Treatment and Addiction

Tom P. Freeman, Peggy van der Pol, Wil Kuijpers, Jeroen Wisselink,Ravi K. Das, Sander Rigter, Margriet van Laar, Paul Griffiths, Wendy Swift,Raymond Niesink and Michael T. Lynskey



The number of people entering specialist drug treatment for cannabis problems has increased considerably in recent years. The reasons for this are unclear, but rising cannabis potency could be a contributing factor. Methods Cannabis potency data were obtained from an ongoing monitoring programme in the Netherlands. We analysed concentrations of δ -9-tetrahydrocannabinol (THC) from the most popular variety of domestic herbal cannabis sold in each retail outlet (2000–2015). Mixed effects linear regression models examined time-dependent associations between THC and first-time cannabis admissions to specialist drug treatment. Candidate time lags were 0–10 years, based on normative European drug treatment data.


THC increased from a mean (95% CI) of 8.62 (7.97–9.27) to 20.38 (19.09–21.67) from 2000 to 2004 and then decreased to 15.31 (14.24–16.38) in 2015. First-time cannabis admissions (per 100 000 inhabitants) rose from 7.08 to 26.36 from 2000 to 2010, and then decreased to 19.82 in 2015. THC was positively associated with treatment entry at lags of 0–9 years, with the strongest association at 5 years, b = 0.370 (0.317–0.424), p < 0.0001. After adjusting for age, sex and non-cannabis drug treatment admissions, these positive associations were attenuated but remained statistically significant at lags of 5–7 years and were again strongest at 5 years, b = 0.082 (0.052–0.111), p < 0.0001.


In this 16-year observational study, we found positive time-dependent associations between changes in cannabis potency and first-time cannabis admissions to drug treatment. These associations are biologically plausible, but their strength after adjustment suggests that other factors are also important.

Source: January 2018

Featuring Thomas Kosten, MD,
Professor and the Jay H. Waggoner Endowed Chair in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine
Dr. Mark Gold and Dr. Thomas Kosten discuss anti-drug vaccines to treat substance use and addiction.

Q – Congratulations on your career to date and most recent work. Can you explain the idea behind your anti-drug vaccines? Are there any of your papers you’d suggest the reader look at?
A – Abused drugs are far too small to produce antibody responses. The vaccines work by covalently attaching the abused drug to 20 to 30 exposed amino acids on a carrier protein such as tetanus toxoid and then injecting this vaccine into humans to produce antibodies to both the tetanus toxoid and to the abused drug, because the drug now “looks like” part of this toxoid.

Q – Is the idea to block the drug’s reinforcing effects? What about overdose effects? Are each of the vaccines specific to a single drug or class of drugs?
A – Yes, the antibodies block reinforcing effects, but a slower process like overdose is still possible unless the drug is typically taken in very small quantities when abused – such drugs include PCP and fentanyl. These vaccines are highly specific to a class of drugs and have limited cross-reactivity.

Q – What happens if the drug abused is cocaine? Heroin? How would this be preferable to methadone or buprenorphine? Naltrexone?
A – For opiates, naltrexone is a better choice as a broad-spectrum blocker, but it does not effectively block the super-agonists related to fentanyl. However, these high potency agents are ideal targets for vaccine development, which is underway.

Q – How long would a single antidrug vaccine treatment last?
A – These antibodies persist at high levels for about three months and then require a booster vaccination about every three months.

Q – Are there risks that would prevent vaccination of women? Other risks? Adverse effects?
A – There are no specific risks from these tetanus toxoid based vaccines for women, since tetanus vaccine is even given to pregnant women. The antibodies cross over the placenta so that the fetus would also be protected.

Q – Are any approved for use? Why?
A – None are approved for use by the FDA because they have not met the criteria set for efficacy with either cocaine or nicotine. There have been no safety concerns, and a cocaine vaccine, particularly combined with the enhanced cholinesterase, would be the most likely to meet FDA efficacy standards relatively easily.

Q – Many experts think that the current opioid epidemic will be followed by a cocaine epidemic. What treatments exist for a cocaine-dependent patient or those presenting to an ED with a cocaine overdose? Are you developing for cocaine overdose? Cocaine addictions?
A – As suggested above, yes, we have a new and much more potent cocaine vaccine than we previously tested, but we need funds to move it forward. This vaccine combined with the Teva or other enhanced cholinesterases (Indivior also has one) would prevent overdoses.

Q – What about methamphetamine?
A – We have a methamphetamine vaccine and hope to have it in humans within a year or so, if our funding continues from NIDA.

Q – What kinds of studies are you doing right now? Planning?
A – The studies are all in animals with methamphetamine, cocaine, nicotine and fentanyl vaccines using a highly effective new adjuvant that has been used in humans at 50 times the dose needed for raising our antibody levels up to sevenfold higher than our previous cocaine vaccine.

Q – Anything else to add?
A – You covered it all, just send money. This is a difficult area for getting venture capital as well as NIDA funds to manufacture and get initial FDA approval to use these vaccines in humans.

Source: Email from Mark Gold, MD <>  September 2017

Dr. Mark Gold and Dr. Stacy Seikel discuss opioid addiction

Experts have concluded that the opioid crisis started with physicians overprescribing opioid pain medication.

Q – You are one of the few double board certified, pain evaluation and treatment experts, and addiction evaluation and treatment expert. How do you decide who should be given opioids for chronic pain? What are your advantages in patient evaluation and treatment as a clinical expert in having such training?
A – The first thing when you are evaluating a patient who has pain, or pain and addiction, is that all pain is real. The patients who have chronic or intermittent pain have an underlying fear of suffering. They may appear controlling or resistant to treatment, but actually it is this “fear of suffering” that is driving most of their behavior.

Q – If the person in recovery needs opioids for chronic pain or acute pain how do you manage that and prevent abuse and/or addiction?
A – If the person in recovery needs opioids for acute pain, such as due to an injury or surgery, we develop a “Pain Management Relapse Prevention Agreement”. I have the patient, family, surgeon, sponsor, caregivers and anesthesiologist involved in that plan.

Q – You have written about how to get off Suboxone. Why is it so hard to get off Suboxone and how do you get off Suboxone?
A – First of all, the goal of patients on Suboxone is not to get off Suboxone. The goal is to get into recovery. The Suboxone and other buprenorphine formulations is one tool, among many, to help patients have a meaningful self-directed life, and not a drug directed life.

Q – You have run methadone programs, how do you get off methadone?
A – I taper methadone the same way I taper buprenorphine, that is slowly and with the patient able to stop the taper at any time. I would typically start a methadone taper in a motivated patient at about 10% per month if tolerated. Maybe less. As you can see it can take over a year to successfully taper someone.

Q – How do you detox and get on naltrexone or Vivitrol. How do you get off naltrexone?
A – In order to start a patient on Vivitrol, the patient needs to have the opiates out of their system and not have any withdrawal symptoms. Typically a patient must be off short-acting opiates for one week or long-acting opiates for 10 to 14 days. There are rapid induction techniques for Vivitrol, but I do not use those in an outpatient setting.

Q – Do you have any advice on how to use Narcan in a suspected opioid overdose?
A – Georgia has made naloxone for overdose reversal available in pharmacies without a doctor’s prescription. With one person dying of overdose every 15 minutes, I believe every citizen needs to be trained in overdose reversal and carry Narcan.

Q – What makes fentanyl so deadly? How do you reverse the fentanyl overdose? Does the overdose reverse successfully?
A – Fentanyl is a very potent opioid and it is very easy to take too much. Most of my patients do not realize that the heroin that they have been using has fentanyl in it. So as you can see, a person may not even know they are taking fentanyl. They may think they are taking heroin and take too much and overdose.

Q – MAT programs often have too little in the way of behavioral health and psychiatric treatment. You do the opposite, please describe.
A – I provide MAT within a treatment program in an outpatient setting. We provide intensive outpatient (three hours per day) or PHP (six hours per day) of counseling and group therapy. In addition we provide a psychiatric evaluation, weekly physician visits, med management, individual therapy and a very robust family program.

Q – Describe your program. Who benefits from this program?
A – Atlanta Addiction Recovery Center, AARC, our Christian program, combines our scientific evidence-based treatment with Christian principles. Biblical teachings are embedded in all aspects of our programming. Though we welcome patients from all faiths, Christian teachings are utilized.

Q – Do you see an upswing in cannabis addiction?
A – I have seen an increase in cannabis addiction. Typically we see young adults who have not been able to move through “adulting” because their cannabis use got in the way of their school, their relationships, their work and their ability to mature.

Source: Email from Mark Gold, MD <>  February 2018

By Jason Schwartz

British Columbia has long been cited as a model for North American drug policy and harm reduction implementation.

BC has established a Death Review Panel in response to the overdose crisis. The panel recently issued a report with 3 recommendations. The first recommendation to regulate recovery homes, which currently require only a simple inspection of the facility. (The other 2 were for more maintenance treatments and more harm reduction.)

The chair of the panel cited the abstinence orientation of houses as a concern.

A columnist at the Vancouver Sun pushes back against the argument that BC is suffering from insufficient harm reduction:

This is, after all, a city and a province that for nearly 20 years has been at the forefront of harm-reduction with needle exchange programs, safe injection sites, methadone and suboxone treatment programs, a prescription heroin program and, more recently, free naloxone kits, free-standing naloxone stations and training for first-responders and even teachers in how to use it as an antidote for fentanyl overdoses.

We’ve gone from crisis to crisis, each one sucking up incredible resources. Currently, a quarter of a million dollars a day goes into the Downtown Eastside alone for methadone treatment. This year, the B.C. government expects the number of British Columbians receiving replacement drug therapy to rise to 30,000 and then nearly double to 58,000 by 2020-21.

In 2006 when Vancouver updated its four pillars approach, it noted that there were 8,319 British Columbians being treated with methadone.

By 2020-21, the province also expects to be supplying 55,000 “free” take-home naloxone kits, up from 45,000 this year.

We keep hearing about an overdose crisis, but what we have is an addictions crisis. Solving it will require a lot more than simply reducing harm.

What’s needed is a recovery orientation. (Which does not rule out harm reduction.)


April 2018

Click on the images to enlarge the detail.


Comments below from David Evans Esq., a lawyer and special adviser to the Drug Free America Foundation, re the suggestion that marijuana could assist in treating opiate addiction.


Memory defect (short and long term) – how are they to remember compliance issues and new problem solving? Masks other mental health issues – anxiety, PTSD, Bipolar

Marijuana use impacts the brain, creates a delay in learning skills to NOT have substance use in life.

In order for change to occur, person must acknowledge loss of control – how can someone do this when control is still lost with marijuana?

Changes in coordination, mood swings, memory/learning problems

Marijuana use deters the return to normal brain functioning and the continued drive for more substances and stimuli in the pleasure seeking area of the brain.

Marijuana use is A-motivational – knocks out drive and ambition

Continued use maintains Arrested Development – low emotional maturity – the maturity level is stumped when start using substances

Recovery – means not using drugs

THC suppresses neurons in information processing system of the hippocampus, the part of the brain that is crucial for learning memory and integration of sensory experiences with emotions and motivations. Learned behaviors, which depend on the hippocampus, deteriorate after chronic exposure

· Because marijuana use impacts learning a person falls behind in accumulating intellectual, job, or social skills. This can directly translate to need for more treatment both with intensity and length

Users have trouble sustaining and shifting their attention in and registering, organizing and using information.

Increase risk of motor vehicle/work accidents

For more detailed information log on to a paper in Support of the UN Drug Conventions: The Arguments Against Illicit Drug Legalisation and Harm Reduction also by David Evans.


During the late 1970s, my colleague, Dr. Herb Kleber, and I introduced a novel neuroanatomical model to explain the pathophysiology of opioid withdrawal and put forth our contention that addiction was not simply a matter of avoiding withdrawal. Using what was then a novel new drug, clonidine, we were able to effectively detox heroin and methadone addicts in half the time, and without the surge of norepinephrine release from the locus coeruleus. This minimized the agitation and somatic anxiety that can be unbearable for some patients.

This helped prove our conviction that addictive disease was the result of numerous and largely unknown factors, and not simply to avoid withdrawal. In spite of effectively and humanely withdrawing addicts from opioids, we also discovered that something was clearly different and unique about their brain and behavior. After being clean and sober for 6-8 months in a safe and secure rehab environment, most addicts returned to using heroin as soon as the door was unlocked. This looked like Pavlovian principles on steroids. Although it was not due to avoidance of withdrawal symptoms, the answer remained unclear.

In some ways, we have travelled light years in furthering our understanding of the brain and addictive disease. Yet, relapse remains the norm and not the exception for opioid addicts. The development and use of naltrexone in the 1990s followed by buprenorphine has helped many addicts achieve a better quality of life. Yet, relapse remains the norm.

In a recent placebo-controlled clinical trial by Kowalczyk, et al, participants were given (0.3 mg/d) of clonidine or placebo during 18 weeks of Medication-Assisted Treatment (MAT) with buprenorphine, and documented their mood and activities via a pre-programmed smart phone.

Study participants receiving clonidine in addition to buprenorphine had increased abstinence from opioids and were able to decouple their stress from drug craving. Additionally, participants in the buprenorphine-plus-clonidine group, not only experienced longer periods of abstinence, but were also better in managing, or coping with their “unstructured” time. In other words, clonidine helped persons deal with their boredom and inability to create or engage in healthy activities, which is a strong predictor of relapse.

Why Does This Matter?

The study replicates previous research demonstrating that 1.) unstructured time, especially during early recovery is a trigger and predictor of relapse, 2.) engaging in responsible or helpful activities is associated with better outcomes among patients receiving Medication-Assisted Treatment, and 3.) clonidine helped participants engage in unstructured-time activities with less risk of craving or use than they might otherwise have experienced.

From a personalized-medicine perspective, these data are a good reminder that addiction is a multifaceted disease requiring a multimodal approach. It is not treatable with any singular intervention. At best, psychopharmacology is adjunctive. And remember before any MAT, many addicted persons enjoyed sustained recovery via 12-step programs.

Source: November 2017

The use of buprenorphine and other Medically-Assisted Treatments (MAT) for opioid use disorder has increased rapidly in response to the opioid epidemic in the United States. From the clinician’s perspective, buprenorphine seemed like a panacea. I remember feeling the same way about methadone in the 70s and Naltrexone in the 80s.

Buprenorphine’s unique chemistry, being a partial agonist and antagonist medication, meant patients were able to detox from heroin or powerfully addictive prescription pain medications using Suboxone (a trade name for buprenorphine) and then taper off with relative ease, compared to heroin or oxycodone. In some cases, patients were not able to come off of Suboxone and remained on a small maintenance dose for months, and even years, but had attained a quality of life they never believed was possible when addicted to illicit opioids.

However, a large study by the Johns Hopkins Bloomberg School of Public Health (2017) reports that a significant proportion of patients on Suboxone therapy, or shortly after the conclusion of their therapy, were attaining and filling prescriptions for other opioid medications. Outcome measures matter. Different treatments work if your outcome measure is one month of adherence to the treatment versus five years of drug-free outcome and return to work.

The methodology in the Johns Hopkins study reviewed pharmacy claims for over 38,000 persons who had been prescribed Suboxone between 2006 and 2013. The results were shocking. Two-thirds of these patients had filled a prescription for an opioid painkiller in the first 12 months following Suboxone treatment—while 43 percent had received a prescription for an opioid during Suboxone therapy. In addition, approximately two-thirds of the patients who received Suboxone therapy stopped filling prescriptions for it after just three months.

What These Data Cannot Tell Us

At first glance these data are disappointing. Just looking at patient return to the program over a short time like six months, it is very clear that most methadone patients come back and many Suboxone patients do not. However, there is much the study results don’t tell us.

In a clinical and policy environment where the number of prescribers, the volume and nature of opioid prescriptions, overdoses, prescribing policies, laws and regulations are changing frequently and dramatically, data loses some of their value. In Florida, for example, the legislature, in response to the “Pill Mills,” enacted a monitoring program whereby all prescribed scheduled medications were on a single database, accessible by any licensed physician.

Twelve months after implementation, the outcomes were evaluated. Overall opioid prescriptions decreased by 1.4%. Opioid volume decreased by 2.5%, and a decrease of 5.6% in MME per transaction was observed. These data were limited to prescribers and patients with the highest baseline opioid prescribing and usage. The findings also accounted for potential confounding variables including sensitivity analyses, varying time windows and dynamic enrolment criteria. The opioid landscape in Florida continues to improve, and the pill mills are virtually gone. This is just one example of how a state’s policies impact the data and the outcome in longitudinal research.

In addition, prescription drug monitoring programs (PDMPs) are associated with reductions in all drug use (including opioids). Data culled from adult Medicare beneficiaries in states that utilize PDMPs compared with states that do not have PDMPs show significant reductions in prescription opioid transactions. Moreover, the top treatment centers may prescribe buprenorphine but also set up voluntary drug monitoring and continuing care programs for their patients, much as the programs do for impaired physicians, nurses and pilots who mandate random and for-cause drug testing for five years.

Most heroin addicts have multiple drug dependencies and problems. They also have multiple medical co-morbidities. It is not as simple as switching the patient’s heroin for buprenorphine. But street heroin is more than a drug, it is many drugs and dangerous adulterants. Over 80 percent of the Physician Health Program participants are treated effectively, monitored and never had a positive drug test throughout the five years of post-treatment outpatient monitoring.

Lastly, the Institute of Medicine released their exhaustive report on Pain in America, revealing that 100 million Americans currently suffer from chronic or intractable pain syndromes. The Johns Hopkins study does not indicate what percent of the study participants have a pain syndrome, requiring treatment with opioid medication, hopefully under the supervision of a specialist in pain managements and addiction medicine.

Why Does This Matter?

The findings certainly raise questions about the effectiveness and the appropriateness of Suboxone for addiction treatment. Clearly, if we were to adopt an oncology standard of five years, Suboxone is not likely to be considered an effective treatment. But it is a viable and important option and part of an arsenal of treatment modalities used to individualize treatment for our patients.

The study researchers noted, and I agree, that the continued use of pain medication during and after addiction treatment indicates that too many patients did not receive a multimodal, integrated treatment plan for their addiction or concurrent chronic pain or co-occurring mental illness, which approximately 50-65% of those with Substance Use Disorder (SUD) have.

Dr. Alexander, the lead author of the study noted: “There are high rates of chronic pain among patients receiving opioid agonist therapy, and thus concomitant use of buprenorphine and other opioids may be justified clinically. This is especially true as the absence of pain management among patients with opioid use disorders may result in problematic behaviors such as illicit drug use and misuse of other prescription medications.”

Addicts are quick to discover the probabilities of attaining a “high” from just about any drug they come across. Buprenorphine, while not commonly abused or sold on the streets, can be used to get high or to ease the pangs of withdrawal when heroin and other opioids are scarce.

The efficacy of treatment for SUD, regardless of the drug, is largely dependent upon non-medical factors. Yes, monitoring is important, but only if the potential for losing something one values is at stake. Surrendering, which cannot be described in medical or psychological language, is the single most important factor in determining recovery. Adjunctive treatments such as Suboxone, Methadone, N.A., A.A., CBT, yoga, meditation, diet and exercise can help a highly motivated individual. When treatment is

individualized and a bond of trust is established between a counselor and patient, good and even improbable things happen, and lives are restored.

MATs are not a replacement for the traditional foundations of treatment and recovery. At best, they can provide a specific need for a specific patient. They are not for everyone. When people ask me what the elements of success are in treatment, I often start with long-term. If a person has been abusing and addicted for years, it is difficult to imagine treatment in weeks. But, as a shortcut to what works, I tell them the 3 M’s: treatment that is high-dose, intense multimodal, multidisciplinary and multifaceted, staffed by dedicated professionals who are experienced and really do care about the patients.

Suboxone and the similar medications that will be developed are inherently not good or bad and certainly don’t work for every opioid addict. But I am thankful we have them. I believe they have saved thousands of lives. The real trick of successful treatment is to know your patients and collaborate with him or her in developing a plan that gives them the best shot at recovery.

Source: Author: Mark Gold, MD

Pain and pleasure rank among nature’s strongest motivators, but when mixed, the two can become irresistible. This is how opioids brew a potent and deadly addiction in the brain. Societies have coveted the euphoria and pain relief provided by opioids since Ancient Sumerians referred to opium poppies as the “joy plant” circa 3400 B.C. But the repercussions of using the drugs were ever present, too. For centuries, Chinese patients swallowed opium cocktails before major surgeries, but by 1500, they described the recreational use of opium pipes as subversive. The Chinese emperor Yung Cheng eventually restricted the use of opium for medical purposes in 1729. Less than 100 years later, a German chemist purified morphine from poppies, creating the go-to pain reliever for anxiety and respiratory conditions. But the Civil War and its many wounds spawned mass addiction to the drugs, a syndrome dubbed Soldier’s Disease. A cough syrup was concocted in the late 1800s — called heroin — to remedy these morphine addictions. Doctors thought the syrup would be “non-addictive.” Instead, it turned into a low-cost habit that spread internationally. More than 70 percent of the world’s opium — 3,410 tons — goes to heroin production, a number that has more than doubled since 1985. Approximately 17 million people around the globe used heroin, opium or morphine in 2016.

Today, prescription and synthetic opioids crowd America’s medicine cabinets and streets, driving a modern crisis that may kill half a million people over the next decade. Opioids claimed 53,000 lives in the U.S. last year, according to preliminary estimates from the Centers for Disease Control and Prevention — more than those killed in motor vehicle accidents.

How did we arrive here? Here’s a look at why our brains get hooked on opioids.

The pain divide

Let’s start with the two types of pain. They go by different names depending on which scientist you ask. Peripheral versus central pain. Nociceptive versus neuropathic pain.

The distinction is the sensation of actual damage to your body versus your mind’s perception of this injury.

Your body quiets your pain nerves through the production of natural opioids called endorphins.

Stuff that damages your skin and muscles — pin pricks and stove burns — is considered peripheral/nociceptive pain.

Pain fibers sense these injuries and pass the signal onto nerve cells — or neurons — in your spine and brain, the duo that makes up your central nervous system.

In a normal situation, your pain fibers work in concert with your central nervous system. Someone punches you, and your brain thinks “ow” and tells your body how to react.

Stress-relieving hormones get released. Your immune system counteracts the inflammation in your wounded arm.

Your body quiets your pain nerves through the production of natural opioids called endorphins. The trouble is when these pain pathways become overloaded or uncoupled.

One receptor to rule them all

Say you have chronic back pain. Your muscles are inflamed, constantly beaming pain signals to your brain. Your natural endorphins aren’t enough and your back won’t let up, so your doctor prescribes an opioid painkiller like oxycodone.

Prescription opioids and natural endorphins both land on tiny docking stations — called receptors — at the ends of your nerves. Most receptors catch chemical messengers — called neurotransmitters — to activate your nerve cells, triggering electric pulses that carry the signal forward.

But opioid receptors do the opposite. They stop electric pulses from traveling through your nerve cells in the first place. To do this, opioids bind to three major receptors, called Mu, Kappa and Delta. But the Mu receptor is the one that really sets everything in motion.

The Mu-opiate receptor is responsible for the major effects of all opiates, whether it’s heroin, prescription pills like oxycodone or synthetic opioids like fentanyl, said Chris Evans, director of Brain Research Institute at UCLA. “The depression, the analgesia [pain numbing], the constipation and the euphoria — if you take away the Mu-opioid receptor, and you give morphine, then you don’t have any of those effects,” Evans said.

Opioids receptors trigger such widespread effects because they govern more than just pain pathways. When opioid drugs infiltrate a part of the brain stem called the locus ceruleus, their receptors slow respiration, cause constipation, lower blood pressure and decrease alertness. Addiction begins in the midbrain, where opioids receptors switch off a batch of nerve cells called GABAergic neurons.

GABAergic neurons are themselves an off-switch for the brain’s euphoria and pleasure networks.

When it comes to addiction, opioids are an off-switch for an off-switch. Opioids hold back GABAergic neurons in the midbrain, which in turn keep another neurotransmitter called dopamine from flooding a brain’s pleasure circuits. Image by Adam Sarraf

Once opioids shut off GABAergic neurons, the pleasure circuits fill with another neurotransmitter called dopamine. At one stop on this pleasure highway — the nucleus accumbens — dopamine triggers a surge of happiness. When the dopamine rolls into amygdala, the brain’s fear center, it relieves anxiety and stress. Both of these events reinforce the idea that opioids are rewarding.

These areas of the brain are constantly communicating with decision-making hubs in the prefrontal cortex, which make value judgments about good and bad. When it hears “This pill feels good. Let’s do more,” the mind begins to develop habits and cravings.

Taking the drug soon becomes second nature or habitual, Evans said, much like when your mind zones out while driving home from work. The decision to seek out the drugs, rather than participate in other life activities, becomes automatic.

The opioid pendulum: When feeling good starts to feel bad

Opioid addiction becomes entrenched after a person’s neurons adapt to the drugs. The GABAergic neurons and other nerves in the brain still want to send messages, so they begin to adjust. They produce three to four times more cyclic AMP, a compound that primes the neuron to fire electric pulses, said Thomas Kosten, director of the division of alcohol and addiction psychiatry at the Baylor College of Medicine.

That means even when you take away the opioids, Kosten says, “the neurons fire extensively.”

The pendulum swings back. Now, rather than causing constipation and slowing respiration, the brain stem triggers diarrhoea and elevates blood pressure. Instead of triggering happiness, the nucleus accumbens and amygdala reinforce feelings of dysphoria and anxiety. All of this negativity feeds into the prefrontal cortex, further pushing a desire for opioids.

While other drugs like cocaine and alcohol can also feed addiction through the brain’s pleasure circuits, it is the surge of withdrawal from opioids that makes the drugs so inescapable.

Could opioid addiction be driven in part by people’s moods?

Cathy Cahill, a pain and addiction researcher at UCLA, said these big swings in emotions likely factor into the learned behaviors of opioid addiction, especially with those with chronic pain. A person with opioid use disorder becomes preoccupied with the search for the drugs. Certain contexts become triggers for their cravings, and those triggers start overlapping in their minds.

“The basic view is some people start with the pain trigger [the chronic back problem], but it gets partially substituted with the negative reinforcement of the opioid withdrawal,” Cahill said.

That’s why Cahill, Evans and other scientists think the opioid addiction epidemic might be driven, in part, by our moods.

Chronic pain patients have a very high risk of becoming addicted to opioids if they are also coping with a mood disorder. A 2017 study found most patients — 81 percent — whose addiction started with a chronic pain problem also had a mental health disorder. Another study found patients on morphine experience 40 percent less pain relief from the drug if they have mood disorder. They need more drugs to get the same benefits.

People with mood disorders alone are also more likely to abuse opioids. A 2012 survey found patients with depression were twice as likely to misuse their opioid medications.

“So, not only does a mood disorder affect a person’s addiction potential, but it also influences if the opioids will successfully treat their pain,” Cahill said.

Meanwhile, the country is living through sad times. Some research suggests social isolation is on the rise. While the opioid epidemic started long before the recession, job loss has been linked to a higher likelihood of addiction, with every 1 percent increase in unemployment linked to a 3.6 percent rise in the opioid-death rate.

Can the brain swing back?

As an opioid disorder progresses, a person needs a higher quantity of the drugs to keep withdrawal at bay. A person typically overdoses when they take so much of the drug that the brain stem slows breathing until it stops, Kosten said.

Many physicians have turned to opioid replacement therapy, a technique that swaps highly potent and addictive drugs like heroin with compounds like methadone or buprenorphine (an ingredient in Suboxone).

These substitutes outcompete heroin when they reach the opioid receptors, but do not activate the receptors to the same degree. By doing so, they reduce a person’s chances for overdosing. These replacement medications also stick to the receptors for a longer period of time, which curtails withdrawal symptoms. Buprenorphine, for instance, binds to a receptor for 80 minutes while morphine only hangs on for a few milliseconds.

For some, this solution is not perfect. The patients need to remain on the replacements for the foreseeable future, and some recovery communities are divided over whether treating opioids with more opioids can solve the crisis. Plus, opioid replacement therapy does not work for fentanyl, the synthetic opioid that now kills more Americans than heroin. Kosten’s lab is one of many working on a opioid vaccine that would direct a person’s immune system to clear drugs like fentanyl before they can enter the brain. But those are years away from use in humans.

And Evans and Cahill said many clinics in Southern California are combining psychological therapy with opioid replacement prescriptions to combat the mood aspects of the epidemic.

“I don’t think there’s going to be a magic bullet on this one,” Evans said. “It’s really an issue of looking after society and looking after of people’s psyches rather than just treatment.


St. Petersburg, FL – Thursday, August 31, 2017 – Drug Free America Foundation today introduced a first-of-its-kind Opioid Tool Kit in an effort to help address the opioid epidemic gripping the United States.

The Opioid Tool Kit was unveiled in conjunction with International Overdose Awareness Day, a global event held on August 31st each year that aims to raise the awareness of the problem of drug overdose-related deaths.

“With more than 142 people dying each day, drug overdoses are now the leading cause of death for Americans under the age of 50,” according to Calvina Fay, Executive Director of Drug Free America Foundation. “Moreover, deaths from drug overdose are an equal opportunity killer, with no regard to race, religion or economic class,” she said.

“While alcohol and marijuana still remain the most common drugs of abuse, the nonmedical use of prescription painkillers and other opioids has resulted in a crisis-level spike in drug overdose deaths,” said Fay.

The Opioid Tool Kit has been designed to educate people about the opioid epidemic and offer strategies that can be used to address this crisis. “The Tool Kit is also intended to encourage collaboration with different community sectors and stakeholders to make successful and lasting change,” Fay continued.

The Opioid Tool Kit is a comprehensive guide that defines what an opioid is, examines the scope of the problem, and addresses why opioids are a continuing health problem.  The Tool Kit also provides strategies for the prevention of prescription drug misuse and overdose deaths and includes a community advocacy and action plan, as well as additional resources.

Fay emphasized that the best way to prevent opioid and other drug addiction is not to abuse drugs in the first place.  “The chilling reality is that the long-term use and abuse of opioids and other addictive drugs rewire the brain, making recovery a difficult and often a life-long struggle,” she concluded. The Opioid Tool Kit can be found on Drug Free America Foundation’s website at

Source:  August 2017

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

The Seven Challenges Program

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

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

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

Q&A: What Should Treatment Look Like?

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

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

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


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

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

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


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

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

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

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


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

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

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

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


A New Version of The Seven Challenges

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

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

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

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

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

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

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

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

Source:     17th July 2017

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

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

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

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

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

The case for prescription heroin

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

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

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

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

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

The research is clear: Medication-assisted treatment works

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The medications used in treatment do carry some risks

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

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

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

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

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

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

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

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

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

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

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

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

Source:  German  Jul 20, 2017


Residential treatment has received a lot of criticism and scepticism over the last several years, especially for opioid use disorders. (Some of it is deserved. Too many providers are hustlers and others provide little more than detox with inadequate follow-up. Of course, many of the same criticisms have been directed at medication-assisted treatment. But, that’s not what this post is about.)

At any rate, the Recovery Research Institute recently posted about a study looking at completion rates for outpatient and residential treatment.   The study looked at A LOT of treatment admissions, 318,924.  Residential completion rates appear to have surprised a lot of people:

Results: Residential programs reported a 65% completion rate compared to 52% for outpatient settings. After controlling for other confounding factors, clients in residential treatment were nearly three times as likely as clients in outpatient treatment to complete treatment.

But, what really surprised some readers was this:

Compared to clients with a primary alcohol use disorder:
Clients with marijuana use disorder were only 74% as likely to complete residential treatment.
Clients with an opioid use disorder were 1.29x MORE likely to complete residential treatment.

So opioid users were much more likely to benefit from residential treatment compared to alcohol users. . . .

We speculate that for opioid abusers, the increased structure and cloistering of residential treatment provide some protection from the environmental and social triggers for relapse or that otherwise lead to the termination of treatment that outpatient treatment settings do not afford. Indeed, environmental risk characteristics in drug abusers’ residential neighbourhoods, such as the presence of liquor stores and indicators of concentrated disadvantage at the neighbourhood level, have been found to be associated with treatment non-continuity and relapse.

Such environmental triggers may play a particularly substantial role for those addicted to opioids compared to those seeking treatment for marijuana abuse. Since opioid users have the lowest raw completion rates in general, this finding that residential treatment makes a greater positive difference for opioid users than it does for any of the other substances represents an important result that merits further investigation. Given the current epidemic of opioid-related overdoses in the U.S., our results suggest that greater use of residential treatment should be explored for opioid users in particular.

For the differences between residential and outpatient, they say the following:

In general, residential treatment completion rates are usually higher compared to outpatient settings, but what is particularly noteworthy is that even after controlling for various client characteristics and state level variations, the likelihood of treatment completion for residential programs was still nearly three times as great as for outpatient settings. Given the more highly structured nature and intensity of services of residential programs compared to outpatient treatment, it is understandable that residential treatment completion rates would be higher. It requires far less effort to end treatment prematurely in outpatient settings com-pared to residential treatment.

Given the strong association between treatment completion and positive post-treatment outcomes such as long term abstinence, the large magnitude of difference between outpatient and residential treatment represents a potentially important consideration for the choice of treatment setting for clients.


“I wish that all families would at least consider investigating medication-assisted treatment and reading about what’s out there,” says Alicia Murray, DO, Board Certified Addiction Psychiatrist. “I think, unfortunately, there is still stigma about medications. But what we want people to see is that we’re actually changing the functioning of the patient.” Essentially, medication-assisted treatment (MAT) can help get a patient back on track to meeting the demands of life – getting into a healthy routine, showing up for work and being the sibling, spouse or parent that they once were. “If we can change that with medication-assisted treatment and with counselling,” says Murray, “that’s so valuable.” The opioid epidemic is terrifying, especially so for a parent of someone already struggling with prescription pills or heroin use. It’s so important to consider any and all options for helping your child recover from their opioid dependence.

Part of the reason it’s so hard to overcome an opioid addiction is because it rewires your brain to focus almost exclusively on the drug over anything else, and produces extreme cravings and withdrawal symptoms as a result. By helping to reduce those feelings of cravings and withdrawal, medication-assisted treatment can help your son or daughter’s brain stop thinking constantly about the drug and focus on returning to a healthier life.

Medication-assisted treatment is often misunderstood. Many traditional treatment programs and step-based supports may tell you that MAT is simply substituting one addictive drug for another. However, taking medication for opioid addiction is like taking medication for any other chronic disease, such as diabetes or asthma. When it is used according to the doctor’s instructions and in conjunction with therapy, the medication will not create a new addiction, and can help.

As a parent, you want to explore all opportunities to get your child help for his or her opioid addiction, and get them closer and closer to functioning as a healthy adult – holding down a job, keeping a regular schedule and tapering, and eventually, stopping their misuse of opioids. Medication-assisted treatment helps them do that.

“MAT medications are most effective when they are used in conjunction with therapy and recovery work. We would never recommend medication over other forms of treatment. We would recommend it in addition to it.”

The three most-common medications used to treat opioid addiction are:

· Naltrexone (Vivitrol)

· Buprenorphine (Suboxone)

· Methadone


Naltrexone, known by its brand-name Vivitrol, is administered by a doctor monthly through an injection. Naltrexone is an opioid antagonist. Antagonists attach themselves to opioid receptors in the brain and prevent other opioids such as heroin or painkillers from exerting the effects of the drug. It has no abuse potential.


Buprenorphine, known by its brand-name Suboxone, is an oral tablet or film dissolved under the tongue or in the mouth prescribed by a doctor in an office-based setting. It is taken daily and can be dispensed at a physician’s office or taken at home. Buprenorphine is a partial agonist. Partial agonists attach to the opioid receptors in the brain and activate them, but not to the full degree as agonists. If used against the doctor’s instructions, it has the potential to be abused.


Methadone is dispensed through a certified opioid treatment program (OTP). It’s a liquid and taken orally and usually witnessed at an OTP clinic until the patient receives take-home doses. Methadone is an opioid agonist. Agonists are drugs that activate opioid receptors in the brain, producing an effect. If used against the doctor’s instructions, it has the potential to be abused. There is no “one size fits all” approach to medication-assisted treatment, or even recovery. Recovery is individual.

The most important thing to do is to consider all of your options, and speak to a medical professional to determine the best course of action for your family. The best path is the path that helps and works for your child.

Source:  19th May 2017

Meet Ryan Hampton, 36, recovery advocate, political activist and recovering heroin addict igniting America’s social media feeds with stories of hope, recovery and activism. From his advocacy that led Sephora to take their eyeshadow branded “druggie” off the shelves to the activism that urged an Arizona politician to apologize for a statement stigmatizing addiction, he’s certainly become a social media powerhouse for all things addiction, recovery and policy. And with an estimated 7 out of 10 people on social media platforms, it’s no coincidence he’s found success taking the addiction advocacy fight digital.

Today, more than 22 million people are struggling with addiction, and it’s estimated that as a result, more than 45 million people are affected. But what many people don’t realize is that there are more than 23 million people living in active, long-term recovery today. Yet, because of shame and stigma, many stay silent. To fight this often-lethal silence, Hampton has urged the public to speak up and share personal stories of recovery through his recently launched Voices Project. The project, a collaborative effort to encourage people across the nation to share their story, exists to put real faces and names behind the addiction epidemic.

A Personal Struggle

Before becoming a national recovery advocate and social media powerhouse, Hampton himself faced a personal struggle with addiction. A former staffer in the Clinton White House, Hampton did not appear to be a likely candidate for heroin addiction, or so stigma would say. But after an injury and subsequent prescription for pain medication, Hampton found himself addicted to opiates, eventually leading to a heroin addiction that would span more than a decade.  After a long struggle, Hampton decided to get help.

It was the phone call that started his recovery journey that changed everything – his life and his view on the power of his phone. After getting sober, he began connecting with others in recovery, amazed at the magnitude of the digital community. But still, while uncovering these online stories of recovery, Hampton lost four friends to opioid addiction.

It was a breaking point for Hampton – one that led to the beginning of a movement that would someday reach and impact millions.

A Notable Partner

Hampton began reaching out to others in recovery and started realizing the power of digital tools to connect and build an online recovery community. And as he was slowly networking and meeting others in recovery, on October 4, 2015, Hampton’s advocacy met its catalyst: Facing Addiction.   The non-profit organization hosted a concert at the National Mall in Washington, D.C., an event that drew thousands to the capitol with celebrities, musicians and other well-known names willing to publicly celebrate the reality of recovery and call for reform in the addiction industry. Hampton, a Los Angeles resident, tuned into the event from across the country through Facebook Live and was again inspired by the content delivered through his mobile phone.

After meeting co-founders of Facing Addiction, Jim Hood and Greg Williams, Hampton plugged in, partnered and even joined the Facing Addiction team as a recovery advocate.

The importance of online advocacy aligns with Facing Addictions’ national priorities, shares CEO Jim Hood, “When enough people tell enough stories and the people who are impacted by addiction look like all of us and our kids and neighbors and relatives, the stigma has to start going away. And then we can get to work.”

After partnering with Facing Addiction, Hampton understood the priorities, the strategy and the mechanism. Said by Hampton, “I stand on the shoulders of giants”.

Leveraging the power of the algorithms at his fingertips every day, Hampton has grown his online presence to be one of the most influential in the recovery movement. Digital communication helped him get to treatment, connected him with Facing Addiction, and now is the platform in which he is sharing recovery stories from across the nation.

In just one week, more than 200 stories were submitted to the Voices Project and over 500 people sent in personal messages to express their support. Among those speaking up are notable voices such as pro skateboarder and former Jackass member Brandon Novak;   Grammy Award-winning musician Sirah;  rapper Royce da 5’9’’;   American politician and mental health advocate Patrick Kennedy;  former child actress and now-addiction counselor Mackenzie Phillips, and more.

According to Royce da 5’9’’, “Addiction is a problem that we all have to deal with. It affects us all in one way or another, and having someone giving it a voice, a name and a face not only helps get rid of the stigma regarding addiction, but he’s [Ryan] on the forefront letting people know there are solutions out there and recovery is real.”

Patrick Kennedy shares the importance of building a digital recovery movement to influence and support political reform in the addiction recovery space. “With the push of a button we’ll be able to have others show up to support communities across the nation,” says Kennedy, “because their fight is our fight.”

“The face of addiction is everyone,” Sirah shares. “The Voices Project gives people a voice and a connection to hope.”

The hope offered through open dialogue about addiction and recovery has now grown into a digital movement.

The pages that Hampton started with $20 and an old computer have gained more than 200,000 followers across platforms, reaching nearly 1 million people each week. “We’re the fastest-growing social movement in history – and the funny thing is, we’re a community that nobody ever wanted to be a part of,” Novak says.

“This is the one space where we cannot be ignored. The time has come for us to speak out, and we’re a community that speaks loudly. With addiction, we’re dealing with imminent death every day,” Hampton says. “Through social media, we’ve found an innovative way to communicate with each other and connect with people we haven’t met, and now, we’re having this conversation with the rest of the world.”

Perhaps the most intriguing impact of Hampton’s work is the paradoxical ability to bring the work of addiction recovery advocacy online – only to take it back offline through real-world change in communities across the country. According to Hampton, the work he’s doing shouldn’t stay digital – it should impact community laws, help new non-profits emerge and influence real people to seek treatment and find it.

“No matter if you have social media or not – your way of doing this is talking about addiction at the dinner table, to a parent or a friend or an employer. You should not be afraid to tell your story of recovery or loss and, most importantly, your story of struggle and how you need help. It may not just change your life, it may change someone else’s life,” Hampton says.

At the crux of digital advocacy in the addiction recovery realm are real lives being saved – people finding treatment, families finding hope and those in recovery being freed of stigma that can keep them in shame and silence.  This is the mission that has fuelled Hampton’s work since the beginning. And Hampton’s reason is hard to refute: “My story is powerful, but our stories are powerful beyond measure.”


(Comment by NDPA:  Some shocking figures from the USA in this article)

In 1964 the Surgeon General’s report on smoking and health began a movement to shine the bright light on cigarette smoking and dramatically change individual and societal views. Today, most states ban smoking in public spaces.

Most of us avoid private smoky places and sadly watch as the die-hard huddle 15 feet from the entrance on rainy, snowy or frigid coffee breaks. Employers often charge higher health insurance premiums to employees who smoke, and taxes on cigarettes are nearly triple a gallon of gas. Yet, some heralded progressive states have passed referendums to legalize the recreational use of a different smoked drug.

Now, more than 50 years later, another very profound statement has been made in the introduction to the recent report, “Substance misuse is one of the critical public health problems of our time.”

“Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health,” was released in November 2016 and is considered to hold the same landmark status as that report from 1964. And maybe, just maybe, it will have the same impact.

Many key findings are included that are critical to garnering support in the health care and substance abuse treatment fields. But the facts are just as important for the general public to know:

— In 2015, substance use disorders affected 20.8 million Americans — almost 8 percent of the adolescent and adult population. That number is similar to the number of people who suffer from diabetes, and more than 1.5 times the annual prevalence of all cancers combined (14 million).

— 12.5 million Americans reported misusing prescription pain relievers in the past year.

— 78 people die every day in the United States from an opioid overdose, nearly quadruple the number in 1999.

— We have treatments we know are effective, yet only 1 in 5 people who currently need treatment for opioid use disorders is actually receiving it.

— It is estimated that the yearly economic impact of misuse and substance use disorders is $249 billion for alcohol misuse and alcohol use disorders and $193 billion for illicit drug use and drug use disorders ($442 billion total).

— Many more people now die from alcohol and drug overdoses each year than are killed in automobile accidents.

— The opioid crisis is fuelling this trend with nearly 30,000 people dying due to an overdose on heroin or prescription opioids in 2014. An additional roughly 20,000 people died as a result of an unintentional overdose of alcohol, cocaine or non-opioid prescription drugs.

Our community has witnessed many of these issues first hand, specifically the impact of the heroin epidemic. The recent Winnebago County Coroner’s report indicated that of 96

overdose deaths in 2016, 42 were a result of heroin, and 23 from a combination of heroin and cocaine.

We know that addiction is a complex brain disease, and that treatment is effective. It can manage symptoms of substance use disorders and prevent relapse. More than 25 million individuals are in recovery and living healthy, productive lives. I, myself, know many. Most of us do.

Locally, the disease of addiction hits very close to many of us. I’ve had the privilege of being part of Rosecrance for over four decades, and I have seen the struggle for individuals and families — the triumphs and the tragedies. Seldom does a client come to us voluntarily and without others who are suffering with them. Through research and evidence-based practices at Rosecrance, I have witnessed the miracle of recovery on a daily basis. Treatment works!

If you believe you need help, or know someone who does, seek help.  Now. Source:  4th March 2017

National statistics show 2,367 users aged 18 to 24 sought treatment in 2015-16 as drug becomes increasingly unfashionable.   A total of 149,807 opiate addicts came for treatment in England during 2015-16, down 12% on a peak of 170,032 in 2009-10.

The number of 18 to 24-year-olds in England entering treatment for addiction to heroin has plummeted 79% in 10 years, as the stigma surrounding the drug and changing tastes in intoxication have made it increasingly unfashionable.

In the year to March, 2,367 people from that age group presented with heroin and opiate addiction at the approximately 900 drug treatment services in England, compared with 11,351 10 years earlier, according to statistics from the National Drug Treatment Monitoring System (NDTMS).

They constituted a tiny fraction of the 149,807 opiate addicts who came for help to kick their habit throughout the year, a number that is itself 12% down on a peak of 170,032 who came for treatment in 2009-10. The median age of those users was 39, the statistics showed.  Michael Linnell, the coordinator of UK DrugWatch, a network of drug treatment professionals, said many of the heroin users currently accessing treatment would have become addicted during a boom in the drug’s popularity in the late 1980s. Young addicts were “as rare as hen’s teeth”, he said.

Our neglect of ageing heroin users has fuelled the rise of drug-related deaths

“For the Thatcher generation who didn’t see a future and there were no jobs or employment and the rest of it, it was an alternative lifestyle in that you were really, really busy being a heroin user: getting up, scoring, nicking stuff to get the money to score and the rest of it,” Linnell said.

“There was a whole series of factors until you got to that point where people from those communities – the poorest communities – where you were likely to get heroin users, could see the visible stigma of the scarecrow effect, as some people called it.

“They didn’t want to aspire to be a heroin user because a heroin user just had negative connotations, rather than someone who was rebelling against something.”

Overall, 288,843 adults aged 18 to 99 came into contact with structured treatment for drug addiction during 2015-16, 52% of whom were addicted to heroin or some other opiate. Among opiate addicts, 41% were also addicted to crack cocaine, with the next highest adjunctive drugs being alcohol (21%) and cannabis (19%).

About half of those presenting to treatment – 144,908 – had problems with alcohol, a fall of 4% compared with the previous year. Among those, 85,035 were treated for alcohol treatment only and 59,873 for alcohol problems alongside other substances.

The most problematic drug among the 13,231 under-25s who came into contact with drug treatment services in the past year was cannabis, which was cited as a problem by 54%, followed by alcohol (44%) and cocaine (24%).

The numbers from this age group accessing treatment had fallen 37% in 10 years, which the Public Health England report accompanying the statistics said reflected shifts in the patterns of drinking and drug use over that time, with far fewer young people experimenting with drugs than in the past.  Karen Tyrell, the spokeswoman for the drug treatment charity Addaction, said the decline in problem drug use among young people reflected what drugs workers see on a daily basis, and credited evidence-based education, prevention and early intervention programmes for the change.

The shift, though, was precarious, Tyrell said, warning that yearly spending cuts to treatment services risked reversing the gains.

She added: “Of course, what this also means is that we have an ageing population of heroin users, many of whom have been using since the 80s or 90s, and who are now dealing with poor physical health and increasing vulnerability. In an environment of ever rising drug-related deaths, it’s imperative we don’t lose sight of their needs.”



* •Motives for cannabis use can predict problematic use and use-related problems.

* •A MET/CBT intervention was associated with significant reductions in motives.

* •Reductions in a subset of motives significantly predicted change in outcomes.



Heavy cannabis use has been associated with negative outcomes, particularly among individuals who begin use in adolescence. Motives for cannabis use can predict frequency of use and negative use-related problems. The purpose of the current study was to assess change in motives following a motivational enhancement therapy (MET) and cognitive behavioral therapy (CBT) intervention for adolescent users and assess whether change in motives was associated with change in use and self-reported problems negative consequences.


Participants (n = 252) were non-treatment seeking high school student cannabis users. All participants received two sessions of MET and had check-ins scheduled at 4, 7, and 10 months. Participants were randomized to either a motivational check-in condition or an assessment-only check-in. Participants in both conditions had the option of attending additional CBT sessions. Cannabis use frequency, negative consequences, and motives were assessed at baseline and at 6, 9, 12, and 15 month follow-ups.


There were significant reductions in motives for use following the intervention and reductions in a subset of motives significantly and uniquely predicted change in problematic outcomes beyond current cannabis use frequency. Change in motives was significantly higher among those who utilized the optional CBT sessions.


This study demonstrates that motives can change over the course of treatment and that this change in motives is associated with reductions in use and problematic outcomes. Targeting specific motives in future interventions may improve treatment outcomes.

Source:   1st October 2016

An intriguing new NIAAA-funded study offers a glimpse at how the adolescent brain responds to the language of therapists. Led by Sarah W. Feldstein Ewing, Ph.D., Professor of Psychiatry and Director of the Adolescent Behavioral Health Clinic at Oregon Health & Science University, the study assessed 17 young people ages 15–19 who were self-reported binge drinkers. Following a psychosocial assessment, the youths received two sessions of motivational interviewing aimed at reducing drinking. Between sessions, the participants underwent a brain scan using functional magnetic resonance imaging, or fMRI.

During the fMRI, the therapist presented two types of statements: one set of “closed questions” based on standard language used within addiction treatment (e.g., “Do your parents know you were drinking?”); the other set included more effortful “complex reflections” (e.g., “You’re worried about your drinking.”)

The youth were re-evaluated one month after treatment. At the follow-up evaluation, the youth showed significant reductions in number of drinking days and binge drinking days. Furthermore, in the fMRI sessions, the researchers observed greater brain activation for complex reflections versus closed questions within the bilateral anterior cingulate gyrus, a brain region associated with decisionmaking, emotions, reward anticipation, and impulse control.

The scientists also noted that greater blood-oxygen level dependent (BOLD) response in the parietal lobe during closed questions was significantly associated with less post-treatment drinking. BOLD response is a way to measure activity in specific brain areas. Previous research has shown that this region’s secondary function is related to a person’s ability to navigate, plan, and make decisions.

