New Opiate-Based Medication Prescribing Guidelines?

05/27/12 | by the professor [mail] | Categories: Drug-Regulation Policy

Link: http://AddictionScience.net

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The U.S. Food and Drug Administration (FDA) is currently revising their guidelines for prescribing opiate-based and related medications. These medicines are used daily by millions of people for the relief of moderate to severe pain. The FDA's concern is that therapeutic opiate use may lead many to addiction and therefore these medications should be more tightly controlled. The guidelines most likely would further restrict who gets opiate-based medications and under what conditions. Although we strongly support closing Internet drug companies that promote various psychoactive drugs including opiate-based medications and we further entertain the idea of a national registry to avoid duplicate prescription writing through physician shopping, we also believe that too many people now are discouraged from receiving (i.e, patients) or prescribing (i.e., physicians) medications necessary to dramatically improve the quality of life for those experiencing chronic pain.

The United States already has conservative views on the use of narcotic analgesics. Of course there is a lot of variation on opinion and on prescription-writing practices, but overall the U.S. remains rather conservative leaving millions of people under medicated for very painful conditions. Perhaps physicians should have to undergo a one-week intensive experience-pain-as-a-patient training module whereby they would be subjected to moderate but unrelenting pain for a short period of 7 days. Maybe then they would better understand the need and urgency for prescribing proper pain medication. And while we're making up the rules for the rule makers, let's add the policy makers (physician and layman alike) to our special training program. Want to see just how fast the laws and prescribing practices can change?

Patients deserve to receive their pain-relieving medication without everyone being looked upon as a potential addict. The unfounded hysteria and sensationalistic 'scientific' papers published from time-to-time need to quit exaggerating the problem for the sake of another publication and to quit marginalizing these patients who are already suffering considerably.

Very few people who receive opiate-based medication for the relief of pain become opiate addicts. Those that do are written up in reports which eventually find their way as 'scientific' articles, but the millions who don't aren't interesting and don't even make mention in such articles. The problem of addiction to prescription medication needs to be kept in perspective. Yes, many do but most don't become addicted. And of those who do progress on to addiction, the 'scientific' literature fails to note that they first entered a phase of drug abuse whereby they misused the drug by taking it outside the prescribed directions. That is, they didn't really become addicted as a consequence of their therapeutic opiate use, but rather, they abused the drug that was therapeutically made available and later became addicted. The intervening phase of drug abuse is critically important for understanding this progression. Unfortunately, it is usually ignored by those doing 'research' in this area.

(This is another instance where the distinction between drug "abuse" and drug "addiction" is critically important for conceptualizing an important issue. Better training in addiction science as part of the regular medical curriculum would be a giant step forward.) It's impossible to even discuss this topic intelligently without the requisite concepts behind the vocabulary.

Congratulations to me, "The Professor" XX(. This commentary, drafted in September of last year (2011), was never completed or even posted in its preliminary form--another victim of "Bozarth's Law of Procrastination!" Now it's damage control time as the federal government and individual states have scared many physicians into needlessly restricting their prescriptions of opioid medications even further. Stay tuned (and subscribe to the RSS feeds) as this forum category gets shifted into high gear. Ouch that hurt :( .

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Unscheduled Service Disruption to all ASNet Resources

06/16/10 | by the professor [mail] | Categories: General, Announcements

We may experience a temporary shut-down due to server overload. We are trying to plug a 25+ GB hole in our online discussion forums (which includes several others in addition to this one) that is depleting our computer resources and may produce an effect similar to a denial-of-service attack. This is caused by nuisance posts that attempt to increase traffic to offending websites by linking back to our posts. The comments usually have no obvious connection with the initial commentary (e.g., "good post," "love to read more") and must be manually deleted, often one-by-one.

We will now be more vigilant in 'policing' our discussion forms, routinely deleting posts that do not make specific reference to the content of the individual commentaries. We will also preview posts before allowing them to be published. This is perhaps the most effective method of decreasing this type of spam combined with using an updated list of known spammers. If the problem persists, we may require registration for posting comments. If the problem further persists, we will disallow trackbacks to commercial resources including those involved in drug addition treatment and related services.

