More Hard Facts About Addiction Treatment

“Yes, we take your insurance.”

Recent reportage, such as Anne Fletcher’s book, Inside Rehab, has documented the mediocre application of vague and questionable procedures in many of the nation’s addiction rehab centers. You would not think the addiction treatment industry had much polish left to lose, but now comes a devastating analysis of a treatment industry at “an ethics crossroads,” according to Alison Knopf’s 3-part series in Addiction Professional. Knopf deconstructs the problems inherent in America’s uniquely problematic for-profit treatment industry, and documents a variety of abuses. We are not talking about Medicaid, Medicare, or Block Grants here. Private sector dollars, Knopf reaffirms, do not “guarantee that the treatment is evidence-based, worth the money, and likely to produce a good outcome.” Even Hazelden, it turns out, is prepared to offer you “equine therapy,” otherwise known as horseback riding.

Knopf, who is editor of Alcoholism and Drug Abuse Weekly, was specifically looking at private programs, paid for by insurance companies or by patients themselves. Who is in charge of enforcing specific standards of business practice when it comes to private drug and alcohol rehabs? Does the federal government have some manner of regulatory control? According to a physician with the Substance Abuse and Mental Health Services Administration (SAMHSA), the feds rely on the states to do the regulating. And according to state officials, the states look to the federal agencies for regulatory guidance.

All too often, the states routinely license but do not effectively monitor treatment facilities, or give useful consumer advice. Florida state officials do not even know, with any certainty, exactly how many treatment centers are in operation statewide. And even if state monitoring programs were effective and aggressively applied, “just because something is legal doesn’t mean it’s ethical,” said the SAMHSA official.

“We see this as a pivotal time for the treatment field as we have come to know it,” said Gary Enos, editor of Addiction Professional, in an email exchange with Addiction Inbox. Enos said that “the Affordable Care Act (ACA) will move addiction treatment more into the mainstream of healthcare, and this will mean that treatment centers' referral and insurance practices will come under more scrutiny than ever before.”

 Among the questionable practices documented by Knopf:

—Paying bounties and giving gifts to interventionists in return for client referrals.

Under Medicare, paying interventionists for referrals is banned. “In the private sector,” says a California treatment official, “it’s not illegal. But it is unethical.” According to treatment lobbyist Carol McDaid, “kickbacks happen all the time. Treatment centers that are doing this will do so at their own peril in the future,” she told Knopf.

—Giving assurances that treatment will be covered by insurance even though only a portion of the cost is likely to be covered.

Under the Affordable Care Act (ACA), says the SAMHSA official, “We are trying to position people to know more about their benefit package. And the industry has to be more straightforward about what the package will cover.” John Schwarzlose, CEO of the Betty Ford Center, told Knopf that “it’s very hard for ethical treatment providers to compete against insurance bait-and-switch,” when patients are told their insurance is good—but aren’t told that the coverage ends after 7 days, or that the daily maximum payout doesn’t meet the daily facility charges.

—Billing patients directly for proprietary nutrient supplements, brain scans, and other unproven treatment modalities.

“Equine therapy, Jacuzzi therapy, those are nice things, and maybe they help with the process of engagement,” said one therapist. “But people need to recognize that these ancillaries aren’t the essence of getting sober.”

—Engaging in dubious Internet marketing schemes.

You see them on the Internet: dozens and dozens of addiction and rehab referral sites. They list private services in various states, and look, on the surface, like legitimate information resources for people in need. As the owner of a blog about drugs and addiction, I hear from them constantly, asking me for links. “Family members and patients frequently have no way of knowing that a treatment program was really a call center they got to by Googling ‘rehab,’ writes Knopf, “and that the call center gets paid for referring patients to the actual treatment center. They don’t know that a program that promises to ‘work with’ health insurance knows full well the insurance will cover only a few days at the facility, and the rest will have to be paid out of pocket.” She points to a 2011 Wired magazine article, which said the Internet marketing cost of key words like “rehab” and “recovery” can be stratospheric. But “by spending that money—not necessarily providing good service—treatment provides can come out on top on searches. It’s the new marketing to the desperate.”