The study team also observed lower brain activation in the precuneus was associated with study participants’ post-treatment ratings of the importance of changing their drinking. The precuneus, a subregion of the parietal lobe located inside the fissure that separates the brain’s hemispheres, is related to self-reflection and introspection and is involved in risk behavior. It is considered to be a hub of the brain’s key resting-state network.

The researchers also noted what they did not find from the brain scans—any link between treatment outcome and activation of the frontal lobes, which are a region tied to complex reasoning. The authors commented that this lack of activation might be

because the frontal lobes of the adolescent brain are still developing, making it difficult for teens to bring their frontal lobes “online.”

The study authors note that their findings have important implications for the treatment of addiction in adolescents and can improve our understanding of youth brain systems and inform how to influence mechanisms of behavior change in this population.


Feldstein Ewing, S.W.; Houck, J.M.; Yezhuvath, U.; Shokri-Kojori, E.; Truitt, D.; and Filbey, F.M. The impact of therapists’ words on the adolescent brain: In the context of addiction treatment. Behavioural Brain Research 297:359–369, 2016. PMID: 26455873

Source:  Volume 8 Issue 3  September 2016.

Some cannabis users have developed an “inverted expertise” on the drug – often equipped with more up-to-date knowledge than the people trying to help them, a conference being held at the University of York was told today.

A group of national experts gathered at the University’s King’s Manor to exchange ideas on effective treatment for cannabis users.

There has been a dramatic increase in the number of people seeking treatment for problems related to cannabis use over the last decade. Research has revealed there was a 64% increase in the number of people seeking treatment between 2005 through to 2015 in England. Cannabis has also now overtaken heroin as the drug most likely to prompt calls for help.

The increase in requests for treatment is in contrast with the steady decline in the population’s use of cannabis, delegates were told.

Researchers at the University of York – including Ian Hamilton, Lecturer in Mental Health and Charlie Lloyd, Senior Lecturer in Health Sciences – and the University of Leeds are investigating why so many cannabis users are seeking treatment and how services are responding.

Initial findings suggest that individuals seek help with problems which are not usually associated with cannabis, such as irritability and poor impulse control.

Also, that treatment services are not sufficiently prepared to offer effective interventions, as cannabis is still seen as a benign drug.

Dr Mark Monaghan, a lecturer in Criminology and Social Policy at Loughborough University, told the delegates: “There is this ‘inverted expertise’ around cannabis in which the users have all the up-to-date knowledge of the local markets and the service providers are lagging behind.

“This can have a significant knock-on effect for the kind of services they are providing. Cannabis users are quite knowledgeable in what is going on in terms of the market.

“The providers are slightly lagging behind in terms of their knowledge base. Because they are lagging behind they don’t have intelligence on what the consumers are using; it creates this situation where they don’t really know what to do.”

He added: “We need to know what people are using and we need to offer them evidence-based treatments.

“Treatment across the sector is really variable. We do need more research on the changing nature of the cannabis market. We need to explore the reason why more people are presenting to treatment centres.”

Ian Hamilton, Department of Health Sciences’ Lecturer in Mental Health, who organised the event, said: “This is the first research that has looked at both the demand for cannabis treatment and the reasons why there’s been a significant rise in it. The outcome of the conference today was agreement amongst commissioners, providers and researchers that there is a problem we need to explore, around why people are presenting to treatment services, and how we can offer effective interventions once they are in treatment.”

Source:   7th June 2016

Hendriks V., van der Schee E., Blanken P.
Drug and Alcohol Dependence: 2011, 119, p. 64–71.

US research led by the programme’s developers has found that a family therapy which intervenes across a child’s social environment is more effective than alternatives for problem substance using teenagers, but this independent European study found individually-focused cognitive-behavioural therapy overall just as effective.

SUMMARY Cognitive-behavioural therapy is a mainstay of addiction treatment, but young problem substance users might benefit more from approaches which intervene with their families and wider environments. The featured study tested this proposition among cannabis users in The Netherlands, pitting multidimensional family therapy against a more conventional, individually-focused cognitive-behavioural therapy.

Key points

  • Multidimensional family therapy is one of a family of approaches which intervene not just with the individual young problem substance user but with their family and other important influences in their lives.

  • US research led by the programme’s developers has found this approach more effective than alternatives or usual treatment or criminal justice procedures.

  • The featured study offers a test of the approach on a non-US caseload and in a study by independent researchers not involved in the programme’s development.

  • As with another independent study, the approach was not found preferable overall to a well-structured alternative, but – again as in other studies – it might have been more effective with the more multiply and severely problematic youngsters.

  • Extra cost and the relative scarcity of qualified practitioners are an obstacle to implementation.

Multidimensional family therapy addresses problem drug use and related problems among adolescents not through a set regimen, but by applying principles and a therapeutic framework to the individual seen as situated within a particular set of environmental influences and constraints. What distinguishes it from some other family therapies is that therapists see substance use as potentially a problem in its own right, and that the intervention extends beyond the child and family to all the social systems (school, juvenile justice, etc) in which the child may be involved.

US studies involving young cannabis users have shown promising results, but almost all these were obtained by one research group. Independent replication studies are needed, and it is unclear whether the impacts of multidimensional family therapy observed in the United States can be generalised to a country such as The Netherlands, where attitudes to cannabis use are more permissive.

To answer these questions the featured study compared the effectiveness of multidimensional family therapy and cognitive-behavioural therapy among adolescent cannabis users in The Netherlands. Between 2006 and 2009 it recruited 109 children aged from 13 to 18 diagnosed as experiencing cannabis abuse or dependence within the past year. They were among the intake at two treatment centres for adolescents in The Hague, one specialising in substance use problems, the other in mental and behavioural health. Patients in the study had to have regularly used cannabis in the past three months and have at least one parent figure who agreed to participate in treatment and in study assessments.

Participants averaged just under 17 years of age and 80% were male. According to their own accounts, they had on average been using cannabis for two years and at study entry had averaged 162 ‘joints’ in the past 90 days – equivalent to nearly two a day. Other substances were used relatively little. They reported an average of about six violent or property crimes in the past three months and a substantial minority were diagnosed with a conduct disorder or oppositional defiant disorder. Four in 10 lived in single-parent households and the same proportion had been imprisoned.

They were allocated at random to multidimensional family therapy or cognitive-behavioural therapy, each planned to last five to six months and delivered on an outpatient basis. In weekly one-hour sessions, the cognitive-behavioural option focused on enhancing patients’ motivation to change their addictive behaviour, and then on changing problem behaviours by means of training in self-control, social and coping skills, and relapse prevention. Monthly sessions were also scheduled for the parents to provide information and support, but not to intervene in family dynamics or parenting.

Multidimensional family therapy was more intensive, scheduled to occupy two one-hour sessions a week with the adolescent, parent(s) and/or family, plus contacts with schools and court staff and other people. It was delivered by trained and supervised therapists who followed a manual by the approach’s developers and were trained by the developers, whose unit in the USA was contacted monthly for feedback and consultation.

An attempt was made to reassess patients to track their progress, the final assessment being 12 months after the baseline assessment conducted just before patients were allocated to the treatments. At the final follow-up, just over 94% of patients were reassessed.

Main findings

Though continued cannabis use was the norm, the general picture was of improvements between the 90 days before starting treatment and the 90 days before the final 12-month assessment. However, these improvements were not significantly greater depending on the treatment to which patients had been allocated. This was the case despite multidimensional family therapy being far better attended; 8 in 10 children completed this treatment compared under 3 in 10 allocated to the cognitive-behavioural option, and they attended sessions totalling 35 hours compared to 10. Significant others in the child’s life also spent much more time engaged in the multidimensional than in the cognitive-behavioural programme.

The number of days in which the children had used cannabis fell from 62–63 days out of 90 to 43 with multidimensional family therapy and 47 with cognitive-behavioural therapy, and the number of joints smoked fell respectively by 38% and 46%. In both options a good treatment response – at least 30% fewer cannabis-using days without substantial increases in use of other substances – was recorded by 42–44% of patients. In both options the number of crimes the children said they had committed fell by over a third.

Despite overall near equivalence, there were indications that children with the severest problems reduced their cannabis use more when allocated to multidimensional family therapy. This was the case whether severity was assessed in terms of intensity of cannabis use or substance use in general, criminality, presence of conduct and/or oppositional defiant disorders (among whom the extra reduction in days of cannabis use peaked at 42 days), and whether the child’s family was assessed as dysfunctional. Differential impacts among children with severe substance use or exhibiting conduct and/or oppositional defiant disorders reached statistical significance.

The authors’ conclusions

The study indicates that multidimensional family therapy and cognitive-behavioural therapy are equally effective in reducing cannabis use and delinquency among adolescents with a cannabis use disorder in The Netherlands, though neither was sufficient to eliminate problem substance use altogether among most of the children. Despite some limitations, the results are robust and applicable to most treatment-seeking adolescents with problem cannabis use in The Netherlands. The results are notable given the much higher treatment ‘dose’ – and consequently, higher costs – of multidimensional family therapy. As others have done, the study also found indications that multidimensional family therapy is differentially effective with adolescents and families with more severe problems.

It should be acknowledged that without a no-treatment control group, it cannot be said for certain that the treatments caused the observed improvements. Also the results derived from youngsters who frequently used cannabis, but not other substances, and who often had a history of delinquency and psychiatric treatment, and from a country with a relatively permissive attitude to cannabis.

COMMENTARY This well designed study has considerable clinical relevance since participants were seeking treatment in the normal way and were clearly using cannabis excessively as well as having other serious problems in their lives – the kind of caseload one would expect at substance use and mental health treatment services for young people, and the kind seen in the UK, where among under-18s cannabis is now by far the most common primary drug in relation to which treatment is provided. Numbers in England in 2013/14 continued to increase to a record 13,659, 71% of all young patients in specialist treatment. Forms of cognitive-behavioural therapy are a common component of treatment in Britain, but family-based therapeutic work is surprisingly rare, given that for example in England, over 80% of young patients were living with their families. Based on the evidence, British practice standardsfrom the Royal College of Psychiatrists on the care of young people with substance misuse problems commend family work, but say it is not standard in British services.

The featured study offers some guidance on whether for young, frequent cannabis users, UK services would do better to replace cognitive-behavioural therapies with family work in the form of multidimensional family therapy. Overall the answer is no; this would cost more without substantially improving outcomes. The finding is particularly important since it derives from a rare test conducted with a European caseload and by a research team independent of the developers of the programme. Independence is important because in several social research areas (1 2 3), programme developers and other researchers with an interest in the programme’s success have been found to record more positive findings than fully independent researchers.

Promising as US studies led by the developers of the programme have been (for example, 1 2), an independent US study found multidimensional family therapy slightly (but not significantly) less effective at promoting recovery from substance use problems than two other therapies, and substantially less cost-effective. Like the featured study, the focus was on young problem cannabis users, and cognitive-behavioural therapy featured among the alternatives.

Multidimensional family therapy is one of a similar set of programmes which integrate intervention in to several domains of a child’s life. Such approaches can improve on typically less well organised and less extensive usual practices (1 2), but this is not always the case, and performance against stronger alternative approaches focused on the individual young cannabis user has been equivalent. Evaluations conducted independently of programme developers have usually been unconvincing, and results overall have not been as impressive as investment in these programmes might be seen to require, especially if they supplement rather than replace legally or socially required procedures. A major obstacle to their use is the expensive training and supervision and considerable skills required to implement them in ways which have been associated with good outcomes.

Best for the hardest cases?

Britain’s National Institute for Health and Clinical Excellence (NICE) has recommended the types of programmes exemplified by multidimensional family therapy for problem-drinking children who also have other major problems and/or limited social support, signalling their particular suitability for the most severely affected and multiply problematic youngsters. In line with this recommendation, the featured study and others suggest that investment in multidimensional family therapy might be warranted for more problematic youngsters – particularly in the featured study, those so at odds with families and society that they can be diagnosed as exhibiting these traits to a pathological degree. That suggestion is tentative, however, primarily because these analyses were not planned in advance so may have capitalised on chance variations in outcomes.

The same limitation applies to the US trials which found multidimensional family therapy particularly suitable for high-severity youngsters. Other limitations too make the US findings an unreliable guide to whether multidimensional family therapy really is best for the most severely affected youngsters (details below), though the plausibility of the findings and the similar findings in The Netherlands mean this contention cannot be dismissed.

One of the US studies compared multidimensional family therapy with cognitive-behavioural therapy. In this study the researchers identified a set of youngsters (about 4 in 10 of the sample) initially more strongly engaged with and affected by substance use, and among whom this engagement weakened less over the course of treatment and a 12-month post-treatment follow-up. They also had more psychological problems. Among this sub-sample, engagement with substance use weakened significantly more when they had been allocated to multidimensional family therapy. Less engaged youngsters were affected about equally by both treatments. But these results were extracted only by a complex analysis which divided the sample up based not just on initial severity, but on their progress in and after treatment. The formation of these categories itself partly depended on the effects of the treatments, then the analysis tested whether the treatments affected each class differently – a circularity which complicates assessment of just what the results mean in practice. This analysis also had to contend with the fact that at each follow-up around 40% or more of the sample could not be reassessed, presumably meaning it had to estimate how they would have scored based on the available data. Such estimates can only be relied on if the data is randomly missing – in this case, if the reasons why a young person did not attend for reassessment had nothing to do with the factors which affected their response to treatment, an unlikely assumption.

Less affected by these complications, a simpler analysis of whether youngsters who started treatment with a deeper engagement with substance use became more disengaged when allocated to multidimensional family therapy was negative, as was one which tested initial psychological problems as a predictor of differential response to treatment. Nor were any relationships found between frequency of substance use and differentially benefiting from multidimensional family therapy. In a similar analysis of a second study comparing multidimensional family therapy to usual criminal justice procedures, the reverse was the case; here it was not the more deeply engaged youngsters who benefited more from multidimensional family therapy, but those who used substances most often. Such inconsistency heightens concerns over cherry-picking of results to demonstrate that multidimensional family therapy is best for most severely affected youngsters.

Last First uploaded 18 April 2015


Revised 27th April 2015

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

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

The Need

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

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

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

Keeping Tabs With Texts

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

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

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

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

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

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

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

Less Relapse, More Engagement

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

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

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

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

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

Text and Thrive

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

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

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

This study was supported by NIH grant DA027754.


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

A woman who was admitted to rehab three times because of her severe drug addiction has turned her life around by becoming an addiction therapist helping others going through what she did.

Vicky, from Hale, Manchester, reveals that her drug addiction started at a young age; she was smoking weed when she was 11 and took acid and mushrooms by the age of 16.

The 49-year-old, who attended Altrincham Grammar School, comes from a wealthy background and was expected to go into medicine or dentistry.

However, her parents split when she was young and she hasn’t seen her biological father since she was seven years old. The breakdown of the family unit, she explains, led her to feel as though there was a deficit in her life.

As a result, she began to use food, substances and sex to fill the void to help her feel better about herself.

Vicky explains that she’s had obsessive behaviours towards food – often bingeing on a whole box of crisps at once – since a young age.

At the age of 11 she moved to Canada for six months to live with relatives where she started smoking cannabis. By 16 she was aware her drinking habits weren’t ‘normal’. Vicky felt she had no cut off point and regularly had memory loss. She also started taking what she considered to be recreational drugs: cannabis, acid and mushrooms.

When she was 17, she was introduced to amphetamine. Looking back, Vicky says she considers that her recreational drug use was about helping her to feel better about herself.

After college, Vicky flitted between working for her mother’s business and restaurants jobs in Hale, during which time the Cheshire-set friendships and free-flowing champagne encouraged her drinking and drug taking habits.

She admits that she was living for the moment, seeking fun and excitement but her lifestyle choices were slowly ruining the opportunities she had been given. When she was 20, Vicky returned to Canada and dated a cocaine dealer – a time that she describes as her ‘Nirvana’ with cocaine on tap.

When her visa expired, she moved back to the UK and began dating someone who had a similar background of drug misuse. She started using heroin and crack for two years and whilst she was able to hold down a job, she admits she started to function less and less.

She started to steal to pay for drugs, received a drink driving conviction at aged 22 and received multiple cautions for drug possession and related incidents. Vicky believes she was merely given a slap on the wrist due to her background.

Aged 23, Vicky felt very isolated and ended up living back at home at which point her parents became aware there was a problem. They called a psychiatrist for help and Vicky was admitted to rehab for eight weeks in 1988, she returned on two more occasions.

Following Vicky’s third admittance to rehab, the alcohol and drug induced death of a close friend and former boyfriend on her 25th birthday hit Vicky very hard. She reached her lowest point and attempted suicide more than once. However, she began to turn her life around.

She had to sign a contract to agree to secondary care treatment at a female-only facility where she was taught to take personal responsibility for her own happiness.

Vicky, who now lives with the father of her two youngest children that she met in recovery 18 years ago, studied for a Diploma in Counselling at the University of the West of England and a Masters at Bristol University; she has been qualified as a counsellor for 18 years.

She met her partner and father of her two youngest children in recovery 18 years ago. Vicky is dedicated to helping others affected by addiction, and has a particular passion for helping and working with families and the ‘forgotten others’. Helping others through her own business, Victoria Abadi Therapies, has helped Vicky’s own recovery.

She said: ‘I had always thought I was fascinated by substances and drugs, but over the years I’ve come to realise that what really interests me is addiction itself. I knew from as young as 21 that I wanted to be an addiction therapist. A lot has changed since my days in detox and rehab, we know so much more about addiction but there’s still more to learn.

‘My main advice to anyone affected by addiction, whether it’s yourself or someone you care about, is to talk. It might seem obvious but it’s not always easy to reach that stage.

‘Once you reach the point of realisation that addiction is a medical issue not simply a moral choice the path to recovery will come easier. Likewise, for families shedding the shame and stigma by talking about your experience will open up the possibility of helping your loved one through it.

‘There are some great impartial services, such as Port of Call, who can help with pointing you in the right direction and getting you or a loved the help they need. ‘The best thing that comes out recovery is the ability to have close meaningful relationships.’

For help and advice on addiction recovery visit Port of Call, Victoria Abadi Therapies or call 0800 0029010.


After the Police Chief of Gloucester, Massachusetts announced the town will connect people with treatment when they come to the police station with illegal drugs and paraphernalia, instead of arresting them, 56 police departments in 17 states have started similar programs.

An additional 110 police departments are preparing to start programs that emphasize treatment over incarceration, The New York Timesreports. Two hundred treatment centers nationwide have agreed to be partners in these programs. In May 2015, Gloucester Police Chief Leonard Campanello posted on Facebook, “We will walk them through the system toward detox and recovery. We will assign them an ‘angel’ who will be their guide through the process. Not in hours or days, but on the spot.” Since then, Gloucester has developed a national network of centers that are willing to provide treatment beds and take referrals by police, whether or not a person has insurance.

Several local pharmacies have agreed to make the opioid overdose antidote naloxone available at a discount.

Most of the program’s costs are covered by the Police Assisted Addiction and Recovery Initiative, which Chief Campanello founded with Gloucester businessman John E. Rosenthal. The initiative has raised hundreds of thousands of dollars. It has also received millions of dollars in in-kind contributions, including placement in treatment centers.

The program has 55 volunteers in recovery or who are familiar with addiction, who listen and offer moral support. Local taxi companies provide free rides to treatment facilities or the airport, if the treatment facility is far away.

Since the program started, 391 people have turned themselves in at Gloucester’s police station. About 40 percent are from the local area. All have been placed in treatment, the article notes.

Source:   26th Jan. 2016

Consumption of illegal drugs begins at the age of 10

The National Council Against Addictions (Conadic) has estimated that over 2.38 million Mexican youths are in need of some kind of rehabilitation treatment for abuse of substances, mainly marijuana and alcohol.

This is but one of the staggering figures presented in the 2014 National Survey on Drug Use Among Students, conducted in public and private schools in the 32 states, which also indicated that children are beginning to consume illegal drugs at 10 years old, two years younger than had been thought.

The survey also established that addiction among youths in secondary and preparatory schools – nearly 80,000 young men and 50,000 young women – requires immediate intervention.

A broader number of the same spectrum of students, about 311,000 men and 260,000 women, were found to need brief support interventions, which could consist of counselling sessions or a short rehabilitation internment period.

The course of action to take in the case of younger, elementary school students is still being assessed.

Conadic chief Manuel Mondragón wants to know the how and where of treatment: “713,963 secondary and preparatory school students need to be treated for use of drugs, and 1.674 million for abuse of alcohol. The question is, where are we going to treat them, and who will provide the treatment? What are our infrastructural capabilities?”

Mondragón said nearly 1.8 million children and teenagers – from elementary to preparatory – have tried illegal drugs, 152,000 of which are fifth and sixth-grade students, and whose first experience was with marijuana, followed by inhalants and cocaine.  Of that 1.8 million, over 108,000 have used marijuana between one and five times.

The abuse of alcohol is no less worrisome: 1.5 million secondary and preparatory school students have abused it, consuming over five drinks at a time and becoming drunk. Over 110,000 elementary school students have done the same.

The states with the most substance abuse among children are Chihuahua, Jalisco, State of México, the Federal District and San Luis Potosí.

Nine out of every 10 children in Michoacán, Campeche and Quintana Roo are experimenting with and abusing harder substances like cocaine.

Mondragón stated that immediate measures to deal with the issue could consist of shutting down all establishments that sell alcohol to minors, as well as signing agreements in every state to strengthen the use of breathalyzers and control the sale of legal and illegal drugs.  Mondragón also said the federal government is open to raising the limit of recreational drugs an individual can carry, currently set at five grams. This would permit the reinsertion into society of non-violent, first-offender youths who are currently in jail for possession of illegal substances.

Meanwhile, in Congress, the first round of discussions around the use of marijuana and its derivatives is taking place with the participation of representatives from the United Nations and parents’ associations.  The discussion is focusing on the legalization of medicinal cannabinoid-based products.

Source:   26th Jan. 2016



Cannabis use is decreasing in England and Wales, while demand for cannabis treatment in addiction services continues to rise. This could be partly due to an increased availability of high-potency cannabis.


Adults residing in the UK were questioned about their drug use, including three types of cannabis (high potency: skunk; low potency: other grass, resin). Cannabis types were profiled and examined for possible associations between frequency of use and (i) cannabis dependence, (ii) cannabis-related concerns.


Frequent use of high-potency cannabis predicted a greater severity of dependence [days of skunk use per month: b = 0.254, 95% confidence interval (CI) 0.161-0.357, p < 0.001] and this effect became stronger as age decreased (b = -0.006, 95% CI -0.010 to -0.002, p = 0.004). By contrast, use of low-potency cannabis was not associated with dependence (days of other grass use per month: b = 0.020, 95% CI -0.029 to 0.070, p = 0.436; days of resin use per month: b = 0.025, 95% CI -0.019 to 0.067, p = 0.245). Frequency of cannabis use (all types) did not predict severity of cannabis-related concerns. High-potency cannabis was clearly distinct from low-potency varieties by its marked effects on memory and paranoia. It also produced the best high, was preferred, and most available.


High-potency cannabis use is associated with an increased severity of dependence, especially in young people. Its profile is strongly defined by negative effects (memory, paranoia), but also positive characteristics (best high, preferred type), which may be important when considering clinical or public health interventions focusing on cannabis potency.

Source: 26213314   July 27th 2015

There’s a new drug in town.

It’s called Shatter and it looks like dark-amber toffee. It’s THC, the chemical that causes the high in marijuana, extracted from the plant and has highly addictive qualities, said Stratford police Insp. Sam Theocharis.

It’s been around for a while but it’s new to Stratford, Theocharis said.  Police have started to see the drug a bit more frequently and wanted to get the message out to the public.

“When you look at it, it just looks like goo but it’s a new form of marijuana drug,” he said.

Shatter is clear, smooth and solid. It can consist of more than 80% THC, according to the High Times website.

Police seized some Tuesday along with methamphetamine, cocaine, marijuana and prescription drugs after an investigation by the Street Crime Unit.  Two men in their 40s were arrested and face several charges including possession for the purpose of trafficking. The drugs seized are valued at more than $1,500. Cell phones, scales and baggies were also seized, police said.

Shatter sells for about $100 a gram on the streets. It’s dangerous and often leads to overdose, police said.  Whether it will overshadow crystal meth and oxycodone in popularity has yet to be seen.

“I can’t predict but anything that gives you a better high is going to be sought after,” Theocharis said.



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

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

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

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

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

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

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

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

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

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


Several students and visitors from Wesleyan University were hospitalized on February 22 after taking the club drug MDMA. U.S. DEA/HANDOUT VIA REUTERS/REUTERS

At least 11 people from the Wesleyan University campus in Middletown, Connecticut, were hospitalized on Sunday with symptoms consistent with drug overdoses. School officials and emergency responders are blaming MDMA, also known as Molly, a form of the drug ecstasy that medical experts say has become increasingly popular on college campuses.

Though some reports said 11 people had received medical treatment, Wesleyan President Michael S. Roth put the number at 12 in an email to students on Monday. That includes 10 students and two visitors.

“I ask all students: Please, please stay away from illegal substances, the use of which can put you in extreme danger. One mistake can change your life forever,” Roth wrote. “And please keep those still hospitalized in your hearts and minds. Please join me in supporting their recovery with your prayers, thoughts and friendship.”

In a statement on Monday, a Middletown Police Department spokeswoman, Lieutenant Heather Desmond, wrote that her department would be involved in an investigation into “the origin of the drugs taken” and to “determine the extent of the criminal involvement in the case.”

A spokeswoman for Middlesex Hospital tells Newsweek it treated 11 people, three of whom are still there and four of whom were airlifted by helicopter to Hartford Hospital. She could not comment on the conditions of the three patients there. A spokeswoman for Hartford Hospital confirmed that four people were there. She too could not speak to their conditions. The police spokeswoman wrote that two individuals are in critical condition and two are in serious condition.

Middletown Fire Chief Robert Kronenberger tells Newsweek his department made seven runs to Wesleyan related to the incident on Sunday after receiving calls between 7:30 a.m. and 1:30 p.m. It rendered aid to eight individuals, including two people in a single dorm room. “We saw the trend and we worked with the university and the police department to notify them of the trend,” Kronenberger says. “We’ve never had anything to this extent,” he says, referring to health and safety issues at Wesleyan. “A couple of them were in some serious dire straits,” he says about the students, adding that they were cooperative. “As a parent of two college-age students, this definitely concerns me and hopefully something to this extent will open eyes,” he says.

Wesleyan’s student newspaper, The Wesleyan Argus, first reported about the incident on its website on Sunday after the school’s vice president for student affairs, Michael Whaley, sent a series of emails to students.

Medical experts say MDMA use on college campuses has grown in recent years, and while there have been reports of bad reactions to the drug, it appears the Wesleyan incident is the most widespread.

In 2013, a University of Virginia sophomore collapsed at a nightclub after taking MDMA and later died. Students at Syracuse University in Syracuse, New York; Plymouth State University in Plymouth, New Hampshire; and Texas State University in San Marcos, Texas have also died after taking the drug. In 2013, organizers of the Electric Zoo music festival in New York City cut the event short after two people died while taking MDMA, including a University of New Hampshire student.

“This age group is a risk-taking group that is willing to follow their friend wherever they go, and if the person next to them is popping a pill, then they’re going to do it too,” says Dr. Mark Neavyn, director of medical toxicology at Hartford Hospital, who treats patients there for MDMA overdoses.

“I think the popular culture engine kind of made it seem safer in some way,” Neavyn says, referring to references to the drug by the singers Miley Cyrus and Madonna that made headlines.

But when it comes to MDMA, people are rarely taking what they think they’re taking, the doctor says.

According to Neavyn, symptoms of an MDMA overdose include fast heart rate, high blood pressure, delirium, elevated body temperature and alterations in consciousness. Extreme cases could involve cardiac arrhythmia and seizures.

Wesleyan, which has about 2,900 full-time undergraduate students and 200 graduate students, also apparently dealt with MDMA-related issues last semester. As the Argus reported, the school’s Health Services Department emailed students on September 16 following a series of MDMA-related hospitalizations.

One former Wesleyan student from the class of 2011, who requested anonymity when discussing drug use, says the news is not surprising, given the prevalence of drugs on campus. “Anything you can imagine…would be readily available there,” the person says. “I don’t think at Wesleyan you need [a campus event] to take drugs. If it’s sunny, there’s probably a good percentage of people that are taking something.”

The campus activities calendar did not show any major events scheduled for Saturday or Sunday.

Another former Wesleyan student from the class of 2012, who also requested anonymity, says the drug culture at Wesleyan is comparable to that at similar schools. “It’s one of those things where, much like at those schools, you kind of have an understanding of where you can go to get it and who had it,” the person says. “If there’s a will there’s a way.” weds Feb. 2015


Between 1986 and 2003, I served as the evaluator of an innovative approach to the treatment of addicted women with histories of neglect or abuse of their children.  Project SAFE eventually expanded from four pilot sites to more than 20 Illinois communities using a model that integrated addiction treatment, child welfare, mental health, and domestic violence services.  

This project garnered considerable professional and public attention, including being profiled within Bill Moyers’ PBS documentary,Moyers on Addiction:  Close to Home.  My subsequent writings on recovery management and recovery-oriented systems of care were profoundly influenced by the more than 15 years I spent interviewing the women served by Project SAFE and the Project SAFE outreach workers, therapists, parenting trainers, and child protection case workers.  This blog offers a few reflections on what was learned within this project about the role of trauma in addiction and addiction recovery.

Trauma, particularly physical/sexual abuse, was ever present in the lives of the women served by Project SAFE, but one must be cautious in over-interpreting trauma as the etiological agent in addiction and related problems.  After all, multitudes of women have experienced childhood and adult trauma without developing the severity, complexity, and chronicity of problems commonly experienced by the women in Project SAFE.  So an early challenge within Project SAFE was to understand what distinguished the trauma resilient from the trauma impaired.  Our collective experience with thousands of women across diverse community and cultural contexts led to the conclusion that the resilient and the impaired differed in two fundamental ways.  They differed in the nature of the trauma they had experienced, and they differed substantially in the recovery capital that influenced their capacities for resilience. 

What separated community populations of women and our clinical population of women was not the presence of trauma but the characteristics of such trauma.  A cluster of traumagenic factors distinguished the clinical group from the more resilient community group.  Trauma in the former was more likely to: 

1) begin at an earlier age (marking less developmental resources to cope with the trauma),

2) involve more physically and psychologically invasive forms of victimization,

3) take place over a longer period of time (e.g., multiple events over days, months, or years rather than a single point-in-time episode),

4) involve multiple perpetrators over time (confirming lack of safety, personal vulnerability, and suspicion that the cause lies within oneself),

5) involve perpetrators drawn from the family or social network (marking a greater violation of trust),

6) involve physical injury/disfigurement or threats of such if event(s) disclosed, and

7) generate environmental responses of disbelief or victim blaming when victimization disclosed.  

Women with histories of perpetration of violence against their children, partners, or others also had experienced three additional factors:  serial episodes of abandonment, desensitization to violence through prolonged horrification (witnessing violence against persons close to them in their developmental years), and violence coaching (transmission of a technology of violence and praise for violence from the family and social environment).  Combinations of these potent traumagenic factors dramatically increased the risk of a broad cluster of problems in personal and interpersonal functioning.

The second conclusion we drew was that women experiencing one or more of these traumagenic factors in community and clinical populations differed widely in the their level of adult functioning, with some exhibiting profound impairments and others exhibiting extraordinary levels of resilience and positive personal and social functioning.  While some of this difference could be accounted for by variations in the number and intensity of traumagenic factors, there was another quite influential force that often tipped the scales from pathology to resilience. Women exhibiting the greatest resilience had experienced trauma, but they also possessed high levels of recovery capital–internal and external assets that could be mobilized to initiate and sustain recovery from trauma and its potential progeny of related problems.  Such resources fell into three categories:  personal recovery capital, family recovery capital, and community recovery capital, with each arena constituting a potential focus of policy development and service programming.   

In contrast to this resilience profile, women served by Project SAFE were collectively marked by the combination of multiple traumagenic factors and low recovery capital.  That combination predictively produced distorted thinking about oneself and the world, emotional distress and volatility, migration from self-medication to addiction, assortative mating (recapitulation of developmental trauma in toxic adult intimate relationships), addiction to crisis, impaired parenting, and chronic self-defeating styles of interacting with professional helpers.

The first challenge in Project SAFE was for the outreach workers, therapists, case workers, parenting trainers, and others not to be personally paralyzed in response to the horror contained in the stories of the women they were serving.  The second challenge was not to be professionally paralyzed by the number, severity, complexity and chronicity of the problems presented by the women entering Project SAFE and the resulting multitude of community agencies involved in their lives.  Through training, skilled clinical supervision, and mutual professional support, those twin challenges were overcome, traditional models of clinical sense-making and intervention were cast aside, and new understandings and approaches were forged that have been described in a series of reports and training manuals.

So let me now share the rest of the story–the story of recovery.  As a long-tenured addiction professional and the evaluator on this project, what most intrigued me was that so many women who were given little chance of success achieved levels of health and functioning that no one, most importantly the women themselves, could have predicted. Equally intriguing were the processes involved in that achievement.  Here are just a few of the lessons of Project SAFE that still have salience today.

Hope, not pain or consequence, is the critical ingredient to successful treatment and recovery of traumatized women. Women with multiple traumagenic factors and low recovery capital don’t hit bottom, they live on the bottom.  They have incomprehensible capacities for physical and psychological pain.  What is catalytic is not pain, but the discovery of hope within relationships that are personally empowering–experienced sequentially within Project SAFE with outreach workers, SAFE clinical staff, a community of peers in recovery, and then within a larger community of recovering women.  In project SAFE, this process most often began through a process of assertive outreach during what I have called a stage of precovery (See Precovery:  “And then the Miracle Occurred”).   The move from precovery to recovery initiation was marked by exposure to women in recovery with whom they could identify and who made recovery contagious by the examples of their own survival and transformed lives.  

Life-limiting mottoes for living must be experientially disconfirmed for recovery to proceed. The mottoes that women brought to their involvement in Project SAFE included:  I am unlovable; I am bad; there is no safety; everybody’s on the make–no one can be trusted; if I get close to people, they will leave me or die; my body does not belong to me; and I am not worthy or capable of recovery. The triple challenges in providing effective addiction treatment to traumatized women are to: 1) avoid confirming these messages by recapitulating processes of victimization (e.g., problems rather than solutions focus, emotional battering via confrontation techniques, or emotional or sexual exploitation) and abandonment (e.g., acute care that provides brief stabilization without continued support or disciplinary discharge from treatment for regressive behavior), 2) experientially challenge these messages (e.g., providing enduring support within frequently tested relationships that unequivocally convey acceptance, regard, respect, safety, and security), and 3) forge new mottoes for living within the processes of story reconstruction and storytelling.

The most powerful catalyst for healing trauma is the experience of mutual identification and support within a community of recovering people.  Such an experience within Project SAFE marked the transition from toxic dependencies on drugs, people, and enabling institutions to healthy interdependence and mutual accountability within a community of recovering women and children.  This suggests that recovery outcomes in traumatized women may be as contingent on community recovery capital (welcoming recovery landscapes) as one’s personal vulnerabilities and resources.  Systematically increasing community recovery capital involves expanding beyond intrapersonal, clinically focused models of recovery support to encompass models for building strong cultures of recovery and models of recovery community building and recovery community mobilization.    

Effective parenting is contingent upon experiencing the essence of such parenting.  Parents cannot authentically give to their children what they have not personally experienced.   In Project SAFE, the journey to effective parenting involved an emotional/relational component (active resistance, emotional regression/dependence, reparenting of mothers by Project SAFE staff and volunteers; and a subsequent focus on selfhood and mutual help) and a skill component (parental modeling, training, and coaching with SAFE clients and their children).  

Effective parenting emerges in middle-to-late stage recovery.  While abuse and neglect of children often remit upon initial recovery stabilization, effective parenting and the larger arena of improved family health must be preceded by heightened recovery stabilization and maintenance and the subsequent transition to an enhanced focus on the quality of personal and family life in long-term recovery.  This suggests the need for structured supports for the developmental needs of children during early recovery (via indigenous peer and professional support) and the need for scaffolding (See Stephanie Brown’s discussion of scaffolding) for the whole family from these same supports during the early recovery process.

Project SAFE began with a focus on the psychopathology of the women it served but quickly shifted its emphasis to the creation of a healing community within which the potential and transformative power of recovery was nurtured and celebrated.  I remain in awe of the stories of these women and what they were able to achieve.

 Source: 28th February 2015

Marijuana Use and Mania

 As the debate continues to rage over the possible risks or advantages of smoking marijuana, new research out of Britain’s Warwick University has found a “significant link” between marijuana use and mania, which can range from hyperactivity and difficulty sleeping to aggression, becoming delusional and hearing voices.

Published in the Journal of Affective Disorders, the study of more than 2,000 people suggested potentially alarming consequences for teenagers who smoke the herb. 

“Cannabis [marijuana] is the most prevalent drug used by the under-18s,” said lead researcher Dr Steven Marwaha. “During this critical period of development, services should be especially aware of and responsive to the problems cannabis use can cause for adolescent populations.”

Researchers examined the effect of marijuana on individuals who had experienced mania, a condition that can include feelings of persistent elation, heightened energy, hyperactivity and a reduced need for sleep. On the other side of the coin, mania can make people feel angry and aggressive with extreme symptoms including hearing voices or becoming delusional.

“Previously it has been unclear whether cannabis use predates manic episodes,” Dr Marwaha said. “We wanted to answer two questions:

1.      Does cannabis use lead to increased occurrence of mania symptoms or manic episodes in individuals with pre-existing bipolar disorder?

2.      “But also, does cannabis use increase the risk of onset of mania symptoms in those without pre-existing bipolar disorder?”

Dr Marwaha found that marijuana use tended to precede or coincide with episodes of mania. Representing what the lead researcher referred to as “a significant link,” there was a strong association with new symptoms of mania, suggesting that these are caused by marijuana use.

The researchers also found that marijuana significantly worsened mania symptoms in people who had previously been diagnosed with bipolar disorder. “There are limited studies addressing the association of cannabis use and manic symptoms which suggests this is a relatively neglected clinical issue,” Dr Marwaha said.

However, our review suggests cannabis use is a major clinical problem occurring early in the evolving course of bipolar disorder.   More research is needed to consider specific pathways from cannabis use to mania and how these may be effected by genetic vulnerability and environmental risk factors.”

These findings add to a body of previous studies that have linked marijuana to increased rates of mental health problems including anxiety, depression, psychosis and schizophrenia, and have suggested that the herb is addictive and opens the door to hard drugs.

A study which was published in the journal Neuroscience earlier this month nevertheless found that marijuana could be used to treat depression.

Scientists at the University of Buffalo’s Research Institute on Addictions said molecules present in marijuana could help relieve the depression resulting from long-term stress.

 Source: Journal of Affective Disorders Feb 2015

The information comes from the Indiana Youth Institute’s annual Kids Count report.

The data is worrisome to area health professionals, like Dr. Ahmed Elmaadawi, who says marijuana is mentally addictive. 

“Cannabis, in general, works in an area of the brain that’s responsible for judgment and well-being. We actually know if you use marijuana for a long period of time, it affects your judgment [and] self-esteem. And longtime use of cannabis can actually cause psychosis,” said Dr. Elmaadawi, a child and adolescent psychiatrist.

Dr. Elmaadawi is concerned mainly for teen use. He says there is proven research marijuana can be healing to cancer patients and others suffering from chronic pain, but use for teens is dangerous. He says those who try the drug before age 18 are 67% more likely to continue using. The number drops to 27% for adults who try it for the first time.

“The pleasurable response is there. They want to have more to get that same feeling from the first time they used marijuana,” said Dr. Elmaadawi.

While health professionals are standing strong in the dangers, there is an overwhelming support for legalization at the national level. According to a Pew Research Poll, millennials are setting aside partisan politics with 77% of Democrats between ages 18-34 and 63% of Republicans agreeing laws that prohibit pot are outdated.

But, not all young people agree, including one local teen who struggled with abuse at an early age. The teen, called “John” for the purpose of this story, went to rehab at age 16. He started using pot at 13. His legal trouble started when he was caught on camera stealing from parked cars with a friend. Both were high and had a history of theft.

“There was an adrenaline part that didn’t make me worry about it. The money part is what made me do it, but the thrill is what didn’t make me afraid of it,” said John.

After his first arrest, John went to the Juvenile Justice Center (JJC) for 10 days. After his release, he started using synthetic marijuana. His mom caught him sometime later, called his parole officer, and he was again arrested. This time, John went to JJC for a month and rehab for 6 months.

“I stopped mainly because it was hurting a lot of the relationships I had, and I wanted to do stuff for myself. I knew if I wanted to go as far as I wanted to, I was going to get backtracked all the time if I smoked weed,” said John.

An arrest record and rehab aren’t enough for everyone. The Indiana Youth Institute (IYI) says while overall substance abuse is declining in terms of alcohol and cigarettes, marijuana use is increasing in teens.

“A big key to being successful to keeping our kids away from any illicit substance is open communication with their parents and other caring adults in their lives,” said Bill Stanczykiewicz, the President and CEO at IYI.

Dr. Elmaadawi and Stanczykiewicz agree there are mixed messages about marijuana legalization and the longtime effects. They agree open communication and community resources are key in helping teens make tough choices. Dr. Elmaadawi says there needs to be more education in schools in addition to collaboration between the resources in the community. Stanczykiewicz says teens are most influenced in their personal decision making by people they know directly.

“Kids benefit when they hear consistent messages about right and wrong from all of the caring adults in their lives. There’s no 100% guarantee that kids are going to make good choices, but what we are trying to do is increase the odds,” said Stanczykiewicz.

To read the Kids Count Data, click here.

Source:  9th March 2015

It started with a wine cooler, said Paige Cederna, describing that first sweet, easy-to-down drink she experienced as a “magic elixir.” 

“I had no inhibitions with alcohol,” said Ms. Cederna, 24. “I could talk to guys and not worry about anyone judging me. I remember being really proud the day I learned to chug a beer. I couldn’t get that feeling fast enough.” But before long, to get over “that feeling,” she was taking Adderall to get through the days.

But it was now more than three years since she drank her last drop of alcohol and used a drug for nonmedical reasons. Her “sober date,” she told the group, many nodding their heads encouragingly, was July 8, 2011.

Ms. Cederna’s story of addiction and recovery, told in a clear, strong voice, was not being shared at a 12-step meeting or in a treatment center. Instead, it was presented on a cool autumn day, in a classroom on the campus of the University of Michigan in Ann Arbor, to a group of 30 undergraduate students in their teens and early 20s.

On the panel with Ms. Cederna were two other Michigan graduate students. Hannah Miller, 27, declared her “sober date” as Oct. 5, 2010, while Ariel Britt, 29, announced hers as Nov. 6, 2011. Like Ms. Cederna’s, Ms. Britt’s problems with drugs and alcohol started in her freshman year at Michigan, while Ms. Miller’s began in high school. All three are participants in a university initiative, now two years old, called the Collegiate Recovery Program.

Staying sober in college is no easy feat. “Pregaming,” as it is called on campus (drinking before social or sporting events), is rampant, and at Michigan it can start as early as 8 a.m. on a football Saturday. The parties take place on the porches and lawns of fraternities, the roofs and balconies of student houses, and clandestinely in dormitories — everywhere but inside the academic buildings.

For this reason — because the culture of college and drinking are so synonymous — in September 2012 the University of Michigan joined what are now 135 Collegiate Recovery communities on campuses all over the country. While they vary in size from small student-run organizations to large embedded university programs, the aim is the same: to help students stay sober while also thriving in college.

“It shouldn’t be that a young person has to choose to either be sober or go to college,” said Mary Jo Desprez, who started Michigan’s Collegiate Recovery Program as the director of Michigan’s Wolverine Wellness department. “These kids, who have the courage to see their problem early on, have the right to an education, too, but need support,” she said, calling it a “social justice, diversity issue.” Matthew Statman, the full-time clinical social worker who has run Michigan’s program since it began in 2012, added, “We want them to feel proud, not embarrassed, by their recovery.”

At the panel presentation, Ms. Britt, who temporarily dropped out of Michigan as an undergraduate, shared with the students her anxiety when she finally sobered up and decided to return to campus. “I had so many memories of throwing up in bushes here,” she said. “I wanted to have fun, but I also had no idea how to perform without partying.”

Ms. Cederna also remembers what it felt like to return to Michigan sober her senior year. Not only did she lose most of her friends (“Everyone I knew on campus drank,” she said), but she also dropped out of her sorority (“I was only in it to drink,” she said). “I ended up alone in the library a lot watching Netflix,” she said. Molly Payton, 24 (now a senior who once fell off an eight-foot ledge, drunk and high at a party), said, “I read all the Harry Potter books alone in my room my first months clean.”

Everything changed, however, when these students learned there were other students facing the same issues. Ms. Cederna first found Students for Recovery, a small student-run organization that, until the Collegiate Recovery Program began, was the only available support group on Michigan’s campus besides local 12-step meetings, most of which tend toward an older demographic.

“Through S.F.R., I ended up having five new friends,” she said of the organization, which still exists but is now run by the 25 to 30 Collegiate Recovery Program students; both groups meet every other week in the health center. The main difference between the two is that students in the Collegiate Recovery Program have to already be sober and sign a “commitment contract” that they will stay clean throughout college through a well-outlined plan of structure. Students for Recovery is aimed at those who are still seeking recovery, may be further into their recovery or want to support others in recovery.

When a young student incredulously asked the panel, “How do you possibly socialize in college without alcohol?” Ms. Britt, Collegiate Recovery Program’s social chairwoman, rattled off a list of its activities — sober tailgates, a pumpkin-carving night, volleyball games, dance parties, study groups, community service projects and even a film screening of “The Anonymous People” that attracted some 600 students. “But we also just hang out together a lot,” she said.

Indeed, looking around the organization’s lounge just before the holidays (a small, cordoned-off corner on the fourth floor of the health center, minimally decorated with ratty couches, a table and a small bookshelf stocking titles like “Wishful Drinking” and “Smashed”), it was hard to believe some of these young adults were once heroin addicts who had spent time in jail. On the contrary, they looked like model students, socializing over soft drinks and snacks as they celebrated one student who had earned back his suspended license.

“By far the biggest benefit to our students in the recovery program is the social component,” said Mr. Statman, who is hoping a current development campaign may provide more funding. (The program is currently supported by a mandatory student health tuition fee.) “Let’s just say, we all wish we could be Texas Tech,” he said.

The Collegiate Recovery Program was established at Texas Tech decades ago, and it is now one of the largest, with 120 recovery students enrolled (along with Rutgers University and Augsburg College in Minneapolis). Thanks to a $3 million endowment, the Texas Tech program now offers scholarships as well as substance-free trips abroad. The students there have access to an exclusive lounge outfitted with flat-screen TVs, a pool table and a Ping-Pong table, kitchen, study carrels and a seminar room. Entering freshmen in recovery even have their own dormitory.

“We found that simply putting them on the substance-free halls didn’t work,” said Kitty Harris, who, until recently, was the director for more than a decade of Texas Tech’s program (she remains on the faculty). “Most of the kids on substance-free floors are just there to make their parents happy.” (The Michigan students in the recovery program mostly live off campus for the same reason; they do not have their own housing.)

“Most students begin experimenting innocently in college with drugs and alcohol,” said Mr. Statman, who just celebrated his 13th year in recovery. “Then there are the ones who react differently. They are not immoral, pleasure-seeking hedonists, they are simply vulnerable, and for their whole life.”

Rates of substance-use disorders triple from 5.2 percent in adolescence to 17.3 percent in early adulthood, according to 2013 data from the Substance Abuse and Mental Health Services Administration. It thus makes this developmental stage critical to young people’s future.

It is at the drop-in Students for Recovery meetings where one often sees nervous new faces. At the beginning of one meeting at Michigan last semester, a young woman introduced herself as, “One day sober.” Shortly afterward, a young man spoke up, “I am five days sober.” Danny (who asked that his last name not be published), a graduating recovery program senior applying to medical schools, later explained an important tenet all of them know from their various 12-step programs. “The most important person in the room is the new person,” he said, adding that after the Students for Recovery meetings, members try to approach any new participants, directing them to the C.R.P. website and to Mr. Statman, who is always on call for worried students.

“In the same way a diabetic might not always get their sugar levels right, part of addiction is relapsing, and we really don’t want our students to see that as a failure if it happens,” said Mr. Statman, adding that it is often the other students in the program who tell him if they suspect a student is using again.

Jake Goldberg, 22, now a junior, arrived at Michigan three years ago as a freshman already in recovery. “I did really well the first five months,” he said. “I was sober. I was loud and proud on panels, but I had internal reservations. I had few friends and felt like I wanted to be more a part of the school.” He recalled that in the spring of his freshman year, he suddenly found himself trying heroin for the first time. “I should have died,” he said, remembering how he woke up 14 hours later, dazed and bruised.

After straightening up, Mr. Goldberg relapsed again his sophomore year when he thought he might be able to have just one drink. “That drink led to drugs and to more drinking,” he said, remembering how Mr. Statman and Ms. Desprez called him into their office one day. “They told me this is not going to end well,” he said. Now sober two years, Mr. Goldberg said: “I now live recovery with all the structure, but I also am in a prelaw fraternity. When they drink a beer, I drink a Red Bull.”

Ms. Miller echoed Mr. Goldberg’s feelings over coffee one day on the Michigan campus. “Most of us did not get sober just to go to meetings all the time,” she said. “We want to live life too.” She also said that socializing with nonrecovery students is still challenging. “I went to a small party recently where everyone was eating pot edibles and drinking top-shelf liquor,” she said. “I got a bit squirrely in my head and had to leave.”

But now students in the Collegiate Recovery Program have a new place in Ann Arbor they can frequent: Brillig Dry Bar, a pop-up, alcohol-free spot that serves up spiced pear sodas and cranberry sours and features live jazz. And in March, four of the students in the program are joining dozens of recovery students from other colleges on a six-day, five-night, “Clean Break” in Florida, arranged by Blue Community, an organization that hosts events and vacations for young adults in recovery. (The vacation package includes music, guest speakers, beach sports and daily transport to local 12-step meetings.)

“My hope is that we continue to get more students who need a safe zone to our social events,” said Ms. Britt, who is about to publicize a “sober skating night” in March at the university ice rink. “They would see you can have a lot of fun in college without drinking.

“And honestly, we really do have fun.”


The largest recent US national survey of drink and drug problems shows that outside the addiction treatment clinic, remission is the norm and recovery common. After 14 years half the people at some time dependent on alcohol were in remission, a milestone reached for cannabis after six years, and for cocaine after just five.

