11/21/17

Cunning, Baffling, Powerful

© Nico Smit | 123rf.com

Vincent Dole was one of the three physicians who originated methadone as a maintenance drug treatment for heroin addiction in the 1960s. Rather unexpectedly, he was asked to serve as a Class A, non-alcoholic, trustee for the General Service Board of Alcoholics Anonymous. He thought they had made a mistake so before accepting the position, he discussed his research into “chemotherapy for narcotic addiction” with executives of the A.A. Fellowship. They didn’t see any problem or conflict of interest with his appointment and Dr. Dole served as a trustee for A.A. for eleven years, from April of 1965 until April of 1975.

At one point in his tenure as a trustee, he served as a co-chair for the General Service Board. In his farewell letter to the A.A. GSO, printed in the August-September issue of Box 4-5-9, the newsletter from the General Service Office of A.A., he said he would always remain identified with A.A. “My heart is with the Fellowship.”

Like most in A.A., I have gained more in the association than I have been able to give. Especially, it has been a privilege to witness the power of love when focused and unsentimental. I have seen that: Salvation is found in helping others; help stems from knowledge, humility, compassion, and toughness; success is possible.My greatest concern for the future of A.A. is that the principle of personal service might be eroded by money and professionalism. Fortunately, most of the membership of A.A., especially the oldtimers, know that A.A. cannot be commercialized. It is not a trade union of professional counselors or an agency hustling for a budget. The mysterious wisdom of A.A. will discover how to cooperate in reaching out to sick alcoholics while maintaining its Traditions.

In a 1991 article he wrote for the journal Alcoholism, “Addiction as a Public Health Problem,” Dr. Dole said that throughout his time as a trustee he was puzzled by why he specifically was asked to serve. He ended by assuming he had been “brought in as a smoke alarm, a canary in the mine” to guard against “the Fellowship being distorted by aggressive person with dogmatic opinions.” Then, in the late 1960s, he believed a more specific reason emerged, not long before Bill W.’s death. An excerpt from that article is available here: “The Methadone/AA Link.”

A more specific answer, however, emerged in the late 1960s, not long before Bill’s death. At the last trustee meeting that we both attended, he spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many sheep who are lost in the dark world of alcoholism. He suggested that in my future research I should look for an analogue of methadone, a medicine that would relieve the alcoholic’s sometimes irresistible craving and enable him to continue his progress in AA toward social and emotional recovery, following the Twelve Steps. I was moved by his concern, and in fact subsequently undertook such a study.

Dr. Dole went on to say he unsuccessfully sought to find that analogue in his laboratory until it closed in 1991. But he thought the work had just begun. Other laboratories and investigators would continue to work on the analogue problem. “With the rapid advance in neurosciences, I believe that Bill’s vision of adjunctive chemotherapy for alcoholics will be realized in the coming decade.”

Since Dr. Dole made that optimistic prediction, several different medications have been used as a harm reduction strategy for individuals with alcohol dependence or alcohol use disorders. Two opioid antagonists, nalmefene and naltrexone and three drugs acting on the gamma-aminobutyric acid (GABA)ergic system (baclofen, acamprosate and toprimate) has been used formally or informally to reduce alcohol consumption or maintain abstinence. Recently in the journal Addiction, Palpacuer et al. did a meta-analysis of 32 double-blind randomized controlled trials of these five medications. The studies were published between 1994 and 2015, and had a combination of 6,036 patients between them. They concluded:

There is currently no high-grade evidence for pharmacological treatment to control drinking using nalmefene, naltrexone, acamprosate, baclofen or topiramate in patients with alcohol dependence or alcohol use disorder. Some treatments show low to medium efficacy in reducing drinking across a range of studies with a high risk of bias. None demonstrates any benefit on health outcomes.

There was no evidence of any significant reduction in serious adverse events or mortality. Studies that sought to assess the efficacy of these medications as maintenance drugs, similar to how methadone is used, “were inadequate to investigate” whether they reduced serious adverse events. “In addition, any pharmacological approach that might benefit patients by reducing their alcohol consumption might also harm them because of safety issues.” As a result, the researchers advocated for long-term mega-trials exploring health outcomes.

To conclude, our results suggest that no treatment currently has high-grade evidence for pharmacologically controlled drinking in the treatment of patients suffering from alcohol dependence or alcohol use disorders. At best, some showed low to medium efficacy in reducing drinking, but across a range of studies with a high risk of bias. Although based on all available data in the public domain, this meta-analysis found no evidence of any benefit of the use of drugs aiming for a controlled drinking strategy on health outcomes. We invite researchers and stakeholders to set up a coherent agenda to demonstrate that pharmacologically controlled drinking can be translated into genuine harm reduction for patients. From the clinical perspective, while this new approach is often presented as a ‘paradigm shift’ in terms of therapeutics, doctors and patients should be informed that the critical examination of the pros and cons of the evidence clearly questions the current guidelines that promote drugs in this indication.

Reporting for The Guardian, Sarah Boseley further noted that one of the reasons for the inconclusive findings in Palpacuer et al. was because of the high drop out rates in the studies. “So many people dropped out of the trials that 26 of the 32 studies – 81% of them – had unclear or incomplete outcome data.” The lead author for the study, Clément Palpacuer, said the report did not mean the drugs weren’t effective. “It means we don’t yet know if they are effective. To know that, we need more studies.” There have also been concerns raised about the drugs by some studies already.

Bosley cited Fitzgerald et al., a review of the trial evidence used to approve nalmefene for use in the NHS. The researchers said at best, there was only modest evidence of efficacy in reducing alcohol consumption. This was despite stacking the deck in how the data was analyzed for approval of the drug.

Important weaknesses in nalmefene trial registration, design, analysis and reporting hamper efforts to understand if and how it can contribute to treating alcohol problems in general practice or elsewhere. The efficacy of nalmefene appears uncertain; a judgement of possible limited efficacy in an unusually defined and highly specific posthoc subgroup should not provide the basis for licensing or recommending a drug.

There are issues noted with baclofen as well. A co-author of Fitzgerald et al. noted one French study raised concerns with the safety of baclofen, with more deaths in the treatment group (7 of 162) than the placebo group (3 of 158). A further study by France’s medicines safety agency drew attention to additional adverse effects: “In particular, the risk of intoxication, epilepsy and unexplained death [on the death certificate] increases with the dosage of baclofen.” See “Sure Cure for Drunkenness” and “A ‘Cure’ for Alcoholism” and “The End of Alcoholism?” Part 1, Part 2 and Part 3 for more concerns with baclofen and nalmefene.

Vincent Dole’s search for a methadone analogue or adjunctive chemotherapy for alcoholism is unlikely to be successful. As Carleton Erickson pointed out in The Science of Addiction, alcohol is different than other drugs. He said: “Unlike other drugs, alcohol has no specific receptor to activate in the brain.” Cocaine works on the dopamine transporter. Heroin and other opioids work on the opioid receptor; and marijuana works on the cannabinoid receptor. “Alcohol is known to affect the GABA receptor, the NMDA receptor, and probably others.”

There isn’t a hand-in-glove fit between a receptor and alcohol as there is with the opioid receptor and heroin or other opioids. So there isn’t a medication that can single handedly block alcohol as there is with heroin and other opioids. As Bill W. knew from personal experience, alcohol is cunning, baffling and powerful.

11/17/17

Evolutionary Wars

credit: Steve Cardino, from “The Lie: Evolution”

The cartoon image here portrays a war between Humanism and Christianity, where Humanism is founded on evolution and Satan, while Christianity is founded on creation and Christ. The castle of Christianity is starting to collapse as the castle of Humanism systematically attacks the rock of its foundation in the cartoon, creation. The Christian guns are ineffectively aimed either nowhere or at the balloons (issues) of humanism instead of it evolutionary foundation. The message it sends is clear: Christianity is in danger of losing the cultural war with Humanism because it isn’t attacking the Satanic foundation it’s based on, evolution.

The cartoon originally appeared in a 1987 book by Ken Ham titled: The Lie: Evolution. In “Creationism and Culture Wars,” Ted Davis said it has been the “signature icon” for Answers in Genesis (AiG), an organization founded by Ken Ham. Over time the image has been modified, as it reflected the ‘evolution’ of Ham’s and AiG’s thought. “Over time, I began to emphasize that believing in the creation account in Genesis means accepting God’s Word as the ultimate authority, and believing in the secular idea of evolution is to accept man’s word as the ultimate authority.”

In a 2002 version of the cartoon, the castle of Christianity was represented as being founded on six literal creation days equaling God’s authority, versus the millions of years equally man’s authority for the foundation of the humanism castle. In 2010, the foundations were “no longer creation vs. evolution or six days vs. millions of years, but ‘autonomous human reasoning”’ vs. ‘revelation/God’s word.’” See “Creationism and Culture Wars” for the images.

Although Ham’s signature icon is still very much alive, it has evolved into a more sophisticated new species that is better adapted to twenty-first century culture wars, in which biblical faith is increasingly seen as contrary to science and reason. Ironically, Ham’s ministry itself is a primary cause of that perception.

Ted Davis noted how Ken Ham echoes the belief of William Jennings Bryan in the early twentieth century, that evolution inevitably undermines Christian faith. Like Ham, Bryan represented his thought in a cartoon. He saw evolution as causing modernism and leading to “the progressive elimination of the vital truths of the bible.” Bryan’s cartoon has three modernists, a student, a minister and a scientist descending a staircase that represents a slippery slope stemming from “the progressive elimination of the vital truths of the bible.” The descent starts with evolution and ends with the scientist stepping from Agnosticism to Atheism.

credit: original cartoon by Ernest James Pace; photograph by Ted Davis

The “Descent of the Modernists” cartoon appeared originally in Bryan’s 1924 book, Seven Questions in Dispute, published the year before his death, which took place days after his participation in the infamous Scope Trial. See “’Conflict Between Science and Religion’” and “No Contest; No Victory” for more on Bryan.

