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People are dying because we misunderstand how those with addiction think

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Brendan de Kenessey, a fellow-in-residence at the Edmond J. Safra Center for Ethics at Harvard University and (as of this fall) a member of the faculty of the philosophy department at the University of Toronto, writes in Vox:

The American opioid epidemic claimed 42,300 lives in 2016 alone. While the public policy challenge is daunting, the problem isn’t that we lack any effective treatment options. The data shows that we could save many lives by expanding medication-assisted treatments and adopting harm reduction policies like needle exchange programs. Yet neither of these policies has been widely embraced.

Why? Because these treatments are seen as indulging an addict’s weakness rather than “curing” it. Methadone and buprenorphine, the most effective medication-assisted treatments, are “crutches,” in the words of felony treatment court judge Frank Gulotta Jr. [see note below – LG]; they are “just substituting one opioid for another,” according to former Health and Human Services Secretary Tom Price.

And as county Commissioner Rodney Fish voted to block a needle exchange program in Lawrence County, Indiana, he quoted the Bible: “If my people … shall humble themselves … and turn from their wicked ways; then will I hear from heaven, and will forgive their sin.”

Most of us have been trained to use more forgiving language when talking about addiction. We call it a disease. We say that people with addiction should be helped, not blamed. But deep down, many of us still have trouble avoiding the thought that they could stop using if they just tried harder.

Surely would do better in their situation, we think to ourselves. We may not endorse the idea — we may think it is flat-out wrong — but there’s a part of us that can’t help but see addiction as a symptom of weak character and bad judgment.

Latent or explicit, the view of addiction as a moral failure is doing real damage. The stigma against addiction is “the single biggest reason America is failing in its response to the opioid epidemic,” Vox’s German Lopez concluded after a year of reporting on the crisis. To overcome this stigma, we need to first understand it. Why is it so easy to see addiction as a sign of flawed character?

We tend to view addiction as a moral failure because we are in the grip of a simple but misleading answer to one of the oldest questions of philosophy: Do people always do what they think is best? In other words, do our actions always reflect our beliefs and values? When someone with addiction chooses to take drugs, does this show us what she truly cares about — or might something more complicated be going on?

These questions are not merely academic: Lives depend on where we come down. The stigma against addiction owes its stubborn tenacity to a specific, and flawed, philosophical view of the mind, a misconception so seductive that it ensnared Socrates in the fifth century BC.

Do our actions always reflect our preferences?

In a dialogue called the Protagoras, Plato describes a debate between Socrates and a popular teacher named (wait for it) Protagoras. At one point their discussion turns to the topic of what the Greeks called akrasia: acting against one’s best judgment.

Akrasia is a fancy name for an all-too-common experience. I know I should go to the gym, but I watch Netflix instead. You know you’ll enjoy dinner more if you stop eating the bottomless chips, but you keep munching nevertheless.

This disconnect between judgment and action is made all the more vivid by addiction. Here’s the testimony of one person with addiction, reported in Maia Szalavitz’s book Unbroken Brain: “I can remember many, many times driving down to the projects telling myself, ‘You don’t want to do this! You don’t want to do this!’ But I’d do it anyway.”

As pervasive as the experience of akrasia is, Socrates thought it didn’t make sense. I may think I value exercise more than TV, but, assuming no one is pressuring me, my behavior reveals that when it comes down to it, I, in fact, care more about catching up on Black Mirror. As Socrates puts it: “No one who knows or believes there is something else better than what he is doing, something possible, will go on doing what he had been doing when he could be doing what is better.”

Now, you might be thinking: Socrates clearly never went to a restaurant with unlimited chips. But he has a point. To figure out what a person’s true priorities are, we usually look to the choices they make. (“Actions speak louder than words.”) When a person binges on TV, munches chips, or gets high despite the consequences, Socrates would infer that they must care more about indulging now than about avoiding those consequences — whatever they may say to the contrary.

(He isn’t alone: Both the behaviorism movement in 20th-century psychology and the “revealed preference” doctrine in economics are based on the idea that you can best learn what people desire by looking at what they do.)

So for Socrates, there’s no such thing as acting against one’s best judgment: There’s only bad judgment. He draws an analogy with optical illusions. Like a child who thinks her thumb is bigger than the moon, we overestimate the value of nearby pleasures and underestimate the severity of their faraway consequences.

Through this Socratic lens, it’s hard not to see addiction as a failure. Imagine a father, addicted to heroin, who misses picking up his children from school because he’s shooting up at home. In Socrates’s view, the father must be doing what he believes to be best. But how could the father possibly think that?

