White House Pushes Cautiously Forward on Needle Exchange

Clean syringes become part of federal AIDS strategy.

As most people know, addicts who inject drugs have played a major role in the HIV epidemic. In the U.S. alone, there are an estimated one million “injection drug users,” as the government calls them. They are linked to almost 20% of new HIV infections each year. (Roughly 56,000 new HIV infections occur in the United States annually, according to CDC estimates.)

And in black and white, on page 16 of the July 2010 position paper titled “National HIV/AIDS Strategy for the United States”, the White House made it official. In a list of “proven biomedical and behavioral approaches that reduce the probability of HIV transmission,” the report has this to say:

 “Among injection drug users, sharing needles and other drug paraphernalia increases the risk of HIV infection. Several studies have found that providing sterilized equipment to injection drug users substantially reduces risk of HIV infection, increases the probability that they will initiate drug treatment, and does not increase drug use.”

That relatively mild statement represents a bold departure from the AIDS/HIV policies of previous administrations--when such policies existed at all. The White House has bolstered its contention with citations:

Latkin, C, Davey, M, and Hua, W. Needle Exchange Program Utilization and Entry into Drug User Treatment: Is There a Long- Term Connection in Baltimore, Maryland? Subst Use Misuse, 41(14):1991-2001.

Vlahov D, Junge B. The role of needle exchange programs in HIV prevention. Public Health Rep. 1998;113 (Suppl 1):75-80.

Put simply, clean needles save lives. Needle exchange programs put more addicts in contact with social services, thereby easing their entry into drug treatment programs.

“Comprehensive, evidence-based drug prevention and treatment strategies have contributed to reducing HIV infections,” the report states. “In 1993, injection drug users comprised 31 percent of AIDS cases nationally compared to 17 percent by 2007. Studies show that comprehensive prevention and drug treatment programs, including needle exchange, have dramatically cut the number of new HIV infections among people who inject drugs by 80 percent since the mid-1990s.”

By the end of this year, the report pledges, “Centers for Disease Control and Prevention (CDC)  and the  Substance Abuse and Mental Health Services Administration (SAMHSA) will complete guidance for evidence-based comprehensive prevention, including syringe exchange and drug treatment programs, for injection drug users.”

One question not answered in the White House document—how to pay for new treatment initiatives of this kind.

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Drug Wars Increase Drug Violence

 Homicides rise with anti-drug expenditures.

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

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

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

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

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

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

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

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

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

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

Consider the CB(2) Receptor

A different destination for cannabinoids.

THC and its organic cousin, anandamide, do what they do by locking into both the CB1 receptor, discovered in 1988, and the CB2 receptor (as it is commonly written in shorthand), discovered 5 years later. THC and anandamide are CB receptor agonists, meaning they activate the receptors in question. (An antagonist blocks the receptor’s action.)

CB1 is a very common receptor in the central nervous system, and, when stimulated by an agonist, is responsible for the well-known roster of alleged medical effects, such as pain relief and nausea from chemotherapy--along with the typical marijuana high. (For more on this, see the excellent 2007 post by Dr. Joan Bushwell.) Conversely, blocking CB1 activity with an antagonist like rimonabant is one controversial avenue being explored in the search for new weight loss drugs. (CB1 antagonists can also produce anxiety and depression.)

However, CB2 was long considered a “peripheral” cannabinoid receptor, meaning that scientists hadn’t managed to find CB2 receptors in the central nervous system. They were, however, plentiful in the immune system, and seemed to be involved in inflammation as well as pain responses. CB2 receptors were in fact eventually discovered in the central nervous system, and are active in the brain during certain kinds of inflammatory responses.

There is a straightforward commercial incentive for tracking the extent of CB2 expression in brain neurons. As the authors of a cannabinoid receptor study wrote in the June issue of the British Journal of Pharmacology:

“As CB(2) is an attractive therapeutic target for pain management and immune system modulation without overt psychoactivity, defining the extent of its presence in neurons will have a significant impact on drug discovery.”

