Naltrexone is Effective for Alcohol Problems – Why Is It So Poorly Adopted?

Last month a client reached out to me because he wanted a prescription for Naltrexone, an FDA-approved medication for addiction to alcohol and opiates, but his doctor wouldn’t give it to him. Was it because his alcoholism wasn’t severe enough for medication, that he had health problems that made him a bad fit for it, or because he was taking another prescription that could dangerously interact with it?

No. None of the above was relevant. Instead, the doctor said that the client needed to show proof of at least 6 months of Alcoholics Anonymous (AA) attendance before she’d even consider Naltrexone as an option. Essentially the client needed to admit he was powerless over alcohol, turn himself over to God, and then pray that God remove his character defects before he could get a prescription for a potentially life-threatening health condition. Not only could this be considered medical malpractice, but it is also symbolic of a troublesome theme in the addiction treatment world.

How Does Naltrexone Work?

Naltrexone is an opioid antagonist medication that works by inhibiting the “euphoria” that alcohol, opiates and potentially other rewards create. It blocks opioid receptors in the brain, thereby inhibiting the release of endorphins that cause the pleasure one associates with these substances. Over time, one no longer experiences the desirable effects of them and cravings gradually cease. While an alcoholic drink may, much like a can of your favorite soda, continue to taste good, it does not create any pleasure or euphoria beyond that.

Naltrexone itself is not addictive and it does not adversely interact with alcohol. Furthermore, the safety and efficacy of Naltrexone for alcoholism have been upheld by a large body of research since the time of its acceptance by the FDA in 1984. Unfortunately, Naltrexone still faces some barriers in becoming a more commonplace choice of treatment.

Strong Evidence, Weak Implementation

A recent national study of addiction treatment centers found that, depending on the type of Naltrexone, only 9 to 17 percent of centers offered it (U.S. Department of Health and Human Services, 2016). Furthermore, while an estimated 16.3 million adults in the U.S. have an alcohol use disorder, in 2010 only 658,000 people received prescriptions for medications like Naltrexone—that’s only 5 percent!

Why has the rollout of Naltrexone been so limited? Abraham et al (2015) found that counselors at addiction treatment centers with a 12-Step ideology, meaning they require clients to follow the 12 Steps of AA (much like the doctor above), were significantly less likely to consider Naltrexone effective. Also, Roman et al (2011) found that addiction programs that place a greater emphasis on the 12 Steps were less likely to adopt any form of medication-assisted therapy (MAT). When you consider that 80% of addiction treatment centers in this country incorporate the 12 Steps, the low uptake of Naltrexone makes a whole lot of sense.

Addiction counselors with a Master’s degree or higher were more likely to view Naltrexone as a viable treatment compared to counselors with less education. Altogether, these results suggest that the misconception that Naltrexone is just another “narcotic” that can be addictive, a commonly-held view in the 12 Step community, and a widespread lack of knowledge regarding its effectiveness are major barriers to its adoption.

So what’s to be done? Abraham et al (2015) have suggested integrating medication-specific training and practice guidelines into coursework for students seeking certification in addiction counseling. Such strategies may contribute to a faster, more efficient adoption of the medication by treatment programs. However, given AA’s stronghold on the treatment community, it may take a while before Naltrexone is widely available enough to meet the need for it. Luckily, there are options out there.

My Approach

I make it my goal to be one of the most forward-thinking recovery resources available, and that includes embracing Naltrexone. I offer support services for the “Sinclair Method,” a controlled drinking program that incorporates Naltrexone to individuals with prescriptions for it. Double-blind clinical trials conducted by creator Dr. JD Sinclair (Sinclair, 2001) have demonstrated the benefits of Naltrexone are most evident when individuals continued consuming alcohol during treatment while taking it (the “Sinclair Method”), whereas individuals who practiced abstinence while taking it did not receive such benefits, suggesting the medication may be better suited for people who wish to control their drinking.

The Sinclair Method takes advantage of “extinction”, a learning mechanism that gradually reduces the positive reinforcement of alcohol use. Individuals with AUDs have been “conditioned” to positively associate benefits with drinking alcohol. Pairing Naltrexone with alcohol consumption helps to break this association. However, this extinction mechanism is not put into action when the original problem stimuli (alcohol) is not presented, supporting the efficacy of the Sinclair Method in the goal of treating AUDs.

Finally, it is important to note that Naltrexone is part of medication-assisted therapy, meaning it is a supplement to a comprehensive program that must include a behavioral component. It is not a magic bullet. That’s why I offer a complete behavioral education and coaching program to support clients through The Sinclair Method experience

 

References

Abraham, A. J., Rieckmann, T., McNulty, T., Kovas, A. E., & Roman, P. M. (2011). Counselor attitudes toward the use of naltrexone in substance abuse treatment: A multi-level modeling approach. Addictive behaviors36(6), 576-583.

Anderson, K., M.A. (2013, July 20). Drink Your Way Sober with Naltrexone.

