American providers – steeped in the Twelve Step tradition – recoil at the phrase “harm reduction” – but it is a service that they can and often do perform quite well. Perhaps the most socially beneficial treatment modality is one that some are reluctant to view as treatment at all – methadone maintenance for heroin addicts. In 2006, there were 254,049 people receiving methadone, only about 20 to 25 percent of all opiate addicts in the US . The gap is partly due to spotty service provision outside major cities, but in even urban centers, many addicts won’t voluntarily seek out methadone, preferring heroin even with its attendant risks. But Switzerland, the Netherlands, and Germany have amassed an impressive body of evidence that hard-core addicts significantly improve their health and reduce their criminality when they are able to obtain heroin directly from government clinics . Similar ideas were rejected in the US several decades ago, but perhaps it is time for a second look . In the US, the dominant form of prevention takes place in the classroom, generally administered by teachers . Ironically, prevention is the least well funded but most thoroughly tested drug intervention. Drug prevention has very modest effects on drug and alcohol use; e.g., the mean effect size in the most recent comprehensive meta-analysis was about 1/20th of a standard deviation . Considering that 1/5th of a standard deviation is usually considered the benchmark “small” effect size, this is not very encouraging. Making matters worse, the single most popular program, Drug Abuse Resistance Education , accounts for nearly a third of all school prevention programs ,commercial solutions for vertical farming but numerous studies show it has little or no detectable effect on drug use . It is not clear whether its ineffectiveness stems from its curriculum or from its reliance on classroom visits by police officers. But classroom based prevention is quite inexpensive, so it doesn’t have to be very effective to be cost-effective.
Caulkins and colleagues estimate over $800 in social benefits from an average student’s participation, for a cost of only $150. Most of the benefits involve tobacco prevention, then cocaine, and only minimally marijuana. Classroom-based prevention materials can’t be effective if the messages aren’t salient in real-world settings where drug taking opportunities occur. But a well-funded campaign of magazine, radio, and television ads by the Office of National Drug Control Policyc appears to have had no positive impact on levels of use . We should be wary of thinking we have evaluated “the impact of mass media”; it may just be that the messages we’ve been using aren’t very helpful. Note that our prevention messages are almost exclusively aimed at prevalence reduction rather than quantity reduction or harm reduction . A greater emphasis on secondary prevention and harm reduction might have real payoffs with respect to social costs, but we won’t know unless we try . Evidence from classroom sex education is instructive in this regard; programs that teach safe sex are reliably more effective at reducing risky behavior than are abstinence-based programs . The conventional wisdom is that ecstasy is a “love drug” or “empathogen,” and that it is the drug of choice for European and Asian American college students and young professionals. But there are many reports of increased ecstasy use by minorities living in several cities . Many observers have noted its prevalence in the “hyphy” movement and the associated rap music . There is evidence of an increase in the number of references to ecstasy use in hip-hop music starting in 1996 . The reported rise in ecstasy use in the hip-hop scene has ignited alarming claims that ecstasy is “the new crack” ; a CBS television story asked whether Ecstasy was a “hug drug or thug drug” . In fact, researchers have only begun to examine the diffusion of ecstasy into inner-city neighborhoods . There is laboratory evidence of heightened aggression in the week following MDMA ingestion , but in a 2001 study of arrestees, ecstasy use was not associated with race, and negatively associated with arrest for violent crimes . It is also unclear whether self-reported “ecstasy” use always involves MDMA, as opposed to closely related drugs like methamphetamine . Thus the emerging “thizzle” scene does raise intriguing questions about psychopharmacology, culture, and their intersection, but whether there is any meaningful causal connection between Ecstasy, race, and crime is far from certain.
Earlier, we offered a thought experiment about a hypothetical drug called Rhapsadol. We now ask the reader to consider a newly created synthetic stimulant, “Quikaine.” Thus, it reduces reaction time and increases the speed with which physical tasks can be accomplished. It in no way alters the user’s emotional state either during or after the drug in is the system. Neither does it affect intellectual functioning. Second, consider “Intellimine.” Its sole impact on the human body is to improve cognitive capacity; it has no other emotional or physical impact, and no lingering effect on mental functioning once the drug leaves the system. In addition,because variants of this drug have been used for decades to help with ADHD/ADD and Alzheimer’s it has a long and empirically sound safety record. In fact, children and the elderly receive maximum benefit of the drug. How should we regulate these drugs? Should they be legally available for purchase by adults? If not, are there more limited circumstances in which their use might acceptable? For example, would Quikane’s use be warranted by those charged with protecting others from danger, such as certain military operatives or police officers? What about for completing tasks faster and more safely, such as on an assembly line? How about for simply reducing the amount of time spent on household chores? Should we allow surgeons, crisis managers, and other high-stakes problem solvers to take Intellimine? These drugs are hypothetical, but new synthetics already have some of their properties, and there is every reason to expect rapid advances in the development of performance enhancers in the near future . They will raise vexing questions about personhood, agency, freedom, and virtue. For centuries, we have associated psychoactive substances with the pursuit of purely personal goals: fun, seduction, escape, transcendence, ecstasy. New drugs like Intellimine and Quikane will force us to come to grips with a radically new framing: Drug use as a tool for enhanced economic competitiveness.