Translated, this means that there are a number of new molecules that are selective for CB2 receptors. Since people don’t get a strong traditional marijuana-style buzz from CB2 receptor activation, and given the active involvement of CB2 receptors in things like immune responses and inflammatory reactions, the possibility exists of finding lucrative spinoffs like pain pills or anti-inflammatory medications.  So drug researchers would like to know exactly where those receptors are, and what they do, in the event that they end up attempting to make a medicine that stimulates or blocks  them artificially. (Credit to Vaughan Bell of Mind Hacks for highlighting this study.) 

The psychologists at Indiana University who produced the paper did their best to shed light on where the CB(2) receptor is hiding, and what, exactly, it does.  But there is still not enough known about how various substances react with this somewhat elusive receptor for cannabinoids. In 2008, scientists at the University of Madrid published research in the Journal of Biological Chemistry indicating that activation of the CB2 receptor reduced nerve cell loss in animals suffering from a disease similar to multiple sclerosis. Researchers point to the possibility that a safe drug for M.S. patients could be one of the results of CB2 research.

Atwood, B., & Mackie, K. (2010). CB2: a cannabinoid receptor with an identity crisis British Journal of Pharmacology, 160 (3), 467-479 DOI: 10.1111/j.1476-5381.2010.00729.x

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Dr. Benjamin Rush and “Diseases of the Mind”

Founding Father also fathered concept of alcoholism.

The “Good Creature of God,” as the Puritans referred to alcohol, was the social centerpiece in taverns throughout the colonies. The phenomenon of the village drunkard was easily understood:  He was simply the person in town of the lowest moral fiber.

One of the first physicians to argue that habitual drunkards were “addicted” was Dr. Benjamin Rush, a signer of the Declaration of Independence, America’s first professor of chemistry, a fervent believer in copious blood-letting, and the author of the 1812 treatise, Medical Inquiries and Observations upon the Diseases of the Mind, for which he is considered by some to be the father of American psychiatry. Rush was another controversial figure, touted by many as a heroic innovator and by others as something of a quack. Rush strenuously emphasized “depletive” remedies—anything that made the patient bleed, sweat, retch, or blister.

As for alcoholism, Dr. Rush considered it a “disease of the will” resulting in loss of control over drinking behavior, and curable only through abstinence. He recommended the creation of “sober houses” where drunkards could acquire the habit of abstinence. John B. Gough, a well-known presence on the temperance lecture circuit, called alcoholism a sin, “but I consider it also a disease. It is a physical as well as moral evil.” The drunkard’s confession was a popular literary motif in the mid-19th Century. A novel written by Walt Whitman was called Franklin Evans, or The Inebriate. If Carrie Nation became the strident public face of the American Temperance Movement, Benjamin Rush was its patron saint. 

Nonetheless, the temperance movement remained largely committed to the notion that habitual drunks could quit if they wanted to. All they really needed was a good dose of Emersonian self-reliance. The temperance movement soon switched to an obsession with nationwide prohibition, and treating alcohol addiction gave way to activist politics and battles with the “liquor trust.” Addiction, as a concept, again transmogrified into a condition brought on exclusively by opium products. The idea of alcoholism and all other substance addictions as recognizable disease states did not significantly reemerge until the founding of Alcoholics Anonymous in the late 1930s.

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Searching for Addiction Rehab

The perils of online rehab finders.

CALL NOW FOR HELP, say the sites designed to assist people in locating addiction treatment services in their area. But when you call that 800 number to speak to a “rehab counselor,” chances are you end up getting a sales pitch for a specific for-profit chain of rehab centers, rather than an objective survey of all available resources and how they might fit your personal needs.

Perhaps it’s not surprising that the simple act of reaching out for help, for pertinent resources, is sometimes perilous online. Everybody’s got something to sell, it seems. Few sites offer objective information in detail, without special pleading of one sort or another.  Even Scientology, working under the alias of Narconon, has its own rehab register, featuring the 120 drug and alcohol centers operated according to the principles of that well-known expert on drug and alcohol problems, L. Ron Hubbard.

One workaround is to stick with government sources. The Substance Abuse and Mental Health Services Administration (SAMSHA) has a decent one HERE.  But even government rehab finding pages are one-size-fits-all affairs, and sometimes suffer from a lack of regular updating.

