paradigm shift, but so self-evident when you see it described. An important question is what interests have us doing hundreds of studies on what are now, clearly, the the wrong questions?

He offers a suggestion. Our research is focused on what he describes as, “Time-limited Professionally Dominated Treatment”. What can we infer from that?

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Patient’s self-ratings? Bah, what do they know?

what-do-they-know_largeThree articles that caught my eye.

First, a meta-analysis on whether antidepressants improve overall wellness for young people. (One issue was that few studies have looked at overall wellness.)

Though limited by a small number of trials, our analyses suggest that antidepressants offer little to no benefit in improving overall well-being among depressed children and adolescents.

Another looks at attempts to see whether antidepressants reduce suicidality.

Based on measures taken pre- and post-treatment, the authors found that all treatments, including the pill placebo with clinical management, significantly reduced scores on both the interview and self-report measures of suicidality, with all having a medium effect size. According to the interview measure, interpersonal psychotherapy and antidepressant medication reduced suicidality more than the pill placebo with clinical management. No differences were found between treatments using the self-report measure.

Finally, an article that suggests that electronic health records and real world data are going to have a significant impact on drug development. I don’t question it, but it’s a lot easier for me to see this having major impact on evaluating drugs that have been approved and in use with patients.

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Dopey, Boozy, Smoky—and Stupid

Kleiman's recent book on marijuana legalization. There's something in it to make everyone mad.

Kleiman’s recent book on marijuana legalization. There’s something in it to make everyone mad.

This week’s Throwback Sunday post focuses on a 2007 policy article by Mark Kleiman. In 2013, Kleiman was selected as the project leader to write Washington State’s marijuana regulations after the drug was decriminalized through a ballot initiative.

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The National Interest has a lengthy article on drug policy by Mark A.R. Kleiman. I disagree with several of his points but this is exactly the kind of thoughtful contribution that the American drug policy debate needs more of.

I tend to see his perspective as hyper-rational (Possibly to balance the moral panic of drug crusaders and fetishization of drug culture by many legalization advocates.) and somewhat removed from both the suffering of addiction and the radical transformation that full recovery offers. I think he risks reducing policy issues to an accounting exercise but he expresses strong, well-informed opinions without and ideological ax to grind (Although there clear Libertarian themes.) and does so without characterizing and dismissing people who think differently.

After outlining the sad state of American drug policy he says:

These are depressing facts that cry out for a radical reform to solve the drug problem once and for all. But the first step toward achieving less awful results is accepting that there is no one “solution” to the drug problem, for essentially three reasons. First, the potential for drug abuse is built into the human brain. Left to their own devices, and subject to the sway of fashion and the blandishments of advertising, many people will wind up ruining their lives and the lives of those around them by falling under the spell of one drug or another. Second, any laws—prohibitions, regulations or taxes—stringent enough to substantially reduce the number of addicts will be defied and evaded, and those who use drugs in defiance of the laws will generally wind up poorer, sicker and more likely to be criminally active than they would otherwise have been. Third, drug law enforcement must be intrusive if it is to be effective, and enterprises created for the expressed purpose of breaking the law naturally tend toward violence because they cannot rely on courts to settle disputes or police to protect them from robbery or extortion.

Any set of policies will therefore leave us with some level of substance abuse—with attendant costs to the abusers themselves, their families, their neighbors, their co-workers and the public—and some level of damage from illicit markets and law enforcement efforts. Thus the “drug problem” cannot be abolished either by “winning the war on drugs” or by “ending prohibition.” In practice the choice among policies is a choice of which set of problems we want to have.

But the absence of a silver bullet to slay the drug werewolf does not mean we are helpless. Though perfection is beyond reach, improvement is not. Policies that pursued sensible ends with cost-effective means could vastly shrink the extent of drug abuse, the damage of that abuse, and the fiscal and human costs of enforcement efforts. More prudent policies would leave us with much less drug abuse, much less crime, and many fewer people in prison than we have today.

