Drugs and Disease: A Look Forward

First published 2/18/2014.

Former National Institute on Drug Abuse (NIDA) director Alan Leshner has been vilified by many for referring to addiction as a chronic, relapsing “brain disease.” What often goes unmentioned is Leshner’s far more interesting characterization of addiction as the “quintessential biobehavioral disorder.”

Multifactorial illnesses present special challenges to our way of thinking about disease. Addiction and other biopsychosocial disorders often show symptoms at odds with disease, as people generally understand it. For patients and medical professionals alike, questions about the disease aspect of addiction tie into larger fears about the medicalization of human behavior.

These confusions are mostly understandable. Everybody knows what cancer is—a disease of the cells. Schizophrenia? Some kind of brain illness. But addiction? Addiction strikes many people as too much a part of the world, impacted too strongly by environment, culture, behavior, psychology, to qualify. But many diseases have these additional components. In the end, the meaning of addiction matters less than the physiological facts of addiction.

One of the attractions of medical models of addiction is that there is such an extensive set of data supporting that alignment. Specifically, as set down in a famous paper by National Institute of Drug Abuse director Nora Volkow and co-author Joanna Fowler: “Understanding the changes in the brain which occur in the transition from normal to addictive behavior has major implications in public health…. We postulate that intermittent dopaminergic activation of reward circuits secondary to drug self-administration leads to dysfunction of the orbitofrontal cortex via the striato-thalamo-orbitofrontal circuit.” This cascade of events is often referred to as the “hijacking” of the brain by addictive drugs, but nothing is really being hijacked. Rather, the abusive use of drugs changes the brain, and that should come as no surprise, since almost everything we do in the world has the potential of changing the brain in some way. “Why are we so surprised that when you take a poison a thousand times, it makes some changes in your head?” said the former director of a chemical dependency treatment program at the University of Minnesota. “It makes sense that [addictive drugs] change things.”

Critics like Fernando Vidal object to a perceived shift from “having a brain” to “being a brain.” He is saying that he cannot see the point of “privileging” the brain as a locus for the study of human behavior. In “Addiction and the Brain-Disease Fallacy,” which appeared in Frontiers in Psychiatry, Sally Satel and Scott Lillienfeld write that “the brain disease model obscures the dimension of choice in addiction, the capacity to respond to incentives, and also the essential fact people use drugs for reasons (as consistent with a self-medication hypothesis).”

An excellent example of the excesses of the anti-brain discussions is an article by Rachel Hammer of Mayo Clinic and colleagues, in the American Journal of Bioethics-Neuroscience. “Many believed that a disease diagnosis diminishes moral judgment while reinforcing the imperative that the sick persons take responsibility for their condition and seek treatment.” But only a few paragraphs later, the authors admit: “Scholars have theorized that addiction-as-disease finds favor among recovering addicts because it provides a narrative that allows the person simultaneously to own and yet disown deviant acts while addicted.” Furthermore: “Addiction reframed as a pathology of the weak-brained (or weak-gened) bears just as must potential for wielding stigma and creating marginalized populations." But again, the risk of this potentially damaging new form of stigma “was not a view held by the majority of our addicted participants…”

And so on. The anti-disease model authors seem not to care that addicted individuals are often immensely helped by, and hugely grateful for, disease conceptions of their disorder, even though Hammer is willing to admit that the disease conception has “benefits for addicts’ internal climates.” In fact, it often helps addicts establish a healthier internal mental climate, in which they can more reasonably contemplate treatment. Historian David Courtwright, writing in BioSocieties, says that the most obvious reason for this conundrum is that “the brain disease model has so far failed to yield much practical therapeutic value.” The disease paradigm has not greatly increased the amount of “actionable etiology” available to medical and public health practitioners. “Clinicians have acquired some drugs, such as Wellbutrin and Chantix for smokers, Campral for alcoholics or buprenorphine for heroin addicts, but no magic bullets.” Physicians and health workers are “stuck in therapeutic limbo,” Courtwright believes.

“If the brain disease model ever yields a pharmacotherapy that curbs craving, or a vaccine that blocks drug euphoria, as some researchers hope,” Courtwright says, “we should expect the rapid medicalization of the field. Under those dramatically cost-effective circumstances, politicians and police would be more willing to surrender authority to physicians.” The drug-abuse field is characterized by, “at best, incomplete and contested medicalization.” That certainly seems to be true. If we are still contesting whether the brain has anything essential to do with addiction, then yes, almost everything about the field remains “incomplete and contested.”

Sociologists Nikolas Rose and Joelle M. Abi-Rached, in their book Neuro, take the field of sociology to task for its “often unarticulated conception of human beings as sense making creatures, shaped by webs of signification that are culturally and historically variable and embedded in social institutions that owe nothing substantial to biology.”

And for those worried about problems with addicts in the legal system, specifically, over issues of free will, genetic determinism, criminal culpability, and the “diseasing” of everything, Rose and Abi-Rached bring good news: “Probabilistic arguments, to the effect that persons of type A, or with condition B, are in general more likely to commit act X, or fail to commit act Y, hold little or no sway in the process of determining guilt.” And this seems unlikely to change in the likely future, despite the growing numbers of books and magazine articles saying that it will.

Opponents of the disease model of addiction and other mental disorders are shocked, absolutely shocked, at the proliferation of “neuro” this and “neuro” that, particularly in the fields of advertising and self-improvement, where neurotrainers and neuroenhancing potions are the talk of the moment. Sociologists claim to see some new and sinister configuration of personhood, where a journalist might just see a pile of cheesy advertising and a bunch of fast-talking science hucksters maneuvering for another shot at the main chance. When has selling snake oil ever been out of fashion?

For harm reductionists, addiction is sometimes viewed as a learning disorder. This semantic construction seems to hold out the possibility of learning to drink or use drugs moderately after using them addictively. The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction. By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base. And that doesn’t help anybody find common ground.

Graphics Credit: http://www.docslide.com/disease-model/

What Mark Kleiman Wants You To Know About Drugs

The public policy guru guiding state legalization efforts.

Mark A. R. Kleiman is the Professor of Public Policy at UCLA, editor of the Journal of Drug Policy Analysis, author of many books, and generally regarded as one of the nation’s premier voices on drug policy and criminal justice issues. Mr. Kleiman provides advice to local, state, and national governments on crime control and drug policy. When the state of Washington needed an adviser on the many policy questions they left unanswered with the passage of I-502, which legalized marijuana in that state, they turned to Kleiman.

In the past two years, Kleiman has co-authored to Q and A-style books: Drugs and Drug Policy: What Everyone Needs to Know (2011) with Jonathan P. Caulkins and Angela Hawken; and Marijuana Legalization: What Everyone Needs to Know (2012) with Hawken, Caulkins, and Beau Kilmer.

Here, excerpted from the two books, is a brief sampling of Kleiman and his colleagues on a variety of drug and alcohol issues.

Is marijuana really the nation’s leading cash crop?

