11/30/15

The Seduction of Opioid Substitution

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© Everett Collection Inc. | Dreamstime.con

Heroin and prescription opioid abuse is a widely recognized public health crisis in the United States. In 2014, Attorney General Eric Holder referred to overdose deaths from heroin and other prescription pain-killers as an “urgent public health crisis.” The CDC reported that heroin use more than doubled among young adults between 18 and 25 over the past ten years. Forty-five percent of the people who use heroin are also addicted to prescription opioids.

A July 2015 “Morbidity and Mortality Weekly Report” report by the CDC recommended a comprehensive response to this public health crisis. The recommendations included: reducing inappropriate prescribing and use of opioids, stronger prescription drug monitoring programs, improved access to evidence-based substance abuse treatment—including medication-assisted treatment for opioid use disorders and greater access and training in the use of naloxone to treat overdoses. There have been several steps taken towards making these recommendations a reality. For example, on November 18, 2015, the FDA approved the first nasal spray version of naloxone hydrocloride: Narcan nasal spray. But not all of the proposals have the same potential to free the individuals caught up in the opioid health crisis.

And legislation has been introduced in the Senate to “combat the opioid crisis.” “The Opioid and Heroin Epidemic Emergency Supplemental Appropriations Act” would dedicate $600 million to this crisis. About $250 million would support programs related to prevention, treatment and recovery. Another $200 million would fund local and state law enforcement programs. Fifty million would go toward the CDC; and $35 million would go to NIDA to monitor prescription drug programs and do targeted research on drug addiction. “We are losing lives daily and our first responders, healthcare providers and criminal justice system are overwhelmed.”

I’m not a fan of increasing the use of opioid maintenance medications such as methadone and buprenorphine because they’re “treating” an opioid addiction with addictive opioids. And I’m concerned that in the midst of the existing health crisis, increased access to such treatment seems to be indiscriminately promoted as the most effective “treatment” approach. Sometimes the studies of medication-assisted treatment fail to consider the negative consequences to individuals when promoting opioid substitution treatment. And sometimes studies that suggest the “effectiveness” of opioid maintenance have a biased interpretation of their results. Often what emerges is a program for the social control of addicts rather than one that helps them establish and maintain a recovery-oriented lifestyle. Here is an example of one such study.

The National Institute on Drug Abuse (NIDA) turned a “Science Spotlight” on a new study that looked at intervention approaches for opioid dependent patients in emergency departments (ED). The idea is a good one—developing an intervention for ED medical personnel to help opioid-dependent patients get into treatment. But what it doesn’t make clear is that the “treatment” is primarily ongoing participation in opioid substitution treatment.

This study showed that patients who received buprenorphine, along with a brief intervention to discuss opioid use, and up to 12 weeks of buprenorphine maintenance, were more likely to get follow-up addiction treatment and had reduced self-reported illicit opioid use. In addition, they were also less likely to need inpatient addiction treatment services, saving treatment costs. This adds to the growing body of literature suggesting that opioid-dependent patients may benefit from immediate initiation of medication while awaiting more comprehensive substance use disorder treatment.

Let’s take a closer look at the study by D’Onofrio et al. to see if it truly lives up to the endorsement it received from NIDA.

The primary outcome was what the researchers called “engagement in treatment.” This was defined as being enrolled in and receiving formal addiction treatment on the 30th day following randomization. “Formal addiction treatment” could include a range of clinical settings such as an opioid treatment program, such as a methadone clinic, inpatient or residential treatment and outpatient services. The outpatient services could be intensive outpatient programs and “office-based physicians who prescribe buprenorphine or other forms of medication-assisted treatment.”

The patients in the buprenorphine group of the study received buprenorphine in the hospital and take-home doses of buprenorphine to last until a scheduled appointment in the hospital’s primary care center, which was within 72 hours of their placement in the group. The buprenorphine patients continued to receive office-based burprenorphine treatment for 10 weeks. At that time they were transferred to a maintenance treatment program or a clinician for ongoing treatment. If they preferred, they were offered a 2-week detoxification.

In the buprenorphine group, 78% of the patients were still engaged in treatment at the thirty-day follow-up. Only 37% of the referral only group and 45% of the brief intervention and referral group were engaged in treatment. But remember what the study considered as “treatment.” Any patient in the buprenorphine group who was still active in the free, office-based treatment after 30 days would have been counted as “still engaged in treatment.”  And they would have had another 40 days of free buprenorphine coming.

There was no information or data available on any of the groups beyond the thirty-day follow-up. So there was no clear indication if the patients in the buprenorphine group remained in treatment beyond the 10 weeks of the study’s subsidy of their substitution treatment. If the goal was to eventually engage individuals in more comprehensive treatment services, this “interim opioid agonist treatment,” should not have been lumped in with others as the outcome measure of “formal addiction treatment.” The failure of the researchers to distinguish this level of care from the others confounds the findings within the study’s primary outcome measure.

These patients had buprenorphine treatment initiated before they left the hospital. They also had an appointment scheduled within 3 days of their initial dose, with sufficient take-home medication to prevent any withdrawal until that appointment time. The other two groups did not receive any medication and so were on their own medically until they made an appointment and became engaged in treatment. They were sitting ducks for resuming the illicit opioid use that initially brought them to the ED. So the deck was staked in favor of the primary outcome measure.

Additionally, the buprenorphine care in the study was provided at no cost to the patients. The researchers dismissed this as a potential bias in their study, saying that 80% of the study’s patients had health insurance. However there are potential cost issues in health insurance despite the authors’ dismissal. Buprenorphine maintenance treatment is not always covered by insurance, as it is considered a “niche” medicine by insurance plans, as it is approved solely for the treatment of opioid dependence. Insurance companies predict that a limited number of their covered clients will need or use it. When there is coverage, there can be high co-pays. Insurance may pay for the prescription but not the office visits. Some Suboxone doctors don’t take insurance.

A secondary outcome measure for the study was self-reported use of illicit opioids. The buprenorphine group reported greater reductions in the mean number of days of illicit opioid use, from 5.4 days per week to .9 days per week. Patients in the referral group decreased from 5.4 days per week to 2.3 days; and the brief intervention group went from 5.6 days to 2.4 days. Remember that the buprenorphine group was treated with medication (buprenorphine) that forestalled withdrawal symptoms from the time they were placed in that treatment group while still in the hospital ED. Also, all three groups reduced their illicit opioid use over time. Comparing the buprenorphine treatment group to the others indicated that even with the medication, there were only 1.4 or 1.5 days less per week of illicit opioid use in the buprenorphine group.

Finally, the decreased use of inpatient treatment by the buprenorphine group was to be expected. The withdrawal symptoms that often precipitate detoxification or residential treatment were being addressed by the buprenorphine.

It has long seemed to me that the so-called harm reduction approach of opioid substitution treatment is more social control than actual treatment aimed at helping the individual addict to establish and then maintain sobriety. The positive outcomes and effects that are highlighted are typically things like lowered costs for residential treatment; lowered ED visits and costs; decreased drug-related crime.

There is proposed legislation, the Recovery Enhancement for Addiction Treatment Act, which would broaden the definition of a qualifying practitioner to include certain nurse practitioners or physician assistants and doctors with a board certification from the American Board of Addiction Medicine. The number of patients that a qualifying practitioner could dispense buprenorphine to within their first year would increase from 30 to 100. After one year, qualifying physicians could request approval to treat an unlimited number of patients under specified conditions. Writing about this proposed bill for the Huffington Post, James Charkis said:

The consensus among the medical establishment is that medically assisted treatments such as buprenorphine (and methadone), along with counseling, represent the best chance for addicts to gain a foothold on sobriety. Both medications can make withdrawal less painful and can significantly diminish further cravings for opioids — greatly reducing the chance of relapse.

