Published by
Stanford Medicine

Category

Addiction

Addiction, Health Policy, In the News, Pediatrics

To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics

To protect teens' health, marijuana should not be legalized, says American Academy of Pediatrics

teen smoking Today, the country’s most prominent group of pediatricians issued a policy statement that opposes marijuana legalization and advocates for policies to help minimize the drug’s harmful effects on children and adolescents. The new statement, from the American Academy of Pediatrics, was written in response to recent research on adolescent brain development and the biology of addiction, as well as a changing national climate on marijuana laws.

I spoke with Stanford’s Seth Ammerman, MD, an adolescent medicine specialist and the lead author of the new statement and accompanying technical report. Ammerman studies substance-use issues in youth and also has extensive experience working with at-risk young people, in part through his role as medical director of the Adolescent Health Van run by Lucile Packard Children’s Hospital Stanford.

“The national trend is definitely toward more medical marijuana, and also toward legalization for adults,” he said. “This trend can definitely affect kids, so it was really important for the Academy to have a voice, to be working on a national conversation about this.”

During our conversation, Ammerman explained some of the latest research that has motivated the AAP’s stance against marijuana legalization:

In the past decade, we’ve learned that brain development doesn’t finish until one’s early to mid-20s, and substance use can alter the developing brain. There are a few ways we know this: One, there’s clear evidence that the younger you start using drugs regularly, the more likely you are to become addicted. This is true for alcohol, tobacco, and marijuana, among others. For those who put off substance use until their late teens or early 20s, addiction rates are significantly lower.

We also know that the developing brain is very vulnerable to substance use. One in 10 adolescents who use marijuana become addicted. That means that 90 percent won’t — which is the good news — but the problem is we can’t predict which 10 percent will develop addiction.

We also have a lot of research about the adverse effects of marijuana use. Heavy users fare worse in many ways: their cognitive levels fall, they are less likely to finish high school or attend college, and they tend to suffer more from depression. Most users are not heavy users, but again, we can’t predict who will fall into this category.

The AAP is also in favor of decriminalizing marijuana, replacing current criminal penalties with lesser criminal or civil penalties and drug treatment. This is an especially important step to reduce the long-term damage to educational and job opportunities that currently comes with marijuana arrests, Ammerman said, adding: “There is a significant problem of racial inequity associated with marijuana arrests: minorities are way over-arrested and their lives are messed up because of marijuana arrests. It’s a very important step to say we need to help kids, not punish them.”

Previously: Medical marijuana not safe for kids, Packard Children’s doc says, Pediatrics group calls for stricter limits on tobacco advertising and To reduce use, educate teens on the risks of marijuana and prescription drugs

Photo by mexico rosel

Addiction, Pain, Public Health, Research

Medical marijuana and the risk of painkiller overdose

Medical marijuana and the risk of painkiller overdose

medical marijuanaAfter a study published this fall showed that that opioid overdoses (e.g., with painkillers such as Oxycontin) occur at lower rates in states with legalized medical marijuana, many people interpreted the results as proof that using medical marijuana lowers an individual’s risk of overdose. For example, some speculated that marijuana allows people in pain to forgo using opioids or at least use them in lower doses. Other suggested that medical marijuana reduces users’ consumption of alcohol and anti-anxiety medications, both of which make opioid use more likely to lead to overdose. Still others hypothesized that medical marijuana improves mental health, reducing the risk of intentional opioid overdose (i.e., suicide attempts),

However, all of this speculation was premature. Many things that are associated when geographic areas are compared are not associated in the lives of the individuals who reside in those areas. For example, geographic areas with higher rates of cigarette smoking and higher radon exposure have lower cancer rates, even though individuals who smoke and/or get exposed to radon have higher rather than lower risk of cancer.

The only way to understand the influence of medical marijuana on individuals’ risk of opioid overdose is to actually research individuals, and that is what an Australian team has done. In a recently published study of more than 1,500 people who were on prescribed opioids for pain, they examined experiences with medical marijuana.

