Summary
Continuing care or aftercare is the stage of treatment following initial, more intensive, treatment. This review focused on psychosocial continuing care interventions (such as individual, telephone, couples, and group therapy; case management; home visits; and brief check-ups) and 12-step mutual aid support groups. Studies of brief continuing care interventions (up to six months) have usually involved standard programmes provided after residential treatment. In contrast, most longer interventions are adapt their frequency or nature in response to systematic assessments of how well the client is doing.

Despite a broadly supportive research record, few efforts have been made to implement and sustain these interventions, and in practice few clients who might benefit from continuing care services actually receive a sufficient dose, either because they do not complete the initial treatment, do not start continuing care, or do not remain in it for a significant time. Among other things, this review seeks to better understand this discrepancy and make recommendations for future implementation efforts.

Effectiveness of continuing care
Though this review and studies have focused on either continuing care treatment or mutual aid groups, it should be remembered that many individuals participate in both and that using both sources of support is associated with improved treatment outcomes.

Studies have shown that receiving continuing care services is generally but not always associated with improved long-term substance use outcomes. This small and varied corpus of studies precludes conclusions about which approaches work best. However, the findings support certain general principles. Among these are increasing the duration of care to at least a year, ongoing monitoring of clients, reaching out actively to engage and link clients to care, and using incentives to improve treatment outcomes. Relatively low-cost practices can dramatically improve rates of sustained engagement in continuing care such as low level incentives and active outreach following discharge or drop-out. In contrast, the theoretical orientation and intensity of the interventions appear less important.

As well as or instead of continuing care treatment services, mutual aid groups are important continuing care resources. The most prevalent like Alcoholics Anonymous and Narcotics Anonymous follow 12-step principles. Several studies have shown that attending these groups after initial treatment is associated with positive substance use outcomes, though they are unable to prove that attendance causes these gains. Additional to attendance as such, being more involved in the groups (such as getting a sponsor or reading 12-step literature) has also been associated with better substance use outcomes. In practice though, while most US patients start attending groups, most of these are no longer attending a year later.

Interventions to promote participation in 12-step mutual aid groups can be traced to the Twelve Step Facilitation therapy trialled in Project MATCH. This large US study of treatment for alcohol dependence found this approach achieved significantly higher rates of continuous abstinence (and equivalent outcomes on other drinking measures) than cognitive-behavioural therapy and a therapy based on motivational interviewing, and did so because it led more patients to engage in 12-step activities. Similar results have emerged from other studies.

Implementing continuing care
A search for studies not of the effectiveness of continuing care, but of how to implement it, uncovered 28 relevant articles and others known to the authors of the review or referenced in the literature. To organise the analysis of these studies, the reviewers used the Consolidated Framework for Implementation Research. In respect of health care innovations in general, this model identifies five implementation domains, each divided in to several sub-domains. The five main domains with relevant examples are:

• Characteristics of the intervention (in this case, continuing care) such as the strength of the evidence for its effectiveness and how far it was adapted to fit the particular circumstances in which it was being implemented.
• Outer setting, which refers to the economic, political, and social environment surrounding and influencing the organisation undertaking the implementation – in this case, typically substance use treatment services; included here might be national political drivers, availability of funding, the demand from patients, and (especially in the case of 12-step groups) the degree to which the broader society is receptive to the intervention’s philosophy.
• Inner setting is pertinent features of the implementing organisation including the degree to which its structures, internal communication mechanisms, resources, leadership, and culture facilitate the adoption of continuing care or the particular continuing care intervention being implemented.
• Characteristics of the individuals conducting the intervention – in this case, typically addiction counsellors – such as what they believe about the intervention and how enthusiastic and ready they are to implement it.
• Process of implementation – the extent and quality of the implementation effort, including the degree to which relevant staff are actively engaged, the efficiency with which the implementation is carried out, the extent to which progress is appropriately monitored against specific goals and progress news fed back to the participants, and the extent to which this feedback is used to adapt and promote implementation.

Generally the few relevant studies have not developed or supported specific packages to promote continuing care implementation. The one clear example of a specific and manualised intervention is Twelve Step Facilitation therapy, an approach which has been successfully adapted to different circumstances and populations. More general evidence-based interventions for promoting mutual aid participation typically entail active and directive efforts to engage and retain clients, including education on the benefits of the groups, orientation to involvement with these groups, and connection with group members to help motivate involvement following initial treatment.

In more detail and organised under the main headings of the Consolidated Framework for Implementation Research, research offers the following guidance.

Intervention Characteristics Clinicians generally know that the evidence for continuing care is strong yet often continue to use interventions and practices without empirical support. A significant number of studies suggest that many interventions can be adapted to the needs of specific sites. Twelve Step Facilitation therapy has for example been successfully adapted to a group format, to focus on individuals’ broader social networks rather than just 12-step groups, and to accommodate individuals with mental health as well as substance use problems. Similarly, treatment-based continuing care efforts have been conducted successfully using telephone and home-based visits and with different types of providers. One difficulty is the relative complexity of such interventions. Knowledge gaps include the relative advantages and cost-effectiveness of different continuing care interventions, and what are their core or essential components as opposed to those which can safely be adapted.

Outer Setting The most frequently cited factors related to successful continuing care implementation are located in the outer setting domain, especially the importance of client characteristics such as their needs and resources to support continuing care involvement. African-Americans (compared to Caucasians), and clients with more severe substance use problems, are more likely to engage in continuing care for a longer time. Psychiatric disorders seem no barrier to engagement in continuing care. Patients who see staff members as supportive and have more recovery resources are more likely to engage in treatment-based continuing care. Clients with beliefs consistent with a disease model or spiritual approach to recovery, women, and those with less prior experience with 12-step groups, may be more easily engaged in mutual aid groups, and those mandated to attend by courts may do as well as those who are not. In addition to client characteristics, the convenience of continuing care is an important facilitating factor while lack of funding is a common and significant barrier. Additionally, inviting mutual aid group members to contact patients in the initial treatment service facilitates post-treatment linkages. The role of external incentives and policies appears to be an extremely important area for future implementation efforts to address and better understand.

Inner Setting Focusing on the treatment service, those oriented to 12-step approaches facilitate linkage to 12-step mutual aid. Low rates of staff and supervisor turnover and multi-stakeholder involvement are important to sustaining continuing care treatment interventions. Goals or benchmarks that allow programmes to monitor performance and modify interventions in response are important factors in successful continuing care implementation. Mutual aid group engagement is facilitated by strong therapeutic alliances, greater supportiveness, and spirituality during initial treatment. Use of incentives with staff to promote implementation of continuing care practices appear to be a potentially powerful, but underused facilitator. Little is known about the implementation climate, including goals and benchmarks for continuing care interventions, or about the role of programme readiness for change (eg, resources and knowledge) as they relate to continuing care implementation.

Characteristics of the individual provider Treatment and mutual aid continuing care implementation are facilitated by providers and programme leaders with beliefs and attitudes supportive of the particular intervention, while a lack of knowledge about the effectiveness of interventions can be a significant barrier. Additionally, clinicians who are in recovery themselves, who have fewer concerns about religion or spirituality as a part of treatment, without allegiance to non-12-step approaches to treatment, and those who require abstinence during treatment, are more likely to facilitate 12-step mutual aid involvement following treatment. It is clear that future implementation efforts will need to address important characteristics such as the knowledge, beliefs, motivation, and self-efficacy of both providers and clients to maximise the potential for implementation success.

Implementation Process Successful continuing care implementation efforts have tended to address the important constructs of planning, engaging, executing, and reflecting and evaluating implementation efforts. These activities will be critical in the development and testing of implementation strategies.

Implication for researchers and clinicians
Having summarised continuing care implementation research, the review ended by drawing out the implications of these findings for researchers and clinicians. Though scarce, viewed through the lens of the Consolidated Framework for Implementation Research, existing research provides a starting point for closing the gap between research and clinical practice. Formative evaluations intended to develop interventions to promote continuing care should be informed by this literature, and these evaluations should address all five domains, or deploy other comprehensive implementation models. Additionally, two primary recommendations emerge from this review.

Basic Continuing Care Implementation Research Is Needed Despite its clinical importance, continuing care implementation research has been relatively neglected. Both the treatment and mutual aid continuing care implementation literature have findings relevant to all five major domains of the Consolidated Framework for Implementation Research, but all the detailed strategies and factors within each domain have yet to be addressed. One of the most striking gaps is the lack of information on the relative advantages, disadvantages, and cost-effectiveness of continuing care interventions. Little is known too about and their core elements and the impact of incentives and/or consequences related to both the inner setting and outer setting domains.

Implementation Efforts Need to Address Multiple Domains The comprehensiveness of the Consolidated Framework for Implementation Research highlights that implementation efforts typically do not consider the importance of intervening across multiple domains. For instance, as already noted, the role of incentives and consequences in the inner setting and outer setting domains and at patient, counsellor and programme level, has been neglected. This review suggests that closing the gap between knowledge about continuing care interventions and their use will require a paradigm change in which both researchers and clinicians consider intervening across multiple domains rather than within a single domain, as has been typical thus far. Research-established interventions may have too few implementation facilitators and too many barriers for them to be adopted in particular settings without attention to all the relevant domains.

People treated for substance use often remain precariously balanced between recovery and relapse following initial treatment. As currently designed, the utility of treatment is limited by high post-treatment relapse and re-admission rates, and frequently prolonged addiction and treatment careers. Assertive linkage to continuing care helps individuals transition from brief experiments in sobriety (recovery initiation) to disease management and sustainable recovery maintenance, and an enhanced quality of life. It requires close connections between the worlds of professional treatment and community recovery support resources, and implementation of continuing care promotion procedures to enhance engagement and retention with these resources.

In the UK financial constraints and the recovery agenda have brought with them potentially conflicting expectations that treatment will end as soon as the patient seems able to manage on their own and rarely extend over years, yet will do more to reintegrate patients in society. More patients exiting briefer treatments would create an increasing potential caseload for aftercare services to ensure they remain safe and can rapidly re-enter treatment if relapse occurs or is threatened. How this configuration of forces will pan out and what it will mean for extended care in the form of aftercare or continuing care is unclear. Funders seeking to contain costs and maximise drug-free treatment exits may be reluctant to fund aftercare services, especially since UK research evidence that they make a difference is lacking, probably because studies have been few. On the other hand, low-cost, check-up style aftercare allied with free mutual aid groups may make it more acceptable to cut back on intensive and expensive initial treatment. These considerations are expanded on below.