“Alas, the facts say otherwise. Analyses purporting to support the claim must contort the numbers, citing the retail price of marijuana but the farmgate price of other products, or pretending that all marijuana consumed in the United States is sinsemilla, or ignoring the fact that most marijuana used in the United States is imported, or simply starting with implausible estimates of U.S. production…. marijuana [is] in the top fifteen, but not the top five, cash crops, ranking somewhere between almonds and hay, and perhaps closest to potatoes and grapes.”

How much drug-related crime, violence, and corruption would marijuana legalization eliminate?

“Not much…. Eighty-nine percent of survey respondents report obtaining marijuana most recently from a friend or relative, and more than half (58 percent) say the obtained it for free. That stands in marked contrast to low-level distribution of heroin and crack which often occurs in violent, place-based markets controlled by armed gangs.”

How much would legal marijuana cost to produce?

“The punch line is that full legalization at the national level—as opposed to only legalizing possession and retail sale—could cut production costs to just 1 percent of current wholesale prices…. This would make legal marijuana far and away the cheapest intoxicant on a per-hour basis.”

How would legalization affect me if I’m a marijuana grower?

“It would almost certainly put you out of business. At first glance, legalization might seem like a great opportunity for you…. But legalization will completely upend your industry, and the skills that made you successful at cultivating illegal crops will not have much value. A few dozen professional farmers could produce enough marijuana to meet U.S. consumption at prices small-scale producers couldn’t possibly match. Hand cultivators would be relegated to niche markets for organic or specialty strains.”

Would marijuana regulations and taxes in practice approach the public health ideal?

“If there is a licit, for-profit marijuana industry, one should expect its product design, pricing, and marketing actions to be designed to promote as much frequent use and addiction as possible. Efforts to tax and regulate in ways that promote public health would have to contend with an industry mobilizing its employees, shareholders, and consumers against any effective restriction. Since the industry profits from problem users, we should expect that lobbying effort to be devoted to blocking policies that would effectively control addiction. The alcohol and tobacco industries provide good examples.”

Can we persuade children not to use drugs?

"Even the best prevention programs have only modest effects on actual behavior, and may programs have no effect at all on drug use…. Anesthesiologists know far more about drugs and drug abuse than could possibly be taught in middle-school prevention programs; nonetheless, they have high rates of substance abuse, in part because they have such easy access.”

Why is there a shortage of drug treatment?

“Some specific categories—especially those in need of residential care, and more especially mothers with children in need of residential care—face chronic shortages. But if we had enough capacity for all those who need treatment, many of those slots would be empty because not all the people who ought to fill them want treatment.”

How much money is involved?

“Most of the numbers about drug abuse and drug trafficking that officials peddle to credulous journalists are little better than fiction. Estimates of hundreds of billions of dollars per year in international drug trade—which would make it comparable to food, oil, and arms—do not have a basis in the real world. The most recent serious estimate of the total retail illicit drug market in the United States—by all accounts the country whose residents spend the most on illicit drugs—puts the figure at about $65 billion.”

When it comes to drugs, why can’t we think calmly and play nice?

“American political analysts talk about ‘wine-track (college-educated) and ‘beer track’ (working-class) voters…. So the politics of drug policy is never very far from identity politics…. The notion that illicit drug taking is largely responsible for the plight of minorities (and of poor people generally) and that income-support programs have the perverse consequence of maintaining drug habits has been a staple of a certain form of American political rhetoric at least since Ronald Reagan.”

Are we stuck with our current alcohol problem?

"By no means…. tripling the tax would raise the price of a drink by 20 percent and reduce the volume of drinking in about the same proportion. Most of the reduced drinking would come from heavy drinkers, both because they dominate the market in volume terms and because their consumption is more price-sensitive…."

Addiction Doctors Pick Top Ten Journal Articles

A screen for problem gambling, medications for insomniac alcoholics, and more.

A group of addiction doctors presented a Top Ten List of peer-reviewed articles from 2011 at the American Society of Addiction Medicine’s Annual Medical-Scientific Conference in Richmond, VA. Dr. Michael Weaver presented the findings, noting that the list was “reached by consensus, and articles were selected not only for their quality but also to represent different areas of addiction medicine.” Dr. Weaver stressed that “not all published studies were done really well, and some may not apply to the patients treated by a particular clinician.”

According to Dr. Edward Nunes, with the Department of Psychiatry at Columbia University, the journal articles provide a "nice mixture on epidemiology and clinical outcome or clinical trials research,” which represent “the type of evidence most relevant to patient care."

Thanks to Catharine Zivkovic (@ccziv) for drawing attention to this list. The summaries are my own. Disclaimer: In some cases, these brief summaries are based solely on a reading of the journal abstracts.

1. 

Hsueh-Han Yeh, M.S. et al. (2011). Five-Year Trajectories of Long-Term Benzodiazepine Use by Adolescents: Patient, Provider, and Medication Factors. Psychiatric Services 62(8): 900–907.

 A Taiwanese study analyzing benzodiazepine prescription records came up with a simple solution: “Prescribers can reduce the risk of long-term use by assessing whether pediatric patients have received benzodiazepines from multiple doctors for various medical conditions.” Huh. Who’d have thought of that one, eh? But for various reasons, such checks, and the open records required to make them possible, are the exception rather than the rule in current health care systems. The study group found that for long-term users under 21, defined as anyone in receipt of a benzodiazepine prescription for 31 or more days in a calendar year, one in four patients fell into the categories of “accelerating or chronic users.” Specifically, “A history of psychosis or epilepsy, prescription by providers from multiple specialties, and receipt of benzodiazepines with a long half-life or mixed indications significantly increased one's risk of becoming a chronic or accelerating user.”

2. 

McBride, O, and Cheng, Hui G. (2011) Exploring the emergence of alcohol use disorder symptoms in the two years after onset of drinking: findings from the National Surveys on Drug Use and Health. Addiction 106(3): 555-563.

This study looked for clinical features of alcohol dependence and socially maladaptive drinking patterns during the first 24 months of alcohol use, based on stats from the 2004-2007 National Surveys on Drug Use and Health (NSDUH). Result: New alcohol users “frequently experienced problems relating to self-reported tolerance, spending a great deal of time recovering from the effects of alcohol and unsuccessful attempts at cutting down on drinking. The likelihood of experiencing the clinical features increased steadily in the first 9 months after use, but appeared to plateau or only gradually increase thereafter.” The researchers suggest there may be a window of opportunity during the 2nd year of drinking.

3.

Volberg, Rachel A., et al. (2011) A Quick and Simple Screening Method for Pathological and Problem Gamblers in Addiction Programs and Practices. The American Journal on Addictions. 20(3): 220-227.

Doctors, as these researchers point out, don’t often screen their patients for pathological gambling. To combat this, the investigators offer health professionals brief computer screenings they have developed for use in identifying problem gambling. “Given the high rates of comorbidity, routine and accurate identification of gambling-related problems among individuals seeking help for substance abuse and related disorders is important.” 

4.

Alford, Daniel. P., et al. (2011). Collaborative Care of Opioid-Addicted Patients in Primary Care Using Buprenorphine: Five-Year Experience. Archives of Internal Medicine 171(5):425-431.

