09/29/17

Ruling over Our Genes

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Coincidentally (or not), I was driving home after church one Sunday, when I heard the TED Radio Hour broadcast a program called, Hardwired. It asked how much of who we are as humans is biology; and how much is learned. There was a neuroscientist who argued that there was no such thing as free will. Then an epigeneticist said he believed that between the hard wiring of our DNA and the ultimate results there is space for free will. Although exploring the existence of free will through the lens of a scientist is an intriguing exercise, don’t expect any conclusive answers.

These men were grappling with a question that was beyond the ability of science to answer. Both individuals acknowledged, in one way or another, that they were giving an opinion on an ultimate question—the existence or nonexistence of free will. Yet they came to different conclusions. While there was no speculation why they reached such different conclusions in the TED broadcast, I think it was because they had such a fundamental difference in how they viewed human nature.

How Much Agency Do We Have Over Our Behavior?

Robert Sapolsky is professor of biology, neurology and neurological sciences at Stanford University. Although he is a self-described hippie-pacifist, he related a horrifically violent fantasy of what he would do to Hitler if he had captured him alive before his suicide. He said he’s had this fantasy since he was little. “We’re capable of a lot of stuff,” he said. When asked what human nature was, where did good and bad behaviors come from, he said it depends.

When, where, what you had for breakfast, what you had when you were a fetus in somebody’s womb back when; what your culture has been; a little bit of what your genes are; how your brain is wired up; it depends. It depends enormously on context.

According to Sapolsky, we are a confusing mixture of impulses. Every bit of human behavior has multiple layers of causality. Everything that has happened in our lives, what goes on in our culture, and even in our history is potentially relevant. “Everything that happened a second before; to everything that happened a million years before; and everything in between.”

His personal bias is that there is no such thing as human agency or free will. What we call free will is simply the biology that hasn’t been discovered yet.  “It’s just another way of stating that we’re biological organisms determined by the physical laws of the universe.” With each passing year of insight into the biology of behavior, what we call free will gets crammed into an increasingly smaller space. At some point, it may even become nonexistent.

“We are biology all the way down. There is no soul; no Calvinistic self-discipline.” There is no real choice in what we do or say; it’s all conditioned by genetics, biology, culture, or history. We shouldn’t really be pleased when complimented by others. Nor should we be surprised by something a person does—good or bad. But curiously, he then added: “At the same time, I realize I have absolutely no idea how somebody is supposed to really believe that stuff.”

Sapolsky’s understanding of human nature leaves no room for a soul, for free will; for anything outside of biology: “We are biology all the way down.” He appears to be alluding here to a response to the unmoved mover paradox in cosmology. The metaphor uses an anecdote represented by the Earth (which is flat) sitting on the back of a World turtle, which is itself supported by an infinite column of turtles. When asked what the final turtle is standing on, the pithy response is that it is “turtles all the way down.”

Intellectually, he believes that what he understands from neuroscience and biology is true. But it seems he can’t consistently live with that belief.

How Do Our Experiences Rewire Our Brains and Bodies?

Moshe Szyf is a geneticist and professor of pharmacology and therapeutics at McGill University in Toronto. One of his primary research interests is with behavioral epigenetics. He described epigenetics as studying how genes are programmed. He said there is a growing consensus in the field of epigenetics that DNA alone is not sufficient to explain behavior. Szyf believes DNA has two, perhaps three identities. One is the classic sense of inheritance. Another occurs as the fetus develops in the womb of its mother.

He believes from his research there is a third-identity formed with experience, which can lead to long-term changes to the way genes are programmed. The environment is constantly changing our genes, so they have both plasticity and a fixed character. We need both aspects— the immutable and the mutable acting together. “This is the amazing paradox and challenge of life.”

DNA, he said is not merely a sequence of letters; a script of human development. It’s rather like a dynamic movie, where our experiences can be written into the movie. We have some agency, but it is split between several sources: our individuality, our family, our community, our country and the world. And there are interactions between all of these. So where does he see a place for free will?

I think that there is, between the hard wiring and the ultimate results, there is a space where freedom of will is operating. And it is operating on these epigenetic processes. If we understand these processes, tap into these processes, we can be ruler over our genes, by providing the right environments; and that is where we as societies have responsibility.

From his perspective, Moshe Szyf sees room for free will and human responsibility—aspects of what has been called the human soul. It’s not affirmed or described by him, but at least he sees a “space” where free will could be; even if there is no concrete scientific way to confirm it. Szyf’s perspective on human nature acknowledges a potential place for the soul, even as he hastens to qualify it as operating on epigenetic principles.

Robert Sapolsky believes humans are biology “all the way down.” Yet interestingly, he isn’t sure how we are supposed to accept that’s true. He seems to imply that lived human experience challenges the scientific evidence that progressively forces the concept of free will into a smaller and smaller space.

When the question becomes what can neuroscience or epigenetics tell us about free will, we’ve gone beyond the realm of science into what Karl Popper called ultimate questions. “It is important to realize that science does not make assertions about ultimate questions—about the riddles of existence, or about man’s task in this world.” There is a limit to what we can learn scientifically about ourselves and about the universe. The question of the existence of free will and the soul reaches beyond that limit.

The biologist and Nobel Prize winner P. B. Medawar agreed with Popper. He believed it was logically outside the competence of science to answer ultimate questions.  He said: “There is a prima facie case for the existence of a limit to scientific understanding.” This limitation is made clear by science’s inability to answer ultimate questions such as: “How did everything begin?”; “What are we here for?”; “Is there a human soul?”

Doctrinaire positivism—now something of a period piece—dismissed all such questions as nonquestions or pseudoquestions such as only simpletons ask and only charlatans of one kind or another profess to be able to answer. This preemptory dismissal leaves one empty and dissatisfied because the questions make sense to those who ask them, and the answers, to those who try to give them; but whatever else may be in dispute, it would be universally agreed that it is not to science that we should look for answers.

Medawar’s observations here are helpful in reconciling the different conclusions of Sapolsky and Szyf on free will. Sapolsky’s philosophy of science seems to have a rather large dose of positivism. Human nature is completely biological. There is no room for non-biological or pseudo-scientific concepts like free will or a soul. What we call free will is simply undiscovered biology. And yet, he admits to a sense of dissatisfaction or emptiness, by noting he has no idea how anyone can believe it.

For more discussion on free will, read “Ability to Choose … Within Limits.” (soon to be posted)

09/26/17

Demolishing ADHD Diagnosis

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The Harvard psychologist, Jerome Kagan, sees ADHD as more of an invented condition than a serious illness. Further, he thinks it was invented for “money-making reasons” by the pharmaceutical industry and pro-ADHD researchers. He believes the drastic increase in the number of children diagnosed with ADHD has more to do with “fuzzy diagnostic practices” and relabeling. Fifty years ago, a 7-year-old child who was bored and disruptive in class was seen as “lazy.” Today he is seen as suffering from ADHD.

Every child who’s not doing well in school is sent to see a pediatrician, and the pediatrician says: “It’s ADHD; here’s Ritalin.” In fact, 90 percent of these 5.4 million kids don’t have an abnormal dopamine metabolism. The problem is, if a drug is available to doctors, they’ll make the corresponding diagnosis.

In his interview with Spiegel Online, Kagan went on to say that the inflated diagnosis of ADHD and other so-called childhood mental health disorders means more money for the pharmaceutical industry, psychiatrists and the people doing research. “We’re up against an enormously powerful alliance: pharmaceutical companies that are making billions, and a profession that is self-interested.” As he said, he’s not the only psychologist who is saying this.

Parenting expert and family psychologist, John Rosemond, agrees with Kagan. In 2009 he co-authored The Diseasing of American’s Children where they argued that ADHD and other childhood behavior disorders “were inventions of the psychological-psychiatric-pharmaceutical industry.” They went further than Kagan in saying that ADHD does not exist; that it is a fiction. In his April 9, 2017 article, “ADHD Simply Does Not Exist,” Rosemond referred to Kagan’s declaration on ADHD, noting that he and other psychologists studied Kagan’s books and research papers on children and child development when they were in graduate school. In The Diseasing America’s Children, Rosemond said:

Science depends on verifiable, objective evidence and experimental results that can be replicated by other scientists. Where ADHD is concerned, neither verifiable, objective evidence nor replicable experimental results exist to support the claims of the ADHD establishment.”

Rosemond and his co-author, Bose Ravenel, believe that childhood behavior disorders like ADHD are manifestations of “dysfunctions of discipline and lifestyle” endemic to modern family culture. Once these problems are identified, they can be easily corrected. And once corrected, the errant behavior “usually recovers to a state of normalcy within a relatively short period of time.” They believe children do not need a psychologist when they misbehave, they need discipline—“firm, calm and loving discipline.”

In Debunking ADHD, educational psychologist Michael Corrigan said ADHD is a negative label that does not exist. “Not unlike the many wonderful stories about unicorns, fairies, and leprechauns, the diagnosis of ADHD is a brilliant work of fiction.” He noted that many of the common childhood behaviors (or supposed symptoms) associated with ADHD are also used to identify giftedness in children. When these behaviors are harnessed and focused, they can help children become “incredibly creative, insightful, and successful individuals in adulthood.” If children don’t learn to harness the power of the behaviors ADHD and giftedness have in common, “such behaviors when displayed might seem annoying and immature.” He said:

My biggest reason for writing this book is my desire to show you that the practice of medicating children for acting like children in the name of ADHD is, in two words, wrong and dangerous. Despite the grandiose claims of the mega-pharmaceutical companies selling ADHD drugs to concerned parents, prescribing pills to young children trying to learn how to become young adults is just a quick fix void of any long-term benefits.