The group with the most to lose from revelations of this nature is the National Association of Addiction Treatment Providers (NAATP), the association representing both private and non-profit rehab programs. The Betty Ford Center has discontinued its membership in NAATP, a move that reflects the turmoil of the industry today. “It’s crazy that we have treatment centers inviting interventionists and other referents on a cruise, and then giving everyone an iPad,” Schwarzlose said.

As one man who lost his son to an overdose said: “I don’t get it. There’s the American Cancer Society, but I look for drugs and alcohol and I can’t find anything. There’s no National Association for Addictive Disease. How can this be?”

The investigative series will be featured in Addiction Professional’s March/April print issue. Enos believes that “influential treatment leaders are more interested than ever to see this debate aired more publically,” and says that the online publication of Knopf’s articles for the magazine has sparked “a great deal of discussion in treatment centers and on social media, including comments about other questionable practices that harm the field’s reputation.”

Craving Relief

Why is it so hard for addicts to say “enough?”

One of the useful things that may yet come out of the much-derided DSM-5 manual of mental disorders is the addition of craving as a criterion for addiction. “Cravings,” writes Dr. Omar Manejwala, a psychiatrist and the former medical director of Hazelden, “are at the heart of all addictive and compulsive behaviors.” Unlike the previous two volumes in this monthful of addiction books, Manejwala’s book, Craving: Why We Can’t Seem To Get Enough,  focuses on a specific aspect common to all addiction syndromes, and looks at what people might do to lessen its grip.

Why do cravings matter? Because they are the engine of addiction, and can lead people to “throw away all the things that really matter to them in exchange for a short-term fix that is often over before it even starts.” When Dr. Manejwala asked a group of patients to explain what they were thinking when they relapsed, their answer was often the same: “I was so STUPID.” But the author had tested these people. “I knew their IQs.” And the best explanation these intelligent addicts could offer “was the one explanation that could not possibly be true.”

In my book, The Chemical Carousel, I quoted former National Institute on Alcohol Abuse and Alcoholism (NIAAA) director T.K. Li on the subject of craving: “We already have a perfect drug to make alcohol aversive—and that’s Antabuse. But people don’t take it. Why don’t they take it? Because they still crave. And so they stop taking it. You have to attack the other side, and hit the craving.” However, if you ask addicts about craving when they are high, or have ready access, they will often downplay its importance. It is drug access unexpectedly denied that sets up some of the fiercest cravings of all. Conversely, many addicts find that they crave less in a situation where they cannot possibly score drugs or alcohol—at a health retreat, or on vacation at a remote locale.

Why are cravings so hard to explain? One reason is that “people use the word to mean so many different things.” You don’t crave everything you want, as Manejwala points out. Cravings are not the same as wants, desires, urges, passions, or interests. They are “stickier.” The brain science behind craving starts with the downregulation of dopamine and other neurotransmitters. As the brain is artificially flooded with neurotransmitters triggered by drug use, the brain goes into conservation mode and cuts back on, say, the number of dopamine receptors in a given part of the brain. In the absence of the drug, the brain is suddenly “lopsided,” and time has to pass while neural plasticity copes with the new (old) state of affairs. In the interim, the unbalanced state of affairs is a prime ingredient in the experience of craving.

Cravings are “disturbingly intense” (Manejwala) and “incomprehensibly demoralizing” (AA). Alcohol researcher George Koob called craving a state of “spiraling distress.” Cravings are not necessarily about reward, but about anticipating relief. “The overwhelming biological process in addictive craving is really a complex set of desperate, survival-based drives to feel ‘normal,’” says Manejwala.