Buprenorphine remains an underused but often effective treatment for opiate addiction, the authors of this study maintain. The cohort being studied was a group of addicted patients under the dual care of general physicians and nurse care managers. “Of patients remaining in treatment at 12 months, 154 of 169 (91.1%) were no longer using illicit opioids or cocaine based on urine drug test results,” the investigators report. However, dropout rates were high. The researchers did find that the nurse-doctor model was workable: “Collaborative care with nurse care managers in an urban primary care practice is an alternative and successful treatment method for most patients with opioid addiction that makes effective use of time for physicians who prescribe buprenorphine.”

5. 

Kolla, B.P., et. al. (2011) Pharmacological Treatment of Insomnia in Alcohol Recovery: A Systematic Review. Alcohol and Alcoholism 46: 578-585.

In this Mayo Clinic review of drugs used for sleep problems in alcohol recovery, the authors combed through more than 1,200 articles and reported that, of all the old and new drugs being used, an old and rarely used medication—trazadone—improved sleep measures as reliably as anything else that was tested. Gabapentin got good but equivocal marks due to questions about testing and inclusion criteria. Topiramate and carbamazepine helped in some cases. Furthermore, “in single, small, mostly open-label studies, quetiapine, triazolam, ritanserin, bright light and magnesium have shown efficacy, while chlormethiazole, scopolamine and melperone showed no difference or worsening. Conclusion: Trazodone has the most data suggesting efficacy.”

6.

Bohnert, A.S., et. al. (2011). Association between opioid prescribing patterns and opioid overdose-related deaths. Journal of the American Medical Association 305: 1315-1321.

Accidental prescription overdose deaths are on the rise, and this group of university researchers in Ann Arbor and Indianapolis thinks it may have something to do with how the dosing instructions are usually worded.  They set out to investigate “the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among patients with cancer, chronic pain, acute pain, and substance use disorders.” They found from VHA hospital records that “the frequency of fatal overdose over the study period among individuals treated with opioids was estimated to be 0.04%.” The risk for overdose was directly related to the “maximum prescribed daily dose of opioid medication.” And patients who stuck with regular dosages, or took opioids “as needed,” were not at any elevated risk for overdose. Another obvious but frequently overlooked conclusion: “Among patients receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of opioid overdose death.”

7. 

Allsop, D.J. et al. (2011). The Cannabis Withdrawal Scale development: patterns and predictors of cannabis withdrawal and distress. Drug and Alcohol Dependence 19(1-2):123-9.

Rates of treatment for marijuana abuse and addiction are increasing, say these Australian authors, along with relapse rates. They have devised a Cannabis Withdrawal Scale that measures such withdrawal effects as associated distress, strange dreams, trouble sleeping, and angry outbursts—common manifestations of withdrawal from weed. The scientists maintain that their “Cannabis Withdrawal Scale can be used as a diagnostic instrument in clinical and research settings where regular monitoring of withdrawal symptoms is required.”

8.

West, R., et al. (2011) Placebo-Controlled Trial of Cytisine for Smoking Cessation. New England Journal of Medicine 365: 1193-1200.

This important study assessed the effectiveness of the drug cytisine in smoking cessation programs, and a potential star was born. In a single-center, randomized, double-blind, placebo-controlled trial, the journal paper concluded that “cytisine was more effective than placebo for smoking cessation. The lower price of cytisine as compared with that of other pharmacotherapies for smoking cessation may make it an affordable treatment to advance smoking cessation globally.”

9. 

Elkashef A., et al. (2011) Topiramate for the treatment of methamphetamine addiction: a multi-center placebo-controlled trial. Addiction Published online 12/16.

Conducted at eight medical centers across the U.S., this study found that for most of the 140 methamphetamine-dependent adults under scrutiny, use of topiramate produced “abstinence from methamphetamine during weeks 6-12.” That’s the good news. Unfortunately,  “secondary outcomes included use reduction versus baseline, as well as psychosocial variables… topiramate did not increase abstinence from methamphetamine during weeks 6-12.” That’s the bad news. And here’s the silver lining, as far as the investigators are concerned: “Topiramate does not appear to promote abstinence in methamphetamine users but can reduce the amount taken and reduce relapse rates in those who are already abstinent.”

10.

Levina. A., et al. (2011). Molecular Mechanism for a Gateway Drug: Epigenetic Changes Initiated by Nicotine Prime Gene Expression by Cocaine. Science Translation Medicine 3(107) 107-109.

There really is s a gateway drug. In fact, there are two of them in our culture. Almost every potential addict starts out with alcohol or cigarettes or both. Because they are legal and easily available. So is cocaine and marijuana, once you get the hang of it, but in the beginning, and all around us, it’s booze and cigs. The amazing premise of this final study is this: “Pretreatment of mice with nicotine increased the response to cocaine, as assessed by addiction-related behaviors and synaptic plasticity in the striatum, a brain region critical for addiction-related reward.” Nicotine primes subjects for cocaine addiction, in effect. “These results from mice prompted an analysis of epidemiological data, which indicated that most cocaine users initiate cocaine use after the onset of smoking and while actively still smoking, and that initiating cocaine use after smoking increases the risk of becoming dependent on cocaine, consistent with our data from mice. If our findings in mice apply to humans, a decrease in smoking rates in young people would be expected to lead to a decrease in cocaine addiction.”

Photo Credit: www.flickr.com/

From Their Mouth to Your Ear: Researchers Talk Drugs

A collection of five-question interviews.

I’ll be away from the Addiction Inbox office this week, attending the big TEDMED health and medicine powwow in Washington, D.C.

In the meantime, here’s a summation (with links) of the interviews I’ve been doing recently in the “five-question interview” series. I’ve been very lucky to nab some state-of-the-art thinkers, working at the top of their fields, from psychiatry to pharmacology to neuroscience.

See below for the story thus far:



David Kroll, former Professor and Chair of Pharmaceutical Science at North Carolina Central University in Durham, is now Science Communications Director for the Nature Research Center at the North Carolina Museum of Natural Sciences.

“The attraction to users was, until recently, that Huffman cannabis compounds (prefixed with "JWH-" for his initials) could not be detected in urine by routine drug testing. Hence, incense products containing these compounds have been called ‘probationer's weed.’" MORE

Vaughan Bell is a Senior Research Fellow at the Institute of Psychiatry, King’s College, London. He is also honorary professor at the Universidad de Antioquia in Medellín, Colombia.

"I was very struck by the appearance of classic Kluver form constants [after taking ayahuasca], geometric patterns that are probably caused by the drug affecting the visual neurons that deal with basic perceptual process (e.g. line detection)." MORE

Jon Simons, a cognitive neuroscientist, is a lecturer in the Department of Experimental Psychology at the University of Cambridge, UK, and principal investigator at the University’s Memory Laboratory.

“If you’re at a party and happen to drunkenly strike up conversation with Angelina Jolie (or Brad Pitt, if you prefer) and, bowled over by your charm and witty repartee, she tells you her phone number, you may well not remember it when you wake up sober the next morning. However, the evidence suggests that you would have a better chance of recalling the number if you got drunk again." MORE

Bankole Johnson is professor and chairman of the University of Virginia’s Department of Psychiatry and Neurobehavioral Sciences.

