tag:blogger.com,1999:blog-3235348990594085432024-02-19T04:53:37.755+02:00Addiction InformationCommitted to furthering the understanding of "addiction" and promoting effective drug policies. This site contains articles, information and resources related to drugs, drug use and the condition many call "addiction". Created and compiled by Shaun Shelly. Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comBlogger32125tag:blogger.com,1999:blog-323534899059408543.post-70231111135323402222016-01-02T17:03:00.002+02:002016-01-02T17:05:02.297+02:00These are my people....<br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-LG4BCN4Ztacb5hYkZQKpLnP5d5rxBZQMZCJ9u91d7M7A8ziCPHKtgpNaCTJmjXQ3FrTlYrXdaXN3aca3tAmidWbS6P8dy-bLFccB3nghVq_ypFME2oKk-D8j7_JQd9I3s5O9RG_j7hY/s1600/Pretoria+CAG.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-LG4BCN4Ztacb5hYkZQKpLnP5d5rxBZQMZCJ9u91d7M7A8ziCPHKtgpNaCTJmjXQ3FrTlYrXdaXN3aca3tAmidWbS6P8dy-bLFccB3nghVq_ypFME2oKk-D8j7_JQd9I3s5O9RG_j7hY/s320/Pretoria+CAG.jpg" width="320" /></a></td></tr>
<tr align="left"><td class="tr-caption">Please see footnote at end of post for photo details</td></tr>
</tbody></table>
Most of the work I currently do is related to<a href="https://www.facebook.com/StepUpHarmReductionServices/?fref=ts" target="_blank"> street-dwelling drug users</a>. As a former street-dwelling drug user (I no longer live on the streets), I have an added empathy for this population. I am aware of this "bias" and I am also aware that my story is not their story. Each person has their own story, and this community is not homogeneous, but there are certainly some generalisations one can make. However, most of the time we have these generalisations wrong. Each time I am fortunate enough to spend some time with street-dwelling drug users, I am reminded of how wrong many of the genrealisations are. This is my final <a href="https://www.facebook.com/shaun.shelly" target="_blank">facebook</a> post for 2015, that expresses some of my frustration around this:<br />
<br />
It was a fitting end to 2015: Central Cape Town doing needle exchange
and chatting to service users - the people I choose to serve and learn
from. Please don't ever tell me "these people" are:<br />
1. In denial<br />
2. Are not resourceful<br />
3. Don't care<br />
4. Are powerless<span class="text_exposed_show"><br /> 5. Should just stop using drugs (and then everything will be OK)<br /> 6. Cannot make a contribution</span><br />
<br />
<span class="text_exposed_show">The truth is: </span><br />
<div class="text_exposed_show">
1. They fully understand the implications of drug use, what drives
their use, what would help them use more safely or cut down their use.
But they are seldom consulted on it.*<span style="font-size: xx-small;">(see footnote)</span><br />
<a name='more'></a>2. The resilience I witness is
amazing. The skill-sets are vast. The ability to survive in a hostile
world is almost beyond belief. The stories of trauma, violence and abuse
are shocking, but I do not want to label "these people" as victims.
They are survivors.<br />
3. The level of community support and care is
evident to see. The compassion they show for one another is clearly
visible. They are family. The only family many of them have.<br />
4.
These are some of the strongest people I have ever met. They make
complex and difficult decisions daily, and contrary to what many people
believe, these decisions are often the best decisions they can make in
very difficult circumstances.<br />
5. For many, using drugs is what keeps
them alive. It is one of the very few acts of meaning that they have in
terms of self-preservation, and certainly it is the one consistent
thing they have in life. And many of them have stopped using drugs for
periods of time, only to find that the world is even crueler and harsher
than they thought. To still be rejected. Stopping drugs means losing
their street family, their means of coping and often much of their
identity all at once. <br />
6. The people I spoke to today all have
talents, and are more than capable of making a contribution, and many do
- taking each other to hospital. Helping distribute health and hygiene
packs. <br />
The truth is that society excludes "these people". The
majority of the suffering I see has nothing to do with drugs, but with
the way drug users are treated and excluded. Most of us have resources,
families and the finances to help us cope with life's tragedies. Many of
us take drugs regularly, but enjoy the privilege of a doctor to
prescribe and access to pharmaceutical grade medications of consistent
dose which we can take in a safe environment.<br />
I will continue to fight and advocate for "these people" in 2016 because "these people" are my people. They are me.<br />
To all of my colleagues, co-advocates, associates and most of all, to
those who continue to suffer needlessly due to a lack of compassion, I
salute you all.<br />
<br />
*Not one person who self-identifies as a user of
illicit drugs was consulted on the National Drug Master Plan, and none
sits on a local drug action committee - my goal for 2016 is to change
that.<br />
<br />
Footnote on photo: These are NOT the people I spent the last day of 2015 with. These are
members of one of the community advisory groups we regularly consult
with around how to improve service delivery and better address the
issues they face. All people in this photograph have consented to having
their image shown on social media. </div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-67632622143405144742014-09-16T12:24:00.000+02:002014-09-16T23:59:24.543+02:00Myths of Addiction<!--[if !mso]> <style>
v\:* {behavior:url(#default#VML);}
o\:* {behavior:url(#default#VML);}
w\:* {behavior:url(#default#VML);}
.shape {behavior:url(#default#VML);}
</style> <![endif]--><br />
<div class="MsoNormal" style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQC975PoUsY-3eprDwHlLSKCEOruU6Y18j3WTUjPAk5Bjq7I8XfICV642o2YyJCeCFLaB5IkhgmHgMZWFk1o-CYi4wTr95dDTxQjPCpk1tGHmzu8EIGHpXK-prqISpTstGgOYzQ8jADso/s1600/biasrearch.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQC975PoUsY-3eprDwHlLSKCEOruU6Y18j3WTUjPAk5Bjq7I8XfICV642o2YyJCeCFLaB5IkhgmHgMZWFk1o-CYi4wTr95dDTxQjPCpk1tGHmzu8EIGHpXK-prqISpTstGgOYzQ8jADso/s1600/biasrearch.jpg" height="320" width="262" /></a></div>
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">This is a recent talk I presented at the <a href="http://www.sacap.edu.za/" target="_blank">South African College of Applied Psychology</a> Festival of Learning and at the University of Cape Town Department of Psychiatry and Mental Health addictions forum.</span><br />
<br />
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">In it I dispel the myths that: </span><br />
<ul>
<li><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">Addiction is caused by drugs, </span></li>
<li><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">once an addict always an addict, </span></li>
<li><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">addiction is progressive </span></li>
<li><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">abstinence is required to initiate treatment or for remission.</span></li>
</ul>
<br />
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;"></span><br />
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">I feel strongly that if we allow these myths to continue, we will not develop practical and helpful treatment modalities or public policies. At the end of the talk I made some suggestions regarding treatment. Comments and criticisms are welcome!</span><br />
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;"></span><br />
<a name='more'></a><br />
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">All around us, on a daily basis, we find news about addiction. We are exposed to a variety of messages, but most of them seem to carry a common theme. Many treatment programs and websites define addiction as a primary, chronic, relapsing, progressive disease of the brain usually caused by the uncontrolled consumption of alcohol or other drugs. What this means, among other things, is that addiction is: </span></div>
<ul>
<li><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">a separate entity on its own – it is a disease in and of itself, not a symptom; </span></li>
<li><span style="color: black; font-family: Symbol; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: EN-ZA;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">a lifelong disorder from which recovery is unlikely;</span></li>
<li><span style="color: black; font-family: Symbol; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: EN-ZA;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">that stable remission is unlikely;</span></li>
<li><span style="color: black; font-family: Symbol; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: EN-ZA;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"></span></span></span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">the longer you have it the less likely you are to remit;</span></li>
<li><span style="color: black; font-family: Symbol; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: EN-ZA;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">that the alcohol and drugs are the cause of addiction.</span></li>
</ul>
<div class="MsoNormal">
<div style="text-align: justify;">
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">What we do know, for certain, is that addictive disorders are complex. They result from a confluence of confounding and poorly understood factors and yet the field of addiction treatment is full of categorical statements, such as those I have mentioned, that the data does not support. </span></div>
<blockquote class="tr_bq">
<div style="text-align: justify;">
<b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">No matter what you have heard or been told, there is no unitary proven model that explains addiction to any degree of satisfaction. </span></i></b></div>
</blockquote>
</div>
<div class="MsoNormal" style="text-align: justify;">
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">Addiction is hugely stigmatised, but even so most people have some sort of addiction-like behaviour. Rather than see ourselves as being on the addiction spectrum, we prefer to examine those that are the worst sufferers of addictive disorders – those that are on the extreme end, the one’s accessing treatment.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br />
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">This is a logical fallacy called Berkson’s bias. Can you imagine looking at only the very sickest of people who contract flu – we would assume that flu was a deadly disease and would hospitalise everyone who developed even a slight cold! This would have disastrous effects. Examples could include –making people even sicker (by exposing them to pathogens in the hospital), it would lead to massive costs in treatment, it would create a huge market in snake-oil “cures”, create fear and stigmatisation….. you get the idea. If you define the problem incorrectly, you will define the treatment incorrectly. We need to see the disorder for what it is in order to develop interventions and treatment approaches that actually work.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br />
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">So one of the ways to get more accurate data is to gather data from a wider representative population, regardless of their treatment history. </span></div>
<div class="MsoNormal">
<br />
<span style="color: black; font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;">I would like to dismantle a couple of myths that are commonly repeated in the field of addiction. I hope that you will begin to see things differently, and perhaps will do your own research to find out what the data really says. The myths I will talk about are: </span></div>
<ul>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Drugs cause addiction</span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"></span></span></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Once an addict always an addict</span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Addiction is a progressive disorder</span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Abstinence is needed to initiate treatment or achieve remission.</span></li>
</ul>
<div class="MsoNormal">
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Each of these could be a book on their own, so I am going to touch on each briefly, giving some of the data, and then I will give us a chance to chat about these statements, and maybe we can have some debate around them.</span></div>
</div>
<div class="MsoNormal">
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">For the sake of clarity let's first define some terms of reference:</span></div>
<div class="MsoNormal">
<br />
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">How will we define “addiction”? </span></b></div>
<div class="MsoNormal">
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The studies cited use the diagnostic criteria for addiction as described in the DSMIII-R, DSMIV and DSMIV-R. There are slight differences in these, and in some studies they include the categories of both abuse and dependence, but it is beyond the scope of this talk to tease out all these subtleties. </span></div>
</div>
<div class="MsoNormal">
<br />
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">How do we define “remission”?</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Remission in most of the studies is the absence of symptoms for the period of a year or more. I know that some people relapse more than a year after stopping, but as we shall see, the data shows that remission rates stabilise and accumulate, indicating there is stable remission.</span></div>
<div class="MsoNormal">
<br />
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The main studies I will be quoting:</span></b></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">During this talk I will be referencing 4 large epidemiological surveys relating to psychiatric disorders and disease that took place in the USA. </span><br />
<ul>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Epidemiological Catchment Area Survey (<a href="http://www.icpsr.umich.edu/icpsrweb/ICPSR/studies/6153" target="_blank">ECA</a>) [</span><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">n=20 000</span></i><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">], </span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">the National Comorbidity Study (<a href="http://www.hcp.med.harvard.edu/ncs/" target="_blank">NCS</a>)[</span><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">n=8 100</span></i><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">], </span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">the National Comorbidity Study Replication (NCS-R)[</span><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">n=9 200</span></i><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">], </span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">and the National Epidemiological Study of Alcohol and other Related Conditions (<a href="http://pubs.niaaa.nih.gov/publications/arh29-2/74-78.htm" target="_blank">NESARC</a>)[</span><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">n=43 000</span></i><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">]. </span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"> I will also refer to data from various annual <a href="https://nsduhweb.rti.org/respweb/homepage.cfm" target="_blank">National Survey on Drug Use and Health</a> reports commissioned by the Substance Abuse and Mental Health Services Administration (SAMHSA).</span></li>
</ul>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The people who I have drawn content from or who have influenced my thinking are: <a href="http://geneheyman.com/" target="_blank">Gene Heyman</a>, <a href="http://www.brucekalexander.com/" target="_blank">Bruce Alexander</a>, <a href="http://www.williamwhitepapers.com/" target="_blank">William White</a>, <a href="http://www.peele.net/" target="_blank">Stanton Peele</a>, <a href="http://www.memoirsofanaddictedbrain.com/" target="_blank">Marc Lewis</a>, <a href="http://andrewtatarsky.com/site/" target="_blank">Andrew Tatarsky</a>, <a href="http://transformationalchairwork.com/about/about-scott-kellogg/" target="_blank">Scott Kellogg</a>, <a href="http://hamsnetwork.wordpress.com/" target="_blank">Ken Anderson</a>, <a href="http://www.drcarlhart.com/" target="_blank">Carl Hart</a> and a few I’m sure I’ve forgotten to mention!</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6zpKDZplApKuVvfG-LmWV8Soh-HZxlf279Fc1NPGccmSLQQee8AgCwxvw-4J_t52tq8-PY9GxyFmQGl_jc9ogVf6g8_hOdE521B36nWtrJt1li9yNhh-IM1jINj59t25_-CAZRmOr4ZU/s1600/Slide15.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6zpKDZplApKuVvfG-LmWV8Soh-HZxlf279Fc1NPGccmSLQQee8AgCwxvw-4J_t52tq8-PY9GxyFmQGl_jc9ogVf6g8_hOdE521B36nWtrJt1li9yNhh-IM1jINj59t25_-CAZRmOr4ZU/s1600/Slide15.JPG" height="180" width="320" /></a></div>
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Myth #1: Drugs Cause Addiction</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Right, first of all, we all hear about the horrors of drugs. How drugs lead to the destruction of not only individuals but whole communities and even societies. Wipe out drugs, and you will solve the problems of society. If only!</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">We hear horror stories backed by scientific studies that show that just once is too much, that heroin is highly addictive – use it and you will be a junky, that dagga is a gateway drug that puts you on the slippery slope to addiction! This may make great headlines, but unfortunately it is simply not true. This is perhaps the easiest of the common myths to disprove.</span></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">If we combine the data for the SAMHSA and NASREC surveys, we can see the numbers of people who have ever tried an illicit substance, and we can see those that have ever met the criteria for addiction.</span></div>
<div class="MsoNormal">
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmEe-vAjYUYXIyzMD07D0m4OaYMumyJiWaOyjqyoyeoHqeq4aVseojdlhAB_CRYwf-_ETA4n3RGbW0zOHhX7rOWr6ad28JFOwzWtp1qJSMoCh_Mes9PfDVwoHtldqKsJcTc90qmCcwZtY/s1600/Slide19.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmEe-vAjYUYXIyzMD07D0m4OaYMumyJiWaOyjqyoyeoHqeq4aVseojdlhAB_CRYwf-_ETA4n3RGbW0zOHhX7rOWr6ad28JFOwzWtp1qJSMoCh_Mes9PfDVwoHtldqKsJcTc90qmCcwZtY/s1600/Slide19.JPG" height="360" width="640" /></a></div>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-language: EN-ZA; mso-no-proof: yes;"></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">As you can see, the chance of getting addicting by using a drug is not very great. Let’s have a closer look at the individual drugs and the probability of getting addicted to them, based on these figures:</span></div>
<div class="MsoNormal">
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiedg0a2aAwfDbtzSDnJO_HKYRP-Lx3xpZGRVx72NbYJXPzswkvBNO6EwQrnrXRSQDRONFf-amubrdM6uE3aa3aNfu3pqkSHZ1l-N8uZTxfpBv9dT_q-rmOk2FD24SpDEbqQowjYrhCJoc/s1600/Slide20.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiedg0a2aAwfDbtzSDnJO_HKYRP-Lx3xpZGRVx72NbYJXPzswkvBNO6EwQrnrXRSQDRONFf-amubrdM6uE3aa3aNfu3pqkSHZ1l-N8uZTxfpBv9dT_q-rmOk2FD24SpDEbqQowjYrhCJoc/s1600/Slide20.JPG" height="360" width="640" /></a></div>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-language: EN-ZA; mso-no-proof: yes;"></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<table cellpadding="0" cellspacing="0"><tbody>
<tr><td height="0" width="83"></td></tr>
<tr><td><br /></td><td><br /></td></tr>
</tbody></table>
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">If I try and show this in yet another way, if we use data from the UNODC 2013 Drug Report, we get the following:</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5MCdwr5_HeWpawquTV1aM6P68M3xMeP7w-SlLxLeemqpPJC-ns5oMRulZXcLFlq91mvUjT-FMogC9xHQQY1aEAA4Ml_Ew2ePzfrecu_CqSmKlCMyfIiw8XEOY64bjlG8VurF8bGgeuiA/s1600/Slide21.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5MCdwr5_HeWpawquTV1aM6P68M3xMeP7w-SlLxLeemqpPJC-ns5oMRulZXcLFlq91mvUjT-FMogC9xHQQY1aEAA4Ml_Ew2ePzfrecu_CqSmKlCMyfIiw8XEOY64bjlG8VurF8bGgeuiA/s1600/Slide21.JPG" height="360" width="640" /></a></div>
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"> </span> <br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">So it is quite clear that drug themselves are not a problem for the majority of drug users. But still there are a lot of people for whom drug use is a massive problem.</span></div>
<div class="MsoNormal">
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Looking at the data, there are two important questions one has to ask here, and </span><br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">the first is: </span><br />
<b><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Why do some drugs appear to be more “addictive” than others?</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Well, some drugs aren’t more addictive than others. They are more dependence forming, in the biological sense. So, for example, heroin, is known for its unpleasant symptoms of withdrawal. This is because the body develops a physical dependency to it fairly quickly, but as I shall show you, this alone does not account for how “addictive” heroin is, and other drugs are.</span></div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The other important question is:</span><br />
<b><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Why do some people become addicted and others not?</span></b></div>
</div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">This is a really interesting question, and one which is really important. I will give you three possible explanations, because this is not the main subject of this talk. </span></div>
</div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">One of the explanations is that somehow some people’s brains are just different. That people who become addicted have a predisposition to addiction. Certainly there is some evidence for this, but even so this does not seem to be enough to fully explain why some people get addicted but others don’t. We also know that even in twin studies, where the genes are the same, one twin may become addicted, while another may not. </span></div>
</div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The next explanation is that perhaps people are using drugs to self-medicate other conditions. This idea was explored by Khantzian. This model essentially proposes that people become addicted because they have underlying psychological and psychiatric conditions they are trying to medicate away. This is indeed and attractive theory, especially when we consider that there is a large correlation between psychiatric disorders and drug use.</span></div>
</div>
<div class="MsoNormal">
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5GV_J2MIRa2XYBh9I8QdEjtZfGn_5CUTs97l-Suf-9velDy4YM7aeKyalSdZ1ha6hA1k6eVBEO6nawHG4SSRNahVDqTQbHMt8-DEd-rvJZ5oBRtpYsImUqVz61hjF8IzgE4wUbYMqFak/s1600/2013-05-en-Rat-Park-01.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5GV_J2MIRa2XYBh9I8QdEjtZfGn_5CUTs97l-Suf-9velDy4YM7aeKyalSdZ1ha6hA1k6eVBEO6nawHG4SSRNahVDqTQbHMt8-DEd-rvJZ5oBRtpYsImUqVz61hjF8IzgE4wUbYMqFak/s1600/2013-05-en-Rat-Park-01.png" height="200" width="141" /></a></div>
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">There is another possible explanation, and this was shown by a really interesting experiment done by Bruce Alexander. This experiment was called Rat Park (<a href="http://www.stuartmcmillen.com/comics_en/rat-park/" target="_blank">check out Stuart McMillen's accurate graphic story</a>). One of the so-called proofs of chemical addiction came from experiments done on rats. Rats were stuck in things called skinner boxes and small cages and taught to self-administer drugs. The rats became addicted and chose the drugs over food and water. Therefore drugs must be addictive. </span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Professor Bruce Alexander thought that this was not the obvious conclusion, and had another hypothesis and decided to test it. Knowing that rats were gregarious creatures, he wondered how they’d behave if they were in a more sociable environment. So he and his team built Rat Park – a space that had all the things that a rat could want – cedar wood shavings, cans, boxes and even pretty pictures of forests on the wall, and most importantly, they put in other rats of both sexes! I won’t go into the details of the experiment, but the bottom line is that the rats of Rat Park didn’t use heroin, even if the heroin was added to a sweetened solution, while rats in isolated little cages did use the heroin, and in great quantities. </span></div>
</div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Then, just to prove the point further, Alexander and colleagues created a bunch of heroin addicted rats and then moved them into Rat Park to see if they remained addicted. What do you know, they stopped using heroin and preferred to live their rat life in rat paradise un-tainted by the haze of opiate addiction!</span></div>
</div>
<div class="MsoNormal" style="text-align: justify;">
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">So, I’ve just shown that given the right environment, rats can recover from their heroin addiction. Is the same true for humans? </span></div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">It appears so. A tragic point in modern history provides the data for this. The Vietnam War.</span></div>
</div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">So remember we said that about 20% of people who use heroin run the risk of becoming addicted. If we look at US troops in Vietnam, that figures rockets to about 45%.</span></div>
<div style="text-align: justify;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyLTI6u1a045kprSNvi0DlCyEjUgBfj4VXj4QgyZULFv1TBziGSqewPxgJ_F8ZwZV09YLRn6v-r8Nt99Jz9KaBod3Q9z80Mel2XXckSOxA3xLv2unmajhCG7stC9KI3oZ0ids5KHJ4rJk/s1600/Slide27.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyLTI6u1a045kprSNvi0DlCyEjUgBfj4VXj4QgyZULFv1TBziGSqewPxgJ_F8ZwZV09YLRn6v-r8Nt99Jz9KaBod3Q9z80Mel2XXckSOxA3xLv2unmajhCG7stC9KI3oZ0ids5KHJ4rJk/s1600/Slide27.JPG" height="360" width="640" /></a></div>
<div style="text-align: justify;">
</div>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-language: EN-ZA; mso-no-proof: yes;"></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">And when these GIs returned home, only 12% continued using heroin (Robins, Helzer et al. 1980).</span></div>
<div class="MsoNormal" style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUv-z0vY47O1FcuRcKJt0_kisuBdRIcbyTV5mD_wfBRA_WtD15xk2KYrpAV5M7dyqufDjuUnfBgMTV7VVR8-LbwZreKilC_UPgvwuRUr8LG4OMG32IcDRHImHRLyv0V20uD1CawHh7L2U/s1600/Slide28.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUv-z0vY47O1FcuRcKJt0_kisuBdRIcbyTV5mD_wfBRA_WtD15xk2KYrpAV5M7dyqufDjuUnfBgMTV7VVR8-LbwZreKilC_UPgvwuRUr8LG4OMG32IcDRHImHRLyv0V20uD1CawHh7L2U/s1600/Slide28.JPG" height="180" width="320" /></a></div>
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">We could also look at the myriad of other behaviours that could conceivably constitute an addiction. Although only gambling is currently listed in the DSM5, there are a number of potential addictive disorders listed in section 3, that are undergoing further investigation</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">So, it appears that drugs are not the cause of addiction – it takes more than just drugs, it takes environment as well. And it looks very much like that given the right environment, most people will stop using drugs.</span></div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">I must just ad a caveat here: This does not mean that drug use is not dangerous. It can be, and it does cause great harm to some people. But it is not true that drugs cause addiction. And if drugs don’t cause addiction, it follows that it is not simply the availability or lack thereof of drugs that help resolve addiction. </span><br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"><br /></span></div>
</div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Myth #2: Once an Addict Always an Addict</span></b><br />
<div class="separator" style="clear: both; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYZf35idiILOxwfHrisz-3-bKWYyWNjXiZqIm8JPY7JHWqx3ix9WhhCQUTPmvJSHQCKTmub3rZiupPsbg0Ndt4gGDdZTUOXEvgGtniy2WVfkA4rAQZbbr-jdpC69EW4-2qUhfoWvFqh_c/s1600/Slide29.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYZf35idiILOxwfHrisz-3-bKWYyWNjXiZqIm8JPY7JHWqx3ix9WhhCQUTPmvJSHQCKTmub3rZiupPsbg0Ndt4gGDdZTUOXEvgGtniy2WVfkA4rAQZbbr-jdpC69EW4-2qUhfoWvFqh_c/s1600/Slide29.JPG" height="180" width="320" /></a></span></b></div>
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">We know that many treatment programs tell us that once you have switched that metaphorical switch from casual drug user to addict you can never go back. That just one lapse will cause a relapse, and that it is best to avoid all mind altering drugs for the rest of your life. If you are a member of a 12-step program, no matter how many years you haven’t used for, you are still required to acknowledge that you are an addict or alcoholic, being ever vigilant of the disease you have. </span></div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Even the APA state that addiction is a “chronic” disease. Although chronic can mean anything longer than a couple of years, in the case of addiction it is generally considered to be life-long.</span></div>
</div>
<div class="MsoNormal">
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">But what does the data say?</span></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The data paints a very different picture. If we look at the data from just the ECA study, this is what we see:</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGRlkCZFQAJVeeHuIxmnLX40mycxTEP9P0_CP3BjxKp-L0Y83R03q6GSLEDCZBmHP12radyIYIHTFDL0_dHmE6806ys8JX_radLOUYGGOOPUIyOgsAqsmW6fhJlwJGYzarJIEfmhrGvdw/s1600/Slide30.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGRlkCZFQAJVeeHuIxmnLX40mycxTEP9P0_CP3BjxKp-L0Y83R03q6GSLEDCZBmHP12radyIYIHTFDL0_dHmE6806ys8JX_radLOUYGGOOPUIyOgsAqsmW6fhJlwJGYzarJIEfmhrGvdw/s1600/Slide30.JPG" height="360" width="640" /></a></div>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-language: EN-ZA; mso-no-proof: yes;"></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<div class="MsoNormal">
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">So this shows, across the board, that at any one time, approximately 57% of all people who suffer addictive disorders are in remission, and that remission rates increase with the age groups. This shows that in many cases, remission is, in fact, stable.</span></div>
<div style="text-align: justify;">
<br /></div>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">But this is one study only. How does it compare with the other major studies?</span></div>
<div class="MsoNormal">
<div class="separator" style="clear: both; text-align: center;">
</div>
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Here are the remission rates across the four studies that I am focusing on today:</span></div>
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"> </span></div>
<div style="text-align: justify;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_iuhU4gEHd5Cko4o2M_kWmuKcIfxaFq7_caHGQEmmsXuJvA9dO8xFtZqT-8DzhQ89hlfYUulcycMEVxZH8xOjsYl_tIPS1mumAyRbBPGAZ4Mw0P8zlmo73c0I1nV2SRyEcKP0nVwnKEs/s1600/Slide31.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_iuhU4gEHd5Cko4o2M_kWmuKcIfxaFq7_caHGQEmmsXuJvA9dO8xFtZqT-8DzhQ89hlfYUulcycMEVxZH8xOjsYl_tIPS1mumAyRbBPGAZ4Mw0P8zlmo73c0I1nV2SRyEcKP0nVwnKEs/s1600/Slide31.JPG" height="360" width="640" /></a></div>
<div style="text-align: justify;">
<br /></div>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-language: EN-ZA; mso-no-proof: yes;"></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">As early as 1962 Winick used the term “maturing out” in relation to heroin addiction. It is widely accepted that of the illicit drugs heroin is possibly the most difficult to get off, yet the vast majority of heroin addicts will remit from addictive heroin use.</span></div>
<div class="MsoNormal">
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Maturing out is a good phrase. We can see that drug use peaks during the early to mid 20s. These are the results of the National Survey on Drug Use and Health (2011) showing past month usage of illicit drugs:</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghW4TXs3urUzyCmCjhdeZE559AFXghdihxsyEXgJXuw2OfgwPMbd6N96xPwrm7Cu_fX1oGnH34pyzwFTLlmlVxQmXh8gNJfDqDuwqKqtbh1ZKBbsdwo-o5apzj7bh6dMtimtf8V6X8CwI/s1600/Slide32.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghW4TXs3urUzyCmCjhdeZE559AFXghdihxsyEXgJXuw2OfgwPMbd6N96xPwrm7Cu_fX1oGnH34pyzwFTLlmlVxQmXh8gNJfDqDuwqKqtbh1ZKBbsdwo-o5apzj7bh6dMtimtf8V6X8CwI/s1600/Slide32.JPG" height="360" width="640" /></a></div>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-language: EN-ZA; mso-no-proof: yes;"></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">What we know is that in the USA, most people are over their addictive disorder by age 30. This correlates with a time in life when individuals start having to take responsibility for themselves, and when they start getting married or having families.</span></div>
<div class="MsoNormal">
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">I say this because we also know that people over the age of 30 are more likely to suffer from addictive disorders if they are single, divorced or widowed.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br />
<a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">In fact, Gene Heyman calls marriage the antidrug relationship. This data is extracted from the ECA study and reported in Robins and Reiger, 1991, reflects marriage across a range of psychiatric disorders and abuse/dependence:</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8gla7wk_konS-RQ-sAYc9FqhH9Ib-k6N6ZiZ0snndOjyu-AamGreICR57r8qqV0_4lyQAB3-hcJfL8oQq9WbAiOwdnRq-2JF_yc1R9eDN79JaYszZZ5QQhIVth6u2vrtB14JCnIzj-5g/s1600/Slide33.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8gla7wk_konS-RQ-sAYc9FqhH9Ib-k6N6ZiZ0snndOjyu-AamGreICR57r8qqV0_4lyQAB3-hcJfL8oQq9WbAiOwdnRq-2JF_yc1R9eDN79JaYszZZ5QQhIVth6u2vrtB14JCnIzj-5g/s1600/Slide33.JPG" height="360" width="640" /></a></div>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-language: EN-ZA; mso-no-proof: yes;"></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<div class="MsoNormal" style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
</div>
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Ok, now just in case you don’t believe me, let’s look at another study done by the venerable William White. White is one of the most respected and prolific researchers and writers in the field of addiction. In 2012 he did an analysis of 415 scientific reports from 1868 to 2011 on remission rates. This is what he found:</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_2a53_pP2JkmCKL6keL9J7LAXpz-0mgyJudTsCUEZ7DGjgHNeBXhPPr1ZHyHXluzEC9xaB_Jat0kOYh4QysxSGtV_3GQdoy88hYPEPh_AA7du8Ab1IEa4KX-t_y5yCBzJPI9uVzJeWQY/s1600/Slide34.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_2a53_pP2JkmCKL6keL9J7LAXpz-0mgyJudTsCUEZ7DGjgHNeBXhPPr1ZHyHXluzEC9xaB_Jat0kOYh4QysxSGtV_3GQdoy88hYPEPh_AA7du8Ab1IEa4KX-t_y5yCBzJPI9uVzJeWQY/s1600/Slide34.JPG" height="360" width="640" /></a></div>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-language: EN-ZA; mso-no-proof: yes;"></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">So if, in fact, addiction is not a life-long disorder for the vast majority of people, how does this affect our current thinking? Well, for one, it is at odds with the stance of the majority of the treatment population. </span><br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgx3r8X1hFFQgK7A1wXj2RD-htMFs8QSEsMHgberQdowzVSNbEq_7o53Mxng-2EE48NIrcsobLPrwrPiEJzo4mgN-PKprnYMbgFhprw1uB5EGoc4LT57Kaw5vw7Kr59kkfJ4Ke718YRGJs/s1600/Slide35.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgx3r8X1hFFQgK7A1wXj2RD-htMFs8QSEsMHgberQdowzVSNbEq_7o53Mxng-2EE48NIrcsobLPrwrPiEJzo4mgN-PKprnYMbgFhprw1uB5EGoc4LT57Kaw5vw7Kr59kkfJ4Ke718YRGJs/s1600/Slide35.JPG" height="180" width="320" /></a><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">In the words of NIDA: ‘drugs change the brain to foster compulsive drug abuse….[which]if left untreated can last a lifetime”.</span></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Dr Mark Willenbring, while director of research at the National Institute of Alcohol Abuse and Alcoholism says of addiction: “It can be a chronic relapsing disease. But it isn’t usually that.”</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">What we also know is that remission rates vary according to both drug and demographic. So the drugs that are more dependence forming take longer to remit, one would presume, but that is not so. Alcohol takes the longest to remit! Once again this is an indicator of the social context of alcohol use.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">We also know that communities that suffer from greater degrees of psycho-social dislocation through poverty, low employment rates and the like take longer to remit.</span></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The point is though, that the majority of people do remit, and remit before they are in their mid-thirties.</span></div>
<div class="MsoNormal">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj31nhYLCX-hOtMkfXDkN-ZIzRONR0j7tbpmlECcxo7jBEFCdOFKI49pLc2ihSeUJ9jIDiL0qhcTL0pzhj5ymTDIh19tq2e-UCwybiT0PLFjcPEdypKmWZBDwspZIS_VJt2hexUrXG2GlQ/s1600/Slide37.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj31nhYLCX-hOtMkfXDkN-ZIzRONR0j7tbpmlECcxo7jBEFCdOFKI49pLc2ihSeUJ9jIDiL0qhcTL0pzhj5ymTDIh19tq2e-UCwybiT0PLFjcPEdypKmWZBDwspZIS_VJt2hexUrXG2GlQ/s1600/Slide37.JPG" height="180" width="320" /></a></div>
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Myth #3: Addiction is a progressive disorder</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Well, the third piece of mythical folk-law is that addiction is progressive: The longer you use, the less chance you have of recovering. In the rooms of 12-step fellowships we hear statements such as “while you not using your addiction is on steroids in the gym, waiting for you to relapse!”</span></div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Once again, the data does not support this claim. It appears, rather, that the chance of remission remains constant over the course of a person’s substance use career. In the paper <i style="mso-bidi-font-style: normal;">Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: results from the National Epidemiological Survey on Alcohol and Related Conditions</i>, Lopez-Quinteor et al. plot the cumulative frequency of remission as a function of time since the onset of dependence. The proportion of addicted individuals who remit each year remains almost constant:</span></div>
<div style="text-align: justify;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5cZmyox20EGcliOWc7QYt3qbKc37Hq493gQyc8EWj3SlFdWdrl8n21XqKxgc-yIOvosv3ZY6uDvSoliZuLv5AH2KfBECNswpi0Nk3oD-l4YSKbwR52fBZwIhBch6gq0CxCRg6ZCJYI7I/s1600/Slide39.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5cZmyox20EGcliOWc7QYt3qbKc37Hq493gQyc8EWj3SlFdWdrl8n21XqKxgc-yIOvosv3ZY6uDvSoliZuLv5AH2KfBECNswpi0Nk3oD-l4YSKbwR52fBZwIhBch6gq0CxCRg6ZCJYI7I/s1600/Slide39.JPG" height="360" width="640" /></a></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The 12-step notion that the only way out is "jails, institutions and death" is patently false, and if addiction was indeed progressive, we would see remission rates decline sharply over a using career. There is no data to support this.</span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">we could also use the smoking example. Today there are more non-smokers than smokers. We know that nicotine is particularly dependence forming with over 1/3 of users becoming dependent on cigarettes. Smoking careers also tend to be longer, and if addiction was progressive it would be less likely for people to stop smoking, yet we see people stopping smoking at all stages of their using career. </span></div>
</div>
<div class="MsoNormal">
<span style="mso-fareast-language: EN-ZA; mso-no-proof: yes;"></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Myth #4: Abstinence is needed to initiate treatment or achieve </span></b><br />
<div class="separator" style="clear: both; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXlu8sbzPg7bHka6AwBSE7Lksiw89MLNvovZUEvivn_CYo8JrJPb6h6TYFJxQQNwAPentA24bNqpJWlsDMqINIwzdbap3TUOKu4adTD1VRnMNMrsy20jVGIQTRwdkeCIByFsRLjHSsorM/s1600/Slide40.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXlu8sbzPg7bHka6AwBSE7Lksiw89MLNvovZUEvivn_CYo8JrJPb6h6TYFJxQQNwAPentA24bNqpJWlsDMqINIwzdbap3TUOKu4adTD1VRnMNMrsy20jVGIQTRwdkeCIByFsRLjHSsorM/s1600/Slide40.JPG" height="180" width="320" /></a></span></b></div>
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">remission</span></b></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Most treatment approaches start and end with abstinence. They insist that the drugs are the problem, in line with the primary disease hypothesis. Stop the drugs and cure the disease! In reality, most people do not stop drugs by just suddenly becoming abstinent. Only 50% of people who once met the criteria for alcohol dependence actually remit via stopping drinking.</span></div>
<div class="MsoNormal">
<a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The fact is that most addictive disorders, given the right circumstances, are self-curative! If this is the case, surely the role of those helping those suffering from addictive disorders is to help create the right circumstances, rather than take away the only apparent coping mechanism the person has?</span></div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<a href="https://www.blogger.com/blogger.g?blogID=323534899059408543" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Taken to its extreme the abstinence model considers that any form of drug could constitute relapse. For this reason many people who may be on Medication Assisted Treatment are openly or subtly made to feel “less than”.</span></div>
</div>
<div class="MsoNormal">
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">There have been a number of studies around moderation vs. abstinence as goals in drinking. In the one study where problem drinkers where randomly assigned to either an abstinence or moderation treatment goal, those put into the abstinence drank more frequently <span style="mso-no-proof: yes;">(Sanchez-Craig, Annis, Bornet, & MacDonald, 1984)</span>!</span></div>
<div style="text-align: justify;">
<br /></div>
</div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">There is also the experiment done by Mark and Linda Sobell in the 70s that also showed similar results. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">William Miller, the father of motivational interviewing, has conducted a number of long-term studies on individuals who can achieve moderation and those who would struggle. In a study of 140 subjects over a period of a number of years was published in 2003. 99 of the original 140 were located. 5 were dead, 23 were abstinent, 14 were moderate drinkers, 22 subjects were improved but impaired and 30 subjects were unremitted. Only 5 had deteriorated (so much for progressive!)</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeqpyi2O99f2-Bpd4z30a4JmtHV2eE4GNvfgFBQkrUCSI9rShopivI9FavNmYfs3CUBbI-jFQozKw0Uxi5VYxB0b1h0kOGu4erVABcJSOFD5FzP_872kah5q1E_Hn5Ikntvl1I5QgvU5o/s1600/Slide41.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeqpyi2O99f2-Bpd4z30a4JmtHV2eE4GNvfgFBQkrUCSI9rShopivI9FavNmYfs3CUBbI-jFQozKw0Uxi5VYxB0b1h0kOGu4erVABcJSOFD5FzP_872kah5q1E_Hn5Ikntvl1I5QgvU5o/s1600/Slide41.JPG" height="360" width="640" /></a></div>
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-language: EN-ZA; mso-no-proof: yes;"></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">So, we can see that for some people moderation can be achieved, and indeed, for some abstinence would be recommended. However, most treatment programs believe that abstinence is the only way to go. I strongly disagree. An insistence on abstinence keeps people out of treatment. As Dr Andrew Tatarsky of the Center for Optimal Living in New York says “Abstinence may be the goal of treatment, but it is not a prerequisite”.</span></div>
<div class="MsoNormal">
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">There are many people who recover from a heroin use disorder but occasionally indulge in marijuana, or drink socially. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">If all of what I’m saying is true, if the popular beliefs about addiction are wrong, then perhaps we have not gotten our treatment modalities right. I would certainly agree with this. We know that treatment can actually predict worse outcomes than no treatment at all.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">In an article in the <a href="http://www.huffingtonpost.com/stanton-peele/addiction-future_b_866009.html" target="_blank">Huffington Post</a> controversial but remarkably prescient addictions psychiatrist Stanton Peele says:</span></div>
<blockquote class="tr_bq">
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">“Rather than convincing people that they have a lifelong disease and that recovery is all about abstinence, treatment needs to encourage and train people toward belief in themselves and the ability for independent living.”</span></div>
</blockquote>
<div class="MsoNormal">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">So, to summarise:</span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l3 level1 lfo4; text-indent: -18.0pt;">
<ul>
<li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Drugs do not cause addiction: It is a confluence of confounding factors in which drugs may or may not play a role.</span></li>
</ul>
</div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l3 level1 lfo4; text-indent: -18.0pt;">
<ul>
<li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">In most cases addiction is not a life-long disorder: The majority of people recover, with or without treatment.</span></li>
</ul>
</div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l3 level1 lfo4; text-indent: -18.0pt;">
<ul>
<li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Addiction is not progressive: The chance of remission remains constant over the drug using career.</span></li>
</ul>
</div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l3 level1 lfo4; text-indent: -18.0pt;">
<ul>
<li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Abstinence is not always the best approach for treatment: Harm reduction and focusing on underlying conditions is helpful.</span></li>
</ul>
</div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">But all of this is meaningless unless we can translate it intro better policies and more effective treatment modalities. Based on the above, I would say that we would need to make the following changes to our current treatment systems:</span></div>
<br />
<ul>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana;">More outpatient treatment<span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">that helps people learn how to function within their current environment</span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">A less punitive approach to treatment and changes to legal policies</span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Lower barriers to entry into treatment and not insist on abstinence</span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Introduce more harm reduction initiatives so as to ensure that people survive and mitigate the harms during their using days</span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"></span></span></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Make treatment more about problem solving, life-skills and developing healthy relationships than about stopping drugs</span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Greater emphasis on treating comorbidity</span></li>
<li><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The Development of a cumulative continuum based model of treatment that addresses the current treatment needs and can be built on as the goals change.</span></li>
</ul>
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"><br /></span>
<br />
<div style="text-align: justify;">
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">Hopefully by reading what the data actually says, we will be able to better understand addiction and it’s course. By doing so we will be better able to develop meaningful and effective interventions that will actually help, not hinder, the recovery process.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"><span style="font-size: large;"><b>Original Sources and References</b></span> </span><br />
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;">The following are the articles and books from which I have drawn my body of information. Since this was not prepared as an academic article, I have not put specific citations except for the graphs, which are cited on the image. This list is not exhaustive.</span><br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"><!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--></span><br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:View>Normal</w:View>
<w:Zoom>0</w:Zoom>
<w:TrackMoves/>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:DoNotPromoteQF/>
<w:LidThemeOther>EN-ZA</w:LidThemeOther>
<w:LidThemeAsian>X-NONE</w:LidThemeAsian>
<w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:SnapToGridInCell/>
<w:WrapTextWithPunct/>
<w:UseAsianBreakRules/>
<w:DontGrowAutofit/>
<w:SplitPgBreakAndParaMark/>
<w:EnableOpenTypeKerning/>
<w:DontFlipMirrorIndents/>
<w:OverrideTableStyleHps/>
</w:Compatibility>
<m:mathPr>
<m:mathFont m:val="Cambria Math"/>
<m:brkBin m:val="before"/>
<m:brkBinSub m:val="--"/>
<m:smallFrac m:val="off"/>
<m:dispDef/>
<m:lMargin m:val="0"/>
<m:rMargin m:val="0"/>
<m:defJc m:val="centerGroup"/>
<m:wrapIndent m:val="1440"/>
<m:intLim m:val="subSup"/>
<m:naryLim m:val="undOvr"/>
</m:mathPr></w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="false"
DefSemiHidden="false" DefQFormat="false" DefPriority="99"
LatentStyleCount="371">
<w:LsdException Locked="false" Priority="0" QFormat="true" Name="Normal"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 1"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 2"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 3"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 4"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 5"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 6"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 7"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 8"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 9"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 9"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 1"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 2"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 3"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 4"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 5"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 6"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 7"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 8"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 9"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="header"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footer"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index heading"/>
<w:LsdException Locked="false" Priority="35" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="caption"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of figures"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope return"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 6"/>
</w:LatentStyles>
</xml><![endif]--><!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:8.0pt;
mso-para-margin-left:0cm;
line-height:107%;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-fareast-language:EN-US;}
</style>
<![endif]-->
</span><!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><br />
<!--[if gte mso 9]><xml>
<w:WordDocument>
<w:View>Normal</w:View>
<w:Zoom>0</w:Zoom>
<w:TrackMoves/>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:DoNotPromoteQF/>
<w:LidThemeOther>EN-ZA</w:LidThemeOther>
<w:LidThemeAsian>X-NONE</w:LidThemeAsian>
<w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:SnapToGridInCell/>
<w:WrapTextWithPunct/>
<w:UseAsianBreakRules/>
<w:DontGrowAutofit/>
<w:SplitPgBreakAndParaMark/>
<w:EnableOpenTypeKerning/>
<w:DontFlipMirrorIndents/>
<w:OverrideTableStyleHps/>
</w:Compatibility>
<m:mathPr>
<m:mathFont m:val="Cambria Math"/>
<m:brkBin m:val="before"/>
<m:brkBinSub m:val="--"/>
<m:smallFrac m:val="off"/>
<m:dispDef/>
<m:lMargin m:val="0"/>
<m:rMargin m:val="0"/>
<m:defJc m:val="centerGroup"/>
<m:wrapIndent m:val="1440"/>
<m:intLim m:val="subSup"/>
<m:naryLim m:val="undOvr"/>
</m:mathPr></w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="false"
DefSemiHidden="false" DefQFormat="false" DefPriority="99"
LatentStyleCount="371">
<w:LsdException Locked="false" Priority="0" QFormat="true" Name="Normal"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 1"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 2"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 3"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 4"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 5"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 6"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 7"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 8"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 9"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 9"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 1"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 2"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 3"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 4"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 5"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 6"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 7"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 8"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 9"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="header"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footer"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index heading"/>
<w:LsdException Locked="false" Priority="35" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="caption"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of figures"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope return"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 6"/>
</w:LatentStyles>
</xml><![endif]--><!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:8.0pt;
mso-para-margin-left:0cm;
line-height:107%;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-fareast-language:EN-US;}
</style>
<![endif]-->
<br />
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Alexander, B.
(2008). <i>The Globalisation of Addiction: A study in the poverty of spirit.</i>
Oxford: Oxford University Pres.</span><span lang="EN-US" style="font-size: 12.0pt; line-height: 107%; mso-ansi-language: EN-US; mso-no-proof: yes;"></span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Alexander, B. k.
(2010). <i>Demon Drug Myths</i>. Retrieved from Bruce K Alexander:
http://www.brucekalexander.com/articles-speeches/demon-drug-myths/164-myth-drug-induced</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Anderson, K.
(2012). <i>Moderate Drinking, Harm Reduction, and Abstinence Outcomes.</i>
HAMS.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Calabria, B.,
Degenhardt, L., Briegleb, C., Vos, T., Hall, W., Lyskey, M., . . . McLaren, J.
(2010). Systematic Review of prospective studies investigating
"remission" from amphetamine, cannabis, cocaine or opioid
dependence. <i>Addictive Behaviours</i>, 741-749.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Compton, W.,
Thomas, Y., Conway, K., & Colliver, J. (2005). Developments in the
Epidemiology of Drug Use and Drug Use Disorders. <i>American Journal of
Psychiatry</i>, 162:1494-1502.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Conway, K.,
Compton, W., Stinson, F., & Grant, B. (2006). Lifetime comorbidity of
DSM-IV mood and anxiety disorders and specific drug use disorders: results
from the National Epidemiologic Survey on Alcohol and Related Conditions. <i>Journal
of Clinical Psychiatry</i>, 67:247-57.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Gossop, M.,
Marsden, J., Stewart, D., & Kidd, T. (2003). The National Treatment
Outcome Research Study. <i>Addiction</i>, 98:291-303.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Heyman, G. (2009).
<i>Addiction: A disorder of Choice.</i> Cambridge, MA: Harvard university
Press.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Heyman, G. (2013).
Quitting Drugs: Quantitative and Qualitative Feature. <i>Annual Review of
Clinical Psychology</i>, 9:29-59.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Lopex-Quintero,
C., & Perez de los Cobos, J. (2011). Probability and predictors of
remission from life-time nicotine, alcohol, cannabis or cocaine dependence:
results from the National Epidemiologic Survey on Alcohol and Related
Conditions. <i>Addiction</i>, 106(3): 657-669.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Miller, W., &
Wilbourne, P. (2003). Whatever happened to controlled drinking? <i>Alcoholism:
Clinical and Experimental Research</i>, 27:5 Poster.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">NIAAA. (September
2009). <i>NIAAA Spectrum.</i> NIAAA.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Peele, S. (2011,
August). <i>On the Future of Addiction</i>. Retrieved from Huffington Post:
http://www.huffingtonpost.com/stanton-peele/addiction-future_b_866009.html</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Robbins, L.
(1993). The sixth Thomas James Okey Memorial Lecture. Vietnam veterans’ rapid
recovery from. <i>Addiction</i>, 88:1041-54.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Sanchez-Craig, M.,
Annis, H., Bornet, A., & MacDonald, K. (1984). Random assignment to
abstinence and controlled drinking: Evaluation of a cognitive-behavioral
program for problem drinkers. <i>Journal of Consulting and Clinical Psychology</i>,
52:390-403.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">Toneatto, T.,
Sobell, L., Sobell, M., & Rubel, E. (1999). Natural recovery from cocaine
dependence. <i>Psychology of Addictive Behaviour</i>, 13:259-68.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">White, W. (2012). <i>Recovery/Remission
from Substance Use Disorders: An analysis of reported outcomes in 415
scientific reports, 1868-2011.</i> Chicago: Philadelphia Department of
Behavioural Health and Intelectual Disability Services.</span></div>
<div class="MsoNormal">
<br /></div>
<br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"><div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal">
<br /></div>
</span><br />
<span style="font-family: "Verdana","sans-serif"; font-size: 12.0pt; line-height: 107%;"><br /></span></div>
<div class="MsoNormal">
<br /></div>
<!--[if gte mso 9]><xml> <o:OfficeDocumentSettings> <o:AllowPNG/> </o:OfficeDocumentSettings> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves>false</w:TrackMoves> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-ZA</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:EnableOpenTypeKerning/> <w:DontFlipMirrorIndents/> <w:OverrideTableStyleHps/> </w:Compatibility> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="false"
DefSemiHidden="false" DefQFormat="false" DefPriority="99"
LatentStyleCount="371"> <w:LsdException Locked="false" Priority="0" QFormat="true" Name="Normal"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 1"/> <w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 2"/> <w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 3"/> <w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 4"/> <w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 5"/> <w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 6"/> <w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 7"/> <w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 8"/> <w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 9"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 9"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 1"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 2"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 3"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 4"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 5"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 6"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 7"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 8"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 9"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="header"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footer"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index heading"/> <w:LsdException Locked="false" Priority="35" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="caption"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of figures"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope return"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/> <w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/> <w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/> <w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/> <w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/> <w:LsdException Locked="false" Priority="39" Name="Table Grid"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/> <w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" Name="Light List"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" SemiHidden="true" Name="Revision"/> <w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/> <w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/> <w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/> <w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/> <w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/> <w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/> <w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/> <w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/> <w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/> <w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/> <w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/> <w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/> <w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/> <w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/> <w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 4"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 4"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 4"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 5"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 5"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 5"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 5"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 5"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 5"/> <w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 6"/> <w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 6"/> <w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 6"/> <w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 6"/> <w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 6"/> <w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 6"/> <w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 6"/> </w:LatentStyles> </xml><![endif]--><!--[if gte mso 10]> <style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:8.0pt;
mso-para-margin-left:0cm;
line-height:107%;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-fareast-language:EN-US;}
</style> <![endif]--><!--[if gte mso 9]><xml> <o:shapedefaults v:ext="edit" spidmax="1027"/> </xml><![endif]--><!--[if gte mso 9]><xml> <o:shapelayout v:ext="edit"> <o:idmap v:ext="edit" data="1"/> </o:shapelayout></xml><![endif]--><br />Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-87206709510168960342014-09-05T13:43:00.001+02:002014-09-16T22:07:13.399+02:00Injecting Drug Use and Harm Reduction<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKUmB__lbtyOxH6BVIDfKC6NAJhVw_5HO0SiAQiId8ru-DWVxaRMVzfI7xbPegAAYQBXqKTojfwzWv1Qr-OyGFtmVvWO6E536JKuUlDNOT7bOZPoPGpRdPHL-Jvi1sBKQ3SpRW1nE394c/s1600/balloons+2.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKUmB__lbtyOxH6BVIDfKC6NAJhVw_5HO0SiAQiId8ru-DWVxaRMVzfI7xbPegAAYQBXqKTojfwzWv1Qr-OyGFtmVvWO6E536JKuUlDNOT7bOZPoPGpRdPHL-Jvi1sBKQ3SpRW1nE394c/s1600/balloons+2.jpg" height="240" width="320" /></a></div>
<div style="text-align: justify;">
I was recently quoted, along with a colleague and some of our out-reach workers in an article on increased levels of injecting drug use in the Western Cape.</div>
<br />
<div style="text-align: justify;">
The message is important, and unless substitution therapies are introduced it is likely that there will be a significant increase in overdose deaths and a spread in HIV and other infectious diseases.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
This article was originally published on <a href="http://groundup.org.za/article/healthcare-workers-worry-injecting-heroin-increase_2189" target="_blank">Ground Up</a> and then on <a href="http://allafrica.com/stories/201409021208.html?viewall=1" target="_blank">allAfrica</a>. The article is by Ian Broughton, and the photo is by Andrea Schneider.</div>
<h1 class="title" id="page-title">
<span style="font-size: large;">Healthcare workers worry injecting heroin on increase</span></h1>
<div class="field field-name-field-nodesummary field-type-text-long field-label-hidden" style="text-align: justify;">
<div class="field-items">
<div class="field-item even">
Sunday
31 August was International Overdose Awareness Day. Health workers in
Cape Town have warned of a possible increase in drug overdoses and the
spread of infectious diseases, including HIV, if the use of needles to
inject drugs increases.</div>
<div class="field-item even">
<a name='more'></a></div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
This
comes as health workers have noticed drug users turning away from
smoking towards injecting. In response, the TB/HIV Care Association
(THCA) in Observatory are preparing to educate needle using drug users
on the safe use of needles.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Heroin abuse is nothing new in the Western Cape, but injecting
appears to be gaining popularity. Some drug users are also injecting
tik.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
“Although injecting drug use has not been very visible, it does
exist,” says Catherine Williams, a Professional Nurse Counsellor with
THCA. “Professionals in the field, and reports from the drug using
community suggest that it is on the rise.”</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Injecting heroin used to be taboo among coloured users and black
users. This has been a cultural phenomenon for years according to users
and the South African Community Epidemiology Network on Drug Use
(SACENDU).</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
‘Only 11% of coloured heroin patients reported injecting the drug
compared to 83% of white heroin patients’, according to SACENDU’s Phase
34 report back.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Whereas once hardcore addicts chose to smoke their unga on tinfoil
and people who “spiked” the drug were shunned and looked down upon, this
is no longer the rule.</div>
<div style="text-align: justify;">
<blockquote class="pquote">
“It has become like a fashion. So many people I know are using needles now”</blockquote>
</div>
<div style="text-align: justify;">
“It has become like a fashion. So many people I know are using
needles now. A few years ago most addicts thought it was crazy to inject
unga,” says Eugene Beukes, a Woodstock addict who has been injecting
drugs for several years.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Another addict said, “I never thought I would be doing this. I used
to think people who spiked were out of their minds. It used to be only
white people who injected and we always thought they were crazy.”</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
According to the Medical Research council there are an estimated 67,000 people injecting drugs in South Africa.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Figures based only on users seeking help at treatment centres (and
therefore statistics that should be used advisedly), show according
SACENDU that the demographic profile of heroin users in the Western Cape
is changing with coloured users making up 85% of the user population.
