Author: anonymous

…by James Morris…

The great “controlled drinking” debate has a controversial history dating back to the 1960’s. Since then, politics, addiction ideology, and evidence have often been hard to separate. In the 1970’s the Sobells were vilified for allegedly skewing the results of research showing that some dependent drinkers achieved controlled drinking, but they were later cleared of any wrongdoing. Audrey Kishline, the founder of Moderation Management (a peer support group), committed suicide after driving drunk and causing a fatal car crash. This tragic event is often cited as an example of how moderation doesn’t work.

Today, recognition of non-abstinence-oriented outcomes is less controversial. However, there is still no shortage of opponents, and not just amongst 12-steppers. Like many complex issues, the “truth” about controlled drinking may depend on which way you cut the cake.

I first became interested in this subject when after many years of abstinence I began to ask myself “could I re-learn to drink?” My relationship with alcohol had started in my early teens and then steadily progressed; by the time I was in my early twenties I drank as much as possible, often to the point of blackout, and was experiencing physical health problems. After a number of failed attempts to cut down, I began to realise I wasn’t in control. I remember thinking to myself “if I don’t act on this now, where will it end?”

Stopping drinking in my twenties was very difficult. During my early months of sobriety I struggled to stop thinking about alcohol and battled with trying to reformulate my identity and social life. Drinking pressures and cues seemed to surround me constantly, but in some ways this made me more determined.

As time passed things slowly became easier and more normal as a “non-drinker,” though initially I sought various other pursuits to try and fill the excitement gap. I also attended AA meetings for a while. Generally I found the meetings positive and could identify with a lot of what I heard, though ultimately I never felt I was powerless and therefore an “alcoholic.”

Around six years later I felt like I was in a very different place, settled with a rewarding job, happier in myself as a person and as a “non-drinker.” During this time psychotherapy helped a lot, especially with anger issues connected with my past drinking. I began to feel things were so different now that normal drinking might be possible, and after a few years of contemplation, I eventually decided to see if I could “re-learn” a problem-free relationship with alcohol.

Many people still believe anyone with an alcohol addiction can never drink again without slipping back into old habits. The disease model of addiction as a “chronic relapsing condition” and associated beliefs about “alcoholics” are deeply entwined with the idea that abstinence is the only genuine option for long-term recovery.

There are some valid reasons to be skeptical of controlled drinking for once-dependent drinkers. Long-term studies suggest only a minority of problem drinkers achieve controlled or problem-free drinking, and for people with severe alcohol addiction, abstinence is usually identified as the most successful route. Indeed, severity of dependence is a central theme in addiction theory and in the concept of “alcohol dependence syndrome” that underpins ICD-10 and DSM classifications. Even so, some controlled-drinking studies have observed success in a subset of drinkers with more severe dependence. Whilst some argue that those with less severe dependence are not really “addicted,” there is no scientifically valid cut-off point.

In fact, the role of severity of dependence as a predictor of controlled drinking is unclear. Some studies have found other measures, like the extent of “impaired control” — i.e. failing to limit one’s drinking — serve as better predictors. Another important factor may be a period of abstinence. A drinker who has had many years without drinking will be more likely to succeed than one who simply tries to cut down straight away. How much of this may be about the brain “un-learning” drinking reward pathways — and how much may be about life changes and other skills that sobriety brings about — is again hard to generalise.

I began controlled drinking six years ago, and despite anxieties that I was doing the wrong thing, there are no signs that my relationship with alcohol has become problematic again. I might drink three times a week, typically with a meal, on weekends, or out with friends, and not more than two or three drinks on an occasion — within the UK’s recommended guidelines.

However, comparing myself then and now feels like comparing two different people. Then I was young and in many ways insecure, anxious and with a lot of fire in my belly. Drinking always felt like it allowed me to let go of this nervous energy. I believe that working through past issues through psychotherapy was as crucial as my long period of abstinence. I strongly feel that this process helped me deal with issues that fuelled my destructive drinking.