Corrigan described eating lunch with a group of children who had just taken their ADHD medication at school. They were now supposedly “good to go” (sufficiently medicated) for an afternoon of learning. It was the longest lunch period he had ever experienced. “Comparing the kids at my table to others in the cafeteria, and slowly watching these playful, creative, energetic, and funny children go from kids being kids to near expressionless robot-like entities, made me sick to my stomach.”

The total number of children on ADHD medication “skyrocketed” from 1.5 million in 1995 to 3.5 million in 2011. “Sales of prescription stimulants quintupled from 2005 to 2015.” The rising rate of ADHD diagnosis has been described as “an unreal epidemic” and a “national disaster of dangerous proportions” by well-known professionals like Allen Frances and Keith Conners. Frances was the chair of the DSM-IV. Conners, now an emeritus professor of medical psychology at Duke University, “spent much of his career in legitimizing the diagnosis of ADHD.”

Allen Frances was one of four authors of an article in the International Journal of Qualitative Studies on Health and Well-Being, “ADHD: A Critical Update for Educational Professionals.” When the DSM-IV was published in 1994, the prevalence of ADHD was estimated to be 3%. Since then, parent-reported ADHD diagnosis increased to 7.8% in 2003; 9.5% in 2007; and to 11% in 2011. Nearly one in five high school boys had been diagnosed with ADHD and around 13.3% of 11-year-old boys were medicated for ADHD.

Teachers and other school personnel are often the first to suggest a child might be “ADHD.” Research suggested teachers felt insecure about dealing with behavioral problems and hesitated to accept responsibility for students with special needs. Frances and his coauthors described six scientifically grounded issues that educational professionals should be aware of when they are confronted with inattention and hyperactivity in the classroom.

First: birth order matters. Several studies have shown “That relative age is a significant determinant of ADHD diagnosis and treatment.” The youngest children in the classroom are twice as likely to be diagnosed with ADHD and receive medication. They suggest teachers take the child’s relative age into account when judging the child’s behavior. “Seeing ADHD as the cause of inattention and hyperactivity is in fact a logical fallacy as it is circular.”

Second, there is no single cause of ADHD. “There are no measurable biological markers or objective tests to establish the presence or absence of ADHD (or any other given DSM syndrome).” ADHD is a description of behavior and is based on “criteria that are sensitive to subjectivity and cognitive biases.” Multiple factors have been associated with ADHD, without necessarily implying causality. Those factors include: divorce, poverty, parenting styles, lone parenthood, sexual abuse, lack of sleep, artificial food additives, mobile phone use and growing up in areas with low solar intensity. “All these factors and more may play a role when a particular child exhibits impairing hyperactive and inattentive behaviours, and there is no conclusive cause of ADHD.”

Third, most children exhibiting “ADHD behavior” have normal-looking brains. Studies that do show small differences in terms of brain anatomy do not apply to all children diagnosed with ADHD. Individual differences refer to slower anatomical development. “They do not reveal any innate defect as is illustrated by the fact that many people with an unusual anatomy or physiology do not experience ADHD related problems.” Also, the test subjects in many brain-related studies are rigorously screened and don’t represent all individuals diagnosed with ADHD.

The samples do not comprise an accurate representation of their respective populations, meaning an average child with a diagnosis of ADHD and an average “normal” child. This problem is particularly urgent since the DSM 5 has lowered the age of onset criterion, as well as the impairment criterion compared to the previous version, the DSM-IV. Alongside the lowered threshold, the potential to generalize earlier research findings has lowered as well.

Fourth, the claims of ADHD being inherited may be overestimated.  The claims vary widely and are subject to debate because of methodological issues used in calculating the heritability coefficient in twin, familial and adoption studies. There is significant difficulty separating genetic influences from environmental ones, such as poverty, parenting styles and divorce, in these studies. “In genetic association studies that really analyse genetic material and that are more powerful when separating the influence of genetics from other etiologic sources, associated genes show only very small effects.” When combined, they explain less than 10% of variance.

This means they occur only slightly more often in diagnosed individuals than in controls, and they do not explain nor predict ADHD behaviours. For educational professionals, this is important to consider as an ADHD label might give a false sense of security with regard to the alleged (genetic) cause of a child’s behaviour and the preferred cure (medication).

Fifth, medication does not benefit most children in the long run. Follow up studies of the long-term effects of the MTA (Multimodal Treatment of Attention Deficit Hyperactivity Disorder) study showed a convergence of outcomes over time between medicated and non-medicated children. Other studies also report either no long-term benefits, or even worse benefits. “While medication may help a small group of children in the long run, most will not benefit from long-term pharmaceutical treatment.”

The sixth and final issue that educational professionals should be aware of when confronted with inattention and hyperactivity in the classroom is the reality that a diagnosis can be harmful to children. A CDC MMWR Report indicated only 13.8% had severe ADHD, with 86.2% having mild (46.7% or moderate (39.5%) ADHD. The authors pointed out a DSM diagnosis opened the door for additional reimbursement to the school for treatment and school services, perhaps promoting a search for pathology in relatively mild cases. “The question is whether in these mild cases the merits of a confirmed diagnosis—such as acknowledgement of problems and access to help—outweigh possible demerits.” Some known disadvantages of a diagnosis are: lower teacher and parent expectations that turn into self-fulfilling prophecies, prejudice and stigmatization of diagnosed children, a more passive role towards problems, difficulties getting life and disability insurances later on in life, and others.

The Allen Frances article linked above was the most accepting of ADHD as a legitimate “neuro-developmental disorder.” Yet it cautioned there was no single cause for ADHD, medications to “treat” ADHD did not have long-term benefits, and there was a problem with its over diagnosis. Jerome Kagan thought 90% children were wrongly diagnosed with ADHD because of “fuzzy diagnostic practices and relabeling.” Michael Corrigan, John Rosemond and questioned the validity of ADHD as a neuro-developmental disorder. Corrigan said it pathologized normal childhood behavior; and medicating these children was wrong and evil. It’s time to demolish the ADHD treatment empire.

Additional articles on ADHD can be found on this website here: “National ADHD Epidemic,” “Misleading Info on ADHD,” “Tip of the ADHD Iceberg,” and “Is ADHD Simply a Case of the Fidgets?” You can also read a longer paper: “ADHD: An Imbalance of Fire Over Water of a Case of the Fidgets?

09/22/17

Be Careful Out There

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Recently, around 6 a.m. on a Wednesday, several law enforcement agencies executed federal search warrants at three locations in the West End area of Pittsburgh. In one home, when the SWAT team members entered, one of the suspects was trying to escape through a back window. Another one of the suspects knocked over a table where they had been bagging drugs, “causing the powder narcotics to become airborne” and exposing the SWAT officers to the airborne drug. Eighteen of them were taken to the hospital suffering from various symptoms.

According to Brenda Waters of KDKA, the CBS Pittsburgh affiliate, all eighteen were medically cleared. “None of the … law enforcement officers taking part in the early morning raid were adversely affected by the drugs.” The agencies participating in the raid included Pittsburgh Police, Pittsburgh SWAT, U.S. Immigration and Customs, state police and Homeland Security. In addition to the airborne substance, they found more than 1,000 stamp bags, 250 grams of unpackaged drugs and a “significant quantity of white powder” on a plate in the kitchen. The airborne substance was probably fentanyl; maybe carfentanil.

Dr. Tureurro, the chief of Emergency Services at UPMC Mercy Hospital, where the officers were treated, said they were fortunate to get out of the situation quickly, thus minimizing their symptoms. They had burning sensations in their throats; some became lightheaded; others were nauseous. “The big thing that we did for them is we basically decreased the chance that they could be exposed to anything that was laying on their bodies or on their clothes.” By removing their clothes, then showering and decontaminating themselves, the officers decreased their chances of exposure to any of the substance. The Justice Department press release said:

Fentanyl exposure is an all too real risk to law enforcement as we learned this morning. Quick and professional action by first responders helped avert a potential catastrophe.

The Pittsburgh Post-Gazette reported that the raid originated from a May investigation by Customs and Border Protection when agents intercepted a fentanyl package marked as “plastic fittings” that was shipped from Hong Kong. The accused leader of the drug operation had a history of repeated arrests for felony drug convictions and disregarding bond conditions in his repeated arrests for drug related charges. He had been initially arrested for possession and distribution on June 1st in relation to the intercepted package of fentanyl from Hong Kong. He was rearrested on July 20th, discarding a brick of fentanyl on the floor of a police car taking him to jail, and then again on August 2nd. Each time he was released on bond he resumed his criminal activities. This time he did not receive bail.

This is not an isolated or freak occurrence. In September of 2016, The Washington Post reported on a raid in Harford Connecticut when 11 SWAT officers were exposed to airborne fentanyl and heroin. The powder may have blown into the air after the tactical team tossed a flash-bang grenade, or the suspects could have swept the table where they were packaging the drugs. The officers moved through a “cloud of dust in the air.” Several officers were lightheaded, nauseous; they had sore throats and headaches. As a precaution, the entire team went to a local hospital for treatment.

Jim Pasco, executive director of the National Fraternal Order of Police, said this has been an inherent risk for law enforcement for decades, beginning with “The granddaddy of all problems—being exposed to meth labs.” A DEA spokesperson said law enforcement officers are concerned with protecting themselves and the public.

Law enforcement officers do carry a bigger burden than ever — we are fighting to protect the American public from poisons that bring death and destruction to our communities — but we are also faced with challenges of educating the public as to the deadly risks of these substances and about the inextricable links between misuse of prescription opioids to heroin and fentanyl use and addiction.

