America Anonymous—Book Review

Sex, drugs, and shoplifting.

New York Times magazine contributor Benoit Denizet-Lewis interweaves eight personal stories of addiction and obsession and ties them in with a well-researched summary of the drug treatment business in his new book, America Anonymous. Offering deft portraits of people suffering from various forms of addiction and compulsion, Denizet-Lewis brings to life much of the denial, prevarication, giddy hopes of victory, incomprehensible relapses, and endless stream of lies and broken promises with which so many active addicts string together their fractured narratives.

By design, Denizet-Lewis swings wide when it comes to defining addiction. In addition to alcoholics and drug addicts, the author, a self-confessed sex addict, includes in his case histories a woman who is a serial shoplifter, a body builder addicted to steroids, a fifty year-old compulsive eater, and a college student addicted to pornography.

“I believe in an expanded understanding of addiction, “ Denizet-Lewis writes. “That is, I believe that gambling, sex, food, spending, and work (to name a few) can, for some people be as addictive and debilitating as an addiction to drugs.”

While I am not as convinced as the author that the scientific evidence is beginning to weigh heavily on the side of accepting behavioral compulsions as classic addictions, I can only agree when he points out that, for all the heady buzz about addiction medicine and pills for alcoholism, 12 Step programs—which originated more than 50 years ago--still arguably represent the most effective approach to treating addiction that we know of. In addition, Denizet-Lewis writes, doctors and clinicians have been promising medical treatments for addiction for 200 years now, and only in the last ten years or so has there been any real progress.

Point taken. The author basically accepts that addictions are chronic diseases with genetic components, “and an onset and course that vary depending on behavior and environmental factors.” Scientific information is presented accurately and in an understandable fashion. Denizet-Lewis knows his subject, even if he uses that data to reach different conclusions than I do. I liked this book, even though I am at odds with many of its arguments.

So, what do Denizet-Lewis’s people teach us about addiction? The crucial need for honesty, to begin with. “If we’re not rigorously honest,” one addict says, “we can’t recover. It’s impossible.” This rule applies to the healers as well. The author quotes one researcher succinctly: “I would distrust anyone who says they can cure addiction.” This sentence alone, if absorbed by addicts seeking treatment, could save them considerable time, money and self-esteem. The author also quotes addiction researcher Anna Rose Childress to good effect: “Relapse is not a failure of treatment. Relapse is part of the disorder.”

What runs through all the personal sagas is the desire of the subjects to feel normal—to “feel feelings” in a normal way. The author offers compelling narratives that catch the flavor of the addicted way of life, a combination of monotony, mood swings, and fear. Denizet-Lewis is particularly adept at making us care about what happens to these people, and we read the book with a hopefulness laced with dread. We know it cannot end happily for everyone. And it does not.

In the end, the author concludes that most forms of addiction can be accounted for by the childhood trauma model. Since a good deal of sex therapy centers on this conception, perhaps the author’s conclusions in this regard are not surprising. However, trauma theories about the origin of addiction have not translated into reliable and effective treatments for addiction, either. And such theories have had a long run, starting even before Freud.

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"Mood Foods"

Why addicts crave sugar and starch.

James Langton of Clearhead.org.uk recently sent me a fascinating article about food and addiction. The technical bulletin from Sure Screen Diagnostics, Ltd., the U.K.'s leading provider of medical and drug testing services, focuses on the age-old and endlessly fascinating connection between addiction and sugar foods (See my post, “Drug Foods and Addiction”).

Entitled "Mood food and Addiction," the technical bulletin asserts that "drug users, alcoholics and those with addictive tendencies routinely resort to certain psychoactive foods between fixes to regulate their mood." Moreover, "certain foods might reduce withdrawal symptoms... the pantry is a veritable 'psychodelicatessen.'"

While some of the conclusions are highly speculative, most of the article is on more solid ground in its discussion of the "psychopharmacology of everyday foods."

