The Brief Addiction Science Information Source (BASIS)

Addiction & the Humanities, Vol. 5 (7) - Maybe it’s just me: The common relapse experience

Relapse is common for multiple paths of recovery from addiction (e.g., self-guided, treatment assisted, etc.). Various studies have shown that most expressions of addiction  carry a significant chance of relapse. For instance, in one 2003 study, 50% of marijuana smokers fit the criteria for relapse (Moore & Budney, 2003). Two other 2005 studies found high relapse rates among those recovering from alcoholism (i.e., 82% of outpatients and 73% of inpatients) (Marlatt & Witkiewitz, 2005)) and quitting smokers (40% of smokers who successfully abstained for one year and 90-97% of smokers who quit alone, (Shiffman, Kassel, Gwaltney, & McChargue, 2005)). 

Illustrating people’s propensity for relapse, Nic Sheff, author of the addiction and recovery memoir, Tweak, (Addiction & the Humanities Vol. 4 (9) – Addiction is more than just science) suffered two relapses during May and October of 2008; these relapses were 3 and 8 months, respectively, after the publication of Tweak. Sheff explained that his relapse episodes were the result of a difficult personal situation and his attempt to deal with this situation alone. The specific difficulties of relapse that Sheff describes (see Table 1) are similar to those often reported for other addictive behavior: common characteristics of relapse include, negative automatic thoughts, mild depressive thoughts, negative emotions, cravings, and dangerous behavior (Marlatt & Witkiewitz, 2005; McKay, Rutherford, Alterman, Cacciola, & Kaplan, 1995).

Relapse prevention programs, self-management programs intended to facilitate maintained recovery ("Preface," 2005), attempt to account for many of the common difficulties associated with relapse. The foundation of relapse prevention is to encourage and assist treatment seekers as they work towards harm reduction, abstinence and moderation ("Preface," 2005) by focusing on the behaviors and environmental factors that make up each individual’s situation. Relapse prevention falls under the Cognitive Behavior Therapy (CBT) umbrella; its focus on individual factors means that each person’s treatment program should adapt to their learning and progress. Research suggests that relapse prevention is often effective for the treatment of addictive behaviors, including stimulant use disorders (e.g., Sheff’s methamphetamine addiction) (Carroll & Rawson, 2005). Table 1 presents some of the parallels in Sheff’s thoughts and behavior regarding his relapse (Bonifield, 2008; Sheff, 2008), and typical relapse prevention treatment efforts.

Table 1: Parallels between Sheff’s relapse and Relapse Prevention Treatment.

Conclusion
Recovery from substance use disorders is difficult because of the prevalence of relapse and the associated problems that accompany relapse episodes. In our last post about Nic Sheff, we interviewed a high school teacher who stated that reading about Sheff’s more difficult experiences (e.g., detox, AA and NA use, near deaths) was beneficial and made the dangers of drug use more evident to her students. Sheff’s public admission to relapsing twice shows readers that, even with successful periods of abstinence, recovering from substance use and remaining drug-free is a difficult struggle that can take many years to resolve.

- Ingrid Maurice

What do you think?  Please use the comment link below to provide feedback on this article.

References

Bonifield, J. (2008). Relapse a constant threat, 'Tweak' author says, CNNhealth.com: CNN.com.

Carroll, K. M., & Rawson, R. A. (2005). Relapse Prevention for Stimulant Dependence. In G. A. Marlatt & D. M. Donovan (Eds.), Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, Second Edition (2 ed., pp. 416). New York: The Guilford Press.

Marlatt, G. A., & Witkiewitz, K. (2005). Relapse Prevention for Alcohol and Drug Problems. In G. A. Marlatt & D. M. Donovan (Eds.), Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, Second Edition (2 ed., pp. 416). New York: The Guilford Press.

McKay, J. R., Rutherford, M. J., Alterman, A. I., Cacciola, J. S., & Kaplan, M. R. (1995). An examination of the cocaine relapse process. Drug Alcohol Depend, 38(1), 35-43.

Moore, B. A., & Budney, A. J. (2003). Relapse in outpatient treatment for marijuana dependence. J Subst Abuse Treat, 25(2), 85-89.

Preface. (2005). (2005). In G. A. Marlatt & D. M. Donovan (Eds.), Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, Second Edition (pp. 416). New York: The Guilford Press.

Sheff, N. (2008). After relapse come terror, hope, CNNhealth.com: CNN.com.

Shiffman, S., Kassel, J., Gwaltney, C., & McChargue, D. (2005). Relapse Prevention for Smoking. In G. A. Marlatt & D. M. Donovan (Eds.), Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, Second Edition (2 ed., pp. 416). New York: The Guilford Press.

Addiction & the Humanities, Vol. 5(6) - Don’t Stop Till You Get Enough: How Media Coverage of Michael Jackson’s Death Might Raise Awareness About the Dangers of Prescription Drug Abuse.

On June 25, 2009 at 5:20 p.m., the celebrity gossip web site TMZ.com posted a story titled “Michael Jackson Dies.” Shortly thereafter, the cable news channels went live with footage of an ambulance taking Jackson’s body to the hospital. For the next few hours, news networks covered countless breaking details without pausing for commercial breaks. The non-stop television coverage coincided with a dramatic spike in Internet activity, particularly on social networking sites. The popular communication site, Twitter, slowed considerably—the result of a surge in Jackson-related “tweets”—up to up 5,000 per minute at peak. This rate of tweets represents the biggest jump since the presidential inauguration.

Before the major news outlets could even confirm that Jackson had died, talk turned to allegations that Jackson had been abusing prescription painkillers. About one-third of the initial stories focused on the potential causes of Jackson’s death, including rumors of drug abuse, according to a report by the Pew Research Center’s Project for Excellence in Journalism. Clearly, Jackson’s death momentarily has focused the nation’s attention on the dangers of prescription drug abuse. And past experience tells us that media coverage of celebrity health issues can influence real-life health behaviors. For instance, colonoscopy rates jumped more than 20% after Katie Couric underwent the procedure live on national television.

