Sometimes when your son or daughter is struggling with substance use, it feels like you’ve tried absolutely everything to help. What if you’ve nearly given up hope?

In this short video, Master Addictions Counselor Mary Ann Badenoch, LPC, offers some new ways to think about opportunities for change. For example, instead of focusing on the end goal, be sure to notice the small victories along the way. This can lead to larger positive change and help you remain hopeful.

Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover In Brief

Fall 2014 • Volume 8 • Issue 3 An Introduction To Co-Occurring Borderline Personality Disorder And Substance Use Disorders

This In Brief is for health and human services professionals (e.g., social workers, vocational counselors, case managers, healthcare providers, probation officers). It is intended to introduce such professionals to borderline personality disorder (BPD)—a condition with very high rates of suicide and self-harm that often co-occurs with substance use disorders (SUDs).

This In Brief presents the signs and symptoms of BPD, with or without a co-occurring SUD, alerts professionals to the importance of monitoring clients with BPD for self-harm and suicidal behavior, and encourages professionals to refer such clients for appropriate treatment.

This In Brief is not meant to present detailed information about BPD or treatment guidelines for BPD or SUDs. How Common Is BPD?1 Estimates of BPD prevalence in the U.S. population range from 1.6 percent to 5.9 percent. BPD affects approximately 10 percent of all psychiatric outpatients and up to 20 percent of all inpatients.

What Is Borderline Personality Disorder?

BPD is one among several personality disorders (e.g., narcissistic personality disorder, paranoid personality disorder, antisocial personality disorder). According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),¹ personality disorders are generally characterized by:

■ Entrenched patterns of behavior that deviate significantly from the usual expectations of behavior of the individual’s culture.

■ Behavior patterns that are pervasive, inflexible, and resistant to change.

■ Emergence of the disorder’s features no later than early adulthood (unlike depression, for example, which can begin at any age).

■ Lack of awareness that behavior patterns and personality characteristics are problematic or that they differ from those of other individuals.

■ Distress and impairment in one or more areas of a person’s life (often only after other people get upset about his or her behavior).

■ Behavior patterns that are not better accounted for by the effects of substance abuse, medication, or some other mental disorder or medical condition (e.g., head injury).

BPD is a complex and serious mental illness. Individuals with BPD are often misunderstood and misdiagnosed. A history of childhood trauma (e.g., physical or sexual abuse, neglect, early parental loss) is more common for individuals with BPD.^1,2 In fact, many individuals with BPD may have developed BPD symptoms as a way to cope with childhood trauma. However, it is important to note that not all individuals with BPD have a history of childhood trauma. It is also important to note that some of the symptoms of BPD overlap with those of several other DSM-5 diagnoses, such as bipolar disorder and posttraumatic stress disorder (PTSD).

Therefore, a diagnosis of BPD should be made only by a licensed and experienced mental health professional (whose scope of practice includes diagnosing mental disorders) and then only after a thorough assessment over time. Individuals with BPD often require considerable attention from their therapists and are generally considered to be challenging clients to treat.^3,4,5 However, BPD may not be the chronic disorder it was once thought to be.

In Brief BPD often respond to appropriate treatment and may have a good long-term prognosis,^1,5 experiencing a remission of symptoms with a relatively low occurrence of relapse.^6,7 The DSM-5 indicates that BPD is diagnosed more often in women than in men (75 percent and 25 percent, respectively).¹ Other research, however, has suggested that there may be no gender difference in prevalence in the general population,^5,6 but that BPD is associated with a significantly higher level of mental and physical disability for women than it is for men.⁶ In addition, the types of co-occurring conditions tend to be different for women than for men. In women, the most common co-occurring disorders are major depression, anxiety disorders, eating disorders, and PTSD. Men with BPD are more likely to have co-occurring SUDs and antisocial personality disorder, and they are more likely to experience episodes of intense or explosive anger.^8,9

What Are the Symptoms of BPD?

The DSM-5 classifies mental disorders and includes specific diagnostic criteria for all currently recognized mental disorders. It is a tool for diagnosis and treatment, but it is also a tool for communication, providing a common language for clinicians and researchers to discuss symptoms and disorders. According to the DSM-5, the symptoms of BPD include:¹

■ Intense fear of abandonment and efforts to avoid abandonment (real or imagined).

■ Turbulent, erratic, and intense relationships that often involve vacillating perceptions of others (from extremely positive to extremely negative).

■ Lack of a sense of self or an unstable sense of self

■ Impulsive acts that can be hurtful to oneself (e.g., excessive spending, reckless driving, risky sex).

■ Repeated suicidal behavior or gestures or self-mutilating behavior. (See the section below on suicide and nonsuicidal self-injury.)

■ Chronic feelings of emptiness

■ Episodes of intense (and sometimes inappropriate) anger or difficulty controlling anger (e.g., repeated physical fights, inappropriate displays of anger)

■ Temporary feelings of paranoia (often stress-related) or severe dissociative symptoms (e.g., feeling detached from oneself, trancelike).

Anyone with some of these symptoms may need to be referred to a licensed mental health professional for a complete assessment. Exhibit 1 presents some examples of how a person with BPD might behave. Suicide and nonsuicidal self-injury BPD is unique in that it is the only mental disorder diagnosis that includes suicide attempts or self-harming behaviors among its diagnostic criteria^.3 The risk of suicide is high among individuals with BPD, with as many as 79 percent reporting a history of suicide attempts¹⁰ and 8 percent to 10 percent dying by suicide—a rate that may be 50 times greater than the rate among the general population.¹¹ More than 75 percent of individuals with BPD engage in deliberate self-harming behaviors known as nonsuicidal self-injury (NSSI) (e.g., cutting or burning themselves).¹² Unlike suicide attempts, NSSI does not usually involve a desire or intent to die. Sometimes the person with BPD does not consider these behaviors harmful.⁴ One study involving 290 patients with BPD found that 90 percent of patients reported a history of NSSI, and over 70 percent reported the use of multiple methods of NSSI.10 Reasons for NSSI vary from person to person and, for some individuals, there may be more than one reason. The behaviors may be: ^4,13,14

■ A way to express anger or pain

■ A way to relieve pain (i.e., shifting from psychic pain to physical pain)

■ A way to “feel” something.

■ A way to “feel real.”

■ An attempt to regulate emotions.

■ A form of self-punishment.

■ An effort to get attention or care from others. NSSI may include: 4,13,14

■ Cutting.

■ Burning.

■ Skin picking or excoriation.

■ Head banging.

■ Hitting.

■ Hair pulling

Exhibit 1. Examples of Symptomatic Behavior (BPD)

■ Patterns of intense and unstable relationships

John comes in to see his case manager, George, and announces that he plans to marry a woman he met at a speed-dating event the night before. George has heard this same story from John at least once a month for the past 4 months.

■ Emotions that seem to change quickly from one extreme to another

Suzie has been working with a vocational rehabilitation counselor, Tony, for 2 weeks to prepare for job retraining. One day, just after Tony gets everything set up for Suzie to begin her training, Suzie storms out of the office screaming at him, “You’re just trying to get rid of me! You don’t understand me at all! I hate you!” Later, when Tony calls to suggest that maybe Suzie would prefer to work with another counselor, Suzie begins to cry and says, “Please don’t drop me, Tony! I need you!”

■ Evidence of self-harm or self-mutilation

José is a probation officer. During his weekly appointment with his client, Annie, José notices a pattern of recent cuts across her left forearm. José asks her about them, and Annie becomes defensive and says, “Okay, I cut myself sometimes, so what? It’s none of your business. I’m not hurting anybody!”

■ Pattern of suicidal thoughts, gestures,* or attempts

Maria is a nurse. As she looks over the health history of her new patient, Sally, she notices that Sally has been hospitalized three times in the past 4 years after suicide attempts, and that she has seen six different therapists. Sally tells her, “Yeah, I get suicidal sometimes. I just can’t seem to find the right therapist who can help me.”

■ Intense displays of emotion that often seem inappropriate or out of proportion to the situation

Regina is a social worker at a domestic violence shelter. She notices one of her clients, Elena, sitting in the living room with a sketchpad in her lap. Regina asks if she can see what Elena is drawing. Elena turns the sketchpad around to reveal a beautiful, detailed drawing of the shelter house. Regina admires it and says how beautiful it is, then says, “That’s funny, I thought that the house number was on the right side of the door.” Elena, who had been smiling, takes the sketchpad from Regina, looks at the drawing, then rips it from the pad and begins tearing it up, saying, “You’re right, it’s all wrong! I’ll have to start all over again!”

*Regarding the word gestures: It is dangerous to dismiss or label any suicidal behavior as a gesture. Anyone who exhibits suicidal thoughts or behaviors of any kind needs to be assessed by a licensed mental health professional.

What Are the Symptoms of SUDs?

SUDs involve patterns of recurrent substance use that result in significant problems, which fall into the following categories:¹

■ Impaired control—taking more of the substance than intended, trying unsuccessfully to cut down on use, spending an increasing amount of time obtaining and using the substance, craving or having a strong desire for substance use

■ Social impairment—failing to fulfill obligations at work, school, or home; continuing substance use in spite of the problems it causes; giving up or reducing other activities because of substance use

■ Risky use—using the substance(s) in situations in which it may be physically dangerous to do so (e.g., driving) or in spite of physical or psychological problems that may have been caused or may be made worse by substance use (e.g., liver problems, depression)

■ Pharmacological criteria—displaying symptoms of tolerance (need for increased amounts of the substance to achieve the desired effect) or withdrawal (a constellation of physical symptoms that occurs when the use of the substance has ceased)

What Is the Relationship Between BPD and SUDs?

One study¹⁵ found that the prevalence of BPD among individuals seeking buprenorphine treatment for opioid addiction exceeded 40 percent, and another16 found that nearly 50 percent of individuals with BPD were likely to report a history of prescription drug abuse. A large survey⁶ found that 50.7 percent of individuals with a lifetime diagnosis (i.e., meeting the criteria for a diagnosis at some point during the individual’s life) of BPD also had a diagnosis of an SUD over the previous 12 months. This same survey found that for individuals with a lifetime diagnosis of an SUD, 9.5 percent also had a lifetime diagnosis of BPD. This is a significantly higher incidence of BPD than that in the general public, which ranges from 1.6 percent to 5.9 percent.¹

One longitudinal study^₁₇ found that 62 percent of patients with BPD met criteria for an SUD at the beginning of the study. However, over 90 percent of patients with BPD and a co-occurring SUD experienced a remission of the SUD by the time of the study’s 10-year follow-up. (Remission was defined as any 2-year period during which the person did not meet criteria for an SUD.) The authors also looked at whether there were recurrences of SUDs after periods of remission and found that the rate of recurrence was 40 percent for alcohol and 35 percent for drugs. The rate of new onsets of SUDs, while lower than expected, was still 21 percent for drugs and 23 percent for alcohol.

Another study¹⁸ found that individuals with BPD had higher rates of new SUD onsets even when their BPD symptoms improved (compared with new SUD onsets for individuals with other personality disorders). A client with BPD and a co-occurring SUD presents some particular challenges. BPD is difficult to treat, partly because of the pervasive, intractable nature of personality disorders and partly because clients with BPD often do not adhere to treatment and often drop out of treatment. The impulsivity, suicidality, and self-harm risks associated with BPD may all be exacerbated by the use of alcohol or drugs.¹⁹ In addition, the presence of BPD may contribute to the severity of SUD symptoms,²⁰ and the course of SUD treatment may be more complicated for clients who also have BPD.²¹

Who Can Best Provide Treatment for People With BPD and SUDs?

Individuals who display some of the symptoms of BPD (as described above) should be referred to an experienced licensed mental health professional for a thorough mental health assessment and possible referral to treatment. It is important to know whether referral sources have experience treating clients with BPD. If individuals display symptoms of substance misuse, they should also be assessed for a co-occurring SUD. Individuals with BPD sometimes trigger intense feelings of frustration and even anger in their therapists and other providers.¹²

Clients with BPD often have difficulty developing good relationships, including productive working relationships with therapists and other providers (e.g., healthcare workers, case managers, vocational counselors). Some individuals with BPD may move from therapist to therapist (or other professionals) in an effort to find “just the right person.” Individuals who have an SUD may receive treatment from an individual counselor or therapist or from an outpatient treatment program. However, a co-occurring diagnosis of BPD may complicate SUD treatment. It is important for the professionals treating the person for either diagnosis to work in consultation with each other.

Treatment for BPD—especially with a co-occurring SUD— sometimes involves a team approach. Depending on the treatment plan, a person may have an individual therapist, a group therapist, a substance abuse counselor, a psychiatrist, and a primary care provider; treatment may need to be planned and managed through the coordinated efforts of all providers. Regular consultation among all providers can ensure that everyone is working toward the same goals from each of their professional perspectives. For example:

■ In individual therapy sessions, a therapist may help the client learn to tolerate gradually increasing levels of uncomfortable emotions (e.g., stress, anxiety) so that the client may begin to have more control over those emotions.

■ A psychiatrist may consider the use of medication for the client or evaluate currently prescribed medications to determine adherence and their effect on the client’s ability to engage in the emotional work of therapy.

■ A substance abuse counselor may work with the client to achieve abstinence, identify relapse triggers that may come up as the client does emotional work in therapy, and identify coping strategies for remaining abstinent.

■ A vocational counselor may need to work with the client on distress tolerance as it relates to employment issues, such as applying for jobs or beginning a new job. This may mean helping the client understand the importance of being at interviews, vocational training classes, or work on time (even if emotional problems make that difficult) and helping the client develop strategies to achieve a pattern of good work habits. Some people with BPD may consciously or unconsciously attempt to sabotage treatment by providing conflicting information to providers or by trying to turn one provider against another. Consultation among all providers can help deter this.

What Treatments Are Available for Individuals With BPD and SUDs?

Many studies have been done on treatment approaches for BPD or SUDs, but very few have involved participants with co-occurring BPD and SUDs.^22,23,24 However, based on the studies that have been done on co-occurring BPD and SUDs, a few approaches seem to show promise.

Perhaps the most researched approach is Dialectical Behavior Therapy, which has been adapted for treatment of co-occurring BPD and SUDs (Dialectical Behavior Therapy-S [DBT-S]). It is important to note, however, that DBT-S and other promising approaches involve structured, manualized treatments that are quite intensive and require a significant amount of training and resources (e.g., staffing, space, finances) that may not be available in all areas.²⁵ Many therapists work on their own with individuals who have BPD, using the best techniques that their training and experience have to offer—hopefully in regular consultation with an experienced clinical supervisor. Therapists often adapt psychotherapy to better meet the needs of an individual client, sometimes combining different therapeutic approaches or mixing techniques.⁴

However, for clients with both BPD and SUDs, the therapist may need to work with an SUD treatment provider to provide comprehensive care. Pharmacotherapy for BPD and SUDs The Food and Drug Administration (FDA) has not approved any medications for the treatment of BPD. However, individuals with BPD may take medications to alleviate some of their symptoms.^11,22 For example, selective serotonin reuptake inhibitors may be prescribed for depressed mood, irritability, anger, and impulsivity.¹¹ There are several FDA-approved medications for SUD treatment. For alcohol use disorder, these include acamprosate, disulfiram, and naltrexone.²⁶

For opioid use disorder, approved medications include buprenorphine, a combination of buprenorphine and naloxone, methadone, and naltrexone.²⁷ Some of these medications may be prescribed on a short-term basis (e.g., to ease withdrawal symptoms, lessen cravings), and others may be prescribed for long-term use (e.g., to facilitate longer periods of abstinence).^26,27 Individuals may receive their prescriptions and medication management from a psychiatrist, from other types of healthcare providers, or from both (or, in the case of methadone, from an opioid treatment program). Individuals may take medication as one part of a treatment plan that also includes attending individual therapy, group therapy, group skill-building sessions, or a mutual-help group (e.g., 12-step program), or some combination of these.

What Are Some Things To Remember When Working With Someone Who Has Co-Occurring BPD and SUDs?

Some of the same guidelines that have been identified as necessary for mental health professionals who work with clients who have these two diagnoses may also be helpful for all human services professionals. Working with a client who has co-occurring BPD and SUDs requires:

■ Strong (but not rigid) professional boundaries—Be clear with the person about the expectations in the working relationship (e.g., length of appointments, level of support, contact outside regular appointments). Be aware of special requests to make exceptions to the usual rules for working with clients. These requests sometimes escalate over time. If in doubt about making an exception to the rules, discuss the situation with a supervisor who is knowledgeable about working with individuals who have BPD (within applicable confidentiality requirements).¹¹

■ A commitment to self-care—If possible, schedule appointments with someone who has BPD right before lunch or before a break. Avoid scheduling back-to-back appointments with two individuals who have BPD. It is important to have some time between them to see clients with other diagnoses, to work on other tasks, or simply to take a break. Develop the habit of leaving work at work (i.e., don’t “replay” interactions with individuals who have BPD).