Litten, R. Z. (2016), Nociceptin Receptor as a Target to Treat Alcohol Use Disorder: Challenges in Advancing Medications Development. Alcohol Clin Exp Res, 40: 2299–2304. doi:10.1111/acer.13222

Roman, P. M., Abraham, A. J., & Knudsen, H. K. (2011). Using medication-assisted treatment for substance use disorders: Evidence of barriers and facilitators of implementation. Addictive behaviors36(6), 584-589.

Sinclair, J. D. (2001). Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholismAlcohol and Alcoholism36(1), 2-10.

Thomas, C., Wallack, S., Swift, R., Bishop, C., McCarty, D., & Simoni-Wastila, L. (2001, January). Adoption of naltrexone in alcoholism treatment. In Journal of Addictive Diseases (Vol. 20, No. 2, pp. 180-180).

Thomas, S. E., Miller, P. M., Randall, P. K., & Book, S. W. (2008). Improving acceptance of naltrexone in community addiction treatment centers: A pilot study. Journal of substance abuse treatment35(3), 260-268.

U.S. Department of Health and Human Services (2016). The Surgeon General’s Report on Alcohol, Drugs, and Health. Office of the Surgeon General, 6-29.

NIAAA Brochures & Factsheets

NIAAA Alcohol Facts & Statistics

World Health Organization Factsheet

Mental Health Labels – Rebranding Our Shame

I recently gave a talk at the TEDxUCLA conference. The point of the talk was to point out just how impactful, often negatively so, mental health labels can be. In case you are not aware, mental health labels typically come with expectations. As I point out in my talk, these expectations can actually alter individual performance and bias those who are labelled towards meeting their reduced expected success. This effect has different names in different contexts including the expectancy effect, stereotype threat, and experimenter bias. Look them up, listen to the talk (and I’ve included the text to make things easier) and start making a difference in your life!

I think you’ll find that there’s a pretty convincing case for reducing our reliance on mental health labels as predictors of success in life.

Rebranding our shame

I’m going to start with an experiment, but I’m going to need your help. What words would you use to describe me?  What labels?

In August of 2001, I woke up in a hospital bed. Now anytime you wake up in a bed you can’t remember going to sleep in, it’s going to cause at least mild concern, but when that bed is in the hospital, you know something has gone wrong. I remember lying there, looking around, trying to figure out what might have happened and who these people around my bed were. And then I realized that my leg was throbbing in agony. Slowly, I stared to remember a little more. I had been riding my motorcycle through Beverly Hills. I remembered a car cutting right in front of me without signaling- I know, in Beverly Hills, it’s hard to believe- and I remembered trying to carefully go around it so I wouldn’t go flying into oncoming traffic. I also remembered not quite making it. I remembered, even while writhing in pain on the street, being pretty worried. One of the things I was dreading was the eventual conversation with my overprotective Jewish mother (who is sitting 20 feet form me right now, btw):

“I would’ve never let this family leave Israel if I knew you were going to be out here risking your life on these stupid crazy motorcycles!” She’d say.

As they were loading me onto the gurney, I remember thinking that I need to call my assistant and cancel the DJ gig I’d booked that night. At least I thought it was that night… I’ve always been terrible at schedules.

Now keep in mind, I’m completely out of it on pain meds, so these pieces are coming together slowly, but there’s definitely something weird going on. And that’s when it hits me: the person sitting next to me was a cop, and I’m handcuffed to the bed. And now I know exactly how I got here and the memories start coming…

Because I didn’t just crash my motorcycle in Beverly Hills. I crashed my motorcycle in Beverly Hills with a half-pound of cocaine in my jacket. During my final 3 years at UCLA I had been using, and selling, what I am pretty sure everyone here would consider a large variety and quantity of drugs. I had been on a delivery run. This was one of the other reasons I’d been worried while lying on the ground…

And then I went to court and rehab, then jail. I got into graduate school and eventually got my Ph.D. In Psychology from UCLA, started a national addiction related website and treatment center and ended up on a Ted X stage giving a speech.

OK. I’m sure as that story went along, you started filling in some details about me. I’ve put the most obvious ones on the screen behind me. Over the course of that story, you learned about more than a few specific labels you could have applied to me: I’m a Bruin; Jew; Immigrant; Musician. But let’s be honest, here-  because I have a strong feeling that those were not the labels that stood out and made an impression. Not compared to Drug Dealer. Or Addict. Or Criminal. Or, soon after that, Inmate.

But I know what part of my story stands out. Sometimes, people even bring it up as a compliment- “you should be so proud, you’ve overcome so much,” stuff like that. What I’m usually too polite to tell those people- but what I’m here to tell you now- is that one of the largest obstacle to my success has been statements just like that.

