Addiction Treatment

I wonder if any of the researchers saw this coming:

The vaccine, called TA-CD, shows promise but could also be dangerous; some of the addicts participating in a study of the vaccine started doing massive amounts of cocaine in hopes of overcoming its effects, according to Thomas R. Kosten, the lead researcher on the study, which was published in the Archives of General Psychiatry in October.
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Nobody overdosed, but some of them had 10 times more cocaine coursing through their systems than researchers had encountered before, according to Kosten. He said some of the addicts reported to researchers that they had gone broke buying cocaine from multiple drug dealers, hoping to find a variety that would get them high. [Washington Post]

Whoa, that's doesn't sound like any fun at all. I assume the researchers told these people not to bother increasing their dose. Stories like this are the reason I'm skeptical of drugs that block receptors for other drugs.

Fresh on the success of NAOMI, the North American Opiate Maintenance Initiative, in which hard-core heroin addicts in Vancouver were given either methadone, heroin, or Dilaudid in maintenance doses, Canadian researchers announced earlier this year plans to broaden and deeper their research with SALOME, the Study to Assess Long-term Opiate Maintenance Effectiveness. SALOME was supposed to begin this fall in Vancouver and Montreal, but Quebec provincial authorities have thrown a wrench in the works. The Toronto Star reported this week that Quebec has balked on paying its share of the project, stopping the Montreal portion of SALOME in its tracks. The Vancouver portion, supported by the British Columbia provincial government, is set to move forth. Quebec's refusal to pay its share—the Canadian Institutes of Health Research are kicking in $1 million for the three-year project—led Montreal's SALOME head researcher to charge the government with discrimination. The decision will have "disastrous consequences for people addicted to heroin and (who) don't respond to standard treatment," said Dr. Suzanne Brissette, chief of addiction medicine at Saint-Luc hospital. "There is no other treatment for these people." NAOMI showed that heroin maintenance worked for people for whom methadone and other forms of treatment had not, she said. Had researchers found a treatment for cancer or diabetes, Quebec would not hesitate to help fund it, she added. "It's a clear case of discrimination," she said. "We have a treatment that works and they're saying, `Sorry folks, you won't get it.'" NAOMI researchers estimate that Canada has between 60,000 and 90,000 heroin addicts. The NAOMI trials found that addicts on maintenance heroin used less illicit heroin, committed fewer crimes, and adapted healthier life-styles.

In a meeting in Bangkok last weekend, more than two dozen drug users from nine different countries came together to put the finishing touches on the creation of a new drug user advocacy organization, the Asian Network of People who Use Drugs (ANPUD). The Bangkok meeting was the culmination of a two-year process began at a meeting of the International Congress on AIDS in Asia and the Pacific in Colombo, Sri Lanka, in 2007, and resulted in creating a constitution and selecting a steering committee for the new group. ANPUD adopts the principles of MIPUD (Meaningful Involvement of People who Use Drugs), and in doing so, aligns itself with other drug user advocacy groups, including the International Network of People who Use Drugs (INPUD), of which ANPUD is an independent affiliate, the Australian Injection and Illicit Drug Users League (AIVL),the Vancouver Area Network of Drug Users, and the Nothing About Us Without Us movement. ANPUD currently has more than 150 members and sees its mission to advocate for the rights of drug users and communities before national governments and the international community. There is plenty to do. Asia has the largest number of drug users in the world, but is, for the most part, woefully retrograde on drug policy issues. Not only do drug users face harsh criminal sanctions—up to and including the death penalty—but Asian has the lowest coverage of harm reduction services in the world. Access to harm reduction programs, such as needle exchanges and opioid maintenance therapy, is extremely limited. "People who use drugs are stigmatized, criminalized and abused in every country in Asia," said Jimmy Dorabjee, a key figure in the formation of ANPUD. "Our human rights are violated and we have little in the way of health services to stay alive. If governments do not see people who use drugs, hear us and talk to us, they will continue to ignore us." The Director of the UNAIDS Regional Support Team, Dr. Prasada Rao, spoke of the urgent need to engage with drug user networks and offered his support to ANPUD, saying that "For UNAIDS, HIV prevention among drug users is a key priority at the global level," said Dr. Prasada Rao, director of the UNAIDS Regional Support Team. "I am very pleased today to be here to see ANPUD being shaped into an organization that will play a key role in Asia's HIV response. It is critical that we are able to more effectively involve the voices of Asian people who use drugs in the scaling up of HIV prevention services across Asia." "When I go back home, I am now responsible for sharing the experiences with the 250 or so drug users who are actively advocating for better services at the national level," said Nepalese drug user and newly elected steering committee member Ekta Thapa Mahat. "It will be a great way for us to work together and help build the capacity of people who use drugs in Asia." "The results of the meeting exceeded my expectations," said Ele Morrison, program manager for AVIL's Regional Partnership Project. "The participants set ambitious goals for themselves and they have achieved a lot in just two days to set up this new organization. The building blocks for genuine ownership by people who use drugs is definitely there." While the meetings leading to the formation were organized and managed by drug users, the process received financial support from the World Health Organization, the UNAIDS Regional Task Force, and AIVL.

