Substance Matters

A Routine Day for an Addiction Psychiatrist

2012-01-04T21:18:00.002-06:00

Today I had a fairly routine day in my practice. On a typical day, I encounter a wide range of people, problems, challenges and successes. I suppose it's not much different from any medical practice that way. But all of my patients are pretty complex and challenging. They all have multiple problems that are intertwined and that cannot be fully teased apart. The most common problems I encounter are addiction, pain, depression, anxiety, insomnia, brain injury, ADHD and PTSD. Relationship, marital and family problems are very common, as are various social and economic problems such as unemployment, disability, poverty, lack of health insurance and homelessness. These are all common problems, and they usually occur in some combination of two, three or more of them. Often there are significant other medical problems as well, including arthritis, heart disease, cancer, multiple sclerosis, lung disease and many others. I have to say it's enough to scare a person once you realize what fate can bestow on you. Most of my patients feel very alone and isolated. They often think they are the only ones who experience what they are experiencing and there is therefore something wrong with them. This isn't true of course. The experience of suffering from these problems is pretty similar across different people, which is not to diminish the importance or meaning of suffering for each person. But most of us don't meet others who are confronting the same or similar issues we are so we feel alone. Those around us who are well almost never understand, and all too often are judgmental. I think some of that is redirected anger at the inconveniences and losses that they experience when a loved one becomes disabled. Most of us think it isn't ok to feel angry with a loved one who becomes ill or disabled, but anger along with sadness and empathy are almost universal. But for someone who has never experienced depression or chronic pain or addiction, it can be very hard to understand why their loved one isn't responding better, isn't getter better or well, or requires ongoing medication to function. I spend quite a bit of time with friends, partners, spouses, children, parents of my patients explaining the illness(es) and treatment(s). It usually makes a difference, sometimes to the point of saving a marriage or preventing rejection from a family. Every day, however, I feel privileged that these people, my patients, let me share their lives in a pretty intimate way. A lot of whatever effectiveness I have comes from simply sharing the path and doing my best to understand what someone is going through without judging them. If nothing else, at least I can give them that.

Revolutionizing Health Care Related to Alcohol Use

2012-01-02T18:56:00.001-06:00

My current organization, Allina Hospitals and Clinics, has embarked on an ambitious and to my knowledge unprecedented effort to rationalize our approach to alcohol throughout the system. (The Veterans Health Administration has been addressing alcohol use in primary care for several decades and is as usual way ahead of private care, yet another example where government beats private care by a wide margin. However, their system is so unlike private practice that what happens in the VHA is difficult to translate.) I am leading Allina's effort and we've developed an ambitious agenda and a very aggressive timeline. If we're successful it will be almost a revolution across a large HCO (health care organization.) Allina consists of 11 hospitals, about 60 primary care clinics and many speciality clinics. Last year, there were more than 1 million hospital admissions and almost 4 million clinic visits within the Allina system.

I'm excited about this. It is nothing short of amazing that a large HCO would choose alcohol as a major focus across the organization. So far, the response has been enthusiastic. Physicians and other clinicians are very frustrated with the lack of consistency across parts of the system. They are frustrated that there seem to be so few options for patients admitted to hospital. Even if someone has been through 12 step rehab a dozen or more times, that is still the only option available: another run through rehab. They are desperate for something new. Clinicians are realistic. Most of what we do in medicine is care for chronic incurable conditions. Although we sometimes make people completely well, more often we help mitigate the ravages of an incurable condition. And sometimes we are pretty poor at even that. In cases with really severe, progressive illness we are often pretty helpless, along with the patients and families. So health care professionals are comfortable with care that is less than curative but is at least comforting, and perhaps that slows the rate of deterioration. And they want to be involved and active in managing chronic diseases.

Allina's initiative is remarkable in that it will address alcohol across an entire HCO. This includes emergency departments, primary care, hospital and ICU care and specialty addiction treatment. The goal is to create a fully integrated system that addresses alcohol wherever a heavy drinker interacts with the system and that coordinates the flow of care across boundaries such as inpatient/outpatient care and primary/specialty care. All of this is intended to be as fully evidence based as possible, which is always a challenge but it's an important aspiration. The vision is very ambitious and I am unaware of any other quite like it. If it succeeds, it can serve as an example for other HCOs.

Translating the science to practice is a daunting challenge. Allina is to be commended for choosing alcohol as a focus for such an effort. I'll keep you updated as this progresses.

Do Scientists Know Nothing About Addiction?

2012-01-01T16:35:00.003-06:00

Here's a comment I received yesterday from someone who didn't identify him or herself:

Anonymous has left a new comment on your post "ALLTYR™ Is Born!":

From this short introduction it is very apparent that despite your credentials you know very little about recovery from substance abuse or its underlying causes.

This comment illustrates a fundamental problem we face in trying to bring addiction treatment into the 21st century and to advance the cause of addiction research and treatment.

I wonder what it is that I don't know? I've treated thousands of patients with addictions of all sorts and run a treatment program. I've conducted research on various kinds of treatments, on AA, and on implementing evidence based practices in addiction treatment. I co-edited the first version of the VA/DOD clinical practice guidelines for the management of substance use disorders. Many of my patients tell me that I understand them and their struggles more than anyone else they've encountered. So what is it that I don't know? (I won't address how so many other people could be wrong about me.)

Since this writer didn't identify him or herself, I can't ask for clarification. I suspect my commenter has a specific idea or theory about what addiction is and how to overcome it, and sees other theories or ideas as a threat, almost as blasphemy. Perhaps even as destructive, because having a plurality of approaches might dilute the "true"message. So I suppose that I don't "know" that this one true way is in fact, the one true way.

But what is it about what I write and speak about that triggers this response? I suspect it is my focus on scientific research. Science is famously viewed with suspicion by true believers. Gallileo was imprisoned for presenting scientific findings that contradicted theology. Science doesn't discriminate either. Many a pet theory scientists have been proved wrong, dashing hopes and ruining careers. So it goes. The scientific method is not perfect but it is structured precisely to minimize scientists' ability to bias the results. In recent years, new research has shown us that much of what we thought we knew about substance use and addiction was wrong or only partially right. This includes many dearly-held notions. For example, addiction is not necessarily chronic or severe or progressive. Most people recover, and most of them do so without treatment or 12 step participation. There are multiple routes to recovery. Spiritual transformation is not necessary for recovery. Multiple different types of behavioral therapy approaches work about equally if delivered well. And the list goes on.

But I worry about the schism this comment suggests, which I encounter frequently. At a recent conference, I talked about treatment for opioid addiction. I said that there was only one treatment that had been proved to be effective for opioid addiction and that was opioid agonist therapy with either methadone or buprenorphine. One of the participants challenged me, saying that the problem was that opioid addicts treated in a 12 step program didn't do well because they didn't do what they were told. Well, I suppose you could say they were told to abstain and they didn't. But I find this kind of argument distressing. For one thing, the same argument could be used for any treatment that didn't work, because treatment failure is the patient's fault, it's not that the treatment is ineffective. What this means is that a treatment could never be proved to be ineffective, because "it would be effective if they did what they were told."

But what concerns me most is how much this schism reduces the effectiveness of our advocacy and efforts. I think this is why there is so little activity on the part of the recovering community to support more addiction research. With other diseases, research is seen as the way towards improved diagnosis and treatment, but in addiction, far too many view research only as a way to validate what they already "know." In this view, it's not that our treatments are not effective enough, it's simply that there isn't enough money for current treatments. So there may be advocacy for treatment accessibility but not for research. Furthermore, new treatments emerging from research are most often viewed with suspicion rather than embraced and widely implemented. Opioid agonist therapy and anti-relapse medications for alcohol dependence are prominent examples.

I find it very discouraging that someone would conclude based on a "short introduction" that "in spite of my credentials" I know very little about addiction or recovery, not because I'm the grand global expert but simply because it simply cannot be true on its face. I can understand disagreeing on various ideas, having a different take on certain findings or experiences. But this tendency to completely dismiss those we disagree with is a major barrier to advancing the cause of improving our understanding and treatment of addiction. Until we find a way to bridge this gap, we will continue to lose out to more integrated and better organized groups advocating for research on heart disease, Alzheimer's disease, or breast cancer.

The time is long overdue for the recovering, treatment and research communities to stop fighting and join together to promote addiction research and treatment.

Good Medical Treatment Beats Rehab Any Day

2011-11-30T19:08:00.001-06:00

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?

2011-11-27T22:37:00.001-06:00

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 reprintAlcohol 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 findingsSix 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' conclusionsThe 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

2011-11-22T13:50:00.001-06:00

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

2011-10-18T16:37:00.000-05:00

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. MWNIH Grants Funding Drops; The success rate of the government agency’s grant applications has hit an all-time low.By Jef AkstTheScientist.comOct. 17, 2011Grant 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!

2011-10-09T19:22:00.000-05:00

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)

2011-10-04T13:59:00.000-05:00

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?

2011-10-02T20:33:00.000-05:00

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

2011-09-30T14:16:00.002-05:00

PBS PROHIBITIONPremieres October 2nd, 3rd & 4th, 2011at 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!

2011-09-30T14:14:00.002-05:00

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

2011-09-20T13:38:00.000-05:00

Subject: NIH STUDY FINDS HOSPITALIZATIONS INCREASE FOR ALCOHOL AND DRUG OVERDOSESU.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, 2011CONTACT: NIAAA Press Office, 301-443-3860, NIH STUDY FINDS HOSPITALIZATIONS INCREASE FOR ALCOHOL AND DRUG OVERDOSESHospitalizations 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

2011-09-16T13:35:00.001-05:00

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

2011-09-15T09:22:00.000-05:00

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.

2011-09-12T10:06:00.005-05:00

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?

2011-09-11T23:19:00.001-05:00

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

2011-09-11T23:14:00.000-05:00

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

2011-09-07T22:31:00.003-05:00

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

2011-09-01T08:59:00.001-05:00

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

2011-08-26T08:58:00.000-05:00

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!

2011-08-21T19:20:00.003-05:00

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?

2011-05-09T00:16:00.000-05:00

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!

2011-05-05T10:36:00.002-05:00

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

2011-05-02T13:12:00.002-05:00

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

2011-04-22T16:45:00.000-05:00

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.

Ideology, Attitude and Science: Buyer Beware!

2011-04-18T09:13:00.003-05:00

In this new publication, the authors found that both counselor and program characteristics influence counselor attitudes towards use of medications in treating addiction. People who are looking for treatment need to ask about these attitudes prior to agreeing to enter a program or therapeutic relationship. It is a sign of how far the US treatment industry must go when "attitude" determines the treatment you get, rather than evidence based guidelines. And be skeptical when a program or staff member says they use "evidence based practices." Too often, that consists primarily of some training to update counseling skills, but it doesn't involve moving beyond an ideological approach to a scientific one. Consequently, too many treatment staff still see science as useful only insofar as it can validate already held assumptions. We all know, however, that's not how science works. It's designed to upset and surprise because it uses methods to minimize bias. And we're all biased, one way or another. Bottom line: people and families looking for treatment need to educate themselves about the scientific knowledge base of what addiction is and the most current methods available to treat it and then be prepared to ask the program or counselor about specific practices and then to look elsewhere if a program doesn't offer what they are looking for. Consumers can be a significant force in moving the industry forward.
MW

Addictive Behaviors
Volume 36, Issue 6, June 2011, Pages 576-583
Special Issue: Addiction Treatment: Evidence-Based Policy and Practice

Counselor attitudes toward the use of naltrexone in substance abuse treatment: A multi-level modeling approach.

Abraham AJ, Rieckmann T, McNulty T, Kovas AE, Roman PM.

Institute for Behavioral Research, Center for Research on Behavioral Health and Human Services Delivery, University of Georgia, 112 Barrow Hall, Athens, GA 30602, USA; Department of Sociology, University of Georgia, Athens, GA 30602, USA.

Abstract

Alcohol use disorders (AUDs) continue to be one of the most pervasive and costly of the substance use disorders (SUDs). Despite evidence of clinical effectiveness, adoption of medications for the treatment of AUDs is suboptimal. Low rates of AUD medication adoption have been explained by characteristics of both treatment organizations and individual counselor's attitudes and behaviors. However, few studies have simultaneously examined the impact of organizational-level and counselor-level characteristics on counselor perceptions of EBPs. To address this gap in the literature, we use data from a national sample of 1178 counselors employed in 209 privately funded treatment organizations to examine the effects of organizational and individual counselor characteristics on counselor attitudes toward tablet and injectable naltrexone. Results of hierarchical linear modeling (HLM) show that organizational characteristics (use of tablet/injectable naltrexone in the program, 12-step orientation) were associated with counselor perceptions of naltrexone. Net of organizational characteristics, several counselor level characteristics were associated with attitudes toward tablet and injectable naltrexone including gender, tenure in the field, recovery status, percentage of AUD patients, and receipt of medication-specific training. These findings reveal that counselor receptiveness toward naltrexone is shaped in part by the organizational context in which counselors are embedded.

Concise description of the neurobiology of addiction

2011-04-15T14:43:00.000-05:00

In this Baltimore Sun article Dr. David Linden of Johns Hopkins University gives an unusually succinct description of the underlying neurobiology of the development of addiction. Note the interplay between genetics and intoxicant exposure: if you're brain isn't genetically vulnerable, you are not likely to become addicted to a particular drug. Note also that this vulnerability is substance-specific, not a generalized "addictive personality."
MW

Baltimore Sun

Johns Hopkins neuroscientist David Linden explains the biology of pleasure
With his new book, he seeks to find out why vices -- and even virtues -- can hold such sway over our lives

By Mary Carole McCauley, The Baltimore Sun

April 14, 2011

Not all addictions live up to their advance press.

In the past decade, it's become common to casually and humorously describe a favorite activity in the parlance of chemical dependency. People speak of being "addicted" to chocolate or high-fat foods, playing video games, buying expensive designer shoes, watching weekly episodes of "American Idol" to sleeping on high-thread-count sheets. But according to "The Compass of Pleasure," a new book by Johns Hopkins neuroscientist David Linden that is being released today by The Viking Press, just two of those pursuits -- eating fatty foods and shopping -- can become genuine addictions for some people. Watching television, playing World of Warcraft and swaddling yourself in Egyptian cotton probably cannot.

Who knew that feeling good could be so complicated?

"Addiction is defined by the changes that certain activities can make in the brain," Linden says.

"Basically, some activities have been shown to short-circuit the medial forebrain pleasure circuit. The process is the same, whether someone is taking crack cocaine or gambling or having risky sex or shopping. These morphological changes bring about a gradual transition from liking to wanting, and the result is compulsive behavior."

The vast majority of people who pursue habit-forming activities will never become compulsive. Our genes play a major role in determining who will become addicted, how badly and to what substance. It also generally takes repeated exposure for a harmful habit to develop.

For example, Linden points out that for even a drug as highly addictive as heroin, two of every three people who inject the narcotic directly into their veins don't become junkies.

In addition, some pursuits that may technically qualify as addictive carry positive benefits for individuals and society that vastly outweigh the potential harm, such as running a marathon, or an extended bout of contemplative prayer.

"Pleasure is our compass, no matter what we do," Linden says.

"But a philosophical question arises from these findings. If we catch a pleasure buzz from our noblest instincts, does that make them less noble?"

Conversely, just because a substance doesn't create a physical dependency doesn't mean it's safe. LSD might not activate the medial forebrain, but someone who drops acid and jumps off the roof because he thinks he can fly is likely to get hurt.

"There's a whole bunch of risk-taking behaviors that aren't addictive," Linden says. "We're motivated by reasons other than seeking pleasure."

Addiction, he says, is just one form of learning. The changes that occur inside the brain when someone studies calculus are nearly identical to the changes that occurs when he smokes crack.

As Linden explains it, when human beings bliss out by watching a sunset, getting a back rub or drinking a glass of red wine, the ventral tegmental area in our brains is releasing a neurotransmitter called dopamine that is getting picked up by a nearby bundle of neurons called the nucleus accumbens.

Under normal circumstances, pleasure flows and ebbs; dopamine gets released and then reabsorbed for later use. But some activities hijack the pleasure circuit, either by increasing the amount of dopamine flooding into our systems or by blocking the portals through which the chemical messenger goes back into storage.

The result is a jolt of pleasure so intense that most people will do anything to feel it again.

"Addiction is a super-potent experience," Linden says. And, just like Pavlov's dog, "we learn to associate it with sensory cues," he says, "because these associations allow us to predict how to behave so we can repeat the experience."

When we make a connection between, say, our sweet tooth and a chocolate store located in the Inner Harbor, our brains get rewired. After repeated exposure, structures on our neurons called "dendrites" grow new spines. (The same thing happens when we learn our multiplication tables or memorize a new route to work -- both experiences that humans experience as pleasurable, though to a lesser degree and by a more indirect pathway.)

In the future, every time our car turns onto Pratt Street, we may feel a sudden urge from out of the blue to stop at the chocolatier we know is just down the block.

"If you look at the neurons under a microscope," Linden says, "you will see that the receiving ends of their dendrites have turned into a shaggily bush of spines.

"This is how people develop cravings. If you're an addict, the more times you take a drug, the more spines you'll have on your dendrites and the harder it will be to stay clean, because everything you do will trigger those associations."

There's also another problem. As any chocoholic will confirm, no mouthful will ever deliver a burst of flavor as sublime as the very first taste. In scientific jargon, we've become "habituated."

The gradual draining away of pleasure is the process that Linden is talking about when he describes "liking turning into wanting."

"We imagine that addicts experience more pleasure from their drug of choice than others, and that this motivates their compulsive drug-seeking," he says.

"But the research shows that addicts get less pleasure from their drug than other people. The chemical contact between the neurons gets less efficient over time. It gets worn out. As a result, addicts need higher and higher doses to get as much pleasure as they received the first time they took the drug."

Linden acknowledges that one of his motivations for writing this book was political.

"The Compass of Pleasure" argues that as our laws ignore the biological basis of addiction and instead treat the problem as simply a matter of insufficient willpower that can be resolved by punishment.

"Once we understand how the biology of pleasure works," Linden says, "the only reasonable conclusion that we can make is that addiction is a disease. What we're left with is a compassion model, not a model that says that addicts are losers and should be locked up in jail."

He concludes that if addictions of all types rewire the brain, the eventual solution may lie in devising medicines that can bring about permanent changes on a molecular and cellular level that can undo the damage caused by too many doughnuts, cigarettes or trips to the casino.

There's no question that addicts attempting to kick their habit face an uphill battle -- but Linden isn't letting them off the hook.

"The development of an addiction is not the addict's fault," he says.

"But believing that addiction is a disease does not absolve addicts from responsibility for their own recovery. It's not a free ride."

The Stigma of Chronic Pain

2011-04-13T20:59:00.001-05:00

Most of the patients I treat who have chronic pain are distressed by stigma and the ignorance behind it. They are often judged by relatives, friends, doctors, nurses and others as being weak, addicted, defective, "not tough enough," "not motivated." Worst of all is the epithet: "Drug Seeking." Drug Seeking is a judgment impersonating an objective clinical observation. Drug Seeking implies asking for ("seeking") pain medication for non-legitimate purposes, such as getting high, "being a chemical coper," or other reasons not related to pain control. These judgments are almost always made by people who have never experienced unrelenting severe pain. Pain wears you down. No matter how good you are at coping, it pushes you to the edge. If you have other problems such as chronic physical or mental illnesses, it's just that much harder. The more chronic illnesses you have to manage the harder it is to manage any of them very well. When one illness recurs it upsets all the others. I have had patients who stopped taking opioid (narcotic) medications for pain, even though it improved their quality of life and function substantially, because they were stigmatized and criticized by health care providers, families members, and others. They subsequently are condemned to reduced quality of life and reduced personal and employment function in order to not be labeled "drug seeking." The level of knowledge about the management of pain by most clinicians is minimal at best. Chronic pain frequently goes untreated, leading to considerable suffering and disability because of this stigma.

Bottom line: medication that 1) improves overall quality of life, and 2) improved function in the absence of 3) serious side effects should be regarded as life saving, not as a way to escape reality.

MW

Message to Chronic Pain Patients: "Cowboy Up!"

2011-04-09T11:11:00.000-05:00

In this recent article in the Washington Post, the growing use of opioid treatment agreements is examined. Although increasing in popularity and pushed strongly by the government (read: DEA) these agreements are at best a mixed blessing. This is all part of a growing sense of unease about using opioids in chronic pain, and a move to further restrict access to them. These agreements may do more to protect the prescriber from liability than to protect patients. What is clear to physicians, however, is that there is no liability from refusing to prescribe opioids even if it leads to serious consequences including disability and suicide because patients are held responsible for them. On the other hand, doctors feels the hot breath of the DEA and state medical boards and the threat of malpractice suites very acutely. As with all medications, opioids carry a risk and it is important to minimize it, but even very reasonable risk in the context of substantial benefit is fraught with danger for the physician. It seems that there are plenty of doctors around who will testify against any doctor prescribing opioids for chronic pain. As I have said before, the vacuum created by the lack of good evidence is filled with strong opinion, often passionately held, and usually by those who take a highly moralistic approach to the issue. The end result is not a reduced risk to patients but increasing restriction on access to appropriate opioid medication for chronic pain. This past year, an opioid addicted nurse at a Minneapolis hospital stole a patient's medications that were to be used for his surgery, and told him he was going to have to "cowboy up." He had surgery without analgesia. That pretty well sums up the message to pain patients from regulatory agencies and doctors antagonistic to opioids. This is not going to change until patients and families put the heat on legislatures and Congress to fund more research in this area, and to back off the persecution of doctors who are trying their best to balance risk and benefit in this most terrible affliction.
MW

Some doctors require patients to sign contracts get opioid painkillers

By Michelle Andrews, Monday, April , 4:38 PM

Chronic pain — the kind that lasts for months or recurs regularly — afflicts more than a quarter of adult Americans. Treating pain can be extremely challenging, however, in part because it can’t be measured with instruments. It’s in the eye — or neck or joint — of the beholder.

