It is vital that physicians—particularly psychiatrists who are on the frontlines with patients who struggle with cannabis use—are able to identify and characterize cannabis use disorders; provide education; and offer effective, evidence-based treatments. This article provides a brief overview of each of these topics by walking through clinical decision-making with a case vignette that touches on common experiences in treating a patient with cannabis use disorder.

A separate and important issue is screening for emerging drugs of abuse, including synthetic “marijuana” products such as K2 and spice. Although these products are chemically distinct from the psychoactive compounds in the traditional cannabis plant, some cannabis users have tried synthetic “marijuana” products because of their gross physical similarity to cannabis plant matter.

CASE VIGNETTE

Mr. M is a 43-year-old legal clerk who has been working in the same office for 20 years. He presents as a referral from his primary care physician to your outpatient psychiatry office for an initial evaluation regarding “managing some mid-life issues.” He states that while he likes his job, it is the only job he has had since graduating college and he finds the work boring, noting that most of his co-workers have gone on to law school or more senior positions in the firm. When asked what factors have prevented him from seeking different career opportunities, he states that he would “fail a drug test.” Upon further inquiry, Mr. M says he has been smoking 2 or 3 “joints” or taking a few hits off of his “vaping pen” of cannabis daily for many years, for which he spends approximately $70 to $100 a week.

He first used cannabis in college and initially only smoked “a couple hits” in social settings. Over time, he has needed more cannabis to “take the edge off” and has strong cravings to use daily. He reports liking how cannabis decreases his anxiety and helps him fall asleep, although he thinks the cannabis sometimes makes him “paranoid,” which results in his avoidance of family and friends.

More recently, he identifies conflict and regular arguments with his wife over his cannabis use—she feels it prevents him from being present with his family and is a financial burden. He admits missing an important awards ceremony for her work and sporting events for his children, for which he had to “come up with excuses,” but the truth is that he ended up smoking more than he had intended and lost track of the time.

Mr. M reports multiple previous unsuccessful attempts to reduce his use and 2 days when he stopped completely, which resulted in “terrible dreams,” poor sleep, sweating, no appetite, anxiety, irritability, and strong cravings for cannabis. Resumption of his cannabis use relieved these symptoms. He denies tobacco or other drug use, including use of synthetic marijuana products such as K2 or spice, and reports having a glass of wine or champagne once or twice a year for special occasions.

The diagnosis

In the transition from DSM IV-TR to DSM-5, cannabis use disorders, along with all substance use disorders, have been redefined in line with characterizing a spectrum of

pathology and impairment. The criteria to qualify for a cannabis use disorder remain the same except for the following:

1. The criterion for recurrent legal problems has been removed.

2. A new criterion for craving or a strong desire or urge to use cannabis has been added, and the terms abuse and dependence were eliminated.

To qualify as having a cannabis use disorder, a threshold of 2 criteria must be met. Severity of the disorder is characterized as “mild” if 2 or 3 criteria are met, “moderate” if 4 or 5 criteria are met, and “severe” if 6 or more criteria are met. Mr. M demonstrates 3 symptoms of impaired control: using longer than intended, unsuccessful efforts to cut back, and craving; 3 symptoms of social impairment: failure to fulfil home obligations, persistent problems with his wife, and reduced pursuit of occupational opportunities; 1 symptom of risky use: continued use despite paranoia; and 2 symptoms of pharmacological properties: tolerance and withdrawal. As such, he meets 9 criteria, which qualify him for a diagnosis of severe cannabis use disorder.

You summarize Mr. M’s 9 symptoms and counsel him about severe cannabis use disorder. He becomes upset and states that he was not aware one could develop an “addiction” to cannabis. He expresses an interest in treatment and asks what options are available.

Treatment options

Psychotherapeutic treatments, including motivational enhancement treatment (MET), cognitive behavioral therapy (CBT), and contingency management (CM), have demonstrated effectiveness in reducing frequency and quantity of cannabis use, but abstinence rates remain modest and decline after treatment. Generally, MET is effective at engaging individuals who are ambivalent about treatment; CM can lead to longer periods of abstinence during treatment by incentivizing abstinence; and CBT can work to enhance abstinence following treatment (preventing relapse). Longer duration of psychotherapy is associated with better outcomes. However, access to evidence-based psychotherapy is frequently limited, and poor adherence to evidence-based psychotherapy is common.

In conjunction with psychotherapy, medication strategies should be considered. Because there are no FDA-approved pharmacological agents for cannabis use disorder, patients should understand during the informed consent process that all pharmacotherapies used to treat this disorder are off-label. A number of clinical trials provide evidence for the off-label use of medications in the treatment of cannabis use disorder. The current strategies for the off-label treatment of cannabis use disorder target withdrawal symptoms, aim to initiate abstinence and prevent relapse or reduce use depending on the patient’s goals, and treat psychiatric comorbidity and symptoms that may be driving cannabis use. Here we focus on the evidence supporting these key strategies.

Targeting withdrawal and craving

Cannabis withdrawal is defined by DSM-5 as having 3 or more of the following signs and symptoms that develop after the cessation of prolonged cannabis use:

• Irritability, anger, or aggression

• Nervousness or anxiety

• Sleep difficulty

• Decreased appetite or weight loss

• Restlessness

• Depressed mood

• At least one of the following physical symptoms that causes discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache

Withdrawal symptoms may be present within the first 24 hours. Overall, they peak within the first week and persist up to 1 month following the last use of cannabis. In the case of Mr. M, insomnia, poor appetite, and irritability as well as sweating are identified, which meet DSM-5 criteria for cannabis withdrawal during the 2 days he abstained from use. He also identifies strong craving and vivid dreams, which are additional withdrawal symptoms included on marijuana withdrawal checklists in research studies, although not included in DSM-5 criteria. These and other symptoms should be considered in clinical treatment.

Medication treatment studies for cannabis withdrawal have hypothesized that if withdrawal symptoms can be reduced or alleviated during cessation from regular cannabis use, people will be less likely to resume cannabis use and will have better treatment outcomes. Studies have shown that dronabinol and nabilone improved multiple withdrawal symptoms, including craving; and quetiapine, zolpidem, and mirtazapine help with withdrawal-induced sleep disturbances.1-5

Combining dronabinol and lofexidine (an alpha-2 agonist) was superior to placebo in reducing craving, withdrawal, and self-administration during abstinence in a laboratory model. However, in a subsequent treatment trial, the combined medication treatment was not superior to placebo in reducing cannabis use or promoting abstinence.6

Six double-blind placebo-controlled pharmacotherapy trials in adults with cannabis use disorder have looked at withdrawal as an outcome.7 Of these studies, only dronabinol, bupropion, and gabapentin reduced withdrawal symptoms.8-10 In addition to reducing withdrawal symptoms, nabiximols/Sativex (a combination tetrahydrocannabinol [THC] and cannabidiol nasal spray not available in the US) increased retention (while actively on the medication in an inpatient setting) but did not reduce outpatient cannabis use at follow-up.11

All of the medications available for prescription in the US can be monitored reliably with urine drug screening to assess for illicit cannabis use except dronabinol, which will result in a positive screen for cannabis. When using urine drug screening, remember that for heavy cannabis users the qualitative urine drug screen can be positive for cannabis up to a month following cessation. When selecting a medication, take into account the cost of the medication, particularly since insurance will likely not cover THC agonists such as dronabinol for this indication, and possible misuse or diversion of scheduled substances (eg, dronabinol, nabilone). In addition, monitoring for reductions in substance use and withdrawal symptoms is key.

Abstinence initiation and relapse prevention

Other clinical trials have looked at medications to promote abstinence by reducing stress-induced relapse, craving (not as a component of withdrawal), and the reinforcing aspects of cannabis. Of these trials, the following results show potential promise with positive findings: gabapentin reduced quantitative THC urine levels and improved cognitive functioning (in addition to decreasing withdrawal), and buspirone led to more negative urine drug screens for cannabis (although the difference was not significant compared with placebo).10,12 However, in a follow-up larger study, no differences were seen compared with placebo and women had worse cannabis use outcomes on buspirone.13

N-acetylcysteine resulted in twice the odds of a negative urine drug screen in young adults and adolescents (although there was no difference between adolescent groups in self-report of cannabis use).14 Gray and colleagues15 reported that no differences were seen between N-acetylcysteine and placebo (results of the trial are soon to be published). Topiramate resulted in significantly decreased grams of cannabis used but no difference in percent days used or proportion of positive urine drug screens.16 In a recent small clinical trial, reductions in cannabis use were seen with oxytocin in combination with MET.17 Studies with nabilone and long-term naltrexone administration reduced relapse and cannabis self-administration and subjective effects, respectively, which suggests promising avenues yet to be explored by clinical trials.2,18

Treatment of psychiatric comorbidity

Other studies have looked at the effects of treating common comorbid psychiatric disorders in adults with cannabis use disorder, postulating that if the psychiatric disorder is treated, the individual may be more likely to abstain or reduce his or her cannabis use. For example, if a person is less depressed, he may better engage in CBT for relapse prevention.

Fluoxetine for depression and cannabis use disorder in adolescents decreased cannabis use and depression, although there was no difference compared with placebo.19 A trial of venlafaxine for adults with depression and cannabis use disorder demonstrated less abstinence with greater withdrawal-like symptoms compared with placebo.20,21 These findings suggest that this antidepressant might not be beneficial for treatment-seeking individuals with cannabis use disorder and may actually negatively affect outcomes.

CASE VIGNETTE CONT’D

After discussing and presenting the different psychotherapy and medication treatment options to Mr. M, you and he decide to start CBT to help with abstinence initiation. In addition, you prescribe 20 mg of dronabinol up to 2 times daily in combination with 50 mg of naltrexone daily, to help globally target Mr. M’s withdrawal symptoms and prevent relapse once abstinence is achieved. However, a few days later, Mr. M calls to say that his insurance will not cover the prescription for dronabinol and he cannot afford the high cost. Given his main concerns of cannabis withdrawal symptoms, you select gabapentin up to 400 mg 3 times daily and continue weekly individual CBT.

Mr. M calls back several days later and reports that he has made some improvements in reducing the frequency of his cannabis use, which he attributes to the medication, but he thinks he needs additional assistance. After reviewing the treatment options again, he gives informed consent to start 1200 mg of N-acetylcysteine twice daily. After 10 weeks of this medication, his urine screens are negative.

You continue to provide relapse prevention CBT. He reports to you that his anxiety and insomnia are almost resolved, and you suspect that withdrawal was the cause of these symptoms. He reports significant improvement in his relationship with his family and recently received a promotion at work for “going above and beyond” on a project he was given the lead.

Over the next 6 months, he has 2 relapses that in functional analysis with you are determined to be triggered by unsolicited contact from his former drug dealer. Together, you develop a plan to block any further contact from the drug dealer. After several months, both the gabapentin and N-acetylcysteine are tapered and discontinued. Mr. M continues to see you for biweekly therapy sessions with random drug screens every 4 to 6 weeks.

Conclusion

Based on the available evidence, gabapentin, THC agonists, naltrexone, and possibly N-acetylcysteine show the greatest promise in the off-label treatment of cannabis use disorders. System considerations, such as medication cost, need to be factored into the decision-making as well as combination medication and psychotherapy approaches, which—as demonstrated in the case of Mr. M—may ultimately work best. Until further research elucidates the standard of medication practices for cannabis use disorder, the best off-label medication strategy should target any co-occurring disorders as well as any identified problematic symptoms related to cannabis use and cessation of use. When available, referral for evidence-based psychotherapy should be made.

Source:  (http://www.psychiatrictimes.com)  30th June 201

Addiction is treatable. So why aren’t more people receiving quality care?

The crisis is well documented and reported: More people are dying of drug overdose than any other non-natural cause—more than from guns, suicide, and car accidents. Politicians have held press conferences, formed commissions and task forces, and convened town-hall meetings. Vivek Murthy, the Surgeon General under President Obama (fired by Donald Trump), issued an historic report on America’s drug-use and addiction crises. Pharmaceutical companies have been blamed. Drug cartels. Physicians who hand out pain pills like Skittles.

In the meantime, the problem worsens. In 2015, 52,000 people died because of overdose, including 33,000 on OxyContin, heroin, and other opioids. Almost three times that number died of causes related to the most-used mood-altering addictive drug, alcohol. The 2016 and 2017 overdose numbers are predicted to be higher. Currently, fentanyl deaths are skyrocketing. If not politicians, to whom can we turn to address the crisis? Since addiction is a health problem, the logical answer would be the addiction-treatment system, but it’s in disarray.

Currently most people who enter treatment are subjected to archaic care, some of which does more harm than good. Only about 10 percent of people who need treatment for drug-use disorders get any whatsoever. Of those who do, a majority enter programs with practices that would be considered barbaric if they were common in treatment systems for other diseases.

Many programs reject science and employ one-size-fits-all-addicts treatment. Patients are often subjected to a slipshod patchwork of unproven therapies. They pass talking sticks and bat horses with Nerf noodles. In some programs, patients are subjected to confrontational therapies, which may include the badgering of those who resist engaging in 12-Step programs, participation in which is required in almost every program. These support groups help some people, but alienate others. When compulsory, they can be detrimental.

Patients are routinely kicked out of programs for exhibiting symptoms of their disease (relapse or breaking rules), which is unconscionable. They are denied life-saving medications by practitioners who don’t believe in them—as Richard Rawson, PhD, research professor, UVM Center for Behavior and Health, says, “this is tantamount to a doctor not believing in Coumadin to prevent heart attacks or insulin for diabetes.”

Patients are put in programs for arbitrary periods of time. Three or five days of detox isn’t treatment. Many residential programs last for twenty-eight days, but research has shown that a month is rarely long enough to treat this disease. Some of those who enter residential treatment do get sober, but they relapse soon after they’re discharged, with, as addiction researcher Thomas McLellan, PhD, sums, “a hearty handshake and instructions to go off to a church basement someplace.” As he says, “It just won’t work.” Finally, people afflicted with this disease are almost never assessed and treated for co-occurring psychiatric disorders, in spite of the fact they almost always accompany and underlie life-threatening drug use. If both illnesses aren’t addressed, relapse is likely.

The disastrous state of the system suggests that addiction-medicine specialists don’t know how to treat substance-use disorders (or even if they can be treated). It’s not the case. The National Institute on Drug Abuse (NIDA) and organizations of addiction-care professionals like the American Society of Addiction Medicine (ASAM) and American Association of Addiction Psychiatry (AAAP) have identified effective treatments. There’s no easy cure for many complex diseases, including addiction. However, cognitive-behavior therapy, motivational interviewing, and addiction medications, often used in concert with one another and in concert with assessment and treatment dual diagnoses, are among many proven treatments. However, most patients are never offered these treatments because of a fatal chasm between addiction science and practitioners and programs.

Fixing the system requires modeling it on the one in place for other serious illnesses. Most people enter the medical system in their primary-care doctors’ offices, health clinics, or emergency rooms. Currently, most doctors in these settings have had little or no education about addiction. A recent ASAM survey of two thirds of U.S. medical schools found that they require an average of less than an hour of training in addiction treatment.

Doctors must be taught to recognize substance-use disorders and treat them immediately—the archaic “let them hit bottom” paradigm has been discredited. They should offer or refer for brief interventions. A program called SBIRT (Screening, Brief Intervention and Referral to Treatment), which seeks to identify risky substance use and includes as few as three counselling sessions, has proven effective in many cases, and may be implemented in general healthcare settings.

Primary-care doctors should be trained and certified to prescribe buprenorphine, a medication that decreases craving and prevents overdose on opioids. Currently, there are limitations on the number of patients doctors can treat. Still, in Vermont, for example, almost 50 percent of opioid users in treatment receive care in their doctors’ offices- they don’t have to go to addiction specialists or intensive treatment programs to receive care.

When a patient requires a higher level of care, doctors must refer them to addiction specialists, which excludes many current practitioners whose only qualification to treat addiction is their own experience in recovery. Instead, patients must be seen by psychiatrists and psychologists trained to diagnose and treat the wide range of substance use disorders. There’s a shortage of these doctors; there needs to be a concerted effort to fill the void.

According to Larissa Mooney, MD, director of the UCLA Addiction Medicine Clinic, “Individuals entering treatment should be presented with an informed discussion about treatment options that include effective, research-based interventions.  In our current system, treatment recommendations vary widely and may come with bias; medication treatments are either not offered or may be presented as a less desirable option in the path to recovery. Treatment should be individualized, and if the same form of treatment has been repeated over and over with poor results (i.e. relapse), an alternative or more comprehensive approach should be suggested.”

When determining if a patient should be treated in physicians’ offices, intensive-outpatient, or residential setting, doctors should rely on ASAM guidelines, not guesses. The length of treatment must be determined by necessity, not insurance. If a patient relapses, is recalcitrant, or breaks rules, treatment should be re-evaluated. They may need a higher level of care, but sick people should never be put out on the street. In addition, all practitioners must reject the archaic proscriptions against medication-assisted treatment; Rawson says that failing to prescribe addiction medications in the case of opioid addiction “should be considered malpractice.”

Programs must also address the fact that a majority of people with substance-use disorders have interrelated psychiatric illnesses. Patients should undergo clinical evaluation, which may include psychological testing. Those with dual diagnoses must be treated for their co-occurring disorders. Finally, initial treatments must be followed by aftercare that’s monitored by an addiction psychiatrist, psychologist, or physician. In short, the field must adopt gold-standard, research-based best practices.

People blame politicians, drug dealers, and pharmaceutical companies for the overdose crisis. However, that won’t help the millions of addicted Americans who need treatment now. Even the most devoted and skilled addiction professionals must acknowledge that they’re part of a broken system that’s killing people. No one can repair it but them.

Source:https://www.psychologytoday.com/blog/overcoming-addiction/201705/sobering-truth-about-addiction-treatment-in-america  May 2017

Prior research has shown Network Support, a treatment designed to increase individuals’ support for recovery and decrease their support for drinking, provides recovery benefit. How did it fare against a well-known, evidence-based cognitive-behavioral treatment?

What problem does this study address?

An individual’s social circle, also called a social network, can serve as a major foundation to help reduce relapse risk for those that are in, or are seeking, recovery from alcohol and other drug use disorder. For example, if these social network members are in recovery themselves, they may be able to serve as recovery role models helping individuals cope with increased stress, instilling confidence that challenging situations can be handled effectively (i.e., self-efficacy), and increasing one’s recovery motivation by responding positively to recovery-related actions. In line with this, Litt and colleagues showed that an intervention called Network Support, which is designed to increase recovery supportive people in one’s network and decrease drinking-supportive individuals, led to 20% more percent days abstinent across 2 years compared to a case management intervention which helped participants set goals and provided information regarding professional and community resources to meet those goals. In the current study, the authors compared recovery benefits of this Network Support intervention to a cognitive behavioral therapy (CBT) intervention, a more active intervention than case management that has a strong scientific evidence base and is commonly delivered in treatment settings.

How was this study conducted?

Before describing the study design, it is important to first outline the content of both treatments. For Network Support, therapists leveraged the existing recovery-supportive communities within Alcoholics Anonymous (AA) to help participants increase the recovery support in their network. In this study, the treatment emphasized the social aspects of AA and recognized, but downplayed its spiritual content. In addition, Network Support also highlighted other ways by which participants could increase recovery support and decrease drinking support in their network because their prior work showed that many individuals were very resistant or unwilling to attend AA. These additional strategies included social and recreational activities that would expose them to individuals that were either recovery supportive, or at a minimum not drinking-supportive. One major difference between this version of Network Support compared to the one from the original study was the inclusion of a social skills training module to help individuals engage in these new social activities. CBT in this study was based on other CBT approaches that had been vetted in prior studies. These CBT approaches are intended to help individuals identify and avoid high-risk situations, as well as to increase their coping skills to manage cravings that might result from exposure to these high risk situations if they cannot or will not avoid them. Both Network Support and CBT consisted of 12 weekly outpatient sessions that lasted 60 minutes each.