In Gauteng, 77% of heroin users were black, a significant increase to
the year before, and in Mpumalanga and Limpopo black users made up 86%
of users compared to 76% the year before.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Injecting heroin increases the chances of death by overdose and the risk of infection with diseases including HIV and Hepatitis.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
One such user, Devon-Lee Zeeman (30) of Summergreens overdosed only a
week after coming out of prison after two and a half years. He was left
to die next to a railway line, deserted by those who had been with him.
His father, Joseph, arrived on the scene after someone came to his
house to tell him his son was lying unconscious next to the railway
line. This was about three hours after he last saw Devon-Lee. Had
someone phoned for help or informed him earlier, his son could have
still been alive.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
“When I found him I noticed his hands were blue and there was a funny noise coming from his mouth,” says Joseph.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
He phoned the paramedics, but it was too late.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
He says his son had been struggling with a drug problem since the age of about 15 and that Devon-Lee had been addicted to unga.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
A few days earlier, he had come home from a night out with friends.
His sister had noticed that his eyes did not look right. When
questioned, Joseph says his son told his sister that a friend had bought
him a drink.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Joseph says he and his son spent the evening before his death
together and the following morning Devon-Lee asked him for R20 for
airtime. This is the price for a bag of unga in many parts of Cape Town.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
South Africa is lagging far behind other countries in dealing with
the problem of needle injecting drug use. THCA works with key
populations who are more at risk of HIV infection. Williams explains
that people who inject drugs have unique health and HIV prevention needs
which have been internationally recognised but have not yet been
effectively met in South Africa.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
“People who inject drugs face many obstacles including stigma from
health care providers as well as profiling by police,” she says. “This
exacerbates the risks faced by this already vulnerable population. With
co-operation from local and national authorities many of the barriers
could be overcome.”</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Williams says that it is vital for people to step up and face this
growing problem. She adds that worldwide there are harm reduction
programmes which have proven to be effective but hardly any such
services are available yet in SA.</div>
<h1 style="text-align: justify;">
Harm reduction</h1>
<div style="text-align: justify;">
Many global health and law enforcement organisations including WHO,
UNAIDS and UN Office on Drugs and Crime recommend a package of services
to reduce the risks of injecting.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The most essential services include needle and syringe programmes,
HIV counselling, testing and treatment with ARVs, and medically assisted
treatment of opioid dependence.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Shaun Shelly, Program Manager: Addiction Services Hope House
Counselling Centre and currently affiliated with the Addictions
Division, Department of Psychiatry and Mental Health, UCT says,
“Currently, evidence for an increase in injecting drug use is anecdotal.
However, we are seeing an increase on the ground, and injecting drug
use is being seen among demographic groups where is wasn’t previously
seen.”</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
“Methadone programs have been running since 1964 and so there has
been a lot of research around them. Consistently they have been shown by
peer-reviewed research to reduce or eliminate the use of heroin, reduce
opioid related mortality and criminality. Importantly, they have also
been shown to reduce the spread of HIV/AIDS and other infectious
diseases. Overall the evidence is extremely strong that these programs
improve the health of both the individual and the community at large.”</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
“The lack of substitution medications such as methadone and
buprenorphine on the essential drugs list is something that urgently
needs to be addressed if we hope to reduce the number of injecting drug
users in the Western Cape.”</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Many harm reduction programs also include overdose awareness and
prevention training for users, their families and first responders such
as firemen and police officers.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
With training in the use of naloxone (an antidote to opioids such as
heroin and codeine), witnesses of overdose can buy time until health
care professionals can provide emergency care.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The South African National Drug Master Plan devotes only two
paragraphs to the subject of harm reduction and states that the term
needs to be defined.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Williams says the definition of harm reduction is well established
and that evidence-based services have been around for 20 years already.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
“We know it works. We would like to see it work in South Africa …
There is a shortage of services for the entire drug using community. For
those who inject drugs existing services are harder to access, and the
recommended HIV prevention package is essentially absent … The
mortality rates among this group are particularly high, and the rate of
infectious diseases is also high. By focusing on this population we
could prevent deaths and the spread of infectious diseases,” says
Williams.</div>
</div>
</div>
</div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-69972232630899768932014-09-02T08:15:00.000+02:002016-01-02T17:11:03.294+02:00August 2014 Newsletter<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLux5ReejXAd07FO4tTIOb9iN-XqKLvTXyE82Qe8QuWWPo_ZmQ9WLEfhTyVChLfEjFgNyAczx4ieF4lLvqIiNQ8_e8BIPfdxzlIF7WL8ywQPiYH1j-ncR5Jjwr2Q7nNM_AF0ZySbU6qIg/s1600/Robin+Williams.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLux5ReejXAd07FO4tTIOb9iN-XqKLvTXyE82Qe8QuWWPo_ZmQ9WLEfhTyVChLfEjFgNyAczx4ieF4lLvqIiNQ8_e8BIPfdxzlIF7WL8ywQPiYH1j-ncR5Jjwr2Q7nNM_AF0ZySbU6qIg/s1600/Robin+Williams.jpg" /></a></div>
The recent death of Robin Williams is incredibly sad. As always, when a celebrity dies, especially when substance use is somehow involved, there is a lot of talk about the dangers of drug use and how addiction so often leads to death. I have a slightly different take on the issue: life long substance use disorders, where there is a constant battle against relapse - are usually the sign of something severe that underlies the SUD.<br />
<br />
In this case, it seems, the monster below the surface was unresolved pathological depression. Of course, that mixed with an alcohol use disorder is a recipe for disaster. But the alcohol is an adjunct - it is both the (temporary) solution, and the (long-term) catalyst. It is not the primary disease.<br />
<br />
I often see how by focusing on the SUD the real pathology is missed. Each relapse brings around renewed focus on the SUD rather than sparking the question: "Well, we know that SUDs die a natural death in most cases, unless there is a contributing factor, this person is not getting better, so what is the contributing factor, and how do we resolve that?"<br />
<br />
It is sad that complex problems get reduced to the simple statement "Oh, he was an alcoholic".<br />
<br />
In this newsletter I bring together some information from different types of addiction and drug use. When put together much of the research seems to be stating the obvious and, in my opinion, addiction looks more like a learning disorder or adaptive process and not a primary disease of the brain. It seems that <a href="http://www.substance.com/most-of-us-still-dont-get-it-addiction-is-a-learning-disorder/9176/" target="_blank">Maia Szalavitz agrees</a> with me.<br />
<br />
We look at Marijuana and brain changes and schizophrenia, methamphetamine and brain changes, porn and brain changes, internet addiction (and brain changes), Tom Hovarth and SMART Recovery, the results of the Global Drug Survey. I hope you enjoy, and please feel free to comment! Please click <a href="http://addictioncapetown.blogspot.com/2014/09/cape-town-recovery-film-festival.html#more" target="_blank">HERE to find out more about the Cape Town Recovery Film Festival 2014</a>.<br />
<br />
<a name='more'></a><br />
<b><span style="font-size: large;">Marijuana Madness!</span></b><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7q0q-8qWzkuegPL2NLs1DVsz6Fas2c3FxOpP8FPcPzWUkO4SRm0JZRz256Qcvy9yLIXkDp5VSbXJIxyWdMlt2SZ4tcBH6EOdU1V_dhCRNAUwgEdBSzxKXkwblLTt9AIY2nWIeyRzauOQ/s1600/10947481_800.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7q0q-8qWzkuegPL2NLs1DVsz6Fas2c3FxOpP8FPcPzWUkO4SRm0JZRz256Qcvy9yLIXkDp5VSbXJIxyWdMlt2SZ4tcBH6EOdU1V_dhCRNAUwgEdBSzxKXkwblLTt9AIY2nWIeyRzauOQ/s1600/10947481_800.jpg" width="221" /></a></div>
<div style="text-align: justify;">
Earlier this year there was a study published in the Journal of Neuroscience entitled <a href="http://www.jneurosci.org/content/34/16/5529.abstract" target="_blank">"Cannabis Use Is Quantitatively Associated with Nucleus Accumbens and Amygdala Abnormalities in Young Recreational Users"</a> and predictably the press went crazy. There followed a spate of alarmist headlines. Reuters reported in a headline that implied certainty that "<a href="http://www.reuters.com/article/2014/04/16/us-usa-marijuana-study-idUSBREA3F04F20140416" target="_blank">Casual pot use causes brain abnormalities in the young:study</a>". Fox News was slightly less certain with their headline <a href="http://www.foxnews.com/health/2014/04/15/casual-marijuana-use-linked-with-brain-abnormalities-study-finds/" target="_blank">"Casual marijuana use linked with brain abnormalities, study finds"</a>. It is embarrasing listening to this cringe-worthy interview with their "expert" who makes some massive leaps in logic.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The study, conducted at Northwest University conducted MRI scans on 20 casual Cannabis users and 20 controls. They conducted three analyses to detect structural differences on the nucleus accumbens and amygdala by looking at gray matter density via voxel-based morphometry, volume and shape. They found (from the abstract): </div>
<blockquote class="tr_bq">
<div style="text-align: justify;">
"Gray matter density analyses revealed greater gray matter density in
marijuana users
than in control participants in the left nucleus
accumbens extending to subcallosal cortex, hypothalamus, sublenticular
extended
amygdala, and left amygdala, even after
controlling for age, sex, alcohol use, and cigarette smoking.
Trend-level effects
were observed for a volume increase in the left
nucleus accumbens only. Significant shape differences were detected in
the
left nucleus accumbens and right amygdala. The
left nucleus accumbens showed salient exposure-dependent alterations
across
all three measures and an altered multimodal
relationship across measures in the marijuana group." </div>
</blockquote>
<div style="text-align: justify;">
and concluded:</div>
<blockquote class="tr_bq">
<div style="text-align: justify;">
"These data suggest
that
marijuana exposure, even in young recreational
users, is associated with exposure-dependent alterations of the neural
matrix
of core reward structures and is consistent with
animal studies of changes in dendritic arborization"
</div>
</blockquote>
<div style="text-align: justify;">
From this one may start thinking that maybe there is a greater-than-observed risk in having the odd joint. However, very soon the study was discredited on many fronts, and one of them from an unexpected source - one of the co-researchers. Although he did not directly criticise the study itself, Dr Jodi Gilman, stated that they did not claim a causitive correlation between canabis use and the observed brain differences. However, if you read the article, this is what they do claim, right up until the second-last paragraph where there is a sudden about-turn.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
But this is not the only problem with this piece of research. Rather than go into it here, I would suggest that you read this <a href="http://liorpachter.wordpress.com/2014/04/17/does-researching-casual-marijuana-use-cause-brain-abnormalities/" target="_blank">great and detailed blog post</a> by <a href="http://math.berkeley.edu/~lpachter/" target="_blank">Professor Lior Pachter</a> of Berkley. The good professor states: "This is quite possibly the worst paper I have read all year......" and then he proceeds to rip it apart on a number of levels.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
So, once again, a badly written and poorly reviewed article combined with a few sensationalist headlines in the popular press will further stigmatise drug users and present the unproven as "fact". </div>
<div style="text-align: justify;">
<br />
<b><span style="font-size: large;">Schizophrenia and Pot</span></b></div>
<div style="text-align: justify;">
Talking of correlation and causation, there has long been heated debate around whether cannabis causes or precipitates schizophrenia. While we know that there is a correlation between schizophrenia, is it causal? <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2005.01070.x/abstract" target="_blank">A previous study</a> has cautiously suggested that the link may be both ways. Many have argued that it is causal, and this has formed one of the arguments against legalisation. Last year a <a href="http://www.schres-journal.com/article/S0920-9964%2813%2900610-5/abstract" target="_blank">Harvard study</a> concluded that the levels of schizophrenia in cannabis users was due to familial risk, and not due to cannabis use.<br />
<br />
Taking things a step further, a recent <a href="http://www.nature.com/mp/journal/vaop/ncurrent/full/mp201451a.html" target="_blank">study in Molecular Psychiatry</a> looked at a sample of 2 082 unrelated healthy males in Australia. The genotype for each individual was obtained. This data was compared with Swedish data which had previously identified a number of Single Nucleotide Polymorphisms that seem to indicate an increased risk of developing schizophrenia.<br />
<br />
In a really clever second part of the study the researchers looked at the genetic risk of 990 twins (approximately 1/3 mono-zygotic) and then predicted whether one or both twins would use cannabis!<br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRlft9PXstajK35Ur4KNirN5aJxlqyYAaeEIho8ZUw9gb0nRoa0CsP8PpVdyyJg4yiAqjywDviFYKIkp-Bh2cGQhE-TiXKgunPoY9xbyN3W38SGIo5VjYF5MsHdVRTTsGrhTOAEeWmXyk/s1600/naturenurture2.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRlft9PXstajK35Ur4KNirN5aJxlqyYAaeEIho8ZUw9gb0nRoa0CsP8PpVdyyJg4yiAqjywDviFYKIkp-Bh2cGQhE-TiXKgunPoY9xbyN3W38SGIo5VjYF5MsHdVRTTsGrhTOAEeWmXyk/s1600/naturenurture2.png" width="180" /></a>A significant association between level of genetic predisposition for schizophrenia and cannabis use was found. Having said this, the genetic risk is a small factor in developing a cannabis habit. What the authors did conclude was: "that to some extent the association between cannabis and schizophrenia
is due to a shared genetic aetiology [cause] across common variants.
They suggest that individuals with an increased genetic predisposition
to schizophrenia are both more likely to use cannabis and to use it in
greater quantities."<br />
<br />
Of course, being a cross-sectional study there are limitations, and the authors also point out a number of other possible confounders and limiters. Interesting though that there were no huge headlines proclaiming "<b>Schizophrenia Causes Cannabis Use!</b>".<br />
<br />
And as for that nature versus nurture debate, it is increasingly becoming clear that it is a false dichotomy.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<b><span style="font-size: large;">Methamphetamine and Cognitive Impairment</span></b><br />
The "controversial" but always thought provoking <a href="http://www.drcarlhart.com/" target="_blank">Dr Carl Hart</a> recently published a <a href="http://www.nature.com/npp/journal/v37/n3/full/npp2011276a.html" target="_blank">critical review on cognitive impairment in methamphetamine users</a>.
Once again the ability to assign causation in cross-sectional studies
comes into question. While Dr Hart certainly has an agenda, as the
recuring themes of his work suggest, he makes some excellent points in
his review of a variety of studies that examine cognitive function in
methamphetamine users. He examines studies in a number of areas: Acute
effects on drug naive and drug accustomed subjects, long-term effects on
current and abstinent drug users, the brain structures and sizes of
currently abstinent methamphetamine users and comprehensive
neuropsychological testing of abstinent abusers.<br />
<br />
While
Hart acknowledges that there are some "brain changes", particularly in
the area of dopamine transporter density in animal studies and that
striatal binding potentials were lower in human subjects, this did not
translate into clinically significant behavioural changes. The same was
found regarding the gray and white matter structural changes observed in
some studies.<br />
<br />
Hart effectively highlights many of the weaknesses in these studies and makes a valid conclusion:<br />
<blockquote class="tr_bq">
"Many
researchers in this area begin with the assumption that methamphetamine
abusers exhibit cognitive dysfunction, and that their research bears
this out. Findings from this review suggest that this assumption should
be reevaluated to document the actual pattern of cognitive effects caused by the drug."</blockquote>
Certainly my experience with treating high dose meth users
is that they do not seem to suffer any long-term cognitive defects, and
certainly there is no problem using cognitive based therapies. There is
some evidence emerging though that shows that cognitive training can
improve outcomes for treatment, although I think we will find this to be
true across all addictive behaviours.</div>
<br />
<div style="text-align: justify;">
Having said that, there is little doubt that drug use changes the brain - as
does virtually everything else, reading, for example - but is this
permanent or as extreme as is believed by many? And who said "change"
was bad? It is this neural plasticity that allows us to learn, grow and
sometimes recover from brain traumas. Is brain change a sign of disease? I don't think so.....</div>
<br />
<b><span style="font-size: large;">Porn and the brain</span></b><br />
<div style="text-align: justify;">
Porn has been in the headlines again...more specifically porn addiction. Something that the DSM5 has deemed not an addiction (at this point in time) but certainly looks like an addiction and shares many neural correlates, as I have previously discussed in two posts: <a href="http://addictioncapetown.blogspot.com/2014/02/the-relationships-of-addiction.html" target="_blank">relationships and addiction</a> and <a href="http://addictioncapetown.blogspot.com/2014/02/the-relationships-of-addiction.html" target="_blank">sexual addiction and drug addiction</a>. Now a study
led by Dr Valerie Voon and <a href="http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0102419" target="_blank">published on PlosOne </a>has shown that when viewing pornography, the brains of sex addicts look remarkably like the
brains of drug addicts. Who would have guessed. Well, quite a few of us
actually.<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVXr-z7M-t3-TuFvxEnbhJUTWVOOBV3fu8CteWkAGxucsQ6tzbCw525JNJ7w8y7ZpZG_eruiiG6RAXTS7dD6Ppj8uTZkzD7pyeq8B76MH05ytRysZ_VaPt7g3ImnNiU9ziP7T2gCYAIV4/s1600/sex-addict1_0.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVXr-z7M-t3-TuFvxEnbhJUTWVOOBV3fu8CteWkAGxucsQ6tzbCw525JNJ7w8y7ZpZG_eruiiG6RAXTS7dD6Ppj8uTZkzD7pyeq8B76MH05ytRysZ_VaPt7g3ImnNiU9ziP7T2gCYAIV4/s1600/sex-addict1_0.jpg" width="320" /></a></div>
</div>
<br />
<div style="text-align: justify;">
Using fMRI, the subject's brains were scanned while watching a series of videos of 5 varying degrees of eroticism and other content. Through self report the researchers tried to quantify subjective experience of "wanting" and "liking". These are important concepts explored by the work of <a href="http://www-personal.umich.edu/~berridge/" target="_blank">Kent Berridge</a>, and the distinction is important in the field of addiction. As predicted, the "wanting" was more important than the "liking" in those that were considered to have compulsive sexual behaviour, and there was greater activation in the "regions implicated in drug cue reactivity studies including the ventral
striatum, dACC and amygdala. We further hypothesized that these regional
activations would be functionally linked across groups but more
strongly in individuals with compulsive sexual behaviour (CSB) as compared to those without, and that
sexual desire (wanting) would be more strongly linked to activity within
these regions in individuals with CSB as compared to those without."</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
So porn addiction is neurologically, to some degree, much like some aspects drug addiction. This to me is obvious because it can easily be seen that the behaviours are really similar, and so one would expect neural correlates. But does it cause cognitive impairment? A recent <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=1874574" target="_blank">German study</a> is speculating a loss of "brain power" in sex addicts due to "over-stimulation of the reward centre".</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Like with many of the methamphetamine studies, the authors found negative association between hours viewing porn per week and <span class="Abstract 0" id="scm6MainContent_ucArticleContent_rptSections_lblSection_0">"gray matter volume in the right caudate (<i>P</i>
< .001, corrected for multiple comparisons) as well as with
functional activity during a sexual cue–reactivity paradigm in the left
putamen (<i>P</i> < .001). Functional connectivity of the right
caudate to the left dorsolateral prefrontal cortex was negatively
associated with hours of pornography consumption."</span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span class="Abstract 0" id="scm6MainContent_ucArticleContent_rptSections_lblSection_0">I wonder what this means for all those hyper-sexual methamphetamine users? Are they doubly cognitively impaired, or is addiction simply addiction with multiple manifestations? </span></div>
<div style="text-align: justify;">
<span class="Abstract 0" id="scm6MainContent_ucArticleContent_rptSections_lblSection_0"><br /></span></div>
<div style="text-align: justify;">
<span class="Abstract 0" id="scm6MainContent_ucArticleContent_rptSections_lblSection_0">It certainly appears so when we look at the rise of internet addiction:</span></div>
<div style="text-align: justify;">
<span class="Abstract 0" id="scm6MainContent_ucArticleContent_rptSections_lblSection_0"><br /></span></div>
<div style="text-align: justify;">
<span class="Abstract 0" id="scm6MainContent_ucArticleContent_rptSections_lblSection_0"><b><span style="font-size: large;">Internet and Gaming Addiction</span></b></span></div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTvm7SqnRTnNTadpAbCHWQjX-aK-MwVpcUybQmnJzOS8QiSt_Ulp34l3zgJM-5ny0HEz-D945uF37XdtTdxqpIo8MN-9ZV5LADOXGu_5H9p3OEnjYCzxiu7YQTovh8KXNGODCqOaJCbgg/s1600/sun2.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTvm7SqnRTnNTadpAbCHWQjX-aK-MwVpcUybQmnJzOS8QiSt_Ulp34l3zgJM-5ny0HEz-D945uF37XdtTdxqpIo8MN-9ZV5LADOXGu_5H9p3OEnjYCzxiu7YQTovh8KXNGODCqOaJCbgg/s1600/sun2.jpg" width="240" /></a></div>
<div style="text-align: justify;">
Gaming and internet addiction also did not make the cut into the DSM5. </div>
<div style="text-align: justify;">
In a recent <a href="http://www.thefix.com/content/video-game-expert-refutes-suns-claim-video-games-are-heroin" target="_blank">Fix article</a> they discussed the Sun's antagonistic headline "Gaming as Addictive as Heroin" and one of the experts consulted for the article refuting the claim. What I find interesting is that the expert, Dr Mark Griffiths of the International Gaming Research Unit at Nottingham Trent University, does not refute the existence of gaming addiction, but that only a minority of problematic game users could be classified as "addicted". I would agree with that.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Where we may differ is that I would argue that the same is true for drug addiction - problematic drug use does not equal addictive drug use, and it is only a small minority of drug users that actually become addicted.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Closely linked with gaming addiction is internet addiction, which is also being shown to change the brain! In a recent <a href="http://www.medscape.com/viewarticle/824600" target="_blank">Medscape Article</a> a paper presented at American Psychiatric Association's 2014 annual meeting is discussed. I could have guessed that internet addiction is linked to a reduction in dopamine transporters. And from a <a href="http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0030253" target="_blank">2012 study</a> "Internet addiction is associated with structural and functional changes in the brain regions involving emotional processing, executive attention, decision making and cognitive control."</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Although internet addiction is looking a lot like other types of addiction, lets hope that treatment doesn't go back to the punitive abstinence based approach that forms the basis of many addiction treatment facilities. It looks like that is the route that the Chinese will be taking if this <a href="https://www.youtube.com/watch?v=jqctG3NnDa0#t=264" target="_blank">New York Times video</a> is anything to go by!</div>
<div style="text-align: justify;">
<br />
<span style="font-size: large;"><b>Tom Horvath and SMART Recovery </b></span><br />
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPKRAD9Tc8lGp85tHDEu42WbKgRcibuk-TyCBTue4KfxmErKfmaX918ZEFE7qM3clN1WbExbxOEGtjLuDLFnhaRgmF4o3WX2UhmNDSsNg0S4qzQ5qa3zk83QB4m9wXEEqSWPIUCceLOZw/s1600/Tom_Horvath1.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPKRAD9Tc8lGp85tHDEu42WbKgRcibuk-TyCBTue4KfxmErKfmaX918ZEFE7qM3clN1WbExbxOEGtjLuDLFnhaRgmF4o3WX2UhmNDSsNg0S4qzQ5qa3zk83QB4m9wXEEqSWPIUCceLOZw/s1600/Tom_Horvath1.jpg" width="145" /></a></div>
Tom Horvath, PhD is strong voice in the field of addiction treatment. Way back in 1985 he founded <a href="http://www.practicalrecovery.com/" target="_blank">Practical Recovery</a> which offers a much-needed alternative to the 12-step models that dominate the treatment field. Anne Fletcher, in her book <a href="http://www.amazon.com/Inside-Rehab-Surprising-Addiction-Treatment/dp/0670025224" target="_blank">Inside Rehab</a>, describes Practical Recovery's approach as completely different from that of other programs.<br />
<br />
Not only is Dr Hovarth the founder and president of Practical Recovery, but he is also president of <a href="http://www.smartrecovery.org/" target="_blank">SMART Recovery</a>, the international nonprofit that offers free, self-empowering, science based mutual help groups for addiction recovery. SMART has over 20 to 30 000 members world-wide. <br />
<br />
In both treatment modalities that Tom oversees the power is vested in the individual - there's no talk of being powerless in the face of addiction. Recently <a href="http://www.smartrecovery.org/meetings_db/view/show_countrysa.php" target="_blank">SMART Recovery</a> has started meetings in Cape Town, and I am hoping that these find traction in my local setting where this type of intervention is much needed.</div>
<br />
<b><span style="font-size: large;">Global Drug Survey Data</span></b><br />
The global drug survey aims to collect data from drug users around the world. It all started 15 years ago as a simple questionaire in a clubbing magazine and has now grown to an international web-based survey.<br />
<br />
Filled with some fascinating pieces of information, such as cocaine was voted the worst value for money drug and MDMA the best, the results of the <a href="http://www.globaldrugsurvey.com/" target="_blank">2014 Global Drug Survey</a> are out. The data was collected from nearly 80 000 self-selected participants around the world. Worth a look even if the sample is not truly representative.<br />
<br />
One of the key messages from the survey was that current drug laws are a barrier to people seeking help for problematic drug use. The Huffington post talks more about this <a href="http://www.huffingtonpost.com/adam-winstock/could-people-who-use-ille_b_5134815.html" target="_blank">issue here</a>.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://capetownrecoveryfilmfestival.com/" target="_blank"><img alt="http://capetownrecoveryfilmfestival.com/" border="0" height="315" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlMQuubW-IByV9UHHD4eZjP6nkkC64e8Oe1Nne_kFtwu4OY4_IClzLWP06MkQZnO_f9D96fbCmey1m24sOikFTTS1WIfycIbmN-DLj7W7uVrX3VbK1eXt0fVrHGCG4ofFMhuWhoRxFe28/s1600/CTRFF+circle++.jpg" width="320" /></a></div>
<br />
<br />
<br />
<br />
<br />
<span id="goog_90476752"></span><a href="https://www.blogger.com/"></a><span id="goog_90476753"></span>Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-36833020075591629902014-03-09T19:26:00.000+02:002016-01-02T17:11:24.429+02:00March 2014 Newsletter<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEia8-uSIP2BfTM4S8icJ-7cbv6x0njSmWzKO6AWyCzWthwJHNJ7P-3SZXLoNJwlWaJphqL8Xx_l-qopPOZwkmX8PZj9YtbG4ox-jycL_ZT2C___WgSNjR9RvTOS7zmNDiu6gWIqgVhLj7w/s1600/Nelson.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEia8-uSIP2BfTM4S8icJ-7cbv6x0njSmWzKO6AWyCzWthwJHNJ7P-3SZXLoNJwlWaJphqL8Xx_l-qopPOZwkmX8PZj9YtbG4ox-jycL_ZT2C___WgSNjR9RvTOS7zmNDiu6gWIqgVhLj7w/s1600/Nelson.jpg" /></a></div>
<div style="text-align: justify;">
It has been a while since the last newsletter. What with holidays, the start of the new academic year, a revamp of the program I run and various other commitments time has been short. I will try to produce at least one newsletter per quarter for 2014, but can't guarantee it! Please feel free to forward any articles you feel should be included.<br />
<br />
It has been a sad time for us in South Africa with the death of Nelson Mandela. Even though this was some months back his presence is very much evident. It is very difficult to explain to those without an intimate knowledge of our history just how much this man has come to symbolise. He is the figurehead that represents the struggle of many other great men, a nation and the political structures he represented. If it was not for the efforts of Mandela and these individuals, the treatment centre I run would not be legal. This is a thought that is truly bizarre, and a sad indictment on those that allowed the apartheid system to flourish under the old regime. We miss Tata Madiba.</div>
<br />
<div style="text-align: justify;">
In the last news letter I spoke about the <a href="http://addictioncapetown.blogspot.com/2013/11/mind-life-xxvii-craving-desire-and.html" target="_blank">Mind & Life Conference</a> on craving, desire and addiction. Well, that is now past, and it was indeed extremely interesting. I have summarised all the presentations, and they can be accessed through this <a href="http://addictioncapetown.blogspot.com/2013/11/mind-life-xxvii-craving-desire-and.html" target="_blank">post here</a>. </div>
<br />
<div style="text-align: justify;">
Due to time constraints this is a shortened newsletter, but I'm sure you will find these articles and subjects as interesting as I have. These include: Addiction as Relationship, Stress and Addiction, Gabapentin, Buprenorphine, Rat Park, Mindfulness and addiction, Mike Ashton, Logical Fallacies.</div>
<a name='more'></a><b><span style="font-size: large;">Addiction as Relationship</span></b><br />
<div style="text-align: justify;">
I have always found this description of addiction useful: "Addiction is a pathological relationship with a substance or activity at the expense of more beneficial relationships". Recently I was asked to give a talk on this subject and you can find it here: <a href="http://addictioncapetown.blogspot.com/2014/02/the-relationships-of-addiction.html" target="_blank">The Relationships of Addiction: Drug is the Love</a>. As with any talk, it is impossible to cover all the bases, so your comments and criticisms would be welcome. </div>
<br />
<b><span style="font-size: large;">Stress and Addiction</span></b><br />
<div style="text-align: justify;">
Many of us are aware of the stress/addiction link. Robinson and Berridge have shown in their lab that there is a sensitization to stress, even after prolonged abstinence from the drug of choice. In 2008 Koob and Le Moal developed the concept of the anti-reward system, which has been hypothesised is a protective mechanism which prevents the excessive activation of the reward system. The negative reinforcement that is viewed by some as the driving force behind the compulsion of late stage addiction is described by Koob and others as the result of "dysregulation of key neurochemical elements involved in the brain stress systems within the frontal cortex, ventral striatum and extended amygdala" in the paper <a href="http://www.ncbi.nlm.nih.gov/pubmed/23747571" target="_blank">Addiction as a stress surfeit disorder.</a> Koob often refers to "the dark side of addiction" and does so again in this paper. Here he looks at the stress system, particularly the extended amygdala and the role of corticotropin releasing factor. The downstream effect is that that there are stress-like responses and a dysphoric state arises.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The article concludes: "brain stress response systems are hypothesized to be activated by acute excessive drug intake, to be sensitized during repeated withdrawal, to persist into protracted abstinence, and to contribute to the development and persistence of addiction. The recruitment of anti-reward systems provides a powerful neurochemical basis for the negative emotional states that are responsible for the dark side of addiction."</div>
<br />
<span style="font-size: large;"><b>Gabapentin and Addiction </b></span><br />
<div style="text-align: justify;">
Following from Koob's work is the conclusion that by reducing stress, we may reduce addictive use and relapse. As we know dysphoria, insomnia and craving all have roles in reinstatement of substance use, particularly alcohol. A study published in the JAMA, <a href="http://archinte.jamanetwork.com/article.aspx?articleid=1764009" target="_blank">Gabapentin Treatment for Alcohol Dependence</a>, describes a randomised clinical trial which shows some promising results: a 45% reduction in heavy drinking for the high-dose group, compared to a 23% reduction for the placebo group, and a 17 vs 4% abstinence level. There appears to be a significant dose-response effect, with those in the lower dose range showing reduced benefits, which is good news.</div>
<br />
<div style="text-align: justify;">
The Gabapentin modulates the levels of GABA in the amygdala, and thereby reduces levels of stress and anxiety. It will be interesting to see the effect on other addictions, which are also easily reinstated through stress. Another plus point is that gabapentin is already freely available as an anticonvulsant and is already used in the primary care setting for pain management, particularly migraines. It is also not metabolised through the liver, but is rather excreted through the kidneys.</div>
<br />
<span style="font-size: large;"><b>Mindfulness and Addiction</b></span><br />
<div style="text-align: justify;">
As a result of the <a href="http://addictioncapetown.blogspot.com/2013/11/mind-life-xxvii-craving-desire-and.html" target="_blank">Mind & Life</a> talks I have been doing some research on mindfulness based interventions in the treatment of addictions. Certainly in my setting I have found these to be useful in the group setting with a particularly difficult and largely forensic and co-morbid population, but I am interested to know if there is a direct effect on substance use. In a <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800788/" target="_blank">2009 systematic review,</a> Zgiersky and others conclude that although Mindful Meditation appears to be safe and there is some preliminary data supporting efficacy, there is little conclusive data for MM as a treatment for addictive disorders. In 2011, Sarah Bowen (<a href="http://addictioncapetown.blogspot.com/2013/11/day-5-mind-and-life-xxvii-craving.html" target="_blank">who also spoke at Mind & Life</a>) drew a similar conclusion when considering <a href="http://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCoQFjAA&url=http%3A%2F%2Fwww.eomega.org%2Fsites%2Fdefault%2Ffiles%2Fresources%2Fsm14-2605-898.requiredreading.pdf&ei=4ZkcU_KAIqWd7QbA8IC4AQ&usg=AFQjCNE-aNssako5jbf8gfOSbOoxbiPX1g&sig2=z4K7AZXlC9o96EWCXgLYWA&bvm=bv.62578216,d.ZGU" target="_blank">mindfulness combined with CBT</a>. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
A very interesting paper that provides more definitive evidence examines mindfulness and smoking. The paper <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3752264/" target="_blank">Brief Meditation Training Induces Smoking Induction</a> hypothesized that a type of mindful meditation, Integrative Mind-Body Training (IMBT), would improve short-term self-control and reduce craving and smoking. This was a randomised control study with a control group who received relaxation therapy. The IMBT group, after 2 weeks of training, there was a 60% drop in smoking. The control group showed no change.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
It is also very interesting in that the study looked at activity in the PFC and ACC prior to intervention and in comparison to a non-smoking control group. As expected, the smokers showed lower activity indicating impaired self-control. After the training, there were marked changes in activity, although in slightly different areas, in the IMBT group, but not in the RT group.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Another very interesting fact is that the subjects who intended to quit showed no significantly better results than those with no intention. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The authors conclude: "Our results to date suggest it may be possible to reduce smoking and
craving, even in those who have no intention to quit smoking. This
low-cost and short-term intervention may influence a common anatomical
pathway to substance abuse and reduce possible risk for drug use in
youth."</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Certainly we need to conduct larger RCTs on mindfulness. </div>
<div style="text-align: justify;">
<br /></div>
<b><span style="font-size: large;">Buprenorphine Hits the Big Times</span></b><br />
Over the last few months there has been more and more mounting research supporting the long-term use of Buprenorphine for the treatment of opioid addiction (<a href="http://addictioncapetown.blogspot.com/p/newsletter-archive.html" target="_blank">see previous newsletters</a>). <a href="http://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html?_r=1&" target="_blank">The New York Times</a> (ok, so maybe the Times in the UK is THE big Times!) featured an article about buprenorphine that received a lot of attention in various addiction forums. The headline "<a href="http://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html?_r=1&" target="_blank">Addiction Treatment With a Dark Side</a>" sets the tone for the article. Although the article is well researched, it distorts many of the "facts".<br />
<br />
<div style="text-align: justify;">
One of these facts is that <i>"A relatively high proportion of buprenorphine doctors have troubled records, a Times examination of the federal “buprenorphine physician locator” found."</i> The implication is, perhaps, that these doctors are little more than glorified drug dealers, but this misses the point that many doctors tend not to choose addiction medicine as they first choice - many have histories of addiction and the corresponding psycho-social and legal problems that come with that.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Another example is the fact that there have been 420 deaths over the last decade where buprenorphine was implicated. This is not off-set by the huge number of lives it has probably saved. Both of these points are covered by to some degree later on in the article, but as we know, most people will never read past the first page when it comes to the internet! </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<a href="http://www.washingtonpost.com/blogs/wonkblog/wp/2013/11/23/this-drug-could-make-a-huge-dent-in-heroin-addiction-so-why-isnt-it-used-more/#!" target="_blank">The Washington Post</a> published an article in response to the New York Times article. It makes some detailed criticisms of the article and is well worth reading.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-size: large;"><b>When to Stop Buprenorphine</b></span></div>
<div style="text-align: justify;">
One of the questions I often hear is "when should someone stop their Buprenorphine?". This is a question that is important, and so I thought I would reference this blog post by Dr Junig who runs the Suboxone Talk Zone website: <a href="http://www.suboxonetalkzone.com/how-and-when-to-stop-buprenorphine-or-suboxone/" target="_blank">How and When to Stop Buprenorphine or Suboxone</a>. I invite any comments about this.<br />
<br />
<b><span style="font-size: large;">Rat Park</span></b><br />
Carl Hart's book, <i><a href="http://www.highpricethebook.com/" target="_blank">High Price</a></i>, and the associated publicity, has brought back into the public eye issues of poverty and how they relate to addiction. Not only the very real plight of financial poverty, but the multiple expressions of financial poverty that lead to a poverty of life experience. This brought me back to the work of Bruce Alexander and his work on environmental influences on self-administration in animal studies. I am eagerly awaiting reading Alexander's book <a href="http://globalizationofaddiction.ca/" target="_blank"><i>Globalization of Addiction</i></a>.<br />
<br />
For those of you not familiar with the Rat Park experiments, I would like to suggest that you take a look at <a href="http://www.stuartmcmillen.com/comics_en/rat-park/" target="_blank">Stuart McMillen's excellent cartoon</a>, which accurately and succinctly describes them. </div>
<br />
<b><span style="font-size: large;">Quote and Personality of the Month: Mike Ashton</span></b><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgABWE2iKHTkbDGpPLAI8Cm_ZslAyp8JzLzkFM9K9vn8ZtOjE42KjmpTY80ih15yuUS4JCBe1WoK5k77DjerEYx-eKIElhu-wYwuTj8TbZYbR6WBib1F6QwVtb0Y3V02WrVJPpXXVBQGk/s1600/mike.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgABWE2iKHTkbDGpPLAI8Cm_ZslAyp8JzLzkFM9K9vn8ZtOjE42KjmpTY80ih15yuUS4JCBe1WoK5k77DjerEYx-eKIElhu-wYwuTj8TbZYbR6WBib1F6QwVtb0Y3V02WrVJPpXXVBQGk/s1600/mike.jpg" width="178" /></a></div>
<div style="text-align: justify;">
I have previously spoken about the <a href="http://findings.org.uk/docs/dmatrix.htm" target="_blank">Drug</a> and <a href="http://findings.org.uk/docs/amatrix.htm" target="_blank">Alcohol</a> Matrices on the <a href="http://findings.org.uk/" target="_blank">Findings website</a>. Mike Ashton is the man behind these fantastic resources. The Matrix is one of the best overviews of Alcohol and Drug use disorders that I have ever seen. I recommend it to everyone in the field, and can safely say if you studied these in depth you would have an excellent understanding of addictive disorders and the best means of treating them.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Each Matrix looks at Harm Reduction, Generic and Cross-cutting Issues, Medical Treatment, Psychosocial Therapies and Safeguarding the Community in each of the areas of Interventions, Practitioners, Management/Supervision/Organisational Functioning and Treatment Systems.</div>
<br />
<div style="text-align: justify;">
Also well worth viewing are the videos of Mike offering his opinion on various addiction related issues, which can be found at <a href="http://www.fead.org.uk/contributor.php?contributorid=9" target="_blank">FEAD</a> (the Film Exchange on Alcohol and Drugs)</div>
<br />
<div style="text-align: justify;">
Mike really stimulates discussion with his regular posts to LinkedIn, and often makes truly insightful and challenging comments about addiction treatment. This is one of his recent comments: </div>
<br />
<blockquote class="tr_bq">
"If it is the case that there is no such thing as 'addiction' as a unitary medical or psychological condition, or even a set of such conditions ('addictions'), then it also makes no sense to construct unitary, standardised responses. This is like developing standard medical responses to the behaviour we recognise as limping. Any number of conditions and combinations of circumstances can lead to this behaviour including being kicked by the doctor, hobbled by prison chains, a cancer, a poorly fitting shoe, or an uneven floor, it may or may not bother the limper in any number of different ways for shorter or longer periods, and what they want done about it, if anything, will similarly vary. We may need a doctor to fix it but we may as easily need a carpenter, a good shoe fitter or a lawyer. The unitary nature of the behaviour does not mean there is a similarly unitary cause or a standard set of responses."</blockquote>
<b><span style="font-size: large;">Logical Fallacies</span></b><br />
In the course of following many of the on-line debates that take place I am becoming very aware of the lack of critical thinking that is happening in the world of addiction. Many so-called facts are, in fact, based on poor evidence and are presented as fact or first principles upon which fallacious arguments are built. For this reason I decided to include this helpful link to help us try and become more critical in our thinking and recognise these <a href="https://yourlogicalfallacyis.com/" target="_blank">logical fallacies</a>. <br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://yourlogicalfallacyis.com/" target="_blank"><img alt="https://yourlogicalfallacyis.com/" border="0" height="451" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFygg9ChKs5WXtD78K_oFiePvmo0gW9LMuC7XW3KMoKLUnQO_tdAF6NpP-HVQyEq2r1Qg-Cmtp3hwRMj5EQ7WaJq9raWaAdhxJKy6hY2yjJRKtWfYa9qg-Q3sNJ4XcJgPXjAfTBDLZULs/s1600/poster.jpg" width="640" /></a></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-5216847748315151782014-02-19T08:56:00.002+02:002015-01-22T21:38:05.637+02:00The Relationships of Addiction<!--[if !mso]> <style>
v\:* {behavior:url(#default#VML);}
o\:* {behavior:url(#default#VML);}
w\:* {behavior:url(#default#VML);}
.shape {behavior:url(#default#VML);}
</style> <![endif]--><i>I would like to thank the ever gracious Marc Lewis for his input and commentary. Please visit Marc's blog site, <a href="http://www.memoirsofanaddictedbrain.com/blog/" target="_blank">Memoirs of an Addicted Brain</a>. Parts of this talk have been taken from my own piece <a href="http://addictioncapetown.blogspot.com/2013/08/a-christian-and-addict-walk-into-meeting.html" target="_blank">A Christian and an Addict Walk Into a Meeting</a></i><br />
<!--[if gte mso 9]><xml> <o:OfficeDocumentSettings> <o:RelyOnVML/> <o:AllowPNG/> </o:OfficeDocumentSettings> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves>false</w:TrackMoves> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-ZA</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:DontVertAlignCellWithSp/> <w:DontBreakConstrainedForcedTables/> <w:DontVertAlignInTxbx/> <w:Word11KerningPairs/> <w:CachedColBalance/> </w:Compatibility> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
DefSemiHidden="true" DefQFormat="false" DefPriority="99"
LatentStyleCount="267"> <w:LsdException Locked="false" Priority="0" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Normal"/> <w:LsdException Locked="false" Priority="9" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="heading 1"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 2"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 3"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 4"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 5"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 6"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 7"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 8"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 9"/> <w:LsdException Locked="false" Priority="39" Name="toc 1"/> <w:LsdException Locked="false" Priority="39" Name="toc 2"/> <w:LsdException Locked="false" Priority="39" Name="toc 3"/> <w:LsdException Locked="false" Priority="39" Name="toc 4"/> <w:LsdException Locked="false" Priority="39" Name="toc 5"/> <w:LsdException Locked="false" Priority="39" Name="toc 6"/> <w:LsdException Locked="false" Priority="39" Name="toc 7"/> <w:LsdException Locked="false" Priority="39" Name="toc 8"/> <w:LsdException Locked="false" Priority="39" Name="toc 9"/> <w:LsdException Locked="false" Priority="35" QFormat="true" Name="caption"/> <w:LsdException Locked="false" Priority="10" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Title"/> <w:LsdException Locked="false" Priority="1" Name="Default Paragraph Font"/> <w:LsdException Locked="false" Priority="11" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" Priority="22" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" Priority="59" SemiHidden="false"
UnhideWhenUsed="false" Name="Table Grid"/> <w:LsdException Locked="false" UnhideWhenUsed="false" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" UnhideWhenUsed="false" Name="Revision"/> <w:LsdException Locked="false" Priority="34" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" QFormat="true" Name="TOC Heading"/> </w:LatentStyles> </xml><![endif]--><!--[if gte mso 10]> <style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-qformat:yes;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:10.0pt;
mso-para-margin-left:0cm;
line-height:115%;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-fareast-language:EN-US;}
</style> <![endif]--> <br />
<div class="MsoNormal">
</div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="MsoNormal">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikcoPukTSGkXXU0DtgmRa8ogbtya4higmPsq5CFmA0qv14vqnIqOubDo0t7oAOc_KSFQAJdgjORq4GPk-52944Cgn12PLXi6fxkge4FvWiQa8XneknelXax_raljtIMSV4qM_OEsV0vIA/s1600/WEB_BM_Love_MAIN.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikcoPukTSGkXXU0DtgmRa8ogbtya4higmPsq5CFmA0qv14vqnIqOubDo0t7oAOc_KSFQAJdgjORq4GPk-52944Cgn12PLXi6fxkge4FvWiQa8XneknelXax_raljtIMSV4qM_OEsV0vIA/s1600/WEB_BM_Love_MAIN.jpg" height="320" width="320" /></a></div>
Those of you who grew up in the eighties will know that Roxy Music had a song called “Love is the Drug”, and indeed, as we shall see, some research shows that being in love is much the same as being in the throes of active addiction. But tonight I want to look at this from another angle as well – addiction as a relationship. This thought started with my looking at a particular definition of addiction:</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;">Addiction is a pathological relationship with a substance or activity at the expense of more beneficial relationships. </i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Now I am very much opposed to the anthropomorphisms that are so common in the addiction field where we often hear about “the disease talking”, but being a child of the 70’s and 80’s I was exposed to Frank Zappa’s rock opera Joe’s Garage where Joe forms an intimate relationship with a household appliance, so maybe my mind has been open to the idea of forming a relationship with inanimate objects – such as drugs, gambling or money!<br />
<i><br /><a href="http://www.memoirsofanaddictedbrain.com/blog/" target="_blank"></a></i></div>
<a name='more'></a><b><span style="font-size: large;">Introduction</span></b><br />
<div class="MsoNormal">
We all have basic relational needs. <a href="http://scholar.google.co.za/scholar_url?hl=en&q=http://www.abebe.org.br/wp-content/uploads/John-Bowlby-Attachment-Second-Edition-Attachment-and-Loss-Series-Vol-1-1983.pdf&sa=X&scisig=AAGBfm2yaRzWf2GAbpiCr3CRWKNO1Ux5Hg&oi=scholarr&ei=A44NU8WGIofD7Abc_ICoAg&ved=0CCcQgAMoATAA" target="_blank">Bowlby</a>, who is known for his attachment theory, says that children need four relational needs to be met in order to grow up with secure attachment: Validation, companionship, the need to have someone “stronger and wiser” to lean on and the need to influence what is happening in the relationship.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I would say that these needs can translate into 3 basic relational needs that we all have<i>:</i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNoSpacing">
<b style="mso-bidi-font-weight: normal;">Spiritual connection</b> </div>
<div class="MsoNormal">
By Spiritual Connection I do not mean in the typical religious sense necessarily, although many people have found this connection in religion, but this could also be a relationship with anything bigger than self that helps inform morals, beliefs, behaviours, ethics and the like. It could be an inner “higher self”: something stronger or wiser to lean on.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNoSpacing">
S<b style="mso-bidi-font-weight: normal;">ocial security</b> </div>
<div class="MsoNormal">
By social security I mean that we want to fit in. We want companionship and validation. We want to belong – even the solitary person identifies themselves with a sub-culture.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNoSpacing">
I<b style="mso-bidi-font-weight: normal;">ndividual significance</b></div>
<div class="MsoNormal">
Individual significance is the search for our place in the universe as an individual – that we are worthy of love, and at the same time we can control our surroundings and environment.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There is a biological imperative to form relationships – after all, no man is an island, or “<i style="mso-bidi-font-style: normal;">to be human is to be in relationship with others”</i><span style="mso-no-proof: yes;">(Erskine, Moursund, & Trautmann, 1999)</span>.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Often it is the breakdown or lack of meaningful relationships that either move the individual towards chaotic substance use or reinforce substance use. Similarly, good relationships can move the individual out of substance use. <span style="mso-spacerun: yes;"> </span>In 1958 epidemiologist William Farr concluded that “Marriage is a healthy estate…The single individual is more likely to be wrecked on his voyage than the lives joined together in matrimony.” Marriage is one of the protective factors when it comes to addictive disorders. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If we look at the large epidemiological studies and the remission rates we find that the majority of people who meet the criteria for substance use disorders “mature out” of these disorders, often as they begin to find social security and individual significance in their interpersonal relationships, jobs, economic status and acceptance of self. For example, if we look at the data from the Epidemiological Catchment Area Survey of 1991 we see that most substance abusers and dependent individuals are not married. The data would seem to indicate that those who are chaotic substance users<span style="mso-spacerun: yes;"> </span>struggle to form enduring relationships with potential life-partners.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEicOtquVqf1C8JHME-E0h69c6GaR3EeT9KkmHtEnpYKrp94Pdn5Bc9RLO_pCF00yckMfkbGitV3O2nJOEay2UQfAUhSIKA-JQkvg4C1x7km19UkgYAw3xbiG4UMcVqyuqdFbBHVCgjrR-s/s1600/Marriage+rates.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEicOtquVqf1C8JHME-E0h69c6GaR3EeT9KkmHtEnpYKrp94Pdn5Bc9RLO_pCF00yckMfkbGitV3O2nJOEay2UQfAUhSIKA-JQkvg4C1x7km19UkgYAw3xbiG4UMcVqyuqdFbBHVCgjrR-s/s1600/Marriage+rates.jpg" height="480" width="640" /></a></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoCaption">
<span style="color: windowtext;"> Figure </span><span style="color: windowtext;"><span style="mso-no-proof: yes;">1</span></span><span style="color: windowtext;">: Married/Single in Psychiatric Disorders</span></div>
<div class="MsoCaption">
<br /></div>
<div class="MsoNormal">
So, can we conceive addictive disorders as a pathological relationship? Let’s start by looking at what happens when we fall in love and how that corresponds with our current understanding of addiction.</div>
<h1>
<span style="font-size: large;">What happens when we fall in love?</span></h1>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i style="mso-bidi-font-style: normal;">Romantic love is mental illness. But it's a pleasurable one. It's a drug. It distorts reality, and that's the point of it. It would be impossible to fall in love with someone that you really saw</i>. </div>
<div align="right" class="MsoNoSpacing" style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-align: right; text-indent: -18.0pt;">
<span style="mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri; mso-hansi-font-family: Calibri;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Frank Liebowitz</div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
Most of us would define love as an emotion. In fact, it is more a type of motivated behaviour. The feelings of love are to be found, neurologically, to be rooted in the limbic reward and motivation systems. When we fall in love, we note a number of profound changes in behaviour. In the paper <i style="mso-bidi-font-style: normal;">“<a href="http://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&ved=0CCsQFjAA&url=http%3A%2F%2Fwww.helenfisher.com%2Fdownloads%2Farticles%2F14defining.pdf&ei=qI4NU-uUOtSy7Abz7oHgDA&usg=AFQjCNFkuwHNnkcep-gO6rX2wYE9_qhXhQ&sig2=egbSSxWkd23ZhAN8KRV7gw" target="_blank">Defining the Brain Systems of Lust, Romantic Attraction and Attachment</a>”</i>, Fisher, Aron and others describe 13 psychophysiological<span style="mso-spacerun: yes;"> </span>characteristics commonly associated with romantic love, and it is clear to see how these are mirrored in addictive disorders. </div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNormal">
To summarise, when we fall in love, the object of affection takes on an undue importance. There is increased salience attribution and a corresponding decline of interest in the things that were once important to us; we focus only on the positive aspects, ignoring the negative. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We know the profile of a person in love: They forget to eat, they focus all their attention on their new-found lover, ignore their friends, miss appointments; they spend undue amounts of time and money on the object of their desire. They do things they would never consider doing in their “sane” state. Sounds like they’re addicted but they are simply in love, a very human condition that makes us seem to take leave of our senses. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Helen Fisher, who has conducted a number of studies, including the one quoted above, is one of the foremost authorities on romantic love and has turned this into fame and fortune through the dating websites match.com and chemistry.com. She says: “Romantic love is an addiction. It’s a very powerfully wonderful addiction when things are going well and perfectly horrible when things are going poorly”</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Neurobiologically there is impaired decision making ability in the pre-frontal cortex. There are brain changes taking place. There is the age-old battle between the limbic system and the executive branch! Serotonin levels drop which leads to intrusive thinking around the object of love. Dopamine increases and focuses attention.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Fisher and Aaron also studied relationship breakups using fMRI scans to see exactly where there was brain activity. Part of this study was to examine the obsessive thinking that is so often part of romantic break-ups. The researchers concluded: <span style="mso-spacerun: yes;"> </span>“The specific findings are significant because they tell us that the basic patterns seen in previous studies of happy love share key elements with love under these circumstances; they also tell us that what is unique to romantic rejection includes elements that are very much like the craving for cocaine.”</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Nietsche wrote “<i style="mso-bidi-font-style: normal;">There is always some madness in love. But there is always some reason in madness</i>.” </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And that reason, it has been proposed by Fisher and others, is because of the evolutionary need to find a mating partner and stay connected with that partner until the off-spring can develop some level of self-sufficiency.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Interestingly not many mammals form monogamous relationships. However, prairie voles do, and so their pairing and mating habits have been studied fairly extensively. In a paper by <a href="http://www.ncbi.nlm.nih.gov/pubmed/22885871" target="_blank">Burkett and Young </a>they state: </div>