SUMMARY Among the US general adult population, and for each of nicotine, alcohol, cannabis and cocaine (including crack), this study sought to estimate the time from onset of dependence to remission, the cumulative probability of remission in different racial/ethnic groups, and to identify factors related to the probability of remission.

It drew its data from the National Epidemiological Survey of Alcohol and Related Conditions (NESARC) conducted in 2000–2001, which focused on drinking disorders but also asked about other forms of drug use and psychological problems. The aim was to interview a representative sample of civilian, non-institutionalised adults aged 18 and over living in households and group residences such as college halls, boarding houses and non-transient hotels. About 8 in 10 of the sample responded to the survey yielding 43,093 respondents. The featured report investigated the subgroups who had some time in their lives been dependent on nicotine (of which there were 6937), alcohol (4781), cannabis (530) or cocaine (408).

Dependence was defined as meeting the dependence criteria of the applicable version of the American Psychiatric Association’s DSM manual, DSM-IV. ‘Lifetime’ dependence was diagnosed if the respondent reported having experienced at least three specific signs of this syndrome within the same 12-month period at some point in their life. The age this first happened for any particular substance was the onset year, while the remission year was based on the age when the respondent’s answers indicatedthey had last stopped meeting dependence criteria for the drug, and had continued to do so for at least a year until interviewed for the survey – essentially, the most recent (at least so far) lastinglysuccessful remission. It was on this basis that the study calculated remission rates for individual substances and related them to the time between the onset of dependence and remission.

Main findings

Proportion of dependent users in remission

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  chart. It could be estimated that by the end of their lives 84% of formerly dependent smokers would be in remission, 91% for alcohol, 97% for cannabis and 99% 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 years.

Once other factors had been taken in to account, for each of the substances, men who had been dependent at some time were significantly less likely than women to be in remission, especially in respect of the two illegal drugs, cannabis and cocaine; for every 10 women only about six men were in remission from dependence on these drugs. Black Americans once dependent on nicotine or cocaine were less likely to be in remission than white Americans – for cocaine, half as likely. After four years, about 50% of whites had sustained remission from dependence on cocaine; African Americans took nine years to reach the same milestone.

About 80% of people at some time dependent on nicotine or alcohol and almost all those once dependent on cannabis or cocaine had also at some time met diagnostic criteria for another psychiatric disorder, including conduct (antisocial behaviour in early life) and personality disorders. Once other factors had been taken in to account, people who had met criteria for conduct disorder were much more likely than others to have overcome their dependence on cannabis. In contrast, a diagnosis of a personality disorder was associated with a lower probability of remission from cannabis (and also alcohol) dependence. Having once experienced mood and anxiety disorders was unrelated to remission from dependence on any of the four substances.

The authors’ conclusions

The general picture is that the vast majority of people in the USA once dependent on nicotine, alcohol, cannabis or cocaine stop being dependent at some point in their lives, and this happens after fewer years for cannabis or cocaine than for nicotine or alcohol. Black Americans stay dependent longer on nicotine and cocaine than white Americans, and probabilities of remission are associated with social and psychological characteristics and dependence on other substances. However, the fact that that many people once dependent were no longer at the time of the survey should be interpreted with caution given the irregular course of addictions punctuated by remissions and relapses; their remission may have been temporary. Possible explanations for these findings are considered below.

More than two thirds of remissions from cannabis and cocaine dependence occurred within the first decade after onset of dependence, but only a fifth for nicotine and a third for alcohol. These differences may be explained in part by how quickly adverse physical, psychological and social consequences become apparent. For instance, the risk of early cardiovascular problems is much higher among individuals dependent on cocaine than among those dependent on nicotine or alcohol. Behavioural disturbances resulting from cannabis or cocaine dependence and their illegal status impose stronger social pressures to remit. The pervasive availability of alcohol and nicotine also means pervasive environmental prompts to using the drugs. Particularly for nicotine, perceived immediate benefits including anxiety and stress reduction, improved cognitive performance, and weight control, may initially outweigh perceived potential harms from long-term use.

Consistent with previous studies, black Americans once dependent on cocaine were less likely to remit than their white counterparts. Psychosocial factors that commonly affect black populations, including discrimination and lower levels of social capital, have been recognised as barriers to remission and triggers to use or relapse; genetic factors may also contribute.

Men were less likely than women to remit from dependence, perhaps because substance use is more damaging (physically, mentally and socially) for women, heightening motivation to stop using. Feelings of guilt and concerns about substance use during pregnancy and child-rearing may also play a particular part in prompting remission among women.

Individuals who met criteria for a personality disorder were less likely to remit from alcohol or cannabis dependence. This may be because characteristics of these disorders such as being impulsive, intolerant to stress, anxious, and craving new experiences, also predispose to substance use, and these characteristics tend to persist.

Among the limitations of the study were that it omitted institutionalised individuals including prisoners. People whose substance use led to their early death would also have been missed, as may some with severe but non-fatal consequences. These omissions may have caused an overestimation of the probability of remission across the entire population. The study also had no information on the number and duration of remission episodes over an individual’s lifetime; it could only relate other factors to the latest of these remissions.


 COMMENTARY The good news from this analysis is that, in the US context, rather than continued dependence, remission is the norm. Most people overcome or grow out of their dependence on the drugs analysed by the study – for cocaine and cannabis, after just five or six years, and for alcohol, after 14, and over their lives people continue to remit until nearly all are no longer dependent. But at least in respect of drinking, there are a set of multiply problematic drinkers who despite treatment, take many more years to stop being dependent. The findings on black versus white Americans suggest that remission rates depend on socioeconomic factors; sampled at another period in the USA’s economic cycles or in respect of drugs used predominantly by more or less advantaged sections of the population, remission rates too might differ, and look more or less like the chronic disease model.

The data presented in the featured article did not show whether the user ‘in remission’ had simply become dependent on another drug. Within the set of illegal drugs and medicines, this seemed uncommon, because the total remission rate was so high. But it seems more than possible that some who matured out of illegal drug use instead took up heavy drinking, in social and legal terms, a dependence easier to live with as an adult.

Remission rates looking forward

An acknowledged weakness of the featured report is that it asked respondents to recall changes which may have happened many years ago. However, the survey was repeated about three years later when 87% of the people who still qualified for the survey were re-interviewed. The follow-up offered an opportunity to see how many dependent at the time of the first survey had recovered three years later. These analyses seem only to have been done for drinking, for which they confirm that most people cease to be dependent though most too continue to experience drink-related problems and to sometimes drink heavily, and remain vulnerable to relapse. This average impression results from the pooling of dramatically different trajectories, from older multiply problematic alcoholics who usually do not remit despite treatment, to youngsters who generally quickly remit without formal help. Details below.

Among the re-interviewed sample were 1172 of the 1484 people who had been dependent on alcohol in the year before the first interview three years before. Nearly two thirds were longer dependent in the year before the follow-up interview. So complete was their recovery that a fifth of those previously dependent had in the past year experienced no indications of abuse or dependence; of these, three quarters were still drinking. About 11% not only had no symptoms, but were exclusively drinking within low-risk guidelines, evenly split between those drinking moderately and those not drinking at all.

But this broad-brush picture hid substantial variation in the fates of different types of dependent drinkers. At one extreme were the most severely affected drinkers with multiple psychological problems and on average about nine years of dependence behind them, two thirds of whom were still dependent at the second interview. At the other were young adults and older drinkers with few complicating psychological disorders and few years of dependent drinking. For most of these the dip in to dependence was a phase which (at least for time being) was over by the the second interview, when just under 30% were still dependent.

At least for the three years between the surveys, remission was very stable. Among the re-interviewed sample were 1772 of the 2109 who three years before had been in “full remission” from past dependence on alcohol, meaning that even though they may sometimes have drunk above low-risk guidelines, for the past 12 months they had reported no symptoms of alcohol abuse or dependence. Of these just 5% had slipped back to being dependent in the year before the second interview, though a third who had been drinking above low-risk guidelines had re-experienced some symptoms of alcohol abuse or dependence. Most stable in their recovery were the abstainers, of whom just 1 in 50 experienced such symptoms. The much greater stability of recovery in abstainers and low-risk drinkers was confirmed when other factors had been taken in to account, but was not apparent among the younger adults in the sample.

Treatment’s impact

Few dependent drug users recover through treatment and fewer still dependent on alcohol – in theNESARC survey on which the featured analysis was based, of those no longer dependent on alcohol,just 24% had at any time been in any kind of treatment for their drinking problems. Over two thirds of those who achieved more complete forms of recovery also did so without treatment.

While this shows that in the USA, treatment is generally not needed to recover from substance dependence, treatment may still make recovery more likely. In respect of dependence on alcohol, one analysis of data from the NESARC survey was consistent with formal treatment promoting recovery characterised by abstinence or low-risk drinking and no symptoms of abuse or dependence, but another and perhaps more reliable analysis found no such association.

Both however found that when treatment had been accompanied by attendance at 12-step mutual aid groups, recovery was more likely – especially abstinent recovery. These analyses could not however disentangle the possible effects of the motivation and conditions which drive someone to seek help, from the effect of actually receiving that help. Complicating the picture is the fact in this survey, the most severely affected and multiply comorbid drinkers with many years of dependence behind them were far more likely to seek treatment than less severely affected types of dependent drinkers. Despite seeking help, they were by a large margin the ones most likely to still be dependent when the survey was repeated three years later.

What about heroin and other opiates?

A notable omission from the illicit drugs included in the featured report was heroin and other opiates. Fortunately these were the subject of the greatest number of relevant studies in another review of follow-up studies of remission from dependence on amphetamine, cannabis, cocaine or opiate-type drugs. It included only studies of general populations or people who entered treatment in the normal way rather than enrolling in treatment trials.

Across the ten studies relevant to opiate-type drugs, every year on average between 22% and 9% of people were either abstinent or no longer dependent; the higher figure is the average of the proportions remitted among people who could be followed up, while the lower estimate includes cases who could not be followed and assumes they are still dependent. Generally the subjects were patients in treatment. Based mainly on patients in treatment, corresponding figures for cocaine were between 14% and 5%. The single study (from the USA) of a general population sample of cocaine-dependent people found that 39% had remitted four years after initially surveyed. For cannabis, the estimate was 17% per annum based on general population surveys and assuming people not followed up were still dependent.

In accordance with the featured article, such figures imply that within 10 years most dependent users of these drugs will no longer be dependent and may have entirely ceased use.

Racial differences reflect socioeconomic status

An analysis of data from the NESARC survey showed that taking alcohol and other drugs together, the longer dependence careers of black versus white Americans was associated with their having less social and socioeconomic resources, signified by fewer being married and fewer having completed their schooling. Once these were taken in to account, racial differences were no longer significant. The implication is that it is not race as such which makes the difference, but the position black people tend to occupy in US society. Given the same disadvantages, white Americans has dependence careers just as extended as black Americans.

Diagnostic system affects remission rate

Much in this analysis depends on the definitions used in the survey. Specifically, the probability of remission equates to the probability that someone will for at least the past 12 months have dropped below experiencing three or more dependence symptoms together in respect of the same drug. From the same survey, it is known for alcohol that many will still be consuming heavily, experiencing symptoms of dependence such as withdrawal and compulsive use, and suffering poor physical and mental health (1 2). They may be remitted from their dependence, but not according to most understandings, ‘recovered’.

Had the line been drawn elsewhere, the chances of remission might have been substantially lower – for example, as commonly in NESARC reports on drinking (1 2 3 4), if remission had been defined as non-problem moderate use or abstinence.

The latest version of the DSM manual (DSM-5) softens this binary system by diagnosing a substance use disorder when at least two symptoms are present in the same 12 months, and rating this as moderate if there were two or three, severe if four or more. ‘Abuse’ and ‘dependence’ are now subsumed within this continuum. The change seems likely to bring many more less severely affected people under the same substance use disorder umbrella as the three-symptom population investigated by the featured analysis. Their remission rates too may differ.

It is also theoretically possible that ‘remission’ may partly reflect the lack of noticeable change or struggle as with the years dependence becomes more deeply embedded and dominant in one’s life, and the change processes probed by some diagnostic questions cease to be live issues – not a sign of recovery, but of the lack such a prospect and the narrowing of life to substance use. For example, having plateaued in their use levels, long-term dependent users may no longer (or not for the past 12 months) have found themselves needing to take more of the drug to feel the desired effects, or taking more than they intended. Perhaps too in the past they had tried unsuccessfully to stop using, or had at least persistently wanted to, but now no longer tried or even wanted to. Ensuring a steady supply of drink or drugs they made no attempt to interrupt would minimise experience of withdrawal. They may also have no important interests and activities left to sacrifice to their dependence – all among the symptoms used to diagnose dependence.

Some findings from NESARC are consistent with this possibility. In the three years between the first interview and the re-interview, the alcohol dependence symptoms which fell away most often and most consistently across different types of drinkers were “taking alcohol often in larger amounts or over a longer period than was intended”, “a persistent desire or unsuccessful efforts to cut down or control use”, and withdrawal.

Similarly, young adult dependent drinkers tend not to endorse the dependence symptom relating to inability to stop drinking or cut back, presumably because they have yet to try.

Related analyses

This data from the featured report has been reanalysed to show that for each of these drugs, the probability that someone would have ceased being dependent remained the same no matter how long ago they had first become dependent. For the author this falsified theories which assume that the longer it lasts, the deeper dependence becomes embedded in neural circuits or lifestyles.

The survey on which the featured article was based and other US national surveys were among those included in a synthesisof hundreds of studies of remission and recovery from substance use problems. This too concluded that “Recovery is not an aberration achieved by a small and morally enlightened minority of addicted people. If there is a natural developmental momentum within the course of [these] problems, it is toward remission and recovery”.

Last revised 24 October 2013. First uploaded 19 October 2013

Source:  Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: results from the National Epidemiologic Survey on Alcohol and Related Conditions.

Lopez-Quintero C., Hasin D.S., Pérez de los Cobos J. et al.
Addiction: 2011, 106(3), p. 657–669.

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.’ 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, exposing the hypocrisy of alcohol-drinking adults. The typically calming use of the drug by adults was seen as preferable to the main alternative, alcohol and its associated violence and disorder. 

Those views retain some validity for the vast majority of cannabis users, but this has become, and/or become seen more clearly as, a drug with a problem tail which justifies therapeutic intervention. As heroin use and treatment numbers fall way, cannabis treatment numbers are on the rise – not, according to Public Health England, because more people are using the drug, 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 stronger strains of the drug are creating more problems.

Cannabis accounts for half of all new drug treatment patients

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 27% in 2013, that year amounting to about 27,270 individuals. Among first ever treatment presentations, the increase was more pronounced, from 19% to 49%, meaning that by 2013 their cannabis use had became the main prompt for half the patients who sought treatment for the first time  chart right. 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 that had used cannabis in the past year fell from about 11% to about 7% in 2013/14, having hovered at 6–7% since 2009/10.

The treatment figures largely reflect trends in England, where in 2013/14 the number of patients starting treatment due primarily to their cannabis use had continued to rise to 11,821, 17% of all treatment starters, up from around 7,500 and 9% just seven years before. The greater ‘stickiness’ of opiate use meant that in the total treatment population – new and continuing – the proportionate trends were less steep, cannabis numbers rising from around 11,000 in 2005/06 to 17,229 in 2013/14, and in proportion from 6% to 9%. Among younger adults, cannabis dominates; in 2013/14, far more 18–24s started treatment for cannabis than for opiate use problems – 5,039 versus 3,142 – and they constituted 43% of all treatment starters.

Further down the age range, among under-18s in treatment in England, cannabis is even more dominant. In 2013/14, of the 19,126 young people who received help for alcohol or drug problems, 13,659 or 71% did so mainly in relation to cannabis, continuing the generally upward trend since 2005/06.

Though the crime reduction justification for treating adult heroin and crack users is not so clear among young cannabis users, still immediate impacts plus the longer term benefits of forestalling further problems has been calculated to more than justify the costs of treating under-18 patients, among whom cannabis is the major player.

Cannabis users rarely stay in long-term treatment

Relative to the main legal drugs, at least in the USA dependence on cannabis is more quickly overcome. 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  chart right. 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.

Unlike heroin users, regular users of cannabis have been seen as sufficiently amenable to intervention to warrant trying brief interventions along the lines established for risky but not dependent drinkers, and sufficiently numerous in some countries to make routine screening in general medical and other settings a worthwhile way of identifying problem users. 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.

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. These studies on adults might not translate to adolescents, for whom approaches which address family, school and other factors in the child’s environment are considered most appropriate for what are often multiply troubled youngsters.

The relative persistence of opiate use problems and 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. 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 not having overcome their dependence, 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 29% of opiate users and 38% 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.

These are some of the issues thrown up by a set of patients and a set of interventions rather different from those associated with the drugs treatment in the UK has normally focused on. If current trends continue, understanding the findings of these and other studies will become yet more important to British treatment services.

Source:     03 March 2015

More media stories of addiction being successfully treated would reduce stigma and ease social reintegration and recovery, suggests this innovative study. Reading just one such story made a national US sample more willing to work with former dependent users of illicit heroin or prescription painkillers and accept them into their families. 

SUMMARY Stigma toward people with mental illness and substance use problems is substantial and widespread. Enduring social stigma is linked to discrimination, under-treatment, and poor health and social outcomes, including difficulty finding and maintaining housing and employment. For example, studies have found that a third of the US public think people suffering from untreated major depression are likely to be violent toward others, as did 60% in respect schizophrenia and 65% and 87% in respect alcohol and cocaine dependence. Expectations that stressing a biological basis for mental illness would defuse stigma have not been realised.

Key points 

A nationally representative sample of the US public read short vignettes either neutrally portraying a woman, portraying the same woman as drug dependent or mentally ill, or as having had these disorders but now in remission through treatment.

Then they answered questions which assessed different dimensions of stigma to people with these disorders.

Vignettes of untreated, active heroin addiction or mental illness – but not untreated addiction to pain medication – heightened the desire be socially distant from addicted or mentally ill people.

In contrast, portraying the same person as in remission from addiction did not exacerbate any negative attitudes, and on some measures actually led to more positive attitudes than the neutral depiction.

For the researchers these results suggest that portraying people who have successfully been treated for mental illness or drug addiction may be a promising strategy for improving public attitudes toward these groups.

These findings are largely based on reactions to written vignettes portraying an addicted or mentally ill person. However, many for whom effective treatment has led to symptom control and recovery bear little resemblance to the untreated, symptomatic individuals portrayed in the vignettes. Such portrayals in the media may spread and intensify social stigma toward these groups. In contrast, portrayals of successfully treated patients may elicit more positive attitudes. Research on other stigmatised health conditions such as HIV infection suggests increased public recognition of their being treatable has reduced stigma and discrimination. 

The featured study was the first to examine whether levels of stigma are influenced by portrayals of untreated, symptomatic sufferers versus those who have successfully recovered through treatment. It did so for schizophrenia, major depression, addiction to prescribed painkillers, and heroin addiction, in each case portraying people whose symptoms met US diagnostic criteria. To eliminate the potentially confounding influences of race, gender, and education, each vignette ( samples) portrayed the same, college-educated, white woman – ‘Mary’. This account focuses on reactions to the addiction vignettes.

Selected from a national US panel, the 3,940 (70% of those asked to join the study) respondents were very similar to the overall US population. In 2013 they were randomly allocated to read either a neutral depiction of Mary, one of the depictions of her as actively suffering one of the untreated conditions, or one of her having recovered from a condition through treatment. Participants who had read about one of the addiction conditions were then asked a series of questions which tapped different dimensions of stigma to a “person with a drug addiction”. Participants who had read the mental illness vignettes were asked corresponding questions about a person with mental illness. Half those who had merely read the neutral depiction of Mary were asked the addiction questions, half the mental illness ones. This methodology made it possible to test the impact on stigma-related beliefs and attitudes of attributing untreated or successfully treated addiction or mental illness to Mary.

Sample vignettes

Neutral Mary is a white woman who has completed college. She has experienced the usual ups and downs of life, but managed to get through the challenges she has faced. Mary lives with her family and enjoys spending time outdoors and taking part in various activities in her community. She works at a local store.

Untreated heroin addiction Mary is a white woman who has completed college. A year after college, Mary went to a party and used heroin for the first time. After that, she started using heroin more regularly. At first she only used on weekends when she went to parties, but after a few weeks found that she increasingly felt the desire for more. Mary then began using heroin two or three times a week. She spent all of her savings and borrowed money from friends and family in order to buy more heroin. Each time she tried to cut down, she felt anxious and became sweaty and nauseated for hours on end and also could not sleep. These symptoms lasted until she resumed taking heroin. Her friends complained that she had become unreliable – making plans one day, and cancelling them the next. Her family said she had changed and that they could no longer count on her. She has been living this way for six months.

Treated heroin addiction [As above up to “…Her family said she had changed and that they could no longer count on her.”] She had been living this way for six months At that point, Mary’s family encouraged her to see a doctor. With her doctor’s help, she entered a detox program to address her problem. After completing detox, she started talking with a doctor regularly and began taking appropriate medication. After three months of treatment, she felt good enough to start searching for a job. Since then, Mary has received steady treatment and her symptoms have been under control for the past three years. She lives with her family and enjoys spending time outdoors and taking part in various activities in her community. Mary works at a local store.

The questions participants were asked were: 

• Desirability of social distance: how willing they would be to have a person with addiction or mental illness marry into their family or start working closely with them;
• Perceptions of treatment effectiveness: whether they saw the treatment options for that condition as being effective, and whether with treatment most can get well and return to productive lives;
• Willingness to discriminate: whether they agreed that discrimination against people with mental illness/drug addiction is a serious problem, that employers should be allowed to deny employment to these people, and landlords deny housing;
• Endorsement of supportive policies: whether for or against requiring insurance companies to offer benefits for treatment equivalent to those for other medical services, and whether they would support increased government spending on treatment, housing subsidies, and on programmes that help these groups find jobs and offer on-the-job support.

Main findings

Relative to the neutral depiction, vignettes of untreated, active heroin addiction or mental illness heightened the desire to be socially distant from such people, but this was not the case after reading about untreated addiction to pain medication charts. Other stigma dimensions (perceptions of treatment effectiveness; willingness to discriminate; endorsement of supportive policies) generally were not significantly affected. An exception was that respondents who read the untreated heroin addiction vignette were more willing to endorse discrimination against people with drug addiction.


In contrast, portraying Mary as having overcome her problems through treatment did not exacerbate any negative attitudes, and on some measures actually led to more positive attitudes than the neutral depiction. In particular, portrayals of successfully treated addiction to heroin or prescribed painkillers led fewer respondents to reject the prospect of working with someone with addiction or having them marry in to the family. Again relative to the neutral depiction, vignettes of successful treatment made respondents more likely to believe treatment can effectively control symptoms. However, in general these successful-treatment vignettes did not weaken preparedness to endorse discrimination or bolster enthusiasm for supportive policies.

Given these different and sometimes opposing effects relative to the neutral depiction, not surprisingly, the effects of portraying an untreated, active disorder differed from those of portraying the same disorder successfully treated. After reading the depiction of successful treatment, significantly fewer respondents wanted to maintain social distance ( charts), more believed in the effectiveness of treatment, and fewer were willing to endorse discrimination. However, beliefs that with treatment most sufferers can get well and return to productive lives were unaffected, as generally was endorsement of supportive polices. Of the two addictions, differences between reactions to treated and untreated vignettes were more consistent and larger after portrayal of heroin addiction than after portrayal of addiction to prescribed painkillers.

As other studies have found, even after reading a vignette portraying successful treatment, more people were willing to work with someone with addiction or mental illness than to welcome them in to the family, and respondents desired more social distance from people with drug addiction than from those with mental illness. For example, 34% and 42% of respondents who read the treated schizophrenia and depression vignettes were unwilling to work closely with a person with mental illness. In contrast, for the prescription painkiller and heroin vignettes, the corresponding figures were 70% and 64%.

The authors’ conclusions

As hypothesised, portrayals of untreated, symptomatic mental illness and drug addiction, characterised by abnormal behaviour including deterioration of personal hygiene and failure to fulfil work and family commitments, heightened desire for social distance from people with mental illness or drug addiction. In contrast, adding a paragraph depicting transition to successful treatment improved some attitudes, even relative to a neutral depiction which did not mention these conditions at all.

These results imply that portraying people who have successfully been treated for mental illness or drug addiction may be a promising strategy for improving public attitudes toward these groups. Exposure to a single, one- or two-paragraph vignette, led to significant movements in public attitudes, suggesting in turn that repeated such depictions presented through the news media, popular media, and other sources, are important influences on public attitudes. The implication is that a shift in emphasis away from portrayals of symptomatic, untreated individuals, and toward portrayals of those who have successfully been treated, could reduce public stigma and discrimination toward people with these conditions.

Rather than seeking directly to influence the media, national stigma-reduction campaigns may be a more feasible route to widespread dissemination of portrayals of successful treatment. In addition, expanding access to effective treatments and encouraging treatment entry is likely be a critical way to reduce public stigma and discrimination. Longstanding social stigma has led current and former sufferers to conceal these conditions; even family members sometimes don’t know that a loved one is an exemplar of successful treatment. Driven by stigma, concealment probably also perpetuates stigma by preventing family members, friends, and acquaintances becoming aware of the possibility of successful treatment.

The findings may help explain why emphasising an inherent biological basis for mental illness and addiction does not reduce stigma. Seeing these conditions as inherent flaws (moral or biological) is not, however, cemented into the public psyche. Portrayals of successful treatment lead to improved public attitudes, suggesting many Americans are receptive to the idea that mental illness and drug addiction are treatable conditions.

Despite other positive changes, the vignettes portraying successful treatment did not increase support for public policies which benefit people with mental illness and drug addiction. Support for increased government spending is in the USA strongly related to political ideology and party identification, affiliations which may have overpowered the influence of portrayals of successful treatment. It is also possible that the vignettes led respondents to believe that supportive policies are not needed.

The results of this study should be interpreted in the context of several limitations. Among these are that exposure to a single, one- or two-paragraph vignette portraying a person with mental illness or drug addiction is not how the public typically experience these conditions, either personally or through the media. Personal experience probably elicits a stronger emotional response, and rather than a single vignette, the news media exposes Americans to multiple, competing portrayals. The effects of the vignettes were assessed immediately after exposure; it is unclear whether these effects persisted. Results may have been different if the portrayed individual had different demographic characteristics.

Source:  Portraying mental illness and drug addiction as treatable health conditions: Effects of a randomized experiment on stigma and discrimination.

McGinty E.E., Goldman H.H., Pescosolido B. et al.
Social Science and Medicine: 2015, 126, p. 73–85.

Though many young people seem to perceive marijuana as harmless, its use may pose serious risk for adverse behaviors and health consequences.

An extensive research review published June 5 in the New England Journal of Medicineconcluded that marijuana use is linked to multiple adverse effects—particularly in youth.

“Despite some contentious discussions regarding the addictiveness of marijuana, the evidence clearly indicates that long-term marijuana use can lead to addiction,” said lead author Nora Volkow, M.D., director of the National Institute on Drug Abuse (NIDA), and three of NIDA’s top officials.

Stanimir G.Stoev/Shutterstock

According to the 2012 National Survey on Drug Use and Health, marijuana is the most commonly used “illicit” drug in the United States, with an estimated 12 percent of people aged 12 or older reporting its use in the prior year. The 2013 Monitoring the Future Survey—supported by NIDA—found that 6.5 percent of 12th graders report daily or near-daily marijuana use, with 60 percent perceiving regular use of marijuana not to be harmful (Psychiatric News, February 6). Volkow and colleagues suggested that as more states move toward policies that legalize cannabis for medical or recreational purposes, rates for marijuana use among teenagers and young adults will increase, as will the negative health consequences associated with its use.

“The regular use of marijuana during adolescence is of particular concern, since use by this age group is associated with an increased likelihood of deleterious consequences,” Volkow and colleagues cautioned.

The review, “Adverse Health Effects of Marijuana Use,” provided science-based reasoning to explain the onset of marijuana addiction and gave an overview of the adverse health consequences associated with marijuana use from data of 77 studies and literature reviews.

From animal studies, the authors concluded that exposure to tetrahydrocannabinol (THC)—the primary psychoactive chemical in cannabis—in early life can recalibrate the dopaminergic system, the reward system of the brain, to become more sensitive to stimulation with drugs. The authors speculated that the findings may help to explain the increased vulnerability to abuse of marijuana and other substances in later life, which have been reported by adults who initiated cannabis use during adolescence.

The review also highlighted studies showing an association between marijuana use and impaired regions of the human brain, including the precuneas, a key node that is involved in alertness and self-conscious awareness, and the hippocampus, which is important in learning and memory. Other adverse consequences of cannabis use included impaired driving, lowered IQ scores into adulthood, and a potential risk to exacerbate psychotic symptoms in those with mental disorders. The review suggested that risks for adverse effects increase when the drug is used along with alcohol.

“Some physicians continue to prescribe marijuana for medicinal purposes despite limited evidence of a benefit,” noted Volkow and colleagues. “Because older studies are based on the effects of marijuana containing lower levels of THC, stronger adverse health effects may occur with the use of today’s more-potent marijuana.”

The authors emphasized that more research must be done on the potential health consequences of second hand marijuana smoke, the long-term impact of prenatal cannabis exposure, and the effects of marijuana legalization policies on public health.

“It is important to alert the public that using marijuana in the teen years brings health, social, and academic risk,” said Volkow. “Physicians in particular can play a role in conveying to families that early marijuana use can interfere with crucial social and developmental milestones and can impair cognitive development.”

Source: June 26, 2014

An ITV documentary will take a look at the impact of drinking alcohol in pregnancy as one in 100 babies are born in Britain each year brain-damaged with Foetal Alcohol Spectrum Disorder (FASD).

These babies will go through life with a range of developmental, social and learning difficulties. A few will have tell-tale facial features which will make it easier to get a diagnosis and access support, but the majority will battle with an invisible disability.

What is FASD?

Foetal Alcohol Spectrum Disorder is a series of preventable birth defects caused entirely by a woman drinking alcohol at any time during her pregnancy, often even before she knows that she is pregnant.

The term ‘spectrum’ is used because each individual with FASD may have some or all of a spectrum of mental and physical challenges. In addition each individual with FASD may have these challenges to a degree or ‘spectrum’ from mild to very severe.

These defects of both the brain and the body exist only because of prenatal exposure to alcohol.

What are the guidelines?

The Government’s current guidelines advise that those who are pregnant or trying to get pregnant should avoid alcohol altogether – but then adds: “If women do choose to drink, to minimise the risk to the baby, we recommend they should not drink more than one to two units once or twice a week and they should not get drunk.”

The Royal College of Obstetricians and Gynaecologists had taken a similar view, although they referred to one or two units a week as a safe amount.

Spokesman Dr Pat O’Brien said: “If nobody drank any alcohol in pregnancy there would be no Foetal Alcohol Syndrome and no Foetal Alcohol Spectrum Disorder. But on the other hand if you look at all of the evidence there appears to be a safe level of alcohol intake in pregnancy.”

However earlier this month they updated their advice, recommending that pregnant women do not drink alcohol during the first three months of pregnancy. The advice does say that drinking small amounts of alcohol after this time does not appear to be harmful for the unborn baby, but that pregnant women should not drink more than one or two units, and then not more than once or twice a week.

Professor Sir Al Aynsley-Green, former Children’s Commissioner for England, said: “Exposure to alcohol before birth is the single most important preventable cause of incurable brain damage. And it’s an issue which affects all of us in society.”

Source: 3rd March 2015

Seeking professional help for addiction is usually overwhelming. In this professional’s opinion, AA and NA (along with your primary care physician) are better starting points, but if you’re going to add a trained clinician, please consider starting with counseling and not therapy.

There’s an important difference between the two. Therapy is about the past and how it continues to affect us today. Counseling is about dealing with today forward. We’re putting the cart before the horse when we consider how and why everything went to hell. It’s infinitely better to concretely plan and be accountable for taking the steps to get out of hell.

You can deal with the past when your ass is no longer on fire.

Go see your doctor and make sure you’re medically safe. Go to a meeting and ask for help. See a counselor if you want additional support but interview them to ensure that they have a thorough understanding of how to treat addiction (your health insurance company will pay virtually any clinician with a masters degree whether they know what they’re doing or not).

How to Pick the Right One:

One of my biggest criticisms of counselors and therapists alike is that a lot of us talk pretty but don’t get down to the nitty gritty of what (specifically) folks need to do in order to change. When you meet with a counselor ask them what their experience is in treating addiction and to what extent they are willing to offer you specific steps toward recovery.

These are the basics that I recommend after a person’s medical well being is assured:

Keep it simple and be willing to make an honest effort. Are you willing to not drink today? Just for today, are you willing to do whatever it takes to not drink? Stop thinking about the rest of your life and focus on not drinking for the next 24 hours. I am totally, unapologetically biased in favor of 12 step programs and so I offer the adage:

Don’t think. Don’t drink. Go to meetings.

If that’s all we do, we’re well on our way.

People often ask me how to not drink. I annoy them by starting with common sense: Get the alcohol out of your home, office, garage, etc. Stay out of bars. Stay away from people you drink with. Do not go to the liquor store. Do not buy alcohol. Then we move on to what they’re really asking, which is what are they supposed to do instead of drinking:

Next step: embrace responsibility and accountability. If you’re doing treatment and a 12 step program you can have at least two folks assisting you with this – your counselor and a temporary sponsor. You don’t need to make huge commitments. You need someone to call and lean on (especially when you crave a drink), guidance for when you’re not sure what to do next, and you need a relapse prevention plan because:

There are few things more dangerous than a person in early recovery with too much time on their hands. AND because the worst possible time to make a plan is when we’re already scared/squirrelly/antsy. There’s a balance to be struck here: We can’t over commit ourselves to the point of going 100 mph but we have to structure our day to incorporate people and meaningful activities that do not include alcohol/drugs.

Personalize Your Plan/Get Specific:

I spoke recently with an active alcoholic who told me he can’t stop drinking screwdrivers (vodka and orange juice). I’m suggesting he brush his teeth once per hour because orange juice and toothpaste are one of the most disgusting combinations I can think of. Put it under the category of “whatever works.”

I note the habits and routines that are part of a person’s life – everything that gets associated with drinking or using. Example: You put on ESPN and crack open a beer. Ok, how about we temporarily ban Sports Center in order to reduce temptation. Instead, let’s change things up and consciously choose what to do instead. Example – put on loud music and drink huge quantities of water (vital in early recovery as your body seeks to right itself).

The same individual was able to share with me how their drinking has had a negative impact on their loved ones. I’m suggesting that conversations with the family are a great starting point. Generally this is poorly received. Folks get concerned about “burdening”, “imposing” or “getting their hopes up.” I ask if this was a concern when they were drinking/using? Whether we tried to hide it or not it’s almost always had some effect. Talk with them. Let them support you and be part of the solution if they’re willing.

Again we’ll deal with the past after the storm has past. Be clear about this and marshal all the support you can. Getting clean/sober is one of the most bad ass things a human being can do and the road to recovery is long and winding. First things first.

Source: 27th Feb. 2015

Putnam County Circuit Court Judge Joeseph K. Reeder and Putnam County Adult Drug Court Probation Officer LaKeisha Barron-Brown applaud the accomplishment/graduation of Stacy Casto Wednesday at the Putnam County Judicial Building in Winfield. Casto was quoted by Judge Reeder as she was being introduced saying, “Judge, I’m gonna graduate and I want my picture in the paper with you.”


Putnam County Drug Court Graduates Lindsey Eddy and Stacy Casto sit relieved and all smiles at their accomplishemnt Wednesday at the Putnam County Judicail Building in Winfield. Bob Wojcieszak/Daily


With a picture of his mug shot on the screen before him, Putnam County Drug Court Graduate Craig Owens goes through the circumstances in his life that forced him to take a long look at where he was going and what made him seek out Putnam County Circuit Judge Joeseph K. Reeder to sign up for drug court and change. Having been arrested twenty one times in his past, Owens used the Putnam County Drug Court to change his life. Behind him is Judge Reeder. Bob Wojcieszak/Daily Mail


Having been involved with drugs since the age of twelve, twenty-year-old Putnam County Drug Court Graduate Lindsey Eddy looks at a composity picture of who she was when she was arrested and what she looks like clean and sober during Putnam County Drug Court Graduation ceremonies Wednesday at the Putnam County Judicial Building.

A drug addict of more than 30 years, Stacy Casto was facing felony drug charges when she was given a second chance in Putnam County’s new adult drug court program.

Putnam Circuit Court Judge Joseph K. Reeder met with the first class of offenders more than a year ago to explain how intensive drug court would be; constant drug testing, home visits, counselling and curfews.

“(Casto) was the first person who spoke up, and when she did, she said ‘Judge, I’m going to graduate and when I do I want my picture in the paper with you,’” Reeder said.

Casto, of Hometown, was among the first five graduates of Putnam County’s adult drug court program. Casto, Lori Hodges, Craig Owens, Lindsey Eddy and Jacob Pauley were honored during a graduation ceremony Wednesday at the Putnam County Courthouse in Winfield.

Family and friends packed a courtroom as Reeder spoke about each graduate’s transformation. Many admitted they believed they would have been dead today if it weren’t for drug court.

Lindsey Eddy, 21, of Hurricane, starting using heroin when she was 12 years old. She had been through the juvenile court system and was most recently arrested for violating her probation order from felony drug charges she received when she was 18 years old.

As of Wednesday, Eddy had been drug-free for 221 days.

“Before, my life was hectic,” Eddy said. “I was always worried about my next high or what I was going to do for my next high. I never really imagined life without drugs. I tried rehabs and regular probation and I failed at that, and until I was entered into the drug court problem, this was the only thing that’s worked for me and it’s helped me out tremendously. I’m responsible now and I have a full time job, and I’ve been sober.”

Putnam adult drug court probation officer Lakeside Barron-Brown said Putnam’s program began in November 2013. She said candidates for the program have had drug-related charges or convictions, and must be willing to work toward a drug-free life.

“Once accepted into our program, they then come into a very intensive, therapeutic setting within our court system,” Barron-Brown said. “They are placed on home confinement, and the judge determines when they should be released.”

Offenders go through three phases, each lasting at least four months. During the first phase, they’re subjected to multiple drug tests and home visits a week. They attend group and individual counselling, put in community service hours and abide by a curfew.

During the second phase, drug court offenders receive help looking for and obtaining a job. In the third phase, Barron-Brown said offenders are given “a little more room” to become stabilized for society.

Barron-Brown said all five graduates had obtained jobs during the program and are still working those jobs to this day.

“We have five graduates here that when they first started, they were apprehensive about not knowing what to expect — the same as when you go into a college class and the professor says ‘Here’s a syllabus, you have a test’ and not knowing what the test is like until you’ve taken the test,” Barron-Brown said. “I think that’s what drug court has been for our clients. It’s a test of seeing how confident they can become and seeing how much self-esteem and self-worth they can gain. Obviously, all of them have shown they can be successful and they can be drug-free.”

West Virginia Supreme Court of Appeals Justice Brent D. Benjamin congratulated the five men and women for turning their lives around. He pointed out that West Virginia’s adult drug court system is celebrating its 10th anniversary this year, and that 1,000 adults and juveniles have successfully completed drug court programs in West Virginia.

“What you’ve done is something a lot of people can’t do or haven’t done,” Benjamin told the graduates during the ceremony. “Thankfully we have a state in which you have an opportunity to do this.

“You’re in control of your lives now, and you weren’t before. And now you have the opportunity that not many people have; to turn around to the next drug court class and help them,” Benjamin said.

Reeder said offenders can get into the drug court by either entering a hybrid or conditional plea that allows for their charges to be lessened or dropped upon successful completion of the program, or by accepting drug court as a sentence in lieu of prison time. He said drug court is a good alternative to prison, but it takes a lot of work and responsibility for those who go through the program.

“I think it’s very important not just for the graduates involved, but it’s also important for Putnam County and our community because drugs have become such a problem in our society,” Reeder said. “It’s good that a program like this does give these folks a chance to rehabilitate and to get back on track.”

Casto said drug court “completely saved my life” because it gave her the ability to get help to fight her addiction ­— something she says prison time wouldn’t have done. Now that she’s sober, Casto said she would like to help juveniles who are battling addiction problems.

“I knew I had to have something in my life in order to change my life,” Casto said. “They offered counseling, they offered classes on drug prevention, they offered all these different things that I knew prison wouldn’t do for me. I’ve been a drug addict for 30 years, but during this time, I’ve started going to church, I’ve given my heart to the Lord and my whole entire life has changed.

Barron-Brown said the graduates will go through six more months of “supervised release” from the drug court program until they are completely finished with the program. She said there are 19 people in Putnam’s adult drug court program, including the graduates.

There are 24 adult drug court programs in West Virginia serving 40 counties, and 16 juvenile drug court programs serving 20 counties with 581 people actively participating in the programs, the Daily Mail reported earlier this month. As part of the Justice Reinvestment Act, which was passed last year, adult drug courts will be in all of West Virginia’s counties by July 1 of next year.

Contact writer Marcus Constantino at 304-348-1796 or Follow him at

Source: 26th Feb. 2015

By Neil McKeganey Posted 8th November 2014 

The UK Advisory Council on the Misuse of Drugs has given the UK’s national methadone programme a bullish seal of approval – it’s not less methadone we need – prescribed to addicts for less time – but more methadone prescribed without time limit. That in a nutshell is the latest recommendation from the ACMD’s Recovery Committee.

To those who have expressed legitimate concern about the UK methadone programme, this report betrays a regrettable reluctance to subject the programme to much needed critical scrutiny. Even within its own report the ACMD acknowledges that 15 per cent of heroin addicts had been prescribed the drug for more at least five years – a finding which once acknowledged is then set aside never to be referred to again.

Within some parts of the UK, methadone is associated with more deaths than the heroin for which it was prescribed as a treatment. An inconvenient fact that does not even get a mention in the report.

Nor does the report give any mention of the finding from research led by one of the UK’s most ardent supporters of methadone (Dr Roy Robertson) who found that addicts prescribed the drug remained drug dependent for decades longer than those who were not prescribed the drug. That finding led those leading the team undertaking this research to conclude that whatever the positive benefits of methadone in reducing drug-related deaths, the drug was inversely related to recovery – in other words those drug users who were prescribed the drug stood less chance of recovering than those who were not prescribed the drug. If ever there was an inconvenient truth for a Recovery Committee looking at the impact of methadone on treating addiction that must surely be it, but this finding does not even get a mention in the report.

The key question in relation to the UK methadone programme is not really about whether addicts should be on the drug for one year or two years, but how to ensure that for however long they are on the drug they are continuing to derive some positive benefit from it.  The case for methadone, including the case for how long it should be prescribed, has to be tied to regular, authoritative and penetrating assessment aimed at answering the question of whether this addict or that addict is continuing to derive benefit from the drug. If they are, then continue to prescribe it to them; but if they are not, then the prescription should cease.

Here of course one runs into the difference between the evidence on the impact of methadone derived from research studies and the evidence of its effectiveness at an individual clinical level. The Council refers to research from the US on the benefits of uninterrupted methadone and the dangers of premature cessation of methadone prescribing. That evidence, however, is a long way from determining the benefit of the drug for individual patients and determining how long individual patients should continue to be prescribed the drug. It also goes without saying that prescribing of methadone in the US is a very different beast to methadone prescribing in the UK. Within the US, drug testing and supportive counselling are integral parts of the methadone programme – within the UK drug testing is a relative rarity, while prescribing methadone in the absence of supportive counselling is  commonplace.

The Council’s report seems to be infused with a belief that individuals should be prescribed methadone for as long as they want it, or for as long as prescribers are happy to prescribe it. The mindset of unlimited methadone prescribing hardly seems congruent with the reality of scarce health resources and economic austerity. Surely we should be undertaking rigorous cost effectiveness assessments of methadone, identifying the length of time over which it remains cost effective to prescribe the drug and ensuring that those analyses contribute to clinical decision-making. The kind of superficial recommendation of limitless prescribing should have no place in a report from the ACMD, which exists to advise ministers on the best available evidence, and to ensure that where the evidence is lacking ministers are charged with the responsibility of ensuring its collection.

Source:   8th November 2014

Michael Botticelli was seated on a tattered purple couch in an old Victorian here, just outside of Boston. Above his head was a photo of Al Pacino as a drug kingpin in “Scarface,” and gathered around was a group of addicts who live together in the house for help and support. On one door hangs a black mailbox labeled “urine,” where residents must drop samples for drug tests. Botticelli is listening to their stories of addiction and then offered this:   “I have my own criminal record,” he said. 

 “Woo-hoo!” one man yelled after Botticelli’s declaration. The crowd burst into applause.  

The nation’s acting drug czar has a substance abuse problem. Botticelli, 56, is an alcoholic who has been sober for a quarter century. He quit drinking after a series of events including a drunken-driving accident, waking up handcuffed to a hospital bed and a financial collapse that left him facing eviction.  Decades later, Botticelli is tasked with spearheading the Obama administration’s drug policy, which is largely predicated around the idea of shifting people with addiction into treatment and support programs and away from the criminal justice system. Botticelli’s life story is the embodiment of the policy choice and one that he credits with saving his own life.

 The approach at the White House Office of National Drug Control Policy has been, Botticelli said, a “very clear pivot to, kind of, really dealing with this as a public health-related issue of looking at prevention and treatment.” He now heads an office that has shifted away from a “war on drugs” footing to expanding treatment to those already addicted and preventing drug use through education.  

Botticelli became the acting director of drug-control policy earlier this year, about a year and a half after he came to Washington to be former drug czar Gil Kerlikowske’s deputy. The White House has not formally nominated him to take over the job permanently. It is a job that has previously been held by law enforcement officials, a military general and physicians. But for now, it is occupied by a recovering addict.

The nation is in the midst of an epidemic of prescription drug and heroin abuse. The number of drug overdose deaths increased by 118 percent nationwide from 1999 to 2011, most of it driven by powerful prescription opioids and a recent shift that many users are making away from prescription drugs to heroin, which can be cheaper and more accessible.  

Drug trends and issues tend to vary geographically, making a sustained national effort difficult. Insurance companies often do not cover inpatient treatment and an obscure federal rule restricts the expansion of addiction treatment under the Affordable Care Act. The White House is also grappling with the legal, financial and political implications of medical and legalized marijuana. Botticelli’s office has taken the administration’s toughest stance against legalization.  

“Part of this is, ‘How do we look at solutions that work for the entirety of the drug issue?’” he asked. “And not just the entirety of the drug issue, but the entirety of the population?” Botticelli is trying to expand on some of the programs he used at the Massachusetts Department of Public Health, where he was director of the state’s bureau of substance abuse services. They include allowing police to carry naloxone — a drug commonly known as Narcan that can reverse a heroin overdose — and helping people who have completed treatment find stable housing and jobs. 

Botticelli spends much of his time on the road, meeting with state and local officials. He visits treatment programs where he is, by all accounts, treated like a rock star by people with substance-abuse issues, a group he calls “my peeps.” While Botticelli easily shares his struggles, those who worked with him said that he doesn’t let it dictate policy. “He was very good at separating his story from the work, which I think allowed him a little more objectivity,” said Kevin Norton, chief executive of Lahey Health Behavioral Services in Massachusetts. 

The bar scene 

Botticelli drank in high school and college, and he once got fired from a bartending job after repeatedly telling the manager he couldn’t work, only to show up as a patron. In the 1980s he moved to Boston, where he spent most of his time outside of work at the Club Café, a legendary Boston gay bar. Along with a group of regulars, Botticelli would stay well into the next morning, knocking back drinks and ridiculing people who were heading into the gym below the bar for an early workout.  “A lot of the center of gay life, particularly in urban areas, focused on bars,” Botticelli said. “And so that’s where you went to socialize, to meet people.”

In May 1988, Botticelli was drunk when he left a Boston bar and drove west on the Massachusetts Turnpike. What happened next is hazy: He may have been reaching for a cigarette in the console of the car. Botticelli’s car collided with a disabled truck. He remembers being placed on a stretcher and put in an ambulance. Hours later he woke up in the hospital, handcuffed to a bed. A state trooper stood sentry in his room. Botticelli was lucky: His injuries consisted mainly of bumps and bruises. He was taken to the state police barracks, booked and had his license suspended. 

“At some level I knew I had a problem,” Botticelli said. “But at another level, because my license was taken away, I thought that my problems were solved. Because I wasn’t drinking and driving anymore, so how could it really be an issue?”  The case was continued without a finding after Botticelli paid the fines and restitution associated with the case. It is no longer a matter of public record. Botticelli had to ask his brother for the money to make the payments, but his downward spiral continued that summer. He ended a relationship and drank heavily, despite going to a court-ordered course on the dangers of drinking and driving and a 12-step recovery group. 

“I felt that because I wore a suit to work and a lot of the other people in the class came from more blue collar jobs, that somehow I was better and I didn’t have a problem. There was a sense of arrogance about me,” he said. “I finally said, ‘Yes’ ” 

Botticelli’s path to recovery began in, of all places, a bar. He met a man who acknowledged that he was an alcoholic. The two swapped stories and went on a date. The romance didn’t materialize, but they remained friends. Botticelli was soon after served an eviction notice and called his brother, who asked if Botticelli was an alcoholic. Botticelli talks with his hands, one of them often nursing an iced coffee. “I finally said, ‘Yes,’ ” he said. “I remember distinctly thinking to myself, ‘If I say I’m an alcoholic, there’s no going back.’” 

Botticelli’s friend took him to a 12-step meeting in downtown Boston. The following night Botticelli stepped into the Church of the Covenant in Boston, a neo-gothic sanctuary with Tiffany glass windows. In the basement there was a 12-step recovery program for gays and lesbians.   “That’s the first time that I raised my hand and said that my name was Michael, and I was an alcoholic, and that I needed help,” he said. “At that point people kind of rally around you.”

Botticelli stuck close to that group, attending meeting after meeting and avoiding his old haunts, going so far as to cross the street when walking past the Club Café. He said he learned something then that has guided him since: Identify with people who have a problem, but don’t compare yourself. 

Botticelli had worked in higher education since finishing graduate school but pivoted toward a career in public health. He started working on AIDS issues and then turned toward helping others with addiction issues. He eventually felt comfortable going to bars and not drinking. He met his husband, David Wells, at one in 1995. They got married in 2009.

The power of recovery 

One of Botticelli’s recent trips took him back to Boston earlier this month. Soon after arriving, he was smoking a cigarette outside a Starbucks when a woman had a question: Why are there burly agents standing around? (He gets a protective detail). They chatted; she told Botticelli she was addicted to prescription painkillers, progressed to heroin and became homeless. She began recovery months earlier and started working at Starbucks the week before.

