The Myth of "Cross-Addiction" Debunked

For decades, the conventional wisdom and clinical lore in rehab facilities and recovery communities has warned against the risks of so-called "cross-addiction". "Be careful," they say, "you're at-risk of picking up a new addiction now that you've kicked one habit." Heroin addicts are warned against developing an addiction to alcohol, and cocaine addicts are warned against developing an addiction to opiates, Cross-addiction can even occur to things like exercise or sugar, according to pamphlets and even therapists who have worked in the field for years and years.

But is it even true? Is the notion of cross-addiction supported by empirical evidence - or does it fall on its face under scientific scrutiny?

According to a new report, published September 10 in JAMA Psychiatry, the answer is a resounding, "No."

The study, "Testing the Drug Substitution Switching-Addictions Hypothesis," analyzed data from the National Epidemiological Study on Alcohol and Related Conditions (NESARC) to investigate whether participants developed new-onset substance use disorders (SUD) after remission from a previous SUD. These data were then compared against people with a SUD who did not achieve remission but also developed a new-onset SUD.

The authors discovered that, "As compared with those who do not remit from an SUD, remitters have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution but rather is associated with a lower risk of new SUD onsets."

This is probably the best evidence to-date that addresses the concept of cross-addiction. Will counselors and agencies begin to pull back from this concept - or will clients still be subjected to homework assignments and lectures warning against it?

Here's the abstract from JAMA Psychiatry (found here: http://archpsyc.jamanetwork.com/article.aspx?articleid=1901525):

Importance  Adults who remit from a substance use disorder (SUD) are often thought to be at increased risk for developing another SUD. A greater understanding of the prevalence and risk factors for drug substitution would inform clinical monitoring and management.

Objective  To determine whether remission from an SUD increases the risk of onset of a new SUD after a 3-year follow-up compared with lack of remission from an SUD and whether sociodemographic characteristics and psychiatric disorders, including personality disorders, independently predict a new-onset SUD.

Design, Setting, and Participants  A prospective cohort study where data were drawn from a nationally representative sample of 34 653 adults from the National Epidemiologic Survey on Alcohol and Related Conditions. Participants were interviewed twice, 3 years apart (wave 1, 2001–2002; wave 2, 2004–2005).

Main Outcomes and Measures  We compared new-onset SUDs among individuals with at least 1 current SUD at wave 1 who did not remit from any SUDs at wave 2 (n = 3275) and among individuals with at least 1 current SUD at wave 1 who remitted at wave 2 (n = 2741).

Results  Approximately one-fifth (n = 2741) of the total sample had developed a new-onset SUD at the wave 2 assessment. Individuals who remitted from 1 SUD during this period were significantly less likely than those who did not remit to develop a new SUD (13.1% vs 27.2%, P < .001). Results were robust to sample specification. An exception was that remission from a drug use disorder increased the odds of a new SUD (odds ratio [OR] = 1.46; 95% CI, 1.11-1.92). However, after adjusting for the number of SUDs at baseline, remission from drug use disorders decreased the odds of a new-onset SUD (OR = 0.66; 95% CI, 0.46-0.95) whereas the number of baseline SUDs increased those odds (OR=1.68; 95% CI, 1.43-1.98). Being male, younger in age, never married, having an earlier age at substance use onset, and psychiatric comorbidity significantly increased the odds of a new-onset SUD during the follow-up period.

Conclusions and Relevance  As compared with those who do not remit from an SUD, remitters have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution but rather is associated with a lower risk of new SUD onsets.

A Sad State of Affairs: Psychostimulant Addiction Treatment Leaves Much to be Desired

The authors of a new paper, published ahead of a special issue of Neuropharmacology, give the reader a good look at the current state of psychostimulant substance use disorder treatment - and the results are disappointing. Starting with behavioral treatments and ending with a review of medications, the clear fact remains that there is no single treatment that outperforms most others.

Meta-analyses of behavioral interventions for the treatment of cocaine use disorder have shown modest benefits; while one review found, "there is currently no evidence for a differential treatment effect of any psychosocial treatment in the management of" cocaine or amphetamine use disorders. CBT and Contingency Management (CM) remain the mainstay of psychostimulant treatment, and the authors cite data suggesting a combination of CM plus Community Reinforcement Approach might produce the best outcomes.

In terms of pharmacological treatments, researched medications include antagonist therapy, agonist therapy, medications to treat withdrawal symptoms and medications to treat co-occurring psychiatric symptoms or disorders; and the authors of the present paper devote the bulk of their attention to weighing the evidence of such options.

Naltrexone, they note, has shown some promise in laboratory studies, as it has been shown to weaken amphetamine- and cocaine-related effects in some subjects in both human and animal trials. Because it also seems to weaken the subjective euphoric effects of methylphenidate (Ritalin), one area of promise could be in the combination of naltrexone and methylphenidate to limit the abuse potential of an agonist-like treatment.