Doctors often prescribe powerful painkillers called opioids — natural or synthetic versions of opium. Sometimes the prescription is for short-term, acute pain: If you’ve ever had a root canal or surgery or thrown out your back, you may have received a prescription for Percocet or Vicodin, both of which are opioids that also contain acetaminophen.

For people with long-term, persistent pain — often from musculoskeletal injuries or nerve damage — opioids may be the best option to manage their pain and enable them to function day after day.

But there’s a hitch: Though highly effective, these drugs are dangerous and addictive. The chief danger is that they can cause respiratory depression: If too much is taken, breathing slows and may eventually stop. And because they cause euphoria, opioids are popular targets for misuse and abuse. In 2007, 11,499 people in the United States died from opioid overdoses, according to the Centers for Disease Control and Prevention. That was more than the number of overdose deaths for heroin and cocaine combined. To help monitor use of the drugs, some doctors ask patients to sign “pain contracts” or “opioid treatment agreements” that spell out the rules patients must follow to take these drugs safely. The contracts aim to discourage people from taking too much medication, mixing medications, or sharing or selling them, among other things.

The agreements may require patients to submit to blood or urine drug tests, fill their prescriptions at a single pharmacy or refuse to accept pain medication from any other doctor. If patients don’t follow the rules, the agreements often state that doctors may drop them from their practice.

Some patient advocates and policy experts say that rather than ensuring safety, the agreements invade patients’ privacy and damage the trust that’s essential to the doctor-patient relationship.

Joan Crowley started taking an opioid in 2003 to treat recurring migraines and an arthritis-like autoimmune disorder that caused her joints to swell. The drug kept her pain under control and allowed her to continue her work as an accountant in the Pittsburgh area.

A few years ago, her primary-care provider asked her to sign a treatment agreement for the opioid and for Xanax, an anti-anxiety drug she also took regularly. Every three months she visited the doctor so he could evaluate her condition and write her a new round of prescriptions. Sometimes he did a urine test as well.

All went smoothly until this past winter. Crowley, 51, went to the emergency room with what she thought was a heart attack but turned out to be anxiety. While there, she says, she was given an anti-anxiety drug and other medications. The next day she had her regular appointment with her doctor, who gave her prescriptions for her regular drugs and took a urine sample. A week later, she says, she got a telephone call from him, saying that an opioid she wasn’t supposed to be taking had turned up in her urine sample. The doctor gave her 60 days to find a new physician — even after she told him about her ER visit.

Crowley acknowledges that her relationship with the doctor had been strained before that. Still, she was stunned. “This is someone I’d been a patient of for 11 years,” she says. “There was a level of trust there.”

Because of a few high-profile prosecutions of doctors for running “pill mills,” some experts say, doctors increasingly use pain contracts to protect themselves.

The subjective nature of pain makes doctors afraid they’ll be scammed by unscrupulous patients, says Myra Christopher, chief executive of the Center for Practical Bioethics in Kansas City, Mo., who co-authored a recent article critical of pain contracts. “Providers’ primary concern ought to be the management of pain and suffering,” she says. “This shifts the locus of concern to the providers’ protection.”

Others disagree. They say treatment agreements can function as an educational tool and a treatment road map. “It provides a framework to talk about the issues that come up in a treatment plan,” says S. Hughes Melton, a family physician in rural Lebanon, Va., where substance abuse, including addiction to pain medication, is a serious problem.

After working in the mining industry for 22 years, Jeffery Boyd, 50, developed continual pain in his back and legs. Working with Melton, he manages his pain with an opioid and another drug. To Boyd, signing a treatment agreement and being closely monitored by Melton are secondary concerns: Mostly he’s just glad to have his pain under control. “The pain won’t ever go away,” he says, “but [Melton] got me to where I can work at my job and do things.”

That attitude is probably shared by many people with chronic pain, say experts. “Most patients who come in, they just want relief,” says Will Rowe, chief executive of the American Pain Foundation, a consumer advocacy group. “They don’t want to hear about the public-health problem of the misuse of opioids.”

This column is produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente. E-mail questions@kaiserhealthnews.org.

New Drugs Boost Response Rates in Hepatitis C

2011-03-31T10:32:00.000-05:00

Good news for those who have chronic hepatitis C, which affects people with addictions much more frequently than others. Two new drugs have been shown to substantially improve sustained remission rates in the Genotype I type of the virus, which is the most common type of infection in the US. Importantly, although the response rate was lower in African Americans (due to genetic factors limiting the drug effectiveness), these drugs improved response rates to respectable levels. The new medications are awaiting approval by the FDA and may be on the market as early as last 2011.

MW

New drug boosts hepatitis C treatments
Experimental medication passes key test on road to FDA approval for treating virus By Nathan Seppa

Science News
Web edition : 10:35 am
Adding an experimental drug to standard treatment more than doubles the likelihood of knocking out hepatitis C in patients with the chronic liver infection, two studies in the March 31 New England Journal of Medicine show.

The new drug, boceprevir, and a similar drug called telaprevir (SN: 5/23/09, p. 12) have now shown the ability to wipe out the virus in many patients. Both drugs are currently under review by the Food and Drug Administration, and scientists feel that both are destined for approval.

“This is the first time I can remember being so optimistic about this really difficult virus,” says Donald Jensen, a hepatologist at the University of Chicago School of Medicine who wasn’t involved in the new studies. Hepatitis C can lead to liver cirrhosis and cancer.

Both new boceprevir trials started with hundreds of hepatitis C patients receiving a four-week course of the current standard medication, a one-two punch of drugs called peginterferon alfa-2b and ribavirin. The patients were then randomly assigned to get boceprevir or a placebo added to this regimen, without knowing which they were getting.

After receiving treatment for up to 44 weeks, those getting boceprevir were two to three times more likely to knock the virus down to undetectable levels in the blood as were those getting only the standard dual-drug therapy, researchers report.

The two trial groups weren’t identical: One recruited previously treated hepatitis C patients, while the other enlisted only patients who hadn’t yet been treated. But both studies showed viral clearance rates of nearly two-thirds among those getting the triple therapy, compared with only 21 to 38 percent success among those getting the standard regimen.

A patient who clears the virus is often cured, says Fred Poordad, a hepatologist at Cedars-Sinai Medical Center in Los Angeles, who coauthored both studies. He cites 10 years of follow-up data from people who had cleared the virus after getting the standard peginterferon/ribavirin treatment. If the virus doesn’t reappear within six months after treatment, he says, close to 100 percent of them remain free of virus for good.

But 25 to 30 percent of those receiving standard treatment typically experience such a relapse shortly after treatment. With boceprevir added to the mix, that figure can be expected to fall below 10 percent, Poordad says.

The results thus indicate that 60 to 70 percent of patients getting the triple therapy “are now cured,” says Bruce Bacon, a hepatologist at Saint Louis University School of Medicine who coauthored both of the new studies.

The treatment does carry side effects. In both trials, nearly half of patients getting boceprevir developed anemia, compared with 20 to 29 percent of those on the standard dual treatment. Anemia is treatable, Bacon says. Nearly all patients in both trials reported some other side effects — including fatigue, headache and nausea — while taking the drug regimen. Bacon acknowledges these adverse effects, but adds that most hepatitis C patients “are willing to tough it out.”

Black patients didn’t benefit as much from the treatment as did other racial groups because some blacks carry a genetic variant that limits the effect of the drugs, Jensen says. Even so, roughly half of blacks getting the triple treatment saw their virus fall below detectable levels, a substantially better rate than those on dual therapy.

Merck makes boceprevir and sponsored these two trials. Vertex Pharmaceuticals makes telaprevir. Bacon notes that these studies now show that the effectiveness of boceprevir and telaprevir are similar. That’s not surprising since both drugs inhibit protease enzymes. While protease enzymes play vital roles in the body, thwarting specific proteases can stall virus replication.

The drugs work only on genotype 1 hepatitis C, but that form accounts for about three-fourths of all hepatitis C in the United States.

How Cocaine Changes the Brain

2011-03-29T12:30:00.001-05:00

This new research identifies how cocaine changes the configuration of receptors and function in the reward areas of the brain. It adds to the evidence that an increase in glutamate is a key feature of addiction. Some of the medications currently used for alcohol dependence, such as topiramate, baclofen and acamprosate, may work by helping to restore the balance between glutamate and GABA.

MW

Cocaine inverts rules for synaptic plasticity of glutamate transmission in the ventral tegmental area

Manuel Mameli, Camilla Bellone, Matthew T C Brown & Christian Lüscher
Nature Neuroscience (2011) 14, 414-416

The manner in which drug-evoked synaptic plasticity affects reward circuits remains largely elusive. We found that cocaine reduced NMDA receptor excitatory postsynaptic currents and inserted GluA2–lacking AMPA receptors in dopamine neurons of mice. Consequently, a stimulation protocol pairing glutamate release with hyperpolarizing current injections further strengthened synapses after cocaine treatment. Our data suggest that early cocaine-evoked plasticity in the ventral tegmental area inverts the rules for activity-dependent plasticity, eventually leading to addictive behavior.

Treating Pain Is a Real Pain

2011-03-27T16:13:00.001-05:00

Our current tools for treating chronic severe pain are inadequate at best. Opioids such as morphine or methadone reduce chronic pain on average about 30%, with a range of perhaps 0-50%. And of course they come with multiple liabilities, such as constipation, sweating, nausea and physiological tolerance which means that symptoms occur if the drug is suddenly stopped. Although unproven there is concern that chronic use of these medications could actually increase pain sensitivity. Other methods such as cognitive behavioral therapy, moderate exercise, physical therapy, injections, surgery, neurostimulators, biofeedback, etc., have a modest impact if any. We desperately need new tools. This article describes new research on a compound that may reduce pain without the disadvantages of opioids. Cannabinoid receptors, by the way, are those that responde to drugs like marijuana and hashish. There are more of these receptors in peripheral tissues than the brain. It is possible that the effect of cannabis on pain are due to their effects on these peripheral receptors.

MW

Anandamide suppresses pain initiation through a peripheral endocannabinoid mechanism

Jason R Clapper, Guillermo Moreno-Sanz, Roberto Russo, Ana Guijarro, Federica Vacondio, Andrea Duranti, Andrea Tontini, Silvano Sanchini, Natale R Sciolino, Jessica M Spradley, Andrea G Hohmann, Antonio Calignano, Marco Mor, Giorgio Tarzia & Daniele Piomelli

Nature Neuroscience 13, 1265–1270 (2010) doi:10.1038/nn.2632

Peripheral cannabinoid receptors exert a powerful inhibitory control over pain initiation, but the endocannabinoid signal that normally engages this intrinsic analgesic mechanism is unknown. To address this question, we developed a peripherally restricted inhibitor (URB937) of fatty acid amide hydrolase (FAAH), the enzyme responsible for the degradation of the endocannabinoid anandamide. URB937 suppressed FAAH activity and increased anandamide levels outside the rodent CNS. Despite its inability to access brain and spinal cord, URB937 attenuated behavioral responses indicative of persistent pain in rodent models of peripheral nerve injury and inflammation and prevented noxious stimulus–evoked neuronal activation in spinal cord regions implicated in nociceptive processing. CB1 cannabinoid receptor blockade prevented these effects. These results suggest that anandamide-mediated signaling at peripheral CB1 receptors controls the access of pain-related inputs to the CNS. Brain-impenetrant FAAH inhibitors, which strengthen this gating mechanism, might offer a new approach to pain therapy.

More on treatment for opioid addiction

2011-03-25T20:48:00.001-05:00

Here is the text of a letter I sent today to a reporter at Minnesota Public Radio. They had previously run a program that was neither accurate nor complete.

MW

Dear Kerri,

I'm writing about your recent program on painkiller addiction. Unfortunately, I was not able to join the call, but became aware of it after the fact. I appreciate your attention to this problem, as it is particularly affecting young people.

I have been an addiction psychiatrist for over 30 years, and I have treated something like 1500 opioid addicts including about 30 in my current practice. In addition, I am an expert in treating highly complex pain patients who are using opioids. I used to run the addiction program at the VAMC in Minnepolis, which included a methadone maintenance clinic and eventually Suboxone treatment. From 2004 to 2009 I was Director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. (Not to brag, but I wanted to give you some sense of bona fides.)

One area where addiction treatment in the US really lags is in making scientifically based treatment available to people who need it, or even informing them of the evidence and their options. This is no where more true than opioid addiction. There are now multiple well done randomized controlled trials that have unequivocally and without exception found that for established (>1 year) opioid addiction, the only proven effective treatment is long-term opioid maintenance with either methadone or Suboxone. The most recent study, reported last spring at the American Psychiatric Association, focused on prescription opioid addicts, not heroin addicts. (Most previous research has been on heroin addicts.) This large and very well done study found that even after 9 months of Suboxone maintenance, along with enhanced psychosocial (behavioral) treatment of a quality far in excess of that available in the community, the relapse rate after tapering off of Suboxone was 95%. A recent naturalistic study in the UK followed opioid addicts who sought treatment. Those choosing abstinence had twice the mortality rate in the following year as compared to maintenance. These are only two of the most recent studies. There are dozens more. Among experts on opioid dependence, there is no controversy about this. (To anticipate a possible counterargument, there is evidence that an injectible drug that blocks the effects of opioids may be effective during the period when someone is on probation under the condition of agreement. However it is also true that almost all relapse as soon as they are off probation.)

Here's the problem. Due to devotion to 12-step concepts of addiction (which are not scientifically grounded), most treatment programs in the US fail to inform people of this evidence, let alone offer to provide it. Opioid dependence continues to be treated with an abstinence based approach grounded in the 12 steps. When the predictable relapse occurs, patients and families are told that the individual needs more abstinence-based rehab. The patient is held responsible for the failure of the treatment. There is an implication that if a person only accepts the program whole cloth and practices it religiously, then success is assured. In fact, it is the treatment that is ineffective, not the patient. Addiction treatment is the only place in modern health care where providers are not held responsible to give full informed consent to their patients, or for the success of their treatment. I currently have several patients who have been through multiple abstinence programs at a cost of tens of thousands of dollars each, who are now doing well on maintenance treatment.

This is not merely about infighting among the experts. Active opioid dependence has a high fatality rate; in one study 50% of the sample died between the mid-twenties and mid-fifties! And in the UK study, there was a mortality difference detectable after only one year. In addition, insurance companies and families spend millions of dollars on treatment clearly demonstrated to be ineffective, as much as $30-60,000 per month for residential treatment. Maintenance treatment, on the other hand is not only much more effective, it is much cheaper, on the order of a few hundred dollars per month. If we use $300 has an average maintenance cost, then one month for one patient in a residential program that cost $30,000 would buy actually effective maintenance treatment for 8 patients for a whole year! And that doesn't factor in the increased health care, criminal justice costs and loss of productivity that occurs with the higher relapse rate for abstinence based treatment. One study estimated the cost of maintenance treatment yielded savings more than 7 times a much.

I apologize for the long email, but I strongly feel that the public needs to have this information available to them. After being involved in research for over thirty years, I decided when I left NIH that the research didn't matter if there wasn't a vehicle for making it available to the people who are suffering with the disorder. So I am now devoted full time to transforming the treatment system into one that is based on science, professionalism, and cost-effectiveness and that is dedicated to offering consumers choice.

Thank you for reading this (if you get this far before pressing Delete). Of course references are available on request. I have had a lot of media experience and I have appeared on Mid-Morning before I went to Washington (I'm back in this area now.) I would be more than happy to participate in a program that presented a more balanced view. I could possibly suggest a patient or two who might be willing to talk about this on air as well.

Warm regards,
Mark

2011-03-25T16:16:00.000-05:00

Here's a recent synthesis of studies on the course and remission rate for amphetamine, cannabis, cocaine and opioid dependence. Importantly they calculated remission rates using the assumption that drop outs from the studies were using and dependent (relapsed). This will result in an overly pessimistic view, since it is almost certain that not all of the study dropouts are still dependent. However, they do point that although addiction is frequently described as a "chronic, relapsing disease," there are surprisingly few studies that examine that.

MW

Systematic review of prospective studies investigating 'remission' from amphetamine, cannabis, cocaine or opioid dependence.
Calabria B., Degenhardt L., Briegleb C. et al. Request reprint
Addictive Behaviors: 2010, 35, p. 741–749.

Review synthesises evidence on how many people recover each year (with or without treatment) from their dependence on stimulants, heroin-type drugs or cannabis, providing a baseline against which to assess improvement efforts.

Original abstract Aims To review and summarise prospective studies reporting on remission from dependence on amphetamines, cannabis, cocaine or opioids.

Methods Systematic searches of the peer-reviewed literature were conducted to identify prospective studies of people dependent on amphetamines, cannabis, cocaine or opioids like heroin, which followed them up for at least three years to investigate how many experienced remission from their dependence. Treatment trials were excluded, but studies of patients who entered treatment in the normal way were included along with non-treatment and general population samples. Remission was defined as abstinence from the drug of dependence or no longer meeting diagnostic criteria for drug dependence. The remission rate was estimated for each drug type, allowing pooling across studies with varying follow-up times. Searches were limited to publications between 1990 and 2009. Reference lists of review articles and important studies were searched to identify additional studies.

Results There were few studies examining the course of psychostimulant dependence that met inclusion criteria (one for amphetamines and four for cocaine). There were ten studies of opioid dependence, none of which were of general population samples, and three of cannabis dependence, all of which were of general population samples. Definitions of remission varied and most studies did not clearly assess remission from dependence. Where possible, data from the studies was used to calculate the annual proportion of patients who remitted, firstly as proportions of the patients who could be followed up. A figure for cannabis was not calculated. Based on a single US study of methamphetamine users, amphetamine dependence had the highest annual remission rate (0.45 or 45% a year no longer dependent), followed by opioid (0.22 or 22%) and cocaine dependence (0.14 or 14%). The single study (from the USA) of a general population sample of cocaine-dependent people found that 39% had remitted four years after initially surveyed.

However, studies reporting remission rates based solely on the followed-up sample inflate remission estimates, given that people who drop out are probably less likely to have remitted. The data was recalculated on the conservative assumption that every patient who could not be followed up was still dependent or had died dependent. These estimates differed quite markedly from the levels typically reported in papers. On this basis, remission rates were highest for cannabis dependence (0.17 or 17% a year no longer dependent) followed by amphetamine (just under 0.17 or 17%), opioids (0.092 or 9%) and cocaine dependence (0.05 or 5%).

Conclusions Despite the fact that drug dependence is commonly described as a "chronic" disorder, surprisingly few follow-up studies have documented the course of this disorder. In addition definitions used are often imprecise and inconsistent across studies. There remains considerable uncertainty about the longitudinal course of dependence upon these most commonly used illicit drugs. The limited prospective evidence suggests that 'remission' from dependence may occur relatively frequently but rates differ across drugs. Remission from amphetamine dependence was highest overall with almost one in two persons remitting during a given year; the conservative estimate of remission from amphetamine or cannabis dependence was one in six annually. Remission from opioid dependence ranged from one to two in ten each year; and remission from cocaine dependence ranged from one in twenty to one in eight. The findings of this review for cannabis are similar to the results of retrospective surveys (when people are asked to look back to recall whether they were dependent on the drugs rather than followed up) that have found cannabis to have the highest rates of cessation of use. The results are not consistent for opioid dependence, which has been found in retrospective surveys to have the lowest remission rates.

Last revised 16 March 2011

SBIRT Doesn't Work in EDs

2011-02-28T09:38:00.001-06:00

Another study documenting that emergency department Screening, Brief Intervention and Referral to Treatment (SBIRT) doesn't work. Unfortunately, advocates for SBIRT have moved out quite a ways ahead of the evidence. This is not likely to be harmful for patients, obviously, but it may hurt the cause in the long run. It's also a waste of money and time. By the way, the same holds true for hospitalized patients. SBIRT doesn't work because most of the patients identified are dependent drinkers.

MW

Oxford Journals
Medicine
Alcohol and Alcoholism
Volume45, Issue6
Pp. 514-519.

The Impact of Screening, Brief Intervention and Referral for Treatment in Emergency Department Patients’ Alcohol Use: A 3-, 6- and 12-month Follow-up

Academic ED SBIRT Research Collaborative

Corresponding author: Robert H. Aseltine, Jr., Division of Behavioral Sciences and Community Health, MC 3910, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-3910, USA. Tel: +1 860 679 3282; Fax: +1 860 679 1342; E-mail: aseltine@uchc.edu

Received October 26, 2009.
Revision received July 30, 2010.
Accepted August 23, 2010.