You see, Branding is an intensely powerful thing. This is why people who don’t know the difference between a first down and a touchdown (like my mother in law)still watch the Super Bowl. It’s why, when I ask you if you’d rather have a BMW or a Saturn, you immediately know the answer even if you’ve never sat inside either kind of car. And for branding to be effective, there has to be a core of truth- the BMW is, generally, going be better engineered, more carefully constructed and more luxurious. But is it truly “The Ultimate Driving Machine?” And while an exaggerated piece of branding material about a car isn’t going to ruin anyone’s life, it’s exactly that type of overstatement and blanket labelling when it comes to those who struggle with mental health issues that often keeps them from getting the help they need and overcoming.  I know that because…

Over the past 12 years, I’ve made the study of addiction my calling, and really, my obsession. In 2010, I conducted a study meant to examine why over 85% of people who struggled with addiction often do not even seek help. I was unsurprised, but terribly disheartened, to see the results: 75% of our participants identified shame, stigma, and the inability to share their problems with others as a main barrier.

Now, let me ask you this: what was the worst situation or lowest point that you’ve ever been in your life, that you ultimately got away from? Maybe you experienced bouts of severe depression in college but made it through without a lifetime of antidepressants. Maybe you woke up behind the wheel of your car after a night of heavy drinking and you’d made it home in one piece. Maybe you did a little cocaine here and there before going to the club with your friends without thinking much of it. Now let me ask you this: would your life be better or worse, right now, if before finding your way out you’d been officially caught and labelled “clinically depressed,” or an “alcoholic”, or an “addict?”

We need labels to help us understand the world and one another. Labels help us figure out which groceries to buy, what car to drive and what school to go to (UCLA logo on screen).

We’re pretty good at understanding physical labels, but when mental health is at issue we struggle. Typically we believe that each “label” comes with a specific amount of dysfunction in a simple, straight-forward way. If you’re depressed, you’re shut in your room all day, if you have ADHD, you do poorly in school, if you’re a drug addict, you’ve let every other responsibility in your life fall by the wayside because getting high is the most important thing in your world. These conclusions are simple, they make sense.

But there’s a cost to that, a human cost. You see, mental health labels in the early 21st century remain one of our clearest bastions of shame. I mean come on, every single person in this room, suffers from some neuroses, insecurities, and weaknesses, right? But the moment your issues cross the threshold into a certifiable Disorder, you become a walking condition. Suddenly you’re a label with a treatment that has less to do with who you are as an individual and more to do with how you’ve been categorized.

The problem is that, in serving as shortcuts to the truth, labels eliminate any sense of nuance.

This is a QEEG scan of my brain. I’ve already said that I struggle with Attention DeficitHyperactivity Disorder, and I obviously have some addictive tendencies as well. But let’s look at my brain and compare it to that of another person with the same ADHD label. They don’t look the same, do they? And you wouldn’t expect our ADHD to manifest in the same way knowing this. In the simplest of terms, what this means is that nearly every manifestation of a disorder is unique, with its own symptoms, its own strengths and weaknesses. We can diagnose and categorize and take our best shot at nailing down conditions, causes, and treatments, but the reality is that mental health as a profession is in an ongoing state of reevaluation and refinement, and labels are approximations. When we act as if we know more than we do, when we treat other human beings- no matter how compassionately- as if we fully understand them because of a mental health label that has been applied to them, we run a serious risk of addressing a concept, rather than the actual person.

Now here’s the question at least some of you are asking yourselves: so what? Who cares if we overgeneralize? Doesn’t an ADHD diagnosis get a student extra help in school?

To answer that question, I’d like to tell you about a group of kids in a California elementary school. At the beginning of the school year these children took the standard battery ofintelligence and performance measures. Afterwards, researchers informed some of the teachers that a specific test called the Harvard Test of Inflected Acquisition had identified a subset of kids who were expected to outperform their peers. They were told to expect great things this year from these children in particular. When these so-called “growth spurters” end-of-year IQ tests were compared to those from the beginning of the year, they were indeed found to have outperformed the student body as a whole by as many as 15 IQ points! The test was right!

Obviously there’s a twist. There was no such thing as the Harvard Test of Inflected Acquisition. In reality the “growth spurters” had been randomly selected, and yet, their IQ improvement results matched the misleading information the teachers were given. The students, btw, were never made aware of these groupings, so we can eliminate their own internalization as the cause for this effect. The only conclusion left to draw is that the teachers, unconsciously acting on a false belief, actually affected these students towards extra success- an actual increase in their measured intelligence – and also condemned others to fall relatively behind.

Or we can also consider the studies that show that African-American students perform more poorly on standardized tests when they are specifically told that those tests will be used to measure their intelligence. and this differences disappears if the tests are labelled as simple experimental exercises but shows back up with the simple act of making students check a box indicating their race group before taking the test. This isn’t a problem of ability. We’re dealing with expectations and the self-recognition by these students that they’re expected to perform more poorly in some contexts.

And if you’re not yet entirely convinced, I’d like to introduce you to the albino rat. Animals like these are used regularly in neuroscience and genetics research to do things like run mazes, press levers and perform other simply tasks. But what if I told you that simply by labelling some rats as “bright” and others as “dull,” experimenters managed to produce a difference of about 50% in the time it took these animals to run a maze? The only issue, of course, is that all of the rats were essentially identical, with the “bright” ones chosen completely at random. The only true difference were the expectations the research assistants had for them based on instructions.

