Substance abuse and recovery
(addiction as a medical condition)

Addiction, treatment, and recovery (generally)

Effective Addiction Treatment (Jane E. Brody, NY Times, 2-4-13) 'Contrary to the 30-day stint typical of inpatient rehab, “people with serious substance abuse disorders commonly require care for months or even years,” she wrote. “The short-term fix mentality partially explains why so many people go back to their old habits.”' "Look for programs using research-validated techniques, like cognitive behavioral therapy, which helps addicts recognize what prompts them to use drugs or alcohol, and learn to redirect their thoughts and reactions away from the abused substance."
"Other validated treatment methods include Community Reinforcement and Family Training, or Craft, an approach developed by Robert J. Meyers and described in his book, Get Your Loved One Sober, with co-author Brenda L. Wolfe. It helps addicts adopt a lifestyle more rewarding than one filled with drugs and alcohol."
Find Help (SAMHSA's links for substance abuse and mental health services)
• Norman Bauman, of the Association of Health Care Journalists, urges (for every recommended path to recovery): " Look at the evidence. Look for a review article in the major peer-reviewed journals (the medical librarians recommended NEJM, JAMA, Lancet, and BMJ to me, and those journals always cite Cochrane). Ask the proponents on all sides for evidence published in the peer-reviewed journals. Go through the HealthNewsReview checklist
Tips for analyzing studies, medical evidence, and health care claims
Cochrane Library
Cochrane evidence and systematic reviews
Story reviews
News release reviews
Symphony Health (monitors drug store sales, sells data to drug companies--a good source for journalists)
Portugal’s radical drugs policy is working. Why hasn’t the world copied it? (Susana Ferreira, The Guardian, 12-5-17) Since it decriminalized all drugs in 2001, Portugal has seen dramatic drops in overdoses, HIV infection and drug-related crime. You can read a longer (the original) version of this story here: Decriminalization: A Love Story (The Common, 11-1-17)
Narcan Opioid Overdose Spray Is Now Stocked By All Walgreens Pharmacies (Bill Chappell, The Two-Way, National Public Radio, 10-26-17)
The Office of National Drug Control Policy (ONDCP) convened a meeting to raise awareness of the importance of incorporating medication assisted treatment (MAT) as part of a comprehensive treatment regimen for incarcerated persons with opioid use disorder (OUD). "We should all remember that we have evidence-based community-standard medications that work for the disease of opioid addiction, and this should become the standard of care in corrections, and the criminal justice system broadly."-Dr. Kathleen Maurer, Connecticut Department of Corrections

There’s a highly successful treatment for opioid addiction. But stigma is holding it back. (German Lopez, Vox Science and Health, 7-20-17) Over the past few years, America’s harrowing opioid epidemic — now the deadliest drug overdose crisis in the country’s history — has led to a lot of rethinking about how to deal with addiction. For addiction treatment providers, that’s led to new debates about the merits of the abstinence-only model — many of which essentially consider addiction a failure of willpower — so long supported in the US....The Hazelden Betty Ford Foundation, for example, used to subscribe almost exclusively to the abstinence-only model, based on an interpretation of the 12 steps of Alcoholics Anonymous and Narcotics Anonymous popularized in American addiction treatment in the past several decades. But in 2012, Hazelden announced a big switch: It would provide medication-assisted treatment....With so many people dying from drug overdoses — tens of thousands a year — and hundreds of thousands more expected to die in the next decade, America is finally considering how its response to addiction can be better rooted in science instead of the moralistic stigmatization that’s existed for so long. The research is clear: Medication-assisted treatment works. Lopez compares the safety, ease of use, and effectiveness of methadone, buprenorphine (also known as Suboxone), and Naltrexone.
"The first US-based study comparing naltrexone and buprenorphine found that once people get on either, they are similarly effective. But that comes with a major caveat: It was much harder to get people started on naltrexone than buprenorphine because naltrexone requires a detox period. So buprenorphine is, on average, more accessible and effective than naltrexone — although results can vary from individual to individual."
• “There’s so much data from so many different places that if you add methadone or Suboxone in, deaths go down, and if you take it away, deaths go up.” Maia Szalavitz, a longtime addiction journalist and author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction
Only One In Twenty Justice-Referred Adults In Specialty Treatment For Opioid Use Receive Methadone Or Buprenorphine (Noa Krawczyk, Caroline E. Picher, Kenneth A. Feder, and Brendan Saloner, Health Affairs, Dec. 2017) "Of all criminal justice sources, courts and diversionary programs were least likely to refer people to agonist treatment. Our findings suggest that an opportunity is being missed to promote effective, evidence-based care for justice-involved people who seek treatment for opioid use disorder."
.• The addiction habit (Marc Lewis, Aeon). By the author of The Biology of Desire: Why Addiction Is Not a Disease (which combines "an account of brain change in addiction with subjective descriptions of what it’s like to live inside addiction"). Medical institutions define addiction as "‘chronic disease of brain reward, motivation, memory and related circuitry." If only the disease model worked. Yet, more and more, we find that it doesn’t. Addiction changes the brain but it's not a disease that can be cured with medicine, writes Lewis. In fact, it's learned – like a habit. Addiction perpetuates the need it was intended to satisfy and the addict learns to satisfy the need by getting and doing more. Neuropsychological habits develop through repetition – not merit, rationality, value or success. Thought-provoking.
Why ‘Substance Abuse’ Is a Label We Should All Reject (Maia Szalavitz, Pacific Standard, 3-26-14) 'Frame addiction as “substance abuse” and it is easy to see why it should be a crime, but call it “substance use disorder” and it sounds like something to be treated medically. If we want to make progress in ending stigma, we should think hard about the words we use....The “substance abuser” label encompasses the whole person, defining him or her by dysfunction. In contrast, the “substance use disorder” tag simply describes one problem, rather than an entire identity.' In a venue for health care journalists, Maia explains: "Addiction, as defined by the National Institute on Drug Abuse and summed up in the DSM, is compulsive drug use despite negative consequences. Substance misuse is just that: taking a drug in a way that it was not intended to be taken....The former "substance abuse" is now "substance use disorder, mild." and the former drug dependence is now 'substance use disorder, moderate to severe.' Personally, I just use addiction and substance misuse." Maia is the author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction. (The reviews on Amazon alone are enlightening.)
'Unbroken Brain' Explains Why 'Tough' Treatment Doesn't Help Drug Addicts (Terry Gross interviews Maia Szalavitz, author of Unbroken Brain, 7-7-16) Tough love, interventions and 12-step programs are some of the most common methods of treating drug addiction, but journalist Maia Szalavitz says they're often counterproductive. Maia challenges traditional notions of addiction and treatment, argues from research and experience; she was addicted to cocaine and heroin from the age of 17 until she was 23. She 'is a proponent of "harm reduction" programs that take a nonpunitive approach to helping addicts and "treat people with addiction like human beings." In her own case, she says that getting "some kind of hope that I could change" enabled her to get the help she needed.' The premise of the self-help 12-step programs, she argues, is that they make people think addiction is a moral problem, a sin, with treatment involving "prayer, restitution and confession." "Buprenorphine and methadone are the two most effective treatments that we have for opioid addiction, and that is when they are taken indefinitely and possibly for a lifetime....these medications are opioids themselves. They each have slightly different properties ... but what they do is they allow you to function completely normally. You can drive. You can love. You can work. You can do everything that anybody else does....The way they are able to do that is because if you take an opioid in a regular steady dose every day at the same time and the dose is adjusted right for you, you will not experience any intoxication. The way people with addiction experience intoxication is that they take more and more and more, they take it irregularly, the dosing pattern is completely different. But if you do take it in a steady-state way — which is what happens when you are given it at a clinic every day at the same time — you then have a tolerance to opioids which will protect you if you relapse, and will mean that the death rate from overdose in people who are in maintenance is 50 to 70 percent lower than the death rate for people who are using other methods of treatment, and that includes all of the abstinence treatments."
On a health journalists listserv, Maia argues: For years, the addiction field got by on claiming that 12 step based abstinence treatment was superior to every other approach for all addictions. Inpatient rehabs made fortunes because you hire a bunch of low cost formerly addicted people with maybe a high school education as counselors and charge hospitalization level rates as if they are being treated by doctors rather than basically getting a whole day of what you could get for free in church basements. It's a bit better now, with some actually providing some semblance of evidence based counseling, psychiatric care (50% have another diagnosis), trauma care (2/​3 have experienced at least one potentially traumatic childhood event, much higher rates of trauma than general population. These however, are difficult to find. Nonetheless, because the field didn't bother to create evidence based care and in fact based the 28 day model on the maximum of what insurance would then cover, rather than data, it's hardly surprising that insurance companies don't want to pay for it and that determining parity is hard. A good start would be to require that no 12 step content be included in paid rehab. That way, they can't argue they're paying for what you can get elsewhere for free, nor will people be forcibly subjected to things like 'surrender to a higher power' and 'moral inventory' when they are supposedly getting treatment for a disease."
The President's Commission on Combating Drug Addiction and the Opioid Crisis (11-2-17)
The Parity Act Tracking Project: Making Parity a Reality (, 6-20-17) At a time of national crisis arising from opioid misuse, abuse and overdose, it is difficult to overstate the urgency of the need for significant improvement in the equitable coverage of addiction treatment benefits, as required by law.
This American War on Drugs (Brooke Gladstone and Bob Garfield, WNYC, On the Media, 4-14-17) Four segments: Breaking News Consumer's Handbook: Drugs Edition, The Man Who Declared War On Drugs (a fascinating and shameful history, in which a man named Harry does a huge disservice to singer Billie Holiday), A (Long) History of American Drug Panics, A Case for Law Enforcement. A whole lot of injustice with various presidents in starring roles. Drug fear often stands in for fear of "the other."
Making Space for Sobriety (Ryan Caron King, Atavist, published on WNPR). When a person who addicted to drugs or alcohol is discharged from rehab, they’ll sometimes live in what’s called a sober house -- a place where there’s supposed to be no drugs or alcohol around. Same as or similar to How One Agency Is Improving Conditions in Connecticut's Sober Houses (Ryan Caron King, WNPR, 10-4-16) "When someone who is addicted to drugs or alcohol is discharged from rehab, they’ll sometimes pay to live in a privately-owned sober living home like this one, Right Path House. But private sober houses aren’t regulated by the state, and experts in the field say some houses don’t enforce their own sobriety rules -- which can jeopardize the safety of the people that live there and the neighborhood the house is in. So Aligata is working to train and certify sober house owners across the state through a voluntary program. He wants to compile an online database of certified sober houses that he hopes will make it easier for people with addiction to find a place to continue their recovery after rehab."
Shattering the Silence (Perry Gaidurgis's video about alcoholism, addiction, children of alcoholics, and recovery)
Understanding Addiction: How Addiction Hijacks the Brain ( Addiction involves craving for something intensely, loss of control over its use, and continuing involvement with it despite adverse consequences. Addiction changes the brain, first by subverting the way it registers pleasure and then by corrupting other normal drives such as learning and motivation. Although breaking an addiction is tough, it can be done.
Help With Addiction and Substance Use Disorders (American Psychiatric Association) Links to useful articles and other resources.
What Is Addiction? (excellent quickie overview of current views and explanations of addiction, from Lumiere, a chain of healing centers)
The AP Learns to Talk About Addiction. Will Other Media Follow? (Maia Szalavitz, UnDark, 6-6-17) The influential stylebook discards ‘addict’ and ‘alcoholic’ for nonjudgmental language that recognizes addiction as a medical disorder. “Addict” should no longer be used as a noun. “Instead,” the stylebook says, “choose phrasing like ‘he was addicted.’” In short, separate the person from the disease. "Language is complicated and often slow to change — and for a group that has been criminalized, fighting stigma and misinformation is a constant struggle. But when the media start treating people with addiction with the same respect that they use for other patients, perhaps the rest of America will start to accept that addiction is a medical problem and that moralizing and punishment have failed." See also Why We Should Say Someone Is A 'Person With An Addiction,' Not An Addict (Maia Szalavitz, Shots, NPR, 6-11-17). On the same message: Journalists, Stop Using Words Like Addict and Drug Abuser (Zachary Siegel, Slate, 6-6-17) Being called an “addict” defines my humanity with one small facet of my identity, essentially erasing the rest of me.
Medicaid Coverage For Addiction Treatment Varies Dramatically (Carmen Heredia Rodriguez, Kaiser Health News, 12-6-16) A study published in the journal "Health Affairs found significant disparities in coverage among the states. Researchers sought to determine the number of substance treatment services available in each state in 2014. They analyzed coverage for the four tiers of services recognized by the American Society for Addiction Medicine, which are classified as outpatient (including group and individual therapy as well as recovery support services), intensive outpatient, short- and long-term residential inpatient and intensive inpatient care for detoxification. At the time of the study, 21 states had expanded Medicaid. The federal health law required states that chose to expand their Medicaid programs to include coverage for substance abuse treatment. But it gave states control to decide the type of treatment and medication that would be covered. Overall, the researchers found the level of Medicaid coverage for substance abuse treatment did not correlate with Medicaid expansion....In particular, states shied away from covering residential interventions, which the federal government had historically chosen not to reimburse for mentally ill patients insured by Medicaid....The coverage disparity across the nation extended to medications used to manage addiction. Every state and the District of Columbia insured buprenorphine, and all but two states covered injectable naltrexone. However, only 32 Medicaid programs covered methadone, one of the most effective drugs in managing addiction, according to the American Society for Addiction Medicine." "But the study also revealed several hurdles in accessing services and life-saving medication. It found many states limited access to substance abuse treatment by requiring preauthorization, imposing annual maximums or asking for patients to pay a share of the costs."
How to Choose an Addiction Treatment Program, an excerpt from The Recovery Book: Answers to All Your Questions About Addiction and Alcoholism and Finding Health and Happiness in Sobriety by Al J. Mooney M.D. and Catherine Dold.
Behavioral Health Treatment Services Locator (SAMHSA) A confidential and anonymous source of information for persons seeking treatment facilities in the United States or U.S. Territories for substance abuse/​addiction and/​or mental health problems. Or Call
SAMHSA’s National Helpline
1-800-662-HELP (4357)
1-800-487-4889 (TDD)
Cognitive-Behavioral Therapy for Substance Use Disorders (R. Kathryn McHugh, Bridget A. Hearon, and Michael W. Otto, Psychiatr Clin North Am. 2010 Sep; 33(3): 511–525.) Cognitive behavioral therapy (CBT) for substance use disorders has demonstrated efficacy as both a monotherapy and as part of combination treatment strategies. This article provides a review of the evidence supporting the use of CBT, clinical elements of its application, novel treatment strategies for improving treatment response, and dissemination efforts.
A physician enters rehab. What happens next should disturb you. (Anonymous doctor, KevinMD, 7-4-15) "The price paid in dollars, reputation, and emotional upheaval in the family might have been justified if these treatment centers had a record of success. Unfortunately, without monitoring and contingency management, there’s no evidence that physician health programs achieve more than the abysmal rates of remission seen with non-MD clients." "Although Alcoholics Anonymous and its many spinoffs do not have a record of success, my medical licensure was contingent upon participation after rehab....without constant and obsessive AA attendance and a relationship with a sponsor that was contingent upon talking about something I had no interest in discussing ad nauseum, the PHP claimed I would not be “in recovery.”
You Can Rely on Drugs Without Being an Addict (Maia Szalavitz, Vice, 12-20-16) "It may seem like a trivial or academic distinction, but addiction is not dependence, and dependence is not necessarily a problem...if addiction is properly understood as compulsive drug use despite negative consequences, maintenance cannot be seen as addiction. What maintenance does, in fact, when it works most effectively, is replace compulsive drug-seeking (in the face of harm) with simple physical dependence. This is not a problem if someone has a safe, regular supply."
Why taking drugs to treat addiction doesn’t mean you’re ‘still addicted’ (Sarah E. Wakeman and Maia Szalavitz, STAT, 5-18-17) Among other things, "people stabilized on medications like methadone are not addicted — they don’t engage in compulsive use despite consequences — but merely dependent. (When opioids are taken in a steady, regular dose appropriate for a particular patient, that person will not be impaired and can safely drive, work, and parent.)"..."confusing “dependence” and “addiction” spurs bias against the most effective known treatment for opioid addiction: long-term use of methadone or buprenorphine (Suboxone). Decades of research show that these medications dramatically reduce the risk of death, HIV infection, and recurrence of drug use....Yet the common myth is that people taking these medications are 'still addicted' and that residential treatment is a better option....Mistaking dependence for addiction can also harm patients with chronic pain. Those who benefit from opioid therapy can be mislabeled as addicted, when, in fact, they are physically dependent. This can lead to cessation of an effective treatment — and sometimes even suicide."
A 20-Year-Old Went to Rehab and Came Home in a Body Bag (Wilbert L. Cooper, Vice, 11-4-14). An expose of the high-end-$$ drug treatment world, through the story of one boy and family it failed: Brandon Jacques, whose dual diagnosis of bulimia and alcohol addiction called for better treatment and medical care than the overpriced "treatment" facility could provide. ("'s illegal for residential drug and alcohol programs like Morningside to provide any medical care in the State of California, because of an old, controversial law that is a vestige of the rehab industries' AA-based, nonmedical beginnings....Because the State of California has done such a poor job of enforcing the ban on in-house professional medical care, facilities like Morningside get the best of both worlds--they can market themselves as medical facilities to attract more clients without fear of getting shut down, but they don't have to spend the money on medical care or jump through the regulatory hoops required of a facility practicing medicine.") Here is video on the same story: From Rehab to a Body Bag: Dying for Treatment (Vice video, Nov 2014) "Although non-hospital residential treatment serves only about 10 percent of those in recovery in the US, the exorbitant cost of such care--as high as $75,000 a month--has made it extremely lucrative....these centers operate in a gray zone somewhere between legitimate medicine and total quackery, offering things like horseback riding and meditation as solutions to addiction, and often promising medical care that they are unable to provide--sometimes with disastrous results."
Point of Return (experts in recovery from benzodiazepine, sleeping pills, and antidepressants)
Neurobiologic Advances from the Brain Disease Model of Addiction (Volkow ND, Koob GF, McLellan AT. N Engl J Med. 2016 Jan 28;374(4):363-71. DOI: 10.1056/​NEJMra1511480) Free full text of a good review article on the science of addiction.

Why It’s Easier to be Prescribed an Opioid Painkiller than the Treatment for Opioid Addiction (Jeffrey Hom and Krisda Chaiyachati, Health Policy$ense, UPenn LDI, 5-31-16) Despite alarming statistics about opioid abuse and the significant attention focused on the epidemic, a hidden regulatory imbalance exists between two types of opioids – those prescribed for pain and those prescribed to treat opioid addiction. "As physicians, we need to obtain only a license from the Drug Enforcement Agency (DEA) in order to prescribe opioid painkillers. Maintaining it requires a licensing fee every three years, but there is no mandatory training on how to safely prescribe these medications and no requirements to monitor patients who receive them. There is, in short, little oversight.
"In contrast, heavy regulations restrict those providers wishing to treat addiction by prescribing buprenorphine, the mainstay of medication-assisted treatment for opioid addiction outside of methadone clinics. Although buprenorphine was approved by the FDA in 2002, it remains underused, far below the levels needed to meet the growing number of individuals requiring treatment."

What’s in a Word? Addiction Versus Dependence in DSM-V (Charles P. O’Brien Nora Volkow T-K Li, American Journal of Psychiatry, 5-1-06) Do not use the word "dependence" to mean addiction," wrote Maia Szalavitz to her fellow health care journalists. DSM dropped that "because dependence can occur without addiction and addiction can occur without dependence. People on maintenance treatment and people in chronic pain can be physically dependent on opioids and people are physically dependent on some antidepressants and blood pressure medications, but if the treatments are
working, these are NOT addictions."
Recovering Together: The Benefits Of Adopting A Companion Animal While In Addiction Recover ( The benefits of a companion animal.
Why It's Wrong to Call Drug Users "Addicts" (Megan Ralston, AlterNet, 3-25-14) We don't say "My mother, the blind" or "my brother, the bipolar."
The Fix (“Addiction and recovery, straight up”). A website about addiction and recovery, featuring a daily mix of breaking news, exclusive interviews, investigative reports, essays and blogs on sober living, lifestyle and cultural resources, as well as knowledge and wisdom from expert counsel. Offers "offer rigorously reported Rehab Reviews ("Zagat-like reviews of rehab facilities"), with input from thousands of alumni, plus extensive directories and practical guides for dealing with addiction and related mental health and life issues." See Challenging the Second ‘A’ in A.A. (David Colman, NY Times, 5-6-11) and Is It Time to Take the Anonymous Out of AA? (Susan Cheever, The Fix, 4-7-11)

Unbroken Brain: A Revolutionary New Way of Understanding Addiction by Maia Szalavitz, to be released in 2016. "Challenging both the idea of the addict's 'broken brain; and the notion of a simple 'addictive personality,' Unbroken Brain offers a radical and groundbreaking new perspective, arguing that addictions are learning disorders and shows how seeing the condition this way can untangle our current debates over treatment, prevention and policy. Like autistic traits, addictive behaviors fall on a spectrum -- and they can be a normal response to an extreme situation. By illustrating what addiction is, and is not, the book illustrates how timing, history, family, peers, culture and chemicals come together to create both illness and recovery- and why there is no "addictive personality" or single treatment that works for all. Combining Maia's personal story with a distillation of more than 25 years of science and research, Unbroken Brain provides a paradigm-shifting approach to thinking about addiction."

Picking Addiction Help (Jane E. Brody, NY Times, 2-11-13) '“Treatment is not a prerequisite to surviving addiction.” This bold statement opens the treatment chapter in a helpful new book, Now What? An Insider’s Guide to Addiction and Recovery, by William Cope Moyers, a man who nonetheless needed “four intense treatment experiences over five years” before he broke free of alcohol and drugs.'

Substance abuse treatment often impossible to find (Larry Copeland, USA Today) Promising strategies gather dust: 'It's hard to get anyone to pay attention until it happens again.' Joan Ayala now works as a mental health clinician trying to help others avoid her decades-long ordeal.

Pornography: Does it pose a public health crisis? (Sarah Glazer, GQ Reports, 10-21-16) Yes, porn addiction is a problem.

We must change the way we think about drug addiction in Maryland (Dan Morhaim, Opinion, Wash Post, 2-5-16) An emergency room physician for more than 30 years, Morhaim is introducing four bills that would fundamentally transform drug policy in Maryland. His proposals aim to reduce the harms associated with drug use, including rates of addiction, deadly overdoses, the spread of infectious disease and the incarceration of people who use drugs. One bill would require addiction treatment in ERs. That’s where addiction treatment should begin, and it’s more effective than jail. Another bill would keep drug users who use minimal amounts out of the criminal-justice system, saving critical resources and avoiding the costs of saddling more Maryland citizens with criminal records and the related adverse consequences. The other two bills require a shift in how we think about and treat addicts. One would allow for the administering of pharmaceutical-grade drugs to a small and unresponsive group of heroin abusers, with medical supervision. The final bill calls for the creation of a safe-consumption program that would create supervised spaces for individuals to consume controlled substances, reducing rates of overdose death and the spread of infectious disease and connecting them with rehabilitation programs.

CRAFT: An Alternative to Intervention (Robert J. Meyers, page on the essence of CRAFT, from the HBO program on ADDICTION)

What I Wish I Had Done Differently With My Drug-Addicted Kid (Ron Grover, Drugfree, 8-13-13). Read the comments for a variety of responses.

