12/9/16

Channeling Your DXM Personality

June of 2016 was a confusing month for DXM. Alaska became the 11^th state to limit the sale of products containing dextromethorphan (DXM) to individuals 18 and older. Representative Charisse Millett of Anchorage thanked her colleagues for passing a bill that will protect Alaska teens. On the other hand, there was a study published in the journal, Substance Abuse Treatment Prevention, and Policy by Spangler, Loyd and Skor that same month which said DXM was a safe, effective cough suppressant, available without a prescription since 1958. The article reported how the annual prevalence of DXM abuse has sharply decreased since 2010. So why would so many states be restricting the sale of a “safe, effective cough suppressant”?

Adding to the issue, there is H.R. 3250, The DXM Abuse Prevention Act, which was sent to both the House and Senate for consideration on April 27, 2016. H.R. 3250 seeks to prevent the abuse of DXM and would restrict its sale to individuals 18 and over. Civil penalties for retailers violating H.R. 3250 would range from a warning for a first offense up to $5,000 for four or more violations. If implemented, the federal law would take precedence over any existing state legislation.

The pro-drug website Erowid noted that while DXM is still unscheduled in the US, and legal to buy, possess and ingest without a prescription, it is becoming increasingly difficult to purchase. “Some pharmacies and mega-stores like WalMart have instituted voluntary procedures to reduce the sale of DXM-containing products to minors.” Erowid listed and commented on the legal status of DXM in 25 different states and was soliciting more information on its status in other states.

In 2007 the DEA requested that the FDA evaluate whether dextromethorphan should be scheduled as a controlled substance. Three years later the FDA held an Advisory Committee meeting on the matter. After hearing presentations on DXM and its abuse potential, the committee voted 15 to 9 against scheduling DXM. An Erowid assessment of the presenters was they did not believe that scheduling was warranted, but were concerned about abuse.

The DXM article by Spangler, Loyd and Skor said that to address reports of abuse, the Consumer Healthcare Products Association (CHPA) initiated a plan to raise awareness of the behavior and “address prevention by focusing on the factors that impact teen behavior.” All three authors were employees of the CHPA, “which represents manufacturers of over-the-counter medicines and dietary supplements.” And funding for the research, collection of the data, analysis, interpretation, plan implementation, and writing of the manuscript was provided by CHPA member companies. They concluded:

It is noteworthy that the annual prevalence of over-the-counter cough medicine abuse has sharply decreased since 2010. While a true cause-and-effect relationship cannot be assured, the Consumer Healthcare Products Association and its member companies believe that the increased awareness of the issue since the 2010 Food and Drug Administration Advisory Committee meeting, and the subsequent implementation of a well-delivered and targeted abuse mitigation plan that addressed the levers influencing teen decisions is contributing to the observed reduction in abuse. During the period of 2010–2015, reported abuse of dextromethorphan by 8^th, 10^th, and 12^th graders decreased 35 %. The authors believe this reduction supports the view of the Consumer Healthcare Products Association at the outset of the abuse mitigation plan effort and today: Controlled substance scheduling or prescription requirements would result in a reduction in the legitimate use of this medicine that has benefits that far outweigh its risks. Instead, there are more targeted, more effective, and less disruptive interventions to address dextromethorphan abuse.

Writing for The Fix, John Lavitt reported that one in 30 adolescents use DXM to get high because it is cheap and accessible. In 2014 there were six DXM-related deaths, according to the American Association of Poison Control Centers. Non-medical use of DXM leads to around 6,000 ER visits per year. Adolescents account for almost 50% of those visits. The effects range from mild stimulation to euphoria and hallucinations. There can be an out-of-body dissociative state, complete dissociation with unresponsiveness and even overdose.

Medline Plus lists some of the many products that contain DXM, including NyQuil, DayQuil, TheraFlu, Tylenol Cold, Dimetapp DM, Robitussin DM, Triaminic DM, and Alka-Seltzer Plus Cold and Cough. Some of the symptoms of a DXM overdose listed included: breathing problems, bluish-colored fingernails and lips, blurred vision, coma, Convulsions, drowsiness, hallucinations, heart palpitations, nausea and vomiting, rapid heart beat.

Now here is some DXM history from Erowid. It was approved by the FDA in 1958. In the early 1960s, there were reports that beat poets like Allen Ginsberg and Peter Orlovsky and the author Jack Kerouac were using DXM in the form of Romilar tablets. Incidentally, Romilar was introduced as a replacement for codeine cough remedies in an attempt to cut down on abuse. In 1973, Romilar DXM tablets were removed from the market after an increase in recreational use was noted. DXM continued to be available as a syrup, with the thinking that consuming large quantities of syrup would be deterrent for recreational use. OTC DXM tablets have been back on the market now for number of years. In the late 1980s DXM use was prominent among the punk subculture.

By the way, codeine cough syrup is main ingredient in the concoction “Sizzurp” that sent rapper Lil Wayne to the hospital with multiple seizures. He even wrote a song about his love for Sizzurp, “Me and My Drank.” Then there’s Justin Beiber and his street-racing-DUI-Sizzrup arrest. Teens and others without ready access to a codeine prescription cough formula can substitute OTC DXM formulas in their Sizzurp knockoff. Add some Jolly Ranchers to make the concoction more drinkable.