The main recent British attempt to evaluate the contribution of aftercare was an analysis of the Scottish DORIS study. On several measures, it found that the few drug dependent patients who accessed aftercare after treatment in the early 2000s did better than the majority left to (or who chose to) fend on their own. However, it was unclear whether this could this be attributed to the aftercare, or whether these patients would have done well anyway. An attempt to statistically control for differences between patients still left recently being heroin free at the last 33-month follow-up associated with having received aftercare from the initial treatment agency. Having received aftercare following methadone maintenance or residential rehabilitation made little difference to whether patients had experienced a period of being entirely drug free. But consistently at each of the three follow-ups, aftercare following non-methadone community treatment like detoxification or psychosocial therapy was associated with about double the chance of having been drug free.

Formal aftercare from the treatment agency was not the only way patients sought to sustain their abstinence. Over the 33 months of the follow-up, nearly a quarter attended mutual aid groups like NA and AA. At each of the follow-ups, patients who had accessed aftercare and mutual aid were most likely to have been drug free for a period, generally those who accessed neither were least likely, and those who accessed one but not the other were in between.
Whatever the meaning of these findings for aftercare’s effectiveness, it was clear that few patients received it, and neither was it targeted at those most at risk of relapse.

An English study of problem drinkers could more securely attribute the results to aftercare enhancements, because patients were randomly allocated to normal aftercare – up to three weekly support groups plus access to the unit’s recreational and social facilities – or to an additional 15 individual sessions modelled on an influential US approach called Early Warning Signs Relapse Prevention Training. During this, patients are helped to recognise personal warning signs of relapse by analysing their most recent attempts at recovery, and then to develop ways to manage these episodes without a return to drinking. Over the following year the benefits of more intensive aftercare were reflected in significantly fewer drinking days (22% of warning sign patients drank on a fifth or more of days compared to 40% in usual aftercare), fewer heavy drinking days (corresponding figures 18% and 28%), avoidance of any return to heavy drinking (45% v 26%), and improved mental well-being. In monetary terms, warning sign patients absorbed slightly less health service and rehabilitation resources, though slightly more if the warning sign regime was itself costed in. However, neither difference approached statistical significance.

In agreement with the featured review was a review of 11 studies which allocated patients at random or in a quasi-random manner to continuing care versus minimal or no continuing care. In terms of each study’s main substance use outcome measures, seven of the 11 found a clear and statistically significant advantage for continuing care. The review’s conclusions were endorsed by a panel of experts convened by the US Betty Ford Institute, who argued that extended and regular monitoring of the patient’s progress was the key component of continuing care and the one with the greatest evidence of effectiveness. Both review and recommendations were based largely on studies of aftercare following residential treatment.

While international and to a degree UK research is at least consistent with aftercare often being an aid to lasting remission, recommendations that it be implemented run up against a strong contrary trend in current UK policy, which emphasises not continuing care, but exit from the treatment system. Without denying the need for long-term care for some patients, the English strategy on drug misuse said services needed “to become much more ambitious for individuals to leave treatment free of their drug or alcohol dependence so they can recover fully … We will ensure that all those on a substitute prescription engage in recovery activities and build upon the 15,000 heroin and crack cocaine users who successfully leave treatment every year free of their drug(s) of dependence”. Scotland’s strategy too stressed the need for more patients to “move on from their addiction towards a drug-free life as a contributing member of society”, implying a corresponding shift away from extended and/or indefinite treatment.

Set against this drive to contain treatment, the recovery agenda has brought with it a greater emphasis on sustained and extensive life change, and an accompanying expectation that treatment services will do more for their patients than a brief treatment for their addiction. At the same time resources are no longer increasing and probably diminishing overall. One way to square this circle is to draw on the free resource of mutual aid groups which offer former patients 24-hour access to support, frequent support meetings, a new social circle, and a new way of life. It comes therefore as no surprise that they feature in recent commissioning guidance from England’s National Treatment Agency for Substance Misuse, which sees them as providing “valuable support and positive social networks for individuals who are addressing their dependency through treatment”. The advice to services is that “Details of how clients can access local recovery networks should be made available throughout their treatment journey. Services may wish to consider more active engagement with local mutual aid groups, for example making rooms within the treatment service or prisons available for meetings”. The agency now sees (see annual reports for 2009–10 and 2010–11) promoting mutual aid networks as a key way to achieve its objectives. Local service commissioners are being called on to ensure that the treatment system is better integrated with wider supportive services, among which mutual aid organisations are seen as the most prominent.

Source Psychology of Addictive Behaviors: 2011, 25(2), p. 238–251.

Professor Neil McKeganey, director of the Centre for Drug Misuse Research at the University of Glasgow, has criticised Scottish Government policy and said the nation is “paying a massive price” for its drugs problem.  Scotland has some 55,000 addicts, so the annual bill in health care, criminal activity, drug driving and other social costs comes to almost £3.5 billion.

Writing in today’s Scotsman, Prof McKeganey argues Scottish society has grown too accepting of all forms of drug abuse and needs instead to preach a doctrine of abstinence. He questions the Scottish Government’s reliance on methadone as a substitute for heroin abusers and argues more effort is required to get addicts off drugs through abstinence.

“At the moment, we have about 22,000 addicts on methadone in Scotland,” he says. “When Scottish ministers are asked whether they have any plans for reducing that number, the typical answer is to say that prescribing methadone is the responsibility of individual doctors.  “Our political leaders, surrounded by those who counsel them on the benefits of methadone, find themselves passing responsibility for our national methadone programme on to the shoulders of those who are prescribing the drug in the first place. This situation is going to get worse.”

Prof McKeganey says Scotland’s drug problem is “virtually without equal anywhere in Europe” and that concern over “legal high” mephedrone, a substance sold as plant food which has become popular as a recreational drug and has been linked to a number of deaths, is just another symptom of the “culture of addiction”.

“What… should we make of a situation in Scotland where young people are prepared to consume plant food to obtain a desired high?” he says.

The Centre for Drug Misuse Research has estimated each problem drug user costs £60,703 a year, while a recreational drug user costs the state only £134.  The costs were calculated by considering the addict’s actions in terms of health, work, driving, crime and other social consequences, such as children in care and even addicts’ deaths.

In 2007, for example, problem drug users made 45,034 visits to accident and emergency departments at a total cost of £9,804,388, while the annual shoplifting bill is £50,611,921.

Prof McKeganey believes that key to tackling Scotland’s drug problem lies in a greater focus on abstinence. “If we are going to change the culture of acceptance around drugs, we need to do something that is almost beyond comprehension – we need to normalise abstinence,” he says.

The growing culture of middle-class drug use, where users argue it is a just reward for personal success, must he tackled, he argues, and there should be more visits to schools by drug addicts and their families to highlight the consequences of addiction.

Last night, a spokeswoman for the Scottish Drugs Forum defended the use of methadone for drug addicts and the necessity for support systems to help drug addicts, even during times of financial hardship.  “Methadone – along with psycho-social support to supplement the pharmaceutical prescription – has an important part to play in helping many people stabilise chaotic drug use, but other approaches must be available, including abstinence-based treatment, for people who want them and who could benefit from them,” she said.  “What matters most is having a range of high-quality and readily accessible treatment which best meets the needs of each individual at each stage of their journey away from harmful drug use.”

Tim Richley, of offenders’ charity Sacro, supported Prof McKeganey’s long-term goal, but said it would require gradual change. “I do understand the argument he is making and I would come down on the side of total abstinence as a good goal that we are trying to achieve, but other factors can help,” he said. “If they were to ditch methadone overnight, there would be a huge rise in criminal activity as addicts seek the money to buy heroin.”

A spokesman for the Scottish Government said it had invested a record £28.6 million in drug treatment and services. He went on:  “It is for individual clinicians to decide on the most appropriate medical treatment for any person, taking into account their lifestyle and what stage they are on the road to recovery.

“The Scottish Government’s new drugs strategy offers a blueprint for all our drug treatment and rehabilitation services based on the principle of recovery, not extending addiction, tailored to the personal needs of individuals.”
Source:  www.scotsman.com 29^th March 2010

The synthetic cannabinoid (cannabis-related) compound, called MDA19, seems to avoid side effects by acting mainly on one specific subtype of the cannabinoid receptor. “MDA19 has the potential for alleviating neuropathic pain without producing adverse effects in the central nervous system,” according to the study by Dr Mohamed Naguib of The University of Texas M.D. Anderson Cancer Center.

MDA19 Works on a Single Cannabinoid Receptor
The researchers performed a series of experiments to analyze the pharmacology and effects of the synthetic cannabinoid MDA19. There are two subtypes of the cannabinoid chemical receptor: CB1, found mainly in the brain; and CB2, found mainly in the peripheral immune system.

Dr. Naguib’s group has been doing research to see if the cannabinoid receptors—particularly CB2—can be a useful target for new drugs to treat neuropathic pain. Neuropathic pain is a difficult-to-treat type of pain caused by nerve damage, common in patients with trauma, diabetes, and other conditions.

MDA19 was designed to have a much stronger effect on the CB2 receptor than on the CB1 receptor. In humans, MDA19 showed four times greater activity on the CB2 receptor than on the CB1 receptor. In rats, the difference was even greater. The experiments also showed that MDA19 had “protean” effects, so-called after the shape-shifting Greek sea god Proteus—under different conditions, it could either block or activate the cannabinoid receptors.

In rats, treatment with MDA19 effectively reduced specific types of neuropathic pain, with greater effects at higher doses. At the same time, it did not seem to cause any of the behavioral effects associated with marijuana.