The Science of Addiction: Drugs, Brains, and Behavior. Two NIH institutes — the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) — have joined with HBO to reveal startling new advances in the fight against alcohol and other drug addiction.
Treatments for Substance Use Disorders (SAMSHA, the federal Substance Abuse and Mental Health Services Organization)

Narcotics Anonymous (NA)
Alcoholics Anonymous (AA)
Al-Anon Family Groups (strength and hope for friends and families of problem drinkers)
Nar-Anon Family Groups (a 12-step program for families & friends of addicts)
Co-Dependents Anonymous (CoDA) What it was like...we found in each of our lives that codependence is a deeply rooted compulsive behavior born out of our dysfunctional family systems.
The Hidden Link Between Autism and Addiction (Maia Szalavitz, The Atlantic, March 2017) It’s believed that people on the spectrum don’t get hooked on alcohol or other drugs. New evidence suggests they do. You can follow Maia on Twitter: https:/​/​​maiasz
Recovery and Recovery Support (SAMSHA)
Drug Abuse (NIDA, links to many resources, including NIH clinical trials locator)
A to Z list of Programs, Campaigns, Initiatives, Technical Assistance Centers, or Resource Centers (SAMHSA)
Where do 12-step or self-help programs fit into drug addiction treatment? (National Institute on Drug Abuse, NIDA)
Medication-Assisted Treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders.
Treatment centers: 12-step and MAT should coexist (Allison Insinger, Alcoholism Drug Abuse Weekly, 2-24-14, posted by Twin Town Treatment Centers)
DC Calls it Quits (David Zauche, Altarum Institute, Systems for Better Health, 9-24-15). "Smoking is the leading cause of preventable death and disease in the United States, taking more than 480,000 lives annually. The economic costs due to smoking-related illness in the United States are estimated at more than $300 billion each year in direct medical expenses and lost productivity. Many states and cities across the nation are answering the call to action by implementing policies to protect against the devastating effects of tobacco. Altarum's ActionToQuit program supports this DC campaign and hopes that more cities will follow suit." See resources on the Altarum website: Altarum Institute.
Substance Abuse: A guide for parents and educators (AddictionResource)
Peer Support and Social Inclusion
Addiction, Heart Disease, and Stroke (Recovery Connection)
Addiction and HIV (Human Immunodeficiency Virus) (Recovery Connection)
Can addiction be treated successfully? (NIDA, or National Institute on Drug Abuse) NIDA states in its Principles of Drug Addiction Treatment, “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems.”
Drugs, Brains, and Behavior: The Science of Addiction
Alcohol and Your Health ( NIAAA, or National Institute on Alcohol Abuse and Alcoholism)
Find an AA meeting (Alcoholics Anonymous)
Refuge Recovery (a Buddhist path to recovering from addiction)
Harm reduction (Harm Reduction Coalition -- a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use)
Ayahuasca Can Change Your Life -- As Long as You're Willing to Puke Your Guts Out (LA Weekly, 11-21-13)
Differences Between SMART Recovery and AA (Smart Recovery)
Why SMART Recovery Will Never Replace Alcoholics Anonymous (Matthew Leichter, The Fix, 9-23-14) Five reasons why SMART Recovery will never push out AA as the main model of recovery, despite higher success rates.
Evidence-Based Approaches to Drug Addiction Treatment, read online this chapter from Principles of Drug Addiction Treatment: A Research-Based Guide (National Institute on Drug Abuse)
Managing chronic pain. Pain patients seek other options.
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No Quick Fixes: Telling the Story of Long-term Recovery from Opioid Addiction (Susan Stellin, NiemanReports, 1-24-18) Journalists do a good job telling stories about drug addiction, but not about the recovery process.As more people in recovery decide to share their stories, journalists are exploring the under-reported experiences of people who have been drug-free for many years. There has been no shortage of stories documenting the toll of the epidemic, but it is much tougher to report on how the U.S. should address it.
Journalist Norman Bauman urges (for every recommended path to recovery): " Look at the evidence. Look for a review article in the major peer-reviewed journals (the medical librarians recommended NEJM, JAMA, Lancet, and BMJ to me, and those journals always cite Cochrane). Ask the proponents on all sides for evidence published in the peer-reviewed journals. Go through the HealthNewsReview checklist
Tips for analyzing studies, medical evidence, and health care claims
Law Enforcement Assisted Diversion (LEAD, an innovative pilot program in a Seattle neighborhood that was developed with the community to divert low-level drug and prostitution offenders into community-based treatment and support services – including housing, healthcare, job training, treatment and mental health support -- instead of processing them through traditional criminal justice system avenues.
The Secret Lives of Recovered, Dual-Diagnosed Alcoholics (Christine Stapleton, Depression on My Mind, Psych Central, 8-22-16)
Focus on good news in addiction treatment (Palm Beach Post, 9-5-17).
The Healing Forest Project (Derek Wolfe, Medium, August 11, 2016) This series explores how Ann Arbor, Michigan has taken a community-based approach to recovery, the idea being to create a “healing forest” locally rather than sending people for treatment in another state. "The series presents a thorough overview of the factors necessary to create a community supportive of recovery, including access to treatment, affordable housing for people transitioning out of residential care, employers willing to hire staff members in recovery, educational programs that offer an alternative to campus drinking culture, and support groups that provide a sober social network, and role models who are in recovery themselves."~Susan Stellin.
“The thing that bothers me most about addiction coverage is that I don’t think it’s really honest about what happens to people when they’re addicted to drugs. That’s not being covered enough—how much addiction ravages people’s lives in every way.” —Derek Wolfe, author of “The Healing Forest Project”
---Part 1: Addiction and Recovery in America Opioid use has risen dramatically. To reverse this trend, the solution lies in our approach to substance use
---Part 2: What, exactly, is a Healing Forest? It’s more than an abstract concept. Ann Arbor, Michigan, is one.
---Part 3: Access to treatment: A look at Dawn Farm and the role of treatment centers in the Healing… Treatment centers play a crucial role in fostering the Healing Forest.
---Part 4: The housing issue (8-11-16) High rent prices make living in Ann Arbor a challenge
---Part 5: Finding a support group and how to get there The role of meetings and transportation in the recovery community
---Part 6: Zingerman’s and The Lunch Room: An examination of inclusive work cultures Restaurants foster honesty and openness among staff that makes for a positive environment for those in recovery
---Part 7: Access to education can be instrumental for recovery The University of Michigan and Eastern Michigan give opportunities to individuals in recovery to turn around their lives.
---Part 8: Reducing the stigma and growing more Healing Forests Changing the culture around addiction and recovery is within our grasp
Addicts Need Help. Jails Could Have the Answer. (Sam Quinones, NY Times, 6-16-17) This sparked criticism, including Jail Isn’t the Place to Treat Drug Addiction (6-6-17)
What Sobriety Taught Me (So Far) (John Gorman, P.S. I Love You, Medium, 1-26-18) The nature and the nurture of reality. "I want to fully inhabit this body and not be the surveillance camera in the corner monitoring my every move. "
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The addiction paradox (Bruce Bower, Science News, 3-7-14). Drug dependence has two faces — as a chronic disease and a temporary failure to cope
Effective Addiction Treatment (Jane Brody, NY Times, 2-4-13)
Adolescent Brain Cognitive Development Study (Collaborative Research at NIH) The ABCD Study is a national longitudinal study that will assess the short- and long-term impact of substance use on brain development. The project will recruit 10,000 youths before they begin using alcohol, marijuana, tobacco and other drugs, and follow them over 10 years into early adulthood. See frequently asked questions about the study and The CRAN blog.
One Hundred Years Ago Today, Prohibition Began in Earnest. We’re Still Paying. (Maia Szalavitz,, 12-17-14). On December 17, 1914, Congress passed the Harrison Act, making nonmedical opium and cocaine illegal. It was really about punishment, not public health. And it set the tone for a disastrous century.
Addiction Medicine: Closing the Gap Between Science and Practice (CasaColumbia, June 2012) “Only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.”
The Clean Slate Addiction Site (maintained by Maia Szalavitz).
Rat Park, Stuart McMillen's comic about a classic study of (experiment about) drug addiction conducted in the late 1970s (and published in 1980) by Canadian psychologist Bruce K. Alexander and his colleagues.
Closing the Addiction Treatment Gap) (CATG, 'Addiction is a disease. Let's treat it that way.") A national program of the Open Society Institute, founded in 2008. This PDF is a 2010 report on three-year $10 million effort to expand treatment by expanding insurance coverage, increasing public funding, and making systems and programs more efficient.
Addiction Recovery Basics
The Recovery Book: Answers to All Your Questions About Addiction and Alcoholism and Finding Health and Happiness in Sobriety by Al J. Mooney M.D. and Catherine Dold
Alcoholics Anonymous: The Big Book, 4th Edition.
Faces & Voices of Recovery (FAVOR) (why living in safe, sober and peer supportive environments matters in recovery) Faces & Voices believes that our nation’s response to the crisis of addiction should be based on sound public health science and the grassroots engagement and involvement of the recovery community – people in recovery, their families, friends and allies – organized in identifiable and mobilized networks of recovery community and allied organizations that foster collaboration, advocacy and public education about the reality of addiction recovery.
ManyFaces1Voice No longer will we remain silent. We want to sensationalize recovery, because recovery is sensational." Together we will change public perception, and ultimately the public response to the addiction crisis.
Gateway Drugs: How Does Addiction Start? (Michael's House).
The Trouble With Tough Love (Maia Szalavitz, Wash Post, 1-29-06) A MUST READ. "The trouble with tough love is twofold. First, the underlying philosophy -- that pain produces growth -- lends itself to abuse of power. Second, and more important, toughness doesn't begin to address the real problem."
NIH State-of-the-Science Conference Statement on Preventing Violence and Related Health-Risking Social Behaviors in Adolescents (NIH, 2004) "Programs that seek to prevent violence through fear and tough treatment appear ineffective. Intensive programs that aim at developing skills and com­petencies can work."
ManyFaces1Voice, a campaign to transform public attitudes and policies affecting people seeking or in recovery from addiction to alcohol and other drugs. Whether behind the scenes or on the front line, every recovery voice is needed. See trailer to the film The Anonymous People.
Crack baby myth goes up in smoke (Todd Reed, America Tonight, Aljazeera, 3-10-15). A Philadelphia study found no gap in health and life outcomes for babies exposed to crack versus ones who weren’t. Poverty, however, posed a major risk.
Exercise: Alternative reward for those battling addiction (James Fell, Chicago Tribune, 6-12-13)
The D.S.M. Gets Addiction Right (Howard Markel, Opinion, NY Times, 6-5-12)
A New Scientific American eBook, Understanding Addiction, Examines the Multifaceted Issue of Substance Abuse (9-17-13)
[Back to Top]

Addiction to opioids and psychoactive drugs

Psychoactive drugs are typically categorized as stimulants, depressants, opiates & opioids, and hallucinogens. As explained on Castle Craig Hospital's very helpful (UK) website:

STIMULANTS--cocaine, crack cocaine, amphetamines (speed) and ecstasy (also a hallucinogen).
These "act on the central nervous system and are associated with feelings of extreme well-being, increased mental and motor activity."

DEPRESSANTS--alcohol and cannabis, in particular, as well as barbiturates and benzodiazepines (e.g. valium, temazepam).
These "slow down the central nervous system and suppress brain activity causing relief from anxiety."

OPIATES & OPIOIDS--heroin, morphine, opium, methadone, dipipanone, and pethidine.
These "provide pain relief, euphoria, sedation and in increasing doses induce coma."

HALLUCINOGENS--cannabis, LSD, ecstasy and psilocybin ("magic mushrooms").
These "cause changes in a person's perception of reality."

We focus at first on the opioid crisis.
OPIATES & OPIOIDS--heroin, morphine, opium, methadone, dipipanone, and pethidine.
These "provide pain relief, euphoria, sedation and in increasing doses induce coma."
America Addicted (PBS Newshour series, October 2017) 91 Americans die every day from opioid overdose. The opioid crisis is devastating communities across the nation. Overdose deaths are at record highs. How can the epidemic be stopped?
The Problem: America’s communities weren’t built to handle the opioid crisis. Across the nation, public services, health care providers and civil servants are overwhelmed by the shared burden of addiction. At their worst, opioids damage communities as severely as they damage individuals.
---At an innovative high school, students get support battling their addictions while they learn (10-3-17)
---Opioid addiction is the biggest drug epidemic in U.S. history. How’d we get here? (PBS, 9-29-17) Every day brings another story about the depth of the country’s opioid crisis. A rise of pain killer prescriptions from doctors and a pharmaceutical industry eager to boost sales in the 1990s sparked a wave of addiction that shot up by almost 500 percent in the last 15 years.
---A community overwhelmed by opioids (PBS, 10-2-17) In Huntington, West Virginia, first responders face burnout after repeated calls, the foster care system strains to support the children of addicts and even the rain sewers are clogged with discarded needles. How can the community cope?
---Saving the babies of the opioid epidemic (Laura Santhanam, PBS, 10-2-17) One in five babies born in West Virginia’s Cabell County-Huntington Hospital were exposed to controlled substances during pregnancy, and as many as 400 require medication for withdrawal. Sara Murray opened a special neonatal unit five years ago to help care for the babies being weaned off opioids.
---Poll: Most Americans think Trump hasn’t done enough to fix opioid crisis (Laura Santhanam, PBS, 10-3-17) The nation’s outlook for the opioid crisis is pessimistic. Four out of 10 Americans foresee no difference in the level of addiction to pain medication a year from now, while another third of U.S. adults only see things getting worse. “There’s quite a gap between people’s awareness of this being a problem and the sense that someone’s actually stepping up to the plate and addressing it.”
---Column: How to talk to your kids about opioids (Margie Skeer, Tufts University, PBS, 10-2-17)
THE DRUGS. "We're talking about a substance that is poison. It's manufactured death." Where do the drugs come from? How do they infiltrate communities? How do opiates alter the minds of users? Understanding the drugs is the first step in understanding the crisis.
Trump Declares Opioid Crisis a ‘Health Emergency’ but Requests No Funds (Julie Hirschfeld Davis, NY Times, 10-26-17) "President Trump on Thursday directed the Department of Health and Human Services to declare the opioid crisis a public health emergency, taking long-anticipated action to address a rapidly escalating epidemic of drug use. But even as he vowed to alleviate the scourge of drug addiction and abuse that has swept the country — a priority that resonated strongly with the working-class voters who supported his presidential campaign — Mr. Trump fell short of fulfilling his promise in August to declare “a national emergency” on opioids, which would have prompted the rapid allocation of federal funding to address the issue." The video that comes up on this story provides an excellent brief account of what opioids are and what caused the current opioid crisis.
In White House opioid plan, advocates see a major puzzle piece missing: naloxone (Lev Fatcher and Andrew Joseph, STAT, 10-27-17)
How the government can fight the opioid epidemic under a public health emergency (Lenny Bernstein, Washington Post, 10-26-17) At this point in the nation's opioid epidemic, fighting back is mainly about quickly making money available: Money for treatment. Money for the overdose antidote naloxone. Money to hire more people to help overwhelmed cities and states battle a crisis that killed an estimated 64,000 Americans last year.
The surgeon general and his brother: A family’s painful reckoning with addiction (Andrew Joseph, STAT, 12-7-17)
Opioids and Paternalism (David Brown, American Scholar, Autumn 2017) "The proliferation of opioid use in the United States is called an epidemic, but it more resembles metastatic cancer. The malignant effects extend far beyond the 300,000 Americans who’ve died since 2000. Prescription opioids are creating a pharmaceutically damaged underclass, trapping millions of people in a culture of victimhood and economic dependence, or for the unlucky, a world of criminal behavior and lethal illicit drugs. At the same time, opioids are damaging the medical profession and its practitioners in ways that will take years to acknowledge and redress....The opioid epidemic is entangled with economic and cultural forces, but it begins with pain. People—physicians especially—are going to have to think differently about pain for the epidemic to end."
STAT forecast: Opioids could kill nearly 500,000 Americans in the next decade (Max Blau, STAT, 6-27-17)
Relaxing privacy rules to fight opioid addiction draws fire from treatment advocates (Erin Mershon, STAT, 9-27-17)
Behind the luxury: Turmoil and shoddy care inside five-star addiction treatment centers (David Armstrong, STAT, and Evan Allen, Boston Globe, 8-25-17) "The marketing blitz and an infusion of private equity money have helped make Recovery Centers of America into the self-described fastest-growing addiction treatment provider in the country. Launched less than three years ago by a high-end real estate developer, it’s part of a rush of entrepreneurs who see opportunity in the treatment business as the opioid crisis sweeps the country." Armstrong and Allen report on "shoddy care and turmoil inside the walls of the company’s two Massachusetts treatment centers."
****Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. (L. Sordo et all, BMJ, PubMed, 4-26-17). "Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids. The induction phase onto methadone treatment and the time immediately after leaving treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies to mitigate such risk. These findings are potentially important, but further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment."

Taylor Wilson’s parents fought for 41 days to get their daughter treatment. They couldn’t stop another overdose (Max Blau, STAT, 3-16-17)
Dope Sick: A harrowing story of best friends, addiction — and a stealth killer (David Armstrong, STAT, 8-2-16) A long-form story.
Chasing Heroin (video, Frontline documentary, 2-23-16) A searing, two-hour investigation of America's heroin crisis.
Another Circle of Hell: Surviving Opioids in the Fentanyl Era (Martha Bebinger, WBUR, KHN, 4-7-17) More powerful and more deadly than heroin, the synthetic opioid fentanyl has sparked a new set of survival rules among people who abuse opioids. "Fentanyl is an opioid 50 times more powerful than heroin. There’s a legal, Food and Drug Administration-approved version. But labs in China are churning out cheap versions of fentanyl that dealers are selling on the streets mixed with fillers, heroin or other drugs. Buyers have no idea how much fentanyl they are getting or how much risk they are taking with every injection." Fentanyl may be especially lethal because it’s strong, it’s mixed with other drugs in varying amounts unknown to the user, and it can trigger an overdose within seconds. Unlike heroin, fentanyl routinely shuts down breathing in seconds, and it’s becoming more common.
Delivered ‘Like A Pizza’: Why Killer Drug Fentanyl Is So Hard To Stop (Martha Bebinger, WBUR/​KHN, 12-2-16) Just a few grains of pure fentanyl is enough to kill most users. But law enforcement sources say stopping the supply of the deadly synthetic opioid from China and Mexico is very difficult.
Down The Rabbit Hole: A Chronic Pain Sufferer Navigates the Maze of Opioid Use (Janice Lynch Schuster, My Narrative Matters, Health Affairs, July 2014). Read full story. See also http:/​/​​newshour/​updates/​one-woman-manages-chronic-pain-invisible-affliction/​ (Ruth Tam's interview with Schuster on PBS Newshour, 7-9-14).
The Truth About Suboxone (Maia Szalavitz, The Fix, 12-01-11) Studies show that maintenance therapy is the most effective treatment for opiate addiction. So why are abstinence fundamentalists so bitterly against it?... an outdated and stigmatizing attitude towards maintenance treatment can—and frequently does—kill hundreds of struggling addicts who depend on these meds to stay off the streets....Even the Betty Ford Center agrees that people taking daily methadone or buprenorphine should be considered every bit as "in recovery" as those who just “don’t drink and go to meetings.” A 2007 consensus panel to define recovery convened by that august facility put it plainly: "To be explicit, formerly opioid-dependent individuals who take naltrexone, buprenorphine or methadone as prescribed and are abstinent from alcohol and all other non-prescribed drugs would meet this consensus definition of sobriety." Some in abstinence-based recovery feel compelled to proselytize about the dangers of the substances they once could not live without. This “drug-free” rhetoric helps them avoid temptation. It also gives the added buzz of self-righteousness that comes from feeling superior to others. [But] It’s not necessary for maintenance to be bad to make abstinence good.
1 Son, 4 Overdoses, 6 Hours (Katharine Q. Seelye, NY Times, 1-21-18) Drug deaths draw the most notice, but more addicted people live than die. For them and their families, life can be a relentless cycle of worry, hope and chaos. Far more, like Patrick Griffin, are snared for years in a consuming, grinding, unending cycle of addiction. "In Patrick’s home state of New Hampshire, which leads the country in deaths per capita from fentanyl, almost 500 people died of overdoses in 2016. The government estimates that 10 percent of New Hampshire residents — about 130,000 people — are addicted to drugs or alcohol. The overall burden to the state, including health care and criminal justice costs and lost worker productivity, has ballooned into the billions of dollars. Some people do recover, usually after multiple relapses. But the opioid scourge, here and elsewhere, has overwhelmed police and fire departments, hospitals, prosecutors, public defenders, courts, jails and the foster care system. Most of all, though, it has upended families. All of the Griffins speak of nonstop stress." A Surgeon General’s report in 2016 said that the younger people are when they start taking drugs, the more likely they are to become addicted long-term. See also How a ‘Perfect Storm’ in New Hampshire Has Fueled an Opioid Crisis (Katharine Q. Seelye, NY Times, 1-21-18)
Facing some unpleasant truths about opioids (David Juurlink, Making Evidence Matter, also Globe & Mail) "Despite the best of intentions, we flooded North American homes with opioids purer and often stronger than heroin. These drugs increasingly fell into the wrong hands, destroying young lives and countless families in the process. But another unfortunate truth is that even when patients with chronic pain followed our instructions, we caused more harm than we anticipated. By some estimates, 10 percent spiraled into addiction, even though we’d been told this would happen only rarely."
The opioid epidemic: It’s time to place blame where it belongs (Ronald Hirsch, MD, Kevin MD, 4-6-16) 1) Physicians ...overprescribe opioids, just as they overprescribe antibiotics. 2) Despite a lack of increased efficacy in treating pain compared to older medications, Purdue Pharmaceuticals, Oxycontin's manufacturer, mounted an aggressive marketing campaign (using scare tactics) which doctors fell for. 3) The "American Pain Society, introduced the “pain as the 5th vital sign” campaign, followed soon thereafter by the VA adopting that campaign as part of their national pain management strategy." 4) The Joint Commission issued "standards requiring the use of a pain scale and stressing the safety of opioids. According to the Wall Street Journal, they even published a guide sponsored by Purdue Pharma....The Joint Commission framed pain as a patient’s rights issue, inferring that inadequate control of pain would lead to sanctions." 5) "Press Ganey deserves a place with their emphasis on patient satisfaction. They monetized their concept, selling not only surveys but also consulting services to help hospitals improve their scores." 6) "Because CMS was now attaching significant reimbursement to patient satisfaction, hospital administrators developed initiatives to improve their scores and avoid a penalty." Making patient satisfaction a comparative advantage has boosted the "business" of medicine but harmed patient safety. (I apologize for summarizing his article but he makes important points. Read Dr. Hirsch's article!)
‘You want a description of hell?’ OxyContin’s 12-hour problem (Harriet Ryan, Lisa Girion and Scott Glover, Los Angeles Times investigative series, 5-5-16). The Times investigation into how America's bestselling prescriptive painkiller helped fuel a nationwide opioid epidemic won a Barlett & Steele bronze award. The Times reporters discovered that marketers at Purdue Pharma had knowingly misrepresented the drug as providing 12-hour relief from pain, an exaggeration that led to abuse and addiction. Here's Sally Kilbridge's story of How They Did It.
Five signs a loved one is abusing painkillers (Dr. Carlos Tirado and CBS News, 2-20-13) 1. Drowsiness, lack of energy; 2. Inability to concentrate, lack of motivation; 3. Social behavioral changes; 4. Changes in appearance; 5. Increased secrecy.
Confessions of a 75-Year-Old Drug Addict (Arlene Silverman, Pulse, 1-22-10) "There's sort of a war going on in the field of pain management, he continues. One camp worries about opiate addiction; the other is more concerned about the effects of long-term pain. It seems that, given my pain's severity, my doctors opted for opiates." This personal story conveys what an elder's addiction and attempts to withdraw feel like. Physicians: Please read.
New Approaches Help Babies Get Through Opioid Withdrawal (Liz Highleyman, MedPageToday, 5-12-17) Newer meds, more time with mom yielded better outcomes.
How Prince Concealed His Addiction: Aspirin Bottles of Opiates (Joe Coscarelli and Serge F. Kovaleski, NY Times, 4-17-17) At the time of Prince’s death, his Paisley Park home and recording compound in Minnesota were strewn with “a sizable amount” of narcotic painkillers for which he did not have prescriptions, including some hidden in over-the-counter vitamin and aspirin bottles and others issued in the name of a close aide, according to newly released court documents. Those documents "sketch a picture of how this musician, a strict proponent of clean living who suffered from chronic hip pain, concealed his opioid addiction using a variety of methods, including mixing various prescription pills in bottles for everyday products like Bayer and Aleve." He died from a "fatal amount of fentanyl, which is often used to manufacture counterfeit pills that are sold on the black market as oxycodone and other pain relievers."
Prince search warrants lay bare struggle with opioids (Amy Forliti, AP, WaPo, 4-18-17) Associates at Paisley Park also told investigators that Prince was recently “going through withdrawals, which are believed to be the result of the abuse of prescription medication,” an affidavit said. Search warrants and affidavits shed no new light on how Prince got the fentanyl that killed him. In practice, laws against prescribing drugs for someone under a false name are not usually enforced when a doctor intends to protect a celebrity’s privacy, said Los Angeles attorney Ellyn Garofalo. They would be indicting every pharmacist in Beverly Hills if this were strictly enforced,” Garofalo said.
My Life Ruined By Oxycodone in 2 Weeks (Healthy Living) Her life is nearly destroyed by two weeks of oxycodone prescribed by a well-meaning physician for arthritis.
Making pain a vital sign caused the opioid crisis. Here’s how. (orthopedic surgeon Thomas D. Guastavino, Kevin MD, 10-6-16) "I place the blame where it started. Those, no matter how well intended, who convinced themselves and had the power to pressure others that pain was a disease onto itself, not what it really is: a symptom. If health care has any hope of getting a handle on this crisis, then we have to go back to a time when physicians first determined why their patients have pain instead of just shooting the messenger. While we’re at it get rid of pain scales, fifth vital signs, and anonymous patient satisfaction scores. If we have not learned by now that these have caused more problems than they have solved, I don’t know what will."