“And that was like ‘Oh my God, our work is done here,’ ” Botticelli said in the back of a black SUV that weaved through the streets of Boston. “Anything else was going to pale in comparison to just listening to people’s stories.”

Botticelli’s day was packed with meetings on what he called his home turf. There was a roundtable with more than a dozen doctors, nurses, law enforcement agents, elected officials and others. He met with Boston Mayor Marty Walsh, who is also an alcoholic. Botticelli had sandwiches with law enforcement agents who spoke about the massive spike in heroin addiction. Here in Lynn, a city of 91,000 people, there were 188 opiate overdoses and 18 deaths in 2013; as of July 31 there were 163 overdoses and 20 deaths.  

Botticelli hugged and shook hands people at the home here, and spoke to the men about the struggles of addiction and finding what he called a bridge job — something that you do while getting better to make money and get back into the workforce. “Don’t be ashamed to work at Dunkin’ Donuts,” one of the men, Pat Falzarano, said.  Botticelli nodded. Hours later, Botticelli stood outside of the church where his recovery started and marveled at how he got from there to the White House. 

“When I first came here was, all I wanted to do was not drink and have my problems go away,” he said, choking up. “I’m standing here 25 years later, working at the White House. And if you had asked me 25 years ago when I came to my first meeting here if that was a possibility, I would’ve said you’re crazy. But I think it just demonstrates what the power of recovery is.”

Source:   26th August 2014

A daily dose of powerful anti-HIV medicine helped cut the risk of infection with the AIDS virus by 49 percent in intravenous drug users in a Bangkok study that showed for the first time such a preventive step can work in this high-risk population.

“This is a significant step forward for HIV prevention,” said Dr. Jonathan Mermin, director of the U.S. Centers for Disease Control and Prevention, which helped conduct the clinical trial along with the Thailand Ministry of Health.

The study, published on Wednesday in the journal Lancet, looked at the treatment approach known as pre-exposure prophylaxis, or PrEP, in which HIV treatments are given to uninfected people who are at high-risk for HIV infection.

The drug used in the study was Gilead’s older and relatively cheap generic HIV drug tenofovir. The study was launched in 2005.

Prior studies of this approach showed it cut infection rates by 44 percent in men who have sex with men, by 62 percent in heterosexual men and women and by 75 percent in couples in which one partner is infected with HIV and the other is not. The new results showed that it also protects intravenous drug users.

“We now know that PrEP can work for all populations at increased risk for HIV,” Mermin said in a statement.  Based on the results, the CDC plans to recommend that U.S. doctors who wish to prescribe this treatment for their patients follow the same interim guidelines issued last year to prevent sexual transmission among other high-risk individuals.

Intravenous use of drugs like heroin accounts for about 8 percent of all new HIV infections in the United States and about 10 percent of new HIV infections worldwide. In some regions, such as Eastern Europe and Central Asia, injection drug abuse accounts for about 80 percent of all new infections.

The new findings involved more than 2,400 intravenous drug users in Bangkok who were not infected with the human immunodeficiency virus, which causes AIDS, and were being treated at the city’s drug treatment clinics.  Half took tenofovir and half took a placebo. All participants were given HIV prevention counseling, risk-reduction strategies such as condoms and methadone treatment, and monthly HIV testing.

At the end of the study, there were 17 HIV infections among people taking the HIV medication, compared with 33 infections among those not taking the drugs, the researchers found.  The researchers also looked to see what factors influenced infection rates among those taking the HIV medication. They found that people who took their medication at least 71 percent of the time had a 74 percent lower risk of becoming infected with HIV.

Although it was not clear how the preventive drug treatment worked – by stopping infections caused by sharing dirty needles or by unprotected sex among drug users – the study produced a reduction in infection rates, said Dr. Salim Abdook Karim of the University of KwaZulu-Natal in Durban, South Africa and of Columbia University in New York.

“The introduction of PrEP for HIV prevention in injecting drug users should be considered as an additional component to accompany other proven prevention strategies like needle exchange programs, methadone programs, promotion of safer sex and injecting practices, condoms, and HIV counseling and testing,” Karim, who was not involved in the study, wrote in a commentary accompanying the study in the Lancet.

“PrEP as part of combination prevention in injecting drug users could make a useful contribution to the quest for an AIDS-free generation,” Karim added.
Source:   13th June 2013

Ask Dr. K: Some who use drugs ‘almost addicted’ 

Q) I think I may have a drug problem. But how can I tell if I’m truly addicted?

A) The world is not divided neatly into those who are “addicts” and those who are not. More and more, doctors are viewing substance use as a spectrum.

Imagine that spectrum as a straight, horizontal line. At the left end are people who do not use potentially addicting substances.

Just in from the left end is a group that uses a potentially addicting substance regularly but only in small amounts — and never feels pressure to use that substance.

At the extreme right end are people who need to use a potentially addicting substance every day, and do. They do whatever it takes to get that substance. They are addicted to it, and they:

– Need ever-increasing amounts of the drug in order to get high.

– Experience unpleasant physical and emotional symptoms when the drug is leaving the body.

– Use more of a drug or use it for a longer period of time than intended.

– Are unable to stop using the drug, having repeated, failed attempts to stop or cut down.

– Spend a lot of time obtaining, thinking about or using the drug.

Just in from the right end are those with substance abuse. This is milder than addiction; it describes those who have experienced significant impairment or distress because of their need to use a potentially addicting substance. One or more of the following is also true:

– They are failing to fulfill major obligations at home, school or work.

– They have repeatedly used substances when doing so may be physically dangerous.

– They have recurrent legal problems as a result of substance use.

– They just can’t stop using the substance despite the problems it is causing them.

There’s also the “almost addicted.” They’re to the right of those who regularly use addicting substances without a problem. And they’re to the left of those with substance abuse. For the almost addicted, substance use:

– Falls outside normal behavior, but is short of meeting the criteria for addiction or abuse.

– Causes problems for the person using drugs or for loved ones or other bystanders.

If you think you might have a problem, one place to start is with your doctor. He or she can help you find the resources you need to help you quit.

Source: ERIE TIMES-NEWS, –  NOVEMBER 06. 2012

Filed under: Treatment and Addiction :

Dr. Robert DuPont, President, Institute for Behavior and Health   |   March 28, 2014

In a recent National Public Radio interview, Dr. Lance Dodes, co-author of a new book that attacks the efficacy of Alcoholics Anonymous (AA) and the many 12-step groups it has inspired, declared that AA — which he repeatedly misidentified as a “treatment” — probably has “the worst success rate in all of medicine,” and is “harmful” to those who do not do well within its program.

He told NPR that AA’s success rate was “between 5 and 10 percent,” and that AA harms people because “everyone believes that AA is the right treatment. AA is never wrong … If you fail in AA, it’s you that’s failed,” he said.

Moreover, Dodes criticized AA and Narcotics Anonymous’ (NA) “tally” system, which recognizes incremental periods of continued sobriety by awarding chips. “The dark side is, if you have a beer after six months of sobriety, you’re back to zero in AA,” Dodes said. “That makes no sense. It’s unscientific. It’s simply crazy. If you have only a beer in six months, you’re doing beautifully.”

I couldn’t disagree more. His message is not only inaccurate and distorted, but also dangerous. No one should be discouraged from participating in these fellowships. They save lives every day.

When people ask me the percentage of success of AA and NA, the 12-step fellowships, I say it is 100 percent — for those who follow the programs as they’re intended to be followed. This means not just going to an occasional meeting, but to many meetings every week, having a sponsor — who is similar to a sober companion — “working” each of the 12 steps in depth, specifically as they apply to the recovering addict, and making recovery the No. 1 priority.  This group of related fellowships is a modern miracle. There are many reasons to be proud of America, but none is more personally important to me — or more unique — than the founding of Alcoholics Anonymous in 1935 in Akron, Ohio.

AA is not “treatment,” and it cannot be meaningfully compared to any treatment. When can anyone find a treatment program located in virtually every part of the world? A treatment program where someone calls you daily? A treatment program where you can call someone at 3 a.m.? And a “treatment” that not only is free to the suffering addict and alcoholic, but that requires no insurance, government funding or a license, and is not subject to any regulation?

No one makes money from it. Rich folks cannot even give money to it, because it needs none, other than the few dollars for administrative costs that its members donate during the meetings themselves. No one writes books about it. The groups actually seek no publicity; in fact, publicity goes against its principles. The word “anonymous” is part of its name for a reason; members respect the anonymity of those who participate, as well as their personal stories.

Moreover, unlike what Dodes apparently believes, no one judges you if you relapse. No one makes you feel as if you’ve failed. Rather, you receive unconditional support. I know of no other programs like these. They are not treatment, nor are they religion. The only requirement is a desire to stop drinking and using drugs.

But to say, as Dodes seems to be suggesting, that AA merely is a supportive social organization completely misses what this miracle is: AA and NA are well-established, sophisticated and effective paths to “recovery,” a term adopted by these fellowships to make clear that AA does not offer to help members get back to their “premorbid” state, but rather to reach an entirely new and better state of living. Its members are not “reformed,” which has a negative connotation, but “recovering,” which is — and must be — a lifelong process.

Those in recovery serve as an inspiration, not only to drug addicts and alcoholics, but to everyone they encounter — a striking and remarkable contrast to the response they would receive if they were still using alcohol and drugs.

The bright line drawn by AA and NA — the sobriety date that marks the last time a recovering addict used alcohol or other drugs — is essential. It differs radically from the academic and professional standard for drug and alcohol addiction , which tolerates slips and relapses. The bright line of the sobriety date is a matter of importance and of huge pride for fellowship members — it is a core marker of identity in the fellowships, and a fundamental defining part of the disease of addiction. One of the true joys of this fellowship is attending a group celebration that commemorates a recovering addict’s “clean time” anniversary.

The all too common academic, professional views on addiction, well represented by Dodes, run counter to the AA and NA goal of sobriety. Many professionals and academics see continued alcohol and drug use as OK but “problem-generating use” as not quite as acceptable. They encourage controlled, responsible alcohol and drug use. They encourage cutting down, but not stopping. They view drug and alcohol use by addicts as a lifestyle alternative that, like sexual orientation, should not be “stigmatized.”

That is a reckless view. An addict who has one beer after six months of sobriety is not doing “beautifully.” Instead, he or she is courting catastrophe, and likely to easily fall back into active addiction. An addict cannot just have one beer, or one cigarette, or one pill. True lifelong recovery does not happen that way, and anyone who believes that it does is heading for a major relapse.

There are endless examples of skeptics like Dodes who seek alternatives to AA, or approaches that attack AA. I suggest to my patients who reject AA that they find one of these alternatives, and see what they think of it. They tell me that such programs are hard to find. I ask them, “Why do you think that is the case? Doesn’t that tell you something?” When they go to these alternative meetings and hear little beyond AA-bashing, I ask them, “How will this help keep you sober?”

AA and NA do not replace treatment; they enhance it. I see this daily in my own practice. Some addicts do get well without AA or NA, but far more of them fail. I encourage my patients to join the fellowships, and I rejoice with them when they do, confident that they have a better chance at lifelong recovery.

When patients tell me they have attended AA or NA meetings but they haven’t helped, it doesn’t take long to discover that their attendance was brief. I urge them to find a sponsor and speak to their sponsor daily. I tell them to work the steps with a life-or-death intensity, and to do what is known as “90/90” — attend 90 meetings in 90 days. Those who follow these suggestions almost always end up with a new outlook on life and the potential for long-term sobriety. [Most Alcoholics in ‘Serious Denial’ About Treatment ]

Clinicians like me all have come to believe that these fellowships are a blessing — not just for our patients, but for all of us.

The wisdom of the 12-step fellowships does not come simply from Bill Wilson or Bob Smith, AA’s founders. It is wisdom distilled from the experiences of millions of suffering addicts and alcoholics. That source makes it utterly different from the academic studies of addiction. With the 12 steps, what works sticks, and what doesn’t disappears. The leaders don’t abandon the latter; the entire community does.

The 12-step approach is ever-changing and growing. It also is endlessly diverse, fitting in with every culture and subculture in the world. It is adaptable and sensitive to vast diversity. It is unlicensed and uncensored. Anyone can start an AA or NA meeting anywhere he or she chooses. Those groups that meet real needs of real people will thrive and grow.

To be sure, attacking AA probably sells books. Sadly, Dodes’ view of the 12-step fellowships, while misguided and ill-informed, is held by many otherwise sensible and well-informed individuals. I never have understood their skepticism. Think about it. Why have these programs endured so long and become so widespread?

The answer: It works if you work it.

Source:  www. 28th March 2014


This article discusses addiction and formation of the Addiction Memory. Addiction has been described as a brain disorder involving brain structures and neural circuits. Addiction impacts long term associative memory including multiple memory systems. Addiction has pathological associations with learning, memory, attention, reasoning, and impulse control. People with addictions suffer from high levels of early maladaptive schemas. The Addiction Memory (AM) plays a crucial role in relapse occurrence and maintaining the addictive behavior. Healing the addiction memory is imperative in treating addictions. Pharmacological and psychological methods are being used to treat addictions. Among the psychological interventions Cognitive Behavior Therapy, Eye movement desensitization and reprocessing (EMDR) and Schema-Focused Therapy (SFT) can be used to heal the addiction memory.

Drug addiction has become an increased phenomenon in the modern civilization. Addiction habits have impacted individuals, families and the society. Addiction has been regarded as an individual disease as well as a social condition. Addictions cause structural changes in cultural, social, political, and economic system in society (Ajami et al., 2014). Addiction is almost universally held to be characterized by a loss of control over drug-seeking and consuming behavior (Levy, 2014).

Addiction is defined as compulsive drug use despite negative consequences (Hyman, 2005). Addiction is a multifactorial phenomenon (Shaghaghy et al., 2011). McLellan and colleagues (2000) conceptualize addiction as a brain disease. Leshner (1997) views addiction as a chronic, relapsing brain disorder that involves complex interactions between biological and environmental variables. According to Mate (2014) addictions are experience based and it has close links with pain, distress, negative emotions, loss of meaning and often connected with adverse early childhood experiences.  Drug addiction leads to profound disturbances in an individual’s behavior that affect his/her immediate environment, usually resulting in isolation, marginalization, or incarceration (Volkow et al., 2004).

 Addictions and Brain Structures

There are numerous brain structures and neural circuits involved in the addiction process. Several studies using a whole brain analysis approach have demonstrated how sensorimotor brain networks contribute to addiction (Yalachkov et al., 2010). Drug addiction causes important derangements in many areas, including pathways affecting reward and cognition (Fowler et al., 2007). Tomkins & Sellers (2001) specify that multiple neurotransmitter systems may play a key role in the development and expression of drug dependence.

Studies indicate that The ventral striatum, a region implicated in reward, motivation, and craving, and the inferior frontal gyrus and orbitofrontal cortex, regions involved in inhibitory control and goal-directed behavior become affected in addictions (Konova et al., 2013). A central concept in drug abuse research is that increased dopamine (DA) in limbic brain regions is associated with the reinforcing effects of drugs (Di Chiara andImperato, 1988; Koob &Bloom, 1988; Volkow et al., 2004). Pharmacological and behavioral studies have indicated that modulation of locus coeruleus (LC) (which is the largest noradrenergic nucleus in brain, located bilaterally on the floor of the fourth ventricle in the anterior pons) neuronal firing rates contributes to physical aspects of opiate addiction, namely, physical dependence and withdrawal, in several mammalian species, including primates (Redmond and Krystal, 1984; Rasmussen et al.,1990;Nestler, 1992).

Memory and Addiction

Inter connection between human memory process and addiction has been speculated by numerous researchers in the past few decades. Theories of addiction have mainly been developed from neurobiologic evidence and data from studies of learning behavior and memory mechanisms (Cami & Farre, 2003). Wang and colleagues (2003) hypothesized that addiction can be resulted by the abnormal engagement of long term associative memory. Volkow et al. (2003) highlight that multiple memory systems have been proposed in drug addiction, including conditioned-incentive learning (mediated in part by the NAc and the amygdala), habit learning (mediated in part by the caudate and the putamen), and declarative memory (mediated in part by the hippocampus). According to Hyman(2005)addiction represents a pathological usurpation of the neural mechanisms of learning and memory that under normal circumstances serve to shape survival behaviors related to the pursuit of rewards and the cues that predict them.

The Process of Learning and Memory in Addiction

The process of learning and memory in addiction has been proposed to involve strengthening of specific brain circuits when a drug is paired with a context or environment (Klenowski et al., 2014). Addiction has pathological associations with learning, memory, attention, reasoning, and impulse control. Addiction related behaviors arise as a result of maladaptive learning process. Following learning pathways individuals with addictions become sensitive and strongly respond to drug cues (Robinson & Berridge, 2000). Drug use in the addicted individual is controlled by automatized action schemata (Tiffany, 1990).

Robbins and colleagues (2002) point out that pathological subversion of normal brain learning and memory processes in drug addiction. They further emphasize that drug related habits evolve through a cascade of complex associative processes with Pavlovian and instrumental components that may depend on the integration and coordination of output from several somewhat independent neural systems of learning and memory, each contributing to behavioral performance.

Tiffany (1990) concluded that drug urges and drug use result from distinct cognitive processes. Some experts believe that addiction related behaviors can be explained via the Feeling-State Theory. According to the Feeling-State Theory positive feelings and behavior are fixated in the body during an intense experience such as drug ingestion creating the feeling-state (Miller, 2005).

A considerable number of researchers point out that subcortical brain region plays a key role in formation of normal as well as drug related behavioral habits. Chronic drug exposure causes stable changes in the brain at the molecular and cellular levels (Nestler, 2001). Drug abusing habits can change the structure and function of the synaptic connections allowing synaptic plasticity for long periods even for a lifetime. Synaptic plasticity may play key roles in the addiction process (Winder et al., 2002). Kelley (2004) states that the process of drug addiction shares striking commonalities with neural plasticity associated with natural reward learning and memory.

 Addictions and Maladaptive Schemas

Segal (1988) viewed schemas as the residue of past reactions and experience that often effect subsequent perception and appraisals. Bakhshi Bojed and Nikmanesh,   (2013) pointed out that drug users suffer from some early maladaptive schemas which can be the potential for drugs abuse. A study done by Shaghaghy and colleagues (2011) indicated that people with addictions suffer from high levels of early maladaptive schemas and they had a more pessimistic attributional style. Maladaptive schemas and inefficient ways the patient learns to adapt with others often lead to chronic symptoms of anxiety, depression and substance abuse (Kirsch, 2009: Shaghaghy et al., 2011).

 Memory and Craving

Craving is often depicted as the subjective experience; craving tends to be highly situationally specific, readily triggered by stimuli previously associated with drug use. Secondly, craving can persist well beyond the cessation of addicted substance (Tiffany & Conklin, 2000). Volkow and colleagues (2004) point out that drugs trigger a series of adaptations in neuronal circuits involved in saliency/reward, motivation/drive, memory/conditioning, and control/disinhibition, resulting in an enhanced (and long lasting) saliency value for the drug and its associated cues at the expense of decreased sensitivity for salient events of everyday life (including natural reinforces).

 The Addiction Memory

The Addiction Memory (AM) plays a crucial role in relapse occurrence and maintaining the addictive behavior. The drug-associated cues are highly connected with Addiction Memory and it helps to maintain drug seeking craving. Boening (2001) views the personal Addiction Memory as an individual acquired software disturbance in relation to selectively integrating “feedback loops” and “comparator systems” of neuronal information processing. The Addiction Memory becomes part of the personality represented on the molecular level via the neuronal level and the neuropsychological level, especially in the episodic memory (Boening, 2001).

 Working with the Addiction Memory

Böning (2009) discusses the difficulties in treating Addiction Memory since it is embedded above all in the episodic memory, from the molecular carrier level via the neuronal pattern level through to the psychological meaning level, and has thus meanwhile become a component of personality. Therefore healing the Addiction Memory is challenging and time consuming.

According to Leshner (1997) in addictions the most effective treatment approaches include biological, behavioral, and social-context components. Among the pharmaco-therapeutic methods Sittambalam, Vij, and Ferguson (2014) highlight Suboxone as an effective treatment method for heroin addiction and as a viable outpatient therapy option. In addition they recommend individualized treatment plans and counseling for maximum benefits.

Carroll & Onken (2005) argued that Cognitive behavior therapy, contingency management, couples and family therapy, and a variety of other types of behavioral treatment have been shown to be potent interventions for several forms of drug addiction. Kauer & Malenka (2007) suggest that reversing or preventing drug-induced synaptic modifications such as mesolimbic dopamine system is one of the key ways to treat addictions.

Gould (2010) stated that from a psychological and neurological perspective, addiction is a disorder of altered cognition. Restoration of altered cognition would be essential in working with the addiction memory. von der Goltz and colleagues (2009) conjectured   that disruption of drug-related memories may help to prevent relapses. Growing evidence from preclinical and clinical studies concur that specific treatments such as extinction training and cue-exposure therapy are effective (von der Goltz & Kiefer, 2008).

Recent researches suggest that EMDR is a potent therapeutic method to treat addictions. Addiction memory could be considered as a form of an unprocessed memory. Unprocessed memories stored in networks that govern explicit and implicit memories. EMDR helps to process unprocessed memories stored in networks. EMDR involves the transmutation of dysfunctionally stored experiences into an adaptive resolution (Solomon et al., 2008).

EMDR reprocessing sessions promote an associative process that clearly reveals the intricate connections of memories that are triggered by current life experiences (Shapiro, 2014). EMDR may be used to ameliorate the effects of earlier memories that contribute to the dysfunction, potential relapse triggers, and physical cravings. In addition, EMDR is used to incorporate new coping skills and assist in learning more adaptive behaviors (Shapiro et al. 1994).

Wide arrays of experimental studies are supportive of a working memory explanation for the effects of eye movements in EMDR therapy (de Jongh et al., 2013). EMDR therapy is guided by the adaptive information processing (AIP) model (Shapiro, 2014). Levin, Lazrov & van der Kol,k (1999) found increased activation of the anterior cingulated gyrus and of the left frontal lobe after 3 sessions of EMDR treatment. Brain scans have clearly demonstrated pre-post changes after EMDR therapy, including increases in hippocampal volume, which have implications for memory storage (Shapiro, 2012).

As reviewed by Andrade and colleagues (1997) EMDR reduces the vividness of distressing images by disrupting the function of the visuospatial sketchpad (VSSP) of working memory. Cecero& Carroll (2000) considered drug cravings as a form of disturbing thoughts and they used EMDR to reduce cocaine cravings.

Young, Zangwill,   and Behary,   (2002) proposed combination of Schema-Focused Therapy (SFT) and Eye Movement Desensitization and Reprocessing (EMDR) would give effectual results processing dysfunctional memories. According to Young , Klosko & Weishaar (2003) Schema-Focused Therapy is an integrative form of psychotherapy combining cognitive, behavioral, psychodynamic object relations, and existential/humanistic approaches. Schema-Focused Therapy helps to modify individual’s maladaptive thoughts about self and others and process the emotions connected with schemas, teach coping skills and break maladaptive behavioral patterns (Young et al., 2003).


Addiction is a chronic, relapsing brain disorder. Addiction related behaviors are complex and these behaviors are strongly connected with the memory system. Formation Addiction Memory helps to maintain the addictive behavior and drug seeking craving. It becomes a component of personality. Therefore working with addiction memory could be challenging. Reduction in maladaptive schema, restoration of drug related altered cognitions help to combat addictions. Pharmacological and Psychological interventions proved to be effective in working with addiction memory. Among the psychological interventions Cognitive Behavior Therapy (CBT) Eye movement desensitization and Focused Therapy (SFT) seem to be useful in treating addiction memory.

Source:   4th May 2014

Many people who undergo treatment for addiction will relapse and begin using drugs again soon after their therapy ends, but a new study suggests that meditation techniques may help prevent such relapses. In the study, 286 people who had been treated for substance abuse were assigned to receive one of three therapies after their initial treatment: a program that involved only group discussions, a “relapse- prevention” therapy that involved learning to avoid situations where they might be tempted to use drugs, and a mindfulness-based program that involved meditation sessions to improve self-awareness.

Six months later, participants in the both the relapse prevention and mindfulness group had a reduced risk of relapsing to using drugs or heavy drinking compared with participants in the group discussions group.

And after one year, participants in the mindfulness group reported fewer days of drug use, and were at reduced risk of heavy drinking compared with those in the relapse prevention group. This result suggests that the mindfulness-based program may have a more enduring effect, the researchers said. [Mind Games: 7 Reasons You Should Meditate]

The researchers emphasized that mindfulness-based programs are not intended to replace standard programs for preventing drug relapse.

“We need to consider many different approaches to addiction treatment. It’s a tough problem,” said study researcher Sarah Bowen, an assistant professor at the University of Washington’s department of psychiatry and behavioral sciences. Mindfulness therapy is “another possibility for people to explore,” she said.  More research is needed to identify which groups of people benefit most from the approach, Bowen said.

Meditation for addiction About 40 to 60 percent of people who undergo addiction treatment relapse within one year after their treatment ends, the researchers said.

Although 12-step and traditional relapse-prevention programs have value in preventing relapse, “we still have a lot of work to do,” Bowen said. Mindfulness-based relapse prevention, a program developed by Bowen and colleagues, is essentially a “training in awareness,” Bowen said.

In this program, each session is about two hours, with 30 minutes of guided meditation followed by discussions about what people experienced during meditation and how it relates to addiction or relapse, Bowen said. The meditation sessions are intended to bring heightened attention to things that patients usually ignore, such as how it feels to eat a bite of food, or other bodily sensations, as well as thoughts and feelings. The mindfulness program may work to prevent relapse in part because it makes people more aware of what happens when they have cravings.

“If you’re not aware of what’s going on, you don’t have a choice, you just react,” Bowen said.

The program also teaches people how to “be with” or accept uncomfortable feelings, such as cravings, rather than fight them, Bowen said. In this way, people learn skills that they can apply to their everyday lives, and not just situations in which they feel tempted, which is usually the focus of other prevention programs, she said.

Addiction and emotions

Dr. Scott Krakower, assistant unit chief of psychiatry at Zucker Hillside Hospital in Glen Oaks, N.Y., who was not involved in the study, said people with addiction often suffer from other conditions that involve problems regulating emotions, such as depression, anxiety or self-harm. Emotional problems, such as feelings of numbness with depression, can be a reason people turn to drugs, he said.

The mindfulness program helps teach people to “tolerate feelings of emotional distress, so when they feel like they’re going to use [drugs], they don’t,” Krakowe said. Krakower noted that mindfulness meditation programs have already been shown to be useful for depression.

Future studies are needed to examine the effectiveness of the therapy for substance abuse over longer periods, Krakower said. But at the very least, it seems that the program can be helpful for people with emotional dysregulation, which is the majority of the substance abuse population, Krakower said.

Source: JAMA Psychiatry. March 19 2014

On the basis of three innovative US programmes for offenders or doctors with substance use problems, this analysis concludes that many seriously dependent individuals stop using if non-use is enforced through intensive monitoring and swift, certain but not necessarily severe consequences.

Summary Typical US substance use treatment amounts to a few weeks of outpatient counselling. Given that these disorders are characterised by lifelong risk of relapse, it is not surprising that many treatments yield suboptimal outcomes for many patients. Interventions that work:

• last months or years rather than weeks; • carefully monitor use of alcohol or other drugs of abuse; • impose swift, certain, and meaningful consequences for use and non-use of substances.

This article profiles three innovative care management programmes with these characteristics: physician health programmes, and two therapeutic jurisprudence programmes – South Dakota’s 24/7 Sobriety Project and HOPE probation. These actively and intensively manage the environments in which people with substance use disorders make decisions to use or not to use.

Physician health programmes

Physician health programmes offer drug- and alcohol-using physicians the opportunity, motivation, and support to achieve long-term recovery, using all three strategies in the new paradigm: monitoring, treatment, and 12-step programmes. In return, physicians sign contracts, typically for five years, to adhere to the programme, including completing treatment and submitting to frequent random drug testing to ensure abstinence. Each working day physicians phone or log-in to find out if they must report for testing. All are expected to be active in 12-step or similar community support programmes. Substance use or any other evidence of non-compliance typically results in immediate removal from medical practice to arrange extended treatment followed by more intensive monitoring. A chart review study of a single episode of physician health programme care involving 904 physicians showed that only 0.5% of tests on this high risk, substance abusing population were positive for alcohol or other drugs of abuse.

Hawaii Opportunity Probation with Enforcement

The Hawaii Opportunity Probation with Enforcement (HOPE) programme manages convicted offenders, most of whom are identified as likely to violate community supervision requirements. Their most common drug problem is smoked crystal methamphetamine. A judge tells offenders about the rules, including that they are subject to intensive random testing similar to that used by physician health programmes. Violations of probation, including any drug or alcohol use, missed drug tests, or missed appointments, are met with certain, swift but brief imprisonment.

When asked at the start of the programme, only a few HOPE probationers choose treatment to help them meet the abstinence requirement. The remainder are simply monitored unless they violate probation; most are then referred to treatment. About 85% complete the programme (which can last up to six years) without treatment.

In a 12-month period, 61% of HOPE offenders had no positive drug tests and fewer than 5% had four or more. A study compared probationers randomly assigned to HOPE or to standard probation. After a year, HOPE probationers were 55% less likely to be arrested for a new crime, 72% less likely to use drugs, 61% less likely to miss supervisory appointments, 53% less likely to have their probation revoked, and were sentenced to 48% fewer days of prison.

South Dakota’s 24/7 Sobriety project South Dakota’s 24/7 Sobriety programme serves drink-driving offenders, nearly half of whom have three or more drink-driving convictions. Participants must undergo twice-daily alcohol breath tests at a local police station or wear continuous transdermal alcohol monitoring bracelets and are also subject to regular drug urinalyses or must wear drug detection patches. Positive tests result in immediate brief imprisonment and missed appointments in immediate issuance of arrest warrants. Results are impressive: over 90% of all types of tests are negative, for alcohol breath tests, virtually all. Post-programme recidivism among twice-daily tested offenders is considerably lower than among comparison offenders.


A distinctive feature of these three interventions is the strong leverage used to sanction substance use and to reward abstinence: in physician health programmes, removal from practice and ultimately the loss of medical license versus continuing to practice in a prestigious and well paid profession; in HOPE and 24/7 Sobriety, immediate brief imprisonment versus freedom.

Mandatory abstinence in this new paradigm contrasts sharply with programmes which mandate treatment but do not impose meaningful consequences for substance use. The two offender programmes contrast with common approaches where consequences for non-compliance, including substance use, are delayed, uncertain, and, when applied often after many violations, draconian. This new way of managing substance use patients challenges the view that relapse is an essential feature of their disorder, shifts the focus away from finding new biological treatments, and shows that the key to long-term success lies in sustained changes in the environment in which decisions to use and not use are made. If this passively or actively rewards substance use, use is likely to continue, but the drinking and drug use of many – not all – seriously dependent individuals stops if the environment not only prohibits use, but enforces this with intensive monitoring and swift, certain but not necessarily severe consequences.

Source:  March 2014


Objective: To promote wider recognition and further understanding of cannabinoid hyperemesis (CH).

Patients and Methods:

We constructed a case series, the largest to date, of patients diagnosed with CH at our

institution. Inclusion criteria were determined by reviewing all PubMed indexed journals with case reports and case series on CH. The institution’s electronic medical record was searched from January 1, 2005, through June 15, 2010.

Patients were included if there was a history of recurrent vomiting with no other explanation for symptoms and if cannabis use preceded symptom onset. Of 1571 patients identified, 98 patients (6%) met inclusion criteria.


All 98 patients were younger than 50 years of age. Among the 37 patients in whom duration of cannabis use was available, most (25 [68%]) reported using cannabis for more than 2 years before symptom onset, and 71 of 75 patients (95%) in whom frequency of use was available used cannabis more than once weekly. Eighty-four patients (86%) reported abdominal pain.

The effect of hot water bathing was documented in 57 patients (58%), and 52 (91%)

of these patients reported relief of symptoms with hot showers or baths. Follow-up was available in only 10 patients (10%). Of those 10, 7 (70%) stopped using cannabis and 6 of these 7 (86%) noted complete resolution of theirsymptoms.


Cannabinoid hyperemesis should be considered in younger patients with long-term cannabis use and recurrent nausea, vomiting, and abdominal pain. On the basis of our findings in this large series of patients, we propose major and supportive criteria for the diagnosis of CH.


Source:   Feb 2012: 87(2)

As in Australia, an alcohol harm reduction curriculum adapted for secondary schools in Northern Ireland curbed the growth in alcohol-related problems and also meant pupils drank less. Results suggest this approach might offer a more fruitful focus for education about commonly used substances than simply promoting non-use.


Alcohol harm reduction approaches aim to decrease the harmful consequences of drinking without requiring abstinence. School-based substance use education programmes in the United Kingdom have mainly tried to delay the onset of use, though more recent programmes have included harm reduction components. Advantages of harm reduction approaches for adolescent pupils may include not stigmatising younger drinkers, not presenting drinking as a moral issue, and being able to tailor education to the specific risk factors of the particular pupil population. Such approaches seem most relevant at the ages when young people are first drinking unsupervised by adults and experiencing intoxication.

Developed and first evaluated in Australia, the School Health and Alcohol Harm Reduction Project (SHAHRP) is an example of harm reduction education, featuring skills training, information and activities designed to encourage behavioural change which reduces harms experienced as a result of drinking. Just such an effect was found in the original evaluation, in which the number of harms experienced by pupils in SHAHRP schools was substantially and significantly less than among pupils in schools not running the lessons, and remained so at the last follow-up 17 months after lessons had ended.

Given the prevalence of underage drinking in Northern Ireland and the associated problems, it was decided to adapt SHAHRP for Northern Irish secondary (or ‘high’) schools. As in the original study, the adapted version was delivered over two school years in two phases. The six lessons of phase one took place when pupils were in year 10 (age 13–14), and the four in phase two the following school year. A pilot study had found pupils and teachers felt the programme was easy to deliver, project materials helpful and easy to follow, and activities and discussions relevant and appropriate.

Having established its feasibility, to test the programme’s effectiveness a new study starting in 2005 recruited 29 secondary schools in the Belfast area. Nine carried on with the normal alcohol education curriculum (the control schools), the remainder also implemented SHAHRP. In eight SHAHRP schools it was delivered by the schools’ own teachers after being trained, in 12 by local voluntary-sector drug and alcohol educators. Rather than being assigned at random, schools were assigned to the three alcohol education options so that they would be comparable in terms of gender, socio-economic profile and location.

2349 pupils were surveyed at the start of the study; about 60% were girls, 17% had not drunk alcohol, and around half had already drunk without adult supervision. Surveys were repeated the following two years after the first and second phases of SHAHRP, and finally in March 2008 when lessons had ended at least 11 months before, at which time 2048 of the 2349 pupils (who now averaged 16½ year of age) could be re-surveyed. Though surveys were anonymous and confidential, identifiers could be used to track changes in each individual pupil across the three years.

Main findings

Generally the trends in how pupils drank and the harms they experienced were most favourable when SHAHRP lessons had been delivered by external specialists, next most favourable when they had delivered by the schools’ own teachers, and least favourable when SHAHRP had not been implemented at all. Selected more detailed findings below.

Each survey asked pupils who had drunk at some time during the study about any resulting harms over the past year, such as drinking more than they had planned, being sick after drinking, having hangover symptoms, being unable to remember what had happened while drunk, becoming verbally and/or physically abusive, and trouble with parents or police. Pupils divided in to four characteristic trajectories over the years of the study. Compared to those in control schools, pupils offered the SHAHRP lessons were more likely to have experienced virtually no harms during the study or a relatively low and stable level, rather than increasing and high levels of harm. When SHAHRP lessons had been delivered by external specialists, pupils were more likely to have experienced virtually no harms than when delivered by the schools’ own teachers. However, both types of SHAHRP delivery significantly improved on usual lessons only.

The drinkers among the pupils were also asked how much they had drunk last time. On this measure pupils again divided in to four characteristic trajectories. Compared to those in control schools, at each follow-up pupils offered the SHAHRP lessons were more likely say they had drunk very little than to have reported increasing and by the end of the study relatively high levels of drinking. When the lessons had been delivered by external specialists, pupils were more likely to consistently have drunk relatively little than when delivered by the schools’ own teachers.

Each survey also included questions about the harms pupils had experienced over the past year arising from someone else’s drinking, such as verbal or physical abuse, sexual harassment, or damage to personal property. Compared to those in control schools, pupils offered the SHAHRP lessons were least likely to have experienced a steep rise in such harms ending in relatively high levels. Whether SHAHRP lessons had been delivered by external specialists or the schools’ own teachers did not significantly affect the trends.

Pupils offered SHAHRP lessons were more likely than those in control schools to have become more knowledgeable about alcohol over the study and to end with relatively high levels of knowledge, more so when the lessons had been delivered by external specialists. However, both SHAHRP delivery options significantly improved on usual lessons only. Results were similar in respect of developing safer attitudes to drinking.

The authors’ conclusions A research review associated with guidance on alcohol education from the National Institute for Health and Clinical Excellence remarked that the Australian SHAHRP evaluation offered evidence that programmes focusing on harm reduction through skills-based activities can produce medium to long term reductions in alcohol use and in particular, risky drinking behaviours. However, the review queried the transferability of these programmes and their results to the UK. The featured study shows that in the UK too, classroom-based harm reduction education can have a significant impact on the harm adolescents experienced from

drinking. The research also suggests these lessons need to incorporate interactive learning, start just prior to and during the times when pupils first try drinking, be culturally sensitive, and provide realistic scenarios and deal with realistic issues.

Compared to control schools, pupils in SHAHRP schools were significantly more likely to be among groups characterised by better growth in knowledge about alcohol and its effects, safer alcohol-related attitudes, fewer harms from one’ own and other’s drinking, and less alcohol consumption. These differences were maintained over the 11 months after lessons had ended, though in some cases with diminished strength. External facilitation of the lessons was associated with the best outcomes, particularly with respect to knowledge and attitudes, harms from one’ own drinking, and alcohol consumption.

SHAHRP offers abstainers, novice drinkers and more experienced drinkers alike the opportunity to reflect on use, harm and personal safety, including the importance of trusted friends, basic first aid techniques, group transport home, mobile phone availability, not to make decisions while drunk, identify friends becoming drunk, drink-spiking, mixing substances, and arguments and aggressive behaviour. The results show that young people are capable of processing such messages developed and presented within the reality of their drinking experiences. SHAHRP addresses harms without causing any increase in drinking (in fact, the reverse) or decreasing rates of abstinence.

It was unfortunate that two of the schools allocated to the control group withdrew from the study, partially upsetting the attempt to ensure comparability of the schools operating the three alcohol education options. However, differences were adjusted for statistically. Also, no systematic record was kept on the alcohol education delivered to control subjects. In Northern Ireland this typically is embedded in the curriculum as part of science or citizenship lessons, so would be identical to that received by intervention students.

Together with the original Australian evaluation, this UK study represents fairly strong evidence that if it focuses on this task, a school curriculum can reduce drink-related problems. In Australia harm-reduction effects were greatest among the higher risk pupils who had already drunk without adult supervision; at each follow-up point they experienced about 20% fewer harms than control pupils.

In that study too, though still very much in the minority, by the last follow up there were a third more abstainers among SHAHRP than control pupils. By the end of the featured study about 6% of control pupils had never drank alcohol compared to 6% of SHAHRP pupils taught by external staff and 3.5% taught by their teachers. These findings offer little support to concerns that safer drinking lessons will encourage more pupils to drink.

In the featured study it seems SHAHRP lessons were additional to usual alcohol education, meaning that impacts might have been due to simply having more time devoted to this topic rather than or as well as the content. In Australia SHAHRP replaced usual alcohol education, thought there too it occupied two years rather than one and occupied more classroom time overall.

In the more restrictive youth drinking environment of the USA, a programme forefronting alcohol problem reduction among its aims has produced similar findings to that in Australia. It retarded growth in alcohol problems (such as getting drunk or sick or complaints from parents and friends), but only among pupils who had already drunk without adult supervision,

and only if the lessons did not occur too early to coincide with the development of this drinking pattern. After disappointing initial results, another US substance use education programme including alcohol adopted harm reduction objectives. The revised programme resulted in a significant reduction in risky or harmful drinking. Parallel and consistent findings in different countries with different curricula suggests that harm reduction education on drinking has a real and transferable impact in Western drinking cultures. Such findings contrast with unconvincing evidence from trials of substance use education in general and alcohol education in particular. For the UK the most important guidance on alcohol education was issued in 2007 by the National Institute for Health and Clinical Excellence. It said this “should aim to encourage children not to drink, delay the age at which young people start drinking and reduce the harm it can cause among those who do drink”. Recommendations included ensuring alcohol education is an integral part of the science and PSHE curricula. The committee stressed that education should be adapted to its cultural context, in particular that in the UK “alcohol use is considered normal for a large proportion of the population [and] a ‘harm reduction’ approach is favoured for young people”. Inspections in 2012 of PSHE lessons suggest English schools are far from adequately implementing NICE’s recommendations, in particular in respect of education aimed at reducing alcohol-related harm. In just under half the inspected schools had pupils learnt how to keep themselves safe in a variety of situations, and the deficits were particularly noticeable in respect of drinking. Inspectors found that although pupils understood the dangers to health of tobacco and illegal drugs, they were far less aware of the physical and social damage associated with risky drinking. Some did not know the strength of different alcoholic drinks or make the links between excessive drinking and issues such as heart and liver disease and personal safety. The report attributed these deficiencies in part to inadequacies in subject-specific training and support for PSHE teachers, particularly in teaching sensitive and controversial topics.

Last revised 18 June 2013. First uploaded 12 June 2013

Source: McKay M.T., McBride N.T., Sumnall H.R. et al.  Journal of Substance Use: 2012, 17(2), p. 98–121.

By Matthew Hill BBC health correspondent

Some analysts suggest that lessons can be learned from Portugal’s drug laws. So how are things done differently there?

As she waited calmly with fellow drug users queuing for their weekly treatment in Lisbon’s main detox centre, Anna was happy to talk about the addiction that has blighted her for the past 15 years.

The 53-year-old drug user, who preferred not to give her surname, said she was now able to lead a normal life because of Portugal’s enlightened approach that favours public health over the criminalisation of drug users.

Anna visits Lisbon’s ‘Centro das Taipas’ each week to receive the heroin substitute methadone.

She explained: “I had a good life, and when I started taking drugs I spoilt my life and now I am drug-free again and I am well. When I feel ok I will stop methadone, if necessary on an in-patient basis.”

The change in law that led to this treatment was a response to a growing drug problem in the late 1990s.

‘No problem’

Portugal had developed a reputation as a gateway for drug trafficking, with more than three quarters of drugs seized destined for other European countries.

By 1999, it had the highest rate of drug-related Aids cases in the EU and there was a growing perception that the criminalisation of drug use was increasingly part of the problem.

So in 2001, the socialist government changed the law to turn possession of drugs into an “administrative offence”, sending those caught with drugs for personal use to a “dissuasion board” rather than face prosecution.

At one of these hearings was a 32-year-old man who had been caught in possession of  hashish.

Paulo showed no regret as he explained his case to a social worker and psychologist, saying: “I don’t feel I have a problem with drugs, so I don’t feel I need to be here”.

As this was his first appearance before the board he was just given a warning. If he is caught again, sanctions will be applied.

But far more drug users are taking up treatment as a result of the change in law, an independent study by Dr Alex Stevens from theUniversity of Kentfound.

It said the overall numbers of drug users in treatment expanded in Portugal from 23,654 to 38,532 between 1998 and 2008. While between 2000 and 2008 the number of case of HIV reduced among drug users from 907 to 267.

“This is a highly significant trend which as been attributed primarily to the expansion of harm reduction services,” it concluded.

Radical change

The advisor of the management board of the Instituto of Drugs in Portugal, Dr Fatima Trigeiros, said its partners had feared decriminalisation would make people flock to Portugal to take drugs, but that did not happen.

“Before the law changed people with drug consumption would fear to come into the treatment structures because they were afraid they would be taken to court,” she said.

Continue reading the main story

“Start Quote

We have a government that on paper at last is a dream ticket for actually putting in place substantive reforms”

End Quote Danny Kushlick Transform

“Also we were not tackling first-time users, those who were experimenting, because the time between being caught and the time they were taken to court was too long. Now they are being taken to the dissuasion boards in 72 hours.”

Would the British government ever entertain such a radical change? The Home Office says decriminalisation is not the answer; instead it wants to reduce drug use and drug-related crime and help addicts kick their habit.

But there is evidence the prime minister thought differently when he was in opposition. Eight years ago, David Cameron wrote in the Daily Telegraph, that “politicians need to get up from behind their barricades and look at what works, rather than what sounds good”.

He called for a declassification of some drugs so cannabis would move from class B to class C and ecstasy from A to B, even allowing some severe heroin users access to injecting rooms.

As a backbench MP, Mr Cameron called on the government to raise a debate at the United Nations on legalisation and regulation. It was the clearest indication ever given by a future British prime minister of a desire to rethink drugs policy.

The charitable think tank “Transform”, which is lobbying for a change in the law, is hoping the prime minister’s past views will prevail.

Its head of external affairs, Danny Kushlick said: “We have a government that on paper at last is a dream ticket for actually putting in place substantive reforms that are going to shift resources from criminal justice and towards public health.”

With difficult public sector cuts looming, drug reform may not be the first priority of the British government, but it is now consulting on the UK Drugs Strategy.

Reformers say if they want to reduce spending on drugs they could do worse than to look to Portugal.

Source 3rd Oct.2010

Australians are the world’s highest ecstasy users in the world.
 (Source: U N Office of Drugs and Crime, World Drug Report June 2009).
Ecstasy is the second most commonly used illicit drug in Australia.
 (Source: Australian Institute of Health and Welfare 2008)
A third of all ecstasy seized globally in 2008 was destined for Australia.
 (Source: International Narcotics Control Board annual report 2010)
Australia has a culture of illicit drug use which is attracting supply.
This culture is supported by policies of syringe distribution, drug maintenance  and drug substitution. Celebrities because of their high public profile highlight this drug culture and the effects on them and their families.
Whilst public debate on the effects of illicit drugs is useful, these drugs are
illegal because they are PROVEN dangerous. The violence, mental illness, psychosis and chaos of all illicit drugs are well documented and scientifically proven.
The drug culture can only be changed with policies that REDUCE demand and
divert illicit drug users into rehabilitation that produce abstinence from
future use.
Court ordered and supervised illicit drug orders should be used to divert all
identified illicit drug users into rehabilitation. Only reduced demand by rehabilitation will starve international criminals of  funds from illicit drugs.

More detoxification & rehabilitation that gets illicit drug user’s drug free.
Court ordered and supervised detoxification & rehabilitation.
Less illicit drug users, drug pushers and drug related crimes.

Source:  Drug Advisory Council of Australia  (DACA) August 2010

“It’s extraordinarily simplistic for the Global Commission to advocate that decriminalising drugs will lead to reduced addiction rates and less crime.  The idea that drug abuse is a victimless crime is also hugely over-simplifying things.

In Scotland there is a huge problem with drug addiction and this has become dramatically worse over recent decades. Such is the scale of the problem now that we have a detection rate of just 1 per cent of all the heroin that’s consumed in Scotland.

That’s a figure we should be hugely discomforted by and it gives us an idea of the scale of the problem we’re facing. The Global Commission’s recommendations seem to have given up on the idea of getting addicts off drugs and seem to be accepting it’s a problem that’s here to stay.

As things stand, we are already leaving too many addicts for too long on methadone, for example. We need to have a policy of supporting people to move from increased stability to abstinence. Legalising drugs would open the floodgates to more drugs problems and would be a catastrophe for the country.

There are areas in Scotland where drug use is already rife, such as some estates in the cities of Edinburgh and Glasgow. If drugs were no longer illegal this would spread rapidly and get out of all control very quickly, we would end up with a drug problem that’s of a similar scale to the one we currently have with alcohol.

The policy advocated by the Global Commission would also lead to higher levels of crime and would corrupt the economy, and there would be huge economic power left with these businesses selling drugs. The power of the drugs gangs would remain in place, but they would now be legitimate in the eyes of the law and would be more likely to diversify into other areas of crime.

We would also see some companies that are currently legitimate corrupted by their involvement in the drugs trade. This has already happened in Columbia, where the gangs have become more powerful and have influence over more parts of society.

Drug dealers and organised crime would all of a sudden have so much more influence and this would be hugely damaging to Scottish society as a whole. We have to look at how to solve the problems with drugs in a much more measured way and that means having joined up strategies in place to treat addicts, as well as an effective criminal justice system.

One of the biggest problems of all though is that we have become too accustomed to having a drug problem in Scotland over the past 20 years and have allowed the problem to get worse and worse. The last thing we want is any sort of knee-jerk reaction or a rushed decision that has come up with all the wrong sorts of ideas. Prevention of drug addiction through education and early intervention have got to be at the heart of any anti-drugs strategy.

But we need to be very clear that a 1 per cent detection rate for all the heroin use in Scotland is just not acceptable and needs to be dramatically improved.  The approach put forward by the Global Commission is certainly not the route to go down, as it would just escalate our problems with crime and addiction.

If we imagine just how bad things have become in Scotland with drug addiction and crime, we should stop to think how much worse they could be if these proposals to decriminalise drugs are introduced.  The crisis could get much worse unless we have a sensible approach that gets to the heart of the problem”.

lNeil McKeganey is a professor of drug misuse research at the University of Glasgow

Source: 2nd June 2011

A United Nations panel today agreed on a set of measures to prevent the use of illicit drugs and strengthen national and regional responses, including using treatment instead of incarceration to stem a worrying global trend in the abuse of narcotics.

Wrapping up its week-long 55th session in Vienna, the Commission on Narcotic Drugs (CND), adopted 12 resolutions, including on the treatment, rehabilitation and social reintegration of drug-dependent prisoners; treatment as an alternative to incarceration; and preventing death from overdose.

The commission, which is made up of 53 member States, underlined the need for gender-specific interventions and called for the promotion of drug prevention, treatment and care for female drug addicts. It also called for more evidence-based strategies to prevent the use of illicit drugs, especially among young people.

Yury Fedotov, the Executive Director of the UN Office on Drugs and Crime (UNODC), hailed the fundamental role of existing international drugs conventions in safeguarding public health.

“It is only by acknowledging the drug conventions as the foundation for our shared responsibility that we can make successive generations safe from illicit drugs,” he said.

The commission acknowledged the role played by developing countries in sharing best practices, including through continental and inter-regional cooperation to promote alternative development programmes in poor rural communities dependent on the cultivation of illicit drug crops.

One of the new issues that emerged during the current session is the increasing diversion of chemicals to manufacture illicit amphetamine-type stimulants, a group of synthetic drugs that includes ecstasy and methamphetamine.