“With growing and clear acceptance of the neurobiological underpinnings of addiction, our work on pharmacogenetics promises to provide effective medications—such as ondansetron—that we can deliver to an individual likely to be a high responder, based on his or her genetic make up." MORE

Michael Farrell is the director of the National Drug and Alcohol Research Centre (NDARC) at the University of New South Wales in Sydney, Australia. Before that, he was Professor of Addiction Psychiatry at the Institute of Psychiatry at Kings College, London.

“The near complete absence of methadone or buprenorphine treatment in American prisons is hard to understand, when you see what a great contribution US research and treatment with methadone and buprenorphine has had globally. Now there are over 300,000 people on methadone in China as part of HIV and AIDS prevention." MORE

Deni Carise is a clinical psychologist who serves as senior vice president and chief clinical officer at Phoenix House, a leading U.S. non-profit drug treatment organization with more than 100 programs in 10 states.

“Those in recovery see the disease of alcoholism or addiction as a moral obligation to get well. If you know you have this disease and the only way to keep it under control is not to use alcohol or drugs, then that’s what you have to do." MORE


Keith Laws is professor of cognitive neuropsychology and head of research in the School of Psychology at the University of Hertfordshire, UK.

"Some may tolerate 100s or even 1000s of E tablets, but for others far fewer may lead to memory problems. We can predict that 3 in 4 users will develop memory problems, but not which 3 or after how many tablets." MORE

photo credit: http://www.startawritingbusiness.co.uk

Nothing Organic About Rodale’s New Book on Addiction

Raw carrots won’t cut it.

How times have changed. You’ve heard of Rodale, the outfit that kicked off organic gardening in America, and publishes Prevention Magazine and Organic Gardening? Founded in 1947, the Rodale Institute’s mandate was to publicize J.I. Rodale’s personal vision of healthy soil and healthy food. So it was with great astonishment that I picked up The Addiction Solution: Unraveling the Mysteries of Addiction Through Cutting-Edge Brain Science, published by Rodale Books, heretofore famous for such perennials best sellers as The Rodale Book of Composting, The Rodale Whole Foods Cookbook, Diabetes Without Drugs, and The Organic Manifesto.

So what is the approach taken in this new paperback about addiction? Herbal treatments for alcoholism? Fresh air and sunshine for meth addiction? No. The “brain science” in the subtitle is really just that. Written by Dr. David Kipper, a Beverly Hills physician, and Steven Whitney, a former addict, the book states that addiction is… er… a brain disease, and not primarily a behavioral issue. It seems that Big Science has gotten its murderous dissecting hands around the Rodale organization at last. In neuroscience, not organic carrots, lies the future of addiction treatment, the book asserts. Is old man Rodale turning over in his grave? It gets worse. The Rodale organization is now saying, through this book, that if you are an addict, you might want to consider taking… more drugs.

Here it is, in a nutshell: “An inherited genetic flaw causes specific imbalances in brain chemistry, that, when impacted by stress, create biochemical ‘wantings,’ or needs, that show themselves as bad feelings, uncharacteristic behaviors, and/or addiction, which is medically treated by a new family of pharmaceutical medications that first regain and then stabilize the biochemical balance. During the rehabilitation of the brain chemistry, the patient enters a personalized recovery program featuring behavioral and other therapies.”

You can argue with certain specifics in that definition—“brain imbalance,” for example, is falling out of favor as a descriptor—but there is no denying that it represents an attempt at a strictly neurophysical definition of the condition.

Traditional addiction treatment, the book argues, hasn’t included any of this. The authors maintain that “traditional 28-day inpatient programs at treatment centers are now largely unnecessary. This is good news, since that kind of treatment costs from $50,000 to $100,000 per month.” [Editor’s note: perhaps in Beverly Hills.]

“In contrast,” the authors write, “the new medical paradigm is grounded in outpatient treatment, making it more affordable, especially with insurance and government benefits that define addiction as a medical disease. Thanks to the Mental Health Parity and Addiction Equity Act of 2008, insurers that offer substance abuse coverage must provide the same lifetime limits on payment as they provide for other medical diseases like diabetes, heart disease, and cancer.”

And what does all this accomplish? “More subtly, the new approach replaces the expectation of failure attached to the old, traditional treatment with a tangible opportunity for success, including raising an addict’s self-esteem.” Away with your old and traditional ways, says this Rodale title. If you are looking for an organic alternative to what is becoming the mainstream view of addiction, you will have to look elsewhere. Perhaps Prevention magazine might have something more in your line.

Graphics Credit: http://metalmother.com/

Falling Down and Getting Up: Nic Sheff’s New Addiction Book

 

Sheff jumps back on the carousel, lives to tell about it.

What would it be like to have written a drug memoir and an autobiography before you turned 30? Would it seem like the end or the beginning? Are there any worlds left to conquer?

The last decade has brought us fleshed-out young examples by Augusten Burroughs, age 37 (Dry); Joshua Lyons, 35 (Pill Head); and Benoit Denizet-Lewis, 33 (America Anonymous). This more or less fits the pattern established by the doyenne of the genre, Elizabeth Wurtzel, who, at age 35, wrote the addiction memoir More, Now, Again. And now along comes Nic Sheff to put them all to shame, making geezers out of every one of them.  Sheff wrote Tweak at 24, telling the world about addiction and how he’d conquered it. Well, as it turns out, not really. But for twenty-somethings, a week is like a year, so two years later, in actual time, comes We All Fall Down, in which we learn—if we didn’t learn it the first time—that the author is still learning about addiction, doesn’t have it figured, and isn’t really qualified to give out lessons to anybody just yet. Or perhaps I should wait for We All Stood Up Again two years from now before drawing any conclusions.

I know I am being a bit unfair to this well-intentioned young author. I blame it on the flood of weighty pronouncements found in the addiction memoirs that have flooded the market lately. God bless ‘em all, but Amazon, by listing Sheff’s book as “Young Adult,” probably gets it about right. You can’t go into these projects expecting great literature. Sheff’s text, perhaps in a deliberate appeal to younger readers, is peppered with whatevers, and clauses that begin with “like.” His favorite adjective, without question, is “super.” Too many one-sentence paragraphs give the book an irritatingly staccato effect at times.

But let’s get beyond that. There are good things here, and Sheff is certainly qualified to tell an addiction story: “We stayed locked in our apartment. I went into convulsions shooting cocaine. My arm swelled up with an abscess the size of a baseball. My body stopped producing stool, so I had to reach up inside with a gloved hand and….” And so forth.

There is a standard tension in addiction memoirs by young writers. The dictates of group therapy and 12-step treatment programs clash mightily with their innately sensitive bullshit detectors. It is hard—understandably—to buy into some of the more narrow-minded and coercive treatment programs they’ve been tossed into along the way. I was chilled to hear Sheff quoting substance abuse counselors threatening to commit him to lockdown psych wards, or blackmailing him into signing contracts about who he could or could not be friends with in the compound. For a free-spirited, open-minded young artist, the distinction between rehab and a Chinese re-education camp is pretty much lost entirely when personal freedoms are arbitrarily limited by lightly qualified drug counselors. One of the more compelling themes of the book is that rehab, as practiced in many treatment centers across the country, is something of a cuckoo’s nest joke.  It is a mutual con, where everybody fools everybody in order to turn a profit, on the one hand, and discharge legal or parental obligations, on the other. “Infallible institutions,” as Sheff derides them, “that know, absolutely, the difference between right and wrong.”

