Americans Spending $100 Billion on Illegal Drugs Annually

The U.S. White House Office of National Drug Control Policy (ONDCP) commissioned the RAND Corporation to investigate how much Americans were spending on the four most common illegal drugs from 2000-2010. The study, published recently on the whitehouse.gov website, uses a variety of sources to develop an estimate in yearly spending by consumers of cannabis, heroin, cocaine (including crack), and methamphetamine. Their conclusion: over $100 billion is spent on just these four drugs, every year. Interestingly, this number has stayed relatively constant throughout the past decade, despite the $25.2 billion that was spent "to reduce drug use and its consequences" in the US in fiscal year 2014 alone (!).

Since 2002, spending on cocaine and marijuana has flipped. Researchers note that cocaine consumption has dropped by about half, while marijuana consumption has increased by around 40%. Heroin consumption has remained stable throughout the decade, with a small increase detected in the later years. Methamphetamine consumption, the authors note, has been harder to track, as "national datasets do not do a good job of capturing its use." Across the board, heavy users are the main drivers of spending and consumption, and are defined as folks who use at least 21 days/month.

The authors culled data from a variety of sources, including the National Survey on Drug Use and Health, the Arrestee Drug Abuse Monitoring Program, various law enforcement and seizure databases, and more. Despite the apparent rigor involved in the creation of these estimates, the authors caution about the inherent uncertainty in this type of data analysis - especially considering that the bulk of the data came from self-report surveys.

Nevertheless, the fact remains that despite the increasing public investments in the so-called War on Drugs, demand-side consumption and expenditures are constant or rising throughout the country. Could this be one reason the Attorney General has agreed to endorse changes to Federal drug sentencing? What do readers think about the current state of availability and expense?

You can read the full report here:

http://www.whitehouse.gov/ondcp/research-and-data/estimation-drug-expenditures-consumption-supply

Illicit Online Retailers Expand In Response to Silk Road Closure

In an editorial published last week in the journal, Addiction, researchers from the University of New South Wales, Australia, sought to quantify the movement of illicit online drug retailers to alternative marketplaces on the so-called "dark web". On October 3, 2013, the FBI shut down the Silk Road, the largest of these marketplaces for illicit substances, and often referred to in mainstream media as the eBay of illegal drugs. Since then, consumers and sellers have simply moved to other sites, which themselves have seen an explosion in the number active retailers since October 3rd.

Two sites in particular have seen dramatic increases: "Black Market Reloaded" has experienced a two-fold increase in active retailers, and "Sheep Marketplace" a five-fold increase. A new version of the Silk Road, "Silk Road 2.0", opened in November and had 92 vendors by their second day of operation.

Here's the graph from the editorial:

Via:
http://onlinelibrary.wiley.com/doi/10.1111/add.12422/full

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.

Cochrane Releases New Reviews on MAT

The highly-respected Cochrane Library, known for its meticulous reviews of the current state of medical knowledge, has updated and released two reviews on medication-assisted treatment recently. The first, "Maintenance agonist treatments for opiate-dependent women", aims to " assess the effectiveness of any maintenance treatment alone or in combination with psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions for child health status, neonatal mortality, retaining pregnant women in treatment and reducing the use of substances." The second, "Pharmacological interventions for drug-using offenders" aims to " assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity and/or drug use." In both cases, the authors note the effectiveness of opioid medications in assisting patients to achieve desired outcomes (although the effect on criminal activity in the second study was significant, but less pronounced). However, they cautioned against generalizing the findings as the body of evidence of both topics is still too small.

Here are the abstracts, via Wiley:

Maintenance agonist treatments for opiate-dependent pregnant women

Abstract

Background

The prevalence of opiate use among pregnant women can range from 1% to 2% to as high as 21%. Heroin crosses the placenta and pregnant, opiate-dependent women experience a six-fold increase in maternal obstetric complications such as low birth weight, toxaemia, third trimester bleeding, malpresentation, puerperal morbidity, fetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal growth deficiency, microcephaly, neuro-behavioural problems, increased neonatal mortality and a 74-fold increase in sudden infant death syndrome.