In this week’s Addiction and the Humanities, we explore whether, and to what extent, the news media used the opportunity of Jackson’s death to highlight the broader issue of prescription drug abuse and its consequences. We are particularly interested in whether news accounts have presented Jackson’s death as an isolated event or as an issue within the larger context of prescription drug abuse.

We conducted an informal analysis of television, print, and on-line stories about Jackson’s death, modeled after a recent analysis of news coverage focusing on celebrity DUI arrests (Smith, Twum, & Gielen, in press). We chose six prominent national sources that together represent a variety of media outlets in terms of media type and intended audience. These include one newspaper (The New York Times), a celebrity news magazine (People Magazine), two primetime cable news shows (Larry King Live and The O’Reilly Factor), one network news website (ABCNews.com), and one National Public Radio program (Talk of the Nation). For each source, we searched published archives for the article or broadcast most relevant to Jackson’s prescription drug abuse. For each article or broadcast we located, we explored the extent to which the writer or host presented a broader public-health perspective by including informative elements, such as facts about prescription painkillers and their health consequences, statistics about prescription drug abuse/dependence, prevention strategies and policy initiatives, and the inclusion of expert perspectives.

There was a wide variety in the tendency to include a public health perspective within articles and broadcasts. The stories produced by The New York Times and The O’Reilly Factor provided no public health elements. The Times article (“Medication is a Focus of Jackson Inquiry,” published on June 27, 2009) focused exclusively on the Los Angeles County coroner’s office efforts to determine the cause of Jackson’s sudden death. In the episode from The O’Reilly Factor airing June 30, 2009, a guest host and two commentators discussed whether Jackson’s race contributed to the media’s focus on his drug abuse and child abuse allegations. The People Magazine story, published on-line the day after Jackson’s death and titled “Drugs and Alcohol: Jackson Family Attempted Vegas Intervention,” detailed a 2006 attempt on the part of Jackson’s siblings to perform an intervention in Las Vegas. Though this story focused mostly on the specifics of Jackson’s case, it included a quote from an unnamed source about “clinically functioning addicts” more broadly: “Michael is a clinically functioning addict and these are the most dangerous…. These are the ones that OD.”

The remaining sources offered several informative elements in their stories. A report published on ABCNews.com the day after Jackson’s death, “Friend Says Michael Jackson Battled Demerol Addiction,” includes expert perspectives, facts about prescription painkillers, and statistics about prescription drug abuse. For instance, a cardiologist was quoted discussing how people build up a tolerance to opiates. Figures from the U.S. Drug Enforcement Administration were used to highlight the growing rate of deaths involving prescription pain relievers. During the episode of Larry King Live that aired June 10, 2000 (“Michael Jackson Drug Abuse Details Emerge”), guests included a psychiatrist who specializes in addiction and an anesthesiologist/pain management specialist. These guests provided information about warning signs of prescription drug abuse and the process of tolerance. However, neither of these stories provided as much public-health information as the broadcast of Talk of the Nation that aired on National Public Radio on July 2, 2009. In this broadcast, host Neal Conan used Jackson's death purely as a starting point for a wide-ranging discussion about prescription drug use and abuse. A pain care specialist, a professor of law and health care ethics, and a representative of the Drug Enforcement Administration discussed methods to reduce prescription drug abuse, including efforts on the part of individual physicians as well as state and federal initiatives to limit drug misuse. People with chronic pain enhanced this discussion by calling in to discuss their need for effective pain management.

At this writing, nearly four weeks have passed since Michael Jackson’s death, and many of the major news providers have offered non-stop coverage. A Google search of “Michael Jackson drug abuse” yields over 1.5 million hits. Because of the sheer amount of articles produced by this coverage, it would be nearly impossible to generate a truly representative sample of articles. However, this informal analysis illustrates the potential for news organizations to use the sad occasion of Jackson’s death to inform the public about the dangers of prescription drug abuse. And there is cause for optimism: according to a survey conducted by the American Society of Health Systems Pharmacists, 28% of pharmacists surveyed said their patients are asking more questions about the risks of prescription pain medications since Jackson’s death.

What do you think?  Please use the comment link below to provide feedback on this article.

References

American Society of Health Systems Pharmacists. (2009). Survey Reveals Public's Concerns About Prescription Medication Overdose Risks Following Death of Michael Jackson. Retrieved July 22, 2009, from http://www.ashp.org/import/news/pressreleases/pressrelease.aspx?id=534

Pew Research Center’s Project for Excellence in Journalism. (2009). PEJ News Coverage Index: June 22 - 28, 2009 Media Swing from Protests in Iran to the Passing of the King of Pop. Retrieved July 21, 2009, from http://www.journalism.org/taxonomy/term/96

Smith, K. C., Twum, D., & Gielen, A. C. Media coverage of celebrity DUIs: Teachable moments or problematic social modeling? In press, Alcohol and Alcoholism.

Addiction & the Humanities, Vol. 5(5) – A Possible Resolution: Regulation of Cognitive-Enhancing Drugs

In our past two issues of Addiction and the Humanities, we discussed the debate within the medical and legal communities about whether people should use powerful drugs for cognitive enhancement. This last installment of the series advances the discussion from whether people should use these drugs to a consideration of safety, distribution, and legalization.

Safety
Cognitive-enhancing drugs specifically affect executive function, and anecdotal evidence claims that they also improve focus and memory and reduce the effects of fatigue (Beddington et al., 2008; Morein-Zamir, Turner, & Sahakian, 2007; Turner et al., 2003). Researchers have tested one drug,  Modafinil, in healthy individuals (Turner et al., 2003) but there is little research on the safe use of other cognitive-enhancing drugs among healthy individuals (Lanni et al., 2008). For example, it is unclear what the difference in dosage for increasing focus would be for a healthy person versus a person with ADHD (Turner et al., 2003). Further, some drugs, such as Ritalin, carry the risk of heart problems and dependency (Hibbert, 2007), two issues that would have to be addressed in order to distribute cognitive-enhancing drugs safely and legally. Lastly, like any other drug, there are unsafe black-market versions of cognitive enhancing drugs available to buyers; it is important to alert the public to the dangers of using these unsafe versions that could lead to lethal side effects. 