The commission called for international cooperation to curb the manufacture of new psychoactive substances. It also recommended the development of an international electronic authorization system for the trade in controlled substances.

This year’s session drew some 1,200 participants from 120 countries, observers, international organizations and non-governmental organizations. 16th March

When it comes to prevention of substance use in our “tween” population, turning kids on to ‘thought control’ may just be the answer to getting them to say no, Medical News Today reports.

New research published in the Journal of Studies on Alcohol and Drugs, co-led by professors Roisin O’Connor of Concordia University and Craig Colder of State University of New York at Buffalo, has found that around the” tween-age” years, youth are decidedly ambivalent toward cigarettes and alcohol. It seems that the youngsters have both positive and negative associations with these harmful substances and have yet to decide one way or the other. Because they are especially susceptible to social influences, media portrayals of drug use and peer pressure become strong allies of substance use around these formative years.

“Initiation and escalation of alcohol and cigarette use occurring during late childhood and adolescence makes this an important developmental period to examine precursors of substance use,” O’Connor said. “We conducted this study to have a better understanding of what puts this group at risk for initiating substance use so we can be more proactive with prevention.”

The study showed that at the impulsive, automatic level, these kids thought these substances were bad but they were easily able to overcome these biases and think of them as good when asked to place them with positive words. O’Connor explains that “this suggests that this age group may be somewhat ambivalent about drinking and smoking. We need to be concerned when kids are ambivalent because this is when they may be more easily swayed by social influences.”

According to O’Connor, drinking and smoking among this age group is influenced by both impulsive (acting without thinking), and controlled (weighing the pros against the cons) decisional processes. With this study, both processes were therefore examined to best understand the risk for initiating substance use.

To do this, close to 400 children between the ages of 10 and 12 participated in a computer-based test that involved targeted tasks. The tweens were asked to place pictures of cigarettes and alcohol with negative or positive words. The correct categorization of some trials, for example, involved placing pictures of alcohol with a positive word in one category and placing pictures of alcohol with negative words in another category.

The next step in the study is to look at kids over a longer period of time. The hypothesis from the research is that as tweens begin to use these substances there will be an apparent weakening in their negative biases toward drinking and smoking. The desire will eventually outweigh the costs. It is also expected that they will continue to easily outweigh the pros relative to the cons related to substance use.

O’Connor said researchers would like to continue to track the youth, who, he said, know that drugs are inherently bad.

“The problem is the likelihood of external pressures that are pushing them past their ambivalence so that they use. In a school curriculum format I see helping kids deal with their ambivalence in the moment when faced with the choice to use or not use substances,” O’Connor concluded. 15th March 2012

Adolescents’ use of marijuana may increase the risk of heroin addiction later in life, a new study suggests. Researchers say the work adds to “overwhelming” evidence that people under 21 should not use marijuana because of the risk of damaging the developing brain.

The idea that smoking cannabis increases the user’s chance of going on to take harder drugs such as heroin is highly contentious. Some dub cannabis a “gateway” drug, arguing that peer pressure and exposure to drug dealers will tempt users to escalate their drug use. Others insist that smoking cannabis is unrelated to further drug use.

Now research in rats suggests that using marijuana reduces future sensitivity to opioids, which makes people more vulnerable to heroin addiction later in life. It does so by altering the brain chemistry of marijuana users, say the researchers.

“Adolescents in particular should never take cannabis – it’s far too risky because the brain areas essential for behaviour and cognitive functioning are still developing and are very sensitive to drug exposure,” says Jasmin Hurd, who led the study at the Karolinska Institute in Sweden.
But Hurd acknowledges that most people who use cannabis begin in their teens. A recent survey reported that as many as 20% of 16-year-olds in the US and Europe had illegally used cannabis in the previous month.

“Teenage” rats

In order to explore how the adolescent use of cannabis affects later drug use, Hurd and colleagues set up an experiment in rats aimed to mirror human use as closely as possible.

In the first part of the trial, six “teenage” rats were given a small dose of THC – the active chemical in cannabis – every three days between the ages of 28 and 49 days, which is the equivalent of human ages 12 to 18. The amount of THC given was roughly equivalent to a human smoking one joint every three days, Hurd explains. A control group of six rats did not receive THC.

One week after the first part was completed, catheters were inserted in all 12 of the adult rats and they were able to self-administer heroin by pushing a lever.
“At first, all the rats behaved the same and began to self-administer heroin frequently,” says Hurd. “But after a while, they stabilised their daily intake at a certain level. We saw that the ones that had been on THC as teenagers stabilised their intake at a much higher level than the others – they appeared to be less sensitive to the effects of heroin. And this continued throughout their lives.”

Hurd says reduced sensitivity to the heroin means the rats take larger doses, which has been shown to increase the risk of addiction.

Drug memory

The researchers then examined specific brain cells in the rats, including the opioid and cannabinoid receptors. They found that the rats that had been given THC during adolescence had a significantly altered opioid system in the area associated with reward and positive emotions. This is also the area linked to addiction.

“These are very specific changes and they are long-lasting, so the brain may ‘remember’ past cannabis experimentation and be vulnerable to harder drugs later in life,” Hurd says.
Neurologist Jim van Os, a cannabis expert at the University of Maastricht in the Netherlands told New Scientist the research was a welcome addition to our understanding of how cannabis affects the adolescent brain.

“The issue of cross-sensitisation of cannabis/opioid receptors has been a controversial one, but these findings show the drug’s damaging effects on the reward structures of the brain,” van Oshe says. “There is now overwhelming evidence that nobody in the brain’s developmental stage – under the age of 21 – should use cannabis.”

Source: On line edition of Neuropsychopharmacology. Reported in July 2006

• Young people in the UK have by far the most positive expectations of alcohol in Europe and are least likely to feel that it might cause them harm.
• Exposure to alcohol marketing increases the likelihood that young people will start to use alcohol and the amount they consume.
• The alcohol industry spends £800 million on marketing in the UK annually
• A spends £153 encouraging drinking per £1 contributed to Drinkaware – the industry led alcohol information organisation charged with promoting sensible drinking.
• Underage drinkers consume approximately the equivalent of 6.9 million pints of beer or 1.7 million bottles each week
• 630,000 11- to 17-year-olds drink twice or more each week.
• Between 2002 and 2009 – 92,220 under-18s were admitted to hospital in England for alcohol-related conditions- over 36 children or young people each day.
• Under-18s alcohol-related hospital admissions increased by 32% between 2002 and 2007.
• The latest European School Survey Project on Alcohol and Other Drugs reported that in the UK 26% of 11-15 year-olds reported suffering an accident or injury because of their drinking, the highest percentage in Europe.
• Although cases of dependence amongst underage drinkers are rare, in 2008/9 – 8,799 younger people accessed treatment for alcohol up from 4,886 in 2005/6. Nov.2011

Position Statement – December 2011

The flawed proposition of drug legalisation

Various well funded pressure groups have mounted campaigns to overturn the United Nations Conventions on drugs. These groups claim that society should accept the fact of drugs as a problem that will remain and, therefore, should be managed in a way that would enable millions of people to take advantage of an alleged ‘legal right’ to use drugs of their choice.

It is important to note that international law makes a distinction between “hard law” and “soft law.” Hard law is legally binding upon the States. Soft law is not binding. UN Conventions, such as the Conventions on Drugs, are considered hard law and must be upheld by the countries that have ratified the UN Drug Conventions.

International narcotics legislation is mainly made up of the three UN Conventions from 1961 (Single Convention on Narcotic Drugs), 1971 (Convention on Psychotropic Substances), and 1988 (Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances):

• The 1961 Convention sets out that “the possession, use, trade in, distribution,import, export, manufacture and the production of drugs is exclusively limited to medical and scientific purposes”. Penal cooperation is to be established so as to ensure that drugs are only used licitly (for prescribed medical purposes).

• The 1971 Convention resembles closely the 1961 Convention, whilst
establishing an international control system for Psychotropic Substances.

• The 1988 Convention reflects the response of the international community to increasing illicit cultivation, production, manufacture, and trafficking activities. International narcotics legislation draws a line between licit (medical) and illicit (non-medical) use, and sets out measures for prevention of illicit use, including penal measures. The preamble to the 1961 Convention states that the parties to the Convention are “Recognizing that addiction to narcotic drugs constitutes a serious evil for the individual and is fraught with social and economic danger to mankind”. The Conventions are reviewed every ten years and have consistently been upheld.

The UN system of drug control includes the Office of Drugs and Crime, the International Narcotics Control Board, and the Commission on Narcotic Drugs. The works of these bodies are positive and essential in international drug demand and supply reduction. They are also attacked by those seeking to legalise drugs.

It is frequently and falsely asserted that the so-called “War on Drugs” is inappropriate and has become a very costly and demonstrable failure. It is declared by some that vast resources have been poured into the prevention of drug use and the suppression of illicit manufacturing, trafficking, and supply. It is further claimed that what is essentially a chronic medical problem has been turned into a criminal justice issue with inappropriate remedies that make “innocent” people criminals. In short, the flawed argument is that “prohibition” monies have been wasted and the immeasurable financial resources applied to this activity would be better spent for the general benefit of the community.

The groups supporting legalisation are: people who use drugs, those who believe that the present system of control does more harm than good, and those who are keen to make significant profits from marketing newly authorised addictive substances. In addition to pernicious distribution of drugs, dealers circulate specious and misleading information. They foster the erroneous belief that drugs are harmless, thus adding to even more confused thinking.

Superficially crafted, yet pseudo-persuasive arguments are put forward that can be accepted by many concerned, well intentioned people who have neither the time nor the knowledge to research the matter thoroughly, but accept them in good faith. Frequently high profile people claim that legalisation is the best way of addressing a major social problem without cogent supporting evidence. This too influences others, especially the ill informed who accept statements as being accurate and well informed. Through this ill-informed propaganda, people are asked to believe that such action would defeat the traffickers, take the profit out of the drug trade and solve the drug problem completely.

The total case for legalisation seems to be based on the assertion that the government assault on alleged civil liberties has been disastrously and expensively ineffective and counter-productive. In short, it is alleged, in contradiction to evidence, that prohibition has produced more costs than benefits and, therefore, the use of drugs on a personal basis should be permitted. Advocates claim that legalisation would eliminate the massive expenditure incurred by prohibition and would take the profit out of crime for suppliers and dealers. They further claim that it would decriminalise what they consider “understandable” human behaviour and thus prevent the overburdening of the criminal justice system that is manifestly failing to cope. It is further argued irrationally that police time would not be wasted on minor drug offences, the courts would be freed from the backlog of trivial cases and the prisons would not be used as warehouses for those who choose to use drugs, and the saved resources could be used more effectively.

Types of drug legalisation

The term “legalisation” can have any one of the following meanings:

1. Total Legalisation – All illicit drugs such as heroin, cocaine, methamphetamine, and marijuana would be legal and treated as commercial products. No government regulation would be required to oversee production, marketing, or distribution.

2. Regulated Legalisation – The production and distribution of drugs would be regulated by the government with limits on amounts that can be purchased and the age of purchasers. There would be no criminal or civil sanctions for possessing, manufacturing, or distributing drugs unless these actions violated the regulatory system. Drug sales could be taxed.

3. Decriminalisation – Decriminalisation eliminates criminal sanctions for drug use and provides civil sanctions for possession of drugs. To achieve the agenda of drug legalisation, advocates argue for:

• legalising drugs by lowering or ending penalties for drug possession and use – particularly marijuana;

• legalising marijuana and other illicit drugs as a so-called medicine;
• harm reduction programmes such as needle exchange programmes, drug injection sites, heroin distribution to addicts, and facilitation of so-called safe use of drugs that normalize drug use, create the illusion that drugs can be used safely if one just knows how, and eliminates a goal of abstinence from drugs;

• legalised growing of industrial hemp;
• an inclusion of drug users as equal partners in establishing and enforcing drug policy; and

• protection for drug users at the expense and to the detriment of non-users under the pretence of “human rights.”

The problem is with the drugs and not the drug policies

Legalisation of current illicit drugs, including marijuana, is not a viable solution to the global drug problem and would actually exacerbate the problem. The UN Drug Conventions were adopted because of the recognition by the international community that drugs are an enormous social problem and that the trade adversely affects the global economy and the viability of some countries that have become transit routes.

The huge sums of illegal money generated by the drug trade encourage money laundering and have become inextricably linked with other international organised criminal activities such as terrorism, human trafficking, prostitution and the arms trade. Drug Lords have subverted the democratic governments of some countries to the great detriment of law abiding citizens.

Drug abuse has had a major adverse effect on global health and the spread of communicable diseases such as AIDS/HIV. Control is vitally important for the protection of communities against these problems. There is international agreement in the UN Conventions that drugs should be produced legally under strict supervision to ensure adequate supplies only for medical and research purposes. The cumulative effects of prohibition and interdiction combined with education and treatment during 100 years of international drug control have had a significant impact in stemming the drug problem. Control is working and one can only imagine how much worse the problem would have become without it. For instance:

• In 2007, drug control had reduced the global opium supply to one-third the level in 1907 and even though current reports indicate recent increased cultivation in Afghanistan and production in Southeast Asia, overall production has not increased.

• During the last decade, world output of cocaine and amphetamines has stabilized; cannabis output has declined since 2004; and opium production has declined since 2008. We, therefore, strongly urge nations to uphold and enhance current efforts to prevent the use, cultivation, production, traffic, and sale of illegal drugs. We further urge our leaders to reject the legalisation of currently illicit drugs as an acceptable solution to the world’s drug problem because of the following reasons:

• Only 6.1% of people globally between the ages of 15 and 64 use drugs (World Drug Report 2011 UNODC) and there is little public support for the legalisation of highly dangerous substances. Prohibition has ensured that the total number of users is low because legal sanctions do influence people’s behaviour.

• There is a specific obligation to protect children from the harms of drugs, as is
evidenced through the ratification by the majority of United Nations Member States of the UN Convention on the Rights of the Child (CRC). Article 33 states that Member States “shall take all appropriate measures, including legislative, administrative, social and educational measures, to protect children from the illicit use of narcotic drugs and psychotropic substances as defined in the relevant international treaties, and to prevent the use of children in the illicit production and trafficking of such substances”.

• Legalisation sends the dangerous tacit message of approval, that drug use is
acceptable and cannot be very harmful.

• Permissibility, availability and accessibility of dangerous drugs will result in
increased consumption by many who otherwise would not consider using them.

• Enforcement of laws creates risks that discourage drug use. Laws clearly define what is legal and illegal and emphasise the boundaries.

• Legalisation would increase the risks to individuals, families, communities and world regions without any compensating benefits.

• Legalisation would remove the social sanctions normally supported by a legal system and expose people to additional risk, especially the young and vulnerable.

• The legalisation of drugs would lead inevitably to a greater number of dependencies and addictions likely to match the levels of licit addictive substances. In turn, this would lead to increasing related morbidity and mortality, the spread of communicable diseases such as AIDS/HIV and the other blood borne viruses exacerbated by the sharing of needles and drugs paraphernalia, and an increased burden on the health and social services.

• There would be no diminution in criminal justice costs as, contrary to the view held by those who support legalisation, crime would not be eliminated or reduced. Dependency often brings with it dysfunctional families together with increased domestic child abuse.

• There will be increases in drugged driving and industrial accidents.

• Drug Control is a safeguard protecting millions from the effects of drug abuse and addiction particularly, but not exclusively, in developing countries.

• Statements about taxation offsetting any additional costs are demonstrably flawed and this has been shown in the case of alcohol and tobacco taxes. Short of governments distributing free drugs, those who commit crime now to obtain them would continue to do so if they became legal.

• Legalisation would not take the profit out of the drug trade as criminals will always find ways of countering legislation. They would continue their dangerous activities including cutting drugs with harmful substances to maximise sales and profits. Aggressive marketing techniques, designed to promote increased sales and use, would be applied rigorously to devastating effect.

• Other ‘legal’ drugs – alcohol and tobacco, are regularly traded on the black market and are an international smuggling problem; an estimated 600 billion cigarettes are smuggled annually (World Drug report 2009). Taxation monies raised from these products go nowhere near addressing consequential costs.

• Many prisons have become incubators for infection and the spread of drug related diseases at great risk to individual prisoners, prison staff and the general public. Failure to eliminate drug use in these institutions exacerbates the problem.

• The prisons are not full of people who have been convicted for mere possession of drugs for personal use. This sanction is usually reserved for dealers and those who commit crime in the furtherance of their possession.

• The claim that alcohol and tobacco may cause more harm than some drugs is not a pharmacokinetics of psychotropic substances suggest that more, not less, control of their access is warranted.

• Research regularly and increasingly demonstrates the harms associated with drug use and misuse. There is uncertainty, yet growing evidence, about the long-term detrimental effects of drug use on the physical, psychological and emotional health of substance users.

• It is inaccurate to suggest that the personal use of drugs has no consequential and damaging effects. Apart from the harm to the individual users, drugs affect others by addiction, violence, criminal behaviour and road accidents. Some drugs remain in the body for long periods and adversely affect performance and behaviour beyond the time of so-called ‘private’ use. Legalisation would not diminish the adverse effects associated with drug misuse such as criminal, irrational and violent behaviour and the mental and physical harm that occurs in many users.

• All drugs can be dangerous including prescription and over the counter medicines if they are taken without attention to medical guidance. Recent research has confirmed just how harmful drug use can be and there is now overwhelming evidence (certainly in the case of cannabis) to make consideration of legalisation irresponsible.

• The toxicity of drugs is not a matter for debate or a vote. People are entitled to their own opinions but not their own facts. Those who advocate freedom of choice cannot create freedom from adverse consequences.

• Drug production causes huge ecological damage and crop erosion in drug producing areas.

• Nearly every nation has signed the UN Conventions on drug control. Any government of signatory countries contemplating legalisation would be in breach of agreements under the UN Conventions which recognise that unity is the best approach to combating the global drug problem. The administrative burden associated with legalisation would become enormous and probably unaffordable to most governments. Legalisation would require a massive government commitment to production, supply, security and a bureaucracy that would necessarily increase the need for the employment at great and unaffordable cost for all of the staff necessary to facilitate that development.

• Any government policy must be motivated by the consideration that it must first do no harm. There is an obligation to protect citizens and the compassionate and sensible method must be to do everything possible to reduce drug dependency and misuse, not to encourage or facilitate it. Any failures in a common approach to a problem would result in a complete breakdown in effectiveness. Differing and fragmented responses to a common predicament are unacceptable for the wellbeing of the international community. It is incumbent on national governments to cooperate in securing the greatest good for the greatest number.

ISSUED this 21st day of December, 2011 by the following groups:
Drug Prevention Network of the Americas (DPNA)
Institute on Global Drug Policy
International Scientific and Medical Forum on Drug Abuse
International Task Force on Strategic Drug Policy
People Against Drug Dependence & Ignorance (PADDI), Nigeria
Europe Against Drugs (EURAD)
World Federation Against Drugs (WFAD)
Peoples Recovery, Empowerment and Development Assistance (PREDA)
Drug Free Scotland

Following the Scottish example, England has piloted drug courts using specially trained magistrates to closely supervise treatment-based community sentences. This initial report found no major glitches but low throughput and uncertain cost-benefits.

Summary The Dedicated Drug Court framework for England and Wales provides for specialist courts which exclusively handle cases relating to drug misusing offenders from conviction through sentence to completion (or breach) of a community order with a Drug Rehabilitation Requirement (DRR). Two magistrates’ courts (Leeds Magistrates’ Court and West London Magistrates’ Court) have been piloting drug courts implemented in line with the Ministry of Justice’s framework.

The critical factors for implementation success are an understanding of local context and scale of need, the enthusiasm of the local judiciary and partner agencies, good partnership working, availability of resources to deliver the drug court and its associated treatment services, the depth of understanding by all staff of offender motivation and, in particular, recognition of the points at which an offender is most likely to make progress in reducing or stopping drug use. Continuity of judiciary is key to successful implementation of a drug court. It provides the focus for communication between the court and the offender and across magistrate panels. Continuity of judiciary was a strong planned feature of both courts. Based on analysis undertaken with data from the Leeds pilot, there is strong evidence that continuity of magistrates has a statistically significant impact on several key drug court outcomes. Greater continuity of magistrates experienced by offenders is associated with their being less likely to miss a court hearing, more likely to complete their sentence, and less likely to be reconvicted.

Break-even analysis showed that (compared to normal adjudication) an extra 8% of offenders seen by the courts would need to stop taking drugs for five years or more following completion of the sentence to provide a net economic benefit to the wider society, and 14% in order to provide a net economic benefit to the criminal justice system. A robust quantification of impact was not possible because of the difficulties in collecting sufficient data on a comparison group of offenders not processed through drug courts.

Findings Commissioned by the UK Ministry of Justice, the report describes the implementation rather than the outcomes of England’s pilot drug courts. In line with international understandings, the courts were intended to specialise in drug-related offenders, presided over by sentencers specially trained for this task who order treatment-based sentences and closely supervise the offender’s progress, aided by regular tests for illegal drug use. The aim is maximise the rehabilitative impact of the sentence by increasing compliance and engagement with treatment through criminal justice pressure (ultimately the prospect of receiving a more typical punishment-based sentence if the drug court’s order fails) and rewards (of which one of the most powerful seems to be the unfamiliar experience of being congratulated by a judge or magistrate).

The report identified no critical fault lines in the implementation of the courts. However, these were particularly promising sites: the Leeds court built on a pre-existing system and in London, court staff were enthusiastic about the proposal and had already been working towards creating a drug court. Nevertheless, offender throughput was lower than expected. Over the 17 months of the evaluation, the London court sentenced just 60 new offenders while in Leeds the total was 276. Low throughput raised costs per offender. Compared to a standard 12-month drug rehabilitation requirement order implemented through normal adjudication, supervising the order through the drug courts cost £4633 extra per offender.

With no comparison group of normally adjudicated offenders, the evaluation was unable to say whether this was money well spent. They were, however, able to calculate the drug use reductions the courts would have to ‘buy’ in order to meet their extra costs – as noted in the abstract, the answer was 8% of offenders ceasing drug use for at least five years compared to the numbers doing so on a normally adjudicated drug rehabilitation requirement order. This calculation though excludes the base costs of normal adjudication and of a normally supervised drug rehabilitation requirement order. This seems to mean that the 8% would also have to be over and above the proportion of offenders who remain abstinent after normal judicial processing. The report gives no indication of how much success would be needed to match the total costs incurred by the criminal justice system in implementing all the elements of a drug court-supervised drug rehabilitation requirement order.

The report’s emphasis on offenders seeing the same magistrate(s) for their sentencing and throughout subsequent progress reviews is backed by evidence from Leeds that continuity is substantially associated with better compliance and drug use and crime outcomes. Steps were taken to reduce the risk that continuity was caused by high compliance and good progress rather than vice versa. However, without actually allocating offenders at random to see or not see the same magistrates, it is impossible to eliminate this possibility. Assuming the effect was real, it is of concern that organising continuity was a challenge, and especially so for ‘breach’ hearings dealing with unacceptable failures to comply with the order, which national regulations required to occur within a set period. Unfortunately, these crucial junctures are just when continuity is most needed, requiring an understanding of whether the offender will do better on a revised order, or the order has failed and should be revoked, often resulting in imprisonment.

A final caution over any such report is that some leading criminologists accuse the UK government of manipulating and distorting criminological research for political gain, to the point where the professor of criminology at the Open University has called for a boycott of government-commissioned work. The featured report was commissioned by the UK Ministry of Justice, a ministry carved out in part from the Home Office, one of the main targets of these accusations.

Scotland preceded England in formally piloting drug courts in Glasgow from 2001 and in Fife the following year. As in England, implementation was not entirely smooth but better than might have been expected. There was a high but it was thought acceptable failure rate, probably aided by Scotland’s more flexible application of drug treatment and testing orders, predecessors to the drug rehabilitation requirements used later by the English courts. However, crime impacts were questionable. Within one year 50% of drug court offenders had been reconvicted and within two years 71%, and the average frequency of reconvictions only slightly dipped in the two years after the order was imposed compared to the two years before. There was no clear crime-reduction benefit from supervising the orders through the drug courts (at an average cost of nearly £18,500 per order) as opposed to normal adjudication. But, as in England, the costs imposed on society by persistent, high-rate offending and drug-related mortality and morbidity, are such that even modest improvements might be cost-beneficial overall.

International experience and research relating to drug courts suggests it is important for courts to emphasise rewards as well as punishments, see offenders frequently enough to apply these swiftly in response to progress, deploy a range of rewards and sanctions short of revocation which are consistently applied, have a strong and sure ultimate sanction when the programme fails, make these consequences absolutely clear to offenders, have rapid access to a range of treatment options, maintain continuity in the judge dealing with the case, and to attend to the range of the individual’s needs. Willingness to continue despite some initial offending makes the structure imposed by stringent requirements and monitoring a positive feature rather than one which leads most offenders to fail. Consistent judicial supervision, the fact that this forces addicts (back) in to treatment, and drug testing which provides a shared measure of how treatment is progressing, probably all play their parts.

Source: March 2009

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

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

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

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

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

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

Main findings

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

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

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

The authors’ conclusions

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

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

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

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

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

CBT in methadone treatment

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

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

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

CBT in substance use treatment generally

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

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

Will CBT help methadone patients leave treatment?

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

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

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

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

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

Last revised 16 December 2011


As this review comments, people treated for substance use often remain precariously balanced between recovery and relapse. Widely seen as valuable if not essential, aftercare is nevertheless more the exception than the rule. How to reverse that ratio is the issue addressed by these leading US analysts.

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

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

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

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

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

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

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

• Characteristics of the intervention (in this case, continuing care) such as the strength of the evidence for its effectiveness and how far it was adapted to fit the particular circumstances in which it was being implemented.

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


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

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

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

Outer Setting

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

Inner Setting

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

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

Implementation Process

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

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

Basic Continuing Care Implementation

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

Implementation Efforts Need to Address Multiple Domains

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

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

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

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

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

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

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

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

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

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


24 February 2011

DrugScope has welcomed new research demonstrating that drug treatment services for young people are extremely cost effective, with long term savings of between £5 and £8 for every pound invested.
Published by the Department for Education, the report, Specialist drug and alcohol services for young people – a cost benefit analysis, finds that drug and alcohol treatment for young people reduces otherwise significant economic, social and health costs. Immediate savings are achieved in reduced crime and improved health. In the longer term, there are reductions in costs associated with problematic drug use in adulthood, including unemployment, crime and drug and alcohol dependency.

Approximately 24,000 young people received specialist drug and alcohol treatment in the UK in 2008/09. Most were treatedprimarily for alcohol (37%) or cannabis (53%); one in ten were treated for problems associated with Class A drugs, including heroin and crack.
A report published by DrugScope in 2009, Young people’s drug treatment at the crossroads, found that as well as helping young people with their drug or alcohol problems, treatment services also address wider needs, such as mental health issues, involvement with the criminal justice system and social exclusion. Despite evidence of the cost effectiveness of spending on substance misuse treatment, many young people’s services have contacted DrugScope to report significant cuts in local funding.  Commenting on the report, Martin Barnes, Chief Executive of DrugScope said:
“At a time when many drug and alcohol services for young people are facing funding cuts, this research makes a timely, compelling and robust case for continued investment. Even on quite cautious and conservative estimates, the evidence shows that there are immediate net gains in return for spending on drug and alcohol treatment. Not only will cuts in services have a negative impact on vulnerable young people, the research confirms that greater costs are likely to be incurred in terms of crime, unemployment and poor health.
“The concern is that with a record number of young people not in education, employment or training there will be a greater demand on prevention and treatment services. It is far easier to prevent young people from developing problems at an early stage that it is to treat adults with addiction issues. A considered assessment of the benefits to local communities of investment in drug and alcohol treatment services needs to be made to inform decisions on funding.”

Source: 24 Feb 2011


A new study by a team of researchers in California shows it is possible to vaccinate laboratory animals against the effects of heroin. The vaccine not only blunted the painkilling action of heroin, it also prevented rats from becoming addicted to the drug. It didn’t keep the animals from gaining pain relief from many other opiates, suggesting the vaccine targets just heroin and a few related compounds. The experiments at the Scripps Research Institute in La Jolla, reported in the current edition of the Journal of Medicinal Chemistry, are the latest effort to bring the power of the immune system to bear against addictive substances. The next task is to see whether the vaccine prevents relapse in previously addicted and then detoxified rats.

Source: Reported in St.Petersburg Times July 28th 2011

This study sets out to broaden the evidence base by running a trial, based in UK general practice, where only brief support was available for participants while they compared nicotine nasal spray to placebo. It was based in 27 general practices and there was a total of 761 heavy smokers (at least 15 cigs/day for at least 3 years) who received brief support and 12 weeks of treatment with either nicotine nasal spray or placebo. The primary outcome was biochemically-verified complete abstinence from smoking throughout weeks 3-12.

The results showed that nicotine nasal spray more than doubled the number who successfully stopped smoking (15.4% vs 6.7%) from weeks 3-12 giving an odds ratio of 2.6 (95% CI 1.5-4.4). Although many reported minor irritant adverse effects it was noted to be particularly effective amongst those who were highly dependent on nicotine.

SMMGP comment: Tobacco harm reduction strategies is a neglected area although we know
that replacing smoking with a smokeless delivery system for the primary drug, nicotine, can reduce risks by about 99%, about the same as abstinence. Because smoking is so popular, the total health benefits from tobacco harm reduction dwarf those from any other area of HR.
There is an increasing array of nicotine replacement therapy options and this study shows one effective way of delivery. One interesting facet was the tiny number (0.2%) that went on to achieve abstinence if they were still smoking at one week. This infers that it may be worth prescribing a single week of nicotine nasal spray and reassessing abstinence. It?s a relatively small, inexpensive punt and it can double the chance of abstinence for that individual – even without the more comprehensive smoking cessation services which some prescribing is based around.

Source: Stapleton JA, Sutherland G. Addiction 2011;106:824-832

The true cost of Scotland’s drug habit has been set out by a leading academic, who says a single addict sets the country back more than £60,000 a year.

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

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

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

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

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

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

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

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

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

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

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

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

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



The nature of addiction is often debated along moral versus biological lines. However, recent advances in neuroscience offer insights that might help bridge the gap between these opposing views. Current evidence shows that most drugs of abuse exert their initial reinforcing effects by inducing dopamine surges in limbic regions, affecting other neurotransmitter systems and leading to characteristic plastic adaptations. Importantly, there seem to be intimate relationships between the circuits disrupted by abused drugs and those that underlie self-control. Significant changes can be detected in circuits implicated in reward, motivation and/or drive, salience attribution, inhibitory control and memory consolidation. Therefore, addiction treatments should attempt to reduce the rewarding properties of drugs while enhancing those of alternative reinforcers, inhibit conditioned memories and strengthen cognitive control. We posit that the time has come to recognize that the process of addiction erodes the same neural scaffolds that enable self-control and appropriate decision making.

Source: Trends in Molecular Medicine, Volume 12, Issue 12, 559-566, 1 December 2006


Addiction coopts the brain’s neuronal circuits necessary for insight, reward, motivation, and social behaviors. This functional overlap results in addicted individuals making poor choices despite awareness of the negative consequences; it explains why previously rewarding life situations and the threat of judicial punishment cannot stop drug taking and why a medical rather than a criminal approach is more effective in curtailing addiction.

Source: Neuron, Volume 69, Issue 4, 599-602, 24 February 2011

Some 56 heroin-dependent patients who had undergone detoxification treatment and were particularly motivated to remain heroin-free took part in a research study. Half of the participants were implanted with a total of 20 subcutaneous pellets containing naltrexone, which was gradually released from a saline solution with the aim of producing a six-month blockage effect. All the participants continued their normal follow-up treatments while the study was ongoing.
After six months, over twice as many in the group receiving naltrexone as in the control group (11 out of 23 as opposed to 5 out of 26) managed to refrain from using heroin and other morphine substances. Heroin use among those patients receiving naltrexone who did not manage to discontinue using heroin altogether was more than halved compared with their level of heroin use before they started treatment. In the control group the majority of patients relapsed to daily heroin use.
Satisfaction with the naltrexone implants was high. On a scale from 0 to 100 the participants gave the capsules a score of 85.

Clear-cut findings

Helge Waal, Professor emeritus at SERAF, would like to see the naltrexone implant included as one of the treatment options offered to heroin-dependent patients in Norway.
“Although this is a relatively small-scale study, the findings are so clear-cut that we think this should become an important treatment option for substance abusers.”

Source: The Research Council of Norway (2011, February 17) Retrieved February 18, 2011, from

Research Summary

Researchers say that a drug that blocks a brain protein called NK1R (neurokinin-1 receptor) involved in stress response appears to reduce alcohol craving, ABC News reported Feb. 14.
Building on studies showing that mice lacking NK1R seemed to lose interest in alcohol, researchers from the National Institute on Alcohol Abuse and Alcoholism gave NK1R-blocking drugs to a group of 25 alcoholics and compared their craving responses to those of 25 other alcoholics given a placebo. Those receiving the blocking drug reported about half the level of craving for alcohol as the control group.
Markus Heilig, NIAAA’s clinical director, said the study points to a new approach to addiction treatment by focusing on reducing craving rather than preventing the pleasurable effects of alcohol consumption. “We’re really trying to open up a new category of treatments that would help most people,” he said.
“This is a potentially important finding which indicates a novel mechanism for reducing craving in individuals who drink to reduce high anxiety,” said pharmacology expert Boris Tabakoff of the University of Colorado at Denver.
“It may be that this medication would help alcoholics who drink when stressed,” added Charles O’Brien of the Treatment Research Center for the University of Pennsylvania Health System, although he stressed: “It is wrong to think of all alcoholics as alike.”
The study was published online in the journal Science.

Source: Join Together Feb. 2008

EDINBURGH: The Scottish Executive’s anti-drug abuse policy was criticized sharply yesterday following a report that the government recommended heroin-substitute methadone is 97% ineffective.

Methadone, a drug used for recovery from heroin addiction, has a success rate of no more than 3.4%, according to Professor Neil McKeganey, chief researcher for Glasgow University’s Centre for Drug Misuse Research. McKeganey has just concluded a study on the effectiveness of the £12m a year Methadone programme.

The study observed a group of 695 heroin addicts who started taking treatment in 2001 at 33 different addiction centers across Scotland. A large percentage of this group was given methadone-based care while the rest were put on rehabilitation. Their progress was recorded over interviews 33 months after they started the treatment to see if they had become drug-free over a 90-day period.

The group given only-methadone had a very poor 3.4 percent recovery rate from drug addiction; whereas the group placed in residential rehabilitation (with no methadone throughout the treatment) showed a 29% success rate.

A key difference in methadone’s success rates between Scotland and England was also pointed out. While England emphasizes on getting people off drugs entirely, Scotland’s drug policy lacks any such direction; as a result, addicts simply substitute methadone with heroin.

McKeganey’s previous research had revealed a greater inclination to commit crimes among methadone patients when compared with addicts placed on abstinence programmes. People in the latter group also showed twice the level of interest in finding a job.

While the report makes no recommendation, sharp reactions have come in from various quarters demanding the Executive at least review its drug policy if not entirely scrap methadone. Tory leader Anabel Goldie said she recommended more investment in residential rehabilitation centres.

Meanwhile an official at the Greater Glasgow NHS facility said methadone may not be suitable for everyone but many addicts do benefit from it. He also said the government was looking to offer “a wider package of support” that would include rehabilitation, education and training, to addicts.

Source: 30.10.06

Whether families benefit from alcohol treatment as well as the patients has rarely been studied. A new US analysis has demonstrated that they do, positioning alcohol treatment as also contributing to child and family welfare policy agendas.

The patients were 301 men living with female partners (all but a few were married) and seeking treatment at two US outpatient alcoholism clinics. Therapy was 12-step oriented with no particular emphasis on marital or family systems. How patients and their families fared was compared against men and women drawn from a national sample
closely matched to each patient and partner, but with no known serious drinking problems.

At treatment entry two-thirds of patients and their partners reported serious relationship problems, virtually all reported verbal aggression, and over half violence. Among the 125 couples with 4–16-year-olds at home, the mother’s reports indicated that 26% exhibited clinically significant behavioural or psychological problems. The proportions of
couples reporting violence or high levels of verbal aggression, and the frequency and severity of violence, fell significantly and substantially from the year before treatment to the year after it had ended
Severe violence (hitting or threatening with a weapon), experienced before treatment by a fifth of the women and a quarter of the men, became a relative rarity, affecting 5–6% of respondents

A similar analysis of the sub-sample with children found that the proportion of children exhibiting clinically significant problems was halved from before treatment to the year after it had ended and the frequency/extent ofthose problems also fell. On both measures and regardless of whether the father had relapsed, the patients’ children were now no worse off than children in the comparison families.
Post-treatment aggression and child welfare outcomes improved more when the patient had sustained their remission, but also improved among patients who relapsed.

In context Earlier studies found similar improvements, but the featured study is the first to do so with an adequate sample size, before and after treatment measures, and a non-alcoholic comparison sample. One earlier study found improvements in child functioning and marital harmony following cognitive-behavioural therapy focused on the male substance user, but these were greater and more lasting if the programme had included couples therapy sessions.

In general it seems that intervening with one family member (whether the problem substance user or not) affects the rest of the family, but impacts are greater when interventions address both the user and their family. Without an untreated comparison group of alcoholics, the featured study could not prove that treatment contributed to the improvements, but this seems highly likely.

Practice implications Though the focus has been more on users of illegal drugs, the welfare of the children of substance users has been highlighted in Britain by recent official reports which recognize that effective treatment of the parent can have major benefits.

Couples and family-based treatments, or patient-focused treatments which at least involve the family, have the greatest impacts on children and on marital harmony. Such services need to be sustained, but where they are unavailable or unacceptable to the families, providers and commissioners can nevertheless expect normal patient focused alcohol treatments to contribute to the reduction of domestic violence and to help intercept the creation of a new generation of
troubled youngsters.

Source: Drug & Alcohol Findings 2006


Using teacher therapists to identify problem personality traits in teenagers, and help them understand their behaviour, could be the key to stopping them binge drinking and taking drugs.
Adolescent alcohol consumption has more than doubled in the past decade and 15% of pupils reported taking drugs last year.
Addiction experts believe prevention is the key – stopping young people abusing drink and drugs before they start, instead of simply treating the addiction once it has taken hold.
Researchers at the Institute of Psychiatry at King’s College, London, asked more than 1,000 13-year-olds at secondary schools in London to answer a range of questions about their personalities.
They were looking for pupils with four problem personality traits: negative thinking, anxiety, impulsiveness and sensation seeking.
Half of those teenagers were then given two tailored therapy sessions – one 90 minutes long, the second an hour. In small groups teenagers with particular personality traits were encouraged to explore their personalities – including strengths and difficulties.
They were encouraged to think about other ways to deal with the risks associated with that behaviour – techniques they hope the teenagers will then use when they come face to face with drink or drugs.
“It’s about coping with the trait rather than changing the personality – in no way do we ever suggest they stop being who they are or change who they are,” says Dr Patricia Conrod, Consultant Clinical Psychologist at King’s College.
“It’s changing how it is they’re coping with who they are and perhaps capitalising on some of the more positive sides of the trait and learning to manage some of its more difficult sides.”
The results, they say, speak for themselves – one study of 13 to 16-year-olds led to a 40% reduction in binge drinking and cut the chance of teenagers taking cocaine by 80%. It is the first school based programme outside the US to successfully prevent alcohol uptake and misuse in teenagers.
Students asked to give feedback about the sessions told the researchers they helped with controlling anger and dealing with negative thinking.
A second trial then looked at whether ordinary teachers, with no psychiatric training, could be taught to deliver the sessions.
Focusing on more than 20 secondary schools and another thousand pupils, it found that with little training: a three day workshop followed by three hours of supervised practice; teachers could do as good a job as the professionals.
Latest figures show that alcohol misuse currently costs the NHS around £2.7bn a year. Charities say as successful as treating an addiction can be, most do begin in adolescence, hence the need to attack the problem before it even exists.
“Prevention is important because we need to stop people progressing to much severer problems later in life,” says Nick Barton, the Chief Executive of Action on Addiction, who helped fund the study.
“We find for instance in our treatment centres that when we assess drinking or drug use history, that very often the onset was way back in adolescence, sometimes as young as 11 but certainly the period between 11 and 16 was when the first attraction to substance use took hold.”
The researchers believe this programme could be delivered with just two well trained counsellors per borough who would teach school staff how to lead the sessions.
It will cost money, they say, but in the long run a little bit of investment now to stop another generation of binge drinkers could save the NHS millions in the future.

Source: 25th August 2010

Addicts require support from other recovering addicts, said the study.
Researchers believe they have identified some of the critical factors that determine whether alcoholics and heroin users can recover.
A study of more than 200 people in Glasgow found that spending time with other recovering addicts made success more likely.
Another predictor of success was whether addicts had something else in their lives to focus on, such as work.
The findings are due to be discussed at a conference in Glasgow.
The research was led by Dr David Best, a reader in criminal justice at the University of the West of Scotland.
“We found that the quality of life maintained by people in methadone maintained recovery wasn’t as good as for people in abstinent recovery” said Dr David Best Researcher He told the BBC’s Good Morning Scotland programme: “Addiction becomes an all-consuming and all-encompassing thing for people “In order for them to meaningfully sustain a recovery, it means it’s not sufficient to have just clinical interventions.
“There have to be a range of replacement activities and the more socially and community-based they are – including things like volunteering, parenting, education and training and obviously working – the more that void is filled and the more successfully individuals manage to build up an architecture of life that replaces that time spent in active addiction.”
The study also considered the role that methadone played in recovery.
Dr Best said: “Certainly as far as our research was concerned, we found that the quality of life maintained by people in methadone maintained recovery wasn’t as good as for people in abstinent recovery.
“It fits with previous research that we’ve done which has shown that there are some long-term effects of methadone, particularly around cognitive functioning, which may act as a mechanism for blunting the aspiration and hope and quality of life.
“It doesn’t mean recovery’s not possible in methadone but there may be some limitations to the extent of it.”
The study, which marks the first Recovery Academy conference in the city, drew parallels between alcoholism and heroin addiction.
Researchers said few differences were noted in the paths to recovery.Community Safety Minister Fergus Ewing, one of the speakers at the conference, said: “The Scottish government’s national drugs strategy, the Road to Recovery, recently reconfirmed by the Scottish Parliament, provides the framework for a fundamental change in our approach to tackling problem drug use through a focus on recovery.
“The Recovery Academy conference, the first of its kind in Scotland, provides the perfect platform for assessing the progress that is being made through this enhanced focus.
“Recovery from serious drug addiction is possible and the research being presented today clearly enhances our knowledge of the challenges faced.”
The event, taking place at the city’s Woodside Halls, is part of the wider Recovery Weekend, which invites people dealing with the effects of addiction, their families and friends to gather in Glasgow to meet and share ideas.

Source: 24th Sept.2010

Doctors have used the drug disulfiram to help patients stay sober for several decades. It interferes with the body’s ability to metabolize alcohol, giving a fierce hangover to someone who consumes even a small amount of alcohol.
More recently, disulfiram was shown to be effective in treating cocaine addiction as well, even though alcohol and cocaine affect the nervous system in different ways.
Now, researchers at Emory University School of Medicine have identified how disulfiram may exert its effects, and have shown that a newer drug with fewer side effects works by the same mechanism.
The results are published online this week by the journal Neuropsychopharmacology. Research assistant professor Jason Schroeder, PhD, and graduate student Debra Cooper are co-first authors of the paper, and the research also involved collaborations with P. Michael Iuvone, PhD, director of research at the Emory Eye Center, Gaylen Edwards, DVM, PhD, head of the department of physiology and pharmacology at the University of Georgia’s College of Veterinary Medicine, and Philip Holmes, PhD, professor of psychology at the University of Georgia.
“Disulfiram has several effects on the body: it interferes with alcohol metabolism, but it inhibits several other enzymes by sequestering copper, and can also damage the liver,” says senior author David Weinshenker, PhD, associate professor of human genetics at Emory University School of Medicine. “We wanted to figure out how disulfiram was working so we could come up with safer and potentially more effective treatments.”
In treating cocaine addiction, there are several challenges: not only getting people to stop taking the drug, but also preventing relapse. Cocaine boosts the levels of several neurotransmitters, including dopamine and norepinephrine, at the junctions between nerve cells by blocking the machinery the brain uses to remove them.
Under normal conditions, dopamine is important for the sensation of pleasure produced by natural rewards such as food or sex, Weinshenker says. Cocaine “hijacks” the dopamine system, which plays a large role in addiction. Similarly, norepinephrine has a role in attention and arousal, but its overactivation can trigger stress responses and relapse, he says.
Weinshenker’s team showed that disulfiram prevents rats from seeking cocaine after a break, a model for addicts tempted to relapse. At the same time, it doesn’t stop them from taking cocaine when first exposed to it, or from enjoying their food.
Disulfiram appears to work by inhibiting dopamine beta-hydroxylase, an enzyme required for the production of norepinephrine. A dose of disulfiram that lowers the levels of norepinephrine in the brain by about 40 percent is effective, while doses that do not reduce norepinephrine have no effect on relapse-like behavior in rats.
To confirm that the beneficial effects of disulfiram were because of dopamine beta-hydroxylase inhibition, the researchers turned to a drug called nepicastat, which was originally developed for the treatment of congestive heart failure in the 1990s.
“Nepicastat is a selective dopamine beta-hydroxylase inhibitor that does not sequester copper or impair a host of other enzymes like disulfiram,” Weinshenker says. “We reasoned that if disulfiram is really working through dopamine beta-hydroxylase, then nepicastat might be a better alternative.”
Researchers at the University of Texas Medical Branch at Galveston have recently completed a Phase I safety trial studying nepicastat for the treatment of cocaine addiction in human subjects.
Weinshenker is co-inventor on a patent on the use of dopamine beta-hydroxylase inhibitors for the treatment of cocaine dependence, and could benefit from their commercialization. This has been reviewed by Emory University’s Conflict of Interest Committee, and a management plan is in place.
The research was supported by the National Institute of Drug Abuse and the National Eye Center.

Source: . ScienceDaily. Retrieved August 30, 2010

A new compound similar to the active component of marijuana (cannabis) might provide effective pain relief without the mental and physical side effects of cannabis, according to a study in the July issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).

