Good Medical Treatment Beats Rehab Any Day

Clinical practice is something of a roller coaster. One day, most of my patients are doing well, the next day, they're all crashing. Today was one of the good ones. Lots of folks doing well. Most doing better than they have in years. Many of my current patients I have picked up in the hospital, doing consultations. Almost all have been through 12-step rehab, most multiple times. The record so far is 43 times! I integrate behavioral treatment (psychotherapy seems to be a bad word in addiction treatment for some reason), medication management, family therapy if needed, and care management. I do this basically by myself (although I do have a couple of great nurses who help with fielding calls from patients and families, medication refills, etc.) Most of the psychotherapy I do takes 20-30 minutes. I try to see patients weekly for awhile and that works really well. Sometimes I've seen patients more often for stabilization but for the most part weekly seems to work well.

One of the first things I do with new patients is to tell them this: "I don't necessarily expect that my patients will never drink again. That is the aspiration [in most cases] and the goal. But clinical experience and scientific research demonstrates that for most patients achieving lasting recovery will take time and repeated efforts. Think of quitting smoking. How many times do most people have to make quit attempts before it sticks? Why would quitting drinking be any different. There is a destructive fiction that when people go to rehab, the clouds part, the light shines through, the angels sing and they never drink (or use) again. This is not typical. The most common outcome of rehab is improvement without remission. "So, if you drink (use) that's when I need to see you the most. Don't stay away because you're afraid I'll be angry or disappointed or because you feel guilty or ashamed. That's like staying away from the doctor when you have an asthma attack because you're afraid she'll be upset that her treatment failed. The goal of treatment is to reduce the frequency and severity of relapses. It will take work and time, and I'll be with you through the process."

Patients become much more engaged in their recovery if they don't fear being blamed for not instantly solving their problems. Finding a solution that works takes time and ingenuity. There is no treatment that always works no matter what anyone tells you. Would you trust a physician who said, "My treatment for breast cancer is 100% effective if you follow my directions?" I wouldn't either.

MW

Hope for Hospitalized Alcoholics?

A new study found that even severely alcohol addicted patients in the hospital responded to a 20 minute counseling session after leaving the hospital. This has not been found in all studies, however. As is the case with many medical or psychological treatments, some studies are positive, some are negative. In the end, it's the balance. This balance is determined in a synthetic process called systematic reviews and meta-analysis. These are techniques to examine the findings of multiple high quality randomized controlled trials (RCTs) to determine if a treatment is effective overall. I think the jury is still out on this one, but this study had some pretty impressive findings and a reasonably large number of participants. What's more interesting is what happens when you combine a brief counseling session in the hospital with ongoing follow up in an outpatient setting. That's what I am currently doing with the patients I see in the hospital - I start the treatment there and ask them to schedule a follow up in the my clinic. This is what's done in every other medical specialty. Why not addiction medicine? MW Brief interventions in dependent drinkers: a comparative prospective analysis in two hospitals. Cobain K., Owens L., Kolamunnage-Dona R. et al. Request reprint Alcohol and Alcoholism: 2011, 46(4), p. 434–440. In the north of England just a few (and often just one) counselling sessions by a specialist nurse had a remarkable impact on dependent drinkers seeking medical care at an accident and emergency department. Summary Unusually this study in England's north west region assessed the impact of relatively brief advice, not on adult drinkers selected to be at risk from their drinking, but those likely already to be dependent. As with studies of non-dependent drinkers, despite their heavy drinking they were not seeking treatment for drink problems but attending a hospital accident and emergency department for some other reason. Patients whose attendance was thought to be related to drinking were referred for assessment to specialist hospital or research nurses by emergency department triage staff in two hospitals in neighbouring cities. The assessments included the AUDIT questionnaire and for patients who scored as possibly dependent, the Severity of Alcohol Dependence Questionnaire. Patients indicated by both to possibly be at least mildly dependent were asked to join the study. In Liverpool the assessments were done by specialist alcohol nurses who immediately engaged possibly dependent patients in about 20 minutes of advice based on the FRAMES model, prioritising exploration of patients' perceptions of the link between their drinking and their hospital attendance. At the nurses' and patients' discretion, further sessions could be arranged. In practice, of the 100 patients recruited to the study, 46 attended typically four further sessions. In the other hospital in nearby Warrington, the same referral and research recruitment procedures operated, but instead patients were referred to a nurse who was part of the research team who did not offer any alcohol-related advice. Again, 100 patients were recruited at this site to act as a control group against which to benchmark any improvements associated with counselling. At both sites most patients were daily drinkers who consumed on average about 27 UK units (216g) of alcohol a day, tested as severely dependent, and were taking alcohol withdrawal medication. Typically they were single, unemployed white men in their mid-40s suffering from gastrointestinal or cardiovascular complaints. Six months later research nurses were able to reassess about half the patients to evaluate changed in their drinking and drink-related problems since they joined the study. Main findings Six months later the general picture was (despite some reductions) of continued severe drinking and drink-related problems in the control group, but substantial remission among patients who had been counselled by specialist alcohol nurses. The controls were still drinking on average 23 units (184g) of alcohol on nearly six days a week, while counselled patients had cut back to nearly four days a week and eight units (64g). These averages reflected the fact that none of the controls but 39% of the counselled patients had stopped drinking altogether. Also, just 17% of the counselled patients scored as severely dependent on the Severity of Alcohol Dependence Questionnaire compared to 56% of the controls chart. The greater reductions in drinking days and intensity and in scores on the two alcohol problem questionnaires were all highly statistically significant. Not statistically significant but almost so was the difference in the times patients returned to accident and emergency departments – about 90 times among the 50 control patients but only 34 times (or 36 extrapolated to 50 patients) among those counselled. The authors' conclusions The study demonstrates that treatment can be accepted and effective among dependent drinkers who have not come seeking treatment for their drinking. Generally it has not been ethically acceptable to deny treatment to dependent drinkers who are seeking it, complicating the evaluation of whether treatment works. In contrast, because patients were not seeking or expecting treatment, this study was able to compare structured treatment with no specific treatment. It showed that treatment is effective, and that even severely dependent patients can substantially benefit from relatively brief treatment. The patients in this study were usually medically ill; providing alcohol treatment in a general hospital offers a way to reach them even if they do not present to alcohol treatment clinics, and may reduce their need for further medical care. The greater drinking reductions among patients at the hospital offering counselling were due to the greater abstinence rate – 39% v. 0%. It seems likely that their medical conditions would have mandated advice to abstain for 8 in 10 patients and that this was the advice given by the specialist nurses, advice often well responded to. From previous research, it seems likely that planned follow-up counselling augmented the impact of the evaluated intervention. Though striking, the results have emerged from a study in which patients were not randomly allocated and attended different hospitals. On the assessed variables, the patients seemed similar but there may have been remaining differences between them and between how they were treated at the hospitals which contributed to the findings. Moreover, the research nurse who conducted the follow-up assessments was not always 'blinded' to whether patients had been counselled. Despite its general brevity, it is a moot point whether the open-ended treatment could be called a 'brief intervention'. Half the patients could not followed up, potentially biasing the findings. These impressive results are weakened somewhat by the low follow-up rate. But even if we assume bad outcomes (severe alcohol dependence, death or imprisonment) in all patients not followed up, at most 60% of the counselled patients met these fates compared to 88% not counselled. Similarly, assuming continued drinking among patients not re-assessed, the abstinence rate would be 19% among counselled patients but zero among those not counselled. Yet on average these patients drank at least as much as those at specialist alcohol clinics in the UKATT trial in England and Wales, who were seeking treatment and offered what was intended to be a full course of psychosocial therapy in addition to medical treatments like detoxification and anti-relapse medications. In that study, 12 months after starting treatment a minimum of 12% of patients had sustained abstinence over the past three months, compared to 19% at six months (over an unspecified period) in the featured study. Despite its successes, for most patients the intervention was not enough. If abstinence is the yardstick of success, 8 in 10 could not be shown to have achieved it; if not being severely dependent was the yardstick, the corresponding proportion was 6 in 10. Whether more extended or intensive intervention would have been accepted by the patients and helped reduce the failure rate is unclear. The main limitation on delivering it might have been staying in touch with the patients. Few were homeless, yet two letters and two phone calls were unable to recall half for follow-up assessments. As the authors speculated, it could be that the nurses and perhaps ward staff were in a position in most cases to credibly counsel abstinence on medical grounds, helping bolster the results. Few patients were there because of injuries which could be avoided by continuing to drink but taking greater care to avoid getting drunk in dangerous situations. Instead, most seemed to be suffering from chronic conditions which would be aggravated by continued drinking. They were also generally the type of people research suggests are most receptive to abstinence as a goal of treatment and least able to sustain non-problem drinking. Among the issues raised by the study are whether extended treatment is always required before dependent patients – especially those with the disadvantages shared by most of the study's sample – can attain non-dependent drinking or abstinence. Along with other research, it clearly indicates that this is not the case for many patients. More generally, added benefits from longer versus shorter treatments (as opposed to post-treatment aftercare) has yet to be adequately established. Another issue is whether brief interventions will only benefit non-dependent patients. Again this study along with other research strongly suggests this is not always (but sometimes) the case. What makes the difference may be whether the patient makes (or can be led to make) a link between their drinking and the medical misfortune which led them to the emergency department. These issues are explored in greater detail in the background notes. Perhaps the most serious of the limitations acknowledged by the authors is that the hospitals may have differed not just in the availability of specialist alcohol counselling, but in how drinking was addressed by other medical staff. With counsellors available to handle the aftermath, in Liverpool they may have been more willing to expose the need for counselling by assessing and discussing alcohol problems with their patients. A hospital which hosts four specialist alcohol nurses is likely to have a different and perhaps more serious attitude to drinking than one which hosts none. But even if this were the case, it would not affect the strength of the intervention's impact, just relocate a greater part of that intervention to usual medical staff

