More addiction cures: Early promise for Risperidone in crystal meth addiction

A recent open label study found some support for the effectiveness of a Risperidone injection, given once every 2 weeks, in reducing crystal meth (speed) use.

The 22 patients who participated reduced their weekly crystal meth use from an average of 4 times per week to only 1 time per week. The difference between those who were able to stay completely clean and the others seemed to have to do with the levels of Risperidone in the blood.

The nice thing about using an injection as addiction treatment is that it removes the possibility of patients choosing not to take their medication on any given day. Such non-adherence to treatment is very often found to be the reason for relapse.

This study will need to be followed up by placebo-controlled double-blind studies, but given Risperidone’s action as a Dopamine antagonist, I suspect that those trials will also show a strong treatment effect. The promise of medicines as addiction treatment cures always seems great, but I believe that at best, they can be an additional tool to be used in conjunction with other therapies.

The question will be whether the side-effects common with antipsychotic medication will be well-tolerated by enough people to make the drug useful for addiction treatment.

The best addiction treatment option

I get asked which addiction treatment option is the best all the time. The short answer? Whichever one ends up working for the client.

I don’t like being stuck in the corner, having to pick a “best of” option just because I’m asked. For some clients Moderation Management will work, others need intense day-treatment or an in-hospital residential treatment program before moving into a more traditional residential place for a year or more. Some clients feel suffocated by such a structured environment and can’t manage it – outpatient treatment options can be a better fit there.

Sometimes we ask ourselves questions in a way that forces us to make bad choices: Which is better, chocolate or vanilla ice-cream? I reject the premise.

It’s about time we all faced the fact that only rare occasions allow for two-word answers that are absolutely true. The world is full of nuance and if we don’t start allowing some gray into our conceptualization of questions and answers we are going to keep repeating the past mistakes of polarized opposition to a small number of camps that are all equally wrong.

Brain research supports the notion that they way in which questions are posed can affect the sort of answers we look for – our brain pays attention to the stimuli it expects to find. So if you think that all you have to pick from are two or three options, your brain will calculate costs and benefits and spit out an answer – 42. It’s what happens when you ask the wrong question – you get a nonsensical answer.

So I don’t answer question like “which treatment is best?” or “which is more important, biology, the environment, or personality?” The way I see it the pieces are all so interconnected that the separation is false. The question is moot. And that’s true whether you’re picking addiction treatment or a your favorite cone.

Evolution of Addiction Treatment – California learning

Addiction conferences are getting more and more common, and quite a few nowadays showcase the talents of some very knowledgeable, and renowned, addiction experts. Coming from the academic side of things, I’ve been to conferences held by the American Psychological Association, the American Public Health Association, the Society for Neuroscience, and the College on Problems of Drug Dependence.

When it comes to more clinical, or addiction treatment oriented, conferences, I think our readers would be hard pressed to find a better conference than the Evolution of Addiction Treatment conference about to take place at the Westin Hotel by the Los Angeles airport in just over a week (December 8th-11th). Some of the biggest names in addiction research and addiction treatment will be there including Drs Allen Berger and David Mee-Lee who have both contributed greatly to the field of addiction during their decades of work. The conference would be worth it even if they were the only ones speaking.

But they’re not. There are literally dozes of speakers and 3.5 full days of amazing talks. If you decide to go, we even arranged for a discount for you by entering the code “AAA10” before you pay. We’ll have a little booth set up in the hall if you want to come by and say “hi” but more than anything, we’d love for you to have the opportunity to learn as much as you can about addiction and addiction treatment options so that you can continue to carry the message that there is more than hope, there’s treatment that works!

See you there!

Shame on me – Stigma and addiction in treatment

I keep hearing that back in the old days of addiction treatment, shame was the main motivating factor used by rehab counselors. Everyone admits that it proved to be a horrible motivator. It simply didn’t work! With all the advances in research into addiction, that must have changed, right?

I don’t think so. I see shame and stigma every time I hear an addict talk about their drug use. The shame is there in their eyes as they tell the stories of their trouble and the struggles of their recovery. Given the low rates of success in addiction treatment, the shame rests firmly in the inability to quit as well. A relapse is often seen as the ultimately shameful experience for an addict. The stigma of addicts as hopeless is rampant.

Still, we have evidence of genetic predisposition to drug abuse and addiction, we know of environmental factors that make it more likely that people will get hooked. The effect of many drugs on the brain make unsuspecting lab animals as likely to become addicted as any one of us and I’m pretty sure that shame doesn’t play a role in their process.

With all this evidence, why is the stigma of drug addicts still around? Why are they the only ones being blamed for their condition?

The evidence I cited isn’t that different from that known for cancer, yet we scarcely blame cancer patients for their disease. Even in the case of smokers who become ill, their is still sympathy for their suffering. So why are addicts different?

There are good addiction treatment options out there, as long as we don’t give up on the person and simply view their addiction as evidence of their weak character. Given the changes that long term drug use produces in the brain, it’s a miracle anyone recovers at all. We should be grateful for that.

Antisocial personality disorder – Drug policy and court mandated addiction treatment

gavelA recent study conducted by a group at the University of Maryland found that court-mandated addiction treatment is especially helpful for those with Antisocial personality disorder (ASPD).

Using 236 men, it was found the overall success for participants without ASPD was high (85%) whether the treatment was court mandated or not. However, for those with ASPD, a whopping 94% remained in court-mandated treatment, though only 63% stayed in voluntary programs!

ASPD is relatively rare in the general population, but it’s estimated that its prevalence is relatively high (some estimate the prevalence as high as 50%) among addicts in drug treatment programs. I personally doubt that ASPD prevalence is that high even among treated addicts but it is certainly higher.