Despite the parallels in their thinking about creationism and the culture, Davis noted that Henry Morris, not Bryan, had the greater influence on Ham’s thought. AiG refers to the late Henry Morris as ‘the father’ of the modern creationist movement. His book, The Genesis Flood (1961), was the beginning of the revival of creationist thought that faded from the church with the passing of Bryan and the retreat of fundamentalism from cultural engagement after the Scopes Trial. Davis noted that in another book by Morris, The Troubled Waters of Evolution (1974), he argued evolutionary thought could be traced back beyond the “evolutionary pantheists” of the ancient Greco-Roman world. True as far as that statement goes, Davis noted where “Darwin’s theory was immensely more sophisticated and far more plausible than any ancient theory—but Morris goes much further.”

Morris traced the origins of evolutionary thought back through all the religions of the world other than Christianity, Judaism and Islam. These are excluded because they are based on Genesis. All other religions are “evolutionary” religions, including: Buddhism, Hinduism, Taoism, Confucianism, Atheism and ‘liberal Christianity.’ He said that evolution itself is a religion. He does not mean Darwinian evolution, but belief in the idea that all things have arisen by innate processes in the universe: the belief that the universe had no beginning; that it is eternal. You can watch a YouTube video series of a talk Morris gave titled “The Troubled Waters of Evolution.” It is in five parts. If you watch Part 1, notice the parallels between the metaphor Morris uses of the “fruit tree” of evolution producing harmful philosophies and evil practices the humanistic “balloons” in Ken Ham’s cartoon.

But Morris goes back even further in his book, The Troubled Waters of Evolution, according to Davis. He attributes the origins of evolution with Nimrod and the Tower of Babel in Genesis 10:8-10. According to Morris, it was part of the pantheistic polytheism of Babel Connected with astrology, idolatry, and the worship of fallen angels. “It is therefore a reasonable deduction, even though hardly capable of proof, that the entire monstrous complex [of evolution] was revealed to Nimrod at Babel by demonic influences, perhaps by Satan himself.” Therefore, evolution is “the world-view with which the whole world has been deceived.”

That’s why the foundation of Ham’s humanism castle connects evolution with Satan—and why evolution gets blamed for social ills that plagued us long before Darwin was born and would still be prevalent today even if Darwin had never existed. Evolution becomes the scapegoat for many sinful behaviors, to such an extent that it is virtually equated with sin itself, or even seen as inherently Satanic. This is a profoundly unhelpful way of approaching historical and cultural aspects of evolution, and it fails entirely to explain why many people who utterly reject evolution commit the very sins that Ham connects with belief in evolution.

Despite the revisions over time to the AiG “signature icon,” its foundations have actually changed very little. For AiG, Christianity sits on the foundation of “Creation;” which means “6  (24 hour) Days” for creation is equivalent to God’s authority; and only this interpretation is true “Revelation in God’s Word.” On the other hand, Humanism sits on the foundation of “Evolution;” which wrongly believes in “millions of years” for creation according to human authority; making “human reason autonomous” from the revelation of God’s Word. In other words, respect for the authority of God’s Word requires an agreement with the AiG view of creation in six 24 hour days—and its companion doctrines of 6,000 years since the creation and a global Noachian Flood (See the AiG Statement of Faith). In contrast, Humanism and its issues rest on autonomous reason, manifested in allowing millions of years for creation and allowing evolution rather than creation to explain how the universe and humanity came into being.

Lastly, the warfare metaphor in the AiG “signature icon” was actually first used by John William Draper and Andrew Dickinson White in their books on the perceived conflict or “war” between science and religion at the end of the 19th century. Draper wrote History of the Conflict Between Religion and Science (1874) and White wrote History of the Warfare of Science with Theology in Christendom (1896). In the Preface of his book, Draper seemed to set conflict between religion and science on a foundation that was eerily similar to the 2010 AiG cartoon. “The history of Science is … a narrative of the conflict of two contending powers, the expansive force of the human intellect on one side, and the compression arising from traditionary faith and human interests on the other.”

Warfare or conflict rhetoric tempts us to see dichotomy where there may not be one. And when Christians use it to compare their understanding of a Biblical passage like Genesis 1 to alternative interpretations by other Christians (who also affirm the authority of Scripture), they need to be aware of the danger of imputing the rightful authority of Scripture onto their interpretation of the Biblical passage in question. It seems to me that is what has happened with Henry Morris and AiG.

11/14/17

Pharma’s Not Getting the Message

© Ioulia Bolchakova | 123rf.com

In response to rapidly increasing prescription drug prices and congressional inability or unwillingness to intervene, individual states are attempting to address the issue. While Californians approved a ballot initiative for recreational marijuana in November of 2016, state voters also turned down one aimed at curbing the high cost of prescription drugs. The California Drug Price Relief Act, or Proposition 61, sought to limit the state’s health programs from paying more than the U.S. Department of Veterans Affairs (VA), which receives the steepest discounts in the country, according to Reuters. Pharma companies lobbying against Proposition 61 spent $100 million to defeat it.

Proposition 61’s opponents, led by global drugmakers such as Pfizer Inc and Amgen Inc, spent around $106 million. They argued that it would benefit only 12 percent of Californians, while putting the other 88 percent, and veterans across the country, at risk of higher drug costs.

The defeat of the measure: “reaffirms the power of the biomedical lobby,” according to Brian Abrahams, a Senior Biotechnology Analyst at CIBC World Markets. Stuart Schweitzer, a professor of health policy and management at the University of California, said the measure would have only had a modest impact on state drug costs. Nevertheless, “They wanted to draw a line in the sand.”  A similar proposition will be on Ohio’s 2017 November ballot.

U.S. New and World Report said New York State approved rules in April of 2017 that will put pressure on pharmaceutical companies if they want to continue doing business in the state. If Pharma companies don’t agree to voluntarily rebate or return money to the state if prescription medication spending is projected to exceed the sum of medical inflation plus 5 percent, New York State could initiate a series of reviews using scientific studies and other information to evaluate whether specific medications are overpriced. “Drug makers generally object to such reviews and often dispute their results.” The NY State Medicaid Director said the law created an incentive for pharmaceutical companies to collaborate and give the state rebates.

New York is not the only state taking action. Vermont lawmakers passed legislation requiring justification for price increases that are driving up spending in state programs like Medicaid. In March of 2017 Maryland lawmakers passed legislation, still not signed by the governor, directing Medicaid to notify the state attorney general when off-patent or generic drugs have “an excessive price increase.” The new law also sets financial penalties if the pharmaceutical company can’t justify the price hike. Louisiana officials are looking into whether a rarely used federal law could be used to “sidestep patents and allow government programs to get lower-cost generic versions of pricey hepatitis C treatments.”

In August of 2017, JAMA gave greater details about the New York legislation in: “Value-Based Pricing and State Reform of Prescription Drug Costs.” Hwang et al. said if the rate of drug spending growth exceeded the 10-year average inflation plus 5% in 2017-2018 or 4% in 2018-2019, the state department of health would be authorized to identify and refer high-cost drugs to a drug utilization review board to determine a target rebate amount. The provisions are likely to trigger a review this year. The board may consider the effectiveness of the drug, its therapeutic alternatives, and the seriousness and prevalence of the disease in formulating its recommendation for a value-based price.

If the state and manufacturer fail to agree on a rebate that is at least 75% of the difference between the drug’s current price and value-based price, the state may waive provisions that currently require managed care plans to cover medically necessary drugs in certain protected classes, including antidepressants, antiretrovirals, and hermatologic drugs. Furthermore, if total drug expenditures continue to increase faster than inflation despite these new rebates, the state may implement more aggressive actions to promote use of clinical alternatives, including directing managed care plans to remove drugs from their formularies that lack new rebate agreements.

The pharmaceutical industry is taking steps to prepare to do battle against these and other steps taken to rein in drug prices. The pharmaceutical lobby, PhRMA (Pharmaceutical Research and Manufacturers of America), is increasing membership dues by 50 percent to raise an additional $100 million PER YEAR to fund its ongoing fight over drug prices.  “PhRMA has consistently ranked among the biggest lobbying spenders in Washington over the past few years.” By August of 2016, it had already spent $11.8 million that year, making it the fourth-largest lobbying group in Washington DC. TV advertising in 2017 was to target how “new drugs could add years to patients’ lives, as well as the years of complex research needed to develop a drug.”

The Intercept reported that newspapers in the Washington D.C. area were getting swamped in April of 2017 with ads warning of the dire consequences of proposals to lower drug prices. The groups placing the ads had no obvious connections to pharmaceutical companies. The ads appeared in the Washington Post, Washington Times, Roll Call, The Hill and Politico just as legislators were taking up proposals to lower drug prices. As it turned out, the organizations had undisclosed financial ties to PhRMA.

A bill proposed by Senator Al Franken would reverse a 2003 law prohibiting Medicare from using its collective bargaining power to negotiate lower drug prices. Legislators who wrote the 2003 bill worked closely with PhRMA lobbyists while drafting the legislation. The bill’s sponsor later became the president of PhRMA.  Franken and others introduced the “Improving Access to Affordable Prescription Drugs Act” on March 29, 2017. Here is a five-page summary of the bill. A companion bill to “Improving Access to Affordable Prescription Drugs Act” was introduced in the House on the same day.

Some of its provisions would include several current problems with prescription drug costs. It would close the coverage gap in Medicare Part D coverage (known as the donut hole) in 2018, two years earlier than under current law. Tax credits given to pharmaceutical companies for their direct-to-consumer (DTC) advertisements would be eliminated. (WE WERE GIVING PHARMA COMPANIES TAX CREDITS WHEN THEY TRY TO GET US TO BUY THEIR DRUGS?) It would allow individuals, wholesalers and licensed U.S. pharmacies to import prescription drugs manufactured at FDA-inspected facilities from licensed Canadian sellers.

Significantly, Section 201 would allow the Secretary of Health and Human Services to negotiate with drug companies to lower prescription drug prices. It directs the Secretary to “prioritize negotiations on specialty and other high-priced drugs.” Under existing law, unlike Medicaid and the VA, Medicare is not allowed to leverage its purchasing power to negotiate lower drug prices.

STAT News reported that the Thursday before the November 2017 election, Andy Slavitt, the acting administrator for Medicare and Medicaid Services, said the rising costs for prescription drugs “will put unsustainable pressure on the Medicare program, and action is going to be necessary to address them.” He was addressing the BioPharma Congress, an industry conference. He said: “Drug costs have become the health policy issue Americans are most anxious to see us act on, and we have a responsibility to them to explore all the options available us to make their medications more affordable.” He told those at the conference that we could have both innovation and affordability. “These two goals shouldn’t be in opposition.”