One of the problems as I see it is that this “best chance” description is often mostly rhetoric. The “along with counseling” add-on becomes more window dressing than reality. Even where there is a tighter requirement for Suboxone patients to be active in some kind of counseling, individuals either fall through the cracks with counseling or just take up space because their presence in counseling is required for them to get what they really think will “treat” them—their Suboxone. Some individuals merely want Suboxone handy in case they can’t get any heroin or their opioid of choice to get high. Others want it to sell on the street to make some cash.

There is a place for opioid substitution treatment as we attempt to address the opioid health crisis. But the potential adverse consequences to the individual receiving the treatment need to be more clearly communicated. And studies of its “effectiveness” need to look beyond just the social benefits and the ability of opioid substitution treatment to seduce addicts into a more socially controlled form of opioid use.

11/27/15

Circumcision of the Heart

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© Zvonimir Atletic | 123f.com

Circumcision in the Bible made its appearance in Genesis 17, when God appeared to Abraham and made a covenant with him. The sign of this covenant for Abraham and his offspring was that “Every male among you shall be circumcised.” (Genesis 17:10) Male slaves were to be circumcised as well. So every living male was to have his foreskin removed and every male child born to Abraham and his descendants was to be circumcised. Any male who was not circumcised would be cut off (excluded) from his people as a covenant breaker.

Circumcision was practiced by Near Eastern cultures outside of the Israelites. “The circumcision of male boys was a common practice among the Ammonites, the Moabites, the Edomites and the Egyptians. “ (Jeremiah 9:25-26) In these cultures, it was adolescent and adult males who were circumcised, not infants. So it is theorized the ritual was associated with male fertility rites or preparation for marriage. The Philistines were an exception to the rule among the people in Canaan, so they were sometimes referred to as uncircumcised Philistines (Judges 14:3).

Early Greek writers such as Heroditus attributed the origins of circumcision to the Egyptians and Ethiopians: “But as to the Egyptians and Ethiopians themselves, I cannot say which nation learned it from the other; for it is evidently a very ancient custom.”

The practice of circumcision continued under the Mosaic Law. Every male child was to be circumcised (Leviticus 12:3), as was every male sojourner or slave who wanted to participate in the Passover (Exodus 12:43-49). No foreigner, “uncircumcised in heart and flesh,” could enter the sanctuary (Ezekiel 44:9). So circumcision became the final step in New Testament times for a male Gentile converting to the Jewish religion. Paul was accused of attempting to violate this restriction by bringing uncircumcised Gentiles into the temple (Acts 24:6).

Circumcision also became a point of contention in the early days of the church. There was a sect of Christians who argued that Gentiles needed to first convert to Judiaism—they should be circumcised—before they could belong to God’s chosen people. The first Council of Jerusalem decided this wasn’t necessary (Acts 15). Yet Paul was still refuting this expectation in his letter to the Galatians. He said if someone accepted circumcision, they were obligated to keep the whole law (Galatians 5: 3). He even wished that those who continued to unsettle the Galatians over the issue of circumcision, even though it had been settled at the Jerusalem Council, would emasculate themselves (Galatians 5:12).

But circumcision had always been an outward sign of an inward change. There was an expectation from the beginning that there would be heart change in the individual that would be witnessed to by the outward sign of circumcision. Deuteronomy 10:16 calls for the Israelites to circumcise the foreskin of their heart and no longer be stubborn. Commenting on the verse, Samuel Driver said an uncircumcised heart is impervious to good influences and impressions, just as an uncircumcised ear is an ear that cannot listen and takes no pleasure in hearing the word of the Lord (Jeremiah 6:10). Later on in Deuteronomy, as Moses renewed the covenant with Israel, he said: “And the Lord your God will circumcise your heart and the heart of your offspring, so that you will love the Lord your God with all your heart and with all your soul, that you may live.”

Jeremiah called for the men of Judah to circumcise themselves to the Lord by removing the foreskin of their hearts (Jeremiah 4:4). He also warned that judgment would come to all those who were uncircumcised in their hearts (Jeremiah 9:26). In the Lexham Bible Dictionary, Kelly Whitcomb and Getachew Kiros said:

This suggests that a circumcised heart, not just a physical circumcision, is necessary to avoid God’s wrath. Even the circumcised Israelites were considered uncircumcised if they did not have knowledge of Yahweh and practice kindness and righteousness.

In Romans 2, Paul made the same point. The circumcised heart is the true circumcision. If uncircumcised people kept the precepts of the law, they would be regarded as if they were circumcised. Robert Mounce commented: “It is one’s action, not one’s physical features, that count.” Therefore, the person who is physically uncircumcised but keeps the law will condemn the person who is circumcised, but breaks the law (Romans 2:27).

 For no one is a Jew who is merely one outwardly, nor is circumcision outward and physical. But a Jew is one inwardly, and circumcision is a matter of the heart, by the Spirit, not by the letter. His praise is not from man but from God. (Romans 2:28-29)

Notice the inward/outward contrast between what can be seen (physical circumcision and Jewish birth) and what only God can see, the changed heart. As we saw above, Paul’s call for circumcision of the heart by the Spirit, is not new. The true circumcision always was a circumcision of the heart. Douglas Moo, in his commentary The Epistle to the Romans, takes us back to Deuteronomy and Jeremiah:

From the earliest history of Israel, God called on the people to display the kind of inner transformation that could be called a “circumcision of the heart” (e.g., Deut. 10:16; cf. Jer. 4:4). Significantly, it was also recognized that only God could ultimately bring about this heart transformation (Deut. 30:6). There thus grew up in Judaism the expectation that God would one day circumcise the hearts of his people through the work of the Spirit.

11/25/15

Drugs, Violence and Revolution

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© loganban | 123rf.com

The recent killings in Oregon at Umpqua Community College by Chris Harper Mercer have again brought the issue of violence and mental health into the news. But there is an element in the narrative that is often missing in media reports of the incidents. Many of the shooters, if not all, were taking psychiatric medications or had recently stopped taking their medications at the time of the shootings. The misdirection of the spin on these incidents has largely been to argue for increased gun control or to press for more screening for mental health problems and to increase forced treatment—meaning increased forced medication.

Writing for The New American in March of 2013, Rebecca Terrell (“Psychiatric Drugs: Prescription for Murder?”) noted ten examples of young people who were the perpetrators of mass school shootings and who had a history of taking psychotherapeutic drugs. Terrell described an incident in 2001 where a 16 year old held a high school class hostage at gunpoint in Washington State. No one was killed or hurt physically. But he has no memory of the incident. “In the morning I didn’t feel like going to school. I felt sick; didn’t feel like I could get up very well. So I went back to bed. And the next thing I remember I’m in juvie in the detention center where I used to live.” He received a reduced sentence because expert psychiatric testimony convinced the jury his crime was the result of adverse effects from Effexor and Paxil.

We can add Mercer to Terrell’s list. C. Mitchell Shaw and Peter Breggin noted that Mercer was taking several medications, including antidepressants. Shaw reported that Mercer’s mother had him admitted to a psych unit because he quit taking his medications. Breggin posted a screen shot of Mercer’s Facebook page where he said: “I have a pill bottle with like five types of pills mixed in.  I don’t know which ones are the sleep aids, so I just took four of each.”  Breggin said that the major news media surely had access to the information on Mercer’s website, “but universally has chosen to withhold it.”

Shaw acknowledged that anecdotes are not proof and most people who take antidepressants do not become violent. “The fact remains, though that young people are particularly at risk of developing violent tendencies, suicidal tendencies, or both while taking these drugs.”

Dr Breggin has been a medical expert in the case surrounding Eric Harris (one of the Columbine shooters) and James Holmes (the Aurora movie theatre shooter). He said that Harris was taking Luvox (fluvoxamine) for a year before the incident. This was before and during the period of his “growing manic-like violent state.” He also had a therapeutic level of Luvox in his system on autopsy. Holmes was prescribed Zoloft by his psychiatrist, whom he told he was having very violent feelings, but did not want to fully describe them to her.

Over 120 days, he became more violent on Zoloft and began elaborately planning the assault on the movie theater. He stopped taking the drug 20 days prior to the shootings, but by then he was grossly psychotic, again in a manic-like state.