The Maryland team’s findings have two important implications for substance abusers with ASPD that should be noted:

  1. Judicial mandates offer a way to keep them in addiction treatment programs.
  2. Voluntary participants may require special interventions to keep them actively engaged in therapy.

Recently, a colleague shared with me some great insight about research into the effectiveness of mandated treatment: Mandated treatment can be effective if implemented well, which may sound simple but isn’t within a system that is used to putting down prisoners and not building them up. However, without aftercare, even the best mandated treatment loses its impact quickly. When it comes to aftercare, when trying to determine the best form of it (outpatient, residential , intensive, medical, etc.) the best thing to do is to ask the released client – if the match between the client’s desires and the treatment provided is high, the results are significantly better.

Citation:

The interactive effects of antisocial personality disorder and court-mandated status on substance abuse treatment dropout. Journal of Substance Abuse Treatment 34(2):157-164, 2008

Two forms of alcoholism: One which warrants a chronic disease model, and college

I respect Stanton Peele, if for no other reason than simply because he is well informed and doesn’t mind telling us all about the way he sees things. However, even the mighty sometime misstep, and this article is about what I see as one of Dr. Peele’s errors.

Why Stanton Peele thinks addiction isn’t a disease

In his recent post about why the disease concept of alcoholism, or addiction, is bull$&%# (his words), Dr. Peele decides to quote a piece from the NIAAA’s website that states that approximately 75% of people who’ve met the definition of alcohol dependence (read: alcoholism) in their lifetime quit by themselves without any outside intervention. That’s great, but what he forgot to also quote is another passage that states that while “70 percent of [alcoholics] have a single episode of less than 4 years, the remainder experience an average of five episodes. Thus, it appears that there are two forms of alcohol dependence: time-limited, and recurrent or chronic.”

Why Stanton Peele is a little right and a lot wrong

Maybe Stanton missed this sentence since it was a few lines above the one he was focusing on, but what it’s telling us is that the vast majority of people who meet alcohol dependence criteria do so for a very limited amount of time (seemingly their 4 years of college) while another 30% or so (or 25% according to the line Dr. Peele decided to use) have the chronic-relapsing version of alcoholism we’ve all come to know. I guess the question of what is substance abuse doesn’t have the simplest of answers.

So yes, most people quit without help, and as we’ve pointed out on this site before, most people who experiment with drugs never develop a problem with them. But the reality is that the remaining group has a hell of a time quitting and most of them need help and even then don’t necessarily respond to addiction treatment. I don’t know that this is very different from the percentage of people that eat too much and gain weight – some stop and return to a normal BMI, the rest become obese. The same story holds for the pre-diabetics who never quite cross that line but once they do, will need insulin and a strictly managed diet. In both cases I don’t think we need to discount the latter because the former exists.

I agree that this sort of nuanced observation is missing from the public discourse, and I think that it’s important to bring it in since it does something important – it lessens the stigma of alcoholism and addiction by showing us what is really happening without distortion. However, showing only the other side does little to improve the situation.

So in closing – most of those who meet the definition of alcohol-dependence should probably not be called alcoholics. Instead, they can be referred to a “Frat boys,” “Sorority girls,” or really “late teens to early adults.” However, there is a large enough group of people out there who really suffer with a condition that doesn’t go away when their first 4 year-long episode of hard alcohol use ends. They need addiction treatment and they’re the focus of most research on addiction and alcoholism, as they likely should be when it comes to treatment.  That other group, they just need to be careful not to get in a car accident or get pregnant too early.

That’s my take anyway.

 

 

p.s.

When people ask “what is substance abuse?”, they are probably referring to the former group most of the time, although based on our present definition, substance abuse per se is a diagnosis that is pretty easy to meet, which likely means both groups actually meet abuse criteria.

Addiction services conference – Addiction research to addiction treatment success

I’m currently attending UCSF‘s Addiction Health Services Research Conference. The 3 day event aims to improve addiction treatment by bringing together researchers, treatment providers, and state and federal policy players. I’m going to write from here after every day filling you all in on the latest and greatest.

Today’s addiction research summary

Today’s main topics focused once again on the shift in addiction treatment conceptualization from a short term, black box sort of model to a more chronic one. I’ve already talked about comparing addiction to other chronic diseases, like diabetes or hypertension, in another post on here (see here). Nevertheless, today’s talks provided some additional insight.

Today’s speakers, members of UCLA‘s Integrated Substance Abuse Program (In the interest of full disclosure, I myself work at ISAP), talked about the notion that in order to provide the best treatment, we need to start looking at some more measures of treatment success. As it stand right now, those who assess treatment success mostly look at abstinence following discharge from treatment. While reductions in drug use are certainly important, they don’t tell the whole story.

Other measures of addiction treatment success

I won’t go into these in too much details (the presentation lasted 3 hours), but here are some of the suggested measures the speakers mentioned:

  1. Good treatment initiation rates.
  2. Client retention rates at or above 90 days.
  3. Percent (%) of clients successfully transferred to next level of care – This is especially important for the chronic care model of addiction.
  4. Treatment completion – A little dicey because providers set their own standards of completion.

Those were the major ones discussed today. Given my experience in research, I thought of some additional ones, including:

  1. Improvement in employment status for clients.
  2. Reductions in client drug use – I think testing should be a standard, and ongoing, aspect of all drug treatment programs. Drug users need to stay clean in early treatment and the only way to tell for sure is by testing them.
  3. Use of research-supported methods to increase treatment retention – There are quite a few tools (like CM, use of medications like suboxone, and more) that are often underused but have shown great promise in helping keep clients in treatment for longer.

That’s it for today. More tomorrow!!!