Trying to answer “when is controlled drinking possible?” is a bit like asking “what’s the best treatment for addiction?” — there are no easy answers; it depends on many factors. But there are some basic principles that might help predict success. Fundamentally, it may be fair to generalise that controlled drinking tends to be less successful for people who’ve been more severely dependent, experienced adverse childhood experiences, previously failed to control their drinking, or endured excessive insecurity or stress in their lives.

To anyone with a history of alcohol problems contemplating controlled drinking, I would suggest they ask themselves what it is they truly want or expect from drinking again. Weighing up the pros and cons objectively can be difficult, and it can be easy to over-value the pleasurable effects of moderate drinking. For me alcohol may have a mild relaxant effect, but it is not to de-stress, let go, or suppress negative emotions. If I go through a tough time in the future, I believe that will be an important time not to drink. Keeping healthy and looking after myself in other ways provide protective effects that allow me to drink without problems.

The author is in no way encouraging those with former alcohol problems to attempt “controlled drinking.” The author wishes to reiterate that controlled drinking is not suitable for many drinkers who seek help for alcohol problems, and anyone considering controlled drinking should consider the possible benefits of professional help.

…by Hanna Anderson…

In marijuana news, the government of Canada is looking to create and finalize a bill that will legalize marijuana in the spring of 2017. Some changes are already in motion.

Just recently, Minister of Justice, Jody Wilson-Raybould, announced the Task Force for Marijuana Legalization responsible for creating Canada’s drug policy on marijuana — and it will be a great undertaking. Thus far, the illicit drug isn’t legal for recreational use, and there are many reinforced misconceptions about the soft drug that make people see it as a hard drug. What regulations can be made that will allow Canadians to see the drug in a different light?

The Current State Of Marijuana

As a soft drug, marijuana is already used for medical purposes. The psychoactive substance in marijuana, THC, is widely used to treat the side effects of certain medical conditions, like nausea experienced by cancer patients.

Currently, only medical marijuana is legal in Canada under its Marijuana for Medical Purposes Regulations (MMPR). This Health Canada program provides users with access to medical marijuana only through licensed producers with a medical document signed by an authorized healthcare practitioner.

Despite this, there are still many legal gray areas and confusion. Moreover, with only 33 licensed producers in the entire country and a policy mandating the substance be distributed only via registered mail, marijuana activists are upset by the inefficiency of the system. Marijuana entrepreneurs, on the other hand, are taking advantage of the marijuana mess.

The Gateway Overlap

In general, soft drugs like marijuana (which are usually illicit) don’t produce physical dependence and are less addictive than hard drugs (such as cocaine and heroin).

Yet it is interesting to note that some smokers may experience withdrawal symptoms that can cause a psychological dependence and use disorder. This is part of the reason why many think of marijuana as a gateway drug to harder drugs and so advocate its prohibition.

But does that indirect connection mean that strict law enforcement is needed? Does it mean strict laws and swift action will solve the problem?

In Canada, illegal dispensaries have been popping up to both establish a stake in the future market and to address the supply shortage. However, marijuana is still officially illegal. Consequently, vendors are being arrested and shut down on the basis of violating municipal zoning bylaws.

When access to medicinal marijuana is limited, drug policies and restrictions are themselves the gateway to hard drugs. Why? Because legal prohibition encourages users in need of medical marijuana to turn to the black market, opening them up to unmonitored marijuana supplies, harder drugs, and criminal charges.

Penalties On Hard Drugs And Marijuana

Currently, the penalties on hard drugs in Canada range from 7 years for possession of cocaine and heroin to life imprisonment for trafficking or possession for the purpose of trafficking the substances.

On the other hand, it takes over 3 kgs of marijuana or hashish to be considered trafficking or to be considered possession for the purpose of trafficking. The maximum penalty for both is life imprisonment. Possession of marijuana penalties range from a 6 month and $1000 fine (for up to 30 g) to 5 years less a day in prison.