Breggin, Shaw and Philip Hickey all noted a newly published study indicating a link between SSRIs and violence, “Selective Serotonin Reuptake Inhibitors and Violent Crime.” Hickey and Breggin also mentioned a study from 2010, “Prescription Drugs Associated with Reports of Violence towards Others.” The 2010 study looked at all the reports of violence reported to the FDA Adverse Event Reporting System (AERS). The other study, which was just published in September of 2015, is a retrospective study of 18 to 25-year-olds on SSRIs. Breggin said the implications of these two studies are enormous.

“Prescription Drugs Associated with Reports of Violence towards Others” showed that “serious acts of violence were regularly reported as an adverse drug event.” Chantix (varenicline), a smoking cessation medication, had the strongest association with violence. Antidepressants showed a consistently elevated risk of violence. See Table 1 in the study for data on drugs associated with violence. See Table 3 for data on the reported incidents of violence and adverse events for psychotropic drugs. The authors concluded:

These data provide new evidence that acts of violence towards others are a genuine and serious adverse drug event that is associated with a relatively small group of drugs. Varenicline, which increases the availability of dopamine, and serotonin reuptake inhibitors were the most strongly and consistently implicated drugs. Prospective studies to evaluate systematically this side effect are needed to establish the incidence, confirm differences among drugs and identify additional common features.

“Selective Serotonin Reuptake Inhibitors and Violent Crime” extracted information on SSRIs prescribed in Sweden between 2006 and 2009 from the Swedish Prescribed Drug Register and information’s on convictions for violent crimes for the same time period from the Swedish national crime register. Their findings showed an association between SSRIs and violent crime that varied by age group. This did not prove a causative relationship between SSRIs and violent crime among young people. Nevertheless, “the association between violent crimes and SSRIs among individuals younger than 25 years is worrying.”

There are two principal clinical implications arising from this study. First, no association between SSRIs and violent crime convictions was found for the majority of people who were prescribed these medications, including individuals aged 25 y and older. Second, the risk increase we report in young people is not insignificant, and hence warrants further examination. If our findings related to young people are validated in other designs, samples, and settings, warnings about an increased risk of violent behaviours while being treated with SSRIs may be needed.

In “Psychiatric Drugs and Violence,” Hickey observed that while both studies indicate a link between SSRIs and violence, they have limitations that make it difficult to draw firm conclusions. So further research is needed into the association. There is a petition on We the People asking to launch a federal investigation into the relationship between school shootings and psychiatric drugs. Hickey said that one of psychiatry’s most obvious vulnerabilities is how various antidepressants induce homicidal and suicidal feelings and actions in some individuals, especially late adolescents and young adults. “This fact is not in dispute, but psychiatry routinely downplays the risk, and insists that the benefits of these drugs outweigh any risks of actual violence that might exist.”

Amazingly, psychiatry has consistently failed to conduct a comprehensive, prospective, formal research study on this matter, even though the need for such a study has been glaringly evident for almost 20 years.  It is very difficult to avoid the conclusion that psychiatry’s refusal to engage this question is motivated by a desire to suppress information, and to avoid the anti-psychiatry publicity that such a study will almost surely entail.

Perhaps psychiatry avoids research into the connection between violence and psychiatric medications to avoid the catastrophe of thousands or millions of individuals going off their psychiatric medications. The adverse effects of this could include an epidemic of self-harm or violence to others by mentally unstable individuals off their meds. So the paradox here is self-harm and violence is avoided by failing to investigate the connection between medication and violence. If this is the rationale of psychiatry, I think Thomas Kuhn’s idea of a paradigm shift in psychiatry applies.

In The Structure of Scientific Revolutions, Thomas Kuhn sees science as alternating between normal and revolutionary phases. Within periods of normal science, a paradigm provides the framework within which scientific work was conducted and evaluated. This view of science sees it as largely consensus-based around a reigning paradigm. Psychiatry fits this view of science to a “t.” Its heart is a consensus-based diagnostic system.

According to Kuhn, a paradigm is “the universally recognized scientific achievements that for a time provide model problems and solutions to a [scientific] community of practitioners.” (The Structure of Scientific Revolutions, viii) Normal science is largely “puzzle-solving” activity—figuring out how to apply the paradigm to new phenomena. “During periods of normal science the shared paradigm serves to define the relevant discipline, … to define what are legitimate scientific problems, to define what are acceptable solutions to problems, and to guide research into new lines of research.”

Occasionally, a result that is contrary to what the paradigm expects—an anomaly—occurs. Since biological psychiatry sees itself as scientific, evidence that medications contribute to violence and self-harm when they are supposed to lessen violence and self-harm is seen as an anomaly. Anomalies are either ignored or explained away if at all possible, according to Kuhn. When there are enough anomalies that defy resolution by the paradigm or when the anomaly involves something so central to the paradigm that it cannot be ignored, a crisis state develops. This is what I see happening to psychiatry. It is in this crisis stage.

If there is an acceptable alternative paradigm available, the new paradigm replaces the old one (a revolution occurs) and a new period of normal science begins with the new paradigm. Kuhn did not presume that a new paradigm would triumph over an older one because of its improved explanatory power. Rather like religion, “The transfer of allegiance from paradigm to paradigm is a conversion experience that cannot be forced.”

Kuhn’s thought it still helpful for anyone opposed to seeing psychiatry as scientific. In an essay he wrote in the early 1960s, “The Function of Measurement in Modern Physical Science,” Kuhn observed that the social sciences were largely in a pre–scientific stage. He said this was because most of the social sciences were still “characterized by fundamental disagreements about the definition of the field, its paradigm achievements, and its problems.” (The Essential Tension, 222) This lack of consensus still largely applies to psychiatry and indicates it is still within a pre-scientific stage. To name but a few of the disagreements, there are disputes over conceptualizing and defining “mental illness,” whether electro convulsive therapy is treatment or torture, and whether the wide-spread use of psychiatric medication been an achievement in treatment or has it caused an epidemic of mental illness.

The effort made by psychiatry to present a united front and to ignore its anomalies like the connection between violence and psychiatric medications indicates it has an entrenched view of what it does as scientific. So be it. Let’s not waste time trying to convince its thought leaders of their error. But let’s continue to present information to the consumers of psychiatry on its anomalies and bankrupt theories. If people no longer believe in psychiatry and its views of how to handle problems in living, it will either have to radically change or be toppled from its position of authority. Let’s work for both options. Long live the revolution.

11/23/15

Cocaine’s Secret Ingredient

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© lldipapp | Dreamstime.com

Writing for Time back in 2010, Maia Szalavitz described how the connection between levamisole and cocaine first came to light. In the summer of 2008, a man and a woman in their twenties were both admitted to a Canadian hospital with fevers, flu-like symptoms and dangerously low white blood cell counts. Although the symptoms were consistent with agranulocytosis, at the time it was only known as rare disease found in chemotherapy patients and others taking certain antipsychotic medications. Neither of the Canadian patients fit that profile. But they had one thing in common: they used cocaine. A search of the medical literature at the time didn’t find any studies linking agranulocytosis with cocaine.

But in April of 2008, a New Mexico lab had notified the New Mexico Department of Health (NMDOH) of a cluster of unexplained agranulocytosis cases in the preceding two months. The NMDOH launched their own investigation and “identified cocaine use as a common exposure in 11 cases of otherwise unexplained agranulocytosis.” In November of 2008, the NMDOH investigation and the Canadian public health officials connected with one another. In January of 2009 the NMDOH posted a notification of its findings on the CDC’s Epidemic Information Exchange. In a still separate investigation, public health officials in Seattle Washington identified 10 cases of agranulocytosis among persons with a history of cocaine use between April and November of 2009.