So while DXM may be safe and effective when used as recommended, it was being used as a recreational high almost from the time it came onto the market as a substitute for codeine. It has ebbed and flowed in its consideration for classification as a controlled substance. Currently it isn’t one. However, it does seem likely to face restricted sales to anyone under the age of 18. Eleven states have already passed legislation to that effect, and larger chains like WalMart, Walgreens, Target, Rite-Aid and others now require ID and limit sales to two DXM-containing products. And there is pending federal legislation that has a 38% of passing that would make it illegal to sell DXM products to minors. The last word on DXM is from Erowid.

Recreational DXM use continues. A number of deaths have been documented due to the recreational use of DXM although a majority of these have been the result of products (such as Coricidin Cough and Cold) that combine DXM with other substances that become dangerous in high doses.

So if you decide to try and contact your inner beat poet, or channel your punk rock personality through DXM, be careful.

05/6/16

Fading Flakka Fad

In the summer of 2015 when flakka was at its zenith in Broward County Florida, police needed four or five officers to subdue one agitated person high on flakka. In The Washington Post, Todd Frankel said people high on flakka were everywhere. “Running into traffic. Zoned-out on curbs. Sometimes naked. Sometimes in the grips of a drug-fueled psychosis.” Emergency departments were overwhelmed. A drug treatment counselor in Florida said: “At the height of the flakka craze, you were almost praying for crack cocaine to come back.”

In the summer of 2015, 12 new cases of flakka-related delirium were admitted daily to South Florida hospitals. Flakka users are resistant to pain and sometimes have superman strength. Tasers were sometimes ineffective. Deputies sometimes had to wrestle users to the ground and punch them to gain control. Talking didn’t work. Reporting for The Fix, Valerie Tejeda said CNN reported there were 63 deaths attributed to using flakka in South Florida between September 2014 and December 2015. Also for The Fix, McCarton Ackerman said some Florida EMS departments were training to use ketamine to sedate flakka users who showed signs of aggression.

Then almost as quickly as flakka came onto the scene, it went away. Returning with Todd Frankel to a gas station that had been a local gathering place to buy and sell flakka, a police lieutenant in Pompano Beach Florida couldn’t find even one person. In a short period of time flakka has disappeared from South Florida. “Experts say drug epidemics almost never burn out like this.”

In March of 2015, the United Way of Broward County organized the Flakka Action Team. The task force consisted of substance abuse counselors, local police officers and others. They developed a plan “to educate the community, to teach the police how to respond and figure out how to stop flakka production.” Anti-flakka posters were put up around the county. Community forums were held. Education presentations were done at schools, jails and homeless shelters.

Traditional drug treatment didn’t work with flakka users. One of the post acute withdrawal effects with chronic users was concentration. “Even filling out paperwork was a challenge.” Some people were light sensitive, so sessions occurred in darkened rooms. Some others struggled with paranoia and insomnia.

Jim Hall, an epidemiologist at Nova Southeastern University in Fort Lauderdale, publicized the Chinese connection with flakka. You could place an online order for flakka from a Chinese manufacturer and have it delivered to your door. A kilo of flakka cost $1,500 and had a street value of $50,000. In mid–October of 2015, the U.S. Treasury imposed sanctions on one alleged synthetic drug producer in China. In November, Florida law enforcement officials and local DEA agents went to China to plead their case directly with the Chinese government.

Afterwards, China announced they had banned 116 different synthetic drugs, including flakka and fentanyl. Confusingly, the announcement said this action had been taken on October 1st. Reported hospital cases of flakka in Broward County went from 306 in October of 2015 to 54 in December. There have been no reported deaths from flakka in 2016 as of the beginning of April 2016. There were only six flakka users admitted to Florida treatment centers in January. In February the Flakka Action Team dropped “flakka” from its name.

Michael Bauman of the National Institute on Drug Abuse (NIDA) said: “History has shown that one of the unintended consequences to banning certain drugs is that it typically leads to an explosion of new replacement drugs.” Whether or not that will occur in response to the 116-drug ban remains to be seen. But there is a next step to be taken, if the recommendations of a Broward County grand jury are activated. They recommended that entire classes of drugs, such as synthetic cathinones or bath salts, which includes flakka, should be banned.

Florida Attorney General Pamela Bondi has proposed the “2016 Florida Designer Drugs Enforcement Act.” The legislation would ban synthetic cathinones, synthetic opioids and synthetic cannabinoids. It could potentially outlaw as many as 1,000 different chemical compounds, according to Jim Hall.

But what’s next? The next “designer-drug battlefield” would seem to be variations of the synthetic opioid fentanyl. Craig Mallak, the Chief Medical examiner for Broward County said: “Flakka is gone … fentanyl is the next big thing.” His office is in the process of developing a database to track the trend of fatalities with fentanyl.

For more information on flakka, read “Flack from Flakka,” “High on Flakka” and “Emerging Public Health Threat.”