Kelly Burch reported for The Fix that in May of 2017 when an East Liverpool Ohio police officer helped in the arrest of drug suspects, they tore open bags of the drugs in an attempt to destroy evidence. Back at the station, the officer noticed a white powder on his uniform and tried to brush it away. “I had placed my thumb, and index finger in it and tried to brush it off. I don’t know if it went through my skin or if it became airborne when I wiped it off, or a combination of both.” Within a few minutes, he didn’t feel like himself. The last thing he remembered was falling backwards into the door.

He received a dose of Narcan at the station and a few more at the hospital. “Never in a million years did I think I would be in the hospital for something that serious, for overdosing.” He knew the job was dangerous and might encounter guns and knives. But “you’re not thinking that a particle of dust or drug killing you.” The experience made him even more determined to keep these powerful drugs off the streets: “I am not letting drug dealers win, you may have almost killed me, but you’re not going to win, you’re not going to come to this city and bring that poison.”

Another Ohio encounter with fentanyl took place in early August of 2017 in Massillion, about 50 miles south of Cleveland. Three nurses at the Affinity Medical Center in Massilon lost consciousness while they were cleaning a room where an overdose victim had been treated. All three were treated with naloxone and are said to have recovered. The nurses union at the hospital  wanted to meet with hospital officials to discuss protocols for environmental contamination, but the hospital declined, saying it already has effective policies. Hmmm … with three nurses becoming unconscious, it seems a review of the policies woudn’t hurt.

CTV Vancouver reported in October of 2016 that the CBSA, Canada’s Border Services Agency advised its officers to avoid contact with a package they suspect contains fentanyl. The president of Canada’s Customs and Immigration Union said: “What we’re telling our officers at this time, from a health and safety point of view, is that if there’s a package and they think there could fentanyl, they shouldn’t touch it. They shouldn’t approach it.” If an agent believes a package contains the drug, they are advised to give it to supervisors. “We need to approach this so our officers have the right tools, right training and the right equipment.”

In a June 2016 press release, the DEA announced they had released a short Roll Call Video to all law enforcement agencies about the dangers of improperly handling fentanyl. You can watch the video here. The press release said the DEA was concerned about law enforcement coming in contact with fentanyl on the streets in the course of enforcement activities, such as buy-walk or buy-bust operations. “Officers should be aware that while unadulterated fentanyl may resemble cocaine or heroin powder, it can be mixed with other substances which can alter its appearance.” The report noted the current outbreak involved not just fentanyl, but fentanyl compounds (like carfentanil) as well.

Universal precautions must be applied when conducting field-testing on drugs that are not suspected of containing fentanyl. Despite color and appearance, you can never be certain what you are testing. In general, field-testing of drugs should be conducted as appropriate, in a well ventilated area according to commercial test kit instructions and training received. Sampling of evidence should be performed very carefully to avoid spillage and release of powder into the air. At a minimum, gloves should be worn and the use of masks is recommended. After conducting the test, hands should be washed with copious amounts of soap and water. Never attempt to identify a substance by taste or odor.

The DEA published “A Briefing Guide for First Responders” on fentanyl. It contained a history of fentanyl, a description of illicit forms of fentanyl and fentanyl-related substances, the risks of exposure and treatment, as well as decontamination recommendations.

Fentanyl was first synthesized in 1959 by a Belgian chemist. Other forms of pharmaceutical fentanyl were developed for pain management, including a transdermal patch, a nasal spray, a sublingual tab and a flavored lollipop—yes a fentanyl lollipop. While pharmaceutical fentanyl is diverted on a small scale, the current problem is due to transnational criminal organizations competing for the U.S. market.

China and Mexico appear to be the main source countries for illicit fentanyl smuggled into the United States for domestic‐based processing and distribution. Seizures indicate that China supplies lower volumes of high‐purity fentanyl, whereas fentanyl seizures from Mexico are higher volume but lower in purity. Fentanyl is also routed and smuggled through Canada. China‐based trafficking organizations have also been known to use the internet to distribute fentanyl, fentanyl‐related substances, and synthetic opioids globally.

Among the current fentanyl-related substances on the illicit market are: 4‐fluoroisobutyryl fentanyl, furanyl‐fentanyl, acryl‐fentanyl, acetyl‐fentanyl, carfentanil, and 3‐methylfentanyl, and other synthetic opioids such as U‐47700. I’ve written previously on this website about the fentanyl-related substance, carfentanil (“The Devil in Ohio”). Recently I received an unsolicited email from a “company” in Shanghi offering to send me a free sample of carfentanil. The DEA “Briefing Guide for First Responders” warned that some organizations are distributing pure fentanyl.

During the first quarter of 2017 the DEA indentified 230 instances of fentanyl, fentanyl-related substances and other synthetic opioids in seized drug evidence. The following graphic illustrates the results of their analysis. Fentanyl accounted for about 58% of the identifications. Of those 134 fentanyl identifications, 61% of the samples were combined with heroin; 28% were fentanyl alone. Carfentanil was found in six identifications. U-47700, alprazolam (Xanax) and cocaine’s were found in others.

Because of their hazardous nature, fentanyl and fentanyl-related substances are a serious threat to the health and safety of law enforcement officers and other first responders, such as EMTs. As little as 2-3 milligrams of fentanyl could bring on respiratory depression and possibly death. “When visually compared 2 to 3 milligrams of fentanyl is about the same as five to seven individual grains of table salt.” See the above photo of a penny.

The “Briefing Guide for First Responders” went on to describe treatment for any exposure to fentanyl, repeating some of the actions taken in the above situations:

  • seek immediate medical attention.
  • remove the person from the contaminated environment, preferably where there is fresh air.
  • If a suspected fentanyl-related substance has been inhaled, move the person to fresh air.
  • If there are overdose symptoms, immediately administer naloxone, which can quickly reverse an opioid overdose.
  • Multiple doses may be necessary, depending upon the drug’s purity and potency. Continue to administer a dose of naloxone every 2-3 minutes until the individual is breathing on their own for at least 15 minutes or until EMS arrives.
  • Someone who entered a badly contaminated area or was otherwise exposed to a suspected fentanyl-related laboratory or milling operation without wearing the proper protective clothing should undress and shower with soap and water as soon as possible.
  • If a suspected fentanyl-related substance was ingested through the mouth or eyes and the person is conscious, rinse their eyes and mouth with cool water.
  • When there has been any skin contact, wash the exposed area immediately with soap and water.
  • Do NOT use hand sanitizer, as it may contain alcohol, which is a skin penetrant. This may increase the absorption of fentanyl through the skin.

So if you are a first responder or law enforcement officer—or if for some reason you find yourself exposed to fentanyl—remember the above advice. And first responders and law enforcement officers, remember the safety call given by Michael Conrad, who played the role of Sergeant Phil Esterhaus in Hill Street Blues: “Let’s be careful out there.”

09/19/17

Aversion to Holiness

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In chapter four of Indwelling Sin in Believers, John Owen began to unpack how indwelling sin is enmity against God. Here in chapter five, he described how this enmity manifests itself as aversation—turning from God and all things associated with God in disgust. Aversation is an older term, with a more intense sense of disgust than the similar modern term aversion. A Biblical example of aversation would be the enmity between the Jews and Samaritans.

The Samaritans believed they were the true descendents of Israel and the keepers of the Torah. During New Testament times, their main religious site was Mount Gerizim. They believed that the Jewish temple and priesthood were illegitimate. They took their name from the Hebrew phrase “keeper of the law.” They believed Mount Gerizim was where both the patriarchs and the Israelites (when they first arrived in Canaan) made sacrifices. The Samaritan version of the Pentateuch also said God’s people should worship him in Shechem, making worship in Jerusalem illegitimate. They also believed that their messiah would be a prophet like Moses.

Needless to say, this made the Jews and Samaritans religious, ethnic and cultural enemies with a strong aversation for one another. This context lays the foundation for the encounter between Jesus and the Samaritan woman in chapter four of the gospel of John. John Owen said there is an aversation in the law of sin against everything of God. All reluctance towards religious practices designed to attain communion with God, all carnality and religious formality springs from this root. “It will allow an outward, bodily presence unto the worship of God, wherein it is not concerned, but it keeps the heart quite away.”

Some people pretend they have no aversation towards the things of God. Rather, they believe they have liberty or freedom from these duties. Owen thought this pretended liberty came from “ignorance of the true state and condition of their own souls.” or through a lack of faith and interest in Christ. “It may be, whatever duties of worship or obedience such persons perform, they may, through want of faith and an interest in Christ, have no communion with them; and if so, sin will make but little opposition unto them therein.” It can often be found in the emotions, where there is a secret loathing about any “close or cordial dealing with God.”

Even when convictions, sense of duty, dear and real esteem of God and communion with him, have carried the soul into its closet, yet if there be not the vigour and power of a spiritual life constantly at work, there will be a secret loathness in them unto duty; yea, sometimes there will be a violent inclination to the contrary, so that the soul had rather do any thing, embrace any diversion, though it wound itself thereby, than vigorously apply itself unto that which in the inward man it breathes after. It is weary before it begins, and says, “When will the work be over?”

Aversation is also found in the mind. When we pray we should be able to  “fill our mouths with arguments” to God (Job 23:4). Our minds should be ready to plead for the considerations that prevail with God. What if it starts, but then wanders or fades—“all from this secret aversation unto communion with God, which proceeds from the law of indwelling sin.” Others are so occupied with family or public duties that they have little time for private prayer. This is the source of many foolish opinions and the beginning of many who fall away from God.