The late Alan Marlatt, a psychologist who studied cravings for years, proposed that apparently irrelevant decisions could trigger or prevent relapse, almost without the addict knowing it. Turning left at an intersection, toward the supermarket, or turning right, toward the liquor store, can feel arbitrary and dissociated from desire. We also know that environmental cues can trigger craving, such as the site of a crack house where an addict used to do his business. Manejwala points to research showing that “some relapses related to cues and context are mediated by a small subgroup of neurons in the medial prefrontal cortex,” and suggests that it may be possible in the future to target this area with drug therapy.

Manejwala is unabashedly pro-12 Step, and favors traditional group work as the standard therapy. For example, he points to a Cochrane analysis of 50 trials showing that group participation roughly doubles a smoker’s chance of quitting. One of the reasons AA works for some people is that AA attendance reduces “pro-drinking social ties.” Simply put, if you are sitting with your AA pals in a meeting, you’re not out with your drinking buddies at the tavern. The author admits, however that alternatives such as SMART recovery work for some people, and that “sadly, much energy has been wasted as members of these various organizations bicker with each other about which works best, and this leaves the newcomer perplexed…. Over 20 million American are in recovery from addiction to alcohol and drugs. I can tell you this much: they didn’t all do it the same way.”

And along the way, you can be sure that all of them became familiar with cravings. Manejwala offers several strategies for managing cravings, and I paraphrase a few of them here:

—Join something. Participate. Get out of your own head and become actively involved in some group, any group, doing something you are interested in.

—Hang around people who are good at recovery. Long-timers, with a solid base of sobriety. You will not only learn HOW to do it, but that it CAN be done.

—Write stuff down. This makes you pay attention to what you’re doing. Keep a cigarette log. Count calories. Know what you’re spending per month on alcohol. Educate yourself about your addiction.

—Tell someone. Tell somebody you trust, because if there is anything harder than dealing with cravings from drinking, smoking, or drugging, it’s doing it in secret.

—Be teachable. Watch out for confirmation bias. “When you think you have the answers, it’s hard to hear alternatives.”

—Empathy matters. The author notes that the Big Book insists that by gaining sobriety, “you will learn the full meaning of ‘Love thy neighbor as thyself.’” Altruism may have evolutionary, physiological, and psychological implications we haven’t worked out yet.

Broken Treatment: How the Addiction Industry is Failing its Clients

It’s not medical. It's not psychiatric. What is it?

1. Most clinicians who treat addicted patients are counselors, not physicians; thus they cannot prescribe medication and they generally don’t “believe” in the use of medication for addictive disorders.

2. Most patients have medical insurance that excludes or severely limits treatment of addictive disorders, so payment for service is not good. This situation may change in the near future with the advent of healthcare reform in the United States.

So writes Dr. Charles O’Brien of the University of Pennyslvania Perelman School of Medicine, in a recent article for The Dana Foundation’s website.  In his article—“If Addictions Can Be Treated, Why Aren’t They?”—Dr. O’Brien asks a basic question: “Why are most patients not even given a trial of medication in most respected treatment programs?”

Even though pharmaceutical companies have throttled back on their interest in anti-craving drugs in recent years, there are, in fact, a few medications recognized by the FDA, primarily for use in the treatment of alcoholism. But they are not much in favor, and O’Brien believes he knows why:

The answer seems to be that there is a bias among treatment professionals, perhaps passed down from past generations when addictions were not understood to be a disease. Medically trained personnel are minimally involved in the addiction treatment system and most medical schools teach very little about addiction so most physicians are unaware of effective medications or how to use them.

What is on offer at most addiction treatment facilities is not actual rehabilitation, but rather short-term detoxification. And what we’ve learned from neuroscience is that taking away the drug is only stage one. The addiction remains, the reward and memory systems still operating erratically. We understand some of this circuitry better than at any time in history, but the concrete effects of these insights at the level of the community treatment clinic have been small to nonexistent. Money, of course, is part of it, since addiction has only recently, and sporadically, gotten the attention of funding agencies in the public health community. 