In every-forward looking industry outside of health care, we see that competition actually fuels innovation, and affordability improves alongside the development of new technologies. . . . There are plenty of policy options and certainly a number of ways innovators like you can choose to respond – from disputing the math and fighting it, to looking for win-wins.

So far, it seems Pharma is ignoring the message. They are still trying to convince the American public and U.S. lawmakers that innovation in drug development will dry up if price caps are enacted.

The debate over the cost of drug development has been going on since the late 1950s, believe it or not. An often-quoted 2003 study, “The Price of Innovation,” which was published in the Journal of Health Economics, estimated it cost $802 million in 2000 dollars to bring a new drug to market. PhRMA’s 2014 profile found that estimate low and said it actually costs $1.2 billion to develop a new drug. However, “Demythologizing the High Costs of Pharmaceutical Research,” in the journal BioSocieties, suggested the true research and development costs were a median of about $43.4 million per new drug. That is about 5.4% of “The Price of Innovation’s” cost projection and 3.6% of the PhRMA estimate. See “Pharma and Its Golden Hoard” for a further discussion of what a new drug costs.

11/10/17

Here’s Some Gray Death

© Artlover | stockfresh.com

The fact-checking website Snopes looked into a report from Indiana claiming there is a new and dangerous drug called “Gray Death.” The report claimed Gray Death could cause the overdose or death of a drug user if it was accidentally inhaled after it became airborne or if it was absorbed through the skin after contact. Their investigation found the report was true.  A local Indiana TV station, WDRB, was the source for the Snopes investigation, saying the Indiana Department of Homeland Security announced Gray Death was found in the Hoosier state beginning in May of 2017. But it seems Indiana was late to the Gray Death party.

Gray Death is a drug cocktail of heroin, fentanyl, carfentanl, and often U-47700 known on the street as “Pink” or “U4.” Heroin is two to three times as powerful as morphine. Fentanyl is about 50 to 100 times more powerful than heroin. Carfentil is about 100 times more powerful than fentanyl. U4 is the weakest drug in the mix after heroin, at only 7. 5 times the strength of morphine. The drug cocktail looks like concrete mix, thus the nickname of gray death.

Russ Baer of the DEA told NBC News on May 5, 2017 that Gray Death was initially limited to the Gulf Coast and states like Georgia and the mid-West state of Ohio. But it’s also been spotted in places like Chicago, San Diego, and Lexington. A “Pink”-free precursor to Gray Death was spotted in the Atlanta area back in 2012. “We are more routinely seeing deadly cocktails of heroin, fentanyl, various fentanyl-class substances, along with combinations of other controlled substances of varying potencies including cocaine, methamphetamine, and THC. . . . No one should underestimate the deadly nature associated with these cocktails.”

CNN noted that not only do the ingredients of Gray Death vary from sample to sample, some are present in such low concentrations (because of their strength) they may not show up on tests. Donna Ula, director of forensic chemistry at a biochemical company working with state and federal officials to identify unknown street drugs, said “It’s going to constantly vary, and it’s going to keep the chemists and the medical examiners on their toes.” She said Gray Death is “a fast-track route to the morgue.” A forensic chemist with the Georgia Bureau of investigation said even its gray color is a mysterious. “Nothing in and of itself should be that color.”

There have been several overdoses and overdose-related deaths in Georgia and Alabama linked to Gray Death. The Georgia Bureau of Investigation issued a public safety alert on May 4, 2017 about illegal synthetic opioids (Gray Death). The GBI Crime Lab has received about 50 cases of suspected Gray Death this year. Many contain three or four different opioids. One Metro-Atlanta law enforcement agency seized around 8 kilograms of a substance that when field-tested, didn’t identify what the mixture was. Further analysis at the GBI Lab found furanyl fentanyl and U-47700, two of the opioids regularly found in the Georgia Gray Death cocktail.

On May 10, 2017 The Morning Call reported there is Gray Death in the Lehigh Valley of Pennsylvania. After making two undercover drug buys at a woman’s home in Bethlehem PA, investigators had the drug packets tested because of their off-white color. They suspected they might contain fentanyl.  But the preliminary results showed the packets contained a mixture of heroin, fentanyl and U4—Gray Death. After the preliminary identification, a search warrant was quickly issued: “We wanted to get it off the street as fast as possible.”

The woman’s three children, between the ages of 3 and 9, were living in the home with their mother. Police found some of the drug in a cup sitting on the shelf of a kitchen cabinet” within east reach of the children. The woman was arrested and charged with endangering the welfare of children, drug possession and possession of drug paraphernalia. She was freed after posting $5,000 bail. No word was reported on the children, but they were likely not in their mother’s custody given her charges.

According to Healthline News, the combination of synthetic opioids and/or heroin making up Gray Death varies widely. Given that the drugs or their precursors are created in unregulated labs, domestic drug dealers don’t always know how strong a batch is. “The potency can change from one batch to the next.” Dr. Seonaid Nolan, a clinical scientist in addiction medication at the University of British Columbia said: “Because it’s so potent, a small misstep in the preparation of the drug can lead to lethal consequences.”

This high potency also means it’s more difficult for customs and law enforcement to make searches and seizures, as it allows the drug syndicates to ship less physical product across the border. Sometimes the drugs are even shipped directly through the postal system. “Drug traffickers can move a high quantity or high volume of the product in a fairly small package.”

Traditional opiates like heroin are derived from the poppy plant, meaning the poppy plants have to be grown, harvested and then processed before heroin can be manufactured. “However, synthetic opioids can be produced entirely from chemical precursors.” This makes their production much simpler than heroin, since the entire manufacturing process can be done in a lab.

Fentanyl and its analogues have a high lipid solubility, meaning they readily pass through fatty tissues in the body. So fentanyl is used in transdermal patches and even lollipops, allowing it to enter the blood stream without having to be digested in the stomach. Since it doesn’t get metabolized, you need smaller amounts of fentanyl because it can go directly to the brain through the blood system. This also explains its danger if it becomes airborne or comes in contact with exposed skin. Edward Bilsky, a professor of Biomedical Sciences at Pacific Northwest University said:

[These drugs] are very fast acting and produce profound depression of respiration and other central nervous system functions leading to many deaths. . . . First responders and others around the victim need to be careful due to secondary exposure.

According to the DEA, fentanyl analogs, like acetyl fentanyl and furanyl fentanyl are manufactured in China by clandestine labs, and then smuggled into the U.S. through established drug smuggling routes in Mexico. Mexican drug traffickers also manufacture their own analogs of fentanyl. In the past, the Chinese government denied they were the source of illicit fentanyl being smuggled into the U.S. But DEA officials and others met with Chinese officials in 2016, which prompted China to regulate four fentanyl-related substances in an effort to help stem the flow of these opioids into the U.S. in action that went into effect in March of 2017.

Carfentanil was one of these substances. Because of its off-the-charts strength, it was receiving a lot of press coverage in 2016. See “Fentanyl: Fraud and Fatality” and “The Devil in Ohio.” But unless you followed news on the death of Prince, you may not have heard of “Pink” (U-47700 or U4) before. In addition to fentanyl and Percocet (oxycodone-acetaminophen), Pink was found in his system. In November of 2016, the DEA temporarily classified U-47700 as a Schedule I controlled substance, due to its “immanent threat to public health and safety.” The DEA received at least 46 confirmed reports of deaths associated with U-47700—31 in the state of New York and 10 in North Carolina. “This scheduling action will last for 24 months, with a possible 12-month extension if DEA needs more data to determine whether it should be permanently scheduled.”

In addition to Georgia, Pennsylvania and Ohio, drug busts in multiple states are reporting they have seized quantities of Grey Death. Traffic stops in Greenville County South Carolina found 17 pounds of heroin and one pound of Grey Death. There have been two reported seizures of Grey Death in Virginia. Grey Death has been reported in Florida since November of 2016. It’s been found in Alabama. In a video from WCPO in Cincinnati, Ohio, Detective Jim Larkin of the Lorain County Sheriff’s Department wondered why anyone would try something called Grey Death. “Here’s some Grey Death. Now what do think is going to happen to you? Why do you think it’s called Grey Death?”

11/7/17

Swallowing a Camel

© Oleg Lopatkin

The Babylon Bee reported that NYPD detectives are investigating an attack on a group of teen-aged youths who were mauled by two female grizzly bears in Central Park. According to witnesses, when pastor and author Tim Keller was on his morning run through Central Park he passed a group of young men. One of them shouted, “Hey baldy! Run, baldy, run!” Another youth echoed the sentiment before the two high-fived each other. Onlookers reported that Keller stopped jogging, closed his eyes and prayed. Immediately two massive grizzlies charged out of a nearby wood and mauled the group of boys.

The event, of course is not true. And if you are not familiar with the Babylon Bee, you would have missed the clue it gave that you were about to read a satirical piece of “news.” The back-story to the above is in 2 Kings 2:23-25, when the newly anointed prophet Elisha was traveling from Jericho to Bethel after his predecessor, Elijah, was taken up to heaven in a fiery chariot. A group of forty-two young boys (The Hebrew phrase can refer to youths between the ages of twelve and thirty) came out of Bethel and jeered at him, saying, “Go on up you bald head!” In his commentary on 2 Kings, Paul House suggested their jeering seems to be a contemptuous reference to Elijah’s being taken up to heaven, with the sense of “Go away like Elijah.” Elisha cursed them in the name of the Lord, as their behavior was an insult directed at him as a prophet, and therefore the Lord who he represented. “And two she-bears came out of the woods and tore forty-two of the boys.”

What happened in the 2 Kings passage was not an example of biblical satire, but Leland Ryken commented in How to Read the Bible as Literature, that there is more satire in the Bible than you might think. Much of the Bible’s truth and wisdom has been shaped as satire. “By framing truth as an attack on vice or folly, biblical satire drives its point home with an electric charge.” Despite the negative approach of the satirist, a positive norm emerges from biblical satire because it includes a foil to the evil it attacks. “That foil is usually the character or law of God.”