Seeking pain relief from medical marijuana was common in the sample, with 1 in 6 participants doing so and 1 in 4 saying they would do so if they had ready access to it. The results did not support the idea that medical marijuana users are at relatively low risk of opioid overdose. Indeed, on every dimension they appeared to be at higher risk than those individuals who did not use medical marijuana for pain.

Specifically, relative to individuals who only used opioids for pain, the medical marijuana users were on higher doses of opioids, were more likely to take opioids in ways not recommended by their doctor, were over twice as likely to have an alcohol use disorder and four times as likely to have a heroin use disorder. Medical marijuana users were also over 50 percent more likely to be taking anti-anxiety medications (benzodiazepines), which when combined with opioids are particularly likely to cause an overdose.

Neither did the medical marijuana users have better mental health. Almost two-thirds were depressed and about 30 percent had an anxiety disorder.   These rates were half again as high as those for non-medical marijuana users.

Medical marijuana thus appears to be commonly sought for pain relief among people who are taking prescribed opioids for pain. But in this population, it’s a marker for much higher rather than lower risk for opioid overdose.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He has served in the past as a senior advisor in the Office of National Drug Control Policy in Washington, DC. He can be followed on Twitter at @KeithNHumphreys.

Previously: Assessing the opioid overdose epidemicTo reduce use, educate teens on the risks of marijuana and prescription drugs and Study shows prescribing higher doses of pain meds may increase risk of overdose
Photo by David Trawin

Addiction, Behavioral Science, In the News, Mental Health, Research, Stanford News

Veterans helping veterans: The buddy system

Veterans helping veterans: The buddy system

image.img.320.highI interviewed Army specialist Jayson Early by phone over the summer, shortly after he completed an in-patient program for PTSD at the Veterans Affairs hospital in Menlo Park. This was for a Stanford Medicine magazine story I was researching about a pilot project to help get much needed mental-health services to the recently returned waves of Afghanistan and Iraqi vets. What struck me most after talking with Early was just how clueless he had been, first as a teenaged-recruit, then as a young veteran, about the fact that going to war could cause mental wounds.

As the mother of a 17-year-old boy, though, I completely understood: Early just wanted to serve his country. He requested to be sent to war. In 2008, he got his wish and was deployed to Iraq just a year after exchanging his high-school baseball uniform for military fatigues. His first field assignment, an innocuous-sounding public affairs errand to photograph a burned out truck at an Iraqi police station, would be the first of many that left him with permanent scars:

“There were body parts, coagulated blood, hair all over,” [Early] says, pausing. “I just wasn’t expecting it.” An Iraqi family had been executed in the vehicle, presumably by insurgents. Early had gone through intense military training to prepare for moments like these. He blocked any emotions. He followed orders, clicked the camera and moved on. It wasn’t until years later that he realized just how permanently those images, and many more like them, had burned into his brain.

Stanford psychiatrist Shaili Jain, MD, interviewed in a podcast about her work with PTSD and veterans, had told me about a new pilot project that connects veterans with other veterans as a unique way to bridge what she called a “treatment gap” – the difficulty of getting mental-health services to the veterans that need them. My article – which is a timely read, given that today is Veterans Day – tells the story of Early’s connection with one of the veteran’s hired through this project, Erik Ontiveros, who went through treatment for addictions and PTSD himself, and just why it’s so hard to get treatment to veterans. As one well-known expert on PTSD explains in the story:

“It’s wicked difficult to treat anyone with moral injuries from combat in the traditional medical model,” says psychiatrist Jonathan Shay, MD, an expert on PTSD known for his books on the difficulties soldiers face returning home from war. “It destroys the capacity for trust. What it leaves is despair, an expectation of harm, humiliation or exploitation, and that is a horrible state of being. The traditional medical model – in an office with the door closed – is the last thing they want. I’m convinced that’s where peers come in. Peers are indispensable.”