Health journalist Maia Szalavitz, writing at Time Healthland concurs: “Unlike most known diseases, the treatment of addiction is not based on scientific evidence nor is it required to be provided by people with any medical education—let alone actual physicians—according to a new report.” The report in question, from Columbia University’s National Center on Addiction and Substance Abuse (CASA), notes that most people are shoehorned into a standardized approach built around the 12 Step model of Alcoholics Anonymous. “The dominance of the 12-step approach,” writes Szalavitz, “also leads to a widespread opposition to change based on medical evidence, particularly the use of medications like methadone or buprenorphine to treat opioid addictions—maintenance treatments that data have show to be most effective.”

  Szalavitz also believes she knows why, and her thinking is similar to O’Brien’s. “Other medications that are known to treat alcohol and drug addiction, such as naltrexone, are also underutilized,” she writes, “while philosophical opposition to the medicalization of care slows uptake.”

There is a straightforward reason for considering the use of medication in the treatment of addiction: strong suggestions of recognizable genetic differences between those who respond to a given medication, and those who don’t. As O’Brien explains, a prospective study now in progress will be looking to see if alcoholics with a specific opioid receptor variant show a better outcome on naltrexone than those with the standard gene for that opioid receptor. And if they do, the FDA may allow a labeling change “stating that alcoholics with this genotype can be expected to have a superior response to naltrexone.”

But that won’t be happening tomorrow. In the meantime, we are stuck with the addiction treatment industry as it is. “The [CASA] report notes that only 10% of people with substance-use problems seek help for them,” Szalavitz concludes. “Given its findings about the shortcomings of the treatment system, that’s hardly surprising.”

Photo Credit: Creative Commons

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/

Treating Addictions [Guest Post]

The ABCs of rehab.

[Journalists like me tend to get immersed in the scientific and medical aspects of addiction. Not a bad thing, to be sure—but sometimes a simpler rendition puts a finer point on the matter. Today’s guest post was contributed by Susan White, who writes on the topic of Becoming a Radiologist.  She welcomes your comments at her email id: susan.white33@gmail.com.]

It’s very easy to find fault and assign blame when you’ve never been in the other person’s shoes; how often have we found ourselves judging people for their bad habits? Why can’t he stop that obnoxious habit? Oh, she’s not strong at all, she cannot stop drinking! I would never sink to the drug-induced state he is in, not even if the worst things were to happen to me – it’s easy to say all these things because we don’t know what an addiction feels like and how hard it is for people to quit. They’re just like you and me; they don’t like the way they are, but their substance abuse controls their bodies, minds and everything they do or say.

To understand an addiction, you need to understand that the body goes through changes, both physiological and psychological. If the addiction is to alcohol, drugs or any other chemical substance, the high euphoric feeling is what makes you go back again and again. But as time goes by, the high decreases and you begin to take in more of the abusive substance in your quest for that initial euphoria. It’s a vicious cycle that feeds itself, and if you stop, you feel withdrawal symptoms because your body is so used to its daily or even hourly fix.

It takes a supreme effort to admit that you have a problem and seek help. Rehab centers work because they make the addict quit cold turkey; they are cloistered and controlled environments where addicts have no access to the abusive substance. The sudden withdrawal causes abnormal reactions in your body, and you’re treated with medicines that help soothe your frayed nerves. When the initial craving subsides, you’re put in therapy and other forms of rehabilitation. Your diet is regulated, and your body slowly starts to recover and rejuvenate. 

The hardest part of rehab however comes when you step out of the cocoon of the de-addiction center and enter the real world. You have to face the demon that had its tentacles around you and fight it down, and for some people, this is where they suffer a relapse. Once they are surrounded by temptation, they succumb and are soon back to their decadent and sorry state. Others however, are made of sterner stuff. They know that they cannot afford to lose control again and they are disciplined enough to say no when they come face to face with temptation.

