On Harm Reduction and Metabolic Chauvinism

My WebTalk Radio interview for the podcast, “Addicted to Addicts.”
  

 Listen to the podcast at WebTalkRadio HERE.
(Addiction Inbox is now on vacation. Hot fun in the summer sun...)

Amy Winehouse Dies at 27

 

Musicians who died of drug-related causes at the age of 27:

Jimi Hendrix
Brian Jones
Janis Joplin
Jim Morrison
Kurt Cobain
courtesy metro.co.uk.

"Sunday tabloids in the UK have claimed Winehouse was seen buying drugs from a dealer in Camden just after 10.30 pm where she was later found dead in her apartment, according to reports in the Daily Mail."

                                                                                                            Moving tribute from Russell Brand

Drug Links, Various

It’s summer vacation. Did I turn off the stove?


Some recent posts I wrote before ending my run as editor of TheFix.com News Blog:

Drugging the Elderly
Why seniors take too many of the wrong medications at the wrong dose.

Never Heard of Kratom? You Will.
A plant from Thailand with opiate-like properties is the latest "designer drug" speeding its way through America.

How Binge Drinking Causes Fetal Damage
Studies in mice show that alcohol is toxic to DNA in the absence of two specialized enzymes.

Senators Blast Feds for Border Scandal
Botched gun-smuggling scheme put weapons in the hands of Mexican drug thugs, endangered informants, and may have gotten agents killed.

Testimonials to Betty Ford
In the wake of Mrs. Ford’s death, celebrities and politicians tell their personal stories about her work in raising awareness of addiction and recovery.

New Synthetic Marijuana Arrives to Replace Spice, K2
Designers are already busy with the second generation of cannabis-like drugs.

Crack and Coke Will Finally Receive the Same Legal Penalties
Civil rights leaders charged that the legal system's intense obsession with crack amped up minority arrests, but had no scientific basis. Turns out they were right.

Miracle-Gro Goes After the Medical Marijuana Market
It’s just quasi-legal cooperative organic gardening, right? All $1.7 billion of it.

(R.I.P. Amy Winehouse)

An Interview With Research Psychologist Vaughan Bell

An expert on abnormal brain function talks about drugs, hallucinations, and addiction.

Vaughan Bell gets around. The multifaceted clinical and research psychologist, currently a Senior Research Fellow at the Institute of Psychiatry, King’s College, London, is, in fact, down in Colombia right now. He arrived in the country to teach clinical psychiatry at Hospital Universitario San Vicente de Paúl and the Universidad de Antioquia in Medellín, Colombia, where he remains an honorary professor, but right now he works for Médecins sans Frontières (Doctors Without Borders) as mental health coordinator for Colombia, which means he is quite frequently off in the jungle, doing good work under very bad conditions. Bell has written for numerous scientific journals, including Cognitive Neuropsychiatry, Psychiatry Research, and Cortex. He has also written for Slate, The Guardian, Scientific American, and is a contributing editor at Wired. The New York Times ran a fascinating profile of Bell’s work on debunking theories about the Internet as a cause of addiction and psychosis. He is well known online for his contributions to the Mind Hacks blog, which covers unusual and intriguing findings in neuroscience and psychology. He is also working on The Enchanted Window: How Hallucinations Reveal the Hidden Workings of the Mind and Brain, a book for Penguin UK.


Q. You’ve been looking into abnormal brain states of late: delusions, hallucinations, and dissociative disorders.  Do drugs, madness, brain injuries, and religious experiences have anything in common? Is there an underlying cause for seeing or experiencing things that aren’t there?

Vaughan Bell: Apart from involving the brain, often not. Unusual perceptions occur because the normal processes that allow us to generate sensory impressions of the world become distorted. For example, the idea that we see the world as it is, is a bit of a myth, because we experience things that aren’t there all the time. The eye allows light to fall on the retina, two flat areas of photoreceptor cells which provide only patchy and poor resolution coverage of the visual field, and yet we have a very rich visual experience. The brain is filling in the rest. In your blind spots, you receive no visual information and yet we don’t have two black spots in our vision because we ‘hallucinate’ the best guess visual experience.

These are not usually considered hallucinations because the experience remains stable and predictable but these same processes, with just slight instabilities, can lead to spectacular hallucinatory states – such as Charles Bonnet syndrome –where damage to the retina leads to visions of monkeys, rabbits and little men. In other words, there are as many causes for hallucinations as there are causes for our perception of reality. If the same processes are affected through drugs, brain damage, trance states, stress or simply expectation, we can say that a particular experience has a similar basis but we have to think of the interaction to understand them fully. Trying to explain experiences solely by the brain, mind or environment makes little sense.