Regarding study design, authors randomly assigned 96 adults with alcohol use disorder to Network Support and 97 to CBT, assessing participants after the treatments were delivered (post-treatment), and every 3 months thereafter up through 24-month follow-up (i.e., 27 months after they entered the study). Those with other drug use disorders apart from marijuana and those with more extensive AA experience (attending 4 or more meetings in the month before entering the study) were excluded from participatiping. The treatments were compared on percent days abstinent from alcohol, as well as percent days with heavy drinking (four or more drinks for a woman and five or more for a man in one day), number of drinks per drinking day, complete abstinence, and drinking-related consequences (i.e., effects on one’s social life, employment, and health). Authors also investigated what processes during treatment explained any differences between Network Support and CBT over time. Participants were 46 years old, on average, and 66% were Male while 93% were White. The average participant had one prior episode of alcohol use disorder treatment in their lifetime, had been to one AA meeting in the past 90 days, and drank on 69 of the past 90 days with about 9 drinks each day. Controlled or moderate drinking was the goal for 30%, while abstinence the goal for 70%. Participants in Network Support and CBT were essentially equivalent on all measured demographic and drinking-related characteristics when entering the study.

What did this study find?

The two treatments had similar rates of attendance with each group attending about 7 sessions on average. As the authors predicted, Network Support participants had more percent days abstinent over time than CBT. As illustrated in the figure on the left, participants increased their percent days abstinent in the past 90 days from about 20% in both groups upon entering the study, to about 70% in Network Support vs. 65% in CBT across 2 years after receiving the treatment. The Network Support participants also had fewer drinking consequences, on average, while percent days heavy drinking and number drinks per drinking day were similar. Complete abstinence overall was statistically similar for the groups (i.e., there was not a statistically reliable difference over time). As illustrated by the figure on the right, though, the proportion of Network Support participants that were completely abstinent during an assessment period lasting 90 days was consistently higher in Network Support than CBT with the lone exception of immediately following treatment. For example, 35% of participants in Network Support were completely abstinent for 90 days compared to only 20% for CBT at the 12-month follow-up. Also as the authors predicted, the small but statistically reliable advantage for Network Support was explained, in part, by an increase in the number of abstinent individuals in one’s close social circle, AA meeting attendance, and abstinence self-efficacy. It is important to note that adopting abstinent individuals into their network through AA, specifically, did not provide additional recovery benefit in comparison to adopting abstinent individuals into their network by other strategies. Also, about half of the Network Support group, and 60% of the CBT group never attended AA during the entire 27-month study period (3-month treatment and 2-year follow-up). Put another way, this also demonstrates that despite not being explicitly encouraged to attend AA in the CBT condition, almost as many patients in the CBT condition (40%) as the Network Support condition (50%) chose to attend AA during the follow-up period.

Why is this study important?

This study shows that specific treatments like Network Support can help individuals make changes to their social network, in particular increasing the number of abstinent individuals, if they are specifically designed to do so. In addition, these changes are important to initiating and sustaining abstinence. In other studies, like this one by Kelly and colleagues, it has been shown that decreasing the number of individuals that are heavy drinkers or who support someone’s drinking also provides benefit. Network Support and CBT provided similar benefit in this area. Another important finding was the lower drinking consequences for those in Network Support despite similar rates of heavy drinking and number of drinks on each drinking day. It could be that on days where individuals drink, networks that strongly support abstinence and recovery can help buffer against consequences, serving as a base to use coping skills and providing individuals with the support and confidence needed to get back on track after a heavy drinking episode. One critical finding was that half of the Network Support group did not attend AA at all during the study period, despite specific encouragement and support to do so. This may have been because of the lower severity of the group’s alcohol problems compared to those who attend residential treatment. Only 70% were interested in an abstinence goal, which may have turned them off to AA, which explicitly encourages abstinence as a solution to alcohol use disorder. Dozens of studies following individuals in treatment over time have shown that those who are more severe, and have more psychosocial difficulties, are more likely to attend AA and other 12-step mutual-help organizations. It is encouraging that increasing abstinent individuals in one’s network by any means, including but not limited to AA, provided recovery benefit, and that such changes can be facilitated in treatment.

Limitations of this study

The focus on the study was individuals whose primary problem was alcohol. People with drug use disorders apart from alcohol and marijuana were excluded. So it is unclear if these findings also apply to individuals that have opioid, cocaine, and amphetamine use disorders, for example.

Next steps

One possible next step is to implement this treatment with a broader patient population in real-world treatment settings. For example, it will be important to see whether Network Support is effective for individuals with primary alcohol problems that also have opioid, cocaine, and/or amphetamine use disorders, as these individuals were excluded from the current study. In addition, it will also be important to see if an adapted version of Network Support is effective for those whose primary substance is an illicit drug, such as opioids. This version of Network Support could aim to leverage the recovery-supportive social networks present in the related 12-step mutual-help group Narcotics Anonymous rather than AA, given its broader focus on all drugs.

Bottom line

For Individuals & families seeking recovery:

Making changes to one’s social circle – especially adding individuals who are abstinent or in recovery themselves – is likely to increase one’s chances of initiating and sustaining abstinence over time. Therefore, treatments that help individuals do this, like Network Support, are likely to offer greater recovery benefit.

For Scientists:

This study used a rigorous design to show that Network  Support provides similar or greater recovery benefit than CBT across a range of outcomes. Their mediation analyses offer a nice example for other clinical research, as authors also showed that Network Support worked, in part, through processes they predicted a priori (e.g., increasing number of abstinent individuals in one’s network, AA meetings, and abstinence self-efficacy).

For Policy makers:

This is the second controlled study showing that Network Support provides benefit for abstinence and other recovery outcomes. Strongly consider funding for research to test its recovery benefit in real world settings.

For Treatment professionals and treatment systems:

Interventions that target social network changes are likely to help your patients. Although research in real world treatment settings is needed before a recommendation to roll Network Support out on a large scale can be made, results to this point are positive, and suggest it is likely to provide an advantage relative to case management and CBT.

Source:Drug AlcoholDepend.doi:10.1016/j.drugalcdep.2016.06.010

Seven out of 100 adolescents attend addiction treatment each year. This study used an in-depth qualitative research approach to examine the processes underlying “successful” adolescent recovery.

What problem does this study address?

Of all individuals who seek treatment for alcohol and other drug use disorders (i.e., substance use disorder), 7% are adolescents between 12 and 17 years old. For these youngest treatment seekers, relapse rates are high, with estimates from different studies suggesting 55-90% drink or use other drugs within the first year after completing treatment. From a developmental perspective, adolescents have unique clinical qualities making them different from young adults and older adults in terms of the nature of their substance use problems, and the different factors that influence these problems positive and negatively. For example, research shows that environmental influences on substance use predominate among adolescents, while family history (e.g., genetic influences) becomes more prominent during young adulthood. Yet, we often conceptualize substance use disorder recovery in adolescents like we do adults: a lifestyle marked by abstinence with an emphasis on personal growth and citizenship. This study used an intensive, qualitative approach to describe and further our understanding of the critical elements of adolescent recovery among members of Teen and Family Services, an Alternative Peer Group in the Southwestern United States nested within a recovery oriented system of care, including a hospital based treatment facility and a recovery high school. Alternative Peer Groups, also referred to as APGs, are recovery support services for adolescents with substance use disorder that engage them in a community of other recovering adolescents, to capitalize on the same desire for peer acceptance that is known to drive, in part, adolescent motivations for substance use. Alternative Peer Groups are grounded in the theory that, if centered on fun activities with peers, recovery will be perceived as more rewarding than substance use.

How was this study conducted?

A qualitative approach called clinical ethnography was used in this study, which is characterized by immersion in the environment being examined, the Alternative Peer Group at Teen and Family Services in this study. The program was designed to last 9 to 12 months, and like other Alternative Peer Groups, its explicit goal is “full engagement in the 12-step program of recovery from substance use disorder”. Study methods include field notes, observation, records examination, as well as group and individual interviews. Participants were 14 alumni of the Alternative Peer Group (11 males and 3 females; 15-30 years old) with 1 or more years abstinent (1-11 years) who were actively involved in a 12-step program. In addition to program alumni, study authors also interviewed parents of Alternative Peer Group participants, and program staff/leadership.

What did this study find?

Study findings yielded two overarching themes of adolescent recovery: 1) “Journey” and 2) Relationships. The “journey” was marked by stages of preparation, engagement, “working a program”, and recovery maintenance. Relationships were key aspects of each of these four stages, with an emphasis on recovery role models, both with similarly-aged individuals as well as those who were older and had more experience in recovery. Participants identified the preparation stage (months 1-2) as most critical given that many adolescents entered the Alternative Peer Group with a great deal of resistance and ambivalence regarding changing their substance use. Young adult staff, who were in recovery themselves, helped adolescents through this ambivalence and provided support to help them get back on track if they drank or used drugs. To work through the preparation stage, participants outlined the importance of “fun friends” and an increased “sense of belonging” in order to help increase their recovery motivation. They also cited the importance of bonding with recovery role models who demonstrated “enthusiastic sobriety”. Engagement (months 3-6 months) was the result of preparation and was typically facilitated through the benefits of a relationship, with a 12-step mutual-help sponsor for example. “Working a program” was characterized by working the 12 steps and spending time with other individuals who had active recovery lifestyles (i.e., “sticking with the winners”). These processes helped individuals cultivate and build on skills and coping strategies they learned in treatment. Recovery maintenance was characterized differently by alumni and program staff. While the alumni all described recovery as maintaining abstinence, program staff felt abstinence was key through adolescence and until their brain development was complete (i.e., through mid to late 20s). They were more open-minded about adolescents being able to engage in low-risk drinking as they entered into adulthood.

Why is this study important?

Elements specific to adolescent recovery identified by this study included participants’ desire for recovery activities and programming to be fun. Other important elements included the structure, monitoring, and reinforcement of recovery activity attendance, and bonding with positive recovery role models. Participation in fun recovery activities and forming relationships with other, particularly more experienced, recovering individuals are characteristics that map onto other qualitative research findings with adolescents and young adults. Regarding their participation and perceived benefit from 12-step mutual-help organizations, like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), for example, research has shown that finding a sense of belonging and feeling a sense of universality — having a shared experience or problem — are important subjective experiences of youth recovery. In a related study, Labbe and colleagues showed that, for young adults, the degree to which other young people are present at AA and NA meetings is related to recovery benefit early on (i.e., 3-6 months after initiating recovery), while meetings with older, more experienced individuals is more strongly related to benefit later on (e.g., 6-12 months after initiating recovery). So while connection with both peers and more experienced recovering individuals may be important, these relationships could serve different purposes depending on a person’s stage of recovery.

The mention specifically of “fun activities” is consistent with adolescent treatments for substance use disorder, such as the Adolescent Community Reinforcement Approach. This evidence-based treatment, like alternative peer groups, emphasizes the benefit of engaging adolescents in rewarding activities while abstinent, to compete with the rewarding effects of alcohol and other drug use.

In addition, the “journey” of recovery described by authors parallels the well-known “stages of change” from the transtheoretical model of changing addictive behaviors delineated by Prochaska and DiClemente, and studied extensively among individuals with SUD. The stages of pre-contemplation and contemplation from the model pre-date the beginning of the “journey” as described in this study. That said, preparation, action, and maintenance from the transtheoretical model map well onto preparation, engagement/working a program, and recovery maintenance from this study.

Limitations of this study

This study was conducted in a single program with only 14 individuals all of whom were immersed in a 12-step focused program and had achieved 1 or more years of recovery. Also, the findings reflected perceptions of parents and staff members. Consequently, the findings may not represent the population of adolescents in, or seeking, substance use disorder recovery, or the multitude of settings where adolescents may seek treatment more generally (school, outpatient, residential, etc.). That said, the similarities between members of this Alternative Peer Group and other adolescent treatment and recovery theories described above raise confidence in the applicability of these general key recovery processes across a range of settings and adolescent clinical samples. Also of note, for some of the older young adults (e.g., in their late 20s), they were reflecting on experiences that occurred several years prior. These retrospective reports may have been influenced by more recent events in the participant’s life (i.e., shaping how they remember the past), and should be interpreted with some caution.

Next steps

Recovery definitions may be variable, but all allude to outcomes beyond abstinence, such as better emotional well-being. The recovery processes described here seemed to focus more on substance use. Future studies might help illuminate adolescent recovery processes in terms of other areas of their functioning. In addition, future work might investigate change more generally among adolescents with substance use disorder. For those not interested in a “program of recovery” closely linked with 12-step mutual-help organizations, for example, how do they initiate and sustain recovery? Are the processes similar or different from those described in this study of alumni in an Alternative Peer Group who were heavily involved in 12-step organizations?

Bottom line

For Individuals & families seeking recovery:

For adolescents, engaging in fun activities with other individuals in recovery, and establishing relationships with recovery role models may be key aspects of the recovery process.

For Scientists:

Clinical ethnography was used in this study to investigate the process of adolescent recovery from substance use disorder. This intensive qualitative approach is somewhat similar to community-participatory research where researchers become well integrated into the community over time. This

model may represent a valuable methodology to understand better the complex process of recovery in subgroups like adolescents that presumably have less traditional experiences compared to adults.

For Policy makers:

Adolescent recovery remains an important field of investigation. It is recommended that policy makers continue to allot funds to investigate optimal strategies to engage and retain adolescents in treatment and recovery support services, and help them successfully re-integrate into their communities.

For Treatment professionals and treatment systems:

Adolescent and adult recovery is likely to have areas where they are similar, like the importance of having a shared experience with other individuals in the program. There might also be processes that adult and adolescents have in common, but are particularly salient in adolescent recovery. These might include, for example, engagement in fun activities with other recovering individuals and cultivating relationships with older individuals who support the adolescent’s recovery. It may be helpful to brainstorm extensively with adolescents a menu of fun activities from which they can choose.

Source: Nash, A., Marcus, M., Engebretson, J., & Bukstein, O. (2015). Recovery From Adolescent Substance Use Disorder: Young People in Recovery Describe the Process and Keys to Success in an Alternative Peer Group. Journal of Groups in Addiction & Recovery, 10(4), 290-312. doi:10.1080/1556035X.2015.1089805

At Californian methadone clinics, group education sessions led by a nurse and focused on the risks of aggravating hepatitis infection led to the same substantial reductions in drinking as one-to-one or group motivational interviewing conducted by highly trained counsellors, offering a cost-effective means to reduce alcohol-related risks.

Summary Many methadone-maintained patients drink excessively, a particular concern among those infected with hepatitis C for whom drinking may accelerate disease progression. Motivational interviewing is the most popular counselling approach found to reduce drinking, but so far no studies have tested it among patients treated for opioid dependence in methadone maintenance programmes.

The featured study aimed to start to fill this gap in the research and at the same time (given the dominance of group counselling in US treatment services) compare one-to-one motivational interviewing with the less familiar group version, and with a nurse-led group education programme focused on the relation between drinking and disease related to hepatitis C infection.

Each of the three approaches occupied three fortnightly one-hour sessions over the first six weeks after patients started methadone treatment. Interventions were guided by set protocols and delivered by staff trained in these approaches and supervised to help ensure they delivered them as intended. Patients were paid $5 for each session they attended.

Group and individual motivational sessions were generally conducted by different counsellors. Sessions explored the impact of drinking on health and risky behaviours and while focusing on life goals, worked through ambivalence about cutting drinking. Sessions were open, meaning that patients who had not completed three sessions in their original group could join a later one. Instead of a motivational approach, the nurse-led (assisted by a hepatitis-trained research assistant) hepatitis health promotion programme adopted an educational format. Sessions focused on the progression of hepatitis infection and culturally-sensitive strategies to prevent liver damage. Content included the dangers of drinking while infected with hepatitis, strategies for avoiding drinking and drug use, diet, the dangers of reinfection with hepatitis C if patients inject, other infection routes, consistently looking after one’s health, and seeking social support and building self-esteem.

After these sessions patients suitable for this started a course of hepatitis A and B vaccinations, concluding at the same time as a six-month follow-up interview.

Participants in the study were 256 adult drinkers starting methadone treatment at five Californian clinics who scored as moderate or heavy drinkers on a baseline questionnaire. They were randomly allocated to the three approaches to reducing drinking. Typically they were black or Latino men. On entering treatment about half had drunk at least 90 US standard drinks in the past month. On average 87% of the patients completed all three of the study’s counselling/education sessions and 91% completed the six-month follow-up.

Main findings

The main outcome tested by the study was the proportion of patients who cut their drinking by half from the month before they started treatment to the month before the six-month follow-up. On this yardstick, and on the yardstick of total abstinence, there were not only no statistically significant differences between patients allocated to the three interventions, but also no substantial differences. In each group about half the patients halved their drinking, ranging from 54% after group motivational sessions to 49% after hepatitis education and 47% after one-to-one motivational sessions, and from 20–23% had not drunk at all in the past month.

Once other variables had been taken in to account, across the three sets of patients the strongest predictor of which patients would halve their drinking was how much they drank before treatment; the more they drank, the more likely they were to halve it. Women were more likely to halve their drinking than men as were better educated patients and those who took at least one dose of vaccine, while less likely were those whose partners were also drug users or who had recently used cannabis.

The authors’ conclusions

The major finding of this study was that all three interventions were followed by roughly equally substantial reductions in drinking at the six-month follow-up. Delivered by trained therapists, group and one-to-one motivational interviewing sessions neither differed in effectiveness from each other nor from a nurse-led group hepatitis education programme focused on reducing drinking.

For services the implications are that the cost-saving group format can be used without detriment to effectiveness and that costs may also be saved by implementing programmes led by nurses rather than therapists, with the potential added benefit that such programmes can be integrated within more comprehensive health promotion. Research nurses also administered the vaccines, receipt of which was associated with drinking reductions, perhaps partly because of the extra time and attention required to explain the vaccine.

It should be acknowledged that any differences between the interventions may have been obscured by differences between the staff implementing them, and that patients had volunteered for a research study rather than being counselled during routine practice.

Source:  Drug and Alcohol Dependence: 2010, 107(1), p. 23–30.Reported in Findings.org.uk

However the following information shows this substance is far from harmless and more and more users are seeking treatment to help them give up.     NDPA  March  2015

The emerging cannabis treatment population:

http://www.emeraldinsight.com/doi/abs/10.1108/DAT-01-2014-0005?journalCode=dat 

Increasing numbers of Belgian teenagers are seeking help for cannabis use, De Standaard reported on Monday.

According to a report by the Flemish Association of Addiction Treatment Centres Care (VVBV), in 2013 495 boys and 78 girls aged between 15 and 19 sought assistance over continued use of the drug.

In addition, 36 children under the age of 15 also asked for help.

The report also found that more and more women are seeking help for heroin and cocaine use.

Counselling services are now been targeted at the young.

“Young men with a cannabis addiction used to be all in their twenties before they took the step to recovery.

In recent years, more and more 15- to 19-year olds are added, and they became a separate group in health care,” said VVBV Chairman Dirk Vandevelde.

“Based on these figures, it is difficult to estimate whether it is youth who are experimenting or already have an advanced addiction, and how long they remain in counselling,” he said.

Last week, a law allowing for the sale of medical marijuana was published in Belgium.

The law will come into effect at the beginning of July.

Amongst the drug’s medical properties is the alleviation of pain for sufferers of conditions such as multiple sclerosis.

Source:

http://news.xinhuanet.com/english/2015-06/15/c_134328368.htm  15^th June 2015

A stressed rat will seek a dose of cocaine that is too weak to motivate an unstressed rat. The reason, NIDA researchers report, is that the stress hormone corticosterone increases dopamine activity in the brain’s reward center. When an animal is stressed, the cocaine-induced dopamine surge that drives drug seeking rises higher because it occurs on top of the stress-related elevation.

Graduate student Evan N. Graf, Dr. Paul J. Gasser, and colleagues at Marquette University in Milwaukee, Wisconsin, traced the physiological pathway that links stress and corticosterone to increased dopamine activity and heightened responsiveness to cocaine. Their findings provide new insight into cocaine use and relapse, and point to possible new medication strategies for helping people stay drug free.