Under an anti-methamphetamine package announced last week by the government of New Zealand, popular cold and flu remedies containing pseudoephedrine will soon be available only by prescription after a visit to the doctor's office. The drug is a precursor chemical for manufacturing meth. "We're asking New Zealanders to band together and to accept using alternatives to treat their colds and flus to ensure New Zealand no longer becomes one of the countries most heavily affected by P [as the Kiwis refer to meth]," said Prime Minister John Key as he announced the a series of moves to combat meth use and production. In addition to restricting access to precursor chemicals, the government will spend more money on drug treatment programs, create a 40-man police anti-meth task force, and charge police with drafting a new anti-meth law enforcement strategy by next month. The government said it would pay for the programs with asset forfeiture funds. The pseudoephedrine announcement in particular brought a mixed reaction from the public. Some, especially those who had friends or family members who had had problems with meth, were supportive. Both others were "annoyed," asking why law-abiding people had to suffer for the actions of drug users and some "voiced concern that it was a bit over the top." Unsurprisingly, New Zealand police were happy with the new meth package. In a statement greeting the package's announcement, Assistant Commissioner Viv Rickard praised the "whole of government approach" as "more effective" in the battle against meth, but, as always, the police wanted more. "Police support the control of pseudoephedrine as it would allow us to concentrate resources and work with Customs on preventing the importation of precursors from overseas," Rickard said. "Precursor control is a vital part of disrupting the supply of methamphetamine, but no one action on its own will solve the methamphetamine problem. Stronger legislation around gangs, the ability to seize assets and profits of organized criminals and enhanced treatment programs will all contribute reducing the supply of methamphetamine and making our communities safer."

