Heroin for Heroin Addiction

Getting your fix at the doctor’s office.

A group of Canadian researchers has demonstrated the truth of a practice commonly used in European countries like The Netherlands and Switzerland: Heroin can be an effective treatment for chronic, relapsing heroin addicts. Published in the New England Journal of Medicine, the study is “the first rigorous test of the approach performed in North America,” according to a New York Times article by Benedict Carey.

In the study, 226 patients were randomly assigned to oral methadone therapy or injectable diacetylmorphine, the primary active ingredient in heroin, over a 12-month period. The “rate of retention in addiction treatment” was 88 percent for the diacetylmorphine group, compared to 54 percent for the methadone group. The “reduction in rates of illicit-drug use” was 67 percent for the heroin group and 48 percent for the methadone group.

Using doctor-prescribed heroin has two advantages, some researchers believe. It gets around the problem of addicts who don’t like the effect of methadone and therefore don’t take it as prescribed. Moreover, as European countries have demonstrated, it brings treatment-resistant opiate addicts into regular contact with physicians and medical treatment professionals, thereby keeping them away from drug dealers and out of jail.

The downside is equally obvious. It keeps addicts hooked on heroin, and may even exacerbate their addiction by providing a higher quality drug. Furthermore, it runs against the prevailing North American notion that heroin should be illegal, period. Certainly, doctors have no business prescribing it to active addicts, critics argue. Furthermore, the risk of overdose or seizure is always present.

According to senior author Martin Schechter of the University of British Columbia’s School of Population and Public Health, as quoted in the New York Times: “The main finding is that for this group that is generally written off, both methadone and prescription heroin can provide real benefits.”

In an editorial accompanying the journal article, Virginia Berridge of the London School of Hygiene and Tropical Medicine cautioned that “the rise and fall of methods of treatment in this controversial area owe their rationale to evidence, but they also often owe more to the politics of the situation.”

At the end of the 19th Century in America, opium was widely prescribed as a cure for alcoholism. For opium addiction, the treatment was often alcohol.

Photo Credit: www.steps2rehab.com

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Who are Cocaine’s Primary Victims?

The answer may surprise you.

They are not necessarily the poor, the desperate, or the weak-willed. A National Institute of Drug Abuse (NIDA) study by Dr. Michael Nader and coworkers at Wake Forest University demonstrates that they are likely to be people with innately low levels of dopamine receptor availability. This flaw, possibly genetic, renders them more sensitive to the rewarding effects of cocaine. Put simply: Individuals with less dopamine naturally available in the brain may have an inherited predisposition for cocaine addiction. [Brains Scans at right: Dopamine receptor availability in yellow falls markedly after 6 and 12 months of cocaine self-administration.]

Dopamine D2 receptors, a crucial part of the brain’s primary reward system, are normally occupied by dopamine molecules—although at any given moment, many of the receptors are empty and remain available until a stimulus like cocaine increases dopamine levels and the empty receptors help mop up the excess. Dr. Nader believes that lower D2 receptor availability could be a precursor of addiction to drugs like cocaine. “Perhaps an individual with low availability gets a greater kick from cocaine because the drug-induced dopamine release stimulates a greater percentage of their receptors,” Dr. Nader told staff writer Lori Whitten in a recent edition of NIDA Notes. “Another possibility is that the drug prompts some individuals’ brain cells to release dopamine in particularly high quantities that are sufficient to fill the great majority of vacant D2 receptors, and this augments the high.”

An obvious question hangs over studies of this kind: Are the D2 receptor differences innate, or do they represent changes induced by drug use? To answer this question, Dr. Nader’s team worked with rhesus monkeys in order to take D2 density measurements with PET scans before the animals had ever been exposed to cocaine. Sure enough, the monkeys with the lowest baseline level of D2 receptor availability went on to self-administer cocaine at much higher rates than their D2-normal compatriots. Offering food to the low-dopamine animals did not prove to be a substitute of cocaine, so the effect does not appear to increase all kinds of reward.