Prometa or Promota? Hope You Didn't Spring for It

A new study just released found that Prometa, a proprietary combination of currently available drugs and nutrients, was no better than placebo in the treatment of methamphetamine addiction. This parallels the negative finding in treatment of alcohol dependence (although most subjects in the alcohol study did worse on Prometa than placebo.) Prometa contains two drugs widely prescribed among people with alcohol dependence, gabapentin (Neurontin) and hydroxyzine (Vistaril.) The third drug, flumezanil, is widely used to reverse the effects of benzodiazepines (such as alprazolam or lorazepam.) However, it can only be given intravenously so it is primarily used to help wake people up after procedures such as colonoscopy where "conscious sedation" is used instead of putting the patient to sleep. The folks at Hythium, Prometa's parent company devised a series of intravenous infusions of these drugs followed by oral medication. They also added various nutrients. Underwritten by wealthy investor Terren Peizer, Hythium hyped Prometa very successfully and in the complete absence of any credible evidence. Prometa is very costly, in the range of $12,000-15,000 or more per month, but enough people addicted to alcohol, methamphetamine or cocaine coughed it up out of desperation, driving the stock very high initially. Those of use who know something about psychopharmacology always knew this was a bunch of horse manure but that doesn't matter much in the addiction treatment world. Prometa wasn't greeted with universal acclaim to say the least. A headline on MSNBC.com in 2007 read: "Unproven meth, cocaine ‘remedy’ hits market. Researchers debate quick fix: Is it good medicine or just marketing?" It took 4 years, but now high quality studies have debunked any claim to efficacy for alcohol or methamphetamine. The meth study, by Ling et al. (Addiction, published online in advance of print, 11/15/11), randomly assigned 120 meth addicts seeking treatment to either the Prometa protocol or a similar set up (with the iv infusions and all) but using placebo instead. As expected, Prometa was no better than placebo. At least it did better in this study than in the study by Anton et al. (J Clin Psychopharmacol 2009;29:334-342,) where for most study subjects, those receiving Prometa had significantly worse outcomes than those receiving placebo! So does this take the wind out of their sales? Of course not! Hythium has the nerve to quote these studies on their website as though they prove than Prometa works, when they show the opposite. That takes real chutzpah. But then again, it's no different than all the treatment centers who offer nutritional supplements, yoga, life coaching, equine therapy etc. as effective for treating addiction. And people keep flocking to them, and paying for them. So until consumers (and payers) wise up, I guess they'll keep selling their snake oil as long as people are buying it.

NIH Funding Success Rate at Historic Low

As expected, recent figures release by the National Institutes of Health (NIH) show a dismal 17.4% success rate for scientists applying for research funding. NIH is the largest funder of biomedical research in the world, and has two institutes devoted to addiction: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA.) It's only through NIH supported research that progress is made on understanding addiction and improving treatment outcomes. Yes, we need more access to treatment but we also need better treatments, and that can only come through scientific research. Anyone who care about addiction and its treatment needs to contact their representatives and let them know we support and need research on addiction. Advocacy matters! Why do you think research funding for breast cancer, HIV/AIDS, and autism has gone up so much! Advocacy! Please support research and urge others to as well. MW NIH Grants Funding Drops; The success rate of the government agency’s grant applications has hit an all-time low. By Jef Akst TheScientist.com Oct. 17, 2011 Grant proposals submitted to the National Institutes of Health (NIH) are less likely to be funded than ever before, according to a sneak peak at this year’s success rates obtained by ScienceInsider last week. According to the new estimate put out by the NIH’s Office of Extramural Research (OER), the fiscal year that ended on September 30 saw the funding of just 17.4 percent of research grant applications—a historic low, according to a comment from NIH Director Francis Collins. The numbers are still “preliminary,” and may rebound slightly in the final release of the data next month, OER chief Sally Rockey told ScienceInsider. Still, it’s a significant drop from the 32 percent of grants the agency was funding around the turn of the millennium, and the first time in NIH history that the success rate has dipped below 20 percent. And the drop in grant funding could get even worse: just last month, the Senate approved a 1 percent drop in the NIH budget. If finalized, it would mark only the second time since 1970 that the agency’s budget has gone down instead of up.

No More Unsupportable Claims!

I had a conversation this past week with another professional who is offering alternatives to 12-step rehab. I had examined his website and had some concerns I wanted to discuss with him. The most important was that on his site, he made claims that I didn't think were scientifically supportable. He claimed, for example, that his program yielded a 70% response (read: cure) rate. So we had a talk. It wasn't easy. I expressed my concern that those of us offering alternatives would be best served by sticking as close as possible to scientifically supportable claims or assertions. I also said that I was concerned that if we acted like current providers in making unsupportable claims that we would hurt our cause. He said that his program is extremely selective in who they take. They accept only "highly motivated" individuals who apparently have little in the way of significant coexisting problems. Among this group, he claimed a 70% rate of success "as the client defined it." He also said some things about accepting only clients with "abuse" rather than "dependence." Finally, he said that a prominent 12-step program had only a 3-5% success rate (compared to his 70%.) Well, as you can imagine, this didn't sit especially well with me. Even with great selection, I have yet to see a credible outcome study demonstrating a 70% rate of remission. Improvement, yes, remission no. Even the worst program in the world is going to have a success rate above 5%, since an evaluation alone yields a success rate of 20-30%. We had a brief discussion about what "abuse" and "dependence" meant in DSM IV (ICD-9 doesn't have an abuse category.) I quoted various studies. None of this mattered. He "respectfully" disagreed. He said he would "take my input under advisement," obviously meaning forget about it as soon as he could get me off the phone. True to form, I received a follow up email saying he'd "appreciated my input" but also that he basically didn't want anything to do with me, since they didn't fit my "model" nor would they be likely to in the future. Since the only "model" I discussed was adhering to scientifically supportable assertions, I have to conclude he decided that no, he didn't want to be held to that standard. In other words, he wanted to say whatever he wanted to, whether it was scientifically supportable or not. What mattered was not the truth, but rather his "model." "Model" and "Philosophy" are two of the most destructive concepts in addiction treatment today. I'll have more to say about this in a future blog. There are so many "programs" out there that provide "miraculous cures" for addiction already. We don't need more. Nutrition therapy, yoga, SPECT scans, yada, yada, yada! Miraculous pharmacotherapy (remember PROMETA anyone?) 12-step programs engage in a more subtle form of this, providing the same treatment over and over again even when it has been proved ineffective. We don't need yet another one. What's needed is straight talk about what we know works, how well (or not) it works, and how best to provide it. We don't need 12-step alternatives that are based on someone's "model" or "philosophy." We need consumer choice based on science and professionalism. The fact is, our treatments for addiction are only partially effective. In many cases they don't work at all. This is how it is in medicine and virtually all other human affairs. Let's face up to this. What's needed is more research, not more unsupportable claims. MW

More NIDA Hype: Vaccines for Addictions (NYT, 10/4/11)

The New York Times today published a story about research on vaccines to prevent or treat substance addictions. The tantalizing title: "An Addiction Vaccine, Tantalizingly Close." The problem? It's not only not close, it's looking more and more unlikely as time goes on. The article details the research career of Kim Janda, an immunologist at the Scripps Institute. Unfortunately, his dedicated quest to develop an effective vaccine for nicotine, alcohol, cocaine, methamphetamine or even obesity have all been dead ends. Often, research in rodents is tantalizing but then human studies are inevitably disappointing. Yet, he is said to be at the "vanguard of addiction research." No less a luminary than the inevitably quoted Drug War General and Director of the National Institute on Drug Abuse (NIDA) Nora Volkow naturally endorses this research, which they funded. Ummmhhh. What am I missing here? I wish that this research offered more promise than it appears to, but I'm afraid I see it on the back burner more than the vanguard.

 Dr. Janda commented that because there is so little available to help some of these addicts, people are desperate to hear something that gives them hope. I am sympathetic to the suffering of individuals with addiction and their loved ones, and I understand their desperation. I see it every day in my practice. Indeed as a physician I experience it, having to give them some pretty bad news about the dearth of highly effective treatments for stimulant addictions. (Note: contingency management, where patients are given rewards for staying abstinent and attending sessions is effective at improving engagement and retention. Whether those effects last very long is still unclear. Also high quality cognitive behavior therapy given to better prognosis addicts is beneficial. However, neither of these treatments is available in the community. The 12-step rehab widely available in the community probably has little if any long term effectiveness.) My interpretation is that non-treatment factors (legal sanctions, accumulating adverse consequences, pressure from others, growing up) are more important than treatment of any kind in determining whether a person will stop.

 Just to be clear, none of this is to say that funding basic and clinical research which has not yet yielded much in the way of clinical breakthroughs is not unique to addiction, and not a reason to decrease funding for it. For all of the billions of dollars put into research on treating solid cancers, for example, there is not much to show for it. In many cases, like cancer of the pancreas, brain or lung, there have been no significant advances at all. We still have no effective way to prevent or treat obesity or osteoarthritis. And yes, new treatments in these other areas that offer modest if any net benefit are also touted by a press looking for something big. So this type of thing seems pretty common in a society that looks to technological solutions for problems where changes in policy and regulation would arguably yield more. But I am concerned when the importance of research findings for treating addiction are exaggerated. I think giving hope that something new may become available has its place here as it does in other diseases. But I also think we have to be careful so we don't lose credibility among a public that is not accustomed to looking to science for an answer for addiction since the most widespread treatment is based on a spiritual transformation.

