Archive for November, 2007

Meth Lab Reduction vs. Demand Reduction

Thursday, November 29th, 2007

A recent report by the Department of Human Services (DHS) in Oregon trumpeted a reduction in meth lab busts from 587 in 2001, to just 21 through the first ten months of 2006. The reasons for this reduction have to do with restrictions placed on the sale of pseudoephedrine, the main raw ingredient (precursor) in the manufacturing process. In 2004, medications containing pseudoephedrine were put behind the pharmacist’s counter and since July, 2006, Oregon law has required a doctor’s prescription for them. This strategy for reducing the availability of an illegal drug is called supply reduction, the theory being that if drugs are not available, people won’t use them.

Even with restrictions in place, Oregon’s DHS found that the number of meth abusers checking into treatment programs has remained the same, as has the number of drug arrests. This is not to say that supply reduction doesn’t work but for it to be effective all supplies must be reduced and the cost of those efforts must not outweigh the benefits. At present, the slack created by the reduction in mom-and pop meth labs has been easily taken up by Mexican super labs set up by Mexican drug gangs, either in the United States or in Mexico. These labs were already providing 70% to 80% of the U.S. supplies. Pseudoephedrine is readily available in Mexico in spite of recent supply reduction efforts to limit importation of precursors from China and Germany.

The other two methods used to control drug use are demand reduction and harm reduction. Demand reduction involves prevention, intervention, and treatment strategies to reduce the need for drugs. This method has proven to work and is extremely cost effective. For example,

  • untreated addiction costs society and the addict $30,000 to $150,000 a year;
  • incarceration costs $20,000 to $30,000;
  • residential treatment costs $4,000 to $15,000;
  • and intensive outpatient treatment averages just $2,500.

California’s CALDATA study found that for every $1 spent on treatment, $7 is saved in direct costs such as incarceration, theft, and absenteeism.

The other strategy, harm reduction, also involves prevention, intervention, and treatment but abstinence is not its primary goal; rather it is reducing the damage the drug use has on society and the individual user. Programs such as methadone maintenance, needle exchange, designated driver, and controlled drinking are some of the strategies. There is still much controversy concerning harm reduction.

Supply reduction makes the news; multi-ton drug busts and hundreds fewer mom and pop meth labs show that law enforcement is doing its job. Nevertheless, supply reduction is often a temporary solution given the porous nature of our borders, airports, and sea-lanes. The law of supply and demand mean that as long as demand remains constant, someone will find a way to make the lucrative drugs available. In other countries, an increasing demand for methamphetamine has led to a growth in production. In the Czech Republic home meth labs are sprouting up everywhere. From 19 labs busted in 2000, the number has grown to 416 in a country with just 10.2 million people. In Europe, heroin and cocaine are more available and abused than meth, but demand is the governing force.

Better treatment success rates, new medications to reduce craving, and prevention programs that keep adolescents from beginning use don’t make for flashy headlines, but they are successful and can be done at a fraction of the price of supply reduction.

William E. Cohen November 26, 2007

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Alcohol and Religion

Monday, November 19th, 2007
A November 7, 2007 article in the Los Angeles Times by Christian Berthelsen and Said Rifai focused on the use of alcohol in Iraq. In spite of being a Muslim country, for the last several decades Iraq had a reputation as being a modern, secular society that allowed alcohol, particularly among the upper classes. Discotheques, members-only clubs, and liquor stores that sold everything from ouzo and arak, (popular local alcohols) to beer and whiskey were plentiful. In the early 1990s, in an effort to win favor with religious conservatives, public use of liquor was restricted though liquor stores remained open. The removal of Saddam Hussein, the Iraqi war, and the growing influence of extremists and religious conservatives brought about the closure of liquor stores. The recent surge in the numbers of U.S. troops afforded more protection and so a number of liquor stores reopened. They are relatively anonymous (no store signs) and have not been harassed or bombed at the same rate they were just a few months ago. Still, there are reports of beatings and harassment by religious conservatives and religious extremists.