Take a moment to consider just how incredible the implications of that experiment are. It suggests that even when the subjects in question are unable to understand the meaning of the labels applied to them or what might be expected of them, the preconceptions of those observing them still undeniably alter the results.

What these examples show us is that labels and expectations pinch those being labelled on both ends. They’re being set up for a failure that, even if they somehow have the strength to overcome, is still almost surely going manifest itself in the eyes of those evaluating them.

So how sure are you now that children with ADHD underperform in school slowly because of their own dysfunction? And in how many other setting are we creating failure?

My ADHD can definitely be a burden to me – I can’t plan ahead to save my life – if we were all friends in this room I would have disappointed many of you by missing some scheduled get together or forgetting an important event. I also get easily frustrated and bored and I hate sitting still. But in other ways my ADHD is a real asset. I think outside the box, even in the face of pressure to conform. I thrive in the face of pressure and multitasking that makes many others crumble. And I’m driven, unable to rest on the laurels of small accomplishments when a bigger prize is out there. My various assistants, in contrast, have some pretty noticeable Obsessive-Compulsive-like tendencies- they needs to fill in details, double and triple-check schedules, make sure they can see the path from A to B to C before starting. And you know what? Together, we’re perfect. The same complementary aspect is there in my relationship with my wife, the most balanced, calm, centered person I know, and the only one who can take my crazy anxiety and balance me out. I’m still not exactly sure how I make her life better…

So what’s the takeaway here? Should we throw all the diagnoses out the window and say that everyone’s normal in their own way? Not quite. We don’t need to eliminate labels- categories are helpful. What we need to do, however, is to get comfortable with a much more expanded and nuanced approach to our labels, and avoid moralistic value judgments. Every disorder has levels, and sub-components of those disorders can be just as beneficial as they are debilitating. Sometimes all it depends on is a simple point of view or context. In this way we can start thinking about these less as disorders and more as simply labels that explain differences in our functioning.

It’s up to us to change the conversation to open our society to the attributes and potential of those who have been labeled. The notion that all psychological differences need treatment with the goal of getting the person in question back to “normal” is only sometimes true- but it’s always stigmatizing and shame-inducing. And that shame leads nearly 9 out of 10 to not even ask for help.

If you’re one of the labeled, like me, I’m asking you here and now to take back ownership of what others have put on you. Forget the meaning of label that’s been applied to you and start building your own brand – Identifying the parts that fit and rejecting the ones that don’t.  Learn more about yourself and find a life that fits your brain, your body, your world. Your disorder might just prove to be your biggest gift.

If you know someone who is labeled, and we all do, I urge you to reconsider your responsibility to that person. Reconsider what it might mean for your daughter to have ADHD and what elements of that disorder might actually apply to her; what your husband might be capable of despite being labeled an addict; or what your friends’ depression, or anxiety, or bipolar disorder might mean for your relationship. That simple act of careful thought can pull you out of that automatic brand-messaging-mode and might allow you to recognize strengths they have that you’ve ignored because of their “disorder”. More importantly, your effort at truly understanding them might be just the glimmer of light through the clouds that the people who are important to you need.

Imagine what we can do if we take shame out of the equation? I am making it my own mission to flip this problem on its head. I want 90% of individuals who struggle in this way to reach out – and I want you to help me!

Because I am definitely not unique in overcoming my difficulties. I am maybe unique in being so public about it – in not succumbing to the shame that I too feel. And I can tell you from personal experience that sure, beating expectations is nice, but it’s a lot nicer not to be chained down by low expectations in the first place.

My name is Adi and I am not an addict. I am not an ADHD sufferer. I am so much more. And I don’t expect failure for myself, I expect success. Fuck Shame. Sure, I work hard every day to overcome the parts of myself that frustrate and complicate me- but who among us, diagnosed or not, can truly say otherwise?

And while I’m pretty sure that your impression of me now is somewhat different from that you had of me 15 minutes ago, I hope you don’t hold that against me…

Breaking Bad, Race, and Meth Addiction

by Emma Haylett

As Breaking Bad ends a wildly successful season—don’t worry, you won’t find spoilers here—

the show is on many of our minds for many different reasons. While the idea certainly wasn’t

groundbreaking (there are so many that deal with drug and alcohol addictions and various forms

of recovery, to varying degrees of accuracy and success), it managed to capture the hearts

and minds of people across the United States. Likely it is because of the variety of emotions a

show like this evokes, often in the span of one episode. As humans, we crave a deep emotional

connection to the media we consume, and in an age of reality television, this may be lacking.

We want good guys and bad guys and carefully constructed (and filmed) plot.

Breaking Bad though doesn’t adhere to our ideas of good and evil, instead subverting them

over and over again. But we stay tuned because we’re interested in how far our own thinking

can go and transform, how like or unlike an addict we might feel in our journey with the show.

Strangely, or perhaps not, is the scenario put in place by writers and producers that even allows

for a man like Walter White to find himself in such predicaments.

