Addiction (Papers)

In its 2023 Annual Report, the International Narcotics Control Board:

– finds that online drug trafficking has increased the availability of drugs on the illicit market;

– warns that patient safety is at risk from illicit Internet pharmacies selling drugs without a prescription directly to the consumer;

– highlights the daunting task facing law enforcement authorities to monitor and prosecute online drug activities;

– sees opportunities to use the Internet and social media for drug use prevention campaigns and to improve access to drug treatment services;

– encourages governments to use the full range of INCB tools and programmes to assist in their efforts to counter exploitation of the Internet for drug trafficking; and

– voices concern about the persistent regional disparities in availability and consumption of licit drugs for the treatment of pain.

VIENNA, 5 March (UN Information Service) – The evolving landscape of online drug trafficking is presenting new challenges to drug control, says the International Narcotics Control Board (INCB) in its Annual Report. There are also opportunities to use the Internet for drug use prevention and treatment to safeguard people’s health and welfare, the Board says.

The increased availability of illicit drugs on the Internet, the exploitation by criminal groups of online platforms including social media, and the increased risk of overdose deaths due to the online presence of fentanyl and other synthetic opioids are some of the key challenges for drug control in the Internet era.

“We can see that drug trafficking is not just carried out on the dark web. Legitimate e-commerce platforms are being exploited by criminals too. We encourage governments to work with the private sector and INCB projects to prevent and detect trafficking of drugs and other dangerous substances online,” said Jallal Toufiq, the President of INCB.

Using social media and other online platforms means drug traffickers can advertise their products to large global audiences. Various conventional social media platforms are being used as local marketplaces and inappropriate content is widely accessible to children and adolescents.

Encryption methods, anonymous browsing on the darknet and cryptocurrencies are commonly used to avoid detection, posing difficulties for prosecuting online trafficking offences. Offenders can move their activities to territories with less intensive law enforcement action or lighter sanctions or base themselves in countries where they can evade extradition. The sheer scale of online activity is an added complication. In one case in France, law enforcement authorities collected more than 120 million text messages from 60,000 mobile phones.

Patient safety is at risk from illicit Internet pharmacies which sell drugs without a prescription directly to consumers. It is impossible for consumers to know whether the drugs are counterfeit, unapproved or even illegal. The global trade in illicit pharmaceuticals is estimated to be worth 4.4 billion USD.

Opportunities for drug treatment and prevention

The Board sees opportunities to use online platforms to prevent non-medical use of drugs, raise awareness about the harms of drug use and support public health campaigns. Governments can use social media platforms to conduct drug use prevention campaigns to prevent substance misuse among young people in particular.

“There are opportunities to use social media and the Internet to prevent drug use, raise awareness of its harms and improve access to drug treatment services,” said INCB President Toufiq, “At the same time we are concerned about the increasing use of social media to market drugs including to children and the ways that criminals are exploiting online platforms for illicit activities.”

Telemedicine and Internet pharmacies could improve access to healthcare and help reach patients with drug use disorders and deliver drug treatment services to more people. Online platforms could also be used for sharing information about adverse consequences of drug use and communicating warnings of adulterated drugs which could save lives.

International cooperation essential to tackle this growing trend

The global nature of online platforms makes collaborative efforts vitally important for identifying new threats and developing effective responses.

INCB is encouraging voluntary cooperation between governments and online industries to tackle the misuse of legitimate e-commerce platforms for drug trafficking. Its initiatives such as the GRIDS programme have led to drug seizures and arrests as well as criminal networks being dismantled.

The manufacturing, marketing, movement and monetization industries are particularly vulnerable to being exploited by those trafficking in dangerous substances. The Board says that increased cooperation is needed between governments, international organizations, regulatory authorities and the private sector to meet these evolving challenges.

Persistent disparities in access to medicines for the treatment of pain

In many parts of the world there is not enough affordable morphine available to meet medical needs. These persistent regional disparities in opioid analgesics used for pain treatment are not due to a shortage of opiate raw materials but rather in part due to inaccurate estimates of the actual medical needs of their populations. Levels of consumption of pain relief medicine remain highest in Europe and North America.

There was an acute need for medicines containing internationally controlled substances in 2023 for people caught up in natural disasters and emergencies related to climate change and conflict. INCB urges governments to use simplified control procedures in such situations to ensure unimpeded availability of these medicines.

Notable developments in illicit drug supply

In Afghanistan, illicit opium poppy cultivation and heroin production declined dramatically. INCB says that alternative livelihoods need to be offered to affected farmers who may not have other sources of income.

The opioid crisis continues to have serious consequences in North America with the number of deaths that involved synthetic opioids other than methadone continuing to increase, reaching more than 70,000 in 2021.

Drug trafficking organizations continue to expand their operations in the Amazon Basin into illegal mining, illegal logging and wildlife trafficking.

Record levels of illicit coca bush cultivation were recorded in Colombia and Peru, rising by 13 percent and 18 per cent respectively. Seizures of cocaine reached a record level in 2021 in West and Central Africa, a significant transit region for cocaine.

Several European countries have continued to establish regulated markets for cannabis for non-medical purposes. These programmes do not appear to be consistent with the drug control conventions.

South Asia appears to be increasingly being targeted for the trafficking of methamphetamine illicitly manufactured in Afghanistan to Europe and Oceania.

Pacific island States have transformed from solely transit sites along drug trafficking routes to destination markets for synthetic drugs. This is posing significant challenges to communities and their public health systems.

Precursors report

As part of international efforts to prevent illicit drug manufacturers from replacing certain controlled chemicals with closely related substitutes, the Board is recommending that a total of 16 amphetamine-type stimulant precursors (two series of closely related chemicals) are put under international control.

Two fentanyl precursors have also been assessed and recommended for international control by INCB, following a request made by the United States. The Precursors report also shows a surge in non-controlled fentanyl precursors in North America in 2023.

The Commission on Narcotic Drugs will vote at its session in March on placing all 18 substances under international control, through placement in Table I of the 1988 Convention.

INCB is concerned about the lack of audits and inspections in certain free trade zones which are susceptible to misuse for illicit activities. The Board calls on governments to ensure proper oversight over these zones to prevent them being exploited for precursor trafficking.


INCB is the independent, quasi-judicial body charged with promoting and monitoring Government compliance with the three international drug control conventions: the 1961 Single Convention on Narcotic Drugs, the 1971 Convention on Psychotropic Substances, and the 1988 Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances. Established by the Single Convention on Narcotic Drugs of 1961, the thirteen members of the Board are elected in a personal capacity by the Economic and Social Council for terms of five years. 



By William Ross Perlman, Ph.D., CMPP, NIDA Notes Contributing Writer

This research:

  • Identified a gene variant that promotes impulsive behavior and enhanced responses to heroin in rats.
  • Linked the corresponding human gene variant to increased risk for impulsivity and drug use.

People who are highly impulsive and those diagnosed with ADHD are at increased risk for substance use disorders (SUD). Recent research implicates a variant of the gene for a protein called cAMP-response element modulator (CREM) in these associations. Drs. Michael L. Miller and Yasmin L. Hurd from the Icahn School of Medicine at Mount Sinai in New York, with colleagues from several other institutions, showed that the gene variant promotes impulsive and hyperactive behavior in both animals and humans, and can contribute to a person’s risk for developing SUD.

Of Rats…

The Icahn researchers began their investigations with a strain of rats that exhibit impulsive behaviors resembling human attention-deficit/hyperactivity disorder (ADHD). Initial experiments confirmed that, compared with a strain (Western Kyoto) of rats that are not known for impulsivity, these “spontaneously hypertensive” (SH) rats:

  • Were more impatient to receive rewards, fidgeted more while waiting to receive rewards, ran around more, and were more attracted to novel experiences.
  • Self-administered more heroin and, when it was made unavailable, gave up seeking it less readily.  
  • Had enhanced elevation of dopamine levels in response to heroin.

The researchers screened the rats’ DNA for genetic differences that might contribute to these behavioral differences. The results revealed that the two strains carried different variants of the gene for CREM. As a result, the SH rats had lower concentrations of CREM in the core of the nucleus accumbens—a key brain region governing reward and movement.

…And People


Figure 1. A CREM Gene Variant Increases HyperactivityHyperactivity scores were higher in ADHD subjects than in control subjects. In addition, ADHD subjects who carried at least one copy of the less highly expressed A variant (i.e., with the G/A or A/A CREM genotype) reported significantly higher hyperactivity than did those carrying only the more highly expressed G variant (i.e., with the G/G genotype). Genotype had no effect on hyperactivity in non-ADHD control subjects

The researchers used genetic and behavioral evidence from previous studies conducted by other researchers to demonstrate that the corresponding variant in the human CREM gene similarly predisposes people to impulsivity. This variant occupies approximately the same position on the human gene that the rodent variant occupies on the rodent gene. At this site, known as rs12765063, the CREM gene exists in two versions—called A and G—and the A variant dials down CREM production. In one study, preschool children with the A variant were found to be more distractible and to engage in more dangerous activities than peers with only the G variant (Figure 1). In another, among adolescents with ADHD, those who carried the A variant reported more symptomatic hyperactivity than those who did not.

The researchers further found that by promoting impulsivity, the variant raises the risk of drug use. Thus, in two studies of adolescents, neither the A variant alone nor ADHD alone increased the risk for drug use, but the two together did. The first analysis looked at adolescents with ADHD, and found higher rates of drug use among those with the A variant than among those with only the G variant. The second analysis looked at adolescents who had the A variant of rs12765063 and histories of childhood ADHD. It found that those whose childhood ADHD still persisted reported more use of alcohol, tobacco, marijuana, and prescription stimulants than those who had outgrown their ADHD (Figure 2). Moreover, those who no longer had ADHD reported no more drug use than a comparison group who did not carry the A variant.


Figure 2. The A Variant of the CREM Gene Is Associated With Increased Drug Use in People With Persistent ADHD Among a cohort whose childhood ADHD persisted through adolescence, those with the CREM A variant reported more drug use than those with only the G variant. Genotype was not linked to risk for drug use in people without ADHD (i.e., those who never had ADHD or those with remitted ADHD).

A Key to Prevention and Treatment?

Dr. Hurd suggests that CREM may be a key link between impulsivity and vulnerability to addiction. Understanding these relationships may help identify new ways of treating or preventing SUD. The protein is known to regulate multiple gene networks and their biological functions, and to influence the growth of structures that neurons use to communicate with each other.

Dr. Hurd says, “These results highlight that CREM is a mediating factor between impulsivity and substance abuse vulnerability. It brings attention to CREM in the nucleus accumbens as a regulator of impulsive action and structural plasticity.”

The study was supported by NIH grants DA015446, DA030359, DA006470, DA038954, DA031559, and DA007135.

Source: June 2018

PHE publications gateway number: 2016490 December 2016

Executive summary

Alcohol is a prominent commodity in the UK marketplace. It is widely used in numerous social situations. For many, alcohol is associated with positive aspects of life; however, there are currently over 10 million people drinking at levels which increase their risk of health harm. Among those aged 15 to 49 in England, alcohol is now the leading risk factor for ill-health, early mortality and disability and the fifth leading risk factor for ill health across all age groups. Since 1980, sales of alcohol in England and Wales have increased by 42%, from roughly 400 million litres in the early 1980s, with a peak at 567 million litres in 2008, and a subsequent decline.

This growth has been driven by increased consumption among women, a shift to higher strength products, and increasing affordability of alcohol, particularly through the 1980s and 1990s. Over this period, the way in which alcohol is sold and consumed also changed. In 2016 there were 210,000 license premises in England and Wales, a 4% increase on 2010. There has been a shift in drinking location such that most alcohol is now bought from shops and drunk at home.

Although consumption has declined in recent years, levels of abstinence have also increased. Consequently, it is unclear how much of the decline is actually related to drinkers consuming less alcohol and how much to an increasing proportion of the population not drinking at all. In recent years, many indicators of alcohol-related harm have increased.

There are now over 1 million hospital admissions relating to alcohol each year, half of which occur in the lowest three socioeconomic deciles. Alcohol-related mortality has also increased, particularly for liver disease which has seen a 400% increase since 1970, and this trend is in stark contrast to much of Western Europe. In England, the average age at death of those dying from an alcohol-specific cause is 54.3 years. The average age of death from all causes is 77.6 years.

More working years of life are lost in England as a result of alcohol-related deaths than from cancer of the lung, bronchus, trachea, colon, rectum, brain, pancreas, skin, ovary, kidney, stomach, bladder and prostate, combined.

Despite this burden of harm, some positive trends have emerged over this period, particularly indicators which relate to alcohol consumption among those aged less than 18 years, and there have been steady reductions in alcohol-related road traffic crashes. The public health burden of alcohol is wide ranging, relating to health, social or economic harms. These can be tangible, direct costs (including costs to the health, criminal justice and welfare systems), or indirect costs (including the costs of lost productivity due to absenteeism, unemployment, decreased output or lost working years due to premature pension or death).

Harms can also be intangible, and difficult to cost, including those assigned to pain and suffering, poor quality of life or the emotional The Public Health Burden of Alcohol and the Effectiveness and Cost-Effectiveness of Alcohol Control Policies: An evidence review 7 distress caused by living with a heavy drinker. The spectrum of harm ranges from those that are relatively mild, such as drinkers loitering near residential streets, through to those that are severe, including death or lifelong disability. Many of these harms

impact upon other people, including relationship partners, children, relatives, friends, co-workers and strangers. In sum, the economic burden of alcohol is substantial, with estimates placing the annual cost to be between 1.3% and 2.7% of annual GDP.

Few studies report costs on the magnitude of harm to people other than the drinker, so the economic burden of alcohol consumption is generally underestimated. Crucially, the financial burden which alcohol-related harm places on society is not reflected in its market price, with taxpayers picking up a larger amount of the overall cost compared to the individual drinkers. This should provide impetus for governments to implement effective policies to reduce the public health impact of alcohol, not only because it is an intrinsically desirable societal goal, but because it is an important aspect of economic growth and competitiveness. Reflecting three key influencers of alcohol consumption – price (affordability), ease of purchase (availability) and the social norms around its consumption (acceptability) – an extensive array of policies have been developed with the primary aim of reducing the public health burden of alcohol. The present review evaluates the effectiveness and cost-effectiveness of each of these policy approaches.

Source: 2016

Researchers map out a cellular mechanism that offers a biological explanation for alcoholism, and could lead to treatments

Credit: Getty Images

You can lead a lab rat to sugar water, but you can’t make him drink—especially if there’s booze around.

New research published Thursday in Science may offer insights into why some humans who drink alcohol develop an addiction whereas most do not. After caffeine, alcohol is the most commonly consumed psychoactive substance in the world. For the majority of people the occasional happy hour beer or Bloody Mary brunch is where it stops. Yet we all know that others will drink compulsively, despite whatever consequence or darkness it brings.

The new research confirms earlier work showing this is true for rats; but it takes things a step further and supports a study design that could help scientists better understand addiction biology, and possibly develop more effective therapies for human addictive behaviors. Led by a team at Linköping University in Sweden, the researchers found that when given a choice between alcohol and a tastier, more biologically desirable sugar substitute, a subgroup of rats consistently preferred the alcohol. The authors further identified a specific brain region and molecular dysfunction most likely responsible for these addictive tendencies. They believe their findings and study design could be steps toward developing an effective pharmaceutical therapy for alcohol addiction, a kind of treatment that has eluded researchers for years.

A taste for sweetness is evolutionarily embedded in the mammalian brain; in the wild, sugar translates into fast calories and improved survival odds. For the new study, 32 rats were trained to sip a 20 percent alcohol solution for 10 weeks until it became habit. They were then presented with a daily choice between more alcohol or a solution of the noncaloric sweetener saccharine. (The artificial sweetener provides sugary-tasting enticement without the potential confounding variable of actual calories.) The majority of rats vastly preferred the faux sugar over the alcohol option.

But the fact that four rats—or 12.5 percent of the total—stuck with the alcohol was telling to senior author Markus Heilig, director of the Center for Social and Affective Neuroscience at Linköping, given the rate of alcohol misuse in humans is around 15 percent. So Heilig expanded the study. “There were four rats who went for alcohol despite the more natural reward of sweetness,” he says. “We built on that, and 600 animals later we found that a very stable proportion of the population chose alcohol.” What’s more, the “addicted” rats still chose alcohol even when it meant receiving an unpleasant foot shock.

To get a better sense of what was going on at a molecular level, Heilig and his colleagues analyzed which genes were expressed in the rodent subjects’ brains. The expression of one gene in particular—called GAT-3—was found to be greatly reduced in the brains of those who opted for alcohol rather than saccharine. GAT-3 codes for a protein that normally controls levels of a neurotransmitter called GABA, a common chemical in our brains and one known to be involved in alcohol dependence.

In collaboration with co-author and University of Texas at Austin research scientist Dayne Mayfield, Heilig’s team found that in brain samples from deceased humans who had suffered from alcohol addiction, GAT-3 levels were markedly lower in the amygdala—generally considered the brain’s emotional center. One might assume that any altered gene expression contributing to addictive behaviors would instead manifest in the brain’s reward circuitry—a network of centers involved in pleasurable responses to enticements like food, sex and gambling.

Yet the decrease in GAT-3 expression in both rats and humans was by far strongest in the amygdala. “Figuring out the reward circuitry has been a fantastic success story, but it’s probably of limited relevance to clinical addiction,” Heilig says. “The rewarding effect of drugs happens in everybody. It’s a completely different story in the minority of people who continue to take drugs despite adverse consequences.” He believes altered activity in the amygdala makes perfect sense, given that addiction—in both rats and humans—often brings with it negative emotions and anxiety.

Much previous addiction research has relied on models in which rodents learn to self-administer addictive substances, but without other options that could compete with drug use. It was French neuroscientist Serge Ahmed who recognized this as a major limitation to understanding addition biology given that, in reality, only a minority of humans develops addiction to a particular substance. By offering an alternative reward (that is, sweet water), his team showed only a minority of rats develop a harmful preference for drug use—a finding that has now been confirmed with several other commonly abused drugs.

Building on Ahmed’s concept, Heilig added the element of choice to his research. “You can’t determine the true reward of an addictive drug in isolation; it’s dependent on what other options are available—in our case a sugar substitute.” He says most models that have been used to study addiction, and to seek ways to treat it, were probably too limited in their design. “The availability of choice,” he adds, “is going to be fundamental to studying addiction and developing effective treatments for it.”

Paul Kenny, chair of neuroscience at Icahn School of Medicine at Mount Sinai, agrees. “In order to develop novel therapeutics for alcoholism it is critical to understand not just the actions of alcohol in the brain, but how those actions may differ between individuals who are vulnerable or resilient to the addictive properties of the drug,” he says. “This Herculean effort to impressively map out a cellular mechanism that likely contributes to alcohol dependence susceptibility will likely provide important new leads in the search for more effective therapeutics.” Kenny was not involved in the new research.

Heilig and his team believe they have already identified a promising addiction treatment based on their latest work,  and have teamed up with a pharmaceutical company in hopes of soon testing the compound in humans. The drug suppresses the release of GABA and thus could restore levels of the neurotransmitter to normal in people with a dangerous taste for alcohol. With any luck, one of civilization’s oldest  vices might soon loosen its grip.. Illumination.

Source:   June 21st 2018

By Christopher Glazek

You’re aware America is under siege, fighting an opioid crisis that has exploded into a public-health emergency. You’ve heard of OxyContin, the pain medication to which countless patients have become addicted. But do you know that the company that makes Oxy and reaps the billions of dollars in profits it generates is owned by one family?

The newly installed Sackler Courtyard at London’s Victoria and Albert Museum is one of the most glittering places in the developed world. Eleven thousand white porcelain tiles, inlaid like a shattered backgammon board, cover a surface the size of six tennis courts. According to the V&A’s director, the regal setting is intended to serve as a “living room for London,” by which he presumably means a living room for Kensington, the museum’s neighborhood, which is among the world’s wealthiest. In late June, Kate Middleton, the Duchess of Cambridge, was summoned to consecrate the courtyard, said to be the earth’s first outdoor space made of porcelain; stepping onto the ceramic expanse, she silently mouthed, “Wow.”

The Sackler Courtyard is the latest addition to an impressive portfolio. There’s the Sackler Wing at New York’s Metropolitan Museum of Art, which houses the majestic Temple of Dendur, a sandstone shrine from ancient Egypt; additional Sackler wings at the Louvre and the Royal Academy; stand-alone Sackler museums at Harvard and Peking Universities; and named Sackler galleries at the Smithsonian, the Serpentine, and Oxford’s Ashmolean. The Guggenheim in New York has a Sackler Center, and the American Museum of Natural History has a Sackler Educational Lab. Members of the family, legendary in museum circles for their pursuit of naming rights, have also underwritten projects of a more modest caliber—a Sackler Staircase at Berlin’s Jewish Museum; a Sackler Escalator at the Tate Modern; a Sackler Crossing in Kew Gardens. A popular species of pink rose is named after a Sackler. So is an asteroid.

The Sackler name is no less prominent among the emerald quads of higher education, where it’s possible to receive degrees from Sackler schools, participate in Sackler colloquiums, take courses from professors with endowed Sackler chairs, and attend annual Sackler lectures on topics such as theoretical astrophysics and human rights. The Sackler Institute for Nutrition Science supports research on obesity and micronutrient deficiencies. Meanwhile, the Sackler institutes at Cornell, Columbia, McGill, Edinburgh, Glasgow, Sussex, and King’s College London tackle psychobiology, with an emphasis on early childhood development.

The Sacklers’ philanthropy differs from that of civic populists like Andrew Carnegie, who built hundreds of libraries in small towns, and Bill Gates, whose foundation ministers to global masses. Instead, the family has donated its fortune to blue-chip brands, braiding the family name into the patronage network of the world’s most prestigious, well-endowed institutions. The Sackler name is everywhere, evoking automatic reverence; the Sacklers themselves, however, are rarely seen. [In 1974, when the Sackler brothers made a large gift to the Met—$3.5 million, to erect the Temple of Dendur—they stipulated that all museum signage, catalog entries, and bulletins referring to objects in the newly opened Sackler Wing had to include the names of all three brothers, each followed by “M.D.”]

The descendants of Mortimer and Raymond Sackler, a pair of psychiatrist brothers from Brooklyn, are members of a billionaire clan with homes scattered across Connecticut, London, Utah, Gstaad, the Hamptons, and, especially, New York City. It was not until 2015 that they were noticed by Forbes, which added them to the list of America’s richest families.

The magazine pegged their wealth, shared among twenty heirs, at a conservative $14 billion. (Descendants of Arthur Sackler, Mortimer and Raymond’s older brother, split off decades ago and are mere multi-millionaires.) To a remarkable degree, those who share in the billions appear to have abided by an oath of omertà: Never comment publicly on the source of the family’s wealth.

That may be because the greatest part of that $14 billion fortune tallied by Forbes came from OxyContin, the narcotic painkiller regarded by many public-health experts as among the most dangerous products ever sold on a mass scale. Since 1996, when the drug was brought to market by Purdue Pharma, the American branch of the Sacklers’ pharmaceutical empire, more than two hundred thousand people in the United States have died from overdoses of OxyContin and other prescription painkillers. Thousands more have died after starting on a prescription opioid and then switching to a drug with a cheaper street price, such as heroin. Not all of these deaths are related to OxyContin—dozens of other painkillers, including generics, have flooded the market in the past thirty years. Nevertheless, Purdue Pharma was the first to achieve a dominant share of the market for long-acting opioids, accounting for more than half of prescriptions by 2001.

According to the Centers for Disease Control, fifty-three thousand Americans died from opioid overdoses in 2016, more than the thirty-six thousand who died in car crashes in 2015 or the thirty-five thousand who died from gun violence that year. This past July, Donald Trump’s Commission on Combating Drug Addiction and the Opioid Crisis, led by New Jersey governor Chris Christie, declared that opioids were killing roughly 142 Americans each day, a tally vividly described as “September 11th every three weeks.” The epidemic has also exacted a crushing financial toll: According to a study published by the American Public Health Association, using data from 2013—before the epidemic entered its current, more virulent phase—the total economic burden from opioid use stood at about $80 billion, adding together health costs, criminal-justice costs, and GDP loss from drug-dependent Americans leaving the workforce. Tobacco remains, by a significant multiple, the country’s most lethal product, responsible for some 480,000 deaths per year. But although billions have been made from tobacco, cars, and firearms, it’s not clear that any of those enterprises has generated a family fortune from a single product that approaches the Sacklers’ haul from OxyContin.

Even so, hardly anyone associates the Sackler name with their company’s lone blockbuster drug. “The Fords, Hewletts, Packards, Johnsons—all those families put their name on their product because they were proud,” said Keith Humphreys, a professor of psychiatry at Stanford University School of Medicine who has written extensively about the opioid crisis. “The Sacklers have hidden their connection to their product. They don’t call it ‘Sackler Pharma.’ They don’t call their pills ‘Sackler pills.’ And when they’re questioned, they say, ‘Well, it’s a privately held firm, we’re a family, we like to keep our privacy, you understand.’ ”

To the extent that the Sacklers have cultivated a reputation, it’s for being earnest healers, judicious stewards of scientific progress, and connoisseurs of old and beautiful things. Few are aware that during the crucial period of OxyContin’s development and promotion, Sackler family members actively led Purdue’s day-to-day affairs, filling the majority of its board slots and supplying top executives. By any assessment, the family’s leaders have pulled off three of the great marketing triumphs of the modern era: The first is selling OxyContin; the second is promoting the Sackler name; and the third is ensuring that, as far as the public is aware, the first and the second have nothing to do with one another.

If you head north on I-95 through Stamford, Connecticut, you will spot, on the left, a giant misshapen glass cube. Along the building’s top edge, white lettering spells out ONE STAMFORD FORUM. No markings visible from the highway indicate the presence of the building’s owner and chief occupant, Purdue Pharma. Originally known as Purdue Frederick, the first iteration of the company was founded in 1892 on New York’s Lower East Side as a peddler of patent medicines. For decades, it sustained itself with sales of Gray’s Glycerine Tonic, a sherry-based liquid of “broad application” marketed as a remedy for everything from anemia to tuberculosis. The company was purchased in 1952 by Arthur Sackler, thirty-nine, and was run by his brothers, Mortimer, thirty- six, and Raymond, thirty-two. The Sackler brothers came from a family of Jewish immigrants in Flatbush, Brooklyn. Arthur was a headstrong and ambitious provider, setting the tone—and often choosing the path—for his younger brothers. After attending medical school on Arthur’s dime, Mortimer and Raymond followed him to jobs at the Creedmoor psychiatric hospital in Queens. There, they coauthored more than one hundred studies on the biochemical roots of mental illness. The brothers’ research was promising—they were among the first to identify a link between psychosis and the hormone cortisone—but their findings were mostly ignored by their professional peers, who, in keeping with the era, favored a Freudian model of mental illness.

Concurrent with his psychiatric work, Arthur Sackler made his name in pharmaceutical advertising, which at the time consisted almost exclusively of pitches from so-called “detail men” who sold drugs to doctors door-to-door. Arthur intuited that print ads in medical journals could have a revolutionary effect on pharmaceutical sales, especially given the excitement surrounding the “miracle drugs” of the 1950s—steroids, antibiotics, antihistamines, and psychotropics. In 1952, the same year that he and his brothers acquired Purdue, Arthur became the first adman to convince The Journal of the American Medical Association, one of the profession’s most august publications, to include a color advertorial brochure.

In the 1960s, Arthur was contracted by Roche to develop an advertising strategy for a new antianxiety medication called Valium. This posed a challenge, because the effects of the medication were nearly indistinguishable from those of Librium, another Roche tranquilizer that was already on the market. Arthur differentiated Valium by audaciously inflating its range of indications. Whereas Librium was sold as a treatment for garden- variety anxiety, Valium was positioned as an elixir for a problem Arthur christened “psychic tension.” According to his ads, psychic tension, the forebear of today’s “stress,” was the secret culprit behind a host of somatic conditions, including heartburn, gastrointestinal issues, insomnia, and restless-leg syndrome. The campaign was such a success that for a time Valium became America’s most widely prescribed medication—the first to reach more than $100 million in sales. Arthur, whose compensation depended on the volume of pills sold, was richly rewarded, and he later became one of the first inductees into the Medical Advertising Hall of Fame.

As Arthur’s fortune grew, he turned his acquisitive instincts to the art market, quickly amassing the world’s largest private collection of ancient Chinese artifacts. According to a memoir by Marietta Lutze, his second wife, collecting, exhibiting, owning, and donating art fed Arthur’s “driving necessity for prestige and recognition.” Rewarding at first, collecting soon became a mania that took over his life. “Boxes of artifacts of tremendous value piled up in numerous storage locations,” she wrote, “there was too much to open, too much to appreciate; some objects known only by a packing list.” Under an avalanche of “ritual bronzes and weapons, mirrors and ceramics, inscribed bones and archaic jades,” their lives were “often in chaos.” “Addiction is a curse,” Lutze noted, “be it drugs, women, or collecting.”

When Arthur donated his art and money to museums, he often imposed onerous terms. According to a memoir written by Thomas Hoving, the Met director from 1967 to 1977, when Arthur established the Sackler Gallery at the Metropolitan Museum of Art to house Chinese antiquities, in 1963, he required the museum to collaborate on a byzantine tax-avoidance maneuver. In accordance with the scheme, the museum first sold Arthur a large quantity of ancient artifacts at the deflated 1920s prices for which they had originally been acquired. Arthur then donated back the artifacts at 1960s prices, in the process taking a tax deduction so hefty that it likely exceeded the value of his initial donation. Three years later, in connection with another donation, Arthur negotiated an even more unusual arrangement. This time, the Met opened a secret chamber above the museum’s auditorium to provide Arthur with free storage for some five thousand objects from his private collection, relieving him of the substantial burden of fire protection and other insurance costs. (In an email exchange, Jillian Sackler, Arthur’s third wife, called Hoving’s tax-deduction story “fake news.” She also noted that New York’s attorney general conducted an investigation into Arthur’s dealings with the Met and cleared him of wrongdoing.)

In 1974, when Arthur and his brothers made a large gift to the Met—$3.5 million, to erect the Temple of Dendur—they stipulated that all museum signage, catalog entries, and bulletins referring to objects in the newly opened Sackler Wing had to include the names of all three brothers, each followed by “M.D.” (One museum official quipped, “All that was missing was a note of their office hours.”)

Hoving said that the Met hoped that Arthur would eventually donate his collection to the museum, but over time Arthur grew disgruntled over a series of rankling slights. For one, the Temple of Dendur was being rented out for parties, including a dinner for the designer Valentino, which Arthur called “disgusting.” According to Met chronicler Michael Gross, he was also denied that coveted ticket of arrival, a board seat. (Jillian Sackler said it was Arthur who rejected the board seat, after repeated offers by the museum.) In 1982, in a bad breakup with the Met, Arthur donated the best parts of his collection, plus $4 million, to the Smithsonian in Washington, D. C.

Arthur’s younger brothers, Mortimer and Raymond, looked so much alike that when they worked together at Creedmoor, they fooled the staff by pretending to be one another. Their physical similarities did not extend to their personalities, however. Tage Honore, Purdue’s vice-president of discovery of research from 2000 to 2005, described them as “like day and night.” Mortimer, said Honore, was “extroverted—a ‘world man,’ I would call it.” He acquired a reputation as a big-spending, transatlantic playboy, living most of the year in opulent homes in England, Switzerland, and France. (In 1974, he renounced his U. S. citizenship to become a citizen of Austria, which infuriated his patriotic older brother.) Like Arthur, Mortimer became a major museum donor and married three wives over the course of his life.

Mortimer had his own feuds with the Met. On his seventieth birthday, in 1986, the museum agreed to make the Temple of Dendur available to him for a party but refused to allow him to redecorate the ancient shrine: Together with other improvements, Mortimer and his interior designer, flown in from Europe, had hoped to spiff up the temple by adding extra pillars. Also galling to Mortimer was the sale of naming rights for one of the Sackler Wing’s balconies to a donor from Japan. “They sold it twice,” Mortimer fumed to a reporter from New York magazine. Raymond, the youngest brother, cut a different figure—“a family man,” said Honore. Kind and mild-mannered, he stayed with the same woman his entire life. Lutze concluded that Raymond owed his comparatively serene nature to having missed the worst years of the Depression. “He had summer vacations in camp, which Arthur never had,” she

wrote. “The feeling of the two older brothers about the youngest was, ‘Let the kid enjoy himself.’ ”

Raymond led Purdue Frederick as its top executive for several decades, while Mortimer led Napp Pharmaceuticals, the family’s drug company in the UK. (In practice, a family spokesperson said, “the brothers worked closely together leading both companies.”) Arthur, the adman, had no official role in the family’s pharmaceutical operations. According to Barry Meier’s Pain Killer, a prescient account of the rise of OxyContin published in 2003, Raymond and Mortimer bought Arthur’s share in Purdue from his estate for $22.4 million after he died in 1987. In an email exchange, Arthur’s daughter Elizabeth Sackler, a historian of feminist art who sits on the board of the Brooklyn Museum and supports a variety of progressive causes, emphatically distanced her branch of the family from her cousins’ businesses. “Neither I, nor my siblings, nor my children have ever had ownership in or any benefit whatsoever from Purdue Pharma or OxyContin,” she wrote, while also praising “the breadth of my father’s brilliance and important works.” Jillian, Arthur’s widow, said her husband had died too soon: “His enemies have gotten the last word.”

The Sacklers have been millionaires for decades, but their real money—the painkiller money—is of comparatively recent vintage. The vehicle of that fortune was OxyContin, but its engine, the driving power that made them so many billions, was not so much the drug itself as it was Arthur’s original marketing insight, rehabbed for the era of chronic-pain management. That simple but profitable idea was to take a substance with addictive properties—in Arthur’s case, a benzo; in Raymond and Mortimer’s case, an opioid—and market it as a salve for a vast range of indications.

In the years before it swooped into the pain-management business, Purdue had been a small industry player, specializing in over-the-counter remedies like ear-wax remover and laxatives. Its most successful product, acquired in 1966, was Betadine, a powerful antiseptic purchased in industrial quantities by the U. S. government to prevent infection among wounded soldiers in Vietnam. The turning point, according to company lore, came in 1972, when a London doctor working for Cicely Saunders, the Florence Nightingale of the modern hospice movement, approached Napp with the idea of creating a timed-release morphine pill. A long-acting morphine pill, the doctor reasoned, would allow dying cancer patients to sleep through the night without an IV. At the time, treatment with opioids was stigmatized in the United States, owing in part to a heroin epidemic fueled by returning Vietnam veterans. “Opiophobia,” as it came to be called, prevented skittish doctors from treating most patients, including nearly all infants, with strong pain medication of any kind. In hospice care, though, addiction was not a concern: It didn’t matter whether terminal patients became hooked in their final days. Over the course of the seventies, building on a slow-release technology the company had already developed for an asthma medication, Napp created what came to be known as the “Contin” system. In 1981, Napp introduced a timed-release morphine pill in the UK; six years later, Purdue brought the same drug to market in the U. S. as MS Contin.

MS Contin quickly became the gold standard for pain relief in cancer care. At the same time, a number of clinicians associated with the burgeoning chronic-pain movement started advocating the use of powerful opioids for noncancer conditions like back pain and neuropathic pain, afflictions that at their worst could be debilitating. In 1986, two doctors from Memorial Sloan Kettering hospital in New York published a fateful article in a medical journal that purported to show, based on a study of thirty-eight patients, that long-term opioid treatment was safe and

effective so long as patients had no history of drug abuse. Soon enough, opioid advocates dredged up a letter to the editor published in The New England Journal of Medicine in 1980 that suggested, based on a highly unrepresentative cohort, that the risk of addiction from long-term opioid use was less than 1 percent. Though ultimately disavowed by its author, the letter ended up getting cited in medical journals more than six hundred times.

As the country was reexamining pain, Raymond’s eldest son, Richard Sackler, was searching for new applications for Purdue’s timed-release Contin system. “At all the meetings, that was a constant source of discussion—‘What else can we use the Contin system for?’ ” said Peter Lacouture, a senior director of clinical research at Purdue from 1991 to 2001. “And that’s where Richard would fire some ideas—maybe antibiotics, maybe chemotherapy—he was always out there digging.” Richard’s spitballing wasn’t idle blather. A trained physician, he treasured his role as a research scientist and appeared as an inventor on dozens of the company’s patents (though not on the patents for OxyContin). In the tradition of his uncle Arthur, Richard was also fascinated by sales messaging. “He was very interested in the commercial side and also very interested in marketing approaches,” said Sally Allen Riddle, Purdue’s former executive director for product management. “He didn’t always wait for the research results.” (A Purdue spokesperson said that Richard “always considered relevant scientific information when making decisions.”)

Perhaps the most private member of a generally secretive family, Richard appears nowhere on Purdue’s website. From public records and conversations with former employees, though, a rough portrait emerges of a testy eccentric with ardent, relentless ambitions. Born in 1945, he holds degrees from Columbia University and NYU Medical School. According to a bio on the website of the Koch Institute for Integrative Cancer Research at MIT, where Richard serves on the advisory board, he started working at Purdue as his father’s assistant at age twenty-six before eventually leading the firm’s R&D division and, separately, its sales and marketing division. In 1999, while Mortimer and Raymond remained Purdue’s co-CEOs, Richard joined them at the top of the company as president, a position he relinquished in 2003 to become cochairman of the board. The few publicly available pictures of him are generic and sphinxlike—a white guy with a receding hairline. He is one of the few Sacklers to consistently smile for the camera. In a photo on what appears to be his Facebook profile, Richard is wearing a tan suit and a pink tie, his right hand casually scrunched into his pocket, projecting a jaunty charm. Divorced in 2013, he lists his relationship status on the profile as “It’s complicated.” WHEN PURDUE EVENTUALLY PLEADED GUILTY TO FELONY CHARGES IN 2007 FOR CRIMINALLY “MISBRANDING” OXYCONTIN, IT ACKNOWLEDGED EXPLOITING DOCTORS’ MISCONCEPTIONS ABOUT OXYCODONE’S STRENGTH.

Richard’s political contributions have gone mostly to Republicans—including Strom Thurmond and Herman Cain—though at times he has also given to Democrats. (His ex-wife, Beth Sackler, has given almost exclusively to Democrats.) In 2008, he wrote a letter to the editor of The Wall Street Journal denouncing Muslim support for suicide bombing, a concern that seems to persist: Since 2014, his charitable organization, the Richard and Beth Sackler Foundation, has donated to several anti-Muslim groups, including three organizations classified as hate groups by the Southern Poverty Law Center. (The family spokesperson said, “It was never Richard Sackler’s intention to donate to an anti-Muslim or hate group.”) The foundation has also donated to True the Vote, the “voter-fraud watchdog” that was the original source for Donald Trump’s inaccurate claim that three million illegal immigrants voted in the 2016 election.

Former employees describe Richard as a man with an unnerving intelligence, alternately detached and pouncing. In meetings, his face was often glued to his laptop. “This was pre-

smartphone days,” said Riddle. “He’d be typing away and you would think he wasn’t even listening, and then all of the sudden his head would pop up and he’d be asking a very pointed question.” He was notorious for peppering subordinates with unexpected, rapid-fire queries, sometimes in the middle of the night. “Richard had the mind of someone who’s going two hundred miles an hour,” said Lacouture. “He could be a little bit disconnected in the way he would communicate. Whether it was on the weekend or a holiday or a Christmas party, you could always expect the unexpected.”

Richard also had an appetite for micromanagement. “I remember one time he mailed out a rambling sales bulletin,” said Shelby Sherman, a Purdue sales rep from 1974 to 1998. “And right in the middle, he put in, ‘If you’re reading this, then you must call my secretary at this number and give her this secret password.’ He wanted to check and see if the reps were reading this shit. We called it ‘Playin’ Passwords.’ ” According to Sherman, Richard started taking a more prominent role in the company during the early 1980s. “The shift was abrupt,” he said. “Raymond was just so nice and down-to-earth and calm and gentle.” When Richard came, “things got a lot harder. Richard really wanted Purdue to be big—I mean really big.”

To effectively capitalize on the chronic-pain movement, Purdue knew it needed to move beyond MS Contin. “Morphine had a stigma,” said Riddle. “People hear the word and say, ‘Wait a minute, I’m not dying or anything.’ ” Aside from its terminal aura, MS Contin had a further handicap: Its patent was set to expire in the late nineties. In a 1990 memo addressed to Richard and other executives, Purdue’s VP of clinical research, Robert Kaiko, suggested that the company work on a pill containing oxycodone, a chemical similar to morphine that was also derived from the opium poppy. When it came to branding, oxycodone had a key advantage: Although it was 50 percent stronger than morphine, many doctors believed—wrongly—that it was substantially less powerful. They were deceived about its potency in part because oxycodone was widely known as one of the active ingredients in Percocet, a relatively weak opioid- acetaminophen combination that doctors often prescribed for painful injuries. “It really didn’t have the same connotation that morphine did in people’s minds,” said Riddle.

A common malapropism led to further advantage for Purdue. “Some people would call it oxy-codeine” instead of oxycodone, recalled Lacouture. “Codeine is very weak.” When Purdue eventually pleaded guilty to felony charges in 2007 for criminally “misbranding” OxyContin, it acknowledged exploiting doctors’ misconceptions about oxycodone’s strength. In court documents, the company said it was “well aware of the incorrect view held by many physicians that oxycodone was weaker than morphine” and “did not want to do anything ‘to make physicians think that oxycodone was stronger or equal to morphine’ or to ‘take any steps . . . that would affect the unique position that OxyContin’ ” held among physicians.

Purdue did not merely neglect to clear up confusion about the strength of OxyContin. As the company later admitted, it misleadingly promoted OxyContin as less addictive than older opioids on the market. In this deception, Purdue had a big assist from the FDA, which allowed the company to include an astonishing labeling claim in OxyContin’s package insert: “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.”

The theory was that addicts would shy away from timed-released drugs, preferring an immediate rush. In practice, OxyContin, which crammed a huge amount of pure narcotic into a single pill, became a lusted-after target for addicts, who quickly discovered that the timed-release mechanism in OxyContin was easy

to circumvent—you could simply crush a pill and snort it to get most of the narcotic payload in a single inhalation. This wasn’t exactly news to the manufacturer: OxyContin’s own packaging warned that consuming broken pills would thwart the timed-release system and subject patients to a potentially fatal overdose. MS Contin had contended with similar vulnerabilities, and as a result commanded a hefty premium on the street. But the “reduced abuse liability” claim that added wings to the sales of OxyContin had not been approved for MS Contin. It was removed from OxyContin in 2001 and would never be approved again for any other opioid.

The year after OxyContin’s release, Curtis Wright, the FDA examiner who approved the pharmaceutical’s original application, quit. After a stint at another pharmaceutical company, he began working for Purdue. In an interview with Esquire, Wright defended his work at the FDA and at Purdue. “At the time, it was believed that extended-release formulations were intrinsically less abusable,” he insisted. “It came as a rather big shock to everybody—the government and Purdue—that people found ways to grind up, chew up, snort, dissolve, and inject the pills.” Preventing abuse, he said, had to be balanced against providing relief to chronic-pain sufferers. “In the mid-nineties,” he recalled, “the very best pain specialists told the medical community they were not prescribing opioids enough. That was not something generated by Purdue—that was not a secret plan, that was not a plot,that was not a clever marketing ploy. Chronic pain is horrible. In the right circumstances, opioid therapy is nothing short of miraculous; you give people their lives back.” In Wright’s account, the Sacklers were not just great employers, they were great people. “No company in the history of pharmaceuticals,” he said, “has worked harder to try to prevent abuse of their product than Purdue.”

Purdue did not invent the chronic-pain movement, but it used that movement to engineer a crucial shift. Wright is correct that in the nineties patients suffering from chronic pain often received inadequate treatment. But the call for clinical reforms also became a flexible alibi for overly aggressive prescribing practices. By the end of the decade, clinical proponents of opioid treatment, supported by millions in funding from Purdue and other pharmaceutical companies, had organized themselves into advocacy groups with names like the American Pain Society and the American Academy of Pain Medicine. (Purdue also launched its own group, called Partners Against Pain.) As the decade wore on, these organizations, which critics have characterized as front groups for the pharmaceutical industry, began pressuring health regulators to make pain “the fifth vital sign”—a number, measured on a subjective ten-point scale, to be asked and recorded at every doctor’s visit. As an internal strategy document put it, Purdue’s ambition was to “attach an emotional aspect to non cancer pain” so that doctors would feel pressure to “treat it more seriously and aggressively.” The company rebranded pain relief as a sacred right: a universal narcotic entitlement available not only to the terminally ill but to every American.

The company rebranded pain relief as a sacred right: a universal narcotic entitlement available not only to the terminally ill but to every American. By 2001, annual OxyContin sales had surged past $1 billion.