Objectives

To assess the effectiveness of any maintenance treatment alone or in combination with psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions for child health status, neonatal mortality, retaining pregnant women in treatment and reducing the use of substances.

Search methods

We searched the Cochrane Drugs and Alcohol Group Trials Register (September 2013), PubMed (1966 to September 2013), CINAHL (1982 to September 2013), reference lists of relevant papers, sources of ongoing trials, conference proceedings and national focal points for drug research. We contacted authors of included studies and experts in the field.

Selection criteria

Randomised controlled trials assessing the efficacy of any maintenance pharmacological treatment for opiate-dependent pregnant women.

Data collection and analysis

We used the standard methodological procedures expected by The Cochrane Collaboration.

Main results

We found four trials with 271 pregnant women. Three compared methadone with buprenorphine and one methadone with oral slow-release morphine. Three out of four studies had adequate allocation concealment and were double-blind. The major flaw in the included studies was attrition bias: three out of four had a high drop-out rate (30% to 40%) and this was unbalanced between groups.

Methadone versus buprenorphine: the drop-out rate from treatment was lower in the methadone group (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.41 to 1.01, three studies, 223 participants). There was no statistically significant difference in the use of primary substance between methadone and buprenorphine (RR 1.81, 95% CI 0.70 to 4.69, two studies, 151 participants). For both, we judged the quality of evidence as low. Birth weight was higher in the buprenorphine group in the two trials that could be pooled (mean difference (MD) -365.45 g (95% CI -673.84 to -57.07), two studies, 150 participants). The third study reported that there was no statistically significant difference. For APGAR score neither of the studies which compared methadone with buprenorphine found a significant difference. For both, we judged the quality of evidence as low. Many measures were used in the studies to assess neonatal abstinence syndrome. The number of newborns treated for neonatal abstinence syndrome, which is the most critical outcome, did not differ significantly between groups. We judged the quality of evidence as very low.

Methadone versus slow-release morphine: there was no drop-out in either treatment group. Oral slow-release morphine seemed superior to methadone for abstinence from heroin use during pregnancy (RR 2.40, 95% CI 1.00 to 5.77, one study, 48 participants). We judged the quality of evidence as moderate.

Only one study which compared methadone with buprenorphine reported side effects. For the mother there was no statistically significant difference; for the newborns in the buprenorphine group there were significantly fewer serious side effects.

In the comparison between methadone and slow-release morphine no side effects were reported for the mother, whereas one child in the methadone group had central apnoea and one child in the morphine group had obstructive apnoea.

Authors' conclusions

We did not find sufficient significant differences between methadone and buprenorphine or slow-release morphine to allow us to conclude that one treatment is superior to another for all relevant outcomes. While methadone seems superior in terms of retaining patients in treatment, buprenorphine seems to lead to less severe neonatal abstinence syndrome. Additionally, even though a multi-centre, international trial with 175 pregnant women has recently been completed and its results published and included in this review, the body of evidence is still too small to draw firm conclusions about the equivalence of the treatments compared. There is still a need for randomised controlled trials of adequate sample size comparing different maintenance treatments.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006318.pub3/abstract

 

Pharmacological interventions for drug-using offenders

Abstract

Background

The review represents one in a family of four reviews focusing on a range of different interventions for drug-using offenders. This specific review considers pharmacological interventions aimed at reducing drug use and/or criminal activity for illicit drug-using offenders.

Objectives

To assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity and/or drug use.

Search methods

Fourteen electronic bibliographic databases (searched between 2004 and 21 March 2013) and five additional Web resources (searched between 2004 and 11 November 2011) were searched. Experts in the field were contacted for further information.

Selection criteria

Randomised controlled trials assessing the efficacy of any pharmacological interventions for reducing, eliminating or preventing relapse in drug-using offenders were included. Data on the cost and cost-effectiveness of interventions were reported.