Recently, the All About Addiction (A3)  website has rolled out a new rehab finder with some nice features that should go a long way toward filling the gap. Adi Jaffe, the site’s director and the motivating force behind the creation of the new rehab finder, is working on his PhD in Psychology at UCLA.  Jaffe’s original idea for a call center gradually morphed into a plan for an online tool. In an interview with Addiction Inbox, Jaffe expanded on the rationale for putting together a rehab finder he believes addresses some of the shortcomings found on other sites:

 “I decided to put together the rehab finder because I thought it was sad that with all the technology we have, the best way to find treatment was either to do a general Google search (cue paid ads by providers that charge a lot and can therefore pay for advertising) that results in lists upon lists of providers, or go the SAMHSA treatment locator, which only searches by location,” Jaffe explained in an email exchange. “I thought we could do better. I believe that if we can make it easier for people to find the right treatment we will increase enrollment in treatment because people will find treatment they can afford, and improve treatment outcomes because the treatment-client fit will improve.”

A further refinement is represented by a 20-question survey.  Questions about gender, employment status, health insurance, and mental health are designed to narrow the field of pertinent recommendations. Detailed questions about drug use, including amount spent per month, are also included. What the new rehab finder does NOT ask for is your name, your phone number, or your e-mail address, as other such sites commonly do. So there is no danger of follow-up sales calls or spam.

“For the most part, we don’t match people based on the treatment approach (CBT, MI, 12 step, or others), that’s been tried and failed – there seems to be little difference and we don’t know how to match there yet,” Jaffe said. “What we do is match on gender, age, insurance, mental health status, specific addiction specialty, and other factors like the need for detox, or specific treatments for specific drugs (like buprenorphine for heroin).”

Jaffe is now seeking funds for a study of the new finder’s effectiveness.  “I’d like to set up a few different versions (including a location-only search like SAMHSA’s) and see if our version works better,” he said. “It also lends itself to constant improvement based on the actual results obtained.”

As the A3 site says: Rehab is hard. Finding it shouldn’t be.

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The Death of “Low Tar” Cigarettes… Or Maybe Not.

Is this the best the FDA can do?

Lots of cigarette news lately. To begin with, cigarette manufacturers will no longer be able to market specific brands as “low tar” or “light.” And while David Kessler, former head of the Food and Drug Administration (FDA), called for the regulation of nicotine levels in cigarettes, cancer researchers were backpedaling away from some questionable numbers about cancer risk from smokeless tobacco offered up by the National Cancer Institute (NCI). Meanwhile, the American Medical Association (AMA) called on the FDA to ban so-called e-cigarettes.

Covering nicotine news is inherently confusing, ambiguous, and tentative, since the product in question is a legal drug responsible for an immense amount of tax revenues. It is also addictive. The relatively inelastic nature of demand for nicotine products makes governments reluctant to, er, snuff out the tax bonanza in its entirety.

Nonetheless, Congress gave the FDA broad new regulatory power over cigarettes a year ago with the passage of the Tobacco Control Act of 2009.  Last week, various provisions of the bill became effective, including provisions that “prohibit the advertising or labeling of tobacco products with the descriptors ‘light,’ ‘mild,’ or ‘low’ or similar descriptors” without specific permission from the FDA.  (See earlier post). In addition, health warning labels will be strengthened on smokeless tobacco packaging.

“As FDA continues implementation of the Tobacco Control act, we are committed to assuring that the actions we are taking are grounded in science and are open and transparent with participation by various stakeholders,” according to a press release from the agency’s Center for Tobacco Products.

The problem, as a glance at the photograph above aptly demonstrates, is that the America tobacco industry is already a jump ahead of the FDA’s measured approach. The industry plans to “let the colors speak to smokers in the same way the soon-to-be banned words ‘mild,’ ‘light,’ and ‘ultralight’ did,” Stephen Smith wrote last year in the Boston Globe.