Opioids Contribute to a Rising Death Toll: 28,647 in 2014 (Nicholas Bakalar, Science, NY Times, 12-24-16) In 2014, according to the Centers for Disease Control and Prevention, there were 47,055 deaths from accidental drug overdoses. Opioids were implicated in 28,647 of them, 60.9 percent of the total. "Morphine and codeine are natural opioids found in the opium poppy. Semi-synthetic opioids like oxycodone, hydrocodone and hydromorphone are derived from them. Many opioids are familiar under brand names — oxycodone is sold as Percocet and Percodan, for example, and hydrocodone as Vicodin." The report suggested several steps, including continuing the careful control of opioid prescriptions and intensifying efforts to distribute naloxone, a drug that reverses an opioid overdose.
Seven Days of Heroin: 911 calls for overdoses at a library and at a park (Video,, 9-8-17) 911 calls for overdoses Monday, July 10 at the Covedale Library and Rapid Run Park in Cincinnati.
Notable Narrative: The Cincinnati Enquirer’s stunning “Seven Days of Heroin” (Katia Savchuk, Nieman Storyboard, 9-25-17) As far as Terry DeMio knows, she’s the only journalist in the country with the title “heroin reporter.” She’s been covering the opioid epidemic for The Cincinnati Enquirer for five years, including two on the beat full time. Over one week in July, the paper sent out more than 60 reporters, photographers and videographers to document the impact of heroin in Greater Cincinnati. “We just wanted to show people: This is what a heroin epidemic looks like.”
The $4,500 injection to stop heroin overdoses (Shefali Luthra, Kaiser Health News, Business, Washington Post, 1-29-17). "Evzio is used to deliver naloxone, a life-saving antidote to overdoses of opioids. As demand for the product has grown, Kaleo has raised its twin-pack price to $4,500, from $690 in 2014....The that policymakers haven’t found a solution to get people needed medication and keep pricing in line with value. “EpiPen happened, and everyone was like, ‘Wow, this is terrible, we shouldn’t allow this to happen,’ ” he said. “And we haven’t done anything about that, and it’s not clear what the solution is. Now, shocker, it’s happening again.”
Where opiates killed the most people in 2015 (Christopher Ingraham, WaPo, 12-13-16) "Nationally, there are about 10.4 deaths by opioid overdose for every 100,000 people. But as you can see, these deaths aren't evenly distributed across the county. New England and the Ohio/​Kentucky/​West Virginia region stand out as two obvious hot spots....Synthetic opioid deaths — again, we're primarily talking fentanyl — are almost exclusively an East Coast phenomenon. Nationally, the death rate from synthetic opioids is 3.1 per 100,000. But in Rhode Island, it's 13.2; in Massachusetts, 14.4; and in New Hampshire, which has the highest synthetic opioid death rate in the country, 24.1 out of every 100,000 people died from synthetic opiates in 2015." As for "deaths from what we might call the “classic” opioid painkillers — substances like hydrocodone and oxycodone.... These deaths are highly concentrated in two places: West Virginia in the East, and Utah in the West. "...there's not just one opiate epidemic but several. Solving the problem will similarly require a more nuanced basket of solutions than a blanket “war on drugs.” One unintended consequence of years of crackdowns on prescription painkillers was a resurgence in the use of heroin, for example."
Physicians are being murdered for not prescribing opioids (Jessica Jameson, KevinMD, 8-15-17) "Until we as a society learn how to be present with negative emotions and to effectively deal with and process the things life brings our way we cannot and will not solve this crisis. Sure, we may prescribe fewer opioids, but people will turn to other substances, good physicians will continue to be murdered, and I and my colleagues will continue to look over our shoulders."
Mother's obituary for Kelsey Grace Endicott, who died from a heroin overdose. "The disease of addiction is merciless. It is up to us to open our minds and hearts to those who are still sick and suffering." (See story by Buzzfeed (ignore the glaring graphics).
This is what heroin addiction looks like (Debbie Moore-Black, RN, Kevin MD, 4-6-17) What can I tell you? It started out innocently. College exams were over. And that meant one thing — party time! Bubbly, shots, beer, cocaine and Percocet. Pam came from a pretty strict religious family: no alcohol, no premarital sex and no crazy music growing up....How could I tell this woman what happened to her son?
Medicare Survey Could Be Contributing To Opioid Epidemic (Jacquelyn Corley, HuffPost, 6-23-16) 'The tragic growth in opioid-related deaths is not an aberration; it’s part of a 15-year-long trend the Centers for Disease Control and Prevention says is now a “national epidemic.” Researchers have identified numerous contributing factors related to the opioid crisis, including the changing dynamics of the doctor-patient relationship, the creation of more potent and long-acting drugs, and trends started by influential medical experts and academic societies in the late 1990s suggesting total pain control should be treated as an attainable medical ideal—the so-called “fifth vital sign.” "Doctors are faced with the challenge of curing patients and treating their pain, but they must also avoid unsafe prescribing practices that could lead to drug tolerance, addiction, or both. The HCAHPS survey inadvertently adds to this dilemma by making patients’ pain management effectively more important than their long-term health."

Nearly 1 in 3 on Medicare Got Commonly Abused Opioids (Carla K. Johnson, ABC News, 6-22-16) The leading opioids taken by Medicare patients were OxyContin, Percocet, Vicodin, fentanyl or their generic equivalents. Overdose risk for older Americans is heightened by medication interactions and alcohol.
Counterfeit Opioid Poisonings Spread To Bay Area (Barbara Feder Ostrov, Kaiser Health News, 4-28-16) In March and April 2016 patients were treated for overdoses after taking what they thought were tablets of Norco, a brand-name painkiller that combines acetaminophen and hydrocodone. But the counterfeit Norco, which the patients bought off the street, mostly contained the opiate fentanyl, which is 100 times more powerful than morphine, according to the CDC. They also contained promethazine, an allergy drug that’s believed to intensify the effects of fentanyl. The only safe prescription to take is one prescribed to you by your doctor and received from a legitimate pharmacy – not from a coworker, a friend or off the street.

America's Heroin Epidemic (Kate Snow and Janet Klein, NBC, 4-7-14). An award-winning series. Click on links to many related stories in the series. Here, Infographic: America's Heroin Epidemic (Janet Klein and Ronnie Polidoro).

Be the Death of Me (Kate Silver, Chicago Health, 8-29-15. Award winner.) Heroin deaths are rising as state-funded treatment falls in Illinois. "Heroin is the second most addictive drug there is--behind nicotine." "On those streets, he says, the DEA is seeing a higher demand coming from younger, wealthier, suburban folks who have been abusing painkillers. They turn to heroin for a simple reason: price."

Prescription For Death: How Painkillers Destroyed the Town of War, West Virginia (Vince Beiser, Playboy, 3-1-14) Prescription pills—especially painkillers—now kill more Americans every year than heroin, cocaine and all other illegal drugs combined. The overdose death rate in the backwater Appalachian town in which this award-winning story takes place is 16 times the national average.

Russia finally admits to its hidden heroin epidemic (Shaun Walker, Independent, 3-10-09) Surge in abuse blamed on West's failings in Afghanistan, but addicts go untreated

Painkiller politics: Effort to curb prescribing under fire (Matthew Perrone, Associated Press, 12-20-15). Perrone examines struggling efforts by the Centers for Disease Control and Prevention to rein in opioid abuse by releasing new guidelines on their use. Facing pushback from the drug industry and the FDA, CDC moved its deadline. Read the story! Also, read While heroin use grabs headlines, don’t forget coverage of prescription pain meds (Susan Heavey, Covering Health, Association of Health Care Journalists, 1-11-16)

Here’s how the White House plans to address rural America’s struggle with heroin (Juliet Eilperin, Washington Post, 1-14-16) The rural poor are “most stricken by the epidemic and have the least access to treatment.” Obama picks Tom Vilsack to address heroin spike (Kevin Liptak, CNN, 1-15-16) Four in five heroin users started out using prescription drugs, says Obama. So prescription drugs are the gateway to heroin addiction.

In Heroin Crisis, White Families Seek Gentler War on Drugs (Katharine Q. Seelye, NY Times, 10-30-15) "When the nation’s long-running war against drugs was defined by the crack epidemic and based in poor, predominantly black urban areas, the public response was defined by zero tolerance and stiff prison sentences. But today’s heroin crisis is different. While heroin use has climbed among all demographic groups, it has skyrocketed among whites; nearly 90 percent of those who tried heroin for the first time in the last decade were white....Over all, drug overdoses now cause more deaths than car crashes, with opioids like OxyContin and other pain medications killing 44 people a day."
Drug Overdoses Propel Rise in Mortality Rates of Young Whites (Gina Kolata and Sarah Cohen, NY Times, 1-16-16)
Organ Donation And The Opioid Epidemic: ‘An Unexpected Life-Saving Legacy’ (Martha Bebinger, WBUR, Kaiser Health News, 10-19-16) So far this year, more than one in four, or 27 percent, of organ donations in New England are from people who died after a drug overdose. Nationally, that rate is 12 percent for the same time period. Alexandra Glazier, president and CEO of the New England Organ Bank said the 12 transplant centers in that region may be more aggressive about finding a match for patients with failing hearts, livers or kidneys. And she said New Englanders tend to be pragmatic about end-of-life decisions.
Prescription Drug Abuse Among Older Adults Is Harder to Detect ) Constance, Gustke, NY Times, 6-10-16) The death of Prince highlighted the extent of prescription drug abuse among older adults, particularly those with plenty of money to spend. More older adults are becoming addicted to powerful pain pills like OxyContin and Percocet to drown out the aches and pains of aging. By 10 days of usage, you can be addicted. The loss of self-worth that sometimes comes with retirement, especially after a lifetime of achievement and accolades, can be the spark. Moreover, addiction thrives on a lack of structure and accountability. A lot of baby boomers are now retired, anxious and have trouble sleeping. Add in arthritis, multiple prescription drugs and more drinks, and that can be the beginning of addiction. “It’s the perfect storm,” said Brenda J. Iliff, executive director of Hazelden Betty Ford Foundation in Naples, Fla.
How the Epidemic of Drug Overdose Deaths Ripples Across America (Haeyoun Park and Matthew Bloch, NY Times, 1-19-16)
Strict opioids laws hit chronic pain sufferers hard (Felice J. Freyer, Boston Globe, 6-18-16) This is the other side of America’s war on opioids. As federal and state regulators rush to curtail access to drugs that have claimed thousands of lives, the rules they’ve enacted fall hard on people who legitimately need relief from pain.
Across Rural America, Drug Casts a Grim Shadow (Fox Butterfield, NY Times, 1-4-04) Lovell, population 2,264, and two nearby towns have become infested by methamphetamine. "What is happening in Lovell is happening across much of Wyoming, the least populated state in the country, where methamphetamine use is now more than twice the national average, according to the federal Substance Abuse and Mental Health Services Administration. Methamphetamine use and crime are also overrunning rural counties in Iowa, Nebraska, Kansas, Colorado, North Dakota and the Texas Panhandle, law enforcement officials say." "To the experts, methamphetamine is both a symptom of rural decline, as people give up on faltering farms and factories, and a cause that makes the decline worse."
‘How’s Amanda?’: A story of lies, truth and American addiction (Eli Saslow, Unnatural Causes: Sick and Dying in Small-Town America, The Washington Post’s series exploring rising death rates for white women in rural America continues with a story about Amanda Wendler — a 31-year-old woman struggling to get clean in the eleventh year of her opiate addiction. The days of waiting — for a key injection (of a drug called naltrexone) that could help curb Amanda’s heroin cravings — seem to go on forever. "... the fact that matters most for a chronic user is what it takes for just one addict to get clean. The relapse rate for heroin has been reported in various studies to be as high as 97 percent. The average active user dies of an overdose in about 10 years, and Amanda’s opiate addiction was going on year 11."
The Lonely Road of Staying Clean (Anne Hull, WaPo, 6-11-16) Jasper, Ala. In a town where pills are currency, opioid addicts have few options. "During a high school volleyball game in the 10th grade, she injured her spinal cord and was prescribed OxyContin. By 17, Jessica was crushing and snorting the pills. With a copy of her MRI, Jessica said she could leave a doctor’s office with prescriptions for 120 Roxicodone pills in 30-milligram strength, 90 additional Roxicodones in 15 mg strength, and 120 blue bars of Xanax — a total of 330 pills with fresh refills in a month."
Nearly six in 10 Americans have leftover narcotics at home (Lenny Bernstein, WaPo, 6-13-16)
CDC warns doctors about the dangers of prescribing opioid painkillers (Karoun Demirjian and Lenny Bernstein, WaPo, 3-15-16) “Starting a patient on opiates is a momentous decision, and it should only be done if the patient and the doctor have a full understanding of the substantial risks involved.” The CDC is encouraging patients to question doctors who prescribe opioids for chronic pain.
For Teenagers, Adult-Sized Opioid Addiction Treatment Doesn't Fit (Heidi Benson, Shots, NPR, 1-15-16) "While a wide range of evidence-based screening, intervention, treatment and disease management tools and practices exist, they are rarely employed," reported the National Center on Addiction and Substance Abuse. And lack of effective treatment in the teen years can blight an entire life. This piece reports on evidence-based treatments--treatments that work. These include Screening, Brief Intervention and Referral to Treatment (SBIRT), a preventative protocol for early detection; Motivational Interviewing (MINT), a counseling approach that guides individuals to set goals; and Functional Family Therapy (FFT), which treats teens in a family setting.

The Opioid Crisis: Facts that news coverage is missing (Alan Cassels, Health News Review, 1-27-16)
Most Americans See Personal Tie toRising Prescription Painkiller Abuse (Lisa Gillespie, Kaiser Health News, 11-24-15) More than 56 percent of the public say they have a personal connection to the issue, reports the latest monthly tracking poll of the Kaiser Family Foundation. That share includes those who say they know someone who died from a painkiller overdose, have been addicted themselves or know someone who has and those who know someone who took painkillers not prescribed to them, the poll’s results show.
How I Learned to Stop Worrying and Love Methadone (Maia Szalavitz, The Fix, 8-19-12) 'Just like ex-junkie Russell Brand, I used to believe that “maintenance” was as bad—if not worse—than active addiction. Here’s how I came to understand how fatally wrong I was.' Maia is the author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, to be released in 2016
Experts Highlight A Growing Problem Of Substance Abuse Among Older Vermonters (Peter Hirschfeld, Vermont Public Radio, 11-5-15)
Covering the growing, underreported problem of elder substance abuse (Liz Seegert, Association of Health Care Journalists, 11-9-15)
Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014 (CDC, Morbidity and Mortality Weekly Report (MMWR), 1-1-16)
Using Patient Review and Restriction Programs to Protect Patients at Risk of Opioid Misuse and Abuse (a fact sheet from PEW Charitable Trusts, July 2015). As one strategy for minimizing deaths from opioids overdoses associated with prescription drug abuse, public and private insurance plans are using patient review and restriction (PRR) programs to encourage the safe use of opioids and other controlled substances. PRR programs identify patients who are at risk for prescription drug abuse and ensure that they receive controlled substance prescriptions only from designated pharmacies and prescribers. These programs have the potential to save lives and reduce health care costs by helping state Medicaid programs and private health plans better coordinate patient care and prevent inappropriate access to medications susceptible to abuse. Medicare beneficiaries could also benefit from PRR programs, but current federal law prohibits their use in this group of enrollees.
Two Acres of Hope for Recovering Addicts (Cara Buckley, NY Times, 8-14-09)
For teens with opioid use disorders, buprenorphine maintenance better than detox (Alison Knopf, Alcoholism Drug Abuse Weekly, 11-24-14)
The drug Suboxone could combat the heroin epidemic. So why is it so hard to get? (Susan Svrluga, Washington Post, 1-13-15)
Dying To Be Free (Jason Cherkis, Huff Post, 1-28-15) There’s A Treatment For Heroin Addiction That Actually Works. Why Aren’t We Using It?
The Neurobiology of Cocaine Addiction (Eric J. Nestler, NCBI, Sci Pract Perspect. Dec 2005; 3(1): 4–10).
Crack: The Drug That Consumed the Nation's Capital (listen online to WAMU-FM, NPR). 25 years ago, dealers sold crack at hundreds of open-air drug markets, addiction swept across entire neighborhoods, and D.C. came to be known as the "Nation's Murder Capital." In this five-part series, WAMU 88.5 explores the legacy of that era and how D.C. continues to grapple with an epidemic that affected families, neighborhoods, politicians, policemen, and schools. Read transcript here.

A Mother's Perspective on Her Son's Addiction (Angela Haupt, US News, her half of a two-part series, 7-24-13). Anita Devlin’s son was a drug addict. She explains how she helped him get better. See also:
One Man's Story: How I Beat Addiction Mike Devlin overcame his addiction to painkillers, cocaine, heroin and more. He shares his story. (Newsweek, his half of a two-part series, 7-24-13)

STIMULANTS--cocaine, crack cocaine, amphetamines (speed) and ecstasy (also a hallucinogen).
These "act on the central nervous system and are associated with feelings of extreme well-being, increased mental and motor activity."

Generation Adderall (Casey Schwartz, NY Times Magazine, 10-12-16) Like many of my friends, I spent years using prescription stimulants to get through school and start my career. Then I tried to get off them. I was terrified I had done something irreversible to my brain, terrified that I was going to discover that I couldn’t write at all without my special pills.
Understanding Stimulants (Addiction (855) 993-5977)
The most common prescription stimulants are amphetamines and methylphenidates. Prescription stimulants are used to treat attention deficit hyperactivity disorder (ADHD), narcolepsy and sometimes obesity.
Treating addiction to prescription stimulants (National Institute on Drug Abuse, NIDA) "Treatment of addiction to prescription stimulants, such as Adderall and Concerta, is based on behavioral therapies used in treating cocaine and methamphetamine addiction. At this time, there are no medications that are FDA-approved for treating stimulant addiction. Thus, NIDA is supporting research in this area."

ADHD and Substance Abuse (WebMD) See ADHD and Drug Abuse Directory

Overcoming cocaine or stimulant addiction (Harvard Mental Health Letter)

How Stimulants Affect the Brain and Behavior (Chapter 2 from Treatment for Stimulant Use Disorders (free from SAMHSA

[Back to Top]

Culprits in the opioid crisis

Who caused what? Who worsened the situation?
How can we effectively resolve the crisis?
The opioid epidemic in the United States has been triggered largely by prescription drugs, exacerbated by heavy marketing of drugs for pain relief (and doctors being persuaded to emphasize treatment of pain, in the 1990s). There is no question we're in the midst of an opioid crisis. The question is, how do we best control or end it? How do we identify and address underlying causes?
Pain as a vital sign has contributed to the opioid epidemic (Skeptical Scalpel, KevinMD, 9-10-14) "Vital signs are the following: heart rate, blood pressure, respiratory rate, temperature.
What do those four signs have in common?
They can be measured.
A sign is defined as something that can be measured. On the other hand, pain is subjective."
And that's where a major crisis started.
Opioid makers gave millions to patient advocacy groups to sway prescribing (Ed Silverman, STAT, 2-12-18) As the nation grapples with a worsening opioid crisis, a new report suggests that drug makers provided substantial funding to patient advocacy groups and physicians in recent years in order to influence the controversial debate over appropriate usage and prescribing. Specifically, five drug companies funneled nearly $9 million to 14 groups working on chronic pain and issues related to opioid use between 2012 and 2017. At the same time, physicians affiliated with these groups accepted more than $1.6 million from the same companies. In total, the drug makers made more than $10 million in payments since January 2012. “The fact that these same manufacturers provided millions of dollars to the groups suggests, at the very least, a direct link between corporate donations and the advancement of opioid-friendly messaging,” according to the report released on Monday night by U.S. Sen. Claire McCaskill, who has been probing opioid makers and wholesalers. “The pharmaceutical industry spent a generation downplaying the risks of opioid addiction and trying to expand their customer base for these incredibly dangerous medications and this report makes clear they made investments in third-party organizations that could further those goals,” McCaskill said. The report noted that, at various times, the groups issued guidelines and policies “minimizing the risk of opioid addiction and promoting opioids for chronic pain, lobbied to change laws directed at curbing opioid use, and argued against accountability for physicians and industry executives responsible for over-prescription and misbranding.”