Finding this aversation in their minds and affections from closeness and constancy in private spiritual duties, not knowing how to conquer and prevail against these difficulties through Him who enables us, they have at first been subdued to a neglect of them, first partial, then total, until, having lost all conscience of them, they have had a door opened unto all sin and licentiousness, and so to a full and utter apostasy.

Owen said he was convinced that among believers, there were two common ways of backsliding. The first was from a great or notorious sin that bloodied their consciences, tainted their affections or and intercepted all delight of having anything more to do with God. The second was from weariness in contending against “the powerful aversation, which they found in themselves.” The reason for all of this is, that giving way to the law of sin in the least is giving strength to it. Leaving it alone lets it grow. Failure to conquer it, is to be conquered by it.

The best way to prevent the fruits and effects of this aversation is to stay in a universally holy frame of mind. It is impossible to keep the heart in a holy frame of mind for one duty, unless it is done for all of them. “A constant, even frame and temper in all duties, in all ways, is the only preservative for any one way.” Strive to prevent the beginnings of this aversation. Guard against temptations; oppose them. Strive to possess your mind with the beauty and excellency of spiritual things, and so this cursed aversation of sin will be weakened.

As an aside, Owen suggested his readers develop a humble awareness of the presence of this aversation to spiritualness present in our nature. If someone were to recognize its efficacy, what consideration can, be more powerful, to bring them unto humbly walking with God?” Since God delights to dwell with individuals who are “of an humble and contrite spirit,” so it can be effective in weakening the remaining sin within us.

In closing the chapter, Owen urged that we labor to occupy our minds with the beauty and excellency of spiritual things, so that “this cursed aversation of sin” can be weakened. “Let, then, the soul labour to acquaint itself with the spiritual beauty of obedience, of communion with God, and of all duties of immediate approach to him, that it may be filled with delight in them.”

09/15/17

Dysfunctional fMRIs

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Neuroscientists at Dartmouth placed a subject into an fMRI machine to do an open-ended mentalizing task. The subject was shown a series of photographs depicting human social situations with a specific emotional reaction. The test subject was to determine what emotion the individual in the photo must have been experiencing. When the researchers analyzed their fMRI data, it seemed like the subject was actually thinking about the pictures. What was unusual about this particular fMRI study was that the subject was a dead Atlantic salmon.

Craig Bennett and other researchers wrote up the study to warn about the dangers of false positives in fMRI data. They wanted to call attention to the need to improve statistical methods in the field of fMRI research. But Bennett’s paper was turned down by several publications. However, a poster on their work found an appreciative audience at the Human Brain Mapping conference and neuroscience researchers began forwarding it to each other. The whimsical choice of a test subject seems to have prevented publication of the study, but it effectively illustrated and important point regarding the potential for false positives in fMRI research. The discussion section of their poster said:

Can we conclude from this data that the salmon is engaging in the perspective-taking task? Certainly not. What we can determine is that random noise in the EPI time series may yield spurious results if multiple comparisons are not controlled for. Adaptive methods for controlling the FDR and FWER are excellent options and are widely available in all major fMRI analysis packages.  We argue that relying on standard statistical thresholds (p < 0.001) and low minimum cluster sizes (k > 8) is an ineffective control for multiple comparisons. We further argue that the vast majority of fMRI studies should be utilizing multiple comparisons correction as standard practice in the computation of their statistics.

According to Alexis Madrigal of Wired, Bennett’s point was not to prove that fMRI research is worthless. Rather, researchers should use a set of statistical methods known as multiple comparisons correction “to maintain most of their statistical power while keeping the danger of false positives at bay.” Bennett likened the fMRI data problems to a kind of darts game and said: “In fMRI, you have 160,000 darts, and so just by random chance, by the noise that’s inherent in the fMRI data, you’re going to have some of those darts hit a bull’s-eye by accident.” So what, exactly, does fMRI measure and why is understanding this important?

The fundamental basis for neural communication in the brain is electricity. “At any moment, there are millions of tiny electrical impulses (action potentials) whizzing around your brain.” When most people talk about ‘brain activity,’ they are thinking about the activity maps generated by functional magnetic resonance imaging (fMRI). Mark Stokes, an associate professor in cognitive neuroscience at Oxford University said fMRI does not directly measure brain activity. Rather, fMRI measures the indirect consequences of neural activity, the haemodynamic response, which permits the rapid delivery of blood to active neuronal tissues. This indirect measurement is not necessarily a bad thing, if the two parameters (neural activity and blood flow) are tightly coupled together. The following figure from “What does fMRI Measure?” illustrates the pathway from neural activity to the fMRI.

A standard fMRI experiment generates thousands of measures in one scan (the 160,000 darts in Bennett’s analogy), leading to the possibility of false positives. This wealth of data in an fMRI dataset means that it is crucial to know how to interpret it properly. There are many ways to analyze an fMRI dataset, and the wealth of options may lead a researcher to choose one that seems will give him or her the best result.  The danger here is that then the researcher may then only see what they want to see.

Anders Ecklund, Thomas Nichols and Hans Knutson said that while fMRI was 25 years old in 2016, its most common statistical methods have not been validated using real data. They found that the most commonly used software packages for fMRI analysis (SPM, FSL, AFNI) could result in false positive rates up to 70%, where 5% was expected. The illusion of brain activity in a dead salmon discussed above was a whimsical example of a false positive with fMRI imaging.

A neuroscientist blogging under the pen name of Neuroskeptic pointed out that a root problem uncovered by Ecklund’s research is spatial autocorrelation—“the fact that the fMRI signal tends to be similar (correlated) across nearby regions.” The difficulty is well known and has software tools to deal with it, but “these fixes don’t work properly.”  The issue is the software assumes the spatial autocorrelation function has a Gaussian shape, when it fact, it has long tails, with more long-range correlations than expected. “Ultimately this leads to false positives.” See Neuroskeptic’s article for a graph illustrating this phenomena.

There is an easy fix to this problem. Ecklund and colleagues suggested using non-parametric analysis of fMRI data. “Software to implement this kind of analysis has been available for a while, but to date it has not been widely adopted.” So there is still value in doing fMRI research, but a proper analysis of the dataset is crucial if the results are to be trusted.

Neuroskeptic also discussed an analysis of 537 fMRI studies done by Sprooten et al. that compared task-related brain activation in people with a mental illness and healthy controls. The five diagnoses examined were schizophrenia, bipolar disorder, major depression, anxiety disorders and obsessive-compulsive disorder (OCD). The analysis showed very few differences between the disorders in terms of the distribution of the group differences across the regions of the brain. “In other words, there was little or no diagnostic specificity in the fMRI results. Differences between patients and controls were seen in the same brain regions, regardless of the patients’ diagnosis.”

Sprooten et al. speculated that the disorders examined in their study arose from largely overlapping neural network dysfunction. They cited another recent meat-analysis by Goodkind et al. that also found “shared neural substrates across psychopathology.” Sprooten et al. said: “Our findings suggest that the relationship between abnormalities in task-related networks to symptoms is both complex and unclear.”

Neuroskeptic didn’t think there was a need to assume this transdiagnostic trait was an underlying neurbiological cause of the various disorders. He wondered if something like anxiety or stress during the fMRI scan could have been captured by the scan.

It’s plausible that patients with mental illness would be more anxious, on average, than healthy controls, especially during an MRI scan which can be a claustrophobic, noisy and stressful experience. This anxiety could well manifest as an altered pattern of task-related brain activity, but this wouldn’t mean that anxiety or anxiety-related neural activity was the cause of any of the disorders. Even increased head movement in the patients could be driving some of these results, although I doubt it can account for all of them.

A paper in NeuroImage by Nord et al. commented how numerous researchers have proposed using fMRI biomarkers to predict therapeutic responses in psychiatric treatment. They had 29 volunteers do three tasks using pictures of emotional faces. Each volunteer did the tasks twice one day and twice about two weeks later. While the grouped activations were robust in the scanned brain areas, within-subject reliability was low. Neuroskeptic’s discussion of the study, “Unreliability of fMRI Emotional Biomarkers,” said these results could be a problem for researchers who want “to use these responses as biomarkers to help diagnose and treat disorders such as depression.”

Neuroskeptic asked one of the researchers if it was a “real” biological fact that activity in the brain areas studied actually varied within subject, or was the variability a product of the fMRI measurement? He didn’t know, but thought it wasn’t simply a measurement issue. He also thought it was perfectly possible “that the underlying neuronal responses are quite variable over time.”

Grace Jackson, a board certified psychiatrist, wrote an unpublished paper critiquing how fMRIs and other functional brain scans are being presented to the public as confirming that psychiatric disorders are real brain diseases. She pointed out the failure of media discussions to point out that functional imaging technologies, like fMRI, “are incapable of measuring brain activity.” They assess transient changes in blood flow. She also commented on the existing controversy of using this technology for diagnosis. “Due to theoretical and practical limitations, their application in the field of psychiatry is restricted to research settings at this time.”

She said even if abnormal mental activity could be objectively defined and reliably determined, “it remains unclear how any functional imaging technology could differentiate the brain processes which reflect the cause, rather than the consequence, of an allegedly impairing trait or state. She concluded with a quote from a position paper drafted by the American Psychiatric Association that said imaging research cannot yet be used to diagnose psychiatric illness and may not be useful in clinical practice for a number of years. “We conclude that, at the present time, the available evidence does not support the use of brain imaging for clinical diagnosis or treatment of psychiatric disorders…”

No current brain imaging technology, including fMRI, can be used to diagnose or treat psychiatric disorders. fMRI technology does not directly measure neural activity and has a demonstrated tendency to generate false positives, especially if the statistical analysis of the fMRI dataset is done incorrectly. Given the limitations of functional imaging technology, it is unclear how fMRI—or any other functional imaging technology—will be able to clearly distinguish between brain activity that causes an impaired neural trait or state, and brain activity that is a consequence of an impaired neural trait or state. And yet fMRI scans are presented to the public, by some individuals, as measuring brain activity and proving the existence of some psychiatric disorders. In their hands fMRI technology has become dysfMRI: dysfunctional MRI technology.

