Stop telling me ‘Everything you think you know about addiction is wrong’

You may have heard Johann Hari declare that ‘everything we think we know about addiction is wrong’ in his Ted talk of the same name (with nearly 4 million views), or his Huffington post article ambitiously titled “The Likely Cause of Addiction Has Been Discovered, and It Is Not What You Think”. Hari emphasizes the need to move away from punishing individuals struggling with addiction and work on compassion and establishing meaningful human connections. Although this is a good message, the talk as a whole is deeply misguided, and filled with inaccurate, overly simplified and categorical information that is misleading. This is largely because Hari is a journalist by training and not a scientist or addiction specialist. Unfortunately he dismisses decades of important research into the neurobiological and genetic components of addiction (Goldman et al., 2005; Koob & Volkow, 2010).

He conjectures that environment and a lack of human connection are to blame for addiction, citing Bruce Alexander’s Rat Park experiment and the return of veterans from the Vietnam War. Few who have experienced addiction or worked in the field would discount the significant role of environment, however it is reckless to discount decades of research in to its biological components. His primary evidence, the Rat Park experiment – which simply put, demonstrated that when morphine-addicted rats were placed in enriched environments they would not drink morphine-laced water – has never been replicated and does nothing to refute neuroimaging research showing that long lasting impairments in decision-making are still present long after abstinence has been achieved (Goldstein & Volkow, 2011). Hari also implies Vietnam veterans came home and easily ceased using heroin, failing to mention that all returning soldiers had to complete urine screens and, if necessary, detoxification before returning to the United States. In addition, he fails to acknowledge that potential soldiers with mental illness were not drafted (Robins et al., 2010). This is extremely important given that concurrent psychiatric illness is very prevalent among heroin users, and is often a key predictor of failure to improve from treatment (Coupland et al., 2014).

The most surprising moment of Hari’s talk, however, is when he argues that if addiction was strongly rooted in biology, people who are given painkillers post-surgery or after an injury would become addicted; “you will have noticed if your grandmother had a hip replacement, she didn’t come out as a junkie”. You can only conclude that Johann Hari is clearly unfamiliar with the ongoing prescription opioid epidemic which in 2014 claimed the lives of nearly 20,000 people in the United States alone (NIH, 2015). This does not reflect well on Hari’s evaluation of the scientific literature, or his three and a half year, 30,000-mile journey to better understand addiction.

Johan Hari’s work on addiction is a good example of the dangers of a little bit of knowledge. He makes unsubstantiated, sweeping statements without any critical appraisal of his own conclusions. It is dangerous to preach such a restrictive ideology about what is likely one of the world’s most multi-dimensional public health issues. Ignoring the biological aspect of addiction will only serve to limit the insight and understanding of those struggling with drug and alcohol abuse. What do you think?

 

References
Coupland, S., Fraser, R., Palaciox-Boix, J., Charney, D.A., Negrete, J.C., Gill, K.J. (2014). Illicit and Prescription Opiate Dependence: The Impact of Axis II Psychiatric Comorbidity on Detoxification Outcome. J Addict Res Ther. S10:008. doi: 10.4172/2155-6105.S10-008

Goldman D, Oroszi G, Ducci F. (2005). The genetics of addictions: uncovering the genes. Nat Rev Genet. 6(7):521-32.

Goldstein RZ, Volkow ND. (2011). Dysfunction of the prefrontal cortex in addiction: neuroimaging findings and clinical implications. Nat Rev Neurosci. 12(11):652-69. doi: 10.1038/nrn3119.

Hari, Johann. (2015). Everything you think you know about addiction is wrong. Retrieved from https://www.ted.com/talks/johann_hari_everything_you_think_you_know_about_addiction_is_wrong?language=en

Koob GF, Volkow ND. (2010). Neurocircuitry of addiction. Neuropsychopharmacology. 35(1):217-38. doi: 10.1038/npp.2009.110.

National Institute on Drug Abuse (NIH). (2015). Overdose Death Rates. Retrieved from http://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

Robins LN, Helzer JE, Hesselbrock M, Wish E. (2010). Vietnam veterans three years after Vietnam: how our study changed our view of heroin. Am J Addict. 19(3):203-11. doi: 10.1111/j.1521-391.2010.00046.x.

RateMyDrugDealer.Com

PILLZ

To my knowledge, ratemydrugdealer.com is not a website that actually exists yet (at least not on the indexed web). But there is a website where you can see if you’re getting a good deal on your prescription drugs.

streetrx.com

On StreetRX, you can get the latest street prices of all sorts of prescription meds, and you can even submit the details of your most recent purchase to see whether you got a good deal or not. Ah, the magic of the internet.

This particular website relies on user-submitted information, so the data should be taken with a grain of salt. We can’t really assume that everyone who purchases prescription drugs goes straight home to upload the pertinent information to the world-wide-web. If only it were that simple.