The reforms needed to achieve these ambitious goals are radical rather than incremental. But they are not simple, or all of a piece, or in any one of the directions defined by current arguments around American dinner tables, on American editorial pages or in American legislative chambers. The conventional division of drug programs into enforcement, prevention and treatment conceals more than it reveals. So does the standard political line between punitive drug policy “hawks” and service-oriented drug policy “doves.” Neither side is consistently right; some potential improvements in drug policy are hawkish, some are dovish, and some are neither.

I disagree with the hawk vs. doves dichotomy. The service-oriented doves are really divided into at least two camps. An older, more deeply entrenched group but shrinking group of treatment professionals who might be dovish relative to hawks, but generally support some form of prohibition. Then there is a newer group of doves who aren’t all that service-oriented but are more radically dovish, advocating more radical decriminalization.

He offers five principles to guide policy decisions:

First, the overarching goal of policyshould be tominimize the damage done to drug users and to others from the risks of the drugs themselves (toxicity, intoxicated behavior and addiction) and from control measures and efforts to evade them.That implies a second principle: No harm, no foul. Mere use of an abusable drug does not constitute a problem demanding public intervention. “Drug users” are not the enemy, and a achieving a “drug-free society” is not only impossible but unnecessary to achieve the purposes for which the drug laws were enacted.

Third, one size does not fit all: Drugs, users, markets and dealers all differ, and policies need to be as differentiated as the situations they address.

Fourth, all drug control policies, including enforcement, should be subjected to cost-benefit tests: We should act only when we can do more good than harm, not merely to express our righteousness. Since lawbreakers and their families are human beings, their suffering counts, too: Arrests and prison terms are costs, not benefits, of policy. Policymakers should learn from their mistakes and abandon unsuccessful efforts, which means that organizational learning must be built into organizational design. In drug policy as in most other policy arenas, feedback is the breakfast of champions.

Fifth, in discussing programmatic innovations we should focus on programs that can be scaled up sufficiently to put a substantial dent in major problems. With drug abusers numbered in the millions, programs that affect only thousands are barely worth thinking about unless they show growth potential.

Finally, he offers an agenda for policy change. I doubt I could ever comfortably endorse some of these. Others, I find myself resisting, but in the context of radical change (rather than incremental), they may be more acceptable.

  • Don’t fill prisons with ordinary dealers.
  • Lock up dealers based on nastiness, not on volume.
  • Pressure drug-using offenders to stop.
  • Break up flagrant drug markets using low-arrest crackdowns.
  • Deny alcohol to problem drinkers.
  • Raise the tax on alcohol, especially beer.
  • Eliminate the minimum drinking age.
  • Prevent drug dealing among kids.
  • Say more than “No.”
  • Don’t rely on DARE.
  • Encourage less risky forms of nicotine use.
  • Let pot-smokers grow their own.
  • Encourage problem drug users to quit without formal treatment.
  • Expand opiate maintenance.
  • Work on immunotherapies.
  • Get drug enforcement out of the way of pain relief.
  • Create a regulatory framework for performance-enhancing chemicals.
  • Figure out what hallucinogens are good for, and don’t let the drug laws interfere with religious freedom.
  • Stop sacrificing foreign policy and human rights objectives to drug control.

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The gold standard

gold standard   definition of gold standard by Medical dictionary

Recovery Review has a terrific post reviewing a journal article examining addiction treatment for physicians.

He pulled this from the source journal article:

Recognizing that SUDs are biological disorders with major behavioral components (just like diabetes and coronary artery disease), the relatively high level of success exhibited by physicians whose care is managed by PHP is important with respect to the potential for success in addiction treatment generally. Indeed, the observed rate of success among physicians directly contradicts the common misperception that relapse is both inevitable and common, if not universal, among patients recovering from SUDs.

Recovery Review summarizes the elements of Physician Health Programs:

  • Doctors sign binding contracts
  • Abstinence is the goal
  • Weekly doctor-specific mutual aid groups
  • Attendance at 12-step mutual aid groups (AA, NA, CA etc)
  • The regulatory boards are often avoided if doctors comply
  • Extended care (five years)
  • Recovery often starts with an active/planned intervention
  • This is followed by an intensive residential (or out-patient) rehab period, usually three months long
  • Withdrawal from work during treatment
  • Active monitoring and care management
  • Active family engagement
  • Mental & physical health needs assessed
  • Active management of relapse
  • Random drug and alcohol tests over the five years

He also summarizes the take-aways to improving treatment for other populations:

  1. Adopt the contingency management aspects of PHPs
  2. Offer frequent random drug testing
  3. Create tight linkages with 12-step programmes and abstinence standards
  4. Active management of relapse by intensified treatment and monitoring
  5. Continuing care approach
  6. Focus on lifelong recovery

This is an important and extremely well written post. Please read the whole thing here.