Potential to Develop Effective Pain Drugs that Avoid Side Effects
The “functional selectivity” of MDA19—the fact that it acts mainly on the CB2 receptor and has a range of effects under differing conditions—could have important implications for drug development. “[W]ith functionally selective drugs, it would be possible to separate the desired from the undesired effects of a single molecule through a single receptor,” Dr. Naguib and colleagues write.
This means that MDA19 could be a promising step toward developing medications that have the pain-reducing effect of cannabinoids while avoiding the mental and physical side effects of marijuana itself. However, more research will be needed before MDA19 or other agents that act on the CB2 receptor are ready for testing in humans.

“These elegant studies by Professor Naguib demonstrate remarkable analgesic properties for this synthetic cannabinoid,” comments Dr. Steven L. Shafer of Columbia University, Editor-in-Chief of Anesthesia &Analgesia. “The studies suggest a novel mechanism for this protean agonist. Although preliminary, these studies suggest that synthetic cannabinoids may be significant step forward for patients suffering from neuropathic pain.”

SOURCE : www.news-medical.net 2nd July 2010

In the study, researchers at The Scripps Research Institute in Jupiter, Florida found that cocaine consumption increased levels of a specific microRNA sequence in the brains of rats, named microRNA-212.

As its levels increased, the rats exhibited a growing dislike for cocaine, ultimately controlling how much they consumed.
On the other hand, as levels of microRNA-212 decreased, the rats consumed more cocaine and became the rat equivalent of compulsive users.

The study’s findings suggest that microRNA-212 plays a pivotal role in regulating cocaine intake in rats and perhaps in vulnerability to addiction.
Interestingly, the same microRNA-212 identified in this study, is also expressed in the human’s dorsal striatum, a brain region that has been linked to drug abuse and habit formation.

“This study enhances our understanding of how brain mechanisms, at their most fundamental levels, may contribute to cocaine addiction vulnerability or resistance to it,” Nature quoted National Institute on Drug Abuse (NIDA) Director Dr. Nora D. Volkow, as saying.

“This research provides a wonderful example of how basic science discoveries are critical to the development of new medical treatments and targeted prevention,” he added.

Rats with a history of extended cocaine access can demonstrate behavior similar to that observed in humans who are dependent on the drug.
Current data show that about 15 percent of people who use cocaine become addicted to it.
The findings suggest that microRNAs may be important factors
contributing to this vulnerability.

“The results of this study offer promise for the development of a totally new class of anti-addiction medications. Because we are beginning to map out how this specific microRNA works, we may be able to develop new compounds to manipulate the levels of microRNA-212 therapeutically with exquisite specificity, opening the possibility of new treatments for drug addiction,” said Paul J. Kenny, senior author on the study.
The study is published in the journal Nature. (ANI)

Source:www.sify.com/news 9th July 2010-07-10

The patient states that his abdominal pain is 10 out of 10 in severity, and that he has been vomiting up to 20 times each day. He has been evaluated at multiple hospitals, and he has had numerous upper endoscopies, colonoscopies, swallowing studies, and CT and MRI imaging studies, all of which were unrevealing.

He underwent a cholecystectomy, but had no improvement in his symptoms after the surgery. His pain and nausea are unresponsive to antacids and antiemetics.

The patient’s only relief is with hot water bathing: he spends hours each day in the shower with the temperature set as hot as he can bear. The patient’s history is otherwise unremarkable, except that he admits to daily marijuana use beginning at the age of 14.

This patient’s story is typical of cannabinoid hyperemesis, a clinical syndrome characterized by intractable vomiting and abdominal pain associated with the unusual learned behavior of compulsive hot water bathing, occurring in the setting of long-term heavy marijuana use.
Treatment consists of medication for immediate symptomatic relief and marijuana cessation for long-term relief. Symptoms usually remit within weeks of becoming abstinent.

If this disorder is so easily diagnosed and treated, why were the patient’s past doctors confused to the point of performing what might have been an unnecessary surgery? Cannabinoid hyperemesis is a new diagnosis, first described in 2004, and currently sixteen papers on the subject have been published.

Therefore, it is likely that the patient’s prior doctors had never considered this disorder. Second, the pathogenesis of cannabinoid hyperemesis is poorly understood.
How can marijuana, which is used in cancer clinics as an anti-emetic, cause intractable vomiting? And why would symptoms abate in response to high temperature?

The connection between marijuana, vomiting, and heat is non-intuitive, and a medical team unfamiliar with this syndrome would be hard-pressed to reach the diagnosis.
The largest study of cannabinoid hyperemesis to date was the landmark report by Allen et al in 2004 in an area of Southern Australia where marijuana use is largely decriminalized.

The report tracked 10 patients who presented with cyclic vomiting after 3 to 27 years of cannabis abuse and no other history of drug abuse. All but one displayed compulsive hot water bathing; the remaining patient had only experienced his symptoms for 6 months, and the authors theorize that he had not yet learned to associate hot water with symptom palliation.

The 9 compulsive bathers reported that this bizarre behavior occupied hours of their days and said that their symptoms were ameliorated within minutes of bathing and returned when the water cooled. All 10 patients were counseled to cease cannabis use, and 7 did so. Within weeks of cessation, the symptoms resolved for these 7 patients; the remaining 3 patients did not cease cannabis use and continued to have cyclic vomiting and abdominal pain.

After several years of abstinence, 3 patients resumed cannabis use and were hospitalized again with cyclic vomiting and abdominal pain. Once again, 2 of these patients successfully stopped using cannabis, and their symptoms resolved. The remaining patient continued to use cannabis and continued to experience symptoms at the time of publication.
Following the first case report, further cases have been described on three continents.

All patients presented with the classic triad of symptoms described by Allen et al: cyclic vomiting and abdominal pain, an extensive history of cannabis abuse, and palliation with hot water bathing. The fact that this unique triad is preserved in diverse patient populations suggests that there is a pathogenic mechanism that underlies this syndrome.

Several authors have speculated about the pathophysiology of cannabinoid hyperemesis, and though the specifics remain unclear, there is consensus over some of the basic principals: It appears that the high lipophilicity of delta-9-tetrahydrocannabinol (Δ9-THC, the active compound in marijuana) causes cumulative increases in concentration with chronic use, which may lead to toxicity in susceptible patients.

The abdominal pain and vomiting are explained by the effect of cannabinoids on CB-1 receptors in the intestinal nerve plexus, causing relaxation of the lower esophageal sphincter and inhibition of gastrointestinal motility. This finding is supported by gastric emptying studies performed on one of the patients presented by Allen et al, which revealed severely delayed emptying. While cannabis appears to have anti-emetic effects that are centrally mediated, it is possible that these effects predominate at low doses whereas the gastrointestinal effects predominate at the high concentrations that occur with long-term use.

The proposed explanation for compulsive hot water bathing is based on the fact that cannabis disrupts autonomic and thermoregulatory functions of the hippocampal-hypothalamic-pituitary system. There is a high concentration of CB1 receptors within the limbic system, and the hypothalamus in particular is known to be responsible for integrating central and peripheral thermosensory input. Furthermore, Δ9-

THC induces hypothermia in mice in a dose-dependent manner. While this evidence links cannabis to the hypothalamus and to thermoregulation, it does not provide a causal relationship. Two mechanisms proposed by Chang et al are that (1) cannabinoid-induced hypothermia causes the desire for hot water bathing, or (2) hot water bathing is the direct result of CB1 activation in the hypothalamus.

The true mechanism underlying hot water bathing remains enigmatic, and further studies are needed to elucidate the relationship between this bizarre learned behavior and the other features of cannabinoid hyperemesis.

A timely diagnosis of cannabinoid hyperemesis is essential not only to effect proper treatment but also to prevent iatrogenic morbidity and mortality from unnecessary diagnostic procedures and surgical interventions. There are, however, several obstacles to effective diagnosis:

First, the legal status of marijuana makes eliciting an accurate drug history challenging. Second, the bizarre hot water bathing is likely often attributed to psychological conditions such as obsessive-compulsive behavior. Third, the knowledge of the anti-emetic effects of cannabis likely disguises cases of cannabinoid hyperemesis, leading to the erroneous belief that cannabis is treating cyclic vomiting rather than causing it.

Finally, the fact that this syndrome is so recently described and relatively unknown outside an esoteric subset of the GI literature means that most clinicians are unaware of its existence. The following diagnostic criteria adapted from Sontineni et al can be used to facilitate a diagnosis of cannabinoid hyperemesis syndrome:

ESSENTIAL FEATURES
History of chronic cannabis use
Nausea and cyclic vomiting over months
Relief with cessation of cannabis use
SUPPORTING FEATURES
Compulsive hot water bathing with transient relief of symptoms
Colicky abdominal pain
Exclusion of other etiologies (especially gall-bladder and pancreas)
In the case of the 18-year-old patient presented above, asking the open-ended question, “What makes you feel better?” followed by more focused questions regarding the temperature of the water and the history of marijuana use were sufficient to suggest the diagnosis of cannabinoid hyperemesis.
We propose that these questions be used as a screening tool for all patients presenting with cyclic vomiting. Based on our experience and a review of the literature, we believe that these questions may be both sensitive and specific for detecting this unusual syndrome.
The patient presented in this case was counseled on his likely diagnosis.

Though he was initially skeptical, giving him printouts of case reports on cannabinoid hyperemesis syndrome and discussing the etiology of the disease were sufficient to convince him of the diagnosis. He was treated symptomatically in the hospital. Two weeks after discharge, he remains abstinent from marijuana and reports that his symptoms are improving.
Sarah A. Buckley and Nicholas M. Mark both are 4th year medical students at NYU School of Medicine
Faculty reviewed by Robert Hoffman, MD, Director NYU Poison Control Center, Associate Professor Departments of Medicine and Emergency Medicine, NYU Langone Medical Center

Source http://www.clinicalcorrelations.org/?p=2877 July 15th 2010

In studies conducted with rats, Dr Andrew Lawrence and his Florey colleagues used a drug that blocked Orexin’s euphoric effects in the brain and the results were remarkable.
“In one experiment, rats that had alcohol freely available to them stopped drinking it after receiving the Orexin blocker.” Dr Lawrence said. “In another experiment, rats that had gone through a detox program and were then given the Orexin blocking drug, did not relapse into alcohol addiction when they were reintroduced to an environment in which they had been conditioned to associate with alcohol use.