<br />
<blockquote class="tr_bq">
<div class="MsoNoSpacing">
“<i>There is an exceptionally strong parallel between these plastic changes from pair bonding and the plastic changes seen in drug addiction. As D1 Receptors are upregulated during pair bonding and D2 Receptor are stable, this plastic change represents an alteration in the balance of D1R/D2R signalling in the striatum in favour of D1R, similar to what is seen in human PET studies of drug addiction” </i></div>
</blockquote>
<br />
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
The paper goes on to explain the similarities between pair bonding and addictive disorders in terms of the endogenous opioid system and the complex interaction with dopamine, <b style="mso-bidi-font-weight: normal;">C</b>orticotropin <b style="mso-bidi-font-weight: normal;">R</b>eleasing <b style="mso-bidi-font-weight: normal;">H</b>ormone, oxytocin and arginine vasopressin. They also have a really interesting table in the paper that shows the parallels between Social Attachment, Maternal Attachment and Drug Addiction, which is worth a look if you are interested, but is outside the scope of this talk.</div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
Burkett and Young conclude: </div>
<br />
<blockquote class="tr_bq">
<div class="MsoNoSpacing">
<i>“These data also provide evidence for the theory that social attachment systems governing maternal bonding and pair bonding to a mating partner are subverted by drugs of abuse to create addictions that are just as powerful as natural attachments. In a very real sense, we may be addicted to the ones we love.”</i><span style="mso-spacerun: yes;"> </span></div>
</blockquote>
<br />
<div class="MsoNormal">
So relationships can be a form of addiction, or even a barrier to developing other kinds of addictions. As we know by curing one addictive behaviour, we may precipitate another. Indeed, the breakdown of romantic relationships can lead to the development of addictive disorders. As Lance Dodes, author of “Heart of Addiction” says “<i style="mso-bidi-font-style: normal;">addictive acts occur when precipitated by emotionally significant events</i>.”</div>
<h1>
<span style="font-size: large;">Addiction as Love/Relationship/Attachment</span></h1>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i style="mso-bidi-font-style: normal;">Never fall in love with a person with a substance abuse problem because that drug will always be the other woman. </i></div>
<div align="right" class="MsoNormal" style="text-align: right;">
– Unknown</div>
<div class="MsoNormal">
The title of the 14<sup>th</sup> Chapter of Dr Gabor Mate’s book “In the Realm of Hungry Ghosts” is “Through the Needle a Soft Warm Hug”. He is obviously talking about IV heroin use. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Lance Dodes writes:<span style="mso-spacerun: yes;"> </span>“For others, taking a drug or eating or gambling substitutes for a loved person whom they have lost. They make, in effect, a new relationship with the bottle or the racing track, a relationship that they never have to lose. “</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Typically one may be inclined to think of drug use as correlating with lust or sexual desire. While there is certainly overlap, addiction is more closely related to romantic love and desire. If you are familiar with the term salience attribution, or motivational wanting, you will most likely be familiar with the work of Kent Berridge and his lab. Berridge has done ground-breaking work in demonstrating that liking and wanting are two distinct states of mind. He also points out that the areas of the brain linked to pleasure are rather small while the areas linked to desire take of a lot more real estate.<span style="mso-spacerun: yes;"> </span>As humans we are driven by desire. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
One of the major questions in the addiction field is “why do people keep using after it stops being pleasurable?”</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>Marc Lewis, the developmental neuroscientist and author of the book “<a href="http://www.memoirsofanaddictedbrain.com/" target="_blank"><i style="mso-bidi-font-style: normal;">Memoirs of an Addicted Brain</i></a>” and I have discussed this issue at some length. We both believe that this apparent paradox can be resolved when we move beyond the reductionist disease paradigm and acknowledge that addiction can be viewed as human attachment.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Early drug use can be compared to that initial period of romance in relationships, and the problems are easily overlooked. Some users are able to end the relationship before it becomes too destructive. But others come to depend on the relationship and find the possible pain of separation greater than the consequences of continued substance use. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The substances become a form of intimacy regulator, and feed into the avoidance of other forms of communication and create a pathological homeostasis of unresolved loss. There is an aspect of continuity in the addictive relationship that gives identity, a certainty of temporary escape from the tragic feelings of loss of true relational connection. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As an interesting aside, the work of Harvard Sociologist Lee Rainwater has shown that in economically disadvantaged areas people are more likely to try and meet their relational needs through a relationship with a substance or behaviour, while the middle-class look towards emotional attachment with other people for self-gratification.</div>
<h1>
<span style="font-size: large;">The Role of sub-culture and Religion</span></h1>
<div class="MsoNormal">
Beyond the search for individual significance through direct relationships, many people also derive their sense of social security from the sub-culture that they enter when using drugs. Even the solitary heroin user derives some sort of collective identity from his choice of heroin. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
William White has examined the complex and diverse roles that individuals play within this drug culture in his book “Pathways: From the Culture of Addiction to the Culture of Recovery: A travel Guide for Addiction Professionals”. Indeed the drug culture provides a place of refuge and social significance for many.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If we look at the need for spiritual connection we can also find that these needs can be met by the addiction. Dr Richard Wilmott, author of “American Euphoria: Saying “Know” to drugs” recently posted this provocative statement:</div>
<br />
<blockquote class="tr_bq">
<div class="MsoNormal">
<span class="usercontent">“Today one of the main criteria for a diagnosis of drug addiction/alcoholism is: continuing to consume alcohol or another drug “despite unpleasant or adverse consequences” (DSM). For the Christian martyrs the same criteria would apply. People of that time and place—Rom</span><span class="textexposedshow">e, 2nd century A.D.—could also say that this new Christianity was like a drug that endangered lives and that being a Christian had all the adverse financial, social, psychological and physical consequences that we now see in the lives of drug addicts and alcoholics. And yet Christians, of all ages, in spite of the consequences, continued to profess their faith… and continued to be eaten by lions………… </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="textexposedshow">Likewise, given contemporary social policy, adverse consequences befall those who abuse drugs. They lose the respect of their peers; they violate the expectations of family, friends, and colleagues; they miss out on educational opportunities; they have poor work performance and lose their job. They make harmful decisions. They "burn their bridges". Their health suffers; they have overdoses, and they die. </span><br />
<br />
<span class="textexposedshow">None of these predictions are of consequence to most “addicts”. Like the Christians who suffered and died for their faith, the addict has also made a choice… to lose everything for the “faith” in the euphoria of the drug experience. In this light it is not difficult to understand that the main treatment for alcoholics and addicts in America is religion as promulgated through the faith based AA Twelve Step programs.”</span></div>
</blockquote>
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="textexposedshow">Marx’s statement that “religion is the opiate of the masses” comes to mind. It forces us to ask the question: “Is the desire for spiritual connection somehow met by the drug use and drug culture”?</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The controversial field of neurotheology seeks to examine the changes in neurobiology caused by the religious commitment that could result in the choice of death over renunciation, or, similarly, the pre-existence of structural brain differences that may pre-dispose the individual towards such commitment. The reductionist or materialist point of view is that religious experience is nothing more than the results of predetermined neural activity that arises as a result of genetic, ecological and/or evolutionary pre-disposition. Similar views are held regarding the field of addiction by Volkow, Leshner and many others.<br />
<br />
In his book <i>The God Gene: How Faith is Hardwired into our Genes, </i>Hamer proposes that a variation in a gene known as VMAT2 is the "God Gene", and through the effect of this gene on dopamine, serotonin and norepinephrine we are hard-wired for transcendence. Anyone with even a basic knowledge of addiction neuroscience will recognise the same monoamines mentioned as being amongst the usual suspects in addictive disorders. Indeed they are closely linked to the motivational and reward system.<br />
<br />
William White in an essay entitled <i>The Role of Spirituality in Substance Abuse Prevention</i>, describes spirituality: "A heightened state of perception, awareness, performance or being that personally informs, heals, empowers, connects, centers or liberates". Once again, this sounds like drug use to me, although for those suffering from addictive disorders the drug often reveals itself to be an imposter, in much the same way as the abusive marriage partner reveals their true nature.</div>
<div class="MsoNormal">
So we can see that love can be conceived as addiction, addiction can be conceived as attachment or relationship and that addictive behaviours can conceivably satisfy the three relational needs.</div>
<h1>
<span style="font-size: large;">Informing Treatment</span></h1>
<div class="MsoNormal">
All this conjecture, in my mind, is only of importance if it can inform treatment. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
One of the most important predictors of success in addiction treatment is indeed the therapeutic bond. Research tells us that the mode or model of therapeutic intervention is less important than the relationship the patient develops with the therapist and facility. The SAMHASA registry of Evidence-Based Practices states:</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-indent: -36.0pt;">
•<span style="mso-tab-count: 1;"> </span>The development of a good alliance is essential for the success of psychotherapy, regardless of the type of treatment. </div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-indent: -36.0pt;">
•<span style="mso-tab-count: 1;"> </span>The ability of the therapist to bridge the client’s needs, expectations, and abilities into a therapeutic plan is important in building the alliance. </div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-indent: -36.0pt;">
•<span style="mso-tab-count: 1;"> </span>Because the therapist and client often judge the quality of the alliance differently, active monitoring of the alliance throughout therapy is recommended. </div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-indent: -36.0pt;">
•<span style="mso-tab-count: 1;"> </span>Responding nondefensively to a client’s hostility or negativity is critical to establishing and maintaining a strong alliance. </div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-indent: -36.0pt;">
•<span style="mso-tab-count: 1;"> </span>Clients’ evaluation of the quality of the alliance is the best predictor of outcome; however, the therapist’s input has a strong influence on the client and is therefore critical.</div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal">
It has been said that in the case of those recovering from addictive disorders the therapist becomes the subject of primary attachment. For this reason ethical/boundary issues are extremely difficult to manage in the treatment of addictive disorders. Certainly in our outpatient program we have found that people form a relationship with the centre, the therapist and the community. It is, in my opinion, vital that this is recognised and be maximised as part of the transient process where the individual patient is encouraged to shift their primary relationship from the drug/culture to the treatment providers and peers, and then on to meaningful external relationships. Unfortunately we often find that the relationship does not grow beyond the therapeutic setting, and therefor as soon as this new supportive relationship is not available, a fall-back to the old relationship, or relapse, is inevitable.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I would say that the “success” of programs such as the 12-step programs does not lie primarily in the process, but rather in the relationships that the addicted person is able to form. To find Individual significance even with the “addict” identity by saying “my names Shaun and I’m an addict”, to find social security in the group, and to find spiritual connection in the "higher power" are for me far more compelling factors in the recovery process than dubious concepts such as “powerlessness”, “denial” and “the disease”.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Similarly we see that “spiritual awakening” can precipitate an almost instant miracle cure for addictive disorders – as Jung has stated “Spritus contra spiritum”, or in the view of William James "The only cure for dipsomania is religiomania." Obviously, in the majority of cases, these awakenings are not Damascus road experiences like Paul’s where it’s only God and the individual, but rather there is a church structure that becomes the new system – satisfying the relational needs on many levels, with the addict experiencing the new identity as the prodigal son, the social security of a non-judgemental community who provide encouragement and the new found spiritual connection with God. <span style="mso-spacerun: yes;"> </span>By finding a new identity in religion the three basic relational needs are met and separation from the drug is less painful, or at least manageable.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Now I’m not suggesting that we send everyone to Church! What I am suggesting is that we need to be cognisant of the importance of the sense of relational loss that occurs when someone decides to leave their drug of choice. <span style="mso-spacerun: yes;"> </span>In the words of Alison Wilson Shaeff: “something that required the best of you has ended. You will miss it.”</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We need to be acutely aware of how we as treatment professionals, both individually and as a collective in the treatment setting, become the focus of attachment and the meters of relational need as the patient divorces their addiction. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In the words of Gabor Mate:</div>
<div class="MsoNormal">
<span class="usercontent">"When my patient addicts look at me, they are seeking the real me. Like children, they are unimpressed with titles achievements, worldly credentials. Their concerns are too immediate, too urgent.........</span><span class="textexposedshow0">What they care about is my presence or absence as a human being. They gauge with unerring eyes whether I am grounded enough on any given day to coexist with them, to listen to them as persons with feelings, hopes and aspirations that are as valid as mine. They can tell instantly whether I am genuinely committed to their well-being or just trying to get them out of my way. Chronically unable to offer such caring to themselves, they are more sensitive to its presence or absence in those charged with caring for them."</span></div>
<h1>
<span style="font-size: large;">Conclusion</span></h1>
<div class="MsoNormal">
So I would like to conclude by suggesting that maybe our patients need less addiction counselling and more counselling relationship; and, perhaps, some relationship counselling.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<!--[if gte mso 9]><xml> <o:OfficeDocumentSettings> <o:RelyOnVML/> <o:AllowPNG/> </o:OfficeDocumentSettings> </xml><![endif]--></div>
<br />
<div class="MsoNormal">
<!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-ZA</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:DontVertAlignCellWithSp/> <w:DontBreakConstrainedForcedTables/> <w:DontVertAlignInTxbx/> <w:Word11KerningPairs/> <w:CachedColBalance/> </w:Compatibility> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
DefSemiHidden="true" DefQFormat="false" DefPriority="99"
LatentStyleCount="267"> <w:LsdException Locked="false" Priority="0" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Normal"/> <w:LsdException Locked="false" Priority="9" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="heading 1"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 2"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 3"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 4"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 5"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 6"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 7"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 8"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 9"/> <w:LsdException Locked="false" Priority="39" Name="toc 1"/> <w:LsdException Locked="false" Priority="39" Name="toc 2"/> <w:LsdException Locked="false" Priority="39" Name="toc 3"/> <w:LsdException Locked="false" Priority="39" Name="toc 4"/> <w:LsdException Locked="false" Priority="39" Name="toc 5"/> <w:LsdException Locked="false" Priority="39" Name="toc 6"/> <w:LsdException Locked="false" Priority="39" Name="toc 7"/> <w:LsdException Locked="false" Priority="39" Name="toc 8"/> <w:LsdException Locked="false" Priority="39" Name="toc 9"/> <w:LsdException Locked="false" Priority="35" QFormat="true" Name="caption"/> <w:LsdException Locked="false" Priority="10" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Title"/> <w:LsdException Locked="false" Priority="1" Name="Default Paragraph Font"/> <w:LsdException Locked="false" Priority="11" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" Priority="22" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" Priority="59" SemiHidden="false"
UnhideWhenUsed="false" Name="Table Grid"/> <w:LsdException Locked="false" UnhideWhenUsed="false" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" UnhideWhenUsed="false" Name="Revision"/> <w:LsdException Locked="false" Priority="34" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" QFormat="true" Name="TOC Heading"/> </w:LatentStyles> </xml><![endif]--><!--[if gte mso 10]> <style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-qformat:yes;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:10.0pt;
mso-para-margin-left:0cm;
line-height:115%;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-fareast-language:EN-US;}
</style> <![endif]--> </div>
<h1>
<span style="font-size: large;">Bibliography</span></h1>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Acevedo, B., Aron, A., Fisher, H., & Brown, L. (2011). Neural correlates of long-term intense romantic love. <i>Social Cognitive and Affective Neuroscience</i> , 1-15.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Burkett, J., & Young, L. (2012). The bahavioural, anatomical and pharmacological parallels between social attachment, love and addiction. <i>Psychopharmacology</i> , 244:1-26.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Earp, B., Wudarczyk, O., Foddy, B., & Savulesca, J. (n.d.). Addicted to Love: What is love addiction and when should it be treated? <i>Under Review</i> .</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Emanuele, E., Bertona, M., Minoretti, P., & Geroldi, D. (2010). An open trial of L-%-Hydrotryptophan in subjects with romantic stress. <i>Activitas Nervosa Superior Rediviva</i> , 52(2):147-150.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Erskine. (2011). Attachment, Relational-Needs and Psychotherapeutic Pressence. <i>International Journal of Integrative Psychotherapy</i> , 10-18.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Erskine, R., Moursund, J., & Trautmann, R. (1999). <i>Beyond Empathy: A Therapy of contact-in-relationship.</i> Philadelphia: Brunner/Mazel.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Fisher, H., & Thomson, A. (2006). Lust, Romance, Attachment: Do the side effects of seratonine-enhancing antidepressants jeopardize romantic love, marriage and fertility? In Platek, Keenan, & Shackelford, <i>Evolutionary Cognitive Neuroscience</i> (pp. 245-283). London: The MIT Press.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Fisher, H., Aron, A., & Brown, L. (2005). Romantic Love: an fMRI study of a neural mechanism of mate choice. <i>The Journal of Comparative Neurology</i> , 493:58-62.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Fisher, H., Aron, A., Mashek, D., Li, H., & Brown, L. (2002). Defining the Brain Systems of Lust, Romantic Attraction and Attachment. <i>Archives of Sexual Behaviour</i> , 413-419.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Fisher, H., Brown, L., Aron, A., Strong, G., & Mashek, D. (2010). Reward, Addiction and Emotion Regulation Systems Associated With Rejection in Love. <i>Journal of Neurophysiology</i> , 104:51-60.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Langeslag, S. (2009). Is the serotonergic system altered in romantic love? A literature review and research suggestions. <i>hdl.handle.net/1765/16690</i> .</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Maloy, J., & Fisher, H. (2005). Some thoughts on the neurobiology of stalking. <i>Journal of Forensic Sciences</i> , 50(6):1472-80.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Meier, P., Barrowclough, C., & Donmall, M. (2005). The role of therapeutic alliance in the treatment of substance use disorders: A critical review of the literature. <i>Addiction</i> , 100(3):304-16.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Miller, W. (1998). Researching the spiritual dimensions of alcohol and other drug problems. <i>Addiction</i> , 93(7): 979-990.</span></div>
<div class="MsoBibliography">
<br /></div>
<div class="MsoBibliography">
<span style="mso-no-proof: yes;">Peele, S., & Brodsky, A. (1974, August). Love can be an addiction: Interpersonal Heroin. <i>Psychology Today</i> , pp. 22-26.</span></div>
<div class="MsoNormal">
<br /></div>
<br />
<br />
<br />
<div class="MsoNormal">
<br /></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-82097447018376125582013-11-14T20:37:00.001+02:002013-11-18T14:56:23.905+02:00Mind & Life XXVII - Craving, Desire and Addiction<div class="separator" style="clear: both; text-align: center;">
</div>
<div style="text-align: justify;">
The <a href="http://www.mindandlife.org/" target="_blank">Mind & Life Institute</a> is an initiative<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCvIOMtKC2-yKMo35jPqx9QzptzJKPt_9xm_VvLCH06AjEpPb3KLXQBCxqKLzO8UBgIjMe6VPn4wJhpRJEXUOPDLUeN-wDd3EIgXmCL2G_BfYN2MIPwdnOM0kX6sVCHkMxAoX2JY6Ksg0/s1600/Mind.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCvIOMtKC2-yKMo35jPqx9QzptzJKPt_9xm_VvLCH06AjEpPb3KLXQBCxqKLzO8UBgIjMe6VPn4wJhpRJEXUOPDLUeN-wDd3EIgXmCL2G_BfYN2MIPwdnOM0kX6sVCHkMxAoX2JY6Ksg0/s1600/Mind.jpg" /></a> that aims to alleviate suffering and promote human flourishing. They aim to bring together scientists, contemplatives and scholars to deepen our understanding of the causes of suffering. </div>
<br />
<div style="text-align: justify;">
Part of their strategy is to hold dialogues with His Holiness the Dalai Lama. This years dialogue focused on craving, desire and addiction. A group of scholars from the fields of neuroscience, Buddhism, Christianity, psychology, psychiatry and the social sciences gathered at Dharamsala to share their ideas and gain a deeper understanding of addiction.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The speakers were: Marc Lewis, Kent Berridge, Thupten Jinpa, Nora Volkow, Vibeke Asmussen Frank, Matthieu Ricard, Wendy Farley and Sarah Bowen. Brief biographies and their topics, as well as the program, can be <a href="http://www.mindandlife.org/wp-content/uploads/2013/10/MindAndLifeXXVII-Program-web-version.pdf" target="_blank">downloaded here</a>.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
I have watched each of the talks and summarised them. None of this is my original work, but rather was done so that I can have a reference for myself, and I have made this available to you simply to help you choose which talks you may wish to watch in full and for academic purposes. All the videos are available in their <a href="http://dalailama.com/webcasts/post/300-mind-and-life-xxvii---craving-desire-and-addiction" target="_blank">entirety here</a>. My summaries can be seen by clicking on the days below:</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<a href="http://addictioncapetown.blogspot.com/2013/11/day-1-mind-life-xxvii-craving-desire.html" target="_blank">Day One</a><br />
Marc Lewis - Craving, Dopamine and the Cycle of Addictive Behaviour </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<a href="http://addictioncapetown.blogspot.com/2013/11/day-2-mind-and-life-xxvii-craving.html" target="_blank">Day Two </a><br />
Kent Berridge - Brain Generators of Intense Wanting and Liking</div>
<div style="text-align: justify;">
Thupten Jinpa - Psychology of Desire: A Buddhist Perspective</div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
<a href="http://addictioncapetown.blogspot.com/2013/11/day-3-mind-and-life-xxvii-craving.html" target="_blank">Day Three </a><br />
Nora Volkow -The Role of Dopamine in the Addicted Human Brain </div>
<div style="text-align: justify;">
Vibeke Asmussen Frank - Beyond the Individual: The Role of Society and Culture in Addiction.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<a href="http://addictioncapetown.blogspot.com/2013/11/day-4-mind-and-life-xxvii-craving.html" target="_blank">Day Four</a><br />
Matthieu Ricard - From Craving to Freedom and Flourishing: Buddhist Perspectives on Desire </div>
<div style="text-align: justify;">
Wendy Farley - Contemplative Christianity, Desire and Addiction. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<a href="http://addictioncapetown.blogspot.com/2013/11/day-5-mind-and-life-xxvii-craving.html" target="_blank">Day Five</a><br />
Sarah Bowen - Application of Contemplative Practices in Treatment of Addiction </div>
<div style="text-align: justify;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEipZCFuU-QRwiW6TDSwwqhZp7X4Ob-r8MwhrOQNyVsmpanWhlfa8HHRVjQQtIY4H1AxSty4r4oh1qY_MYkYMMiKLuCf7CAqC920qRNOdFnlDz295tCEL3xPPOQ47ig7wxc5KOoJLkFIdkA/s1600/Mind+Life+27.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEipZCFuU-QRwiW6TDSwwqhZp7X4Ob-r8MwhrOQNyVsmpanWhlfa8HHRVjQQtIY4H1AxSty4r4oh1qY_MYkYMMiKLuCf7CAqC920qRNOdFnlDz295tCEL3xPPOQ47ig7wxc5KOoJLkFIdkA/s1600/Mind+Life+27.jpg" /></a></div>
<div style="text-align: justify;">
<br /></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-91959277117097589042013-11-14T19:48:00.000+02:002013-11-18T15:01:06.370+02:00Day 5 - Mind and Life XXVII - Craving, Desire and Addiction<div style="text-align: left;">
</div>
<div style="text-align: right;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfReLTBQbSWAPYFfIDXVU53JR-ahdxk08BJd8yy32VbS4sY5d9kbQyDgK8LF_UaHXLaENavMqFVS4Z5zbVTJ4mBP77JgCivF7Hvq4xDe0jZFvGCrPmP6z0GJCWiDkhYW1z8CctePyy-uI/s1600/Sarah+Bowen.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfReLTBQbSWAPYFfIDXVU53JR-ahdxk08BJd8yy32VbS4sY5d9kbQyDgK8LF_UaHXLaENavMqFVS4Z5zbVTJ4mBP77JgCivF7Hvq4xDe0jZFvGCrPmP6z0GJCWiDkhYW1z8CctePyy-uI/s1600/Sarah+Bowen.jpg" /></a></div>
<i>You can <a href="http://dalailama.com/webcasts/post/300-mind-and-life-xxvii---craving-desire-and-addiction" target="_blank">view the videos here</a>.</i><br />
<div style="text-align: justify;">
<i>The point of this summary is not to replace the complete video and nor is it fully comprehensive, but rather the intention is to give a brief overview of proceedings so as to assist the reader in determining which sessions they would like to watch in full. </i><br />
<br />
Day Five of Mind and Life XXVII - <b>Sarah Bowen </b>discusses<b> the Application of Contemplative Practices in Treatment of Addiction</b><i><b> </b></i><br />
<i></i><br />
<a name='more'></a><span style="font-size: large;"><b>DAY 5 AM - Sarah Bowen </b></span><br />
<span style="font-size: large;"><b>Application of Contemplative Practices in Treatment of Addiction </b></span></div>
<div style="text-align: justify;">
<br />
Dr Bowen presented an exploration of contemplative practice in the treatment of addiction. She explains the key practices and treatment targets, has a look at what the data says and where do we go from here?<br />
<br />
One of the core features is the relapsing nature of addiction. There are approaches based on 12-step approaches and CBT, but still 60% in first year of treatment will relapse. Studies have looked at causes of relapse, and negative emotions are a primary cause, with craving, social issues and low self-efficacy (self trust as Marc has spoken about).<br />
<br />
She described behavioural models of relapse, there is a trigger which leads to discomfort which leads to a craving which leads to use, and there is then a temporary alleviation, but soon there is more shame. Many addicts will describe this as almost automatic:<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgY3hQKtCJcJl67b4fAS-Bp3je3vbwFF0OFPd1SH5Mm2QjuEsUTo_-AuOvHyVDcRO6TTx4fVnz6VmBSSp1DkInG_Ed86BasG6Yk4iFif4mKquDRZpGSeCdOy79vsTgstZWbkDbP972-y78/s1600/SB1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgY3hQKtCJcJl67b4fAS-Bp3je3vbwFF0OFPd1SH5Mm2QjuEsUTo_-AuOvHyVDcRO6TTx4fVnz6VmBSSp1DkInG_Ed86BasG6Yk4iFif4mKquDRZpGSeCdOy79vsTgstZWbkDbP972-y78/s640/SB1.jpg" width="640" /></a></div>
<br />
What they are trying to do is create an awareness that could lead to the ability to make a choice. The aim is to bring some level of curiosity, rather than avoidance, to the craving or discomfort. This takes some compassion.<br />
<br />
Dr Bowen referenced <a href="http://en.wikipedia.org/wiki/G._Alan_Marlatt" target="_blank">Alan Marlatt</a>'s work in <a href="http://www.amazon.com/Relapse-Prevention-Second-Edition-Maintenance/dp/1593856415" target="_blank">relapse prevention</a>, as well as <a href="http://www.umassmed.edu/content.aspx?id=43102" target="_blank">John Kabat-Zinn</a> and <a href="http://www.camh.ca/en/research/about_research_at_CAMH/scientific_staff_profile/Pages/Zindel-Segal.aspx" target="_blank">Zindel Segal</a> in the area of mindfulness. This informs mindfulness-based relapse prevention. It is working with patients who have completed initial treatment and consists of an 8 week out-patient program, 2 hours a week. It is group based. Each session has:<br />
<ul>
<li>Formal meditation skills</li>
<li>Informal mindfulness practice</li>
<li>CBT skills</li>
</ul>
The intention is to have a progressive awareness. It starts with a very tangible external object. They start with eating a raisin as a first step - they explore the raisin using all senses. They then move towards intangible sensations such as breath, and then to thoughts and emotions.They move towards a more compassionate response. Finally they create an awareness of the relapse state:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6xHvC1X0X2L3S0ZLtOLpSpPqcAstLovkdHhREBifh8pK3rEeoAOkr8MZDq6tt2STSnhgg_fZ6c1cZS3F0luiHKRnsaQJ_JzSWn0xaBgcQtjHHQAo-YUOFfSXR10leHfbTBy45M0bvd30/s1600/SB2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6xHvC1X0X2L3S0ZLtOLpSpPqcAstLovkdHhREBifh8pK3rEeoAOkr8MZDq6tt2STSnhgg_fZ6c1cZS3F0luiHKRnsaQJ_JzSWn0xaBgcQtjHHQAo-YUOFfSXR10leHfbTBy45M0bvd30/s640/SB2.jpg" width="640" /></a></div>
In the course they dismantle craving, understanding what it is - just a thought, feeling or emotion. They look at the urge to react, and what they are projecting onto the object of desire. Can we pause and shift our focus in the midst of craving? This is what is being attempted.<br />
<br />
The first session examines the sensation of eating a raisin. They then ask the patient to bring that level of attention to some other activity - brushing teeth, or putting on a shoe, for example. They also teach the body scan, so as to be more aware of the internal experience. This then moves to breath, thoughts and emotion. They use the mountain meditation for example so as to create a sense of groundedness and dignity. They also focus on kindness and self. This meta practice is extremely difficult to send kindness to self, so they tend to start with kindness for someone easy. Forgiveness is also integrated into this process.<br />
<br />
They are attempting to examine the relationship between direct experience and reactions stories and judgement, so they can discern the difference between reality and perception. Within the group setting, people see that this is just how the mind works - it is not personal.<br />
<br />
Dr Bowen explained the SOBER practice:<br />
<ul>
<li>Stop</li>
<li>Observe</li>
<li>Breath</li>
<li>Expand</li>
<li>Respond</li>
</ul>
She then went on to explain urge surfing. This explores experiencing craving, recognising it and "surfing" the wave of something that is transient. By learning to "ride" the wave of craving, we promote self-efficacy, and over time the experience of craving reduces.</div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
Patients are encouraged to identify relapse thoughts. These are analyzed ahead of time and dealt with. Eventually patients can track the whole course of their process and can map this using a worksheet, and create alternative pathways.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Bowen then discussed how they are putting this into practice, and the feedback that they had been getting. She discussed some of the outcome studies that they have been doing. There are about 24 studies across the field, and main outcomes suggest reduced substance use. Perhaps one of the reasons why is because of the changed relationship with the substance. It is still a fairly young field of study, and studies are small and have limitations.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The questions they needed to look at were:</div>
<div style="text-align: justify;">
<ul>
<li>How do we train clinicians and implement these programs</li>
<li>Who are they for and what are the mechanisms</li>
<li>How can they be adapted for other populations and settings</li>
<li>Motivation for treatment and practice</li>
</ul>
<span style="font-size: large;"><b>Discussion</b></span><br />
<br />
Dr Davidson asked about follow-up. Dr Bowen said that in the most recent study they had followed people over a year. They found in one study that 84% practiced outside sessions, and 2-4 months later over 50% were still practicing. <br />
<br />
Dr Davidson asked HH for his reflections. HH said that this was perhaps more a painkiller, than the preventative - it was best to tackle the problem before it arose. He said it should be left to the experts, who could monitor, research and adapt. HH said that even in difficult circumstances our approaches and mental attitude is protective. He spoke about the human capacity to maintain compassion and peace of mind using examples of those who had been incarcerated in Chinese prisons.<br />
<br />
Dr Bowen spoke about how they were expanding their research to, for example, problem gambling, impulsivity, anxiety and the like. In multi-problem groups, the individuals recognise commonalities.<br />
<br />
HH pointed out that underlying craving is desire. Desire is not good or bad. What makes desire dysfunctional? It is often the object of desire. Awareness of the true nature of things is important. What is helpful, what is not. If you have a greater awareness, you have the ability to exercise choice. And this protects us from addictive use. Investigation and skepticism is vital. People who do not pay attention into the inner world of the mind get stuck - or habituated.<br />
<br />
HH raised a very important point that we must keep a broader perspective. Dr Volkow emphasized that our knowledge is indeed limited, and we need to seek further understanding.<br />
<br />
Diana Chapman Walsh raised the possibility that these approaches, rather than being a headache tablet, could be the doorway to change - in the way that Rosa Parks became uncomfortable with the duality of segregation and sat on a different seat in the bus. Sarah's approach may create the glimpse of another way of living. <br />
<br />
Dr Ricard spoke how the surfing is a very useful image that can be used to reduce the levels of craving over time. The conversation continued around teaching the teachers and means of delivering these services.<br />
<br />
I response to a question from Dr Berridge HH pointed out that these techniques need not be based in Buddhism, but rather in the common experience. Science is unifying. There is no right or wrong, but merely what is or isn't. Buddhism is a kind of inner science that seeks to understand the mind. Ultimate reality is the absence of independent existence. <br />
<br />
Dr Davidson wondered how analytic meditation could be brought into play. HH said that scientists use analytical meditation all the time - their just needed to be a focus toward inner world.<br />
<br />
Dr Lewis brought up the question as to whether addiction is a disease? Dr Davidson brought the session to a close before the question could be discussed - much to my disappointment!<br />
<br />
<br />
<a href="http://addictioncapetown.blogspot.com/2013/11/mind-life-xxvii-craving-desire-and.html">Return to complete list of sessions and summaries.</a></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-26039273024209137502013-11-14T19:45:00.001+02:002013-11-18T14:59:50.387+02:00Day 4 - Mind and Life XXVII - Craving, Desire and Addiction<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPLXCfpQ76Pau4BlR0cp3fJvVDs83GWihMCMUHUkgsqIrClSGFVxH7jKV_iKwtn35gV5BPYyxiqf2VfjhNRG0YQUtobLg6_Mq83p-pQs9pTcT2Q37B7gEcHFHQYkqHRBV41WcgmXDn7jo/s1600/Matthieu+Ricard.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPLXCfpQ76Pau4BlR0cp3fJvVDs83GWihMCMUHUkgsqIrClSGFVxH7jKV_iKwtn35gV5BPYyxiqf2VfjhNRG0YQUtobLg6_Mq83p-pQs9pTcT2Q37B7gEcHFHQYkqHRBV41WcgmXDn7jo/s200/Matthieu+Ricard.jpg" width="152" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dr Matthieu Ricard</td></tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgk3ZR-XaST5O8s9tj3BEow3Oj3ofRxt1mskRmHmcISXyNrHxPX3eLZKH6dM4QtMSElr3GJRZk_39QRkZ6zms82EFYjtp5pJ9fSYMTLvmrYA-sA7eNb827Pf_FYkYex_GXppqg3jo_r7yk/s1600/Wendy+Farley.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgk3ZR-XaST5O8s9tj3BEow3Oj3ofRxt1mskRmHmcISXyNrHxPX3eLZKH6dM4QtMSElr3GJRZk_39QRkZ6zms82EFYjtp5pJ9fSYMTLvmrYA-sA7eNb827Pf_FYkYex_GXppqg3jo_r7yk/s200/Wendy+Farley.jpg" width="152" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dr Wendy Farley</td></tr>
</tbody></table>
<i>You can <a href="http://dalailama.com/webcasts/post/300-mind-and-life-xxvii---craving-desire-and-addiction" target="_blank">view the videos here</a>.</i><br />
<div style="text-align: justify;">
<i>The point of this summary is not to replace the complete video and nor is it fully comprehensive, but rather the intention is to give a brief overview of proceedings so as to assist the reader in determining which sessions they would like to watch in full. </i><br />
<br />
Day Four of Mind and Life XXVII - Matthieu Ricard discusses <b>From Craving to Freedom and Flourishing: Buddhist Perspectives on Desire</b> and Dr Wendy Farley talks about <b>Contemplative Christianity, Desire and Addiction.</b><i><b> </b></i><br />
<i></i><br />
<a name='more'></a><span style="font-size: large;"><b>DAY 4 AM - Matthieu Ricard </b></span><br />
<span style="font-size: large;"><b>From Craving to Freedom and Flourishing: Buddhist Perspectives on Desire </b></span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Ricard explained that craving begins much earlier. First we perceive outer objects, and if we did not create a gap between perception and the way things are then we would be awakened - but this is not the case. Basic ignorance from the Buddhist perspective is a basic distortion of reality. As we perceive things, we superimpose meaning upon them. Although we are forever living, there is an inner self that is constant, that we rely on. This means we reify the self and phenomena - and this means we become a construct of the mind. All things become a mixture of projections and mixtures of perceptions and realities. We function within this misconceptions, and we develop mechanisms for the protection of "self".</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
We create an uneasy state of attraction and repulsion as a result of this superimposition of self. This can lead to hatred, craving, lack of discernment, arrogance and jealousy. This will lead to suffering. We create a dysfunctional version of reality. The antidote is wisdom. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
There are degrees of desire or craving. We can start at aspiration - and this depends on motivation or world view. Desire and wanting are driving forces, Buddhism is not about the suppression of these things. These can be wholesome. Craving and grasping are, however, afflictive mental states - this is not a moral judgement, but rather a reflection that these will lead to suffering. There can be triggers, but these are also not a problem - it is the proliferation of thoughts that creates kindling for the fire from the spark of the trigger. You now move out of sync with reality - objects become 100% desirable.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Ricard recalled how HH and <a href="http://www.beckinstitute.org/aaron-beck/" target="_blank">Aaron Beck</a> discussed that when we are angry, most of the thoughts and actions are not based on reality, but a superimposition due to the anger. Addiction comes further because we become so engrossed we lose control and our freedom.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Can there be a positive addiction? It is a tireless action, and with the right mental states free from affliction, with the right motivation and endowed with wisdom, there could conceivably be a positive addiction. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Ricard asks how can we cure the negative addictive state? We could indulge in it. Obviously this does not work because by indulging we do not sate the desire, rather we lower the threshold and we reinforce the tendency. We could repress it, but that also does not work. Rather we could try to manage with skillful means. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
How can we deal with these thoughts or cravings? Before, during or after they arise. We can start with the after, by examining the causes and consequences by honest appraisal. Regret (not guilt or shame) can create momentum to seek support, apply an antidote and make a pledge. This prepares us a little bit better for before the next craving arrives. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
We need an awareness that these cravings may arise, and as we seen them arise we can put out the spark. Once the spark arises we can apply the antidote. In the Buddhist practice there are many ways of doing this, too many to describe - 84 000! The three main ones are: Direct antidote, for example hatred can be treated with loving kindness. In the case of craving we can focus on the undesirable aspects. We can, in the case of addiction, focus on our loss of control - we can locate a place of inner freedom.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Ricard suggests that the second option after applying a direct antidote is to look at the nature of craving. We could not associate mentally with the craving - we can see ourselves not as the craving, but removed from it. We can be aware of the craving without response. By recognising it and labeling it, the craving can melt away. We can also recognise its lack of intrinsic existence. The feeling or experience of craving has no substance to it - it is like a cloud, and is simply a mental construct. We can eventually let it immediately dissolve as it arises.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The third method, which is a higher level, is to use the craving as a catalyst. If you could stay with the initial feeling without moving off that, it would be fine.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
These techniques have one goal: to claim our freedom.</div>
<div style="text-align: justify;">
<br /></div>
Addiction has a triple challenge:<br />
<ul>
<li>Sustained efforts are required to bring about neuroplasticity</li>
<li>Neuroplasticity is slowed down</li>
<li>Motivation is weakened</li>
</ul>
<div style="text-align: justify;">
We need to solve these problems, but there are means of this. Using Buddhist principles we can learn to deal with addictions. We can deal with cues through awareness of the mental image, and re-focus on something else. We can deal with repetitive behaviour also by mindful awareness. Beneath the screen of thoughts there is always awareness. Visualisation can be helpful. We need to practice. Freedom does not come easy, freely or cheap. It requires effort.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Ricard ended by thanking those who have helped him.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<b>DISCUSSION</b></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
HH pointed out that not only is there a strongly held image of self, but also a self-grasping of this self. We need to find a way of releasing this self grip - and we can do this by focusing more on others. Everything is self reverential, so we need to learn to bring others into consideration, which will assist in this. This is why secular ethics is so important to HH. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Sarah Bowen raised the issue of those that self-sacrifice. How does the this relate to the notion of self-centeredness? Dr Ricard explained how self-compassion can perhaps help in these cases. HH pointed out that these are not diametrically opposed ideas - there needs to be a fulfillment of self-interest as well as a compassion for others. There can be pathological altruism as Joan Halifax pointed out. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Volkow pointed out that 12-step groups rely heavily on helping others and this may be the most important aspect of these groups. She also pointed out that we are social creatures, and our brains are wired to interact with others.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Berridge spoke about how some sparks are harder to control - some may already start very hot. Animal studies may show that in the right situation there can be massive sparks, and he was wondering if we could stop this. Dr Ricard suggested that this required training and practice, and this over time can lower the intensity. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
There were a number of other discussions about how Buddhism and science can interact. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Davidson pointed out how against the scientific knowledge goes against the principles of weekly therapy, but that daily practice of small behaviours should be explored. He pointed out that we can train attention through many means, but usually without the ethical underpinnings. Sarah Bowen pointed out how awareness to the damage that the addiction is doing to self and others (in a non-judgemental way) can perhaps be the starting point for treatment.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Marc Lewis pointed out how through the process of addictions most addicts have found a richer sense of self.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Volkow asked if it was a disease of the mind or the brain. HH says there are perhaps two dimensions - initially there may be more of a mental pain, or a social context, but it may eventually result in a physical brain change.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
At this point the proceedings ended.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-size: large;"><b>DAY 4 PM - Wendy Farley </b></span><br />
<span style="font-size: large;"><b><b>Contemplative Christianity, Desire and Addiction.</b><i><b> </b></i></b></span><br />
<br />
Dr Farley introduced two lesser known forms of contemplative Christianity - the desert ascetics who were intoxicated with the idea of love, and withdrew into the desert to contemplate love. The other group is the women contemplatives - the 12th century Beguines who wanted to be able to live in the world but be contemplative. This did produce some profound and beautiful Christian texts.<br />
<br />
She gave the following quote from Isaac of Ninevah as an example of what these Christians hope for:<br />
<blockquote class="tr_bq">
"What is a merciful heart? A heart burning for all creation, for human beings, for birds, for animals, and even for demons. It cannot endure hearing or seeing any injury or slight sorrow to anything in creation. Because of this, great compassion offers tearful prayers that every being be guarded and forgiven"</blockquote>
Dr Farley gave an outline of her talk, which has three main headings:<br />
<ul>
<li>Christian interpretation of different dimensions of desire - healthy and distorted</li>
<li>Parallel between dynamics of craving and addiction</li>
<li>Supporting practices to restore healthy desire and heal from craving and addiction</li>
</ul>
Healthy desire (eros in the greek) is a joyful, self emptying sort of desire. It is self-forgetful. From the Christian point of view, the only object of healthy desire is God. The love of God is self-transcending. But the concept of God can be unhealthy, so perhaps the object of desire is love itself. In religious <i>eros</i>, the way we desire is completely different - it is non-dual, it is open-ended and non-possessive. Distorted desire reorientates desire to the ego. In pain, we find it difficult to think outside self. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
We desire our own happiness and relief from suffering - we believe that things of the world will help us achieve this. We grant the world a kind of reality that it cannot fulfill. In distorted desire there is a dualistic approach. I become disconnected from the world. We ascribe inordinate powers to objects of the world. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Farley explained how these become habits that continue, rather than passing emotion. The mind is absorbed into the underlying structures before the desires even arise - there is a deeper interlocking set of patterns. Things become real in terms of the ego's needs and fears. She explained how things disguise themselves and we end up still acting out of ego-self.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Fear is also related to the craving and can manifest in false humility. Our cultural alienation contributes to the state of suffering. We have an increased vulnerability to the state of addiction. Dr Farley, when referring to craving and addiction, said:</div>
<div style="text-align: justify;">
<ul>
<li>Mind is hidden from itself</li>
<li>There are false objects of relief and happiness</li>
<li>This undermines relationships</li>
<li>There is bondage to this</li>
<li>The habits are embedded in bodies and minds</li>
</ul>
</div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
She described addiction as being trapped in a golden cage. A vital part of the Christian message is that there is no-one so broken that they cannot receive healing through a great mercy that holds us. The ultimate reality is compassion, and this "opposite" spark can become inflamed. Because craving is so deeply rooted, many interlocking practices must be engaged to transform it:<br />
<ul>
<li>Watching the mind</li>
<li>Meditation</li>
<li>Contemplation</li>
<li>Compassionate Action</li>
</ul>
She expanded briefly on each of these, one being contemplation - dwelling in the non-discursive dimension of "mind" where the distinction between self and other breaks down.</div>
<div style="text-align: justify;">
<ul>
<li>Non-duality</li>
<li>union</li>
<li>imageless</li>
<li>dissolution into love</li>
</ul>
Love is the manifest form of the divine. <br />
<br />
There was a discussion around the avoidance of nihilism and how to safe guard against this. Dr Farley described how Jesus saw the divine in all beings.<br />
<br />
She concluded by saying thank you to the lineage of contemplatives and the conversations between Buddhism and Christianity.</div>
<div style="text-align: justify;">
<br />
<a href="http://addictioncapetown.blogspot.com/2013/11/mind-life-xxvii-craving-desire-and.html">Return to complete list of sessions and summaries.</a></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-36216132028651827672013-11-11T17:46:00.000+02:002014-02-17T11:13:08.371+02:00Day 3 - Mind and Life XXVII - Craving, Desire and Addiction<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRo8rxUuLuVv1WN_i7rheADI0L_MAX4gy5-JV2gDjAsU8GzepK0EVnn-Zlh1KuIlX5Vg3FLPRlHlmidCKoeNkWobat7HYjZik0rNHnvs3iEgpRz_o-FvaMKUcDBTfl3Eb_YZGC-efBy5o/s1600/nidadirector_noravolkow.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRo8rxUuLuVv1WN_i7rheADI0L_MAX4gy5-JV2gDjAsU8GzepK0EVnn-Zlh1KuIlX5Vg3FLPRlHlmidCKoeNkWobat7HYjZik0rNHnvs3iEgpRz_o-FvaMKUcDBTfl3Eb_YZGC-efBy5o/s200/nidadirector_noravolkow.jpg" height="200" width="146" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dr Nora Volkow</td></tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg99fd1ZnFVEO_FE_kRpdQps8J8Vraz8xjM9aETiLPCof_h2nNLxnKvK_4RL4FRz3dNW2z8Y6TvOD77N-VopjZF1f9TyVJt9_pSUSzrvfh7GK8zSmPuD-D9clWGHX4effMGrvTtTh9-MNw/s1600/Dr+Frank.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg99fd1ZnFVEO_FE_kRpdQps8J8Vraz8xjM9aETiLPCof_h2nNLxnKvK_4RL4FRz3dNW2z8Y6TvOD77N-VopjZF1f9TyVJt9_pSUSzrvfh7GK8zSmPuD-D9clWGHX4effMGrvTtTh9-MNw/s200/Dr+Frank.jpg" height="200" width="158" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dr Vibeke Amussen Frank</td></tr>
</tbody></table>
<i>You can <a href="http://dalailama.com/webcasts/post/300-mind-and-life-xxvii---craving-desire-and-addiction" target="_blank">view the videos here</a>.</i><br />
<div style="text-align: justify;">
<i>The point of this summary is not to replace the complete video and nor is it fully comprehensive, but rather the intention is to give a brief overview of proceedings so as to assist the reader in determining which sessions they would like to watch in full. </i><br />
<br />
The third day of Mind & Life XXVII - Dr Laura Volkow talks about <b>The Role of Dopamine in the Addicted Human Brain</b> and Dr Vibeke Amussen Frank follows with <b>Beyond the Individual: The Role of Society and Culture in Addiction</b>.<i> </i><br />
<br />
<br />
<a name='more'></a><span style="font-size: large;"><b>Day 3 AM - Nora Volkow</b></span><br />
<span style="font-size: large;"><b>The Role of Dopamine in the Addicted Human Brain</b></span><br />
<br />
Dr Volkow sees addiction as that point where a person has lost the ability to exert control over their desires and emotions, and the Buddhist tradition tries to achieve exactly the opposite. She discussed the criminalisation of drug use, and her commitment to help those addicted to drugs so they don't end up in prison. She explained how imaging techniques gave us the opportunity to see the brain and the effects of addiction on it. By collecting this knowledge we will be able to provide targeted interventions. Dr Volkow gave a brief overview of positron emission tomography (PET).<br />
<br />
Dr Volkow spoke about the <a href="http://addictioncapetown.blogspot.com/2013/01/the-common-reward-pathway.html" target="">common reward pathway of drugs of abuse</a>, and how all drugs had an effect on dopamine. She explained that 'reward' is an inclusive phrase, but that the experiences may be different. I will not go into detail about this here. She described addiction as a disease of learning.<br />
<br />
One of the critical points that Dr Volkow made was that dopamine release was not consistent across all people, and this variability made some people more vulnerable than others to drug addiction. She explained how they expected those who were addicted to drugs to have large dopamine responses, or larger reward. What they found was the opposite. In detoxified cocaine addicts (3 weeks) when given Methylphenidate, they had approximately half the response when compared to the control group.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
</div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRXyVMRGf77zyzaUWAMmYM8a8oeS6_eiCblG2WvXjmF5jBPbJPCyKdIyr4lblHtuLQsagoOsMilD3ajft4B4qOr2TTwP16Sua3J1EZ6bpDJkE4z5YadKbtretyXMjs7LJOgJ3ntZXNLl4/s1600/fig+4+addict+vs+control+MP.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRXyVMRGf77zyzaUWAMmYM8a8oeS6_eiCblG2WvXjmF5jBPbJPCyKdIyr4lblHtuLQsagoOsMilD3ajft4B4qOr2TTwP16Sua3J1EZ6bpDJkE4z5YadKbtretyXMjs7LJOgJ3ntZXNLl4/s640/fig+4+addict+vs+control+MP.gif" height="304" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Images from Volkow's research (not the same images as used in her presentation)</td></tr>
</tbody></table>
<br />
Dr Volkow explained that one hypothesis is that there is a down regulation, and thus natural rewards become "less rewarding". This is presumed to happen after repeated use of the drug. In experimentation they found an attenuation of the system of motivation. She then explained Pavlov's experiments and the principles of classical conditioning, and how they are able to now measure dopamine in relation to these experiments. Basically it was found that conditioned stimuli increased the levels of dopamine. This is very important because it is at this point that attention is focused and motivation for receiving the reward gets established.<br />
<br />
When you get rapid increases in dopamine, this helps create stronger memories. The hippocampus and amygdala send projections to the nucleus accumbens, so these memories cause motivated behaviour. Images of drug cues have been shown to increase levels of dopamine in addicted individuals, and this leads to craving. The larger the increases dopamine, the greater the increase in craving. Dr Volkow made a vital point: The reward system of the consumption is attenuated, while the expectation of the reward is sensitized or heightened. <br />
<br />