Early told me many of his horror stories from war – stories that he rarely talks about. The time he was called to another execution area where there were enough body parts for 12 people who had all been gagged, bound, shot and burned. But, he said, they could only put together eight people. “We were trying to find a way to identify them,” he said. “Whenever I grabbed a hand, it would just crumble to dust.”

Continue Reading »

Addiction, Emergency Medicine, Health Policy, Research, Stanford News

Assessing the opioid overdose epidemic

Assessing the opioid overdose epidemic

Vicodin bottle Flickr Sharyn MorrowIn recent years, doctors and policy-makers have become aware of the dangers of prescription opioid medications like methadone, oxycodone and hydrocodone (which is sold as OxyContin or Vicodin). In a study published in this month’s JAMA Internal Medicine, Stanford medical student Michael Yokell and Stanford surgeon Nancy Wang, MD, took a new approach to quantifying those dangers.

Many previous studies of the toll of opioids looked at death certificate data and examined trends among deaths due to opioid overdoses, including street drugs like heroin and prescription painkillers. The new study looked at emergency department admissions and found that more than two thirds of ER visits due to overdoses were related to prescription opioids, while heroin overdoses accounted for 16 percent. Moreover, only about 2 percent of cases that made it to the ER died, but more than half the patients needed further hospitalization.

The study also found that those admitted to the emergency room because of opioid overdoses are more likely to have conditions such as chronic breathing problems, heart problems or mental health issues. Yokell explained that it’s important for doctors to be aware of the possibility of overdose and consider prescribing alternatives or discuss the risk of overdose with patients.

Beyond providing better access to emergency medical care and treatments for patients, an important next step to resolving the problem of opioid misuse is to establish or improve statewide prescription monitoring programs. For example, California has a prescription drug-monitoring database called CURES, but not all doctors actively use the program. “We can do a better job of making that database more widely used by physicians in the state.  We need more doctors to sign up and use it. It’s a valuable resource,” said Yokell.

Additionally, many people get access to prescription opioids via fraudulent prescriptions or from dealers that have illegally obtained the drugs – sometimes from breaking into and raiding pharmacies. “It’s important to keep in mind that good prescribing practices are one component of an effective strategy. There are many other ways for people to get their hands on [prescription opioids] and use them inappropriately.”

Although fixing things on the prescription side is important for managing the opioid overdose epidemic, Yokell notes that it’s not enough. Cases that make it to the ER are likely to survive, but Yokell noted that the fear of criminal charges often results in people avoiding medical care for overdoses caused by opioids and that getting this group better access to emergency services and treatment could improve outcomes. Paramedics and doctors have access to the drug naxolone, marketed as Narcan, which is safe and effective treatment for opioid overdose. But “people don’t call 911, so they are dying,” Yokell told me.

Previously: Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse, Increasing access to an anti-overdose drug and A focus on addiction, the country’s leading cause of accidental death
Photo by Sharyn Morrow

Addiction, Bioengineering, Mental Health, Neuroscience, Stanford News, Stroke

Neuroscientists dream big, come up with ideas for prosthetics, mental health, stroke and more

Neuroscientists dream big, come up with ideas for prosthetics, mental health, stroke and more

lightbulbs

So there you are, surrounded by some of the smartest neuroscientists (and associated engineers, biologists, physicists, economists and lawyers) in the world, and you ask them to dream their biggest dreams. What could they achieve if money and time were no object?

That’s the question William Newsome, PhD, asked last year when he became director of the new Stanford Neurosciences Institute. The result is what he calls the Big Ideas in Neuroscience. Today the institute announced seven Big Ideas that will become a focus for the institute, each of which includes faculty from across Stanford schools and departments.

