Only One in Ten Who need Treatment Get it.

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Some snapshots from the nation’s fight against drug abuse: President Donald Trump at every opportunity calls for the building of the wall, which he says will stop drugs (along with immigrants) from entering the country; he has also endorsed tougher criminal sanctions for traffickers, including the death penalty for major ones. Twenty-four states are suing Purdue Pharma (the maker of OxyContin) and other manufacturers of painkillers for their deceptive marketing practices. Federal prosecutors in Brooklyn are preparing to try Joaquin “El Chapo” Guzman, the Mexican cartel leader, on charges of drug trafficking, money laundering and horrific acts of violence. New York Mayor Bill de Blasio recently announced plans to open four supervised drug-injection sites in the city; San Francisco, Seattle and Philadelphia have similar intentions.

None of this, however, is likely to make much of a dent in an epidemic that last year claimed 72,000 lives due to overdoses, for they fail to address the truly urgent need in the fight against substance abuse: repairing and expanding a treatment network that is severely underfunded, badly splintered and completely overwhelmed. At a time of widespread anguish and hand-wringing about addiction, neither the president, nor Congress, nor governors, nor journalists are paying enough attention to the one thing that could truly make a difference: more and better treatment.

According to a 2016 report by the Surgeon General, only 1 in 10 people who needs drug and alcohol treatment gets it. Of course, not everyone who needs treatment wants it, but enough do to create shockingly long waiting lists across the country. In West Virginia, the state with the highest rate of overdose deaths, there are a mere 171 beds for detox (which weans users off drugs over a period of days) and 151 for longer-term residential treatment, forcing carpool moms and dads to drive up to five hours to find an opening. (The number of beds is expected to more than double thanks to new state and federal funding, but that’s still a fraction of what’s needed.) In New Hampshire, another hard-hit state, waits of four to six weeks are common for a publicly funded residential bed, while in Maine the primary detox facilities are the state’s 15 county jails. The small subset of users who have private insurance can generally gain quick access to facilities that cost up to $10,000 a week and (in the upper tier) feature saunas, yoga, rock climbing and aromatherapy. The vast majority who rely on Medicaid or are uninsured, however, face long waits for admission to facilities that often lack even basic medical, psychiatric and therapeutic services.

For those in the grip of drugs, the openness to treatment is often fleeting, and if a slot is not immediately available, they’re back on the street, snorting, shooting up, overdosing, landing in emergency rooms or worse. In New Hampshire, a heroin user was found dead in his apartment along with a list of rehab facilities on the table next to his bed, which he had called in vain. In Springfield, Massachusetts, beds are in such short supply that those seeking help sometimes have to get arrested so that a judge can mandate them to a facility. In Huntington, West Virginia, the parents of a 21-year-old woman spent 41 days trying to get her into a facility, without success; on the 42nd day, she overdosed and died.

Dr. James Berry, the director of the addictions program at the West Virginia University School of Medicine in Morgantown, says hospital emergency rooms throughout the state “are flooded every day with scores of people who are desperate for treatment.” The courts are similarly overwhelmed. “I get calls from various courts asking for help in getting people into treatment because it’s not available in local communities.” The three hardest words for a user to say are “I need help,” he observes. If they can’t get it when the window is open, the opportunity quickly fades. “Every community should be able to provide immediate access.”

But does treatment work? By now, there is a shelf-full of studies showing that it significantly reduces the harms associated with drug and alcohol abuse. According to the Surgeon General’s report, every dollar spent on treatment saves about $4 in health care costs and $7 in criminal costs. The savings mount when one adds in family anguish, days lost at work, child abuse and neglect, newborns going through withdrawal and homelessness. Needless to say, relapse often occurs; in fact, it is chronic. Yet even if people refrain from using drugs for a limited period, the benefit-to-cost ratio is high. And over time, many do return to a productive life.

In the case of opioids, the treatment options include two medications, methadone and buprenorphine, that both have a well-documented record of helping stabilize users. Yet these treatments remain in pitifully short supply, particularly in rural areas that have been especially hard hit by the epidemic. Since methadone and buprenorphine (marketed under the name Suboxone) are both opioid-based, they are frequently dismissed as just another form of addiction, but this is misguided, for both reduce the craving for drugs and the symptoms of withdrawal and so help the drug-dependent function normally.

That making such treatment more accessible could help stanch the current epidemic is clear from the nation’s experience with an earlier one—the heroin wave of the late 1960s and early 1970s. In 1971, President Richard Nixon, intent on combating the crime associated with drugs—set up a special drug-abuse prevention office in the White House and authorized its director, Dr. Jerome Jaffe, to make methadone (and other forms of treatment) widely available. Clinics were quickly established across the country, and within 18 months almost everyone seeking treatment could find it. Both heroin use and the crime related to it sharply declined.

