Deputy Drug Czar Goes His Own Way

Doctors are part of the problem, says McLellan.

In a March 15 cover story titled “The American Way,” Drink and Drugs News  of the UK ran an insightful interview with America’s “deputy” Drug Czar, Thomas McLellan. Professor McLellan, deputy director of the Office of National Drug Control Policy, is not a cop, like his boss Gil Kerlikowske, or a retired Army general, like former Drug Czar Barry McCaffrey. McLellan is a rare breed, a treatment specialist, and brings an entirely different viewpoint to an office that has traditionally been strongly oriented toward law enforcement.

“In the US we’ve been thinking about addiction as just a lot of drug use,” McLellan told a group of addiction specialists and policy professionals at the Institute of Psychiatry in London. “And as a result we’ve been purchasing [treatment] stupidly. We can’t decide if addiction is a crime or a disease so we’ve compromised and given them treatments that aren’t any good.”

McLellan singled out doctors for special attention: “Most physicians are not trained in how to treat substance abuse. They don’t see it as a disease and don’t see why they should look for it.”

Treating addiction like any other medical condition is still a goal rather than a reality. “You may know that the relapse rates for diabetes, hypertension and asthma are almost identical to the relapse rates for any addictive disorder…. And no one puts their hands on their hips when a diabetic comes back and says, ‘I ate half a bucket of fried chicken and I forgot to take my insulin, and now I’m back here.’ They just treat them.”

If there are doctors who don’t believe in the disease model of addiction, we can’t be surprised if members of the general public—and addicts themselves--often feel the same way.  McLellan said that less than 3 % of all referrals for addiction treatment and specialty care originate with doctors. Moreover, roughly half of 12,000 smaller treatment programs in the U.S. have no doctor, nurse, or psychologist on staff. And counselors, who make up the majority of treatment staff, suffer from a 50 % turnover rate.

In addition, McLellan took on the traditional British aversion to methadone treatment for heroin addicts: “That this has been a battle, that you are either on methadone or you are on the path of truth, beauty and light, is artificial and unfortunate…. I’m now officially wagging my finger and saying not just to Britain, but to the whole damn field; get past this, this is an artificial contrivance. People ought to have the opportunity to get the medications and other services they need.”

McLellan also had choice words for politicians and policy makers who see incarceration as the only acceptable response to drugs and drug-related crime.  He referenced studies that “suggest very clearly that in a prison situation, when you release somebody with a drug problem, they are back and you’re going to do it all over again. It’s a bad business deal.”

Ongoing care—after prison, or after treatment—is essential to success. “I think residential care is important and necessary, but not sufficient,” McLellan maintained. “It is like having a very good junior high school education.”

Photo Credit: http://www.csam-asam.org/

Can I Smoke in Here?

New tobacco map highlights state differences.

An interactive online map set, showing state-by-state variations in smoke-free laws, cigarette tax rates, and rates of tobacco control spending, has been put together by the Robert Wood Johnson Foundation, and is now available for viewing at the foundation’s Public Health site HERE.

“Users will be able to see whether a state is ahead or behind the curve in protecting and promoting health,” says Michelle Larkin, the leader of the Robert Wood Johnson Foundation Public Health Team. “We know from the research that the two most effective policies to pursue are raising tobacco taxes and putting smoke-free air laws into place,” says Larkin, adding that “these two policies help to prevent youth from ever starting to smoke and they also help smokers quit.”

To that end, the interactive maps that comprise the project can be used to track changes from state to state in smoke-free legislation and taxation rates over time. A third map can be used to track the extent to which states are complying with CDC recommendations for tobacco control expenditures. (Answer: most of them aren’t.)

The hope is that the interactive tobacco map will provide policymakers with a nationwide picture of tobacco policy, using the state-by-state breakdowns to predict trends and to demonstrate how the tobacco control landscape has evolved and changed over the years.

