Friday, September 2, 2016

Synthetic Dialectic

Banning New Drugs: What is the Path Forward?

Eighteen months ago, in a post on novel synthetic drugs in the cannabinoid and cathinone families, I wrote that the new fake marijuana and fake Ecstasy were “very nearly the perfect overdose drugs.”  An MDMA-like stimulant called PMMA was implicated in a number of deaths in Florida, Chicago, and Ireland back then. PMMA, like many synthetic highs, is toxic at low doses, and takes a fair amount of time to take effect, thereby encouraging double dosing.

A year and a half later, what has changed? Today’s synthetic pharmaceuticals are not coming from secret underground laboratories, but rather from legitimate, existing Chinese pharmaceutical and chemical companies. In a commentary published in Addiction, Michael Evans-Brown and Roumen Sedefov of the European Monitoring Centre for Drugs and Drug Addiction in Lisbon present an unusually dystopian picture of new psychoactive substances fueling ever-increasing complexities in the world drug market. The authors refer to the situation as a textbook example “of what can happen when entrepreneurs exploit globalization and technology.” They write:

The market continues to grow. Consumers are no longer limited to psychonauts and clubbers, but include the vulnerable and marginalized, such as problem drug users and prisoners… manufacturers have replacement substances ready for sale even before a substance is controlled; the recipes for many thousands more are in the scientific and patent literature ripe for the picking.

The authors provide a grisly list of recent synthetic cannabinoid incidents: In Russia, products containing MDMB-FUBINACA were implicated in more than 600 poisonings and 15 deaths in two weeks in 2014. The same drug was linked to as many as 700 suspected adverse events in a single month in Mississippi in 2015, and in Europe, more than 200 people were hospitalized in Poland last year after smoking something called Mocarz. The causes of these mass poisonings, according to the authors include “high potency of synthetic cannabinoids, producers guess[ing] how much substance to use, and poor manufacturing processes leading to uneven distribution of the substance in the product—manufacturing flaws that are a recipe for disaster.” When users have no idea—not even a reasonable guess—at what chemical they are actually using, regulation and public health initiatives become exceedingly difficult.

In a bold and, according to some drug policy analysts, deeply misguided move, UK officials, tired of the drugs “arms race,” and the cat-and-mouse game of enforcement, made an attempt to do away with synthetic drugs in one monumental swipe, passing the Psychoactive Substances Act. In its earlier incarnations, the measure banned just about everything, including foods with caffeine and alcohol. Having straightened that out somewhat, the United Kingdom now faces a synthetic highs crackdown that drug charity DrugWise said will only push the market underground, “from the shops to the street.” If you think that’s a major improvement, raise your hand.

Another drug policy group, Transform, believes that the ban was aimed rather cynically at “visible sales,” in an effort to demonstrate some political PR success stories. Jane Slater, head of operations for Transform, told Huffington Post UK : “Far from making our communities safer the ban has resulted in increased health harms and criminality.”

“Laws just push forward the list of compounds,” according to Dr. Duccio Papanti, a psychiatrist at the University of Trieste who studies the new drugs. “The market is very chaotic, bulk purchasing of pure compounds are cheaply available from China, India, Hong-Kong, but small labs are rising in Western Countries, too.”

A spokesman for the UK Home Secretary pushed back, saying that “These drugs are not legal, they are not safe and we will not allow them to be sold in this country.”

Still, this negative spiral is not steady or inevitable. “Given how fashions and societies change," the authors note, "it is true that we do not know what the fate will be for many substances [remember that Quaaludes, not MDMA were the original disco biscuits]: but it is also fair to say that suppliers are not looking for the next cannabis, MDMA, heroin or diazepam; they simply make substances that can mimic their effects and that can be produced, transported and sold freely.”

It continues. On September 1, the Irish Examiner  reported that a related cannabis drug, MDMB-CHMICA, often peddled as Black Mamba, has been linked to more than two dozen death in Europe. The European Monitoring Centre for Drugs and Drug Addiction confirmed 25 cases, involving comas, heart problems or seizures. “The high potency of MDMB-CHMICA and the highly variable amounts of the substances in ‘legal high’ products constitute a high risk of acute toxicity.”

