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

Gaps in Clinical Prevention and Treatment for Alcohol Use Disorders

Dr W's article, "Gaps in Clinical Prevention and Treatment for Alcohol Use Disorders" was published this month online in the journal Alcohol Research: Current Reviews. Here's the abstract:

Abstract

Heavy drinking causes significant morbidity, premature mortality, and other social and economic burdens on society, prompting numerous prevention and treatment efforts to avoid or ameliorate the prevalence of heavy drinking and its consequences. However, the impact on public health of current selective (i.e., clinical) prevention and treatment strategies is unclear. Screening and brief counseling for at-risk drinkers in ambulatory primary care has the strongest evidence for efficacy, and some evidence indicates this approach is cost-effective and reduces excess morbidity and dysfunction. Widespread implementation of screening and brief counseling of nondependent heavy drinkers outside of the medical context has the potential to have a large public health impact. For people with functional dependence, no appropriate treatment and prevention approaches currently exist, although such strategies might be able to prevent or reduce the morbidity and other harmful consequences associated with the condition before its eventual natural resolution. For people with alcohol use disorders, particularly severe and recurrent dependence, treatment studies have shown improvement in the short term. However, there is no compelling evidence that treatment of alcohol use disorders has resulted in reductions in overall disease burden. More research is needed on ways to address functional alcohol dependence as well as severe and recurrent alcohol dependence.

And check out the full piece here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3908715/

Study: Healthcare Utilization Rates After Treatment Are Equivalent Among Abstinent and Low-Risk Drinkers

A fascinating new study will add to the small, but growing, treatment literature suggesting that low-risk drinking is a viable option for people receiving treatment for alcohol-use disorders. The paper, published this month in Alcoholism: Clinical and Experimental Research, measured healthcare utilization rates and associated costs over a 5-year period among clients receiving treatment in a large Northern California healthcare system. The results show that outcomes for abstainers and lower-risk drinkers were equivalent (and far better than the high-risk drinkers), despite the fact that the abstinence-based treatment received by all groups was the same.

According to the authors, "The finding that lower-risk drinkers did not differ from those of abstinent individuals, in inpatient use in particular, even when controlling for patient characteristics, suggests that a health policy perspective may consider benefits of lower-risk drinking."

Here's the abstract via Wiley:

Background

Lower-risk drinking is increasingly being examined as a treatment outcome for some patients following addiction treatment. However, few studies have examined the relationship between drinking status (lower-risk drinking in particular) and healthcare utilization and cost, which has important policy implications.

Methods

Participants were adults with alcohol dependence and/or abuse diagnoses who received outpatient alcohol and other drug treatment in a private, nonprofit integrated healthcare delivery system and had a follow-up interview 6 months after treatment entry (N = 995). Associations between past 30-day drinking status at 6 months (abstinence, lower-risk drinking defined as nonabstinence and no days of 5+ drinking, and heavy drinking defined as 1 or more days of 5+ drinking) and repeated measures of at least 1 emergency department (ED), inpatient or primary care visit, and their costs over 5 years were examined using mixed-effects models. We modeled an interaction between time and drinking status to examine trends in utilization and costs over time by drinking group.

Results

Heavy drinkers and lower-risk drinkers were not significantly different from the abstainers in their cost or utilization at time 0 (i.e., 6 months postintake). Heavy drinkers had increasing odds of inpatient (p < 0.01) and ED (p < 0.05) utilization over 5 years compared with abstainers. Lower-risk drinkers and abstainers did not significantly differ in their service use in any category over time. No differences were found in changes in primary care use among the 3 groups over time. The cost analyses paralleled the utilization results. Heavy drinkers had increasing ED (p < 0.05) and inpatient (p < 0.001) costs compared with the abstainers; primary care costs did not significantly differ. Lower-risk drinkers did not have significantly different medical costs compared with those who were abstinent over 5 years. However, post hoc analyses found lower-risk drinkers and heavy drinkers to not significantly differ in their ED use or costs over time.

Conclusions

Performance measures for treatment settings that consider treatment outcomes may need to take into account both abstinence and reduction to nonheavy drinking. Future research should examine whether results are replicated in harm reduction treatment, or whether such outcomes are found only in abstinence-based treatment.