Disulfiram (aka Antabuse) has also shown some promise in the lab, but mainly in the treatment of cocaine-use disorders. It was shown to increase the brain ratio of dopamine to norepinephrine and to prevent stress-induced cocaine reinstatement. In pilot studies, disulfiram was shown to be effective in reducing cocaine use in patients with cocaine use disorders (CUD), and among buprenorphine-maintained polydrug users. However, in a more recent study, disulfiram showed less promise reducing cocaine use among methadone-maintained patients. The authors of the review point to evidence that disulfiram may only be effective among CUD patients with specific genotypes - and may be more effective among men than women.

Agonist-like treatments are also reviewed by the authors, and appear to offer some of the more exciting, and possibly effective, interventions for psychostimulant addiction. D-amphetamine has been shown to improve treatment retention and reduce illicit cocaine use in early trials; while a later study showed a reduction in withdrawal and craving, but a failure to reduce methamphetamine use. Not mentioned in the review, but a small study we wrote about in 2012 appeared to show promising results in the combination of mixed amphetamine salts (Adderall) and topiramate (Topamax)

For its part, sustained-release methamphetamine has been tested as a maintenance agent for CUD, and appeared to significantly reduce cocaine-positive urine samples and cocaine craving. The familiar medication, methylphenidate, has been shown to be non-superior to placebo in some studies for meth/amphetamine use and cocaine use, but appears to warrant further research at improved dosages. The other agonist-like medication discussed, modafanil, seems to be an interesting candidate for maintenance treatment. Known to be a cognitive enhancer, modafanil may be useful in addressing the impairments in a range of cognitive functions that can result from psychostimulant addiction; but studies have thus far produced more "equivocal" results in most trials as treatments for cocaine or for methamphetamine - even when combined with D-amphetamine. Post-hoc analysis of the available data does, however, suggest efficacy in the less severe cases of addiction.

Additionally, researchers in Latin America have argued in favor oral coca for the treatment of cocaine use disorder. Their "Handbook on Oral Cocaine as Agonist Therapy for Cocaine Dependence" is an intriguing read, and the authors of the review posit that political, cultural and commercial barriers - not scientific ones - are likely to blame for the "lack of follow-up on this line of research".

A host of other medications have been tried and tested for psychostimulant use disorders, with little success. Vaccines, on the other hand, are now gaining momentum in the field and are being used in multiple studies at various phases. A vaccine that that produces antibodies to prevent cocaine from crossing the blood-brain barrier has performed well in Phase I and Phase II trials. A methamphetamine vaccine is still in preclinical development, but initial results have shown good levels of antibodies in animal models and a Phase I  trial is scheduled to begin in 2015.

Considering the vast global toll which is the result of psychostimulant addiction, treatment for these disorders is as desperately needed as ever. If there is one thing that this review makes clear, it's the fact that we still have a long way to go before we can say that we have effective treatment options for the consumer. A question for readers of this blog: what are the techniques and interventions that you have found to be helpful stimulant use disorders? Is there a particular line of research that you feel would be important to investigate further? Do you see the utility of agonist-like medications? Your thoughts are always appreciated.

Can THC Protect the Brain against Methamphetamine's Toxicity?

A fascinating new study in the journal Neuropharmacology, suggests the brain's endocannabinoid system can be aided in its neuroprotective efforts against the toxicity of methamphetamine by introducing external cannabinoids to increase the system's "endogenous tone". The cannabinoids in question, THC, URB and JZL, appear to inhibit the breakdown of the brain's own endocannabinoids, improving the ability of the brain to protect itself against the "external insult" of overdoses of methamphetamine.

Here is the abstract, via ScienceDirect:

Abstract

Methamphetamine toxicity is associated with cell death and loss of dopamine neuron terminals in the striatum similar to what is found in some neurodegenerative diseases. Conversely, the endocannabinoid system (ECS) has been suggested to be neuroprotective in the brain, and new pharmacological tools have been developed to increase their endogenous tone. In this study, we evaluated whether ECS stimulation could reduce the neurotoxicity of high doses of methamphetamine on the dopamine system. We found that methamphetamine alters the levels of the major endocannabinoids, anandamide (AEA) and 2-arachidonoyl glycerol (2-AG) in the striatum, suggesting that the ECS participates in the brain responses to methamphetamine. Δ⁹-tetrahydrocannabinol (THC), a cannabis-derived agonist of both CB₁ and CB₂cannabinoid receptors, or inhibitors of the main enzymes responsible for the degradation of AEA and 2-AG (URB597 and JZL184, respectively), blunted the decrease in striatal protein levels of tyrosine hydroxylase induced by methamphetamine. In addition, antagonists of CB₂, but not of CB₁, blocked the preventive effects of URB597 and JZL184, suggesting that only the former receptor subtype is engaged in neuroprotection exerted by ECS stimulation. Finally, we found that methamphetamine increases striatal levels of the cytokine tumor necrosis factor alpha, an effect that was blocked by ECS stimulation. Altogether, our results indicate that stimulation of ECS prior to the administration of an overdose of methamphetamine considerably reduces the neurotoxicity of the drug through CB₂ receptor activation and highlight a protective function for the ECS against the toxicity induced by drugs and other external insults to the brain.