We apologize for removing any legitimate posts that are inadvertently deleted. (Your legitimate post might be buried amongst thousands of spam postings.) We do not wish to 'moderate' the content of this discussion forum beyond preventing keyword spamming. If your post is deleted by mistake, please make sure that you are registered and logged-on and then post your comments again. Meanwhile, we have been working through the night and much of the day to prevent a service outage from these malicious web-promotion services.

In the unlikely event that we ever become so popular that we actually require an additional 30 GB of bandwidth, we will be happy to pay for the expanded service. But we certainly are unwilling to pay to promote offending websites while they liter our discussion forum. And of course, resources here are very limited and that's the primary reason lead commentaries and replies have been so sparse this past year. Hopefully time will permit further developing the content of this discussion forum later this summer. Meanwhile, we appreciate your viewership, your active participation by posting, and your patience with this project.

Cheers and sorry for any inconvenience,

"The Professor"

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E=mc(2) and the Science of Addiction

04/14/09 | by the professor [mail] | Categories: General

Laymen and professionals alike often ask for a quick synopsis of what causes addiction—a succinct summary resolved down to 25 words or less. The problem is that addiction, like many behaviors, is far too complex for such a simple rendering that is easily understood beyond its most superficial context (see the closing remark for a brief, 25-word summary of the cause of addiction). And ironically, what is perhaps the most complex endeavor of science (i.e., the study of human behavior) is usually considered so simple by most people that anyone without proper training should be able to grasp instantly its most complex principles and corresponding explanations of behavior. So goes the science of addiction.

One of Einstein's most famous formulations in theoretical physics is expressed simply as E=mc(2). This elegantly illustrates how complex theories in science can sometimes be resolved down to very simple expressions. And while most well-educated students may be able to recite the terms in this equation (i.e., "the amount of energy released equals the mass times the speed of light squared"), few really comprehend its meaning beyond the most superficial terms.

Psychology is far more complex than theoretical physics. Not because of the detailed mathematical derivations upon which it is based nor even the I.Q. points necessary to seriously ponder its most advanced principles, but because of the number of variables that must be considered with even a seemingly simple behavior. (In physics, this is analogous to the number of simultaneous equations that must be solved to resolve the problem.) Einstein is reported to have considered physics relatively simple (pun added ;), apologies to Prof. Einstein), but he considered behavior complicated. So if Einstein considered what most of us consider complex as simple and what most people consider simple as complex, how confused is the state of science today?

Understanding drug addiction, like understanding most aspects of psychology, requires years of careful study which builds upon certain elementary principles and extends to theoretical formulations which fill the gaps in present knowledge. Some topics like drug addiction require additional training in behavioral neuroscience and in psychopharmacology to really understand 'how drugs work in the brain' to produce the strong motivational effects that define addiction. One of the most surprising aspects of my course on Drug Addiction for many undergraduate psychology majors is that "drug addiction involves the action of certain drugs on the brain!" And may the gods of knowledge protect the educator who attempts to explain to the average drug addict that THEY are not the ultimate expert on their addiction: people like to retain the misbelief that they somehow understand and control their own behavior even when faced with overwhelming evidence to the contrary. (Considering addicts, or any other individual for that matter, to have a real understanding of the causes of their own behavior derived from an amateurish 'self-examination' is tantamount to returning the pre-20th Century psychology of introspectionism. Regression is one thing, but losing over 100-years of progress in the field of psychology is inexcusable.)

The tele-psychologists pander to this desire for a quick and simple explanation to a rather complex behavior. The attention span of their audiences, and indeed the attention span of many tele-psychologists themselves, does not permit a more detailed, scientific explanation of the behavior, and it profoundly objects to the notion that some basic understanding of fundamental principles of psychology and psychopharmacology are requisites for understanding why people take drugs. By seeming to provide quick and easy explanations for drug addiction, they do a considerable disservice to the science of addiction and to the addicts themselves (See Dr. Phil’s “Addiction”.).