The RWJF Tobacco Map uses data from the Campaign for Tobacco-Free Kids and Americans for Non-Smokers’ Rights.

Meth Babies—Fact or Fiction?

Research team finds brain abnormalities.

When it came to babies born to crack-addicted mothers, the media went overboard, creating a crisis in the form of an epidemic that never quite was. By contrast, when it came to babies born to alcoholic mothers, Fetal Alcohol Syndrome went unrecognized in the science and medical community until 1968.

Now comes a study on prenatal methamphetamine exposure in The Journal of Neuroscience, headed up by Elizabeth Sowell of the University of California, Los Angeles, with support from both the National Institute on Drug Abuse (NIDA) and the National Institute of Alcoholism and Alcohol Abuse (NIAAA.) The report garnered considerable media attention. “We know that alcohol exposure is toxic to the developing fetus and can result in lifelong brain, cognitive and behavioral problems,” Sowell said in a press release. “In this study, we show that the effects of prenatal meth exposure, or the combination of meth and alcohol exposure, may actually be worse.”

It makes sense that meth might effect the health of unborn children.  There is a modest body of research to support the notion. The Sowell study points a finger at the caudate nucleus, a brain region involved with learning and memory.  The study showed that the caudate nucleus of the meth-using group was reduced in size. “Identifying vulnerable brain structures may help predict particular learning and behavioral problems in meth-exposed children,” the press release optimistically states. And the potential problem is real enough: More than 16 million Americans have used meth, according to government numbers. An estimated 19,000 of these users are pregnant women.

But is this particular study a definitive one? The icing on the cake? To begin with, the press release from The Journal of Neuroscience admits to a major problem right up front: “About half of women who say they used meth during pregnancy also used alcohol, so isolating the effects of meth on the developing brain is difficult.”  Even in cases of meth exposure only, there are a host of negative behavioral factors that often accompany meth addiction (bad nutrition, minimal health care, poor health) that can significantly effect fetal development.

The study team compared the MRI brain scans of 61 children: “21 with prenatal MA (methamphetamine) exposure, 18 with concomitant prenatal alcohol exposure (the MAA group), 13 with heavy prenatal alcohol but not MA exposure (ALC group), and 27 unexposed controls. While finding “striatal volume reductions,” as well as increases in the size of certain limbic structures in both groups with meth and/or alcohol exposure, the researchers conclude that striatal and limbic structures “may be more vulnerable to prenatal MA exposure than alcohol exposure.” However, that conclusion was apparently reached despite the fact that only 3 of the 61 children under study were born to mothers who did meth, and meth only, during pregnancy.

Furthermore, there is significant controversy over brain scan studies that measure gross anatomical changes in the size of specific brain regions, rather than brain region activity based on blood flow.

Is there other evidence for the danger of meth use during pregnancy? There is, but as is frequently the case, some of the best evidence comes from animal studies. A 2008 guinea pig study by Sanika Chirwa showed neural damage to the hippocampus, another region involved in memory, in newborn animals with prenatal meth exposure. Furthermore, the newborn animals showed an impaired ability to distinguish novel objects from familiar ones.

In 2006, a study at Brown Medical School, published in Pediatrics , found that newborns exposed to meth during pregnancy were born “small for gestational age,” meaning they were born full-term, but smaller than babies not exposed to meth in utero.  According to study author Barry Lester, “Children who are born underweight tend to have behavior problems, such as hyperactivity or short attention span, as well as learning difficulties.”

However, Lester added an important caveat in a Brown University press release : “I hope that the ‘crack baby’ hysteria does not get repeated. While these children may have some serious health and developmental challenges, there is no automatic need to label them as damaged and remove them from their biological mothers.”

Similar caution was urged by the authors of a 2009 report in the Journal of Developmental and Behavioral Pediatrics: “Efforts to understand specific effects of prenatal methamphetamine exposure on cognitive processing are hampered by high rates of concomitant alcohol use during pregnancy.”