Satire, Ryken said, is “the exposure, ridicule or rebuke, of human vice or folly.” It can “appear in any literary genre (such as narrative, lyric or parable), and it may be either a minor part of a work or the main content of an entire work.” The reader’s task with satire is fourfold: to identify the object(s) of attack, the satirical vehicle that embodies the attack, the tone (either biting or laughing), and the norm or standard by which the criticism is made.

Satire usually has one main object of attack, but it could also have a number of jabs in various directions, called “satiric ripples.” When satire “is an attack on historical particulars it means that the reader of satire usually needs help in reconstructing the assumed social context—the economic, political, religious, or social conditions that the satirist attacks.”

The object of attack could be a single thing, as in the parable of the rich man and Lazarus (Luke 16:19-31), which attacks the love of money and the callous unconcern it encourages. Or it could be a series of objects as with Jesus’ discourse against the Pharisees in Matthew 23. There Jesus rapidly ridiculed the scribes and Pharisees, saying they tithe mint, dill and cumin, but neglect the weighty matters of justice, mercy and faithfulness. They are like whitewashed tombs that outwardly appear beautiful, but are full of dead bones and uncleanness. “So you also outwardly appear righteous to others, but within you are full of hypocrisy and lawlessness.”

The object could be a historical particular, like the attack on the self-righteousness of the Pharisees in parable of the Pharisee and the tax collector (Luke 18:9-14); or it could be about a universal vice like greed, as in the parable of the rich fool (Luke 12:13-21), planning to build larger barns to store all his grains and goods.

The most common satiric vehicle is story, as with Jonah or the satiric parables of Jesus. There may also be brief snatches of action, as when Isaiah 46:5-7 briefly narrates how idol worshipers first have to have a goldsmith make an image in order for them to fall down before it and worship! Or there could be a portrait or character sketch as in Isaiah 3:16: “The Lord said: Because the daughters of Zion are haughty and walk with outstretched necks, glancing wantonly with their eyes, mincing along as they go, tinkling with their feet.” Narratives and portraits are among the most artistic and sophisticated types of satiric vehicle. At the more informal end are cruder statements, as when Amos calls the wealthy women of Israel “cows of Bashan” (Amos 4:1); or the “woe formula” used by Jesus in Matthew 23 cited above.

Biblical satire always has one of two prevailing tones. One is gentle, smiling and subtle. “It aims to correct folly or vice by gentle laughter, on the premise that it can be laughed out of existence.” Examples of such a “soft sell” would include the story of Jonah as a whiny, pouting prophet. Or Isaiah 44:9-17, where those who fashion idols are described as taking part of a tree to build a fire in order to warm himself or bake bread, while with the rest he makes into a god, his idol, and falls down and worships it.

The second tone is biting, bitter and sharp. “It points with contempt and moral indignation at the corruptness and evil of people and institutions.” Most biblical satire is of this type, and includes a good bit of scorn, as opposed to humorous laughter.

The fourth and final aspect of satire to look for is the satiric norm; the standard by which the object of attack is being criticized. “The satiric norm is the positive model that is offered to the reader as an alternative to the negative picture that always dominates a satiric work.” In Jonah, the universal mercy of God is extended to the repentant city of Nineveh as a positive foil to Jonah’s misguided patriotism. “In the Sermon on the Mount, each of Jesus’ satiric charges against the Pharisees is accompanied by a positive command (Matt. 6:1-14).”

Satire is found throughout the Bible. The books of Jonah and Amos are entirely satirical. The orthodox comforters in Job are the ones who are rebuked. “The book of Ecclesiastes is a prolonged satiric attack against a society that is much like our own—acquisitive, materialistic, hedonistic, secular.” Many of Jesus’ parables, like the rich man and Lazarus (Luke 16:19-31) or the tax collector and the Pharisee (Luke 18:9-14) are satiric. Whenever a biblical narrative prominently displays a character’s flaws, as with Jacob’s greed or Haman’s pride, there is a thread of satire.

Given this discussion of satire, I’ll offer the following suggestion of why the Babylon Bee story about Tim Keller is satirical. Remember that satire is “the exposure, ridicule or rebuke, of human vice and folly.”

The object of attack is against the infighting that occurs among evangelicals when ministers are perceived to be “too liberal” because they don’t hold to certain doctrinal positions. You can Google “Tim Keller” and “critique” to see what I mean. There are articles on Tim Keller’s “false gospel,” his “disappointing” comments on homosexuality and more. He’s been roundly criticized for what he’s said with regard to evolutionary creation. There’s even a book giving “a gracious criticism of some aspects” of his theology.

The satiric vehicle is an alternate reality story that portrays Tim Keller as Elisha in a modern version of 2 Kings 2:23-25. The satiric tone is subtle and laughing. Praying for judgment against his critics is the last thing to expect from someone like Tim Keller. Note also how the Babylon Bee article said Keller “calmly closed his eyes and uttered a prayer” as opposed to Elisha calling down a curse against those who were ridiculing him.

The satiric norm for the Babylon Bee article would be to remind those critics of Keller that they are also, in a manner of speaking, being critical of the God he serves as a minister. I don’t mean that questioning the opinions of Tim Keller is tantamount to debating Paul or Moses on some of their doctrinal positions. But (to use another satirical image), I think they are straining out a gnat and swallowing a camel (Matthew 23:24). With all the cultural critiques they could be addressing today, they are going after Tim Keller. Really?

11/3/17

Downward Spiral of Antipsychotics

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Antipsychotic or neuroleptic drugs became big business for pharmaceutical companies about nine years ago, reaching sales of $14.6 billion in 2008. This made them the best selling therapeutic class of medications in the U.S that year. Not only are they used to treat psychosis and bipolar disorder, several have been approved as an add-on medication to treat depression. Additionally they are used off-label with children and the elderly for behavioral control. And they are the primary cause for a serious neurological disorder called tardive dyskinesia.

Tardive dyskinesia (TD) is a group of involuntary movement disorders caused by drug-induced (iatrogenic) neurological damage, primarily from antipsychotic drugs and a few others that block the function of dopamine in the brain. “TD can vary from a disfiguring grimace to a totally disabling array of spasms and often bizarre movements of any part of the body.” If TD is not identified early on and the drugs stopped, “these disorders nearly always become permanent.” Both patients and their doctors often fail to recognize or diagnose its symptoms.

The above short introduction was gleaned from Dr. Peter Breggin’s “Antipsychotic Drugs and Tardive Dyskinesia (TD) Resources Center.” If you can spare a few minutes, watch a ten-minute TD video edited by Dr. Breggin from existing videos available on the Internet. The video contains a series of individuals with the three general types of tardive dyskinesia whose ages range from pre-adolescence to seniors. These types are: tardive dystonia, a series of involuntary movements that include painful muscle contractions or spasms; tardive akathisia, psychomotor agitation; and classic tardive dyskinesia, the rapid, jerky movements or uncontrollable head bobbing or movements of the arms, hands, feet fingers or toes. The following is a reproduction of a table from Psychiatric Drug Withdrawal by Peter Breggin more fully describing the symptoms of tardive dyskinesia.

Symptoms of Tardive Dyskinesia

Tardive Dyskinesia (Classic)

Rapid, irregular (choreiform), or slow and serpentine (athetoid) movements; often bizarre looking; involving any voluntary muscle, including:

Face, eyelids and eye muscles, jaw (chewing movements, tongue biting), mouth lips, or tongue (protruding, trembling curling, cupping)

Head (nodding), neck (twisting, turning), shoulders (shrugging), back, torso (rocking movements), or abdomen

Arms and legs (may move slowly or jerk out of control)

Ankles, feet and toes; wrists, hands, and fingers (sometimes producing flexion, extension or rotation)

Breathing (diaphragm and ribs; grunting), swallowing (choking), and speaking (dysphonis)

Balance, posture, and gait (sometimes worse when slow, often spastic)

Tardive Dystonia

Often painful sustained contractions (spasms) of any voluntary muscle group; potentially causing muscular hypertrophy, arthritis, and fixed joints; frequently involving the following:

Neck (torticolis, retrocollis) and shoulders

Face (sustained grimacing and tongue protrusion)

Mouth and jaw (sustained opening or clamping shut)

Arms and hands; legs and feet (spastic flexion or extension)

Torso (twisting and thrusting movements; flexion of spine)

Eye lids (blepharospasm)

Gait (spastic; mincing)

Tardive Akathisia

Potential agonizing inner agitation or tension, usually (but not always) compelling the patient to move, commonly manifested as the following:

Restless leg movements (when awake)

Foot stamping

Marching in place, pacing

Jitteriness

Clasping hands or arms

Inability to sit still

TD can impair any muscle functions that are partially or wholly under voluntary control such as the face, eye muscles, tongue, neck, back, abdomen, extremities, diaphragm and respiration, swallowing, and vocal cords. Coordination and posture can be afflicted. TD can cause tremors, tics, and paresthesias (e.g., burning sensations, numbness). TD can also afflict the autonomic nervous system, especially impairing gastrointestinal functioning.

TD sufferers are often exhausted by these unrelenting body movements; even when they are limited to one area of the body, such as the jaw, neck or feet. They become socially withdrawn and isolated—humiliated by the stigma of their uncontrollable movement disorder. One muscle group, such as the tongue or fingers, or various muscle groups can be afflicted. TD symptoms can also change over time from one muscle group to another. This can occur over a period of minutes, days, weeks or years. “Especially in the dystonic forms, the pain can be very severe, and the physical stress can cause serious orthopedic problems.” Antipsychotic drugs are the primary cause of this neurological disorder.

Antipsychotic drugs are also called neuroleptics. Prescribers often promote them in a misleading fashion as antidepressants, mood stabilizers, bipolar drugs, sleeping pills, and behavior control drugs in children. Recent ones include Risperdal (risperidone), Abilify (aripiprazole), Geodon (ziprasidone), Invega (paliperidone), Latuda (lurasidone), Rexulti (brexpiprazole), Risperdal (risperidone), Saphris (asenapine), Seroquel (quetiapine), and Zyprexa (olanzapine). Older antipsychotics include Haldol (haloperidol) and Thorazine (chlorpromazine). [See a more complete listing of antipsychotics here]

Drug companies have made claims that the newer, so-called atypical antipsychotic drugs are less likely to cause TD, but those claims are false or misleading. A 2008 study by Chouinard found a high prevalence of DIMD (drug-induced movement disorders). Nearly 50% of patients had a definite DIMD. The authors also said that DIMD persisted with atypical antipsychotics. “It is crucial to acknowledge that there is a persistence of DIMD with atypical antipsychotics, which are not recognized and confounded with psychiatric symptoms.” Caroff, Miller and Rosenheck reported in “Extrapyramidal Side Effects” that there were no significant differences in measuring the incident rates of TD and other DIMDs between atypical antipsychotics and an older antipsychotic, perphenazine (Trilafon).