Distribution
The widespread use of cognitive enhancing drugs for self-improvement also brings up the issue of fairness and equal access (Dekkers & Rikkert, 2007). As more people request to use these drugs, legislators, researchers, and clinicians will have to work together to ensure that groups of people with a greater need will always be given priority access to cognitive enhancing drugs. Furthermore, a discussion about access ought to stimulate discussion about where people should be purchasing cognitive-enhancing drugs (i.e. prescriptions vs. over the counter availability).

Legalization
Although cognitive-enhancing drugs such as Ritalin, Adderall, and Modafinil are legal, there are issues surrounding use, supplier authorization, and possession that will have to be addressed. For example, if cognitive enhancers can only be obtained via prescriptions, then regulations will have to be put in place to determine how much of each substance an individual is allowed to have in their possession. Furthermore, discussion of necessary rules and regulations should encourage discussion about whose responsibility it will be to make these rules (i.e., legislators vs. clinicians)

Conclusion
The use of cognitive enhancing drugs is already fairly common (DeSantis et al., 2008; Greely et al., 2008). In fact, some experts consider these drugs the next logical step in human self-improvement (Greely et al., 2008). However, if we, as a society, are willing to legitimize the use of drugs for cognitive enhancement, then we must also accept the unavoidable changes that they will bring to opportunities for success, academics, and even creativity. In order to manage cognitive-enhancing drug use, there needs to be enough regulation to prevent harm.

- Ingrid Maurice

What do you think? Please use the commen tlink below to provide feedback on this article.

References

Beddington, J., Cooper, C. L., Field, J., Goswami, U., Huppert, F. A., Jenkins, R., et al. (2008). The mental wealth of nations. Nature, 455(7216), 1057-1060.

Dekkers, W., & Rikkert, M. O. (2007). Memory enhancing drugs and Alzheimer's disease: enhancing the self or preventing the loss of it? Med Health Care Philos, 10(2), 141-151.

DeSantis, A. D., Webb, E. M., & Noar, S. M. (2008). Illicit use of prescription ADHD medications on a college campus: a multimethodological approach. J Am Coll Health, 57(3), 315-324.

Greely, H., Sahakian, B., Harris, J., Kessler, R. C., Gazzaniga, M., Campbell, P., et al. (2008). Towards responsible use of cognitive-enhancing drugs by the healthy. Nature, 456(7223), 702-705.

Hibbert, K. (2007, November 8). Ways to make you think better. guardian.co.uk.

Lanni, C., Lenzken, S. C., Pascale, A., Del Vecchio, I., Racchi, M., Pistoia, F., et al. (2008). Cognition enhancers between treating and doping the mind. Pharmacol Res, 57(3), 196-213.

Morein-Zamir, S., Turner, D. C., & Sahakian, B. J. (2007). A review of the effects of modafinil on cognition in schizophrenia. Schizophr Bull, 33(6), 1298-1306.

Turner, D. C., Robbins, T. W., Clark, L., Aron, A. R., Dowson, J., & Sahakian, B. J. (2003). Cognitive enhancing effects of modafinil in healthy volunteers. Psychopharmacology (Berl), 165(3), 260-269.

Addiction & the Humanities, Vol. 5 (4) - On the other hand: An argument against Cognitive Enhancing Drugs

Our last issue of Addiction & the Humanities presented one side of the debate about the use of cognitive-enhancing drugs; Greely and colleagues argued that the use of cognitive-enhancing drugs by healthy individuals is akin to the use of good nutrition and better technology to improve performance and should be accepted by society as part of the next wave of self-improvement methods (Greely et al., 2008). This week we present the other side of this discussion: the argument against the use cognitive-enhancing drugs by healthy individuals.

In a column for the website LiveScience.com, Christopher Wanjek argues that Greely and colleagues do not fully address the potential long-term consequences of using drugs for cognitive enhancement. Table 1 below summarizes their primary opposing arguments. Wanjek’s main point is that there is not enough information about the long-term effects, on healthy individuals, of drugs like Ritalin and Aderall to defend widespread use for cognitive enhancement. These drugs can have serious side effects (e.g, heart problems and chemical dependency, respectively). Further, Wanjek argues, the “reported minimal boost in cognitive ability is anecdotal.” According to Wanjek, use of these drugs by healthy people is a risky decision with little scientific evidence to support the benefits (Wanjek, 2008).

The use of cognitive enhancing drugs raises ethical questions. If these drugs provide substantial long-term enhancement, Wanjek argues, then whose needs should be prioritized? Healthy individuals interested in purchasing cognitive-enhancers for self-improvement would be competing with individuals who need cognitive enhancers as treatment for diagnosed conditions. The principles of supply and demand could spark debate about the importance of treatment needs versus the importance of self-improvement. Wanjek also voices another concern about the use of cognitive enhancers by healthy individuals – the widespread use could yield a society of “genetically manipulated” individuals. Today’s culture, commends minimally enhanced (but diligently practiced) talents and skills; a change in society’s genetic make-up would make it difficult to differentiate between drug-induced and natural creativity.

Conclusion

The debate surrounding cognitive enhancing drugs is intimately tied to public and personal opinions about a variety of values: principles (man-made versus natural enhancers), rules (who should get these drugs and how), and cheating (cognitive-enhancers give an unfair advantage). Previously questioned forms of self-improvement such as vitamins (in pill form), technology, and even some medical procedures are currently mainstream; however, society’s acceptance of general cognitive-enhancing drug distribution would call for an acceptance that many future successes and accomplishments would develop as a consequence of these drugs. Perhaps cognitive enhancers, man–made substances, are simply the next logical step in progressive self-improvement.
If this is the case, how will this discussion, intimately tied to addiction research, change the study of addictions? In the next part of this series about the use of cognitive-enhancing drugs, we will explore the details that associated addiction with the use of cognitive enhancers.

Table 1: Evaluating key arguments for and against general use of cognitive-enhancing drugs.

- Ingrid Maurice

What do you think? Please use the comment link below to provide feedback on this article.

References

Greely, H., Sahakian, B., Harris, J., Kessler, R. C., Gazzaniga, M., Campbell, P., et al. (2008). Towards responsible use of cognitive-enhancing drugs by the healthy. Nature, 456(7223), 702-705.