In 1975, underground chemist Alexander Shulgin wrote that the variety of drugs capable of causing abuse problems was expanding rapidly. He did not envision an adroit way out of that spiral: “As these materials become better defined and their use better controlled, they will be replaced with substitute compounds, which will provide society with new, unknown, and unmanageable substances.” Managing these new risks effectively will require new and almost unimaginably sophisticated early warning systems to protect the public from new toxic offerings.

Monday, August 1, 2016

The Poetry of “Irresistible Descent”

 John Berryman in the Penal Colony

 “Will power is nothing. Morals is nothing. Lord, this is illness.”
—John Berryman, 1971

A year before he committed suicide by jumping off a Minneapolis bridge in 1972, Pulitzer Prize-winning poet John Berryman had been in alcohol rehab three times, and had published a rambling, curious, unfinished book about his treatment experiences. Recovery is a time capsule. If you think we have little to offer addicts by way of treatment these days, consider the picture in the 60s and 70s. In Recovery, treatment consists almost entirely of Freudian group analysis, and while there is regular talk of alcoholism as a disease, AA style, there is no evidence that it was actually dealt with in this way, after detoxification.

Best known for “Dream Songs,” Berryman taught at the University of Minnesota, and was known as a dedicated if irascible professor. Scientist Alan Severence, Berryman’s stand-in persona in the book, comes into rehab hard and recalcitrant, despite his previous failures: “Screw all these humorless bastards sitting around congratulating themselves on being sober, what’s so wonderful about being sober? Great Christ, most of the world is sober, and look at it!” And he is suffering from “the even deeper delusion that my science and art depended on my drinking, or at least were connected with it, could not be attacked directly. Too far down.”

Berryman was a difficult man, and knew it. He quotes F. Scott Fitzgerald: “When drunk, I make them pay and pay and pay and pay.”

Alcoholics, writes Berryman, are “rigid, childish, intolerant, programmatic. They have to live furtive lives. Your only chance is to come out in the open.” Berryman catches the flavor of group interaction after too many hours, too much frustration, and too much craving. One inpatient lashes out: “You’re lying when you say you do not do anything about your anger. You get bombed. It is called medicating the feelings, pal. Every inappropriate drinker does it. Cause and effect. Visible to a child. Not visible to you.”

Berryman was a shrewd observer, a singular writer, and, after all, a poet. He is extraordinary on the subject of alcoholic dissociation: “I found myself wondering whether I would turn off right towards the University and the bus home or whether I would just continue right on to the Circle and up right one block to the main bar I use there, and have a few. Wondering. My whole fate depending on pure chance…. as if one were not even one’s own actor but only a spectator.”

Berryman puts it all together in a horrific capsule description of the “irresistible descent, for the person incomprehensibly determined.”

Relief drinking occasional then constant, increase in alcohol tolerance, first blackouts, surreptitious drinking, growing dependence, urgency of FIRST drinks, guilt spreading, unable to bear discussion of the problem, blackout crescendo, failure of ability to stop along with others (the evening really begins after you leave the party)… grandiose and aggressive behavior, remorse without respite, controls fail, resolutions fail, decline of other interests, avoidance of wife and friends and colleagues, work troubles, irrational resentments, inability to eat, erosion of the ordinary will, tremor and sweating… injuries, moral deterioration, impaired and delusional thinking, low bars and witless cronies….

Berryman had no illusions about his failed attempt to hide behind the mask of a social drinker: “It seems to be loss of control. Unpredictability. That’s all. A social drinker knows when he can stop. Also, in a general way, his life-style does not arrange itself around the chemical, as ours does. For instance, he does not go on the wagon…”

In the end, he was "pleading the universal case of hope for abnormal drinkers, for all despairing and deluded sufferers fighting for their sanity in a world not much less insane itself and similarly half-bent on self-destruction…”

As the head nurse in the facility tells the group: “You are all suffering from the lack of self-confidence… often so powerful that it leads to consideration of suicide, a plan which if adopted will leave you really invulnerable, quite safe at last.”