According to Dr. Breggin, TD occurs around a rate of 5 to 8 percent per year in adults up to the age of 40, with an accumulating risk of 20% to 24% after four years. The rates increase rapidly over forty. “For a 40-year-old patient, the risk is 18% at 2 years [9% per year] and 30% at 4 years.” In patients over 45, “the cumulative incident of TD after neuroleptic exposure is 26%, 52%, and 60% after 1, 2, and 3 years, respectively.”

Recently the FDA approved two medications to treat TD. Let this sink in. A serious neurological disease, which is primarily caused by a class of psychiatric medications, is being treated with another medication. Neurology Advisor interviewed two experts medical experts on the current state of treatment for TD. One of the experts interviewed said:

The main issue in the “treatment” of TD is prevention. It is important to use offending agents only when the potential benefit is higher than this risk. Once it appears, the first step is to determine whether symptoms are bothersome or disabling to warrant treatment. If possible, either discontinue the offending agent, although this might not improve symptoms permanently, and they will probably worsen initially, or change to a similar agent less likely to cause TD. In terms of prescription medications for TD, I have observed significant variability in treatment approaches depending on physician choice. Over the last few years, I personally found tetrabenazine to be the most efficient agent.

Tetrabenazine (Xenazine) was approved to treat the movement disorder associated with Huntington’s chorea, but has been used off-label to treat TD. It is now off patent and available as a generic. On patent, it sold for $152,000 per year. The generic version is $96,000 per year. However, there have been two new drugs approved specifically to treat TD: Austedo (deutetrabenazine) and Ingrezza (vabenazine). Both are being priced at around $60,000 per year. All three medications carry “black box” warnings from the FDA because of their risk for depression and suicide. You can read more about these medications here, here, here and here.

In addition to TD, antipsychotics have been linked to adverse cardio vascular events, brain shrinkage, dopamine supersensitivity, weight gain, diabetes, a shortened life span and more. The risk-benefit ratio may see a need for short-term use of antipsychotics, but the long-term benefits of their use are questioned by many credible sources. There have been follow up studies that support that concern. See this blog post by Thomas Insel, the former director of the NIMH, the National Institute of Mental Health.

It seems to be stepping onto a downward spiral to use medications with serious side effects to treat TD, a serious side effect from antipsychotics. As the above quoted expert, suggested, the best treatment for tardive dyskinesia is prevention—avoid antipsychotics if at all possible. For more information on concerns and adverse effects with antipsychotics, see: “Blind Spots with Antipsychotics” Part 1 and Part 2, “Antipsychotic Big Bang”, “Wolves in Sheep’s Clothing” and “Hollow Man Syndrome.”

10/31/17

Mistaken Beliefs About Addiction Relapse

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The coroner’s report on Carrie Fisher’s death listed sleep apnea as the primary cause of death with drug intake as a contributing factor. In addition to the medications prescribed for her bipolar disorder (Abilify, Lamictal and Prozac), toxicology results found cocaine, methadone, heroin, oxycodone, and MDMA (ecstasy) in her system at the time of her death. Fisher’s family objected to a full autopsy, so the coronor’s conclusions were based on the toxicology results and an external examination of her body. “Based on the available toxicological information, we cannot establish the significance of the multiple substances that were detected in Ms. Fisher’s blood and tissue, with regard to the cause of death.”

The above information was from an article in Variety, but several media outlets were citing the coroner’s report and the same information. People said the coroner’s report indicated Ms. Fisher used cocaine sometime in the 72 hours prior to her death. During her 10-hour flight, she had multiple apneic episodes, which her personal assistant said was normal for her. Towards the end of the flight, she could not be roused. The report also noted she suffered from atherosclerotic heart disease, but then said: “The manner of death has been ruled undetermined.”

Although the official coroner’s report listed the manner of death as undetermined, it seems reasonable to assume from the toxicological information that Ms. Fisher had relapsed into active substance use. Billie Lourd, her daughter, said in a statement to People: “My mom battled drug addiction and mental illness her entire life. She ultimately died of it.” The cocktail of substances in Carrie Fisher’s system at the time of death, along with her history of heart disease, coupled with the increased risk of sudden cardiac death due to the medications used to treat her bipolar disorder lends credibility to Ms. Lourd’s statement.

The use of psychiatric medication to treat her bipolar disorder may have been a contributing factor to Ms. Fisher’s heart failure. See the article, “Blind Spots with Antipsychotics” Part 1 and Part 2 for more on the health problems with antipsychotics. But the range of substances she used just before her death may also have been enough to precipitate a sudden cardiac death, particularly since she already suffered from heart disease. Struggling with a concurrent bipolar disorder and a substance use disorder is a double whammy to anyone in recovery. Instability with either issue is a serious risk factor for relapse. I knew of someone with a bipolar diagnosis and cocaine dependence. They bounced back-and-forth between active cocaine use and inpatient psychiatric treatment for depression ten times within a single year.

Ms. Lourd said her mother would want her death to encourage people to be open about their struggles, and to seek help for them. Historically, Carrie Fisher talked openly about her proneness to relapse. She told People in 1987: “I couldn’t stop, or stay stopped. It was never my fantasy to have a drug problem.” She would stop for a couple of months and then celebrate her abstinence by using again. “I got into trouble each time. I hated myself. I just beat myself up. It was very painful.” With that in mind, let’s assume the immediate cause for her untimely death was due to an apparent relapse into active drug use, and then discuss some mistaken beliefs about addiction relapse.

Terrance Gorski is a leading expert on addiction relapse prevention. He’s written several books on the subject, many of which are available through Herald House Independence Press at relapse.org. He also has a blog, Terry Gorski’s Blog, where he has made a significant amount of his material available for free. Here we’ll concentrate on his article, “Relapse Does not Mean Failure?

Gorski said there were three mistaken beliefs that often interfered with helping relapse prone individuals. They are: (1) Relapse is self-inflicted; (2) Relapse is an indication the person is a failure who doesn’t want to recover; and (3) Once relapse occurs the patient will never recover.

In most cases, relapse is not self-inflicted. There isn’t a fully conscious, willful decision to throw over abstinence and return to active drinking or drug use. Relapse-prone individuals “experience a gradual progression of symptoms in sobriety that create so much pain that they become unable to function in sobriety. They turn to addictive use to self-medicate the pain.” They can learn to stay sober by recognizing these symptoms as early relapse warning signs. Next is identifying the self-defeating thoughts, feelings and actions used to cope with the symptoms and then learn more effective coping mechanisms, more healthy ways of responding to them.

Unfortunately, most relapse-prone patients never receive relapse prevention therapy, either because treatment centers don’t provide it or their insurance or managed care provider won’t pay for it.

Relapse is not automatically a sign that treatment has failed or the person really doesn’t want to recover. It is more likely that the root-cause of the person’s problems wasn’t addressed by the “standard package of treatment offered.” If this is the case, the risk of relapse increases dramatically. Learning to recognize relapse warning signs and how to cope with them would minimize this risk.

Gorski said that between one half and two-thirds of all individuals treated for alcohol and drug use problems will relapse. At least one half of those who relapse will establish long-term recovery within five to seven years of their first treatment experience. Believing that relapse means both the person and the treatment failed ignores the reality that for many, recovery involves a series of relapse episodes. “Each relapse, if properly dealt with in a subsequent treatment, can become the a learning experience which makes the patient less likely to relapse in the future.”

Chemically dependent people can be grouped into three types based upon their recovery and relapse histories. The first type is recovery prone and maintains total abstinence from their first serious attempt at change. Another type is relapse prone, with a series of short-term, low consequence relapse episodes before finding long-term abstinence. The third type is chronically relapse prone, who can’t seem to find long-term sobriety regardless of what they do.

Recovery prone individuals tend to be dependent on a single drug. They also have higher levels of social and economic stability. They may have steady employment, friendships and stable living situations. And they don’t have coexisting mental health issues, as Carrie Fisher did, or physical health issues, like chronic pain problems. These “garden variety addicts” have chemical addictions with few additional serious personal or social problems.

The second type of transitionally relapse-prone individuals, seem to have more severe addictions that are complicated by other problems. However, they learn from each relapse episode and take steps to modify their recovery programs to avoid future relapses. For example, they may downplay the risks of going around good friends who still drink or use drugs until they find themselves actively drinking or drugging again. Afterwards, they set and keep boundaries with those friends that better support their recovery.

The third type— chronically relapse-prone individuals—not only have the primary addiction for which they are being treated, but also a combination of the following coexisting issues. They may have multiple drug addictions, especially with opiates and methamphetamines. They can have an undiagnosed physical condition, a personality disorder or other mental health problem. There could be issues with severe post acute withdrawal (PAW), which becomes even more severe when the person is under high levels of stress.

Many relapse-prone patients fail to recover because these coexisting [issues] are not properly diagnosed and treated and they interfere with the primary treatment being given.

The third mistaken belief sees recovery as an all-or-nothing process—you either have it or you don’t. And if you relapse, you just don’t want recovery bad enough. Actually, recovery is a learned skill, acquired mostly by trial and error.  Rarely does someone with long-term recovery get there without one or more short series of relapse episodes. “They learned from these experiences and figured out how to put together a meaningful and comfortable long-term recovery.”

So when you think about Carrie Fisher’s toxicology report, don’t assume she threw away her sobriety like it was an old, worn out Alderaan gown. Her relapse was likely the result of a gradual progression of symptoms occurring in her life. In time, they created so much pain in sobriety that she wasn’t able to function. So she tried to self-medicate. She also wasn’t a failure who didn’t want to recover. The openness in her life about her struggles with addiction and mental health belie such an assessment.

Like thousands of others each year, she died with multiple psychoactive substances in her system. But that doesn’t mean she would have never made it back to abstinence. Remember, she was Princess Leia; and Leia Organa never gave in to the tyranny of the Empire. Carrie Fisher would never have given up fighting against her addiction and mental health demons.

