STATS

Senator Joe Manchin: Time for a New ‘War on Drugs' to Tackle Opioids

Senator Joe Manchin: Time for a new ‘war on drugs' to tackle opioids

Senator Joe Manchin stepped onto the Senate floor last week to read a letter sent to him by Leigh Ann Wilson, a home caregiver whose 21-year-old daughter, Taylor, died from an opioid overdose last fall. "Please work quickly to prevent thousands of other Taylors from the same fate," Manchin read. That was just the latest of…

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Let's Maximize the Medical Use of Marijuana

As the smoke cleared after Election Day 2016, we found ourselves at the dawn of a new era for cannabis in the United States.

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We Break Down Macklemore's New Song About Opioids, Line By Line

We break down Macklemore's new song about opioids, line by line

In the latest sign of how the opioid crisis is permeating popular culture, the rapper Macklemore this week put out a remarkable new song about prescription painkillers and other addictive drugs. Titled "Drug Dealer," the song parcels out blame for an opioid crisis that kills 78 Americans a day, up fourfold since 1999. It forcefully calls…

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The Binge and the Bias

The April 17 edition of 60 Minutes included a piece on parents who allow teens to drink at parties in an attempt to prevent drunk-driving and other alcohol-related problems. It could have been a great opportunity to explore the complex issues and controversies surrounding under-age drinking. But as with almost all of the media coverage of this issue, it was one-sided.

There are two expert views on teen drinking: one that says it cannot be stamped out and that adults should try to "reduce the harm" associated with it; and another, which says that only a "zero tolerance" approach will work. There is data to support both perspectives.

The problem is that, typically, only the latter view gets a hearing-- which was the case in Lesley Stahl's segment. While parents on both sides of the issue were given a chance to say their piece, the only expert interviewed was Jim Mosher, who comes down clearly on the zero-tolerance side. He told Stahl, "We are not doing our children a favor by providing them a quote, 'safe place' to drink."

The slant of the piece was clear from its opening sentence, which claimed that the fact that 10-20 percent of all alcohol is consumed by under-age drinkers is "stunning." While this might shock people living under a rock, with more than 75 percent of Americans taking their first drink before they graduate high school the truly amazing fact is that the statistic is not higher. (In fact, the National Center on Addiction and Substance Abuse got into trouble when it miscalculated the number as 25 percent a few years ago).

The segment didn't include the most relevant study--one recently published in the Journal of Adolescent Health in 2004, which demonstrates the equivocal nature of the data in this area. It found that teens whose parents held drinking parties for them were twice as likely to binge drink as teens whose parents did not. But it also found that teens who drink with their parents were half as likely to have had a drink in the last month and one-third as likely to binge drink as those who didn't.

Does this mean that parents shouldn't hold parties for their teens, but should teach them to drink moderately? Which teens are at greater risk for drunk-driving deaths--those who binge more, but whose parents hold parties and take away the keys or those who binge less but do so underground with no supervision? Is the stigma associated with criminalizing these parties a factor in why they might be associated with greater binge drinking -- perhaps because the only parents who will hold them in such circumstances are those who have drinking problems themselves, and thus have children at higher risk for such difficulties?

There's a lot to debate here -- but you'd never know it from the way teen drinking is covered by news organizations like 60 Minutes. By reporting that the only way to stop adolescent alcohol use is to "crack down harder," such as by passing laws which criminalize parents who hold drinking parties for teens, is neither an accurate account of the research into alcohol abuse, nor a genuine way to help create better alcohol policies.

Bad Advice Hangover

In a program remarkable for the number of myths and misconceptions about addiction it managed to include in a single broadcast, CNN's medical correspondent Sanjay Gupta interviewed Drew Pinsky, M.D. for the March 5 edition of his House Call show.

Dr. Sanjay Gupta asked Pinsky whether addicts could recover without help from 12-step programs. Pinsky, author of the book, Crack, responded, "I've not seen it. There are certainly behavioral programs, cognitive – something called cognitive behavioral interventions that have been shown to be quite effective. But by far, the most effective is the 12-step program."

In fact, 12-step programs like Alcoholics Anonymous have not been proven superior to cognitive-behavioral treatments: Both methods were statistically equal in the largest study ever done on alcoholism treatment and cognitive-behavioral treatments have been shown to be superior in some other studies.

