Sentences to ponder

My beautiful picture“The average person, understandably, doesn’t realize how careful scientific research has virtually wiped out skepticism of AA and twelve-step facilitation counseling among researchers. Many scientists — including me — were skeptical of AA 25 years ago, but a series of rigorous outcome studies supporting AA’s effectiveness changed our minds. Unlike in much of popular debate, within science it is generally accepted that if your beliefs don’t accord with the data, then it is your beliefs that must change.”

Keith Humphreys, Stanford Professor of Psychiatry, on the effectiveness of AA and Twelve Step Facilitation. He also wrote a Washington Post piece this weekend.

Strong evidence

Keith Humphreys directs us to a new paper by SMART Recovery UK in support of mutual aid groups in general. It’s well written and avoids sectarian arguments of 12 step vs. SMART.

Although there is an extensive body of research into Mutual Aid, most studies are methodologically weak, typically describing correlations without the ability to infer causation (see Appendix A). This has led some commentators to conclude that there is little or no evidence for this form of support. We conclude that this is an out-dated position. The increasing numbers of higher quality studies, along with extensive corroborative research supports more robust conclusions.

There is strong evidence that participation in Mutual Aid groups improves recovery outcomes and evidence that greater levels of participation are associated with better outcomes.

Non-Violent State Inmates Declining for 20 Years

From Keith Humphreys:

Prison is the subject of many myths in the public policy world. For example, many people believe that the size of the prison population has continued to rise under President Obama, when in fact it has fallen. Other observers maintain that prison populations drop during economic downturns, when in fact the reverse has generally been true. An even more widely embraced myth is that states have been increasingly incarcerating non-violent offenders. But as this chart from the Bureau of Justice Statistics (BJS) shows, the proportion of the state prison population that is serving time for a non-violent crime has been declining since the early 1990s.

I want to read more about this. I know that prison populations have been declining in recent years, but my impression was that they’ve grown considerably over 20 years and that violent crime is down. Those impressions may have been wrong, but if they are not, I want to see how you have shrinking violent crime, growing prison populations and declining non-violent prison populations.

I wonder if rolling in federal inmates would change the percentages much.


without someone like me!?!?!?

Keith Humphreys is pretty great in this interview:

Harold Pollack: I should say you’ve also done some research on AA [Alcoholics Anonymous]. I think some folks would be interested to know that, at least according to your research, AA is actually a pretty impressive intervention in some ways.

Keith: Yeah. I don’t mind people who are skeptical of AA, because when I first heard about it, I thought it sounded kind of hokey. I was in a medical school. I met an AA member, and I was like, “What do you do, exactly?” “We sit around in a room. We talk about spirituality and making amends.” I go, “This is run by a psychologist, a psychiatrist?” He goes, “No, no. There’s no one. It’s just alcoholics.” I, already getting socialized a little into the worst parts of professionalism, had a very dismissive response to that. “My god, without someone like me around, how could you possibly cope with anything?” It’s an attitude that is sadly in medicine, but, like I said, fortunately I wasn’t far enough along in my education that I was incapable of further learning. I was taken to open AA meetings, Cocaine Anonymous, and Narcotics Anonymous meetings in Detroit and in Western Michigan, where I was going to school. I thought, “This is pretty interesting.” I could see that my initial snobbery was not well-founded. It was later, when I started doing prospective studies with good measures and had done some work… with actual randomized clinical trials. Lo and behold, it comes out as well or better as do people like me, who have a lot letters after their name. I’m quite comfortable recommending AA to people as something they should try, as well the other…There are other self-help organizations. It’s incredibly easy to get to. It’s motivating. It’s more fun, I think, than [usual medical treatments]…There’s more friendship than you might get from psychotherapy, something like that. We are social creatures. All the evidence we have shows that social ties are good for health. That’s a way to quickly build up some social capital. I think in the long-term, it helps people not just with their drinking but also with things like friendship. Sometimes job-finding happens in AA, finding someone to marry, all that sort of stuff.

Humphrey’s professional humility stands in sharp contrast with this rant at Mark Willenbring’s blog.

Buried in the report, however, is the shocking statistic that a full 56.4% of the programs (publicly- or privately-funded) prescribed no medications whatsoever.

…while publicly-funded treatment programs were almost 14% less likely to prescribe buprenorphine, only 32.5% of all programs offered the medication. Only 20.6% of programs offered disulfiram, 27% offered tablet naltrexone, 27% offered acamprosate, and a slim 13.1% of programs offered injectable naltrexone….

These findings beg the question: why are evidence-based practices so rare and why is this tolerated in addiction treatment but not in other professional treatments? … When patients are not informed of the full array of treatment options, the lack of informed consent becomes an ethical – and likely legal – issue.

First off, why assume that the absence of meds means that evidence-based practices are absent? (There are lots of non-pharmacological evidence-based practices. )

Secondly, Mark Willenbring himself said:

Occasionally I see patients who have been prescribed acamprosate (Campral) for their alcohol dependence. Campral is the med most likely to be prescribed by general psychiatrists because it was marketed to them. In the US, physicians tend to rely on pharmaceutical representatives too much, as opposed to reading the scientific literature themselves. Unfortunately, I don’t think Campral works. Although a few of the first studies showed very strong effects subsequent studies have not. There now have been three large multi-site studies that have shown no effect of acamprosate, including one in Germany. (There had been speculation that acamprosate worked there because people drank more and they had a month of abstinence in the hospital before starting the drug.)


This is your culture on pot

Medical Cannabis Growing Operation in Oakland,...
(Photo credit: Blazenhoff)

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

First, Humphreys:

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

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

But, he argues price would likely drop and …

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

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

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

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

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

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

At what cost? By what right?

Image via Wikipedia

Why I’m drawn to and repelled by Megan McArdle:

…no policy question is ever as simple as “How can we stop X”, unless “X” is an imminent Nazi invasion.  We also have to ask “at what cost?” and “by what right?”

She’s so smart, but can frequently appears to be blind to her own bias and pretty dismissive of others.

“At what cost?” and “by what right?” are exactly the kinds of questions that should be discussed when wrestling with responses to drug problems.

We also need to identify, examine and discuss our assumptions and our values. Only then can we begin to discern the proper perspective on the problem (avoiding drug panic), the costs (the discomfort of sinus congestion) and the rights involved.

PROMETA ineffective…duh

Clark Stanley's Snake Oil Liniment. Before 1920.
Image via Wikipedia

PROMETA as been demonstrated to be the sham we all knew it was.

Keith Humphreys offers a brief history of the “treatment” and some lessons:

  1. …when the next wonder drug for addiction comes along (and it will), we must not yield to our powerful collective desire to believe before we have hard evidence of effectiveness from disinterested, respected sources. The simpler, faster and more miraculous-seeming the cure, the greater should be our skepticism.
  2. There is a worrisome vulnerability in the US FDA’s new drug approval process. As was the case with another would-be ‘miracle cure’—ultra-rapid opiate-detoxification—a manufacturer was able to market an untested treatment protocol to addicted patients because the components of the treatment protocol had been previously FDA-approved for the treatment of other disorders.
  3. Independent scientific research on addiction is essential for public health and safety.

If only it was easier to know what research and perspectives are independent and disinterested.