I see two possibilities. As Socrates’s illusion analogy suggests, the father could be grievously mistaken about the consequences of his actions. Perhaps he has convinced himself that his kids can get home on their own, or that he’ll be able to pick them up while high. But if the father has seen the damaging effects of his behavior time and again — as happens often to long-term addicts — it becomes harder to see how he is not complicit in this illusion. If he really believes his choice will be harmless, he must be willfully, and condemnably, self-deceived.

Which leads us to the second, even more damning possibility: Perhaps the father knows the consequences shooting up will have on his children, but he doesn’t care. If his choice cannot be ascribed to ignorance, it must reveal his preferences: The father must care more about getting high than he cares about his children’s well-being.

If Socrates’s model of the mind is right, these are the only available explanations for addictive behavior: The person must have bad judgment, bad priorities, or some combination of the two.

Our philosophy of addiction shapes our treatment of it — whether we realize it or not

It’s not exactly a sympathetic picture. But I suspect it underlies much of our thinking about addiction. Consider the popular idea that someone with addiction has to hit “rock bottom” before she can begin true recovery. In the Socratic view, this makes perfect sense. If addiction is due to a failure to appreciate the bad consequences of getting high, then the best route to recovery might be for the person to experience firsthand how bad those consequences really are. A straight dose of the harshest reality might be the only cure for the addict’s self-deceived beliefs and shortsighted preferences.

We could give a similar Socratic rationale for punishing drug possession with decades in jail: If we make the consequences of using bad enough, people with addiction will finally realize that it’s better to be sober, the thought goes. Once again, we are correcting their flawed judgment and priorities, albeit with a heavy hand.

Socrates’s view also makes sense of our reluctance to adopt medication-assisted treatment and needle exchange programs. These methods might temporarily mitigate the damage caused by addiction, but on the Socratic view, they leave the underlying problem untouched.

By giving out clean needles or substituting methadone for heroin, we may prevent some deaths in the short term, but we won’t change the skewed priorities that caused the addictive behavior in the first place. Worse, we may “enable” someone’s bad judgment by shielding her from the worst effects of her actions. In the long run, the only way to save addicts from themselves is to make it harder, not easier, to pursue the lifestyle they so clearly prefer.

Is Socrates right? Or can we find a better, more sympathetic way of thinking about addiction?

To see things differently, we need to question the fundamental picture of the mind on which Socrates’s view rests. It is natural to think of the mind as a unified whole and identify ourselves with that whole. But this monolithic view of the mind leads to the Socratic view of addiction. Whatever I choose must be what my mind wants most, and so what want most. The key to escaping the Socratic view, then, is to realize that the mind has different parts — and that some parts of my mind are more me than others.

The “self” is not a single, unitary thing

This “divided mind” view has become popular in both philosophy and psychology over the past 50 years. In psychology, we see it in the rise of “dual process” theories of the mind, the most famous of which comes from Nobel laureate Daniel Kahneman, who divides the mind into a part that makes judgments quickly, intuitively, and unconsciously (“System I”) and a part that thinks more slowly, rationally, and consciously (“System II”).

More pertinent for our purposes is research on what University of Michigan neuroscientist Kent Berridge calls the “wanting system,” which regulates our cravings for things like food, sex, and drugs using signals based in the neurotransmitter dopamine. The wanting system has powerful control over behavior, and its cravings are insensitive to long-term consequences.

Berridge’s research indicates that addictive drugs can “hijack” the wanting system, manipulating dopamine directly to generate cravings that are far stronger than those the rest of us experience. The result is that the conscious part of a person’s mind might want one thing (say, to pick his kids up from school) but be overruled by the wanting system’s desire for something else (to get high). . .

Continue reading.

Note: I wonder whether Judge Gulotta wears glasses (an obvious “crutch”). If he breaks his leg, will he refuse to use a crutch because it’s just a crutch? I wear hearing aids—obviously a crutch. I think Judge Gulotta is a moron.

Written by LeisureGuy

17 March 2018 at 1:48 pm

Excellent idea: Limit the amount of (addictive) nicotine in cigarettes

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Once again we see an example of how some actions require a government: the libertarian hope that all problems can be resolved through the free market with no government interference is an illusion based on a bad novel by Ayn Rand. Unfortunately, some (I’m looking at you, Paul Ryan) fall for it hook, line, and sinker. Julia Belluz writes in Vox:

America could become the first country in the world to force tobacco companies to reengineer their products so they’ll be less addictive.