Unfortunately, during his 1972 reelection campaign, Nixon—wanting to look tough on crime and drugs—began shifting federal attention away from treatment to law enforcement and incarceration. In May 1973, New York adopted the Rockefeller Drug Laws, mandating long prison sentences even for minor offenses. Other states rushed to copy them, and the war on drugs was on. Prisons filled with low-level offenders, many of whom would have been more effectively dealt with through treatment. During the Reagan years, the national treatment network set up under Nixon crumbled. When the crack and cocaine epidemic hit in the mid-to-late 1980s, the treatment centers that remained were completely overwhelmed; waiting lists grew and crime rates and the associated costs soared.

Amid today’s exploding opioid use, we are paying the price for this long neglect of the nation’s treatment infrastructure. The Trump administration in its 2019 budget has proposed an additional $900 million for Health and Human Services to help address the epidemic—a mere droplet of what’s needed. To make treatment available on demand would require spending tens of billions of dollars annually for years to come. That might seem like a lot, but it’s modest compared with the estimated $450 billion that substance abuse costs the nation every year.

Some of the needed sums could be diverted from programs that seek to keep drugs out of the country, for they are generally futile. Despite all the efforts to seal the nation’s borders against drugs, they continue to pour in; heroin and cocaine are easily concealed and transported, and hypertoxic fentanyl can be purchased online with cryptocurrencies. The war on drugs in Mexico, meanwhile, is not only ineffective but counterproductive; the drive to dismantle the Mexican cartels has served mainly to destabilize the market, setting off bloody wars among traffickers, with countless civilian casualties. Our anti-drug efforts should be directed at reducing the demand for drugs rather than cutting off the supply—an approach that is not only more humane but also more cost-effective.

In addressing demand, it’s essential to offer a full array of services. The effectiveness of methadone and buprenorphine can be enhanced when accompanied by counseling. To treat the most serious cases, residential facilities (both long- and short-term) need to be vastly expanded. Supplementary services are needed to help those in recovery find jobs, housing and mental-health support. Outreach workers are needed to locate users and connect them with services. Central intakes need to be established in cities and towns to help connect people with services and track their progress through the system. More doctors and nurses should be trained to diagnose drug disorders and prescribe medications like buprenorphine. Treatment should be made more available in the nation’s prisons and jails, and schools should have counselors trained to watch for adolescents struggling with drugs and alcohol. Needle-exchange programs should be expanded and more closely connected with treatment facilities. And the treatment industry as a whole should be subject to stricter regulation and oversight. (Many centers are unlicensed and amateurishly run.)

All of this would require a vast expansion in staffing. Establishing treatment on demand could thus become a substantial provider of jobs, especially in regions where factories have shut down. Rehab centers could even be opened in shuttered industrial facilities.

Finally, news organizations need to rethink their approach to the drug issue. They too often focus on sideshows—the drug war in Mexico, police raids in big cities, the culpability of Big Pharma. (The number of opioid prescriptions nationwide actually peaked in 2012, and in 2016 they reached their lowest level in a decade, yet the epidemic continues.) Journalists should instead seek to expose the glaring gaps in the nation’s treatment system and dramatize the plight of those who want help but can’t get it—the real scandal in the fight against drugs.

Drug Overdoses Killed 72,000 Americans Last Year: CDC Reports

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Drug overdoses rose 10 percent last year, killing an estimated 72,000 Americans, according to a new report by the Centers for Disease Control and Prevention (CDC).

More Americans are using opioids, and the drugs are becoming more deadly as fentanyl is increasingly mixed into heroin, cocaine and methamphetamine, The New York Times reports.

The CDC reported that overdose deaths involving synthetic opioids such as fentanyl increased sharply, while deaths from heroin, prescription opioid painkillers and methadone decreased.

Overdose deaths increased by more than 17 percent in Ohio, Indiana and West Virginia, while New Jersey saw an increase of 27 percent.

Meth Use is Rising Among People Who Use Opioids

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Over one-third of people using opioids in 2017 reported also using methamphetamine – more than double the rate in 2011, according to a new study.

The study included 13,251 participants in 47 states who entered a substance abuse treatment program for opioid use disorder. The researchers found past month concurrent opioid and methamphetamine use doubled from 16.7 percent in 2011 to 34.2 percent in 2017.

Concurrent meth and opioid use increased among both men and women, among whites and in those under age 45, the researchers found. Past-month meth use significantly increased among those using prescription opioids alone, heroin alone and both prescription opioids and heroin.