by Bernd Debusmann, Jr. Mexican drug trafficking organizations make billions each year trafficking illegal drugs into the United States, profiting enormously from the prohibitionist drug policies of the US government. Since Mexican president Felipe Calderon took office in December 2006 and called the armed forces into the fight against the so-called cartels, prohibition-related violence has killed over 12,000 people, with a death toll of over 5,000 so far in 2009. The increasing militarization of the drug war and the arrest of several high-profile drug traffickers have failed to stem the flow of drugs -- or the violence -- whatsoever. The Merida initiative, which provides $1.4 billion over three years for the US to assist the Mexican government with training, equipment and intelligence, has so far failed to make a difference. Here are a few of the latest developments in Mexico's drug war: Thursday, September 10 Last Thursday morning, the body count for the year passed 5,000. Four people were killed in Guerrero, among them a rural law enforcement officer. Additionally, in Chiapas, a group of gunmen threw a fragmentation grenade at a municipal office. Several people were wounded and a vehicle parked outside was damaged. Friday, September 11 In Tijuana, authorities reported a spike in drug prohibition-related violence. Nineteen people were killed in the first eight days of September. Authorities have reported 405 homicides in Tijuana from January 1st through September 11th. This is less than half of the 843 homicides reported in 2008, but 68 more than the 2007 total. The Baja California attorney general’s office believes that much of the recent violence is due to reprisals against suspected informers following the arrest of several high-level traffickers. Saturday, September 12 In the resort city of Acapulco, five bullet riddled bodies were found dumped in a landfill. According to Mexican authorities, police found a note near the bodies which was signed “the boss of bosses”. It is unclear to whom the note refers. In Sinaloa,a municipal police commander was killed when his car was ambushed by four vehicles carrying an estimated twenty armed men. His 13-year old son and a friend of his were wounded. Two innocent bystanders, aged 14 and 17, were killed by stray bullets as they sat under a tree near the road. Meanwhile, four charred corpses were found in a burning car on the Mexico City-Oaxaca highway. In Ciudad Juarez, 12 drug-related murders were reported. Sunday, September 13 In Ciudad Juarez, eight people were killed in just a few hours. The eight people who were killed died in six different incidents. Among the dead was Jose Robles Ortiz, who was riddled with bullets on September 11th. His death is being investigated by the state prosecutor’s office for the state of Chihuahua. Monday, September 14 At the El Paso border checkpoint, over $1 million in cash was seized over the period of a few days. The largest seizure took place on Friday afternoon, when U.S. Customs and Border Protection officials found $802,720 in an SUV that was headed towards Mexico. Two Mexican nationals, aged 33 and 34, were detained and remain in El Paso County Jail. Two other seizures made during the week totaled $206,000. El Paso is just across the border from Ciudad Juarez, and is a lucrative drug trafficking corridor for Mexican drug trafficking organizations. It is a federal offense to not declare currency over $10,000 dollars upon leaving or entering the US. Tuesday, September 15 In Tijuana and Ciudad Juarez, 21 people were killed on Tuesday. In Tijuana, firefighters found six bodies inside a burning car. Four of the men were seated in the car, while two were found in the trunk. In Ciudad Juarez, five people-including two brothers-were gunned down at a car wash. Ten people were killed in other acts of violence in the city. Five people were killed when gunmen opened fire at a hardware store, and five men in a pickup truck were killed when they were ambushed. Wednesday, September 16 In Ciudad Juarez, suspected drug cartel gunmen attacked a drug rehabilitation clinic, killing ten. This is the second such attack this month. Drug gangs have targeted rehab clinics in Ciudad Juarez, claiming that they are protecting members of rival trafficking organizations. A spokesman for the states attorney’s office said that the dead included nine men and one woman. Mexican independence day celebrations took place under extremely heavy security, due to fears of violence. Security was especially tight in Morelia, Michoacán, where a grenade attack by members of La Familia cartel killed eight people and wounded over 100 during last year’s celebrations. In many cities, traditional children’s parades and outdoor parties were canceled because of security concerns. Read last week's Mexico drug war update here.

Some interesting comments from former drug czar Barry McCaffrey at Huffington Post:

Our traditional justice system has been inadequate to the task of breaking the cycle of substance abuse and crime. Four out of every five offenses are committed by someone with a drug or alcohol problem; and we just keep locking them up!
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Given the abysmal outcomes of incarceration on addictive behavior, there's absolutely no justification for state governments to continue to waste tax dollars feeding a situation where generational recidivism is becoming the norm and parents, children and grandparents may find themselves locked up together.

And here's Robert Weiner, former spokesman at the drug czar's office, writing in the Baltimore Sun:

Why…is the Obama administration proposing to spend an even higher percentage of its anti-drug resources on law enforcement than the administration of George W. Bush?
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Mr. Kerlikowske has said, "It is only through a balanced approach - combining tough but fair enforcement with robust prevention and treatment - that we will be successful in stemming both demand and supply of illegal drugs." Yet, in the 2010 budget, there is a 3.3 percent reduction in treatment and prevention initiatives since 2008, exacerbating the bias toward enforcement, which now represents 65.6 percent of the budget, even higher than the last administration's 62.3 percent.