 One more quick note: Dr. Janda also made the unfortunate comment about addicts needing to "want to stop." In my experience, all addicts want to stop because being addicted is so miserable. But breaking up with cocaine is hard to do. Changing behavior of any type is very hard to do. We aren't very good at it, and we are overall pretty poor at helping others change health behavior and maintain the change. It's possible, it happens more often than we might even expect, but when it doesn't happen it's just too easy to blame the victim as "not wanting to change." And it's too scary to realize that sometimes it's impossible to change even when your life depends on it. Just ask the smokers inhaling through their tracheostomy tubes after having treatment for throat cancer. How terrifying is it to watch yourself die of a behavioral disorder that you abhor and despise and want desperately to change?

 MW

OK, So What's With the Hype About the "Drunk Protector" Drug?

Recently there have been some breathless reports about an experiment conducted by Mark Hutchinson, a scientist at the University of Adelaide, Australia. Hutchinson targeted a novel receptor, TLR4, that is involved in modulating the immune system. It is possible that this receptor is involved in some of the symptoms of drunkenness, like imbalance and slurred speech. Hutchinson gave alcohol to mice who were either normal mice ("wild type") or who had been genetically modified to lack genes encoding two different receptors involved in the TLR4 cascade. They also used a medication that blocked opioid receptors, naltrexone as a comparison group. In addition, they conducted some studies on cell cultures rather than live animals. One of the findings was that mice without these genes had shorter durations of imbalance on two difference measures when given alcohol, compared to mice who were genetically normal. This is what led to the media hype. So does this mean that we are close to a pill that allows people to drink and not get drunk, as media reports suggest? No, of course not. First, this is a very complex experiment that could only be understood by someone steeped in the neurobiology of brain transmission and alcohol's effects on various types of receptors and cells. Second, it has no current or near-term impact. It's meaning only be discerned by other neuroscientists, and it has not even been replicated by another investigator, let alone been translated into a treatment. So, don't get excited, college students! That said, the immune system is something of a trendy thing right now in just about every malady known to humankind, from diabetes to heart disease, stroke to depression. There's no question it is involved in and affected by alcohol consumption. Some effects might be positive, such as a reduced risk of diabetes or Alzheimer's Disease in moderate drinkers, and some might be negative, such liver fibrosis and dysfunctional brain neurotransmission. Here is the website for the original report, for those of you who are undaunted by lots of scientific jargon: http://onlinelibrary.wiley.com/doi/10.1111/j.1476-5381.2011.01572.x/pdf MW

New Documentary on Alcohol Prohibition

PBS PROHIBITION Premieres October 2nd, 3rd & 4th, 2011 at 8 PM on PBS PROHIBITION is a three-part, five-and-a-half-hour documentary film series directed by Ken Burns and Lynn Novick that tells the story of the rise, rule, and fall of the Eighteenth Amendment to the U.S. Constitution and the entire era it encompassed. The culmination of nearly a century of activism, Prohibition was intended to improve, even to ennoble, the lives of all Americans, to protect individuals, families, and society at large from the devastating effects of alcohol abuse. But the enshrining of a faith-driven moral code in the Constitution paradoxically caused millions of Americans to rethink their definition of morality. Thugs became celebrities, responsible authority was rendered impotent. Social mores in place for a century were obliterated. Especially among the young, and most especially among young women, liquor consumption rocketed, propelling the rest of the culture with it: skirts shortened. Music heated up. America's Sweetheart morphed into The Vamp. Prohibition turned law-abiding citizens into criminals, made a mockery of the justice system, caused illicit drinking to seem glamorous and fun, encouraged neighborhood gangs to become national crime syndicates, permitted government officials to bend and sometimes even break the law, and fostered cynicism and hypocrisy that corroded the social contract all across the country. With Prohibition in place, but ineffectively enforced, one observer noted, America had hardly freed itself from the scourge of alcohol abuse – instead, the "drys" had their law, while the "wets" had their liquor. The story of Prohibition's rise and fall is a compelling saga that goes far beyond the oft-told tales of gangsters, rum runners, flappers, and speakeasies, to reveal a complicated and divided nation in the throes of momentous transformation. The film raises vital questions that are as relevant today as they were 100 years ago – about means and ends, individual rights and responsibilities, the proper role of government and finally, who is — and who is not — a real American. http://www.pbs.org/kenburns/prohibition/

If you care about science funding support this!

NIH's 2012 Budget Would Get 3.3% Boost in House Bill By Jocelyn Kaiser Science.com Sept. 29, 2011 A House of Representatives panel released a 2012 draft spending bill today with surprisingly good news for the National Institutes of Health (NIH): The agency's budget would rise $1 billion to $31.7 billion, a 3.3% increase compared with this year's level. However, the bill does not carry out a major reorganization proposed by NIH leaders, and it is more prescriptive about other management issues than biomedical lobbyists feel is appropriate for a research agency. The proposed spending boost matches the president's request and reverses a $190 million cut approved by the Senate Appropriations Committee last week. It also comes as a surprise, given that 7 months ago the full House approved a 2011 spending bill that would have slashed $1.6 billion, or 5%, from NIH's budget. (The final legislation trimmed NIH's 2011 budget by 1%.) The increase is "pretty remarkable" given overall budget constraints, says David Moore of the Association of American Medical Colleges (AAMC) in Washington, D.C. But he points out that the bill also slashes health professions training programs that are important to AAMC. "We're heartened by the statement of support for the NIH, but that's tempered by what else has been cut," he says. Moore's group is also concerned about provisions that it believes "micromanage" NIH. Those provisions include requiring a minimum of 9150 new and competing grants and a 90-10 split between the size of the extramural and intramural research programs. Such decisions are best left to peer review and the scientific judgment of NIH staff, Moore says. The bill does not mention NIH's plan to create a National Center for Advancing Translational Sciences (NCATS) and to abolish the National Center for Research Resources (NCRR). (The Senate bill would make these changes.) In June, the chair of the House appropriations Labor, Health and Human Services, Education, and Related Agencies subcommittee, Representative Denny Rehberg (R-MT), said that his subcommittee could not act on the changes until it received an official budget request directly from the White House. Nor does the bill allocate funding for the Cures Acceleration Network (CAN), a new program that the Senate bill would fund at $20 million within NCATS. However, the bill says the NIH director's office can spend $2 million to set up a CAN board to begin planning the network. And it appears to move $100 million that NIH had requested for CAN to NCRR to expand its Institutional Development Award program to $330.6 million. Rehberg's state, Montana, receives funding from this program for have-not states to help their researchers be more competitive for NIH grants. The House spending panel followed an unusual process in issuing its 2012 draft prior to a meeting of the subcommittee. Such a session was scheduled for 9 September and then canceled. No new date has been set. But the draft gives the House committee a "marker" for upcoming negotiations with its Senate counterpart. In the meantime, Congress has approved a temporary measure to keep the federal government funded at the 2011 level through 4 October that will likely be extended next week until 18 November. Moore expects the two chambers to negotiate an "omnibus" appropriations measure by late November that would fund most, if not all, of the federal government.

Overdose Hospitalizations Increase Dramatically Among Young Adults

Subject: NIH STUDY FINDS HOSPITALIZATIONS INCREASE FOR ALCOHOL AND DRUG OVERDOSES U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH NIH News National Institute on Alcohol Abuse and Alcoholism (NIAAA) For Immediate Release: Tuesday, September 20, 2011 CONTACT: NIAAA Press Office, 301-443-3860, NIH STUDY FINDS HOSPITALIZATIONS INCREASE FOR ALCOHOL AND DRUG OVERDOSES Hospitalizations for alcohol and drug overdoses - alone or in combination - increased dramatically among 18- to 24-year-olds between 1999 and 2008, according to a study by researchers at the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health. Led by Aaron M. White, Ph.D. and Ralph W. Hingson, Sc.D., of NIAAA's division of epidemiology and prevention research, the study examined hospitalization data from the Nationwide Inpatient Sample, a project of the U.S. Agency for Healthcare Research and Quality designed to approximate a 20 percent sample of U.S. community hospitals. The findings appear in the September issue of the Journal of Studies on Alcohol and Drugs. Drs. White, Hingson, and their colleagues report that, over the 10-year study period, hospitalizations among 18-24-year-olds increased by 25 percent for alcohol overdoses; 56 percent for drug overdoses; and 76 percent for combined alcohol and drug overdoses. "In 2008, 1 out of 3 hospitalizations for overdoses in young adults involved excessive consumption of alcohol," notes Dr. White. "Alcohol overdoses alone caused 29,000 hospitalizations, combined alcohol and other drug overdoses caused 29,000, and drug overdoses alone caused another 114,000. The cost of these hospitalizations now exceeds $1.2 billion per year just for 18-24-year-olds." According to the authors, this is a growing problem for those outside of the 18-24 age range, as well. "Among the entire population 18 and older, 1.6 million people were hospitalized for overdoses in 2008, at a cost of $15.5 billion, and half of these hospitalizations involved alcohol overdoses," adds Dr. Hingson. The current study also showed an increase of 122 percent in the rate of poisonings from prescription opioid pain medications and related narcotics among 18-24 year olds. An alcohol overdose was present in 1 of 5 poisonings on these medications. "The combination of alcohol with narcotic pain medications is particularly dangerous, because they both suppress activity in brain areas that regulate breathing and other vital functions," says Dr. White. The researchers note that the steep rise in combined alcohol and drug overdoses highlights the significant risk and growing threat to public health of combining alcohol with other substances, including prescription medications. They call for stronger efforts to educate medical practitioners and the general public about the dangers of excessive alcohol consumption alone or in combination with other drugs. "An increase in screening for alcohol misuse would help clinicians identify patients at particularly high risk for excessive drinking and for alcohol and medication interactions," says NIAAA Acting Director Kenneth Warren, Ph.D. "Clinicians should use brief intervention techniques to help young adults evaluate their relationship with alcohol and other drugs and make wise choices regarding future use." The National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health, is the primary U.S. agency for conducting and supporting research on the causes, consequences, prevention, and treatment of alcohol abuse, alcoholism, and alcohol problems. NIAAA also disseminates research findings to general, professional, and academic audiences. Additional alcohol research information and publications are available at . About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit . ----------------- REFERENCE: Hospitalizations for Alcohol and Drug Overdoses in Young Adults Ages 18-24 in the United States, 1999-2008: Results from the Nationwide Inpatient Sample Aaron M. White, Ralph W. Hingson, I-Jen Pan, Hsiao-Ye Yi Journal of Studies on Alcohol and Drugs (September 2011)