Dr Volkow described how they were looking effects on the frontal cortex. The question is "are the changes in dopamine a function in addicted subjects linked with disruption of frontal activity?" It was shown that dopamine D2 receptors are lower in addiction across all drugs. She stressed, however, that there is significant variability. Low levels of D2 receptors is NOT enough to explain addiction. She suggested that perhaps a medication that increased D2 receptors may help, and would, if worked, prove causality. Or, as Richard Davidson suggested, and for me intriguingly, we could develop behavioural interventions. She explained how animal experiments had been done through gene therapy.<br />
<br />
D1 and D2 (there are 5 DA receptors) are very important in addiction (see <a href="http://addictioncapetown.blogspot.com/2013/11/day-2-mind-and-life-xxvii-craving.html" target="_blank">Kent Berridge's talk</a>). If you upgrade D1 receptors you would enhances the rewarding effects of drugs. D2 decreases them, if you decrease D2 it makes you vulnerable, but an increase is protective. In addiction we see a decrease in D2 receptors. <br />
<br />
Dr Volkow moved on to describing the glucose metabolism in the frontal cortex. There are decreases of D2 receptors in the orbito frontal cortex and anterior cingulate girrus, and this lowers metabolism. What are the consequences, Dr Volkow asks. Well, they are complex and many. The anterior cingulate girrus allows us to detect discordance. If this does not operate properly, we are less able to spot inconstancy or errors. The orbito frontal cortex attributes importance or present salience to an object or behaviour. There develops a rigidity and inflexibility. This is similar to <a href="http://addictioncapetown.blogspot.com/2013/01/obsessive-compulsive-disorder.html" target="_blank">OCD</a>. There is often a continuation of use and behaviour in spite of the loss of reward. <br />
<br />
There develops a perseverance of the behaviours without mediation by the frontal cortex. There is a loss of integration of the levels of consciousness. She spoke of addiction as being part of a behavioural continuum. Dr Volkow spoke of the default mode network, and we are able to shift between conscious and unconscious modes. This can be lost, and the default mode network can become "hyper-engaged". <br />
<br />
There was then a discussion, at some length, about what can and can't be seen through brain scans, for example compassion, or sensory pain, or craving. Dr Volkow explained that she was able to see craving from brain imaging.<br />
<br />
Dr Volkow spoke about genetic variability and vulnerability, which is estimated at about 50%. She spoke about the importance of childhood stressors as factors in developing a vulnerability. The levels of D2 receptors were found not to be inherited by the children of alcoholics. There was compensation through increased receptor level and activity in the PFC.<br />
<br />
Dr Volkow then showed the same diagram as had been shown by Dr Davidson, and explained how the addict brain is affected:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsn5xLYKvkmRBFFdkaGGHPjvFs20tQXiBk4QkvWX6dr8GpLMwTf5rYpUuvDvkiqk5fxdSu-xU9tO8UGh5OTT01H6c7jXEJui3Pmfxy5dGrM-4_HjPZFZFjjVZw9086GpZkDWBoP242f9o/s1600/NIDA3.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsn5xLYKvkmRBFFdkaGGHPjvFs20tQXiBk4QkvWX6dr8GpLMwTf5rYpUuvDvkiqk5fxdSu-xU9tO8UGh5OTT01H6c7jXEJui3Pmfxy5dGrM-4_HjPZFZFjjVZw9086GpZkDWBoP242f9o/s640/NIDA3.gif" height="480" width="640" /></a></div>
<br />
The amygdala has the ability of disconnecting the PFC. There is a positive feedback loop that develops. <br />
<br />
Dr Volkow believes that there needs to be a multiprong approach to treating addictive disorders. NIDA are funding research into various interventions, and that possibly pharmacology could help focus on the intervention in a temporary way. She spoke of a meditation/mindfulness intervention for smokers where without even discussing the intended outcomes, smoking was reduced. There is a computer program that helps give biofeedback to help train the frontal cortex to override the amygdala. Another intervention strengthens the power of non-drug stimulation, for example spiritual interventions which provide a "richness of life".<br />
<br />
Dr Volkow showed a painting by Gustafson that she feels captures the "poverty yet intensity" of the addictive experience. Unfortunately I cannot find this painting on the web, but it can be seen at 1:48:58 on the video. <br />
<br />
Her talk ended there.<br />
<br />
<span style="font-size: large;"><b>Day 3 PM - Vibeke Asmussen Frank</b></span><br />
<span style="font-size: large;"><b>Beyond the Individual: The Role of Society and Culture in Addiction.</b></span><br />
<br />
Dr Frank is a social anthropologist. She explained that her main interest is how people live with substances, whay and when they use them and the context and social practices with them. Here overall perspective is:<br />
<ul>
<li>relationships between individuals and the dynamics between the individual and the psycho-social context.</li>
<li>Processes in and out of substance use and addiction from a relational perspective.</li>
<li>How the substance is experienced by individuals.</li>
</ul>
The research is mainly qualitative research. The research is circular not linear and is in constant change - it is a reflexive process. Analysis is part of the project, and the purpose is to find meaning, looking for patterns and complexity. Dr Frank said we need to be aware of context and relations. She said there were two main points of discussion:<br />
<ul>
<li>Ways out of problematic substance use, looking at treatment efficacy and self-change</li>
<li>Regulating substances, which in itself can in itself cause harm.</li>
</ul>
Dr Frank pointed out that a quarter of the European population have used an illicit drug. There are 1,4 million problem opioid users in Europe and 3 million daily marijuana users. She explained that substance users tended to be younger, with a "leveling out" with age due to life-style changes.<br />
<br />
Dr Frank described treatment according to Blomquists definition " Any kind of structured intervention, either medical or psychosocial or a combination of both." She discussed the various forms of treatment briefly. Dr Frank showed how between the 70s and 2011we have seen limited improvements in treatment efficacy.<br />
<br />
If we ask patients as to why they seek treatment, it is often so they can control drug use or pause from the lifestyle, and as such the goals may differ from the treatment provider. She spoke how the close monitoring of substitution therapies may actually deter people from seeking treatment. Structural conditions may also affect motivations to stay in or out of treatment, such as the potential loss of social networks. Perhaps the an option would be to shift the focus from compliance to treatments concordance with everyday life and thereby reduce the internal dilema.<br />
<br />
Dr Frank then moved to self-change as a mode of recovery. She quoted figures for alcohol use and remission via self-change. People with less problems related to the DSM criteria were more likely to remit than those with multiple problems.<br />
<br />
What are the reasons to start and maintain self-change?<br />
<ul>
<li>Positive life circumstances</li>
<li>Social influences</li>
<li>Health concerns</li>
<li>Change in perception of substance use</li>
<li>Both sudden or planned decisions were made</li>
</ul>
In the case of controlling substances, society has various means:<br />
<ul>
<li>public policy</li>
<li>health policy</li>
<li>prevention policy</li>
<li>control policy</li>
</ul>
Dr Frank looked specifically at criminalisation and the detriments. She explained the racial bias in arrests for possession, and how this results in further discrimination. This has led to mass incarceration and an entrenched level of disparity in the USA as Dr Walsh pointed out.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Walsh pointed out that the majority of European offenders are non-violent drug offenders. There is also an educational imbalance in these populations. Dr Volkow spoke a bit about the drug courts that seemed to be effective, but that resources are limited. The discussion moved towards the legalization of cannabis. Dr Lewis pointed out that the legal status in the Netherlands had only affected the tourist market, rather than local consumption. Dr Volkow pointed out the large sums of money invested in lobbying for the legalisation of cannabis. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Dr Frank also pointed out that legal policy was also linked to social policy, so in the USA, a record for a drug offence often prevented access to social services. She spoke about non-abstinence based approaches.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The conclusions were:</div>
<div style="text-align: justify;">
<ul>
<li>Addiction is experienced by individuals who are embedded in social and cultural settings</li>
<li>Not only the way substances are used, but also the way societies control and regulate substances causes harm.</li>
</ul>
Dr Frank asked HH how we can society avoid and reverse the stigmatisation related to substance use disorders. HH suggested that we need to absorb these marginalised people into society. Wendy Farely spoke about the importance of having a non-judgemental attitude. Dr Volkow spoke about the difference between legalisation and decriminalisation. She also spoke of social neuroscience, and how by putting drug users in prison we are reducing D2 receptor levels, and thereby making the problem worse.<br />
<br />
The session then ended.</div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
<a href="http://addictioncapetown.blogspot.com/2013/11/mind-life-xxvii-craving-desire-and.html">Return to complete list of sessions and summaries.</a></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-38075704366043353082013-11-08T16:15:00.002+02:002013-11-18T14:58:24.868+02:00Day 2 - Mind and Life XXVII - Craving, Desire and Addiction<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_SM7Hgyycjy_bgSOGYTxqmhoVJnYqWgH7ANIqQ8Ctz7ZMRrhry3opXnjcoTFvyZ-i8-Rm-YtrFo_m7cWs_eXH-mgX3I-_o2NWHHRBFo9rGGzfT44XBZV3LEjoLy5kygCRSBKztV4BU7k/s1600/Kent+Berridge+2005+small+web.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_SM7Hgyycjy_bgSOGYTxqmhoVJnYqWgH7ANIqQ8Ctz7ZMRrhry3opXnjcoTFvyZ-i8-Rm-YtrFo_m7cWs_eXH-mgX3I-_o2NWHHRBFo9rGGzfT44XBZV3LEjoLy5kygCRSBKztV4BU7k/s200/Kent+Berridge+2005+small+web.jpg" width="159" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dr Kent Berridge</td></tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCGqyIYmSPqCu2aUvVH1Sj41QJdoFBAS3MSqYjfEI7wZd7DA0vJDLMefRGsfNAKYYCHFySPlElJNEEYlRm7IOUSha7KXG1WBK4jOBtsbI7bXr22ILOw1F6R_LfxjQY1H9RPetMHrO8b-A/s1600/Thupten+Jinpa.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCGqyIYmSPqCu2aUvVH1Sj41QJdoFBAS3MSqYjfEI7wZd7DA0vJDLMefRGsfNAKYYCHFySPlElJNEEYlRm7IOUSha7KXG1WBK4jOBtsbI7bXr22ILOw1F6R_LfxjQY1H9RPetMHrO8b-A/s200/Thupten+Jinpa.jpg" width="149" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dr Thupten Jinpa</td></tr>
</tbody></table>
<i>You can <a href="http://dalailama.com/webcasts/post/300-mind-and-life-xxvii---craving-desire-and-addiction" target="_blank">view the videos here</a>.</i><br />
<div style="text-align: justify;">
<i>The point of this summary is not to replace the complete video and
nor is it fully comprehensive, but rather the intention is to give a
brief overview of proceedings so as to assist the reader in determining
which sessions they would like to watch in full. </i></div>
<br />
<div style="text-align: justify;">
The second day of Mind & Life XXVII - Kent Berridge talks about <b>Brain Generators of Intense Wanting and Liking</b> followed by Thupten Jinpa presenting <b>Psychology of Desire: A Buddhist Perspective.</b></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The day got off to a light-hearted start with Dr Richard Davidson putting single marshmallows in front of the delegates, offering them two if they could resist. This was in response to the discussions about delay discounting and restraint on day one. His Holiness (HH) wanted to know if he could get three if he waited 15 minutes!<b><br /></b></div>
<br />
<a name='more'></a><span style="font-size: large;"><b>Day 2 AM - Kent Berridge</b></span><br />
<span style="font-size: large;"><b>Brain Generators of Intense Wanting and Liking</b></span><br />
<br />
Dr Berridge started by expressing some of the conclusions that they are reaching as a result of the <a href="http://www-personal.umich.edu/~berridge/" target="_blank">research being done in his lab</a>. The first conclusion is that suffering is not craving, and craving is not suffering. It is possible for these two to exist independently. This means that by curing the suffering, we may not cure the craving. Similarly pleasure may lead to craving and may be the object of craving, but it may simply be the key to unlocking the craving. It is therefore possible to have craving without even the hope of future pleasure.<br />
<br />
What is craving? The laboratory is saying that there is a special state and that this may, together with imagining create a craving.<br />
<br />
Dr Berridge stated that desires have a life and mechanism of their own. The outline for his talk is:<br />
<ul>
<li>The desiring brain is a large system that generates intense "wanting" through the dopamine system.</li>
<li>Pleasure or liking is a different and fragile system. It is a smaller system in the brain.</li>
<li>Craving may require no pleasure object - we can "want" even though the object of desire is unrewarding.</li>
<li>The craving brain system can generate both "wanting" and "fear" - this is a shared system. These may cycle, they may or may not converge.</li>
</ul>
This last point prompted some debate. Dr Davidson pointed out that temporally many more activities are taking place at a brain level than we can consciously resolve. Dr Berridge spoke about the limitations of the experiments that can be conducted.<br />
<br />
Dr Berridge explained the similarities between the rodent and human brain in terms of the "craving" system. He explained the hypothesis that the same brain systems are turned on for all states of sensory pleasure - whether food, sex, well-being or drugs. He continued to explain the paradox of dopamine - that the same neurotransmitter can be responsible both for the "stimulate and go" mechanisms when acting on the D1 receptors as well as the "suppress and stop" mechanisms when acting on the D2 receptors.<br />
<br />
Incentive salience adds urgency urgency to conscious desires, but it can also lead to a "grasping" at unconscious levels. This is a deep brain system, and the question is how can we bring this into the level of awareness. The discussion moved towards the differences between the dream state and the conscious state, and how these are achieved through shared systems - they are essentially very efficient systems. <br />
<br />
Dr Berridge then spoke of his and <a href="http://rstb.royalsocietypublishing.org/content/363/1507/3137.full" target="_blank">Terry Robinson's incentive-sensitization theory</a> of addiction. He used a graph to explain how incentive value may increase while subjective pleasure may decrease. Dopamine sensitization may account for this - the system becomes more reactive to the drug or related things.<br />
<br />
Dr Berridge explained how they conduct experiments on rats using optogenic laser stimulation of the amygdala to focus "wanting" on a single reward above others. He explained how a virus carries a gene for a photoreceptor molecule, and this can be injected into the brain neurons. This makes it possible to use a painless light to make the neurons fire. Dr Berridge showed a video of how this works and explained how an intense wanting can be produced by firing an amygdala laser while feeding the rat a sugar pellet. The combination of the laser in the brain and the sugar pellet, makes the sugar pellet particularly desirable. <br />
<br />
Dr Berridge showed how human babies and rats react to water when thirsty, when it get sugar water and when it gets a bitter taste. This is a video from his lab:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dwg1w69oFpvRiC5o1J48rJsMRhuFP4Ca4h4Y2U_7P6C3TIXJy0V9wBHj6NKllEpTVJHUMlMdnTeQOzJrmGrBQ' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
<br />
<br />
Dr Berridge explained how we can make the rat "want" things, even if they don't like them more. The brain system can make things immensely more attractive than they are.<br />
<br />
He then went on to explain how we have seen similar reactions in humans were deep brain stimulation has been used to treat depression. In case one a woman became euphoric, developed flight of ideas and fell instantly in love with the neurologists. She later went shopping and spent money on unnecessary items of clothing. She had impulsive desires whether happy or tense. Two other cases were also discussed.<br />
<br />
Dr Berridge explained that this was all about 'wants' or 'desires' without 'pleasure'. He went on to say that the system for pleasure was much smaller, and pleasure was indeed fleeting and required the entire 'pleasure' system to be activated, and was therefore unstable.<br />
<br />
Dr Berridge then went on to show we can 'want' something that is not 'liked'. The experiment uses saline water, which rates do not want. They are programed to not like this, and there can be no expectation of 'future liking' - it avoids that taste. By administering a drug that creates a salt appetite, the rat will go towards the salt drink. With the combination with the cue, there is a dopamine activation, and this can create a desire for something that is not liked. In the addict, this means that 'wanting' can be present without 'liking' or the expectation of 'liking'.<br />
<br />
HH wondered if there was a disconnect between the 'wanting' and the understanding of future consequence. Dr Davidson pointed out that there often exists a disparity between cognitive understanding and bodily experience.<br />
<br />
Dr Berridge made a very interesting point by stating his belief that there needs to be no positive memory of something for it to become the object of desire.<br />
<br />
Dr Berridge then went on to briefly explain how the same inhibitory drug can produce both intense desire and active fear. This is a similar illustration to the one Berrdige used:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyuT_g6ExHKqQjySRZzm04w8wjfiEAt8ACiPpqc_v6-EX6yHX-bqyEwk8hkwoW75PiWVj6gwAt4mbP7zUzlpYkGUG18rsNVEAPfGsPeWkY5D3TYYVC_x9u_4FSmS2ZTotpZbcOQcE5QPc/s1600/Summary+map+of+glutamatergic+valence+generation+in+the+medial+shell.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyuT_g6ExHKqQjySRZzm04w8wjfiEAt8ACiPpqc_v6-EX6yHX-bqyEwk8hkwoW75PiWVj6gwAt4mbP7zUzlpYkGUG18rsNVEAPfGsPeWkY5D3TYYVC_x9u_4FSmS2ZTotpZbcOQcE5QPc/s640/Summary+map+of+glutamatergic+valence+generation+in+the+medial+shell.jpg" width="304" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<br />
This shows how three micro-injections in different contexts or environments can produce different results. So the same system can 'flip' producing different results.<br />
<br />
In conclusion Dr Berridge said:<br />
<ul>
<li>deep brain 'wanting' gives a grasping quality to desires and that individuals differ in propensity for dopamine activation.</li>
<li>Wanting can occur without distress or need, so relieving withdrawal distress will not eliminate the addictive grasp</li>
<li>Wanting can occur without pleasure. Liking is not needed as a trigger, and expectation of 'liking' is not needed.</li>
<li>'Wanting' mechanism can flip to fear</li>
</ul>
This all raises the questions:<br />
<ul>
<li>What is shared by opposite emotions?</li>
<li>Can unconscious wanting be brought into awareness?</li>
<li>Can awareness techniques gain better control of intense 'wants'?</li>
</ul>
<br />
<b><span style="font-size: large;">Day 2 PM - Thupten Jinpa </span></b><br />
<b><span style="font-size: large;">Psychology of Desire: A Buddhist Perspective</span></b><br />
<br />
Dr Jinpa started by giving a brief overview of what had been discussed to date. His initial point was to point out that if we viewed addiction from a reductionist disease model point of view, then Buddhist thinking or psychology has little to offer to the understanding of addiction. If we expand our view to consider the underpinnings of addiction, then there is a lot to add, especially considering the importance of craving in the Buddhist context. He also made the valid the point that if we view addiction purely as a disease then many people would not identify themselves with this, whereas the majority of people do have a problem with craving, especially when living in a Western consumerist society.<br />
<br />
Dr Jinpa believes that in all of us there is some form of addiction potential, and by bringing together multiple fields we can perhaps gain a better understanding of craving and addiction. He suggested that while Kent Berridge went into the brain, he would go into the mind.<br />
<br />
Dr Jinpa started by referring to some of the key metaphors of early Buddhist texts:<br />
<ul>
<li>Drowning in a mire of sensual desire</li>
<li>Being swept by currents of craving</li>
<li>The thirst of craving</li>
<li>Caught by the noose of craving</li>
<li>Bound by the long rope of craving</li>
</ul>
These give some indication of the enormity of the challenge of craving.<br />
<br />
Dr Jinpa then brought to attention the early Buddhist text showing the process of craving:<br />
<blockquote class="tr_bq">
"Conditioned by <i>contact</i> feeling/experience arises; conditioned by <i>feeling</i>, craving arises; conditioned by <i>craving</i> grasping arises; conditioned by <i>grasping</i> becoming arises......"</blockquote>
In other words, when you come into contact with something there is an effective response. So it is not the object that results in the craving, but rather the feeling. And from this arises grasping, which can be seen as a level beyond craving. The becoming is the act of fulfillment. He then goes on to expand upon each of these themes from the view of one of the Buddhist scholars and describe the Buddhist representations of the phases as related to the wheel of life.<br />
<br />
Dr Jinpa explained the complexity of the terms 'attachment' and 'craving'. Craving is more future focused and attachment more in the present liking. There are 3 types of craving - existential craving, craving as in desire and craving borne of fear. Craving can also be seen as craving for future objects, craving as attachment through not wanting to be separated and craving in the form of love for continued existence.<br />
<br />
Attachment is seen as inappropriate current joining with the object of desire, while craving is more about the future - it is seen as inflictive. He then explained the cycle of craving:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDLTDhMzNGjAUmy0FUJiXSByIO0FjZ_Lkd9OvQHCdVE0pVwA5SdlCspzWMD0ADWoZSfv3RvX7oojXvkleuYKzRXtVpMUK29DOvgnrBZ9c0uw6m4vtT2Se4-93yatJP9Kq4I1pSJk2yeP8/s1600/Presentation1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDLTDhMzNGjAUmy0FUJiXSByIO0FjZ_Lkd9OvQHCdVE0pVwA5SdlCspzWMD0ADWoZSfv3RvX7oojXvkleuYKzRXtVpMUK29DOvgnrBZ9c0uw6m4vtT2Se4-93yatJP9Kq4I1pSJk2yeP8/s640/Presentation1.jpg" width="640" /></a></div>
<br />
<br />
The Buddhists would suggest that we require "imagining" or "inappropriate mentation" to keep this cycle moving. To quote Vasubhandu (4th Century): "One has not abandoned the proclivities; and the objects [of temptations] remain nearby; so with inappropriate mentation, the conditions [for the arising] of afflictions are complete."<br />
<br />
Dr Jinpa also spoke of the role of habituation and reduced the process into a simple 4-stage cycle:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEichx3OSZH6hWWMhnaD46ivOCyVPye4le-y7ZspGvS58UASPoR_7FaOjDfb7wHypGqIXp6mOULAMG-cONIcSrQXkNQzfb6OsihZefQwvE8IC-Duj9VnkbpRwGescjDabLJFskBlKDexHFg/s1600/Presentation1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEichx3OSZH6hWWMhnaD46ivOCyVPye4le-y7ZspGvS58UASPoR_7FaOjDfb7wHypGqIXp6mOULAMG-cONIcSrQXkNQzfb6OsihZefQwvE8IC-Duj9VnkbpRwGescjDabLJFskBlKDexHFg/s640/Presentation1.jpg" width="640" /></a></div>
<br />
He spoke about how habitation creates a kind of short-cut. This how Buddhism explains the cycle, and it expands each stage by focusing on causation so that we can get a deeper understanding of the processes involved.<br />
<br />
He explained that he was presenting more the theory of the Buddhist view, while Matthieu Ricard will talk about the application. The concluding points were:<br />
<br />
<ul>
<li>Craving is about the experioence not the object</li>
<li>Inappropriate mentation plays a role</li>
<li>Something about the experience of sensory gratification makes it addictive</li>
<li>Addiction may be understood as an extreme end of a spectrum within the family of desire, wanting, attachment and craving</li>
<li>Temporal distinction between craving and grasping - differences in degree, or progressive loss of agency.</li>
<li>Habituation/sensitization is a key to perpetuating the cycle of craving, grasping and action</li>
<li>Key links in the chain of causation suggests different stages for interventions that could break the cycle</li>
</ul>
He used a simple example of how his family did not place the TV in the main living room to illustrate how changing the environment could bring about change - this would be a great example of self-programming, which Marc Lewis discusses in <a href="http://www.memoirsofanaddictedbrain.com/connect/self-programming-how-choice-actually-works/" target="_blank">his blog</a> and I refer to, along with pre-commitment in my <a href="http://addictioncapetown.blogspot.com/2013/11/september-2013-newsletter.html">October Newsletter</a>. <br />
<br />
<br />
Dr Jinpa then spoke about the possibilities of active interventions:<br />
<br />
<ul>
<li>Mindfulness when fantasizing process begins</li>
<li>awareness when craving arises</li>
<li>applying specific antidotes to craving</li>
<li>conscious awareness when craving does lead to action</li>
<li>consciously connecting to resolve not to repeat the act</li>
</ul>
<span style="font-size: large;"><b>Discussion</b></span><br />
<br />
Dr Davidson started the discussion by pointing out that there are many sources of commonality and certainly there seems to be common themes in he presentations of Dr Lewis and Dr Berridge. He spoke about the environmental cues and the role of the hippocampus. There is neurogenesis in the hippocampus, but this may be affected by those with addictive disorders. Dr Volkow spoke how the hippocampus is essential for remembering where things are. She raised the importance of the orbital frontal cortex and its role in salience, as well as the role in craving and context. She asked if there was such a thing as positive craving in the Buddhist context. Dr Jinpa spoke about the narrow and compulsive focus to it, which is perhaps not healthy.<br />
<br />
This brought the discussion to romantic relationships, and this could be seen as the seed of these behaviours. There was the potential for toxicity - this is something that interests me in the light of seeing addiction as a "pathological relationship". This was later built on by Dr Zajonc in relation to how much art is driven by romanticism, and the progress to the modern interpretation of love: <span class="st">“I hold this to be the highest task of a bond between two people: that each should stand guard over the solitude of the other.” ― Rainer Maria Rilke</span><br />
<br />
Dr Lewis spoke of reinforcement through relief, and spoke about the role of trauma in addiction - and this could be the glue that holds the cycle together. Dr Volkow spoke about how some craving in a biological context could be positive, such as between mother and child. This, Dr Zajonc expressed that this could be hijacked for addictive purpose.<br />
<br />
Dr Ricard said that we sometimes lacked the words to clearly define the meaning of what we are saying, and that each word we are using has nuances. He spoke of how compassion can have an anesthetic effect on pain, he spoke about how the concept of "hedonic" and "compassionate" pleasure are different and can have different effects. This them was expanded upon. This conversation at around 1:25:00 into the video is dense with ideas and possibilities.<br />
<br />
This was then framed within the context of social setting and Dr Asmussen Frank spoke of how we could be "distracted" from the cycle of addiction by the community. They spoke about how the environment for learning new skills is important.<br />
<br />
Dr Ricard and Dr Jinpa spoke about care and compassion without attachment and other negative projections, and it takes training to develop this kind of attachment. Dr Bowen asked how we could create awareness of the distinct processes taking place. HH said that the key of awareness was a knowledge of the pros and cons - this would agree with the motivational approaches that have good evidence.<br />
<br />
The Session came to a close after a final comment by Kent Berridge.<br />
<br />
<a href="http://addictioncapetown.blogspot.com/2013/11/mind-life-xxvii-craving-desire-and.html">Return to complete list of sessions and summaries.</a>Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-32823669229211871252013-11-06T17:38:00.002+02:002013-11-18T14:58:00.430+02:00Day 1 - Mind & Life XXVII - Craving, Desire and Addiction<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhj9k3qLbd6wWdjhrJ5TVmo5_X-FtePFl12CL7K2YiO0QY2YPdV5pt-skmVjInfiwEG4nnB3lRs-Ts54b6FEOkaQ3E_F3zZsZMlkpbo5ESjNLn-_19kQdl50YpL-Pk5lQfuzXfnPYEuoZo/s1600/Marc_Lewis__Duncan_de_Fey_72_dpi.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhj9k3qLbd6wWdjhrJ5TVmo5_X-FtePFl12CL7K2YiO0QY2YPdV5pt-skmVjInfiwEG4nnB3lRs-Ts54b6FEOkaQ3E_F3zZsZMlkpbo5ESjNLn-_19kQdl50YpL-Pk5lQfuzXfnPYEuoZo/s200/Marc_Lewis__Duncan_de_Fey_72_dpi.jpg" width="133" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dr Marc Lewis</td></tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoF99MogEnJ9I8TGGNSnrljT8F3TYx00YFoEJ4ktFx5d4wNy01LphJF-nX4mh2qlICjW0PBLhtBgy93IEpBYrRG2lrbv6QpgPISsj2fymec9jd2xqBiXy1FTYj-oxhrPVZ1-ddm2lSBw4/s1600/Davidson_Richard_hs08_2878.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoF99MogEnJ9I8TGGNSnrljT8F3TYx00YFoEJ4ktFx5d4wNy01LphJF-nX4mh2qlICjW0PBLhtBgy93IEpBYrRG2lrbv6QpgPISsj2fymec9jd2xqBiXy1FTYj-oxhrPVZ1-ddm2lSBw4/s200/Davidson_Richard_hs08_2878.jpg" width="133" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dr Richard Davidson</td></tr>
</tbody></table>
<i>You can view the videos on <a href="http://www.youtube.com/watch?v=XIvc6YHFebYhttp://dalailama.com/webcasts/post/300-mind-and-life-xxvii---craving-desire-and-addiction" target="_blank">HERE</a>. </i><br />
<div style="text-align: justify;">
<i>The point of this summary is not to replace the complete video and nor is it fully comprehensive, but rather the intention is to give a brief overview of proceedings so as to assist the reader in determining which sessions they would like to watch in full.</i><br />
<br />
<i>I would also strongly recommend visiting <a href="http://www.memoirsofanaddictedbrain.com/blog/" target="_blank">Marc's blog</a> where he will be offering his first-hand insights into the experience. </i></div>
<br />
The first day of the XXVII Mind & Life gathering includes an introduction and establishment of context by Arthur Zajonic, Diana Chapman Walsh and Richard Davidson. In the afternoon session Dr Marc Lewis, author of <a href="http://www.memoirsofanaddictedbrain.com/blog/" target="_blank">Memoirs of an Addicted Brain</a>, spoke about Craving, Dopamine and the Cycle of Addictive behaviour. <br />
<a name='more'></a><br />
<span style="font-size: large;"><b>Day 1 AM </b></span><br />
<span style="font-size: large;"><b>Introductions and Context</b></span><br />
<br />
Arthur Zajonc mediated the first session. He invited the Dalai Lama (HH) to make an initial introduction. His holiness discussed the commonalities between the 6 billion people on the planet. He said that science was very important to Buddhists, and while scientists have lots of knowledge, they don't know much about the mind.<br />
<br />
In spite of advances in science making life easier, negative emotions lead to many of the problems we need to address. This would lead to happier individuals, which would lead to happier families, communities and human beings, leading to more non-violence. Essentially through training the mind we can reduce violent emotions and create positive emotions.<br />
<br />
One of the purposes of the meeting was to make a contribution to the world.<br />
<br />
Desire must be there for movement. No desire, no action, no progress. His holiness asked the question if addiction, or an exagerated sense of focus, was always bad. Craving, was in essence, too much attachment, and there was lots of mental projection involved.<br />
<br />
Dr Zajonc then pointed out that the search for the truth or knowledge can be perverted (Nazi experiments), as the search for beauty (lust) as the search for goodness (religiousity) and that indeed the possibility for distortion is not only in the realm of addiction.<br />
<br />
He mentioned that the meeting was part of a greater involvement by Mind &Life in the areas of desire and addiction as related to the concept of self, and that the institute had offered small research grants, and this also fit in with the larger realm of secular ethics.<br />
<br />
He said that this was an opportunity for awakening and creating friends across cultures and disciplines.<br />
<br />
Diana Chapman Walsh asked the question: Are we putting our effort in the right places? She spoke around our obsession with the internet, multitasking and social addictions. These could become destructive mind patterns, later to be adopted into "normal" society. She also pointed out that at a previous Mind & Life conference the principles of neuroplasticity had been discussed and that we could indeed train the mind.<br />
<br />
<span style="font-size: large;"><b>Richard Davidson</b></span><br />
<br />
Dr Davidson provided an orientation for the coming days. He pointed out that addiction is not restricted to substances. In contemplative traditions the roots of suffering are considered to be craving, desire and aversion, and these play important roles in addiction. Neuroscience teaches us how these neural circuits are co-opted, creating bias in perception and decision making. There are individual differences in vulnerability and some of these have antecedents in early life.<br />
<br />
He spoke of the brain areas implicated in addiction using a diagram from NIDA similar to these:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEisLX5hBBKnvQSzg1ffewgT-VrSOBqSrEOZY4TICmtPCMVm-ky2Tv5tl2OOgCDzCl03PPDfD1q69yM2Y54-I74jJ-l79-McUCb-5HcCMEkRV12_B8kRTrxx350Y5CiXHv7HBcHu0sVIZfo/s1600/NIDA+BRAIN+1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEisLX5hBBKnvQSzg1ffewgT-VrSOBqSrEOZY4TICmtPCMVm-ky2Tv5tl2OOgCDzCl03PPDfD1q69yM2Y54-I74jJ-l79-McUCb-5HcCMEkRV12_B8kRTrxx350Y5CiXHv7HBcHu0sVIZfo/s400/NIDA+BRAIN+1.jpg" width="371" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2LAmHLtIdyO3L3DHVt7A9wwkNJ9dQc5PBnmLFV4h44W08XGJbH1G1WQcn9HQNZhra6XD_B6TDTfkRLJDp40LPnC8CQF2s84vq531DcFoFtnEUM2A3dFb1eOUowcnXFq5BBZ_E0oN_MBc/s1600/NIDA+2.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2LAmHLtIdyO3L3DHVt7A9wwkNJ9dQc5PBnmLFV4h44W08XGJbH1G1WQcn9HQNZhra6XD_B6TDTfkRLJDp40LPnC8CQF2s84vq531DcFoFtnEUM2A3dFb1eOUowcnXFq5BBZ_E0oN_MBc/s400/NIDA+2.gif" width="400" /></a></div>
<br />
Dr Davidson discussed how memories become distorted and salience is increased and how disruption of the pre-frontal cortex (PFC) leads to the erosion of free will. In response to a question from HH he said this was seen as a consequence, not a cause. He used this diagram to show the differences in process between a "normal" and "addicted" individual:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwzhLPfSJ0OGnXFZjyDaeXKRW6JDs561jZ0wFGpv8_avp_UGDSxeYTUVKefC_VRHGqQoxap9RokhLDgwHnJv2doF7XLczpCD23XedRokOqePi8-5_5fTzjayxA_OCAuB4qNJDsaKCI8ws/s1600/NIDA3.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwzhLPfSJ0OGnXFZjyDaeXKRW6JDs561jZ0wFGpv8_avp_UGDSxeYTUVKefC_VRHGqQoxap9RokhLDgwHnJv2doF7XLczpCD23XedRokOqePi8-5_5fTzjayxA_OCAuB4qNJDsaKCI8ws/s400/NIDA3.gif" width="400" /></a></div>
<br />
<br />
<br />
The decreased activity leads to ethical impairments:<br />
<ul>
<li>PF impairments lead to problems with ethics of constraint</li>
<li>Limbic and ventral striatial impairments compromise ethics of virtue and compassion.</li>
</ul>
He also briefly discussed dopamine, but explained that others would discuss this in detail later.<br />
<br />
He then quoted the <a href="http://dunedinstudy.otago.ac.nz/news/children-with-more-self-control-turn-into-healthier-and-wealthier-adults" target="_blank">Dunedin study</a> that followed 1000 children from age 4-5 into adulthood, examining issues of delayed gratification. He discussed how interventions addressing self control might reduce a panoply of societal costs.<br />
<br />
Dr Davidson showed a video of the<a href="http://www.youtube.com/watch?v=Yo4WF3cSd9Q" target="_blank"> marshmallow test with some children</a>, while explaining the principles of delayed gratification.<br />
<br />
Dr Davidson then explained how the various brain areas develop at different rates thereby creating a particularly vulnerable stage during adolescence. He quoted <a href="http://heckman.uchicago.edu/" target="_blank">James Heckman</a>: "There is a return of $7 for every $1 invested in quality pre-school programs."<br />
<br />
Dr Davidson briefly described his own <a href="http://www.investigatinghealthyminds.org/" target="_blank">pre-school kindness curriculum</a> and the positive outcomes, concluding that a simple mindfulness curriculum can lead to improved ethics of restraint in pre-school children.<br />
<br />
He briefly discussed the very high levels of alcohol use disorder amongst Tibetans and the particular genetic vulnerability they may suffer.<br />
<br />
In conclusion, Dr Davidson asked what are the major outstanding outstanding questions when it comes to addiction?<br />
<ul>
<li>To what degree are drug addiction and other forms of addiction similar?</li>
<li>What are the predisposing factors that make some people more vulnerable?</li>
<li>How should the issue of free will be considered in relation to addiction?</li>
<li>Are there preventative strategies that can be implemented early in life to minimize later problems?</li>
<li>What specific contemplative approaches may act as an antidote?</li>
</ul>
He ended his talk at this point.<br />
<br />
<span style="font-size: large;"><b>Day 1 PM - Marc Lewis</b></span><br />
<b><span style="font-size: large;">Craving, Dopamine and the Cycle of Addictive Behaviour </span></b><br />
<br />
Marc started his talk by showing some images of people who were affected by drug addiction so as to establish the human context.<br />
<br />
Marc's outline was as follows:<br />
<ul>
<li>Addiction works through repeating cycles, both in mind and brain</li>
<li>Craving relies on dopamine</li>
<li>To overcome craving, addicts need to develop self-trust</li>
</ul>
HH asked if craving was always negative. The point was raised that addiction is similar to falling in love, but generally craving is considered a "bad" thing.<br />
<br />
Dr Lewis discussed his own experience of addiction, which can be read about in his excellent book, <a href="http://www.memoirsofanaddictedbrain.com/" target="_blank">Memoirs of an Addicted Brain</a>.<br />
<br />
Dr Lewis related the importance of environment and used the rat park experiment as an example. <a href="http://www.stuartmcmillen.com/comics_en/rat-park/#page-2" target="_blank">Here is a really neat comic strip about rat park</a>. He then went on to give a brief description of the behavioural cycle of addiction:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitqyMQUAgKcfSelhwErVEXAz56aqmAnpaiLQgPzVUjrebRVtLS8V44yv4CKaJGma7rMNx4nzeJc5ZG3nPKexKHsV50S1zfrIwp5vrzwQaQ7C6bPwcEGpOB5l2k3F-febwU-XmAVquBIHQ/s1600/Slide5.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitqyMQUAgKcfSelhwErVEXAz56aqmAnpaiLQgPzVUjrebRVtLS8V44yv4CKaJGma7rMNx4nzeJc5ZG3nPKexKHsV50S1zfrIwp5vrzwQaQ7C6bPwcEGpOB5l2k3F-febwU-XmAVquBIHQ/s400/Slide5.JPG" width="400" /></a></div>
<br />
Dr Lewis went on to explain how this process is echoed in the brain through various neurological processes. He discussed how triggers lead to imagining which through the actions of Dopamine causes craving which causes planning, which leads to action, and this repeats in a cycle.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoNzQOUtDwj4YaVUR2nLAvw1I99eeJzFui0B21Y8Xy4QDdIswM2mnRs2ghK9g12ODK9pkQ1VjUXLJa-ak7RY07mCGdI1VZa3YJ_OklxuWxWYtKAKg2cWAxlsftoVwlvi7JgopMaEV_hjI/s1600/Slide7.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoNzQOUtDwj4YaVUR2nLAvw1I99eeJzFui0B21Y8Xy4QDdIswM2mnRs2ghK9g12ODK9pkQ1VjUXLJa-ak7RY07mCGdI1VZa3YJ_OklxuWxWYtKAKg2cWAxlsftoVwlvi7JgopMaEV_hjI/s400/Slide7.JPG" width="400" /></a></div>
<br />
Dr Lewis then spoke about the relationship between this cycle and the Buddhist cycles of life and their ideas of suffering. He spoke specifically about 5 domains and how the relate to addiction:<br />
<ul>
<li>Contact - a trigger</li>
<li>Craving - Craving</li>
<li>Grasping - Planning and Getting</li>
<li>Becoming - State of being high</li>
<li>Pain/Despair - loss of high</li>
</ul>
He then focused on craving. Dr Lewis explained that neuroscience helps us understand why craving is so nasty. He explained briefly how dopamine motivates us. He then explained how dopamine narrows attention and creates desire at the same time, leading to delay discounting:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqEUjvK0r7zZvFu0Iw1ZtsJh8Gk9C6YfK6jI5PlAXgFsTamkgxsV6BkRV-cxBf6NW4m117oBrCA5FHJn75CYzkVlhFpooUdy-nBxqXaaW-UL5hiyvxjrTaKDTWVZRLRVk3lKy4w_lE6kw/s1600/Slide14.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqEUjvK0r7zZvFu0Iw1ZtsJh8Gk9C6YfK6jI5PlAXgFsTamkgxsV6BkRV-cxBf6NW4m117oBrCA5FHJn75CYzkVlhFpooUdy-nBxqXaaW-UL5hiyvxjrTaKDTWVZRLRVk3lKy4w_lE6kw/s400/Slide14.JPG" width="400" /></a></div>
<br />
The discussion led to considering issues such as restraint, and how not only the individuals are different, but also individuals experience different rates of exchange based on experience, learning and level of addiction. It was pointed out that addiction is a developmental process.<br />
<br />
Dr Lewis then discussed how addicts lose trust in self through repeated failures at restraint. They eventually trust only in the drug, which also betrays them, and this leads to a miserable existence. Dr Lewis jokingly asked HH what the solution was. Taking the question seriously, the Dalai Lama suggested that to some degree the answer lay in understanding and environment.<br />
<br />
Dr Lewis suggested the need for some form of internal dialogue with future self, or perhaps with the higher self, however higher self could become judgmental, which could reinforce the negative cycle. HH suggested that this could lead to anger and hopelessness. Dr Lewis suggested that some form of internal self agreement need to be reached.<br />
<br />
He finished off by explaining that this is perhaps how it has worked for him.<br />
<br />
<span style="font-size: large;"><b>Discussion</b></span><br />
<br />
Dr Lewis ask HH how one could develop compassion for self. HH commented that when he heard of the concept of self-hatred for the first time, he could not understand this. As he thought about it, he felt that there was an underlying self-love, causing the self anger because of failure to meet ones own expectations. Once there is a level of trust, there is an ability to accept the harsher words. Personally I feel that this echoes my personal belief that in treating addictive disorders the establishment of a good and trusting therapeutic bond is essential, and this trust that the patient develops in the therapist can later be transferred to self.<br />
<br />
Dr Lewis expressed that this is perhaps why group work with peers can be so helpful, because of the shared experience and mutual trust. He then brought up the issue of shame and how painful it is to addicts. HH pointed out that in Buddhist context shame is seen as a sign of morality, but in the English word there is an irredeemable quality to it. What struck me was the approach to things that may be considered negative - it was more encompassing, seeing the good and bad in the concept.<br />
<br />
Dr Halifax asked Dr Lewis what the role of remorse was. He explained that a small proportion of the addicted population disengage and cannot integrate their remorse into their narrative, and end up going in a circle. The discussion moved to ethics, and ethics as a direction. Dr Halifax wondered what the view of ethics and remorse within the 12-step programs. HH pointed out that with such a heterogeneous population it must be difficult to develop a single treatment modality. <br />
<br />
The question was asked if a knowledge of the neuroscience could assist an addict in recovery. Dr Lewis commented that his book had resulted in lots of positive response from people who had benefited from it, which suprised him as it was not intended to be a self-help book! Dr Davidson explained how the concept of plasticity can help develop hope in those recovering from addictive disorders. Dr Berridge hoped that future knowledge and understanding can inform treatment.<br />
<br />
Dr Davidson spoke about targeting specific circuits. He made the vital point that currently we can target specific areas of the brain more effectively through behavioural methods than through pharmacology currently available. In other words, we can develop specific training exercises that are designed to target specific brain systems.The point was made that mindful awareness can slow down or perhaps interrupt the addictive cycle. <br />
<br />
Dr Zajonc suggested that perhaps there was a positive virtue that gets diverted or substituted by the delusion of the drug - perhaps this is the healthy attachment to the family? Dr Lewis referred to the book <a href="http://www.amazon.com/Drinking-Love-Story-Caroline-Knapp/dp/0385315546" target="_blank"><i>Drinking: A love story</i></a>, and related how the drug can be the source of a relational comfort. <br />
<br />
After a brief discussion around the benefits of AA, Dr Lewis discussed the rigidity of the cycle of addiction. He described very briefly some of the models of addiction, and expressed his hope that the discussions would help him understand craving as a part of the normal adaptive human experience, and perhaps addiction was a branch off this "normal" behaviour.<br />
<br />
HH pointed out that the higher emotions, such as compassion, require training and awareness while emotions such as craving are more instinctive. Craving is seen as the root of unenlightened existence, with ignorance and distortion underlie it. He suggested that ignorance is perhaps the starting point, an ignorance of the deeper understanding of reality. If we are able to bring awareness we are able to understand consequence, and that can help us exercise restraint.<br />
<br />
The meeting then drew to a close.<br />
<br />
<a href="http://addictioncapetown.blogspot.com/2013/11/mind-life-xxvii-craving-desire-and.html">Return to complete list of sessions and summaries.</a>Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-53200398159210452632013-11-02T20:53:00.001+02:002013-11-03T14:43:42.775+02:00October 2013 Newsletter<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjB_uPGMq3vyyY0Y1Wb6WIsaKdhhyphenhyphen61L_-YsvMRYLJ7GzgY_YlsDlZaLzurtF8FRQEQF1gfysR7QZ_lrC5rI0uCODRY9XRZ9lGZ7xGq-IFzmAjS73SPv8t8p2P8mroe-yiLIDozda75h5k/s1600/Dan+Siegel+and+me.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="170" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjB_uPGMq3vyyY0Y1Wb6WIsaKdhhyphenhyphen61L_-YsvMRYLJ7GzgY_YlsDlZaLzurtF8FRQEQF1gfysR7QZ_lrC5rI0uCODRY9XRZ9lGZ7xGq-IFzmAjS73SPv8t8p2P8mroe-yiLIDozda75h5k/s200/Dan+Siegel+and+me.jpg" width="200" /></a></div>
<div style="text-align: justify;">
It's almost the end of the year. In our setting, because we are moving into summer and festivities, this usually sees a drop in those seeking help for their substance use issues, but often their is a brief spike shortly after new year as resolutions are made and the after-effects of the partying are felt! I recently attended the Dan Siegel Interpersonal Neurobiology workshop that was held in Cape Town, hence the photo. In this month's edition of Addiction Information we hope to spark some thought around some controversial topics, but one topic that should become less controversial is that of opioid substitution therapy, for which their seems to be mounting evidence as a stand-alone treatment modality.</div>
<br />
We look at: An opioid addiction switch, Behavioural Interventions and Buprenorphine Maintenance, Chronic Care, Remission Rates, Choice and Will Power, Dr Dan Siegel and the Mind & Life Conference.<br />
<br />
<a name='more'></a><br />
<b><span style="font-size: large;">Opiate Addiction Switch?</span></b><br />
<div style="text-align: justify;">
Recent research by <a href="http://www.uwo.ca/anatomy/department/laviolettes/slaviolette.html" target="_blank">Dr Steven Laviolette</a> has identified a molecular switch in the amygdala of rats with chronic exposure to heroin. This switch is linked to environmental triggers. The paper,<i><a href="http://www.jneurosci.org/content/33/37/14693.abstract" target="_blank">Opiate Exposure and Withdrawal Induces a Molecular Memory Switch in the Basolateral Amygdala between ERK1/2 and CaMKIIα-Dependent Signaling Substrates</a></i> was recently published in the Journal of Neuroscience. The perpetuation of heroin addiction is often caused by environmental cues having an abnormally strong link to pleasurable memories related to heroin use. What Laviolette and his team discovered was that the move from use to addiction was linked to a change in the way memories were formed in the amygdala.</div>
<br />
<div style="text-align: justify;">
In a non-dependent state they found that extracellular signal-related kinase (ERK) was recruited in the creation of drug-related memories. Once the addiction had developed a functional switch to a seperate molecular memory pathway occurred. This pathway was controlled by CaMKII. What is also interesting is that the initial memory process involving ERK requires intra-basolateral amygdala D1 transmission, whereas the addiction phase involves a D2 mediated mechanism.<br />
<br />
This is indeed really fascinating when we consider the roles of D1 and D2 receptors and memory in addiction, and I look forward to further research in this area.<br />
<br />
<span style="font-size: large;"><b>Behavioural Interventions and Buprenorphine Maintenance</b></span><br />
It seems that every month there is another research piece that says there is little benefit when adding behavioural therapies to maintenance therapies. <a href="http://addictioncapetown.blogspot.com/2013/09/august-2013-newsletter.html" target="_blank">Last month</a> it was methadone and counselling, and this month it is Buprenorphine and CBT and Contingency Management. Ling and others conclude "There remains no clear evidence that cognitive behavioural therapy and contingency management reduce opiate use when added to buprenorphine and medical management in opiate users seeking treatment." The paper, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23734858" target="_blank"><i>Comparison of behavioral treatment conditions in buprenorphine maintenance</i></a>, adds to the body of evidence that shows effective pharmacology is often all that is needed in the case of heroin addiction where there is no co-occuring psychiatric disorders (personally, I may add severe environmental/social challenges - more research in this area is needed).<br />
<br />
What stands out to me is the manner in which the treatment was administered: There was a significant incentive to engage in the treatment - gift cards to a potential value of US$410 could be earned if all assessments were completed over the 52 weeks. Then there were also twice weekly urine tests for 18 weeks, and there was a discussion around the results, and perhaps most importantly, dosages were adjusted until an optimal therapeutic dose was established. The outcome showed at least a 50% suppression in illicit opioid use, even at the most conservative measures.<br />
<br />
I would like to see more studies with a more representative treatment setting - indeed we may find that application does not match the research findings, in which case we would need to improve the treatment application. I would also like to see research done in more vulnerable populations with significant social problems, such as homelessness, and using more intensive outpatient services (the study by Ling used a single CBT session per week). A recent review of <i><a href="http://www.sciencedirect.com/science/article/pii/S0376871613004225" target="_blank">OST studies in low and middle income countries</a></i> as shown that quality of life does improve, although I have not looked into this in any depth.<br />
<br />
Certainly I have shifted my position regarding maintenance therapies from "showing promise" to "essential option" when it comes to treating opioid dependency.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6nDaBGglY6NFkbOz-ZlM4QoQtMnrhTaw2_63d-cuXWo9nEnntC0umfFw3my2788RSaPw9nyeSxKUqOBtEoUIlvvgDH4M8itqlSZ4Oyrv7dK_sN7whWAacrLJ5XK5thcH28Wbj3SBfBg4/s1600/131478.strip.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="196" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6nDaBGglY6NFkbOz-ZlM4QoQtMnrhTaw2_63d-cuXWo9nEnntC0umfFw3my2788RSaPw9nyeSxKUqOBtEoUIlvvgDH4M8itqlSZ4Oyrv7dK_sN7whWAacrLJ5XK5thcH28Wbj3SBfBg4/s640/131478.strip.gif" width="640" /></a></div>
<br />
<span style="font-size: large;"><b>More evidence for Opioid Substitution Therapy</b></span><br />
<a href="http://www.ncbi.nlm.nih.gov/pubmed/23834887" target="_blank"><i>Predicting biopsychosocial outcomes for heroin users in primary care</i></a> is a fascinating longitudinal prospective cohort study conducted in at a Primary Care Addiction Service in Shefield, England over 11 years. Over the period 53% of the patients achieved a drug free discharge (22%) or retention in medically assisted recovery. 21% dropped out, including those in prison or who died<i>,</i> which is significantly lower than the usual 40% cited in most literature.<br />
<br />
One of the key findings was that retention in a continuous treatment process produced significantly better results as opposed to having revolving door patients - this, as the authors point out, has significant implications regarding public policy. Overall, there was a 98% reduction in heroin and opiate use. <br />
<br />
<b><span style="font-size: large;">Is there benefit from chronic care management?</span></b><br />
Possibly the most controversial study in this period was published in the JAMA: <a href="http://jama.jamanetwork.com/article.aspx?articleID=1738895" target="_blank"><i>Chronic care management for dependence on alcohol and other drugs: The AHEAD randomized trial</i>.</a> The conclusion of this paper reads: "<span class="Abstract 0" id="scm6MainContent_ucArticleContent_rptSections_lblSection_0">Among persons with alcohol and other drug dependence, CCM compared with a primary care appointment but no CCM did not increase self-reported abstinence over 12 months. Whether more intensive or longer-duration CCM is effective requires further investigation." </span><br />
<br />
<span class="Abstract 0" id="scm6MainContent_ucArticleContent_rptSections_lblSection_0">The authors describe chronic care management as "</span>multidisciplinary patient-centered proactive care, a way to organize services that provides coordination and expertise, and has been effective for depression, medical illnesses, and tobacco dependence (a substance use disorder)". What this meant in the application of this study was that the individuals randomized to the CCM group received not only an appointment with the primary care physician, but also motivational enhancement therapy, relapse prevention and onsite treatment, as well as referrals and social work assistance. That may sound like a lot of services, but in fact service the average number of appointments was only 6.This would certainly not constitute "treatment". What was shown was that a greater number of visits to the AHEAD clinic (>3 vs. <3) had a significant effect on abstinence levels.<br />
<br />
The study only looked at 1-year outcomes. I would have been interested to look at specific sub-populations within the study, such as those who had decided to engage in in-patient services or self-help groups, but this data was not reported. Interestingly the alcohol group did show a statistically significant improvement. Perhaps the primary care environment is suitable for the delivery of some services, but not for others.<br />
<br />
One of the authors, Dr Samet, who <a href="http://newsatjama.jama.com/2013/09/17/author-insights-chronic-care-model-may-not-work-for-patients-with-addiction/" target="_blank">was interviewed</a>, had this to say: <br />
<blockquote class="tr_bq">
"If you feel sometimes that treating patients with addiction is even harder than treating asthma or depression, there may be some basis for that feeling in reality. As shown in these results, a care system that worked for other chronic diseases didn’t work for these patients. <br />
Moving forward, we need to be creative with our patients who have these problems. In terms of improving quality of care, we need both randomized control trials and observational studies. I wouldn’t steer the ship away from primary care treatment; the reality is that most patients with depression and addiction get their care in primary care. Do we need specialist help? Yes, but we need a primary care system that will do its bit as well."</blockquote>
<b><span style="font-size: large;">We do remit</span></b><br />
Most definitions of the term "addiction" will use the words "chronic" and "progressive". But what do the remission rates of those who can be diagnosed with substance use disorders say? While looking into the paper cited in the previous section, I came across Gene Heyman's very well written paper <i><a href="http://www.ncbi.nlm.nih.gov/pubmed/23330937" target="_blank">Quitting Drugs: quantitative and qualitative features.</a></i> <br />
<br />
Heyman has relied on four major epidemiological studies to examine remission rates. The main findings of his analysis may surprise many of us: Firstly, addictive disorders are generally not chronic, with approximately 80% showing remission for a period of a year or more. In fact, the chances of an individual giving up cocaine, given enough time, are in the region of 98%.<br />
<br />
The second even more suprising finding is that remission rates remained constant. That means that no matter how long an individual had been using, the likelihood of remission in any particular year remained unchanged. If addiction was a progressive disease, this would not be true. Heyman states that addiction "involves a steady but fragile state that can abruptly shift to a new state".<br />
<br />
Heyman usefully examines a number of other issues around the data, such as racial/ethnic differences and the legal status of drugs in relation to remission. Many of the main findings have also been supported and discussed in another study: <a href="http://www.ncbi.nlm.nih.gov/pubmed/21077975" target="_blank"><i>Probability and predictors of remission of life-time nicotine, alcohol, cannabis or cocaine dependence: Results from the National Epidemiological Survey on Alcohol and Related Conditions</i>.</a><br />
<br />
For a more complete analysis of both papers, I would highly recommend the <a href="http://findings.org.uk/" target="_blank">Drug and Alcohol Findings</a> site.<br />
<br />
In a separate paper, Heyman draws some conclusions that would be considered very controversial by many in the addiction field. In the paper <i><a href="http://www.readcube.com/articles/10.3389/fpsyt.2013.00031" target="_blank">Addiction and choice: theory and new data</a></i>, he disputes the brain disease model, and proposes that the data supports his conclusion that addiction is more clearly "choice" based than "compulsion" based. This is not a comfortable conclusion, but when we look at research that shows that motivational interviewing and other motivational interventions have a strong evidence base, we must at least consider that there may be truth in Heyman's conclusions. Having said this, I think it is quite safe to conclude that there are degrees of choice, and in life there are very few opportunities to exercise "free" choice.<br />
<br />
<span style="font-size: large;"><b>Choice and Will Power </b></span><br />