Data collection and analysis

We used standard methodological procedures as expected by The Cochrane Collaboration.

Main results

A total of 76 trials across the four reviews were identified. After a process of prescreening had been completed, 17 trials were judged to meet the inclusion criteria for this specific review (six of the 17 trials are awaiting classification for the review). The remaining 11 trials contained a total of 2,678 participants. Nine of the eleven studies used samples with a majority of men. The interventions (buprenorphine, methadone and naltrexone) were compared to non pharmacological treatments (e.g., counselling) and other pharmacological drugs. The methodological trial quality was poorly described, and most studies were rated as 'unclear' by the reviewers. The biggest threats to risk of bias were generated through blinding (performance and detection bias) and incomplete outcome data (attrition bias). When combined, the results suggest that pharmacological interventions do significantly reduce subsequent drug use using biological measures, (three studies, 300 participants, RR 0.71 (95% CI 0.52 to 0.97)), self report dichotomous data (three studies, 317 participants, RR 0.42, (95% CI 0.22 to 0.81)) and continuous measures (one study, MD -59.66 (95% CI -120.60 to 1.28)) . In the subgroups analysis for community setting, (two studies, 99 participants: RR 0.62 (95% CI 0.35 to 1.09)) and for secure establishment setting, (one study, 201 participants: RR 0.76 (95% CI 0.52 to 1.10)), the results are no longer statistically significant. Criminal activity was significantly reduced favouring the dichotomous measures of re arrest, (one study, 62 participants, RR 0.60 (95% CI 0.32 to 1.14)), re-incarceration, (three studies, 142 participants, RR 0.33 (95% CI 0.19 to 0.56)) and continuous measures (one study, 51 participants, MD -74.21 (95% CI -133.53 to -14.89)). Findings on the effects of individual pharmacological interventions on drug use and criminal activity show mixed results. Buprenorphine in comparison to a non pharmacological treatment seemed to favour buprenorphine but not significantly with self report drug use, (one study, 36 participants, RR 0.58 (95% CI 0.25 to 1.35)). Methadone and cognitive behavioural skills in comparison to standard psychiatric services, did show a significant reduction for self report dichotomous drug use (one study, 253 participants, RR 0.43 (95% CI 0.33 to 0.56)) but not for self report continuous data (one study 51 participants) MD -0.52 (95% CI -1.09 to 0.05)), or re incarceration RR 1.23 (95% CI 0.53 to 2.87)). Naltrexone was favoured significantly over routine parole and probation for re incarceration (two studies 114 participants, RR 0.36 (95% CI 0.19 to 0.69)) but no data was available on drug use. Finally, we compared each pharmacological treatment to another. In each case we compared methadone to: buprenorphine, diamorphine and naltrexone. No significant differences were displayed for either treatment for self report dichotomous drug use (one study, 193 participants RR 1.23 (95% CI 0.86 to 1.76)), continuous measures of drug use MD 0.70 (95% CI -5.33 to 6.73) or criminal activity RR 1.25 (95% CI 0.83 to 1.88)) between methadone and buprenorphine. Similiar results were found for comparisons with Diamorphine with no significant differences between the drugs for self report dichotomous drug use for arrest (one study, 825 participants RR 1.25 (95% CI 1.03-1.51)) or Naltrexone for dichotomous measures of re incarceration (one study, 44 participants, RR 1.10 (95% CI 0.37 to 3.26)), and continuous outcome measure of crime MD -0.50 (95% CI -8.04 to 7.04)) or self report drug use MD 4.60 (95% CI -3.54 to 12.74)).