Figure 1 shows Adjusted odds ratios of utilization by 6-month drinking group over time:

Figure 2 shows Adjusted average costs per member month by 6-month drinking group over time:

                                               






As mentioned above, these are the results from patients who attended abstinence-based treatment. It will be
interesting to see if these results are replicated among patients who are instructed on low-risk drinking. What experience do readers have with this issue? Do results like these make those directing abstinence-based programs think twice about the policy? It would be great to hear from you.

Hat tip: Thanks, Dr Reid Hester, for bringing this study to our attention.

Source: Kline‐Simon, A. H., Weisner, C. M., Parthasarathy, S., Falk, D. E., Litten, R. Z., & Mertens, J. R. (2013). Five‐Year Healthcare Utilization and Costs Among Lower‐Risk Drinkers Following Alcohol Treatment. Alcoholism: Clinical and Experimental Research.
http://onlinelibrary.wiley.com/doi/10.1111/acer.12273/abstract

New Report Sheds Light on Global Epidemiology of Stimulant-Use Disorders

A brand new study by researchers at the Australia National Health and Medical Research Council estimates the global burden of disease due to cocaine and amphetamine. Based on large systematic reviews of epidemiological data, disease models and global prevalence estimates, the authors present comorbidity-adjusted years of life lost to disability (YDL), years of life lost (YLL) and disability-adjusted life years (DALY) estimates. The authors note that their estimates include only the disease burdens attributable directly to amphetamine- and cocaine-use disorders, leaving out the likely considerable HIV- and HCV-attributable costs and burden.

via ScienceDirect:

Abstract

Aims

To estimate the global prevalence of cocaine and amphetamine dependence and the burden of disease attributable to these disorders.

Methods

An epidemiological model was developed using DisMod-MR, a Bayesian meta-regression tool, using epidemiological data (prevalence, incidence, remission and mortality) sourced from a multi-stage systematic review of data. Age, sex and region-specific prevalence was estimated for and multiplied by comorbidity-adjusted disability weightings to estimate years of life lost to disability (YLDs) from these disorders. Years of life lost (YLL) were estimated from cross-national vital registry data. Disability-adjusted life years DALYs) were estimated by summing YLDs and YLLs in 21 regions, by sex and age, in 1990 and 2010.

Results

In 2010, there were an estimated 24.1 million psychostimulant dependent people: 6.9 million cocaine and 17.2 million amphetamines, equating to a point prevalence of 0.10% (0.09-0.11%) for cocaine, and 0.25% (0.22-0.28%) for amphetamines. There were 37.6 amphetamine dependence DALYs (21.3-59.3) per 100,000 population in 2010 and 15.9 per 100,000 (9.3-25.0) cocaine dependence DALYs. There were clear differences between amphetamines and cocaine in the geographic distribution of crude DALYs. Over half of amphetamine dependence DALYs was in Asian regions (52%), whereas almost half of cocaine dependence DALYs was in the Americas (44%, with 23% in North America High Income).

Conclusion

Dependence upon psychostimulants is a substantial contributor to global disease burden; the contribution of cocaine and amphetamines to this burden varies dramatically by geographic region. There is a need to scale up evidence-based interventions to reduce this burden.

Figure 1 compares the DALYs of amphetamines and cocaine between genders:

Fig. 2 shows the distribution of "crude estimated DALYs" due to either substance:

And Fig. 3 shows "Country-level DALYs per 100,000 population due to amphetamine dependence, age-standardized, for persons in 2010":

Source:
http://www.sciencedirect.com/science/article/pii/S0376871614000234

Study: Looking for the uninsured in Massachusetts? Check opioid dependent persons seeking detoxification

An interesting study from Drug and Alcohol Dependence cites the rate of uninsurance at a large Massachusetts detox program as 23% in the 2013 sample they observed (five years after the insurance mandate). That's nearly five times higher than the state average of 4.8%. The authors highlight correlates of being uninsured (table below), which include being young and being male (expected), but also having a higher level of education (unexpected). Finally, more than half of the uninsured participants in the study had been so for more than one year, highlighting the ongoing need for outreach and education about public programs.

Here is the abstract via ScienceDirect:

Abstract

Background

We examined the rate of uninsurance among persons seeking detoxification at a large drug treatment program in Massachusetts in 2013, five years after insurance mandates.

Methods

We interviewed three hundred and forty opioid dependent persons admitted for inpatient detoxification in Fall River, Massachusetts. Potential predictors of self-reported insurance status included age, gender, ethnicity, employment, homelessness, years of education, current legal status, and self-perceived health status.