And here is a table showing levels of two of the major endocannabinoids, AEA and 2-AG,  following doses of methamphetamine:

And finally striatal levels of the cytokine tumor necrosis factor alpha:

Source:
http://www.sciencedirect.com/science/article/pii/S0028390814001099

Baclofen Shows Promise for Treating Relapse in Cocaine Use Disorders

Via ScienceDaily:

Relapse is the most painful and expensive feature of drug addiction -- even after addicted individuals have been drug-free for months or years, the likelihood of sliding back into the habit remains high. The National Institute on Drug Abuse estimates that 40 to 60 percent of addicted individuals will relapse, and in some studies the rates are as high as 80 percent at six months after treatment. Though some relapse triggers can be consciously avoided, such as people, places and things related to drug use, other subconscious triggers related to the brain's reward system may be impossible to avoid -- they can gain entry to the unconscious brain, setting the stage for relapse.

Researchers at Penn Medicine's Center for Studies of Addiction have now found that the drug baclofen, commonly used to prevent spasms in patients with spinal cord injuries and neurological disorders, can help block the impact of the brain's response to "unconscious" drug triggers well before conscious craving occurs. They suggest that this mechanism has the potential to prevent cocaine relapse. The new findings are reported in the Journal of Neuroscience.

"The study was inspired by patients who had experienced moments of 'volcanic craving', being suddenly overcome by the extreme desire for cocaine, but without a trigger that they could put their finger on," says senior author Anna Rose Childress, PhD,research professor of Psychiatry, director of the Brain-Behavioral Vulnerabilities Division in the Perelman School of Medicine at the University of Pennsylvania. Dr. Childress and colleagues previously found that subliminal drug "reminder cues" (the sights, sounds, smells, and memories of the drug) could activate the brain's reward circuit. "Now, we wanted to understand whether a medication could inhibit these early brain responses," said Childress.

Kimberly Young, PhD, an NIH/NIDA Post-doctoral Fellow at Penn, and first author of the study explained that, "Drug reward and motivation is largely mediated by dopamine transmission in the brain's reward circuit -- even drug "reminder cues" can cause dopamine release. Since baclofen and similar medications reduce these effects in laboratory animals, we wanted to examine whether it could prevent drug-cue induced activation in the human brain."

The study tested baclofen, which was approved by the U.S. Food and Drug Administration in 1977 for spasm, on 23 cocaine-dependent men, ages 18 to 55. Each reported using cocaine on at least eight of 30 days before screening. Inclusion in the study required that they stay for up to 10 days in a supervised inpatient drug treatment facility, be drug-free for the duration, not be on any medication affecting dopamine or neurotransmitter response, and have no history of psychosis, seizures, or brain syndromes unrelated to cocaine use.

Upon admission, patients were randomized to receive baclofen or placebo. Over the first six days, patients in the baclofen group received the medication in increasing dosage to 60 mg. While on the full 60 mg dose of baclofen, patients were placed in an fMRI and shown a series of images, to measure their neural responses to "ultra-brief" pictures of cocaine or other comparison pictures. Each of the ultra-brief 33 msec "target" pictures was immediately followed by longer picture of non-drug objects or scenes. Under these conditions, the participants are aware of the longer pictures, but the ultra-brief target pictures remain completely outside conscious awareness -- they are "backward-masked."

"We wanted to present the key stimulus: images of drug use and preparation, sexual images, and other aversive images in a way such that the brain could not consciously process them, but so that we could measure their earliest, subconscious effect on the brain," said Childress.

What the team found was that the patients who were treated with baclofen showed a significantly lower response in the reward and motivational circuits to subliminal cocaine cues versus neutral cues, as compared to the placebo-treated control group. In addition, no difference was seen in the active versus the control group in their response to sexual and aversive cues, indicating that the effects of baclofen on cue-induced brain activation were specific to drug cues.

"These findings suggest that the brain response to drug cues presented outside of awareness can be pharmacologically inhibited, providing a mechanism for baclofen's potential therapeutic benefit in addiction," says Young. "Further studies will show whether the prevention of these early brain responses is associated with reduced rates of craving and relapse in cocaine-dependent patients," added Childress. 

Source: http://www.sciencedaily.com/releases/2014/04/140401172914.htm

This could be exciting news for one of the most difficult substance use disorders to treat. Does anyone have experience using baclofen with patients with cocaine use disorders?