There is no doubt that the use of cocaine itself does lead to a rapid reduction of available dopamine receptors, as the brain seeks to achieve a new equilibrium in the face of regular dosings of dopamine-active chemicals. In five monkeys that self-administered cocaine for a year, three of the monkeys showed a strong recovery of receptor availability after only a month of abstinence. However, two of the monkeys showed slower recovery of previous D2 receptor levels. Dr. Cora Lee Wetherington, a neuroscience researcher at NIDA, said that the research thus posed the question of whether people whose dopamine receptor levels recover more slowly during abstinence might prove to be those most likely to relapse.

Medications that increase D2 receptor availability without themselves being highly rewarding represent another promising avenue for treatment. The drugs most likely to help, Dr. Nader thinks, are drugs that act indirectly on dopamine levels through alterations of serotonin and GABA levels in the brain. In addition, researchers are pursuing environmental enrichment experiments in animals and human subjects. Some studies have shown that enriching the environment results in greater D2 receptor levels, Dr. Nader says.

Photo Credit: NIDA

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Rules for a Night of Serious Drinking

Simple moves to dodge a hangover.

Let's face it: Despite all the folk remedies--ginseng, prickly pear extract, peanut butter, miso soup, and Vitamin B6, there really is no cure for a hangover except more alcohol.

However, there are things you can keep in mind when contemplating a night of serious drinking. What you do while you are drinking can mitigate or exacerbate the effects of the Day After. The following list was adapted from a post by the folks over at the Nursing Schools Network and Directory and used with their kind permission.

--If you're in it for the long haul, consider alternating an alcoholic beverage with a non-alcoholic drink. The reward for this is continual hydration, which helps offset the tendency of alcohol molecules to replace water molecules in the cells.

--Choose your liquor carefully. Red wine and cheap dark booze have more congeners, which are organic molecules that can contribute to a hangover. ML01, a genetically-modified yeast, is being touted as a way of cutting back on the headaches commonly associated with a night of red wine.

--Keep Count. When you lose count, it's time to stop. Know your measure.

--Skip the Sugar. Sweet drinks mess with your blood sugar level even more than regular drinks.

--Keep the smoking to a minimum. You'll need your oxygen come morning.

--Don't diss the bar and cocktail snacks. Foods high in fat well help absorb excess alcohol.

--Skip the Tylenol and Ibuprofen before going out. They probably won't help, and the combination with alcohol taxes the liver.

--Drink water. And keep drinking water. Morning-after dehydration causes many of a hangover's lingering effects.

--Stop drinking an hour before you go to bed. Better to nod off than to pass out, and you will have a better chance of sleeping through the night.

Picture Credit: www.ehow.com

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The Medicalization of Legalization

Punish the crime, treat the disorder.

The alcoholic in A.A. and the cocaine addict on the street share a common appetite. This shared appetite, and the behaviors that come with it, are played out in a larger social context. For a practicing addict, the world is filled with risks, and some of these risks are invariably connected with the web of prohibitive laws and legislation governing the sale and use of addictive drugs. The movement for drug legalization, which began to coalesce about twenty years ago, is a collection of public voices spanning a variety of political and cultural points of view. Many prominent voices in the ranks of the legalization movement are public officials who have become disillusioned with the current state of affairs, and are now convinced that the present system is doing more harm than good.

The essential argument against legalization is that some drugs are not bad because they are illegal—they are illegal because they are bad. If alcohol and tobacco are legal, and we are only now beginning to come to terms with the health implications of that historical decision, it is insane to add heroin and marijuana and everything else to the list.

Harvard psychiatrist Robert Coles, a specialist in working with children, holds that legalization would be tantamount to a “moral surrender of far-reaching implications about the way we treat each other.” Such an act, Coles believes, would signal an acceptance of the pursuit of hedonism for its own sake.

However, the medicalization of addiction requires people to consider the possibility that drug abuse is less of a problem than drug crime--and that drug crime can be attacked differently. Very few of legalization’s adherents can be considered “pro-drug.”

