12/8/14

The New Frontier of Synthetic Drugs

In 1988, Gary Henderson, a professor of pharmacology at the University of California-Davis Medical School, predicted the coming global problem with synthetic drugs. He wrote that the scientific literature was full of potential synthetic routes and pharmacological properties for a wide variety of drugs. He said that information was readily available for “clandestine chemists” to exploit. Restricting access was not feasible and controlling the chemicals needed to make these drugs would only have a minimal effect. Henderson prophetically said:

It is likely that the future drugs of abuse will be synthetics rather than plant products. They will be synthesized from readily available chemicals, may be derivatives of pharmaceuticals, will be very potent, and often very selective in their action. In addition, they will be marketed very cleverly.

Today, news about the problems with synthetic drugs or new psychoactive substances (NPS) is hard to avoid. The parents on a 19-year-old who died after smoking synthetic marijuana started a facebook page in his memory. The governor of New Hampshire declared a state of emergency because of the overdose deaths from “Smacked,” a synthetic marijuana sold in convenience stores.

A Minnesota teen pled guilty to third-degree murder when the N-Bomb, a synthetic form of LSD, he supplied to several other teens resulted in an overdose death. The DEA reported that N-Bomb was responsible for at least 19 deaths between March of 2012 and November of 2013. A survey of 15,000 high school students in Minnesota revealed that 12% had used synthetic drugs. Minnesota has responded by launching a synthetic drug awareness website, KnowTheDangers.com. Drug WarFacts.org has a page devoted to information on NPS.

The problem is truly a worldwide one. By 2013, NPS had been identified in every region of the world. The majority of NPS worldwide were in three basic groups: synthetic cathinones, synthetic cannabinoids and phenethylamines. Together they accounted for 70% of the total number of reported NPS. See the following chart found in the 2014 Global Synthetic Drugs Assessment:

UntitledJapan introduced new laws to combat its growing synthetic drug problems. “Speckled Cross” resulted in 20 deaths in Northern Ireland. Synthetic cannabis is a growing problem in UK prisons. One prison reported that 85% of its inmates were using or supplying Spice. The chief inspector of prisons in the UK said: “What we can say for definitive is that spice is a significant problem in a number of prisons and it is rising.” DrugScope put together a status report on NPS and ‘club drugs’ in the UK.

A DEA spokesperson, Rusty Payne, called synthetic drugs the new frontier: “As chemistry and science advances, we’re seeing more and more drugs, designer drugs, new derivatives, new compounds that are making their way into the Unites States and across the world.”

Effects and Risks Associated with Novel Psychoactive Substances” gathered together helpful information on the pharmacology, clinical effects and adverse effects of the more common classes of NPS. See the original article for more details than the following summary.

Synthetic cathinones or “bath salts” can have both stimulant and hallucinogenic effects. They can cause severs intoxication. Their adverse effects include cardiovascular problems such as tachycardia—a faster than normal heart rate (22-56%), arterial hypertension (4-25%), palpitations (11-28%), dyspnea—shortness of breath (8-11%), and others. Psychiatric adverse effects include: agitation (50-82%), aggression (57%), hallucinations (27-40%), confusion (14-34%), anxiety (15-17%), and others. The psychotic adverse effects often consist of paranoia and hallucination (auditory and visual) that can persist for up to four weeks.

“Spice” or synthetic cannabinoids are much more potent, longer-acting and have worse adverse effects than THC. These adverse effects include: cardiovascular problems such as tachycardia (36-76%), arterial hypertension (10-34%), ECG changes (2-14%), chest pain (7-10%) and others. Neurological effects are present and can include: dizziness (9-24%), loss of consciousness (2-17%), somnolence—sleepiness (17-19%) and others. Psychiatric adverse effects include: agitation (19-41%), hallucinations (11-38%), anxiety/panic attacks (21%), and others.