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

10/27/17

Ability to Choose … Within Limits

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It’s not too difficult to discover where Sam Harris stands on whether or not humans have free will. We unequivocally don’t. “Free will is an illusion.” In a lecture Harris gave for Skeptic Magazine that was based on his book, Free Will, he added that if the scientific community were to publically declare free will to be an illusion, “it would precipitate a culture war.” Science has revealed that we are “biochemical puppets” and “The universe is pulling your strings.”

Free will is an illusion. Our wills are simple not of our own making. Thoughts and intentions emerge from background causes of which we are unaware and over which we exert no conscious control. We do not have the freedom we think we have.

This illusion of free will is based on two false assumptions, according to Harris. The first is that we can behave differently than we did in the past. But since we live in a world of cause and effect, our wills are determined by a long chain of prior causes, “and we’re not responsible for them.” Alternately, what we perceive as free will is the product of chance; and again, we’re not responsible. Or there could be some combination of chance and cause and effect, but still no personal agency. Whichever way we conceive it, free will is an illusion in a world ruled by chance and cause and effect.

The second false assumption is that we are the conscious source of our thoughts and actions. “We presume an authorship over our own thoughts and actions that is illusory.” There is no self, no ego, no soul to generate thoughts and actions, according to Harris. They just emerge in our consciousness. And if we cannot control our thoughts, if we don’t know what our next thought will be until it consciously emerges, where is our free will?

How can we be free as conscious agents, if everything we consciously intend was caused by events in our brain, which we did not intend, and over which we had no control?

Sam Harris is an author, philosopher and neuroscientist who has written several popular books in addition to Free Will. Along with Richard Dawkins, Daniel Dennett and Christopher Hitchens, he has been referred to as one of the “Four Horsemen of New Atheism.” The reference draws on the title of a 2-hour unmoderated discussion between the four that is available here on the website for the Richard Dawkins Foundation for Reason and Science. They discussed the public reaction to some of their books critical of religion, and some common misrepresentations of them and their beliefs.

Harris’s position on free will assumes the universe is a closed system of cause and effect. Since there are no creator gods, everything that now exists is the result of what has come from “a long chain of prior causes.” The theologian Francis Schaeffer referred to the understanding of science that comes from this view of the universe as modern, modern science—science rooted in naturalistic philosophy. The uniformity of natural causes, which is an essential starting point for scientific investigation, must be understood as occurring entirely within the natural order of the universe. Nature is closed to any causal intervention from outside.

There is no Creator; no First Cause. There is only chance or cause and effect. Not only physics, but psychology, social science and human nature must be explained within the confines of this closed system. The biologist and neuroscientist Robert Sapolsky believes that every bit of human behavior has multiple layers of causality. He said what we call “free will” is simply 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.” See “Ruling Over Our Genes” for more on Sapolsky.

In Escape From Reason, Schaeffer concluded this materialist unity of all things leaves us afloat on a deterministic sea with no shore. The only way this unity can be achieved is by ruling out freedom. “The result of seeking for a unity on the basis of the uniformity of natural causes in a closed system is that freedom does not exist.” Free will is therefore an illusory cognitive construct.  The nonmaterial mind or soul is also an illusion.

However, Harris and Sapolsky aren’t the only neuroscientists to ever consider the possibility of free will. Harvey McMahon is a staff scientist and group leader at the Medical Research Council Laboratory of Molecular Biology in Cambridge. He is also a member of The Royal Society, the world’s oldest independent scientific academy. Past members of the Society have included Isaac Newton, Albert Einstein and Charles Darwin. Current members include Richard Dawkins and Stephen Hawking.

McMahon discussed free will in: “How Free Is Our Free-Will?” He opened his essay by noting science has provided evidence that free-will may be an illusion. Yet free-will was fundamental to our sense of wellbeing, and underwrote our sense of morality, our judicial system, and our Judeo-Christian faith. “We may not be as free as we would like to think, but within boundaries shaped by our individual histories, our genetics, and our environment we can make decisions that determine our character, relationships and future.”

He noted the paradoxical nature of freedom. For example, if we marry we limit the relationships we will have with others, while at the same time opening up new avenues of freedom from being settled in our choice of partner. This principle, McMahon said, applies to all our choices. We change our future possibilities by the choices we make today. “Thus freedom is not unconstrained choice, for with each choice we limit our freedom, and in so doing shape our environment and ourselves.”

These constraints are from our culture, our relationships, our jobs and our families, and other influences. Added to these is the subconscious working of our brain, processing cues of which we are not aware. “Thus the brain may even be making decisions for us.” Do we really have a choice? Here McMahon acknowledged Harris’ above noted argument (and book), that free-will was an illusion. But rather than an illusion, he thought it better to say it was constrained by many factors.

Free-will, McMahon thought, “is a cognitive concept, involving the mind.” It is the ability to choose deliberately between options. “It cannot be regarded as the opposite of determinism, where events have cause and effect outside human control.” He illustrated what he meant with the following diagram. Free-will only applied to cognitive processes where we use our minds to make choices—in between the two extremes. Although not stated by McMahon, I’d say completely free choice is only possible within the mind of God.

Human free-will is then not completely determined, nor is it completely free. McMahon suggested free-will occurred within the boundaries of predetermined factors, where there was little or no freedom to choose. These factors could be biological or genetic. They could also be family, culture, or environmental factors. See the diagram below.

Within an outer sphere of predetermined boundaries, lies a continuum of interaction between prior free-will and proximal free-will. Prior free-will is where an immediate decision is constrained by past decisions and history. Going to work on a given day is more the result of a past decision than one made when you woke up that day. You can re-assess the decision and not go to work for some reason, “yet the choice does not have to be constantly re-evaluated.” In-the-moment or proximal decisions can be inconsequential, like choosing between tea or coffee, or involve active cognition, as when we weigh our options. “Both of these give a strong sense of free-will in the moment.”

Plasticity refers to the fact that our brains are moldable. “We are constantly learning new information, meeting new people and acquiring new skills, which all require that our brains are ‘plastic’.” New synapses can be formed or existing synapses can be modified or lost. “At a molecular level there can be changes in the expression of various proteins which in turn influence the excitability of a given synapse or circuit.”

The choices we make influence the behavior patterns we develop, which are laid down as neuronal pathways. In turn, these pathways influence other choices. “So in this sense we are masters of our own destiny… all because we have a ‘plastic’ brain (i.e. not completely preprogrammed).” Although there is difficulty in the process, we can change. If we make certain choices repetitively, they lay down neuronal pathways and turn into learned behaviors.

Plasticity is thus key to the possibility of free-will [see the above diagram]. While memories of past experiences may not be completely eradicated, they can be scaled back by the new experiences that occupy our minds as we choose to dwell on other things.

Jeffery Schwartz and Rebecca Gladding coauthored You Are Not Your Brain, a self-help book that applies the principles of neuroplasticity discussed above. Like McMahon, Schwartz and Gladding affirm the reality of the human mind and the existence of free-will. Dr. Schwartz is one of the world’s leading experts in neuroplasticity. You can read more about him and his books on his web page here.

McMahon said the relationship between this conception of free-will and intentionality is complex. To the extent we willfully choose and can foresee certain outcomes, ”we can be held responsible for the outcome.” However, if we could not foresee the potential consequences of decisions, to what extent can we say their outcome was intentional? Furthermore, what about when reason has been suppressed for some reason, or if it has been erroneously applied (if we haven’t reasonably weighed our potential thoughts or actions), and non-intended consequences result.

Despite the caveats, in general each of us is responsible today for what we did yesterday because these were acts of free-will, or actions resulting from an absence of self-control. The responsibility for evil can be lessened by considering our circumstances but it never excuses us because at some point in the past we have actively participated in shaping who we are today.

McMahon goes on to describe how he believes our brains and free-will interact with each other. He suggested that while individual neurons do not have free-will, “it is an emergent property of neuronal networks.” He suggested free-will sits upon a tripod of past memories, present inputs (combined with the ability to compute and learn) and future predictions and aspirations within the plasticity of the brain.

There is more to read and think about in his article. McMahon also shares his thoughts on how God constrains us and yet frees us. He wrestles with the question of whether free-will is compatible with divine sovereignty. Read more on how he applies the above discussion to this theological dilemma. His conclusions are worth repeating here.

With the above in mind the following definition of free-will can be offered: Free-will is the ability to choose intentionally within limits placed by a sovereign God, with resulting human responsibility. Free-will is not the opposite of determinism: one can have free-will within the limits set by determinism. Indeed our relationships and our decisions are not absolutely predetermined, and this is a reflection of the freedom given to us by being made in the image of God. So, we have the best of both worlds, where we have freedom to make decisions and yet our personal future and that of the world are secure.

The above understanding of free-will indicates we are less free than we may like to think we are at any given moment, because of prior decisions and predetermined factors. And while neuroscience hasn’t extinguished free-will, it does help us see why we do the things we do. So we are not biochemical puppets, but biology constrains us. “We are not determined by our past, but certainly influenced by it.”

10/24/17

Feuding Ideologies, Part 3

© Navakun Phuangchan

“Dying To Be Free,” an article on the opioid addiction crisis, was well written and effectively communicated its message. That message was that abstinence-based treatment “didn’t work well for opioid addicts.” Medication-assisted treatment (MAT), especially with Suboxone, should be the standard of care. Nominated for a Pulitzer, “Dying To Be Free” was said to have influenced “a series of state and federal policy changes” away from abstinence to embrace MAT. But it has a glaring blind spot with regard to MAT, particularly Suboxone.

Pragmatically speaking, abstinent-based treatment and MAT need to learn to work together in order to effectively address the opioid addiction crisis in the U.S. “Dying To Be Free” systematically put these two approaches as being at odds with each other. It suggested we need to choose between the two, and argued that we should choose MAT. In order to support Suboxone MAT, it failed to acknowledge several serious concerns with Suboxone and other MATs. In this sense the persuasive rhetoric of the article had a blind spot.

In what follows, I hope to shine a light on what was missed with regard to Suboxone and other MATs. My intent is to bring to light the potential cons with Suboxone treatment in order to counterbalance the many pros found in “Dying To Be Free.” In order to make a truly informed addiction treatment choice both the strengths and weaknesses, the pros and cons need to be known and understood.