Abstract

Aims: This study aims to determine the impact of Screening, Brief Intervention and Referral for Treatment (SBIRT) in reducing alcohol consumption in emergency department (ED) patients at 3, 6, and 12 months following exposure to the intervention. Methods: Patients drinking above the low-risk limits (at-risk to dependence), as defined by National Institute of Alcohol Abuse and Alcoholism (NIAAA), were recruited from 14 sites nationwide from April to August 2004. A quasi-experimental comparison group design included sequential recruitment of intervention and control patients at each site. Control patients received a written handout. The Intervention group received the handout and participated in a brief negotiated interview with direct referral for treatment if indicated. Follow-up surveys were conducted at 3, 6, and 12 months by telephone using an Interactive Voice Response (IVR) system. Results: Of the 1132 eligible patients consented and enrolled (581 control, 551 intervention), 699 (63%), 575 (52%) and 433 (38%) completed follow-up surveys via IVR at 3, 6, and 12 months, respectively. Regression analysis adjusting for the clustered sampling design and using multiple imputation procedures to account for subject attrition revealed that those receiving SBIRT reported roughly three drinks less per week than controls (B = −3.00, SE = 1.06, P < 0.05) and the level of maximum drinks per occasion was approximately three-fourths of a drink less than controls (B = -0.76, SE = 0.29, P < 0.05) at 3 months. At 6 and 12 months post-intervention, these effects had weakened considerably and were no longer statistically or substantively significant. Conclusion: SBIRT delivered by ED providers appears to have short-term effectiveness in reducing at-risk drinking, but multi-contact interventions or booster programs may be necessary to maintain long-term reductions in risky drinking.

Charlie Sheen on the Myths of Rehab - Time Gets It Right!

2011-02-27T18:44:00.000-06:00

Here's a brief snippet from Maia Szalavitz, a health reporter at Time. She really hits the facts right on.

MW

Can You Use Crack 'Socially?' Addiction Myth Watch: Charlie Sheen Edition
By Maia Szalavitz Tuesday, February 15, 2011

The subject of addiction swirls with myths and misinformation. It doesn't help that so many people seem to believe that their own struggle with addiction — or a few drop-ins to Alcoholics Anonymous meetings — make them unquestionable experts on the topic. As the latest news about Charlie Sheen's escapades show, sometimes the seemingly crazy statements of an apparently active addict can be more accurate than those of people who have spent years in recovery and even some "addiction experts" — if you go by the science, that is. (More on Time.com: New Hope For An Anti-Cocaine Vaccine)

Myth One: Everyone Who Takes Crack Is An Addict

On Monday, during a radio interview with the sports-talk "Dan Patrick Show," Sheen mentioned that some crack users can "manage it socially." (He said his own attempts to be a social crack user "kind of blew up in my face. Like an exploding crack pipe, Dan.")

Although crack cocaine is indeed one of the most addictive drugs, Sheen's statement about social use is true of most people who have tried the drug, if by "social" you mean use that does not qualify you for a diagnosis of substance dependence. Far from being universally addictive, crack is actually unattractive to the majority of people who've tried it: only about 15%-20% of initial users become hooked. (More on Time.com: Bonus: 4 Tips for Staying on the Wagon)

Indeed, according to data from the National Survey on Drug Use and Health, about 75.6% of those who tried crack between 2004 and 2006 were not using it at all two years later. Another 15% were still hitting the pipe occasionally, but not at levels that would qualify them as addicts. About 9.2% were addicted.

So, although Sheen's terminology may be inexact, he's correct about the existence of non-addicted crack users. He's also correct to note that drinking chocolate milk is much, much safer.

Myth Two: Residential Treatment Works Better than Outpatient Treatment, and Must Be Done in Groups

People magazine recently reported that Sheen would go into treatment for substance abuse for the third time, this time at home: "Surrounded by a team of professionals, the Two and Half Men star will attend no meetings with other patients, check into no center. He could do it all at home or in some other private setting." (More on Time.com: Does Suffering From Withdrawal Really Mean You're Addicted?)

Commenting on Sheen's rehab plan, Dr. Drew told the magazine that "treatment of addiction is a group process when done properly — not an individual thing at all." Yet actual addiction research shows this is not the case. For example, the largest study ever done on alcoholism treatment, Project Match, was conducted mainly through individual therapy sessions (though one arm did focus on improving 12-step group participation): its aim was not to compare individual to group treatment, but overall, it found individual treatment just as successful.

Further, studies that have directly compared inpatient treatment to outpatient therapy have found that there is little difference in outcomes for most addicts, except for very severe cases, particularly amongst the homeless and jobless — these people lack social and family support, or other important goals to work toward, things that have been found to aid recovery. For employed professionals — like Sheen — outpatient and inpatient treatment tend to be equally effective. (More on Time.com: 'i-Dosing': Can You Download a Drug High?)

Myth Three: 12-Step Programs are Required for Recovery

Although celebrities, including Sheen's own father, swear by them, 12-step programs like Alcoholics Anonymous are not the only way to recover from addiction. Project Match, in fact, found that on most measures, cognitive behavioral therapy and motivational enhancement therapy were as effective as 12-step facilitation (TSF), a program that worked to enhance 12-step attendance. When patients received these therapies as after-care following inpatient treatment, all three groups did equally well. However, in outpatient-treated addicts, those in the TSF group had slightly better rates of complete abstinence in the year following treatment. (More on Time.com: Study: Do Energy Drinks Lead to Alcohol Abuse?)

So, although Sheen may not exactly be a model citizen — or rehab patient — his distaste for 12-step programs does not mean that he's untreatable. Maybe he just needs to find a rehab or addiction "professional" who is familiar with the scientific literature.
Find this article at:
http://healthland.time.com/2011/02/15/can-you-use-crack-socially-addiction-myth-watch-charlie-sheen-edition/

Addiction Treatment Parity Doesn't Add Costs

2011-02-07T18:51:00.001-06:00

Contrary to the hysterical warnings issued by the insurance industry and the Chamber of Commerce, it turns out that parity for addiction treatment does not add significantly to costs. One key reason is underutilization. Replacing the expensive and minimally effective rehab approach with a fully professional, scientifically based approach will not only make treatment even more cost effective, it will increase access to and utilization of treatment.

MLW

From Medscape Medical News > Psychiatry
No Increase in Substance Abuse Treatment Due to Mental Health Parity Law
Findings Should Squelch Fears That Controversial Legislation Will Cause Health Costs to Skyrocket
Deborah Brauser

February 4, 2011 — Parity in insurance coverage of substance abuse treatment has not led to increased use of this service or an increase in costs. It has done what it was designed to do — lower out-of-pocket expenses for covered individuals, new research suggests.

Employers who provide health insurance plans for mental and substance use disorders are now required by the Federal Mental Health Parity Act of 2008 to provide benefits that are equal to those given for general medical care.

There is always a fear that for substance abuse and for mental health, every time a plan is more generous, utilization will skyrocket...But this is not true.
"There is always a fear that for substance abuse and for mental health, every time a plan is more generous, the utilization will skyrocket, the costs will be so high, and all the insurance companies will start complaining that they won't be able to afford these services. But this is not true," lead study author Vanessa Azzone, PhD, researcher and biostatistician in the Department of Health Care Policy at Harvard Medical School in Boston, Massachusetts, told Medscape Medical News.

"I think these findings, along with those found in other studies, clear the air for all the people who have been criticizing parity law for mental health treatment," said Dr. Azzone.

The investigators note that the extensive use of managed care organizations (MCOs) within employer-based health insurance may be the reason for costs not rising.

"These MCOs administer behavioral health benefits and contain costs by managing the delivery of care — for example, through negotiated reduction in fees with a network of preferred providers and review of appropriateness of services to eliminate unnecessary use," they explain.

"Still, it's always a balance between getting more for the patient but also, from the plan side, controlling that services are only provided as needed," added Dr. Azzone.

The study is published in the February issue of Psychiatric Services.

Paucity of Research

Although previous research on the impact of mental health parity mandates "has undoubtedly helped to pave the way for passage of comprehensive federal legislation," there have been few studies on the effects of parity mandates for substance abuse treatment benefits, write the study authors.

"This is a group that is not studied as much. They're pretty sick and their services are very expensive. So there's been fear that the parity law could have a real impact," said Dr. Azzone.

Insurance plans for federal workers have been required to provide parity coverage since 2001. Because of this, the investigators decided to evaluate claims data on substance abuse treatment in 6 Federal Employees Health Benefit (FEHB) preferred provider organization plans between 1999 and 2001 (before parity was implemented) and between 2001 and 2002 (after implementation).

The use and costs of these plans were then compared with those found in a matched set of health plans without parity coverage.

Results showed no statistically significant differences in the use of substance abuse treatment services between the 2 plan types and no significant differences in probability rates of initiation and engagement.

Those enrolled in the FEHB plans had a significantly larger reduction in average out-of-pocket spending for these services (mean difference per user, −$101.09; P < .05) compared with those in the non-FEHB plans.

Although the FEHB group also had smaller increases in total substance abuse spending compared with the non-FEHB group, these differences were not significant.

Finally, more of the patients with parity were identified by their care providers as having a substance use disorder (difference-in-difference risk, 0.10; 95% confidence interval, 0.02 to 0.19; P < .05).

"Findings suggest that for continuously enrolled populations, providing parity of substance abuse treatment coverage improved insurance protection but had little impact on utilization, costs for plans, or quality of care," write the researchers.

Clinicians' 'Biggest Stress'

According to Dr. Azzone clinicians' biggest stress is trying to get paid for services because insurance companies erect so many barriers to reimbursement.

"Still, there is this law, and I think clinicians should push more for their patients, even if it is hard for them to promote services when they have so many obstacles. This is already a population that finds it very hard to engage in and continue to get services," she said.

She added that her team is conducting other studies looking at the possibility of parity coverage differences for other groups.

"This includes patients with bipolar disorder or major depression that usually are more expensive and require more services. These patient populations could have a differential effect. We're also concentrating on children to see if the effect we found in adults overall is the same or not," she explained.

"I think this study is significant and an important step in the analysis of overall healthcare costs," Anita S. Everett, MD, director of Community Psychiatry Services at Johns Hopkins Bayview Medical Center in Baltimore, Maryland, told Medscape Medical News.

Dr. Anita Everett
"Providing parity for substance abuse services didn't increase the overall costs. And that is the big fear that everyone has — open the floodgates and all these people will want these very expensive services," said Dr. Everett, who was not involved with this study.

"Also, the number of individuals who actually sought the services didn't go up that much. I think that that is important, although not shocking, and consistent with what we already know: a lot of people with a substance abuse disorder don't recognize their need for treatment or are unwilling to seek treatment. Offering parity is not all of a sudden going to break down their resistance."

Dr. Everett pointed out that a big part of "substance abuse disease" is to be in denial about the magnitude of the problem.

Parity Law Won't 'Break the Bank'

"The clinical significance of parity is that it enables a clinician to be able to help patients and to 'strike while the iron is hot,' so to speak. If they're at a point where they're ready, then hopefully we'll be able to immediately meet that readiness," she said.

Dr. Everett, who is also chair of the American Psychiatric Association's Council on Healthcare Systems and Finance, said that some primary care physicians might not be aware that the parity law has passed.

"I know that the American Psychiatric Association, along with a number of other organizations, is actively working to promote awareness for healthcare providers, patients, and their families that parity for substance abuse and for mental health services does exist," she said.

"I also think that resources such as referral services should be collected and offered in primary care offices."

I think this is critical information that helps us understand that enabling access to some of these services is not going to break the bank.
She noted that, although these findings are important, the study population might not be representative of all groups in the United States.

"These were people who were fairly motivated and are probably comparable to other private pay insurance groups — but maybe not to the Medicare or Medicaid populations. We know it can give us some ideas about applicability to the general public, but it may or may not be predictive of the other 300 million Americans who are not federal employees," explained Dr. Everett.

"However, I think this is critical information that helps us understand that enabling access to some of these services is not going to break the bank."

The study was funded by a grant from the National Institute on Drug Abuse through the Brandeis-Harvard Center for Managed Care and Drug Abuse Treatment. Its data were originally collected in a study funded by the Department of Health and Human Services. The study authors and Dr. Everett have disclosed no relevant financial relationships.

Psychiatr Serv. 2011;62:129-134.

Medscape Medical News © 2011 WebMD, LLC
Send comments and news tips to news@medscape.net.

ALLTYR™ Is Born!

2011-02-01T20:15:00.000-06:00

Over the past year, I have blogged and spoken about the need for transformational change in the addiction treatment system. This week, we took a major step towards stimulating that change, by forming a corporate structure for clinical, educational, advocacy and research efforts. ALLTYR™, the name of the organization, has now been incorporated in Minnesota!

There are two major areas of activity. The first is to develop a model for 21st Century specialty addition treatment. Built on a foundation of science, compassion and common sense, the ALLTYR™ Clinic will provide medically based, multidisciplinary evaluation and treatment for the entire spectrum of substance use disorders. The Clinic will use the ASSET™ Model of care. ASSET™ stands for Alcohol and Substance Use Screening, Evaluation and Treatment. We will provide comprehensive evaluations with recommendations for any indicated treatment. The ASSET Clinic will have several areas of specific expertise, including impaired professionals and executives, managing patients with brain injuries, complex chronic pain management, patients with serious medical problems such as cirrhosis and pancreatitis, patients with treatment-resistant alcohol or drug addiction and patients with complex mixes of psychiatric, medical and addictive disorders. The planned opening for the ASSET Clinic is Fall 2011, although we may be able to start accepting patients sooner.

The second focus for ALLTYR will be to help existing healthcare organizations address substance use throughout their system of care. Most people who drink too much or use other psychoactive drugs are not addicted, but are “at-risk” users. That is, they are using at a level that places them at elevated risk for developing problems later. They are currently not symptomatic. For example, someone drinking 4 or 5 drinks several days a week, or using marijuana several times a week, but who does not endorse any criteria for substance dependence. For this group, who do not have a diagnosable disorder, the goal is to counsel them about their use, so as to reduce the risk. They are similar to people with high cholesterol before a heart attack, or high blood pressure before a stroke. Treatment is not appropriate for them. This group is quite responsive to brief counseling, either by health care clinicians or on the internet, by workplace health initiatives, and so forth. When I was at NIH, we developed a product specifically for at-risk drinkers called Rethinking Drinking.

The second group are people who have some symptoms of alcohol addiction (or dependence, these are interchangeable terms) but who are functional. This group primarily endorses symptoms such as repeatedly going over limits, a persistent desire to quit or cut down, and use despite physical or psychological problems caused or exacerbated by their use, such as hangover, nausea, or insomnia. They do not have the kind of problems we usually associate with addiction such as major life disruptions involving employment, parenting, school performance, or serious interpersonal or legal problems. This group, called functional alcohol dependents, are not appropriate for specialty addiction treatment, but respond well to medications and brief support, much like mild to moderate depression is treated in primary care. Both of these groups are best dealt with in non-addiction specialty settings such as primary care or mental health care (general psychiatry).

For these groups, ALLTYR will provide consultation and training for existing health care systems. The goal is to help them address substance use throughout their healthcare system. For too long it has been considered forbidden for anyone but an addiction counselor to address substance use, which is why so few people now receive any risk reduction or treatment. Attending to substance use needs to be brought back into the mainstream of health care, including mental health care.

I am very excited about this next step in my new venture: making scientifically based addiction treatment available to the public in ways that are attractive, accessible, affordable and effective.

A Vaccine Against Addiction?

2011-01-24T18:46:00.000-06:00

In this recent post on Science News, more information about a potential cocaine vaccine. You know my view: we need as many tools as possible to fight addiction. Use everything available.

MW

Vaccine against cocaine makes headway

Injections gin up antibodies that limit drug's effects, study in mice showsBy Nathan Seppa Web edition : Thursday, January 20th, 2011
Vaccine against cocaine makes headway
Injections gin up antibodies that limit drug's effects, study in mice showsBy Nathan Seppa Web edition : Thursday, January 20th, 2011 Mice vaccinated against cocaine show less agitated behavior when exposed to the drug than do unvaccinated mice on the drug, as shown by the average time the animals spend on various activities.Crystal et al/Molecular Therapy 2011Antibodies generated by a new vaccine can capture molecules of cocaine in the precious few seconds that lapse before the drug reaches the brain, a study in mice shows. Although the antibody brigade doesn’t snag all the cocaine, it seems to collar enough to greatly subdue the agitation that mice exhibit when given the drug.

Based on these findings, the researchers are moving on to studies in rats and monkeys in hopes of testing the vaccine in people. The new report will appear in the March Molecular Therapy.

“When someone takes cocaine — whether snorted, smoked or injected — you don’t have much time,” says study coauthor Ronald Crystal, a pulmonary physician at Weill Cornell Medical College in New York City. “It takes about six second to pass from the lungs to the blood to the brain.”

A vaccine would need to elicit a standing army poised to intercede. “You need avid antibodies, at high levels,” Crystal says.

In the new study, Crystal and his colleagues gave mice three injections over six weeks. Some of the animals received a placebo while the others got the experimental vaccine, which combines a cocainelike substance with noninfectious portions of an adenovirus that stimulate an immune response but don’t cause disease. Four weeks later, all the mice were exposed to cocaine by injection.

Antibodies elicited by the vaccine kept about three-fifths of the cocaine from reaching the brain in vaccinated animals, according to examinations of the mice, which were given the maximum dose of cocaine. This effect translated into behavioral changes: Cocaine makes mice hyperactive, Crystal says, and in this study the unvaccinated mice were running around much of the time. In contrast, vaccinated mice ran one-third as much and performed repetitive motions half as much, behavior similar to that of mice not given cocaine at all.

Crystal says the vaccine might be ready to test in people in a year or two. “The most obvious strategy is to use it in people who are addicted but who want to stop and have enrolled in a program. This would help them,” he says.

Cocaine dependence accounts for more than one-third of illicit-drug-related emergency room visits, according to the U.S. Drug Abuse Warning Network.

About 40 percent of cocaine users are in denial about their addiction, and another 40 percent are not yet willing to take on the challenge of quitting, says Stephen Ross, an addiction psychiatrist at New York University. “The other 20 percent are ready to make a change,” he says. Such people need behavioral therapy and all available support. “The more tools we have, the better,” Ross says. “A vaccine could be part of that arsenal.” Vaccination might also prevent cocaine addiction in young adults and adolescents who are at high risk, he says.

Any prospective anticocaine vaccine needs a lot of testing, in part because it isn’t clear whether just taking more of the drug might overwhelm a vaccine’s effect, says Frank Orson, a physician and immunologist at the Baylor College of Medicine in Houston. Also, the researchers in the new study used an additive called complete Freund’s adjuvant to boost the immune reponse in the mice. The adjuvant cannot be used in people because of side effects, he says.

Other researchers have sought to build vaccines using adenoviruses, which normally cause the common cold and other ailments, Orson says. These efforts include work on vaccines for HIV, influenza, malaria and other ailments. Adenovirus particles are good at triggering an immune response, he says, which is important for vaccines against addictive drugs because the drugs otherwise go largely unnoticed by immune forces, which are geared up to catch infectious microbes, he says.

Nevertheless, Orson says, “I think there is a good chance we will have vaccines against some of these agents — cocaine being pretty high on the list because of its properties of being fairly short-lived.” Since cocaine is naturally degraded in the blood stream more rapidly than some other illicit drugs, such as methamphetamine, cocaine might make a better target, he says. Orson and his colleagues are currently working on vaccines against cocaine, heroin and methamphetamines.

Two recent presentations available on the web

2011-01-24T09:10:00.000-06:00

Colleagues and friends,

After a prolonged absence from the blog due to holidays and the press of other business, I'll be now keeping up with the blog again. I now have a site for posting my presentations, and I recently uploaded two of my most recent slide sets. I'll be posting additional ones as they are developed. The URL is https://show.zoho.com/public/mwillenbring.

Much has happened in the past 3 months. I have incorporated a new company, ALLTYR, Inc. ALLTYR is dedicated to transforming treatment for addictions through multiple activities. My goal is to open a clinic, the ASSET Clinic, in the Twin Cities in the fall of 2011. The ASSET Clinic will be a model for providing scientifically informed specialty treatment for addictions and will serve as a prototype, laboratory and clinical teaching site. The Clinic will provide the full array of services for all degrees of substance involvement and for as long as needed. It is not a "program," but will function like any other professional specialty clinic. A key focus will be on customer service. ALLTYR will also provide consultation to existing healthcare systems to help them integrate attention to substance use throughout their organization, especially in primary care, mental health care, the ed, and inpatient services. ALLTYR will provide materials, training, technical support, and will also offer the opportunity to either operate or develop an ASSET Specialty Clinic within existing health care organizations (HCOs). Much more on this later as it develops.

MW

Abstinence based treatment for opioid addiction kills people

2010-11-09T09:00:00.000-06:00

So how can abstinence based programs not inform patients about these studies and the alternatives to abstinence? In any other branch of medicine this is called negligence and the Supreme Court has clearly ruled that to not inform a patient of alternative therapies and relative rates of recovery is unethical and negligent practice. Why do state licensing agencies allow this to happen? As noted below, although this new study adds to the literature, many other studies have shown reduced mortality from maintenance as opposed to either detox, stabilize and taper or simply abstinence-based treatments. In my view, programs that are based on an ideological belief in abstinence but who do not inform patients of the relative risks, benefits and likelihood of recovery are risking a lawsuit because they are not providing basic informed consent for patients and families.

MW

From Medscape Medical News

Opiate Replacement Treatment Reduces Mortality in Addicted Patients

Deborah Brauser

October 29, 2010 — Year-long treatment with either buprenorphine or methadone can substantially decrease the number of drug-related deaths in opiate misusers, suggests new findings from British researchers.

