Recovery Month 2014

September 8th, 2014

It’s September, National Recovery Month. It brings out a lot of tweets and blogs by a lot of people in the addiction treatment industry all giving their view of what they bring to Recovery Month. There’s a particular brand of this kind of thing I find really interesting. It probably has to do with the word recovery and confusion over what The Substance Abuse and Mental Health Services Administration (SAMHSA), the people who run Recovery Month, really mean when they say recovery.

See, recovery already had a meaning 25 years ago when SAMHSA started Recovery Month; at least it did to those people in addiction recovery via 12 step programs. For them recovery meant not using and working the steps in a loving community of other recovering people. Since 12 step organizations don’t really have any opinion on outside issues, they just look at recovery month and say, “Cool, back to step work.” But there are a lot of bloggers, tweeters, pinteresters, etc that come out of the 12 step recovery community that want to co-opt recovery month for their very own.

I’ve seen posts about how we should focus, given that this is recovery month, on treating people with addiction without the use of medications so that they can get into “real” recovery. I’ve seen tweets equate recovery with membership in a 12 step organization (#XA). I’ve seen people entering into the politics of repeal of marijuana prohibition saying this is recovery month so let’s not go any further down that road. I’m not real sure many have read the SAMHSA website linked above. If you read it, it’s pretty clear that they’re interested in recovery from mental health and substance use disorders, that they are focusing on prevention and treatment, and that they aren’t in any way saying don’t use medications.

Even though this is a government program, hence the URL, politics aren’t involved. There’s no politicking on the website, no grandstanding against the use of this or that substance. But we’re all going to use Recovery Month for our own purposes. I’ll be honest, I did too. Two years ago Michael Handley and I picked September to publish a book we wrote of stories useful in getting people to accept recovery. Almost every treatment provider I know does something to make Recovery Month their own.

But this year I went to the SAMHSA website and took a look at what it really means. People with any behavioral brain illness can recover, that is, get better. Prevention doesn’t have to be primary prevention that keeps people from getting ill, but can be secondary prevention that keeps people from getting related conditions and tertiary prevention to keep people from getting worse. SAMHSA talks about using any and all tools possible, and mostly, this year they talk about something we all can do whether we treat addiction or not. We can “speak up” and “reach out.”

We can speak up and tell Congress, insurance companies and our neighbors that we think addiction and mental illnesses are biological brain diseases deserving of the care we’d give any physical illness. We can reach out to those currently suffering from these diagnoses and tell them that they are not less than for having them, but that we admire their struggle with these symptoms.

Recovery Month is like a blank canvas and we’ll all want to use it our own way, but at the end of the day, it’s about hope. Hope that we’ll find a better way, hope that we’ll find the political will to pay for the life saving care that is available today, hope that we’ll end the stigma, in short, hope for healing. So let’s remember this September to Speak Up and Reach Out with hope for the day when we don’t need Recovery Month any more.

The Homeless Under the Overpass Problem

September 1st, 2014

I’m from New Orleans, and New Orleans had a big problem. It seems there was a camp of homeless people using the area underneath the Pontchartrain Expressway for shelter. They had tents, and carts everything they needed. It was a tent city. The homeless shelters were complaining because people were donating essentials to these people and the homeless didn’t feel they needed the shelters anymore. The City started wondering if this was going to get dangerous. It was a big problem.

Well it was, but it isn’t anymore. City government, the police, the health department and others all swept in after 72 hours notice and took all those homeless people away. The city’s media expressed a deep sigh of relief. The Great Homeless Under the Overpass Problem was gone.

I don’t know if you’re laughing, crying or just incredulous at this point. But whatever your reaction, you’ll have to admit, this problem was handled in the great American tradition: if the real problem seems too big to handle, just narrow the problem until it’s manageable, define that as THE problem, and fix IT. Problem solved.

That’s what we do with addiction and have done for over 100 years. Addiction is a big messy problem that until a couple of decades ago we really had no idea how it worked or why it was happening. It really was too big to solve. But there were parts that we could see that seemed easier to solve. There was alcohol and marijuana and cocaine and all the rest. Each one popped up as a problem and we solved it, only to see the next problem after that.