For Walter White to make and deal methamphetamines, he had to get cancer, be unable to

treat it, be unwilling to accept money from friends, know a shady high school student, and be

later consumed by a world darker than he could have imagined. It’s an excellent premise e for a

show, certainly—but imagine the setup for a black man. Other shows have proven that we don’t

need to suspend our disbelief by establishing a crazy cancer scenario to believe that a minority

might make, sell, or do drugs.

And Breaking Bad has other issues with race—while Albuquerque, New Mexico is nearly half

Latino, Gus Fring is the only Latino character to reoccur enough to get a billing as regular cast.

In a Salon article titled “Breaking Bad’s Racial Politics Walter White, Angry White Man”, Todd

Van Derwerff suggests that it is the idea of the antihero that speaks most effectively to white

privilege. “His is the voice of white male privilege, the angry, unfiltered sense that one is owed

something and has had it taken away. Never mind that Walter built an empire worth $80 million.

He always wanted more—respect or fear or worship—and he never got it. He could never quite

get over the fact that other people weren’t placed on Earth to play supporting characters in his

own story, and even in the series’ pilot, he’s bogged down by an overbearing boss and a wife

who seems interested in anything but him,” writes Van Derwerff.

But Breaking Bad is good television, and, while ignoring some aspects of racial diversity, it

perhaps addresses the reality of methamphetamine in rural areas—states like Idaho and

Wyoming have documented problems with the use of meth. If we look at Idaho, 70% of drug

related offenses are meth related, which costs the state between $60 million and $102 million

for incarceration and arrest. 89% of women in Idaho jails are meth users, and 80% of children

placed by Health and Welfare are removed from their homes because of drug abuse—mostly

meth.

Meth is affecting areas that are not dirty or dangerous—teachers and factory workers, high

school students and high school dropouts are part of the growing meth problem and, if nothing

else, Breaking Bad has drawn attention to it. To the show’s credit, it doesn’t glamorize the

addiction or recovery from addiction in the way that some shows have—the characters who use

are decaying, they’re mean, they’re painfully addicted and involved in an extremely dangerous

world.

Ultimately, Breaking Bad presents a scenario in which the viewer is asked to examine the good

and evil within themselves. It is also (though perhaps not intentionally) raising a discussion

about race—who deals and uses, who produces, develops, and distributes meth. And that’s a

conversation worth having.

 

Emma Haylett is really good at thinking up nicknames, though she has few of her own. When she’s not

packing around a too-heavy backpack at graduate school or working as a Certified Prevention Specialist

Intern, you can find her advocating for healthy drug rehabilitation programs around the US.

Managing Opiate Addiction During Pregnancy

By Lisa Simpson

According to figures from the National Survey on Drug Use and Health, 5% of pregnant women in the US use illicit drugs, which rises to just over 20% in the under 18 age group. While heroin is used by only around 0.1% of women during pregnancy, a further 1% admit to using opiate based medications for purposes other than pain relief; prescribed opiates include codeine, fentanyl, hydrocodone, meperidine, morphine and oxycodone. Women are usually asked about their use of drugs early in their obstetric care to identify those who, along with their developing baby, are at risk from this habit. Displaying erratic behavior, signs of intoxication or withdrawal are easy to spot, but waiting till later in pregnancy to seek obstetric care, poor attendance at appointments and below expected weight gain are also indicators that a woman may be using opiates.

Risks from opiate use

Women who continue to use heroin during pregnancy risk reduced growth of their developing baby, fetal death, separation of the placenta from the uterus and premature labor. While birth defects have rarely been observed in babies born to women using opiates during pregnancy, a number of studies have demonstrated codeine use during the first trimester is linked to heart abnormalities; though this has not been seen with other prescribed opiates that have also been studied.

Methadone program during pregnancy

As well as treating pregnant women addicted to heroin with methadone, a similar maintenance plan is starting to be used with addiction to other opiates; there is also evidence that buprenorphine may be used as a safe alternative for management of opioid use, so this option may be presented to women. The dosage of methadone is determined by addiction specialists, who adjust the dose as required throughout pregnancy to avoid withdrawal; symptoms of this include cravings, anxiety, difficulty sleeping, feeling irritable and nauseous. Not only does this prevent these unpleasant symptoms for the mother, but protects her unborn baby; while withdrawal from opiates is rarely fatal for adults who are in good health, fetal death may occur in women who do not seek help with their addiction and try to withdraw on their own.

However, as with others who access help with opiate addiction, therapy goes beyond the prescription of methadone for pregnant women; she will also receive dependency counseling and have access to other medical and psychological interventions, as well as any other services deemed necessary. This ensures that by engaging in a program for therapy, women are more likely to receive prenatal care, which reduces the likelihood that complications will arise during their pregnancy. It is possible for most pregnant women to attend a methadone program on an outpatient basis, though in some cases it may be advisable to initiate methadone during a short stay at an opiate treatment center. While maintenance with methadone is preferred to withdrawal during pregnancy – even when medically supervised – due to the high risk of relapse, if participation within a methadone program is refused by a woman, the second trimester is the safest time for her to withdraw under the guidance of a specialist.