CLIPS -- (Lancet) An international consensus for medical leadership on alcohol

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61461-X/fulltext
The Lancet, Early Online Publication, 15 September 2011
An international consensus for medical leadership on alcohol
Cordelia Coltart, Ian Anderson, Benson Barh, Neil Dewhurst, John Donohoe, Andrej Dukat, Ian Gilmore, Padma Gunaratne, Virginia Hood, David Kershenobich, John Kolbe, Patrick Li, Raymond Liang, Anil Madaree, Bongani Mayosi, Kammant Phanthumchinda, Richard Thompsona

2 billion people worldwide consume alcohol, and of these 76·3 million have alcohol misuse problems,1 with substantial morbidity, mortality, and social harm. Alcohol use is the third leading risk factor for preventable and premature disease, with a lamentable lack of any global remediable action.2

Despite the clear evidence of harm from excess alcohol, there is little will to prioritise the problem in the global health agenda. Therefore the challenge is to reduce this harm by strengthening policies and their implementation locally, nationally, and globally. Such strengthening requires influence and commitment at all levels of the health, political, and legal systems, but the health harms mandate that physicians must take a lead.
Evidence-based cost-effective interventions reduce harm from alcohol, but advocacy for an alcohol policy is not politically attractive. The conflict between government-driven health policy and commercial or social governmental influences impedes the progress of any national or international policy. There is, therefore, an urgent need to put pressure on governments to recognise, adopt, and scale up appropriate health policies.
WHO's Global strategy to reduce harmful use of alcohol,3 ratified at the World Health Assembly in 2010, is the first step towards the introduction of an effective co-ordinated response. Physicians are in a unique position to lead and inform this initiative. An international clinical network with a coherent voice should demand action to reduce alcohol misuse across the globe.
Medical professionalism includes the responsibility to speak out, to lead, and to voice advocacy. It is every clinician's responsibility to address alcohol harm, both on a daily basis with individual patients and in the wider context of health harms and inequalities at the population level. The voice of doctors is valued and trusted within societies, and therefore we call on all doctors to show effective leadership by holding ministries of health accountable for their lack of action in the face of such robust evidence. We ask governments to act urgently and to champion evidence-based initiatives for the implementation of effective alcohol strategies at all levels to improve the health of populations worldwide.
We declare that we have no conflicts of interest.
References
1 WHO. Global status report on alcohol 2004. http://www.who.int/substance_abuse/publications/global_status_report_2004_overview.pdf. (accessed Sept 12, 2011).
2 WHO. Global Health risks: mortality and burden of disease attributable to selected major risk factors. Geneva: World Health Organization, 2009. http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf. (accessed Sept 12, 2011).
3 WHO. Global strategy to reduce harmful use of alcohol. http://www.who.int/substance_abuse/activities/gsrhua/en/index.html. (accessed Sept 12, 2011).
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61461-X/fulltext

More Evidence of Health Benefits of Moderate Drinking in Middle Age

This latest study from PLOS Medicine found that among women, moderate drinking in midlife and living to age 70 without serious or chronic illness are correlated. This is the latest addition to an already robust evidence base for health benefits of moderate drinking, especially in midlife and older individuals. Strengths of this particular study were the prospective design, large sample size and the ability to statistically adjust findings to minimize bias from other factors such as diet and exercise. A few caveats are in order, however. First, correlation is not causation. In spite of statistical adjustments, it is simply not possible to completely eliminate the possibility that other, possibly unmeasured factors account for the correlation. Similarly, correlation is association and does not imply directionality. That is, do women who drink live longer and in better health, or do women who live longer and in better health drink more? Second, don't be too mesmerized by the "one standard drink a day" idea. That number is not what or how people actually drank. Instead, it is a number based on some question(s) about drinking, which are then usually grouped into categories for statistical analysis. For example, abstainers, less than monthly or weekly drinkers, weekly, daily drinkers. Or they may ask "On average, how many drinks do have in a day (or in week)?" and then average that number. The fact is, almost nobody in the US actually drinks one standard drink a day. Drinking varies a lot from day to day and week to week. I think of moderate drinking as regular non heavy drinking. For example, weekly or more often, and for women, never more than 3 standard drinks in any day or 7 drinks in any week (the NIAAA low risk drinking guideline.) For men, the numbers are no more than 4 standard drinks in any day and no more than 14 standard drinks in any week.

Oh, and by the way the type of alcoholic beverage is not important. Wine, beer and spirits all have pretty much the same effect.

OK, so caveats aside, what does this mean? My interpretation is that the evidence overwhelmingly supports a real health benefit associated with moderate drinking. That is, it is very unlikely that these findings are simply due to other factors. Moderate drinking is associated with reduced all cause and especially cardiovascular mortality, lower risk of developing diabetes, Alzheimer's Disease and rheumatoid arthritis. The likely mechanisms for this effect are several. First, drinking raises HDL (good) cholesterol levels. Second, it reduces inflammation, a key factor in development of many disorders. Finally, it increases insulin sensitivity. A decrease of insulin sensitivity is associated with developing Type II diabetes, the most common type.

Everyone is always worried about saying this, for fear that the streets will be flooded with middle aged alcoholics who started drinking to improve their health. Or, that currently addicted people will use this type of finding as an "excuse" to keep drinking. Hogwash! The risk that someone who starts moderate drinking in middle age will become addicted is trivial. In fact if they stay within the NIAAA guidelines, it's nonexistent. And my experience is that addicted people don't need an excuse to keep drinking. They don't drink for their health.

So if anyone is so inclined to start drinking or drink more regularly because of these findings, keep track of your drinking. If it goes above the low risk guidelines, cut back. Also, of course, the guidelines are for healthy adults. People with various health conditions such as liver disease may need to either abstain or drink at even lower levels. People older than 65 or 70, or those taking medications that might interact with alcohol should either abstain or modify their limits. I know I'm supposed to also suggest talking to your doctor about it first, but I'm afraid most doctors know almost nothing about drinking and its effects, and you are likely to get widely divergent advice from different doctors. Also, asking a doctor about something like this is like asking a lawyer about risk. You'll always get the most "conservative" answer, meaning one that puts the expert at lowest risk of being vulnerable. So doctors will be inclined to say don't drink at all, or keep it to one standard drink per day, or something like that. My advice: use your own best judgement, and stay within the low risk guidelines. You are very unlikely to cause harm, and keep in mind that the health benefits are pretty substantial. So advice to a middle aged person to abstain is not conservative in that abstainers get sick more and die younger than moderate drinkers. Finally, women who are pregnant or at risk of becoming pregnant should abstain due to potential fetal effects.

MW

Alcohol Consumption at Midlife and Successful Ageing in Women: A Prospective Cohort Analysis in the Nurses' Health Study

Qi Sun1,2*, Mary K. Townsend2, Olivia I. Okereke2,3, Eric B. Rimm1,2,3, Frank B. Hu1,2,3, Meir J. Stampfer1,2,3, Francine Grodstein2,3
1 Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, United States of America, 2 Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America, 3 Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America

Sun Q, Townsend MK, Okereke OI, Rimm EB, Hu FB, et al. (2011) Alcohol Consumption at Midlife and Successful Ageing in Women: A Prospective Cohort
Analysis in the Nurses’ Health Study. PLoS Med 8(9): e1001090. doi:10.1371/journal.pmed.1001090

Abstract
Background
Observational studies have documented inverse associations between moderate alcohol consumption and risk of premature death. It is largely unknown whether moderate alcohol intake is also associated with overall health and well-being among populations who have survived to older age. In this study, we prospectively examined alcohol use assessed at midlife in relation to successful ageing in a cohort of US women.