Stress Increases Sensitivity to Relapse Triggers

Former drug users who relapse often cite stress as a contributing factor. The Marquette researchers observed that when stress figures in relapse, other relapse promoters are almost always present as well. Dr. Gasser explains, “It’s never one single event that triggers relapse. It’s the convergence of many events and conditions, such as the availability of the drug, cues that remind people of their former drug use, and also stress.” On the basis of this observation, the researchers hypothesized that stress promotes relapse by making a person more sensitive to other relapse triggers.

To test their hypothesis, the researchers put stressed and unstressed rats through an experimental protocol that simulates regular drug use in people followed by abstinence and exposure to a relapse trigger. As the stressor, they used a mild electric foot shock; as the relapse trigger, they administered a low dose of cocaine (2.5 milligrams per kilogram).

The results confirmed the hypothesis. The stressed rats, but not the stress-free animals, responded to the small cocaine dose with a behavior that parallels relapse in people: They resumed pressing a lever that they had previously used to self-administer the drug (see Figure 1, top graph).

Text Description of Graphic

A Stress Hormone Underlies the Effect

Mr. Graf and colleagues turned their attention to the question of how stress sensitizes animals to cocaine’s motivational effect. One likely place to start was with the hormone corticosterone. In stressful situations, the adrenal glands release corticosterone into the blood, which carries it throughout the body and to the brain. Among corticosterone’s physiological roles is that it affects glucose metabolism and helps to restore homeostasis after stress. The Marquette researchers demonstrated that increasing cocaine’s potential to induce relapse also belongs on the list of corticosterone’s effects. Reprising their original experimental protocol with a couple of new twists, they showed that:

• Corticosterone is necessary for stress to promote relapse to cocaine seeking: The researchers removed rats’ adrenal glands, which prevented the animals from producing corticosterone. In this condition, the animals did not exhibit relapse behavior when exposed to the stressor and low-dose cocaine.
• Corticosterone in the brain reward center is sufficient by itself to increase cocaine’s potency as a relapse trigger:The researchers injected these same rats with corticosterone, bringing the hormone concentration up to stress levels in the brain reward center (nucleus accumbens, NAc). Now the animals exhibited relapse behavior when exposed to cocaine, even without the stressor (see Figure 1, middle graph).

Enhanced Dopamine Activity…

The researchers next took up the question: What does corticosterone do in the NAc to increase cocaine’s potency to induce relapse? A hypothesis that suggested itself immediately was that the hormone enhances dopamine activity. Dopamine is an important neuromodulator in the NAc, and all addictive drugs, including cocaine, produce their motivating effects by increasing dopamine concentrations in the NAc.

The Marquette team showed that, indeed, stress-level concentrations of corticosterone enhance the cocaine-induced rise in extracellular dopamine in the NAc. In this experiment, the researchers exposed two groups of rats to low-dose cocaine, then measured their NAc dopamine levels with in vivo microdialysis. One group, which was pretreated with corticosterone injections, had higher dopamine levels than the other, which was not pretreated.

The Marquette team firmed up their hypothesis with a further experiment. They reasoned that if corticosterone promotes relapse behavior by increasing dopamine activity, then preventing that enhancement should prevent the behavior. This indeed turned out to be the case. When the researchers injected animals with corticosterone but also gave them a compound (fluphenazine) that blocks dopamine activity, exposure to low-dose cocaine did not elicit relapse behavior.

…Due To Reduced Dopamine Clearance

So far the Marquette team had established that the stress hormone corticosterone promotes relapse behavior by increasing dopamine activity in the NAc. Now they moved on to the next question: How does corticosterone enhance dopamine activity?

To address this question, the researchers considered the cycle of dopamine release and reuptake. In the NAc, as elsewhere in the brain, dopamine activity depends on the concentration of the neurotransmitter in the extracellular space (space between neurons): the higher the concentration, the more activity there will be. In turn, the extracellular dopamine concentration depends on the balance between two reciprocal ongoing processes: specialized neurons releasing dopamine molecules into the space, and specialized proteins drawing molecules back inside the neurons.

Mr. Graf and colleagues discovered that corticosterone interferes with the removal of dopamine molecules from the extracellular space back into cells. It shares this effect with cocaine, but achieves it by a different mechanism.

In this experiment, the researchers measured real-time changes in dopamine concentration in the NAc in response to electrical stimulation of dopamine release in the area. This technique allowed the team to measure both A) the rate of increase in dopamine concentration, indicating the amount of dopamine released; and B) the rate of decrease in dopamine concentration, indicating the rate of dopamine clearance. The scientists measured stimulation-induced increases and decreases in extracellular dopamine concentrations under three conditions: at baseline, after giving the animals a compound that blocks the dopamine transporter (DAT), which is the mechanism whereby cocaine inhibits dopamine removal; and, last, after injecting the animals with corticosterone. They found that:

• As happens with cocaine, the clearance of extracellular dopamine decreased after DAT blockade.
• Clearance of extracellular dopamine decreased further after corticosterone.

A Candidate Mechanism

One question remained outstanding to complete the picture of how stress potentiates the response to cocaine: What is the mechanism whereby corticosterone reduces dopamine clearance?

Mr. Graf and colleagues noted that previous research provides a likely answer: Corticosterone has been shown to inhibit the functioning of the organic cation transporter 3 (OCT3), which is another of the specialized proteins that, like DAT, remove dopamine from the extracellular space. To confirm this hypothesis, the researchers resorted again to their initial experimental protocol. This time, they injected rats with a compound (normetanephrine) that blocks OCT3, followed by low-dose cocaine. The animals responded by resuming their previously abandoned lever pressing  behavior, proving that OCT3 blockade is sufficient to potentiate the response to cocaine (see Figure 1, bottom graph).

The Marquette researchers say that further studies will be required to definitively establish that OCT3 plays the role their evidence points to. Taken together, however, their experiments trace a complete pathway connecting stress to an animal’s enhanced responses to cocaine (see Figure 2):

• Stress raises corticosterone levels.
• Corticosterone blocks OCT3, inhibiting dopamine clearance and thereby raising dopamine activity in the NAc.
• When a stressed animal is exposed to cocaine, the resulting dopamine surge builds on the foundation of this already higher-than-normal level of dopamine activity.
• The added elevation of the dopamine surge increases the animal’s motivation to seek the drug.

Figure 2. Stress Amplifies Cocaine’s Effect on Dopamine Release in the Nucleus Accumbens (NAc) The schematic illustrates how stress may enhance cocaine’s motivational effect and increase the risk for relapse. A) Cocaine binds to the dopamine transporter (DAT) on dopamine-releasing neurons in the NAc, reducing dopamine (DA) clearance and, in turn, increasing extracellular dopamine. B) Stress causes release of corticosterone, which inhibits the OCT3 transporter, further reducing dopamine clearance and increasing extracellular dopamine. The resulting heightened dopamine stimulation of medium spiny neurons (MSNs) enhances drug seeking.

Text Description of Graphic

Stress–Relapse Connection Unraveled

“Our findings show that stress doesn’t just cause relapse behavior by itself, but interacts with other ongoing behaviors to influence relapse,” Dr. Gasser says. “This insight provides a better picture of how stress can affect addiction. It helps us understand why treating cocaine addiction is so difficult and will help in designing therapies whether they be based on pharmacotherapy or counseling.” The researchers believe—and are testing as a hypothesis—that stress increases the power of environmental drug-associated cues to trigger relapse, just as it does the power of low-dose cocaine.

Although researchers have long known that stress plays an important role in relapse, pinning down its role experimentally has been a challenge, says Dr. Susan Volman, program officer and health science administrator at NIDA’s Behavioral and Cognitive Science Research Branch. “This study provides a perspective of stress as a stage-setter or modulator for relapse, and it gets all the way down to the molecular mechanism. Based on this team’s findings, OCT3 offers a potential new target for developing pharmacological therapies to help with treating addiction,” Dr. Volman says.

This work was supported by NIH grants DA017328, DA15758, and DA025679.

Source:

Graf, E.N.; Wheeler, R.A.; Baker, D.A. et al. Corticosterone acts in the nucleus accumbens to enhance dopamine signalling and potentiate reinstatement of cocaine seeking. Journal of Neuroscience 33(29):11800-11810, 2013. Full text

An interactive mobile texting aftercare program has shown promise as a means to help teens and young adults engage with post-treatment recovery activities and avoid relapse, researchers report. In a NIDA-supported pilot study, the program, called ESQYIR (Educating & Supporting Inquisitive Youth in Recovery), reduced young people’s odds of relapsing by half compared with standard aftercare.

Dr. Rachel Gonzales and colleagues at the University of California, Los Angeles (UCLA), designed ESQYIR to teach and reinforce wellness self-management in a manner that fits young people’s attitudes and communication styles. The researchers cite numerous advantages of the mobile texting approach: It is inexpensive and features personalization of content, convenience of use, ease of assessment and monitoring, and flexibility in the time and location of delivery.

The Need

Many young people comply poorly with aftercare interventions and resist involvement in 12-step programs and other post-treatment recovery activities. Dr. Gonzales says, “Teens and young adults don’t want to be stigmatized as having a disease or as still being in recovery. In their minds, after the primary treatment, they are done.” Young people often don’t view addiction as a disease, she adds. Instead, they regard substance use as a matter of lifestyle and personal choice. As a result, as many as 85 percent of teens and young adults relapse within 1 year.

Dr. Gonzales and her research team reckoned that young people might engage more readily with aftercare built on text messaging. This mode of communication is ubiquitous among young people, surpassing most other forms of social interaction. Messages can be personalized and can be accessed and responded to privately, when and where youths find it convenient or feel a need for help. Text messaging interventions are already used to treat maladies including obesity, sexually transmitted diseases, and tobacco dependence in young adults.

“The most effective programs take into consideration the users, their needs, their desires, and their way of connecting,” Dr. Gonzales says. Accordingly, when she and her team composed the text messages for Project ESQYIR, they solicited input from young people in recovery from substance use disorders (SUDs). “The program’s text messages are based on their voices, parallel their views of recovery, and speak to their recovery needs,” Dr. Gonzales says.

Keeping Tabs With Texts

The participants in the ESQYIR pilot study were 80 volunteers, ages 14 to 26, who had been treated in outpatient and residential community treatment centers in the Los Angeles area. The drugs that had caused them problems included marijuana (55 percent), methamphetamine (30 percent), cocaine (15 percent), heroin (11 percent), prescription drug (6 percent), and other substances including alcohol (4 percent). Half of the participants received the mobile texting ESQYIR program, the other half received the standard aftercare offered by their treatment facilities, which consisted of referral to 12-step programs.

Figure 1. Daily Mobile Texts Prompt Self-Monitoring, Give Recovery Advice and Encouragement

The participants in the text messaging program received daily text messages with tips to self-monitor their recovery- and substance use–related behaviors and with alerts to aftercare services in their community.

Each weekday at 12 noon, the participants in the ESQYIR group received a text that reminded them about being in recovery and provided a wellness tip for the day. The reminder portion of the text said, “Today’s a new day in ur recovery! Think about the change ur working towards.” The wellness tip promoted personal, social, physical, or emotional health. For example, one message read, “Write down the top 3 stressors that u need to avoid or deal with for helping u not use.”

Weekdays at 4 p.m., the participants in the ESQYIR group received a text that prompted them to self-monitor and text back numerical ratings of their abstinence confidence, wellbeing, substance use, and recovery behaviors (see Figure 1). The participants then received a feedback text, automatically selected from more than 600 possible messages, which provided motivational/inspirational encouragement, coping advice, or positive appraisal tailored to the participants’ self-rating. For example, motivational feedback texts encouraged participants to keep on track with recovery and attend therapy or self-help meetings when needed.

Dr. Gonzales says, “The self-monitoring texts helped participants remain mindful and aware of potential relapse triggers, particularly in risky situations.” With that awareness and the feedback provided by the program, the young people were able to generate strategies for coping with such situations without drugs, the researchers suggest.

On weekends, the participants received personalized texts with educational information adapted from NIDA reference materials and resource information on local support services.

Less Relapse, More Engagement

Figure 2. Text-Based Delivery of Aftercare Content Decreases Relapse

Teens and young adults receiving daily text messages had lower relapse rates than peers receiving only standard aftercare.

The UCLA researchers monitored the participants’ urine for alcohol and drugs monthly during the program. The results indicated that with passing time, the text-based aftercare participants’ odds of relapsing to their primary substances rose only half as fast as those of the standard aftercare group. Compared with the participants in standard aftercare, those assigned to the ESQYIR group were less likely to have relapsed 1 month (8.6 percent vs. 30.3 percent), 2 months (3.6 percent vs. 39.3 percent), and 3 months (14.7 percent vs. 62.9 percent) after the end of their substance abuse treatment (see Figure 2).

The researchers followed up with 55 of the original 81 study participants 180 days after the end of treatment (90 days after the end of the aftercare programs). Those who had received the ESQYIR mobile wellness aftercare intervention were still less likely to have relapsed (21.4 percent vs. 59.3 percent).

The ESQYIR and standard aftercare participants both attended on average ten 12-step meetings per month during their last month in substance abuse treatment. Both groups reduced their 12-step attendance in the aftercare period, but the ESQYIR participants did so to a lesser degree (8.9 vs. 2.9 meetings in the final month). The two groups no longer differed significantly in 12-step attendance during the third month post-aftercare (7.0 vs. 4.6 days per month). However, during that month the ESQYIR participants were more involved in other recovery-related extracurricular activities (e.g., exercise, walking, and community/volunteer service) than those who received the standard aftercare.

Text and Thrive

Dr. Gonzales and colleagues are planning a larger, stage II efficacy trial of the mobile-based ESQYIR aftercare wellness intervention. For this trial, they are enhancing the program with new features, including text messages to foster HIV awareness and prevention.

“We look forward to further research in this line of work and to learning more about the efficacy of this intervention,” says Dr. Jessica Campbell Chambers, health science administrator at NIDA’sBehavioral and Integrative Treatment Branch. “This work is extremely important given the high rates of relapse among recovering adolescents.”

Dr. Campbell Chambers concurs with Dr. Gonzales that although the pilot nature of the study and its relatively small cohort size make its results only preliminary, the findings are very promising. The UCLA study team will soon publish a report on the ESQYIR program’s effects at 6- and 9-months post-participation.

This study was supported by NIH grant DA027754.

Source

Gonzales, R.; Ang, A.; Murphy, D.A. et al. Substance use recovery outcomes among a cohort of youth participating in a mobile-based texting aftercare pilot program. Journal of Substance Abuse Treatment 47(1):20-26, 2014.

Berlin, like many big cities has a heroin problem. People presenting for help are being prescribed opioid replacement therapy (ORT) in greater numbers. That’s a good thing isn’t it? Well it depends on what you think is the end goal of treatment. At the start of this interesting recent German paper “Why do patients stay in opiod maintenance treatment?”, Dr Stefan Gutwinski and colleagues say that the scientific literature indicates the point of ORT is: “to increase survival and bring stabilization to patients, in order to enable them to reach abstinence of opioids.” The Scottish Government’s drugs policy and the UK policy agree.

We can simplify this into two aims:

1. To make things better, then

2. To move on to abstinence

The problem is that while the evidence is pretty solid that number one is generally achieved, there is less to convince us that the next bit is happening. The paper outlines that retention in ORT is not great, with just over half of patients sticking with methadone and fewer with Suboxone. Despite this, in Berlin, as we have said, there are growing numbers of people on ORT. These are people who are not moving on; I suppose the ones the press call ‘parked’ on methadone. So the authors ask: “Why is this?”

The researchers speculated that it could be because:

* fewer people are dying;

* that people don’t want to move on because of the benefits they are getting;

* that detox is generally unsuccessful, or

* that what staff think patients want is not what patients actually want.

To test this out they sent out an anonymous questionnaire to treatment settings in Berlin. Forty-six staff (more than half doctors and the rest nurses and admin) and 986 patients completed it. They focussed on whether ORT was of benefit, whether it was perceived as harder to detox from than heroin and how strongly patients wished to come off of ORT compared to how strongly staff thought their patients wanted to come off.

What did they find?

1. Both patients and staff thought ORT helped physical and mental health. Beneficial effects of ORT on the ability to work and on crime were rated significantly higher by patients compared to staff.

2. Staff and patients agreed that coming off ORT was hard. Patients thought it harder than coming off heroin.

3. Patients wanted to eventually come off ORT at a significantly higher rate than staff estimated.

About half of the patients in the sample were over 40 years old and more than one in ten were over 50 with almost three quarters of patients struggling with opiate dependency for more than ten years. Only ten percent had never tried to detox, suggesting high failure rates which may have reinforced the belief that ORT was hard to more on from. There was no differentiation made between methadone and Suboxone. Perhaps methadone is seen as more ’sticky’ to move on from. The study didn’t look at whether evidence based support and treatment was given at the time of the detox.

The thing that intrigues me the most is the “striking discrepancy between the patients’ and staff members’ assessment of the patients’ desire to end OMT on the long term. The large majority of patients report the desire to end OMT on the long term, whereas only a minority of staff members believe that their patients might really have such a desire.”

David Best found much the same thing (in aspirational terms) in a sample of drugs workers in the UK. They believed only 7% of their clients would eventually recover. The DORIS study in Scotland angered some professionals when it reported that many patients entering treatment wanted only to become drug-free; something treatment was not delivering. A recent study in Leeds found that service users, their families and friends placed “considerable weight” on abstinence and “ways of maintaining abstinence”. It’s clear to me that where there is such a mismatch, when the bar is set so low and when there is little hope pervading treatment settings, then it’s no wonder that so few actually do move on.

By the conclusion the authors find themselves at odds with the assertion at the start of the paper (that ORT has an aim of ‘abstinence from opioids’.) Here’s what they say (my emphasis):

“Finally, detoxification of OMT is not the prime objective of treatment. The prime objective of treatment is continued physiological and social stabilization. As yet, there is no validated medical cure for opioid addiction. Until a curative medication or a safe curative procedure is developed, many of the patients may have to remain in treatment for the duration of their lives to avoid relapses, increased criminality, subsequent overdoses, and death during the post treatment period.”

So the solution to the mismatch between the low expectation of staff and the higher expectation of patients is to lower the expectation of patients to that of staff? Well that’s one way of looking at it. We still have the problem that lifelong ORT, whatever its evidenced benefits, is not what people want and that, in fact, many do move out of opiate dependence into long term abstinent recovery. These people would no doubt agree that methadone did make things better, but for them it was not the final destination.

What would it be like if the dearth of recovery-oriented research in the UK was addressed, if we focussed on what works rather than what doesn’t? If all we do is compare ORT with stand-alone detox, then we are always going to see poor outcomes. Another more enlightened and rewarding approach might be to move away from thinking about a drug or a medical ‘cure’ as being the solution to addiction and looking to introduce recovery-oriented systems of care using strongly evidence-based psychosocial interventions and treatment where those interventions are of adequate intensity and duration. Linking people to recovery communities is protective with regards to relapse, but there is little evidence that it is happening.

In the UK we have recovery-oriented drugs policies which aim for rapid access to treatment with a variety of approaches on offer. The answer is not to lay out the choice as ‘methadone or abstinence’ but to see how we use ORT as a tool and to find ways of bridging people out of treatment and reliance on services into recovery. Some may have to remain in treatment in the long term, but we need to set the bar high and be positive about patients’ ability to move on. Professionals should spend time with people in recovery to engender hope in themselves. The ethos and structure of systems of care need to change so that recovery becomes the norm instead of a wild aspirational status that we actually believe most people will never achieve.

Now how do we make that happen?   D. J. Mac

Thanks to Stefan Gutwinski for a copy of the paper to review. For information: I wrote a shorter piece on this based on the abstract a few weeks ago.