Neonatal Abstinence Syndrome

Although treatment with methadone is more likely to lead to a healthy pregnancy than if illicit opiate use was to continue, her newborn baby is at risk of developing a condition known as neonatal abstinence syndrome, which affects the nervous syndrome. As a result a baby’s sucking reflexes are uncoordinated, which interferes with feeding, and they are also more prone to be irritable. Babies who were exposed to methadone in the uterus usually develop withdrawal symptoms within their first three days after birth and while in some cases this may only last for a matter of days, in other infants they may remain for weeks. It is protocol for babies born to women who took opiates during pregnancy to be monitored for this syndrome so that treatment can be initiated as necessary; the obstetric and pediatric team work closely to ensure that the newborn receives optimal care to achieve normal feeding, weight gain and sleep patterns. As neonatal abstinence syndrome can be successfully managed and does not appear to have any lasting adverse consequences to physical or mental health, the advantages of initiating methadone in pregnancy far outweighs the risks.

Adderall use and college students

All About Addiction has profiled stories of college addiction in the past, but most have centered on illegal drugs and the rampant problem of alcohol abuse. Education blogger Valerie Harris joins the community today to talk about a very disturbing new trend: the rise of “study aid” dependencies, usually in the form of prescription ADHD meds like Adderall. Valerie writes a student resource website for those looking into different college and grad school options, and is an expert in many of the issues modern students face.  As prescription drug abuse is a major problem in our society, a specific focus on prescriptions relevant to college studentsis noteworthy.Study Drug Addiction Plagues Students From Masters Programs to Community College Illicit Adderall usage on college campuses has been on the rise in recent years, mostly stemming from its use as a study aid. The amphetamine salts that make up Adderall accelerate the heart rate and increase alertness, enabling students to put in long hours of continuous and focused study. However, due to its amphetamine base, Adderall can also be addictive, leading some students to use the drug as a crutch, causing long term issues both academic and social.

Increasing Use
A 2009 article in the Cornell Sun stated that Adderall was estimated to be used by 6% of college students, while a 2011 survey in the journal Addiction reported that on some campuses, as many as 25% of students were abusing the drug. A study conducted by the National Survey on Drug Use and Health found that 15% of college students have illegally ingested Adderall, Ritalin or another stimulant in the past year, while only 2% of these hold a prescription for the drug. This suggests that there might be an overall increase in Adderall abuse although longitudinal data from single sources is relatively scarce.

Campus Responses

In light of this possible increase, and the problems associated with it, universities are beginning to fight back. Recently, Duke University added “the unauthorized use of prescription medication to enhance academic performance” to its student conduct policies that equate to academic dishonesty. Wesleyan and Dartmouth have also amended their policies to include a ban on prescription drug abuse, while students with ADHD prescriptions at George Washington University are told to purchase a safe for their dorm. Other schools more aggressively target potential dealers.

The Illusion of Safety

Due to its prescription drug status, many college students believe Adderall to be safe and non-addictive. It’s true that when used with a prescription and with the supervision of a doctor, Adderall can be safe. However, when used without a prescription Adderall use  is essentially akin to unregulated speed abuse. As an amphetamine drug, Adderall is listed by the Drug Enforcement Agency as a Schedule II Controlled Substance, meaning anyone caught with pills not prescribed by a doctor is subjected to the same criminal charges as those possessing opiates or methamphetamine. Schedule II drugs involve an extremely high risk of addiction and overdose, as well as a potential to lead to depression or heart failure.

A University of Pittsburgh newspaper notes that side effects can include irregular heart rate, increased blood pressure, headaches, sleep deprivation, and loss of appetite, among others. When abused, the adverse effects of the drug can be substantially exacerbated. Instances of acute exhaustion or psychosis during withdrawal have been documented, and when it’s mixed with alcohol, Adderall can even cause death. Among young people with developing prefrontal cortexes, the effects can be even more pronounced and long-term, essentially changing the chemistry of the brain.

Safer Solutions
Perhaps the biggest hurdle schools and medical professionals face in weaning students away from prescription drug addiction in their genuine effectiveness. Still, statistics show that students using Adderall illicitly are often far from the highest achieving, with an average GPA among abusers of less than 3.0. The fact that the vast majority of students who take Adderall use it legally and likely suffer with learning disabilities clearly affects these performance numbers, but it is clear that Adderall is not a panacea. Students who truly achieve long term success usually do so by disciplining themselves and utilizing time effective time management skills. “The most important thing to have for time management is some kind of system” says Kelci Lynn Lucier, author of The College Parent Handbook. “Some students use the calendars are their phones: others use things like Google Calendar; others still use the classic paper-calendar model.”Lucier also asserts the importance of maintaining a regular and appropriate sleep schedule. “While it may be common among college students, a lack of sleep is more detrimental than you might think,” says Lucier. “It can throw everything out of whack: your mental health, your physical health, your stress level, and, of course, your schedule.”There is no doubt that Adderall offers a short-term solution for students that are behind in their studies, their sleep, or generally overwhelmed by their many burdens. However, the adverse effects of continued use on one’s mental and physical health, as well as the potential risks towards one’s education and future success, can prove devastating. Students who are genuinely invested their academics and career training are often best served by taking the time to study while maintaining a disciplined and manageable lifestyle.