Nonetheless, it is an interesting tool for a few reasons.

Someone who might think that good quality is equated with high prices would be able to find some beneficial information here. This type of communication also allows people to buy drugs more safely by making sure they are getting good quality, clean products. There’s also the potential to analyze trends in prescription drug misuse, availability, street costs, etc. All of that data can then be used to help develop appropriate resources for people seeking help in those specific communities.

So – are you getting a good deal?

Naloxone Distribution for Canada’s Opioid Overdose Epidemic – Does it save lives?

Naloxone-Kit

Lots of people have been prescribed an opioid at some point in their lives – in fact, Canada is the second-largest per capita consumer of prescribed opioids [1]. And about 99 000 Canadians used opioids recreationally in 2012 [2] (although the real number is probably higher. If Statistics Canada called you up one day for a survey, would you honestly tell them you take OxyContin for fun from time to time?).

With these high rates of both prescribed and non-prescribed usage, both Canada and the United States have seen huge increases in opioid-related overdose deaths in the past few years. Part of the problem has to do with how many opioids are prescribed, because that means there are more opioids to go around to both those with and without a prescription. As Dowell, Kunins, & Farley (2013) put it:

From 1999 to 2010 the number of people in the United States dying annually from opioid analgesic–related overdoses quadrupled, from 4030 to 16 651. Patients’ predisposition to overdose could not have changed substantially in that time; what has changed substantially is their exposure to opioids. During this same time, the amount of opioids prescribed also quadrupled [3].

Similar prescription increases have been reported in Canada. While rates can differ a lot between provinces, high-dose opioid prescriptions went up by 23% between 2006 and 2011 [4]. Many people who die of opioid overdoses held an active prescription in the weeks preceding their deaths [5, 6], and geographical studies show that where more opioids are prescribed, more overdose deaths occur [7].

Prescribed drugs are a main source for those who use opioids recreationally: drug diversion occurs via theft, prescription forgery, and ‘Dr Shopping’ [8]. One American study found that in 2010, 60% of abused opioids were obtained directly or indirectly through a doctor’s prescription [9].  In Canada, a study of youth in grades 7-12 in Ontario found that 14% had used prescription opioids recreationally in the past year, and most (67%) of them had obtained the opioids from someone within the home; those students also ranked opioids as the fourth easiest drug to obtain (following alcohol, cigarettes, and cannabis) [10].  A Toronto study of opioid users entering detox treatment found that 37% obtained their drugs through doctor’s prescriptions, 26% from both a prescription and street dealings, and 21% from street sources only [11].

The links between physician-prescribing of opioids and increased overdoses has led many to argue that we need to start prescribing less and monitor more. Many voices, both within and outside the medical community, are suggesting we start limiting opioid prescriptions by basing prescriptions on physical functionality rather than reported pain levels and emphasizing alternative forms of chronic pain management, or that we increase opioid-safety by screening patients for high-risk of dependency or co-prescribing naloxone with opioids [12, 13].

In an effort to reduce the harm of this opioid explosion, organizations have started distributing naloxone to people who use these drugs. Naloxone is an antagonist that blocks the effects of opiates and reverses the effects of an overdose. Through these programs, naloxone vials are given to opioid users and their friends or family members so that they have it on hand in case of an overdose emergency. Think of it as the opioid-EpiPen: upon injection, it quickly bumps opioids out of their neural receptors for about 45 minutes, giving the person time to regain consciousness and access medical care. The earliest program started in Edmonton in 2005, and since then many other provinces and municipalities have launched their own.

However, opioid users who don’t hold a valid prescription are often hesitant to call 911 in the event of an overdose for fear of legal repercussions [14]. The institution of ‘Good Samaritan’ laws – which grant immunity from possession charges to people calling emergency services in the case of an overdose – could potentially quell these fears and help save lives [15].

If you use opioids, would you carry naloxone around in case of emergency? Would you call 911? The Government of Canada [16], the World Health Organization [17], and the United Nations [18] have argued for the expansion of such initiatives. But naloxone distribution could be more effective if it was bolstered by supportive changes to prescribing practices to curtail opioid availability, as well as changes to drug laws that would protect those who use them without a prescription from persecution in the event of an emergency.

 

References

[1] International Narcotics Control Board. (2013). Annual Report. Retrieved from: https://www.incb.org/incb/en/publications/annual-reports/annual-report.html

[2] The Canadian Tobacco, Alcohol and Drugs Survey (CTADS) (2013). Health Canada. Retrieved from: http://healthycanadians.gc.ca/science-research-sciences-recherches/data-donnees/ctads-ectad/summary-sommaire-2013-eng.php

[3] Dowell, Deborah, Kunins, Hillary V., & Farley, Thomas A. (2013). Opioid Analgesics—Risky Drugs, Not Risky Patients. JAMA, 309(21): 2219-2220. doi:10.1001/jama.2013.5794.