So Sheff plays along, he shucks, he jives, he lies, and it’s hard not to sympathize with him as he summarizes one counselor’s admonitions: “We don’t allow any non-twelve-step-related reading material, and you won’t be able to play that guitar you brought with you—so we’ll go ahead and keep that locked in the office.” Much like prisoners who leave prison chomping at the bit to commit new and more lucrative crimes, these kids are coming out of misguided drug rehab centers with nothing but an urgent desire to wipe away the bad memories of mandatory treatment by getting wasted as soon as possible.

And yet, and yet… “Once I had some knowledge about alcoholism and addiction, it was impossible to go back to using all carefree and fun,” Sheff writes. “The meetings and the things people told me had pierced the armor of my fantasy world. Somewhere inside I knew the truth.”

Maybe there won’t be a need for a third memoir. The book has a provisionally happy ending. Sheff found the right doctor, got on the right medications after a diagnosis of Bipolar Disorder (comorbidity, the elephant in the rehab room), and, when last seen, is clean and optimistic.

Sheff does have an appealing, Holden Caulfield-type persona, and this Catcher in the Rye mentality perhaps excuses the litany of things in this world that are phony, fucked up, and lame to this endlessly hip kid. All carpets are faded, all motel rooms are dingy. Even his airline boarding pass is “stupid.” But the style sometimes works for him: “Thinking, man, even that cat’s got enough sense not to jump on a hot grill twice, no matter how good whatever’s left cooking on there might look to her.” Or the time when he realizes that, like any old alkie, it was time to “start switching up liquor stores. That goddamn woman makes me feel as guilty as hell. And, I mean, who is she to judge? Christ.” And he’s got some nice truisms to deliver: “The most fucked-up detoxes I’ve ever seen are the people coming off alcohol. It’s worse than heroin, worse than benzos, worse than anything. Alcohol can pickle your brain—leaving you helpless, like a child—infantilized—shitting in your pants—ranting madness—disoriented—angry—terrified… You don’t go out like Nic Cage in Leaving Las Vegas, with a gorgeous woman riding you till your heart stops.”

Photo Credit: http://www.goodreads.com/

Drug Wars Increase Drug Violence

 Homicides rise with anti-drug expenditures.

In a large review of studies evaluating the association between drug law enforcement and violence, the Vancouver-based International Centre for Science in Drug Policy (ICSDP) concluded that “the existing scientific evidence strongly suggests that drug prohibition likely contributes to drug market violence and higher homicide rates. On the basis of these findings, it is reasonable to infer that increasingly sophisticated methods of disrupting drug distribution networks may increase levels of drug-related violence.”

This finding is either self-evident or counterintuitive, depending upon your point of view. But it is entirely consistent with several historical examples, most notably the breakup of the Cali and Medellin cartels in Columbia during the 1990s. “The destruction of the cartels’ cocaine duopoly,” says the report, “was followed by the emergence of a fractured network of smaller cocaine-trafficking cartels that increasingly used violence to protect and increase their market share.”

In its review of available English language studies focusing on the association between drug enforcement and violence, the ICSDP looked at “longitudinal analyses involving up to six years of prospective follow-up, multilevel regression analyses, qualitative analyses, and mathematical predictive models.” The result? “Contrary to our primary hypothesis, among studies that employed statistical analyses of real world data, 82% found a significant positive association between drug law enforcement and violence.” 

According to Harvard economist Jeffrey Miron, who is quoted in the report: “Prohibition creates violence because it drives the drug market underground. This means buyers and sellers cannot resolve their disputes with lawsuits, arbitration or advertising, so they resort to violence instead.”

The drug policy group estimates that the worldwide illicit drug trade adds up to as much as $320 billion annually. Latin America is still the world’s leading supplier of marijuana and cocaine, but it has also become a major player in the opium and heroin trade. Afghanistan and West Africa are also plagued with serious political and social instability and violence due to drug traffic.

In light of the continuing economic downturn, it seems pertinent to note that the study estimates total U.S. drug law enforcement expenditures at about $15 billion a year for roughly the past 15 years. During that period, illegal drugs “have become cheaper and drug purity has increased, while rates of use have not markedly changed.” As an example, the report points to the “startling increase in heroin purity” from 1980 to 1999, when the Drug War was in full swing, and contrasts that trend with the “equally startling drop in price over the same period.”

The ICSDP is a recently-formed multinational network of scientists, health practitioners, and academics who seek to move the focus on drugs from law enforcement to harm reduction through “evidence-based drug policy guidelines and research collaborations with scientists and institutions across continents and disciplines.” Among its members are Michel D. Kazatchkine, executive director of The Global Fund to Fight Aids, TB and Malaria; Dr. David Nutt, a professor of neuropsychopharmacology at Imperial College, London, who was recently dismissed as a drug adviser by the British government for his anti-drug war views; and Dr. Julio Montaner, president of the International AIDS Society.

The report, like all such summary studies, is open to dispute by scholars and scientists on the grounds of statistical methodology, but to date it serves as additional evidence for the proposition that federal drug control officials must seek alternative regulatory models--or risk being responsible for helping to lower price, increase supply, and foment a truly appalling level of homicidal violence in their efforts to interdict drug traffic and incarcerate users. 

Drug wars never work. The report from the International Centre for Science in Drug Policy is another reminder that drug wars intrinsically raise the level of violence in the countries and the communities where they are quixotically waged.

Graphics Credit: http://www.icsdp.org/

The Three-Headed Dragon

A symbol of need.

 Getting off drugs, or learning to stop drinking, is very often easier than staying off them. As Mark Twain remarked about tobacco, quitting was easy—he’d done it dozens of times. Relapse, the biological imperative, will have its way with most of those abstaining for the first time. Addiction is a psychological disorder with strongly cued behavioral components, whatever its dimensions as a biochemically-based disease.

The three-headed dragon is a metaphor first popularized by alternative therapists at the Haight Ashbury Free Medical Clinic in San Francisco. The first head of the dragon is physical. Addiction is a chronic illness requiring a lifetime of attention. The second head is psychological. Addiction is a disorder with mental, emotional, and behavioral components. And the third head of the dragon is spiritual. Addiction is an existential state, experienced in isolation from others.

Addicts speak of “chasing the dragon” in an effort to catch the high that they used to achieve so easily. It is also drug slang for the use of small metal pipes to catch and inhale the wisps of smoke from a pile of burning opium, crack, or speed. We can picture the dragon chasing his own tail, snapping at it with all three hungry mouths, in an endless escalation of tolerance and need.