And as Saul Bellow wrote in the introduction to Recovery: “At last there was no more. Reinforcements failed to arrive. Forces were not joined. The cycle of resolution, reform and relapse had become a bad joke which could not continue.” Berryman agreed. Toward the end, he wrote: “I certainly don’t think I’ll last much longer.”

“There’s hope until you’re dead,” a woman tells him during his final stay in rehab. Sadly, that hope ended a few months later.

[First published July 21, 2012]

Monday, June 20, 2016

Monday, June 13, 2016

Nicotine Genes: Evidence From a 40-Year Study

 How adolescent risk becomes grownup addiction.

 Pediatricians have often remarked upon it: Give one adolescent his first cigarette, and he will cough and choke and swear never to try another one. Give a cigarette to a different young person, and she is off to the races, becoming a heavily dependent smoker, often for the rest of her life. We have strong evidence that this difference in reaction to nicotine is, at least in part, a genetic phenomenon.

But so what? Is there any practical use to which such knowledge can be put? As it turns out, the answer may be yes. People with the appropriate gene variations on chromosomes 15 and 19 move very quickly from the first cigarette to heavy use of 20 or more cigarettes per day, and have more difficulty quitting, according to a new report published in JAMA Psychiatry in 2013. From a public health point of view, these findings add a strong genetic rationale to early smoking prevention efforts— especially programs that attempt to “disrupt the developmental progression of smoking behavior” by means of higher prices and aggressive enforcement of age restrictions on smoking.

What the researchers found were small but identifiable differences that separated people with these genetic variations from other smokers. The gene clusters in question “provide information about smoking risks that cannot be ascertained from a family history, including information about risk for cessation failure,” according to authors Daniel W. Belsky, Avshalom Caspi, and colleagues at the University of North Carolina and Duke University.

The group looked at three prominent genome-wide association studies of adult smoking to see if the results could be applied to “the developmental progression of smoking behavior.” They used the data from the genome work to analyze the results of a 38-year prospective study of 1,037 New Zealanders, known as the Dunedin Study. A total of 405 cohort members in this study ended up as daily smokers, and only 20% of the daily smokers ever achieved cessation, defined as a year or more of continual abstinence.

The researchers came up with a multilocus genetic risk score (GRS) based on single-nucleotide polymorphisms associated with smoking behaviors. Previous meta-analyses had identified several suspects, specifically a region of chromosome 15 containing the CHRNA5-CHRNA3-CHRNB4 gene cluster, and a region of chromosome 19 containing the gene CYP2A6. These two clusters were already strong candidate genes for the development of smoking behaviors. For purpose of the study, the GRS was calculated by adding up the alleles associated with higher smoking quantity. The genetic risk score did not pertain to smoking initiation, but rather to the number of cigarette smoked per day.

When the researchers applied these genetic findings to the Dunedin population cohort, representing ages 11 to 38, they found that an unfortunate combination of gene types seemed to be pushing some smokers toward heavy smoking at an early age. Individuals with a high GRS score “progressed more rapidly to heavy smoking and nicotine dependence, were more likely to become persistent heavy smokers and persistently nicotine dependent, and had more difficulty quitting,” according to the study. However, these effects took hold only when young smokers “progressed rapidly from smoking initiation to heavy smoking during adolescence.” The variations found on chromosomes 15 and 19 influence adult smoking “through a pathway mediated by adolescent progression from smoking initiation to heavy smoking.”

Curiously, the group of people who had the lowest Genetic Risk Scores were not people who had never smoked, but rather people who smoked casually and occasionally—the legendary “chippers,” who can take or leave cigarettes, sometimes have one late at night, or a couple at parties, without ever falling victim to nicotine addiction. These “light but persistent smokers” were accounted for “with the theory that the genetic risks captured in our score influence response to nicotine, not the propensity to initiate smoking.”

Naturally, the study has limitations. Everyone in the Dunedin Study was of European descent, and the life histories ended at age 38. Nor did the study take smoking bans or different ages into account. The study cries out for replication, and hopefully that won’t be long in coming.

Could information of this sort be used to identify high-risk young people for targeted prevention programs? That is the implied promise of such research, but no, probably not. The gene associations are not so dramatic as to cause youngsters with the “bad” alleles to inevitably become chain smokers, nor do the right set of genes confer protection against smoking. It’s not that simple. However, the study is definitely one more reason to push aggressive smoking prevention efforts aimed at adolescents.