Q: You’ve experimented with “the vine”—ayahuasca, a powerful South American hallucinogenic plant that contains DMT. You obviously lived to tell about it. Did you see any transdimensional machine elves?

Bell: There were no transdimensional machine elves, although the whole experience was quite striking. I was kindly invited to take part in the ceremony by a chap called Romualdo, a Uitito taita (shaman), who I happened to meet in a conference about indigenous culture and I was very grateful for the opportunity.

I suspect the experience of meeting what McKenna called the "machine elves" is more prominent when pure DMT is smoked which gives a more concentrated acute dose. The traditional process of taking ayahuasca, known as yagé in Colombia, involves drinking a potion made from the vine until you start puking. To get a fair dose you need to repeat this process several times, so the absorption is much slower. I managed three or four drink – puke cycles and the psychedelic effects were prominent although I never lost track of reality. I was, however, very struck by the appearance of classic Kluver form constants, geometric patterns that are probably caused by the drug affecting the visual neurons that deal with basic perceptual process (e.g. line detection).

Q. As a research psychologist, you have been critical of the disease model of addiction for being both too simplistic about mind and behavior, and too all-encompassing to be credible. In an article for Slate, you wrote: "Despite the scientific implausibility of the same disease—addiction—underlying both damaging heroin use and overenthusiasm for World of Warcraft, the concept has run wild in the popular imagination. Our enthusiasm for labeling new forms of addictions seems to have arisen from a perfect storm of pop medicine, pseudo-neuroscience, and misplaced sympathy for the miserable." How should we view addiction, and how should we be dealing with it?

Bell: I think we should view addiction as an over-applied label that is distracting us from the fact that not everyone’s difficulties with unhelpful repetitive behavior can be understood and treated in the same way. Often compulsive behaviors do have shared factors. Obsessive-compulsive disorder, impulse control disorders (like pathological gambling or compulsive stealing) and drug addictions are all known to have shared similar behavioral, neurological and genetic features but that does not mean that each disorder is essentially the same.

The idea that playing too many computer games or compulsive use of the Internet is an addiction like any other is really obscuring the fact that different compulsive behaviors also have many different components. It would be like saying that all "mood disorders" are essentially the same—it would neither be scientifically nor clinically helpful and would cause more confusion than insight. This is the situation we have with addiction at the moment.

Q. You’ve been living and working in South America for some time now. How has the drug trade and the drug war changed that part of the world, in your own experience?

Bell: If you don’t mind, I’m going to skip this question. The drug trade is interwoven with the conflict in Colombia and myself and my colleagues in Médecins sans Frontières (Doctors Without Borders) work in areas where the fighting is live and ongoing. One of the things that allows us to do our work in areas controlled by armed groups is that we are a neutral organization solely concerned with providing medical care without getting involved in the politics behind the conflict. Of course, like everyone else, I have a view, but in case it affects either our access to the people we’re trying to treat or the security of our teams in the field, I’ll keep it to myself when I’m mentioned alongside the organization.

Graphics Credit:  http://news.softpedia.com/

There’s No Agreement on DUIC: Driving Under the Influence of Cannabis

The ACLU squares off against law enforcement over how to measure marijuana impairment.

What’s your blood cannabis content? You don’t know, and neither does anybody else, without a fair bit of effort. There’s no device to blow into, no quick chemical field test. You’re impaired by marijuana if the officer says you’re impaired by marijuana, and in most states he or she will decide that matter by using a series of sobriety checks not dissimilar to the well-known alcohol exercises: standing on one foot, walking a line, having your eyeballs and blood pressure checked—and my personal favorite, a test of how well you can guess when 30 seconds is up. Time passes more slowly when you’re about to be arrested for drugs, I’m guessing, since it takes a little while for your life to pass before your eyes. Even the National Highway Traffic Safety Administration admits that it is “difficult to establish a relationship between a person's THC blood or plasma concentration and performance impairing effects. Concentrations of parent drug and metabolite are very dependent on pattern of use as well as dose."

The point is, observable indications of impairment, as they’re called, are really all that law enforcement currently has as a tool for policing the use by drivers of American’s second most popular drug. At one extreme end of the spectrum are the pot enthusiasts who argue that no amount of marijuana significantly impairs you behind the wheel. At the other end of the spectrum stand the zero-tolerance advocates: No amount of marijuana is safe, if you’re planning to get behind the wheel within the next several hours—or at any time during the rest of your life, as some anti-drug advocates seem to be saying.