In my story about the Big Ideas,I quote Newsome:

The Big Ideas program scales up Stanford’s excellence in interdisciplinary collaboration and has resulted in genuinely new collaborations among faculty who in many cases didn’t even know each other prior to this process. I was extremely pleased with the energy and creativity that bubbled up from faculty during the Big Ideas proposal process. Now we want to empower these new teams to do breakthrough research at important interdisciplinary boundaries that are critical to neuroscience.

The Big Ideas are all pretty cool, but I find a few to be particularly fascinating.

One that I focus on in my story is a broad collaboration intended to extend what people like psychiatrist Robert Malenka, MD, PhD, and psychologist Brian Knutson, PhD, are learning about how the brain makes choices to improve policies for addiction and economics. Keith Humphreys, PhD, a psychiatry professor who has worked in addiction policy and is a frequent contributor to this blog, is working with this group to help them translate their basic research into policy.

Another group led by bioengineer Kwabena Boahen, PhD, and ophthalmologist E.J. Chichilnisky, PhD, are working to develop smarter prosthetics that interface with the brain. I spoke with Chichilnisky today, and he said his work develop a prosthetic retina is just the beginning. He envisions a world where we as people interface much more readily with machines.

Other groups are teaming up to take on stroke, degenerative diseases, and mental health disorders.

One thing that’s fun about working at Stanford is being able to talk with really smart people. It’s even more fun to see what happens when those smart people dream big. Now, they face the hard work of turning those dreams into reality.

Previously: This is your brain on a computer chip, Dinners spark neuroscience conversation, collaboration and Brain’s gain: Stanford neuroscientist discusses two major new initiatives
Photo by Sergey Nivens/Shutterstock

Addiction, In the News, Public Health

Stanford experts skeptical about motives behind e-cigarette health warnings

11359245033_0a05d9c884_z

Quotes can sometimes make or break a news article. I was skimming a New York Times article on new, harsh health warnings from tobacco companies when a quote from Stanford otolaryngologist Robert Jackler, MD, stopped me in my tracks.

“When I saw it, I nearly fell off my chair,” Jackler told the Times. What made a renowned expert in tobacco advertising fall off his chair? I was hooked (and not on cigarettes, thankfully) and had to keep reading.

It turns out that Jackler had spotted the warning on MarkTen e-cigarette packs, which details many of the deleterious effects of nicotine, calling it “very toxic by inhalation, in contact with the skin, or if swallowed.” The product is not to be used by children, women who are pregnant or breast-feeding, anyone with heart disease or high blood pressure, or those taking medication for depression or asthma. The list goes on.

These warnings are voluntary, explained the Times‘ Matt Richtel, who also wrote:

Experts with years studying tobacco company behavior say they strongly suspect several motives, but, chiefly, that the e-cigarette warnings are a very low-risk way for the companies to insulate themselves from future lawsuits and, even more broadly, to appear responsible, open and frank. By doing so, the experts said, big tobacco curries favor with consumers and regulators, earning a kind of legitimacy that they crave and have sought for decades. Plus, they get to appear more responsible than the smaller e-cigarette companies that seek to unseat them.

The tobacco companies say they are striving to be honest and open. With another choice quote, Stephanie Cordisco, president of the R. J. Reynolds Vapor Company, told the Times: “We’re here to make sure we can put this industry on the right side of history.”

Not so, Stanford science historian Robert Proctor, PhD, responded. He called the voluntary warnings “totally Orwellian.”

“They do everything for legal reasons, otherwise they’d stop making the world’s deadliest consumer products,” Proctor said.

Becky Bach is a former park ranger who now spends her time writing about science and practicing yoga. She is an intern in the Office of Communications and Public Affairs. 