Methods and Findings
Alcohol consumption at midlife was assessed using a validated food frequency questionnaire. Subsequently, successful ageing was defined in 13,894 Nurses' Health Study participants who survived to age 70 or older, and whose health status was continuously updated. “Successful ageing” was considered as being free of 11 major chronic diseases and having no major cognitive impairment, physical impairment, or mental health limitations. Analyses were restricted to the 98.1% of participants who were not heavier drinkers (>45 g/d) at midlife. Of all eligible study participants, 1,491 (10.7%) achieved successful ageing. After multivariable adjustment of potential confounders, light-to-moderate alcohol consumption at midlife was associated with modestly increased odds of successful ageing. The odds ratios (95% confidence interval) were 1.0 (referent) for nondrinkers, 1.11 (0.96–1.29) for ≤5.0 g/d, 1.19 (1.01–1.40) for 5.1–15.0 g/d, 1.28 (1.03–1.58) for 15.1–30.0 g/d, and 1.24 (0.87–1.76) for 30.1–45.0 g/d. Meanwhile, independent of total alcohol intake, participants who drank alcohol at regular patterns throughout the week, rather than on a single occasion, had somewhat better odds of successful ageing; for example, the odds ratios (95% confidence interval) were 1.29 (1.01–1.64) and 1.47 (1.14–1.90) for those drinking 3–4 days and 5–7 days per week in comparison with nondrinkers, respectively, whereas the odds ratio was 1.10 (0.94–1.30) for those drinking only 1–2 days per week.

Conclusions
These data suggest that regular, moderate consumption of alcohol at midlife may be related to a modest increase in overall health status among women who survive to older ages.

Link fixed on 9/11 post.

The link has been fixed on the post yesterday about Maia Szalavitz' column on addiction and 9/11. Thanks to readers for letting me know!

Did Addiction Increase After 9/11?

Maia Szalavitz has written a great piece on substance use and addiction after 9/11. You can see it here. Maia is one of the best interpreters of new research and event in addiction.

MW

Little Progress in Tackling Smoking, Drinking, Obesity Worldwide

September 9, 2011

Prognosis Poor for U.N. Chronic Disease Meeting

By REUTERS

LONDON (Reuters) - Ten years after committing to fight AIDS, the United Nations is taking on an even bigger bunch of killers -- common chronic diseases -- in what is shaping up to be a bruising battle between big business, Western governments and the world's poor.

Tobacco, food and drinks companies are in the firing line for peddling products linked to cancer, diabetes and heart disease, while politicians in the rich world are accused of failing to set firm targets or provide funds for a decent fight.

"This is a once in a generation opportunity. We could save millions of lives here, and it's shameful and immoral that industry lobbying has put short-term profits in front of a public health disaster," Rebecca Perl of the World Lung Foundation (WLF) told Reuters. WLF has been involved in tetchy preliminary talks for several months.

The fear is that big business has successfully lobbied rich governments to be only half-hearted in battling non-communicable diseases, or NCDs, despite predictions that they could cripple healthcare systems of developing countries.

A bit like climate change, preventing and treating non-communicable diseases requires wealthy nations and multinational firms to take a near-term financial hit to help prevent poor nations being overwhelmed in the future.

In these austere times, fears are already growing that a high-level U.N. meeting in New York on September 19-20 -- only the second to focus on disease after one on AIDS in 2001 -- could be a flop.

The gathering will include scores of delegates from U.N. member states, including around 20 heads of government as well as representatives from public health groups, non-governmental organisations, the private sector and academia.

According to those close to the negotiations, a draft version of the political declaration that will form the cornerstone of the U.N.'s thinking on NCDs contains many platitudes but few tangible commitments.

"There are no strong, time-bound commitments in there," Ann Keeling, chair of the NCD Alliance which groups 2,000 health organisations from around the world, told Reuters. "It's a great disappointment from that point of view."

NOT ROCKET SCIENCE

The scale of the problem is immense. Around 36 million people die every year from NCDs -- around 80 percent of them in poor nations where prevention programmes are virtually non-existent and access to diagnosis and treatment is very limited.

As a result, death rates from NCDs are nearly twice as high in poor countries as in the industrialised world.

Preventing these deaths -- or at least a good proportion of them -- isn't rocket science. Proven measures such as reducing smoking rates, improving diets, making simple drugs available and boosting exercise could knock a huge hole in that figure.

"There is a common story that unites cancer, cardiovascular, diabetes and respiratory medicines around tobacco, alcohol, diet and exercise -- and that is where we have the most cost-effective impact," says David Kerr, president of the European Society of Medical Oncology.

The crucial sticking points are targets, taxes and money.

Stopping a billion people from lighting up every day or providing cheap drugs like aspirin and statins to prevent heart attacks and strokes may be cost effective, but the payback won't be quick and it is unlikely to win many votes.

"The time horizon for the return on that investment is very long and beyond many political horizons. So it's difficult to get people to commit to these kinds of resources," says Gordon Tomaselli, president of the American Heart Association.

The NCD Alliance says spending $9 billion (5.6 billion pounds) a year on tobacco control, food advice and treatment for people with heart risks would avert tens of millions of untimely deaths this decade.

Is that a lot? By comparison, caring for HIV patients in developing countries already costs around $13 billion a year.

In contrast to the AIDS fight that was the UN's focus a decade ago, the price of drugs is less an issue here, since many are available as cheap generics, although there are disputes over the cost of some more pricey products like insulin.

STUBBING OUT TOBACCO

The sharpest focus this time is on makers of fatty foods, sugary drinks and -- above all -- the tobacco industry, which World Health Organisation director general Margaret Chan has described as "an industry that has much money and no qualms about using it in the most devious ways imaginable."

With tobacco predicted to kill more than a billion people this century, if current trends persist, the public health lobby says if the U.N. meeting does nothing else, it should at least make a smoke-free world one of its central targets.

Smoking alone causes one in three cases of lung disease, one in four cases of cancer, and one in 10 cases of heart disease, says Perl. "So look what a bang you get for your buck there."

Conflicted governments will find it tough. Japan Tobacco, for example, is 50 percent owned by the Japanese government, and the massive profits of U.S. cigarette makers bolster the U.S. economy.

In China, home to a third of the world's male smokers, the combination of taxes and sales from China National Tobacco -- a wholly state-owned entity -- account for around 9 percent of the government's annual fiscal revenues.

This is all the more reason, according to Paul Lincoln of the UK National Heart Forum and Jaakko Tuomilehto, an epidemiologist at the University of Helsinki, to hike cigarette taxes, curb advertising and insist on graphic health warnings.

"There are no more excuses," said Lincoln. "We have the know-how. The challenge as ever in public health is to overcome the ideological and vested interests."

Tuomilehto is more blunt: "It's a crazy thing to have a product in the shops that kills every second consumer -- it's madness."

Promises Offers a False Promise: Where “Belief” Trumps Science

Promises Malibu is one of the high-end programs frequented by Hollywood celebrities and other wealthy people that charges in the neighborhood of $55,000+ per month for “treatment” that includes things like “equine assisted therapy” and the “ropes course,” which is described as “…a fun, safe yet challenging personal growth and team building activity that our clients partake in.” Promises says it offers “… the most diverse, cutting edge, and non-traditional forms of therapy available in order to give our clients an individualized and well-rounded treatment experience.”

Unfortunately, they also offer treatment that causes relapse and kills people. The “Detoxification from Suboxone Maintenance Program” purports to offer a “clinically sound detox program” that “fills this gap in addiction treatment.” What is the rationale, the sound underpinning of this program? “At Promises we have always believed that drugs such as buprenorphine, Suboxone, and Subutex are best used for detox and stabilization, and that our clients are best served by helping them become completely free of them.” They believe that these drugs are best used for detox and the clients are best served by detox.

However, they evidently do not believe in the scientific method. There is not one single study that shows that withdrawal from maintenance medication improves outcomes. In fact, every study ever published concludes the exact opposite. In 2009, the United Nations World Health Organization published guidelines based on an international consensus that maintenance therapy with either methadone or buprenorphine produced far better outcomes than detoxification. Here is their summary of the available evidence: “Of the treatment options examined, opioid agonist maintenance treatment, combined with psychosocial assistance, was found to be the most effective. Oral methadone liquid and sublingual buprenorphine tablets are the medications most widely used for opioid agonist maintenance treatment. In the context of high-quality, supervised and well-organized treatment services, these medications interrupt the cycle of intoxication and withdrawal, greatly reducing heroin and other illicit opioid use, crime and the risk of death through overdose. Compared to detoxification or no treatment, methadone maintenance treatment (using mostly supervised administration of the liquid methadone formulation) significantly reduces opioid and other drug use, criminal activity, HIV risk behaviours and transmission, opioid overdose and all-cause mortality; it also helps to retain people in treatment. Compared to detoxification or no treatment, buprenorphine also significantly reduces drug use and improves retention.” Every single study or review of the data has concluded the same thing: opioid agonist therapy with methadone or buprenorphine saves lives, reduces drug use and crime and leads to improved overall outcomes, as compared with any “abstinence oriented” treatment.

But in the United States, “belief” trumps science when it comes to addiction. Treatment programs talk about their “philosophy” as though this were a matter of epistemology or ethics. It isn’t either. This is as cut and dried as it gets in modern medicine. The evidence for agonist therapy is much better than for stenting of coronary arteries, joint replacement, back surgery or most treatments for cancer. It is one of the most cost effective interventions in all of health care. About the only thing more cost effective is vaccination for childhood diseases. Yet we somehow are cowed by the “special knowledge” that “addiction experts” allege but that they can’t really share or explain the basis for. It’s time for the American public to demand that addiction treatment be based not on personal conviction, but on scientific evidence and professional scholarship.