And somewhere in between, according to the American Civil Liberties Union (ACLU) of Washington State, lies a possible compromise for gauging marijuana impairment. “Adding a science-based threshold for likely impairment to the mix and providing educational information that allows people to estimate their personal level of intoxication can be effective strategies for preventing impaired driving in the first place and improving public safety,” the  ACLU asserts.

The ACLU favors the so-called Pennsylvania Model, which sets that state’s legal limit for cannabis in whole blood at 5 nanograms per milliliter (ng/mL). Why 5, and not some other number? Because a legal cut-off of 5 ng/mL is also what the National Organizaton for the Reform of Marijuana Laws (NORML) recommends, based in turn on an analysis of scientific studies of marijuana’s effect on driving skills. Specifically, NORML recommends a limit in the range of 3.5-5.0 ng/mL, which the group says will “clearly separate unimpaired drivers with residual THC concentrations of 0-2 ng/mL from drivers who consumed cannabis within the last hour or so.” Levels under that range tend to indicate that the driver smoked at least 1 to 3 hours ago. Anyone testing over that range, says NORML is “likely to be impaired.”

But it’s not quite that simple, of course. First, you have to rule out a whole roster of cannabis metabolites that stay in the system for days or weeks, but have no impact on driving skills. And the metabolism of cannabinoid by-products varies so widely from person to person (this is just beginning to be understood scientifically), that the results of testing are not foolproof. The iron law of metabolic diversity makes that claim unlikely. Moreover, there is currently no reliable way of testing blood in the field for THC concentrations. But there will be. Introducing the Vantix Biosensor, a device that looks, ironically, like a portable vaporizer for marijuana. Open your mouth, please, as the officer politely swabs the inside of your cheek with a plastic wand, and inserts the wand in the handheld machine. Sensors on a microchip react with telltale antibodies, and you test positive for cocaine, or marijuana, or, soon, synthetic marijuana. Or perhaps it will be some other company’s device. But rest assured it is being looked upon as a growth market.

And then there is, as the ACLU points out, the wrong way to go about it: zero tolerance. At least 11 states have now set the requisite cut-off level for illegal drugs at zero. That may raise a cheer in certain quarters of the anti-drug movement, but it is a decision “based not in science but on convenience,” says the ACLU. It establishes a crime wholly “divorced from impairment” behind the wheel. Put simply, zero tolerance “does not differentiate between a dangerously incapacitated driver and an individual who may have smoked the past Monday but was pulled over as a sober ‘designated driver’ on Saturday night.” Furthermore, “even a statute excluding cannabis metabolites but criminalizing trace amounts of THC” could result in the arrest of drivers several days after they last smoked pot. It’s pretty simple, really. “If science dictates that the presence of a trace amount of cannabis or a cannabis metabolite in an individual’s blood has NO ‘influence’ on his capacity to drive, it should not constitute per se evidence of ‘driving under the influence.’” But toxicologist Marilyn Huestis, at the National Institute on Drug Abuse, disagrees. She believes that there is no safe level of marijuana consumption, where driving is concerned. Paul Armentano, deputy director for NORML, scoffs at that, telling the Los Angeles Times that individual states “are not setting a standard based on impairment, but one similar to saying that if you have one sip of alcohol you are too drunk to drive for the next week.”

 One abiding problem is that for car accidents, it’s not necessarily a pure play. Alcohol mixed with one or more additional drugs is common, and if it’s difficult to set limits for alcohol and marijuana alone, imagine the permutations involved in creating legal limits for a combination of both. A 2007 survey of experimental studies, published in Addiction by a group of researchers in six countries, concluded that a rule of thumb police might want to consider is based on the finding that “a THC concentration in the serum of 7–10 ng/ml is correlated with an impairment comparable to that caused by a blood alcohol concentration (BAC) of 0.05%. Thus, a suitable numerical limit for THC in serum may fall in that range.” Considering that we allow drivers to exhibit blood alcohol limits as high as 0.08, NORML’s 5 ng/mL limit looks downright conservative.

There’s no simple solution. Maybe that’s because cannabis is not a simple drug. We’re still teasing apart its effects, and nailing down the particulars of driving under the influence of cannabis is one of them. As Jeffrey P. Michael of the National Highway Traffic Safety Adminstration refreshingly disclosed to the Los Angeles Times, “We don’t know what level of marijuana impairs a driver.” But they are trying to find out. A federal study in Virginia intends to round up more than 7,000 blood samples by showing up at the scene of car accidents and asking drivers to provide random, anonymous  samples to compare with control samples.

Other studies of a similar nature are underway. Driving under the influence of drugs could become as common a criminal charge as classic DUIs and DWIs.

