Self-Exclusion, Unabridged
- posted by Jim Leitzel @ 4:03 PM

Vice Squad has something of a fixation with self-exclusion, those programs whereby problem gamblers (or people who fear that they might become problem gamblers) can volunteer to be barred from access to casinos. I have a short article in the Winter, 2008 Milken Institute Review on self-exclusion, arguing that parallel programs should be part of the mix when the currently illegal drugs are legalised. That article was a by-product of a longer paper that I let languish in an unfinished state. But now I have finished it, after a fashion, and posted it on SSRN, free for the downloading. The longer version isn't really all that much longer -- it's 20 pages. If that is too daunting, here's the rather tepid abstract:

Gambling jurisdictions around the world have adopted self-exclusion programs in which gamblers can voluntarily agree to be barred from further gambling. The popularity of self-exclusion stems from its aid in combating problem or pathological gambling, along with its non-coercive nature. To bolster the self-control of problem gamblers, exclusion programs combine physical inaccessibility and reward diminution: bettors are supposed to remain (or be kept) away from gambling sites, and the gambling winnings of excluded bettors can be confiscated. Other elements of program design that can affect the workings of a self-exclusion program include the duration of an exclusion, its revocability, and the breadth of gambling activities to which the prohibition applies. Self-exclusion or broader user licensing programs can be helpful for control of vices other than gambling. I argue that self-exclusion should form an integral component of drug regulatory frameworks that offer substantial improvements over drug prohibition.

The title of the paper is tepid too: "Self-Exclusion". But the ideas, well, they are revolutionary (in a tepid sort of way).

Update: There were some annoying ersatz characters at the beginning of the abstract on the SSRN page, so I just made a bid to remove them. We'll see if this works...

Labels: addiction, drugs, gambling, self-exclusion

 
Newish Habits in the New York Times
- posted by Jim Leitzel @ 11:54 PM

Today's Sunday Style section contains two front page articles on forming bad relationships. One is about forming a bad relationship with both food and alcohol; the second is about forming a bad relationship with the wired and wireless world.

The bad relationship with food and alcohol is too little of one and too much of the other: an eating disorder co-existing with large alcohol consumption. These two disorders can be complementary: "Many bulimics who drink use alcohol to vomit, experts on eating disorders say, because liquid is easier to purge. They also tend to vomit because they often drink on empty stomachs." And while abstinence can be an effective strategy for overcoming substance abuse, it is of no avail in combating an eating disorder.

A weekly day (more or less) of abstinence is the approach taken by the author of the second article, in dealing with his fixation on connectivity. It took a while, but he came to embrace his "secular Sabbath": "It’s been more than six months, and while I’m hardly a new man — no one has yet called me mellow — this achievement is unlike any other in my life. And nothing bad has happened while I’ve been offline; the e-mail and phone messages, RSS feeds, are all there waiting for me when I return to them."

For addictions as "bad relationships," see Peter McWilliams's Ain't Nobody's Business If You Do.

Labels: addiction, alcohol, internet

 
Regulating Vice: Chapter 2, "Addiction: Rational and Otherwise" (part V)
- posted by Jim Leitzel @ 8:23 PM

OK, I simply refuse to have any more posts -- after this one -- about Chapter 2 of surprise bestseller Regulating Vice. Following a look at comparative addictiveness -- itself a slightly misguided concept, given that the addictiveness of a drug or activity varies among, well, everything: people, time, place, manner, and so on -- Chapter 2 notes how addiction is not, and should not be, an excuse for committing a non-victimless crime. (While behaviors such as simple possession should not be illegal in any case, if they are illegal, there's a decent argument that addicts should not be held responsible for breaking a drug possession law.) Then Chapter 2 offers a summary of a sort, suggesting that: (1) there is a case -- not airtight, but a significant case -- that some addictive-type behavior lies outside the bounds of standard notions of rationality or even dynamic inconsistency; (2) self-control problems and addiction lie on a continuum, and even in a world without addiction, there might be a role for public policy to help (adults) manage their self-control problems; and (3) that despite all the discussion of addiction and self-control when, for instance, drug policy is being discussed, actual public policies (and even private responses) to vice do not seem to be closely tied to changes in our scientific understanding of addiction. Following the conclusion is the first of many "Vice Verdicts" sections; this one looks at four court cases in which addiction and responsibility for behavior were central concerns.