Addiction, be it to a substance, person or thing, is not something to be taken lightly. Unless admitted to and treated at the earliest, it could end up having serious physical and mental consequences. 

Graphics Credit: http://www.nida.nih.gov/

Why Don't They Just Say No?

Are addicts at fault for refusing to get well?

It often seems as if alcoholics and other drug addicts are at fault for perversely refusing to get well. Rarely do the treatment methods, or lack of them, come under question. The traditional view of the addict as an immature and irresponsible person, short on will power, low on self-esteem, and forever at the mercy of his or her “addictive personality,” works at cross-purposes with the goal of helping addicts recognize the need for treatment. Addicts have traditionally been taught to think of themselves the way Franz Kafka thought of himself in relation to his tuberculosis: “Secretly I don’t believe this illness to be tuberculosis, at least not primarily tuberculosis, but rather a sign of my general bankruptcy.”

Who is really at fault here—the patients, or the healers? Most of our current medical, legal, and psychiatric approaches to the prevention and treatment of drug addiction have failed—and are continuing to fail. As Susan Sontag has written: “Psychological theories of illness are a powerful means of placing the blame on the ill. Patients who are instructed that they have, unwittingly, caused their disease are also being made to feel that they have deserved it.”

In Samuel Butler’s classic utopian satire, Erewhon, sick people are thrown in prison, under a statute that makes it a crime to be ill. Is that our current approach to addiction? Does the drug problem belong in the Attorney General’s office, as it now stands, or in the Surgeon General’s office, where a growing number of researchers say it belongs? In light of new medical findings about addictive disorders, what is enlightened public policy, and what is not?

Recent research in neurophysiology, cell biology, and molecular genetics, coupled with breakthroughs in the science of brain imaging, have made it possible, for the first time, to venture a solid assault on the basic mysteries of addiction. The past fifteen years have been exhilarating times for biomedical researchers in general; a time when basic breakthroughs in the biomedical sciences have changed the way science approaches a variety of human afflictions. We have been used to thinking of such conditions as alcoholism, drug addiction, depression, and suicide in terms of causes rooted firmly in the environment. What events in a person’s life, what outside social factors, led to the problem? However, the new medicine is telling us that we have been looking in all the wrong places for causality.

When I first began following the scientific research on addiction and alcoholism, the field was small, the insights tentative, and the overall enterprise woefully underfunded. Today, more than a decade later, an interlocking maze of biomedical and psychiatric sub-specialties make up the world of addiction science. I can only hope to impart a sense of the important work being done in addiction science. What I had originally viewed as a series of potential breakthroughs in addiction research very rapidly became the tip of an enormous iceberg: brain science, and the revolutionary new directions represented by modern biological psychiatry. The brave new sciences strongly suggest that, when it comes to addiction, the place to look is inside the brain itself.

Photo Credit: Conversations on the Fringe

Addiction Treatment: Who is the Client?

The Overselling of Drug Rehab.

Professor David Clark, who runs the Wired In recovery website in the U.K., recently posted several passages from William L. White's "Slaying the Dragon: The History of Addiction Treatment and Recovery in America."

According to Professor Clark, "In highlighting [these quotes] on my Blog, I am not questioning the value of treatment. However, I am providing a word of caution to those who are trying to tell 'society' that the government-led treatment system is successful and is a panacea to some of society's problems."

Among the observations from White's book:

Who is the client?

"Addiction treatment swings back and forth between a technology of personal transformation and a technology of coercion. When the latter dominates, counselors become, not helpers, but behavioral police. The fact that today’s treatment institutions often serve more than one master has created the ethical dilemma of “double agentry,” wherein treatment staff profess allegiance to the interests of the individual client, while those very interests may be compromised by the interests of other parties to whom the institution has pledged its loyalty.’

--White, p. 335.