The Food and Drug Administration announced Thursday that it’s moving to put in a place a regulation that will set a maximum amount of nicotine cigarettes can have.

The FDA first discussed the measure last summer as part of its comprehensive new plan for tobacco and nicotine regulation. But today’s advance notice of proposed rulemaking is the first real step in initiating the long, bureaucratic process that would make the regulation a reality.

“We believe the public health benefits and the potential to save millions of lives, both in the near and long term, support this effort,” FDA Commissioner Scott Gottlieb said in a statement.

Researchers who modeled the health impact of nicotine limits for a new paper in the New England Journal of Medicine showed the policy could help some 5 million adult smokers quit smoking within one year, and by 2100 prevent more than 33 million people from becoming regular smokers at all.

Cigarette use has been on a downward trajectory for decades in the US thanks to tobacco taxes, smoking bans, and public awareness campaigns. But smoking is still the leading cause of preventable disease and death in America, contributing to nearly half a million early deaths and more than $300 billion in health care expenditures and productivity losses every year.

According to the model, smoking rates could drop from 15 percent to as low as 1.4 percent, Gottlieb said. “All told, this framework could result in more than 8 million fewer tobacco-caused deaths through the end of the century — an undeniable public health benefit.”

“Cigarettes are as or more harmful, and as or more addictive, than they were 60 years ago, when people were using cigarettes without filters,” said University of Waterloo public health researcher David Hammond (who was not involved in the NEJM paper). “It’s a bizarre historical coincidence nothing has been done to change that fundamental equation.”

The proposed policy could change the equation — but it’s by no means a standard anti-smoking regulation; no other country has ever tried such a measure. So it’s a big deal the US is going first.

“If the US does this, and is successful, other countries will join in,” said David Liddell Ashley, the previous director of the office of science in the Center for Tobacco Products at FDA. “You will see a reduction in deaths from tobacco — tens of millions of people a year will no longer die from tobacco use.”

The news is also a reminder of America’s somewhat schizophrenic relationship with regulating smoking. Nicotine limits would be one of the most avant-garde tobacco policies in the world. And yet the US still lags behind many other countries — including low-income countries — on many other tobacco control basics. . .

Continue reading.

The reason that the US still lags behind many other countries on tobacco control is that Congress caters to corporations and fails to protect consumers, and the GOP in particular is guilty of this (though some Democrats are as well: the Democrats who voted to weaken Dodd-Frank, for example).

I think the restriction on the level of nicotine should also apply to cigarettes exported from the US and imported into the US. And the levels should be monitored: cigarette companies will try to cheat, since they depend on addiction to keep their customers, which is why they work to get young people smoking.

Written by LeisureGuy

16 March 2018 at 1:48 pm

Addiction is learned: It’s a habit

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Marc Lewis has a very interesting article in Aeon. Here’s his background:

Marc Lewis is a neuroscientist and a recently retired professor of developmental psychology. He was at the University of Toronto from 1989 to 2010 and at Radboud University in the Netherlands from 2010 to 2016. His latest book is The Biology of Desire (2015). He lives in the Netherlands.

His article begins:

Three years ago, I put out a call to my blog community: would anyone be willing to tell me the story of their addiction, from start to finish, in all of its gory detail, for the book I am writing? The book would combine an account of brain change in addiction with subjective descriptions of what it’s like to live inside addiction. More than 100 people replied. Two years later, I’d recorded intimate biographies of a heroin addict, a meth addict, an alcoholic, a pill-popper and someone with an eating disorder, and my book The Biology of Desire was published in 2015.

I already knew a lot about addiction. I had struggled with my own drug compulsion, back in my 20s, and lost most of what I valued as a result. But then I quit, returned to university, earned a PhD in developmental psychology, and went on to become a professor at the University of Toronto. For more than 20 years, I researched the emotional development of children and adolescents. And after 10 of those years, I switched my focus to brain science, since the broad brushstrokes of psychology couldn’t quite capture the concrete, biological factors that interact to create our personalities. When I returned to addiction, it was as a scientist studying the addicted brain. The data were indisputable: brains change with addiction. I wanted to understand how ­– and why. I wanted to understand addiction with fastidious objectivity, but I didn’t want to lose touch with its subjectivity – how it feels, how hard it is – in the process.