09/12/17

Trouble in Plumas County

© Natallia Yeumenenka | 123rf.com; “Plumas” is Spanish for feathers.

Situated in the Sierra Nevada region of California, Plumas County is an attractive recreational destination for a wide variety of activities, including boating, camping, fishing, hiking, skiing, hunting and others. The Explore Plumas County webpage says it is “a Wilderness of Wonders,” where the wilderness is untouched. “Natural beauty is etched in the snow-capped peaks and towering pines.” It is said to be a four-season travel destination with fresh mountain air and pristine, blue waters. You are encouraged to explore the mountain ranges and wilderness, where there is “something new to discover with each experience”—including illegal marijuana growers.

I’m not a resident of Plumas County. But as I was completing another article (“Pot Market Getting a ‘Black’ Eye”) on the problems with how the expanding recreational marijuana has helped the black market for marijuana to flourish instead of weakening it, I ran across the current debate over marijuana in Plumas County. Looking closer at the issues in this small, rural county helps to illustrate some of the problems that come with the political and cultural pressures to legalize marijuana.

The photos on the Explore Plumas County webpage are seductively beautiful. I want to go visit; maybe for a very long time. The county is in the northern end of the Sierra Nevada range. The entire county population is only 20,007, as of the 2010 census. But Plumas County is in the midst of a political and culture war over whether or not there should be a greater presence of marijuana in the county. Cannabusiness Law noted currently there is a ban on the retail sales of marijuana as well as manufacturing. Current zoning codes do not permit commercial marijuana growing, but the codes are under review. The webpage also provides you with information to contact local officials and let them know you oppose the bans … or approve them, I’d add.

On November 8, 2016, California voters approved Proposition 64, the Adult Use of Marijuana Act (AUMA). Beginning in 2018, it allows “the sale of marijuana for adult use in licensed stores under regulations to be established by the state Dept. of Marijuana Control (DMC) in conjunction with local governments.” The possession and use of up to one ounce of marijuana (or 8 grams of concentrates) and personal use cultivation of up to six plants is also legal. It also reduces fines for most illegal cultivation, sale, transport and possession for sale offenses from felonies to misdemeanors—with possible exceptions for violent or repeat offenders. See the California NORML website for the following quote and more information on Proposition 64 and other California marijuana laws.

Commercial sale, cultivation, and production of marijuana are allowed only by licensed providers. Illegal sale, transport, manufacture, cultivation, or possession with intent to sell are generally punishable as misdemeanors, with felony enhancement allowed for special circumstances and three-time offenders. Minors under 18 are in no case subject to imprisonment, but may be punished by drug education and community service.

Medical marijuana has been legal in California since 1996 with Proposition 215, the Compassionate Use Act. And it is because of the fallout from that change that many of the current problems in Plumas County have occurred. The Los Angeles Times reported that four weeks before the 1996 general election where Proposition 215 was approved, Senator Diane Feinstein said “you’ll be able to drive a truckload of marijuana through the holes in it.” The devil is in the details, and she said this particular bill lacked details. Nevertheless, the assessment of the author of the LA Times article was it had been an incredible success, despite its vague wording and instances of abuse. Read on before you accept that statement.

After the approval of Proposition 215, the cultivation of marijuana took off in the so-called Emerald Triangle, consisting of the counties of Mendocino, Humboldt and Trinity, along the northern coast of California. Plumas County is on the opposite, eastern side of the state, at the same latitude as the Emerald Triangle counties. The Emerald Triangle has been estimated to produce 60% of America’s marijuana. As was noted above, Plumas County previously banned the retail sales and manufacturing of marijuana, and had zoning restrictions for the cultivation of marijuana. Nevertheless there have been serious problems with illegal activities involving marijuana within the county.

In July of 2015, Plumas County authorities reported that along with Forest Service law enforcement, they recovered about 23,000 marijuana plants at two separate locations. The estimated value of the plants was in excess of $10 million. Officers from Plumas County SWAT, the Forest Service and California Fish and Wildlife took part in the eradication raids. Two suspects were encountered near one site, but they avoided capture in the brushy steep terrain. Residents were encouraged to contact authorities if they saw any signs of marijuana gardens, such as drip lines, gardening tools, bags of fertilizer or pesticides, trash piles or remote campsites.

In August of 2016, John Bartell reported for KXTV how the Plumas National Forest was plagued with illegal grows. Reportedly, teams were finding illegal grows on a weekly basis. One local cattle rancher said he lived next to an illegal marijuana grow. “They had pit bulls running free and they attacked 2 cows and bit their ears off.” A Plumas County detective said they regularly encounter a number of individuals who are not residents of the United States cultivating the gardens. Often they turn out to be Mexican nationals. “Some are out here for 3 or 4 months and are promised $10,000 or $20,000 to grow.” There have been instances of hunters wandering into fields where they were killed. Safety in the Plumas National Forest is now a serious concern.

This is not simply an isolated problem for Plumas County. In Yosemite National Park, park rangers are regularly discovering and destroying large marijuana growing operations, attributed to the same Mexican cartels. Here is a video report on this problem from the Travel Channel. A park ranger is quoted as saying the park has had several marijuana growing plantations located within its borders. Some of these growing plantations have been worth as much as $14 million. “These are not simply a few people that want to have a garden and grow something for their use.”

There is a “Plumas People Opposed to Commercial Cannabis” Facebook page with multiple articles describing issues from the illegal marijuana grows. Banned pesticides are showing up in California water. A Reuters article, appearing on US News & World Report, noted toxic chemicals from illegal marijuana farms are found in California’s rivers and streams feeding the state’s water supply. The chemicals have turned thousands of acres into toxic waste dumps. Law enforcement officers who have inadvertently touched plants and equipment have been hospitalized. ”Scores of animals have died.”

A New York Times article noted that despite the promise of a legal market, many growers are not signing up. Hezekiah Allen, the executive director of the California Growers Association, estimated only about 11% of growers in the Emerald Triangle have applied for grow permits. The paperwork to obtain a permit, the fees and the taxes are given as reasons for not doing so. Lori Ajax, the chief of California’s Bureau of Cannabis Control said there are folks who have been operating for a long time with minimal local oversight or no oversight at all. She thought it was going to take some strong enforcement to bring people into the regulated market.

California, which by one estimate produces seven times more marijuana than it consumes, will probably continue to be a major exporter — illegally — to other states. In part, that is because of the huge incentive to stay in the black market: marijuana on the East Coast sells for several times more than in California.

The drastically reduced legal consequences in Proposition 64 for most of the illegal offenses related to the cultivation, sale, transport and possession of illegal marijuana from felonies to misdemeanors, at least for the first couple of offenses, means there is very little motivation for illegal growers to enter the legal market. The Mendocino County district attorney said people living in the urban centers of California, like San Francisco, Los Angeles, and San Diego don’t realize the crime rate in the rural areas where marijuana is being grown.

Among the cases he is handling are a robbery and slashing death of a grower; the murder of a man at a marijuana farm by a co-worker wielding a baseball bat; an armed heist in a remote area by men who posed as law enforcement officers; and a robbery by two men and a juvenile who were invited to a barbecue and then drew guns on their hosts and fled with nine pounds of marijuana.

There was a meeting of the Plumas County Cannabis Working Group on the afternoon of Thursday, September 7th, 2017. The Facebook page for the Plumas People Opposed to Commercial Cannabis Facebook page related some of the concerns expressed by residents. One concerned resident noted how the drafted ordinance document was written by a pro commercial growing committee, “whose members stand to make large amount of money.” She also raised the issue of the potential environmental impact of water, pesticides and drainage into their creeks and rivers. Another person during the meeting raised a concern that approving commercial grow operations would lead to less county and/or state support to address the anticipated increase in local crime. A pro grower responded by saying high fences, guard dogs and private security forces would keep criminals in check. The concerned individual responded: “Yes, that’s JUST what we want here.”

In an open letter to the Plumas County Supervisors, another Plumas county resident noted how some individuals said the best way to improve Plumas County was to bring in the anticipated influx of cash from approving commercial growing. “They urge us to look for the money, trust them for a higher standard of character and compliance than has been reported elsewhere, and trust the free market.” But that isn’t happening in other areas. See “Pot Market Getting a ‘Black’ Eye.”

Another resident also voiced her concerns that every member of the Cannabis Work Group was someone in favor of commercial cultivation. The Work Group was “not a balanced representation.” She noted where the issue of odor was minimized. See the above linked New York Times article for a report that a police reconnaissance helicopter could smell pungent marijuana plants from 800 feet above an illegal grow. Concerns over an increase in crime, homelessness and changes in the community culture have been largely unanswered, she said.

credit: Sierra REC Magazine

People move to or visit Plumas County for the natural beauty, rural lifestyle, recreational opportunities, the mountain air, the open vistas, to raise families, to escape the culture and crime of the city. All of these would be changed in some degree by widespread cannabis cultivation. High fences would predominate, along with heavily secured tall hoophouses. The oft-referenced Mexican Cartels are unlikely to simply pack their suitcases and go home; what will they do here instead? Who will buy up properties and small farms and lease acreage for this lucrative crop? What large commercial interests may impact land use, local politics, ecological concerns, the small town culture? How does greed divorced from responsible citizenship change a community?