As the National Institute on Alcohol Abuse and Alcoholism puts it on their web site, "Although AA is generally recognized as an effective mutual help program for recovering alcoholics, not everyone responds to AA's style or message, and other recovery approaches are available. Even people who are helped by AA usually find that AA works best in combination with other forms of treatment, including counseling and medical care."

In a taped segment which, like most of the other recent coverage on this topic, promoted potentially dangerous rapid detox programs without noting their serious risks, Gupta himself then managed to misstate the facts on addiction to painkillers. His voiceover proclaimed, "A federal study shows that 1.5 million of the 30 million patients who use prescription pain relievers in 2002 became dependent."

But the study shows nothing of the kind: it looked at people who abuse painkillers, not pain patients. The vast majority of these abusers either bought the drugs on the street, obtained them from friends or family who were legitimate patients or otherwise illegally acquired them. The statistic offers no information on what percent of legitimate pain patients become hooked on their medications.

Pinsky went on to make other equally unsupportable and unchallenged claims, saying of marijuana, "The fact it is addictive [sic]. And it seems to be an opioid mechanism, very much like heroin." In reality, marijuana affects the brain's cannabinoid receptors, not the opioid receptors. While the drug can lead to addiction in some cases, the percent of marijuana users who become addicts is far smaller than that for heroin users.

There are so many other misstatements, myths and outright errors in the rest of the piece that it's not worth listing them. The bottom line: Pinsky is clearly not an expert on addiction and CNN did its viewers a great disservice by presenting him as one.

More Meth Mania

The Today show jumped on the methamphetamine epidemic bandwagon with a recent segment on "Suburban Moms on Meth." Claiming that an increasing number of mothers are using methamphetamine, the show failed to present any evidence to support this notion.

For the record, among females 12 and older, methamphetamine use is stable, with 4.1 percent reporting having tried it, .3 percent (three-tenths of one percent) reporting use in the last year, and .1 percent (one-tenth of one percent) reporting past month use in 2003 according to the government's National Household Survey on Drug Use and Health.

In general, methamphetamine use among youth (which tends to foreshadow adult trends) shows a downward trend in all grades since the government's Monitoring the Future figures began looking at the drug in 1999.

Today also presented a classic example of what scientists call "the clinician's error." In an interview with a researcher from the Hazelden treatment center, Katie Couric asked whether recreational use of the drug was possible. The researcher replied that she'd "never seen" it.

But why would a treatment provider see a recreational user? Recreational users don't voluntarily seek treatment: why would they? And at least with adults, those forced into treatment through the criminal justice system are mainly addicts, not casual users.

The "clinician's error" occurs throughout medicine when clinical workers believe that those they treat for a condition are typical of people in the population with the condition. In fact, those who seek treatment are the worst cases – and their prognoses will look far less promising than if the disease was studied in the general population.

The photos Today aired of what it called "typical users" – which are genuinely shocking "before" and "after" pictures of addicts taken from police mug shots – represent this selection effect visibly. They do accurately show the rapid aging and skin problems common to methamphetamine addicts seen in treatment and by police; but they aren't an accurate picture of most users.

This is not to say that methamphetamine use isn't highly dangerous, nor to suggest that recreational use is a good idea; but the government's own statistics cited above show that the majority of methamphetamine users do not take it regularly.

At least the Today show did not report that meth addicts are untreatable or have a worse prognosis than other addicts. Couric asked about this, seemingly expecting to be told dire news. But the Hazelden researcher debunked the notion, noting that when crack was the hot drug, crack addicts were seen as incurable and that this was not true, either with crack or today's drug of the moment.

Hope for Meth Addicts

In a moving and brutally honest account of his son's methamphetamine addiction in The New York Times Magazine, David Sheff noted that the addiction treatment industry "must be the most chaotic and flailing field of health care in America." When he asked about treatment success rates for meth addiction, he writes, "I was quoted success rates in a range from 20 to 85 percent. An admitting nurse at a North California hospital insisted: 'The true number for meth addicts is in the single digits. Anyone who promises more is lying.'"