Hibbert, K. (2007, November 8). Ways to make you think better. guardian.co.uk.

Lanni, C., Lenzken, S. C., Pascale, A., Del Vecchio, I., Racchi, M., Pistoia, F., et al. (2008). Cognition enhancers between treating and doping the mind. Pharmacol Res, 57(3), 196-213.

Morein-Zamir, S., Turner, D. C., & Sahakian, B. J. (2007). A review of the effects of modafinil on cognition in schizophrenia. Schizophr Bull, 33(6), 1298-1306.

Turner, D. C., Robbins, T. W., Clark, L., Aron, A. R., Dowson, J., & Sahakian, B. J. (2003). Cognitive enhancing effects of modafinil in healthy volunteers. Psychopharmacology (Berl), 165(3), 260-269.

Wanjek, C. (2008, December 9). Smart Pills: The Truth About Cognitive-Enhancing Drugs. www.livescience.com.

Addiction & the Humanities, Vol. 5(3) - On the one hand: In support of Cognitive Enhancing Drugs

In an earlier BASIS (STASH 4(11)), we noted the increase in college student use of prescription drugs for cognitive enhancement. This growing trend has not only sparked a debate within the medical and legal communities about drug safety and prescription drug abuse (Greely et al., 2008); it also has raised broader cultural issues about competitiveness, fairness, and what it means to “cheat.” In this issue and the next issue of Addiction and the Humanities, we examine both sides of this debate and hope that you will also weigh in with your opinion. First, we present the Greely and colleagues case for the responsible use of cognitive enhancing drugs by healthy individuals for whom these drugs were not prescribed (Greely et al., 2008).

The drugs most commonly used for cognitive enhancement work by enhancing “executive function,” either by improving the ability to focus (Ritalin and Aderall), remember (Aricept), or avoid fatigue (Provigil) (Greely et al., 2008). Greely and colleagues argue that the use of these drugs for cognitive enhancement is simply a new tool in the persistent human quest for self-improvement, one that requires less effort than more conventional methods of improving brain function such as education, exercise, and proper nutrition.

Greely and colleagues argue that the potential benefits of drug use for cognitive enhancement justify a serious evaluation of the risks and benefits. Among the potential benefits, they suggest, are “improved quality of life and extended work productivity, as well as [the ability to] stave off normal and pathological age-related declines” (Beddington et al., 2008; Greely et al., 2008, p. 705). 

Greely and colleagues dismiss three commonly raised arguments against the use of prescription drugs for cognitive enhancement in otherwise healthy adults (i.e., it is cheating, unnatural, and it amounts to drug abuse). However, due to the risks and benefits of new advances, they believe that the concern for safety, freedom, and fairness of cognitive-enhancing is justified, and suggest some policy methods to control usage and prevent its potential negative impact (i.e. an accelerated research program, the participation of relevant professional organizations to formulate guidelines for use, education to increase the understanding of cognitive enhancement, and legislation that will change with shifting social norms).

Discussion

Greely and colleagues present an argument in favor of drug use for cognitive enhancement and discuss the need for more research about the long-term effects of these drugs. In the next HUMANITIES, we will present an opposing view from dissenters who disagree with the assertion that prescription drugs should be used by otherwise healthy individuals for cognitive enhancement. 

- Ingrid Maurice

What do you think? Please use the comment link below to provide feedback on this article.

References

Beddington, J., Cooper, C. L., Field, J., Goswami, U., Huppert, F. A., Jenkins, R., et al. (2008). The mental wealth of nations. Nature, 455(7216), 1057-1060.

Greely, H., Sahakian, B., Harris, J., Kessler, R. C., Gazzaniga, M., Campbell, P., et al. (2008). Towards responsible use of cognitive-enhancing drugs by the healthy. Nature, 456(7223), 702-705.

Addiction & the Humanities, Vol. 5(2) - Magic Mushrooms in the Media and in Reality

Turn on the television or watch a movie and it will not take you very long to find a depiction of drug use. This issue of Addictions & the Humanities will consider how the media depicted the effects of hallucinogenic mushrooms in a particular instance and how well that depiction portrays the reality of mushrooms’ effects. We will use “Tree Trippers,” an episode of HBO’s popular television series Entourage, as media reference point.

Mushroom Types & Usage
There are hundreds of types of hallucinogenic mushrooms (Cunningham, 2008); some are safe to consume, while others have toxic effects. People can grow hallucinogenic mushrooms in kits and purchase them on the Internet. People also can find them naturally in manure and forested areas around the world (Cunningham, 2008; Diaz, 2005b). Individuals can consume mushrooms raw, cooked, smoked, or used in a tea-like drink (Cunningham, 2008; Diaz, 2005b). Individuals also have reported spending time setting up their environment before consuming mushrooms because the popular wisdom considers that your last thoughts (i.e., positive or negative) and the social setting (e.g., nature or domestic) as a major influence on the “trip” (Riley & Blackman, 2008). One of many risks to individuals is that many mushrooms appear similar (e.g., the Galerina Mushrooms closely resembles some magic mushroom species, but is deadly) (Cunningham, 2008).

Figure 1 illustrates two common hallucinogenic mushrooms: the Fly Agaric and the Liberty Cap. The Fly Agaric is purportedly the stronger of the two types.

Figures 1 and 2: Two Types of Hallucinogenic Mushrooms.

       

Fly Agaric (Amanita Muscaria)                      Liberty Cap (Psilocybe Semilanceata)
 

*Please note that these images are public domain. Fly Agaric- http://www.publicdomainpictures.net/view-image.php?image=163; Liberty Cap- http://en.wikipedia.org/wiki/File:Libertycap.jpg.

Clinical Effects of Hallucinogenic Mushrooms
Some of the effects of hallucinogenic mushrooms include hyperactivity, hallucinations, deep sleep, diarrhea, ataxia (lack of coordination), mydriatic pupils (dilated pupils), dizziness, vomiting, seizures, laughter, and muscle relaxation (Cunningham, 2008; Riley & Blackman, 2008). Mushroom users also report experiencing altered perspectives including spiritual enlightenment or connectedness to nature and other people, as well as a sense of mental revelation and introspection (Riley & Blackman, 2008). Other effects include reports of flashbacks, impaired memory, tolerance and addiction. Several other more serious reactions include kidney failure, neurotoxic, hepatoxic, allergic and gastrointestinal poisoning, and triggered mental health problems (e.g., psychosis). Deaths from common mushroom species have been reported, although much less frequently compared with other mushroom effects (Cunningham, 2008; Diaz, 2005b; DrugScope, 2005; Riley & Blackman, 2008). Adverse reactions remain infrequent, but the number of reactions is increasing and more research is needed to determine hallucinogenic mushroom poisoning prevalence percentages (Diaz, 2005a).

