Bath Salts – Pressing the Issue

Q &A – Dr. Adi Jaffe PhD Interviewed By Tony O’Neil of The Fix

“A man was attacked on the side of the highway, authorities find the attacker eating a the victims face, and only after multiple bullet wounds is the attacker stopped.” This Zombie-like behavior is common in Hollywood scary movies, but as of late the new “Bath Salt” epidemic has turned places is like Miami into a real life Zombieland, or at least that’s what we have been told.

UPDATE: We now know that the assailant in this case (Rudy Eugene) had only traces of marijuana in his blood and no evidence of bath salts use. However he was previously diagnosed as schizophrenic and we know that especially for those at risk, marijuana use is associated with psychotic breaks.

What are “Bath Salts”?

Bath Salts are a street name given to a number of meth like drugs, so we’re not talking about your everyday Epson salt here. Although drugs like MDPV have just been made illegal, most of these substances seem to be cathinone derivatives and are central nervous system stimulants that act through interruption of dopamine, norepinephrine and to a more limited extent serotonin function.

It’s very important to note that research on this is still in its early stages and so reports are limited. However, it seems that at low to moderate doses the most common effects for MDPV can be thought of as either meth-like or like very strong adderall or ritalin – so users experience stimulation, euphoria, and alertness. Mephedrone seems to act more like MDMA (ecstasy) than meth, at least in early animal research with these drugs. At high doses however, and obviously there is no one regulating the dose since these drugs are sold as if not for human consumption, the effects can look like psychosis. These are not necessarily very different from meth induced psychosis which can include panic attacks, severe paranoia, self-mutilation, and violence.

There are several confirmed research reports (individuals who had only MDPV in their system) of people injecting or snorting MDPV and developing severe psychosis, “running wildly throughout the local neighborhood,” foaming at the mouth and being combative when approached. Worse still, these individuals can develop severe organ failure, require intubation (breathing tube insertion through throat), and at times die even in the face of extreme medical intervention.

How do Bath Salts affect the nervous system?

These drugs tend to be sympathomemetic, which means they induce sympathetic nervous system activation – the increased heart rate, temperature, etc. This is also where they can be most dangerous even when people don’t develop the possible psychotic effects (due to organ failure from the hyper activation).

Can one become addicted to Bath Salts?

I think that there’s no question that this stuff can cause physical dependence. I personally know of a client at matrix here in west la who came in specifically for “over the counter stimulant addiction” to drugs like these. He was snorting, then injecting them and stayed up for days. Eventually he was hospitalized with severe agitation and mild psychosis. These high doses are almost certainly, based on what we know with meth and MDMA, also causing neurotoxicity (some of the effects irreversible).

What Harm Reduction model should be used for Bath Salts?

It seems that MDPV and mephedrone are indeed drugs worth worrying about, at least in so much as they are completely unregulated when sold “not for human consumption.” While their effects at low/moderate doses are not severe are can be thought of as related to those of other stimulants, at high doses they can be lethal and can certainly bring about serious negative psychological effects. I always think that there is some room for harm reduction when trying to get some control over abuse of such drugs. In this case, while it’s probably best to stay away completely, I would urge people who are going to use to be careful and not to use large amounts of this stuff before seeing how they react. The neurotoxicity and cardiac effects can be too extreme and may lead to severe irreversible consequences at high doses.

How can the media help resolve this epidemic?

Press coverage always makes more people aware of an issue than they were before the topic was covered. In this case, especially if we can sneak in some of the above harm-reduction messages along with the overall “don’t use this stuff” text we normally see, we might be able to use the opportunity to save some lives. I think, as I’ve said before, that people (especially kids) are going to be on the lookout for ways to change their experience no matter what. The question is how we react when they do things we don’t like and how does our reaction affect their future behavior.

I think that we can use the real information – possible death and psychosis, especially when snorted or injected – to alter the ways people use Bath Salts, allowing for a campaign that isn’t only looking to stop the use of the drug but that is focused on minimizing consequences. However it seems that the press isn’t covering the range of possible effects but is choosing instead to focus on the most outrageous. These types of scare tactics haven’t worked too well in the past for curving drug use, but it doesn’t hurt TV ratings so I don’t expect it to stop.

Will banning bath salts help?

I believe that in this case, as we can already see, we are once again going to be playing a cat and mouse game that congress seems happy to play. They’ll outlaw more components of Bath Salts (MDPV, mephedrone, and methylone apparently already are controlled) but new ones will continue to come out. To me, the question is whether we believe we will one day ban all psychoactive substances we have issue with or whether we will be successful in developing a strategy for dealing with their abuse in a way that helps recognize and intervene early.