In 2005, an open letter from the Center for Substance Abuse Research at the University of Maryland warned about the dangers of hyperbole, calling upon the media and public officials to “stop perpetuating ‘meth baby’ myths.” The Center argued that “The terms ‘ice babies’ and ‘meth babies’ lack medical and scientific validity and should not be used,” and requested that “policies addressing prenatal exposure to methamphetamines and media coverage of this issue be based on science, not presumption or prejudice.”

Sowell, E., Leow, A., Bookheimer, S., Smith, L., O'Connor, M., Kan, E., Rosso, C., Houston, S., Dinov, I., & Thompson, P. (2010). Differentiating Prenatal Exposure to Methamphetamine and Alcohol versus Alcohol and Not Methamphetamine using Tensor-Based Brain Morphometry and Discriminant Analysis Journal of Neuroscience, 30 (11), 3876-3885 DOI: 10.1523/JNEUROSCI.4967-09.2010

Smith, L., LaGasse, L., Derauf, C., Grant, P., Shah, R., Arria, A., Huestis, M., Haning, W., Strauss, A., Grotta, S., Liu, J., & Lester, B. (2006). The Infant Development, Environment, and Lifestyle Study: Effects of Prenatal Methamphetamine Exposure, Polydrug Exposure, and Poverty on Intrauterine Growth PEDIATRICS, 118 (3), 1149-1156 DOI: 10.1542/peds.2005-2564

Photo credit: http://www.psychiatry.emory.edu

Germs in Tobacco

Bacteria found in major cigarette brands.

It’s not enough that smoking causes all manner of cardiopulmonary complications, or that more than 3,000 chemicals and heavy metals have been identified as additives. Now comes evidence that tobacco particles extracted from cigarettes contain markers for hundreds of known bacteria. Lung infections in some smokers may be caused by germs on shredded tobacco, rather than the act of smoking itself.

According to a report by Janet Raloff in Science News, Amy Sapkota and a team of researchers at the University of Maryland screened tobacco flakes from cigarettes for bacterial DNA using known markers. In an online paper for Environmental Health Perspectives, the scientists explored the bacterial metagenomics of cigarettes using standard cloning and sequencing processes. The team provided evidence for the presence of Campylobacter (a cause of food poisoning), E. coli, several Staphylococcus varieties, as well as a number of bacteria, such as Clostridium, which is directly associated with pneumonia and other infections. Fifteen different classes of bacteria in all, with no significant variation from one cigarette brand to another. 

The time has come, Sapkota and coworkers conclude, “ to further our understanding of the bacterial diversity of cigarettes,” given the more than 1 billion smokers worldwide.  Smoking is now recognized as a risk factor for a basketful of respiratory illnesses, including influenza, asthma, bacterial pneumonia, and interstitial lung disease. In light of this, the authors have advanced their study as solid evidence that “cigarettes themselves could be the direct source of exposure to a wide array of potentially pathogenic microbes among smokers and other people exposed to secondhand smoke.”

In 2008, researcher John Pauly and coworkers at the Roswell Park Cancer Institute in Buffalo, New York, helped provide early evidence by conducting a tobacco flake assay and publishing the results in the journal Tobacco Control. The scientists opened a package of cigarettes “within the sterile environment of a laminar flow hood. A single flake of tobacco was collected randomly and aseptically from the middle of the cigarette column and placed onto the surface of a blood agar plate. The test cigarettes included eight different popular brands, and these were from three different tobacco companies.”

And the results? “After 24 hours of incubation at 37 degrees C, the plates showed bacterial growth for tobacco from all brands of cigarettes. Further, more than 90% of the individual tobacco flakes of a given brand grew bacteria.” Pauly believes that “the results of these studies predict that diverse microbes and microbial toxins are carried by tobacco microparticulates that are released from the cigarette during smoking, and carried into mainstream smoke that is sucked deep into the lung.”