Belsky D.W.  Polygenic Risk and the Developmental Progression to Heavy, Persistent Smoking and Nicotine DependenceEvidence From a 4-Decade Longitudinal StudyDevelopmental Progression of Smoking Behavior, JAMA Psychiatry,   1. DOI: 10.1001/jamapsychiatry.2013.736

Wednesday, June 8, 2016

From Failure to Enthusiasm

Guest Post

By Andy

"Success is walking from failure to failure with no loss of enthusiasm." —Winston Churchill

One of the reasons I love this quote, is because for many of us, being able to keep our enthusiasm up in the midst of trying times can be very difficult to achieve. But once you figure out how to never lose it, no matter how hard life can get, it will mark the difference between giving up and succeeding. I love this quote and remind myself every time that sobriety success is shaped by my attitude. In this post I’m going to take you through my personal sobriety journey.

The Addict/Alcoholic

When I was 4 years old my parents made the life changing decision of moving from Colombia to California. It was 1986 and the situation in my country was scary and very violent. Upon arrival in California my parents took on many jobs to be able to provide for me and my siblings; they worked really hard to make sure we would have a life full of opportunities.

The great thing about latinos is that culturally not only are we very hard working people, but we are also very happy people who love to party. And of course, no Colombian party is ever complete without that anise-flavored drink called Aguardiente. Not that all Colombian’s are drunks, it’s just simply something they enjoy once in awhile, when there’s a good excuse to celebrate.
The first time I got drunk was at a family friend’s house party when I was nine years old. I was always a pretty mischievous kid, therefore at the party my cousin and I played a game to see who could steal more shots of aguardiente without getting caught.

After a few shots I was feeling very different inside. I felt comfortable, more secure, I danced salsa with my sister and all my cousins, I felt great. From that night on I drank every time I had the chance.
At 15 a friend introduced me to marijuana. Although today teen drug use is declining, back when I was a teenager the statistic was increasing and at 19 I attended a party and some guys introduced me to meth and so began the downward spiral. At 23 I found myself incarcerated in Idaho on drug related charges for two years.

You might be wondering why I left so many parts of the story untold. Well, I’m not writing this to reminisce on war stories, being eight years sober now I believe myself to be a bit wiser and truth be told, a little tired of recounting my crazy times. Jail in Idaho was the starting point of my recovery, and that is the part of THIS story I really want share.

AA and NA

When you are in prison, any activity that can take you out of your cell is welcomed with open arms. So when I was told that I could attend the Alcoholics Anonymous meetings I did not hesitate. At the time I was not interested in recovery, in fact, I thought I didn't have a drinking problem or substance abuse problem. I just needed to do something else than read in bed. So I attended meetings without participating. It took three months of going to these meetings to realize that I might have a slight drinking and drug problem.

One day, a fellow inmate told the story of how he hit rock bottom. He was a high level accountant abusing drugs in order to deal with the insane amount of work and stress at his job, until one day, having suicidal thoughts, he got drunk and drove his car into a local store. He lost his job, his wife filed for divorce, his family had lost hope (this wasn’t his first run in with the law). He shared that apart from coming to terms with his drug and alcohol problems he had also realized that he also had an anger management problem, he concluded that “rage spawns from anger, anger spawns from hurt, hurt spawns from getting your feelings hurt.”

Like I said before, I thought I didn't have a problem. I was convinced that I was fine, that I wasn’t hurting anyone. But thanks to that inmate sharing his story and his realization my eyes were opened: I had hurt the only person I had to live with for the rest of my life and the damage I had done to myself needed to be repaired. I had a drinking problem, a drug problem, a personality problem...a life problem.

The Workaholic

Prison was everything but easy, but attending the AA and NA meetings and the friendships I built helped me get through it. Once I was released I had a new sense of responsibility, I knew I needed to find a job, and be able to provide for myself. But it wasn't easy. Having a criminal record made it a challenge to find a good job, so I struggled for months. And when I finally found one, I was unmotivated and feeling trapped in a routine. Despite attending my AA and NA meetings on a regular basis, I relapsed. I lost my job and life seemed unbearable, hence my voluntary check in to a rehab center in Idaho.

