Obama’s Addiction

President-elect should come clean about cigarettes.

For a candidacy built on transparency and straightforward messaging, the Obama juggernaut is missing a wonderful opportunity to send direct aid and comfort to struggling addicts everywhere. All the president-elect has to do is admit that he is still struggling to quit smoking cigarettes.

It doesn’t take a campaign genius to understand the reasoning during the primaries: Smoking, something now done behind closed doors, or while leaning against a dark wall out back, was not something Obama’s handlers were eager to have taken up as a topic of discussion with respect to their candidate. The U.K. Guardian maintains that certain opinion polls found Obama’s smoking to be a greater hindrance to his election than the color of his skin.

The recent release of candid black and white photos from Obama’s college years, showing him casually smoking, has brought the issue back to the forefront. “It is a sign of our anxious, needy condition,” opined the Guardian, “that Americans are willing to overlook the president-elect's filthy habit.”

While Nancy Reagan banned smoking in the White House years ago, the cigar-smoking Clinton seems to have gotten a pass, cigars in the popular culture being to cigarettes as the occasional brandy is to a six-pack. While the New York Times debates whether graphic warning labels only increase people’s desire to smoke, nobody seems to be asking whether a president who sneaks out to the Rose Garden to field-strip a Marlboro will serve as a role model or an enabler for fellow smokers.

In a separate article in the Guardian, Alexander Chancellor writes that “Obama appears to have tried really hard to stop, and says he had cut his smoking down to the occasional fag bummed from a member of his staff; but he still hasn’t give up completely, despite being a fitness fanatic who spends more than an hour a day in the gym.” As every addicted smoker who ever tried to quit has discovered, nobody ever sneaks by for long on two or three bummed cigarettes a day. “You either smoke none or you smoke 20,” writes Queenan. “There is no middle ground.”

More to the point, President-Elect Obama is missing out on an opportunity to speak out on a major public health issue. By coming clean about his struggle to overcome his nicotine addiction, Obama would give renewed hope and courage to struggling smokers and ex-smokers everywhere. If Obama, the icon of cool, the Unruffled One, cannot make good on a promise to his wife to quit smoking, then quitting smoking must be one hell of an undertaking.

As Chancellor writes: “The most striking thing about it all is that a man as calm, controlled and disciplined as the next president should have so far failed in his efforts to set himself free. At least I can take comfort from the fact that I am in the most distinguished company. But I also intend to join him in his New Year resolution to stop smoking, mainly in my case because it’s just too expensive.”


Photograph: Lisa Jack/Bloomberg News/Time

addiction smoking nicotine

A Dubious Choice for Drug Czar

Obama should just say no to Congressman Ramstad.

At the Huffington Post, Maia Szalavitz deconstructs the exaggerated outcome data being used by Minnesota Teen Challenge (MNTC) to document the supposed effectiveness of their addiction treatment program. Plenty of treatment programs inflate their success numbers, knowingly or unknowingly, by using flawed statistics to support their arguments. Often--as in this case--there is no control group, thereby making firm statements about the “success” of a treatment all but impossible to prove.

So why bother pointing out such obvious problems in the case of Minnesota Teen Challenge? Primarily, Szalavitz writes, because “the sole sponsor of an earmark providing $235,000 to Minnesota Teen Challenge, a branch of a national anti-addiction group which believes that recruiting people into the Assemblies of God ministry will cure their addiction,” was none other than Jim Ramstad (R-Minnesota) a populist conservative Obama is considering as the nation’s new “Drug Czar.”

(Earlier this year, Congressman Ramstad came out in opposition to plans for the crescent-shaped Flight 93 Memorial Project, arguing that the design had “Islamic features.”)

NORML, the National Organization for the Reform of Marijuana Laws, gives Ramstad a grade of 30, indicating a “hard-on-drugs” stance. Ramstad, an alcoholic in recovery, backs expanded drug testing for federal employees, and beefed-up military patrols along the Mexican border in order to battle “drugs and terrorism.”

Unfortunately for the country’s hard drug addicts, Ramstad is also adamantly opposed to such things as needle exchange programs and medical marijuana.

No word yet from Ramstad on sentencing issues or the matter of addiction treatment rather than incarceration.

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Doctors Still Don’t Understand Addiction

Med schools ignore major health problem.

If there is one thing most workers in the field of addiction treatment can agree upon, it is that doctors are inadequately trained to deal with addicted patients.

Researchers at the Boston Medical Center recently reported that “education on addiction is inadequate during medical training, resulting in suboptimal medical care for those at risk.” In a study published in the Journal of General Internal Medicine, the Boston researchers found that a “Chief Resident Immersion Training” program yielded significant benefits. This “train the trainers” approach “effectively transferred evidence-based addiction knowledge and practice to 64 chief residents in generalist disciplines and more importantly, enhanced the addiction curriculum in 47 residency programs,” according to Daniel P. Alford, associate professor of medicine at Boston University School of Medicine.