In most Muslim countries, alcohol is banned on religious principles. The Qur’an (Koran) makes few references to wine and intoxicants. Unlike Catholic sacraments, wine is not used in Muslim services because drinking wine is frowned upon. The prophet Mohammed did not mention it directly, but he chastised a drunkard for not performing his duties. This concept was delineated by Mohammed’s brother-in-law Ali:

“He who drinks gets drunk, he who is drunk, does nonsensical things, he who acts nonsensically says lies, and he who lies must be punished.”

A further passage from Yusaf Ali includes all intoxicants:

“O ye who believe! Intoxicants and gambling . . . . are an abomination-of Satan’s handiwork: eschew such [abomination] that ye may prosper.” – Qur’an 590

Many alternative substances were tried over the centuries, especially those that didn’t interfere with one’s religious duties. Hashish and opium were tried but it was stimulants such as coffee, tobacco, and khat that continued to be used because they (especially coffee and tobacco) did not intoxicate to the point of indifference to one’s religious duties.

By contrast, the Christian bible has more than 150 references to wine, some positive and some negative. A quote similar to Ali’s admonition is

“And don’t get drunk with wine, which leads to reckless actions, but be filled with the Spirit speaking to one another in psalms, hymns, and spiritual songs, singing and making music to the Lord in your heart.” –Ephesians 5:18-19.

Other Christian religions that forbid or discourage any alcohol consumption are the Church of Jesus Christ of Latter-day Saints, the Seventh-day Adventist Church, and some Protestant sects of fundamentalist Christianity. However, there is ambivalence in the Bible towards wine and its place in society.

“God give you of the dew of the sky, of the fatness of the earth, and plenty of grain and new wine.” — Genesis 27:28

The Jewish religion has historically use wine as part of their religious and secular celebrations, including circumcisions, weddings, and the Sabbath. And even though wine is praised in the Old Testament, there are still warnings about over indulgence. Drunkards are not allowed to perform religious, legal, or political functions and are even forbidden from praying until sober.

The Buddhist attitude towards alcohol and other intoxicants has similarities to both Islam and Christianity. Buddhists believe that using alcohol or other intoxicants interferes with understanding the Four Noble Truths and the Noble Eightfold Path, which lead to an awakening or enlightenment about the true nature of reality. The guiding principle of Buddhism is known as the Middle Way, often described as the practice of non-extremism; a path of moderation away from the extremes of self-indulgence and opposing self-mortification.

Hinduism, the worlds oldest extant religion, disapproves of alcohol consumption, particularly excessive consumption, because it interferes with leading a moral life. However, certain passages in Hindu scriptures seem to condone its moderate use by certain classes such as kings, nobles, warriors and manual workers. Its use is prohibited for priests, students and those seriously following Hinduism as a way of life. India’s constitution (written in 1947) declared, “The State shall endeavor to bring about prohibition of the consumption of intoxicating drinks.” Prohibition was enacted in 1977 but lasted only 2 years except for a few more conservative states. Unfortunately, the written provision has not been able to prevent the rapid increase in the consumption of alcohol in India during the last few decades.

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Problem Gambling Clinical Training Conference

Friday, November 9th, 2007

I recently attended and spoke at a training seminar put on by the Problem Gambling Services of the State of Oregon (a division of the Addictions and Mental Health Services of Oregon.) The two main speakers were Chris Anderson who spoke on the “Healing Power of Presence,” and Philip Yassenoff who spoke on “Gambling Treatment: a Gestalt Approach. A panel concerning “Gamblers Anonymous and Recovery” was followed by an open GA meeting. About 150 gambling treatment counselors and supervisory personnel from all over Oregon attended the 2-day meeting, held at the convention center in Seaside, Oregon.