Researchers Take a Novel Approach to Vivitrol Induction

Researchers and clinicians at Duke University performed a small, open label study to test a new induction protocol for opioid detoxification in an outpatient setting. Much has been written about the pros and cons of antagonist medication for opioid dependence, with most evidence supporting agonist medications like buprenorphine or methadone. One of the most difficult aspects of maintenance antagonist treatment is the detoxification and induction phases of treatment, considering the intolerability of the experience to most patients - especially those in outpatient settings. So, the authors of a new study, published recently in Drug and Alcohol Dependence, sought to make this experience a little more tolerable. The administered increasing doses of naltrexone and decreasing doses of buprenorphine to treatment-seeking opioid addicts until their first dose of extended-release injectable naltrexone (Vivitrol). The results were encouraging:

Abstract

BACKGROUND

The approval of extended release injectable naltrexone (XR-NTX; Vivitrol®) has introduced a new option for treating opioid addiction, but studies are needed to identify its place within the spectrum of available therapies. The absence of physiological opioid dependence is a necessary and challenging first step for starting XR-NTX. Outpatient detoxification gives poor results and inpatient detoxification is either unavailable or too brief for the physiological effects of opioids to resolve. Here we present findings from an open label study that tested whether the transition from opioid addiction to XR-NTX can be safely and effectively performed in an outpatient setting using very low dose naltrexone and buprenorphine.

METHODS

Twenty treatment seeking opioid addicted individuals were given increasing doses of naltrexone starting at 0.25 mg with decreasing doses of buprenorphine starting at 4 mg during a 7-day outpatient XR-NTX induction procedure. Withdrawal discomfort, craving, drug use, and adverse events were assessed daily until the XR-NTX injection, then weekly over the next month.

RESULTS

Fourteen of the 20 participants received XR-NTX and 13 completed weekly assessments. Withdrawal, craving, and opioid or other drug use were significantly lower during induction and after XR-NTX administration compared with baseline, and no serious adverse events were recorded.

CONCLUSIONS

Outpatient transition to XR-NTX combining upward titration of very low dose naltrexone with downward titration of low dose buprenorphine was safe, well tolerated, and completed by most participants. Further studies with larger numbers of subjects are needed to see if this approach is useful for naltrexone induction.

Mean opioid withdrawal and craving scores during induction and after naltrexone extended release administration (Days 1-9), using SOWS (Subjective Opioid Withdrawal Scale), COWS (Clinical Opioid Withdrawal Scale) and VAS (Visual Analog Scale) for craving. Time point scores are the results of the mean score of each day of treatment, error bars represent + -1 SEM. Number of participants is reported on the X-axis.

In-treatment proportion of opioid positive urine samples (Day1-9, N = 20).

Source:

http://www.sciencedirect.com/science/article/pii/S0376871614000568

Do Adverse Childhood Experiences Make Amphetamine More Pleasurable?

In a fascinating new study, researchers from the University of Maryland and Johns Hopkins University observed the way amphetamine affects the brain, comparing subjects who reported adverse childhood experiences (ACE) with those who did not. They found significant differences between groups in the way the drug impacted the dopamine (DA) neurotransmitter in the ventral striatal (VS) region of the brain, finding a significant positive correlation between early childhood trauma and VS DA release.

The results, published online in the journal, Psychopharmacology, suggest that adverse childhood experiences may enhance vulnerability to amphetamine-use disorders later in life by changing the way the brain transmits dopamine. Interestingly, a positive association between childhood trauma and amphetamine-induced pleasure was suggested for men, but vice versa for women.

Here's the abstract via SpringerLink, and an interesting image from the article:

Abstract

Rationale

Childhood exposure to severe or chronic trauma is an important risk factor for the later development of adult mental health problems, such as substance abuse. Even in nonclinical samples of healthy adults, persons with a history of significant childhood adversity seem to experience greater psychological distress than those without this history. Evidence from rodent studies suggests that early life stress may impair dopamine function in ways that increase risks for drug abuse. However, the degree to which these findings translate to other species remains unclear.

Objectives

This study was conducted to examine associations between childhood adversity and dopamine and subjective responses to amphetamine in humans.

Methods

Following intake assessment, 28 healthy male and female adults, aged 18–29 years, underwent two consecutive 90-min positron emission tomography studies with high specific activity [11C]raclopride. The first scan was preceded by intravenous saline; the second by amphetamine (AMPH 0.3 mg/kg).

Results

Consistent with prior literature, findings showed positive associations between childhood trauma and current levels of perceived stress. Moreover, greater number of traumatic events and higher levels of perceived stress were each associated with higher ventral striatal dopamine responses to AMPH. Findings of mediation analyses further showed that a portion of the relationship between childhood trauma and dopamine release may be mediated by perceived stress.