Results

Participants mean age was 32 years, 71% were male, and 87% were non-Hispanic Caucasian. Twenty-three percent were uninsured. In the multivariate model, the odds of being uninsured was positively associated with years of education (OR = 1.22, 95%CI 1.03; 1.46, p < .05), higher among males than females (OR = 2.63, 95%CI 1.33; 5.20, p < .01), and inversely associated with age (OR = 0.94, 95%CI 0.90; 0.98, p < .01).

Conclusion

Opioid dependent persons recruited from a detoxification program in Massachusetts are uninsured at rates far above the state average. With the arrival of the Affordable Care Act, drug treatment programs in Massachusetts and nationally will be important sites to target to expand health coverage.

And here's a table from the report:

Correlates of Being Uninsured (n = 340).

Correlate	Unadjusted OR (95%CI)	Adjusted OR (95%CI)
Age	0.95** (0.91; 0.98)	0.94** (0.90; 0.98)
Gender (Male)	1.98* (1.07; 3.69)	2.63** (1.33; 5.20)
Non-Hispanic Caucasian (Yes)	2.48 (0.94; 6.54)	2.30 (0.83; 6.41)
Homeless (Yes)	0.38 (0.11; 1.29)	0.33 (0.09; 1.21)
Employed Part- or Full-Time (Yes)	1.09 (0.49; 2.42)	0.77 (0.32; 1.89)
Education (Years)	1.16* (1.01; 1.33)	1.22* (1.03; 1.46)
Pending criminal charges (Yes)	1.03 (0.58; 1.82)	0.92 (0.51; 1.65)
Perceived Health	0.71* (0.54; 0.93)	0.78 (0.58; 1.05)

* p < .05, **p < .01

http://www.sciencedirect.com/science/article/pii/S0376871613005322

Is Florida Turning a Corner?

According to a brand new study, published online this week in the journal, Pharmacoepidemiology and Drug Safety, Florida's recent legislative actions to 1.) strengthen the state's prescription drug monitoring program, and 2.) toughen the regulation of the state's pain clinics, seem to be having the desired effect: drug diversion has been dropping steadily since 2011. In addition, according to the state's commission of medical examiners, prescription opioid overdose deaths are dropping too. Here's the abstract from the article and a figure of the models of longitudinal change, according to each drug: 

Reductions in prescription opioid diversion following recent legislative interventions in Florida

Surratt, et al., 2013

Purpose
Florida has been at the center of the nation's ongoing prescription opioid epidemic, with largely unregulated pain clinics and lax prescribing oversight cited as significant contributors to the opioid problem in the state.

Methods
In an effort to mitigate prescription opioid abuse and diversion in Florida, legislative interventions were implemented during 2010 and 2011, which included two primary elements: (i) comprehensive legislation to better regulate the operation of pain clinics; and (ii) a statewide prescription drug monitoring program to promote safer prescribing practices. Using systematic longitudinal data collected on a quarterly basis from law enforcement agencies across Florida, this report examined changes in prescription opioid diversion rates following implementation of these regulatory initiatives. Quarterly diversion rates for buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, and tramadol were calculated, and subsequently, hierarchical linear models were fit to test for differences in diversion rates over the 15 quarter period of interest.

Results
Significant declines in diversion rates were observed for oxycodone, methadone, and morphine; hydrocodone displayed a marginally significant decline.

Conclusions
This study documented reductions in statewide opioid diversion rates following implementation of Florida's pain clinic and prescription drug monitoring program legislative interventions. Although these initial findings appear promising, continued surveillance of diversion is clearly warranted. Copyright © 2013 John Wiley & Sons, Ltd.

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?

DSM5 Substance Use Disorders Part 2

Yesterday, I posted about the changes in diagnosis of substance use disorders (SUDs) in DSM5 by addressing a key point about whether addiction is a disease, and what that actually means. This is second post that derives from a conversation that Maia Szalavitz and I have been having on this topic. You can read her post on this topic here.