The idea behind the opening chapters of Regulating Vice, just to recap, is to examine what we can learn from John Stuart Mill's harm principle, and then to look closely at addiction and self-control, to see if our 21st century understanding of addiction provides any (further?) reason to accept or amend or reject the harm principle. This is the point at which Chapter 3 picks up. Whew.

Regulating Vice Posts Roundup:
(1) Announcement
(2) Introduction (part I)
(3) Introduction (part II)
(4) Introduction (part III)
(5) Erratum, Page 2!!
(6) Chapter 1, The Harm Principle (part I)
(7) Chapter 1, The Harm Principle (part II)
(8) GMU Talk (part I)
(9) GMU Talk (part II)
(10) Chapter 2, Addiction (part I)
(11) Chapter 2, Addiction (part II)
(12) Chapter 2, Addiction (part III)
(13) Chapter 2, Addiction (part IV)

Labels: addiction, Mill, Regulating Vice

 
US Military Gambling
- posted by Jim Leitzel @ 10:17 PM

Stars and Stripes has been investigating gambling on US military bases abroad. It turns out that in places like South Korea and Germany, there are slot machines located on-base:

The U.S. Army and Air Force generated more than $83.6 million in revenue via 1,191 slot machines in South Korea in fiscal 2007, according to data provided by the Army’s Family MWR [Morale, Welfare and Recreation] Command and the Air Force Personnel Center.

The Army, which also runs the machines on Navy facilities in South Korea, earned the lion’s share: about $73.5 million with 927 machines. As a comparison, the Army’s 1,550 machines in Europe, including machines the service runs on Air Force and Navy installations, brought in $38.5 million during the same time period.

South Koreans are not supposed to gamble on US military bases but it appears that some of that revenue did come from officially-ineligible Koreans. Some of the revenue comes from military personnel or family members who gamble pathologically.

At least one congressman wants to put an end to on-base gambling. I have some sympathy for that point of view, but I also have another suggestion. Require every person who wants to gamble at an on-base facility to have pre-committed to a daily, weekly, and monthly (and possibly annual) total bet limit. Rig the slots so that they only operate when the player inserts his card into the relevant card reader, so that the previously recorded betting limits can be enforced electronically. (That is, the betting limit cards are like "frequent player cards" that casinos use to track betting and to target freebies.) A gambler who is afraid of his own susceptibilities to addiction can then choose low limits, or even totally self-exclude by not acquiring a card with limits in the first place. This voluntary system is not foolproof, but it is helpful. If this suggestion is seen as too tepid, then the limits can be chosen by the military.

Back in 2005, the New York Times explored some of the problems associated with gambling on US military bases abroad.

Labels: addiction, gambling, Korea, military, self-exclusion, slot machine

 
Regulating Vice: Chapter 2, "Addiction: Rational and Otherwise" (part IV)
- posted by Jim Leitzel @ 6:07 PM

When last we left off in our tortuous journey through the surprise bestseller Regulating Vice, we were nearing the end of Chapter 2's exploration of addiction. There's a short section entitled "Comparative Addictiveness," that explores such claims as "heroin is more addictive than alcohol." Is it? Probably depends on who the consumer is, the mode of ingestion, the social setting: Zinberg's Drug, Set, and Setting, yet again. (Comparative addictiveness even depends on the regulatory structure facing the various vices.) Nevertheless, ice cream is probably more addictive than spinach, and there are methods of trying to formalize such commonsense notions. One method is to ask what percentage of casual users of a drug go on to become habitual users; a second is to try to gauge the difficulty of quitting an acquired habit.

It is probably the case that for formulating desirable policy, dangerousness is more important than addictiveness. Most people think of caffeine as rather addictive, but not as particularly harmful. What is most striking about typical rankings of dangerousness is how poorly they map onto existing public policy, however. In particular, marijuana and many hallucinogens do not appear to be all that dangerous, but they face prohibitions. Alcohol and tobacco are more dangerous, and quite legal.

Labels: addiction, Regulating Vice

 
Pinball
- posted by Jim Leitzel @ 10:52 PM

Today's trip back to cold Chicago on Southwest Airlines provided an opportunity to read up on the Pinball Hall of Fame in Las Vegas in Southwest's Spirit Magazine. The fine linked article mentions that pinball machines were illegal in New York City well into the 1970s, until a live demonstration by a pinball maestro in an NYC courtroom led to the recognition of pinball as a game of skill, and hence, legalization. Pinball machine production peaked in the early 1990s, with some 100,000 machines being produced per year. Now the sole remaining producer makes about 10,000 machines annually, and many of those go to private residences, as public locations have turned away from pinball towards video games.