About Addiction: Alcohol, Legalization, Internet-Addiction, the Drug war, and Teen Drug Use

a couple weeks away, A3 Link posts are back with a brand-new set of addiction article straight off the press! With election season gearing up we have some news regarding new laws on the ballot for legalization in some states, as well as internet-addiciton being deemed an official diagnosis in the new DSM, and everything in between. Check out all of the new articles in this week’s posts!

Does trying alcohol in youth develop a distaste for it?-  How does tasting alcohol in childhood affect later alcohol use in adolescence? This question has long been debated by parents, with some feeling they should keep their children as far away from alcohol as possible and some believing they should let their children taste alcohol in order to take away the temptation of alcohol as a “forbidden fruit” and/or so they can develop a distaste for it early on. According to a recent study by RTI International and the University of North Carolina at Chapel Hill based on data collected from interviews with 1,050 mothers and their third-grade children, 25% of the mothers thought that allowing their kids to try alcohol would discourage them from drinking in their adolescence, and 40% believed that not allowing children to taste alcohol will only make it more appealing to them. Twenty-two percent of the mothers believed that children who taste alcohol at home with their parents would be better at resisting alcohol-related peer pressure, and 26% thought it would make them less likely to experiment with risky drinking in middle school. Amongst the children, 33% of those in the study admitted to having tasted some alcoholic beverage. While these findings may not be surprising to some, they are interesting and, to some extent, worrisome because, according to the researchers, early introduction to alcohol is a primary risk factor for problem drinking during adolescence.

Internet Addiction an Official Diagnosis?- The term addiction has historically been used primarily to indicate addiction to drugs and alcohol. Now, there are many different forms of “addiction”, some included in the worldwide psychiatric manual and others simply used by people in everyday conversation. Reportedly, if confirmed by further research, a new addiction included as ”internet-use disorder” will be included in the new psychiatric manual the DSM-V, and children addicted to using electronic devices 24/7, will be diagnosed with a serious mental illness. While this may seem a bit excessive to those who feel there are no ill effects of internet use, recent research has found that children get aggressive, irritable and hostile when their iPads or laptops are taken away from them. Some researchers even found that screen addictions have characteristics similar to other addictions, including emotional shutdown, lack of concentration and withdrawal symptoms if they are kept away from their gadgets and games. While it may soon become an official mental illness, for now overuse of technologies would be classified under internet-use disorder alongside other mental disorders.

Legalization on the Ballot in Multiple States- With election season quickly approaching, multiple states have initiatives on the ballot regarding the legalization of marijuana. According to pre-election polls, it seems likely that at least one of these bills will pass. While Oregon, Washington, and Colorado all have a proposition on their ballot, it looks like Washington or Colorado might be the first state to officially legalize recreational marijuana use, as both states showing at least 50 percent support in the polls. In Washington in particular, there is little organized opposition, with opponents raising only $6,000 compared to supporters, who have collected more than $4 million. Ironically, medical marijuana dispensaries have been the most publicly opposed to the bill. While some of them worry about marijuana dispensaries being put out of business, others fear new DUI laws that could make it illegal to be driving with even a trace of THC in one’s system, an intimidating fact due to the extended time period THC stays in one’s system. For now, those in other states will just have to wait and see what happens at election time. But pay close attention, because the results could have an enormous impact on the future of marijuana legalization across the country, and around the world.

Teen Drug Use Leads to Successful Lives? It has long been thought, and often commonly accepted, that drug use is “bad”, dangerous, and even deadly. However, in a surprising discovery, a recent study conducted at the University of Minnesota Institute of Child Development by Michelle M. Englund found that teens experimenting with drugs and alcohol are more likely to attain higher levels of education and be in stable romantic relationships early into adulthood than those who abstain. This is not to say that heavy drug use leads to more successful individuals, as those who were deemed to be drug abusers and even at-risk users did not reach the same levels of success as experimental users or even those who abstained. One explanation offered is that many of the successful users developed a strong foundation both academically and socially before they tried the drugs and/or alcohol. This seems logical when compared with studies that have shown drug and/or alcohol use earlier in adolescence to be harmful to brain development. While this particular study was conducted with a small sample size and researchers admits that similar studies of larger populations need to be done to verify their results, they do insist that these results show that experimental drug use in adolescence may not be as harmful as previously thought, and may actually be a normal part of adolescent development. Since approximately 80% of teens admit to using drugs, it makes sense that drug use of some sort would be normative and not problematic.

The Drug War- The “Drug War” has been going on for many years now, with the government seemingly spending more to fight the spread of drug use by the year. Using data from government agencies such as the Substance Abuse and Mental Health Services Administration and the National Drug Control Surveys, Matt Groff created a graph showing the relationship between government spending on the Drug War and the drug users in America, per 100 citizens, over the last 35 years. You can see the graph for yourself via this link. While it seems there may have been a slight correlation in the ‘80’s as spending began to increase and drug use dipped , the impact has disappeared since then. While Drug War spending has increased to at least 3 times the amount being spent at the end of the 80s, drug use has not decreased and has even been on a slow but steady rise since then. With the effectiveness of the drug war being called into question, it seems prudent to look into more effective ways to be fight drug use nationwide.