On September 20, 2017, Scott Gottlieb, the FDA Commissioner released a statement that said combined with counseling and behavioral therapies, MAT (medication-assisted treatment) was one of the main pillars of the federal response to the opioid epidemic. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), it cuts the risk of death from all causes in half among individuals who use MAT to treat their opioid use disorder. But methadone and buprenorphine are themselves opioids and when they are combined with benzodiazepines or other central nervous system (CNS) depressants, there is a risk of serious side effects, such as difficulty breathing, coma and death.

Since the harm caused by untreated opioid addiction can outweigh these risks, the FDA advised against withholding buprenorphine or methadone-based MAT from individuals taking benzodiazepines or other CNS drugs. Nevertheless, the agency is requiring changes to the MAT drug labels to help decrease the risks of combining these drugs. Heath care professionals should educate patients about the risks of combined use, “including overdose and death.” They should taper the benzodiazepine or CNS depressant to discontinuation, if possible. They should verify the diagnosis if a patient was prescribed these drugs for anxiety or insomnia, and consider other treatment options for these conditions.

The new labeling recommends that health care providers develop a treatment plan that closely monitors any concomitant use of these drugs, and carefully taper the use of benzodiazepines, while considering other treatment options to address mental health conditions that the benzodiazepines might have been initially prescribed to address.

The FDA prescribing information for buprenorphine already notes that: “significant respiratory depression and death has occurred in association with buprenorphine,” particularly when it is used intravenously (IV) or in combination benzodiazepines or other CNS depressants, including alcohol. “Many, but not all post-marketing reports regarding coma and death associated with the concomitant use of buprenorphine and benzodiazepines involved misuse by self-injection.” Unintentional exposure of buprenorphine to children, which can cause possibly fatal respiratory depression, was warned against. It also notes the potential for dependence:

Buprenorphine is a partial agonist at the mu-opioid receptor and chronic administration produces physical dependence of the opioid type, characterized by withdrawal signs and symptoms upon abrupt discontinuation or rapid taper. The withdrawal syndrome is typically milder than seen with full agonists and may be delayed in onset. Buprenorphine can be abused in a manner similar to other opioids. This should be considered when prescribing or dispensing buprenorphine in situations when the clinician is concerned about an increased risk of misuse, abuse, or diversion.

Buprenorphine and methadone are both opioids, with the potential for physical dependence. Therefore, they are both diverted from legitimate medical treatment for illicit use. Buprenorphine is a Schedule III controlled substance, while methadone is a Schedule II controlled substance. Buprenorphine is said to have a tolerance ceiling with respiratory depression, meaning it has a lower potential when used alone to cause respiratory depression and death. Given that buprenorphine is a partial agonist, its physical euphoria is less intense than other opioids. But tolerance to many of the effects will develop with prolonged and repeated use.

Methadone was first synthesized by the Nazis, who never brought it into widespread use because of side effects, which included its addictive potential. After WWII, the Americans took control of the factory where methadone, then known as dolophine or polamidon, had been invented. A 1947 study demonstrated its addictive potential, warning if the manufacture and use was not controlled, “addiction to it could become a serious health problem.” See “The Consequences of Ignoring the Past,” for more on methadone.

The addictive potential and the abuse potential for buprenorphine or methadone was not readily discussed in “Dying To Be Free.” Nor were the above-noted concerns of mixing buprenorphine and CNS depressants. The author, Jason Cherkis, did say that neither drug was a miracle cure. Suboxone blocks both the effects of heroin withdrawal and an addict’s craving and, if used properly, does it without causing intoxication.” But saying both drugs were comparable to “the insulin that a diabetic needs to live” was inaccurate and disingenuous. Chronic, long term use could lead to a lifelong dependency.

There is no getting around this. Chronic, long term use of buprenorphine and methadone produces physical dependence. A too rapid taper or an abrupt discontinuation will produce symptoms of withdrawal. Extended, chronic use over months or years could result in a lifelong reliance on the medication to avoid the discontinuation or withdrawal crisis—and the danger of returning to active illicit opioid use. In the documentary Methadonia, about methadone maintenance in New York City, one individual referred to methadone as “liquid handcuffs.”

Another disturbing blind spot in Dying To Be Free” was its discussion of a 2009 study, “Illicit Use of Buprenorphine/Naloxone Among Injecting and Noninjecting Opioid Users.” Cherkis cited it, stating the majority of addicts surveyed were buying Suboxone on the black market “in an attempt to get sober.” 74% of those surveyed said they were using Suboxone to “ease withdrawal symptoms; 64% said they were using it because they couldn’t afford drug treatment. “Even when purchased on the black market, regardless of the intentions of the user, the medication works as intended — as harm reduction.”

The study abstract contains the information Cherkis noted. But let’s take a closer look at the further results reported in the full article. First recognize the sample size was small: 51 injection opioid drug users (IDUs) and 49 noninjection opioid dug users (non-IDUs). It was also drawn from a limited area, opioid users in Providence, RI. Only 7% reported current employment and 52% reported current homelessness. The 64% who were using diverted Suboxone because they couldn’t afford treatment are easily explained by the high unemployment and homelessness figures.

In addition to the results reported by Cherkis was the following data. Among those who had used diverted buprenorphine, 60% reported using it for less than 1 week; 13% for 1 week; and 28% for more than 1 week. Of those using diverted buprenorphine less than 1 week, 32% said they only used it for one day. Fifty seven percent said they used diverted buprenorphine because they couldn’t obtain heroin; a greater percentage (68%) of IDUs than non-IDUs (41%). Forty seven percent said they used diverted buprenorphine to ‘get high’; a greater percentage of non-IDUs (69%) than IDUs (32%). Seventy six percent said it was easy or very easy to obtain Suboxone on the street.

The following quote by Tom Frieden, the former director of the Centers for Disease Control and Prevention (CDC), appeared after the selective reporting on the above study, arguing for the need of more MAT programs: “If buprenorphine is being used and being bought on the street to self-treat addiction, that’s a reflection of a need to have better medically assisted treatment programs out there.”

I don’t really think these patterns of and reasons for diverted buprenorphine use are best described as harm reduction, as Cherkis said. Technically, there are high percentages of individuals saying they used it to reduce withdrawal, and/or self-treat opioid addiction, as well to stay “clean” for some time. But most also said they used buprenorphine because they couldn’t obtain heroin. The reported time of buprenorphine use for the majority of individuals was less than a week; 32% said it was for only one day! In addition, 32% of IDUs and 69% of non-IDUs said they used it to “get high.” It seems it would be more accurate to describe this behavior as attempting a time period of controlled opioid use, rather than harm reduction.

About fourteen months before “Dying To Be Free” was published, “Addiction Treatment With A Dark Side” appeared in The New York Times. It too looked at Suboxone treatment, but presented a different, more nuanced side to Suboxone treatment. Cherkis selected out one aspect of the article, that it “linked hundreds of deaths in the U.S. to buprenorphine and Suboxone.” He focused in on the phrase used to say buprenorphine was a “primary suspect” as a cause of death in CDC data analyzed by the NYT. He then noted there should be caution used before attributing a “primary suspect” drug as a cause of death, which he neglected to show is exactly what the NYT article did do.

The NYT article said the 420 deaths with buprenorphine as a “primary suspect” paled in comparison to those reported to the FDA from methadone for the same time period. It also said “The F.D.A. information, which is spare, does show that more than half of the American buprenorphine deaths involved other substances and that only two of 224 cases specifying ‘route of administration’ indicated injection — the primary concern of regulators.” Fifty deaths were noted as suicides, 69 as unintentional overdoses from drug abuse, and 30 were fetal or infant deaths after exposure in the womb.

The NYT claimed some experts believe buprenorphine is not being monitored systematically enough to gauge the full scope of its misuse. The CDC does not track buprenorphine deaths. Most medical examiners, emergency rooms, prisons, jail and drug courts don’t routinely test for it. The director of the Center for Substance Abuse Research at the University of Maryland said: “I’ve been studying the emergence of potential drug problems in this country for over 30 years. . . . This is the first drug that nobody seems to want to know about as a potential problem.”

Then “Addiction Treatment With A Dark Side” had a section noting some of the aggressive actions taken by Reckitt Benckiser, the company that brought Suboxone to market, “to protect its lucrative franchise.” I’ve noted these and similar actions by Reckitt Benckiser in previous articles: “A Double-Edged Drug,” “The Seduction of Opioid Substitution” and “The Opioid Buzzard.” The Times article documented the widespread association between Reckitt Benckiser and the federal government in bringing Suboxone to market, and in providing a place for lucrative employment when government officials left public service for employment in the private sector.

At one point in “Dying To Be Free,” Cherkis said the “squeeze of regulation” was responsible for opportunistic forces, such as “cash only Suboxone clinics and shady doctors,” as well as the “vibrant black market for illicit buprenorphine. Read the section, “Troubled Histories” in the NYT article and the follow up NYT article, “At Clinics, Tumultuous Lives and Turbulent Care” to get a clearer, more accurate picture of the problems with some of the existing Suboxone treatment centers and providers.

You also find a lengthy section describing the benefits of Suboxone treatment. Cherkis did say in “Dying to Be Free” that the NYT article did not question the efficacy of Suboxone when it was used properly. But why didn’t he discuss or cite some of the concerns? I think it was because “Dying To Be Free” was intended to be a persuasive piece of rhetoric to promote the widespread use of buprenorphine in MAT.

Undoubtedly, “Dying To Be Free” has had a significant influence on opioid treatment. But it seems that it did not present a well-rounded picture of both the problems and the benefits with MAT, specifically Suboxone. It seems to have a biomedical bias with regard to conceiving and treating opioid addiction. In Part 1 of “Feuding Ideologies,” I indicated how its rhetoric was a straw man attack on abstinent-based treatment while it extolled MAT. In Part 2, I showed how it misrepresented the recovery philosophy of Alcoholics Anonymous. Here in Part 3, I looked at how its biomedical bias seemed to dismiss or ignore many of the problems with Suboxone as a MAT for opioid addiction.