Conclusions

Overall, results are consistent with preclinical findings suggesting that early trauma may lead to enhanced sensitivity to psychostimulants and that this mechanism may underlie increased vulnerability for drug abuse.

http://link.springer.com/article/10.1007%2Fs00213-013-3407-z

Study: Burden of Disease Associated with Alcohol-use Disorders Higher Than Previously Thought

In a paper published online last week in the journal, Alcoholism: Clinical and Experimental Research, a group of international researchers have brought fresh eyes to a familiar data set: the NIAAA's NESARC. Whereas past studies have estimated the alcohol-attributable global burden of disease, or rates of alcohol-attributable deaths and years of life lost, no study has focused specifically on the burden of disease in the United States associated with alcohol-use disorders (AUD). This is important, the authors note, because alcohol-use disorders (including "abuse" and "dependence" from DSM or "the harmful use of alcohol" from ICD) "were identified as the largest disease category contributing to the alcohol-attributable global burden of disease for the year 2004, making up approximately one-third of this burden." By using US-specific data, including population and death statistics as well as Waves 1 and 2 of the NESARC, the authors were able to estimate the burden of disease from AUD in the US in 2005.


Results

"In the United States in 2005, 65,000 deaths, 1,152,000 years of life lost due to premature mortality (YLL), 2,443,000 years of life lost due to disability (YLD), and 3,595,000 disability-adjusted life years (DALYs) lost were associated with AUD. For individuals 18 years of age and older, AUD were associated with 3% of all deaths (5% for men and 1% for women), and 5% of all YLL (7% for men and 2% for women). The majority of the burden of disease associated with AUD stemmed from YLD, which accounted for 68% of DALYs associated with AUD (66% for men and 74% for women). The youngest age group had the largest proportion of DALYs associated with AUD stemming from YLD."

Some figures from the article:

Prevalence of alcohol use disorders by category, sex, and age in 2005. 

And:

Proportion of all deaths associated with alcohol use disorders in 2005, by sex and age


You can read the abstract of the paper by Rehm, et al. here:

http://onlinelibrary.wiley.com/doi/10.1111/acer.12331/abstract

Would love to hear readers reactions to these numbers. 

Study: Sex-Dependent Differences in Subjective Cannabis Effects (Do Women Enjoy Pot More Than Men?)

A new article by researchers at the New York State Psychiatric Institute and Department of Psychiatry at Columbia University explores the differences in the way men and women report their subjective experiences of the effects of cannabis. The authors reviewed data from four separate outpatient studies evaluating a range of cannabis-induced effects. In the final analysis, the subjects (35 men and 35 women) were all daily or near-daily cannabis users and their responses to standardized measures of mood, physical symptoms, and cannabis-related drug effects were recorded over time, beginning immediately after consumption.

It turns out, women were significantly more likely to report more feelings associated with enjoyment (and abuse liability) than men were:

According to the authors: "The results from this study demonstrate that when cannabis smokers are matched for use, ratings of cannabis’ subjective effects that are associated with abuse liability are higher in women compared to men. Although men and women significantly differed in body weight, sex differences were not observed for all subjective effects, including ratings of cannabis intoxication. "

In addition, cannabis use is more prevalent among men than women in the US (51.4% vs 37.4%, resp.). "Yet among cannabis smokers, women have a faster trajectory to cannabis-use disorders, which the current findings might in part explain." The authors call for more research to further explain the clinical significance of sex differences in the effects of cannabis and cannabis-use disorders.

The article by Cooper & Haney can be viewed here:

http://www.drugandalcoholdependence.com/article/S0376-8716%2813%2900529-2/abstract

Study: Hallucinogen Use Predicts Reduced Criminal Justice Recidivism

In a potentially fascinating article, published in this month's Journal of Psychopharmacology, researchers identified a correlation between naturalistic hallucinogen use and reduced recidivism among substance-involved offenders under community corrections supervision. The sample is very large (n=25,622) and it appears the relationship remains after controlling for "an array of potential confounding factors." Given the report last year that lifetime psychedelic use was not associated with current mental health problems in an adult population, this study's implications could be especially interesting.

Unfortunately, my institution doesn't allow me access to this journal - if there are any readers who can access the full article, please let me know.

(Comment after the fact: Keep in mind that this shows a correlation and that correlation does not establish directionality. That it, it's at least equally plausible that people with a diagnosis of psychedelic use disorder (a tiny fraction of the population) are different in ways that statistical controls cannot compensate for, and are therefore less like to reoffend. This makes sense in that psychedelic drug use is minimally addictive, if at all, and craving and urges are not typical in this group. It seems highly implausible to me that hallucinogen use had a beneficial effect. The authors should never have been allowed to make that claim, a fault of the editor. In addition, use of LSD or psilocybin has never been associate with increased incidence of mental disorders, in contrast to MDMA or synthetic cannabinoids.)

