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Addiction, Parenting, Pediatrics, Public Health

How to prevent prescription-drug misuse among teens

How to prevent prescription-drug misuse among teens

The Medicine Abuse Project is being launched this week by a coalition of public-health, public-safety, governmental and private-sector organizations. The Project is a response to the past decade’s sharp increase in medicine abuse – including among teenagers. Overdose from prescription drugs is now more common than overdose from heroin and cocaine combined. And medication abuse carries a high risk of addiction, particularly in the teenage years, a period of significant neuroplasticity in brain development.

What can be done to reduce the prevalence of prescription medicine misuse among teens? The Medicine Abuse Project suggests two important strategies:

  1. Secure your medicine cabinet. In many American homes, parents keep the liquor cabinet locked, but leave potentially dangerous medicines in an unlocked cabinet to which their children have easy access. Survey research shows that this is a far more common source of abused medicines than is the stereotypical “street corner” drug dealer.
  2. Participate in National Prescription Drug Take-Back Day this September 29. Take-Back Days, which are coordinated by the Drug Enforcement Agency, allow anyone to drop off leftover, expired and/or unwanted prescription medications with no questions asked. The most recent take back day resulted in the disposal of an astounding 276 tons of medication.

In addition to these two steps, parents can also do more to educate themselves and their children about the dangers of abusing medicine. For example, while almost all parents would agree that heroin (an illegal opioid) is dangerous and would not want their children using it, many of these same parents are unaware that prescription opioids such as Oxycodone can be just as dangerous. Indeed, parents may worry about the wrong thing: An American 12th-grader is more than 10 times as likely to abuse prescription opioids than they are to abuse heroin.

To get involved and learn more visit the Medicine Abuse Project’s website.

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

Previously: Examining how addiction in the U.S. has changed over the last decade, Turn in your old pills on April 28, Governors to Congress: Help us fight prescription-drug abuse and How to combat prescription-drug abuse
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Addiction, Health Policy

Do opium and opioids increase mortality risk?

Overdose from prescription opioids (e.g., Oxycodone or Hydrocodone) has become one of the most common causes of accidental death in the United States. Two new articles in BMJ suggest that overdose is not the only risk about which patients, prescribers and policy makers should be concerned.

Khademi and colleagues conducted a prospective study of a cohort of 50,045 Iranians. They followed up over 99 percent of the sample and then assessed the impact of opium use on mortality. After statistically adjusting for cigarette smoking, education, age and other factors, the research team reported that opium use nearly doubled the risk of death. The number of diseases with increased incidence among opium users was large, and included tuberculosis, cancer and COPD. The results held even when the researchers excluded from analysis individuals who started using opium in response to the onset of a chronic illness.

These results do not necessarily generalize to prescription painkillers such as Oxycontin. Unlike opium, which comes directly from the poppy flower, modern, synthetic opioids are free of impurities and are never smoked. Further, opium use in Iran may be a marker for other risk factors (e.g., poor self-care habits or social isolation) for which the epidemiological study could not fully adjust.

That said, in an accompanying commentary in BMJ, Dhalla notes that preliminarystudies have found indications of higher death rates in patients who take opioid medications (versus, for example, NSAIDs). The increased death rates are not simply attributable to accidental overdoses. None of these studies of prescription opioids is definitive, but they certainly justify a larger replication research effort along the lines of the Iranian study of opium users.

The worrisome fact about prescription opioids is that their use has grown (.pdf) extraordinarily rapidly in a very short period in the United States, to over 200 million prescriptions in 2010 alone. As a result, any adverse impacts of opioids that take a few years to accrue may hit the population in a tidal wave before there is time to understand and prevent the damage.

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

Photo by Ingrid Taylar

Addiction, Research, Technology

CDC binge-drinking study demonstrates cell phones’ value in research

CDC binge-drinking study demonstrates cell phones' value in research

The Centers for Disease Control and Prevention’s new finding that 38 million Americans engage in binge drinking is, quite appropriately, causing widespread alarm. But below that headline is an important secondary point: We have been underestimating the rate of binge drinking for a long time because researchers haven’t surveyed cell phone users until now. This year’s survey was the first to include cell phones, and the number of binge drinkers jumped as a result.

There’s an intriguing history here.

The arrival of landlines in virtually every American home was a godsend to survey researchers. A survey researcher could draw a random sample of phone numbers and be confident that it was representative of the U.S. population.