Sweet foods and fruits can mitigate or eliminate cravings, the author says, and examples of this are abundant in the addict and treatment communities. Abstinent cigarette smokers sometimes find that "a piece of fruit or something sweet" can banish cravings by temporarily and partially restoring dopamine and serotonin levels.

In an unconscious effort to raise brain levels of serotonin and dopamine, drug users often discover that doughnuts, cakes, ice cream, soft drinks, and other sugar foods can lessen withdrawal symptoms. As evidence, we are far more likely "to see a user with a bar of chocolate in his hand than a sausage roll."

Complex carbohydrates, the bulletin asserts, do not have the same effect. Whole grain breads and starchy vegetables, unlike table sugar and white bread, do not have the same reinforcing impact on neurotransmitters along the reward pathway. "For that reason, they do not tend to be craved as much as sweets, even though they still satisfy [serotonin] 5-HT needs." Because simple sugars eaten in large quantities can cause blood sugar levels to drop below baseline, the result can be the abrupt return of drug withdrawal symptoms.

How does this work out in practice? The bulletin speculates, for instance, that “a amphetamine user who has exhausted his dopamine and noradrenaline levels, and feels depressed and unable to think straight, may be drawn to high-protein, tyramine-rich foods, such as a steak, pizza or a cheese sandwich and a glass of milk. An MDMA or "ecstasy" user experiencing fatigue... would probably crave something like fish and chips rich in carbohydrates, and a sugar-rich drink to temporarily bring the depleted 5-HT levels back up to normal." As for opiate users, foods such as whole milk, ice cream, and milk chocolate are appealing because they contain "biologically active opioid peptides.... It no doubt explains why a pint of full fat milk and a Snicker's bar is a perennial snacking favourite of opiate users."

As for chocolate (you didn’t think I’d forget chocolate, did you?), “the most widely preferred chocolate among the general population is not unsweetened dark chocolate with its higher drug cocktail, but sweetened milk chocolate suggesting that the majority of us may in fact be craving its addictive psychoactive sugars, fats and narcotic casomorphins more than anything else.”

In the end, the specific food preferences of addicts force us “to reconsider how fragile the food-drug distinction actually is.”

Graphic Credit: Anselm

dopamine

Obama’s Emerging Drug Program

President to lift ban on needle exchanges.

While reformers are far from pleased with the initial rollout of President Obama’s drug policy agenda, treatment activists can at least point to a significant change in the federal stance on clean needle exchange programs. Unlike former President Bush, who supported a ban on federal funding of such public health programs, Obama’s agenda, as spelled out at Whitehouse.gov, calls for rescinding the ban in an effort to save lives by reducing the transmission of HIV/AIDS. "The President," according to the agenda, "supports lifting the federal ban on needle exchange, which could dramatically reduce rates of infection among drug users."

Opponents of needle exchange say the effort is similar to the medical marijuana movement—a stealth strategy for the legalization of drugs. However, as I wrote in an earlier post, the administration’s support of needle exchange is a timely recognition that cities like Vancouver and San Francisco are already experimenting with the notion of safe drug injection sites. (Part of the argument in favor of such sites is the opportunity for clean needle exchanges.)

Under the heading “Civil Rights,” the White House web site has also signaled support for the expanded use of drug courts to allow non-violent offenders into “the type of drug rehabilitation programs that have proven to work better than a prison term in changing bad behavior.” The agenda also calls for the reduction of sentencing inequities (“President Obama and Vice President Biden believe the disparity between sentencing crack and powder-based cocaine is wrong and should be completely eliminated”).

An article in Drug War Chronicle notes that “reformers may find themselves pleased with some Obama positions, but they will be less happy with others. The Obama administration wants to reduce inequities in the criminal justice system, but it is also taking thoroughly conventional positions on other drug policy issues.”

To wit, marijuana. Activists were hoping for a clear demonstration of support for the use of medical marijuana. So far, that hasn’t happened. Marijuana is not mentioned at all in the relevant sections of the online policy agenda, though the document is known to be a work in progress.