WHO: Opioid Agonist Therapy Only Effective Treatment for Opioid Addiction

This 2009 publication from the United Nations once again states the obvious: abstinence based treatment for opioid addiction does not work. Will US rehab programs and government policy ever wake up? How many people have to die on the altar of 12-Step ideology before the industry will be forced to provide evidence based treatment? MW

Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. World Health Organization. World Health Organization, 2009. Unequivocal backing from UN agencies for methadone and other forms of long term maintenance treatments as the prime modality for the treatment of dependence on heroin and allied drugs. In contrast say the experts, detoxification results in poor long term outcomes. These guidelines were developed in response to a resolution from the United Nations Economic and Social Council (ECOSOC), which invited the World Health Organization (WHO) in collaboration with the United Nations Office on Drugs and Crime (UNODC) "to develop and publish minimum requirements and international guidelines on psychosocially assisted pharmacological treatment of persons dependent on opioids". The recommendations were based on systematic reviews of the literature and consultation with experts from different regions of the world. Treatment of opioid dependence is a set of pharmacological and psychosocial interventions aimed at reducing or ceasing opioid use, preventing related harms, and improving the quality of life and well-being of the patient. In most cases, treatment will be required in the long term or even throughout life. The aim in such instances is not only to reduce or stop opioid use, but also to improve health and social functioning, and to help patients avoid some of the more serious consequences of drug use. Such long-term treatment should not be seen as a failure, but rather as a cost-effective way of prolonging and improving the quality of life, supporting the natural and long-term process of change and recovery. Psychosocially assisted pharmacological treatment refers to the combination of specific pharmacological and psychosocial measures used to reduce illicit opioid use and related harms and improve quality of life. Opioid agonist maintenance treatment Opioid agonist maintenance treatment is the administration of thoroughly evaluated opioid agonists (ie, drugs with opiate-type effects) to opioid dependent patients by accredited professionals in the framework of recognised medical practice to achieve defined treatment aims. Of the treatment options examined in these guidelines, such treatment, combined with psychosocial assistance, was found to be the most effective. Clinicians should offer other modalities including opioid withdrawal and opioid antagonist (naltrexone) treatment, but most patients should be advised to use opioid agonist maintenance treatment. Oral methadone liquid and sublingual buprenorphine tablets are the medications most widely used for opioid agonist maintenance treatment. Both are sufficiently long acting to be taken once daily. They have a strong evidence base and have been placed on the WHO model list of essential medicines. Prescribed in the context of high quality, supervised and well-organised treatment services, they do not produce the cycles of intoxication and withdrawal seen with shorter acting opioids such as heroin and greatly reduce heroin and other illicit opioid use, crime, and risk of death through overdose. Both can also be used in reducing doses to assist in withdrawal or 'detoxification' from opioids. More specifically, the evidence is that compared to detoxification or no treatment, methadone maintenance (using mostly supervised administration of liquid methadone) significantly reduces opioid and other drug use, criminal activity, HIV risk behaviours and transmission, opioid overdose and all-cause mortality; it also helps retain people in treatment. Compared to detoxification or no treatment, buprenorphine also significantly reduces drug use and extends treatment retention. Comparing the two medications, both generally provide good outcomes. Methadone is preferred because it is more effective and costs less, but buprenorphine has a slightly different pharmacological action. Making both available may attract greater numbers of people to treatment and improve the matching of patients to appropriate treatments. In new patients, methadone doses should gradually be increased to the point where illicit opioid use ceases; this is likely to be in the range of 60–120 mg per day. Methadone consumption should initially be supervised as suited to the individual patient, balancing the benefits of reduced attendance requirements in stable patients with the risks of injection and diversion of methadone to the illicit drug market. Psychosocial assistance should be offered to all patients. Buprenorphine doses should be rapidly increased (ie, over days) to a dose that produces stable effects for 24 hours, generally 8–24 mg per day. If opioid use continues, usually the dose should be increased. Dosing supervision and other aspects of treatment should be determined on an individual basis, using the same criteria as for methadone maintenance treatment. Treatment for withdrawal and prevention of relapse An alternative to maintenance is to help patients completely withdraw from opioids, a process also referred to as opioid detoxification. Methadone and buprenorphine can be used in reducing doses; alpha-2 adrenergic agonists such as clonidine can also be used to ameliorate withdrawal symptoms. Following detoxification, the long-acting opioid antagonist naltrexone can be used to help prevent relapse. Naltrexone produces no opioid effects itself, and blocks the effects of opioids for 24–48 hours. Compared to maintenance treatment, opioid withdrawal results in poor outcomes in the long term; however, patients should be helped to withdraw from opioids if it is their informed choice to do so. Methadone and buprenorphine are the preferred treatments because they are effective and can be used in a supervised fashion in both inpatient and outpatient settings. Inpatient treatment is more effective, but also more expensive, and is recommended only for a minority of patients, such as those with polysubstance dependence or medical or psychiatric comorbidity. Accelerated withdrawal techniques using opioid antagonists in combination with heavy sedation are not recommended because of safety concerns. Naltrexone can be useful in preventing relapse in those who have withdrawn from opioids, particularly in those motivated to abstain from opioid use. Following opioid withdrawal, such patients should be advised to consider naltrexone to prevent relapse. Psychosocial treatment Psychosocial interventions – including cognitive and behavioural approaches and contingency management techniques – can add to the effectiveness of treatment if combined with agonist maintenance treatment or medications for assisting opioid withdrawal. Psychosocial services should be made available to all patients, although those who do not take up the offer should not be denied effective pharmacological treatments. Treatment systems In planning treatment systems, resources should be distributed in a way that delivers effective treatment to as many people as possible. Opioid agonist maintenance treatment appears to be the most cost-effective treatment, and should therefore form the backbone of the treatment system for opioid dependence. Countries with established opioid agonist maintenance programmes usually attract 40–50% of dependent opioid users into such programmes, with higher rates in some urban environments. Because of their cost, inpatient facilities should be reserved for those with specific needs, and most patients wanting to withdraw from opioids should be encouraged to attempt opioid withdrawal as outpatients. Ethical principles of care Ethical principles should be considered together with evidence from clinical trials; the human rights of opioid-dependent individuals should always be respected. Treatment decisions should be based on standard principles of medical-care ethics: providing equitable access to treatment and psychosocial support that best meets the needs of the individual. Treatment should respect and validate the autonomy of the individual, with patients being fully informed about the risks and benefits of treatment choices. Furthermore, programmes should create supportive environments and relationships to facilitate treatment, provide coordinated treatment of comorbid mental and physical disorders, and address relevant psychosocial factors. These guidelines (to which Findings contributed) constitute an important and authoritative statement from international experts issued with the backing of the relevant United Nations agencies. Their target is largely nations which are ambivalent about, unduly restrict, or oppose drug-based treatments of heroin addiction and other forms of opioid dependence, particularly treatments which involve the prescribing of opiate-type drugs like methadone. To these treatments – which should form the "backbone" of national treatment systems – the guidelines lend their unequivocal backing. They are also clear that long-term prescribing is no failure and that interventions aimed at healing psychological wounds and social reintegration should be provided when possible, though their rejection by the patient should not be grounds for denying them the benefits of the drug element of the treatment. Last revised 31 August 2011

ASAM Blunders in New Definition of Addiction

Alcoholism & Drug Abuse Weekly

Volume 23 Number 33
August 29, 2011

ASAM admits error in omitting NIAAA in definition publicity


In announcing its new broader definition of addiction to include non-substance addictions such as sex and gambling (see ADAW, August 22), the American Society of Addiction Medicine (ASAM) made an almost fatal error. It treated alcohol like an afterthought and pointedly omitted any mention of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) while suggesting — incorrectly, as it turns out — that the National Institute on Drug Abuse (NIDA) was involved in crafting the definition, ADAW has learned.

ASAM past president Michael Miller, M.D., told ADAW last week that nobody from NIDA was involved officially in the process leading to release of the definition. “The press release did not state things in a clear manner and clearly led people to believe that we had some kind of formal connection with NIDA,” Miller said.

It strains belief for some leaders, however, to think that ASAM physicians were not aware of the bitter struggle between NIDA and NIAAA
researchers over the upcoming merger of the institutes, which will create a new, single institute of addiction — a merger NIDA supported
and NIAAA opposed. NIAAA officials were furious when the definition — and the press release — came out, published August 15 on the ASAM website.

“We recognize that ASAM is extremely important to physicians who are specializing in substance use disorders,” said Howard B. Moss, M.D., associate director for clinical and translational research at NIAAA. “But we are concerned that the narrow definitional focus on neuroscience
doesn’t really address the psychological and sociocultural aspects of addiction,” he told ADAW. “We view it as reductionist.”

Moss also said the timing of the definition’s release was awkward, since the DSM-5 process is taking place at the same time. “DSM will
have definitions that will be discussed in the diagnostic criteria,” he said. And finally, calling addiction a disease is hardly new.

NIAAA is also very concerned about binge drinking, underage alcohol use, and drinking and driving — problems that aren’t necessarily facets
of addictive disorders, said Moss.

“We met with NIAAA to explain to them how sorry we are that we did not vet this with them more officially,” ASAM’s Miller said. “They
are at least embarrassed and extremely disappointed because they were blindsided with people coming to them with questions about
things they haven’t even seen.”

When we talked to Miller last week, no decision had yet been made about whether ASAM would publicize a correction about NIDA/
NIAAA involvement. But, he said, “We have apologized to NIAAA very publicly.”

NIAAA is “not aware of any public apology,” according to a NIAAA press officer.