So why are these prominent drug warriors now criticizing U.S. drug policy for its perpetual focus on enforcement and incarceration? The short answer is probably that they now work as consultants with clients in the drug treatment industry who love seeing editorials like these.

But I'd like to think that on some level they feel maybe just a little bit responsible for their role in filling our prisons with an unfathomable number of people who don't belong there.

President Bush did a photo-op today in which he delivered used coats at the headquarters of Pathways to Housing and praised the organization’s efforts to help the homeless. Of course, there’s nothing surprising about the President doing charitable appearances during the Christmas season. What’s interesting is that Pathways to Housing offers a quite unique and forward-thinking approach to the problem of homelessness:

Founded in 1992, Pathways to Housing, a not-for-profit organization, works with individuals who have been turned away from other programs because of active substance use/abuse, refusal to participate in psychiatric treatment, histories of violence or incarceration, or other behavioral problems.
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Pathways to Housing separates housing from treatment. It treats homelessness by providing people with individual apartments, and then treats mental illness by intensive and individualized programs that seek out and actively work with clients as long as they need, in order to address their emotional, psychiatric, medical, and human needs, on a twenty-four-hour, seven-day-a-week basis.

This is basically a harm reduction approach to homelessness, in that active drug users receive services (including an apartment) in order to stabilize their situation and connect them to opportunities for treatment and health care. It’s a fantastic program that is achieving remarkable success, which is exactly why I’m surprised to see the President associate himself with it.

Bush’s White House has vehemently pushed an abstinence-first approach to drug treatment, even going so far as to oppose overdose prevention kits on the theory that overdosing would teach users a lesson. Pathways to Housing’s approach to drug addiction is just the complete opposite of everything Bush’s drug policy has stood for. Thus today’s appearance illustrates once again the gaping disparity between what actually works and what his priorities have been for the last 8 years.