Beyond the hint in the information about the New York City ban, the article explicitly notes that early pinball machines often involved gambling. Indeed, the relationship between pinball and gambling profoundly affected the design of pinball machines. (Here's an article with lots of apposite info that I draw upon below.) Pinball machines have come in many flavours over the years, including some that were mainly for gambling purposes, some that could easily be adapted for gambling, and others that did not directly facilitate gambling, but could be used for that purpose via side bets by competing players or high score monetary bonuses from the till of the host establishment. The institution of free games for high scores was motivated in part to reward pinball players without violating anti-gambling statutes that rendered cash payouts illegal. Possibilities to win extra balls were developed to avoid anti-gambling laws that extended to the provision of free games. And flippers, virtually a defining feature of pinball machines for more than 50 years, were helpful in promoting the idea that pinball is a game of skill, not chance, and hence exempt from anti-gambling laws.

Of course, pinball has an addictive quality that might surface even without monetary stakes. The author of the Spirit Magazine article notes that after his girlfriend dumped him, he had a fling with a pinball machine -- one that was obsessive, but does not seem to be entirely negative: "I tragically played that machine for hours and hours, week after week, mourning my loss and perfecting my skill. I became…not to brag or anything, but I became truly great."

Labels: addiction, gambling

 
Regulating Vice: Chapter 2, "Addiction: Rational and Otherwise" (part III)
- posted by Jim Leitzel @ 10:44 PM

When we last checked in with Regulating Vice, we saw how time inconsistent preferences might recommend (public and private) policies that would differ from those that would be appropriate for rational, time-consistent addicts. Chapter 2 continues by looking at further departures from the "standard" rationality story, i.e., where addictive choices are made outside of the usual cognitive framework, or are the result of a diseased mind. One piece of evidence that addictive-type choices are not simply reflecting time inconsistency is that cues in the environment can bring on intense cravings for addicts -- though there is little reason to think that these cues alter discount rates generally, since they only seem to affect choices made in relation to the addictive good or substance. When a smoker has a beer in a bar in night, he might crave a cigarette, but he doesn't necessarily want to lower his savings in favor of more present consumption.

The disease view of addiction has much to recommend it -- at least more than I suggested in an early Vice Squad attempt to come to grips with it. The basic idea is that our brains evolved "reward mechanisms" that give us pleasure when we engage in activities that are (or at least were) helpful for propagating our genes. These mechanisms -- think about those pathways from Monday's post -- have a biochemical substrate, of course. Along comes some chemical like cocaine or morphine that acts as a key that unlocks the pleasure pathway, though these chemicals were not part of the environment in which the pleasure pathways evolved. People try morphine, they really enjoy it, so naturally they try it again -- and again, and again. The brain, awash with external opiates, cuts back on its own endogenous production of pleasure chemicals (endorphins, or endogenous morphines), so now, without the external morphine, the addict is less happy than she was to begin with. Eventually, she needs the morphine not to make herself happy, but to prevent her from being miserable.

Regulating Vice Posts Roundup:
(1) Announcement
(2) Introduction (part I)
(3) Introduction (part II)
(4) Introduction (part III)
(5) Erratum, Page 2!!
(6) Chapter 1, The Harm Principle (part I)
(7) Chapter 1, The Harm Principle (part II)
(8) GMU Talk (part I)
(9) GMU Talk (part II)
(10) Chapter 2, Addiction (part I)
(11) Chapter 2, Addiction (part II)

Labels: addiction, Regulating Vice

 
The 5-fold Pathway to Addiction
- posted by Jim Leitzel @ 9:35 PM

The Economist reports this week on a recent article in Computational Biology, one of the journals associated with the Public Library of Science -- hence the article is freely available on the web. The article set out to find the neuro-molecular pathways that are common to alcohol, nicotine, cocaine, and opiate addiction. The authors took a meta-analytic approach, combing the existing research database for articles reflecting upon the issue -- and they came up with something new. They identified five neuro-pathways that seem to be common to the four types of addictive substances. Two of these pathways were not seriously under consideration in the past, if I understand correctly, for being involved with addiction. The authors then went one step further, modeling the interactions within these five pathways. The model suggested various types of positive feedback, which would seem to be consistent with the loss of control associated with addiction. (Though perhaps some sort of chemical reversal of this mechanism could lead to a quick recovery, my untutored, neuro-naive self asks?) Is their diagram of the feedback mechanisms one of the keys to understanding addiction?