■ An awareness of how BPD may affect any kind of work with the individual—For example, fearing abandonment and avoiding abandonment are characteristics of BPD and may manifest in some unexpected ways. For example, if the professional relationship has focused on the person with BPD completing certain goals, that person may thwart his or her own progress to avoid the feelings of abandonment that would result from ending the working relationship.

■ Knowledge about what skills the individual who has BPD is learning in therapy—The person may need assistance applying those new skills to broader life situations. For example, perhaps one skill the person has learned is how to break down a seemingly overwhelming task into a series of small steps. Work with the person to apply that particular skill to the situation at hand.

Conclusions

It is important to remember that:

■ Most human services professionals will encounter clients with BPD in the course of their work.

■ Individuals with BPD often have co-occurring diagnoses (e.g., depression, SUDs). ■ BPD is often characterized by intense emotional displays and impulsive acts (e.g., self-harm, suicide attempts).

■ Working with an individual with BPD (with or without a co-occurring SUD) can be challenging.

■ Individuals with BPD (with or without a co-occurring SUD) deserve to receive appropriate treatment and deserve to be treated with compassion and respect.

■ Individuals with BPD often respond to appropriate treatment and experience a remission of symptoms with a relatively low occurrence of relapse.

■ Individuals with BPD (with or without a co-occurring SUD) may have a team of professionals who provide different aspects of care (e.g., therapist, psychiatrist).

■ It is important for all professionals involved in the care of an individual with BPD to communicate and work together.

Resources

SAMHSA resources

National Registry of Evidence-based Programs and Practices http://nrepp.samhsa.gov

Treatment Improvement Protocols (TIPs) (see back page for electronic access and ordering information)

TIP 36: Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues

TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders

TIP 44: Substance Abuse Treatment for Adults in the Criminal Justice System

TIP 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment Web resources

American Psychiatric Association http://www.psych.org

American Psychological Association http://www.apa.org

Borderline Personality Disorder Resource Center http://bpdresourcecenter.org

Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover 7 An Introduction to Co-Occurring Borderline Personality Disorder and Substance Use Disorders Fall 2014, Volume 8, Issue 3

National Education Alliance for Borderline Personality Disorder http://www.borderlinepersonalitydisorder.com

National Institute of Mental Health http://www.nimh.nih.gov

National Institute on Drug Abuse http://www.drugabuse.gov

Notes

¹ American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

² Battle, C. L., Shea, M. T., Johnson, D. M., Yen, S., Zlotnick, C., Zanarini, M. C., et al. (2004). Childhood maltreatment associated with adult personality disorders: Findings from the Collaborative Longitudinal Personality Disorders Study. Journal of Personality Disorders, 18(2), 193–211.

³ Dimeff, L. A., Comtois, K. A., & Linehan, M. M. (2009). Cooccurring addiction and borderline personality disorder. In R. K. Ries, D. A. Fiellin, S. C. Miller, & R. Saitz (Eds.), Principles of addiction medicine (4th ed., pp. 1227–1237). Philadelphia: Lippincott Williams & Wilkins.

⁴ National Institute of Mental Health. (2011). Borderline personality disorder. NIH Publication No. 11‑4928. Bethesda, MD: Author.

⁵ Substance Abuse and Mental Health Services Administration. (2011). Report to Congress on borderline personality disorder. HHS Publication No. (SMA) 11‑4644. Rockville, MD: Substance Abuse and Mental Health Services Administration.

⁶ Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., et al. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69, 533–545.

⁷ Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B., & Silk, K. R. (2005). The McLean Study of Adult Development (MSAD): Overview and implications of the first six years of prospective follow-up. Journal of Personality Disorders, 19(5), 505–523.

⁸ Sansone, R. A., & Sansone, L. A. (2011). Gender patterns in borderline personality disorder. Innovations in Clinical Neuroscience, 8(5), 16–20.

⁹ Tadíc, A., Wagner, S., Hoch, J., Başkaya, Ö., von Cube, R., Skaletz, C., et al. (2009). Gender differences in axis I and axis II comorbidity in patients with borderline personality disorder. Psychopathology, 42, 257–263.

¹⁰ Zanarini, M. C., Frankenburg, F. R., Reich, D. B., Fitzmaurice, G., Weinberg, I., & Gunderson, J. G. (2008). The 10-year course of physically self-destructive acts reported by borderline patients and axis II comparison subjects. Acta Psychiatrica Scandinavica, 117, 177–184.

¹¹ American Psychiatric Association. (2001). Practice guideline for the treatment of patients with borderline personality disorder. American Journal of Psychiatry, 158, 1–52.

¹² Black, D. W., & Andreasen, N. C. (2011). Introductory textbook of psychiatry (5th ed.). Washington, DC: American Psychiatric Publishing.

¹³ Brown, M. Z., Comtois, K. A., & Linehan, M. M. (2002). Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. Journal of Abnormal Psychology, 111(1), 198–202.

¹⁴ Kleindienst, N., Bohus, M., Ludäscher, P., Limberger, M. F., Kuenkele, K., Ebner-Priemer, U. W., et al. (2008). Motives for nonsuicidal self-injury among women with borderline personality disorder. Journal of Nervous and Mental Disease, 196(3), 230–236.

¹⁵ Sansone, R. A., Whitecar, P., & Wiederman, M. W. (2008). The prevalence of borderline personality among buprenorphine patients. International Journal of Psychiatry in Medicine, 38(2), 217–226.

¹⁶ Sansone, R. A., & Wiederman, M. W. (2009). The abuse of prescription medications: Borderline personality patients in psychiatric versus non-psychiatric settings. International Journal of Psychiatry in Medicine, 39(2), 147–154.

¹⁷ Zanarini, M. C., Frankenburg, F. R., Weingeroff, J. L., Reich, D. B., Fitzmaurice, G. M., & Weiss, R. D. (2011). The course of substance use disorders in patients with borderline personality disorder and axis II comparison subjects: A 10-year follow-up study. Addiction, 106(2), 342–348.

¹⁸ Walter, M., Gunderson, J. G., Zanarini, M. C., Sanislow, C. A., Grilo, C. M., McGlashan, T. H., et al. (2009). New onsets of substance use disorders in borderline personality disorder over 7 years of follow-ups: Findings from the Collaborative Longitudinal Personality Disorders Study. Addiction, 104, 97–103.

¹⁹ van den Bosch, L. M. C., Verheul, R., & van den Brink, W. (2001). Substance abuse in borderline personality disorder: Clinical and etiological correlates. Journal of Personality Disorders, 15, 416–424.

²⁰ Morgenstern, J., Langenbucher, J., Labouvie, E., & Miller, K. J. (1997). The comorbidity of alcoholism and personality disorders in a clinical population: Prevalence rates and relation to alcohol typology variables. Journal of Abnormal Psychology, 106(1), 74–84.

²¹ Center for Substance Abuse Treatment. (2005). Substance abuse treatment for persons with co-occurring disorders. Treatment Improvement Protocol (TIP) Series 42. HHS Publication No. (SMA) 13‑3992. Rockville, MD: Substance Abuse and Mental Health Services Administration.

²² Gianoli, M. O., Jane, J. S., O’Brien, E., & Ralevski, E. (2012). Treatment for comorbid borderline personality disorder and alcohol use disorders: A review of the evidence and future recommendations. Experimental and Clinical Psychopharmacology, 20(4), 333–344.In Brief In Brief, An Introduction to Co-Occurring Borderline Personality Disorder and Substance Use Disorders

²³ Kienast, T., & Foerster, J. (2008). Psychotherapy of personality disorders and concomitant substance dependence. Current Opinion in Psychiatry, 21, 619–624.

²⁴ Pennay, A., Cameron, J., Reichert, T., Strickland, H., Lee, N. K., Hall, K., et al. (2011). A systematic review of interventions for co-occurring substance use disorder and borderline personality disorder. Journal of Substance Abuse Treatment, 41(4), 363–373.

²⁵ Zanarini, M. C. (2009). Psychotherapy of borderline personality disorder. Acta Psychiatrica Scandinavica, 120, 373–377.

²⁶ Center for Substance Abuse Treatment. (2009). Incorporating alcohol pharmacotherapies into medical practice. Treatment Improvement Protocol (TIP) Series 49. HHS Publication No. (SMA) 13‑4380. Rockville, MD: Substance Abuse and Mental Health Services Administration.

²⁷ Center for Substance Abuse Treatment. (2005). Medication-assisted treatment for opioid addiction in opioid treatment programs.

Treatment Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) 12‑4214. Rockville, MD: Substance Abuse and Mental Health Services Administration.

In Brief

This In Brief was written and produced under contract numbers 270-09-0307 and 270-14-0445 by the Knowledge Application Program, a Joint Venture of JBS International, Inc., and The CDM Group, Inc., for the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Christina Currier served as the Contracting Officer’s Representative.

Disclaimer: The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS.

Public Domain Notice: All materials appearing in this document except those taken from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. Electronic Access and Copies of Publication: This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web page at http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

Recommended Citation: Substance Abuse and Mental Health Services Administration. (2014). An Introduction to Co-Occurring Borderline Personality Disorder and Substance Use Disorders. In Brief, Volume 8, Issue 3. Originating Office: Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. HHS Publication No. (SMA) 14-4879 Printed 2014

Source:

https://store.samhsa.gov/product/An-Introduction-to-Co-Occurring-Borderline-Personality-Disorder-and-Substance-Use-Disorders/SMA14-4879

Interviewed by Mark Gold, MD

FEATURED ADDICTION EXPERT: Brian Fuehrlein, MD, PhD, Assistant Professor, Yale University Director, Psychiatric Emergency Room, VA Connecticut Healthcare System

If a patient has overdosed on opioid, can you describe your approach to the emergency including the exam, medications, observation and discharge-transfer?

As the director of a psychiatric emergency room at VA Connecticut and Yale, I assume the care of patients after medical stabilization. Medical stabilization often includes Narcan administration and other possible treatments. While I am not generally directly involved in the Narcan administration, I will frequently see patients soon after a Narcan reversal (days to weeks). I have a very clear approach to these patients. My approach to a patient post Narcan reversal is aggressive and assertive. In my mind, I may be the last physician that this patient sees alive. I am very aggressive when discussing the severity of the illness and the critical need for treatment. When developing a treatment plan, I am very assertive. I will spend as much time as I can with the patient attempting to motivate them for treatment. When a patient has already required a Narcan reversal (and hence nearly died) they are high risk for this to occur again. This is as critical of a patient that I care for.

We generally refer to opioid overdoses as accidental, but do you have an idea of what percentage of the patients are depressed, wanted to die, or had passive suicidal ideation? Do you formally evaluate them for concurrent psychiatric illness at some time after you save their lives?

All patients who present to the psychiatric emergency room receive a thorough psychiatric and substance use assessment. The prevalence of co-occurring psychiatric illness with opioid use disorder (OUD) is very high. By the time the OUD has progressed to the point of intravenous use leading to Narcan reversal, there are typically many psychosocial consequences and stressors. In addition, these patients are often young (<30). These severe consequences, which often occur quickly, may lead to feelings of hopelessness, helplessness and passive suicidal ideation (SI). While I do not know firm percentages, in my experience the majority of those with severe opioid use disorder suffer from comorbid anxiety and/or depression. A lower percentage, but still significant amount, experience passive SI and will report things like “I was not trying to kill myself, but if I were to never wake up the world would be better off without me”. I would say that a small but significant percentage is actively suicidal at the time of the overdose with intent to die.

Patients will often have a history of multiple overdoses. What is your approach and ideal post rescue plan? Do you transfer them to a locked unit or give them a follow-up appointment? What happens to a person who is given Narcan and rescued by an EMT?

I tend to be as aggressive and assertive as possible while discussing the severity of the illness and the dire need for intensive treatment, especially in a patient who has had multiple overdoses. I attempt to motivate every patient who has experienced an overdose to be initiated on medication-assisted treatment (MAT). If agreeable, I will start buprenorphine in the VA/Yale psychiatric emergency room. Initiating buprenorphine in an emergency room setting is difficult in practice. Given the resources available at the VA we are able to do it. This practice is based upon a recent study at Yale that showed that initiating buprenorphine in emergency setting results in patients more likely to be connected to treatment. I also educate every patient about the need for a psychosocial support structure. I am a proponent of AA/NA programs and I discuss with all patients the importance of meetings/sponsorship. The goal for all patients who present post overdose is to initiate them on buprenorphine, transfer them to our substance use treatment program (either inpatient or IOP level of care) and then to attend 90 meetings in 90 days.

Unfortunately, many patients request discharge without willingness to engage directly in treatment. While state laws differ, in CT it is often hard to commit patients involuntarily specifically for substance use. If the patient is actively or passively suicidal or manic/psychotic, etc., we can often commit them on a psychiatric commitment. But if the risk stems primarily from ongoing substance use, we are often unable to hold the patient and force treatment upon them. We try very hard to motivate them for treatment. We will also engage their family to help with the motivation. But many patients are discharged home with outpatient follow-up only. We will prescribe a Narcan rescue kit, educate about harm reduction strategies, provide an appointment to see mental health within 7 days and place a follow-up phone call the day after discharge. But we are often unable to do more unless the patient is willing.

What is your suggestion for the role of Vivitrol post Narcan care?

I attempt to motivate all patients with opioid use disorder, particularly those post overdose, to initiate buprenorphine in the psychiatric emergency room. The first line treatment is buprenorphine, unless there is a reason/contraindication. For example, if adequate trials of buprenorphine have demonstrated its lack of efficacy in that patient, or if there was an intolerable side effect or adverse reaction. Methadone is generally the second line agent that is used following a buprenorphine failure. Following a Methadone treatment failure (side effect, etc), then Vivitrol the third line agent. Veterans at the VA will have an assigned outpatient treatment coordinator. We will collaborate with the outpatient team to determine the appropriate management of the opioid use disorder. We are able to initiate buprenorphine or Vivitrol the PER but Methadone initiation is deferred to the opioid treatment program. It is critical that patients with OUD are initiated on maintenance medication (one of the 3 mentioned) AND referred to a treatment program AND AA/NA.

Can you compare patients that you would suggest for Methadone vs. Suboxone vs. Vivitrol? How do you decide the doses? How long do you suggest MAT plus therapy and when to stop?

In general, buprenorphine is the first line, Methadone is second line and Vivitrol is third line, though this depends greatly on the individual patient. At times, Methadone is the first line agent if the patient requires the structure of the opioid treatment program or if the severity of the addiction is such that high dose Methadone is preferred. In general, buprenorphine is appropriate for the majority of the patients that I see in the psychiatric emergency room. Duration of MAT therapy remains debated. It depends on many factors and is an individual decision between the physician and the patient. In my opinion, a very important consideration when deciding whether to stop MAT is the patient’s commitment to a recovery program. If the patient is going to daily meetings, has a sponsor and is completing step work, I am more likely to endorse a plan of tapering down the buprenorphine than the same patient who is relying solely on the buprenorphine for sobriety.

Other considerations include IV use, previous OD with Narcan administration and other high risk behaviors. These would make me more likely to recommend longer term use of buprenorphine. In addition, the decision to stop MAT would depend on factors like cost, side effects, etc. Opioid use disorder is a deadly illness that requires long term treatment. When the illness is severe, high risk behaviors are present and the buprenorphine is not causing problems, I am unlikely to recommend tapering it off.

Are you seeing opioid overdose and addicts concurrently using marijuana, alcohol, cocaine, methamphetamine, other? Can you give us a sense of how many patients just use one drug or are just addicted to one drug? Do you do drug testing on all patients in the ED?

Yes, we perform urine drug screens on all patients who present to the psychiatric emergency room (PER). In my experience there are several groups of patients with opioid use disorder.

The most common group of patients with OUD also have a history of other substance use disorders. Most common would be marijuana, alcohol, cocaine and sedatives. While this group has struggled with an addiction to multiple substances, the opioids are the clear drug of choice. Many patients in this group will set all other drugs aside and only use them occasionally once opioids are discovered.

The second most common group with OUD continues to use other drugs concomitantly with the opioids. They may not identify opioids (or any of the others) as a clear drug of choice. This group will often speedball (mix opioids and cocaine). They also may unfortunately mix alcohol or sedatives with opioids, which is an unfortunate combination.