04/19/16

Ketamine to the Rescue?

Enthusiasm for using ketamine to treat depression has been growing. The interest in the fast action effects of ketamine for treatment-resistant depression began with the publication of a study by Zarate et al. in 2006 that found “Subjects receiving ketamine showed significant improvement in depression compared with subjects receiving placebo within 110 minutes after injection.” Since then, dozens of studies have been done and thousands of people have been treated for depression off label with ketamine. Now the American Psychiatric Association has a ketamine task force and is seriously considering an endorsement of ketamine for treatment-resistant depression.

An NPR story featured psychiatrist David Feifel’s work in treating depression with ketamine. Feifel began treating people with low dose ketamine in 2010. After reading the papers on ketamine, he said he was electrified. People were getting better in hours. “It became clear to me that the future of psychiatry was going to include ketamine, or derivatives of ketamine, or the mechanism of action in some way.”

He said it was hard for him to take the “wait and see” approach suggested by other psychiatrists when people are desperate for help. It didn’t make sense to him. Sara Solovitch, writing for The Washington Post, said some experts are calling it the most significant advance in mental health treatment in fifty years.

Ketamine has been around since the 1960s. It is regularly used as an ER anesthetic because it can rapidly stop pain without affecting vital functions like breathing. It’s often the go-to painkiller for children who come to the ER, say with a broken bone. It’s used in veterinary medicine and is an important tool in burn centers. It’s also been used as date-rape drug, because of some of the self-same properties that make it an attractive ER anesthetic. It will quickly numb and render someone immobile.

A single dose of ketamine costs under $2. The drug is easily available in any pharmacy; and doctors are free to prescribe it for off-label use. But ketamine treatment for depression is expensive. Dr. Feifel charges $500 for an injection and $1,000 for an intravenous infusion. The high cost is attributed by practioners to the medical monitoring and IV equipment required during an infusion.

It isn’t an approved depression treatment, so the costs are out-of-pocket, placing it out-of-reach for many people. But clinics are going up everywhere. A directory found 19 different centers in the US as of the beginning of February, in 2016. Dr. Feifel is afraid something will happen to a depressed patient at one of these unregulated clinics that could set back efforts to make the drug more widely available.

Sara Solovich reported there a growing number of academic medical centers that are offering ketamine treatments off-label for severe depression. These medical centers include: Yale University, the University of California at San Diego, the Mayo Clinic and the Cleveland Clinic. A San Francisco psychiatrist, Alison McInnes, thinks this is the next big thing in psychiatry. Psychiatry has “run out of gas” in trying to help depressed patients. “There is a significant number of people who don’t respond to antidepressants, and we’ve had nothing to offer them other than cognitive behavior therapy, electroshock therapy and transcranial stimulation.”

Dr. McInnes reported a 60% success rate for people with treatment-resistant depression who try ketamine. Dr. McInnes is also a member of the APA’s ketamine task force. She expects the APA to support ketamine treatment in 2016.

Ryan, Marta and Koek did a literature review on ketamine as a treatment for depression in a 2014 issue of the International Journal of Transpersonal Studies, “Ketamine and Depression: A Review.” They acknowledged that the largest challenge with ketamine was extending its benefit for the longer term. Repeated infusions of ketamine showed some promise, but it is far from clear what the optimum dose, frequency and number of infusions should be. “It also worth noting that some patients do not benefit from ketamine, despite multiple treatments.”

Ready for the drawbacks? “Even low-dose ketamine infusion can cause intense hallucinations.” Patients experience a kind of lucid dreaming or dissociative state where they lose track of time and have out-of-body experiences. Many people enjoy it; but others don’t. The treatment effects are often temporary. Dr. Feifel reported one patient whose depression remission would begin to fade within twenty-four hours. With others, the remission can be longer; even weeks. The fleeting remission effect means that many patients return for booster infusions. A business executive from Seattle flies back-and-forth to New York for bimonthly infusions. Sometimes his remission periods will last six months.

Gerald Sanacora, the director of the Yale Depression Research Program, said ketamine infusion is an extremely important treatment. His concern is that people may begin using it as a first-line treatment—before CBT (cognitive behavioral therapy) or antidepressants like Prozac. “Maybe someday it will be a first-line treatment. But we’re not there yet.”

It’s a medication that can have big changes in heart rate and blood pressure. There are so many unknowns, I’m not sure it should be used more widely till we understand its long-term benefits and risks.

There isn’t a registry yet for tracking ketamine patients treated for depression. So the number of people treated, the frequency of those treatments, the dosage levels, follow up care—and importantly—adverse effects from ketamine treatment aren’t known. Carlos Zarate, the NIMH’s chief of neurobiology and treatment of mood disorders, said: “We clearly need more standardization in its use.” In his opinion, it should still be used in a research setting or a highly specialized clinic.