Mushroom “trips” are dichotomous; users tend to categorize “trips” as good or bad. Users recognize that bad experiences can occur and have developed strategies to cope with a bad trip (e.g., the “ride it out” strategy) (Riley & Blackman, 2008). Experiences vary widely from person to person. Typically the onset of the effects of hallucinogenic mushrooms is between 30 minutes and two hours after ingestion. The clinical effects last between 4 and 12 hours depending on the dose and type of mushroom ingested, tolerance levels, body size, and personal characteristics (expectations, experience, mood) (Cunningham, 2008; DrugScope, 2005; Riley & Blackman, 2008).

Mushroom Representation in the Media: Entourage as a Case Study
The “Tree Trippers” episode depicts hallucinogenic mushroom use when cast members decide to take the drug and then go to the Joshua Tree desert to help Vince, the lead role, make a major career decision. The characters experienced a number of the clinical effects that mushrooms stimulate, as described before. For example, characters demonstrated the commonly held belief that by experiencing mushroom induced heightened introspection and mental revelation they would be able to make a major decision. The difference between good and bad “trips” is also apparent in this portrayal. Characters hallucinated or had altered perspectives (e.g., feeling that one’s hands were really big, feeling that they were being chased by a mythical creature, thinking that your mouth will not speak, and believing they had the telepathic ability to talk with a dog). The characters also experienced anxiety, paranoia, and excessive laughter. The episode portrayed the clinical effects of mushrooms as different for each user. The cast members’ trips” started and ended at different times, they discussed how many mushrooms each person should take based on previous experience, and also were unsure of whether their “trip” was over hours later.

It is important to remember that it is not Entourage’s objective to provide drug education. With that being said, it is fair to assess whether they present a fair and unbiased view of hallucinogenic mushroom use. It is difficult to generalize from this particular representation to the media’s general ability to accurately depict mushroom use without knowing the specific type of mushroom the characters were using. However, this episode was successful in accurately representing many common—albeit mostly positive—clinical effects of hallucinogenic mushrooms. However, the episode failed to take full advantage of the opportunity to include several more common negative effects or any severe negative effects during the depiction of mushroom use1.

Discussion
In this instance, the media portrayed certain aspects of mushroom use well, including good and bad “trips.” However, it missed the opportunity to address the darker side of psychoactive mushroom use. Although this BASIS only considers one episode of a television show into account, other recent media depictions (e.g., Shrooms, Harold and Kumar Escape from Guantanamo Bay and a scene from Knocked Up) similarly do not  show adverse reactions to ingesting mushrooms (with some exceptions in Shrooms). Some might argue that this is fair because such effects are not very common. However, by avoiding the possibility of adverse consequences, the media paints a simplistic and one-sided picture. 

What do you think? Comments can be addressed to Tasha Chandler.

References
Cunningham, N. (2008). Hallucinogenic plants of abuse. Emergency Medicine Australasia, 20(2), 167-174.

Diaz, J. H. (2005a). Evolving global epidemiology, syndromic classification, general management, and prevention of unknown mushroom poisonings. Critical Care Medicine, 33(2), 419-426.

Diaz, J. H. (2005b). Syndromic diagnosis and management of confirmed mushroom poisonings. Critical Care Medicine, 33(2), 427-436.

DrugScope. (2005). What are Magic Mushrooms?   Retrieved February 25, 2009, from http://www.drugscope.org.uk/resources/drugsearch/drugsearchpages/mushrooms.htm

Riley, S. C. E., & Blackman, G. (2008). Magic mushroom use: Between prohibitions: Patterns and meanings of Magic Mushroom use in the UK. Substance Use & Misuse, 43, 55-71.

Notes

1 Usage patterns also seem to reflect convention reports of mushroom usage.

Popular wisdom for hallucinogenic mushrooms includes planning and setting up an environment before consumption. Popular wisdom cannot be categorized as a clinical effect, but it is clinically useful because it provides supplementary information regarding hallucinogenic mushroom’s psychological effects. In addition to the clinical effects the characters from Entourage experienced (discussed above), popular wisdom surrounding mushrooms is also depicted. Characters set up their environment by traveling to a place where they felt they would be one with nature; this wisdom can be considered to be consistent with clinical accounts of commonly reported altered perspectives. For example, compare the two following statements from a focus group in the (Riley & Blackman, 2008) study with from the Entourage episode, respectively: “It’s a natural drug and it should be done in nature…its all about like becoming one with nature;” and nature “is where we’ll find the answers [because it is where we] lose stresses, not control.”

Additionally, this episode also showed that mushrooms are grown in a variety of ways (e.g. this batch of mushrooms most likely came from manure as one cast member commented on the taste and another responded that it is because of where they are grown) and recognized that there are multiple ways to consume them (e.g. all characters ate them raw except one who had a peanut butter and shroom sandwich, perhaps to alter the taste) (DrugScope, 2005). *This information was included in a footnote because although it cannot be classified as a clinical effect, it does help in supporting why this Entourage episode was categorized as successful in accurately representing common effects of hallucinogenic mushrooms.

Addiction & the Humanities, Vol. 5(1) - The green monster: Absinthe

Absinthe, a bitter green liqueur, has had an interesting history, ranging from being a luxury beverage for the rich, to a popular drink amongst all social classes, to the supposed cause of social degeneration for all consumers. Huisman, Brug and Mackenbach compare the social history of absinthe and tobacco to show the similarities between consequences that result from different threats to the public health. As we explore the history of absinthe in this BASIS, we also will discuss how the use of history can help us to better understand potential responses to public health threats.