Drug prohibition itself is a major part of the reason why the more potent and problematic refinements of plant drugs keep taking center stage. Since crack cocaine is more potent, more profitable, and more difficult to detect in transit, it replaces powdered cocaine, which, in its turn, replaced the chewing of cocoa leaves. Similarly, in the old days bootleggers switched from beer to hard liquor, just as modern international drug dealers switch from cannabis to cocaine whenever the U.S. enforcement engine lumbers off in the direction of marijuana interdiction and eradication. Is there anyone prepared to argue that the gruesome scenes along the Mexican border, as rival militias battle it out for control of the drug trade and the U.S. tries to interdict it, is somehow helping alcoholics and other drug addicts find their way to abstinence?

While the fact of addiction may be beyond the individual addict’s control, addicts nonetheless have a responsibility to do something about their disorder. What would we think of a diagnosed diabetic who told us there was no point in trying to treat his disease; it was all genetic and physical and therefore a waste of time to treat, and impossible to overcome? We would think they were nuts.

From a legal point of view, the biochemical model of addiction does not change the basic proposition that, with few exceptions, people must be held responsible for the crimes they commit in connection with drug or alcohol use. But simple possession should rarely be one of those crimes.

In time, it may be possible to separate out the criminals suffering from concrete biochemical abnormalities, so that they can receive medical treatment in addition to, or in lieu of, a prison sentence.

Punish the crime, treat the disorder.

Adapted from The Chemical Carousel: What Science Tells Us About Beating Addiction.

Photo Credit: NIDA

It’s So Easy To Slip

Simple reasons to kick addictions.

In a recent article for Scripps Howard News Service, Dr. Barton Goldsmith, a family therapist in California, listed "10 Reasons to Kick Addictions."

Nothing in the doctor’s list is shocking, or especially revelatory, or novel. But what caught my eye about his list was the simplicity with which Goldsmith states certain common facts about abstinence--facts that struggling alcoholics and other drug addicts often tend to deny or “forget.”

Here is a brief synopsis of some of Goldsmith’s observations:

--“Your friends and family will be happy to see and count on you again.”

In part, that’s because you will no longer being blaming them for your own problem.

--“You will like yourself better.”

Say goodbye to a whole lot of guilt and misdirected anger.

--“Your body and mind will feel awake and alive once again. One reason people continue to drink and use is because they physically experience the withdrawals of the substance and need to continue the addiction just to "feel normal.’”

The idea of a certain subset of people using drugs to “feel normal” is one of the crucial insights into modern research on addictive disorders.

--“You will make the world a tiny bit better. Just by being a little nicer, as well as extending a helping hand to others, (which will help you stay sober), you will make this world a better place.”

This may sound a bit twee, but it is a guiding principle in Alcoholics Anonymous and other non-profit self-help groups. Committing charitable acts for others is a classic way of seeking to go beyond the boundaries of the commanding self.

--“Others can once again trust you. An added benefit is that you can also trust yourself again, because you have gotten through one of the most frightening things in life.”

If you can do this one thing, you can do practically anything.

--“You will have more joy in experiencing a day rather than sleeping through it.”

You will also find that you have considerably more time available to you. In the early going, that can be a challenge, but it eventually becomes a wonderful thing.

-- “You will have more money.”

Indisputably true.

Photo Credit: www.zazzle.com

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A (Belated) Review of "The Los Angeles Diaries"

A powerful—and true—memoir of addiction.

I’ll admit it: I don’t like drug memoirs. I didn’t like drug memoirs even before James Frey blew up the whole genre by telling a heartfelt story about addiction that turned out to be a tissue of lies.

But The Los Angeles Diaries by James Brown transcends all that. I’ve never read a better true story about addiction. It’s also one of the best modern autobiographies I have ever read, addiction notwithstanding. In addition to having been an alcoholic and a meth head, James Brown is a very talented writer, the author of four novels, and it shows.