In a recent study published in Immunological Research , Pauly and others expanded on their findings, writing that “Cured tobacco in diverse types of cigarettes is known to harbor a plethora of bacteria (Gram-positive and Gram-negative), fungi (mold, yeast), spores, and is rich in endotoxin (lipopolysaccharide).” This time out, the researchers conclude that “lung inflammation of long-term smokers may be attributed in part to tobacco-associated bacterial and fungal components that have been identified in tobacco and tobacco smoke.”

Cigarette manufacturers already use antibacterial washes during the curing process in order to reduce infection by fungi and bacteria.

If the findings are sound, they could place the argument over secondhand smoke in a vastly different light—cigarettes smoke may be taking the rap for respiratory infections cause by extant bacteria. With smoking rates in the U.S. holding at a steady 21 percent of the population, the issue is not trivial.

Graphics Credit: http://commons.wikimedia.org/

Sapkota, A., Berger, S., & Vogel, T. (2009). Human Pathogens Abundant in the Bacterial Metagenome of Cigarettes Environmental Health Perspectives, 118 (3), 351-356 DOI: 10.1289/ehp.0901201

Pauly, J., Smith, L., Rickert, M., Hutson, A., & Paszkiewicz, G. (2009). Review: Is lung inflammation associated with microbes and microbial toxins in cigarette tobacco smoke? Immunologic Research, 46 (1-3), 127-136 DOI: 10.1007/s12026-009-8117-6

Marijuana Q & A

My interview with AllTreatment Blog.

Denny Chapin, Managing Editor of AllTreatment.com, was recently invited to participate in an extended debate over marijuana withdrawal at the Drug WarRant blog site. I followed that debate with interest, due to the unusually high volume of responses to my own post on that subject.

Now Denny has kindly provided me the opportunity to offer my own views on a set of questions about cannabis use and cannabis dependency. The complete interview can be read at the AllTreatment site HERE.

Photo credit: http://www.medicalmarijuana.co.cc

The Cocaine Conundrum

Effective treatment remains elusive.

For addiction to cocaine, amphetamine, and other stimulants, the treatment picture has been complicated by the lack of any truly significant anti-craving medications. (See post, “No Pill for Stimulant Addiction"). The National Institute on Drug Abuse (NIDA) has yet to approve any medications for the treatment of either cocaine or amphetamine addiction.

Take the case of cocaine. Partly the problem stems from the direct effect cocaine has on dopamine transmission.  The hunt for a pharmaceutical approach to blunt that effect is complicated by the problematic nature of dopamine receptors.  Dopamine antagonist drugs like the antipsychotic drug haloperidol do not always block the stimulant rush. And their side effects, such as lethargy, emotional blunting, and tardive dyskinesia, make them unsuitable for ongoing addiction therapy. Conversely, some drugs that act as dopamine agonists turn out to be addictive in their own right. Many designer drugs are like that.

Because of all this, different approaches may be needed. The direct ride to the pleasure pathway provided by stimulants makes it difficult to tamper selectively with their effects. An antibody that would reduce cocaine consumption and sop up cocaine molecules in the brain, a kind of vaccine against cocaine, is one approach being pursued (See post, “Cocaine Vaccine Hits Snag”).

But other avenues of attack are being exploited.  Scientists in NIDA’s Intramural Research Program are testing compounds that target certain proteins known as dopamine transporters. Transporters move dopamine molecules in and out of the synaptic gap between neurons in the brain. Interfering with that transportation system is another way of altering dopamine uptake, and it represents one active avenue of approach to the treatment of cocaine addiction.

The researchers tested Benztropine Mesylate (BZT), brand name Cogentin, one of a class of drugs known as anticholinergic suppressants commonly used in the management of Parkinson’s disease. What exactly does benztropine do? It possesses both anticholinergic (acetylcholine-blocking) and antihistaminic effects. It has chemical similarities to atropine, which is used for Parkinson’s and for heart disease.