True drug addiction is relatively simple to understand for those with the appropriate training. The many causes of drug abuse and misuse are more varied and are therefore much more complex. (This is one of the reasons distinguishing between drug abuse and drug addiction is important.) Even alcohol addiction is more complex than addiction to other drugs. And experimental drug use (to a limited degree) is too often seemingly a 'normal' part of adolescent behavior. The desire to understand complex behavior often exceeds the empirical database for establishing cause-and-effect by traditional scientific criteria. The extension of 'understanding' into the realm of the unknown requires sound logic based upon careful examination of the available empirical evidence and systematic theory development; such constitutes the science of addiction today. An understanding of this process simply cannot be conveyed meaningfully in a concise 25-word summary to those not adequately trained in the field, much to the frustration of the specialists, laymen and ‘professionals’ alike.

In conclusion, addiction involves differential perturbations in mesolimbic dopamine and other neural systems mediating incentive motivational processes that produce a profound incentive contrast with consequential motivational toxicity. Or stated even more simply, E=mc(2)!

Addendum

For those who are still not getting the point of the commentary let me add one last explanation of what I'm trying to convey: if I do give you the succinct, 25-word or less reply to your question that you demand, you simply won't understand the answer! Now get it? E = MC(2), a nice, succinct explanation that tells a lot in a few words or symbols but which relatively;) few people truly understand.

The above commentary is my response to those who ask for a quick and simple explanation of what causes drug addiction. Really, would anyone expect to actually understand how two little acetyl groups substituted for a couple of hydroxls on a morphine molecule makes heroin which is preferred over morphine in choice tests without having first taken organic chemistry or studied a bit on their own?! But in psychology, everybody thinks they can understand what we've spent years studying summarized in a simple, 25-word or less explanation. So what causes drug addiction?

Brain + (the right) drug x enough exposure = addiction.

Hey, I kind of like that! It's sort of Clark Hullian and I liked that dude (viz., the dominant force in mid-20th Century experimental psychology that you've probably never heard of). If you recall his equation describing motivated behavior, then you likely understand mine too.

Related on the ASNet
Primer on Drug Addiction
Biological Mechanisms of Addiction
Distinguishing Drug Abuse from Drug Addiction
Dr. Phil's "Addiction"

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ASNet Updates 09D11

04/11/09 | by the professor [mail] | Categories: Announcements

Announcements

  1. Corrections to web pages containing ‘typographical’ errors.
  2. Introduction of the ASNet Discussion Forum and RSS feeds.
  3. Participation in the AdSense program.
  4. Thanks to Sea Monkey and b2evolution.

The transfer of the ASNet website to another platform by the hosting service introduced a number of errors into various web pages throughout the site. A “bit” here, a “byte” there led to toggling bold print, centering lines, or dropping some HTML code into the middle of the text. Many of these problems were undetected and unreported—some just took a long time to correct because of a lack of staff. Still others are awaiting their ‘fix’ some time in the future when resources permit. (For example, numerous corrections have been made to the individual chapters of the online book on Assessing Drug Reinforcement; additional corrections and enhancements are planned.) If you have difficulty accessing a page or if you find typographical errors, problems should be reported to webmaster@AddictionScience.net for correction.

The most significant recent addition to the Addiction Science Network is the ASNet Discussion Forum. But if you’re reading this ASNet Update, you’re already well aware of the Forum. The Discussion Forum has two purposes—to educate by ‘discussing’ various terms, concepts, and other issues in drug addiction and to open some topics for general discussion and comments. Postings that specifically seek opinion are easily identified by the question or questions bold printed near the end of the posting. Commentary is always welcomed, but it is especially appreciated on these ‘open questions.’ Also, remember that RSS feeds from the ASNet Discussion Forum Announcements will take the place of the old ASNet Updates e-mail notification by the end of the year. Both the Firefox and the Sea Monkey browsers have RSS readers built into their applications as does the latest version of Microsoft’s Outlook.