The least common group has OUD with no other history of substance use.

Methamphetamine is not as common in the northeast and hence for regional considerations I do not see it commonly. As a resident in Dallas, TX, methamphetamine use, with or without opioids, was common.

Do you have a protocol for switching someone from Suboxone to Naltrexone?

In the PER we do not generally complete an opioid detox and hence do not generally switch from buprenorphine to Naltrexone. We either initiate and titrate buprenorphine for maintenance or transfer to a local rehab or detox facility for completing detox.

Do you have an opioid detox protocol that you’d use in the hospital or ED?

First, we try hard to not detox OUD patients. Patients with OUD should be on MAT and we use the psychiatric emergency room (PER) visit as a means to initiate buprenorphine. We aggressively recommend buprenorphine initiation. If agreeable, we generally will start buprenorphine 4mg in the PER once withdrawal symptoms are moderate (COWS >8). We will then repeat the 4mg dose if indicated for a maximum dose of 8mg on day 1. The patient will then spend the night in the PER for observation.

On day 2, we titrate up to a maximum dose of 16mg if indicated. At that point the patient is ready for movement to the next level of care. Occasionally, patients will require a second night in the PER to titrate the buprenorphine up and for complete stabilization of withdrawal symptoms.

Once at a stabilizing dose the patients will generally move to our 21-day substance use treatment program. While in the program the buprenorphine is titrated as necessary. Upon completion of the program the patient is referred to the buprenorphine clinic in conjunction with a psychosocial program.

If the patient is unwilling to attend the 21-day program, and buprenorphine is initiated in the PER, the patient is discharged from the PER and seen daily in the outpatient detox/stabilization clinic until an appointment is available in the buprenorphine clinic. Given the resources at the VA we are able to initiate buprenorphine in the PER with confidence that a plan on the backend is achievable.

If the patient is unwilling to be on maintenance therapy then an opioid detox is completed. This is done with either buprenorphine or symptom-driven. Typically for detox, the patient is transferred to a local detox facility that the VA contracts with.

You have worked in both the inpatient and residential drug free drug programs and now Yale in ED and MAT, can you give me a sense of what lessons you have learned from each and how each might have a role and limitations?

Residential programs are a very important part of the recovery process but are not a cure for addiction. I often encounter patients who have completed our 21-day treatment program multiple times, each time having relapsed almost immediately after completion. When patients and/or families expect that years or decades of use will be cured after 21 days in a program they will naturally be disappointed. “Treatment begins when you leave the program” is a very important tenet of recovery. A good residential program will introduce/reinforce recovery principles and motivate the patient to continue this process after completion of the program. Without a solid aftercare program, residential programs are destined to fail.

Regarding the emergency room, many providers may not see the emergency room as an ideal environment for a discussion about recovery. Every patient that I see in the PER will hear about the importance for long term treatment and the need for a solid recovery program. I will discuss long term strategies including MAT, NA and other treatment options. Even with patients who present to the PER frequently, I always spend time discussing the importance of a solid foundation of recovery and the need for MAT. Even in the context of a busy emergency room, there is always time for a brief motivational interaction which may make a real difference and save a life.

Are you seeing meth or cocaine emergencies and/or overdoses? What is your approach?

Methamphetamine is not a common drug of abuse in this region of the country. Cocaine is incredibly common and it is commonly abused in the powder form or in the form of crack. It is often used in conjunction with opioids (speedballs). When cocaine overdoses occur (rarer than opioid overdoses), the patient is seen and stabilized in the medical ER prior to transfer to the PER. With patients who are using cocaine at levels so dangerous that it leads to overdose, I am aggressive and assertive the way I am with opioids. The difference with stimulants is the lack of MAT. Hence the reliance on a psychosocial treatment becomes more important. Patients are referred to the substance use treatment program to begin the recovery process. They are then referred to AA/NA, contingency management, CBT for addiction or other psychosocial support programs.

Source: https://www.rivermendhealth.com/resources/q-a-with-brian-fuehrlein-md-phd-the-opioid-epidemic-and-emergency-room-visits November 2017

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.

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.’’

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.’’

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.

Source:  https://www.nytimes.com/2017/07/12/magazine/a-small-town-police-officers-war-on-drugs 

 

 

 

Investigating the proposition that cannabis is worth bothering with, this hot topic looks at reports that stronger cannabis on the market is increasing harms to users, prospects of recovery from disorders and dependence, and the emerging response to synthetic forms of cannabis like ‘spice’.

CANNABIS IN THE LAW

A controlled ‘Class B’ substance, cannabis carries legal penalties for possession, supply, and production. Between 2004–2009 cannabis was reclassified as a ‘Class C’ substance, meaning for a brief period of time it carried lesser penalties for possession. In 2009, the Association of Chief Police Officers issued new guidance, advising officers to take an escalating approach to the policing of cannabis possession for personal use: • A warning • A penalty notice for disorder (PND) • Arrest

This three-tiered approach was designed to be “ethical and non-discriminatory”, but also reinforce the “national message that cannabis is harmful and remains illegal”.

In 1990s Britain a common reaction to allocating resources to treating cannabis users was, ‘Why bother? We have more than enough patients with problems with serious drugs like heroin.’ The typically calming use of the drug by adults was seen as preferable to the main alternative – alcohol and its associated violence and disorder. Calls for a treatment response were seen as pathologising what in many societies is both normal and in some ways desirable youth development: trying new experiences, challenging conventions, and exposing the hypocrisy of alcohol-drinking adults. In 1997 the Independent on Sunday launched a campaign to decriminalise cannabis, culminating in a mass ‘roll-up’, and 16,000-strong pro-cannabis march from Hyde Park to Trafalgar Square. Its Editor Rosie Boycott wrote in the paper about her own coming-of-age experience smoking cannabis, telling readers:

“I Rolled my first joint on a hot June day in Hyde Park. Summer of ’68. Just 17. Desperate to be grown-up. … My first smoke, a mildly giggly intoxication, was wholly anti-climatic. The soggy joint fell apart. I didn’t feel changed. But that act turned me – literally – into an outlaw. I was on the other side of the fence from the police – or the fuzz, as we used to call them. So were a great many of my generation.”

The campaign was explosive, but short-lived, apparently subsiding when Boycott left to take up her role as Editor of the Daily Express. A decade later, the Independent issued an apology for the campaign. ‘If only they had known then, what they knew now’, was the message of the article, referring to the reportedly damaging impact of the more potent strains of cannabis and its links to “mental health problems and psychosis for thousands of teenagers”.

Are stronger strains creating more problems?

There has been a long-standing, but controversial, association between cannabis strength and harm. Reading newspaper articles on the subject, it wouldn’t be unusual to see a headline drawing a straight line between ‘super-strength skunk’ and addiction, violence, deaths, or psychosis. In 2008, then Prime Minister Gordon Brown spoke in a similar vein, telling a breakfast-television viewing audience:

I have always been worried about cannabis, with this new skunk, this more lethal part of cannabis.

I don’t think that the previous studies took into account that so much of the cannabis on the streets is now of a lethal quality and we really have got to send out a message to young people – this is not acceptable.

Brown was warning of a dangerous new strain of cannabis on the market, that caused very severe harms to users – contrasting starkly with the common perception of cannabis as a ‘low harm’ or ‘no harm’ drug. The strength or potency of cannabis is determined by the amount of ‘THC’ it contains. THC produces the ‘high’ associated with cannabis, and another major component ‘CBD’ produces the sedative and anti-anxiety effects. As well as potency, the relative amounts of THC and CBD are important for understanding the effects of cannabis – something explored in a University College London study during the programme Drugs Live: Cannabis on Trial. The research team compared two different types of cannabis: the first had high levels of THC (approx. 13%) but virtually no CBD; and the second had a lower level of THC (approx. 6.5%) and substantial amounts of CBD (approx. 8%). They found that CBD had a moderating or protective effect on some of the negative effects of THC, and that “many of the effects that people enjoy are still present in low-potency varieties without some of the harms associated with the high-potency varieties”. At least in the US over the last two decades (between 1995–2014), potency has increased from around 4% to 12%, and the protective CBD content of cannabis has decreased, from around 28% to less than 15%, significantly affecting the ratio of THC to CBD, and with it, the nature and strength of the psychoactive effect of cannabis. Until the 1990s, herbal cannabis sold in the UK was predominantly imported from the Caribbean, West Africa, and Asia. After this time, it was increasingly produced in the UK, being grown indoors using intensive means (artificial lighting, heating, and control of day-length). A study funded by the Home Office analysed samples of cannabis confiscated by 23 police forces in England and Wales in 2008, and found that over 97% of herbal cannabis had been grown by intensive methods; its average potency of 16% compared with just 8% for traditional imported herbal cannabis. This matched other reports of home-grown cannabis being consistently (around 2–3 times) stronger than imported herbal cannabis and cannabis resin.

In 2015, observing a decrease in the use of cannabis in England and Wales, but parallel increase in demand for treatment, a UK study examined whether the trend could be explained by an increase in the availability of higher-potency cannabis. Over 2500 adults were surveyed about their use of different types of cannabis, severity of dependence, and cannabis-related concerns. The researchers found that higher potency cannabis was associated with a greater severity of dependence, especially in young people, and was rated by participants as causing more memory impairment and paranoia than lower potency types. However at the same time, it was reported to produce the best ‘high’, and to be the preferred type.

By definition cannabis is a psychoactive substance, which means it can change people’s perceptions, mood, and behaviour. Higher potency cannabis contains more of the psychoactive component, so it makes sense that higher potency cannabis could increase the risk of temporary or longer-term (adverse) problems with perceptions, mood, and behaviour. However, there is a particular concern that cannabis use could be linked to ‘psychosis’, a term describing a mental illness where a person perceives or interprets reality in a very different way to those around them, which can include hallucinations or delusions.

Whether cannabis causes psychosis, precipitates an existing predisposition, aggravates an existing condition, or has no impact at all on psychotic symptoms, has for decades been hotly contested. With our focus on evaluations of interventions, Drug and Alcohol Findings is in no position to pronounce on this issue, nor on the possibility that the drug might sometimes improve mental health, but some examples of research informing this debate are included below. A 2009 UK study examined whether daily use of high-potency cannabis was linked to an elevated risk of psychosis, comparing 280 patients in London presenting with a first episode of psychosis with a healthy control group. The patients were found to be more likely to smoke cannabis on a daily basis than the control group, and to have smoked for more than five years. Among those who used cannabis, 78% of the patients who had experienced psychosis used higher-potency cannabis, compared with 37% of those in the control group. The findings indicated that the risk of psychosis was indeed greater among the people who were using high potency cannabis on a frequent basis, but couldn’t show that the cannabis use caused the psychosis, or even that the cannabis use made the group more susceptible to psychosis. The wider literature on mental health and substance use would suggest that the association is more complex than this. A recently published paper from the University of York has demonstrated the complications of attributing any association between cannabis use and psychosis to a causal effect of cannabis use rather than other factors or a reverse causal effect. A calculation based on data from England and Wales helped to put this into perspective, indicating that even if cannabis did cause psychosis more than 20,000 people would need to be stopped using cannabis to prevent just one case of psychosis. The apparent steady increase in cannabis potency in the UK since the 1990s is important context for further research. Where higher potency cannabis is increasingly becoming the norm, and is the preference for cannabis users, it would be relevant to generate more evidence of the health-related problems with high potency cannabis, and the treatment and harm reduction solutions based around these health-related problems.

Cannabis accounts for half of all new drug treatment patients

The most widely used illegal drug in Europe, many seemingly enjoy cannabis without it leading to any significant negative social or health effects. However, numbers entering treatment for cannabis use problems have been on the rise (both in the UK, and the rest of Europe), while heroin treatment numbers have fallen  chart. According to Public Health England, this is not because more people are using cannabis, but perhaps because services relieved of some of the recent pressure of opiate user numbers are giving more priority to cannabis, because they are making themselves more amenable to cannabis users, and because of emerging issues with stronger strains of the drug. Whatever the causes, across the UK figures submitted to the European drug misuse monitoring centre show that the proportion of patients starting treatment for drug problems who did so primarily due to their cannabis use rose steadily from 11% in 2003/04 to 22% in 2011/12. With the caveat that data from 2013 onwards is not directly comparabledue to changes in methodology, in 2014 and 2015 the proportion of patients who entered treatment primarily because of a cannabis issue hovered above previous years at 26% (25,278 and 26,295 respectively). Among first ever treatment presentations, the increase from 2003/04 was more pronounced, from 19% to 37%. By 2013, cannabis use had become the main prompt for half the patients who sought treatment for the first time (at 49%), and stayed relatively constant at 47% in 2014, and 48% in 2015.

Showing that more users was not the reason for more starting treatment, over about the same period, in England and Wales the proportion of 16–59-year-olds who in a survey said they had used cannabis in the past year fell from about 11% to 7% in 2013/14, then stayed at that level in 2014/15 and 2015/16. The treatment figures largely reflect trends in England, where in 2013/14 the number of patients starting treatment with cannabis use problems had risen to 30,422, 21% of all treatment starters, up from 23,018 and 19% in 2005/06. Subsequently the number dropped to 27,965 in 2015/16, still around a fifth of all treatment starters. Among the total treatment population – starting or continuing in treatment – cannabis numbers rose from 40,240 in 2005/06 to peak at 64,407 in 2013/14 before falling back to 59,918 in 2015/16; corresponding proportions again hovered around a fifth. As a primary problem substance among under-18s cannabis dominated, accounting for three-quarters of all patients in treatment in 2015/16 and in numbers, 12,863. The dominance of cannabis increased from 2008/09 as numbers primarily in treatment for drinking problems fell.

‘All treatments appear to work’

According to the two main diagnostic manuals used in Europe and the USA, problem cannabis use can develop into a cannabis use disorder or cannabis dependence, identifiable by a cluster of symptoms including: loss of control; inability to cut down or stop; preoccupation with use; neglecting activities unrelated to use; continued use despite experiencing problems; and the development of tolerance and withdrawal. This level of clinical appreciation for cannabis use problems didn’t exist when researcher and writer William L. White entered the addictions field half a century ago:

“When I first entered the rising addiction treatment system in the United States nearly half a century ago, there existed no clinical concept of cannabis dependence and thus no concept of recovery from this condition. In early treatment settings, cannabis was not consider[ed] a “real” drug, the idea of cannabis addiction was scoffed at as remnants of “Reefer Madness,” and casual cannabis use was not uncommon among early staff working in addiction treatment programs of the 1960s. Many in the field remain sceptical of the idea of cannabis dependence, specifically whether problem users at the severe end experience physiological withdrawal. However, reviewing what they believe is mounting evidence, these authors suggest there can be confidence in the existence of a “true withdrawal syndrome” – albeit one that differs qualitatively from the “significant medical or psychiatric problems as observed in some cases of opioid, alcohol, or benzodiazepine withdrawals”. In the case of cannabis, the main symptoms are primarily emotional and behavioural, although appetite change, weight loss, and some physical discomfort are reported. A brief review aimed at practitioners in UK primary care provides guidance on how to manage symptoms of withdrawal among patients trying to stop or reduce their cannabis use.

Research has come a long way, says William L. White, with now “clear data supporting the dependency producing properties of cannabis, a clear conceptualization of cannabis use disorders (CUD) and cannabis dependence (CD)”, but until recently, very little evidence about the prospects of long-term recovery. Yet, key papers – found here and here – indicate that:

• Full remission from cannabis use disorders is not only possible, but probable.

• Stable remission takes time – an average of 33 months.

• Abstinence may not be initially realistic for heavy cannabis users – but those in  remission are usually able to reduce the intensity of their use and its  consequences.

At least in the United States, it seems dependence is more quickly overcome from cannabis than the main legal drugs. A survey of the US general adult population found that within a year of first becoming dependent, 3% each of smokers and drinkers were in remission and remained so until they were surveyed. For cannabis the figure was nearly 5% and for cocaine, nearly 9%. After ten years the proportions in remission had risen to 18% for nicotine, 37% for alcohol, 66% for cannabis and 76% for cocaine. About 26 years after first becoming dependent, half the people at some time dependent on nicotine were in remission, a milestone reached for alcohol after 14 years, for cannabis six years, and for cocaine, five.