[4] Gomes, Tara (2014). Trends in high-dose opioid prescribing in Canada. Canadian Family Physician, 60(9): 826-832.

[5] Fischer, B., De Leo, J.A., Allard, C., Firestone-Cruz,M., Patra, J., & Rehm, J. (2009). Exploring drug sourcing among regular prescription opioid users in Canada: Data from Toronto and Victoria. Canadian Journal of Criminology and Criminal Justice, 51: 55–72.

[6] Gladstone, E.J., Smolina, K., Weymann, D., Rutherford, K., & Morgan, S.G. (2015). Geographic Variations in Prescription Opioid Dispensations and Deaths Among Women and Men in British Columbia, Canada. Medical Care, 53(11): 954-959.

[7] Fischer, B., Jones, W., & Rehm, J. (2013). High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005 – 2009. Pharmacoepidemiology and Drug Safety, 22(4): 438-442.

[8] El-Aneed, A., Alaghehbandan, R., Gladney, N.,Collins, K., MacDonald, D., & Fischer, B. (2009). Prescription drug abuse and methods of diversion: The potential role of a pharmacy network. Journal of Substance Use, 14: 75–83.

[9] Lembke A. (2012). Why doctors prescribe opioids to known opioid abusers. N Engl J Med., 367:1580-1581.

[10] Paglia-Boak, A., Adlaf, E.M., & Mann, R.E. (2011). Drug use among Ontario students, 1977-2011: Detailed OSDUHS findings (CAMH Research Document Series No. 32). Toronto, ON: Centre for Addiction and Mental Health.

 [11] Sproule, B., Brands, B., Li, S., & Catz-Biro, L. (2009). Changing patterns in opioid addiction. Canadian Family Physician, 55: 68–69. 

[12] Albert, S., Brason II, F.W., Sanford, C.K., Dasgupta, N., Graham, J., & Lovette, B. (2011). Project  Lazarus: Community-based overdose prevention in rural North Carolina. Pain Medicine, 12: S77–S85.

[13] Coffin, P., & Banta-Green, C. (2014).The dueling obligations of opioid stewardship. Annals of Internal Medicine, 160, 207–208.

[14] Banjo, O., Tzemis, D., Al-Qutub, D., Amlani, A., Kesselring, S., Buxton, J.A. (2014). A quantitative and qualitative evaluation of the British Columbia Take Home Naloxone program. CMAJ Open, 2(3): E153–E161.

[15] Davis, C., Webb, D., & Burris, S. (2013). Changing law from barrier to facilitator of opioid overdose prevention. Journal of Law, Medicine & Ethics, Spring, 33–36.

[16] Ambrose, R. (2014). Government response: Second report of the Standing Committee on Health, Government’s Role in Addressing Prescription Drug Abuse”. June 16. Retrieved from: http://www.parl.gc.ca/HousePublications/Publication.aspx?DocId=6676682&Language=E&Mod

[17] World Health Organization (2014). Community management of Opioid Overdose. Retrieved from: http://www.who.int/substance_abuse/publications/management_opioid_overdose/en/

[18] United Nations Commission on Narcotic Drugs. (2012). Resolution 55/7: promoting measures to prevent drug overdose, in particular opioid overdose. United Nations Economic and Social Council: Vienna, March 16.

 

Spice World

People of the world…don’t spice up your life. Seriously.

Why? Well, the chemical composition of Spice products is constantly changing to avoid regulation. So each package is different and – like a box of chocolates – you never know what you’re gonna get. Different compounds, different amounts, and different potencies. While this doesn’t completely answer the question, it gives us an idea why people can react so differently.

Here’s a closer look at the Spice World.

The two Americans dubbed the “Spice Girls” were so disoriented after smoking 1g of Banana Cream Nuke that they called 911 and were taken to the hospital [1]. But they had enjoyed using it in the past; what was so different about this blend?

The thing is you’re not going to know until you smoke it. Unless you have access to a mass spectrometer and are fluent in chemistry lingo.

Spice Boys, a recent Vice documentary about the legal high, paints a more disturbing picture. The homeless youth in the UK offer their opinions on the product and share horror stories of its use. One boy describes his pain and frustration related to his Spice dependence and sees no way out.

What do you think about Spice?

Spice Boys – Vice Documentary

[1] Schneir, A. B., Cullen, J., & Ly, B. T. (2011). “Spice” Girls: Synthetic Cannabinoid Intoxication. The Journal of Emergency Medicine, 40(3), 296-299. doi: http://dx.doi.org/10.1016/j.jemermed.2010.10.014

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