In the midst of this growing public health mystery, two high profile overdose deaths occurred. Celebrity disk jockey Adam Goldstein, better known as DJ AM, died of an overdose of cocaine and prescription drugs in September of 2009. Among the drugs found in his system was levamisole. Goldstein had been a fixture on the A-list party circuit and was a well-known cocaine user. Ted Koppel’s son Andrew accidentally overdosed in June of 2010. The medical examiner found a combination of drugs in his system at the time of death, including cocaine and levamisole. It was likely that neither men knew they had been snoorting any levamisole.

SAMHSA, the Substance Abuse and Mental Health Administration, posted a public health alert the same month of Adam’s death warning of the dangers of levamisole. Citing information from the DEA, the report said the percentage of cocaine specimens containing levamisole tested in its labs has steadily risen since 2002. In July of 2009, 70% of the illicit cocaine tested contained levamisole. They said there had been around 20 cases agranulocytosis, including two deaths associated with cocaine adulterated with levamisole.

Levamisole is used in veterinary medicine as a deworming agent for cattle, sheep and pigs. In the past, it was approved for use with humans to treat autoimmune diseases and cancer. It’s been increasingly found as an additive to cocaine in samples tested worldwide. It has some serious side effects like a weakened immune system, painful sores and wounds that don’t heal—the above noted condition called agranulocytosis. Left untreated, it could lead to death. Here is a short video on Adam’s death and some pictures of individuals with agranulocytosis from cocaine use. Don’t watch it if you have a weak stomach.

A recent case report in the British Medical Journal described a 42 year-old woman who came to an outpatient clinic in Britain suffering from vasculitis, an inflammation of the blood vessels. She had severe joint pain, muscle pain, intermittent abdominal pain and lesions. Initially, she repeatedly denied any cocaine use, but eventually admitted using it in the past. Hair testing done was positive for her recent use of levamisole-contaminated cocaine.

Erowid, a pro-drug website cautioned its readers to be honest with healthcare providers about their illicit substance use when they seek treatment for conditions like high fever that could be from levamisole to improve their chances of proper diagnosis and quick recovery. In other words, don’t do what the woman in the BMJ case report did. There was an informative article there on levamisole that noted how widespread levamisole-tainted cocaine is: Australia, Canada, Colombia, France, Guyana, Italy, Jamaica, the Netherlands, Spain, Switzerland, the United Kingdom, and the United States. Speculating why cocaine is adulterated with levamisole, Erowid said:

According to the DEA, levamisole–as well as other adulterants–is apparently present in some shipments of cocaine intercepted before they are broken up for further distribution to consumers. Considering that, in one batch, only 6% by weight of the total product sold as cocaine was levamisole, it seems possible it is more than simply a bulking agent. One theory is that levamisole or other adulterants boost the effects of cocaine, permitting material to pass for higher-quality product despite additional cuts made down the line. Another theory is that levamisole or other adulterants are added as chemical signatures used to track distribution of material.It may be that levamisole has been used because it has similar solubility properties to cocaine and therefore is difficult to remove and has not previously been considered a serious health hazard. As of October 1, 2009, there is no definitive answer as to why it is used as a cocaine adulterant.

Kim Gosmer, a chemist specializing in narcotic samples at the Department of Forensic Medicine as Aarhus University in Denmark speculated that levamisole-tainted cocaine originated from South America. Cited in a Vice article, he said that forensic chemists are finding levamisole-tainted cocaine all over world, increasingly from every level of distribution. Gosmer believed this suggested the adulterant is added to the cocaine in South America before it is exported. “So the question is: Why bother diluting high-grade cocaine that costs almost nothing to produce (compared to street prices) with a compound that’s more expensive than other adulterants and diluents?”

He went on to say that the amount of levamisole found in cocaine is typically not very large. So it’s not added strictly to cut the cocaine. But one of its metabolites called aminorex has amphetamine-like properties. Another possibility is that levasimole increases the amount of dopamine released by glutamate levels in the brain. “Levasimole could potentially increase the effect of cocaine through its release of dopamine.”

Casual cocaine users purportedly don’t have to worry; but habitual users should worry. With upwards of 70% of the cocaine from around the world testing positive for levamisole, the typical cocaine user will snort some levamisole sooner or later. SAMHSA warned levamisole was a dangerous substance and that agranulocytosis was a very serious illness that needed to be treated at a hospital. Remember the similar warning given by Erowid. So if you use cocaine, watch out for:

  • high fever, chills, or weakness
  • swollen glands
  • painful sores (mouth, anal)
  • any infection that won’t go away or gets worse very fast, including sore throat or mouth sores -skin infections, abscesses -thrush (white coating of the mouth, tongue, or throat) -pneumonia (fever, cough, shortness of breath).”

It used to be that you could trust drug dealers to only cut their cocaine and heroin with inert ingredients. It seems that the cost of snorting cocaine is going up in more ways than one.

11/20/15

Powerless Over Lust

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© flairmicro | 123rf.com

Francis Hartigan, a biographer of Bill W., described him as seemingly being unable to control himself sexually. Despite knowing how his philandering was a potential threat to A.A., Bill couldn’t/wouldn’t stop. At times his despair and self loathing over this issue left him feeling unworthy to lead A.A. There was a “Founder’s Watch” committee of friends who would keep track of Bill during the socializing that took place at A.A. functions. When they saw “a certain gleam in his eye,” they would steer Bill off in one direction and the young woman he had been talking to in the other. “Sexual fidelity does not seem to be something Bill was capable of.”

Matthew 5:27-32 in the Sermon on the Mount addresses the issue of adultery. The passage begins rather clearly: “You have heard that it was said, ‘You shall not commit adultery.’ But I say to you that everyone who looks at a woman with lustful intent has already committed adultery with her in his heart.” Jesus begins with a repetition of the Seventh Commandment’s restriction against adultery to his largely Jewish audience. The understanding to his audience and to other men in the ancient world was that the commandment forbade having sexual intercourse with a married woman. Leon Morris’s comment on this matter was that: “A married man could have sexual adventures as long as they did not involve a married woman.”

But as was typical of Jesus in the Sermon on the Mount, he challenges the restricted interpretations of Old Testament commandments given to God’s people. “But I say to you,” even looking lustfully at a woman means you have already committed adultery with her in your heart. Even the great rabbis stopped short of making such an important declaration about the importance of fidelity in marriage. In effect, Jesus was doing away with the old “double standard.” Men and women were equally required to be faithful in their marriages.

Note that Jesus includes matters of the heart—the thoughts, emotions and desires—as equal to overtly sinful behavior. Craig Blomberg said: “Christians must recognize those thoughts and actions which, long before any overt sexual sin, make the possibility of giving in to temptation more likely, and they must take dramatic action to avoid them.” Elaborating on this point, Jesus pointed to two of the primary bodily offenders in sexual sin outside of adultery—eyes and hands. With figurative and hyperbolic language, he said it was better to lose an eye or a hand, “one of your members,” than to end up in hell as a consequence of your sin. The message is to do whatever it takes “to control natural passions that tend to flare out of control.”

Alcoholics Anonymous, the A.A. Big Book, spent a good bit of time talking about sex. Given that Bill wrote the “How It Works” where that the section on sex appears, we may get some insight into his views on his problems with sexual fidelity and why he struggled with depression and self-loathing over his inability to control this compulsion.

Bill began by saying: “Now about sex. Many of us needed an overhauling there.” He then noted the extremes of human opinion between a view of sex being “a lust of our lower nature” and the voices who cry for sex and more sex; those who “bewail the institution of marriage.” And those who see most of human troubles traceable to sexual causes. He said A.A. didn’t want to be the arbiter of anyone’s sexual conduct. “We all have sex problems.” It’s part of being human. But what can we do about it?

The answer begins with an inventory of your sexual conduct. Where were you selfish, dishonest, or inconsiderate? Who have you hurt? Where did you unjustifiably arouse jealousy, suspicion or bitterness? Where were you at fault and what should you have done differently? “We got this all down on paper and looked at it.” The test of each relationship was whether or not it was selfish. “We asked God to mold our ideals and help us live up to them. We remembered always that our sex powers were God-given and therefore good, neither to be used lightly or selfishly not to be despised and loathed.”

