Last week, the New York Times’ Sabrina Tavernese published a moving account of how prescription painkiller addiction is destroying the lives of people in Scioto County, Ohio. The county is a microcosm of the national epidemic of prescription drug addiction and overdose, which has spurred Congress to introduce legislation to crack down on “pill mills” and led the White House to unveil a new policy initiative comprising prescriber education, addiction treatment and law enforcement. What is less well known is how the surge in prescription drug addiction is overturning three prevalent beliefs in the drug policy field:

1. It is generally accepted among addiction specialists and drug policy analysts that drugs with similar effect can substitute for each other. For example, if you provide methadone (a synthetic opiate) to someone addicted to heroin (another opiate), their heroin use will usually decline. Likewise, some drug policy analysts believe that if marijuana were legal, alcohol use would decline because some people could get some of the alcohol consumption effects they enjoy by smoking marijuana instead. But throughout the wave of prescription opioid addiction, heroin addiction in the United States hasn’t dropped a bit. A number of smart people have been speculating about this mystery, but no one has an empirically based explanation of why the complementarity hypothesis isn’t panning out.
2. The fact that pharmaceutical drugs are now the leading causes of drug overdose in the U.S. challenges the common assumption that overdoses result primarily from the variable content of drugs in the black market (i.e., you can’t assess the purity of what you are buying from transaction to transaction). Pharmaceuticals are consistently pure and their dose is standardized, such that everyone knows what they are taking in a way they can’t with illegal drugs such as heroin and cocaine. Yet overdoses on those illegal drugs are flat while overdoses on prescription drugs such as Oxycontin and Vicodin are soaring. It may be that the rationality of addicted people has been overestimated in regards to overdose, i.e., even when they know the exact content of the drug and that it may produce overdose, their desire to use trumps that risk in their minds. The extra information about purity and dose is therefore of little consequence.
3. Finally, the epidemic throws cold water on the theory that if we legalized all the illegal drugs and let physicians dispense them as they would any other drugs, our national drug problem would abate. People who buy this theory generally point to Britain before World War II, during which any physician could prescribe heroin and cocaine as they saw fit. Physicians are overwhelmingly trustworthy and responsible, but it only takes a few bad apples to feed a drug epidemic. Several hundred dishonest prescribers in South Florida for example managed to cause overdose deaths all over the Southeastern United States. No profession can ensure that not even one tenth of one percent of its members will break professional codes and standards. Turning the currently illegal drugs over to doctors for dispensing is therefore an extraordinarily risky proposition. In Britain, it took years for the addicted community to spread the word about which physicians were reckless prescribers, leading to a drug epidemic. In the era of Internet communication, it now happens within days, and cheap air travel does the rest to spread the epidemic. See the award-winning film Oxycontin Express, available for free viewing on Hulu, for a glimpse of this frightening reality.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

Long-acting prescription opioids (e.g., Oxycodone, Hydrocodone) are powerful clinical tools in some cases but a curse in others. As prescriptions for these medications have increased more than tenfold in the past 12 years, many people in pain have gotten relief, sometimes for the first time since their illness struck. But the abuse of such medications has also increased, to the point that overdosing on prescription opioids will probably be the most common cause of accidental death in the U.S. this year (surpassing gunshot wounds and car accidents).

My home state of West Virginia has been particularly hard hit, and now leads the nation in overdose death rates. At the invitation of Senator Daniel Foster, MD, (a Stanford alum) and Delegate Don Perdue (a pharmacist), I returned home last week to testify in both houses and brief Governor Earl Ray Tomblin on how the state could respond. These were my key points:

• More than once a week, a West Virginian dies of a drug overdose while holding prescriptions from five or more providers. This implies that West Virginia must strengthen its prescription monitoring system to better identify doctor shopping as well as to catch the extremely small number of providers who are engaging in criminal conduct.
• Putting pain-pill addicted people who commit petty crimes (e.g., doctor shopping, disorderly conduct, petty theft) into prison is a mistake. A new generation of community supervision programs has shown that many drug-involved offenders can be placed in programs that help them stop drug use while keeping the community safe, at far lower cost than prison.
• Naloxone, an opiate antagonist that temporarily reverses the effects of opioids, should be made available to every public health and public safety professional who is likely to encounter people in overdose (e.g., highway patrol officers, fire fighters, homeless shelter staff).
• Expanding addiction treatment is both the right thing to do and a cost-effective investment. Washington State found that its Medicaid program actually saved money when it expanded treatment because people with untreated addictions otherwise are frequent users of emergency rooms.
• Prescription drug “take back events” can be valuable. At a small town in Arkansas I visited last year, a sheriff held a 5-hour event in a mall parking lot, during which 50,000 pills were turned in by local residents. That was twice as many pills as the town had people. These events are also an opportunity to create a broader public perception that unused medications are not safe enough to simply leave lying around or to give away to friends and relatives.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

As if the thought of drivers who are drunk or texting isn’t enough to make you anxiously tighten your grip on the steering wheel, two just-released government studies show that Americans are increasingly driving under the influence of drugs.