The decision on commercial marijuana growing in Plumas County isn’t finalized yet. The next scheduled meeting of the Cannabis Working Group is Thursday September 14th, starting at 10 AM PDT. There are a number of issues it seems; these are only a few. Will the façade of an unbalanced work group be addressed? What about the impact on local crime and the environment? If this is supposed to bring money into the county, how will that work when already California produces multiple times the amount of cannabis that can be consumed in the state? And it will be illegal to send any cannabis grown in Plumas County out-of-state. Doesn’t that set the county residents up for an explosive increase in illegal grows if commercial marijuana growth is approved? That is what happened in Colorado, which was better prepared enforcement-wise for recreational marijuana than California seems to be.

I live in Allegheny County, Pennsylvania, in a township whose population in the 2010 census was over 8,000 more than the entire population of Plumas County. My home state approved the Pennsylvania Marijuana Act (for medical marijuana) on April of 2016. There aren’t any dispensaries open yet; the state has just begun to register practitioners. In June of 2017 twelve companies were awarded growing licenses, including one in western PA fronted by Jack Ham, a former linebacker for the Pittsburgh Steelers. Growing will only be done in warehouses.

The only types of medical cannabis allowed initially are pills, oils, gels, creams, ointments, tinctures, liquid, and non-whole plant forms for administration through vaporization. Given the issues noted above in Plumas County and other counties in California, I hope residents of my home state will work together, as the residents of Plumas County are currently doing, to prevent similar concerns from developing in Pennsylvania. Residents of other states that have started down the road to legalization, be forewarned and learn from the current trouble in Plumas County.

If you sympathize with those Plumas County residents opposed to commercial marijuana growth in their county, give them some encouragement on the “Plumas People Opposed to Commercial Cannabis” Facebook page.

09/8/17

Pot Market Getting a “Black” Eye

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On April 3, 2017 the governors of four states with legalized recreational marijuana—Alaska, Colorado, Oregon and Washington—sent a letter to Attorney General Jeff Sessions. They asked that the Trump administration “engage” with them before making any changes to the existing federal regulatory and enforcement systems. Their particular concern was potential revision to the “Cole Memo,” an Obama-era policy that attempted to strike a balance between federal interests and state sovereignty in the growing legalization of marijuana. The governors said the Cole Memo provided guidance to the foundation of state regulatory systems and was “vital to maintaining control over marijuana in our states.” They warned that overhauling it could produce unintended consequences such as diverting “existing marijuana product into the black market and increase dangerous activity in both our states and our neighboring states.”

On July 24, 2017, Attorney General Sessions replied individually to the governors who signed the April 3rd letter. You can review copies of the letters sent to Governor Brown of Oregon and Governor Inslee of Washington. Each letter pointed to documents from the respective states that raised serious questions about the efficacy of marijuana “regulatory structures” in that state. He then directed their attention to the concluding paragraph of the memo that said it “does not alter in any way the Department’s authority to enforce federal law, including federal laws relating to marijuana, regardless of stat law.”

Among the specific concerns for Oregon Sessions highlighted was that only 30% of the marijuana market in Oregon was compliant with state marijuana laws. There was a “pervasive illicit cannabis cultivation in the state,” which was trafficked out-of-state. Law enforcement was said to be unable to keep pace with out-of-state diversion. “The reality of legalization is that it has provided an effective means to launder cannabis products and proceeds.” Individuals were said to be exploiting legal mechanisms to obscure their products’ origin and their true profits.

Among the concerns he highlighted for Washington was the lack of regulation and oversight of the medical marijuana market has “unintentionally” led to a growth of the black market. “Since legalization in 2012, Washington State marijuana has been found to have been destined for 43 different states.” The recreational marijuana market is incompletely regulated. One of the leading regulatory violations has been the failure to use and/or maintain the traceability of marijuana products.

Writing for The Washington Post, Christopher Ingraham said the Sessions’ letter indicated he remained deeply skeptical of efforts to legalize recreational marijuana. But for now, Justice Department actions will be dictated by the Cole Memo. Federal non-interference seems to hinge on whether there is evidence of a public health or safety threat. John Hudak, a drug policy expert with the Brookings Institution, said the Sessions letter is an important indicator that Sessions is serious about enforcing marijuana law under the Cole Memo. He also expressed concerns with the accuracy of the data Sessions cited. He said reports compiled by law enforcement authorities were “notorious for cherry-picking data and failing to put data into context.” He suggested the Attorney General was drawing conclusions on incomplete data or data taken out of context.

Reporting for the Associated Press, Andrew Selsky said Governor Brown responded to Attorney General Sessions, noting the document he cited to her on Oregon marijuana problems was invalid and had incorrect data and conclusions. She went on to say new laws, including the tracking of all marijuana grown for legal sale, will help cut down on diversion into the black market. She added that she had recently signed legislation making it easier to prosecute the unlawful import and export of marijuana products. A Washington state official similarly said Sessions made claims about the situation in the state of Washington that were “outdated, incorrect, or based on incomplete information.”

Pause for a moment here. There isn’t denial that diversion occurs, just that the data the reports were based on was incorrect, outdated, incomplete. The thinking seems to be that more legalization will lessen the black market problem. Oregon Congressman Earl Blumenauer said: “”The more that we go down the path of legalization, regulation and taxation, diversion becomes less and less of a problem.” But is this just wishful thinking, rhetoric expressed to encourage the ongoing march towards nationwide legalization?

In a different article, Selsky noted the movement in several states, including Oregon, Colorado and California to implement tracking systems for marijuana and marijuana products. “The tracking system is the most important tool a state has,” according to Michael Crabtree. But as the systems rely on user honesty, they aren’t fool-proof. ““We have seen numerous examples of people ‘forgetting’ to tag plants.”

In California, recreational pot sales become legal in January of 2018. The Emerald Triangle area of northern California is the largest cannabis-producing region in the U.S. It is estimated to produce 60% of America’s marijuana. Although growers have been cultivating marijuana in the area since the 1960s during San Francisco’s Summer of Love, the industry really took off when Proposition 215 legalized medical marijuana in 1996.

Senator Mike McGuire, who represents the Emerald Triangle region, thought California’s tracking program would help limit the cannabis black market. But implementing a fully operational legal market in California could take years. “In the first 24 months, we’re going to have a good idea who is in the regulated market and who is in the black market.”

Anthony Taylor is a licensed marijuana processor and lobbyist. But as far back as the 1970s, he was growing cannabis illegally in an area east of Portland. He said it is easier to grow marijuana illegally these days because authorities don’t have the resources to uncover every operation. Growers who risk selling outside the state can earn thousands of dollars per pound, according to Taylor.

The Los Angeles Times reported that Hezekiah Allen, the executive director of the California Grower’s Association, warned that California growers are in for a “painful downsizing curve” when new laws go into effect in January of 2018. “We are producing too much.” He estimated the state cannabis growers produce eight times the amount of marijuana the citizen’s of the state can consume. He expects that some growers will stay in the black market and continue to illegally send marijuana to other states. Some growers may stop growing cannabis, but he expects others simply just won’t apply for state permits.

Lori Ajax, chief of California’s Bureau of Medical Cannabis Regulation said: “For right now, our goal is to get folks into the regulated market, as many as possible.” But, “There are some people who will never come into the regulated market.”

A Denver Grand Jury indicted 62 people and 12 businesses for operating the largest illegal marijuana uncovered in Colorado since Colorado legalized recreational marijuana in 2012. The drug bust, known as Operation Toker Poker, executed almost 150 search warrants at 33 homes and 18 warehouses and storage units in Denver. Seizures included 2,600 illegally cultivated marijuana plants and 4,000 pounds of marijuana. The ring operated from 2012 to 2016 and brought in an estimated $200,000 a month. The operation produced more than 100 pounds of cannabis monthly and shipped it to Kansas, Texas, Nebraska, Ohio, Oklahoma and other states.

Read original articles on Operation Toker Poker here at: The Denver Post, U.S. News, and the Daily Mail.

The DEA and State Patrols for Kansas and Nebraska participated in the investigation. Barbara Roach, special agent in charge of the DEA’s Denver field office, said since 2014 there has been an influx of organized criminal groups coming to Colorado in order to produce marijuana to sell in other states. “The marijuana black market has increased exponentially since state legalization.” Colorado Attorney General Cynthia Coffman said: “The black market for marijuana has not gone away since recreational marijuana was legalized in our state, and in fact continues to flourish.”

Andrew Freedman, a cannabis regulation consultant, said he is hopeful that state legislation passed in 2017 will make it more difficult for criminal to grow quantities of marijuana for the so-called “gray market,” while using a legal interest in the business as a cover. “

 I do think the experiment is under the microscope, . . . Anything negative that happens will be a national story. This was a weakness in our system, and I’m hopeful the legislation shores up that weakness, but it is something the story will be judged on.

So it seems the expectation that ongoing legalization of recreational marijuana will make diversion less of a problem is wishful thinking. It may even be rhetoric to calm the fears of individuals who are unsure about where they stand on the issue. What does seem clear from the information above is that legalizing recreational marijuana in Colorado hasn’t made diversion go away; and officials seem to think it has been “flourishing.” At least one California official expects state regulation will not be followed by all the instate cannabis growers when the new laws go into effect. Even cannabis supporters acknowledge there will be a time lag of perhaps years before the regulatory machinery can get a handle on illegal cannabis growers.