“Orexin reinforces the euphoria felt when drinking alcohol, so if a drug can be developed to block the Orexin system in humans, we should be able to stop an alcoholic’s craving for alcohol, as well as preventing relapse once the alcoholic has recovered,” he said.
Dr Lawrence said that this research could also lead to treatments for eating disorders, such chronic over-eating, which leads to obesity. “Our research shows that alcohol addiction and eating disorders set off common triggers in the brain, so further investigations may uncover drug targets in the Orexin system to treat both conditions,” Dr Lawrence said.

The Florey scientists are now conducting multiple experiments to discover the precise circumstances that activate the Orexin system. “To explore this discovery further we are now investigating how different experimental paradigms and environmental situations impact on the Orexin system, which will hopefully pinpoint therapeutic drug targets,” Dr Lawrence said.
“Before a therapeutic Orexin-blocking drug can be developed, we need to ensure that it will be safe to use in the long-term and that issues surrounding a person’s compliance in taking the drug are considered,” he said.

According to the World Health Organisation, alcohol is one of the most widely used and abused substances in the world and causes as much, if not more death and disability as measles, malaria, tobacco, or illegal drugs.
Dr Lawrence and his colleagues were the first in the world to demonstrate the Orexin system’s involvement in alcohol addiction and their research paper was recently published in the prestigious British Journal of Pharmacology. Dr Lawrence’s paper was downloaded 658 times by researchers from around the world in the first three months of its publication, making it the most downloaded research paper in that issue and supporting the research’s importance.
The Howard Florey Institute is Australia’s leading brain research centre. Its scientists undertake clinical and applied research that can be developed into treatments to combat brain disorders, and new medical practices. Their discoveries will improve the lives of those directly, and indirectly, affected by brain and mind disorders in Australia, and around the world. The Florey’s research areas cover a variety of brain and mind disorders including Parkinson’s disease, stroke, motor neuron disease, addiction, epilepsy, multiple sclerosis, autism and dementia.

Source: ScienceDaily. Retrieved March 28, 2010 Howard Florey Institute (2006, December 13).
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While youth who had a history of abuse or mental health problems were more likely to become homeless, those same characteristics didn’t predict teens and young adults getting off the street six months later.

“It looks like the predictors of homelessness might be different than the predictors of exiting homelessness,” lead author Natasha Slesnick of Ohio State University said in a statement. “So that means prevention targets should be different from intervention targets.”

Source:Reported in Join Together April 2006

It is indicated for the substitution maintenance treatment of opiate addiction in adults previously treated with methadone. In a public statement dated December 19, the EMEA said: “ 10 cases of life threatening cardiac rhythm disorders have been reported since 1 July 1997. They include five cases of cardiac arrest associated with ventricular arrhythmias, three cases of cardiac arrhythmia and two cases of syncope.” “Finally three patients required a pacemaker insertion,” the agency added . “This raises a major concern given the fact that these life  cases occurred in young patients (median age 39/ range 23— 57)  a population at low risk of developing these cardiac disorders, and given the relatively low exposure to the product.”  Furthermore, these cardiac disorders might have been under recognised or under reported.”

The study by the independent Institute of Applied Research found that nonviolent drug offenders who are placed in treatment instead of prison generally earn more money and took less from the welfare system than those on probation.

The study compared the 219 individuals who were the program’s first graduates in 2001 with 219 people who pleaded guilty to drug charges during the same period and completed probation.

For each drug-court graduate the cost to taxpayers was $7,793, which was $1,449 more than those on probation. However, during the two years after drug court, each graduate cost the city $2,615 less than those on probation. The savings were realized in higher wages and related taxes paid, as well as lower costs for health care and mental-health services.

“What you learn is that drug courts, which involve treatments for all the individuals and real support — along with sanctions when they fail — are a more cost-effective method of dealing with drug problems than either probation or prison,” said Tony Loman, the lead researcher.

The St. Louis drug court allows addicted individuals who have been arrested to voluntarily enrol in the program. Participants are required to submit to periodic drug and alcohol testing, appear in court during scheduled times, find and keep jobs, and enrol in drug and alcohol treatment. Those who successfully complete the program have their charges dropped.

The 4,005 patients in the study were treated for addiction to cocaine, heroin, or marijuana in 62 drug treatment units throughout the United States. As part of the National Treatment Improvement Evaluation Study, they were interviewed at admission, discharge, and one year after therapy ended between 1993 and 1995. Treatment programs included methadone maintenance programs, outpatient non methadone programs, short-term residential programs, and long-term residential programs. There was no significant relationship between treatment duration and overall drug use improvement for individuals in methadone maintenance and short- term residential programs.
WHAT IT MEANS: Remaining in treatment for an extended time has beneficial outcomes for people in residential or outpatient drug treatment programs. Insurers may consider changing their policies to include a longer length of stay so people can be more effectively treated for their addictions.

In a collaborative study, researchers from the School of Social Work and the Centre for Addiction and Mental Health (CAMH) in Canada evaluated more than 600 families from New York’s Buffalo-Niagara region and Canada’s southern Ontario area who participated in the Families Working Together program.

The program targets families with a child between the ages of 9 and 12 who has or had a parent with an alcohol problem. The families were selected to either receive an informational booklet on preventing addiction or participate in weekly sessions focusing on family relationships, parenting skills, and children’s coping and competency skills.

The study found that the family-treatment approach, which emphasized communication and skill-building, was effective in preventing children from falling into the same negative patterns that led their parents to alcohol and other drug use.

“Children of alcoholics are at higher risk of certain negative outcomes, including alcoholism, substance abuse, depression, and anxiety,” said Andrew Safyer, interim dean of the School of Social Work and a co-investigator on the project. “Studies show that programs that target parents, children and the family itself are more effective in preventing further substance abuse.”
Source:University of Buffalo Reporter, March 2004

In Rochester, N.Y., the juvenile treatment court is using mentors as aids in recovery, the first treatment court to systematically do so, USA Today reported on September 30. Rochester is a Demand Treatment community.

“There’s the thought in the drug court movement that it’s not programs that influence people — it’s relationships,” says Judge Anthony Sciolino. “We find that where we’re successful with youngsters turning their lives around, it’s because they’ve connected with a caring adult.”

The court finds its mentors through Compeer, Inc., a Rochester-based volunteer organization with national and international affiliate offices. Compeer matches community volunteers with children and adults who are receiving treatment for mental health disorders.

In Rochester, the treatment court coordinators approached Compeer just as the organization was starting a program to match adults with troubled teens. Mentors have been working with 20 adolescents so far, and at least half of the matches have been successful.

Compeer would like to extend mentoring to its chapters in other cities; however, the program has not secured money for next year.
Source:Indiana Prevention Resource Center at Indiana University Bloomington; June 2004.

The Independent reported July 14 that physicians may someday be able to treat addicts by altering neurotransmitters in the brains, and prevent addiction with vaccines such as the one currently under development by the firm Xenova to address cocaine use.

The U.K. Department of Trade and Industry set up the “Foresight” project to consider new technologies and their impact on society in the next 20 years. The group has proposed ideas like a national immunization programme for addiction. It also has predicted that drugs will come to market that are designed to improve mood, intelligence, and memory. Panel members expect pharmaceutical companies to find new ways to deliver medicinal and pleasure-enhancing drugs, such as through impregnated clothing.

“We hope that these findings will give us guidance about what could possibly happen in the future and give us some guidelines about how we can respond to certain issues, like addiction,” said a U.K. health ministry spokesperson.

Fewer side effects
Chemically, the drug partially blocks the same brain receptors that heroin and methadone target. But unlike those drugs, it doesn’t produce the same “high” or level of dependence. In addition, withdrawal from buprenorphine produces less severe symptoms and fewer drug cravings.

“The new medicine works differently in two ways,” Sederer said. “Bupe has a ceiling effect and reaches a certain point where it doesn’t get you higher, so it is much less likely to be abused or sold on the streets. With heroin and methadone, the more you take, the higher you get, and your lung function is depressed. The respiratory failure is what results in death.”

Methadone has been the standard for heroin addiction treatment since the early 1970s. But the syrupy, amber liquid is highly habit-forming and by law must be distributed — one dose at a time — at a special clinic. That stricture causes some who would seek treatment to shy away.

“People say that methadone leaves them punchy, and they have difficulty thinking and working,” Sederer said. “The long-term data on people in methadone programs shows that they are more stable, not involved in crime, and that’s a good thing, but only a small percentage are working [in jobs].”

Relatively new drug
Despite the potential benefits of buprenorphine, the drug remains virtually unknown and unused by the city’s heroin addicts. According to city health officials, only about 1,000 people use it, compared with an estimated 34,000 taking methadone.

Sederer and other city health officials want to see a significant change in those numbers. The goal is to have more than 100,000 opiate addicts using buprenorphine for detox maintenance by 2010.

“We are not reaching enough people with the treatments that we have,” Sederer said. “Not everybody should be on methadone.”

Like methadone, buprenorphine is heavily regulated, and may be prescribed only by certified doctors, of which there currently are 345 statewide. In addition, those prescribing the drug are bound by a 30-patient limit, a federal restriction guarding against prescription abuse that Sederer and other health officials hope will be changed so that more patients can be treated.

Some private doctors have been reluctant to prescribe the drug, fearing their offices would be inundated with addicts.

The drug’s pill form would be more attractive to white-collar users trying to avoid methadone clinics, experts said.

Somewhat complicating the picture, there are varying camps in the medical community about how to treat opiate addiction. Some, including Phoenix House, the country’s largest drug-free residential rehabilitation program, use bupe for detoxification; other programs use it solely as a maintenance drug to replace methadone.

Dr. Terry Horton, the medical director of Phoenix House in the city, calls buprenorphine “the most significant development in the treatment of opiate addiction in 40 years.”

“But,” Horton noted, “it is not a replacement for methadone but should be considered another tool we can use to treat opiate addiction.”

Could streamline treatment
The goal, drug treatment experts said, is for more doctors to be able to prescribe buprenorphine and for patients to be able to pick it up at the pharmacy.