The drug industry’s triumph over the DEA (Scott Higham and Lenny Bernstein, Washington Post and 60 Minutes, 10-15-17) In April 2016, at the height of the deadliest drug epidemic in U.S. history, Congress effectively stripped the Drug Enforcement Administration of its most potent weapon against large drug companies suspected of spilling prescription narcotics onto the nation’s streets. The chief advocate of the law that hobbled the DEA was Rep. Tom Marino, a Pennsylvania Republican who is now President Trump’s nominee to become the nation’s next drug czar. He and other members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, undermining efforts to stanch the flow of pain pills....The law was the crowning achievement of a multifaceted campaign by the drug industry to weaken aggressive DEA enforcement efforts against drug distribution companies that were supplying corrupt doctors and pharmacists who peddled narcotics to the black market. The industry worked behind the scenes with lobbyists and key members of Congress, pouring more than a million dollars into their election campaigns. The chief advocate of the law that hobbled the DEA was Rep. Tom Marino, a Pennsylvania Republican who was President Trump’s nominee to become the nation’s next drug czar, but withdrew it when this story broke, thanks to whistleblowers.
The opioid epidemic: It’s time to place blame where it belongs (Ronald Hirsch, Kevin MD, 4-6-16) "I call on Congress to hold hearings and compel the top executives from Purdue Pharmaceutical, the Joint Commission, Press Ganey, and CMS and hospital administrators to appear and testify as to their role in this national epidemic." (Charles Ornstein, ProPublica, 9-26-17) The move follows a story by ProPublica and The New York Times detailing how insurance companies and pharmacy benefit managers have made it easier to get opioid painkillers than less risky alternatives. "Only one-third of the people covered, for example, had any access to Butrans. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval from the insurer for them. Moreover, we found that many plans make it easier to get opioids than medications to treat addiction, such as Suboxone."
In recovery, Nan Goldin calls on Harvard to reject money from family tied to OxyContin,(Mark Shanahan, Boston Globe, 1-22-18) Celebrated photographer Nan Goldin says the benefactor of Harvard's Arthur M. Sackler Museum should be shunned by US arts organizations. Goldin, who's been drug-free for 10 months after entering a Massachusetts rehab center for an addiction to Oxycontin, believes museums should no longer accept money from the Sacklers due to the family’s role in the manufacture of the powerful pain medication.
Senator Calls on Insurers to Improve Access to Non-Opioid Pain Treatments
John Oliver Explains How Drug Companies Helped Cause Our Opiate Epidemic (Bryan Menegus, Gizmodo, 10-24-16) "In John Oliver’s latest report, he unpacks the alarming history of the epidemic, and how the drug companies we entrust with our health helped create it....Opiates were hardly prescribed in the 90s except in the most extreme cases of pain management. How did we go from that to nearly half a million opiate-related deaths between 2000 and 2014? The answer, as John Oliver explains, lies in greedy drug companies. When Oxycontin was developed by Purdue in the late 90s, the company marketed it aggressively—in itself not unusual. Oliver points out that what made Purdue’s campaign bad was how grossly it misrepresented the product’s addiction potential. Not only did the company invent the term “pseudo-addiction” to discredit the seriousness of patient dependence, but it also claimed actual addiction befell “less than 1 percent” of those prescribed Oxycontin."...
"Easily the shadiest and most disgusting example Oliver gives involves the company Insys getting fentanyl into the hands of people who didn’t really need it. Easily the shadiest and most disgusting example Oliver gives involves the company Insys getting fentanyl into the hands of people who didn’t really need it. While only approved for use in treating cancer pain, Insys found a loophole to get this powerful drug prescribed to patients, and to get insurance companies to pay for it."
How a ‘Perfect Storm’ in New Hampshire Has Fueled an Opioid Crisis (Katharine Q. Seelye, NY Times, 1-21-18) New Hampshire "leads the nation in overdose deaths per capita from fentanyl, a powerful synthetic opioid that has virtually replaced heroin across New England. Because fentanyl is so potent, the risk of overdose is high....An astonishing 53 percent of adults said in a Granite State poll last year that drugs were the biggest problem facing the state...Researchers at Dartmouth College in Hanover, N.H., have been studying the issue to try to understand why the state’s opioid problem is so dire. One big reason, they say, is the proximity to an abundant drug supply in neighboring Massachusetts, the center of drug distribution networks that traffic opioids throughout New England....Another, they say, is New Hampshire’s low per capita spending on services to help drug users break free from addiction....The researchers also noted that the state has pockets of “economic degradation,” especially in rural areas where jobs are few, and that may contribute to the problem. Beyond that, the researchers say, doctors here have long prescribed “significantly higher rates” of opioid pain relievers, almost twice the national average. The researchers noted other factors, too: A shortage of workers in addiction and recovery. No needle exchanges. For some the state’s “Live Free or Die” motto might justify risky behaviors.
Online Sales of Illegal Opioids from China Surge in U.S. (Ron Nixon, NY Times, 1-24-18) Nearly $800 million worth of fentanyl pills were illegally sold to online customers in the United States over two years by Chinese distributors who took advantage of internet anonymity and an explosive growth in e-commerce, according to a Senate report released on Wednesday. A yearlong Senate investigation found that American buyers of the illegal drugs lived mostly in Ohio, Pennsylvania and Florida.
American Pain: How a Young Felon and His Ring of Doctors Unleashed America’s Deadliest Drug Epidemic by John Temple. “John Temple’s American Pain takes you on a hysterically funny, yet equally tragic, tour of Florida’s pill mill industry as the painkiller epidemic was reaching a fever pitch.... a must-read for anyone trying to understand this government-sanctioned drug and the destructive power of Big Pharma.” —Melisa Wallack, co-writer of Dallas Buyers Club
Pressure Mounts on Insurance Companies to Consider Their Role in Opioid Epidemic (Charles Ornstein, ProPublica, 10-19-17) Another lawmaker is asking insurers whether their policies have made it easier for patients to access cheaper, more addictive drugs over less addictive alternatives. Meanwhile, the insurance industry trade group pledged additional steps to combat inappropriate prescribing.
Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers (Katie Thomas, NY Times, and Charles Ornstein, Pro Publica, 9-17-17) Opioid drugs are generally cheap while safer alternatives are often more expensive. "ProPublica and The New York Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them. In contrast, almost every plan covered common opioids and very few required any prior approval. The insurers have also erected more hurdles to approving addiction treatments than for the addictive substances themselves, the analysis found."
Dreamland: The True Tale of America's Opiate Epidemic by Sam Quinones. "Journalist Sam Quinones weaves together two classic tales of capitalism run amok whose unintentional collision has been catastrophic. The unfettered prescribing of pain medications during the 1990s reached its peak in Purdue Pharma’s campaign to market OxyContin, its new, expensive--extremely addictive--miracle painkiller. Meanwhile, a massive influx of black tar heroin--cheap, potent, and originating from one small county on Mexico’s west coast, independent of any drug cartel--assaulted small town and mid-sized cities across the country, driven by a brilliant, almost unbeatable marketing and distribution system. Together these phenomena continue to lay waste to communities from Tennessee to Oregon, Indiana to New Mexico." See How Heroin Made Its Way From Rural Mexico To Small-Town America (NPR's interview with the author, 5-19-15)
Politics of pain: Drugmakers fought state opioid limits amid crisis (Liz Essley Whyte, Geoff Mulvihill, and Ben Wiederemail, The Center for Public Integrity and Associated Press, 9-18-16) Who’s Calling the Shots in State Politics? Makers of prescription painkillers tried to kill state measures aimed at stemming the tide of opioid drugs. An investigation revealed that drug companies and allied advocates spent more than $880 million on lobbying and political contributions over a decade, and that drugs for which they racked up billions in sales would cost government-funded health programs hundreds of millions in higher medication costs. Judges for an AHCJ journalism award called this "a tour de force about the politics, lobbying, and influence-peddling that have helped cause the American opioid epidemic."
A Long and Winding Road: Kicking Heroin in an Opioid ‘Treatment Desert’ (Brian Rinker, Kaiser Health News, 8-11-17) Experts recommend medication-assisted treatment for drug users like Menzel, one of nearly 2 million Americans struggling with opioid addiction, whether to prescription pills or heroin. MAT, as the therapy is known, has been proven far more effective — and less dangerous and miserable — than cold-turkey quitting. Drugs like methadone and buprenorphine can help suppress opioid cravings and stave off the physical and psychological symptoms of withdrawal. When carefully managed, MAT can cut the risk of overdose death by half, research shows. But not all medical providers are properly trained and approved to provide the treatments, which themselves are opioids (albeit less likely to be abused). Lake Isabella sits in the Kern River Valley, home to 32 churches but not a single methadone clinic or doctor able or willing to prescribe buprenorphine. Like half the counties in California, the valley is an opioid “treatment desert.”
No, High Workers Aren't What's Wrong with America's Economy (Maia Szalavitz, Vice, 8-10-17) According to one study, "the regions where the epidemic is most serious are often also the ones in which deindustrialization has wrought the most havoc. In these despairing environs, existing jobs often pay rock-bottom wages, and many workers with the means and skills to take higher-paid positions have taken off in search of education and opportunity elsewhere. It's not exactly surprising that businesses remaining in these extremely depressed areas would have difficulty hiring....Regardless of your view on the merits of drug testing, it's clearly wrong to suggest rampant drug use is holding back the growth of the middle class. A better bet is greedy bosses, and a political class that hasn't responded to workers' needs."
Unable To Arrest Opioid Epidemic, Red States Warm To Needle Exchanges (Shefali Luthra, KHN, 6-14-17) The North Carolina Harm Reduction Coalition has advanced a local shift from a tough-on-drugs approach to harm-reduction philosophy. Other red states signal they may follow suit.
The opioid epidemic may be even deadlier than we think (German Lopez, Vox, 4-26-17) The current drug crisis already kills more people than guns or cars. But a new study suggests it’s even worse than the current numbers say. See section labeled "The opioid epidemic, explained in fewer than 600 words."
Public Restrooms Become Ground Zero in the Opioid Epidemic (Martha Bebinger, WBUR, Kaiser Health News, 5-11-17) People often turn to public restrooms as a place to get high on opioids. It has led some establishments to close their facilities, while others are training employees to help people who overdose.
Getting Patients Hooked On An Opioid Overdose Antidote, Then Raising The Price (Shefali Luthra, Kaiser Health News, ) First came Martin Shkreli, the brash young pharmaceutical entrepreneur who raised the price for an AIDS treatment by 5,000 percent. Then, Heather Bresch, the CEO of Mylan, who oversaw the price hike for its signature Epi-Pen to more than $600 for a twin-pack, though its active ingredient costs pennies by comparison. Now comes Evzio, a device that administers just enough naloxone (Vivitrol) to stabilize someone who has overdosed on drugs. Its manufacturer, Kaleo, may be positioning itself to find profits in a dire health care crisis. (Will Republicans, who are heavily supported by the pharmaceutical industry, be willing to limit price-gouging on life-saving medicine and devices?)
Drug Epidemic: 1 Small-Town Mayor Takes on Pill Distributors (AP, NY Times, 4-7-17) In this once prosperous West Virginia coal town of 1,900 people, residents say it's not just the decades-long demise of mining that hurt the community — it's the scourge of drug use that came with it. Here, almost everyone knows someone who became addicted. And the Appalachian town is fighting back by suing some of the biggest U.S. drug distributors, hoping to make them pay for the damage done by addiction. Lawyers say growing pushback by communities, many in West Virginia, could ultimately rival the scope of litigation against tobacco companies over smoking.
Here’s What’s Wrong With How US Doctors Respond to Painkiller Misuse(Maia Szalavitz,, 1-13-15). Too often, Americans with painful medical conditions who misuse pain pills like Oxycontin are denied further treatment and even prosecuted. There are more effective, enlightened responses—as the UK has shown for decades.
The Other Victims of the Opioid Epidemic (Susan A. Glod, New England Journal of Medicine, 6-1-17) Solving the problem of the opioid epidemic "will require careful thought, consideration, and most important, development of meaningful interventions to improve both pain management and substance-misuse prevention. These interventions should not come at a cost to the epidemic’s other victims — hospice patients who are too afraid to take the medications they need to control their symptoms; people whose history of substance abuse, no matter how remote, determines whether their pain will be treated; patients like Jerry, who, dying from cancer, his body containing more tumor than anything else, was told he is a monster. He, too, is a victim of this epidemic."
‘You want a description of hell?’ OxyContin’s 12-hour problem (Harriet Ryan, Lisa Girion and Scott Glover, LA Times, 5-5-16--Part 1 of a 4-part series). See also More than 1 million OxyContin pills ended up in the hands of criminals and addicts. What the drugmaker knew (Harriet Ryan, Scott Glover and Lisa Girion, Part 2 of series, LA Times, 7-10-16). OxyContin goes global — “We’re only just getting started” (Harriet Ryan, Scott Glover and Lisa Girion, Part 3 o series, LA Times, 12-18-16). And How black-market OxyContin spurred a town's descent into crime, addiction and heartbreak (Harriet Ryan, Scott Glover and Lisa Girion, LA Times, 7-10-16).
Update on Medication Assisted Treatment (MAT) in a County Health and Behavioral Health System (Robert Paul Cabaj, MD, San Mateo County report to SAMHSA) San Mateo reported a dramatic drop in ER visits (from 5.8 to 0.2) and number of drinking days for the patients they treated with Vivitrol.
Former Addict: What Indiana Can Learn From New York About Needle Exchanges (Maia Szalavitz, Time, 4-5-15) "The fact that in 2015, federal funding is still banned for needle exchange and 25 states still require people to get a prescription to buy needles is an outrage — both from the human and from the economic perspective. But what’s even more frustrating is that politicians and many journalists still see needle exchanges as controversial when the data on their safety and efficacy is actually stronger than for virtually any other public health intervention, including condoms."
Nonprofit Provides Financial Assistance For Opioid Treatment (Zoe Mitchell, Deborah Becker, WBUR, 2-22-17) Despite efforts to stem the tide of opioid overdose deaths in Massachusetts, the latest numbers suggest that a record number — some 2,000 people — died of overdoses last year. One of the grassroots groups working to make a dent in this crisis is called Magnolia New Beginnings. It was formed by parents on the North Shore a few years ago to provide support to other parents and to help financially, providing scholarships for long term substance use treatment, which typically is not covered by health insurance.
Facing Pressure, Insurance Plans Loosen Rules For Covering Addiction Treatment (Shefali Luthra, Kaiser Health News, 2-21-17) Insurance companies slowly reconsidering the insurance practice of requiring "prior approval" before doctors prescribe particular medications-- such as Suboxone--that are used to mitigate withdrawal symptoms, drugs typically given along with steady counseling. Addiction specialists say this red tape puts people’s ability to get well at risk. It gives them a window of time to change their minds or go into withdrawal symptoms, causing them to relapse. “If someone shows up in your office and says, ‘I’m ready,’ and you can make it happen right then and there--that’s great.
Pharmacies Thrive Selling Opioids For Depressed Small Town Pain (Phil Galewitz, Kaiser Health News, 2-8-17) Eleven drug stores, mostly independents, are scattered about a tiny Kentucky city of 1,500 people. Manchester’s closest inpatient drug treatment facility carries a waiting list of 100 people that’s grown more than 50 percent in recent years. The state’s Medicaid expansion was both good and bad for those fighting the opioid epidemic. “It did enable people to get pain pills for free if they can get someone to prescribe them but it also increased their ability to get treatment because they now had a way to pay for it." If the ACA made cheap drugs more available, it also made treatment more accessible because it required coverage of mental health and substance abuse treatment.
A Tide of Opioid-Dependent Newborns Forces Doctors to Rethink Treatment (Catherine St. Louis, NY Times, 7-13-17) "From 2003 to 2012, the last year for which statistics are available, the number of babies born dependent on drugs grew nearly fivefold in the United States. Opioids are the main culprit, and states like Kentucky are particularly hard-hit: 15 of every 1,000 infants here are born dependent on opioids. Babies with the worst withdrawal symptoms are routinely separated from their mothers and whisked by ambulance, at great expense, to hospitals hours away, filling up beds intended for newborns who have even more serious problems, like heart defects....Moreover, a growing body of evidence suggests that what these babies need is what has been taken away: a mother."
New study tracks hospital opioid prescribing for older adults (Liz Seegert, Covering Health, AHCJ, 6-1-17) “Pain control is different in a hospital setting, where we not only have to manage pain for patients we don’t necessarily know well, but also set realistic expectations for them.” Forty-nine states have initiated the CMS-mandated prescription drug monitoring programs. These efforts collect data on prescriptions of controlled substances as part of ongoing efforts to reduce prescription drug abuse and diversion. Missouri is the only state not participating.
I am a doctor, but I didn’t cause the opioid epidemic (Tanya Feke, Kevin MD, 5-26-16) "While JCAHO did not demand doctors write prescriptions for narcotics per se, their emphasis on pain led to significant changes in medical practices. Patient satisfaction surveys too have permeated health care. Patients often give low scores when their pain is not *completely* controlled or when they do not get the medications they want. This, in turn, affects how hospitals are paid, and hospitals go on to penalize doctors. Clearly, these surveys should not be tied to financial incentives....Decreasing the number of opioid prescriptions will not solve the problem on its own. The problem is much larger than that.... We need an American detox, and we need one now. The large majority of doctors are not part of the problem but can be part of the solution. A group of physicians in my hometown of New Bedford, Massachusetts has formed a group, Physicians to Prevent Opioid Abuse, to combat the issue. We bring creative solutions to a challenging problem, but we cannot do it alone. We need your help. America needs to stand together, not pointing fingers, but working as one to make a difference and save lives.
Drug firms poured 780M painkillers into WV amid rise of overdoses (Eric Eyre, Charleston Gazette-Mail, 12-17-16). Part of its painkiller profiteers series, which includes Drug wholesaler agrees to pay $3.5M to settle WV lawsuit (1-3-17). See also WV’s horrible painkiller death toll (12-21-16), Painkiller Profiteers ; Opioid Abuse in West Virginia; Pill Rules Not Enforced; Suspicious Drug Order Regulation Not on Pharmacy Boards Radar.
Doctor charged with selling pain pills pleads not guilty (AP, WaPo, 4-7-17) A New Jersey doctor has pleaded not guilty to charges that he sold prescriptions for highly addictive opioid painkillers to people who had no medical need for them, including one man who died from an overdose. An attorney representing Dr. Byung Kang, of Little Falls, entered the plea during a court hearing.
Is Prescription Opioid Abuse a Crime Problem or a Health Problem? (Nancy Shute, NPR, 12-3-15) Although many people know someone who has abused prescription opioids, people still think of opioid abuse as a criminal justice issue more than a health problem, a study finds. When it came to possible solutions, more than half the news stories, 64 percent, mentioned law enforcement...41 percent mentioned prevention, and just 3 percent mentioned expanding treatment.
Paper makes audacious decision to highlight silent epidemic (Susannah Nesmith, Columbia Journalism Review, 12-2-16) "The Palm Beach Post made the bold decision to profile all 216 people who died of an opioid overdose in its coverage area last year, risking the wrath of victims’ families, some of whom were horrified to have their private pain publicized. The stark display of photos of each of the dead, accompanied by brief profiles, effectively served The Post’s goal—drawing attention to the magnitude of the crisis in a way statistics simply could not, while bringing addiction out of the shadows. The “Generation Heroin” project, rolled out last month, was motivated by the reporters’ discovery that many people were overdosing inside controversial sober homes where they had gone to get better. When the reporters dug deeper, they realized the sheer scope of the problem was far worse than they had imagined: More people died in Palm Beach County from heroin, fentanyl, or illicit morphine overdoses in 2015 than in car accidents.
Killer Drugs: Tackling Opioid Addiction and Overdose (Kristin Gourlay, Rhode Island Public Radio). Also of interest: RI Hospital ER Chief: "There has to be a better way." (about a Rhode Island plan to open a sobering center in Providence, to move people who simply need to sober up out of the emergency room, to a place where they can be offered substance abuse treatment and other resources, like housing. Says Brian Zink, that would save money and free up beds, and would mean that addicts get more appropriate treatment.
Hooked: Tracking Heroin's Hold on Arizona, a special investigative report and documentary produced by advanced journalism students at the Walter Cronkite School of Journalism and Mass Communication on the growing perils of heroin and opioid use (Cronkite News Online, 1-13-15). As the drug pours into the state, an epidemic of addiction threatens a generation of young people, their families and friends. Many pieces here.
Drug maker thwarted plan to limit OxyContin prescriptions at dawn of opioid epidemic (David Armstrong, STAT, 10-26-16) Officials of West Virginia's state employee health plan "noticed a surge in deaths attributed to oxycodone, the active ingredient in the painkiller OxyContin. They quickly decided to do something about it: OxyContin prescriptions would require prior authorization. It was a way to ensure that only people who genuinely needed the painkiller could get it and that people abusing opioids could not. But an investigation by STAT has found that Purdue Pharma, the manufacturer of OxyContin, thwarted the state’s plan by paying a middleman, known as a pharmacy benefits manager, to prevent insurers from limiting prescriptions of the drug."
How Doctors Helped Drive the Addiction Crisis (Richard A. Friedman, NY Times, 11-7-15) "The rate of death from prescription opioids in the United States increased more than fourfold between 1999 and 2010, dwarfing the combined mortality from heroin and cocaine. In 2013 alone, opioids were involved in 37 percent of all fatal drug overdoses....starting in the 1990s, there has been a vast expansion in the long-term use of opioid painkillers to treat chronic nonmalignant medical conditions, like low-back pain, sciatica and various musculoskeletal problems. To no small degree, this change in clinical practice was encouraged through aggressive marketing by drug companies that made new and powerful [i.e., dangerous] opioids, like OxyContin, an extended-release form of oxycodone...What the public — and physicians — should know is that there is strong evidence that nonsteroidal anti-inflammatory drugs (Nsaids), like Motrin, and other analgesics like Tylenol are actually safer and more effective for many painful conditions than opioid painkillers." Physicians: Stop prescribing opioids promiscuously!
The Children of the Opioid Crisis (Jeanne Whalen, series for Wall Street Journal, 12-15-16) Left behind by addict parents, tens of thousands of youngsters flood the nation’s foster-care system; grandparents become moms and dads again. See also More than 300,000 Americans have died from opioid overdoses since the late 1990s, nearly as many as claimed by leukemia. (WSJ, graphic) And Hooked: One Family’s Ordeal With Fentanyl ( Jon Kamp andArian Campo-Flores, WSJ, This deadly synthetic painkiller, up to 50 times as powerful as heroin, presents a new level of peril in America’s opioid crisis. About the award-winning series: As deaths from powerful opioid drugs exploded, a team of Wall Street Journal reporters uncovered how fentanyl and other synthetic opioids, often made in overseas chemical labs, had made America's drug problem far more lethal. Their reporting exposed the multiple factors that produced the epidemic. They laid bare the terrible human toll on addicts, families and entire communities who feel powerless against the hold these drugs have over their victims. And they showed why the Drug Enforcement Administration is in a high-stakes game of cat-and-mouse, with overseas labs churning out new synthetic drugs at a furious pace, often staying a step ahead of authorities and helping to fuel the rampant opioid crisis."
Heroin: Killer of a Generation (Pat Beall et al., Palm Beach Post, 2015). A multimedia story of 216 teenagers, men, and women who died of a heroin-related overdose in Palm Beach County in 2015. The stories "explained why so many were dying, explored the science behind the disease of addiction and documented the government inaction that enabled the epidemic to continue unabated." (Quote from judges for AHCJ journalism award)
Judges for AHCJ journalism award.)
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Side issues and practical ramifications of the opioid crisis

You can keep up with stories like this by subscribing to KHN Morning Briefing (Kaiser Health News, invaluable for keeping up with breaking health stories)
Death in the Family: An Uncle’s Overdose Spurs Medicaid Official to Change Course (Emmarie Huetteman, KHN, 1-29-18) Andrey Ostrovsky’s family did not discuss what killed his uncle. He was young, not quite two weeks past his 45th birthday, when he died, and he had lost touch with loved ones in his final months. Ostrovsky speculated he had committed suicide. Almost two years later, Ostrovsky was Medicaid’s chief medical officer, grappling with an opioid crisis that kills about 115 Americans each day, when he learned the truth: His uncle died of a drug overdose.
Is 20.8 Million Pain Pills Over a Decade a Lot for One Town? It Depends. (Alex Barasch, Slate, 1-30-18) Over-prescription is a real danger, but reducing the opioid crisis to a numbers game won’t bring about a solution. Some pain patients are being cut off from medications that can help them.
Opioid Drug Users Tell Of Rarely Discussed Injury: Rape (Martha Bebinger, CommonHealth, WBUR, 9-6-17) How sexual assault is becoming 'normalized' in a crisis. "It's an injury active drug users often don't report out of shame, distrust of police or fear they'll be labeled a "cop caller" and have trouble buying heroin. It's an injury women say they can't figure out how to prevent. And it's one few doctors think to ask about, and thus do not treat. The road to trouble starts many mornings, says Kristin, when she wakes up, sick and desperate for heroin but afraid to shoplift, sell the goods, and seek a dealer on her own. So she finds a male buddy, someone she calls a running partner....Sometimes that strong man with a good reputation turns out to be another danger. Kristin cringes at the memory of falling into a drug-induced sleep near a running partner she’d come to trust."
Underground Needle Exchange Helps Iowans Who Inject Drugs (Katarina Sostaric, Iowa Public Radio, 1-25-18) Staff from the nonprofit Iowa Harm Reduction Coalition meet clients wherever they are to provide several services, including on-site blood tests for HIV and hepatitis C. Volunteers from a collective called Prairie Works sometimes join the nonprofit and give out clean needles and syringes to prevent the spread of those diseases. That’s the illegal part. This illegal needle exchange is trying to prevent diseases among injection drug users while Iowa lawmakers consider a bill to legalize that kind of program.
Opioid Crisis Blamed For Sharp Increase In Accidental Deaths In U.S. (Scott Neuman, The Two-Way, NPR, 1-17-18) Accidental deaths in the United States rose significantly in 2016, becoming the third-leading cause of fatalities for the first time in more than a century – a trend fueled by the steep rise in opioid overdoses, the National Safety Council reports. Accidents — defined by the council as unintentional, preventable injuries — claimed a record 161,374 lives in 2016, a 10 percent increase over 2015. They include motor vehicle crashes, falls, drowning, choking and poisoning, a category that encompasses accidental overdoses.
There Is More Than One Opioid Crisis (Kathryn Casteel, FiveThirtyEight, 1-17-18) To better tackle the epidemic, Kentucky needed to know which drugs were causing lethal overdoses.
What to Make of a Head-to-Head Test of Addiction Treatments (Jake Harper, NPR, 11-16-17) The largest study so far to directly compare the widely used treatment Suboxone with relative newcomer Vivitrol found them equally effective once treatment started. But there are fundamental differences in the way treatment begins, which makes these findings difficult to interpret. Vivitrol, an injection of naltrexone that lasts 28 days, has gained a foothold among treatment providers, especially those working with the criminal justice system. Until recently, no major study had compared it to Suboxone, a combination of buprenorphine and naloxone that is taken by mouth daily. Now researchers have found the two medications to be equally effective at preventing relapse once patients start treatment, but a Lancet study highlights a limitation for patients starting on extended-release naltrexone: Patients have to detox before receiving their first dose of Vivitrol (which is also far more expensive). That requirement creates a significant barrier to beginning treatment, says Dr. Joshua Lee. Clearly there is a place for both treatments.
Is America’s opioid epidemic killing the economy? (Michael E. Kanell, Atlanta Journal-Constitution, 9-5-17) Estimates are that abuse of legal drugs cost more than $70 billion last year – and that doesn’t include the surge of heroin and fentanyl. ... And it is so widespread and so damaging that it seems to be a partial answer to some big puzzles that economists have been grappling with. “We are missing about 3 million people out of the labor force,” Korzenik said. “If we had a participation rate – for each demographic – that we had in 2003, we would have 3 million more people working. That is adjusting for the baby boomer retirement. So if it is not the people aging out, what else is it?” There are other explanations, but the more he looked at it, the more the data drove him toward opioids as explanation. “Eight years of economic expansion and we are running out of labor. We are in the end game of the economic expansion. And we have never had anything like the opioid epidemic hit the labor force. Maybe the 1918 influenza epidemic, otherwise nothing.”• Bridgewater State Says It Will Be First US University To Make Narcan Publicly Available (Ben Thompson, Boston Globe, 9-5-17) Bridgewater State University will offer public access to Narcan in locations across campus to combat potential overdoses, the university said. The university’s police department is launching an “aggressive” opioid overdose prevention program, making the overdose-reversing drug available in 50 defibrillator boxes across campus buildings, including all 11 residence halls, university officials said.
Mapping How the Opioid Epidemic Sparked an HIV Outbreak (Heather Boerner, Shots, Public Health, NPR, 1-14-18) Genetic data has been used to track HIV before. But now, the technology is being used to map HIV outbreaks in real time, lending molecular weight to the in-person interviews that public health officials have used for centuries to track and stop outbreaks. The Austin reconstruction is an example of what it can do....the CDC decided to use the same kind of molecular sleuthing that ferreted out Dugas's real place in the epidemic, and layer those results over the data health workers collected in interviews. The idea was that they'd test it on the Indiana outbreak first, and then offer the technology, which uses multiple programs and takes partner interviews into account, for free to public health departments across the country....At each step in this outbreak, officials could have intervened without the DNA map, Cooke says. If that early person with HIV were able to access treatment, the risk of transmitting the virus in the first place would have been negligible. If there had been a syringe access program, there would have been less needle sharing and even injecting drugs wouldn't have transmitted the virus. If there was adequate mental health care, people might deal with childhood traumas differently. If addiction treatment were more readily available, if HIV prevention tools like Truvada were available everywhere — all of these could have deescalated the outbreak, he says."
Some of the best opioid coverage is not where you’d expect (Anna Clark, Columbia Journalism Review, 10-17-17) Stories about the opioid crisis aren’t just being told in expansive features and smartly reported articles. They’re being told in the obituaries. They carry the most weight across the huge swaths of the country that are near-news deserts, like southwest Michigan, where the Jonatzkes live. In these places, there aren’t any deeply reported local stories about heroin use. But there are obituaries. Lots of them. These obituaries track the devastating human cost of a modern-day plague, challenge the stigma of addiction, and build a case for better public policy and social services. In some cases, the person who died specifically requested that their story be told honestly.
Seeking Payback for Opioid Costs, Manchester Files Suit Against Drug Makers (Casey McDermott, New Hampshire Public Radio, 9-6-17) Opioid-related overdoses rose more than 80 percent in August compared to a year earlier, but the number of deaths dropped by more than half, authorities said Tuesday. Such overdoses were up slightly during the first eight months of this year over the same period last year, but the number of fatalities fell by more than a third, according to city fire department figures. "New Hampshire became the latest state to go after Purdue Pharma, alleging the company’s marketing practices were partially to blame for the state’s opioid epidemic. Now, the city of Manchester is also suing Purdue — as well as other opioid manufacturers and distributors — seeking payback for the cost it's incurred because of the drug crisis. The city’s 234-page complaint, filed Friday in Hillsborough County Court North, minces no words. It begins: 'This case is about one thing: Corporate greed. Defendants put their desire for profits above the health and well-being of the City of Manchester, its residents and consumers, all at the cost of the plaintiff.' Defendants in this case include Purdue Pharma as well as several other opioid manufacturers and distributors: Teva Pharmaceuticals, Johnson & Johnson, Cephalon, Allergan and Endo Pharmaceuticals, among others. [Emphasis added.]
Second patient says doctor under FBI investigation pushed opioid spray (Andy Marso, Kansas City Star, 9-5-17) "A lawsuit filed Friday alleges that Steven Simon urged Johnson County resident Carey Ballou to take Subsys, an oral fentanyl product with a high potential for addiction, even though less risky, less expensive alternatives existed, and she was reluctant to take the drug. The complaint was similar to a lawsuit filed the same day on behalf of Olathe resident James Whiting, who told the Star in July that Simon pressured him to take Subsys without informing Whiting that he was being paid by the drug’s Arizona-based manufacturer, Insys Therapeutics."
Jobs are here; Ky.’s workforce needs addiction treatment (Dave Adkisson, Lexington Herald Leader, ) Among the many health challenges facing America, none has hit Kentucky harder than opioid addiction. The impact of the opioid crisis on Kentuckians’ health is staggering, with more than 1,400 overdose deaths reported last year. Less obvious, however, is the toll it has taken on the state’s economic growth and development. In Kentucky, the opioid crisis has contributed to a workforce participation challenge that undermines the competitiveness of existing businesses while creating barriers to new investments.
My Fellow Conservatives Should Protect Medical Marijuana From The Government ((Rep. Dana Rohrabacher (R-Calif.), Washington Post, 9-5-17)) "I should not need to remind our chief law enforcement officer nor my fellow Republicans that our system of federalism, also known as states’ rights, was designed to resolve just such a fractious issue. Our party still bears a blemish for wielding the “states’ rights” cudgel against civil rights. If we bury state autonomy in order to deny patients an alternative to opioids, and ominously federalize our police, our hypocrisy will deserve the American people’s contempt."
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Fraudulent practices in addiction treatment