About Absinthe
Absinthe’s primary ingredient, oil of wormwood, was initially valued for its medicinal qualities. However, this changed when doctors recognized that ingesting absinth could produce hallucinogenic effects and consequences that resembled an epileptic seizure.

During the early 1800’s, absinthe was available to, and most popular with, the upper classes; its popularity trickled down to the lower classes during the middle 1880’s when cheaper production led to a lower price. The increase in absinthe consumption led to its downfall. Doctors surmised that absinthe caused absinthism (i.e., feelings of uneasiness and anxiety, and hallucinations due to the oil of wormwood effects) and described the adverse effects as unrelated to but worse than those brought on by alcohol. Politicians in France viewed absinthe as the root of the possible future degeneration of the French people. They suggested that  those who drank absinthe excessively could develop physical and mental symptoms that would then pass on to their progeny (Huisman, Brug, & Mackenbach, 2007).

Figure 1: Edgar Degas’ “L’Absinthe” (1876).

However, warning signs hinting toward absinthe’s toxicity were largely ignored by those who found it profitable (Arnold, 1989; Vogt & Montagne, 1982). In fact, the worldwide bans on the sale and distribution of the liquor were not put in place until the mid 20th century but “consumer reaction at the turn of the century … [did include] mild restraint in drinking the spirit”(Arnold, 1989). The Congo Free State colony was the first to enact a ban in 1898; prohibitions in Belgium, Brazil, Switzerland, The Netherlands, the United States, and France followed during the first decades of the 20th century.

These bans were a public health measure used in an effort to stop the epidemic use of absinthe, and the negative health consequences that resulted. According to Huisman et al “silence … surrounded absinthe for almost a century”, however, absinthe production and sale continued in other countries in which the liqueur was not banned. As a result of this selective banning, absinthe drinkers still had some access to the liqueur. This suggests that the bans were only partially successful in stopping epidemic absinthe consumption. Furthermore, it is difficult to infer just how much absinthe was produced elsewhere, and on the black market, and how this affected the anti-absinthe campaign.

Figure 2: F. Monod’s “Absinthe is death!”(1905).
Skulls were a popular image in anti-absinthe campaigns, with many artists choosing to represent impending death, or absinthe itself as a skull head or a skeleton.

Discussion
A century later, a new and milder form of absinthe, containing less thujone1 is available. As absinthe’s popularity returns, its history provides clues as to how to control risky substance consumption. Huisman et al. suggest that current public health efforts focus on other substances (e.g., tobacco) that pose greater threats to the public health. Although Huisman et al.’s analysis of absinthe’s history is limited by possible inaccuracies among the historical accounts, the authors stress that we can use history to implement improved public health efforts against dangerous substances. The case of absinthe demonstrates the need for action and an understanding of when to act. In the case of absinthe, the bans came just as consumption began to decrease, suggesting a decrease in the liqueur’s popularity. However, each substance has its own characteristics requiring a different course of action. The lesson to be learned from absinthe is knowing when and how to react to possible substance use epidemics.

Notes
1. A neurotoxin and an active ingredient in wormwood that blocks receptors in the Central Nervous System; Modern-day absinthe contain roughly 25 times less thujone than absinthe from the past.

What do you think? Comments can be adressed to Ingrid Maurice.

References
Arnold, W. N. (1989). Absinthe. Scientific American (June), 112-117.

Huisman, M., Brug, J., & Mackenbach, J. (2007). Absinthe--is its history relevant for current public health? International Journal of Epidemiology, 36(4), 738-744.

Vogt, D. D., & Montagne, M. (1982). Absinthe: behind the emerald mask. International Journal of the Addictions, 17(6), 1015-1029.

Addiction & the Humanities Vol. 4 (9) – Addiction is more than just science

Although we hope that reading the BASIS provides the public with access to the latest scientific findings about addiction research, addiction information also includes personal accounts of struggles with various objects of addiction. Science often leaves little room for such personal accounts, but humanities-based studies provide such important opportunities. Undoubtedly, there are many different ways of approaching a humanities-based study of addiction, for example, the use of literature and the power of the written narrative. This week’s BASIS presents readers with a different approach to understanding addiction: an interview of a teacher who recently assigned the NY Times Bestsellers, A beautiful boy: A father’s journey through his son’s addiction and its complementary book Tweak, to her students in a NY Preparatory High School Honors English class as a summer reading book.

Question & Answer*
1. Why did you choose a book that focuses on addiction? Why did you choose a book written from a parent’s perspective?

“I thought it would be interesting for the boys to see the story from two perspectives. I find personal stories fascinating and think that a story about the perils of drug addiction is important and very interesting for high school students.”

“Assigning these books was about finding comparison pieces for a personal writing class. I assigned A beautiful boy: A father’s journey through his son’s addiction and Tweak so that the boys could see how the same story could be told in different ways, and focus on different things, but still be compelling.”

2. Why did you choose to assign a book dealing with methamphetamine as opposed to more popular/well known substances/behaviors (i.e. alcohol, cigarettes, marijuana, or gambling)? What are you hoping that the students will gain or learn by reading this book?

“Drugs are a problem in high school and I know that the boys know people who are or have been addicted. I don’t think that the boys necessarily know anyone dealing with crystal meth but I know that they are familiar with marijuana. I wanted them to see, from two perspectives, how horrible a life of addiction can be for an entire family.”

3. You mentioned that “Tweak was a very disturbing book.” With this view of the book in mind, did you have any personal hesitation in assigning the book?

“I like assigning books that will make my students think, because good discussions generate from these types of books.  Also, I find that high school boys appreciate true stories, so I knew they would enjoy reading Tweak.”

 
Figure 1: Cover art for "Tweak" by Nic Sheff

4. Were any parents or other teachers surprised or displeased with the two book choices? Was there any resistance from parents or other teachers? If yes, why? Did they have particular reasons for their opinion?

“The books were chosen for a senior honors English class, and the texts were never questioned by parents or my colleagues.”  

5. What was your perception of the boys’ responses to the two books? Did they react differently to the father’s book vs. the son’s (or vice versa)?

“The students liked both books but felt that Beautiful Boy focused more on the science of drug addiction than Tweak did, and they thought some of that was boring.  They thought it was important, however, that David discussed how he and his family were affected by Nic’s drug addiction.”

