Keep your head up – no shame in addiction

April 12th, 2012

A client come in today for an addiction treatment evaluation. She had so much shame about her drug use that even the relative who brought her in didn’t know what drug she’d been using every day for the last year or so. I told her the same thing I tell all those who ask me for help – it is absolutely up to you to figure out who you feel comfortable telling about your alcohol, drug, gambling, or sex addiction problems. Just keep in mind that being shameful and secretive about your problems can cause addicts in recovery to be secretive when they experience cravings, triggers, and thoughts about using or acting out.

As hard as it is, disclosing these issues can provide an amazing amount of support while also allowing those close to you to be a real part of your recovery. Importantly, you don’t have to disclose to your significant other, your daughter, or your aunt. You can find an outside support system, either through peer-support groups like the 12-steps or SMART recovery or another group where you feel truly comfortable sharing. Shame will keep you isolated, sharing will help set you free.

Honesty, trust, and humility, along with the ability to admit that you are not necessarily managing recovery perfectly can actually be seen as strengths, not weaknesses. Try it out.

Posted in:  Education Tags: 12 steps, addiction, drug, recovery, shame, SMART, support, treatment

Criminal drug possession – Felony versus misdemeanor

April 8th, 2012

In all but 13 States in the U.S., drug possession for personal use is still considered a felony punishable by years in prison and hefty fines. This despite the fact that a significant portion of those arrested meet criteria for dependence (addiction) on the drugs they are caught with, and the fact that our own federal drug abuse agencies (The National Institute on Drug Abuse – NIDA) considers addiction to be a medical condition that involves reduced control over the drug use itself. I guess that’s why the federal government also considers possession for personal use as a misdemeanor.

In essence these state laws are putting drug users, and especially drug addicts, at risk of being locked up for years, placed on parole, and subject to the endless other barriers to employment and housing, which make it more difficult for these convicted felons to reintegrate into the community. As if fighting drug addiction wasn’t hard enough.

The question is, would reducing the penalty for drug possession for personal use to a misdemeanor in more states result in increased drug use and crime or would it actually help free up resources being used for incarceration towards more effective strategies for combating the problem?

California State senator Mark Leno is bringing up a bill for consideration in the state senate (SB1506) that is seeking to do just that – reducing the penalty for possession for personal use of any drug to a misdemeanor. Mind you, this law is not to affect any other drug-related offenses such as drug possession for sale, drug manufacturing, or transportation. What it would do is cap the maximum incarceration length of possession at one year in jail (not more years in prison) as well as cap the maximum community supervision length at 5 years (3 years are commonly assigned for such offenses).

I know what some of you are saying – drug users know they’re breaking the law and they should be punished for it. Indeed, punishing them for it will make them less likely to use, which will leave them facing no jail time instead of continuously facing single years in jail for reduced drug possession offenses. Besides, if we cut the penalties for drug possession aren’t we being soft on crime? Aren’t we saying that using drugs is okay?

The problem with that argument is that it assumes that states that have higher penalties for drug possession for personal use have lower rates of crime, drug use, or drug possession arrests. The don’t. Indeed, the 13 states (and D.C.) that already consider drug possession for personal use a misdemeanor have incarceration rates that are no higher, illicit drug use rates that are slightly lower, and addiction treatment admission rates that are on par and even a bit higher than the rates of felony states. Again, that means the states that reduced the penalty for drug possession see less arrests, more people in addiction treatment, and a smaller percentage of their population using such drugs. Interestingly, those results are somewhat similar to the effect complete decriminalization had on drug use, crime, and addiction treatment in Portugal.