Agencies target 'illegal, unapproved' products that claim to treat opioid addiction (Laurie McGinley, WashPost, 1-24-18) Federal regulators said Wednesday that they are cracking down on marketers and distributors selling a dozen products that “illegally” claimed to treat or cure opioid addiction and withdrawal. In letters sent earlier this month, the Food and Drug Administration and the Federal Trade Commission cited products that target people desperate to find relief from their addictions. They include “Opiate Freedom 5-Pack,” “CalmSupport” and “Soothedrawal.” Most of the 12 items are marketed as dietary supplements, while two are homeopathic remedies, the FDA said.
The Giant, Under Attack (Michael Corkery and Jessica Silvr Greenberg, NY Times, 12-27-17) of America’s biggest rehab companies built an empire. But after a patient named Gary Benefield died, its enemies — investors and business rivals alike — struck hard. "Mr. Cartwright’s company, American Addiction Centers, operates treatment centers in eight states around the country. That was how Mr. Benefield ended up in a treatment facility in California: Eager to get sober, he and his wife searched online from their home in Arizona for a clinic, found A Better Tomorrow — which eventually became part of Mr. Cartwright’s business — and then called up to book a spot. This account of Mr. Benefield’s final days, and the battle over American Addiction Centers, draws on interviews with executives, front-line employees, addicts, police and investors, as well as thousands of court documents."
Rogue doctors exploit loopholes to let a powerful drug ‘devastate a community’ (Laura Ungar, Courier Journal, 6-8-17) 'How a medication intended to curb opioid cravings and ease withdrawal was being prescribed by doctors with disciplinary records, fueling misuse and the rise of rogue clinics that Kentucky’s attorney general called “the second coming of our pill mills.”~Susan Stellin
Arizona lawsuit opens window into lucrative drug rehab business — and allegations of fraud (Ken Alltucker, The Republic, AZCentral, 12-4-17) Nine alcohol and drug rehabilitation centers claim in a Maricopa County Superior Court lawsuit that the health insurance company Health Net of Arizona improperly withheld or delayed lucrative payments for treatment of people struggling with addiction. But Health Net says in a counterclaim that there was widespread fraud among Arizona and California drug rehab centers in 2015 and 2016, when it alleges "teams of brokers" recruited out-of-state clients to fraudulently obtain insurance policies and to seek treatment in Arizona. Those actions have cost the insurance company — and Arizona consumers through higher monthly premiums — tens of millions of dollars, the Health Net counterclaim say...The growth of rehab centers corresponds with the rise of residential “sober homes” that have sprouted in upscale neighborhoods of Phoenix, Paradise Valley, Scottsdale and other communities in metro Phoenix. The proliferation of these homes pits residential neighbors against rehab entrepreneurs in standoffs that have created headaches for local government officials as they try to determine how to manage the unregulated industry....A key funding source for the rehab centers, which often work in tandem with sober homes, has been urinalysis testing. These tests, for which the centers charged large and repetitive fees, proved lucrative from 2014 through 2016."
Searching for help She turned to Google for help getting sober. Then she had to escape a nightmare. As a NiemanReports article reported, "deep-pocketed and sometimes unethical treatment providers can manipulate Google’s advertising program to attract clients. For instance, an online search for a rehab center could lead to a site with a toll-free phone number for a business selling patient referrals to the highest bidder." After the Verge article appeared, "Google announced a crackdown on rehab ads, a business Bloomberg reported may have added up to $1 billion a year in revenue for Google, which charged $100 or more in fees for clicks on ads linked to searches like “heroin rehab near me.” See Why It Took Google So Long to End Shady Rehab Center Ads (Bloomberg Business Week, 9-26-17) and Exclusive: Google is cracking down on sketchy rehab ads (Cat Ferguson, The Verge, 9-14-17) "Following a Verge report about rehabs gaming Google, the company has begun pulling AdWords." (Journalism, not law enforcement, brought about change.)
Doctors Make Big Money Testing Urine For Drugs, Then Ignore Abnormal Results (Fred Schulte, Kaiser Health News, 11-29-17) A KHN investigation earlier this year found that dozens of pain doctors with their own labs took in $1 million or more in 2015 from Medicare for running urine and, in some cases, genetic drug tests. Some doctors derived at least 80 percent of their Medicare income this way. Medicare and other insurers pay for urine tests with the expectation that clinics will use the results to detect and curb dangerous drug abuse. But some doctors have taken no action when patients are caught misusing pharmaceuticals, or taking street drugs such as cocaine or heroin. Medicare and private insurers acknowledge that they lack the resources to routinely verify that doctors who order a high volume of drug-related tests do so to improve patient care, not fatten the bottom line.
Called ‘hogwash,’ a gene test for addiction risk exploits opioid fears (Charles Piller, STAT News, 12-13-16) Proove Biosciences, a Southern California company that markets an unproven “opioid risk” test, claims its test can predict, with 93 percent accuracy, which patients will become addicted to or misuse prescribed opioid pain pills. But STAT has found that the opioid risk test lacks a firm scientific basis. Genetics and addiction experts — including one of Proove’s medical advisers — said genetic testing isn’t able to predict addiction, and questioned the evidence used to back up the company’s accuracy claim. Erroneous results could misinform doctors and lead them to unnecessarily refuse opioids to patients suffering severe pain, the experts warned. (Follow-up for journalists: Story about genetic testing company’s problems shows how good reporting stands up to criticism (Joseph Burns, Covering Health, AHCJ, 11-17-17) Piller wrote four articles about Proove over eight months that questioned the validity of the test and the company’s marketing practices. Piller addresses common issues in reporting this kind of story and offers suggestions for journalists seeking to gain the trust of sources who might be unwilling to speak on the record and how to identify clinical lab testing companies that might be selling questionable tests.
Addiction Inc. (NY Times, 1-3-18) Marketing wizards and urine-testing millionaires: Inside the lucrative business of America’s opioid crisis.
"Desperate for addiction treatment, patients are pawns in lucrative insurance fraud scheme (David Armstrong and Evan Allen, STAT and Boston Globe, 7-27-17) Drug users, desperate to break addictions to heroin or pain pills, are pawns in a sprawling national network of insurance fraud, an investigation by STAT and the Boston Globe has found. They are being sent to treatment centers hundreds of miles from home for expensive, but often shoddy, care that is paid for by premium health insurance benefits procured with fake addresses. Patient brokers are paid a fee to place insured people in treatment centers, which pocket thousands of dollars in claims for each patient. They often target certain Blue Cross Blue Shield plans, because of their generous benefits and few restrictions on seeking care from out-of-network treatment programs."
The addict brokers: Middlemen profit as desperate patients are ‘treated like paychecks’ (David Armstrong and Evan Allen, STAT and Boston Globe, 5-28-17) "Patient brokers can earn up to tens of thousands of dollars a year by wooing vulnerable addicts for treatment centers that often provide few services and sometimes are run by disreputable operators with no training or expertise in drug treatment, according to Florida law enforcement officials and two individuals who worked as brokers in Massachusetts. Cleggett refused to say whether he was paid to find customers for Florida treatment centers. The facilities are tapping into a flood of dollars made available to combat the opioid epidemic and exploiting a shortage of treatment beds in many states. As center owners and brokers profit, many patients get substandard treatment and relapse."
Profit-Mining the Opioid Crisis: Targeted by an addiction treatment center, union workers feel trapped as their benefits are drained (David Armstrong and Evan Allen, STAT and Boston Globe, 11-10-17) "One after another, New Jersey public school teachers arrived at the Recovery Institute of South Florida after asking their union to find them addiction or mental health treatment. Instead of getting the help they needed, many said they were essentially trapped at the facility while their health insurance was billed tens of thousands of dollars....The teachers’ experience is a stark example of what’s happening around the country to union members fighting addiction. Treatment center operators and middlemen who act as brokers for those facilities are targeting these workers because they usually have generous insurance benefits that pay for long stays in rehab. They also often need a health care provider’s clearance to return to work, handing the centers tremendous power over patients....teachers, mostly from New Jersey, as well as school custodians and social workers or their relatives. Most said they were allowed only limited contact with family. They complained about inadequate and cookie-cutter treatment, consisting mostly of group counseling and 12-step meetings, massages at a local chiropractor’s office, and plenty of free time."
Some Addiction Treatment Practices are Making Me Sick (Deni Carise, HuffPost, 3-13-17) There are " unscrupulous people trying to make a profit off of our nation’s current drug epidemic with unethical and shocking practices like patient brokering, identity theft, kickbacks and insurance fraud. It’s not widespread abuse – fortunately, there are still many high-quality, ethical treatment programs in this country – but it is happening often enough for us all to be concerned."
Addicts For Sale (Cat Ferguson, BuzzFeedNews, 3-19-16) In the rehab capital of America (Del Ray, Florida), addicts are bought, sold, and stolen for their insurance policies, and many women are coerced into sex. They are kids who are often broke and far from home, with limited support from family and friends; they can be mentally and physically unstable; and they’re frequently running from parole or pending court cases. The people targeting them are variously called “marketers,” “body brokers,” and even “junkie hunters.” They know addicts better than anyone (and many used to be addicts themselves).
Preying on the Vulnerable: Sober Home Fraud (Jean Lyon, HMS, 4-27-17) A sober living home is generally defined as an alcohol- and drug-free living environment for newly sober individuals who are trying to abstain. Because sober homes can be an important step between inpatient rehabilitation and an independent living environment, many insurers provide coverage for not only the SLH, but also for related services such as outpatient rehab, counseling, and drug testing to monitor the patient’s sobriety. But a variety of schemes have been perpetrated in sober homes, including patient brokering, kickbacks, not being a sober home, identity theft, billing for services not needed or rendered, predatory marketing practices, and waiver of the co-pay.
Addiction Treatment: Inside the Gold Rush (Palm Beach Post
County’s $1 billion gold rush: Addiction treatment draws FBI (Pat Beall, Palm Beach Post, 8-14-15) t took Frank Cid just six years to create a lucrative, one-stop addiction recovery empire big enough to bring Wall Street to town. And Wall Street brought cash. Last September, an affiliate of Goldman Sachs was preparing to shell out $32.5 million for the real estate investor’s portfolio of high-end treatment programs: detox, rehab, outpatient sober living rentals and a lab to test his clients’ urine. Post reporters investigated corruption, patient brokering, and insurance fraud in the sober home industry since 2015. Also known as halfway houses, sober homes offer transitional housing for people who have completed in-patient rehabilitation, typically requiring drug testing and imposing other rules. The series includes "articles about sober home residents openly using drugs, allegations that one owner was using clients as part of a prostitution business, and reports that some owners are cashing in on the chance to bill insurance companies for urine samples collected from residents for drug testing—earning $150 for each sample collected as many as five times per week." In other words, about corruption in the sober home industry.
New Law Aims To Prevent Fraud In Florida Recovery Industry (Victoria Kim, The Fix, 7-06-17) The billion-dollar addiction recovery industry, especially prevalent in South Florida’s Palm Beach County, has come under fire for reports of fraud and abuse. "Florida officials say many of South Florida’s private treatment centers “aggressively” market recovery services in other parts of the United States like the Northeast and Midwest, hoping to draw clients to the Sunshine State with promises of lasting results. According to the Sun Sentinel, every three out of four clients in private treatment for substance use disorder in Florida are from out of state....The law establishes tighter rules and penalties on sober living homes that falsely advertise its services and companies that scam clients. Sober home telemarketers must also register with the state to prevent patient brokering, and background checks are now mandatory for any owners, directors and clinical supervisors at treatment centers."
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Opioid addiction treatment with a dark side

Addiction Treatment With a Dark Side (Deborah Sontag, NY Times, 11-16-13) The Double-Edged Drug. Many addicts credit buprenorphine, sold mostly in a compound called Suboxone, with saving their lives. "Suboxone is the blockbuster drug most people have never heard of. Surpassing well-known medications like Viagra and Adderall, it generated $1.55 billion in United States sales last year, its success fueled by an exploding opioid abuse epidemic and the embrace of federal officials who helped finance its development and promoted it as a safer, less stigmatized alternative to methadone. But more than a decade after Suboxone went on the market, and with the Affordable Care Act poised to bring many more addicts into treatment, the high hopes have been tempered by a messy reality. Buprenorphine has become both medication and dope: a treatment with considerable successes and also failures, as well as a street and prison drug bedeviling local authorities. It has attracted unscrupulous doctors and caused more health complications and deaths than its advocates acknowledge. It has also become a lucrative commodity, creating moneymaking opportunities — for manufacturers, doctors, drug dealers and even patients — that have undermined a public health innovation meant for social good."
"Intended as a long-term treatment for people addicted to opioids — heroin as well as painkillers — buprenorphine, like methadone, is an opioid itself that can produce euphoria and cause dependency. Its effects are milder, however, and they plateau, making overdoses less likely and less deadly."
In other words, Methadone and buprenorphine are subject to "street use" and abuse -- partly because of the hoops we make people jump through to get access to them.
The Giant, Under Attack (Michael Corkery and Jessica Silver-Greenberg, NY Times, 12-27-17) One of America’s biggest rehab companies built an empire. But after a patient named
Gary Benefield died, its enemies — investors and business rivals alike — struck hard....The doctor prescribed Mr. Hill buprenorphine, which satisfies the craving for opiates but does not result in a high. Mr. Hill’s successful treatment with buprenorphine was for him a revelation. Mr. Cartwright, by contrast, believes that ultimately “abstinence has to be the goal.” That is only the start of their differences. Mr. Hill prefers an outpatient approach that is close to the patient’s support network... believes the inpatient model is motivated more by greed than doing good. Inpatient providers can bill insurers up to $10,000 for 28 days of services; Mr. Hill charges $1,400 a month for his outpatient treatments. "Mr. Hill’s concerns about American Addiction Centers were not just about the debate between inpatient vs. outpatient philosophies of treatment. He told Mr. Drose about patients who had died in rehab homes around Temecula and nearby Murrieta that Mr. Cartwright later acquired.The deaths, Mr. Hill contended, showed how the company was unequipped to deal with medically fragile addicts."...The driver and other employees also testified that staff members were discouraged from taking patients to a hospital emergency room — even when they appeared to be in distress — because A Better Tomorrow might risk losing a paying customer. The feeling was, “they are taking our clients,” the driver said of the hospital....On and off in the years since Mr. Benefield’s death, a cast of characters — the empire builder Mr. Cartwright, the budding short-seller Mr. Drose, the crosstown rival Mr. Hill — had made A Better Tomorrow and American Addiction Centers a focus of their lives. Some hoped to build it up. Others dreamed of tearing it down. Mr. Cartwright and Mr. Drose, in particular, saw fortunes to be made...."
Prisons fight opioids with $1,000 injection: Does it work? (Carla K. Johnson, AP, AARP, 11-14-16) "The evidence for giving Vivitrol to inmates is thin but promising. In the biggest study, sponsored by the National Institute on Drug Abuse, about 300 offenders — most of them heroin users on probation or parole — were randomly assigned to receive either Vivitrol or brief counseling and referral to a treatment program. The evidence for giving Vivitrol to inmates is thin but promising. In the biggest study, sponsored by the National Institute on Drug Abuse, about 300 offenders — most of them heroin users on probation or parole — were randomly assigned to receive either Vivitrol or brief counseling and referral to a treatment program. After six months, the Vivitrol group had a lower rate of relapse, 43 percent compared with 64 percent. A year after treatment stopped, there had been no overdoses in the Vivitrol group and seven overdoses, including three deaths, in the other group.... Yet addiction is stubborn. When the injections stopped, many in the study relapsed. A year later, relapse rates looked the same in the two groups."
A little explanation (drawn from website of The National Alliance of Advocates for Buprenorphine Treatment): "An agonist is a drug that activates certain receptors in the brain. Full agonist opioids activate the opioid receptors in the brain fully resulting in the full opioid effect. Examples of full agonists are heroin, oxycodone, methadone, hydrocodone, morphine, opium and others."
"An antagonist is a drug that blocks opioids by attaching to the opioid receptors without activating them. Antagonists cause no opioid effect and block full agonist opioids. Examples are naltrexone and naloxone. Naloxone is sometimes used to reverse a heroin overdose."
Methadone and buprenorphine are "agonists." Vivitrol is an extended release formulation of naltrexone, an opioid receptor "antagonist." Buprenorphine is a "partial agonist," meaning it activates the opioid receptors in the brain, but to a much lesser degree than a full agonist. Buprenorphine also acts as an antagonist, meaning it blocks other opioids, while allowing for some opioid effect of its own to suppress withdrawal symptoms and cravings....Buprenorphine is in a category of its own and therefore should not be seen as “replacement” or "substitution" for anything else.
At Clinics, Tumultuous Lives and Turbulent Care (Deborah Sontag, NY Times, 11-17-13) "Buprenorphine was developed as a safer alternative to methadone for treating heroin and painkiller addiction, a take-home medication that could be prescribed by doctors in offices rather than dispensed daily in clinics. But in some areas a de facto clinic scene, unregulated, has developed, and it has a split personality — nonprofit treatment programs versus moneymaking enterprises built by individual doctors, some with troubled records....Since March, The New York Times has visited and tracked the patients of two of the largest buprenorphine programs in this region, where addiction rates are high, for-profit clinics have proliferated, doctors go in and out of business and the black market is thriving."
• In a discussion among health journalists in March 2017, Elizabeth Leary (MSN, RN) explained : "Vivitrol at least is not an opioid and, for patients who are so addicted that they are in the criminal justice system, not having to give a daily dose is actually more effective for what is essentially a homeless and transient street population. Good luck getting them into clinic every day for observed drug therapy. With Vivitrol you can reduce the cravings by not trading one opioid for another, and the patient's thought process begins to change. The real downside to Vivitrol is if the patient happens to need surgery within the 28 days that the shot lasts, because these are high risk patients (often GI bleeders from alcohol abuse for example) where the need for surgery is a real risk and you can't give them opioids for pain control with Vivitrol on board. You basically have to control the pain with anesthesia, which is less than ideal."
When you stop using Vivitrol for opioid treatment, you have a very high risk of death from relapse to opioid use. You don't have that same risk of death using Vivitrol to treat alcoholism, because alcohol relapses are rarely deadly, says journalist Maia Szalavitz, author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, who has written extensively on addiction and treatments for it.
A Shot in the Dark: Can Vivitrol Help Us Control Our Addictions? (Walter Armstrong, The Fix, via Pacific Standard, 5-7-13) "Called Vivitrol and made by Boston-based biotech Alkermes, it has been on the market for alcoholism since 2006 and for opiate addiction since 2010. It is not, however, a new drug. It is a new injectable formulation of an old drug called naltrexone, a once-a-day pill prescribed since the mid-‘90s for addiction. The newsiest thing about Vivitrol may be its price tag. While naltrexone, a generic, has an insurance copay averaging $11 a month, Vivitrol costs — deep breath! — about $1,100 a month. A growing number of health insurers are covering all or part of the bill." "Many doctors, when faced with a patient with a drinking problem, don’t think to offer it as a treatment option. Likewise, this addiction medication often gets short shrift in rehabs and 12-step programs. But being a patient means advocating for yourself, so if you want to, you may have to demand to give this shot a shot....The prevailing treatment philosophy is that no single approach is best for everyone. Tailoring the treatment to the individual is the standard of care, even if doing so can involve trial and error." An exploratory article worth reading.
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Kratom is an opioid