2. What about DSM5 and the changes from DMS4? This is mostly a technical question relating to cut points. How many substance-related symptoms or criteria does one have to have before calling it a disease, meaning a focus of treatment interventions? As it turns out, there is no clear cut-point. Essentially, the more symptoms one has, the more likely they are to be associated with distress and dysfunction. Earlier in the course of the disorder (and most cases don't progress beyond mild to moderate disorder), most symptoms are "internal" meaning that the individual struggles with control of ingestion, especially once ingestion starts. (Going over self-limposed limits, persistent desire to quit/cut down, continued use despite internal problems such as heartburn, hangover, nausea.) The only "external" one is driving while intoxicated (no DUI). About 3/4 of people meeting DSM4 criteria for alcohol dependence only have these symptoms, and the problem is resolved after about 3-4 years on average and does not recur. 20 years after onset 40% report low risk non problem drinking. Proportions differ by drug of course, especially in the proportion of ever-users who become dependent (highest for smoking, lowest for cannabis/hallucinogens, intermediate for alcohol.) 

We have been studying people in rehab, hospitals and AA for the past 60 years, and then generalizing to people with the disorder in the community who are not in those places. It turns out that people in rehab are those with the most severe, treatment-refractory disease, the most co-morbidity, and the least social support. In terms of the spectrum of severity, the folks in rehab are the equivalent to people with depression or asthma who are hospitalized: a small proportion with the most severe, treatment-refractory illness. The problem is, we've made the mistake of generalizing from that sample to community dwellers, thinking everyone has exactly the same disease. Of course, this is absurd. This mistake has cost us dearly. For example, there are no treatment options for people with milder forms of the disorder, since no one goes to rehab who doesn't have to, usually with significant overt coercion such as a DUI. In SUDs, we are now where depression was 60 years ago. Then the only options you had were the state hospital, where you'd get committed for 6-12 months and get thorazine and ECT, or psychoanalysis which didn't work and was available only to a few. Prozac, in 1988, changed all that. Now, most people with depression go to their family physician and get a prescription for an antidepressant. Obviously this is much less stigmatizing and traumatic that the state hospital. Rehab is essential the state hospital at this point. This is all going to change soon, especially for alcohol. 

Another consequence of the peculiar development of ideas about addiction in the US (because of AA, as you (Maia) have pointed out) is that it is all or none, and inevitably severe and progressive. The new (really old and backward looking) definition of addiction by ASAM is an example of that kind of thinking. In your (Maia's) post, you use the word "alcoholic." This term needs to be retired for several reasons. First, it suggests black/white thinking, although the reality is infinite shades of grey when discussing SUDs. Second, it is strongly associated with images of severe, end-stage drunks (another stigmatizing term.) Third, it has no scientific or clinical meaning and is imprecise, being defined by the writer and readers in whatever way this wish.

But rather than only two or three discreet versions of "problem drinking" (another imprecise term), there are instead infinite shades of grey. Furthermore, severity or even presence of a problem usually waxes and wanes over the years. Again, contrary to popular belief, SUDs are not always progressive. For alcohol use disorder most are not. 

3. What else could the committee have done? There was and is no scientific basis for creating two distinct categories. Well, they could have made the cut point higher, such as 5 criteria rather than 2 for a diagnosis. But then that would simply be enshrining the AA ideology into medical diagnosis: you either have it or you don't, it's always severe or it isn't addiction, it's something else. And there would be no impetus to provide treatment for the much larger group of people who have milder forms of the illness and who desire help. They don't go to rehab because who would? It's an obnoxious often toxic treatment with enormous stigma that is terribly inconvenient and expensive. Other alternatives are needed. I believe that over time, people with come to understand that mild SUD is very common, and often self limited, or at least not chronic. In my opinion this will reduce stigma.

4. Finally, the new criteria at least technically will not increase diagnosis of an SUD, especially when it comes to drinking, since almost all cases of alcohol abuse w/o dependence are due to one criterion: admitting to drinking and driving (no DUI.) All other abuse criteria only occur among people with severe chronic addiction. How this is used in practice will become clear over time. My guess is that there will not be a significant increase in clinicians making diagnoses, although there should be. There should be because mild alcohol dependence is unrecognized and not diagnosed or addressed. So I think the same severely addicted people who are are now clinical diagnosed will continue to be.*

*A new study was published online 1/24/13 that shows very little change in overall prevalence of alcohol use disorder between DSM-IV and DSM5 diagnoses. I'll have more on that article later.

MW

DSM5 Substance Use Disorders 1: Advance or Retreat?