Specialised treatment programmes for cannabis users in European countries

Generally for people with cannabis use problems, the European Monitoring Centre for Drugs and Drug Addiction concluded in 2015, and before that in 2008, that “all treatments appear to work”. For adults, effective treatments include motivational interviewing, motivational enhancement therapy and cognitive-behavioural therapy, and for younger people, family-based therapies seem most beneficial. Less important than the type of treatment is the treatment context and the individual’s determination to overcome their problems through treatment. And there is “no firm basis for a conclusion” that cannabis-specific interventions (designed around the risks and harms associated with cannabis) are more effective than general substance use treatment tailored to the individual needs of the cannabis user seeking treatment chart. In some studies brief interventions have been found to work just as well as more intensive treatment, but when the patients are heavily dependent, and the most difficult cases are not filtered out by the research, longer and more individualised therapies can have the advantage. When the World Health Organization trialled its ASSIST substance use screening and brief advice programme in Australia, India, the United States, and Brazil, just over half the identified patients (all had to be at moderate risk of harm but probably not dependent) were primarily problem cannabis users. Among these, risk reduction in relation to this drug was significantly greater among patients allocated to a brief advice session than among those placed on a three-month waiting list for advice. In each country too, risk reduction was greater among intervention patients, except for the USA, where the order was reversed. Suggesting that severity of use was not a barrier to reacting well to brief intervention, only patients at the higher end of the moderate risk spectrum further reduced their cannabis use/risk scores following intervention. The ASSIST study was confined to adults, but young people in secondary schools in the USA whose problem substance use focused mainly on cannabis also reacted well to brief advice.

The relative persistence of opiate use problems versus the transitory nature of those primarily related to cannabis seemed reflected in an analysis of treatment entrants in England from 1 April 2005 to the end of 2013/14, the last time this particular analysis was published. At the end of this period just 7% of primary cannabis users were still in or back in treatment compared to the 30% overall figure and 36% for primary opiate users. The figure peaked at 43% for users of opiates and crack. Over half – 53% – of primary cannabis users had left treatment as planned, apparently having overcome their cannabis problems, compared to 27% of primary opiate users and just 20% with dual opiates and crack use problems. Another 40% of cannabis users had left treatment in an unplanned manner, a slightly higher proportion than among opiate users. The figures tell a tale of relatively high level of success which enables cannabis users to leave treatment, though even in the absence of recorded success, few stay long-term.

However, the forms patients in England complete with their keyworkers while in treatment seem to tell a different story. Compared to how they started treatment, around six months later 45% of primary cannabis users were assessed as using just as often (including a few using more), compared to 30% of opiate users and 42% whose main problem drugs were both opiates and crack, suggesting more rapid and/or more complete remission for opiate users than for cannabis users. One interpretation is that the widespread use of substitute drugs like methadone more reliably reduced the illegal opiate use of opiate users and also helped retain them in treatment, while cannabis users tended quickly to leave treatment, having done well or not. However, these figures relate only to patients who completed the forms at their six-month review, which in practice could have happened anywhere from about one to six months after their assessment for treatment. What proportion of primary cannabis users were still in treatment at that point and available to complete the forms is not clear, but they may have been the patients whose problems were deep seated enough to require extended treatment.

Enjoyable and trouble-free for many, but not without harms Harm reduction – the “set of practical strategies and ideas aimed at reducing negative consequences associated with drug use” – is mostly associated with ‘harder’ drugs like heroin, for which blood-borne viruses and drug-related deaths are clear and severe risks. Yet while “many people experience cannabis as enjoyable and trouble free”, there are also varying degrees of harm with this drug depending on the characteristics of the person using, the type of the cannabis, and the way they consume it. Many formal cannabis harm reduction programmes borrow from the fields of alcohol and tobacco. Advice includes:

• safer modes of administration (eg, on the use of vaporisers, on rolling safer joints, on less risky modes of inhaling) Many people experience cannabis as enjoyable and trouble free … some people require help to reduce or stop

• skills to prevent confrontation with those who disapprove of use

• encouraging users to moderate their use

 

• discouraging mixing cannabis with other drugs

• drug driving prevention and controls

• reducing third-party exposure to second-hand smoke

• education about spotting signs of problematic use

• self-screening for problematic use

In some parts of the UK, National Health Service tobacco smoking cessation services incorporated cannabis into their interventions with adults; and Health Scotland, also addressing the risks of tobacco and cannabis smoking, published a booklet for young people titled Fags ‘n’ Hash: the essential guide to cutting down the risks of using tobacco and cannabis.

Vaporising or swallowing cannabis offers a way to avoid respiratory risks, but only a minority of cannabis do this, most choosing to smoke cannabis joints (or cannabis and tobacco joints). While not all will know about the different health risks, cannabis users may choose against safer consumption methods anyway for a range of reasons (including their own thoughts about safe use):

• Users may find it easier to control the effects (eg, severity, length of effect) of cannabis when inhaling in the form of a joint or spliff

• Preparing and sharing joints can be an enjoyable part of the routine, or part of a person’s social activities

• Alternative methods of smoking (eg, bongs and vaporisers) may be inconvenient to use, or expensive to buy

 

Most harm reduction advice is delivered informally long before users come into contact with drugs professionals – for example through cannabis magazines, websites, and headshops – highlighting the importance of official sources engaging with non-official sources to promote the delivery of accurate, evidence-based harm reduction messages.

A new high

In May 2016 the Psychoactive Substances Act placed a ‘blanket ban’ on new psychoactive substances (previously known as ‘legal highs’), including synthetic cannabinoids (synthetic forms of cannabis). Prior to this, in 2014, there had been 163 reported deaths from new psychoactive substances in the UK, and 204 the year after. The average age was around 28, younger than the average age for other drug misuse deaths of around 38. The fact that these psychoactive substances – which produced similar effects to illicit drugs like cannabis, cocaine, and ecstasy – could be bought so easily online or on the high street, appeared inconsistent; and each fatality prompted “an outcry for something to be done to prevent further tragedies”. This was the context (and arguably the political trigger) for the introduction of the Psychoactive Substances Act. While possession of a psychoactive substance as such wasn’t criminalised;, production, supply, offer to supply, possession with intent to supply, import or export were – with a maximum penalty of seven years’ imprisonment.

Just seven months after the Act came into effect, the Home Office labelled it a success, with a press release stating that nearly 500 people had been arrested, 332 shops around the UK had been stopped from selling the substances, and four people had been sent to prison. But did the Psychoactive Substances Act have the presumably desired effect of limiting access to psychoactive substances (and reducing deaths), or did it just push the drugs the way of dealers? It is perhaps too early to tell, but former chair of the Advisory Council on the Misuse of Drugs Professor Nutt had warned before the Act came into effect that the ‘blanket ban’ would make it harder (not easier) to control drugs. And while Chief executive of DrugWise Harry Shapiro had said the new law would make new psychoactive substances harder to obtain, he also agreed that sale of the drugs would not cease, but merely be diverted to the illicit market: “The same people selling heroin and crack will simply add this to their repertoire.” The paper “From niche to stigma” examined the changing face of the new psychoactive substance user between 2009 and 2016, focusing on people using the synthetic cannabis known as ‘spice’. It looked at the transition of (then) ‘legal highs’ from an “experimental and recreational” scene associated with a “niche middle class demographic”, to “those with degrees of stigma”, especially homeless, prison, and socially vulnerable youth populations (including looked after children, those involved in or at risk of offending, and those excluded or at risk of exclusion from mainstream education). In 2014, the DrugScope Street Drug Survey also observed a problem among these particular groups, recording a “rapid rise in the use of synthetic cannabinoids such as Black Mamba and Exodus Damnation by opiate users, the street homeless, socially excluded teenagers and by people in prison”.

‘SPICE’ AND OTHER SYNTHETICS

Cannabis contains two key components:

• ‘THC’ (tetrahydrocannabinol), which produces the ‘high’

• ‘CBD’ (cannabidiol), which produces the sedative and anti-anxiety effects

Synthetic forms of cannabis contain chemicals that aim to copy the effects of ‘THC’ in cannabis. But the effects of synthetic cannabis can be quite different (and often stronger): firstly, because synthetic production makes it easier to manipulate the amount of the THC-like chemical; and secondly, because of the absence of the moderating equivalent of ‘CBD’. Some synthetics are purposely designed to resemble herbal cannabis, and can be consumed in the same ways (eg, smoked or inhaled). The names also often have deliberate cannabis connotations. The risk of this is that people wishing to take cannabis may be initially unaware that they have been sold the synthetic form, or may believe from the look of it that it will produce similar sought-after effects. The greater intensity of synthetic cannabis at lower dose levels ( box) ensures that it has an appeal in terms of potency and affordability, but may put those with fewer resources at greater harm.

In 2014, the prison inspectorate for England and Wales raised concerns about the rise in the use of psychoactive substances in prisons, in particular synthetic cannabis. A study set in an English adult male prison found that the nature of the market was posing significant challenges to the management of offenders. There, the primary motivation for consumption was being able to take a substance without it being detected. Given this motivation, and the greater likelihood of harms from synthetic versus natural cannabis, the researchers concluded that it was imperative for mandatory drug-testing policies to be revised, and instead rooted in harm reduction – something which would also apply to people on probation subject to mandatory drug-testing.

Cannabis throws up a range of issues rather different from those associated with the drugs treatment in the UK has normally focused on. If current trends continue, understanding the findings will become yet more important to British treatment services.

Source:   http://findings.org.uk/PHP/dl.php?file=cannabis_treat.    Last revised 10 July 2017. 

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 agostiv@pi.cpmc.columbia.edu.

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

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.”

Sources:
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

In the 15th Judicial District of Louisiana

Introduction and Review of Relevant Literature

During the second half of the twentieth century, two opposing views of drug use and abuse began to coincide. First, the disease concept of drug abuse and addiction became commonplace, as seen in the action of Congress passing the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act in 1970. This led to the designation of monies for federal treatment programs, while simultaneously major health insurers began to include treatment plans for same in their coverage (Lemanski,2001). As a result, the numbers of treatment facilities increased dramatically.

Second, there was a simultaneous increase during this time period in the criminalization of drug use, with harsh penalties attached to drug related crimes (Andrews et al, 1990). The consequence was a growth in the criminal justice system’s control over drugs, resulting in a dramatic increase of drug-related incarcerations (Lock et al., 2002). Recognition of the futility of the effort to use entirely punitive measures, and overcrowding in correctional facilities and court systems has led to a search for viable alternatives. Into this abyss has entered the drug court treatment program.

The first such program began in Miami in 1989, and by the year 2000, more than 650 drug courts were in existence across the country (Dechenes et al., 2002). A decade later, there were 2,038 fully operational drug courts in the United States and 226 that were in the planning stages, as of July 2009 (Office of National Drug Control Policy, 2010). The U.S. Department of Justice, in association with the National Association of Drug Court Professionals has defined ten key components for the establishment of drug court programs, though some variation exists from program to program.

Specifically, eligibility and suitability requirements vary, as well as what types of treatment are offered. Essentially, drug courts are a compromise between punitive and treatment strategies (Dorf and Fagan, 2003). These programs combine the extensive supervision of punitive models of justice with the treatment model of drug addiction to seek a reduction in criminal recidivism and improve the life chances of participants (Belenko, 1998; Gottfredson et al., 2003). Empirical evidence has supported the view that recidivism is reduced, as well as the corresponding monetary spending on drug cases throughout the justice system (Banks et al., 2003; Gottfredson et al., 2003; Hora et al., 1999; Kalich and Evans, 2006).

The evaluation of the effectiveness of drug court programs has been necessitated by the tremendous proliferation of such programs across the United States. This paper is a follow-up report of one such program, upon the request of the program particularly due to the amount of time that has passed since program inception and also due to the
implementation of a particular type of therapy into the program (moral reconation therapy). At a time when drug court monies may be looked to for utilization in other budgetary locations, it is especially important to know whether drug court participants fare better than non-participants who qualified for drug court but refused to participate
and were instead assigned to either straight probation supervision or to a modified educational probation supervision. In only this way is it possible to really begin to address any possible savings in terms of criminal recidivism and therefore monetary and other costs. The report detailed below also examines the perceptions of drug court
graduates toward the drug court program, in order to investigate the meaning and impact of the program on the lives of its participants. The most rigorous evaluations of drug court programs compare drug offenders who enter the program to those who qualified but chose not to enter the program. Additionally, rigorous studies include those that randomly assign clients to receive drug court services. These have consistently indicated lower recidivism rates for drug court participants and graduates (Deschenes, et al., 1995; Finigan, 1998; Gottfredson et al., 1997; Peters and
Murrin 2000, Wolfe et al., 2002).

The two primary components of all drug court programs are intensive supervision and drug treatment. The implementation of these two components varies across jurisdictions. Intensive supervision typically combines elements such as small caseloads for probation officers and frequent court appearances and urinalysis testing. Treatment typically fuses several well documented types of drug abuse treatment programs. Very few studies have attempted to differentiate the impact of these two components on drug court participants and even fewer have specifically focused on long-term effectiveness. However, they do suggest the need for further evaluation of drug court outcomes, with particular attention to identification of predictors of those outcomes.

Background of the F.I.S.T. Drug Court Program and Parameters for this Study

The general criminal justice system in the 15th Judicial District is actually one which
utilizes two types of drug courts via what is known as Tract 1 and via the F.I.S.T.
(Focused Intervention Through Sanctions and Treatment) Drug Court Program.
However, of the two, only the F.I.S.T. Drug Court Program is eligible to receive federal monies from the 1994 Crime Act, and it is restricted further by that Act to accept only defendants with drug-related crimes and no history of violent offenses. Tract 1 processes all other drug defendants. Thus, Tract 1 remains the traditional adversarial drug tract, with the F.I.S.T. drug court technically under that tract as a special non-adversarial court to which eligible non-violent felony offenders may be referred (if identified as eligible by the Assistant District Attorney assigned to Drug Court).
The prosecutor is obliged to prosecute only when there is proof of guilt. Consequently, prior to declaring a defendant eligible, he is to check all available information to insure the appropriateness of prosecution. Eligibility also depends upon the lack of exclusionary factors. Exclusionary criteria for entry into the program include: violent criminal history and conviction of four or more felonies. Misdemeanor offenders are usually excluded unless they aggressively seek inclusion.

Upon referral to the Drug Court by the prosecutor, potential participants are then
clinically screened for suitability using the Substance Abuse Subtle Screening Inventory (SASSI3), the Substance Abuse Questionaire, and a personal interview. Clinically, exclusionary criteria for entry into the program include: mental illness that has not received clearance from a doctor indicating participation will not negatively affect the illness (for example, no schizophrenia diagnoses are accepted into the program because the clinical structure of the program has been deemed unacceptable for said diagnosis). Acute health problems are excluded on a case-by-case basis,

depending on the level of function present. If deemed suitable, the offender is referred for a consultation with the public defender or a privately retained defense attorney. After consultation with a defense attorney, if the offender is interested in participating in the drug court program, the defense attorney notifies the F.I.S.T Drug Court prosecutor, who files a Bill of Information. Some offenders choose to participate in drug court as a condition of probation (after admitting to the crime and receiving a suspended sentence), while others choose to remain in Tract1 and go to trial, or plead guilty and receive a suspended sentence with less intensive conditions of probation. Still others opt to participate in drug court as a condition of bond, while awaiting motion hearings in Tract 1. If found guilty in Tract 1, the probationers must attend drug education classes, monthly meetings with the judge, and comply with periodic random drug screens. One year of sobriety completes the program for these individuals.

However, if the random test is positive for drugs, drug treatment is ordered (drug
education has proven insufficient) and graduated sanctions are imposed. At the third
positive drug screen, and pending a positive determination of both eligibility and
suitability for Drug Court, probationers in Tract 1 (as of August 2002) will be given a
coerced choice: participate in drug court or go to jail for one year. This choice will not
be offered, however, if the defendant was offered drug court before entering Tract 1 and rejected that treatment option. Such rejection is final, and is justified by the F.I.S.T. Team on the grounds that although addiction to drugs is an illness, the choices individuals make also have consequences. The goal of such a stance is to encourage responsible decision-making; therefore, if an addict chooses against treatment, he/she must endure those consequences. Thus, at this stage in Tract 1, if the choice of entering the F.I.S.T. program has never before been offered, and if the probationer chooses jail rather than treatment, upon the fourth positive drug screen, probation is revoked, and a sentence is imposed.

If, however, the probationer chooses drug court at any point, the sanctions for continued positive drug screens increase according to the F.I.S.T drug court schedule of sanctions. Unless the individual has been rearrested for another felony or violent offense, no definitive point marks the termination of a drug court client=s participation. When revocation from drug court does occur, the previously suspended sentence is reinstated, minus any reductions the probationer may have earned for compliance to program requirements up to that point.