OxyContin’s sales started out small in 1996, in part because Purdue first focused on the cancer market to gain formulary acceptance from HMOs and state Medicaid programs. Over the next several years, though, the company doubled its sales force to six hundred—equal to the total number of DEA diversion agents employed to combat the sale of prescription drugs on the black market—and began targeting general practitioners, dentists, OB/GYNs, physician assistants, nurses, and residents. By 2001, annual OxyContin sales had surged past $1 billion. Sales reps were encouraged to downplay addiction risks. “It was sell, sell,

sell,” recalled Sherman. “We were directed to lie. Why mince words about it? Greed took hold and overruled everything. They saw that potential for billions of dollars and just went after it.” Flush with cash, Purdue pioneered a high-cost promotion strategy, effectively providing kickbacks—which were legal under American law—to each part of the distribution chain. Wholesalers got rebates in exchange for keeping OxyContin off prior authorization lists. Pharmacists got refunds on their initial orders. Patients got coupons for thirty- day starter supplies. Academics got grants. Medical journals got millions in advertising. Senators and members of Congress on key committees got donations from Purdue and from members of the Sackler family.

It was doctors, though, who received the most attention. “We used to fly doctors to these ‘seminars,’ ” said Sherman, which were, in practice, “just golf trips to Pebble Beach. It was graft.” Though offering perks and freebies to doctors was hardly uncommon in the industry, it was unprecedented in the marketing of a Schedule II narcotic. For some physicians, the junkets to sunny locales weren’t enough to persuade them to prescribe. To entice the holdouts—a group the company referred to internally as “problem doctors”—the reps would dangle the lure of Purdue’s lucrative speakers’ bureau. “Everybody was automatically approved,” said Sherman. “We would set up these little dinners, and they’d make their little fifteen-minute talk, and they’d get $500.”

Between 1996 and 2001, the number of OxyContin prescriptions in the United States surged from about three hundred thousand to nearly six million, and reports of abuse started to bubble up in places like West Virginia, Florida, and Maine. (Research would later show a direct correlation between prescription volume in an area and rates of abuse and overdose.) Hundreds of doctors were eventually arrested for running pill mills. According to an investigation in the Los Angeles Times, even though Purdue kept an internal list of doctors it suspected of criminal diversion, it didn’t volunteer this information to law enforcement until years later. As criticism of OxyContin mounted through the aughts, Purdue responded with symbolic concessions while retaining its volume-driven business model. To prevent addicts from forging prescriptions, the company gave doctors tamper-resistant prescription pads; to mollify pharmacists worried about robberies, Purdue offered to replace, free of charge, any stolen drugs; to gather data on drug abuse and diversion, the company launched a national monitoring program called RADARS.

Critics were not impressed. In a letter to Richard Sackler in July 2001, Richard Blumenthal, then Connecticut’s attorney general and now a U. S. senator, called the company’s efforts “cosmetic.” As Blumenthal had deduced, the root problem of the prescription-opioid epidemic was the high volume of prescriptions written for powerful opioids. “It is time for Purdue Pharma to change its practices,” Blumenthal warned Richard, “not just its public-relations strategy.”

It wasn’t just that doctors were writing huge numbers of prescriptions; it was also that the prescriptions were often for extraordinarily high doses. A single dose of Percocet contains between 2.5 and 10mg of oxycodone. OxyContin came in 10-, 20-, 30-, 40-, and 80mg formulations and, for a time, even 160mg. Purdue’s greatest competitive advantage in dominating the pain market, it had determined early on, was that OxyContin lasted twelve hours, enough to sleep through the night. But for many patients, the drug lasted only six or eight hours, creating a cycle of crash and euphoria that one academic called “a perfect recipe for addiction.” When confronted with complaints about “breakthrough pain”—meaning that the pills weren’t working as long as advertised—Purdue’s sales reps were given strict instructions to tell doctors to strengthen the dose rather than increase dosing frequency.

Sales reps were encouraged to downplay addiction risks. “It was sell, sell, sell,” recalled Sherman. “We were directed to lie. Why mince words about it?”

Over the next several years, dozens of class-action lawsuits were brought against Purdue. Many were dismissed, but in some cases Purdue wrote big checks to avoid going to trial. Several plaintiffs’ lawyers found that the company was willing to go to great lengths to prevent Richard Sackler from having to testify under oath. “They didn’t want him deposed, I can tell you that much,” recalled Marvin Masters, a lawyer who brought a class-action suit against Purdue in the early 2000s in West Virginia. “They were willing to sit down and settle the case to keep from doing that.” Purdue tried to get Richard removed from the suit, but when that didn’t work, the company settled with the plaintiffs for more than $20 million. Paul Hanly, a New York class-action lawyer who won a large settlement from Purdue in 2007, had a similar recollection. “We were attempting to take Richard Sackler’s deposition,” he said, “around the time that they agreed to a settlement.” (A spokesperson for the company said, “Purdue did not settle any cases to avoid the deposition of Dr. Richard Sackler, or any other individual.”)

When the federal government finally stepped in, in 2007, it extracted historic terms of surrender from the company. Purdue pleaded guilty to felony charges, admitting that it had lied to doctors about OxyContin’s abuse potential. (The technical charge was “misbranding a drug with intent to defraud or mislead.”) Under the agreement, the company paid $600 million in fines and its three top executives at the time—its medical director, general counsel, and Richard’s successor as president—pleaded guilty to misdemeanor charges. The executives paid $34.5 million out of their own pockets and performed four hundred hours of community service. It was one of the harshest penalties ever imposed on a pharmaceutical company. (In a statement to Esquire, Purdue said that it “abides by the highest ethical standards and legal requirements.” The statement went on: “We want physicians to use their professional judgment, and we were not trying to pressure them.”)

Fifty-three thousand Americans died from opioid overdoses in 2016, more than the thirty-six thousand who died in car crashes in 2015 or the thirty-five thousand who died from gun violence that year.

No Sacklers were named in the 2007 suit. Indeed, the Sackler name appeared nowhere in the plea agreement, even though Richard had been one of the company’s top executives during most of the period covered by the settlement. He did eventually have to give a deposition in 2015, in a case brought by Kentucky’s attorney general. Richard’s testimony—the only known record of a Sackler speaking about the crisis the family’s company helped create—was promptly sealed. (In 2016, STAT, an online magazine owned by Boston Globe Media that covers health and medicine, asked a court in Kentucky to unseal the deposition, which is said to have lasted several hours. STAT won a lower-court ruling in May 2016. As of press time, the matter was before an appeals court.)

In 2010, Purdue executed a breathtaking pivot: Embracing the arguments critics had been making for years about OxyContin’s susceptibility to abuse, the company released a new formulation of the medication that was harder to snort or inject. Purdue seized the occasion to rebrand itself as an industry leader in abuse-deterrent technology. The change of heart coincided with two developments: First, an increasing number of addicts, unable to afford OxyContin’s high street price, were turning to cheaper alternatives like heroin; second, OxyContin was nearing the end of its patents. Purdue suddenly argued that the drug it had been selling for nearly fifteen years was so prone to abuse that generic manufacturers should not be allowed to copy it.

On April 16, 2013, the day some of the key patents for OxyContin were scheduled to expire, the FDA followed Purdue’s lead, declaring that no generic versions of the original OxyContin formulation could be sold. The company had effectively won several additional years of patent protection for its golden goose.

Opioid withdrawal, which causes aches, vomiting, and restless anxiety, is a gruesome process to experience as an adult. It’s considerably worse for the twenty thousand or so American babies who emerge each year from opioid-soaked wombs. These infants, suddenly cut off from their supply, cry uncontrollably. Their skin is mottled. They cannot fall asleep. Their bodies are shaken by tremors and, in the worst cases, seizures. Bottles of milk leave them distraught, because they cannot maneuver their lips with enough precision to create suction. Treatment comes in the form of drops of morphine pushed from a syringe into the babies’ mouths. Weaning sometimes takes a week but can last as long as twelve. It’s a heartrending, expensive process, typically carried out in the neonatal ICU, where newborns have limited access to their mothers.

But the children of OxyContin, its heirs and legatees, are many and various. The second- and third-generation descendants of Raymond and Mortimer Sackler spend their money in the ways we have come to expect from the not-so-idle rich. Notably, several have made children a focus of their business and philanthropic endeavors. One Sackler heir helped start an iPhone app called Red Rover, which generates ideas for child-friendly activities for urban parents; another runs a child- development center near Central Park; another is a donor to charter-school causes, as well as an investor in an education start-up called AltSchool. Yet another is the founder of Beespace, an “incubator for emerging nonprofits,” which provides resources and mentoring for initiatives like the Malala Fund, which invests in education programs for women in the developing world, and Yoga Foster, whose objective is to bring “accessible, sustainable yoga programs into schools across the country.” Other Sackler heirs get to do the fun stuff: One helps finance small, interesting films like The Witch; a second married a famous cricket player; a third is a sound artist; a fourth started a production company with Boyd Holbrook, star of the Netflix series Narcos; a fifth founded a small chain of gastropubs in New York called the Smith.

Holding fast to family tradition, Raymond’s and Mortimer’s heirs declined to be interviewed for this article. Instead, through a spokesperson, they put forward two decorated academics who have been on the receiving end of the family’s largesse: Phillip Sharp, the Nobel-prize-winning MIT geneticist, and Herbert Pardes, formerly the dean of faculty at Columbia University’s medical school and CEO of New York-Presbyterian Hospital. Both men effusively praised the Sacklers’ donations to the arts and sciences, marveling at their loyalty to academic excellence. “Once you were on that exalted list of philanthropic projects,” Pardes told Esquire, “you were there and you were in a position to secure additional philanthropy. It was like a family acquisition.” Pardes called the Sacklers “the nicest, most gentle people you could imagine.” As for the family’s connection to OxyContin, he said that it had never come up as an issue in the faculty lounge or the hospital break room. “I have never heard one inch about that,” he said.

Pardes’s ostrich like avoidance is not unusual. In 2008, Raymond and his wife donated an undisclosed amount to Yale to start the Raymond and Beverly Sackler Institute for Biological, Physical and Engineering Sciences. Lynne Regan, its current director, told me that neither students nor faculty have ever brought up the OxyContin connection. “Most people don’t know about that,” she said. “I think people are mainly oblivious.” A spokesperson for the university added, “Yale does not vet donors for controversies that may or may not arise.”

In May, a dozen lawmakers in Congress sent a bipartisan letter to the World Health Organization warning that Sackler-owned companies were preparing to flood foreign countries with legal narcotics.

The controversy surrounding OxyContin shows little sign of receding. In 2016, the CDC issued a startling warning: There was no good evidence that opioids were an effective treatment for chronic pain beyond six weeks. There was, on the other hand, an abundance of evidence that long-term treatment with opioids had harmful effects. (A recent paper by Princeton economist Alan Krueger suggests that chronic opioid use may account for more than 20 percent of the decline in American labor-force participation from 1999 to 2015.) Millions of opioid prescriptions for chronic pain had been written in the preceding two decades, and the CDC was calling into question whether many of them should have been written at all. At least twenty-five government entities, ranging from states to small cities, have recently filed lawsuits against Purdue to recover damages associated with the opioid epidemic.

The Sacklers, though, will likely emerge untouched: Because of a sweeping non-prosecution agreement negotiated during the 2007 settlement, most new criminal litigation against Purdue can only address activity that occurred after that date. Neither Richard nor any other family members have occupied an executive position at the company since 2003.

The American market for OxyContin is dwindling. According to Purdue, prescriptions fell 33 percent between 2012 and 2016. But while the company’s primary product may be in eclipse in the United States, international markets for pain medications are expanding. According to an investigation last year in the Los Angeles Times, Mundipharma, the Sackler-owned company charged with developing new markets, is employing a suite of familiar tactics in countries like Mexico, Brazil, and China to stoke concern for as-yet-unheralded “silent epidemics” of untreated pain. In Colombia, according to the L.A. Times, the company went so far as to circulate a press release suggesting that 47 percent of the population suffered from chronic pain. [Napp is the family’s drug company in the UK. Mundipharma is their company charged with developing new markets.]

In May, a dozen lawmakers in Congress, inspired by the L.A. Times investigation, sent a bipartisan letter to the World Health Organization warning that Sackler-owned companies were preparing to flood foreign countries with legal narcotics. “Purdue began the opioid crisis that has devastated American communities,” the letter reads. “Today, Mundipharma is using many of the same deceptive and reckless practices to sell OxyContin abroad.” Significantly, the letter calls out the Sackler family by name, leaving no room for the public to wonder about the identities of the people who stood behind Mundipharma.

The final assessment of the Sacklers’ global impact will take years to work out. In some places, though, they have already left their mark. In July, Raymond, the last remaining of the original Sackler brothers, died at ninety-seven. Over the years, he had won a British knighthood, been made an Officer of France’s Légion d’Honneur, and received one of the highest possible honors from the royal house of the Netherlands. One of his final accolades came in June 2013, when Anthony Monaco, the president of Tufts University, traveled to Purdue Pharma’s headquarters in Stamford to bestow an honorary doctorate. The Sacklers had made a number of transformational donations to the university over the years—endowing, among other things, the Sackler School of Graduate Biomedical Sciences. At

Tufts, as at most schools, honorary degrees are traditionally awarded on campus during commencement, but in consideration of Raymond’s advanced age, Monaco trekked to Purdue for a special ceremony. The audience that day was limited to family members, select university officials, and a scrum of employees. Addressing the crowd of intimates, Monaco praised his benefactor. “It would be impossible to calculate how many lives you have saved, how many scientific fields you have redefined, and how many new physicians, scientists, mathematicians, and engineers are doing important work as a result of your entrepreneurial spirit.” He concluded, “You are a world changer.”

Source: This article appears in the November ’17 issue of Esquire.

In his last article for Pro Talk, Renaming and Rethinking Drug Treatment, psychologist Robert Schwebel, Ph.D., author and developer of The Seven Challenges program, expressed his views about problems in typical drug and alcohol treatment. In this interview, he focuses on changes that he thinks would better meet the needs of individuals with substance problems.

The Seven Challenges Program

The Seven Challenges is described as “a comprehensive counselling program for teens and young adults that incorporates work on alcohol and other drug problems.” The program addresses much more than substance issues because it also helps young people develop better life skills, as well as manage their situational and psychological problems. Although there is an established structure for each session and a framework for decision-making (see website for the youth version of “The Seven Challenges”), it is not pre-scripted as in many traditional programs. Rather it is “exceptionally flexible, in response to the immediate needs of the clients.”

Independent studies funded by The Center for Substance Abuse Treatment and published in peer-reviewed journals have provided evidence that The Seven Challenges significantly decreases substance use of adolescents and greatly improves their overall mental health status. The program has been shown to be especially effective for the many young people with drug problems who also have trauma issues.

Just recently, a new version of The Seven Challenges program was introduced for adults and is being piloted in a research project. Soon, a book geared toward the general public by Dr. Schwebel that incorporates much of the philosophy of the program, as well as many of the decision-making and behavior change strategies, will be available.

Q&A: What Should Treatment Look Like?

Q: In your last article for Pro Talk, you argued strongly against the word “treatment” and suggested that we use the word “counselling” instead. Will you reiterate why you prefer using “counselling” when talking about professional help for people with substance problems?

Dr. S.: Counselling is an active and interactive process that’s responsive to the needs of individuals. It may include education, but it’s more than that because the information is personalized and offered in the context of a discussion about what’s happening in a person’s life. Effective counsellors help clients become aware of their options, expand those options, and make their own informed choices.

Treatment, on the other hand, sounds like something imposed and passive that an authority (say a doctor) does to someone else or tells them to do. It also implies recipients receive a standardized protocol or regime with a preconceived goal, usually abstinence when we’re talking about addiction. It doesn’t suggest autonomy of choice or collaboration.


Q: You stress the importance of choice and collaboration, suggesting both are important in addiction counselling. Please tell us more.

Dr. S.: In collaborative counselling that allows choices, clients get to identify the issues they want to work on. They make the decisions. We make it clear that we’re not there to make them quit using drugs…and couldn’t even if we tried. We tell them, “We’re here to support you in working on your issues, things that are important to you; things that are not going well in your life or as well you would like them to be going.”

We also support clients in decision-making about drugs. They set their own goals about using. One person might want to quit using, while another might want to set new limits. For those who want to change their drug use behavior, we check in with them about how they’re doing regarding their decision on a session-by-session basis. If they have setbacks, we’ll provide individualized support to help them figure out why, We’re not doubting them or trying to “catch” them. Rather, we’re helping them succeed with their own decisions to change. This type of check-in would not apply to individuals who have not yet decided to make changes.


Q: Many addiction programs feel that dealing with addiction should be the first priority and that other issues are secondary. What are your thoughts about this?

Dr. S.: I’ll start by saying that they have equal importance. Drug problems have everything to do with what is going on in a person’s life. And, a person’s life is very much affected by drug problems. I do want to say, however, that not everyone who winds up in an addiction program has an addiction. That’s a ridiculous generalization. They may be having problems with binge drinking, issues with family or jobs because of substance misuse, or legal problems because they were unlucky and got caught. (For instance they got arrested for another crime and tested positive for drugs.) They often wind up in places that require abstinence and wonder, “What am I doing here?” Then they’re told they’re “in denial.”

Traditional treatment tends to focus narrowly on drug problems, usually pushing an agenda of immediate abstinence. However, drug problems – whether or not they qualify as “addiction,” are very much connected to the rest of life. Therefore, clients need comprehensive counselling that addresses what’s happening in their overall lives and helps clients make their lives better. So it’s not all about use of substances and making the individual quit. The goal is to support clients and to help them make their own decisions about life and substance use.

We use the term “issues” – not “problems.” Whatever is most important to the individual that day is what we work on. A client might say, “I have an issue with my mother.” We don’t just want to have a discussion about the issue; we want to set a session goal so that a client gets practical help with an issue each time. Ideally we try to facilitate a next step, some sort of action that can be taken between sessions. We want to support our clients in making their own lives better. We like to reassure clients that we won’t be harping on drugs all the time: At least half of what we do is about everything else besides drugs. This means that counsellors need to know how to help people with their other problems. Unfortunately, many have a narrow background in drug treatment and don’t yet know how to do that.


Q: How do you address the issue of “powerlessness” which a number of young people have told me they struggled with in12-step treatment programs they’ve attended? Don’t adolescents by nature resist anything that threatens to take away their autonomy?

Dr. S.: One of our main messages is “You are powerful; people do take control over their drug use. You have that power within you.” We also say, “You don’t need to do it alone. You are entitled to support. We’re behind you. We’re not saying it’s easy and

there won’t be setbacks along the way. If there are, we’ll help you figure out why and how to handle it differently the next time. At the same time we’ll help you with other issues in your life so you’ll have less need for drugs.”

I think there is great harm in the all-or-nothing approach to drug and alcohol problems and that more people would come for help if they were not told that they’re powerless. Also, many more would come if they felt they could make a choice about drugs and did not expect to be coerced.


A New Version of The Seven Challenges

Following is the new adult version of Dr. Schwebel’s The Seven Challenges program:

· Challenging Yourself to Make Thoughtful Decisions About Your Life, Including Your Use of Alcohol and Other Drugs

· Challenging Yourself to Look at Your Responsibility and the Responsibility of Others for Your Problems

· Challenging Yourself to Look at What You Like About Alcohol and Other Drugs, and Why You Use Them

· Challenging Yourself to Honestly Look at Your Life, Including Your Use of Alcohol and Other Drugs

· Challenging Yourself to Look at Harm That Has Happened or Could Happen From Your Use of Alcohol and Other Drugs

· Challenging Yourself to Look at Where You Are Headed, Where You Would Like to Go, and What You Would Like to Accomplish

· Challenging Yourself to Take Action and Succeed With Your Decisions About Your Life and Use of Alcohol and Other Drugs

Source:     17th July 2017

Medication-assisted treatment is often called the gold standard of addiction care. But much of the country has resisted it.

If you ask Jordan Hansen why he changed his mind on medication-assisted treatment for opioid addiction, this is the bottom line.

Several years ago, Hansen was against the form of treatment. If you asked him back then what he thought about it, he would have told you that it’s ineffective — and even harmful — for drug users. Like other critics, to Hansen, medication-assisted treatment was nothing more than substituting one drug (say, heroin) with another (methadone).

Today, not only does Hansen think this form of treatment is effective, but he readily argues — as the scientific evidence overwhelmingly shows — that it’s the best form of treatment for opioid addiction. He believes this so strongly, in fact, that he now often leads training sessions for medication-assisted treatment across the country.

“It almost hurts to say it out loud now, but it’s the truth,” Hansen told me, describing his previous beliefs. “I was kind of absorbing the collective fear and ignorance from the culture at large within the recovery community.” Hansen is far from alone. Over the past few years, America’s harrowing opioid epidemic — now the deadliest drug overdose crisis in the country’s history — has led to a lot of rethinking about how to deal with addiction. For addiction treatment providers, that’s led to new debates about the merits of the abstinence-only model — many of which essentially consider addiction a failure of willpower — so long supported in the US.

The case for prescription heroin

The Hazelden Betty Ford Foundation, which Hansen works for, exemplifies the debate. As one of the top drug treatment providers in the country, it used to subscribe almost exclusively to the abstinence-only model, based on an interpretation of the 12 steps of Alcoholics Anonymous and Narcotics Anonymous popularized in American addiction treatment in the past several decades. But in 2012, Hazelden announced a big switch: It would provide medication-assisted treatment.

“This is a huge shift for our culture and organization,” Marvin Seppala, chief medical officer of Hazelden, said at the time. “We believe it’s the responsible thing to do.”

From the outside, this might seem like a bizarre debate: Okay, so addiction treatment providers are supporting a form of treatment that has a lot of evidence behind it. So what?

But the growing embrace of medication-assisted treatment is demonstrative of how the opioid epidemic is forcing the country to take another look at its inadequate drug treatment system. With so many people dying from drug overdoses — tens of thousands a year — and hundreds of thousands more expected to die in the next decade, America is finally considering how its response to addiction can be better rooted in science instead of the moralistic stigmatization that’s existed for so long.

The problem is that the moralistic stigmatization is still fairly entrenched in how the US thinks about addiction. But the embrace of medication-assisted treatment shows that may be finally changing — and America may be finally looking at addiction as a medical condition instead of a moral failure.

The research is clear: Medication-assisted treatment works

One of the reasons opioid addiction is so powerful is that users feel like they must keep using the drugs in order to stave off withdrawal. Once a person’s body grows used to opioids but doesn’t get enough of the drugs to satisfy what it’s used to, withdrawal can pop up, causing, among other symptoms, severe nausea and full-body aches. So to avoid suffering through it, drug users often seek out drugs like heroin and opioid painkillers — not necessarily to get a euphoric high, but to feel normal and avoid withdrawal. (In the heroin world, this is often referred to as “getting straight.”)

Medications like methadone and buprenorphine (also known as Suboxone) can stop this cycle. Since they are opioids themselves, they can fulfil a person’s cravings and stop withdrawal symptoms. The key is that they do this in a safe medical setting, and when taken as prescribed do not produce the euphoric high that opioids do when they are misused. By doing this, an opioid user significantly reduces the risk of relapse, since he doesn’t have to worry about avoiding withdrawal anymore. Users can take this for the rest of their lives, or in some cases, doses may be reduced; it varies from patient to patient.

The research backs this up: Various studies, including systemic reviews of the research, have found that medication-assisted treatment can cut the all-cause mortality rate among addiction patients by half or more. Just imagine if a medication came out for any other disease — and, yes, health experts consider addiction a disease — that cuts mortality by half; it would be a momentous discovery.

“That is shown repeatedly,” Maia Szalavitz, a long time addiction journalist and author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, told me. “There’s so much data from so many different places that if you add methadone or Suboxone in, deaths go down, and if you take it away, deaths go up.” That’s why the biggest public health organizations — including the Centers for Disease Control and Prevention, the National Institute on Drug Abuse, and the World Health Organization — all acknowledge medication-assisted treatment’s medical value. And experts often describe it to me as “the gold standard” for opioid addiction care.

The data is what drove Hansen’s change in perspective. “If I wanted to view myself as an ethical practitioner and doing the best that I could for the people I served, I needed to make this change based on the overwhelming evidence,” he said. “And I needed to separate that from my personal recovery experience.”

Medication-assisted treatment is different from traditional forms of dealing with addiction in America, which tend to demand abstinence. The standards in this field are 12-step programs, which combine spiritual and moralistic ideals into a support group for people suffering from addiction. While some 12-step programs allow medication-assisted treatment, others prohibit it as part of their demand for total abstinence. The research shows this is a particularly bad idea for opioids, for which medications are considered the standard of care.

There are different kinds of medications for opioids, which will work better or worse depending on a patient’s circumstances. Methadone, for example, is only administered in a clinic, typically one to four times a day — but that means patients will have to make the trip to a clinic on a fairly regular basis. Buprenorphine is a take-home drug that’s taken once or twice a day, but the at-home access also means it might be easier to misuse and divert to the black market.

One rising medication, known as naltrexone or its brand name Vivitrol, isn’t an opioid — making it less prone to misuse — and only needs to be injected once a month. But it doesn’t work in the same way as methadone or buprenorphine. It requires full detoxification to use (usually three to 10 days of no opioid use), while buprenorphine, for example, only requires a partial detoxification process (usually 12 hours to two days). And instead of preventing withdrawal — indeed, the detox process requires going through withdrawal — it blocks the effects of opioids up to certain doses, making it much harder to get high or overdose on the drugs. It’s also relatively new, so there’s less evidence for its real-world effectiveness.

One catch is that even these medications, though the best forms of opioid treatment, do not work for as much as 40 percent of opioid users. Some patients may prefer not to take any medications because they see any drug use whatsoever as getting in the way of their recovery, in which case total abstinence may be the right answer for them. Others may not respond well physically to the medications, or the medications may for whatever reason fail to keep them from misusing drugs.

This isn’t atypical in medicine. What works for some people, even the majority, isn’t always going to work for everyone. So these are really first-line treatments, but in some cases patients may need alternative therapies if medication-assisted treatment doesn’t work. (That might even involve prescription heroin — which, while it’s perhaps counterintuitive, the research shows it works to mitigate the problems of addiction when provided in tightly controlled, supervised medical settings.)

Medication can also be paired with other kinds of treatment to better results. It can be used in tandem with cognitive behavioral therapy or similar approaches, which teach drug users how to deal with problems or settings that can lead to relapse. All of that can also be paired with 12-step programs like AA and NA or other support groups in which people work together and hold each other accountable in the fight against addiction. It all varies from patient to patient.

It is substituting one drug for another, but that’s okay

The main criticism of medication-assisted treatment is that it’s merely replacing one drug with another. Health and Human Services Secretary Tom Price recently echoed this criticism, saying, “If we’re just substituting one opioid for another, we’re not moving the dial much. Folks need to be cured so they can be productive members of society and realize their dreams.” (A spokesperson for Price later walked back the statement, saying Price supports all kinds of drug treatment.)

On its face, this argument is true. Medication-assisted treatment is replacing one drug, whether it’s opioid painkillers or heroin, with another, such as methadone or buprenorphine.

But this isn’t by itself a bad thing. Under the Diagnostic and Statistical Manual of Mental Disorders, it’s not enough for someone to be using or even physically dependent on drugs to qualify for a substance use disorder, the technical name for addiction. After all, most US adults use drugs — some every day or multiple times a day — without any problems whatsoever. Just think about that next time you sip a beer, glass of wine, coffee, tea, or any other beverage with alcohol or caffeine in it, or any time you use a drug to treat a medical condition.

The qualification for a substance use disorder is that someone is using drugs in a dangerous or risky manner, putting himself or others in danger. So someone with a substance use disorder would not just be using opioids but potentially using these drugs in a way that puts him in danger — perhaps by feeling the need to commit crimes to obtain the drugs or using the drugs so much that he puts himself at risk of overdose and inhibits his day-to-day functioning. Basically, the drug use has to hinder someone from being a healthy, functioning member of society to qualify as addiction.

The key with medication-assisted treatment is that while it does involve continued drug use, it turns that drug use into a much safer habit. So instead of stealing to get heroin or using painkillers so much that he puts his life at risk, a patient on medication-assisted treatment can simply use methadone or buprenorphine to meet his physical cravings and otherwise go about his day — going to school, work, or any other obligations.

Yet this myth of the dangers of medication-assisted treatment remains prevalent — to deadly results.

In 2013, Judge Frank Gulotta Jr. in New York ordered an opioid user arrested for drugs, Robert Lepolszki, off methadone treatment, which he began after his arrest. In January 2014, Lepolszki died of a drug overdose at 28 years old — a direct result, Lepolszki’s parents say, of failing to get the medicine he needed. In his defense,  Gulotta has continued to argue that methadone programs “are crutches — they are substitutes for drugs and drug cravings without enabling the participant to actually rid him or herself of the addiction.”

This is just one case, but it shows the real risk of denying opioid users medication: It can literally get them killed by depriving them of lifesaving medical care.

The myth is also a big reason why there are still restrictions on medication-assisted treatment. For example, the federal government still caps how many patients doctors can prescribe buprenorphine to, with strict rules about raising the cap. This limits how accessible the treatment is. A Huff Post analysis found that even if every doctor who can prescribe buprenorphine did so at the maximum rate in 2012, more than half of Americans with opioid use disorders could not get the medication. That’s on top of barriers to addiction treatment in general. According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report attributed the low rate to severe shortages in the supply of care, with some areas of the country, particularly rural counties, lacking affordable options for treatment — which can lead to waiting periods of weeks or even months. Only recently has there been a broader push to fix this gap in care.

The medications used in treatment do carry some risks

None of this is to say that the medications used in these treatments are without any problems whatsoever. Methadone is tied to thousands of deadly overdoses a year, although almost entirely when it’s used for pain, not addiction, treatment — since it’s much more regulated in addiction care. Buprenorphine is safer in that, unlike common painkillers, heroin, and methadone, its effect has a ceiling — meaning it has no significant effect after a certain dose level. But it’s still possible to misuse, particularly for people with lower tolerance levels. And there are some reports of buprenorphine mills, where patients can get buprenorphine for misuse from unscrupulous doctors — similar to how pill mills popped up during the beginning of the opioid epidemic and provided patients easy access to painkillers.

Naltrexone, meanwhile, can heighten the risk of overdose and death in case of full relapse. Overdose and death are risks in any case of relapse, but they’re particularly acute for naltrexone because it requires a full detox process that eliminates prior tolerance. (Although this would typically require someone to stop taking naltrexone, since otherwise it blocks the effects of opioids up to certain doses.)

But when taken as prescribed, the medications are broadly safe and effective for addiction treatment. For regulators, it’s a matter of making sure the drugs aren’t diverted into misuse, while also providing good access to people who genuinely need them.

The fight over medication-assisted treatment is really about how we see addiction

Behind the arguments about medication-assisted treatment is a simple reality of how Americans view addiction: Many still don’t see it, as public health officials and experts do, as a disease.

With other diseases, there is no question that medication can be a legitimate answer. That medication is not viewed as a proper answer by many to addiction shows that people believe addiction is unique in some way — particularly, they view addiction as at least partly a moral failing instead of just a disease.

I get emails all the time to this effect. Here, for example, is a fairly representative reader message: “Darwin’s Theory says ‘survival of the fittest.’ Let these lost souls pay the price of their criminal choices and criminal actions. Society does not owe them multiple medical resuscitations from their own bad judgment, criminal activity, and self-inflicted wounds.”

This contradicts what addiction experts broadly agree on. As Stanford psychiatrist and Drug Dealer, MD author Anna Lembke put it, “If you see somebody who continues to use despite their lives being totally destroyed — losing their jobs, losing loved ones, ending up in jail — nobody would choose that. Nobody anywhere would ever choose that life. So clearly it is beyond this individual’s control on some level.”

Many Americans may understand this with, say, depression and anxiety. We know that people with these types of mental health problems are not in full control of their thoughts and emotions. But many don’t realize that addiction functions in a similar way — only that the thoughts and emotions drive someone to seek out drugs at just about any cost.

Some of the sentiment against medications, as Hansen can testify, is propagated by people suffering from addiction. Some of them believe that any drug use, even to treat addiction, goes against the goal of full sobriety. They may believe that if they got sober without medications, perhaps others should too. Many of them also don’t trust the health care system: If they got addicted to drugs because a doctor prescribed them opioid painkillers, they have a good reason to distrust doctors who are now trying to get them to take another medication — this time for their addiction.

The opioid epidemic, however, has gotten a lot of people in the addiction recovery world to reconsider their past beliefs. Funeral after funeral and awful statistic after awful statistic, there is a sense that there has to be a better way — and by looking at the evidence, many have come to support medication-assisted treatment.

“I remember sitting there,” Hansen said, speaking to his experience at a funeral, as a mother sang her dead son a lullaby, “thinking that we have to do better.”

Source:  German  Jul 20, 2017


Medical Illness Model:

Near the end of the Second World War researchers and leaders in the recovery community jointly formulated the problem of uncontrolled drinking into what is now known as the Disease Model of alcoholism. This model postulates that, like medical illnesses, alcoholism–more specifically alcohol dependence, or addiction—can be diagnosed, its course observed, and its physical causes understood.

Further, scientific trials can be undertaken to identify the best treatments for those who suffer from it. The diagnosis of Alcohol Dependence, in this model, rested on four symptoms: 1) a tolerance to alcohol in which a person needs to drink ever greater amounts to reach a desired effect, 2) withdrawal symptoms, such as “the shakes” and others, on stopping use, 3) the Loss of Control phenomenon in which affected persons lose the ability to control how much they drink at a sitting and thereby can no longer predict how much they will drink from one episode to the next, and 4) social or physical impairment resulting from combinations of the first three symptom categories1.

This model pictures a condition from which many alcohol dependent people emerge every year, and into which many others return. View as a disease, alcoholism takes on the characteristics of a remitting-relapsing illness with primary symptoms that direct us to brain functioning. And, because ethyl alcohol is a very small molecule with easy access to most parts of the body, moderate to heavy alcohol use often injures other organs, such as the liver and heart among others.

Uncontrolled, or dependent, alcohol use also affects the social network setting of family as well as work activities, friendships, and legal involvement. Last, however, the Disease model brings with it the possibilities of treatment and of hope. At this date, effective medicinal agents against alcoholism are very few. But hope, that necessary ingredient for recovery, waxes strong in the illness model. In the words of the alcoholic patient quoted in the Part 2, “It is much easier to think of myself as an ill person working to become well, rather than a bad person trying to become good.”

Genetic Models:

From the Disease model has come another, that of genetic influence. The observation that alcoholism often runs in families for many years meant that family cultures or mores determined who would become alcoholic and who would not. While it is clear that cultural and family life influences are very powerful, more recent studies have noted that an underlying genetic disposition may be at play in some genealogical lines2. If so, the evidence suggests a confluence of many gene effects rather than the dominant/recessive results of inheritance in Mendelian models of genetic death, as for example, in Huntington’s Disease.

Instead, the gene effects seem to have more to do with the vulnerability towards alcoholism. One form appears in those who have a genetically-based insensitivity to alcohol—an “inborn tolerance,” and develop alcohol dependence at much higher rates than alcohol sensitive comparison groups. Another form may require a combination of

gene influences and environment conditions to come together to result in alcohol-plus-multiple drug dependence, sometimes referred to as Type 2 or Type B alcoholics.

Unexpectedly, the news of gene involvement was greeted with enthusiasm among some quarters of the actively drinking alcoholic public: “Since alcoholism is genetic, we can’t escape our genes and may as well keep drinking.” As with older models however, the element of choice remains present in the sober periods between drinking episodes. As some of the other models suggest, healing from alcoholism remains an individual process.

Psychological Adaptation Models in Illness and Recovery:

Further modern research asks that we look at individuals and their abilities to adapt to the stresses of life. Careful observation has established that individual humans have the ability to adapt creatively to the painful thoughts and feelings of living and to do so in ways that connect us together rather than drive us apart3. This model of Mature human psychological adaptation, however, emphasizes that the brain function at its healthy best. Heavy, continuous use of alcohol carries often subtle, if severe, effects on the brain that are as yet poorly understood.

But we know they exist because of their effects in driving down the ability to adapt, from psychological Maturity to much more rigid Primitive mechanisms of coping, such as when an alcoholic “denies” that an obvious problem exists at all. This kind of Denial can occur in the actively drinking alcoholic who understands that resolving his or her ambivalence toward drinking is too painful to contemplate; therefore, a failure to perceive the problem seems preferable than facing it.

So it is that the Adaptation model views the First of the Twelve Steps as addressing primitive Denial in coming to recognize that the individual’s alcoholism exists. Progressing along the continuum of the Steps leads finally to the Twelfth: helping others who have the same problem. In the Psychological Adaptation model, this exemplifies the Mature mechanism of Altruism: selflessly helping others. The occurrence of brain healing as abstinence continues—along with the progression towards psychological maturity, whether viewed in the Psychological Adaptation or the Twelve Step models—suggests that brain recovery process are at work. We can only recognize their existence at this point, and need to understand their biology if we are to improve treatments in the Disease model.

Many Models, More Questions:

With this overview of the different model formulations of the problem of alcoholism and what to do about it, we are now ready to look as specific questions from a scientific point of view. As this series unfolds, we will have recourse to use all of the models mentioned—now adding the crucial ingredient of evidence, systematically gathered. In future Updates, the discussion will focus on specific problems and what we can learn about them.

Source:  14th Jan. 2014

New Hampshire has the second-highest rate of drug overdoses in the country. Eric Adams in Laconia (population 16,000) has been assigned one task to stop them.

Eric Adams is a handsome, clean-shaven man, almost 41, with a booming voice and hair clipped short enough for the military, which once was an ambition of his. After high school, he tried to join the Marines but was turned away because of his asthma. He needed three different inhalers then, plus injections. Today he has outgrown the problem. He is 5-foot-10, weighs 215 pounds and can dead lift 350.

Adams has worked in law enforcement for almost two decades.

He began as a guard at the New Hampshire state prison, where he asked to work in maximum security, then left to become a police officer in Tilton and was soon recommended for the Drug Task Force, a statewide operation against narcotics dealers. Adams grew his hair long and arranged undercover buys, a Glock 27 concealed in a holster beneath his jeans. Later he would return wearing a bulletproof vest, surrounded by fellow officers, to kick in the door with his pistol drawn.

Eric Adams in his office at the Laconia Police Department.
CreditNatalie Keyssar for The New York Times

Laconia, where Adams works today, is a former mill town in central New Hampshire surrounded by lakes. In midwinter, Laconia is home to 16,000 residents, though in summer that number swells to 30,000. Those are gleaming, sun-dappled days. Then winter falls on New England like a gavel.

A blight in the region is especially acute. Of the 13 states with the highest death rates from drug overdoses, five are in New England. New Hampshire in particular has more per capita overdose deaths than anywhere but West Virginia. In 2012, the state had 163 such deaths, a majority of them (as elsewhere in the country) from heroin and prescription opioids. In 2015, the state had nearly 500 deaths, the most in its history. In Manchester, its largest city, the police seized more than 27,000 grams of heroin that year, up from 1,314 grams a year earlier. In certain neighborhoods, a single dose of heroin can cost less than a six pack of Budweiser. Waiting lists for treatment programs stretch as long as eight weeks.

Those years spent guarding prisoners, and later kicking down doors, changed Adams’s thinking. So many of the drug users he saw had made one bad decision and then became chained to it, Adams realized. Or they had begun on a valid prescription for pain medication, after an injury, and then grew addicted. When refills grew scarce, they turned to alternatives. Many were no longer even using to get high, only to avoid the agony of withdrawal.

They were teenaged, middle-aged and elderly; they were students, bankers and grocery clerks. They were businesswomen with six-figure salaries and homeless men with shopping carts. Arresting a person like this did no good, because there was always another to replace him or her — and regardless, any jail sentence had limits. Afterward, Adams saw, everyone landed right back where they started.

‘‘We’re not getting anywhere,’’ he told his chief, Christopher Adams (the two men are not related), and his lieutenant. It turned out that they had already reached a similar conclusion. Until recently, Christopher Adams told me, he couldn’t recall ever hearing of a heroin case. ‘‘Now it’s every day,’’ he said. ‘‘It’s a majority. Not just in Laconia. It’s all over.’’ He and his lieutenant sat down to consider what their department might do. It seemed that there were three conceivable approaches to a drug problem: prevention, enforcement and treatment. To accomplish all three would mean regarding drug users, and misusers, as not only criminals. They were also customers who were being targeted and sold to; they were also victims who needed medical treatment. To coordinate all those approaches would require a particular sort of officer.

In September 2014, Eric Adams became the first person in New England — to his knowledge, the only person in the country — whose job title is prevention, enforcement and treatment coordinator. ‘‘I never thought I’d be doing something like this,’’ he told me. ‘‘I learned fast.’’ The department printed him new business cards: ‘‘The Laconia Police Department recognizes that substance misuse is a disease,’’ they read. ‘‘We understand you can’t fight this alone.’’ On the reverse, Adams’s cell phone number and email address were listed. He distributed these to every officer on patrol and answered his phone any time it rang, seven days a week. Strangers called him at 3 a.m., and Adams spoke with them for hours.

The department assigned him an unmarked Crown Victoria, and in it he followed the blips and squawks of a police scanner, driving to the scene of any overdose it reported and introducing himself to the victim, as well as any friends or family he could locate. Residents like these often shrank from the police or stiffened defensively. But when Adams told them that they weren’t under arrest, that he had only come to help, they seemed to sag in relief.

People who work with addicts generally agree that this moment, immediately after an overdose, offers the greatest chance to sway an addict, when he or she feels most vulnerable. ‘‘You’re at a crossroads right then and there,’’ a local paramedic told me. If an addict agreed to Adams’s help, Adams drove him to a treatment facility, sat beside him in waiting rooms, ferried his parents or siblings to visit him there or at the jail or hospital. He added the names of everyone he encountered to a spreadsheet, and he kept in touch even with those who relapsed. Were they feeling safe? Attending support meetings? Did they have a job? A place to sleep?

In the nearly three years since, as overdose rates have climbed across New Hampshire, those in Laconia have fallen. In 2014, the year Adams began, the town had 10 opioid fatalities. In 2016, the number was five. Fifty-one of its residents volunteered for treatment last year, up from 46 a year before and 14 a year before that. The county as a whole, Belknap, had fewer opioid-related emergency-room visits than any other New Hampshire county but one. Of the 204 addicts Adams has crossed paths with, 123 of them, or 60 percent, have agreed to keep in touch with him. Adams calls them at least weekly. Ninety-two have entered clinical treatment. Eighty-four, or just over 40 percent of all those he has met, are in recovery, having kept sober for two months or longer. Zero have died.

On most mornings, Adams arrives at his office well before 9 to answer email. By then, his phone is already chiming. ‘‘I thought when I got this position: Monday through Friday, day shifts, weekends off. I’m going to see my kids and wife more,’’ Adams said, laughing. ‘‘That’s not the case.’’ Pinned to the walls of his office, a windowless room on the second floor of the department, are pamphlets and resource guides for homelessness, peer-support groups and addiction hotlines, as well as a dry-erase board listing drug-treatment centers statewide. In December, when I visited one morning, the floor was cluttered with toys for local families in preparation for Christmas: doll sets, wireless headphones, a pillow the color of sorbet.

As soon as he began the job, Adams researched what social-service organizations the region had to offer and drove to their offices to introduce himself. A few employees at places like these knew one another from previous referrals, but many didn’t, so Adams went about acquainting them. At health conferences, he arrived to the quizzical frowns of social workers and realized that, of some 200 attendees, he was the only police officer. A network gradually sprouted around him. One morning in December, his first call was from Daisy Pierce, the director of a non-profit organization whose doors opened two weeks earlier; Adams is its chairman. Might Adams help her get a teenager into the Farnum Center, a treatment facility in Manchester, an hour south? Adams dialled a pastor he knew, who phoned a recovery coach. ‘‘For the first year and a half, I was the only transportation around here,’’ he told me when he hung up. ‘‘I would drive people down to Farnum all the time.’’

Next, Adams turned to a matter unresolved from the day before: a woman the county prosecutor had phoned about, asking if Adams could find her housing. Until recently, the woman had been staying at a homeless shelter, but that stay had ended and, because she was on probation, with nowhere else to sleep, Adams’s fellow officers had taken her to jail, though they could hold her for only one night. She would be released that day, still with nowhere else to stay. The next 48 hours would be critical, Adams felt. Here was a person who wanted to get sober but for whom the local authorities had little to offer.

From his desk, he dialled a treatment center, then various landlords and non-profit directors he knew. ‘‘Hi, this is Eric Adams over at the Laconia Police Department. I’m calling to see if you have anything. . . . ’’ Then he tried calling back the county prosecutor, tapping his fingers impatiently as the phone rang. When no one answered, he pulled a cellphone from his pocket and looked through it for numbers to dial on his office phone, while scribbling notes on two different legal pads. A cup from Dunkin’ Donuts sat on his desk, but he hadn’t had time to sip from it. After a half-dozen calls, he hung up the phone and sighed. ‘‘This is the biggest problem in the area,’’ he said. ‘‘It’s housing. There are only a handful of landlords that own so many properties.’’ Adams tried to be up front with landlords, and he didn’t blame them for sometimes rebuffing him, because they had to look out for their other tenants. But it meant limited options for a woman like the one he was trying to help.