I think that the banning approach makes it less likely that people with abuse problems, or even acute medical problems, will contact authorities for help. Worse yet, it makes it nearly impossible for us to get a handle on safer use practices for a specific drug as they all get replaced by new variations – often ones that are even more dangerous.

Although the press has made the Bath Salt epidemic much more like a Hollywood production than reality, there are issues that need to be addressed. I just don’t believe in scaring the public into action, I’d prefer if popular media were just honest with the public about these drugs so that people can draw their own conclusions.

Barriers to Addiction Treatment Entry

By Dr. Adi Jaffe and Tariq Shaheed

How annoying is it to be running late for work unable to find your keys, wallet, or coveted smart phone? You check under the bed, between the sofa cushions, and in your useful phone valet, before giving up and calling in late to work (if it’s not your phone you’re missing). You ask your wife, who says she hasn’t seen it, and your child, who thinks it’s under the bed (you’ve looked, it’s not). Finally, giving up, you go to your car, where your phone sits smugly right on the passenger seat. As troubling and frequent as this story might be, it’s nothing compared to the difficult experience of over 20 million Americans who annually look for addiction treatment but don’t find it [2]. So what’s keeping so many Americans out of treatment?

Internal and external barriers to addiction treatment entry

Barriers to addiction treatment entry are plentyIn a study done in 2008, researchers surveyed a sample of 518 subjects varying in race and age, to find out about the barriers keeping them out of addiction treatment. [1] The study was conducted in Montgomery County Ohio, was a part of nationally funded “Drug Barrier Reduction” effort lead by the National Institute on Drug Abuse (NIDA). Most participants were using crack (38.4%), heroin (25.1%), marijuana (14.9%), and alcohol (11.2%). The researchers found a number of internal and external barriers that keep drug abusers from getting the help they need. Internal barriers included stigma, depression, personal beliefs, and attitudes about treatment, while external barriers (systematic or environmental circumstances that are out of a person’s control) include time conflicts, addiction treatment accessibility, entry difficulty, and cost of addiction treatment. [1]

The researchers concluded that both internal and external barriers can be addressed and improved, but that eliminating the external barriers to addiction treatment is most feasible and could substantially decrease the number of untreated addicts in the United States. Since addressing an internal barrier like “believing one can quit at anytime” (accounts for 29.3% untreated Americans) still requires the ability of the substance user to get treatment, it seems that addressing external triggers will be more immediately effective. Just as motivation to find an item such as keys, phone, or wallet is not the only factor in obtaining that item, a substance user with no internal barriers to treatment is still constrained by all those external barriers, and still not in substance abuse treatment.

The most commonly cited external barriers in the study were:

  1. Time conflicts – being unable to get off work for treatment, household obligations, busy schedules and simply not having time for substance abuse treatment.
  2. Treatment accessibility –  living too far away for treatment, not knowing where to go for treatment, having difficulty getting to and from treatment, and not understanding the addiction treatment options. Subjects reported that being wait-listed for a facility, and having to go through to many steps contributed to deterring them from seeking treatment.
  3. Financial barriers included inability to pay for treatment and being uninsured.

Some common internal barriers include:

  1. Stigma associated with the label of being call an alcoholic or an addict, or stigma regarding addiction treatment. Thus being unwilling to share problems and ask for help.
  2. Psychological distress such as depression and neuroticism which produces a lack of motivation among substance abuse treatment seekers.
  3. Personal beliefs
    1. Religion- God will remove the addiction at the right time
    2. Denial – User doesn’t believe they are an addict
    3. Doesn’t need treatment – For example 30% of heroin abuser believed they would recover without treatment.

Although getting substance abusers help is difficult, it starts by understanding the nature of the problem. While one person may not believe they are addicted, another may not understand how sliding scale payment for treatment works. Different individuals may need different helpful resources when it comes to understanding their options.

Thoughts and limitations regarding the research

As we pointed out in a recent article, it’s important to know who is participating in addiction research. In this case, the individuals recruited were reporting for substance abuse treatment assessment at a county intake center. This means the clients are likely from relatively low Socioeconomic Status (SES) groups, but also that they are for some reason motivated to find treatment. Those reasons themselves could be internal (decided to make a change) or external (got arrested), but it’s important to know that these findings do not necessarily apply to more affluent, insurance carrying, or addiction treatment uninterested, individuals. We are currently in the process of conducting a more general study to assess needs in that group.