Nonetheless, it might be well to heed the advice offered by the U.K.’s Transform Drug Policy Foundation: “Lifting the disgraceful needle exchange funding ban is a good start considering we are only in day one—and the generally pragmatic tone bodes well. Can we be cautiously optimistic? Yes we can.”

Graphics Credit: Pharmacy Exchange

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America’s Top Drug Cities

And the winner is.... Espanola, N.M.?

Forbes Magazine, in an  article by Nathan Vardi last year, listed what it calls “The Drug Capitals of America.”

Using data from the Drug Enforcement Administration (DEA) and the Substance Abuse & Mental Health Services Administration (SAMSHA)--two not-always-terribly-reliable federal agencies--Forbes announced that the small agricultural community of Española, with a population of about 10,000 Hispanics and a high poverty rate, consistently leads the nation in drug overdoses per capita. “Española recorded 42.5 drug-related deaths per 100,000, compared with a national average of 7.3,” Forbes reports.

Not unaware of the problem, the New Mexico state government has begun a program of distributing Narcan, the overdose-reversing drug, and now grants immunity from prosecution for those who seek help for an overdose victim, Forbes reports.

Coming in for special consideration this year is Missoula, Montana, which SAMSHA claims has the highest rate of illicit drug use in the nation. According to the survey, “averages taken in 2004, 2005 and 2006 showed 13.8% of households polled in the Missoula region reported using illicit drugs in the last month.” The state has recently been in the throes of a mammoth methedrine epidemic, say the drug agencies, with as many as 50 per cent of the state’s prisoners now incarcerated for meth-related crimes.

Washington, D.C. held on to its well-earned reputation as a cocaine hub, with SAMSHA reporting that the 2nd Ward in the nation’s capital “had the highest rate of cocaine use of any area it polled in the nation.” The city racked up 75 cocaine overdoses in 2006.

Baltimore, for its part, has run up staggering numbers of heroin-related overdoses. "Baltimore is home to higher numbers of heroin addicts and heroin-related crime than almost any other city in the nation," says the Drug Enforcement Administration.

New Orleans, now leading the nation in murder rates, has seen new drug turf wars. Says Forbes: “At 95 murders per 100,000 people, New Orleans led the nation in killings by a wide margin in 2007.”

And finally, let us not forget San Francisco, home of the highest rate of illegal drug-related emergency room visits in the nation. SAMSHA’s survey estimated that there were 809 illicit drug-related emergency room visits per 100,000 in the San Francisco area. “Heroin remains the No. 1 abused drug in San Francisco, while heroin and crack cocaine continue to impact Oakland, says the DEA.”

As a footnote, look for Atlanta to score heavily in next year’s survey. Drug-related crimes are on the increase, and Forbes suggests that “Atlanta has become the East Coast distribution hub of the violent Mexican cartels that now dominate the drug trade.”

Drug Addiction Goes Untreated in Prison

Only 20% of addicted inmates get rehab.

Among the many ironies of the American War on Drugs, the situation of drug abusers in prison ranks high on the list. Despite decades of research showing that drug treatment can be effective, the federal government has failed to offer it consistently, on demand, for prisoners who need rehabilitation. The National Institute on Drug Abuse estimates that only one-fifth of inmates needing formal treatment are able to get it.

Why aren’t imprisoned drug addicts getting treatment, instead of ready access to a continuing supply of whatever they are addicted to? “Addiction is a stigmatized disease that the criminal justice system often fails to view as a medical condition,” says the report’s lead author, Dr. Redonna K. Chandler, chief of NIDA’s Services Research Branch. “As a consequence, its treatment is not as available as it is for other medical conditions.”

The report, published in the Journal of the American Medical Association (JAMA) found that roughly half of all prisoners suffer some degree of drug dependency. “Treating drug abusing offenders improves public health and safety,” asserts co-author and NIDA director Dr. Nora D. Volkow, citing increased risk of infectious diseases like HIV and hepatitis C among addicts. “Providing drug abusers with treatment also makes it less likely that these abusers will return to the criminal justice system.”