Effects and Risks” also had some information on a phenylethylamine first synthesized in 1998, “Bromo-dragonfly.” It has a LSD-like effect that could last up to six hours. The effect includes visual and auditory hallucinations and a feeling of well-being that could last up to three days. It is highly toxic and has been associated with a number of deaths from overdose (study abstract here). A pro-drug website, Erowid, has a page of information (positive and negative) on Bromo-Dragonfly that included difficult experiences, bad trips and health problems. One report was titled: “Thankful That I’m Alive.” Probably the most disturbing piece I saw was a YouTube video, “My Bromo-DragonFLY Trip” by a young woman who sounded like she was describing an exciting, unexpected encounter while on a road trip with friends.

The 2014 Global Synthetic Drugs Assessment said it was still not clear if NPS were replacing other controlled substances. Maybe they are simply supplements to the existing bevy of drugs under international control. Then again, maybe we ain’t seen nothing yet.

 

12/5/14

Counterfeit Repentance

I think one of the greats needs for the practice of discipleship and biblical counseling is a clear understanding of what repentance looks like. I’ve known of tearful confessions of wrong doing to spouses and church leaders that had the appearance of sorrow, but failed to last. There wasn’t a true heart change aligned with the expression of sorrow. The thought and writings of the Puritans are full of the riches on how to discern and produce true repentance. What follows are just a few of the gems ready to be mined if you take the time to search for them.

One of the devotionals I regularly read is Day by Day with the English Puritans. Within there, the reading for November 14th, was a passage quoted from the work of Richard Stock (1569-1626). He lectured at several churches in London and is buried in St. Paul’s Cathedral. He said there that:

Repentance is the constant turning of a man in his whole life from all sin unto God, arising from true faith and the true knowledge of a man’s own spiritual estate, ever joined with true humiliation.

Given a modern sense of language, it is better to substitute the word “humility” where Stock said “humiliation.” The person who looks deeply into the mirror of their own heart, and sees clearly what God sees, will always have a sense of their unworthiness joined with the wonderful knowledge of their forgiveness before God. Along with Isaiah, we will express our woe. For we are people of unclean lips who have seen the Lord of hosts. But He will see that our guilt is taken away; that our sin is atoned for (Isaiah 6:5-7).

In The Doctrine of Repentance, published in 1668, Thomas Watson examined the topic of repentance in great detail. We’ll look here at some of what he has to say about counterfeit repentance. You can get a paperback of his work on Amazon, or turn here for an online, updated language version.

Watson said the two essential graces in this life were faith and repentance. By them we fly to heaven. “Faith and repentance preserve the spiritual life just as heat and radical moisture preserve the natural.” He went on to discuss repentance, saying that in order to discover what is true repentance, he would first show what it is not—how a person may delude himself with “counterfeit repentance.” Watson felt there were three “deceits” in counterfeit repentance.

The first counterfeit for repentance is legal terror. Let’s say there was a man who remained in his sin for long time. Finally, God shows him what a desperate hazard he has run and the man is filled with anguish. The storm of conscience blows over, and again the man is quiet. He may believe that he is a true penitent because he has felt some bitterness in sin. “Do not be deceived; this is not repentance.” A sense of guilt can breed terror, but an infusion of grace breeds repentance.

If pain and trouble were sufficient for repentance, then the damned in hell would be the most penitent, for they are most in anguish. Repentance depends upon a change of heart. There may be terror and yet no change of heart.

A second counterfeit for repentance could look like resolution against sin. Watson observed that a person could be resolved to not sin and still not truly be repentant. Such a resolution arises because sin is painful, not because it is sinful. This resolve will vanish. It could also proceed from a fear of death and hell. Self-love, Watson said, is at work here and the love of sin will prevail against it. He warned, “Do not trust to a passionate resolution; it is raised in a storm and it will die in a calm.”