He swivelled toward his computer and began scrolling through notes. Finding nothing, he rubbed his eyes with frustration, propped his elbows onto his desk and rested his chin on his hands to think. ‘‘Oh! Let me try — I haven’t talked with her in a while.’’ He dialled another number. ‘‘Hi, this is Eric Adams over at the Laconia Police Department. . . . ’’ A moment later, he hung up. ‘‘All right, this is the last one I can think of.’’ He dialled again. ‘‘I was wondering if you had any rentals available for a female. Oh, really? That’d be great.’’ He recited his email address. ‘‘Thank you!’’

Good news?  Adams shook his head. ‘‘Not for a couple weeks.’’ He stood, pushing back his chair, and cursed. Out of the office he strode to make a lap around the building to clear his head, then returned and looked at the clock — 9:40 a.m. He had a meeting at 10 at the local branch of the Bank of New Hampshire to help Pierce, the nonprofit director, apply for a new line of credit for their organization. Halfway to the door, he backtracked to pluck the Dunkin’ Donuts cup from his desk and sipped. ‘‘My coffee’s cold.’’

On a glass table in the bank lobby lay that morning’s copy of The Laconia Daily Sun. ‘‘Drug Sweep in Laconia Results in 17 Arrests,’’ its front page read. Headlines like that had become increasingly common, especially as the drugs themselves changed — first to opiates, then to opioids. They weren’t the same thing, Adams had learned. Opiates are derived from nature, and there are only so many, drugs like morphine, heroin and codeine. By contrast, opioids — though the word is now often used as an umbrella term for all these substances — technically means synthetic drugs like Vicodin, Percocet, fentanyl and OxyContin, all of which were invented in a laboratory.

This is why detectives sometimes encountered new opioids that were 20, 50, 100 times as potent as heroin. In a lab, you can do nearly anything. A dealer, even if he or she knows the difference, rarely bothers labelling, so a dose of so-called heroin might include fractions of nearly anything — meaning, of course, that the potency might be nearly anything. Overdoses happen not just when a person knowingly ingests a large dose but also when he or she ingests a dose of unknown composition.

After the meeting at the bank, Adams’s phone rang, and he vanished briefly. The call was from a woman whose son was arrested on charges of dealing meth. She wanted an intervention and hoped Adams might help. Steering toward the Belknap County jail, past homes spangled with Christmas lights, Adams admitted that he felt wary. He had already met this young man, who wanted nothing to do with him. Still, Adams would try. He never knew when an addict might begin saying ‘‘yes’’ to him. Sometimes this happened quickly: Adams’s phone would ring, and it was someone he met the previous day. ‘‘I’m exhausted,’’ the person would confess. Others waited a year or longer. All that time, they had hung onto his card. ‘‘I think I’m ready now,’’ they said.

Occasionally an addict used similar words even in rebuffing him — ‘‘I don’t think I’m ready yet’’ — a phrase that implicitly acknowledged a problem even as he or she denied one. It was the kind of sign Adams kept on the lookout for. Possibly this moment had come for the young man in jail.

When we arrived, Adams hustled through the drably carpeted lobby, hardly slowing before a receptionist and a guard waved him inside. A half-hour later, he returned, his face tight with frustration, and strode past me to the car without speaking. ‘‘He doesn’t have a problem,’’ he told me. ‘‘That’s what he said. He doesn’t have a problem.’’

Inside, he told me, guards had brought the young man from his cell into a windowed conference room, where he recognized Adams, as Adams predicted. ‘‘You know why I’m here,’’ Adams began gently.  ‘‘You’re trying to be nosy,’’ the man replied.

‘‘If you want to think of it that way, that’s fine.’’ Adams glanced at the young man’s file and explained that the man’s mother had called. ‘‘So I wanted to talk to you a little bit. This is an opportunity for you to get some help.’’ The young man went silent. ‘‘I mean, you got arrested,’’ Adams added, gesturing toward the file.  The man told him that he didn’t do the stuff, just sold it. He didn’t need help.

‘‘O.K.,’’ Adams told him, crossing his arms and leaning forward. Was the young man on any weight-loss program, then? ‘‘Because when I saw you before, to now, you’ve lost a lot of weight.’’ He nodded toward the young man, who was twitching uncomfortably in his chair. ‘‘And you’re all over the place, just sitting there.’’

When the man told Adams he was innocent, Adams reminded him that he was always available and slid him another one of his cards. Adams wished him well, then he asked guards to briefly fetch the woman they were holding overnight — the one for whom Adams was searching for housing — to check in and promise that he was trying.

Even as Adams nosed the Crown Vic out of the parking lot, he couldn’t get the episode out of his head. ‘‘Why won’t you just say, ‘I need this’?’’ he asked aloud, thinking of the young man. ‘‘Your life is going this way. You’ve been arrested. You’re homeless. It’s all drug-related.’’ He sighed. ‘‘The thing I had the hardest time learning was you’re not going to save everyone. That was very hard for me to accept.’’

A common sentiment among the police was that officers interacted with just 5 percent or so of the residents they served. In certain communities, that fraction was smaller. Laconia wasn’t a large town. ‘‘You think, mathematically,’’ Adams began, before pausing, ‘‘why can’t I? Why can’t I fix this?’’

For several miles he steered quietly, past muddied snowbanks. ‘‘It bothers me, but I’ve done what I can do right now. I can’t force him to want help.’’ He turned into the lot of the department and slowed into a parking spot.

‘‘Is there such a thing as an addict you have no sympathy for?’’ I wondered.  Adams considered this, letting the engine idle, and dropped his hands into his lap. Eleven seconds passed in silence. ‘‘I don’t think so,’’ he said finally. ‘‘There are reasons they are the way they are.’’

A kit with Narcan, a nasal spray that blocks the effect of opioids on the central nervous system. CreditNatalie Keyssar for The New York Times

Adams could list, from memory, addicts who had opened their lives to him, had volunteered for treatment, had wept in relief and gratitude. Already I had met two young adults who were newly in recovery and partly credited Adams for the lives they had regained. But those weren’t the names that tormented him.

Inside his office, he noticed two new voice-mail messages. The first was from a woman who read of Adams in the newspaper. ‘‘If you could tell me what to do? I’m more than willing to do whatever I need.’’ Adams scribbled something on a legal pad, then played the second voice mail. The same voice filled the room again, but now it broke into tears. Could Adams please tell her what to do?

Adams jotted another note, then checked his watch. Just past noon. Because he knew the work schedule of the mother of the young man he visited in jail, he knew she would be off soon and expecting his call. ‘‘She’s not going to be happy,’’ he said, mostly to himself. Rubbing his forehead, he sat down and dialed.

In so many towns all across the country, it is difficult to talk about an issue like heroin, not only because there is a stigma or because people worry about sounding impolite, but because everyone calibrates differently, based on neighbors and co-workers they see all day, how much of a problem it is or whether it is a problem at all. There were towns near Laconia — diplomatically, Adams declined to name them — that denied they had any drug crisis, even as the numbers they had showed otherwise. When presented with those numbers, some officials found alternative explanations.

Those were residents from other towns who just happened to cross the border, they argued. This reasoning just contributed to the problem, Adams said. Between 2004 and 2013, the number of New Hampshire residents receiving state-funded treatment for heroin addiction climbed by 90 percent. The number receiving treatment for prescription-opiate abuse climbed by 500 percent. But in terms of availability of beds, New Hampshire ranks second to last in New England in access to drug-treatment programs, ahead of only Vermont. The number who still need treatment is probably much higher. In October 2014, New Hampshire became the second-to-last state in the country to begin a prescription-drug-monitoring program, leaving only Missouri without one.

Engler, who was cautious and businesslike, with slicked hair and a graying goatee, had been mayor for three years, though he had lived in Laconia for almost 17 and owned The Laconia Daily Sun. Over his dress shirt he wore a fleece vest embroidered with the paper’s logo. Engler referred to what was happening in Laconia as ‘‘this so-called heroin epidemic,’’ his tone melodramatic, raising his hands defensively above his head.

‘‘We’re the county seat,’’ Engler told me. ‘‘We’re also the home of the regional hospital. Towns in New Hampshire are extremely close together. I think we tend to get credit for more things than are directly attributable to our residents.’’ Though he thought highly of Eric Adams, he also felt sceptical that heroin deserved to be considered an epidemic, regardless of the statistics. ‘‘When I go to a Rotary Club meeting, I don’t hear people sitting around talking about, ‘Woe is us, everybody’s dying of heroin.’ ’’

Might that be because, in a setting like the Rotary Club, heroin was not a topic of polite conversation?

‘‘There could be something to that,’’ Engler admitted. Still, an overdose death was an overdose death — it would appear in the news that way, and Engler would have heard of it. ‘‘I don’t believe there has been a huge, communitywide reaction to this. There’s not 100 people showing up at City Council meetings saying: ‘You have to do something about this. This is terrible.’ The papers aren’t full of letters to the editor. Not at all. And I think there’s a reason for that. The reason for that is’’ — Engler paused and crossed his arms — ‘‘since we have been in the so-called heroin epidemic in New Hampshire, I don’t believe there has been an instance in the Lakes Region, in Belknap County, where we have had a tragic story involving the son or daughter of someone from a prominent family. All it takes is one, usually. Somebody in Londonderry, some girl who was valedictorian of her class, her dad was a doctor or a lawyer or something like that, overdoses and dies, and suddenly it’s a crisis to everyone in town.’’

That very week, I told Engler, while tagging along with Adams for a meeting at the high school, I’d heard teachers mention a current student, a well-liked senior athlete, a team captain, whose sister had struggled with addiction and who had been open about the experience. Another member of the same graduating class, a girl whose grades ranked her in the top 10, had been walking with a friend in 2012 when a local mother, high while driving to pick up her own child from the middle school, swerved and struck them on the sidewalk. The girl survived. Her friend was killed.

The mayor was unmoved. ‘‘That was oxycodone,’’ Engler said dismissively. ‘‘Here, locally, the heroin epidemic, whatever you want to call it, has not crossed over in any obvious way from the underclass to the middle, middle–upper class.’’

Chadwick Boucher, a former addict and an early client of Eric Adams’s, with his work truck in his father’s yard. CreditNatalie Keyssar for The New York Times

Later that week, another prospective client phoned Adams. ‘‘I’m at wits’ end,’’ the man said. For the woman who needed housing, Adams helped track down a relative, at whose home she could stay until an apartment opened. On Friday evening, two more residents overdosed. Adams intended to visit them. Whether either one would accept Adams’s card, would call him, would enter treatment, would achieve recovery, would some day relapse, Adams couldn’t predict. There were no guarantees in this sort of work.

Early in his tenure, Adams made a presentation to ‘‘some prominent people in the community’’ — he didn’t want to name anyone — and afterward, as much of the room applauded, a man approached to shake Adams’s hand. As he reached out, the man said: ‘‘It’s a really good job you’re doing. I think it’s great. But my opinion is, if they stick a needle in their arm, they should die.’’

‘‘I’m sorry you feel that way,’’ Adams said, startled. ‘‘I’d hope you would feel differently if it was your own family member.’’  But the man shook his head. ‘‘That will never happen.’’

This sort of thing happened all the time when Adams began. Today it happened far less frequently. So many others had grown into Adams’s approach: fellow officers, downtown business owners, the captain at the Belknap County jail. Police officers from around New England and even farther away had phoned or travelled to Laconia to learn what Adams was doing, and whether the model could be replicated. Other towns, independently, had been pressed by the crisis to conceive approaches of their own. Manchester had turned its firehouses into safe stations. Gloucester, across the border in Massachusetts, had a network of community volunteers.

A city as large as Philadelphia or Boston could sensibly implement a PET approach too, Adams’s supervisors argued; a community like that would simply need more than one officer, with each assigned to a geographical area. But the shift this required would be profound, asking departments that for so long had thought mainly of enforcement to think differently. In Adams’s daily work, it was unavoidable that certain values competed. A client might divulge a crime to him, and he would be forced to interrupt her to give a Miranda warning. ‘‘If there is a crime, that individual needs to be held accountable,’’ he said. ‘‘But this is where our prosecutor, our judges, come into play.’’ Some attorneys had expressed discomfort with him and had insisted on being present when he met their clients. ‘‘I’m totally fine with that,’’ he said, ‘‘because it’s an opportunity for me to educate the attorney, to let them know what I do, how I do it, what the processes are.’’ In a role so complicated, with so much at stake, clearly it was vital that the right officer held the job.

In an empty conference room on the first floor of the department, I met a young man named Chadwick Boucher, an early client of Adams’s. The two men hugged when they saw each other, and then Adams disappeared upstairs to make calls while Boucher and I spoke. He was 27, though he had the calm demeanour of someone two or three times as old. As early as middle school, Boucher began sneaking his parents’ liquor, partly to fit in with older boys he admired, he told me. Soon he added marijuana. He played hockey then, and played well — invitations came from showcases in Boston and scouts from Division I colleges, including the University of New Hampshire, a national power. Instead, Boucher quit. It was too much pressure. He finished high school and moved in with a friend, who introduced him to OxyContin.

What followed was difficult to align into a neat chronology. He bounced from one friend’s apartment to another, from Oxy to Percocet and finally, when pills grew scarce, to heroin. There was a criminal distribution charge, probation, two treatment programs that he abandoned, feeling as though he didn’t belong. There were short-term jobs tending bar or waiting tables, collecting pay-checks before inevitably being fired. Suddenly he was high behind the wheel of his father’s Cutlass — not in the road, but in a driveway — startling awake to the police rapping on his window. Then he was at the Laconia police station, in a room with a plainclothes officer named Eric Adams.

‘‘He opened his arms to me,’’ Boucher recalled. It had felt bizarre, sharing the truth with a cop. But things had changed so quickly. Most of his family had stopped returning his calls, and all his friends had vanished. The only people around him now were strangers who shared his addiction, and he didn’t like or trust them. The difference in meeting someone like Adams was obvious. ‘‘He cares about my well-being,’’ Boucher said. ‘‘I needed that.’’

Adams wanted him to call every day, so Boucher called every day. Then every week. He entered another treatment program, and this time he graduated. He was now nearing a year sober. He owned a business and was caught up on his bills. He lived up the road in an apartment and had friends again, some of whom were in recovery, too. They made a point to talk openly about it, to keep an eye out for one another. Some he referred to Adams. He knew that recovery demanded his full attention, that it probably always would. If he lost anything else in his life — an apartment, a business — he lost that one thing only and could do without it. If he lost his recovery, he would lose everything, all at once.

I asked Boucher how he preferred to be named in this article — by only ‘‘Chad’’? Or would he prefer anonymity? But he shook his head. It was important to him to be honest about who he was. He hoped this would send a message to other addicts and to those who encountered them. ‘‘It’s important that people know there’s a way out.’’ Recovery from addiction was an achievable thing and, having discovered this fact, having discovered Eric Adams, Boucher intended to share it. The news might save lives. He knew it was possible that a business client might discover his unflattering past, that he might lose an account or two. ‘‘I’ve come way too far for that,’’ he said.





LOWELL, Mass. — They hide in weeds along hiking trails and in playground grass. They wash into rivers and float downstream to land on beaches. They pepper baseball dugouts, sidewalks and streets. Syringes left by drug users amid the heroin crisis are turning up everywhere.

In Portland, Maine, officials have collected more than 700 needles so far this year, putting them on track to handily exceed the nearly 900 gathered in all of 2016. In March alone, San Francisco collected more than 13,000 syringes, compared with only about 2,900 the same month in 2016. People, often children, risk getting stuck by discarded needles, raising the prospect they could contract blood-borne diseases such as hepatitis or HIV or be exposed to remnants of heroin or other drugs.

Activist Rocky Morrison, of the “Clean River Project,” holds up a fish bowl filled with hypodermic needles, that were recovered during 2016, on the Merrimack River. Charles Krupa / AP

It’s unclear whether anyone has gotten sick, but the reports of children finding the needles can be sickening in their own right. One 6-year-old girl in California mistook a discarded syringe for a thermometer and put it in her mouth; she was unharmed.

“I just want more awareness that this is happening,” said Nancy Holmes, whose 11-year-old daughter stepped on a needle in Santa Cruz, California, while swimming. “You would hear stories about finding needles at the beach or being poked at the beach. But you think that it wouldn’t happen to you. Sure enough.”

They are a growing problem in New Hampshire and Massachusetts — two states that have seen many overdose deaths in recent years.  “We would certainly characterize this as a health hazard,” said Tim Soucy, health director in Manchester, New Hampshire’s largest city, which collected 570 needles in 2016, the first year it began tracking the problem. It has found 247 needles so far this year.

Needles turn up in places like parks, baseball diamonds, trails and beaches — isolated spots where drug users can gather and attract little attention, and often the same spots used by the public for recreation. The needles are tossed out of carelessness or the fear of being prosecuted for possessing them.

One child was poked by a needle left on the grounds of a Utah elementary school. Another youngster stepped on one while playing on a beach in New Hampshire.

Even if adults or children don’t get sick, they still must endure an unsettling battery of tests to make sure they didn’t catch anything. The girl who put a syringe in her mouth was not poked but had to be tested for hepatitis B and C, her mother said.

Some community advocates are trying to sweep up the pollution. Rocky Morrison leads a clean-up effort along the Merrimack River, which winds through the old milling city of Lowell, and has recovered hundreds of needles in abandoned homeless camps that dot the banks, as well as in piles of debris that collect in floating booms he recently started setting.

He has a collection of several hundred needles in a fishbowl, a prop he uses to illustrate that the problem is real and that towns must do more to combat it.

“We started seeing it last year here and there. But now, it’s just raining needles everywhere we go,” said Morrison, a burly, tattooed construction worker whose Clean River Project has six boats working parts of the 117-mile river.

Among the oldest tracking programs is in Santa Cruz, California, where the community group Take Back Santa Cruz has reported finding more than 14,500 needles in the county over the past 4 1/2 years. It says it has gotten reports of 12 people getting stuck, half of them children.

“It’s become pretty commonplace to find them. We call it a rite of passage for a child to find their first needle,” said Gabrielle Korte, a member of the group’s needle team. “It’s very depressing. It’s infuriating. It’s just gross.”

Some experts say the problem will ease only when more users get treatment and more funding is directed to treatment programs.  Others are counting on needle exchange programs, now present in more than 30 states, or the creation of safe spaces to shoot up — already introduced in Canada and proposed by U.S. state and city officials from New York to Seattle.  Studies have found that needle exchange programs can reduce pollution, said Don Des Jarlais, a researcher at the Icahn School of Medicine at Mount Sinai hospital in New York.

But Morrison and Korte complain poor supervision at needle exchanges will simply put more syringes in the hands of people who may not dispose of them properly.

After complaints of discarded needles, Santa Cruz County took over its exchange from a non-profit in 2013 and implemented changes. It did away with mobile exchanges and stopped allowing drug users to get needles without turning in an equal number of used ones, said Jason Hoppin, a spokesman for the Santa Cruz County.

Along the Merrimack, nearly three dozen riverfront towns are debating how to stem the flow of needles. Two regional planning commissions are drafting a request for proposals for a clean-up plan. They hope to have it ready by the end of July.

“We are all trying to get a grip on the problem,” said Haverhill Mayor James Fiorentini. “The stuff comes from somewhere. If we can work together to stop it at the source, I am all for it.”

Source:  July 2017


Blue Cross Blue Shield issued a report on the opioid crisis with their data from all members in their commercial plans.  Early in the document, they report a pair of striking numbers.

First, that 21% of members filled a prescription for an opioid in 2015. I’ve heard these kinds of numbers before, but I never get numb. That’s 1 in 5 members, despite growing attention to excessive prescribing of opioids.

Second, a 493% increase in diagnosis of opioid use disorders over 7 years. My reaction is that this has to reflect changes in coding or diagnostic practices rather than the population. It’s implausible that there was an increase this large in the number of people with an opioid use disorder.

The document then devotes a great deal of attention to opioid prescribing.

Toward the end, there are a couple of graphics that caught my attention.

First, a map showing rates of opioid use disorders.


Then, this:

Though critical to treating opioid use disorder, the use of medication-assisted treatments (e.g., methadone) does not always track with rates of opioid use disorder (compare Exhibits 10 and 11). For example, New England leads the nation in use of medication-assisted treatments but it has lower levels of opioid use disorder than other parts of the country


So . . . they note that New England has average rates of opioid use disorders, yet they have high rates of utilization of medication-assisted treatment. This caught my attention because New England has higher rates of overdose, as depicted in the CDC graphics below.

Number and age-adjusted rates of drug overdose deaths by state, US 2015


Statistically significant drug overdose death rate increase from 2014 to 2015, US states

(It’s worth noting that BCBS is not among the top 3 insurers in Maine or New Hampshire, but they are the biggest in Massachusetts and Vermont.)

It begs questions about what the story is, doesn’t it?

I don’t presume to know the answers.

§ What was the sequence of events for the high OD rates and the utilization of MAT? And, what impact, if any, has the expansion of MAT had on overdose rates?

§ Is the BCBS data representative? (This brand new SAMHSA report suggest that the data about use is representative.)

§ We know that opioid maintenance meds reduce risk of OD, but we also know that people stop taking these meds at high rates. Does this imply that, in the real world, these meds end up providing less OD protection than hoped?

§ What are the policies and practices of the other insurers in the state?  (For example, we know that Anthem [the largest insurer in Maine and Vermont] recently ended prior authorization requirements for MAT. It’s not clear how restrictive they had been. They also are attempting to institute reformsto address the fact that, “only about 16 to 19 percent of the members taking the medications for opioid use disorder also were getting the recommended in-person counseling.”)

§ Are there regional differences in drug potency that explain this?

Let’s hope that more insurers follow suit and share their data.


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

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


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

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

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

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

The diagnosis

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

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

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

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

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

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

Treatment options

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

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

Targeting withdrawal and craving

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

• Irritability, anger, or aggression

• Nervousness or anxiety

• Sleep difficulty

• Decreased appetite or weight loss

• Restlessness

• Depressed mood

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

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

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

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

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

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

Abstinence initiation and relapse prevention

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

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

Treatment of psychiatric comorbidity

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

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


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

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

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

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


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

Source:  (  30th June 201


Drug addiction is a chronic and relapsing disease that often begins during adolescence.

Epidemiological evidence documents an association between marijuana use during adolescence and subsequent abuse of drugs such as heroin and cocaine (1, 2). While many factors including societal pressures, family, culture, and drug availability can contribute to this apparent `gateway’ association, little is known about the neurobiological basis underlying such potential vulnerability.

Of the neural substrates that have been investigated, the enkephalinergic opioid system is  consistently altered by developmental marijuana exposure (3–5), perhaps reflecting neuroanatomical interactions between cannabinoid receptor type 1 and the enkephalinergic system (6, 7).

Debates exist, however, regarding the relationship between proenkephalin (Penk) dysregulation and opiate susceptibility. We previously reported that adult rats exposed to Δ9-tetrahydrocannabinol (THC; primary psychoactive component of marijuana) during adolescence exhibit increased heroin self administration (SA) as well as increased expression of Penk, the gene encoding the opioid neuropeptide enkephalin, in the nucleus accumbens shell (NAcsh), a mesolimbic structure critically involved in reward-related behaviors (3).

Although these data suggest that increased NAcsh Penk expression and heroin SA behavior are independent consequences of adolescent THC exposure, they do not address a possible causal relationship between THCinduced  Penk upregulation in NAcsh and enhanced behavioral susceptibility to opiates.

Moreover, insights regarding the neurobiological mechanisms by which adolescent THC exposure maintains upregulation of Penk into adulthood remain unknown.

Here, we take advantage of viral-mediated gene transfer strategies to show that adulthood addiction-like behaviors induced by adolescent THC exposure are dependent on discrete regulation of NAcsh Penk gene expression. A number of recent studies have demonstrated an important role for histone methylation in the regulation of drug-induced behaviors and transcriptional plasticity, particularly alteration of repressive histone H3 lysine 9 (H3K9) methylation at NAc gene promotors (8, 9).

We report here that one mechanism by which adolescent THC exposure may mediate Penk upregulation in adult NAcsh is through reduction of H3K9 di- and trimethylation, a functional consequence of which may be decreased transcriptional repression of Penk.



Marijuana use by teenagers often predates the use of harder drugs, but the neurobiological underpinnings of such vulnerability are unknown. Animal studies suggest enhanced heroin self-administration (SA) and dysregulation of the endogenous opioid system in the nucleus accumbens shell (NAcsh) of adults following adolescent Δ9-tetrahydrocannabinol (THC) exposure. However, a causal link between Penk expression and vulnerability to heroin has yet to be established.


To investigate the functional significance of NAcsh  Penk tone, selective viral mediated knockdown and overexpression of Penk was performed, followed by analysis of subsequent heroin SA behavior. To determine whether adolescent THC exposure was associated with chromatin alteration, we analyzed levels of histone H3 methylation in the NAcsh via ChIP atfive sites flanking the Penk gene transcription start site.


Here, we show that regulation of the proenkephalin (Penk) opioid neuropeptide gene in NAcsh directly regulates heroin SA behavior. Selective viral-mediated knockdown of Penk in striatopallidal neurons attenuates heroin SA in adolescent THC-exposed rats, whereas Penk overexpression potentiates heroin SA in THC-naïve rats. Furthermore, we report that adolescent THC exposure mediates Penk upregulation through reduction of histone H3 lysine 9 (H3K9) methylation in the NAcsh, thereby disrupting the normal developmental pattern of H3K9 methylation.


These data establish a direct association between THC-induced NAcsh Penk upregulation and heroin SA and indicate that epigenetic dysregulation of Penk underlies the long term effects of THC.

Source:  Biol Psychiatry. 2012 November 15; 72(10): 803–810. doi:10.1016/j.biopsych.2012.04.026.

Findings From A UK Birth Cohort



Evidence on the role of cannabis as a gateway drug is inconsistent. We characterise patterns of cannabis use among UK teenagers aged 13–18 years, and assess their influence on problematic substance use at age 21 years.


We used longitudinal latent class analysis to derive trajectories of cannabis use from self-report measures in a UK birth cohort. We investigated (1) factors associated with latent class membership and (2) whether latent class membership predicted subsequent nicotine dependence, harmful alcohol use and recent use of other illicit drugs at age 21 years.


5315 adolescents had three or more measures of cannabis use from age 13 to 18 years. Cannabis use patterns were captured as four latent classes corresponding to ‘non-users’ (80.1%), ‘late-onset occasional’ (14.2%), ‘early-onset occasional’ (2.3%) and ‘regular’ users (3.4%).

Sex, mother’s substance use, and child’s tobacco use, alcohol consumption and conduct problems were strongly associated with cannabis use.

At age 21 years, compared with the non-user class, late-onset occasional, early-onset occasional and regular cannabis user classes had higher odds of nicotine dependence (OR=3.5, 95% CI 0.7 to 17.9; OR=12.1, 95% CI 1.0 to 150.3; and OR=37.2, 95% CI 9.5 to 144.8, respectively); harmful alcohol consumption (OR=2.6, 95% CI 1.5 to 4.3; OR=5.0, 95% CI 2.1 to 12.1; and OR=2.6, 95% CI 1.0 to 7.1, respectively); and other illicit drug use (OR=22.7, 95% CI 11.3 to 45.7; OR=15.9, 95% CI 3.9 to 64.4; and OR=47.9, 95% CI 47.9 to 337.0, respectively).


One-fifth of the adolescents in our sample followed a pattern of occasional or regular cannabis use, and these young people were more likely to progress to harmful substance use behaviours in early adulthood.


One in 5 adolescents at risk of tobacco dependency, harmful alcohol consumption and illicit drug use

Researchers from the University of Bristol have found regular and occasional cannabis use as a teen is associated with a greater risk of other illicit drug taking in early adulthood.   The study by Bristol’s Population Health Science Institute, published online in the Journal of Epidemiology & Community Health, also found cannabis use was associated with harmful drinking and smoking.

Using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), the researchers looked at levels of cannabis use during adolescence to determine whether these might predict other problematic substance misuse in early adulthood — by the age of 21.

The researchers looked at data about cannabis use among 5,315 teens between the ages of 13 and 18. At five time points approximately one year apart cannabis use was categorised as none; occasional (typically less than once a week); or frequent (typically once a week or more).

When the teens reached the age of 21, they were asked to say whether and how much they smoked and drank, and whether they had taken other illicit drugs during the previous three months. Some 462 reported recent illicit drug use: 176 (38%) had used cocaine; 278 (60%) had used ‘speed’ (amphetamines); 136 (30%) had used inhalants; 72 (16%) had used sedatives; 105 (23%) had used hallucinogens; and 25 (6%) had used opioids.

The study’s lead author, Dr Michelle Taylor from the School of Social and Community Medicine said:

“We tend to see clusters of different forms of substance misuse in adolescents and young people, and it has been argued that cannabis acts as a gateway to other drug use. However, historically the evidence has been inconsistent.

“I think the most important findings from this study are that one in five adolescents follow a pattern of occasional or regular cannabis use and that those individuals are more likely to be tobacco dependant, have harmful levels of alcohol consumption or use other illicit drugs in early adulthood.”

In all, complete data were available for 1571 people. Male sex, mother’s substance misuse and the child’s smoking, drinking, and behavioural problems before the age of 13 were all strongly associated with cannabis use during adolescence. Other potentially influential factors were also considered: housing tenure; mum’s education and number of children she had; her drinking and drug use; behavioural problems when the child was 11 and whether s/he had started smoking and/or drinking before the age of 13.

After taking account of other influential factors, those who used cannabis in their teens were at greater risk of problematic substance misuse by the age of 21 than those who didn’t.

Teens who regularly used cannabis were 37 times more likely to be nicotine dependent and three times more likely to have a harmful drinking pattern than non-users by the time they were 21. And they were 26 times more likely to use other illicit drugs.

Both those who used cannabis occasionally early in adolescence and those who starting using it much later during the teenage years had a heightened risk of nicotine dependence, harmful drinking, and other illicit drug use. And the more cannabis they used the greater was the likelihood of nicotine dependence by the age of 21.

This study used observational methods and therefore presents evidence for correlation but not does not determine clear cause and effect — whether the results observed are because cannabis use actually causes the use of other illicit drugs. Furthermore, it does not identify what the underlying mechanisms for this might be. Nevertheless, clear categories of use emerged.

Dr Taylor concludes:

“We have added further evidence that suggests adolescent cannabis use does predict later problematic substance use in early adulthood. From our study, we cannot say why this might be, and it is important that future research focuses on this question, as this will enable us to identify groups of individuals that might as risk and develop policy to advise people of the harms.

“Our study does not support or refute arguments for altering the legal status of cannabis use — especially since two of the outcomes are legal in the UK. This study and others do, however, lend support to public health strategies and interventions that aim to reduce cannabis exposure in young people.”

Journal Reference:

1. Michelle Taylor, Simon M Collin, Marcus R Munafò, John MacLeod, Matthew Hickman, Jon Heron. Patterns of cannabis use during adolescence and their association with harmful substance use behaviour: findings from a UK birth cohort. Journal of Epidemiology and Community Health, 2017; jech-2016-208503 DOI: 10.1136/jech-2016-208503

Source:<.htm>. 7 June 2017.

HUNTINGTON, W.Va. — Officer Sean Brinegar arrived at the house first — “People are coming here and dying,” the 911 caller had said — and found a man and a woman panicking. Two people were dead inside, they told him.

Brinegar, 25, has been on the force in this Appalachian city for less than three years, but as heroin use has surged, he has seen more than his fair share of overdoses. So last Monday, he grabbed a double pack of naloxone from his gear bag and headed inside.

A man was on the dining room floor, his thin body bluish-purple and skin abscesses betraying a history of drug use. He was dead, Brinegar thought, so the officer turned his attention to the woman on a bed. He could see her chest rising but didn’t get a response when he dug his knuckle into her sternum.

Brinegar gave the woman a dose of injected naloxone, the antidote that can jumpstart the breathing of someone who has overdosed on opioids, and returned to the man. The man sat up in response to Brinegar’s knuckle in his sternum — he was alive after all — but started to pass out again. Brinegar gave him the second dose of naloxone.

Maybe on an average day, when this Ohio River city of about 50,000 people sees two or three overdoses, that would have been it. But on this day, the calls kept coming.

Two more heroin overdoses at that house, three people found in surrounding yards. Three overdoses at the nearby public housing complex, another two up the hill from the complex.

From about 3:30 p.m. to 7 p.m., 26 people overdosed in Huntington, half of them in and around the Marcum Terrace apartment complex. The barrage occupied all the ambulances in the city and more than a shift’s worth of police officers.

By the end of it, though, all 26 people were alive. Authorities attributed that success to the cooperation among local agencies and the sad reality that they are well-practiced at responding to overdoses. Many officials did not seem surprised by the concentrated spike.

“It was kind of like any other day, just more of it,” said Dr. Clay Young, an emergency medicine doctor at Cabell Huntington Hospital.

But tragic news was coming. Around 8 p.m., paramedics responded to a report of cardiac arrest. The man later died at the hospital, and only then were officials told he had overdosed. On Wednesday, authorities found a person dead of an overdose elsewhere in Cabell County and think the death could have happened Monday. They are investigating whether those overdoses are tied to the others, potentially making them Nos. 27 and 28.

It’s possible that the rash of overdoses was caused by a particularly powerful batch of heroin or that a dearth of the drug in the days beforehand weakened people’s tolerance. But police suspect the heroin here was mixed with fentanyl, a synthetic opioid that is many times more potent than heroin. A wave of fatal overdoses signaled fentanyl’s arrival in Huntington in early 2015, and now some stashes aren’t heroin laced with fentanyl, but “fentanyl laced with heroin,” said Police Chief Joe Ciccarelli. Another possibility is carfentanil, another synthetic opioid, this one used to sedate elephants. Police didn’t recover drugs from any of the overdoses, but toxicology tests from the deaths could provide answers.

A battle-scarred city

In some ways, what happened in Huntington was as unremarkable as the spurts in overdoses that have occurred in other cities. This year, fentanyl or carfentanil killed a dozen people in Sacramento, nine people in Florida, and 23 people in about a month in Akron, Ohio. The list of cities goes on: New Haven, Conn.; Columbus, Ohio; Barre, Vt.

But what happened in Huntington stands out in other ways. It underlines the potential of a mysterious substance to unleash wide-scale trauma and overwhelm a city’s emergency response. And it suggests that a community that is doing all the right things to combat a worsening scourge can still get knocked back by it.

“From a policy perspective, we’re throwing everything we know at the problem,” said Dr. James Becker, the vice dean for governmental affairs and health care policy at the medical school at Marshall University here. “And yet the problem is one of those that takes a long time to change, and probably isn’t going to change for quite a while.”

Surrounded by rolling hills packed with lush trees, Huntington is one of the many fronts in the fight against an opioid epidemic that is killing almost 30,000 Americans a year. But this city, state, and region are among the most battle-scarred. West Virginia has the highest rate of fatal drug overdoses of any state and the highest rate of babies born dependent on opioids among the 28 states that report data. But even compared with other communities in West Virginia, Huntington sees above-average rates of heroin use, overdose deaths, and drug-dependent newborns. Local officials estimate up to 10 percent of residents use opioids improperly.

The heroin problem emerged about five years ago when authorities around the country cracked down on “pill mills” that sent pain medications into communities; officials here specifically point to a 2011 Florida law that arrested the flow of pills into the Huntington area.

As the pills became harder to obtain and harder to abuse, people turned to heroin. It has devoured many communities in Appalachia and beyond.

In Huntington, law enforcement initially took the lead, with police arresting hundreds of people. They seized thousands of grams of heroin. But it wasn’t making a dent. So in November 2014, local leaders established an office of drug control policy.

“As far as numbers of arrests and seizures, we were ahead of the game, but our problem was getting worse,” said Jim Johnson, director of the office and a former Huntington police officer. “It became very obvious that if we did not work on the demand side just as hard as the supply side, we were never going to see any success.”

The office brought together law enforcement, health officials, community and faith leaders, and experts from Marshall to try to tackle the problem together.

Changes in state law have opened naloxone dissemination to the public and protected people who report overdoses. But the city and its partners have gone further, rolling out programs through the municipal court system to encourage people to seek treatment. One program is designed to help women who work as prostitutes to feed their addiction. Huntington has eight of the state’s 28 medically assisted detox beds, and they’re always full.

Also, in 2014, a center called Lily’s Place opened in Huntington to wean babies from drugs. Last year, the local health department launched this conservative state’s first syringe exchange. The county, health officials know, is at risk for outbreaks of HIV and hepatitis C because of shared needles, so they are trying to get ahead of crises seen in other communities afflicted by addiction.

“Huntington just happens to have taken ownership of the problem, and very courageously started some programs … that have been models for the rest of the state,” said Kenneth Burner, the West Virginia coordinator for the Appalachia High Intensity Drug Trafficking Areas program.

‘A revolving door’

While paramedics in the area have carried naloxone for years, it was this spring that Huntington police officers were equipped with it. Just a few officers have administered it, but Monday was Brinegar’s third time reviving overdose victims with naloxone.

Paramedics, who first try reviving victims by pumping air with a bag through a mask, had to administer another 10 doses of naloxone Monday. Three doses went to one person, said Gordon Merry, the director of Cabell County Emergency Services. During the response, ambulances from stations outside Huntington were called into the city to assist the eight or so response teams already deployed.

Merry was clearly proud of the response, but also frustrated. He was tired, he said, of people whom emergency crews revived going back to drugs. Because of the power of their disease, saving their lives didn’t get at the root of their addiction.

“It’s a revolving door. We’re not solving the problem past reviving them,” he said. “We gave 26 people another chance on life, and hopefully one of those 26 will seek help.”

In the part of town where half the overdoses happened, some homes are well-kept, with gardens, bird feeders, and American flags billowing. “Home Sweet Home,” read an engraved piece of wood above one front door; in another front yard, a wooden sculpture presented a bear holding a fish with “WELCOME” written across its body.

But many structures are decrepit and have their windows blacked out with cardboard and sheets. At one boarded-up house, the metal slats that once made up an overhang for the front porch split apart and warped as they collapsed, like gnarled teeth. On the plywood that covered a window frame was a message spelled out in green dots: GIRL SCOUTS RULE.

In and around the public housing complex, which is made up of squat two-story brick buildings sloping up a hill, people either said they did not know what had happened Monday, or that “lowlifes” in another part of the complex sparked the problem. Even as paramedics were responding to the overdoses, police started raiding residences as part of their investigation, including apartments at the complex, the chief said.

Just up the hill, a man named Bill was sitting on a recliner on his front porch with his cat. He said he saw the police out in the area Monday, but doesn’t pay much attention to overdoses anymore. They are so frequent.

Bill, who is retired, asked to be identified only by his first name because he said he has a son in law enforcement. He has lived in that house for five decades and started locking his door only in recent years. His neighbors’ house had been broken into, and he had seen people using drugs in cars across the street from his house. He called the police sometimes, he said, but the users were always gone by the time the police arrived.

“I hate to say this, but you know, I’d let them die,” Bill said. “If they knew that no one was going to revive them, maybe they wouldn’t overdose.”

Even here, where addiction had touched so many lives, it’s not an uncommon sentiment. Addiction is still viewed by some as a bad personal choice made by bad people.

“Some folks in the community just didn’t care” that 26 of their fellow residents almost died, said Matt Boggs, the executive director of Recovery Point.  Recovery Point is a long-term recovery program that teaches “clients” to live a life without drugs or alcohol. Boggs himself is a graduate of the program, funded by the state and donations and grants.

The clients live in bunk rooms at the facility for an average of more than seven months before graduating. The program says that about two-thirds of graduates stay sober in the first year after graduation, and about 85 percent of those people are sober after two years.

Local officials praise Recovery Point, but like many other recovery programs, it is limited in what it can do. It has 100 beds for men at its location in Huntington, and is expanding at other sites in the state, but Boggs said there’s a waiting list of a couple hundred people.

Mike Thomas, 30, graduated from the main part of the program a month ago and is working as a peer mentor there as he transitions out of the facility. Thomas has been clean since Oct. 15, 2015, but has dreams about getting high or catches himself thinking he could spare $100 from his bank account for drugs.

Thomas hopes to find a full-time job helping addicts. His own recovery will be a lifelong process, one that can be torn apart by a single bad decision, he said. He will always be in recovery, never recovered.    “I’m not cured,” he said.


A killer that doesn’t discriminate

As heroin has bled into communities across the country, it has spread beyond the regular drug hotbeds in cities. On a 2004 map of drug use in Huntington — back then, mostly crack cocaine — a few blocks of the city glow red. Almost the entire city glows in yellows and reds on the 2014 map.

In 2015, there were more than 700 drug overdose calls in Huntington, ranging from kids in their early teens to seniors in their late 70s. In 2014, it was 272 calls; in 2012, 146. One bright spot: fatal overdoses, which stood at 58 in 2015, have ticked down so far this year.

“I used to be able to say, ‘We need to focus here,’” said Scott Lemley, a criminal intelligence analyst at the police department. “I can’t do that anymore.”

Heroin hasn’t just dismantled geographic barriers. It has infiltrated every demographic “It doesn’t discriminate.   Prominent businessmen, their child. Police officers, their child. Doctors, their child,” Merry said. “The businessman and police officer do not have their child anymore.”

The businessman is Teddy Johnson. His son, Adam, died in 2007 when he was 22, one of a dozen people who died in a five-month period because of an influx of black-tar heroin. The drug hadn’t made its full resurgence into the region yet, but now, Johnson sees the drug that killed his son everywhere.


Teddy Johnson lost his son, Adam, in 2007 to a heroin overdose. He has several tattoos dedicated to Adam’s memory.  He runs a plumbing, heating, and kitchen fixture and remodelling business. From his storefront, he has witnessed deals across the street.

Adam, who was a student at Marshall, was a musician and artist who hosted radio shows. He was the life of any party, his dad said.

Johnson was describing Adam as he sat at the marble countertop of a model kitchen in his business last week. With the photos of his kids on the counter, it felt like a family’s home. Johnson explained how he still kept Adam’s bed made, how he kept his son’s room the same, and then he began to cry.

“The biggest star in the sky we say is Adam’s star,” he said. “When we’re in the car — and it can’t be this way — but it always seems to be in front of us, guiding us.”

Adam’s grave is at the top of a hill near the memorial to the 75 people — Marshall football players, staff, and fans — who died in a 1970 plane crash. It’s a beautiful spot that Johnson visits a few times each week, bringing flowers and cutting the grass around his son’s grave himself. Recently a note was left there from a couple Johnson knows who

just lost their son to an overdose; they were asking Adam to look out for their son in heaven.

But even here, at what should be a respite, Johnson can’t escape what took his son. He said he has seen deals happen in the cemetery, and he recently found a burnt spoon not more than 20 feet from his son’s grave.

Johnson keeps fresh flowers on his son’s grave and cuts the grass around the grave himself.

“I’ve just seen too much of it,” he said.

If Huntington doesn’t have a handle on heroin, at least the initiatives are helping officials understand the scale of the problem. More than 1,700 people have come through the syringe exchange since it opened, where they receive a medical assessment and learn about recovery options. The exchange is open one day a week, and in less than a year, it has distributed 150,000 clean syringes and received 125,000 used syringes.

But to grow and sustain its programs, Huntington needs money, officials say. The community has received federal grants, and state officials know they have a problem. But economic losses and the collapse of the coal industry that fueled the drug epidemic have also depleted state coffers.

“We have programs ready to launch, and we have no resources to launch them with,” said Dr. Michael Kilkenny, the physician director of the Cabell-Huntington Health Department. “We’re launching them without resources, because our people are dying, and we can’t tolerate that.”

In some ways, Huntington is fortunate. It has a university with medical and pharmacy schools enlisted to help, and a mayor’s office and police department collaborating with public health officials. But what does that herald then for other communities?

“If I feel anxious about what happens in Huntington and in Cabell County, I cannot imagine what it must be like to live in one of these other at-risk counties in the United States, where they don’t have all those resources, they don’t have people thinking about it,” said Dr. Kevin Yingling, the dean of the Marshall University School of Pharmacy.

Yingling, Kilkenny, and others were gathered on Friday afternoon to talk about the situation in Huntington, including the rash of overdoses. But by then, there was already a different incident to discuss.

A car had crashed into a tree earlier that afternoon in Huntington. A man in the driver seat and a woman in the passenger seat had both overdosed and needed naloxone to be revived. A preschool-age girl was in the back seat.

Source: 22.08.16

Addiction Advocacy Needs A Bill Gates, David Geffen, Warren Buffett, Or Tom Steyer

Addiction doesn’t need someone to put their name on a building, or name a research institute. Addiction desperately needs bold philanthropists who want to leverage the people power of the grassroots. Addiction and drug overdoses claim one life every four minutes in America. In the time it takes to order a latte, someone dies—from an illness that is highly treatable. The addiction crisis is the result of social prejudice; criminal justice policies that incarcerate people with addiction instead of giving them treatment; health care policies that make it difficult or impossible to get medical help for substance use disorders; ignorance; and “abstinence-only” drug policies that are ineffective and backwards.