To begin with, the researchers wanted to establish that benztropine itself is non-addictive. By substituting different BZT analogs for cocaine during self-administration testing on addicted rats, “two of the three BZT analogs that were tested significantly reduced drug self-administration… which indicates that those BZT analogs themselves have low potential for abuse.”

Next, the cocaine-addicted rats were given different BZT analogs before they got their cocaine. “When given before rats had access to cocaine in the self-administration chambers,” the researchers reported in the Journal of Pharmacology and Experimental Therapeutics, “two BZT analogs also significantly reduced the number of times the rats would press a lever to receive cocaine.” Monoamine uptake inhibitors were used as a control. The authors conclude that “these compounds are promising candidates for the development of medications for cocaine addiction.”

Hiranita, T., Soto, P., Newman, A., & Katz, J. (2009). Assessment of Reinforcing Effects of Benztropine Analogs and Their Effects on Cocaine Self-Administration in Rats: Comparisons with Monoamine Uptake Inhibitors Journal of Pharmacology and Experimental Therapeutics, 329 (2), 677-686 DOI: 10.1124/jpet.108.145813

Photo credit: http://www.drugabuse.gov

Just for Fun: Simple Science Facts

Back to basics.

[Guest post adapted from 50 Simple Science Facts Everyone Should Know (But Doesn’t), from the folks at X-Ray Technician Schools.]

While obviously not everyone remains ignorant of the realities behind the myths, it is the sad truth that many of the following facts remain entirely obscured in the common consciousness – victims of myth and misconception in spite of reliable evidence to the contrary:

--Eating poppy seeds will not always result in a failed drug test. : The common myth about eating poppy seeds can lead to failing a drug test has a solid foundation in reality, as heroin, morphine, codeine, and other opiates are created from the plants. But Indiana University sheds some light on the reality of the situation, pointing out that only the seeds of opiate poppies cause false positives. For those who have eaten the offending poppyseeds, however, there are ways to determine whether or not the opiate traces come from narcotics or a harmless bagel.

--Do not mix ammonia and bleach together. : While death does not generally factor into the equation, blending ammonia and bleach together releases extremely harmful chlorine and other noxious gases that can cause serious damages to the lungs and brain – if not outright kill, of course. The State of New Jersey provides more details on using these cleansers safely.

--Acid into water, never water into acid. : The reliable mnemonic relating the procedure to A&W Root Beer helps students and chemists alike remember that the opposite effect may result in painful or disfiguring chemical burns. University of Oregon has more information on this and other lab safety tips.

--What goes up, must come down. : Anyone shooting a bullet or other dangerous projectile straight into the air ought to think towards one major aspect of Newton’s Universal Law of Gravitation, as explained by the University of Tennessee at Knoxville.

--Lightning can actually strike the same place twice. : Information on lightning striking the same location multiple times abounds online, but no research acts as the most compelling evidence to the same extent as NASA’s exhaustive testing of the myth at hand. Not only can it hit a target more than once, but the likelihood of it happening ended up being 45% higher than anticipated.

--Shaving does not cause thicker, darker hair. : Mayo Clinic weighs in on the myth that shaving directly causes hair to grow back thicker and darker, providing a much-needed dose of reality to a concerned populace. Lawrence E. Gibson, M.D. sheds light on how genetics determine hair structure and the ways in which the perception of coarser, darker strands initially came into play.

--The “5 second rule” is a fallacy. : Popular schoolyard mantras dictate that any food dropped on the floor fails to pick up microbes within the first 5 seconds. Paul Dawson, a food scientist at Clemson University, discovered that bacteria climbs onto food particles immediately upon contact and thus dispelled this eerily common myth.

--There is actually gravity in space. : Northwestern University lays to rest the general claim of zero gravity in outer space by explaining how its influence relates to distance. Every entity in the universe is actually subjected to some degree of gravitational pull, no matter its location.

Photo Credit: www.worldsciencefestival.com