In previous articles we’ve spoken about the stigma of addiction and the barriers people report to entering addiction treatment in the U.S. Aside from cost and lack of information, people usually report that they either don’t want help, think they can handle the problem on their own or are too ashamed to ask for help. We’ve also reported on the ridiculous prison overcrowding problem in California due to the high incarceration rates of drug users. The question of decriminalization has come up many times (see here, here, and here) and the evidence I’ve seen keeps pointing towards the conclusion that reduced penalties get more people into addiction treatment while reducing incarceration rates with no real collateral increased in illicit drug use or crime. When you think about it, since the Harrison Narcotics act of 1914 essentially created the black drug market in the U.S. when it restricted, for the first time, the sale of narcotics, it makes sense that loosening up those restriction would reduce the size of that same black market and with it drug-associated crime.

I have spent the last 10 years researching the best ways to fight addiction problems and almost everything I’ve seen suggests that treatment and prevention efforts, not long jail or prison sentences, are the best ways to combat the problem. I have seen evidence that very shirt-term incarceration can help certain resistant offenders, but those efforts can easily be applied for misdemeanor and require nothing close to multiple-year sentences. For that reason, I support not only Senator Leno’s SB1506 bill in California, but other efforts around the country to reduce the criminal penalties associated with simple drug possession to get more of the people who need help into addiction treatment and away from jails. It saves us money, it is more humane, and it just makes sense.

If you want to help Senator Leno pass this bill, contact his office through this link: http://sd03.senate.ca.gov/

 

Citations/Reading:

U.S. Census Bureau, 2012 Statistical Abstract, Table 308. Crime Rates by State, 2008 and 2009, and by Type, 2009 (2012).

Collins et al., (2010). The Cost of Substance Abuse: The Use of Administrative Data to Investigate Treatment Benefits in a Rural Mountain State. Western Criminology Review 11(3), 13-28.

Gardiner, Urada, and Anglin (2011). Band-Aids and Bullhorns: Why California’s Drug Policy Is Failing and What We Can Do to Fix It. Criminal Justice Policy Review, 23, 108-135.

Posted in:  Education, Links, Opinions, Treatment Tags: addiction, drug, drug possession, drug possession personal, drug use, drug use crime, Leno, Mark Leno, personal use, personal use misdemeanor, possession, possession personal use, SB1506, treatment, use

Addiction research – Who are we studying?

March 4th, 2012

I teach a class on the psychology of addiction (Psych 477 at California State University in Long Beach) and as I have been preparing the lectures something has become very clear to me – textbooks patently gloss over important details about the addiction research they cite. One of the most obvious gaps I’ve noticed this semester concerns the population of research subjects most addiction research is conducted on. An example will clarify:

A student group in my class had to read a study assessing the residual effects of methamphetamine on mood and sleep. They were amazed that no changes in mood were observed and that participants slept a full 6-8 hours the night after being administered meth! Would you have been surprised with these results given that we all have been told that crystal meth improves mood and causes insomnia?

Would it matter at all if I told you that the participants in the study were current meth abusers who use an average of 4 times every week?

For anyone not aware of the tainted history of health research in the U.S. (I’m including psychological research in this group), go ahead and read about the Tuskegee Syphilis Experiment and Stanford Prison Experiment (video here). There are other examples including Stanley Milgram‘s obedience studies, and more but as exciting as the discussion of these studies is, it’s time to get back to my main point.

It is mostly due to the ethically-questionable, psychologically damaging, research above that research institutions are now required to vet proposed research studies using Institutional Review Boards (IRBs) to assure that human participants in studies are consenting to participate of their own free will, are not coerced, and are not suffering undue damage. This is also true of addiction research. Rarely does the public consider this fact however when they are being reported on research relevant to addiction. I know this because the kids in my class never gave it a second thought.

Nearly all addiction research, especially studies utilizing “hard” drugs like cocaine, meth, opiates, etc., are required to make use of a very limited part of society – drug using individuals with a history of use of the specific drug of interest who are specifically not interested in treatment. Individuals who have never tried the drug or who want to be treated for drug abuse or dependence (addiction) are excluded due to ethical concerns. In most studies, participants can not qualify if they are addicted to drugs other than those being studies (except smoking, for which exceptions are usually made since we’d be able left with no participants otherwise) or have any associated mental health disorders, which are very common among addicted individuals. I would further assert that for at least a substantial portion of these research participants, the term “addicts” may not be appropriate since many addicts would not willingly give up using their favorite substance for a week or two to be replaces with a hospital bed and an experimenter controlled dose of drug or placebo. Taken together, our research subjects are pretty obviously not representative of all drug users, or all addicts, or all anything else. They make up a very specific group – less than perfect, but what we have to work with.