The fact is, people who struggle with substance use disorder are treated like second-class citizens. Admitting there’s a problem can mean losing your job, home, and custody of your children. That makes addiction a civil rights issue. And, thanks to the work of advocates across the nation, it’s finally being recognized as a moral issue, as well. Thought leaders like Tom Steyer are helping to drive this message home. I first met Tom during the Democratic National Convention. I had just shared my experience with addiction and recovery when Tom approached me. I was taken aback by the story he shared. He, too, lost someone very dear to him due to addiction: his best friend, who struggled with addiction for decades. His friend contracted HIV and Hepatitis C through drug use, and died of medical complications due to his illnesses. A few months later, Tom joined me at the Facing Addiction in America summit in Los Angeles, where we invited him to share his story on stage with the U.S. Surgeon General. As Tom talked, tears filled my eyes. He said, “We must embrace our shared humanity and recognize that addiction is a deadly, chronic illness, not a personal failing.” I’d lost friends, too. I was at risk, too. It was time to bridge the gap between policies and public awareness.

People like Tom Steyer and other pioneering philanthropists, who give tens of millions to progressive causes such as medical research, environmental causes, and water quality, must also step up to end the addiction crisis in America. Our fight is America’s fight. The sooner they do, the quicker we can heal this nation from our generation’s most urgent public health crisis.

Working alongside lobbyists, nonprofit groups, social organizers, and peer recovery groups, they can help fill the gaps left by policies and laws that omit or punish people with substance use disorder. As the current administration takes steps toward a health care bill that will leave people suffering from addiction without medical care, these philanthropic giants are in a unique position to help. Why? Because their involvement would not be tied to political party or personal gain. Rather, they would focus on the solution, plain and simple.

Addiction should be one of the issues on the list of social problems we urgently address, next to finding a cure for cancer and ending childhood hunger. Addiction permeates the social fabric of America. Nobody is exempt. As many people suffer from addiction as diabetes; more people use pain medications than tobacco products. For every person who’s developed full blown substance use disorder, another dozen are on the road to addiction. Substance use disorder affects every corner of society, including our collective health, family unity, the economy, workplace productivity, and our reliance on social programs. It also keeps jails full of people who may struggle to find jobs to support their families once they’re released, and will never be able to vote again.

The recovery advocacy movement has been built slowly, through the efforts of individuals and highly fragmented groups. We have an incredible grassroots movement that addresses an issue that directly impacts one in every three families in America, and indirectly touches all of us. But fundraising for recovery advocacy has been largely through family and friend donations—which, although heartfelt, aren’t sufficient to fund serious research, create desperately needed social infrastructure, or provide education about the true nature of addiction. While organizations dedicated to battling cancer, heart disease, and diabetes raise hundreds of millions of dollars annually, the “addiction field,” such as it is, raises perhaps $25 million from private sources. This is unconscionable.

Gates, Geffen, Buffett, Steyer, and other philanthropic giants have the potential to be visionaries in this space. They could quickly stem the addiction epidemic without waiting for policy makers to hammer out yet another law that places people’s recovery at risk. They could find the solution that keeps families intact. With their help, nobody will lose another friend to this disease or the health problems that come with it. Bob and Suzanne Wright demonstrated the power and possibility of this kind of giving when they funded Autism Speaks. Their philanthropy helped move autism front and center: why not do the same for addiction?

What will our society, our culture, be like when we finally take addiction out of the equation? For many people, and their families, the answer is coming much too slowly.

It’s time to apply our knowledge, build a coalition, and offer the solutions our country so desperately needs. It’s time to change the framework of this crisis and confront our deepest values. Instead of punishment, we need to help the people who are sick—dying from this illness. It’s time to work together and end America’s addiction crisis for good.

What we need now is for America’s philanthropic visionaries to step up to help us dramatically accelerate the pace of progress in this urgent effort. Addiction doesn’t need someone to put their name on a building, or name a research institute. Addiction desperately needs bold philanthropists who want to leverage the people power of the grassroots. Ryan Hampton is an outreach lead and recovery advocate at Facing Addiction, a leading nonprofit dedicated to ending the addiction crisis in the United States.

Source:   30th May 20127

 A New Agenda to  Turn Back the Drug Epidemic

Robert L. DuPont, MD, President , Institute for Behavior and Health, Inc.

A. Thomas McLellan, PhD, Senior Strategy Advisor , Institute for Behavior and Health, Inc.  May 2017

Institute for Behavior and Health, Inc. , 6191 Executive Blvd , Rockville, MD 20852 , 1


The Institute for Behavior and Health, Inc. (IBH) is a 501(c)3 non-profit substance use policy and research organization that was founded in 1978. Non-partisan and non-political, IBH develops new ideas and serves as a force for change.

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health was published in November 2016. Four months later, in March 2017, IBH held a meeting of 25 leaders in addiction treatment, health care, insurance, government and research to discuss the scope and implications of this historic document. The US Surgeon General, VADM Vivek H. Murthy, MD, was an active participant in the meeting. The significance of this new Surgeon General’s Report is analogous to the historic 1964 Surgeon General’s report, Smoking and Health, a document that inspired an extraordinarily successful public health response in the United States that has reduced the rates of cigarette smoking by over 64% and continues its impact even today, more than 50 years following its release.

The following is a summary of the discussion at the March 2017 meeting and the conclusions and recommendations that were developed.

Introduction: The 2016 Surgeon General’s Report 

The two primary objectives of the US Surgeon General’s Report of 2016 are first to provide scientific evidence that shows that in addition to nicotine, other substance misuse and addiction issues (e.g., alcohol, opioids, marijuana, etc.) also are best understood and addressed as public health problems; and second to encourage the inclusion of addiction – its prevention, early recognition and intervention, treatment and active long-term recovery management – into the mainstream of American health care. At present these elements are not integrated either as a stand-alone continuum or within the general medical system. As is true for other widespread illnesses, addiction to nicotine, alcohol, marijuana, opioids, cocaine and other substances is a serious chronic illness. This perspective is contrary to the common perception that addiction reflects a moral failing, a personal weakness or poor parenting. Such opinions have stigmatized individuals who are suffering from these often deadly substance use disorders and have led to expensive and ineffective public policies that segregate prevention and treatment outside of mainstream medical care. A better public health approach encourages afflicted individuals and their family members to seek and receive help within the current health care system for these serious health problems.

An informed public health approach to reducing the prevalence and the harms associated with substance use disorders requires more than the brief treatment of serious cases. Particularly important are substance use prevention programs in schools, healthcare and in all other parts of the community to protect adolescents (ages 12 – 21), the group most at risk for the initiation of substance-related harms and substance use disorders.  Importantly, abundant tragic experience and accumulating science show that substance use disorders are not effectively treated with only short-term care. Because substance use disorders produce 2 significant long-lasting changes in the brain circuits responsible for memory, motivation, inhibition, reward sensitivity and stress tolerance, addicted individuals remain vulnerable to relapse years following specialized treatment.1, 2, 3 Thus, as is true for all other chronic illnesses, long periods of personalized treatment and monitoring are necessary to assure compliance with care, continued sobriety, and improved health and social function. In combination, science-based prevention, early intervention, continuing care and monitoring comprise a modern continuum of public health care. The overall goals of this continuum comport well with those of other chronic illnesses:

1 US Department of Health and Human Services (HHS), Office of the Surgeon General. (2016). Chapter 2. The Neurobiology of Substance Use, Misuse, and Addiction. In: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS. Available:

2 US Department of Health and Human Services (HHS), Office of the Surgeon General. (2016). Chapter 5. Recovery: The Many Paths to Wellness. In: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS. Available:

3 Betty Ford Institute Consensus Panel. (2007). What is recovery? A working definition from the Betty Ford Institute. Journal of Substance Abuse Treatment, 33(3), 221-228.

4 White, W. L. (2012). Recovery/remission from substance use disorders: An analysis of reported outcomes in 415 scientific reports, 1868-2011. Philadelphia, PA: Philadelphia Department of Behavioral Health and Intellectual Disability Services.

· sustained reduction of the cardinal symptom of the illness, i.e., substance use;

· improved general health and function; and,

· education and training of the patient and the family to self-manage the illness and avoid relapses.

In the addiction field achieving these goals is called “recovery.” This word is used to describe abstention from the use of alcohol, marijuana and other non-prescribed drugs as well as improved personal health and social responsibility.3,4 Over 25 million formerly addicted Americans are in stable, long-term recovery of a year or longer.4 Understanding how to consistently accomplish the life-saving goal of recovery must inform health care decisions.

The 2016 Surgeon General’s Report offers a science-informed vision and path to recovery in response to the nation’s serious addiction problem, including specifically the opioid overdose epidemic. Research shows that it is possible to prevent or delay most cases of substance misuse; and to effectively treat even the most serious substance use disorders with recovery as an expectable result of comprehensive, continuous care and sustained monitoring. To do this, substance use disorders must be recognized as serious, chronic health conditions that are both preventable and treatable. The nation must integrate the short-term siloed episodes of specialty treatment that now are isolated from mainstream healthcare into a fully integrated continuum of care comparable to that currently available to those with other chronic illnesses such as diabetes, hypertension, asthma and chronic pain.

Meeting Discussion and Conclusions 

The Surgeon General’s Report and the meeting convened by the Institute for Behavior and Health, Inc. (IBH) to promote its recommendations are significant responses to the expanding epidemic of opioid 3 and other substance use disorders, an epidemic that struck nearly 21 million Americans aged 12 and older in 2015 alone.5 That year saw more than 52,000 overdose deaths.6 This drug epidemic has devastated countless families and communities throughout the US. Unlike earlier and smaller drug epidemics, the current opioid epidemic is not limited to a few regions or communities or a narrow range of ethnicities or incomes in the United States. Instead it afflicts all communities and all socioeconomic groups; its impacts include smaller communities and rural areas as well as suburban areas and inner cities. Fuelled by the suffering of countless grieving families, the nation is in the early stages of confronting the new epidemic. A growing national determination to turn back this deadly epidemic has opened the door to innovation that is sustained by strong bipartisan political support for new and improved efforts in both prevention and treatment of substance use disorders.

5 Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Available:

6 Rudd, R. A., Seth, P., David, F., & Scholl, L. (2016, December 30). Increases in drug and opioid-involved overdose deaths – United States. Morbidity and Mortality Weekly Report, 65(50-51), 1445-1452. Available:

7 Levy, S. J., Williams, J. F., & AAP Committee on Substance Use and Prevention. (2016). Substance use screening, brief intervention, and referral to treatment. Pediatrics, 138(1), e20161211. Available:

8 US Department of Health and Human Services (HHS), Office of the Surgeon General. (2016). Chapter 3. Prevention Programs and Policies. In: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS. Available:

Abstinence is an Achievable Goal, both for Prevention and for Treatment 

Embracing and synthesizing the 30 years of science supporting the findings of the 2016 Surgeon General’s Report, the group discussed a single goal for the prevention of addiction: no use of alcohol, nicotine, marijuana or other non-prescribed drugs by youth for reasons of health. This goal should be the core prevention message to all children from a very young age. Health care professionals, educators and parents should understand the importance of this simple, clear health message. They should continue to reinforce this message of no-use for health as children grow to adulthood. Even when prevention fails, it is possible for parents, other family members, friends, primary care clinicians, educators and others to identify and to intervene quickly to stop youth substance use from becoming addiction.7

The science behind this ambitious but attainable prevention goal is clear. Alcohol, nicotine products, marijuana and other non-prescribed drug use is uniquely harmful to the still-developing brains of adolescents. Thus any substance “use” among youth must be considered “misuse” – use that may harm self or others. The goal of no substance use is not just for the purpose of preventing addiction, though that is one clear and important by product of successful prevention. Addiction is a biological process that can take years to develop. In contrast, even a single episode of high-dose use of alcohol or other substance could immediately produce an injury, accident or even death. While it is true that most episodes of substance misuse among adults do not produce serious problems, it is also true that substance misuse is associated with 70% or more of the injuries, disabilities and deaths of young people.8 These figures are even higher for minority youth. Many adolescent deaths are preventable 4 because most are related to substance use – including substance-related motor vehicle crashes and overdose.9

9 Subramaniam, G. A., & Volkow, N. D. (2014). Substance misuse among adolescents. To screen or not to screen? JAMA Pediatrics, 168(9), 798-799. Available:

10 Data analyzed by the Center for Behavioral Health Statistics and Quality. CBHS. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15- 4927, NSDUH Series H-50).

11 2014 data obtained by IBH from the Monitoring the Future study. For discussion of data through 2013 see DuPont, R. L. (2015, July 1). It’s time to re-think prevention; increasing percentages of adolescents understand they should not use any addicting substances. Rockville, MD: Institute for Behavior and Health, Inc. Available:

Youth who use any one of the three most common “gateway” substances, i.e., alcohol, nicotine and marijuana, are many times more likely than those who do not use that single drug to use the other two substances as well as other illegal drugs.10 The use of any drug opens the door to an endless series of highly risky decisions about which drugs to use, how much to use, and when to use them. This perspective validates the public health goal for youth of no use of any drug.

Complete abstinence from the use of alcohol or any other drug among adolescents is not simply an idealistic goal – it is a goal that can be achieved. Data were presented at the meeting from the nationally representative Monitoring the Future study showing that 26% of American high school seniors in 2014 reported no use of alcohol, cigarettes, marijuana or other non-prescribed drugs in their lifetimes. 11 This is a remarkable increase from only 3% reported by American high school seniors in 1983. Moreover, in the same survey, 50% of high school seniors had not used any alcohol, cigarettes, marijuana or other non-prescribed substance in the past 30 days, up from 16% in 1982. These largely overlooked and important findings show that youth abstinence from any substance use is already widespread and steadily increasing.

In parallel with the goal of abstinence for prevention, the recommended goal for the treatment of those who are addicted is sustained abstinence from the use of alcohol and other drugs, with the caveat, explicitly acknowledged by the group, that individuals who are taking medications as-prescribed in the treatment of substance use disorders (e.g., buprenorphine, methadone and naltrexone) and who do not use alcohol or other non-prescribed addictive substances – are considered to be abstinent and ”in recovery.” Abstinence from all non-prescribed substance use is the scientifically-informed goal for individuals in addiction treatment. This treatment goal is widely accepted in the large national recovery community. The long-lasting effects of addiction to drugs are easily seen among cigarette smokers: smoking only a single cigarette is a serious threat to the former smoker, even decades after smoking the last cigarette. There is incontrovertible evidence from brain and genetic research showing the long-term effects of substance misuse on critical brain regions.2 It is unknown when or if these brain changes will return to being entirely normal following cessation of substance use; however, it is known that the recovering brain is particularly vulnerable to the effects of return to any substance use, often leading to overdose or rapid re-addiction. 5

Participants in the IBH meeting supported the idea that abstinence is the high-value outcome in addiction treatment; and that while any duration of abstinence is valuable, longer-term, stable abstinence of 5 years is analogous to the widely-used standard in cancer treatment of 5-year survival. The scientific basis for the value of sustained recovery is validated by the experience of the estimated 25 million Americans now in recovery. This increasingly visible recovery community is a remarkable and very positive new force in the country.

Measuring and Attaining these Goals 

The mantra from the IBH meeting was, if you don’t measure it, it won’t happen. The group of leaders recognized the paucity of current models for systematic integration of addiction treatment and general healthcare. The group encouraged the identification of promising models and the promotion of innovation to achieve the goal of sustained recovery. Even programs that include fully integrated care of other diseases, managed care and other comprehensive health programs do not reliably achieve the goal of sustained or even temporary recovery for substance use disorders. The meeting participants noted the absence of long-term outcome studies of the treatment of substance use disorders and encouraged all treatment programs not only to extend the care of discharged patients but also to systematically study the trajectories of discharged patients to improve their long-term treatment outcomes. The increasing range of recovery support services after treatment is an important and promising new trend that is now actively promoting sustained recovery.

Meeting participants noted one particularly promising model of public health goal measurement and attainment – the 90-90-90 goals for the treatment of HIV/AIDS: 90% of people with HIV will be screened to know their infection status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all patients receiving antiretroviral therapy will have viral suppression (i.e., zero viral load).12 These measurable goals provide an operational definition of public health success for the country, states and individual healthcare organizations.

12 UNAIDS. (2014). 90-90-90: An Ambitious Treatment Target to Help End the AIDS epidemic. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS. Available:

With this model as background, the IBH group concluded that a similar public health approach and similarly specific numeric goals should be established for preventing and treating substance use disorders. Examples of parallel national prevention goals could include 90% rates of screening for substance misuse among adolescents; 90% provision of interventions and follow-up for those screening positive; and 90% total abstinence rates among youth aged 12-21. While these are admittedly ambitious prevention goals, adoption of them could incentivize families, schools and communities to increase the percentage of youth who do not use any alcohol, nicotine, marijuana or other drugs every year.

A similar approach was adopted by the IBH group to improve the impact of addiction treatment. Again, there would be significant public health value if the US adopted the following goals: 90% of individuals aged 12 or older receive annual screening for substance misuse and substance use disorders; 90% of those who receive a diagnosis of a substance use disorder are referred and meaningfully engaged (at 6 least three sessions) in some form of addiction treatment; and 90% of those engaged in treatment achieve sustained abstinence as measured by drug testing, during and for six months following treatment.

Source:  IBH-Report-A-New-Agenda-to-Turn-Back-the-Drug-Epidemic  May 2017

In Southern Ohio, the number of drug-exposed babies in child protection custody has jumped over 200%.  The problem is so dire that workers agreed to break protocol to invite a reporter to hear their stories.  Foster care placements are at record levels, and the number of drug-exposed newborns in their custody has jumped over 200% in the past decade

Inside the Clinton County child protection office, the week has been tougher than most.

Caseworkers in this thinly populated region of southern Ohio, east of Cincinnati, have grown battle-weary from an opioid epidemic that’s leaving behind a generation of traumatized children. Drugs now account for nearly 80% of their cases. Foster-care placements are at record levels, and the number of drug-exposed newborns in their custody has jumped over 200% in the past decade. Funding, meanwhile, hasn’t budged in years.

“Many of our children have experienced such high levels of trauma that they can’t go into traditional foster homes,” said Kathi Spirk, director of Clinton County job and family services. “They need more specialized care, which is very expensive.”

The problem is so dire that workers agreed to break protocol and invite a reporter to camp out in a conference room and hear their stories. For three days, they relived their worst cases and unloaded their frustrations, in scenes that played out like marathon group therapy, for which they have no time. Many agreed that talking about it only made them feel worse, yet still they continued, one after another.

Hence the bad week.

Given the small size of their community, they asked that their names be changed out of concern for their own safety and the privacy of the children.

The caseworkers, like most, are seasoned in despair. Many worked in the 1990s when crack cocaine first arrived, followed by crystal meth in the early 2000s. In 2008, after the shipping giant DHL shuttered its domestic hub here in Wilmington and shed more than 7,000 jobs, prescription pill mills flourished while the economy staggered. Back then, a typical month saw 30 open cases, only a few of them drug-related. But the flood of cheap heroin and fentanyl, now at its highest point yet, has changed everything. A typical month now brings four times as many cases, while institutional knowledge has been flipped on its head.

“At least with meth and cocaine, there was a fight,” said Laura, a supervisor with over 20 years of experience. “Parents used to challenge you to not take their kids. And now you have them say: ‘Here’s their stuff. Here’s their formula and clothes.’ They’re just done. They’re not going to fight you any more.”

Heroin has changed how they approach every step of their jobs, they said, from the first intake calls to that painstaking decision to place a child into temporary foster care or permanent custody. Intake workers now fear what used to be routine.

“Occasionally, we’d get thrown a dirty house, something easy to close and with little trauma to the child,” said Leslie, another worker. “We’re not getting those any more.

Now they’re all serious, and most of them have a drug component. So you may get a dirty house, but it’s never just a dirty house.”

‘I had a four-year old whose mom had died in front of her and she described it like it was nothing’ Children come into the system in two ways. The first is through a court order after caseworkers deem their environment unsafe, and if no friends or family can be found.

Because of the added trauma, removing a child is always the last option, caseworkers said. But in a county with only 42,000 people spread out over 400 square miles, the magnitude of the epidemic has compromised an already delicate safety net. Relatives are overwhelmed financially. Multiple generations are now addicted, along with cousins, uncles, and neighbors. In many cases, a safe house with a grandparent or other relative will eventually attract drug activity.

Law enforcement will also bring children in, usually after parents overdose. These cases often reveal the most horrendous neglect: a three-year old who needed every tooth pulled because he’d never been made to brush them, or kids found sleeping on bug-infested mattresses, going to the toilet in buckets because the water had been shut off. Children are coming in more hardened, they said, older than their years.

“I had a four-year-old whose mom had died in front of her and she described it like it was nothing,” said Bridgette, another caseworker. “She knew how to roll up a dollar bill and snort white powder off the counter. That’s what she thought dollar bills were for.” She added that many of the children could detail how to cook heroin. One foster family had a five-year-old boy who put his medicine dropper in his shoe. “Because that’s where daddy hid his needles,” she said.

“The kids are used to surviving in that mess,” added Carole, another veteran. “Now all the sudden the system is going in and saying it’s not safe. All their survival instincts are taken away and they go ballistic. They don’t know what to do.”

During the first weeks of foster care, meltdowns, tantrums, and violence are common as children navigate new landscapes and begin to process what they’ve experienced.

One afternoon, the caseworkers brought in a foster couple who’d taken in two sisters, an infant born drug-exposed, and her four-year old sister. The baby had to be weaned off opioids and now suffered chronic respiratory problems. Part of her withdrawal had included non-stop hiccups. The older girl had lived with her parents in a drug house and displayed clear signs of post-traumatic stress. Once, a family friend sitting next to her in a car had overdosed and turned purple. She’d witnessed domestic abuse, and one day a neighbor shot and killed her dog while she watched (she’d let the dog out). After a meltdown at a classmate’s pool party, over a year after entering foster care, she revealed having seen a toddler drown in a pond while adults got high. Through therapy, she’d also revealed sexual assault. The foster mother described how the girl suffered flashbacks, triggered by stress and certain anniversaries, like the day of her removal, and other seemingly random events. When this happened, she slipped into catatonic seizures.

“Her eyes are closed and you can’t wake her,” she said. “It’s like narcolepsy, a deep, unconscious sleep. We later discovered it was a coping mechanism she’d developed in order to survive.”

Despite what they’ve endured, most children wish desperately to return to their parents. Many come to see themselves as their parents’ caretakers and feel guilty for being taken away, especially if they were the ones to report an overdose, as in the case of a four-year-old girl who climbed out of a window to alert a neighbor. “She asked me: if I took her away, who was going to take care of mommy?” Bridgette remembered.

For caseworkers, reunification is the endgame. After children enter temporary foster care, the agency spends up to two years working closely with the family while the parents try to stay sober. The only contact with their children comes in the form of twice-weekly visits held in designated rooms here at the office. Each contains a tattered sofa and some second-hand toys. Currently, the agency runs about 200 visits each week. The encounters are monitored through closed-circuit cameras. For everyone involved, it can be the most trying period.

Many parents use the time to build trust and re-establish bonds. “During those first four years, a child gets such good stuff from their parents,” said Sherry, the caseworker who monitors the visits. “The kids are just trying to get that back.” Some parents bring doughnuts and pictures, while others need more guidance. Caseworkers hold parenting classes. Some moms lost newborns at the hospital after they tested positive for drugs; workers teach them how to feed and hold the child, and encourage them to bring outfits to dress their babies.

For other children, the visits trigger a storm of emotion that churns up the trauma of removal. “We had one girl who’d scream and wail at the end of every visit,” Laura, the supervisor, remembered. “Each time she thought she’d never see her mother again. We’d have to pry her out of mom’s arms and carry her down the hallway.”

“We’d sit in our offices and just sob,” added another worker. “But that girl’s cries weren’t enough to keep Mom off heroin.”

The number of available foster families is dwindling, while the cost of supporting them has never been higher

Perhaps the greatest difference with heroin and opioids, caseworkers said, is their iron grasp. Staying sober is a herculean task, especially in this rural community short on resources, where the nearest treatment facilities are over 30 miles away in Dayton, Cincinnati, or Columbus. At some point, nearly every parent falls off the wagon. They disappear and miss visits, leaving children to wait. One of the hardest parts of the job is telling a child that mom or dad isn’t coming, or that they can’t even be found.

“You see the hurt in their eyes,” Sherry said. “It’s a look of defeat, and it just breaks your heart.” She remembered a mother who’d failed to show up for months, then made it for her twin boys’ birthday. “The next day she overdosed and died.”

A tally sheet is used to track how many times prospective clients waiting to enter the program call a detox center, in Huntington, West Virginia. Photograph: Brendan Smialowski/AFP/Getty Images

When parents fail drug screenings during the 18-month period, caseworkers use discretion. Parents might be doing better in other areas like landing a job, or finding secure housing, so workers help them to get back on the wagon. “It’s all about showing progress,” Laura said. Some parents make it 16, 17 months sober and fully engaged. “And they’re the toughest cases, because we’ve been rooting for them this whole time and helping them. We’re giving kids pep talks, saying: ‘Mom’s doing great, she’s getting it together!’ They’re so happy to be going home. And then it all falls apart.”

With heroin, defeat is something the workers have learned to reckon with. Lately they’ve started snapping photos of parents and children during their first visit together, getting medical histories and other vital information – something they used to do much later. “Because we know the parents probably aren’t going to make it,” Laura admitted. “And if we never see them again, this is the info we need.” When asked how many opioid cases had ended in reunification, only two workers raised their hands.

The repeated disappointments come as resources and morale have reached their tipping point. The number of available foster families is dwindling, they said, while the cost of supporting them – over $1.5m a year – has never been higher.

Spirk, the agency’s director, said that all the agency’s budget was paid for with federal dollars and a county tax levy, although they’ve been flat-funded for nearly 10 years. The state contributes just 10%. When it comes to investing in child protection, Ohio ranks last in the country – despite having spent nearly $1bn fighting its opioid problem in 2016 alone.

The Ohio house of representatives recently passed a new state budget with an additional $15m for child protective services, but the state senate has yet to pass its own version. The only bit of hope came in March, when the Ohio attorney general’s office announced a pilot program that will give Clinton County, along with others, additional resources to help treat children for trauma, and to assist with drug treatment. It starts in October.

The epidemic’s unrelenting barrage has also taken a toll on mental health. “Our caseworkers are experiencing secondary trauma and frustration at not being able to reunify children with their parents because of relapses,” Spirk said.

Almost every caseworker said they had experienced depression or some form of PTSD, although no one had sought professional help. The privacy of their cases also means that few can speak openly with friends or family members. Some chose to drink, while others leaned on their faiths. But most said coping mechanisms they once relied on had failed.

“I used to have a routine on my drive home,” Laura said. “I’d stop in front of a church, roll down my window, and throw out all the day’s problems. The next morning I’d pick them back up. These days, I can’t do that anymore.”

“There’s no more outlet,” added Shelly, another supervisor. “You think you’re able to separate but you can’t let it go anymore. You try to eat healthy, do yoga, whatever they tell you to do. But it’s just so horrific now, and it keeps getting worse.”

At some point, the inevitable happens. When a parent can’t stay sober, or stops showing progress, the decision is made to place the child into permanent custody and put them up for adoption. For everyone, including caseworkers, it’s the most wrenching day.

The final act of every case is the “goodbye visit”, held in one of the nicer conference rooms. It’s a chance for parents to let their children know they love them and will miss them, and that it’s time to move on. Adoptive parents can choose to stay in contact, but it isn’t mandatory.

To make the time less stressful, Sherry, the worker who monitors the visits, has them draw pictures together, which she scans and gives to them as mementoes. She also tapes the meetings for them to keep. Watching from her tiny room full of TV screens, she can’t help but cry. “What people don’t realize is that when a baby comes into our custody, they’re still in a carrier seat. By the time the case is over, we’ve helped to potty train them. Two years is a very long time with a child. So in a way, it’s like my goodbye visit, too.”

Caseworkers have started making “life books” for kids once they come into the system. It’s where they put the photos they’ve taken, plus any pictures of birth parents or relatives they can find, report cards, ribbons and medals – the souvenirs of any childhood.  “It’s their history,” Sherry said, “so that one day they can make sense of their lives.”   She noted that one kid, after turning 18, tore his to pieces, taking with him only the good memories.


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Source:  May 2017

“We should all be dead,” said Jonathan Goyer one bright morning in January as he looked across a room filled with dozens of his co-workers and clients. The Anchor Recovery Community Center, which Goyer helps run, occupies the shell of an office building in Pawtucket, Rhode Island. Founded seven years ago, Anchor specializes in “peer-to-peer” counselling for drug addicts. With state help and private grants, Anchor throws everything but the kitchen sink at addiction. It hosts Narcotics Anonymous meetings, cognitive behavioral therapy sessions, art workshops, and personal counselling. It runs a telephone hotline and a hospital outreach program. It has an employment center for connecting newly drug-free people to sympathetic hirers, and banks of computers for those who lack them. And all the people who work here have been in the very pit of addiction—shoplifting to pay for a morning dose, selling their bodies, or dragging out their adult lives in prison. Some have been taken to emergency rooms and “hit” with powerful anti-overdose drugs to bring them back from respiratory failure.

That is how it was with Goyer. His father died of an overdose at forty-one, in 2004. His twenty-nine-year-old brother OD’d and died in 2009. When he was shooting heroin he slept on the floor of a public garage. He would pick up used hypodermic needles if they were new enough that the volume gauges inked on the outside hadn’t been rubbed off with use. He OD’d several times before getting clean in 2013. Now he visits people after overdoses and tells them, “I was right where you’re at.”

There have always been drug addicts in need of help, but the scale of the present wave of heroin and opioid abuse is unprecedented. Fifty-two thousand Americans died of overdoses in 2015—about four times as many as died from gun homicides and half again as many as died in car accidents. Pawtucket is a small place, and yet 5,400 addicts are members at Anchor. Six hundred visit every day. Rhode Island is a small place, too. It has just over a million people. One Brown University epidemiologist estimates that 20,000 of them are opioid addicts—2 percent of the population.

Salisbury, Massachusetts (pop. 8,000), was founded in 1638, and the opium crisis is the worst thing that has ever happened to it. The town lost one young person in the decade-long Vietnam War. It has lost fifteen to heroin in the last two years. Last summer, Huntington, West Virginia (pop. 49,000), saw twenty-eight overdoses in four hours. Episodes like these played a role in the decline in U.S. life expectancy in 2015. The death toll far eclipses those of all previous drug crises.

And yet, after five decades of alarm over threats that were small by comparison, politicians and the media have offered only a muted response. A willingness at least to talk about opioid deaths (among other taboo subjects) surely helped Donald Trump win last November’s election. In his inaugural address, President Trump referred to the drug epidemic (among other problems) as “carnage.” Those who call the word an irresponsible exaggeration are wrong.

Jazz musicians knew what heroin was in the 1950s. Other Americans needed to have it explained to them. Even in the 1960s and 1970s, with bourgeois norms and drug enforcement weakening, heroin lost none of its terrifying underworld associations. People weren’t shooting it at Woodstock. Today, with much of the discourse on drug addiction controlled by medical bureaucrats, it is common to speak of addiction as an “equal-opportunity disease” that can “strike anyone.” While this may be true on the pharmacological level, it was until quite recently a sociological falsehood. In fact, most of the country had powerful moral, social, cultural, and legal immunities against heroin

and opiate addiction. For 99 percent of the population, it was an adventure that had to be sought out. That has now changed.

America had built up these immunities through hard experience. At the turn of the nineteenth century, scientists isolated morphine, the active ingredient in opium, and in the 1850s the hypodermic needle was invented. They seemed a godsend in Civil War field hospitals, but many soldiers came home addicted. Zealous doctors prescribed opiates to upper-middle-class women for everything from menstrual cramps to “hysteria.” The “acetylization” of morphine led to the development of heroin. Bayer began marketing it as a cough suppressant in 1898, which made matters worse. The tally of wrecked middle-class families and lives was already high by the time Congress passed the Harrison Narcotics Tax Act in 1914, threatening jail for doctors who prescribed opiates to addicts. Americans had had it with heroin. It took almost a century before drug companies could talk them back into using drugs like it.

If you take too much heroin, your breathing slows until you die. Unfortunately, the drug sets an addictive trap that is sinister and subtle. It provides a euphoria—a feeling of contentment, simplification, and release—which users swear has no equal. Users quickly develop a tolerance, requiring higher and higher amounts to get the same effect. The dosage required to attain the feeling the user originally experienced rises until it is higher than the dosage that will kill him. An addict can get more or less “straight,” but approaching the euphoria he longs for requires walking up to the gates of death. If a heroin addict sees on the news that a user or two has died from an overly strong batch of heroin in some housing project somewhere, his first thought is, “Where is that? That’s the stuff I want.”

Tolerance ebbs as fast as it rises. The most dangerous day for a junkie is not the day he gets arrested, although the withdrawal symptoms—should he not receive medical treatment—are painful and embarrassing, and no picnic for his cellmate, either. But withdrawals are not generally life-threatening, as they are for a hardened alcoholic. The dangerous day comes when the addict is released, for the dosage he had taken comfortably until his arrest two weeks ago may now be enough to kill him.

The best way for a society to avoid the dangers of addictive and dangerous drugs is to severely restrict access to them. That is why, in the twentieth century, powerful opiates and opioids (an opioid is a synthetic drug that mimics opium) were largely taboo—confined to patients with serious cancers, and often to end-of-life care. But two decades ago, a combination of libertarian attitudes about drugs and a massive corporate marketing effort combined to instruct millions of vulnerable people about the blessed relief opioids could bring, if only mulish oldsters in the medical profession could get over their hang-ups and be convinced to prescribe them. One of the rhetorical tactics is now familiar from debates about Islam and terrorism: Industry advocates accused doctors reluctant to prescribe addictive medicines of suffering from “opiophobia.”

In 1996, Purdue Pharmaceuticals brought to market OxyContin, an “extended release” version of the opioid oxycodone. (The “-contin” suffix comes from “continuous.”) The time-release formula meant companies could pack lots of oxycodone into one pill, with less risk of abuse, or so scientists claimed. Purdue did not reckon with the ingenuity of addicts, who by smashing or chewing or dissolving the pills could release the whole narcotic load at once. That is the charitable account of what happened. In 2007, three of Purdue’s executives pled guilty to felony misbranding at the time of the release of OxyContin, and the company paid $600 million in fines. In 2010, Purdue brought out a reformulated OxyContin that was harder to tamper with. Most of Purdue’s revenues still come from OxyContin. In 2015, the Sackler family, the company’s sole owners,

suddenly appeared at number sixteen on Forbes magazine’s list of America’s richest families.

Today’s opioid epidemic is, in part, an unintended consequence of the Reagan era. America in the 1980s and 1990s was guided by a coalition of profit-seeking corporations and concerned traditional communities, both of which had felt oppressed by a high-handed government. But whereas Reaganism gave real power to corporations, it gave only rhetorical power to communities. Eventually, when the interests of corporations and communities clashed, the former were in a position to wipe the latter out. The politics of the 1980s wound up enlisting the American middle class in the project of its own dispossession.

OxyContin was only the most commercially successful of many new opioids. At the time, the whole pharmaceutical industry was engaged in a lobbying and public relations effort to restore opioids to the average middle-class family’s pharmacopeia, where they had not been found since before World War I. The American Pain Foundation, which presented itself as an advocate for patients suffering chronic conditions, was revealed by the Washington Post in 2011 to have received 90 percent of its funding from medical companies.

“Pain centers” were endowed. “Chronic pain” became a condition, not just a symptom. The American Pain Society led an advertising campaign calling pain the “fifth vital sign” (after pulse, respiration, blood pressure, and temperature). Certain doctors, notoriously the anaesthesiologist Russell Portenoy of the Beth Israel Medical Center, called for more aggressive pain treatment. “We had to destigmatize these drugs,” he later told the Wall Street Journal. A whole generation of doctors was schooled in the new understanding of pain. Patients threatened malpractice suits against doctors who did not prescribe pain medications liberally, and gave them bad marks on the “patient satisfaction” surveys that, in some insurance programs, determine doctor compensation. Today, more than a third of Americans are prescribed painkillers every year.

Very few of them go on to a full-blown addiction. The calamity of the 1990s opioid revolution is not so much that it turned real pain patients into junkies—although that did happen. The calamity is that a broad regulatory and cultural shift released a massive quantity of addictive drugs into the public at large. Once widely available, the supply “found” people susceptible to addiction. A suburban teenager with a lot of curiosity might discover that Grandpa, who just had his knee replaced, kept a bottle of hydrocodone on the bedside table. A construction boss might hand out Vicodin at the beginning of the workday, whether as a remedy for back pain or a perquisite of the job. Pills are doseable—and they don’t require you to use needles and run the risk of getting AIDS. So a person who would never have become a heroin addict in the old days of the opioid taboo could now become the equivalent of one, in a more antiseptic way.

But a shocking number of people wound up with a classic heroin problem anyway. Relaxed taboos and ready supply created a much wider appetite for opioids. Once that happened, heroin turned out to be very competitively priced. Not only that, it is harder to crack down on heavily armed drug gangs that sell it than on the unscrupulous doctors who turned their practices into “pill mills.” Addicts in Maine complain about the rising price of black-market pharmaceutical pills: They have risen far above the dollar-a-milligram that used to constitute a kind of “par” in the drug market. An Oxy 30 will now run you forty-five bucks. But you can shoot heroin when the pills run out, and it will save you money. A lot of money. Heroin started pouring into the eastern United States a decade ago, even before the price of pills began to climb. Since then, its price

has fallen further, its purity has risen—and, lately, the number of heroin deaths is rising sharply everywhere. That is because, when we say heroin, we increasingly mean fentanyl.

Fentanyl is an opioid invented in 1959. Its primary use is in transdermal patches given to people for end-of-life care. If you steal a bunch of these, you can make good money with them on the street. Addicts like to suck on them—an extremely dangerous way to get a high. Fentanyl in its usual form is about fifty times as strong as street heroin. But there are many different kinds of fentanyl, so the wallop it packs is not just strong but unpredictable. There is butyrfentanyl, which is about a quarter the strength of ordinary fentanyl. There is acetylfentanyl, which is also somewhat weaker. There is carfentanil, which is 10,000 times as strong as morphine. It is usually used as an animal tranquilizer, although Russian soldiers used an aerosol version to knock out Chechen hostage-takers before their raid on a Moscow theater in 2002. A Chinese laboratory makes its own fentanyl-based animal tranquilizer, W-18, which finds its way into Maine through Canada.

China manufactures a good deal of the fentanyl that comes to the U.S., one of those unanticipated consequences of globalization. The dealers responsible for cutting it by a factor of fifty are unlikely to be trained pharmacists. The cutting lab may consist of one teenager flown up from the Dominican Republic alone in a room with a Cuisinart and a box of starch or paracetamol. It takes considerable skill to distribute the chemicals evenly throughout a package of drugs. Since a shot of heroin involves only the tiniest little pinch of the substance, you might tap into a part of the baggie that is all cutting agent, no drug—in which case you won’t get high. On the other hand, you could get a fentanyl-intensive pinch—in which case you will be found dead soon thereafter with the needle still sticking out of your arm. This is why fentanyl-linked deaths are, in some states, multiplying year on year. The federal CDC has lagged in reporting in recent years, but we can get a hint of the nationwide toll by looking at fentanyl deaths state by state. In Maryland, the first six months of 2015 saw 121 fentanyl deaths. In the first six months of 2016, the figure rose to 446.

Sometimes arrested or hospitalized users are surprised to find that what they thought was heroin was actually fentanyl. But there are addicts who swear they can tell what’s in the barrel of their needles. One in Rhode Island, whom we’ll call Gilberto, says heroin has a pleasant caramel brown tint, like the last sip of Coca-Cola in a glass. Fentanyl is clear. And many addicts claim they can recognize the high. “Fentanyl just hits you. Hard,” Gilberto says. “But it’s got no legs on it. It lasts about two hours. Heroin will hold you.” This makes fentanyl a distinctly inconvenient drug, but many addicts prefer it. All dealers, at least around Rhode Island, describe their heroin as “the fire,” in the same way all chefs describe their ribs as so tender they just fall off the bone.

“I knew we were screwed, as a state and as a country,” Jonathan Goyer says, “when I had a conversation with a kid who was going through withdrawals.” Although he had enough money to get safer drugs, the kid was going to wait through the sweats and the diarrhea and the nausea until his dealer came in at 5 p.m. That would allow him to risk his life on fentanyl.

Those in heroin’s grip often say: “There are only two kinds of people—the ones I get money from and the ones I give money to.” A man who is dead to his wife and his children may be desperate to make a connection with his dealer. They don’t buy much besides heroin—perhaps a plastic cup of someone else’s drug-free urine on a day when they need to take a drug test for a hospital or employer. This will set them back twenty or thirty dollars. In addiction, as in more mainstream endeavors, the lords of hedonism

are the slaves of money. Gilberto in Rhode Island claims to have put a million dollars into each of his needle-pocked arms, at the rate of three fifty-bag “bricks” of heroin a day.

Dealers are businessmen and behave like businessmen, albeit heavily armed ones. They may “throw something” to a particularly reliable customer—that is, give him enough heroin from time to time to allow him to deal a bit on his own account and stay solvent. An addict who discovers that the 10mg pills he is paying $18 each for in Maine are available for $10 in Boston, a three-hour drive away, may be tempted to sell them to support his own habit. The line between users and pushers blurs, rendering impractical the policy that most people prefer—be merciful to drug users, but come down hard on dealers.

Addicts wake up “sick,” which is the word they use for the tremulous, damp, and terrifying experience of withdrawal. They need to “make money,” which is their expression for doing something illegal. Some neighborhood bodegas—the addicts know which ones—will pay 50 cents on the dollar for anything stolen from CVS. That is why razor blades, printer cartridges, and other expensive portable items are now kept under lock and key where you shop. Addicts shoplift from Home Depot and drag things from the loading docks. They pull off scams. They will scavenge for thrown-out receipts in trash cans outside an appliance store, enter the store, find the receipted item, and try to return it for cash. On the edge of the White Mountains in Maine, word spread that the policy at Hannaford, the dominant supermarket chain, was not to dispute returns of under $25. For a while, there was a run on the big cans of extra virgin olive oil that sold for $24.99, which were brought to the cash registers every day by a succession of men and women who did not, at first sight, look like connoisseurs of Mediterranean cuisine. Women prostitute themselves on Internet sites. Others go into hospital emergency rooms, claiming a desperately painful toothache that can be fixed only with some opioid. (Because if pain is a “fifth vital sign,” it is the only one that requires a patient’s own testimony to measure.) This is generally repeated until the pain-sufferer grows familiar enough to the triage nurses to get “red-flagged.”

The population of addicts is like the population of deer. It is highest in rustic places with access to urban supplies. Missouri’s heroin problem is worst in the rural counties near St. Louis. New Hampshire’s is worst in the small cities and towns an hour or so away from the drug markets of Massachusetts: Lawrence, Lowell, and Boston. But the opioid epidemic of the past decade is unusually diverse. Anchor’s emergency room clients are 82 percent white, 9 percent Hispanic, and 6 percent black. The state of Rhode Island is 85 percent white, 9 percent Hispanic, and 5 percent black. “I try to target outreach,” Goyer says, “but the demographics are too random for that.”

Drug addiction used to be a ghetto thing. Now Oxycodone has joined shuttered factories and Donald Trump as a symbol of white working-class desperation and fecklessness. The reaction has been unsympathetic. Writes Nadja Popovich in The Guardian: “Some point to this change in racial and economic demographics as one reason many politicians have re-evaluated the tough ‘war on drugs’ rhetoric of the past 30 years.”

The implicit accusation is that only now that whites are involved have racist authorities been roused to act. This is false in two ways. First, authorities have not been roused to act. Second, when they do, they will have epidemiological, and not just tribal, grounds for doing so. A plague afflicting an entire country, across ethnic groups, is by definition more devastating than a plague afflicting only part of it. A heroin scourge in America’s housing projects coincided with a wave of heroin-addicted soldiers brought back from Vietnam, with a cost peaking between 1973 and 1975 at 1.5 overdose deaths per 100,000. The Nixon White House panicked. Curtis Mayfield wrote his soul ballad

“Freddie’s Dead.” The crack epidemic of the mid- to late 1980s was worse, with a death rate reaching almost two per 100,000. George H. W. Bush declared war on drugs. The present opioid epidemic is killing 10.3 people per 100,000, and that is without the fentanyl-impacted statistics from 2016. In some states it is far worse: over thirty per 100,000 in New Hampshire and over forty in West Virginia.

In 2015, the Princeton economists Angus Deaton and Anne Case released a paper showing that the life expectancy of middle-aged white people was falling. Prominent among the causes cited were “the increased availability of opioid prescriptions for pain” and the falling price and rising potency of heroin. Census figures show that Case and Deaton had put the case mildly: Life expectancy was falling for all whites. Although they are the only racial group to have experienced a decline in longevity—other races enjoyed steep increases—there are still enough whites in the United States that this meant longevity fell for the country as a whole.

Bill Clinton alluded to the Case-Deaton study often during his wife’s presidential campaign. He would say that poor white people are “dying of a broken heart.” Heroin has become a symbol of both working-class depravity and ruling-class neglect—an explosive combination in today’s political climate.