At last, my final day in Vienna attending the United Nations' "Technical Seminar on Drug Addiction Prevention and Treatment: From Research to Practice" conference. (To read my scene-setting preamble from earlier this week, click here. Day 1 is here and day 2 is here.) It's a wind-down day for a conference that never wound up — the day when harm reduction was finally allowed to rear its head — so often unwelcome at any conference dominated, as this one is, by the United States, whose official governmental representatives are highly and categorically opposed to harm reduction. Harm Reduction appeared in that very earnest fashion whereby presenters say, "Here is the science. We need no more evidence. However, I can tell that you're not listening, so I'm going to tell you again that this all works, folks." It was also the day that I made a diplomatic faux pas (as we say in the language of diplomacy). More about that later. I missed the first couple of presenters as I was grappling with the sudden disappearance of Internet connectivity and was hoping that the coffee would kick in. The Viennese make good coffee although it's more of a utility tool than anything pleasurable, kind of like putting socks on in the morning. As I arrived, Dr. Shanti Ranganathan from TTK Ranganathan Treatment Centre in India had just finished her talk. I gather that she covered home detoxification and a camp for drug injectors (it could be fun to speculate how that camp would work). Speaking to a colleague later in the day, I learned that due to the rural nature of India, the approach to drug treatment there is very different from the way it's done in the northern hemisphere. It's very community oriented, and villages have a say-so in the process. I wish I'd caught more of Ranganathan's presentation, which was more along the lines of what I'd been hoping to get information about. How do you deliver drug services in resource poor countries? A gentleman behind me asked, "Haven't we overspecialized drug addiction treatment and shouldn't it be mainstreamed to take advantage of existing resources?" At last, a cri de coeur from the audience! Drug services including treatment, harm reduction, and diversion programs have all sprouted like varieties of weeds. They're somehow related, but the root system and the genetic coding are different. So how could countries and governments differentiate and choose among them? Or figure out how to construct the best array of services based upon what was on show? They couldn't, to my mind. After all, how could anyone possibly make sense of the patchwork quilt of treatment systems and social services in the north given that they don't necessarily make sense — or work — for drug users in their country of origin to begin with? It's as if we're displaying the leaning tower of Pisa or parading the Venus de Milo as models that they should aspire to, and then wondering why the resource poor world makes buildings that lean and statues that have no arms. One place I would not want to live is Sweden, where a random study of the kids at the youth program being trumpeted revealed that each youth suffered from an average of four mental disorders; the majority of parents had one. It must be good to have sane parents. Nothing like pathologizing the young, is there? The Dutch rolled into town with their admirably well-developed harm reduction knowledge and advocacy models. Dr. Wim van den Brink from the Academic Medical Centre at the University of Amsterdam in the Netherlands ran through the continuum of the stages of a drug user's drug taking career and discussed where, when, and which type of a wide range of interventions can and should occur. He included heroin maintenance in this list. (It is widely accepted that heroin maintenance is the fallback option for users who seek treatment but for whom methadone or buprenorphine has not worked. It's not usually a first line option. Outcomes are comparable to all other maintenance programs.) In van den Brink's view, drug-using patients should be able to talk over what their expectations are with their doctors and then negotiate their options. Fancy that. He was pretty much the first speaker who identified drug users as having a role in their own treatment. And he identified abstinence, maintenance, a safe high, and chaotic use as markers on a scale. That may be the first time in 20 years I've heard a clinician identify pleasure as part of the range of options. The legendary Dr. Franz Trautmann from the Netherlands Institute on Mental Health and Addiction ran through the evidence supporting harm reduction interventions including outreach, drop-in centers, and "drug consumption rooms" — the Dutch term for what we in the United States call safer injection facilities or medically supervised injection centers. (The panel facilitator, Gilberto Gerra, Chief of Health and Human Development Section of UNODC, chimed in to reassure everyone that drug consumption rooms do not violate international conventions). It was kind of a relief to hear Dr. Evgeny Krupitsky, head of a laboratory that conducts research on drug addiction at St. Petersburg State Pavlov Medical University, give a convoluted and amusingly wrong-headed talk about the desperate need for the Russians to make naltrexone the first-line response to drug addiction in Russia. (US rejection of harm reduction has its parallel in Russia's refusal to allow methadone.) Naltrexone is an opioid antagonist, which means you can't get high after you've taken it. The opioid receptors in the brain get too blocked up to let any more opioid in. However, as a form of treatment, it's just not very effective. So the Russians keep adding medications to the basic naltrexone dose, unwittingly creating an out of control medication pharmacopoeia for their patients. Monica Beg of UNODC had the task of informing everyone again that syringe exchange is effective in stopping the spread of HIV. Her PowerPoint showed the global distribution of exchange programs (probably limited to the UN-influenced world, to be fair) and did not cover the United States. "The science is clear. Syringe exchange works. The debate is over." Within UNODC there is no debate on the science but as mentioned in my original preamble, UNODC acts as the secretariat for the Commission on Narcotic Drugs (CND) and so when the member States of CND produce Political Declaration, those member states can completely ignore the science as is the case with the US and Russia. In fact, the HIV Prevention Unit deserve a medal for its work in pushing for support from within UNODC. And that's when I just had to speak. I pointed out that despite all of the evidence that needle exchange has been effective in the US (there are 200+ programs, with some of the larger ones federally funded; needle exchange has reversed the HIV epidemic in NYC, once the global epicenter of injection drug use and HIV; scientists at NIDA, NIH, CDC, NIAID are all on record as saying syringe exchange works), an article still appeared on CNN.com just this last July with David Murray, a supposed scientist for the Office of National Drug Control Policy, saying needle-exchange programs "do not succeed in its effort to control the contagion of disease." My point being that while the scientific debate may be over, the political debate continues in the US — not least in the way the US government has been disrupting the process leading up to this March's United Nations General Assembly Special Session on drugs. (While representatives to the UNGASS, plus numerous non-governmental agencies around the world have been calling for harm reduction to be recognized as an important part of demand reduction, US representatives have continued their war against it.) The chair responded to me by saying that there couldn't be a response to my point as it was a political question and inappropriate for this forum. And that science would win out. Stymied at not having a planned end point, I emotionally said that I was glad that this administration was now out. (Apparently it's taken as bad form to name names.) The interaction was filmed by an Iranian television crew that's covering the Iranian involvement in this meeting, which included Azarahksh Mokri of the Iranian National Center for Addiction Studies, who gave a wonderful presentation on how to introduce a methadone program into a country like Iran. He is a brilliant, charismatic speaker who was succint and on point throughout his talk. Christian Kroll of the UNODC HIV Unit, the last speaker before the closing, had that second returned from a UNAIDS Prgramme Coordinating Board meeting and was fired up from saying farewell to Peter Piot, the UNAIDS Executive Director and Under Secretary-General of the United Nations. Kroll ran through the history of the AIDS movement (accidently conflating Gay Men's Health Crisis and ACT-UP) and the importance of civil society input into the UN process. I kept waiting and waiting for the punch line. "Are you asking for more civil society input into UNODC?", I asked. Kroll's response: "Yes I am." Being practically the only representative from "civil society" at the meeting and definitely the only person that spoke, I can see his point. We then sang the Internationale and Mr. Kroll and I caught the subway home together. Allan Clear is executive director of the Harm Reduction Coalition.