There also seems to be a turf war or sorts brewing. Ketamine was once almost exclusively a drug known to anesthesiologists. Psychiatrists are now saying that with the use of ketamine for depression growing, it should be left for psychiatrists to prescribe. David Feifel said:

The bottom line is you’re treating depression. . . . And this isn’t garden-variety depression. The people coming in for ketamine are people who have the toughest, potentially most dangerous depressions. I think it’s a disaster if anesthesiologists feel competent to monitor these patients. Many of them have bipolar disorder and are in danger of becoming manic. My question [to anesthesiologists] is: “Do you feel comfortable that you can pick up mania?”

Six of the providers in the above-linked directory are specialists in anesthesiology. Six are psychiatric specialists. The rest are a mixture of specialists in emergency medicine, neurology, internal medicine and even family medicine. Enrique Abreu, A Portland Oregon anesthesiologist who began treating depressed patients with ketamine in 2012, said: “Most anesthesiologists don’t do mental health, and there’s no way a psychiatrist feels comfortable putting an IV in someone’s arm.”

Ketamine in larger doses than are being used in the above discussed depression research is a club drug known as “Special K,” “K,” or Ket.” It is a Schedule III Controlled Substance, meaning it is classified as having an addictive potential. Current depression research has not indicated dependence as an adverse effect, likely because of the low doses currently being used. When used with other sedating drugs like alcohol, the potential of slowing or shutting down the central nervous system are increased. And it is possible to overdose on ketamine. While some clinicians like Drs. Feifel and McInnes would like to see ketamine treatment revolutionize the psychiatric treatment of depression, caution in waiting for the results of further research seems advisable.

Unfortunately, I don’t think that will happen. Psychiatric treatment of depression is in crisis. Even the articles and researchers cited here seemed to acknowledge this. Dr. McInnes said psychiatry has “run out of gas” in trying to help depressed patients. Dr. Fiefel said he found it hard to “wait and see” what further research found regarding ketamine, when so many people were desperate for help.

Pharmaceutical companies stopped doing research into new antidepressants. The chemical imbalance theory of depression is now referred to as more of an urban myth than a true description. Pharma and psychiatry need an antidepressant savior and it seems they hope it will be ketamine.

12/28/15

Weaponized Marijuana

William Wells, a homeless man living in New York City, first started using K2 about a year ago. “My brain is connected to the chemicals,” he said. “It will have you running down the block. It will have you fighting yourself. It will have you getting very violent. It will have you living like a bum. . . . I wish I could stop, but I can’t stop. I can’t stop.” An East Harlem resident said that K2 was being sold 24 hours a day in the area. “Every day I see people doing it right there on the street. It makes them stuck. They stand in one place for hours at a time.” Read more from the original article by Matthew Speiser here.

New York City Mayor Bill de Blasio signed legislation recently that banned the sale of synthetic cannabinoids, commonly known as K2 or spice. The law also bans the sale of synthetic stimulants known as bath salts. Not only are there possible civil and criminal penalties, the legislation authorizes the city to close down businesses that violate the law twice in a three-year period. The New York Times reported in September 2015 that the proposed ban would include selling any drug marketed as synthetic marijuana and any imitations with effects similar to the synthetic cannabinoids.

Authorities did begin to crack down on the sale and distribution of these new psychoactive substances (NPS). Ten defendants were charged and 90 bodegas (convenience stores) were raided. These included six retail outlets on 125th Street in Harlem, which has become ground zero for K2 use among the homeless in the City. Nicholas Casey wrote how:

Crowds of up to 80 or 100 homeless people come in on buses from a nearby shelter on Randalls Island, drawn by heroin recovery clinics nearby, and spend the day there under the influence of this cheaper narcotic. The block between Park and Lexington Avenues appears at times to be a street of zombies.

Police raids on 125th Street in July of 2015 led to confiscations of more than 8,000 packets of K2. But many of the stores continued selling the drug. The sheer number of users on the block has left police officers edgy. “It quickly can become a kind of group mentality where the officers, or even multiple officers, are outnumbered,” according to Tom Harnisch, commander of the 25th Precinct. NYPD Commissioner Bill Bratton described the drugs as “weaponized marijuana.” He said: “This is a scourge on our society, affecting the most disadvantaged neighborhoods and our most challenged citizens. It affects teenagers in public housing, homeless in the city shelter system, and it’s quite literally flooding our streets.”

The New York Daily News filmed a six-minute documentary,”K2 in New York City.” It opens with a 20 second shot of a guy catatonically zoned out on K2. A homeless man who sells K2 held up a packet of “Trippy,” saying: “I want Obama to see this too.” Another person said it was ten times worse than heroin. Against the background of two police officers standing by a person crying out on the sidewalk, a graphic noted that: “Between April 2015 and September 2015 there were more than 4,700 K2-related emergency room visits in NY state compared to just 230 during the same period in 2014.” Another man said that was how he got through the day, dealing with his misery and pain by doing the drug.

A woman said: “Don’t do it. If people haven’t done it … if I know for a fact that you haven’t smoked it, I will not let you smoke it. I wouldn’t ruin somebody’s life like that.” NYC paramedic Robert Kelly said it seems to be effecting mentally ill homeless people in the shelter systems; people that are known drug users. “Unfortunately it’s cheap; it’s easy to get.” US Attorney Preet Bharara announced an operation that seized over 200 kilograms of chemicals and an estimated 275,000 packets of finished product that would have totaled more than 2,700 kilograms of spice. A conservative estimate of the street value of that amount of spice is over $30 million dollars.