Also, the time and costs constraints identified by participants can often be overcome by increasing flexibility in searches and by better tailoring the treatment referrals (see our Rehab Finder articles). Costs can be reduced while saving time by looking into outpatient, rather than residential, treatment options. Unfortunately, Americans have been exposed only to the residential treatment model (a la the Dr. Drew and Intervention television shows), but outpatient addiction treatment is effective, costs less, and truly a better fit for many clients (especially those still working, attending school, etc.).

Finally, not all of the internal beliefs can be written off as unreasonable barriers – indeed, it is likely that most individuals who do not seek official substance abuse treatment, and certainly most of those who never enter official substance abuse treatment, will still recover from their addiction without it. As we pointed out in previous articles (see here, and here), most people who use drugs do recover and many do it with no treatment per se, especially when looking at our biggest substance abuse problem – alcohol. That means that some people termed “in denial” and “not needing treatment” were actually either correct, lucky, or both. Recovery doesn’t have to look like we expect it to, it just has to result in a person who is no longer suffering with addiction.

A3 Plug (you knew it was coming)

At A3 we believe information is the key; by dispelling myths about addiction, removing stigma and anonymity, reviewing the latest research in treatment, and finding 21st century solutions to barriers, we hope to reduce the number of untreated. Join us in the fight to educate and treat addiction.

Citations:

1. Jiangmin Xua; Richard C. Rappa; Jichuan Wanga; Robert G. Carlsona. (2008) The Multidimensional Structure of External Barriers to Substance Abuse Treatment and Its Invariance Across Gender, Ethnicity, and Age.
2. An investigation of stigma in individuals receiving treatment for substance abuse

Decision-making and alcoholism: what’s the risk?

By James R. Ashenhurst

Every day we are faced with decisions to make, both simple and complex: should I buy the bargain brand cereal or do I really want to pay more for those Cheerios? Sometimes, we’re faced with decisions that carry a bit more risk to our health and safety: should I jump out of this plane and skydive like I planned to, or is the risk that something might go wrong too high? In the addiction world, decisions must be made about the risks of buying and using drugs and alcohol: Should I really be driving home from the bar now, risking a DUI? What if the police catch me buying crystal meth?

People naturally vary in the amount of risk they are generally willing to take. Especially when potential rewards are great, some people will take rather extreme risks, while others are more hesitant. Clearly, the world needs risk-takers to brave the waters with new business ideas, or to risk rejection to gain romance. Risk-taking is by no means a uniformly bad trait. But, when it comes to drug use, how might having a risk-taking personality affect how people choose to use? Understanding how risk-taking relates to drug and alcohol dependence (alcoholism) might help clinicians and addiction treatment centers be more effective by making patients aware of how their own risk-propensity influences their disease.

The difficult part of answering these questions is deciding how you’re going to figure out exactly how risk-taking a person is. In the past, many researchers used simple self-report questionnaires that boil down to essentially asking participants how risk-taking they think that they are. However, there is a good deal of self-report bias when using these questionnaires; in other words, the accuracy of a person’s answer depends on how self-aware they are and how well they evaluate themselves compared to others (which also requires them to evaluate others objectively). To deal with this problem, Carl Lejuez developed an elegantly simple experimental task that avoids self-report bias: the Balloon Analogue Risk Task [1] (named the BART in honor of The Simpsons, they also made a task called the MRBURNS).

Balloon analog risk-taking taskIt works like this: you see a balloon on a computer screen and you can press a button to inflate it by a small amount. Every time you inflate it, you get a small amount of money. But, there is always a chance that when you inflate it, the balloon will pop and you’ll loose all the money you’ve accumulated for that balloon. You can also decide to “cash out” at any point and add the money you’ve earned to a guaranteed bank and move on to the next balloon to pump. Participants actually receive the money they’ve banked in the task. So, how far would you go?

As it turns out, how people behave in this task relates pretty well to how they behave in the world (this is known as external validity); a person who inflates a lot (and probably pops more than a few balloons) is more likely to not wear a seatbelt, practice unsafe sex and, yes, experiment with drugs and drink problematically [1] [2, 3]. Also, a twin study has shown that risk-taking in the BART is heritable in males [4] and I have demonstrated that behavior is heritable in a rat version of the task [5], suggesting that at least some of it is due to nature and some due to nurture. This is good news for medical research, because it means that there is some discoverable biological pathway that determines, in part, how people behave in the BART.