In fact, actual research studies – and Sheff's son's own story – suggest a brighter picture than the nurse claims. Methamphetamine addicts have relapse rates no worse – and no better – than for those of any other drug. If you compare the course of various addictions, alcoholism and opioid addictions tend to run longer than meth addiction.

This is because alcohol and opioids like heroin tend to put users to sleep and calm them – but stimulants like cocaine and methamphetamine keep users awake for days on end, causing anxiety and paranoia. There is only so much sleep loss one can take: After a few years of such a lifestyle, stimulant addicts tend to quit, switch to more calming drugs, or, in a minority of cases, die. If you determine "addictiveness" by how long one's life is dominated by a drug, then, cocaine and amphetamine are less addictive.

Of course, the admitting nurse is correct to say that rehab facilities over-promise when they claim 85 percent success rates – but single digit success is not correct either. Research has consistently shown one-year abstinence rates from all addictions following treatment at about 40-60 percent, with an additional 15-30 percent having some relapses but not returning to chronic daily use. This is actually slightly better than for other chronic illnesses which require lifestyle changes for successful outcomes, like diabetes and hypertension. The prognosis is more positive for people of high socioeconomic status, with college educations and with strong family support.

The problem with addiction treatment now is not that it doesn't work, but that the best treatment is hard to find and that outdated methods still dominate the field. Parents and reporters like Sheff need to demand that this "chaotic and flailing" field adopt evidence-based methods to improve outcomes – not hype "the worst drug ever" over and over as different drugs fall in and out of favor.

Wired and Tired

Wired Magazine joins a long list of major media organizations – from "20/20" to "48 Hours" to the Orlando Sentinel – to be drawn in by the unproven promises of "rapid opioid detox." While the magazine did note that there are serious concerns about proponents' claims to withdraw heroin and other prescription opioid addicts safely and more effectively than other methods, it missed the fact that rapid detox promoters can't even prove their main contention: better relief of withdrawal pain.

Instead, Wired called rapid detox "a useful treatment that can seem like a miracle cure," saying, "for addicts who cannot make it through withdrawal any other way, the $15,000 procedure may be their only hope." It quoted an addiction doctor who "claims [that rapid detox] is one of the most innovative developments in the field since the advent of the 12 step program in the 1930s."

Rapid detox proponents say that they can put an opioid addict to sleep with anesthesia, pump him full of opioid-blocking drugs, and when he awakes, he will suffer no withdrawal symptoms.

But Wired should have been far more skeptical about this notion, given the inflated claims it documented the programs making in other areas. For one, though promoters claim a 65 percent recovery rate after one year (compared to 30-40 percent for other treatments), controlled research doesn't support this. The largest NIDA-funded study found that after three months, those who underwent rapid detox were clean in no greater numbers than those who kicked by other methods.

Claims of safety are also problematic: ordinary detox methods kill no one (withdrawal from opioids itself, while unpleasant, is not deadly) but about a dozen deaths are known to be associated with complications from this procedure. As the Wired article notes, seven of these were caused by one New Jersey doctor – still practicing! – alone. While these deaths appear to be related to lack of proper monitoring of patients under anesthesia and immediately following it (the known deaths followed outpatient, not hospital-based, treatment), there's another risk associated with the procedure that Wired failed to even mention.

Rapid detox involves giving large doses of opioid-blocking drugs, including a follow-up prescription for one called naltrexone to be taken for several months afterwards. This will prevent any new use of opioids from producing a high – and is supposed to reduce craving.

But Australian researchers have found increased overdose death rates amongst heroin addicts who ended naltrexone treatment, compared to those who quit treatment with methadone or buprenorphine. Naltrexone drug reduces patients' tolerances for opioids, so that when they stop taking it, they are at far greater risk of death from doses they used to take without problem if they relapse.

In the Australian study of over 1,200 patients, the overdose rate was eight times higher amongst former naltrexone patients, compared to former methadone or buprenorphine patients. The Wired article didn't include this information.

The magazine did note, however, that many rapid detox programs simply provide the detox, a few follow-up phone calls and a naltrexone prescription: exactly the situation in which such overdoses are likely to go unprevented and undetected.

In terms of comfort, rapid detox proponents claim that because opioid-blockers are administered in high doses while the patient is sedated, the withdrawal period is shortened because the receptors are stripped of opioids, then blocked.