In fact, results from this large cohort study showed that patients given "opiate substitution treatment" for 12 months or more had a greater than 85% reduced overall mortality risk.

"This treatment reduces the risk of death — but treatment duration matters," investigative team member Matt Hickman, professor in public health and epidemiology at the School of Social and Community Medicine at the University of Bristol in the United Kingdom, told Medscape Medical News.

In addition, the investigators write that "closer supervision is needed" because significant mortality risks were found for these patients during both the first 28 days after beginning and the first month after ending treatment compared with other times.

"We found that the risk of death in the first month leaving...was about 4 times higher than rest of time off treatment, which is very similar to difference in risk of death after leaving prison," said Professor Hickman.

The investigators write that although "the difference in mortality between opiate users in and out of treatment is stark and well known," few studies have looked at this risk at specific time points.

"We hypothesize that the raised risk of death in the first month of treatment and especially in the month after the end of treatment may negate any protective effect of opiate substitution treatment, unless treatment is prolonged," they add.

The study was published online October 27 in the British Medical Journal.

Opiate Use Continues to Increase

For opiate users, "systematic reviews estimate annual death rates of about 1%, which is more than 10 times that of the general population and contributes more than 10% of adult mortality," write the study authors. Most of these deaths are due to overdose.

"Estimates of the prevalence of opiate use in the UK suggest 30-fold increases between 1970 and 2000, but more recent estimates are stable at around 250,000 opiate users," they add, noting that opiate substitution therapy in their country is given mainly within primary care.

For this study, the investigators pulled information from the United Kingdom's General Practice Research Database. They then evaluated data on 5577 primary care patients between the ages of 16 and 59 years (58% younger than 30 at start of treatment, 69% male) diagnosed as having "substance misuse" and prescribed noninjectible methadone or buprenorphine between 1990 and 2005.

A total of 267,003 prescriptions were written for these patients. A total of 57% of the patients were prescribed methadone only; 19% were prescribed methadone and dihydrocodeine; 9% were prescribed methadone and buprenorphine; 8% were prescribed buprenorphine only; 4% were prescribed buprenorphine and dihydrocodeine; and 4% were prescribed methadone, buprenorphine, and dihydrocodeine.

All patients were followed up "until 1 year after the expiry of their last prescription, the date of death before this time had elapsed, or the date of transfer away from the practice," report the investigators. The median length of follow-up was 2 years.

The main outcome measure was all-cause mortality. Secondary measures included risk for death at different periods during and after treatment.

They also estimated "the probability that opiate substitution treatment reduces average mortality for patients exposed to different durations of treatment compared with if they had been unexposed."

Mortality Doubled When Not Receiving Treatment

Results of the analysis showed that 178 of the patients died (62 while undergoing treatment, 116 within 1 year of their last prescription).

The overall crude mortality rates were 0.7 per 100 person-years while receiving opiate replacement treatment and 1.3 while not receiving treatment.

"The crude mortality rate off treatment was almost double that on treatment, and after adjustment (for age, sex, calendar period, and comorbidity) the mortality rate ratio was more than twice as high" (2.3; 95% confidence interval [CI], 1.7 – 3.1), write the investigators.

Standardized mortality ratios, "comparing death rates among study patients with the population of England and Wales," were 5.3 (95% CI, 4.0 – 6.8) while undergoing treatment and 10.9 (95% CI, 9.0 –13.1) while not undergoing treatment.

In addition, men using opiates almost doubled the risk for death of women users (mortality rate ratio, 1.97; 95% CI, 1.4 – 2.9). However, the standardized mortality ratios were similar between men and women when both receiving and not receiving treatment.

Also, "mortality increased with age and was positively associated with comorbidity score," report the researchers.

When looking at treatment duration, the crude mortality rate was highest during the first 2 weeks at 1.7 per 100 person-years. After adjustment, this was 3.1 (95% CI, 1.5 – 6.6) times higher than the rate during the remainder of time receiving treatment.

The crude mortality rate during weeks 3 and 4 of treatment was 1.3, and the adjusted mortality rate ratio was 2.4 (95% CI, 0.95 – 6.0).

The mortality rates and ratios during the first month after stopping treatment were even higher:

Table. Mortality Rates and Ratios

Time Not Receiving Treatment Crude MR Adjusted MR Ratio (95% CI)

1-2 weeks 4.8 9.0 (5.4 – 14.9)

3-4 weeks 4.3 8.0 (4.7 – 13.7)

Remainder of time 0.95 1.9 (1.3 – 2.8)

CI = confidence interval; MR = mortality rate

"We found no evidence of any difference in the risk of death between buprenorphine and methadone when we compared the whole period on and off treatment," the study authors write.

Finally, short treatment durations of between 20 to 30 weeks reduced the overall risk for death by less than 25%. However, that rate increased to 65% at 40 weeks' duration and to more than 85% at durations "approaching or exceeding a year.

"The overall risk of death, standardized mortality ratios, and overall difference in mortality between time on and off treatment for opiate users in UK primary care in this study are consistent with international literature," report the investigators.

"Further research is needed to investigate the effect of average duration of opiate substitution treatment on drug related mortality," they write.

"We hope that others also will examine further what interventions might reduce risk of relapse following treatment," added Professor Hickman.

Twice as Likely to Live If in Treatment

"This study is based on the British concepts of treatment, which are different from the US," Mary Jeanne Kreek, MD, professor and head of the Laboratory of the Biology of Addictive Diseases at Rockefeller University in New York City, told Medscape Medical News.

"They simply took all comers over a protracted period of 15 years who were labeled as receiving prescriptions for opiate substitution treatment. So their data will not look like US, Swedish, Norwegian data. Any place where they carefully follow up their people with more oversight," said Dr. Kreek.

She said that the British do not have tight control regarding this treatment "because individual doctors can do the prescribing."

Also, she noted that the word "substitution" is not used in the United States. "That's not allowed. Instead, we call it 'replacement treatment' or simply 'maintenance treatment.'"

Dr. Kreek, who was not involved with this study, has served on the National Institute on Drug Abuse National Advisory Council and is a past president of the College on Problems of Drug Dependence.

She said that "the most important result" from this study is the substantial crude mortality rate difference between people receiving and not receiving treatment. "That's the critical thing."

However, this finding isn't new. Dr. Kreek noted that Dr. Lars Gunne wrote that heroin addicts untreated had a death rate that was "multifold higher, based on a randomized study of methadone treatment in Sweden in the late 70s" (Drug Alcohol Depend. 1981;7:249-256).

She also noted that "there isn't really an end-of-treatment phase" for these types of patients in the United States.

"There is only about 5% to 10% who've been successfully treated and request to have their medication dose reduced and eliminated," said Dr. Kreek. "To take people off treatment is, to us, unethical unless they really ask and will work with you as a care provider to be followed up in a medication-free state.

"So why are these people [in this study] coming off treatment? The [investigators] don't really get into that, but in Britain there is more of a casual entry to and exit from treatment."

Another big difference is that "we've never seen a death in this country at the induction of this treatment," reported Dr. Kreek. "With buprenorphine, we don't watch people, but we have a very tight induction schedule that's well regulated, starting low and going on up."

Overall, Dr. Kreek said that this study is interesting to look at but "isn't really relevant to US practice" — except for the crude mortality rate difference.

"It doesn't matter what kind of program you have, people are twice as apt to live if they're in treatment than if they're not in treatment. That's what's important. Methadone and buprenorphine both can be very effective if properly used," she summarized.

This study was funded in part by a grant from the National Institute of Health Research (NIHR) for the Center for Research on Drugs and Health Behavior, a career scientist fellowship award from the NIHR, and an Medical Research Council new investigator award. The study authors and Dr. Kreek have disclosed no relevant financial relationships.

BMJ. Published online October 27, 2010.

Do AA and Medications Mix?

2010-10-18T20:25:00.000-05:00

Any addiction professional who has worked with program directors of 12 step-based treatment centers, sponsors in Alcoholics Anonymous (AA), and long-term members of AA has experienced the anti-medication bias harbored by some.

However, there is nothing inherent in the 12-step approach that contradicts the use of medication for craving reduction, abstinence enhancement, or for that matter any psychiatric condition or disorder (Brigham 2003). An interesting side note to history occurred during the 1960s and involved a conversation between Dr. Vincent Dole, co-originator of methadone maintenance for heroin addiction, and Bill Wilson, co-founder of AA. Dr. Dole served as a trustee of AA, became friends with Bill Wilson, and recalled a conversation they had (Dole, 1991) where Wilson expressed his concern over alcoholics who could not achieve sobriety despite repeated attempts through AA:

“At the last trustee meeting (of AA) that we (Vincent Dole and Bill Wilson) both attended, he (Bill Wilson) spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many lost sheep who are lost in the dark world of alcoholism. He suggested that in my future research I should look for an analogue of methadone, a medication that would relieve the alcoholic’s sometimes irresistible craving and enable him to progress in AA toward social and emotional recovery, following the Twelve Steps.”

This highly revealing anecdote reflects the open-mindedness and recognition by the co-founder of AA that some alcoholics require a pharmacotherapeutic intervention to bridge the gap from initial abstinence to stable abstinence and integration in AA. How unfortunate it is that many ardent believers in the 12-step approach have adopted an attitude of rigidity and dogmatism regarding addiction medicine.

Brigham GS. 12-step participation as a pathway to recovery: The Maryhaven experience and implications for treatment and research. Clinical Perspectives-12 Steps and Treatment. 2003;46:43-52.

Dole V. Addiction as a Public Health Problem. Alcoholism: Clinical and Experimental Research. 1991;15:749-752.

Mark Rose

Agonist Therapy for Stimulant Addiction

2010-10-17T11:28:00.000-05:00

Agonist therapy is the use of a (usually) long-acting medication that stimulates the same brain receptors as the drug of addiction. The most obvious example is opioid agonist therapy for opioid addiction using methadone or buprenorphine. Several medications potentially useful for alcohol addiction stimulate GABA receptors as does alcohol. One reason agonist therapy works is that it relieves drug hunger without inducing intoxication. Antagonist therapy, such as using naltrexone to treat opioid addiction can work, but it usually does not relieve drug hunger, so people stop them to seek intoxication. In this new study in Neuropsychopharmacology, a controlled-release form of amphetamine was studied as a treatment for cocaine addiction, with some intriguing results.

MW

Sustained Release d-Amphetamine Reduces Cocaine but not ‘Speedball’-Seeking in Buprenorphine-Maintained Volunteers: A Test of Dual-Agonist Pharmacotherapy for Cocaine/Heroin Polydrug Abusers

Mark K Greenwald1, Leslie H Lundahl1 and Caren L Steinmiller1,2

1. 1Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA
2. 2Department of Pharmacology and Toxicology, University of Toledo, Toledo, OH, USA

Correspondence: Dr M Greenwald, Department of Psychiatry and Behavioral Neurosciences, Substance Abuse Research Division, 2761 East Jefferson Ave., Detroit, MI 48207, USA. Tel: +1 313 993 3965; Fax: +1 313 993 1372; E-mail: mgreen@med.wayne.edu

Received 18 May 2010; Revised 27 August 2010; Accepted 28 August 2010; Published online 29 September 2010.
Top of page
Abstract

The aim of this study was to determine whether oral sustained release d-amphetamine (SR-AMP) reduces cocaine and opioid/cocaine combination (‘speedball’-like) seeking in volunteers with current opioid dependence and cocaine dependence. Following outpatient buprenorphine (BUP) 8 mg/day stabilization without SR-AMP, eight participants completed a 3-week in-patient study with continued BUP 8 mg/day maintenance and double-blind ascending SR-AMP weekly doses of 0, 30, and 60 mg/day, respectively. After 3 days (Saturday–Monday) stabilization at each SR-AMP weekly dose (0, 15, or 30 mg administered at 0700 and 1225 each day), on Tuesday–Friday mornings (0900–1200 hours), participants sampled four drug combinations in randomized, counterbalanced order under double-blind, double-dummy (intranasal cocaine and intramuscular hydromorphone) conditions: cocaine (COC 100 mg+saline); hydromorphone (COC 4 mg+HYD 24 mg); ‘speedball’ (COC 100 mg+HYD 24 mg); and placebo (COC 4 mg+saline). Subjective and physiological effects of these drug combinations were measured. From 1230 to 1530 hours, participants could respond on a choice, 12-trial progressive ratio schedule to earn drug units (1/12th of total morning dose) or money units (US$2). SR-AMP significantly reduced COC, but not HYD or speedball, choices and breakpoints. SR-AMP also significantly reduced COC subjective (eg, abuse-related) effects and did not potentiate COC-induced cardiovascular responses. This study shows the ability of SR-AMP to attenuate COC self-administration, as well as its selectivity, in cocaine/heroin polydrug abusers. Further research is warranted to ascertain whether SR-AMP combined with BUP could be a useful dual-agonist pharmacotherapy.

Navy Offers On-Line Help for Addictions

2010-10-04T08:27:00.002-05:00

Now, if only they'd offer CBT and medications as well... (sigh)

MW

October 3, 2010

Navy Offers Sailors Online Help to Quit Addictions

By THE ASSOCIATED PRESS

Filed at 1:13 p.m. ET

RICHMOND, Va. (AP) — The Navy is teaming up with a highly regarded addiction treatment center to provide Web-based support for thousands of sailors, their families and retired personnel struggling with alcohol and drug abuse.

The $3.25 million program is intended to keep sailors with addiction problems on the road to recovery and links them to support programs anywhere in the world, at anytime, even when they're deployed. It is tailored primarily to younger sailors, who are at greater risk and are comfortable navigating the Internet and social programs.

It was developed in collaboration with Hazelden, a nonprofit alcohol and drug addiction treatment center based in Minnesota, and aimed at the 10,000 patients who receive primary treatment annually under the Navy's Substance Abuse and Rehabilitation Services program. While families and retired Navy also receive treatment, the majority of patients are on active duty.

The online program launched in August is called Navy MORE, an acronym for My Ongoing Recovery Experience. An estimated 1,000 patients are expected to use the program in its first year.

"It's patient-centered care," said Master Chief Michael P. Brown, a Navy recovery coach for the Pacific Northwest, the Great Lakes and Hawaii. "We just assist them along the way.

Capt. Richard D. Bergthold, a clinical psychologist with the Navy, said the program is tailored to military use but also provides the continuing, immediately accessible support and resources that anyone overcoming addiction needs.

"We know it's the investment in the continuing care that makes or breaks a successful treatment," said Bergthold, chief of staff for the Navy's Wounded, Ill and Injured directorate. "We recognize more and more the importance of maintaining continuous engagement with an individual's recovery plan."

A 2005 Department of Defense study found that all military personnel between the ages of 18-25 were more likely to drink heavily than their civilian counterparts. Seventeen percent of Navy personnel described themselves as heavy drinkers, defined as someone who consumes five or more alcoholic drinks at one sitting at least once a week. Illicit drug use has trended down over the past few decades, according to the Pentagon.

Hazelden, which has worked with the Navy for 10 years and already trains Navy counselors, developed MORE over several years to help sailors who have struggled with addiction problems to stay clean and sober once they have gone through the Navy's treatment program.

"One of the main reasons for relapse is the loss of that connectivity during early recovery," said Nick Motu, a Hazelden vice president who worked with the Navy on the program. "We believe that if you can maintain a real solid recovery platform for the first 18 months, the chances of your success and long-term recovery are much higher."

Navy MORE extends this connectivity by putting Navy-specific programs online, including 12-step recovery approaches and a suicide hotline as well as treatment programs tailored to sailors or retirees who are suffering from post traumatic stress disorder.

Sailors, their families and retirees also will have access to a virtual "recovery coach" to manage their post-treatment progress; an online library of recovery topics; and online support groups, including real-time connections with counselors.

"They don't have access to the traditional recovery communities that someone on the outside world would have," Motu said of sailors who are deployed around the world.

While a sailor assigned to an aircraft carrier would have access to program counselors, other military personnel including Marines in a carrier group might not have the same access to services, Bergthold said.

The Web program's key benefits are immediacy and the ability to access resources with the click of a mouse.

"It's when they go back to their homes, when they go back to their ships, when they go into the increasingly stressful environments in which they work that they require these continuing care services," he said.

Brown, who is based at Naval Hospital Bremerton in Washington, said it's in the Navy's interest to return "productive sailors to the fleet."

"Everyone in life has their bumps. We're here to assist them and we're here to help them on their path," he said.

The program is free to its users and the Navy has signed a five-year contract. Motu said Hazelden is in discussions with other branches of the military to develop similar programs.

___

Online:

Navy MORE: http://www.navymore.org/home.html

Acamprosate Review Concludes It's Effective

2010-09-13T13:07:00.000-05:00

The most recent meta-analysis regard acamprosate concluded that it was safe and effective for treating alcohol dependence, with a number needed to treat (NNT) of 9 (9 patients have to be treated to prevent one relapse.) This NNT is quite acceptable. I remain skeptical, however. I'm going to look the paper over in more detail and weigh in with my own take.

MW

Medscape Medical News

Acamprosate May Be Helpful to Treat Alcohol Dependence

Laurie Barclay, MD

September 13, 2010 — Acamprosate appears to be effective and safe for supporting continuous abstinence after detoxification in alcohol-dependent patients, according to the results of a systematic review reported September 8 in the Cochrane Database of Systematic Reviews.

"Alcohol dependence is among the main leading health risk factors in most developed and developing countries," write Susanne Rösner, from the University of Munich in Munich, Germany, and colleagues. "Therapeutic success of psychosocial programs for relapse prevention is moderate, but could potentially be increased by an adjuvant treatment with the glutamate antagonist acamprosate."

To compare the efficacy and tolerability of acamprosate vs placebo or active control, the reviewers searched the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, PubMed, EMBASE, and CINAHL in January 2009. They also asked manufacturers and investigators for data from unpublished studies.

Inclusion criteria were double-blind, randomized controlled trials (RCTs) comparing drinking-related outcomes obtained with acamprosate vs those obtained with placebo or with other pharmacotherapy. Two authors independently extracted data; one author evaluated trial quality, and a second author verified this assessment. Primary efficacy outcomes were confirmed with use of meta-analyses of individual patient data.

There were 24 RCTs meeting selection criteria, enrolling a total of 6915 alcohol-dependent participants. Risk of any drinking was significantly lower with acamprosate vs placebo (relative risk [RR], 0.86; 95% confidence interval [CI], 0.81 - 0.91). The number needed to treat [NNT] to benefit was 9.09 (95% CI, 6.66 - 14.28), and cumulative abstinence duration MD was significantly higher (10.94; 95% CI, 5.08 - 16.81). However, gamma-glutamyltransferase (GGT) levels, heavy drinking, and other secondary outcomes did not reach statistical significance.

"Acamprosate is certainly no magic bullet, but it is a safe and effective treatment for patients who are trying to stop drinking," Dr. Rösner said in a news release. "The benefits we have seen in these trials are small. However, we must remember that these are additional benefits on top of those from other non-drug therapies."

The only adverse effect reported more frequently with acamprosate vs placebo was diarrhea (RD, 0.11; 95% CI, 0.09 - 0.13). The NNT to harm was 9.09 (95% CI, 7.69 - 11.11). Compared with nonprofit-funded trials, findings from industry-sponsored trials were not significantly different, and the linear regression test did not demonstrate any significant risk for publication bias (P = .861).

"Acamprosate appears to be an effective and safe treatment strategy for supporting continuous abstinence after detoxification in alcohol dependent patients," the study authors write. "Even though the sizes of treatment effects appear to be rather moderate in their magnitude, they should be valued against the background of the relapsing nature of alcoholism and the limited therapeutic options currently available for its treatment."

Limitations of this study include those inherent in the included trials, such as poor compliance with assigned study drug, as well as some heterogeneity between studies.

Three of the reviewed trials compared acamprosate vs naltrexone. These trials showed comparable effects of the 2 drugs on return to any drinking, return to heavy drinking, and cumulative abstinence duration.

"Patients' doubts and reservations against a strategy that uses one substance to treat dependency on another should be taken seriously, while interventions that have been shown to work should not kept back from patients," Dr. Rösner said.

The Federal Ministry of Education and Research supported this study.