Parents who now worry about how marijuana might jeopardize their children’s Ivy League prospects may soon worry about whether abstinence lowers SAT scores. Employers who now screen urine for marijuana may come to view abstainers as slackers. It will be fascinating to see how we learn to reconcile these new pressures with our traditional attitudes toward drugs. We close with a brief list of topics that are sorely in need of research attention. Rather than a long wish list, we confine our attention to priorities that are implied by our analytical framework; specifically, the argument that quantity reduction and harm reduction deserve a more equal footing with prevalence reduction. The first priority is to give far greater attention to the development of quantity and harm indicators in epidemiological research. Our national drug surveys devote far more attention to prevalence than to dosage, settings of use, or consequences of use, and the reliance on household and classroom populations over represents casual users and under represents the heaviest users . And we would like to see the Gold stein et al. analysis of types of New York drug-related deaths replicated in many different cities on a periodic basis . The second priority is to incorporate more sophisticated quantity and harm measures into drug policy program evaluations. We rarely evaluate drug law enforcement, and when we do we typically seek changes in drug use without considering effects on patterns of drug use, much less the harms of drug use and the harms of aggressive policing. Treatment and prevention evaluators do attend to changes in quantity as well as prevalence, but they devote far less attention to changes in the harms. They are particularly resistant to assessing the possibility that participants who continue using might develop less harmful patterns of use. Finally, we would endorse a greater willingness to directly test interventions designed to directly reduce drug-related harm. Only needle exchange has received much study in the US,commercial vertical farming system much of it conducted in without any federal research support. More radical proposals like safe injection sites, “safer use” education, and government-regulated heroin maintenance have been completely off the table despite receiving serious investigation in Europe. A more open inquiry could establish whether such policies are harmful or helpful, and it would do much to help restore the perceived legitimacy of the US drug control establishment among elites and ordinary citizens alike. Among individuals diagnosed with substance dependence, major depressive disorder is a common and problematic psychiatric comorbidity, affecting an estimated 22% of persons with alcohol dependence and 40% with drug dependence . Compared to individuals without comorbidity, those with MDD have a poorer long-term course of substance use , greater risk of suicide , and greater treatment costs . In clinical settings the prevalence of comorbid MDD is even greater, exceeding 50% in some settings , and these patients typically have poorer outcomes from inpatient or outpatient treatment .
Given the vast prevalence and complications associated with comorbid substance dependence and MDD, there is a clear need to better understand processes that contribute to long-term outcomes in these chronically-disabled patients, and to develop treatments that better sustain long-term change. Researchers have recently stressed the importance of identifying mechanisms of behavior change , the factors that explain why and how treatments work. Some of the most prominent mediating variables in this line of research have been those related to 12-step involvement, such as attendance at 12-step meetings and affiliation with 12-step principles. Greater levels of 12-step affiliation and attendance have been consistently associated with reduced alcohol and drug use in general samples , but fewer studies have examined these relations in patients with psychiatric comorbidity. Similar levels of participation and degree of benefit from 12-step meetings have been found for patients with psychiatric conditions, but other studies found reduced long-term benefits for patients with comorbid MDD. Given the inconsistent and limited body of research, further studies are needed to clarify the importance of post-treatment 12-step affiliation and meeting attendance for patients with comorbid substance dependence and MDD. The extent to which specific interventions can produce sustained levels of 12-step involvement in comorbid patients is also relatively unknown. Treatments designed specifically to increase 12-step attendance and affiliation can achieve these goals in substance-dependent patients , including those with greater psychiatric severity . Similar results were found in our sample of veterans with comorbid MDD, where patients receiving group Twelve-Step Facilitation had increased levels of 12-step affiliation during treatment . However, it is not known whether comorbid patients can sustain high levels of 12-step participation after the conclusion of TSF therapy, and if any changes in long-term participation will impact substance use. Surprisingly few studies of substance dependent samples have directly examined post-treatment change in 12-step involvement, but some investigations have found no decline in 12-step attendance or affiliation in the first six months or one year following treatment. Patients with comorbid MDD could have greater difficulty sustaining 12-step involvement, possibly due to persistent depressive symptoms interfering with meeting attendance, difficulty making social connections with group members, or group resistance to the use of psychotropic medication . Difficulty sustaining 12-step involvement may contribute to the poorer long-term treatment outcomes for patients with comorbid MDD, but to date this question has not been examined empirically. This study involves secondary analyses of a sample of veterans enrolled in a 6-month trial of group TSF and Integrated Cognitive Behavioral Therapy for treatment of comorbid substance dependence and major depression . Utilizing latent growth curve models which explicitly model individual patterns of change in specified variables, we had three primary aims related to 12-step involvement and post-treatment substance use during the one-year follow-up period. First, we aimed to describe the post-treatment trajectories of12-step affiliation and meeting attendance separately for the TSF and ICBT groups. Secondly, we examined if the post-treatment trajectories of 12-step affiliation and meeting attendance differed between TSF and ICBT, hypothesizing that patients in TSF would have difficulty sustaining within-treatment levels of 12-step affiliation and attendance and evince greater decline in these variables during follow-up. Thirdly, we examined if post-treatment change in 12-step affiliation and meeting attendance predicted post-treatment change in drinking and drug use.