Maine’s politicians have taken the opioid epidemic as seriously as any in the country. Various new laws have capped the maximum daily strength of prescribed opioids and limited prescriptions to seven days. The levels are so low that they have led some doctors to warn that patients will go onto the street to get their dosages topped off. “We were sad,” State Representative Phyllis Ginzler said in January, “to have to come between doctor and patient.” She felt the deadly stakes of Maine’s problem gave her little alternative.

Paul LePage, the state’s garrulous governor, has been even more direct. Speaking of drug dealers at a town hall in rural Bridgton in early 2016, he said: “These are guys with the name D-Money, Smoothie, Shifty, these types of guys. They come from Connecticut and New York, they come up here, they sell their heroin, they go back home. Incidentally, half the time they impregnate a young white girl before they leave.” This is what the politics of heroin threatens to become nationwide: To break the bureaucratic inertia, one side will go to any rhetorical length, even invoking race. To protect governing norms, the other side will invoke decency, even as the damage mounts. It is what the politics of everything is becoming nationwide. From town to town across the country, the correlation of drug overdoses and the Trump vote is high.

The drug problem is already political. It is being reframed by establishment voices as a problem of minority rights and stigmatization. A documentary called The Anonymous People casts the country’s 20 million addicts as a subculture or “community” who have been denied resources and self-respect. In it, Patrick Kennedy, who was Rhode Island’s congressman until 2011 and who was treated for OxyContin addiction in 2006, says: “If we can ever tap those 20 million people in long-term recovery, you’ve changed this overnight.” What’s needed is empowerment. Another interviewee says, “I refuse to be ashamed of what I am.”

This marks a big change in attitudes. Difficult though recovery from addiction has always been, it has always had this on its side: It is a rigorously truth-focused and euphemism-free endeavor, something increasingly rare in our era of weasel words. The face of addiction a generation ago was that of the working-class or upper-middle-class man, probably long and intimately known to his neighbors, who stood up at an AA meeting in a church basement and bluntly said, “Hi, I’m X, and I’m an alcoholic.”

The culture of addiction treatment that prevails today is losing touch with such candour. It is marked by an extraordinary level of political correctness. Several of the addiction professionals interviewed for this article sent lists of the proper terminology to use when writing about opioid addiction, and instructions on how to write about it in a caring way. These people are mostly generous, hard-working, and devoted. But their codes are neither scientific nor explanatory; they are political.

The director of a Midwestern state’s mental health programs emailed a chart called “‘Watch What You Call Me’: The Changing Language of Addiction and Mental Illness,” compiled by the Boston University doctor Richard Saltz. It is a document so Orwellian that one’s first reaction is to suspect it is a parody, or some kind of “fake news” dreamed up on a cynical website. We are not supposed to say “drug abuse”; use “substance use disorder” instead. To say that an addict’s urine sample is “clean” is to use “words that wound”; better to say he had a “negative drug test.” “Binge drinking” is out—“heavy alcohol use” is what you should say. Bizarrely, “attempted suicide” is deemed unacceptable; we need to call it an “unsuccessful suicide.” These terms are periphrastic and antiscientific. Imprecision is their goal. Some of them (like the concept of a “successful suicide”) are downright insane. This habit of euphemism and propaganda is not merely widespread. It is official. In January 2017, less than two weeks before the end of the last presidential administration, drug office head Michael Botticelli issued a memo called “Changing the Language of Addiction,” a similarly fussy list of officially approved euphemisms.

Residents of the upper-middle-class town of Marblehead, Massachusetts, were shocked in January when a beautiful twenty-four-year-old woman who had excelled at the local high school gave an interview to the New York Times in which she described her heroin addiction. They were perhaps more shocked by her description of the things she had done to get drugs. A week later, the police chief announced that the town had had twenty-six overdoses and four deaths in the past year. One of these, the son of a fireman, died over Labor Day. At the burial, a friend of the dead man overdosed and was rushed to the hospital. One fireman there said to a mourner that this was not uncommon: Sometimes, at the scene of an overdose, they will find a healthy- and alert-looking companion and bring him along to the hospital too, assuming he might be standing up only because the drug hasn’t hit him yet. In communities like this, concerns about “hurtful” words and stigma can seem beside the point.

Former Bush administration drug czar John Walters and two other scholars wrote last fall, “There is another type of ‘stigma’ afflicting drug users—that their crisis is somehow undeserving of the full resources necessary for their rescue.” Walters is talking largely about law enforcement. As he said more recently: “If someone were getting food poisoning from cans of tuna, the whole way we’re doing this would be more aggressive.”

Which is not the direction we’re going. In state after state, voters have chosen to liberalize drug laws regarding marijuana. If you want an example of mass media–induced groupthink, Google the phrase “We cannot arrest our way out of the drug problem” and count the number of politicians who parrot it. It is true that we cannot arrest our way out of a drug problem. But we cannot medicate and counsel our way out of it, either, and that is what we have been trying to do for almost a decade.

Calling addiction a disease usefully describes certain measurable aspects of the problem—particularly tolerance and withdrawal. It fails to capture what is special and dangerous about the way drugs bind with people’s minds. Almost every known disease is something people wish to be rid of. Addiction is different. Addicts resist known cures—even to the point of death. If you do not reckon with why addicts go to such

lengths to continue suffering, you are unlikely to figure out how to treat them. This turns out to be an intensely personal matter.

Medical treatment plays an obvious role in addressing the heroin epidemic, especially in the efforts to save those who have overdosed or helping addicts manage their addictions. But as an overall approach, it partakes of some of the same fallacies as its supposed opposite, “heartless” incarceration. Both leave out the addict and his drama. Medicalizing the heroin crisis may not stigmatize him, but it belittles him. Moral condemnation is an incomplete response to the addict. But it has its place, because it does the addict the compliment of assuming he has a conscience, a set of thought processes. Those thought processes are what led him into his artificial hell. They are his best shot at finding a way out.

In 1993, Francis F. Seeburger, a professor of philosophy at the University of Denver, wrote a profound book on the thought processes of addicts called Addiction and Responsibility. We tend to focus on the damage addiction does. A cliché among empathetic therapists, eager to describe addiction as a standard-issue disease, is that “no one ever decides to become an addict.” But that is not exactly true, Seeburger shows. “Something like an addiction to addiction plays a role in all addiction,” he writes. “Addiction itself . . . is tempting; it has many attractive features.” In an empty world, people have a need to need. Addiction supplies it. “Addiction involves the addict. It does not present itself as some externally imposed condition. Instead, it comes toward the addict as the addict’s very self.” Addiction plays on our strengths, not just our failings. It simplifies things. It relieves us of certain responsibilities. It gives life a meaning. It is a “perversely clever copy of that transcendent peace of God.”

The founders of Alcoholics Anonymous thought there was something satanic about addiction. The mightiest sentence in the book of Alcoholics Anonymous is this: “Remember that we deal with alcohol—cunning, baffling, powerful!” The addict is, in his own, life-damaged way, rational. He’s too rational. He is a dedicated person—an oblate of sorts, as Seeburger puts it. He has commitments in another, nether world.

That makes addiction a special problem. The addict is unlikely ever to take seriously the counsel of someone who has not heard the call of that netherworld. Why should he? The counsel of such a person will be, measured against what the addict knows about pleasure and pain, uninformed. That is why Twelve Step programs and peer-to-peer counselling, of the sort offered by Goyer and his colleagues, have been an indispensable element in dragging people out of addiction. They have authority. They are, to use the street expression, legit.

The deeper problem, however, is at once metaphysical and practical, and we’re going to have a very hard time confronting it. We in the sober world have, for about half a century, been renouncing our allegiance to anything that forbids or commands. Perhaps this is why, as this drug epidemic has spread, our efforts have been so unavailing and we have struggled even to describe it. Addicts, in their own short-circuited, reductive, and destructive way, are armed with a sense of purpose. We aren’t. It is not a coincidence that the claims of political correctness have found their way into the culture of addiction treatment just now. This sometimes appears to be the only grounds for compulsion that the non-addicted part of our culture has left.

Christopher Caldwell is a senior editor at the Weekly Standard.


The Director of the NDPA, Peter Stoker, visited Vancouver East Side in 1999.  It was tragic to see drug dependent men and women living rough on the streets – in the alleys behind the main road – injecting in public.  A team of police officers called The Odd Squad worked the area and did everything they could to help these people – producing a great video called ‘Through the Blue Lens’ – we took this video into schools and it was the most powerful drug prevention message we had ever used.  We would urgently ask you to see this video on You Tube –

The article below is covering the same story – 19 years later.  Isn’t it about time that Canada began to promote good drug prevention instead of relaxing their drug laws? 

As overdose deaths spike, provincial health officials say more overdose prevention sites will soon open across the province.

The number of overdose deaths related to illicit drugs in British Columbia leapt to 755 by the end of November, a more than 70-per-cent jump over the number of fatalities recorded during the same time period last year.

In August, 50 people died of drug overdoses in British Columbia.  In September, 57 died. In October, the number jumped to 67 — an increase that worried health officials, who had thought that increasing the supply and training for administering the overdose reversal drug naloxone was making a difference.

In November, drug overdoses caused 128 deaths — 61 more than the previous month, and nearly double the October total. That spike has brought the total number of deaths between January and November to 755, the highest number ever recorded by the BC Coroner and a 70 per cent increase over this time last year

“We’re quite fearful that the drug supply is increasingly toxic, it’s increasingly unpredictable, and it’s very, very difficult to manage,” said Lisa Lapointe, B.C.’s chief coroner, referring to the increasing prevalence of the synthetic opioid fentanyl being added to many illicit drugs.  “Those who…attempt to use drugs safely, it’s almost impossible.”

With advance notice from the coroner that November numbers would be much higher, provincial health officials announced three weeks ago that several overdose prevention sites would open in Vancouver, Surrey and Victoria. People can go inside the sites to inject drugs, and are given first aid if they overdose.

An unofficial safe consumption site located in the alley behind the Downtown Eastside Market off East Hastings Street.

Health officials have insisted the sites are temporary and are not supervised injection sites, which are currently difficult to open because of a strict Conservative-era law that current federal health minister Jane Philpott has promised to change.

If there is any good news to be found within the grim statistics, it is that no deaths have occurred at any of those overdose prevention sites. And no one has died at a volunteer-run tent that has been operating since September, without official permission or government funding, out of an alley in the heart of the Downtown Eastside. People can smoke or snort drugs at that site, not just inject.

“We’re pretty steady, we get about 100 people a day,” said Sarah Blyth, the Downtown Eastside market coordinator and one of the organizers of the tent. “We’re coming up to welfare (day)…it’s happening this Wednesday, so I imagine up until Christmas it’s going to be pretty busy.”

A sign on the front door of VANDU’s storefront at 380 E. Hastings advertises that the location is an overdose prevention site, with volunteers trained in first aid

“A lot of people use during Christmas,” Blyth added. “Not everybody’s Christmas is as happy as others.”  At the Vancouver Area Network of Drug Users storefront further down East Hastings Street, Linda Bird confirmed the overdose prevention site located there has been busy, with around 60 people a day passing through. Volunteers, who are paid a small stipend by Vancouver Coastal Health, work two to four hour shifts. Overdoses are common, small stipend by Vancouver Coastal Health, work two to four hour shifts. Overdoses are a small stipend by Vancouver Coastal Health, work two to four hour shifts. Overdoses are common, Bird said.

“A lot of them are taking this very, very seriously,” Bird said of the volunteers. “It’s a crisis and a lot of them have seen their friends dropping.”

Vancouver Coastal Health has announced a fourth overdose prevention site in Vancouver, while Fraser Health has added more sites in Langley, Abbotsford and Maple Ridge.

Overdose deaths in November were nearly double the number seen in October

Health authorities in the Interior, Vancouver Island and the north are also planning to open sites in the future, said Perry Kendall, B.C.’s health officer.  “We’re still struggling in many communities with the idea of having these (overdose prevention) sites open,” Kendall said. “That doesn’t help.”

He urged the federal government to introduce the new legislation as soon as possible.

“You must use (drugs) in the presence of somebody who can help you,” Lapointe emphasized. “We are seeing people die with a naloxone kit open beside them, but they haven’t even had time to use it. We are seeing people die with a needle in their arm or a tablet nearby…You must go somewhere where someone is able to give you immediate medical assistance.”


I was just a year old when I had my first experience with opioids. I was born with a hiatal hernia, which constricted my esophagus and caused me to reflux like crazy. I couldn’t keep breast milk down and I became malnourished, tiny and weak. One night, my parents, Gayle and Morty Gebien, rushed me to the hospital. I was dehydrated and spitting up everything they tried to get me to eat or drink. The doctors told my parents to prepare themselves for the possibility that I wouldn’t live through the night. They brought me into surgery and gave me morphine for the pain. Maybe that’s where it all began.

I’ve always had a difficult time coping with stress. I sucked my thumb until I was eight years old. I started smoking at age 14 and never stopped. In high school, I was a pothead, and so were most of my friends. I dropped acid and did ecstasy a handful of times. Academically, I was apathetic, skipping class often and bringing home terrible report cards. One day, when I was 17, I went golfing with friends. When I got home, my back began to ache, a dull pain like a hand wrapping around my spine and squeezing it tight. I didn’t know it then, but I had a herniated disc. I lay down on the floor of my bedroom, and it felt like my vertebrae were shifting beneath me. Eventually, the sensation passed, and I got up.

The next year, I started volunteering at a hospital in Richmond Hill, folding blankets, mopping floors and stocking shelves. That’s when I first considered becoming a doctor. I studied science at the University of Toronto Scarborough, but my grades weren’t strong enough to get me into medical school, so I moved to Montreal and did a master’s in molecular biology at McGill. After that, I went to med school at the University of Queensland in Australia and did my residency in emergency medicine in Michigan.

In 2007, I visited my parents on vacation in Florida. I slept on the couch and, during the night, I displaced the disc in my back. The pain was much stronger than what I’d experienced in high school. My mother, who had prescriptions for her own back issues—she’d slipped on wet stairs a few years before I was born—gave me a powerful opioid called Dilaudid to soothe it. I knew I liked it too much. The back pain melted away, but so did everything else. It was like taking a happy pill. I immediately felt calm, relaxed, brighter and more wakeful than usual. Later that month, I sprained my thumb playing hockey. I went to the hospital, where the doctor asked me if I wanted codeine-based Tylenol 3s or oxycodone-based Percocet. I chose the latter. I knew Percs were the stronger of the two and I wanted to know just how strong. The feeling was great—similar to how I’d felt on Dilaudid that morning in Florida. My first bottle of Percocets—30 tiny white pills—lasted about a year.

In 2008, following stints as a cruise-ship doctor and an air-ambulance physician, I landed an ER job in Saint John, New Brunswick. At the bar one night, I met a blond girl named Katie, a personal support worker at a pain clinic. I was taken by her eyes, a light bluish-grey I’d never seen before. It took me a couple of tries, but, eventually, she agreed to go out with me. In February 2009, I moved back to Toronto to take a job as an ER doctor at the York Central Hospital, and Katie and her two-year-old daughter soon followed. They rented an apartment at Bathurst and Steeles, and began settling into a routine.

I found a new doctor in Toronto who prescribed me another 30 Percocets for my back, and I started taking them more often. After a few weeks, the pain subsided, and I stopped using them, but I stashed the extras, maybe half the bottle, in my medicine cabinet. One Friday night, some buddies came over for a few beers and some PlayStation golf, and I popped a few Percocets. It wasn’t some big decision, but, in hindsight, I realize that was the moment I crossed the line. It was the first time I took them purely recreationally. They gave me a fuzzy, happy feeling I couldn’t access any other way. Soon, I was dipping into my bottle once every few weeks—if Katie and I were going camping with friends or if I needed a boost of energy to play with Katie’s daughter after a long shift. She couldn’t tell when I was high and, at first, neither could Katie. The following year, in early 2011, we learned that Katie was pregnant with a boy and we bought a five-bedroom stone house at Bathurst and Sheppard.

My parents lived a short drive away and were proud grandparents. They were over at least once a week, but my mom and Katie didn’t get along. Katie felt they were too involved in her daughter’s life—they weren’t biologically related, after all. My mom would get upset if Katie’s daughter didn’t call her on her birthday. A series of slights, real and imagined, between my mother and Katie culminated in an exchange of profanity-laden emails. I became the rope in a vicious tug-of-war. My mother would tell me to assert myself and “be a man.” Katie would say I wasn’t standing up for her. Eventually, Katie asked me to choose between her and my parents. I was dedicated to making my life with Katie work, so I told my parents that they weren’t welcome at the house anymore. Shortly after that, Katie and I flew to Las Vegas to get married. A little more than a year later, she gave birth to our second child together, a girl. My parents weren’t there for the birth, which broke my heart.

Over time, I began to rely on the pills not just to help my back pain but also to cope emotionally. Initially, I went to my doctor every couple of months, then once a month and then every couple of weeks. He recommended that I exercise, lose weight and see a physiotherapist, but he always filled my prescription. He never told me it was too much.

In August 2012, I got a job as an emergency room doctor at the Royal Victoria Regional Health Centre in Barrie. Katie and I bought a spectacular five-bedroom house on the waterfront, at the end of a cul-de-sac. We had a dock and a boat. I was making roughly $300,000 a year. I bought Katie a Lexus SUV, which we eventually traded in for an Audi Q7. But our marriage was deteriorating. We were arguing all the time—about my family, about my parenting. I’d reprimand her daughter for misbehaving, and Katie would undermine me, saying, “Daddy’s just had a bad day.” Katie had also noticed my drug use, which had gone from two pills a day to as many as eight. We fought about it at least once a week.

She wanted me to get help, but I always refused. Seeking help would have meant two things: one, admitting that I had a problem; and two, admitting that I was no longer in control. The pills helped me get through my days, and I wasn’t ready to let that go. Sometimes I slept in my car to avoid another fight.

The first time it occurred to me that I might have a drug problem, I was standing next to a lumber pile in Rona, waiting for my contractor to pick out aluminum framing for our basement renovation. I felt irritation wash over me, totally unprovoked. I couldn’t figure out what was wrong, but I popped a Percocet and immediately felt relieved. I wondered if I had been experiencing withdrawal symptoms, but I felt ashamed even considering it. I dealt with patients every day and didn’t see myself as one. Throughout my career as a doctor, I was trained to believe I was infallible. As far back as medical school, we were told that, no matter what, you don’t call in sick; you show up. So, even though I knew I was in trouble, I didn’t ask for help.

As the months went on, I continued using. That May, I was visiting my folks when I started having withdrawal symptoms. I asked my mom for a few fentanyl patches and she obliged, thinking that I just needed relief for my back pain. She had a prescription for the opioid, which is up to a hundred times more powerful than morphine. The intensely potent drug is usually doled out in surgery or given to patients with chronic pain who have built up a tolerance to other opioids. The transparent squares, which at the time looked a little like clear Band-Aids, contained two layers: one with the slow-release drug and one that’s skin adhesive. I slapped one on my back and stashed the others for later.

About a week later, I got home after a long shift and typed, “How to smoke fentanyl” into Google. My kids were with their nanny at the park near our house. I went to the garage and cut a patch into one-centimetre squares. I lined each piece up on a larger square of tin foil, then I held the lighter under the first piece, watched the puff of smoke come up and inhaled. The sweet smell of burnt plastic filled my nose and travelled deep into my lungs. It was as if I were being pushed by a powerful but gentle wave. Calm washed over me. My anxiety and fear were gone. I slowly lowered myself backward into a chair. I was higher than I’d ever been. Imagine a surge of confidence kicking in, a worldly reassurance that all of your problems will just dissolve. A soft happiness sets in, then a creativity spike. You feel totally alert, more awake and sharper than ever. Everything around you feels warmer. Now, imagine those sensations happening within a few milliseconds of each other. And that’s what it’s like to smoke fentanyl. I sat there, eyes glazed, staring out at the street for 20 minutes. I was in heaven.

Gayle Gebien, above, gave her son a few fentanyl patches for his back pain. He took them home and Googled “How to smoke fentanyl”

A drug like fentanyl doesn’t inject your body with new feelings; it borrows from the ones you already have. When the high starts to wear off, the positive sensations retreat and the negative ones become amplified. And addicts have no shortage of negative emotions. A dark cloud descends upon your brain. You become scared, anxious, agitated. The warmth rolls away and leaves you in cold sweats, shivering. Self-loathing kicks in, followed by guilt, fear, sadness, paranoia. Coming down off that first rush, my body began to ache. All I could focus on was escaping those feelings as quickly as possible, and the only solution was to smoke again. And again—each iteration sinking me deeper into dependency. From that day on, I smoked fentanyl at least six times a day and sometimes as many as 15 times.

The scariest part was that, as a doctor, I knew exactly what I was getting into, and I didn’t care. Fentanyl is one of the most dangerous opioids on the market. It can be smoked, injected or dissolved under your tongue. The federal health minister, Jane Philpott, has called Canada’s opioid problem a national public health crisis. In Ontario, 162 people died of fentanyl overdoses in 2015. In B.C., 332 people died in the first nine months of 2016.

Doctors are part of the problem. One of the most common complaints we get from patients is that we under-treat chronic pain. And, because pain is subjective and difficult to diagnose, we tend to take patients’ word for it when they say they’re in pain. Late last year, the College of Physicians and Surgeons announced it was investigating 86 doctors for prescribing daily opioid dosages that wildly exceeded national guidelines. One patient was prescribed the equivalent of 150 Tylenol 3s per day. Some of those cases occur because patients undergoing cancer treatment or living with multiple sclerosis may need very high dosages. But, in other cases, like mine, there’s rampant abuse of the system.

When I think about it now, I’m disgusted that I kept drugs in the same house as my children. At first, I locked up my patches in my toolbox in the garage. Later, I would smoke in the shower stall in our basement and hide my fentanyl under the sink behind the pipes. I convinced myself that, by taking those precautions, I was being a responsible father. I was high-functioning, but, still, my kids were getting a stoned daddy, even if they were too young to realize it. I wanted to believe that I was like any other doting dad—I took my kids to the beach in the summer, dunking the little ones in the water and wading hand in hand with the eldest. I took them apple-picking in the fall and tobogganing in the winter. The only difference was that, 15 times a day, I’d head to the basement to smoke up. That I was high around my kids is one of the hardest things for me to forgive of myself.

That summer, my cravings were ruthless, and I had no legitimate access to patches. I knew I couldn’t write prescriptions in my own name, so I came up with a plan: I began to write prescriptions for Katie, then I’d go to the pharmacy to pick them up. But I didn’t want pharmacists getting suspicious of Katie, so I began to recruit other pretend patients. I had become friendly with one of the contractors renovating our basement. At one point, I asked him: “Can you do me a favour?” I explained that I needed someone to pick up my fentanyl and that I could supply him with Percocet if he agreed, which he did. I’d write two prescriptions in his name: one for fentanyl and one for Percocet. He’d get them both filled and keep the Percs. One night, my supply was dry and I was going through withdrawal. Katie and I were arguing, and I left the house. I got in a taxi and went into town. I was so desperate that I began going from taxi to taxi, knocking on windows and asking strangers, “Are you interested in doing a swap? I can get you Percocet, but I need you to pick up some fentanyl for me.” The first three weren’t interested. The fourth was.

From August to October, I also cajoled two assistants and a nurse into giving me painkillers from the hospital. I never offered to pay them; I just told them I was in a lot of pain and couldn’t write prescriptions in my own name. I put them in a terrible position and I minimized the stakes. “Oh, it’s not a big deal,” I said. They saw I was hurting and agreed. (They were later fired for it.) Over 16 months, I acquired 445 patches of fentanyl with fraudulent prescriptions, smoking about a patch a day.

At home, my relationship with Katie was in tatters. Instead of offering support, Katie would yell at me, and I would yell back or retreat in silence. “You’re smoking again,” she would shout when she caught me going downstairs. She threatened to leave. She called me a junkie.

I never smoked before work. But I did wear a patch to stave off withdrawal symptoms. Twice I had to leave work because my cravings were too intense to keep going. I lost more than 30 pounds, my cheeks were sunken and I became irritable and jittery. Once, a colleague asked me if I was okay. I told her there were problems at home and left it at that. She didn’t ask again.

My mom had noticed my ragged state and, unbeknownst to me, called and told the hospital I might have a drug problem. My supervisor and the hospital’s chief of staff called me into a meeting and asked me if I had any problems they should be aware of. I lied. I said that things were rocky with Katie but, otherwise, no. They gave me pamphlets on addiction and mental health, and I went back to work.

I decided to change tactics. For the next four months, I forged prescriptions from other doctors in my own name. I’d go to the pharmacy and sweet-talk the staff—it was usually the same guy—into not faxing my prescription over to the hospital. Pharmacists hate to bother busy doctors, and I played on that. Every time I went to get one filled, I threatened everything: my job, my family, my freedom. I didn’t care.

One Sunday in November 2014, the pharmacist was too busy administering flu shots to speak to me and faxed the prescription. I could have tried harder to intervene, but, for some reason, I didn’t. My endless scheming had worn me down. The doctor who happened to pick it up in the ER was the same doctor whose signature I’d forged on the script, which requested a dozen patches. I didn’t know it then, but the doctor reported me to my supervisor. After 20 minutes of nervously waiting, I was waved over by the pharmacist. “We’ve run out of supplies, actually,” she said. She gave me what she claimed were her last few patches, and I went home none the wiser. Two days later, the chief of emergency and the chief of staff greeted me in the doctors’ change room. They told me that they knew about the false prescriptions, that the pharmacy had called the police and that I couldn’t work—I’d be going on unofficial leave without pay, and my medical licence would be suspended. I was scared shitless. The shame of being caught in a tangle of lies was overwhelming. I was afraid for my family, afraid I’d lose my job, afraid of what other people would say. I should have felt lucky to be alive—at that point I was a bag of skin and bones—but I just felt dizzying fear for the future. And yet, on top of all that was an unexpected wave of relief. My life had just come crashing down; at least I couldn’t deny it anymore.

I was arrested at home. Police charged me with three counts of forgery and gave me a notice to appear in court. Three days later, I went to Homewood Health Centre in Guelph, a facility recommended to me by a psychiatrist at my hospital, for five weeks. My parents covered the $10,000 bill. There, the doctors decided I should go into a rapid wean, a process intended to produce intense withdrawal and, with it, a deterrent to using drugs again. First, doctors gave me Suboxone, a pill used to get addicts off opiates. The drug satisfies some of the body’s narcotic cravings but doesn’t get you high. Coming off the Suboxone was vicious, as my endorphin levels plummeted and my brain began to rewire itself. I thought I was going to die. When I tried to walk, my body curled inward, neck down, arms tight to my chest, in a position known in rehab as the Suboxone shuffle. My ears were ringing. My body temperature began to swing like crazy: one moment I’d soothe my chills in a hot shower and the next I’d be running aimlessly outside, rubbing snow on my face. I remember telling the doctor that I couldn’t handle the pain. He agreed to give me another two milligrams of Suboxone to stave off my withdrawal. I knew that would only delay the inevitable, but, at that point, I didn’t care—I was so desperate I considered throwing myself in front of a bus. My body felt like it was disintegrating. Lifting a spoon to my mouth was tiring; walking up a ramp left me winded. The next day, I thought I was progressing, but, 32 hours later, I was still in the throes of withdrawal. I lay down on the hospital bed in my room to take a nap. When I woke up four hours later, the weakness was gone, my limbs had uncurled and my gait returned to normal. The week from hell was over.

On my 14th day in rehab, Katie brought the kids to visit. She told them that I was sick, and they assumed Homewood was a regular hospital. I’ll never forget my son asking why I wasn’t coming home with them that day.

My return from rehab was strange. Katie was exhausted from caring for the kids by herself for five weeks, and we were soon back to our bickering. I was sleeping on the couch and I was still on leave from my job, so my days were empty.

There’s a grieving process that comes with addiction, and I was grieving the loss of my drug of choice. The cycles of shame, self-loathing, rationalization and apathy returned. So I did what I always did to cope: I wrote a prescription for fentanyl using one of my old prescription pads. I didn’t realize the police were monitoring me.

Within a week, I was back to getting high 15 times a day. On the morning of January 4, I lost track of how much I’d smoked. I overdosed and collapsed in my basement shower stall. My face was a putrid shade of green, drool was dribbling down my chin and my dry tongue was hanging from my open mouth. I was barely breathing when Katie walked in. She had seen me high many times before, and she could spot the telltale bursts of energy, hoarse voice and constricted pupils, but that day was different. I’d been downstairs for longer than usual, and she hadn’t seen my face like that before. I remember her screams tearing through the fog in my head. “I’m calling an ambulance,” she cried. I jolted awake, flailing my arms as my paraphernalia went flying. I gasped for breath a few times, head lolling, then lunged for the toilet and vomited. “I thought you were dead,” she said. I told her I didn’t need an ambulance and, eventually, she stopped insisting, worn down from so many arguments. A few hours later, I was back in the stall lighting up another patch.

At 7 a.m. on January 19, 2015, 10 officers from the Barrie drug crimes unit showed up at my front door. If I have a rock bottom, I hit it that day. I woke to my three dogs barking and peered out the window to see the cops on the front steps. I opened the door in my underwear. “Sorry to do this, but your life is never going to be the same,” one of them said to me. I asked for a minute to put the dogs out in the backyard, and the officer

agreed. Another went upstairs to tell Katie she would be arrested, too, wrongly thinking she was involved. They let me put my clothes on and have a cigarette in the garage. They handcuffed me as we were walking outside, so that my kids wouldn’t see if they came downstairs. I was taken to the police station and charged with 72 counts of trafficking—for compelling the pharmacist to supply drugs under false pretences—plus six counts of forging prescriptions.

From January 19 to February 5, I was in jail at the North Correctional Centre in Penetanguishene awaiting my bail hearing. I was despondent. There was a stairwell on the second storey that overlooked the unit’s concrete floor, and I figured that if I jumped headfirst I would die. I told one guy I’d made friends with about my plan, and he pulled me aside. “Wait a second, motherfucker,” he said. “You’ve got your wife, your kids. That’s the most selfish thing you could do.” I went back to my cell. I hadn’t been using long enough after my first stint in rehab to go through acute withdrawal again, but I had the munchies like crazy, a sign of early recovery. I had an appetite so ferocious I’d chug the syrup that came with our French toast in the morning. My cellmate let me eat some of his snacks, too—Rice Krispies Treats, ketchup chips, Twix bars.

With the help of my parents, I made the $80,000 bail, but one of the conditions was that I live with my mom and dad at their Yonge and Sheppard condo. I went home briefly to collect my things. Katie wanted a stable environment for the kids, so she moved them back to New Brunswick 10 days later. I was devastated but didn’t have a choice. In April, I enrolled in Renascent, a clinic at Spadina and Bloor, for my second stint in rehab. I stayed for four weeks. During my daily walks in the neighbourhood, every time I saw a homeless person, I’d think to myself that I was closer to becoming one of them than I was prepared to admit. I was nearly out of money, my marriage was probably over and my network of friends had dwindled. I was initially represented by Marie Henein and Danielle Robitaille, the lawyers who represented former attorney general Michael Bryant and CBC host Jian Ghomeshi. I put the first payment of $35,000 on a line of credit but changed lawyers shortly after. I was still paying the mortgage on our home in Barrie and couldn’t keep up with their retainer.

In August, I walked into the Vitanova Foundation recovery centre in Woodbridge, another government-funded facility, not knowing how long I would be there. The centre offered a free rehab program and dorm-style residence, and, as the weeks passed, I felt my strength and clarity returning.

Three months later, on November 2, 2015, my 45th birthday, I got a call from my dad telling me that my mom had died. He’d found her in bed, non-responsive, wearing three 50-milligram fentanyl patches that we think she applied by accident. Her usual dose was a 25-milligram patch. It was the worst day of my life. I redoubled my efforts to stay clean. I checked out of Vitanova and moved back into my father’s condo. I slept on the couch and have continued to for the past two years. I FaceTime with my kids every couple of days, but it feels like no way to be a father. I’m on social assistance and help my dad with rent when I can—his pension isn’t enough to support both of us. Our Barrie home sold shortly after my mom’s death, and I gave most of the money to Katie, knowing that I might not be working much in the next few years. I run a flooring company with an old friend to make extra cash. And I’m still drug-free.

But my body hasn’t fully recovered: my short-term memory is spotty, I have hearing loss in my right ear and, for the first time in my life, I suffer from panic attacks. I apologized to the City of Barrie for betraying the trust of its residents. And I’ve done some outreach work, speaking to officials at the Ontario Ministry of Health and Toronto Public Health about how to tackle the opioid epidemic.

In April 2016, I filed for bankruptcy. Katie sent divorce papers a few months later. I had been hoping we’d find a way to make it as a couple, but I understood. In February, my biological kids came to stay with me for a week. I got to see my son—now five years old—skate for the first time; my little girl, who’s four, was so excited with the Hatchimal we picked out at Toys’R’Us that she carried the box around with her everywhere and showered me with hugs. I didn’t explain what was going on—I just said I’d talk to them soon. They’re too young to understand what happened. I worry about what they’ll think of me when they do find out. I hope they can be proud of my recovery, but that day is a long way away.

In December 2016, I pleaded guilty, and, as part of the deal, Katie’s charges were finally dropped. I’m awaiting my sentence. The Crown wants me locked up for eight years; my lawyer is arguing for house arrest. Most likely, the judge will settle on a multi-year prison term. My dad has early-stage Alzheimer’s, and I’m concerned about how he’ll cope while I’m gone. I worry constantly about Katie and our kids, too. I’m embarrassed that my life has become a cautionary tale, but I’m thankful that I got caught. Had I not been arrested, I’m certain I’d be dead right now.

When I get out, I will have to face the College of Physicians and Surgeons’ discipline committee, as is standard in cases like mine. My medical licence is currently suspended, and they’ll probably revoke it entirely. If they don’t, I plan to practise again, ideally in the area of addiction. I became a doctor so that I could help people. I messed up my life, but I can still help others avoid the same fate.

Correction  March 30, 2017

An earlier version of this story indicated that Darryl Gebien’s stay at Renascent was covered by OHIP, when in fact the fees there are covered by the Ministry of Health, as well as the centre’s foundation.


Ontario opted not to follow B.C.’s lead on harm reduction, rejecting the idea of creating safe injection sites similar to the one in Vancouver. Postmedia News files

In December, the Liberal government introduced Bill C-37 in response to an epidemic of illicit drug use. The bill facilitates the creation of additional supervised injection sites by reducing previously established restrictions.

The decision to promote supervised injection sites is in line with the latest philosophy guiding addiction management — that of harm reduction. Proponents claim harm-reduction institutions will save lives while averting hundreds of thousands in medical and criminal-legal expenses.

Much in the harm-reduction philosophy is laudable — the desire to destigmatize and protect those with severe illnesses for one — but the field is slipping into dangerous, almost Brave-New-World territory.

In Toronto and Ottawa, supposedly inveterate alcoholics receive calculated amounts of alcohol hourly throughout the day at designated wet shelters and managed alcohol programs. Residents line up on the hour to receive just enough house-made wine to keep withdrawal symptoms at bay. Some drink almost three bottles of wine daily with little to do in between scheduled drinks.

Vancouver, which was Canada’s first city to establish a safe injection site in 2003, has now progressed to experimenting with “heroin-assisted treatment” as a means of further protecting addicts from the harms of tainted street drugs. Participants receive pharmaceutical-grade heroin injections two to three times daily. Recently, in place of heroin, the more innocuous-sounding but no less potent opiate, hydromorphone, is being administered instead.

Is their drug use no longer a problem because they’re off the street? And where exactly do the patients go from here?

Most lay supporters of harm-reduction policy assume a gradual attempt is made to wean the addict off the substance of abuse. Proponents claim that harm reduction isn’t about “giving up” on the addict but is actually a temporary stepping stone towards the ultimate goal of recovery.

But the reality is different.

Dr. Jeffrey Turnbull, who established Ottawa’s managed alcohol program, offers a more sober portrayal of the goals of harm reduction. In a Fifth Estate documentary, he compares his program for those with chronic and severe addictions to palliative care. He agrees his facility is a place for alcoholics to “die with dignity” as opposed to dying on the streets. One resident featured in the episode had been using the program’s services for four years; he was only 24 when he first entered the managed alcohol program.

No doubt, the medical community is frustrated by the high failure rates associated with abstinence-based treatment programs but the criteria for determining when an addict now warrants a harm-reduction approach is unclear. Addiction does not follow a linear natural history akin to metastatic cancer; rather, there exists a variable trajectory and the possibility for recovery is always there.

However, Turnbull’s admission points to an uncomfortable belief underlying the harm-reduction philosophy — the view that some addicts are without hope of ever leading a full, productive life free of drug use.

It may be true that, for some, the best we can do is safe, controlled sedation. But the medical community and society should not be so quick to condemn many others to the compromised mental prison that is the life of the addict.

Proponents argue that harm reduction and abstinence are not mutually exclusive, and some even suggest that harm-reduction institutions actually improve recovery rates. But this is a fiction and is without evidence.

Harm-reduction researchers have conveniently neglected to investigate any potentially negative findings of their policies. Their studies focus exclusively on the obvious benefits such as decreased overdose deaths, cost savings, and so-called “treatment retention.” That addicts will remain “in treatment” longer when freely administered their drug of choice is not surprising, but that this is in their best interests is highly questionable.

Politicians insist supervised injection sites and managed substance programs are effective “evidence-based” interventions, but these assertions are problematic when the evidence only tells half the story.

Canada is quickly moving towards an addiction defeatist infrastructure. Toronto, Montreal, Ottawa and Victoria are all following Vancouver’s lead in constructing further supervised injection sites. Widespread creation of managed substance programs is the next logical step of the harm-reduction approach. Unless vigilance is exercised, we risk relegating addicts to a half-conscious state whereby life is maintained but not really lived.

It is both tragic and ironic that the activist responsible for implementing widespread harm reduction policies in Toronto, Raffi Balian, recently died from an accidental overdose while attending a harm-reduction conference in Vancouver. His death highlights the inadequacy of half measures when dealing with the insidious and powerful disease that is addiction.

Jeremy Devine is a medical student at the University of Toronto’s Faculty of Medicine and a CREMS research scholar in the medical humanities and social sciences

Source:     2nd March 2017


Long-term heavy use of alcohol in adolescence alters cortical excitability and functional connectivity in the brain, according to a new study. These alterations were observed in physically and mentally healthy but heavy-drinking adolescents, who nevertheless did not fulfil the diagnostic criteria for a substance abuse disorder.

Long-term heavy use of alcohol in adolescence alters cortical excitability and functional connectivity in the brain, according to a new study from the University of Eastern Finland and Kuopio University Hospital. These alterations were observed in physically and mentally healthy but heavy-drinking adolescents, who nevertheless did not fulfil the diagnostic criteria for a substance abuse disorder. The findings were published in Addiction Biology.

Constituting part of the Adolescents and Alcohol Study, the study analysed the effects of heavy adolescent drinking on the electrical activity and excitability of the cortex. The study did a follow-up on 27 adolescents who had been heavy drinkers throughout their adolescence, as well as on 25 age-matched, gender-matched and education-matched controls with little or no alcohol use. The participants were 13 to 18 years old at the onset of the study.

At the age of 23-28, the participants’ brain activity was analysed using transcranial magnetic stimulation (TMS) combined with simultaneous electroencephalogram (EEG) recording. In TMS, magnetic pulses are directed at the head to activate cortical neuronal cells. These magnetic pulses pass the skull and other tissues, and they are safe and pain-free for the person undergoing TMS. The method allows for an analysis of how different regions of the cortex respond to electrical stimulation and what the functional connectivities between the different regions are. Indirectly, the method also makes it possible to analyse chemical transmission, i.e. mediator function. The effects of long-term alcohol use haven’t been studied among adolescents this way before.

The cortical response to the TMS pulse was stronger among alcohol users. They demonstrated greater overall electrical activity in the cortex as well as greater activity associated with the gamma-aminobutyric acid, GABA, neurotransmission system. There were also differences between the groups in how this activity spread into the different regions of the brain. Earlier research has shown that long-term, alcoholism-level use of alcohol alters the function of the GABA neurotransmission system. GABA is the most important neurotransmitter inhibiting brain and central nervous system function, and GABA is known to play a role in anxiety, depression and the pathogenesis of several neurological disorders.

The study found that alcohol use caused significant alterations in both electrical and chemical neurotransmission among the study participants, although none of them fulfilled the diagnostic criteria of a substance abuse disorder. Moreover, in an earlier study completed at the University of Eastern Finland, also within the Adolescents and Alcohol Study, cortical thinning was observable in young people who had been heavy drinkers throughout their adolescence. For young people whose brain is still developing, heavy alcohol use is especially detrimental. The findings of the study warrant the question of whether the diagnostic criteria for substance abuse disorders should be tighter for adolescents, and whether they should be more easily referred to treatment. The use of alcohol may be more detrimental to a developing brain than previously

thought, although it takes time for alcohol-related adverse effects to manifest in a person’s life

Source: February_2017)

Drug education is the only part of the middle school curriculum I remember — perhaps because it backfired so spectacularly. Before reaching today’s legal drinking age, I was shooting cocaine and heroin.

I’ve since recovered from my addiction, and researchers now are trying to develop innovative prevention programs to help children at risk take a different road than I did.

Developing a public antidrug program that really works has not been easy. Many of us grew up with antidrug programs like D.A.R.E. or the Nancy Reagan-inspired antidrug campaign “Just Say No.” But research shows those programs and others like them that depend on education and scare tactics were largely ineffective and did little to curb drug use by children at highest risk.

But now a new antidrug program tested in Europe, Australia and Canada is showing promise. Called Preventure, the program, developed by Patricia Conrod, a professor of psychiatry at the University of Montreal, recognizes how a child’s temperament drives his or her risk for drug use — and that different traits create different pathways to addiction. Early trials show that personality testing can identify 90 percent of the highest risk children, targeting risky traits before they cause problems.

Recognizing that most teenagers who try alcohol, cocaine, opioids or methamphetamine do not become addicted, they focus on what’s different about the minority who do.

The traits that put kids at the highest risk for addiction aren’t all what you might expect. In my case, I seemed an unlikely candidate for addiction. I excelled academically, behaved well in class and participated in numerous extracurricular activities.

Inside, though, I was suffering from loneliness, anxiety and sensory overload. The same traits that made me “gifted” in academics left me clueless with people.

That’s why, when my health teacher said that peer pressure could push you to take drugs, what I heard instead was: “Drugs will make you cool.” As someone who felt like an outcast, this made psychoactive substances catnip.

Preventure’s personality testing programs go deeper.

They focus on four risky traits: sensation-seeking, impulsiveness, anxiety sensitivity and hopelessness.

Importantly, most at-risk kids can be spotted early. For example, in preschool I was given a diagnosis of attention deficit/hyperactivity disorder (A.D.H.D.), which increases illegal drug addiction risk by a factor of three. My difficulty regulating emotions and oversensitivity attracted bullies. Then, isolation led to despair.

A child who begins using drugs out of a sense of hopelessness — like me, for instance — has a quite different goal than one who seeks thrills.

Three of the four personality traits identified by Preventure are linked to mental health issues, a critical risk factor for addiction. Impulsiveness, for instance, is common among people with A.D.H.D., while hopelessness is often a precursor to depression. Anxiety sensitivity, which means being overly aware and frightened of physical signs of anxiety, is linked to panic disorder.

While sensation-seeking is not connected to other diagnoses, it raises addiction risk for the obvious reason that people drawn to intense experience will probably like drugs.

Preventure starts with an intensive two- to three-day training for teachers, who are given a crash course in therapy techniques proven to fight psychological problems. The idea is to prevent people with outlying personalities from becoming entrenched in disordered thinking that can lead to a diagnosis, or, in the case of sensation-seeking, to dangerous behavior.

When the school year starts, middle schoolers take a personality test to identify the outliers. Months later, two 90-minute workshops — framed as a way to channel your personality toward success — are offered to the whole school, with only a limited number of slots. Overwhelmingly, most students sign up, Dr. Conrod says.

Although selection appears random, only those with extreme scores on the test — which has been shown to pick up 90 percent of those at risk — actually get to attend. They are given the workshop targeted to their most troublesome trait.

But the reason for selection is not initially disclosed. If students ask, they are given honest information; however, most do not and they typically report finding the workshops relevant and useful.

“There’s no labeling,” Dr. Conrod explains. This reduces the chances that kids will make a label like “high risk” into a self-fulfilling prophecy.

The workshops teach students cognitive behavioral techniques to address specific emotional and behavioral problems and encourage them to use these tools.

Preventure has been tested in eight randomized trials in Britain, Australia, the Netherlands and Canada, which found reductions in binge drinking, frequent drug use and alcohol-related problems. A 2013 study published in JAMA Psychiatry included over 2,600 13- and 14-year-olds in 21 British schools, half of whom were randomized to the program. Overall, Preventure cut drinking in selected schools by 29 percent — even among those who didn’t attend workshops. Among the high-risk kids who did attend, binge drinking fell by 43 percent.

Dr. Conrod says that Preventure probably affected non-participants by reducing peer pressure from high-risk students. She also suspects that the teacher training made instructors more empathetic to high-risk students, which can increase school connection, a known factor in cutting drug use. Studies in 2009 and in 2013 also showed that Preventure reduced symptoms of depression, panic attacks and impulsive behavior.