Advocates for harsh marijuana laws can be counted on to infuse their rhetoric with incessant declarations that marijuana is highly addictive. Rarely, if ever, could one expose oneself to such discussion without being told something like this:

Decriminalizing marijuana – the drug which sends the most of America's youth into substance abuse treatment and recovery – is a dangerous first step towards complete drug legalization. In fact, marijuana sends the highest percentage of New Hampshire residents into drug treatment than any other illicit drug.
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I strongly urge responsible leaders in New Hampshire to stop any effort to decriminalize or legalize the highly addictive drug marijuana."

These words belong to the Deputy Drug Czar and they are less than a week old, thus they represent what his office currently believes to be the strongest and most important argument for marijuana prohibition: that the drug is highly addictive.

As Paul Armentano at NORML points out, however, the government's own data on marijuana dependency shows that a plurality of people entering treatment for marijuana hadn't smoked it in a month or more. Isn't that just amazing? I mean, wow. 36% of people entering treatment for pot addiction had already kicked the habit on their own. Highly-addictive my ash.

But how could this be? The answer can be found on this page, which shows that 58% of people entering marijuana treatment were referred by the criminal justice system. They didn't ask for help, rather they were found in possession of marijuana, which led a judge to issue a diagnosis of "marijuana addiction" and order them to get help for that.

When more than half the sample consists of people who were forced into treatment, it should come as no surprise that so many of them haven't actually been smoking marijuana. Some may never have been marijuana users to begin with and just happened to be in the wrong place at the wrong time. More commonly, I suspect, a large number of marijuana arrestees simply quit after getting busted, either voluntarily or because their lawyers recommended it, pretrial drug screenings, etc. Since marijuana isn't actually very addictive to begin with, this is easy to do.

And yet we continue to waste limited government resources investigating, arresting, adjudicating, and treating these people for an addiction they never actually had. In sum, the Drug Czar's best evidence of marijuana addiction comes from the fact that the government categorizes people as marijuana addicts if they're found sitting near a bag of marijuana. The instant we stop calculating it that way, the evidence ceases to exist and the drug warriors' favorite and best argument against marijuana reform is, well…cashed.