The Only Effective Treatment for Opioid Dependence is Maintenance (again)

2010-09-07T14:33:00.000-05:00

Here is a report on Medscape about a large study comparing short and long-term tapering strategies using Suboxone to treat prescription opioid dependence. As with virtually every other study comparing taper and discontinuation with maintenance, virtually all participants relapsed following discontinuation. It didn't matter whether they tapered over one month or nine. It didn't matter whether they received only medical management or enhanced addiction counseling. Drug free treatment for established (> 1 years) opioid dependence does not work! (Except in highly unusual situations such as airline pilots or physicians who are required to get a shot of extended release naltrexone once a month.)In spite of this and dozens of other high quality studies, treatment programs continue to promote "drug free" treatment for opioid dependence, thus condemning their unwitting customers to relapse. And why? Because they don't believe in it. How would you feel if your doctor knew of an antibiotic that would treat your chronic infection but who didn't tell you about it because she didn't believe in using drugs to treat infections? Or who knew of a surgery that would cure your disability but didn't offer it and discouraged you from having it because he didn't believe in surgery? How long are we going to let this happen before treatment programs are held accountable to offer scientifically sound treatment and advice?

www.medscape.com

[CLOSE WINDOW]

Authors and Disclosures
Journalist
Caroline Helwick
From Medscape Medical News
For Prescription Opioid Dependence, Relapses Associated With Shorter Treatment Course
Caroline Helwick
May 24, 2010 (New Orleans, Louisiana) — In persons dependent on prescription opioids, tapering with buprenorphine during a 9-month period, whether initially or after a period of substantial improvement, led to nearly universal relapse in the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study, presented here at the American Psychiatric Association 2010 Annual Meeting.
"There has been virtually no research on the treatment of persons dependent on prescription opioids, in spite of the major increase in prescription opioid abuse and in the numbers of persons entering treatment for addiction to prescription opioids," said Roger D. Weiss, MD, professor of psychiatry at Harvard Medical School, Boston, and chief of the Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts.
The study, which is the largest treatment study ever conducted for prescription opioid dependence (POD), sought to answer several questions regarding the optimal length of pharmacotherapy, the value of intense counseling, and the role of chronic pain.
Specifically, the study asked whether adding individual drug counseling to buprenorphine-naloxone (a semisynthetic opioid and a partial agonist) plus standard medical management improves outcomes, what duration of buprenorphine is best for these patients, and whether presence or absence of current chronic pain influences outcomes.
"The trial was designed to help the physician manage patients who are dependent on opioids and want off the drugs but refuse treatment in a drug abuse treatment program," Dr. Weiss said.
The study enrolled 653 persons with POD and offered them standard medical management, which included buprenorphine (usually 12 - 16 mg maximum, adjusted for addiction, not pain), an initial 1-hour visit, and weekly 20-minute sessions with a physician who counseled the patients and monitored for drug adverse effects. Half the group remained in this standard medical management (SMM) group and half received enhanced medical management (EMM), which included twice-weekly 60-minute individualized drug counseling focusing on interpersonal issues, coping with triggers and high-risk situations, homework, and so forth.
Under a somewhat complicated schema, patients were evaluated after periods of individualized buprenorphine tapering and maintenance and were assessed for abstinence from opioids at various times.
Study Population
All patients had a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, diagnosis of opioid dependence and had used opioids for at least 20 of the last 30 days. Other substance abuse disorders were allowed, with the exception of active heroin use or history of injecting heroin. All patients expressed an interest in stopping opioids.
The population was made up of 60% men, was 91% white, had a mean age of 33 years, was likely to be cigarette smokers (71%), and had been using opioids for an average of 4.5 years. Most patients had received some college education and were employed full-time. There were no significant differences at baseline between the SMM and EMM groups.
A number of patients reported current chronic pain (42%), and some were taking opioids for this condition. Although current polypharmacy was uncommon, many patients reported a lifetime history of heroin use (23%), alcohol abuse (60%) or dependence (27%), cannabis abuse (47%) or dependence (15%), and cocaine abuse (32%) or dependence (18%). Stimulant and sedative use were less common.
Opioids used within 30 days included sustained-release oxycodone (35%), hydrocodone (32%), immediate-release oxycodone (19%), methadone (6%), and others (8%).
Thirty percent of subjects had received some previous treatment for opioid dependency, primarily "self help" (59%), inpatient/residential treatment (42%), outpatient counseling (40%), and methadone maintenance (31%).
"For most subjects, this was the first treatment for opioid dependence," said Dr. Weiss.
Treatment and Maintenance
Treatment success was defined as 4 or fewer days of opioid use per month, no positive urine screens for opioids for 2 consecutive weeks, no other formal substance abuse treatment, and no injection of opioids.
Phase 1 included 1 month of tapering and 2 months of stabilization. At the end of this time, few patients were successfully treated, and enhanced management did not influence the results, Dr. Weiss reported.
In the SMM group, only 7% met the criteria for success, as did just 6% of the EMM group (P = .45). "Nearly all patients relapsed after a 4-week taper," Dr. Weiss said.
Patients who relapsed were asked to enter phase 2, at which time 360 patients were again randomly assigned to SMM or EMM and received 3 months of buprenorphine stabilization, then had treatment tapered for 1 month, with a 2-month follow-up.
At the end of the stabilization (at week 12), substantial improvement was noted for 52% of the EMM group and 47% of the SMM group, though again there was no additional benefit to enhanced management (P = .3). Substantial improvement was defined as abstinence for 3 or more of the final 4 weeks of buprenorphine stabilization (urine-confirmed self-report).
However, by the end of the stabilization period, many patients had relapsed again, Dr. Weiss reported.
"We went from an average success rate of 49% to 26% at week 16,"he said. At week 24 (8 weeks posttaper), only 9% of patients remained successfully treated.
"At the end of the study, we were back into phase 1 territory," he said. "Seven of 8 patients doing well on buprenorphine maintenance had relapsed."
Predictors of Outcome
The only predictor outcome was ever-use of heroin. At week 12, improvement was noted for 37% of those reporting lifetime heroin use compared with 54% of those without such a history (P = .003); at week 24, this was 5% and 10%, respectively (P = .13). "Having dabbled in heroin was a bad prognostic sign," Dr. Weiss observed.
The presence of chronic pain did not influence outcomes. Patients with chronic pain were equally likely to enter phase 2 (indicating early treatment failure) and were equally likely to be substantially improved at week 12 of phase 2 (53% vs 47% for those without chronic pain).
Chronic pain tended to be lumbar/sacral (65%) and classified as only moderate (median 4.4 on 10-point scale) but was of long duration, as more than half the patients had suffered from it for at least 4 years, he said.
"Interestingly, we found that in many cases the patient's pain got better," he added. More than half the subjects reported at least a moderate reduction of pain from baseline (≥30%), and one third had a substantial improvement (≥50%).
Nevertheless, Dr. Weiss said one cannot assume that buprenorphine itself improved the pain, as there was no control group, "but it is an intriguing possibility," he commented.
Sean Mackey, MD, PhD, associate professor of anesthesia and chief of the Division of Pain Management at Stanford University, Palo Alto, California, who delivered an overview of the treatment of pain in patients with addiction at the session, commented on the current study for Medscape Psychiatry.
He was particularly interested in the finding that persons with a history of heroin use had worse outcomes. "Could it be that prior exposure to heroin fundamentally alters the neurobiology in this group such that they need higher doses of buprenorphine to prevent relapse?" he asked.
Dr. Mackey maintained that the study is important because it asked a clinically relevant question: "Does putting people on a short period of buprenorphine maintenance combined with counseling lead to reductions in relapse? It's a great idea, and a wonderful hypothesis, because if it does work then this would be a huge win. We would not have to use extended maintenance. Unfortunately, it did not work, but the study needed to be done."
He further noted that the standard management group was likely getting better care in this study than is delivered in usual practice, which may have diluted potential differences.
Dr. Weiss has reported receiving research support from Eli Lilly. Dr. Mackey has disclosed no relevant financial relationships.
American Psychiatric Association 2010 Annual Meeting: Symposium 36, presentation 4. Presented May 23, 2010.
Medscape Medical News © 2010 Medscape, LLC
Send press releases and comments to news@medscape.net.

And another response to Dr. Johnson

2010-08-16T20:52:00.001-05:00

From The Huffington Post

Deni Carise

Chief Clinical Officer, Phoenix House
Posted: August 16, 2010 12:00 PM

Examining the Viability of Substance Abuse Treatment Today

Earlier this week, I was more than a little put off by Bankole Johnson's Washington Post editorial, "We're Addicted to Rehab. It Doesn't Even Work." It's interesting to note that this piece comes just six months before the release of his new book on medications that "conquer alcoholism," which will join countless other tomes that also claim to have the cure.

In his searing op-ed, Johnson, chair of psychiatry and neurobehavioral sciences at the University of Virginia, argues that there is little empirical evidence to suggest that substance abuse treatment programs are effective. Making sweeping generalizations, he points a finger at our country's treatment centers, including nonprofit providers, calling them both "ruinously expensive" and "divorced from state-of-the-art medical knowledge."

I take issue with these charges first and foremost as a scientist who has dedicated her career to studying the effectiveness of substance abuse treatment. In equal measure, I disagree with Johnson's allegations as a person in long-term recovery who might not be here were it not for the treatment I received.

Johnson calls substance abuse a devastating disease, yet he fails to acknowledge the limitations of treating a condition that is chronic by nature, like diabetes and hypertension. When evaluating the effectiveness of a particular medication for diabetes, treatment providers don't expect their diabetic patients to be "cured" after one treatment, nor do they define success as never having another sugar crisis. Similarly, defining successful substance abuse treatment as one that produces 100 percent abstinence for the rest of a person's life is a naïve and useless benchmark. However, if we define success as learning to manage your condition and gaining the support needed to do so, there are literally hundreds of controlled studies documenting the effectiveness of various forms of treatment. And they meet FDA levels of effectiveness.

As for Johnson's claim that substance abuse treatment is "too costly for most people," this is simply not the case. The two programs he mentions, Promises and Hazeldon, are geared toward individuals of higher socioeconomic status. However, there are many programs in our country that serve those with more modest means. When I entered substance abuse outpatient treatment in 1984, I paid just five dollars for each counseling session I attended. I later found out that the remainder of my treatment costs had been covered by the federal block grant. At Phoenix House, where our programs receive both state and federal funding, some clients stay with us even when they have no funds to cover their care. Many other non-profits do the same. Listing two expensive programs as if they are representative examples does not convey the wide range of treatment options available to people from all walks of life.

Johnson primarily aims his criticism at AA and it's true that not every substance abuser who enters AA will achieve long-term recovery. Likewise, not every diabetic who tries a particular medication will achieve long-term recovery from diabetes. As with other chronic conditions, there are many evidence-based treatment methods for substance abuse--not just the 12-step model. To discredit an entire spectrum of care that has worked for hundreds of thousands of people--and has been backed by scientific research--is to ignore the facts. It says to those of us who work with substance abusers each day that our efforts to help them are futile. And it says to those who need treatment that there is no real help available. That's inaccurate and irresponsible.

I'm certainly not dismissing the benefits of incorporating medication into substance abuse treatment. That would be irresponsible as well. But research has shown that meds alone will not produce a cure and traditional "rehab" components such as group counseling are equally important. Dr. Johnson himself runs a treatment program that includes cognitive behavioral therapy in addition to pharmacology. So why can't he acknowledge that any and all empirically-proven methods of helping people with this disease need to be included in their treatment options?

Maybe it's simply the fact that presenting a more balanced op-ed piece wouldn't sell as many books.

More on Dr. Johnson's Critique of 12-step Programs

2010-08-16T20:42:00.000-05:00

Letters to the editor in response:

The pros and cons of 12-step rehab

Thursday, August 12, 2010

I take issue with Bankole A. Johnson's Aug. 8 Outlook commentary, "12 steps to nowhere," which essentially devalued alcohol rehabilitation in order to sell "effective medicine" to treat alcoholism.

I have been treating alcoholism in the Defense Department and the Navy for 33 years. Alcoholics Anonymous works for us. Both the Defense Department and the Navy have used AA and Twelve Step Facilitation Treatment for 40 years and have a recovery rate five years after treatment of about 75 percent. The Navy has some experience with drinking -- and it knows how to treat alcoholism. Our lives depend on it. Marines like to go to war sober.

Dr. Johnson is paid to develop drugs as the primary treatment for alcoholism. However, he knows so little about how AA works and takes quotes from the Big Book completely out of context.

Two million sober members of AA, most not on medication, will see his article and know how wrong he is for them.

Ronald Earl Smith, Bethesda
ad_icon

The writer is a captain in the Navy's medical corps and a senior psychiatrist and psychoanalyst at the National Naval Medical Center.

--

I attended 150 12-step meetings in 90 days (versus the prescribed 90 meetings in 90 days) and have not been to a meeting since, in about 12 years. I also have had no alcohol in that time. The pros and cons of 12-step rehab

Network News
X Profile
View More Activity
TOOLBOX
Resize
Print
E-mail
Yahoo! Buzz
Reprints
COMMENT
8 Comments | View All »
COMMENTS ARE CLOSED
Your browser's settings may be preventing you from commenting on and viewing comments about this item. See instructions for fixing the problem.
Discussion Policy
CLOSE
Comments that include profanity or personal attacks or other inappropriate comments or material will be removed from the site. Additionally, entries that are unsigned or contain "signatures" by someone other than the actual author will be removed. Finally, we will take steps to block users who violate any of our posting standards, terms of use or privacy policies or any other policies governing this site. Please review the full rules governing commentaries and discussions. You are fully responsible for the content that you post.
Who's Blogging
» Links to this article

I agree with everything Bankole Johnson said about the problems with 12-step rehabilitation. However, he failed to appreciate that if AA works for only a minority of people who try it, for that group "it works if you work it." Let others try something else.

If Dr. Johnson and his colleagues find a better cure, more power to them. Only do not let them or anyone say that AA does not work. It does for countless thousands, and at virtually no cost but time and effort.

Philip Saunders, Dunn Loring

--

In his commentary, Bankole Johnson stated that "no experimental studies have unequivocally demonstrated the effectiveness" of the 12-step approach to addiction.

In an experimental study in 2006 conducted at the Veterans Affairs Palo Alto Health Care System, randomly selected addicted patients who received a structured introduction to Alcoholics Anonymous and Narcotics Anonymous had a more than 60 percent greater reduction in the severity of their substance abuse problems six months later than did patients not receiving such an introduction. In a different experimental study, also in 2006, of a 12-step-oriented sober-living home, addicted individuals were, relative to those receiving other forms of care, twice as likely to be abstaining from substance use and three times as likely to not be incarcerated.
ad_icon

Both of these widely cited studies were funded by major, peer-reviewed federal research grants and were published in high-profile peer-reviewed journals.

Dr. Johnson's failure to mention them resulted in a mischaracterization of what research has established about the effectiveness of the 12-step approach.

Keith Humphreys, Palo Alto, Calif.

Controversial editorial in Washington Post

2010-08-10T11:37:00.000-05:00

In case you missed it, Bankole Johnson wrote an op-ed for the Washington Post that appeared 2 days ago. Here's a link: http://www.washingtonpost.com/wp-dyn/content/article/2010/08/06/AR2010080602660.html

You may need to register with the Post to see this link, but it's free and they don't hassle you in any way, such as spam or solicitations.

What do you think about his piece? I'm really interested in hearing.

The Need for Medical Treatment for Addiction

2010-08-08T20:21:00.002-05:00

It's been some time since I've blogged. For those of you who are followers or check in on the blog I'm sorry for the lack of activity. The transition to Minnesota has taken a lot of energy, but I have a lot of progress to report.

My practice here in Minnesota has really taken off. Once the other physicians in the hospital and indeed throughout the entire community have become aware of an alternative to another run through rehab the referrals have become consistent. I was just away from the hospital for a week, and I suspect that the hospitalists who take care of most hospitalized patients have missed me. Once they got a taste of getting help with complex pain patients, difficult withdrawal problems, and a physician who was willing to take their referrals for patients with addiction in conjunction with medical and psychiatric disorders, they have gotten very enthusiastic. This is similar to my experience when I first started a clinic for medically ill alcoholics at the Minneapolis VA hospital years ago. The attitude towards alcohol dependent patients admitted with liver disease, pancreatitis, withdrawal, and other problems up to then had been hopeless, nihilistic. What was the use when a consultation resulted in a nurse or counselor suggesting another run through rehab even if the patient had already had that treatment multiple times? But when there was a clinic where these patients could receive ongoing care that incorporated medical, psychiatric and addiction treatment, you could almost feel the change throughout the medical center. Staff became enthusiastic about identifying and referring patients like this to the clinic. It took about 3 years to develop the clinic and figure out how to provide this type of treatment. After that, I received a grant from the the VA to study whether this treatment was effective. In order to do that, we had to assign study participants to either this new clinic or to usual care which consisted of referral to primary care clinic. At that point, it became difficult, because staff were so enthusiastic about this new approach they were reluctant to have patients assigned to usual care. That's the hardest thing about test new treatments; although you might believe strongly in the new treatment you have to be willing to randomized and let the chips fall where they may. It turned out that the new approach was significantly more effective: mortality was reduce by 30% after two years, and more patients were able to achieve abstinence. So I'm finding that the same thing is happening where I currently work at United Hospital in St. Paul. Only it's even better: I'm providing a much broader range of services. One thing that has become apparent: there is a tremendous need for innovation in treating complex chronic pain. Chronic pain and how to appropriately use opioid (narcotic) medication is one of the most difficult and under-appreciated areas in medicine right now.

Vodka Eyeballing: The latest stupid drinking trend

2010-05-25T08:49:00.000-05:00

or, "kids do the darnedest things"...

KTLA News (Los Angeles)
Dangerous 'Vodka Eyeballing' Popular with College Students
Eyeballing can cause damage to the optic nerve, leading to blindness.
9:11 AM PDT, May 20, 2010

LOS ANGELES -- A dangerous drinking fad known as "Vodka eyeballing" is growing in popularity on college campuses in the UK and the United States, and experts say it could leave students blind.

So-called "eyeballers" claim it's an instant high with a splash of alcohol giving them a buzz, literally, in the blink of an eye.

But, doctors say, it's a dangerous trend that could cause permanent vision damage.

Dr. Elise Brisco of the Hollywood Vision Center told KTLA that the practice creates an almost instant buzz "because it's going into the central nervous system into the brain."

The alcohol can damage the optic nerve, creating spotty vision and even complete blindness.

"If it's severe enough and there's a lot of optic nerve damage, your vision may not return," Brisco said.

Some eyeballers have posted videos of themselves online, and there are even "fan" pages for the practice on Facebook.

It's believed the dangerous trend started in the United States, but it is quickly gaining popularity at British universities, according to the UK Daily Mail.

Why do you think they call it DOPamine?

2010-05-19T07:19:00.002-05:00

More on that infamous substance we all seem to be trying to maximize day to day:

U.S. Department of Health and Human Services
National Institutes of Health
NIH News
National Institute on Alcohol Abuse and Alcoholism (NIAAA) http://www.niaaa.nih.gov

EMBARGOED FOR RELEASE: Tuesday, May 18, 2010 @ 9:00 AM EDT
Contact: NIAAA Press Office, 301-443-3860, NIAAAPressOffice@mail.nih.gov<mailto:NIAAAPressOffice@mail.nih.gov>

Receptor Variant Influences Dopamine Response to Alcohol

A genetic variant of a receptor in the brain’s reward circuitry plays an important role in determining whether the neurotransmitter dopamine is released in the brain following alcohol intake, according to a study led by researchers at the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health. Dopamine is involved in transmitting the euphoria and other positive subjective effects produced by alcohol.

A report of the findings, which help explain the diverse genetic susceptibility for alcohol use disorders, will appear online in Molecular Psychiatry on May 18, 2010.

“By advancing our understanding of the neurobiology that underlies the addictive properties of alcohol, this finding helps us understand why alcohol affects people in very different ways,” says NIAAA Acting Director Kenneth R. Warren, Ph.D. “This kind of information also aids the development of personalized medications for alcohol problems.”

Receptors for brain molecules known as opioid peptides help initiate the neurochemical reactions that underlie the positive effects produced by alcohol. Activation of the mu-subtype of opioid receptor following alcohol consumption triggers the release of dopamine from the forebrain.

“But there is much variation in alcohol-induced responses that are thought to be related to dopamine,” explains Markus Heilig, M.D., Ph.D., NIAAA clinical director and the study’s senior author. “Previous studies by our group and others suggest that variants of opioid genes may contribute to the observed variation, possibly through effects on alcohol-induced dopamine release.”

He notes, for example, that people who carry the mu-opioid receptor variant designated as 118G report increased euphoria following alcohol consumption. Dr. Heilig’s group has reported that a similar mu-opioid receptor variant in monkeys heightened the stimulating effects of alcohol and increased their alcohol consumption.

In the current study, first author Vijay A. Ramchandani, Ph.D., an investigator in NIAAA’s Laboratory of Clinical and Translational Studies, Dr. Heilig, and their colleagues explored whether the 118G mu-opioid receptor variant influences dopamine release from a forebrain region called the ventral striatum in response to alcohol.

Using human positron emission tomography (PET), an imaging technique that allowed the researchers to analyze dopamine activity in the brain, they compared dopamine release in two groups of people that had been given a dose of alcohol. The groups consisted of those who carried a copy of the gene for the 118G mu-opioid receptor variant, and those who carried only genes for the more common 118A variant. They found that only people with the 118G variant had a dopamine response to alcohol – no such response happened in subjects with the 118A receptor variant.

In a separate experiment, they inserted genes for the human 118G or 118A mu-opioid receptor variants into mice and then directly measured the animals’ dopamine response to a dose of alcohol. Mice with the 118G variant showed a fourfold higher peak dopamine response to the alcohol challenge compared to mice with the 118A variant.

“Taken together, our data strongly support a causal role of the 118G variant of the mu-opioid receptor to confer a more vigorous dopamine response to alcohol in the ventral striatum,” says Dr. Ramchandani. “The findings add further support to the notion that individuals who possess this receptor variant may experience enhanced pleasurable effects from alcohol that could increase their risk for developing alcohol abuse and dependence. It may also explain why these individuals, once addicted, benefit more from treatment with blockers of endogenous opioids.”

Additional Information

Why Meds Work for Some People, but Not for Others<http://nihrecord.od.nih.gov/newsletters/2010/05_14_2010/story2.htm>
NIH Record, 5/14/2010

Alcohol’s effects on endogenous opioids in the brain<http://www.niaaa.nih.gov/Resources/GraphicsGallery/Neuroscience/31_4_endogenous.htm>

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 www.niaaa.nih.gov<http://www.niaaa.nih.gov>.