The methodology in this article is striking. One venerable view of economic productivity associates it with making stuff, with production. Often merchant behavior, trading activity, is seen as somehow inferior or disreputable, even when production is held in high regard. Economists tend to a hold a different view, however -- a good is valuable only if it is at the right place at the right time, so merchants are as productive as they are indispensable: manufacturing without effective distribution is not productive. The analogy I see with the Computational Biology paper is that research, especially neuroscientific research, might be thought of as consisting of running experiments. But unless someone sifts through those experiments to extract and combine the information, the experiments themselves might not produce usable knowledge. The Economist article concludes with the following observation:

And this study also shows that the old cry “more research is necessary” is not always true. Sometimes all you need to do is look at what you already have in a different way.

I would have put it slightly differently: "More research is necessary" remains true, but research can consist of such meta-analyses, too. (Maybe The Economist was trying to avoid rhyming?)

Labels: addiction

 
Regulating Vice: Chapter 2, "Addiction: Rational and Otherwise" (part II)
- posted by Jim Leitzel @ 9:52 AM

My project of providing a running summary of Regulating Vice came a cropper in early December, but is herewith revived. We left off after characterising rational addiction. Chapter 2 continues with a look at time inconsistency, which we first blogged about during Vice Squad's inaugural week. The basic idea is that people tend to be more impatient with respect to choices concerning the here and now and near future, than they are about choices over alternatives for the more-distant future. So folks have a sort of prudent, patient, long-view Dr. Jekyll side, and an imprudent, impatient, live-for-the-moment Mr. Hyde side. Mr. Hyde decides how much to drink today, and Dr. Jekyll finds the choices made on his behalf by Mr. Hyde to involve excessive drinking.

There is nothing obviously "irrational" about time inconsistency -- that is, there is nothing inherent in rational choice which requires dynamically consistent choices. But private and public vice policies appropriate for a rational, time inconsistent person might differ from those policies appropriate for a dynamically consistent rational consumer. (Similarly, policies appropriate for irrational consumers also might differ from those of rational, time consistent consumers.) Dr. Jekyll's might look for some commitment device that will keep Mr. Hyde's from drinking too much, and public policies such as taxes or buyer licenses can help Jekyll gain the upper hand. [We could be evenhanded, and say that the public has no more reason to side with Jekyll than with Hyde, but vice tends to be associated with excess. It seems to be more common (or more painful) to regret one too many drinks than one too few.] The costs that Hyde imposes upon a non-consenting Jekyll have many of the marks of economic externalities -- the difference being that rather than Hyde and Jekyll being two physically separate people, they are different incarnations of the same person. In an analogy with "externalities," these costs are called "internalities." And if you accept the externality-internality analogy, then a harm to Jekyll is a type of "harm to others," and hence social coercion of Hyde does not violate John Stuart Mill's harm principle.


Regulating Vice Posts Roundup:
(1) Announcement
(2) Introduction (part I)
(3) Introduction (part II)
(4) Introduction (part III)
(5) Erratum, Page 2!!
(6) Chapter 1, The Harm Principle (part I)
(7) Chapter 1, The Harm Principle (part II)
(8) GMU Talk (part I)
(9) GMU Talk (part II)
(10) Chapter 2, Addiction (part I)

Labels: addiction, dynamic inconsistency, Mill, Regulating Vice

 
More Reaction to Sun's Light on Buprenorphine
- posted by Jim Leitzel @ 9:51 AM

A few days ago Vice Squad mentioned the Baltimore Sun's investigative reporting on buprenorphine, an opioid commonly used to treat heroin addiction (which is rife in Baltimore). One part of the series concerns France, where buprenorphine is widely prescribed to addicts. This part of the series, like other parts, has attracted critical commentary from the treatment community. Today's letter (scroll down a bit) from two French addiction workers expresses dismay about both the story and the Sun's Public Editor's tepid endorsement. Their letter points out some information that did not appear in the Sun story:

Opioid substitution treatment now covers about 70 percent of drug users in France, and most receive buprenorphine. This change in policy has achieved:

• An 80 percent reduction in heroin overdose deaths (from 500 to 100 per
year).