On blaming

"Harold Hughes, the political Godfather of the modern alcoholism treatment system, often noted that alcoholism was the only disorder in which the patient was blamed when treatment failed.... For decades many addicts have been subjected to treatment interventions that had almost no likelihood of success; and when that success has indeed failed to materialize, the source of that failure has been attributed, not to the intervention, but to the addicts’ recalcitrance and lack of motivation. The issue is, not just that such mismatches do not work, but that such mismatches generate their own iatrogenic effects via increased client passivity, helplessness, hopelessness and dependence."

--White, p. 331.

Historical tendency to oversell what treatment can achieve

"The overselling of the ways in which addiction treatment could benefit the home, the workplace, the school, the criminal justice system, and the broader community during the 1970s and 1980s sparked a subsequent backlash. When time - the ultimate leveller – began to expose the fact that these benefits were not forthcoming at the level promised, a rising pessimism fueled the shift toward increased criminalization of addiction."

--White, p. 338

Photo Credit: Cliffside Malibu

Book Review (Part Three): Women Under the Influence

Rehab and the Working Mother

According to Columbia University’s National Center on Addiction and Substance Abuse, more than 2.5 million women abuse or are dependent on illegal drugs. Women are almost 50 per cent more likely to be prescribed a narcotic or sedative, and teenage girls are more likely than teenage boys to abuse prescription drugs, with dramatic increases among 12 to 17 year old girls.

Statistics cited in Women Under the Influence, produced by the Center, show that while women convicted of drug-related offenses represent the fastest growing subset of America’s prison population, their representation in the drug rehab community has not kept pace. Fully three-fourths of these incarcerated women are mothers, and that fact is at the heart of the difficulties women face when they seek treatment.

Put simply, millions of women who need treatment for addiction to alcohol and illegal drugs do not receive it. This has been true throughout American history. Women were not admitted to meetings during the formative years of Alcoholics Anonymous (AA), and there is evidence that the 19th Century practice of performing hysterectomies on alcoholic women as a last resort quietly persisted until the 1950s.

AA soon opened its doors to women, who now comprise roughly one third of its membership. But when it comes to rehab centers, the treatment gap has not closed: “For women with small children, lack of childcare is a serious obstacle to seeking treatment…. For some women, fear of losing their children to the child custody system upon admission that they have a problem makes them apprehensive about entering treatment.”

Moreover, there are no universal standards of training, practice or accountability among the nation’s treatment providers, and women face differing approaches to their needs for child care, pediatric services, transportation, and the like. While older women have treatment needs that differ from girls and pregnant women, very few treatment centers offer programs designed specifically for older females.

If treatment is to become noticeably more effective for addicted women, “it must be readily available, tailored to fit the needs of the individual patient, and part of a comprehensive program that addresses associated medical, psychological, social, and economic needs…. Appropriate, research-based, and effective prevention efforts tailored specifically to the unique needs of girls and women are in desperately short supply.”

Women Under the Influence--purchase info

A View From the Other Side: What Disease?

A psychiatrist takes issue with the semantics of addictive disease in SLATE.

See "Medical Misnomer: Addiction isn't a brain disease, Congress."
By Sally Satel and Scott Lilienfeld

Drug Rehab in China

After two years of a nationwide “people’s war” against drug addiction in China, government authorities are claiming major accomplishments—but treatment, which is mostly compulsory, remains limited and largely ineffective, Chinese doctors say.

The Chinese surge against drugs was credited with numerous successes almost before it had begun. Zhou Yongkang, Minister of Public Security, told the official news agency Xinhua that officials had seized more than two tons of methamphetamine, and three million “head-shaking pills”--otherwise known as Ecstasy tablets.

Two years later, in June of 2007, Minister Yongang, claimed that the number of drug abusers in China had been cut from 1.16 million to 720,400 due to compulsory rehabilitation measures. “The effort has yielded remarkable results,” Yongang told the China Daily. (Other drug experts estimate the number of Chinese drug addicts to be 3 million or more.)