Potentially, thousands of people could benefit from the drug. The city spends $50 million annually on treatment of an estimated 200,000 heroin addicts and 200,000 others addicted to prescription painkillers like Vicodin, Percocet and OxyContin. The state Office of Alcoholism and Substance Abuse Services will spend $313.7 million in 2005-06 to treat those battling against alcohol and other drug-related addictions, spokeswoman Jennifer Farrell said.

Injection drug use is a major factor in the transmission of HIV internationally. Around 10% of all HIV transmissions can be attributed to the consequences of intravenous drug use including needle sharing or unsafe sex. Drug use has also been linked to the majority of HIV transmissions in central and Eastern Europe and Southeast Asia.

The most commonly used treatment for addiction to opioids, such as heroin and morphine, is replacement therapy with methadone. This drug mimics the effects of opioids by binding to the same receptor molecules as these drugs. These receptors, called mu-opioid receptors, are found on the surface of cells in the brain and spinal cord and trigger the drugs’ sedating, euphoric and pain-killing effects.

Methadone works by preventing the withdrawal symptoms and craving brought about when an addict stops injecting drugs. By reducing the frequency of drug injection, it has been shown to reduce the incidence of HIV infection. However, the use of methadone has a number of problems, including being itself addictive, and its risk of causing breathing problems and overdose. It also interacts with many HIV drugs.

Buprenorphine, in contrast to methadone, is a partial agonist of the mu-opioid receptor. This means that it binds to the receptor less strongly than methadone and is less likely to be abused itself. It is also very difficult to overdose on buprenorphine as its effects plateau at high doses, and it has fewer interactions with HIV drugs, so is easier to use in patients taking antiretroviral therapy.

“The introduction of buprenorphine, a new medication to treat opioid dependence that has fewer restrictions than methadone, holds promise for reducing HIV transmission and improving the care of patients with opioid dependence and HIV disease,” write the review’s authors, Lynn Sullivan and David Fiellin from Yale University School of Medicine. “Methadone has a long history of proven efficacy and benefits in treating opioid dependence, and the addition of buprenorphine serves to expand the treatment options”.

Buprenorphine has become more widely available over the last ten years, and is available alone or in combination with naloxone, a drug that blocks the mu-opioid receptor. It is taken as a tablet dissolved under the tongue daily or three times a week, and was recently added to the WHO’s list of essential drugs. This lists all medicines that should be available in adequate amounts and at an affordable price within all health systems, and are selected according to public health relevance, efficacy, safety and cost-effectiveness.

In their review, the authors summarise the results of cost-effectiveness studies comparing buprenorphine to methadone. These have concluded that buprenorphine treatment programmes may be preferable, both in the treatment of opioid dependence itself, and in its effects on reducing new HIV infections.

However, despite the drug’s benefits, the authors point out that few studies have examined its effects on HIV risk behaviours, such as needle sharing and unsafe sex, although larger scale studies are planned.

In injecting drug users (IDUs) who are already HIV-positive, there is evidence from the French Manif 2000 cohort study that use of buprenorphine improves adherence to antiretroviral drugs. Although this was not associated with a better response to therapy, and over half of the patients reverting to drug use during the study, they point out that, despite limited evidence, buprenorphine is less likely to interact with HIV drugs than methadone.

AZT (zidovudine, Retrovir) and some protease inhibitors may increase buprenorphine levels, but the pharmacological properties of buprenorphine mean that its effects are not increased above a ‘ceiling’ level, so increased buprenorphine levels are unlikely to cause dangerous side-effects. However, the authors write, “as efforts continue with the goal to integrate use of buprenorphine into HIV care, further studies will need to be undertaken to make more than theoretical statements about these interactions.”

In conclusion, there is room for substantial optimism about the inclusion of buprenorphine in the treatment of IDUs for the prevention of HIV transmission and the treatment of IDUs who are already HIV-positive. Although the practicalities of treatment programmes remain to be fully evaluated, many of the questions surrounding the drug’s role will be answered in ongoing and future studies.

“In the meantime, office-based clinicians, for the first time in nearly 100 years, have the opportunity to provide a unique treatment to minimise the adverse impact of opioid dependence,” the authors conclude.

Reference Sullivan LE et al. Buprenorphine: its role in preventing HIV transmission and improving the care of HIV-infected patients with opioid dependence. Clin Infect Dis 41: 891-896, 2005.

The authors from the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA found that cocaine-using research subjects reported a quicker peak and decline of their “high” than methamphetamine users. The body’s cardiovascular system responds quickly to both drugs, but physical responses to cocaine also decline more quickly than with meth use.

“These differences help explain patterns of use by addicts. Methamphetamine users, for instance, report using the drug daily throughout each day, while cocaine users typically engage in binges that occur most often in the evening,” said lead study author Thomas F. Newton. “In addition, the study results may impact development of medication treatments for addiction to these two very different stimulants.”

Following up on anecdotal evidence from China, researchers at McLean Hospital in Boston, led by Scott Lukas, gave test subjects either kudzu or a placebo and measured their beer consumption. They found that the kudzu group drank an average of 1.8 beers per research session, compared to 3.5 beers consumed by the control group.

Lukas said that it is possible that kudzu raises blood-alcohol levels quickly, so drinkers need to consume less to feel drunk. “That rapid infusion of alcohol is satisfying them and taking away their desire for more drinks,” Lukas said. “That’s only a theory. It’s the best we’ve got so far.”

Animal research conducted in 2003 also suggested that kudzu reduced alcohol intake. “There’s a lot of anecdotal evidence from China that kudzu could be useful, but this is the first documented evidence that it could reduce drinking in humans,” said researcher David Overstreet, who conducted the animal study.

Fourteen men and women in their 20s, who habitually consumed three or four drinks daily, took part in the study, spending four 90-minute sessions drinking beer and watching TV.

Kudzu won’t prevent drinking, researchers said, but could help heavy drinkers cut their consumption.

The report appears in the May 2005 issue of the journal Alcoholism: Clinical and Epidemiological Research.

Lukas, S., et al. (2005). An Extract of the Chinese Herbal Root Kudzu Reduces Alcohol Drinking by Heavy Drinkers in a Naturalistic Setting. Alcoholism: Clinical and Epidemiological Research, 29(5): 756-762.

Source: Alcoholism: Clinical and Epidemiological ResearchAssociated Press May 17 2005

People with short-term drug-induced psychosis and longer-term mental illness, compounded by pot smoking, are seeking medical help at an increasing rate. Mental Health Services clinical statewide director Peter Norrie said the Royal Hobart Hospital was seeing many cannabis cases.

First-time pot smokers were turning up at the Royal with full-blown psychosis — delusional, confused and anxious. Other more regular pot smokers with long-term mental illness were fronting for treatment for episodes likely to have been triggered or related to using cannabis.

“These days it’s close to every day,” said Dr Norrie, who is a senior clinical consultant psychiatrist at the Royal. He said he was talking about “drug-induced psychosis or long-term mental illness associated with pot smoking”. Dr Norrie said it was “very common” for first-time users to present with “floridly psychotic” behaviour.

He said psychiatrists were increasingly concerned with the link between substance abuse and mental illness. Cannabis use had been linked with depression, anxiety and schizophrenia. International studies show modern strains of marijuana are from three to 10 times stronger than those used by previous generations.

“Clinically psychiatrists have suspected a link for many years and the latest research seems to confirm this,” Dr Norrie said.

“The chicken-and-egg debate has raged for years – whether pot causes psychosis or people with a tendency to psychotic illness are predisposed to smoke pot.”

Dr Norrie said the first signs of schizophrenia were often a lack of engagement with society. But those symptoms could also be what is commonly known as “typically teenage” or a sign of the onset of depression.

Disengaged teenagers could then turn to cannabis.

If psychosis did occur it was hard to tell whether smoking pot was a cause or a symptom. Dr Norrie said some pot smokers appeared to be able to continue the habit without serious mental illness but others were prone to individual cases of psychosis or longer-term mental disease.

“There’s a certain group of people who smoke pot who are unlikely to develop mental illness but there’s certainly a significant number of the population who suffer from mental illness and pot smoking adds to the risk,” Dr Norrie said.

Drug-induced psychosis usually consists of paranoia, confusion and anxiety.

Sufferers present with memory problems and delusions. They can believe they have special powers, hear and see things that are not there and are unable to distinguish what is real.

The vaccine works by producing antibodies to a certain substance. When that substance is used, the antibodies bind to it as it enters a person’s system. In doing so, the vaccine stops most of the chemical from the drug from crossing into the brain. The substance is then metabolized by the liver and secreted from the body.

The two companies furthest along in the research are Nabi Biopharmaceuticals in Boca Raton, Fla., and Xenova Group PLC of Slough, England.

Nabi Biopharmaceuticals is working on a nicotine vaccine. The company has completed a trial involving 68 smokers to test safety and measure the levels of antibodies produced by the vaccine. The vaccine has also resulted in smoking cessation among a group of participants.

Xenova Group is working on a cocaine vaccine and reports that the vaccine has reduced relapse in a small group of cocaine users.

Researchers at the University of Pennsylvania School of Medicine said that the findings about orexin – previously linked to wakefulness and appetite – could provide new avenues for addiction treatment research. Orexin seems to be involved in communication between the lateral hypothalamus region of the brain and the ventral tagmental area and nucleus accumbens.

“The lateral hypothalamus has been tied to reward and pleasure for decades, but the specific circuits and chemicals involved have been elusive,” said Gary Aston-Jones, Ph.D., one of the study authors. “This is the first indication that the neuropeptide orexin is a critical element in reward-seeking and drug addiction. These results provide a novel and specific target for developing new approaches to treat addiction, obesity, and other disorders associated with dysfunctional reward processing.”

The association between orexin activation and reward seeking for morphine, cocaine, and food was found to be strong in animal studies, the researchers said. Scientists were able to initiate and curb craving by introducing and blocking orexin.

“These findings indicate a new set of neurons and associated neuronal receptors that are critical in consummatory reward processing,” said Aston-Jones. “This provides a new target for developing drugs to treat disorders of reward processing such as drug and alcohol addiction, smoking, and obesity.”