“Because of the unique reaction that the genetically addiction-prone individual experiences to his drug of choice, he or she programs his or her belief system with the deep conviction that the substance is ‘good,’” writes Richard Seymour. “This is where self-help becomes intrinsic to recovery. Unless one deals with the third head, unless one changes the belief system and effects a turning-about in the deepest seat of consciousness, there is no recovery.” The “X” factor in recovery, for many people, turns out to be a form of inner self-awareness; something that includes the attributes of will power and determination yet transcends them through a form of surrender.

And speaking of changing one’s belief system, experience has shown that it is a spectacularly bad idea to sit around and do nothing but stare at the wall during the early phase of recovery. Psychologist Mihaly Csikszentmihalyi argues, in The Evolving Self, that when attention wanders, and goal-directed action wanes, the majority of thoughts that come to mind tend to be depressive or sad. (This does not necessarily apply to formal methods of meditation, which cannot be described as states marked by wandering attention.) The reason that the mind turns to negative thoughts under such conditions, he writes, is that such pessimism may be evolutionarily adaptive. “The mind turns to negative possibilities as a compass needle turns to the magnetic pole, because this is the best way, on the average, to anticipate dangerous situations.” In the case of recovering addicts, this anticipation of dangerous situations is known as craving. The next step is often drug-seeking behavior, followed by relapse.

For a highly motivated addict with a stable social life, a safe and effective medication to combat craving might be all that is needed. For many others, however, attention to the other two heads of the dragon is going to be necessary. An addict’s ability to experience pleasure in the normal way has been biochemically impaired. It takes time for the addict’s disordered pleasure system to begin returning to normal, just as it takes time for the physical damage of cigarette smoking to partially repair itself.

Alternative therapists are fond of referring to recovery as a process, with an emphasis on the importance of time. Medication of any disease, even if successful, does not treat the continuing need for healing. It is now well understood that mood and outlook can have an effect on healing. Positive emotional states can be beneficial to the maintenance of good health. Thoughtful physicians make the distinction between a disease and an illness. A disease is a chemically identifiable pathological process. An illness, by contrast, is the disease and all that surrounds it—the sociological environment, and the individual psychology of the patient who experiences the disease.

From The Chemical Carousel By Dirk Hanson, pp. 311-313.  © Dirk Hanson, 2008.

Graphics Credit: wwwwilliammorristile.com

Addiction Assumptions: Denial

Is denial always part of the deal?

Maybe denial really IS just a river in Egypt. Lorraine T. Midanik, dean of the School of Social Welfare at the University of California in Berkeley, is convinced that the contemporary concept of denial as applied to alcoholism represents a weak link in the disease model of addiction.

Neither the founding fathers of Alcoholics Anonymous, nor the foremost early proponent of the disease model—E.M. Jellinek—specifically identified denial as a core concept of alcoholism, according to Midanik. In “The Philosophy of Denial in Alcohol Studies: Implications for Research,” which appears as a chapter in The Praeger International Collection on Addictions, Midanik highlights the conclusion that often results from making a strict association between alcoholism and denial: “There is no room in this perspective for truth telling from the drinker himself.”

The more often and the more energetically a drinker protests against the hypothesis that he is drinking alcoholically, the more telling the proof that the drinker is “in denial” and therefore incapable of rational decision-making about drinking. Clearly, this is exactly the case in many instances. Denial exists. However, Midanik argues that “the definition of denial in alcohol studies has been expanded well beyond its original meaning” to include a host of vaguely Freudian defense mechanisms, including hostility and other forms of negative behavior. Midanik, who is openly skeptical regarding many aspects of the disease model, complains that denial has been broadened into a catchall category “for any behavior that prevents the adoption of the disease model system.”

As the “disease model system” is often presented to patients in various rehab centers around the country, I would tend to agree. But Midanik also questions whether there really exists anything beyond what she labels “tactical denial,” meaning “deceptive maneuvers used by alcoholics to conceal the extent of their drinking.” In such cases, the drinker is obviously aware of what he or she is doing, so the more appropriate term might be “lying.” Nonetheless, I firmly believe that denial, in the sense of lack of self-awareness, or dissociation, is often an acute part of the presenting symptoms of alcoholism, if not quite the “central core of alcoholism treatment,” as Midanik sees it.

Midanik describes something like a cabal of interests helping to foster and inflate the denial concept—AA, Al-Anon, and various codependency groups in particular—even though “study after study and review after review report that alcoholics give valid self-reports....” Here Midanik is onto something interesting. As she intriguingly relates, the near-universal presumption guiding “interventions” or “structured encounters” with supposed alcoholics is that “there is a continuum with denial on one end and truth telling on the other. Overreporting rarely if ever exists.”

Yet overreporting is a well-known issue in clinical research. Midanik refers to the “hello-goodbye effect,” in which patients tend to overemphasize their symptoms when entering treatment, and to minimize them at the end of treatment. If new patients overreport their alcohol consumption, “there are important implications for treatment personnel who base treatment decisions on these self-reports.” Moreover, overreporting may also bias clinical studies “by inflating success rates (presuming there was an opposite bias after treatment). Yet despite the implications of these findings, little interest has been shown by researchers in the alcohol field to explore this area.”

Photo Credit: shatteringdenial.com

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NIDA'S Updated Guide Book Emphasizes Science

Drug addiction treatment trends.

Favoring objective medicine over moral exhortation, the National Institute on Drug Abuse (NIDA) has updated one of its primary research guides, continuing the trend toward focusing on the scientific aspects of drug and alcohol addiction.

In the preface to the updated 2nd Edition of Principles of Drug Addiction Treatment, available here, NIDA Director Nora D. Volkow writes:

“Addiction affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. Some individuals are more vulnerable than others to becoming addicted, depending on genetic makeup, age of exposure to drugs, other environmental influences, and the interplay of all these factors.”

Looking toward the future, Volkow writes that “we will harness new research results on the influence of genetics and environment on gene function and expression (i.e., epigenetics), which are heralding the development of personalized treatment interventions.”

Here are excerpts from a section of the updated guide titled “Principles of Effective Treatment.”

--No single treatment is appropriate for everyone.

“Matching treatment settings, interventions, and services to an individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.”

--Treatment needs to be readily available.

“Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.”

-- Remaining in treatment for an adequate period of time is critical.

“Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment. Recovery from drug addiction is a longterm process and frequently requires multiple episodes of treatment.”

-- Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

“For example, methadone and buprenorphine are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opioid-addicted individuals and some patients with alcohol dependence. Other medications for alcohol dependence include acamprosate, disulfiram, and topiramate.”

-- Many drug-addicted individuals also have other mental disorders.

“Because drug abuse and addiction—both of which are mental disorders—often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co-occur, treatment should address both (or all), including the use of medications as appropriate.”

-- Treatment programs should assess patients for the presence of HIV/ AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.

“Typically, drug abuse treatment addresses some of the drug-related behaviors that put people at risk of infectious diseases. Targeted counseling specifically focused on reducing infectious disease risk can help patients further reduce or avoid substance-related and other high-risk behaviors.”

Graphics Credit: NIDA

Drug Addicts Punished in New York Prisons

Drug offenders get “the box” instead of treatment.