Quitting smoking without help is hard: Effects of motivation and other personality factors

Quitting smoking is hard, but that suggestion probably isn’t terribly exciting all on its own since most of our readers probably knew it already. Still, while we’ve talked about quitting smoking using nicotine replacement and medication, we haven’t really touched the subject of all those people out there who just decide to give quitting smoking a try one day without those patches, gums, or pills.

Since something like 95% of those who try their hand at quitting smoking relapse within one year, and most of these people try to quit unaided, I think this is an important topic to touch on. Fortunately, recent research conducted in the U.K. tried to assess the personality and cognitive aspects that end up predicting who will succeed, or fail, in their quit attempt.

The effects of expectation, motivation, and impulsivity when quitting smoking

Quite a bit of research has already shown that when smokers are trying to quit (so we’re talking early on during abstinence), their brains react differently to stimuli in the environment depending on the relationship between those stimuli and nicotine. Stimuli that aren’t associated with smoking (or some other form of nicotine intake) get less attention and show overall less activation of important brain circuits while nicotine associated cues light up the brain just as if nicotine was on board (even though participants were drug free at the time). Essentially, if a stimulus predicts getting a hit, the brain gets smokers to pay attention to it so that they can do whatever is necessary and get a little drug in. Throw in some of that reduced ability to control behavior that we talk about so much (like impulsivity), and which is common not only in smokers but in users of almost every other drug (heroin might be the exception) and you have a recipe for disaster, or at least for a good bit of smoking relapse. And yet if we want to fight the horrible health consequences of cigarettes, then quitting smoking has to be made easier, which nicotine replacement and medications like bupropion have done to some extent.

As part of this equation, knowing the specific predictors of early relapse in people who are quitting smoking may be useful so that professionals planning smoking interventions can do a better job of targeting the most important factors. The study recently published the journal Psychopharmacology tried to assess the relationship between the severity of smoking, the above-mentioned personality factors, and the success of the quitting attempt.

The cool thing about this study is that the 141 people who participated were assessed on a whole set of these cognitive tests twice – once after a smoking free night and a nicotine lozenge and another time after a smoking free night followed by a nicotine-free lozenge. While they couldn’t tell which was which, the procedure gave the researchers an assessment off how different participants’ reactions were with or without nicotine on board. Following the assessments participants were directed to begin their attempt at quitting smoking. While they were asked not to use nicotine replacement options or other medications, they were allowed to use any other resource available and were given a set of information pamphlets that explained expected side effects and likely difficulties during the quit attempt. They were then followed up after 1 week, 1 month, and 3 months. Quitting was identified as minimal smoking (less than 2 cigarettes per week) and was verified both by self report and cotinine testing. There was a small financial incentive to quitting, with people who relapsed after a week getting only £40 (about $60) and those who made it through month 3 getting £150 (about $250), though I’m pretty sure that if $200 was enough to make people quit we’d have just paid up already…

The first thing to note in the results was that 24% of the participants were still not smoking at the 33 month followup. This seems to be about on par with the usually low success rates at 1 year though I’m sure this research group will try to continue following these participants at least up to the 1 year mark and hopefully produce another paper.

The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interfering with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After the 1-week follow-up, at the 1 and 3 month assessment, the odds of quitting had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.

The take-home: Quitting smoking is hard for different reasons in the first week and later on

If you’ve ever tried to quit you’ve been told you that the first week is the hardest and that once you make it through that the rest is a piece of cake. While this research doesn’t necessarily support that notion, since about 25% of the sample relapsed between each of the followups, it does seem to indicate that the reasons for relapse change after that first week.

It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking seems to be associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward.

Overall, these findings suggest that the cognitive function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.

Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can reduce relapse numbers at 1 week we can have a more gradual fall-off for the following month resulting in significantly higher quit rates.

Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medications like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?

Citation:

Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.

 

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The first thing to  note in the results was the 24% of the participants were still not smoking at the 33 month followup. This seems to be about on track for the normally low success rates at 1 year though I’m sure this group will try to follow these individuals up at that point and hopefully produce another paper. The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interruption with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After that point, at the 1 and 3 month follow-ups, had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.

The take-home: Quitting smoking is hard for different reasons in the first week and later on

If you’ve ever tried to quit you’ve heard someone telling you that the first week is the hardest and once you make it through that the rest is a piece of cake. Well, this research doesn’t really support that notion since about 25% of the sample relapsed between each of the followups, but it does seem to indicate that the reasons for relapse change after that first week. It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking was associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward. Overall, these findings suggest that the brain function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.

Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can bring the relapse numbers down at 1 week we can have a more gradual fall-out for the following month resulting in significantly higher quit rates. Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medication like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power that nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?

Citation:

Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.