I recently had a (friendly) exchange with Maia Szalavitz on the changes to the diagnosis of substance use disorders in DSM5. She and I disagree as to what is likely to happen, and whether DSM5 is a step forward or backward, although we agree on the eventual goal of reducing stigma and making treatment more accessible in more places and with more choice concerning the type and format of treatment offered. 

Here are some of my thoughts about the changes in diagnosis in DSM5. This is Part 1 from an email reply to Maia. 

1. First, is addiction a disease? Well, of course it is. it's hereditary, has a predictable onset, course, complications and characteristics. It causes people great harm and even death. It is a disorder of brain regulation of ingestive behavior, similar to eating disorders. Two ideas can make this assertion seem less clear. 

The first is that disordered behavior is caused by something other than a disordered brain. Western analytical philosophy and religions have asserted that there is a "mind" or "soul" that is not produced by a brain, but there certainly is no evidence to that effect. Try behaving or thinking or feeling without a brain. What is the function of a brain? Besides regulating basic physiological functions such as heart rate or blood sugar, it also regulates mood, thinking, perception, memory and behavior. Example: there is an optimal range for mood just as there is an optimal range for blood pressure, temperature or blood sugar. Basically the optimal mood is neither too high nor too low. When the brain/body loses the capacity to regulate blood pressure, we have hypertension. With blood sugar we get hyperglycemia (diabetes) or hypoglycemia. And with mood, we get mania or depression. Depression is almost never a natural response to anything that happens, you've got to be genetically vulnerable. Same goes for ingesting intoxicants. With drinking, for example, there is an optimal range ("moderate" or "social" drinking.) When the brain loses the capacity to regulate intake you get addiction. 

The second idea that gets in the way is that we have to pin down the exact pathophysiology before calling something a disease, but there are many/most diseases where we really do not understand them that well. Alzheimer's disease, multiple sclerosis, arthritis, and macular degeneration are all examples. The hang-up is the false distinction between "physical" (e.g. below the neck) and "behavioral or psychological" meaning roughly above the neck. But this is really just a distinction of scale. It seems "physical" if we can somehow see the pathology (including with a microscope, scanner or blood test), but "psychological" (again, meaning non-material) if we cannot. That's why people make the mistake of thinking that being able to detect blood flow changes in the brain means it is "real," but we don't need an fMRI scan to know that something like addiction is real, we already know that from other data.

An additional concern that is often expressed is that calling addition a disease may absolve a person of moral blameworthiness for what they do, such as commit a crime while high. The mistake is thinking that calling something a disease makes it inevitable and out of any control of an individual, and it quickly gets into the question of free will vs determinism. I thought this one through a long time ago and concluded that in practical terms it makes no difference. That is, if in fact everything is predetermined we cannot know that and it simply means that as we deliberate using our "free will" the resultant decision is predetermined. But so what? We still have to go through the process because that's how things work. Even if you try to "opt out" by saying, "Well, I have no control, so I'm not going to do anything" is a decision that itself would have been predetermined, but it is still a "freely made" decision, meaning that the individual can "change her mind" later and "decide" to take a different course. So in my view, a more practical question is: what would be the effect of absolving everyone of responsibility for their actions if they could show their behavior was due to a genetic abnormality or disease? It turns out, for example, that a tendency towards criminality is inherited, and is triggered by serious abuse or neglect in the first few years of life. This event causes changes in gene expression and is irreversible. Should we hold serial murderers responsible because they lack empathy for others, which is not something they had a choice about? Studies of twins reared apart demonstrate that almost all of our personality traits, career paths, preferences, even the way we part our hair is genetically influenced, often to a remarkable degree. Pedophiles don't choose their urges and preferences for small children. Should they be held accountable? I use these examples to point out that on a practical basis, we have to protect ourselves collectively against these destructive behaviors and the people who carrry them out, whether they "have a choice" or "can't help themselves" or not. So, should drunk drivers be prosecuted for their behavior? Should someone who kills a convenience store clerk during a meth binge be held responsible? Should opioid addicts who steal and rob to obtain opioids be held responsible? Obviously, the answer is yes, because otherwise we will end up with a world that looks like Mad Max, or The Congo. 

Overdose Hospitalizations Increase Dramatically Among Young Adults

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

Did Addiction Increase After 9/11?

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

MW

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

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

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

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

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

WHO: Opioid Agonist Therapy Only Effective Treatment for Opioid Addiction

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

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