New drug testing technology? Cocaine and saliva

A recent development (check it out here) might lead the way to a quicker, more easily administered drug test. Instead of the lab analysis of urine, blood, or other fluids, this recent technology might allow first responders, such as EMTs, to assess a person’s exposure to drugs (prescription and otherwise) by simply dipping this device (think pregnancy test) into their saliva.

As of right now, the researchers have been able to demonstrate the success of the technology with cocaine, but it shouldn’t be too long before they can provide similar devices for many different drugs.

Now, it’s true that I usually focus on abused drugs in this blog, but this technology could help medical professionals identify dangerous drug interactions common to many prescribed, properly taken, medications. Given the huge increases in prescription medication abuse in the United States, that could be extremely useful and might save some of the 12,000 lives annually lost to accidental overdoses.

Maybe when these devices get cheap enough they can be used in addiction treatment centers to provide more immediate testing results.

Who knows, one day, the technology might be widespread enough to make home drug-testing a simple reality. Whether that’s a good or bad thing should probably be left to another post…

Opioid prescription overdose and abuse – Staying safe while reducing pain

A new article just published in JAMA (see here) reports a strong relationship between high-dose opiate prescribing and accidental overdose deaths. The authors focused on a sample of Veterans and found that those prescribed more than 50mg of morphine per day, or the equivalent of other opiate drugs, we much more likely to die of such overdose than patients being prescribed lower doses. Fortunately, only about 20% of the patient-months (a measure of how many people were prescribed a specific dose for how long) were prescribed these high doses but the rate of overdose for this group was 3 to 20 times higher! Continue reading “Opioid prescription overdose and abuse – Staying safe while reducing pain”

The placebo effect: So strong, doctors don’t even have to lie!

Almost everyone has heard about the placebo effect – the finding that treatment that have no particularly relevant effect (like a sugar or vitamin pill, or a behavioral equivalent) can make patients feel better. The placebo effect is actually the reason that all FDA approved drugs have to go through a double-blind placebo-controlled clinical trial before being approved for use – It has to be shown that using a specific medication is more beneficial than a non-active placebo even when the experimenter (or doctors) and the patient have no idea which treatment the patients are receiving. Otherwise, companies could simply continuously create placebos, show that they produce improvements in patients, and bring in the dollars.

Until now, it’s been assumed that in order for placebos to work, the patients have to be told that they are effective medications, amounting to an unethical lie by the doctors that prescribe them. This is the reason that very few doctors use pure placebos, though in a recent survey more than 50% of doctors reported using mild prescriptions (like over-the-counter pain medications) that they don’t believe are actually relevant to the condition as “impure placebos.” Given the large placebo effect, we can expect that these treatment, even if unethical, resulted in significant improvements in conditions that those same doctors were unable to treat using conventional methods. Still, it doesn’t feel good to know your doctors have to lie to you to make you feel better, right? Well they might not have to.

This fake placebo pill might make you feel better

A very recent study conducted at Harvard and published in the journal PLoS One examined whether placebos would still work for irritable bowel syndrome (IBS) patients even if they were explicitly told that the pills were inactive. The 80 IBS patients were randomly selected to receive either no treatment (the control condition) or a pill they were told was inactive “like a sugar pill” without any medication in it. Patients in the placebo condition were also told about the placebo effect and that such inactive sugar pills have been shown to produce significant mind-body self-healing processes. The placebo pills were marked with clear labels that read “placebo pills” so that there would be no confusion and so that patients would be constantly reminded that they pills they were taking were placebo pills 2 times a day. Amazingly, the placebo effect was still found to be present.

At the end of 3 weeks of treatment, participants in the placebo group reported significantly greater improvement in their symptoms on a number of different scales used for IBS as well as an overall Quality of Life measure. Even more amazingly, nearly twice as many patients in the placebo condition (59% versus 35%) reported that the treatment gave them “adequate relief” from their IBS symptoms!!! Patients got better taking pills that did nothing even though they knew that the pills were completely inactive. In fact, the effect was so great it was similar to the effects commonly seen with actual approved medications for IBS.