However, a recent paper co-authored by several Chinese physicians, published in the Journal of Substance Abuse Treatment, suggests that things are not so rosy. The report, titled, “Attitudes, Knowledge, and Perceptions of Chinese Doctors Towards Drug Abuse,” paints a dismal picture: Less than half the Chinese doctors working in drug abuse had any formal training in the treatment of drug addicts, the report found. Moreover, less than half of the treatment physicians believed that addiction was a disorder of the brain. (One cannot help wondering whether the percentage for American doctors would be any higher.)

The study could find no coherent doctrine or set of principles for drug rehabilitation being employed in China, beyond mandatory detox facilities. In the Chinese government’s White Paper on “Narcotics Control in China,” the practice of “reeducation-through-labor” is considered to be the most effective form of treatment. Another name for this form of treatment would be: prison.

There are perhaps as many as 200 voluntary drug treatment centers as well. These centers emphasize treating withdrawal symptoms, and feature more American-style group interaction and education, but observers say such centers are often used by people evading police or running from their parents.

In addition, the lack of formal support from the Chinese government has led to the closing of several such facilities after only a few months. The American origins of such treatment modalities have not helped sell such programs to government officials. Pharmaceutical treatments for craving remain unavailable in China.

SOURCES:

--Fan, Maureen. “U.S.-Style Rehabs Take Root in China as Addiction Grows.” Washington Post Foreign Service, A14, January 19, 2007.

--Yi-Lang Tang, et. al. “Attitudes, Knowledge, and Perceptions of Chinese Doctors Towards Drug Abuse.” Journal of Substance Abuse Treatment. vol. 29 no. 3. 215-220.

--“Anti-Drug Campaign Yields Result.” China Daily. June 16, 2007. http://www.china.org.cn.

--“With Prohibition Failing, China Calls for ‘People’s War’ on Drugs.” Drug War Chronicle. vol. 381. 4/8/05 http://stopthedrugwar.org

Neurobiology of Addiction

Book Review




By George F. Koob and Michel Le Moal.
Academic Press
(Elsevier), London, 2006.

Over the past twenty-five years, the neurobiology of addiction has become established as an important arena of scientific study. In particular, the molecular adaptations the brain makes in response to addictive drugs has placed addiction squarely in the forefront of modern brain science.

Dr. George F. Koob, a respected American alcoholism researcher of long standing, has put together an academic treatise beyond the expertise and the pocketbooks of most laypersons, but the book is of crucial importance in the burgeoning
field of addiction science.

In Neurobiology of Addiction, Koob and co-worker Michel Le Moal review the neural and molecular mechanisms responsible for the effects of individual addictive drugs in five categories--psychostimulants, opium, alcohol, nicotine,and cannabis.

Particularly well documented is the “anti-reward” system, by which the abuse of addictive drugs leads to a net decrease in dopamine and serotonin in the nucleus accumbens,the brain structure associated with withdrawal and craving. Thus, the
pursuit of artificial pleasure becomes, through the process of addiction, a state of chronic depletion of the brain neurotransmitters associated with states of joy, happiness and well-being.

The authors also do a good job of putting forth their theory of “allostasis,” defined as a “state of chronic deviation of the regulatory system from its normal (homeostatic) operating level.” The addicted brain is constantly attempting to normalize through counteradaptions at the neural level, as well as by switching on the body’s stress responses. Craving and anxiety are among the behavioral results.

[For more on George Koob,
The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.

Sources:

--Koob, George, and Le Moal, Michel. “Drug Abuse: Hedonic Homeostatic
Dysregulation.” Science. October 3, 1997. 278: 55.

--Everitt, Barry J. “From the Dark Side to the Bright Side of Drug Addiction.”
Science 314 p. 59, 6 October 2006.