Clearly, this is a story that changed midstream.
Kratom Now an Opioid, FDA Says (Megan Brooks, Medscape, 2-7-18) "A new analysis by scientists at the US Food and Drug Administration (FDA) shows that compounds in kratom act like prescription-strength opioids, the agency said today. The agency also said kratom has now been linked to 44 deaths, up from 36 reported in November.The scientific data and adverse event reports have "clearly revealed" that compounds in kratom make it "not just a plant — it's an opioid," FDA Commissioner Scott Gottlieb, MD, said. "And it's an opioid that's associated with novel risks because of the variability in how it's being formulated, sold, and used recreationally and by those who are seeking to self-medicate for pain or who use kratom to treat opioid withdrawal symptoms," added Dr Gottlieb.
The following stories are now more or less out of date, as FDA has ruled kratom an opioid.
Why Banning the Controversial Painkiller Kratom Could Be Bad News for America's Heroin Addicts (Maia Szalavitz, Vice, 1-20-16) "It sounds like the perfect drug. At low doses, it's stimulating, like a strong cup of coffee; at higher doses, it's sedating and kills pain. And it's a legal, natural plant that has been used in Asian medicine for centuries. Indeed, a growing number of Americans are finding it to be a useful alternative to heroin and prescription pain relievers. But of course, there's a catch. Like the opioid drugs it is used to replace, this stuff can be addictive, and it can also cause serious nausea. Unlike other opioids, however, it seems to have an extremely low overdose risk, which has caught the eye of people working to fight the record high level of overdose deaths." We need new, more flexible ways of regulating drugs—especially opioids—in order to truly protect the public.
Kratom with a side of cheesesteak: A sub shop’s vending machine draws customers desperate to kick opioids (Eric Boodman, STAT News, 6-1-17) Customers at this Tucson sub shop keep "heading for a vending machine that they hope will keep them off opioids. Kratom is the pulverized version of a plant from Southeast Asia. Last fall, the Drug Enforcement Administration nearly made kratom as illegal as the federal government can make a substance, on par with heroin and LSD, because of an increase in poison center calls about the substance, as well as worries that it might be addictive. “A lot of people found out about kratom because of all the bad publicity. … People were like, ‘Wow, if the government doesn’t want me to have it, I want to try it.’”
Turning to Kratom For Opioid Withdrawal (Jennifer Clopton, WebMD, 10-26-17) One of the most talked about methods for opioid withdrawal is using kratom, a little-known herb made from the leaves of a tree that grows on the other side of the world. A recent survey found that nearly 70% of people using kratom were doing so to cut back on or get off of opioids or heroin. But there’s little research on the herb’s effects on people, and some experts say it also can be addictive. The herb is illegal in six states and the District of Columbia, and the Drug Enforcement Administration is considering labeling it as a Schedule I drug -- a category that includes heroin, ecstasy, marijuana, and LSD. For now, the agency calls it a “drug of concern.”...“It is probably addictive, but its addictive equivalent is something like coffee, which isn’t surprising because the leaf is in the coffee family,” says Christopher R. McCurdy, PhD, a professor of medicinal chemistry at University of Florida’s College of Pharmacy in Gainesville. “We firmly believe that it will be very good for treating opioid withdrawal and may be a possible solution to the opioid epidemic we are facing as a country.” But he says that would require testing kratom in clinical trials and controlled studies. He’s hopeful that will happen in the next 5 to 10 years. For now, he warns buyers to beware.
What’s Next for Kratom after the DEA Blinks on Its Emergency Ban? (Angus Chen, Scientific American, 10-17-16) "Public pressure keeps the herbal supplement unregulated for now, encouraging users and researchers seeking a safer alternative to opioids. The DEA’s about-face comes about a month and a half after it first announced its intent to put kratom in its most restrictive drug category, Schedule I, which is reserved for substances deemed to have no currently accepted medical use and a high risk of abuse. It also includes heroin and LSD....For its next step, the DEA is opening a six-week period for the public to comment on concerns, research and science related to kratom. After that the agency will look to the Food and Drug Administration to complete an evaluation of kratom’s medical and scientific potential."
Kratom Drug Ban May Cripple Promising Painkiller Research (Angus Chen, Scientific American, 9-27-16) Compounds from the Southeast Asian tree offer hope for a safer opioid alternative, but research could slow to a crawl as the DEA steps in. center>[Back to Top]

Alcoholism--and approaches to treatment

Alcohol Does More Harm than Heroin and Crack (Temma Ehrenfeld. YourCareEverywhere, 6-3-15) 'Legal drugs are the deadliest. Alcohol use causes more than 4 percent all deaths worldwide, more than the number caused by HIV/​AIDS, violence, or tuberculosis, according to a 2011 report by the World Health Organization. It is associated with violence, child neglect and abuse, crime, missing work-days, and of course, traffic accidents. ”Yet, despite all these problems, the harmful use of alcohol remains a low priority in public policy, including in health policy,” the authors write. We spend huge sums on fighting a war on illegal drugs and pay little attention to the misuse of a legal one.'
Alcoholics Anonymous: The Big Book and Twelve Steps and Twelve Traditions (Alcoholics Anonymous). Or go to a meeting. Eleven of the steps do not mention alcohol. As one reviewer, Barry, writes, "Sobriety is about a new way of life free of alcohol, and this life is meant to be happy, joyous and free, not merely 'dry' and miserable. The best way to achieve this is to get a sponsor and make use of that sponsor, which will likely involve reading these books and considerable other action as well."
Hiding Addiction Behind Depression (Temma Ehrenfeld, The Fix, 03/​03/​16) Alcoholism cost him his life, after professionals said. my partner was just depressed. A must read if someone you love is struggling with both depression and a tendency to drink too much.
Does Alcoholics Anonymous Work? (Scott O. Lilienfeld and Hal Arkowitz, Scientific American 2-17-11) For some heavy drinkers, the answer is a tentative yes.
After 75 Years of Alcoholics Anonymous, It's Time to Admit We Have a Problem (Maia Szalavitz, Pacific Standard, 2-10-14) Challenging the 12-step hegemony -- a review of several books on addiction treatment and thereby a survey of treatment. Definitely read this one.
The Recovery Book: Answers to All Your Questions About Addiction and Alcoholism and Finding Health and Happiness in Sobriety by Al J. Mooney MD and Catherine Dold
Alcoholics Anonymous (AA) is self-help group, organised through an international organization of recovering alcoholics, that offers emotional support and a model of abstinence for people recovering from alcohol dependence using a 12-step approach. (M Ferri, L Amato, M Davoli, Cochrane Primary Review Group, 7-19-06). "No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [twelve-step] 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."
How Alcoholics Anonymous Psychologically Abuses the Marginalized (harMONEY🇵🇷samiruhh, The Establishment, 5-24-17) In some ways, AA helped me. But as an afrolatin trans woman, it also hurt me. I was typically the only trans person in the room. 62% of AA members are male, and 89% are white. "There are also underlying issues with the 12-step ideology itself, with fundamental program principles effectively encouraging abuse against the marginalized." As alternatives, if AA doesn't work for you, she recommends "SMART Recovery, Women for Sobriety, LifeRing Secular Sobriety, Moderation Management, the Sinclair Method, and drug replacement therapies are all viable options. Hell, seek someone like me out, someone who lives by the 12 steps but doesn’t attend AA."
How Smart Is Smart Recovery? (Joe Schrank, The Fix, 8-30-12) The leader of the largest alternative to AA sounds off on the disease model of addiction, whether crack can be smoked in moderation, and why the 12 Steps shouldn't be the only path to sobriety.
Non 12-Step Fellowships and Programs (The Fix) LifeRing, Moderation Management, Rational Recovery, Secular Organizations for Sobriety (SOS), SOS Behind Bars, Women For Sobriety. (for those interested in AA history and resources)
Alcoholism In-Depth Report (NY Times)

Trading Alcoholism for Sugar Addiction: Here’s the Not-So-Sweet Truth (Promises Treatment Center). See also The Importance of Nutrition in Addiction Recovery
5 Things I Miss About Alcoholism (Emerson Dameron, Be Yourself, 12-6-16) A look at life viewed through those rose-colored glasses he took off when he went sober.
A daughter’s lifetime with a father’s slow self-destruction (Alisa Schindler, WaPo, 2-29-16) "Amazingly, a small glimmer of childhood idolization lingers. Forget the hospital stays, the dependencies, the self-destruction, the emotional manipulation, the cries for help that always leave me crying. I want to believe that this 73-year-old man will somehow find his way back..."
Alcoholism: The Science Made Easy (free, Addiction Technology Transfer Center Network)
Alcoholism and alcohol abuse (Medline Plus)
Giving up alcohol opened my eyes to the infuriating truth about why women drink (Kristi Coulter, 24-Hour Women, Quartz, 8-21-16) I’m newly sober and dog-paddling through the booze all around me. It’s summer, and Whole Foods has planted rosé throughout the store....
Why SMART Recovery Will Never Replace Alcoholics Anonymous (Matthew Leichter, The Fix, 9-23-14) "Alcoholics Anonymous thrives as a social network, more than a recovery program. In terms of being a place where someone can go on a daily basis to socialize, Alcoholics Anonymous kicks everyone else into the dirt. Clubhouses, halfway houses, and thousands of meetings a day all across the United States place this goliath as #1 in accessibility. Regardless of anything else, their mere size and emphasis on constant contact and socialization is something that no other program has been able to replicate....While recovery rates are better for SMART Recovery in clinical settings, SMART Recovery® fails to embrace the idea of building a social network. While they encourage a healthy support group, they really don’t do anything about it....While AA is rather zealous in its demands for attending meetings, the fact is that some people do need a new daily social structure to start their new life. Even Dr. Lance Dodes in his book The Sober Truth, a brutally critical account of AA, recognizes that the social aspect of AA is valuable."
Mom's Night in the Slammer (Leslie Schwartz, Narratively, 6-4-14) A recovering alcoholic rebuilds her life and becomes the perfect doting mother, until a fateful relapse sparks a downward spiral and a tumultuous night in jail.
The little pill that could cure alcoholism When an alcoholic doctor began experimenting with Baclofen, he made what could be the medical breakthrough of the century. Is alcoholism "a physical condition with a spiritual solution," as Alcoholics Anonymous has long insisted? Dr Olivier Ameisen no longer thinks so --having successfully ended his own debilitating addiction, he thinks he's found a revolutionary cure for the disease in the form of a widely available pill. His book: The End of My Addiction: How One Man Cured Himself of Alcoholism.
The Drunk's Club: A.A., the Cult that Cures (PDF, Clancy Martin, Harper's, Jan. 2011)
Surviving an Alcoholic (Paula Ganzi Licata, NY Times, 5-27-16) Shame is just one challenge for survivors of alcoholics. But it’s nothing compared with the guilt.
Drinking Causes Gut Microbe Imbalance Linked to Liver Disease (Bob Roehr, Scientific American, 2-10-16)
Alcohol and Cirrhosis of the Liver (Recovery Connection)
A 20-Year-Old Went to Rehab and Came Home in a Body Bag (Wilbert L. Cooper, Vice, 11-4-14). An expose of the high-end-$$ drug treatment world, through the story of one boy and family it failed: Brandon Jacques, whose dual diagnosis of bulimia and alcohol addiction called for better treatment and medical care than the overpriced "treatment" facility could provide. ("'s illegal for residential drug and alcohol programs like Morningside to provide any medical care in the State of California, because of an old, controversial law that is a vestige of the rehab industries' AA-based, nonmedical beginnings....Because the State of California has done such a poor job of enforcing the ban on in-house professional medical care, facilities like Morningside get the best of both worlds--they can market themselves as medical facilities to attract more clients without fear of getting shut down, but they don't have to spend the money on medical care or jump through the regulatory hoops required of a facility practicing medicine.") Here is video on the same story: From Rehab to a Body Bag | Dying for Treatment (Vice video, Nov 2014) From Rehab to a Body Bag | Dying for Treatment. "Although non-hospital residential treatment serves only about 10 percent of those in recovery in the US, the exorbitant cost of such care--as high as $75,000 a month--has made it extremely lucrative....these centers operate in a gray zone somewhere between legitimate medicine and total quackery, offering things like horseback riding and meditation as solutions to addiction, and often promising medical care that they are unable to provide--sometimes with disastrous results." (I've repeated this entry from general section above on addiction, treatment, and recovery, generally, because it makes an important point.)
The scientific effects of drunk driving ( infographic)
Is your health care provider an addict? The problem we can’t ignore (Judi Kanne, Georgia Health News, 9-11-16)
50 Essential Tips To Help You Stay Clean And Sober
and Alternatives To AA and Is There Such Thing As An Alcoholic Personality? (Clean and Sober Live)
Did Alcoholism Kill Joan Didion's Daughter? (Jenna Sauer, Jezebel, 12-13-11)
The pseudo-science of Alcoholics Anonymous: There’s a better way to treat addiction (Dr. Lance Dodes and Zachary Dodes, Salon, 3-23-12). An excerpt from their book The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. Read the comments on Amazon, for views pro and con, including "one size does not fit all."
Acute alcohol use temporally increases the odds of male perpetrated dating violence: a 90-day diary analysis (PubMed Jan. 2014)
Alcohol Awareness. Emphasizes how alcohol is often abused as a way to deal with depression, which may make the symptoms worse, and lead to suicide.

Helpful books about addiction and recovery

Unbroken Brain: A Revolutionary New Way of Understanding Addiction by Maia Szalavitz (2016). She argues "that addictions are learning disorders and shows how seeing the condition this way can untangle our current debates over treatment, prevention and policy. Like autistic traits, addictive behaviors fall on a spectrum -- and they can be a normal response to an extreme situation. By illustrating what addiction is, and is not, the book illustrates how timing, history, family, peers, culture and chemicals come together to create both illness and recovery- and why there is no "addictive personality" or single treatment that works for all." Writes the Wall Street Journal reviewer: "Ms. Szalavitz deftly threads her life story through the book to illustrate the dynamics that put people at risk of addiction."
Inside Rehab: The Surprising Truth About Addiction Treatment--and How to Get Help That Works by Anne M. Fletcher (2013). Review from Publishers Weekly: "Some things never change. And as Fletcher (Sober for Good) finds in this bold report on 15 rehab facilities—from high-end, celebrity-friendly outposts to those treating people on welfare—that fact especially pertains to addiction treatment. Collecting stories from more than 100 interviews, Fletcher methodically dissects the myths about the programs that treat 2.5 million people every year. She finds, for example, that rehab isn't necessary for recovery—some heal on their own, attend self-help groups, or see therapists; that most of the treatment in rehab programs is handled not by highly trained pros but by counselors with varying levels of education and training. She debunks myths, such as that the 12 steps of Alcoholics Anonymous are essential for recovery. Fletcher concludes that traditional programs, such as group treatment, 12 step programs, and counseling, work for some but not for all. Dimitri, for instance, began abusing drugs at 15 and cycled in and out of programs that failed to help him. Fletcher also highlights the exorbitant cost of rehab: one young woman's treatment drained her parents.... Fletcher presents what works, why, where to find it, and how much it costs. It's startling, difficult, and important information for those traveling toward recovery, and anyone who wants to help."
Clean: Overcoming Addiction and Ending America’s Greatest Tragedy by David Sheff, author of Beautiful Boy: A Father's Journey Through His Son's Addiction. "Addiction is a preventable, treatable disease, not a moral failing. As with other illnesses, the approaches most likely to work are based on science — not on faith, tradition, contrition, or wishful thinking. These facts are the foundation of Clean, a myth-shattering look at drug abuse by the author of Beautiful Boy. Based on the latest research in psychology, neuroscience, and medicine, Clean is a leap beyond the traditional approaches to prevention and treatment of addiction and the mental illnesses that usually accompany it. The existing treatment system, including Twelve Step programs and rehabs, has helped some, but it has failed to help many more, and David Sheff explains why. He spent time with scores of scientists, doctors, counselors, and addicts and their families to learn how addiction works and what can effectively treat it. Clean offers clear, cogent counsel for parents and others who want to prevent drug problems and for addicts and their loved ones no matter what stage of the illness they’re in. But it is also a book for all of us — a powerful rethinking of the greatest public health challenge of our time."
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Rehab facilities

First, the bad news
10 things rehab centers won’t tell you (Charles Passy, MarketWatch, MSN, 5-16-04). They aren't always effective, their success rates may mean little, a pricier program is not necessarily a better program, their staff may not be all that well-schooled. they'll invade your neighborhood, they may be a scam, you may be better off at home, etc. "The month-or-longer stint in rehab may be the classic treatment model, but it’s far from the only option. And depending on a patient’s needs and situation, it may not even be the best, according to many in the field. In fact, some studies have shown that success rates – in terms of maintaining sobriety – are just as high for outpatient programs (which are often much more affordable) as inpatient ones. On top of that, Fletcher, author of Inside Rehab raises the notion that some addicts may also do just as well with one-on-one counseling or self-help programs. Or to quote a subheading in one of the chapters of her book: 'Does anyone need residential rehab?'"
The Rehab Racket: The Way We Treat Addiction Is a Costly, Dangerous Mess (John Hill, Mother Jones, May.June 2015 issue) On December 30, 2012, as part of a series called Drugged, the National Geographic Channel aired an hourlong documentary about a 28-year-old named Ryan Rogers. It appeared to be a classic tale of a drunk trying against the odds to sober up, albeit with especially harrowing footage and an unusually charismatic protagonist, often shown with a radiant smile on his handsome face. Ryan Rogers was a 28-year-old alcoholic who entered a posh rehab facility to sober up. "Ryan took a courageous step," the narrator intoned. "But 17 days into rehab, he died."
"What transpired at Bay Recovery is one example of why the rehab regulatory system is so often described as fragmented. DADP was responsible for licensing the facility, but it's unclear whether it knew about Rand's earlier probations. And while the medical board had charged that Rand was admitting patients who were too medically and psychologically unstable to be treated at his facility, DADP never addressed this issue while Ryan was alive."
Rehab Racket (Center for Investigative Reporting) The programs are supposed to help struggling addicts. But scammers make millions running troubled rehab clinics, even inventing fake clients to rip off taxpayers. The Center for Investigative Reporting teamed with CNN to expose fraud in California's taxpayer-funded drug and alcohol counseling program.
---Bill seeking background checks for rehab clinic owners advances (Will Evans, 4-24-14)
---California rehab clinics bill taxpayers for fake clients, addictions (Will Evans, Christina Jewett, 7-29-13)
---Lax oversight leaves California drug rehab funds vulnerable to fraud (Christina Jewett, Will Evans, 7-29-13)
---Clinic leaders tied to fraud in LA reap taxpayer funds in Riverside County (Christina Jewett, Will Evans, 7-29-13)
---Video: Watch CNN's three-part series "Rehab Racket."
---Amid fraud allegations, rehab doctor OKs treatment without seeing patients (Will Evans, Christina Jewett, Special to CNN, 10-22-13)

I am still trying to figure out how to guide others on how to find the good rehab facilities. Advice welcome.
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Sober living housing options

Making Space for Sobriety (Ryan Caron King, Atavist, published on WNPR). When a person who addicted to drugs or alcohol is discharged from rehab, they’ll sometimes live in what’s called a sober house -- a place where there’s supposed to be no drugs or alcohol around. Same as or similar to How One Agency Is Improving Conditions in Connecticut's Sober Houses (Ryan Caron King, WNPR, 10-4-16) "When someone who is addicted to drugs or alcohol is discharged from rehab, they’ll sometimes pay to live in a privately-owned sober living home like this one, Right Path House. But private sober houses aren’t regulated by the state, and experts in the field say some houses don’t enforce their own sobriety rules -- which can jeopardize the safety of the people that live there and the neighborhood the house is in. So Aligata is working to train and certify sober house owners across the state through a voluntary program. He wants to compile an online database of certified sober houses that he hopes will make it easier for people with addiction to find a place to continue their recovery after rehab."
Sober Living Homes and Housing Options ( What are sober living homes? How are they different from rehab centers? Why types of rules do sober living facilities require? Who can live in a sober living house? How much does it cost?
Living With a Recovering Drug Addict or Alcoholic (
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Issues associated with addiction and the drug industry

Prescription Drug Costs Are On The Rise; So Are The TV Ads Promoting Them (Bruce Horovitz and Julie Appleby, Kaiser Health News, 3-20-17) Pharmaceutical advertising exceeded $6 billion in 2016, with television picking up the lion’s share. Critics say the ads encourage patients to ask their doctors for expensive, often marginal — and sometimes inappropriate — drugs that are fueling spiraling health care spending. The American Medical Association called for a ban on such ads, but "Such a prohibition is unlikely. Previous efforts to push such an outcome have stalled, generally on free-speech arguments by the powerful drug lobby and assertions that such ads provide valuable information to patients about treatment options." “A lot of these ads target the caregivers and the children of older folks." The United States is one of two countries — the other is New Zealand — that allows direct-to-consumer drug advertising.
I Spent a Week in the Colombian Jungle Harvesting Cocaine (Felipe Chica Jiménez, trans. by Jenna Cgy, Narratively, 8-4-17) To understand the drug that has shaped her country's history, she sets her fear aside and gets to work. The family she works with, "like so many other campesino families, whether they have their own crops or buy the leaves loose, they have taken the risk of installing their own homemade processing lab. The real money lies in not only growing and harvesting the plant, but preparing paste from the leaves.... In the end, this family is nothing more than a small and fragile link in the immense chain that continues to mark Colombia’s history."
Taking A Page From Pharma’s Playbook To Fight The Opioid Crisis, ( Pauline Bartolone, KHN, 11-4-27) Dr. Mary Meengs remembers the days, a couple of decades ago, when pharmaceutical salespeople would drop into her family practice in Chicago, eager to catch a moment between patients so they could pitch her a new drug. She is one of 10 California doctors and pharmacists funded by Obama-era federal grants to persuade medical colleagues in Northern California to help curb opioid addiction by altering their prescribing habits. This one-on-one, personalized medical education is called “academic detailing” — lifted from the term “pharmaceutical detailing” used by industry salespeople.Detailing is “like fighting fire with fire,” said Dr. Jerry Avorn, a Harvard Medical School professor who helped develop the concept 38 years ago. “There is some poetic justice in the fact that these programs are using the same kind of marketing approach to disseminate helpful evidence-based information as some [drug] companies were using … to disseminate less helpful and occasionally distorted information.”
The blurred boundaries of mothering an addict (Erika Sauter, Motherwell, 4-26-17) "This wasn’t the first time my daughter had stolen from me."
Desperate for addiction treatment, patients are pawns in lucrative insurance fraud scheme ( David Armstrong for STAT and Evan Allen for Boston Globe, 7-7-17) Drug users, desperate to break addictions to heroin or pain pills, are pawns in a sprawling national network of insurance fraud, an investigation by STAT and the Boston Globe has found. They are being sent to treatment centers hundreds of miles from home for expensive, but often shoddy, care that is paid for by premium health insurance benefits procured with fake addresses. The fraud is now so commonplace that brokers use a simple play on words to describe how it works: “Do you want to Blue Cross the country?” Peter SanAngelo found himself another victim of a system in which people profited off him every step of the way. The one person left with nothing was Peter SanAngelo.
Just Say Know: Norman Bauman passes his urine test (orig. published in New Scientist vol 141 issue 1907 - 08 January 94, page 43) In 1986, President Ronald Reagan decided to test government workers for drugs. He excluded tobacco and alcohol, despite the serious health and safety problems to which they contribute. ("The 'War on Drugs' is a morality campaign by social conservatives to impose their own drugs preferences - alcohol and nicotine - on everyone else.") Norman questions the efficacy of drug screening (particularly noting the frequency of false positive results for those taking bupropion, an antidepressant often used as an aid for smoking cessation--see Casey -- and other substances that can affect test results, and see this, too) but takes the test anyway.
The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research (National Academies Press). Read online free, or download PDF.
New York Announces Health Insurance Reforms to Combat Opioid Crisis (Insurance Journal, 12-30-16)
My Damn Mind. Act 1: When Your Hospital-Borne Infection Is a Bullet. (This American Life, 2-12-16) The story of patient Alan Pean and how his delusions lead him to a situation that's just as strange as the worst thoughts his mind is cooking up. This story is a collaboration with the following NY Times story.
When the Hospital Fires the Bullet (Elisabeth Rosenthal, NY Times, 2-12-16) More and more hospital guards across the country carry weapons. For Alan Pean, seeking help for mental distress, that resulted in a gunshot to the chest."Like Mr. Pean, [mentally ill] patients seeking help at hospitals across the country have instead been injured or killed by those guarding the institutions. Medical centers are not required to report such encounters, so little data is available and health experts suspect that some cases go unnoticed. Police blotters, court documents and government health reports have identified more than a dozen in recent years. They have occurred as more and more American hospitals are arming guards with guns and Tasers, setting off a fierce debate among health care officials about whether such steps — along with greater reliance on law enforcement or military veterans — improve safety or endanger patients." (See also the preceding radio story on This American Life.)
No, Native Americans aren't genetically more susceptible to alcoholism (Maia Szalavitz, The Verge, 10-2-15) Time to retire the 'firewater' fairytale. There’s "no evidence that Native Americans are more biologically susceptible to substance use disorders than any other group, says Joseph Gone, associate professor of psychology at the University of Michigan. American Indians don’t metabolize or react to alcohol differently than whites do, and they don’t have higher prevalence of any known risk genes."
The President's Commission on Combating Drug Addiction and the Opioid Crisis (11-2-17)
The Parity Act Tracking Project: Making Parity a Reality (, 6-20-17) At a time of national crisis arising from opioid misuse, abuse and overdose, it is difficult to overstate the urgency of the need for significant improvement in the equitable coverage of addiction treatment benefits, as required by law.
The Brave New World of Precision Addiction Medicine (Kathy Jean Schultz, The Fix, 2-9-17) "New medical techniques can isolate substance-damaged brain tissue, pinpoint cravings and predict relapse: Is this a good thing?...The irony is that if substance misusers learn they have a solid chance of relapse, the emotions that follow—hopelessness, anger, depression—might themselves trigger relapse. A prediction of relapse could itself breed relapse. Finding out that one will relapse does not exactly light up the reward neurons, but it might light up the need to escape reality."
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Smoking and smoking cessation