10/20/17

Beginning of the End?

credit: Chuck Sigler

According to David Meade, September 23, 2017 was a momentous day—the day that the prophecies written in chapter 12 of the book of Revelation will be evident. He said the world itself was not ending then, but the world as we know it will end. There was to be a series of catastrophic events over the course of weeks afterwards. “A major part of the world will not be the same the beginning of October.” … Still waiting … Anything happening yet?

As The Washington Post noted, the pregnant woman described in the twelfth chapter of Revelation was to appear in the sky on September 23rd. On her head will be a crown of twelve stars. She’ll be clothed with the sun; the moon will be under her feet. The woman represents the constellation Virgo, which will be “clothed in sunlight” and positioned over the moon and under nine stars and three planets. The planet Jupiter will emerge from Virgo, “as though she is giving birth.”

But then Meade revised his prediction, saying that while there were major signs in the skies on September 23rd, but the most important date of the millennium was October 15th, 2017—which would be the beginning of the world’s destruction, the beginning of a seven-year period of tribulation. On his website, Meade wrote: “Hold on and watch — wait until the middle of October and I don’t believe you’ll be disappointed.” You could buy and read his book, but he warned, “You don’t have long to read it.”

Before Meade there was Harold Camping, who predicted the end of the world twice. The first time was supposed to happen between September 15th and 27th, 1994. The second prediction by Camping said it was supposed to happen in 2011. On May 21, 2011, at 6 pm local time, the Rapture and Judgment Day was to take place. Then on October 21, 2011 would be the end of the world. He would later write that while his statements were incorrect and sinful, they allowed God to get the attention of a great many people who otherwise would not have paid attention. “Even as God used sinful Balaam to accomplish His purposes, so He used our sin to accomplish His purpose of making the whole world acquainted with the Bible.”

Meade and Camping are examples of a repeated mistake made by Christians when they fail to read and interpret the visionary texts of the Bible correctly. They often confuse or misinterpret two related visionary genres, prophecy and apocalypse. In How to Read the Bible as Literature, Leland Ryken described visionary literature as picturing setting, characters and events in an imaginary context as opposed to ordinary, empirical reality. This, however, does not mean that the visionary literature of the Bible is pure fantasy.

Visionary literature pictures settings, characters, and events that differ from ordinary reality. This is not to say that the things described in visionary literature did not happen in past history or will not happen in future history. But it does mean that the things as pictured by the writer exist in the imagination, not in empirical reality.

Neither prophecy nor apocalypse is entirely visionary; nor are they necessarily futuristic in their orientation. But they will transform the known world or the present state of things into an imagined reality. “In one way or another, visionary literature takes us to a strange world where ordinary rules of reality no longer prevail.” Ryken said the simplest form of this kind of transformation is to give a futuristic picture of the changed fortunes of a person or group or nation. The motifs of transformation and reversal in visionary literature mean that when interpreting it, the reader needs to be “ready for the reversal of ordinary reality.”

There are several elements or themes within Biblical visionary literature that form its otherness that must be cautiously read and interpreted. There is the portrayal of a transcendental or supernatural world, usually of heaven. This transcendence primarily takes the reader beyond the visible, spatial world and not forward in time. The scope of Biblical visionary literature is cosmic rather than localized. There are supernatural, fantastic agents and creatures. Inanimate objects and forces of nature become actors in the visionary drama.

In the strange and frequently surrealistic world of visionary literature, virtually any aspect of creation can become a participant in the ongoing drama of God’s judgments and redemption. It is a world where a river can overflow a nation (Isaiah 8:5-8), where a branch can build a temple (Zechariah 6:12) and a ram ‘s horn can grow to the sky and knock stars to the ground (Daniel 8:9-10).

The strangeness of such writing leads to a related rule for reading it: visionary literature is a form of fantasy literature in which readers use their imaginations to picture unfamiliar scenes and agents. And the reader must remember that the vision is an imagined reality—different than ordinary, empirical reality. “The best introduction to such visionary literature in the bible is other fantasy literature, such as the Narnia stories of C. S. Lewis.”

The purpose of visionary literature is to break through our normal way of thinking and shock us into seeing that things are not as they appear. The world may not continue on as it is now; there is something wrong with the status quo; or reality cannot be confined to what we can see with our senses. This element of the unexpected extends even into the structure of visionary literature. It has brief, shifting units. There is a range of diverse literary material in the Biblical visionary texts. There can be visual descriptions, dialogues, monologues, brief narrative segments, letters, prayers, hymns, or parables. Visionary elements may be mixed with realistic scenes and events. “Instead of looking for the smooth flow of narrative, be prepared for a disjointed series of diverse, self-contained units.”

There is more that could be said, but this gives us a sense of what constitutes visionary literature in the Bible. Now back to Meade and his prophesied end of the world. He is taking an explicitly apocalyptic text, Revelation 12, and treating it as if it were a prophetic text.  There are specific features of apocalypse that distinguishes it from its literary cousin, prophecy. The Biblical scholar Leon Morris summarized the features found in apocalyptic literature as follows:

  • The vision or revelation is of the secret things of God, inaccessible to normal human knowledge. There are secrets of nature, of heaven, of history of the end.
  • Pseudonymy
  • History is rewritten as prophecy
  • There is a determinism in history ending in cosmic cataclysm, which will establish God’s rule.
  • Dualism (good and evil).
  • Pessimism about God’s saving rule in the present.
  • Bizarre and wild symbols denote historical movements or events.

Apocalyptic is a rather loose category, meaning that texts designated as such won’t always share all the same features. Revelation, for example is not pseudonymous. And the book of Revelation often modifies the apocalyptic features it does have. The golden age for apocalyptic literature was roughly between 200 BC and 400 AD. It is primarily found in Jewish and early Christian texts. Some examples include: Assumption of Moses, 1-2-3 Enoch, 2-3 Baruch, 4 Ezra, Apocalypse of Peter, Apocalypse of Paul, Apocalypse of Thomas, and Ascension of Isaiah. Within the Bible, the following show some features of apocalyptic literature: Numbers 23-24 (Balaam’s oracles), Daniel, Ezekiel, Isaiah 24-27, 1 Thessalonians 4-5, 2 Thessalonians 1-2, the Olivet Discourse (Matt. 24; Mark 13; Luke 21), Revelation. Some scholars would also add parts of Zechariah. With these particular in mind, here is how another Biblical scholar, J. J. Collins, defined apocalypse:

A genre of revelatory literature with a narrative framework, in which a revelation is mediated by an otherworldly being to a human recipient, disclosing a transcendent reality which is both temporal, insofar as it envisages eschatological salvation, and spatial insofar as it involves another, supernatural world.

Now let’s turn to the text of Revelation 12 used by Meade in his prediction that October 15th, 2017 would initiate a seven-year period of tribulation, resulting in the destruction of the world. Here is a four-minute YouTube video by Unsealed that illustrates how Meade and other Christians believe September 23rd represents a spiritual sign of the ending of the “Church Age.” On his website, Meade said: “We’re all watching for the September 23 Sign because we know it means the end of the ‘Church Age.’  That is a spiritual sign only.  But it is huge.” Now compare the video to the following verses in Revelation 12 that it interprets.

And a great sign appeared in heaven: a woman clothed with the sun, with the moon under her feet, and on her head a crown of twelve stars. She was pregnant and was crying out in birth pains and the agony of giving birth. And another sign appeared in heaven: behold, a great red dragon, with seven heads and ten horns, and on his heads seven diadems. His tail swept down a third of the stars of heaven and cast them to the earth. And the dragon stood before the woman who was about to give birth, so that when she bore her child he might devour it. She gave birth to a male child, one who is to rule all the nations with a rod of iron, but her child was caught up to God and to his throne. (Revelation 12:1-5)

This passage in chapter 12 of Revelation is one visionary unit in a series of visions give to John by an angel (Revelation 1:1). After the letters to the seven churches, which represent the Church universal, John looked up and saw a door open in heaven (Revelation 4:1). Then came a series of visions including the throne room in heaven. The scroll and the Lamb, the seven seals, the 144,000 of Israel, the seven trumpets, the angel and the little scroll, the two witnesses, and more. At the sound of the seventh trumpet, the twenty-four elders worshiped God. Then God’s temple in heaven opened to reveal “the ark of his covenant.”

The context of Revelation has many of the characteristics of apocalyptic literature. There is a vision framed within a narrative. It’s mediated by an angel to John, and discloses a series of scenes of what is happening in heaven. Chapter 12 describes the conflict between good and evil; the pregnant woman and the dragon. There was the symbolic representation of the encounter of the woman and the dragon; and what happened afterwards.

Revelation 12:1-5 is a condensed retelling of the story of the gospel using apocalyptic. There will be enmity between the seed of the woman and the serpent. In pain she will bring forth children (Genesis 3:15-16). Jesus is that seed, and the verse in Genesis 3 has been traditionally identified as the protoevangelium—the first gospel. Satan intended to “devour” him, but failed. Jesus was caught up—by God—to his throne at his ascension (Acts 1:9-11). A final clue that the passage is not a prophetic foretelling of a future time to John, namely the September 23, 2017 initiation of the end of the church age, is the parallel here to the Greek myth about the birth of Apollo. Gordon Fee, in his commentary on Revelation related the following.

It is important for the modern reader to know that the whole scene is a common one in ancient mythology as well; thus the first readers of this book, mostly Gentile converts in the province of Asia, could hardly have missed here an echo of the well-known myth from their own history. In that myth about the birth of Apollo to Leto, wife of Zeus, the dragon Python hoped to slay the child (Apollo) but he was protected by Poseidon. When grown Apollo then slew the dragon. But whatever the coincidences that may exist between that myth and the essential Christian story, John’s imagery has effected its total transformation into the basic (historical) story of Christ, who through his cross and resurrection thus defeated the dragon. At the same time, the astute biblical reader will see something of a replay, but in a radically new way, of the scene in the Garden of Eden in Genesis 3; but now the woman withstands the snake, and her child is rescued by God, who also protects the woman in “the wilderness.”

The interpretation of Biblical apocalyptic literature is fraught the dangers of misunderstanding and misinterpretation, as Harold Camping discovered and hopefully David Meade will himself acknowledge. In his own apocalyptic narrative in the Olivet Discourse of Matthew 24, Jesus said: no one knows the time of his return and the end of the age; not even the angels in heaven, nor the Son, but the Father only (Matthew 24:36). Not even David Meade knows.