Still, this preliminary research about the BART and alcohol was gathered from young undergraduates who do not have long histories of alcoholism or drug dependence. Thus, for my research, I wanted to know how older folks who are diagnosably alcoholic might behave in the BART [6]. We invited 158 gracious volunteers from the Los Angeles community (who identified themselves as having problems with alcohol) to the lab and evaluated their dependency severity under the same guidelines used by psychiatrists in the DSM-IV. We also had them play the BART. My prediction was that participants with more severe alcoholism would also tend to be bigger risk-takers.

To my surprise, everything flipped around. People who were more risk-taking (inflated the balloons bigger) actually had fewer alcoholism symptoms. In other words, the more severe the case of alcoholism, the less risks they would take in the BART. How could this be, and what does this tell us about the role of risk-taking in alcoholism?

There are several possibilities. For one, it could be the case that while young risk-takers tend to drink problematically, as alcoholism develops, it is actually the problem-drinkers who are more risk-averse who tend to go on into more severe cases of alcoholism. This theory relies on the idea that risk-taking personality is fixed and doesn’t change much in adulthood; it might be a stable trait that influences the developmental course of alcoholism.

It could be, however, that the trait is not always stable across a lifetime, and experience with alcohol changes one’s risk-taking personality. If we assume instability, it could be either social and/or biological factors that cause the change. Maybe people with more severe alcoholism face more problems in their personal life, and this changes their temperament to be more risk averse. Or, it could be that the continued exposure to a lot of alcohol changes the parts of the brain that evaluate risks and underlie the decision-making process. It is well-known that chronic exposure to alcohol at high levels for long periods of time changes the quantity and subtypes of neurotransmitter receptors in the brain as part of an adaptive process; the brain adjusts itself to tolerate the constant signals it’s getting from alcohol. Thus, it is a reasonable idea that decision-making parts of the brain could change too.

Lastly, it could also just be an observation that is specific to this task in this population. While the task has been shown to be externally valid in the college-aged sample, we didn’t reassess that here for older alcoholics. We’re talking about people taking small risks to earn relatively small amounts of money by the end of the task. Usually, participants are rewarded with somewhere between $5 to $20, depending on the study.

What if larger sums of money were at play? Or access to alcohol was at risk? Once a person is an active alcoholic, what feels risky and what’s not might change too. Acknowledging that you have a problem and starting to try to cut down or abstain might feel more risky than continuing as normal. Nevertheless, even if this flip is specific to behavior in a laboratory task, it means that the relationship between risk-taking and alcoholism is not as straightforward as we might expect.

So, what do you think? In your experience, are the more severely alcoholic people you’ve known not big risk-takers? If you’re an alcoholic in recovery, does it seem like your risk-taking personality changed over time? Hopefully, we’ll get more clues down the line and we’ll be better positioned to say which theory is correct, and this can then help alcoholics in their own pathway to addiction recovery.

 

1. Lejuez, C.W., et al., Evaluation of a behavioral measure of risk taking: the Balloon Analogue Risk Task (BART). Journal of Experimental Psychology: Applied, 2002. 8(2): p. 75-84.

2. Fernie, G., et al., Risk-taking but not response inhibition or delay discounting predict alcohol consumption in social drinkers. Drug and Alcohol Dependence, 2010. 112(1-2): p. 54-61.

3. Lejuez, C.W., et al., Differences in risk-taking propensity across inner-city adolescent ever- and never-smokers. Nicotine Tob Res, 2005. 7(1): p. 71-9.

4. Anokhin, A.P., et al., Heritability of risk-taking in adolescence: a longitudinal twin study. Twin Research and Human Genetics, 2009. 12(4): p. 366-71.

5. Ashenhurst, J.R., M. Seaman, and J. David Jentsch, Responding in a Test of Decision-Making Under Risk is Under Moderate Genetic Control in the Rat. Alcoholism: Clinical and Experimental Research, in press.

6. Ashenhurst, J.R., J.D. Jentsch, and L.A. Ray, Risk-Taking and Alcohol Use Disorders Symptomatology in a Sample of Problem Drinkers. Experimental and Clinical Psychopharmacology, 2011. 19(5): p. 361-70.

 

 

Addiction stigma – Making addiction recovery, and addiction treatment entry, even harder

When people think about drug addicts, they often bring-up the negative stereotypical hippie, or homeless, image that movies, television, and much of our daily experience has left us with. Its usually not a successful business man, doctor, or lawyer that comes to mind.