For kids with personality traits that put them at risk, learning how to manage traits that make us different and often difficult could change a trajectory that can lead to tragedy.


Knowing what to say or do can be tough, but your help can make a huge difference

Helping a friend or family member through an alcohol or drug addiction is by no means easy, but with the right help and knowledge it can be incredibly successful (and rewarding). First things first, there’s no perfect way to behave and it’s rare that the recovery process is understood by anyone except for the individual, but that doesn’t mean you shouldn’t try. Ian Young founder of Sober Services says,

“When someone begins (or even continues or returns to) their addiction recovery journey, the love and support of friends and family is often crucial to their success. This begins with their acceptance of the addictive illness and then continues with sensitivity around the recovery seeking addict’s requirements, such as not visiting bars initially and not socialising with friends who are still using.”

So here are some of the most helpful things you can do to help a loved one tackle addiction…

1. Speak up and offer support

Just the act of offering support alone goes a long way towards helping recovery (whether it’s taken up or not), says Deirdre Boyd, founder of DB Recovery Resources. And to know that people have offered it means a lot. There’s a few different ways you can do this, for example:

“If they attend Alcoholics or Narcotics Anonymous, ask them if they would like you to accompany them to an ‘open’ meeting.”

2. Focus on the replacement rather than sacrifice

Remember that recovery is not about sacrificing something but about replacing it with something healthier (and happier), advises Deirdre. Suggest meeting friends in a coffee bar or even a recovery café instead of the pub, or in a restaurant instead of a night club. There’s now a growing trend of recovery cafes and dry bars, with more people trying to curb their drinking completely. If you’re going out, arrange to meet in the company of ‘safe’ friends instead of old drinking companions, advises Deirdre.

“Don’t replace drinks only with water but with sparkling flavoured waters offered by many supermarkets and interesting drinks, such as those from Schloer. This is especially important on celebratory occasions where others might use champagne to toast, so that they don’t miss out on the ‘ritual’ and sense of belonging.”

You could also suggest a physical activity: perhaps go for a walk. The combination of the natural environment acts as a calming backdrop to any issues up for discussion. Events are also a good option.

“Music and comedy are also often the best anchors for this as they naturally offer a good time to the recovering addict without the requirement for alcohol or drugs, though maybe avoid rave parties or rock concerts,” advises Ian.

3. Be sure they know you’re not judging

Deirdre says:

“People that are in their active addiction can be ashamed of themselves, and they feel that everyone else feels that way. But it is not always the case. A lot of times, good friends and healthy friends are just worried about the person and want them to be the best they can be.”

Understand that an addict is not responsible for their addiction, but when they learn about recovery, they are accountable for their actions.

4. Listen

If you’re helping a friend, listening is the best thing you can do. Deirdre says,

“You can’t always fix someone but you can always say, ‘Have you gone to your meeting?’, ‘Have you spoken to your sponsor?’.”

5. Educate yourself on addiction

There are plenty of resources available for those that want to learn about addiction. The most important part of the family or friends role in the addict’s early recovery will be their own education to what’s appropriate and what isn’t, says Ian.

“For instance, the addict will know it’s not a good idea to visit a pub where their friends may be drinking. But if the family or friend is unaware of this then the simple invitation could be enough to trigger their obsession to drink. Or maybe the suggestion that the recovering addict visits an ex-girlfriend whom the family/friend thinks is a safe person for them to be around, could be bringing up deep emotions that could destabilise the newly recovering addict.”

7. Know that it’s not your job to ‘fix them’

If you notice that your friend is struggling or they tell you that they are, Deirdre says to listen and ‘echo’ what they have said – you don’t have to fix them, just be there for them and advise them to share also at an AA or NA meeting.

In most cases, if the recovering addict is serious about their recovery, they’ll inform the family and friends of their boundaries, but they may not think to speak of everything, or they may be more introverted or shy about specifics, and so sensitivity is encouraged here by the loved ones, says Ian.

Source:   17th June 2016

Do manualized psychosocial interventions help reduce relapse among alcohol-dependent adults treated with naltrexone or placebo? A meta-analysis.

Agosti V., Nunes E.V., O’Shea D. et al.

Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Agosti at

Supplementing the medication naltrexone with psychosocial relapse-prevention therapies has not helped prevent relapse among alcohol-dependent patients. However, these therapies have elevated outcomes among placebo patients to the level of those prescribed naltrexone.

SUMMARY Medications such as naltrexone and acamprosate are used in the treatment of alcohol dependence to combat frequent relapse to heavy drinking, but their impact has overall been modest, and many patients leave treatment early or do not take medication as intended. Researchers have tried to address these shortcomings by supplementing medication with psychosocial interventions. The featured review assessed whether these attempts have been successful by conducting a meta-analytic synthesis of results from studies which used psychosocial relapse-prevention interventions (typically cognitive-behavioural in approach) to support adult, alcohol-dependent patients who had achieved abstinence, and then randomly been allocated either to naltrexone or a placebo. Relapse was defined as a return to drinking at least 70g alcohol a day for men or 56g for women.

Key points

The review synthesised results from relevant studies to test whether supplementing the medication naltrexone with psychosocial relapse-prevention therapies helps prevent relapse among adult, alcohol-dependent patients.

It concluded this was not the case, though one finding suggested that psychosocial therapies can elevate outcomes for patients prescribed a placebo to the level of those prescribed naltrexone.

The implications of this and of other studies are that naltrexone can be a valuable supplement to medical counselling of dependent drinkers, especially when specialist therapies such as cognitive-behavioural therapy are refused or unavailable.

In some situations these therapies also work better when naltrexone is added. But if the core treatment is naltrexone, good quality medical care or counselling will on average be as effective as specialist structured psychosocial therapies.

Four of the 18 studies which met these criteria had also randomly allocated patients to cognitive-behavioural therapies versus a different approach – specifically either medical management or supportive psychotherapy. These direct tests of the impact of a cognitive-behavioural approach were analysed separately from the remaining 20 studies, in which all the patients were offered the same psychosocial therapies, either cognitive-behavioural or one typical of that type of service.

All 18 studies had recruited nearly 2,600 patients on average about 42 years old. Where this was known, three-quarters were men, 71% were employed, and about half were married.

Main findings

Within each of the four studies which had randomly allocated patients to these therapies, generally the proportions who relapsed when supported by cognitive-behavioural therapies were about the same as those who relapsed when supported in other ways. This was the case both among patients given naltrexone and those allocated to a placebo. When results from these studies were pooled, relapse rates among patients allocated to naltrexone or placebo were virtually the same regardless of the type of psychosocial support.

Among the remaining studies which each allocated all their patients to the same form of psychosocial support, results were available from seven in which this was a structured, manualised programme, usually cognitive-behavioural in nature. Across these studies, virtually the same proportion of patients (about half) relapsed whether prescribed naltrexone or placebo. In contrast, when support took a typical, less structured form such as counselling, fewer naltrexone patients relapsed (33%) than did patients prescribed a placebo (43%). This contrast was statistically significant, and was largely due to results from older studies published between 1992 and 1997. Another unexpected finding was that whether prescribed naltrexone or a placebo, fewer patients relapsed when the treatment was a typical approach than when it was a structured psychosocial therapy.

The authors’ conclusions

Results show that relative to other approaches, cognitive-behavioural therapy did not significantly decrease the likelihood of relapse to heavy drinking among patients prescribed naltrexone or among those prescribed a placebo, and did not augment the impacts of naltrexone relative to an inactive placebo. In the four studies which made direct comparisons, supportive psychotherapy and medical management interventions worked as well. Among the remaining studies, overall those which used a manualised programme such as cognitive-behavioural therapy actually recorded higher rates of relapse than studies which used a more typical, less structured approach.

These results should be viewed in the light of several major limitations. No adjustments could be made for important factors related to the chance of successful treatment such as severity of dependence, and relapse to heavy drinking was the only drinking outcome sufficiently commonly reported to be amalgamated across the studies. Also, the results derived from studies that required initial abstinence and excluded patients with major comorbid disorders, diminishing their applicability to routine practice.

Source: American Journal on Addictions: 2012, 21(6), p. 501–507. April 2015

COMMENTARY The weight of the evidence in respect of treating alcohol or drug dependence is that despite the prominence of cognitive-behavioural therapies, their theoretical pedigree, and an extensive research effort which has distilled them in to expert manuals (for example, 1 2), overall the advantage they confer over alternatives is minor, and especially so when added to a drug-based treatment. In respect of alcohol problems, an analysis has concluded that any variation in outcomes across different psychosocial therapies is likely to have been due to chance or to the allegiance of the researchers.

However, the large US COMBINE trial did find that supplementing inactive placebo pills with psychological therapy incorporating cognitive-behavioural elements raised outcomes to the level of patients prescribed naltrexone. A similar message emerged from another US study which found that as long as naltrexone was prescribed, primary care-style consultations were as effective as specialist cognitive-behavioural therapy in initiating and sustaining recovery from alcohol dependence. Without the medication, cognitive-behavioural therapy was the more effective option. A similar result emerged from the featured review’s analysis of studies which offered the same psychosocial support to all patients; when this was a structured therapy (generally cognitive-behavioural), it helped raise outcomes for placebo patients to the level of those prescribed naltrexone.

All these results suggest that structured therapies can elevate the outcomes of patients not prescribed an active medication to the level of those prescribed naltrexone – that either medication or structured therapy help relative no medication plus typical care. Combining the two does not augment the drug’s impacts – a surprise, since relapse-prevention therapies would be expected to have their own impacts and to give medication greater leverage by persuading more patients to complete treatment and take the pills as intended.

Even if adding structured cognitive-behavioural therapy to naltrexone does not help, the reverse may still be the case – that supplementing cognitive-behavioural therapy with naltrexone makes a more effective package. In several studies (described in these notes) this has indeed been the case. The findings are in line with guidance from the UK’s National Institute for Health and Clinical Excellence (NICE) that in addition to evidence-based psychological interventions, patients whose alcohol dependence is moderate or severe should also be able to access relapse prevention medication, including naltrexone.

Practice implications seem to be that naltrexone can be a valuable supplement to the medical counselling (by GPs or nurses) of dependent drinkers of the kind who might be treated in primary care, especially when specialist therapies such as cognitive-behavioural therapy are refused or unavailable. In some situations these therapies also work better when naltrexone is added. But if the core treatment is naltrexone, a good quality medical care approach or counselling will on average be as effective as specialist structured psychosocial therapies.

Last revised 17 April 2015. First uploaded 10 April 2015

Neuroscientist Woody Hopf opens a cabinet in his alcohol research laboratory at the University of California, San Francisco. Inside is a cage containing a rat that is being taught addictive behaviours. The rat has been conditioned to press a lever to release a squirt of alcohol when it hears a beep. Hopf closes the cabinet so that the rat will not be distracted by the sights and sounds of human visitors. Just as it takes time for people to undergo the characteristic brain changes that enforce addiction, he says, it will take time for his rat to become dependent on alcohol.

Researchers such as Hopf view addiction as a disease of the brain circuits responsible for pleasure, stress and decision-making. “Addictive substances come at the brain in different ways,” says George Koob, director of the US National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Bethesda, Maryland. “But in the end, they’re activating some of the same circuitry and patterns of behaviour.”

For decades, researchers have been mapping the electrical and chemical circuits that underlie addiction. Now they are working on strategies for healing these neural pathways. Imaging studies show how the brain rewires during recovery from addiction. When combined with studies of how the brain develops during adolescence, the work could help researchers to understand how the brain changes that are characteristic of addiction occur, as well as who is most vulnerable and why. This work is rapidly being translated into treatments. By using electrodes and fibre-optic cables, researchers can intervene in neural circuits with great precision, causing animals to lose their taste for alcohol or their interest in cocaine, not just for days but for weeks or months. This work is now being tested in people. Researchers hope that therapies to heal damaged brain circuits will improve the odds of people overcoming addictions.

Crossed wires

Koob divides addiction into three stages, each with its own brain circuit — groups of neurons or larger structures that interact in a characteristic way (see page S46). Addiction starts with the feel-good binge stage, which is fuelled by the brain’s reward circuit, particularly at the nucleus accumbens. Withdrawal brings stress, centred in the emotional amygdala. Finally, craving and compulsion circuits extending from the prefrontal cortex keep someone using a drug, regardless of negative consequences. Impulsive bingeing leads to habits as the user needs the drug to feel normal.

The changes to the brain’s circuitry are long-lasting, so people trying to give up will often relapse. Even years after recovery, people often start using again when some cue, such as the smell of alcohol or the site of an old hangout, retriggers old patterns. But the changes are not permanent. “The brain can enjoy some recovery, probably through remodelling to override the broken parts,” says Edith Sullivan, an experimental psychologist at Stanford University in California.

Some of the physical damage caused by alcohol misuse can be undone. For example, says Sullivan, the brains of people who have misused alcohol for a long period shrink, but some of that brain volume can be regained by sustained sobriety. There is also some functional recovery — even if the pathways are not fully restored, the recovering brain starts to find workarounds.

Sullivan’s group has been using functional magnetic resonance imaging (fMRI) to study cognition in those recovering from alcoholism. A cognitive skill the researchers focused on is spatial working memory — the thinking that helps you to remember where you parked your car, for example. Poor spatial working memory is characteristic of alcohol misuse.

Sullivan’s research suggests that people recovering from alcohol addiction manage to work around brain damage; in other words, their brains find ways of accomplishing tasks by avoiding using damaged areas and they start to regain their working memory1. The group found that alcohol-dependent people who had been sober for at least a month performed as well as non-alcohol-dependent controls on spatial working-memory tasks, but used a different part of the brain to do it. Sullivan gave them a more abstract task than looking for a lost object or a parked car, but like those tasks it required visual processing, which can take one of two broad neural paths. Patients without brain damage typically rely on a ‘where’ pathway to do the task, whereas those in recovery from alcohol dependence activate a ‘what’ pathway, which tends to be used for recognizing and identifying what we see.

“The next step is to find out how to train a person with brain damage to use these new pathways,” says Sullivan. Encouraging the natural recovery process could help people who are dependent on alcohol to make faster progress. Sullivan compares the brain damage from alcohol addiction to that caused by stroke. “Recovery won’t take three days, it may take three or six months, or a year,” she says. It takes time for changes to occur in the brain when someone develops a dependence on alcohol, and it takes time to undo that.

Sullivan is currently investigating whether there is a cost to this rewiring. She suspects that people in recovery are performing the cognitive steps needed for these tasks sequentially, so they take longer than people without addictions who do the steps rapidly in parallel. The damaged brain has fewer circuits to use, so the brain finds it harder to multitask.

Early start

“There is a lot of debate about how harmful substance abuse is for brain development.”

Our understanding of the addicted brain comes from animal studies and from research on people who are already addicted or are in recovery, such as Sullivan’s participants. Researchers can only guess at how these changes develop in people. Henning Tiemeier, a psychiatric epidemiologist at Erasmus Medical Center in Rotterdam, the Netherlands, says that the only way to see these changes is to follow people over time. “There is a lot of debate about how harmful substance abuse is for brain development, and you cannot prove it with one brain image,” he says.

Two studies, one planned in the United States and one already underway in the Netherlands, could provide some answers. Both will follow adolescents. The adult brain is already formed, although it is still plastic, which is why alcoholism and drug addiction become so engrained, and why the resulting damage cannot be fully repaired. The worry, says Koob, is that the developing brain may not form properly under the influence of drugs and alcohol. Children do not have the cognitive skills to make good choices, making them particularly vulnerable. “Young people have a well-developed reward system but they don’t have a good executive control centre,” says Koob. The key part of that centre, in the brain’s prefrontal cortex, does not finish developing until about the age of 25.

The US National Institutes of Health (NIH), a federal agency that includes the NIAAA and the National Institute on Drug Abuse (NIDA), is currently accepting proposals for the Adolescent Brain Cognitive Development study, which will enrol 10,000 children aged 10 and follow them into adulthood, using neuropsychological tests, brain imaging and surveys, focused specifically on addiction.

Tiemeier is working on the Generation R study in the Netherlands, which has a broader focus on fetal and childhood development and has been following 10,000 children from before birth. The youngest are now aged 9, and the oldest are 12, a stage when some will begin experimenting with cigarettes and alcohol.

Generation R is collecting the first set of brain MRI scans from children in the study, and has about 3,300 so far. By continuing to collect them as the children grow, changes over time will become clear. This is by far the largest brain-imaging study on adolescents in the world, says Tiemeier, so it should provide evidence about how substance use affects the developing organ. He does not expect to see major developmental changes associated with the occasional substance use likely to be found in Generation R because it is a general population study, rather than being focused on people who are addicted to a substance. For this reason, such studies need to be as large as possible if they are to find out what damage drug use does, and how it interacts with puberty, when surges of hormones affect behaviour and brain development.

More information will be available when the Generation R data are combined with results from the NIH study, says Nora Volkow, director of NIDA. These studies will provide a better understanding of the brain changes that reflect what she calls “the skeleton of addictive behaviours”. Addiction to cigarettes is different from addiction to heroin, for example, but all addictions have a common neurological framework. These studies will show how it grows. They should also yield insight into who is vulnerable and why, and how they might be helped sooner.

But as further research deepens our understanding of addiction as a disease characterized by changes in the brain, researchers and policymakers need to think about better ways to evaluate medications and therapies, says Volkow. Currently, any pharmaceutical treatment for addiction needs to show that the patient is now completely free of their addiction, which is difficult to prove and takes a long time (see page S53). “Rather than ask for an outcome of complete abstinence, shouldn’t we evaluate these treatments on their ability to counteract these brain changes?” she asks.

Painful realities

This focus on reversing changes to the addicted brain is leading to therapy ideas that are showing promising early results in animals. Hopf’s rat studies, for example, have led to a potential therapy for alcoholism that is focused on countering the compulsion to use despite negative consequences such as the loss of relationships with family and friends, employment or health. Because rats do not fear these outcomes, Hopf uses simpler analogues. In some experiments, alcohol-dependent rats are given extremely bitter alcohol instead of the expected normal flavour, or in the lever-pressing test they occasionally receive a painful electric shock to their paw. “The rats want the alcohol but they are not happy about it,” Hopf says.

After years of painstaking research and some luck, Hopf found that a particular group of neurons in the reward-centred nucleus accumbens has a key role in promoting compulsive drinking. This year, he found that an approved drug called D-serine binds to receptors on these neurons, causing them to fire less often, leading the alcohol-dependent rats to drink less2. It seems to work by disabling the compulsive behaviour — by turning off the power to deny painful realities. Rats that experience bitter or painful consequences drink less when given the drug. Rats have no such negative consequences to fear and are not affected by the drug and drink as normal.

The nucleus accumbens and a denial of the reality of the situation are involved in multiple stages of addiction, according to Koob, and have a role in both intoxication and the withdrawal process. Hopf is now writing up a plan for a clinical trial of D-serine.

Other techniques target addiction circuits by using physical interventions, rather than drugs. Researchers at the University of Geneva in Switzerland led by neurologist Christian Lüscher have used a method called optogenetics to target a particular group of cells and receptors involved in cocaine addiction in mice. Optogenetics allows researchers to turn off gene expression precisely by shining light into the brain through implanted optical fibres. When Lüscher’s group used the method to calm a group of overactive dopamine-receptor neurons in the nucleus accumbens, the mice stopped seeking cocaine3.

However, optogenetics cannot be used to treat people. The method first requires genetic engineering to render the target cells sensitive to light, and it is not yet possible to safely implant optical fibres in the human brain.

Stimulating recovery

Instead, Lüscher’s team is attempting to emulate the effects of optogenetics by using methods that translate better to the clinic. They are developing a variation on deep-brain stimulation (DBS), a technique that uses an electric current to silence overactive neurons, which is commonly used to treat movement disorders such as Parkinson’s disease. By careful placement of the electrodes, clinicians can target DBS to a particular region in the brain. Researchers have tried using it to treat addiction in people, but results have been mixed.

Lüscher is combining DBS with drugs to block particular receptors in the rat brain, making it possible to silence specific cell types. First they implant an electrode in the nucleus accumbens. Then they use a drug that blocks the neurons’ dopamine receptors. Finally, they switch on the electrode for ten minutes. The effects of DBS for treating Parkinson’s are transient: when the electric field is turned off, the tremor returns. But Lüscher’s combined therapy had a longer-lasting effect4. After 10 minutes of stimulation, the rats exhibited normal behaviour for the following 21 days. Lüscher thinks this means that the treatment may be repairing part of the circuit that was damaged by addiction. He says that the group’s next step will be to test this approach in primates, or possibly take it to clinical trials.

This demonstration of an apparently long-term reversal of drug-related behaviour is “a miracle”, says Jessica Wilden, a neurosurgeon at the Louisiana State University Health Center in Shreveport. Could this lead to a therapy in which you give a patient a pill and a day of brain stimulation and then they are drug free? “In a small way that’s what they’re showing,” she says. But doing it in people will be harder, she warns.

Wilden is investigating whether DBS can be used to treat methamphetamine (meth) addiction. Meth affects dopamine receptors (see ‘Methamphetamine misuse’) and is a growing problem, particularly in Iran and in the southern United States, often for military veterans. Unlike other drugs, which tend to be misused mostly by men, meth use is equally common in women, and has a burden on children because women tend to be the primary caretakers, says Wilden.

“I’m trying to set up a stable model of meth abuse, abstinence and relapse in rats, and then try DBS treatment,” says Wilden. It is a huge challenge. The drug is a potent stimulant, with effects lasting for 16–20 hours in the rats; the animals become agitated and stressed, and get tangled up in the equipment used to administer the drug and the cables that connect them to the DBS system.

Although DBS is a helpful research tool, Wilden and Lüscher both doubt whether it can be widely used to treat addiction — and Wilden’s work with meth illustrates the difficulties. The therapy is expensive, invasive and requires patients to care for the implants and to return to the clinic for regular follow-ups. Those motivated to overcome alcoholism might be able to do it. But people with more destructive addictions, particularly to meth, are less cooperative and have high rates of homelessness, making the treatment even less suitable. “The deep-brain stimulator is a pacemaker, with wires going under the skin into the chest where they connect to a battery,” says Wilden. “That’s a lot of metal, especially in people who are fragile. There’s no way I can implant this in someone living on the streets.”

Lüscher and Wilden plan to validate their interventions with optogenetics and DBS in animals, and then adapt the results to clinically realistic techniques. The most likely candidate is transcranial magnetic stimulation (TMS), which uses a magnetic field to stimulate electrical activity in neurons deep in the brain. One advantage is that TMS is non-invasive: treatment simply involves wearing a magnetic helmet for a few minutes. It is currently used to treat depression and migraines.

So TMS is more patient friendly, but it is also more mysterious — researchers do not know why it works. Furthermore, it has poor spatial precision, which frustrates neuroscientists who want to target specific brain locations. But this might not matter, says Antonello Bonci, a clinical neurologist and scientific director at NIDA.

In 2013, Bonci published a paper describing how his team had used optogenetics to reactivate an area of the prefrontal cortex that was abnormally quiet in cocaine-addicted rats5. The treated rats lost interest in pressing a lever to get cocaine. A few months later, Luigi Gallimberti and Alberto Terraneo at the University of Padova in Italy started using TMS to target the equivalent area in the brains of people addicted to cocaine. They have since been successfully using the technique to treat such people.

“It’s up to us to figure out who’s getting better and why, and how many sessions it takes.”

Bonci says that the results are anecdotal, but exciting: most people who stuck with the treatment for a few weeks have now been clean for several months, and testify that they do not even think about cocaine any more, he says. With this black cloud lifted, they are able to enjoy food, sex, reading, family time and all the other good things in life. Bonci is now working with the Italian group to design a double-blind clinical trial, and is collaborating with another group to work out how the TMS works. “It’s up to us now to figure out who’s getting better and why, and how many sessions it takes,” he says.

In addition to TMS, the Italian patients also received supportive medical care and psychological therapy. Even with brain stimulation or medication, people still need emotional support, as well as therapy “to identify triggering cues and memories, and practise making new grooves of thought”, says Hopf. But with tools such as DBS and TMS, neuroscientists’ deepening understanding of the circuitry of addiction is now being translated to the clinic much more rapidly than ever before.

“For the first time in the history of neuroscience, we can think about translating basic science to the clinic in months, as opposed to the 15 years it can take for drug development,” says Bonci. Thanks to the new technologies, he says, “we’re close to a treatment”.

Source:   Nature 522, S50–S52(25 June 2015) doi:10.1038/522S50a

So much has been said and written about addiction, much of it so wisely put by individuals in and out of recovery. One popular adage is “the definition of insanity is doing the same thing over and over again and expecting a different outcome.” In clinical terms, one of the most distinguishing diagnostic features of addictive disorders is that those affected continually and repeatedly revert to their addictive behaviors, despite the devastating negative and adverse consequences.

In my own career and investigative studies as an addiction specialist spanning many decades, I have emphasized that a primary factor that contributes to repeated abuse is that addictive substances temporarily relieve emotional pain and suffering that otherwise feel unmanageable or intolerable. That is, those who endure such distress self-medicate, and they wittingly or unwittingly provide support for the self-medication hypothesis (SMH) of addictive disorders, a theory that has received much endorsement and at least an equal amount of criticism and rejection.

On occasion, I somewhat satirically comment that I believe in the SMH more on some days than others. Although I continue to believe that it is a powerful paradigm to explain addictive disorders, today was one of those times when I found myself thinking it does not satisfy the complexities (or perhaps the subtleties) involved in the bedevilling, repetitious, self-harming behaviors associated with addictions. An e-mail from a former patient with whom I had parted ways because I relocated my office to another community, stimulated my thoughts about the irrationality of addiction and doubt and curiosity about the SMH aspect of addiction.


Matthew is a 55-year-old gifted author and college professor of English studies. After struggling for many years as a heavy drinker, he sought out professional help with only modest progress in obtaining control over his drinking. He finally established abstinence and a protracted period of sobriety (5 years) before he started treatment with me. He then immersed himself in AA meetings where he felt supported and found a caring sponsor to work with him.

For reasons not entirely clear but at least to some extent related to recent stressors (some related to chronic musculoskeletal pain), he resorted to periodically drinking large amounts of alcohol. The following e-mail typified that pattern, in this case indicating that his current drinking was in part celebratory:

Dear Dr K,

I finally felt okay physically last week, when my class began. I had a great week, so much so that I wanted to celebrate/prolong and drank a bottle and a half of wine Friday night. Saturday was a total loss, but I managed to get out and buy one bottle of wine, which I consumed. Feel okay now and am ready for 4 straight days of classes.

Not worried about drinking during the class, but certainly when it ends. The whole thing is very strange. I guess my life was turned upside down by the pain in recent months, not able to go to early morning meeting, etc. But something has to give . . . haven’t quite figured it out. Don’t feel committed to sobriety.

Thanks so much for your text. Would love to come see you, but obviously I need to find someone in the area, sooner than later.     Best,Matt

I responded to his e-mail as follows:

Dear Matt,

Get back to basics. That should include someone to work with you on the insanity of addiction. You know what to do as well as anyone else, and that is to get a safety net of others who care about and love you. YOU CAN’T DO THIS ALONE.

I would also add that I am not entirely surprised about your notion that when you complete your course, you will be more apt to drink. Perhaps success creates the illusion that you can control the uncontrollable and be immune to the consequences of drinking.

And should you continue to delay in finding someone, come see me in the interval for a sanity check.    EJK

I was reminded that persons addicted to substances find countless reasons to drink and drug—to grieve, to celebrate, to heighten feelings, to reduce or drown feelings, to get a job done, to drink when a job is done, and so on. Obviously, the reasons to self-medicate are myriad and the motives, seemingly contradictory.

My response to Matt was guided in part by my unyielding, evolving curiosity and interest in what it is that governs and drives the needs and issues that perpetuate addictions. So notwithstanding the criticisms of self-medication motives, the repetitious nature of the “insanity of addiction” does not necessarily contradict. Rather, it begs the question whether addictive behaviors accomplish or fix anything for those who repeatedly resort to it.

To Matt’s credit, he followed up with several e-mails and a phone call to indicate that he was more aggressively seeking out an addiction counsellor locally to obtain support and to regain control of the drinking.


When addicted persons in recovery speak of the puzzling sense of powerlessness and inability to control their drinking, as Matthew suggests in his e-mail, they also often indicate how the irrationality of it is so painful and bedevilling. As I indicated, the irrational component challenges me as well, on some days more than others, including whether the ideas and theories of addiction psychiatry are sufficient to address and explain what seems so unexplainable and confusing. I offer a few thoughts here, drawing on my clinical experiences and ideas about addiction, which might shed light on what often can seem irrational and incomprehensible. Although modern neuroscience research has yielded important findings on how substances alter the brain and contribute to addictive patterns of use and misuse, such brain changes and mechanisms alone are insufficient to explain the complexities of dependence on alcohol and addictive drugs. I do not suggest that I have all the answers, but I believe that clinical study and treatment of addiction offer valuable insights into repetitious, self-harm behaviors, as unreasonable as they may seem.

In treatment, my patients consistently reveal their life-long difficulties in dealing with their feelings. They have been plagued by issues of poor sense of self and low self-

esteem. Their relationships with others suffer, and they find it difficult to practice self-care. Often they fail to appreciate very real danger—in their surroundings and especially those associated with addiction. I refer to these issues as the human challenge of self-regulation. Persons at risk for addiction are underdeveloped or deficient in some or all of these areas.

In my experience, in the context of experimenting with addictive substances, some people discover (italics for emphasis) that addictive substances provide short-term relief from the pain, suffering, and dysfunction associated with their problems in regulating their emotions, low self-esteem, and difficulties with interpersonal relationships. These factors then malignantly interact with deficits in self-care to make addictive attachments more likely.

Thinking about addiction as a self-regulation disorder “helps” in part to explain how addictive substances assist in regulating a wide range of challenges. Considering addiction from such a perspective provides some measure of understanding for what seems so unreasonable, irrational, and incomprehensible.

Returning to Matthew and his dilemma: he knows that resorting to alcohol will be devastating, but he nevertheless feels powerless to avoid that prospect. As we so often say in our work as psychiatrists and mental health professionals, people have their reasons for what they believe, say, and do, as unreasonable and irrational as it may seem. Addicted individuals, including my patient Matthew, do not have exclusive claim to this aspect of human existence.

See more at:

Source:    3rd March 2015

Filed under: Addiction (Papers) :

Some good news, some not-so-good news about brain recovery from alcohol use disorders

According to a recent review article on recovery of behavior and brain function after abstinence from alcohol[1], individuals in recovery can rest assured that some brain functions fully recover; but others may require more work. In this article, authors looked at 22 separate studies of recovery after alcohol dependence, and drew some interesting conclusions.

First, the good news; studies show improvement or even complete recovery to the performance level of healthy participants who had never had an alcohol use disorder in many important areas, including short-term memory, long-term memory, verbal IQ, and verbal fluency. Even more promising, not only behavior, but the structure of the brain itself may recover; an increase in the volume of the hippocampus, a brain region involved in many memory functions, was associated with memory improvement.

Another study showed that after 6 months of abstinence, alcohol-dependent participants showed a reduction in a “contextual priming task” with alcohol cues; in day to day terms, this could mean that individuals in early recovery from alcohol dependence may be less likely to resume drinking when confronted with alcohol and alcohol-related cues in their natural environment because these alcohol-related triggers are eliciting less craving.- a good thing for someone seeking recovery!

Still other studies showed that sustained abstinence was associated with tissue gain in the brain; in other words, increases in the volumes of brain regions such as the insula and cingulate cortex, areas which are important in drug craving and decision-making, were seen in abstinent alcoholics. This increase is a good thing, because more tissue means more recovery from alcohol-induced damage. A greater volume of tissue in these areas may be related to a greater ability to make better decisions.

Now, the not-so-good news: these studies reported no improvement in visuospatial skills, divided attention (e.g. doing several tasks at once), semantic memory, sustained attention, impulsivity, emotional face recognition, or planning.  This means that even after abstinence from alcohol, people in recovery may still experience problems with these neurocognitive functions, which may be important for performing some jobs that require people to pay attention for long periods of time or remember long lists of requests. These functions may also be important for daily living (i.e. assessing emotions of a spouse, planning activities, etc.).

Importantly, there were many factors that influenced the degree of brain recovery; for example, the number of prior detoxifications. Those with less than two detoxifications showed greater recovery than those with more than two detoxifications.  A strong family history of alcohol use disorder was associated with less recovery. Finally, cigarette smoking may hinder recovery, as studies have shown that heavy smoking is associated with less recovery over time.

So what does all this mean? Recovery of brain function is certainly possible after abstinence, and will naturally occur in some domains, but complete recovery may be harder in other areas. Complete recovery of some kinds of behavior (e.g. sustained attention, or paying attention over long periods of time) may take more time and effort! New interventions, such as cognitive training or medication (e.g. modafinal, which improved neurocognitive function in patients with ADHD and schizophrenia, as well as in healthy groups), may be able to improve outcomes even more, but await further testing.

[1] Recovery of neurocognitive functions following sustained abstinence after substance dependence and implications for treatment

Source:  Mieke H.J. Schulte et al., Clinical Psychology Review 34 (2014) 531–550   October 2014


Teens can’t control impulses and make rapid, smart decisions like adults can — but why?

Research into how the human brain develops helps explain. In a teenager, the frontal lobe of the brain, which controls decision-making, is built but not fully insulated — so signals move slowly.  “Teenagers are not as readily able to access their frontal lobe to say, ‘Oh, I better not do this,’ ” Dr. Frances Jensen tells Fresh Air’s Terry Gross.

Jensen, who’s a neuroscientist and was a single mother of two boys who are now in their 20s, wrote The Teenage Brain to explore the science of how the brain grows — and why teenagers can be especially impulsive, moody and not very good at responsible decision-making. “We have a natural insulation … called myelin,” she says. “It’s a fat, and it takes time. Cells have to build myelin, and they grow it around the outside of these tracks, and that takes years.”  This insulation process starts in the back of the brain and heads toward the front. Brains aren’t fully mature until people are in their early 20s, possibly late 20s and maybe even beyond, Jensen says.

“The last place to be connected — to be fully myelinated — is the front of your brain,” Jensen says. “And what’s in the front? Your prefrontal cortex and your frontal cortex. These are areas where we have insight, empathy, these executive functions such as impulse control, risk-taking behavior.”   This research also explains why teenagers can be especially susceptible to addictions — including drugs, alcohol, smoking and digital devices.

Interview Highlights

On why teenagers are more prone to addiction

Addiction is actually a form of learning. … What happens in addiction is there’s also repeated exposure, except it’s to a substance and it’s not in the part of the brain we use for learning — it’s in the reward-seeking area of your brain. … It’s happening in the same way that learning stimulates and enhances a synapse. Substances do the same thing. They build a reward circuit around that substance to a much stronger, harder, longer addiction.

Just like learning a fact is more efficient, sadly, addiction is more efficient in the adolescent brain. That is an important fact for an adolescent to know about themselves — that they can get addicted faster.

It also is a way to debunk the myth, by the way, that, “Oh, teens are resilient, they’ll be fine. He can just go off and drink or do this or that. They’ll bounce back.” Actually, it’s quite the contrary. The effects of substances are more permanent on the teen brain. They have more deleterious effects and can be more toxic to the teen than the adult.

On the effects of binge drinking and marijuana on the teenage brain

Binge drinking can actually kill brain cells in the adolescent brain where it does not to the same extent in the adult brain. So for the same amount of alcohol, you can actually have brain damage — permanent brain damage — in an adolescent for the same blood alcohol level that may cause bad sedation in the adult, but not actual brain damage. …

Because they have more plasticity, more substrate, a lot of these drugs of abuse are going to lock onto more targets in [adolescents’] brains than in an adult, for instance.

We have natural cannabinoids, they’re called, in the brain. We have kind of a natural substance that actually locks onto receptors on brain cells. It has, for the most part, a more dampening sedative effect. So when you actually ingest or smoke or get cannabis into your bloodstream, it does get into the brain and it goes to these same targets.

It turns out that these targets actually block the process of learning and memory so that you have an impairment of being able to lay down new memories. What’s interesting is not only does the teen brain have more space for the cannabis to actually land, if you will, it actually stays there longer. It locks on longer than in the adult brain. … For instance, if they were to get high over a weekend, the effects may be still there on Thursday and Friday later that week. An adult wouldn’t have that same long-term effect.

On marijuana’s effect on IQ

People who are chronic marijuana users between 13 and 17, people who [use daily or frequently] for a period of time, like a year plus, have shown to have decreased verbal IQ, and their functional MRIs look different when they’re imaged during a task. There’s been a permanent change in their brains as a result of this that they may not ever be able to recover.

It is a fascinating fact that I uncovered going through the literature around adolescence is our IQs are still malleable into the teen years. I know that I remember thinking and being brought up with, “Well, you have that IQ test that was done in grade school with some standardized process, and that’s your number, you’ve got it for life — whatever that number is, that’s who you are.”

It turns out that’s not true at all. During the teen years, approximately a third of the people stayed the same, a third actually increased their IQ, and a third decreased their IQ. We don’t know a lot about exactly what makes your IQ go up and down — the study is still ongoing — but we do know some things that make your IQ go down, and that is chronic pot-smoking.

On teenagers’ access to constant stimuli

We, as humans, are very novelty-seeking. We are built to seek novelty and want to acquire new stimuli. So, when you think about it, our social media is just a wealth of new stimuli that you can access at all times. The problem with the adolescent is that they may not have the insider judgment, because their frontal lobes aren’t completely online yet, to know when to stop. To know when to say, “This is not a safe piece of information for me to look at. If I go and look at this atrocious violent video, it may stick with me for the rest of my life — this image — and this may not be a good thing to be carrying with me.” They are unaware of when to gate themselves.

On not allowing teenagers to have their cellphones at night

It may or may not be enforceable. I think the point is that when they’re trying to go to sleep — to have this incredibly alluring opportunity to network socially or be stimulated by a computer or a cellphone really disrupts sleep patterns. Again, it’s also not great to have multiple channels of stimulation while you’re trying to memorize for a test the next day, for instance.

So I think I would restate that and say, especially when they’re trying to go to sleep, to really try to suggest that they don’t go under the sheets and have their cellphone on and be tweeting people.  First of all, the artificial light can affect your brain; it decreases some chemicals in your brain that help promote sleep, such as melatonin, so we know that artificial light is not good for the brain. That’s why I think there have been studies that show that reading books with a regular warm light doesn’t disrupt sleep to the extent that using a Kindle does.


 An early onset of drinking is a risk factor for subsequent heavy drinking and negative outcomes among high school students, finds a new study. 

Researchers asked 295 adolescent drinkers (163 females, 132 males) with an average age of 16 years to complete an anonymous survey about their substance use. These self-report questions assessed age at first intoxication – for example, “How old were you the first time you tried alcohol/got drunk?”  They also took stock of the previous month’s consumption of alcohol, including an assessment of the frequency of engaging in binge drinking.

“Teenagers who have their first drink at an early age drink more heavily, on average, than those who start drinking later on,” said Meghan E. Morean, an assistant professor of psychology at the Oberlin College, Ohio and adjunct assistant professor of psychiatry at Yale School of Medicine. The findings also suggest that how quickly teenagers move from having their first drink to getting drunk for the first time is an important piece of the puzzle.

“In total, having your first drink at a young age and quickly moving to drinking to the point of getting drunk are associated with underage alcohol use and binge drinking, which we defined as five or more drinks on an occasion in this study,” Morean noted. We would expect a teenager who had his first drink at age 14, and who got drunk at 15, to be a heavier drinker than a teenager who had his first drink at age 14, and waited to get drunk until age 18, researchers emphasised.

“The key finding here is that both age of first use and delay from first use to first intoxication serve as risk factors for heavy drinking in adolescence,” said William R. Corbin, associate professor and director of clinical training in the department of psychology at Arizona State University

The study is scheduled to be published in the journal Alcoholism: Clinical and Experimental Research.

Source:  20th Sept 2014

Many people who struggle with alcohol or drugs have a difficult time getting better. There are many reasons why these people do not get the help they need to get better. Many family members who see their loved ones struggle have a very difficult time in getting their loved ones assistance. Here are six suggestions on how to convince a person struggling with alcohol or drugs to get the help they need to get better. 

1. Family Intervention

The most popular way to get someone the help they need is to do a family intervention. This is when family members and an interventionist get together with the addict to tell them how they love them and wish that they get help to get better. Each family member takes a turn and tells the person how special they are and that they need to get help. The person who is struggling listens and hopefully they become convinced to get the help they need.

2. Talk To The Person On What Will Happen If They Do Not Get Help

Another way to convince the person who is struggling with alcohol or drugs is to get someone who is an expert on addiction and have them do a one on one talk with this person. This expert on addiction should explain to the addict what will happen if they do not get the help they need to get better. Basically, the expert should warn the person of the dire consequences of what will happen if they do not change their ways. The expert should be vivid as possible and hold nothing back. The goal is to convince the person to get help or they will suffer and eventually their life will slowly come to an end.

3. Use The Services of A Professional Or A Former Addict

Try to find a professional or even a former addict who has “Been There” to talk to the person. This is similar to Step Two, however instead of warning the person, these professionals can use their skills to talk and try to reason with the person. These experts are usually trained and can use a proactive approach into trying to convince the addict to get help. The goal is to try to reason and talk with the person so they can get professional help.

4. Find Out The Reasons Why The Person Won’t Get Help

Many people overlook this suggestion. Ask the person who is struggling with alcohol or drugs to list 3 reasons why they will not get help. At first, they will say all kinds of things, but continue to engage the person and get the 3 main reasons why they refuse to get help. It might take a couple of tries but listen to what they say. Once you get the answers, WRITE them down on a piece of paper. Note: Fear and Frustration are huge factors for the person not getting help.

5. Determine The Solutions To Those Barriers

Once you get those 3 reasons, get a professional or an expert to find the solutions to those issues. For example, the person says that they will not get help because they tried a few times and they failed and that they will fail again. Ask a few addiction professionals to find a solution to this issue that will help the addict overcome this barrier. One good answer to this example is the following: “Yes, you tried to get better and failed however this time we will do things differently. We will keep a daily diary of everything you do and you or someone else will document what you do each day. If you stumble or fail you will write down your feelings at the time and why you failed. When you recover from a bad episode you can READ your diary and find out what went wrong. Once you know what went wrong you will know why you failed and will find a way to prevent this from happening again.”

Use your list from step three and list every positive thing that will counter those barriers. When you are finished, present this to the person who is struggling and explain what you came up with. This will help reduce the person’s fears and anxieties and may convince them to get help. Developing a plan to counter their reasons of not getting help will go a long way.

6. Talk to the Person Instead of Talking At Them

Nobody wants to be lectured. Be honest with them and tell them that it will require some hard work on their part but that they can get better. If they don’t get help, they will suffer. The person who is struggling is scared and they need help in overcoming their fears and resistance to getting help. Remember to find out those fears, address possible solutions to those fears, and you will have a better chance of getting through to that person. Hopefully, sooner or later, you will be able to get through to the person. The key is to be persistent. Be very persistent.

Source:  25th September 2014

Patients taking opioid painkillers for chronic pain not associated with cancer — conditions such as headaches, fibromyalgia and low-back pain — are more likely to risk overdose, addiction and a range of debilitating side effects than they are to improve their ability to function, a leading physicians group declared Wednesday.

A leading physicians group has laid out the conditions that should govern the long-term use of opioid painkillers such as OxyContin. (Toby Talbot / Associated Press)

The long-term use of opioids may not, in the end, be beneficial even in patients with more severe pain conditions, including sickle-cell disease, destructive rheumatoid arthritis and severe neuropathic pain, the American Academy of Neurologists opined in a new position statement released Wednesday.

But even for patients who do appear to benefit from opioid narcotics, the neurology group warned, physicians who prescribe these drugs should be diligent in tracking a patient’s dose increases, screening for a history of depression or substance abuse, looking for signs of misuse and insisting as a condition of continued use that opioids are improving a patient’s function.

In disseminating a new position paper on opioid painkillers for chronic non-cancer pain, the American Academy of Neurology is hardly the first physicians group to sound the alarm on these medications and call for greater restraint in prescribing them. But it appears to be the first to lay out a comprehensive set of research-based guidelines that outline which patients are most (and least) likely to benefit from the ongoing use of opioids — and what practices a physician should follow in prescribing the medications for pain conditions.

The statement would govern the prescribing of morphine, codeine, oxycodone, methadone, fentanyl, hydrocodone or a combination of those drugs with acetaminophen. It was published Wednesday in the journal Neurology.

The American Academy of Neurology’s position statement also urges physicians to work with officials to reverse state laws and policies enacted in the late 1990s that made the prescribing of opioid pain medication vastly more commonplace.

The position paper notes that despite a national epidemic of painkiller addiction that has claimed more than 100,000 lives in just over a decade, many of the laws and practices adopted in the late 1990s remain unchanged. It adds that prescription drug monitoring programs — online databases that would allow physicians to quickly check on all controlled substances dispensed to a patient — “are currently underfunded, underutilized and not interoperable across state lines or healthcare systems.” The result is that patients’ tendency to develop a tolerance for opioid drugs — and to require ever-higher doses to achieve pain relief — often go unnoticed. The result is not only addiction and misuse, but an escalating risk of accidental overdose, since opioid narcotics depress breathing and, especially when mixed with alcohol or other sedative drugs, can prove deadly.