The Fix described this joint DEA and NYPD operation as targeting the sale of the drugs in all five NYC boroughs. Part of the operation raided five processing facilities and warehouses used to store and distribute the drugs. More than 80 bodegas were searched as part of the overall operation. DEA Special Agent in Charge, James Hunt said: “Synthetic cannabinoids are anything but safe. They are a toxic cocktail of lethal chemicals. . . . By investigating and arresting manufacturers and distributors of ‘spice’ in the city, we have cut off the accessibility for those feeding the beast.”

The NYC Department of Health and Mental Hygiene has an information page on K2 that describes some of the risks associated with K2 use. “Information for Consumers” said the most common adverse effects of K2 reported include: lethargy, confusion, drowsiness, respiratory depression, nausea, vomiting, tachycardia (increased heart rate), paranoid behavior, agitation, irritability, headache seizures, and loss of consciousness. Severe side effects could include acute renal failure and cardiovascular and central nervous system complications. “In rare instances, use of cannabinoids has been linked to death.”

John Lavitt opened his article for The Fix with a comment on how synthetic drug sales have allegedly fueled terrorism, a claim which has some clear evidence for it. One of the name brands of synthetic marijuana named in The New York Daily News video described above, Scooby Snax, was involved in a DEA raid on a Birmingham Alabama warehouse in May of 2013. Sales from the product were linked to $40 million in wire transfers to Yemen. See “Strange Bedfellows: Terrorists and Drugs.” Also see “The Double-Edged Sword of Narco-Terrorism.”

05/18/15

Cross Addiction Isn’t a Myth

Last year there was a study published in JAMA Psychiatry that concluded there was a lower risk of developing a new SUD (substance use disorder, the new DSM-5 lingo) if the individual had “remitted” from a SUD in the past. The results indicated that remitters had “less than half the risk of developing a new SUD.” So contrary to “clinical lore,” achieving remission does not lead to drug substitution, but rather to a lower risk of new SUDs.

There was a Reuters article, “Former Addicts May be at Lower Risk of New Addictions,” that discussed the study’s results. Mark Olfson, the senior author of the study, was quoted by Reuters as saying the results “cut against conventional clinical lore” that suggests people who stop one addiction are at risk of starting a new one. “The results challenge the old stereotype that people switch or substitute addictions but never truly overcome them.” He went on to say:

While it would be foolish to assume that people who quit one drug have no risk of becoming addicted to another drug, the new results should give encouragement to people who succeed in overcoming an addiction.

Commenting on the study to Reuters, Olaya García-Rodríguez, who was not one of the study’s researchers, said: “To achieve remission, most individuals need to make changes in their lifestyle and learn strategies to avoid substance use that will eventually protect against the onset of new addictions.” They learn to avoid substance-related people, place and things. They develop more behavioral coping strategies. Improved family relationships, better health and financial stability can also contributed to their ability to maintain abstinence. She suggested that we should rethink the perception that SUDs are chronic illnesses as the study indicated that remission was possible.

There was also an article on The Fix, titled: “New Study Disproves So-Called ‘Cross-Addiction’ Myth. The author began her article by saying that it is often believed that people who have a substance use disorder are at increased risk for developing another. However, the JAMA Psychiatry study debunked this so-called “cross-addiction” myth. When comparing the two articles, it seemed to me that they both reported much of the same information. Both even quoted the above block quote by Mark Olfson. And yet The Fix article concluded the study had debunked the cross-addiction myth, while the Reuters article was suggesting that there was little support for the hypothesis that conquering one addiction leaves you vulnerable to substituting another substance.

It does seem that Mark Olfson sees his work as challenging the notion of switching or substituting addictions, but even he said it would be foolish to assume people who quit one drug have no risk of becoming addicted to another drug. Not only would it be foolish to conclude the study disproved cross-addiction, but to simply stop where The Fix author did with her understanding of its implications would be dangerous for some people with a SUD. So I decided to look at the study myself, “Testing the Drug Substitution Switching-Addictions Hypothesis.” You can review the article abstract here.

There were two “waves” to the data gathering that occurred an average of 36 months apart. Individuals were considered to have remitted from an SUD (abuse or dependence) if by the wave 2 assessment they did not meet the DSM-IV criteria for that disorder in wave 2, but had met the criteria in wave 1.

Individuals who met the criteria for abuse at wave 1, but later met the criteria for dependence (a more serious diagnosis) at wave 2, were seen as having a new-onset SUD. Individuals who met the criteria for dependence at wave 1 (which meant they also met the criteria for the less serious diagnosis of abuse), were not counted as in remission at wave 2 if they still met the abuse criteria, but no longer met the dependence criteria.

Having a new SUD was defined as having an SUD at wave 2, but no lifetime history of that SUD at wave 1. Relapse was a new episode of an SUD at wave 2 among individuals with a lifetime history of the SUD that was in remission at wave 1. So far, so good. The diagnostic distinctions and operational definitions for remission, relapse and a new SUD made sense. Now let’s look at the results. Remember that there was a 36-month average time period between wave 1 and wave 2.