The National Institutes of Health (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. It is the primary Federal agency for conducting and supporting basic, clinical, and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit http://www.nih.gov.

More on "process addictions"

2010-05-12T09:17:00.000-05:00

This new study found that the same brain mechanisms that are dysregulated in drug addiction are also dysregulated in binge eating. This is not surprising, of course, since behavior is dysregulated in similar ways in both disorders. That is, the behavior already tells us that the same underlying brain regulatory systems are not working properly, so these studies help confirm what we already suspected. However, these findings are not profound or startling unless one starts with the assumption that behavior can become consistently dysregulated without the corresponding systems in the brain also becoming dysregulated. To put it simply: dysregulated behavior<=>dysregulated brain. In addition, social interactions also have a correlary dysfunction, and there are additional corresonding changes at other levels of analysis, such as gene function, metabolism, and so forth. In other words the system changes at all levels at once. The other thing to keep in mind is that a study such as this does not mean that compulsive behaviors are just and only "brain diseases," since there are correlary changes up and down the system chain of events. It also does not mean the the only appropriate place to intervene is by directly manipulating neurotransmitters, e.g. medication therapy. Although that might be a useful tool, because all of these subsystems are interconnected, it is also possible to change the brain by changing the environment, or to focus on changing behavior and so forth. In addition, the study does not demonstrate that "obese people really cannot help it," or at least it is not news that this is true. We already knew that, with hundreds of studies showing that 95% of weight loss is regained after 5 years. Finally, remember that, as technically impressive as this study is, it is still a short-term study of rodents, and humans are not rodents. Rodent models give us clues, but findings in rodents do not directly translate to humans.

MW

Compulsive Eating Shares Addictive Biochemical Mechanism With Cocaine, Heroin Abuse, Study Shows

ScienceDaily (Mar. 29, 2010) — In a newly published study, scientists from The Scripps Research Institute have shown for the first time that the same molecular mechanisms that drive people into drug addiction are behind the compulsion to overeat, pushing people into obesity.
The new study, conducted by Scripps Research Associate Professor Paul J. Kenny and graduate student Paul M. Johnson, was published March 28, 2010 in an advance online edition of the journal Nature Neuroscience.
The study's startling findings received widespread publicity after a preliminary abstract was presented at a Society for Neuroscience meeting in Chicago last October. Articles heralding the new discovery appeared in news publications around the world, focusing on the point obese patients have been making for years -- that, like addiction to other substances, junk food binging is extremely difficult to stop.
The study goes significantly further than the abstract, however, demonstrating clearly that in rat models the development of obesity coincides with a progressively deteriorating chemical balance in reward brain circuitries. As these pleasure centers in the brain become less and less responsive, rats quickly develop compulsive overeating habits, consuming larger quantities of high-calorie, high-fat foods until they become obese. The very same changes occur in the brains of rats that overconsume cocaine or heroin, and are thought to play an important role in the development of compulsive drug use.
Kenny, a scientist at Scripps Research's Florida campus, said that the study, which took nearly three years to complete, confirms the "addictive" properties of junk food.
"The new study, unlike our preliminary abstract, explains what happens in the brain of these animals when they have easy access to high-calorie, high-fat food," said Kenny. "It presents the most thorough and compelling evidence that drug addiction and obesity are based on the same underlying neurobiological mechanisms. In the study, the animals completely lost control over their eating behavior, the primary hallmark of addiction. They continued to overeat even when they anticipated receiving electric shocks, highlighting just how motivated they were to consume the palatable food."
The scientists fed the rats a diet modeled after the type that contributes to human obesity -- easy-to-obtain high-calorie, high-fat foods like sausage, bacon, and cheesecake. Soon after the experiments began, the animals began to bulk up dramatically.
"They always went for the worst types of food," Kenny said, "and as a result, they took in twice the calories as the control rats. When we removed the junk food and tried to put them on a nutritious diet -- what we called the 'salad bar option' -- they simply refused to eat. The change in their diet preference was so great that they basically starved themselves for two weeks after they were cut off from junk food. It was the animals that showed the "crash" in brain reward circuitries that had the most profound shift in food preference to the palatable, unhealthy diet. These same rats were also those that kept on eating even when they anticipated being shocked."
Lethally Simple
What happens in addiction is lethally simple, Kenny explained. The reward pathways in the brain have been so overstimulated that the system basically turns on itself, adapting to the new reality of addiction, whether its cocaine or cupcakes.
"The body adapts remarkably well to change -- and that's the problem," said Kenny. "When the animal overstimulates its brain pleasure centers with highly palatable food, the systems adapt by decreasing their activity. However, now the animal requires constant stimulation from palatable food to avoid entering a persistent state of negative reward."
After showing that obese rats had clear addiction-like food seeking behaviors, Johnson and Kenny next investigated the underlying molecular mechanisms that may explain these changes. They focused on a particular receptor in the brain known to play an important role in vulnerability to drug addiction and obesity -- the dopamine D2 receptor. The D2 receptor responds to dopamine, a neurotransmitter that is released in the brain by pleasurable experiences like food or sex or drugs like cocaine. In cocaine abuse, for example, the drug alter the flow of dopamine by blocking its retrieval, flooding the brain and overstimulating the receptors, something that eventually leads to physical changes in the way the brain responds to the drug.
The new study shows that the same thing happens in junk food addiction.
"These findings confirm what we and many others have suspected," Kenny said, "that overconsumption of highly pleasurable food triggers addiction-like neuroadaptive responses in brain reward circuitries, driving the development of compulsive eating. Common mechanisms may therefore underlie obesity and drug addiction."
Consistent with common mechanisms explaining addiction and obesity, levels of the D2 dopamine receptors were significantly reduced in the brains of the obese animals, similar to previous reports of what happens in human drug addicts, Kenny noted. Remarkably, when the scientists knocked down the receptor using a specialized virus, the development of addiction-like eating was dramatically accelerated.
"This addiction-like behavior happened almost from the moment we knocked down the dopamine receptors," Kenny noted. "The very next day after we provided access to the palatable food, their brains changed into a state that was consistent with an animal that had been overeating for several weeks. The animals also became compulsive in their eating behaviors almost immediately. These data are, as far as we know, the strongest support for the idea that overeating of palatable food can become habitual in the same manner and through the same mechanisms as consumption of drugs of abuse."
The study was supported by a Bank of America Fellowship, The Margaret Q. Landenberger Research Foundation and the National Institutes of Health.

Parkinson's Medications and Impulsive Behavior

2010-05-11T21:01:00.000-05:00

There have now been several studies documenting an increase in impulse control disorders such as compulsive gambling, sexuality, shopping and other similar behaviors in people taking medications for Parkinson's Disease. These studies demonstrate that the brain, which regulates thinking, feeling and behaving, can become disordered in certain ways. In this case it is from a medication to treat Parkinson's Disease. These medications increase dopamine release, thus they add evidence to the dopamine hypothesis of impulse control disorders, including addiction to drugs. What I find interesting about them is that these were not previous drug or sex addicts or compulsive gamblers. But once their dopamine balance became dysregulated, their behavior became dysregulated. Thus, if our brain is dysregulated in certain ways, it constrains our ability to exercise choice or will. This complicates questions about responsibility, moral blameworthiness, and criminal liability. But what is becoming ever more clear as I work with many patients again is that there is a dysregulation of the ability to control behavior. The ethical and political arenas will simply have to deal with that. Here is a recent study:

Impulse Control Disorders in Parkinson Disease
A Cross-Sectional Study of 3090 Patients
Daniel Weintraub, MD; Juergen Koester, PhD; Marc N. Potenza, MD, PhD; Andrew D. Siderowf, MD, MSCE; Mark Stacy, MD; Valerie Voon, MD;Jacqueline Whetteckey, MD; Glen R. Wunderlich, PhD; Anthony E. Lang, MD, FRCPC
Arch Neurol. 2010;67(5):589-595.
Context  An association between dopamine-replacement therapiesand impulse control disorders (ICDs) in Parkinson disease (PD)has been suggested in preliminary studies.
Objectives  To ascertain point prevalence estimates of4 ICDs in PD and examine their associations with dopamine-replacementtherapies and other clinical characteristics.
Design  Cross-sectional study using an a priori establishedsampling procedure for subject recruitment and raters blindedto PD medication status.
Patients  Three thousand ninety patients with treated idiopathicPD receiving routine clinical care at 46 movement disorder centersin the United States and Canada.
Main Outcome Measures  The Massachusetts Gambling Screenscore for current problem/pathological gambling, the MinnesotaImpulsive Disorders Interview score for compulsive sexual behaviorand buying, and Diagnostic and Statistical Manual of MentalDisorders research criteria for binge-eating disorder.
Results  An ICD was identified in 13.6% of patients (gamblingin 5.0%, compulsive sexual behavior in 3.5%, compulsive buyingin 5.7%, and binge-eating disorder in 4.3%), and 3.9% had 2or more ICDs. Impulse control disorders were more common inpatients treated with a dopamine agonist than in patients nottaking a dopamine agonist (17.1% vs 6.9%; odds ratio [OR], 2.72;95% confidence interval [CI], 2.08-3.54; P < .001).Impulse control disorder frequency was similar for pramipexoleand ropinirole (17.7% vs 15.5%; OR, 1.22; 95% CI, 0.94-1.57;P = .14). Additional variables independently associatedwith ICDs were levodopa use, living in the United States, youngerage, being unmarried, current cigarette smoking, and a familyhistory of gambling problems.
Conclusions  Dopamine agonist treatment in PD is associatedwith 2- to 3.5-fold increased odds of having an ICD. This associationrepresents a drug class relationship across ICDs. The associationof other demographic and clinical variables with ICDs suggestsa complex relationship that requires additional investigationto optimize prevention and treatment strategies.

Useful information about opioid misuse in chronic pain

2010-05-10T19:31:00.000-05:00

With all the concern recently about misuse of prescription opioids in pain patients, this study offers additional information about risk factor evaluation when considering one's approach. The study also adds further to the large body of knowledge concerning different patterns and reasons for using intoxicants between men and women. There's an old adage about this: Men go to the bar, women go to the doctor.

From Medscape Medical News

Risk Factors for Opioid Misuse Among Pain Patients Differ by Sex

Barbara Boughton

Authors and Disclosures

Physician Rating:

( 11 Votes )

Rate This Article:

INFORMATION FROM INDUSTRY

Therapeutic Goals in Major Depressive Disorder (MDD)
In a survey published in JAMA, <22% of respondents received adequate treatment for 12-month MDD. Explore pharmacotherapy for patients in therapy for depression.
Click here

May 4, 2010 — A new study published in the April issue of theJournal of Pain reveals men and women with chronic pain who misuse opioid medications — including taking these medications at a dose frequency unsanctioned by treating physicians — do so for different reasons.

Women with chronic pain are more likely to misuse opioids because of emotional issues and psychological distress, whereas men who do the same are more likely to report social and behavioral problems, such as associating with friends who use drugs or alcohol, having a bad temper, or having legal difficulties.

"We found from our analysis that women tend to misuse pain medications for mood problems — when they are anxious or depressed — while men misuse them for euphoric or behavioral reasons that are less associated with mood," lead researcher Robert Jamison, PhD, associate professor in the Department of Anesthesia and Psychiatry at Brigham and Women's Hospital, Boston, Massachusetts, told Medscape Psychiatry.

"So these may be important markers for clinicians that can help identify patients who might have trouble with opioid misuse — and it's important to provide these patients with interventions that might be helpful. For women, the characteristics to look for are whether they are depressed or anxious, and for men, past history would be a marker," Dr. Jamison added.

Pain Severity Similar Between Sexes

In the study, 662 patients with chronic noncancer pain who take opioid medications were recruited from medical centers in 5 states and surveyed with pain assessment questionnaires to examine rates and characteristics of problematic opioid use.

The investigators also examined predictive associations between risk factors for abuse and misuse by patients of their prescription medications. At baseline, patients completed a series of questionnaires, including the revised Screener and Opioid Assessment for Pain Patients and the Brief Pain Inventory, a multidimensional pain questionnaire.

After 5 months, they underwent a structured prescription drug use interview with a clinician, the Prescription Drug Use Questionnaire (PDUQ), and their clinicians completed the Physician Opioid Therapy Questionnaire (POTQ) — an 11-item scale used to assess misuse of opioids.

Patients were asked to undergo a urine toxicology screen and were classified by the Aberrant Drug Behavior Index (ADBI) concerning their opioid medication abuse based on a combination of self-report in the PDUQ, the physician-reported POTQ, and urine toxicology results. Because some patients had missing data on 2 or more variables, they were excluded from the final analyses — leaving a total of 455 patients or 74.2% of those who began the study.

Results indicated that there was little difference between men and women in the severity of their pain or their rate of opioid misuse — the ADBI indicated prescription opioid misuse in 31% of males and 36.7% of females in the final analysis, a difference that was not statistically significant.

Yet results from both patient self-reports and clinician evaluations indicated that women who misused their opioid medications were more likely to report a history of physical and sexual abuse, psychiatric diagnoses, or a history of psychiatric illness and family concerns. Counting pain pills was also predictive of opioid misuse among women.

High Rate of Misuse

By contrast, men who misused opioids were more likely to have close friends who used alcohol or drugs, to have a bad temper, to have legal problems, and to have a history of drug and/or alcohol abuse.

Other research by Dr. Jamison and colleagues, based on satisfaction questionnaires of chronic pain patients who misuse prescription medications, have suggested that women may benefit most from clinical interventions such as antidepressant and individual and group cognitive or behavioral therapy that addresses the psychological risk factors for misuse. Education about avoiding the use of opioids as a way of dealing with anxiety or sleep disturbances due to stress may also be helpful, he said.

Yet, men may benefit more from monthly urine screens, pill counts, and compliance monitoring to reduce opioid misuse, as well as behavioral consequences of misuse such as more frequent dosing and clinic visits, he added.

Certainly, the study calls attention to the problem of opioid misuse among chronic pain patients. And although only a small percentage of these patients actually develop dependence or addiction, clinicians at the pain management center of Brigham and Women's Hospital have found through urine screens that up to 42% of pain patients misuse their medications, he said.

"These folks have terrible pain as well as clinical history issues that make them very difficult to manage. It really is very challenging to treat these patients, and the idea of the study was to help piece together the puzzle of how to best help them," he said.

"Opioid misuse is a growing concern for chronic pain patients," commented Larissa Mooney, MD, assistant professor of psychiatry at the University of California–Los Angeles. "The vast majority of patients with chronic pain don't develop a problem, but there are vulnerable subgroups," she said.

"This study adds to an emerging literature on gender differences in addiction — how men and women are different in terms of etiology, consequences, and the mechanisms of drug misuse," she said.

Dr. Mooney cautioned that the study's conclusions may not be applicable to all patients with chronic pain. Many of the patients in the study were older (older than 50 years), had long-standing chronic pain, and were often disabled by their pain conditions. "It would be interesting to see if these findings apply to younger patients with less chronic pain history," she said.

She noted that counseling, as well as careful monitoring, for pain patients who misuse prescription opioids or have risk factors for prescription abuse may be helpful for both men and women, she said.

"I don't think that these treatment recommendations are applicable only to men or women," she added.

The study was supported by grants from the National Institute on Drug Abuse and the Arthritis Foundation. Dr. Jamison reported research support from Inflexxion Inc. Dr. Mooney has disclosed no relevant financial relationships.

J Pain. 2010;11:312-320

Study: Viagabatrin not effective for cocaine addiction

2010-05-09T21:21:00.001-05:00

Here is the latest in a long series of studies that have failed to demonstrate a single medication with efficacy in treating cocaine dependence. In some ways this is surprising because cocaine is a single receptor focused drug, so it simplifies the search for medications that have activity at that receptor. Alcohol, on the other hand, is highly complex and affects many areas of the brain at once. It is not receptor focused. Yet, there are proven effective treatments for alcohol dependence.

From Medscape Medical News

Vigabatrin Fails to Achieve Efficacy for Cocaine Dependence in Phase 2 US Trial

Barbara Boughton

Authors and Disclosures

Physician Rating:

( 2 Votes )

Rate This Article:

INFORMATION FROM INDUSTRY

Patients may experience core emotional depression symptom improvement with Cymbalta as early as week 1

April 23, 2010 (San Francisco, California) — A double-blind, placebo-controlled phase 2 clinical trial of the anticonvulsant agent vigabatrin for cocaine dependence in the United States failed to show that the drug was effective for achieving abstinence, according to research presented here at the American Society of Addiction Medicine 41st Annual Medical-Scientific Conference.

The trial's results contradict those of a similar phase 2 Mexican trial, published in the American Journal of Psychiatry in 2009, which showed a significant difference between subjects given vigabatrin vs placebo for cocaine addiction.

Yet researchers who conducted the US trial said the negative results may have been the result of problems with study design, rather than failure of vigabatrin to achieve efficacy in treating cocaine dependence.

"The take-home message from our trial is that it didn't work," said Eugene Somoza, MD, PhD, from the University of Cincinnati College of Medicine and the Veteran's Administration Medical Center in Cincinnati, Ohio. "But it's not that vigabatrin doesn't work — the study didn't work."

High Drop-Out Rate

In the US trial, 186 participants from 11 medical centers were randomly assigned either to 3 g/day vigabatrin daily by mouth in 2 divided doses or to placebo for 12 weeks. All patients received computerized behavioral therapy and counseling once a week, and urine specimens were collected 3 times a week to test for cocaine use.

There was a high drop-out rate — 61 patients dropped out of the study and only 125 completed at least 12 weeks of treatment. Abstinence was defined as not having used cocaine for the last 2 weeks of the study treatment period, validated by self-report and levels of benzoylecgonine in urine samples. Treatment adherence was evaluated through pill counts and self-reports.

The study failed to meet its primary endpoint — a significantly greater rate of drug abstinence in the vigabatrin group. However, the researchers found that patients receiving vigabatrin used consistently less cocaine than placebo during the 12-week treatment phase (P = .006), as measured by benzoylecgonine levels.

In a secondary analysis, the researchers also examined patient compliance with their medication regimens by reviewing urine vigabatrin concentrations in the treatment group. They found that 47.6% of the 61 patients who had completed the study in the vigabatrin group were not compliant with their medication regimens. Compliers were considered to be those with vigabatrin concentration of 630 μg/mL or more, and partial compliers were defined as those with levels of 158 μg/mL or more in urine samples. Secondary analysis indicated that those in the complier vigabatrin group used cocaine for fewer days than those in the noncomplier group (P = .084).

Although concerns have been raised about visual field defects with long-term use of vigabatrin, the researchers did not observe this adverse effect in either the treatment or placebo group. Adverse events included headache, nasopharyngitis, diarrhea, nausea, and back pain.

Lack of Adherence

So why did the US study fail while the Mexican trial showed that vigabatrin was effective for achieving abstinence? "The 2 main reasons are that patients didn't take their medications in the American study, and those in the Mexican study may have been a lot more motivated to abstain from cocaine," Dr. Somoza said in an interview with Medscape Psychiatry.

He noted that in the Mexican study, patients were observed taking their medication for 2 of 7 days. The subjects in the Mexican study were also parolees from prison, and showing up at least once per week at the vigabatrin study treatment center satisfied requirements for parole. In contrast, the American study consisted of patients who had been recruited by academic medical centers through radio and TV ads and who were paid for their participation. Dr. Somoza said.

The 9-week phase 2 Mexican trial of 103 patients randomly assigned to either vigabatrin or placebo used a treatment dosage similar to that administered in the US trial, and cocaine use was also determined with twice-weekly urine toxicology tests. In that trial, 28% of vigabatrin-treated patients vs 7.5% of participants in the placebo group achieved abstinence, defined as 3 weeks without using cocaine.

In an accompanying editorial to the publication of the Mexican trial in the American Journal of Psychiatry in November 2009, Kathleen Brady, MD, PhD, from the Medical University of South Carolina, Charleston, noted that the results were "not tremendously robust." She also cautioned that vigabatrin can cause visual field defects in 30% to 50% of patients who take it for more than 12 months. The question of whether this adverse effect could affect those with cocaine dependence who use the drug for a shorter time remains open, she said.

"We've been looking for a medication for cocaine addiction for 35 years, and to date we have no [US Food and Drug Administration]-approved medications. We haven't found anything that works," commented Timothy Fong, MD, assistant professor of psychiatry and codirector of the addiction medicine clinic at the University of California–Los Angeles.

Whether or not the differences in the Mexican and US trial results could be the result of dissimilarity in the 2 studies' population characteristics is difficult to assess, Dr. Fong noted. "But when we have used advertisements to recruit people for cocaine trials in Los Angeles, we find that their motivations are pretty high to quit — even though it's sometimes difficult to get them to stay and finish the experiment," he said.

New Trial Planned

One problem with studies on cocaine dependence is that cocaine addiction is a complicated disease, and cocaine addicts are not all the same, Dr. Fong said. "The differences between those who use crack vs powder and those who inject vs snorting need to be teased out a little more," he added. "There may be people with cocaine addiction who may respond to vigabatrin, but I don't think we've figured out who that would be yet," he said.

Although Dr. Fong noted that, in his clinical experience, vigabatrin is not that effective for treating cocaine addiction, the investigators working on the US trial plan to continue studying the drug.