However, there is little evidence to support the idea that simply stripping and blocking these receptors makes the brain return to normal faster. And there are many rapid detox patients who claim that after waking from anesthesia, they actually suffered more intense and difficult withdrawal periods than they had when they used other detox methods. Without controlled research, it's impossible to know if comfort or extra pain is more common – and for whom.

Some rapid detox programs implant naltrexone under the skin to ensure that addicts won't skip doses – but some addicts find this so unpleasant that they've literally cut the implants out themselves rather than continue the treatment. Naltrexone can also cause extreme anxiety in certain patients.

While studies find naltrexone to be well-tolerated and effective for treating alcohol problems, it seems far less helpful to opioid addicts. A 2002 study, for example, found that only 19 percent of heroin addicts completed a six-month course of naltrexone treatment, which had been especially designed to encourage them to take the medicine faithfully. This does not suggest that most opioid addicts find the drug helpful – nor that a procedure involving taking it orally with no support would be particularly effective.

Without further research, and as presently conducted, the media should not be using words like "miracle" in association with rapid detox. If it could be proven more comfortable for addicts – even if it had added safety risks and no added advantage in efficacy – that would be a reason to offer it. It could draw people in then, people who might otherwise die on the street. But if the programs can't even prove they are more comfortable than other detoxes, why add the risks and the high cost?

Sadly, I have to close this article with the same cautionary quote I used when I wrote about rapid detox for Newsday in 1996 – because research still hasn't answered the key questions and the media still doesn't get that claims about extra comfort are as suspect as other claims made for the treatment.

Herbert Kleber, director of the division of substance abuse at Columbia University School of Medicine, is also a former deputy drug czar. It was his work that showed that rapid detox didn't actually improve long-term outcomes. He wrote this back in 1982, and just like in 1996, it's just as true today:

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Statistics Happen

On the heels of a survey conducted by the University of Michigan, the media has sent mixed or incorrect messages to the public about teen use of cigarettes, alcohol, and other drugs. While long-term trends in increases or decreases in smoking and drug use can be measured with this survey, many changes from 2003 to 2004 were not statistically significant.

Despite this, the findings were reported – if not trumpeted – by the media as if they had great meaning. Worse yet, by emphasizing which drugs are being used by current drug users – and neglecting the larger context – the public is misled about drug abuse by teens.

USA Today, for example, headlined its report with "Survey: More teens using Oxycontin."

Sure, the percentages of 12th-graders reporting having used Oxycontin went from 4 percent in 2002 to 4.5 percent in 2003, and now to 5 percent in 2004. The 1 percent increase from 2002 to 2004 is statistically significant. However, highlighting this small-yet-noteworthy increase in Oxycontin use over this two-year period (an increase that was not noted in 8th or 10th grades) eclipses the brighter picture of drug use among teens: Since 2002, the use of illicit drugs in the last year has declined by 2.2 percent among 12th graders.

The increase in Oxycontin use may be more accurately described as a gain in popularity among drug users. In the same time period, the use of LSD any time over the past year went down 1.3 percent, and the use of ecstasy went down 3.4 percent among 12th graders. Perhaps those who have used Oxycontin this year would have used LSD two years ago; these shifts in drug popularity are not indicative of more teens becoming addicted to, or even trying, illicit drugs.

Another source for confusion were the reports on smoking. The Associated Press heralded "progress" in preventing teen smoking by leading with "Federal study finds modest drop in teen drug use, smoking in 2004." Indeed, smoking has been reduced significantly since the early 90s, but the changes from 2003 to 2004 are almost entirely insignificant. The survey asked students four relevant questions about smoking:

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The Suicide Myth

The controversy over prescribing antidepressants to children and teenagers deepened recently, when a Food and Drug Administration (FDA) advisory committee recommended that the agency issue a "black box" warning to doctors about the increased risk of suicidal behavior from taking such drugs.

The panel tried to weigh the risk of suicide from taking antidepressants against the risk from not taking antidepressants. But the evidence under consideration was insufficient to draw easy or strong conclusions, thus making the issue a complicated one for the public to understand.

To make matters worse, the media did not always promote a consistent story about these risks. For instance, the New York Times reported that,

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