6. Overall, which book did the majority of the students identify with? Whose story could they relate to more, and why?

“The boys enjoyed reading both books but could identify more with Nic Sheff’s Tweak because he was close to their age and they liked his style of storytelling.  Overall, they felt his book was very honest.”

 
Figure 2: Cover art for "A Beautiful Boy" by David Sheff

7. You mention that you find personal writing fascinating. How effective do you think that these two particular books are in shaping young students’ ideas about addictions, and debunking possible myths?

“The course that I teach focuses on personal writing, and the most important thing I tell my students is that they should write about what they know.  The fairly recent controversies regarding the truth of memoirs allow interesting discussion about what one can do when writing personal stories.  The students realize that memoirs are not autobiographies and are written from an author’s memory.  The interesting thing about Tweak is that Nic was addicted throughout most of the story, so they questioned if some of his story was fabricated.  The point we arrived to is that it doesn’t matter; the story is compelling and shows the perils of drug addiction regardless of whether or not it is entirely true.  Still, they were shocked by the lengths an addict will go to obtain his drug of choice. They were disgusted that Nic turned to prostitution and stole from people he loved, even from his little brother, to buy meth and heroin.  They were particularly touched by David’s pain as the father of a drug addict, and how Nic’s siblings were affected by his drug addiction.”

8. Some people complain that Tweak ends with Nic breaking away from his addiction and getting his life back and that this perpetuates the “not me, I can get over this” idea that young people have about life. Based on your experience with your class and with other books written from a firsthand perspective, how would you respond to that claim?

“We discussed in class that drugs are dangerous, and that although it is possible to get help and recover from an addiction, death from drug addiction is very common.  I previously assigned James Frey’s A Million Little Pieces to a different class, and I think that book is more dangerous, in a sense, to teenagers because Frey claims to have recovered without AA or NA.  At least Tweak shows that Nic received therapy, went through a detox and rehab program, and continues to live a sober life by attending AA meetings and finding other outlets, like writing and bike riding.”

Discussion
Personal narratives recounting the struggles of addiction are popular because of the firsthand experiences that they describe; these stories represent only one type of humanities-based studies focusing on addiction. In addition to literary narratives, humanities-based studies about addiction could include philosophical discourse, plays, musical performances, and visual art. These alternatives each provide unique information about addiction. One benefit common to them all, however, is that an understanding of the personal struggle of those who are addicted or their loved ones puts the evidence-based facts reported in the BASIS and in peer-reviewed journals into perspective by showing the real life ramifications of addiction.

What do you think? Comments can be addressed to Ingrid R. Maurice

*In the interest of BASIS length guidelines, the teacher’s responses were edited into quotes from her original answers.

Addiction & the Humanities, Vol. 4(8) - “What I look like when I’m drinking:” The production of self-portraits during art therapy for substance abuse

        Relapse is a major issue in substance abuse treatment: the majority of those struggling with chemical dependence return to use within the first 6 months after treatment (Brown, D'Amico, McCarthy, & Tapert, 2001). The intractability of addiction likely stems, at least in part, from its complex, multi-faceted nature. As a result, for most individuals the best course of treatment is a combination of biochemical and psychotherapeutic interventions. One psychotherapeutic intervention that shows promise in treating addiction is expressive art therapy. This week’s Addiction and the Humanities reviews recent case examples of the spontaneous production of self-portraits during art therapy for substance abuse.
        Art therapy likely makes its most unique therapeutic contribution by providing an opportunity for clients to creatively explore their previously unacknowledged emotions, thoughts, conflicts, and impulses. This can result in self-understanding and positive change, both during the early stages and the relapse-prevention stages of recovery. This type of change opportunity is particularly limited among individuals whose neurological dysfunction compromises their verbal self-expression.
        Creating self-portraits can be helpful in many ways (Muri, 2007). Creating an image of oneself provides a means for “stepping back” and reflecting on intense negative feelings. This added psychological distance can make clients more comfortable working through difficult issues. Often, self-portraits allow clients to gain an understanding that addiction is only a part of them and not the entirety of their being. By providing a representation of a client’s self-image, self-portraits provide important information to the therapist in a way that words cannot. In addition, sharing self-portraits with others presents an opportunity for clients to develop social and communication skills, which often enhances self-esteem.
        Hanes (2007) presents perhaps the first clinical observation of the spontaneous production of self-portraits during art therapy for substance abuse. He focuses on the role of self-portraits in overcoming denial. Denial is an important barrier to change because over time, the addiction often causes the individual to construct a worldview that is harmonious with maintenance and progression of the disease (Grant, 1997). Hanes suggests that the spontaneous production of self-portraits indicates that the individual is “ready to contend with reality and confront painful truths that may alter his or her self-image” (2007, p. 33). Hanes provides two case examples obtained from individuals in an acute psychiatric hospital who were participating in group art therapy.
        The first is “Bob,” a 50-year-old divorced man with two children, hospitalized for a depressive episode and alcohol binge. Bob had sought treatment several times in the past, but his sobriety had always been fleeting—presumably a result of his inability to recognize the severity of his addiction.  After a great deal of encouragement during a group art therapy session, Bob produced a self-portrait (Figure 1). He identified the contorted face as a portrait of himself while drinking. “That’s what I look like when I’m drinking,” he remarked. “I don’t like what I see.” Producing the self-portrait might have allowed Bob to recognize painful realities and begin to alter his self-image. After being released from the hospital, he began attending Alcoholics Anonymous and outpatient services.Figure 1: "Bob's" self-portrait.  Reprinted from Hanes (2007)

        “Kevin” also produced an impromptu self-portrait during art therapy for substance abuse, although his story ends less optimistically. Kevin is described as a 23-year-old man, married with one child, hospitalized for polysubstance dependence. Like Bob, Kevin refused to verbally recognize the severity of his addiction. However, during an art therapy session, he produced an image of himself emerging from behind a large and crumbling cinder-block wall (Figure 2). Kevin spontaneously indicated that the wall symbolized his addiction, and the fact that parts of the wall were crumbling suggests that he was beginning to overcome his denial. Written on a cinder block placed precariously over the figure’s head is “Wake up dumb ass.” Kevin explained “I guess I need to get hit over the head. Maybe then I can deal with my drug problem.” Despite this heightened self-awareness, Kevin remained ambivalent about the severity of his addiction. He discontinued treatment and relapsed shortly after being released from the hospital. Kevin’s story highlights the fact that recognizing the severity of one’s addiction does not automatically lead to recovery or even help-seeking. Research indicates that problem recognition occurs, on average, a full 9 years before individuals begin formal treatment. During the intervening years, individuals experience a wide range of legal, relationship, occupational, and financial problems, along with tolerance, withdrawal, and neurological symptoms (Simpson & Tucker, 2002). Decreasing the economic barriers to health care, along with the stigma associated with treatment, might help shorten the gap between problem recognition and help seeking.