To preserve this representativeness, researchers wouldn’t necessarily survey the person who answered the phone. If you’re old enough to remember growing up in a home with a landline, you’ll know why: who answered the family phone was rarely random. For example, in some homes mom always did it even when dad was home, in other homes dad did it only if he had a teenage daughter and wanted to screen potential suitors, and so on.

Telephone survey researchers would handle this by asking the person who answered the landline phone a randomizing question within the household (e.g., the would ask to speak to the person in the household whose birthday was closest to a randomly chosen date).  This technique combined with the ubiquity of landlines made household landlines a fabulous way to survey random, representative samples of Americans about political attitudes, dietary habits, product purchasing patterns and a million others things, including, of course, drinking patterns.

The emergence of cell phones ruined all that. Particularly when they first became available, people who owned them were a non-representative sample of the population. Since they were usually not shared, you couldn’t “re-randomize” within a group when someone answered as you could on a shared household landline; your only choice was typically the phone owner. In addition, the phone numbers weren’t usually listed so it was hard to get the sample of phones to call in the first place.

For years I’ve been attending meetings of alcohol survey researchers during which colleagues lamented the rise of cell phones as a threat to survey research but couldn’t come up with a solution. Each year their response rates were getting lower, and their samples less representative as younger people opted not to have landlines.

The CDC managed to crack into the cell phone survey game with its latest effort – something for which they should be applauded. (How they got the numbers I don’t know.) The changed picture reflected in this year’s results show the advantage of their method, and show that cell phone surveys are the wave of the future not just for drinking problems but for all the other health and social phenomena that are the focus of survey research.

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

Addiction, Cancer, In the News

The wrong reason to lionize Christopher Hitchens

At a party last year I chanced to turn my head and see a famous person, about whom two things immediately impressed me: One, he was downing glasses of whisky at an alarming rate, and two, he looked pale and sickly. The man was Christopher Hitchens, who died of esophageal cancer this past week at the age of 62.

As tributes to Hitchens have poured in from around the world, many people who knew him have appropriately lauded his astonishing erudition and stylish writing. But a disturbing number have either made light of or even romanticized his prodigious consumption of alcohol. This is at best foolish and at worst dangerous.

The contribution of heavy alcohol consumption to automobile accidents, family violence, liver cirrhosis and a host of other problems has been well-known for decades. In more recent years, increasing evidence has implicated alcohol consumption in the genesis of many cancers (e.g., of the oral cavity, larynx and pharynx). Most cases of esophageal cancer, which ended Hitchens’s life as well as that of his alcoholic father, are attributable to heavy, regular alcohol consumption. When heavy alcohol consumption is combined with smoking, the risks of cancer rise even further.

Whether they intend it or not, in their public statements some people who clearly cared about Hitchens have trivialized the behavior that took their friend from them years before his time. Hitchens himself was both more serious and honest, when he said in one of his last television interviews “to anyone watching, if you can hold it down on the smokes and the cocktails you may be well advised to do so.”

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

Clinical Trials, Research

Clinical trial research that knocked my socks on

Every once in a while, a colleague gives a research presentation that knocks your socks off. John Strang, MD, of Kings’ College London, gave one last week that had the reverse effect.

Strang was discussing randomized clinical trials and noting that they are useless for some very important questions (e.g., “Should I ask that nice girl out?”) and unneeded for others (e.g., “Does wearing a parachute when jumping out of the plane actually confer an advantage over the no-parachute control condition?”). But when randomized trials meet the right sort of question, there is no more powerful method for gaining knowledge that can literally be life-saving.

The example Strang gave was that of compression socks and deep vein thrombosis (DVTs) on long haul flights. Also known as “coach class syndrome,” DVTs are a blood clot which forms in the vein when you sit still for hours. Theoretically you can avoid them by getting up regularly and moving around the plane, but, even if you don’t fall asleep, that’s often hard to do on packed flights (and can feel awkward in an age of post-9/11 wariness among flight crews). Compression socks have none of those practical barriers. But do they work?

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Addiction, Mental Health

Addiction: All in the mind?

For a brief period of my life, I consumed far more opioids than the most hardened heroin addict. After a freak injury that left me with my femur broken into two jagged pieces that spiraled past each other, shredding my muscle and flesh, I was in so much pain that my doctors attached a self-controlled morphine pump to my body. For the next five days I voluntarily consumed an amount of morphine that literally would have been fatal before my injury. But the day after the surgery that pinned my femur back into one piece, my pain lessened enormously and I immediately lost all interest in using morphine. So, was I addicted for those five days or not? And if so, did my doctors do me a disservice by letting me take large doses of powerful drugs?