Conclusion and implications

Overall, these findings are encouraging on a number of fronts: If confirmed by future studies and using other conditions, these results suggest that doctors don’t have to lie to their patients since the placebo effect is strong enough to work even when patients are aware of it as long as the person giving the treatment is trusted. In fact, even this last piece should probably be put to the test since as far as I know, it has never been put to the test itself. Still, there is a whole body of literature in psychology telling us that when people of authority, people we respect, tell us to do something we react favorably.

Unfortunately, this has resulted in some pretty disturbing results including Stanley Milgram’s 1960s studies that revealed the power of authority in directing people to harm others (if you’ve never looked into these experiments you really should – here’s a video link to get you started). However, this time the results suggest that doctors may be able to help patients for whom there is no specific approved treatment. Obviously this is of interest to me because of the relatively low success in clinical addiction treatment. It may actually also suggest that a number of the treatments we’re using now – especially those that have never been subjected to a Randomized Placebo-Controlled Clinical Trial – may in fact simply be placebos. I have my own sneaking suspicions about some specific treatments…

Like every other study, this one is not without limitations. First of all, these results have to be replicated with other conditions and in other hospitals with other patients before doctors should feel comfortable simply prescribing placebos. There could be specific aspects of this sample that made the results so convincing. Indeed, even the no treatment condition got some benefit from their interaction with the medical and research staff involved in the study (or maybe just due to the passage of time). It’s as if we are now comparing the placebo effect to the time/human-interaction effect, gradually making our way towards some “no-effect” condition.  We also want to see these sort of results with a larger sample, and although conducting a double-blind trial isn’t possible (one group takes pills and the other doesn’t so everyone knows who is in what condition), I’m certain that future experiment will figure out more subtle controls.

Still, this study definitely indicates that giving placebos openly can work for patients who are open to it. It should also make everyone aware that just because someone tells you a treatment is objectively helpful doesn’t mean it is. In the end though, if the psychological placebo effect brings about actual improvement in symptoms, shouldn’t we consider it effective?

Citation:

Ted J. Kaptchuk, Elizabeth Friedlander, John M. Kelley, M. Norma Sanchez, Efi Kokkotou, Joyce P. Singer, Magda Kowalczykowski, Franklin G. Miller, Irving Kirsch, Anthony J. Lembo1 (2010) Placebos without deception: A randomized controlled trial in irritable bowel syndrome. PLoS One, 5,

These Fake Pills May Help You Feel Better – Science Now

A new candidate for ADHD medication: Amantadine and the rise of non-stimulants

It is well known that ADHD diagnoses and substance abuse problems are closely associated. It is estimated that substance abuse problems including dependence are up to twice as common among individuals with ADHD, which is not surprising given the impulsivity factor involved in ADHD. The problem is that until recently, most medications for ADHD have belonged to the stimulant category and as many, including us, have written before it is probably not the best idea ever to give drugs that have a relatively large abuse probability to people who are relatively likely to develop substance abuse problems. Right?

We’ve already written about atomoxetine and bupropion, two drugs with relatively low abuse potential (since patients don’t actually feel “high” from them) that are being successfully used in treating ADHD. But there is little doubt that the type of effect seen among patients who are using stimulants (like adderall, ritalin, etc.) isn’t being observed among patients taking non-stimulant medications. All of this means that patients on non-stimulants are getting less bang but with less risk. A dopamine agonist by the name of amantadine might change all of that according to a recent study.

Amantadine versus stimulants for ADHD treatment

Fourty children between the ages of 6 and 14 were enrolled in the study conducted in a psychiatric hospital in Iran. The kids were randomized into two groups a methylphenidate (ritalin) and amantadine group. Over a six week period the kids were assessed four times – at intake and then every two weeks -using an instrument that parents and teachers (who didn’t know what medication the kids were getting) would use to rate the child’s behavior on the 18 ADHD symptoms listed in the DSM-IV.