First published in 2003, The Los Angeles Diaries is a spare, utterly harrowing account of the author’s experience in a family marked by a history of virulent alcoholism. Brown’s unvarnished truth-telling about addiction is evident early on: “I know there’s no excuse for getting drunk when you’re supposed to be home with your family and I wish knowing this would stop me from doing it. I wish that’s all it took. That I could will it to happen. But it doesn’t work that way, it never has, and in my state of mind, at this particular moment, I can’t imagine living without it.”

While offering up memorable sketches of his boyhood in Los Angeles, Brown paints a devastating picture of the “denial and rage” that characterize full-blown addiction. He deals with the suicide of family members, divorce, the neglect of his children—all of it caused by addiction—without a shred of self-justification. It is, he writes, “a constant quest for more when there can never be enough.”

Interspersed throughout are the author’s mordantly funny adventures in the screen trade, as book after book is optioned for the movies, taken apart and ultimately scrapped before reaching the screen. However, we are never far from the author’s chilling revelation: “Never underestimate the power of denial.”

I can’t improve on the review that appeared in Washington Post Book World: “It’s the balance of agony and grace, of course, that makes life so ferociously interesting. Brown has perfectly captured that balance in his unpretentious, very profound book.”

Inspiring, witty, and bleak, all at the same time, James Brown’s book will appeal to anyone with an interest in addiction—and anyone who enjoys tough, spare prose.

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E-Cigarettes: Another Look

FDA remains conflicted over safety concerns.

The Food and Drug Administration (FDA) issued a controversial Safety Alert over electronic cigarettes, known as “e-cigarettes,” then held a press conference to explain itself. The agency’s muddled response to the issue has prompted increased advertising and online sales for Asian e-cigarette manufacturers, as well as a countering burst of criticism about the newest nicotine delivery system under the sun.

The FDA conducted a small-scale lab analysis of two different brands of e-cigarettes, and found “carcinogens and toxic chemicals such as diethylene glycol, an ingredient used in antifreeze.” The FDA’s Division of Pharmaceutical Analysis also found evidence of small amounts of cancer-causing nitrosamines. “These products do not contain any health warnings comparable to FDA-approved nicotine replacement products or conventional cigarettes,” the agency bulletin said. Therefore, the agency “has no way of knowing, except for the limited testing it has performed, the levels of nicotine or the amounts or kinds of other chemicals that the various brands of these products deliver to the user.”

The agency did not seek to ban e-cigarettes, as Canada did in March. However, in a written statement to CNN in March, the FDA admitted it had been detaining or refusing importations of electronic cigarettes for more than a year.

Debate has raged recently over the safety of e-cigarettes, which are battery-operated cigarette substitutes that technically dodge no-smoking bans, since no actual smoke is emitted. When a smoker inhales on the e-cigarette, the battery warms liquid nicotine stored in a plastic filter, producing a smokeless but inhalable form of synthetic nicotine. Upon exhalation, there is a small puff of vapor that quickly evaporates (See my earlier post, "E-Cigarettes and Health").

Michael Levy, director of compliance for the FDA’s division of drug evaluation and research, said he believes the products are illegal. However, “There is pending litigation on the issue of FDA’s jurisdiction over e-cigarettes,” he said.

Proponents of the e-cigarette claim that the devices are self-evidently safer than smoking cigarettes, and can help people stop using tobacco products. Critics respond that the safety of synthetic nicotine drug-delivery devices has not been established. Moreover, the range of fruit and candy flavors offered by e-cigarette manufacturers suggests to Jonathan Inickoff of the American Academy of Pediatrics Tobacco Consortium that the devices seem “tailor-made to appeal to kids,” while addicting them to nicotine and turning them into future cigarette smokers.

With half a million Americans dying prematurely each year from smoking, according to figures from the Centers for Disease Control (CDC), some doctors and tobacco researchers have pointed out that nitrosamines are also found in everything from nicotine patches to bacon. According to one researcher, “FDA should be encouraging, not maligning the manufacture and sale of electronic cigarettes, and working with manufacturers to assure the highest possible quality control.”

For a robust discussion of the e-cigarette question, see www.e-cigarette-forum.com


Photo Credit: www.politech.wordpress.com

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