It gets discouraging handling problem after problem after problem with no end in sight, but we were caught in a rut and couldn’t find our way out. Tired and angry after years of failures we started to use a defense mechanism that psychiatrists call projection. We projected our problems onto others: it was those damned addicts, it was those damn Columbians, it was those damned Mexicans, etc. And we started solving other people’s problems. We’d put the addicts in jail so they’d learn not to use, we’d go down to Columbia and burn plants; we’d spray poisons on Mexican cannabis.

And in all this time, we’ve never looked at ourselves. That’s the essence of addiction recovery, by the way, taking an honest look at yourself. But since the problem was the behavior of some other people, there was no need for us to look at our behavior. That’s our habit for the last 100 years, and perhaps it served a social purpose at first as there was no real solution to the problem of addiction. But now there is.

It’s well understood, or could be by anyone willing to be less than willfully blind to the data, that addiction is an illness that encompasses more than drugs and alcohol. It is an illness of the brain, not the drug. It most often exists before the person takes the first drink or drug, and it is the illness that causes the abnormal first response that leads to problematic use. Addiction is an illness that is largely genetic, very heterogeneous, and moderately easy to treat if one has the right paradigm. We don’t, on a daily basis in this country, use the right paradigm.

So it’s been 25 years since DiChiara’s first paper showing the unity of all drugs used in addiction. The work has been extended over the years to show that all rewarding behaviors useful to the person with addiction act in the same way. Yet we still talk about the marijuana problem and the cocaine problem, and, lately, the opioid problem. We still create medications for people who use a drug rather than for people with a particular biology regardless of drug used. We still fund large Federal institutions that work to stifle change rather than bring it about. I don’t know how much longer it will go on. But perhaps no one really cares, because, after all, the homeless problem under the overpass was solved.

Why Test Alcoholics for Drugs in Treatment?

August 27th, 2014

If you’ve been reading what I write you probably read the title and said, “Wait a minute. Howard doesn’t think there’s any difference between addicts just because of the drug they use. Why would he ask this question?” And you’d be right. It doesn’t make sense. People with addiction can use anything and often switch; monitoring for this illness should be broad and frequent. In addition, people in treatment are thrown together with others who have experience with drugs they’ve never tried. Unless monitoring is comprehensive, people can start taking something they’ve never taken before that you’ll never think to look for if you limit your monitoring to their usual suspects.

So why would I bring this up? Well, there are two groups of people who have a problem with the policy of comprehensive testing for addicts who have only used alcohol in the past: insurance companies and alcoholics. The insurance companies don’t want to pay to test alcoholics for cocaine, “They’d never use cocaine; they’re alcoholics.” Alcoholics don’t want to be tested for drugs, “What do you think I am, an addict?” Why yes, I do.

Recently an offended alcoholic complained to his insurance company that we wasted their money testing him for drugs he’d never use. They showed us his case and told us it did not meet their medical necessity criteria to test alcoholics for drugs. I don’t know who makes up these rules, but they don’t seem to have any data.

Well, you know me. I went for the data.

In our EHR we have 340 patients from this insurance company. 117 or 34.4% have a primary alcohol dependence diagnosis and the other 223 (65.6%) have a primary dependence dx with another drug. We also have the results of all the Medical Monitoring for Adherence tests we’ve done. Here’s what we’ve learned.

It is indeed more common for a person with a non-alcohol primary drug than alcohol as a primary drug to have at least one positive for a non-alcohol drug. 136 or 61% of the non-alcoholics had at least one positive for a drug other than alcohol. Of the 117 “alcoholics” 41 or 35% had at least one positive for a drug other than alcohol. So it’s a little more than half as common as with those “drug addicts.” More than one in three “alcoholics” had confirmed positives indicating new use of some drug other than alcohol at some point in treatment.

We also looked at it the other way; who drank during treatment. Of the 117 “alcoholics,” 46 (39.3%) were positive for alcohol at some point while “only” 22.4% of the “non-alcoholics” were positive for alcohol at some point during treatment. Maybe we should stop testing “drug addicts” for alcohol; they might get insulted.

So 35% of the primary alcohol dependent patients used a non-alcohol drug at some point and 39% used alcohol at some point. I feel an odds ratio coming on. (39/35 = 1.11) So it’s 1.11 times more likely that a primary alcohol patient will be positive for alcohol than positive for another drug. That’s a pretty wimpy odds ratio; not the kind of thing I’d drop important monitoring for. I think if I was 11% less likely to get malaria if I went to the tropics I’d still take the prophylactic medicine.