A third counterfeit for repentance is wrapped up in leaving some sinful ways. Here Watson means that a sin might be truly abandoned, but not because of repentance. He agreed that it is a good and great thing for a person to put away sin. However, the individual could part ways with some sins and keep others. The husband who ceases to physically abuse his wife, but continues to demean and criticize her is such a person.

A second leaving could be where an old sin is abandoned, but a new one taken up. This is merely an exchange of sin, for the heart, again, remains unchanged. The person who reforms his delinquent youth, but becomes a corrupt banker as an adult. “So a man moves from one vice to another but still remains a sinner.”

A third leaving is from prudence, not from grace. A woman may realize that while her sin is a pleasure, it could ruin her good name, prejudice her health and impair her wealth. So counting the cost, she decides to stop using drugs. In all these leavings, the initial sin is left, but not because of repentance. “True leaving of sin is when the acts cease because of the infusion of a principle of grace, just as it ceases to be dark when there is an infusion of light.”

In future posts, we’ll look at the true nature of repentance, according to Watson and other Puritans. We’ll close where we started, with Richard Stock.  Above, we noted that Stock said the life of a believer is one of constant repentance. And it seems he walked his talk. Within The Lives of the Puritans, Volume 2, it was said of Richard Stock that he was the means of bringing many persons to the saving knowledge of the truth. “Though many ministers preached to others, and not to themselves, Mr. Stock practiced what he preached. His life was one uniform practical comment upon his doctrine.” He lived a life of true repentance.

 

12/3/14

To Use or Not Use Antidepressants

Image by Lightsource

Image by Lightsource

I ran across a report from the National Center for Health Statistics when reading Saving Normal by Allen Frances that had some incredible facts about antidepressant use in the United States. The report said that 11% of Americans 12 years and over take antidepressant medication. Women were 2.5 times as likely to take antidepressants as men. Individuals 40 and over are more likely to take antidepressants than those younger than 40. “Twenty-three percent of women aged 40-59 take antidepressants, more than any other age-sex group.”

When the severity of depressive symptoms was considered, use of antidepressant medication rose as the severity of symptoms increases. This seems logical; the worse your depression is, the more likely you are to try medication. But look at the other end of symptom severity—7.6% of those taking antidepressants have NO REPORTED symptoms of depression. The Data Brief pointed out that this group could include people taking antidepressants for reasons other than depression and those who are being “successfully” treated with antidepressants, and just don’t have any symptoms currently. See the table below.

Depressive symptoms

Percent

Total

   None

7.6

   Mild

19.2

   Moderate

28.4

   Severe

33.9

Males

   None

4.4

   Mild

11.5

   Moderate

18.6

   Severe

21.0

Females

   None

10.9

   Mild

24.6

   Moderate

34.5

   Severe

39.9

Allen Frances suggested that part of the problem was that drug companies capitalized on the placebo effect, that is: “people getting better because of positive expectations independent of any specific healing effect of the treatment.” Treating the “worried well” expanded the customer pool and guaranteed a pool of satisfied customers. “Placebo responders often become long-term loyalists to medication use even when the medication is perfectly useless.”

The best way to get great results with a pill is to treat people who don’t really need it—the highest placebo response rates occur in those who would get better naturally and on their own.

What’s at stake? The Statistics Portal indicated that the top ten selling antidepressants in 2011-2012 grossed 8.5 billion dollars. Considering that most of the antidepressants are off patent and not as profitable to the drug companies, this is an incredible haul. Another indication of the pervasiveness of antidepressant use in the U.S. is to look at the number of prescriptions written. The top antidepressant drugs in the U.S. based upon the number of dispensed prescriptions in 2011-2012 are given in the following chart, again from The Statistics Portal.