In the age group at highest risk for overdose — those between 35 and 54 — opioid use has vaulted ahead of firearms and motor vehicle crashes as a cause of death.

The American Academy of Neurology statement cites studies showing that roughly half of patients taking opioids for at least three months are still on opioids five years later. Research shows that in many cases, those patients’ doses have increased and their level of function has not improved.

In addition to screening patients for depression or past or present drug abuse, physicians prescribing a long-term course of opioids to patients with pain should draw up an “opioid treatment agreement” which sets out the responsibilities of patients and physicians. Physicians should track dose increases and assess changes in a patient’s level of function, and if a specific daily dose is reached (a “morphine equivalent dose” of 80-120 mg) and a patient’s pain is not under control, doctors should seek the help of a pain specialist.

The statement also recommends against prescribing any benzodiazepines or other sedating drugs to patients who take opioid painkillers. And it recommends the “prudent use” by physicians of random urine testing for patients taking opioids to detect misuse of the drugs or abuse of other, non-prescribed drugs. When a physician takes on the care of a patient who has taken opioid painkillers for more than three months and has aberrant behaviour or a history of overdose, he or she should consider a trial aimed at weaning the patient off such medication.

Source:  1st October 2014

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

We can simplify this into two aims:

1. To make things better, then

2. To move on to abstinence

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

The researchers speculated that it could be because:

* fewer people are dying;

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

* that detox is generally unsuccessful, or

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

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

What did they find?

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

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

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

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

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

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

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


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

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

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

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

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

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

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

New evidence shows that ‘God consciousness’ can keep young people off drugs.

Young people who regularly attend religious services and describe themselves as religious are less likely to experiment with alcohol and drugs, a growing body of research shows. Why? It could be religious instruction, support from congregations, or conviction that using alcohol and drugs violates one’s religious beliefs.

Moreover, frequent involvement in spiritual activities seems to help in the treatment of those who do abuse alcohol and drugs. That’s the conclusion of many reports, including our longitudinal study of 195 juvenile offenders that will be released in May in Alcohol Treatment Quarterly.

Fewer and fewer adolescents today are connected to a religious organization. Young people are less affiliated than previous generations, with 25% of the millennial generation unattached to any particular faith, according to a 2010 Pew Research report. The problem is more fundamental than missing church on Sunday. Young people in our study of juvenile offenders seem to lack purpose and are overwhelmed by feelings of not fitting in. Meantime, the legalization of marijuana in several states, the flood of prescription medications, and the availability of harder street drugs gives youth wide access to mind-altering substances.

How do we help them? As one troubled young woman in our study, whom we will call Katie to protect her identity, said: “I started to get better when I started to help out in Alcoholics Anonymous. When we help others, we get connected to a power greater than ourselves that can do for us what alcohol and drugs used to do.”  Katie’s idea, to connect those who are struggling to a “higher power,” may seem too simple. Clinicians remain divided about whether AA’s goal of helping alcoholics find a higher power to solve their problems is appropriate in treatment planning. But new research, including our own study, is beginning to lend support to Katie’s conclusion.

There are two key elements of the 12-step program AA uses: helping others and God-consciousness. Those who help people during treatment—taking time to talk to another addict who is struggling, volunteering, cleaning up, setting up for meetings, or other service projects—are, according to our research, statistically more likely to stay sober and out of jail in the six months after discharge, a high-risk period in which 70% relapse.

Increasing God-consciousness also appears to produce results. Our study showed daily spiritual experiences predicted abstinence, increased social behavior and reduced narcissistic behavior. Even those who enter addiction treatment without a religious background can benefit from an environment where they are encouraged to seek a higher power and serve others.  Nearly half of youth who self-identified as agnostic, atheist or nonreligious at treatment admission claimed a spiritual affiliation two months later. This change correlated with a decreased likelihood of testing positive for alcohol and drugs during treatment.

A connection with the divine and service to others both seem to enhance sobriety. That’s because they provide what young people like Katie have been missing: a deep sense of purpose, opportunities to provide help to other people, connections with others, and the chance to make a difference in the world. This reduces self-absorbed thinking, something AA cites as a root cause of addiction.

Though AA was designed with Christian principles, its founders ultimately developed an approach that did not require participants to hold any particular religious beliefs. But the founders were on to something when they rooted AA core tenets in a connection with a higher power and service to others.   Why might this combination work? Neuroscientists, including Andrew Newberg in his 2010 book “How God Changes Your Brain,” are beginning to uncover what happens to the mind when the unconscious neurological foundations of addiction are short-circuited by spiritual awakening and a new focus on helping others. Neuronal pathways in the brain appear to be instantaneously realigned.

Research suggests that addicts may be prisoners of the left hemisphere of their brain, which tends to ruminate on problems such as social anxiety. But when their right brains are triggered by an intense emotional experience, unexpected solutions appear. Spiritual experience can be an important catalyst to this kind of brain rewiring.

As a teen we will call Ben told us, “I am aware today in sobriety that my thinking has drastically changed. You take a telescope and move it a centimeter, and your whole world changes. Now I ask myself: What can I bring to the table? How can I help?” How does a person rewire their own brain? There are many paths, but some adolescents agree with “Allen,” who told us, “I need a power greater than myself to enter my life.”

Source:  WALL STREET JOURNAL    March 27, 2014 

In 2012, 44.1 percent of 12th graders said there was a great risk in smoking marijuana regularly. These numbers had been steadily declining over the last six years.

Is it Addictive? Marijuana is often thought to not be addictive. However, marijuana—not alcohol— dependence is the number one reason why youth in the U.S. seek substance-abuse treatment. Youth are more likely than adults to become addicted to marijuana. About 4.5 million people in the U.S. meet clinical criteria for marijuana dependence. THC stimulates brain cells to release the chemical dopamine, which creates a euphoric feeling and can lead to a physical addiction. Similar to tobacco withdrawal, people trying to quit marijuana use report irritability, sleeping difficulties, craving, and anxiety.

What is Marijuana? Marijuana is a drug made from the dry, shredded parts of the Cannabis sativa hemp plant. It is usually smoked in hand-rolled cigarettes called joints, in pipes, or in water pipes called bongs. It is also smoked in blunts, which are hollowed-out cigars filled with a mixture of tobacco and marijuana. Marijuana contains a potent chemical called delta-9- tetrahydrocannabinol, more commonly known as THC. It’s very similar to chemicals that the brain naturally produces, and disrupts the function of these chemicals in the brain. Marijuana today is more potent than marijuana of past decades. For a long time THC levels averaged 2.3 percent of the known compounds in marijuana. Today, average THC levels are higher than 8 percent and can go up to 35 percent in medical marijuana.

Tobacco vs. Marijuana

Like tobacco smoke, marijuana smoke contains cancer-causing chemicals. There are 33 cancer-causing chemicals contained in marijuana. Marijuana smoke also deposits tar into the lungs. In fact, when equal amounts of marijuana and tobacco are smoked, marijuana deposits four times more tar into the lungs. This is because marijuana joints are un-filtered and often more deeply inhaled than cigarettes. Marijuana smoke is also an irritant to the lungs, and frequent marijuana smokers can have many of the same respiratory problems experienced by people who smoke tobacco. These include coughing and on most days, wheezing, bronchitis, and greater risk of lung infection.

Other Health Effects

Marijuana has many effects on the brain. It impairs short-term memory and motor coordination; slows reaction time; alters mood, judgment and decision-making; and in some people can cause severe anxiety or loss of touch with reality. Because of these effects, marijuana use more than doubles a driver’s risk of being in an accident. Marijuana also affects the heart. The heart rate is raised 20-100 percent shortly after smoking, an effect which can last up to 3 hours and put users at an increased risk of heart attack. Marijuana use can affect the general quality of the user’s life as well. Daily marijuana users generally report poorer mental and physical health, more relationship problems and lower academic and career success compared to their peers.

Can Marijuana be Medicine?

While TCH has been approved by the FDA as a drug, smoking marijuana has not. This is because there’s no proof yet that the benefits of smoking marijuana outweigh the risks.

Youth and Marijuana

youth and Marijuana

Marijuana use is particularly harmful to youth since the part of the brain that craves pleasure matures earlier than the area that controls our ability to understand risks and consequences. A national study by Monitoring the Future showed that in 2012, 6.5 percent of 12th graders reported using marijuana daily. Marijuana is highly accessible, especially to older teenagers. In 2012, 82 percent of 12th graders reported marijuana as being fairly easy or very easy to get. Studies show that as availability increases, perception of harm decreases.


¨ Tomar, Rajpal C.; Beaumont and Hsieh (August 2009) (PDF), Evidence on the carcinogenicity of marijuana smoke, Reproductive and Cancer Hazard Assessment Branch Office of Environmental Health Hazard Assessment, California Environmental Protection Agency, retrieved 24 January 201

¨ Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2013). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2012. Ann Arbor: Institute for Social Research, The University of Michigan.

¨ Thurstone, C. Understand the Big Deal: How Marijuana Harms Youth. Retrieved February 18, 2013, from http:// How_Marijuana_Harms_Youth_brochure.pdf

¨ National Institute on Drug Abuse. (July 2012). DrugFacts: Is Marijuana Medicine? Retrieved February 18, 2013, from

¨ National Institute on Drug Abuse. (December 2012). DrugFacts: Marijuana. Retrieved February 18, 2013, from

¨ National Institute on Drug Abuse. (October 2002). Marijuana abuse (10-3859). Retrieved from http:// -abuse

Please contact the American Lung Association in CO for more references.


Filed under: Addiction (Papers) :

CHEVY CHASE, MD, AUGUST 12, 2013 – The American Society of Addiction Medicine (ASAM) expresses its concern that the CNN documentary “Weed”, hosted by Dr. Sanjay Gupta, CNN Chief Medical Correspondent, may mislead Americans about the “medical” nature of smoked marijuana.


ASAM, the largest American medical professional society dedicated to the treatment and prevention of addiction, issued a white paper in 2011 that examined the therapeutic potential of cannabis and the role that Medicine, in particular, physicians, play in the delivery of “medical” marijuana. In short, there is some evidence that the cannabis in marijuana has certain palliative properties when it interacts with the body’s endocannabinoid receptor system. However, cannabis used for medicinal purposes is neither standardized nor quality-controlled. Furthermore, it is typically smoked which is not a safe means of drug delivery.


“Dr. Gupta is a respected physician, recognized by many as a medical authority, “offers Dr. Stuart Gitlow, MD, ASAM President. “We are concerned that his endorsement of marijuana as medicine may support the idea that smoked marijuana is safe and non-addictive.” Neither notion is supported by research. According to the National Institute on Drug Abuse, marijuana is an intoxicating drug that impairs memory, motor function, and, when smoked, respiratory health. And, for nearly one in ten habitual users, marijuana is addictive.


“I see more and more patients who regularly use marijuana and many of them are young people”, reflects Dr. Gitlow. “They think marijuana is harmless because it’s ‘medicine’.” In fact, according to the 2011 National Survey on Drug Use and Health (SAMHSA, 2011), the decreasing perception among youths of risk of smoking marijuana from 2007 to 2011 is consistent with the increase in past month marijuana use among youths between 2007 and 2011 (7.9 percent reported using marijuana in the past month in 2011 versus 6.7 percent reporting use in 2007).


ASAM encourages an open and balanced dialogue about the possible benefits and risks of marijuana and is grateful to CNN and Dr. Gupta for advancing this discussion. “Marijuana may prove to have some clinical applications,” says Dr. Gitlow. “But, until and when high quality scientific research supports that and the drug is subject to the same standards that are applicable to other prescription medications, marijuana cannot be called “medical.”


The American Society of Addiction Medicine is a national medical specialty society of over 3,000 physicians. Its mission is to increase access to and improve the quality of addiction treatment, to educate physicians, and other health care providers and the public, to support research and prevention, to promote the appropriate role of the physician in the care of patients with addictive disorders, and to establish Addiction Medicine as a specialty recognized by professional organizations, governments, physicians, purchasers and consumers of health care services and the general public. ASAM was founded in 1954, and has had a seat in the American Medical Association House of Delegates since 1988.

Source:    www.  12th August 2013

Filed under: Addiction (Papers) :

‘‘One drink’s too many and a thousand’s never enough.’’

This has been the mantra for people struggling with alcoholism, warning them against the dangers of having ‘‘just one’’. But what if you had a drink problem and could still have the occasional beer? Could a heroin addict continue to shoot up and consider themselves on the road to recovery?

As Australia grapples with the rise in illicit drug use and a binge drinking culture that shows no signs of abating, a new breed of addiction specialists are reshaping the way we view this complex and insidious problem. Born out of the United States, and also burgeoning in Britain, the ‘‘recovery’’ movement aims to challenge community perceptions of addiction by not only publicly celebrating those working their way out of it, but by redefining what it means to be substance dependent. While still in the fledgling stages in Australia, it’s already causing division within the drug and alcohol treatment sector.

Its most controversial tenet is that abstinence is a personal choice not a necessity. What it means to be recovering from drug or alcohol abuse is, according to the movement’s guiding principles, ‘‘experienced and defined by the individual’’. In essence, recovery is a journey not a destination.

Proponents say it’s a fresh, non-proscriptive approach that takes addiction out of the shadows and offers more chance of success through empowerment and self-determination. But some addiction doctors are concerned that this ‘‘recovery is what you want it to be’’ notion is an ill defined philosophy that undermines traditional medical treatment by letting addicts set their own recovery agenda.

‘‘A big risk of this approach is that the patient no longer becomes a patient, they become a willing servant of their own outcome and therefore if they don’t do well it’s their fault and so you then have a situation where you blame the victim,’’ says Professor Jon Currie, one of Australia’s most prominent drug and alcohol specialists, who is the former head of addiction medicine at St Vincent’s in Melbourne, and now works in private practice. ‘‘It moves away from a medical health model and towards an idea that everyone can do this if they try hard enough. But addiction has complex neurobiology behind it, so for a lot of people if they could have stopped using they would, but they have a brain structure that doesn’t allow them to do this.’’

David Best, a recently emigrated Scottish addiction specialist now working with Turning Point Drug and Alcohol Centre in Melbourne, is leading the recovery movement here. He says critics misunderstand the model and place too much focus on the abstinence-as choice ethos. ‘‘We still say that your best bet is to be abstinent from your primary drug of choice, and if you possibly can be completely sober from psychoactive substances apart from medications, but it’s a personal journey so everyone will be different,’’ Associate Professor Best said. ‘‘The best evidence we have is the length of an addiction career is typically around 27 years from age of first use of psychoactive substance to five years in stable or sober recovery, so it’s a long journey and it’s really more about the journey and the quality of life than whether you happen to be abstinent at a particular time.’’

Kim Riley’s path out of addiction was a long and arduous one that she traces all the way back to that first sip of alcohol, aged 10. At her lowest point she was waking up in the middle of the night for a fix. The three bottles of wine she’d start drinking from breakfast time were never enough. Now a drug and alcohol counsellor, the 40-year-old from Parkdale has been sober for 3 1/2 years, and is an advocate of the recovery approach.

After trying moderate drinking following stints in rehab she ultimately decided abstinence was her best option, although she says she respects those who take a different path. ‘‘I still had in the back of my mind that I would have a champagne on New Year’s Eve. Some people might be able to be that social drinker but I couldn’t,’’ she says.

One of the approach’s other key principles is encouraging those who have struggled with addiction to go public with their experiences. Advocates believe that while traditional Alcoholics/Narcotics/Gamblers Anonymous 12-step programs have helped countless people, the insistence on anonymity may also have inadvertently exacerbated the shame and silence surrounding addiction.

Indeed, when Fairfax Media approached Alcoholics Anonymous Australia’s general services officer for an interview, he agreed but only if his name was not published. ‘‘We don’t want to be known as some secret, unknown society that doesn’t celebrate that we’ve found a solution that works, but we do ask that members don’t get in front of a television camera recognisable or nominate their name in a radio or newspaper interview. AA has a spiritual approach and we don’t want to big note ourselves,’’ he said.

Ms Riley believes sharing her story has played a key part in her conquering her addiction. ‘‘Not only does it make your own recovery stronger but it instils within other people the idea of hope, and as you watch them get better it reinforces the belief that your life is just going to continue to get better,’’ she says.

Recovery proponents say secrecy surrounding drink and drug problems, while arguably vital in the early stages of treatment to build trust among members at ‘‘tell-all’’ support group meetings, has also helped entrench stereotypes.

“The old guy on the park bench drinking whisky from a paper bag is the visible alcoholic, everybody sees him. The guy who’s a professional and living in Toorak is invisible but there are just as many of them, they’re just being hidden by their families,’’ says George Thompson, program director of Recovery Foundation, a Melbourne addiction treatment program that embraces aspects of the recovery approach. ‘‘The AA model works and it has helped millions of people, but one of the biggest drawbacks of those 12-step groups has been anonymity. Alcoholism and addiction in general is an illness. It’s a serious mental disease. Why are we anonymous about somebody who has a mental health problem?’’

The success of organisations such as beyond blue and headspace in de-stigmatising depression and mental illness has largely been driven by their ability to put people with lived experience in front of journalists and TV cameras. The subsequent shift in public consciousness has inspired those in the addiction space.

David Best hopes to have a similar effect with Recovery Academy Australia – an organisation he set up to support and celebrate people dealing with addiction. Based on events he staged in Glasgow, he started an annual ‘‘recovery walk’’ in Melbourne last year to publicly celebrate the journeys of those navigating the addiction pathway, and the friends and family who support them. The inaugural event attracted 400 people, and today the second walk from Federation Square is expected to draw an even bigger crowd.

This public affirmation is part of the recovery movement’s core belief that messages of hope have a social contagion effect. The visible presence of recovering alcoholics, gamblers and drug users coming together in a major city centre also challenges stigma and discrimination, he said. ‘‘It makes it apparent that yeah, addiction is a terrible blight but people do overcome it, they do get on with their lives. . .The notion of it somehow being this chronic relapsing condition that leads to degradation and death is unhelpful, for family members, and for the people who are going through it.’’

Another concern in the treatment sector is that governments will capitalise on the recovery model’s growing popularity by cutting back on addiction services in favour of cheaper recovery-based approaches. Already, there are signs that the Victorian government has been captivated by the approach. In its recently released four year plan to tackle the state’s alcohol and drug toll it promised to deliver a ‘‘redeveloped, recovery-oriented alcohol and drug treatment system’’. ‘‘So you get a relatively cheap service which provides some support and the rest is up to the family and the person and their support group,’’ Professor Currie says.

For Kim Riley, recovery is, above all, about hope. ‘‘It’s time to break that stigma and this is an opportunity for people to say you don’t have to keep going down that same path, you can turn things around and find success. I feel just really a part of life now, which is a feeling that I’ve not ever experienced before.’’

Source: ? Melbourne Age May 2013

Review of the application of positive psychology to substance use, addiction, and recovery research. (link to:

If unable to obtain a copy by clicking on title above you could try asking the author for a reprint (normally free of charge) by adapting this prepared e-mail or by writing to Dr Krentzman at

The contemporary recovery movement in addictions and the positive psychology movement in the broader field of psychological health have recently grown in prominence but almost entirely in parallel streams, yet the overlaps and possible synergies between them suggest that an integration could be a step forward in recovery from addiction.


This review and conceptual analysis explores the overlaps and differences between (only briefly mentioned in this account) and research findings relating to two relatively new movements in psychology and addiction. Over the past decade, both fields independently recognised their work focused disproportionately on illness and pathology. Scholars in psychology called for the scientific study of human flourishing, which become the fast-growing subspecialty of positive psychology, while scholars in addictions research called for a new focus on recovery and sobriety, which became realised in the grassroots recovery movement.

Their similarities are in the emphasis on wellness rather than illness, and optimism that people can not only overcome pathology but develop more positive lives. However, they differ in important ways. The addiction recovery movement is a multifaceted grassroots effort led by people in recovery from substance use disorders, built on a recovery-oriented rather than pathology-oriented framework. Participants in the recovery movement work collectively to remove obstacles to treatment, support multiple paths to recovery, and make broader social systems more supportive of recovery lifestyles. The distinctive focus is primarily on macro-systemic change targeting policies, treatment systems, community resources, and social phenomena including stigma.

While the recovery movement has grass roots, positive psychology was sprouted in academic soil, but quickly spread to sections of the general population eager to improve their lives, lending it the character of a larger movement spreading beyond academia. Although positive psychology is concerned with positive organisations, its primary emphasis has been psychological change at the level of the individual. It recognises that there is more to mental health than the absence of mental illness – strengths, well-being, optimal functioning and flourishing. Flourishing individuals have been defined as “filled with emotional vitality … [and] functioning positively in the private and social realms of their lives”. Rather than seeking to overturn previous ‘psychologies’, positive psychology emphasises what it sees as some important but previously neglected perspectives.

Within this perspective, a positive intervention is defined as “an intervention, therapy, or activity primarily aimed at increasing positive feelings, positive behaviors, or positive cognitions, as opposed to ameliorating pathology or fixing negative thoughts or maladaptive behavior patterns”. A subset of these interventions called ‘positive activity interventions’ can be completed without professional help. Two widely tested examples which may have potential in substance use disorders are the gratitude intervention called Three Good Things (write down three things that went well each day and their causes every night for a week) and the optimism intervention, Best Future Self (write

down the realisation of all of your life dreams when in the future everything has gone as well as it possibly could).

Main findings

Recovery approaches

So far limited work on contemporary recovery approaches to addictions suggests that new recovery institutions are filling a gap left by traditional professional treatment and mutual aid groups, and that continuing care interventions may offer benefits beyond those provided by acute care.

Some of the strongest findings (because they derive from randomised trials) related to the Oxford House recovery homes where individuals in recovery live, share expenses, and provide mutual abstinence-specific social support and other forms of concrete and emotional assistance. Residents themselves manage the business of the household and there are no limits on stays. For the randomised trial researchers recruited 150 adults from inpatient units in Illinois who agreed to be randomly allocated to usual care (the control group) or to apply to Oxford Houses. Compared to the control group, over the two-year follow-up period fewer Oxford House assignees were using alcohol or drugs or charged for a recent offence and more were employed. By the end fewer than half as many (31% v. 65%) were using alcohol or drugs, a third as many were in prison (3% v. 9%), and average earnings were substantially higher. All these differences were reported as statistically significant. Additionally, at two years 27% more Oxford House assignees had their own accommodation and nine more mothers had regained or retained custody of their children.

Another set of findings from randomised trials support the recovery movement’s insistence that addiction should be treated as a chronic rather than acute disorder, implying long-lasting or open-ended support. Two trials have tested so-called ‘recovery management checkups’, quarterly meetings between counsellors and clients that take place consistently for two or three years – longer than traditional aftercare models – and treat each follow-up as an opportunity for intervention. After improvements were made, in the later trial checkup patients were more likely than controls to re-enter treatment if needed and received more treatment, attended more self-help meetings, achieved more days of abstinence, and lived in the community for shorter periods in a state where they needed, but did not receive, treatment. [Editor’s note: these and other studies have recently been reviewed, the results of which led an expert panel to argue that extended and regular monitoring of patient progress was the key component of continuing care and one with the greatest evidence of effectiveness.]

Positive psychology How well do positive psychology interventions work? Beyond the addictions, a meta-analysis of 51 randomised controlled studies of positive interventions amalgamated data from studies of healthy individuals and those suffering from depression. It found beneficial impacts in the form of moderate effect sizes for well-being and depression.

But a closer look at the research reveals that ‘it works’ would be too simple a verdict. In one body of work statistically significant differences were found when gratitude interventions were contrasted with ‘hassles’ conditions which ask participants to list things that irritate, annoy, or bother them, but not when they were compared to nothing intended to be an active intervention, except among groups more at risk than healthy populations. An emerging pattern suggests that those at a slight or great disadvantage, either because of illness, feeling bad, or being highly self-critical, seem to benefit more from a gratitude intervention than healthier individuals. In respect of substance use, just one study (conducted in the UK) has applied positive psychology, in this case during group therapy of ten 14–20-year-olds attending an alcohol and drug treatment service for young people, comparing their results to a control group of ten not offered this extra intervention until later. The eight-week intervention promoted positive emotions, savouring, gratitude, optimism, strengths, relaxation, meditation, goal-setting and change, relationships, nutrition, physical activity, resilience, and growth. Compared to the controls, it led to greater increases in happiness, optimism, and positive emotions, and a much greater but (given small samples and highly variable levels of drinking) not statistically significant remission in symptoms of alcohol dependence.

Though these are the only findings specifically testing effectiveness, engagement in anti-relapse mutual aid and variables related to relapse to dependent substance use have been found to be related to key constructs in positive psychology. For example, among 126 former problem substance users abstinent for at least six months, the construct of ‘hope’ was strongly and positively correlated with other positive psychology constructs and with relapse-related variables including having a sense of purpose in life, social support, self-efficacy and psychiatric symptoms. The same was generally not the case however for ‘spiritual transcendence’ and ‘flow’ – the experience of losing oneself in pleasing, enjoyable activity.

In another study of 164 AA members sober for at least a year, the intensity of affiliation to AA was significantly associated with optimism, gratitude, purpose in life, and spirituality. However, this sample were relatively well-off and well educated and highly involved with AA.

These findings suggest that hope is possibly important in sustaining recovery, and are in line with findings that spiritual/religious practices are a mechanism via which AA affiliation affects drinking.

The author’s conclusions

Despite tremendous growth in both positive psychology and the recovery culture, only the nine studies reviewed in this article have so far explicitly applied the discoveries of positive psychology to substance use, addiction treatment, and recovery, yet in other sectors these approaches have become prominent. The recovery movement has historically been an initiative for macro systemic change, while positive psychology has historically promoted micro interventions designed to create change at the level of the individual. Integrating the two can more comprehensively engage the spectrum of care necessary to adequately address addiction.

Source: 17th October 2012 Krentzman A.R. Psychology of Addictive Behaviors: 2012

Filed under: Addiction (Papers) :

Alan Markwood
June, 2012


Confusion about whether a “gateway” effect is part of young people’s development of substance use is not surprising, given the wide variety of interpretations of “gateway effect.” Also, in discussions of gateway drug use marijuana plays a key role, and marijuana itself is widely misunderstood. Some clarification is needed, starting with marijuana and then the concept of gateway drug use.

Perceptions of Marijuana

There are a number of aspects of marijuana that have been poorly understood or misunderstood. A number of reasons can be given for such misunderstandings, including:

1. Increase in average potency of marijuana over the past 3-4 decades. The potency of marijuana’s primary psychoactive ingredient, THC (tetrahydroannabinol), has at least doubled in the past fifteen years. Going back thirty years, the potency of marijuana typically smoked in the U.S. may have been a third or less of average current potency. Effects of the drug that were imperceptible or mild for most users in the 1970s and 1980s are becoming more severe and more common.

2. Efforts by legalization advocates to present marijuana as being relatively harmless. Advocacy for legalizing marijuana cannot succeed unless marijuana is believed to have only mild negative effects (at worst) on marijuana users and on communities as a whole. So, whenever advocacy for marijuana legalization is prevalent, along with it come statements minimizing the magnitude of any problems associated with marijuana use.

3. Differences between marijuana’s method of acting and the more common patterns of other illicit drugs. Marijuana is a fat-soluble drug, unlike most others typically used. Rather than just circulating in the bloodstream, and quickly clearing from the body after use, THC is absorbed into fatty tissue in various parts of the body, and only slowly is eliminated. Four relatively unique effects based on this are the lingering effects, potential for unending effects, low overdose impact, and blunting of withdrawal symptoms.

a. Lingering Effects: Studies have shown that while a perceived “high” from marijuana may last about two hours after use, residual impairments of various skills can linger up to 24 hours.

b. Potential for Unending Effects: With a half-life of 3-4 days after using marijuana, THC can actually be continually affecting a person if the person’s rate of marijuana use exceeds their rate of elimination of THC from their body..

c. Low Overdose Impact: Because THC goes partly into fatty tissue rather than all circulating in the blood, there is typically little permanent damage from a single heavy dose, and marijuana overdose deaths don’t occur.

d. Blunting of Withdrawal Symptoms: Because THC is eliminated so slowly from the body, symptoms of withdrawal when marijuana use stops can be less

apparent than is the case for some other drugs. This has contributed to a perception of lack of addictive potential, but as average THC content has increased, withdrawal symptoms have become more common. Scientifically, the fact that some users become addicted has been established beyond doubt. As stated by NIDA (the National Institute on Drug Abuse), “Estimates from research suggest that about 9 percent of users become addicted to marijuana; this number increases among those who start young (to about 17 percent) and among daily users (25-50 percent).”

4. Impact of marijuana on users’ perception, memories, and judgment/decision-making skills. The hallmark short-term effects of marijuana use include “distorted perceptions, memory impairments, and difficulty thinking and solving problems” (NIDA). So, if a marijuana user (especially one with frequent and/or heavy use) is asked during or after use about any negative effects, they often may have forgotten or not noticed in the first place any decrease in mental skills under the influence. The accuracy of self-reports about marijuana use is spotty, and omissions are likely, even if the person giving the report is himself/herself convinced of its accuracy.

Gateway Phenomenon Described

One aspect of marijuana use that has been consistently misunderstood has to do with the ways that it does or doesn’t function as a “gateway” drug. Before discussing how it does function as a gateway drug, and implications of that, let’s review some of the many ways in which one’s definition of “gateway” may not apply to marijuana.

* If gateway means that marijuana is typically the first drug used, marijuana isn’t a gateway drug. Alcohol would better fit that definition.

* If gateway means that marijuana is always the first drug used among all “scheduled” (controlled) drugs, marijuana isn’t a gateway drug. Marijuana is very often the first illicit drug used by those who use one or more illicit drugs, but some others can also be common. During the past decade, the number of instances of prescription drugs being the first controlled substance used (with alcohol and tobacco not being included in the definition of “controlled substance”) has grown rapidly, apparently due to the rapid growth of prescriptions for narcotic drugs.

* If gateway means that marijuana is always in a sequence that starts with alcohol or tobacco, then marijuana, and then other drugs … marijuana isn’t a gateway drug. That sequence is common, but so are a few others.

* If gateway means that most young people who use marijuana go on to use other drugs, marijuana is not a gateway drug. The truth is that although hardly anyone starts use of a “post-gateway” drug like cocaine, meth, or heroin without having already used either alcohol, tobacco, marijuana, or some combination among those three gateway drugs, the majority of young people who have used marijuana will not go on to other illicit drugs. The real gateway effect isn’t that everyone who reaches a gate goes through it, but that: 1) Any who have reached the other side are very likely to have come through a gate, and 2) Any who turn away before reaching the gate are extremely unlikely to later find themselves beyond the gated wall. In other words, 1) Most of the people who use cocaine, meth, or

heroin (or some other “post-gateway” illicit drugs) have used marijuana, either concurrently or previously, and 2) Among the people who have never used marijuana, use of any “post-gateway” drugs is extremely rare.

Does this description of “gateway drug use” mean something important enough to merit sorting through all the potential confusion in order to understand it? I’d say it does. First, I’d define a gateway drug as the first drug of abuse used regularly (at least once a month) by a young person who begins regular use of a substance. That definition fits across most times and places, while the following two sentences are more specific to the United States and to the past ten years. A person’s gateway drug could be alcohol, tobacco, marijuana, or inhalants. Rarely it could be some other drug, particularly a prescription or over the counter drug used for psychoactive effect rather than as directed.

The current prevalence of teen use of each of the listed substances in the United States gives an indication of the relative role of each as a gateway drug, even though the picture is complicated by the many instances of multi-drug use. According to the national “Monitoring the Future” findings, the “30-day prevalence of use” by 10th grade students in 2011 for: alcohol was 27.2%; tobacco/cigarettes was 11.8%; tobacco/smokeless was 6.6%; marijuana was 17.6%; and for inhalants was 1.7%. Youth use of tobacco used to be (in the 1990’s) consistently between the alcohol prevalence and marijuana prevalence, but youth tobacco use decreased a great deal in the past decade, while teen use of marijuana decreased until about five years ago and has since risen.

Now, revisit the statement that,

“The real gateway effect isn’t that everyone who reaches a gate goes through it, but that: 1) Any who have reached the other side are very likely to have come through a gate, and 2) Any who turn away before reaching the gate are extremely unlikely to later find themselves beyond the gated wall.”

Although quantifying “extremely” can vary according to things like what’s defined as the “gateway” substance(s), or the population studied, the percentages are usually more than 90% and often near 99%. As an example, consider data from a 2002 study by the U.S. Dept. of Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies (Gfroerer, J. C., Wu, L.-T., & Penne, M. A. (2002). Initiation of Marijuana Use: Trends, Patterns, and Implications (Analytic Series: A-17, DHHS Publication No. SMA 02-3711). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies.) In this study, the “gateway” was only marijuana use, and among the results studied were the extent to which age at first marijuana use was related to later use of either heroin, cocaine, or “any psychotherapeutic” (prescription) drug used “non-medically”. These results were based on information from adults age 26 or older who participated in the government’s main national survey of adult substance use. Two of the findings shown in the results were:

1. Among adults who had never used marijuana, only 0.1% (that is, one-tenth of a percent) had used heroin, only 0.6% had used cocaine, and only 5.1% had used prescription drugs for non-medical (i.e., “recreational”) effect.

2. For each substance (heroin, cocaine, or prescription drugs used for subjective effect rather than medically), there was consistently a pattern of decreasing

prevalence of use as age of first marijuana use categories went from “14 or younger” to “15-17”, then “18-20”, then “21 or older”, and finally “never used marijuana.” In regard to cocaine use, for example, the percent of people who had used cocaine, among the people who started marijuana use at age 14 or younger, was 62.0%. Looking at all who started marijuana use at ages 15-17; then 18-20; then 21 or older; and finally those who had never used marijuana, the respective percent who used cocaine went from 40.9% to 28.8%, then 16.4%, and finally 0.6% among those who never used marijuana.

In this particular example, “Any who turn away before reaching the gate are extremely unlikely to later find themselves beyond the gated wall,” means that only 0.6% of those who had never used marijuana later used cocaine (343,021 divided by 57,170,147). And, “Any who have reached the other side are very likely to have come through a gate” means that of the 1,341,359 adults who had used cocaine in their lifetime, nearly 75% (998,338) had previously used marijuana.

Gateway Phenomenon Applied

The prevalence of alcohol use and of other drug use increases as a cohort of youth (e.g., those born between 1995 and 1998) move through their junior high and high school years. During those years, alcohol, tobacco and marijuana are the drugs most prevalent among youth, but the majority of youth don’t regularly (at least once a month) use any of those gateway substances. Of those who do regularly use at least one, most use only one. However, regular use of just one raises the odds of use of a second, and each additional drug used raises the odds that even more will be used. In other words, drug use raises the odds of more drug use. What is behind this pattern of use?

Once a single gateway substance is regularly used, a number of potential risks based on use of that substance can strongly affect whether regular use of a second (or third, etc.) substance is begun. Here is one list of many possible ways that regular use of one gateway substance can increase risk of other drug use:

1. The lack of observed major negative effects on oneself and on peers who are using a substance can seem to validate a young person’s perception that trying to get high isn’t as dangerous as many adults warn it is. Some youths may recognize that heavy use of a substance or use of more than one substance raises the risk, but other youths may not see this.

2. Even if risk is perceived, it can be overtaken by the appeal of repeating a “high”, especially to the extent that dependency is developing. The sensation of being high can be extremely motivating, especially to persons more vulnerable to that effect. An extension of this is that in some instances regular use of one substance may chemically “prime” the brain for use of other substances that affect the brain similarly. The existence of this kind of “priming” has been documented, but how often this happens is not yet known.

3. When a young person connects with a substance-using peer group:

a. His/her perception of peer norms can be skewed toward drug use.

b. His/her access to a variety of substances may be facilitated by the group.

4. Depending on the interaction of a) substance(s) used; b) user vulnerability; and c) frequency of use, gateway substance use can impair key aspects of thought involved in decision making about other drug use. Marijuana is particularly suited to this effect due to the combination of its subtle, yet measurable impact on thought and the longer amount of time it remains in a person, compared to drugs that aren’t fat-based.

With the above discussion in mind, consider one key question about marijuana’s role as a gateway drug: Given that there is some gateway effect between marijuana use and use of other drugs, is that effect due to marijuana use causing increased risk of other substances (whether chemically or via situational factors such as interaction with other drug users), or due to marijuana use being an indicator of a young person who, for other reasons, is at elevated risk for a variety of problems? Recent research (e.g., “Is It Important to Prevent Early Exposure to Drugs and Alcohol Among Adolescents?”, Odgers et al, Pscyhological Science, v 19, n10, pp 1037-1044) shows that both are true: Some youth have problems early in life that put them at future risk of multiple other problems, but:

1) An equal (or greater) number of youth don’t have such problems, but become likely to have other youth or adult problems if they begin substance use at an early age.

2) Youth who are already at higher risk due to problems early in life and who begin substance use early in adolescence become even higher risk for a variety of problems.

3) The above observations hold true even if just alcohol is used by young teens, but the effects are worse for those with “poly-substance” (usually alcohol and marijuana) use.

So, regarding causation, research results suggest the following:

1. Some youth are more at risk of multi-substance use even before they start regular use of a gateway drug, but their risk increases with regular use of a gateway substance.

2. Three dimensions of youth alcohol, marijuana, or other gateway substance use that can greatly heighten the probability of multi-substance use, drug dependence, and a number of other problems are how early in life the regular use begins, how frequently the substance is used, and how heavy a “dose” is typically used.

3. The earlier that a teen or pre-teen starts use of marijuana (or alcohol), and the heavier and more frequent their use, the greater the likelihood that their rapidly increasing risk of multi-substance use and other problems is at least partly (and perhaps substantially) caused by the gateway substance use.

The term “causation” as used in this discussion doesn’t mean that use of one gateway substance dooms a person to using additional drugs: typically more youth do not progress to other drug use than do. However, for many who do progress, use of the first substance and the results of that use often can make the difference. The most typical pattern is alcohol as the first substance, but marijuana can be that first substance and in many cases is at least the first illicit drug used. In either case, marijuana use serves as a potential gate to other use. Most youth may not proceed through that gate, but the percent of marijuana users among those who go on is very high. So is the percent of alcohol users. The odds multiply if both those substances are used. Some people may prefer to say that marijuana

use “can contribute to risk for other drug use,” to emphasize that there are multiple factors involved, and that marijuana use certainly doesn’t guarantee any further use of any drug. Such a view is most appropriate when considering one person’s experiences. There is variation among individuals, so in regard to any one person, the role of marijuana use in the development of other drug use may not be clear. However, when large groups of young people are considered, there is no doubt that increases in marijuana use will result in more use of other drugs among that group or population. Increased marijuana use causes much of the increase in other drug use, by multiplying the risk already present at the start of regular use of marijuana.

In the 1970’s public opinion about marijuana was biased toward the negative. Today, with the (previously discussed) confusion about marijuana effects, public opinion is becoming very biased in the other direction. The toll taken on individuals and on society by marijuana use is growing at the same time public perception of individual and societal damage from marijuana is decreasing. One of the least well understood aspects of marijuana’s potential effect on individuals and marijuana’s measurable negative effect on communities is the way in which marijuana use can play a causal role in the development of other substance use. It is not “the” cause of other use, but is one of the most powerful contributing causes, in terms of increased risk to the individual and increased damage to populations. Marijuana users and others in favor of allowing use may continue to deny this gateway effect, but their denials don’t invalidate the consistent findings of objective study of population-wide substance use patterns.

Filed under: Addiction (Papers) :

July 30, 2012

Physicians should take lead against efforts in Colorado, Washington and Oregon.

The American Society of Addiction Medicine (ASAM) opposes proposals to legalize marijuana anywhere in the United States, including three state measures on November 2012 ballots.

Legalization initiatives in Colorado, Washington and Oregon create unacceptable risks to public health, according to a white paper approved by the ASAM Board of Directors at its July 25 meeting. Physicians and other health professionals must learn more about the real health threats posed by marijuana use, all of which are made worse by legalization. Physicians should encourage public education about these facts and lead efforts against ballot initiatives to legalize marijuana, the report said.

ASAM is the nation’s foremost association of physicians dedicated to the diagnosis and treatment of the disease of addiction.

“ASAM has brought to bear its commitment to science and public health in taking a strong position against marijuana legalization,” said Robert DuPont, M.D., the report co-author, who is a former White House Drug Czar and former director of the National Institute on Drug Abuse (NIDA). “ASAM can provide leadership to all physicians and all medical associations about the dangerous and seductive mirage of drug legalization, including marijuana legalization, as a so-called solution to serious health problems resulting from drug use.”

ASAM asserts that the significant public health problems and costs related to marijuana legalization are not well-understood by the public or policymakers. ASAM’s conclusion that marijuana legalization would threaten public health is based on the following:
•Marijuana use is neither safe nor harmless. Marijuana contains psychoactive cannabinoids which can produce a sense of discomfort and even paranoid thoughts in some users. Cannabinoids interact with brain circuits in comparable ways to opioids, cocaine and other addictive drugs. Marijuana use is associated with damage to specific organs and tissues and impairments to behavioral and brain functioning.
•Of greatest concern is marijuana use during adolescence—a time of ongoing brain development and heightened vulnerability to addiction. Research shows that heavy marijuana use decreases neurocognitive performance, with worse neurocognitive effects seen among those who begin marijuana use early.
•Marijuana is addictive. Repeated marijuana use is reinforcing because the drug increases activation of reward circuitry in the brain. Approximately 9% of people who try marijuana become dependent. For those who begin using the drug in their teens, approximately 17% become dependent. These figures are similar to alcohol dependence.
•Legalization would promote the public perception that marijuana is harmless at the same time that availability of the drug would grow exponentially. The rate of marijuana use and marijuana-related substance use disorders, including addiction, would increase.
•Increased marijuana addiction would heighten demand for substance use disorder treatment services, which already are inadequate for current needs.
•Marijuana use is associated with increased rates, and worsening symptoms, of psychosis. Increased marijuana use caused by legalization and increased access to high-potency marijuana could result in rising rates of psychotic illnesses.
•Marijuana-related crashes are major traffic safety threats; marijuana use doubles the risk of a crash. Research in Washington State showed that 12% of drivers killed in car crashes were positive for marijuana. Legalization would increase drugged driving.

Marijuana legalization will increase its availability to young people, who are the most at risk from this drug. Research shows that marijuana leads to a host of significant health, social, learning and behavioral problems in young users.

“Children who use marijuana are more likely to struggle in school, because it impairs their ability to concentrate and retain information during their peak learning years when their brains are developing,” said Andrea Barthwell, M.D., the report co-author who is a former ASAM president and former Deputy Director for Demand Reduction in the Office of National Drug Control Policy. “Even short-term use can cause problems with memory, learning, cognitive development and problem solving. Research shows a clear link between adolescent marijuana use and a decrease in academic achievement.”

ASAM has previously issued policy statements urging that people addicted to marijuana, like those addicted to any drug, should receive treatment rather than punishment for their illness. That position, however, makes no reference to the question of legalization, the report stated.

“ASAM believes that addiction should be primarily treated as a health issue rather than a criminal justice issue,” said Stuart Gitlow, M.D., ASAM Acting President. “But that does not mean we would support a social experiment dramatically changing the legal status of marijuana and resulting in an upsurge in marijuana use. Health problems caused by marijuana would grow with increased use; marijuana addiction rates would undoubtedly rise. ASAM must oppose any public policy changes that would cause a significant increase in addictive substance use.”

Source: ASAM White Paper 26th July 2012

A NIDA-supported clinical trial, the Maternal Opioid Treatment: Human
Experimental Research (MOTHER) study, has found buprenorphine to be a safe and effective alternative to methadone for treating opioid dependence during pregnancy. Women who received either medication experienced similar rates of pregnancy complications and gave birth to infants who were comparable on key indicators of neonatal health and development. Moreover, the infants born to women who received buprenorphine had milder symptoms of neonatal opioid withdrawal than those born to women who received methadone.

Methadone and buprenorphine maintenance therapy are both widely used to help individuals with opioid dependence achieve and sustain abstinence. Methadone has been the standard of care for the past 40 years for opioid-dependent pregnant women.

However, interest is growing in the possible use of buprenorphine, a more recently approved medication, as another option for the treatment of opioid addiction during pregnancy.

“Our findings suggest that buprenorphine treatment during pregnancy has some advantages for infants compared with methadone and is equally safe,” says Dr. Hendrée JonesExternal link, please review our disclaimer., who led the multicenter study while at the Johns Hopkins University School of Medicine and is now at RTI International.

A Rigorous Trial Design
Methadone maintenance therapy (MMT) enhances an opioid-dependent woman’s chances for a trouble-free pregnancy and a healthy baby. Compared with continued opioid abuse, MMT lowers her risk of developing infectious diseases, including hepatitis and HIV; of experiencing pregnancy complications, including spontaneous abortion and miscarriages; and of having a child with challenges including low birth weight and neurobehavioral problems.