What’s key to understand here is that addiction is deadly, just like malaria, diabetes, and heart disease. We don’t do drug screens on substance abusers. We are treating ill people for the biological illness of addiction and we are using medical testing to monitor their progress in treatment. So who would want to save 10% even if it meant some cases weren’t found and treated correctly? I don’t know, but I bet they don’t believe addiction is an illness.

Now Here’s a Crazy Idea

August 23rd, 2014

“It might sound crazy what I’m ’bout to say…”
– “Happy” by Pharrell Williams

I’m a big fan of always questioning the received wisdom. For instance, while it’s true that heavy early use of drugs and alcohol is correlated with later diagnoses of “substance abuse,” it does not necessarily follow that it was the early use that caused the later abuse. It could have been the primary symptoms of addiction that caused both the early use and the later attachment seen to the drug that relieved the symptoms.

Another example is the growing prison population in America. I’ve heard lot’s of reasons for it and many of them seem to have face validity: the war on drugs, more effective prosecutorial tools to force pleas, increased mandatory sentences, etc. I came across another correlation that is interesting. Remember, I’m about to tell you about a correlation, not a causation. The two things seem to go together, but that doesn’t mean that one causes the other. But maybe we can figure out a test to see if one does.

Here’s the correlation. The green line is prison population per capita, that is, the prison population divided by the number of people in the country. You could also consider it the percent of Americans in prison or jail. The orange line is the pounds of high fructose corn syrup (HFCS) consumed per person in the US. Notice that the prison population is fairly stable to declining until right after the invention of HFCS and its first report here in 1966. Also notice that shortly after the consumption of HFCS starts to decline there begins a slight decline in the prison population.

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For those of you who are statistically inclined. The variance in prison population explained by the amount of HFCS consumed is 79% and p<.0001. For those of you not statistically inclined, just enjoy that I put green and orange on the same graph.

Am I saying that the introduction of HFCS caused the increase in the prison population? No, I'm not.

This is just correlation, mind you, not causation, but one thing we can do in time-series like this is instead of matching one year's prison population to the same year's HFCS intake we can vary the year to find if HFCS for a certain time before the prison population is a better correlation. We could also use later dates compared to the prison population. It turns out that the best correlation is the prison population to the HFCS 6 years prior. I picked six years because the prison population peaked 6 years after HFCS peaked. Here's that picture:

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And for those of you who are statistically inclined, the variance explained is 97% and p<.0001. But does this show causation?

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No, correlation is still only correlation, but even if there was causation here, we’d need some theory to test. Can you think of some way that HFCS could increase the prison population? Well, oddly, I can. I know, it’s going to be odd, but in my defense, I first heard the idea from an NIH researcher. Here’s the issue: corn and all its components are high in omega 6 fatty acids and very low in omega 3 fatty acids.

Not only that, the researcher pointed to his work and that of others at NIH and in England that showed that the higher the omega6/omega3 ratio was, the more inflammation, and the greater the manifestation of several problems including violence, anhedonia, and substance use. Now that last one I’m not so sure of because of the negative correlation I see in alcohol and nicotine intake with HFCS, but he was talking about his tests of inflammation in individuals who changed their diets and noted changes in drug intake.

But there aren’t any fatty acids in HFCS you say, and you’d be right! I’m not saying that there’s a direct causation. It could be that a diet high in HFCS is also one likely to be low in omega3 fatty acids. It might be that because we are making a lot of HFCS we have a lot of the rest of the corn left over and getting more of it as filler in other foods and getting the omega6 that way. It could be there’s no connection with omega6 and this is completely wrong. So here’s the test.

We could take a look at two groups of people. Those who use a lot of HFCS and have their own diet and those that use a lot of HFCS but have a diet supplemented with a lot of omega3 fatty acids. The second group will have a lower 6/3 ration and we can compare the differences. It’s an expensive study with a very large N to be able to look at incarceration rates. I didn’t say it’s an easy study. I just said I could think of a way to test the hypothesis.

Maybe someone else can come up with a better way. I just wanted you to see the pretty picture. I have to go now – I have to go get some more fish oil so I can get “Happy.”

A New Paradigm?

August 15th, 2014

I was recently told about a report of the Institute of Behavior and Health Inc. titled “A New Paradigm for Recovery” that purported to be a road map for making recovery and not relapse the expected outcome of addiction treatment. So I took a look at the report and found an old paradigm in a new wrapper.