Marc Slors discusses the issue of free choice in his paper <i><a href="http://www.academia.edu/2048332/Conscious_Intenting_as_Self-Programming" target="_blank">Conscious Intending as Self-programming</a></i> (Thank you <a href="http://www.memoirsofanaddictedbrain.com/connect/self-programming-how-choice-actually-works/" target="_blank">Marc Lewis for pointing this paper</a> out to me and your discussion around it). He starts by pointing out that much of the discussion these days revolves around the idea that we actually have very little conscious control over our behaviour. In other words, "free choice" is not as free as we may suspect, but is rather the result of a number of underlying unconscious processes. When it comes to our conscious actions "there is merely temporal succession and no causation." Slors argues that while this may be true of proximal (short-term) conscious intentions, distal intentions may result from earlier conscious intention, allowing us a greater degree of control over our behaviour. He argues that when we make distal decisions, we may well be evaluating various scenarios, which requires consciousness. Slors theorizes that if we create clear distal intentions, we undertake "self-programming", and this can inform proximal actions in a way that facilitates distal choices, ensuring the chosen outcome.<br />
<br />
The relevance for addiction is quite profound. Indeed we know that a trigger can result in a cascade of events that happen so quickly that there is no chance for rational thinking. Or rather, immediate intentions are not congruent with actions or behaviours. This would seem to indicate that planning ahead may be the best way to prevent relapse.<br />
<br />
This idea is supported in another recent paper <i><a href="http://www.cell.com/neuron/retrieve/pii/S0896627313004480" target="_blank">Restricting Temptations: Neural Mechanisms of Precommitment</a>. </i>Will power is something that is in short supply when it comes to addictive disorders, and delay discounting and ego depletion tend to over power will power in the presence of the drug of choice, or even a trigger. It seems that a much more effective strategy is precommittment. Precommitment is when the individual makes advance decisions about their actions when they are aware of possible future failures in will power. For example, putting money on a 30-day call. In the case of addiction, it may be choosing a different route home so as not to pass the dealer, even though it will take much longer. Dirk Hanson provides a brief summary of this paper <a href="http://addiction-dirkh.blogspot.com/search?updated-max=2013-09-08T16:30:00-05:00&max-results=7" target="_blank">here</a>. The bottom line is that precommitment seems to be a viable means of avoiding future failure, or to frame it from Slors perspective, it may be a form of self-programming that will improve our ability to make conscious choices.<i> </i><br />
<br />
It is also interesting to note that different brain regions are involved in these processes, with the DLPFC, PPC and inferior frontal gyrus being activated when exerting will power, while LFPC became active during precommitment and showed increased functional connectivity with the DLPFC and PPC and the relationship between impulsivity and LFPC connectivity was mediated by value-related activation in ventromedial PFC.<br />
<br />
So much for "just for today"!<br />
<br />
<br />
<span style="font-size: large;"><b>Dr Dan Siegel </b></span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5aGot3B3jhtmb68ShZMg8VmCVEosV08aagJ-kulXqt0cb57N1ZXsaj-qECSkpLDcLK6xrJXRA0m5oZcvSZyh6DAmU_MC3hi12ugIPQeQoC2yTApZJliCJWMpc9EVUgRmPEaa78FtGcAs/s1600/dan+siegel.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="132" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5aGot3B3jhtmb68ShZMg8VmCVEosV08aagJ-kulXqt0cb57N1ZXsaj-qECSkpLDcLK6xrJXRA0m5oZcvSZyh6DAmU_MC3hi12ugIPQeQoC2yTApZJliCJWMpc9EVUgRmPEaa78FtGcAs/s200/dan+siegel.jpg" width="200" /></a></div>
As mentioned earlier, I attended the Dan Siegel training workshop entitled Mindsight & Interpersonal Neurobiology. Siegel is currently the clinical professor of psychiatry at UCLA and he is the <a href="http://marc.ucla.edu/" target="_blank">Co-Director of the mindful Awareness Research Center </a>. Dr Siegel also coined the term "<a href="http://drdansiegel.com/about/mindsight/" target="_blank">mindsight</a>" - "to describe our human capacity to perceive the mind of the self and others. It is a powerful lens through which we can understand our inner lives with more clarity, integrate the brain, and enhance our relationships with others. Mindsight is a kind of focused attention that allows us to see the internal workings of our own minds. It helps us get ourselves off of the autopilot of ingrained behaviors and habitual responses. It lets us “name and tame” the emotions we are experiencing, rather than being overwhelmed by them."<br />
<br />
Although Dr Siegel's work is not specifically related to addiction, I found much of it very helpful and relevant to the field. His desire to seek similar patterns in diverse approaches is something that I think is essential when trying to develop an understanding of addictive disorders. <br />
<br />
I have also used his <a href="http://drdansiegel.com/resources/wheel_of_awareness/" target="_blank">wheel of awareness</a> mindfulness practice to good effect in contemplation groups. I would strongly advise those who would like to get a better understanding of issues such as attachment and mindful awareness in addiction to have a look at Dan Siegel's work. <br />
<br />
<span style="font-size: large;"><b>Mind & Life XVII</b></span> <br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgadvLpPF_-B5lbYd8EPNq2yw8pNBJg56qY7vENzpsl1XgfhMA3Os9yve1jmVOSZMG8G9OydF8xF6lYjb4oEy4y2i_0RuyIAY6nuNcBwL2Nuy6NrktGIw9O54JGx-ppnpMlVK2aa9d2UDM/s1600/mindlife.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgadvLpPF_-B5lbYd8EPNq2yw8pNBJg56qY7vENzpsl1XgfhMA3Os9yve1jmVOSZMG8G9OydF8xF6lYjb4oEy4y2i_0RuyIAY6nuNcBwL2Nuy6NrktGIw9O54JGx-ppnpMlVK2aa9d2UDM/s1600/mindlife.jpg" /></a>Speaking of mindfulness, the Dalai Lama has been hosting the Mind & Life conference which this year focuses on craving, desire and addiction. This has brought a number of leading thinkers into the same room to discuss their insights and debate the various views that their various backgrounds bring to our understanding. Delegates and their topics are:<br />
<br />
<a href="http://www.memoirsofanaddictedbrain.com/" target="_blank">Marc Lewis</a>: The Role of Craving in the Cycle of Addictive Behaviour<br />
<a href="http://www.lsa.umich.edu/psych/research&labs/berridge/researchteam/kent_berridge/" target="_blank">Kent Berridge:</a> Brain Generators of Intense Wanting and Liking<br />
<a href="http://en.wikipedia.org/wiki/Geshe_Thupten_Jinpa" target="_blank">Thupten Jinpa:</a> Psychology of Desire, Craving and Action<br />
<a href="http://www.drugabuse.gov/about-nida/directors-page" target="_blank">Nora Volkow</a>: The Role of Dopamine in the Human Addicted Brain<br />
<a href="http://pure.au.dk/portal/en/persons/vibeke-asmussen-frank%2836613d04-3a16-4160-b63b-b5d8b12f8f67%29.html" target="_blank">Vibeke Asmussen Frank:</a> Beyond the Individual: The Role of Society and Culture in Addiction<br />
<a href="http://www.matthieuricard.org/en/" target="_blank">Mitthieu Ricard:</a> From Craving to Flourishing: Buddhist Perspectives on Desire<br />
<a href="http://www.religion.emory.edu/faculty/farley.html" target="_blank">Wendy Farley:</a> Contemplative Christianity, Desire, and Addiction<br />
<a href="http://socant.chass.ncsu.edu/faculty_staff/skbowen" target="_blank">Sarah Bowen:</a> Application of Contemplative Practices in Treatment of Addiction<br />
<br />
The discussions have been webcast, and have been extremely interesting. The videos can be found on <a href="http://www.youtube.com/watch?v=rCK81vNCtz8&list=PLPx-_Z9jSc5kgmIucJe4GlbNE8uAjhkgj" target="_blank">YouTube</a>.<br />
<br />
<b><span style="font-size: large;">Thought of the Month</span></b><br />
<blockquote class="tr_bq">
In the words of <span class="userContent" data-ft="{"tn":"K"}">Victor Frankl: "between stimulus and response there is a space. In that space is our power to choose our own personal response and in that response lies our growth and freedom." <br />
<br />
Unfortunately narrowed focus, implicit memory and learned response all shorten the gap between stimulus and reaction. By becoming more mindful and aware, we can exploit that space, expand it and explore that opportunity for growth and become free of our perceived constraints.</span></blockquote>
<br />
Until next time. <br />
<br />
<br /></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-1332611413439746732013-09-10T08:55:00.000+02:002013-11-03T07:46:46.456+02:00August 2013 Newsletter<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_aOXVKRnR0TcuRjnxzrMflcdwERfM4OoS08QUbNcq0DALlmCLH5gwZ6hNZpqwaSvpquNAjiu4dnOtE-cHBVC1KRYqqK8Kg51e5LXcoTnXZCjSyU9E5C-H2iMCAE57puQZxGjxTJdW1ec/s1600/heart.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="133" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_aOXVKRnR0TcuRjnxzrMflcdwERfM4OoS08QUbNcq0DALlmCLH5gwZ6hNZpqwaSvpquNAjiu4dnOtE-cHBVC1KRYqqK8Kg51e5LXcoTnXZCjSyU9E5C-H2iMCAE57puQZxGjxTJdW1ec/s200/heart.jpg" width="200" /></a></div>
<div style="text-align: justify;">
This newsletter was delayed, but I have a reasonably good excuse. I had a heart attack. Not to be put down by something minor, I used the opportunity to find out how much emergency room personnel know about addiction. Not very much it appears! I wrote about it in this piece: <a href="http://www.addictioncapetown.blogspot.com/2013/08/substance-use-knowledge-amongst.html" target="_blank">Substance Use Knowledge Amongst Emergency Room and General Medical Personnel.</a> I am back at the office and its business as usual, which in the addiction field is anything but usual. Hope you enjoy this months newsletter, because it very nearly didn't happen!</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
This time we talk about: The Reward Pathway of Opioid Addiction, Does Maintenance Therapy Need Counselling?, The Scottish Review of Methadone Treatment, Is One Too many?, The Multistep Theory of Transition to Addiction, Internet Addiction, Scott Kellogg.</div>
<a name='more'></a><br />
<span style="font-size: large;">The not-so-common Reward Pathway? </span><br />
<div style="text-align: justify;">
Has dopamine been getting a bad rap? In an article in <a href="http://onlinelibrary.wiley.com/doi/10.1111/adb.12073/full" target="_blank">Addiction Biology</a> titled<span style="font-weight: normal;"><span style="font-size: normal;"><span class="mainTitle"> <i>Investigating expectation and reward in human opioid addiction with [<sup>11</sup>C]raclopride PET</i> </span></span></span>the authors have created an experiment to test striatal levels of dopamine when administering heroin to former heroin dependent individuals who are now stabalised on either buprenorphine or methadone. As we know, it has often been postulated that the rewarding properties of many substances of abuse lies in their ability to elevate striatal dopamine levels. Perhaps suprisingly the paper found: "There was no detectable increase in striatal dopamine levels to either heroin reward or expectation of reward." Is this really suprising? Well not really. Kent Berridge suggested that dopamine was not necessary as part of the reward mechanism underlying opiate use disorders.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
After discussing this a bit, <a href="http://www.memoirsofanaddictedbrain.com/connect/the-face-of-pleasure/" target="_blank">Marc Lewis</a> made some suggestions:</div>
<blockquote class="tr_bq">
<div style="text-align: justify;">
"The four probable explanations of the null finding are presented by the authors, though not with much guidance as to how to think about them.<br />
1.The heroin shots were passive — the subject knew that he didn’t have to do a thing to get his shot. So maybe DA only gets activated when drug-taking is active, not passive.<br />
2. The PET methodology is simply too insensitive to pick up DA differences at this scale.<br />
3. Despite what looks like sufficient statistical power, ten subjects just weren’t enough to get the effect.<br />
4. Methadone blunts the system enough to quash or even reverse differences in DA."</div>
</blockquote>
<div style="text-align: justify;">
Point 1 and 4 are very interesting to me. Also, if we could replicate these results in individuals who are not on substitution therapy, could it be that maybe we have this whole “common reward pathway” thing wrong – if so we would have to re-write the whole book on addiction and that maybe we need more specific interventions based on the individual type of drugs used.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Considering point 4, my immediate thought on reading this paper was: the results showed that the agonist (or partial agonist in some) therapy was doing its work and blunting the effect was due to this – for me this would be a great explanation because it would show that these therapies do work by reducing expectation, and that even with the sensitised stimulus (visual and the DOC), there is a muted response. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
It would be great if we could repeat this experiment using a combination of maintained and non-maintained opiate users. Any thoughts would be appreciated.<br />
<br />
<span style="font-size: large;"><b>Does Maintenance Therapy Need Counselling?</b></span><br />
I have in previous newsletters questioned the validity of research that claims that maintenance therapy for heroin addicted individuals is sufficient and that further counselling or therapy is not needed. I have, <a href="http://addictioncapetown.blogspot.com/2013/01/cbt-doesnt-work-for-heroin-addiction.html" target="_blank">in this article</a>, suggested that perhaps we are measuring the wrong things. There is also a worrying divide that is occurring amongst treatment professionals regarding Maintenance Therapy, and <a href="http://addictioncapetown.blogspot.com/2013/05/opioid-substitution-therapy-treatment.html" target="_blank">I have discussed this here</a>. A study has just been published: <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03700.x/full" target="_blank">Randomized trial of standard methadone treatment compared to initiating methadone without counseling: 12-month findings</a>. For a summary and some thoughts around this paper, refer to the ever-reliable<a href="http://findings.org.uk/count/downloads/download.php?file=Schwartz_RP_10.txt" target="_blank"> findings site</a>.<br />
<br />
The conclusions tend to show that there is little significant difference between initiating methadone treatment with or without counselling, either "as usual" or with intensive therapy. This would indicate that there is no reason to delay maintenance therapy because additional services are not available, or, as I would strongly agree, that maintenance should not be terminated because the patient does not attend mandated counselling sessions.<br />
<br />
Where the counselling did make a difference was in terms of methadone dose: the dossages of those who received the "expert" counselling were significantly lower than those that didn't, and the ones who received the intensive counselling exited treatment earlier - but these extrapolations are not evidence that this is so as there are other possible explanations as the <a href="http://findings.org.uk/count/downloads/download.php?file=Schwartz_RP_10.txt" target="_blank">Findings</a> article points out.<br />
<br />
<br />
<span style="font-size: large;"><b>Scottish Review of Methadone Treatment</b></span><br />
The recent <a href="http://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&ved=0CDkQFjAC&url=http%3A%2F%2Fwww.scotland.gov.uk%2FResource%2FDoc%2F180406%2F0051268.pdf&ei=hFgrUo3PKIGVhQeeqYGwAg&usg=AFQjCNEAoDZdfRqo1fXMzqyKfU3gjA7NvA&sig2=eUobEDjQMomAeLoZlU_dtQ&bvm=bv.51773540,d.ZG4" target="_blank">Review of Methadone in Drug Treatment </a>has highlighted why the general public and many professionals are often so misinformed about addictive disorders. The headlines in the press are diverse and could easily be believed to come from very different sources. While some headlines proclaim "<a href="http://www.bbc.co.uk/news/uk-scotland-23786759" target="_blank">Scottish methadone program should continue</a>" and <a href="http://news.stv.tv/scotland/236962-methadone-review-by-scottish-government-group-backs-drugs-use/" target="_blank">"Methadone should continue to be central drug addict treatment"</a> others appear to sound dire warnings: <a href="http://www.christian.org.uk/news/methadone-bigger-killer-than-heroin-in-scotland/" target="_blank">"Methadone bigger killer than heroin in Scotland"</a> and "<a href="http://www.scotsman.com/news/health/calls-for-review-of-100k-a-day-methadone-programme-1-3058003" target="_blank">Calls for review of 100k-a-day methadone programme.</a>" No wonder the public are confused!<br />
<br />
<span style="font-size: large;"><b>One is too Many?</b></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAW7sIGuZ63u_1nLhxnhijy29bYmjc6TI2BI5F8p329533M0d40Dwu9Z0qho73F3_AQNinAoxttoZT18iKjze-Z44QvnICtR1ehDWbWvI3lMXO2DhVHoYntUBB8y-ZydtNpisspj5NU6Q/s1600/dendrites.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAW7sIGuZ63u_1nLhxnhijy29bYmjc6TI2BI5F8p329533M0d40Dwu9Z0qho73F3_AQNinAoxttoZT18iKjze-Z44QvnICtR1ehDWbWvI3lMXO2DhVHoYntUBB8y-ZydtNpisspj5NU6Q/s320/dendrites.jpg" width="320" /></a></div>
<div style="text-align: justify;">
<span style="font-size: small;">Again, some of the <a href="http://www.foxnews.com/health/2013/08/28/cocaine-rewires-brain-after-single-use-study-says/" target="_blank">headlines</a> are to be believed, just one use of cocaine doesn't only <a href="http://www.foxnews.com/health/2013/08/28/cocaine-rewires-brain-after-single-use-study-says/" target="_blank">rewire your brain</a>, but also has you <a href="http://www.prweb.com/releases/2013/9/prweb11086058.htm" target="_blank">addicted</a>! </span>But before all those once off users who "didn't really sniff" get into a panic, this has only been demonstrated in mice. The original paper, <a href="http://www.nature.com/neuro/journal/vaop/ncurrent/full/nn.3498.html" target="_blank">Cocaine-induced structural plasticity in frontal cortex correlates with conditioned place preference</a>, describes how after a single dose of cocaine there was significant growth of new dendritic spines in the brains of mice. The more spines the more the mice sought out the context associated with the cocaine administration. One of the author's concludes "These drug-induced changes in the brain may explain how drug related cues come to dominate decision-making in a human drug user, leaving more mundane tasks and cues with relatively less power to activate the brain’s decision-making centers."</div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
However, we know that we don't get "addicted" in one day. So I would argue that these brain changes just signify normal responses to certain substances, and not a pathology. I feel that with all the advances in neuroscience, we are becoming over-awed with our observations into a world that was hidden to us. While this can, and indeed will, provide many answers to confounding questions, it can also muddy the waters and lead false conclusions. Like just one line and you're addicted!</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-size: large;"><b>Multi-step General Theory of Transition to Addiction</b></span><br />
Piazza and Deroche-Gamonet have published an interesting <a href="http://link.springer.com/article/10.1007/s00213-013-3224-4#page-1" target="_blank">Multi-step Theory of Transition to Addiction</a>. What I like about this paper is that they regard drug seeking and consumption as within the range of normal behaviours, reserving the term pathological for late stage addictive behaviours. They propose that the transition from substance use to addiction is a three step sequential action between individual vulnerability and the level of drug exposure. They further propose that this transition is determined by two distinct vulnerable phenotypes along the path to addiction. one being those who have a sensitized dopaminergic system and impaired PFC function which leads to intensified, sustained drug use. The second phenotype is characterised by long lasting loss of synaptic plasticity and results in a "form of behavioural crystalization."<br />
<br />
In short, the theory attempts to reconcile the drug centered and individual centered theories, and attempts to find a unified model drawn from the research of Koob, Volkow, Robson, Berridge, Nestler and others. One of the problems with this theory, in my opinion, is that it doesn't address behavioural addictions. Talking of behavioural addictions....<br />
<br />
<b><span style="font-size: large;">Internet Addiction? We Have a Bed for You</span></b></div>
<div style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7RF8UO-x9_ExralmVM-epefWJaPPC0Fn-9DtLRlrlj4MFwVmjd8DJl8YymkNRjRWQbwlSXWYDhgKcEdD2_6sJyb4cSq0t4PfdaFWajn8uzJMm8RVbAPA6a9-gU_1vJcrGxdtWaxJq2Jg/s1600/Work-Week.jpeg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="273" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7RF8UO-x9_ExralmVM-epefWJaPPC0Fn-9DtLRlrlj4MFwVmjd8DJl8YymkNRjRWQbwlSXWYDhgKcEdD2_6sJyb4cSq0t4PfdaFWajn8uzJMm8RVbAPA6a9-gU_1vJcrGxdtWaxJq2Jg/s320/Work-Week.jpeg" width="290" /></a></div>
A Pennsylvania hospital, the <a href="http://www.brmc.com/" target="_blank">Bradford Regional Medical Center</a>, has opened the first inpatient treatment program for internet addiction. At a cost of US$14 000. For a 10-day treatment program. In cleverly worded statements the founder of the program, <a href="http://netaddiction.com/" target="_blank">Dr Kimberley Young</a>, puts the phrases DSM5 and Internet Gaming Addiction in the same sentence. Of course Internet Gaming Addiction is not yet a diagnosable disorder, but is rather included in the "Emerging Measures and Models" section of the DSM5.<br />
<br />
Certainly Stanton Peele may argue that the internet is <a href="http://www.huffingtonpost.com/stanton-peele/addiction_b_1407724.html" target="_blank">the perfect tool for delivering</a> content that could be addictive, whether it be games, gambling, google or girls. And indeed there may be some people suffering from what appears to be internet addiction, but I doubt if a 10-day harm reduction approach program will solve their problem. Maybe I should start a program for those who are addicted to addiction programs - at US$28 000 it will be cheap as chips (as long as they not casino chips)!<br />
<b><span style="font-size: large;"><br />
</span></b></div>
<div style="text-align: justify;">
<b><span style="font-size: large;">Personality of the Month: Scott Kellogg</span></b><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggGGjgVxxTa0wx97RbfH9jfRZKiFxJNDh_7gJMMm_GwcoN7UokF5vjS8euSl7Q0wm-TejyWIXO5hFRHsoR1ed-ghkViuRpqlzbinXVd5v2mijLPqIIJZdmyNTP4QQyrgdY6kY4wiaeeHw/s1600/Scott+Kellogg.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggGGjgVxxTa0wx97RbfH9jfRZKiFxJNDh_7gJMMm_GwcoN7UokF5vjS8euSl7Q0wm-TejyWIXO5hFRHsoR1ed-ghkViuRpqlzbinXVd5v2mijLPqIIJZdmyNTP4QQyrgdY6kY4wiaeeHw/s1600/Scott+Kellogg.jpg" /></a></div>
Scott Kellogg has many ideas which dovetail with mine when it comes to the progressive treatment of addictive disorders. Scott calls it gradualism, which I think is a really useful term. Dr Kellogg is a Clinical Psychologist, Addiction Psychologist, and a Gestalt-trained Schema Therapist who currently works as a psychotherapist and supervisor at the Schema Therapy Institute in New York City. Currently a Clinical Assistant Professor in the New York University Department of Psychology, he was previously on the faculties of The Rockefeller University, the Yale University School of Medicine, and the Clinical Psychology Program at Teachers College/Columbia University.<br />
<br />
To find out more on gradualism and Integrative Addiction Psychotherapy, <a href="http://gradualismandaddiction.org/" target="_blank">visit Scott's website</a>. I was first made aware of his work when I read the paper he wrote with Dr Andrew Tatarsky: <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3379781/" target="_blank">Re-envisioning Addiction Treatment: A Six-Point Plan</a>, which, in my opinion, is essential reading for all program directors.</div>
<span style="font-size: large;"><b><br />
</b></span> <span style="font-size: large;"><b>Quote of the Month</b></span><br />
Time for some controversy. <span class="usercontent">Recently Richard Wilmot(PhD), author of “<a href="http://www.amazon.com/American-Euphoria-Saying-Drugs-ebook/dp/B0053ZH1PY" target="_blank">American Euphoria: Saying 'Know' to Drugs</a>”, posted a provocative statement on a LinkedIn discussion group. This is a brief extract:</span><br />
<blockquote class="tr_bq">
<i><span class="usercontent">"Today one of the main criteria for a diagnosis of drug addiction/alcoholism is: continuing to consume alcohol or another drug “despite unpleasant or adverse consequences” (DSM). For the Christian martyrs the same criteria would apply. People of that time and place—Rom</span><span class="textexposedshow">e, 2nd century A.D.—could also say that this new Christianity was like a drug that endangered lives and that being a Christian had all the adverse financial, social, psychological and physical consequences that we now see in the lives of drug addicts and alcoholics. And yet Christians, of all ages, in spite of the consequences, continued to profess their faith… and continued to be eaten by lions.</span></i> <i><br />
</i> <i><span class="textexposedshow">Obviously there was something to Christianity that prevented the Christian from being abstinent from Christianity..............</span><span class="textexposedshow">Like the Christians who suffered and died for their faith, the addict has also made a choice… to lose everything for the “faith” in the euphoria of the drug experience."</span></i></blockquote>
Marc Lewis and I expanded on this idea in our blogs. <a href="http://www.addictioncapetown.blogspot.com/2013/08/a-christian-and-addict-walk-into-meeting.html" target="_blank">Dr Wilmott's complete posting can be found here</a>, along with my comments. <a href="http://www.memoirsofanaddictedbrain.com/connect/getting-high-and-getting-god-might-not-be-so-different/" target="_blank">Marc's blog </a>also has some really interesting insights and reader comments on this same subject.<br />
<br />
Ok, so that's it until next time. Remember, I welcome your comments, ideas, criticisms and input.Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-91297369494088659912013-09-01T17:58:00.000+02:002013-09-21T00:24:45.965+02:00Famous for Being Homeless<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTDjT7bW1qc0LPLn3sOP6l6398s_xoWY2GhTTaj8mCIUiMW5JCu6oi2f5jsG_Bn-66rHXFES3o5R6qIwEPNBWVQt8F3riV6ZhgxbZCIli745UO1LYqMOYn9NJE_lqQaAYyjE3h89eI_3o/s1600/shelley-250x250.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTDjT7bW1qc0LPLn3sOP6l6398s_xoWY2GhTTaj8mCIUiMW5JCu6oi2f5jsG_Bn-66rHXFES3o5R6qIwEPNBWVQt8F3riV6ZhgxbZCIli745UO1LYqMOYn9NJE_lqQaAYyjE3h89eI_3o/s200/shelley-250x250.jpg" width="200" /></a></div>
<div style="text-align: justify;">
I went viral. I wrote a seemingly innocuous anonymous letter to the press about being homeless and it received over 60 000 views and 700 shares from one <a href="https://www.facebook.com/CapeTalk/posts/582951925081787" target="_blank">facebook</a><a href="https://www.facebook.com/CapeTalk/posts/582951925081787" target="_blank"> page</a> alone. It was suggested that I did not exist and that the journalist who read out my letter on air had made me up, so I decided to "out" myself. Since then I have been sought for interviews in the press and on radio. I am not necessarily comfortable with all this media exposure, but if it can help give the marginalised a voice, I will use it. Hopefully this will help me bring the issues that are on my heart regarding addictive disorders and mental health into the public consciousness and promote debate. Here is the story:<br />
<a name='more'></a></div>
<br />
<div style="text-align: justify;">
Recently there was a proposal to remodel benches in the public space known as the Company Gardens in Cape Town. The article in the local newspaper reported: .</div>
<div class="arcticle_text">
</div>
<br />
<blockquote class="tr_bq">
"Councillor Dave Bryant said Government Avenue
was one of the city’s most well known attractions and that there had
recently been a strong call from the Company’s Garden steering committee
to inject more vibrancy into the area.</blockquote>
<blockquote class="tr_bq">
<div class="arcticle_text">
He
said some of the benches did not have a bar in the middle and therefore
encouraged people, mostly vagrants, to lie down and sleep rather than
sit."</div>
</blockquote>
and continued<br />
<blockquote class="tr_bq">
<div class="arcticle_text">
“By involving designers and artists in a collaborative process, public benches can become more than just furniture.</div>
<div class="arcticle_text">
“By
utilising creative inspiration and inventive design it is possible to
create pieces of more functional art which can also help to create a
safer and more vibrant environment in a public space like the Company’s
Garden.”</div>
</blockquote>
In response I wrote the following:<br />
<br />
<blockquote class="tr_bq">
<span class="userContent" data-ft="{"tn":"K"}">I
have been homeless. I wouldn’t have thought I would end up as being a
vagrant and you probably wouldn’t guess, by looking at me now, that a
few years ago I was the person you crossed the road to avoid. From my
experience I <span class="text_exposed_show">can tell you that when you
are homeless things take on a new meaning. The 1,5 litre Coke bottle
left lying on the side of the road is not litter. It is R2. R2 is not
for the car guard. R2 is half way to half a loaf of bread. Half a loaf
of bread is a meal. A meal is not a family occasion or something enjoyed
in front of the TV. It is a break from the pangs of hunger. It is a
couple of hours of forgetting that you do not know where your next meal
will come from.<br /> <br /> Similarly, a bench in a park is not a bench. It
is a place to rest. It is a place to lie back. It is a place to close
your eyes and dream of a time less awful. It is a place to catch a few
minutes sleep in the sun and forget that you are, in fact, homeless and
for you there is no place in the sun. <br /> <br /> And now even that small
pleasure is being removed from the homeless who frequent Cape Town’s
Company Gardens. There a plans afoot to replace the “problematic”
benches that “encourage people, mostly vagrants, to lie down and sleep
rather than sit”, according to Counsellor David Bryant. The language he
uses is upholstered in euphemism. The unupholstered sharp edge is that
the homeless shouldn’t be allowed to sleep on benches, even though this
is a public space. The way people enjoy public space is becoming more
and more prescriptive. For the wealthy who have gardens and homes to
retreat to, a walk in the park is, well, a walk in the park. Not being
able to lie on a park bench may seem insignificant. For the homeless it
just adds to the strain of day-to-day survival. <br /> <br /> The problem
with living on the street is that it keeps you living on the street. You
become more and more removed from what is considered normal. The things
we take for granted are no longer easily available. Like water - water
to drink, let alone wash in. Think about it – where would you go to get a
drink of water? More and more taps have had the handle removed so that
vagrants do not loiter at the street equivalent of the office water
fountain. Washing is even more difficult. How would you wash if you
lived on the street? That’s why the homeless smell. Not because we want
to, but because we have no other choice. And bodily functions? How many
public toilets do you know of that are not in shopping centres? There
used to be the station toilets, but these days stations have security
guards that prevent access unless you have a ticket. Do you have any
idea of the indignity of having to crap behind a bush? In the city?<br /> <br />
The Company Gardens are an amazing place for many people, but for the
homeless they have a group of resources that they seldom get access to
in a single environment – toilets, a water fountain, a soup kitchen (at
St George’s Cathedral), a place to be amongst the rest of society and a
bench to sit or lie on and get a few minutes respite from the struggle
for daily survival. <br /> <br /> One of the greatest desires of the
marginalised is to feel normal. To be treated like the rest. To enjoy
the same real estate they enjoy. When I was homeless I was painfully
aware of the things that separated me from the people around me. The
dirty clothes. The dirty hair. The rank smell. The pangs of hunger. The
shopping bag holding all my worldly possessions. The constant harassment
by security guards and over zealous neighbourhood watch members. Your
lack of greeting and eye contact. I was aware of these things and they
hurt. These are the things that keep people on the street, that move
them further from the belief that they can belong, that they have a
contribution to make.<br /> When the city redesign and replace benches
with the soul motivation being so that people cannot lie on them and try
to hide this by calling it “functional art”, as Mr Bryant does, they
insult artists. To say that by preventing people (read vagrants) from
sleeping on the bench by designing these new benches they are somehow
are creating “a safer and more vibrant space” is insulting to the
public’s intelligence. It is one of many steps intended to create a more
sterile and less diverse place for the privileged. It is another brick
in the wall that divides the “haves” from the “have nots”.<br /> <br /> If
there is a shortage of benches, put in more benches. If people are
sleeping on them, let them lie. You see, these are not the real
problems. The real problem is the vagrants. The truth is many would
prefer not to have them there. They remind us that our own success is
often based on luck or circumstance. There, by the grace of whoever, go
you. I know. I’ve been there. These sleeping vagrants are monuments to
the failure of our public representatives who have been sleeping on
their back benches. By denying the problem instead of accepting
homelessness as inevitable and waking up and catering for it, our
authorities are perpetuating the problem. By hiding the homeless, we are
becoming blind to their plight. We forget that there are people less
fortunate than ourselves. We can continue with our privileged existence
without distracting reminders of the less fortunate. <br /> <br /> As a
former homeless person camping is not high on my list of hobbies, but
every now and then I’d like to lie down on a park bench and remember
that once this was the only place I could dream of a better future."</span></span></blockquote>
The good news is that a few days later the proposal was withdrawn and a lot of people came forward to help various homeless organisations. Hopefully when I confront issues of addiction and harm reduction services this coverage will have given me some credibility.<br />
<br />
Further coverage of the story can be found at these links:<br />
<br />
Radio Interview on <a href="https://soundcloud.com/primediabroadcasting/the-man-behind-the-i-was" target="_blank">567 Cape Talk</a>.<br />
Interview in <a href="http://www.rapport.co.za/Rubrieke/HanlieRetief/Van-Gucci-tot-gutter-20130831" target="_blank">Rapport</a>.<br />
Letter in <a href="http://www.citypress.co.za/columnists/whats-wrong-with-a-place-in-the-sun/" target="_blank">City Press</a>.<br />
Radio Interview <a href="http://www.jacarandafm.com/post/whats-wrong-with-a-place-in-the-sun/" target="_blank">Jacaranda FM </a><br />
Social Media can make a difference <a href="http://www.bizcommunity.com/Article/196/23/100394.html" target="_blank">Biz Community.com</a><br />
Interview <a href="http://www.bigissue.org.za/news/the-cape-town-bench-saga-a-place-to-rest-a-weary-head" target="_blank">Big Issue</a> <a href="http://www.blogger.com/null"> </a>Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-75055591487070646812013-08-11T17:33:00.000+02:002013-08-15T23:11:08.207+02:00A Christian and an addict walk into a meeting...<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgYUG9A59_CSzFkISEQCnuVNli7PksZbev3W0CwlhWCgLVBjDe3z9E7Rm-dyWsf3SDiOq2vsImwOr890SMBZz4yPeIJQD172sboP56QF4ouqpZppcAEX-aMPeRJ12pCi7kO97z-HJkgv8/s1600/3327958502_907e964316.jpg" imageanchor="1" style="clear: left; display: inline !important; float: left; margin-bottom: 1em; margin-right: 1em; text-align: center;"><img border="0" height="154" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgYUG9A59_CSzFkISEQCnuVNli7PksZbev3W0CwlhWCgLVBjDe3z9E7Rm-dyWsf3SDiOq2vsImwOr890SMBZz4yPeIJQD172sboP56QF4ouqpZppcAEX-aMPeRJ12pCi7kO97z-HJkgv8/s200/3327958502_907e964316.jpg" width="200" /></a><br />
<div class="MsoNormal">
<span class="usercontent">Recently Richard Wilmot(PhD), author of “<a href="http://www.amazon.com/American-Euphoria-Saying-Drugs-ebook/dp/B0053ZH1PY" target="_blank">American Euphoria: Saying 'Know' to Drugs</a>”, posted this provocative statement on a LinkedIn discussion group:</span></div>
<blockquote class="tr_bq">
<div class="MsoNormal">
<span class="usercontent">“Today one of the main criteria for a diagnosis of drug addiction/alcoholism is: continuing to consume alcohol or another drug “despite unpleasant or adverse consequences” (DSM). For the Christian martyrs the same criteria would apply. People of that time and place—Rom</span><span class="textexposedshow">e, 2nd century A.D.—could also say that this new Christianity was like a drug that endangered lives and that being a Christian had all the adverse financial, social, psychological and physical consequences that we now see in the lives of drug addicts and alcoholics. And yet Christians, of all ages, in spite of the consequences, continued to profess their faith… and continued to be eaten by lions.</span><br />
<br />
<span class="textexposedshow">Obviously there was something to Christianity that prevented the Christian from being abstinent from Christianity. It was something internal… an internal euphoria. It was something that could not be seen but nevertheless was something that was felt… and felt as something awesomely significant. It was something that made all the pain and suffering worthwhile: it was a religious experience.</span><br />
<br />
<a name='more'></a><br />
<span class="textexposedshow">Likewise, given contemporary social policy, adverse consequences befall those who abuse drugs. They lose the respect of their peers; they violate the expectations of family, friends, and colleagues; they miss out on educational opportunities; they have poor work performance and lose their job. They make harmful decisions. They "burn their bridges". Their health suffers; they have overdoses, and they die. </span><br />
<br />
<span class="textexposedshow">None of these predictions are of consequence to most “addicts”. Like the Christians who suffered and died for their faith, the addict has also made a choice… to lose everything for the “faith” in the euphoria of the drug experience. In this light it is not difficult to understand that the main treatment for alcoholics and addicts in America is religion as promulgated through the faith based AA Twelve Step programs.</span><br />
<br />
<span class="textexposedshow">Because we cannot have addicts going around talking openly about experiences like this:</span><br />
<br />
<span class="textexposedshow">“I watched him smoke it (heroin), and without any hesitation, I asked for a hit. The first hit that I took was strong. It wasn't like smoking pot. This was much more intense. It had a funny taste at first. I took another hit and held the smoke in and slowly released it from my lungs. At that moment, I finally found what I had been searching for--- the perfect high. The feeling ran through every pore and cell on my body. It was though God himself had scooped me up in his arms and brought me to heaven. It was just too good to describe; it was like looking into the face of God.” (The</span> <span class="textexposedshow">Alcoholism Addiction Cure, Chris Prentiss, 2005:130) "</span>”</div>
</blockquote>
<br />
<div class="MsoNormal" style="text-align: justify;">
<span class="textexposedshow">It was Jung who </span>coined the phrase “Spritus contra spiritum” and described alcoholism in one patient as “the equivalent, on a low level, of the spiritual thirst of our being for wholeness, expressed in medieval language: the union with God.”</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
This raises the question: is addiction part of the very essence of who we are. Are we born to give ourselves over to something that we view as bigger than self<span class="textexposedshow">?</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="textexposedshow">From the religious perspective this is not an illogical conclusion. The Christian believes we are created to worship God. John Piper, a Baptist minister and the author of many books talks about “<a href="http://www.desiringgod.org/resource-library/articles/we-want-you-to-be-a-christian-hedonist" target="_blank">Christian Hedonism</a>”</span><span class="textexposedshow">. Piper says “</span>We all make a god out of what we take the most pleasure in. Christian Hedonists want to make God their God by seeking after the greatest pleasure—pleasure in him.”<br />
<br />
Piper agrees with and quotes the French philosopher Blaise Pascal:<br />
<blockquote class="tr_bq">
<div class="MsoNormal">
"All men seek happiness. This is without exception. Whatever different means they employ, they all tend to this end. The cause of some going to war, and of others avoiding it, is the same desire in both, attended with different views. The will never takes the least step but to this object. This is the motive of every action of every man, even of those who hang themselves."</div>
</blockquote>
</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Marx said that “religion is the opiate of the masses”. Is the desire for spiritual connection fulfilled by a relationship with the drug and the drug culture? In a world where religion is no longer seen as the norm, are we looking for a new religion? One we are prepared to die for? Just as the religious seek a relationship with God at all costs, do the addicted find that relationship in their drugs?<br />
<br />
Certainly there are similarities. It was Jesus who said "<span style="background-color: white; text-align: start;"><span style="font-family: inherit;">Whoever loves father or mother more than me is not worthy of me, and whoever loves son or daughter more than me is not worthy of me." Without getting into the theology of that statement, we understand the principles: Forsake the relationships that mean the most for a relationship that transcends our earthly connections. There are other similarities between addictive disorders and religious experience: ritual, commitment, sacrifice, a new identity, an abandonment of past behaviours and connections, evangelical passion, continuation in spite of adverse consequences and the such.</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
The controversial field of neurotheology seeks to examine the changes in neurobiology caused by the religious commitment that could result in the choice of death over renunciation, or, similarly, the pre-existence of structural brain differences that may pre-dispose the individual towards such commitment. The reductionist or materialist point of view is that religious experience is nothing more than the results of predetermined neural activity that arises as a result of genetic, ecological and/or evolutionary pre-disposition.<br />
<br />
In his book <i>The God Gene: How Faith is Hardwired into our Genes,</i> Hamer proposes that a variation in a gene known as VMAT2 is the "God Gene", and through the effect of this gene on dopamine, serotonin and norepinephrine we are hard-wired for transcendence. Anyone with even a fundimental knowledge of addiction neuroscience will recognise the same monoamines mentioned as being amongst the usual suspects in addictive disorders. Indeed they are closely linked to the motivational and reward system.<br />
<br />
William White in an essay entitled <i>The Role of Spirituality in Substance Abuse Prevention</i>, describes spirituality: "A heightened state of perception, awareness, performance or being that personally informs, heals, empowers, connects, centers or liberates". Once again, this sounds like drug use to me, although for those suffering from addictive disorders the drug often reveals itself to be an imposter, in much the same way as the abusive marriage partner reveals their true nature.<br />
<br />
So, if as Dr Wilmot and the evidence I've listed above suggests, addictive disorders look a lot like the religious experience, did the early Christians, and those willing to suffer for faith, or any other cause, suffer from a disease? Freud said that religion was "mass obsessional neurosis". There has been some suggestion that radical religious experience is linked to temporal lobe epilepsy, this is by no means proven, and is certainly not true for all religious experience. Similarly we often see religious fervour in the manic and schizophrenic, but this is usually easily differentiated from the non-pathelogical religious commitment, even if the behaviour is no less outside the boundaries of what many would consider normal.<br />
<br />
If the religious experience and the drug experience do indeed look similar, why do we label the one virtue and the other disease? Certainly we see some severe substance use disorders become pathological or disease like, but the same could be said of the religious experience. Is it, perhaps, that addiction is a social construct?<br />
<br />
In spite of the promotion of the disease model, the traditional treatment models have acted as though the drug experience is all the more unacceptable because it is an imposter, taking the role of God in the addicts life. AA and 12-step programs seem to uphold the view of William James - "The only cure for dipsomania is religiomania."<br />
<br />
For more comments on this post please visit <a href="http://www.memoirsofanaddictedbrain.com/connect/getting-high-and-getting-god-might-not-be-so-different/" target="_blank">Memoirs of an Addicted Brain </a></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-4869778852042320972013-08-06T19:37:00.001+02:002013-08-09T10:25:35.259+02:00Substance Use Knowledge Amongst Emergency Room and General Medical Personnel<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:RelyOnVML/>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhEd6u4g8arO9nLxyJhaFJMsgFS3E1t5XofShPQOxQDzCddiq3rZPqfZwibrnvUPN17P-Edcepu4MumuOEOY0B4FW6z21qd8yqaWyayjcS2sEvaERlG9QWLfXHWNCpKLHBgjDH3Qfa5S9A/s1600/emergencyroom.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="133" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhEd6u4g8arO9nLxyJhaFJMsgFS3E1t5XofShPQOxQDzCddiq3rZPqfZwibrnvUPN17P-Edcepu4MumuOEOY0B4FW6z21qd8yqaWyayjcS2sEvaERlG9QWLfXHWNCpKLHBgjDH3Qfa5S9A/s200/emergencyroom.jpg" width="200" /></a></div>
Recently I had the misfortune of having to receive emergency
treatment for a heart attack. I used this opportunity to do some investigation
into how much emergency and other medical personnel know about substance use,
and how much training they have been given.<br />
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Before I go any further, I would like to state that all the
staff that I interacted with were excellent, and I believe I received a high
standard of care, so I am not looking to criticise them or their abilities, but
rather spot gaps in their training, pertaining specifically to substance use.</div>
<div class="MsoNormal" style="text-align: justify;">
<br />
<a name='more'></a></div>
<div class="MsoNormal" style="text-align: justify;">
Let me explain the setting: I live in Cape Town, South
Africa. Medically speaking, we have some excellent medical schools here, specifically
the University of Stellenbosch and the University of Cape Town. Medical
students have a particular advantage in the South African medical schools in
that they receive first world training and third world experience, meaning that
by the time they qualify they have usually seen pretty much everything first
hand. The public health sector, where I received my treatment, is generally
good, but overburdened.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
From a substance use point of view we have a large portion
of the population who are economically disadvantaged, and, as a legacy of
apartheid, we have townships where the previously disenfranchised were forced
to live. This has led to a gang culture, and this economy is fuelled by,
amongst other things, the drug trade. The main drug of choice for those seeking
treatment in the Cape Town area is methamphetamine (33%), but those seeking
treatment for heroin use has risen to 15% recently, and heroin is fast becoming
the come-down drug of choice, and because of the rapid rate of dependence that
users experience, will become a much bigger problem in the future. Most of
these substances are of high quality, and are smoked, although we are seeing
increasing numbers of IV users.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
In the ambulance I was able to talk to the paramedics. Did
they come across a lot of overdoses? Yes, but these were mainly suicide
attempts. When I asked them if they had seen any heroin overdoses, they said
yes, but had not received any formal training on how to deal with these or any
other illicit drug overdoses. They did not carry Naloxone in the ambulance, and
were not aware of its role in the prevention of opioid overdose. When I asked
about psychosis, they said that this was one of the more common things they
saw, but usually it was left to the police rather than the ambulance service to
collect these patients due to the violent response that was often encountered.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
At the emergency room I had the opportunity of speaking to a
number of the doctors about substance related issues. By far the most common
consequence of drug use they had to deal with was Substance Induced Psychosis,
either as the result of Methamphetamine use or related to the use of high grade
cannabis. These patients were stabalised and referred to the psychiatric ward
for 72-hour observation. Most of those with a substance induced psychosis would
be absent of the psychotic symptoms at the end of the observation period and
would be discharged. What I found interesting was that there was no screening
for substance use and no referral process. The emergency staff would only
suspect that illicit substance use was involved if the family informed them or
if the patient became a revolving door patient.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Most of the doctors had little understanding of substance
use, and there seemed to be a level of prejudice against substance users. One
of the doctors said “these addicts are just wasting our time. They should just
stop”.<span style="mso-spacerun: yes;"> </span>She was also responsible for
taking my medical history and it was a bit awkward when I informed her that I
had been a methamphetamine user for nearly a decade! We did have the
opportunity to chat for a while, and hopefully I was able to explain a few
things about addiction to her. In spite of this doctor’s lack of knowledge
about substance use, it was still better than the doctor who asked if cocaine
was the same as heroin. Both of these doctors had only had a couple of lectures
dedicated to addictive disorders in 6 years of training.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
The nurses had had a lot more direct experience with
substance users, but then many of them came from communities where substance
use and gangsterism was common. Many of them were more adept at spotting
substance users, but also seemed to have a more judgemental attitude. Many of
them said that if a psychotic patient came in on a weekend shift they presumed
it was due to drug use, and they would just wait for the drugs to wear off.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
On the other end of the scale the emergency room cardiologist
I saw certainly wasn’t judgemental at all, but did highlight another problem.
She was looking at my file and calmly suggested that if I was concerned about
not having another heart attack it would perhaps be a good idea to consider
stopping my methamphetamine use! Didn’t raise an eyebrow or have a hint of
condescension in her voice! Since this was an academic hospital she was
accompanied by a group of medical students, some of whom seemed a little unsure
of her casual approach.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>I was quick to point out that my substance use
disorder had been in remission for a number of years. The problem this
highlighted was that the doctors have little idea of how to record substance
use disorders in the medical history of a patient. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
After 18 hours in emergency I was transferred to the medical
ward which was adjacent to the psychiatric ward. I was able to speak with many
of the nurses about their experiences with substance users. None of them had
had any specialised training in substance use disorders. Many of them seemed
exasperated by the behaviour of substance users: Continued use in the ward
toilets in spite of serious medical conditions, repeated visits to the psych
ward due to substance induced psychosis.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
After I was discharged I had the opportunity of speaking
with the head psychiatrist and the social worker at the hospital. Both were
aware of the stigma attached to addictive disorders, and felt that there was
discrimination. The social worker particularly acknowledged that amongst
medical staff there was the feeling that substance users and suicide survivors
were wasting resources because they had brought things upon themselves. When a
patient did happen to be identified as having a substance use disorder, usually
by family members, they were referred to the social worker. The major problem
as expressed by both the psychiatrist and social worker was the lack of
appropriate services to refer those with substance use disorders to. Even if
the patient was admitted to services there was little long-term follow-up. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
In essence, there seems to be little knowledge about
substance use disorders amongst general medical staff. Training is at best
limited. This, I believe, is a sad state of affairs because the emergency room
often an ideal opportunity for brief intervention and referral.</div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-78646990541087809762013-06-30T18:46:00.000+02:002013-06-30T18:47:41.130+02:00June 2013 Newsletter<div class="svTitle" id="" style="text-align: justify;">
After a busy two months I have finally managed to produce a newsletter. I recently gave a talk on the emerging divide between those who believe that opioid substitution is a treatment in itself, and those who believe that it is not really recovery. <a href="http://www.addictioncapetown.blogspot.com/2013/05/opioid-substitution-therapy-treatment.html" target="_blank">My talk, Opioid Substitution Therapy: Treatment vs. Recovery can be found here</a>. This was prior to me being aware of the DSM qualification of "on maintenance therapy" for those in remission from Substance Use Disorders. I think we will see this argument developing in the States, and opinions will remain polarised. Hopefully we will see a more balanced approach in the South African setting. Comments are most welcome.<br />
<br />
In this month's newsletter we talk about: Agonist Therapy for Stimulant Addiction, Is addiction a Disease?, The Anti-Reward System, Stimulant Addiction and Gray Matter, The Most Important Treatment Studies Matrix, Chris Arnade, Mindfulness and Improved RCTs in addiction.<br />
<br />
<a name='more'></a><br />
<span style="font-size: large;"><b>Agonist Therapy for Stimulant Addiction?</b></span><br />
If
we thought opioid maintenance therapy was controversial, how about
dopamine agonist therapy (okay, well indirect agonist, to be precise!). Many stimulant users will tell you that
methamphetamine use all but stopped their cocaine use, and now science
is agreeing, suggesting that methylphenidate (Ritalin) may be good for
the treatment of cocaine addiction. But don't get too excited, the study
published in <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=1699378" target="_blank">JAMA</a> by a group of researchers, including Volkow and Goldstein, is based only on fMRI and not on actual treatment studies.
The study showed that after methylphenidate administration there was a
reduction in the abnormally strong connectivity of the ventral striatum
and dorsal stratium that is seen in after cocaine administration, and at
the same time there was a strengthening in the corticolimbic and corticocortical connections.
This could theoretically translate into increased top-down control, and
in conjunction with behavioural therapies, could help in the treatment
of cocaine and other stimulant use disorders. We wait for the debate to start! <br />
<br />
<b><span style="font-size: large;">Brain Disease or Not?</span></b><br />
These days when we hear that addiction is a brain disease we all nod our heads. I have advocated that this may not be the most useful approach when treating patients. To see addiction only from the disease model runs the risk of narrowing treatment options. We all know Leshner's seminal article <a href="http://scholar.google.co.za/scholar_url?hl=en&q=http://ecnp-congress.eu/~/media/Files/ecnp/communication/talk-of-the-month/Wim%2520van%2520den%2520Brink/Addiction%2520is%2520a%2520brain%2520disease%2520and%2520it%2520matters.pdf&sa=X&scisig=AAGBfm0WZeyC8mtWJ79kzQthfGnqfUrjSQ&oi=scholarr&ei=v-u1UYbGE5G0iQf5m4HIDA&sqi=2&ved=0CCgQgAMoADAA" target="_blank">Addiction is a Brain Disease and it Matters</a>. In the latest issue of Frontiers in Psychiatry, Levy writes <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3622902/" target="_blank">Addiction is Not a Brain Disease (and it Matters).</a> Indeed, Levy is not alone in this criticism of addiction as a brain disease. <a href="http://blogs.plos.org/mindthebrain/2012/11/12/why-addiction-is-not-a-brain-disease/" target="_blank">Marc Lewis</a>, <a href="http://www.psychologytoday.com/blog/addiction-in-society/201110/the-benefits-addiction-why-alcoholics-drink" target="_blank">Stanton Peele</a> and <a href="http://www.psychologytoday.com/blog/the-heart-addiction/201112/is-addiction-really-disease" target="_blank">Lance Dodes</a> have all been critical, to lesser or greater degrees, of the disease model. Another article that questions the disease model is to be found in Inquiry. The article called Addiction: <a href="http://www.tandfonline.com/doi/abs/10.1080/0020174X.2013.806126#.UdA769hcNQk" target="_blank">An Emergent Consequence of Elementary Choice Principles</a>, argues that "normal" processes in nature can lead to extreme events, and as such, addiction is an extreme manifestation of a normal process, and could be seen as a function of the rules of everyday choice.<br />
<br />
An interesting article on the hyping of neuroscience in the Guardian is worth a read: <a href="http://www.guardian.co.uk/science/2013/jun/30/brain-mind-behaviour-neuroscience-neuroimaging" target="_blank">Human Behaviour: Is it all in the Brain - or the Mind?</a>. In it Sally Satel and Scott O Lilienfield have this to say about addiction: <br />
<blockquote class="tr_bq">
"Understanding the biological basis of pleasure leads us to
fundamentally rethink the moral and legal aspects of addiction," writes
neuroscientist <a href="http://bigthink.com/users/davidlinden2" title="">David Linden</a>.
This is popular logic among addiction experts; yet, to us, it makes
little sense. Granted, there may be good reason to reform the way the
criminal justice system deals with addicts, but the biology of addiction
is not one of them. Why? Because the fact that addiction is associated
with neurobiological changes is not, in itself, proof that the addict is
unable to choose. Just look at American actor <a href="http://www.guardian.co.uk/film/robertdowneyjr" title="">Robert Downey Jr</a>.