The suffering, the intense effort, failure and eventual triumph I remembered from my own years of addiction coursed through each of the biographies I collected. Each revealed the agonising counterpoint of fear and shame sculpted by addiction. For example, Donna described the strange conceit that came with her talent as a pill thief, until she was caught rummaging through drawers by family members primed by suspicion. Donna cared for children with severe illnesses in a Los Angeles hospital; friends and coworkers thought her a saintlike being, overflowing with generosity and competence. What they did not see was her overflowing hunger for opiate painkillers – the special treats she saved up for after work and weekends.

Donna continued to steal pills from friends and relatives, forge doctors’ prescriptions, and raid her husband’s painkiller supply to achieve that precious buzz. She developed compelling rationalisations as to why she deserved this vacation from her high-stress life. And finally she was caught red-handed by a video camera set up in her mother-in-law’s bedroom – an event that precipitated massive trauma, fear of abandonment, and then months of intensive therapy.

What Donna and the other very different people I spoke with had in common was what all addicts find most maddening (and terrifying) about addiction: its staying power, long after the pleasure has worn off, long after the relief has transformed into extended anxiety, long after they’ve sworn up and down, to themselves and others, that this would not continue. It’s that resilience that has made addiction so incomprehensible to addicts, their families and the experts they turn to for help, while feeding a firestorm of clashing explanations as to what it actually is.

One explanation is that addiction is a brain disease. The United States National Institute on Drug Abuse, the American Society of Addiction Medicine, and the American Medical Association ubiquitously define addiction as a ‘chronic disease of brain reward, motivation, memory and related circuitry’ – a definition echoing through their websites, lectures and literature, and, most recently, ‘The Surgeon General’s Report on Alcohol, Drugs, and Health’ (2016). Such authorities warn us that addiction ‘hijacks the brain’, replacing the capacity for choice and self-control with an unremitting compulsion to drink or use drugs. In the UK, the medical journal The Lancet has provided a forum for figurehead proponents of the brain-disease model, echoing the government’s emphasis on ‘withdrawal symptoms, tolerance, detoxification or alcohol-related seizures’,  which suggests that the royal road to understanding addiction is still medicine.

This mania for medicalisation has been evolving for decades, an outgrowth of the strange marriage between support groups such as Alcoholics Anonymous (AA) and institutional care. It became the dominant approach to addiction throughout the Western world in the 1990s – the so-called decade of the brain – largely due to the discovery of brain changes that correspond with addiction, some of them long-lasting if not permanent.

If addiction changes the brain and drugs cause addiction, the argument went, then perhaps drugs unleash pathological changes, literally damaging neural tissue. The implication that addicts do the things they do because they are ill, not because they are weak, self-indulgent, spineless pariahs (a fairly prevalent view in some quarters) also seemed to benefit addicts and their families. The anger and disgust they often experienced could be mitigated by the presumption of illness; and social stigmatisation – known to compound the misery of those with mental problems – could be relieved, even reversed, by the simple assumption that addicts can’t help themselves.

If only the disease model worked. Yet, more and more, we find that it doesn’t. First of all, brain change alone isn’t evidence for brain disease. Brains are designed to change. That is their modus operandi. They change massively with child and adolescent development: roughly half the synapses in the cortex literally disappear between birth and adulthood. They change with learning, throughout the lifespan; with the acquisition of new skills, from taxi-driving to music appreciation, and with normal ageing. Brains change with recovery from strokes or trauma and, most importantly, they change when people stop taking drugs.

Secondly, we now know that drugs don’t cause addiction. People become addicted to gambling, porn, sex, social media, gaming, shopping, and of course food; many of these dependencies are now classed as ‘disorders’ in the canonical (but controversial) Diagnostic and Statistical Manual of Mental Disorders (DSM). Moreover, the brain changes observed in drug addiction look the same as those underlying these ‘behavioural’ addictions. What is particularly interesting to me is that brain changes in addiction also resemble those underlying sexual attraction and romantic love: the brain restructures itself, at least to an extent, when attraction runs high.

The supposed social and clinical benefits of the disease model are equally unconvincing. For one thing, psychiatric patients report that the ‘illness’ label causes more stigma, not less. We might not want to sit next to someone in the waiting room if they have a ‘mental illness’. But someone with an ‘emotional problem’ doesn’t seem so very different from members of our own group or family, or even from ourselves. More intriguingly, a number of studies have shown that the belief that addiction is a disease actually decreases the odds of sustained recovery. AA has long overwritten the notion of self-generated change with that of vigilant control: once an addict, always an addict, so watch out!

No doubt the fellowship aspect of 12-step groups is valuable, but there’s little indication that the presumption of a life-long flaw facilitates recovery. Expensive private rehabs don’t do much better, partly because their core programmes still revolve around 12-step methods, with an overlay of medical supervision. Because relapse rates are so high, both in AA and in private rehabs, addicts continue to feel the burden of shame, isolation and rejection. Something fundamental about our treatment philosophy has to change. Yet the disease model seems to lock it in place.

So what are the alternatives? One idea is that addicts voluntarily choose to remain addicted: if they don’t quit, it’s because they don’t want to. Anyone who has spent even a little time with someone struggling with addiction can see the shallowness of this view. The other contender is the idea that addiction develops, it is learned, which might make it similar to other detrimental behaviour patterns: racism, religious extremism, obsessive involvement with sports or tattoos, or with romantic partners who aren’t working out, or might even be abusive. Addiction might be hard to give up because it is so deeply learned – or learned in urgent circumstances – while alternative means for arranging one’s life are not.

The view that addiction arises through learning, in the context of environmental forces, appears to be gathering momentum. An international policy group of more than 50 scholars, researchers, policy advisers and treatment professionals was coordinated earlier this year by the British researchers Derek Heim and Nick Heather, specifically to oppose the ‘brain disease model’. This group, the Addiction Theory Network, emphasises the social and psychological factors that promote addiction. And although some group members ignore the biology of addiction, presumably to distance themselves as far as possible from the disease model, others (myself included) view brain change as essential to learning addiction. After all, how do we learn anything except by modifying the connections in our brains?

Yet the question remains: if addiction is learned, how does it become so much more crystallised, entrenched, in fact stuck, than other learned behaviours? Given that what we learn we can often unlearn, why is addiction so hard to get rid of?

Johnny was a British plant manager, and his childhood included several years in a boarding school where sexual abuse by clergymen lurked insidiously behind the rustlings of bedtime. Johnny grew up anxious but competent; he married, then divorced, and enjoyed regular visits with his grown children – a relatively normal and predictable life. Until it all unravelled. His friends and business associates found it hard to watch, and impossible to interfere, as Johnny approached end-stage alcoholism. He drank himself so close to death that his first reaction to waking up was surprise. By the final six months, Johnny’s days acquired a strange rhythm. They began with a walk to the fridge, rum and ice already crackling by the time he got to the toilet. They would end when he crawled to bed on his hands and knees, unable to stand. After a few hours’ sleep, there’d begin another ‘day’ of drinking, which lasted only until his next collapse. Johnny told me he would have committed suicide, but it was happening by itself.

Why was it so hard to overcome this behaviour pattern when it got close to destroying him? Why the horrendous sameness, the insidious stability in his habits, in his life? Johnny is an intelligent man. He knew what he was doing. So why couldn’t he stop? These are the questions that a learning model of addiction has to answer.

We often think of learning in terms of skill-learning. Language, self-control, bike-riding, algebra, table manners and playing the piccolo are such skills. But we also learn habits such as nail-biting, TV-watching and folding our napkins a certain way. A focus on habits is distinct from a focus on skills: loosely speaking, habits are acquired without intention; skills are acquired deliberately. But do they differ in other ways? . . .

Continue reading. There’s a lot more.

I hope Kellyanne Conway is aware of this new paradigm, given her responsibility to combat the opioid crisis.

Written by LeisureGuy

16 March 2018 at 9:48 am

America Is Giving Away the $30 Billion Medical Marijuana Industry

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The subhead is good:

Why? Because the feds are bogarting the weed, while Israel and Canada are grabbing market share

Josh Dean reports in Bloomberg Businessweek:

Lyle Craker is an unlikely advocate for any political cause, let alone one as touchy as marijuana law, and that’s precisely why Rick Doblin sought him out almost two decades ago. Craker, Doblin likes to say, is the perfect flag bearer for the cause of medical marijuana production—not remotely controversial and thus the ideal partner in a long and frustrating effort to loosen the Drug Enforcement Administration’s chokehold on cannabis research. There are no counterculture skeletons in Craker’s closet; only dirty boots and botany books. He’s never smoked pot in his life, nor has he tasted liquor. “I have Coca-Cola every once in a while,” says the quiet, white-haired Craker, from a rolling chair in his basement office at the University of Massachusetts at Amherst, where he’s served as a professor in the Stockbridge School of Agriculture since 1967, specializing in medicinal and aromatic plants. He and his students do things such as subject basil plants to high temperatures to study the effects of climate change on what plant people call the constituents, or active elements.

Craker first applied for a license to grow marijuana for medicinal research in 2001, at the urging of Doblin, the founder and executive director of the Multidisciplinary Association for Psychedelic Studies(MAPS), a nonprofit that advocates for research on therapeutic uses for LSD, MDMA (aka Ecstasy), marijuana, and other psychedelic drugs. Doblin, who has a doctorate in public policy, makes no secret of his own prior drug use. He’s been lobbying since the 1980s for federal approval for clinical research trials on various psychedelics, and he saw marijuana as both a promising potential medicine and an important front in the public-relations war. Since 1970 marijuana has been a DEA Schedule I substance, meaning that in the view of the federal government, it’s as dangerous as LSD, heroin, and Ecstasy, and has “no currently accepted medical use and a high potential for abuse.”

By that definition, pot—now legal for medicinal use by prescription in 29 states and for recreational use in eight—is more dangerous and less efficacious in the federal government’s estimation than cocaine, oxycodone, or methamphetamine, all of which are classified Schedule II. Scientists and physicians are free to apply to the Food and Drug Administration and DEA for trials on Schedule I substances, and there are labs with licenses to produce LSD and Ecstasy for that purpose, but anyone who seeks to do FDA-approved research with marijuana is forced to obtain the plants from a single source: Uncle Sam. Specifically, since 1968 the DEA has allowed only one facility to legally cultivate marijuana for research studies, on a 10-acre plot at the University of Mississippi, funded by the National Institute on Drug Abuse and managed by the Ole Miss School of Pharmacy.

The NIDA license, Doblin says, is a “monopoly” on the supply and has starved legitimate research toward understanding cannabinoids, terpenes, and other constituents of marijuana that seem to quell pain, stimulate hunger, and perhaps even fight cancer. Twice in the late 1990s, Doblin provided funding, PR, and lobbying support for physicians who wanted to study marijuana—one sought a treatment for AIDS-related wasting syndrome, the other wanted to see if it helped migraines—and was so frustrated by the experience that he vowed to break the monopoly. That’s what led him to Craker.

In June 2001, Craker filed an application for a license to cultivate “research-grade” marijuana at UMass, with the goal of staging FDA-approved studies. Six months later he was told his application had been lost. He reapplied in 2002 and then, after an additional two years of no action, sued the DEA, backed by MAPS. By this point, both U.S. senators from Massachusetts had publicly supported his application, and a federal court of appeals ordered the DEA to respond, which it finally did, denying the application in 2004.

Craker appealed that decision with backing from a powerful bench of allies, including 40 members of Congress, and finally, in February 2007, a DEA administrative law judge ruled that his application for a license should be granted. The decision was not binding, however; it was merely a recommendation to the DEA leadership. Almost two years later, in the last week of the Bush administration, the application was rejected. Craker threw up his hands. He firmly believed marijuana should be more widely grown and studied, but he’d lost any hope that it would happen in his lifetime. And he had basil to attend to. . .

Continue reading.

Written by LeisureGuy

8 March 2018 at 2:21 pm

Why the Disease Definition of Addiction Does Far More Harm Than Good

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Interesting article in Scientific American by Marc Lewis, a neuroscientist and professor emeritus in developmental psychology at the University of Toronto:

Over the past year and a half, Scientific American has published a number of fine articles arguing that addiction is not a disease, that drugs are not the cause of addiction, and that social and societal factors are fundamental contributors to opioid addiction in general and the overdose crisis in particular. The dominant view, that addiction is a disease resulting from drug use, is gradually being eroded by these and other incisive critiques. Yet the disease model and its corollaries still prevail in the domains of research, policy setting, knowledge dissemination and treatment delivery, more in the United States than in any other country in the developed world. You might wonder: what are we waiting for?

The disease model remains dominant in the U.S. because of its stakeholders. First, the rehab industry, worth an estimated $35 billion per year, uses the disease nomenclature in a vast majority of its ads and slogans. Despite consistently low success rates, that’s not likely to stop because it pulls in the cash. Second, as long as addiction is labeled a disease, medical insurance providers can be required to pay for it.

Of course they do so as cheaply as possible, to the detriment of service quality, but they at least save governments the true costs of dealing with addiction through education, social support, employment initiatives and anti-poverty mechanisms. Third, the National Institute on Drug Abuse (NIDA), a part of the National Institutes of Health (NIH) that funds roughly 90 percent of addiction research worldwide, is a medically oriented funder and policy setter, as are the American Society of Addiction Medicine and other similar bodies.

For these organizations to confess that addiction isn’t really a disease would be tantamount to admitting that they’re in no position to tackle it, which would be a form of institutional suicide. And finally, there are the families of addicts, many of whom welcome the idea that addiction is a disease because that implies that their loved ones are not bad people after all. More on that shortly.

My own role in the controversy has been to keep up a spate of arguments against the disease model of addiction, in books, the press and online, mostly on scientific grounds. As a neuroscientist, I’m able to show why brain change—either in general or specifically in the striatum, the motivational core—does not equal pathology or disease. And as a developmental psychologist (my other hat), I highlight the role of learning in brain change (or neuroplasticity) and reinterpret NIDA’s findings in terms of deeply ingrained habits of thought and action. Both arguments are presented in some detail here.

But why does the definition of addiction matter? Isn’t this just a word game? . . .

Continue reading.

Written by LeisureGuy

9 February 2018 at 9:52 am

Kellyanne Conway’s ‘opioid cabinet’ sidelines drug czar’s experts

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Brianna Ehly and Sarah Karlin-Smith report in Politico:

President Donald Trump’s war on opioids is beginning to look more like a war on his drug policy office.

White House counselor Kellyanne Conway has taken control of the opioids agenda, quietly freezing out drug policy professionals and relying instead on political staff to address a lethal crisis claiming about 175 lives a day. The main response so far has been to call for a border wall and to promise a “just say no” campaign.

Trump is expected to propose massive cuts this month to the “drug czar” office, just as he attempted in last year’s budget before backing off. He hasn’t named a permanent director for the office, and the chief of staff was sacked in December. For months, the office’s top political appointee was a 24-year-old Trump campaign staffer with no relevant qualifications. Its senior leadership consists of a skeleton crew of three political appointees, down from nine a year ago.

“It’s fair to say the ONDCP has pretty much been systematically excluded from key decisions about opioids and the strategy moving forward,” said a former Trump administration staffer, using shorthand for the Office of National Drug Control Policy, which has steered federal drug policy since the Reagan years.

The office’s acting director, Rich Baum, who had served in the office for decades before Trump tapped him as the temporary leader, has not been invited to Conway’s opioid cabinet meetings, according to his close associates. His schedule, obtained under a Freedom of Information Act request, included no mention of the meetings. Two political appointees from Baum’s office, neither of whom are drug policy experts, attend on the office’s behalf, alongside officials from across the federal government, from HHS to Defense. A White House spokesperson declined to disclose who attends the meetings, and Baum did not respond to a request for comment, although the White House later forwarded an email in which Baum stressed the office’s central role in developing national drug strategy.

The upheaval in the drug policy office illustrates the Trump administration’s inconsistency in creating a real vision on the opioids crisis. Trump declared a public health emergency at a televised White House event and talked frequently about the devastating human toll of overdoses and addiction. But critics say he hasn’t followed through with a consistent, comprehensive response.

He has endorsed anti-drug messaging and tougher law enforcement. But he ignored many of the recommendations from former New Jersey Gov. Chris Christie’s presidential commission about public health approaches to addiction, access to treatment, and education for doctors who prescribe opioids. And he hasn’t maintained a public focus. In Ohio just this week, it was first lady Melania Trump who attended an opioid event at a children’s hospital. The president toured a manufacturing plant and gave a speech on tax cuts.

Much of the White House messaging bolsters the president’s call for a border wall, depicting the opioid epidemic as an imported crisis, not one that is largely home-grown and complex, fueled by both legal but addictive painkillers and lethal street drugs like heroin and fentanyl.

“I don’t know what the agency is doing. I really don’t,” said Regina LaBelle, who was the drug office’s chief of staff in the Obama administration. “They aren’t at the level of visibility you’d think they’d be at by now.”

Conway touts her opioids effort as policy-driven, telling POLITICO recently that her circle of advisers help “formalize and centralize strategy, coordinate policy, scheduling and public awareness” across government agencies.

That’s exactly what the drug czar has traditionally done.

Conway’s role has also caused confusion on the Hill. For instance, the Senate HELP Committee’s staff has been in touch with both Conway and the White House domestic policy officials, according to chairman Lamar Alexander’s office. But lawmakers who have been leaders on opioid policy and who are accustomed to working with the drug czar office, haven’t seen outreach from Conway or her cabinet.

“I haven’t talked to Kellyanne at all and I’m from the worst state for this,” said Sen. Shelley Moore Capito, a Republican from West Virginia, which has the country’s highest overdose death rate. “I’m uncertain of her role.” The office of Sen. Rob Portman (R-Ohio), another leader on opioid policy, echoed that — although Portman’s wife, Jane, and Conway were both at the event with Melania Trump this week. . .

Continue reading. And read the whole thing. There’s more.

Kevin Drum comments:

The reason for sidelining the actual drug professionals is pretty obvious: they would recommend programs that cost a lot of money and regulate pharmaceutical companies, and Trump doesn’t want to do either. He just wants to sound really tough, like he did yesterday in Ohio:

America will not overcome this epidemic overnight….Our children are being decimated. You know, one drug dealer can kill thousands of people. One drug dealer. If you ever did an average — nobody has ever seen this, you’ve probably never heard this before — but if you ever did an average, a drug dealer will kill thousands of people. And we don’t even come down on these people. So it’s time to start, and that time is now. Right now.

….People form blue ribbon committees, they do everything they can. And, frankly, I have a different take on it. My take is, you have to get really, really tough — really mean — with the drug pushers and the drug dealers. We can do all the blue ribbon committees we want. We have to get a lot tougher than we are. And we have to stop drugs from pouring across our border.

There you go. If we just get a lot meaner, the opioid epidemic will go away. I wonder why no one ever thought of that before?



Written by LeisureGuy

6 February 2018 at 10:48 am

Some items from Radley Balko’s Trump Watch

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Radley Balko writes in the Washington Post:

  • President Trump accuses another political opponent of committing crimes. He of course has a long history of this, going back to the campaign. It’s easy to get used to this sort of thing. But we shouldn’t lose sight of what’s at stake. The chief law enforcement official in the country repeatedly accusing his critics and opponents of criminality is a dangerous thing. And it will be all the more dangerous if he begins doing it to his potential 2020 opponents.
  • Immigration and Customs Enforcement officers arrest a Kansas chemistry teacher who was about to take his daughter to school. He came here 30 years ago and overstayed his visa. He has no criminal record. He has three children. The Trump administration is preparing to deport him to Bangladesh.
  • The administration has also deported a Detroit father of two who was brought to the United States at age 10 and has also been here for almost 30 years. He and his wife have spent more than $100,000 trying to obtain legal citizenship for him. According to his supporters, he has no criminal record and has paid taxes every year.
  • In fact, arresting undocumented parents as they drop their children off at school seems to be an increasingly common tactic.
  • Other recent deportations or arrests and pending deportations: A green card veteran who served two tours of duty in Afghanistan, suffers from post-traumatic stress disorder and was brought here at age 8 (he had a felony drug conviction); a single mom with three children who are U.S. citizens (her only crime was to lie about her status on a driver’s license application — her husband was deported for the same offense); two Salvadoran brothers who were detained when one went to notify immigration officials that he was just given a scholarship to play college soccer; a host of pro-immigration activists; and a Palestinian father of four who was brought here at age 17 and owned a successful small business in Youngstown, Ohio;
  • Meanwhile, Trump’s pick to head up ICE said that politicians in sanctuary cities should be arrested and charged with crimes.
  • Why fears about “chain migration” are mostly a myth.
  • The Treasury Department may soon lift Obama administration-era protections for banks that do business with marijuana businesses in states where the drug is legal.
  • We noted this story previously, but it’s worth archiving in Trump Watch: ICE will soon have access to a license-plate database with billions of photos showing the time and location of various vehicles. It’s a good reminder that it will be impossible to enforce the Trump administration’s ideal immigration policy without severe restrictions on the civil liberties of everyone, not just immigrants.
  • A California woman died while waiting on the State Department to approve a visa for her sister to come to the United States from Vietnam for a stem-cell transplant.
  • The Justice Department will oppose leniency for a Nashville man who served more than 20 years in prison for a drug crime and was released in 2016 under new sentencing guidelines. He had a spotless record in prison. But the federal government appealed, arguing that his criminal history as a juvenile precluded his release. Despite a federal judge’s opinion that he is completely rehabilitated, he now faces another 15 years in prison. (To be fair, the appeal of his release was initiated during the Obama administration. But the current administration could still recommend leniency.)
  • The Justice Department has effectively shut down an office that facilitated legal aid for the poor.

Written by LeisureGuy

5 February 2018 at 6:28 pm

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