A new trial funded by the National Institute on Drug Abuse is planned, Dr. Somoza said. The investigators hope to address some of the problems in the US trial by using more observed doses, by adding a marker substance to vigabatrin and placebo formulations to better assess adherence, and by enrolling patients who might be more motivated to quit cocaine, such as those in substance abuse treatment centers, Dr. Somoza added.

The study was supported by Catalyst Pharmaceutical Partners. Dr. Fong disclosed being on speakers' bureaus for Reckitt-Benckiser, Pfizer Pharmaceuticals, and Lilly Pharmaceuticals. Dr. Somoza has disclosed no relevant financial relationships.

American Society of Addiction Medicine 41st Annual Medical-Scientific Conference: Abstract 4. Presented April 16, 2010.

Is addiction a brain disease?

2010-05-07T09:31:00.002-05:00

A blog reader recently sent me this message:

First, it still seems like the act of drinking, smoking or doing other drugs is behavior and over time this behavior can lead to real health problems. Even by your own analogy, if someone were predisposed to heart disease because their father and grandfather had heart attacks because they smoked, never exercised and were overweight does not mean that you will have a heart attack especially if you exercise, eat properly and don't smoke. So, because someone is predisposed does not mean they are diseased. It would seem reasonable to suggest that addiction is a behavior that taken to the extreme over time can lead to very real organ and organ system impairment. This distinction I think is important because doctors that subscribe to the disease model and who state that addiction is a chronic progressive brain disease which you have clearly pointed out is not necessarily the case, imply this then with addiction is general. The person addicted to the Internet has a brain disease? The person addicted to their relationship has a brain disease? Studies on addiction are mainly about drinking which makes sense because substances do effect the brain. But, if I was a chronic Blackberry user, would I be damaging my brain and need rehab? The answers to these questions would be a great follow up to your response which you stated would require further responses any way.

There is a lot of confusion about the concept of a disease, especially when it comes to behavior. I think the primary problem is that we are not used to thinking of the brain as an organ, and we don't usually associate behavioral disturbances with brain dysfunction. A second problem is that of biological reductionism, where certain classes of phenomena (e.g., genomics, cell function, neurotransmission, etc.) are considered more real or important than other classes, such as thinking, feeling or behaving. We are used to thinking that if we are retaining too much fluid there might be something wrong with our kidneys, or if we have trouble breathing there might be something wrong with our lungs. We have no trouble believing that a brain tumor can produce seizures or paralysis. However, when it comes to more functional disturbances of the brain, our brains can't handle the idea. We think the mind and will are disembodied, existing in the ether out there somewhere, not attached to flesh and blood.

But this isn't true. Our minds, our wills, our thoughts, our feelings and our behavior all involve and depend upon proper function in the physical brain. For example, try thinking, feeling or doing something without a brain. It doesn't get you very far. Does this mean that these things are just biological machinations of this organ inside our heads? No, not at all. Does it mean that we are simply computer-controlled organisms living out our programmed lives? No. Does this mean that existential meaning, relationships, and spiritual striving are merely chimera? No, absolutely not. That's just it: Just because we require a brain for those things (and we do) does not mean that they are simply reducible to brain activity. To conclude so is to fall victim to biological reductionism.

I have been thinking about and studying these things for many years, and this is one of the toughest things I have ever struggled with. Here is my conclusion: one can study a living being at a multitude of levels, from genes to cells to organs to individual organisms to collections of living organisms such as a hive or city. Each level of analysis is valid in its own rite. None are fundamentally more valid than another, and they all influence each other constantly. These are systems of parts where the system is more than the sum of its parts, it is its own thing. A person, for example, or more than a collection of organs. A heart is more than a collection of cells, etc.

So, is addiction a brain disease? Well, addiction is a disorder of behavior so clearly the brain is involved. Are compulsive gambling, sexual activity or shopping brain diseases? They involve disordered behavior, so yes, the brain is involved. Are panic attacks or schizophrenia or depression brain diseases? Again the answer is that the brain is involved, and it must be dysfunctional in some ways for the disordered behavior to occur (by definition.) BUT, are they only and simplistically brain diseases? No they are not. Does brain involvement imply that they are pre-determined, not alterable, and not amenable to social influences, psychotherapy, will and effort or medication? No it does not.

You see, taken to its extreme, all disordered behavior involves the brain. Not only that, but the definition of “disordered behavior” is heavily culturally determined. For example, in Saudi Arabia drinking alcohol at all is “disordered” (except among the royalty), while cannabis or opiate use is much more normative. The opposite holds true for North America. Compulsive sexuality in the US might be considered normal male behavior in many other cultures. Drunkenness is almost a requirement in some Asian business environments whereas it has increasingly become stigmatized in the US. Another prime example is the gradual disapproval and stigmatization of smoking tobacco in the US. What was once a symbol of sophistication has become a symbol of lower class behavior, of “inferior” people who can't quit smoking and put on Lycra for their bike ride or run after eating granola and yogurt for breakfast. Now, the same is happening for obesity.

So the bottom line is that disordered behavior necessarily involves the brain because it cannot otherwise be possible. Ergo, the brain is disordered if behavior is disordered. However, brains can become disordered by hostile environments, extreme stress and many other outside influences. To say that disordered behavior is only the product of an individually “diseased” brain is to blame the victim in many cases. One cannot separate the internal environment, the brain, and the external environment. They are all part of the same organic system. Biological reductionism is therefore inherently politically reactionary: it places the problem squarely in a disordered individual, perhaps genetically inferior, while ignoring larger social influences that have substantial effects on individuals and therefore individual brains. More on this to come.

At Risk Drinking Common Among Older Primary Care Patients

2010-04-30T09:17:00.002-05:00

Journal of General Internal Medicine

Online First

16 April 2010

Prevalence and Correlates of At-Risk Drinking Among Older Adults: The Project SHARE Study

Andrew J. Barnes, Alison A. Moore, Haiyong Xu, Alfonso Ang, Louise Tallen, Michelle Mirkin and Susan L. Ettner

ABSTRACT

BACKGROUND

At-risk drinking, excessive or potentially harmful alcohol use in combination with select comorbidities or medication use, affects about 10% of elderly adults and is associated with higher mortality. Yet, our knowledge is incomplete regarding the prevalence of different categories of at-risk drinking and their associations with patient demographics.

OBJECTIVE

To examine the prevalence and correlates of different categories of at-risk drinking among older adults.

DESIGN

Cross-sectional analysis of survey data.

SUBJECTS

Current drinkers ages 60 and older accessing primary care clinics around Santa Barbara, California (n = 3,308).

MEASUREMENTS

At-risk drinkers were identified using the Comorbidity Alcohol Risk Evaluation Tool (CARET). At-risk alcohol use was categorized as alcohol use in the setting of 1) high-risk comorbidities or 2) high-risk medication use, and 3) excessive alcohol use alone. Adjusted associations of participant characteristics with at-risk drinking in each of the three at-risk categories and with at-risk drinking of any kind were estimated using logistic regression.

RESULTS

Over one-third of our sample (34.7%) was at risk. Among at-risk individuals, 61.9% had alcohol use in the context of high-risk comorbidities, 61.0% had high-risk medication use, and 64.3% had high-risk alcohol behaviors. The adjusted odds of at-risk drinking of any kind were decreased and significant for women (odds ratio, OR = 0.41; 95% confidence interval: 0.35-0.48; p-value < 0.001), adults over age 80 (OR = 0.55; CI: 0.43-0.72; p < 0.001 vs. ages 60-64), Asians (OR = 0.40; CI: 0.20-0.80; p = 0.01 vs. Caucasians) and individuals with higher education levels. Similar associations were observed in all three categories of at-risk drinking.

CONCLUSIONS

High-risk alcohol use was common among older adults in this large sample of primary care patients, and male Caucasians, those ages 60-64, and those with lower levels of education were most likely to have high-risk alcohol use of any type. Our findings could help physicians identify older patients at increased risk for problems from alcohol consumption.

This project was funded by the National Institute of Alcohol Abuse and Alcoholism 1RO1AA013990 (PI: Ettner). Dr. Moore’s time was additionally supported by the National Institute on Alcoholism and Alcohol Abuse 1R01AA15957 (PI: Moore).

Moderate drinking linked to lower diabetes risk

2010-04-28T20:37:00.000-05:00

Moderate drinking linked to lower diabetes risk
By Amy Norton
2010-04-27 (Reuters Health)

NEW YORK (Reuters Health) - Adults who have a drink or two per day may have a lower diabetes risk than teetotalers -- and the link does not appear to be explained by moderate drinkers' generally healthier lifestyle, a new study finds.
A number of studies have found an association between moderate drinking and a relatively lower risk of developing type 2 diabetes. However, whether that reflects a benefit of alcohol has been unclear. A central issue is the fact that, compared with both non-drinkers and heavy drinkers, moderate drinkers tend to have a generally healthier lifestyle.

In the new study, researchers found that among more than 35,000 Dutch adults followed for a decade, those who averaged a drink or two per day were 45 percent less likely than teetotalers to develop type 2 diabetes.

Moreover, the lower risk was seen among men and women whose diabetes risk was already relatively low because of their weight and lifestyle habits -- namely, not smoking, eating a healthy diet and getting regular exercise.

Even among study participants with at least three of those protective factors, moderate drinkers were 44 percent less likely than non-drinkers to develop type 2 diabetes.

The findings, reported in the American Journal of Clinical Nutrition, do not prove that drinking itself lowers diabetes risk. But they do suggest that the alcohol-diabetes connection is not explained away by other lifestyle factors.

"Our results indicate that this is very unlikely, because moderate drinkers with the most healthy lifestyle behaviors...had a lower chance of developing diabetes compared with subjects with these healthy lifestyle behaviors who did not drink," lead researcher Dr. Michel M. Joosten, of Wageningen University in the Netherlands, noted in an email to Reuters Health.

The findings are based on 35,625 adults who were between the ages of 20 and 70 and free of diabetes, heart disease and cancer at the outset. Participants had their weight, height and waist and hip circumference measured and completed questionnaires on their health and lifestyle habits.

Over the next 10 years, 796 developed type 2 diabetes.

In general, moderate drinkers -- up to a drink per day for women, and up to two for men -- were less likely to develop the disease than non-drinkers. And that remained true when Joosten and his colleagues examined the effects of other lifestyle-related factors.

For example, when they looked only at normal-weight men and women, moderate drinkers were 65 percent less likely to develop diabetes than teetotalers. Similarly, among regular exercisers, moderate drinkers had a 35 percent lower risk of diabetes.

The "take-home message," Joosten said, is that moderate drinking "can be part of a healthy lifestyle to lower your risk of type 2 diabetes, even if you already comply with multiple other low-risk lifestyle (behaviors)."

That said, he also noted that experts do not recommend that non-drinkers take up moderate drinking simply because it is related to lower risks of certain diseases. Alcohol always carries the potential for abuse, and the known risks of problem drinking have to be balanced against the possible health benefits of moderate drinking.

SOURCE: American Journal of Clinical Nutrition, online April 21, 2010

Is addiction a disease?

2010-04-15T19:36:00.004-05:00

Recently, a reader wrote to me with the following question:

“You state that alcoholism can be a chronic progressive disease but is not most of the time. So, do you still believe addiction is a disease or that for the 1% of hard core drug addicts and chronic alcoholics who are literally killing themselves, that at this extreme end of the continuum their brains are no longer able to change without abstinence?”

This is a sophisticated question, which means that the answer is complicated. It's clear I will need to address this question in more detail over a series of blogs, but let me at least take a stab at a relatively straightforward answer. In order to do so, I'm going to break this question into smaller bits and answer them in sequence.

“You state that alcoholism can be a chronic progressive disease but is not most of the time.”

Yes, that's true.The NIAAA Epidemiological Study of Alcohol and Related Conditions (NESARC) is a very large (n=43,000) study of a random sample of the US adult population age 18+. So far participants have been interviewed at two different times 3 years apart, and the third wave is underway. One thing that makes this study unique is that it is following the same very large sample over time, something that has never been done before. Deborah Hasin of Columbia University and her colleagues examined the natural history of alcohol dependence (AD), and determined that about three-fourths of people who had an episode of AD in their lifetime had a single episode lasting on average about 3-4 years, and the disorder then went away and did not recur. The remaining quarter had an average of five episodes, each one of decreasing length. So their appears to be two forms of AD, one relatively mild and self-limited and a more chronic or recurrent form.

“So, do you still believe addiction is a disease...?”

Yes, I do, not the simplistic disease model that has been part of the Minnesota Model, but a disease in the same way that asthma, diabetes and depression are diseases. Why do I think this? 1) It is a genetically influenced disorder. About 50-60% of the variation in who gets or does not get AD is due to heritable factors, which is very similar to these other disorders. Not everyone with a family history gets the disorder, and not everyone with the disorder has a family history, but the same is true for heart attacks. 2) Both genetic and environmental factors are usually necessary in order for the disease to develop. Some people can drink a lot for a long time and never lose control of their drinking (impaired control over use is the hallmark of addiction,) but vulnerable individuals are more likely to. 3) There is a broad spectrum of severity, ranging from mild to moderate and severe. 4) Need for and response to treatment is predicted by severity and other patient factors. 5) As a clinician, treating addiction feels the same to me as treating any other disease, I use the same basic approach and skills and the response is similar. So, in short, AD resembles other diseases in many ways.

“... or that for the 1% of hard core drug addicts and chronic alcoholics who are literally killing themselves, that at this extreme end of the continuum their brains are no longer able to change without abstinence?”

NESARC and many other studies have shown that the more severe the dependence, the less likely that anything other than complete abstinence will lead to sustained remission (recovery.) Most of the people who are in treatment programs or AA have the more severe, recurrent, familial form of the illness. Thus, for them, abstinence is by far the best, safest option. For them, any drinking is likely to be very dangerous. However, for the people who have the mild to moderate, self-limiting form, non-abstinent recovery (low-risk drinking without any alcohol related symptoms) eventually occurs in about 40%.

Finally, I'll just briefly comment on the issue of addiction as a “brain disease.” Addiction is a dysregulation of a specific behavior. Where does behavior come from? Is there an organ involved? What organ might that be? Right, behavior is regulated or through the brain. Trying doing, thinking or feeling something without a brain. You won't get very far. So if addiction is characterized by dysregulated behavior, it naturally follows that self-regulatory systems in the brain are out of whack. If you think about it, you'll recognize that we don't need a brain scan to know that. How else could it be? New scientific tools are giving us a more refined view of which systems are involved and in what ways they are dysfunctional. This can be useful in leading us to develop new more powerful tools for aiding recovery, such as medication. With addiction, chronic or frequent exposure to high levels of intoxicants leads the brain to adapt in an attempt to normalize itself (in technical terms homeostasis.) Given enough time these adaptations are not easily reversed, such that if you take away the intoxicant you develop “symptoms” such as acute withdrawal, craving and preoccupation and an exaggerated response to stress. If you take a single dose of the intoxicant, you may lose control and binge even though that was not your intention. This whole topic requires more space than I want to devote here, but I'll just end by noting that this hypothesis does not in any way explain that wide variation in intoxicant use among people. But it is a decent place to start and probably applies pretty well to severe recurrent addiction.

The Brave New World of Genomics

2010-04-01T21:20:00.000-05:00

Here's a fascinating piece published in Nature by Francis Collins, the new NIH Director. Although addictions are not addressed directly (or mental illness), the coming revolution in genomics and individualized medicine has major implications for people who suffer from mental and addictive disorders, as well as their children. Dr. Collins predicts a complete ban on discrimination based upon genetic information, but addiction is one of the most highly stigmatizing diseases, perhaps the single most stigmatizing. At the same time there will be opportunities to identify children at higher risk for these disorders, providing at opportunity for earlier intervention. It's not going to be easy to navigate these waters. Here's Dr. Collin's statement:

Opinion: Has the revolution arrived?

By Francis Collins

Nature.com

March 31, 2010

Looking back over the past decade of human genomics, Francis Collins finds five key lessons for the future of personalized medicine — for technology, policy, partnerships and pharmacogenomics.

On 26 June 2000, Craig Venter and I stood next to the President of the United States, in the same room of the White House where the explorers Meriwether Lewis and William Clark had unfurled their map of the Northwest Territories for Thomas Jefferson. “Today,” Bill Clinton said, “the world is joining us here in the East Room to behold a map of even greater significance. We are here to celebrate the completion of the first survey of the entire human genome ... With this profound new knowledge, humankind is on the verge of gaining immense, new power to heal. Genome science will have a real impact on all our lives — and even more, on the lives of our children. It will revolutionize the diagnosis, prevention, and treatment of most, if not all, human diseases.”

I was honoured to be standing there, but also somewhat embarrassed: the milestone being reported was not yet attached to a publication — there was a lot of analysis still to do, and the paper would not appear in Nature until eight months later. Still, it was a heady moment.

Wisely, the president did not attach timetables to his bold predictions, even though in the early days of the millennium, everyone wanted to hear where this genome revolution was going. I even made my own predictions for 2010. Never having discarded a PowerPoint file, I can reproduce my list verbatim:

Predictive genetic tests will be available for a dozen conditions

Interventions to reduce risk will be available for several of these

Many primary-care providers will begin to practise genetic medicine

Preimplantation genetic diagnosis will be widely available, and its limits will be fiercely debated

A ban on genetic discrimination will be in place in the United States

Access to genetic medicine will remain inequitable, especially in the developing world

It is fair to say that all of these predictions have come true, with some caveats that offer important lessons about the best path forward for genomics and personalized medicine. The promise of a revolution in human health remains quite real. Those who somehow expected dramatic results overnight may be disappointed, but should remember that genomics obeys the First Law of Technology: we invariably overestimate the short-term impacts of new technologies and underestimate their longer-term effects.

Breathtaking acceleration

The decade from 2000 to 2010 was characterized by breathtaking acceleration in genome science. Thanks to advances in DNA sequencing technology that dropped the cost approximately 14,000-fold between 1999 and 2009, finished sequences are now available for 14 mammals, and draft or complete sequences have been done for many other vertebrates, invertebrates, fungi, plants and microorganisms. Comparative genomics has emerged as a powerful approach for understanding evolution and genome function at a level of detail barely imagined a few years ago.

For humans, the HapMap project produced a remarkable catalogue of common variation in the genome in just three years, from 2002 to 2005. As full sequencing has become more practical, researchers have been releasing complete genomes of individuals — a total of 13 at the time of this writing, including my personal hero, Archbishop Desmond Tutu of South Africa. In 2011, an international team is set to complete the data-production phase of the 1000 Genomes Project, designed to produce highly accurate assembled sequences from more than 1,000 individuals whose ancestors came from Europe, Asia and Africa.

The same determination to study the entire genome, not just isolated segments, has now been applied to understanding its function — although this quest is, of course, much more complicated and open-ended. The Encyclopedia of DNA Elements (ENCODE) project (started in pilot form in 2003 and slated to run at least until 2011) and the US National Institutes of Health (NIH) Roadmap Epigenomics Program (started in 2008 and funded until 2013) continue to define the 'parts list' of the human genome. These projects identify the locations of genes (protein coding and non-coding) and the patterns that determine whether genes are switched on or off in a given tissue — patterns of chromatin modification, transcription factors and DNA methylation.

With regard to medical applications, genome-wide association studies (GWAS) have now revealed an astounding number of common DNA variations that play a part in the risk of developing common diseases such as heart disease, diabetes, cancer or autoimmunity. To identify less common variations, methods to target DNA sequencing to subsets of the human genome have been developed. These methods can now sequence 80–90% of the protein-coding regions — the exons or 'exome' — of a human DNA sample for just a few thousand dollars.

Genome research has already had a profound impact on scientific progress. The combination of new technologies and freely accessible databases of high-quality genomic information has enabled the average investigator to make discoveries much more quickly than would otherwise have been possible. For example, the search for the cystic fibrosis gene finally succeeded in 1989 after years of effort by my lab and several others, at an estimated cost of US$50 million. Such a project could now be accomplished in a few days by a good graduate student with access to the Internet, appropriate DNA samples, some inexpensive reagents, a thermal cycler and a DNA sequencer (see graphic).

The consequences for clinical medicine, however, have thus far been modest. Some major advances have indeed been made: powerful new drugs have been developed for some cancers; genetic tests can predict whether people with breast cancer need chemotherapy; the major risk factors for macular degeneration have been identified; and drug response can be predicted accurately for more than a dozen drugs. But it is fair to say that the Human Genome Project has not yet directly affected the health care of most individuals.

GWAS have so far identified only a small fraction of the heritability of common diseases, so the ability to make meaningful predictions is still quite limited, even using chips that test for a million or more common variants. Nonetheless, direct-to-consumer marketing of genetic risk prediction, based on the rapidly growing database of GWAS results, is attracting early adopters. Having gone through that process myself, I can report that I found the opportunity to view my own personal genotype results rather riveting, despite the limited clinical validity and utility of many of these predictions.

This dynamic is likely to change in the next five years. Much of the missing heritability (the 'dark matter' of the genome) will probably turn up as the technology advances. Whole-genome sequencing, coming into its own as the cost per genome falls below $1,000 in the next three to five years, will identify rare variants of larger effect and the copy number variants that GWAS may have missed. With an increasing inventory of these discoveries, prediction of disease risk and drug response will continue to improve.

This profusion of therapeutic opportunites is a challenge to prioritize.

As the cost falls and evidence grows, there will be increasing merit in obtaining complete-genome sequences for each of us, and storing that information, with appropriate privacy protections, in our medical records, where it will be quickly available to guide prevention strategies or medication choice.