Nonsmokers benefit under the Affordable Care Act, but quitting smoking is not easy and most interventions have a low success rate. Although the U.S. spends more on health care than any other country, we rank 43rd in health globally. "Tobacco remains the #1 cause of preventable death in America, accounting for 1 in 5 deaths, and costs the U.S. economy more than $300 billion per year," according to Tobacco in America, a report from Action on Smoking and Health (ASH), which you can download here.
Anti-Smoking ads to finally debut on TV (AP, video) Decades after they were banned from the airwaves, Big Tobacco companies return to prime-time television this weekend — but not by choice. Under court order, the tobacco industry for the first time will be forced to advertise the deadly, addictive effects of smoking, more than 11 years after a judge ruled that the companies had misled the public about the dangers of cigarettes. The corrective messages come more than a decade after a judge ruled that the industry had lied about the risks. "More people die every year from smoking than from murder, AIDS, suicide, drugs, car crashes, and alcohol, combined."
Smoking Cessation (Graham McMahon, New England Journal of Medicine blog, 9-30-11) "The prevalence of smoking has declined dramatically in the United States over the past half century, decreasing from about 42% in the 1960s to about 20% today. However, this decline has stalled recently, and higher prevalence rates are concentrated in populations with low incomes, low educational levels, and psychiatric conditions."
CDC statistics on which groups smoke the most (by race, ethnicity, gender, age, education level, and poverty status)
Tips from former smokers (CDC)
Campaign for Tobacco-Free Kids
Whether a pack or a puff, smoking habits pose significant risk ( Chloe Reichel, Journalist's Resource, 1-29-18) Smoking just one cigarette a day puts people at a much higher risk of heart disease and stroke than those who abstain entirely.
Amendment 3: A choice between cheap cigarettes or kids (Melissa Randol, St. Louis Post-Dispatch, 11-3-16) Unfortunately, there is a considerable amount of inaccurate information being circulated about Amendment 3, the initiative petition to increase investments in early childhood health and education through a 60-cent-per-pack increase on cigarettes. ... The primary opposition to Amendment 3 is being driven by the cheap cigarette industry and for good reason. They have a lot to lose. They are being subsidized by Missouri’s taxpayers to the tune of $80 million every year.
Truth Initiative (inspiring tobacco-free lives). Click on "explore by topic" to see the breadth of coverage. Helped bring teen cigarette use down from 23 percent in 2000 to 6 percent in 2016. Established as part of the 1998 Master Settlement Agreement between major U.S. tobacco companies and 46 U.S. states, the District of Columbia and five territories.
Graphic images influence intentions to quit smoking (Science Daily) Marketing researchers surveyed more than 500 U.S. and Canadian smokers and found that the highly graphic images of the negative consequences of smoking have the greatest impact on smokers' intentions to quit. The most graphic images, such as those showing severe mouth diseases, including disfigured, blackened and cancerous tissue, evoked fear about the consequences of smoking and thus influenced consumer intentions to quit.
Diseases and conditions through which smoking can kill you (CDC) Smoking leads to disease and disability and harms nearly every organ of the body. It is the leading cause of preventable death. Learn the facts about asthma, second-hand smoke, cancer, chronic obstructive pulmonary disease (COPD), gum disease, vision loss and blindness, and so on. , links to resources for people who want to quit smoking.
Know the Risks: E-cigarettes and young people (U.S. Surgeon General) Statement from Action on Smoking and Health on E-Cigarettes Following the U.S. Surgeon General’s Report: E-Cigarette Use Among Youth and Young Adults. U.S. Surgeon General Vivek Murthy released a report Dec. 8, 2016, explaining that while electronic cigarettes are less harmful than cigarettes, they are not harmless. “While alternative nicotine delivery devices may have a role in cessation, this role needs to be supported by science. In addition, there is a worrying trend that major tobacco companies such as Philip Morris (Altria), British American Tobacco, Japan Tobacco International, RJ Reynolds and others are aggressively expanding into the electronic cigarette markets, in part due to the less strenuous regulatory environment.” "E-cigarette use poses a significant – and avoidable – health risk to young people in the United States. Besides increasing the possibility of addiction and long-term harm to brain development and respiratory health, e-cigarette use is associated with the use of other tobacco products that can do even more damage to the body. Even breathing e-cigarette aerosol that someone else has exhaled poses potential health risks."
Smoke and mirrors (Deborah Arnott and Ian Willmore, The Guardian, 7-19-06). "The law banning smoking in public places [in England] is the culmination of one of the most successful social change campaigns in recent years. When Action on Smoking and Health (Ash) started campaigning for smoke-free legislation in 2003, we were told by politicians, civil servants and commentators that there was no chance. So how does a controversial social change go from being "an extreme solution" (Labour party official) to a "historic piece of legislation" (Labour minister) in under three years?" Interesting and informative.
Why Tobacco Companies Are Spending Millions To Boost A Cigarette Tax (Alex Smith, KCUR, Kaiser Health News, 11-3-16) Interesting insight into the politics of smoking taxes. Tobacco companies are backing a low (60-cent) cigarette tax, and anti-smoking groups are against it, because they worry that creating such a small tax now might eliminate the chance of future tax that would be big enough to significantly change smokers’ behavior. Linda Rallo and early education advocates proposed a 60-cent tax to help fund early education in Missouri, but public health researchers say the size of the tax in Rallo’s amendment is too small to make a difference in smoking rates. Meanwhile Amendment 3 pits the Big Tobacco giant against smaller manufactures, known collectively as “Little Tobacco.” "At 17 cents for a pack of cigarettes, Missouri’s tax is the lowest in the country — a fraction of what you’d pay in many states. New York’s tax is the highest at $4.35 a pack, for example, and Florida ranks around the middle of the states at $1.34 a pack. Missouri’s cigarette tax hasn’t changed since 1993."
VAPing and Parenting Guide (Mig Vapor) Using e-cigarettes, also known as vaporizers or just e-cigs, is many times safer than smoking. But do you want your kids to vape? No, and here's why. See also What is vaping? Myths vs. facts. Mig Vapor is an online store selling ecig starter kits, vape mods, refillable ecig tanks, custom e-liquid, etc. and boy, can they use an editor, but there is also information here. See also The Potential Dangers of E-Cigs for Teens and Young Adults (
Vaping Can Be Addictive and May Lure Teenagers to Smoking, Science Panel Concludes (Sheila Caplan, NY Times, 1-23-18) A national panel of public health experts concluded in a report released on Tuesday that vaping with e-cigarettes that contain nicotine can be addictive and that teenagers who use the devices may be at higher risk of smoking. Whether teenage use of e-cigarettes leads to conventional smoking has been intensely debated in the United States and elsewhere. While the industry argues that vaping is not a steppingstone to conventional cigarettes or addiction, some antismoking advocates contend that young people become hooked on nicotine, and are enticed to use cancer-causing tobacco-based cigarettes over time.
The Vape Debate: What You Need to Know (Regina Boyle Wheeler, WebMD, 7-24-16) The pros and cons, but especially the dangers.
Treating Smokers in the Health Care Setting (Michael C. Fiore, M.D., M.P.H., M.B.A., and Timothy B. Baker, Ph.D., New England Journal of Medicine, 9-29-11). This Journal feature begins with a case vignette highlighting a common clinical problem. Then follows evidence supporting various strategies, a review of formal guidelines, when they exist, and the authors' clinical recommendations.
E-cigarette critics get research dollars from industry competitors (Kathy Hoekstra,, 4-10-17) The nicotine patch "is one of four nicotine replacement therapies (NRT) approved by the FDA to help people quit smoking. Three others are prescription-only. Nicotrol NS is a nicotine nasal spray, while Chantix and Zyban are non-nicotine medications. The FDA, however, does not report success rates for these products. And the best can do is say they “increase your chances of quitting successfully.” FDA doesn't report success statistics on quitting smoking, doesn't list e-cigarettes as a way of quitting smoking (despite a known success rate), and the research criticizing e-cigarettes is funded by pharmaceutical firms.
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Eating disorders

National Eating Disorders Association (NEDA) (forums and other forms of support)
Eating Recovery Center
***Patient Voices: Eating Disorders (NY Times Health Guide) How does an eating disorder take over someone’s life? Is it a matter of losing control or trying to seize it? Eight men, women and children tell of their struggles with anorexia, bulimia and other forms of eating disorders. Join the discussion.
Eating Disorders News (blog of Psychology Today)
Unhealthy Weight Loss or Gain from Eating Disorders (Pritikin Wellness Resources)
Critical Points for Early Recognition and Medical Risk Management in the Care of Individuals with Eating Disorders (10 pages, free download from Academy for Eating Disorders (AED) .
Videos about eating disorders (Academy for Eating Disorders)
Anorexia (NY Times fact sheet)
Eating disorder not otherwise specified (EDNOS), Wikipedia entry\
Something Fishy (website on eating disorders)
Eating Disorders (free detailed booklet describes the symptoms, causes, and treatments of eating disorders, National Institutes of Mental Health)
National Eating Disorder Information Centre's blog
My name is Ron, and I am a food addict (Ron Cothran, CNN, 3-28-14 ) He writes that after gastric bypass surgery, "I no longer could eat to feel better; I needed to find a healthier way to deal with life." One reader comments: "You know what's worst of all? The treatment for chronic overeating is to think about every food choice you make for the rest of your life."
A Small Loss (Mary W's blog about her struggle with weight loss-gain-loss).
Eating disorders 'prevalent among fitness professionals' (Rhiannon Beacham, BBC News, 12-31-12)
Gaining: The Truth About Life After Eating Disorders by Aimee Liu, whose memoir of life with anorexia, Solitaire, came out when she was 25.
YMCA patrons stage intervention for anorexic woman (Steve Hartman, CBS News, 5-2-14)
Wasted: A Memoir of Anorexia and Bulimia by Marya Hornbacher. Written at 23 for young adults, this brutally candid memoir may "trigger" those still in grips or early stages of disease, say some readers, serving as a how-to guide for eating disorders. Good insight for families of those with ED.
Mirror, Mirror Off the Wall: How I Learned to Love My Body by Not Looking at It for a Year by Kjerstin Gruys
Diabulimia: All in Our Heads? (Amy T, DiabetesMine, 10-28-10). In 2007, journalists began writing about diabulimia (women with type 1 diabetes, who were shunning their medication for fear of getting fat-- or restricting or stopping taking their insulin to lose weight). See articles by expert Ann Goebel-Fabbri, at the Joslin Diabetes Center. There is a new book by Maryjeanne Hunt about battling this eating disorder: Eating to Lose: Healing from a Life of Diabulimia, which is reviewed here.
Binge Eating in Men: Understanding a Widely Misunderstood Eating Disorder (Carolyn C. Ross, Psychology Today, 10-2-12)
Narrowing an Eating Disorder (Eating Disorder Not Otherwise Specified, or Ednos, by Abby Ellin (NYTimes, 1-18-10)
Shattered Image: My Triumph Over Body Dysmorphic Disorder by Bryan Cuban
Obesity (Making Evidence Matter links to useful evidence-based articles about obesity.)
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Addiction to gambling

How the Brain Gets Addicted to Gambling (Ferris Jabr, Scientific American) Addictive drugs and gambling rewire neural circuits in similar ways.
Gamblers Anonymous
National Council on Problem Gambling (NCPG)
Call 1-800-522-4700
Text 1-800-522-4700
National Center for Responsible Gaming (NCRG), exclusively devoted to funding research that helps increase understanding of pathological and youth gambling and find effective methods of treatment for the disorder.
Know the Odds (resources for help with gambling problems)
Do You Have a Gambling Problem or Addiction? (HelpGuide)
Understanding gambling addiction (MIT News, 2012) For machine gamblers, it’s not whether they win or lose — it’s how much they play the game.
Gambling addiction linked to brain reward system (BBC News, 10-19-14) he 'high' or feeling of euphoria created by addictive behaviour is less obvious in the brains of problem gamblers, research suggests.

Losing Everything to Gambling Addiction (Peter Jaret and Bill Hogan, AARP Bulletin, Jan/​Feb 2014) "In 2013, for the first time, the American Psychiatric Association officially recognized compulsive gambling as an addiction (rather than a personality disorder), acknowledging that it shares many features with alcoholism and drug addiction....The nation's $40 billion a year gambling industry aggressively targets older customers, as they have accumulated wealth and are especially vulnerable, experts say, to wagering more than they can afford. The enticements range from free bus trips, meals and even discount prescription cards to "comped" hotel accommodations — not to mention the private jets dispatched to pick up high-rollers like O'Connor."
"Older people with dementia are at especially high risk because they are unable to recognize limitations or use appropriate judgments. And dopamine agonists, a class of prescription drugs used to treat the symptoms of Parkinson's disease and restless legs syndrome, seem to be associated with compulsive gambling as a side effect, according to Marc Potenza, M.D., a professor of psychiatry at Yale University who studies problem gambling.
"Psychologists also suspect that people are more likely to run into problems if they turn to gambling for the wrong reasons — to escape loneliness, depression or even chronic pain."
Problem gambling. This Wikipedia entry provides an excellent overview, with plenty of references.
The Billion-Dollar Jackpot: Engineered to Drain Your Wallet (Jeff Sommer, NY Times, 8-12-16) If your goal is actually to win money, your chances are much better at the blackjack table in a casino. "Mr. Mehta persuaded me to crunch the numbers to see what effects the government-sponsored lotteries are having on people who buy tickets regularly. The results are troubling."
Gambling addiction affects more men and women, seduced by growing casino accessibility (Daniel Bortz, NY Daily News, 3-28-13)
A Prepaid Card for Recovering Addicts The Next Step Prepaid Mastercard, the first prepaid card designed for recovering addicts, allows a caregiver to put money onto the card and then monitor how the money is spent.
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Virtual addiction-- to smartphones, the internet, video games, online technology

(aka "dependence syndrome")

How Smartphones Are Making Kids Unhappy (Audie Cornish, All Things Considered, NPR, 8-7-17) "Jean Twenge, a professor of psychology at San Diego State University, has a name for these young people born between 1995 and 2012: "iGen." "She says members of this generation are physically safer than those who came before them. They drink less, they learn to drive later and they're holding off on having sex. But psychologically, she argues, they are far more vulnerable....Given that using social media for more hours is linked to more loneliness, and that smartphones were used by the majority of Americans around 2012, and that's the same time loneliness increases, that's very suspicious. You can't absolutely prove causation, but by a bunch of different studies, there's this connection between spending a lot of time on social media and feeling lonely." "for parents, I think it is [a] good idea to put off giving your child a smartphone as long as you can. If you feel they need a phone, say, for riding a bus, you can get them a flip phone. They still sell them. And then once your teen has a smartphone, there are apps that allow parents to restrict the number of hours a day that teens are on the smartphone, and also what time of day they use it."
Are Teenagers Replacing Drugs With Smartphones? (Matt Richtel, NY Times, 3-13-17) Amid an opioid epidemic, the rise of deadly synthetic drugs and the widening legalization of marijuana, a curious bright spot has emerged in the youth drug culture: American teenagers are growing less likely to try or regularly use drugs, including alcohol. Use of smartphones and tablets has exploded over the same period that drug use has declined. Are teenagers using drugs less in part because they are constantly stimulated and entertained by their computers and phones? “Playing video games, using social media, that fulfills the necessity of sensation seeking, their need to seek novel activity,” Dr. Silvia Martins said, but added of the theory: “It still needs to be proved.”
What is video game addiction? (Illinois Institute for Addiction Recovery) Video game addiction is described as an impulse control disorder, which does not involve use of an intoxicating drug and is very similar to pathological gambling. Video game addiction has also been referred to as video game overuse, pathological or compulsive/​excessive use of computer games and/​or video games." A page about what the known facts are.
Frequently asked questions about Internet addiction (The Center for Internet and Technology Addiction)
HouseSmarts KidSmarts Tech Addiction, Episode 170 (Dr. David Greenfield). It's a process addiction, as opposed to a substance addiction. It's a mood-altering behavior. "All of us are unable to keep track of time or space while we are on it." It gives us the illusion of being more efficient, but it actually makes us more distracted. We experience withdrawal when it is taken away from us. It will usually affect social, family, and personal relations. Setting limits on use is important. (Along the right side are links to Dr. G speaking about other aspects of technology addiction.
Internet Sex Addiction: Case Studies and Treatment (Dan Pollets, Psychology Today, 8-6-08)
Are we addicted to technology? (Zoe Kleinman, BBC News, 8-31-15) Symptoms and suggestions for change.
Teens say they’re addicted to technology. Here’s how parents can help. (Amy Joyce, Washington Post, 5-3-16)
Technology Addiction: Concern, Controversy, and Finding Balance Common Sense Media polled over 1,200 parents and teens to find out how the saturation of mobile devices in family life is playing out in homes and child-parent relationships. See the infographic Dealing with Devices: The Parent-Teen Dynamic
We Spend More Time Watching Netflix Than With Our Friends (Lindsay Holmes, HuffPost, 5-17-16)
American Time Use Survey: Leisure time on an average day (Bureau of Labor Statistics) Watching TV takes up far and away the most time.
Smartphone dependency: a growing obsession with gadgets (Ellen Gibson, Associated Press, USA Today, 7-27-11) More Americans are ditching their iPods, cameras, maps and address books in favor of the myriad capabilities of a smartphone.
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Helpful organizations and publications

Self-help groups
Alcoholics Anonymous (AA) Very popular, but does not work for everyone.
Families Against Narcotics (FAN)
Narcotics Anonymous (NA)
SMART Recovery (Smart Management and Recovery Training)
Dual Recovery Anonymous (men & women who meet to support each other in our common recovery from two No-Fault illnesses: an emotional or psychiatric illness and chemical dependency)
Co-Dependents Anonymous (CoDA) We found in each of our lives that codependence is a deeply rooted compulsive behavior born out of our dysfunctional family systems.
Al-Anon Family Groups (strength and hope for friends and families of problem drinkers)
Nar-Anon Family Groups (a 12-step program for families & friends of addicts)
Self-Help Groups for Drug Addiction (with descriptions)
Women for Sobriety (WFS) and WFS Message Forum and Chat/a>
Secular Organizations for Sobriety (SOS), a nonprofit network of autonomous, non-professional local groups, dedicated to helping individuals achieve and maintain sobriety/​abstinence from alcohol and drug addiction, food addiction and more.

Organizations focused on understanding and dealing with substance abuse and misuse
Action on Smoking and Health (ASH, building a world with ZERO deaths from tobacco)
Addiction and Suicide (Ocean Recovery)
Addiction Journal
Alcoholism & Drug Abuse Weekly
American Society of Addiction Medicine (ASAM) (The Voice of Addiction Medicine -- professional society representing over 4,200 physicians, clinicians and associated professionals ) Connect. Advocate. Educate. Treat.
Drug Abuse (NIDA, links to many resources, including NIH clinical trials locator)
Drug Facts: Understanding Drug Abuse and Addiction (NIDA)
Foundation for Advancing Alcohol Responsibility
Harm Reduction Coalition Founded in 1993 and incorporated in 1994 by a working group of needle exchange providers, advocates and drug users--today, strengthened by a network of allies who challenge the persistent stigma faced by people who use drugs and advocate for policy and public health reform. See The Controversial Answer To America’s Heroin Surge (John Knefel, Buzzfeed, 5-16-14) With heroin use at epidemic levels, harm reduction — a bold, long-contested approach to treating addicts — is gaining political traction. But are we ready to make it easier to shoot heroin even if it means fewer deaths?
An Interactive Lesson Guide for Parents and Teachers to Teach Kids About Drugs and Alcohol (White Sands Treatment)
Legal Action Center. Nonprofit U.S. law and policy organization that fights discrimination against people with histories of addiction, HIV/​AIDS, or criminal records, and advocates for sound public policies in these areas. Staff members serve as legal advocates for drug and alcohol abuse treatment centers and their patients.
National Institute on Drug Abuse (NIDA)
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
National Registry of Evidence-based Programs and Practices (NREPP) (SAMHSA)
Partnership for Drug-Free Kids (Helpline: 1-855-DRUGFREE)
Physicians to Prevent Opioid Abuse (Facebook page)
Prevention Coalition (founded by a group of retired school counselors and therapists to provide an accessible drug use and abuse prevention resource for parents, teachers, counselors and other concerned adults)
Substance Abuse and Mental Health Services Administration (SAMHSA)

Addiction Treatment Events (event announcements from national organizations, AddictionResource) (listings for individuals and families seeking treatment: 15,936 alcohol treatment centers, 14,732 drug treatment centers, and 16,946 mental health centers in U.S. and Canada) For 24/​7 Treatment Help Call: (888) 352-9771

Memoirs and fiction about addiction and alcoholism
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The war on drugs