• A 75 percent reduction in HIV prevalence among drug users (from 40
percent in 1995 to 11 percent in 2004).

• A 75 percent reduction in drug-related crimes.

Causality is always tricky, but it does seem that buprenorphine has been a very successful treatment for heroin addicts in France. Incidentally, much of the Sun's concern about buprenorphine "abuse" draws upon heroin addicts who purchase street bupe to stave off withdrawal when they cannot afford or access heroin. This use may not be undertaken under a physician's care, but it is far from clear that it constitutes "abuse" in the usual sense. (Though in the drug policy world, the abuse of "abuse" is common.)

Labels: addiction, buprenorphine, France

 
Regulating Vice: Chapter 2, "Addiction: Rational and Otherwise"
- posted by Jim Leitzel @ 9:59 PM

Chapter 2 of Regulating Vice starts by describing addiction, while noting the myriad definitions of addiction and dependence that previously have been offered. (In The Addiction Concept, Glenn D. Walters writes: "After reviewing the addiction literature, one might be inclined to conclude that there are as many definitions of addiction as there are investigators conducting research in the area.") Reinforcement, tolerance, and withdrawal are generally part of the mix, but not all vicious compulsions that people would likely term "addiction" demonstrate all three of these traits. Nevertheless, the chapter moves ahead with a description of rational addiction theory, as developed by two University of Chicago economists, Gary Becker and Kevin Murphy:

A capsule summary of rational addiction theory begins with the description of a potentially addictive good (a drug, say) as having the quality that the consumer’s current satisfaction from the drug depends on the extent of previous drug consumption. Other factors such as price will also influence current drug use, but the amount of past consumption plays a key role in generating today’s demand for the drug. In keeping with the notion that addiction involves reinforcement, the more you have consumed in the past, the more that you will choose to consume now, holding all other factors constant.

What separates rational addiction theory from most other approaches is that the basic description just provided is understood by the consumer as well as by the armchair addiction theorist. So when you make a choice to consume an addictive drug today, you recognize that today’s consumption will increase your desire for the drug tomorrow.

Rational addiction theory, it turns out, provides a solid underpinning for much addiction-related behavior, and also gains support from empirical tests when it is compared to addiction models where consumers lack foresight. One type of behavior that rational addiction cannot easily explain, however, is the costs that some people impose on themselves to try to commit to reduced future consumption. [Stomach reduction surgeries are one example.] In its pure form, rational addiction theory suggests that public policies that try to make drugs (or whatever) harder to obtain cannot make anyone, even addicts, better off (at least directly); private policies adopted towards the same end also would not make sense -- and yet such private policies are commonly undertaken.

Labels: addiction, Regulating Vice

 
Gambling and Other Vices
- posted by Jim Leitzel @ 9:09 PM

The British Gambling Prevalence Survey that we mentioned yesterday looked into smoking and drinking as well as gambling behavior. The unsurprising bottom line: smokers and heavy drinkers gamble more than others, and they also are more likely to be problem gamblers. For instance, 67 percent of current smokers play the National Lottery (that is, played at some point during the previous year), while only 54 percent of non-smokers play; 23 percent of smokers play slots, versus 12 percent of non-smokers. The alcohol question concerned how many drinks that the respondent consumed during their heaviest drinking day in the past week. Broadly speaking, the more they drank, the more they gambled. Of people who claimed that their largest day of consumption during the past week involved twenty or more units (! -- a unit is the amount of alcohol in a 12-ounce beer, a five ounce glass of wine, or a shot of liquor), 68 percent played the National Lottery during the previous year, while the overall percentage was 57 percent; 18 percent of these big bingers placed bets with bookmakers, versus 6 percent of the overall population.

Smokers were 3.5 times as likely to be problem gamblers than non-smokers, and heavy drinkers faced even steeper increases in problem gambling prevalence relative to their light-drinking peers.

Our old friend Bingo has some anomalous characteristics. First, unlike most forms of gambling, it is dominated by women. Second, and not anomalously, smokers are about twice as likely to play Bingo than are non-smokers -- this is about the same as with slot machine players, and helps to explain why casinos and Bingo parlours are particularly vulnerable to smoking bans. Third, Bingo participation does not appear to vary with drinking status -- about seven or eight percent of people play Bingo, whether we are talking about light drinkers or big bingers or the population at large.