Source: Substance Use and Misuse, 49:694-699, 2014

Kouimtsidis C., Reynolds M., Coulton S. et al.
Drugs: Education, Prevention and Policy: 2011, early online publication.
Request reprint using your default e-mail program or write to Dr Kouimtsidis at drckouimtsidis@hotmail.com

Compromised by an inability to interest enough patients, the only randomised UK trial of cognitive-behavioural therapy for methadone patients was unable to be definitive but did find some signs of benefit and that the therapy had pulled some of the intended psychological levers.

Summary Cognitive approaches to treating substance misuse problems are still relatively new and it is important to understand how they work. Relevant treatment models emphasise the role of: self-efficacy to cope with situations associated with drug use without using; developing skills to cope with these situations as well as skills to generate broader lifestyle changes; and changing patients’ expectations of the positives and negatives of using the substance. Successful treatment is theorised to result from a reduction in the extent to which patients expect positive outcomes from substance use, an increase in their negative expectations, and enhanced self-efficacy and coping skills.

The featured study was the first study to directly test this model in the context of substitution treatment for opiate dependence. The findings derive from the UKCBTMM United Kingdom Cognitive Behaviour Therapy Study In Methadone Maintenance Treatment. study, which investigated the effectiveness and cost-effectiveness of cognitive-behavioural therapy for patients in opiate substitute prescribing programmes, itself the first randomised controlled trial of a psychosocial intervention in this setting in the UK.

At several UK treatment centres, the study randomly allocated substitute prescribing patients to keyworking only or keyworking plus cognitive-behavioural therapy, and assessed whether the additional therapy improved outcomes six and 12 months later. Additional therapy was offered weekly for 24 weeks but typically patients attended only four sessions. Therapists and keyworkers were recruited from existing staff and the therapists were trained and supervised in the therapy.

Perhaps because so few patients were eligible for and prepared to join the trial (just 60 did so of 369 who were eligible), though there were outcome gains from the extra therapy, none were statistically significant. Nevertheless, as measured by their effect sizes, A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen’s d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. In the featured study effect sizes were expected to be about 0.3. the gains were as large as expected in terms of reductions in the severity of addiction and heroin use, and improved compliance with prescribed methadone use. The cost of the extra therapy was more than outweighed by savings in health, social, economic, work, and criminal justice costs. Perhaps because patients had already been in methadone treatment for on average five months, these savings were less than in some other studies, and the difference in cost savings between therapy and non-therapy groups was not statistically significant.

Main findings

However, the featured report was less concerned with whether extra cognitive-behavioural therapy improved the end result of methadone treatment, than with how it might have done so. One way was expected to be by improving how well patients coped with life’s problems, a concept measured by a standard questionnaire which assessed different aspects of this ability. Relative to keyworking only, as expected, at six months the therapy was followed by a significant improvement in the degree to which patients positively reappraised problems, and a non-significant improvement in problem solving. Other domains where additional improvements were expected (logical analysis, seeking guidance and seeking alternatives) improved to roughly the same degree regardless of the extra therapy. Six months later (and 12 months after therapy had started) a similar analysis revealed that nearly all the expected mechanisms had improved after cognitive-behavioural therapy but deteriorated without it. The exception was logical analysis, where the reverse pattern was seen. Despite these trends, none of differences between patients who had or had not been offered cognitive-behavioural therapy were statistically significant, so chance variation could not be ruled out.

As expected, the degree to which patients felt confident that they could resist the urge to use drugs (‘self-efficacy’) increased after cognitive-behavioural therapy but decreased (at six months) or increased less (at 12 months) without this therapy. Patients were also asked about the good and bad consequences they expected from cutting down their heroin use. These measures changed in the opposite to what was expected; patients offered the therapy became relatively less positive and more negative about cutting down. Again, none of these differences between the two groups of patients were statistically significant.

Further analyses not reported here assessed changes among only patients who attended at least one session of their intended psychosocial intervention and related changes to the number of therapy sessions attended.

The authors’ conclusions

Though no definite conclusions can be taken from this study, there are indications that the therapy may be effective through at least some of the intended mechanisms, but also that methadone-maintained patients at services as configured in England in the 2000s generally reject the chance for this form of extra therapy.

The fact that few patients were prepared to join the study and that those who did attended few therapy sessions suggest there could be major barriers to implementing cognitive-behavioural therapy in routine practice in the British drug treatment system, perhaps associated with a culture of limited psychological therapy and relatively low expectations of clients’ engagement and compliance with treatment.

With such a small sample there is a heightened possibility that real differences made by the therapy will fail to meet conventional criteria for statistical significance and be mistakenly dismissed as chance variation. That this might have happened is suggested by the fact that the relative increase in days free of heroin use after six months was as great as expected. With a larger sample, it might well have also proved statistically significant. Economic analyses also found non-significant but appreciable net social cost-savings. The featured analysis supplements these outcome findings with indications that cognitive-behavioural therapy may have fostered some but not all of the crucial problem-solving skills.

The main seemingly counter-productive finding related to expectations about the pros and cons of reducing heroin use as measured by a scale yet to be validated. Also, more sessions of therapy did not further enhance the presumed psychological mechanisms through which the therapy worked. Nor were these mechanisms significantly related to substance use and other outcomes – again, perhaps due to the small sample size.

While appreciating the limits set by sample size, the non-significant trends suggesting that the therapy worked though the intended mechanisms were generally small in size. Of 22 comparisons between the two sets of patients, in only one had a mechanism (positively reappraising life’s problems) changed to a statistically significant degree in the expected direction – a result to be expected purely by chance. Together with a few counterproductive trends, these minor changes in the mechanisms thought to be specific to cognitive-behavioural therapy do not suggest it has a special role (that is, over and above other forms of psychological therapy) as a supplement to routine keyworking in the circumstances of the trial. At the same time the findings suggest that extra therapeutic contact did help stabilise patients who were prepared to accept it. Whether this needed to be cognitive-behavioural or a recognised therapy of any kind is impossible to tell from the study. Broader research offers little support for a distinctive role in addiction treatment for cognitive-behavioural approaches, results from which are generally equivalent to other approaches. It also seems that, at least in the mid 2000s, a steep hill remained to be climbed before formal psychological interventions of any kind were routinely and expertly implemented inBritain’s methadone clinics. How far that has changed is unclear. Details below.

CBT in methadone treatment

Guidelines from Britain’s National Institute for Health and Clinical Excellence (NICE) recommend cognitive-behavioural therapy not as a routine means of further stabilising patients, but to help with lingering anxiety and/or depression among those already stabilised in maintenance treatment. However, the analyses which led NICE to counsel against routine use did not show that cognitive-behavioural therapy was ineffective, just that it was not convincingly more effective than other well structured therapies.

Published in 2007, these guidelines did not have available to them the latest update of an authoritative meta-analytic A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention’s effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. review conducted for the Cochrane collaboration which combined results from studies comparing structured psychosocial interventions against normal counselling among methadone and other opiate substitution patients. Taking in new studies available up to 2011, it found that overall such interventions had improved neither retention nor outcomes (including opiate use) to a statistically significant degree. In particular, the same was true of the family of behavioural interventions including cognitive-behavioural therapy. Contrary to expectations, this update found contingency management conferred no significant benefits, contradicting both its earlier findings and the NICE guidelines referred to above.

In the Cochrane review, verdicts in respect of cognitive-behavioural therapy rested on three studies, one of which does not appear to have reported substance use outcomes but did find greater improvements in psychological health. Relative to drug counselling alone, so too did a study of male US ex-military personnel starting methadone treatment. A year later, in this study cognitive-behavioural patients had improved more on a much wider range of psychological, social and crime measures, but not in respect of substance use. From methadone plus routine drug counselling only, so complete were the reductions in opiate use that little space was left for additional therapy to further improve outcomes. These two US studies are supplemented by a German study which found that group cognitive-behavioural therapy led to significantly greater post-therapy reductions (at the six-month follow-up) in drug use than routine methadone maintenance alone. The effect was largely due to changes in cocaine use, but there were also minor extra improvements in abstinence from opiate-type drugs and benzodiazepines. What these three studies suggest is that offering extra psychotherapy (not necessarily cognitive-behavioural therapy in particular) improves psychological and social adjustment and perhaps too helps reduce non-opiate substance use, but that methadone maintenance itself as implemented in these studies was such a powerful anti-opiate use intervention that further gains on this front were harder to engineer.

CBT in substance use treatment generally

If in terms of core substance use outcomes, cognitive-behavioural therapy in methadone maintenance does little to improve on routine counselling, this will simply be in line with findings in respect of the therapy’s role in treating drug and alcohol problems in general. A review combining results from relevant studies suggested that it remains to be shown that cognitive-behavioural therapies are more effective than other similarly extensive and coherent approaches. Studies which directly tested this proposition often found little or no difference, even when the competing therapy amounted simply to well structured medical care.

The implication is that choice of therapy can be made on the basis of what makes most sense to patient and therapist, availability, cost, and the therapist’s training. In respect of cost and availability, cognitive-behavioural therapy may (more evidence is needed) prove to have two important advantages. The first is that effects may persist and even amplify without having to continue in therapy. The second is that it lends itself to manualisation to the point where it can be packaged as an interactive computer program and made available in services lacking trained therapists – potentially a crucial advantage for widespread implementation.

Will CBT help methadone patients leave treatment?

Beyond core substance use outcomes is what in Britain is now a priority issue – whether more intensive therapy, even if it seems to add little to the powerful opiate use reduction effect of methadone treatment, might help people gain sufficient psychological and social stability to leave this treatment, and leave it sooner. In respect of psychotherapy in general and cognitive-behavioural therapy in particular, this remains a live possibility with some support from studies of during and post-treatment changes, though none have directly tested whether these enable patients to more safely leave the shelter of substitute prescribing programmes.

However, from the starting point revealed by the featured study, there seems a long way to go before structured psychosocial interventions of any kind are routine in Britain’s methadone services. An earlier report from the study commented that services were overstretched and understaffed and suffered from high staff turnover. Very few staff had been trained in psychological interventions and sometimes even basic individual client keyworking was extremely limited. Difficulties in engaging clients in the study were attributed partly to a low level of psychological interventions in services, which in turn led to low expectations of clients engaging with these interventions. Perhaps too, the authors speculated, some clients were reluctant to become involved in more intensive treatment or to address psychological issues not previously identified in usual clinical care. Most tellingly, the researchers observed “a nihilistic view of psychological intervention and clients’ capacity for change among some staff”.

In this climate, and with the added burden of research procedures, the small proportion of patients prepared to accept therapy and attend more than a few sessions is likely to be an underestimate of the possible caseload if cognitive-behavioural therapy were well promoted as a part of usual care, especially if elements of the approach were incorporated in keyworking rather than offered as an optional add-on.

In a different set of services probably sampled in the mid-2000s, perfunctory brief encounters focused on dose, prescribing and dispensing arrangements, attendance records, and regulatory and disciplinary issues characterised the keyworking service offered by some British criminal justice teams to offenders on opiate substitute prescribing programmes. However, ‘relapse prevention’ was the most common therapeutic activity in the sessions, featuring in 44% of the last sessions recalled by the staff, a term often taken to imply cognitive-behavioural approaches. What staff included under this heading was unclear, and the time given to it averaged just seven minutes, but is does suggest that there is a platform which could be built on. Unfortunately the need to do this building to foster recovery and treatment exit has coincided with resource constraints which make widespread training in and implementation of fully fledged therapy programmes seem unlikely.

Thanks for their comments on this entry in draft to Christos Kouimtsidis of the Herts Partnership NHS Foundation Trust in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 16 December 2011

Source: www.findings.org.uk

A Blueprint to build strong Foundations for Change.
Professor Carlo DiClemente’s Stages of Change model is feted worldwide for enhancing the understanding and skills which make a substance-abuse treatment provider effective. It helps clinicians develop thoughtful, individually tailored, scientifically grounded treatment plans – here he extends it to policy and programmes.
This article was originally published in Addiction Today journal, March 2005. As we prepare for new – and hopefully more progressive -policies to address addiction treatment, this information is increasingly relevant.
Research tells us that central qualities of the effective clinician are empathy, warmth and positive regard. It also tells us that developing and implementing a clearly articulated treatment plan and providing treatment for the problems a client presents are effective skills. But putting these qualities and skills into action is a challenge.
How does an individual clinician learn to express these central human qualities of caring and compassion with clients who are often difficult and unhappy about being in treatment, and whose central disorder is often characterised by behaviours which do not easily elicit empathy? And given the incredible heterogeneity among substance-use clients, how can a clinician develop a personalised treatment plan grounded in science?
Further, how can we apply those same principles to other workers in the field of substance-use treatment, including members of drug/alcohol action teams? Is there a common framework? Can the process of change be applied at a systemic level as well as at an individual level?
We answered these questions at ARF’s UK/European Symposium on Addictive Disorders in London (where photo on this page was taken). But let’s open up the issue… Deepening our understanding of addiction can also deepen our understanding of the implications for policy and programmes. It can let us see that we need a common framework – such as Models of Care – and a common assessment tool, which has eluded drug/alcohol action teams, to their increasingly vocal frustration. Deep understanding of what our clients are all about, and the meaning of what we are doing, can lead us to a conceptualisation of the entire process of change and the entire continuum of care.

WHAT IS THE STAGES OF CHANGE MODEL?

Developing genuine understanding of – even empathy for – a client requires professionals to look beyond that client’s behaviour when using alcohol or drugs, and to understand the nature of substance-use disorders and difficulties inherent in changing long-standing, pervasive patterns of thought and behaviour. They are helped in this by the ‘stages of change’ model, combined with a good treatment plan.

The current model posits five stages of change:
o precontemplation
o contemplation
o preparation
o action and
o maintenance.

People in the first stage show no sign of intent to change a problem behaviour, be it because of a lack of awareness, unwillingness or a lack of hope because previous attempts failed. Contemplators are more visibly distressed about their problem behaviours than precontemplators and have begun to weigh the positives and negatives of change.
The preparation stage covers people who are ready to change both attitude and behaviour, and to change soon. When people are in the action stage, behaviour change has clearly begun. So they need skills to implement specific change methods. They also need to be aware of the psychological – cognitive, behavioural and emotional – events which can work against their best efforts. And they need to learn how to prevent major reversals, such as having a relapse and returning to pre-change patterns. The action stage lasts an average of about six months.
The last major stage of change is maintenance, where people sustain and strengthen improvements they have made. They can take a few years to eel “secure”.
_____________________________________________
“The stages of change are a model of ‘how to think’
rather than ‘how to do’…
They describe attitudes, intentions and behaviours
related to tasks of change”
_____________________________________________
All of this is voluntary rather than coerced change. Indeed, the stages of change are a model of “how to think” rather than “how to do”. They describe attitudes, intentions and behaviours related to the tasks of change. Note that the “change” sought is specific: commitment to change one behaviour might say nothing about commitment to change a related behaviour. And each stage refers to a time period and to tasks which a person or organisation must complete before moving to the next stage.

COMMON CHARACTERISTICS

Let’s look at the commonalities of clients in the five stages of change – then readers can draw their own conclusions as to the similarities at a systemic level for change in our field.
The common characteristics of people in the precontemplative stage are: defensive, resistant to suggestion of problems associated with their use/ behaviour, uncommitted or passive in treatment/work, consciously or unconsciously avoiding steps to change their behaviour, lacking awareness of a problem, often pressured by others to change, feeling coerced and ‘put upon’ by significant others.
The characteristics of contemplators of change are: seeking to evaluate and understand their actions, distressed, desirous of exerting control or mastery, thinking about making change, have not begun taking action and are not yet prepared to do so, many previous attempts to change, evaluating pros and cons of their behaviour and of changing it.
Now we come to the preparation stage, where people: intend to change their behaviour, are ready to change attitude and behaviour, are on the verge of taking action, are engaged in the change process, are prepared to make firm commitments to follow through on the action option they choose, and are making or have made the decision to change.
Common characteristics of people in the action stage are that they have: decided to change, verbalised or otherwise shown a firm commitment to change, tried to modify behaviour and/or environment, demonstrated motivation, and are willing to follow suggested strategies and activities for change.
And what do we share at the maintenance stage? Characteristics are: working to sustain changes achieved to date, focusing considerable attention on avoiding slips or relapses, feeling fear or anxiety about relapse and facing high-risk situations, and less frequent but often intense temptations to return to old habits.

MOTIVATIONAL STRATEGIES to promote change include giving advice, practising empathy, removing barriers, providing feedback, providing choice, clarifying goals, decreasing desirability of unhealthy habits, and active helping.
CLINICAL STRATEGIES for people in the action stage include maintaining engagement in the change process/treatment, supporting a realistic view of change through small successive steps, acknowledging the difficulties, helping people to identify high-risk situations through a functional analysis and developing coping strategies to overcome these, helping people to find new reinforcers of positive change, and helping people to assess if they have strong support networks.
Clinical strategies for people in the maintenance stage include helping them to identify and sample drug-free sources of satisfaction, supporting lifestyle changes, affirming people’s resolve and self-efficacy, helping them to practise and apply new coping strategies to avoid a return to unhealthy habits, and maintaining supportive contact.

TREATMENT/ACTION PLANNING

Based on information gathered during assessment, this is created in collaboration with each person wishing to change and addresses mutually agreed goals. It serves a variety of purposes, including prioritising short- and long-term goals, choosing the optimal interventions for specific goals, identifying barriers to the achievement of goals, and monitoring progress towards goals over time.
For our new purposes, goals can be as much on a national or local level as they can be on a personal level. They can include decrease in or cessation of substance use, which can impact on other goals such as improving family and employment situations, extending social support networks, and returning to school or college. One obvious benefit of prioritising goals is that attention is focused on the most pressing problems.
Another is that successes in these main areas often place people in a better position to address secondary goals.
It is important to recognise the treatment/action plan as flexible and changeable. Unexpected needs or problems can arise. Some goals might depend on others. Some might take longer than anticipated.

Common features of treatment plans include:
o developed as a result of a comprehensive assessment and modified over time as warranted
o reflects participation from appropriate disciplines – medicine, psychiatry, psychology, social work or vocational rehabilitation – as warranted
o reflects the person’s presenting needs and specifies their strengths and limitations
o consists of specific goals which pertain to the attainment, maintenance and/or re-establishment of physical and emotional health
o identifies specific objectives which relate directly to the treatment/change goals
o specifies the frequency of treatment/change contacts
o includes provisions for periodic re-evaluations and revisions, as needed, of the plan, and
o identifies criteria for determining if goals have been achieved, as well as for terminating change.
Some qualities of well-formed treatment/change goals are that they are: salient and meaningful to the person or organisation wishing change, incremental and so more manageable, concrete, specific and behaviour focused, able to increase desired behaviours, realistic and achievable, seen as requiring work and effort, and are appropriate for the projected change period.

FUTURE DIRECTIONS
In addition to its popularity with many addiction counsellors and researchers, the stages of change model should prove useful in tracking and predicting change. Most people have followed problematic paths over many years and made multiple attempts to change before being successful. They get stuck at certain points in the process of change and invest more time and energy in not changing than in activities to promote change. There is an ebb and flow, and important, distinct tasks which mark the process.
People can move forward and backward through the stages, and they can do so quickly. Their tasks involve a number of dimensions – motivation, decision making, efficacy, coping activities – which have an ongoing influence on the change process, can be accomplished quickly or slowly, and can be done more or less completely. These stages of change seem to resemble the stage dimensions of personality development proposed by Erickson in 1963.
Moving through change does not appear to be a case of doing more of the same thing, but instead doing the right thing at the right time.

There is also a growing body of literature which appears to support the relationship of stages to important outcomes.
One advantages of model is that the process of change is assumed to be the same for substance-abuse problems as well as other life problems.

It has been applied to changes related to many behaviours, including anxiety, medication compliance and health protection. The stages cover considerable ground, since the process of intentional behaviour change is central in the life of an individual, with major implications for growth and development.
There are few models which can be applied to such a variety of behaviours with such consistent results… Let’s change together.