The problem is not a new one. In 2003, Howard Markel of the New York Times wrote that the failure of primary care physicians to diagnose substance abuse was due to “insufficient training in the treatment of addiction, doctor’s frustration with afflicted patients, the common perception among doctors that treatment for substance abuse does not work, and a poor rate of insurance reimbursement for such services.” Dr. June E. Osborn of the Josiah Macy Jr. Foundation put it bluntly: “In clinical situations where they don’t know exactly what they are doing, doctors tend to walk away and adopt an attitude of blaming the patient.”

The Times article concluded that “scant formal training on addiction and substance abuse is available in American medical schools. Now, most of them offer only a few hours on these complex subjects and even less is offered during most residency or postgraduate programs.”

Moreover, in actual practice, insurance benefits for substance abuse problems present a difficult reimbursement problem in many cases. Hence doctors may be more reluctant to offer a formal diagnosis of addictive disorder.

Joseph Califano Jr. of Columbia University’s National Center on Addiction and Substance Abuse told a conference in October: “Although doctors and nurses have the best opportunity to intervene with alcoholics and substance abusers, our research indicates they are woefully inadequate at even diagnosing someone with this disease." Surveys conducted by the center showed that 90% of primary care doctors fail to offer a diagnosis of addiction even in patients clearly displaying classic hallmarks of the condition.

To redress the current state of affairs, the center recommends formal substance abuse training for med students, residents, and doctors, expanding drug dependency coverage under Medicare, Medicaid and private insurers, and “adding legal accountability” for doctors who fail to diagnose addiction when warranted.

To be fair, however, the plight of doctors in this regard is not to be underestimated. Dr. Catherine D. DeAngelis, editor-in-chief of the Journal of the American Medical Association, told the New York Times that “caring for patients with substance abuse is one of the most difficult things I have ever had to deal with as a doctor.... when the ailment in question carries a substantial behavioral component, like substance abuse, physicians get frustrated and don’t do as well.”

Graphics Credit: Codinghorror.com

Rate Your Drugs

Web site gives patients a chance to sound off.

A reader kindly pointed me to www.rateadrug.com, which claims as its mission the creation of “healthcare’s most comprehensive user-sourced database of short and long- term prescription drug side-effects, efficacy and overall benefits information.”

RateADrug, with a small but growing database, says that the site “picks up where clinical trials and FDA disclosures leave off. By taking a free five-minute survey, the users of over 5,000 prescription drugs can complete an unprecedented evaluation of their own experiences and reactions and then compare them with other users worldwide.”

“If Vioxx has taught us anything,” according to the site’s home page, "it’s that sometimes it takes a while for adverse effects to be identified.”

RateADrug claims to provide “an online, community-based rating system that allows users to share information about possible side effects and benefits they experience from prescription drugs, medical procedures and nutritional supplements. The site uses anecdotal reports from highly diversified user groups to add to data from clinical trials and FDA disclosures. Users can evaluate and share their experiences about a broad range of medical treatments, alternative therapies and prescription drugs by participating in RateADrug's ongoing surveys.”

The surveys are anonymous, the site declares, and become part of statistically aggregated scores for each prescription medication.

RateADrug does not accept advertising or infomercials from pharmaceutical companies. Doctors and other health care providers are invited to participate and submit comments.

According to Mark Deuitch, RateADrug.com founder and CEO:

"The one constant in health care is the need for greater creativity, discovery, and transparency in dealing with the effectiveness and potential negative side effects of prescription drugs and other medical treatments."

Rain Forest Being Lost to Coca Production

5.5 million acres of devastation.

The vice president of Columbia told a conference of police chiefs in Belfast that drug users in the United Kingdom were responsible for environmental catastrophe in his country.

Citing figures that claim roughly 500,000 acres of Columbian rain forest are decimated each year to make room for the production of coca, vice president Francisco Santos Calderon also claimed that drug gangs now use of land mines to protect their crops, resulting in the accidental maiming of rural Columbians. According to a BBC News report last month, the use of landmines has been described as “similar to a war zone.”

In remarks earlier this year reported in the U.K. Telegraph, Mr. Santos said: "This destruction of the rainforest for coca production and coca plantation has gone on under the radar of the environmentalists. We hope that this will be a wake-up call. We hope that the World Wildlife Fund and Greenpeace will start saying 'what is this?' "

Bill Hughes of the U.K.’s Serious Organized Crime Agency told the BBC that “not only is cocaine ripping the country apart through deforestation, landmines are creating amputees on a scale not recognized.” Moreover, drug operations frequently make us of banned pesticides, thereby endangering soil and water quality.

Over the past 20 years, according to vice president Santos, almost 5.5 million acres of rain forest have been sacrificed to cocaine production in “the world’s second most bio-diverse country.” He urged policymakers to consider such results as a major part of what Home Office Minister Vernon Croaker called the “real price” of cocaine use. According to Mr. Croaker, cocaine was the only drug in the U.K. to have shown an increase in consumption since 1998.

Cocaine remains more popular than marijuana in many areas of the U.K. However, the BBC also reports that the purity of imported cocaine is at its lowest ebb ever—as low as 10%, in some cases. According to Mr. Hughes, “This is being put together by seriously bad organized criminals; they don’t care what they are giving to people.”

Photo Credit: Telegraph.co.uk

Marijuana Panic Revisited

U.K. journal casts doubt on psychosis connection.