The big point of the report is to trumpet the success of professional monitoring programs and propose an expansion to the general population. These programs place the professional’s license in jeopardy of loss if there is a positive drug test and then impose a long term (at least 5 year) random urine monitoring program to ensure abstinence. They are successful as has been shown in many reports, but the success is always abstinence from identified drugs that are impairing. There has not been a study of such programs that encompass addiction symptom suppression as an end point, or, for that matter, the cessation of all use of compulsive rewards. Specifically, such professionals may still be overeating, gambling, compulsively working or engaging in compulsive sexual activity and the studies would have shown the same outcome.

Here are some of old paradigm idea celebrated in this report:
1. Stigma: “Unhealthy patterns of drug and alcohol use warrant “stigma”, to warn others to avoid such behaviors and to help persons engaged in such behaviors identify the need for help. In itself, illegal drug use merits stigma.” The report goes on to say that we should limit stigma to the bad behavior and not encompass the person. Good luck with that.
2. Focus on substances only: “The disease of addiction results from use of alcohol and other drugs. In many ways addiction is a disease of youth; the earlier the initiation of substance use, the more likely an individual will have later substance use problems, including addiction.” This is after listing the ASAM definition that the report’s writer clearly doesn’t subscribe to. There is no recognition in this report that addiction is a primary disease that may involve other rewards besides drugs and alcohol.
3. Sees the illness as non-progressive biologically: “This is because drugs hijack the brain’s thinking and change the brain over time in persons with substance use disorders.” They completely miss that the brain with addiction continues to get worse even if it’s not using drugs to feel better. That leads me to the next old idea.
4. Focus on behavior and not symptoms: “All substance use disorder treatment programs, whether abstinence-based or medication-assisted, need to focus during treatment on the use of alcohol and other drugs, and all treatment programs need to extend their focus beyond discharge to what happens to patients after they leave formal episodes of treatment.” Couched in the laudatory sentiment of seeing addiction as a chronic illness is the idea that the chronicity is only about behavior. There is not one mention in this report about the individual pain of the untreated addict, the mental anguish caused by the primary symptoms. That mental anguish is described by newcomers in the same language in an Overeaters Anonymous meeting as in a meeting of Alcoholics Anonymous. The symptoms of the illness are no different regardless of reward used to feel better.

Four’s enough for now, but there are more, like the legalistic approach and the use of urine monitoring to “catch” people as opposed to medical monitoring. We desperately need a new paradigm for the treatment of addiction in this country, but this report isn’t the answer. It is, in fact, highly unlikely that the same minds that created or participated in the “War on Drugs” is going to come up with the new answer after 40 years of failure. As Thomas Kuhn related in his book on scientific revolutions, the new paradigm has been there all along. What was necessary was for the people invested in the old paradigm to go out of power. We’re still waiting, I guess.

Suicide and Addiction

August 12th, 2014

I don’t know Robin Williams. I’ve never met Robin Williams. This blog entry isn’t about Robin Williams. But since he was found dead yesterday, someone will think it might be, and I must admit that his death at his own hand inspired me to write this. I’ve been treating addiction for a long time and I’ve seen more people with addiction commit suicide than I’d like. I’ve searched my memory and there seem to be three main classes of such people.

First is the group that has never been able to get sober. Nothing they’ve tried has ever worked. They can’t see a way out and a way forward has become impossible. There seems to hope and they are completely isolated.

Second is the group that have made some progress. They’ve felt sobriety; they’ve had success. But the disease is progressive and active again. Because this is a progressive disease the way they got sober the first time doesn’t work as well now. They think it’s because they are doing something wrong, that they can’t recover. They know that success is possible but not for them any longer. They see other recovering people and have just a sense of isolation that they cannot reasonably expect to rejoin and stay in that group. They are completely isolated.

Third is the group that have long term success in recovery. They have never, in the common usage, “relapsed.” Their disease and the primary symptoms have continued to progress, and while abstinent, they no longer enjoy life. They know they should feel better and imagine that the reason is because of something they are doing wrong. Not enough meetings, not enough service, not enough or the right kind of something that works to make others in their situation happy. They wonder is this all there is to sobriety and they feel the desperate pointlessness of going on with everyone else. They are completely isolated.