The war on drugs in Canada is seen as ineffective. For example, drug-policy spending under the Conservative government (in power for the last eight years) went to apprehending, charging and defending users in possession of small amounts of marijuana! With the new Liberal government, the focus is on approaching marijuana policy with an emphasis on regulation, not prohibition.

What New Policies Should Canada Implement?

But what key areas in marijuana law and policy should Canada look at to ensure that the regulations are appropriate for a soft drug? To which countries can Canada refer?

The USA, Portugal and the Netherlands — countries that have legalized marijuana (or chosen to ignore it) — offer examples of what to expect regarding the implementation of a national framework. OMQ Law (the author’s law firm) has put together an infographic that takes a close, visual look at how these countries have legitimized marijuana use.

From the Netherlands, which allows users to smoke in openly accepted, though illegal, marijuana cafes, to Portugal, where all drugs were decriminalized and addiction treatment programs aggressively implemented, the infographic explores the nuances in soft drug policies. In the USA, though five states have legalized marijuana medically and recreationally, it still has yet to be fully legalized across the country.

Laws are constantly evolving to ensure that effective drug policies are in place. Part of the task will be to keep in mind how a legalized soft drug will impact other international drug policies, social acceptance, and the perception of hard drugs in general.

In Canada it seems likely that supply and production will be controlled at the federal level and the provinces will control distribution — in the same way that the provinces control distribution of alcohol. Some provinces are advocating or suggesting that their liquor distribution networks are an obvious choice for distribution.

Our position is that a distribution framework should be set up separately, and have room for both public and private avenues for sales. We expect there to be a phase-in period of several years, as current levels of supply will be completely inadequate to handle initial demand.

omqlaw.ca

…by Colin Brewer…

Greetings from London and thanks, everybody, for what are — amazingly for this field — almost entirely positive comments on the ‘language’ analogy that I first suggested in 1989 and that my co-author Emmanuel Streel and I have been writing about since 2003. (Emmanuel is a neuropsychologist but also a psychopharmacologist.) Since Marc has honoured me with an invitation to do a guest column, here it is, partially in response to comments following the previous post.

First, my removal from the medical register had absolutely nothing to do with rapid opiate detox under anaesthesia. From about 1995 to 2001, we detoxed over 700 people with this technique without any significant problems. It wasn’t even discussed at my hearing. I qualified in 1963 and when I saw my first heroin detox two years later, it was routine to use generous sedation if severe distress tempted patients to withdraw from treatment rather than from heroin. If patients can withdraw — slowly or quickly — without much medication, that’s fine by me, but if they can’t (and there are many in that category) I think it is the traditional duty of doctors to make unpleasant procedures as comfortable as possible. Does anyone — apart from the extreme ‘no pain, no gain’ fundamentalists — seriously disagree with that? Consequently, for patients who wanted to try or resume abstinence, we offered a wide range of withdrawal techniques, from slow tapers, through 4-5 day withdrawal with mainly oral sedation to 24hr techniques under oral and/or intramuscular sedation to i/v sedation and full General Anaesthesia. (Historical note: at one point, I was threatened with a lawsuit by the Spanish-Israeli CITA group who claimed I had infringed their ‘patented’ GA detox technique. Apart from the fact that the use of particular drugs (as opposed to the details of their manufacture) can’t be patented in Europe, I had described and published the technique, in an admittedly obscure journal, several years before they first used it.)