Drug court participants who are initially offered and choose drug court must plead guilty to their crime in order to receive a suspended or deferred sentence and participate in the program as a condition of probation, the outcome of their sentence pending the successful completion of the F.I.S.T. Drug Court Program. Individuals deemed eligible and suitable can also try the F.I.S.T. Drug Court Program as a condition of bond, while awaiting the outcome of their case in Tract 1. All drug court participants have 30 days to opt out of the program and to choose adjudication via Tract 1. Incentives to remain are strong, such as dismissal of the prosecution upon satisfactory completion of the drug court program (the equivalent of an acquittal) and expungement of the charge from the participants record. Defendants in the F.I.S.T. Drug Court Program, then, are voluntary participants, who agree to comply with a number of general and special conditions of their suspended sentence with active supervised probation and treatment.
A third option also exists for drug offenders in the 15th JDC, aside from the assignment to Drug Court or Tract 1. Individuals may be deemed both eligible and suitable but refuse to participate in drug court and receive supervised probation instead. In this case, the individual must report to the probation officer, comply with random urinalyses, and otherwise not violate the conditions of his/her probation. These individuals are on Tract 3 or “straight probation.” Successful completion of probation means that probation is not revoked, nor is a sentence imposed.

Statement of Purpose
The primary goal of this evaluation is to explore the effectiveness of the F.I.S.T. Drug
Court Program at reducing recidivism rates of participants when compared to nonparticipants of varying kinds. The universe of offenders who were deemed both eligible and suitable and who were offered the F.I.S.T. Drug Court Option is the population under examination. This examination will determine whether the outcome target has been met (the number and % of participants who achieve the outcome, in this case, lower recidivism rates) for all eligible and suitable individuals, regardless of the tract to which they belong. Tests of significant differences between the tracts will also be determined between the previously described tracts: Tract 1 completers (Prevention Plus), Tract 3 completers (Straight Probation), and Drug Court Completers. In the analyses that follow, the Drug Court population is further divided into two groups, those who completed the Program prior to the introduction of MRT (Moral Reconation Therapy), and those who completed the program with the MRT component in place. All analyses are controlled for time in tract and recidivism rates are calculated from time of initial arrest for which Drug Court was offered to 6 months, 6 months to 12 months, and 12 plus months. Finally, Drug Court Alumni are interviewed about their drug court experiences.

Methods
Data were obtained from several sources: F.I.S.T. Program Records, Tract 1 Program
Records, the State of Louisiana Office of Probation and Parole, and F.I.S.T. Alumni
interviews. Only variables available for all offenders were included in these analyses.

F.I.S.T. Program records have been maintained since program inception in 1998. As
such, a list of names and identification information was available for use by the Office of Probation and Parole to locate arrest records for each individual. For some individuals no records were found by the Office of Probation and Parole,and
therefore, these individuals were excluded from the analyses due to missing information. Similarly, some participant names were on some lists and not others, or on multiple lists. In each of these cases, the participants were excluded from the analyses. All coding was double coded and entered by hand into an SPSS database in electronic format. While it is possible that some bias might be present in the resulting dataset, this is not likely, as excluded cases were statistically examined for patterns in demographics or other key variables of interest. None were identified. Descriptive statistics were performed using SPSS to produce percentages, averages, and frequencies. Additionally, tests of significance were performed using the Chi Square statistic
.
In addition, qualitative interviews were obtained from 30 F.I.S.T. Alumni who were
willing to be interviewed. The interviews were conducted in Spring 2010 via

telephone. Not all participants who were contacted were willing to be interviewed (n=5), and not all of the phone numbers were still working and accurate numbers (n=22). However, it is important to note that this information was given voluntarily, and did not take place under the supervision of any Drug Court Personnel.

Findings

Most of the sample was not re-arrested in the first six months after the initial eligible drug court arrest (79%). However, the re-arrests were nearly 3 times as many for drug arrests as for violent or other crimes (n= 362 v. 143 v. 79). During the 6-12 months after the initial eligible drug court arrest, again, 79% of the total sample was rearrested. Again, the pattern emerged of nearly 3 times as many drug re-arrests than violent or other crimes (n= 376 v. 138 v. 89). Thus, the pattern emerges that for all persons in the sample, during the first year after the initial eligible drug court arrest, most re-arrests were drug related.

However, these initial data are over-general and need to be examined more closely to
identify the makeup of each tract within the drug offending population. Specifically,
when examining the total dataset by tract, it becomes clearer that those who choose to
complete drug court are slightly older than those completing Tract 1 or Tract 3 (52% are age 26 and older v. 46% and 49%, respectively). In addition, those who choose to
complete drug court are much more likely to be white (64%) than those completing Tract 1 (54%) or Tract 3 (53%). Finally, those who choose to complete drug court are much more likely to include females (31%) than what is found in Tract 1 or 3 (15% v. 20%). This pattern of older, more white and more female participants may suggest that drug court is a more appealing choice for such a population to choose to complete, or to complete successfully.

Drug Court Completers V. Prevention Plus/Tract 1 Completers
In any evaluation of outcomes, it is important to evaluate the differences between groups for statistical significance. This component of the evaluation seeks to examine the differences between drug court completers and Tract 1 completers in terms of statistical significance. Recall that participants in drug court are subject to rigorous educational and therapeutic tools, while there is a small educational component in Tract 1. First, the data were analyzed for statistically significant differences in age, and the differences that were found were found not to be significant (chi square < .12). However, this changes when the data are analyzed according to race and gender there is clearly a significant difference between completers in Tract 1 and Drug Court completers in that Drug Court completers are significantly more likely to be white. Likewise, there is a significant difference between completers in Tract 1 and Drug Court completers in that Drug Court completers are significantly more likely to be female. More importantly, when examining the effectiveness of these two programs with regard to recidivism, statistically significant differences are found in re-arrest records. Specifically, when comparing Tract 1 completers to Drug Court completers Tract 1 completers are twice as likely to be re-arrested within the first six months than are Drug Court completers This is especially the case with drug crimes, where Tract 1 completers are nearly 5 times more likely to recidivate a drug crime than are Drug Court completers. Finally, when looking at long term completers of either Tract 1 or Drug Court where re-arrests occur at 12 plus months, those participants who complete Drug Court are significantly less likely (30% v. 52%) to be rearrested after 12 months, especially for drug crimes and violent crimes than are those participants who complete Tract 1.it is clearly significant that more completers of Tract 1 are re-arrested for drug crimes than are Drug Court completers (37% v. 20%) at this point in time. It is clearly also the case that completers of Tract 1 are significantly more likely to be re-arrested for violent crimes than are Drug Court Completers at this time (25% v. 12%). Drug Court Completers V. Straight Probation/Tract 3 Completers

This component of the evaluation seeks to examine the differences between drug court completers and Tract 3 completers in terms of statistical significance. Recall that participants in drug court are subject to rigorous educational and therapeutic tools, while there is no therapeutic or educational intervention in Tract 3. First, the data were analyzed for statistically significant differences in age, and the differences that were found were found not to be significant (chi square < .45). However, this changes when the data are analyzed according to race and gender . There is clearly a significant difference between completers in Tract 3 and Drug Court completers in that straight probationers are significantly more likely to be non-white . Likewise, there is a significant difference between completers in Tract 3 and Drug Court completers in that Drug Court completers are significantly more likely to be female. Furthermore, when examining the effectiveness of these two programs with regard to recidivism, statistically significant differences are found in re-arrest records at all levels. Specifically, when comparing Tract 3 completers to Drug Court completers in Tract 3 completers are nearly 6 times more likely to be re-arrested within the first six months than are Drug Court completers (28.3% v. 5.4%, Chi square <.00). This is especially the case with drug crimes, where Tract 3 completers are nearly 8 times more likely to recidivate a drug crime than are Drug Court completers. Likewise, straight probationers are 3 times more likely to recidivate a violent crime than are Drug Court completers within this time period . Likewise, straight probation completers are significantly more likely at the 6-12 month time period to recidivate, and especially to recidivate drug and violent crime when compared to completers of Drug Court . Finally, straight probation completers on Tract 3 are also statistically more likely to reoffend after one year than are drug court completers, and they do so with both drug and violent crimes .In sum, then, Drug Court completers have a better recidivism rate at all times and for all crimes, especially drug and violent crimes in comparison to both groups of eligible and suitable persons who were offered drug court during the same time period. These other groups, tracts 1 and 3, are interesting comparisons further in that the former offers some prevention education and seems to have a better rate of recidivism than does the latter which offers no prevention education and which has the worst rate of recidivism. Certainly these findings offer strong support for the continued use of drug courts and prevention education to reduce recidivism rates in the communities where they are provided. Drug Court: Pre v. Post Moral Reconation Therapy

As part of this evaluation, analyses were conducted within the Drug Court Completer
population by further subdividing the population into those who finished the program
before Moral Reconation Therapy (MRT) was introduced (n=74) and those who finished the program after MRT was introduced in February 2005 (n=112). MRT is conducted via structured facilitated groups in order to overcome problems encountered in individual therapy for substance abusers, such as over-exploration of a client’s past and over discussion of their feelings at a particular time. MRT is a cognitive-behavioral group method which allows problems such as this to be avoided.

Furthermore, the use of MRT as a group treatment is economical and efficiently incorporates more clients with fewer hours by the group counselor. Group sessions have always been a part of Drug Court, but the MRT group is special in that it is goal oriented and present-focused. For these reasons, analyses were conducted to determine if clients receiving MRT have a lower recidivism rate than do clients receiving more traditional drug court therapies. It is important to remember, however, that regardless of the subgroup analyses, Drug Court Completers are significantly lower in recidivism than other drug crime offenders.

For the analyses between pre-MRT and post-MRT completers, the total sample of
completers (n=186) was subdivided. Each group was compared for significant
differences in age, race, and sex, and no statistically important differences in the two
groups were identified. Furthermore, time since completion of the program was
statistically controlled (as with the above analyses). Interestingly, there are no significant differences between pre and post MRT completers at time periods less than 12 months (analyses available upon request). However, over the long term, post-MRT completers appear to respond better and to recidivate less frequently than do pre-MRT completers, especially in drug and violent crimes. Thus, it seems in the short term there is no MRT advantage but over a longer period of time the advantage is statistically significant.

Qualitative Component: Drug Court Completers Perceptions of Drug Court
In this final component of the evaluation, Drug Court Completers were interviewed and asked a series of questions about their experience with drug court. Thirty interviews were obtained with detailed responses for these interviews. Each interviewee was asked the following set of open-ended questions:

1. How did you feel when you were assigned to drug court?
2. If pleased, what pleased you…
3. If disappointed, what was disappointing…
4. What was the first session like for you?
5. What do you feel worked best for you in the program?
6. Why was , best for you in the program?
7. What do you feel did not work?
8. Why do you feel did not work?
9. How did you feel when you finished?
10. If you will miss the group, why?
11. If you are just glad it’s over, why?
12. What benefits did you receive from this program?
13. Do you have any suggestions for changes to the program?

Below, a random representation of the comments given in the responses are presented in composite form for qualitative purposes.

Interview 1: I felt lucky when I was assigned to drug court; my choice was drug court or jail. I was lucky to go to drug court. What worked best for me in the program was
putting me in jail because I had never been in jail where I could not bond out and this
time I couldn’t. It’s not that drug court does not work; it’s that you don’t want it to work. If not for drug court, I would not be clean today.
Q: Do you have any suggestions for change for the program? Yes, I believe they should have more involvement with the people who graduate because I disagree with [the person] running the alumni program. She is a self admitting crack head and still drinks to this day, and if you go to NA they will tell you alcohol is a drug too. Everybody else, except for her, was very helpful to me.

Interview 2: My counselor worked best for me. He enlightened me and let me know that there was life without dope and I am grateful for that. I think it worked. I have a life. I have been clean and I am grateful I have had the same job for over two years. The day I graduated I felt good, it was the first time I had finished something in a long time. I felt accomplished. I am still active with Drug Court because I want to share with others what I learned about structure, honesty, and integrity. I have my family back in my life and God I live without drugs, life is good. I’m back in school getting my Master’s.
Q:Do you have any suggestions for change for the program? Just maybe offer the
program to more people; it will benefit them. The doors should maybe be opened to
repeat offenders so they may have this opportunity. The criteria should maybe be looked at.

Interview 3: The thing that worked best for me was the complete package. It was
probably at the very beginning they left no room for failure; it was very intensive. They had all the bases covered and there was no time to go out and relapse. I don’t think there was any part that was a waste of time. When I graduated, I was elated but scared but I had my support group in place so that when I left their nest I still had people who I could call on. I also still have a few friendships that were forged. There is a certain sense of being glad it is over due to the fact that it was time consuming, but it needed to be.
Q:What benefits did you receive from this program? The program gave me the tools I needed to continue recovery. It made me confident to become a contributing part of society. There are also legal benefits and one being having my record expunged
Q: Do you have any suggestions for change in the program? They are out-growing the building they were in; they need more space. It’s an awesome program – well worth it – it saved my life – it gave it back to me.

Interview 4: Q: What was the first session like for you? It was probably the hardest because I was miserable. I wanted to get high. I was fearful of the unknown. The first session was overwhelming. I was still loaded. I had several sanctions that were due to my use. I was still confused. But Drug Court gave me the structure to save my life. That was what worked best for me. The structure of drug court and the length of time. The different phases are really strenuous and we need the structure, we need the time because it takes all of that. What did I feel did not work? What does not work is the individual. Drug court works. It’s not drug court that failed me, but me that failed drug court. I have the experience of knowing today that at first the sanctions don’t work and then it happens that you stop and surrender to the program.
Q: If you are glad it’s over, why? One of the reasons I’m glad it’s over is because now I get to use what they taught me. I get to get back into society and make amends for the wrong I’ve done.

Interview 5: There are two types: those that need and those that want it. The ones who want it stay sober. Drug court is a long treatment that not only gives you a stable
environment but it gives you guidance. There are people like me who have flaws and
drug court has given me all of the tools I could ever need to keep me going. Now with
this change, everybody whose life I touch is better because of my experience with drug court. I am just so grateful. I was a convicted felon looking at 60 years. Drug court gave me a chance.

Interview 6: What worked best for me was the MRT book was absolutely wonderful. By the time I reached the 40th meeting it started to all click for me. I got a sponsor and saw how the MRT’s worked with the 12 steps. The discipline worked really good.
Q: How did you feel when you graduated? Relieved. I felt I had learned so much. I had high respect for the counselors there. Actually I wanted to cry. I had bonded with the people there – it was kind of sad. I love group and I still make 4 meetings a week. I really would not feel right if I didn’t go to at least 3 meetings a week, so I’m still working the 12 steps. Q: What benefits did you receive from this program? Definitely I kicked my addiction, I also quit smoking, I was given an opportunity to look at myself living life on life’s terms. I just never realized how it affected my spiritual growth. Q: Any suggestions for change to the program? I would incorporate the 12 steps into the program. The MRTs are important but I would add the 12 steps, and the meetings are very important. Something else I would add is alternate NA and AA to the meetings and what it is that the alcohol began you on your journey to drugs.

Interview 7: What worked best for me was the MRT book and the involvement of the
counselors. The book explains how and talks about social and moral responsibilities.
The involvement of the counselors gave you someone who was not your peers to
encourage you and go over things with. Q: Any suggestions for change to the
program? In some respects I think they should have more restrictions on how they
present themselves to society.

Interview 8: After graduation, I felt great, but a little nervous about stepping out into the world without being drug tested. Twenty five months sober, I feel good! Q: Are you glad it’s over? Well because of the time it took you know, to leave work early and go and UA or go to a meeting. Q: What did you learn from this program? I learned to not depend on drugs. I learned tools about what I can do when I’m stressed out about a situation instead of using.

Interview 9: Q: What do you feel worked best for you in the program? Having a
very close set of peers, because as peers it’s easier for them to relate to you on the same level. What did NOT work for me was the numerous meetings because Phase 1 is 4 of everything a week. There is no time to do anything else. Q: Any suggestions for change to the program? I think they should let people choose. I went because I wanted to andothers were forced and it makes it difficult going through phase 1 and 2 for those that want to be there. Everyone is grown enough to make their own decisions.

Interview 10: Everything worked – if you work the program it will work you. When I was finished I was happy but felt like I was losing a family. Q: What benefits did you receive from the program? I got an apartment, job, a bank account, friends, my
respect, dignity, family, peers. I benefitted a lot. Q: Any suggestions for change to the program? If they could just not have call in everyday – not weekends – and it could give people the chance to be responsible to come back on Monday. It’s too much everyday; they need to want for themselves.