By now you’ve figured out what the three groups have in common; they are alone. It may not look that way to you, but that’s how it feels to them. It’s not the fault of their family or friends. It’s nothing that anyone is doing wrong. The disease does that.

And the great and terrible shame of all this is that most of these deaths could be prevented. Another thing that all three of these groups have in common is the unsuppressed primary symptoms of addiction: relative anhedonia, poor motivation, poor memory, poor attention, inability to attach to others, etc. These are symptoms of low midbrain dopamine and not, in these people, symptoms of depression. But so many talk shows use the word depression today, and it’s so much more socially acceptable to have that than be struggling with addiction, that depression is how these symptoms are labeled. The problem is that most treatments for depression can actually make these symptoms worse, and I’ve met dozens of people who have told me of the seemingly endless cycle of feeling better on SSRIs only to feel worse and the resulting thoughts that it could work if only they were better. I think this is why SSRIs are associated with suicide; I think further research, if anyone ever does any, will show that it’s primarily people with low midbrain dopamine that have this effect.

But even if you’re not a psychopharmacologist you can do something for the people in these three groups. Name the problem. Be willing to look at it in the face. Don’t shrink from it or acknowledge stigma. It’s diabetes; it’s a broken leg; it’s addiction; it’s just an illness. Tell them you love them not just in spite of addiction but for entirely who they are including addiction, and that you’ll walk with them to go get help. Because there is help. There is primary medical treatment for addiction, and it has nothing to do with how long ago someone’s last drink was.

Is High Fructose Corn Syrup a Drug?

August 11th, 2014

Anyone following this blog or who has read my book knows the graph I use all the time to show that we’ve started to eat more as a country when we stopped using as much alcohol and tobacco. Here it is just as a reminder:

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As you can see, the data ends in 2005 which was the last federal data available before the first printing of the book. I’ve been working on a revision so I went to get the latest data. It’s not easy to do, because the USDA doesn’t report the alcohol figure anymore in a direct way, but that’s another story. Anyway, I got the data and took a look. I found something interesting.

I found some new historical data on caloric intake that was broken down into sugars and fat, so I had some new data on the pounds of caloric sweetener we consume per person by year. I thought I’d do a statistical comparison of that with the Nicotine-Alcohol Dopamine Load.

Screen Shot 2014-08-11 at 10.02.47 AM

The first thing I noticed was that the statistical test told me that the relationship was not statistically significant. Then I looked at the picture. You can clearly see there are two curves instead of one. The top curve which does seem to vary by dopamine load and the bottom curve that is more flat. Well I took a look and it turns out that every dot in the bottom curve was before 1966. That was curious. What happened in 1966 that all of a sudden changed the relationship between caloric sweeteners and intake of nicotine and alcohol. You guessed, I’m sure. It’s high fructose corn syrup (HFCS), first reported in 1966 by the USDA as having zero pounds per person in that year. Before then, in the report, it didn’t exist.

So I went back and got the data specifically on HFCS. Different picture.

Screen Shot 2014-08-11 at 10.09.50 AM

This relationship is highly significant. The variance in dopamine load that’s explained by HFCS intake is 79% and p<0.0001. It doesn't get much better than that. You'll notice those three little dots in the lower right that seem to be out of sync with the rest. Those are the first 3 years that HFCS were reported in this series, before the "drug" became widely used.

In short the more we smoke and drink, the less we eat HFCS. The more HFCS we eat, the less we smoke and drink. Addiction is still the same; we're just switching drugs. And now we're switching again.

There's been a lot of controversy over HFCS and obesity in the past several years and concerted educational efforts to get us to use less of it. In fact those efforts have succeeded to some part. Notice below that HFCS rises to about the year 2000 and then starts to fall. Also notice that after a 20 year fall in the percentage of the population that has used illicit drugs in the last month there was a plateau at 5% until the year 2000 and a start to increase again.

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We don’t have any good government statistics on the amount of drugs used, only this SAMHSA data on percent of the population that used. Could we be seeing a return to drugs with a decrease in cigarettes, tobacco and HFCS? Another possibility is the rise of “vaping” nicotine which doesn’t show up in government cigarette statistics.

In any case, these relationships just further highlight the need to see addiction as an illness. We have to stop focusing on a drug, or the drugs, or this or that substance and start looking at the underlying illness. Otherwise we’ll just continue this shift, and we’ll never see the next one coming.