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

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

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

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

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

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

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

SOURCE : 2nd July 2010

Researchers have found that a specific and remarkably small fragment of RNA appears to protect rats against cocaine addiction – and may also protect humans.
The discovery could lead to better ways of predicting drug abuse risk and treating addictions

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

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

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

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

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

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

“The results of this study offer promise for the development of a totally new class of anti-addiction medications. Because we are beginning to map out how this specific microRNA works, we may be able to develop new compounds to manipulate the levels of microRNA-212 therapeutically with exquisite specificity, opening the possibility of new treatments for drug addiction,” said Paul J. Kenny, senior author on the study.
The study is published in the journal Nature. (ANI) 9th July 2010-07-10

Few studies can manage the painstaking analyses needed to identify what makes for successful counselling. This Swiss study broke new ground in dissecting why some brief interventionists had far better results than others with risky drinking A&E patients.
Abstract The featured report is one of several from a study of brief advice to heavy drinkers among injured adult patients attending a Swiss emergency department. Among 8439 patients, 1472 heavy drinkers were identified by a health screening survey, of whom 987 joined the study. They were randomly allocated to carry on as usual, to also be assessed by a researcher for about half an hour, or in addition to receive about 15 minutes of advice on drinking immediately after assessment. Adopting the style of motivational interviewing, this compared the patient’s drinking with national norms and led the patient to consider the pros and cons of their drinking and their readiness to change, culminating if appropriate in a setting a goal for change. Over the following year, this typical brief intervention format did not lead to greater reductions in drinking. About two-thirds of the patients continued to drink heavily regardless of advice and/or assessment.
During a period of the study and when patients allowed, intervention sessions were audio-taped. 97 sessions could be rated for the degree to which the counsellor adhered to a motivational style, and for comments from the patient indicative of their ability and willingness to change their drinking. Of these ratings, an initial analysis found that only the patient’s expressed degree of ability to change was related to later drinking; none of the counsellor’s behaviours was significantly linked. However, this analysis tried to separately link each behaviour (in)consistent with motivational interviewing’s principles with drinking. The possibility remained that combining these behaviours to characterise the counsellor’s overall style would yield significant results.
This was the approach taken in two further reports, one of which was the featured report. An earlier analysis established that counsellor comments consistent with the style of motivational interviewing were most likely to elicit positive statements about changing their drinking from the patient. The featured report related the same (and other) measures of counselling style to later drinking, limiting itself to interventions conducted by five counsellors with similar qualifications and experience and uniform preparatory training. Despite this they differed significantly in the their patients’ weekly drinking at the 12-month follow-up, and in the degree to which this represented an improvement on the amount they were drinking on entry to the study. At the extremes were one counsellor whose patients ended up drinking on average 18 UK units more per week, while another registered an average nine unit reduction.
These differences were at least partly accounted for by how far the counsellor was able to actually deliver the intervention in a motivational style. Drinking reductions were greater the more the counsellor demonstrated acceptance of the patient, conducted the intervention in the intended spirit, made more comments consistent versus inconsistent with a motivational approach, avoided inconsistent comments, elaborated on the patient’s comments rather than simply reflecting them back, and reflected back the patient’s comments with or without elaboration rather than asking questions. Empathy levels narrowly missed featuring among these strong and statistically significant links. These same attributes tended to even out the relationship between the patient’s expressed feelings of (in)ability to change and how much they did change their drinking over the 12 months. Highly skilled counsellors had good outcomes almost regardless of the patient’s doubts. The less skilled were effective mainly with patients who already expressed high levels of ability to change.
While accepting the need for replication in a larger study, for the authors their results suggested that an optimal combination of motivational interviewing skills results in better drinking outcomes, regardless of whether the patient is confident (or expresses confidence) in their ability to cut back. The pattern of results across all the reports from the study implies that training should focus on developing an overall approach consistent with motivational interviewing (with a particular focus on avoiding inconsistent behaviour) rather than on the frequent use of particular ‘micro’ techniques. Since training was equalised in the study, it also seems important to select staff with a ‘natural’ ability to adhere to the spirit of motivational interviewing when counselling patients.
These comments are more fully explained and referenced in the associated background notes. This study is one of the few in substance misuse to deeply address how therapists relate to clients in ways which promote positive change. It seems the first to depth-analyse interactions during a brief intervention which (from the patient’s point of view) unexpectedly addresses their drinking while they are seeking help for something else entirely. The implication is that in this situation, the impact of motivational interviewing with heavy drinkers depends on the ability of the counsellor to embody the spirit of the approach, not in minute or tick-box detail, but in broad-brush and consistent application. Given this spirit, as intended, patients in general respond not by defensively deflecting this uncalled-for advance, but by re-evaluating their drinking in ways which lead to a lasting reduction.
As intended by its creators, the findings show that true-to-type motivational interviewing can counter low motivation and doubts, elevating outcomes to near those of the most promising patients. While training doubtless played its part in developing this ability, still it left big differences between counsellors, who presumably varied in the degree to which they could implement what they learned. The more ‘trainable’ dimensions of the frequency of recommended types of comments were relatively uninfluential, the more nebulous ‘spirit’ dimensions more important. Despite expert training and supervision, the result was some therapists whose patients drank more than they did before, others whose patients drank less, a finding which turns the spotlight on staff recruitment. The implication is that without appropriate recruitment, much of the effort put in to training and supervision will be wasted.
The same message emerged from a study of motivational interviewing training which found that initial gains in skills had waned two months later. However, this was not the case for the addiction and mental health clinicians who, even before training, had been more proficient than the other trainees would be after training. Not only did these ‘natural experts’ start from a higher level, they went on to absorb and retain more of what they had learned.
How easy it is to find such people must be a concern. In the featured study all the counsellors were clinical psychologists educated to master degree level, trained by an experienced therapist and supervised throughout using actual client session recordings or observations. This exceptional combination of qualifications, training and ongoing support still resulted in just one of the therapists having a marked positive effect on drinking.
While these are important findings with echoes in other studies, inevitably they stand on a narrow and inadequate evidence base. Studies which probe deeply enough to make sense of what is going on in therapy require labour-intensive analyses, so tend to be limited to perhaps one site and a few therapists, by-products of studies designed to address the effectiveness not of therapists, but of therapies.
Particular caution is needed before assuming that the implications extend to substance misuse treatment. The dynamics in the emergency department are likely to be very different from those in substance misuse treatment clinics, whose patients have already acknowledged their problems and decided at least to give treatment a try. In this situation, the overwhelming influence is the strength of the patient’s resolution. Therapists can still make a noticeable and sometimes substantial difference, but generally more in terms of whether clients want to extend the relationship by staying in treatment, than in whether they change their substance use.
Among several less serious concerns, the featured study’s main weakness is the non-random allocation of patients to therapists, meaning varying caseloads might have influenced the therapists’ performances. However, this does not seem to account for the findings. Confidence in these and in their generalisability is increased by findings from different contexts with similar implications.
Across a range of caseloads, one review of how motivational interviewing works has highlighted (as the featured study did) the importance of therapists avoiding behaviours inconsistent with a motivational approach. Most relevant however are other brief intervention studies of patients not seeking treatment. These confirm that in such circumstances, some therapists are much more able than others to realise the potential of a motivational approach. Avoiding directive and confrontational behaviour seems particularly important with people who when they attended their GP, emergency department, or college, were not expecting their substance use to be addressed at all, let alone in such terms. Even patients who, while not seeking treatment, have volunteered for a check-up of their drinking habits, have reacted badly to such approaches. As in the featured study, other studies have also found that embodying the overall spirit of the approach is related to good outcomes, while the sheer quantity of ‘correct’ micro-behaviours is not. In one study the least effective of three therapists conducting motivational interventions for heavy drinking was also the one who most often used specific recommended techniques.
The dynamics of the therapist-patient encounter seem to differ in a treatment context. Like brief intervention studies, studies of patients actually seeking treatment for substance use problems have confirmed the importance of the overall spirit of the approach rather than micro measures of the frequency of correct therapist behaviours. However, they have been less clear about the damaging impact of behaviours inconsistent with a motivational approach. Within an overall supportive and accepting context, patients react well, or at least, not badly, to a degree of confrontation and caring concern, even if the patient’s permission has not been sought. With clients seeking help for a serious substance use disorder, there is more reason to show concern, be directive, and to warn about possible consequences. Patients who themselves are concerned and seeking direction might see the total absence of such comments from their therapists as withholding their true feelings, perhaps even as uncaring. For these patients the absence of a directive approach can be positively damaging, while those who like to see themselves as in control react badly to directive therapists.
Thanks for their comments on this entry in draft to Jacques Gaume, of the Alcohol Treatment Centre at Lausanne University Hospital. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Source: Findings Sept. 2009 Journal of Substance Abuse Treatment: 2009, 37, p. 151–159.

Combining a randomised trial with a ‘real-world’ test, studies of the Dutch Drinking Less programme have gone further than any others to establish the beneficial impacts of web-based alcohol self-help interventions.


The study was a ‘real-world’ test of a promising Dutch internet-based self-help intervention for problem drinking. A previous randomised trial employing the methodological safeguards possible in tightly controlled research (particularly the recruitment of a comparison group not given access to the intervention) had established that the intervention reduced drinking. At issue in the featured study was whether similar drinking reductions would be seen when the intervention was made freely available to the general public. If they were, then the assumption could be made that these too were caused by having access to the intervention.

Drinking Less is an on-line, interactive programme with no personal therapist input. Aimed at risky drinkers among the general adult population, the intervention is based on principles derived from motivational interviewing, cognitive-behavioural therapies and self-control training. Its home page offers links to alcohol-related information, treatment services, a discussion forum, and the Drinking Less self-help programme, the core of the intervention. Over a recommended six weeks (though this is entirely up to the user) the programme guides visitors in preparing to change their drinking, setting goals , implementing change, and finally sustaining it, preferably by drinking within recommended limits.
The earlier trial had found that six months later, at least 17% of adult problem drinkers randomly allocated to this intervention had reduced their drinking to within Dutch guidelines, compared to just 5% allocated to an on-line alcohol education brochure. Before the study, both groups had averaged about 55 UK units a week. At follow-up, the Drinking Less group had cut consumption to about 36 UK units a week, but the brochure group had barely changed.
The featured study monitored what happened when over 10 months spanning 2007 and 2008 the web site was advertised to the Dutch public. During this time round 27,500 people visited the site, of whom 1625 signed up for the self-help programme, accessing it on average 23 times. Typically they were well educated, employed, middle-aged men. On average they drank about 50 UK units a week, and nearly all who completed the on-line AUDIT screening questionnaire scored in a range indicative of alcohol abuse or dependence.
During the first seven of the 10 months, 378 of site visitors who signed up to the Drinking Less programme also agreed to participate in research to assess its impact. On average they drank roughly the same amount (95% exceeded Dutch guidelines) as all 1625 who signed up and were also similar in age, sex, employment, and motivation to change. Despite some statistically significant differences, they were also broadly similar to participants in the earlier randomised trial. Over 8 in 10 had never received professional help for their drinking. A few weeks later a survey suggested that after signing up, nearly 9 in 10 went on to use the programme, though generally only a few times.
Of the 378 in the baseline sample, 153 responded to an on-line follow-up survey six months later. Before signing up to the programme, just 4% had confined their drinking within Dutch guidelines; six month later, 39% did so. They had also nearly halved their average consumption from 50 UK units to 27. On the ‘fail-safe’ assumption that the intervention had no impact on people who were not followed up, still the drinking reductions were statistically significant; from 5%, the proportion drinking within guidelines rose to 19%, and consumption fell from 51 UK units to 42.
Next the analysts compared these results with those from the six-month follow-up in the randomised trial. Based only on respondents to the follow-up surveys, and adjusting for differences between the samples, in the ‘real-world’ test over twice as many (unadjusted figures 36% v. 19%) people moved to drinking within Dutch guidelines. When the assumption was made that in both trials the intervention had no impact on people not followed up, the figures still favoured the ‘real-world’ test (15% v. 10%), but the difference was no longer statistically significant.
The researchers concluded that the featured study had shown that the benefits established by the randomised controlled trial would be sustained when the intervention was made routinely and generally available to the public. The expected throughput of 3000 Drinking Less programme users a year would amount to nearly 3% of the country’s problem drinkers who would otherwise not have received professional help. Probably because they require the drinker to take the initiative and visit the site, such interventions reach people who, compared to the totality of problem drinkers, are more likely to be women, employed, highly educated, and motivated to change their drinking. Given its low cost per user, this type of intervention seems to have a worthwhile place in a public health approach to reducing alcohol-related problems.
Though only a minority of site visitors may sign up for web-based alcohol programmes, nevertheless the numbers engaged can be very large, and the risk-reductions seem of the order typical in studies of brief advice to drinkers identified in health care settings. In these settings screening programmes typically identify people who are not actually seeking help for drinking problems – ‘pushing’ them towards intervention and change – while web sites ‘pull’ in people already curious or concerned about their drinking. As such these two gateways can play complementary roles in improving public health and offering change opportunities to people who would not present to alcohol treatment services. However, in Britain and elsewhere, both tactics reach only small fractions of the population who drinking excessively, leaving the bulk of the public health work to be done by interventions which drinkers generally cannot avoid and do not have seek out, such as price increases and availability restrictions.
With its combination of a randomised trial and a ‘real-world’ test, the featured research programme has gone further than any other in establishing the beneficial impacts of web-based alcohol interventions. However, largely because many site users do not complete research surveys, it remains impossible to be sure that the results seen in such studies will be replicated across the entire usership of the sites. Details below.

Strengths and limitations of the featured study

The featured study’s combination of a randomised trial with all its methodological safeguards, and a ‘real-world’ trial approximating normal conditions, affords what seems to be the best indication to date of the contribution web-based self-help interventions could make to reducing heavy drinking and associated health risks. However, its twin pillars are weakened by the fact that many people either did not join the studies or did not supply follow-up data; those who did may not have been typical of all the people who might access such sites. In the randomised trial, 40% of the baseline sample did not complete the six-month follow-up survey, and in the featured study, nearly 60%. Though on the measures taken by the study the respondents generally seemed typical of the baseline sample, clearly something was sufficiently different to cause them to respond while the others did not. In both studies this problem was catered for by assuming that non-responders were also non-changers. Though this almost certainly underestimated the impact of the intervention, still in both there remained significant and worthwhile improvements.
What could not be catered for in either study was the degree to which people who join such studies differ from the much greater number who would use the web sites, but decline participation in research. This problem was especially apparent in the featured study, in which it seems that around 6% of site visitors signed up for the self-help programme. Of these, perhaps a third or slightly more of the people who signed up for the programme during the relevant period also agreed to participate in the research. In some important ways (including amount drunk and motivation to change) they seemed similar to the bulk of programme sign-ups, though the researchers suspect they were more likely to have engaged with the programme.

Opening more doors to change for more people

A review of computer-based alcohol services for the general public has rehearsed the advantages: immediate, convenient access for people (the majority in developed nations) connected to the internet; consequently able to capitalise on what may be fleeting resolve; anonymous services sidestep the embarrassment or stigma which might deter help-seeking; such services are available to people unwilling or less able to talk about their problems to a stranger; generally they are free and entail no travel costs or lost income due to time off work; very low operating cost per user if widely accessed; easily updated. In consumption terms, the drinking problems of web site users are comparable to those of drinkers who seek treatment, yet few have received professional help, perhaps partly because their higher socioeconomic status and greater resources have enabled them to restrict the consequential damage. People who actually engage with web-based assessments of their drinking problems have more severe problems than those who just visit and leave. Including the randomised trial which paved the way for the featured study, the review found eight studies which evaluated the effectiveness of computer-based interventions for the general public. In all but one the users significantly improved on at least one of the alcohol-related measures recorded by the studies.
A particular role for alcohol self-help sites may be to offer an easy, quick and accessible way to for drinkers to actualise their desire to tackle their problems, especially when that desire is allied with the resources to implement and sustain improvements without face-to-face or comprehensive assistance. After conducting the Project MATCH trial, some of the world’s leading alcohol treatment researchers argued that “access to treatment may be as important as the type of treatment available”. The implication is that in cultures which accept ‘treatment’ as a route to resolving unhealthy and/or undesirable drinking, having convincing-looking and accessible ‘treatment doors’ to go through may be more important than what lies behind those doors, as long as this fulfils the expectations of the client or patient. This is likely to be especially the case for people who retain a stake in conventional society in the form of marriages, jobs, families, and a reputation to lose. These populations – the kind the featured study suggests are attracted to self-help alcohol therapy web sites – have more of the ‘recovery capital’ resources needed to themselves do most of the work in curbing their drinking.

The British Down Your Drink site

The best known British alcohol self-help web site is the Down Your Drink site run by a team based at University College London, an initiative originally funded by the Alcohol Education and Research Council and now by the Medical Research Council’s National Prevention Research Initiative. In 2007 this was revised to offer set programmes from a one-hour brief intervention to several weeks, but also to generally give the user greater control over the use they made of the site. The approach remained based on principles and techniques derived from motivational interviewing and cognitive-behavioural therapies.
The previous version had been structured as six consecutive modules to be accessed weekly. An analysis of data provided by the first 10,000 people who registered at the site after piloting ended in September 2003 revealed that most were in their 30s and 40s, half were women, nearly two-thirds were married or living with a partner, just 4% were unemployed, and most reported occupations from higher socioeconomic strata. As an earlier study commented, site users were predominantly middle class, middle aged, white and European. Six in 10 either did not start the programme, or completed just the first week. About 17% completed the six weeks. Of these, 57% returned an outcome questionnaire. Compared to their pre-programme status, on average they were now at substantially lower risk, and functioning better and living much improved lives. The sample had been recruited over about 27 months, a registration rate of about 4500 a year. By way of comparison, in England during 2008/09, around 100,000 adults were treated for their alcohol problems at conventional services. User profile and site usage had been similar during the earlier pilot phase. Results from surveys sent to pilot programme completers indicated that three quarters had never previously sought help for their drinking.

Source: Published in Findings 19 May 2010 Alcoholism: Clinical and Experimental Research: 2009, 33(8), p. 1401–1408

Combining a randomised trial with a ‘real-world’ test, studies of the Dutch Drinking Less programme have gone further than any others to establish the beneficial impacts of web-based alcohol self-help interventions.
Abstract The study was a ‘real-world’ test of a promising Dutch internet-based self-help intervention for problem drinking. A previous randomised trial employing the methodological safeguards possible in tightly controlled research (particularly the recruitment of a comparison group not given access to the intervention) had established that the intervention reduced drinking. At issue in the featured study was whether similar drinking reductions would be seen when the intervention was made freely available to the general public. If they were, then the assumption could be made that these too were caused by having access to the intervention.

Drinking Less is an on-line, interactive programme with no personal therapist input. Aimed at risky drinkers among the general adult population, the intervention is based on principles derived from motivational interviewing, cognitive-behavioural therapies and self-control training. Its home page offers links to alcohol-related information, treatment services, a discussion forum, and the Drinking Less self-help programme, the core of the intervention. Over a recommended six weeks (though this is entirely up to the user) the programme guides visitors in preparing to change their drinking, setting goals , implementing change, and finally sustaining it, preferably by drinking within recommended limits.
The earlier trial had found that six months later, at least 17% of adult problem drinkers randomly allocated to this intervention had reduced their drinking to within Dutch guidelines, compared to just 5% allocated to an on-line alcohol education brochure. Before the study, both groups had averaged about 55 UK units a week. At follow-up, the Drinking Less group had cut consumption to about 36 UK units a week, but the brochure group had barely changed.
The featured study monitored what happened when over 10 months spanning 2007 and 2008 the web site was advertised to the Dutch public. During this time round 27,500 people visited the site, of whom 1625 signed up for the self-help programme, accessing it on average 23 times. Typically they were well educated, employed, middle-aged men. On average they drank about 50 UK units a week, and nearly all who completed the on-line AUDIT screening questionnaire scored in a range indicative of alcohol abuse or dependence.
During the first seven of the 10 months, 378 of site visitors who signed up to the Drinking Less programme also agreed to participate in research to assess its impact. On average they drank roughly the same amount (95% exceeded Dutch guidelines) as all 1625 who signed up and were also similar in age, sex, employment, and motivation to change. Despite some statistically significant differences, they were also broadly similar to participants in the earlier randomised trial. Over 8 in 10 had never received professional help for their drinking. A few weeks later a survey suggested that after signing up, nearly 9 in 10 went on to use the programme, though generally only a few times.
Of the 378 in the baseline sample, 153 responded to an on-line follow-up survey six months later. Before signing up to the programme, just 4% had confined their drinking within Dutch guidelines; six month later, 39% did so. They had also nearly halved their average consumption from 50 UK units to 27. On the ‘fail-safe’ assumption that the intervention had no impact on people who were not followed up, still the drinking reductions were statistically significant; from 5%, the proportion drinking within guidelines rose to 19%, and consumption fell from 51 UK units to 42.
Next the analysts compared these results with those from the six-month follow-up in the randomised trial. Based only on respondents to the follow-up surveys, and adjusting for differences between the samples, in the ‘real-world’ test over twice as many (unadjusted figures 36% v. 19%) people moved to drinking within Dutch guidelines. When the assumption was made that in both trials the intervention had no impact on people not followed up, the figures still favoured the ‘real-world’ test (15% v. 10%), but the difference was no longer statistically significant.
The researchers concluded that the featured study had shown that the benefits established by the randomised controlled trial would be sustained when the intervention was made routinely and generally available to the public. The expected throughput of 3000 Drinking Less programme users a year would amount to nearly 3% of the country’s problem drinkers who would otherwise not have received professional help. Probably because they require the drinker to take the initiative and visit the site, such interventions reach people who, compared to the totality of problem drinkers, are more likely to be women, employed, highly educated, and motivated to change their drinking. Given its low cost per user, this type of intervention seems to have a worthwhile place in a public health approach to reducing alcohol-related problems.
Though only a minority of site visitors may sign up for web-based alcohol programmes, nevertheless the numbers engaged can be very large, and the risk-reductions seem of the order typical in studies of brief advice to drinkers identified in health care settings. In these settings screening programmes typically identify people who are not actually seeking help for drinking problems – ‘pushing’ them towards intervention and change – while web sites ‘pull’ in people already curious or concerned about their drinking. As such these two gateways can play complementary roles in improving public health and offering change opportunities to people who would not present to alcohol treatment services. However, in Britain and elsewhere, both tactics reach only small fractions of the population who drinking excessively, leaving the bulk of the public health work to be done by interventions which drinkers generally cannot avoid and do not have seek out, such as price increases and availability restrictions.
With its combination of a randomised trial and a ‘real-world’ test, the featured research programme has gone further than any other in establishing the beneficial impacts of web-based alcohol interventions. However, largely because many site users do not complete research surveys, it remains impossible to be sure that the results seen in such studies will be replicated across the entire usership of the sites. Details below.
Strengths and limitations of the featured study
The featured study’s combination of a randomised trial with all its methodological safeguards, and a ‘real-world’ trial approximating normal conditions, affords what seems to be the best indication to date of the contribution web-based self-help interventions could make to reducing heavy drinking and associated health risks. However, its twin pillars are weakened by the fact that many people either did not join the studies or did not supply follow-up data; those who did may not have been typical of all the people who might access such sites. In the randomised trial, 40% of the baseline sample did not complete the six-month follow-up survey, and in the featured study, nearly 60%. Though on the measures taken by the study the respondents generally seemed typical of the baseline sample, clearly something was sufficiently different to cause them to respond while the others did not. In both studies this problem was catered for by assuming that non-responders were also non-changers. Though this almost certainly underestimated the impact of the intervention, still in both there remained significant and worthwhile improvements.
What could not be catered for in either study was the degree to which people who join such studies differ from the much greater number who would use the web sites, but decline participation in research. This problem was especially apparent in the featured study, in which it seems that around 6% of site visitors signed up for the self-help programme. Of these, perhaps a third or slightly more of the people who signed up for the programme during the relevant period also agreed to participate in the research. In some important ways (including amount drunk and motivation to change) they seemed similar to the bulk of programme sign-ups, though the researchers suspect they were more likely to have engaged with the programme.
Opening more doors to change for more people
A review of computer-based alcohol services for the general public has rehearsed the advantages: immediate, convenient access for people (the majority in developed nations) connected to the internet; consequently able to capitalise on what may be fleeting resolve; anonymous services sidestep the embarrassment or stigma which might deter help-seeking; such services are available to people unwilling or less able to talk about their problems to a stranger; generally they are free and entail no travel costs or lost income due to time off work; very low operating cost per user if widely accessed; easily updated. In consumption terms, the drinking problems of web site users are comparable to those of drinkers who seek treatment, yet few have received professional help, perhaps partly because their higher socioeconomic status and greater resources have enabled them to restrict the consequential damage. People who actually engage with web-based assessments of their drinking problems have more severe problems than those who just visit and leave. Including the randomised trial which paved the way for the featured study, the review found eight studies which evaluated the effectiveness of computer-based interventions for the general public. In all but one the users significantly improved on at least one of the alcohol-related measures recorded by the studies.
A particular role for alcohol self-help sites may be to offer an easy, quick and accessible way to for drinkers to actualise their desire to tackle their problems, especially when that desire is allied with the resources to implement and sustain improvements without face-to-face or comprehensive assistance. After conducting the Project MATCH trial, some of the world’s leading alcohol treatment researchers argued that “access to treatment may be as important as the type of treatment available”. The implication is that in cultures which accept ‘treatment’ as a route to resolving unhealthy and/or undesirable drinking, having convincing-looking and accessible ‘treatment doors’ to go through may be more important than what lies behind those doors, as long as this fulfils the expectations of the client or patient. This is likely to be especially the case for people who retain a stake in conventional society in the form of marriages, jobs, families, and a reputation to lose. These populations – the kind the featured study suggests are attracted to self-help alcohol therapy web sites – have more of the ‘recovery capital’ resources needed to themselves do most of the work in curbing their drinking.
The British Down Your Drink site
The best known British alcohol self-help web site is the Down Your Drink site run by a team based at University College London, an initiative originally funded by the Alcohol Education and Research Council and now by the Medical Research Council’s National Prevention Research Initiative. In 2007 this was revised to offer set programmes from a one-hour brief intervention to several weeks, but also to generally give the user greater control over the use they made of the site. The approach remained based on principles and techniques derived from motivational interviewing and cognitive-behavioural therapies.
The previous version had been structured as six consecutive modules to be accessed weekly. An analysis of data provided by the first 10,000 people who registered at the site after piloting ended in September 2003 revealed that most were in their 30s and 40s, half were women, nearly two-thirds were married or living with a partner, just 4% were unemployed, and most reported occupations from higher socioeconomic strata. As an earlier study commented, site users were predominantly middle class, middle aged, white and European. Six in 10 either did not start the programme, or completed just the first week. About 17% completed the six weeks. Of these, 57% returned an outcome questionnaire. Compared to their pre-programme status, on average they were now at substantially lower risk, and functioning better and living much improved lives. The sample had been recruited over about 27 months, a registration rate of about 4500 a year. By way of comparison, in England during 2008/09, around 100,000 adults were treated for their alcohol problems at conventional services. User profile and site usage had been similar during the earlier pilot phase. Results from surveys sent to pilot programme completers indicated that three quarters had never previously sought help for their drinking.
Source: Published in Findings 19 May 2010 Alcoholism: Clinical and Experimental Research: 2009, 33(8), p. 1401–1408

Government drug policy is too centred on heroin abuse, fails to take account of the realities of current usage trends and needs to focus on individual user behaviour if it is to reflect the true picture and formulate meaningful responses, a leading academic at National University of Ireland Maynooth urged.
‘A Dizzying Array of Substances; An Ethnographic Study of Drug Use in the Canal Communities’ is the result of a long-term study which closely examined the realities of drug use in local life of Rialto, Bluebell and Inchicore, three communities served by the Canal Communities Local Drugs Task Force. It was led by principal investigator Dr A Jamie Saris and primary field researcher Fiona O’Reilly at the Department of Anthropology, NUI Maynooth.
The ethnographic research, carried out mostly in 2008 and early 2009, gives the most compelling evidence to date that multiple drug use is the norm amongst drug users in the Canal Communities and, the researchers concluded, most probably in other areas.
“The big problem is that as far as government is concerned, ‘drugs’, from a treatment perspective, has traditionally meant heroin. Thus, the apparent leveling off of the need for a very opiate-centric treatment service in the Canal Communities in recent years is deceptive” said Dr Saris.
Besides the ethnographic work, the study surveyed, on a long term basis, 92 people using either heroin or methadone in the study area. Unsurprisingly most of those surveyed were on methadone (98%). Of those surveyed:
•63% claimed to have used heroin in the previous three months
•30% had used crack cocaine
•22% had used powder cocaine
•46% had also taken street tranquilisers
•50% were on prescribed tranquillisers, and
•60% had also smoked cannabis within the past three months.
“The majority of those registered on the methadone treatment programme are also using a cocktail of other substances, very often including heroin. Multiple drug use is the reality for nearly all users, and official policy needs to have this understanding at its centre”, Saris said.
In the course of their study, the research team also noted a strong stigma against heroin use amongst the 16-25 age group who still regularly used a lot of other substances, including cocaine and off-label prescription medication. “The reality is that these people are difficult for a treatment infrastructure built around opiates to service. If they have issues, they are more difficult to address,” said Saris.
” The stress that policy-makers and community activists place on ‘crack’ or ‘heroin’ or any other single drug as clear and present social dangers obscures the ubiquity of polydrug use. It makes it appear that these users are very different from other drug-users in the rest of society including cannabis and recreational cocaine users, and it also obscures how commonly legal pharmaceuticals, such as benzodiazepines, even methadone itself, are regularly consumed ‘illegally’.”
He said that a focus on drug use alone is the mistake. “The lives we examined, however damaged by an attraction to certain pharmaceuticals, are rarely defined solely by such behaviour. These people are also sons and daughters, fathers and mothers, partners and lovers, as well as employees and community members. This sensibility does in fact inform a lot of local community activities aimed at assisting users, but such work is often difficult to justify to official funders under the rubric of ‘treatment’, as currently understood. Unless we can understand who users are, what they are taking and why, we will not be able to assign the appropriate resources, treatments or management systems.”
Tony MacCarthaigh, chairperson of the Canal Communities Local Drugs Task Force commented that “individuals and not chemicals need to become the focal point of treatment, and treatment needs to assist individuals in developing another orientation not just to drugs, but to life”.
Source: 9th July 2010

An 18-year-old male presents complaining of crampy abdominal pain, nausea, and intractable vomiting for the past year. The symptoms are episodic, lasting several weeks and remitting for weeks to months.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Source July 15th 2010

A TENFOLD increase in hospital treatment for cannabis poisoning or dependence among people in their 30s and 40s suggests the habit has run out of control for a hard core of long-term users.
Australian research shows that while cannabis consumption overall decreased during the past decade, the rate of hospital treatment rose. Treatment rates are highest among people in their 20s, but the steepest increase has been among older people, with those in their 30s only slightly less likely to seek help than younger people by 2007, the study shows.
Seven years earlier, people in their 30s were being treated at only half the rate of their younger counterparts, according to the findings of the National Drug and Alcohol Research Centre at the University of NSW. Their faster rise in cannabis-related health problems coincided with greater frequency of daily use.
“These people started their use early and have [in some cases] then gone on to develop problems,” the study leader, Amanda Roxburgh, said. “They might not necessarily think that they have a problem with their use until it kicks into crisis mode.” People in their 20s were about 50 per cent more likely to have used cannabis during a one-year period compared with those in their 30s. But of those who did so, nearly 20 per cent of the older age group had developed a daily habit, against about 15 per cent of the younger adults.
Ms Roxburgh, whose results are published in the journal Addiction, said the rise in problematic use might reflect increased cannabis potency, though there was no formal evidence the drug had become stronger. Its falling price suggested it was being produced more efficiently – perhaps through indoor hydroponic cultivation – and this might have made it more accessible.
Jan Copeland, who heads the National Cannabis Prevention and Information Centre, said older people were more likely to consider cannabis safe. “These people come from age groups where cannabis is a benign herb and natural,” she said. “But when you are doing something every day you don’t realise the difficulties when you try to stop”.
Cannabis use among people aged 14 to 19 more than halved between 1996 and 2005, but the study also found pockets of harmful use in that group. Nearly two-thirds of young daily cannabis users reported difficulties controlling their use.
Members of this group were also more likely to report smoking 10 or more cones or joints a day, and if they were treated in hospital for their cannabis use were more likely to be treated for psychosis than older users.
Professor Copeland said young people now understood cannabis could be dangerous, and fewer were experimenting, but dedicated treatment programs were still needed for young people with a serious habit.
Will Temple, chief executive officer of the Watershed drug and alcohol recovery and education centre in Wollongong, said his centre had gone from treating almost no cannabis users to in the past six months treating 30 per cent of clients for cannabis use.
Source: The Sydney Morning Herald 29th March 2010

Scientists at Melbourne’s Howard Florey Institute have discovered a system in the brain that stops an alcoholic’s craving for alcohol, as well as prevent relapse once they have recovered from alcohol addiction.
The ‘Orexin’ system is a group of cells in a part of the brain called the hypothalamus. These cells produce Orexin, which was originally implicated in the regulation of feeding, but it soon became apparent that Orexin was also involved in the ‘high’ felt after drinking alcohol or taking illicit drugs.

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

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

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

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

Source: ScienceDaily. Retrieved March 28, 2010 Howard Florey Institute (2006, December 13).


The present study represents the first large-scale test of the capacity to predict illicit drug treatment outcomes of an instrument [Stages of Change and Treatment Eagerness Scale (SOCRATES)] purporting to measure processes underlying stages of change. The main hypothesis was that ‘taking steps’ should be predictive of less frequent use of illicit opiates (heroin and non-prescribed methadone) at follow-up.

The sample comprised 1075 people seeking treatment for drug abuse problems in 54 treatment agencies in England. The study uses a longitudinal, prospective cohort design. Structured interviews were conducted at treatment intake and at 1-year follow-up. Data were collected about illicit drug use (frequency of use of heroin, non-prescribed methadone, cocaine and amphetamines, and non-prescribed benzodiazepines) and other problems.

Results failed to support the hypothesis that taking steps should be associated with less frequent use of illicit opiates at follow-up. No statistically significant associations of any kind were found between readiness for change measures and use of opiates or stimulants at follow-up. A negative association was found between taking steps and benzodiazepine misuse. Readiness for change measures were correlated with heroin use and psychiatric symptom scores at treatment intake.
Readiness for change measures were not associated with illicit drug use outcomes. Of the 12 hypothesized relationships between readiness for change measures and outcomes, our results show only one ‘hit’ and 11 ‘misses’.

Source: Addiction Volume 102 Issue 2 Page null – February 2007 Addiction 102 (2)

Research Summary

Researchers from Stanford University found that a *12-step oriented treatment program that included attending Alcoholics Anonymous meetings boosted two-year sobriety rates by 30 percent compared to cognitive-behavioral (CB) programs, the BBC reported Jan. 29.
Twelve-step oriented programs also cost 30 percent less than CB-based treatment for addiction, the researchers said.
Lead study author Keith Humphreys said the spiritual dimension of AA may explain why recovering alcoholics in such programs are better able to resist the temptation to return to drinking.
The study appears in the journal Alcoholism: Clinical and Experimental Research.
*Editor’s Note, Jan. 31, 2007:
As originally published on January 30, the title of the summary read: “AA Boosts Sobriety by 30 Percent, Study Says.” We have changed the title and summary to clarify that the researchers studied 12-step oriented treatment programs — not only AA meetings.

Source: Humphreys, K., Moos, R.H. (2007) Encouraging Posttreatment Self-Help Group Involvement to Reduce Demand for Continuing Care Services: Two-Year Clinical and Utilization Outcomes. Alcoholism: Clinical and Experimental Research, 31(1): 64–68; doi: 10.1111/j.1530-0277.2006.00273.x.

Brief skills training is effective to curb college drinking
A study in Swedish colleges, where over-use of alcohol is widespread, showed that a Brief Skills Training Program was effective in reducing alcohol consumption over a two-year period.

Students were randomly assigned to a brief skills training program (BSTP) with interactive lectures and discussions, a twelve-step–influenced (TSI) program with didactic lectures by therapists trained in the 12-step approach, and a control group. More than three quarters of the students were rated “high risk” on an alcohol consumption score.

At follow-up two years later, the high-risk students who had received the BSTP program showed significantly better outcomes than high-risk students who had undergone TSI. The TSI students did no better than the control group.

Source:The study results are in the March issue of Alcoholism: Clinical and Experimental

Research Summary

Smoking among young adults has plummeted since California implemented a groundbreaking tobacco-control plan 12 years ago, according to new research from the University of California at San Diego.

The California Tobacco Control Program, established in 1989, has been credited with reducing smoking among all adult smokers, but the decline among young adults has been especially striking, researchers said. Notably, cessation rates among young Californians were higher than among young adults in New York and New Jersey, which have similarly high tobacco prices but lack comprehensive stop-smoking campaigns, as well as compared to young adults in tobacco-growing states (TGS).

“We were surprised to find that, since the advent of the California campaign, young people have increased their rate of quitting by 50 percent, far more than their older counterparts,” said study author Karen Messer, Ph.D. “It used to be that smokers over age 50 were the ones quitting because they understood the health consequences of smoking …
“These young adults have grown up in a tobacco-controlled climate, where smoking isn’t the norm and isn’t socially supported. We may be seeing the first generation who believe it’s not cool to smoke, which could pay huge dividends in their future health.”

Another UCLA study focused on tobacco consumption trends. “We found that there is a national trend of declining cigarette consumption for all age groups, but the most significant by far was observed in California smokers over age 35,” noted researcher Wael K. Al-Delaimy, M.D., Ph.D.
“The data suggest that — compared with states with no tobacco control initiatives (TGS) or states with an increased cigarette price as the principal tobacco control measure (NY/NJ) – California’s comprehensive tobacco control program is more effective in decreasing cigarette consumption for those over age 35.”

Source: journal Tobacco Control April 2007

A Temple University psychologist argues that society would be better off using strict laws to prevent risky behaviors by adolescents rather than education programs, saying that teens’ brains are too immature to avoid risk-taking, USA Today reported April 5.
“We need to rethink our whole approach to preventing teen risk,” said researcher Laurence Steinberg, who drew his conclusions after reviewing a decade’s worth of research on the adolescent brain. “Adolescents are at an age where they do not have full capacity to control themselves. As adults, we need to do some of the controlling.”
Steinberg said society would be best served by raising the driving age, increasing cigarette prices, and enforcing underage-drinking laws than investing in prevention programs. “I don’t believe the problem behind teen risky behavior is a lack of knowledge,” he said. “The programs do a good job in teaching kids the facts. Education alone doesn’t work. It doesn’t seem to affect their behavior.”
“Kids will sign drug pledges. They really mean that, but when they get in a park on a Friday night with their friends, that pledge is nowhere to be found in their brain structure,” agreed psychologist Michael Bradley. “They’re missing the neurologic brakes that adults have.”
Isabel Sawhill, co-director of the Center on Children and Families at the Washington-based Brookings Institution, said the findings are “good research for policymakers to consider, but we shouldn’t infer from this research that all our past efforts have been ineffective. I’m not in favor of just doing education, but I’m also not in favor of not doing it, either. We need to do some of both.”

Source: Current Directions in Psychological Science. April 2007

A drug which reduces the desire for marijuana and blocks its effect on the brain has been successfully tested in rats. Scientists say the findings may translate into better therapies for cannabis addiction in humans.
Rodents given a compound derived from a plant in the buttercup family lose their hankering for a synthetic version of tetrahydrocannabinol (THC) – the active compound in marijuana. The treatment also blocked a reward response in the animals’ brains when they did receive synthetic THC.
In the first part of the experiment, Steven Goldberg at the National Institute on Drug Abuse in Maryland, US, and his colleagues placed rats in a cage with a lever the animals could push. Each time the rats leaned on the lever, they received a dose of the synthetic THC through a small tube running into their body.
Over a period of three weeks the rats learned to enjoy the effects of synthetic THC and frequently self-administered the drug. By comparison, rats that received saline solution did not press the lever often.
Goldberg’s team then injected the rats with a compound derived from the seeds of the Delphinium brownii plant, which is in the buttercup family. The compound, known as methyllycaconitine (MLA), had a dramatic effect on the animals’ behaviour.

Blocking dopamine
On the day that they received MLA they pushed the lever for synthetic THC 70% less than before. The drug did not seem to otherwise change the rats’ movement and coordination, and had no other apparent side effects.
The scientists also took a close look at the effects of MLA on the rats’ brains. They used a technique called microdialysis to take tiny fluid samples from a reward-signalling area of the brain known as the nucleus accumbens, which sits near the base of the head.
When rats receive synthetic THC, levels of the reward chemical dopamine normally shoot up in the nucleus accumbens – but MLA blocked the release of dopamine in this brain region.
“The increases in dopamine are virtually non-existent because of MLA,” says Goldberg. He adds that MLA did not lower dopamine levels below normal amounts. This is important, says Goldberg, because it suggests that a similar therapy for humans would not interfere with normal reward signalling in the brain.
He notes that the drug Rimonobant, which makes monkeys less likely to self-administer THC, has been linked to depression in humans.
The exact mechanism by which MLA works remains a mystery. Scientists know that MLA binds to specific cell receptors in the brain called alpha-7 nicotinic receptors. They speculate that cannabis indirectly triggers these receptors, but cannot do so when the receptors are blocked by MLA.

Human potential
There is a genuine need for medications to help cannabis addicts overcome their drug problem, according to Goldberg: “About 10% of the people who experiment with it go on to heavy use and have trouble voluntarily giving it up. I think there is a proportion of the population who need ways to make them stop.”
Drug-makers have recently made medications such as Chantix available to help people quit tobacco smoking. But researchers say that these drugs affect different nicotinic receptors than those triggered by THC.
And while some people have pushed Rimonobant as a possible remedy for addiction, Goldberg says that more options – such as one based on MLA – must be explored: “Each patient is different and what works in one might not work in another.”

Source: Journal of Neuroscience (DOI: 10.1523/JNEUROSCI.0027-07.2007)

May 23, 2007
Research Summary

A compound known as methyllycaconitine (MLA) appears to block craving for and the effects of a synthetic version of THC, the main active ingredient in marijuana, New Scientist reported May 22.
Animal tests revealed that MLA, derived from Delphinium brownii, a plant in the buttercup family, cut craving for THC and blocked the brain’s reward response for the drug. Rats that received injections of MTA pushed a lever for doses of THC 70 percent fewer times than on days where they did not receive MLA.
Studies of the rats’ brains also showed that THC did not increase dopamine levels when MLA was present. “The increases in dopamine are virtually nonexistent because of MLA,” said lead researcher Steven Goldberg of the National Institute on Drug Abuse, who said the findings could have implications for addiction treatment for humans.

Source: The study was published in the Journal of Neuroscience.

A prescription-only pill with a high success rate in helping people to quit smoking is to become available on the NHS after a decision yesterday by the government’s drugs watchdog.
The National Institute for Clinical Excellence gave draft approval for the health service to provide varenicline, which is manufactured by Pfizer under the brand name Champix. Trials showed the twice-daily pill provided relief from cravings and withdrawal symptoms experienced by smokers in the weeks after quitting.

The manufacturers said it also reduced the satisfaction smokers would get from cigarettes in the event of a relapse.
During the trials, 44% of smokers had quit by the end of a 12-week course. This compared with a 30% success rate for the anti-smoking drug Zyban and 18% for smokers who were given a placebo.
The recommended 12-week course of treatment costs about £163.80.
Giving draft approval allows NHS trusts or professional bodies to register objections before a decision in July. NHS trusts would then have three months to make funding available. A spokeswoman for Nice said: “Having looked at all the evidence, our independent committee has concluded that varenicline appears to be a good way to help people who want to quit smoking.”
Robert West, professor of health psychology at University College London, said: “This guidance gives smokers who are serious about stopping another choice from a good range of clinically proven treatments. Smokers who combine treatments with the right support…could significantly increase their odds of successfully quitting for life.”

Source Thursday May 31, 2007 The Guardian

A record number of young people were treated for a drugs and alcohol problem last year.
Counsellors in England alone saw 52,294 people aged 13-24, a rise of 12% in two years, according to data from the National Treatment Agency (NTA).
There’s been a sharp drop in those addicted to ‘hard’ drugs like heroin.
Instead under-25s are now more likely to have a problem with a cocktail of ‘party’ drugs like cocaine, cannabis and ecstasy, often mixed with alcohol.
Campaigners say treatment services aimed at young adults need to change quickly to deal with what some are calling the biggest shift in drug habits in a generation.
‘Taken it all’
Newsbeat went to a drug treatment scheme in Stockport to speak to 24-year-old Steve, not his real name, from Liverpool.
“It first started when I was 15,” he said.
“Cannabis led to whizz, Es, pills and coke. Alcohol and drugs were a major part of my life for five years.
“When you’re young you hate to be the one left out and most my friends at school were alcohol and drug users.
“I was taking whatever I could get my hands on and mixing them with alcohol. We would come back at one or two in the morning every night and my mum and dad would be fuming.”
Treatment rises
Officials from the NTA say the overall rise in treatment over the last three years does not necessarily mean a record number of young people are abusing drugs and alcohol.
They claim at least part of the increase can be explained by the growth in treatment services.
Young people picked up by the police are also more likely to be drug tested and referred to a treatment centre.
But the figures do show a major change in the kind of drugs young people are getting treated for.
Counsellors are seeing a dramatic shift away from heroin and crack use, the two ‘problem drugs’ typically linked to serious abuse.
18,597 people aged 13-24 were treated for an addiction to those two drugs last year, down 19% in just two years.
At the same time, more young people are having a problem with booze mixed with ‘softer’ party drugs, a phenomenon nicknamed ACCE (pronounced ‘ace’) by drug workers, short for Alcohol plus Cocaine, Cannabis and Ecstasy.
The number of under-25s getting treatment for one or more of those drugs has gone up 44% from 21,744 in 2005/6 to 31,401 in 2007/8.
“Alcohol is cheaper and more available, cannabis is far stronger, cocaine is half the price it used to be and you can get half a dozen ecstasy tablets for £10,” according to Howard Parker, Professor Emeritus at Manchester University, who coined the term ‘ACCE’ last year.
“Put those three together and you’ve got just as serious a problem for health, family life and society as heroin.”
Work carried out by Parker and researchers at Liverpool John Moores University shows the average age of a heroin user in treatment in North West England has risen to 36. The average age of someone with an ACCE problem is just 22.
But while youth services aimed at under-18s can be effective at dealing with an ACCE-type problem, when users hit their 18th birthday they are often forced to switch to an adult-only drug treatment service.
“Those [adult] services are there to deal with heroin and crack users,” said Parker. “The real issue is why there are hardly any services for ACCErs when they get to 18. It’s just pot luck; it’s a postcode lottery.”
Adult drug projects are paid twice as much for treating a heroin and crack user as someone with a powder cocaine or ecstasy problem.
As a result, those services tend to focus on medical treatment like methadone replacement, a drug used to wean heroin users off their addiction.
But there are no ‘replacement’ drugs to treat a cocaine or cannabis problem.
Instead months or even years of therapy and support are needed to get users to manage their drug problem and eventually quit.
Alcohol plus drugs
The man in charge of young people’s drug policy for the National Treatment Agency, Tom Aldridge, told Newsbeat that adult services focus on heroin and crack users for a reason.
“There are very clear links between acquisitive crime and problematic [heroin and crack] drug use,” he said.
“We want to prioritise those drugs because they have more of an impact on society in terms of criminal activity and public health.
“But we are very clear that people should be given a service depending on their need, not depending on their age.
“If you have a 20 or 21-year-old that requires treatment best given by an under-18 service then they should go to that service.”
All under-18 services in England combine alcohol and drug treatment so young people can get detox and therapy for both problems at the same time.
But almost all adult services split alcohol and drugs into two completely separate programmes in different locations with different counsellors and critics say that can often mean young people drop out.
Tom Aldridge accepts that there may be an argument for combining alcohol and drug treatment for over-18s in England, as they have recently decided to do in Northern Ireland.
“We have no responsibility for the alcohol agenda,” he said. “If that were the case, there may well be lots in advantages in that. But it’s not the case at the moment.”
The Stockport solution
But in some parts of the country a handful of treatment services are already changing the way they work to deal with the ACCE phenomenon.
Newsbeat went to see a council-run drug scheme for young people in Stockport that has increased the age range of its patients from 18 all the way up to 25.
Heidi Shaw, who runs the centre called Mosaic, said that decision was a direct result of seeing more young people with recreational drug problems come through the doors.
“We knew those young people would not get help elsewhere,” she said. “Their lives are still being devastated by drugs. They are still having problems with crime, housing, training and employment.
“The same profile of substance misuse is coming through. It’s cannabis, alcohol and then cocaine.”
Mosaic also runs a service to support parents and family members of people in treatment and carries out drug prevention work in Stockport’s 14 schools.
Steve has been getting treatment for his alcohol and drug problems there for four years.
“I feel more comfortable because they seem to understand more about you,” he said. “They contact you virtually every day to see how you are doing.
“I went through detox. They put you in a dry house for a week and give you medication to counteract the effects of alcohol and the cravings.
“Since then I’ve not touched a drop and I’ve got Mosaic to thank for that.
“My life’s changed because I’m off alcohol completely and I’m working on the drugs. Hopefully this time next year, I will be off them as well.”
Source:  BBC Newsbeat 8th June 2009

The annual United Nations World Drug Report published yesterday confirmed my analysis of the available data which shows the UK to have the worst drugs problem in Europe. Yet a month ago when the The Phoney War on Drugs was published by the CPS Jacqui Smith and the Home Office went into denial mode.
While repeating Labour’s worn out justification that “overall drug use is lower than when Labour took office”, and that this is “a clear sign that our strategy is working” – exactly the myth that my paper debunked – she resolutely turned her back on the facts of rising drug deaths, rising ‘problem’ drug use (now put by the UN at 400,000, some 70,000 higher than 2006 measures)  rising prescribed methadone dependency and the doubling of cocaine consumption.
Even before the latest UN report figures were released new data in the last month on drugs related damage and a new analyses of seizure data confirmed my thesis.  The Independent on Sunday  revealed a 67% increase in the number of babies born suffering from drug withdrawal symptoms in the past 10 years even though these statistics (of opiate addicted babies) exclude those newborns with problems due to their mother’s exposure to cocaine, amphetamines and cannabis.
Yesterday’s UN Report repeated my comparative data analysis which showed that the UK is the largest market for cocaine and that consumption has more than doubled in recent years and is higher than anywhere else in Europe.
Martin Blakebrough, the CEO of the drug charity Kaleidoscope said in response that, “The numbers exploded probably around five years ago and they’ve continued to rise because it’s become more mainstream .. it has a kudos or glamour not associated with other substances”. Meanwhile drugs counsellors confirm that teenagers are moving from cannabis to cocaine as young as 14 and that use by children as young as 11 is rising. It is something that the government’s preferred treatment intervention, methadone prescribing, can do nothing about.
SOCA’s claim that this consumption rise is despite cocaine prices reaching record levels due to their interdiction must however be treated with extreme scepticism. These are not street prices and reflect currency exchange rate changes as I pointed out a few weeks ago.
The truth is that the explosion in cocaine use mirrors a period in which UK cocaine quantity seizures have dropped, as have prices, while the market has expanded. The hard evidence I detailed in my paper points to failing enforcement competence and commitment on the part of the government and SOCA. Furthermore publication this month of an analysis of Scottish heroin seizures by Professor Neil McKeagney confirmed that these are at record lows.
So, surely now the Government and its various drugs satellites and quangos must face the truth of the uniquely appalling social problem we face in Britain and the extent to which their misguided policy has contributed to it.  They must finally give up trying to justify themselves by one selective measure of drugs use prevalence picked from the British Crime Survey and the English Schools survey and accept the fact that this does not even begin to measure the extent of drugs related harm. Even less does it measure policy efficacy.
Nowhere is this claim less credible than in their resort to these ‘official’ measures of declining cannabis use to ‘prove’ that adolescent drug use and addiction are under control.  Neither of these surveys reach the part of the population that drugs reach most. Fewer schools sampled each year chose to cooperate.  The number of truanting, absentee and excluded children continues to rise.  The Government apparently remains convinced that if schoolchildren’s cannabis use is dropping that this is sufficient unto the day. The ‘if’ remains quite big.
The reality on the streets however is one of a youth alcohol and drugs crisis that Ray Lewis illustrated powerfully in response to my paper. The number in need of drugs treatment continues to rise (alongside hospital admissions); demand outpaces provision while the ‘treatment’ on offer is totally inadequate.
One thin and poorly nourished boy I met last week told me that on his estate he knew no one, neither adolescent nor adult, who did not use drugs.  And just a few weeks ago when I asked a health visitor working in inner London how many of the 400 families on her books had a drug problem, she countered defensively, “don’t ask, it is a fact of life, we have to accept it.”  That is the trouble. This is the official attitude to drug use and everything that goes with it is: ‘There is nothing you can do’.
But it is the Government’s performance-driven, methadone ‘treatment’ drugs policy that is maintaining these lifestyles rather than changing them. All the kids do, one adolescent addiction counsellor told me, is use ‘community treatment’ on offer as part of this lifestyle.  They are offered nothing to make them change or to enable such a change. Treatment ‘in the community’ leaves them with the same older adults still in their lives and subject to the same environment. They may go through several methadone ‘detoxes’ with the aim of ‘bringing down’ their illicit drug use, but this is often even without a plan to reduce the methadone use. There is no other ambition. “You can get up to 40mls of methadone a day if you are under 16”, one girl confidently told me. “All it does”, she said, “is to keep everything going – to maintain everything else”.
She was one of the handful of lucky ones. Two three month sessions at Middlegate, the only dedicated residential adolescent addiction centre in the country, had changed her life. A heroin addict at 14, moved from one inadequate foster home to another, finding herself on the street and in dealers flats, missing out on years of her education, she had, thanks to one enlightened and persistent social worker who forced the local authority to stump up the cash, been sent to Middlegate. This summer she has been sitting four academic AS levels.
The staff at Middlegate despair at the years of wasted public money pumped into ‘community treatment’ when they know what they can achieve with the most desperate of cases. What the kids need, they say, is rescuing and lifting out of their environments – not a sequence of social workers and drug workers operating with their government defined agendas to ‘rebuild families’ at whatever the cost yet incapable of providing the long term commitment required.
Yet the National Treatment Agency, wedded to this ‘treatment in the community’ agenda for all adolescents,  refuses to ring fence any funds for Middlegate to ensure this life changing programme can continue, let alone be replicated anywhere else.
Responding to The Phoney War on Drugs one highly respected addiction psychiatrist commented that I had not emphasised sufficiently “the huge waste of resource brought about by the NTA’s enthusiasm to allow managerialism to take over the field.”  He is right. The NTA’s approach to treatment is now so entrenched in a complex, resource hungry but inflexible bureaucracy that it is standing in the way of the revolution in rehabilitation that is required.  Nothing less than a major diversion of resources in the direction of rehabilitation and away from people processing plus a clearly conditional and contractual approach to drug treatment will work.
The government would do well now, before inflicting more damage on our society, to face the facts and acknowledge that their approach to ‘treatment’ and their drugs policy has failed abysmally.
Source:  25.06.2009

Research Summary

Vitamin K helps prevent brain injury in newborns. If alcohol dependence is associated with brain development in infancy, giving babies vitamin K might reduce their future risk of dependence. To explore this possibility, researchers studied a 30-year prospective cohort of male infants in Denmark.
Of 238 men, 18% had received 1 mg of vitamin K intramuscularly at birth, 16% had alcohol dependence (assessed at age 30), and 68% had fathers with alcohol dependence. Receipt of vitamin K was not significantly associated with gestational age, birth weight, birth complications, or signs of neurological impairment at birth.
• Only 5% of men who had received vitamin K at birth had alcohol dependence compared with 18% of men who had not received the vitamin.
• In an analysis adjusted for birth weight and having a father with alcohol dependence, men who had received vitamin K had significantly fewer symptoms of alcohol dependence.
Comments by Richard Saitz, MD, MPH:
The results of this analysis suggest that perinatal brain injury (e.g., hemorrhage, which is now much less common due to universal administration of vitamin K to neonates) increases the risk of alcohol dependence. These results also imply that preventive interventions that reduce neurological trauma early in life may lower vulnerability to dependence later.
Reprinted with permission from Alcohol and Health: Current Evidence.