Source: Addiction Today Aug.1st 2010

Ryan Vandrey1 and Margaret Haney2
1 Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
2 New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University,
New York, New York, USA

Abstract

Cannabis is the most widely used illicit drug in the world. Treatment admissions for cannabis use disorders have risen considerably in recent years, and the identification of medications that can be used to improve treatment outcomes among this population is a priority for researchers and clinicians.
To date, several medications have been investigated for indications of clinically desirable effects among cannabis users (e.g. reduced withdrawal, attenuation of subjective or reinforcing effects, reduced relapse). Medications studied have included those: (i) known to be effective in the treatment of other drug use disorders; (ii) known to alleviate symptoms of cannabis withdrawal (e.g. dysphoric mood, irritability); or (iii) that directly affect endogenous cannabinoid receptor function. Results from controlled laboratory studies and small open-label clinical studies indicate that buspirone, dronabinol, fluoxetine, lithium and lofexidine may have therapeutic benefit for those seeking treatment for cannabis-related problems. However, controlled clinical trials have not been conducted and are needed to both confirm the potential clinical efficacy of these medications and to validate the laboratory models being used to study candidate medications. Although the recent increase in research towards the development of pharmacotherapy for cannabis use disorders has yielded promising leads, well controlled clinical trials are needed to support broad clinical use of these medications to treat cannabis use disorders.

Cannabis (also known as marijuana or hashish) is obtained from the plant Cannabis sativa. Cannabis contains many psychoactive compounds that affect the endogenous cannabinoid receptor system, of which D-9-tetrahydrocannabinol (THC) has been identified as the compound primarily responsible for the subjective ‘high’ experienced by users.[1] The acute effects of cannabis include subjective feelings of euphoria, relaxation, dream-like state, altered sensory perception, slowing of time, anxiety/paranoia and increased appetite. Cannabis also increases heart rate and, in rare instances, can induce hallucinations or psychosis.

THC is a partial agonist of the cannabinoid receptor type 1 (CB1), a G protein-coupled receptor that is expressed in the brain at highest concentrations in the basal ganglia (motor control), cerebellum (sensorimotor coordination), hippocampus (memory) and cortex (higher-order cognition). Like most, if not all, addictive drugs, exposure to psychoactive cannabinoids stimulates brain reward areas and can induce appetitive drug-seeking and drug-taking behaviours. Evidence of these effects includes studies in which exposure to cannabis increased dopamine release in the mesolimbic-dopamine reward pathway, enhanced electrical brain stimulation reward, established conditioned place preference and established drug self-administration.
Similarly, abrupt cessation of long-term cannabinoid exposure produces cellular changes in the brain reward pathway (increased corticotrophin releasing factor, decreased dopamine) that have been linked to the dysphoric effects associated with withdrawal from drugs such as alcohol, opioids and cocaine, and are thought to contribute to relapse. Recognizing that cannabis shares neurobiological features associated with dependence on other drugs is important when considering pharmacological treatment of cannabis use disorders.

The rationale for developing pharmacological treatments for cannabis use disorders is clear. There are an estimated 160 million current cannabis users worldwide, and the number of people who meet criteria for cannabis dependence exceeds that for dependence on any other illicit drug. Treatment admissions for cannabis use disorders in many areas have steadily increased in the past decade, including a 2-fold increase in the US and 3-fold increases in Australia and Europe. Clinical trials have demonstrated that evidence-based psychosocial interventions (e.g.motivational enhancement, contingency management, cognitive-behavioural therapy) result in overall improved clinical outcomes compared with usual care or delayed control conditions. However, as is common with other drugs (e.g. opioids, cocaine, nicotine), adults and adolescents seeking treatment for cannabis-related disorders have great difficulty achieving and sustaining periods of abstinence: the majority relapsing to use following therapeutic interventions.Thus, there exists a clear need for the development and dissemination of interventions that improve clinical outcomes (e.g. reduced use/abstinence, fewer drug-related problems) for the increasing number of those seeking treatment for their cannabis use.

One method of improving clinical outcomes for patients seeking treatment for cannabis use disorders is to identify medications that exhibit clinical benefit and could be added to existing evidence-based psychosocial treatments. There is evidence that a combination of pharmacotherapy and psychosocial therapy can significantly improve substance abuse treatment outcomes relative to psychosocial treatments alone. Pharmacotherapies can aid in the treatment of drug dependence in several ways. One approach is to identify medications that attenuate symptoms of withdrawal. This can be achieved with agonist/substitute medications (e.g. nicotine patch for tobacco dependence, methadone for opioid dependence) or by use of medications known to alleviate specific withdrawal symptoms (e.g. clonidine for sweating, gastrointestinal disturbance and hypertension during opioid withdrawal).

Another approach for pharmacotherapy is the use of medications that attenuate the reinforcing effects of the target drug. One way this can be done is by directly blocking the receptor with an antagonist (e.g. naltrexone for opioid dependence) or partial agonist (e.g. buprenorphine for opioid dependence). A third approach is the use of medications that induce adverse effects when combined with the drug of dependence (e.g. disulfiram induces nausea when combined with alcohol). There are currently no accepted pharmacological treatment interventions for cannabis use disorders. Identification of such medications is an increasing priority among researchers and clinicians working with cannabis users and has been addressed in a number of recent papers. In this manuscript, we review the extant research investigating medications of potential therapeutic efficacy for the treatment of cannabis dependence. Because of space constraints and the clinical focus of this review, preclinical laboratory studies will not be covered but can be found in other reviews. Areas of focus will include human laboratory studies, clinical case reports and small open-label trials, and controlled clinical trials. This paper will complement and extend previous reviews on the topic.

1. Human Laboratory Studies
1.1 Attenuation of Withdrawal Symptoms Research dating back to the 1970s provides clear evidence that a valid and reliable cannabis withdrawal syndrome occurs. Common symptoms of withdrawal in humans include: anger and aggression, anxiety, depressed mood, irritability, restlessness, sleep difficulty and strange dreams, decreased appetite and weight loss. Chills, headaches, physical tension, sweating, stomach pain and general physical discomfort have also been observed during cannabis withdrawal but are less common.Most symptoms begin within the first 24 hours of cessation, peak within the first week and last approximately 1–2 weeks. Because there is evidence that cannabis withdrawal contributes to the high relapse rates among heavy cannabis users,amelioration of cannabis withdrawal symptoms may be an important target for the development of pharmacological treatment interventions for heavy cannabis users. Much of the current research in humans has been conducted by a group of researchers at Columbia University in the US. There, an inpatient human laboratory model was designed to characterize the effects of medications on the consequences of abstinence from cannabis (e.g. withdrawal symptoms). Research volunteers who smoked cannabis multiple times per day and who were not seeking treatment for their cannabis use were enrolled in a series of studies investigating several medications. Participants smoked cannabis (active or placebo) and received oral medication (active or placebo) each day under double-blind conditions. The protocol used a within-subject crossover design so that each participant received each active and placebo combination of cannabis and medication. Further, most of the laboratory studies administered
medication repeatedly each day until steady state levels were attained prior to assessing the effects of cannabis. The effect of receiving placebo versus active medication during the periods of cannabis abstinence (placebo cannabis) was then evaluated. Outcome variables included round the-clock data on mood and physical symptoms, psychomotor task performance, food intake, social behaviour and sleep. Medications investigated in this model to date have been bupropion, divalproex, nefazodone, lofexidine and dronabinol. Bupropion is used clinically as an antidepressant and for smoking cessation, and is thought to exert clinical effects by inhibiting reuptake of noradrenaline (norepinephrine) and dopamine, and possibly by acting as a nicotine receptor antagonist. Divalproex is used clinically as a mood stabilizer as well as to treat epilepsy and migraine headaches. Divalproex dissociates into valproate ions in the gastrointestinal tract and, though uncertain, clinical effects are thought to be mediated by increased GABA levels in the CNS. Nefazodone is an antidepressant and is believed to operate by blocking postsynaptic serotonin 5-HT2A receptors and, to a lesser extent, by inhibiting presynaptic serotonin and noradrenaline reuptake. Lofexidine is used to treat symptoms of opioid withdrawal and acts as an agonist at the a2-adrenergic receptor. Dronabinol is used clinically as an antiemetic and appetite stimulant, and is a partial agonist of CB1 receptors.
In laboratory studies using the methods described previously, administration of bupropion (placebo or 300 mg/day for 17 days)[42] and divalproex (placebo or 1500mg/day for 29 days) during periods of cannabis abstinence significantly worsened mood compared with placebo. Nefazodone (placebo or 450mg/day for 26 days) significantly decreased ratings of anxiety and muscle pain during abstinence but did not alter other essential features of cannabis withdrawal. Lofexidine (2.4mg/day for 8 days) significantly reduced ratings of chills, restlessness and upset stomach, and improved sleep but was associated with increased sedation during the day. Not surprisingly, the medication that has demonstrated the most clinical potential in reducing cannabis withdrawal has been dronabinol. Dronabinol is a synthetic formulation of THC, the primary psychoactive component in cannabis. In that regard, it is similar to using nicotine replacement products to suppress withdrawal during tobacco abstinence. In one study by the Columbia University researchers, dronabinol (10 mg five times daily for 6 days) significantly
decreased ratings of cannabis craving, anxiety, misery, chills and self-reported sleep disturbance,
and reversed the anorexia and weight loss associated with cannabis withdrawal. This attenuation of withdrawal symptoms occurred even though participants in this study were unable to reliably distinguish dronabinol from placebo. In a follow-up study, dronabinol administered at a higher dose and less frequently (20 mg three times daily for 8 days) again decreased ratings of restless and chills, and reversed anorexia but was associated with significant increases in drug effect, drug liking, irritability and latency to sleep compared with placebo. However, in this same study a combination of dronabinol (20 mg three times daily) and lofexidine (mg/day) decreased ratings of restlessness, chills, craving and upset stomach, and improved multiple measures of sleep but also increased sedation during the day and drug effect ratings. The effects of dronabinol (0 mg, 10 mg and 30 mg, three times daily for 15 days) on cannabis withdrawal were also recently reported in an outpatient study of daily cannabis users not seeking treatment. Dronabinol dose dependently decreased withdrawal symptoms during 5-day periods of abstinence while participants were in their home environment. Compared with placebo, the 10 mg dose reduced participant ratings of aggression, craving, irritability, sleep difficulty and total withdrawal. Though withdrawal was attenuated at the 10 mg dose, it remained significantly elevated compared with a baseline period when participants smoked cannabis as usual. When participants received the 30 mg dose, withdrawal symptom severity was significantly reduced compared with both the placebo and 10 mg conditions and, more importantly, none of the withdrawal symptom ratings differed from the cannabis-as-usual baseline condition, indicating
a maximum therapeutic effect at this dose. Consistent with the initial study described previously, the 10 mg dose regimen was not associated with increased ratings of intoxication and was not reliably distinguished from placebo. However, the 30 mg dose was distinguished from placebo by all participants and resulted in significantly increased drug effect ratings.

1.2 Attenuation of Subjective and Reinforcing Effects
Laboratory studies have also investigated the ability of medications to reduce the acute effects of smoked cannabis or orally administered THC. In one experiment, pretreatment with the CB1 receptor antagonist rimonabant significantly attenuated the physiological and subjective effects of smoked cannabis administered 2 hours later. Acute administration of rimonabant 90 mg reduced participant ratings of the strength and liking of the smoked cannabis by approximately 40% and reduced cannabis-induced tachycardia by 59%. In a subsequent study, acute administration of rimonabant 90 mg again reduced cannabis-induced tachycardia, but the attenuation of subjective drug effects was not replicated. In this same study, repeated daily doses of rimonabant (40 mg) administered for 15 consecutive days to a second group of participants reduced cannabis-induced tachycardia following acute cannabis administration on days 8 and 15. The subjective effects of cannabis were also reduced by rimonabant in this group, but that reduction was only significantly different from placebo on day 8 and not on day 15. Thus, rimonabant reduced the effects of smoked cannabis in two studies, but a reduction of subjective drug effects was not consistently observed. Additional research is needed to investigate the dose effects of this antagonism and whether it translates to clinically meaningful behaviour change (reduced use or relapse prevention). Studies have also investigated whether the m-opioid receptor antagonist naltrexone, which has been shown to decrease cannabinoid self administration in non-humans, can reduce the subjective effects of cannabinoids in humans. In cannabis users, pretreatment with high doses of naltrexone (50–200 mg) failed to attenuate,and in some cases enhanced, the subjective effects of dronabinol and smoked cannabis. By contrast, a lower, more opioid-selective dose of naltrexone (12 mg) decreased the intoxicating effects of dronabinol 20mg but not 40 mg in a recent study. These findings indicate that the influence of naltrexone on cannabinoid effects may vary as a function of the naltrexone dose, but also that the effect of naltrexone can be overcome with higher doses of cannabis. The effect of dronabinol on the subjective and reinforcing effects of smoked cannabis has also been investigated. Participants received dronabinol 0 mg, 10 mg or 20 mg four times daily for 3 consecutive days. Each day, participants sampled the dose of cannabis cigarette available that day and were then given four choices during the course of that day to smoke the sampled dose of cannabis or receive a voucher worth $US2 that would be added to their study earnings.

Subjective drug effect ratings were obtained following the sample dose of cannabis under each dronabinol dose condition. Dronabinol attenuated the subjective effects of smoked cannabis but did not affect the choice to smoke cannabis (reinforcing effects). Of note, the competing reinforcer, a voucher worth $US2, may not have been sufficiently sensitive to detect changes in cannabis reinforcing efficacy. Also, each dronabinol dose condition only lasted for 3 days, whereas more time may be needed to see an effect of maintenance medication. Thus, more data are needed to determine whether dronabinol disrupts ongoing cannabis use.

The subjective effects of cannabis have also been evaluated in single studies for several other medications. In a small laboratory study, a 0.4mg dose of clonidine (an a2-adrenoreceptor agonist and opioid withdrawal medication) administered 3 hours prior to smoked cannabis reduced cannabisinduced tachycardia but did not reduce subjective effects. Bupropion (300 mg) decreased ratings of the ‘high’ following smoked cannabis, but, as described previously, this dose also exacerbated withdrawal effects during a period of abstinence. In two other laboratory studies described previously, the subjective effects of smoked cannabis were not altered by nefazodone (450 mg) and were increased following administration of divalproex (1500 mg).

1.3 Relapse Prevention
In one recent study, relapse was modelled in non-treatment seekers by structuring laboratory conditions (charging participants $US10 for a single initial puff of cannabis) so that a return to cannabis use was costly. The effects of dronabinol (20 mg three times daily) and lofexidine (2.4 mg/day) were evaluated both when administered alone and when administered together. In this study, neither dronabinol nor lofexidine alone reduced the number of participants who elected to smoke any amount of cannabis compared with placebo during a 4-day maintenance period, but the combination of the two drugs doubled therate of complete abstinence (25% abstinent for each medication alone, 50% for the combination).Compared with the placebo condition, the average amount of money spent per day on cannabis was reduced in both the lofexidine alone and the combined medication conditions.

2. Case Reports and Small Open-Label Studies

Several studies have investigated the efficacy of potential treatment medications for cannabis dependence in small clinical samples. One recent open-label study investigated atomoxetine as a potential pharmacotherapy in adults presenting for treatment of cannabis dependence. Atomoxetine is a non-stimulant medication that inhibits noradrenaline reuptake and is used to treat attention-deficit hyperactivity disorder. Thirteen participants received atomoxetine (25–80 mg/day; mean 62 mg/day) for 11 weeks. A non-significant reduction in cannabis use was
observed. However, several adverse events were reported, including clinically significant gastrointestinal problems in 77% of participants. Two participants withdrew from the study because of these adverse effects. An open-label investigation was also conducted with the anxiolytic medication buspirone, a 5-HT1A receptor agonist and dopamine D2 receptor mixed agonist/antagonist.[60] Ten treatment-seeking cannabis users received buspirone (up to 60 mg/day; mean 39 mg/day) for up to 12 weeks. Self-reported cannabis use declined from
use on 73% of days prior to treatment to use on 39% of days during treatment, and 44% of urine drug screens conducted during treatment were negative for cannabis (100% positive at intake). Significant decreases in craving and irritability during treatment were also observed. However, several adverse events were reported during the trial and only two participants completed the entire 12-week study. Following a preclinical study showing that lithium, a mood stabilizer that enhances oxytocin expression, attenuated cannabis withdrawal in rats, two small open-label clinical studies were conducted. In one study, lithium was administered to nine adults presenting for treatment of cannabis dependence. All participants indicated that previous quit attempts resulted in significant withdrawal symptoms and that abstinence failed to extend beyond a few days or weeks.

Lithium (600–900 mg/day) was administered for 6 days and resulted in reduced withdrawal severity in four of the nine participants. However, cannabis was admittedly smoked during this period by one of these four participants and cannabis abstinence was not verified in the others. In the second study, 20 cannabis-dependent participants received lithium (500 mg twice daily) for 7 days in an inpatient detoxification facility. Twelve participants (60%) completed the 7-day inpatient detoxification (two were removed because of adverse events). Cannabis abstinence at post-treatment follow-up sessions was 64% (day 10), 65% (day 24) and 41% (day 90). Participants also self-reported cannabis abstinence on 88% of days post-treatment, with five participants reporting continuous abstinence that was corroborated with urine toxicology tests on day 90. To date, the only published report in which dronabinol has been used clinically to treat cannabis dependence is a paper describing two case studies. In both cases, the patients used cannabis daily and had repeatedly failed in prior quit attempts. Dronabinol was started at a dosage of 30 mg/day (10 mg three times daily) and then adjusted in both cases. Both patients were able to achieve sustained periods of abstinence; however,adjunct medications were required (divalproex for case 1 and venlafaxine for case 2). In case 1, the patient was successfully tapered off dronabinol without relapse.

In case 2, removal of dronabinol resulted in either relapse or heavy alcohol use. This patient continued using dronabinol (5 mg two to three times daily) as a maintenance medication. A case report has also been published in which the atypical antipsychotic medication quetiapine was administered to eight cannabis-dependent patients with a diagnosis of either schizophrenia or bipolar disorder. Following quetiapine administration at a mean dosage of 388 mg/day (range 100–1200 mg/day) for an average of approximately 6 months, cannabis use in these eight patients was reported as being reduced from an average of 35.6 g/week to 1.1 g/week. Concomitant medications administered during the
quetiapine treatment period included unspecified antidepressants (n = 4), gabapentin (n = 2) and methadone (n = 1). It is unclear from the report whether cannabis use rates were verified via objective measures (e.g. urine toxicology) or if the medication was well tolerated by all patients who received it.

3. Clinical Trials

At this time, there is only one published controlled clinical trial in which a medication was tested for efficacy in participants presenting for treatment where cannabis dependence was the primary problem. In this double-blind trial, 25 participants were randomized to receive divalproex (500–2000 mg/day; mean 1673 mg/day) or placebo for 6 weeks and were then crossed over to the opposite medication condition. Participants also received weekly relapse prevention counselling throughout the study. Cannabis use was assessed via self-reporting and quantitative urine testing. An overall reduction of cannabis use was reported, but few urine drug screens were free of cannabis, suggesting that sustained abstinence was not achieved. There was no effect of divalproex compared with placebo on any cannabis use measures. Adverse events related to divalproex were common and resulted in discontinuation for three participants, and toxicology analyses indicated that medication compliance was poor among those receiving active medication. One other controlled clinical trial has been published in which cannabis use was measured following administration of medication, but in this study participants represented a subgroup of participants within a larger trial for the treatment of alcoholism and depression primary to their cannabis dependence.

Following a brief inpatient detoxification, participants were randomly assigned to receive fluoxetine 20–40 mg/day (a selective serotonin reuptake inhibitor used to treat depression) or placebo for 12 weeks (n = 11 group). Compared with placebo, those who received fluoxetine reported using less cannabis, using cannabis on fewer days, drinking less alcohol and had a greater decrease in ratings of depression. No objective measures of substance use were obtained to verify the self-reports in this study, and it is unclear whether the decrease in cannabis use was mediated by reductions in alcohol use or depression.