Whatever your ideal was, you should be willing to grow toward it. Be willing to make amends, provided that doesn’t bring about more harm than good. God alone can judge your sexual situation. Counsel with others, but avoid hysterical thinking or advice. Suppose you fall short of the chosen ideal and “stumble.” Does that mean you are going to get drunk? Some people say that will happen, but it is only a half-truth. It depends on our motives.

If we are sorry for what we have done, and have the honest desire to let God take us to better things, we believe we will be forgiven and have learned our lesson. If we are not sorry, and our conduct continues to harm others, we are quite sure to drink. We are not theorizing. These are facts out of our experiences.

To sum up about sex: We earnestly pray for the right ideal, for guidance in each questionable situation, for sanity, and for the strength to do the right thing. If sex is very troublesome, we throw ourselves the harder into helping others. We think of their needs and work for them. This takes us out of ourselves. It quiets the imperious urge, when to yield would mean heartache.

Hartigan said a close friend and confidant of Bill’s thought that his guilt over his infidelities was a large part of his struggle with depression. Bill would always agree with the friend that he needed to stop. But just when the friend thought they were getting somewhere, Bill would say he can’t give it up and start rationalizing. “Bill’s behavior caused some of his most ardent admirers to break with him.”

Bill seems to have kept himself on the razor’s edge of not drinking over his sexual conduct. He didn’t drink, but he suffered from depression for a number of years. He also didn’t seem to have true sorrow or repentance for his actions and an honest desire to let God take him to better things sexually. Returning to the Matthew passage, I wonder if Bill never really accepted that he needed to stop lusting after women in his heart (Matthew 5:28). While he practiced and wrote about doing whatever it took to not drink, he failed to apply that principle to his sex life. We could even say, perhaps, he never truly applied the First Step to his sexual conduct.

This is part of a series of reflections dedicated to the memory of Audrey Conn, whose questions reminded me of my intention to look at the various ways the Sermon on the Mount applies to Alcoholics Anonymous and recovery. If you’re interested in more, look under the category link “Sermon on the Mount.”

11/18/15

The Cycle of Antidepressant-Induced Helplessness

© Everett Collection, Inc. | dreamstime.com

© Everett Collection, Inc. | dreamstime.com

Lawyers for GlaxoSmithKline (GSK) recently referred to evidence presented by a well-respected expert, Dr. Joseph Glenmullen, as “junk science.” He was irrational enough to testify that there was a connection between suicidality (the likelihood of an individual completing suicide) and suicide attempts. The case is one where the widow of a lawyer sued GSK because her husband committed suicide shortly after taking a generic version of the antidepressant. “Since there is no way Dr. Glenmullen can establish causation based on suicide data, he relies instead on data on ‘suicidality’ and suicide attempts, which are not appropriate surrogates for reaching conclusions about suicide.”

The above was taken from a brief news report on Mad in America, “Paxil Manufacturer Calls Evidence of Suicide Risk ‘Junk Science.’” The article said GSK has routinely overstated the drug’s efficacy. A widely cited 2001 study funded by GSK known as “Study 329” was recently reanalyzed and these results then published in the British Medical Journal. The reanalysis showed that the original claim by Study 329 that Paxil (paroxetine) was safe and effective for adolescents was wrong. The September 16, 2015 BMJ press release also noted where GKS had been fined $3 billion ($1 billion criminal, $2 billion civil) for fraudulently promoting paroxetine, among other violations.

Using previously confidential documents, researchers reanalyzed the original data from Study 329 and found that paroxetine was not more effective than placebo in treating major depression in adolescents. They concluded: “paroxetine was ineffective and unsafe in this study.” And yet for fourteen years Study 329 has been cited as demonstrating the safety and efficacy of paroxetine to treat adolescent depression. The BMJ Editor-in-Chief said the publication of the reanalyzed data “set the record straight” while it also “shows the extent to which drug regulation is failing us.”

All antidepressant medications are required to include a warning similar to what follows, which was taken from the Medication Guide for Paxil:

PAXIL and other antidepressant medicines may increase suicidal thoughts or actions in some children, teenagers, or young adults within the first few months of treatment or when the dose is changed.

Psychiatrist Peter Breggin noted in “The Proven Dangers of Antidepressants” that the FDA warning cautioning about the risks of newer antidepressants (Prozac, Zoloft, Paxil, Luvox, Celexa, and Lexapro, as well as Wellbutrin, Effexor, Serzone, and Remeron) followed a public hearing with dozens of family members and victims testifying about suicide and violence committed by individuals taking these medications.

While stopping short of concluding the antidepressants definitely cause suicide, the FDA warned that they might do so in a small percentage of children and adults. In the debate over drug-induced suicide, little attention has been given to the FDA’s additional warning that certain behaviors are “known to be associated with these drugs,” including “anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia (severe restlessness), hypomania, and mania.

Breggin was himself an expert witness in a 2012 court case that awarded $1.5 million medical malpractice verdict to a family of a man who committed suicide. He testified how antidepressants such as Paxil and Effexor could increase suicide risk in adults.

After reviewing extensive records and interviewing Mr. Mazella’s wife Janice, I concluded that Dr. Beals was negligent in reportedly prescribing Paxil for 10 years without seeing the patient, in failing to warn the patient and his wife about the serious risks associated with Paxil, in his doubling the Paxil dose and adding Zyprexa by telephone, and then in abandoning the patient during his decline. I also concluded that a hospital psychiatrist was negligent in not recognizing that Mr. Mazella was suffering from adverse drug effects and in discharging him without proper follow up two weeks before his death.

In his discussion on “The Proven Dangers of Antidepressants” linked above, Breggin also commented how there has been little attention to the additional FDA warning that additional behaviors are known to be associated with antidepressants, including “anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia (severe restlessness), hypomania, and mania.” He noted how he has repeatedly documented how the stimulation and activation profile of antidepressants can lead to out-of-control behavior, including violence.

In his article, “Antidepressant-Induced Mania,” psychologist Philip Hickey described how circular reasoning about activation from antidepressants becomes evidence of “an underlying latent bipolar disorder.” He indicated that psychiatry retrospectively applies their explanation as follows: “Before the individual showed any signs of mania, he must have had bipolar disorder because he became manic at a later date.” The hypothesis cannot be verified because the occurrence of a manic or hypomanic episode is the primary criterion for the bipolar diagnosis.

Yet there has been recent evidence that manic/hypomanic episodes can be caused by the use of antidepressant medications. Hickey reviewed a Psychiatric Times article written by Ross Baldessarini that reported on a meta-analysis that he and his colleagues did on antidepressant-associated mood-switching. Bipolar disorder is often seen as beginning with at least one episode of major depression, followed by an episode of mania or hypomania. This ‘switching’ of mood may occur during treatment with an antidepressant or other mood-elevating agent. And it is especially common among juveniles and young adults using an antidepressant for a mood disorder (depression or anxiety) or a stimulant for attention. “Such pathological shifts of mood and behavior may represent adverse drug actions or a manifestation of undiagnosed bipolar disorder.”

Hickey noted that Baldessarini et al. found that manic or hypomanic episodes were 5.6 times more common per year for individuals diagnosed with major depression who were taking antidepressants and others with the same diagnosis who were not taking them. After citing several quotations from the Baldessarini et al. study and the Psychiatric Times article, Hickey said: “What the authors are pointing out here is that antidepressants are clearly implicated in the ‘excess’ incidents of mania/hypomania, and they have even raised the question of a direct causal link.”

Baldessarini even suggested that when antidepressant-related manic episodes occur, the continued use of antidepressants might contribute to recurrent manic episodes. Although it is widely assumed that mood-stabilizing drugs are highly effective in preventing antidepressant-associated mood switching, it is not conclusively proven to be true. “Moreover, there is very limited evidence that prolonged antidepressant treatment provides substantial protection against recurrences of bipolar depression and that it might contribute to emotional instability or rapid cycling.”