Source: JoinTogether Online. Jan.2006

A longer-acting alternative to methadone that never quite caught on following its FDA approval in 1993 may now greatly increase the number of addicts who stick with treatment, thanks to a new Johns Hopkins study.

The study suggests better ways of taking LAAM (levomethadyl acetate hydrochloride), a drug similar to methadone in its capacity to discourage heroin use and block withdrawal symptoms. However, unlike methadone, which addicts must use daily, LAAM can be taken three times a week, making it far more convenient and potentially less expensive.
LAAM isn’t widely used, because of both uncertainties about how effective it is in the first stages of addiction treatment and doubts that it would be accepted by addicts. Earlier this year, for example, only about 3,000 U.S. patients were getting the drug.
“Use of LAAM has been less than hoped for since its approval by the Food and Drug Administration,” says Rolley E. Johnson, Pharm.D, associate professor of psychiatry, who headed the Hopkins study. Early studies didn’t test participants’ responses at various dosages, and under the cautious little-by-little approach to giving the medication, it appeared less effective than methadone at the first stage of treatment. Because of this, many assumed that LAAM lacked the necessary opiate-like effects early on. “Users said they couldn’t feel the drug working and were more likely to drop out of treatment,” Johnson noted.
The new Hopkins study, however, reported in this month’s Archives of General Psychiatry, shows that at the proper dosage on the proper schedule, LAAM is safe, effective and acceptable to addicts. “It could become a valuable addition to heroin addiction programs. Its convenience compared with methadone is a great advantage for addicts who hold jobs,” says Hendree Jones, Ph.D., one of the investigators. “They can earn a living more easily while continuing to receive treatment.”
To test LAAM, researchers gave 180 heroin-addicted volunteers either low-, medium-, or high-dose schedules, phasing in the drug over 17 days. They then looked at a combination of drug tests on subjects’ urine samples and subjects’ own reports to get a picture of how their heroin use had changed.
Heroin use dropped in all groups. The reduction was significant, though, in the high-dose group, showing a more than 80 percent plunge in self-reported heroin use. Also, more than 80 percent of the volunteers stayed with the trials, says Johnson. “That’s high for a study like this. It’s a good sign that most participants accepted LAAM.”
Though LAAM seems to work best on the high-dose course, Johnson says, that dose also had the most subjects drop out of the study. “It’s mostly because side effects begin to appear at higher doses.” So he suggests an approach that uses careful monitoring as the dose gets higher. Johnson would like to see more studies to help figure the optimal LAAM dose for individual patients: “Then we’ll be able to help even more addicts.”
LAAM works on the tiny receptors in the membranes of nerve cells in the brain. It binds to the so-called mu opioid receptors, the same ones that heroin and methadone target. Once attached, molecules of LAAM stimulate the receptors. But because LAAM remains there for a relatively long time, it blocks receptor access for other opioid drugs: addicts take heroin, for example, and it has none of its usual effects.

Source. ScienceDaily. Retrieved March 11, 2009, from¬ /releases/1998/08/980817081828.htm

According to details given by the NHS, there has been a 65 per cent increase in people receiving treatment for cocaine addiction in UK. These are teenagers which is cause of concern.
These figures correspond to the announcement by the Advisory Council on the Misuse of Drugs (ACMD) earlier. It was found by an NHS study, conducted by the National Treatment Agency for Substance Misuse, that the number these teenagers has doubled since 2005.
It was reported that users were combining cocaine with alcohol that causes more damage to the heart and makes users more violent. It was noticed that a six-month treatment treated four in 10 people and they were no longer addicted, but several left the treatment midway.
In England, about 12,354 people were treated for cocaine addiction last year. Between 2005-06 and 2008-09 a rise was seen in the number of people coming for treatment and the figures increased from 453 to 745, and the number of 18- to 24-year-olds doubled from 1,586 to 3,005.
The chairman of the ACMD, Professor Les Iversen stated, “The figures were deeply concerning.”
The Conservatives and Liberal Democrats both stated that a change was needed in the government’s approach to tackling addiction.

Source: 3rdMarch 2010

Research Summary
Using electrical charges to stimulate the subthalmic nucleus region of the brain may mitigate cocaine addiction without disrupting the dopamine system like current anti-addiction medications, according to French researchers.
The Los Angeles Times reported Dec. 28 that researchers reported that deep brain stimulation performed on cocaine-addicted lab rats resulted in the rats exhibiting less self-administration of the drug than an untreated control group.
Researchers also found that the treated rats seemed to break the association with an area where cocaine had been distributed, preferring to instead linger in an area where food was provided.
Source: Proceedings of the National Academy of Sciences (PDF). Dec.2009

For Immediate Release – January 5, 2010 – (Toronto) – A recent evaluation by the Centre for Addiction and Mental Health (CAMH) shows that online interventions for problem alcohol use can be effective in changing drinking behaviours and offers a significant public health benefit.
In the first evaluation of its kind, the study published in Addiction found that problem drinkers provided access to the online screener, reduced their alcohol consumption by 30% — or six to seven drinks weekly – rates that are comparable to face-to-face interventions. This result was sustained in both the three and six month follow-up.
Source: 5 Jan.2010

The present study was conducted to determine whether methadone maintenance alters the pharmacodynamic effects of single doses of cocaine. Twenty-two current users of IV cocaine who were not seeking treatment for their illicit cocaine use participated while living on a research unit.
Eleven were maintained on methadone 50 mg PO daily as treatment for their opioid abuse; 11 were opioid abusers who were not physically dependent on opioids and who provided opioid-free urines throughout the study. Each subject received acute cocaine challenge doses of 0, 12.5, 25, and 50 mg intravenously in random order under double-blind conditions in separate test sessions.
Physiologic and subject-rated responses were measured before injection and for 2 h after. In the methadone maintenance group, cocaine challenge sessions occurred 15.5 h after the daily methadone dose. There were significant differences between the methadone-dependent and nondependent groups: 1) baseline differences related to chronic methadone administration and not associated with cocaine administration (lower respiration rates and pupil diameter; higher skin temperature) and 2) differences in response to cocaine administration; cocaine-induced increases in subject ratings of Drug Effect, Rush, Good Effects, Liking, and Desire for Cocaine and in heart rate were greater in the methadone maintenance patients compared to the non-dependent group.
These results indicate that the positive subjective effects and some physiological effects of cocaine are enhanced in methadone-maintained individuals, suggesting a pharmacological basis for the high rates of cocaine abuse among methadone maintenance patients.

Source: Psychopharmacology (Berl) 1996 Jan;123(1):15-25

Although methadone failure has been studied, the contribution of plasma binding proteins like AGP (α1-acid-glycoprotein) has not been thoroughly examined. For a drug to confer a desired therapeutic effect it must reach a minimal effective concentration (MEC) at its site of action, often accessed via the bloodstream. It is proposed that when plasma AGP concentration increases, like in the acute phase response to stress and inflammation (Elliott et al., 1997, Paterson et al., 2003) more methadone binds the protein and so there is less free (unbound) drug available to bind receptors and achieve the desired therapeutic effect. This could cause therapy failure with patients taking additional opiates to compensate; Methadone Maintenance is a corrective, not a permanent curative procedure (Sees et al., 2000).

The aim of this research is to determine, in a sample of people undergoing methadone therapy, whether there are individual differences in the concentration and glycosylation pattern of the plasma protein AGP. Also, the extent it binds methadone will be investigated to determine whether the MEC is reduced and therefore the therapeutic effect.

It is hypothesised that there will be an increased concentration of AGP present in the samples which will cause a decrease in the concentration of free methadone available to bind receptors. Therefore the normal pharmaco-logical effect is lost causing the therapy to fail (individuals would take additional opiates).

The work is being carried out at School of Life Sciences, Napier University, Edinburgh who is working in conjunction with Dr Malcolm Bruce, Consultant Psychiatrist in Addiction, Community Drug Problem Service, 22-24 Spittal Street, Edinburgh, EH3 9DU and is being funded by the Carnegie Trust.

Filed under: Treatment and Addiction :

Use of a controversial stomach implant designed to block the effects of heroin must be urgently reined in, according to drug specialists who say addicts are being harmed. A new report found that naltrexone implants commonly cause severe adverse reactions, including extreme dehydration and acute renal failure in those who are fitted with them.
Nine Sydney specialists writing in the Medical Journal of Australia have called for an urgent review of use of the product, which blocks the effects of heroin and stops cravings for about six months. It has not been registered or rigorously tested in Australia but about 1,500 addicts have obtained it through the Therapeutic Goods Administration’s Special Access Scheme for people with a life-threatening need.
Controversy has surrounded the use of the implants for several years, with advocates arguing they offer addicts the best chance of overcoming their addiction and opponents branding them dangerous and ineffective.
One study published last March linked the implant to five deaths. A new study published has found that of 12 implant patients who were admitted to two Sydney hospitals last year, eight hospitalisations were implant-related. Six were suffering severe dehydration, one had acute renal failure and another had an abscess at the implant site.
“These cases challenge the notion that a naltrexone implant is a safe procedure,” said study leader Nicholas Lintzeris, a senior addiction specialist at the Sydney South West Area Health Service. He called for the widespread and unregulated use of implants to be restricted until they have been properly tested for safety and effectiveness.
Professor Robert Ali, director of the Drug Alcohol Services Council in Adelaide, agreed the product should not be so widely available.
“The disturbing suggestions of mortality and morbidity from unregistered naltrexone implants makes a strong case for an independent review to determine whether this treatment is sufficiently safe for such widespread use,” Prof Ali said.
However, another specialist, University of Western Australia Professor of Addiction Gary Hulse, said a trial he had undertaken had found the implant to be just as safe and effective as the oral form of the drug. He defended its use and said many of the criticisms levelled at naltrexone occurred because people’s withdrawals from heroin were not being managed properly.
Source: April 17th 2008

Long-acting injections of the drug naltrexone, combined with psychotherapy, significantly reduced heavy drinking in patients being treated for alcohol dependence, according to a study in the Journal of the American Medical Association by a Yale School of Medicine researcher.

“The decision to take medication can wane over time,” said Stephanie O’Malley, professor of psychiatry and director of the Division of Substance Abuse Research at the Connecticut Mental Health Center at Yale. “This provides coverage for an entire month.”
Acohol dependence ranks as the fourth leading cause of disability worldwide, as reported by the World Health Organization’s Global Burden of Disease project. Nationwide, it is believed to contribute to more than 100,000 preventable deaths a year.
Naltrexone belongs to a class of drugs called opioid antagonists. Although many clinical trials have shown that oral naltrexone can be effective in treating alcohol dependence, its use in clinical practice has been limited, in part patients have to take the pill daily.
In this trial conducted at 24 sites, 627 alcohol dependent patients were randomly assigned to receive either an injection of long-acting naltrexone or a placebo injection; 624 ultimately received at least one injection. All participants received 12 counseling sessions during the six-month study in addition to the medication. Long-acting naltrexone was associated with a reduction in heavy drinking within the first month of treatment, and this response was maintained over the six month treatment period.

Source:Yale University (2005, May 17). Once-a-month Naltrexone Successfully Used To Treat Alcohol Dependence. ScienceDaily. Retrieved August 17, 2008, from¬ /releases/2005/05/050517094735.htm

Published: May 13, 2008 at 1:23 PM
COLUMBUS, Ohio, May 13 (UPI) — U.S. researchers say getting homeless youth off of alcohol and drugs is hard unless basic needs are met first.
The study, published in the Journal of Youth and Adolescence, concludes homeless youth — linked to the street subculture — can be brought back into society through education, employment and other activities that strengthen social ties. Those with the most social stability — such as those who attended school more often or those who had a job — were most likely to reduce their homeless days over a six-month period.

While youth who had a history of abuse or mental health problems were more likely to become homeless, those same characteristics didn’t predict teens and young adults getting off the street six months later.

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

The study, conducted between 2001 and 2005, interviewed 180 homeless youth between ages 14 and 22 at New Mexico drop-in centers.


Naltrexone is one of four oral medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of alcoholism. A recent large multicenter research study of alcohol dependence supported by the National Institute of Alcoholism and Alcohol Abuse (NIAAA), the COMBINE Study, suggested that naltrexone produced a modest but significant benefit but another FDA-approved medication, acamprosate, was ineffective.   Perhaps consistent with its modest effects in COMBINE, naltrexone is not widely prescribed in the treatment of alcoholism. Yet, clinicians report that naltrexone may have significant benefits for individual patients. To make naltrexone a more useful medication, it would be important to begin to identify groups of patients who might be more or less likely to show a significant clinical benefit from naltrexone prescription and to understand the causes of differential naltrexone efficacy.
A new study that will appear in the September 15th issue of Biological Psychiatry suggests that alcohol dependent individuals with a family history of alcohol dependence may be more likely than alcohol dependent individuals without a family history of alcohol dependence to reduce their drinking in the laboratory when prescribed naltrexone.
Krishnan-Sarin and colleagues at the NIAAA Center for the Translational Neuroscience of Alcoholism studied alcohol consumption in the laboratory by alcohol-dependent individuals who were not seeking treatment. The participants were studied in the laboratory after 6 days of treatment with 0 mg (placebo), 50 mg, or 100 mg of naltrexone. The authors discovered that naltrexone decreased drinking in those with a family history of alcoholism and this effect was greatest with the highest naltrexone dose. However, it increased drinking in those without a family history of alcoholism and this effect was greatest at the highest naltrexone dose.
John H. Krystal, M.D., one of the authors, notes that “When studied in large groups, naltrexone appears to have a rather small effect upon the ability to reduce drinking or remain abstinent from alcohol. However, there is growing evidence that there are subgroups of patients who show substantial benefit from naltrexone, even when naltrexone fails to work in the overall trial.*
“According to Suchitra Krishnan-Sarin, Ph.D., the lead author, “The results suggest that family history of alcoholism may be an important predictor of clinical response to naltrexone and could potentially be used to guide clinical practice.” Dr. Krystal agrees, “These data suggest that family history might influence the optimal dosing of naltrexone and the nature of the clinical response.” Their hope is that these findings ultimately can contribute to a better treatment experience for some who are seeking to end their battle with alcohol.
This research article: “Family History of Alcoholism Influences Naltrexone-Induced Reduction in Alcohol Drinking” by Suchitra Krishnan-Sarin, John H. Krystal, Julia Shi, Brian Pittman and Stephanie S. O’Malley. All authors are affiliated with the Department of Psychiatry at Yale University School of Medicine in New Haven, Connecticut. Dr. Krystal is also affiliated with the VA Connecticut Healthcare System in West Haven, Connecticut and he serves as the Editor of Biological Psychiatry. This article appears in Biological Psychiatry, Volume 62, Issue 6 (September 15, 2007), published by Elsevier.

Source: Elsevier (2007, September 24). Family History Of Alcoholism Affects Response To Drug Used To Treat Heavy Drinking. ScienceDaily. Retrieved August 17, 2008, from¬ /releases/2007/09/070919101735.htm

Filed under: Treatment and Addiction :

Long-acting injections of the drug naltrexone, combined with psychotherapy, significantly reduced heavy drinking in patients being treated for alcohol dependence, according to a study in the Journal of the American Medical Association by a Yale School of Medicine researcher.
“The decision to take medication can wane over time,” said Stephanie O’Malley, professor of psychiatry and director of the Division of Substance Abuse Research at the Connecticut Mental Health Center at Yale. “This provides coverage for an entire month.”
Acohol dependence ranks as the fourth leading cause of disability worldwide, as reported by the World Health Organization’s Global Burden of Disease project. Nationwide, it is believed to contribute to more than 100,000 preventable deaths a year.
Naltrexone belongs to a class of drugs called opioid antagonists. Although many clinical trials have shown that oral naltrexone can be effective in treating alcohol dependence, its use in clinical practice has been limited, in part patients have to take the pill daily.
In this trial conducted at 24 sites, 627 alcohol dependent patients were randomly assigned to receive either an injection of long-acting naltrexone or a placebo injection; 624 ultimately received at least one injection. All participants received 12 counseling sessions during the six-month study in addition to the medication. Long-acting naltrexone was associated with a reduction in heavy drinking within the first month of treatment, and this response was maintained over the six month treatment period.Source: Yale University (2005, May 17). Once-a-month Naltrexone Successfully Used To Treat Alcohol Dependence. ScienceDaily. Retrieved August 17, 2008, from¬ /releases/2005/05/050517094735.htm

Patients with a certain gene variant drank less and experienced better overall clinical outcomes than patients without the variant while taking the medication naltrexone, according to an analysis of participants in the National Institutes of Health’s 2001-2004 COMBINE (Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence) Study. About 87 percent of patients with the variant who received naltrexone experienced good outcomes, compared with about 49 percent of those who received a placebo. About 55 percent of patients without the variant experienced a good outcome regardless of whether they received naltrexone or placebo. Good outcome was defined as abstinence or moderate drinking without related problems, according to an article in the Feb. 4 issue of the Archives of General Psychiatry.Drinking alcohol increases the release of endogenous opioids, compounds that originate in the body and promote a sense of pleasure or well-being. An opioid antagonist, naltrexone blocks brain receptors for endogenous opioids, making it easier for patients to remain abstinent or stop quickly in the event of a slip. In clinical studies, naltrexone has been shown to reduce relapse and craving for alcohol in some but not all treated patients. Earlier studies had suggested that a specific DNA variant of the opioid receptor gene (OPRM1) might have role in patients’ response to naltrexone.
“Analysis of the large COMBINE patient population increases confidence that the OPRM1 variant is in part responsible for positive responses to naltrexone. This study points to the promise of research on gene-medication interactions to refine treatment selection, improve clinical results, and inform ongoing medications development,” said National Institute on Alcohol Abuse and Alcoholism (NIAAA) director Ting-Kai Li, M.D.
Of the original 1383 COMBINE Study participants, 1013 were available to be genotyped for the current study, conducted by Raymond F. Anton, M.D., Medical University of South Carolina, and other COMBINE Study principal investigators in collaboration with David Goldman, M.D., and his colleagues in NIAAA’s Laboratory of Neurogenetics. The researchers successfully genotyped 911 of the available patients and conducted their initial analysis in 604 who are white, 135 of whom were found to carry the genetic variant. Approximately 15 to 25 percent of humans carry the variant, with considerable variation among ethnicities.
As in the COMBINE clinical trial, drinking variables evaluated in the pharmacogenetic study included the percentage of days abstinent from alcohol, the percentage of heavy drinking days, and clinical outcome during 16 weeks of active treatment. In addition to naltrexone or placebo, all patients received medical management (nine brief, structured outpatient sessions delivered by a health professional) and some also received a combined behavioral intervention (integrated cognitive-behavioral and motivational enhancement therapies, together with techniques to enhance mutual-help participation).
The researchers found that, compared with patients who do not carry the variant, white variant carriers who received naltrexone fared substantially better than other groups on all measures, including almost a 6 times greater likelihood of good clinical outcome. Extending the clinical outcome measure to variant carriers of all ethnicities reduced the benefit to just over a 3 times greater likelihood of good outcome. The researchers found no gene-medication interaction in patients who received specialized alcohol counseling, leading to them to conclude that genotyping for the variant may be most useful when naltrexone is used without intensive counseling.
Approved by the U.S. Food and Drug Administration in 1994, naltrexone is one of three indicated medications* shown to help patients reduce drinking, avoid relapse to heavy drinking, achieve and maintain abstinence, or gain a combination of these effects. The COMBINE trial showed either specialized counseling or naltrexone–each delivered with medications management–to be effective options for treating alcohol dependence. “Given that alternative treatments such as combined behavioral interventions, acamprosate, and topiramate can be offered, one could make the case that naltrexone should be used first or used primarily in carriers of the OPRM1 [variant],” state the authors.
“Research studies designed to ensure appropriate medication targeting are critical, especially as treatment for alcohol use disorders increasingly involves primary care physicians as well as specialists,” notes Mark L. Willenbring, M.D., director of NIAAA’s Division of Treatment and Recovery Research. “Without the ability to predict response for a specific patient, we must use trial-and-error to determine the correct medication–a process that may prolong illness and lead to more side effects. This study highlights the promise of truly personalized medicine and could help to move treatment of alcohol dependence into the medical mainstream.”

Source: NIH/National Institute on Alcohol Abuse and Alcoholism (2008, February 12). Gene Variant Predicts Medication Response In Patients With Alcohol Dependence. ScienceDaily. Retrieved August 17, 2008, from¬ /releases/2008/02/080207172332.htm

Research Summary
Continuing to use nicotine patches or gums after cancer surgery — to say nothing of smoking — makes chemotherapy less effective, according to researchers at the University of South Florida.
The Associated Press reported April 2 that a study of lung-cancer patients found that nicotine appears to protect cancer cells from chemotherapy drugs like gemcitabine, cisplatin, and taxol. Srikumar Chellappan of the University of South Florida and colleagues studied the impact of nicotine on non-small cell lung cancer, the most common form of the disease.
“Our findings are in agreement with clinical studies showing that patients who continue to smoke have worse survival profiles than those who quit before treatment,” the study noted. “They also raise the possibility that nicotine supplementation for smoking cessation might reduce the response to chemotheraputic agents.”
The research appears in the online edition of Proceedings of the National Academy of Sciences. 

Source:Reported in Join Together April 2006


Scientists at Stanford University School of Medicine have discovered that a commonly available non-addictive drug can prevent symptoms of withdrawal from opioids with little likelihood of serious side effects.
The drug, ondansetron, which is already approved to treat nausea and vomiting, appears to avoid some of the problems that accompany existing treatments for addiction to these powerful painkillers, the scientists said.
Opioids encompass a diverse array of prescription and illegal drugs, including codeine, morphine and heroin. In 2007, about 12.5 million Americans aged 12 and older used prescription pain medications for non-medical purposes, according to the National Survey on Drug Use and Health, administered by the federal government’s Substance Abuse and Mental Health Services Administration.
“Opioid abuse is rising at a faster rate than any other type of illicit drug use, yet only about a quarter of those dependent on opioids seek treatment,” said Larry F. Chu, MD, assistant professor of anesthesia at the School of Medicine and lead author of the study that will be published online Feb. 17 in the Journal of Pharmacogenetics and Genomics. “One barrier to treatment is that when you abruptly stop taking the drugs, there is a constellation of symptoms associated with withdrawal.” Chu described opioid withdrawal as a “bad flu,” characterized by agitation, insomnia, diarrhea, nausea and vomiting.
Current methods of treatment are not completely effective, according to Chu. One drug used for withdrawal, clonidine, requires close medical supervision as it can cause severe side effects, while two others, methadone and buprenorphine, don’t provide a satisfactory solution because they act through the same mechanism as the abused drugs. “It’s like replacing one drug with another,” said co-investigator Gary Peltz, MD, PhD, professor of anesthesia.  “What we need is a magic bullet,” said Chu. “Something that treats the symptoms of withdrawal, does not lead to addiction and can be taken at home.”
The researchers’ investigation led them to the drug ondansetron, after they determined that it would block certain receptors involved in withdrawal symptoms.
The scientists were able to make this connection thanks to their having a good animal model for opioid dependence. Mice given morphine for several days develop the mouse equivalent of addiction. Researchers then stop providing morphine to trigger withdrawal symptoms. Strikingly, these mice, when placed into a plastic cylinder, will start to jump into the air. One can measure how dependent these mice are by counting how many times they jump. Like humans, dependent mice also become very sensitive to pain when they stop receiving morphine.
But the responses vary among the laboratory animals. There are “different flavors of mice,” explained Peltz. “Some strains of mice are more likely to become dependent on opioids.” By comparing the withdrawal symptoms and genomes of these different strains, it’s possible to figure out which genes play a major role in addiction.
To accomplish this feat, Peltz and his colleagues used a powerful computational “haplotype-based” genetic mapping method that he had recently developed, which can sample a large portion of the genome within just a few hours. This method pinpoints genes responsible for the variation in withdrawal symptoms across these strains of mice.
The analysis revealed an unambiguous result: One particular gene determined the severity of withdrawal. That gene codes for the 5-HT3 receptor, a protein that responds to the brain-signaling chemical serotonin.   To confirm these results, the researchers injected the dependent mice with ondansetron, a drug that specifically blocks 5-HT3 receptors. The drug significantly reduced the jumping behavior of mice as well as pain sensitivity – two signs of addiction.
The scientists were able to jump from “from mouse to man” by sheer luck: It turns out that ondansetron is already on the market for the treatment of pain and nausea. As a result, they were able to immediately use this drug, approved by the Food and Drug Administration, in eight healthy, non-opioid-dependent humans. In one session, they received only a single large dose of morphine, and in another session that was separated by at least week, they took ondansetron in combination with morphine. They were then given questionnaires to assess their withdrawal symptoms.
Similar to mice, humans treated with ondansetron before or while receiving morphine showed a significant reduction in withdrawal signs compared with when they received morphine but not ondansetron. “A major accomplishment of this study was to take lab findings and translate them to humans,” said principal investigator J. David Clark, MD, PhD, professor of anesthesia at Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System.
Chu plans on conducting a clinical study to confirm the effectiveness of another ondansetron-like drug in treating opioid withdrawal symptoms in a larger group of healthy humans. And the research team will continue to test the effectiveness of ondansetron in treating opioid addiction.
The scientists warned that ondansetron will not by itself resolve the problems that arise with continued use of these painkillers. Addiction is a long-term, complex process, involving both physical and psychological factors that lead to compulsive drug use. “This is not a cure for addiction,” said Clark. “It’s (wrong) to think that any one receptor is a panacea for treatment. Treating the withdrawal component is only one way of alleviating the suffering. With luck and determination, we can identify additional targets and put together a comprehensive treatment program.”
Collaborators on this study included De-Yong Liang, PhD, the study’s co-lead author, previously a research associate in the Department of Anesthesia and currently a research associate at the Palo Alto Institute for Research and Education; Xiangqi Li, MD, a life science research assistant in the department; Nicole D’Arcy, a medical student: Peyman Sahbaie, MD, a research associate at the institute; and Guochun Liao, PhD, of the pharmaceutical company Hoffman-La Roche. This work was supported by grants to Clark from the National Institutes of Health and the National Institute on Drug Abuse, and grants to Chu from the NIH and the National Institute of General Medical Sciences.
The researchers are working with the Stanford University Office of Technology Licensing to seek a patent for the use of ondansetron and related medicines in the treatment of drug addiction.
Source:   18-Feb-2009

Filed under: Treatment and Addiction :

ScienceDaily (Feb. 20, 2009) — An ingredient in licorice shows promise as an antidote for the toxic effects of cocaine abuse, including deadly overdoses of the highly addictive drug, researchers in Korea and Pennsylvania are reporting.
In the new study, Meeyul Hwang, Chae Ha Yang, and colleagues note that there is currently no effective medicine for treating cocaine abuse or addiction. Recent animal studies conducted by the researchers show that a licorice ingredient called isoliquiritigenin (ISL) can block the nervous system’s production of dopamine. That neurotransmitter is involved in emotion, movement, and other brain activities.
Cocaine and other addictive drugs stimulate dopamine and help produce the pleasurable and addictive effects. Drugs that block dopamine block this response. The scientists used rats as model animals to show that rats injected with ISL just prior to cocaine-administration showed 50 percent less of the behavioral effects associated with the illicit drug.
They also showed that ISL injections protected nerve cells in the brain from cocaine-associated damage.

Source: ScienceDaily.¬ /releases/2009 February 22, 2009

ScienceDaily (Feb. 19, 2009) — Scientists at Stanford University School of Medicine have discovered that a commonly available non-addictive drug can prevent symptoms of withdrawal from opioids with little likelihood of serious side effects. The drug, ondansetron, which is already approved to treat nausea and vomiting, appears to avoid some of the problems that accompany existing treatments for addiction to these powerful painkillers, the scientists said.

Opioids encompass a diverse array of prescription and illegal drugs, including codeine, morphine and heroin. In 2007, about 12.5 million Americans aged 12 and older used prescription pain medications for non-medical purposes, according to the National Survey on Drug Use and Health, administered by the federal government’s Substance Abuse and Mental Health Services Administration.
“Opioid abuse is rising at a faster rate than any other type of illicit drug use, yet only about a quarter of those dependent on opioids seek treatment,” said Larry F. Chu, MD, assistant professor of anesthesia at the School of Medicine and lead author of the study that will be published online Feb. 17 in the Journal of Pharmacogenetics and Genomics. “One barrier to treatment is that when you abruptly stop taking the drugs, there is a constellation of symptoms associated with withdrawal.” Chu described opioid withdrawal as a “bad flu,” characterized by agitation, insomnia, diarrhea, nausea and vomiting.
Current methods of treatment are not completely effective, according to Chu. One drug used for withdrawal, clonidine, requires close medical supervision as it can cause severe side effects, while two others, methadone and buprenorphine, don’t provide a satisfactory solution because they act through the same mechanism as the abused drugs. “It’s like replacing one drug with another,” said co-investigator Gary Peltz, MD, PhD, professor of anesthesia.
“What we need is a magic bullet,” said Chu. “Something that treats the symptoms of withdrawal, does not lead to addiction and can be taken at home.”
The researchers’ investigation led them to the drug ondansetron, after they determined that it would block certain receptors involved in withdrawal symptoms.
The scientists were able to make this connection thanks to their having a good animal model for opioid dependence. Mice given morphine for several days develop the mouse equivalent of addiction. Researchers then stop providing morphine to trigger withdrawal symptoms. Strikingly, these mice, when placed into a plastic cylinder, will start to jump into the air. One can measure how dependent these mice are by counting how many times they jump. Like humans, dependent mice also become very sensitive to pain when they stop receiving morphine.
But the responses vary among the laboratory animals. There are “different flavors of mice,” explained Peltz. “Some strains of mice are more likely to become dependent on opioids.” By comparing the withdrawal symptoms and genomes of these different strains, it’s possible to figure out which genes play a major role in addiction.
To accomplish this feat, Peltz and his colleagues used a powerful computational “haplotype-based” genetic mapping method that he had recently developed, which can sample a large portion of the genome within just a few hours. This method pinpoints genes responsible for the variation in withdrawal symptoms across these strains of mice.
The analysis revealed an unambiguous result: One particular gene determined the severity of withdrawal. That gene codes for the 5-HT3 receptor, a protein that responds to the brain-signaling chemical serotonin.
To confirm these results, the researchers injected the dependent mice with ondansetron, a drug that specifically blocks 5-HT3 receptors. The drug significantly reduced the jumping behavior of mice as well as pain sensitivity — two signs of addiction.
The scientists were able to jump from “from mouse to man” by sheer luck: It turns out that ondansetron is already on the market for the treatment of pain and nausea. As a result, they were able to immediately use this drug, approved by the Food and Drug Administration, in eight healthy, non-opioid-dependent humans. In one session, they received only a single large dose of morphine, and in another session that was separated by at least week, they took ondansetron in combination with morphine. They were then given questionnaires to assess their withdrawal symptoms.
Similar to mice, humans treated with ondansetron before or while receiving morphine showed a significant reduction in withdrawal signs compared with when they received morphine but not ondansetron. “A major accomplishment of this study was to take lab findings and translate them to humans,” said principal investigator J. David Clark, MD, PhD, professor of anesthesia at Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System.
Chu plans on conducting a clinical study to confirm the effectiveness of another ondansetron-like drug in treating opioid withdrawal symptoms in a larger group of healthy humans. And the research team will continue to test the effectiveness of ondansetron in treating opioid addiction.
The scientists warned that ondansetron will not by itself resolve the problems that arise with continued use of these painkillers. Addiction is a long-term, complex process, involving both physical and psychological factors that lead to compulsive drug use. “This is not a cure for addiction,” said Clark. “It’s naïve to think that any one receptor is a panacea for treatment. Treating the withdrawal component is only one way of alleviating the suffering. With luck and determination, we can identify additional targets and put together a comprehensive treatment program.”
Collaborators on this study included De-Yong Liang, PhD, the study’s co-lead author, previously a research associate in the Department of Anesthesia and currently a research associate at the Palo Alto Institute for Research and Education; Xiangqi Li, MD, a life science research assistant in the department; Nicole D’Arcy, a medical student: Peyman Sahbaie, MD, a research associate at the institute; and Guochun Liao, PhD, of the pharmaceutical company Hoffman-La Roche. This work was supported by grants to Clark from the National Institutes of Health and the National Institute on Drug Abuse, and grants to Chu from the NIH and the National Institute of General Medical Sciences.
The researchers are working with the Stanford University Office of Technology Licensing to seek a patent for the use of ondansetron and related medicines in the treatment of drug addiction.

Source:  Science Daily 19th Feb 2009

Filed under: Treatment and Addiction :

ScienceDaily (Mar. 8, 2009) — New findings may significantly improve the safety of methadone, a drug widely used to treat cancer pain and addiction to heroin and other opioid drugs, according to researchers at Washington University School of Medicine in St. Louis and the University of Washington in Seattle.
The researchers discovered that the body processes methadone differently than previously believed. Those incorrect assumptions about methadone have been making it difficult for physicians to understand how and when the drug is cleared from the body and may be responsible for unintentional under- or overdosing, inadequate pain relief, side effects and even death.
For many years, methadone has been a mainstay in the treatment of opioid addiction. Taken orally, it suppresses withdrawal and reduces cravings. In recent years, doctors have prescribed methadone more frequently as an effective treatment for acute, chronic and cancer pain. Use of the drug for pain treatment rose 1,300 percent between 1997 and 2006. As more methadone was prescribed, however, adverse events increased by approximately 1,800 percent, and fatalities were up more than 400 percent (from 786 to 3,849) between the years 1999 and 2004.
“Unfortunately, increased methadone use for pain has coincided with a significant increase in adverse events and fatalities related to methadone,” says principal investigator Evan D. Kharasch, M.D., Ph.D., an anesthesiologist and clinical pharmacologist at Washington University School of Medicine and Barnes-Jewish Hospital in St. Louis. “The important message is that guidelines used by clinicians to direct methadone therapy may be incorrect.”
Kharasch, the Russell D. and Mary B. Shelden Professor and director of the Division of Clinical and Translational Research in Anesthesiology at the School of Medicine, and his colleagues report the findings in the March issue of the journal Anesthesiology and online in the journal Drug and Alcohol Dependence.
The investigators wanted to understand how protease inhibitors, drugs that keep the immune system functioning in patients with HIV, interact with methadone. For years, the enzyme P4503A was believed to be responsible for clearing methadone from the body. But when healthy volunteers were given a low dose of methadone together with protease inhibitors that caused profound decreases in the activity of P4503A, there was no reduction in the clearance of methadone.
There were two reasons to study what happened to methadone when taken together with those drugs: First, HIV-AIDS patients may receive methadone for pain and, in some cases, for accompanying substance abuse problems, along with one or more protease inhibitors. In addition, many protease inhibitors interact with the P4503A enzyme that traditionally was thought to be important to methadone clearance. In these studies, Kharasch and his team looked at interactions among methadone, the P4503A enzyme in the intestine and liver and the protease inhibitors nelfinavir, indinavir and ritonavir.
They gave study volunteers a combination of the protease inhibitors ritonavir and indinavir. Both drugs profoundly inhibited the actions of the enzyme. If that enzyme were responsible for methadone clearance, then inhibiting it should have caused methadone to build up in the body. But the researchers found that it had no effect on methadone levels.
Volunteers in the second study received the protease inhibitor nelfinavir. Again, the drug inhibited the action of the P4503A enzyme. That should have meant methadone concentrations would rise, but they actually decreased by half.
“For more than a decade, practitioners have been warned about drug interactions involving the enzyme P4503A that might alter methadone metabolism,” Kharasch says. “The package insert says inhibiting the enzyme may cause decreased clearance of methadone, but our research demonstrates that P4503A has no effect on clearing methadone from the body. So the package insert appears to be incorrect, or certainly needs to be reevaluated, as do guidelines that explain methadone dosing and potential drug interactions.”
That can be dangerous, Kharasch explains, because a clinician may prescribe too much or too little methadone for patients taking drugs that interact with P4503A, having been informed that they also would influence methadone clearance. Too little methadone will not relieve pain. Too much can contribute to the unintentional build-up of methadone in the system, which can cause slow or shallow breathing and dangerous changes in heartbeat. Physicians could be unintentionally prescribing methadone incorrectly.
“The highest risk period for inadequate pain therapy or adverse side effects is during the first two weeks a patient takes methadone,” Kharasch says. “If we can provide clinicians with better dosing guidelines, then I believe we will be able to better treat pain and limit deaths and other adverse events.”
About a dozen related liver enzymes are part of the P450 family, and Kharasch believes another enzyme from that family may be the one actually involved in methadone metabolism and clearance. His laboratory is determined to identify the correct enzyme to limit over-and under-dosing of patients taking methadone to improve addiction and pain treatment as well as patient safety. Currently, he’s testing the related enzyme P4502B. Laboratory studies and preliminary clinical results indicate that P4502B may be involved, but he says more clinical research is needed.
“The research also is important for the treatment of HIV-AIDS,” Kharasch says. “Protease inhibitors can interfere with the activity of P4503A but increase the activity of P4502B. This paradox is highly unusual, and because these two enzymes metabolize so many prescription drugs, there are many potential drug interactions that we’ll be able to understand better if we can get a better handle on how these pathways absorb drugs into the system and clear them from the body.”
This research was supported by grants from the National Institute on Drug Abuse of the National Institute of Health and by an NIH grant to the University of Washington General Clinical Research Center.
Source: ScienceDaily 8 March 2009. 11 March 2009 <¬ /releases/2009/03/090303102736.htm>.

Filed under: Treatment and Addiction :

Researchers in the Discipline of Pharmacology have discovered a genetic variation that may help determine the most effective methadone dosage levels for individual heroin addicts.
The genetic discovery reveals why some people are either less efficient or more effective in distributing drugs throughout their body to the central nervous system.
Lead researcher Dr Janet Coller says accurate dosing of methadone is essential to successfully treat drug addicts because up to 62% fail to remain in the methadone program due to the severe withdrawal symptoms.
“Individualised dosing may decrease the incidence of withdrawal symptoms in some people and therefore encourage them to continue with the methadone treatment.”
An estimated 10 million people worldwide are heroin dependent, including 74,000 Australians, incurring enormous health, social and economic costs.
“More than 40,000 people are undergoing methadone treatment in Australia and only 38% of them are staying in the program at the moment. Most drop out at the start of the treatment when the withdrawal effects are severe,” Dr Coller says.
This breakthrough will allow individuals undergoing the methadone treatment program to be tested for the genetic variation to determine optimal treatment doses.
The pharmacology study was conducted collaboratively as part of Dr Coller’s postdoctoral and Daniel Barratt’s PhD studies, supervised by Professor Andrew Somogyi, with the assistance of Karianne Dahlen and Morten Loennechen, Masters of Science students from Denmark. The results have been published in the December issue of the journal Clinical Pharmacology and Therapeutics.
Source: University Of Adelaide (2007, January 29). Breakthrough For Heroin Addiction Treatment. ScienceDaily. Retrieved March 11, 2009, from¬ /releases/2007/01/070128135642.htm

 COST OF SUBSTANCE  The breakdown on federal and state money for substance abuse and addiction (numbers don’t add up to 100% due to rounding):
     95.6% Health care/assistance/prosecution
      2.4% Prevention/treatment/research
      1.4% Regulation/compliance
      0.7% Interdiction (federal only)
Source: The National Center on Addiction and Substance Abuse at Columbia University
Most of the taxpayer money devoted to combating alcohol and drug abuse goes to cleaning up its consequences, while only about 2% of the funding is used for prevention, says a report from the National Center on Addiction and Substance Abuse (CASA) at Columbia University.
The study found that 96% of the $467.7 billion a year that federal, state and local governments spend on substance abuse is used to deal with consequences such as crime and homelessness.
Of that money, according to the report, governments spend the most on health care costs associated with substance abuse (58%) followed by the costs of prosecuting and jailing the offenders (13.1%).
“The killer finding is that we are spending 96 cents of every dollar we spend on substance abuse and addiction to shovel up the human wreckage,” says Joseph Califano Jr., founder and chairman of CASA. “We’re making this really tiny investment in prevention and treatment when we have enough experience to know that prevention and treatment can reduce the shoveling-up burden.”
Researchers determined spending amounts by analyzing federal, state and local budgets for the year 2005, the most recent year that complete data were available, Califano says.
“These governments have it backwards,” he says. “They’re wasting billions of dollars of taxpayers’ money and not making some relatively simple investments that could sharply reduce the consequences of drug and alcohol addiction.”
Califano says the main reason that federal and state governments aren’t ready to change priorities is because there is a stigma attached to alcohol and drug addiction.
To reduce the amount spent on substance abuse, Califano says, the government needs to “mount major prevention programs,” with a focus on kids.
He adds that increasing taxes on alcohol and training doctors to talk to patients about their substance use also will help decrease associated costs.
“This is a problem we can deal with. We know a lot more about it than we knew years ago,” Califano says.
Source: USA Today 27th May 2009

It seems like such an unlikely finding: In a University of Minnesota study of kleptomania—the compulsion to steal—a popular medicine used to treat both heroin addiction and alcoholism drastically reduced stealing among a group of 25 shoplifters. The drug, naltrexone, blocks brain receptors for opiates. It is one of the few drugs available for the treatment of alcoholism, and continues to gain momentum as a treatment for opiate addiction.

In an article for the April issue of Biological Psychiatry, Jon Grant and colleagues at the University of Minnesota School of Medicine record the results of their work with 25 kleptomaniacs, most of them women. All of the participants had been arrested for shoplifting at least once, and spent at least one hour per week stealing. The 8-week study is believed to be the first placebo-controlled trial of a drug for the treatment of shoplifting.

In the April 10 issue of Science, Grant said that “Two-thirds of those on naltrexone had complete remission of their symptoms.” According to Samuel Chamberlain, a psychiatrist at the University of Cambridge in the U.K., the study strongly suggests that “the brain circuits involved in compulsive stealing overlap with those involved in addictions more broadly.” The study, in short, strengthens the hypothesis that the shoplifting “high” may have much in common with the high produced by heroin or alcohol.

Researchers are also working with the drug memantine as a treatment for compulsive stealing.

The finding lends additional evidence to the theory that shoplifting is a dopamine- and serotonin-driven disorder under the same medical umbrella as drug addiction and alcoholism. Preliminary research has shown that naltrexone may also have an effect on gambling behavior.

If so-called “behavioral addictions” continue to display biochemical similarities with “chemical addictions,” the move to broaden the working definition of addiction will continue to intensify. And the same sorts of questions that plague addiction research will be replayed in the behavioral sphere: What level of shoplifting constitutes the disorder called kleptomania? Isn’t the medicalization of shoplifting just a way to excuse bad behavior? Is medical treatment more effective than jail time? From a legal point of view, what is the the difference between kleptomania and burglary?

In his book, America Anonymous, Benoit Denizet-Lewis quotes lead study author Jon Grant: “With all addictions, a person’s free will is greatly impaired, but the law doesn’t want to entertain that…. Why shouldn’t someone’s addiction be considered as a mitigating factor, especially in sentencing?”
Source: April issue of Biological Psychiatry, published in Addiction Inbox (USA) Monday 8th June 2009

Filed under: Treatment and Addiction :

Vigabatrin, an anticonvulsive drug marketed by Ovation Pharmaceuticals, has been “fast-tracked” by the Food and Drug Administration (FDA) and could become the first drug approved by the agency as a treatment for cocaine and methamphetamine dependence, the.
The drug, which would be marketed under the brand name Sabril, is though to work by blocking craving and euphoria by increasing the level of a neurotransmitter called gamma-aminobutyric acid.
Animal testing and two small-scale human trials have shown that the drug inhibits craving and euphoria. Sabril is currently in Phase II drug-safety trials, and the third and potentially final stage of testing before FDA approval should begin next year.
“We believe this fast track designation for Sabril will accelerate our efforts to bring to market a treatment option for the hundreds of thousands of people who suffer from dependence on cocaine and methamphetamine,” said Tim Cunniff, Ovation’s vice president for global regulatory affairs.
Sabril has already been approved by the FDA for treatment of seizures and infantile spasms.
Source: Chicago Sun-Times Jan. 22 2008

Filed under: Treatment and Addiction :

New research from Stanford University suggests that a drug used to treat nausea may be effective in combating withdrawal from opioid drugs, U.S. News and World Report reported Feb. 20.
Researchers testing mice found that the drug ondansetron (Zofran) blocks certain 5-HT3 receptors involved in withdrawal. The researchers proceeded to test eight non-opioid-dependent human volunteers.
The subjects were given two doses of morphine, one with and one without ondansetron. The study showed that ondansetron reduced withdrawal symptoms without some of the side effects caused by current treatments for opiate addiction.
The “constellation of symptoms associated with withdrawal” can create a barrier to opiate treatment, said lead author Larry Chu. “What we need is a magic bullet, something that treats the symptoms of withdrawal, does not lead to addiction, and can be taken at home,” Chu said.
The researchers plan to continue testing ondansetron and to conduct a clinical study to investigate the effectiveness of an ondansetron-like drug in treating opioid addiction. “Treating the withdrawal component is only one way of alleviating the suffering,” said Dr. J. David Clark, principal investigator of the study. “With luck and determination, we can identify additional targets and put together a comprehensive treatment program.”
Source: March 2009 issue of the Journal of Pharmacogenetics and Genomics.

Filed under: Treatment and Addiction :

For the minority of patients for whom it feasible, acceptable and safe, this meta-analytic review of behavioural couples therapy suggests it reduces substance use relative to other therapies, and the benefits are more likely to extend to the whole family.
Behavioural couples therapy assumes that substance use problems and intimate relationships are reciprocally related, such that substance use impairs relationship functioning, and severe relationship distress combined with attempts by partners to control substance use may prompt craving, reinforce substance use, or trigger relapse. To break this vicious circle and transform the relationship in to a positive force, the therapy aims to build support for abstinence and to improve relationship functioning. It features a ‘recovery contract’ which involves the couple in a daily ritual to reward abstinence, together with techniques for increasing positive activities and improving communication. A requirement for the therapy is that the partner of the problem substance user does not themselves have the same sort of problem.
Descriptive Reviews have concluded that behavioural couples therapy produces better outcomes than individual-based treatment for alcoholism and drug abuse problems. However, the strength and consistency of this effect has not been examined because a meta-analysis of studies of the therapy has not been reported. This meta-analysis combines multiple, well controlled studies to help clarify the overall impact of behavioural couples therapy in the treatment of substance use disorders, and to determine whether this varies across different types of outcomes (such as relationship functioning and substance use) and/or with time after treatment.
A comprehensive search found 12 (eight dealing with drinking problems, four with other substances instead or as well) randomised controlled trials of behavioural couples therapy which could be included in the final analyses, involving altogether 754 couples in intimate relationships. In all but two, couples therapy supplemented other approaches. Eight of the studies compared couples therapy with cognitive-behavioural therapy.
Behavioural couples therapy manuals are available free of charge on request from the web site of the Addiction and Family Research Group. The same site offers a link to a free training program.
Across the studies and amalgamating all outcomes and lengths of follow-up, there was a clear advantage for treatment including behavioural couples therapy versus solely individual-based treatment. At 0.54, the effect size indicated a medium-size impact. Effects were comparable for alcohol studies and for studies including other drugs, for studies which did or did not combine the therapy with medication, which featured more or less extended versions of the therapy, and (but slightly less strongly) when comparison treatments were limited to cognitive-behavioural therapy without a focus on relationships. Across all the studies, effects were slightly greater for measures of the adverse consequences of substance use and for satisfaction with the relationship (0.52 and 0.57 respectively), than for the frequency of substance use (0.36). However, this pattern varied with time. Immediately after treatment ended, couples therapy was superior to comparison treatments only in respect of satisfaction with the relationship. At later follow-ups, it was superior in respect of all three types of outcomes and to roughly the same medium degree of strength. Possibly substance use outcomes were so good immediately after treatment that it was difficult to improve on them, or perhaps relationship benefits from couples therapy took time to impact on substance use.
When the clients are married or cohabiting couples seeking help for substance dependence problems confined to one of the partners, the authors concluded that behavioural couples therapy results in better outcomes than more typical individual-based treatments. The benefits extend beyond substance use to related problems and the quality of the relationship. Immediate improvements in relationships seem to pave the way for later relative gains in substance use outcomes. Though these outcomes were not included in the analyses, studies have also shown that the therapy outperforms individual-based treatments in respect of child adjustment, cost-effectiveness, and reduced interpersonal violence.
Behavioural couples therapy was one of only two psychosocial therapies recommended by Britain’s National Institute for Health and Clinical Excellence (NICE) for the treatment of problems related to illicit drug use. In particular, NICE said it should be considered for problem users of stimulants or opioids who are in close contact with a non-drug-misusing partner. Experts reached a similar conclusion after reviewing the alcohol treatment literature for England’s National Treatment Agency for Substance Misuse.
Both reviews noted the therapy’s limited applicability: the patient must share an intact, live-in relationship with a relative or partner not also experiencing substance use problems, and the relationship must be sufficiently supportive for both to productively engage with the therapy. This will be the case for many (especially male) drinkers, but usually not for long-term dependent users of cocaine or heroin. Care will also be needed to exclude the risk that such therapies, particularly when they engage women in the treatment of male substance users, might perpetuate or aggravate victimisation by abusive partners. Another major limitation is the availability of family therapy of any kind. The dominant paradigm sees addiction as a disorder of the individual and treats it accordingly. Few drug misuse professionals have been trained in family approaches and in the UK there is no appreciable national drive to widen their perspective. The recent emphasis on addressing not just substance use but also other recovery-relevant issues may alter this situation.
The analysis shares the limitations of many meta-analyses. These mean that it is best seen not as an indication of the generalised impact of the therapy, but of how it performed in this set of studies. One assumption underlying the analysis – that the studies were entirely independent of each other – is certainly violated because eight of the 12 involved one or both of the developers of the therapy. Among the remaining four were the three with the least convincing results overall, raising the issue of whether outcomes depend on who is organising the study. Research conducted by teams linked in some way to the intervention they are testing has been found (1 2) to produce more positive findings than fully independent research. In relation to psychosocial therapies for drinking problems, an analysis of relevant studies concluded that therapies were generally equivalent, and that where they were not, the researcher’s allegiance to the therapy accounted for a significant portion of the differences.
What all this means is that it cannot be assumed that fresh applications of the therapy will produce the average advantages over other therapies noted in the featured analysis. Still the analysis offers more support to this therapy than most others can muster, especially since the usual comparator (cognitive-behavioural therapy) was itself a generally effective approach and one relatively hard to better. For the minority of patients for whom it feasible, acceptable and safe, behavioural couples therapy seems a good option relative to other therapies, and one whose benefits are more likely to extend to the whole family.