Labels: addiction, alcohol, bingo, Britain, gambling, smoking

 
British Gambling Survey
- posted by Jim Leitzel @ 9:13 PM

New gambling regulations went into effect in Britain this month. What will be their impact? To make it easier to eventually know the answer to that question, a pre-reform survey of gambling prevalence was commissioned; the report (182-page pdf) was released last week. (Less hefty versions can be found at this Gambling Commission webpage; also available there is the 1999 survey.)

Some of the findings: about 2/3 of the British adult population gambled in the previous year (quite similar to US gambling rates), and more than half participated in the National Lottery. The percentage of adults who are pathological or problem gamblers is about 0.6, lower than in the US (where it is estimated to be about 3.5%). Internet gambling is not very popular, with only about 3% of the population playing casino-type games or poker online; including web-based betting with bookies brings the total up to about 6%. Richer people were more likely to gamble than were poorer people, but college-educated people were less likely to gamble than those who had not earned a college degree. Like everyone else, Britons are completely wacko when it comes to estimating their gambling losses. (The usual story is a massive underestimate of net losses.) They recognize that they did not win the lottery in the past week. That is a good sign. But they recalled amazing past-week success in other types of gambling. From page 40 of the report:

Participants reported nine gambling activities on which they claimed there
was an overall net win over the past week. These were scratchcards (71 pence),
bingo (91 pence), slot machines (£1.13), horse races (£1.49), fixed odds betting
terminals (£3.27), casino table games (£17.22), online betting with a bookmaker
(£4.89), online gambling (£10.72), and private betting with friends (£3.42). In
general, the smaller the number of participants gambling on the activity, the
greater the overall net win claimed.

I suppose that the smaller the number of participants, the fewer the witnesses.

Labels: addiction, Britain, gambling

 
Drugs Blur Vision...
- posted by Jim Leitzel @ 10:48 PM

...oops, I mean, Blur's Drug Vision. David Rowntree, recovering addict, aspiring barrister/politico, and the drummer for the British band Blur has an op-ed on drug policy in Tuesday's Guardian. First, Rowntree points to the ineffectiveness of drug policy, or at least to the paucity of data pointing to policy efficacy: "there seems to be no evidence that any country's policy has had any lasting effect on the number of recreational or dependant [sic] drug users at all. Ever." He then suggests that in shaping policy it is sensible to consider dependent and non-dependent users separately, recognizing that for most users, there are no negative long-run consequences from a standard recreational drug career that fades away by the age of thirty. Eventually, Rowntree proposes "a strategy based on research, education and harm reduction." But en route he offers what I consider to be some profound insights into his own addiction. At first the alcohol and coke seemed to be problem solvers.

However, my experience of life when not on drink or drugs got progressively worse. The world became an increasingly hostile place, relationships got more difficult and an all-encompassing sense of dread and paranoia set in. Drink and drugs became progressively less effective in soothing those feelings. At some point, the drugs stopped working, but life without them had become impossible. It was a catch-22 situation where it was impossible to live without alcohol or drugs but impossible to continue using. I managed to get help before they destroyed my life, and these days I'm active in the recovery community. The key point is that all the way along, I thought my behaviour was normal and it was the rest of the world that had gone mad. I had no idea my experience was different to anyone else's because I had nothing to measure it against.

So if my experience is typical, and I think it probably is, many addicts aren't interested in treatment because they don't believe there's anything wrong with them.

Incidentally, both Rowntree and Blur hail from Colchester, where Vice Squad was happily seconded for a year in the mid-1990s. Speaking of secondments, I have returned (sans luggage) to Chicago, allowing me to pick up the Guardian in one of the too-many airports that I visited today; I hope that more regular Vice Squad posting will ensue.

Labels: addiction, Britain, drugs, treatment

 
Bupe in B-more
- posted by Jim Leitzel @ 12:10 AM

In 2002, new FDA rules made it possible for doctors to meet in their offices with addicts, and to prescribe the opiate agonist buprenorphine. In the form prescribed, the buprenorphine is combined with the antagonist naloxone, thereby rendering the compound ineffective in taking by injection for a high. Unlike methadone clinics, which generally require daily visits by patients, addicts treated with the bupe/naloxone mix could receive a month's supply at a time.