“We were surprised to see such an increase in meth use among people using opioids,” said lead researcher Theodore Cicero, Ph.D, John P. Feighner Professor of Psychiatry at Washington University in St. Louis, who described the findings at the recent annual meeting of the College on Problems of Drug Dependence. “We knew that since there was a clamp-down on opioid abuse, people were switching to other drugs, but our main concern was heroin. We were surprised to not only see a rise in heroin use, but a sharp increase in the use of methamphetamine.”

Specifically, Dr. Cicero said, amphetamines, such as meth, produce the opposite effect of opioids. “They wake you up, while opioids are downers,” he said. “Apparently, more people use both drugs so one counteracts the effect of the other – they can balance each other out.” He emphasized that each drug alone carries dangers, and mixing them is especially hazardous.

When meth use was at its peak, Congress passed the Combat Methamphetamine Act in 2005, which required stores to put the cold medicine pseudoephedrine – a key meth ingredient – behind the counter, and limited sales. Meth sales plunged as a result. Then Mexican drug cartels started bringing meth into the country, according to the Drug Enforcement Administration. In the past five years, the amount of meth seized has tripled, U.S. Customs and Border Protection reports.

The new study illustrates that public health policies can have unintended effects, Dr. Cicero says. “As we address the opioid epidemic, we’re creating a different problem,” he said. “We have to realize that people often take drugs trying to escape from depression, anxiety and the circumstances of their lives. We have to address the demand side of the equation – why do people need to escape from life, not just try to limit the supply.”

Synthetic Cannabis Laced With Rat Poison a Risk to US Blood Supply, FDA Warns

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Illegal synthetic cannabis products laced with rat poison continue to be sold in the United States and pose a significant health risk not only to people who use these products but also the US blood supply, the US Food and Drug Administration (FDA) said this week in an update on the ongoing problem.

Hundreds of people in about 10 states have been hospitalized with serious and sometimes fatal bleeding linked to use of synthetic cannabinoids laced with brodifacoum, a highly lethal long-acting vitamin K antagonist anticoagulant commonly used in rat poison, the agency said on July 19.

For months, the Centers for Disease Control and Prevention (CDC) and the FDA have been warning about the dangers of illegal synthetic cannabis products that are sold under names such as K2 and Spice in convenience stores and gas stations.

“But despite our efforts, certain entities continue to bypass state and federal drug laws by making and distributing these products — often marked or labeled as ‘not for human consumption’ — and changing the structure of the synthetic chemicals to try to skirt legal requirements,” the FDA said. In some cases, makers of synthetic cannabinoids have deliberately added brodifacoum, which is thought to extend the duration of the “high.”

In an advisory issued in May, the CDC said case patients have presented with a variety of signs and symptoms of coagulopathy, including bruising, nosebleeds, excessively heavy menstrual bleeding, hematemesis, hemoptysis, hematuria, flank pain, abdominal pain, and bleeding from the gums or mouth.

At the time, more than 95 biological samples from case patients tested positive for brodifacoum.

The effects of brodifacoum are treatable, and the FDA said people who use synthetic marijuana products should be vigilant for signs of bleeding and should seek immediate medical attention.

“We also want to alert health care providers, particularly those delivering care in emergency settings, to be aware of these risks and consider the possibility of synthetic cannabinoid exposure when individuals present with unexplained bleeding,” the FDA said. “Standard coagulation tests, such as the prothrombin time, can be dramatically elevated in these settings, and prompt treatment with high doses of vitamin K and other supportive care can potentially be life-saving,” they add.

All Young Cannabis Users Face Psychosis Risk

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Cannabis use directly increases the risk for psychosis in teens, new research suggests.

A large prospective study of teens shows that “in adolescents, cannabis use is harmful” with respect to psychosis risk, study author Patricia J. Conrod, PhD, professor of psychiatry, University of Montreal, Canada, said.

The effect was observed for the entire cohort. This finding, said Conrod, means that all young cannabis users face psychosis risk, not just those with a family history of schizophrenia or a biological factor that increases their susceptibility to the effects of cannabis.

“The whole population is prone to have this risk,” she said.

The study was published online June 6 in JAMA Psychiatry.

Rigorous Causality Test
Increasingly, jurisdictions across North America are moving toward cannabis legalization. In Canada, a marijuana law is set to be implemented later this year.

With such changes, there’s a need to understand whether cannabis use has a causal role in the development of psychiatric diseases, such as psychosis.