Here's the abstract via SagePub:

Abstract

Hallucinogen-based interventions may benefit substance use populations, but contemporary data informing the impact of hallucinogens on addictive behavior are scarce. Given that many individuals in the criminal justice system engage in problematic patterns of substance use, hallucinogen treatments also may benefit criminal justice populations. However, the relationship between hallucinogen use and criminal recidivism is unknown. In this longitudinal study, we examined the relationship between naturalistic hallucinogen use and recidivism among individuals under community corrections supervision with a history of substance involvement (n=25,622). We found that hallucinogen use predicted a reduced likelihood of supervision failure (e.g. noncompliance with legal requirements including alcohol and other drug use) while controlling for an array of potential confounding factors (odds ratio (OR)=0.60 (0.46, 0.79)). Our results suggest that hallucinogens may promote alcohol and other drug abstinence and prosocial behavior in a population with high rates of recidivism.

Sources:
http://jop.sagepub.com/content/28/1/62.abstract
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0063972

Update:
Thanks to Paul and Jason for sending the full piece. 
Treatment Accountability for Safer Communities (TASC)provided the authors access to de-identified records on 25,622 felony-charged individuals on community corrections supervision from  between 2002-2007. "Any hallucinogen use" was not a descriptor in the data, so they were confined to hallucinogen-use disorder, abuse or dependence, assuming that case workers would likely interpret any use as disordered. Interestingly, 73.6% of folks with a hallucinogen-use disorder in the sample were white/Caucasian. And, according to the researchers, hallucinogen-use disorder was the third strongest predictor of recidivism rates, behind cocaine- and cannabis-use disorder, respectively, which most strongly (but positively) predicted recidivism.The authors call for RCTs to explore hallucinogen-based therapies in the criminal justice population.

Wacky Progressives and Scientific Illiteracy

In a disturbing article in the New York Times, Amy Harmon chronicles the tale of a brave county councilman on the island of Kona, Hawaii, who refused to be steamrolled by those who categorically believe that genetically modified organisms (GMOs) are dangerous and should be banned across the board. He actually took the time to look into the scientific research, to consult with scientists who know about this, and he attempted to draw a reasonable conclusion. He is faced, however, with a group of true believers, who keep repeating obscure claims based on long-discredited "research." They shout down their opponents and make outlandish claims that have no scientific basis or rationale. They demonize their opponents, and constantly shift the arguments when faced with scientific facts. Most disturbing of all was the refusal of his fellow council members to even allow scientists to testify, instead giving the floor repeatedly to unqualified zealots who continued to make broad, unsupportable statements. 

It turns out, then, that it's not only climate-change deniers and birthers who maintain passionately held beliefs that have no scientific basis. Worse, it shows how repeating false claims becomes a sort of echo chamber for those with similar beliefs. Finally it shows that such behavior is not limited to Tea Party fanatics or religious zealots, but applies equally to so-called progressives on the left side of the political spectrum. I write about this because it applies as well to too much in the fields of psychotherapy, behavior change and addiction treatment.

We tolerate too much of this type of thinking in our field. How many treatment centers offer "holistic" therapies such as yoga, energy field work, Reiki, or massage, or worse, "nutritional treatment" that is not only unsupported, but may well be harmful? Why are state agencies still allowing such centers to obtain licensure? Why are people paying for brain scans or quantitative EEGs or neurofeedback? And, of course, why do so many people cling to the fiction that 90x90 is effective for most people, or that 12-step approaches are 100% effective if you follow directions? (What treatments for human maladies, short of penicillin for strep throat, can claim 100% effectiveness?)

I'm not arguing that an absence of evidence of effectiveness is evidence of ineffectiveness. There is lots we all do that hasn't been studied well, simply because it is impossible to conduct a large randomized controlled trial on every possible therapy. However, in addiction treatment we have a very large and very strong evidence base from which to draw. It's actually far better than in many other areas of health care. In order to include an approach in a licensed program, at the least, we should require 1) a scientifically plausible rationale for a treatment, 2) that unsupported treatments should not be likely to cause significant harm or cost a significant amount of money, 3) that there is not significant evidence that the approach is not effective, and 4) that there is not a well-supported approach already available.

I'm also not suggesting that yoga, meditation, Reiki, energy field work, reflexology, acupuncture, massage, etc., may not be experienced as beneficial to some people. I recently underwent Rolfing, for example, which I found to be very helpful (if painful). But I didn't expect my health insurance to pay for it, and I reject any large claims concerning what it and similar approaches might accomplish. Such approaches might be made available to clients (at their own expense), but not as presented as a scientifically based health practice.

I have been surprised at how trendy the psychotherapy community is in general, not just in addiction treatment. One current example is the spread of dialectical behavior therapy (DBT) beyond its proven focus on borderline personality disorder. It seems that it's being applied to anyone and for every condition short of psychosis. Another trend is "trauma informed therapy" using eye-movement desensitization and reprocessing therapy (EMDR), DBT, prolonged exposure, or mindfulness. All of a sudden, everyone has "trauma" for which these are appropriate treatments, even though many do not meet criteria for post-traumatic stress disorder (PTSD.) What was psychoanalysis if not focused on trauma? For that matter, "mindfulness" is another trendy approach, with practitioners charging for something the Buddha gave away 2600 years ago and which can be had for free at your local Buddhist meditation center.