The common practice of placing drug addicts in “disciplinary segregation” for drug use violations in New York state prisons has drawn fire from Human Rights Watch. The international human rights group issued a report condemning the practice of placing addicts in “the box” and denying them treatment for their drug dependence, calling it “cruel, inhuman, and degrading treatment.”

In the report, entitled “Barred from Treatment: Punishment of Drug Users in New York State Prisons,” Human Rights Watch notes that even addicts who are allowed to seek treatment face major delays “because treatment programs are filled to capacity.” New York State Assemblyman Jeff Aubry, chair of the State Committee on Corrections, told the investigators: “Denying treatment to inmates who suffer from a drug dependency is illogical and counterproductive to the goal of rehabilitation.”

Some of the findings in the report are shocking: “Despite overwhelming evidence that medication-assisted therapy is the most effective treatment for opiate addiction, the majority of New York State prisoners dependent on heroin or other opiates have no access to methadone or buprenorphine.” Furthermore, the state’s Department of Correctional Services “has conducted few evaluations of its own treatment programs.” Prison officials have estimated that as many as eight out of ten inmates have substance abuse problems. A National Institute of Drug Abuse (NIDA) study earlier this year, covered in a previous post, estimated that only one-fifth of the nation’s inmates needing formal treatment are able to get it.

The report comes just as New York legislators have agreed to revamp the so-called Rockefeller drug laws, which are among the strictest in the nation. “Reforming the Rockefeller drug laws to prevent drug users from being sentenced to long prison sentences is critically important, said Megan McLemore, a researcher with Human Rights Watch. “But timely and effective programs must be available to serve the inmates still in prison.” McLemore said in a press release that “discipline should be proportionate to the offense, and should never prevent prisoners from getting the treatment they need.”

As a prisoner at Attica told Human Rights Watch, “Here is a notice telling me ‘it could be a long time’ until I get into treatment again. There’s plenty of room for me in the box, but not in a program.”

Photo Credit: ACS blog

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Drug Research and the Recovery Act of 2009

What's in the budget for addiction scientists?

Scientists were among the likely beneficiaries of President Obama’s American Recovery and Reinvestment Act of 2009.

The National Institutes of Health (NIH) is slated to receive $10 billion for use over the next two years. A yet-to-be-determined portion of the grant will end up with the National Institute on Drug Abuse (NIDA).

Here is a sampling of NIDA’s wish, or “Challenge Topics” for which the agency is seeking grant proposals. The application due date is April 27, 2009.

--Dietary treatment of substance disorders.
“There is abundant preclinical and clinical evidence that suggest dietary therapies and behavioral interventions can promote neurogenesis, diminish susceptibility to metabolic and excitotoxic injury (e.g., diets rich in antioxidants), and/or counteract stress responses within the brain. Dietary regimens or supplements can be evaluated as individual treatments or as adjuncts to FDA-approved medications.”

--Drug genetics and informed consent.
“Address ethical issues related to access to broad sharing and use of new genetic information and technologies for addiction research to improve treatment and prevention options for addicts.”

--Addiction drugs combined in treatment.
“Network biological analysis predicts that modification of a single target by a drug is not nearly as likely to affect disease outcome as would rational combinations of drugs that target multiple, complementary mechanisms. Applications will focus on combination of medication strategies for the treatment of substance use disorders.”

--Neurobiology of opioid addiction.
“There is an urgent need for research that will more thoroughly delineate the neurobiological implications of long-term opioid use. This knowledge gap is of particular concern when it comes to the developing brain - and the urgency is underscored by the fact that increasing numbers of adolescents and young adults are using opioid medications, prescribed and otherwise.”

--Research on addiction drugs for pregnant women.
“Substance abuse during pregnancy often occurs in the context of complex environmental factors and poly-drug exposure, as well as medical conditions which are associated with adverse neonatal consequences. Much is known in regard to the negative effects of substances of abuse on the pregnant/post partum women and their substance exposed neonates but relatively little is known in regard to medication treatment strategies and research methodology.”

--Internet-based prevention and treatment in rural locations.
“Many persons living in remote or rural locations have limited opportunities to obtain drug abuse treatment services, due to a lack of available service settings, the barrier of traveling long distances, and/or the perceived lack of private and confidential treatment options. This program seeks to develop web-based drug abuse treatment interventions that do not necessitate frequent in-person visits to a central facility.”

--Finding new molecular targets for addiction treatment drugs.
“Projects may utilize techniques ranging from gene knockout technologies, behavioral evaluations, assay development, and targeted library synthesis and screening that could lead to the development of medications for drug addiction treatment. The focus may be on the identification of new molecular targets, and/or the discovery of small molecule selective ligands for previously identified targets, such as muscarinic M5 antagonists, neuropeptide Y antagonists, and neurotensin agonists.”

For general information on the National Institute on Drug Abuse implementation of NIH Challenge Grants, contact:

Christine Colvis, Ph.D.
NIDA Challenge Grant Program Coordinator
National Institute on Drug Abuse
National Institutes of Health
Phone 301-443-6480
Email ccolvis@nida.nih.gov


Photo Credit:www.ecampusnews.com

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Stone Age Drug Paraphernalia

Ceramic bowls and tubes discovered--but what were they sniffing?

Archeologists have never doubted that prehistoric man liked to get high. Previous excavations in Mexico and Texas have yielded indirect evidence of the New World use of peyote and mescal several thousand years ago. However, researcher Quetta Kaye of University College, London, says she has found the actual works—“The objects tested for this study are ceramic inhaling bowls that were likely used for the ingestion of hallucinogenic substances,” Kaye wrote in the Journal of Archaeological Science.

Such physical finds are not uncommon, but the estimated age of these ceramic items caught the attention of archeologists. In a report published in the London Sunday Times, science editor Jonathan Leake writes that the bowls likely originated in South America between 100 and 400 B.C., and were carried to the Caribbean island of Carriacou, where Kaye, along with Scott Fitzpatrick from North Carolina State University, discovered the artifacts.

So what, exactly, were Stone Age Caribbeans snorting or smoking? It wasn’t cannabis, since the plant was not growing in the Caribbean at that time, experts say. Some form of psychoactive fungi or mold, like ergot, or a mind-altering mushroom are always possibilities. But according to the Times report, “Kaye believes one of the most likely [drugs] was cohoba, a hallucinogen made from the beans of a mimosa species.” This DMT-containing plant is known to have been used as a hallucinogenic snuff by the Taíno, a Caribbean people who dominated the islands of Puerto Rico, the Dominican Republic, Haiti, Cuba, and Jamaica from 1200 A.D. until the time of Columbus.

Jonathan Ott writes in “Pharmacotheon” that “during Columbus' second voyage to the Americas, 1493-1496, the Admiral himself commented on a mysterious ‘powder’ which the ‘kings’ of the Taíno Indians of the island of Hispaniola would ‘snuff up,’ and that ‘with this powder they lose consciousness and become like drunken men’" (Torres 1988; Wassén 1967).