Answering questions like these is one of the main motivations behind recent efforts to reclaim “addiction” from popular slang (e.g., America is “addicted to debt,” Robert Palmer was “addicted to love,” etc.) and make it a credible, reliable, and understandable medical diagnosis. Distinguishing a “large amount of substance use” from “addiction” has been central to this effort, not least so that doctors will be unafraid to adequately treat acute pain such as I experienced in the hospital. A further motivation, which no doubt inspired the American Society of Addiction Medicine’s just-released redefinition of addiction (.pdf), is to help addicted people better understand their condition and to help the rest of us understand how to help them.

In addiction, something happens in the brain that did not happen in mine during my hospital stay: An enduring change to the structures and systems that shape memory, learning, emotion and reward. Although both genetic and environmental factors are known to be implicated, no one knows precisely why some people undergo these changes when they extensively use psychoactive substances and other people do not. But scientists do know that once these changes have occurred, they persist long after the substance use has stopped. Once someone is addicted, they will, even during periods of non-use, think about the psychoactive substances more often, overestimate their value (i.e., feel they are more important than eating, sleeping, work and family responsibilities) and have urges to return to use.

As half of the U.S. population is overweight, many people are familiar with an analogous biological process. Once you have put on a lot of weight, even if you lose it later, it is as never as easy as it once was to maintain a healthy weight. Your body has produced more fat cells and you have a different appetitive set point such that if you diet to get back to the normal weight, you may feel as hungry as if you were starving. If you respond to this feeling by eating more you will eventually regain the weight you lost, sometimes again and again, just as an alcoholic might get on and fall off the wagon over and over.

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Addiction, Behavioral Science, Medicine and Society

College without booze: harder than it sounds

“Still Sociable at Stanford” wrote to Dear Abby last week asking for advice about a problem that usually isn’t mentioned in discussions of college drinking: How does a non-drinker handle social pressure to imbibe?  The members of the Stanford community have a widely shared commitment to diversity, and we are almost self-consciously laid back and accepting of people whose beliefs, behaviors and background are different than our own. If you are a left-handed Lithuanian lesbian who uses a wheelchair, supports nuclear power and dabbles in paganism, we are totally cool with that, but if you don’t drink alcohol, some of us just can’t let that pass without comment. Why?

Social-norms research reveals that people judge how much drinking is too much by looking at the people around them, and they don’t like feeling that they are above the norm. I’ve studied this phenomenon in a research program directed by John Cunningham, PhD, of the University of Toronto. When we show heavy drinkers objective data on where they stand relative to other people of their age and sex (e.g., “You drink more than 85 percent of the population”) they feel uncomfortable, which often leads them to cut back on their alcohol consumption.

Similar psychological processes may come into play when non-drinking and heavy-drinking college students interact on campus. Heavy drinkers among a group of other heavy drinkers (e.g., at a party) will feel more comfortable about their level of alcohol consumption than they would if there were non-drinkers hanging around to provide a different comparison point, much as Bashful and Grumpy probably had no anxieties about their height until Snow White met them and the other dwarves.

As Dr. Cunningham’s studies show, heavy drinkers sometimes react to their discomfort at seeing that they drink relatively more than other people by taking a hard look at their own drinking.  But in a research study, such feedback comes from a standardized computer printout, whereas at a party it comes from the behavior of another human being, which opens up a different way for a heavy drinker to respond: Pressure the abstainer who makes you uncomfortable into having some drinks.

On a typical U.S. campus, between a quarter to a third of students never or almost never drink alcohol, so there is no rational basis for such students to be viewed as bizarre outliers. With more than 1,800 college students dying in alcohol-fueled incidents a year, and many times that number being involved in alcohol-related injuries and assaults, it would be more sensible for us to collectively apply social pressure to people who drink too much rather than those who don’t drink at all.

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

Addiction, Health Policy, In the News

Prescription drug addiction: How the epidemic is shaking up the policy world

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

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

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

Addiction, Health Policy, Mental Health, Pain

How to combat prescription-drug abuse

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

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

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

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

Addiction, Health Policy, In the News

The frightening rise of drugged driving

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

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

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

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

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

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

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

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

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