Did Prohibition Work?

July 30th, 2014

In the last week, and in the context the New York Times coming out in favor of repeal cannabis prohibition, two of my colleagues have used a graph that I showed them from my book to make the point that prohibition worked. Here’s the graph:

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So yes, in the year after prohibition, this country consumed half as much alcohol for every man, woman, and child as it did in the year before prohibition. Both of these colleagues used this data to argue for prohibition of a drug, in this case cannabis. They missed the larger point of the graphs that follow in my book.

First look at the graph of alcohol use. It was pretty steady at around 25 gallons before prohibition, but then started to fall off even before the law was passed. While the end of prohibition shows that the per capita intake was only 10 gallons, half of the 20 gallons per capita before prohibition, notice how fast the number rises. The slope was much higher than seen before prohibition. We see the same increase in craving when someone with addiction stops using but doesn’t get treatment. Periods of “stopping” often end with use escalated to levels above those seen before the stop.

Yes alcohol use dropped, so will use of any drug when we make it more costly, either socially or economically, to use. And normal people who don’t need or generally use drugs will probably not use it at all once we make it illegal. However people with addiction will still look for something to calm the symptoms of the biological brain illness they suffer from. So, what, I asked myself, might addicts who used alcohol have moved to when alcohol became illegal. Here’s the graph of cigarettes.

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In that last year before prohibition, 1919, America drank 19.6 gallons per 10 people, or 1.96 gallons per capita and smoked 727 cigarettes per person. Let’s just assume that we’re getting dopamine from both and multiply them together to get what you might term a “dopamine load.” 1.96 X 727 = 1424. Now let’s look after prohibition. In 1934, America drank only .97 gallons of alcohol per capita and smoked 1483 cigarettes per person. .97 X 1483 = 1438. No decrease; those who needed dopamine and couldn’t get alcohol just smoked more. Here’s a graph of the combined product for each year:

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One colleague answered the New York Times in a letter to the editor and said that while prohibition may have been a political failure, it was a public health success. Really? Before prohibition, alcohol use was falling. After prohibition it rose faster. Before prohibition tobacco use was rising slowly. During and after prohibition tobacco use rose far faster. Before prohibition we did not have powerful organized crime syndicates with access to large amounts of money. Prohibition gave us this, and when the crime bosses saw the money about to go away with the end of prohibition, they used their organizations to start pushing a new drug, heroin, into the same markets they ran. An increase in smoking, an increase in heroin, and an increase in violent crime. A public health success? We don’t need many more of those.

Is smoking pot a good idea? No, even if you don’t have addiction. It’s not a good idea to smoke anything. How about not smoking, but taking another way if you don’t have addiction? I don’t know. There’s no evidence that’s yet good enough to say. Healthy? doubtful. Harmless in moderation? don’t know. We live in a free society and if you want to take a chance I can’t stop you.

This is our opportunity to stop worrying about the drug and start looking at the real cause of the problem. Normal people actually don’t like drugs that much, and their use of them tends to be moderate and temporary. People with addiction however aren’t safe using anything. Unless we treat the illness they’ll most likely switch back and forth between sources of dopamine spikes depending on the social and economic costs at the moment. Can we make them use less of something? Sure, but they’ll just use something else. Here’s what happened when we got people to drink less and smoke less in the 80′s:

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We stopped drinking and smoking as much and started eating more. Are we healthier? Not if you use our healthcare expenditures as a measure of success.

Goodhart’s law says that once a measure becomes the object of policy it stops being an accurate measure. I’m all for people smoking less pot, but let’s not target the pot. The real low hanging fruit is the disease of addiction. Treat that, and a lot of things will get better.

Abstinent Harm Reduction

July 27th, 2014

I have a lot of colleagues who work in inpatient addiction treatment at places that don’t allow the long term use of medication in primary treatment. These places largely refer to themselves as abstinence based. Many do not address smoking in their patients.

I have had disagreements with some of these colleagues in the past about my using medications in primary addiction treatment and my understanding of addiction as a biological illness. They have said such things as “You should really get your patients abstinent. Recovery can’t start on those medications.” When they are feeling charitable they even have said, “I’m not against harm reduction, but you really shouldn’t call it treatment and recovery.” They talk about Harm Reduction as a lower form of intervention, not treatment. I’d agree – harm reduction isn’t meant to be treatment. Harm reduction is an attempt to reduce the harm from continued drug use while not addressing the underlying illness. But that’s not what I do.