4. Conclusion
Efforts to identify medications that can improve treatment outcomes for cannabis use disorders have increased considerably in recent years but still lag far behind the medication development efforts for treating dependence on other drugs (e.g. alcohol, cocaine, opioids). Most of the current research is limited to laboratory models and small open-label trials, with only one published controlled clinical trial (compared with dozens to hundreds of controlled pharmacotherapy trials for treating dependence on alcohol, cocaine, nicotine and opioids). The laboratory studies described in section 1 all employed cannabis users who were not trying to reduce or quit their cannabis use.

Although it is possible that this limits the generality of these studies, it is important to point out that for drugs such as cocaine and heroin, the validity of human laboratory studies of self-administration for predicting
medication efficacy in the clinic is better than most other models, including open-label clinical studies, which are often characterized by a high number of false positives. That said, controlled clinical trials for cannabis dependence are clearly needed, not only to determine the efficacy of candidate medications but also to evaluate the predictive validity of the laboratory models being used. At this point, several medications that were studied appear to warrant further investigation (table I). Dronabinol has been the most extensively studied and appears to be the strongest candidate medication to date. Studies have indicated several clinically important effects of dronabinol (reduction of withdrawal and decreased relapse when combined with lofexidine, and possibly divalproex or venlafaxine). Moreover, agonist medications have demonstrated efficacy in the treatment of tobacco and opioid dependence. Replication in controlled clinical trials is needed (two placebo-controlled trials are currently being conducted in patients specifically seeking treatment for their cannabis use). Dronabinol has a slow rate of onset and low rates of abuse. However, the safety and abuse liability/ diversion of dronabinol in addiction treatment settings needs to be assessed because the population seeking treatment for cannabis dependence (many adolescents, people with extensive drug use histories and a preference for cannabinoid self-administration) may present with unique safety and abuse liability concerns.
The cannabinoid receptor antagonist rimonabant reduced the effects of smoked cannabis in two studies, but a reduction of subjective drug effects was not consistently observed. Since this research began, clinical use of rimonabant for any indication has been suspended because of the risk of adverse psychiatric effects. While this will preclude the use of rimonabant for the treatment of cannabis use disorders, these data indicate that cannabinoid receptor antagonists may be clinically useful in the treatment of cannabis use disorders should alternative compounds with better safety profiles be developed. That administration of fluoxetine has been associated with reduced cannabis use among depressed alcohol-dependent individuals suggests therapeutic potential. Replication of this effect is needed in either laboratory or clinical studies in which cannabis is the primary drug of abuse among participants. A laboratory study with lofexidine showed promise, but needs to be replicated. Finally, findings with buspirone, lithium and quetiapine have also been in a positive direction, but need to be verified using placebo controlled studies. The occurrence of adverse effects may also limit the use of these medications.

In conclusion, the need for identifying medications to improve treatment outcomes for cannabis dependence is clear. Medications should be used in conjunction with evidence-based psychosocial treatments to maximize clinical benefit, and some combination of multiple medications may be needed to achieve sustained abstinence in more severe cases. At this time, although it does not appear that we are close to the broad use of pharmacotherapies for cannabis dependence, several promising candidate medications have been identified. Continued research studies, particularly controlled clinical trials, are obviously needed for the medications that have demonstrated promise to date. Moreover, there are a number of compounds (e.g. second-generation cannabinoid receptor antagonists, fatty acid amide hydrolase [FAAH] inhibitors) for which mpreclinical data indicate potential for treating cannabis use disorders once they are approved for research in humans. It will be important for scientists and clinicians to continue to investigate these and other medications that could reasonably be considered to have therapeutic potential for treating cannabis use disorders.

Acknowledgements: We thank the US National Institute on Drug Abuse (Dr Vandrey: DA12471 and DA025794; Dr Haney: DA09236 and DA19239) for its support. Dr Vandrey also thanks the Johns Hopkins University School of Medicine Department of Psychiatry and Behavioral Sciences for support. The authors have no conflicts of interest that are directly relevant to the content of this review. E-mail: rvandrey@jhmi.edu

Source: Pharmacotherapy for Cannabis Dependence 553. CNS Drugs 2009; 23 (7)

TESTIMONY OF DAVID G. EVANS, ESQ.
EXECUTIVE DIRECTOR, DRUG-FREE SCHOOLS COALITION
BEFORE THE HEALTH AND HUMAN SERVICES
COMMITTEE OF THE NEW JERSEY ASSEMBLY
SEPTEMBER 20, 2004
TRENTON, NJ

IN OPPOSITION TO A-3256

SUMMARY OF THE TESTIMONY:

THE PUBLIC HEALTH BENEFITS AND SOCIAL EFFECTS OF NEEDLE EXCHANGE PROGRAMS ARE AT BEST UNCERTAIN, AND AT WORST ARE DEVASTATING TO BOTH ADDICTS AND THEIR COMMUNITIES

A.   NEEDLE EXCHANGE PROGRAMS ARE NOT SCIENTIFICALLY
       PROVEN TO REDUCE THE EPIDEMIC OF HIV OR HCV INFECTION
       AMONG INJECTION DRUG USERS

B.   NEEDLE EXCHANGE PROGRAMS DO NOT REDUCE SUBSTANCE
       ABUSE, BUT IN FACT FACILITATE AND ENCOURAGE SUBSTANCE
       ABUSE

C.   NEEDLE EXCHANGE PROGRAMS ARE DESTRUCTIVE TO THE
       COMMUNITIES IN WHICH THEY ARE USED

D.  NEEDLE EXCHANGE SENDS A BAD MESSAGE TO SCHOOL CHILDREN.
      PROVISION OF NEEDLES TO ADDICTS WILL ENCOURAGE DRUG USE.
      THE MESSAGE IS INCONSISTENT WITH THE GOALS OF OUR
      NATIONAL YOUTH-ORIENTED ANTI-DRUG CAMPAIGN.
 
A. NEEDLE EXCHANGE PROGRAMS ARE NOT SCIENTIFICALLY PROVEN TO REDUCE THE EPIDEMIC OF HIV OR HCV INFECTION AMONG INJECTION DRUG USERS 
 
(i) The New Haven Study

NEP activists frequently cite the results of a New Haven, Conn., study, published in the American Journal of Medicine, which reported a one-third reduction of HIV among NEP participants. However, the New Haven researchers tested needles from anonymous users, rather than the addicts themselves, for HIV.  They never measured “seroconversion rates,” which determine the portion of participants who become HIV positive during the study.  Also, sixty percent of the New Haven study participants dropped out; those who remained were presumably more motivated to protect themselves, while the dropouts likely continued their high risk behavior.

 Essentially, the New Haven study merely reported a one-third decrease in HIV-infected needles themselves, which, considering the fact that the NEP flooded the sampling pool with a huge number of new needles, is hardly surprising.  Even Peter Lurie, a University of Michigan researcher and avid NEP advocate, admits that “the validity of testing syringes is limited.”

Furthermore, the New Haven study was based on a mathematical model of anonymous needles using six independent variables to predict the rate of infection. The unreliability of any of the variables invalidates the result. The New Haven study also assumed that any needle returned by a participant other than the one to whom it had been given had been shared, and that any needle returned by the original recipient had not been shared. Both assumptions are suspect.   Also, the role of HIV transmission through sexual activity is downplayed. Prostitution often finances a drug habit. Non-needle using crack addicts have high incidence of HIV. Recent studies reveal that the greatest HIV threat among heterosexuals is from sexual conduct, not from dirty needles.   Less than one-third of the New Haven subjects practiced safe sex. In the New Haven study, sampling error alone could account for the 30 percent decline.
(ii) The HHS / NAS Study

In 1992, Congress directed the U.S. Department of Health and Human Services (HHS) to study NEPs. HHS in turn commissioned the National Academy of Sciences (NAS), an independent, congressionally chartered, non-government research center, to conduct the study.  According to the Congressional directive, if the NAS could show that NEPs worked and did not increase drug use, the Surgeon General could lift the ban on federal funding. The study was completed in 1995, and it concluded that well run NEPs could be effective in preventing the spread of HIV, and do not increase the use of illegal drugs. The NAS panel further recommended lifting the ban on federal funding for NEPs and legalization of injection paraphernalia. Now, seven years after the NAS study, Congress has yet to lift the NEP funding ban, clearly indicating that Congress maintains serious doubts as to the validity of the NAS/HHS conclusions regarding NEPs.  Of note is that study chairman Dr. Lincoln E. Moses cites the dubious New Haven study as a basis for the NAS findings.   The NAS panel admitted that its conclusions were not based on reviews of well-designed studies, and the authors admitted that no such studies exist.  Incredibly, the panel reported that “the limitations of individual studies do not necessarily preclude us from being able to reach scientifically valid conclusions.”

Two of the physicians on the NAS panel, Herbert D. Kleber, M.D. and Lawrence S. Brown, M.D., say the news media exaggerated the NAS’s findings. “NEPs are not the panacea their supporters hope for…We personally believe that the spread of HIV is better combated by the expansion and improvement of drug abuse treatment rather than NEPs, and any government funds should be used instead for that purpose.”   Dr. Kleber, executive vice president for medical research at Columbia University, added: “The existing data is flawed.  NEPs may, in theory, be effective, but the data doesn’t prove that they are.”  

This questionable NAS study represents the cornerstone research data used by the notoriously-politicized U.S. Department of Health and Human Services.  The pro-NEP advocacy of HHS, and its supporting data, has yet to convince Congress that NEPs are scientifically proven to reduce HIV infection while not increasing drug usage.

6 Id.
7  See Loconte, Joe, Policy Review, supra, note 2.
8  See New Jersey Family Policy Council, ANeedle Exchange Programs – Panacea or Peril, supra, note 1 
9    See Loconte, Joe, Policy Review, supra, note 2.
   (iii) The CDC Study

The Centers for Disease Control (CDC) conducted a study whose chief architect, Dr. Peter Lurie, recommended NEPs.  The CDC report calls for federal funds for NEPs and the repeal of drug paraphernalia laws
 
However, although the CDC study endorses NEPs, Dr. Lurie, the study’s author, acknowledges numerous problems:  None of the studies were randomized, and self reported behavior was often the basis for outcomes. Poor follow up and rough measurement of risk behavior also present problems, and he notes that syringe studies have limited validity. The report concludes: “Studies of needle exchange programs on HIV infection rates do not, and in part due to the need for large sample sizes and the multiple impediments to randomization, probably cannot provide clear evidence that needle exchange programs decrease HIV infection rates.”

(iv) The Montreal Study

A 1995 Montreal study, published in the American Journal of epidemiology, showed that IDUs who used the NEP were more than twice as likely to become infected with HIV as IDUs who did not use the NEP. Thirty three percent of NEP users and 13 percent of nonuser became infected.  There was an HIV seroconversion rate of 7.9 per 100 person years among NEP participants, and a rate of 3.1 per 100 person years among non-participants. 

A high percentage of both groups shared intravenous equipment in the last six months: 78 percent of NEP users and 72 percent of non-NEP users. Risk factors identified as predictors of HIV infection included previous imprisonment, needle sharing and attending an exchange in the last six months. The study authors stated: “We caution against trying to prove directly the causal relation between NEP use and reduction in HIV incidence. Evaluating the effect of NEPs per se without accounting for other interventions and changes over time in the dynamics of the epidemic may prove to be a perilous exercise.”  The study concluded:  “Observational epidemiological studies…are yet to provide unequivocal evidence of benefit for NEPs.” 
(v) The Vancouver Study
Vancouver has the largest NEP in North America, and was praised in the 1993 CDC report. It is financed by public funds, and by 1996 was distributing over 2 million needles per year.  A 1997 evaluation of the needle exchange program in Vancouver showed that since the program began in 1988, AIDS prevalence in intravenous users rose from approximately 2% to 27%.  This occurred despite the fact that 92% of the intravenous addicts in that jurisdiction participated in the needle exchange program.
 
The Vancouver study also found that 40% of the HIV-positive addicts who participated in the program had lent a used syringe in the previous six months, and that 60% of HIV-negative addicts had borrowed a used syringe in the previous six months.  Despite the enormous number of clean needles provided free of charge, active needle sharing continued at an alarming rate.  After only eight months, 18.6 percent of those initially HIV negative became HIV positive. 

The Vancouver study corroborates a previous Chicago study which also demonstrated that its NEP did not reduce needle-sharing and other risky injecting behavior among participants. The Chicago study found that 39% of program participants shared syringes, compared to 38% of non-participants; 39% of program participants, and 38% of  non-participants “handed off” dirty needles; and 68% of program participants displayed injecting risks vs. 66% of non-participants.
 
The Vancouver report noted that “it is particularly striking that 23 of the 24 seroconverters reported NEP as their most frequent source of sterile syringes, and only five reported having any difficulty accessing sterile syringes.”
The authors continue: “Our data are particularly disturbing in light of two facts:  first, Vancouver has the highest volume NEP in North America; second, HIV prevalence among this city’s IDU population was relatively low until recent years.  The fact that sharing of
injection equipment is normative, and HIV prevalence and incidence are high in a community where there is an established and remarkably active NEP is alarming.”  

What should be obvious from all of the studies above is that there is no conclusive scientific evidence that NEP’s arrest HIV infection.  Indeed, there is evidence that NEP’s breed HIV infection.

Some claim that the federal government supports NEPs. While the previous administration’s Department of Health and Human Services actively favored NEPs, those who were actually in charge of our national drug policy do not. General Barry McCaffrey, then director of the Office of National Drug Control Policy (ONDCP), when addressing the issue of NEPS stated “we have a responsibility to protect our children from ever falling victim to the false allure of drugs. We do this, first and foremost, by making sure that we send them one clear, straightforward message about drugs: They are wrong and they can kill you.” McCaffrey’s strong views influenced President Clinton not to approve federal aid money for NEPs.
A further elaboration of the ONDCP’s policy was provided by James R. McDonough, Director of Strategic Planning for ONDCP, who wrote:

       ‘  The science is uncertain. Supporters of needle exchange frequently gloss over gaping holes in the data — holes which leave significant doubt regarding whether needle exchanges exacerbate drug use and whether they uniformly lead to decreases in HIV transmission. It would be imprudent to take a key policy step on the basis of yet uncertain and insufficient evidence.

     The public health risks may outweigh potential benefits. Each day, over 8,000 young people will try an illegal drug for the first time. Heroin use rates are up among youth. While perhaps eight persons contract HIV directly or indirectly from dirty needles, 352 start using heroin each day, and more than 4,000 die each
     year from heroin/morphine-related causes (the number one drug-related cause of death).Even assuming that NEWS can further accelerate the already declining rate

  of  HIV transmission, the risk that such programs might encourage a higher rate of heroin use clearly outweighs any potential benefit.

    Treatment should be our priority. Treatment has a documented record of reducing drug use as well as HIV transmission. Our fundamental obligation is to provide treatment for those addicted to drugs. NEPS should not be funded at the expense of treatment.

Supporting NEPS will send the wrong message to our children. Government provision of needles to addicts may encourage drug use. The message sent by such government action would be inconsistent with the goals of our national youth-oriented anti-drug campaign.

NEPS do nothing to ameliorate the impact of drug use on disadvantaged neighborhoods. NEPS are normally located in impoverished neighborhoods. These programs attract addicts from surrounding areas and concentrate the negative consequences of drug use, including of criminal activity. 

 (vi) Among IV drug users, HIV is transmitted primarily through high-risk sexual      contact
 
Another reason why NEPs may not retard the spread of HIV is that HIV is transmitted primarily through high-risk sexual contact, even among IV drug users.  Contrary to prior assumptions, recent studies on the efficacy of NEPs have discovered that it is not needle exchange, but instead, high-risk sexual behavior which is the main factor in HIV infection for men and women who inject drugs, and for NEP participants. A recently released 10-year study has found that the biggest predictor of HIV infection for both male and female injecting drug users (IDUs) is high-risk sexual behavior and not sharing needles. High-risk homosexual activity was the most significant factor in HIV transmission for men and high-risk heterosexual activity the most
significant for women.  The study noted that in the past the assumption was that IDUs who were HIV positive had been infected with the virus through needle sharing.

The researchers collected data every 6 months from 1,800 IDUs in Baltimore from 1988 to 1998. Study participants were at least 18 years of age when they entered the study, had a history of injection drug use within the previous 10 years, and did not have HIV infection or AIDS. More than 90 percent of them said they had injected drugs in the 6 months prior to enrolling in the study. In their interviews, the participants reported their recent drug use and sexual behavior and submitted blood samples to determine if they had become HIV POSITIVE since their last visit. The study showed that sexual behaviors, which were thought to be less important among IDUs, are the major risk for HIV seroconversion for  both men and women. 

If the above conclusions are correct, the very presumption of NEP efficacy becomes suspect.  Indeed, the use of needle exchange programs to address a problem which is caused primarily by high-risk sexual behavior would seem to be highly misguided.

Another reason that Needle Exchange Programs do not effectively address the issue of “saving lives” is that HIV (regardless of how it is contracted) is not the primary cause of death for IVUs.  A study conducted at the University of Pennsylvania followed 415 IV drug users in Philadelphia over four years.  Twenty eight died during the study.  Only five died from causes associated with HIV.  Most died of overdose, homicide, suicide, heart or liver disease, or kidney failure.

Clean needles, even if they in fact prevent HIV, will do nothing to protect the addict from numerous more imminent fatal consequences of his addiction.  It is both misleading and unethical to give addicts the idea that they can live safely as IV drug abusers.  Only treatment
and recovery will save the addict.  The myth of “safe IV drug use” is a lie which is perpetuated by NEPs, and it is a lie which will tend to kill the addict, although his corpse may be free of HIV, for whatever consolation that will provide to the NEP proponent.  
B. NEEDLE EXCHANGE PROGRAMS DO NOT REDUCE SUBSTANCE ABUSE, BUT IN FACT FACILITATE AND ENCOURAGE SUBSTANCE ABUSE.

The rise of NEPs, with their inherent facilitation of drug use (coupled with the provision of needles in large quantities), may also explain the rapid rise in binge cocaine injection which may be injected up to 40 times a day. Some NEPs encourage cocaine and crack injection by providing “safe crack kits” with instructions on how to inject crack intravenously.  Crack cocaine can be, and generally had been, ingested through smoking.  But the easy and plentiful availability of needles facilitates crack injection, creating a new segment of IV drug users, subject to health dangers they would otherwise have been spared exposure to.  In some NEPS, needles are provided in huge batches of 1000, and although there is supposed to be a one-for-one exchange, the reality is that more needles are put out on the street than are taken in.

NEPs also facilitate drug use through lax law enforcement policies.  Police are instructed not to harass addicts in areas surrounding NEPs. Addicts are exempted from arrest because they are given an anonymous identification code number. Since police in these areas must ignore drug use, and obvious and formidable disincentive to drug use disappears.  As the presence of law enforcement declines in these areas, the supply of drugs rises, with increased purity and lower prices, attracting new and younger consumers. 

Many drug prevention experts have warned that the proliferation of NEPS would result in a rise in heroin use, and indeed, this has come to pass. (However, the increase in drug use was ignored by the federally-funded studies which recommended federally funding NEPS). The National Center on Addiction and Substance Abuse at Columbia University reported August 14, 1997 that heroin use by American teens doubled from 1991 to 1996.  In the past decade, experts
estimate that the number of US heroin addicts has risen from 550,000 to 700,000. 
In 1994, a San Francisco study regarding a local NEP falsely concluded that there was no increase in community heroin use because there was no increase in young users frequenting the NEP.  The actual rate of heroin use in the community was not measured, and the lead author, needle provider John Watters, was found dead of an IV heroin overdose in November 1995. According to the Public Statistics Institute, hospital admissions for heroin in San Francisco increased 66% from 1986 to 1995.

In Vancouver, site of the largest NEP in North America, heroin use has risen sharply.  In 1988 when the NEP started, 18 deaths were attributed to drugs.  In 1993, 200 deaths were attributed to drugs. A 1998 report notes that drug deaths were averaging 10 per week.  Now Vancouver has the highest heroin death rate in North America, and is referred to as Canada’s “drug and crime capital.”

