Addiction

Two years ago, the National Institute on Alcohol Abuse and Alcoholism and American Academy of Pediatrics released a screening tool designed to help clinicians overcome time constraints and other common barriers to youth alcohol screening. But new research shows that many physicians still aren’t discussing alcohol use with their teen patients, resulting in missed opportunities for screening for underage drinking.

In the study, researchers randomly surveyed 2,500 students with an average age of 16 years. Among the participants, 34 percent said they had consumed alcohol in the past month and 26 percent reported binge drinking. However, a significant portion of those who admitted to drinking were not questioned, or counseled, by a doctor, according to an National Institutes of Health release:

“While more than 80 percent of 10th graders said they had seen a doctor in the past year, just 54 percent of that group were asked about drinking, and 40 percent were advised about alcohol harms,” says lead author Ralph W. Hingson, Sc.D., M.P.H., director of NIAAA’s division of epidemiology and prevention research. He adds that, among students who had been seen by a doctor in the past year and who reported drinking in the past month, only 23 percent said they were advised to reduce or stop drinking. The findings are now online in the February issue of Pediatrics.

The researchers also reported that students who said that they had been asked about their drinking were more likely to be advised about alcohol. Nevertheless, among the 43 students who said that they were drunk six times or more in the past month and who said they had been asked about their drinking by a doctor, about 30 percent were not advised about drinking risks, and two-thirds were not advised to reduce or stop drinking.

The findings are notable in light of past research showing that just a two- or three-minute intervention during doctor visits can go a long way in combating underage drinking.

Previously: Personality-based approach can reduce teen drinking, Are some teens’ brains pre-wired for drug and alcohol experimentation?, CDC binge-drinking study demonstrates cell phones’ value in research and National survey shows teen girls more vulnerable to drug and alcohol abuse
Photo by Capsun Poe

A new paper published this week in JAMA Psychiatry draws exciting conclusions at the intersection of two fields dear to me: pediatrics and personality science. The paper reports on the success of a personality-based program to reduce teen drinking. In a nutshell, an alcohol-prevention program tailored to teens with high-risk personality traits shows promise for preventing drinking among the young people who might be most prone to drink.

More on that in a minute, but first, a quick anecdote about why I care about personality research: Back when I was in graduate school, my roommate would sometimes do a web search for cheap, last-minute airline tickets, then jet off on almost no notice to some exotic locale. Once, when she neglected to tell her mom that she was going out of the country, I answered our phone to hear her very worried mother say “Erin, do you know where Gina is?” My reply: “Uh, Venezuela?”

If you asked Gina, then a psychology PhD student who was studying personality, about the motivation for these adventures, she sometimes jokingly replied in the jargon of her academic field, pointing out that she scores highly on “openness to new experiences,” one of the standard dimensions by which personality is assessed.

A brief program of cognitive behavioral therapy reduced high-risk teens’ total drinking by 29 percent and binge drinking by 43 percent

Now Gina and I are grown-ups with real jobs. I write about pediatrics at Stanford, while my old friend, known in her professional life as Angelina Sutin, PhD, is an assistant professor at Florida State University, where she is continuing her personality research. When I saw the new paper, I jumped at the chance to call Dr. Sutin, as I guess I’d better refer to her, to get her thoughts on this work that’s relevant to both of our professional lives.

The teen-drinking researchers, who are from Canada, the U.K. and Australia, screened young teens for four personality traits that could predispose them to high-risk behaviors, and then provided prevention programs targeted to the specific high-risk traits. Instead of simply being told, “Don’t drink,” high-risk teens received a brief program of cognitive behavioral therapy to help them recognize healthy and risky coping behaviors that could arise from emotional responses specific to their personalities. Substance abuse was mentioned as one of several risky coping behaviors, but was not the main focus of the program.

This approach reduced high-risk teens’ total drinking by 29 percent and binge drinking by 43 percent. Schools where high-risk students received the intervention also had less total drinking than control schools, suggesting that low-risk students drank less if they saw less drinking among their peers.

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The uncertainties of using medical marijuana mean that it should not be given to pediatric patients, writes Packard Children’s adolescent medicine specialist Seth Ammerman, MD, in today’s U.S. News & World Report.

Why not? Ammerman gives several reasons in the opinion piece, including lack of knowledge about the effects, individually and in combination, of the various drug compounds in marijuana. He adds that there are significant concerns about the variation in drug levels between individual plants, poor understanding about how to safely and effectively dose marijuana to children and teens, and inadequate information about short-term side effects of the drugs in marijuana.