To these colleagues, the illness is a spiritual malady more than a physical illness, and they’d not want the patient to miss the opportunity to find a loving God in their recovery program. They are afraid that won’t happen if the patient gets to feel better. I happen to think God is bigger than me and will have no problem reaching my patient even without “authentic suffering.” Normal people without addiction find God all the time. I don’t think we need to withhold treatment to help someone find a spiritual life. And we don’t use medication to help people avoid it.

We use medications to affect the primary symptoms of the illness that get in the way of someone getting into recovery. If you don’t have enough dopamine tone you can’t remember what you heard in the meeting, you can’t pay attention in the meeting, you can’t see the other people as individuals and care about them, you can’t feel motivated enough to even go. You certainly won’t enjoy the experience and want to go again. But if you can have these symptoms suppressed, recovery becomes something that is actually fun and enjoyable. In short we use medications to further recovery, not to give an alternative to it.

But harm reduction has it’s place. Let’s say we just want to replace one drug (say, alcohol) that will kill you relatively quickly with another drug (say, tobacco) that will kill you slower. Not a medication, a drug. Not something you take when prescribed no matter how you feel, but something you take when you want to change how you feel. Let’s say we accomplish that. We put a patient in “abstinent” inpatient treatment and get him to want to stop drinking. He starts going to AA. He now smokes twice as much as he did when he drank but he isn’t drinking. His wife is happier, his kids are happier, his boss is happier, his liver is happier; we have definitely reduced harm in all those areas. But as to his larynx and his lungs? Are they happier? Have we done someone any favors by getting him to stop drinking so that he can die twenty years later than he would have of lung cancer instead of liver failure? Probably so. That’s harm reduction.

Now if we’d actually treated his illness with a safe medication taken regularly, he might not have had to continue dosing with the tobacco. He would have had even greater reduction of harm. In fact, treating the primary illness is the best way to reduce harm there is. If you have tuberculosis, we can reduce harm to you by giving you a good diet and a quiet place to rest. We can reduce harm to society by secluding you away. But we’d do our best at harm reduction if we gave you the right medication to treat the tuberculosis directly. Same goes for addiction.

Addiction is not drug use, it isn’t even drug abuse. It isn’t any behavior. It is a primary illness of the brain with primary symptoms that exist whether you’re using or not. It is the symptoms that cause the using, not the using that cause the symptoms. It is a complex illness with continual progression, sober or not. It’s time we focused on the illness that is there instead of the illness we wish it was.

Can We Still Treat Addiction if Cannabis is Legalized?

July 27th, 2014

There’s probably two issues being talked about in addiction today more than any other. The first is the epidemic of opioid overdose deaths and the second is the legalization of marijuana by some states. I haven’t heard of anyone in favor of opioid overdoses so that has little controversy. The same cannot be said for legal pot.

One of the reasons for the controversy in this issue is that it’s really the amalgamation of more than one issue. The arguments I’ve heard both for and against have all been the conflation of arguments for and against four separate proposals. They are: legalizing marijuana for medical use (medical marijuana), local and state decriminalization of marijuana (decriminalization), state legalization of personal use marijuana (personal use legalization), and full federal legalization of marijuana (repeal of prohibition). The mixing and matching of these arguments adds to confusion. It isn’t uncommon, for example, for a person arguing for repeal of prohibition to use arguments for medical marijuana and be answered by the arguments against personal use legalization. In this case neither debater is actually debating the question they think they’re talking about.

Please understand, I actually am quite neutral on this issue. All I do is treat addiction and it’s just as easy for me to treat a patient using a legal drug as an illegal drug. I really don’t care one way or the other.

This was going to be a large opus listing all the pros and cons of the various proposals above, and it has sat in draft form for over a month, but time has gotten ahead of me. Two things have prompted me to wrap this up and put it out in a smaller form: the increasing negative health affects of synthetic cannabinoids and the recent editorial in the New York Times supporting repeal of prohibition.

Anyone who’s read my book or has followed my blog knows that I see addiction as a single illness. The effect of prohibiting a drug is to increase the cost (both economic and social) of using that drug. People with and without addiction will be incentivized to not use it, however people with addiction will just switch to another drug – unless we treat the illness. And make no mistake, cessation of drug use is not treating the illness; neither is putting people in jail. So prohibiting a drug, any drug, is not helpful to addicted patients.