The 1997 National Institutes of Health Consensus Panel Report on HIV Prevention praised the NEP in Glasgow, Scotland, but the report failed to note Glasgow=s massive resultant heroin epidemic. Subsequently, as revealed in an article entitled “Rethinking Harm Reduction for Glasgow Addicts,” Glasgow took the lead in the United Kingdom in deaths from heroin overdose, and its incidence of AIDS continues to rise. 

Boston’s NEP opened in July 1993, and the city became a magnet for heroin. Logan Airport has been branded the country’s “heroin port.”  Boston soon led the nation in heroin purity (average 81%), and heroin samples of 99.9% are found on Boston streets. Subsequently, Boston developed the cheapest, purest heroin in the world and a serious heroin epidemic among the youth.  The Boston NEP was supposed to be a “pilot study,” but there was no evaluation of seroconversion rates in the addicts nor of the rising level of heroin use in the Boston area.

Similarly, the Baltimore NEP is praised by those who run it, but the massive drug epidemic in the city is overlooked.  The National Institute of Health reports that heroin treatment and ER admission rates in Baltimore have increased steadily from 1991 to 1995. At one open-air drug supermarket (open 9 a.m. to 9 p.m.) customers were herded into lines  sometimes 20 or 30 people deep. Guarded by persons armed with guns and baseball bats, customers are frisked for weapons, and then allowed to purchase $10 capsules of heroin.
One thing should be clear from the foregoing: since the implementation of NEPs, heroin use in our country has boomed.  It is obvious:  a public policy of giving needles to heroin addicts facilitates and encourages heroin use. 
C. NEEDLE EXCHANGE PROGRAMS ARE DESTRUCTIVE TO THE COMMUNITIES IN WHICH THEY ARE USED.

Most citizens oppose NEPs in their communities, and are concerned about the prospect of dirty needles being discarded in public places.  These fears are not without merit.  NEPs distribute millions of needles every year, and there is little or no accountability for needles once they have been distributed.  A survey conducted in 1998 revealed that in that year 19,397,527 needles handed out, and at best 62% were exchanged, leaving 7-8 million needles unaccounted for.   Carelessly discarded needles create a well-documented public hazard:

* On February 11, 2001, a six-year old from Glade View, Florida, stabbed five children with a discarded syringe. (Kellie Patrick/Scott Davis, “Playground Attack Raises Health Worries,” Sun Sentinal, 2/9/00, p 1B).

* On February 2, 2001, a nine year old from the Bronx stabbed four children with a discarded needle. (Diane Cardwell, “Boy Accused of Needle Attack,” The New York Times, 2/2/01, p. A17.)

* On February 13, 2001, a syringe left at a bus station stuck a four year old boy. (Mike Hast, “Big Fines for Syringe Litterers,” Frankson & Hastings Independent, February 13, 2001,www.mapinc.org/drugnews/v01/n304/ a08.html.)

Besides the physical hazard created by discarded needles, there is a commonsense perception that NEPs bring an air of decay to the communities that host them.  After several years of operation, 343 Massachusetts towns and cities (out of a total of 347) continue to decline the option of approving a local NEP, although of the 10 available slots, only 4 are taken.
31  Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, HHS,       Washington, DC 2001;50:384-388. 
32  Maginnis, Robert L., 2001 Update On The Drug Needle Debate, Insight, Number 235, July 16, 2001, Family Research Council, 801 G. St. NW, Washington, DC 2001.
In March 1997, accompanied by a New York Times reporter, a member of the Coalition for a Better Community, a New York City group opposed to NEPs, visited the Lower East Side Needle Exchange. She was not asked for identification and was promptly given 40 syringes (without having to produce any to exchange).  She was also given alcohol wipes and “cookers” for mixing the drugs, and she was given an exchange ID card that would exempt her from arrest for possession of drug paraphernalia. She was then shown how to inject herself. 

Community opposition to the Lower East Side Needle Exchange arose soon after implementation of the local NEP due to an increase in dirty syringes on neighborhood streets, in school yards and in parks. There was observed to be a dramatic increase in the public display of injecting drugs.  NEP users were seen selling their syringes to buy more drugs. Exchange workers themselves were photographed selling needles offsite.  Neighbors perceived the Lower East Side NEP as little more than a wholesale distribution center for clean needles and a social club for addicts. 

Pro-needle activist Donald Grove concurred: “Most needle exchange programs actually provide a valuable service to users beyond sterile injection equipment. They serve as sites of informal organizing and coming together. A user might be able to do the networking to find good drugs in the half an hour he spends at the street based needle exchange site networking that might otherwise have taken half a day. [Grove, D. The Harm Reduction Coalition, N.Y.C., Harm Reduction Communication, Spring 1996].

In 1998, a U.S. Government official was sent to Vancouver, site of the largest NEP in North America, to assess the high incidence of HIV among NEP participants, and the skyrocketing death rate due to drug overdose.  He reported that the highest rates of property crime in Vancouver were within two blocks of the needle exchange.  He also observed, pursuant to a tour with the Vancouver Police, that there was a 24 hour drug market and plain view injection activity in the area immediately adjacent to the needle exchange.  Most poignantly, he was told, in a private interview with an elementary school teacher, that the children at area schools are not allowed outside at recess for fear of needles. 
CONCLUSION

There is ample evidence to suggest that very fundamental premises used to justify and support NEPs are seriously flawed.  First, NEP participants routinely continue to share needles and large percentages of the NEP participants are HIV positive, meaning that NEPs do nothing more than continue the spread of HIV (and HCV).  Significantly, no one has been able to explain satisfactorily why enhanced needle availability in and of itself would discourage needle sharing: needle sharing is an intrinsic aspect of IV drug use, and a NEP-issued needle will transmit HIV as well as any other needle.

Second, NEP studies have discovered (inadvertently) that needle sharing is not even the primary cause of HIV infection for IVUs.  It is primarily through high-risk sexual behavior that IVUs contract HIV; free needles do nothing to prevent sexually transmitted disease.  Furthermore, HIV (regardless of how it is contracted) is not even the primary cause of death for IVUs.  Most die of overdose, homicide, suicide, heart or liver disease, or kidney failure.  Clean needles may protect an addict from HIV, but they do nothing to protect him from the more numerous, and more imminent fatal threats of his addiction.  Several key NEP proponents have died of heroin overdose; no doubt their needles were very clean.

Third, the science is inconclusive.  Although the proponents of NEPs uniformly aver that the scientific debate regarding the efficacy of NEPs is over, in truth, even the reports favoring NEPs are burdened with imprecise methodology, and many of the authors of those reports caution that their results should not be deemed conclusive. Today, there is still no conclusive scientific evidence: (1) that NEPs reduce the spread of HIV and HCV, or (2) that NEPs do not encourage IV drug use.  Indeed, the correlation between the rise of NEPs and the explosion of IV drug use, if it is a coincidence, is a remarkable one.  Dispassionate observers will look at the current epidemic of heroin and IV cocaine use as a tragedy which might have been averted, or mitigated, but for the misguided mercies of the NEP concept.
 
Fourth, while the benefits of NEPs may be in doubt, the costs to the surrounding communities are very real.  The overwhelming majority of communities dread the prospect of a local NEP, for self-evident and well-documented reasons.

 34  D.B. Des Roches, Information, Memorandum for the Director, Through: the Deputy Director, Subject: Vancouver Needle Exchange Trip Report, Executive Office of the President, Office of National Drug Control Policy, Washington, D.C. 20503, April 6, 1998.

 Peer-based addiction recovery support: history, theory, practice, and scientific evaluation.
White W.L.
Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Mental Retardation Services, 2009.
This monograph is likely to become the handbook for the growing peer-based recovery movement in the UK. For administrators, the approaches it reviews offer a way to reconcile decreasing per-patient resources with a policy agenda now focused on reintegration and recovery.
Abstract This seventh monograph* in a series on recovery management and recovery-oriented systems of care synthesises knowledge about the history, theoretical foundations, methods, and scientific status of peer-based recovery support for individuals with the most severe and complex alcohol and other drug problems. It was written primarily for people directly involved in planning, funding, delivering, supervising, and evaluating peer-based recovery support services, but will also be of interest to policymakers, purchasers of care, treatment programme administrators, and addiction counsellors and other service professionals. Though rigorously researched, information is presented in a clear and accessible language.
The report focuses on:
• Peer-based recovery support in general, meaning any form of mutual assistance aiming for long-term recovery from alcohol and other drug problems. Such assistance can and often does occur informally. The focus here is primarily on recovery support provided through recovery mutual aid societies and abstinence-based religious and cultural revitalisation movements by people whose credentials rest on personal experience.
• Peer-based recovery support services, a narrower term for assistance directed toward the same goal but delivered through more specialised roles with more formal resources, service protocols and safeguards. The key distinction is the term ‘services’, which implies a more formal structure though which recovery support is delivered. Here the focus is on recovery community organisations other than mutual aid societies, and on peer-based services provided through addiction treatment programmes and allied health and human service agencies. These services are distinguished from other programmes by their: mobilisation of personal, family, and community recovery capital to support long-term recovery; respect for diverse pathways and styles of recovery; focus on immediate recovery-linked needs; use of self as a helping instrument; and their emphasis on continuity of recovery support over time.
After comprehensively reviewing the literature and profiling peer-based recovery support initiatives, the author reached (among others) the following conclusions:

• Peer-based recovery support services are today growing out of the failure of addiction treatment to provide a continuum of care that is accessible, affordable, and capable of helping people with the most severe and complex problems move beyond brief episodes of recovery initiation to stable long-term recovery.

• Their distinctive strategy is to improve linkage to recovery mutual aid groups and other recovery support institutions, and their value is founded in what specifically those in recovery bring to the helping process. As with any effective helpers, those in recovery relate not primarily through techniques, but through humanness. They are able to do so, not because they once experienced addiction, but because they completed their own recovery experiences and emerged as men and women committed to this demanding way of life.

• Peer-based models of care can have a transforming effect on larger systems of care and on our society, but can also be corrupted and devoured when integration in to these systems leads to pressure to emulate the ethos of current professional treatment models. Care must be taken not to over-professionalise the roles of peer helpers, but training, guidelines, supervision and recognising the limits of one’s competence and role, are as important for services based on the power of mutual identification as for professional services.

• Rather than view peer-based and professional-based styles of knowing and doing as antagonistic models rivalling for superiority, it is more helpful to view these approaches as complementary. We need a community in which both professional and peer-based services are available as needed, and are supported and integrated into a seamless system of long-term recovery support.

• One unique quality separates the addictions field from peer models in allied fields: the growth of spiritual, secular, and religious recovery mutual aid groups, and new recovery support institutions, has gifted it the oldest and largest recovery mutual aid network in the world. New peer-based models must capitalise on these strengths rather than undermining or replacing them. The long-term goal is not to create a larger treatment system or new profession, but the establishment of recovery support relationships that are non-hierarchical, non-commercialised, and enduring in recovery-friendly communities.

• The question, ‘Who is most qualified to treat the alcoholic?’ is ill-framed because it assumes a homogeneity within the label ‘alcoholic’ and within the boundaries of particular helping roles or categories of helpers. In terms of recovery status, the question is not whether professional and peer helpers with or without a history of addiction recovery are most effective, but which helper is most effective with which person or family at a particular point in time. There are so many kinds of alcoholics and so many different kinds of alcoholism that a therapist eminently qualified to treat one type may fail completely with another.

• Recovery stages might be broadly conceived in terms of:
• 1 a sudden or unfolding opportunity for change;
• 2 a commitment to recovery experimentation;
• 3 recovery initiation and stabilisation;
• 4 recovery consolidation and maintenance; and
• 5 enhanced quality and meaning of life in long-term recovery.
 Peer-based recovery support services will probably be found most critical in stages 1, 2, and 4. Traditional professionals may be most effective in stages 3 and 5.
Every effort has been made to meticulously document sources, but many critical research questions about peer recovery support have yet to be studied and many studies suffer from methodological problems, so these findings are best viewed as probationary, pending new studies of greater methodological sophistication.
Though written by an advocate of peer-based recovery, this monograph is careful to adhere to the research (more comprehensively reviewed here than in any other publication) and to point out the limitations and risks involved in this route to recovery and the continuing role of professional treatment and other formal services. In it the British reader will find unfamiliar but potentially promising manifestations of mutual aid such as recovery social clubs, recovery community centres, and recovery homes, with profiles of how these have worked in practice and relevant research. Attention is not limited to 12-step based approaches, but extends to mutual aid based on other philosophies and understandings of addiction and recovery. For the growing peer-based recovery movement in the UK, it is likely to become an essential handbook to clarify thinking, offer practical ways forward, identify pitfalls and risks, and to encourage further research.
As the author comments, most of the reviewed research lacks the methodological safeguards of a randomised trial or some other research design capable of eliminating influences on outcomes other than mutual aid or peer support. Typically studies have recorded the degree to which substance dependent individuals participated in mutual aid activities and groups, and then assessed how closely this was associated with substance use and related problems. Such designs leave open the possibility that good outcomes encourage increased mutual aid participation rather than the reverse, or that people who are in any event going to do well also tend to participate in whatever in that society is the accepted route to doing well in terms of recovery from addiction. In the USA, where most studies originate, that route entails 12-step mutual aid.
When (as in a review for the Cochrane Collaboration) the focus is limited to the few randomised or other well controlled trials, there is no convincing advantage for 12-step mutual aid or allied services over other approaches. This review was unable to take in to account an influential later study which randomly assigned patients in formal treatment to standard versus intensive referral to 12-step groups. As intended, intensive referral improved 12-step mutual aid participation and this in turn improved substance use outcomes, confirming that participation was indeed an active ingredient. However, the effects on both participation and substance use were not great. While such studies can demonstrate the value of the extra element of mutual aid participation they ‘artificially’ generate, they say nothing about the value of the bulk of mutual aid participation as it naturally occurs. For this we must turn to the less well controlled studies excluded from the Cochrane review but included in the featured report, yet these are not capable of delivering convincing answers. This bind arises from the fact that mutual aid cannot be imposed or withheld by researchers and the results observed. Rather, it is generated (or not) organically by the nature of the society and of the individuals who choose (or not) to participate. It makes little sense to ask what the recovery chances of that society or those individuals would be if they did not generate or participate in mutual aid, because then they would not be the same societies or individuals. Another limitation of the controlled research is that typically it has studied mutual aid as an add-on to current treatment models, not the thoroughgoing systemic transformation called for in the featured report.
Even if given these difficulties, peer support and mutual aid struggle to demonstrate a superiority, where they can have a distinct advantage is in accessibility and (by reducing resort to public services) cost to society. For administrators in the UK, such approaches offer a way to reconcile increasing numbers in treatment, decreasing per-patient resources, increasing pressure to move patients through and out of treatment, and a policy agenda now focused on secure reintegration and recovery. Formal services seem unlikely to be able to make major advances in the availability to dependent substance users of (among other supports to reintegration and recovery) supported housing, suitable training and education opportunities, sheltered, graduated and attractive employment, and satisfying non-drug focused social and lifestyle options. Within available resources and political and public willingness to redirect these, transformations of the kind described in the featured report may be the only feasible way to create a more recovery-friendly environment which can protect greater numbers of people leaving treatment from repeated relapse.
However, risks of the kind warned about in the report are already apparent in parts of Britain where services concerned to safeguard vulnerable adults and who have clinical responsibility for patients seem reluctant to refer those patients to untried and unqualified mutual aid organisations, leading to pressure for those organisations to implement safeguards and protocols potentially antithetical to their self-help ethos. Such pressures have also been apparent in the UK mental health service-user/survivor movement. There is also a tendency for mutual aid recovery enthusiasts to see formal treatment services and their workers as ‘part of the problem’ rather than collaborators. The result is an imperfect interface between mutual aid and formal services which impedes beneficial complementarity and movement between them. As with other collaborations between organisations with different traditions and agendas, these difficulties will need to be carefully and respectfully worked through if patients are to benefit maximally from the potentially huge reservoir of voluntary effort represented by current and former problem substance users.
In the UK employment of current or former problem substance users in drug and alcohol services may be seriously impeded by the new requirements and powers associated with the advent in 2009 of the Independent Safeguarding Authority and of a similar scheme in Scotland. Among the criteria for banning people working with vulnerable adults (which would embrace many attending drug and alcohol services) are a history of acquisitive crime or fraud, addictive behaviour, or persistent offending. Such histories are common among drug addicted populations who have recovered through treatment and who might be employed as a paid employee or volunteer to offer peer-based support to substance users in contact with services. These problems have been recognised and representations are being made to the authority.
SOURCE: Peer-based addiction recovery support: history, theory, practice, and scientific evaluation.
White W.L.
Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Mental Retardation Services, 2009.

Fred M. Jacobs, M.D., J.D., Commissioner,
New Jersey Department of Health and Senior Services
August 2007

Dear Dr. Jacobs,

Re: Establishment of Needle and Syringe Programs

I understand that the state of New Jersey is considering a needle and syringe “exchange” program. I am also advised that New Jersey is a liberal democratic society whose members for the most part believe in freedom of the individual to pursue “life, liberty and happiness”. This of course is wonderful! And also provides a useful opportunity to note that no drug addict enjoys real freedom while their will, their lives, their relationships and their resources are largely dedicated to the service and slavery of their chemical addiction. This would make your lovely part of the world an excellent place in which to pursue those liberties which should be the birthright of every human being.

To introduce myself I am a family physician in Australia, and have pursued a special interest in the treatment of addiction especially for heroin, but also other drugs of addiction for the last ten years. Health department figures indicated last year that in the years 2001-2006 I single handedly registered 11,000 of the 14,000 registrations for opiate detoxification in the state of Queensland. I have also attained one of the three largest numbers of naltrexone based rapid opiate detoxifications in the country of Australia with over 1,800 procedures performed including 600 naltrexone implants. This was done with only two overnight hospital admissions which is a world safety record. I have also submitted evidence to several Government committees and leaders on the subject of drug policy.

As the so-called “needle “exchange” programmes” make little effort to exchange syringes, and as actual exchange makes little difference to the operation or mission of the programs, it is probably more accurate to refer to them as needle and syringe distribution programs, or NSP’s. It is important that your community appreciate this because syringe disposal is a real problem with these facilities. It has been so in this country. Our lovely and world famous Bondi beach in Sydney is now said to be one of the best places in the country to get a needle stick injury, due to the many syringes hidden in the sand. Clean up patrols have operated in King’s Cross twice daily for years to clean up the extreme public nuisance of hundreds of used syringes left dangerously in the streets and side walks, to protect the public . This is a well recognized problem with NSP’s which is generally covered up while such programs are in the planning phase.

Epidemiological Evidence

Since the NSP experts readily resort to discussion of “evidence based treatments”, and since the community decision to fully implement this program has such far reaching implications both in terms of needle disposal bins in all public toilets and for the time and direction of public health policy in the management of addiction, it is very appropriate that careful consideration be given to the quality of evidence which is typically cited in support of NSP’s. In particular the evidence based literature waxes lyrical about “levels of [reliability of] evidence.”

Self-report data is widely used in the addiction literature but it has been shown many times to be highly flawed and unreliable, and to fails to correlate with more objective and hard signs of HIV rates. As was pointed out to you by Dr. Fred Payne’s letter, and as was noted in the Institute of Medicine Report on this subject, it is well recognized that most of the literature on the subject of needle exchange is based on self report. This would clearly make it the least reliable form of evidence by their own criteria. Actually one would have to wonder if the evidence based gurus would accept such data at all.