Figure 2: "Kevin's" self-portrait     Reprinted from Hanes (2007)

        In sum, clinical observation suggests that producing self-portraits during therapy for substance abuse might be helpful to combat the denial often associated with addiction. This is consistent with recent work indicating that another innovative method for combating denial—exposing patients to videotapes of themselves experiencing delirium tremens—seems to be effective in reducing relapse risk (Mihai, 2006). However, empirical investigations are needed to document the extent to which the production of self-portraits contributes to problem recognition and eventual recovery.

What do you think? Comments can be addressed to Heather Gray.

References

Brown, S. A., D'Amico, E. J., McCarthy, D. M., & Tapert, S. F. (2001). Four-year outcomes from adolescent alcohol and drug treatment. Journal of Studies of Alcohol, 62(3), 381-388.

Grant, B. F. (1997). Barriers to alcoholism treatment: reasons for not seeking treatment in a general population sample. Journal of Studies on Alcohol, 58(4), 365-371.

Hanes, M. J. (2007). 'Face-to-face' with addiction: The spontaneous production of self-portraits in Art Therapy. Art Therapy, 24(1), 33-36.

Mihai, A., Damsa, C., Allen, M., Baleydier, B., Lazignac, C., & Heinz, A. . (2006). Viewing videotapes of themselves while experiencing delirium tremens could reduce the relapse rate in alcohol-dependent patients. Addiction, 102, 226-231.

Muri, S. A. (2007). Beyond the face: Art therapy and self-portraiture. The Arts in Psychotherapy, 34(4), 331-339.

Simpson, C. A., & Tucker, J. A. (2002). Temporal sequencing of alcohol-related problems, problem recognition, and help-seeking episodes. Addictive Behaviors, 27(5), 659-674.

Addiction & the Humanities, Vol. 4(7) - Cultural Anthropology Guiding Addiction Research

Scientific research focusing on addiction, especially research on effective interventions and treatments, is typically grounded in the disciplines of psychology, psychiatry, and other behavioral sciences. An important but less frequently used guide could be cultural anthropology, especially when researchers explore cultures other than their own. This issue of Addictions and the Humanities will explore how cultural anthropology raises psychological scientists’ awareness about cultural context, and how this awareness is essential to advance meaningful research.

Beatrice Medicine, a member of the Lakota Indian tribe, was a cultural anthropologist who spent her life writing and studying Native Americans, particularly those living on her reservation in North and South Dakota. 

Medicine’s posthumously published Drinking and Sobriety among the Lakota Sioux shows differences between Native and Euro-American perspectives about drinking and problem drinking.  She maintained that research and interventions conducted by those unfamiliar with the Sioux were not sufficiently culturally specific to be socially relevant or effective enough to make a meaningful impact.

Table 1 summarizes examples of three miscommunications that have occurred between cultures during the past sixty years.

Table 1. Cultural context clashes with Euro-American centered approaches to studying Native American drinking patterns.

(Click image to enlarge.)

Medicine suggests that comparing Native American drinking to Euro-American drinking is unfair because drinking fits into each culture differently.  The effect, then, is that Euro-Americans view drinking as a problem to eliminate.  Among some Indian groups, however, it is an entity too entrenched to blindly dismantle.  This “‘problem’ approach [that] has superseded most other approaches” (Medicine, 2007, p. 15) not only supersedes, but excludes them.  Limited knowledge of Native American culture limits the effectiveness of interventions.

Medicine wrote her book decades ago; it was published posthumously, therefore, the bulk of the evidence that supports her arguments dates from the 1960s–1980s.  The impact of Medicine’s research over the decades is difficult to measure. However, there is evidence that some modern researchers have become more culturally sensitive with time (e.g., Marlatt et al., 2003).  By being watchful, researchers have limited the problem.  Medicine’s work focuses on alcohol’s cultural context, but we must keep in mind that culture is dynamic.  Therefore, the strength of this book lies not in its specific culture-related information, but rather in the awareness it promotes regarding the importance of cultural context for psychological research. 

Medicine’s cultural anthropologic approach places drinking problems among the Lakota Indians into context.  Her exploration of alcohol in Native American history detangles the substance’s foundation within the culture. A cultural anthropological approach, therefore, can help psychological researchers ask relevant questions and design sensitive studies that will effectively and accurately reflect the population under study.  It also can encourage cooperative partnerships between cultures to address alcohol problems within Native American communities.

What do you think?  Comments can be addressed to Leslie Bosworth.

References

Braroe, N.W. (1975).  Indian and White. Stanford, Calif: Stanford University Press.

Dorris, M. (1989).  Broken Cord. New York: Harper Perennial.

Medicine. An Ethnography of Drinking and Sobriety Among the Lakota Sioux.  Doctoral Dissertation, University of Wisconsin at Madison.

Marlatt, G. A., Larimer, M. E., Mail, P. D., Hawkins, E. H., Cummins, L. H., Blume, A. W., et al. (2003). Journeys of the circle: A culturally congruent life skills intervention for adolescent Indian drinking. Alcoholism: Clinical and Experimental Research, 27(8), 1327-1329.

Medicine, B. (2007). Drinking and sobriety among the Lakota Sioux. Lanham: Altamira Press.

Whittaker, J.O. (1961). Alcohol and the Standing Rock Sioux tribe.  Fort Yates, North Dakota: Commission on Alcohol Standing Rock Sioux Tribe.