Along with these benefits, MMT may also produce a serious adverse effect. Like most drugs, methadone enters fetal circulation via the placenta. The fetus becomes dependent on the medication during gestation and typically experiences withdrawal when it separates from the placental circulation at birth. The symptoms of withdrawal, known as neonatal abstinence syndrome (NAS) include hypersensitivity and hyperirritability, tremors, vomiting, respiratory difficulties, poor sleep, and low-grade fevers. Newborns with NAS often require hospitalization and treatment, during which they receive medication (often morphine) in tapering doses to relieve their symptoms while their bodies adapt to becoming opioid-free.

The MOTHER researchers hypothesized that buprenorphine maintenance could yield methadone’s advantages for pregnant women with less neonatal distress. Buprenorphine, like methadone, reduces opioid craving and alleviates withdrawal symptoms without the safety and health risks related to acquiring and abusing drugs. Therapeutic dosing with buprenorphine, as with methadone, avoids the extreme fluctuations in opioid blood concentrations that occur in opioid abuse and place physiological stress on both the mother and the fetus. However, unlike methadone, buprenorphine is a partial rather than full opioid and so might cause less severe fetal opioid dependence than methadone therapy.

The MOTHER study recruited women as they sought treatment for opioid dependence at six treatment centers in the United States
and one in Austria. All the women were 6 to 30 weeks pregnant. The research team initiated treatment with morphine for each woman, stabilized her dose, and then followed with the daily administration of buprenorphine therapy or MMT for the remainder
of her pregnancy. Throughout the trial, the team increased each woman’s medication dosage as needed to ease withdrawal symptoms.

The study incorporated design features to ensure that its findings would be valid. Among the most notable were measures taken to prevent biases that might arise if staff and participants knew which medication a woman was getting.

To treat the participants without knowing which medication each woman was receiving, the study physicians wrote all prescriptions in pairs, one for each medication, in equivalent strengths. Study pharmacists matched the patient’s name and ID number to her medication group and filled only the prescription for the medication she was taking.

Each day, participants dissolved seven tablets under their tongues and then swallowed a syrup. If a woman was in the buprenorphine group, one or more of her tablets contained that medication, depending on her prescribed dosage, while the rest of the tablets and the syrup were placebos. If a woman was in the methadone group, the syrup contained that medication in her prescribed strength and the tablets all were placebos. In this way, each woman’s complement of medications appeared identical to that of every other participant. The placebo tablets and syrup were crafted to look, taste, and smell like the active medications.

As Good For Mothers, Better for Infants
Of 175 women who started a study medication, 131 continued until they gave birth. Those who received MMT and those given buprenorphine experienced similar pregnancy courses and outcomes. The two groups of women did not differ significantly in maternal weight gain, positive drug screens at birth, percentage of abnormal fetal presentations or need for Cesarean section, need for analgesia during delivery, or serious medical complications at delivery.

As the MOTHER researchers had hypothesized, the infants whose mothers were treated with buprenorphine experienced milder NAS than those infants exposed to methadone (see graph). Whereas most infants in both groups required morphine to control NAS, the buprenorphine group, on average, needed only 11 percent as much, finished its taper in less than half the time, and remained in the hospital roughly half as long as the infants exposed to methadone.

At Dr. Gabriele Fischer’s Medical University of Vienna site in Austria, three women became pregnant for a second time during the time MOTHER was enrolling participants. This development allowed researchers to compare the two medications’ relative safety and efficacy in individual women as well as across groups. During her second pregnancy, each of the three women took the alternative medication to the one she took in her first pregnancy. In each instance, the child born following buprenorphine treatment exhibited milder NAS symptoms than the one born following methadone treatment. This result suggests that differences in the effects of the two medications, rather than women’s individual differences in physiology, underlie the group findings.

“Buprenorphine may be a good option for pregnant women, particularly those who are new to treatment or who become pregnant
while on this medication,” says Dr. Jones. “If a patient is on methadone maintenance and stable, however, she should remain on methadone.”

MOTHER researchers observed that although the women in their buprenorphine and methadone groups benefited equally from treatment, the drop-out rate was higher in the buprenorphine group (33 vs. 18 percent). This difference was not statistically
significant. The researchers speculate that if it is meaningful, it may be owing to factors other than different responses to the two medications. They surmise that the experimental treatment protocols may have moved patients from morphine to buprenorphine too rapidly, causing discomfort, or that buprenorphine may have been easier than methadone to discontinue when women decided to become abstinent.

The MOTHER study did not include women with some substance use disorders that are commonly comorbid with opioid abuse.

“Future studies should compare neonatal abstinence syndrome, birth outcomes, and maternal outcomes of these two medications for pregnant women who also abuse alcohol and benzodiazepines,” Dr. Jones says.

“The field also needs data on neonatal outcomes when pregnant women are treated with buprenorphine combined with naloxone, the current first-line form of buprenorphine therapy for opioid dependence,” Dr. Jones notes. The MOTHER study administered buprenorphine without naloxone to avoid exposing the fetus to a second medication with potential adverse effects.

“Research challenges remaining after this brilliant study are to determine the factors that resulted in the differential drop-out rates between the two medications,” says Dr. Loretta P. Finnegan, who did pioneering work in the assessment and treatment of NAS. “Additionally, researchers need to conduct followup research on these children to determine the longer term significance of the differences in newborn withdrawal symptoms.” Dr. Finnegan, now president of Finnegan Consulting, was formerly the medical advisor to the director of the Office of Research on Women’s Health at the National Institutes of Health.

“Neonatal abstinence syndrome is a terrible experience for infants, and there is a great need to improve care for this condition,” says Dr. Jamie Biswas of NIDA’s Division of Pharmacotherapies and Medical Consequences of Drug Abuse. “Dr. Jones’ study is a superb contribution to this area of clinical research, and the robust results should provide more treatment options for a syndrome that affects thousands of infants each year.”

Unger, A., et al. Randomized controlled trials in pregnancy: Scientific and ethical aspects. Exposure to different opioid
medications during pregnancy in an intra-individual comparison. Addiction 106(7):1355–1362, 2011. Abstract Available

The number of teenage and adult users will double or triple if marijuana is legalized. This will mean an additional 17 to 34 million adult and young users in the United States. [FN1]
Marijuana businesses will promote their products and package them in attractive ways to increase their market share (see attached pictures of marijuana “candy”).
ASK YOURSELF: Do you think increased marijuana use among teenagers and adults is good for our country and its future?
Marijuana can cause disinterest in activities, lower grades and isolation from the family. It can permanently impair brain development. Problem solving, concentration, motivation and memory are negatively affected. Teens who use marijuana are more likely to engage in delinquent and dangerous behavior and experience increased risk of schizophrenia and depression including being three times more likely to have suicidal thoughts. [FN2]
Marijuana-using teens are more likely to have multiple sexual partners and engage in unsafe sex. [FN3]
Our drug treatment facilities are full of young people dealing with marijuana related problems. One study of children in treatment showed that, 48% were admitted for abuse or addiction to marijuana, while only 19.3 % for alcohol and 2.9 % for cocaine, 2.4 % for methamphetamine and 2.3 % for heroin. [FN4]
Marijuana use accounts for tens of thousands of marijuana related complaints at emergency rooms throughout the United States each year. Over 99,000 are young people. [FN5]
Despite arguments by the drug culture to the contrary, marijuana is addictive. [FN6] The levels of THC (marijuana’s psychoactive ingredient) have never been higher. Higher potency marijuana is a major factor why marijuana is the number one drug causing young people to enter treatment and why there has been a substantial increase in the number of Americans in treatment for marijuana dependence. [FN7]
ASK YOURSELF: Would you want your son or daughter to become involved in using marijuana?
Marijuana significantly impairs the ability to safely operate a motor vehicle. Driving problems include: decreased handling performance, inability to maintain headway, impaired time and distance estimation, increased reaction times, sleepiness, impaired sustained vigilance and lack of motor coordination. [FN8]
Marijuana is the most prevalent drug found in fatally injured drivers testing positive for drugs. [FN9]
More than 12 % of high school seniors admitted to driving under the influence of marijuana in the two weeks prior being surveyed. [FN10]
13 % of high school seniors said they drove after using marijuana while only 10 % drove after having five or more drinks. Vehicle accidents are the leading cause of death among those aged 15 to 20. [FN11]
A study of high school students showed that about 28,000 seniors each year admitted that they were in at least one accident after using marijuana. [FN12]
ASK YOURSELF: Do you want more impaired drivers on our interstates and roadways?
Employees who tested positive for marijuana had 55% more industrial accidents and 85% more injuries compared to those that tested negative on a pre-employment exam and they had absenteeism rates 75% higher than those that tested negative. [FN13]
Marijuana use can cause impairment of short-term memory, attention, motor skills, reaction time, and the organization and integration of complex information. Marijuana use can cause decreased motivation and can cause mental health problems. Employees who use marijuana off-duty are still effected by it at work for the next few days. Impaired cognition can remain for a long period. Memory defects can last as long as six weeks. [FN14]
Employers may be liable for the actions of employees who use marijuana especially those employees in safety sensitive positions.
ASK YOURSELF: If you were an employer, would you want to hire an employee who uses marijuana?
A study of all patients admitted to a shock-trauma unit showed 34.7% had used marijuana very recently. [FN15]
In a study of seriously injured drivers admitted to a shock-trauma center, 26.9 % of the drivers tested positive for marijuana. [FN16]
ASK YOURSELF: Is using marijuana a safe thing to do?
If you answered ‘no’ to any one of the above questions, then you should also say ‘no’ to legalizing marijuana for recreational use.
[FN1] Based on experience in the US and Europe when marijuana laws have been relaxed, the number of users will double or triple. See, Speaking Out Against Drug Legalization, U.S. Department of Justice, Drug Enforcement Administration (DEA), Washington, DC U.S.A. 2010,, pages 46 and 57; Currently, there are 16.7 million regular marijuana users in the US (12 years old or older.) SAMHSA, 2009 Annual Survey on Drug Use and Health, September 2010; The benchmark surveys of drug use show that that perception of harm with respect to marijuana has dropped off since the drive to legalize marijuana began. The benchmark surveys are the Monitoring the Future Survey, which has tracked drug use among American high school students annually since 1975 and the National Household Survey on Drug Abuse, which has tracked drug use among Americans ages 12 and older since 1972. Monitoring the Future, National Institutes of Health, National Institute on Drug Abuse, available on the Internet at; Overview of Findings from the 2002 National Survey on Drug Use and Health (Office of Applied Studies, NHSDA Series H-21, DHHS Publication No. SMA 03- 3774). Rockville, MD; Conducted for SAMHSA (the Substance Abuse and Mental Health Services Administration, Department of Health and Human Services) by North Carolina’s Research Triangle Institute.
[FN2] DEA Position on Marijuana, U.S. Department of Justice, Drug Enforcement Administration (DEA), Washington, DC U.S.A. July 2010,, pages 23-26 and 33-34; Speaking Out Against Drug Legalization, DEA, pages 51-53
[FN3] Bovassco, G., American Journal of Psychiatry, 2001
[FN4] “Non-medical Marijuana: Rite of Passage or Russian Roulette?” July 1999 obtained at website; Kaplan, H.B., Martin, S.S., Johnson, R.J., and Robbins, C.A., Escalation of marijuana use: Application of a general theory of deviant behavior. Journal of Health and Social Behavior.1986:27:44-61; Clayton, R.R., and Leukefeld, C.G., The prevention of drug use among youth; implications of “legalization” Journal of Primary Prevention. 1992:12:289-302
[FN5] Drug Abuse Warning Network, 2004: National Estimates of Drug-Related Emergency Department Visits U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration
9[FN6] The Occurrence of Cannabis Use Disorders and Other Cannabis Related Problems Among First Year College Students, Addictive Behaviors 33(3):397-411, March 2008; Compton, Dewey & Martin, Cannabis dependence and tolerance production, Advances in Alcohol and Substance Abuse 1990:9:129-147; Miller & Gold, The diagnosis of marijuana cannabis dependence, Journal of Substance Abuse Treatment 1989:6:183-192; Clayton & Leukefeld, The prevention of drug use among youth: implications’ of legalization, Journal of Prevention 1992:12:289-302; Kaplan, Martin, Johnson & Robbins, Escalation of marijuana use: Application of a general theory of deviant behavior, Journal of Health and Social Behavior 1986:27:44-61; “Regular or Heavy Use of Cannabis Was Associated with Increased Risk of Using Other Illicit Drugs” Addiction, 2006; 101:556-569; “As Marijuana Use Rises, More People Are Seeking Treatment for Addiction” -Wall Street Journal, 2 May 2006; “Twenty-Five Year Longitudinal Study Affirms Link Between Marijuana Use and Other Illicit Drug Use” – Congress of the United States,14 March 2006; “New Study Reveals Marijuana is Addictive and Users Who Quit Experience Withdrawal”- All Headline News, 6 February 2007; “Escalation of Drug Use in Early Onset Cannabis Users Vs. Co-twin Controls” – Journal of the American Medical Association, 2003; 289:4
[FN7]  New Report Finds Highest-Ever Levels of THC in US Marijuana, June 12, 2008,
[FN8] National Highway Traffic Safety Administration, Use of Controlled Substances and Highway Safety; A Report to Congress (U.S. Dept. of Transportation, Washington, D.C., 1988); “White House Drug Czar Launches Campaign to Stop Drugged Driving.” Office of National Drug Control Policy Press Release. 19 November 2002
[FN9] “One-third of Fatally Injured Drivers with Known Test Results Tested Positive for at Least one Drug in 2009.CESARFAX. Vol. 19, Issue 49. December 20, 2010.
[FN10] Ibid.
[FN11] Drug-Impaired Driving by Youth Remains Serious Problem. NIDA News Release, October 29, 2007.
[FN12] O’Malley, Patrick and Johnston, Lloyd. “Unsafe Driving by High School Seniors: National Trends from 1976 to 2001 in Tickets and Accidents After Use of Alcohol, Marijuana and Other Illegal Drugs.” Journal of Studies on Alcohol. May 2003; The DEA Position On Marijuana,
[FN13] Abbie Crites-Leoni, Medicinal Use of Marijuana: Is the Debate a Smoke Screen for Movement Toward Legalization? 19 J. Legal Med. 273, 280 (1998) (citing Schwartz, et al., Short- Term Memory Impairment in Cannabis-Dependent Adolescents, 143 Am. J. Dis. Child. 1214 (1989))
[FN14] ONDCP, “Marijuana: Know the Facts”, October 2010
[FN15] Soderstrum, C., Trifillis, A., Shankar, B., Clark, W., and Cowley, R. Marijuana and Alcohol Use among 1023 Patients. Archives of Surgery, 123 (June 1988): 733–37; Skolnick, Illicit Drugs take still another toll; death or injury from vehicle-associated trauma, JAMA 1990:263:3122-3125; Soderstrom, Drug involvement among drivers admitted to a regional trauma center, Presented at the Transportation Research Board 70th Annual Meeting (Washington, D.C., Jan. 15, 1991).
[FN16] DuPont, Robert. “National Survey Confirms that Drugged Driving is Significantly More Widespread than Drunk Driving.” Commentary, Institute for Behavior and Health, July 17, 2009. page 1.
Some of this information was borrowed with permission from: Healthy and Free Colorado, affiliated with the Colorado Drug Investigators Association, POB 372394, Denver, CO 80237
Drug legalization advocates claim that prisons are overflowing with people convicted for only simple possession of marijuana. This claim is aggressively pushed by groups seeking to relax or abolish marijuana laws. A more accurate view is that the vast majority of inmates in prison for marijuana have been found guilty of more than simple possession. They were convicted for drug trafficking, or for marijuana possession along with other offences. Many of those in prison for marijuana entered a guilty plea to a marijuana charge to avoid a more serious charge. In the US, just 1.6 percent of the state inmate population were held for offences involving only marijuana, and less than one percent of all state prisoners (0.7 percent) were incarcerated with marijuana possession as the only charge. An even smaller fraction of state prisoners were first time offenders (0.3 percent). The numbers on the US federal prisons are similar. In 2001, the overwhelming majority of offenders sentenced for marijuana crimes were convicted for trafficking and only 63 served time for simple possession. [FN1]
Plea Bargains Distort the Picture
The standard practice in drug cases is for the offender to be given the opportunity to plead guilty in exchange for lighter punishment thus sparing the taxpayers the expense and risk of a trial. If the offender is only charged with one crime, the prosecutor will typically offer a shorter sentence to a lesser charge. If the offender has multiple charges, the common practice is to dismiss one charge in exchange for a guilty plea to another lesser charge, especially if the government feels the offender can provide valuable assistance to law enforcement by providing information on drug trafficking.
Drug legalization advocates claim that nearly one-third of all federal drug defendants are charged with marijuana offences. [FN2] However, only a tiny percentage of that number are actually convicted for marijuana possession. [FN3]
There are a number of circumstances under which a simple-possession marijuana offender might receive a sentence to prison. For example, this may happen if:
1. the marijuana offence was committed while the offender was on probation or parole;
2. an offender charged with a more serious crime pleads guilty to the lesser offence of marijuana possession but as part of a plea bargain is required to serve a prison sentence;
3. the offender has a criminal history, particularly one involving drugs or violent crime;
4. the violation took place in a designated drug-free zone (such as on school property); or
5. the marijuana sentence runs concurrent with the sentence for one or more other offences;
How Much Marijuana Did the Average Offender Possess to Get a Prison Sentence?
According to US Bureau of Justice Statistics estimates based on a survey of federal prisoners, the median amount of marijuana involved in the conviction of marijuana-only possession offenders was 115 pounds. [FN4] This is far more than is needed for personal use.
[FN1]  Who’s Really in Prison for Marijuana?, Office of National Drug Control Policy,; Substance Abuse and Treatment, State and Federal Prisoners, 1997,” BJS Special Report, January 1999, NCJ 172871; Unpublished BJS estimates based on the 1997 Survey of Inmates in State and Federal Correctional Facilities, National Archive of Criminal Justice Data; Prison and Jail Inmates at Midyear 2002, Bureau of Justice Statistics Bulletin, April 2003, NCJ 198877; Prisoners in 2002, Bureau of Justice Statistics, July 2003, NCJ 200248; Who’s Really in Prison for Marijuana?, Office of National Drug Control Policy,
[FN2] Pot Violators Comprise Largest Percentage of Federal Drug Offenders, Department of Justice Study Shows, NORML News, August 30, 2001; Who’s Really in Prison for Marijuana?, Office of National Drug Control Policy,
[FN3] US Sentencing Commission’s 2001 Sourcebook of Federal Sentencing Statistics; Who’s Really in Prison for Marijuana?, Office of National Drug Control Policy,
[FN4] Who’s Really in Prison for Marijuana?, Office of National Drug Control Policy,
Most of the arguments in favor of drug legalization focus on marijuana. However, marijuana is far more powerful today than it was years ago and it serves as an entry point for the use of other illegal drugs. This is known as the “gateway effect.” Despite arguments from the drug culture to the contrary, marijuana is addictive. This addiction has been well described in the scientific literature and it consists of both a physical dependence (tolerance and subsequent withdrawal) and a psychological habituation. [FN1]
According to a US report released in June of 2008, the levels of THC – the psychoactive ingredient in marijuana – have reached the highest ever amounts since scientific analysis of the drug began in the late 1970s. The average amount of THC has now reached average levels of 9.6 percent (the highest level in one of the samples was 37.2 percent). This compares to the average of just under 4 percent reported in 1983. Additionally, higher potency marijuana may be contributing to a substantial increase in the number of American teenagers in treatment for marijuana dependence. According to the U.S. 2006 National Survey on Drug Use and Health (NSDUH), among Americans age 12 and older there are 14.8 million current (past-month; 6.0 percent) users of marijuana and 4.2 million Americans (1.7 percent) classified with dependency or abuse of marijuana. Additionally, the latest information from the U.S. Treatment Episode Data Set (TEDS, 2006), reports that 16.1% of drug treatment admissions were for marijuana as the primary drug of abuse. This compares to 6% in 1992. A similar trend is taking place in the Netherlands, where new data indicate that the number of people seeking assistance for cannabis there has risen, from 1,951 in 1994 to 6,544 in 2006 – a 235 percent increase.  [FN2] In 2006, the average THC concentration in Dutch marihuana was 16% which is even higher than that in the US. [FN3]
Marijuana is an addictive drug. It poses significant health consequences to its users, including those who may be using it for “medical” purposes. In the U.S., marijuana is the number one drug that young people are in treatment for. [FN4]
The use of marijuana in early adolescence is particularly dangerous. Adults who used marijuana early were five times more likely to become dependent on any drug and eight times more likely to use cocaine and fifteen times more likely to use heroin later in life.” [FN5]
The damage to health caused by marijuana
Drug legalization advocates claim that marijuana is less dangerous than drugs like cocaine, heroin, and methamphetamine. Some European countries have lowered the classification of marijuana based on the false perception that it is less harmful. However, studies over the last few years give us a lot of new information about marijuana. They show that marijuana is not harmless but that it is toxic and addictive. Recent studies show the following destructive effects of marijuana use: [FN6]
birth defects
      the worsening of pain
      respiratory system damage
      links to cancer
      AIDS – marijuana opens the door to Kaposi’s sarcoma
      brain damage
      immune system damage
      mental illness
[FN1]; The Occurrence of Cannabis Use Disorders and Other Cannabis Related Problems Among First Year College Students, Addictive Behaviors 33(3):397-411, March 2008;Compton, Dewey & Martin, Cannabis dependence and tolerance production, Advances in Alcohol and Substance Abuse 1990:9:129-147; Miller & Gold, The diagnosis of marijuana cannabis dependence, Journal of Substance Abuse Treatment 1989:6:183-192; Clayton & Leukefeld, The prevention of drug use among youth: implications’ of legalization, Journal of Prevention 1992:12:289-302; Kaplan, Martin, Johnson & Robbins, Escalation of marijuana use: Application of a general theory of deviant behavior, Journal of Health and Social Behavior 1986:27:44-61; Bailey, Flewelling & Rachal, Predicting continued use of marijuana among adolescents: the relative influence of drug-specific and social context factors, Journal of Health and Social Behavior 1992:33:51-66; “Regular or Heavy Use of Cannabis Was Associated with Increased Risk of Using Other Illicit Drugs” Addiction, 2006; 101:556-569; “As Marijuana Use Rises, More People Are Seeking Treatment for Addiction” -Wall Street Journal, 2 May 2006; “Twenty-Five Year Longitudinal Study Affirms Link Between Marijuana Use and Other Illicit Drug Use” – Congress of the United States,14 March 2006; “New Study Reveals Marijuana is Addictive and Users Who Quit Experience Withdrawal”- All Headline News, 6 February 2007; “Cannabis Withdrawal Among Non-Treatment-Seeking Adult Cannabis Users” -The American Journal on Addiction, 2006; 15:8-14; “Escalation of Drug Use in Early Onset Cannabis Users Vs. Co-twin Controls” – Journal of the American Medical Association, 2003; 289:4
[FN2]  New Report Finds Highest-Ever Levels of THC in US Marijuana, June 12, 2008,
[FN3] The Netherlands Drug Situation 2007 – National Drug Monitor, European Monitoring Centre for Drugs and Drug Addiction 2008, pgs. 107 and 108
[FN4] Non-medical Marijuana: Rite of Passage or Russian Roulette?” July 1999 obtained at website; The Occurrence of Cannabis Use Disorders and Other Cannabis Related Problems Among First Year College Students, Addictive Behaviors 33(3):397-411, March 2008.
[FN5] What Americans Need to Know about Marijuana.” Office of National Drug Control Policy. October 2003. Page 9.; The DEA Position On Marijuana,
[FN6]  Birth Defects – Risk of Selected Birth Defects with Prenatal Illicit Drug Use, Hawaii, 1986-2002, Journal of Toxicology and Environmental Health, Part A, 70: 7-18, 2007
Pain – “Too Much Cannabis Worsens Pain” – BBC News, 24 October 2007; “Study Finds that Marijuana Won’t Stop Multiple Sclerosis Pain”- Neurology, 2002; 58:1404-1407
Respiratory System Damage – “Marijuana Associated with Same Respiratory Symptoms as Tobacco,” YALE News Release. 13 January 2005. (14 January 2005); Marijuana Smoke Contains Higher Levels of Certain Toxins Than Tobacco Smoke, Science Daily, December 18, 2007; Marijuana Smokers Face Rapid Lung Destruction – As Much as 20 Years Ahead of Tobacco Smokers, Science Daily, January 27, 2008; “Respiratory and Immunologic Consequences of Marijuana Smoking”- Journal of Clinical Pharmacology, 2002; 42:71S-81S
Cancer – “Association Between Marijuana Use and Transitional Cell Carcinoma”- Adult Urology, 2006; 100-104
AIDS/HIV – “Marijuana Component Opens The Door For Virus That Causes Kaposi’s Sarcoma” -Science Daily, 2 August 2007
Brain Damage – “Neurotoxicology; Neurocognitive Effects of Chronic Marijuana Use Characterized.” Health & Medicine Week. 16 May 2005; “Marijuana May Affect Blood Flow in Brain” – Reuters, 7 February 2005;
Strokes – “More Evidence Ties Marijuana to Stroke Risk” – Reuters Health, 22 February 2005
Immune System Damage – “Immunological Changes Associated with Prolonged Marijuana Smoking” -American College of Allergy, Asthma and Immunology, 17 November 2004
Mental Illness, Schizophrenia, Depression – Kearney, Simon. “Cannabis is Worst Drug for Psychosis.” The Australian. 21 November 2005; Curtis, John. “Study Suggests Marijuana Induces Temporary Schizophrenia-Like Effects.” Yale Medicine. Fall/Winter 2004; “Cannabis-Related Schizophrenia Set to Rise, Say Researchers” – Science Daily, 26 March 2007; “Report: Using Pot May Heighten Risk of Becoming Psychotic” – Associated Press, 26 July 2007; “Marijuana Linked to Schizophrenia, Depression” – British Medical Journal, 21 November 2007; “Anterior Cingulate Grey-Matter Deficits and Cannabis Use in First-Episode Schizophrenia” The British Journal of Psychiatry, 2007; 190: 230-236; Marijuana Increases the Risk of Both Psychosis In Non-Psychotic People As Well As Poor Prognosis For Those With Risk of Vulnerability to Pyschoses” American Journal of Epidemiology, 2002; 156:319-327; Psychophysiological Evidence of Altered Neural Synchronization in Cannabis Use: Relationship to Schizotypy” Am J Psychiatry, 2006; 163:1798-1805
Violence – “Cannabis ‘Linked to Aggression'” – News, Press Association 2006; “Marijuana Had a Greater Effect on Increasing the Degree of Violent Behavior in Non-Delinquent Individuals Than in Delinquent Individuals” – J Addict. Dis. 2003; 22:63-78
Infertility – “Marijuana Firmly Linked to Infertility” – Scientific American, 22 December 2000
Hepatitis –  Clinical Gastroenterology and  Hepatology 2008, Vol. 6, No.1, pages 69-75, captioned “Influence of Cannabis use on Severity of Hepatitis C Disease”

When we say that someone is “addicted” to a behavior like gambling or eating or playing video games, what does that mean? Are such compulsions really akin to dependencies like drug and alcohol addiction — or is that just loose talk?

This question arose recently after the committee writing the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (D.S.M.), the standard reference work for psychiatric illnesses, announced updated definitions of substance abuse and addiction, including a new category of “behavioral addictions.” At the moment, the only disorder featured in this new category is pathological gambling, but the suggestion is that other behavioral disorders will be added in due course. Internet addiction, for instance, was initially considered for inclusion but was relegated to an appendix (as was sex addiction) pending further research.

Skeptics worry that such broad criteria for addiction will pathologize normal (if bad) behavior and lead to overdiagnosis and overtreatment. Allen J. Frances, a professor of psychiatry and behavioral sciences at Duke University who has worked on the D.S.M., has said that the new definitions amount to “the medicalization of everyday behavior” and will create “false epidemics.” Health insurance companies are fretting that the new diagnostic criteria may cost the health care system hundreds of millions of dollars annually, as addiction diagnoses multiply.

There is always potential for misuse when diagnostic criteria are expanded. But on the key scientific point, the D.S.M.’s critics are wrong. As anyone familiar with the history of the diagnosis of addiction can tell you, the D.S.M.’s changes accurately reflect our evolving understanding of what it means to be an addict.

The concept of addiction has been changing and expanding for centuries. Initially, it wasn’t even a medical notion. In ancient Rome, “addiction” referred to a legal dependency: the bond of slavery that lenders imposed upon delinquent debtors. From the second century A.D. well into the 1800s, “addiction” described a disposition toward any number of obsessive behaviors, like excessive reading and writing or slavish devotion to a hobby. The term often implied a weakness of character or a moral failing.

Addiction” entered the medical lexicon only in the late 19th century, as a result of the over-prescription of opium and morphine by physicians. Here, the concept of addiction came to include the notion of an exogenous substance taken into the body. Starting in the early 20th century, another key factor in diagnosing addiction was the occurrence of physical withdrawal symptoms upon quitting the substance in question.

This definition of addiction was not always carefully applied (it took years for alcohol and nicotine to be classified as addictive, despite their fitting the bill), nor did it turn out to be accurate. Consider marijuana: in the 1980s, when I was training to become a doctor, marijuana was considered not to be addictive because the smoker rarely developed physical symptoms upon stopping. We now know that for some users marijuana can be terribly addictive, but because clearance of the drug from the body’s fat cells takes weeks (instead of hours or days), physical withdrawal rarely occurs, though psychological withdrawal certainly can.

Accordingly, most doctors have accepted changes to the definition of addiction, but many still maintain that only those people who compulsively consume an exogenous substance can be called addicts. Over the past several decades, however, a burgeoning body of scientific evidence has indicated that an exogenous substance is less important to addiction than is the disease process that the substance triggers in the brain — a process that disrupts the brain’s anatomical structure, chemical messaging system and other mechanisms responsible for governing thoughts and actions.

For example, since the early 1990s, the neuropsychologists Kent C. Berridge and Terry E. Robinson at the University of Michigan have studied the neurotransmitter dopamine, which gives rise to feelings of craving. They have found that when you repeatedly take a substance like cocaine, your dopamine system becomes hyper-responsive, making the drug extremely difficult for the addicted brain to ignore. Though the drug itself plays a crucial role in starting this process, the changes in the brain persist long after an addict goes through withdrawal: drug-using cues and memories continue to elicit cravings even in addicts who have abstained for years.

Furthermore, a team of scientists led by Nora Volkow at the National Institute on Drug Abuse have used positron emission tomography (PET) scans to show that even when cocaine addicts merely watch videos of people using cocaine, dopamine levels increase in the part of their brains associated with habit and learning. Dr. Volkow’s group and other scientists have used PET scans and functional magnetic resonance imaging to demonstrate similar dopamine receptor derangements in the brains of drug addicts, compulsive gamblers and overeaters who are markedly obese.

The conclusion to draw here is that though substances like cocaine are very effective at triggering changes in the brain that lead to addictive behavior and urges, they are not the only possible triggers: just about any deeply pleasurable activity — sex, eating, Internet use — has the potential to become addictive and destructive.

Disease definitions change over time because of new scientific evidence. This is what has happened with addiction. We should embrace the new D.S.M. criteria and attack all the substances and behaviors that inspire addiction with effective therapies and support.

Howard Markel, a physician and a professor of the history of medicine at the University of Michigan, is the author of “An Anatomy of Addiction: Sigmund Freud, William Halsted, and the Miracle Drug Cocaine.”

Source: 5th June 2012

In human populations, cigarettes and alcohol generally serve as gateway drugs, which people use first before progressing to marijuana, cocaine, or other illicit substances. To understand the biological basis of the gateway sequence of drug use, we developed an animal model in mice and used it to study the effects of nicotine on subsequent responses to cocaine. We found that pretreatment of mice with nicotine increased the response to cocaine, as assessed by addiction-related behaviors and synaptic plasticity in the striatum, a brain region critical for addiction-related reward. Locomotor sensitization was increased by 98%, conditioned place preference was increased by 78%, and cocaine-induced reduction in long-term potentiation (LTP) was enhanced by 24%. The responses to cocaine were altered only when nicotine was administered first, and nicotine and cocaine were then administered concurrently. Reversing the order of drug administration was ineffective; cocaine had no effect on nicotine-induced behaviors and synaptic plasticity. Nicotine primed the response to cocaine by enhancing its ability to induce transcriptional activation of the FosB gene through inhibition of histone deacetylase, which caused global histone acetylation in the striatum. We tested this conclusion further and found that a histone deacetylase inhibitor simulated the actions of nicotine by priming the response to cocaine and enhancing FosB gene expression and LTP depression in the nucleus accumbens. Conversely, in a genetic mouse model characterized by reduced histone acetylation, the effects of cocaine on LTP were diminished. We achieved a similar effect by infusing a low dose of theophylline, an activator of histone deacetylase, into the nucleus accumbens. These results from mice prompted an analysis of epidemiological data, which indicated that most cocaine users initiate cocaine use after the onset of smoking and while actively still smoking, and that initiating cocaine use after smoking increases the risk of becoming dependent on cocaine, consistent with our data from mice. If our findings in mice apply to humans, a decrease in smoking rates in young people would be expected to lead to a decrease in cocaine addiction.

Source:  Science Translational Medicine 2 November 2011:
Vol. 3, Issue 107, p. 107ra109

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

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

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

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

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

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

Main findings

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

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

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

The authors’ conclusions

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

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

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

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

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

CBT in methadone treatment

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

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

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

CBT in substance use treatment generally

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

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

Will CBT help methadone patients leave treatment?

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

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

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

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

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

Last revised 16 December 2011



Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors. Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.
The neurobiology of addiction encompasses more than the neurochemistry of reward.1 The frontal cortex of the brain and underlying white matter connections between the frontal cortex and circuits of reward, motivation and memory are fundamental in the manifestations of altered impulse control, altered judgment, and the dysfunctional pursuit of rewards (which is often experienced by the affected person as a desire to “be normal”) seen in addiction–despite cumulative adverse consequences experienced from engagement in substance use and other addictive behaviors. The frontal lobes are important in inhibiting impulsivity and in assisting individuals to appropriately delay gratification. When persons with addiction manifest problems in deferring gratification, there is a neurological locus of these problems in the frontal cortex. Frontal lobe morphology, connectivity and functioning are still in the process of maturation during adolescence and young adulthood, and early exposure to substance use is another significant factor in the development of addiction. Many neuroscientists believe that developmental morphology is the basis that makes early-life exposure to substances such an important factor.
Genetic factors account for about half of the likelihood that an individual will develop addiction. Environmental factors interact with the person’s biology and affect the extent to which genetic factors exert their influence. Resiliencies the individual acquires (through parenting or later life experiences) can affect the extent to which genetic predispositions lead to the behavioral and other manifestations of addiction. Culture also plays a role in how addiction becomes actualized in persons with biological vulnerabilities to the development of addiction.
Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include:
a. The presence of an underlying biological deficit in the function of reward circuits, such that drugs and behaviors which enhance reward function are preferred and sought as reinforcers;
b. The repeated engagement in drug use or other addictive behaviors, causing neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors;
c. Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception;
d. Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies;
e. Exposure to trauma or stressors that overwhelm an individual’s coping abilities;
f. Distortion in meaning, purpose and values that guide attitudes, thinking and behavior;
g. Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others); and
h. The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviors.
Addiction is characterized by2:
a. Inability to consistently Abstain;
b. Impairment in Behavioral control;
c. Craving; or increased “hunger” for drugs or rewarding experiences;
d. Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and
e. A dysfunctional Emotional response.
The power of external cues to trigger craving and drug use, as well as to increase the frequency of engagement in other potentially addictive behaviors, is also a characteristic of addiction, with the hippocampus being important in memory of previous euphoric or dysphoric experiences, and with the amygdala being important in having motivation concentrate on selecting behaviors associated with these past experiences.
Although some believe that the difference between those who have addiction, and those who do not, is the quantity or frequency of alcohol/drug use, engagement in addictive behaviors (such as gambling or spending)3, or exposure to other external rewards (such as food or sex), a characteristic aspect of addiction is the qualitative way in which the individual responds to such exposures, stressors and environmental cues. A particularly pathological aspect of the way that persons with addiction pursue substance use or external rewards is that preoccupation with, obsession with and/or pursuit of rewards (e.g., alcohol and other drug use) persist despite the accumulation of adverse consequences. These manifestations can occur compulsively or impulsively, as a reflection of impaired control.
Persistent risk and/or recurrence of relapse, after periods of abstinence, is another fundamental feature of addiction. This can be triggered by exposure to rewarding substances and behaviors, by exposure to environmental cues to use, and by exposure to emotional stressors that trigger heightened activity in brain stress circuits.4
In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications. The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the connection with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of 12 Steps programs.
Addiction is more than a behavioral disorder. Features of addiction include aspects of a person’s behaviors, cognitions, emotions, and interactions with others, including a person’s ability to relate to members of their family, to members of their community, to their own psychological state, and to things that transcend their daily experience.   Behavioral manifestations and complications of addiction, primarily due to impaired control, can include:
a. Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control;
b. Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the neglect of responsibilities at home, school or work);
c. Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems which may have been caused or exacerbated by substance use and/or related addictive behaviors;
d. A narrowing of the behavioral repertoire focusing on rewards that are part of addiction; and
e. An apparent lack of ability and/or readiness to take consistent, ameliorative action despite recognition of problems.
Cognitive changes in addiction can include:
a. Preoccupation with substance use;
b. Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviors; and
c. The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction.
Emotional changes in addiction can include:
a. Increased anxiety, dysphoria and emotional pain;
b. Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and
c. Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).
The emotional aspects of addiction are quite complex. Some persons use alcohol or other drugs or pathologically pursue other rewards because they are seeking “positive reinforcement” or the creation of a positive emotional state (“euphoria”). Others pursue substance use or other rewards because they have experienced relief from negative emotional states (“dysphoria”), which constitutes “negative reinforcement.“ Beyond the initial experiences of reward and relief, there is a dysfunctional emotional state present in most cases of addiction that is associated with the persistence of engagement with addictive behaviors. The state of addiction is not the same as the state of intoxication. When anyone experiences mild intoxication through the use of alcohol or other drugs, or when one engages non-pathologically in potentially addictive behaviors such as gambling or eating, one may experience a “high”, felt as a “positive” emotional state associated with increased dopamine and opioid peptide activity in reward circuits. After such an experience, there is a neurochemical rebound, in which the reward function does not simply revert to baseline, but often drops below the original levels. This is usually not consciously perceptible by the individual and is not necessarily associated with functional impairments.
Over time, repeated experiences with substance use or addictive behaviors are not associated with ever increasing reward circuit activity and are not as subjectively rewarding. Once a person experiences withdrawal from drug use or comparable behaviors, there is an anxious, agitated, dysphoric and labile emotional experience, related to suboptimal reward and the recruitment of brain and hormonal stress systems, which is associated with withdrawal from virtually all pharmacological classes of addictive drugs. While tolerance develops to the “high,” tolerance does not develop to the emotional “low” associated with the cycle of intoxication and withdrawal. Thus, in addiction, persons repeatedly attempt to create a “high”–but what they mostly experience is a deeper and deeper “low.” While anyone may “want” to get “high”, those with addiction feel a “need” to use the addictive substance or engage in the addictive behavior in order to try to resolve their dysphoric emotional state or their physiological symptoms of withdrawal. Persons with addiction compulsively use even though it may not make them feel good, in some cases long after the pursuit of “rewards” is not actually pleasurable.5 Although people from any culture may choose to “get high” from one or another activity, it is important to appreciate that addiction is not solely a function of choice. Simply put, addiction is not a desired condition.
As addiction is a chronic disease, periods of relapse, which may interrupt spans of remission, are a common feature of addiction. It is also important to recognize that return to drug use or pathological pursuit of rewards is not inevitable.
Clinical interventions can be quite effective in altering the course of addiction. Close monitoring of the behaviors of the individual and contingency management, sometimes including behavioral consequences for relapse behaviors, can contribute to positive clinical outcomes. Engagement in health promotion activities which promote personal responsibility and accountability, connection with others, and personal growth also contribute to recovery. It is important to recognize that addiction can cause disability or premature death, especially when left untreated or treated inadequately.
The qualitative ways in which the brain and behavior respond to drug exposure and engagement in addictive behaviors are different at later stages of addiction than in earlier stages, indicating progression, which may not be overtly apparent. As is the case with other chronic diseases, the condition must be monitored and managed over time to:
a. Decrease the frequency and intensity of relapses;
b. Sustain periods of remission; and
c. Optimize the person’s level of functioning during periods of remission.
In some cases of addiction, medication management can improve treatment outcomes. In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results. Chronic disease management is important for minimization of episodes of relapse and their impact. Treatment of addiction saves lives †
Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction. As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery. ‡
Recovery from addiction is best achieved through a combination of self-management, mutual support, and professional care provided by trained and certified professionals.

Source: April 2011

Explanatory footnotes:
1. The neurobiology of reward has been well understood for decades, whereas the neurobiology of addiction is still being explored. Most clinicians have learned of reward pathways including projections from the ventral tegmental area (VTA) of the brain, through the median forebrain bundle (MFB), and terminating in the nucleus accumbens (Nuc Acc), in which dopamine neurons are prominent. Current neuroscience recognizes that the neurocircuitry of reward also involves a rich bi-directional circuitry connecting the nucleus accumbens and the basal forebrain. It is the reward circuitry where reward is registered, and where the most fundamental rewards such as food, hydration, sex, and nurturing exert a strong and life-sustaining influence. Alcohol, nicotine, other drugs and pathological gambling behaviors exert their initial effects by acting on the same reward circuitry that appears in the brain to make food and sex, for example, profoundly reinforcing. Other effects, such as intoxication and emotional euphoria from rewards, derive from activation of the reward circuitry.

While intoxication and withdrawal are well understood through the study of reward circuitry, understanding of addiction requires understanding of a broader network of neural connections involving forebrain as well as midbrain structures. Selection of certain rewards, preoccupation with certain rewards, response to triggers to pursue certain rewards, and motivational drives to use alcohol and other drugs and/or pathologically seek other rewards, involve multiple brain regions outside of reward neurocircuitry itself.
2. These five features are not intended to be used as “diagnostic criteria” for determining if addiction is present or not. Although these characteristic features are widely present in most cases of addiction, regardless of the pharmacology of the substance use seen in addiction or the reward that is pathologically pursued, each feature may not be equally prominent in every case. The diagnosis of addiction requires a comprehensive biological, psychological, social and spiritual assessment by a trained and certified professional.
3. In this document, the term “addictive behaviors” refers to behaviors that are commonly rewarding and are a feature in many cases of addiction. Exposure to these behaviors, just as occurs with exposure to rewarding drugs, is facilitative of the addiction process rather than causative of addiction. The state of brain anatomy and physiology is the underlying variable that is more directly causative of addiction. Thus, in this document, the term “addictive behaviors” does not refer to dysfunctional or socially disapproved behaviors, which can appear in many cases of addiction. Behaviors, such as dishonesty, violation of one’s values or the values of others, criminal acts etc., can be a component of addiction; these are best viewed as complications that result from rather than contribute to addiction.
4. The anatomy (the brain circuitry involved) and the physiology (the neuro-transmitters involved) in these three modes of relapse (drug- or reward-triggered relapse vs. cue-triggered relapse vs. stress-triggered relapse) have been delineated through neuroscience research.  Relapse triggered by exposure to addictive/rewarding drugs, including alcohol, involves the nucleus accumbens and the VTA-MFB-Nuc Acc neural axis (the brain’s mesolimbic dopaminergic “incentive salience circuitry”–see footnote 2 above). Reward-triggered relapse also is mediated by glutamatergic circuits projecting to the nucleus accumbens from the frontal cortex.
Relapse triggered by exposure to conditioned cues from the environment involves glutamate circuits, originating in frontal cortex, insula, hippocampus and amygdala projecting to mesolimbic incentive salience circuitry.
Relapse triggered by exposure to stressful experiences involves brain stress circuits beyond the hypothalamic-pituitary-adrenal axis that is well known as the core of the endocrine stress system. There are two of these relapse-triggering brain stress circuits – one originates in noradrenergic nucleus A2 in the lateral tegmental area of the brain stem and projects to the hypothalamus, nucleus accumbens, frontal cortex, and bed nucleus of the stria terminalis, and uses norepinephrine as its neurotransmitter; the other originates in the central nucleus of the amygdala, projects to the bed nucleus of the stria terminalis and uses corticotrophin-releasing factor (CRF) as its neurotransmitter.
5. Pathologically pursuing reward (mentioned in the Short Version of this definition) thus has multiple components. It is not necessarily the amount of exposure to the reward (e.g., the dosage of a drug) or the frequency or duration of the exposure that is pathological. In addiction, pursuit of rewards persists, despite life problems that accumulate due to addictive behaviors, even when engagement in the behaviors ceases to be pleasurable. Similarly, in earlier stages of addiction, or even before the outward manifestations of addiction have become apparent, substance use or engagement in addictive behaviors can be an attempt to pursue relief from dysphoria; while in later stages of the disease, engagement in addictive behaviors can persist even though the behavior no longer provides relief.


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