To date, the evidence with respect to causality has been limited, as studies typically assess psychosis symptoms at only a single follow-up and rely on analytic models that might confound intraindividual processes with initial between-person differences.

Determining causality is especially important during adolescence, a period when both psychosis and cannabis use typically start.

For the study, researchers used random intercept cross-lagged panel models (RI-CLPMs), which Conrod described as “a very novel analytic strategy.”

RI-CLPMs use a multilevel approach to test for within-person differences that inform on the extent to which an individual’s increase in cannabis use precedes an increase in that individual’s psychosis symptoms, and vice versa.

The approach provides the most rigorous test of causal predominance between two outcomes, said Conrod.

“One of the problems in trying to assess a causal relationship between cannabis and mental health outcomes is the chicken or egg issue. Is it that people who are prone to mental health problems are more attracted to cannabis, or is it something about the onset of cannabis use that influences the acceleration of psychosis symptoms?” she said.

The study included 3720 adolescents from the Co-Venture cohort, which represents 76% of all grade 7 students attending 31 secondary schools in the greater Montreal area.

For 4 years, students completed an annual Web-based survey in which they provided self-reports of past-year cannabis use and psychosis symptoms.

Such symptoms were assessed with the Adolescent Psychotic-Like Symptoms Screener; frequency of cannabis use was assessed with a six-point scale (0 indicated never, and 5 indicated every day).

Survey information was confidential, and there were no consequences of reporting cannabis use.

“Once you make those guarantees, students are quite comfortable about reporting, and they become used to doing it,” said Conrod.

Marijuana Use Highly Prevalent
The first time point occurred at a mean age of 12.8 years. Twelve months separated each assessment. In total, 86.7% and 94.4% of participants had a minimum of two time points out of four on psychosis symptoms and cannabis use, respectively.
The study revealed statistically significant positive cross-lagged associations, at every time point, from cannabis use to psychosis symptoms reported 12 months later, over and above the random intercepts of cannabis use and psychosis symptoms (between-person differences). The statistical significances varied from P < .001 to P < .05.

Cannabis use, in any given year, predicted an increase in psychosis symptoms a year later, said Conrod.

This type of analysis is more reliable than biological measures, such as blood tests, said Conrod.

“Biological measures aren’t sensitive enough to the infrequent and low level of use that we tend to see in young adolescents,” she said.

In light of these results, Conrod called for increased access by high school students to evidence-based cannabis prevention programs.

Such programs exist, but there are no systematic efforts to make them available to high school students across the country, she said.

“It’s extremely important that governments dramatically step up their efforts around access to evidence-based cannabis prevention programs,” she said.

Currently, marijuana use in teens is “very prevalent,” she said. Surveys suggest that about 30% of older high school students in the Canadian province of Ontario use cannabis.

“I’d like to see governments begin to forge some new innovative policy that will address this level of use in the underaged,” Conrad said.

Reducing access to and demand for cannabis among youth could lead to reductions in risk for major psychiatric conditions, she said.

A limitation of the study was that cannabis use and psychosis symptoms were self-reported and were not confirmed by clinicians. However, as the authors note, previous work has shown positive predictive values for such self-reports of up to 80%.

Unique Research
Commenting on the findings Robert Milin, MD, child and adolescent psychiatrist, addiction psychiatrist, and associate professor of psychiatry, University of Ottawa, said the study is at “the vanguard” of major research investigating cannabis use in adolescents over time that is being carried out by that National Institute on Drug Abuse in the United States.

“The study is at the forefront because it is specifically looking to measure psychosis symptoms and cannabis use in adolescents, and the model they are using strengthens the study,” said Milin.

That model uses “refined measures or improved measures to look at causality, vs what we call temporal associations,” he said.

The fact that the study investigated teens starting at age 13 years is unique, said Milin. In most related studies, the starting age of the participants is 15 or 16 years.

He emphasized that the study examined psychosis symptoms and not psychotic disorder, although having psychotic symptoms increases the risk for a psychotic disorder.

Heavy Drinking and Early-onset Dementia

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A new study suggests heavy alcohol consumption is a major risk factor for all types of dementia, but particularly early-onset dementia.

The retrospective analysis involving 30 million people in France shows that those with a history of alcohol use disorders had a threefold increased risk for dementia and that over half those with early-onset dementia had a history of alcohol problems.

“Our results suggest that heavy drinking is the strongest potentially modifiable risk factor for dementia that we have ever seen,” lead author, Michaël Schwarzinger, MD, Translational Health Economics Network, Paris, France, said.

Their data make a strong argument for lower consumption of alcohol generally, he added. “If people are consuming more than a couple of alcoholic drinks a day, they could be putting themselves at increased risk of dementia. Our results suggest that one of the best things you can do for your brain health is to cut down your alcohol intake.”