Interview 11: Q: What was the first session like for you? I honestly can’t tell you
because I didn’t want to be there. I closed my mind and one week later I got sanctioned and went to the halfway house. When I came back from the halfway house I was so ready to change until I was ready to do anything and everything they told me to do. I can’t think of anything that didn’t work. Probably the assignments for each phase worked best because it got deep into the way reality really was; it helped me to be a better mother and daughter. I got my GED, I held a job for almost 2 years, I became independent, I got engaged, I mended the wounds between my parents and I, I became a friend and sponsor. They gave me my life back. I was able to keep my little girl and I really feel that if not for Drug Court I would probably be dead on the side of the road.

Interview 12: I think what worked best for me was the MRT book – it made me go deep into ME and not just blaming other people but holding myself accountable. Everything worked, but especially the MRT book. Q: How did you feel when you finished? I was proud of my accomplishment, it was the first thing I ever accomplished in my life. It will forever be a part of my life. I wear a shirt that says DRUG COURT WORKS. Q: What benefits did you receive from the program? That drug court introduced me to Narcotics Anonymous. Q: Do you have any suggestions for changes to the program? Drug court has changed a lot and now the clients are doing different drugs and they’re taking coricidin as a drug. I learned this through Narcotics Anonymous.

Interview 13: Q: What do you feel worked best for you? The meetings – they got me to interact with a bunch of people just my kind. Q: What do you feel did not work? Sanctions because I felt that drug court was being vengeful for my actions. I think they need to do away with the sanctions. What benefits did you receive from this program? Sobriety, gained new sober friends, much more clearer thinking, a new aspect on life, a greater relationship with God.

Interview 14: Q: What do you feel worked best for you? The immediate consequences if you do something wrong. Q: What do you feel did not work? They have stuff that they make you do like case management and gender group. It’s the same thing over and over. I’m sure that with their time they can come up with more and you see the same people over and over like housing – you can learn something else. Q: Any suggestions for changes to the program? Yes, just for the upper part of the program – be more equal – don’t let personal feelings get in the way they treat people.

Interview 15: Q: How did you feel when you got assigned to Drug Court? I was
glad. I had been in jail for 8 months. It was like a ticket out of jail at first. Q: What
was the first session like for you? It was kind of questionable; it was like how could
these people really help me – I like getting high. It was something I had to do to stay
free. Q: What worked best for you? It would have to be the rules that they gave me. I had to make 4 meetings, I had to UA, I had to attend meetings and go to the outside
meetings. This was what stood out to me and what helped me because my life had no
rules. I had nowhere to be. I had no structure. You see, I just lived. I would be out all
night, so when I had rules then I was there you make meetings and you hear things that relate to your life and you get exercises. They did a lot of exercises that would make you think about your life. It gave me structure. I spent a year and a half in drug court, and you know I never missed one group, I wasn’t glad it was over, but I was glad I had finished something because you know I didn’t finish much in my life. I had accomplished something. Q: Do you have any suggestions for change to the program? If it’s not broke, don’t fix it. If my car comes with a certain type of rims, and I like it, I ‘m not going to put any 20’s on it.

(Interviews 16-30 available upon request)

Conclusions and Key Findings

While different interviewees preferred different parts of the program, it seems that all
agreed that drug court worked for them and changed their lives for the better. In the U.S. we house proportionately more of our population in prison than does any other country and for longer periods of time than do many countries (Tischler, 1999). Recidivism rates of inmates suggest that prison is not successful at rehabilitation, and alternatives to incarceration such as the F.I.S.T. drug court therefore seem to offer a more viable and affordable option to the thousands of dollars spent per year on housing individual prisoners. This evaluation supports a previous evaluation completed in 2005 for the F.I.S.T. program in which findings strongly suggest the success rate of the program supersedes that of other alternatives to incarceration such as Tracts 1 and 3. Furthermore, the effect is stronger over the long term when participants have been exposed to the MRT component of the program.

Re-arrest rates are dramatically and statistically significantly lower for Drug Court completers than for Prevention Plus (Tract 1) or Straight Probation (Tract 3). This is especially true for drug crimes and violent crimes. While there may be some differences in the population of drug court versus these programs, these differences fail to explain the success of the program relative to the other two programs. This, along with the interviews of graduates of the program demonstrate overall positive perceptions
on the part of the participants. The findings of this evaluation should clearly show that a need for continued financial support of the F.I.S.T. Drug Court Program will be money well spent.

Source: www.ind.com 6th August 2010

References

Andrews, D.A., I. Zinger, R.D. Hoge, J. Bonta, P. Gendreau and F. Cullen. 1990. “Does
Correctional Treatment Work? A Clinically Relevant and Psychologically Informed
Meta-Analysis.” Criminology 28(3): 369-404.
Belenko, S. 1998. “Research on Drug Courts: A Critical Review”. National Drug Court
Institute Review 1(1): 1-43.
Deschenes, E.P., S. Turner, and P.W. Greenwood. 1995. “Drug Court or Probation? An
Experimental Evaluation of Maricopa County’s Drug Court.” The Justice System Journal
18: 55-73.
Deschenes, E., Peters, R., Goldkamp, J., and S. Belenko, 2002. Drugs courts. In J.
Sorenson, R. Rawson, J. Guydish, & J. Zweben (Eds.), Research to practice, practice to
research: Promoting scientific clinical interchange in drug abuse treatment. Washington,
D.C.: American Psychological Association.
Dorf, M.C. and J. Fagan. 2003. “Problem-Solving Courts: From Innovation to
Institutionalization.” The American Criminal Law Review 40(4): 1501-1511.
Finigan. M.W. 1998. “An Outcome Program Evaluation of the Multnomah County
S.T.O.P. Drug Diversion Program.” Portland, ORE: NPC Research Inc.
Gottfredson, D. C., K. Coblentz, and M.A. Harmon. 1997. “A short-term Outcome
Evaluation of the Baltimore City Drug Treatment Court Program.” Perspectives (Winter):
33-38.
Gottfredson, D.C., S.S. Najaka and B. Kearley. 2003. “Effectiveness of Drug Treatment
Courts: Evidence from a Randomized Trial.” Criminology and Public Policy 2(2): 401-
426.
Lemanski, M. 2001. A History of Addiction and Recovery in the United States. Tucson,
AZ: See Sharp Press.
Lock, E., J. Timberlake, and K. Rasinski. 2002. “Battle Fatigue: Is Public Support
Waning for ‘War’ –Centered Drug Control Stategies?” Crime and Delinquency 48: 380-
398.
Office of National Drug Control Policy. 2010. “National Criminal Justice Reference
Service.”http://www.ncjrs.gov/spotlight/drug_courts/facts.html Accessed 15 June 2010.
Peters, R. H. and M. R. Murrin. 2000. “Effectiveness of Treatment-Based Drug Courts in
Reducing Criminal Recidivism.” Criminal Justice and Behavior: 27(1): 72-96.
21
Wolfe, E., J. Guydish and J. Termondt. 2002 “A Drug Court Outcome Evaluation
Comparing Arrests in a Two Year Follow-Up Period.” The Journal of Drug Issues: 1155-
1172.
References
Andrews, D.A., I. Zinger, R.D. Hoge, J. Bonta, P. Gendreau and F. Cullen. 1990. “Does
Correctional Treatment Work? A Clinically Relevant and Psychologically Informed
Meta-Analysis.” Criminology 28(3): 369-404.
Belenko, S. 1998. “Research on Drug Courts: A Critical Review”. National Drug Court
Institute Review 1(1): 1-43.
Deschenes, E.P., S. Turner, and P.W. Greenwood. 1995. “Drug Court or Probation? An
Experimental Evaluation of Maricopa County’s Drug Court.” The Justice System Journal
18: 55-73.
Deschenes, E., Peters, R., Goldkamp, J., and S. Belenko, 2002. Drugs courts. In J.
Sorenson, R. Rawson, J. Guydish, & J. Zweben (Eds.), Research to practice, practice to
research: Promoting scientific clinical interchange in drug abuse treatment. Washington,
D.C.: American Psychological Association.
Dorf, M.C. and J. Fagan. 2003. “Problem-Solving Courts: From Innovation to
Institutionalization.” The American Criminal Law Review 40(4): 1501-1511.
Finigan. M.W. 1998. “An Outcome Program Evaluation of the Multnomah County
S.T.O.P. Drug Diversion Program.” Portland, ORE: NPC Research Inc.
Gottfredson, D. C., K. Coblentz, and M.A. Harmon. 1997. “A short-term Outcome
Evaluation of the Baltimore City Drug Treatment Court Program.” Perspectives (Winter):
33-38.
Gottfredson, D.C., S.S. Najaka and B. Kearley. 2003. “Effectiveness of Drug Treatment
Courts: Evidence from a Randomized Trial.” Criminology and Public Policy 2(2): 401-
426.
Lemanski, M. 2001. A History of Addiction and Recovery in the United States. Tucson,
AZ: See Sharp Press.
Lock, E., J. Timberlake, and K. Rasinski. 2002. “Battle Fatigue: Is Public Support
Waning for ‘War’ –Centered Drug Control Stategies?” Crime and Delinquency 48: 380-
398.
Office of National Drug Control Policy. 2010. “National Criminal Justice Reference
Service.”http://www.ncjrs.gov/spotlight/drug_courts/facts.html Accessed 15 June 2010.
Peters, R. H. and M. R. Murrin. 2000. “Effectiveness of Treatment-Based Drug Courts in
Reducing Criminal Recidivism.” Criminal Justice and Behavior: 27(1): 72-96.
21
Wolfe, E., J. Guydish and J. Termondt. 2002 “A Drug Court Outcome Evaluation
Comparing Arrests in a Two Year Follow-Up Period.” The Journal of Drug Issues: 1155-
1172.

To get an idea of how pervasive drug testing has become, consider Florida Drug Screening Inc.’s long list of clients.
The Palm Bay-based company provides drug-testing for 380 businesses and organizations in Brevard County, and for about 8,000 nationwide.
“We have seen a strong increase of businesses wanting to implement a (drug-testing) program,” said Florida Drug Screening President Joe Reilly, who founded the company in 1993.
Drug-testing programs generally started in government, and began spreading to the private sector in the late-1980s. They started to take hold on a widespread basis in the early-1990s, Reilly said.
Today, drug-testing is being done by businesses of all sizes — from large corporations to mom-and-pop operations, he said.
Pip Printing in Palm Bay has only several employees, but the shop has a drug-testing program through Florida Drug Screening.
“We think it’s a good thing to do. It’s the responsible thing to do,” said Beverley Wiggins, who owns the shop with her husband, Leslie. “We’re against drugs.”
The couple require job applicants to take a drug test, and they also have random drug tests — for both employees and themselves.
“If we’re asking the staff to do something, we should also do it ourselves to set an example,” Wiggins said.
Since the couple bought the printing shop last year, no one has tested positive for drug use, she added.
Overall, Florida Drug Screening’s Reilly said, his clients’ drug tests for applicants and employees come back positive about 4.8 percent of the time.
Most of the testing done by the firm is for job applicants, and the majority of employers do not test employees after they are hired, he said.
The growth of Florida Drug Screening’s business isn’t surprising, considering some of the latest data on drugs in the workplace.
About one in 12 American workers — 8.2 percent — has engaged in illicit drug use in the past month, according to a newly released survey by the U.S. Department of Health and Human Services.
The survey of 128,000 adult workers from 2002 to 2004 also found:
• The highest rates of employee drug use, by industry, were among restaurant workers, with 17.4 percent reported using in the past month; and construction workers, with 15.1 percent reporting using in the past month.
• Four percent of teachers and social-service workers reported using drugs in the past month.
• The 8.2 percent overall rate of employee drug use was higher than previous surveys, which found overall rates of 7.6 percent in 1994 and 7.7 percent in 1997.
In addition, the survey found that 48.8 percent of full-time workers reported that their employer conducts drug testing, most often prior to being hired; and 30 percent reported that their employer conducts random drug testing of current employees.
Many observers “believe these statistics actually underestimate the magnitude of illicit drug use and alcohol abuse problems in the workplace, because substance abusers are likely to be harder to reach,” said Mark de Bernardo, executive director of the Institute for a Drug-Free Workplace.
Also, employees are “less likely to self-report their substance abuse, particularly of illegal drugs,” de Bernardo said.
Some organizations feel not enough is being done to address the issue.
A recent survey by the Hazelden Foundation, a nonprofit group that helps people overcome addictions, found that substance abuse and addiction are recognized by human-resource professionals as among the most serious problems in the workplace.
The survey of 1,356 human-resource professionals nationwide also found that employers’ policies and practices are not fully addressing the problem.
Although many companies offer employee-assistance programs, many do not openly and proactively deal with employee substance-abuse issues, according to the Hazelden Foundation.
“Addiction is this country’s No. 1 public-health problem,” said Jill Wiedemann-West, senior vice president of clinical and recovery services at the Hazelden Foundation.
“We know that treating drug and alcohol addiction results in more people finding their path to recovery,” Wiedemann-West said. “It results in more resilient families, more productive workplaces, and healthier and safer communities.”
Among the barriers to helping employees with substance abuse problems, the Hazelden survey found:
• Fifty-four percent of human-resource professionals believe that getting employees to acknowledge or talk about the issue is their toughest challenge.
• Forty-nine percent of human-resource professionals cited at least one of four personal hurdles to helping employees: lack of experience in identifying substance abuse and addiction; lack of information about treatment options; personal discomfort in approaching employees about the issue; and not having enough time to deal with the issue.
Florida Drug Screening’s standard “five-panel” test looks for marijuana, cocaine, amphetamine (“speed”), opiates (such as heroin, morphine, opium) and PCP (“angel dust”).
The firm also has an expanded “10-panel” test that also looks for five other categories of drugs: barbiturates (“downers”), methamphetamine (“meth,” “crystal meth”), benzodiazapines (tranquilizers), methadone (commonly used for treating narcotics addiction) and propoxyphene (“painkillers”).
Reilly said some local companies that have drug testing also have confidential employee-assistance programs to provide workers with counseling and other services to help them.
But, often, the programs are underused.
“Companies have these programs, but they don’t promote them enough,” he said.

Source: www.floridatoday.com, Aug 19th 2007

The last few months have seen a dramatic increase in use of –
and media interest in – ‘legal highs’, especially mephedrone or ‘miaow/meow’.
David Gilliver takes a look at a legislative minefield

When the government announced its intention last year to ban a range
of ‘legal highs’ and make them class C drugs, Release accused it of
‘chasing its tail’ in an attempt to ‘stay ahead of the demand for drugs
and those who supply them’ (DDN, 7 September 2009, page 4).
The chemicals were BZP and related piperazines, GBL and a related chemical
and the synthetic cannabinoids used to make smoking products like Spice.
Release’s accusation seemed to be vindicated very quickly, however. Anecdotal
evidence soon started to filter through about a sharp increase in use of the
stimulant mephedrone (4-methylmethcathinone), known as ‘miaow’. After the drug was implicated in the death of a young woman in Brighton late last year, there was a rash of mephedrone stories in the press, followed – a couple of weeks later – by stories about how that coverage had led to a huge boost in sales, with many online suppliers selling out altogether. Luci Hammond is a young person’s alcohol worker at Brighton-based service ruok? She started to notice a very sharp increase in miaow use in the second half of last year. ‘It just hit very quickly,’ she says. ‘We started getting reports of it being used by young people and we had parents and professionals asking questions about it, but since then we’ve had a lot of young people coming to us themselves.’

There has been much talk about the drug’s growing use in clubs, with people
turning to it because of the poor quality of available ecstasy and cocaine – as little as 2 per cent purity in the latter case (DDN, 21 September 2009, page 5).
However, what Hammond has found – and what the press has been quick to pick
up on – is the worrying popularity of the drug among children. So far, her youngest client to have used miaow is 12. The majority are 14 and up, but ‘14 is common’ she says. Where are they taking it – presumably they can’t get into nightclubs? ‘The majority of them can’t, but there are under-18 nights where they use it, as well as at parties and out on the streets. They’ll sit in parks and cemeteries, so they’re putting themselves at risk just through the location.’
And what about other legal highs? ‘This is the big one. We’re hearing bits about
BZP and Spice but nothing compared to this.’ John Ramsey runs the TICTAC drug-testing database at St. George’s, University of London, and has seen a dramatic increase in the use of legal highs. ‘We analyse the contents of club amnesty bins and we test purchase stuff from websites – that’s how we come to be pretty up-to-date on new and emerging compounds,’ he says. ‘We’ve been doing this for ten or 15 years and at one time it was really unusual to find anything new. Now we find something new virtually weekly. We go to Glastonbury each year and there were huge amounts of mephedrone there last
time – there was one seizure of 120g. Two or three years ago there wasn’t any.’
Legal highs are available in ‘head’ shops but anecdotal evidence – and the
scale of use being reported – would suggest that most people are buying them
quickly and easily online. Indeed, many of the press mephedrone stories have
practically been guides to getting hold of the drug, couched in obligatory
disapproving language. ‘If you go online and put in ‘legal highs’ you get hundreds of results,’ says Renato Masetti, training coordinator at Suffolk DAAT, who puts on conference workshops to essentially it’s an online phenomenon – you’ve got comments, forums, you can write in and say which one was good and which wasn’t, just like on Amazon. There’s a whole community out there – the online forums have gone mad.’