Antidepressants

Prescriptions

Celexa (citalopram hydrobromide)

39,087,000

Zoloft (sertaline hydrochloride)

37,893,000

Prozac (fluoxetine hydrochloride)

24,961,000

Trazadone (trazadone hydrochloride)

23,449,000

Cymbalta

18,468,000

Lexapro

16,367,000

Paxil (paroxetine hydrochloride)

13,834,000

Effexor (venlafaxine hydrochloride ER)

13,679,000

Wellbutrin (bupropion hydrochloride XL)

13,365,000

Elavil (amitriptyline hydrochloride)

12,880,000

Returning to the NCHS Data Brief, once people start taking antidepressants, they tend to continue taking them. Sixty-one percent of Americans taking an antidepressant have been taking it longer than 2 years; 13.6% have been taking them ten or more years. The problem is that the widespread use of antidepressants and their long-term use may be actually causing depression.

Robert Whitaker commented in Anatomy of an Epidemic that prior to the appearance of antidepressant drugs, depression was seen as a rare problem with typically good outcomes over time. Now the NIMH says that an episode of major depression “can occur only once in a person’s lifetime, but more often, a person has several episodes.” In 2012, an estimated 16 million adults and 2.2 million adolescents had at least one depressive episode in the past year.

Whitaker noted how Italian psychiatrist, Giovanni Fava began in 1994 to look at the changing face of depression. In that article, Fava raised the possibility that “long-term use of antidepressant drugs may also increase the biochemical vulnerability to depression and decrease its likelihood of subsequent response to pharmacological treatment.” In a 2003 article, Fava suggested that antidepressants may, in some cases, actually cause depression.  “Whether one treats a depressed patient for 3 months or 3 years, it does not matter when one stops the drugs. A statistical trend suggested that the longer the drug treatment, the higher the likelihood of relapse.”

In a 2014 article, “Rational Use of Antidepressant Drugs,” Fava said that rational use of antidepressant drugs should consider all the potential benefits and harms. They should only be used with the most severe and persistent cases of depression. They should be used for the shortest possible duration. Using antidepressants to treat anxiety disorders should be reduced, unless a major depressive disorder is present or other treatments have been ineffective.

These suggestions may seem to be radically different from current guidelines such as those of the American Psychiatric Association, but they reflect the weighing of risk, responsiveness and vulnerability that should be applied to the use of AD [antidepressant drugs] in each individual case.

To use or not to use antidepressants, that is the question. There is serious potential harm that may occur with their use. And sometimes they can literally save a life. What seems to be clear is that current guidelines for their use can, in the long run, worsen the problem they were originally supposed to “treat.” Along with the above suggestions for the rational use of antidepressants given by Fava, I think there needs to be a change in how we think about psychiatric drugs. The current disease-centered model of drug action needs to be replaced by a drug-centered model of drug action. You can find more on this distinction in the writings of Joanna Moncrieff, such as The Myth of the Chemical Cure and my article, “A Drug is a Drug is a Drug.” Also see two longer articles on antidepressants available in the Counseling Issues section under the “Resources” link of this site.

12/1/14

Look Before You Speak

© Panpalini | Dreamstime.com - Toad Photo

© Panpalini | Dreamstime.com – Toad Photo

I am concerned about an article I read recently on alcohol treatment, “The Best Treatment for Alcohol Use Disorder Your Addiction Counselor Isn’t Telling You.” It seemed like it was more of a rant than an attempt to constructively make a point. The author is an epidemiologist who wanted people to know that “medication is a vital key” in treating addiction. But some of the comments he made were surprisingly biased for someone who is “a published healthcare statistician and epidemiologist currently pursuing a doctorate in epidemiology.”

One example of this is a study from the Journal of Alcohol Studies that he linked in his article. He cherry picked how the study found that 29% of a sample of A.A. members said they received some pressure to go off their medication (of any type). But he failed to report that over half of the A.A. sample believed that using relapse-preventing medications “either was a good idea or might be a good idea.” Seventeen percent didn’t think that it was a good idea to take relapse-preventing medications; and only 12% said they would tell another member to stop taking it. Sixty-nine percent of these didn’t listen and continued taking their medication. The conclusions from the article’s abstract were:

The study did not find strong, widespread negative attitudes toward medication for preventing relapse among AA members. Nevertheless, some discouragement of medication use does occur in AA. Though most AA members apparently resist pressure to stop a medication, when medication is prescribed a need exists to integrate it within the philosophy of 12-step treatment programs.