Thus Pall Mall Lights become Pall Mall Blues. Whereas Salem Lights will forever after be known as Salem Gold Box. And so on. “These tricks are now well-established,” tobacco control specialist Stanton Glantz of the University of California told the Boston Globe. “The real question for the FDA is, are they going to let them get away with these shenanigans?”

The FDA is changing colors on the packages, and roughing up the warning labels, and starting to zero in on menthol, but one of the things it won't be doing is lowering the nicotine levels in cigarettes. Former FDA chairman David Kessler, for one, insists that this is the only substantive change likely to make a difference in addiction rates. In an AP report by Michael Felberbaum, Kessler said: “The tobacco industry knew 40 years ago that there was a threshold below which people would quit. Reducing the level of nicotine in cigarettes will change smoking as we know it. It is the ultimate harm reduction strategy.”

Meanwhile, on another contested front, (see earlier post) the Partnership at Drugfree.org reported that the AMA called on the FDA to regulate electronic cigarettes, which to date the agency has declined to do.  “Very little data exists on the safety of e-cigarettes,” said AMA board member Edward Langston. “Because e-cigarettes have not been thoroughly tested, one cannot conclude that they are less harmful or less dangerous than conventional cigarettes.” E-cigarettes also come in different candy and fruit flavors, the AMA pointed out during the process of adopting the policy at its annual meeting in Chicago.

And finally, a Wall Street Journal report by Carl Bialik in April caused a good deal of embarrassment at the American Cancer Society, which conceded that it had stopped using its long-cited figure of a 50-fold increase in the risk of oral cancer among users of smokeless tobacco. The National Cancer Institute has also cited the 50-times risk figure in its literature. As it turned out, the original survey had been about dry snuff, a form of tobacco rarely used in America today. Other scientists have concluded that the increased risk of oral cancer from smokeless tobacco is on the order of a factor of 10, not 50.

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Vitamin B6 May Lower Risk of Lung Cancer

Large European study confirms earlier findings.

It doesn’t mean you should start popping handfuls of B vitamins if you are a smoker or a former smoker (those who never smoked rarely get the disease). What it appears to mean is that people with the highest levels of vitamin B6 in their bodies may have as little as half the risk of developing lung cancer as people with very low levels of B6--also known as pyridoxine.

In a June 16 article in the Journal of the American Medical Association (JAMA) , dozens of researchers from around the world deconstructed a European medical database from the 1990s, containing medical data and blood test results for more than 380,000 people. They were looking for meaningful statistical correlations having to do with the 899 people in the study who eventually developed lung cancer.

According to Nathan Seppa in Science News, the international research team found that “people with vitamin B6 levels ranking in the top one-fourth of all the samples taken had less than half the risk of lung cancer as those with the lowest vitamin B6. A similar comparison found that people with high levels of [the amino acid] methionine seemed to have almost half the cancer risk of people with low levels. High folate levels seemed to give less protection.” The researchers calculated that having high levels of all three compounds could reduce lung cancer risk by as much as two-thirds.

Much remains unknown. Can smokers use B6 vitamin supplements to protect against lung cancer, or are the protective effects, if verified, due to a B6 level that reflects diet and other metabolic factors at work over decades? And, as always, there is the question of B6 from vitamin supplements vs. B6 from B6-rich foods like fish, beans, and grains.

A smaller prospective study undertaken in 2001 came up with similar results. Published in the American Journal of Epidemiology, the study involved 300 lung cancer patients in Finland between 1985 and 1993. The researchers looked at B6, B12, and folate, and found “significantly lower risk of lung cancer among men who had higher serum vitamin B6 levels. Compared with men with the lowest vitamin B6 concentration, men in the fifth quintile had about one half of the risk of lung cancer.” The researchers speculate that one of the mechanisms by which B6 could influence carcinogenesis is the role the vitamin plays in homocysteine metabolism. B6 is involved in the complex process of metabolizing homocysteine, another amino acid. Absent sufficient B6, homocysteine levels can build up in the body, causing heart disease and other ailments.

Mattias Johansson, et. al. (2010). Serum B Vitamin Levels and Risk of Lung Cancer Journal of the American Medical Association, 303 (23), 2377-2385

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