Chris Anderson, MS, LMFT, NCGC, is a nationally known gambling and addiction therapist from Chicago, Illinois. He offers therapy, clinical supervision, forensic evaluation and forensic testimony, program consultation, and professional training. He believes that the core process of gambling addiction involves the repetitive pattern of escape from an unmanageable reality into a manageable fantasy (dream world.) Gamblers believe that “all the good things in life are just around the corner after the big win is finally made,” that life for them is not in the here and now but at some point in the future. There is a healing power that manifests when a person is present to themselves and to another. The workshop addressed how clinicians can access the power of presence and utilize it in the treatment of pathological gamblers. Normally, compulsive gamblers often feel that the more vague they can keep issues in their lives, the more they can avoid the present. The aim of Anderson’s therapy is “To help clients live fully into the here and now reality of their lives in order to live into a sense of vision that calls them forth.” It is important to move things from the abstract to the specific. He says that during therapy, the therapist should avoid rushing to fix things. It is important that the client recognizes the problems himself and becomes motivated to change. Many therapists try to lower anxiety and relieve emotional pain but Anderson says that the pain and anxiety can help motivate a client to change. Anderson was a compulsive gambler (day trading on the stock market) and has been heavily involved in Gamblers Anonymous for over 20 years.

Philip Yassenoff, LPCC, a therapist and trainer of drug, alcohol, and gambling therapists and counselors, talked about gestalt therapy and the gambler. Gestalt is focused on “How” and “What is,” especially what is taking place in the present moment. It is concerned with “organizing self in one’s environment;” it is interpersonal and contextual and supports flexibility, choice, and integration. Part of the technique is bringing gambling issues into the present much like Chris Anderson’s technique of bringing clients into the here and now. Clients need to become aware of what is happening now and not what they hope will happen in the future. He talked about a number of techniques that can be used to bring the client into the present including pointing out congruence and incongruence in their daily lives, asking them to exaggerate or diminish feelings to get a sense of their importance. One thing he does is to ask clients to heighten their awareness of breathing, talking, and how they live their daily lives, (in the present, not in the future.) Again, like Chris Anderson, he feels that the therapy can be too safe so the client feels no urgency to change but it can also be too intense (which turns off the client). The therapist has to operate at the therapeutic boundary between too much and too little stress. Ideally, the session should feel lively and engaging; the client should talk, listen, and dialogue. In a good session, the therapist is energized.

The panel on Gamblers Anonymous discussed the need for aftercare in the therapeutic process. It focused on Gamblers Anonymous and its usefulness in keeping the pathological gambler from relapsing after they have gone through the state gambling awareness treatment program for 6 or 8 months (or any other gambling treatment program.) GA’s literature states that “Gamblers Anonymous is a fellowship of individuals who share their experience, strength, and hope with each other that they may solve their common problem and help others to recover from a gambling problem.” The basic process in Gamblers Anonymous and other 12-step groups is a technique somewhat similar to Chris Anderson’s “Healing Power of Presence,” and Philip Yassenoffs “Gambling Gestalt Therapy.” In GA and other 12-step groups, members share their experience, strength, and hope by telling what they were like, what happened to change them and what they are like now. The other members just listen and do not interrupt. They can “take what they want and leave the rest.” This way, compulsive gamblers avoid confrontational situations which can be counterproductive in addicts because they find it difficult to ask for help and want to do everything on their own. Members also can get a sponsor to talk with, advise them on following the 12-steps, and in general, help them follow the program.

As a recovering compulsive gambler, I have seen the program work for hundreds of others. Attending meetings on a regular basis is key. Addicts need to be reminded, on a daily basis, that practicing our addiction on a regular basis has altered our brain chemistry making us permanently more susceptible to addiction and relapse than the public at large.

All in all, it was an exhilarating meeting. Seaside is a good place for a meetings with good hotels, excellent restaurants, and access to a fine beach. The city has indeed changed and improved over the last 20 years.

William E. Cohen.

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