Vaccinating Against Vices

Developing a pill or a vaccine for a specific drug addiction has long been one of the tantalizing potential rewards of addiction research. Now a company in Florida has garnered national attention, a spate of clinical trails, and a positive response from the National Institute on Drug Abuse (NIDA) with a compound called NicVAX, aimed at nicotine addiction. In addition, Celtic Pharma in Bermuda is working on a similar product for cocaine addiction.

The idea of vaccinating for addictions is not new. If you want the body to recognize a heroin molecule as a foe rather than a friend, one strategy is to attach heroin molecules to a foreign body--commonly a protein which the body ordinarily rejects--in order to switch on the body’s immune responses against the invader. The idea of a vaccine for cocaine, for example, is that the body’s immune system will crank out antibodies to the cocaine vaccination, preventing the user from getting high. A strong advantage to this approach, say NIDA researchers, is that the vaccinated compound does not enter the brain and therefore is free of neurological side effects.

Preliminary research at the University of Minnesota showed that a dose of vaccine plus booster shots markedly reduce the amount of nicotine that reaches the brain. Animal studies have shown the same effect. NicVAX, from Nabi Biopharmaceuticals, consists of nicotine molecules attached to a protein found in a species of infectious bacteria. When smokers light up, antibodies attack the protein-laden nicotine molecules, which, further encumbered by these antibodies, can no longer fit through the blood-brain barrier and allow the user to enjoy his smoke.

That, at least, is the idea. It is a difficult and expensive proposition, the closest thing to a miracle drug for addiction, but it does not specifically attack drug craving in addicted users. The idea of vaccination is that, once a drug user cannot get high on his or her drug of choice, the user will lose interest in the drug.

This assertion is somewhat speculative, in that users of the classic negative reinforcer, Antabuse, have found ways to circumvent its effects--primarily by not taking it. There remain a wealth of questions related to the effects of long-lasting antibodies. And it is sometimes possible to “swamp” the vaccine by ingesting four or five times as much cocaine or nicotine as usual.

Drugs that substantially reduce the addict’s craving may yet prove to be a more fruitful avenue of investigation. While several anti-craving medications have been approved for use by the Food and Drug Administraton (FDA), no vaccines have made it onto the approved least yet.

For more on pharmaceutical approaches to fighting drug addiction, see my website at http://www.dirkhanson.org

New Drug For Smokers

First there was Wellbutrin, an antidepressant which helped cut down on the cravings and nicotine withdrawal symptoms for many addicted smokers when it was marketed as the smoking cessation aid Zyban. In May, the Food and Drug Administration (FDA) okayed a second medication for the treatment of nicotine addiction. Chantix, the trade name for varenicline tartrate, works on the dopamine system to reduce withdrawal and craving symptoms, like Zyban. In randomized, placebo-controlled clinical studies involving more than 3,500 smokers, Chantix outperformed both placebos and Zyban. Common side effects included nausea, headache and vomiting. Two studies published in the Journal of the American Medical Association (JAMA) showed that about 22 per cent of smokers on Chantix were abstinent at the one-year mark, compared to 15 per cent for Zyban, and 9 per cent for placebos.

Zyban and Chantix are frequently used by doctors in combination with nicotine replacement therapy, such as gum or patches. Zyban was the first major success story in the burgeoning field of pharmacological treatments for addiction--fighting fire with fire.

According to the Centers of Disease Control and Prevention (CDC), more than 44 million American adults continue to smoke cigarettes, a fifth of whom suffer from smoking-related illnesses.

See more on anti-craving drugs at http://dirkhanson.org

Sources:

--”FDA Approves Novel Medication for Smoking Cessation.” U.S. Food and Drug Administration. www.fda.gov/bbs/topics/NEWS/2006/NEW1370.html. May 11, 2006.

Kotulak, Ronald. “New Drug Shows Promise in Helping Smokers Quit.” Chicago Tribune July 5 2006.