Source:Clinical Psychology Review: 2008, 28(6), p. 952–962.

Filed under: Treatment and Addiction :

Alcohol’s inebriating effects are familiar to everyone. But the molecular details of alcohol’s impact on brain activity remain a mystery. A new study by researchers at the Salk Institute for Biological Studies brings us closer to understanding how alcohol alters the way brain cells work.Their findings, published in the current advance online edition of Nature Neuroscience, reveal an alcohol trigger site located physically within an ion channel protein; their results could lead to the development of novel treatments for alcoholism, drug addiction, and epilepsy.
Ethanol, the alcohol in intoxicating beverages, is known to alter the communication between brain cells. “There’s been a lot of interest in the field to find out how alcohol acts in the brain,” says Paul A. Slesinger, Ph.D., an associate professor in the Peptide Biology Laboratory at the Salk Institute, who led the study. “One of several views held that ethanol works by interacting directly with ion channel proteins, but there were no studies that visualized the site of association.”
Slesinger and his team now show that alcohols directly interact with a specific nook contained within a channel protein. This ion channel plays a key role in several brain functions associated with drugs of abuse and seizures.
Previous research by Slesinger and his group focused on the neural function of these ion channels, called GIRK channels. GIRK channels, short for G-protein-activated inwardly rectifying potassium channels, open up during periods of chemical communication between neurons and dampen the signal, creating the equivalent of a short circuit.
“When GIRKs open in response to neurotransmitter activation, potassium ions leak out of the neuron, decreasing neuronal activity,” says UCSD Biology graduate student and first author Prafulla Aryal. Alcohols had been previously shown to open up GIRK channels but it was not known whether this was a direct effect or whether this was the by-product of other molecular changes in the cell.
Having the location of a physical alcohol-binding site important for GIRK channel activation could point to new strategies for treating related brain diseases. Using this protein structure, it may be possible to develop a drug that antagonizes the actions of alcohol for the treatment of alcohol dependence. Alternatively, “If we could find a novel drug that fits the alcohol-binding site and then activate GIRK channels, this would dampen overall neuronal excitability in the brain and perhaps provide a new tool for treating epilepsy,” says Slesinger.
Epilepsy is a neurological disease characterized by episodic, abnormal electrical activity that affects more than 3 million Americans. Current medications have serious side effects and the search for new, specific mechanisms of treatment is an area of intense research across the globe.
To gain more insight into how alcohols work, Slesinger and Aryal teamed up with Salk colleagues Senyon Choe, Ph.D., a professor in the Structural Biology Laboratory, and Hay Dvir, Ph.D., a postdoctoral researcher in Choe’s lab, to determine whether tiny pockets found in a high resolution, three-dimensional structure of a potassium channel were, in fact, the sites of alcohol action in GIRK channels. The Salk researchers noted the similarity of these candidate alcohol-binding sites with alcohol pockets visualized in two other alcohol-binding proteins: alcohol dehydrogenase, the enzyme that breaks down alcohol in the body, and a fruit fly protein, LUSH, that senses alcohol in the environment.
When Aryal systematically introduced amino acid substitutions that denied alcohol molecules access to the potential alcohol binding site, alcohol could no longer efficiently activate the channel, confirming that they had hit upon an important regulatory site for alcohol. The team further established that this pocket is a trigger point for channel activation since G protein activation was also altered. “We believe alcohol hijacks the intrinsic activation mechanism of GIRK channels and stabilizes the opening of the channel,” says Aryal. “Alcohol may accomplish this by lubricating the activation gears of the channel,” adds Slesinger.

Source: ScienceDaily. Retrieved July 5, 2009, from¬ /releases/2009/06/090628171951.htm

Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial.
This unique randomised trial tested what would happen if detoxified opiate addicts were then maintained on a substitute drug, on an opiate-blocking medication, or simply counselled. The results led to the introduction of methadone prescribing programmes in Malaysia.
Abstract As a follow-on treatment after opiate detoxification, this study compared the efficacy of the opiate-blocking medication naltrexone, the opiate substitute buprenorphine, or no treatment other than the drug counselling all patients received. In Malaysia at the time naltrexone was the main long-term pharmacotherapy and maintenance substitute prescribing was not permitted.
Between July 2003 and May 2005, 215 people contacted the study of whom 143 heroin dependent patients began a preparatory 14-day detoxification programme in the study’s inpatient clinic. Most of the remaining contacts did not complete the study’s initial assessments; just 12 were excluded due to complicating conditions. 126 completed detoxification and started 24 weeks of weekly individual and group drug counselling in the study’s outpatient research clinic. For randomly selected patients, counselling was supplemented either by oral naltrexone, sublingual buprenorphine, or placebos. In the first week the medications were given daily, then multiple doses were given on Mondays, Wednesdays and Fridays. All the doses were consumed under supervision at the clinic and all the patients consumed similar tablets and capsules, either active or placebos depending on their assignment. Nevertheless, most on the active medications correctly identified what they were taking, though most on placebos did not. Typically the patients were poorly educated single men with a history of imprisonment who had been using heroin for on average 15 years and had used near-daily in the previous month.
Outcomes were assessed mainly by urine tests three times a week while patients were still in treatment, the credible assumption being made that the few tests missed by retained patients would have been positive for heroin, and that patients who dropped out of treatment had resumed heroin use. When it became apparent that buprenorphine was clearly the best option, the study was terminated early after 103 patients had completed it and 10 remained in treatment.
Supplementing counselling with naltrexone slightly improved treatment retention and heroin use outcomes, but not to a statistically significant degree according to the study’s stringent criteria. In contrast, outcomes on these measures were clearly and universally superior for the buprenorphine patients, significantly better than placebo, and generally also significantly better than naltrexone. For example, of the 24 weeks patients could have stayed in treatment, on buprenorphine they stayed on average for 17 weeks, naltrexone 12, and placebo 10 chart. Corresponding figures for retention without a positive/missed test for heroin use were 7, just over 3, and just under 3 weeks. For retention without relapse to sustained heroin use, the figures were 11, 9, and just under 6 weeks.
For the authors their findings showed the efficacy of maintenance treatment with buprenorphine in sustaining abstinence, delaying time to resumption of heroin use and relapse, and retaining patients in treatment, lending support to the widespread dissemination of maintenance treatment with buprenorphine as an effective public health approach to heroin dependence.
Uniquely the study answered the question: What would happen if continuing care for patients who completed detoxification consisted of low intensity counselling only or with attempts to sustain abstinence using naltrexone, versus effectively accepting that many will relapse and instead prescribing a substitute drug? When these were the only options available, the answer seemed to be that naltrexone offers no substantial advantages, but that substitute prescribing makes a big difference to how long and how many patients are able to live without regular resort to illegal opiates. Without this, for most rapid relapse is the norm even after they have been able to complete detoxification; opiate blocking medication does little to improve the situation.
Though this is the verdict from among the range of options on offer in the study, long-acting forms of naltrexone which last weeks or months might have tipped the balance in favour of abstinence-based therapy, and seamless entry in to (to the patient) acceptable forms of residential rehabilitation or intensive day care might have raised outcomes to the point where the choice of medication was less decisive. In both cases, the caveat is that compared to substitute prescribing, fewer patients are prepared to accept or can access these options, and in the case of residential rehabilitation, the costs per year of heroin use averted are likely to be considerably greater.
The main issue with the study from a UK perspective is its applicability to a country where these are not the only options available, and where even if they were, patients would be expected to be allocated to them on an individual basis in the light of what seems best for that individual. However, there are parallels. As in the featured study, in the UK (and elsewhere) failure to complete detoxification or post-detoxification relapse are the norm, long-acting naltrexone formulations have yet to be licensed and made widely available, and residential rehabilitation remains in short supply. The relevance of the study could be heightened if (as strongly advocated by some political advisers) substitute prescribing is de-emphasised in favour of abstinence-based approaches, especially if the need for economies forces these to take the form of naltrexone or counselling rather than intensive, extensive and expensive psychosocial rehabilitation.
Currently the study usefully reinforces existing guidance on the need for anti-relapse support after detoxification, the limitations of oral naltrexone as a means of providing or reinforcing that support, and the more widespread applicability and more securely established effectiveness of substitute prescribing using methadone or buprenorphine. It also provides an argument for maintenance prescribing to be made rapidly available for the many patients unable to avoid a return to regular opiate use after detoxification.
The implications of the study are supported by other studies of detoxification, oral naltrexone and substitute prescribing, though no other study has within itself compared these options. As commentators on the study put it, this wider research base indicates that “The preferred oral pharmacological treatment for opioid dependence should be agonist maintenance with either methadone or buprenorphine.” This verdict carefully limited itself to “pharmacological” treatments and to “oral” medications, leaving out more intensive or improved psychosocial approaches or long-acting implanted or injected medications.
In Australia, where polarised opinions favoured substitute prescribing or rejected this in favour of naltrexone, the federal parliament reacted by conducting a review of their respective advantages in the Australian context. The conclusion was that both had their place, but that place was much greater for substitute prescribing. Oral naltrexone was seen as a niche option for the minority of opioid-dependent individuals capable of remaining compliant with the treatment, but for most it had been consistently been linked with high rates of non-compliance, a greater risk of death and reduced likelihood of long-term success. In contrast, methadone and other opioid substitution treatments were seen as widely applicable treatments acknowledged as effective in reducing opioid dependence and associated health and social problems.
The featured study seems to support this conclusion, but perhaps not as strongly as it might have done. On one key measure – retention without relapse to sustained heroin use – buprenorphine’s advantage over naltrexone was small (two weeks) and not statistically significant, possible an artefact of the way relapse was defined. Despite its advantages, at best half the patients on buprenorphine stayed in treatment for six months, less than in other studies possibly due to insufficiently supportive psychosocial care, or because the study’s standard dose was at the lower end of what is considered effective. It also seems likely that buprenorphine’s advantage would have been greater had patients not been required to complete detoxification in advance, presumably weeding out those less able or willing to attain abstinence from opiates. On the other hand, the naltrexone patients might have been disadvantaged by the dosing schedule. Both buprenorphine and naltrexone are known to be able to bridge alternate-day dosing schedules, but in studies naltrexone is normally taken daily, providing a daily reminder to the patient that any heroin they try will be more or less wasted. Dosing every two or three days left gaps during which the patients might have been tempted to try heroin. However, this schedule probably reflects how both drugs are commonly prescribed in normal practice.
Source: Schottenfeld R.S., Chawarski M.C., Mazlan M Lancet: 2008, 371, p. 2192–2200.

In a small pilot study, Topiramate – a medication currently used to treat seizure disorders – has helped cocaine-addicted outpatients stay off the drug continuously for 3 weeks or more. That may not seem like a long time, but previous research has shown that outpatients who avoid relapse for 3 to 4 weeks during treatment with behavioral therapy and medication have a good chance of achieving long-term cessation. In other clinical trials Topiramate has helped prevent relapse to alcohol and opiate addiction; these new results with cocaine add to hopes that it may prove a versatile treatment medication for several drugs of abuse.

Dr. Kyle M. Kampman and colleagues at the University of Pennsylvania School of Medicine and the Veteran Affairs Medical Center in Philadelphia treated 40 crack-cocaine-smoking outpatients, mostly African American males, for 13 weeks at the University of Pennsylvania Treatment Research Center (TRC). All participants met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for cocaine dependence. They were typical of the chronic, relapsing abusers who seek treatment at the TRC: They abused cocaine an average of 10 years, preferring crack to the powder form, and demonstrated the average level of drug-related problems. However, participants’ abuse was atypical in one way; they were on the “milder end of the addiction severity spectrum measured by cocaine withdrawal symptom severity and days of abuse and money spent on cocaine,” says Dr. Kampman. On average, participants abused cocaine 6 to 8 days and spent $300 to $500 on the drug in the month before treatment compared with the 10 to 13 days and $400 to $600 reported by most patients at the facility. Because Topiramate exacerbates cocaine withdrawal symptoms, the investigators selected patients who were able to attain at least 3 days of self-reported abstinence immediately before starting the trial and who, based on their level of addiction, were not likely to enter severe withdrawal. Dr. Kampman says that about 40 percent of patients treated at the TRC experience relatively mild withdrawal symptom severity.

After a 1-week baseline period, Dr. Kampman’s team gave Topiramate to 20 study participants, and placebo to the other 20. To avoid potential Topiramate side effects, including sedation and slurred speech, they initiated treatment with 25 mg/d and increased it by 25 mg/d every week to 200 mg/d. They maintained this maximum dose during weeks 8 through 12, then tapered to zero during week 13. The patients also received cognitive behavioral coping skills therapy twice weekly throughout the study. The researchers verified cocaine abstinence two times a week with urine tests.

By the end of the 13th week, almost 60 percent of patients taking Topiramate attained 3 or more weeks of continuous abstinence from cocaine compared with 26 percent of those taking placebo. All 40 patients showed improvement from week 1 to week 13, as reflected by lower Addiction Severity Index (ASI) scores. Patients taking the medication improved more, with average scores in the topiramate group falling by 69 percent, from 0.210 to 0.066, compared with 50 percent, from 0.162 to 0.081, in the placebo group. Dr. Kampman says the improvement in ASI scores reflects fewer days of cocaine abuse and patients’ perceptions of reduced cocaine-related problems. “Patients saw the improvement in their condition, which is an important part of recovery,” he says.

“Based on our findings and other work showing this medication’s effectiveness as a treatment for alcohol and opiate addiction, topiramate appears to have great potential as a relapse prevention medication for people who have achieved initial abstinence from cocaine,” says Dr. Kampman.

Possible Mechanisms

All addictive drugs deliver pleasurable effects by enhancing the neurotransmitter dopamine in the mesocorticolimbic pathway – areas of the brain involved in reward and motivation. Topiramate seems to change the – gamma aminobutyric acid (GABA) and glutamate. Animal studies have suggested to scientists that either activating GABA-producing neurons or blocking glutamate receptors would lessen craving in cocaine-addicted human subjects. “Topiramate does both simultaneously, a unique dual action that appears to underlie its’ promise as a relapse prevention medication,” says Dr. Kampman.

“These are preliminary results, but researchers are very excited about the potential Topiramate has shown as a treatment for a range of problems, including addiction to several drugs and some impulse control disorders,” says Dr. Frank Vocci, director of NIDA’s Division of Pharmacotherapies and Medical Consequences of Drug Abuse. In addition to its initial successes in preventing relapse in patients with alcohol, opiate, and now cocaine addiction, animal studies have suggested it may attenuate nicotine addiction. “Topiramate may prove an effective treatment for patients who are addicted to multiple drugs,” Dr. Vocci adds.

Dr. Kampman plans additional studies to further evaluate Topiramate as a treatment for cocaine addiction. In addition to confirming the present results, obtained with African American male crack smokers, the medication must be tried in other racial groups, women, and powder-cocaine abusers. Dr. Kampman and his colleagues also plan to study Topiramate therapy for patients with coexisting cocaine and alcohol addiction – a group that comprises half of people treated for cocaine abuse.
• Kampman, K.M., et al. A pilot trial of topiramate for the treatment of cocaine dependence. Drug and Alcohol Dependence 75(3):233-240, 2004.

Source: Lori Whitten, NIDA NOTES Staff Writer; Volume 19, Number 6 (May 2005)

Researchers say that two drug advances may help millions of Americans addicted to alcohol control their cravings, The drug Naltrexone, which was available in capsule form for years, is now offered as a once-a-month injection. “People came in saying that they really wanted to try this because they had a hard time remembering to take the drug on their own,” said lead researcher Dr. Henry Kranzler, a psychiatry professor at the University of Connecticut School of Medicine.

Kranzler’s study, involving 315 patients addicted to alcohol, found that the monthly version of the drug increased the total number of days that the participants abstained from consuming alcohol.

The drug Acamprosate, which is in use in Europe and awaiting approval from the U.S. Food and Drug Administration, also has showed success in studies led by Elizabeth Houtsmuller, a professor of behavioral biology at Johns Hopkins University School of Medicine.

Houtsmuller’s research examined the physiologic and behavioral changes in 10 heavy drinkers who were given daily Acamprosate. The participants were given opportunities to drink during various points in the study period.

The study found that those who took Acamprosate became more sedate than usual. However, it was not clear whether this sedation would discourage repeat alcohol consumption. “It doesn’t work by altering alcohol absorption or elimination,” said Houtsmuller. “And it doesn’t appear to work by changing alcohol’s subjective effects – the alcohol ‘experience’ that people have.”

Kranzler said the medical advances, combined with psychotherapy and assistance from groups like Alcoholics Anonymous, are helping many alcoholics turn their lives around. “We see people getting better all the time,” he said.

Source: Health Day News reported July 14.2004. published in Alcoholism: Clinical and Experimental Research July 2004

Researchers plan to conduct trials to determine whether a skin patch containing the drug mecamylamine can reduce excess drinking by curbing alcohol cravings, Nature reported April 20.

The patch was originally developed as a quit-smoking aid. But preliminary research shows that mecamylamine also may help curb alcohol addiction. An initial study conducted by Jed Rose at Duke University in Durham, N.C., found that people who consumed more than 10 alcoholic drinks a week reduced their intake to six after taking mecamylamine for four weeks.

Mecamylamine, which has been used since the 1950s to reduce high blood pressure, dulls the addictive effects and cravings of drugs by reducing the release of dopamine.

Rose and his team of researchers are applying for funding and ethical approval for a formal trial.

Source: ‘ Nature’ April 20th 2004

La Jolla, CA. June 21, 2004 — Scientists at The Scripps Research Institute have designed a potentially valuable tool for treating cocaine addiction by creating a modified “phage” virus that soaks up the drug inside the brain.They coated the virus with an antibody that binds to molecules of cocaine and helps to clear the drug from the brain, which could suppress the positive reinforcing aspects of the drug by eliminating the cocaine high.

“Typically one would think of a virus as a bad entity,” says principal investigator Kim D. Janda, Ph.D., who holds the Ely R. Callaway, Jr. Chair in Chemistry and is an investigator in The Skaggs Institute for Chemical Biology at Scripps Research. “But we are taking advantage of a property it has—the ability to get into the central nervous system.”

The structure and design of the virus and its effect in rodent models are described in an article that will be published in an upcoming issue of the Proceedings of the National Academy of Sciences.


Source: June 2004

The European Agency for the Evaluation of Medicinal Products reports that ten cases of life threatening cardiac rhythm disorders have occurred in young patients taking Orlaam (levacetylmethadol) for opiate addiction, the European Agency for the Evaluation of Medicinal Products (EMEA) reported. The agency believes the risks are serious enough to advise prescribers not to introduce any new patients to Orlaam therapy until a full risk benefit assessment has been completed by its scientific committee.

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

Source:  The European Agency for the Evaluation of Medicinal Products, Jan 2001.

A new study shows that women receive different types of benefits from prison-based addiction treatment programs and those located off prison grounds. Elizabeth Hall, project director of the Forever Free Substance Abuse Treatment Program Outcomes Study at the University of California, said the study found that women who received prison-based treatment initially did better on parole and with cutting drug use. On the other hand, women in the non-prison program fared better finding jobs. But a year later, when researchers conducted a review of study participants, they found that 35 percent of the prison group had used alcohol or other drugs during the month before the interview, compared with 8 percent of the non-prison group. Also, 75 percent of the prison group reported using alcohol or other drugs at some time during their parole period, compared with half of the non-prison group.

Source: The study’s findings were presented at a National Institute of Justice’s Research &
Evaluation Conference in Washington, DC. Aug 2001.

Burenorphine is widely prescribed in France  used to be THE substitute drug but isn’t any longer in France. Instead som 50.000 opiate addicts use Buprenorphine in France at the moment. Experiments with the drug are also being carried out in Sweden. CSAT( USA)  is  proposing regulatory changes to make buprenorphine more accessible for the treatment of addicts. Unlike  methadone, it is a fairly mild narcotic that should block craving while  having negligible effects. One proposed preparation will mix this with  naloxone which is a narcotic antagonist and which is used to reverse the effects of narcotics abruptly in overdose situations. If the pill is crushed, the Naloxone would be activated.

Source: Dr. Eric Vott Drug Strategy institute June 2000
Filed under: Treatment and Addiction :

Buprenorphine is available as a sublingual tablet formulation, and many assorted studies have been performed to determine its effectiveness in the treatment of opiate addiction.
Preliminary studies using low dose Buprenorphine (Temgesic) tablets performed in Belgium and France were the first to demonstrate its effectiveness. Elsewhere in Europe, several studies have been completed that have compared the use of high-dose buprenorphine and methadone.
The major comparison studies have been performed in Switzerland, Italy and Austria and these have confirmed the equivalence of the two agents in all outcome measures, apart from retention rates in some cases probably due to protracted induction phases)
Trials in Spain and Australia have been performed to investigate less than daily dosing, again demonstrating buprenorphines effectiveness in different dosing regimens.
Concerns about misuse/diversion of the product led to studies investigating the injection of doses ranging from 2-6 mg. Results demonstrated the well known ceiling effect of Buprenorphine, in this case maximal effect was seen at approximately the 12 mg dose level.
In summary, Buprenorphine has a wide effective dose range (2—32 mg/day), a wide safety margin, is well tolerated, is widely accepted by addicts, has only mild withdrawal and a low dependence liability, and offers flexibility in dosing.

Source: Author C.B. Chapleo, Reckitt & Colman Products Ltd, Hull, UK
Filed under: Treatment and Addiction :

Jonathan Freedman, Associate Professor of Pharmacology in the Department of Pharmaceutical Sciences at Northeastern University’s Bouve College of Health Sciences, has discovered why people who suffer from drug addictions or chronic severe pain crave larger dosages of drug treatments over time.
The findings of Professor Freedman and his team resulted from a three- year project funded by the National Institute on Drug Abuse in Bethesda, Maryland. Freedman and his team discovered a specific molecular change in the brain using a research method called ‘patch clamp electrophysiology” on the surface of rat brain cells, one molecule at a time. They found that rats treated with morphine eventually needed higher dosages of drugs to achieve the same effect. Freedman and team hope this understanding will later give way to practical applications in human patients.
“Scientists have been looking for almost 30 years for the molecular mechanism of opiate drug tolerance, says Professor Freedman. “I hope that our discovery will be a significant step towards understanding it. Eventually, we may be better able to treat heroin addicts, and better able to help people like cancer patients who have chronic severe pain.”

Source: Author Professor J Freedman et al published in  Proceedings of the National Academy of Sciences December 2000.
Filed under: Treatment and Addiction :

A study on the effectiveness of the 7-year-old drug court in St. Louis, Mo., finds that the program’s benefits far outweigh its costs, the Associated Press reported Feb. 2.

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

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

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

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

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

Source:  Author Tony Loman et al published by Institute of Applied Research reported on JTO Online 2003

A team of NIDA-funded researchers from the University of Chicago, Brown University, and Rhode Island Hospital  has found that, in general, the more time a person spends in treatment for addiction, the better. The scientists found that treatment for up to 18 months in residential settings, or almost 14 months in outpatient non methadone treatment, yielded the greatest reductions in illicit drug use. Both overall and primary drug use declined after 18 months in long-term residential programs, at which point peak use measured about one-tenth the pre treatment level. After 18 months in this setting, the amount of improvement began to wane. A similar effect was seen in people treated in non methadone outpatient settings. Individuals in non methadone programs who reduced drug use on their own before entering a treatment program were better able to remain in recovery.

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

Source: Author  Dr. Zhiwei Zhang et al of the National Opinion Research Center (NORC), University of Chicago, Published in Addiction May 2003.
Filed under: Treatment and Addiction :

New research suggests that a family-treatment approach may be effective in preventing children of addicted parents from becoming addicts themselves.

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

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

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

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

Filed under: Treatment and Addiction :

Across the United States, drug treatment courts for adults and juveniles offer an alternative to incarceration for non-violent offenders.

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

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

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

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

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

Advisers to the British government say future remedies for drug addiction could include “reprogramming” the brains of addicts and inoculating children against alcohol or other drug abuse.

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

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

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

Source: Independent July 14 2005
Filed under: Treatment and Addiction :

In an unusual move, city Health Department officials are quietly encouraging physicians, hospitals, methadone clinics and prisons to prescribe the drug buprenorphine to heroin addicts, believing it will lure more addicts into treatment. Buprenorphine — a relatively new drug that goes by the nickname “bupe” and comes in a pill form — offers a new set of treatment options for opiate abusers, said Dr. Lloyd Sederer, executive deputy commissioner of the city Department of Health and Mental Hygiene.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


A review article has outlined the benefits of buprenorphine (Subutex) in the treatment of intravenous drug use. The drug, which was added to the World Health Organization’s (WHO’s) list of essential drugs in July 2005, may be beneficial in reducing HIV transmission through injection practices, as well as treating HIV-infected drug users.

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

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

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

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

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

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

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

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

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

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

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

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

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

Source: Clinical Infectious Diseases September 2005

Researchers say that the onset, pattern, and duration of the “highs” produced by cocaine and methamphetamine differ significantly — findings that could have implications for development of anti-addiction medications.

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

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

Source: Momstell News online Aug. 2005

A compound in the common kudzu weed seems to help drinkers cut back on their alcohol consumption, the Associated Press reported May 17.

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

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

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

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

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

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

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

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

PATIENTS suffering the effects of cannabis abuse are being treated by Tasmanian public hospitals every day, says a leading health authority.

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

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

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

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

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

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

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

Disengaged teenagers could then turn to cannabis.

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

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

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

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

Source: Sunday Tasmanian 30th January 2005

Scientists report that they are inching closer to developing a vaccine that would effectively treat drug addiction. Although the research is several years away from putting a vaccine on the market, the studies are meeting with success. The research suggests that the vaccine is able to activate the immune system to block the effects of substances such as cocaine or nicotine.

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

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

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

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

Source: Wall St. Journal October 2004
Filed under: Treatment and Addiction :

Orexin (hypocretin), a neurotransmitter recently detected by researchers, is involved in the brain’s pleasure and reward system and could play a role in addiction and treatment.

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

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

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

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

Source: Nature. Aug. 14, 2005
Filed under: Treatment and Addiction :
People who are in recovery from addiction are often advised to avoid the “people, places and things” associated with their past drinking or other drug use. But adolescents who’ve been through treatment for drug dependence may find this impossible to do.

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

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

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


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

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

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

Adolescents who are fresh out of treatment are also at greatest risk for relapsing to alcohol and other drug use. This is the time when such students return to their homes, schools and neighborhoods — the very milieu that supported their abuse or dependence in the first place.

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

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

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

According to the ARS, recovery schools should:


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


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


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


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


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

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

Source: Hazelden’s Alive & Free news column April 4, 2005

A U.K. detox program is using healthy snacks as a way to help addicts overcome anxiety and sleeplessness.

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

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

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

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

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

Source: BBC July 18 2005

Researchers say that using benzodiazepines — drugs like Valium, Halcion and Xanax — to help ease withdrawal from alcohol addiction works better than a placebo. But benzodiazepines worked no better than other drugs commonly used to help patients through withdrawal.

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

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

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

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

Source: of The Cochrane Library. (2005, Vol. 3)

Participation in Alcoholics Anonymous (AA) concurrent with professional treatment appears to improve alcohol outcomes in people with alcohol use disorders. Whether AA alone or the timing of participation (e.g., before or after entering treatment) affects these outcomes is unclear.

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

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

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

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

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

Source: Moos RH, Moos BS. Paths of entry into Alcoholics Anonymous: consequences for participation and remission. Alcohol Clin Exp Res. 2005;29(10):1858-1868.

The San Francisco Health Department is offering cash rewards to methamphetamine users who quit using the drug and stay clean, the reported.

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

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

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

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

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

Source: Los Angeles Times Dec. 28 2005
While Alcoholics Anonymous (AA) is a preferred form of aftercare for patients “completing” formal treatment programs, little is known about AA involvement and its effects on abstinence over time. In this study, researchers assessed participation in AA, abstinence, and other alcohol outcomes over 5 years among 349 patients who entered treatment at baseline and attended AA at least once during follow-up.

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

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

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

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

Comments by Joseph Conigliaro, MD, MPH:

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

Source: Kaskutas LA, Ammon L, Delucchi K, et al. Alcoholics Anonymous careers: patterns of AA involvement five years after treatment entry. Alcohol Clin Exp Res. 2005:29(11);1983–1990.

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

Cannabis extracts can be harmful because of the unpredictable way the body reacts, New Scientist said.

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

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

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

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

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

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

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

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

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

But he found boosting levels could actually worsen seizures.


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

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

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

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

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

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

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

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

However, it is made using plant cannabinoids, rather than those found in the body. 27th July

QCT Europe: UK findings


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

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

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

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

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

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

• Improving access to education, training and employment schemes.

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

How to get further information

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

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

Source: Daily Dose. June 2006
Filed under: Treatment and Addiction :
According to new research by Liverpool John Moores University, the proportion of drug users who completed treatment for drug addiction decreased between 1998 and 2002, although the overall number of drug users who entered treatment increased.

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

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

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

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

Source: MedicalNews Today 17th August 2006
Filed under: Treatment and Addiction :

A plant-derived medication that has been used to treat tobacco dependence in Eastern Europe for 40 years may be effective for smoking cessation, but it remains largely unnoticed in English-language literature, according to a review article in the same issue.

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

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

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

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

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

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

Source Aug. 2006

Much is known about the rate of relapse after formal alcohol treatment but not after “spontaneous” or “natural” remission. Researchers studied remission and relapse in 461 individuals with an alcohol use disorder who had not received help before study entry. Subjects were interviewed at baseline and then 1, 3, 8, and 16 years later. At each follow-up, they were asked about their alcohol use and whether they had obtained professional treatment or participated in Alcoholics Anonymous at any time since the last follow-up.

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

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

Comments by Peter Friedmann, MD, MPH:

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

Source: Moos RH, Moos BS. Rates and predictors of relapse after natural and treated remission from alcohol use disorders. Addiction. 2006;101(2):212–222.
Researchers at the Molecular Neurobiology Branch of the National Institute on Drug Abuse (NIDA), National Institutes of Health, have completed the most comprehensive scan of the human genome to date linked to the ongoing efforts to identify people most at risk for developing alcoholism. This study represents the first time the new genomic technology has been used to comprehensively identify genes linked to substance abuse.

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

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

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

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

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

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

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

For more information, visit the NIDA home page at

Source: CADCA Coalitions online. 31.08.06

A drug recently approved by the U.S. Food and Drug Administration as an aid to smoking cessation appears effective both short and long-term for smokers trying to quit, according to two reports in the August 14/28 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.

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

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

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

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

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

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

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

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

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

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

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

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

Source: Arch Intern Med. 2006;166:1571-1577 Aug. 2006

To quantify the effect of help seeking on recovery from alcoholism, researchers in the United States analyzed data from 4,422 adults who had participated in a nationally representative survey and developed alcohol dependence at least 1 year before their participation.

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

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

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

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

Comments by Peter Friedmann, MD, MPH:

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

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


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

Source: Addiction. 2006;101(6):824–834.

By Sara Solovitch

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

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

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

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

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

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

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

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

Sourde: l7th August 2006

A review of hundreds of studies examining substance abuse treatment found that treatment is not only effective in reducing alcohol and drug use, it also helps lower crime and healthcare costs. The report offers a helpful resource for coalitions looking to demonstrate the value of treatment to their community or for coalitions looking to enhance their treatment capacity.

Source: 380K
Filed under: Treatment and Addiction :

A drug that Duke University Medical Center researchers have successfully used to help some people quit smoking may also help curb cocaine cravings, according to studies conducted in rats.

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

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

Rose et al. International Behavioural Neuro Science Society, April, 2000.

Researchers at The Scripps Research Institute have developed a second-generation, long-lived cocaine immunoconjugate that blocks cocaine passage into the brain of rats.
The new immunoconjugate displays two amide groups in the stereochemical configuration found in the cocaine framework, so that antibody affinity to cocaine is optimized, Dr. Janda and associates report in the Proceedings of the National Academy of Sciences.
Rats were immunized with the vaccine and challenged with systemic cocaine.  Compared with unimmunized controls, locomotor activity was significantly reduced, as were stereotypic patterns of behavior, such as sniffing and rearing.  Effects were sustained throughout the 12 days of the study.
“We have been able to tap into the immune system to immobilize antibodies to recognize cocaine as foreign and remove it from the body,” Dr. Janda said.  “The current vaccine provides a much longer lasting effect than our previous vaccines, suggesting that boosting requirements would be minimal and the antibody circulation time would be increased.”
Dr. Janda added that the vaccine would be of most use in addicts who are motivated to stop using cocaine.  “Typically an addict will relapse several times before he or she will ‘kick’ the drug,” he said.  “We believe the vaccine will protect addicts at weak moments when they have the urge to get high.  If we can prevent the high we can prevent relapse and this would speed the process of kicking the addiction.”

(Source: Proc National Academy of Science, USA 2001;98:1988-1992.)


More U.S. teens are being admitted to centres to be treated for alcohol and drug abuse, a government report released on Thursday shows. The report, by the Substance Abuse and Mental Health Services Administration (SAMHSA), shows that the number of adolescents aged between 12 and 17 admitted to substance abuse treatment increased by 20 percent between 1994 and 1999.
The survey, which covered 1.6 million cases of adults and youths over age 12 who were admitted for treatment at a centre, found that most were abusing alcohol – 47 %.  16% were users of opiates. mostly heroin, 14% used cocaine and 14% marijuana or hashish. More than half the patients abused more than one substance.
But for teen-agers the numbers were dramatically different. In 1994, 43% of teens treated for substance abuse were marijuana users. In 1999, 60% were. Half of them were sent to treatment by the courts, the report finds.  While we can all be thankful that people who need help are getting it, this report shows some of the real-life consequences of marijuana use,” said John Walters, appointed this month as director of the Office of National Drug Control Policy.

Source:   Report from SAMHSA December 2001

 A New York addiction-treatment provider is seeing positive results using Exposure Response Prevention (ERP) therapy as part of its treatment regimen.
SLS Health in Brewster, has been using the behavioural therapy with a portion of its clients. “We’ve taken the principles of desensitisation and brought it to [illicit] drug and alcohol treatment,” said Robert DeLetis, senior addiction counsellor.  The therapy exposes individuals to alcohol and the other drugs to which they are addicted, to teach them how to deal with their cravings.
“The exposure to these catalysts elicits powerful cravings that the addict is taught how to handle without giving in to them,” said Joseph Santoro, Ph.D., chief operating officer, “in this way, they are exposed to their triggers but prevented from getting high.  This leads to the extinction of their desire to use.”
An internal study found that ERP is having a positive impact when used in conjunction with standard treatment, such as 12-step meetings, cognitive and group therapy, and medication.
For the study, 57 patients, 33 of whom received ERP, were contacted one to two years after completion of treatment.  The study found that those who participated in ERP had a 55% relapse rate, compared to 88% who did not receive the therapy.

Source: Alcoholism & Drug Abuse Weekly. January 2002
Filed under: Treatment and Addiction :

Snippets from SAMHSA

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

Source: Substance Abuse and Mental Health Services Administration. (2002) The DASIS Report:
Hispanics in Substance Abuse Treatment: 1999. office of Applied Studies, Rockville, MD.

Methadone substitution has long been used as a treatment for heroin addiction. But a new 33-year follow-up study has found that equally satisfactory results are possible without recourse to long-term prescribing of opioids.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Scientists at the National Institute on Drug Abuse (NIDA) have demonstrated that laboratory animals will self-administer marijuana’s psychoactive component, THC (delta-9-tetrahydrocannabinol), in doses equivalent to those used by humans who smoke the drug.
Self-administration of drugs by animals, long considered a model of human drug-seeking behavior, is characteristic of virtually all addictive and abused drugs.
“This study is simple and its findings are clear,’ says NIDA Director Dr. Alan I. Leshner. ‘Animals will work to get THC. This emphasizes further the similarity between marijuana and other abusable, addicting substances. Both animals and humans will work to acquire access to marijuana in the same way that both animals and humans change their behavior to get other drugs of abuse, like cocaine and heroin.”
“This is the first study in which it has been possible to show that monkeys or other research animals will self-administer THC. There are many factors which may explain this behavior, including the fact that in our study we used doses of THC that are directly comparable to doses in marijuana smoke inhaled by humans,” Dr. Goldberg says.
Before the study began, the scientists first established self-administration behavior in squirrel monkeys that received repeated intravenous injections of cocaine after pressing a lever 10 times for each injection. At the start of the study, the researchers replaced cocaine with saline solution and the animals’self-administration stopped. When saline was replaced with THC in a solution that would rapidly pass from blood to the brain, the animals resumed self-administration, rapidly pressing the lever to obtain on average 30 injections of THC during each of a series of 1-hour sessions. Treatment with a compound that prevented TI-IC from binding to cannabinoid receptors on brain cells almost completely eliminated self-administration of THC, but had no effect in another group of monkeys self-administering cocaine under identical conditions.
“The drug-seeking behavior in these animals was comparable in intensity to that maintained by cocaine under identical conditions, and was obtained from a range of doses comparable to those self-administered by humans smoking a single marijuana cigarette,” Dr. Goldberg says. “This finding suggests that marijuana has as much potential for abuse as other drugs of abuse, such as cocaine and heroin.”

Source:Dr.Steven Goldberg at NIDA’s Intramural Researh program,Baltimore
Reported in Nature Neuroscience 2000,volume 3 1073-74.

People who begin using marijuana early are more likely than others to become dependent, new findings show.
In a study of over 2700 marijuana users in Ontario, Canada, those who started smoking at 17 years or later were twice as likely to eventually quit compared with those who started at 14 years or younger. “We believe this study has uncovered important information regarding the effects of patterns of marijuana use on the risk of desistance and progression to marijuana- related harm Dr. David J. DeWit, of the Centre for Addiction and Mental Health, in London, Ontario.
“We observed a significant.. relationship between frequency of lifetime marijuana use and marijuana desistance,” the authors say.
Compared with infrequent use, a lifetime frequency of 100 to 199 uses predicted an almost five fold higher likelihood of developing marijuana disorders, they report.
Prevention programs that are effective in delaying initiation of marijuana use until the age of 16 and beyond may greatly diminish the likelihood of prolonged consumption and consequently serve to avert serious problems later in life” DeWit and colleagues conclude.

People who begin using marijuana early are more likely than others to become dependent, new findings show.
In a study of over 2700 marijuana users in Ontario, Canada, those who started smoking at 17 years or later were twice as likely to eventually quit compared with those who started at 14 years or younger. “We believe this study has uncovered important information regarding the effects of patterns of marijuana use on the risk of desistance and progression to marijuana- related harm Dr. David J. DeWit, of the Centre for Addiction and Mental Health, in London, Ontario.
“We observed a significant.. relationship between frequency of lifetime marijuana use and marijuana desistance,” the authors say.
Compared with infrequent use, a lifetime frequency of 100 to 199 uses predicted an almost five fold higher likelihood of developing marijuana disorders, they report.
Prevention programs that are effective in delaying initiation of marijuana use until the age of 16 and beyond may greatly diminish the likelihood of prolonged consumption and consequently serve to avert serious problems later in life” DeWit and colleagues conclude.

SOURCE: Preventive Medicine 2000;31 :455-464

A St. Louis study finds that drug courts and addiction treatment are far more cost-effective than probation over the long run, Alcoholism & Drug Abuse Weekly reported March 8.

The study by the Institute of Applied Research focused on the city’s adult felony drug court. Researchers concluded that drug court costs about $1,449 per offender more up front than probation, but end up saving taxpayers $7,707 within four years of discharge.

“The drug-court client pays for his drug-court experience within about 3.5 years by avoiding costs [such as reinvolvement with the criminal-justice system] and paying taxes,” said Jeffrey N. Kushner, the city’s drug-court administrator.

The complete report is available on the Institute of Applied Research website.

Source: JTO online March 2004

How likely you are to becoming a cocaine addict could well depend on your genetic make up, say researchers from the Institute of Psychiatry. Some people have a gene variation which stops the production of a protein that regulates dopamine in the brain.

The researchers said that if you have two copies of this gene variation, your chances of becoming addicted to cocaine are 50% higher.

You can read about this study in the Proceedings of the National Academy of Sciences. The study was funded by the Medical Research Council (UK).

The researchers studied the DNA of 1550 people. 700 of them were cocaine abusers while 850 were not.

We all produce a protein called DAT. DAT controls the removel of excess dopamine from the brain. Cocaine inhibits the action of DAT leading to dopamine overload. The dopamine overload is what gives the cocaine abuser the “high” feeling.

Part of our genetic code controls the production of DAT. The researchers found that people who had two copies of the variant that controls DAT production were 50% more likely to become cocaine addicts.

Obviously, if you have two copies of this variant and never touch cocaine your chances of becoming addicted to it are zero. Everyone will eventually become addicted to cocaine, if they take it often enough and for long enough. People with this gene variant are more likely to become addicted sooner.

Dr Gerome Breen, head researcher, said “This study is the first large scale search for a genetic variant influencing the risk of developing cocaine addiction or dependence. The target we investigated, DAT, is the single most important in the development of cocaine dependence. It made sense that variation within the gene encoding DAT would influence cocaine dependence.”

It was found that people who had the genetic variant were more likely to inhibit the DAT response when taking cocaine.

Hopefully, this new finding may eventually help in the designing of new drugs for the treatment of cocaine addiction, say the researchers.

Written by: Christian Nordqvist, Editor: Medical News Today


LONDON (Reuters) British scientists are closer to developing drugs based on cannabis that will take away pain but also take away the “high”.

Researchers from Imperial College in London have separated cannabinoids, the active components of the popular the recreational drug, and shown that they act on both the brain and spinal cord.

The findings will allow scientists used receptors for cannabinoids on the spinal cord, particularly the areas concerned with pain processing.

By delivering drugs directly to the spinal cord to relieve pain they bypass the brain so there are no psychoactive effects.

New drugs based on cannabis are still years away but the findings are an important first step.

Source: Reuters Report July 2000.

“Drug abuse treatment can have important positive public health benefits even if the outcomes are less than perfect,” lead study author DL George Woody told Reuters Health. “The 12-step oriented combination of group and individual counselling worked the best, though all patients reduced their risk.”

Woody urged everyone to “support substance abuse treatment. It can do a lot of good both in the short and long term.”

In an article in the Journal of Acquired Immune Deficiency Syndromes, Dr. Woody who is at the University of Pennsylvania in Philadelphia and his colleagues report on changes in HIV risk among 487 people undergoing treatment for cocaine addiction.

Treatment was associated with an average reduction of cocaine use from 11 days per month to one day per month after six months, the authors report, with participants who received both individual and group drug counselling faring best.

Treatment participation was also associated with significant reductions in risky sex and the total risk of HIV infection, the report indicates.

Those who completed treatment showed a trend toward less sex risk and significantly less total risk than did patients who dropped out before completing their program, the researchers note.

HIV risk reduction corresponded to reductions in drug use and to improvements in psychiatric symptoms, the results indicate. This improvement was similar regardless of race, gender, sexual orientation or the presence of antisocial personality disorder.

“The fact that all treatments consisted of no more than three weekly outpatient sessions that included risk reduction counselling is worth noting,” the authors conclude, “because it suggests that reductions in cocaine use and HIV risk can be achieved at a relatively low cost, at least for a portion of the patients who seek treatment for cocaine dependence.”

SOURCE: Journal of AIDS (news -web sites) 2003;33:82-87.

(The Substance Abuse and Mental Health Services Administration’s Drug Abuse Warning Network ( DAWN ) found that the most common single-drug suicide deaths involved opiates, followed by antidepressants and then cocaine, sedatives and anti-anxiety medications.

DAWN information showed that 7 out of 10 of the suicide deaths involved multiple drugs. The highest rates included combinations of alcohol and antidepressants, anti-anxiety medications and opiates, alcohol and opiates, and then antidepressants with opiates. One quarter of the overall deaths in the metropolitan areas and states involved multiple antidepressants.

“What this data shows is what we teach in our education presentations,” comments a supervisor at Narconon Arrowhead, which is one of the nation’s largest and most successful drug rehabilitation and education programs, “that all drugs are basically poisons and that enough of any drug can cause extreme adverse reactions and even death.”

The DAWN study of 32 metropolitan areas and six states also looked for mortality rates for drug abuse. Of the cities that were examined, Baltimore and Albuquerque had the highest rates with more than 200 deaths per million people. Another 14 metropolitan areas had drug misuse death rates that exceeded 100 per 1,000,000.

In the six states, the number of deaths related to drug misuse or abuse ranged from 74 to 697. After adjusting for population differences, the rates of drug misuse/abuse deaths ranged from 88 deaths per 1,000,000 in Maine and New Hampshire to 162 deaths per million in New Mexico.

The Drug Abuse Warning Network is a public health surveillance system that monitors drug-related hospital emergency department visits and drug-related deaths to track the impact of drug use, misuse, and abuse in the U.S.

This survey did not include any deaths from adverse reactions to drugs. Such cases would include the consequences of using a prescription or over-the-counter pharmaceutical for therapeutic purposes and include deaths related to adverse drug reactions, side effects, drug-drug interactions, and drug-alcohol interactions.

Source: Jan.2006

Over 160,000 people admitted for drug addiction treatment in 2003 started using drugs before the age of 13.

The Substance Abuse and Mental Health Services Administration (SAMHSA) recently released a report from ongoing monitoring of the Treatment Episode Data Set (TEDS) showing an increase in the number of people in treatment for drug addiction who started at an earlier age.

The report tracked treatment admissions from 1993 to 2003 and the percentage of people in treatment who started using drugs before the age of 13 had increased from 12% to 14% during that time span. The total number of people jumped from about 114,000 to more than 162,000.

In a SAMHSA release, Administrator Charles Curie exclaimed, “Age at first use is an important predictor of the potential for serious substance abuse problems later in life. The increase in the proportion of the admissions for drug use before age 13 should be a wake-up call to parents to speak with their children early and often about the dangers of drug use.”
Source: (PRWEB) February 1, 2006

Filed under: Treatment and Addiction :

Methadone substitution has long been used as a treatment for heroin addiction. But a new 33-year follow-up study has found that equally satisfactory results are possible without recourse to long-term prescribing of opioids.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Need for meth treatment programs growing dramatically

Two new surveys released today by the National Association of Counties (NACo) show that methamphetamine abuse continues to have a devastating effect on America’s communities.

One survey, “The Effect of Meth Abuse on Hospital Emergency Rooms,” revealed that there are more meth-related emergency visits than for any other drug and the number of these visits has increased substantially over the last five years. The second survey, “The Challenge of Treating Meth Abuse,” showed that the need for treatment programs for meth addiction is growing dramatically and lack of funding is an obstacle in meeting this demand.

“There is no question that meth abuse is having a devastating effect on America’s communities,” said Bill Hansell, President of NACo and Commissioner in Umatilla County, Ore. “Some states have enacted legislation that has been effective in reducing the number of local labs that produce meth. But officials in two of those states have said that the number of users has not been reduced. We still have a fight on our hands. The vast majority of meth being used today is being imported into our country. We have to find a way to treat those people that have become addicted and prevent others from becoming addicted.”

Both surveys were conducted in late 2005. The results of the emergency room survey are based on 200 responses from hospital emergency room officials in 39 states. Most of the hospitals participating in the survey are either county owned or operated. The second survey asked 200 county behavioral health officials in 26 states about drug treatment programs and how they have been affected by the meth epidemic.

A factor affecting treatment programs is that treatment for meth addiction is different from other drugs. 54% of the officials reported that the success rate is different and 44% said that the length of time in the program is longer for meth addicts. Meth users seeking treatment require special protocols and longer treatment periods than users of other drugs. said. “We hope that he will recognize the need for more funding for treatment.”

This is the second set of surveys that NACo has released on meth abuse. In July 2005, NACo released the results of two surveys it conducted on the impact of meth. The surveys reported responses from county sheriffs and police departments and from child welfare officials. The survey of 500 sheriffs and police departments showed that meth abuse is the top drug problem facing counties in America.

In an alarming number of meth arrests, there is a child living in the home. Often, these children suffer from neglect and abuse. 40% of the counties where child welfare activities are the responsibility of the county reported that out of home child placements have increased because of meth, according to the second survey released in July.
Source: January 18, 2006

Inbred strains of rats differ in how aggressively they seek cocaine after a few weeks of use, researchers say. The finding, posted online Jan. 18 by Psychopharmacology, is another piece of evidence that genetics plays a role in the relapse of drug-seeking behavior in humans, says Dr. Paul J. Kruzich, behavioral neuroscientist at the Medical College of Georgia and lead study author.

It also fingers glutamate, a neurotransmitter involved in learning and memory, as an accomplice in stirring the cravings and uncontrollable urges that drive some drug users to use again, he says.

“Given the right environmental stimuli, all persons addicted to psychostimulants can relapse, but potentially some people are a little more susceptible than others * it’s all about gene-environment interaction,” says Dr. Kruzich.

He took two strains of inbred rats – Fischer 344 and Lewis – with known genetic differences, enabled each to self-adminster cocaine for 14 days, then took the drug away for a week but not the levers the animals used to access it. During that hiatus, he adminstered a drug that stimulates glutamate receptors, possible targets for drugs of abuse.

He found that the F344 strain worked harder to get cocaine than the Lewis rats following treatme