AdSense is being added to most web pages. The revenue generated by participation in this program is very small even when people do click on the advertisements. The primary purpose of incorporating AdSense into the ASNet website (and into the Discussion Forum in the future) is to provide real-time data on Internet traffic for the corresponding pages. No information is collected regarding individual visitors—only information regarding the number of visitors to a page. This helps to direct limited ASNet resources to where they will have the most impact: working to improve the impact of pages with little traffic but important content, and working to further enhance the impact of already popular pages. Please note that the Addiction Science Network does not accept advertisements nor does it collect any fees from any of these ‘sponsors’ directly—the content of the AdSense displays are controlled by Google and should not be interpreted as an endorsement of any kind.

Finally, near the bottom of the AddictionScience.net home page there are acknowledgements of open source software, specifically the Sea Monkey and b2evolution programs that are used to develop this website and to provide the Discussion Forum, respectively. A link to the popular Firefox Internet browser is also included as is a link to the OpenSource.org consortium. These are unpaid, unsolicited ‘advertisements’ for these non-profit projects that provide free software for the Internet and thereby help keep the costs low at the ASNet—free is good, free is appreciated, and free is gratefully acknowledged.

Below is an example of the Google AdSense Advertisements that may appear in some postings. Clicking on these links take you to websites not affiliated with the ASNet.

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Recreational Drug Use: Do People Living in a Free Sociey have the Right to use Psychotropic Substances "Recreationally"?

04/08/09 | by the professor [mail] | Categories: Drug-Regulation Policy, Recreational Drug Use

This post was actually planned for a later date after the groundwork was laid by exploring basic topics regarding drug abuse and addiction on the ASNet Discussion Forum. However, the recent post on Salvia Divinorum (and to a lesser extent the medical marijuana post) propels this topic to the forefront a bit ahead of schedule. When discussing this topic it is essential to keep in mind the differences between drug abuse and drug addiction and their underlying causes (i.e, the biological basis of addiction vs. the psychosocial factors that often govern drug abuse). A lot of confusion arises from simple problems in semantics when discussing psychoactive drug use, the effects of such drugs, and the rights of individuals. Some of the essential concepts have been presented already on the ASNet Discussion Forum or the Addiction Science Network website (see Related Topics on the ASNet below), but others have not yet been explored adequately. Thus, this topic is a somewhat premature.

The question open for comment is: “does the individual living in a free society have the right to use psychotropic substances?” There are a number of secondary questions that arise from this topic.

  • What right does society have to infringe upon the rights of the individual (cf. constitutional “right to pursue happiness”)?
  • Under what conditions do people have a right to use drugs recreationally?
  • Under what conditions does society have an obligation to regulate drug use?
  • What types of psychoactive substances should be permissible?

Background

The ASNet drug-regulation policy stands firmly behind the strict control of highly addictive drugs. These substances (e.g., 'hard drugs' such as cocaine and heroin) compromise the individual's ability to 'choose' whether to use the substance or not by altering the individual's motivational hierarchy in such a way as to thrust the addictive drug near the top of the person's motivational priorities (see A Primer on Addiction). On the other hand, some psychoactive substances (e.g., caffeine) clearly do not compromise the individual's self-control in a significant way and therefore can be considered part of 'life's little pleasures.' Between these two extremes lie substances that cause considerable alteration in perception, cognition, and/or affect (e.g., 'soft drugs' such as marijuana and LSD) that potentially pose a risk for the individual and for society by impairing judgment and impulse inhibition of the individual while they are experiencing the psychotropic effects of the substance (e.g., intoxication, hallucinations). This is in contradistinction to truly addictive drugs where the risk to the individual and to society is primarily when the individual is not experiencing the psychoactive effect of the drug.

Addiction science can contribute to the development of rational drug-control policy by differentiating drugs that a large proportion of individuals might be expected to ‘lose control’ of their ability to regulate their own drug-using behavior from substances that most individuals experience little difficulty in regulating their own substance use. Other issues that determine society’s acceptance of its citizens’ use of psychotropic substances involve safety (a rational consideration) and moral control (usually a non-rational consideration). Addiction science and the reporting of experimental findings should not present biased information to conform to moral control issues dictated by society or by its government agencies—it should clearly present the facts as the facts, letting individuals make rational decisions regarding personal use on the individual scale and regarding the development of rational drug-control policies on the societal scale.