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhvA2w8dFSdlFI1ogXVwvqN8alfJaOm0pAi5tfZcyAuoXknOTON6-vC1X2kNId2lMtkY83sNOtMMVPhXzsWqmlS2EBxvEbXQPn2aDqwSrnZOJze14YumCa4bLTYVHklHOXGCjyqi47o4hU/s1290/robert_downey_jr_mug_shot.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhvA2w8dFSdlFI1ogXVwvqN8alfJaOm0pAi5tfZcyAuoXknOTON6-vC1X2kNId2lMtkY83sNOtMMVPhXzsWqmlS2EBxvEbXQPn2aDqwSrnZOJze14YumCa4bLTYVHklHOXGCjyqi47o4hU/s200/robert_downey_jr_mug_shot.jpg" width="150" /></a></div>
He was once a poster boy for drug excess. "It's like I have a loaded
gun in my mouth and my finger's on the trigger, and I like the taste of
gunmetal," he said. It seemed only a matter of time before he'd meet a
horrible end. But Downey Jr entered rehab and decided to change his
life. Why did Robert Downey Jr use drugs? Why did he decide to stop and
to remain clean and sober? An examination of the brain, no matter how
sophisticated, cannot tell us that at this time, and probably never
will. The key problem with neurocentrism is that it devalues the
importance of psychological explanations and environmental factors, such
as familial chaos, stress and widespread access to drugs in sustaining
addiction."</blockquote>
<br />
As for me, when I am asked "what is addiction? Is it a disease or a behavioural condition? Is it a social construct or the result of environmental influences? Perhaps it is self-medication or a learned condition?" - my clear and unequivocal answer is "Yes!". <br />
<br />
<b><span style="font-size: large;">The Anti-Reward System </span></b><br />
<a href="http://graphics8.nytimes.com/images/2012/06/10/opinion/10thestone-image-brain/10thestone-image-brain-tmagArticle.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="" border="0" height="115" id="100000001597714" src="http://graphics8.nytimes.com/images/2012/06/10/opinion/10thestone-image-brain/10thestone-image-brain-tmagArticle.jpg" width="200" /></a>We often hear about the reward system, and sometimes how it is hi-jacked in the case of addiction. A recent <a href="http://opinionator.blogs.nytimes.com/2012/06/10/the-hijacked-brain/?hp" target="_blank">New York times article</a>
suggests that it is time to retire the phrase and to look at addiction
from the view of both choice and disease. George Koob and others propose
a new hypothesis that turns the "Hi-jacked reward system" concept
around and concludes "The <b>recruitment of anti-reward systems</b>
provides a powerful neurochemical
basis for the negative emotional states that are responsible for the
dark side of addiction." I, and others, have long described the move
from use to addiction as a move from "positive" reinforcement towards
"negative" reinforcement. Or from impulsive to compulsive. The writers
describe "<a href="http://www.sciencedirect.com/science/article/pii/S0028390813002384" target="_blank">Addiction as a Stress Surfeit Disorder</a>" in the paper published in the June edition of Neuropharmacology. They propose "brain
stress response systems are hypothesized to be activated by acute
excessive drug intake, to be sensitized during repeated withdrawal, to
persist into protracted abstinence, and to contribute to the development
and persistence of addiction." <a href="http://www-personal.umich.edu/~berridge/" target="_blank">Berridge</a> would also agree that these
same mechanisms could also play a significant role in the reinstatement
of drug use.<br />
<br />
<span style="font-size: large;"><b>Stimulant Addiction and Gray Matter </b></span></div>
<div class="svTitle" id="" style="text-align: justify;">
In our <a href="http://addictioncapetown.blogspot.com/2013/01/addiction-information-january-newsletter.html" target="_blank">January newsletter</a> I reported on Dr Karen Ersche's work that suggests that brain structure may predict vulnerability to cocaine addiction. In a new paper in Current Opinion in Neurobiology, she conducts a "<a href="http://www.sciencedirect.com/science/article/pii/S0959438813000652" target="_blank">Meta-analysis of structural brain abnormalities associated with stimulant drug dependence and neuroimaging of addiction vulnerability and resilience</a>". Gray matter decline in various brain areas is well documented in cases of addictive stimulant use as this paper shows. What is less well researched is to what extent the low density preceded or was caused by the drug use. </div>
<div class="svTitle" id="" style="text-align: justify;">
<br /></div>
<div class="svTitle" id="" style="text-align: justify;">
What has been even less researched, and is of particular interest to me, is what happens with prolonged abstinence? Does the patient regain the density of a "normal" brain? This is exactly what Connolly, Bell, Foxe, and Garavan have researched in their paper "<a href="http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0059645" target="_blank">Dissociated Grey Matter Changes with Prolonged Addiction and Extended Abstinence in Cocaine Users</a>". What is amazing, is that in certain areas, after 35 weeks of abstinence, the gray matter density of a recovering addict exceeds that of a drug naive subject. Not only this, but there is asymmetry between the losses and gains, pre and post use. This would imply that recovery does not simply reverse the affects of drug use but involves distinct neurological processes. The implications of this are profound, and I hope to do further reading and writing around this issue.<br />
<br />
<span style="font-size: large;"><b>The Most Important Treatment Studies Matrix: Fantastic Resource</b></span><br />
The <a href="http://findings.org.uk/index.php" target="_blank">Effectiveness Bank</a> and the <a href="http://www.skillsconsortium.org.uk/" target="_blank">Substance Misuse Skills Consortium</a> in the UK have created a fantastic resource. They have created a matrix of <a href="http://findings.org.uk/docs/Matrix/Drugs/drugs_table.htm" target="_blank">addiction treatment approaches</a> with corresponding research and the settings in which they are relevant. There is also a separate <a href="http://findings.org.uk/docs/amatrix.htm" target="_blank">matrix for alcohol use disorders</a>. Having had a brief look at this, I would highly recommend it to anyone in the field as a starting point when doing research into various treatment modalities. I'm sure that there will be much future debate regarding the particular research they have referenced, but no matter what our thoughts are, this is a great idea - well thought out and well executed.<br />
<br />
<span style="font-size: large;"><b> Personality of the Month</b></span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgI3hsFWuNCVXQbKoM7DUXbxg5bgKVHAyvWE1Df-2VQLDHmyHXlG2UzYKTx7JsE9qzpokUHcN0Ql4xzrGUUDcM-NxD4KLIUWdUlvKqSdtL2SLRR5T_8wnmgSSr0_u6TdEG2zaqMBLk2A4E/s720/Chris+Arnade.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgI3hsFWuNCVXQbKoM7DUXbxg5bgKVHAyvWE1Df-2VQLDHmyHXlG2UzYKTx7JsE9qzpokUHcN0Ql4xzrGUUDcM-NxD4KLIUWdUlvKqSdtL2SLRR5T_8wnmgSSr0_u6TdEG2zaqMBLk2A4E/s200/Chris+Arnade.jpg" width="150" /></a></div>
Chris Arnade is not directly involved in the addiction treatment field, but he comes face to face with addiction on a daily basis. Chris received a PhD in Physics from Johns Hopkins University and then went to work on Wall Street. He left his job as a trader on the Emerging Markets trading desk to start telling the stories of the people of Hunts Point. Chris says: "What I am hoping to do, by allowing my subjects to share their dreams
and burdens with the viewer and by photographing them with respect, is
to show that everyone, regardless of their station in life, is as valid
as anyone else."<br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNOkQcSpVzeRM_1yzEwTyqMdgi6oTvUTvizTr5CINoyo1kNhzO28C-DN3XwhyczlIPzWN9-ByW0nA62OTHhe-lhFtPwJrg0BcSAmqrHKBVMu_wcpOFpSOi-1YNSbC4i2fURn89tuwkbkI/s720/Micahel.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNOkQcSpVzeRM_1yzEwTyqMdgi6oTvUTvizTr5CINoyo1kNhzO28C-DN3XwhyczlIPzWN9-ByW0nA62OTHhe-lhFtPwJrg0BcSAmqrHKBVMu_wcpOFpSOi-1YNSbC4i2fURn89tuwkbkI/s200/Micahel.jpg" width="200" /></a>Any clinican working with the disenfranchised/homeless population should follow <a href="http://www.facebook.com/pages/Chris-Arnade-Photography/281993958534617" target="_blank">Chris's facebook page</a>. I have been doing so for a while now, and no matter where you are in the world, addictive disorders have the same effect on this population: The use of drugs both frees the individual from the reality of their existence, while simultaneously often preventing them from rising above their situation. Chris catches this contradiction in a way that shows empathy and respect for his subjects. By following this page I believe a clinician can begin to gain an understanding of what their patients are really going through. It is easy to intellectualize, moralize and give advice. Chris's photos bring a healthy dose of reality into the mix. I find it interesting the juxtaposition between Chris's <a href="http://www.flickr.com/photos/arnade/sets/72157627894114489/" target="_blank">Faces of Addiction</a> project and the well-known faces of Meth project. Chris's pictures educate, elucidate and encourage empathy, while the <a href="http://www.facesofmeth.us/main.htm" target="_blank">Faces of Meth</a> have become a freak-show parody of the "evils" of drugs.<br />
<br />
<div class="separator" style="clear: both; text-align: left;">
<span style="font-size: large;"><b>Mindfullness and Addiction</b></span></div>
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfWr6Rbd5-Mb83672Vlk1xiWi-uuD-3cpGalcdKWVjcn4H_VuSyN7U-bk4W__vfSSOmjSDajb3aBo5ku5aOo8bAQUMDTkKi5hk4UfnpjED6JsdRAOU93Y9c2iaHw5Ry5RgAQSINUpV_AM/s280/Dalai.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfWr6Rbd5-Mb83672Vlk1xiWi-uuD-3cpGalcdKWVjcn4H_VuSyN7U-bk4W__vfSSOmjSDajb3aBo5ku5aOo8bAQUMDTkKi5hk4UfnpjED6JsdRAOU93Y9c2iaHw5Ry5RgAQSINUpV_AM/s280/Dalai.png" /></a>My e-mail friend, neuroscientist Marc Lewis, author of Memoirs of an Addicted Brain, is off to see the<span id="goog_1333400786"></span><span id="goog_1333400787"></span> Dalai Lama in October. It's part of the <a href="http://www.mindandlife.org/" target="_blank">Mind and Life</a> initiative - the group that organizes the Dalai Lama's interactions with scientists. The meeting will be entitled "Craving, Desire and Addiction." Also present will be Nora Volkow and Kent Berridge, so this is a pretty heavy-weight delegation. You can catch up with Marc's experiences by reading his blog: <a href="http://www.memoirsofanaddictedbrain.com/blog/" target="_blank">Memoirs of an Addicted Brain</a>.<br />
<br />
All this got me thinking about mindfulness and its increasing role in addiction treatment. I touched on it during some studies last year, and have found mindfulness to be very valuable in recovery. Most of the people I see moving from active drug use towards recovery from their disorder move from a state of reaction to considered response. They stop being driven by their impulses and compulsions, and rather learn to accept the present moment as passing. This is at the centre of mindfulness practices. I decided to have a look at some of the research and found this useful article on mindfulness based relapse prevention: <a href="http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2012-18077-001" target="_blank">Retraining the Addicted Brain: A Review of Hypothesized Neurobiological Mechanisms of Mindfulness-Based Relapse Prevention.</a><br />
<br />
I also found this article on neuroplasticity and mindfulness pretty interesting:<span style="font-size: small;"><span style="font-weight: normal;"> <a href="http://www.jneurosci.org/content/32/44/15601.abstract" target="_blank">Cognitive-Affective Neural Plasticity following Active-Controlled Mindfulness Intervention</a></span></span><br />
<br />
<span style="font-size: large;"><b>Improving Randomized Control Trials in Addiction Research</b></span><br />
A collaboration between the Centre for Evidence Based Intervention and the Centre for Outcomes Research and Effectiveness, as well as the Institute of Child Care Research in association with CONSORT Group aims to create new guidelines for RCTs in the addictions field. This will be referred to as CONSORT-SPI (an extension for Social and Psychological Intervention). As they say in the latest issue of Addiction: "RCTs of addiction interventions are particularly challenging to report
clearly and comprehensively. These interventions are often complex; they
include multiple, interacting components at several levels and have
various relevant outcomes<a class="referenceLink" href="http://onlinelibrary.wiley.com/doi/10.1111/add.12249/full#add12249-bib-0003" rel="references:#add12249-bib-0003" shape="rect" title="Link to bibliographic citation"></a>.
RCTs of these interventions are often reported insufficiently to
understand internal validity (bias) and external validity (the
applicability of a study's results in other settings or populations). To
use the evidence provided by RCTs for developing and disseminating
these interventions, the quality of reporting must be addressed."<br />
<br />
You can have your say and get involved in this process by going here: <a href="http://www.spi.ox.ac.uk/research/centre-for-evidence-based-intervention/consort-study.html" target="_blank">Oxford university Department of Social policy and Intervention.</a></div>
<div class="svTitle" id="" style="text-align: justify;">
<br />
<b><span style="font-size: large;">Quote of the Month</span></b><br />
This adaption of a statement attributed to Goethe comes from Dexter, Season 7, and I felt it was rather apt for those of us in the addiction field, and more so for our patients:<br />
<blockquote class="tr_bq">
<span style="font-size: large;"><i>" Trust those who seek the truth, but never those who claim to have found it!"</i></span></blockquote>
<br />
Til next time.</div>
<div class="svTitle" id="" style="text-align: justify;">
<br /></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-51360143462482033642013-05-10T17:00:00.002+02:002013-05-10T17:07:02.430+02:00Opioid Substitution Therapy: Treatment vs. Recovery<div style="border-bottom: solid windowtext 1.0pt; border: none; mso-border-bottom-alt: solid windowtext .5pt; mso-element: para-border-div; padding: 0cm 0cm 1.0pt 0cm;">
<span style="font-size: x-large;"><span style="font-size: x-large;">I</span>ntroduction</span></div>
<div class="MsoNormal" style="text-align: justify;">
Opioid Substitution Therapy has been a controversial topic. Somehow
it is easier for the addiction recovery industry to accept medications such as Disulfiram
with its aversive effect or acamprosate which does not carry the risk of
approximating the state of alcohol intoxication and because studies have suggested
that it is only effective in conjunction with psycho-social interventions. OST,
on the other hand, uses opioid agonists or partial agonists that act in similar
ways to the drugs of dependence, albeit without the same quality of high, and
this, some have suggested, shifts the addiction from opioid dependence to
another dependence and may be of more harm than good to the addict.<br />
<a name='more'></a></div>
<div class="MsoNormal" style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
Methedone, the original medication of choice in OST, has
been described as both saviour and devil by addiction professionals, lay
counsellors and those recovering from or still suffering from addiction. More
recently Buprenorphine has taken centre stage. At any rate, it has always been
proposed that it is “Medication Assisted Treatment”, with treatment being some
form of psycho-social intervention, while it is the medication that is the
add-on in this process of recovery. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Because of this thinking OST has largely been used as a temporary
means of managing the short-term issues of dependence i.e. detox. Recent
research, however, has shown that rather than being a supplement to treatment,
OST may be the treatment itself. Two recent studies both suggest that adjunctive
counselling and/or CBT do nothing to improve outcomes. These are also consistent
with previous studies, although more adamant <span style="mso-no-proof: yes;">(Fielin, Pantalon, & et al, 2006)</span>.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
This research flies in the face of traditional “recovery”
based thinking and there is now a debate between two seemingly opposing factions.
It is “Recovery” versus “Treatment”, and as more and more addiction treatment
professionals accept that addiction is a brain disease that can be treated by
medication, and as medication for other addictive substances emerges, this
topic is going to be more hotly contested. And there is a lot at stake: If
addiction can be treated by a series of 15 minute General Practitioner office
based interventions a lot of people will be out of a job, the rehab industry
would shut down and there would be little need of 12-step fellowships. On the
other hand the insurance companies would save millions while the pharmaceutical
companies would make billions.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal">
So what is this debate all about? Let’s start by looking at
the two research papers I have mentioned above. </div>
<div style="border-bottom: solid windowtext 1.0pt; border: none; mso-border-bottom-alt: solid windowtext .5pt; mso-element: para-border-div; padding: 0cm 0cm 1.0pt 0cm;">
<h1>
<span style="font-weight: normal;"><span style="font-size: x-large;">The Research</span></span></h1>
</div>
<span style="font-size: large;">The Weiss Study</span><br />
<div class="MsoNormal" style="text-align: justify;">
One study <span style="mso-no-proof: yes;">(Weiss, Potter, & et al, 2011)</span> looked at over 600
prescription opioid dependent individuals who received buprenorphine in a
2-phase randomized control trial. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal">
What the study concluded was:</div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 38.5pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Addiction counselling made little or no
difference to outcomes</div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 38.5pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Tapering, even after 12 weeks resulted in poor
outcomes </div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 38.5pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Those who were stabilized on buprenorphine had
considerably better outcomes</div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 38.5pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Physician initiated office based <span style="mso-spacerun: yes;"> </span>treatment is possible</div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 38.5pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<br /></div>
<div class="MsoNormal" style="margin-left: 2.5pt; text-align: justify;">
For the purposes of this article,
what is important in these findings is that drug counselling made almost no
difference. What should be noted, however, and what may be of importance, is
that the majority of the patients in this study where employed, well educated,
had short histories of opioid dependence and virtually no polysubstance use. </div>
<div class="MsoNormal" style="margin-left: 2.5pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-left: 2.5pt; text-align: justify;">
Although this study does not provide
a complete description of the Opioid Dependence counselling they used, it
sounds a lot like psycho-education and CBT: “Counsellors educated patients
about addiction and recovery, recommended self-help groups, and emphasized
lifestyle change. Using a skills-based format with interactive exercises and
take-home assignments, ODC over a wider range of relapse prevention issues in
greater depth than did Standard Medical Management, including coping with
high-risk situations, managing emotions, and dealing with relationships.”</div>
<div class="MsoNormal" style="margin-left: 2.5pt; text-align: justify;">
<br /></div>
<span style="font-size: large;">The Yale Study</span><br />
<div class="MsoNormal" style="margin-left: 2.5pt; text-align: justify;">
In early 2013 headlines proclaimed
“CBT is not effective in treating heroin addiction” (or words to that effect) after
the publication of a study by David Fielin and others at Yale University School
of Medicine<span style="mso-no-proof: yes;"><span style="mso-spacerun: yes;"> </span>(Fiellin, Barry, & al, 2013)</span>. </div>
<div class="MsoNormal" style="margin-left: 2.5pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-left: 2.5pt; text-align: justify;">
This study “conducted a 24-week randomized
clinical trial in 141 opioid-dependent patients in a primary care clinic.” One
group received only physician management while getting their buprenorphine,
while the other group received this plus CBT.</div>
<div class="MsoNormal" style="margin-left: 2.5pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-left: 2.5pt;">
The conclusion: CBT added no
benefit.</div>
<div class="MsoNormal" style="margin-left: 2.5pt;">
<br /></div>
<span style="font-weight: normal;"><span style="font-size: large;">The Controversy</span></span><br />
<div class="MsoNormal" style="margin-left: 2.5pt; text-align: justify;">
Why these findings are
controversial is because it has always been assumed that psycho-social
interventions form the core of addiction treatment and recovery from the
addicted state. A Cochrane Review entitled “Psychosocial and pharmacological
treatments versus pharmacological treatments for opioid detoxification” <span style="mso-no-proof: yes;">(Mato, Minozzi, Davoli, & Vecchi, 2011)</span> concluded: “The
review authors searched the medical literature and found evidence that
providing a psychosocial treatment in addition to pharmacological detoxification
treatment to adults who are dependent on heroin use is effective in facilitating
opioid detoxification.” This seems to conflict with the findings of these other
studies.</div>
<div class="MsoNormal" style="margin-left: 2.5pt; text-align: justify;">
<br /></div>
<span style="font-weight: normal;"><span style="font-size: large;">Long-Term OST</span></span><br />
<div class="MsoNormal" style="text-align: justify;">
What research certainly does tell us more clearly is that
Opioid Maintenance Therapy does keep patients engaged in therapy and keeps them
abstinent longer <span style="mso-no-proof: yes;">(Mattick, Breen, Kimber, & Davoli, 2009)</span> <span style="mso-no-proof: yes;">(Sees, et al., 2000)</span> <span style="mso-no-proof: yes;">(Kleber, 2007)</span><span style="mso-no-proof: yes;"><span style="mso-spacerun: yes;"> </span>(Caldiero,
Parran, CL, Piche, & B, 2006)</span> <span style="mso-no-proof: yes;">(Donovan, Knox, Skytta, Bayney, & DiCenzo, 2012)</span>. There appears to be
little research doubt that open-ended Maintenance Therapy is better than using
OST as a means of detox.</div>
<span style="font-weight: normal;"><span style="font-size: large;">So why the controversy?</span></span><br />
<div class="MsoNormal">
If one looks at the various discussions that take place
between addiction professionals and those recovering from addiction on sites
such as The Fix and LinkedIn, we can easily see that two camps have emerged. </div>
<div class="MsoNormal" style="text-align: justify;">
I know that many will criticise the names I have given these
two camps, they are not perfect, and I know that there are many who fit
somewhere between the two, but for the purposes of this article I have chosen
these names and I have defined them as such:</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<span style="font-size: large;">The Recovery Camp</span><br />
<div class="MsoNormal" style="text-align: justify;">
Those that believe that abstinence means that long-term OST
is not an option, or is somehow second rate, and that there should always be
the goal of medication-free recovery. They also believe that medication is an
adjunct to other treatment modalities. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<span style="font-size: large;"><span style="font-weight: normal;">The Treatment Camp</span></span><br />
<div class="MsoNormal" style="text-align: justify;">
This camp says that indefinite OST is what the research is
saying is effective, and they further believe that OST is the treatment in
itself, and anything else is at best an adjunct, and often not necessary. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<span style="font-size: x-large;">Opinions of the two Camps</span><br />
<div class="MsoNormal" style="text-align: justify;">
Until recently you could not go to Hazeldon and be on OST.
Most of the Minnesota model based recovery industry is still firmly in the “recovery”
camp. They are/were firmly abstinence based. <span style="mso-spacerun: yes;"> </span>In the world of celebrity and television the
program “Celebrity Rehab with Dr Drew” has reinforced this school of thought:
Dr Drew claims that methadone “takes your soul away”. To reinforce this view,
here is an extract from an article from the Canadian press:</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div style="border-left: solid windowtext 2.25pt; border: none; margin-left: 22.7pt; margin-right: 0cm; mso-element: para-border-div; padding: 0cm 0cm 0cm 4.0pt;">
<div class="MsoQuote" style="margin-left: 0cm;">
<span class="comment-body"><b style="mso-bidi-font-weight: normal;">Harm reduction just keeps addicts enslaved</b></span></div>
<div class="MsoQuote" style="margin-left: 0cm;">
<span class="comment-body"><span style="font-size: 8.0pt;">By Jon Ferry, The Province March 13, 2013</span></span></div>
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<span class="comment-body">The UN
Commission on Narcotic Drugs is meeting in Vienna this week to recommend
measures to combat the world drug problem.</span></div>
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<span class="comment-body">But in
Vancouver, the war against illegal drugs appears to have been won already by
those who favour "harm reduction," with its publicly funded crackpipe
kits, safe-injection rooms and "free" heroin and methadone fixes.</span></div>
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<span class="comment-body">This does
little more than apply a Band-Aid — as opposed to abstinence-based treatment,
which actually gets people off drugs but is frowned upon by the politically correct
powers-that-be.</span></div>
</div>
<div class="MsoNormal" style="margin-left: 2.5pt;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Here is another typically representative comment from a
LinkedIn discussion in a closed Addiction Professionals group:</div>
<div style="border-left: solid windowtext 2.25pt; border: none; margin-left: 22.7pt; margin-right: 0cm; mso-element: para-border-div; padding: 0cm 0cm 0cm 4.0pt;">
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
I guess I just find it a little disappointing
that after 50 years of research and study, the best we've come up with for
opioid addicts is a way to make them more successfully dependent on an opioid.</div>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
There are whole websites dedicated to the cause, and they
are evangelical about the matter: check out the site called www.subsux.com.
Filled with graphic descriptions and an alternative dictionary of expletives,
the editor of the site says that:</div>
<div style="border-left: solid windowtext 2.25pt; border: none; margin-left: 22.7pt; margin-right: 0cm; mso-element: para-border-div; padding: 0cm 0cm 0cm 4.0pt;">
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
If you want to read actual unedited
experiences that aren't sponsored by the pharmaceutical companies or filled
with suboxone promoting sub sucking zombies telling the "victim" that
the reason their wd's are lasting so long is that they tapered wrong, or that
it wasnt the sub but all the drugs they did prior to sub, or depression then
you're in the right place.</div>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
On the other side of this camp are the likes of Dr Mark
Willenbring, former director of Treatment and Recovery Research at the National
Institutes of Alcohol Abuse and Alcoholism and now CEO of Altyr, who made the
following comments in a discussion on the LinkedIn Addictions Professionals
Group:</div>
<div style="border-left: solid windowtext 2.25pt; border: none; margin-left: 22.7pt; margin-right: 0cm; mso-element: para-border-div; padding: 0cm 0cm 0cm 4.0pt;">
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<span class="comment-body">As for whether opioid medication is a black or white issue,
it is. This is not one of those situations where some studies are positive,
some negative, and only in the meta-analysis can you conclude whether something
works. This is a situation where every quality study ever done comparing
abstinence to maintenance shows a very powerful effect for medication. It is
the primary treatment recommendation of the World Health Organization. Opioid
agonist therapy is more effective than treatments for high cholesterol,
diabetes, heart disease or arthritis.</span></div>
<div class="MsoQuote" style="margin-left: 0cm;">
<br /></div>
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<span class="comment-body">What happened to requiring counseling along with Suboxone?
We found out it didn't matter for most people, unless they had co-existing
mental disorders. As I posted in my blog, it's not medication-assisted
treatment, the medication is the treatment. And like it or don't but the
relapse rate is >90% when people go off of it, or methadone, even after
being on one of them for months (or years) and being given counseling of a
quality far superior to anything available in the community. These are
established facts, no matter how distasteful one might find them. Nasty little
thing about scientific research is that it doesn't always reinforce what we
already "know" to be The Truth. But that's what the scientific method
is for. </span></div>
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<br />
<span class="comment-body">And as professionals we are ethically bound to tell
our patients what the evidence shows even if (or especially if) we wish the
facts were different. As Bernard Russell once said: "When the facts
change, I change my mind. What do you do, sir?"</span></div>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And then from private correspondence with Dr Willenbring:</div>
<div style="border-left: solid windowtext 2.25pt; border: none; margin-left: 22.7pt; margin-right: 0cm; mso-element: para-border-div; padding: 0cm 0cm 0cm 4.0pt;">
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<span style="mso-fareast-language: EN-ZA;">My own experience is that for many people
with opioid addiction, agonist therapy is all they need. Others who have
additional psychopathology need other services as well. It does need to be
individualized. What I like about this finding, along with others, it that it
disputes the prevailing notion that therapy or counseling is a required element
of recovery, when it clearly is not. I think we cling to that belief mostly out
of (unconscious) self interest. </span></div>
</div>
<div class="MsoNormal">
<span style="mso-fareast-language: EN-ZA;"><span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"> </span></span></div>
<div class="MsoNormal">
And then again from the otherside:</div>
<div style="border-left: solid windowtext 2.25pt; border: none; margin-left: 22.7pt; margin-right: 0cm; mso-element: para-border-div; padding: 0cm 0cm 0cm 4.0pt;">
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<span class="comment-body">I've sent plenty of addicts to OST/OMT programs but I don't
like the idea of referring to a program with little or no treatment and no exit
plan to speak of. This came to my attention recently through a friend who's
trying to help his sponsee leave bupe maintenance after 3 years of otherwise
productive recovery. It seems to be a pretty difficult process, which makes me
think bupe isn't as easy to detox from as I had been told.</span></div>
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<br />
<span class="comment-body">The other thing that concerns me: pretty soon we're
going to have a million addicts on bupe OMT.</span></div>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And in case you were wondering about my own beliefs, here is
my response:</div>
<div style="border-left: solid windowtext 2.25pt; border: none; margin-left: 22.7pt; margin-right: 0cm; mso-element: para-border-div; padding: 0cm 0cm 0cm 4.0pt;">
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<span class="comment-body">By no manner of speaking is long-term OST addiction, or
keeping a person addicted. To equate dependence and addiction is also
misguided. There are many amongst us who need long-term or even life-long OST
and to deny them that is unethical. Research tells us that OST is the primary
treatment in many cases. But as they say, one good personal anecdote destroys
10 years of double blind studies. No matter what our personal feelings, if we
are addictions professionals, OST and harm reduction HAVE to be on the front
page of the menu of treatment options, otherwise we are nothing more than
quacks.</span></div>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
But does that mean that I am firmly in the treatment camp?
Certainly not. I have a lot of worries about us seeing OST as a complete
treatment by itself. I have criticised the Yale study in a previous article
which can be found on my blog site: <a href="http://www.addictioncapetown.blogspot.com/">www.addictioncapetown.blogspot.com</a>.
Some of my thinking about long-term use has changed in the face of research,
but essentially my criticisms of the research findings as reported and
perceived still stand:</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<span style="font-size: x-large;"><span style="font-weight: normal;">Criticism of the OST studies and Treatment Camp</span></span><br />
<div class="MsoNormal" style="text-align: justify;">
Most of my criticism of the Yale study can be extended to
the Weiss study, and indeed most other studies that propose medication as the
end in itself revolve around the following main issues:</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l2 level1 lfo2; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>They measure the wrong thing </div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l2 level1 lfo2; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>They measure it over too short a time</div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l2 level1 lfo2; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>They exclude some significant populations</div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l2 level1 lfo2; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>They focus on CBT as the counselling approach
with which to compare outcomes</div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l2 level1 lfo2; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>They ignore other aspects of recovery</div>
<div class="MsoListParagraphCxSpLast">
<br /></div>
<h3>
<span style="font-weight: normal;"><span style="font-size: large;">They measure the wrong thing</span></span></h3>
<div class="MsoNormal" style="text-align: justify;">
What should we measure when it comes to recovery from
addiction? If we regard abstinence as the measure of success, then certainly
OST is successful. If we see heroin addiction as equalling heroin dependence, I
think we are missing the root of addiction. Through various processes, and on
many levels, those with an addictive disorder have developed a set of thinking
patterns and behaviours which are often not compatible with the achievement of
their life goals. The drug has a salience that exceeds mere physical dependence,
there is a lot invested in the processes and relationships of the addicted
state and to simply measure abstinence is not giving a clear picture. The Weiss
research reports that there is little or no change in levels of criminal behaviour,
for instance<span style="mso-no-proof: yes;"><span style="mso-spacerun: yes;"> </span>(Weiss, Potter, & et al, 2011)</span>. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal">
We should be measuring quality of life as well, in my
opinion.</div>
<div class="MsoNormal">
<br /></div>
<span style="font-size: large;">They measure it over too short a time</span><br />
<div class="MsoNormal" style="text-align: justify;">
Most studies, with a few notable exceptions, report on
relatively short-term outcomes. Certainly the studies I have referred to in
this article have focused on a maximum of 6 months after treatment initiation.
We also know that in these studies if the patient discontinued use the relapse
rate was >90%. My question is: Is long-term OST sustainable? We know that
adherence to chronic medication is not good – about 50% <span style="mso-no-proof: yes;">(Brown & Bussell, 2011)</span>, so this does not
bode well for continued sobriety.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<span style="font-size: large;">They exclude some significant populations</span><br />
<div class="MsoNormal" style="text-align: justify;">
The perception created by the Yale paper, especially evident
in the interviews with the researchers and in the press, is that those
suffering with opioid addiction can be cured with medication. What they fail to
point out is that within the “addicted” group there are a large number of
patients with comorbidity and those who clearly self-medicate. There is little
doubt that these populations require further interventions, and if we start
presuming that a simple office initiated medication based regimen will be
sufficient for this population we are naive. <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></div>
<span style="font-size: large;"><span style="font-weight: normal;">They focus on CBT as the counselling approach with which to compare outcomes</span></span><br />
<div class="MsoListParagraphCxSpFirst" style="margin-left: 0cm; text-align: justify;">
I
agree that CBT is a fair place to start when comparing various modalities of
treatment for addictive disorders. CBT seems to be the recommended
intervention, but then again I have similar criticisms of CBT studies as I do
of the Yale study. Most studies focus on abstinence not quality of life and
short periods of up to 12 months after treatment initiation. Most people
seeking treatment have been users of their drugs or activities of choice for
many years. The mean using years in the Yale study was 8. </div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 0cm; text-align: justify;">
CBT
in addictions treatment focuses on the “here and now” and is essentially
designed to bring about behaviour modification, prevent relapse and provide techniques
to reduce cravings. It does this fairly well compared with other modalities in
short-term comparisons, but there is little difference when compared with other
modalities in longer term studies. </div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 0cm; mso-add-space: auto;">
So,
essentially, you are double-treating the same issue. No wonder CBT seems to add
little value. Medications work better when it comes to short-term behaviour
modification. But do they work better in the long-term? We will have to wait
and see.</div>
<div class="MsoNormal">
<br /></div>
<span style="font-size: x-large;"><span style="font-weight: normal;">Criticism of the Recovery Camp</span></span><br />
<div class="MsoNormal">
My criticisms of the Recovery Camp are:</div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo3; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>They place undue emphasis on 12-Step recovery</div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo3; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>They believe OST is not abstinence </div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo3; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>They tend to ignore the evidence</div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo3; text-indent: -18.0pt;">
<br /></div>
<span style="font-size: large;"><span style="font-weight: normal;">They place undue emphasis on 12-Step recovery</span></span><br />
<div class="MsoNormal" style="text-align: justify;">
Both in the outpatient and inpatient settings, the recovery
camp tend to place too much emphasis on 12-step programs. In-patient facilities
often charge a fortune for what are essentially nothing more than a bunch of
12-step meetings in a draconian environment. Out-patient settings are much the
same and often focus on confrontational styles of intervention as laid out in
many 12-step facilitation manuals. In my mind, while 12-step programs are a
fantastic and free resource and undoubtedly work for some, they have little
place as a stand-alone treatment modality in the professional setting.</div>
<div class="MsoNormal" style="text-align: justify;">
Along with 12-step recovery comes a number of other issues
that are problematic in the professional addiction care setting, which I will
not discuss here, but there is one major problem:</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<span style="font-size: large;"><span style="font-weight: normal;">They Believe OST is not abstinence</span></span><br />
<div class="MsoNormal" style="text-align: justify;">
Abstinence is where it starts and ends in the recovery camp.
You must abstain from all mind-altering drugs. Full stop. Some 12-step programs
will not allow those on OST to hold service positions. The more radical ones
say that taking an opioid for pain management is relapse. Just like the
treatment camp, but in reverse, they see dependence as addiction.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<span style="font-size: x-large;">Finding the Middle Ground </span><br />
<div class="MsoNormal" style="text-align: justify;">
To consider one of these camps as either definitive or irrelevant
would be missing an opportunity to find a more complete and balanced approach
to addiction care. And although I used him as an example of the “treatment”
camp, Dr Willenbring also wrote this to me in our private correspondence:</div>
<div style="border-left: solid windowtext 2.25pt; border: none; margin-left: 22.7pt; margin-right: 0cm; mso-element: para-border-div; padding: 0cm 0cm 0cm 4.0pt;">
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<span style="mso-fareast-language: EN-ZA;">And, BTW, I use both CBT and brief
psychodynamic therapy myself, as well as supportive therapy. </span></div>
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<br /></div>
<div class="MsoQuote" style="margin-left: 0cm; text-align: justify;">
<span style="mso-fareast-language: EN-ZA;">Here in the USA, which is so dominated by
12-step ideology, it needs to be said again and again that not everyone has to
go to AA the rest of their lives, and that 12-step counseling is not always
needed. That may color my remarks. What I was trying to do in the blog was to
counter the notion that 12-step rehab is the necessary and sufficient condition
for recovery. In other countries where the 12-step influence isn't so strong,
that might come across as too pharmacotherapy oriented, which I am not. I do
more psychotherapy that most of my psychiatry colleagues here, where the norm
is strictly psychopharmacology.</span></div>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Perhaps the answer lies in knowing when and how to apply
each of these modalities. I would agree with Avial Goodman <span style="mso-no-proof: yes;">(Goodman, 2001)</span> who suggests that there are 4 phases of
recovery from an addictive disorder:</div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 38.5pt; mso-add-space: auto; mso-list: l4 level1 lfo4; text-indent: -18.0pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Behaviour modification</div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 38.5pt; mso-add-space: auto; mso-list: l4 level1 lfo4; text-indent: -18.0pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Stabilisation</div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 38.5pt; mso-add-space: auto; mso-list: l4 level1 lfo4; text-indent: -18.0pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Character Healing (personally I prefer Capacity Building)</div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 38.5pt; mso-add-space: auto; mso-list: l4 level1 lfo4; text-indent: -18.0pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Self-Renewal </div>
<div class="MsoNormal" style="text-align: justify;">
I would suggest that medication and short term “treatment” therapies
like CBT (as applied in addiction treatment), are best suited to the first two
phases while more “recovery” orientated interventions, such as life-skills,
psychodynamic therapies, longer term CBT and peer support groups are more
suitable for the final two phases.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
So where does long-term OST fit in? Well, for some opioid
addiction is a means of self-medicating a sluggish opioid system, and so they
would need to compensate for this in order to feel “normal”. Perhaps this is pre-existing
or as a result of extended substance abuse, either way the opioid absent system
is not a comfortable one, and so they would find themselves vacillating between
behaviour modification and short-term stabilisation. Surely for this individual
it would be better for them to stay on indefinite OST so as to maximize their
ability to engage in long term therapy?</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal">
Further, I would like to suggest that addiction takes place
across three planes:</div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l3 level1 lfo5; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Neurobiology – Neurochemistry</div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l3 level1 lfo5; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Thought – Behaviour (short-term and long-term) </div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l3 level1 lfo5; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Microsystem – Macrosystem</div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l3 level1 lfo5; text-indent: -18.0pt;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Each of these planes interact with and influence each other.
So, for example, the neurobiology – Neurochemistry plane will have an effect on
the other planes, to a greater or lesser degree. In the case of OST, this will
have an almost immediate effect on the short-term Thought-Behaviour plane (the
same plane where brief CBT therapies operate). These changes in behaviour can,
in turn, influence the Systems plane. Positive feedback from the system will in
turn influence the Thought-Behaviour plane and the Neurological plane and so
on. In cases where there has not been long term abuse that has caused
significant damage to the Thought-Behaviour plane or the Systems plane, I would
suggest that OST may be enough to bring to life the process described here, and
this will be enough for the capacity building and self-renewal mentioned above
to take place.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
For most opioid abusers, however, the Systems and long-term
Thought-Behaviour planes have been so influenced by the Neurological Plane
through the constant Neurochemical and behavioural influences of the opioids,
that simple medication is not enough. I have spoken to many former substance
users whose longing is not for the drug, but for the lifestyle. It is about the
excitement and chaos and sense of control over one’s feelings and being able to
self-regulate on a whim. It is the using friends, the sense of rebellion and
the easy means of coping that have all become expected and easily attained by
drug use that hold a far stronger allure than mere physical dependence. These
aspects will seldom be addressed by OST.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
And so, in conclusion, I would say: Treatment treats
dependence, and helps one disrupt the addictive cycle, recovery treats
addiction and helps build the capacity to engage in life without illicit
substance use, and in many cases both are needed to in varying degrees to reach
the goal of a meaningful existence.<span style="font-family: inherit;"><span style="font-size: 11pt; line-height: 115%;">This
all brings as back to the first principle of addiction treatment: “There is no
one-size fits all solution.”</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<!--[if gte mso 9]><xml>
<w:WordDocument>
<w:View>Normal</w:View>
<w:Zoom>0</w:Zoom>
<w:TrackMoves/>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:DoNotPromoteQF/>
<w:LidThemeOther>EN-ZA</w:LidThemeOther>
<w:LidThemeAsian>X-NONE</w:LidThemeAsian>
<w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:SnapToGridInCell/>
<w:WrapTextWithPunct/>
<w:UseAsianBreakRules/>
<w:DontGrowAutofit/>
<w:SplitPgBreakAndParaMark/>
<w:EnableOpenTypeKerning/>
<w:DontFlipMirrorIndents/>
<w:OverrideTableStyleHps/>
</w:Compatibility>
<m:mathPr>
<m:mathFont m:val="Cambria Math"/>
<m:brkBin m:val="before"/>
<m:brkBinSub m:val="--"/>
<m:smallFrac m:val="off"/>
<m:dispDef/>
<m:lMargin m:val="0"/>
<m:rMargin m:val="0"/>
<m:defJc m:val="centerGroup"/>
<m:wrapIndent m:val="1440"/>
<m:intLim m:val="subSup"/>
<m:naryLim m:val="undOvr"/>
</m:mathPr></w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
DefSemiHidden="true" DefQFormat="false" DefPriority="99"
LatentStyleCount="267">
<w:LsdException Locked="false" Priority="0" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Normal"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="heading 1"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 2"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 3"/>
<w:LsdException Locked="false" Priority="0" QFormat="true" Name="heading 4"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 5"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 6"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 7"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 8"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 9"/>
<w:LsdException Locked="false" Priority="39" Name="toc 1"/>
<w:LsdException Locked="false" Priority="39" Name="toc 2"/>
<w:LsdException Locked="false" Priority="39" Name="toc 3"/>
<w:LsdException Locked="false" Priority="39" Name="toc 4"/>
<w:LsdException Locked="false" Priority="39" Name="toc 5"/>
<w:LsdException Locked="false" Priority="39" Name="toc 6"/>
<w:LsdException Locked="false" Priority="39" Name="toc 7"/>
<w:LsdException Locked="false" Priority="39" Name="toc 8"/>
<w:LsdException Locked="false" Priority="39" Name="toc 9"/>
<w:LsdException Locked="false" Priority="35" QFormat="true" Name="caption"/>
<w:LsdException Locked="false" Priority="10" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" Priority="1" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" Priority="11" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" Priority="22" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" Priority="59" SemiHidden="false"
UnhideWhenUsed="false" Name="Table Grid"/>
<w:LsdException Locked="false" UnhideWhenUsed="false" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" UnhideWhenUsed="false" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" QFormat="true" Name="TOC Heading"/>
</w:LatentStyles>
</xml><![endif]--><!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:10.0pt;
mso-para-margin-left:0cm;
line-height:115%;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;
mso-fareast-language:EN-US;}
</style>
<![endif]-->
</div>
<div style="border-bottom: solid windowtext 1.0pt; border: none; mso-border-bottom-alt: solid windowtext .5pt; mso-element: para-border-div; padding: 0cm 0cm 1.0pt 0cm;">
<h1>
<span style="font-weight: normal;">Works Cited</span></h1>
</div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Brown, M., & Bussell, J. (2011). Medication
Adherence: WHO Cares? <i>Mayo Clinical Proceedings</i>, 304-314.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Caldiero, R., Parran, T. J., CL, A., Piche, & B.
(2006). Inpatient initiation of buprenorphine maintenance vs. detoxification:
can retention of opioid-dependent patients in outpatient counseling be
improved? <i>American Journal of Addiction</i>, 15(1):1-7.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Donovan, D., Knox, P., Skytta, J., Bayney, B., &
DiCenzo, J. (2012). Buprenorphine from detox and beyond: preliminary
evaluation of a pilot program to increase heroin dependent individuals'
engagement in a full continuum of care. <i>Journal of Substance Abuse
Treatment</i>, 44(4):426-432.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Fielin, M., Pantalon, M., & et al. (2006).
Counseling plus Buprenorphine–Naloxone Maintenance Therapy for Opioid
Dependence. <i>The New England Journal of Medicine</i>, 355:365-374.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Fiellin, D., Barry, D., & al, e. (2013). A
Randomized Trial of Cognitive Behavioral Therapy in Primary Care-based Buprenorphine.
<i>The American Journal of Medicine</i>, 126(1):74e11-74e17.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Goodman, A. (2001). What's in a Name? Terminology for
Designating a Syndrome of Driven Sexual Behaviour. <i>Sexual Addiction and
Compulsivity</i>, 8: 191-213.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Kleber, H. (2007). Pharmacologic treatments for
opioid dependence: detoxification and maintenance options. <i>Dialogues
Clinical Neuroscience</i>, 9(4): 455-470.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Mato, L., Minozzi, S., Davoli, M., & Vecchi, S.
(2011). <i>Psychosocial and pharmacological treatments versus pharmacological
treatments for opioid detoxification.</i> The Cochrane Collaboration, Wiley.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Mattick, R., Breen, C., Kimber, J., & Davoli, M.
(2009). <i>Methadone maintenance therapy versus no opioid replacement therapy
for opioid dependence.</i> The Cochrane Review.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Sees, K., Delucchi, K., Masson, C., Rosen, A., Clark,
H., Robillard, H., et al. (2000). Methadone maintenance vs 180-day
psychosocially enriched detoxification for treatment of opioid dependence: a
randomized controlled trial. <i>Journal of the American Medical Association</i>,
283(10)1303-10.</span></div>
<div class="MsoBibliography" style="margin-left: 36.0pt; text-indent: -36.0pt;">
<span style="mso-no-proof: yes;">Weiss, R., Potter, J., & et al. (2011).
Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone
Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled
Trial. <i>Arch Gen Psychiatry</i>, 68: 2011-2121.</span></div>
<div class="MsoNormal">
<br /></div>
<br />
<br />
<br />
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-27826823499786300392013-03-26T09:51:00.000+02:002013-12-26T09:24:16.160+02:00Addiction Information March 2013 Newsletter<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvM06k86BAVtf-Jh-6kqLAdzHJYMD_ghoV9exI8JgmLjrF0j4wqFOKki1YlllbVO5h4pCjLel17U3Nmr2YkYbSB1pJRbyhvhaUzLL67pcu90YcXocXuTmtIJVvGOPvI5PWzEQLyqHniL4/s1600/CityLead-570.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="182" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvM06k86BAVtf-Jh-6kqLAdzHJYMD_ghoV9exI8JgmLjrF0j4wqFOKki1YlllbVO5h4pCjLel17U3Nmr2YkYbSB1pJRbyhvhaUzLL67pcu90YcXocXuTmtIJVvGOPvI5PWzEQLyqHniL4/s320/CityLead-570.jpg" width="320" /></a></div>
<div style="text-align: justify;">
<span style="font-size: small;">This month we celebrated Human Rights Day in Sou<span style="font-size: small;">th Africa. <span style="font-size: small;">I was given the opportunity to share my opinion on why those suffering from addiction are seldom afforded the same rights as others. <span style="font-size: small;">A copy of my speech can be found here: <a href="http://addictioncapetown.blogspot.com/2013/03/human-rights-day-speech.html" target="_blank">Human Rights Day: Addicts are </a><span style="font-size: small;"><a href="http://addictioncapetown.blogspot.com/2013/03/human-rights-day-speech.html" target="_blank">also Human</a>. This month saw the first <a href="http://icba.mat.org.hu/" target="_blank">International Conference on Behavioral Addictions</a> taking place in Budapest<span style="font-size: small;"> and so it is fitting to talk a bit about <b>gambling addiction</b>. Also in th<span style="font-size: small;">is issue: </span></span></span></span></span></span></span></div>
<div style="text-align: justify;">
<span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><b>The Delta<span style="font-size: small;">FOSB Feedforward Loop, Drug Court, The Portuguese Drug Policy, Russel Brand on Addiction, Discontinuation of Sublingual Buprenorphine and <span style="font-size: small;">Possible Approval for</span> Buprenorphine Implants</span></b> </span></span></span></span></span></span></span></span></div>
<br />
<a name='more'></a><br />
<span style="font-size: x-large;">Gambling Addiction</span><br />
<span style="font-size: large;">Skinner boxes for human rats?</span><br />
<div style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqCbNbV3TtqSBe4gevo9vSBmNR3c1NybnNOGyQg42L-rPJ1RFdBULyL6iKa0ES9YgJ-ny33m04WwiKNWgyyseCFBlk_skbxHnuRIJPGhJRxp2XKYEWUUd_tZPMGMIePjogsG1ka0KsM2w/s1600/tumblr_inline_mhjus5Ho071qz4rgp.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="162" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqCbNbV3TtqSBe4gevo9vSBmNR3c1NybnNOGyQg42L-rPJ1RFdBULyL6iKa0ES9YgJ-ny33m04WwiKNWgyyseCFBlk_skbxHnuRIJPGhJRxp2XKYEWUUd_tZPMGMIePjogsG1ka0KsM2w/s200/tumblr_inline_mhjus5Ho071qz4rgp.jpg" width="200" /></a></div>
Dirk Hansen, author of <a href="http://www.amazon.com/dp/1439212996?tag=addicinbox-20&camp=14573&creative=327641&linkCode=as1&creativeASIN=1439212996&adid=0WD68Y1Z661CZ864H1QD&&ref-refURL=http%3A%2F%2Faddiction-dirkh.blogspot.com%2F2013%2F03%2Faddiction-machines-how-slots-are.html" target="_blank">"The Chemical Carousel</a>" talks about gambling machines in his article on his blog, "<a href="http://addiction-dirkh.blogspot.com/2013/03/addiction-machines-how-slots-are.html" target="_blank"><i>Addiction Machines: How Slots are Designed for Compulsive Play</i></a>". I have seen many meth addicts become compulsive machine addicts, and even when the meth use stops, the gambling continues. This is not surprising, as " recent research seems to show that machine gambling pushes gamblers into an addictive relationship with gambling at a rate three times faster than gamblers who stick to live table games" says Hansen. Surely it is unethical to create an Addiction Creating Machine? Sounds like something out of a sci-fi movie, but the world of economics keeps turning and it's often in government's favour to allow gambling to encourage gambling, as Staton Peele says in his Psychology Today blog: "<i><a href="http://www.psychologytoday.com/blog/addiction-in-society/201302/look-whos-addicted-gambling/comments" target="_blank">Look Who's Addicted to Gambling</a></i>".<br />
<br />
<span style="font-size: large;">Paralimbic Interaction</span><br />
Altered paralimbic interaction in gambling addicts has been noted in a new study published<a href="http://www.pnas.org/content/early/2013/02/28/1302374110" target="_blank"> in PNAS</a>. The study examined communication between the medial prefrontal/anterior cingulate (ACC) and medial parietal/posterior cingulate (PCC) cortices using magnetoencephalography. These two regions of the brain are linked to self-awareness and are considered important in the expression of self-control. Not suprisingly, pathelogical gamblers show low levels of self-control, and they show a corresponding impaired communication between these two areas. This has been previously demonstrated with exogenous addictions, but this is, apparently, the first time it has been shown with behavioural addictions. What is of particular interest is, to quote the study, " gamblers with a history of stimulant abuse had up to four times higher power at the ACC site during rest and the task compared with controls. In conclusion, pathological gamblers had higher impulsivity and functional paralimbic abnormalities, which could not be explained by a history of stimulant abuse. In addition, previous stimulant abuse had a marked effect on the amplitude of oscillatory brain activity in the ACC and PCC, suggesting long-term deleterious effects of repeated dopaminergic drug exposure." The million dollar question is, of course, which came first, the dysfunction or the addiction, but what is clear is that even after drug use has stopped, the effects linger, making one more susceptible to alternative expressions of addiction.<br />
<br />
<span style="font-size: x-large;">Research</span><br />
<span style="font-size: large;">DeltaFOSB Feedforward Loop in Cocaine Addiction</span><br />
The NAc has long been described as the brain's pleasure centre, and the link to drug addiction is well documented (See "<a href="http://www.scribd.com/doc/119795741/Common-Reward-Pathway" target="_blank">Common Reward Pathway</a>" and "<a href="http://www.scribd.com/doc/120620905/The-Neurobiological-Underpinnings-of-Addiction" target="_blank">Neurological Underpinnings of Addiction</a>" for an overview). We have also seen how DeltaFOSB levels are elevated in addicts and could lead to sustained changes in gene expression in addicts. A. J. Robison and his research team at Michigan State University have been examining the production of both DeltaFOSB and calcium/calmodulin-dependent protein kinase II (CaMKIIα) in the NAc. The DeltaFosB is linked with addiction and the CaMKIIα linked with memory. The proteins have a reciprocal relationship—they increase each other’s production and stability in the cells—so the result is a snowball effect that Robison calls a feed-forward loop. In this fascinating research they found that by elevating the levels of DeltaFOSB caused rats to behave as though on cocaine. Both these proteins regulate AMPA receptor expression in the NAc, bringing glutamate into play. What they have been able to do in rats is interrupt this loop by preventing the function of the learning protein. This fascinating study was published in this month's issue of "<a href="http://www.jneurosci.org/content/33/10/4295.abstract" target="_blank">The Journal of Neuroscience</a>".<br />
<br />
<span style="font-size: x-large;">Policy</span><br />
<span style="font-size: large;">One Day Drug Store Will Mean Drug Store?</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgx5OjhNICnuW9JMRa4YuFi3bvYrWOlWHlgmkm6BcdJbqEhtBJN1CfkQmG_sPb0uUrh5m7pg-mzk03yw9z27T_z4j5GqDL0W8-H52js1IhmgpUd1QnuHR2DOUlhWyqS-ohunA7dgupJIHg/s1600/3327958502_907e964316.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="154" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgx5OjhNICnuW9JMRa4YuFi3bvYrWOlWHlgmkm6BcdJbqEhtBJN1CfkQmG_sPb0uUrh5m7pg-mzk03yw9z27T_z4j5GqDL0W8-H52js1IhmgpUd1QnuHR2DOUlhWyqS-ohunA7dgupJIHg/s200/3327958502_907e964316.jpg" width="200" /></a></div>
Jeffrey Miron, Director of Undergrad Studies at Havard University Department of Economics has been a long-time <a href="http://www.cato.org/publications/white-paper/budgetary-impact-ending-drug-prohibition" target="_blank">advocate of legalising drugs</a>. So much that he would like to see drugs sold in supermarkets. In his interview in <a href="http://www.spiegel.de/international/world/harvard-economist-jeffrey-miron-on-why-drugs-should-be-legalized-a-886289.html" target="_blank">Der Spiegel</a> he outlines his argument. He argues that by decriminalising drugs the US would save between $85 to $90 billion per year. No doubt his views are controversial. He says in the interview: <br />
<blockquote class="tr_bq">
<i>"The effects of cocaine are described in a highly exaggerated way. There are Wall Street bankers who snort coke; they have high incomes, access to a good healthcare system, are married and have a stable life situation. Many of them subsequently stop taking cocaine. I get the impression that these people enjoy consuming it. Then there are people who smoke crack cocaine and lead lives that are very different from those of stockbrokers; they are people with low incomes, no jobs and poor health. Many of these people come to a sorry end. But cocaine's not to blame for that. Those people's lousy lives are to blame" </i></blockquote>
These are clearly the views of a libertarian economist, and seem to avoid the very real issue of the harm caused by addiction. However, before writing off his ideas as being totally crackpot, read the interview. Certainly he does make some good arguments. As he says:<br />
<blockquote class="tr_bq">
<i>"If a friend of yours does something that's stupid, do you think about whether it would make the situation better or worse if you intervened? Maybe putting your friend in prison and forcing him to undergo therapy isn't the best solution. Maybe it's better to talk to your friend in a calm and collected way." </i></blockquote>
<span style="font-size: large;">Drug Court </span><br />
A little less controversial is the concept of the drug court. <a href="http://www.thefix.com/content/drug-courts91363" target="_blank">The Fix</a> give a glimpse of a day in drug court. Drug courts have been shown to reduce the cost of addiction by saving $3.36 on the dollar, and also the <a href="http://www.nadcp.org/nadcp-home/" target="_blank">NADCP</a> research claims that 75% of drug court graduates remain arrest-free for at least two years. This seems very attractive, but for me there are two major problems: The individual usually has to plead guilty to a crime before they will be considered for treatment diversions - which means they are criminalised in the process and also they are forced to attend 12-step programs or enter rehabs with no desire to get clean. This is one of the NIDA principles that I disagree with - forcing someone into treatment often sabotages future treatment attempts, and goes strongly against the latest evidence (think Miller and motivational interviewing).<br />
<span style="font-size: large;"><br />
</span> <span style="font-size: large;">The Portuguese Model</span><br />
They will soon be famous for more than Nando's chicken! Since 2001 Portugal has decriminalised drug use and posession. Instead of appearing before a criminal court, drug users who are arrested appear before "Dissuasion Committee" which consists of specially trained justice officials, a social worker and psychologist. Dealing and trafficing are still illegal. While this is not news, <a href="http://www.cato.org/publications/white-paper/drug-decriminalization-portugal-lessons-creating-fair-successful-drug-policies" target="_blank">the research over the last 11 years</a> is beginning to look credible. In 2001 an estimated 100 000 were addicted to drugs - that is 1% of the population! Between the implementation of the law and now there have been significant changes:<br />
<ul>
<li>Small increases in illicit drug use among adults, but decreases for adolescents and problem users such as drug addicts and prisoners;</li>
<li>Drug-related HIV cases dropped 75 percent. In 2002, 49 percent of people with AIDS were addicts; by 2008 that number fell to 28 percent;</li>
<li>The number of regular users held steady;</li>
<li>The number of addicts has halved;</li>
<li>Drug related diseases including STDs and overdoses have halved;</li>
</ul>
I find this very exciting. Imagine the data collected from these non-threatening dissuasion sessions and how this can be used to address socio-economic and community issues.<br />
<br />
So where did Portugal get the motivation to pass such controversial legislation? Jose Socrates, the Prime Minister's brother was an addict and he learned from this experience. "It was a very hard change to make at the time because the drug issue involves lots of prejudices," he said. "You just need to rid yourselves of prejudice and take an intelligent approach."<br />
<br />
<span style="font-size: large;">The Addiction Brand-wagon</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRxc8PkDBiHKbK6SX7pRjKw4nGoRx6iUM6qLljezGY-kJukfNTtI0UE44A_SS2XR4lzGGHltGzulgasmhv2Y_5L8jXdNauOMJzaIk2DlWyXpEs-gyXo0TZOTz7rLh-ZAz490_-TyI24Gk/s1600/LM-food-trucks_20120425132635658037-420x0.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="190" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRxc8PkDBiHKbK6SX7pRjKw4nGoRx6iUM6qLljezGY-kJukfNTtI0UE44A_SS2XR4lzGGHltGzulgasmhv2Y_5L8jXdNauOMJzaIk2DlWyXpEs-gyXo0TZOTz7rLh-ZAz490_-TyI24Gk/s320/LM-food-trucks_20120425132635658037-420x0.jpg" width="320" /></a></div>
Comedian Russell Brand has been on the wagon for the last ten years. Now he has started a charity with the Comic Relief structure called "Give It Up". Love him or hate him, Brand is one of the most vocal of drug policy advocates, appearing before the <a href="http://www.dailymail.co.uk/news/article-2134442/A-stranger-house-Russell-Brand-appears-Commons-select-committee-wearing-torn-vest-cowboy-hat-tattoos-show.html" target="_blank">House of Commons last year to promote</a> addiction as a health issue. Brand is no big fan of Methadone, as he states in <a href="http://www.guardian.co.uk/culture/2012/aug/12/russell-brand-methadone-treating-heroin-addicts" target="_blank">this article</a> published in the Guardian last year. In spite of his cavalier attitude and constant joking (he is a comedian after all) Brand has some worthwhile comments and is doing a lot to create a more balanced view of addiction and decrease the stigma. In his latest very frank article in <a href="http://www.guardian.co.uk/culture/2013/mar/09/russell-brand-life-without-drugs" target="_blank">the Guardian</a> he talks about his new charity and continued vulnerability. He offers this little gem of an insight into the addictive mind: "Drugs and alcohol are not my problem, reality is my problem, drugs and alcohol are my solution". Read Beth Burgess' opinion as to why she thinks Brand has it right at the <a href="http://www.huffingtonpost.co.uk/beth-burgess/russell-brand-is-right-about-addiction_b_2847134.html?goback=.gde_862107_member_222054829" target="_blank">HuffPost</a>.<br />
<br />
<span style="font-size: large;"><span style="font-size: x-large;">General News</span> </span><br />
<span style="font-size: large;">Caffeine</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNVYRQiFsSDOCIUwPC9CdivfSEVNaS51WnBx8UmuEttjdF7ir4g5YEmNFYeezkiYH0lp9qihr-pG0tVCQ6tKva0VmC-cEcTPZkCIu5Pz3kI700U25qv-bPr2Utbkq1rFIDP9Pv_s6iqiU/s1600/coffee.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="149" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNVYRQiFsSDOCIUwPC9CdivfSEVNaS51WnBx8UmuEttjdF7ir4g5YEmNFYeezkiYH0lp9qihr-pG0tVCQ6tKva0VmC-cEcTPZkCIu5Pz3kI700U25qv-bPr2Utbkq1rFIDP9Pv_s6iqiU/s200/coffee.jpg" width="200" /></a></div>
What's the link between interns and 12-step meetings? Caffeine! Most of us rely on a daily boost in the form of coffee, coke or energy drinks. Dirk Hanson, author of "<a href="http://www.amazon.com/dp/1439212996?tag=addicinbox-20&camp=14573&creative=327641&linkCode=as1&creativeASIN=1439212996&adid=0QDX20VYGJB944E7C0NZ&&ref-refURL=http%3A%2F%2Faddiction-dirkh.blogspot.com%2F" target="_blank"><i>The Chemical Carousel</i></a>" has put together a really neat synopsis of the war on <a href="http://addiction-dirkh.blogspot.com/" target="_blank">caffeine in his blog</a>. Amazing that this battle began in 1911 with the confiscation of Coca-Cola concentrate! It appears caffeine is lurking everywhere, according to a list formulated Jack E.James in the "<i>Journal of Caffeine Research</i>". Its even in shampoo! And is drunk in such large quantities that it is a contaminant of our fresh and salt water. Meanwhile, the Atlanta Journal-Constitution reports <a href="http://www.ajc.com/news/lifestyles/health/caffeine-how-much-is-too-much/nWpyC/" target="_blank">American's caffeine addiction intensifies</a>, but if you are worried, fret not, because apparently in Africa, its not a problem, according <a href="http://www.codewit.com/diet-and-nutrition/6259-drink-coffee-without-fear-of-addiction-experts" target="_blank">to Dr Kemi Odukoya </a>of the University of Lagos: "Mechanisms of action of caffeine are very different from that of drug abuse and they do not affect the brain circuit and structure for reward, motivation or addiction." And we all breathe a collective sigh of relief!<br />
<br />
<span style="font-size: x-large;">Buprenorphine </span><br />
<span style="font-size: large;">Buprenorphine Implant</span><br />
Titan Pharmaceuticals may be given approval by the FDA for the marketing of Probuphine, a matchstick sized implant designed to fight opioid dependance. The implants are effective for up to 6 months. Although the FDA advisory board has recommended that the medication is approved on April 30, there are still some concerns regarding dosage. Each implant contains 80 mg of the drug, and four to five rods are usually implanted under the skin for a 4- to 6-month treatment course.<br />
<br />
<span style="font-size: large;">Sublingual Buprenorphine Manufacture Halted </span><br />
The introduction of the implants may be good news considering that Reckitt Benckiser discontinued the manufacture of <a href="http://www.ashp.org/DrugShortages/NotAvailable/bulletin.aspx?id=967" target="_blank">Buprenorphine tablets</a> on 18 March in the US, citing concerns about accidental Paediatric exposure. This is after analysis of data from the US Poison Control Centres. Instead the company is recommending the migration to the Suboxone film. Call me cynical, but I believe this has less to do with safety concerns and more to do with the fact that the patent on the sublingual tablet is about to expire and the patent on the film is still valid for a number of years! For more on transdermal buprenorphine safety, and its use in pain management, read this paper: <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661652/" target="_blank">Transdermal buprenorphine in the management of persistent pain - safety aspects.</a><br />
<br />
<span style="font-size: large;">Quote of the Month</span><br />
To end this months newsletter, how about a quote from the inventor of the detective fiction genre, Edgar Allan Poe:<br />
<blockquote class="tr_bq">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmwHxDD1GxtsMsGUWojPUXaiXadJm5p4-Aa-ANAV-IxOq6CjtfXdmVjupsftntoOE8OtM0cR1HhuwIx8x6TXcbMnfN8Jt9MAXBJ4gkItYtkyxrxTuUhvUOchzJu2MT20YoLafMuSitVlI/s1600/edgar-allan-poe.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmwHxDD1GxtsMsGUWojPUXaiXadJm5p4-Aa-ANAV-IxOq6CjtfXdmVjupsftntoOE8OtM0cR1HhuwIx8x6TXcbMnfN8Jt9MAXBJ4gkItYtkyxrxTuUhvUOchzJu2MT20YoLafMuSitVlI/s1600/edgar-allan-poe.jpg" /></a></div>
<span style="font-size: large;"><i><span class="userContent">“I have absolutely no pleasure in the stimulants in which I sometimes so madly indulge. It has not been in the pursuit of pleasure that I have periled life and reputation and reason. It has been the desperate attempt to escape from torturing memories, from a sense of insupportable loneliness and a dread of some strange impending doom.”</span></i></span></blockquote>
<br /></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-8977576053593336112013-03-22T12:18:00.000+02:002013-03-23T14:30:47.197+02:00Human Rights Day Speech<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg14vmdd7QgJEdwKyZbQY6Apt7tWstBWkbzv-kCzkyAkHkg5QH9v2BX8AHcnKdAz5HozXD9yTxgjgQaCzQCecZ_83T7aJbGVLFOdA5ouZEc2dAlwQz0TKCDDC4x7WSQKMTQX3HEuBTdfWg/s1600/Haven+Talk.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg14vmdd7QgJEdwKyZbQY6Apt7tWstBWkbzv-kCzkyAkHkg5QH9v2BX8AHcnKdAz5HozXD9yTxgjgQaCzQCecZ_83T7aJbGVLFOdA5ouZEc2dAlwQz0TKCDDC4x7WSQKMTQX3HEuBTdfWg/s200/Haven+Talk.jpg" width="200" /></a><b><span style="font-size: large;">Addicts Are Also Human</span></b><br />
<div class="MsoNoSpacing" style="text-align: justify;">
By Shaun Shelly<br />
<i>This is a speech I delivered at a public function held to celebrate Human Rights Day in South Africa. Addicts are one of the most marginalised groups in society, not even enjoying the right to freedom or medical care:</i><br />
<br />
The Bill of Rights is a cornerstone of democracy in South Africa. It enshrines the rights of all people in our country and affirms the democratic values of human dignity, equality and freedom. <span style="mso-spacerun: yes;"> </span>It places a responsibility on the state to respect, protect, promote and fulfill the rights in the Bill of Rights. </div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br />
<a name='more'></a></div>
<div class="MsoNoSpacing" style="text-align: justify;">
It further goes on to say everyone is equal before the law and has the right to equal protection and benefit of the law. We are also told that we have a right to freedom and a right of control over our own bodies. We also, apparently, all have a right to healthcare.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
There is, however, a group that has been marginalised and seems to have slipped between the cracks. Those who suffer from the condition known as addiction. Medically addiction is considered a chronic relapsing disorder of the brain, and the addict is regarded as someone in need of care. In society the addict is seen as a product of their own bad choices who deserves to suffer the consequences. But if we believe in the Bill of Rights, we must consider the addict.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
Take for example the story of a young girl who was caught with a minor quantity of drugs in her possession. She was undoubtedly an addict. She had turned to drugs due to difficult life circumstances. She did not choose to become an addict, in spite of what many may think. Instead of being referred to health services, instead of receiving treatment, she was sent to prison for months. Has this helped her? No, it has scarred her for life, and increased the length of the course of her condition. Has it helped society or the community? No, it has added an extra burden. </div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
Earlier this week I was in court presenting evidence in mitigation of sentence. This particular individual has a heroin addiction, and as part of his treatment he is on an opioid substitution medication. Research tells us that without this medication he will suffer painful withdrawals and will most likely relapse into full-blown heroin addiction. Along with this comes the need to interact with criminals to aquire his drugs, the risk of drug-related medical conditions and a number of other social ills. In spite of having a medical diagnosis, and in spite of the risk, he is unable to continue his medication while incarcerated and may not undergo psycho-social treatments in prison.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
In my opinion both these cases are in direct opposition to the Bill of Rights. We are refusing people who have a medical condition treatment. That is wrong. But worse still, we are criminalising their condition. We are, effectively, making it illegal to suffer from addiction.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
You may say that addicts choose their disease. That is not true. Over 50% of all adolescents will at some time or other try illicit drugs. Many more will try alcohol. Most will never become addicted and most will therefore never face consequences for their drug use. But for some, due to genetic disadvantage, economic disadvantage, social disadvantage, familial disadvantage or some other circumstance, the initial casual use of drugs will turn into a disease that kills more than any other disease: Addiction. </div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
Does the diabetic get refused treatment because they had a sugar- rich diet? Of course not - that would be wrong!</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
So why are addicts automatically regarded as criminals. <span style="mso-spacerun: yes;"> </span>By throwing those who are suffering from addiction into jail only because they are caught in possession of illegal substances is counter-productive and creates significantly more of a problem than it solves.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
I am not suggesting that drug addicts are not punished for breaking the law – driving under the influence, stealing, abusing others or the like. Like the rest of society they should pay the price. To, however, criminalise someone for possession is not helping any one.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
During the holiday period last year LEAD SA launched their Drug Watch Campaign. Towards the end of this campaign they proudly announced that over 8000 people had been arrested and over R5million of drugs had been confiscated. This is not good news. Once the major drug hauls are removed this means that the average value of the drugs seized was less than R400 per person! These are hardly high-flying drug dealers – these are our children, our friends, our associates who happen to suffer from this thing called addiction. What these figures do tell us is that whatever we are doing to combat addiction, it is not working. </div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
These arrests are contributing to the societal issues that breed addiction:</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 36.0pt; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>The police resources wasted on attaining and processing these arrests are significant with little return. Police will tell you that many are repeat drug offenders because their addiction drives their need and potentially getting caught is not an effective deterrent.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 36.0pt; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>To process all of these cases will take the courts well over 200 court days, tying up much of our already strained judicial system. Added to this is a low conviction rate, and often it is only the repeat offenders or those who have no representation who are convicted – most of the dealers are escaping conviction.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 36.0pt; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Add to this the fact that those who do end up in prison will be schooled in the number while incarcerated and will return to the streets not only as addicts, but also as gangsters.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 36.0pt; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Further, it places the police in an “us and them” position. A drug user sees the police as the enemy, rather than as a means of help. A drug user will seldom approach the police to report a more serious and real crime.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 36.0pt; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>I have met many people who have fought the battle against addiction, fighting hard for their sobriety, only to be held back by a criminal record for drug related crimes.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 36.0pt; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Perhaps, most importantly, we need to see who is getting arrested. There are addicts in all sectors of society, but it is not the wealthy addicts who are getting arrested. Doors are seldom being kicked down in Bishops Court or Constantia. It is the previously disadvantaged and the poorer communities who are being targeted. </div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
This is not justice. It is criminal. It not only undermines the human rights of the chronically ill, but it also undermines society! The United Nations Office on Drugs and Crime says: “There is considerable evidence that effective drug dependence treatment offering clinical interventions as an alternative to criminal justice sanctions substantially increases recovery, including a reduction in crime and criminal justice costs. This improves the outcomes of both the person with the drug disorder and the community.”</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
Any family who has had first-hand experience of addiction will know that there is little hope of access to treatment. Daily I hear how the psychotic patient is turned away from a hospital because they are an addict. Daily I hear about the addict being refused the rights we are supposed to enjoy, simply because they are an addict. The waiting lists for affordable treatment are long. <span style="mso-spacerun: yes;"> </span>It is time to wake up.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
In 2001, Portugal took the radical step of decriminalising drug use.<span style="mso-spacerun: yes;"> </span>When someone is caught in possession of drugs they appear before a social worker and psychologist who gather data that enables government to improve communities and socio-economic conditions, and the person is offered treatment. 10 years later, the results speak for themselves:</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 45.75pt; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Small increases in illicit drug use among adults, but decreases for adolescents and problem users such as drug addicts and prisoners;</div>
<div class="MsoNoSpacing" style="margin-left: 45.75pt; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Drug-related HIV cases dropped 75 percent. In 2002;</div>
<div class="MsoNoSpacing" style="margin-left: 45.75pt; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>The number of addicts has halved;</div>
<div class="MsoNoSpacing" style="margin-left: 45.75pt; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Drug related diseases including STDs and overdoses have halved;</div>
<div class="MsoNoSpacing" style="margin-left: 45.75pt; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Criminal justice costs fell;</div>
<div class="MsoNoSpacing" style="margin-left: 45.75pt; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Access to treatment was increased.</div>
<div class="MsoNoSpacing" style="margin-left: 45.75pt; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;"><br />
<span style="font: 7.0pt "Times New Roman";"> </span></span></span></div>
<div class="MsoNoSpacing" style="text-align: justify;">
This goes to prove that there are viable alternatives.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
So why do we continue to do what does not work? </div>
<div class="MsoNormal" style="text-align: justify;">
It is politically expedient. Communities are suffering due to the prevalence of illicit substance use, and particularly due to the criminal activities that are involved in the acquiring of drugs and the gangsterism that so heavily depends on the drug trade for survival, and so we take comfort in seeing headlines that proclaim large numbers of arrests and big values of confiscated drugs. It makes us feel a little safer and that earns votes.</div>
<br />
<div class="MsoNormal" style="text-align: justify;">
Secondly, our local Police are expected to meet certain performance criteria that are based on invalid measurement tools. Each Police station is expected to deliver a certain number of drug arrests per month. These figures (along with other arrest rates) are what our station commanders live or die by. This makes absolutely no sense. By stopping major dealers from operating in an area, station commanders are, effectively, guaranteeing poor performance evaluations. It is much better for performance ratings to patrol the areas around these dealers and stop and search those walking back home after scoring.</div>
<br />
<div class="MsoNormal" style="text-align: justify;">
There are other reasons as well, but essentially for the sake of political posturing we are trampling on the very bill of rights we so proudly celebrate at this time of year. We should hang our heads and think of one of the most disadvantaged of groups: the addict. The addict who is denied the rights we are holding up for the rest of the world to see. Until we treat addiction as a medical condition, until we stop criminalising someone simply because they are neurologically disadvantaged, until we are able to offer treatment to our addicted children, until we are able to break the cycle of addiction that is getting worse with each generation, until we can treat addicts with dignity, until we can guarantee not only their right to freedom, but their right to freedom from drugs, we have no right to celebrate.</div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-12219512133550444772013-03-02T17:24:00.000+02:002013-03-02T17:27:27.753+02:00Addiction Information February 2013 Newsletter<div style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhEPHH2uKfZDrNuvDzBCQQt3v4bhgRo289pe3rHt_kyRk19AyiDRNI8Xyf6vKy1Go7DnegdHWOz_LXX7rVXoYXWzKbkSs0-5zeHhLipr3Wrk1l61hybxmz4UKWq1rCeevXt-5pJQDo5O3I/s1600/alcohol-addiction-brain-scan.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhEPHH2uKfZDrNuvDzBCQQt3v4bhgRo289pe3rHt_kyRk19AyiDRNI8Xyf6vKy1Go7DnegdHWOz_LXX7rVXoYXWzKbkSs0-5zeHhLipr3Wrk1l61hybxmz4UKWq1rCeevXt-5pJQDo5O3I/s200/alcohol-addiction-brain-scan.jpg" width="194" /></a></div>
This is Newsletter Number 2, which is a little late due to a crashed hard-drive. The only two documents I had not backed up were the talk I was due to present <a data-cke-saved-href="http://addictioncapetown.blogspot.com/2013/02/sex-drugs-and-no-control.html" href="http://addictioncapetown.blogspot.com/2013/02/sex-drugs-and-no-control.html"><i>"Sex, Drugs and No Control"</i></a>, and this newsletter, so it was back to the keypad! But we've made it, although in a slightly shorter version. I hope you find this summary of addiction news from around the world useful. Your suggestions are again most welcome, and articles for the website or that you would like to have linked to this newsletter can be directly submitted to me by e-mailing <a data-cke-saved-href="mailto:shaun.shelly@yahoo.com" href="mailto:shaun.shelly@yahoo.com">shaun.shelly@yahoo.com</a>.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Please like us on <a data-cke-saved-href="http://www.facebook.com/pages/Addiction-Information/509564762408169?ref=ts&fref=ts" href="http://www.facebook.com/pages/Addiction-Information/509564762408169?ref=ts&fref=ts">facebook.</a></div>
<span style="font-size: 14px;">In this issue: </span><br />
<b><span style="font-size: 14px;">Inside Rehab, Celebrity Rehab, Recovery or Treatment?, Dr Mark Willenbring, OST, Naloxone, NMDA Modulators, Epigenetics, Frankenstien Drugs, Local Research, </span>Ibudilast for Meth addiction?, Policy in NZ, Columbia and Africa, Banker or Dealer?</b><br />
<br />
<a name='more'></a><span style="font-size: x-large;">The State of Treatmen<span style="font-size: x-large;">t</span></span><span style="font-size: x-large;"><span style="font-size: large;"> </span></span><br />
<span style="font-size: large;">Inside Rehab</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEja7XUU5Z68Jx-fe7ORi1yrOEkDq5QrsJ1QzN1sAEL-TEFsLMHHqaO3BGkaLrjovFcv0FkHzDUzVw0NWRZyeVNOuHI27oMZCHxAnWk0POw7LiJFIWF-vLuZ5spTW9FTLivHzr819KvnfTI/s1600/Inside+Rehab.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEja7XUU5Z68Jx-fe7ORi1yrOEkDq5QrsJ1QzN1sAEL-TEFsLMHHqaO3BGkaLrjovFcv0FkHzDUzVw0NWRZyeVNOuHI27oMZCHxAnWk0POw7LiJFIWF-vLuZ5spTW9FTLivHzr819KvnfTI/s200/Inside+Rehab.jpg" width="132" /></a></div>
<div style="text-align: justify;">
Anne Fletcher's new book "Inside Rehab" has caused a lot of press, and has most certainly generated a lot of strong opinion. It hit the New York Times best seller list before it was even released. My copy has just arrived, so I will, no doubt, offer some opinions in the future. The book is the culmination of 4 years of research, during which time the author visited fifteen addiction programs and interviewed over a hundred clients. What emerges is an alarming discrepancy between science and practice. One of the most important points to emerge is that by far the most addicts don't need rehab to recover. The <a href="http://well.blogs.nytimes.com/2013/02/04/effective-addiction-treatment/" target="_blank">New York Times</a> and <a href="http://www.thefix.com/node/4632#comment-798000038" target="_blank">The Fix</a> have both covered the book and both articles have brought about heated debate.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
I too am concerned about the state of rehabs, especially the multitude of faith based facilities we see in the local context. I have written about this here: "<a href="http://addictioncapetown.blogspot.com/2013/02/faith-based-rehabs-what-in-gods-name-is.html" target="_blank">Faith Based Rehabs: What in God's Name Is Going On?</a>" </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-size: large;">Dr Who?</span></div>
<div style="text-align: justify;">
If we are wondering why the majority of those seeking treatment are misguided about evidence based care, this is a reason why: Turning addiction treatment into entertainment. For those of you who have time to watch DSTV, you may have stumbled upon Dr Drew. Now that the "Dr" has lost yet <a href="http://www.nypost.com/p/news/national/exploiting_addiction_U3UMrCD3UvvWGdK0OVsh2N" target="_blank">another patient to suicide</a>, his mortality rate is at 11% for patients/supporting cast of Dr Drew Celebrity Rehab.<br />
<br />
<span style="font-size: large;">Recovery or Treatment?</span><br />
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 "<a href="http://dev.facesandvoicesofrecovery.org/pdf/White/2013_Recovery-focused_Knowledge.pdf" target="_blank">Toward a Core Recovery-Focused Knowledge Base for Addiction Professionals and Recovery Support Specialists</a>". 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.<br />
<br />
<span style="font-size: large;">Dr Willenbring</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPyidmEqZxqsIq4kfHBqqn3kRLSOlYRu8_l7A78YYzXYYkQxEhsTAmVyeev-8aVrwVI_J3a_wfRI5vDomGvWZJ5ayNB0ORi_W7AmMBYXzT-mvVbG-ti-ZFzp19as9Qhtq5KPhsBa779b8/s1600/Willenbringa_190.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPyidmEqZxqsIq4kfHBqqn3kRLSOlYRu8_l7A78YYzXYYkQxEhsTAmVyeev-8aVrwVI_J3a_wfRI5vDomGvWZJ5ayNB0ORi_W7AmMBYXzT-mvVbG-ti-ZFzp19as9Qhtq5KPhsBa779b8/s200/Willenbringa_190.jpg" width="155" /></a></div>
Dr Mark Willenbring is an addictions psychiatrist focused on transforming treatment for addiction in America by offering a comprehensive continuum of care based in science, compassion, consumer choice, access and affordability. As a former Director of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism he is well qualified to talk about evidence based treatment practices.<span style="font-family: inherit;"> </span><br />
<br />
<span style="font-family: inherit;">Dr Mark Willenbring also commented on the state of treatment programs in the States in his post "<a href="http://www.mattsub.blogspot.com/2013/02/whats-wrong-with-addiction-treatment-in.html" target="_blank">What's Wrong With Addiction Treatment in America</a>". He has this rather poignant<span style="font-size: medium;"><span style="line-height: 115%;"> </span></span></span>observation to make:<br />
<blockquote class="tr_bq">
<span style="font-family: inherit;"><span style="font-size: medium;"><i><span style="font-family: inherit;"><span style="line-height: 115%;">"</span></span></i></span></span><span style="font-family: inherit;"><span style="font-size: medium;"><i><span style="font-family: inherit;"><span style="line-height: 115%;">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.</span></span></i></span></span><span style="font-family: inherit;"><span style="font-size: medium;"><i><span style="font-family: inherit;"><span style="line-height: 115%;">"</span></span></i></span></span></blockquote>
<br />
<span style="font-size: large;"><span style="font-size: x-large;">Pharmacology</span> </span><br />
<span style="font-size: large;">Opioid Substitution Treatment</span> <br />
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: <a href="http://www.bjmp.org/files/2013-6-1/bjmp-2013-6-1-a601.pdf" target="_blank">"Evidence and recovery; improving outcomes in opiate substitution treatment</a>." The other paper in the <a href="http://www.journalofsubstanceabusetreatment.com/article/S0740-5472%2812%2900154-7/abstract?elsca1=etoc&elsca2=email&elsca3=0740-5472_201304_44_4&elsca4=elsevier" target="_blank">Journal of Substance Abuse Treatment</a> 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.<br />
<br />
<span style="font-size: large;">Naloxone</span><br />
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. <a href="http://www.theargus.co.uk/news/10258570.Brighton_and_Hove_finally_winning_war_on_drug_deaths/" target="_blank">This article</a> 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 <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm" target="_blank">CDC in the US</a> 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.<br />
<br />
<span style="font-size: x-large;">Quote of the Month</span><br />
<div class="MsoNormal">
I think <a href="http://www.memoirsofanaddictedbrain.com/" target="_blank">Marc Lewis</a> nailed it perfectly when he had this to say about addiction:<span style="font-size: large;"><i> </i></span></div>
<blockquote class="tr_bq">
<span style="font-size: large;"><i><span style="font-size: large;">"</span>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."</i></span></blockquote>
<span style="font-size: x-large;">Research</span><br />
<span style="font-size: large;">NMDA Receptor Modulators </span><br />
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: <a href="http://scholar.google.co.za/scholar_url?hl=en&q=http://www.mdpi.com/1424-8247/6/2/251/pdf&sa=X&scisig=AAGBfm3zQCt-vkwwRO1bBZb_g5KRvi8Kfw&oi=scholaralrt" target="_blank">NMDA Receptor Modulators in the Treatment of Drug Addiction</a>. 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."<br />
<br />
<span style="font-size: large;">Epigenetics and Psychostimulant Addiction</span><br />
There has been evidence of long-term changes the neural networks through gene expression in the presence of chronic drug use. This <a href="http://perspectivesinmedicine.cshlp.org/content/early/2013/01/28/cshperspect.a012047.full.pdf+html" target="_blank">paper examines the regulation of BDNF</a> (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 "<a href="http://www.sciencedirect.com/science/article/pii/S0959438813000160" target="_blank">Epigenetic Mechanisms of Drug Addiction</a>", 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. <br />
<br />
<span style="font-size: large;">Frankenstein Drugs</span><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXoPOamZuaW47PT0SLucDKbsSwLIfn3yFqMQVNundzIFgG2KnT8DrMrjT5QLvR4jce3LR54G8BVetEOwisvzVsnrM2OEjJ55RoPibUqjb7Pvm8KshoX5GJUhQWmnOEnBZ3hiHW1nKc738/s1600/curse_of_frankenstein-preview.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXoPOamZuaW47PT0SLucDKbsSwLIfn3yFqMQVNundzIFgG2KnT8DrMrjT5QLvR4jce3LR54G8BVetEOwisvzVsnrM2OEjJ55RoPibUqjb7Pvm8KshoX5GJUhQWmnOEnBZ3hiHW1nKc738/s200/curse_of_frankenstein-preview.jpg" width="200" /></a>Last month we spoke about Frankenstein Treatments, talking about ablative surgery. This month we have a Frankenstein Drug! In a paper in <a href="http://www.fsijournal.org/article/S0379-0738%2812%2900434-3/abstract" target="_blank">Forensic Science International</a> 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.</div>
<div style="text-align: justify;">
<br />
<span style="font-size: large;">Local Heroes</span><br />
Bronwyn Meyers, Charles Parry and others have just published an new paper entitled "<a href="http://www.biomedcentral.com/content/pdf/1471-2458-13-174.pdf" target="_blank">Ethnic differences in alcohol and drug use and related sexual risks for HIV among vulnerable women in Cape Town, South Africa: Implications</a>". 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. <br />
<br />
<span style="font-size: large;">New Drug for Meth Addiction?</span><br />
<div class="separator" style="clear: both; text-align: center;">
</div>
MN-166 (Ibudilast), primarily used in the treatment of strokes and multiple sclerosis, has received <a href="http://finance.yahoo.com/news/fda-grants-fast-track-designation-230000967.html" target="_blank">FDA fast-track status</a> and is in Phase 2 Clinical trials - specifically because of the lack of medications available for Methamphetamine addiction. MediciNova chief scientific officer Kirk Johnson explains: "Ibudilast acts on certain brain cells called astrocytes and microglia that play important roles in inflammation, neurotransmitter regulation, and protecting neurons and calms these cells down when they get overactive. Importantly, that phenomenon is common in these three areas we’re developing our drug in, methamphetamine and opioid addiction, chronic pain and in progressive multiple sclerosis."<br />
<br />
<span style="font-size: x-large;">Policy</span><br />
<span style="font-size: large;">New Zealand leads the way?</span> <br />
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 <a href="http://www.bbc.co.uk/news/uk-21615971" target="_blank">BBC report</a>, they describe New Zealand's approach as shifting responsibility to the manufacturer and retailer. Columbia, who have <a href="http://www.ibtimes.com/meth-ecstasy-ok-colombia-mulls-laxer-policy-synthetic-drug-use-1050040" target="_blank">decriminalised marijuana and cocaine</a> for personal use and the possession of small quantities, are now looking at decriminalising synthetic drugs, including Methamphetamine.<br />
<br />
<span style="font-size: large;">Africa</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkkeVLVZLzGrh-NqdUwJFY105hNgaugRpkJcMmwyc7HCCGPbe4pHvwPbmtCnQvT3xlZud2gLpVtaKXA2Kun0x77tN02Aum6vpcAJuL-I57FYFHprX6qSAaL2N5jMqyUNWhbtMF8dCGaJ0/s1600/war-on-drugs1.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkkeVLVZLzGrh-NqdUwJFY105hNgaugRpkJcMmwyc7HCCGPbe4pHvwPbmtCnQvT3xlZud2gLpVtaKXA2Kun0x77tN02Aum6vpcAJuL-I57FYFHprX6qSAaL2N5jMqyUNWhbtMF8dCGaJ0/s200/war-on-drugs1.jpg" width="130" /></a></div>
For those of you looking for more information on the African situation, the <a href="http://africanarguments.org/" target="_blank">African Arguments</a> series of books has just published "<a href="http://africanarguments.org/category/politics-now/africa-and-the-war-on-drugs/" target="_blank">Africa and the War on Drugs</a>". 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 <a href="http://africanarguments.org/2012/10/19/africa-and-the-war-on-drugs-the-west-african-cocaine-trade-is-not-just-business-as-usual-by-james-cockayne/" target="_blank">James Cockayne's commentary.</a> 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.<br />
<br />
<span style="font-size: large;">Banker or Dealer</span></div>
<div style="text-align: justify;">
The London Evening Standard poses the question "<a href="http://www.standard.co.uk/lifestyle/london-life/who-earns-the-most--a-goldman-sachs-banker-or-a-street-drug-dealer-8502963.html" target="_blank">Who earns the most - a Goldman Sachs banker or a street drug dealer?"</a> One of the things this article talks about is a program to reform young drug offenders:"a former Barclays banker who now works in prisons and young offenders’ institutes, giving talks about understanding money, setting offenders up with work experience at a Swiss company on virtual spread betting platforms and finding them mentors.“We give them [offenders] inspiration about investment bankers because they work in very similar ways ... If you are investing you are managing a portfolio — you are the CEO of that portfolio. These guys are the CEOs of their council estates. They understand how to market, to distribute. We’re [investment bankers are] managing a portfolio, but they’re managing drugs.”" </div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
This may seem a stretch, but one of the brightest men on the planet (in my opinion), Chris Arnarde, who has a PhD in Physics, worked for years on Wall Street and now documents the lives of addicts in Hunt's Point, wrote a piece for Scientific American called <a href="http://blogs.scientificamerican.com/guest-blog/2013/02/27/why-its-smart-to-be-reckless-on-wall-street/" target="_blank">"Why it's smart to be reckless on Wall Street"</a>, and in the article he says of the life of a trader: <span data-ft="{"tn":"K"}" id=".reactRoot[3].[1][2][1]{comment166343183515615_439052}.0.[1].0.[1].0.[0].[0][2]"><span class="UFICommentBody" id=".reactRoot[3].[1][2][1]{comment166343183515615_439052}.0.[1].0.[1].0.[0].[0][2].0"><span id=".reactRoot[3].[1][2][1]{comment166343183515615_439052}.0.[1].0.[1].0.[0].[0][2].0.[3]"><span id=".reactRoot[3].[1][2][1]{comment166343183515615_439052}.0.[1].0.[1].0.[0].[0][2].0.[3].0"><span id=".reactRoot[3].[1][2][1]{comment166343183515615_439052}.0.[1].0.[1].0.[0].[0][2].0.[3].0.[0]"> "It rewards short-term gains without regard to long-term consequences." And that sounds a lot like addiction to me!</span></span></span></span></span></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-37762466590038235442013-02-24T17:49:00.000+02:002014-09-20T21:42:13.205+02:00Sex, Drugs, and No Control<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg4S-IOIpNWB-OJIABObH3fgKOPRq03V1fue2DrQG1M76TrsdA16P4AxNNItdGb6nRzGGvmacirOWDHrWG63F3xoWMy5LkhL5fsyrUjDYjjAO01oI3KvCfPTmsgkwV5CZqqtY6TJCM0XuY/s1600/sex+and+drugs.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg4S-IOIpNWB-OJIABObH3fgKOPRq03V1fue2DrQG1M76TrsdA16P4AxNNItdGb6nRzGGvmacirOWDHrWG63F3xoWMy5LkhL5fsyrUjDYjjAO01oI3KvCfPTmsgkwV5CZqqtY6TJCM0XuY/s200/sex+and+drugs.jpg" height="150" width="200" /></a><span style="font-size: large;"><b>Sex as Addiction and the Treatment Ther<span style="font-size: large;">eof</span></b></span><br />
<div style="text-align: justify;">
<i><span style="font-size: small;">There is much controversy around the use of the term "sex addiction." This article gives a brief overview of the arguments against this term, and then shows some of the aspects as to why sex may indeed be an addiction and how it may be treated. There is certainly a need for further research in this area before anything definitive can be proclaimed, but perhaps the study of behaviours that present as addiction can give us further insight and understanding of exogenous addictions.</span></i></div>
<a href="http://www.scribd.com/doc/127013577/Sex-Drugs-and-No-Control-Sex-as-addiction-and-the-treatment-thereof" target="_blank">PDF Version (Printable)</a><br />
<!--[if gte mso 9]><xml> <o:OfficeDocumentSettings> <o:RelyOnVML/> <o:AllowPNG/> </o:OfficeDocumentSettings> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves>false</w:TrackMoves> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-ZA</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:EnableOpenTypeKerning/> <w:DontFlipMirrorIndents/> <w:OverrideTableStyleHps/> </w:Compatibility> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
DefSemiHidden="true" DefQFormat="false" DefPriority="99"
LatentStyleCount="267"> <w:LsdException Locked="false" Priority="0" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Normal"/> <w:LsdException Locked="false" Priority="9" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="heading 1"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 2"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 3"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 4"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 5"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 6"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 7"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 8"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 9"/> <w:LsdException Locked="false" Priority="39" Name="toc 1"/> <w:LsdException Locked="false" Priority="39" Name="toc 2"/> <w:LsdException Locked="false" Priority="39" Name="toc 3"/> <w:LsdException Locked="false" Priority="39" Name="toc 4"/> <w:LsdException Locked="false" Priority="39" Name="toc 5"/> <w:LsdException Locked="false" Priority="39" Name="toc 6"/> <w:LsdException Locked="false" Priority="39" Name="toc 7"/> <w:LsdException Locked="false" Priority="39" Name="toc 8"/> <w:LsdException Locked="false" Priority="39" Name="toc 9"/> <w:LsdException Locked="false" Priority="35" QFormat="true" Name="caption"/> <w:LsdException Locked="false" Priority="10" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Title"/> <w:LsdException Locked="false" Priority="1" Name="Default Paragraph Font"/> <w:LsdException Locked="false" Priority="11" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" Priority="22" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" Priority="59" SemiHidden="false"
UnhideWhenUsed="false" Name="Table Grid"/> <w:LsdException Locked="false" UnhideWhenUsed="false" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" UnhideWhenUsed="false" Name="Revision"/> <w:LsdException Locked="false" Priority="34" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" QFormat="true" Name="TOC Heading"/> </w:LatentStyles> </xml><![endif]--><!--[if gte mso 10]> <style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:10.0pt;
mso-para-margin-left:0cm;
line-height:115%;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;
mso-fareast-language:EN-US;}
table.MsoTableGrid
{mso-style-name:"Table Grid";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-priority:59;
mso-style-unhide:no;
border:solid windowtext 1.0pt;
mso-border-alt:solid windowtext .5pt;
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-border-insideh:.5pt solid windowtext;
mso-border-insidev:.5pt solid windowtext;
mso-para-margin:0cm;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;
mso-fareast-language:EN-US;}
</style> <![endif]--><!--[if gte mso 9]><xml> <o:shapedefaults v:ext="edit" spidmax="2051"/> </xml><![endif]--><!--[if gte mso 9]><xml> <o:shapelayout v:ext="edit"> <o:idmap v:ext="edit" data="2"/> </o:shapelayout></xml><![endif]--> <br />
<div class="MsoNormal" style="text-align: justify;">
According to the DSM-V Sex Addiction is not a diagnosable condition. Sexual addiction was mentioned in the DSM-III-R, but disappeared in the DSM-IV, threatened a come-back in the DSM-V but has now been discarded. Sex, however, has long been described as addictive. In the late 1800s Freud described masturbation as the “original addiction.” Rado in the 20’s described addiction as “compulsive” and made the reward/pleasure/sex link. We saw words such as nymphomania (Ellis) and the clumsy “Don Juanism”(Stoller). In the 70’s Mac Dougall spoke of “addictive sexuality”. It was originally proposed that sex be included under the heading of addiction in the DSM-5, and then that was discarded and the idea of hyper-sexuality was introduced as a possibility. Eventually none of these proposals was accepted, and so sexual addiction has ceased to exist, according to the DSM, that is.</div>
<div class="MsoNormal">
</div>
<a name='more'></a><span style="font-size: large;"><br /></span>
<br />
<h2>
<span style="font-size: large;">Sex Addiction Doesn’t Exist?</span></h2>
<div class="MsoNormal" style="text-align: justify;">
There are many others who say that there is no such thing, or at the very least, call it a misnomer. Thomas Szasz (Humanist Psychiatrist and author of <i style="mso-bidi-font-style: normal;">The</i> <i style="mso-bidi-font-style: normal;">Myth of Mental Illness</i>) said: "Masturbation: the primary sexual activity of mankind. In the nineteenth century it was a disease; in the twentieth, it's a cure." Is it this paradigm shift that has moved us to become more tolerant of sexual excess and discard the notion of sex addiction? Certainly one of the common arguments against the label of sex addiction is that we are pathologising the “different” as determined by a set of arbitrary parameters. This could at times be true, and we do need to be careful. For example Dr Martin Kafka, a Harvard professor and a member of the APA sexual disorders workgroup describes men who have 7 or more orgasms a week for 6 months or more as hypersexual. This was in a 2009 paper. Some may rather call this behaviour “first year at varsity”! </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
On the other side of this coin, there are those who argue against the term “sexual addiction” because it “pathologises deviance” and thereby creates a convenient label that enables the individual to abdicate responsibility. This is the view often taken by our self-appointed defenders of morality.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal">
I feel that both of these views fail to understand the true definition of addiction. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
A third argument against the use of the term sex addiction, which has been presented by Coleman, is that the term “addiction” is so stigmatised that “there seems to be more uncertainty and potential harm” to use the term addiction. Coleman preferred the term “compulsion”, and there is indeed good reason to use the word compulsion, but in many opinions it does not fully encompass the severity of the condition called sexual addiction. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
The bottom line is that with anything of a sexual nature, society has both a fascination and avoidance. There are few topics that are so tainted by personal experience and upbringing.<br />
<br /></div>
<h2>
<span style="font-size: large;">So Does Sex Addiction Actually Exist?</span></h2>
<div class="MsoNormal" style="text-align: justify;">
St Augustine said “Inter Faeces et Urinam nascimur”, but for some of the population “Inter Faeces et Urinam mortimur!” <span style="mso-spacerun: yes;"> </span>There are undoubtedly patients who have problematic sexual behaviours, and these behaviours will, if left untreated, be the death of them. If we take the current DSM criteria for addiction and apply it to sexual behaviours, we would find that it would fit the behaviour of many of the patients I have mentioned above:</div>
<br />
<ul>
<li><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span>Tolerance (marked increase in amount; marked decrease in effect)</li>
<li>Characteristic withdrawal symptoms; sexual activities undertaken to relieve withdrawal</li>
<li><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span>More sexual behaviour in larger amount and for longer period than intended</li>
<li><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span>Persistent desire or repeated unsuccessful attempt to quit</li>
<li>Much time/activity to obtain, use, recover</li>
<li>Important social, occupational, or recreational activities given up or reduced</li>
<li>Use continues despite knowledge of adverse consequences </li>
</ul>
<br />
<div class="MsoNormal" style="text-align: justify;">
So, what behaviours characterise sexual addiction? I would argue it is foolish to try and list specifics of behaviour and quantify these behaviours to try and diagnose sex addiction. It is not the behaviour, but rather the pattern and consequences of the behaviour. It is here that I would differ with Carnes – considered by many to be the spokesman of sex addiction after the publishing of his 1983 book “Out of the Shadows” - who describes “levels” of addictions. He starts with <b style="mso-bidi-font-weight: normal;">Level 1 </b>behaviours, which include what many would classify as “normal” sexual behaviours: Masturbation, homo and heterosexual relationships, pornography, strip shows, prostitution. He then describes <b style="mso-bidi-font-weight: normal;">Level 2</b> behaviours as exhibitionism, voyeurism and indecent phonecalls, while <b style="mso-bidi-font-weight: normal;">Level 3</b> is reserved for the behaviours most of us would classify as abhorrent – paedophilia, rape and the like. <span style="mso-spacerun: yes;"> </span>I would argue that the paraphilias have nothing to do with sexual addiction, but would rather be a co-occurring disorder co-existing with sex addiction in some cases.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
If addiction is a pathological relationship with a substance or activity at the expense of more beneficial relationships or activities, then sex addiction is when our relationship with sex is more important than our relationship with the person with whom we are (or are not) having sex.<br />
<br /></div>
<div style="border-bottom: solid windowtext 1.0pt; border: none; mso-border-bottom-alt: solid windowtext .5pt; mso-element: para-border-div; padding: 0cm 0cm 1.0pt 0cm;">
<h1>
The Evidence for Sex as Addiction</h1>
</div>
<div class="MsoNormal" style="text-align: justify;">
If sex is an addiction, it should present as an addiction in the same ways as other addictions. It is my belief that addiction is an underlying syndrome which may manifest itself in many different ways. This model has also been proposed by Shaffer <span style="mso-no-proof: yes;">(Shaffer, La Plante, La Brie, Kidman, Donato, & Stanton, 2004)</span>, and he describes all addictions as having similar etiology but varied expressions. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
I explain addiction as something that takes place on three planes: The thought-behaviour plane, the neurobiology-neurochemistry plane and the macro/micro-system or environmental plane. These three influence each other over time, and any addiction brings about fundamental changes in each of these areas, and that in turn amplifies the effects on each plane individually and collectively. Therefore, for something to be an addiction it must be demonstrated to some or other degree in each of these planes.<br />
<br /></div>
<h2 style="text-align: justify;">
<span style="font-size: large;">Behaviour – Compulsive, Impulsive or addiction?</span></h2>
<div class="MsoNormal" style="text-align: justify;">
As stated earlier, Coleman suggests the use of the term “sexual compulsivity”. Compulsive disorders, according to the DSM IV, reduce anxiety or distress, even though the act is not pleasurable or gratifying. The purpose of the act is to reduce the anxiety of the obsession, rather than find pleasure in the action itself. It could be regarded as negative reinforcement. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
The impulsive disorders would be the (apparently) immediate satisfaction of cue-based desires despite negative consequences. This could be considered a form of positive reinforcement.<span style="mso-spacerun: yes;"> </span>Although I have used the terms negative and positive, these two states should not be seen as diametrically opposed. The relationship between the two is far more complex. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Addiction seems to include aspects of both compulsive and impulsive behaviour types. I would suggest that it may start as impulsive and move towards being compulsive, often vacillating between the two. Similarly, sexual addiction both gratifies and repulses the patient, often giving the briefest moment of respite after hours, or even days, of obsession and ritual, shortly followed by deep shame and repeated promises of “never again!” </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
In the film Shame, <span class="st">Michael Fassbender portrays a sex addict living in New York. The film graphically shows just how unfulfilling sex can be, and how when sex is an end in itself, all normal boundaries seem to dissolve - a “not yet” list quickly becomes “done that and more” confession. Just like with substance addiction. It is at this point that we see how closely sex and drug addiction are intertwined and it becomes difficult to see what fuels what – it is for this reason that syndromal models seem to carry weight.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="st">Behaviourally we see the addict engaging in increasingly dangerous and uncharacteristic behaviours in spite of extreme consequences. Cognitively we see the move towards less-helpful patterns of thinking. Wrong (from the patients original point-of-view) becomes right, the cognitive distortions become more obvious, and have a greater effect which is increasingly catastrophic. </span><br />
<br /></div>
<h2 style="text-align: justify;">
<span style="font-size: large;">Neurology</span></h2>
<div class="MsoNormal" style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjS6sPhEiYcnQOe7h1CZhojs1rkKeC1wdMzzkDHynZTPKZSNuZvVJs1yzKsWIgcKQ00FzCvB0DlLAYrpdQFhrxv91Sjc3RWMk_AQ9ipl0MqDFgSvZSd28GQCVRIAmD0WqR_6b1ja0hT4QY/s1600/didier.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjS6sPhEiYcnQOe7h1CZhojs1rkKeC1wdMzzkDHynZTPKZSNuZvVJs1yzKsWIgcKQ00FzCvB0DlLAYrpdQFhrxv91Sjc3RWMk_AQ9ipl0MqDFgSvZSd28GQCVRIAmD0WqR_6b1ja0hT4QY/s320/didier.jpg" height="213" width="320" /></a></div>
This tragic photo shows Didier Jambert with his wife Christine at a press conference after he was awarded damages because his ReQuip tablets turned him into a “hypersexual, gay, cross-dressing gambling addict.” The apparent cause of this sudden and unprecedented change in behaviour was dopamine. Dopamine is certainly one of the usual suspects when it comes to drug addiction, and similarly it has been shown to have a role in behavioural addictions. There certainly seems to be significant correlation between dopamine levels and behavioural addictions, including sex addiction. However, the reward system is not enough to explain addiction. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
One of the more useful theories of addiction is the iRISA theory of Goldstein and Volkow <span style="mso-no-proof: yes;">(Goldstein, 2002)</span>. <span style="mso-fareast-language: EN-ZA;">Basically this says that addiction can be considered an impairment of inhibition and/or an over exaggerated drive or motivation.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-ZA;"> </span><span style="mso-fareast-language: EN-ZA;">During drug use there is a repetitive cycle of salience attribution, craving, bingeing and withdrawal. Each of these phases involves different brain regions and neurotransmitters and neuropeptides. Similarly Carnes describes a cycle of sexual behaviour in the addict, although I found earlier references of this process in the work of Reed and Blaine from a 1988 paper. I would like to propose that these could possibly be corresponding and that the underlying neurology may be similar:</span><br />
<br /></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: medium none; margin-left: 0px; margin-right: 0px; text-align: left;"><tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"> <td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 111.75pt;" valign="top" width="149"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-language: EN-ZA;">iRISA</span></b></div>
</td> <td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 120.45pt;" valign="top" width="161"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-language: EN-ZA;">Carnes/Reed & Blain</span></b></div>
</td> <td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.9pt;" valign="top" width="307"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-language: EN-ZA;">Possible underlying Neurobiological processes</span></b></div>
</td> </tr>
<tr style="mso-yfti-irow: 1;"> <td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 111.75pt;" valign="top" width="149"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="mso-fareast-language: EN-ZA;">Salience Attribution</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 120.45pt;" valign="top" width="161"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="mso-fareast-language: EN-ZA;">Pre-occupation</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.9pt;" valign="top" width="307"><div align="left" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: left;">
<span style="font-family: "Wingdings 3";">h</span>DA levels in limbic brain regions particularly NAcc, evidence of <span style="font-family: "Wingdings 3";">h</span>DA levels in frontal regions.<span style="mso-fareast-language: EN-ZA;"></span></div>
</td> </tr>
<tr style="mso-yfti-irow: 2;"> <td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 111.75pt;" valign="top" width="149"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="mso-fareast-language: EN-ZA;">Drug Expectation</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 120.45pt;" valign="top" width="161"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="mso-fareast-language: EN-ZA;">Ritualisation</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.9pt;" valign="top" width="307"><div align="left" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: left;">
Likely involvement of Amygdala, PFC and Hippocampus. Activation of Thalamo-orbitofrontal circuit and anterior cinculate.<span style="mso-fareast-language: EN-ZA;"></span></div>
</td> </tr>