After 3 months in rehab I moved back to California where I landed a job selling knock-off cologne. Being closer to my family helped me immensely, therefore my motivation was higher than ever. I would wake up at 5:00 am to pick-up my co-workers and go to gas stations, shopping center parking lots, flea markets, etc. to sell perfume out of the trunk of my car. After a few months I had become very good at selling. I had learned how to approach strangers, how to pitch my product, make people feel comfortable and how to overcome rejection. The job was purely commission based, thus if I didn’t sell, I didn’t make money. There is a great feeling about making cash on a sale that I cannot really describe. It is a feeling of accomplishment, it is a feeling that I wanted to replicate time and time again. I was determined to keep working harder and harder.

Months went by and next thing I knew I was training more than 10 people to sell perfumes and other beauty products on the street. I had my own office, had ads running in the paper, had a secretary taking calls, etc. In that year I had lost ten pounds, I had zero friends, and I barely saw my family.

After a long conversation with a friend he presented me with a book by Jeffery Combs called Psychologically Unemployable (Jeffery is also a recovering addict). One of the most important things said is that you should never confuse obsession with passion. After reading it and studying it for a few weeks, I understood that I had simply traded drugs and alcohol for work. It was an addiction and it wasn't any better. I was getting physically sick and emotionally unstable from the pressure I was putting on myself.

The Entrepreneur

I sold my perfume business and moved into my parents house. It was really important in my road to recovery to have their support. After a month I got a job at Target, so I could help my parents pay the bills and have some sort of income. I had no passion for that job whatsoever, and I was completely unmotivated in that point of my life. I couldn't find balance between success and a healthy, happy life. Being afraid of relapsing I started attending weekly AA/NA meetings. I acquired a really good sponsor that I am very grateful for. He gave me the task of taking a class at the local community college.

At the time I was not very happy to do the task. I felt old and I thought there was no point in taking a measly course. I just wanted to go to work, do my job and pay my bills, that was it. Nevertheless, I forced myself to take a class. The class I took was called Introduction to Website Development (HTML). I liked computers and websites, so I thought, why not give it a shot?

You should have seen my bedroom after three months in the class. I had stacks of books and papers about HTML and website design. I found myself at the computer for hours, coding, creating, learning. Finally, one day I thought to myself that it would be great if I could make a business out of my new acquired skill.

Nine years later I co-own a successful digital marketing agency. I have a great team that I feel are like my family, in fact, my brother is part of it. We are based in Medellin, Colombia, which means my life has taken a 180 degree turn. 30 years ago my parents left Colombia to give my siblings and I a better life, now I am back with that better life.

I still go to meeting and try to keep in touch with some of the good friends I made on my way to recovery. We always give each other support during rough times. Being sober has become a part of my life now. My attitude defines me and I do not let anything take control of my emotions, it only gets easier with time. I have learned to attend dinner parties and skip the wine; to dance with my colombian friends and kindly decline those beers and still enjoy myself. In regards to my business, I didn't let myself get lost while pursuing success. I have learned that balance is what makes you successful. Being able to work hard for months enjoying what you do, but also taking a weekend off to recharge has proven to be a critical part of my work-life balance. I feel very fortunate because I went out and found something I was passionate about, put my skills and knowledge to work and built a business. Sobriety, just like building a business, does not happen overnight, one has to commit to it and work hard.

It’s Not All About You

When you are in the process of recovering, every single thing you do to maintain your sobriety seems to be about you. Every one of the 12 steps you complete, every single task or piece of homework your sponsor gives you, every book or article you read is all about you and your recovery. But after a while you realize, there's a bigger picture. And going back to that Winston Churchill quote, "Success is walking from failure to failure with no loss of enthusiasm," learning that failing is just a part of the process. Behind the most successful people are years of failure, even if it's on their way to sobriety or on their way to being a successful entrepreneur. The issue is not failing, since we all will go through it, it's to never lose enthusiasm. Good luck and thank you for reading my story.

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