When you add the research of Irving Kirsch, who has shown that antidepressants have little or no therapeutic effect at all (See “Do No Harm with Antidepressants”), we are left with a class of drugs that are no more effective than the placebos used in their clinical trials. As we saw here, they could also activate what they are taken to prevent or stabilize—depressive symptoms such as suicidality. Moreover, their use could also lead to mania or hypomania and thus elevate the initial diagnosis of major depression to the more serious one of bipolar disorder. And the icing on the cake is that if antidepressants are continued, they may contribute to further emotional instability or rapid cycling. This is a cycle of what Peter Breggin called iatrogenic helplessness generated by antidepressants. Here is his description in Brain-Disabling Treatments in Psychiatry:

The concept of iatrogenic helplessness and denial includes the patient’s and the doctor’s mutual denial of the damaging impact of the treatment as well as their mutual denial of the damaging impact of the patient’s underlying psychological and situational problems. Overall, iatrogenic helplessness and denial accounts for the frequency with which psychiatry has been able utilize brain-damaging technologies, such as electro-shock and psychosurgery, as well as toxic medications.

Iatrogenic refers to something induced inadvertently by a physician, medical treatment or diagnostic procedures. Breggin has been challenging the iatrogenic nature of psychiatric treatment for essentially his entire professional career as a psychiatrist. In 1983 he wrote in The Iatrogenics Handbook that iatrogenic denial involved the infliction of brain damage and dysfunction upon the patient to encourage them to deny both the existence of his problems and the iatrogenic brain damage. “I developed the brain-disabling hypothesis which states that all the major psychiatric treatments disable the normal brain rendering the individual more helpless and hence easier to manage or to ignore.”

11/16/15

A Blood Test for Addiction?

© Judith Flacke | 123rf.com

© Judith Flacke | 123rf.com

A research team with the Scripps Research Institute has published the results of a study that shows how a specific protein molecule controls the mu-opioid receptor (MOR) in a small group of brain cells. The mu-opioid receptor is the main one activated by morphine. When study animals lacking a specific protein called RGS7 were given morphine, they had an increased reward response, increased pain relief, delayed tolerance and a heightened withdrawal response. “In other words, without the protein, the animals were predisposed to morphine addiction.”

Several news outlets, including The Fix and HCP Live described the research and its implications. The research team hypothesized that RGS7 may regulate morphine behavior through neurons located in the nucleus accumbens, part of the neural circuitry that seems to be involved in the development of addiction. Kirll Martemyanov, who led the research team, said: “The mu opioid receptor acts as a conductor of the drug’s effects, while RGS7 acts as a brake on the signal.” Laurie Sutton, one of the researchers and the lead author of the published study, said that RGS7 could be a potential target for future drug development. “Pharmacological intervention at the level of RGS7 may reduce some of the detrimental side-effects associated with opiates.”

Martemyanov also sees where their research findings have a potential future in diagnosis. There are also some implications for why certain individuals have a difficult time with opioid addiction, while others are not so susceptible. In addition to drug craving, the animals lacking RGS7 also worked harder for a food reward, suggesting RGS7 may be a more general regulator of reward behavior beyond just drug-induced euphoria.

If our findings hold true for human patients, you could look specifically for RGS7 levels for any disabling mutation with a simple blood test. . . . Mutations could indicate a strong reaction to a drug such as morphine—people carrying a deficient copy of the RGS7 gene might need much lower doses of opioids and could be cautioned to be extra careful with these substances.

Martemyanov is currently a tenured Associate Professor for the Department of Neuroscience for the Scripps Research Institute in Jupiter Florida. He has done extensive past research into the potential role of the RGS protein. Here are links to abstract for two of his previous research studies: “A Role of RGS Proteins in Drug Addiction” and “The R7 RGS Protein Family.” Here is a link to the study discussed here: “Regulator of G-Protein Signaling 7.”

Keri Blakinger for The Fix is getting a bit ahead of the research in saying it could mean a near-future genetic test for opiate addiction. Martemyanov clearly said that IF their findings held true for humans (the study was done on animals) a simple blood test for people with a deficient RGS7 gene could be done. As explained above, this would indicate a predisposition to opiate addiction because of the dysregulation that occurs with the mu receptor. A defective RGS7 gene would reinforce the euphoria and pain relief experienced with opiates, while heightening the withdrawal when the levels drop. Chasing the high or pain relief of opiates coupled with a desire to avoid the pain and discomfort of withdrawal is the classic dynamic in opiate addiction.

If the research holds true for humans, individuals with a deficient RGS7 gene could be treated with lower doses of opioids and cautioned to be careful with opioids of all kinds. Drug development that targets RGS7 would need to explore how other mechanisms are effected by the RGS7 gene. Remember that it may be a more general regulator of reward behavior beyond drug-induced euphoria. “Fixing” the addiction problem may cause another neurochemical one. Another important research question I see is whether or not the abuse of opiates leads to a dysregulation of the mu receptor similar to what Martemyanov found with a defective RGS7 gene.

Let’s see where this research takes us. It is exciting, basic research. But don’t run ahead of it, trying to anticipate where it will lead.

11/13/15

From Darkness to Light

© andreiuc88 | stockfresh.com

© andreiuc88 | stockfresh.com

Douglas Moo said Romans 1:21 was the “missing link” for Paul’s argument in Romans 1:20, where he said those who suppress the truth God reveals about himself in creation have no excuse for their actions. “For although they knew God, they did not honor him as God or give thanks to him, but they became futile in their thinking, and their foolish hearts were darkened” (Romans 1:21). In other words, if you deny or suppress what creation reveals about God, you will never truly understand it. What’s more, your failure to understand is inexcusable because it should have been quite plain to you.

According to Robert Mounce, we can reasonably expect that knowing God should lead us to honor him as God, since He plainly gives all people the basic requirements for life, regardless of their relationship to him. Their response should be gratitude, “But people choose to ignore God and come up with their own version of reality. By rejecting the knowledge of the true God, religion is born.” Mounce’s sense of religion here  seems to be a revision of Edmund/Edward Tylor’s definition of religion as follows: “the belief in spiritual beings” other than the true God. This turning from the revealed truth of God to a personal interpretation of that revealed truth has been described as “the triumph of gods over God.”

The sense of “God as you understand him” in Twelve Step recovery strikes off in two separate directions when the truth about God in creation is encountered. One is compatible with the Romans Road, and one is not. God as you understand Him is essentially “God as I am willing to accept” or “God as I am able to comprehend” Him. This first sense can be portrayed by the word “god” within a circle representing the person’s understanding. This sense of  “god” becomes a projection or manifestation of a purely human attempt to explain reality.

small god

The alternate sense, and one that is compatible with the Romans Road, is a circle of understanding that is infinitesimally smaller than God Himself. Something that looks like what follows: the representation of our understanding as a circle barely discernable with the “O” of God.

big GodThe distinction between these two “understandings” of God is illustrated in Anselm’s Ontological Argument for God’s Existence. Anselm said that even a fool can conceive of the idea of “god” as an absolutely perfect being; a being greater than anything we can imagine or conceive. But if this idea exists in our understanding, “then it can be conceived to exist in reality; which is greater.” So if someone accepts that God is greater than our ability to imagine Him, He must exist in reality because existing in reality is greater than merely existing in the imagination. “Hence, there is no doubt that there exists a being, than which nothing greater can be conceived, and it exists both in the understanding and in reality.” Brian Davies and G. R. Evans noted in Anselm of Canterbury: The Major Works that Anselm believed:

God cannot be thought of simply as a concept people have. He [Anselm] thinks people who deny God’s existence can nevertheless be thought of as having some concept of God, for so he says, they have some idea of what it is whose existence they deny.