Vice Squad hometown of Baltimore, Maryland, is racked by a terrible heroin problem. In October, 2006 Baltimore announced that it was going to promote buprenorphine treatment for heroin addicts; the state of Maryland has earmarked $3 million for bupe treatment in the coming fiscal year. Unfortunately, Maryland doctors do not seem all that eager to climb aboard the bupe train, and those that do board find the journey to be arduous, according to an article this week in the Baltimore Sun:

"One of the biggest barriers to prescribing buprenorphine is dealing with the insurance companies," said Dr. Christopher Welsh, a psychiatrist and assistant professor at the University of Maryland School of Medicine in Baltimore. Welsh uses the drug to treat patients at the university's hospital. Some come from hundreds of miles away to get a prescription, only to have their treatment thwarted by red tape.

"A few hours later, you'll get a call, and the patient will tell you that the pharmacy said the prescription wasn't authorized," said Welsh, who participated in the survey.

He added that a physician who intervenes to help the patient is often "passed from voice mail to voice mail" by the health care provider, and the experience "can be very time- and labor-intensive."

Two years ago, Vice Squad noted a prescient Wired article detailing barriers to the spread of bupe treatment for heroin addicts.

Labels: addiction, buprenorphine, heroin, treatment

 
Another "Soft" (?) Addiction: The Internet
- posted by Jim Leitzel @ 10:59 PM

Two days ago Vice Squad mentioned Nora Ephron's addiction to a form of Scrabble -- an online form of Scrabble. Via Andrew Sullivan, we learn of the writer Stephen Elliott's experiment with being internet-free for one month -- and more importantly, of the observations and suggestions sparked by Mr. Elliott's experiment. He notes that it took him awhile to break a habit taught by the internet, that of being in throe to "continual bursts of small information," but that eventually, his ability to sustain attention upon a single task or book grew. After the month-long hiatus, Elliott implemented some rules to manage his internet usage: he abandoned his blog, stopped going online from home or on weekends, and limited his internet at work to 1 to 5 PM. Sounds like there's some wisdom in the Elliott approach, but giving up a blog -- well, that is taking things just a bit too far (June 6, 2005), no?

Labels: addiction, internet

 
Scrabble Addiction
- posted by Jim Leitzel @ 11:45 PM

Nora Ephron has an op-ed in Sunday's New York Times that details her addiction to a form of on-line Scrabble. Here's the start:

About three years ago, I stumbled onto something called Scrabble Blitz. It was a four-minute version of Scrabble solitaire, on a Web site called Games.com, and I began playing it without a clue that within 24 hours — I am not exaggerating — it would fry my brain.

And slightly later in the article:

My brain turned to cheese. I could feel it happening. It was clear that I was becoming more and more scattered, more distracted, more unfocused; I was exhibiting all the symptoms of terminal attention deficit disorder; I was turning into a teenage boy.

I think that the fact that the game can be completed within four minutes is an important part of its reinforcing nature -- playing just one more game is no big deal. And it is amazing how large a role easy access plays in these sorts of addictions -- if the Scrabble site goes down, an addict for whom access has become impossible might not even feel cravings, might be almost instantly "cured."

So-called soft addictions have been receiving a fair amount of publicity of late. (The term 'soft addiction' apparently was coined by Judith Wright, author of this book.) The list of common soft addictions includes much of, well, life: excessive procrastination, work, television, and coffee, for instance. Here's a quiz devised by Ms. Wright to help determine if you suffer from a soft addiction; I am addicted to quizzes.

Labels: addiction, internet

 
Informal Heroin Maintenance
- posted by Jim Leitzel @ 6:40 AM

The Guardian today reprints (from Black Poppy magazine) a moving story about a family that is being devastated by a son's ten-years-and-counting heroin addiction. The author of the story is the addict's mom, who also serves as his drug dealer. (She's a college teacher, too.) That is, she decided that the best way to minimize the harms of her son's addiction -- and they have tried many, many alternatives -- is to buy heroin herself and to dole it out to him. But this measure has not made the situation bearable, in part because the purity of the black-market heroin is variable and the cost of street heroin, as her son's tolerance grows, is close to prohibitive.

The son tried various treatment regimens, including methadone maintenance -- all have failed. The article does not mention heroin maintenance, but it seems like it offers the best (short-term, perhaps) hope for improvement. After all, the son already is on a heroin maintenance scheme, but one that is partly undermined by variable purity and high cost. An official heroin maintenance scheme, one that would eliminate these two problems, could hardly be worse.