Sensitivity issues

Miller blamed some of the “lack of sensitivity” to the fact that ASAM has a new CEO and a new staffer in charge of communications. “ASAM
has learned through this process that it must be much more sensitive to these delicate differences of the two institutes, and that so many
people are looking for messages in the tea leaves that may not be there.”

ASAM has “no official position” on the proposed merger of the institutes, said Miller.

Sources at NIAAA said people there are “absolutely furious.” They believe that ASAM is saying — just as the pro-merger researchers had
said — that all neurochemical pathways to addiction are the same. In fact, they say, alcohol is not the same — it goes everywhere in the
brain. There is no alcohol receptor, said Moss.

Not diagnostic criteria

The ASAM definition is just that — it is not diagnostic criteria, and it can’t be used for diagnosis, said Miller. That is the province of the
American Psychiatric Association (APA), which field-tests its criteria.

ASAM really wanted to update its definition because the organization had two different definitions out there — one that applies only to alcoholism
and that dates back to 1990, and one for addiction that was created in 2001 in collaboration with the American Pain Society, Miller said. “These two did not align, there were subtle differences,” he said. So the new definition eliminated the old definition of alcoholism and added various “process” addictions.

“We did get some cautionary advice from different quarters,” said Miller. For example, alcoholism researcher Carlton Erickson “blasted the whole project,” said Miller. Erickson suggested not to talk about spirituality or non-substance addictions, but to “stick to what is known,” recalled Miller. But in general there was consensus, he said.

“Most clinicians said this makes sense, and the board of directors of ASAM unanimously approved it,” said Miller.

Back for more!

I think I'm ready to again take up my lance and tilt at the windmill of changing the paradigm of treatment in this country (if not everywhere!) I haven't been posting mostly because I've been overwhelmed with the realities of trying to earn a living seeing patients in a heavily managed care environment. I've learned a lot, some of it quite painfully. I think in the long run it will serve me, and hopefully others, well, because this is a harsh, difficult and treacherous environment. I understand much better why physicians avoid particularly challenging patients, and why they are so conservative in their approach. Everyone is overwhelmed. There are so many patients we really don't have any treatment for or even understand what is wrong with them. It feels like we are putting Band-Aids on gaping infected wounds and sending people out the door. Many are simply left to cope on their own. All of this has been exacerbated by the Great Recession, which is wreaking havoc on anyone but the wealthy, and by a system of care heavily dominated by procedure-oriented specialty care rather than compassionate, comprehensive care. One reason for feeling overwhelmed is that it all seems so well, overwhelming. How can anyone hope to change this terribly dysfunctional system? Lately I've adopted the strategy of focusing on smaller, more achievable goals. This fall I will start seeing more patients in private practice and fewer in a managed care setting. I hope to build on this seedling to establish the first ALLTYR Clinic. Wish me luck.

Opioids for Treatment Resistant Depression?

My colleague, Mark Rose, recently submitted this post about the potential use of buprenorphine as an antidepressant treatment for treatment resistant depression. To our knowledge, no further studies of this have been done. Perhaps it's time?

MW


Buprenorphine may be effective in treatment-refractory depression

Mark E. Rose, MA
Licensed Psychologist

Persons with major depressive disorder (MDD) are considered treatment-refractory (TRD) when they fail to respond to multiple trials of antidepressant medication from different classes (Keller 2005). TRD is a devastating condition that results in substantial health care and economic cost, and untold suffering to the patient and family members (Nierenberg et al. 2007). Most FDA-approved antidepressant drugs act through monoamine reuptake inhibition, and medications that act through alternate mechanisms need to be available to patients with unrelenting depression that is untreatable with conventional antidepressants. The results of a study published 15 years ago hint that a currently available drug may provide greater benefit to patients with TRD than any other known pharmaceutical agent.

Although opioids were used to treat MDD until the late 1950s, research evaluating their antidepressant potential has been very rare in the past 60 years (Berrocoso et al. 2009). The synthetic opioid buprenorphine is a partial mu receptor agonist and kappa receptor antagonist, is exceptionally safe in overdose, and produces substantially less euphoria than pure mu receptor agonists such as morphine and oxycodone. A small study (Bodkin et al. 1995) evaluated the therapeutic potential of buprenorphine in the treatment of TRD. The 10 study participants averaged a 20.7–year duration of unipolar major depression, 7.6 previous unsuccessful antidepressant trials, and a HAM-D score of 28.1. Buprenorphine was initiated in open-label manner at 0.15 mg/d with maximum upward titration to 1.80 mg/d over the 4-6 week trial (final mean dose 1.26 mg/d). Three subjects dropped out due to malaise, nausea, and dysphoria. Of the remaining 7 subjects, 6 achieved marked clinical improvement. The mean endpoint HAM-D score was 10.7, a 60.7% reduction from baseline, and 4 patients achieved complete remission (HAM-D ≤ 6). The mean overall level of functioning increased 45.5% and mean subjective depression rating decreased 50%. Significant improvement became apparent at the end of week 1.

The authors conclude that the results are remarkable, with the number of previous treatment failures, the level of disease severity, and the duration of improvement arguing against placebo effect as the basis of treatment response. Patients did not report euphoria or intoxication but instead felt ‘more normal’, which together with the 33% drop-out suggest limited abuse liability in persons with TRD. These results are literally begging for replication, but sadly, despite awareness of this data for 15 years, researchers have not conducted follow-up studies due to the stigma surrounding opioid drugs and their association with addiction.

Keller MB. Issues in treatment-resistant depression. J Clin Psychiatry. 2005;66(Suppl 8):5-12.

Nierenberg AA, Katz J, Fava M. A critical overview of the pharmacologic
management of treatment-resistant depression. Psychiatr Clin North Am. 2007;30(1):13-29.

Berrocoso E, et al. Opiates as antidepressants. Current Pharmaceutical Design. 2009;15:1612-1622.

Bodkin JA, Zornberg GL, Lukas SE, Cole JO. Buprenorphine treatment of refractory depression. J Clin Psychopharmacol. 1995;15:49-57.

Research Study Results: Skepticism Required!

This new study identified some functional neuroimaging correlates to performance on a task that measures something called "delay discounting." This now highly popular test (among scientists) gives people a choice or series of choices that boils down to this question: "Do you want a smaller reward (typically money) sooner, or a larger reward later?" For example, a subject might be asked to decide between getting $1 right now, or getting $20 in two weeks. "Delay discounting" refers to discounting the value of a future reward, thus increasing the likelihood of choosing the smaller reward sooner. While there have been many such studies, I'm posting this one because of the comments made by Dan Hommer at the National Institute on Alcohol Abuse and Alcoholism. His comments focus on the concept of "impulsivity." As it turns out, there is no gold standard for measuring this construct, nor is there any consensus about what it means in more than general terms. The same holds true for many other terms used in imaging and other studies, including reward, behavioral inhibition and disinhibition, liking, wanting, attention and so forth. Bottom line: read or listen to the results of studies like this skeptically. Remember that scientists and media professionals want something to be newsworthy, leading to inflation of the importance and clarity of much research.

MW

Researchers Link Alcohol-Dependence Impulsivity to Brain Anomalies

ScienceDaily

May 1, 2011

Researchers already know that alcohol dependence (AD) is strongly associated with impaired impulse control or, more precisely, the inability to choose large, delayed rewards rather than smaller but more immediate rewards. Findings from a study using functional magnetic resonance imaging (fMRI) to investigate the neural basis of impulsive choice among individuals with alcohol use disorders (AUDs) suggest that impulsive choice in AD may be the result of functional anomalies in widely distributed but interconnected brain regions that are involved in cognitive and emotional control.

Results will be published in the July 2011 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

"Individuals with AD score higher on questionnaires that measure impulsivity -- for example, 'I act without thinking' -- are less able to delay gratification, and are less able to inhibit responses," said Eric D. Claus, a research scientist with The Mind Research Network and first author of the study.

Given that impulsive choice in AUDs has been associated with impairment of frontal cortical systems involved in behavioral control, Claus explained, this study was designed to examine the neural correlates of one specific aspect of impulsivity, the ability to delay immediate gratification and instead choose rewards in the future.

"We investigated this choice process in individuals with alcohol use problems ranging from alcohol abuse to severe AD that required treatment," said Claus. "This is the largest study to date that has investigated the neural correlates of impulsive choice in AD, which enabled us to examine the full range of AUDs instead of only examining extreme group differences."

Claus and his colleagues examined 150 individuals (103 males, 47 females) with various degrees of alcohol use. All of the participants completed a delay discounting task -- during which two options were presented, a small monetary (e.g., $10) reward available immediately or a larger monetary reward (e.g., $30) available in time (e.g., two weeks) -- while undergoing fMRI. Impulsive choice was defined as the selection of the more immediate option.

"We showed two things," said Claus. "We replicated previous research by showing that AUD severity was associated with a greater tendency to discount future rewards. In addition, we showed that when individuals with more severe AUDs did delay gratification, they engaged the insula and supplementary motor area -- regions involved in emotional processing and response conflict -- to a greater degree than individuals with less severe AUDs. In summary, these findings suggest that the dysfunction in these regions is graded and increases as a function of AUD severity, rather than operating as an all-or-none function."

"This work showed that the brains of alcoholics don't behave all that differently from the brains of non-alcoholics during delay discounting but that the alcoholic brain had to work harder when they chose the delayed reward," said Daniel W. Hommer, chief of the Section of Brain Electrophysiology & Imaging at the National Institute on Alcohol Abuse and Alcoholism. "Many different studies have shown similar results, that is, alcoholics have a greater increase in brain blood flow to perform the same task as non-alcoholics."