Previously: How e-cigarettes are sparking a new wave of tobacco marketing, E-cigarettes and the FDA: A conversation with a tobacco-marketing researcher and What the experience of Swedish snuff can teach us about e-cigarettes
Photo by Lindsay Fox

Addiction, In the News, Pain, Public Health

Stanford addiction expert: It's often a "subtle journey" from prescription-drug use to abuse

Here are some frightening facts you might not know: Drug overdose death rates in the United States have more than tripled since 1990, with the majority of drug-related deaths caused by prescription drugs. And as of 2010, about 18 women in the U.S. die every day of a prescription painkiller overdose. Prescription-drug abuse, which we’ve written about extensively here on Scope, is a very real and pressing issue – and it was the focus of a recent Forum on KQED-FM.

Among the panelists on Friday’s show was Stanford addiction psychiatrist Anna Lembke, MD, who made the important point that most people who end up addicted to prescription painkillers didn’t start out “looking for a buzz” and that most doctors who prescribe the drugs are merely trying to help their patients. As she explained to listeners:

The problem with… prescription opioids is that they actually do work for pain initially… But for most people, after you take them every day for let’s say a month or more, [you] build up tolerance where they stop working so then you need more of the same drug to get the same effect and it escalates on like that. I really think the process is insidious, both for the patients who become addicted and the doctors who prescribe them. It happens in a subtle journey – when all of the sudden [patients are] using them not just for pain but also maybe to relax themselves, to lift their mood, to be able to go out to a party if they’re feeling anxious, and the doctors continue to prescribe them because they started out working, the patients were happy [and] their function improved. The dose is escalating, but they want to keep the patient happy for all kinds of reasons.

The entire conversation is worth a listen.

Previously: Why doctors prescribe opioids to patients they know are abusing them, Patients’ genetics may play a role in determining side effects of commonly prescribed painkillers, Report shows over 60 percent of Americans don’t follow doctors’ orders in taking prescription meds and Study shows prescribing higher doses of pain meds may increase risk of overdose and Prescription drug addiction: How the epidemic is shaking up the policy world

Addiction, In the News, Public Health, Public Safety

Can the "24/7 sobriety" model reduce drunken disorderly conduct and violence in London?

beer_london_pubIn an article published yesterday in the Telegraph, Stanford addiction expert Keith Humphreys, PhD, discusses how public officials in London are turning to the United States’ “24/7 sobriety” model in an effort to reduce repeat offenders convicted of alcohol-related crimes. The program, which combines mandatory sobriety and daily breathalyser tests, was created under Humphreys’ guidance. He writes:

Research by the RAND Corporation – a US-based non-profit global policy think tank – found that 24/7 sobriety dropped repeat drink driving arrests by 12 per cent. The same study also yielded a pleasant surprise: domestic violence arrests dropped by 9 per cent, despite not being a focus of the programme. Removing alcohol from the lives of criminals can apparently have radiating benefits beyond those directly related to their most recent offence.

In light of its positive results, judges across the U.S. have been adopting the 24/7 sobriety approach. This week, under the leadership of Mayor Johnson and his team, a pilot of the programme will be launched in South London. Leaping the pond will come with some challenges, particularly around delivering sanctions swiftly within the constraints of British law, but local tailoring of innovations is always an essential part of making them spread.

In any event, with over one million alcohol-related assaults occurring nationally each year and many London boroughs being regularly marred by violence and disorder on weekend evenings, the time for new approaches to binge drinking criminal offenders has clearly arrived. The judges and probation officers who are undertaking this pilot should be applauded for refusing to accept the status quo.

Previously: Text messages after ER visit could reduce young adults’ binge drinking by more than 50 percent, Study shows legal drinking age of 21 saves lives and reduces health risks for young adults, Alcoholism: Not just a man’s problem and Stopping criminal men from drinking reduces domestic violence
Photo by Paul Downey

Addiction, Emergency Medicine, Public Health, Research, Technology

Text messages after ER visit could reduce young adults' binge drinking by more than 50 percent

Text messages after ER visit could reduce young adults' binge drinking by more than 50 percent

Bar_texting_0701414Researchers have demonstrated that text message programs can, among other things, help diabetes patients better manage their condition, assist smokers in kicking their nicotine habit, and encourage expecting mothers to get flu shots.