But presumably most 13 and 14-year-olds aren’t buying the drugs online,
unless they’re using their parents’ credit cards? ‘A lot of our young people are
getting it from friends, but we’re hearing of dealers specialising in miaow and
selling it to school-age children,’ says Hammond. ‘They’re buying it in bulk online,
possibly cutting it, and selling it on. We’ve also heard reports of young people
dealing because they think it’s risk-free, a legal substance. At the start the reports were “you get no comedown, it’s all legal”. It was seen as pure – everything sounded lovely. Now it’s being used more frequently we’ve discovered it’s not so lovely.’ She’s started to see behaviour change in her clients, like paranoia, aggression and anxiety, and even signs of dependency. ‘We’ve heard about shakes and poor co-ordination with withdrawal,’ she says. How widespread is the problem in Brighton? ‘I would say in terms of speaking to young people, it’s probably about five a day,’ she says. ‘One young person will tell us that their friends are doing it, or a teacher will ring up and say that the whole class is talking about it. I’m a young person’s alcohol worker but almost all my clients have tried miaow, even the ones who’ve always said “I’d never do drugs”,
because it isn’t considered a dangerous drug. This is the message we’re trying to
get across – that it does seem to be a dangerous drug.’ How are they taking it? ‘Most are snorting, which is what we’re trying to advise against – if you are going to use it we’d rather it was bombed [swallowed]. We’ve had people smoking it as well, in a bong or cone. But it’s really painful to snort, and we’re hearing of nosebleeds that recur for days afterwards, as well as spinal and joint ache. And miaow isn’t enough now – they want to do it with ketamine or acid or nitrous oxide. There seems to be a cocktail culture out there.’

Clubbers of the ’80s and ’90s were sometimes described as the ‘guinea pig
generation’, as no one really knew what effects long-term ecstasy use might have. But with mephedrone and other legal highs – anecdotal chat room accounts aside – there really is no information, because there’s been no research. ‘How can there be – who’s going to pay for it?’ says John Ramsey. ‘For example the cannabinoids in things like Spice are completely untested and yet they clearly work – the legislation has got to control about 240 of the things. Who can research 240 new chemical compounds?’ Indeed even the names seem something of a moveable feast, with a variety of drugs passed off as miaow depending on who’s selling it and in what part of the country. ‘There are fewer dealers in the chain and there does seem to be some evidence of people selling allegedly illegal drugs which when they’re tested are found to be legal, so you have this fascinating phenomenon of the illegal market pinching from the legal market and pretending it’s illegal – because people think illegal stuff is better,’ says Masetti. ‘We’ve been told that miaow can be made up of different compounds, and it’s also being mixed with stuff now,’ says Hammond. ‘It started off a few months ago at £15 per gram and now it’s £3.50. You can get pure mephedrone but you don’t really know from mix to mix what you’re getting.’ However the miaow John Ramsey has tested has been consistent. ‘Every time we’ve analysed it it’s been 4-methylmethcathinone, and there appear to be vast amounts of it about. I get a lot of calls from police officers who are being asked what they’re going to do about it. Of course the answer is “nothing”, because it’s not illegal.’

The legal status does really appear to mean that many people think the drugs
are safe and harmless. ‘We’ve had parents saying “we’re telling our kids not to do
illegal things” and they’re saying “but it’s not illegal” says Hammond. ‘I don’t think many teenagers would think that they could buy something from a high street head shop that’s going to cause them to end up in an A&E department,’ says Ramsey. ‘They wouldn’t think people would be allowed to sell things that would do that.’ And A&E, it seems, is not an exaggeration. Luci Hammond visits regularly and whereas before her clients were there through drink or illegal drugs, now it’s often miaow. ‘We’re starting to see people coming in with miaow overdoses – anxiety, excessive aggression, disturbed sleep, being sick. One parent brought her child in because he was screaming and shaking in his sleep and they put that down to a miaow overdose. One client did it at a party and kept collapsing – his knees would just buckle underneath him.’ ‘I’ve seen a couple of forums where there was talk about it causing blue knees and blue elbows,’ adds John Ramsey. ‘That means it could be an inhibitor of muscle metabolism – that’s not beyond the realms of possibility.’ Does he think the government is really chasing its tail when it comes to legislating on legal highs? Won’t the chemists just come up with a slightly different compound? ‘To some extent, but the new legislation includes piperazines – BZP and that whole family – and it is proper generic classification, not a list of compounds, so it should cut off the piperazines as a family. While there’s always scope for somebody to innovate something that hasn’t been foreseen, it makes it much more difficult to do that. But obviously the legislation completely ignores the cathinones, like mephedrone, which haven’t even been risk-assessed yet. The alternative is to do nothing, but you’ve got teenagers buying chemicals which are completely untested for safety and using them as drugs – you’ve got to try and prevent that.’ ‘It’s an interesting challenge,’ says Renato Masetti. ‘I think we need to be creative about other responses, rather than just straight legislation. You’ve got the example of GHB and GBL – GHB was made class C a while back and yet you found the same amount of seizures of GHB as GBL. The fact that you’ve classified doesn’t seem to have made much difference. Legislation is a very heavy hammer, and it’s too clumsy with chemicals that can be altered quickly. Legislation becomes really difficult because if it’s too broad it captures useful products in industry.’ He’s also unconvinced that people are switching to these drugs on a large scale because of the declining quality of cocaine and ecstasy. ‘That upshares/downshares has been going on for ages – purity rates go up and down. I think to some extent this
is probably a separate thing – experimental people who don’t wish to break the law and are looking for legal alternatives. This happened years ago when there was a big ‘herbal highs’ thing, but they were awful, caffeine-based things. I think people have been quite surprised this time – they’ve found that actually they’re effective.’

In the myriad of online forums, the effects of mephedrone are often described
as a kind of mix of amphetamine and MDMA, but with a shorter-lasting effect than the latter. ‘The chemical structures are based on the khat plant, but the
compounds have nothing to do with the plant – they’re modifications of a molecule derived from the plant – so from a chemical point of view you’d predict that it’s going to be a stimulant,’ says Ramsey. ‘I can’t see how it’s likely to be
empathogenic like MDMA, it’s more likely to be like amphetamine or even
methylamphetamine. But it’s never been used as a drug before so there’s no data
on its half-life, its potency or anything.’ The similarity with methylamphetamine/ methamphetamine is borne out by the behaviour of Hammond’s clients. ‘We’re hearing of people aged 14 or 15 who are doing three-day binges, seven-day binges. They’re not able to go to school and we’ve had people saying “I feel like I’m dying, I can’t stop.” We’ve had people who’ve used illegal drugs saying this is the most addictive thing they’ve ever had.’

So what’s the answer – is it better education? ‘Absolutely, but it’s a fine line
between educating and promoting,’ says Ramsey. ‘We’re used to that in the drug
field, but we do need some sort of generic education.’ What about the FRANK ‘crazy chemist’ campaign launched last year? (DDN, 5 October 2009, page 4). ‘That’s not based on any sound knowledge,’ he says. ‘Just anecdotal observations.’ ‘I’m a trainer so I’m biased but I think training is really important,’ says Masetti. ‘It’s important for drug teams to know the specifics about these drugs, but not because treatment is going to be any different from what they’re doing already – it’s more around confidence-building. I’d like to see awareness-raising in services so they can engage with these clients who don’t see themselves as traditional illegal drug users. We know very little about these drugs but because they’re synthetic mimickers that work similarly to the illegal drugs they’re mimicking, the treatments will be very similar – you don’t need to learn any special techniques. But we do need to get some research going on these drugs asap, along with general harm reduction advice.’ Late last year two members of the Advisory Council on the Misuse of Drugs (ACMD) told The Times that the council had serious concerns about drugs like mephedrone and was proposing a more rapid system of appraisal, and the ACMD had in fact constituted a working group on cathinone compounds of which John Ramsey was a member. ‘But all of that’s collapsed now because everybody’s resigned,’ he says. Sacked ACMD chair Prof David Nutt has said his new organisation, the Independent Council on Drug Harms, plans to produce guidance on legal highs, but they will be operating outside of government (see page 4). ‘It’s definitely getting to the “something must be done” stage,’ says Ramsey. ‘It’s not going to go away, and it’s not likely to be controlled by the Misuse of Drugs Act in the foreseeable future as they can’t legislate under that without ACMD.

ACMD would normally conduct a risk assessment and then recommend control or
non-control but, given the disarray ACMD seems to be in, the alternative is the
same process through the EMCDDA in Lisbon. They’ve collected information about
these compounds, and it may well be that they’ll do a risk assessment and
recommend control throughout Europe, with all member states expected to follow.’ In fact the EMCDDA has called Britain the online capital of Europe for legal highs, with 37 per cent of all retailers operating from the UK compared to just 14 per cent in the Netherlands. ‘True, but we bought some from a website that had a UK address – the credit card was debited in France and the material was shipped from New Zealand,’ says Ramsey. ‘But one thing is certain – there’s very big money in it.
Source: drinkanddrugsnews 18 January 2010

 

Naltrexone implants after in-patient treatment for opioid dependence: randomised controlled trial.

In the first randomised trial, implants which block opiate-type drugs for months helped heroin addicts in Norway avoid relapse after detoxification. If these or allied products gain a UK licence, they could help pave the way to abstinence for the minority of suitable addicts.
Abstract Naltrexone is a medication which blocks the effects of heroin and other opiate-type drugs. Its considerable potential in helping to prevent post-detoxification relapse has not been realised because patients generally refuse to take it or quickly discontinue. However, these limitations apply to the oral formulation which has be taken daily. Longer-lasting formulations in the form of a depot injection or an implant inserted under the skin avoid the need to take the medication daily. This is the first randomised trial of an implant whose opiate-blocking effects last for about six months.
Over 18 months from January 2006, staff at inpatient drug clinics in south-eastern Norway invited opiate-dependent patients on abstinence–oriented programmes to participate in the study. Patients who agreed were contacted by researchers at the end of their detoxification or residential treatment. The 56 who joined the study were told that for the first six months they would be randomly allocated to the implant or to usual aftercare arrangements, but that then all would be offered (re)implantation. Typically they were male injectors in their 30s who had used heroin for on average seven years; nearly all also used other drugs.

Three of the implant group left the clinic before they could be implanted and another three had the implants removed. All but three of the surviving (there were two deaths) patients were reassessed six months later. The main analysis included all the patients whether or not they had received or retained their implants. Over the six months of the follow-up, usual-care patients recalled using opiate-type drugs on average on 97 days, the implant group on just 37 days chart. This differential remained in the last month of the follow-up, when the corresponding figures were 17 and six days, a statistically significant difference. Average frequency of use was also significantly higher among the usual-care patients. At the six-month follow-up assessment, 18 out of 27 usual-care patients but just 9 of the 29 implant patients continued to meet criteria for opioid dependence. In line with this, implant patients were much less likely to experience craving. Nevertheless, during the study over half (18 of 29) tried opioids at least once.
In the last month of the follow-up, implant patients scored significantly lower on an index of multiple drug use and injected less often, but there were no significant differences in drinking or use of non-opioid drugs. Over the follow-up, usual-care patients averaged significantly more repeat detoxifications (0.71 versus 0.21); there were no significant differences in outpatient treatment attendance or use of aftercare services. By the end of the follow-up, implant patients expressed greater satisfaction with their lives but there were no significant differences in levels of depression, work, or criminal activity.
One patient in the implant group reported three non-fatal overdoses (there were four in the usual-care group) while using combinations of opioids, amphetamines and benzodiazepines. Three had implants removed due to infection, discomfort or side-effects. In another two, wound-opening required antibiotic treatment, and three had allergic reactions treated with antihistamines. The single death among patients allocated to implants was an overdose prior to implantation. There was also one overdose death among the usual-care patients.
The authors concluded that naltrexone implants safely and significantly reduced opioid use in a motivated population of patients.
As with oral naltrexone, the main limitation of the treatment is its acceptability to patients. In Norway acceptability will have been heightened by restricted access to substitute prescribing programmes, particularly for people unwilling to contract to forgo not just heroin, but persistent substance use of any kind. Nevertheless, recruitment to the study seems to have been slow. The 56 out of 667 patients who joined the study were probably unusually highly motivated to sustain abstinence from opiates, yet over half the implant patients tried resuming opiate use, and those who did used for on average 60 days. This degree of persistence seems incompatible with the implant having totally eliminated opiate-type effects. The reduction in multiple drug use seems to have been mainly due to the effect on opiate use, since drinking and use of other drugs were not significantly affected. As this study shows, implants and depot injections do not guarantee abstinence. Implants can be removed and both these and depot injections can be sidestepped by turning to non-opiate drugs (as may have happened in Australia) or overridden by very high doses of opiate-type drugs, attempts which risk overdose.
The implants were compared against relatively weak aftercare arrangements; more active and structured aftercare (for example, regular monitoring, continued well organised care from the initial service, or active referral) might have narrowed the differences between the groups. However, highly motivated patients and imperfect aftercare arrangements probably reflect the conditions in which implants would be deployed in normal practice, as does the fact that patients knew whether they had an active implant; unlike some other studies, there was no placebo comparison group.
Of the 26 patients who were implanted, eight (nearly 1 in 3) experienced complications which led three to have the implant removed. One other potential problem is that implants impede opiate-based pain relief. To cater for this, participants were given a card to carry which specified the presence of a naltrexone implant, its expected duration, possible pain relief options, and contact details for study staff. Without this (as reported in Australia) hospital staff sometimes make futile attempts to relieve pain using opiate-type medications. The same report of hospital admissions after implantation identified severe withdrawal symptoms after rapid detoxification to the point where hospitalisation was required. Long-acting naltrexone means the most effective way of relieving these symptoms (using opiate-type drugs) is denied to the patient.
Other occasionally severe reactions to implants and injections have been observed, but generally these are mild and/or short-lived and treatable. As with any abstinence-based treatment, overdose due to lost tolerance to opiate-type drugs is a serious concern. However, the few studies to date suggest these products protect against overdose while they are active, and that in caseloads prepared to undertake these procedures, opiate overdose reductions can outlast the active period of the implants. These findings are consistent with findings from Britain (1) and elsewhere (1 2 3 4 5) tentatively suggesting that long-acting naltrexone can be used to create an opiate-free period which extends beyond the initial blockade, sometimes aided by further administrations (1 2). In the UK, neither implants nor depot injections of naltrexone have been licensed for medical use; they can still be (and have been; 1 2 3 4) used, but patient and doctor have to accept the added responsibility of a product which has not yet been shown to meet the safety and efficacy requirements involved in licensing. See background notes for more on these important issues of adverse effects and overdose protection.
Among the studies is another randomised trial of a different long-acting form of naltrexone conducted in the USA. Compared to placebo, this injection lasting four weeks nearly doubled the time heroin dependent patients were retained in aftercare following inpatient detoxification. On the credible assumption that drop-outs relapsed, there was a similar impact on heroin use. At the four-week choice point when the naltrexone patients could have refused the second set of injections, few did so, most committing themselves to another period without (or with reduced) opiate effects. Though encouraging, multiple exclusions (such as psychiatric conditions or dependence on other drugs) and the recruitment procedures (partly through newspaper ads) meant the patients may not have been typical of usual caseloads.
A criticism of trials to date is that they included highly selected patients. However, in this they may have reflected normal practice. Patients will only opt for such procedures if they are prepared (irreversibly in the case of depot injections) to commit to weeks or months without the effects of heroin or other opiate-type drugs, or with severely attenuated effects requiring higher than usual doses. From the control groups in naltrexone implant/depot studies, we know that even in these caseloads, treatment drop-out and relapse are common. Long-acting naltrexone helps these highly motivated patients sustain their resolve. The clearest candidates for the treatment are patients who are motivated to return to a life without opiate-type drugs (including prescribed substitutes), have the resources, stability and support to sustain this, are unlikely to simply use other drugs instead, but who when free to experience heroin and allied drugs cannot resist using them, possibly reflected in their poor compliance with oral naltrexone regimens. The treatment may also be considered for unstable patients at very high risk of overdose, but who will not accept or do poorly in substitute prescribing programmes.
Thanks for their comments on this entry in draft to Nikolaj Kunøe of the Norwegian Centre for Addiction Research, Liv Langberg of the Drammen Council Drug Addiction Prevention Centre in Norway, and Duncan Raistrick of the Leeds Addiction Unit. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Source: Drug and Alcohol Findings July 2009 British Journal of Psychiatry: 2009, 194, p. 541–546.