Photo credit: http://www.janisian.com/

Alcoholic Deception

Big Alcohol Wants a Piece of the Health Market

For a long time now, snack food companies have been spending billions to convince shoppers that their fattening food offerings are fit and healthy nutrition alternatives. Big Alcohol, which has played around the edges of all this with “lifestyle” beer commercials, has been pushing into the health business more steadily of late, as opportunities for advertising shrink. The Marin Institute, which has got to be Big Alcohol’s least favorite advocacy group in the world, just released its new study: “Questionable Health Claims by Alcohol Companies: From Protein Vodka to Weight-Loss Beer.” The group documents the many ways in which alcoholic beverage makers are seeking to emulate food corporations in staking a misleading claim to words like “natural” and “organic.”

“The wine industry has been exaggerating wine’s health benefits for years. Now Big Alcohol is taking such messages to a whole new level,” said Marin Institute’s Research and Policy Director Michele Simon, one of the report’s authors. “Major alcohol companies are exploiting ineffective or non-existent regulatory oversight,” she added.

The Marin Institute breaks down Big Alcohol’s advertising assault into three areas of concern: adding nutrients, using the term “natural,” and using alcoholic beverages in fitness-themed promotional campaigns. It’s a free country, more or less, and there’s no point being a prude about these things. But a deeper look at alcohol advertising strategy can be enlightening. As the Marin Institute admits, alcohol’s advertising strategies “may seem relatively harmless.” but when it comes to promoting sales, the consequences are “potentially dangerous.” And overlapping regulatory agencies don’t make it any easier. Technically, the U.S. Alcohol and Tobacco Tax and Trade Bureau (TTB) is in charge of regulating alcoholic beverages, but the U.S. Federal Trade Commission has control over alcohol advertising, and determines whether it is unfair, false, or deceptive.

Here is a portion of the Marin Institute’s list of unsupported health claims:

--Fortified vodkas. Fortified foods have been around forever, but it wasn’t until 2007 that the first fortified vodka hit the market. Lotus White, infused with added B vitamins, “could actually be good for you,” said the company’s CEO. The Federal Trade Commission (FTC) prohibited Lotus from advertising the B vitamins on its packaging, so CEO Bob Bailey told the press that Lotus White provided drinkers with 100% of their daily recommended intake of B vitamins. “Alcohol is bad for you,” he told the press, according to the Marin Institute report. “Ours is just slightly less bad.” The report says that retailers in Los Angeles advertise Lotus as a “Vitamin B Enhanced Super Premium Vodka.” However, since alcohol is known to inhibit the absorption of nutrients like Vitamin B1 and B12, and folic acid, Dr. R. Curtis Ellison at the Boston University Medical School says that putting B12 in alcohol is “like putting vitamins in cigarettes.” Nonetheless, sales of Lotus vodka shot up 50% in 2009, says the Marin Institute, before the company went out of business last year. In November of 2009, along came Devotion, billed as the world first “protein-infused ultra premium” vodka. Sounds more like shampoo than a shot of vodka, but adding “protein” is now another marketing angle. The problem is that these approaches appear to fail the basic health rules of the regulatory agencies, to wit, that such claims must be “substantiated by medical research.” Try this one: Fragoli, introduced three years ago, a red liquid with a little red strawberry at the top of the bottle. “Forbidden Fruit,” has been one of the company taglines. And a company press release put it this way: “In a recent scientific study, researchers found that the addition of ethanol—the type of alcohol found in most spirits—boosts the antioxidant nutrients in strawberries and blackberries.” As the Marin Institute pointed out: “While the study they referenced did find that ethanol increased antioxidant levels in berries Fragoli implies that drinking cocktails is one way for people to get those antioxidants, which the study does not conclude.”

--All-natural spirits. Flavored vodkas have been with us for decades. But the competition is brutal. By 2008, there were at least 120 flavored vodka products on the market. The Marin Institute found that in that year, “three of the five top-selling vodka companies in the U.S. had ad campaigns with fruit and positioned their products as fresh or all-natural: Absolute (2nd), Skyy (4th), and Stoli (5th). Skyy was advising drinkers to “Go Natural,” with “100% real fruit and premium Skyy vodka,” as well as its line of “all-natural infusions.” Notably, the words “infusion” and “all-natural” remain undefined by the TTB. Similarly, Blue Ice vodka was among the 84 “organic” alcohol products that came on the market between January, 2008 and October, 2009. My particular favorite is Blue Ice Organic Wheat—certified organic by the U.S. Department of Agriculture (USDA), in a classic case of federal agencies in conflict. 