According to one study, almost all adolescents returning to their old school after completing a treatment program were offered drugs on their first day back. Findings such as this sparked a recent innovation in American education: recovery schools, which are high school or college programs designed to support young people in recovery from addiction.

Recovery schools have developed quickly over the past few years, but often in isolation from each other. That’s changing, however. Staff members at recovery schools are making connections with each other, a body of best practices is emerging to guide their work, and formal research to evaluate recovery schools is on the horizon. The bottom line: Parents and students looking for an academic environment that supports sobriety can now rely on more than guesswork and gut feelings when choosing a recovery school.

The need for recovery schools will not go away, as evidenced by the 2003 National Survey on Drug Use and Health from the Substance Abuse and Mental Health Services Administration, which found that:

• Nearly 1 percent of 12-year-olds in the United States either abused or became dependent on alcohol or illicit drugs in 2001

• the percentage of abusing or dependent adolescents increased each year up to age 21, when 22.8 percent fit the abuse or dependence criteria

• in both 2002 and 2003, nearly 2.3 million Americans aged 12 to 17 needed treatment for an alcohol or drug problem. Of this group, only 168,000 received care at a dedicated treatment facility.

Here is where the benefits of recovery schools click in. According to Andrew Finch, director of the Association of Recovery Schools, such programs offer a “protective cocoon” that supports recovery as students work towards graduation.

Since 2002, the number of recovery schools has doubled to 25 high schools and eight college programs. According to Finch, some lessons have emerged from all this activity. If a group is starting a recovery school, Finch recommends that the founders “be patient and persistent and reach out to people who have established schools. Also, be aware of referral sources and funding opportunities. One of the biggest mistakes a new school can make is to open but not have a consistent referral base of local treatment centers, schools, and other resources.”

Finch adds that recovery schools must stay on top of local and state education laws: “These must be followed, and they differ greatly from state to state and district to district.”

According to the ARS, recovery schools should:

• Operate with state approval and be designed specifically for students recovering from chemical dependency.

• Provide academic services and recovery assistance – but not operate primarily as treatment centers or mental-health agencies.

• Require students to be sober and working a program of recovery.

• Offer academic courses for credit and assist students to make transitions to college, a career, or another school.

• Have a plan to handle student crises, including access to counselors on staff, on contract, or available by written referral.

Finch has written a new book, “Starting a Recovery School: A How-To Manual” (Hazelden, 2005), that offers a blueprint for developing an effective recovery school and includes details about existing schools. Related information and a list of sobriety schools in the United States are online at the Association of Recovery Schools website.

Crack and cocaine addicts going through detox are given snack packs that include brazil nuts and sunflower seeds — natural remedies for relaxation — along with cognitive therapy and acupuncture.

“You’ve got to want to come off crack cocaine or stimulants yourself, but the packs help like mad,” said Joe, an ex-crack cocaine user. “Once you can suppress your cravings you can get on with life. It’s working for me.”

And Karl Sheldon of the Middlesbrough, England drug-action team, added: “When it comes to drug addiction we always think of the usual stuff, opiates and physical addiction. Stimulants like cocaine and crack cocaine are more psychologically addictive, so you are looking at a different way of treating these addicts. For example, the licorice root you chew on is good for sweet cravings and also for liver function. And again with brazil nuts, the chemicals inside attach onto receptors in the brain which deal with opiates and also stimulants.

“You are not going to eat a brazil nut and all your cravings are going to go away,” continued Sheldon. “This is about dealing with your cravings and taking the edge off them.”

Sheldon said about 50 snack packs have been given to addicts over the past two months, and seem to be having a positive effect.

Dr. Christos Ntais of the University of Ioannina School of Medicine in Greece and colleagues found that patients given benzodiazepines were 84% less likely to suffer withdrawal-related seizures than those given a placebo. “This might suggest that their [benzodiazepines'] current status as first-line treatment for alcohol withdrawal syndrome is justified,” the authors said.

But Ntais and the other researchers noted that other drugs, such as anticonvulsives like carbamazepine, are equally effective. “There was no conclusive evidence or even hints for superiority of specific drugs, but modest differences could have been missed due to limited data,” Ntais said.

The Greek researchers received 57 studies on benzodiazepine use for withdrawal; a separate group of scientists reviewed 48 studies on anticonvulsive use. Both reviews found that cases of death or serious complications were rare. “The extremely small mortality rate in all these studies is reassuring, but data on other harms-related outcomes are sparse and fragmented,” said Ntais.

Sarah Book of the Medical University of South Carolina noted that — unlike anticonvulsives — benzodiazepines have the potential to trigger relapse, and the interaction of benzodiazepine and alcohol can be fatal.

In this study, researchers assessed remission (no heavy drinking or related problems in the past 6 months) in 362 people with an alcohol use disorder who entered treatment (inpatient or outpatient), AA, or both in the year after they sought help. Subjects were surveyed at baseline and 4 subsequent times over 16 years.

• Remission was more common in people who had participated in both treatment and AA (e.g., 65 percent at 16 years) followed by AA only (57 percent) and treatment only (50 percent). Differences were significant between the two treatment groups (for 3 of 4 time points).

• Remission did not significantly differ between people in treatment only and those who initially received treatment but later entered AA.

• As duration of AA participation increased, the likelihood of remission significantly increased.

Comments Rosanne Guerriero, MPH Richard Saitz, MD, MPH: This study supports the notion that long-term participation in AA, particularly when begun soon after seeking help, is an important adjunct to professional treatment for alcohol use disorders. Treatment of alcohol dependence should include referral to mutual help groups and encouragement for patients to continue their participation.

Payments of up to $40 per week have been given to meth users who quit. Program participants are required to visit a clinic three times weekly for a drug test; clean urines are rewarded with a check, and participants are not even required to go to counselling as part of the deal, even if they fail a drug test.

“Here I am getting clean, I feel better and I’m getting something for it,” said said former meth addict Robert Bowers. “That means something.”

Experts say that many addicts respond very well to rewards, even small ones, that acknowledge their progress toward sobriety. “You’re using the exact same technique that parents use with their children every day,” said Nancy Petry of the University of Connecticut School of Medicine. “It’s behaviour modification and behaviour shaping.”

The 12-week San Francisco program has had 159 participants since November 2004; backers see it as an effective and inexpensive alternative for those who can’t get into treatment or are on waiting lists.

A recent UCLA study found that a cash voucher program for meth addicts was actually more effective in producing clean urine tests than a therapy program lacking a reward component. “Clearly, it wasn’t the money,” said UCLA researcher Steven Shoptaw. “It was the fact that somebody recognized them.”

• Four patterns of AA attendance emerged: low (mainly during the year following treatment entry); medium (about 60 meetings per year with a slight increase by year 5); high (over 200 meetings per year with a slight decrease by year 5); and declining (almost 200 meetings the year following treatment entry and about 6 meetings in year 5).

• Abstinence (past 30 days) in year 5 significantly differed across groups: 79% of patients with high attendance reported abstinence, followed by 73 % with medium attendance, 61% with declining attendance, and 43% with low attendance.

• Patients with medium or high attendance had the largest social networks of people who supported patient abstinence or decreased alcohol use.

• Patients across the groups had similar numbers of dependence symptoms and social consequences of drinking.

Comments by Joseph Conigliaro, MD, MPH:

Patients who attend AA after treatment can be characterized as those who never connect, those who connect briefly, and those who maintain stable (and sometimes quite high) attendance. Even those who connect for a short while appear to benefit years later, though higher attendance was associated with a greater likelihood of long-term abstinence. Providers should reinforce AA attendance as part of a comprehensive effort to improve long-term abstinence.

Reprinted with permission from Alcohol and Health: Current Evidence. March 10, 2006

Research detailed to the Federation of European Neuroscience Societies found boosting levels of some cannabinoids worsened epilepsy and Alzheimer’s.

Experts said it was hard to target the drug at specific parts of the body.

Some compounds in cannabis interfere with a natural signalling system in the brain, nerves and immune system.

The signalling system, which produces its own cannabinoids, plays a role in conditions such as MS, epilepsy, Alzheimer’s disease, schizophrenia and Parkinson’s disease.

Extra cannabinoids, from smoking cannabis or from medications, can therefore have a significant effect, researchers suggest.

Vincenzo Di Marzo, of Italy’s National Research Council, told the conference that he had found boosting the level of one natural cannabinoid, andandamide, in rats initially appeared to protect the animals from memory loss and nerve degeneration.

But if the rise was prolonged, the cannabinoid could be ineffective, or even damaging.

Beat Lutz, of the University of Mainz in Germany, found a another paradox in models of epilepsy in mice.

The same cannabinoid is normally produced by the body during an epileptic seizure to produce a calming effect.

But he found boosting levels could actually worsen seizures.

Reason

He said he believed the reason for the findings was that there were cannabis receptors on two different types of neuron populations which the drug could affect.

In one group, exposure to cannabinoids increases activity while in the other, it inhibits it.

Dr Lutz said this meant that depending on which one they hit, the effect was different.

Professor David Baker, from University College London, who has studied the impact of cannabis extracts in treating multiple sclerosis, said: “The problem with cannabis is that there’s no way of targeting the drug to any particular place.”

He said the hope was that scientists could manipulate the nervous system by managing the way cannabis compounds are released just as the depression drug Prozac does for serotonin by delaying release.

The only cannabis-based drug which can be used in the UK is a treatment for MS called Sativex.

It has been granted a special licence meaning it can only be used if the doctor takes responsibility for prescribing it.

The drug, produced by GW Pharmaceuticals, is a mouth spray containing two chemicals found in cannabis, THC and cannabidiol.

However, it is made using plant cannabinoids, rather than those found in the body.

Conclusions

Findings from our study reveal that DTTO clients showed considerable and sustained reductions in substance use, injecting risk and offending behaviours, and some improvements in their mental health. Outcomes were similar for those respondents who entered comparable ‘voluntary’ treatment options. The results – which are consistent with those from the other four partner countries involved in the QCT Europe study – suggest that drug treatment that is motivated, ordered or supervised by the criminal justice system can have comparable retention rates and outcomes to drug treatment entered through non-criminal justice routes. The approach should therefore be considered a viable alternative to imprisonment. However, from our qualitative analysis, there appeared to be considerable scope for improving arrangements for aftercare and resettlement for both groups across the UK sites.