Authors' conclusions

Pharmacological interventions for drug-using offenders do appear to reduce overall subsequent drug use and criminal activity (but to a lesser extent). No statistically significant differences were displayed by treatment setting. Individual differences are displayed between the three pharmacological interventions (buprenorphine, methadone and naltrexone) when compared to a non pharmacological intervention, but not when compared to each other. Caution should be taken when interpreting these findings, as the conclusions are based on a small number of trials, and generalisation of these study findings should be limited mainly to male adult offenders. Additionally, many studies were rated at high risk of bias because trial information was inadequately described.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010862/abstract

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

We Still Have a Ways to Go

Very excited to feature a post written by Paula DeSanto, Founder and President of Minnesota Alternatives and a leader in the movement to bring paradigm change to chemical dependency and mental health treatment in Minnesota. Thank you, Paula

We Still Have a Ways to Go

Four years ago I was inspired to open a clinic to help people with substance use issues because of the many, many stories I was hearing about ineffective and often times, harmful treatment.

While we are making progress with embracing more person-centered, stage matched interventions; I continue to have experiences that affirm how far we still have to go.  For example:

I was training a large group of clinicians and practitioners about person-centered care, and we were having a very spirited discussion about why drug and alcohol counselors seem compelled to report their clients use to probation officers.  I have worked as a mental health professional for over 2 decades and mental health clinicians don’t share this compulsion.   In fact, I can’t recall any MH worker ever thinking that this was their professional responsibility.

As this discussion progressed, a man raised his hand and offered a useful perspective.  He commented, “I worked as a probation officer for over 8 years, and throughout that time, we always thought of addiction providers as extensions of us.  There was a strong sense of “we – they” and the counselors job entailed trying to catch the clients using.”

Why do drug and alcohol clinicians think their job includes the role of a correctional officer?

No wonder clients “go underground” in treatment and say whatever they think others want to hear.

Another example:

I was interviewing a young woman who smoked a large quantity of cannabis daily and her parents were very concerned about her well-being.  She had been in treatment previously including some very prominent programs.   I asked this young woman why she smoked pot but before she had a chance to answer her mother jumped and stating, “She smokes because she has a brain disease, and her disease is controlling of her life”.

I again asked the young woman why she smokes, and she proceeded to explain that she smokes to relax especially at night before bed. What unfolded was a discussion about other motives for use and exploration as to whether this young woman even thought she had a problem.

A few days later her mother called me and shared this comment:

“My daughter has been in some of the best programs in the state and I have never heard anyone ever ask her why she uses.  She has always been told that she has a brain disease and they have the fix for it.”

“Kudos to you for asking.”

Gender Specific Treatment Reduces Recidivism by 67%

Here's the abstract from a new study that used random assignment in prison (a nearly impossible task in itself) and found that trauma-informed, gender-specific care served female inmates better. Not very surprising but the authors are to be commended for their methodological rigor. Even more impressive, though was a whopping 67% reduction in reincarceration within 12 months after parole. Wow!

Read more about it here.

MW

 A randomized experimental study of gender-responsive substance abuse treatment for women in prison

• Nena Messina, Ph.D.
, 
• Christine E. Grella, Ph.D.
, 
• Jerry Cartier, M.A.
, 
• Stephanie Torres, M.S.

UCLA Integrated Substance Abuse Programs, 1640 S. Sepulveda Blvd., Suite 200, Los Angeles, CA 90025, USA

Received 1 July 2009; received in revised form 26 August 2009; accepted 20 September 2009. published online 16 December 2009.

• Abstract
• Full Text
• PDF
• References

Abstract 

This experimental pilot study compared postrelease outcomes for 115 women who participated in prison-based substance abuse treatment. Women were randomized to a gender-responsive treatment (GRT) program using manualized curricula (Helping Women Recover and Beyond Trauma) or a standard prison-based therapeutic community. Data were collected from the participants at prison program entry and 6 and 12 months after release. Bivariate and multivariate analyses were conducted. Results indicate that both groups improved in psychological well-being; however, GRT participants had greater reductions in drug use, were more likely to remain in residential aftercare longer (2.6 vs. 1.8 months, p < .05), and were less likely to have been reincarcerated within 12 months after parole (31% vs. 45%, respectively; a 67% reduction in odds for the experimental group, p < .05). Findings show the beneficial effects of treatment components oriented toward women's needs and support the integration of GRT in prison programs for women.