Individuals who did not remit an SUD were more likely to have a new SUD at wave 2 than individuals who did remit (43.3% for non-remitters versus 8.7% for remitters). This makes sense. People with an SUD who continued active substance use had a greater likelihood of “catching” a second one in 3 years. Remitters with only one SUD at wave 1 were less likely to have a new SUD at wave 2 than non-remitters (10.0% versus 24.3%). Remitters with two or more SUDs at wave 1 were also less likely to have a new SUD at wave 2 than non-remitters (21.4% versus 46.3%).

It seemed the presence of multiple SUDs at wave 1 was a significant factor in remission. The proportion of individuals with 1 SUD at wave 1 who remitted was 41.1%. “Among individuals with 2 or more SUDs, 17.1% remitted from all of them, 46.9% from at least 1 of them, and 36.6% did not remit from any of them.”

Taken together, our findings indicate that remission of an SUD is not associated with an increase but rather with a dramatic decrease in the risk of a new-onset SUD or relapse onto a previously remitted SUD.

Some observations need to be made about the study. First, as the study noted, there were several likely mechanisms that contributed to “the protective effects of SUD remission from new-onset SUDs.” The avoidance of drug-related cues and drug-using peers (avoiding people, places and things associated with addiction) would not only assist in blocking SUD remission, but also in inhibiting new-onset SUDs. The lifestyle changes made by successful remitters would make it less likely they could “catch” a new SUD.

The study also did not include any information on whether other substances were used during the time of remission. For example, someone with an opioid SUD remission in the study could have used and even been drunk on alcohol off and on during their remission time without meeting the criteria for an alcohol use disorder diagnosis. Alcohol use disorders will typically take a longer period of time to progress from initial use to meeting the criteria for an SUD diagnosis.

In addition, the assessment of what the researchers referred to in their study title as “switching-addictions hypothesis” was limited to assessing the risk of developing another SUD. “Adults who recover from an SUD are often thought to be at increased risk for developing another SUD.” Ironically, the study cited in support of this statement, “Substitute Addiction: A Concern for Researchers and Practitioners,” had a broader understanding of what a substitute addiction could be. In addition to substance addictions, they also looked at how process addictions and food could become “substitute addictions.”

Sussman and Black, the authors of the study, described process addictions as “a series of pathological behaviors that exposes one to ‘mood-altering events’ on which one achieves pleasure and becomes dependent.” They said process addictions involved a relatively indirect manipulation of pleasure through situational and physical activity. Examples of process addictions they said were identified in the literature included: video game playing, gambling, Internet use, sex, work, exercise, compulsive spending, and religion.

That there may be a wide variety of behaviors that one can become dependent on, repeat excessively, and suffer consequences from, suggests the opportunity for someone to participate in these behaviors sequentially; one replacing functions of the other. In the recovery movement, substitute addictions have been addressed as an issue about which persons in recovery should be vigilant.

So I don’t think the study goes against conventional clinical lore that people who stop one addiction are at risk to develop a new one. It does not debunk the so-called “cross-addiction” myth. It does indicate that individuals who successfully establish a lifestyle that is not full of drug-related cues and drug-using peers will have a decreased chance of developing a new SUD.

In closing, I thought the following results, while not directly related to the purpose of the study, were particularly interesting. Individuals who sought treatment between wave 1 and wave 2 “were significantly more likely to remit than those who did not (36.8% versus 19.2%).” After adjusting for remission status (remission versus non-remission), individuals who sought treatment had the lower odds of a new-onset SUD at wave 2. “The probability of a new-onset SUD was lowest for abstinent remitters (12.4%), intermediate for nonabstinent remitters (15.2%), and highest for nonremitters (27.2%).”

I’d say the “cross-addiction myth” is very much alive and well. And it isn’t just a myth.

04/17/15

The Blessing of Persecution

It seems Jesus thought what he said in the eighth beatitude, namely that his disciples will be persecuted, needed to be driven home and required some unpacking. Leon Morris noted where Matthew used the verb “persecute” in three consecutive verses (5:10-12), underlining the importance of the concept. In Matthew 5:11 and 12, Jesus then switched from the third person to the second person, now speaking directly to his audience. You are blessed when others revile (mock) you and persecute you (harass you for what you believe) falsely on his account. You are to rejoice and be glad if it happens, because you must be doing something right.

What they are doing right is living out the righteousness he just described in verses 5:3 through 5:10. There is also a warning in what Jesus said. If you attempt to live righteously in this world for me (on my account), then you will be persecuted. When we try to live as Jesus would live, we should expect the same persecution he received. As he said elsewhere, “If the world hates you, know that it hated me before it hated you” (John 15:18).

The hatred, persecution or abuse can be both verbal (mocking, demeaning, reviling) and physical. Pointing to the persecution of the prophets, then telling his disciples to rejoice when they are persecuted as the prophets were persecuted, clearly indicates this. Jeremiah’s life and ministry is a good example. He was mocked for his prophetic declaration of God’s judgment against Judah (Jer. 18:18). The religious leaders and false prophets also tried to have him executed for treason when he was imprisoned in a cistern (Jer. 38:1-6).