NIDA NOTES Staff Writer

NIDA, joined by the National Cancer Institute (NCI) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), sponsored a symposium on drug discovery. development, and delivery as part of the 2003 Annual Meeting of the Society for Research on Nicotine and Tobacco. More than 300 researchers, treatment providers, and policymakers attended the 1-day meeting on February 9 in New Orleans. The symposium featured discussions of current efforts to discover new targets for potential medications, the development of medications based on existing knowledge of nicotine’s effects in the brain and factors that might speed the delivery of new treatments to smokers who want to quit.

During the discovery section of the program, speakers discussed recent findings in nicotine receptor biology and the role of neurotransmitters such as gamma-aminobutyric acid (GABA) and glutamate, in nicotine’s effects on the brain. The presentations on medication development provided a background on the drug development process; emerging medications, such as antidepressants and nicotine vaccines; and an overview of medications now in development. The delivery portion of the symposium focused on strategies to create widespread medication access and use by individual smokers and within the health care system.

Discovery. Dr. William Corriigall director of NIDA’s Nicotine and Tobacco Addiction Program and symposium moderator, described the neurobiological targets of current research: genes and gene products that play a role in the structure and response of nicotinic receptors and in brain signalling pathways that involve the neurotransmitters dopamine, GABA, serotonin, and glutamate. Dr. Caryn Lerman. of the University of Pennsylvania in Philadelphia further explored the genetic factor in nicotine research, describing studies on the effect of genetic variations on the activity of enzymes that metabolize nicotine (see ‘Genetic Variation May Increase Nicotine Craving and Smoking Relapse p. 1.)

Dr. Marina Picciotto, of Yale University in New Haven, Connecticut. discussed research that has expanded our understanding of the role of nicotine receptors—the sites at which nicotine attaches to brain cells. This portion of the program also featured discussions of the possibility that neurotransmitters other than dopamine might represent new avenues for pharmacotherapy. For example, Dr. Julie Staley. also of Yale University, described current investigations into the treatment possibilities represented by medications known to act on the serotonin system. The GABA neurotransmitter system, which normally acts to limit dopamine’s effect in the brain’s pleasure centre, might also help in smoking cessation treatment, according to Dr. George McGehee of the University of Chicago. He discussed the mechanism by which nicotine simultaneously stimulates dopamine release and depresses the effect of GABA.

Development. Dr. Frank Vocci, director of NIDA Division of Treatment Research and Development, described the steps involved in the development of new medications and their approval by the Food and Drug Administration (FDA)—a process that may require a decade of research and testing, at a cost as high as $500 million per medication. Accelerating the process at any stage, from basic research to human clinical trials, will speed the availability of new treatments. Dr. John Hughes, of the University of Vermont in Burlington, suggested that psychiatric medications already approved for treating neurochemical imbalances in the brain might hold clues for developing medications to treat the neurochemical effects of smoking.

Dr. Charles Grudzinskas, of Georgetown University Medical Centre in Washington, D.C., summarized potential medications now in FDA phase I, II, or III trials. These medications include additional nicotine replacement therapies and nicotine vaccines. Dr. Paul Pentel of the Hennepin County Medical Centre in Minneapolis Minnesota, described progress in the development of one type of nicotine vaccine—antibodies that bind to nicotine in the blood, preventing it from crossing the blood brain barrier and reaching the areas of the brain that underlie addiction. Vaccines may be particularly effective as relapse-prevention medications for smokers who are trying to remain abstinent.

Delivery. Dr. Scott Leischow, chief of NCI’s Tobacco Control Research Branch, discussed barriers to delivery and utilization of current tobacco cessation treatments. These include the high relapse rate associated with current treatments and the cost and ‘hassle’ factor that deter patients from using nicotine replacement therapy. which they contrast to the simplicity of nicotine delivery by cigarettes To address barriers to use, Dr. Saul Shiffman of the University of Pittsburgh discussed strategies that might increase utilization of existing treatments, including regulatory changes that make cigarettes more expensive and increased advertising and education to encourage more smokers to try to quit.

Providers and insurers also need to address barriers within their control, noted several speakers. Dr. Richard Hurt, of the Mayo Clinic’s Nicotine Dependence Centre in Minneapolis. Minnesota, discussed the limitations of current clinical treatment. He noted that relatively few medications are available, clinicians are not familiar with them, and patients are reluctant to begin treatment because of embarrassment, inadequate relief from withdrawal, and the difficulty of complying with instructions for use of gum. inhalers, or nasal sprays. Dr. Susan Curry of the University of Illinois at Chicago suggested steps that insurers and health care organizations could take to improve the delivery, utilization, and effectiveness of treatment. For example, she said, health care .systems should adopt a chronic disease model to treat smoking, and insurers should include the cost of medications in coverage that provides comprehensive pharmacological and behavioural treatment.

In concluding remarks, Dr. Corrigall noted that the enthusiastic response to the day-long discussion illustrates broad support for steps that will increase and accelerate available treatment options for smokers. “Clinicians and patients need better treatment options. and this symposium represents a significant first step in a collaboration that can help speed the process of getting new and more effective medications to smokers who want to quit.”

 

Drug use can interfere with memory, sensation, and perception. Drugs distort experience and can cause a loss of self-control that can lead users to harm themselves or others. They interfere with the brain’s ability to take in and analyze information. Drug use erodes self-discipline and motivation which is essential for learning. The Court has noted that maturing nervous systems are more critically impaired by intoxicants than mature ones are, and childhood losses in learning are lifelong and profound. Children grow chemically dependent more quickly than adults, and their record of recovery is depressingly poor. (Several of the Amici are parents who had lost children to drugs).
A strong correlation between drug use and juvenile delinquency is documented in a study sponsored by the United States Department of Justice’s Office of Juvenile Justice and Delinquency Prevention. The study found that the more involvement a youth had with drugs, the more likely that youth was involved in delinquency. Substance use creates danger in classrooms and increases the risk of accidents when students drive to and from school.
Students who avoid drug use during their high school years are not likely to subsequently use drugs; but if they later do, they more easily can stop using them. Drug testing can help students stay away from drugs. It gives students a reason to say “no” when their peers ask them to use drugs.

Drug testing is an extremely effective deterrent as was demonstrated by the Hunterdon Central Regional High School in Flemington, New Jersey, by surveys taken before and after implementing random drug testing for all student athletes. Approximately half of the student body participated in athletics. In the two years between surveys when there had been no changes in the school anti-drug program except the introduction of random testing, drug use went down in 20 of 28 categories. In the highest risk drug use category of “Multi-Drug Users” the rates went down as follows: 57% for 9th grade, 100% for 10th grade, 14% for 11th grade, and 52% for the 12th grade. Drug testing in other contexts has also enjoyed remarkable success, e.g., drug use in the U.S. Navy dropped from 47% in 1981 to 4% in 1984 after implementation of a drug prevention program including random testing.

 

One reason may be that it is easier to kick a man when he’s down, and if the polls are anything to go by, Mr Blair is nearer the floor than George at present. Even despite the WMD farrago and much excitement from the Democratic hustings, Mr Bush continues to float at around a 50% approval rating.

Another defensible explanation is the greater stranglehold that liberal – or frequently libertarian – thinking in Britain has on life in the professions which take a particular interest in drug abuse; social services, counselling and treatment agencies, prevention agencies, police, the media, and – not least – the teachers (and their unions). And that other vitally important group who are not graced with the title of ‘professional’ – the parents.

Yet another, but simpler reason is that the USA schools have been involved in a testing programme for several years now. Not all the results are good, but enough of them are, to allow Mr Bush to celebrate their impact. 400, 000 fewer kids use drugs now, he said, and drug testing can take the credit for that. He has seen the future, and it works, he asserted. The truth is not that simple, or problem-free, but he was not unreasonable in taking encouragement from what successes there were.

In the punch-up which followed Mr Blair’s announcement the police generally kept their collective head down, probably relieved that here was one aspect on which they could avoid the flak. But everyone else got into the fight … each quoting the selection of figures that suited them … the old parliamentary jibe, that some people use statistics as a drunk uses a lamp post; more for support than enlightenment, comes to mind.

Some teachers dismissed the scheme as unworkable, and a waste of academic teaching time. This fear of being tested would also damage trust between pupil and teacher, it was said – but some of those saying it went on to say that they would automatically exclude any pupil found in possession. So, fear of testing, bad; fear of exclusion, not bad. Hmm.

NDPA Director Peter Stoker tried to pick some peace from the conflict by suggesting that the way forward was to examine the successes – and failures – of the American experience, and elsewhere, such as Australia. Stoker’s colleague in the Institute for Global Drug Policy, Dr Ivan van Damme, who works out of Belgium, is currently making an international study of the practice. Another NDPA colleague, Stuart McNeillie, runs Restorative Justice Consultants, specialising in what to do with young people you have found to be errant in some way – quite often including drugs. The indications are that linking Restorative Justice to random testing, as well as nurturing a far better system of drug prevention than most British schools currently bother with, could produce a benefit far greater than the sum of its parts.

There can be pro-active and positive slants to drug testing. In the Houston area of Texas, and with the support of the student bodies, pupils joined a scheme whereby they could volunteer to sign up for a ‘drug-free identity card’. To qualify for the card one had to be willing to undergo a random test at any time. Holders of the card were given substantial discount at major stores and leisure facilities in the region which supported the scheme. The usual safeguards as to proof of identity were applied. Discuss !

Reviewing the various arguments put forward in the past few days, Peter Stoker offers the following guide through
the Random Drug Testing jungle ……

– a good practice if properly administered. A useful addition to the wider array of initiatives. Not a cure-all on its own.

– has disincentive value, like visible speed cameras.

– allows pupils to resist peer pressure to use … “I would, but we have testing in our school”.

– must be part of a wider policy of prevention and intervention – and , we would say, Restorative Justice.

– must not be merely a punitive practice, or an excuse to sack pupils the school would like to be rid of.

– response to discovery of use must be graded to severity of discovery. Not all need ‘treatment’ as Blair implies; a talk may be enough, with involvement of counselling, or just a good talking-to, being other options.

– police should not need to be involved, unless there is discovery of aggravating circumstances … the person is dealing; involved in crime etc.

– ample evidence of success in USA, over 1000 schools using it. Times editorial today (23 February) reported indifferent outcomes – on average – from a Michigan study, but it is likely that outcomes were better in some schools, worse in others, depending on general calibre of prevention in each.

– one US school encountered a hostile parent body, so they suspended the scheme, only to find that use soared; on reintroducing the scheme use was greatly reduced, and parents became strong supporters of it.

– one teaching union, said it would damage trust. Our response is that ‘trust’ based on turning a blind eye is trust not worth having, and the young are attuned to smelling out this kind of hypocrisy. Trust is something you have to earn; not to be cheaply given.

– “Invasion of personal liberty” ? No; read John Stuart Mill ‘On Liberty’ – personal actions which affect the liberty of others are not acceptable.

– “Because cannabis stays in your body longer, youth will switch to cocaine or heroin, simply to beat the test”. This is scare-mongering; no evidence of this in the US experience.

– “It won’t work” – see above.

 

*************************

If state legislators wrote a bill outlawing a critical remedy to help kids avoid a disease like tuberculosis, there would probably be a major effort to boot every single one of them out of office. Recently, the state Senate did something just as asinine — except the condition in question was drug use by kids, far more prevalent than TB. Bowing to pro-drug interest groups, a bill is making its way to the governor’s desk that would stymie efforts by local schools to test students for drugs. Unlike lawmakers in other states, Sacramento bureaucrats would like to control the way schools drug-test students, making such testing voluntary and placing restrictions on how it is administered.

Drug testing sounds costly, unnecessary, uncompassionate, even unconstitutional. Those who want to legalize and legitimize drug use caricature drug testing as a draconian policy designed to catch kids using drugs and throw them into jail.

It’s time to set the record straight. At a time when drug abuse in California plagues many students, it makes sense to drug-test students as a part a comprehensive drug-prevention program (which includes after-school programs). Since addiction is spread from peer to peer, drug testing gives a student another more credible reason to say “no” when offered drugs by his or her friend.

Unfortunately, the sponsors of Senate Bill 1386 miss the point of random drug testing when they assume that the practice is unnecessary because it is already easy to detect drug use: “You come into class, your eyes are red, you’re falling asleep, and yesterday you weren’t like that,” argues Assemblywoman Jackie Goldberg, D-Los Angeles, who coauthored the bill with Sen. John Vasconcellos, D-Santa Clara.

But drug testing is not meant to catch the kid who “everyone knows” is using drugs. The purpose of testing is to get those kids who have yet to show symptoms of their drug use the help they need before their “recreational fun” turns into dependence or addiction. It’s meant to prevent the scenario described above so that the student and his or her peers don’t have to live with the consequences of their classmate coming to school on drugs.

Drug testing is also not intended to detect drug use for punitive purposes — in fact, the U.S. Supreme Court prohibited that in its recent landmark ruling defending random drug tests for kids involved in activities at school. No student goes to jail as a result of a positive drug test. Instead, the family’s privacy is respected and the child is referred to get help to stop his or her use. Consequences entail being denied involvement in sports or other extra curricular activities during the treatment period and until the child tests negative for drugs.

Employing this carrot-and-stick method works. For example: After two years of a drug testing program, Hunterdon Central High School in New Jersey saw significant reductions in 20 of 28 drug use categories, including a drop in cocaine use by seniors from 13 percent to 4 percent. The U.S. military saw drug-use rates drop from 27 percent in 1981 to 3 percent today, thanks to the introduction of random drug testing. Schools like St. Patrick’s High in Chicago are seeing a total change in the culture of education at their school as a result of drug testing.

Compared to other health interventions, drug testing is cheap. It costs roughly $10 to $50 per student, per year. Most parents would gladly pay that small fee in exchange for knowing that their child was safe. In addition, the federal government has proposed $25 million to help school districts offset the costs.

Unfortunately, opponents of random drug tests (many of whom carry mission statements dedicated to legalizing drugs) can claim some victories in our state. Already, schools such as Bret Harte Union High School in Angels Camp (Calaveras County) have said that they will pull their effective drug testing program if SB1386 passes.

Principals, teachers and parents who employ an effective drug-testing program at school realize it is a valuable tool to deter kids from delving into drug use in the first place and to refer troubled teens to help. Our elected officials should not make that tool harder to use with this misguided legislation.

Source: Kevin A. Sabet. Former chief speechwriter for the Bush administration’s drug czar. A Marshall scholar at Oxford University, Sabet and is writing on book on drug use.

Background
3.4 methylenedioxymethamphetamine (MDMA, ‘Ecstasy”) is a popular recreational drug that selectively damages brain serotonin (5-HT) neurons in animals at doses that closely approach those used by humans. We investigated the status of brain 5-HT neurons in MDMA users.

Methods
The study enrolled 14 previous users of MDMA who were currently abstaining from use and 15 controls who had never used MDMA. It used positron emission tomography (PET) with the radioligand carbon-11-labelled McN-5652, which selectively labels the 5-NT transporter. It analysed whether there were differences in 5-HT transporter binding between abstinent MDMA users and participants in the control group. Blood and urine samples were taken and tested to check for abstinence.

Findings
MDMA users showed decreased global and regional brain 5-HT transporter binding compared with controls. Decreases in 5-HT transporter binding positively correlated with the extent of previous MDMA use.

Interpretation
Quantitative PET studies with a ligand selective for 5-HT transporters can be used to assess the status of 5-HT neurons in the living human brain. The study shows direct evidence of a decrease in a structural component of brain 5-NT neurons in human MDMA users.

Source: U D McCann, Z Szabo, U Scheffel, R F Dannals, GA Ricaurte – Biological Psychiatry Branch, National Institute of Mental Health,- Bethesda, Maryland, USA (U D McCann MD); and Departments of Radiology (Z Szabo MD, U Scheffel ScD, R F Dannals PhD) and Neurology (G A Ricaurte MD), Johns Hopkins Medical Institutions, Baltimore, MD 21224, USA – published: The Lancet Vol 352, Oct 98. (Correspondence to: Dr G A Ricaurte)