‘We feel like our system was hijacked’: DEA agents say a huge opioid case ended in a whimper (Lenny Bernstein and Scott Higham, WashPost, 12-17-17) "After two years of painstaking investigation, David Schiller and the rest of the Drug Enforcement Administration team he supervised were ready to move on the biggest opioid distribution case in U.S. history. The team, based out of the DEA’s Denver field division, had been examining the operations of the nation’s largest drug company, McKesson Corp. By 2014, investigators said they could show that the company had failed to report suspicious orders involving millions of highly addictive painkillers sent to drugstores from Sacramento, Calif., to Lakeland, Fla. Some of those went to corrupt pharmacies that supplied drug rings. The investigators were ready to come down hard on the fifth-largest public corporation in America, according to a joint investigation by The Washington Post and “60 Minutes.”...Instead, top attorneys at the DEA and the Justice Department struck a deal earlier this year with the corporation and its powerful lawyers, an agreement that was far more lenient than the field division wanted, according to interviews and internal government documents. Although the agents and investigators said they had plenty of evidence and wanted criminal charges, they were unable to convince the U.S. attorney in Denver that they had enough to bring a case."
Prosecutors Treat Opioid Overdoses as Homicides, Snagging Friends, Relatives (Joseph Walker, WSJ, 12-17-17) As U.S. drug deaths hit record levels, prosecutors and police are trying a tactic that echoes tough-on-crime theories of the 1990s
This company’s drugs helped fuel Florida’s opioid crisis. But the government struggled to hold it accountable. (Lenny Bernstein and Scott Higham, WaPo, 4-2-17) "To combat an escalating opioid epidemic, the Drug Enforcement Administration trained its sights in 2011 on Mallinckrodt Pharmaceuticals, one of the nation’s largest manufacturers of the highly addictive generic painkiller oxycodone....the DEA and federal prosecutors would contend that the company ignored its responsibility to report suspicious orders as 500 million of its pills ended up in Florida between 2008 and 2012 — 66 percent of all oxycodone sold in the state....Florida’s lax laws, dishonest doctors and unscrupulous pharmacists had turned the state into ground zero for the nation’s prescription opioid crisis....Prosecutors noted that the DEA had twice placed the industry on notice about its responsibility to report suspicious orders. They also said Mallinckrodt was aware of enforcement actions the agency had taken against distributors for failing to report the inordinate amounts of painkillers they were shipping to retail customers in states such as Florida." Significant cash sales are an indication of diversion (to illegal sales of drugs). Look for patterns of pharmaceutical firms illegally promoting off-label drug use and paying kickbacks to doctors. Sources close to the negotiations said that the two sides had recently reached a tentative agreement to settle the case for $35 million. Mallinckrodt told its shareholders the investigation “will not have a material adverse effect on its financial condition” because it has set aside the money."For a company the size of Mallinckrodt, a $35 million fine is “chump change,” one government official said.
"Drug manufacturers have paid much larger fines for other misdeeds. Glaxo­SmithKline was fined $3 billion, and Pfizer was fined $2.3 billion for illegally promoting off-label drug use and paying kickbacks to doctors. Purdue Pharma paid a $600 million fine, and three of its executives pleaded guilty to charges that they misled regulators, doctors and patients about the risks of the painkiller that is widely blamed for setting off the nation’s opioid crisis: OxyContin. All of those cases were initiated by the Food and Drug Administration. The largest fine the DEA has levied against a drug distributor was the $150 million that McKesson, the nation’s largest drug wholesaler, recently agreed to pay following allegations that it failed to report suspicious orders of painkillers."
Investigation: The DEA slowed enforcement while the opioid epidemic grew out of control (Lenny Bernstein and Scott Higham, Washington Post, 10-22-16) "he epidemic began in the late 1990s after the introduction of the powerful, long-acting opioid OxyContin and an aggressive marketing campaign by the drug’s manufacturer, Purdue Pharma, to persuade doctors to prescribe it for all kinds of pain. A new philosophy of pain management resulted in a surge in demand and the U.S. addiction rate. From 2000 to 2014, 165,000 people died of overdoses of prescription painkillers nationwide. The crisis has also fostered follow-on epidemics of heroin, which caused nearly 55,000 overdose deaths in the same period, and fentanyl, which has killed thousands more. The number of U.S. opioid prescriptions has risen from 112 million in 1992 to 249 million in 2015." The Justice Department "issued a statement saying that the drop in diversion cases reflects a shift from crackdowns on “ubiquitous pill mills” toward a “small group” of doctors, pharmacists and companies that continues to violate the law."
"In the summer of 2014, Rannazzisi said that he received an unusual request. To foster better relations with industry, the Justice Department wanted to meet with senior representatives of drug distributors and pharmacy chains. Rannazzisi said he was appalled. Some of the companies were either under investigation or in the midst of settlement negotiations with the DEA diversion office, he said....That summer, lobbying by the pharmaceutical industry intensified on Capitol Hill. Several members of Congress, led by Reps. Tom Marino (R-Pa.) and Marsha Blackburn (R-Tenn.), were proposing a measure that critics said would undercut the DEA’s ability to hold drug distributors accountable. Four major players lobbied heavily in favor of the legislation, called the Ensuring Patient Access and Effective Drug Enforcement Act. Together, McKesson, AmerisourceBergen, Cardinal and the distributors’ association, the Healthcare Distribution Alliance, spent $13 million lobbying House and Senate members and their staffs on the legislation and other issues between 2014 and 2016, according a Post analysis of lobbying records."
The Likely Cause of Addiction Has Been Discovered, and It Is Not What You Think (Johann Hari, author of Chasing the Scream: The First and Last Days of the War on Drugs, Huffington Post, 1-20-15)
Should Even Heroin Be Legal? (Andrew Sullivan, The Dish, part 1 of book club discussion of Johann Hari's book Chasing the Scream: The First and Last Days of the War on Drugs. See also part 2. "In Chasing the Scream, Hari reveals his startling discoveries entirely through the true and shocking stories of people across the world whose lives have been transformed by this war. They range from a transsexual crack dealer in Brooklyn searching for her mother, to a teenage hit-man in Mexico searching for a way out. It begins with Hari’s discovery that at the birth of the drug war, Billie Holiday was stalked and killed by the man who launched this crusade – while it ends with the story of a brave doctor [in Portugal] who has led his country to decriminalize every drug, from cannabis to crack, with remarkable results." Listen to Hari's TED talk Everything you think you know about addiction is wrong (June 2015) or read the transcript (TED talk, June 2015). "For 100 years now, we've been singing war songs about addicts. I think all along we should have been singing love songs to them, because the opposite of addiction is not sobriety. The opposite of addiction is connection."
‘Pimping out’ drug addicts for cash (Alfred Lubrano, Philadelphia Inquirer, 6-1-17) In Philadelphia, addicts have become a cash crop, used by some treatment centers and recovery houses to create a perpetual money churn. On the street, it's called "pimping out." Stripped of basic rights, addicts are told by the people who run their boarding houses — called recovery houses — what facility to attend, when to go, and for how long. If addicts don’t take the van rides, house operators threaten them with eviction...In exchange for herding people into centers, recovery house operators pocket illegal, under-the-table payments – ranging from $100 to $400 per person monthly – that keep them in business. The centers, in turn, bill the government for a piece of the $680 million in Medicaid and state money disbursed in 2016 by a nonprofit contracted by the city to combat addiction and mental health issues.
A tool to protect police dogs in drug raids from overdosing (Associated Press, 6-1-17) Police dogs simply follow their noses to sniff out narcotics. But inhaling powerful opioids can be deadly, so officers have a new tool to protect their four-legged partners: naloxone, a drug that has already been used for years to reverse overdoses in humans.
Overcoming Opioids: The Quest for Less Addictive Drugs (AP, NY Times, 4-17-17) "Tummy tucks really hurt. Doctors carve from hip to hip, slicing off skin, tightening muscles, tugging at innards. Patients often need strong painkillers for days or even weeks, but Mary Hernandez went home on just over-the-counter ibuprofen. The reason may be the yellowish goo smeared on her 18-inch wound as she lay on the operating table. The Houston woman was helping test a novel medicine aimed at avoiding opioids, potent pain relievers fueling an epidemic of overuse and addiction." (KHN)
Locating blame in the opioid epidemic (Washington Post editorial, 10-30-16) "Destructive and persistent, the epidemic of opioid addiction is also deeply ironic: Unlike previous drug scourges in U.S. history, this one spread via perfectly legal channels. Millions of people were introduced to addictive pain-killing medications by doctors’ prescriptions, filled at pharmacies, ultimately supplied by pharmaceutical manufacturers. All of this went on in one of the most heavily regulated sectors of the U.S. economy — health care — which is supervised by a veritable army of officials working for dozens of agencies, state and federal.
Controversies involving Corizon Health (Wikipedia). "CMS became Corizon Health, Inc., in 2011, after essentially merging its operations with PHS Correctional Healthcare (previously known as Prison Health Services, Inc.), its largest competitor in the correctional health care industry. Corizon Health, like its predecessors CMS and PHS, and its competitors, along with self-operated correctional health programs, has faced criticism from government officials, public-health advocates and experts for being more concerned with maintaining lucrative government contracts than effectively treating sick inmates, who are considered the most chronically and profoundly physically and mentally ill members of any society." It keeps changing its name.
Medicaid Coverage Inconsistent for Addiction Tx (Neel A. Duggal, MedPage Today, 12-22-16) Some states skimp, others generous. "Overdose deaths are robustly correlated with lack of treatment access." -- David Kan, MD, of the University of California San Francisco, on the wide variation among states in their Medicaid coverage of substance abuse treatments.
How drugs intended for patients ended up in the hands of illegal users: ‘No one was doing their job’ (Lenny Bernstein, David S. Fallis and Scott Higham, WaPo, 10-22-16) "For 10 years, the government waged a behind-the-scenes war against pharmaceutical companies that hardly anyone knows: wholesale distributors of prescription narcotics that ship drugs from manufacturers to consumers....Many companies held back drugs and alerted the DEA to signs of illegal activity, as required by law. But others did not. Collectively, 13 companies identified by The Washington Post knew or should have known that hundreds of millions of pills were ending up on the black market, according to court records, DEA documents and legal settlements in administrative ­cases, many of which are being reported here for the first time.
"A review of the DEA’s campaign against distributors reveals the extent of the companies’ role in the diversion of opioids. It shows how drugs intended for millions of legitimate pain patients ended up feeding illegal users’ appetites for prescription narcotics. And it helps explain why there has been little progress in the U.S. opioid epidemic, despite the efforts of public-health and enforcement agencies to stop it. A Post investigation published Saturday revealed that beginning in 2013, some officials at DEA headquarters began to block and delay enforcement actions against wholesale drug distributors and others, frustrating investigators in the field.
"The 13 companies include Fortune 25 giants McKesson, Cardinal Health and Amerisource­Bergen, which together control about 85 percent of all pharmaceutical distribution in the United States. They also include regional wholesalers such as Miami-Luken and KeySource Medical, both based in Ohio, as well as Walgreens, the nation’s largest retail drugstore chain. Many of the distributors are tiny operations with just a few employees."
Where the most prescriptions are prescribed, the most overdoses happen. Counties with high rates of prescription and overdose include Appalachia, the California-Oregon border, Pennsylvania, Oklahoma, and Arizona.

Drug industry hired dozens of officials from the DEA as the agency tried to curb opioid abuse (Scott Higham, Lenny Bernstein, Steven Rich and Alice Crites, WaPo, 12-22-16) Critics say the revolving door undercuts the agency’s ability to curb the rising opioid epidemic. Since 2004, "the pharmaceutical companies and law firms that represent them have hired at least 42 officials from the DEA — 31 of them directly from the division responsible for regulating the industry, according to work histories compiled by The Post and interviews with current and former agency officials."
An opioid epidemic is what happens when pain is treated only with pills (Joel Achenbach, WaPo, 12-23-16)Yet the crisis masks a "pain gap" for many people.
One-third of long-term users say they’re hooked on prescription opioids (Scott Clement and Lenny Bernstein, WaPo, 12-9-16) And 6 in 10 day say doctors aren’t helping them figure out how to quit.
The Controversial Answer To America’s Heroin Surge (John Knefel, Buzzfeed, 5-16-14) With heroin use at epidemic levels, harm reduction — a bold, long-contested approach to treating addicts — is gaining political traction. But are we ready to make it easier to shoot heroin even if it means fewer deaths? "There’s the just-passed plan to have New York City police officers carry a heroin “antidote” to reverse overdoses, part of a $5 million program; the state legislature passed a Good Samaritan law to protect users who call 911 if they witness an overdose and another law that decriminalizes heroin residue in used needles. At the federal level, Attorney General Eric Holder has endorsed first responders carrying similar kits, and a spokesperson for the Drug Enforcement Administration echoed support for the programs. But a significant reason for the shift in lawmakers’ attitudes is the advocacy work done on the national level by groups like the New York City-based Harm Reduction Coalition, and the local organizing that groups like Brooklyn’s VOCAL-NY are doing on the city and state level."
Opioid Crisis: Can recent reforms curb the epidemic? (Peter Katel, CQ Researcher, 10-7-16) "Overdoses of opioid drugs, including powerful prescription painkillers and heroin, have killed almost 250,000 Americans since 2000, leading many experts to compare the crisis to the HIV and AIDS epidemics. Opioid addiction, once largely an urban minority affliction, has spread to every corner of the United States, hitting young adults and white people especially hard. One study has found that more adults use prescription painkillers than cigarettes, smokeless tobacco and cigars combined. As opioid abuse grows, propelled in part by a flood of cheap heroin from Mexico, alarmed authorities are trying to figure out how to fight back. In July, President Obama signed a bill encouraging the expansion of treatment programs and the development of alternatives to opioid painkillers. But many experts are divided over how best to help opioid addicts. Some advocate providing them with limited doses to control their addiction, while others say that such an approach would make the crisis worse."

Why I stopped prescribing narcotics, and never looked back (Alan A. Berg, Kevin MD, 4-10-16) "After 30 years, I have learned that I can’t recognize who has a drug problem and I don’t want to play the game any longer."

Political Gridlock Blocks Missouri Database For Fighting Drug Abuse (Bram Sable-Smith, Side Effects Public Media, 4-14-16) In the battle against America’s surging opioid drug addiction, 49 states, the District of Columbia and even Guam have all implemented some kind of prescription drug monitoring program (PDMP). Missouri is the sole holdout. State Sen. Rob Schaaf blocks it in the state senate, saying the bill interferes with the right to medical privacy, fearing hackers.

Legalize It All: How to win the war on drugs (Dan Baum, Harper's, April 2016) "Nixon’s invention of the war on drugs as a political tool was cynical, but every president since — Democrat and Republican alike — has found it equally useful for one reason or another. Meanwhile, the growing cost of the drug war is now impossible to ignore: billions of dollars wasted, bloodshed in Latin America and on the streets of our own cities, and millions of lives destroyed by draconian punishment that doesn’t end at the prison gate; one of every eight black men has been disenfranchised because of a felony conviction." Nixon's top aide John Ehrlichman revealed to Baum that the invented "war" targeted Vietnam war protesters and Black Americans: "We knew we couldn't make it illegal to be either against the war or Black, but by getting the public to associate the Hippies with marijuana and Blacks with heroin, then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up meetings, and vilify them night after night on the evening news. Did we know we were lying about drugs? Of course we did."
Baum reports, "I must have looked shocked. Ehrlichman just shrugged."

Republicans — Then And Now — Talking About Drug Addiction (Eyder Peralta, The Big Listen, 2-8-16). "This talk of redemption and second chances fits right in with conservative narratives of sin and redemption.'...This suggests a conservative model of treatment couched in terms of sin and salvation rather [than] diseases and cures--which is in keeping with certain conservative ideas about religion and individual responsibility. From that perspective, drug abuse remains a moral failing but one that can be better addressed in treatment than in prison. But again the key point is that so far, such a model of drug treatment has been more inclined to find possibilities for redemption among white drug users than among drug users of color."
The Use of Confrontation in Addiction Treatment: History, Science, and Time for Change (William L. White and William R. Miller, Counselor, 2007) "It is time to declare a final moratorium on the use of harsh, humiliating confrontational techniques in addiction treatment. It is time to lay to rest once and:for all the arrogant notion that we should or even can dismantle other human beings and then put them back together in better and wiser form. With impressive consistency, research tells us that authoritarian confrontation is highly unlikely to heal and may well do harm, particularly to the more vulnerable among those we serve. Within this context, such confrontational treatment is professionally unethical, and is doubly problematic when used with coerced populations such as court-ordered or employer-mandated populations." (p. 24)

War on Drugs (Wikipedia's helpful overview. which places the drug war in political and military context)

Impact of the War on Drugs on Incarceration (Human Rights Watch on racially disproportionate drug arrests). See Summary and Recommendations.
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Memoirs and fiction about drug abuse, addiction, and alcoholism

The Basketball Diaries by Jim Carroll (about his teen years, growing up hip, with drugs and sex, on New York"s mean streets)
Beautiful Boy: A Father's Journey Through His Son's Addiction (David Scheff chronicling a precocious teenager's spiral downward from abuse of mind- and mood-altering drugs to meth addiction)
Chancers: Addiction, Prison, Recovery, Love: One Couple's Memoir by Susan Stellin and Graham MacIndoe. In this powerful memoir of addiction, prison, and recovery, a reporter and a photographer tell their gripping story of falling in love, the heroin habit that drove them apart, and the unlikely way a criminal conviction brought them back together. Read more about it.
Double Double: A Dual Memoir of Alcoholism, mystery novelist Martha Grimes and her son Ken Grimes' memoir about alcoholism, creeping up on them until in 1990 they faced the problem and dealt with it, she at a rehab clinic, he through a 12-step program.
Drinking: A Love Story by Caroline Knapp. "Freelance journalist Knapp began drinking in her early teens and continued unabatedly until she "hit bottom" in 1995 and checked herself into a rehab at the age of 36....a confession utterly devoid of self-pity, an extraordinarily lucid and very well-written personal account of a common addiction that is filled with insights as well as a comprehensive treatment of the subject." --Publishers Weekly
A Drinking Life: A Memoir by Pete Hamill. As a child during the Depression and World War II he learned that drinking was to be an essential part of being a man, it was only later he discovered its ability to destroy lives.
Dry: A Memoir by Augusten Burroughs. "Imagine coming home to find hundreds of empty scotch bottles and 1,452 empty beer bottles in your apartment. This is what Burroughs (Running with Scissors) encountered upon returning from Minnesota's Proud Institute (supposedly the gay alcohol rehab choice). "--Publishers Weekly
How to Stop Time: Heroin from A to Z by Ann Marlowe. "Part memoir, part cultural criticism and part junkie riff, journalist Marlowe's fragmented reflections on her seven years as a heroin addict....She also proves to be an excellent cultural commentator, presenting insights into why people start using drugs, how society glamorizes heroin whereas actual users do not and how men and women take drugs differently."~Publishers Weekly. “Addiction is a mourning for the irrecoverable glories of the first time"
I’m Dancing as Fast as I Can (Barbara Gordon on her addiction to prescription drugs)
Junky by William S. Burroughs. "Burroughs fictionalized his experiences using and peddling heroin and other drugs in the 1950s into a work that reads like a field report from the underworld of post-war America. The Burroughs-like protagonist of the novel, Bill Lee, see-saws between periods of addiction and rehab, using a panoply of substances including heroin, cocaine, marijuana, paregoric (a weak tincture of opium) and goof balls (barbiturate), amongst others."
Lit by Mary Karr (her memoir about alcoholism, getting sober, and getting God, by the author of The Liars' Club (in which the addiction is her mother's).
The Long Run by Mishka Shubaly. After nearly twenty years of chasing oblivion, a fight in a bar reveals to a newly sober Mishka Shubaly that he is able to run long distances. Despite his best attempts to dodge enlightenment and personal growth, the irreverent young drunk and drug abuser learns to tame his self-destructive tendencies through ultrarunning.
The Los Angeles Diaries: A Memoir by James Brown. Brown details in vignettes how, after growing up with an emotionally disturbed mother and drifting with his brother and sister into addiction, "he screwed over his first wife, children, sister, writing students, and agent--all while feeding addictions to booze, crank, and novels by hustling hollow teaching and scriptwriting gigs....Brown says meeting his second wife changed his life and then keeps the process to himself, omitting the third act. Even though his is a story of selfishness selfishly told, Brown's blackout days make for a darkly alluring read. This is the kind of book that becomes an underground classic for all the wrong reasons." ~Booklist

Mother Daughter Me: A Memoir by Katie Hafner. "“Weaving past with present, anecdote with analysis, [Katie] Hafner’s riveting account of multigenerational living and mother-daughter frictions, of love and forgiveness, is devoid of self-pity and unafraid of self-blame."~Cathi Hanauer, Elle
The Night of the Gun: A reporter investigates the darkest story of his life. His own. by David Carr. Built on sixty videotaped interviews, legal and medical records, and three years of reporting, The Night of the Gun is a ferocious tale that uses the tools of journalism to fact-check the past. Carr’s investigation of his own history reveals that his odyssey through addiction, recovery, cancer, and life as a single parent was far more harrowing—and, in the end, more miraculous—than he allowed himself to remember.
Parched: A Memoir by Heather King. "It’s a story about a good girl gone bad - gone good. "Parched,"…lays naked her 18 years wrapped in drugs and alcohol: sweet memories, toilet rims and all." - Jeanné McCartin, Portsmouth Herald
Permanent Midnight by Jerry Stahl. “Permanent Midnight is one of the most harrowing and toughest accounts ever written in this century about what it means to be a junkie in America, making Burroughs look dated and Kerouac appear as the nose-thumbing adolescent he was.”~Booklist
Portrait of an Addict as a Young Man: A Memoir by Bill Clegg. A charismatic, high-profile literary agent with an inferiority complex binges on crack cocaine. The Globe and Mail called Clegg's unflinching, intelligent, and grim account "a skillfully conjured, slow-motion train wreck from which it's impossible to look away."
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The problems with drug courts

Dying To Be Free (Jason Cherkis, Huffington Post, 1-28-15) This investigation into how the drug treatment system was failing heroin addicts spotlighted Kentucky’s drug courts and their failure to embrace medical treatment options for opiate addicts. (Powerful story supplemented by video.) A powerful piece of reporting. Twelve-step programs treat alcohol and drugs according to the same principles. But heroin changes the way the brain works. There is a treatment for heroin addiction that actually works. Why isn't it being used? One point among many: There is a "newer maintenance medication on the market sold under the brand name Suboxone. Like methadone, Suboxone blocks both the effects of heroin withdrawal and an addict’s craving and, if used properly, does it without causing intoxication. Unlike methadone, it can be prescribed by a certified family physician and taken at home, meaning a recovering addict can lead a normal life, without a daily early-morning commute to a clinic. The medical establishment had come to view Suboxone as the best hope for addicts like Patrick. Yet of the dozens of publicly funded treatment facilities throughout Kentucky, only a couple offer Suboxone, with most others driven instead by a philosophy of abstinence that condemns medical assistance as not true recovery. Even at clinics that offer the medication, the upfront costs and budget limitations render it out of reach for the vast majority who come through their doors." But read the whole story of how the criminal justice approach to the "war on drugs" is failing Kentucky.
"There’s no single explanation for why addiction treatment is mired in a kind of scientific dark age, why addicts are denied the help that modern medicine can offer. Family doctors tend to see addicts as a nuisance or a liability and don’t want them crowding their waiting rooms. In American culture, self-help runs deep. Heroin addiction isn’t only a disease – it’s a crime. Addicts are lucky to get what they get."

New Meds Block Heroin Craving, But Reporter Finds Treatment Centers Don't Use Them (Terry Gross, Fresh Air, NPR, 2-4-15). Listen to the story or read the text. The Huffington Post's Jason Cherkis investigated the heroin epidemic in Kentucky, and found that the abstinence-based approach used in most treatment centers was leading to many fatal relapses. If you relapse on alcohol, the chances of dying are slim. When you relapse on heroin, especially after a period of abstinence, there's a much greater chance of dying. A 30-day drug treatment program is common, partly because that's what insurance will cover, but that's not long enough to deal with the changed brain. Methadone was use to help addicts get off heroin as far back as the '70s, but you have to go to a clinic to get methadone, which is regulated. Now there are new drugs, buprenorphine and Suboxone, which doctors can prescribe and which block the craving for heroin, makes addicts feel normal, calms them down, and cuts down on the painful withdrawal. They can begin to rebuild their life. A combination of such "medication and counseling is sort of the accepted standard of care among medical authorities in the United States but is not largely practiced."

Kentucky Considers Changes To Drug Courts For Heroin Addicts (Jason Cherkis, Huffington Post, 2-25-15)

How America Overdosed on Drug Courts (Maia Szalavitz, Pacific Standard, 5-18-15) Hailed as the most compassionate way for the criminal justice system to deal with addicts, drug courts were designed to balance punishment with rehabilitation. But after 25 years, the verdict is in: Drug courts embolden judges to practice medicine without a license—and they put lives in danger....When people who are addicted refrain from using heroin for over a week, they lose their built-up tolerance to opioids. A dose that a week ago barely produced a high might now be fatal." Within hours of getting out of jail, an addict can overdose on what was the habitual amount used. "Any addiction doctor—or anybody who simply follows evidence-based treatment guidelines—would know exactly what to prescribe for [an addict at high risk of returning to addiction]: opioid maintenance, by far the most effective treatment, known to lower the death rate of opioid addiction by between 66 and 75 percent. Maintenance is the indefinite use of an opioid medication such as methadone or buprenorphine, typically combined with counseling. The World Health Organization has called it “essential medicine,” and the National Institutes of Health, the Institute of Medicine, and the White House Office of National Drug Control Policy have all endorsed it in various consensus statements....But many drug court judges vociferously oppose the practice and require patients to become completely abstinent as a condition of participation or graduation. They believe that maintenance simply amounts to swapping one drug addiction for another. This critique betrays a fundamental misunderstanding of opioid pharmacology and addictive behavior."
Should We Have a Bailiff and a Judge at Weight Watchers? (Clovis Thorn, Managing Director of Development, Drug Policy Alliance, Huffington Post, 5-3-13) "I hope we never mandate that someone has to lose weight or face the criminal justice system, or has to stop smoking cigarettes, or has to stop cheerleading. (Have you seen the statistics for cheerleading injuries?!) If our government was to criminalize any of these things, we'd cry totalitarianism, gulags and Big Brother. Yet we criminalize people who use drugs. We call it the drug war. We dress it up as drug courts. Drug courts are part of a kinder, gentler drug war. Mind your manners, pass clean urine screenings, and everyone wins. The reality is much different."

Drug Courts Are Not the Answer: Toward a Health-Centered Approach to Drug Use (Drug Policy Alliance, 3-22-11) This report finds that "drug courts are an ineffective and inappropriate response to drug law violations. Many, all the way up to the Obama administration, consider the continued proliferation of drug courts to be a viable solution to the problem of mass arrests and incarceration of people who use drugs. Yet this report finds that drug courts may not reduce incarceration, improve public safety, or save money when compared to the wholly punitive model they seek to replace. The report calls for reducing the role of the criminal justice system in responding to drug use by expanding demonstrated health approaches, including harm reduction and drug treatment, and by working toward the removal of criminal penalties for drug use."

Every Drug Court Should Allow Methadone Treatment (Maia Szalavitz, Op Ed, NY Times, 7-20-15) Complete abstinence programs are the only treatments some courts allow. Among those who administer drug courts, which are aimed at helping defendants get treatment and avoid prison, "only a third allow maintenance use of methadone or a newer medication called buprenorphine (Suboxone) and 50 percent ban maintenance outright. But they are ignoring medical evidence showing that maintenance is the best approach to opioid use disorders, which involve drugs in the same class as heroin, like OxyContin and Vicodin." "In the scientific literature..., there’s no question that maintenance works. Every expert group that has ever studied it — from the Centers for Disease Control to the Institute on Medicine and the World Health Organization — has determined that, for opioids, ongoing maintenance is superior to abstinence." "Drug courts were first offered as an alternative to punishment at the height of the war on drugs in Florida in 1989. Today, they serve around 120,000 defendants. If their goal is actually to treat addiction, they need to offer individualized treatment that meets a higher standard of care and gives participants the best odds of survival and recovery."

Google "Drug Court" and you will find many interesting (and disturbing) stories.
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