The long-term effects of marijuana on young brains are also worrying, Ammerman explains:

Cognitive impairment is of special concern. New research in brain development found that brain maturation isn’t completed until the early to mid-20s. The developing brain of a child is often more vulnerable to exposure to compounds than that of an adult.

Finally, the younger an adolescent starts using substances, whether tobacco, alcohol, or other drugs including marijuana, the more likely they are to develop dependence on, or addiction to, that substance. Brain imaging studies in adolescents demonstrate that use of substances, including marijuana, may alter the developing brain itself. The significance of these changes is not fully understood, but is clearly not normal.

Better research on the role of the class of drugs found in marijuana, called cannabinoids, may eventually clarify possible uses of these drugs in disease treatment. But in the absence of such research parents and physicians should avoid giving medical marijuana to children or teenagers, concludes Ammerman.

Previously: To reduce use, educate teens on the risks of marijuana and prescription drugs, Do people really get addicted to marijuana? and A look at marijuana prescriptions in Northern California

Tobacco companies began a campaign to manipulate throat doctors into helping calm the public’s growing fears that smoking might be bad for their health in the 1920s. The practice of using doctors to peddle tobacco products continued for 50 years, despite overwhelming scientific evidence pointing to the hazards of smoking.

Through his studies on the intricate relationship between doctors and cigarette companies, Robert Jackler, MD, professor and chair of otolaryngology, and his wife, Laurie, have amassed a collection of more than 10,000 original tobacco ads, which were featured in an exhibit at the New York Public Library.

Doctors weren’t the only ones proclaiming the merits of various cigarette brands. A number of Christmas-themed ads, such as the above image, feature Santa. You can read more about Jackler’s work and collection in this archived Stanford Medicine article.

Previously: What’s being done about the way tobacco companies market and manufacture products, Stanford chair of otolaryngology discusses federal court’s ruling on graphic cigarette labels, Hey doc, got a light? Research highlights Big Tobacco’s long history with the medical community and NPR’s Picture Show highlights Stanford collection of cigarette ads

I was recently at a private home for a small holiday dinner with colleagues, all of whom work in the field of addiction. The host, himself a physician who treats substance use disorders, pressed a drink on a young male colleague who had politely declined the proffered glass of wine.

“Come on,” said the host, elaborating on his favorite vino, “it’s got a great bouquet.”

The young man refused again, but the host would not be deterred, and insisted that he at least try it. The room became silent, seeming to hang for a moment on the young man’s decision. He reluctantly took the drink, letting only the merest amount of alcohol pass his lips, then placed the glass on the table and did not touch it again for the rest of the evening.

I assume, though I acknowledge I may be entirely wrong in my assumption, that the young man declined the drink because he is an alcoholic in recovery - as are a sizable percentage of physicians in the field of addiction-treatment – and he was embarrassed to admit among professional peers that he abstains for this reason. Yet caught unawares, he was equally unable to conjure another explanation. If I am correct, then this scenario speaks to the need for greater general awareness among hosts about the alcoholic’s dilemma.

Addiction is a stigmatizing illness, and many individuals who suffer from addiction are careful about with whom they share this information, for good reason. ‘Recovery’ is the catch-phrase for the process whereby the addiction is treated, and for many, recovery involves abstinence from the drug of choice. The dilemma then becomes how to abstain in a context where consuming the substance is considered standard behavior, while still preserving one’s anonymity.

As we move through this holiday season and plan gatherings with friends and family - adding rum to our eggnog and whisky to our mulled wine - we might give some thought as to how to make these events as warm and welcoming as they can be for those in recovery, while still continuing time-honored traditions of serving alcoholic beverages to those who are not.

Therefore, I offer up these suggestions to guide hosts and hostesses this holiday season:

• Serve plenty of non-alcoholic alternatives. Especially welcome are those that can ‘pass’ as alcohol, like sparkling water in a champaigne glass, or a non-alcoholic beer.
• Host a Saturday brunch, for example, rather than Saturday dinner, when alcoholic beverages are less likely to be expected or consumed.
• When offering alcohol to guests, offer once, and if declined, move on! Better yet, simply ask guests what they would prefer to drink, and let them generate the response, rather than forcing a ‘yes/no’ response to alcohol.
• If you as a host are made that uncomfortable by people who do not drink, you might ask yourself what is behind that discomfort.

Naturally I look forward to the day when addiction can be openly acknowledged and accommodated, without the accompanying shame. But in the meantime, during this time between Thanksgiving and New Year’s, the heaviest drinking days of the year, be thoughtful about spreading good cheer in a way that also honors anonymity and recovery from substance use disorders.

Photo in featured entry box by Muffet

In an article I wrote on addiction several months ago for our in-house magazine, Stanford Medicine, I reported that the mammalian brain’s reward center - the complex of neural circuitry that guides our behavior by doling out or denying pleasure in response to the result of our behavior - does its work by squirting out (or withholding) various secreted chemicals, especially one called dopamine. Interestingly, the amount of dopamine secreted corresponds not so much to how “good” or “bad” the outcome of our action was, but rather to whether and by how much the result exceeded or fell short of our expectations.

I can personally attest to this. A few weeks ago I got one of those Ur-official-looking letters from a county government whose location I will not specify. In my experience, these letters almost never augur an auspicious outcome. But this one wasn’t too terrifying: It was a summons to report for jury duty.

So the other day I strode through a metal detector into the Luminous Lair of the Law. I’ll abridge my account of the ensuing bureaucratic shuffle and simply note that I was one of perhaps 100 prospective jurors who eventually filed into a large room peopled by at least five lawyers and several other court appointees. We were being considered for a case that, were I to be selected, promised to be hugely interesting. But it also promised to pin me down for an entire month, which would totally torpedo my long-planned, pricey, non-refundable and unrescheduleable 12-day vacation trip to Montreal, where my daughter temporarily works and where my wife comes from.

Once we were informed that pre-paid vacation plans might pass for a “hardship,” I began breathing easier. I filled out the one-page sheet stating my name, occupation, employer and excuse and submitted it (as did about 70 others) to the Court Clerk, who hustled the stack of forms to the judge’s chambers for his sign-off. Then, in two gigantic batches separated by about 10 or 15 minutes, she read off the names of those who’d been officially excused and could go home.

Every name got called but mine. Finally, the Court Clerk said, “Mr. Goldman, the judge will see you in his chambers in a few minutes.” I stared back at her like a trapped animal, privately panicking: Were they really going to blow my vacation and my life apart? Why mine, and nobody else’s? What had I done? What had I not done? What was I presumed to be thinking of doing? Wherefore art thou, Dopamine?

After a seemingly interminable wait, I got led into the judge’s quarters. He’d recognized me from my form and wanted to take this opportunity to say hello. It turned out we’d exchanged a few e-mails regarding my addiction article, which the judge had read and about which he’d had some questions concerning a personal acquaintance’s apparent addiction to food. I doubt I’d been very helpful, but he treated me with immense respect for the twenty-five minutes or so we spent talking.

This was a two-fer. Not only was I getting out of jail - er, jury duty - free. A very busy, very accomplished person had read something I’d written and liked it enough to stall a half-dozen high-salary suits for almost a half hour to tell me so. EXPECTATIONS EXCEEDED!!

At the end of our conversation, he proferred the crucial form, the judge’s signature properly affixed. My reward center squirting geysers of dopamine, I strutted out of his chambers, past the civilly suited pokerfaces, into the elevator, and out to the street convinced, if for but the moment, that I was above the law and distributing good medicine.

Previously: Better than the real thing: How drugs hot wire our brains’ reward circuitry and Revealed: the brain’s molecular mechanism behind why we get the blues
Photo by s_falkow

Last year, we reported on a study showing that text messaging can be an effective and economic anti-smoking tool. Today, NPR aired a segment on a recent review of studies showing something similar: Evidence from five trials indicate that receiving text messages that “provide motivation, support and tips” can increase a smoker’s odds of quitting.

In her piece, reporter Patty Neighmond details the services offered to study participants:

In the texting groups, smokers started with an online support system and set a date to quit. When that day arrived, [Robyn Whittaker, MD, of the University of Auckland in New Zealand, who led the review] says, so did practical advice via text messages like this: “Today, you should get rid of all the ashtrays in the house or car; you should have a plan because it’s going to be hard in the first few days; make sure you have a plan to get support from friends and family.”

These were automated responses, but they could get personal. For example, if someone started to feel desperate, he could text a one-word reply: “Crave.” In response, says Whittaker, he would receive tips about how to get through the cravings. Things like “take a walk” or “eat a little something.” The good news, she says, is that cravings last only a few minutes.

And even setbacks got a quick, supportive response. “Sometimes people have one puff or a couple of puffs while out socially and think, ‘Oh, no, it’s all over, I’ve ruined it,’ ” says Whittaker. “But that’s not true. A lot of people have little lapses like that, and we can just try and boost their motivation to keep going because they can keep going, even after a relapse.”