In May of this year, The University College of London reports that different strains of marijuana cause different types of psychological maladies. Shortly thereafter, Prime Minister Brown "publically described new strains of cannabis as 'lethal,' as if they could trigger a fatal overdose," according to an editorial in the Guardian. (See "U.K. Marijuana Panic Continues"). And in August, a mental health story run by the London Daily Mail claimed that smoking a single joint of marijuana increased the risk of developing schizophrenia by 41 per cent—an erroneous statistic that was also hotly contested by various U.K. drug experts. (See "Media Suffers Attack of Cannabis Psychosis").

Now comes a review article from the British Journal of Psychiatry, published by the Royal College of Psychiatrists, strongly suggesting that the odds of an association between cannabis and psychosis is “low.”

A group of drug experts and psychiatrists, including scientists from the University of Bristol, Imperial College London, Cambridge University, and Cardiff University undertook to “systematically review the evidence pertaining to whether cannabis affects outcome of psychotic disorders.”

The group searched relevant databases and compiled a list of more than 15,000 relevant references. A total of 13 longitudinal studies were included in the quality assessment.

The authors concluded that, despite prevailing clinical opinion, it remained “unclear” whether cannabis led to worse outcomes for people with psychosis, “or whether this impression is confounded by other factors. Specifically, the review authors noted that “few studies adjusted for baseline illness severity, and most made no adjustment for alcohol, or other potentially important confounders. Adjusting for even a few confounders often resulted in substantial attenuation of results.”

In the end, “confidence that most associations were specifically due to cannabis is low.”

Graphics Credit: COSMOS

addiction drugs

E-Cigarettes and Health

Smokeless nicotine comes under scrutiny.

You may never have heard of it—but it’s the newest drug in town. It’s called an electronic cigarette, or “e-cigarette.” Electronic cigarettes use batteries to convert liquid nicotine into a fine, heated mist that is absorbed by the lungs. No smoke, but plenty of what makes cigarettes go, if you don’t account for taste—or ashtrays and smoke rings.

In an attempt to work around the world’s growing ban on cigarette smoking in public places, a Hong Kong-based company developed the first e-cigarette in 2004. Since then, other companies have done the same, claiming that e-cigarettes are much healthier than regular smokes.

Last month, that claim was vigorously disputed by the World Health Organization (WHO). In fact, WHO said electronic cigarettes can be deadly. Stressing that the device had not been adequately tested, Douglas Bettcher, the director of WHO’s Tobacco Free Initiative, told the Associated Press that “there’s no experience in pharmacology yet of nicotine replacement therapies which actually inhale nicotine in the lungs.” Replacement therapies such as skin patches and gum have undergone thorough clinical testing, Bettcher said. For these reasons, “the World Health Organization does not consider the electronic cigarette to be a legitimate nicotine replacement therapy.”

The anti-smoking group Action on Smoking and Health (ASH) doesn’t think much of e-cigarettes, either. In the U.K. Times Online, ASH director Deborah Arnott said that “at the moment we don’t know enough about this product. Quality control in China is not the highest, and our advice is it’s best to use nicotine products like gums and patches. The electronic cigarettes fall into a regulatory gap and they haven’t been chemically tested.”

So far, electronic cigarettes are being actively marketed in China, Great Britain, Canada, Brazil, Israel, Sweden, and other countries. The cartridges containing the liquid nicotine are available in several flavors, and battery life is estimated at one to three days for most units. The e-cigarette web site www.e-cig.org offers a list of “best places to use your electronic cigarette,” such as airplanes, in church, at the mall, in a restaurant, bar or hospital, or “at your kid’s school recital.”

According to China View News , a “changeable filter contains a liquid with nicotine and propylene glycol. When the user inhales as he would when smoking, air flow is detected by a sensor and a micro-processor activates an atomizer which injects tiny droplets of the liquid into the flowing air, producing a vapour.”

The unit, which looks like a long cigarette, is powered by a rechargeable battery. Propylene glycol is a commercial product sold as a low-toxicity version of antifreeze, among other applications.

E-cigarettes are readily available for purchase online, and at least one American firm has announced plans to market versions of e-cigarettes domestically. However, none of the manufacturers to date seems to be working through the existing regulatory framework, which in most countries calls for toxicity analyses and clinical studies. Jason Cropper, managing director of the Electronic Cigarettes Company, told BBC News that e-cigarettes “are certainly healthier than smoking cigarettes. Tests have been done on mice in the lab and they have shown they are not harmful.” However, Cropper said, no human trials had been undertaken because they are too expensive.

The World Health Organization became involved in the matter after several e-cigarette manufacturers began using the World Health Organization’s logo on advertisements and product inserts. “It’s 100 percent false to affirm this is a therapy for smokers to quit,” Bettcher said. “There are a number of chemical additives in the product that could be very toxic.”

Meanwhile, The Ruyan e-cigarette, a joint effort by Ruyan Holdings Ltd. of Hong Kong and Ruyan America, Inc., won Most Innovative Product of 2008 at the Tobacco Plus Expo in Las Vegas last May.

addiction drugs smoking nicotine