He described the benefits of two medications for treating alcohol use disorder, Naltrexone and Campral (acamprosate) and claimed that: “ These medications are very likely the ones that your counselor or sponsor is not telling you about. In fact, the majority of the rehabs in the United States do not use any of this medication.”  The author made, but did not support that claim.

The rehab I work for part time knows of and supports the use of both of these medications and has done so for a number of years. A.A. sponsors might be violating their Traditions in recommending or telling people they sponsor that they should try Naltrexone or Campral. They certainly would be involved in ethically questionable advice-giving since their sponsor role is not as a doctor or an addictions professional.

The most disturbing claim was that “Naltrexone is an opioid inhibitor that has been FDA approved as a constant low dose (daily intake) or as a supplement prior to drinking.” He noted its use to inhibit cravings for chronic alcoholics, cautioning that it could “up-regulate” the opioid system and cause worse relapses when the person was off Naltrexone. Then he suggested that it was best served as an “emergency relapse drug.” From the article:

Patients, prior to relapse, have taken this drug and report significantly lower impact of their relapse. In fact, naltrexone works so well to reduce relapse that many alcoholics use it to successfully drink on a regular basis with very few reports of high binge drinking. It is entirely possible that rather than going to AA meetings, the majority of alcoholics in the near future can simply carry a bottle of naltrexone with them for drinking occasions.

I’ve reviewed information on Naltrexone from Medline Plus, WebMD, Drugs.com, and SAMHSA (Substance Abuse and Mental Health Services Administration) here and here. I did not find ANY indication that Naltrexone was “FDA approved” as a supplement prior to drinking. To be sure, Naltrexone is an FDA-approved medication for alcohol dependence. But there was no indication that Naltrexone was approved as a “supplement prior to drinking” or as an “emergency relapse drug” that “many alcoholics use it to successfully drink on a regular basis with very few reports of high binge drinking.”

There have been studies that indicated Naltrexone led to reduced drinking in both the amounts of alcohol and the frequency of drinking. And there have been studies where individuals used Naltrexone to limit or control their drinking, as with pharmacological extinction in the Sinclair Method. Here is an article written by John Sinclair, after whom the method was named. There is also information on the Sinclair Method here and on Facebook. Also see my article, “A ‘Cure’ for Alcoholism.” But Naltrexone is not FDA approved to limit, control or extinguish alcohol use at this time.

To make the claim as the author does—“It is entirely possible that rather than going to AA meetings, the majority of alcoholics in the near future can simply carry a bottle of naltrexone with them for drinking occasions”—is foolhardy, irresponsible, and dangerous. Also, it is a wrong interpretation of the state of current research into the use of Naltrexone with alcohol use disorders.

The most positive statement I found about Naltrexone in that regard on the above noted websites was in one of the SAMSHA publications, “Incorporating Alcohol Pharmacotherapies Into Medical Practice.” What follows is that statement:

Naltrexone appears to be effective for attenuating craving in people who are alcohol dependent (Monti et al., 1999, 2001). By blocking craving, naltrexone may enhance the ability of patients to abstain from drinking. By blocking the pleasure from alcohol, naltrexone also may reduce the amount of heavy drinking in those who do drink.

If he wrote the article as a rhetorical device to help people see how medications can be helpful when treating alcoholism, okay.  He accomplished that goal. It had generated 1276 comments as of 10/25/2014 when I last looked. But if he was attempting to give credible information as an epidemiologist on pharmacological treatments for alcohol use disorder, he did not succeed.