If reflecting on the meaning of the word ‘God’ shows that God necessarily exists in reality and not just in the mind as an idea of him, then someone who denies there is a God is ultimately proposing what must necessarily be false. Anselm saw his argument for the existence of God as paving the way for serious reflection on what we mean when we use the word ‘God.’ He also believed his ‘proof’ showed that God was what Christians believed God to be. But according to Romans, if this knowledge doesn’t lead the individual to honor and give thanks to God, it is not saving knowledge of God (Romans 1:16, 21).

So if this knowledge does not lead to reverence and gratitude towards God, then it “falls far short of what is necessary to establish a relationship” with God. In Romans 1:21 Paul points to what will happen with an understanding of God based solely on the knowledge of God revealed in creation—your thinking becomes futile; and your foolish heart becomes darkened. Whatever your initial capacity to reason about God may have been, whatever initial knowledge of creation you might have had, failing to acknowledge God’s hand in it means your thinking about it will ultimately be in vain; futile.

You can understand God to be greater than your ability to imagine Him, but still not have that knowledge lead you to worship Him. It requires the light of the gospel. Knowledge of God that does not lead you to honor and give thanks to Him leads to futile thinking and darkened, foolish hearts. Douglas Moo commented that at the very center of every person where the knowledge of God must be embraced is darkness. If the knowledge of God is to have any positive effects, then only the light of the gospel can penetrate that darkness.

As Paul has already said in verse 1:18 of Romans, the wrath of God is revealed against individuals who suppress the truth of what God has revealed. You need more than just an understanding of God as a being greater than anything we can imagine or conceive to have a relationship with “the God of the preachers.” John Calvin said of the individuals Paul described in Romans 1:21, “They quickly choked by their own depravity the seed of right knowledge, before it grew up to ripeness.” Robert Mounce put it this way:

To turn from the light of revelation is to head into darkness. Sin inevitably results in a darkening of some aspect of human existence. In a moral universe it is impossible to turn from the truth of God and not suffer the consequences. Ignorance is the result of a choice. People who do not “know” God are those who have made that choice. Understanding God requires a moral decision, not additional information.

According to the Reformation Study Bible, God will not allow human beings to entirely suppress their sense of God. Even in a fallen world people have a conscience; they have some sense of right and wrong. “When conscience speaks in these terms it speaks with the voice of God.” And I think this is true for the Twelve Steps. By meditating on what ‘God as I understand Him’ means, perhaps someone will have a deeper appreciation of what Christians believe God to be.

If you’re interested, more articles from this series can be found under the link for “The Romans Road of Recovery.” “A Common Spiritual Path” (01) and “The Romans Road of Recovery” (02) will introduce this series of articles. If you began by reading one that came from the middle or the end of the series, try reading them before reading others. Follow the numerical listing of the articles (i.e., 01, 02, etc.), if you want to read them in the order they were originally intended. This article is “04,” the fourth one in the series. Enjoy.

11/11/15

Trick or Trick

© Тимур Салман | 123f.com

© Тимур Салман | 123f.com

A grocery store pharmacy in Quebec Canada was giving out psychiatric drugs for Halloween treats this year. A mother accidentally dropped divalproex (Depakote) and quetiapine (Seroquel) pills that she had picked up for her son. Other customers picked up the pills, which were wrapped in a blister packet, and placed them on the counter next to a candy basket. Somehow the pills were mixed in with the candy. “Seven of the pills ended up in the hands and bags of trick-or-treating children.”

A Constable said that an employee mixed the medications in with the candy by accident. But one mother said she immediately recognized the pills were drugs and took them away from her daughter who had “chewed and spat out the drugs distributed by mistake.” The “mistake” is puzzling, as the girl’s mother said: “It was a transparent bag, with the name of the person, the drug, the dosage, the pharmacist and the date and time the prescription was filled; October 31 at 8 a.m. in the morning,”

Police told parents that the pills weren’t dangerous, but that is just not true. The medication guide for quetiapine lists potential side effects as: the risk of suicidal thoughts or actions, depression, anxiety, panic attacks, irritability, anger or aggression, unusual changes in mood or behavior. The medication guide for divalproex lists similar potential side effects: the risk of suicidal thoughts or actions, depression, anxiety, agitation or restlessness, anxiety, irritability, anger or aggression, unusual changes in mood or behavior. And it can cause serious liver damage in children younger than 2 years old. Granted, these adverse effects would in all probability not occur if a child had wrongly ingested one pill, but the describing the pills as not dangerous was deceitful. Read more on this incident at The Fix or Vice.

Seroquel is an antipsychotic medication and Depakote is an anti-seizure medication that carries the label of “mood stabilizer” when used as a psychiatric medication. Antipsychotics are frequently combined with mood stabilizers in the treatment of bipolar disorder. A September 2105 study published in JAMA Psychiatry, “Treatment of Young People with Antipsychotic Medications in the United States,” examined at the prescription patterns among young people in the United States. The study looked at four age groups: younger children (1-6 years), older children (7-12 years), adolescents (13-18 years), and young adults (19-24 years).

The researchers found that most of the individuals treated with antipsychotics did not have a medical claim that included a mental disorder diagnosis. The percentages by age group were as follows: younger children (60.0%), older children (56.7%), adolescents (62.0%), and young adults (67.1%). When there was a diagnosis, the most common one was ADHD with younger children (52.5%), older children (60.1%) and adolescents (34.9%). Depression was the most commonly given diagnosis among young adults (34.5%).

Consistent with clinical diagnoses suggesting that antipsychotics are primarily used to manage impulsive or aggressive behaviors in children associated with ADHD, the highest rate of antipsychotic treatment was in adolescent boys, approximately half of whom also filled prescriptions for stimulants. Young adults treated with antipsychotics were more frequently diagnosed as having depression, bipolar disorder, and anxiety disorder than ADHD.

A National Institute of Mental Health (NIMH) press release on the study, quoted a co-author, Michael Schoenbaum, as saying antipsychotics should be prescribed with care. “They can adversely affect both physical and neurological function and some of their adverse effects can persist even after the medication is stopped.” He added what was particularly important about the study’s findings was that 1.5% of boys aged 10-18 are on antipsychotics. This rate was abruptly cut in half as adolescents become young adults.

In the current study, the combination of peak use of antipsychotics in adolescent boys and the diagnoses associated with prescriptions (often ADHD) suggest that these medications are being used to treat developmentally limited impulsivity and aggression rather than psychosis.

Mad in America quoted Dr. Christopher Correll, the medical director of the New York State Office of Mental Health, who noted that the powerful and almost immediate problems with antipsychotics can include weight gain and high glucose levels (a possible precursor of diabetes). “Prescribing antipsychotics seems predominantly aimed at aggressive and impulsive behaviors, especially in males, where the disruption in school and home insists on action and remediating symptoms.”

The study commented how the above noted decrease in prescribed antipsychotics after adolescence may be due to the normal maturation of neurobiological systems in late adolescence and early adulthood. “This normal maturation of neurobiological systems may underlie the decrease in antipsychotic treatment prevalence during late adolescence among youth who do not have enduring cognitive impairments and long-term severe behavioral disorders.” High rates of coprescribing antipsychotics with other classes of drugs were observed across all age groups. Stimulants (probably for ADHD) were the most commonly prescribed psychotropic class during preadolescent years.

A likely outcome in these cases is that agitation from the ADHD stimulants contributes to an increase in aggression among preadolescents, which results in the prescription of an antipsychotic to address the aggression. Dr. Peter Breggin said: “The antipsychotic drugs are often given to children when their behavior and mental state deteriorates as a result of being given stimulants.”  Follow the link here to a page on his website where he discusses the potential harm from the psychiatric diagnosing and drugging of children. The page includes links to several videos in his Simple Truth series on YouTube that address topics such as: the harmful effects and action of stimulant drugs; and the negative effects of diagnosing children with ADHD. There is also a link to one of his articles published in Children & Society that “presents a scientific and ethical overview of the harm done to children by stimulants and by antipsychotics.”