In some studies that attempt to make a direct comparison between controls (or drug naive participants) and drug users, this is likely less of an issue. This can happen when researchers try to examine brain structure differences, or performance on a specific psychological or physical test. In such cases researchers can at least statistically identify contributions of length of use, method of use, and other relevant data on differences between people who use and those that don’t. There are probably still some serious differences between “true” addicts, recreational users, and semi-chronic users that would be important to understand here, but we can’t so we don’t. But when it comes to assessing mood effects, or indeed any of a number of subjective effects of drugs, drug cravings, and withdrawal, this limitation in the population to be studied is something that often needs to be made explicitly clear to most public consumers of research. Since we can’t assess changes in mood, absorption rate, anxiety, or any other such measure (some exceptions for very low doses in very specific circumstances) among people who are new to the drug, we end up assessing them among people with a lot of experience, but not enough of a problem to want addiction treatment. Again, this should be considered a pretty specific type of drug user in my opinion.

There are other types of studies – those conducted with abstinent ex-users or addiction treatment intervention studies utilizing addicts who want, or who reported to, treatment on their own or in response to advertisements. While these studies make use of populations that can be considered at least closer to the individuals they are specifically aimed at – assessing the return of  cognitive function after short or long term abstinence or testing a new intervention on those who want treatment – they still bring on limitations that need to be specifically considered.

An important point – most researchers recognize these issues and make them explicitly part of their research publications, in a specific section called “Limitations” but what seems troubling is that the public doesn’t have any awareness of these issues. So when someone tells you that “they just found out meth doesn’t actually make people lose sleep,” take a second to ask “for who?”

Posted in:  Education Tags: addiction, addiction research, anxiety, Brain, cocaine, cravings, drug, drug use, insomnia, mental health, meth, milgram, mood, opiates, psychology, research, studies, treatment, tuskegee, withdrawal

Drug Policy Alliance and the Recovery Movement

November 4th, 2011

I had the opportunity to sit on a panel today during a drug policy alliance session on the role of the recovery movement in drug policy discussions. While it was obvious that everyone on the panel could generally agree that the current U.S. policy when it comes to drug use, abuse, and addiction is not working and unsustainable, it wasn’t clear that we had a common roadmap of how to get to a better place.

Some of the panel speakers were in recovery and others weren’t and while most were from the U.S. we had a representative of the Scandinavian approach for a nice little “reality check” and a bit more balance than one normally gets on these things. From student representatives of the Columbia University Students for Sensible Drug Policy to the distinguished William Moyers from Hazeldon, our panel certainly didn’t lack in a breadth of experiences. Still, even our eight member-panel couldn’t appease everyone when it came to diversity (we missed the mark on racial representativeness). The discussion was civil, but definitely showed that there are serious differences that need to be bridged if the decriminalization discussion is to ever get serious.

I’m all for collaboration and I definitely think that we need to end up in a place where drug use is no longer criminalized as it currently is. Quadrupling our prison population in a few decades with approximately 20% of inmates incarcerated for drug offenses is stupid, expensive, and does little to stop the problem we’re trying to deal with as evidenced by the relatively stable rate of use, abuse, and addiction in this country.

But how do we move forward? Do we make these drugs legal for everyone to use or place an age limit on it? Do we pretend that there’s no risk that use of legal substances will go up to meet the rates of alcohol and tobacco abuse or do we prepare for the possibility that it might? Do we completely remove legal sanctions from the discussion or do we keep them for a specific subset of hard to reach individuals?