At the same time, I seldom encounter high quality cognitive-behavior therapy (CBT) being applied to co-existing anxiety or depressive disorders, in spite of a mountain of evidence supporting their effectiveness. And too many in our field still believe that "I don't believe in it" is an adequate reason to not support anti-relapse medications that also have a strong evidence base. When we have such well-supported therapies, why aren't we using them? Why are we instead embracing half-baked ideas and approaches? Why do we tolerate so much scientific ignorance? Why do we tolerate lack of informed consent, where clients are not given information about what the evidence supports and what it does not, but instead receive biased and incorrect information that deprives them of the opportunity to make an informed decision?

If You Build It, They Will Drink

If there were lingering doubts about the effect of alcohol availability on alcohol consumption, a host of new studies seem to lead the reader to the same conclusion: that increases in availability are correlated to increases in consumption. In other words: if you build it (bar, liquor store, etc), we will drink. What's more, in many cases, it's not just drinking that will happen. So-called alcohol outlet density has been linked to interpersonal and intimate partner violence, adolescent consumption and beliefs about alcohol, and even alcohol-attributable deaths. On the other hand, raising the minimum prices or implementing taxes on alcohol sales seems to go a long way in reducing these potential harms.

The journal, Addiction, has published several of these studies online in the past few weeks. Gruenewald and colleagues analyzed survey data from 50 California cities with populations between 50,000 - 500,000. They found "greater on-premise outlet densities were related to greater drinking frequencies and volumes, and use of on-premise drinking places" (like bars and restaurants).  The researchers concluded that, in addition to characteristics of the individual drinkers (e.g. "impulsivity, risky driving), alcohol availability is correlated with consumption and related problems.

Also in-press at Addiction, Paschall and colleagues analyzed the same sample, but instead focused on adolescent drinking. Some 1478 California youths, aged 13-17, responded to survey questions about past-year alcohol consumption, perceived availability, and questions related to underage enforcement and parental views toward drinking. The answers to these questions were then compared against alcohol outlet (bar) density, public policy, law enforcement activity and city demographics. The authors found that adolescent behaviors and attitudes were significantly affected by their environments. For example, past-year alcohol use was positively correlated to bar density and inversely correlated to "the comprehensiveness and stringency of local alcohol policies". In addition, higher rates of adult drinking were associated with greater increases of past-year adolescent drinking over the three-year study period.

Over in Alcohol and Alcoholism, Grubesic and colleagues studied the association between outlet density in Philadelphia and violent crime. Once again, the researchers found consistent association between the two. Here is a pair of maps, the first showing assault density, the second showing outlet density:

Contrary to the popular belief, no association was found between assault density and "transportation nodes and risky retailers". However, alcohol expenditures and general commercial activity were "positively and significantly" associated with assault density. 

The connection between intimate partner violence (IPV) and alcohol outlet density seems to be well established. In 2012, Conradi and colleagues reported that the density of bars in California was positively associated with IPV-related emergency department visits between 2005-2008. Then, earlier this year, Waller and colleagues found alcohol outlet density to be positively correlated to male-to-female physical - but not sexual - IPV among a national sample. Finally, in March, Zhao and colleagues showed that alcohol outlet density was associated with an increase in alcohol-attributable deaths in British Columbia between 2002-2009. In fact, they calculated that a 10% increase in private liquor stores was associated with a 2.45%, 2.36% and 1.99% increase in acute, chronic and total alcohol-associated (AA) mortality rates.

Interestingly, the single policy that seemed to have the biggest impact in turning these numbers around: raising the minimum price for alcohol. A 10% increase in the minimum price was associated with a 31.72% reduction in "wholly AA deaths". Pretty big numbers. As Dr W observed recently, "raising taxes on alcohol would do more for public health than all the treatment in the world." 

What do you think?

New Findings in Medication-Assisted Treatment

Some interesting new studies are showing promising results for patients all over the world:

Turns out, Quality of Life improvements aren't just for the wealthy:
Quality of Life (QoL) scores significantly improved in ALL four domains (psychological, physical, social and environmental) of the WHO QoL scale in patients in low and middle income countries, according to the authors of a systematic review of 13 studies involving over 1800 participants. The findings, published online last week in the Journal of Drug and Alcohol Dependence, show that despite the apparent lack of resources in these countries, opiate replacement therapy with methadone or buprenorphine can be an effective treatment tool - with scores increasing along with the length of time at followup - and offering outcomes comparable to those seen in high income countries.
You can read the abstract of the study by Feelemeyer, et al., here: http://www.sciencedirect.com/science/article/pii/S0376871613004225