--Fitness campaigns. Miller Lite, the “healthy” beer that started it all, launched in 1973, and ever since, commercial viewers have been subject to an endless collage of young people running, dancing, and diving into crystal streams. But it was not until the diet-conscious new century that sales of light beer exploded along with low carb diets. In 2004, Great Britain went after Michelob Ultra for its “lose the carbs, not the taste,” advertising, on the grounds that the campaign implied that beer drinking was part of a healthy lifestyle. No matter; Michelob went on to sponsor the UK Olympic teams in 2006 and 2008. By 2009, Michelob Ultra had no qualms about advertising itself as “a smart choice for adult consumers living an active lifestyle.” The Marin Institute has always been particularly rankled by the mainstay of beer advertising—sponsored sporting events. When Michelob signed a three-year deal with Lance Armstrong, the Marin Institute howled, because “the advertising campaign mixed images of Armstrong exercising and consuming beer while in the context of this activity,” another violation of the advertising rules concerning alcohol consumption and health. “Probably the most blatantly illegal advertisement came in early 2009,” says the Institute’s report, “when a new beer called MGD 64 (boasting just 64 calories) sponsored an online fitness program in association with Shape and Men’s Fitness magazines.” Again, the authors argue that if FTC and TTB standards don’t apply to alcohol-sponsored weight loss programs, then what DO they cover?

If you put it all together, “such marketing represents a significant failure in the regulatory oversight of alcohol advertising.” Small wonder, since regulatory oversight is split across two or three federal agencies, 50 state beverage control agencies, and state attorneys general. Plenty of regulating to go around, if it was more sensibly deployed. But if it were, protein vodka would probably not be on the market. The Marin Institute’s modest proposal is to transfer jurisdiction over the regulation of alcohol advertising practices to the Food and Drug Administration (FDA), to which Congress recently granted greater powers of regulation for cigarette products. Once again, the institutional confusion and inertia caused by the artificial distinction between “legal” and “illegal” drugs is hampering efforts to effectively regulate the sale of this addictive drug.

Graphics Credit: http://www.marininstitute.org/site/

Teachable Moments in the Life of a Cigarette Smoker

Child surgery makes smoking parents more likely to try quitting.

Here’s a strange one: Doctors at Mayo Clinic wanted to find out whether children undergoing surgery had any effect on the smoking behavior of their parents. And it did—but the effect appears to be short-lived.

The Mayo researchers began from the already well-tested proposition that smokers who have surgery are more likely to quit smoking. In fact, they quit at twice the rate of smokers who haven’t had surgery. Not hard to understand, intimations of mortality and all that. They pass through a teachable moment, the scientists write in Anesthesiology, defined as “an event that prompts behavioral change.” As for smokers with kids, doctors have always had recourse to two tactics for creating teachable moments for cigarette cessation. First, they could point to increased illness and asthma in the innocent children of smokers. And when that didn’t work, they could throw in the cold fact that children exposed to secondhand smoke have a higher risk of respiratory complications during and after surgical anesthesia. And in a further queasy irony, “the increased frequency of conditions such as middle ear diseases caused by secondhand smoke may also make it more likely that children will require surgery.”

For documentation, the investigators turned to the massive National Health Interview Survey (NHIS), a questionnaire served up annually to 35,000 households by personal interview. About 12% of children in the NHIS survey in 2005 were exposed to secondhand smoke. Of the thousands of children undergoing surgery, there was an increased likelihood that a parent of one of them would inaugurate a no-smoking attempt. But these quitters were no more likely to succeed in their attempt than any other quitters.

However, “parents having surgery within the previous 12 months was associated with more quit attempts, more successful attempts, and a greater intent to quit among those still smoking.” What happened to the indestructable bond between parent and child? It appears that concerns about one’s own health trump concerns about the health of offspring when it comes to quitting cigarettes. “We can only speculate about why surgery was a significant factor associated with sustained abstinence when experienced by the smoker but not the smoker’s child.”

There are plenty of limitations to these kinds of self-reported surveys, but it is hard not to speculate, along with the researchers. One obvious implication: the chances of a smoker quitting are at their maximum when parent and child both have surgeries.

“Our current findings suggest that having a child undergo surgery can serve as a teachable moment for quit attempts,” said Dr. Warner. “The scheduling of children for surgery may present us with an opportunity to provide tobacco interventions to parents, who are apparently more motivated to at least try to quit – but who need assistance to succeed.”

Shi, Y., & Warner, D. (2011). Pediatric Surgery and Parental Smoking Behavior Anesthesiology, 115 (1), 12-17 DOI: 10.1097/ALN.0b013e3182207bde

Photo Credit: http://special-needs.families.com/