Perhaps the most profound consequence of the genome revolution in the long run will be the development of targeted therapeutics based on a detailed molecular understanding of pathogenesis. However, this is also the goal most challenged by long timelines, high failure rates and exorbitant costs. Despite those obstacles, inspiring examples of success are in hand, many of them (trastuzumab, imatinib, gefitinib and erlotinib) for the treatment of cancer. Furthermore, the identification of new cancer drug targets is accelerating rapidly as a consequence of the ability to do deep genome sequencing of many tumours to identify recurrent mutations. Projects such as the Cancer Genome Atlas, which is carrying out the equivalent of 20,000 genome projects on matched tumour and blood DNA samples from 20 common types of cancer, have begun to reveal numerous opportunities for therapeutic development. And GWAS have pointed to hundreds of previously unrecognized drug targets for dozens of other diseases.

This profusion of therapeutic opportunities is a challenge to prioritize. Efforts are now under way to forge innovative partnerships between the traditional strengths of the private sector and academic labs. The NIH has provided new resources to catalyse such partnerships, including access by academic investigators to high-throughput screening through the Molecular Libraries Roadmap project, and to preclinical testing of promising lead compounds through the Therapeutics for Rare and Neglected Disease initiative.

Enabling the future

I propose five major lessons that could be gleaned from this first decade of the genome era. First, free and open access to genome data has had a profoundly positive effect on progress. The radical ethic of immediate data deposit, adopted by the Human Genome Project in 1996 and now the norm for other community resource projects, empowers the best brains on the planet to begin work immediately in analysing the massive amounts of genomic data now being produced. It is a very good thing that the 'race for the genome' in 1998–2000 resulted in the human genome sequence being immediately and freely available to all, rather than becoming a commercial commodity.

Second, technology development for sequencing and functional genomics — key to the success achieved thus far — must continue to be a major focus of investment by both the public and private sectors. Although huge leaps have been made in increasing the speed and reducing the costs of DNA sequencing, expression analysis and methods to assess the epigenome, the limits are still nowhere near being reached.

Third, the success of personalized medicine will depend on continued accurate identification of genetic and environmental risk factors, and the ability to utilize this information in the real world to influence health behaviours and achieve better outcomes. This will require well designed, large-scale research projects, for discovering risk factors and for testing the implementation of prevention and pharmacogenomic programmes.

Fourth, achieving the enormous promise of the myriad new drug targets emerging from genomic analysis of common and rare diseases requires new paradigms of public–private partnership. Academic investigators will have a much more important role in the early stages, effectively 'de-risking' projects for downstream commercial investment. Closer relationships between the US Food and Drug Administration and the NIH, announced this February, will assist this process.

Finally, good policy decisions will be crucial to reaping the benefits that should flow from the coming revelations about the genome. These will include protection of individual privacy, effective education of health-care providers and the public about genomic medicine, and appropriate health-care system reimbursement for the cost of validated preventive measures.

In The Wisdom of the Sands, author Antoine de Saint-Exupéry wrote: “As for the future, your task is not to foresee, but to enable it.” Genomics has had an exceptionally powerful enabling role in biomedical advances over the past decade. Only time will tell how deep and how far that power will take us. I am willing to bet that the best is yet to come.

Francis Collins is director of the National Institutes of Health, Bethesda, Maryland 20892, USA. Between 1993 and 2008 he was director of the National Human Genome Research Institute.

Email: francis.collins@nih.gov

Good news for people with combined depression and alcohol dependence

2010-03-18T12:11:00.002-05:00

Depression combined with alcohol dependence has been a tough combination to treat, with a number of negative trials. However, a new trial of the combination of an antidepressant and naltrexone, a medication for treating alcohol dependence, showed excellent results. PI Helen Pattinati, PhD, is a well-respected and meticulous clinical scientist so one can be assured of proper attention to methodological detail. Also, since both drugs are generic, there is no drug company conflict of interest. (The downside to that is there is also no incentive to market the drug combination to doctors or consumers.)

PsychCentral.com

Treat Alcoholism and Depression Together

By Rick Nauert PhD Senior News Editor

Reviewed by John M. Grohol, Psy.D. on March 18, 2010
A new study discovers a treatment regimen combining cognitive-behavioral therapy and medications for depression and alcohol addiction improves clinical outcomes.

Specifically, combining the antidepressant sertraline (Zoloft) with the alcohol dependence treatment naltrexone produced a 54 percent abstinence rate in patients with both major depression and alcohol dependence, whereas the rates were only 21 to 28 percent for patients taking a placebo, sertraline only, or naltrexone only.

This study shows an important advancement in the treatment of patients who live with both alcoholism and depression because the co-occurrence of these disorders is common in clinical practice, yet antidepressants alone are not sufficient for reducing excessive drinking in these patients.

All 170 patients also received cognitive-behavioral therapy, and the four treatment groups all showed clinical reductions in depressive symptoms over the 14-week study, which was conducted by Helen Pettinati, Ph.D., and colleagues of the University of Pennsylvania.

In addition to a higher abstinence rate, the group receiving combination treatment had a longer interval before resumption of drinking: a median of 61 days compared with 15 days for the other groups combined.

Serious adverse events were actually less frequent in the group receiving both medications, since the most common serious event was hospitalization for detoxification or rehabilitation.

“When depression and alcohol dependence occur together, each condition has a negative influence on the outcome of the other, so not only does this pairing of illnesses affect a lot of patients, it also makes the individual disorders worse,” Dr. Pettinati stated.

“Combining sertraline and naltrexone could be a practical approach for these patients because both have FDA approval.”

The study appears in AJP in Advance , the online advance edition of The American Journal of Psychiatry (AJP), the official journal of the American Psychiatric Association.

Do computerized assessments and interventions work?

2010-03-15T08:53:00.002-05:00

Here's a recent review of internet based assessment and intervention sites:

Journal of Substance Abuse Treatment

Volume 38, Issue 3, April 2010, Pages 203-211

Regular article

A review of computer-based alcohol problem services designed for the general public

Michael L. Vernon Ph.D., a,

a Alcohol Research Group, Emeryville, CA, USA

Abstract

This review summarizes the literature on computer-based drinking assessment and intervention programs evaluated using members of the general public. The primary aim was to summarize the demand, usage, and effectiveness of these services. A systematic search of the literature identified seven online drinking assessments and eight computerized interventions that were evaluated using members of the general public. Internet assessment users tend to be in their early 30s, are more often male, tend to be at risk for or are experiencing alcohol-related problems, more fully explore assessment sites, and are more likely to enroll in interventions linked to these sites when their drinking problem is more severe. Although dropout from computer-based interventions is often very high and treatment models vary widely, program completers appear to show improvements.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T90-4XY3KB6-4&_user=10843&_coverDate=04%2F30%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000000150&_version=1&_urlVersion=0&_userid=10843&md5=a4af488b2a9d2006da9fd4d063ed948c

Another new mechanism for medication treatment of alcohol dependence?

2010-03-12T08:05:00.001-06:00

Here's an intriguing new study that suggests yet another novel mechanism of action for treating alcohol dependence:

Alcoholics' Relapses Better Understood; Brain mechanism could be key, and an existing drug might help, scientists say

HealthDay

March 10, 2010

U.S. scientists say they've learned new details about molecular mechanisms associated with alcohol addiction and relapse. The findings could lead to new treatments for alcoholism.

The University of California, San Francisco researchers gave lab rats free access to alcohol or sugar for nearly two months, followed by a few weeks of abstinence. The rats who had consumed alcohol, but not those that had consumed sugar, showed increased electrical activity in a part of the brain called the nucleus accumbens (NAcb) core, which plays a role in motivation and goal-directed behaviors.

This increased activity in the NAcb core after abstinence resulted from the inhibition of small-conductance calcium-activated potassium channels (SK).

Futher tests showed that drug-induced activation of SK channels resulted in greater inhibition of NAcb activity in the alcohol-abstinent rats and significantly reduced their desire for alcohol. This type of effect did not occur with sugar-abstinent rats.

The results indicate that decreased SK currents and increased activity in the NAcb core play a critical role in alcoholics' relapse after quitting drinking, said the researchers.

The study appears in the March issue of the journal Neuron.

"Our findings are particularly exciting because the FDA-approved drug chlorzoxazone, which has been used for more than 30 years as a muscle relaxant, can activate SK channels," senior author Dr. Antonello Bonci said in a UCSF news release. "Although SK channels are not the only target of this drug and it can present a variety of clinical side effects, it provides an unexpected and very exciting opportunity to design human clinical trials to examine whether chlorzoxazone, or other SK activators, reduce excessive or pathological alcohol drinking."

What do medications add to recovery?

2010-03-08T09:02:00.000-06:00

Do medications provide added value in addiction treatment? And, what is the downside, or potential cost, financially but more importantly on long term outcomes? I think this benefit/burden calculation is central to deciding whether they should be the standard of care or not. Opponents of medications question whether medications lead to “real” recovery, whether they are crutches, and why they are necessary when there is a clear path to recovery through AA. In many people there is an inherent gut response: “Why can’t you (or I) just stop? Isn’t taking a medication to treat a chemical addiction a contradiction in terms? Aren’t you just substituting one addiction for another?”

Let’s take a look at each question. Do medications lead to “real” recovery? It depends on how you define recovery. Most people would say that abstinence or even occasional use without problems would constitute recovery. Members of 12-step programs are more likely to assert that “real” recovery is abstinence plus something else that can only be obtained in 12-step programs: a spiritual transformation, or somewhat differently put, a major shift in values and character. My interpretation of what 12-step programs are aiming for is maturity. That is, the ability to love and be loved, to make a contribution to society, to be a good citizen of the world and to achieve a certain measure of acceptance of the world as it is and our place in it. From a medical standpoint the traditional goal of treatment is the absence of symptoms or signs of a disease, which is called remission (think of cancer.) I think 12-step “recovery” is remission plus maturity. Medical recovery is simply remission. This has implications for how one interprets the results of treatment studies, and also for how the boundaries of medical care are defined. I will write more about outcome measurement in another blog. However, for this discussion, I will adopt the assumption that the goal of professional treatment is remission, and that achieving personal growth and maturity is the responsibility of the patient.

So, if the goal of any treatment is remission, are medications effective? The unequivocal answer is yes. More people taking medications will achieve remission than those who do not. This is not a matter of personal opinion, but of scientific fact and clinical experience. Is every study positive? No. But more are positive than not, so it’s important to look at the totality (and quality) of all the studies. Look, a lot of people can stop smoking without any medication, but many other people require multiple attempts and multiple medications and counseling to quit. It’s no different for alcohol dependence. In the case of opioid (heroin, morphine, Dilaudid, Oxycontin) addiction, medication treatment is the only one showing consistent success. And in that case, long-term maintenance is usually required. So, the bottom line is: medications for treating addictions allow some people a chance at recovery who otherwise would fail at that quit attempt.

So, are these medications crutches, which implies that they are something for weak people and that one shouldn’t need them. Use of the term further implies that using them weakens the natural healing power, so that discontinuation will lead to relapse. Is there any evidence for that? Short answer: no. Unfortunately, most of the studies only provide a few weeks or months of medication treatment, so that they are discontinued at an arbitrary point rather than when it is best for the patient. Over time, after medication discontinuation, the positive medication effect fades so that the difference between medication and placebo groups decreases. However, there is no evidence that relapses suddenly rise after medication discontinuation. In fact, there remains an advantage in remission in the medication group as far out as one year even when treatment only lasted 16 weeks. In addition, at least as many people who are receiving medications also participate in community support groups like AA as those who are not. So there is no evidence that using them constitutes crutches in the negative sense of the term. Are they necessary? Well, for some people, the answer is yes. That is, they are unable to recovery without the aid of medications, at least for a specific quit attempt (most people have multiple quit attempts before one sticks.) Others don’t need them to stop. Are they substituting one addiction for another? The answer is yes, but only if you consider a diabetic addicted to insulin, or someone with high cholesterol addicted to lipid-lowering agents like statins. To me, the most important question is whether they are helpful to people and improve the odds of remission. If the answer to that is yes, and the burden or cost is reasonable, then they ought to be readily available to people. The medication treatment most often cited by medication opponents is long-term maintenance on methadone or buprenorphine (Suboxine, Subutex) for heroin or prescription narcotic addiction. Here the evidence is very stark: among those with established addiction (i.e., more than one year) long-term maintenance on an opioid medication is the only effective treatment. There are now dozens of studies, including high quality randomized controlled trials that have compared enhanced state-of-the-art behavioral treatment alone with medication-assisted treatment, and the answer is unequivocal. In my clinical work with this group of patients, I have concluded that after sufficient time addicted to opioids, the brain is changed in ways that are not reversible. In a way, this group of people suffers from an “opioid deficiency” which can only be treated with opioid supplementation.

Bottom line: Medications result in more people achieving remission (recovery) and in the case of established opioid dependence, they are the only effective treatment. They might be crutches, but when your leg is broken, you may need a crutch for a period of time to allow the bone to heal. Unfortunately, effective medications are only available for smoking cessation, alcohol dependence and opioid dependence. Unfortunately, there are no effective medications available yet for cocaine or methamphetamine or cannabis (marijuana) dependence. But there will be.

More information:

For alcohol dependence: www.niaaa.nih.gov/guide

For opioid dependence: http://csat.samhsa.gov/publications.aspx

Smoking cessation: http://www.smoking-cessation.org/

More debunking of widely held assumptions

2010-03-01T21:27:00.001-06:00

Here's another study that found that drinking did not affect the outcome of bipolar disorder. By the way, I disagree with the assumptions made by the authors that the directionality of the correlation between manic or hypomanic switching was from substance use to switching. To me, it makes more sense that people who are more likely to end up in a manic or hypomanic state are more likely to use alcohol and other substances to help cope with their mania.

MW

Am J Psychiatry.. [Epub ahead of print]

Impact of Substance Use Disorders on Recovery From Episodes of Depression in Bipolar Disorder Patients: Prospective Data From the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

Ostacher MJ, Perlis RH, Nierenberg AA, Calabrese J, Stange JP, Salloum I, Weiss RD, Sachs GS; for STEP-BD Investigators.

Objective Bipolar disorder is highly comorbid with substance use disorders, and this comorbidity may be associated with a more severe course of illness, but the impact of comorbid substance abuse on recovery from major depressive episodes in these patients has not been adequately examined. The authors hypothesized that comorbid drug and alcohol use disorders would be associated with longer time to recovery in patients with bipolar disorder. Method Subjects (N=3,750) with bipolar I or bipolar II disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) were followed prospectively for up to 2 years. Prospectively observed depressive episodes were identified for this analysis. Subjects with a past or current drug or alcohol use disorder were compared with those with no history of drug or alcohol use disorders on time to recovery from depression and time until switch to a manic, hypomanic, or mixed episode. Results During follow up, 2,154 subjects developed a new-onset major depressive episode; of these, 457 subjects switched to a manic, hypomanic, or mixed episode prior to recovery. Past or current substance use disorder did not predict time to recovery from a depressive episode relative to no substance use comorbidity. However, those with current or past substance use disorder were more likely to experience switch from depression directly to a manic, hypomanic, or mixed state. Conclusions Current or past substance use disorders were not associated with longer time to recovery from depression but may contribute to greater risk of switch into manic, mixed, or hypomanic states. The mechanism conferring this increased risk merits further study.

Medications -1

2010-02-27T21:04:00.002-06:00

I've recently received a number of questions about medications used to treat alcohol dependence. The use of medications is a crucial concern. Treating alcohol or other drug dependence represents the transition from lectures and AA to modern, professional treatment. It is a symbolic as well as a concrete advance that can help many people with substance use disorder to recover. So, I'm going to devote several blogs to this topic. It deserves more, but there are so many other important topics that it will have to take it's place.

The primary concerns among consumers are: do drugs work? are there harmful side effects or other downsides? how does taking a medication fit with 12-step programs? isn't taking a medication to stay sober a "crutch?" shouldn't I be able to stay sober without taking a medication?

OK. Let's take them one at a time. Do these drugs work? Yes. Without question, yes. One might debate whether it is "right" or not, but the answer from dozens of studies is this: certain medications (currently naltrexone and topiramate) reduce the number of people having relapses in early recovery by 20-40% and increase the number who embrace ongoing abstinence as their goal. The latter statement might be news to people, because of the way that research study findings are reported. But it's true: these medications increase the number of people who are able to recover. Keep in mind that these are people who otherwise would not recover but instead would relapse and have another failed quit attempt. When looking at results like these, there are essentially two types of people: those who don't care about the results, but are focused on intention, and those who focus on the results, as long as getting there was ethical and where the benefit/burden ratio was positive. As you might expect, I fall into the latter. Pragmatists, as opposed to idealists, who don't care if you fail as long as your motives are pure. Pragmatists are primarily interested in the outcome, whether the method comports with your preconceptions or not. That's me. Results are more important than intentions alone. Just because this point seems to get so easily lost: for some people who are trying to quit, medications make the difference between successful recovery or continued suffering, injury and even death.

The bottom line is that these medications offer people a greater chance at success. Why should they be deprived of the option of using them? Who should make that decision for them? Some people will prefer to not take medications, and others will opt to do so. That is the same way it is for every other disease: take an antidepressant or try therapy, take a medication for high blood pressure or lose weight and exercise more. My point is this: consumers should have the choice, and no matter where they enter the system, they should be informed of all available scientifically supported approaches and empowered to decide for themselves. In other words, whether or not a particular professionals "believes" in a particular approach should be secondary to whether there is evidence in support of it. One of the key principles of being a professional is that one has a fiduciary duty to the client/patient/consumer. That means putting the well-being of the client ahead of one's own needs, be they financial, ideological, religious, ethnic, or otherwise. In this case, it means that full disclosure is an ethical and legal requirement for any licensed professional irrespective of their own beliefs or preferences.

As another way to bring this home, let's assume you notice a lump in your armpit. You go to your neighborhood oncologist, who performs a biopsy and determines your worst fear: you have a lymphoma, a cancer of the lymph glands. However, this particular oncologist has recently been really into the benefits to health of radical dietary changes. So, in spite of the fact that her professional community and the published research support radiation and chemotherapy, the doctor recommends a macrobiotic diet and some nutritional supplements, without informing you of the other options. You like this doctor, and she is very persuasive, so you follow her recommendations. As you lay dying a year later, you learn that the other treatments have a cure rate of 50%, while there is no support for nutritional treatment. And now, it is too late for you. How would you feel? How would your family feel? How long would it take them to consult a lawyer and sue this doctor for malpractice? How is this different from what happens every day in almost every treatment center in the country?

Dr. Willenbring quoted in Reuters article on medications for alcohol dependence

2010-02-25T08:23:00.001-06:00

Here's a nice piece by Reuters that focuses on the potential market for medications for alcohol dependence.

The New York Times Consults Blog

2010-02-24T13:01:00.001-06:00

Here's my answer to a question in the New York Times Consults blog. I'll either comment on the comments there or here soon.

More debunking of easy assumptions

2010-02-24T08:28:00.000-06:00

Here's a recent new item from Reuters Health. This among many similar studies shows how easy it is to assume certain "obvious" truths, when in fact there is little or no evidence for them. Professionals, families and patients often look to drug or alcohol use as a factor to explain things for which their may be no easy explanation, and those assumptions are seldom challenged.

MW

Drinking may not worsen bipolar symptoms

2010-02-18 (Reuters Health)

By Joene Hendry

NEW YORK (Reuters Health) - Among people with bipolar disorder who strictly followed their medication plan, drinking alcohol did not appear to worsen their mood symptoms, hint findings of a small study from the Netherlands.

Bipolar disorder can cause extreme mood swings that require medication to control, and among those with the disease about half abuse alcohol and other drugs, Dr. Jan van Zaane, at University Medical Center Amsterdam, and colleagues note in the Journal of Clinical Psychiatry.

Other studies in patients with bipolar disorder have looked at substance abuse overall rather than just drinking.

To better understand specific effects from alcohol, van Zaane's team examined daily mood symptoms and alcohol intake over one year in 137 community living men and women with bipolar disorder but no other serious physical illness.

The study group was 23 to 68 years old. About half were women and about half lived with a partner and held a job.

The investigators describe 44 as "incidental" or non-drinkers, and 49 as moderate drinkers (21 and 14 or fewer drinks per week for men and women, respectively). The remaining 44 reported drinking more than moderate amounts.

A total of 104 kept diaries for the entire year. About half who stopped said they tired of the daily records and monthly monitoring required for study participation, while others did so due to worsening bipolar disease, alcohol dependence, and other reasons.

Still, all 137 participants kept daily mood diaries for at least two months, providing investigators with 44,808 days of mood data (about 327 days per participant).

The researchers were surprised to find the group of heavy drinkers did not have greater numbers of depressed days, number or severity of mood swings, or any other bipolar disorder symptom than the occasional or moderate drinkers.

More than 90 percent of the current participants reported taking prescribed bipolar disorder medication as directed. This, and the monthly clinical assessments required for participation in this study, likely partially explain the current findings, the researchers note.

However, this study compared groups, not individual patients, who should each monitor, with their doctor, how daily drinking affects bipolar mood symptoms, van Zaane said in an email to Reuters Health.

The investigators also call for confirmation of the current findings in further long-term evaluations of larger groups of patients with bipolar disorder.

SOURCE: Journal of Clinical Psychiatry, published online January 26, 2010.