Friday, September 30, 2011

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.

If you care about science funding support this!

NIH's 2012 Budget Would Get 3.3% Boost in House Bill By Jocelyn Kaiser 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.

Tuesday, September 20, 2011

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)

Friday, September 16, 2011

CLIPS -- (Lancet) An international consensus for medical leadership on alcohol
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.
1 WHO. Global status report on alcohol 2004. (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. (accessed Sept 12, 2011).
3 WHO. Global strategy to reduce harmful use of alcohol. (accessed Sept 12, 2011).

Thursday, September 15, 2011

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.


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

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.

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.

Monday, September 12, 2011

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!

Sunday, September 11, 2011

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.


Little Progress in Tackling Smoking, Drinking, Obesity Worldwide

September 9, 2011

Prognosis Poor for U.N. Chronic Disease Meeting


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."


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.


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."

Wednesday, September 7, 2011

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.

Thursday, September 1, 2011

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