The National Highway Traffic Safety Administration recently reported that 18% of drivers who died in car accidents in 2009 tested positive for legal or illegal drugs. And that figure is actually quite conservative, because it assumes no drug use by the drivers in the more than one-third of fatal crashes in which no drug tests was conducted.

Resonating with these disturbing results, a national survey by the Substance Abuse and Mental Health Services Administration showed that 10 million Americans admitted to driving under the influence of illegal drugs in 2009. Again, this is a conservative estimate because many people who drug and drive are not going to admit it in a government survey.

Because the amount of drugs Americans use (both by prescription and illegally) and the amount of miles they drive both rose from 2008 to 2009, the increase in driving under the influence of drugs is perhaps to be expected. But that, of course, doesn’t make it safe. Certainly, some people with legal or illegal drugs in their system crash for other reasons, but no reasonable person would dispute that 10 million (or more) drug-intoxicated drivers on the roads poses a grave risk to public health and public safety.

How can we respond to this problem? With drunk driving, public policies that increased the drinking age, punished convicted offenders more consistently and promoted safe-server training in bars and restaurants all helped reduce the problem. But fundamentally, there are simply too many cars and too many drinking opportunities in a nation of 300 million people for public policy to be the sole or even primary source of our success at reducing drunk driving: Government simply can’t be everywhere. What mattered the most was a transformation in widely shared cultural norms, knowledge and values.

In the Mad Men episode Red in the Face, Don and Betty Draper make sure their heavily drunken friend Roger Sterling has one more for the road, and stand at the doorway and laugh as he tries to get into the wrong car and then drives off in darkness with the headlights off. That is an accurate reflection of attitudes about drunk driving that are mercifully behind us. Today, Don and Betty would cut Roger off, or drive him home, or call a cab, or cajole him into sleeping on their couch.

We need to expand such cultural norms, knowledge and attitudes to include driving under the influence of drugs. Health professionals can aid this process by more consistently letting patients know that a number of prescribed drugs can impair driving ability, particularly if they are abused or combined with alcohol. If we don’t start taking drugged driving as seriously as we do drunk driving, the former may someday outstrip the latter as a risk to our collective safety.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA.

Photo by rocknjosie

There have been dramatic public policy developments surrounding caffeinated alcohol beverages since Michelle Brandt wrote about them here less than a month ago. Half a dozen states have banned or announced plans to ban “black out in a can,” as these drinks are sometimes called. Today, the FDA issued a warning letter to manufacturers of these products, one which has already announced that it will remove caffeine from its popular and potent drink “Four Loko.”

Consuming stimulants (e.g., cocaine) with alcohol is a common practice among heavy drinkers. Many heavy drinkers find the combination reinforcing because the stimulant wards off some of the negative subjective effects of alcohol (e.g., drowsiness) and in some cases may result in a unique third chemical reward in the brain - cocaine and alcohol, for example, combine to create a drug known as cocaethylene that creates an extended feeling of euphoria.

The minimization of alcohol’s subjective negative effects makes the combination of stimulants and alcohol more rather than less dangerous. In experiments on perception and reaction time, people who consume alcohol and caffeine show the same deficits as those who just drink alcohol, but they are not as aware of them. It thus seems subjectively more reasonable to the consumer of combined alcohol and caffeine behaviors to have a few more drinks because they don’t feel very intoxicated. They are also more likely to overestimate their ability to engage in tasks involving concentration, perception and coordination, such as driving a car down a busy interstate at night. More information on the health risks of these beverages is available in a letter (.pdf) to state attorneys general written by some leading scientists, who concluded that adding caffeine to alcoholic beverages did not meet FDA’s “generally recognized as safe” (GRAS) standard.

Does the regulatory action by states and the FDA end this problem, for example, on the many college campuses where these beverages are quite popular? Not entirely. Removing the cheap, heavily promoted pre-mixed products form the shelves is a significant victory for public health, but some drinkers will continue to buy a few cans of Red Bull along with their vodka and produce a homemade version of Four Loko. To further constrain the health damage of combined alcohol and stimulant use, public education by health officials, clinicians and college administrators will be required, as will public health warnings and potentially further regulation at points of sale.

Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA.

Previously: The dangers of caffeinated alcohol drinks and Don’t add buzz to the booze, says FDA

Last week, the Los Angeles Times profiled a woman who was addicted to marijuana for 19 years, during which she used marijuana compulsively several times a day, experienced physical withdrawal symptoms, and spent as much as $5,000 a year to maintain her habit. A number of well-educated and successful people asked me in shock: “That story couldn’t have been accurate could it? I mean, no one gets addicted to marijuana, right?” I have been asked similar questions over the years by top-flight journalists, respected scientists, Members of Congress and White House staffers.

This led me to contemplate an interesting mystery: How is it that over 4 million Americans meet medical criteria for marijuana abuse or dependence, yet many of the most educated and accomplished people in our society are not aware that marijuana can be addictive?

A cottage industry of bloggers and talking heads aggressively deny that anyone is ever harmed by marijuana, much as the Tobacco Institute used to deny any ill effects of smoking tobacco. But that’s about ideology and not science: Among pharmacologists, the recognition that psychoactive drugs like marijuana can produce dependence is uncontroversial. And among treatment researchers and clinicians, it is a fact of life that many people seek treatment for marijuana addiction, including in countries such as the Netherlands where there is no legal pressure at all to do so.

In any event, I doubt pro-pot pundits affect the views of the well-educated professional class as much as does the “availability heuristic” a form of cognitive bias documented by the late, great Stanford psychologist Amos Tversky and his collaborator Daniel Kahneman. To reduce Nobel Prize-winning work to oversimplified form, we tend to think what we experience personally is more representative than it really is.

The normative experience of marijuana use for the educated middle and upper classes is to use it casually a bit in the late teen years and early adulthood. Many then stop using without significant effort or even thought, although some do remain occasional users throughout their lives. Most people in this well-tended segment of the population thus has used and seen other people use marijuana recreationally without apparent problems, and believes a la Tversky and Kahneman that this is the universal pattern.

But it’s not. U.S. and International data tell us that about 10 percent of people who use cannabis will become dependent on it. The dependent population tends to use the drug every day, often several times a day. They have about three times the unemployment rate of the rest of the population and are disproportionately concentrated in lower income and minority communities (out of sight, effectively, to much of the middle class educated population).

Within the educated middle classes, some people do of course become marijuana dependent, and I will close by telling a story of this sort about a college friend whom I had forgotten about (I mentioned that advisedly) until I thought about writing this blog post. She began as a casual user and ramped up to once a day use and then all the time use. This is not a reefer madness story: She graduated and got a decent job and I heard later that she married a nice fellow. But for lack of a better term she slipped a bit. Her grades stayed okay, but not enough to keep her in the honors college. She did graduate, but it took her an extra 1.5 years, dropping her out of the circle of us who graduated on time. And we slowly forgot about her - leaving the availability bias to exercise its power and make us certain that lots of people at college were casual marijuana users and none of them suffered any ill effects.

In the race of striving middle class life, the alcohol or cocaine addict is the one who crosses into your lane and knock you painfully to the ground. You therefore can’t fail to notice or remember them. The marijuana addict is the person who loses a few steps early on, finishes the race after you have showered and dressed and forgotten they were there standing next to you at the starting line.

Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences and addiction expert. He recently returned to Stanford after a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

When my friend Paul Costello left the Carter Administration, he wrote a funny New York Times article suggesting a special course for departing staffers:

There ought to be an “outward bound” course for White House employees facing exile.

Must we face this cruel and unusual punishment cold turkey?

Maybe people were tougher back then - I personally would have collapsed five minutes into the first day of the course. My experience is not unusual: White House jobs are hazardous to your health.

As our own Bill Dement, MD, PhD, would likely predict, one of the fundamental strains on the health of staffers is a lack of sleep, both in terms of quantity and quality. My worst night personally was when I was a point person on an internal policy debate that required input from staffers who were in California, Washington, Belgium and China. As one would finally go to sleep, another would wake up in the next time zone and begin calling and sending me e-mail. I ended up lying in my bed with my Blackberry wedged between my ear and a pillow, waking up every 10 minutes or so each time it buzzed.

The next morning I stumbled to the airport for a flight to London, during which I had planned to sleep but couldn’t because I had too much work to do. That night, after speaking at Parliament, I was suddenly aware of an MP asking me a question and realizing that I had lapsed into microsleep and not heard it. The audience in the packed room looked at me expectantly, so I bluffed by asking, “Upon what specific aspect of this important issue do you wish me to comment?” The MP repeated the entire question and saved my bacon. We became friends later, and he told me he was not fooled at the time, but having been in the same situation himself, treated me with mercy.

The other major strain on White House staff is the 24-hour news cycle and rough-and-tumble of politics, which keep most people in flight-or-fight mode all the time. Lacking a time of true, deep relaxation, the body begins to break down. Lots of people get headaches, back aches and almost everything-else aches. Above is a photo I took of my friend Howard Koh, MD, the Assistant Secretary of Health. We were headed in to a reception for the AIDS strategy writers with President Obama for what should have been a laid back evening of music, good food and mutual congratulations. But just right after we checked our coats, he got an urgent call and turned away, deeply engaged in a crisis that couldn’t wait until the next morning. I’m not actually sure he ever got to go the remaining 50 feet into the East Room for the fun.

Lack of sleep and high stress drives many people to endure wild oscillations in weight. I gained over a pound per month. In one of those weird Star-Trek-like-conservation-of-mass effects, my boss lost over a pound a month. I often had less than five minutes for lunch, so I would inhale a burrito and a liter of Coke to keep myself going. Other people simply never got around to eating when they should and thinned out accordingly.

Because the work is always pressing and always seems more important, many people give up long-established exercise regimes. They also don’t get to the doctor when they should, even though there is one on site all the time. You could make a good living being a dentist for senior White House aides as long as you charged for last-minute appointment cancellations. You might not even have to ever see a patient.

On my last day, I looked at the White House mess menu and ordered a salad and a glass of water - a symbolic new start. Within eight weeks of returning to California, I lost 15 pounds. I slept 10 hours a night for several weeks as I paid off that debt. I bench pressed my weight at the gym for the first time in a year last week. I think I’m finally ready for that Outward Bound course.

Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences and addiction expert. He recently returned to Stanford after a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

On Tuesday, Paul Costello posted an entry discussing our recent interview about Proposition 19, and a number of readers left comments. I wanted to respond to three themes in the comments and then make an observation about process.

Hasn’t marijuana consumption stayed flat in all the countries that have already legalized marijuana, like the Netherlands?

No country has legalized the commercial production of marijuana as Proposition 19 would. Indeed the world’s nations have signed an international treaty pledging not to take such a radical step. In the Netherlands, using cannabis in licensed shops is legal, but commercial production and trafficking are still illegal and Dutch enforcement against marijuana traffickers is quite tough.

In contrast, some countries have taken the less radical step of making cannabis use a civil infraction subject to a fine but no jail time (e.g., like a parking ticket). If you think that is a good policy you should be happy with California’s current law, which does the same thing for individuals possessing an ounce or less of marijuana.

Legalization will take some money away from criminal organizations. Isn’t that good?

Yes, it is very good. But that good has to be weighed against the damage of creating another corporation that makes money by generating addiction, and the increase in cannabis use the new law will generate. Obviously, people disagree about which is the greater cost - and that is what drives much of the debate on this issue.

Alcohol causes more harm than cannabis, but it’s legal, so why shouldn’t cannabis be legal?

The misuse of alcohol does indeed cause more harm, particularly violence, than does cannabis. We also have a serious problem in this country with binge drinking among underage drinkers. Part of the reason for that is that alcohol is legal, and therefore can be marketed aggressively and skillfully to young people, and is protected by a powerful and highly effective lobbying industry that can blunt efforts to tax and regulate alcohol. Cannabis doesn’t have those political advantages, but it would get them if it were legalized and thus be able to do more harm than it does now.

***

Let me close by returning to an observation I made in the podcast with Paul, about the nature of drug policy debate in the U.S. If you read the companion piece to my opposition to legalization in the Los Angeles Times, you will see reader comments calling me a Nazi, drug warrior, right-wing nut, and so on. If you read the op-ed I published in San Francisco Chronicle on Monday praising the recent reduction in crack cocaine sentences, you will see reader comments labeling me a loony liberal who wants the streets run with crack cocaine.

This level of hostility in rhetoric, along with the unwillingness of many people to admit that drug policy is not an issue with just two simple points of view or “teams”, has been a major stumbling block to the development of nuanced, careful effective drug policy. I am therefore grateful to those of you who posted on Scope or e-mailed me with thoughtful, considered critiques of what I said in the podcast.

Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences and addiction expert. He recently returned to Stanford after a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.