But then I hear the arguments from colleagues “Repealing prohibition of cannabis will make it harder to treat addiction because people will claim they should still be able to smoke it like cigarettes.” I think that’s ridiculous. If you have to threaten your patients with legal consequences you probably don’t know how to treat addiction. If you aren’t addressing smoking as part of the illness, you probably don’t know how to treat addiction. Okay, I say to patients everywhere, “Maybe it is just like smoking cigarettes, and there’s good evidence that if you continue to pop your dopamine with cigarettes you’re more likely to restart the use of the thing you just went to treatment for. We’re not asking you to stop smoking and be miserable; we’re asking you to let us help you with medication and other treatments to improve the state of your illness so that your brain no longer wants to smoke.” I really don’t care that tobacco is legal; it’s not a good idea for someone with addiction to smoke. I don’t care that sugar is legal; it’s not a good idea for someone with diabetes to eat it.

So really, purely as an addiction doctor, I can’t say that repeal of prohibition would make my job any harder. Are there going to be social consequences? Quite likely. But I think society gets to make that choice, and does so, with all sorts of things. What society is doing when it says one drug is legal and another isn’t, is choosing the social consequences. All drugs have them, and democratic society has a right to pick which ones it will tolerate and which it won’t. I’ll never live in a society free from social consequences of drug use, so I’ll get used to whatever you guys choose. The real choice society hasn’t faced yet is whether we’re going to continue on this prohibition marry-go-round regulating one drug or the other while the disease goes undressed or if we’re tired of 50 years of a drug war and want to start actually addressing the illness.

And speaking on consequences, there’s one we should ask ourselves about concerning cannabis prohibition. THC is a partial agonist at the Cannabinoid Receptor Type I (CB1), that means that it turns on the receptor part of the way. Cannabis has been grown so that it’s more potent per gram than it was 30 years ago but THC is still a partial agonist, and cannabis still has more than THC in it. There are many cannabinoids in cannabis, and some may counter the effects of THC. It’s not completely known. But one thing is certain, it’s not like pot is a pure agonist at CB1, but the synthetic cannabinoids being marketed in convenience stores are.

With the rise of an internationalized world, chemists in the eastern hemisphere were able to synthesize an increasing number of pure full agonists at CB1 that are far more powerful than even the most potent cannabis out there. The first synthetic cannabinoids were the JWH compounds and after a couple of years they were made illegal. Before they even were, the chemists had the next set ready, and the next. We will never be able to make new chemicals illegal faster than scientists in another country can make new ones we’ve never heard of. On top of that, we can’t create confirmatory tests to use for these things at anywhere near the pace of their invention so we’ll always have people in treatment who are negative for existing tests even though they are using. That’s new, and that does make treating addiction harder. Now we aren’t dealing with a readily available partial agonist with known effects and a good way to track its use, but a range of unknown full agonists that are causing an increasing number of catastrophic health effects (this will be the next epidemic after opioids calm down).

So the question society needs to ask is this, “Would there be as much use of synthetic cannabinoids with the attendant psychosis, suicides, and homicides we’ve been seeing lately if cannabis itself were legal and regulated?” I won’t pretend for a minute that if we repealed prohibition that synthetic cannabinoids would go away; that genie is out of the bottle, but would there have been as much economic incentive to create these things if cannabis had been legal? We need to take a look at the second order costs of our decisions, and so far, we only look at the first order savings. We see there are problems with pot and we make it illegal to save those problems. Now we have bigger problems that we didn’t see coming.

The real problem is how we look at costs and benefits. We keep thinking that the choices for people are between using this bad thing and not using anything. That’s never been the choice. The overwhelming amount of drugs used are used by the few people who use a lot and those people, mostly, have addiction. For them not using isn’t an option without treatment and recovery, so the choice we are really making with prohibition is this, take legal risks and keep using this or go find something else. We might even like what they find (smoking cigarettes, over work, eating too much), but the disease, without treatment, just gets worse regardless of the social acceptability of the drug used. Whether pot is legal or not, the real question before is whether we’re ready to look at this disease the way it exists in nature and deal with it, or if we want to continue our half-century of delusion and continue to complain.