09/5/17

Darwin’s Conversion: Not

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Surrounded by family members and in the arms of his loving wife Emma, Charles Darwin died on Wednesday, April 19, 1882. Among his last spoken words was a statement that he was not “the least afraid to die.” Darwin’s hope, and the family’s original intention, was for him to be buried in the family vault in St. Mary’s church at Downe. History intervened, and Charles Darwin was instead interred in Westminster Abbey on the morning of April 26, 1882—not far from the resting place of Sir Isaac Newton. Ironically, although Darwin indentified himself as an agnostic, and said he had rejected Christianity at the age of forty, within two weeks of his burial, there was a sermon preached in Wales saying that Darwin had, “in his last utterances confessed his true faith.” The problem is, it wasn’t true.

Dearman Birchall, his wife and their four children had taken a holiday at the southern Wales resort town of Tenby. On May 7th they head a minister named Huntingdon preach a sermon in which: “He spoke of Darwin one of the greatest thinkers who had in his last utterances confessed his true faith.” The quote was from a diary entry, and can be found in The Darwin Legend, by James Moore. There were other scattered rumors of a deathbed conversion by Darwin over the next three decades, including an 1887 sermon in Toronto by the Reverend John Mutch. This led a reporter for the Toronto Mail to write to Darwin’s close friend and supporter, Thomas Huxley to confirm the truth of Mutch’s statement. Huxley’s reply, on February 12, 1887 follows:

I have the best authority for informing you that the statement which you attribute to the Revd Mr. Mutch of Toronto that “Mr Darwin, when on his death bed, abjectly whined for a minister and renouncing Evolution, sought safety in the blood of the Saviour” is totally false and without any kind of foundation.

Huxley consulted Darwin’s son Francis, who gave Huxley permission to reply to the reporter, denying any deathbed conversion of his father. Yet the question is how such a rumor could have arisen and been repeated by a minister so far away from Darwin’s home in Downe. James Moore convincingly demonstrated the likely source was a British evangelist active in the temperance movement, named Elizabeth Cotton, who became Lady Hope in 1887 when she married Sir James Hope. She reported meeting Darwin in the autumn of 1881, about six months before his death.

However the story of their meeting did not appear in print for thirty-four years. Moore speculated that if this encounter was the origin of all the post-1882 deathbed stories of Darwin’s conversion, it was spread initially by word of mouth among English evangelicals and their American connections. John Mutch could then have heard the story from someone in those circles and repeated it in his 1887 sermon. “Whatever the case, there is no doubt that Lady Hope was making discreet comments about Darwin to her religious friends long before the story was published.”

In August of 1915 Lady Hope was in East Northfield Massachusetts for the annual conference at Northfield Seminary, the girl’s preparatory school founded by D. L. Moody. She approached one of the speakers, A. T. Robertson, and told him her story of Darwin’s conversion. Robertson then repeated it when he next spoke. An editor from the Watchman-Examiner was there and insisted Lady Hope write the story out so he could publish it, giving it “the widest publicity.” Two weeks later, the Watchman-Examiner carried her story under the title, “Darwin and Christianity.”

In The Darwin Legend, Moore quoted the entire story, which can also be found in the Wikipedia entry for “Elizabeth Cotton, Lady Hope.” The story went “viral,” to use a modern idiom, with over fifty known texts identified by James Moore that repeated the Lady Hope legend through 1993, when he published his book. The story happened to take place in the midst of the anti-evolution crusade involving William Jennings Bryan and the “monkey trial” of 1925. See “Structure of an Evolutionary Revolution” for more on Bryan and the Scopes Trial. Bryan did not repeat the story even though he knew of it, saying that using it would only aid the other side in the fight against evolution. But that did not deter others.

Members of Darwin’s family repeatedly and vehemently denied Lady Hope’s story. Darwin’s son Francis, who edited The Life and Letters of Charles Darwin, including an Autobiographical Chapter, in 1887, wrote Huxley in 1887 about the Toronto Mail reporter. He said: “By all means answer as you propose. You have my authority that the statement is false and without any kind of merit.” Francis wrote at least three letters after the Lady Hope story was published denying its veracity. In a letter to the secretary of the Protestant Press Bureau, on May 28, 1918, Francis said:

Lady Hope’s account of my father’s views on religion is quite untrue. I have publically accused her of falsehood, but I have not see a reply. My father’s agnostic point of view is given in my “Life and Letters of Charles Darwin,” Vol. I., pp. 304-317. You are at liberty to publish the above statement. Indeed, I shall be glad if you will do so.

Henrietta Darwin Litchfield, Darwin’s third daughter and the eldest daughter to reach adulthood, responded to an enquiry from the editors of The Christian, an interdenominational evangelical weekly, who asked her to confirm or deny the truth of a “highly-colored story . . . going the round of the American papers” about her father’s death-bed. If it was true, then many people would have been glad to learn that “some higher and deeper devotion claimed his soul.” If it wasn’t true, then “the facts should be known.” On February 23, 1922 in The Christian, Henrietta said:

I was present at his deathbed. Lady Hope was not present during his last illness, or any other illness. I believe he never even saw her, but in any case, she had no influence over him in any department of thought or belief. He never recanted any of his scientific views, either then or earlier. We think the story of his conversion was fabricated in [the] U.S.A. In most of the versions hymn-singing comes in, and a summer-house where the servants and villagers sang to him. There is no such summer-house, and no servants or villagers ever sang hymns to him. The whole story has no foundation whatsoever.

Lady Hope died in Sydney Australia on March 9, 1922. She had traveled there for medical treatment for breast cancer. Eighteen years after her death, a professor of biology, S. James Bole, published an undated letter he had received from her in the early 1920s, having promised to keep it private during her lifetime. He had written to her, “asking for the story.” She said Darwin heard she was in his village, holding meetings to discuss the Gospel and Temperance and asked if she would call upon him. She said when she arrived, he had a large Bible open before him to the book of Hebrews, which he said was “the Royal Epistle.” The contents of the letter to Bole are quite similar to the account Lady Hope gave in the Watchman-Examiner.

Darwin is supposed to have commented on some of the great Gospel truths to her, and how Christ was the King, Savior and Intercessor. When Lady Hope asked him about certain doubts that were raised about Creation from what he wrote,

He seemed greatly distressed, his fingers twitched nervously, and a look of agony came over his face as he said: “I was a young man with unformed ideas. I threw out queries, suggestions, wondering all the time over everything, and to my astonishment, the ideas took like wildfire. People made a religion of them.”

So she continued to tell her story until the day she died. But as Francis Darwin said, if his father had had an evangelical conversion experience in the last years of his life, surely that would have become known to his family. They have spoken and were quoted above as saying it never happened.

However, there is an outside chance that some kind of an encounter happened between Darwin and Lady Hope, but it would not have unfolded as she related in her story. Lady Hope was in Downe Village, near the Darwin estate, in September and possibly early October of 1881. Moore said: “The story, though imaginative, cannot be dismissed as pure invention. It contains striking elements of authenticity, to which Lady Hope added convincing new detail.”

For proprieties sake, she would not have met with him alone; and a likely third party would have been Darwin’s wife, Emma, who was well known for her own Unitarian faith. Before they married, his father, Robert Darwin, warned Charles that a husband should conceal his religious doubts from his wife so that she didn’t fear for his salvation. The younger Darwin ignored his father’s advice, revealing his doubts to Emma while they courted. When she was first pregnant, she wrote him that she didn’t feel she could say exactly what she wanted to him. What if she died in childbirth? Would he join her in heaven? It would be a nightmare “if I thought we did not belong to each other forever.”

Emma’s silence on the possibility of a conversion experience by her husband in the final months of his life speaks loudly to the fact that it did not happen. After her husband’s death, the family debated over whether a section of his autobiography, a private narrative originally written only for family members, should be published. In a section on religious beliefs Darwin had wondered how anyone “ought to wish Christianity to be true,” given its doctrine of everlasting punishment for unbelievers. For in those numbers would be his father, his older brother Erasmus, and almost all his best friends. Emma wrote to Francis, who was editing the Life and Letters, wondering how Charles’s religious friends would react to the sometimes-raw honesty of his thoughts. If there had been any legitimate reversal in Darwin’s agnosticism at the end of his life I think Emma would have insisted on its inclusion.

The autobiography was dismembered, the section on religious belief was removed to a separate chapter in the Life and Letters, and only “extracts, somewhat abbreviated,” were printed.

The unedited version of Life and Letters with Darwin’s clear rejection of many basic Christian beliefs would not be published until 1958, almost 100 years after Origin of the Species. Darwin’s unvarnished religious convictions were apparently more of a concern than his scientific ones.

09/1/17

Circle the Pfizer Wagons

© Darin Burks | 123rf.com

The U.S. Preventive Services Task Force (USPSTF) recommended that all adults, including pregnant women and women who have recently given birth, be screened in primary care settings for depression. The screening would be done by: general practitioners, family physicians, nurse practitioners or physician assistants. USPSTF said screening adults for depression in primary care settings was accurate, it was effective in relieving depressive symptoms and the likelihood of harm from screening and treatment was small. The problem is that over 60% of individuals diagnosed with depression in primary care did not meet the DSM criteria for major depressive disorder. This rises to 80% with individuals over 65.

Albert Siu and the USPSTF published “Screening for Depression in Adults” in the January 2016 issue of JAMA. The authors said: “The USPSTF found convincing evidence that treatment of adults and older adults with depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.” Commonly used screening instruments included the Patient Health Questionnaire (PHQ) in its various forms, as well as several others. But the USPSTF did not believe these instruments were getting as many false positives as noted above. “The accuracy of screening tests in the general adult population was established in the 2002 and 2009 USPSTF reviews and found to be convincing.”

Psychiatrist Vivek Datta pointed out the USPSTF guidelines did recommend that screening occurred when there were “adequate systems in place” for further evaluation and treatment. However, “55% of all US counties do not have a single mental health provider.” He noted that many of the symptoms screened for are nebulous and include “symptoms that are quite common in the general population and do not necessarily indicate a mental disorder requiring treatment.” They could represent the effects of a chronic medical problem. Moods are influenced by a variety of factors, such as our level of physical activity, what we eat, our financial security, alcohol and drug use, to name a few.

Symptoms of depression can occur as a result of lifestyle factors, substance use, medical illness, life events, interpersonal difficulties, and as a consequence of wider social policies. Comprehensive assessment frequently does not occur because of the lack of adequate services for those with mental health problems. The recommendation to screen all adults for depression ignores the social matrix in which depression occurs, will lead to further overdiagnosis and overtreatment of minor morbid mental states, and further overburden mental health services.

A Glut of Antidepressants” was published on August 12, 2013, in The New York Times. It mentioned an April 2013 study published in the journal Psychotherapy and Psychosomatics that found almost 62% of 5,639 individuals “who had been given a diagnosis of depression within the previous 12 months did not meet the criteria for major depressive episode.” Several other studies have reported that: “diagnostic accuracy is low in general practice offices.” The study’s lead author said: “The vast majority of individuals diagnosed with depression, rightly or wrongly, were given medication.” Doctors must resist the temptation “to take out the prescription pad and write down an antidepressant and hand it to the patient.”

The NYT article did indicate that not only are doctors prescribing more medication, their patients are demanding it more. I think this is a likely an outcome of the decision to permit direct-to-the-consumer advertising for pharmaceuticals in 1997. See “Pharma and Advertising” or “Not Everything is As It Appears” for more on this topic. If anything at all was done to “confirm” the patient’s or doctor’s impression that there was a depressed mood state, using a quick screening instrument seems likely given the short time period most patients spend with medical staff in a primary care setting.

James Davies, the co-founder of the Council for Evidence-Based Psychiatry, wrote “The Sedated Society,” where he commented on how a BBC radio program had failed to mention the problem with the PHQ-9 (mentioned above) and the GAD-7, which he said two of the most powerful questionnaires in the NHS (National Health Service). He said they have been used throughout the primary care system in the UK to assess whether or not a person has depression or anxiety. He said: “They set a very low bar for what constitutes having a form of depression or anxiety for which a drug should be prescribed.” He said the tens of millions of people who filled out these screening questionnaires don’t know that Pfizer Pharmaceuticals paid for their development and continues to hold the copyright for them. Their distribution throughout the NHS was paid for by Pfizer, which incidentally makes two of the most prescribed antidepressant and anti-anxiety drugs in the UK.

Although the BBC didn’t get Davies’s message out about the PHQ-9 and GAD-7, several news outlets did. At Vice, Hannah Ewens said “a few of us in the office” took the test, with everyone except one person got at least a score of mild depression. She personally scored within the “moderately severe depression” range, but doesn’t have depression at the moment. “If I have trouble sleeping ‘on several days’ or ‘nearly every day’ that bumps up my score significantly. And herein lies the problem: all of the indicators are symptoms of a modern lifestyle as well as signals of depression.” Ewens added that James Davies believes reliance on these questionnaires is becoming too commonplace because GPs don’t have the time to do proper interviews.

The Telegraph, another UK media outlet, echoed the Davies concern that the threshold for identifying possible depression was too low. Henry Bodkin noted that a PHQ chart was likely present in almost every GP consulting room over the last 20 years. He also said critics like Davies have said the GAD-7, also developed by Pfizer to screen for anxiety, sets the diagnosis bar too low. “These forms have a very low criteria for anxiety and depression. . . . Millions of people have filled them in and got medication, but did they know they were developed by Pfizer?”

Pfizer enlisted two “rock stars” in the field of psychiatric diagnosis to develop the PHQ-9 and GAD-7: Robert Spitzer and Janet Williams. Spitzer was the chairperson for the seminal changes incorporated into the DSM-III. Originally Williams was his text editor; later she became his wife and collaborator. Listen to an All Things Considered broadcast on Spitzer and the DSM, “The Man Behind Psychiatry’s Diagnostic Manual.”

In the September of 2001 issue of the Journal of General Internal Medicine, Kurt Kroenke, Robert Spitzer and Janet Williams published “The PHQ-9.” Their article examined “the validity of a brief, new measure of depression severity” called the PHQ-9. They concluded that data from their two studies provided “strong evidence for the validity of the PHQ-9 as a brief measure of depression severity.” Kroneke et al. also said brief measures were more likely to be used in the busy setting the typical medical practice. The brevity of the PHQ-9 was thought to make it “an attractive, dual-purpose instrument for making diagnoses and assessing severity of depressive disorders.” The Acknowledgements section said the development of the PHQ-9 was underwritten by an educational grant from Pfizer US Pharmaceuticals. Scrolling down further you’ll see:

From the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ). The PHQ was developed by Drs. Robert L. Spitzer, Janet BW Williams, Kurt Kroenke, and colleagues. . . . PRIME-MD is a trademark of Pfizer Inc. Copyright 1999 Pfizer Inc.

Then in the May 2006 issue of JAMA Internal Medicine, the same three authors introduced the GAD-7, a brief self-report scale to identify generalized anxiety disorder (GAD). Not surprisingly, they concluded: “The GAD-7 is a valid and effective tool for screening for GAD and assessing its severity in clinical practice and research.” They expected the GAD-7 to have “considerable utility in busy mental health settings and clinical research.” Once again is an acknowledgement that the development of the GAD-7 was underwritten by an unrestricted educational grant from Pfizer Inc.

If you want to see or use copies of these scales, Pfizer’s lawyers have been clearly involved in dialing back the company’s responsibilities if the scales don’t live up to their creator’s optimistic expectations. On the Pfizer website, on the “Terms of Use” page for the two scales, is the following. Pfizer said since the questionnaires relied on patient self-report, all responses should be verified by the clinician. A definitive diagnosis should be made on clinical grounds, “taking into account how well the patient understood the questionnaire, as well as other relevant information from the patient.” Diagnoses should rule out normal bereavement, Bipolar Disorder, and other potential causes of depressive symptoms. Then there is the following disclaimer. The “all caps” formatting is in the original.

PFIZER MAKES NO WARRANTIES OR REPRESENTATIONS OF ANY KIND AS TO THE ACCURACY, CURRENCY, OR COMPLETENESS OF THE INFORMATION ACCESSED AND USED THROUGH THIS WEB SITE.
YOU AGREE THAT ACCESS TO AND USE OF THE PHQ AND GAD-7 SCREENERS IS AT YOUR OWN RISK. PFIZER DISCLAIMS ALL WARRANTIES, EXPRESS OR IMPLIED, INCLUDING WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. NEITHER PFIZER NOR ANY PARTY INVOLVED IN CREATING, PRODUCING, OR DELIVERING THE PHQ/GAD-7 SHALL BE LIABLE FOR ANY DAMAGES, INCLUDING WITHOUT LIMITATION, DIRECT, INCIDENTAL, CONSEQUENTIAL, INDIRECT, OR PUNITIVE DAMAGES, ARISING OUT OF ACCESS TO, USE OF OR INABILITY TO USE THE PHQ/GAD-7, OR ANY ERRORS OR OMISSIONS IN THE CONTENT THEREOF.

The rhetoric about the GAD-7 and PHQ-9 and its variations related by their creators, Spitzer, Williamson and Kroneke seems to have been negated by Pfizer. Instead of the PHQ-9 being “an attractive, dual-purpose instrument for making diagnoses and assessing severity of depressive disorders” and the GAD-7 being “a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research,” Pfizer disclaimed all warranties expressed or implied for a particular purpose. Pfizer nor any party involved in creating the PHQ/GAD-7 will be liable for any damages from access or use of these questionnaires. Any users access and use the PHQ and GAD-7 does so “at your own risk.”

It seems that Pfizer circled their wagons to avoid any corporate liability coming from the use of these questionnaires despite the fact they paid for their development and continue to market them aggressively to general practitioners in the US and the UK. But the potential for the over diagnosis and over treatment of depression through the PHQ-9 has now reached a new height. Psychiatry Advisor reported in August of 2017 that Google announced whenever someone searches for ‘clinical depression,’ they have an option to take the PHQ-9. Google partnered with NAMI, the National Alliance on Mental Illness, to make depression screening with the PHQ-9 part of searching for ‘depression’ on the site. NAMI said: “We hope that by making this information available on Google, more people will become aware of depression and seek treatment to recover and improve their quality of life.”

So where did all that effort with the PHQ-9 and GAD-7 get Pfizer? Pfizer currently hold the rights to the brand rights for Xanax (alprazolam), an anti-anxiety drug, and Zoloft (sertraline), an antidepressant. Both have been available as generics for a number of years. And although The Telegraph article didn’t name Pfizer’s top selling antidepressant and anti-anxiety drugs in the UK, they must be the same two. Up-to-date yearly sales data for psychiatric drugs is hard to come by, unless you pay an organization like IMS for access to their sales data. But there is data available from 2013.

IMS Health listed the top 25 dispensed prescriptions in the US in 2013. Xanax and its generic, alprazolam, was the 13th most prescribed medication. Zoloft and its generic, sertraline, was the 18th most prescribed medication. Among the psychotropic medications listed they were number one and number three respectively. PsychCentral reported similar findings, with the added information that Xanax was the number one prescribed psychiatric drug in 2005, 2009, 2011 and 2013. Zoloft sank as low as the 4th most prescribed psychiatric drug in 2009 and the 3rd most in 2011.