As far as I’m concerned, until these questions are considered and dealt with, there’s not going to be any change. Unfortunately, from my reading of the panel and crowd today, even at a Drug Policy Alliance conference, the responses to each of those questions is likely to bring up a lot of debate. I guess that means our work is not yet done…

Posted in:  Education Tags: abuse, abuse addiction, drug, drug policy, drug policy alliance, drug use, panel, policy, use, use abuse addiction

New drug testing technology? Cocaine and saliva

October 30th, 2011

A recent development (check it out here) might lead the way to a quicker, more easily administered drug test. Instead of the lab analysis of urine, blood, or other fluids, this recent technology might allow first responders, such as EMTs, to assess a person’s exposure to drugs (prescription and otherwise) by simply dipping this device (think pregnancy test) into their saliva.

As of right now, the researchers have been able to demonstrate the success of the technology with cocaine, but it shouldn’t be too long before they can provide similar devices for many different drugs.

Now, it’s true that I usually focus on abused drugs in this blog, but this technology could help medical professionals identify dangerous drug interactions common to many prescribed, properly taken, medications. Given the huge increases in prescription medication abuse in the United States, that could be extremely useful and might save some of the 12,000 lives annually lost to accidental overdoses.

Maybe when these devices get cheap enough they can be used in addiction treatment centers to provide more immediate testing results.

Who knows, one day, the technology might be widespread enough to make home drug-testing a simple reality. Whether that’s a good or bad thing should probably be left to another post…

Posted in:  Education Tags: cocaine, devices, drug, drug test, Drugs, emergency, EMT, Medications, prescription, prescription drug abuse, rehab, saliva, technology, treatment

Addiction treatment in Vietnam – Beatings and forced labor

September 8th, 2011

You’ll never think of Cashews in the same way after reading the first few pages of this recent report by the Human Rights Watch group that looked into the abuses in Vietnamese “drug treatment” centers.

The detainees in these facilities, whether they checked themselves in voluntarily or were committed after being arrested for using or possessing drugs, describe terrible conditions, hard forced labor, and extensions to sentences that make their experience seem much more like jail than any form of drug treatment. Indeed the report states that “no one who had been detained described any form of scientifically or medically appropriate drug dependency treatment within a center. Psychosocial counseling involved lectures on the evils of drug use and morning exercises while chanting slogans such as ‘Healthy! Healthy! Healthy!’ .”

It should be pretty obvious that relapse rates are extremely high since, as we’ve talked about numerous times here on A3, at least part of addiction involves compulsive behavior affected by biology and early experiences and therefore punishment alone will simply not work for true addicts… And still we put all of our addicts in jails and prisons with little actual drug treatment in our own country – I guess at least we don’t have forced labor.

Read this thing  by the Human Rights Watch group – it’ll leave you just a little speechless.

Posted in:  Education, Treatment Tags: addicts, drug, drug treatment, forced, forced labor, human rights, human rights watch, treatment, treatments, vietnam, vietnamese

Money or cocaine? It all depends on timing

August 16th, 2011

People who are looking for treatment for their cocaine addiction still really like cocaine, but they’ll choose money as an immediate reward if they can only get their drug of choice later.

Cocaine or money? Depends on how long the wait is

Although it might be somewhat surprising, the above finding is the result of a recent study by a team of researchers spanning the U.S. and Australia that was recently published in the journal Psychophramacology.

We’ve talked about the concept of relatively high impulsivity among addicts on A3 before and the concept isn’t a new one — Addicts make drug-focused choices in the short term even if there are larger rewards far off in the horizon. In fact, this sort of delay-discounting (considering future rewards as being worth less) is a general human phenomenon that has simply been found to be exaggerated among addicts.

Think about it – Would you prefer $50 now or $1000 in 6 year? What about $100 now?

By asking a set of similar questions researchers can determine an individuals discounting rate or the amount of discounting people put on the delay in getting the later reward. Up to now, most of this sort of research has been conducted using the same “now” and “later” rewards. People were asked to decide between money now or later, cocaine now or later, cigarettes, meth… you get it.