Cohoba was also sniffed in Trinidad, and in parts of northern South America. DMT is a powerful, short-acting hallucinogen with striking visual imagery, often combined with an MAOI inhibitor for maximum effectiveness. Ayahuasca is another potent South American brew with similar effects. Cohoba is reportedly still in use by shamans in the Amazon basin.

Richard Davenport-Hines, author of “The Pursuit of Oblivion,” and a former history professor at the London School of Economics, told The Times: “Drug use became widespread in many early agriculture-based societies simply because it was the only way people could cope with spending long hours working in the fields, often in horrible conditions like baking sun.”

That’s one theory, anyway. Other archeologists and anthropologists have long maintained that humans have used psychoactive plants for thousands of years primarily in shamanic practices and religious rituals.

Recovery and Stigma

Jason Schwartz at Addiction and Recovery News has a similar reaction to the happy spin SAMHSA put on its recent survey:

Addiction and Recovery News: Recovery and stigma

"I'm not sure what to make of the prevention attitudes," Jason writes. "I suspect SAMHSA finds them encouraging, but I assume that they are more symptomatic of the belief that addiction has a lot to do with a person "losing their way", "getting hooked", or falling in with the wrong crowd."

Addiction: The Stigma Lives On

Would you live next door to a drug addict?

A telephone survey by the Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the U.S. Department of Health and Human Services, shows that public attitudes toward addiction and recovery are still laced with negativity.

Undertaken as part of National Alcohol and Drug Addiction Recovery Month, the survey was released in late September. For all the positive spin SAMHSA puts on the findings—emphasizing that only a fifth of survey respondents said they would think less of a friend or relative who was in recovery from addiction--the telephone survey also showed that negative attitudes and stigmas associated with drug and alcohol addiction are slowly waning—but still demonstrably present. People continue to view alcohol addiction differently than drug addiction. Only about 60 per cent of Americans said they would be comfortable living next door to someone in recovery from alcohol abuse. In contrast, (SAMHSA), a branch of the U.S. Department of Health and Human Services, shows that public attitudes toward addiction and recovery are still laced with negativity. Less than half of the respondents said they would be comfortable living next door to someone in recovery from drug abuse.

In addition, the public remains split on the role of “willpower” in treatment and recovery from addiction: “Slightly less than half of the general public (44%) believes that people who are addicted to alcohol could stop using the substance if they had enough willpower. Even fewer (38%) believe that people who are addicted to drugs could stop using them if they had enough willpower. However, two population segments with statistically significant differences from the general public are African Americans and young adults age 18 to 24. Both groups are much more likely than other population categories to believe addiction can be stopped by willpower.”

Other evidence of addiction stigmas:

• “Almost one-third would think less of a person with a current addiction.”

• “Almost three-quarters of young adults agree with the statement that people who are addicted to alcohol could stop if they had enough willpower. Twice as many young adults age 18 to 24 believe that willpower could play a decisive role in recovery from addiction than does the general population.”

• “In general, the older a person is, the more likely he or she is to think less of someone who is in recovery from drugs or alcohol, and the less likely he or she is to feel comfortable with someone in recovery from alcohol or drug abuse. In general, respondents are more comfortable with someone in recovery from alcohol abuse than drug addiction."

• Overall, respondents feel that persons who are addicted to illicit drugs such as cocaine and heroin are much more of a danger to society than those addicted to alcohol, prescription drugs, or marijuana.”

• “Females are much more likely than males to agree that individuals who are addicted to any of the substances mentioned in the survey are dangers to society. This is particularly true in relation to alcohol addictions.”

• “Women are more likely than men to agree that a person in recovery from an addiction to prescription drugs or illicit drugs can live a productive life.”

• “Respondents see programs to help people with addictions to alcohol, marijuana, and prescription drugs more favorably than treatment programs designed to help people with addictions to illicit drugs such as heroin, cocaine, or methamphetamines.”



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Cindy McCain’s Drug Addiction

She’s no Betty Ford.

In 1989, Cindy McCain had back surgery for ruptured disks. By her own admission, she became addicted to powerful painkillers—Vicodin and Percocet. Mrs. McCain spoke openly on television about her addiction, which had culminated in 1992 with an intervention staged by her parents. She told Jay Leno on the “Tonight Show” that she wanted to talk about the experience as often as possible, “because I don’t want anyone to wind up in the shoes that I did at the time.” She also penned a column about her addiction for Newsweek in 2001, and did an interview for Harper’s Bazaar.

As it turns out, however, Mrs. McCain’s openness about her addiction may have been the involuntary result of a yearlong DEA investigation into her drug use. Moreover, it is far from clear that addiction awareness and treatment are high on her list of First Lady priorities, should John McCain win in November.

Writing in the September 15 New Yorker, Ariel Levy says that the McCain campaign “has attempted to portray McCain’s past addiction to prescription painkillers and her public statements about it as a Betty Ford-style story of altruism and accountability.” However, in an investigation by the Washington Post into the circumstances surrounding Mrs. McCain’s 4-year bout with painkillers, reporter Kimberly Kindy writes: “Her misuse of painkillers prompted an investigation by the Drug Enforcement Administration and local prosecutors that put her in legal jeopardy. A doctor with McCain’s medical charity who supplied her with prescriptions for the drugs lost his license and never practiced again. The charity, the American Voluntary Medical Team, eventually had to be closed in the wake of the controversy.”

The Washington Post probe, based in part on official county records in Phoenix, documented that Mrs. McCain obtained her drugs from her medical charity non-profit organization through the group’s medical director, who wrote prescriptions for her in the names of unsuspecting employees. The Phoenix New Times obtained excerpts from a journal kept by an employee of the American Voluntary Medical team. One such excerpt begins: “I do not know what Cindy is up to but it appears as though she is trying to use several doctors’ DEA #s so that she can acquire drugs for personal use....”

In 1993, the DEA began to take an interesting in Cindy McCain’s case. The DEA pursued the investigation for almost a year, during which Mrs. McCain hired John Down, the attorney who had defending her husband in the Keating 5 scandal. She faced several federal charges, including fraud and forgery, which could have resulted in a jail sentence of up to 20 years. According to the Post, “Down negotiated a deal with the U.S attorney’s office allowing McCain, as a first-time offender, to avoid charges and enter a diversion program that required community service, drug treatment, and reimbursement to the DEA for investigative costs.”

Mrs. McCain has not publically discussed the nature of the treatment she received as a result of the deal. The Washington Post article said that “the only public reference to treatment is her mention in the county investigator’s report of a one-week stay at the Meadows,” a treatment facility in Arizona.

First Lady Betty Ford went through a similar addictive ordeal with painkillers. From her biography at the National First Ladies’ Library:

“Her family became alarmed with Betty’s drinking and apparent addiction to pain pills. In 1978, just before her 60th birthday, they had an intervention. Thereafter, Betty Ford checked into the Long Beach Naval Hospital for treatment. The treatment was tough, but she later acknowledged that it probably saved her life.

“Betty’s experiences led her to create the Betty Ford Treatment Center in Rancho Mirage, California. From the start, Mrs. Ford was open with what she had gone through. The Center has become her greatest accomplishment. As the head of the Board, she continues to be actively involved in the Center.”