While the high cost of treatment is often cited as a reason for its general absence from the prison infrastructure, Chandler says the cost benefits of treating drug-involved offenders is obvious: “A dollar spent on drug courts saves about $4 in avoided costs of incarceration and health care; and prison-based treatment saves between $2 and $6.”

Adds Volkow: “Viewing addiction as a disease does not remove the responsibility of the individual. It highlights the responsibility of the addicted person to get drug treatment and society’s responsibility to make treatment available.”

Photo Credit: www.thecyncom

Addiction Research Highlights

Clinical studies in 2008.

Alcohol, Other Drugs, and Health: Current Evidence—a free online newsletter from the Boston Medical Center—offers summaries of relevant clinical research on drugs of abuse and related drug issues.

In the November-December 2008 issue, the editors present “a comprehensive guide to all the clinically relevant research articles published by the newsletter in 2008.”

Herewith, a brief sampling:

Topiramate Reduces Drinking in Adults With Alcohol Dependence

“Topiramate may decrease alcohol consumption among people with alcohol dependence by reducing the release of dopamine.”

Treatment for Alcohol Withdrawal Is Poor Despite Proven Therapies

“Evidence-based practice guidelines are clear that patients at risk for alcohol withdrawal should be monitored and treated with benzodiazepines if the risk is high enough or symptoms are substantial.”

Oral Naltrexone Decreases Use and Extends Time to Relapse in Amphetamine Dependent Patients

“Currently, no medications are FDA-approved to treat amphetamine dependence. Naltrexone, an opioid antagonist, has shown efficacy in reducing relapse among subjects with opioid or alcohol dependence.”

Alcohol Counseling Can Reduce Blood Pressure

“Unhealthy alcohol use is associated with hypertension. Two recent articles examined whether reductions in drinking can decrease blood pressure among hypertensive heavy drinkers.”

Levetiracetam (Keppra) Shows Promise in Treating Alcohol Dependence

“Anticonvulsants have shown promise as pharmacologic agents in the treatment of alcohol dependence, although none are yet approved by the Food and Drug Administration for this indication.”

Are Myocardial Infarction Survivors Who Smoke Marijuana at Higher Risk of Death?

“Although a previous study demonstrated an increased risk of myocardial infarction (MI) within 1hour of smoking marijuana compared with periods of nonuse, the net impact of marijuana use on mortality has not been established.”

American Heart Association Releases Guidelines on Treatment of Cocaine-Associated Chest Pain

“There are approximately 500,000 cocaine-associated emergency department visits annually, and it is estimated that 40% involve chest pain.”

Opioid Maintenance Therapy Saves Lives

“Opioid-dependent patients are 13 times more likely to die than their age- and sex-matched peers in the general population.”

Bupropion Added to Nicotine Replacement for Patients in Alcohol Treatment

“The effectiveness of bupropion, an antidepressant approved for smoking cessation in the general population, has not been studied in people being treated for alcoholism.”


Photo Credit: Brief-TSF.com

Safe Drug Injection Sites

Will San Francisco follow Vancouver’s lead?

San Francisco is on the brink of agreeing to open what would officially be the nation’s first medically supervised injection facility for addicts--despite mixed feelings about the program in the Bay Area.

The Safer Injection Facility is likely to be located in San Francisco’s Tenderloin District, where drug abuse is rampant. If it moves forward, the site will be modeled after an equally controversial Canadian program, the Insite injection facility, established in Vancouver in 2003.

“None of us want to shoot out here in front of kids,” a homeless drug user told the Oakland Tribune. “If we had a place to shoot, then we’d also have a place to put our dirty needles, which is a problem out there.” However, there has been considerable community resistance to the idea, say police, with more affluent areas declaring, in essence, “not in my neighborhood.”

The Harm Reduction Coalition (HRC) maintains that the Vancouver safe injection facility has resulted in fewer fatal overdoses, lower disease rates, and more addicts in recovery. HRC defines Safe Injection Facilities as “legally protected places where drug users consume pre-obtained drugs in a non-judgmental environment and receive health care, counseling, and referrals to other health and social services, including drug treatment.

