a “selfish” and “untrusted” professional attitude*

b547Bankole Johnson, who was featured in HBO’s Addiction documentary touting the use of Topiramate and wrote an anti-treatment screed years ago (my response here), has left his post after losing a whistleblower lawsuit.

A University of Virginia department chairman nationally known for his addiction research has resigned less than 10 months after a subordinate won an $820,000 whistleblower lawsuit filed against the school, officials said Friday.

Featured in the 2007 HBO documentary “Addiction,” Johnson is known for his advocacy of medication, rather than 12-step programs or rehabilitation, to treat addiction.

He was named in a lawsuit filed in 2011 by Weihua Huang, a UVa researcher who lost his job after charging that his supervisor altered a grant awarded him by the National Institutes of Health.

Huang claimed Johnson fired him after he reported that Ming Li, a scientist who works in the university’s Center for Addiction Research and Education, misrepresented the amount of time each researcher was spending on a project. The time spent on projects determines how much money each researcher is paid.

Johnson is leaving for a post at the University of Maryland Medical Center.

In short, it appears that Huang reported that the Ming Li and the University of Virginia’s Center for Addiction Research and Education were charging NIH for research that was not performed and was terminated by Johnson for reporting this fraud and had his character assassinated in the process.

Apparently, Johnson also works with Li at ADial Pharmaceuticals and had to declare a conflict of interest for research related to Topiramate:

Earlier this year, Johnson declared a potential conflict of interest in one of his research projects. That led the NIH to put a temporary hold on funding for the work until UVa could come up with an oversight plan, officials said.

“The idea here … is to ensure that whatever the outcome is, it’s based on science and research,” Eric Swensen, a spokesman for the UVa Health System, said when asked about the issue earlier this week.

Johnson cited the potential conflict involving his company, ADial Pharmaceuticals, located in the UVa Research Park off Fontaine Avenue in Charlottesville. ADial’s website lists Li on the company’s seven-member Board of Directors, headed by Johnson as CEO.

The project cited in the potential conflict seeks to examine the effects of Topiramate on people with different genetic makeups, Swensen said. According to ADial’s website, the company is developing two drugs to help treat alcoholism. Topiramate is listed as an ingredient in one of the drugs.

Titled “Pharmacogenetic Treatments for Alcoholism,” the project received $543,690 in NIH funding in 2012. It was supposed to receive $417,578 by the end of this year.

Interestingly, Johnson’s interest is ADial is not new—he founded the company in 2007. And, ADial’s investment in Topiramate is not new—they’ve been working on drugs with Topiramate since at least 2008.

 

* These are the words Ming Li used to describe Weihua Huang to justify his termination

Buprenorphine and emotional reactivity

The following article was shared with me by a reader. Not surprisingly, the emphasized portion below caught my eye. [emphasis mine]

Abstract

Addictions to illicit drugs are among the nation’s most critical public health and societal problems. The current opioid prescription epidemic and the need for buprenorphine/naloxone (Suboxone®; SUBX) as an opioid maintenance substance, and its growing street diversion provided impetus to determine affective states (“true ground emotionality”) in long-term SUBX patients. Toward the goal of effective monitoring, we utilized emotion-detection in speech as a measure of “true” emotionality in 36 SUBX patients compared to 44 individuals from the general population (GP) and 33 members of Alcoholics Anonymous (AA). Other less objective studies have investigated emotional reactivity of heroin, methadone and opioid abstinent patients. These studies indicate that current opioid users have abnormal emotional experience, characterized by heightened response to unpleasant stimuli and blunted response to pleasant stimuli. However, this is the first study to our knowledge to evaluate “true ground” emotionality in long-term buprenorphine/naloxone combination (Suboxone™). We found in long-term SUBX patients a significantly flat affect (p<0.01), and they had less self-awareness of being happy, sad, and anxious compared to both the GP and AA groups. We caution definitive interpretation of these seemingly important results until we compare the emotional reactivity of an opioid abstinent control using automatic detection in speech. These findings encourage continued research strategies in SUBX patients to target the specific brain regions responsible for relapse prevention of opioid addiction.

