Inside Rehab, Celebrity Rehab, Recovery or Treatment?, Dr Mark Willenbring, OST, Naloxone, NMDA Modulators, Epigenetics, Frankenstien Drugs, Local Research, Ibudilast for Meth addiction?, Policy in NZ, Columbia and Africa, Banker or Dealer?
The State of Treatment
Recovery or Treatment?
One of the hot debates at the moment is that the concept of "recovery" has run its course and we should be looking towards harm reduction and treatment. Of course we tend to throw the baby out with the bath water, and forget that there is probably truth in both arguments. White and Evans have provided a neat summary of this two views in a table in their paper "Toward a Core Recovery-Focused Knowledge Base for Addiction Professionals and Recovery Support Specialists". I think that we are going to see increasing division in the treatment of addictive disorders with one side advocating "recovery" while the other side advocates "pharmacology". Hopefully sense will prevail.
Dr Mark Willenbring also commented on the state of treatment programs in the States in his post "What's Wrong With Addiction Treatment in America". He has this rather poignant observation to make:
"We need to foster the humility to care, even though our treatments are only partially effective, and in some cases totally ineffective. We can't abandon our patients because we cannot change the course of their illness."
Opioid Substitution Treatment
There is increasing evidence for the effectiveness of OST, and a fair share of controversy that typically pits those who see OST as an end in itself and those who see it as a means to an end (more on this next month). The one thing both sides can agree upon is that treatment retention rates are typically very low. Two studies this month try to address this issue. One is UK based and focuses on Methadone: "Evidence and recovery; improving outcomes in opiate substitution treatment." The other paper in the Journal of Substance Abuse Treatment examines the use of buprenorphine in an abstinence-based continuum of care. Neither comes up with any convincing answers, and I would suggest that we need to focus our attention on treatment retention. Unfortunately this is often a function of the clinician's ability to engage the patient, and as such is difficult to measure.
Perhaps more controversial than OST is the distribution of Naloxone to at risk populations for administration in the event of overdose. Naloxone, an opioid antagonist with a high affinity for the opioid recepetor, reverses the effect of heroin and can prevent death if administered soon enough after a potentially fatal overdose. This article describes how the distribution of free Naloxone has reduced the number of deaths in Brighton and Hove. The drug has also been introduced into the prisons. In 2012 the CDC in the US reported that over 10 000 lives had been saved through Naloxone distribution. In the South African context we are seeing increasing heroin use. Currently most users are smokers, but soon we can expect a sharp increase in injectors over the next few years if anecdotal evidence proves to be prescient.
Quote of the Month
"But I sometimes wonder if one of the most bizarre paradoxes is that the addictive goal — the drug or drink — really does replace the thing that we wanted most. Warmth, connection, safety….all so complicated, so difficult to control — some kind of purgatory compared to the sheer end-of-the-world salvation of the addictive act, which takes us straight to hell but passes by heaven en route."Research
NMDA Receptor Modulators
Glutamate is one of my favorite subjects because of its apparent role in the reinstatement of addictive behaviours through cues. We have seen Topiramate show some success in the reduction in cue-reinstated drug acquisition. This month Pharmaceuticals published an article: NMDA Receptor Modulators in the Treatment of Drug Addiction. The frustrating conclusion: "However, the lack of consistency in results to date clearly indicates that additional studiesare needed, as are studies examining novel ligands with indirect mechanisms for altering NMDA receptor function."
Epigenetics and Psychostimulant Addiction
There has been evidence of long-term changes the neural networks through gene expression in the presence of chronic drug use. This paper examines the regulation of BDNF (Brain-Derived Neurotrophic Factor) and the epigenetic mechanisms around this. The expression of BDNF seems to have a distinct effect on drug taking behaviour. Nestler and Feng also examine the "Epigenetic Mechanisms of Drug Addiction", summarizing the latest advances in the field. Further studies into the epigenetic processes will help explain the long-term effects of drug taking, and shed light on the road that leads from "use" to "addiction" as well as how best to reverse or compensate for these changes in treatment.
Last month we spoke about Frankenstein Treatments, talking about ablative surgery. This month we have a Frankenstein Drug! In a paper in Forensic Science International they describe the identification of URB-754, a new designer drug. What is indeed a first, is that the reaction between a synthetic cannabinoid and a cathinone-type designer drug has resulted in a a new substance - (N,5-dimethyl-N-(1-oxo-1-(p-tolyl)butan-2-yl)-2-(N′-(p-tolyl)ureido)benzamide). The study also identified 12 new synthetic cannabinoids. This is going to be more and more common as products like "spice" and "bathsalts" hit the streets in an attempt to avoid detection through drug tests and criminal sanction for those carrying and dealing.
Bronwyn Meyers, Charles Parry and others have just published an new paper entitled "Ethnic differences in alcohol and drug use and related sexual risks for HIV among vulnerable women in Cape Town, South Africa: Implications". Perhaps suprising from this research was the prevalence of Methamphetamine use amongst black women. Particularly concerning was the levels of AOD-influenced and unprotected sex amongst coloured women.
New Drug for Meth Addiction?
New Zealand leads the way?
In order to counteract synthetic drugs, New Zealand has taken a rather novel approach: Regulate the industry. Synthetic drugs are a nightmare for legislators because there are new ones being invented all the time, often with the sole purpose of evading use and distribution laws. In this BBC report, they describe New Zealand's approach as shifting responsibility to the manufacturer and retailer. Columbia, who have decriminalised marijuana and cocaine for personal use and the possession of small quantities, are now looking at decriminalising synthetic drugs, including Methamphetamine.
African Arguments series of books has just published "Africa and the War on Drugs". Africa has, in recent years, become an active player in the international drug trade. The American War on Drugs has not left the continent unaffected. From Nigerian drug lords in UK and South African Prisons, to Khat chewing Somali Pirates and Meth fueled gangs on the Cape flats, we are experiencing the effects. The book also explains how foreign-inspired policies have created corrupt law enforcement officers. One of the major criticisms of the book is that they perhaps downplay the complicity of government in the drug trade. This is highlighted in James Cockayne's commentary. We in South Africa have certainly experienced the effects of drug diversion of cargoes traveling via West Africa en-route to primary markets as law enforcement measures become more effective. Drug policy is certainly going to shape the future of many countries, especially as we find great disparities in policies and a waning of American influence in the war on drugs.
Banker or Dealer