Amantadine may soon offer a new non-stimulant medication option for ADHD treatmentThe final findings were very encouraging (see picture): The kids in both conditions improved greatly over the 6 weeks of the study and no difference was found between the two medications. the children in the amantadine condition actually suffered less side effects and significantly so when looking at side effects common to stimulant medication such as decrease in appetite and restlessness. While more studies are obviously needed, this randomized trial shows that amantadine is not only safe, but it may be safer than at least some stimulant medications while also providing the same effect on ADHD symptoms. Given that approximately 30% of patients don’t respond well to stimulants and that some families are afraid of giving stimulant medications to their children, at least partially because of the risk of substance abuse issues, non-stimulant medications can be an attractive alternative, and it seems like amantadine can deliver.

Final thoughts from Dr. Jaffe on ADHD medications and amantadine

One of the main reservations I have about the notion of using this medication for ADHD is that NMDA receptors are very important in learning, so it may be that we’re helping to resolve attention problems but making it more difficult to actually create memories that are crucial for learning. More research is necessary to see if these decreases in impulsivity are accompannied by improvements, and not reductions, in learning ability.

So, if you’re considering medicating a child who has been diagnosed with ADHD, I strongly support the notion given the difference that medication has made in my own life. However, I urge you to be educated and to consider non-stimulant options, especially as more are researched and as that treatment option becomes more available, less costly, and less likely to lead to abuse of the drug. With prescription drug abuse one of the fastest growing problems in the U.S., being careful is just sound advice.

Citation:

Mohammad-Reza Mohammadi, Mohammad-Reza Kazemi, Ebtehal Zia, Shams-Ali Rezazadeh, Mina Tabrizi, Shahin Akhondzadeh (2010) Amantadine versus methylphenidate in children and adolescents with attention deficit/hyperactivity disorder: a randomized, double-blind trial. Human Psychopharmacology.

Some parkinson work showing effect of amantadine: http://www.springerlink.com/content/76r5wxux8wn52rq5/fulltext.pdf

Crystal meth and cocaine, Agassi and Gasquet- The reality of drug use in our society.

AgassiAfter Andre Agassi’s recent confessions in a tell-tale book about his use of crystal meth during his playing days, Richard Gasquet, who recently made it to the Wimbledon semifinals has just tested positive for cocaine.

He says he was contaminated with the drug when he kissed a woman who was using it.  Right. Unless the woman was covered in an inch thick layer of coke, or unless Gasquet drank about a pint of her heavily intoxicated saliva, we all know that’s a lie. I’m pretty sure the committee now deliberating will come to the same conclusion.

Drug use in our society

The bottom line is that drugs are everywhere, including our star athletes, night-club hopping starlets, and big-time business executives. And in case you haven’t figured this out, they’re not going away. The best we can do is to keep researching the problem so that we can:

  1. Educate the public (educational and dissemination research).
  2. Identify risky users earlier (assessment and genetics research).
  3. Figure out the most effective ways to get them into treatment (intervention research).
  4. Discover the best methods to treat them (clinical and pharmacological research).
  5. Repeat the cycle.

That’s it! That’s all we’ve got. Recreational drug use will most likely continue forever, and I for one think that’s the wrong problem for us to be focusing on.

Interdiction – Our current solution to drug use

Limiting the drug supply, which is a big part of how our government currently deals with the problem, drives up the price of street drugs. This in turn reduces their purity (dealers have to make money) and gets in the way of recreational drug use. So far so good. But guess what?

Addicts don’t care about the cost of drugs.

Trust me, I used to sell them and use. I used to know a lot of other people who did too. Addicts are not making rational decisions based on economic realities. They’ll sell their stuff, lie cheat and steal their way to more drugs. Their brains are no longer depending on rational thinking when it comes to their drug use. That’s pretty much the definition of addiction.

Decriminalization – Our next step

I’m going to write a post soon about the notion of decriminalization. Decriminalization is different from legalization. Making drugs legal is like sanctioning their use – making citizens think the drugs are okay. For the most part, they’re not. But decriminalization would take addicts out of our prisons and give them the treatment they need. I think it’s time we faced the music and dealt with drug use problems at their core, with the people most often negatively affected by them.