When I look at the character traits listed in the beatitudes, there doesn’t seem to be anything that should target the disciples of Jesus for persecution. Striving to be poor in spirit, meek, merciful, pure in heart or a peacemaker seem to be good things. Individuals who grieve or mourn their own sinful actions aren’t readily seen as people who need or should be mocked and reviled. In a similar way, I don’t get the mocking and ridicule I’ve seen heaped upon Alcoholics Anonymous and Twelve Step recovery. Here are a couple of examples.

The first is the “Cougarblogger.” Here is a sampling of some of her articles: “12 Things the Cult of Religion of the 12 Steps Does NOT Want You to Know;” “Rules for Sex Offenders—Attendance in 12 Step Cult Meetings;” “Dangerous Criminal in You Alcoholics Anonymous Meeting;” Fake ASAM ‘Doctors’ Push AA Cult for Profit;” “Never Call Yourself an “Alcoholic” or “Addict.” Here is a quote from the last listed article:

“Why do you hate 12 step programs so much?” When I get asked this question, in my head I think, “Why don’t you?!?!” Then I realize they are either ignorant, have a relative/friend in the cult, (who gives all credit for their very lives to the cult), or are a stepper (or ex-stepper), themselves. What is most astounding is when ex-steppers defend the cult, but then I quickly realize the power of the brainwashing. Even those who have left (gotten free really), feel the need to defend the cult.

There is no way to have a conversation with someone like that. Her mind is made up. To use a 12 Step recovery saying, it’s either her way or the highway.

The charge of A.A. being a religious cult has been around for awhile. I think the classic argument for this position is Alcoholics Anonymous: Cult or Cure? by Charles Bufe. Even Bufe, who assessed A.A. according to a description of what a cult was that he himself developed, acknowledged that it is difficult to answer if A.A. is a cult. Unequivocally, he thought A.A. was religious (the first of his 23 criteria). He distinguished between institutional and communal A.A and thought that institutionally, A.A. was a cult; but communally, it wasn’t, “though it comes close, and does have many dangerous, cult-like tendencies.”

Another blogger, julietroxspin, is a self-described activist for secular treatment options for alcohol and drug abuse treatment. She also blogs on The Fix (as Juliet Abram). A sampling of her articles on A.A.R.M.E.D. with Facts, are: “There are No Rules Only Suggestions;” “I’m Deathly Allergic to AA;” “AA Needs to Give a Damn About It’s Bad Reputation.” A sampling of her articles for The Fix are: “Normies React to the 12 Steps;” “Can an AA Critic and a 12-Step Advocate Get Along?;” “Recovery Bullies.” In “I’m Deathly Allergic to AA,” Juliet stated:

I can say I worked the steps, I felt the mental shift inside changing my interpretation of the past. Guilt. Blame. Darkness. The steps were harming me, not because I “quit before the miracle happened,” but because I “kept coming back.” Because I’ve been abused, I can get addicted to abuse. It’s real simple, and real deadly.

While Juliet is clearly anti-A.A., I think she is trying to be more objective than “Cougarblogger.” I suspect that both of them would see my reflections on how the Sermon on the Mount applies to A.A. and recovery as evidence of how A.A. is religious. But to do so you have to assume an understanding of “religion” that different than that of A.A. and William James in The Varieties of Religious Experience from which they self consciously drew their distinction between “spiritual” and “religious.”

Evangelical Christians have also been critical of A.A. and what they saw as integrating psychology with Christian doctrine. Gary and Carol Almy said that: “The 12-step groups follow the doctrine of the psychology gospel and are determined to grab the benefits of what Paul called ‘the new life in Christ’ without the crucifixion of the old.” Martin and Deidre Bobgan see A.A. as Christless religion, offering a counterfeit salvation: “Because of the many versions of God represented in AA, professing Christians are uniting themselves with a spiritual harlot when they join A.A.”

The “persecution” of A.A. and 12 Step recovery has been mocking and demeaning at times—curiously—from both religious and nonreligious sources. But remember what Jesus says here in the Sermon on the Mount: “rejoice and be glad” when you are persecuted. Nonreligious members of A.A. won’t like or agree with the promised reward in a heaven they don’t believe in. But they could see an “eschatological” ending of their own by working the Steps—continuing in abstinence until they die.

One last comment related to the “prophets” mentioned by Jesus in the Sermon on the Mount. Stanton Peele, another A.A. critic, approvingly mentioned Charles Bufe’s prediction of the end of “A.A.’s reign of terror over” American alcoholism treatment. Bufe, writing in 1998, suggested that several factors would “virtually ensure that AA will begin to shrink significantly” within five to ten years. “They make it entirely possible that AA will cease to exist as a significant social movement by the second quarter of the 21st century.”