This recent study made things more interesting by creating a few different conditions:

1. Money now Versus Money later
2. Cocaine now Versus Cocaine later
3. Money now Versus Cocaine later
4. Cocaine now Versus Money later

The goal was to see if people discount money and drugs equally. Since one of the hallmarks of addiction is that addicts seem to undervalue everything else while overvaluing drugs, figuring out whether bringing delay into the mix was at the least interesting but at best possibly useful in treatment.

The researcher used participants who were actively looking for cocaine treatment and ended up with a relatively small sample of 47 individuals who met criteria for cocaine addiction. As is usually the case with these sorts of studies, most of the participants were men, the average education equaled high-school and the average age was early 40s.

Participants were asked how many grams of cocaine a $1000 was worth and that unique number was used for each participant as the equal point between money and drug. Then they were presented with options such as the above (X number of dollars now or X number of dollars in six months).  As participants made selections, the immediate amount was changed by 50% to counter their choice (it was reduced if they chose immediate and increased if they chose delayed rewards) and the procedure repeated six times for each of seven different delay periods (1 day, 1 week, 1 month, 6 months, 1 year, 5 years, and 25 years).

So, let’s say a participant was first asked if they wanted $500 now or 20 grams of cocaine. If they chose cocaine, their next choice would be $750 now or 20 grams of cocaine later; now if they chose money, the choices became $375 now or 20 grams of cocaine later… and on the experiment went.

Cocaine addicts choose cocaine if they can get it now, but not later

First of all, it’s important to note that the research showed that different participants had pretty stable discounting characteristics. That is, if a participant preferred to get things now rather than later, that was likely true across all conditions regardless of whether the reward was drugs or money. However, the different rewards also had a large influence on this equation.

The main finding from this study was that when faced with the option, cocaine addicts chose immediate money over later cocaine even if the immediate money amount was relatively low. That finding might seem surprising at first given what we think we know about addicts. Aren’t they supposed to always choose drugs regardless of what else we put in front of them?

Apparently, what matters is not only what we put in front of them but also when. Of course, anyone who actually knows an addict (or is one themselves) already understands that trying to simplify addiction to an ability to only choose drugs is silly. Addicts would die of starvation or a host of other issues pretty quickly if that was true. Addiction is much more nuanced than that, and as I mention at the end of this piece, this finding might not be as clear as one might think.

In fact, this finding has already been greatly supported by at least one addiction treatment tactic that we’ve discussed here on A3 – Contingency Management (CM). In CM, individuals in treatment are rewarded for staying clean and doing well in treatment. They’re not given cash but instead are rewarded with vouchers that let them buy food, clothes, etc. for providing drug-free urine tests and going to their assigned group meetings. This addiction treatment method follows the basic tenant of the psychology of learning – people do what they’re rewarded to do. This study offers a fresh perspective on the matter, suggesting that one of the reasons people do well and stay longer in treatment when given CM is that the immediate money reward is thought to be worth more than the possibility of getting drugs later. It might also explain why CM has only really been shown to work well while people are in treatment and not when they leave…

I mentioned earlier that I think these findings may be a little more complicated than they first seem. One of the major issues I have with this study stems from my life as a drug dealer. The users I know quickly equate money with drugs and so it is very possible that in their minds money now also equals cocaine now, although a smaller amount of it and they’ll take whatever drug they can get now instead of having to wait for it. Most regular users I’ve met would easily choose a single gram of meth now instead of 4 or 5 in 6 months. They simply don’t want to wait that long to get high. Money holds its value much better in the long run and this research supports that idea.

Citation:

Bickel, Landes, Christensen, Jackson, Jones, Kurth-Nelson, Redish (2011). Single- and cross-commodity discounting among cocaine addicts: the commodity and its temporal location determine discounting rate, Psychopharmacology

Posted in:  Education Tags: addiction, addicts, cocaine, cocaine addicts, cocaine later, delay discounting, discounting, drug, Drugs, immediate money, impulsivity, later, later cocaine, money, money later, money later cocaine, people, treatment