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Brighten the day!

Some old Ritalin ads.

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Strange conclusions – updated w/ link

Choose you evidence carefully by rocket ship

Choose you evidence carefully by rocket ship

We’ve been seeing a lot of claims about the comparative effectiveness of AA or 12 step facilitation (TSF) versus motivational interviewing (MI) or motivational enhancement therapy (MET), most recently here. That AA/TSF is superstitious  voodoo and MI/MET is rational, evidence-based and effective. (Interestingly, the author of the piece used an appeal to authority argument by invoking Bill Miller, one of the developers of MI. Keith Humphreys points out that, “the Miller work is cited to say things he doesn’t believe”.)

Just to be clear, Dawn Farm likes MI. We train staff in MI. We believe it’s a useful tool. However, we also believe it’s often oversold.

At any rate, a new study on MET just popped up in my feed reader. It included a very positive conclusion.

CONCLUSION: Motivational enhancement therapy (MET) appears to increase the percentage of days abstinent in patients with chronic hepatitis C, alcohol use disorders and ongoing alcohol use.

What was that conclusion based on?

FINDINGS: At baseline, subjects in MET had 34.98% days abstinent which increased to 73.15% at 6-months compared to 34.63% and 59.49% for the control condition. Multi-level models examined changes in alcohol consumption between MET and control groups. Results showed a significant increase in percent days abstinent overall [F(1,120.4)=28.0, p<.001] and a significant group by time effect [F(1,119.9)=5.23, p=.024] with the MET group showing a greater increase in percent days abstinent at 6 months compared with the education control condition.

So far, so good. Right? MET resulted in more days without drinking. It’s not total abstinence, but it’s movement in the right direction. That’s a good thing, right?

Oh, wait. There’s more.

There were no significant differences between groups for drinks per week.

Wait. What?

If I understand correctly, that sounds like the MET group drank more when they drank.

The MET group appears to have gone from 19.5 drinking days per month with an average of 7.8 drinks per drinking day, to 8 drinking days per month with an average of 8.3 drinks per drinking day.

The control group appears to have gone from 19.5 drinking days per month with an average of 8.5 drinks per drinking day, to 12 drinking days per month with an average of average 7.8 drinks per drinking day.

Even if you accept drink counting as a good way to measure outcomes, that positive conclusion seems a little less positive, doesn’t it? And, when these authors argue AA or TSF don’t work, but MI or MET do, what does “works” mean?

This isn’t to say that MI isn’t useful, just that you should be suspicious when you see these comparative claims.

So, why do we see this over an over again? I imagine there are a lot of reasons. However, I heard something on the radio last week that might shed some light on on the persistence of these assertions and my sense that we’re caught up in a battle of the culture wars. I hesitate to bring this up, because I don’t want to nourish arguments that AA is religion (I’m an agnostic.), but last weeks’ episode of On Being was on science/religion debates. One of the guests said the following:

Dr. Bradley Correct. There’s another factor that you are alluding to here which is — is that not only is there a science and religion issue going on here, but there is also a power struggle going on, too. This is very much tied up with issues of power. Um, if you go back to the 19th century and look at the writings of people like T. H. Huxley, and, uh, Andrew Dickson White, um, these folks, um, saw so much of the formative influences in culture as coming from religion and they wanted to switch the locus of the power to shape culture to scientists.

And so it became a power struggle. And you see it on the Christian side as well. There are communities that, uh, that kind of want to stay closed, and one way is to make sure that people don’t talk too much to people who think differently themselves. And to create fear and suspicion and I think that’s a lot of what’s going on as well. So you’ve got all these power dynamics outside of the science and religion…

Has addiction treatment become an arena for these power dynamics? A struggle for the locus of power to shape culture?

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