I started out skeptical of the methods and researchers, but, from what I can tell, the methods don’t seem to be fringe pseudoscience.

I don’t know what to make of the associations of Blum, it looks like he was involved in very important research on the genetics of alcoholism in 1990. Since then, it looks like he’s been involved in a lot of entrepreneurial ventures. Bios say that he’s on faculty at Department of Psychiatry and McKnight Brain Institute, but I could find no reference to him on  their website.

Berman appears to have a robust academic career and is affiliated with NIAAA, VA, Boston University and ATTC.

The article was also peer reviewed.

What do you think?

 

“No” to rehab?

Alcoholism 01
Alcoholism 01 (Photo credit: Wikipedia)

I was asked by a friend to comment on this article.

Here’s the response I sent him:

Well, he’s got a point. But he’s also gotten a lot wrong, including the name of the NIAAA. It’s National Institute on Alcohol Abuse and Alcohol-ism.
What he’s right about is that not everyone who has an alcohol problem needs or should receive treatment. And, surveys of looking at the prevalence and course of alcoholism and addiction find that large numbers of people experience “natural recovery”, “maturing out” or “spontaneous remission”. Some abstain and others moderate.

He interprets these findings as meaning that anyone who chooses to quit, can.

My interpretation of the findings are that “alcohol dependence” does not equal alcoholism and that conflating the two produces a lot of false positives for alcoholism. The NIAAA article says:

In most persons affected, alcohol dependence (commonly known as alcoholism) looks less like Nicolas Cage in Leaving Las Vegas than it does your party-hardy college roommate or that hard-driving colleague in the next cubicle.

Large numbers of college students meet criteria for dependence but will moderate or quit once they graduate, start careers and form families.

We have the same problem in studies of “recovery”: http://wp.me/p1n5A8-2Em

It’s a lot like the stories of Vietnam veteran spontaneous recoveries from heroin addiction: http://wp.me/p1n5A8-1SO

We also know that lots of alcoholics recover without treatment. (Jim and I did.) Whether your an alcoholic or a heavy drinker, you’re more likely to successfully resolve your problem if you have a lot of recovery capital. His 7 things address a lot of recovery capital domains.

I’m a fan of motivational interviewing, we train staff in it (Though I see it as a tool rather than a solution.) and I agree that a confrontive style is both ineffective and unethical. However, studies don’t find it to be more effective than other approaches. Just this week, a study was published that found few differences between MET (based on motivational interviewing) and counseling-as-usual: http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/a0017045

Prescription drug overdose statistics visually

drug_overdose

Popular Science has a chart with US overdose deaths by drug:

…the rate of reported overdoses the U.S. more than doubled between 1999 and 2010. About half of those additional deaths are in the pharmaceuticals category, which the CDC has written about before. Nearly three-quarters of the pharmaceuticals deaths are opioid analgesics—prescription painkillers like OxyContin and Vicodin. And while cocaine, heroin and alcohol are all responsible for enough deaths to warrant their own stripes on the chart, many popular illegal drugs—including marijuana and LSD—are such a tiny blip as to be invisible.

A recently published study confirms the relationship between prescription opioid sales and opioid overdoses.

And, SAMHSA reports on the growing role of prescription opioids in treating opioid addiction.

  • …the number of clients receiving methadone on the survey reference date increased from about 227,000 in 2003 to over 306,000 in 2011
  • The percentage of OTPs offering buprenorphine increased from 11 percent in 2003 to 51 percent in 2011; the percentage of facilities without OTPs offering buprenorphine increased from 5 percent in 2003 to 17 percent in 2011
  • The numbers of clients receiving buprenorphine on the survey reference date increased between 2004 and 2011: at OTPs, from 727 clients in 2004 to 7,020 clients in 2011, and at facilities without OTPs, from 1,670 clients in 2004 to 25,656 clients in 2011

Balancing pain management and public health

Advertisement for curing morphine addictions f...
Advertisement for curing morphine addictions from Overland Monthly, January 1900 (Photo credit: Wikipedia)

I blogged before about the availability of opiates for pain management and the need to try to limit their diversion. While others have complained about draconian limitations on the prescribing of opiates and being too afraid to treat pain, I pointed out the explosion in opiate prescriptions and overdoses. It’s a complex problem that demands a solution that balances the needs of pain patients with the public health risks of easily available opiates.