There are many small insights in the article. I'll only mention one here, the notion that an addict's knowledge of his own failure to handle his addiction can spur more drug use, as a way of blotting out a painful self-awareness.

Labels: addiction, Britain, heroin, treatment

 
Comparative Drug Harms
- posted by Jim Leitzel @ 7:15 AM

The Lancet recently published an article ranking twenty drugs, legal and illegal, according to their potential for harm. (The article is here, though a free registration is required.) They had groups of experts score each of the substances along nine dimensions of harm, on a four-point scale, from 'zero' representing no risk to 'three' representing extreme risk. The dimensions comprised three categories: physical harm (acute, chronic, intravenous); dependence (intensity of pleasure, psychological, physical); and social harm (intoxication, health-care costs, other). The nine individual scores were averaged for the overall assessment, which ranked heroin as the most harmful drug. Cocaine was second, alcohol fifth, tobacco ninth, cannabis eleventh, LSD fourteenth, ecstasy eighteenth, and the least harmful of the twenty ranked drugs was Vice Squad fetish khat. The authors note that their ranking does not cohere with the scheduling of drugs that is the basis for drug policy and enforcement.

The harms of drugs, of course, are dependent upon the public policies that are adopted towards them. The authors note as much when they caution against direct comparisons in their rankings between the legal alcohol and tobacco and the illegal drugs. But I think that this point could be further stressed. The Swiss experiment with heroin maintenance (along with subsequent heroin maintenance trials) shows that even with that drug, harms can greatly be reduced through easy availability of a standardized dose in a controlled setting. Dependence responds to policy, too; for instance, a prohibition that renders availability sporadic and purity uncertain lends a gambling element to drug acquisition that itself can be addictive for some users. Nevertheless, rankings such as the one in The Lancet can be helpful in highlighting the inordinately repressive control regime that has been adopted towards marijuana, hallucinogens, ecstasy, and, in the United States (though not in Britain), khat.

Labels: addiction, drugs, khat

 
Twelve-Step Success?
- posted by Jim Leitzel @ 1:18 PM

Treatment programs for addiction often have vocal adherents, but rarely is there much solid scientific evidence for dramatic (or even not so dramatic), replicable success. The sense of futility that infuses the war on drugs* has a parallel with respect to drug treatment. Here is Jon Elster, in the Introduction (page xvii) to his 1999 edited volume, Addiction: Entries and Exits: "There is a wide range of drug treatments. The main thing they have in common is that they rarely work."

Alcoholics Anonymous and similar 12-step-style treatment programs have been popular for decades, but again, the evidence for their success is more anecdotal than systematic. AA itself generally has not been subjected to randomized trials, which offer the best hope for gauging treatment effects. Claimed success rates often seem to cherry-pick, ignoring, for instance, those patients who drop out of treatment or who cannot be located post-treatment. But researchers have been chipping away at this longstanding dearth of evidence.

The May 2006 issue of Addiction opens with a two-page editorial by Keith Humphreys ("The Trials of Alcoholics Anonymous") that summarizes what has been learned so far from methodologically sophisticated analyses of 12-step programs. One study, for instance, documented a harm reduction-versus-abstinence-style result, in which intensive referral to couples therapy (AA and Al-Anon) led to more abstinence but also to more severe problems for those drinkers who did not achieve abstinence.

The systematic evidence remains far from conclusive. Here is how Humphreys, however, concludes his editorial:

Strong views about AA one way or the other will always survive, no matter what evidence accumulates, but the studies of the past 15 years have established beyond any reasonable doubt that high-quality AA trials are possible, and that such studies usually reinforce rather than undermine the excellent reputation the fellowship enjoys around the world.

Update: A less sanguine view, however, is found in a review undertaken under the auspices of The Cochrane Collaboration, an organization that evaluates the evidence concerning the effects of healthcare interventions. The Cochrane review of AA, written by M. Ferri, L. Amato, and M. Davoli, offers these "Authors' conclusions":

No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [Twelve Step Facilitation] approaches for reducing alcohol dependence or problems. One large study focused on the prognostic factors associated with interventions that were assumed to be successful rather than on the effectiveness of interventions themselves, so more efficacy studies are needed.

*Incidentally, I don't accept that the war on drugs is futile -- if only it were! With respect to an alcohol-style regulatory structure, our current prohibition probably does lower the consumption of some drugs, while worsening a host of other social ills.

Labels: AA, addiction, alcohol, treatment