Previously: Exercise may help smokers kick the nicotine habit and remain smoke-free, National Cancer Institute introduces free text message cessation service for teens, Kicking the smoking habit for good and Can daily texts help smokers kick their nicotine addiction?
Via @SusannahFox
Photo by Joi

Over the holiday weekend, Stanford professor and Scope contributor Keith Humphreys, PhD, discussed in the Wall Street Journal the possibility of treating addiction with a vaccine. After referencing a groundbreaking 2009 study that showed an anti-cocaine vaccine reduced cocaine use among participants, Humphreys wrote:

Treating addiction with a vaccine strikes most people, including many of my colleagues in the field, as radical. For other addictions (to nicotine, alcohol and opiates like heroin) the approach has been very different: The pharmacologic breakthroughs have come from medications that alter neurochemistry to reduce cravings or block the rewarding effects of drugs at particular receptors in the brain. Billions of dollars have been spent trying to develop similar medications for cocaine and methamphetamine addiction, but the results have been disappointing. A vaccine to combat addiction to these drugs would work as soon as the drug enters the body, before it has a chance to exert its powerful effects in the brain.

A vaccine would not be a magic bullet; it couldn’t stand on its own as a solution to cocaine and methamphetamine addiction. Cognitive-behavioral psychotherapy and 12-step groups have been shown to reduce stimulant drug use in rigorous research studies. Another approach using small, prompt rewards contingent on stopping drug use—rewards like meal vouchers and movie tickets—has been shown to be effective both in health-care settings and in the criminal justice system. But like everyone else in the addiction treatment field, I know that these approaches aren’t always helpful and might become more effective if combined with a medical approach.

Previously: Can an antidepressant help meth addicts stop using? and Addiction: All in the mind?
Photo by stevendepolo

Living in London this year on sabbatical, I worked with the Mayor’s Office and Parliament on a law that gave courts the power to sentence alcohol-abusing criminals to a period of mandatory sobriety. The new law was modeled on the successful “24/7 sobriety” program in South Dakota, which requires convicted drunk drivers to submit to twice-a-day breathalyzation.

At the time of the UK law’s passage, some women’s rights activists and politicians expressed concern that what worked with drunk drivers could be counter-productive with binge drinking wife batterers. Thanks to a study released on Friday by researchers at the RAND Corporation, these concerns can be laid to rest: Mandatory sobriety programs reduce both drunk driving and domestic violence.

The RAND research team, led by Beau Kilmer, PhD, exploited the fact that the mandatory sobriety program was initially rolled out slowly across South Dakota (it now operates statewide). This created a natural experiment in which counties that had yet to start their 24/7 sobriety program could be compared to those where the program was up and running. After looking at data on 17,000 offenders from 2005-2010, the researchers found that, as intended and expected, the program reduced repeat drunk driving arrests by 12 percent.

The pleasant surprise of the study was that domestic violence arrests dropped by almost as much as 9 percent. To put that figure in human terms, consider that even conservative estimates (link to .pdf) place the number of American women who are assaulted by an intimate partner at 1 million per year. A 9 percent drop would result in more than 100,000 fewer women being victimized each year, which would be an enormous benefit for women’s rights, health and safety.

How did 24/7 sobriety achieve this remarkable effect? Part of it is the program’s structure. Any offender who misses a breath test or shows up intoxicated endures a swift and certain consequence (typically, a night in jail). Faced with an approach that differs starkly from the more traditionally leisurely and unpredictable habits of the criminal justice system, most offenders change their ways. Indeed, over 99 percent of the more than 4 million breathalyzer tests done by the program have been negative.

But another factor is clearly at play. Though heavy drinking has become more common among young women, getting drunk and wreaking havoc remains primarily a young man’s game. In some South Dakota counties, as many as 10 percent of all young adult males have been on 24/7 sobriety. To quote Dr. Kilmer, “If you get a bunch of problem drinking males aged 18-40 to massively reduce their alcohol consumption, you shouldn’t be surprised to see a reduction” in domestic violence. After all, many a yob who drinks and drives also drinks and beats up his spouse or girlfriend.

Now that the data are in, courts should go forward without fear in applying mandatory sobriety sentences to a broad range of alcohol-involved crimes, including domestic violence. The result will be fewer road deaths, less property damage and less victimization of women.

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.

Photo by kraszipeti

In a recent New England Journal of Medicine Perspective piece (subscription required), Stanford psychiatrist Anna Lembke, MD, explored why physicians today experience intense professional pressure to prioritize pain treatment above other competing clinical issues.

Lembke discusses her work more in-depth in a podcast posted today on the blog Substance Abuse 411. During the conversation, she touched on reasons contributing to prioritizing pain treatment above other competing clinical issues and offered recommendations to address such problems.

Previously: Why doctors prescribe opioids to patients they know are abusing them