Here’s a new study looking at the issue [emphasis mine]:

While overdose death rates related to heroin, cocaine, sedative hypnotics, and psychostimulants increased between 1999 and 2009, deaths related to pharmaceutical opioids increased most dramatically, nearly 4-fold. In 2000, the Joint Commission on the Accreditation of Health Care Organizations introduced new standards for pain management which focused on increased awareness of patient’s right to pain relief which contributed to an increase in prescribing of opioid analgesics (Phillips, 2000 and Federation of State Medical Boards of the US, 1998). The average milligrams of morphine prescribed per patient per year increased more than 600% from 1997 to 2007, which led to an increased availability of pharmaceutical opioids for illicit use (US Department of Justice, 2012). From 1999 to 2007, substance abuse treatment admissions for pharmaceutical opioid abuse increased nearly 4-fold and emergency department visit rates related to pharmaceutical opioids increased 111% from 2004 to 2008; visit rates were highest for oxycodone, hydrocodone, and methadone (SAMHSA, 2009aSAMHSA, 2009b and SAMHSA, 2011). Risks associated with pharmaceutical opioid related overdose included taking high daily doses of opioids and seeking care from multiple healthcare providers to obtain many prescriptions (Paulozzi et al., 2012 and Hall et al., 2008). “Doctor shopping” has also been associated with opioid diversion and illicit use (SAMHSA, 2010 and Rigg et al., 2012). National survey data showed that 75% of pharmaceutical opioid users were using opioids prescribed to someone else (Substance Abuse and Mental Health Services Administration, 2010).

Diagnosing ADHD in detox?

fear_false_evidence_appearing_realUnreal. Someone’s got an awful lot of faith in their diagnostic skills. Diagnosing ADHD with addicts in a detox unit? Really?

And, now that it’s published, it’s “evidence”.

Rates of undiagnosed attention deficit hyperactivity disorder in London drug and alcohol detoxification units

Background

ADHD is a common childhood onset mental health disorder that persists into adulthood in two-thirds of cases. One of the most prevalent and impairing comorbidities of ADHD in adults are substance use disorders. We estimate rates of ADHD in patients with substance abuse disorders and delineate impairment in the co-morbid group.

Method

Screening for ADHD followed by a research diagnostic interview in people attending in-patient drug and alcohol detoxification units.

Results

We estimated prevalence of undiagnosed ADHD within substance use disorder in-patients in South London around 12%. Those individuals with substance use disorders and ADHD had significantly higher self-rated impairments across several domains of daily life; and higher rates of substance abuse and alcohol consumption, suicide attempts, and depression recorded in their case records.

Conclusions

This study demonstrates the high rates of untreated ADHD within substance use disorder populations and the association of ADHD in such patients with greater levels of impairment. These are likely to be a source of additional impairment to patients and represent an increased burden on clinical services.

Intellectual conflicts of interest

DSM_5_2Allen Frances, Chair of the DSM-IV Task Force lets loose on the DSM-5. He acknowledges the noxious effects of professional interests on research and practice in a way that is rarely seen from leaders of his stature. [emphasis mine]

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense.

The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their’s is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

More evidence for 12-step approaches

photo credit: Jeff Tabaco

Another study finding the 12-step involvement is associated with continuous abstinence:

Abstract

A longitudinal analysis of 12-step involvement was conducted among a U.S. sample of patients exiting treatment for substance dependence. Categorical involvement in a set of 12-step activities and summary scores of involvement from the Alcoholics Anonymous Affiliation Scale were examined in relation to continuous abstinence and aftercare (Oxford House or usual care) condition. Participants who were categorically involved in 12-step activities were significantly more likely to maintain continuous abstinence at 2 years compared with those who were less involved, predicting a greater likelihood of complete abstinence than summary scores of involvement. In addition, participants in the Oxford House condition were significantly more likely to remain continuously abstinent throughout the course of this randomized clinical trial. Findings suggest that categorical involvement in a set of 12-step activities and communal-living settings such as Oxford Houses are independent factors associated with continuous abstinence from both alcohol and illicit drugs among substance dependent persons.