The drugging of children in America and increasingly throughout the world is a tragedy.  Millions upon millions of children and youth will never know their full potential because they grew up with an intoxicated brain — their neurotransmitters forever deformed by being bathed in these drugs during their formative years.  Additional millions will become career consumers of psychiatric drugs with a vastly reduced quality of life and shortened lives.

11/9/15

Managing Your PAWS

© eriklam |stockfresh.com

© eriklam |stockfresh.com

The presence of some brain dysfunction is common with recovering alcoholics/addicts. Some studies have suggested that 71% to 96% of individuals perform in the impaired range of various psychological tests. McGrady and Smith in a 1986 article, “Implications of Cognitive Impairment for the Treatment of Alcoholism,” said: “Given the bulk of evidence, it is reasonable to conclude that cognitive impairment is a concomitant of alcoholism.” An “Alcohol Alert” by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicated that even mild to moderate drinking could affect cognitive functioning. But although it stood to reason that cognitive impairment could impede recovery, “evidence has not conclusively shown this to be the case.”

However, a study by Fein et al., “Cognitive Impairments in Abstinent Alcoholics,” published in Addiction Medicine found: “The most significant determinant of the presence of cognitive deficits in persons recovering from alcoholism is the time elapsed since their last drink.” When the time period was controlled, different patterns emerged. They classified the abstinence time into three time periods. The acute detoxification period could last as long as the first two weeks of abstinence. The intermediate abstinence period was from the end of the detoxification time through the first two months. The long-term abstinence period extended from two months to five years of abstinence. The general pattern of deficits in these three time periods is shown within Table 1 taken from Fein et al.

Untitled

Alcohol use has well-documented effects on attention, concentration, reaction time, motor coordination, motor speed, judgment, problem solving, learning and short-term memory. Because these impairments are substantially reduced with detoxification, neuropsychological testing during this time period is of little value. “It is the residual deficits in patients following detoxification that are relevant to the diagnosis of cognitive impairment.”

Fein et al. stated that sensitivity to the possibility of cognitive impairments in abstinent alcoholics was essential to informed treatment planning. Individuals with deficits to learn new information were at a disadvantage in intensive treatment programs. They could be seen as “unmotivated” or “not ready to stop drinking” rather than “impaired.” They suggested early treatment focus on enforced abstinence and be supportive, rather than make the patients learn new material or think analytically about their experience. As cognitive functioning improves, these patients may begin to participate in the more educational and insight-oriented aspects of treatment.

We note that the Alcoholics Anonymous program is appropriate to the cognitive limitations of newly abstinent alcoholic persons. The focus in Alcoholics Anonymous is on maintaining abstinence from alcohol within the context of acceptance and support. New initiates are told to come to as many meetings as possible (“90 meetings in 90 days”), with- out an expectation that they become fully indoctrinated into the culture of the program (“fake it until you make it”). Indeed, during the initial period, the emphasis is on behavioral change rather than on understanding or a change of attitude.

The apparent discrepancy between the NIAAA statement and the Fein et al. study may be explained by an observation made by Terence Gorski of how symptoms of post acute withdrawal (PAW) associated with the brain dysfunction from alcohol/drug use may contribute to many cases of relapse. According to Gorski, “Post acute withdrawal is a group of symptoms of addictive disease that occur as a result of abstinence from addictive chemicals.” Too often these “sobriety-based symptoms” of alcoholism and drug addiction are neglected or ignored. See “Recognizing Your PAWS” for more information on PAW symptoms. Or you can read Gorski’s Comprehensive Guide to PAW here.

PAW symptoms are not the same in everyone. There can be a wide variance from person to person in how severe they are, how often they occur and how long they last. Gorski suggested there were four patterns in PAW symptoms. If they get better over time, that is a regenerative pattern. If they get worse, he says it is degenerative. If it stays the same, that is a stable pattern. If it comes and goes, that is an intermittent pattern.

The most common pattern of PAW is regenerative and over time it becomes intermittent. It gradually gets better until the symptoms disappear and then it comes and goes. The first step is to bring PAW symptoms into remission. This means bringing them under control so that you are not experiencing them at the present time. Then the goal is to reduce how often they occur, how long the episode lasts, and how bad the symptoms are. You must remember that even when you are not experiencing them there is always the tendency for them to recur. It is necessary to build a resistance against them – an insurance policy that lowers your risk.

Stress triggers and intensifies PAW symptoms. Conversely, lower stress means less severe PAW. So learning to manage stress will help you manger PAW. Mindfulness meditation has been shown to be very effective in reducing stress levels. In How God Changes Your Brain, Andrew Newberg and Mark Waldman noted that animal studies have shown how mild, short-term or chronic stress impairs memory by disrupting dendritic activity. “If the situation that is causing the stress is removed, function is restored.” Intentional relaxation, as with deliberately scanning each part of your body to reduce muscular tension and fatigue will not only relieve bodily tension, it will interrupt the release of stress-stimulating neurochemicals.

When all is said and done, you are responsible for protecting yourself from anything that threatens your sobriety or anything that triggers post acute withdrawal symptoms. Reducing the stress resulting from and contributing to the symptoms of post acute withdrawal must be of prime consideration for you. You must learn behavior that will protect you from the stress that might put your sobriety in jeopardy.

Good nutrition plays a role in stress reduction and managing PAW. Gorski suggests a high protein, complex carbohydrate meal plan. Eat three well-balanced meals daily. Eat three nutritious snacks to stave off hunger, which is a stress producer. Potato chips, candy and other high calorie low nutrient foods are no-nos. Avoid foods high in sugar and limit your caffeine intake. Also use multiple vitamins, vitamin B-12 and broad-spectrum amino acids.

Regular aerobic exercise helps to reduce stress. “Many recovering people will testify to the value of exercise in reducing the intensity of PAW symptoms. After they exercise they feel much better, find it easier to concentrate and remember, and are able to be more productive.” Exercise will stimulate the release of neurochemicals that help relieve pain, anxiety and tension.

In The Emperor’s New Clothes, Irving Kirsch reported that studies of physical exercise as a treatment for depression have shown several surprising findings. Exercise is more beneficial for moderate to severe depression than it is for mild to severe depression. These benefits seem to be long lasting, if the person continues to exercise regularly. Twenty minute three days per week is enough to produce the antidepressant effect. But Gorski suggests daily exercise because of its added value in reducing stress.

According to Gorski, spirituality is an important tool in managing PAW symptoms. “Through spiritual development you can develop new confidence in your own abilities and develop a new sense of hope.” Using the principles of the AA/NA program to increase your conscious contact with your higher power is an important part of this spiritual development. You simply have to be open to the possibility of a Higher Power and be open to experimenting with a form of communication with that Power. There isn’t a required structure to that communication.

Try reading Greenberg’s and Waldman’s book, How God Changes Your Brain for suggestions on how meditation can be practiced from a nonreligious point of view. Greenberg has done research that has showed neurological changes in the brains of praying nuns that was nearly the same as that in the brains of Buddhist monks meditating. This evidence confirmed their hypothesis that the benefits gleaned from prayer and meditation may have less to do with a specific theology “than with the ritual techniques of breathing, staying relaxed, and focusing one’s attention upon a concept that evokes comfort, compassion, or a spiritual sense of peace.”

A final area in managing PAW is living a balanced life. “It means your are healthy physically and psychologically and that you have healthy relationships.” You have time for your job, your family, and your friends, as well as your own growth and recovery. It also means wholesome living. It needs a strong social network that nurtures you and encourages a recovery-oriented lifestyle. The two primary goals in any person’s recovery are to establish and maintain a recovery-oriented lifestyle and to establish and maintain a sober support system.

It [balanced living] means having a balance between work and play, between fulfilling your responsibilities to other people and your need for self-fulfillment. It means functioning as nearly as possible at your optimum stress level, maintaining enough stress to keep you functioning in a healthy way and not overloading yourself with stress so that it becomes counterproductive. With balanced living, immediate gratification as a lifestyle is given up in order to attain fulfilling and meaningful living.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s Blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.