"The current study suggests that the neural dysfunction underlying impulsive choice seems to increase with AD severity," added Claus. "Now that we know that this neural dysfunction is associated with impulsivity, the next steps are to determine whether this impulsivity predates the onset of AD and whether neural measures of impulsivity can predict who will respond best to particular types of treatment. Further, the particular neural dysfunction that we observed indicates that individuals with more AD may be more impulsive because their brain is aversive to delay gratification, and not because it is rewarding to be impulsive. Clinicians might need to deal directly with the aversion of choosing future benefits over immediate ones."

"The most important thing about this paper is that it leads you to question what people mean by impulsive behavior and how should it be measured," said Hommer. "The field has defined increased discounting of time -- failure to delay gratification -- as a good measure of impulsiveness, but the results reported in this paper say 'Wait a minute, delay discounting does not correspond to what is usually meant by impulsiveness.' Rather, brain activity during a delay discounting task looks more like how the brain responds during conflicted decision-making than it does during rapid, unconflicted choice of a highly valued goal." Hommer added that this sort of debate is important to researchers, forcing them to think more carefully about what they mean by impulsive choice.

Evidence Stronger for Cannabis-Psychosis Link

I've been a skeptic about the potential role of cannabis as an independent risk factor for developing psychosis, but this new study addresses some of the weaknesses of previous studies and shows a strong association between persistent cannabis use and the later development of psychosis. They only studied cannabis use that started after the study baseline to eliminate the effects of preexisting use, and they excluded anyone at baseline with any psychotic symptoms. The authors suggest that the risk might involve increasing the persistence of subclinical psychotic phenomena that would otherwise be transient, an interesting hypothesis. Underlying that suggestion is recent evidence that psychotic phenomena exist along a continuum from minor transient symptoms (quite common) to persistent and then more severe symptoms. Also note that the risk associated with cannabis was independent of family history of psychosis. There are still many unanswered questions about this link, but the evidence for it is growing and is strong enough now that warning parents and adolescents is probably warranted. Here's the link to the article.

MW

BMJ 2011; 342:d738

Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study
OPEN ACCESS
Rebecca Kuepper, research psychologist1, Jim van Os, professor1, visiting professor2, Roselind Lieb, professor34, Hans-Ulrich Wittchen, professor45, Michael Höfler, research statistician5, Cécile Henquet, lecturer1
+ Author Affiliations

1Department of Psychiatry and Neuropsychology, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht University Medical Center, Maastricht, Netherlands
2King’s College London, King’s Health Partners, Department of Psychosis Studies, Institute of Psychiatry, London, UK
3Department of Psychology, Division of Epidemiology and Health Psychology, University of Basel, Switzerland
4Max Planck Institute of Psychiatry, Munich, Germany
5Institute of Clinical Psychology and Psychotherapy, Technical University Dresden, Germany
Correspondence to: J van Os, Department of Psychiatry and Neuropsychology, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht University Medical Center, PO Box 616, NL-6200 MD, Maastricht, Netherlands j.vanos@sp.unimaas.nl
Accepted 31 December 2010
Abstract
Objective To determine whether use of cannabis in adolescence increases the risk for psychotic outcomes by affecting the incidence and persistence of subclinical expression of psychosis in the general population (that is, expression of psychosis below the level required for a clinical diagnosis).

Design Analysis of data from a prospective population based cohort study in Germany (early developmental stages of psychopathology study).

Setting Population based cohort study in Germany.

Participants 1923 individuals from the general population, aged 14-24 at baseline.

Main outcome measure Incidence and persistence of subthreshold psychotic symptoms after use of cannabis in adolescence. Cannabis use and psychotic symptoms were assessed at three time points (baseline, T2 (3.5 years), T3 (8.4 years)) over a 10 year follow-up period with the Munich version of the composite international diagnostic interview (M-CIDI).

Results In individuals who had no reported lifetime psychotic symptoms and no reported lifetime cannabis use at baseline, incident cannabis use over the period from baseline to T2 increased the risk of later incident psychotic symptoms over the period from T2 to T3 (adjusted odds ratio 1.9, 95% confidence interval 1.1 to 3.1; P=0.021). Furthermore, continued use of cannabis increased the risk of persistent psychotic symptoms over the period from T2 to T3 (2.2, 1.2 to 4.2; P=0.016). The incidence rate of psychotic symptoms over the period from baseline to T2 was 31% (152) in exposed individuals versus 20% (284) in non-exposed individuals; over the period from T2 to T3 these rates were 14% (108) and 8% (49), respectively.

Conclusion Cannabis use is a risk factor for the development of incident psychotic symptoms. Continued cannabis use might increase the risk for psychotic disorder by impacting on the persistence of symptoms

Addiction: A Potentially Fatal Behavioral Disease

A few months ago, an article in the St. Paul Pioneer Press described a "wet house," where people who were unable to stop drinking were able to get housing and access to services without requiring that they stop drinking. A very typical response, especially from people in 12-step programs and in treatment programs, was that this was "giving up" on these unfortunate individuals, that the proper treatment or 12-step participation would result in their being able to sustain abstinence. A number of people have asked me about this. Here's my response to a recent inquiry.

MW

I actually did research on this in the late 1980s and got quite deep into what the best approach was for chronic public inebriates. The problem we were trying to address was that these folks would cycle through the detox center over and over. A minority of users accounted for the majority of visits to detox, which is expensive. In addition they are frequent guests in emergency rooms and hospitals. Here's what we found:

1. Many of them were using detox as a shelter. They were homeless, couldn't maintain a home, and shelters wouldn't take anyone who appeared to be drinking. Some of them would drink a little alcohol and fall down in front of a police car to get transported to detox.
2. For about 1/2 of them, a case manager was able to work with them and get them housed and help them with their food purchases, housekeeping, money management and so forth. This group saw dramatic drops in detox and emergency room usage.
3. The other half were so damaged from their early lives (including many American Indians who were dependent before age 12, and grew up in chaotic environments) that they couldn't form a helping relationship with a case manager. For this group there was nothing we could do to help. Trying to coerce them (e.g., attempt to get control of their disability payments) was counterproductive.
4. All in all providing housing even though people kept drinking was highly cost effective and resulted in better health for the individuals.

There is a similar place in Minneapolis and I know of one in Portland, possibly Seattle.

Here's the sad fact: a small proportion of people with alcohol or drug dependence are unable to quit and will die of their disease. After decades of working with them, I have concluded that any of them would quit drinking or using if they could. Most make multiple efforts. We accept that heart disease, neurological disease and cancer often lead to death in spite of our best efforts and treatments. We have trouble accepting that there are fatal behavioral diseases. This is because we don't think of the brain as an organ. What happens when this organ gets dysfunctional, cannot do its normal job of regulating thinking, feeling, perception, memory, communication, and most importantly here, behavior? Severe, progressive addiction is a result of multiple social, personal, and genetic factors, but the end result is that the individual loses control over their behavior, much like the diabetic loses control of her blood sugar. If you reflect on it, most of our behavior is regulated by unconscious processes that are automatic. It is difficult under good conditions to alter that. Think of smoking, exercise, diet, aggression, how we behave towards our spouses or boss. Our (rational, deliberate) control over our behavior is at best partial. How often do we do something when we are angry that we regret later? Don't all of us have repetitive behavior patterns that are clearly dysfunctional but persist in spite of our best efforts to change them? An example: the fall of Elliot Spitzer, governor of New York, who got caught with a stripper. This was not a rational decision on his part. Another: President Bill Clinton, whose compulsive sexual behavior destroyed his second term.

In addiction, the brain loses the ability to regulate behavior relative to a specific intoxicant. In really severe addiction this loss of control may lead to death. I think that people in this situation are horrified at what is happening to them and terrified that they can't stop it. I've never met an addict who liked being addicted. (They want intoxication, but not addiction.)

In the 1990s, there was a group of us in Minnesota who regularly met to discuss what the optimal approach was to helping public inebriates. We examined everything from locking them up in the state hospital (which is what used to be done), to case management, housing, offering medical and psychiatric services, etc. We concluded that having a safe place for people to live when they can't stop drinking was the best overall solution, most cost effective, most protective of human rights, and most humane.

The idea that someone can stop if they really want to, or if they really work a 12 step program, is a terrible thing. It's not true. Why would brain dysregulation be 100% curable merely by the individual wanting it to be so? We blame obese people for their problems, we blame people who get heart disease for eating too many hamburgers and not exercising enough, we blame people with cancer for not doing the right preventive thing. We do this because it protects us from the terrifying reality that these things occur in spite of everything we can do to prevent them, that our own behavior is not well controlled, that our environment is often responsible for our predicament, or worst of all that it's simply a gene-environment interaction over which we are powerless.

There are many other potentially fatal behavioral disorders, including antisocial personality disorder (death from violence,) anorexia nervosa, depression (suicide,) schizophrenia (suicide, heavy smoking,) obesity and lack of exercise (the second most important cause of preventable mortality,) reckless or distracted driving or speeding, overwork and sleep deprivation, post traumatic stress disorder (suicide, addiction, violence,) uncontrolled aggression (assault and murder,) and addiction to pain killers and sedatives (unintentional overdose.)

I have (clinically) stayed with many people as they died of their addiction. I didn't abandon them because they "didn't get the program" or "didn't really want to get sober." They all did, desperately. But they couldn't. And I couldn't help them. And they died.