This is an issue because many addicts attempt to disassociate themselves from this negative stigma, often resorting to denial of their drug problem or secrecy coping,  and not seeking the addiction treatment they need.

The truth is that addicts are found in every socioeconomic class and within every ethnic group and gender. On this site we have talked about doctors with addictions, the reality of behavioral addictions, and the science behind the compulsive behavior that addicts are so well known for. We have attempted to destroy myths about addictions, by informing our readers about the neuroscience of addiction, and allowing people “to come out” about their addictions. By doing this we hope to encourage openness about addictions, and not allow stigma to get in in the way of recovery.

Addiction stigma hurts addiction treatment success

The center for Addictions and Substance Abuse Technologies, at The University of Nevada, did a study on the affects of stigmatization on 197 drug users. The findings indicated that there is a direct correlation between the degree to which drug users are perceived negatively (stigmatized) and whether or not they overcome their addiction. The study suggested that addicts become more dependent on the substance they use because of the stigma (actual or perceived).

Researchers looked at six questions regarding stigmatization which were:

  1. To what degree do drug users experience stigma?
  2. Were the metrics of stigmatization conceptually distinct?
  3. Is the perceived stigma related to the number of previous addiction treatment episodes?
  4. How does secrecy as a coping strategy affect drug users?
  5. Do intravenous drug users have higher levels of perceived stigma than non-intravenous users?
  6. Do people with current contact with the legal system report higher levels of stigma?

The study found that there are varying degrees of stigmatization and that the most prevalent stigmas were; drug users felt that people treated them differently after finding out about their drug use (60%), felt that others were afraid of them when finding out about their drug use (46%), felt some of their family gave up on them after finding out about their substance use (45%),  felt that some of their friends rejected them after finding out about their substance use (38%), and felt that employers paid them a lower wages after finding out about their substance use (14%). My own personal experience certainly supports the first three findings – I have encountered people who stopped talking to me after finding out about my drug addiction past, and during my addiction there were long stretches of time during which my family completely gave up on the possibility that I would ever recover. At the time I simply shrugged these things off and pretended like they didn’t matter, but they certainly didn’t give me a good reason to stop using drugs.

The results of the study indicated that the measures of stigma are conceptually unique. These measures included Internalized shame Perceived stigma, and stigma-related rejection, all of which were correlated with one another to some extent.

Users with a higher number of addiction treatment episodes also engendered higher levels of stigma and had a more difficult time succeeding in treatment. These results  support earlier findings (Sirey et al. 2001) that showed that users with higher levels of perceived stigma were more likely to prematurely discontinue treatment, confirming that stigmatized drug users are not likely to seek addiction treatment and are more likely to relapse after starting treatment.

Addicts have a sense of shame associated with seeking treatment for their problem

The current addiction treatment system has produced a seeming paradox within the mind of the struggling addict – By owning up to their addictions, addicts reduce the invisibility of the problem, helping others claim back their lives from the secrecy of substance abuse and behavioral addictions. Unfortunately, that process takes far longer than the stigma the confessing addict has to immediately confront.

The study showed that secrecy coping is associated with lower quality of life because of the drug user’s inability to openly discuss their addiction. Subjects  that dealt with their addiction alone had poorer mental health, decreasing their chances of recover due to the stigma of addiction. Much like with many other chronic mental, and physical, conditions, the stigma attached to addiction, and addiction treatment seeking, can often lead to poorer outcomes in the long run and less successful treatment development due to low participation rates in the kind of groundbreaking research necessary. By reducing the shame associated with confessing to an addiction, society could drive forward the advancement of addiction treatment, helping us treat addiction like we treat cancer, parkinson’s disease, and many other chronic diseases.

Surprisingly the results from the study showed that the legal system does not increase the  level of stigmatization, yet subjects that used intravenous drugs felt a higher level of stigma.

Citations:

Sirey, J. A., Bruce, M. L., Alxopoulos, G. S., Perlick, D., Raue, P., Friedman, S. J., et al. (2001). Perceived stigma as a predictor oftreatment discontinuation in young and older outpatients with depression. American Journal of Psychiatry, 158, 479−481.

Luoma J.B., Twohig M.P., Waltz T., Hayes S.C., Roget N., Padilla M., Fisher G. (2007) An investigation of stigma in individuals receiving treatment for substance abuse.