Secondly we are aware of the “ecological” studies where they repeatedly report many cities with and without NSP’s. The work of Dr. Kirsten Kall’s group from the University of Linkoping shows clearly that in such an epidemic the rate of rise of the epidemic is related to the population at risk. Epidemics it is argued have a natural life history with a rise, fall and usually stabilization levels. Depending where in the natural history of the epidemic one takes one’s samples one will get a different picture of the efficacy of the NSP’s. It is for this reason that showing either a rise or a fall in HIV incidence or prevalence after NSP introduction is irrelevant if one is not informed of the natural history of the epidemic, and unless one can adduce by other means the likely outcome in its absence. This is a severe criticism, and one which effectively invalidates the whole of this genre of studies. I am also assured by epidemiologists familiar with such matters, that such studies are given no weight in epidemiological circles for this reason. That they have been foisted upon the rest of the world and even mentioned in major UN reports shows the degree to which such sloppy unscientific methods have been adopted within such agencies.

Indeed Dr. Alex Wodak, understood to be one of the primary authors of the relevant section of the 2006 UNAIDS report which eulogized NSP’s and the harm minimization addiction management paradigm, unequivocally stated in 1995 that formal proof of the methods of harm minimization would be impossible as it would not be possible to control in real life the many confounding factors which would be acting, and thereby prove that any particular intervention alone had been salient in controlling the target disorder .

Furthermore there is a clear conflict of interest by some of the leading proponents of NSP’s . Dr. Alex Wodak was for many years the President of the International Drug Law Reform Foundation and is the current president of the Australian Drug Reform Foundation which lobbies unceasingly for drug decriminalization. Dr. Don Jaralais in the USA is also understood to be of a similar ideology, and his advocacy for NSP’s is well known. I am of the understanding that such parallels could be made repeatedly for many of the most ardent advocates of NSP’s.

Dr. Payne’s letter mentions the very high rates of HIV in Vancouver at present despite the operation of an NSP, having risen from 1% to 35%. It was also shown long ago in Montréal that the HIV rate amongst NSP attendees was 2.5 times that amongst non-attendees (3.1 Vs. 7.9%) .

In terms of its control of other virus transmission NSP’s seem to substantially lack power. They failed to control Hepatitis B in Amsterdam , or Hepatitis C in Australia where rates of HCV carriage amongst IVDU who have been involved in the lifestyle for longer than six months exceed 80%.

Special Situations

Some situations are special and require special consideration. We are well aware that the apparent success of harm minimization techniques in this country is frequently cited overseas and in international fora as proof of principal of the efficacy of harm minimization epidemic management techniques. What is repeatedly overlooked in such discussions is our record rates of other infections such as Hepatitis B and C, and the venereally transmitted agents Herpes, Warts and Chlamydia. Indeed recently released data shows 30-100% growth in the last five years in Queensland in Gonorrhea, Hepatitis C, Chlamydia and Syphilis . Indeed it has been estimated that the Australian health care system has now to plan for over 100,000 liver transplants required for Hepatitis C alone in the next 20 years. One also notes that the outcome after transplantation for Hepatitis C is inferior to that for other infections due to the universal early graft re-infection which invariably occurs in the first few post-operative days, and the clash between anti-rejection immunosuppressive therapy and the anti-viral needs of fighting an aggressive viral infection in the context of the immuno-suppression and likely immuno-senescence induced by drug addiction, which is reversed to an unknown extent by abstinence.

In Australia our HIV rate amongst IVDU who do not share other risk factors is very low by international standards of the order of 1%. New cases of HIV nationally in all groups have risen from about 100 in 1991 to around 300 in 2005 . There appears to be significant variation in the estimates for the number of syringes distributed to addicts in this country with estimates varying from 20,000,000 to 200,000,000 – a level of inexactitude which in itself should give us pause. The former number was more than our total population at the time, and the latter number is substantially greater than the number of sheep here (which says a lot for a nation which for a long time was said to ride on the sheep’s back!) One important feature then facing the advocates of any NSP program is exactly how many syringes do they want to distribute? One for every man woman and child in the state?

However in the case of Australia we would do well to heed Wodak’s warnings about the inability to control for other confounders. From a modeling point of view the epidemic began in certain well known high risk groups. Its spread would then have been related to the population at risk, the activity of the various risk taking behaviours, and the intersection of these behaviors with the wider general community. Still today over half of all HIV infections in this country occur amongst men who have sex with men. It should also be added that the rate of IVDU in this group is 10-20 times higher than it is in the general community. Clearly then the spread of the disease into the wider community is related to the behaviour of this reservoir of infected people. One of the obvious confounding factors which has never been studied or quantified is what might be termed the homosexualization of the Australian culture with many laws, many bureaucracies, and schools of public health completely subsumed by the new ideology accompanying the public health impetus of the HIV epidemic. In that this likely instilled major good will in the primary target community, and is likely to have very positively influenced the relevant risk taking behaviours, it is clearly an intimate confound which confuses and likely dilutes any effects which might be attributable strictly to NSP’s.

Another important confounding factor was that Australia made treatment for HIV free to all patients who would have benefited from it from the outset of the epidemic. Assuming that the most at risk individuals were infected near the beginning of the epidemic, then those that survived their infection might reasonably be expected to have had a lower viral load for most of this time making them les infectious. This can be expected to have significantly slowed the rate of progression of the epidemic in this country.

Sweden is an important case in point which must be mentioned in any intelligent discussion of the NSP movement. Sweden has very limited methadone treatment availability, until recently no NSP activity, and no legal “shooting galleries” and a very low rate of HIV in IVDU. Hence the methods of harm minimization cannot strictly be said to be required for HIV control. Clearly HIV control can occur in a very effective manner in the absence of the model harm minimalist strategies.

The situation in prisons, or penitentiaries, is a special one and well worth at least some specific consideration. I was privileged to give evidence to the Inquiry into the Impact of Illicit Drug Use on Families before the Federal House of Representatives of the Australian Parliament on 3rd April 2007 . During that interview I stated that “my blood ran cold at the thought of 500 inmates all sharing the same syringe barrel” as was recounted to me by one of my HIV positive patients. However typical harm minimalist solutions such as methadone, syringe distribution and bleach use have been found to be impractical in the prison environment, and in this country have triggered strikes and industrial disputes by the prison warders due to the creation of unsafe workplaces. Since making those comments to the committee I have considered what might best be done about this appalling situation. One approach follows below (see “Other Treatment Modalities”).

In essence it is my belief that where the crime for which a person is committed is referable to opiate drugs, the standard of care will become naltrexone implant insertion on admission to the jail (after appropriate detoxification procedures), naltrexone implant maintenance during incarceration, and naltrexone implant prior to discharge to prevent the overdose which so often accompanies discharge (and the ritualistic “get a whack, get a woman” routine which is invariably followed). Indeed in Perth patients discharged from the prison are taken by volunteer escort from the prison gates to the clinic for implantation before the whole destructive cycle can re-commence. This seems the most sensible, responsible and compassionate management of this problem.

Other Treatment Modalities

Naltrexone was fist synthesized in the USA 1963 at Endo laboratory by Matossian acting under Blumberg’s instruction . Naltrexone implants and depot preparations have recently received a lot of attention from the international addiction management literature, and have been commercially introduced in the USA. American developed depot injections typically last 3-4 weeks. A preparation recently developed in this country lasts typically 4-6 months. The results of the first formal clinical trial conducted in Perth will soon be announced, probably in a leading medical journal such as JAMA or New England Medical Journal. They have been extensively used in this clinic where we have inserted over 600 USA (Wedgewood) and Australian (Perth “Go Medical”) implants. I was asked by the Preventative and Community Medicine Committee of the Queensland Faculty of the Royal Australian College of General Practitioners to evaluate naltrexone medicine including the Perth naltrexone program in 1998, and since 2001 I have been involved with the development in Perth of their naltrexone implant.

Unofficially the abstinence rate in terms of not returning to dependent heroin use at five months was well in excess of 50% in a study which set new standards international medical literature for patient follow-up. Only 11% of the 70- patients were lost to follow-up compared to over 90% in a similar (larger) study conducted in leading centres in the USA reported by Hollister in 1977 for NIDA at the NIH . Naltrexone is also a widely recognized and used technique for reducing problem drinking in alcoholics. It has also been used for gambling addiction, with positive results on some occasions. Moreover other results reported from the Perth clinic indicate that naltrexone is likely to have a controlling effect on other chemical addiction such as benzodiazepines, cannabis and stimulants such as amphetamines.

It is my personal view that they are excellent and will soon revolutionize the treatment of opiate addiction. Opiate dependence of course is the most addictive and refractory of all drug addictions, and the possibility of gaining control of such patients in a drug free context, as opposed to the usual medical model involving the indefinite maintenance of addiction, must be one of the most exciting opportunities ever to be offered to physicians in addiction medicine.

Another medical agent which has shown enormous promise in the control of multiple addictions is the cannabinoid antagonist rimonabant (“Accomplia”; SR141716A) which has been used with success against opiate, tobacco, alcohol, amphetamine food and cocaine addictions. This drug has attracted attention from NIDA and is undergoing further testing. I am not sure what its regulatory status is in the USA. It was available in eight European nations when I enquired with the pharmaceutical company (Sanofi-Synthelabo) about four months ago. The drug is still under patent, so this impedes its being re-formulated into an implant or depot preparation.

The combination of naltrexone and rimonabant has yet to be tested but would appear to show obvious promise, and it would be a priority in a rational testing program to investigate this further.

Future Research Directions

Many studies show increased evidence of drug use in young people.

All senior authorities in the world agree that there is far too little resources put towards investigating the toxicological effects of addictive drugs in general, and in adolescents in particular.

If we are ever going to do more than shut the door after the horse has bolted, clearly the issue of the true toxicity of addiction must be much better investigated, and the results of such studies broadcast far and wide to our young people, to de-glamourize the dreadfully seductive marketing program to which the rock music and popular culture misleadingly subjects them. If we are ever going to contain the monster of rampant destructive drug use in our younger people, then their dangers must be better emphasized.

Given the obvious multi-system damage of long term chemical addiction which is immediately apparently to even the untrained observer, one can only conclude which a Science which espouses the relative benignity of addiction must be grossly and egregariously deficient.

I have formulated a detailed plan by which such a strategy can be put in place, based around the accumulated ageing changes evident in the skin, teeth, hair, blood vessels, bones, immune system, stem cells and brains of addicts. It invites international collaboration and multi-system multilevel cooperation and the application of state of the art techniques to classical clinical problems. That however, is another story.

CONCLUSION

In summary NSP’s incur great social cost and are clearly part of the problem rather than part of the solution. Their scientific literature is remarkable for its lack of compelling evidence and methodological rigor, not to mention the prominence of adverse findings, when properly adjudicated. Rather the global penetration of NSP’s is an indicator of the strength of the marketing strategy of the ideology they enshrine. They are in any case about to be phased out like old dinosaurs by the cutting edge technologies which are moving ever closer to being a real market alternative, particularly the revolutionary long lasting Australian naltrexone implant.

I have been advised that now methadone is worth $150/week to dispensing hospitals in Federal hospital subsidies. As some of the most famous institutions in the USA have 10,000 – 20,000 patients enrolled on it, this income source forms a major stream of hospital funding. As such it is not likely to be disrupted. What the management of the Australian HIV epidemic does teach us is that it is best to get on and treat the HIV infection as soon as medically appropriate. In addiction medicine we have up until now largely done the reverse, for there we have deliberately continued indefinitely maintenance treatment designed to not to confront the addicted physiology, but rather to postpone indefinitely the definitive redress of that medical condition. The Australian success with HIV management tends to rather emphasize the reverse approach. This is the therapeutic route suggested by naltrexone implant maintenance. In all the discussion we would appear to have forgotten that in the early 1960’s New York was in urgent need of a treatment for addicted GI’s returning home from Vietnam. Methadone as the only medical solution then available was adopted and quickly came to command tremendous official support to the point where it became in time, the established industry. We have now a far more exciting opportunity to launch naltrexone implants and other new treatments in a similar and innovative manner. In would be my sincere hope that nations can move speedily to deliver proven and safe medical treatments to vulnerable populations without incurring undue, unnecessary and officious regulatory obstruction.

This would appear to be the visionary, drug free and health enhancing approach. As these concepts are more widely understood it is hoped that regulators and administrators will cooperate to mobilize international best medical practice on behalf of those with whose care they have been entrusted. I would invite the legislators of New Jersey to work with us on these issues of major cultural importance.

Yours Sincerely,

A. Stuart Reece, MBBS (Hons.), FRCS (Ed.), FRCS (Glas.), MD, FRACGP.
Family Physician, Highgate Hill Brisbane,
Senior Lecturer, Medical School, University of Queensland,
Fellow, Drug Watch International,
Fellow, Drug Free Australia,
Member, Society for Neuroscience,
Member, International Cannabinoid Research Society,
Attendee, College of the Problems of Drug Dependence Conferences 2002-2006.
Awardee, National Institute of Drug Abuse, International, 2003, 2004, 2006.

Motivational interviewing can yield excellent results and the basic skills and techniques are easy to learn. Dr Malcolm Thomas sets out the basics of promoting behaviour change

Helping patients or clients to change their behaviour can be frustrating. As professionals, we can get into a cycle of giving advice and making suggestions, only to feel that everything we suggest is being rejected. Specialist workers often have some training in more effective techniques – this article is aimed at frontline staff, most of whom will not have had such training.
There is now rather compelling evidence that the approach known as motivational interviewing produces better results than standard care (also called ‘business as usual’ or ‘finger wagging’). A full motivational interview takes between
45 and 60 minutes. The necessary training takes two, three or more days so it’s not surprising that this has been the preserve of specialists. However, the insights and techniques of motivational interviewing are available to ‘ordinary’ practitioners. I work for a training company and it’s our contention that everyone whose job includes counselling patients or clients regarding behaviour
change can enhance their professional effectiveness with some understanding, and judicious use, of relevant techniques.
Each of the following techniques takes no more than a few minutes to use and frontline practitioners can use them flexibly in relevant professional conversations. Regard the list as a toolkit from which the relevant tool can be unpacked as needed.

Many clients exhibit two or more behaviours that may profitably be changed, such as alcohol, drug use and diet. Usually it’s the professional who chooses which one to talk about, but allowing the client to choose the focus may enhance motivation. This can be achieved by running verbally through the options as the professional sees them and inviting the client to choose, such as:
‘It looks there are three things we could talk about today. Firstly your drug use, secondly your drinking and thirdly your diet. Does that sound right?’ Then, if the client agrees: ‘OK, so which would you like us to focus on today?’ People can be a bit vague about their habits. A typical answer to ‘how much alcohol do you drink’ is likely to be something like ‘Well, that’s a good question. It’s hard to say. Depends on this and that.’ It’s usually profitable to clarify what is going on at an early stage in your
professional relationship. A recommended technique is the ‘typical day’ question. For example, ‘I wonder if I could spend a couple of minutes learning more about your drinking? Can I ask you to talk me through a typical day, starting when you wake up
and finishing when you go to bed? Tell me where you go, what you do and where your drinking fits in.’ Variations on this include asking about a specific day (yesterday, last Saturday) or a typical week (which can be better for some behaviours). It’s normally very helpful to gauge the client’s readiness to change or consider changing. This may be apparent from things they have said and it certainly can emerge naturally from the conversation, but this is not always the case. While it’s rare for there to be no real clue, it can often be very unclear just how much readiness there is to change. It’s helpful to break readiness to change down into two components – importance and confidence. One strategy is to ask specifically about these in turn, using ‘scaling questions’. For example, ‘Can I just ask you a couple of questions? On a scale of one to ten, how important is it for you to cut down your drug use?’ Say the client responds with ‘Oh, I don’t know. Maybe around a three,’ your response could be ‘I see – thanks. Can I ask a similar question? On a scale of one to ten, if you decided to cut down, how confident would you be that you could make the change?’ Their response might be: ‘That’s a good question. Maybe six-ish. I cut down quite well for a while once. I think I could do that again.’

One advantage of this approach is that you can use it as a launch pad for further exploration, such as: ‘You told me you were at three or four for importance. So can I ask you why three and not one or two?’ ‘Well, it does sometimes get me into trouble. I’d like to think I had a bit more control over it and that it didn’t dominate my life quite so much.’ ‘Alright, so what would have to happen to move that score up to say five or six?’ ‘Well, if I got properly sick with it, I think that might do it.’ People aren’t daft. They indulge in unhealthy behaviours because there’s a payoff. Being overweight is a side effect of eating, which is usually pleasurable. Substance users get some sort of ‘high’ from their substance, or a relief from withdrawal effects if dependent. Behaviours have a social context and many people enjoy doing things with friends, whether smoking, drinking or injecting.
An axiom of motivational interviewing is that our client can see pros and cons to their behaviour. Rather than offering our professional opinion, we can help by allowing the client to bring these out into the open – and then feed it back to them: ‘Can I just try to understand a bit better? Can I ask you about the pros and cons of your marijuana use? First, what are the pros of smoking it from your point of view, the things you like about smoking marijuana? ‘Well, it relaxes me a bit, you know. And when I light up a joint with my mates, we have a good laugh. And to be honest, I prefer a smoke to a drink because you don’t
get the hangovers – you know what I mean?’ ‘Yes, I think I see that. Ok, what about the cons? The things you don’t like so much?’ ‘Well, it sometimes costs me quite a bit you know. And if I get really stoned, then I miss half the day, which isn’t right. And my girlfriend isn’t keen – I think she might not stand for it forever.’ ‘Can I recap then? You’re telling me that it relaxes you, that you do it with your mates and that you prefer it to alcohol. On the other hand, it can cost a lot, you sometimes miss half a day and your girlfriend doesn’t like it?’ ‘That’s about right, yeah.’ ‘Where does that leave you today?’ This can really help in our efficient use of interview time. The client response usually tells us if they are ready to go further and get involved in change talk – or alternatively it may be clear that it isn’t profitable to take things any further today.

At any point in the discussion, resistance may emerge. It is tempting to meet resistance with reasoned argument – pointing out all the scientific reasons on the side of a behaviour change. Unfortunately, this usually has the effect of stiffening resistance. For example, ‘You really need to lose weight you know.’ ‘I guess so.’ ‘I think you should go on a diet.’ ‘I can’t because…’ This is known as negative self-talk. It has been shown that an increase in the amount of negative self-talk in an interview is associated with a lower chance of behaviour change occurring. It seems prudent to avoid provoking such statements. For example, ‘I get the impression I may be pushing you a bit too far here. Shall we stop talking about this today?’ ‘No… It’s ok, go on. It’s just that this is difficult for me to get my head around.’ This is known as ‘rolling with resistance’. It can be a very effective tactic to
prevent the emergence of negative self-talk. It demands that professionals should be on the lookout for signs of resistance at pretty much any stage in a behaviour change discussion.

Most of us who work with clients develop a well-polished series of mini-lectures by way of explaining all the regular things that come up and need explaining. Unfortunately, these mini-lectures may not really be wanted. Or else, we may fail to address important questions on the mind of the client. A mini-seminar might be better. A useful way of looking at this is ‘elicit – provide – elicit’. Elicit any questions or information needs and provide answers or information in response. When it comes to action talk, it is better to provide a range of options to be chosen from. Finally, elicit a response – find out how your information has been received. An example: ‘Can I explain anything to you, answer any questions?’ ‘Well, have you got any information about how many units are in my various drinks. And what do you think I should do to cut down?’ ‘Ok. Let’s see. This leaflet is good for information about units. How does this look?’ ‘Very clear, actually. Can I have that?’ ‘Definitely – it’s for you to take away. Anything catch your eye?’ ‘Yes. Look at this about glasses of wine. I had no idea there were so many units.’ This approach can lead to more effective use of professional time, while again minimising the risk of negative self-talk developing. Motivational interviewing gives better results than ‘business as usual’ and many of the individual skills and techniques are easy enough to learn and can be used in routine conversations with patients or clients. I’ve outlined and demonstrated a range of the most useful
micro-skills, with examples of how they might fit into your conversations but a very readable and immensely practical textbook I’d recommend to any DDN reader is Health Behavior Change – a guide for practitioners by Stephen Rollnick, Chris Butler
and Pip Mason (Churchill Livingstone) – despite the spelling, it’s a British book.

Dr Malcolm Thomas is director of national training provider Effective Professional
Interactions Ltd. www.effectivepi.co.uk

Source: drinkanddrugsnews Jan 2010