More attention should also be paid to issues of treatment process and coordination between health and criminal justice systems in order to provide high quality and consistent treatment that is likely to optimise outcomes for individuals and the wider community. Attention should particularly be focused on:

• Ensuring that treatment is made quickly available to those offenders who are likely to produce the most significant benefits (i.e. those who have high levels of offending) in a manner which enhances motivation and engagement.

• Developing supportive “therapeutic alliances” between offenders and their probation officers and treatment staff.

• Dealing effectively with non-compliance. This does not mean that any lapses in drug use or attendance should be heavily punished; rather that they should be dealt with in a prompt and consistent way, recognising positive as well as negative behaviour changes.

• Making the full range of treatment options available to people who enter treatment as part of a court order, so that they can access support appropriate to their needs.

• Improving access to education, training and employment schemes.

Recent years have seen a rapid expansion in the options available for the criminal justice system to encourage or direct drug-dependent offenders into treatment in England and Wales. Our hope is that the results from the QCT Europe study can be used constructively to inform debate about the appropriate use of these options.

How to get further information

Copies of the full report, The quasi-compulsory treatment of drug-dependent offenders in Europe: Final National Report – England, by Tim McSweeney

The QCT Europe study was funded by the Fifth European Community Framework Programme covering Research, Technological Development and Demonstration activities (Quality of Life programme, contract number QLG4-CT-2002-01446). The authors are solely responsible for the content of this document. It does not represent the opinion of the Community. The Community is not responsible for any use that might be made of data appearing in it.

A British study of the outcome of treatment for drug addiction, published today in the open access journal BMC Public Health, also reveals that drug users were more likely to drop out of treatment if they had been coerced into it by the criminal justice system than if they had entered by other routes.

The authors of the study conclude that efforts to make treatment for drug addiction more accessible have succeeded in getting more people into treatment, but the impact of coercive measures to push drug users into treatment needs further consideration. They write: “recent measures to increase drug treatment participation have speeded up a revolving door both into and out of treatment”.

Dr. Caryl Beynon and colleagues from Liverpool John Moores University, analysed the records of 26,415 anonymous drug users who had entered treatment for drug addiction between 1997 and 2004 in Cheshire and Merseyside (England, UK).

The results of Beynon et al.’s study show that the proportion of individuals who dropped out of treatment increased from 7.2% in 1998 to 9.6% in 2002. Individuals coerced into treatment by the criminal justice system were more likely to drop out of treatment than those referred through other routes. The proportion of drug users who successfully completed treatment decreased from 5.8% in 1998 to 3.5% in 2002, but the proportion of drug users who came back to start treatment again after dropping out of treatment increased from 22.9% in 1998 to 48.6% in 2002.

Cytisine is an alkaloid found in a plant known as the golden rain tree, or Cytisus laburnum. It has been used for decades as a smoking cessation drug in Eastern European countries, according to background information in the article.

Jean-Francois Etter, Ph.D., M.P.H., of the University of Geneva, Switzerland, reviewed the literature on the effect of cytisine on smoking cessation. Ten studies were found, and all were conducted in Bulgaria, Germany, Poland and Russia between 1967 and 2005.

“Research conducted during the past 40 years suggests that cytisine is effective for smoking cessation,” Dr. Etter reports. “Thus, an apparently effective smoking cessation drug that has been used for decades in Germany and Eastern European countries remained unnoticed in other countries.”

Most of the articles reviewed by Dr. Etter were never cited in English-language literature. Recent reviews of the efficacy of smoking cessation drugs omitted cytisine, and little research on the drug has been conducted in recent years.

Dr. Etter suggests the omission may be explained because studies on the efficacy of cytisine were not published in English and because the available research is based on studies that do not conform to current standards in conducting and reporting drug trials.

“An apparently effective treatment for the first avoidable cause of death in developed countries remained largely unnoticed, despite research published during the past 40 years,” he concludes. “How many other effective drugs are there for which efficacy remained unnoticed because existing trials were not published in English in Western countries?” (Arch Intern Med. 2006;166:1553-1559. Available pre-embargo to the media at http://www.jamamedia.org.)

• At the 3-year follow-up, remission occurred in 62 percent of subjects who had received help and in 43 percent of subjects who had not received help (P <0.01).

• Among these remitted subjects, relapse by year 16 occurred in 43 percent of those who had received help and in 61 percent of those who had not received help (P <0.05).

Comments by Peter Friedmann, MD, MPH:

Like previous studies, this study found that receiving help improves the chances of short-term remission and decreases the risk of relapse. Therefore, clinicians should emphasize the importance of early help seeking to their patients with alcohol use disorders and should offer ongoing support to help their patients in remission remain remitted.

“Previous studies established that alcoholism runs in families, but this research has given us the most extensive catalogue yet of the genetic variations that may contribute to the hereditary nature of this disease,” says NIDA Director Dr. Nora D. Volkow. “We now have new tools that will allow us to better understand the physiological foundation of addiction.”

The study can be viewed online and will be published in the December 2006 issue of the American Journal of Medical Genetics Part B (Neuropsychiatric Genetics).

“This is an important contribution to studies of the genetics of alcoholism and co-occurring substance use disorders,” adds Dr. Ting-Kai Li, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). “The findings will open many new avenues of research into common factors in genetic vulnerability and common mechanisms of disease.”

NIDA researchers found genetic variations clustered around 51 defined chromosomal regions that may play roles in alcohol addiction. The candidate genes are involved in many key activities, including cell-to-cell communication, control of protein synthesis, regulation of development, and cell-to-cell interactions. For example, one gene implicated in this study — the AIP1 gene — is a known disease-related gene expressed primarily in the brain, where it helps brain cells set up and maintain contacts with the appropriate neighboring cells. Many of the nominated genes have been previously identified in other addiction research, providing support to the idea that common genetic variants are involved in human vulnerability to substance abuse.

The scientists, led by Dr. George Uhl, included Ms. Catherine Johnson, Ms. Donna Walther, Dr. Tomas Drgon, and Dr. Qing-Rong Liu. Their team developed, validated, and applied a new genetic platform that allowed them to generate the equivalent of more than 29 million individual genotypes and to analyze 104,268 genetic variations from unrelated alcohol-dependent and control individuals. The scientists used DNA samples that were collected by investigators of the Collaborative Study on the Genetics of Alcoholism (COGA), a study funded by NIAAA that included Dr. Howard Edenberg, Dr. Tatiana Foroud, and Dr. John Rice, who are coauthors of the paper. These samples had been analyzed previously to look for genetic associations to alcoholism, but the resolution and coverage achieved in the present study are unprecedented.

Dr. Volkow said finding ways to identify who is most physiologically vulnerable to addiction ‘will be a tremendous step towards more effective prevention and treatment approaches.’

The term ‘genome’ refers to the total genetic information of a particular organism. The normal human genome consists of about 3 billion base pairs of DNA in each set of chromosomes from one parent.

For more information, visit the NIDA home page at www.drugabuse.gov

Smoking is the leading cause of preventable death in the United States and worldwide. Currently available pharmacotherapies for smoking cessation include nicotine replacement therapy (NRT) – such as gum, skin patches, tablets, nasal spray and inhalers – and the antidepressant drugs bupropion hydrochloride and nortriptyline hydrochloride. These have shown limited success rates, with success at one year averaging approximately seven percent to 30 percent, according to background information in the articles.

The new drug varenicline tartrate mimics the effects of nicotine to help offset cravings, and in the presence of nicotine it helps suppress some of the reinforcing effects of smoking.

Mitchell Nides, Ph.D., of Los Angeles Clinical Trials, and colleagues with the Varenicline Study Group conducted a randomized, double-blind, placebo-controlled study to evaluate the efficacy, tolerability and safety of varenicline for smoking cessation. Healthy smokers aged 18 to 65 years were randomly assigned to receive varenicline in a dosage of .3 milligrams once daily, 1 milligram once daily, or 1 milligram twice daily for six weeks, plus placebo for one week; to 150 milligrams of sustained-release bupropion hydrochloride twice daily for seven weeks; or to placebo for seven weeks.

The authors report that varenicline, in combination with brief behavioral counseling, was more effective for short and long-term smoking cessation than placebo.

“Efficacy improved as the dose increased, with varenicline tartrate, 1 milligram twice daily, providing the highest rates of continuous abstinence across all treatment groups, including bupropion,” they write. Four-week continuous quit rates were 48 percent for varenicline, 1 milligram twice daily; 37.3 percent for varenicline, 1 milligram daily; 33.3 percent for bupropion hydrochloride; and 17.1 percent for placebo. Long-term quit rates from four weeks to one year were 14.4 percent for the group that received varenicline, 1 milligram twice daily, vs. 4.9 percent for placebo.

“In this study, varenicline tartrate, 1 milligram twice daily, effectively helped subjects quit smoking, with response rates three times higher than those for placebo while demonstrating a good tolerability profile in this population of smokers who on average had smoked approximately 20 cigarettes per day for approximately 24 years,” the authors write. “Efficacy was maintained in the non–drug treatment phase through week 52. The significant reductions in craving and in some of the rewarding effects of smoking seen with varenicline tartrate, 1 milligram twice daily, may assist in promoting abstinence and preventing relapse,” they conclude

In an accompanying article, the same research team reports that varenicline taken over 12 weeks was effective in helping smokers quit, and was generally well tolerated.

Cheryl Oncken, M.D., of the University of Connecticut Health Center, Farmington, and colleagues studied 647 patients to evaluate the efficacy, safety and tolerability of four varenicline dose regimens–two with titrated, or progressive, dosing over the first week, and two with a non-titrated, or fixed, dosing schedule, for promoting smoking cessation. Healthy smokers aged 18 to 65 years randomly received varenicline, .5 milligrams twice daily non-titrated, .5 milligrams twice daily titrated, 1 milligram twice daily non-titrated, 1 milligram twice daily titrated or placebo for 12 weeks, then with a 40-week follow-up period to assess long-term efficacy.