In San Francisco, an injection facility has been an idea in search of a political sponsor for some time. Moreover, advocates can expect no help whatsoever from the federal government. Last year, the Office of National Drug Control Policy said it found preliminary plans for a safe injection site “disconcerting” and called it “poor public policy." An AP/Google report from last year reported that overdoses from injected drugs represented one of every seven emergency calls handled by paramedics in San Francisco.

Last year, Sarah Evans of Vancouver’s Insite center, told the San Francisco Chronicle: “The evidence is really clear that we’re achieving our goals for the users and the community. The more you look into it, the more you realize it’s crazy not to do it.” Not all Canadian politicians agree, however, even though the majority of physicians in the Canadian Medical Association appear to support safe injection sites. Recently, as reported in the Drug War Chronicle, Canadian Health Minister Tony Clement said he would question the ethics of doctors who support the use of safe injection sites for drug addicts.

HRC’s petition for a safer injection facility in San Francisco can be found online at Democracy in Action.


Photo Credit: Inky Circus

States Unleash New Ignition Lock Laws

The brave new world of DUI enforcement.

Starting this month, drivers convicted of driving while intoxicated in at least six new states will face a hi-tech hurdle to repeat offenses: ignition interlocks. After a high profile national campaign, Mothers Against Drunk Driving and other organizations convinced several state legislatures to pass laws mandating the dashboard installation of small ignition interlock device activated by a breathalyzer.

“It’s amazingly inconvenient, “ David Malham of the Illinois MADD group told Associated Press. “But the flip side of the inconvenience is death.”

Will high technology really help keep drunk drivers off the streets and highways? Malham, quoted in the Chicago Tribune, insisted that “it’s not about changing human nature, it’s about science interfering and preventing reckless behavior.” Maltham also said he is looking forward to technology that will be able to sniff a car’s interior, scan the eyes of drivers, and test sweat on the steering wheel before allowing the driver to turn the key.

In addition to Illinois, states that passed laws requiring the use of ignition locks for drunken driving convictions of varying degrees include Nebraska, Colorado, Washington, and Alaska. Other states with similar but unevenly enforced laws on the books include South Carolina, Arizona, New Mexico, and Louisiana.

Illinois is attempting to work around the program’s most obvious flaws—the convicted drinker could drive someone else’s car, or get someone else to blow into the breath-monitoring device—by instituting heavy penalties for non-compliance if the driver is caught cheating.

Lined up in opposition to ignition lock legislation, thus far, is the American Beverage Institute, a lobby group for restaurant owners. In the AP article, the Institute’s Sarah Longwell objected to the fact that states might decide to apply the laws to people other than repeat offenders—to anyone who, on any given night, blows a 0.08 or a 0.10, the common denominators of alcohol intoxication in most states.

Sounding a bit more like the National Rifle Association (NRA) than perhaps it intended, the Beverage Institute offered a dire vision of a slippery slope: “We foresee a country in which you’re no longer able to have a glass of wine, drink a beer at a ball game or enjoy a champagne toast at a wedding. There will be a de facto zero tolerance policy imposed on people by their cars.”

My modest prediction: A tangle of state lawsuits and questions over civil liberties, the more so since many of the laws are first-pass efforts and subject to interpretation.

Photo Credit: HTB

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Recovery in 2009

Some resolutions for the New Year.

The SoberRecovery site has put up a forum entitled: "Anybody up for New Year Resolutions?" You can read the thread at the link above. There are old ones, new ones, and in-between ones.

From the practical...

“i will buy an accordion folder (if santa doesn't bring me one)--and i will organize my recipes”.

To the whimsical...

“I want a *real* accordion."

From the personal...

“To practice the golden rule even in heavy traffic.”

To the profound...

“My New Year's Resolution is to embrace life--to fully come out of the tiny, insular, self-absorbed world that drinking kept me in for so long and live to my full potential!

And organize my garage!”

Happy New Year to All.

Dirk Hanson
Site editor, Addiction Inbox


Graphic Credit: Vox Sacramento