Now new findings published in the Annals of Emergency Medicine show that text messages can also be an effective tool for reducing binge drinking among young adults whose hazardous alcohol use has resulted in an emergency room visit. During a 12-week study, 765 patients who were treated in the emergency room and screened positive for a history of hazardous drinking were divided into three groups. The first group received text messages prompting them to respond to drinking-related queries and received text messages in return offering feedback aimed at either strengthening their low-risk drinking plan or promoting reflection on their drinking plan or decision not to set a low-risk goal. Another group received only text queries about their drinking, and the remaining individuals received no text messages.

A story published today on PsychCentral reports on the researchers’ results:

The group receiving both text message queries and feedback decreased their self-reported binge drinking days by 51 percent and decreased the number of self-reported drinks per day by 31 percent.

The groups that received only text messages or no text messages increased the number of binge drinking days.

“Illicit drugs and opiates grab all the headlines, but alcohol remains the fourth leading cause of preventable death in the U.S.,” said [Brian Suffoletto, MD, assistant professor in the Department of Emergency Medicine at the University of Pittsburgh School of Medicine].

“If we can intervene in a meaningful way in the health and habits of people when they are young, we could make a real dent in that tragic statistic. Alcohol may bring them to the ER, but we can do our part to keep them from becoming repeat visitors,” [he added].

Previously: CDC explores potential of using smartphones to collect public health data, Could better alcohol screening during doctor visits reduce underage drinking?, Personality-based approach can reduce teen drinking and The costs of college binge drinking
Photo by Anders Adermark

Addiction, FDA, Health Policy, otolaryngology, Public Health

How e-cigarettes are sparking a new wave of tobacco marketing

e-cig tip - smallFollowing the FDA’s announcement earlier this spring that it would regulate the sale – but not marketing – of electronic cigarettes, debate has continued on the safety of using e-cigarettes and the ethics of advertising them.

In case you missed it, today’s New York Times delves into the issue and highlights how Big Tobacco is now rolling into the world of e-cigarettes, which writer Matt Richtel calls an “overnight sensation.” A subsidiary of Reynolds American plans to begin distributing its Vuse e-cigarette line nationwide on June 23 with a campaign that includes television ads (forbidden for cigarettes) in major markets, and other tobacco companies have similar entries in the works. Questions about the potentially far-reaching effects advertising of e-cigarettes, including promoting smoking tobacco and reaching child audiences, concern public-health advocates and other critics – and a U.S. Senate hearing is planned for Wednesday.

From the article:

Matthew L. Myers, [JD,] president of the Campaign for Tobacco-Free Kids, who is scheduled to testify at the Senate hearing, said the fact that the F.D.A. did not limit marketing allowed tobacco companies to return to the airwaves with ads that make e-cigarettes sexy, rebellious, glamorous — “exactly the same themes we saw work with kids in the U.S. for decades with cigarettes.”

In the absence of marketing regulation, “they will set the agenda,” Mr. Myers said of the tobacco companies. “They will drive the evolution of the product in a way that serves their interests and not public health, and that’s exactly what’s happening.”

Robert Jackler, MD, chair of otolaryngology at Stanford Medicine, is an expert on tobacco marketing who studies it through his center, the Stanford Research Into the Impact of Tobacco Advertising. Like Myers, he has vocalized his concerns about e-cigarettes and tobacco companies’ aggressive marketing tactics – especially those targeted toward teens – and you can hear more about his views and research in this recent podcast.

Previously: E-cigarettes and the FDA: A conversation with a tobacco-marketing researcherE-Cigarettes: The explosion of vaping is about to be regulatedStanford chair of otolaryngology discusses federal court’s ruling on graphic cigarette labels and What’s being done about the way tobacco companies market and manufacture products
Photo by Li Tsin Soon

Stanford Medicine Resources: