With Rise Of Painkiller Abuse, A Closer Look At Heroin

English: Pre-war Bayer heroin bottle, original...
English: Pre-war Bayer heroin bottle, originally containing 5 grams of Heroin substance. (Photo credit: Wikipedia)

 

The number of people who had used heroin in the previous year increased between 2007 and 2012, from 373,000 to 669,000. Meanwhile, federal data from 2011 finds that nearly 80 percent of people who had used heroin in the past year had also previously abused prescription painkillers classified as opioids.

 

via With Rise Of Painkiller Abuse, A Closer Look At Heroin : NPR.

 

More on choice and addiction

why oh why by larryosan
why oh why by larryosan

From Kevin McCauley:

The argument against calling addiction a disease centers on the nature of free will. This argument, which I will refer to as the Choice Argument, considers addiction to be a choice: the addict had the choice to start using drugs. Real diseases, on the other hand, are not choices: the diabetic did not have the choice to get diabetes. The Choice Argument posits that the addict can stop using drugs at any time if properly coerced.

As evidence, the Choice Argument offers this scenario: a syringe of drugs is placed in front of an intravenous drug addict and the offer is made to “Spike up!” When the addict picks up the needle and bares his arm, a gun is placed to his temple and the qualifier is added that if the addict injects the drug his brains will be blown out. Most addicts given this choice can summon the free will to choose not to use drugs. The Choice Argument claims this proves that addiction is not a disease. But in real diseases – diabetes, for instance- a gun to the head will not help because free will plays no part in the disease process. So the Choice Argument draws a distinction between behaviors – which are always choices – and diseases.

This is a powerful argument. It is also wrong.

While it is true that a gun to the head can get the addict to chose not to use drugs, the addict is still craving. The addict does not have the choice not to crave. If all you do is measure addiction by the behavior of the addict – using, not using – you miss the most important part of addiction: the patient’s suffering. The Choice Argument falls into the trap of Behavioral Solipsism.

Just as a defect in the bone can be a fracture and a defect in the pancreas can lead to diabetes, a defect in the brain leads to changes in behavior. In attempting to separate behaviors (which are always choices) from symptoms (the result of a disease process), the Choice Argument ignores almost all of the findings of neurology. Defects in the brain can cause brain processes to falter. Free will is not an all or nothing thing. It fluctuates under survival stress.

Hat tip: Matt Statman

 

If it wasn’t rational, they wouldn’t be doing it

mencken-complex-problem

Ugh.

The NY Times has another column promoting a rational addiction model.

“When they were given an alternative to crack, they made rational economic decisions.”

When methamphetamine replaced crack as the great drug scourge in the United States, Dr. Hart brought meth addicts into his laboratory for similar experiments — and the results showed similarly rational decisions.

“If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure,”

Here we go again. Their drug use by addicts is rational. A rational choice. If you had their lives, you’d be an addict too.

I’m not even clear that there’s a causal relationship from poverty to addiction. If so, how strong is that relationship?

In an article titled, “Taking Absurd Theories Seriously“, Ole Rogeberg walks through an extensive takedown of rational addiction theories. This video is great.

Why do people insist on framing addiction as rational?

For others, it’s assimilation into the monoculture:

To begin with, in the economic story, you are an individual.

The economic story also says that as a human being, you’re rational. In economic thought, being rational doesn’t mean that you’re sensible or that you’re a clear thinker. Being rational means that when you’re faced with a decision, you move through a three-stage process to decide what to do. Assuming you know what your goals are, you first lay out all the ways you could reach each goal and identify the costs and benefits of each possibility. Next, you analyze which option is most efficient — the one that most directly lets you get the most of what you want while costing you the least of your resources. Finally, you choose that most efficient option, because in the economic story, your best choice is always the most efficient choice.

In the economic story, you’re someone who is self-interested, in the most positive sense possible.

Being cast as someone who is rational and self-interested might sound relatively harmless, but that way of thinking has implications because it’s based on the assumptions that you know what condition you’re in, you know what your options are, and you know what you want, but those assumptions don’t necessarily hold. … The story says that you act as you do because you’re trying to get what you want, and the rest of us can tell what you want by watching how you act.

For others it’s philosophical:

Although addiction may be defined and operationalized in a number of different ways, the heart and core of the concept lies in its implication of the loss of the ability to choose – that is, the loss of free will.  Hence, and logically, the concept of addiction also implies the actual existence of free will.  And there lies the rub.

The addiction concept repackages one of the Big Questions – free will and determinism – into a new and seemingly more manageable form.   But should we be entirely comfortable with the tacit implication that ordinary, non-addictive conduct is freely willed?

Of course, this assumption underlies much of our day-to-day lives.  We show up at work late and we are responsible for the choices we made that caused our lateness.  Our legal system relies on the same assumption as well.  It assumes people freely do what they do and must take responsibility for their actions.

This came up again recently when Sally Satel published a book questioning neuroscience and addiction:

“Brainwashed” is nervously libertarian; Satel is a scholar at the American Enterprise Institute, and she and Lilienfeld are worried that neuroscience will shift wrongdoing from the responsible individual to his irresponsible brain, allowing crooks to cite neuroscience in order to get away with crimes.

Once it’s defined as a choice, and the rational choice theory isn’t satisfactory, we’ve got economists coming up with their own answers to the age old question of, why do they do it? [emphasis mine]

First-hand accounts of poverty generally recognize that heavy users of drugs and alcohol pay a high material cost.  Yet they rarely reach my verdict: that other factors – like low IQ, low conscientiousness, low patience, or plain irrationality – must be driving both poverty and substance abuse.  Instead, observers usually say that the poor consume drugs and alcohol to “dull the pain.”  Some even argue that the poor are being entirely rational: If your life is a living hell, narcoticizing yourself is the simplest solution.

There’s just one problem with this explanation: By almost all accounts, substance abuse eventually makes your life worse.  The long-term addict’s life is utterly wretched – even if you average in his periodic drug-induced euphorias.  Someone who has yet to start using drugs and alcohol doesn’t face a choice between “full pain” and “dulled pain.”  Instead, he chooses between two paths of pain:

Path #1: Full pain in the short-run, followed by gradual life progress.

Path #2: Dulled pain in the short-run, followed by a gradual downward spiral into abject misery.

Suppose you’re poor.  Your life is unusually painful, so the immediate effect of drugs and alcohol is especially attractive.  The long-run prognosis for a poor substance abuser, however, is especially repellent.  You hit “rock bottom” sooner because you don’t have far to fall.  And your version of “rock bottom” is extra bleak because you lack the financial resources and social connections to cushion the blow and get back on your feet.

The lesson: On net, poverty isn’t a believable root cause of substance abuse, because being poor doesn’t make substance abuse a better overall deal.  Why then would poor people be more inclined to narcoticize themselves?  Once again, we should look for root causes of poverty and pathology.  Low patience is the most obvious suspect.  If you loathe to defer gratification, you’ll tend to have low income, and eagerly use drugs and alcohol today despite their awful cost down the line.

While I detest the blogger’s character-based explanation. He closes with a very salient question and observation:

Closing questions: If you were poor, would you turn to drugs and alcohol?  If you were a social worker, would you advise the poor to turn to drugs and alcohol?  I doubt it.  The reason, of course, is that on some level you already know what I’m telling you: Poverty is no excuse for substance abuse because substance abuse is an absurd response to poverty.

UPDATE: I’ve had several posts over the years about free will and addiction. One important thing to keep in mind is that when we say it’s a brain disease, it doesn’t mean the person always has zero control over their behavior.

Here are some excerpts that offer different ways to think about it.

On co-existing deterministic factors and free will:

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?

On deterministic factors as a continuum:

There is certainly room to incorporate biological and genetic vulnerabilities in such a model. People may vary as to the reward power of drugs and alcohol: Some people get more pleasure than others from them. Social factors and personal experiences may also contribute to individual differences in such propensities. Thus, some people end up with stronger cravings than others.

Still, some freedom remains. The wine does not pour itself into a glass and thence down the alcoholic’s throat. The person thus makes a choice between competing impulses: indulging pleasure now versus abstaining for the sake of nonspecific but substantial delayed gains. Choosing the path of virtuous abstention depends on willpower, however. When willpower has been depleted (such as by other acts of self-control, or even by decision making in any context; see Vohs et al. 2008), their likelihood of choosing the immediate pleasure increases.

If a disease model for addiction is to be retained, we suggest abandoning the virus or germ models in favor of something more like Type II diabetes. One does not become infected with diabetes. Rather, a natural bodily vulnerability becomes exacerbated by experiences, many of which are based on personal choices. Many people will not become diabetics regardless of what they eat, but others will suffer diabetes to varying degrees as a function of diet and exercise. Moreover (and again unlike a virus), there is no definite boundary that separates the sick from the healthy. Diabetes, and by analogy addiction, is a continuum. Those who are constitutionally vulnerable move themselves along this continuum by virtue of the choices they make.

On will power as psychological energy:

…within the context of their metaphor of psychological energy, there might be times when a person has none and times when a person has no internal or external resources to replenish this energy.

…Acknowledging these considerations does disavow the role of choice. Even on the end of the continuum where a person’s biology and environment doom them to developing addiction, choices could influence the onset, course and severity. And, within the psychological energy metaphor, during periods of replenished energy a person may have the power to make choices that will protect or expend this energy in ways that preserve it (and initiate/maintain recovery) or diminish it (and lead to relapse).

On ditching the all or nothing mentality:

One way to partially reconcile the dilemma between the traditional and emerging views of choice is to first acknowledge that free will in addiction and recovery is not an all or none phenomena. The capacity for volitional control over AOD use and related decisions is variable across individuals (as a function of the interaction between problem severity/complexity and recovery capital) and is dynamic (shifts incrementally on a continual basis within the same individual through both addiction and recovery processes).

24 month outcomes

 

surprise result road by dougtone
surprise result road by dougtone

Another study supports the effects of twelve step participation over 24 months. (I know the abstract says “self help”, but the pay-walled article makes it clear that they were looking at twelve step participation.)

Abstract

The goal was to identify factors that predicted sustained cocaine abstinence and transitions from cocaine use to abstinence over 24 months. Data from baseline assessments and multiple follow-ups were obtained from three studies of continuing care for patients in intensive outpatient programs (IOPs). In the combined sample, remaining cocaine abstinent and transitioning into abstinence at the next follow-up were predicted by older age, less education, and less cocaine and alcohol use at baseline, and by higher self-efficacy, commitment to abstinence, better social support, lower depression, and lower scores on other problem severity measures assessed during the follow-up. In addition, higher self-help participation, self-help beliefs, readiness to change, and coping assessed during the follow-up predicted transitions from cocaine use to abstinence. These results were stable over 24 months. Commitment to abstinence, self-help behaviors and beliefs, and self-efficacy contributed independently to the prediction of cocaine use transitions. Implications for treatment are discussed.

It’s worth noting that some of these factors predicting abstinence are enhanced by twelve step participation:

These models represented fairly stringent tests of the predictive power of the time varying variables, as they controlled for both baseline (i.e., early treatment) cocaine use and cocaine use status at the time the predictor variables were assessed. In analyses that included multiple time-varying predictors and baseline cocaine use, the variables that contributed independently to the prediction of transitions in cocaine use states were self-efficacy, self-help participation (for those who were currently using cocaine), commitment to abstinence, and self-help beliefs. Three of these four variables assessed self-help group related factors, which highlights the important role that self-help involvement and beliefs play in sustained recoveries in this population.

2012′s most popular posts #7 – K2, Spice and legalization

I do not consider myself a drug warrior. (Though, few people do these days. It can be a little like racism. People attribute it to others, but never themselves.) I oppose incarcerating people for possession of quantities consistent with personal use. I favor policies that target demand rather than supply. I’m also skeptical of hype around new drugs that are predicted to lead the the decline of western civilization.

There’s been a lot of talk about the evolving, softening public position on marijuana. We’re seeing more and more public discussion about straight up legalization of drugs, domestically and internationally. (Those NYT discussions should be so great, but they are nothing approaching great.)
Then you have K2/Spice. It’s been a few years since it’s appeared in Michigan and the reflex to ban it does appear to slowed.

However, this small scale experiment with tolerating a drug appears to be coming to an end.

I have a few observations:

  • I’ve been reluctant to buy into the hype and, to be sure, there has been hype. At the same time, many people have responded to the hype by arguing that it’s just a cannabis analog and is no more or less harmful than cannabis. I don’t know a lot about the drug, but anecdotal reports seem to suggest that it’s not just marijuana by another name. There appear to be as many negative Erowid reports as there are positive or neutral reports. And, many of them state that there are differences between K2 and marijuana.
  • I find the marriage of legal capitalism and the drug troubling. Local gas stations, smoke shops and party stores display dozens of varieties more prominently than anything else in the store. (This NORML post describes the marketing.) The packaging uses images like cartoons, ninjas, yoga and Bob Marley to market it. A lot of it looks like it could be candy packaging. (Ugh! I feel like such a geezer saying this, but some of it reminds me of Warheads packaging.)
  • There does not appear to have been an attempt to regulate the drug(s). Could this have worked? I don’t know. Regulation seems to do little to hamper the marketing of legal drugs. I’d still prefer a ban with less harsh criminal penalties. My sense is that, with the possible exception of marijuana, the public doesn’t have the stomach for legalization. I wonder if tide will turn on marijuana as marketing increases. Time will tell.
UPDATE: I wonder what would happen if is wasn’t banned. I’m guessing you’d start to see some large manufacturers get more market share, more wealth, more clout and market in a more organized and effective way.
On the flip side, I also wonder if these kinds of companies would end up enjoying the kind of immunity that alcohol manufacturers maintain. We have a special place in our culture of alcohol and guns. Tobacco lost this protected status. It’s hard to imagine these companies enjoying this status. As suppliers go corporate, they become a target for lawsuits and risk management becomes necessary. What kind of risk management would they employ and what kinds of marketing restraint or checks would the create? I dunno.

 

Gateway Theory Revisited

 

A small but elegant gate to a meadow path.
(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.”

 

 

 

GlaxoSmithKline’s corruption

GlaxoSmithKline
(Photo credit: Ian Wilson)

The details are simultaneously exactly what you’d expect and shocking.

And some people wonder why we’re reluctant to embrace the latest and greatest pharmacological fad. Keep all of this in mind next time someone suggests that medicalizing addiction treatment will improve professionalism, ethics and reliance on scientific evidence.

Sham advisory boards:

Glaxo also used sham advisory boards and speakers at lavish resorts to promote depression drug Wellbutrin as an option for weight loss and a remedy for sexual dysfunction and substance addiction, according to the government. Customers were urged to use higher-than-approved dosages, the government said.

Phony continuing education programs:

GSK paid millions to doctors to promote the drug off-label during meetings sometimes held at swanky resorts, the government said. The company relied on pharmaceutical sales reps, “sham advisory boards,” and continuing medical education programs that appeared independent but were not.

Misleading doctors:

The company went to extreme lengths to promote the drugs, such as distributing a misleading medical journal article and providing doctors with meals and spa treatments that amounted to illegal kickbacks, prosecutors said.

Bribing doctors:

“GSK’s sales force bribed physicians to prescribe GSK products using every imaginable form of high priced entertainment, from Hawaiian vacations to paying doctors millions of dollars to go on speaking tours to a European pheasant hunt to tickets to Madonna concerts, and this is just to name a few,” said Carmin M. Ortiz, U.S.attorney in Massachusetts.

Widespread:

Crimes and civil violations like those in the GlaxoSmithKline case have been widespread in the pharmaceutical industry and have produced a series of case with hefty fines. One reason some have said the industry regards the fines as simply a cost of doing business is because aggressively promoting drugs to doctors for uses not officially approved — including inducing other doctors to praise the drugs to colleagues at meetings — has quickly turned numerous drugs from mediocre sellers into blockbusters, with more than $1 billion in annual sales.

Stories have noted that Pfizer agreed to a $2.3 billion settlement in 2009. Also, Johnson & Johnson settled with Arkansas for $1.2 billion for several violations, including:

…for not disclosing the risks of the antipsychotic Risperdal.

Withholding data on Paxil:

GSK allegedly participated in the publishing of medical journal articles that stated paroxetine was effective in patients under 18, when, in fact, the data showed that the opposite was true. At the same time, the company withheld study data in from two other studies in which Paxil also failed to demonstrate efficacy in treating depression in patients under 18, according to a press release from the Justice Department.

Kept safety issues secret:

…the company kept secret data on raised cardiovascular effects.

Disease and choice

A NY Times philosophy blogger challenges the hijacked brain metaphor for addiction:

It might be tempting to claim that in an addiction scenario, the drugs or behaviors are the hijackers. However, those drugs and behaviors need to be done by the person herself (barring cases in which someone is given drugs and may be made chemically dependent). In the usual cases, an individual is the one putting chemicals into her body or engaging in certain behaviors in the hopes of getting high. This simply pushes the question back to whether a person can hijack herself.

There is a kind of intentionality to hijacking that clearly is absent in addiction. No one plans to become an addict.

My problem with this is that it assumes the hijacking occurs only after the first dose is consumed. AA insightfully broke the problem of loss of control into two parts, a physical allergy that causes loss of control once one takes the first drink and a mental obsession that leads to the first drink. She is only addressing the physical allergy. Of course, if the physical allergy were the only problem, jails and detoxes would be churning out recovered alcoholics and addicts.

She seems to operate from the premise that the addict is in control at the time of the first dose. But it’s a little like a person who is in full control who loves and craves strawberries with rare intensity but is allergic to them. AND, they have some sort of memory impairment that periodically interferes with their ability to recall the misery and danger of their allergic reaction and while the craving for strawberries is greatly intensified. Is that person in control?

Her solution is to reject the binary choice we’re so often presented with. It’s not choice or disease, it’s choice and disease.

A little logic is helpful here, since the “choice or disease” question rests on a false dilemma. This fallacy posits that only two options exist. Since there are only two options, they must be mutually exclusive. If we think, however, of addiction as involving both choice and disease, our outlook is likely to become more nuanced. For instance, the progression of many medical diseases is affected by the choices that individuals make. A patient who knows he has chronic obstructive pulmonary disease and refuses to wear a respirator or at least a mask while using noxious chemicals is making a choice that exacerbates his condition. A person who knows he meets the D.S.M.-IV criteria for chemical abuse, and that abuse is often the precursor to dependency, and still continues to use drugs, is making a choice, and thus bears responsibility for it.

Linking choice and responsibility is right in many ways, so long as we acknowledge that choice can be constrained in ways other than by force or overt coercion. There is no doubt that the choices of people progressing to addiction are constrained; compulsion and impulsiveness constrain choices. Many addicts will say that they choose to take that first drink or drug and that once they start they cannot stop. A classic binge drinker is a prime example; his choices are constrained with the first drink. He both has and does not have a choice. (That moment before the first drink or drug is what the philosopher Owen Flanagan describes as a “zone of control.”) But he still bears some degree of responsibility to others and to himself.

The complexity of each person’s experience with addiction should caution us to avoid false quandaries, like the one that requires us to define addiction as either disease or choice, and to adopt more nuanced conceptions. Addicts are neither hijackers nor victims. It is time to retire this analogy.

The concern I have is that she reduces addiction to being like any other chronic illness that may require difficult to make lifestyle changes, like diet and exercise.

The hijacked brain metaphor may be flawed, but it’s attempting to communicate that the addiction uses the addict’s own self-preservation instincts, desires and will to maintain addiction. For the active alcoholic who is sober at the moment and wishes to stay that way, it might be thought of as a struggle between a present self and a future self. He knows and fears that his future self will drink and will, once again, be off to the races. The question is who or what is in control of his future self’s taking of that drink?

K2, Spice and legalization

I do not consider myself a drug warrior. (Though, few people do these days. It can be a little like racism. People attribute it to others, but never themselves.) I oppose incarcerating people for possession of quantities consistent with personal use. I favor policies that target demand rather than supply. I’m also skeptical of hype around new drugs that are predicted to lead the the decline of western civilization.

There’s been a lot of talk about the evolving, softening public position on marijuana. We’re seeing more and more public discussion about straight up legalization of drugs, domestically and internationally. (Those NYT discussions should be so great, but they are nothing approaching great.)
Then you have K2/Spice. It’s been a few years since it’s appeared in Michigan and the reflex to ban it does appear to slowed.

However, this small scale experiment with tolerating a drug appears to be coming to an end.

I have a few observations:

  • I’ve been reluctant to buy into the hype and, to be sure, there has been hype. At the same time, many people have responded to the hype by arguing that it’s just a cannabis analog and is no more or less harmful than cannabis. I don’t know a lot about the drug, but anecdotal reports seem to suggest that it’s not just marijuana by another name. There appear to be as many negative Erowid reports as there are positive or neutral reports. And, many of them state that there are differences between K2 and marijuana.
  • I find the marriage of legal capitalism and the drug troubling. Local gas stations, smoke shops and party stores display dozens of varieties more prominently than anything else in the store. (This NORML post describes the marketing.) The packaging uses images like cartoons, ninjas, yoga and Bob Marley to market it. A lot of it looks like it could be candy packaging. (Ugh! I feel like such a geezer saying this, but some of it reminds me of Warheads packaging.)
  • There does not appear to have been an attempt to regulate the drug(s). Could this have worked? I don’t know. Regulation seems to do little to hamper the marketing of legal drugs. I’d still prefer a ban with less harsh criminal penalties. My sense is that, with the possible exception of marijuana, the public doesn’t have the stomach for legalization. I wonder if tide will turn on marijuana as marketing increases. Time will tell.
UPDATE: I wonder what would happen if is wasn’t banned. I’m guessing you’d start to see some large manufacturers get more market share, more wealth, more clout and market in a more organized and effective way.
On the flip side, I also wonder if these kinds of companies would end up enjoying the kind of immunity that alcohol manufacturers maintain. We have a special place in our culture of alcohol and guns. Tobacco lost this protected status. It’s hard to imagine these companies enjoying this status. As suppliers go corporate, they become a target for lawsuits and risk management becomes necessary. What kind of risk management would they employ and what kinds of marketing restraint or checks would the create? I dunno.