In 2014, Alcoholics Anonymous estimated its total groups at 115,300, with more than 2 million members in over 170 different countries. Data on A.A. members and groups I received in 2007 indicated there were an estimated 2,044,855 members and 113,168 groups worldwide. (See my free ebook, The Age of Miracles is Still with Us). So far, it doesn’t seem that A.A. is “shrinking significantly.” And it doesn’t seem likely that it will “cease to exist as a significant social movement” by the beginning of the second quarter of the 21st century. Will it still be around by 2050? Let’s wait and see. I think the words that Sam Shoemaker, an Episcopal minister, spoke in 1955 are relevant: “I believe that A.A. will go on serving men and women as long as it may be needed, if it keeps open to God for inspiration, open to one another for fellowship, and open to people outside for service.”

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

10/13/14

Russian Roulette with Heroin?

Some of the most intriguing research into addiction treatment being done today is with vaccines. The idea is rather simple. Drugs of abuse pass through the blood-brain barrier because they are too small, too simple to be targeted by the immune system. So researchers have designed vaccines that take key fragments of the drug molecules and attach them to larger, more immune-provoking carriers (such as a cholera toxin or a tetanus toxin). The antibodies produced by this work-around will attack the drug and prevent it from passing through the blood-brain barrier and reaching the reward pathway in the brain. In other words, you can ingest the drug BUT WON’T GET HIGH!

Vaccines are being developed for drugs of abuse like alcohol, marijuana, heroin, methamphetamine, nicotine, and cocaine. A previous blog post, “Raising the Stakes in the War on Cocaine Addiction,” looked at the attempts to develop a cocaine vaccine by Thomas Kosten. His research has developed to the stage of clinical trials with humans, but a concern was discovered. Some of the human participants used ten times as much cocaine while attempting to override the blocking action of the cocaine vaccine. That trick could kill an individual who tried it with heroin.

Heroin has been a moving target for vaccine research because it quickly degrades into 6-acetylmorphine (6AM) and morphine. Kim Janda and his team of researchers associated with The Scripps Research Institute have developed a “dynamic vaccine” that creates antibodies against heroin and its psychoactive metabolites. You can read the academic journal article on their work found in the Proceedings of the National Academy of Sciences here or a summary of their research on The Scripps Research Institute website here or here.

There are positives and negatives to Janda’s dynamic heroin vaccine. First, while it will attach to heroin and its metabolites, it won’t work with oxycodone (OxyContin) or hydrocodone (Vicodin, Zohydro); or any other opioid. This is a trade-off because of the above-mentioned rapid degradation of heroin into its psychoactive metabolites. Second, this means the dynamic vaccine also won’t work with methadone or buprenorphine (Suboxone, Subutex), which are both opioids. So it can be used in conjunction with opioid maintenance therapy.

Although Janda’s research suggested that his vaccine helped limit heroin seeking behavior and halted the progression of compulsive heroin taking with rats, there are easy work-arounds for human beings. A human addict could ingest oxycodone or hydrocodone while taking the heroin vaccine to get high. They could even take a benzodiazepine along with their methadone or Suboxone for a nice, heroin-like buzz while taking the Janda vaccine. These limitations were acknowledged by Janda’s research team: “Although the dynamic heroin vaccine is not targeted to treat the ‘addicted’ brain, it represents a robust tool in the continuous blockade of all heroin activity.” In the concluding paragraph of the journal article, the research team said:

The prospect of heroin vaccine use in the treatment of addiction presents a high-payoff, low-risk opportunity. Drug vaccination requires minimal medical monitoring and compliance to maintain opiate resistance, allowing for greater potential worldwide accessibility. Furthermore … drug vaccines represent a low risk for long-term side effects. . . . Although it may not be a “magic bullet” against all aspects of drug addiction, the dynamic nature of our heroin vaccine represents a promising and innovative adjunct therapy in the treatment of heroin addiction.

But Janda’s research is stalled because it ran out of funding. In an interview with The Fix, he said: “We are not anywhere near human trials because nobody wants to pay for them.” Earlier funding was obtained by the Scripps Research Institute, the Pearson Center for Alcoholism and Addiction Research and the National Institute of Health (NIH). Janda and others have approached the NIH for additional funding, but so far have been unsuccessful.

Pharmaceutical companies aren’t interested either. Janda commented: “I have talked to many different companies and not one has shown any interest whatsoever. They don’t feel there is value for their company.” He doesn’t understand this from the standpoint of the greater good of society, but will attempt the route of applying for more research grants from the government. “I think we’ll probably just have to keep going it alone.”

I have mixed feelings about this vaccine, not because of the research, but because of what I know about how some addicts think. The research from the cocaine vaccine clinical trails discussed above noted how some addicts tried to test the vaccine with ten times as much cocaine as they usually ingested to get high. If heroin addicts test Janda’s heroin vaccine in a similar way, they will be risking their lives. It will be like playing Russian roulette with heroin.

There is also an “addiction” to the ritual of getting high (tying off, cooking the heroin, etc) for some addicts that the vaccine will not touch. I’ve known heroin addicts under the influence of this kind of obsession who compulsively “shoot up” water attempting to satisfy this urge. As Janda himself said, while it will blockade all heroin activity, it is not targeted to treat the “addicted brain.”

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag: The Fix