The study is published online in Lancet Public Health on February 20.

In an accompanying Comment, Clive Ballard, MD, and Iain Lang, MD, University of Exeter Medical School, United Kingdom, say the study is “immensely important and highlights the potential of alcohol use disorders, and possibly alcohol consumption, as modifiable risk factors for dementia prevention.”

“This study used a phenomenally large database, and the result showing that half the cases of early-onset dementia were associated with alcohol use disorders is truly staggering,” Ballard told Medscape Medical News.

“This has flagged something that has long been neglected, so it is a very important contribution to our knowledge,” he added. “It does suggest that heavy drinking increases the risk for dementia and could be a significant contributing factor to early-onset dementia. That is important to know as we can potentially do something about it.”

In the paper, the researchers call for screening and interventions for heavy drinking and treatment for alcohol use disorders to reduce the alcohol-attributable burden of dementia.

“In our view, this evidence is robust and we should move forward with clear public health messages about the relationship between both alcohol use disorders and alcohol consumption, respectively, and dementia,” Ballard and Lang add. “We might want to consider the extent to which the growing prevalence of dementia worldwide might be curbed by reductions in population-level alcohol consumption.”

Quite a lot of work has looked at the effects of light drinking, with several cohort studies suggesting health benefits, including a possible reduction in dementia. But there has been very little research on the effects of heavy drinking, Schwarzinger noted, “so we wanted to look at this.”

For the study, they analyzed a database covering all hospital admissions in France. “We had data on around 30 million people over a 6-year period, including 80% of the French population more than 60 years of age,” Schwarzinger reported.

The researchers used diagnostic codes on hospital records to identify patients with dementia and those who had a history of alcohol use disorders. They found over a million cases of dementia, after excluding people with diseases that can lead to rare types of dementia and those with early-life mental disorders that can increase or confound dementia diagnosis. There were also 945,000 people with alcohol use disorders.
Results showed a strong association between a history of alcohol problems and dementia. This was especially noticeable in early-onset dementia, with 57% of the 57,000 patients who had developed dementia under the age of 65 years having a history of alcohol use disorders (66% of men and 37% of women).

In an analysis of just those patients in whom the first record of dementia occurred in 2011-2013 and adjusted for other risk factors found in the medical records, the risk for dementia was three times greater if the patient had a history of alcohol use disorders. The hazard ratio was 3.36 for men and 3.34 for women.

Is There a J-shaped Curve?

“We have very little information on the effects of heavy drinking as these people don’t generally participate in studies and if they do they frequently drop out,” Schwarzinger explained. “So this is the first solid data we have on this issue.”

But he pointed out that some small neuroimaging studies have shown a relationship between alcohol use and gray matter damage. “This association appears to be linear — the more alcohol is consumed the more gray matter damage — right down to very low levels.”

Because the current study used diagnostic codes to identify people with alcohol use disorders, it doesn’t give a level of alcohol consumption considered to be hazardous for dementia risk.

“We don’t know how much they were actually drinking, but usually anyone with an alcohol use disorder would be drinking more than 5 units of alcohol a day,” he said.

The World Health Organization defines chronic heavy drinking as consuming more than 60 g of pure alcohol a day for men (around six or more standard drinks per day on average) and more than 40 g per day for women (around four or more standard drinks per day), the study authors note.

“Cohort studies suggest a J-shaped curve for the alcohol and dementia relationship, with low and moderate levels of drinking possibly having a benefit, but our study shows a clear harmful effect of heavy levels of drinking,” Schwarzinger said. “We don’t know where the threshold is. We cannot discern that information from this study.”

He himself is not convinced about a J-shaped curve. “Personally I doubt there is a J-curve for the relationship between alcohol and brain health — the suggestion of benefit with low alcohol consumption has been seen in cohort studies in healthy people, which can have many biases, and the neuroimaging studies show brain damage with even low doses of alcohol.”

Ballard added: “There is a fair amount of evidence that modest alcohol consumption may be protective against dementia, and this study now suggests strongly that heavy drinking is harmful. We don’t know the specifics and we need to do a lot more work to find where the threshold may be, but possibly one or two drinks a day could be protective while five or more could be harmful.”

He further pointed out that there were almost certainly confounding factors that could have contributed to the current results.

“People with alcohol use disorders often also have many other risk factors for dementia, such as depression, social isolation, and poor nutrition, that may not have shown up in this study,” he said. “But having said that, the very high hazard ratio in this study is certainly a big push for further research on heavy drinking.”