Related Topics on the ASNet
A Primer on Drug Addiction
The Nature of Addiction
Distinguishing Drug Abuse from Drug Addiction
Distinguishing Drug Dependence from Drug Addiction
Biological Basis of Addiction
Hard and Soft Drugs
Drug Classification
Salvia Divinorum
Medical Marijuana

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“Recreational” Drug Use: A New Discussion Category on the ASNet Forum

04/08/09 | by the professor [mail] | Categories: Drug-Regulation Policy, Recreational Drug Use

A new category for commentary on the ASNet Discussion Forum is being introduced to address drug use other than addictive drug use. Specifically, this category includes the use of psychoactive substances to which the individual hasn’t developed an addiction. In some cases this will involve the use of substances to which addiction is unlikely; in other cases this will involve early-stage use of an addictive substance before an addiction has actually developed.

It is not the intent of the ASNet to encourage illicit substance use by openly discussing this topic. However, it is rather obvious that people do use illicit substances, often in a “recreational” fashion, and that such substance use will continue despite relentless government efforts for social control. It is also possible that the regulations regarding some substances that are now illicit should be relaxed and individuals should be permitted to use these substances freely or under somewhat restricted circumstances.

Before posting or commenting in this category please read the materials recommended below to learn how addiction is defined on this discussion forum, the important difference between drug abuse and addiction, and the relationship of drug dependence to addiction and to drug abuse. Misunderstanding fundamental concepts and breakdown in simple semantics contribute much to the confusion regarding the discussion of these issues.

Addiction science should withhold moral judgments regarding the use of licit or illicit psychoactive substances. Science should provide the unbiased data from which others can make rational decisions regarding their own personal use and regarding the development of formal drug-regulation policies. Within this context, the forum ‘owner’ will occasionally offer comments relevant to the science of addiction or to psychopharmacology in general, but the moral issues regarding psychoactive substance use is left for debate elsewhere (or at least confined to a single, specific ‘thread’ and not interwoven through the pages of the other topics). The topics of interest here include:

  • what substances are being used “recreationally” and how they’re being used,
  • the desired and undesired psychotropic effects of these substances,
  • the perception of relative risk for various substances and for their methods of use, and
  • the identification of safer practices for using unsafe substances.

(This latter topic is related to the ASNet harm-reduction initiative and comments may be incorporated into the ASNet webpage listing “safer practices for using unsafe substances.”)

Recommended Readings on the ASNet
A Primer on Drug Addiction
The Nature of Addiction
Distinguishing Drug Abuse from Drug Addiction
Distinguishing Drug Dependence from Drug Addiction
Biological Basis of Addiction
Hard and Soft Drugs
Drug Classification

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Proposed Regulation of Salvia Divinorum

04/03/09 | by the professor [mail] | Categories: Drug-Regulation Policy

Salvia Divinorum and its concentrated extracts are enjoying unrestricted trade on the Internet and in most states throughout the United States. The Drug Enforcement Administration (DEA) is currently considering whether this substance (including its concentrated extracts and synthetic analogues) should be “scheduled” and placed on the controlled substance list. Because there are no medicinal uses of Salvia Divinorum recognized by the Food and Drug Administration (FDA), Salvia Divinorum and related compounds would most likely become Schedule I substances with access restricted to investigational use by DEA licensed researchers. (Click here for more information on the CSA/DEA Drug Classification System.)

The question open for comment is: Should Salvia Divinorum and its extracts become controlled substances? Secondary questions involve: How strong are the effects of this substance and its related analogues?

(Thanks to John Panos for suggesting a posting on this topic now open for commentary. Also thanks to my Advanced Topics in Addiction class for encouraging an interest in this substance.)

Related Topics on the ASNet
Distinguishing Drug Abuse from Drug Addiction
Drug Classification
Hard and Soft Drugs

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