In case you’re wondering what “categorical 12-step involvment is, here’s the definition:

Categorical 12-step involvement is a term used to indicate simultaneous involvement in several 12-step activities

 

 

Motivational Interviewing works, but no better than other treatments

Cochrane conducts a meta-analysis of motivational interviewing (MI) and concludes that it’s no more effective than other treatments.

More than 76 million people worldwide have alcohol problems, and another 15 million have drug problems. Motivational interviewing (MI) is a psychological treatment that aims to help people cut down or stop using drugs and alcohol. The drug abuser and counsellor typically meet between one and four times for about one hour each time. The counsellor expresses that he or she understands how the clients feel about their problem and supports the clients in making their own decisions. He or she does not try to convince the client to change anything, but discusses with the client possible consequences of changing or staying the same. Finally, they discuss the clients’ goals and where they are today relative to these goals. We searched for studies that had included people with alcohol or drug problems and that had divided them by chance into MI or a control group that either received nothing or some other treatment. We included only studies that had checked video or sound recordings of the therapies in order to be certain that what was given really was MI. The results in this review are based on 59 studies. The results show that people who have received MI have reduced their use of substances more than people who have not received any treatment. However, it seems that other active treatments, treatment as usual and being assessed and receiving feedback can be as effective as motivational interviewing. There was not enough data to conclude about the effects of MI on retention in treatment, readiness to change, or repeat convictions.The quality of the research forces us to be careful about our conclusions, and new research may change them.

This is a great example of a major flaw in research. There are so many assumptions in every study. One wrong assumption can lead to bad findings. For example, that motivational interviewing is an especially effective and sufficient intervention to treat alcoholism.

MI is being integrated into treatment for all sorts of medical problems, chronic health problems in particular, where part of treatment is recruiting the patient into participating in a treatment that is known to be effective but often suffers from low rates of patient compliance.

The difference here is that researchers seem to be interested in replacing existing treatments for addiction with MI.

One big problem here is that this inserts the assumption that alcoholism is resolved be increasing motivation to quit or reduce drinking.

I believe that these assumptions may be correct for low severity alcohol problems and that MI may be an effective intervention for these problems.

I also believe that MI is probably a valuable tool for more severe alcohol problems, but, in these cases, its proper use is to get patients to accept and participate in treatments that are known to be effective when patients comply. Twelve step facilitation, for example.

Why is there this push for MI as a replacement treatment rather than a treatment inducement tool? Does this constitute a bias on the part of researchers? I don’t know, but note that I’m not the one tossing out the baby with the bath water. I’m suggesting MI might be very important but that they are just asking the wrong questions. It’s also a little ironic that the push to use MI to replace other treatments actually weakens the case for MI having an important role in treating alcoholism.

Changes in brain gray matter in abstinent heroin addicts

English: Middle frontal gyrus. 日本語: 中前頭回。前頭葉にあ...
English: Middle frontal gyrus. (Photo credit: Wikipedia)

A few years ago, Bill White called for research on the neurobiology of recovery. (He noted that all of our research efforts have been focused on understanding addiction without any research on understanding recovery.)

Well, some Chinese researchers have made a contribution. Good news for heroin addicts.

Background

Previous neuroimaging studies have documented changes in the brain of heroin addicts. However, few researches have detailed whether such changes can be amended after short-term abstinence.

Methods

We used magnetic resonance imaging (MRI) to investigate gray matter volume in 20 heroin-dependent patients at 3 days and at 1 month after heroin abstinence; 20 normal subjects were also included as controls.

Results

Decreased gray matter density in frontal cortex, cingulate and the occipital regions were found in heroin users after three days of abstinence. In contrast, after 1-month abstinence, no significant difference was found in superior frontal gyrus between heroin addicts and controls, but changes in other brain regions, including right middle frontal gyrus, left cingulate gyrus and left inferior occipital gyrus, still remained.

Conclusion

Our findings illustrate that abnormal gray matter in some brain regions of heroin addicts can return to normal after one-month abstinence.