The methadone of methamphetamine?:
In encouraging news for stimulant users, a small study has shown methylphenidate (Ritalin) to both improve symptoms and reduce use episodes, in a cohort of criminal justice-involved stimulant users with co-occurring ADHD. Similar findings have been published supporting mixed-amphetamine salts (Adderall) plus topiramate (Topamax) for the treatment of cocaine dependence, and more recently topiramate by itself. The authors of the small study note the high prevalence of ADHD among stimulant users in the criminal justice population and in their research used dosages that were high enough to be therapeutically effective for patients with a history of substance use disorders (a flaw, they argue, in previous studies of this kind). Could it be that we are getting closer to an accepted agonist maintenance treatment for stimulant use disorders? Read the results of the Swedish study by Konstenius, et al., published online this month in the journal Addiction:
http://onlinelibrary.wiley.com/doi/10.1111/add.12369/abstract

Groups could improve access to AUD medications:
And finally, in a new study in the Journal of Substance Abuse Treatment, researchers have shown that group pharmacotherapy is an effective intervention for patients on medication-assisted treatment of alcohol use disorders. The authors provide a brief description of this novel approach and their experiences implementing the program. They note that, for many clinicians, providing ongoing monitoring of these effective medications can create a barrier to implementation. What the team found however, was that a "medication group" was not only feasible, but it actually increased their patients' access to meds like disulfiram (Antabuse), naltrexone and acamprosate (Campral). Read the abstract from the report by Dr Shannon Robinson and a team at San Diego's VA Health Care System here: http://www.sciencedirect.com/science/article/pii/S0740547213001347

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a randomized clinical trial

This week's entry comes from Dr Reid K Hester, PhD. He is Director of the Research Division at Behavior Therapy Associates, LLC, where they have been conducting some exciting new research using a web-based application, Overcoming Addictions. Thank you, Dr Hester, for the guest post:

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a 

randomized clinical trial

My research staff and I recently published the early outcomes of a new web app, Overcoming Addictions in the Journal of Medical Internet Research (http://www.jmir.org/2013/7/e134). Overcoming Addictions (OA, www.overcomingaddictions.net) is an abstinence-oriented, cognitive behavioral program based on the protocol of SMART Recovery. SMART Recovery (www.smartrecovery.org) is an organization that has adapted empirically supported treatment strategies for use in a mutual help framework with in-person meetings, online meetings, a forum and other resources.

A firm believer of “In God we trust, everyone else has to show their data,” we evaluated the effectiveness of OA and SMART Recovery (SR) with problem drinkers in a randomized clinical trial. We recruited 189 heavy problem drinkers primarily through SMART Recovery’s web site and their online and in-person meetings. We randomly assigned them to: (1) OA alone, (2) OA+ attend SMART Recovery meetings (OA +SR), or to (3) attend SMART Recovery meetings (SR) only. Outcome measures included self-reported percent days abstinent, mean drinks per day when they did drink , and alcohol/drug related consequences. We also interviewed significant others to corroborate the participant’s self-report.

We predicted that: (1) All groups would reduce their drinking and alcohol/drug related consequences at follow-up compared to their baseline levels; (2) the OA groups would reduce their drinking and alcohol/drug related consequences more than the control group (SR).

There were several striking features of our participants. First, 60% of them were female. While this is consistent with the clinical trials of our other web applications like the Drinker’s Check-up (www.drinkerscheckup.com) and Moderate Drinking (www.moderatedrinking.com), it is significantly more than what one would predict given the prevalence of problem drinking in women versus men (35 vs. 65% respectively) in the epidemiological data. Second, this was a highly educated group with an average of 16 years of education. Third, while these folks were not seeking formal treatment, they had a level of alcohol problems comparable to the outpatient arm of Project MATCH.

At the 3 month follow-up both the intent-to-treat analyses and the actual use analyses showed highly significant improvement from baseline to follow-ups.  Mean within-subject effect sizes were large (d > .8) overall. There were, however, no significant differences between groups. Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001) by about 50%. These are clinically meaningful improvements in outcomes.

These outcomes indicate that both our Overcoming Addictions web app and attending SMART Recovery meetings and using their resources online (www.smartrecovery.org) were effective in helping people recover from their problem drinking.

These graphs reflect outcomes of the actual use analyses.

UMN Researchers: Brief Intervention Effective with Adolescent Substance Users

Some promising results out of the University of Minnesota’s Center for Adolescent Substance Abuse Research: brief interventions can help students aged 12-18 dramatically reduce their substance use – in as few as 2 sessions. The team, led by clinical psychologist Ken Winters, PhD, Tamara Fahnhorst, MPH, and Andria Botzet, M Ed., implemented a randomized controlled trial in an urban public school system, delivering one of two treatment conditions, plus a control. The first, student-only condition delivered two one-hour therapy sessions in a two-week period; the second added a session with the parent(s) of the student. The results are impressive: while 37% of the control group reported avoiding cannabis during the last three months at the 6-month follow-up, 63% of the parent-group and over 50% of the student-only group reported the same.

See a complete rundown at Drug and Alcohol Findings or check the Journal of Substance Abuse Treatment for the abstract.