“In this study, treatment with varenicline tartrate at doses of .5 milligrams and 1 milligram twice daily, was associated with significantly higher smoking cessation rates compared with placebo,” the authors report. At weeks nine to 52, the abstinence rates were 22.4 percent in the 1-milligram group, 18.5 percent in the .5-milligram group and 3.9 percent in the placebo group.

Among those who were treated with varenicline, 16 percent to 42 percent experienced nausea. Reports of nausea were lower among those who received progressive dosing.

“In summary, varenicline tartrate (.5-milligram and 1-milligram doses taken twice daily for 12 weeks) significantly improved short- and long-term abstinence rates compared with placebo,” the authors conclude. “Future studies are warranted to compare the efficacy of varenicline to other smoking cessation pharmacotherapies and to determine whether a longer duration of medication treatment improves smoking cessation rates.”

The results of the studies by the Varenicline Study Group demonstrate that varenicline is a novel medication to aid in smoking cessation, writes Bankole A. Johnson, D.Sc., M.D., Ph.D., of the University of Virginia, Charlottesville, in an accompanying editorial. Dr. Johnson also summarizes other approaches to treating nicotine addiction now in development, including medications and a vaccine. “In sum, pharmacological and immunological studies are opening up new vistas for safe, efficacious and potent treatments for nicotine dependence,” he writes. “Molecular genetic studies also are investigating how to identify those individuals vulnerable to becoming nicotine dependent and, once they are dependent, the treatments that might work best for them. All these advances will deliver real aid to craving.

• Only 26 percent of subjects had ever sought help for their alcohol problems; 3 percent participated in a 12-step program only, 6 percent in formal treatment only, and 17 percent in both.

• Help seekers drank more and had higher lifetime prevalences of other drug use, mood disorders, and personality disorders than did subjects who had not sought help.

• In analyses adjusted for potential confounders, help seeking significantly increased the likelihood of any recovery (odds ratio [OR] 2.4) and of abstinence (OR 4.0). Any recovery was defined as, in the past year, having no symptoms of alcohol abuse or dependence and either drinking low-risk amounts* or abstaining.

• The odds of recovery were greater for those who had participated in 12-step programs with or without formal treatment than for those who had participated in formal treatment only.

Comments by Peter Friedmann, MD, MPH:

Even though they had more comorbidity and therefore were at risk for worse outcomes, seekers of formal and informal treatment had better odds of recovery from alcohol dependence. This study could not separate the motivation inherent in seeking help from the therapeutic effects of help received. However, help seeking—regardless of the patient’s level of readiness—should be encouraged.

*up to 14 drinks per week and up to 4 drinks on any day for men; up to 7 and up to 3, respectively, for women.

Reference:

Dawson DA, Grant BF, Stinson FS, et al. Estimating the effect of help-seeking on achieving recovery from alcohol dependence.

When a man and a woman drink too much alcohol — by far the most widely abused substance in the country  they not only do it for different reasons, they also get different results.

Where men may use alcohol to feel “powerful,” women usually drink to fight feelings of hopelessness and anger.

Though women generally drink less than men, the risk of alcoholism kicks in a lot faster: Seven or more glasses a week is considered risky for a woman, compared to 14 or more for a man.

Alcoholism also carries greater risks to women. Heavy drinking increases the chances of a woman becoming a victim of violence and sexual assault. Most women who abuse alcohol and drugs — studies show as many as 80 percent to 90 percent — have a history of physical or sexual abuse.

Women are more likely than men to develop liver inflammation and to die from cirrhosis. They are more vulnerable to alcohol-induced brain damage and cardiovascular disease. And heavy drinking appears to increase the risk of breast cancer, as well as cancers of the digestive tract.

The stigma for using drugs and alcohol also is greater, and it’s often one of the biggest obstacles to a woman seeking treatment. She fears — rightly — that she will lose custody of her children if she admits to having a substance abuse problem. Or she’s so busy being the caregiver that she puts off asking for help, often for so long that she develops serious ailments.

The numbers, fairly consistent since the 1990s, say it all: Of the 15.1 million people who abuse alcohol, 4.6 million are women, and only 25 percent of them are in traditional treatment, according to the National Institute on Alcohol Abuse and Alcoholism. Women also tend to go more nontraditional routes for help with addiction, looking to either their doctors, therapists or psychiatrists.

During the past decade, segregated treatment has become a key to success for women, providing a more nurturing environment that encourages patients, often childhood victims of physical and sexual abuse, to open up and talk about the traumas that led to their substance abuse.

The drug mecamylamine, used in combination with nicotine to help reduce the urge to smoke cigarettes, has now been shown in animal studies to reduce their self-administration of cocaine.  Rats that were trained to press a lever in order to get cocaine no longer pressed it with the same frequency after they were given mecamylamine, said Edward Levin, lead author of the study.  When injected with mecamylamine, the mice infused cocaine 11 times per hour, versus 19 times per hour when they received a placebo injection of saline – a reduction of more than 40 percent.  “It’s always very exciting when a drug used for one addiction has implications for a broader range of addictive drugs,” said Levin, whose study was funded by the National Institutes of Health.  Mecamylamine is an older medication originally used to treat high blood pressure.  Researchers now know it blocks some of nicotine’s ability, and potentially that of other drugs, to generate feelings of pleasure in the brain.  Levin said it works by occupying specific sites, called “nicotinic receptors,” on nerve cells where nicotine would normally act.  When mecamylamine blocks these receptors, nicotine can no longer exert its full action, that of stimulating the release of dopamine.  Dopamine is the primary brain chemical involved in generating pleasure.  Drugs like nicotine, alcohol and cocaine all increase available amounts of dopamine and thereby increase the pleasure sensation, said Jed Rose, chief of the Nicotine Research Program at Duke and study co-author.  Eventually, the brain may prefer the drug over natural rewards like food or sex, and hence, the person can become addicted.  Mecamylamine blocks the action of nicotine, and potentially cocaine, by lowering the net amount of dopamine available in the brain.  While cocaine still boosts available levels of dopamine, its overall amount is decreased because mecamylamine has plugged up some of the nicotinic receptor sites where the brain would naturally be activating its own dopamine.  “In other words, the brain has its own chemical, acetylcholine, that stimulates the release of dopamine.  Mecamylamine comes along and occupies some of the nicotinic acetylcholine receptor sites and prevents them from activating dopamine,” Rose said.  “So the net effect is that less dopamine is being produced, even when cocaine comes along and boosts dopamine levels through a different pathway.”  Rose said the person still desires nicotine or cocaine, but the desire is weakened because the brain is no longer being flooded with dopamine.  “Mecamylamine reduces desire, but it doesn’t quench it,” he said.  “Yet given how few medications there are to combat serious addictions, even a medication that reduces craving can be of significant benefit.”  Already, mecamylamine has proven to be of significant benefit in helping people quit smoking.

In earlier Duke studies, Rose demonstrated that using a patch with nicotine and mecamylamine together helped 40 percent of smokers quit for at feast one year, while only 15 percent of smokers were able to do so using the patch alone.  The researchers expect mecamylamine to be approved for smoking cessation sometime this year.

In 2000, an estimated 4.7 million people aged 12 or older (2.1 percent of the  total population) needed treatment for an illicit drug abuse problem.
16.6 percent of the people who needed treatment in 2000, received Priority treatment services at a specialty facility.
Among Hispanic male admissions in 1999, alcohol was the most common primary substance of abuse(39%), followed by opiates (32%) and marijuana(14%).
In 1999, the most common primary substance of abuse among Hispanic female admissions was opiates (34%), followed by alcohol (26°/o) and cocaine (16%).
In 1999, opiates were the most common substance of abuse for Hispanic admissions aged 25-44, while alcohol was the most common substance of abuse for non-Hispanic admissions in the 25-44 age group.

Until now there has been no long-term study of people addicted to injected heroin who have been treated without the prescribing of methadone substitute.

This study set out to look at the outcome for patients treated for injected heroin 33 years after they were first seen, and 26 years after they were first followed up. Measures included sustained abstinence from heroin, continued maintenance on methadone and deaths.

86 people with heroin addiction first seen in 1966-67 in a small town in the south-east of England were studied. At the time of diagnosis the patients were aged between 16 and 20, were single and living at home with their parents. They all injected heroin.

All the patients were treated in the local general psychiatric service, which differed from most other UK services for heroin addiction in that it did not prescribe methadone substitute for 23 years after recruitment of the patient group (i.e. until 1989).

The main provisions of the service were immediate help in times of crisis; personal counselling; regular follow-up; an ongoing relapse prevention group; and symptomatic relief with drugs other than methadone.

The first follow-up took place after six years. At that assessment 13% of the patient group were judged to have stopped using any illegal drugs, 51% were still injecting, 6% had died and 12% had experienced alcohol-related problems.

For this follow-up study, 45 of the original patient group were located and their clinical state assessed using multiple sources, including personal interviews with some of them.

It was found that 42% of the group had been abstinent for at least 10 years. 10% were taking methadone and were classified as addicted. 22% had died. 8% of the group could not be located.

The authors of this study compared their results with three other British studies. They found the death rates comparable (15%-20%), but the rates of abstinence and methadone dependency differed.

The researchers comment that it is encouraging that trend studies show agreement that the proportion of people maintaining sustained abstinence rises with time, whilst the proportion of those still addicted declines.

One worrying feature, however, is the high proportion of premature deaths, mainly due to overdoses. As overdose with opioid drugs is often mentioned as a cause of death, there is a need for closer monitoring of these drugs, and regular health screening and intervention to reduce premature deaths.

The advantages of long-term substitute prescribing of methadone are obvious in terms of increased social stability and reduction of crime. However, the researchers were struck not only by the number of premature deaths in people taking methadone, but also by the negative perceptions of life among those who are currently prescribed this opioid.

The findings of this study highlight the need to compare outcomes between people prescribed substitute drugs for addictions, and those who are not.

Reference Nehkant H, Rathod R, Addenbrooke WM and Rosenbach AF (2005) Heroin Dependence
in an English town: 33-year follow-up. British Journal of Psychiatry, 187, 421-425