Because addiction treatment provided by the National Health Service (NHS) was so lousy in the 1980s and 90s (for example, the addiction establishment were very anti-methadone maintenance from 1980-1999), there were long waiting lists for in-patient withdrawal, and when they were eventually admitted, completion rates in one of our flagship centres were barely 25%, of whom nearly half had relapsed four weeks later. We therefore found ourselves treating many people who would not normally have considered — or been able to afford — private treatment, and quite a few more prosperous patients whose insurance had refused to continue paying or who had simply impoverished themselves through repeated self-funded treatment. For this large group, we devised a home detox programme that involved training the family to act as carers. As with all our detoxes, after completion and naltrexone (NTX) induction, we very strongly encouraged patients to take family-supervised oral naltrexone for at least six months and, after 1997, to have a NTX implant, to increase the chances that they would get through the crucial and often difficult first couple of months, when relapse rates are highest. We did around 2000 home detoxes before one family fatally misunderstood the instructions. Naturally, I feel bad about that but I don’t feel bad about trying to devise affordable treatment. I think that case made the difference between a reprimand and being removed from the register, but many addiction clinicians and academics in Britain (and several abroad who gave evidence for me) will tell you that the establishment were out to get me and were looking for excuses.

Marc asked me if I’d ever written anything about the hearings. I haven’t, and these are my first published comments, but the two most bizarre features were (1) some three weeks spent by the panel trying, unsuccessfully, to prove that a case not written by one of our counsellors, whose handwriting was similar to mine, had actually been written by me, even though one of his notes read: ‘Must discuss this with CB’! and (2) a serious — as in six-fold — miscalculation by two of our leading academics of the methadone equivalent of another opiate.

If Marc thinks I look a bit weird in some of the online images, that’s probably because they were taken when I was trying to force my way through a rat-pack of paparazzi after the final hearing. Fortunately, the clinic I set up continues and is still doing most of the things that we had been doing up to the hearings. Some of those — e.g. using slow-release morphine for people who don’t get on well with methadone or buprenorphine — are now pretty normal, at least outside the USA. The clinic is also expanding its patient groups to include the growing problem — though it’s still small by US standards — of prescription opiate abuse and the management of ‘therapeutic addiction’ to opiates in pain problems. I only have an advisory role these days but we hope to extend what Emmanuel and I suggested should be called ‘Antagonist-Assisted Abstinence’ (AAA – geddit?) to benzodiazepines. Using s/c or slow i/v flumazenil infusions, it’s quite easy to take people off fistfuls of diazepam and other benzodiazepines in five days with very little discomfort, and a flumazenil implant is being developed in Australia.

The clinic still does plenty of maintenance treatment, and I was told recently that the new emphasis on ‘recovery’ (read: we don’t like indefinite methadone maintenance) means that, as in the 1980s, increasing numbers of well-functioning methadone-maintenance patients — many with good jobs that they don’t want to jeopardise by having to take weeks or months off for withdrawal — are being put on forced reductions. I never claimed to be perfect (as we say in the trade, ‘if you haven’t made any mistakes. you’re not seeing enough patients’) but I don’t think that anything I did caused remotely as much misery and disaster to opiate addicts as the policies encouraged by the addiction establishment in the face of mounting evidence for the value of methadone-maintenance treatment.

Finally, I wrote a paper a few years ago suggesting that harm reduction in family planning (avoiding unwanted pregnancies) could teach some useful lessons to conventional harm reduction (avoiding unwanted addictions), in that it uses a variety of techniques and tries to fit the treatment to the particular needs of the patient, rather than the prevailing ‘one size fits all, take it or leave it’ approach of so many clinics and — even worse — rehabs. I’ll provide references to this and other papers on request.

…by Matt Robert…

There is a well-known unconscious defense mechanism in psychology—compartmentalization. All humans compartmentalize. It’s one of the ways we make sense of the world, putting things in little boxes, so we can understand and move through the world more effectively.

But compartmentalization can cause more harm than good. Especially when it comes to addiction. We learn that our addictive behavior provides us something we are missing, some relief from anxiety, some focus free of the stressful distractions of daily life. Then we notice we want to keep using it, using it in a way that may not be acceptable to us or to our community. We want the resulting ambivalence and cognitive dissonance to go away. So we put the addiction in a compartment, over to the side in our psyche. A little box of respite and relief when we need it, and no one else needs to know about it or disapprove.