<tr style="mso-yfti-irow: 3;"> <td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 111.75pt;" valign="top" width="149"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="mso-fareast-language: EN-ZA;">Impaired Inhibition</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 120.45pt;" valign="top" width="161"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="mso-fareast-language: EN-ZA;">Compulsive Behaviour</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.9pt;" valign="top" width="307"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
Loss of top down control DA, 5-HT & Glutamate play active role<span style="mso-fareast-language: EN-ZA;"></span></div>
</td> </tr>
<tr style="mso-yfti-irow: 4; mso-yfti-lastrow: yes;"> <td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 111.75pt;" valign="top" width="149"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="mso-fareast-language: EN-ZA;">Depression</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 120.45pt;" valign="top" width="161"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="mso-fareast-language: EN-ZA;">Depression</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.9pt;" valign="top" width="307"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
Disruption of frontal cortical circuits. <span style="font-family: "Wingdings 3";">i</span>DA <span style="mso-spacerun: yes;"> </span><span style="font-family: "Wingdings 3";">i</span>5-HT<span style="mso-fareast-language: EN-ZA;"></span></div>
</td> </tr>
</tbody></table>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="mso-fareast-language: EN-ZA;">For more detail on this, check out this article of mine: <a href="http://www.scribd.com/doc/120620905/The-Neurobiological-Underpinnings-of-Addiction" target="_blank">The Neurobiological Underpinnings of Addiction</a></span><br />
<br />
<span style="mso-fareast-language: EN-ZA;">Like drug addiction, sex addiction breeds tolerance, and like drug addiction “real-life” becomes less rewarding neurologically and experientially. There is evidence that low levels of pre-addiction serotonin are also linked, like in other addiction, with behavioural and sexual addictions <span style="mso-no-proof: yes;">(Grant, Brewer, & Potenza, 2006)</span>. </span><br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Also, what must be noted, is that addiction-like sexual behaviours, as well as paraphilias, can be the result of brain lesions or underlying organic conditions. This, I believe, shows us that addiction is a lot more than a simple choice process, and that brain dysfunction can have a significant role to play.<br />
<br /></div>
<h2 style="text-align: justify;">
<span style="font-size: large;">The System</span></h2>
<h3 style="text-align: justify;">
The Micro-environment</h3>
<div class="MsoNormal" style="text-align: justify;">
A study by Carnes in 1991 suggested that 82% of the sex-addict subjects had experienced childhood sexual abuse. This figure is incredibly high, but is supported to some degree by other studies. Not only does this point to the psychology of the sex addict, but also to the biology. We know that early childhood abuse has major effects on the pre-frontal cortex circuitry, and we see reduced size in the left-hippocampus and a corresponding set of dissociative symptoms in adulthood. It should also be noted that these abnormalities were seen in cocaine addicts <span style="mso-no-proof: yes;">(Ersche, Jones, Williams, Smith, & Bulmore, 2012)</span>. We also see less left-right brain integration with corresponding opposing views of the world in which they live, and to further complicate this we see alterations in oxytocin and vasopressin mediated sexual arousal.<br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
There has long been the proposed link between the lack of early attachment and addictive disorders. It may be that the corresponding drop in dopamine and noradrenaline may drive the individual to seek behaviours or drugs that boost levels just so they can feel “normal”. What means they choose may have a lot to do with the broader eco-system in which they find themselves, rather than with direct conscious choice. We also see the imprint of childhood trauma on the limbic system, leading to a hypersensitive amygdala, which may contribute to impulsivity and this adds credence to the idea that for the sex addict, sex is not merely pleasure seeking, but survival seeking.<br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Undoubtedly, like with other addictions, but more so, the neurological effects of childhood abuse and attachment issues move the individual towards a predisposition for sexual behaviour that presents as addiction.<br />
<br /></div>
<h3 style="text-align: justify;">
The Macro-Environment</h3>
<div class="MsoNormal" style="text-align: justify;">
In the world of the internet we have what is referred to as the triple A-engine: affordability, accessibility and anonymity. The availability of sexual images at ever decreasing ages has certainly fuelled what Carnes calls the Tsunami of sexual addiction. The estimated first age of exposure to pornography is 11 in the United States<span style="mso-no-proof: yes;"><span style="mso-spacerun: yes;"> </span>(Bryant & Brown, Pornography: research advances and policy considerations)</span>.<br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
I alluded to the effect of this macro-system or ecosystem in that it may push the addiction prone individual towards a particular manifestation of the underlying condition or need. In a world where sex, drugs and rock and roll are the norm we will get more addicts of the drug and sex type than in a more conservative society, where we may get religious addicts – which is arguably a more acceptable manifestation – it doesn’t mean the individual isn’t sick, it just means that they aren’t being as harshly judged for their particular symptoms!<br />
<br /></div>
<div style="-moz-border-bottom-colors: none; -moz-border-left-colors: none; -moz-border-right-colors: none; -moz-border-top-colors: none; border-color: -moz-use-text-color -moz-use-text-color windowtext; border-image: none; border-style: none none solid; border-width: medium medium 1pt; padding: 0cm 0cm 1pt; text-align: justify;">
<h1>
The Treatment of Sex Addiction</h1>
</div>
<div class="MsoNormal" style="text-align: justify;">
The first thing to remember is that the majority of patients who have sex as addiction issues do not usually present with an obvious sexual addiction. Because of the shame surrounding sexual issues the patient will often present with other issues, sometimes even because of a lack of sex with a romantic partner. Often there may be anxiety, depression, suicidality, substance abuse or criminality. It is only later, once a good therapeutic relationship has been built, that the sexual behaviour is discussed.<br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
So how would we treat sex that presents as addiction? Well, in much the same way as we would an addiction. We need to examine three main areas: The system: past, present and future; the immediate thoughts and behaviours; and the neurobiology and neurochemistry. Like all addictions all these planes of treatment should be considered to ensure that an effective treatment plan is formulated. The treatment of sex addiction is hard. Like with all addictions we are expecting the individual to move from instant gratification with delayed (possible) consequences to instant turmoil with future (possible) satisfaction. This is a difficult task. Goodman proposes an outline that I have found useful: He proposes 4 stages of treatment <span style="mso-no-proof: yes;">(Goodman, 2001)</span>:</div>
<ul>
<li>Behaviour Modification</li>
<li><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span>Stabilisation</li>
<li>Character Healing</li>
<li><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span></span></span>Self-Renewal</li>
</ul>
<div class="MsoNormal" style="text-align: justify;">
These should not be seen as hard and fast individual processes that happen independently of one another, but should rather be seen as interrelated aspects of the recovery process.<br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
The biggest challenge is that when it comes to sex addiction, all treatments, except in the case of a few co-occurring paraphilia, are essentially harm reduction and not abstinence based. It is important to help the patient define healthy sexual behaviours as opposed to unhealthy behaviours, and facilitate the move away from pathological behaviours. Having said this, many of those that treat sexual addiction may suggest an initial period of abstinence to help establish initial behavioural modification.<br />
<br /></div>
<h2 style="text-align: justify;">
<span style="font-size: large;">Psycho-social interventions:</span></h2>
<div class="MsoNoSpacing" style="text-align: justify;">
Most searches on the internet when it comes to treatment for sex addiction invariably lead to 12 step programs. In the local context we see SLA – Sex and Love Addicts anonymous. While many have described these groups as very helpful in overcoming the sense of shame and isolation that many sex addicts experience, these groups should not be seen as treatment, but rather as an adjunct to treatment. It should also be borne in mind that these groups are also filled with sex addicts, and as such can be a trigger for the recovering sex addict.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="text-align: justify;">
Another problem with this approach, especially in the treatment setting, is that many 12-step based treatment plans are confrontational and expect the sharing of one’s deepest and darkest secrets in the group setting. If we consider that the majority of sex addicts have a history of being sexually abused this could be extremely counterproductive. We need to tread carefully, and above all, non-judgementally.</div>
<div class="MsoNoSpacing" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
For this reason, sexologists would immediately feel that the treatment of sexual addiction falls firmly into their field, however many of those seeking treatment for sex addiction feel that they need less therapy and more treatment. According to Robert Weiss, one of the major complaints received from patients is that therapists don’t understand how destructive their behaviour is. Many may also misconstrue the source of the shame felt by sex addicts. While it may be caused by some of the activities they engage in, it is often more about the levels of salience they have attributed to the pursuit of their sexual behaviours <span style="mso-no-proof: yes;">(Hall, 2011)</span> at the expense of the ones they love and the values they consider important.<br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
The types of psycho-interventions that have shown to benefit sex addicts are cognitive behavioural therapies, particularly in the stages of behaviour modification and stabilisation, and then a gradual move towards psycho-dynamic psychotherapy which is often essential to long-term recovery and the process of character healing. I would also like to see more research on the use of Dialectical Behavioural Therapy due to the similar aetiologies of Borderline Personality Disorder and Sex Addiction.<br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
In managing the environmental aspect of the addiction, it is also helpful to include the spouse, although this, I would suggest, be left till later in the process. Dealing with constant relapse within the couples therapy environment is difficult and can be damaging to the process, and until there has been some demonstrable changes in behaviour, the partner is more likely to be oppositional than reconciliatory.<br />
<br /></div>
<h2 style="text-align: justify;">
<span style="font-size: large;">Pharmacological Interventions</span></h2>
<div class="MsoNormal" style="text-align: justify;">
Most of the limited research revolves around the SSRIs. There have been limited successes, and a few double blind trials, which have tended to be focused on very specific target groups, and have had limited research value. Both Citalopram and Fluoxetine (Prozac) has also been shown to have some effect in the reduction of acting out with sexual behaviours<span style="mso-no-proof: yes;"><span style="mso-spacerun: yes;"> </span>(Garcia & Thibaut, 2010)</span>.<br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Naltrexone, the opioid antagonist that has been used across a multitude of addictions, has also been shown to have some effect on compulsive sexual behaviour<span style="mso-no-proof: yes;"><span style="mso-spacerun: yes;"> </span>(Raymond & Grant, 2010)</span> <span style="mso-no-proof: yes;">(Bostwick & Bucci, 2008)</span>.</div>
<div class="MsoNormal" style="text-align: justify;">
Topiramate, originally used as an anticonvulsant, and more recently approved for weight loss, has, in one case report <span style="mso-no-proof: yes;">(Khazaal & Zullino, 2006)</span> shown to possibly mediate the cue effect in sexual addictions. Interestingly a 2010 Cochrane Review concluded that there was evidence supporting the use of Topiramate in the treatment of borderline personality disorder, which I have suggested earlier could have a similar origin to sex addiction. Topiramate has also shown some success in the treatment of cocaine addiction in clinical trials<span style="mso-no-proof: yes;"><span style="mso-spacerun: yes;"> </span>(Kampman KM, 2004)</span> as well as alcohol <span style="mso-no-proof: yes;">(Johnson, 2005)</span>. Topiramate increases cerebral GABA levels and inhibits glutametergic activity.<br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
There is also literature regarding the use of antiandrogen medications for nonparaphilic sexual behaviour, but, personally, I have some unresolved ethical issues surrounding this and so won’t discuss this here.<br />
<br /></div>
<div style="-moz-border-bottom-colors: none; -moz-border-left-colors: none; -moz-border-right-colors: none; -moz-border-top-colors: none; border-color: -moz-use-text-color -moz-use-text-color windowtext; border-image: none; border-style: none none solid; border-width: medium medium 1pt; padding: 0cm 0cm 1pt; text-align: justify;">
<h1>
Conclusion</h1>
</div>
<div class="MsoNormal" style="text-align: justify;">
It is obvious that whether or not we buy into the term “Sex Addiction” there are significant similarities with addictive disorders when it comes to pathological non-paraphilic sex. We need to keep in mind that the only reason we seek to label is so that we can identify a treatment path. Certainly there needs to be a lot more research into what I have termed sex addiction: the neurobiology, chemistry, behaviours, and biopsychosocial interventions to bring some level of comfort to those who find themselves suffering from this particular manifestation of addictive disorders.<br />
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Even once we have achieved some measure of clarity there will always remain the unanswered key question in the world of sex addiction: “Is Tiger Woods a sex addict or not?”<br />
<br /></div>
<div style="border-bottom: solid windowtext 1.0pt; border: none; mso-border-bottom-alt: solid windowtext .5pt; mso-element: para-border-div; padding: 0cm 0cm 1.0pt 0cm;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCfXC7EGfacFNUIAw4Kl6OZCfdkw5qSQ3PhzFMoXeSR8dL1McINDI000l5CN3tRYZJcSbBj1-9HBV5GG2nD7GQ3q7kWMx-k-pOl542aTpCsPfQSh30Zx7ENfT-3wETWoH67ys3R0tmD9U/s1600/sex-addict-Tiger-Woods.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCfXC7EGfacFNUIAw4Kl6OZCfdkw5qSQ3PhzFMoXeSR8dL1McINDI000l5CN3tRYZJcSbBj1-9HBV5GG2nD7GQ3q7kWMx-k-pOl542aTpCsPfQSh30Zx7ENfT-3wETWoH67ys3R0tmD9U/s200/sex-addict-Tiger-Woods.jpg" height="200" width="170" /></a></div>
<h1>
Bibliography</h1>
</div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Bostwick, J., & Bucci, J. (2008). Internet sex addiction treated with naltrexone. <i>Mayo Clinic Proceedings</i>, 83(2):226-230.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Brenhouse, H., Lukkes, J., & Anderson, S. (2013). Early life adversity alters the developmental profiles of addiction related prefrontal cortex circuitry. <i>Brain Science</i>, 143-158.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Bryant, J., & Brown, D. (Pornography: research advances and policy considerations). <i>Use of pornograph.</i> Hillsdale (NJ): Erdbaum.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Carries, C., & Delmonico, D. (2007). Childhood abuse and multiple addictions: Research findings in a sample of self-identified sexual addicts. <i>Sexual Addiction and Compulsivity</i>, 3(3):258-268.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Davis, J., Loos, M., Sebastiano, A., & Brown, J. (2011). Lesions of the Medial Prefrontal Cortex Abolish Conditioned Aversion Associated with Sexual Behavior in Male Rats. <i>Biological Psychiatry</i>, 67(12):1199-1204.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Ersche, K., Jones, P., Williams, G., Smith, D., & Bulmore, E. (2012). </span>Distinctive<span style="mso-no-proof: yes;"> Personality Traits and Neural Correlates Associated with Stimulant Drug Use Versus Familial Risk of Stimulant Dependence. <i>Biological Psychiatry</i>.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Fong, T. (2006). Understanding and Managing Compulsive Sexual Behaviours. <i>Psychiatry</i>, 51-57.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Garcia, F., & Thibaut, F. (2010). Sexual Adictions. <i>The American Journal of Drug and Alcohol Abuse</i>, 254-260.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Giugliano, J. (2003). A Psychoanalytic overview of excessive sexual behaviour and addiction. <i>Sexual Addiction and Compulsivity</i>, 10: 275-290.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Gold, S., & Heffner, C. (1998). Sexual Addiction: Many Conceptions, Minimal Data. <i>Clinical Psychology Review</i>, 367-381.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Goldstein, R. V. (2002). Drug addiction and its underlying neurobiological basis: Neuroimaging evidence for the involvement of the frontal cortex. <i>American Journal of Psychiatry</i>, 159(10): 1642-1652.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Goodman, A. (1998). Sexual Addiction: Diagnosis and Treatment. <i>Psychiatric Times</i>, 15(10).</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Goodman, A. (2001). What's in a Name? Terminology for Designating a Syndrome of Driven Sexual Behaviour. <i>Sexual Addiction and Compulsivity</i>, 8: 191-213.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Grant, J., & Potenza, M. (2006). Compulsive Aspects of Impulse-Control Disorders. <i>Psychiatr Clin North Am.</i>, 29(2)539-550.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Grant, J., Brewer, J., & Potenza, M. (2006). The Neurobiology of Substance and Behavioural Addictions. <i>CNS Spetr</i>, 11(12):924-930.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Hall, P. (2011). A Biopsychosocial view of sex addiction. <i>Sexual and Relationship Therapy</i>, 26(3): 217-228.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Johnson, B. (2005). Recent Advances in the Development of Treatments for Alcohol and Cocaine Dependence: Focus on Topiramate and Other Modulators of GABA or Glutamate Function . <i>CNS Drugs</i>, 873-896.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Kafka, M. (2010). What is Sexual Addiction? A response to Stephen Levine. <i>Journal of Sex and Marital Therapy</i>, 36(3): 276-281.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Kampman KM, P. H. (2004). A pilot trial of topiramate for the treatment of cocaine dependence. <i>Drug Alcohol Depndence</i>, 75(3):233-40.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Khazaal, Y., & Zullino, D. (2006). Topiramate in the treatment of compulsive sexual behaviour: Case report. <i>BMC Psychiatry</i>.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Polusny, M., & Follette, V. (1995). Long-term correlates of child sexual abuse: Theory and review of the empirical literature. <i>Applied & Preventive Psychology</i>, 4: 143-66.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Raymond, N., & Grant, J. (2010). Augmentation with naltrexone to treat compulsive sexual behavior: A case series. <i>Annals of Clinical Psychiatry</i>, 22(1):56-62.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Remschmidt, H. (2011). The emotional and neurological consequences of abuse. <i>Dtsch Arztebl Int</i>, 108(17):285-6.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Shaffer, H., La Plante, D., La Brie, R., Kidman, R., Donato, A., & Stanton, M. (2004). Toward a Syndrome Model of Addiction: Multiple Expressions, Common Etiology. <i>Harvard Review Psychiatry </i>, 12:367-374.</span></div>
<div class="MsoNoSpacing">
<span style="mso-no-proof: yes;">Teicher, M. H. (2000). Wounds That Time Won’t Heal: The Neurobiology of Child Abuse. <i>Cerebrum</i>.</span></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNormal">
<br /></div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-72947881398719018522013-01-24T18:42:00.001+02:002013-01-24T21:20:12.667+02:00Addiction Information January Newsletter<b><span style="font-size: x-large;">Introduction</span></b><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMQDET-nLxVMl3gVO31UJ4x_b6WnIlZQYJ7IMTWhVQ3L3XDZFGxYbojcoFRak3qPZ3qhjmbyH0CCnyikU3nyvrL2ufaWwnjN0MsSU05KLb7kvTN8m2gpNsP9odLZkt8l548MHC59ixFsM/s1600/shaunhead.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMQDET-nLxVMl3gVO31UJ4x_b6WnIlZQYJ7IMTWhVQ3L3XDZFGxYbojcoFRak3qPZ3qhjmbyH0CCnyikU3nyvrL2ufaWwnjN0MsSU05KLb7kvTN8m2gpNsP9odLZkt8l548MHC59ixFsM/s200/shaunhead.jpg" width="174" /></a></div>
<div style="text-align: justify;">
Welcome to the first Addiction Information Newsletter. The object of this newsletter is to give you a monthly overview of what is happening in the world of addiction across a number of fields<span style="font-size: small;"><b>.</b></span> You can subscribe to this newsletter and receive an e-mail version by joining our <a href="http://addictioncapetown.blogspot.com/p/news-letter.html" target="_blank">mailing list</a>. Your suggestions are most welcome, and articles for the website or that you would like to have linked to this newsletter can be directly submitted to me by e-mailing <a href="mailto:shaun.shelly@yahoo.com">shaun.shelly@yahoo.com</a>.</div>
<div style="text-align: justify;">
<span style="font-size: large;">In this issue: </span><br />
<div class="MsoNormal">
<b>The Motivated Addict, Dual-process models, CBT Ineffective?, Drug Policy, Brain Structure, Meth Psychosis, Transcriptional Mechanisms, Nepicastat & 18-MC Trials, Neuroscientist Marc Lewis, Dr Frankenstein's Cure and "beating addiction"</b></div>
<a name='more'></a><br />
<b><span style="font-size: x-large;">Psychology</span></b><br />
<div font-size:="" id="motivate><span style=" large="">
<span style="font-size: large;"><b>The Motivated Addict</b></span></div>
</div>
<div style="text-align: justify;">
Kopetz and others have published an informative paper, <a href="http://pps.sagepub.com/content/8/1/3.abstract" target="_blank">Motivation and Self-Regulation in Addiction: A Call for Convergence</a>. This paper neatly summarises some of the "Big Questions" of addiction from a motivational point of view: What moves an individual from user to addict?; Who is more vulnerable and why?; and What keeps the addict using?. What is interesting is they look at similarities between addiction and other "normal" motivated behaviours. They also touch on the move from the drugs being a means to an end to becoming an end in itself. This fits in nicely with my view of addiction being a form of pathological relationship (more on the neurology of this in a later newsletter). Towards the end of the paper they casually drop a potential bombshell: "<i>addiction is in many ways psychologically similar to motivated behaviour in general, whereas in some rare and extreme cases it appears more like a "brain disease""</i>. Now there's something that can motivate some discussion.<br />
<br />
<b id="dual"><span style="font-size: large;">Dual-process Models and Addiction</span></b><br />
There is an article that makes interesting reading in the Clinical Psychological Science Journal entitled <a href="http://cpx.sagepub.com/content/early/2013/01/08/2167702612466547.abstract" target="_blank">Cognitive Bias Modification and Cognitive Control Training in Addiction and Related Psychopathology: Mechanisma, Clinical Perspectives and Ways Forward.</a> It examines arguments against and support for dual-process models, using the metaphor of the rider and horse. The horse being impulsive processes and the rider representing the more top-down reflective processes.The article goes on to examine how each of these dual processes can be modified through targeted training. When taken in the context of current findings in neurobiology the dual-process model, can, I feel, provide some good directions for effective addiction treatment. I have certainly found that both the rider and the horse, to extend the metaphor, need work!</div>
<br />
<b><span style="font-size: x-large;">Junk Science</span></b><br />
<span style="font-size: large;"><b id="CBT">Therapy Ineffective for Opioid Addiction?</b></span><br />
<div style="text-align: justify;">
"CBT is not an effective way to treat opioid dependence". So begins an article in the <a href="http://yaledailynews.com/blog/2013/01/22/therapy-ineffective-for-opioid-addiction/" target="_blank">Yale Daily New</a>s that highlights a study by the Yale University School of Medicine: <a href="http://download.journals.elsevierhealth.com/pdfs/journals/0002-9343/PIIS0002934312006353.pdf" target="_blank">A Randomized Trial of Cognitive Behavioural Therapy in Primary Care-based Buprenorphine.</a> The tone of the article suggests that Buprenorphine is enough to cure heroin addiction. <span style="font-family: inherit;">I know that this is not exactly what they say, but as researchers they are well aware that the careful choice of words will determine how the article is reported and absorbed into popular thinking. There are already articles popping up all over the place making sweeping statements such as "the study could change how such dependence is viewed and treated in the U.S. healthcare system". Let's hope not. I feel strongly that this kind of "study" is wrong and have written a more detailed explanation of why I think so: <a href="http://addictioncapetown.blogspot.com/2013/01/cbt-doesnt-work-for-heroin-addiction.html" target="_blank">Buprenorphine is enough? I think not.</a></span></div>
<br />
<div style="text-align: justify;">
<span style="font-size: x-large;"><b id="policy">Drug Policy</b></span><span style="font-family: inherit;"> </span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: large;"><b>Taboo or Not Taboo </b></span></span><br />
<span style="font-family: inherit;">The news from around the world has been filled with a variety of articles about drug policy. Sam Branson (Richard's son) released the film "<a href="http://www.breakingthetaboo.info/" target="_blank">Breaking the Taboo</a>", which focuses on the harm done by and the ending of the Global War on Drugs. Because of this there has been renewed coverage of the <a href="http://www.drugpolicy.org/" target="_blank">Drug Policy Alliance</a>. This group has the support of such luminaries as Sir Richard Branson, George Soros, Former Surgeon General Joycelyn Elders, a number of former presidents and political leaders....oh, and Sting. Their mission is <i>"advance those policies and attitudes that best reduce the harms of both drug use and drug prohibition, and to promote the sovereignty of individuals over their minds and bodies."</i></span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br />
</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">In America there has been a lot of focus on <b>Marijuana Policy</b> and <b>The War on Drugs</b>. Marijuana is now legal for recreational use in Colorado and Washington. It is There is a lot of coverage on this issue, but most of it is not well thought out and written by either side of the lunatic fringe, so, frankly I found none of it worth featuring here. Except maybe for this article by psychiatrist David Nathan who is a clinical associate professor at Robert Wood Johnson Medical School: <a href="http://edition.cnn.com/2013/01/09/opinion/nathan-legal-marijuana/?hpt=hp_t3" target="_blank">Why marijuana should be legal for adults</a>. Nathan basically argues that Marijuana should be handled like alcohol and cigarettes. Le<span style="font-size: small;">ga</span>l to adults, but children should be taught the risk. </span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br />
</span></div>
<div style="text-align: justify;">
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYcSAS7ERxFMBAGPV_rDR5Q2npmxTfHlHxQzGhRDTPaVGA3xHsHhZI9Pe3YhOexQtOdRICNWCuZRIJcB1VwWyCGoetDwNpXARxPLHm3gSG0Rwo75OhlB_Eu1xe88nVWWKBvA20V7C90Qk/s1600/DrugsFinal.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="157" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYcSAS7ERxFMBAGPV_rDR5Q2npmxTfHlHxQzGhRDTPaVGA3xHsHhZI9Pe3YhOexQtOdRICNWCuZRIJcB1VwWyCGoetDwNpXARxPLHm3gSG0Rwo75OhlB_Eu1xe88nVWWKBvA20V7C90Qk/s200/DrugsFinal.jpg" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Illustration by Norma Bar</td></tr>
</tbody></table>
<span style="font-family: inherit;">The debate surrounding the War on Drugs is extremely lively. The Wall Street Journal asks <a href="http://online.wsj.com/article/SB10001424127887324374004578217682305605070.html?mod=WSJ_hps_MIDDLENexttoWhatsNewsTop" target="_blank">"Have we lost the war on drugs?"</a>. Understandably there is a significant economic slant to this article. This is not a new angle. In the late 90's The Economist dedicated a whole issue to the legalisation of all narcotics because it made "economic sense". Here are two articles from 2001 from the same publication: <a href="http://www.economist.com/node/706591" target="_blank">Stumbling in the Dark</a> and <a href="http://www.economist.com/node/709603" target="_blank">The case for Legalisation</a>. Tony Newman, Director of the aforementioned Drug Policy Alliance listed "<a href="http://www.huffingtonpost.com/tony-newman/drug-war-consequences_b_2404347.html" target="_blank">10 disastrous consequences of the drug war</a>" in the Huffington post. Some of these have little relevance in the local context, but others, such as Racial Injustice, Unsafe Neighbourhoods, Compromising Teenagers Safety and Destroyed Families, certainly do. More on the local situationnext month.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br />
</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: large;"><b>Lord of the Drugs</b></span> </span><br />
<span style="font-family: inherit;">Across the pond in the United Kingdom the <a href="http://www.ukdpc.org.uk/" target="_blank">UK Drug Policy Commission</a> wrapped up 5 years of work and published their final report: <a href="http://www.ukdpc.org.uk/publication/a-fresh-approach/" target="_blank">A Fresh Approach to Drugs</a>. Arguably the most important recommendation is that the political lead for national drug policy be moved from the Home Office to the Department of Health.This recommendation is embraced by the British Medical Association who are encouraging their members to join the <a href="http://bma.org.uk/news-views-analysis/news/2013/january/doctors-urged-to-join-debate-on-drugs-policy" target="_blank">debate on drugs policy.</a></span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br />
</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Cries for reform have also been heard in the House of Commons and the House of Lords. Baroness Molly Meacher chairs the All Party Parliamentary Group for Drug Policy Reform, and she is all for the <a href="http://www.guardian.co.uk/commentisfree/2013/jan/14/decriminalise-drugs" target="_blank">decriminalisation of drugs</a>. The MailOnline make her sound like a raving looney with the headline "<a href="http://www.dailymail.co.uk/news/article-2262176/Baroness-Meacher-Taking-drugs-like-having-cup-coffee-says-peer-wants-ecstasy-sold-chemists.html" target="_blank">Let young have drugs instead of drink says peer as she compares taking substances to drinking coffee</a>". If only that were true! </span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br />
</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Downing Street will have none of it however, and have <a href="http://www.telegraph.co.uk/news/9800676/Downing-Street-rejects-calls-to-decriminalise-drugs.html" target="_blank">rejected calls for the decriminalising</a> of drugs. David Cameron claims "our current policies are working". That paragon of British press virtue The Sun also seems to think its not a good idea, because a girl called Ocean smoked cannabis and it turned her "<a href="http://www.thesun.co.uk/sol/homepage/features/4728447/Dont-go-soft-on-cannabisit-turned-me-into-a-thieving-heroin-addict.html" target="_blank">into a thieving heroin addict"</a>. So there we have it!</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br />
</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: large;"><b><span style="font-size: large;">Something That Is <span style="font-size: large;">W</span>orking</span></b></span> </span><br />
<span style="font-family: inherit;">In amongst all of this I found this article about a program in Seattle that seems to be working, and I really think this LEAD program has some really good points. Basically it enables Police officers to divert those arrested on possession charges directly into housing and treatment facilities, by-passing the criminal justice system. I first read about it in the <a href="http://seattletimes.com/html/localnews/2020045102_lead03m.html" target="_blank">Seattle Times</a>, and took a look at the <a href="http://leadkingcounty.org/" target="_blank">LEAD website</a>. There is also a <a href="http://www.law.seattleu.edu/Documents/cle/archive/2010/032610%20Restorative%20Justice/215pm%20LEAD%20concept%20paper.pdf" target="_blank">short concept paper</a>. <b>There is great potential in this project, and perhaps it is small projects like these that will change the hearts and minds of the people and result in more effective public policy.</b></span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: x-large;"><b>Research</b></span></span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><b id="brain"><span style="font-size: large;">Susceptibility to addiction linked to brain structure?</span></b></span></div>
<div style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-uO1QGy5t_nmEc9tjJkH8YKgAxckmaSAXS3h80I1tD4XpDN1ILsrHO9gEAicDIStMNg6mv3QIyCGB2E_2PBO7mtR32gg_ELhs5HZMSsTwgf1AAsq3sTOFr-sZhsqOGdpOKufwYFzxUfQ/s1600/phrenology.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-uO1QGy5t_nmEc9tjJkH8YKgAxckmaSAXS3h80I1tD4XpDN1ILsrHO9gEAicDIStMNg6mv3QIyCGB2E_2PBO7mtR32gg_ELhs5HZMSsTwgf1AAsq3sTOFr-sZhsqOGdpOKufwYFzxUfQ/s200/phrenology.gif" width="186" /></a></div>
<span style="font-family: inherit;">The paper that seems to be creating the most attention at the moment is <a href="http://www.sciencedirect.com/science/article/pii/S0006322312010049" target="_blank">Distinctive Personality Traits and Neural Correlates Associated with Stimulant Drug Use Versus Familial Risk of Stimulant Dependence</a>. Building on her <a href="http://brain.oxfordjournals.org/content/134/7/2013.short" target="_blank">2011 work</a> where Karen Ersche and others found that a sample of cocaine addicted individuals displayed reduced levels of grey matter and anatomical changes in the orbitofrontal cortex compared to non-users, she now examines non-addicted long-term cocaine users (n=27), addicted users (<i>n</i>=50) and the family members of addicted users (<i>n</i>=50), and unrelated healthy non-using volunteers (<i>n</i>=50). She examined these groups both in terms of personality traits and brain anatomy. One of the conclusions drawn from the findings is that cocaine use does not always lead to addiction - something I often have to point out to concerned family members. What is more interesting is that perhaps resilience or vulnerability towards addiction could be predicted according to brain structure, and that some of the structural abnormalities we observe in addicted individuals, although compounded by drug use, may pre-exist the onset of substance use. Maybe the phrenologists of past just needed to dig a little deeper!</span><br />
<br />
<span style="font-family: inherit;"><span style="font-size: large;"><b id="meth">Meth Psychosis Confirmed in Study</b></span></span><br />
<span style="font-family: inherit;">A <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=1555603#qundefined" target="_blank">recent study published in JAMA Psychiatry</a> confirms what many of us in the Western Cape already know: Meth use causes psychosis. The lead author, Dr Rebecca McKetin studied 278 meth users in Australia. She observed their meth use and psychotic behaviours over a period of 4 years, and the study concludes that Meth use significantly increases incidence of psychosis - 27% likelihood for those that use 1-15 times a month and a massive 48% for those who use16 or more times. Across the board, the chances of having a psychotic episode increased 5 times with Meth use. This particular study listed pre-existing psychotic episodes as an exclusion criteria, so it would appear that Meth may actually cause the psychosis rather than catalyze a pre-existing condition. As Dr McKetin says: "I think this is probably as close as we're going to get to showing a causal relationship between methamphetamine use and psychotic symptoms. There's actually quite a lot of evidence when taken together that suggests that that is the case." Also important to note was that when combined with heavy cannabis and alcohol use psychosis was seen in 69% of the cases.</span> <br />
<span style="font-family: inherit;"><br />
</span> <span style="font-family: inherit;"><b id="trans"><span style="font-size: large;">Transcriptional Mechanisms of Drug Addiction</span></b></span><br />
<span style="font-family: inherit;">In his article, <a href="http://synapse.koreamed.org/search.php?where=aview&id=10.9758/cpn.2012.10.3.136&code=0195CPN&vmode=FULL" target="_blank">Transcription Mechanisms of Drug Addiction</a>, Eric Nestler briefly reviews the growing evidence for the role played by prominent transcription factors in gene expression in addiction. This is an area of particular interest because, in my mind, it is these transcription factors that may affect gene expression that leads to the long-term effects of addiction even after extended abstinence. In this article Nestler discusses <b>Nuclear Factor Kappa B, cAMP and Delta-Fos B</b>. Delta-Fos B has long been linked with the development of spiny neurons in cocaine addicts, but what Nestler doesn't discuss or explain is the increases we see in Delta-Fos B in behavioural addictions. Could it be that increases in Delta Fos-B are not the result of the drug action, but as a result of some internal mechanism that results from addictive behaviour? Could the levels of Delta Fos B perhaps be the biological marker for the move from user to addict? More research is needed to examine the transcription factors in behavioural addictions before we can answer these questions.</span><br />
<span style="font-family: inherit;"><br />
</span> <span style="font-family: inherit;">A little further down the cAMP line we find <b>CREB</b> (cAMP response element-binding protein). The upregulation of CREB is thought to contribute to the tolerence and withdrawal states of addiction through increased dynorphine transmission.. Elevated levels of CREB in the NAc of rats seem to make the rats less sensitive to the rewarding effects of cocaine. It is thought that further investigation may lead to the development of pharmaco-therapies for stimulants. You can read more about this in the paper <a href="http://perspectivesinmedicine.cshlp.org/content/early/2013/01/04/cshperspect.a012005.full.pdf" target="_blank">Roles of Nucleus Accumbens CREB and Dynorphine in Dysregulation of Motivation.</a></span><br />
<span style="font-family: inherit;">If you have no idea what any of this is about you may want to read my essay <a href="http://addictioncapetown.blogspot.com/2013/01/the-neurobiological-underpinnings-of.html" target="_blank">The Neurobiological Underpinnings of Addiction. </a></span><br />
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;"><br />
</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><b><span style="font-size: x-large;">Pharmacology</span></b></span><br />
<span style="font-family: inherit;"><b id="meds"><span style="font-size: large;">Nepicastat Clinical Trials Target Relapse</span></b> </span><br />
<span style="font-size: small;"><span style="font-family: inherit;">Some of us may be familiar with the work of Berridge, Robinson, Steketee, Kalivas and others in the area of long-term sensitisation of addicts to stress, drug cues and the drug itself, which can lead to the reinstatement of drug seeking behaviours even after long-term abstinence. It is proposed that by inhibiting the enzyme dopamine beta-hydroxylase and lowering norepinephrine levels, the desire to reinstate drug seeking behaviour may be reduced<b>. </b><a href="http://www.nature.com/npp/journal/vaop/naam/abs/npp2012267a.html" target="_blank">Pre-clinical</a> trials have shown that Nepicastat doesn't stop rats from administering a steady stream of cocaine, but it does reduce reinstatement after a break, and they do not work as hard to get cocaine when exposed to stress or drug related cues. Interestingly it does not seem to stem their desire for other behaviours, such as getting food or sugar. The double blind <a href="http://clinicaltrials.gov/show/NCT01704196" target="_blank">clinical trials</a> are being sponsored by NIDA.</span></span><br />
<div style="text-align: justify;">
<span style="font-family: inherit;"><br />
</span> <span style="font-family: inherit;"><b><span style="font-size: large;"><span style="font-size: large;">1</span>8-MC Trials Target Reward System in Addiction and Obesity</span></b></span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">NIDA has also made funding available to <a href="http://www.savanthwp.com/" target="_blank">Savant HWP</a> for the development of 18-methoxycoronaridine as a potential orally active treatment for drug addiction, obesity and other forms of compulsive behavior. 18-MC is an alpha-3-beta-4 nicotinic receptor antagonist that modulates excessive dopamine fluctuations in the mesolimbic system of the brain. It therefore targets the reward system directly by modulating the excessive dopamine fluctuations in the mesolimbic system, but is not drug specific because it is not an agonist or antagonist for the primary receptor site of a specific substance. Interestingly, 18-MC is a derivative of <b>Ibogaine</b>, the controversial underground cure for addiction. The difference between ibogaine and 18-MC is that 18-MC has no affinity for the alpha-4-Beta-2 subtype, NMDA-channels or 5HT transporter. It does have modest affinity for the mu and kappa opioid receptors.<br />
<br />
<span style="font-family: inherit;"><span style="font-size: x-large;"><b>Personality of the Month</b></span></span><br />
<span style="font-family: inherit;"><b id="marc"><span style="font-size: large;">Marc Lewis </span></b></span><br />
</span><br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: inherit;"><span style="font-family: inherit;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-yMBoOrCBdxjA11atPCab-MQkb3Aoum-P_dZy9cF2k-aRQa3k2GZvtkob4BmROKVKiTl3xUEjfhWCSmfacvYptBAb1soCoPEmqR4uorILIv6xhTmwreLP2P_YBHJV4CV1JhIiT8L2o00/s1600/Marc_Lewis__Duncan_de_Fey_72_dpi.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-yMBoOrCBdxjA11atPCab-MQkb3Aoum-P_dZy9cF2k-aRQa3k2GZvtkob4BmROKVKiTl3xUEjfhWCSmfacvYptBAb1soCoPEmqR4uorILIv6xhTmwreLP2P_YBHJV4CV1JhIiT8L2o00/s200/Marc_Lewis__Duncan_de_Fey_72_dpi.jpg" width="133" /></a></span></span></div>
<span style="font-family: inherit;"><span style="font-family: inherit;">Marc is a developmental neuroscientist and professor of developmental psychology, recently at the University of Toronto. He is currently at Radbound University in the Netherlands. He has authored over 50 journal articles in psychology and neuroscience. The reason, however, I have decided to feature Marc is because of his personal history of addiction which is documented in his <a href="http://www.amazon.com/Memoirs-Addicted-Brain-Neuroscientist-Examines/dp/1610391470" target="_blank">book</a> and his amazing blog, <a href="http://www.memoirsofanaddictedbrain.com/blog/" target="_blank">Memoirs of an Addicted Brain.</a>. This blog has some really fascinating posts that stimulate all sorts of conversation, and the comments are of a far higher standard than we usually see on the web. Marc also makes the effort of responding to many of the comments and he also has a guest memoirs section. Reading these memoirs and Marc's blog brings home the fact that addiction affects all walks of life and that these are people we are dealing with. And that neatly brings me to this month's quotes:</span><br />
<br />
<b><span style="font-size: x-large;">Quotes of the month:</span></b><br />
<br />
<span style="font-family: inherit;">Lee Hoffer criticizes the "overly quantitative presentations on the "behaviors" of drug users that dominate conferences in the field" in his article <a href="https://sfaa.metapress.com/content/2hn672m0158u5152/resource-secured/?target=fulltext.pdf" target="_blank">Unreal Models of Real Behaviour: The Agent-Based Modeling Experience</a>. He goes on to say:<span style="font-size: large;"><i><span style="line-height: 115%;"> </span></i></span></span><br />
</span><br />
<blockquote class="tr_bq">
<span style="font-family: inherit;"><span style="font-size: large;"><i><span style="font-family: inherit;"><span style="line-height: 115%;">"The highly personal narratives of participants framed by equally complex social environments are not visible in the numbers. To epidemiologists and other like-minded health researchers, the numbers are the narrative and all that is required for informing and evaluating theories, models, interventions, treatment programs, or policy."</span></span></i></span></span></blockquote>
<span style="font-family: inherit;">
<span style="font-family: inherit;">And if that isn't enough for the scientists among us to take things personally, i<span style="font-size: 11pt; line-height: 115%;">n his article titled <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.03967.x/full" target="_blank">Too many rating Scales: Not enough Validation</a> published in the December 26 issue of Addiction, Duncan Raistrick says: </span></span><br />
</span><br />
<blockquote class="tr_bq">
<span style="font-family: inherit;"><i><span style="font-size: large;"><span style="font-family: inherit;"><span style="line-height: 115%;">“Experts and stakeholders are, by definition, selected because they are distinguished in their field, and have opinions and experience to bring to the table. The problem is that opinions are often very strongly held to the exclusion of equally strong scienc<span style="font-size: large;">e"</span> </span></span></span></i></span></blockquote>
<span style="font-family: inherit;">
<br />
<br />
<b id="cure"><span style="font-size: x-large;">Crazy "Cures"</span></b><br />
<span style="font-size: large;"><b>Dr Frankenstein's School of Ablative Surgery</b></span><br />
Forget the pharmacological approach, let's just get in there and "vaporize" the nucleus accumbens. For those of you who haven't studied the dark arts, the procedure involves drilling a couple of holes in the skull and inserting long electrodes into the "pleasure center" of the brain. An electrical current is then passed through the electrodes which kills the cells in the nucleus accumbens. A recent paper published in<a href="https://www.ncbi.nlm.nih.gov/pubmed/23154203" target="_blank"> </a><i><a href="https://www.ncbi.nlm.nih.gov/pubmed/23154203" target="_blank">Stereotactic and Functional Neurosurgery</a> </i>reports that 60 opioid addicted patients in mainland China were followed up 5 years after surgery. and 47,4% were seen to be abstinent.On the other side of the coin, memory deficits were seen in 21%, motivational loss in 18% and some changes in personality in 53%. In spite of this the paper concludes: "The bilateral ablation of NAc by stereotactic neurosurgery was a feasible method for alleviating psychological dependence on opiate drugs and preventing a relapse. Long-term follow-up suggested that surgery can improve the personality and psychopathological profile of opiate addicts with a trend towards normal levels, provided persistent abstinence can be maintained; relapse, on the other hand, may ruin this effect.". Hopefully they wont use the same technique to cure my skepticism.<br />
<br />
<span style="font-size: large;"><b>"Beating" Addiction</b></span><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-_rFlLbU5Vwqechg9wO13jnVTLmgKwcsXd3WVYvQw6EAjw4bEk7-yWGxVD-0A05IQFNX7lD-iY3zCpku_a20B3kB37_0nEJ7zT05jyAIqK_hHYdfIaKFe3oxKjD8fGeXFoGNg43rZuNY/s1600/inside,+Andrew+is+caned+by+Marina+2.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-_rFlLbU5Vwqechg9wO13jnVTLmgKwcsXd3WVYvQw6EAjw4bEk7-yWGxVD-0A05IQFNX7lD-iY3zCpku_a20B3kB37_0nEJ7zT05jyAIqK_hHYdfIaKFe3oxKjD8fGeXFoGNg43rZuNY/s200/inside,+Andrew+is+caned+by+Marina+2.jpg" width="176" /></a>Those of you who are excited by the prospect of ablative surgery may also derive some pleasure out of the cure described in the <a href="http://siberiantimes.com/other/others/features/beating-addiction-out-of-you-literally/" target="_blank">Siberian Times</a> (where else): Dr German Pilipenko and Professor Marina Chukhrova believe that their "limited pain exposure" method of treating addictions stimulates the brain to produce endorphins, thereby "making patients happier in their skins". The amazing thing about this "cure" is that it apparently treats depression and obsessions as well. Natasha, one of the success stories says: "I wouldn't keep coming back for this if I didn't think it was working. I know many of my friends think I am mad to trust these doctors. But I want to live. For the first time since I because an addict five years ago, I feel I have a chance. I just want to be like all those thousands of girls who have a normal life - finding a man, getting married, having kids, going through the problems of life together. I want that kind of normal life - and finally I can feel I am coming back to it." Maybe in Siberia a "normal" life involves having the crap hit out of you.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br />
</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;">That's it for this month<span style="font-size: large;">.<span style="font-size: small;"> I hope you <span style="font-size: small;">found something that met your interest. Once again<span style="font-size: small;">, comments are welcome. Please feel <span style="font-size: small;">free to contact me directly by e-mail, and don't forget to subscribe to my monthly reminder.</span></span></span></span></span></span></span><br />
</div>
<div style="text-align: justify;">
</div>
</div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-323534899059408543.post-50919177126157086762013-01-24T17:58:00.001+02:002013-01-24T21:49:25.551+02:00CBT Doesn't Work for Heroin Addiction?<!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
DefSemiHidden="true" DefQFormat="false" DefPriority="99"
LatentStyleCount="267"> <w:LsdException Locked="false" Priority="0" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Normal"/> <w:LsdException Locked="false" Priority="9" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="heading 1"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 2"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 3"/> <w:LsdException Locked="false" Priority="0" QFormat="true" Name="heading 4"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 5"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 6"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 7"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 8"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 9"/> <w:LsdException Locked="false" Priority="39" Name="toc 1"/> <w:LsdException Locked="false" Priority="39" Name="toc 2"/> <w:LsdException Locked="false" Priority="39" Name="toc 3"/> <w:LsdException Locked="false" Priority="39" Name="toc 4"/> <w:LsdException Locked="false" Priority="39" Name="toc 5"/> <w:LsdException Locked="false" Priority="39" Name="toc 6"/> <w:LsdException Locked="false" Priority="39" Name="toc 7"/> <w:LsdException Locked="false" Priority="39" Name="toc 8"/> <w:LsdException Locked="false" Priority="39" Name="toc 9"/> <w:LsdException Locked="false" Priority="35" QFormat="true" Name="caption"/> <w:LsdException Locked="false" Priority="10" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Title"/> <w:LsdException Locked="false" Priority="1" Name="Default Paragraph Font"/> <w:LsdException Locked="false" Priority="11" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtitle"/> <w:LsdException Locked="false" Priority="22" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Strong"/> <w:LsdException Locked="false" Priority="20" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Emphasis"/> <w:LsdException Locked="false" Priority="59" SemiHidden="false"
UnhideWhenUsed="false" Name="Table Grid"/> <w:LsdException Locked="false" UnhideWhenUsed="false" Name="Placeholder Text"/> <w:LsdException Locked="false" Priority="1" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="No Spacing"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 1"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 1"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 1"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 1"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 1"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 1"/> <w:LsdException Locked="false" UnhideWhenUsed="false" Name="Revision"/> <w:LsdException Locked="false" Priority="34" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="List Paragraph"/> <w:LsdException Locked="false" Priority="29" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Quote"/> <w:LsdException Locked="false" Priority="30" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Quote"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 1"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 1"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 1"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 1"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 1"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 1"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 1"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 1"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 2"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 2"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 2"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 2"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 2"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 2"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 2"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 2"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 2"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 2"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 2"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 2"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 2"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 2"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 3"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 3"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 3"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 3"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 3"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 3"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 3"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 3"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 3"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 3"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 3"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 3"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 3"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 3"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 4"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 4"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 4"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 4"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 4"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 4"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 4"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 4"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 4"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 4"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 4"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 4"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 4"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 4"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 5"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 5"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 5"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 5"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 5"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 5"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 5"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 5"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 5"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 5"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 5"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 5"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 5"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 5"/> <w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 6"/> <w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 6"/> <w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 6"/> <w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 6"/> <w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 6"/> <w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 6"/> <w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 6"/> <w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 6"/> <w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 6"/> <w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 6"/> <w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 6"/> <w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 6"/> <w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 6"/> <w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 6"/> <w:LsdException Locked="false" Priority="19" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Emphasis"/> <w:LsdException Locked="false" Priority="21" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Emphasis"/> <w:LsdException Locked="false" Priority="31" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Reference"/> <w:LsdException Locked="false" Priority="32" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Reference"/> <w:LsdException Locked="false" Priority="33" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Book Title"/> <w:LsdException Locked="false" Priority="37" Name="Bibliography"/> <w:LsdException Locked="false" Priority="39" QFormat="true" Name="TOC Heading"/> </w:LatentStyles> </xml><![endif]--><!--[if gte mso 10]> <style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-qformat:yes;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:10.0pt;
mso-para-margin-left:0cm;
line-height:115%;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;}
</style> <![endif]--><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhu8yhX0E-WlxMEcP-Q3P1ts3P_BzhCLkIBmC8fmYd0_Asd0pyLES1dZ4p6KUop-INIkk4FIEB2PVaJ8OjOj5BYQ2chN6jOAbadXbSfarl51MEDLeNdF0U6bsjSl2BiCLYhCkHYzjvtFwg/s1600/heroin_red_carpet.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhu8yhX0E-WlxMEcP-Q3P1ts3P_BzhCLkIBmC8fmYd0_Asd0pyLES1dZ4p6KUop-INIkk4FIEB2PVaJ8OjOj5BYQ2chN6jOAbadXbSfarl51MEDLeNdF0U6bsjSl2BiCLYhCkHYzjvtFwg/s200/heroin_red_carpet.gif" width="200" /></a><span style="font-size: large;"><b>Study Suggests Buprenorphine is enough.<span style="font-size: x-large;"> <span style="font-size: large;">I Disagree.</span></span></b></span><br />
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
In the January 2013 edition of The American Journal of Medicine there is a clinical research study conducted by members of the Yale University of the School of Medicine entitled: <a href="http://www.amjmed.com/article/S0002-9343%2812%2900635-3/fulltext">A Randomized Trial of Cognitive Behaviour Therapy in Primary Care-based Buprenorphine.</a><span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;"><span style="mso-spacerun: yes;"> </span>(Fiellin, et al., 2013)</span>. In the abstract for the study, the stated objective was “To determine the impact of cognitive behavioral therapy on outcomes in primary care, office-based buprenorphine/naloxone treatment of opioid dependence.” The abstract concludes: “Among patients receiving buprenorphine/naloxone in primary care for opioid dependence, the effectiveness of physician management did not differ significantly from that of physician management plus cognitive behavioural therapy.”</div>
<div class="MsoNormal" style="text-align: justify;">
<br />
<a name='more'></a></div>
<div class="MsoNormal" style="text-align: justify;">
Already this article is causing misleading headlines. First up were the partisan Yale Daily News and the Yale News. The Yale Daily declares “<a href="http://yaledailynews.com/blog/2013/01/22/therapy-ineffective-for-opioid-addiction/">Therapy Ineffective for Opioid Addiction</a>” <span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;">(Goldberg, 2013)</span> and the News “<a href="http://news.yale.edu/2013/01/03/cognitive-behavioral-therapy-adds-no-value-drug-treatment-opioid-dependence">Cognitive behavioral therapy adds no value to drug treatment for opioid dependence</a>”<span lang="EN-US" style="mso-ansi-language: EN-US; mso-no-proof: yes;"><span style="mso-spacerun: yes;"> </span>(Dodson, 2013)</span>.<span style="mso-spacerun: yes;"> </span><a href="http://medicalxpress.com/news/2013-01-cognitive-behavioral-therapy-drug-treatment.html">Medicalxpress.com</a> makes similar claims and adds the study “could change how such dependence is viewed and treated in the U.S. healthcare system”. <a href="http://www.medscape.com/viewarticle/777451">Medscape</a> says there is “no additional benefit of CBT in Opioid Addiction”. Soon, no doubt, the mainstream press will have similar headlines and the general public and, more dangerously, policy makers will believe that all that we need to cure heroin addiction is enough doctors handing out Buprenorphine.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Taken at face value it seems an attractive prospect to be able to simply hand out a pill to addicts who come with a plethora of bio-social ills that have, until now it seems, required specialised and intensive interventions. Already we are seeing that 41% of those receiving Buprenorphine treatment in the United States are not getting any psycho-social treatment in their first month and 56% of doctors allowed to prescribe buprenorphine were in non-addiction specialties. (To read more about this and to find out how the Buprenorphine market is primarily the domain of the affluent, read this article at <a href="http://www.thefix.com/">www.theFix.com</a>: <a href="http://www.thefix.com/content/methadone-Suboxone-stigma-maintence-treatment8555?page=2">The Other Side of the Tracks</a>). </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Even though the study includes a brief paragraph that outlines one or two study limitations, and the authors do address some of my concerns, I feel that this study is seriously limited in possible application. Here are my reasons:</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<b><span style="font-size: large;">It measures the wrong thing</span></b><br />
<div class="MsoNormal" style="text-align: justify;">
The impression the article creates, and this impression is backed up by the subsequent quotes by the authors in the cited articles, is that they are measuring the effectiveness of treatment for heroin addiction. It doesn’t. It measures simply heroin abstinence, while on a partial opioid agonist. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Heroin addiction is not heroin dependence. It is a lot more. This is demonstrated by the psycho-social and behavioural issues that addicts across the spectrum of addictions suffer. This study does not examine the quality of life, nor claim to. Does Buprenorphine help keep people off Heroin? Absolutely. We know that already. Buprenorphine is a very useful tool in the treatment of opioid addictions. In a few cases this migratione from opioid dependence to Buprenorphine dependence and the possible associated move away from “drug culture” is enough motivate a person from “addicted lifestyle” to “living”. But this is the exception.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
Long-term drug use causes neurological changes and these are reflected in behaviours. Addicts have, through various processes, adopted a set of behaviours and thinking patterns that are not effective in achieving their long-term life goals. Most of us who treat addictions will agree that abstinence is only a very small part of the treatment process. Whatever theory or model of addiction you subscribe to, addiction is not simply about drug use. This thinking is reflected in the NIDA document <a href="http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment">Principles of Addiction Treatment</a> where point 4 states: “Effective treatment attends to multiple needs of the individual, not just his or her drug abuse”. <span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
If this study had included some indicators that reflected quality of life, and it was shown that these individuals had improved in these areas, then perhaps it would have had more application in the all too real world of addiction.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<b><span style="font-size: large;">Long-Term Sustainability</span></b><br />
<div class="MsoNormal" style="text-align: justify;">
Further in the <a href="http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment">Principles of Addiction Treatment</a> document we read: “Remaining in treatment for an adequate period of time is critical” and “Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.” <span style="mso-spacerun: yes;"> </span>What we have here is a limited time study of people who have not yet been detoxed. These are opioid addicts who have moved from opioid dependency to opioid agonist dependency. They are not “cured”. By cutting out the CBT component we are not providing any tools for living without pharmacological intervention. This is more in the line of harm reduction rather than treatment or rehabilitation. I’m a huge proponent of harm reduction and medium to long term substitution, but not at the expense of abstinence based psycho-social solutions geared towards effective living and functioning.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
The big question is if this is sustainable. 6 months (the period of the study) is a short time when it comes to addiction treatment. The mean years of dependency in this study was around 8 years. How many of these patients will still be visiting their physician monthly for the next 8 years? How are they going to develop drug refusal behaviours or deal with underlying issues if their drug use is a form of self-medication or self-soothing if there are no real psycho-social interventions? Eventually many will either taper or simply end the medication, which costs between US$250 and US$500 per month to maintain. The study itself had a huge drop-off rate. (An interesting area of research would be to see if Motivational Interviewing before and during early treatment initiation would reduce dropout rates)<span style="font-size: large;">.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
If the authors were suggesting Buprenorphine alone as a temporary holding pattern that primary health settings can initiate before treatment starts, then great. Unfortunately they are not saying that.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<b><span style="font-size: large;">CBT as an Approach</span></b><br />
<div class="MsoNormal" style="text-align: justify;">
The Yale study examines the impact of adding CBT to the Buprenorphine protocol. They do this probably because CBT is the preferred and most researched psychological intervention for addictive disorders. Personally I have found that while stimulant users get significant benefits from initial CBT interventions, heroin addicts respond more favourably to a psychodynamic approach which is less structured, seeks to examine personal history and has more focus on the therapeutic relationship. There is <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev.clinpsy.4.022007.141252?journalCode=clinpsy">research</a><span style="mso-ansi-language: EN-US; mso-no-proof: yes;"><span style="mso-spacerun: yes;"> </span><span lang="EN-US">(Gibbons, Crits-Christopn, & Hearon, 2007)</span></span> to back this up and others I have consulted have also found this thinking to be useful. </div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
To use the blanket term “therapy” as some of these headlines do, is misleading.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<span style="font-size: large;"><b>Conclusion</b></span><br />
<div class="MsoNormal" style="text-align: justify;">
If our goal is abstinence, reduced mortality amongst heroin users and less crime, then this study has some merits. However, if our goal is to help heal the addicted and to empower those who want to find long-term recovery without life-long dependence, this study says little and <span style="font-size: small;">if </span>adopted into our evidence base, could potentially do a lot of harm.</div>
Shaun Shellyhttp://www.blogger.com/profile/00320880733187014324noreply@blogger.com