The problem is that, in addiction, the compartment starts to leak. The tendrils of our secret start to surround us to the point where everyone else can see that it’s a problem–before we do. We think it’s still back in its box, there for when we need it. But now it’s taking up more and more space in our mind and in our life. And the leaky compartment is getting more and more difficult to manage.

Addictions aren’t the only thing we compartmentalize to our detriment. Sometimes we also compartmentalize our recovery. Our recovery is boxed away in the meeting we go to on Tuesdays, or the medicine we take every morning, or the program we went to for 3 months. Our recovery is under control: it’s in a box. But unlike addiction, our recovery compartment doesn’t usually leak. It just sits there. It doesn’t become the central part of our daily life that the addiction was. In fact, with recovery, compartmentalization poses the opposite threat: the danger that it may dry up and disappear if left in its box.

Rather than compartmentalizing our recovery, we need to integrate it with the rest of our life if we want our addiction to shift. When we quit doing whatever we did, it leaves a very big hole that something else needs to fill. If nothing fills that hole, whatever it is we quit is going to come back. A compartmentalized approach to recovery is not enough to allow the strands of workable change, the tendrils of real transformation, to be established and maintained.

It doesn’t matter what you do, whether it’s HAT, MAT or Hazelden. It matters how you do it. It matters that you carry your recovery around with you like a precious jewel wherever you go, not leave it in a safety deposit box you visit on weekends. People say that spirituality shouldn’t be something you talk about in church every Sunday, then lose sight of the minute someone cuts you off pulling out of the parking lot. Neither should our recovery be. Recovery is about purposeful re-engagement and reintegration into this absurd enterprise we call life.

More effective treatment approaches actually fight the compartmentalization of recovery. They are integrative, and they fold treatment modalities that are effective for individuals into their daily life, their personal ecosystem. The community of caregivers, friends, family and fellow addicts are all connected and can troubleshoot and collaborate to solve problems as they arise. There is the feeling that we are all in this together, all on the same team. When we feel this way, alienation tends to dissolve, and the need to compartmentalize, to control, lightens up. It’s safe for our recovery to emerge from its box, like a butterfly from its cocoon.

How do you compartmentalize your addiction, and why? How do you compartmentalize your recovery, and why? What would help you take your recovery out of its box and integrate it into all parts of your life? If we can find the answers to these questions, we can learn new ways of being that will take us beyond our addictions. As we learn to dissolve these boxes, we can build new lives. As I once heard an old timer say, “This isn’t a fucking dress rehearsal. This is it.” When we have everything to lose, we have to be open to anything that makes a difference. And compartmentalizing our recovery, putting it in a box, is unlikely to take us where we need to go.

…by Gina Murillo (comments by “Gina”)…  

So much of what we’re trying to hash out about drug courts here wouldn’t be an issue but for poor drug policy (the War on Drugs — as discussed in the comment section following the last post). The War on Drugs causes far more harm than good. I agree with Marc that Johann Hari makes that case more compellingly than just about anyone else, with the possible exception of Ethan Nadelmann, executive director of the Drug Policy Alliance. (I’m not a huge fan of TED talks, but highly recommend his powerful talk on why we need to end the War on Drugs.)

This really all comes down to how society has been conditioned to view different substances and behaviors. Alcohol and tobacco are far from harmless, but are not only socially acceptable, they’ve both been glamorized to one extent or another. They both kill many times more people each year than all illegal substances combined, even in the midst of the opiate “epidemic”. Yet, we manage to find (admittedly imperfect) ways to deal with the harms they cause as best we can. We do this because we recognize that the harms of prohibiting these substances would likely be significantly greater than simply finding more effective ways to live with them.

Imagine people being arrested for possessing cigarettes (one of the toughest addictions to quit and the #1 cause of preventable death in the U.S.) and facing a drug court judge with the threat of jail or a longer prison sentence for failing to quit smoking. Sure, probably fewer people would smoke and fewer would suffer debilitating disease as a result. But at what (and whose) cost? After all, if legal consequences are so effective at changing negative behaviors, why don’t we criminalize all behaviors we’d like to extinguish for society’s benefit? For another example, how about obesity courts? Health care costs attributed to obesity in the U.S. alone are staggering, with the number of deaths increasing steadily each year — making it the #2 cause of preventable death (behind good ole’ tobacco). And the data strongly suggest that households with just one obese parent are at least twice as likely to raise obese children who are doomed to a shorter life expectancy than their parents. Using drug war logic, this ought to be as good a reason as any to criminalize obesity or the behaviors (and foods) that “cause” it.

Sound crazy? That’s how crazy drug criminalization and drug courts seem to me now. Having dealt with my daughter’s heroin addiction for the past five years, it really hit me, after her most recent “relapse” (for lack of a better term) a little over a year ago, that it wasn’t so much her addiction that was causing the pain and trauma we were both experiencing as it was dealing with the woefully ineffective — and often counterproductive and EXPENSIVE — U.S. legal and treatment systems.

Whether to decriminalize or even legalize powerfully addictive drugs like heroin is a topic of ongoing heated debate. Decriminalization of the use and possession of all drugs is a no-brainer to me. Legalization is more tricky, but still requires an honest and intelligent discussion about the inherent risks and potential benefits. Because while we labor under the delusion that prohibiting a given substance outright is the ultimate form of control, it is in fact the mechanism by which we relinquish all control to criminals, who have in turn been empowered by such policies to build massive global organizations. The only way to undercut that power is to minimize the enormous profits that are generated by prohibitionist policies.

Those who have considered the idea of legalization in any serious way are quick to couple it with proposals for control, which should address, at the very least, protection of minors (who are, incidentally, not protected from heroin availability at present), and, especially in the case of opioids, prevention of leakage or diversion to others, policies for supervision and safety, and strict constraints on who might be eligible for prescriptions. One model of a successful quasi-legalization policy comes from Switzerland, which implemented heroin-assisted treatment (HAT) with great success to stem the tide of its own heroin epidemic in the late 1980s and early 1990s. Here is a brief description of the outcome from an article by Johann Hari in Huffington Post:

Switzerland also had a huge heroin crisis. Under a visionary president — Ruth Dreifuss — they decided to try an experiment. If you are a heroin addict, you are assigned to a clinic, and you are given your heroin there, for free, where you use it supervised by a doctor or nurse. You are given support to turn your life around, and find a job, and housing.

The result? Nobody has died of an overdose on legal heroin — literally nobody. Street crime fell significantly. The heroin epidemic ended. Most legal heroin users choose to reduce their dose and come off the program over time, because as they find work, and no longer feel stigmatized, they want to be present in their lives again.

I would clarify Hari’s description further by pointing out that (1) while Switzerland didn’t legalize heroin, per se, it did make it de facto legal for a very specific subset of the heroin-using population; (2) HAT is a treatment of last resort offered only to those for whom all other methods of treatment have failed; and (3) most HAT patients actually become re-engaged in their lives once stabilized on HAT, regardless of whether they ultimately choose to taper off.

HAT has been so effective in Switzerland that it’s no longer even controversial there, and HAT trials have been implemented in a growing number of European countries and Canada. Very recently, a couple of forward-thinking lawmakers have even made attempts to introduce legislation that would authorize HAT trials in Nevada and Maryland.

I dream of the day our society can, in the inimitable words of Ethan Nadelmann, learn how to live with drugs sensibly, so that they cause the least possible harm and produce the greatest possible benefit to all. Because if there’s one thing we need to recognize, it’s that drugs aren’t ever going to go away, no matter how many laws we pass or how many people we put in jail.